Nurse Recruitment and Retention Committee

Final Report

May 2001

Further InformationFor further information contact:Geraiut DugganNurse Policy BranchPolicy and Strategic Projects

Department of Human ServicesLevel 12, 555 Collins StreetMelbourne 3000

Telephone: (03) 9616 6984Facsimile: (03) 9616 9877

The government response to theserecommendations can be found at:nursing.health.vic.gov.au

AcknowledgmentsThe members of the Nurse Recruitment andRetention Committee have many people tothank for their input into the deliberations ofthe Committee. This includes the memberscoopted to the subcommittees who gave freelyof their time, effort and expertise over anintense period of time. It also includes themany people who prepared submissions for theCommittee and responded to our surveys, andthe peak and other groups that engaged indiscussion with members of the Committee.Special thanks to the many nurses whoattended the public forums and the focusgroups and who were free, frank and open intheir comments. We also appreciate the effortsof many in the Department of Human Serviceswho provided us with technical advice anddata to inform our deliberations.

The report was prepared for the VictorianMinister of Health.

Published by Policy and Strategic ProjectsDivision

Victorian Government Department of HumanServices, Melbourne Victoria

May 2001

Also Published on www.dhs.vic.gov.au

© Copyright State of Victoria 2001

(1310101)

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2 May 2001

The Hon John Thwaites MPMinister for Health555 Collins StreetMELBOURNE 3000

Dear Minister

It is with pleasure that I present to you the completed report of the Nurse Recruitment andRetention Committee.

As you requested, we sought information through an exhaustive consultation process, ensuringthat all levels of nurses in all areas of practice had the opportunity to bring issues to us. Inaddition, a literature search was undertaken that emphasized the national and internationaldimensions of the problems we are facing in Victoria. Although issues of recruitment and retentionare complex, common themes have emerged from our consultations and information gathering. Inessence these relate to conditions of work, especially heavy workloads and inflexible workingconditions, the absence of a clinical career structure, lack of recognition for and support of nurses,difficulties with education and the image of nursing.

I am pleased to report that the members of the committee have unanimously endorsed all therecommendations.

The report initiates the extent of the problems of recruitment and retention in Victoria. Itrecommends strategies aimed at attracting people into nursing, recruiting those who have left backinto nursing and retaining nurses who are currently employed in the public health sector inVictoria. The recommendations are organized in an order of priority, so that not only immediateissues are addressed, but those of the medium and longer term.

A small number of the recommendations contained in this report have already been recommendedas part of the arbitration decision handed down by Commissioner Blair on 31st August 2000. Thesefocus largely on the improvement of working conditions for nurses and are considered as highpriority areas in this report. However, the issues are many and complex and require long term aswell as immediate solutions. The wide range of strategies recommended here requires co-ordinatedaction by Governments, State and Commonwealth health care facilities and education providers.

Currently, many parts of the world are addressing issues of nurse recruitment and retention. Thereis a paucity of information of the effectiveness or otherwise of strategies that are implemented.Victoria needs to evaluate its implemented strategies. They should result in the attraction ofsufficient people of high calibre to nursing to ensure supply meets demand, the stemming of theexodus of experienced qualified nurses not only from the bedside but also from the profession, andthe retention of nurses who not only provide best practice care, but are satisfied in their work

I commend the report of the committee to you for your consideration.

Yours sincerely

Professor Margaret BennettChair, Nurse Recruitment and Retention Committee

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The Government appointed the Nurse Recruitment and Retention Committee in February 2000 to provideadvice on matters relating to the registered nurse workforce in Victoria.

Nurses are critical to the delivery of quality healthcare in the State, in both the hospital and community set-tings. The Government moved quickly to establish the Committee in response to widespread concern regard-ing staffing shortages and the lack of workforce planning to address the shortages. Of particular concern tothe Government were reports that around 20% of the registered nursing workforce were choosing not to workin the profession. The Committee was charged with investigating why nurses were leaving the profession, toadvise on strategies to encourage existing nurses to remain, and to recruit nurses back into the public healthsystem.

The Committee was asked to consult widely, and to seek the views of the healthcare industry, the educationsector, trade unions and peak bodies. In particular, the Government wished to hear the views of nurse clini-cians who deliver nursing care, in the acute care, mental health, aged care, community and midwifery set-tings. In seeking these views the Committee was asked to consult with nurses working in regional and ruralVictoria, as well as those in metropolitan areas. I would like to thank all nurses who contributed to the commit-tee’s consultation, either through submissions, focus groups, surveys or attendance at public forums.

The work of the committee was undertaken during the period when extensive discussion was taking place,under the direction of the Australian Industrial Relations Commission, on the public sector and mental healthnursing workforce agreements. Since that time many of the recommendations in this report have been fullyfunded and implemented by the Government following the finalisation of the industrial agreement.

Of the report’s 86 recommendations, 44 are targeted at Government. The Government has already enacted orcommenced work on over half of these, and in many cases it has exceeded the Committee’s recommendation,including:• paid study leave for over 1200 nurses• scholarships for Division 1 nurses undertaking post-graduate programs in four areas of critical shortage:

perioperative, neonatal intensive care, intensive care and emergency nursing• an extensive print and radio advertising campaign to inform the nursing workforce of changed pay and

conditions• $7 million spent establishing refresher and re-entry programs to assist nurses returning to work• a review of the provision of childcare for nurses• funding to assist undergraduate nurses undertaking clinical placements

The Government remains committed to supporting and promoting the profession of nursing in Victoria. I haveestablished the Nurse Policy Branch within the Department of Human Services to coordinate and oversee theimplementation of this report’s recommendations, in addition to policy work related to, amongst other things,the Nurse Practitioner Project, the extension of the scope of practice for Division 2 nurses and the ongoingwork of the Nurse Back Injury Prevention Project.

I would like to take this opportunity to thank Professor Bennett and all the committee and sub committee mem-bers (listed in Appendix Two of this report) for their hard work and dedication in completing this report. Inaccepting the report’s recommendations, I am confident that Victorian nurses will now feel that they can prac-tice in an environment where they are valued and rewarded for their crucial contribution to the health of allVictorians.

John Thwaites MPMINISTER FOR HEALTH

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Foreword

Acknowledgements ........................................................................................................................................ii

Foreword ............................................................................................................................................................iv

Abbreviations and Conventions ......................................................................................................vii

Executive Summary and Recommendations ......................................................................1

Recommendations — High Priority ................................................................................................................2

Recommendations — Medium Priority ......................................................................................................11

Recommendations —Long Term Priority ..................................................................................................13

The Nurse Recruitment and Retention Committee and the Enterprise Agreement for Nurses ..................................................................................................................14

1. Introduction ......................................................................................................................................................19

1.1 Committee Process......................................................................................................................................19

1.2 Committee Membership .......................................................................................................................... 19

1.3 Establishment of Sub-Committees ......................................................................................................19

1.4 Information Collection and Consultation Process......................................................................20

1.5 Context ............................................................................................................................................................20

1.6 Report Structure ............................................................................................................................................20

Part 1—The Scope of the Problem ..............................................................................................23

2. Nursing Shortages....................................................................................................................................25

2.1 The International Experience ................................................................................................................25

2.2 The Victorian Nursing Workforce ......................................................................................................31

2.3 National Data Sets ......................................................................................................................................34

2.4 Victorian Data ................................................................................................................................................35

2.5 Indicators of Shortage in Victoria ......................................................................................................37

3. Problems in Nursing ..............................................................................................................................41

3.1 Workload ..........................................................................................................................................................41

3.2 Unsafe Working Environment ................................................................................................................44

3.3 Equipment Available ..................................................................................................................................45

3. 4 Career Structure............................................................................................................................................45

3.5 Support for Nurses ......................................................................................................................................45

Contents

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3.6 Education Cost and Access ....................................................................................................................46

3.7 Family Issues ..................................................................................................................................................46

3.8 Specific Issues for Rural Nurses ........................................................................................................47

3.9 Specialty Issues ............................................................................................................................................47

3.10 Management ..................................................................................................................................................48

Part Two – Strategies ..................................................................................................................................49

4. Attracting Nurses into the Workforce..............................................................................51

4.1 The Image of Nursing ................................................................................................................................51

4.2 Undergraduate Recruitment ..................................................................................................................51

4.3 Attracting Nurses Back into Nursing ................................................................................................52

4.4 Injured Nurses................................................................................................................................................56

5. Education of Nurses ..............................................................................................................................57

5.1 Undergraduate Education ........................................................................................................................57

5.2 Postgraduate Education............................................................................................................................65

5.3 Graduate Nurse Programs ......................................................................................................................67

5.4 Continuing Education ................................................................................................................................69

5.5 Study Leave......................................................................................................................................................72

5.6 The Training and Development Grant ................................................................................................73

6 Retaining Nurses in the Workforce ....................................................................................77

6.1 The Workplace ..............................................................................................................................................77

6.2 Working Conditions ....................................................................................................................................88

6.3 Special Issues ............................................................................................................................................102

Bibliography ........................................................................................................................................................107

AppendicesOne—Terms Of Reference ..............................................................................................................................113

Two—Committee Membership ....................................................................................................................114

Three—Quantitative Survey of Registered, Non-Working Nurses ..........................................115

Four—Qualitative Survey of Registered, Non-Working Nurses ................................................143

Five—Report of the Open Consultation Forums ..................................................................................155

Six—Report of the Focus Group Consultation ....................................................................................165

Seven—Submissions Received ..................................................................................................................205

Eight—Survey Instruments ............................................................................................................................207

Nine—Training and Development Grant Details ................................................................................208

ABS Australian Bureau of Statistics

ACCCN Australian College of Critical Care Nurses

ACNMI Australian College of Nurse Management Inc

ADO Accrued day off

AHMAC Australian Health Ministers Advisory Council

AIRC Australian Industrial Relations Commission

AIH&W Australian Institute of Health and Welfare

AMHS Area Mental Health Service

ANUM Associate Nurse Unit Manager (formerly Associate Charge Nurse)

ANCI Australian Nursing Council Inc.

ANF Australian Nursing Federation, Victorian Branch (unless otherwise stated)

ANZCMHN Australia and New Zealand College of Mental Health Nurses

Acute inpatient unit Short stay psychiatric ward, usually co-located with a general hospital.

Assistants in nursing Non-nursing trained workers whose duties involve direct patient contact.Often assisting nurses.

AQF Australian Qualification Framework

Award Nurses (Victorian Health Services) Award 1992

Casemix Health service funding formula based on clinical activity

CAT (Psychiatric) Crisis Assessment and Treatment

CEAV Careers Education Association of Victoria.

Certificate IV in Course leading to registration as a Division 2 Nurse with the Nurses Board ofHealth (Nursing) Victoria

CNC Clinical Nurse Consultant

CNS Clinical Nurse Specialist

DETYA Department of Education, Training and Youth Affairs

Department of Department of Human Services (Victoria) Human Services

Division (1–5) This refers to the Division of the Nurses register maintained by the NursesBoard of Victoria. The number refers to the specific division.

Division 1 Formerly known as general nurses, now includes all (since 1994) three-yearuniversity educated nurses

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Abbreviations and Conventions

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Division 2 Formerly known as enrolled nurses. Now trained in the VocationalEducation and Training sector.

Division 3 Formerly known as psychiatric nurses. register closed; new, overseas orinterstate trained psychiatric nurses are now registered in Division 1.

Division 4 Formerly known as intellectual disability nurses, register closed.

Division 5 Mothercraft nurses, register closed.

DoN Director of Nursing

EFT Effective full-time

EN Enrolled Nurse (Division 2 Nurse)

ENTER Formerly TER: the tertiary entry score required for university application.

ENSIG Enrolled Nurses Special Interest Group

FFP Full Fee Paying (Fee charged on full cost recovery basis for Universitycourses)

FTE Full-time equivalent Graduate Nurse Program A hospital-based educationprogram for nurses in their first year of postgraduate clinical practice

HACSU Health and Community Services Union

HECS Higher Education Contribution Scheme (A proportion of the cost of auniversity course charged to the student)

Horizontal Violence Covert or overt harassment perpetrated by nurses against their colleagues

HSUA Health Services Union of Australia

NBV Nurses Board of Victoria

NENA National Enrolled Nurses Association

NHS National Health Service (United Kingdom)

NUM Nurse Unit Manager (formerly Charge Nurse)

Nurse Policy Branch The Branch of Department of Human Services established to coordinateVictorian Government nursing policy

PETE (Office of) Post-Compulsory Education, Training and Employment

OTFE Office of Training and Further Education

Postgraduate A University course undertaken in advanced or specialist practice by a Qualification registered nurse

Preceptor A trained nurse acting in a mentor-type role for a student or new graduatenurse

RCNA Royal College of Nursing Australia

RFM Relative Funding Model

RN Registered Nurse

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RPN Registered Psychiatric Nurse

SCN Senior Clinical Nurse. Proposed title to replace Clinical Nurse Specialist CNS

TAFE Tertiary and Further Education

Telehealth Videoconferencing network

Time in lieu Time taken off to compensate for extra time worked. An alternative to payingovertime rates.

T&D Grant Training and Development Grant

UHCW Unlicensed Health Care Workers, for example, Personal Care Attendant

VET Vocational Education and Training

VHA Victorian Healthcare Association

VHIA Victorian Hospitals Industrial Association

Victorian Deans Victorian and Tasmanian Deans of Nursing of Nursing

VTAC Victorian Tertiary Admissions Centre

VCOPNO Victorian Council of Peak Nursing Organisations

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As a result of a Government initiative toaddress the current shortage of nurses inVictoria, in February 2000, the Minister forHealth established the Nurse Recruitment andRetention Committee. The purpose of theCommittee was to provide advice to theMinister on matters in relation to the registerednurse workforce in Victoria.

The Committee membership was chosen by theMinister for Health and was composed of abroad cross-section of the nursing workforce,drawn from metropolitan and rural clinicalnurses, industrial and professional bodies, thetertiary sector and hospital management.

The Committee focuses on issues relating to theattraction and recruitment of nurses, the exodusof nurses from the workforce, and the retentionof qualified, experienced nurses within thepublic hospital sector.

The Committee established three sub-committees to explore the issues aroundattraction and recruitment, education andretention. Each sub-committee coopted a widerange of specialist expertise from the healthcare and education sectors to add todeliberations. Emphasis was placed onensuring that the rural and regional perspectivewas well represented.

The Committee sought information through aprocess involving an extensive literature reviewand submissions from public and privatehospitals and peak organisations. TheCommittee undertook an exhaustiveconsultation process to access the views ofclinical nurses and conducted a series ofsurveys, focus groups, nine open forums inboth metropolitan and regional Victoria, as wellas consultation with individuals and groups inrelation to specific areas of nursing. All levels ofnurse, in all areas of practice, had theopportunity to bring issues to the Committee.

The Committee handed down an interim reportto the Minister for Health in April 2000. As aresult the of its recommendations, the

Government announced $1 million funding forpublic hospitals and health services to developand run re-entry and supervised practiceprograms to enable nurses who had allowedtheir registration to lapse to regain registrationand re-enter the nursing workforce.

ContextThere is widespread support for the view thatthere are insufficient nurses staffing theVictorian public health care system. TheDepartment of Human Services, in its NurseLabourforce Projections, Victoria 1998–2009 reportof 1999, estimated that with current levels ofdemand for health services, Victoria would facea shortfall of 5,500 registered nurses by 2008.Department of Human Services datademonstrates that, of 69,000 nurses withcurrent registration in Victoria, more than13,000 are not currently employed in thenursing workforce.

While Victoria, unlike many other States andTerritories, has been able to fill places onundergraduate nursing courses, there isconcern that 30 per cent of new graduates ofDivision 1 and Division 2 courses choose not topractise nursing or leave the nursing workforceafter their first year of employment.

The problems facing the nursing workforce arenot unique to Victoria. New South Wales,Queensland, South Australia and WesternAustralia have all conducted and reported onnurse recruitment and retention issues withinthe last five years as have, amongst others, thegovernments of the United Kingdom and NewZealand. The findings of many of these reportsare applicable to Victoria.

The Committee has been hampered by the lackof available nursing workforce data. A reviewof local and international literature has shownthat many state and federal governments haveidentified lack of workforce data and lack ofintegrated nurse labourforce planning as majorimpediments to addressing nursing workforceshortfalls. The Committee makes several

Executive Summary and Recommendations

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recommendations aimed at improving the dataavailable to Victorian labour force planners.

The issues surrounding recruitment andretention of nurses are complex and areinfluenced by a multitude of factors, not all ofwhich are within the scope of governments tocontrol. The ageing of the nursing workforce,the proliferation of career opportunitiesavailable to women, the increasing demandsplaced on the health care system by society,rapid changes in health care technology withassociated requirements for educationalpreparation, and the trend towards communitycare for all but the sickest patient, have a directeffect on the demands made on the nursingworkforce.

This report describes in detail many of theissues that have been brought to the Committeeas pressing issues that need to be addressed toreturn stability to the nursing workforce. Whilesome of the issues apply to clearly definedareas of nursing specialty, there are othergeneral issues which the Committee considersto be of paramount importance, and which areraised in this summary.

During the lifetime of the Committee, theAustralian Nursing Federation (ANF), theHealth Services Union of Australia Number 1Branch (HSUA) and the Health Services Unionof Australia Number 2 Branch (Health &Community Services Union—HACSU) lodgedenterprise bargaining claims on behalf of publicsector nurses in the general and mental healthsectors. There was considerable overlap inmany of the issues considered by theCommittee and those contained in the claims.The claim for general nurses went before theIndustrial Relations Commission for arbitrationin August 2000, and a decision was handeddown on 31 August 2000. A comparison of theCommission’s decision and the Committee’srecommendations is made following the list ofrecommendations on page 32.

WorkloadRepresentations to the Committee from thoseworking in the public hospital system, andthose who have left, make clear the view thatnursing is increasingly becoming physicallyand mentally exhausting. For a variety ofreasons, the workload has increased to the

point where many nurses are no longerprepared to work under the resultant stress. Itis clear that unless workloads are reduced, andnurses feel they have more control over theirworking conditions and environment, there willnot be the attraction for either recruitment orretention in the Victorian nursing workforce.The control of nursing workloads is discussedin section 6.1 of this report.

EducationThe Committee makes recommendations aboutthe educational preparation of nursesthroughout the continuum from undergraduatepreparation to postgraduate, specialisteducation. It is clear that preparation forclinical practice and access to continuingeducation are key factors influencing theretention of nurses. The Committee receivednumerous submissions relating to theundergraduate preparation of nurses,particularly in relation to the transition toclinical practice and ability of new graduates tocare for those with mental illness. In addition,issues relating to the cost of, and access to,postgraduate specialist education have beenconsistently raised with the Committee as acause of stress to the nursing workforce.Education issues are discussed in Chapter 5 ofthis report.

Career StructureThe consultation process has revealed to theCommittee the extent to which the currentcareer structure acts as a disincentive forclinical nurses with skill and expertise toremain in the patient care setting. Theinterpretation of the existing career structure,particularly in relation to Clinical NurseSpecialists (CNSs), and the lack of coherentcareer paths within clinical nursing andmanagement, have led the Committee to makea series of recommendations in section 6.2.

AttritionThe Committee is concerned with the currentrate of attrition from the nursing workforce. Asgraduates decline to enter the workforce, newpractitioners leave the workforce early in theircareers and experienced clinicians reduce theirworking hours or leave nursing altogether,there is concern that losses to the workforce

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will continue to outstrip the number that enter.Of concern are the nurses currently in theworkforce who have indicated their intention toleave the industry within the short term unlesschanges in workload and working conditionsoccur.

Rural VictoriaRepresentations before the Committeehighlighted that the recruitment and retentionissues common in the rural and regional areasare different from those in the metropolitanarea. This report addresses these issues in aseries of specific recommendations.

Specialty AreasThe problems surrounding specialty nursingpractice were highlighted in the consultationprocess. Of particular concern was the inabilityto attract and retain specialist clinical nurseswithin the aged care sector, and the continuingpoor reputation of the specialty amongst manynurses in the acute sector. Mental healthnursing faces similar problems attracting newgraduates into the specialty, and theconsultation process revealed increasingdifficulties retaining experienced staff,particularly in the acute inpatient setting. TheCommittee also identified structural,recruitment and retention issues in the specialtyareas of critical care, emergency, neonatal,medical/surgical, neuroscience, cardiothoracic,perioperative, rural midwifery and renalnursing. However, the Committee concludesthat there are few, if any, nursing specialtiesthat have not experienced some degree ofrecruitment and retention problems in recentyears.

Division 2 Nurses Numerous representations were received fromnurses registered in Division 2. The Committeebelieves that many of the issues for this sectorof the workforce relate to the inherent tensionbetween the desire for extended scope ofpractice held by many Division 2 nurses, andthe requirements of the aged care industry. TheCommittee has identified major problems in thehealth care industry relating to the image ofDivision 2 nurses, amongst both patients andhealth care workers. The Committee takes the

position that the under-utilisation of Division 2nurses has contributed to current problems inthe industry.

Priority of RecommendationsIn order to attract, recruit and retain nurses inthe Victorian nursing workforce, thoserecommendations rated high priority, ifapproved by the Minister of Health, requireimmediate implementation. At thecommencement of the Committee’sdeliberations, it was anticipated that the NursePolicy Branch of the Department of HumanServicesDepartment of Human Services wouldbe in operation some time in September 2000,soon after the report was presented to theMinister of Health. Unfortunately, at the timeof writing, processes are still in progress for theappointment of the Assistant Director, NursePolicy Branch. To expedite the approvedrecommendations, the Committee considers itessential that the Department sets up processesfor the immediate implementation of therecommendations and ensures that there iseffective input from nurses in all phases of thisimplementation. The report contains otherrecommendations that do not require specificimplementation dates. These are listed as longterm priority recommendations.

Recommendations—HighPriorityRecommendation 1That the Department of Human Servicesestablishes mechanisms and strategies to ensurethe immediate implementation of therecommendations approved by the Minister ofHealth and that there be effective nursing inputinto this process through consultation andestablishment of appropriate work groups.

That the Department of Human Servicesmonitors the strategies in relation to workload,working conditions, career structure,qualifications, allowance and study leave asdetermined by the Australian IndustrialRelations Commission (AIRC) and evaluatestheir impact on recruitment and retention ofnurses in the Victorian public health workforce.

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Refresher and Re-Entry

Recommendation 10 (section 4.3.3)That the Department of Human Servicesensures that Group A, B and C public hospitalshave access to refresher and re-entry programsfor Division 1 and 2 nurses, and that regionalmental health services have programs in placefor nurses in Divisions 1 and 3.

Recommendation 11 (section 4.3.3)That Government provides funding toparticipating hospitals of $2100 for each nurseundertaking re-entry programs or accreditedsupervised practice programs.

The following criteria must be met:• Tailored nursing programs must contain

clear learning and performance parameters.• Nurses participating in the re-entry program

will not be charged fees or other costs.• The course must be accredited by the

Nurses Board of Victoria (NBV).

The educational component of the re-entrycourse may involve consortia arrangements asappropriate to local needs.

Recommendation 12 (section 4.3.3)That Government provides funding of $130 perweek Full-Time Equivalent (FTE) to eachunregistered nurse undertaking a re-entryprogram or accredited supervised practiceprogram, in line with current Austudyarrangements. Rural nurses required to travelmore than 100km each way to undertake aprogram will attract $170 per week (FTE), toreflect the increased burden of travel costs onrural nurses.

Recommendation 13 (section 4.3.3) That the NBV review its current policies,procedures and publications in relation torecency of practice requirements.

Recommendation 14 (section 4.3.4): That regionally-based health services establisha uniform approach to refresher programs thatconsider both education and clinicalrequirements of the individual nurse, and mayinclude consortia arrangements as a method ofprogram delivery.

Recommendation 16 (section 4.3.5): That the Department of Human Servicesconducts a statewide advertising programaimed at encouraging both registered non-practising and unregistered nurses to return towork.

Recommendation 15 (section 4.3.4)That Government pays $450 to each healthservice providing refresher or reskillingprograms for every registered nurse notcurrently practising that they place on arefresher or reskilling program.

The following criteria must be met: • Individual nursing programs must contain

clear learning and performance parameters.• Nurses participating in the refresher or

reskilling program will not be charged feesor other costs.

• Nurses undertaking refresher or reskillingprograms are entitled to be paid accordingto the provisions of the Nurses (VictorianHealth Services) Award 1992.

Education

Recommendation 19 (section 5.1.1.1) That the Minister for Health, in conjunctionwith the Victorian Minister for PostCompulsory Education, Employment andTraining, approaches the Commonwealth toreview the funding model for the clinicallearning component of the degree programsleading to nursing registration to ascertain ifthe current level accurately reflects the truecosts of clinical learning programs.

Recommendation 20 (section 5.1.1.1)That nurses undertaking preceptorship roleshave access to suitable education to equip themto perform this role. Funding for theseprograms should be accessed through theundergraduate teaching allowance of theTraining and Development (T&D) Grant.

Recommendation 21 (section 5.1.1.1)That the Department of Human Servicesestablishes a working party with the VictorianDeans of Nursing, Directors of Nursing andother relevant bodies to review the clinicallearning programs in the undergraduateprograms for Division 1 nurses to develop a

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statewide strategy to maximise clinical learningoutcomes.

Recommendation 22 (section 5.1.1.2) That the Victorian Deans of Nursing, throughthe Nurse Policy Branch, develop a group ofrelevant stakeholders (including theprofessional colleges) to review the place of thespecialty components within the undergraduatecourse. This review should investigate thedevelopment of innovative curricula that takesinto account the accommodation of specialistareas through streaming and also considers theappropriate length of funded degree programsleading to nursing registration in the context ofthis issue.

Recommendation 23 (section 5.1.1.3)a) That financial support of $100 per week be

provided to both metropolitan and ruralundergraduate students in their second andsubsequent year(s) of the undergraduatecourse undertaking rural placements, wheresignificant travel and accommodation costsare incurred.

b) That the Department of Human Servicesadminister this initiative using the followingcriteria.

That the student be:• An Australian permanent resident or

citizen undertaking a rural placement inthe second or subsequent year(s) of aBachelor of Nursing program.

• Not in receipt of any other scholarship orgrant for this purpose.

• Required to travel in excess of 100 kmeach way from their usual place ofresidence to attend the rural placement.

• Required to provide supportingdocumentation from the universityacknowledging placement.

• Required to undertake a placement of notless than two or more than five weeks.

c) That the Department of Human Servicesadopts a ‘first come’ basis once equity acrossregions had been achieved for its allocationshould the number of applicants exceed theavailable funding.

d) That the Department of Human Servicesreviews the initiative as a retention strategypaying particular attention to the length ofthe time of the placement.

Recommendation 24 (section 5.1.2.1) That the Department of Human Services,together with the Australian & New ZealandCollege of Mental Health Nurses(ANZCMHN), develops a marketing strategyto attract and recruit nurses into the mentalhealth areas.

Recommendation 25 (section 5.1.2.2.)That all area mental health services (AMHS)offer placements, appropriate to the clinicallearning needs of students, at all stages of theundergraduate course. The requirement foragencies to provide these placements, withintheir service capacity, be incorporated intohealth service agreements between theDepartment of Human Services and theindividual agencies.

Recommendation 26 (section 5.1.2.2) That the Mental Health Branch of Departmentof Human Services coordinates a group ofrelevant stakeholders to review the mentalhealth content—both theory and clinicallearning—of the Bachelor of Nursing coursesand make recommendations to the NBV as tothe guidelines that should be adopted inrelation to mental health content. This processto be completed by June 2001 so that theguidelines developed can be adopted for the2002 academic year.

Recommendation 27 (section 5.1.3)That Department of Human Services convenesan intersectoral steering committee comprisingrepresentatives of vocational education andtraining sector, the health care industry, thehigher education sector, professionalorganisations, NBV, and the Industry TrainingBoard. The role of this group will be to addressthe educational issues associated with thedeveloping role and expanded scope of practiceof the Division 2 nurse. In particular, but notlimited to, the committee should pay attention to:• The need to revise the Certificate IV in

Health (Nursing) curriculum, including theclinical practice component, to reflectrelevant changes flowing from changes inthe scope of practice, new modes of servicedelivery and current areas of practice, thatis, acute care and its specialties, aged care,mental health and community settings.

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• The current credit transfer arrangementsbetween Certificate IV in Health (Nursing)course and undergraduate degrees leadingto registration in Division 1

Recommendation 29 (section 5.2.1.2)That the Minister of Health:a) Approach the Commonwealth government

to increase the number of Higher EducationContribution Scheme (HECS) placesallocated to nursing.

b) Make an approach to the university vicechancellors to increase the number of HECSplaces allocated to nursing within Victorianuniversities.

Recommendation 30 (section 5.2.1.2) To increase uptake of postgraduate places: • That the Department of Human Services

funds scholarships to a maximum of 50 percent of the fee (HECS or full fee) forpostgraduate courses in areas of identifiedneed over the next three years.

• That the Department of Human Servicesestablishes an equitable, transparent processand provides feedback to the profession onthe number of places funded.

• That heath care facilities consider ways toprovide financial support to nurses under-taking such courses in identified areas of need.

• That a minimum of 25 per cent of thesescholarships be allocated to regional/ruralareas.

• That the Nurse Policy Branch monitors thisstrategy and evaluates its effectiveness as arecruitment and retention strategy byDecember 2003.

Recommendation 31 (section 5.2.1.2)That the Victorian Deans of Nursing developoptions to facilitate easier access topostgraduate study, especially through theencouragement of multiple entry and exitpoints, a variety of modes of delivery andsystems that enable maximum recognition ofprior learning, especially learning achievedthrough continuing education modules.

Recommendation 32 (section 5.2.1.2)That the Victorian Deans of Nursing developcollaborative arrangements that maximisepostgraduate courses for smaller specialties andsmall cohort courses.

Recommendation 33 (section 5.2.2) That the intersectoral group inRecommendation 27 also pay attention to the:• Effectiveness of current post-basic modules

and the need for additional modules to meetindustry requirements.

• Recognition of prior learning arrangementsbetween post-basic and continuingeducation undertaken and for post-basicmodules and the Division 1 degree program.

Recommendation 36 (section 5.3.2) That the intersectoral group (Recommendation27) should look to developing programs toassist Division 2 nurses to make the transitionfrom the educational to industry sector duringthe first six months of practice. These programsshould reflect the principles adopted for theDivision 1 graduate nurse program and includea preceptor component.

Recommendation 37 (section 5.4.1) That the Department of Human Services collectdata relating to current expenditure oncontinuing education for nurses in each facility.Through its health services agreements withhealth care facilities, the Department of HumanServices ensures that funding is provided forcontinuing education to a level of 1.5 per centfor metropolitan and two per cent for ruralfacilities based on the budget for the totalnursing EFT across the facility. These funds tobe shown as a separate line item. The T&DGrant for continuing education should becontinued in its present form.

Recommendation 38 (section 5.4.2)That the Department of Human Services: a) Ensures information on existing multimodal

education products and postgraduatemodules and courses be disseminated tohealth care facilities and their nurses via themost appropriate method, such as theClinicians Health Channel.

b) Reviews existing multimodal educationproducts with a view to identifying what iscurrently available, the product’s ability tomeet current industry needs, and to identifyunmet needs. The review should alsoevaluate, as well as recommend, appropriateproducts for multimodal education such astele/video conferencing, distance education

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and CD-ROMs, to fill identified gaps incontinuing education.

c) Explores what is currently available intele/video conferencing facilities in Victoriaand that a strategy be developed to makeeffective use of these as a means of deliveryof continuing education in rural andregional Victoria.

Recommendation 39 (section 5.5.5)That the Department of Human Servicesallocates places for paid study leave for fourhours per week per place for nursesundertaking postgraduate and post-basiccourses by any mode of delivery. Suchallocation is to be based on areas of identifiedneed and EFT with a minimum of 25 per centof the total places allocated to theregional/rural areas and 25 per cent of totalplaces allocated to Division 2 nurses. TheDepartment of Human Services should ensure amechanism for reporting back to the professionon its process.

Recommendation (section 5.5.5)That nurses apply for study leave to theirhealth service or AMHS. Where applicationsexceed allocations, a ranking system be usedincorporating the following principles as guides—length of service, results of performanceappraisal where available and, if not available,their contribution to the service and servicepriority for its areas of need/shortage,including aged care and mental health nursing.

Recommendation 41 (section 5.6.5) That the Department of Human Servicesreviews the T&D Grant in relation to theundergraduate teaching allowance, thegraduate nurse program, and the postgraduateprogram (including midwifery). The reviewshould ensure that: a) The manner in which the Grant is made

available to the hospitals is transparent andacquittal processes ensure the funds areused for their intended purpose.

b) The funding for undergraduate nursing beallocated according to student numbersundertaking placements in a hospital.

c) The medical and nursing components areseparated and the nursing component isshown as a line item in the budget.

d) A nursing reference group is established to

review the graduate nurse programguidelines paying particular attention to:• How the funds are used to support the

new graduate through supervision andpreceptorship

• The capacity to provide for rotations inspecialty areas such as critical care, renal,perioperative nursing

• The provision for both rotations in, andseparate programs for, aged care andmental health as a positive recruitmentstrategy

• Provide for Division 2 nurses.e) A nursing reference group is established to

develop guidelines for postgraduate coursesalong the lines of the graduate nurseprogram, ensuring that the distribution ofthe monies provides for equity betweenfacilities.

f) That allocation to the aged care T&D Grantbe increased as a positive recruitmentstrategy.

g) That the mental health funding beanalogous in structure to the acute T&Dgrant.

h) That the continuing education grantcontinue as it is.

Retention

Recommendation 42 (section 6.1.1.2) That in the absence of statewide workload data,each ward/unit establishes a template for anappropriate workload for that ward/unitconsistent with a ratio ranging from 1:3 to 1:5(excluding the nurse in charge of the am andpm shifts) for the acute generalmedical/surgical wards/units. The NursePolicy Branch reviews the impact of ratios onworkloads until more explicit data are collectedand analysed.

Recommendation 43 (section 6.1.1.2) That the Department of Human Servicesconvenes a working party comprising relevantstakeholders including ANF, HSUA andDirectors of Nursing to jointly:

a) Determine the data needed to evaluate nurse/patient ratios and skill mix across the State.

b) Review available dependency systems and,if needed, commission further studies onsuch systems to evaluate their effectivenessand report back to the Minister for Health.

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Recommendation 44 (section 6.1.1.2) That policies and procedures should be in placeto enable the Nurse Unit Manager andAssociate Nurse Unit Manager (ANUM) tocontrol workloads by adjustment of staffnumbers as appropriate and, where workloadsare unreasonably high, additional staff areunavailable and patient flow cannot becontrolled, that adequate support be given toenable beds to be closed as a last option in thecontrol of workload.

Recommendation 45 (section 6.1.1.2)School holidays are known periods of nurseshortages and that hospitals minimise theamount of elective surgery during such times.

Recommendation 47 (section 6.1.1.3) That health facilities establish a policy thatnursing be undertaken only by those nursesregistered under the provisions of the NursesAct 1993.

Recommendation 48 (section 6.1.2.2) That attention be paid to rostering and that thefollowing principles be implemented:a) Flexibility, fairness and equity of rostering—

through such means as self-rostering and jobsharing.

b) No gaps in the roster caused by short shifts.c) Encouragement of voluntary permanent

night duty, but with access to continuingeducation, periods of day duty andstrategies to avoid a ‘night duty culture’.

Recommendation 49 (section 6.1.2.2)That strategies be put in place by each hospitalto reduce the need for excessive overtime, butwhere it is required, hospitals be reminded oftheir award obligations regarding overtimeprovisions.

Recommendation 50 (section 6.1.2.2) That management encourage Nurse UnitManagers to claim legitimate overtime toensure that a negative culture does not developin relation to payment of overtime.

Recommendation 51 (section 6.1.2.3)That all health care facilities restore an overlapperiod between shifts. The length to bedetermined by local need and the requirement

for sufficient hand-over time, meal relief,undertaking of double duties and provision ofsome in-service education and team building.

Recommendation 52 (section 6.1.2.4) That full-time nursing staff have access to anaccrued day off (ADO), to be taken in a flexiblemanner suitable to the nurse and the localfacility circumstances, and that the Departmentof Human Services adjusts the casemix fundingformula to allow for the full implementation ofADOs.

Recommendation 53 (section 6.1.3.1) Health care facilities ensure that:a) Strategies are being implemented to employ

nurses on a permanent basis to fillpermanent vacancies.

b) Recruitment procedures for replacement ofpermanent positions are developed toensure that such vacancies are filled withineight weeks of notice of resignation.

c) Use of agency nurses is restricted tounplanned absences only.

Recommendation 54 (section 6.1.3.1) That the Department of Human Servicesmonitors statewide trends in agency usage inthe public health care industry on a quarterlybasis.

Recommendation 55 (section 6.1.3.1)That casemix funding be adjusted so thathospital funding is sufficient to ensure thatward/unit budgets and permanent staffingprofiles include provision for leave relief suchas annual leave and ADOs.

Recommendation 56 (section 6.1.3.2)That health facilities are encouraged to (re-)establish Nurse Banks to meet the ad hocstaffing needs of the facility and that thesenurses have access to the ongoing educationprogram of the facility.

Recommendation 58 (section 6.1.4.2) That the Department of Human Services reviewof the Graduate Nurse Program address theissue of the vulnerability of new graduates tophysical and horizontal violence in theworkplace.

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Recommendation 59 (section 6.1.4.2)That provision of formal independentcounselling for victims of bullying andinterpersonal conflict, be available for all nursesworking in the public system. In addition, theCommittee recommends that all nursesworking in the public system have access tocritical incident debriefing services.

Recommendation 60 (section 6.1.4.2)That the Department of Human Services, inconjunction with key stakeholders (whichshould include relevant industrial andprofessional bodies, as well as human resourcesprofessionals and the Victorian WorkcoverAuthority), establishes a review of workplaceculture with the aim of ensuring that eachhealth care facility has in place a formalmechanism for dealing with workplacebullying.

Recommendation 61 (section 6.1.4.2)That the Department of Human Servicesencourages all publicly funded agencies toundertake an appropriately recognised andvalidated staff satisfaction survey on a regularbasis, and that these agencies demonstrate tothe Department of Human Services changesthey have initiated as a result of surveyfindings.

Recommendation 62 (section 6.1.4.3) That all hospitals review their budgetallocations for medical consumables andequipment for nursing care and where thebudget is inadequate, in order to avoid theinefficiencies of practice that results from suchinadequacies, to request that the Department ofHuman Services considers additional financesto restore and maintain medical consumablesand equipment levels.

Recommendation 63 (section 6.1.5.1) That the Department of Human Services, as amatter of urgency, undertakes a review ofnurses’ childcare needs across all sections of thenursing workforce, with a view to formulatinga strategy to best meet assessed needs.

Recommendation 66 (section 6.2.1.1) That the CNS position at Grade 2 year 7 bemaintained in the health care sector and be

used as a strategy for retaining experienced,qualified nurses at the bedside.

Recommendation 67 (section 6.2.1.2) a) That for candidates applying for CNS

positions, hospitals adopt the followinggeneral principles: • Recognition of the Registered Nurses

(Victorian Health Services) Award 1992definition.

• Level of clinical practice reflects the levelof remuneration, that is, higher level ofskill than would be expected of othergrade 2 nurses but less than grade 3positions.

• The primary focus of the position isclinical.

• Criteria for CNS must be achievable innormal paid rostered hours.

• Criteria for performance reviewprocesses be consistent with the reviewprocess of all nurses in the facility.

• Publish criteria for the CNS position.b) Applicants must show a commitment to the

development of an area of specialty, theirown development and the hospital in whichthey are employed, and must demonstrateone criterion in each of the three sections.

Clinical Skill

• Higher levels of skill demonstrated inclinical decision making—in particular inproblem identification and solution, andanalysis and interpretation of clinical data.

• Maintenance and improvement of clinicalstandards.

Professional Behaviour

• Positive role modelling.• Act as mentor or preceptor to less

experienced nurses, including graduatenurses.

• Support of, and contribution to, qualityimprovement and research projects withinthe area of practice and ward/unit.

• Acting as a resource person to others inrelation to clinical practice.

Professional Development

• Membership of relevant professional body. • Contribution to the education of other

professionals, for example, being willing to

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provide at least one in-service educationprogram each year.

• Undertaking own planned professionaldevelopment and competence throughvarious forms of continuing education, suchas conferences, study days, formal study,reading.

c) Department of Human Services to review allcriteria and ensure statewide consistency ofapplication of criteria.

Recommendation 68 (section 6.2.1.3)That as a matter of urgency, the Department ofHuman Services requests that facilities indicatethe number of CNS positions that are neededfor the implementation of recommendation 67above. That data be collected regarding thenumber of CNS positions in the public sector,following implementation of thisrecommendation and that this number is usedas a baseline for the funding of CNS positionsacross the public sector.

Recommendation 69 (section 6.2.1.3)That the Department of Human Servicesrecommends a mechanism to ensure thatadequate funding is provided for the CNSclassifications according to the baseline figuresas established in recommendation 68 above, forthe 2001–2002 financial year and beyond.

Recommendation 71 (section 6.2.1.4):That Victorian Hospitals Industrial Association(VHIA), ANF and the Department of HumanServices develop a CNS stream within theRegistered Nurse Award which ensures thatthere are CNS positions at grades 2, 3 and 4,and that the definition of the responsibilities ofthe Grade 3 and 4 be completed by the end 2001.

Recommendation 72 (section 6.2.2) That in order to ensure an appropriate clinicalcareer path for nurses in Victoria, the partiesrespondent to the Registered Nurses (VictorianHealth Services) Award 1992 remove thecurrent award provision which restricts ClinicalNurse Consultants (CNC) to chemotherapy,stomal therapy, diabetes education andinfection control, to ensure that the CNCposition can be appointed in any clinical area.

Recommendation 74 (section 6.2.4.1)That the senior nurse manager (however titled)be a member of the hospital executive and haverecognized input into resource allocation andutilisation appropriate to the nursing servicesof the facility.

Recommendation 75 (section 6.2.4.2) That all health care facilities ensure thatstrategies are in place for succession planningfor all levels of nursing management.

Recommendation 76 (section 6.2.4.2) That nurse managers have input into thebudget setting process and have responsibilityfor its ongoing implementation.

Recommendation 77 (section 6.2.4.2) That all nurse managers be encouraged to:a) Participate on a regular basis in in-service

education in general, financial and humanresource management.

b) Pursue postgraduate management and haveaccess to paid study leave.

Recommendation 79 (section 6.3.1)a) That clinical supervision for registered

nurses be introduced into the public healthsystem as a strategy for retainingexperienced, qualified nurses in clinicalsettings and that each nurse, regardless offull-time or part-time status, will receive twohours per month of clinical supervisiontime.

b) That funding be provided for theintroduction, implementation andevaluation of clinical supervision forregistered nurses and that the Departmentof Human Services take responsibility forthe allocation of funds and establish aprocess for the allocation to health services.

c) That the Department of Human Servicesevaluates the implementation of clinicalsupervision.

Recommendation 85 (section 6.3.3.4)That the Department of Human Servicesprovides specific funding for the completeimplementation of a no lift program in thepublic aged care sector.

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Recommendations—MediumPriorityData

Recommendation 4 (section 2.2.1)That nurses in education courses be reportedfrom the Victorian Department of Education,Employment and Training to the Departmentof Human Services annually (for Division 1)and six-monthly (for Division 2).

Recommendation 5 (section 2.3)That the Department of Human Services, inconjunction with the NBV, publish the Victorianproportion of the AIH&W labour force statisticsin ‘real time’ as a separate report.

Recommendation 7 (section 2.4) That the Department of Human Servicescommissions regular payroll reports (at leastthree-monthly), reporting total numbers andtotal EFT of nurses by agency by grade, byservice and by full-time or part-time status.

Recommendation 8 (section 2.4) That the Department of Human Servicesrecommends the following changes to theAIH&W annual survey tool:

Q16: To assist workforce planning, mentalhealth be categorised by community mentalhealth and inpatient mental health, andpalliative care to be added as a clinical specialtyin its own right.

Q17: Specify that the post-basic qualificationsbe graduate certificate (including hospital-based courses which predate the transfer ofnurse education to the tertiary sector), graduatediploma, masters, PhD or post-basicTAFE/VET module. This is to exclude‘informal’ courses and in-service educationwhich confound interpretation of Victorianspecialist nurses.

Recruitment

Recommendation 9 (section4.2) That the Department of Human Services:• Liaises with the Careers Education

Association of Victoria (CEAV) andVictorian Directors of Nursing (public andprivate) to increase the provision of the

number and quality of work experienceplaces for Year 10 secondary schoolstudents.

• Explores the feasibility of using the schoolnurse network as a method of raising theprofile of nursing amongst school students.

• Works closely with CEAV to ensure thatteachers have a better understanding ofnursing as a career.

• Undertakes research to prepare a core set ofmaterials to be made available for highschool students describing the role andeducation pathways for nursing. Thematerials should emphasise the variety ofclinical settings, should avoid gender andracial stereotypes and should give equalprominence to Division 1 and 2 educationpathways. The materials should also beavailable in both paper and electronicformats.

• Seeks advice on materials and strategies toattract people in age groups other thantraditional school leavers to considernursing as a career.

Recommendation 17 (section 4.4)That the Department of Human Servicesexplores the extent to which return to workprograms for injured nurses have beenimplemented in public health care facilities inVictoria.

Education

Recommendation 18 (section 5.1.1.1)That the Victorian Deans of Nursing carry out amapping exercise to ascertain both theavailability of clinical placements within thehealth system and the requirements of thestudents for such placements. The results ofsuch a project should form the basis for theestablishment of a coordinated system tofacilitate bookings and placements of allundergraduate nursing students.

Recommendation 28 (section 5.1.3) That the Minister of Health recommends to theMinster for Post Compulsory Education andTraining that the level of funding for theCertificate IV in Health (Nursing) reflect therequirements for registration.

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Retention

Recommendation 46 (section 6.1.1.3) That each facility undertakes a review ofactivities, such as telephone answering, routineclerical activities and some housekeepingactivities, such as unmade bed making, andrecommend to the Department of HumanServices strategies that will either introducesuch positions in addition to nursing positionsthat assist the nurse at ward/unit level, orextend the hours of such assistance asnecessary.

Recommendation 64 (section 6.1.6) That the Department of Human Services, inconjunction with its regional offices, establishwork groups of relevant stakeholders to: • Develops strategies to provide support and

peer review opportunities for nurses in ruralhospitals.

• Explores the establishment of a locum nursebank in rural areas where relieving nursesare not available and develop marketingstrategies and an incentive scheme for thebank

• Examines the security risks for nursesworking in both the hospital andcommunity in rural regions and develop astatewide policy with strategies such astraining programs, use of two staff whereappropriate, suitable vehicles,telecommunication devices and safetyequipment and personnel for securitymanagement and risk minimisation.

Policy and strategy implementation and theiroutcomes to be reported to the Department ofHuman Services Nurse Policy Branch.

Recommendation 65 (section 6.1.6.1)That regional and rural health facilities ensurethat classification structures in rural areasadequately reflect the levels of responsibilityassociated with the isolated environment inwhich nurses practise and is no less thancomparative services/functions in themetropolitan areas.

Recommendation 70 (section 6.2.1.4) That the parties respondent to the RegisteredNurses (Victorian Health Services) Award 1992work towards a consent award variation,

whereby the title ‘CNS’ be changed to SeniorClinical Nurse (SCN) to more accurately reflectthe expectations of the position.

Recommendation 73 (section 6.2.3.1) That ANF, HCSUA, VHIA and Department ofHuman Services establish a suitable mechanismfor recognising postgraduate qualifications fornurses within areas of nursing at specific levelswithin the context of the career structure. Untilthis mechanism is established and qualificationsare recognised in this process, an interimqualifications allowance for nurses should beintroduced, similar to that of other healthprofessionals in Victoria for qualificationsrelevant to the area of current practice.

Recommendation 78 (section 6.2.4.2)That rural and regional hospitals explorestrategies to ensure that there is training anddevelopment for ANUMs to facilitatesuccession planning to Nurse Unit Manager(NUM) positions and that, where appropriate,consideration be given to jobsharing within theNUM position.

Recommendation 80 (section 6.3.2)That health agencies be encouraged to considerwhether there are opportunities to employDivision 2 nurses in the acute sector inpositions currently not filled by Division 2nurses.

Recommendation 81 (section 6.3.2) That the Department of Human Servicesconsiders a campaign amongst Division 1nurses, undergraduates and the wider healthcare industry, to promote a betterunderstanding of the role of Division 2 nurses.

Recommendation 82 (section 6.3.3.1) That ongoing in-service education be providedin the public aged care sector (nursing homesand hostels) and that resources be sufficient forthis activity.

Recommendation 83 (section 6.3.3.2) That the Department of Human Servicescollects data relating to the staffing mix in thepublic aged care sector and, in particular,identifies:

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• The number of CNS positions requiredfollowing the implementation ofRecommendation 68 and ensures that thisnumber be used as a basis for the funding ofCNS positions.

• The number of CNC positions, especially,but not limited to continence management,and dementia care.

• Nurse practitioner roles as they areimplemented and evaluated as part of theGovernment’s funding of nurse practitionerprojects.

Recommendation 84 (section 6.3.3.3)That the State Government recommends to theCommonwealth Government that thedocumentation required for the ResidentialClassification Index Tool currently being usedin the aged care sector be simplified, to reducethe documentation required to allow more timefor nurses to be able to deliver direct patientcare. The Committee recommends that theVictorian Minister for Health raises this issue atthe Australian Health Ministers AdvisoryCouncil (AHMAC) to seek the support of otherState Governments.

Recommendation 86 (section 6.3.4)That the Department of Human Services,together with key stakeholders, collects datarelating to the recruitment and retention ofmidwives in rural areas and the implementedstrategies be evaluated by the Department ofHuman Services.

Recommendations—Long TermPriorityRecommendation 2 (section 2.1.11) That the Commonwealth include all States andTerritories, and all relevant nursing peakbodies, in its new Health Workforce AdvisoryCouncil when issues relating to nursing areconsidered.

Recommendation 3 (section 2.1.11)That notwithstanding local initiatives, theVictorian Government continues to lobby theCommonwealth to coordinate issues relating tonursing workforce planning for which it hasresponsibility, including the tertiary educationof nurses, migration policy and aged carenursing.

Recommendation 6 (section 2.3)That the Department of Human Services makesavailable to the Victorian Department ofEducation, Employment and Training nursinglabour force statistics, on a regular basis, toassist in the provision of postgraduate andpost-basic specialty nurse course planning inthe university and VET sector.

Recommendation 34 (section 5.2.2)That the Department of Human Servicesevaluates the effectiveness of the provision ofscholarships for Division 2 nurses to undertakepost-basic modules as a recruitment andretention strategy by December 2003.

Recommendation 35 (section 5.3.1)That the Department of Human Servicescommissions and funds a research project toevaluate differing models of preceptorshipwithin Graduate Nurse Programs in order toidentify best practice.

Recommendation 57 (section 6.1.4.1)That the Department of Human Services, inconjunction with key stakeholders, evaluateswork currently in progress in the health careindustry to assess the prevalence and control ofworkplace violence (physical and verbal) bothdirected at nurses, and from within nursing,and to consider whether a coordinatedstatewide campaign is required.

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Running in parallel to the work of theCommittee was a round of negotiations for anenterprise agreement being conducted by theANF and HSUA. Because of its focus on nurserecruitment and retention, the Committeeaddressed several of the matters that wereincluded in the ANF claim.

The negotiations over the claim resulted inindustrial action being taken and the matterswere forwarded to the Australian IndustrialRelations Commission (AIRC). CommissionerBlair handed down a ruling on the issues on 31August 2000. As indicated below, of the mattersin the claim that were being addressed by theCommittee, some were in accord, others agreedin part, but in some areas the Committee chosea different approach from the unions. These areshown in Table 1.

In terms of recruitment and retention, there isno doubt that short term measures arenecessary to ensure that the workload isreduced and that working conditions are mademore attractive to recruit nurses back into theworkforce and to retain those nurses who arethere.

WorkloadsThe AIRC and the Committee considered nursepatient ratiosThe AIRC established fixed ratiosfor different hospitals and some specialty areas.The Committee considered that more flexibilityshould be introduced and that the judgment ofthe NUM should be recognised as an importantfactor. Therefore, the recommendations of theCommittee include a range of ratios and theuse of local templates. While both groupsconsidered bed closure, the approach by theCommittee allows for more flexibility at thelocal level, without compulsory involvement ofthe ANF.

Given the lack of data on which measurementof workload is based, both groupsrecommended the establishment of a workingparty to examine workload issues. Until suchdata are derived, the Committee saw a need for

the Department of Human Services to monitorthe impact of the ratios on workload prior tothe reporting of such a working party.

A fixed skill mix was decided by the AIRC, butthe Committee considered that there wereinsufficient data available to make suchjudgments across the range of clinical settings.It therefore recommended that data be collectedprior to the establishment of fixed skill mixratios. The Committee recommends that theimposition of a skill mix ratio be monitoredprior to the establishment of a firm database foran appropriate skill mix in the different clinicalareas.

Workload can be affected by not only the skillmix, but also the assistance available to thenurse. The Committee has also recommendedthat consideration be given to either theintroduction or, where already available, anextension of the hours of the position termed‘ward assistant’ or ‘ward clerk’. In this way,some of the activities of the nurse can bedelegated to enable the nurse to focus onnursing activities.

Working ConditionsBoth groups urged the filling of permanentpositions, the use of nurse bank where interimvacancies occurred, and the use of agencynurses for ‘ ‘unexpected” or ‘ ‘unplanned’’vacancies only. Similarly, both groups saw aneed to restore the ADO as a strategy toencourage nurses to fill full-time positions. TheCommittee, however, emphasised the need forflexibility in implementation of the ADO tomeet both local needs and the needs of theindividual. While the AIRC ruled in favour ofrestoring the 8:8:10 rosters, the Committee sawthis as too rigid. Underlying the notion of the8:8:10 rosters is an overlap period and theCommittee considered that there should be adegree of flexibility in that period, notnecessarily tied to the fixed rosters. AIRCdecided on the inclusion of a secret ballot ofward/unit nurses if alternatives to the 8:8:10were being considered.

The Nurse Recruitment and Retention Committee and the EnterpriseAgreement for Nurses

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The Committee heard many arguments forflexibility in rostering and notes that the AIRCrecommended local discussion about part-timerosters. The Committee introduced principles tobe considered, to ensure that there wasmaximum flexibility in relation to the length ofshift and the number of days worked. Suchflexibility was seen as one of the mostimportant factors in recruiting nurses back intothe workforce. Both groups recognised theproblems associated with night duty althoughthe Committee was in a position to consider awider range of issues other than increasedallowances.

Both groups recognised the need to collectworkforce data on a regular basis.

Study LeaveBoth groups recommended four hours studyleave for 26 weeks for postgraduate studies.The AIRC also decided to introduce two dayspaid study/conference leave and three dayspaid professional development leave. TheCommittee addressed the matter of funding forboth these activities in some of itsrecommendations.

Career StructureUnlike the AIRC, the Committee consideredthat it did not have enough data to support theappointment of a full-time Grade 7 (DoN) andGrade 6 (Deputy DoN) on each campus, butrather saw the need for such data to becollected. In relation to Grade 5 (AssistantDoN) positions , while data before theCommittee indicated that the shortfall could bein the vicinity of 200 positions. It welcomes theadditional 50 positions as a starting point . Bothgroups saw the need for further data collection.The issue of full-time charge nurses (NUMs) isagreed by both groups, however, informationbefore the Committee strongly indicated theneed for joint appointments in rural andregional areas to overcome the shortage ofattracting nurses on a full-time basis.

In relation to Nurse Educators, the Committeeheard considerable anecdotal information on aperceived shortage of nurse teachers. However,information gathered by survey indicated asmall deficit only.

Both groups supported removal of thelimitation of areas of practice of the CNC andthe Committee demonstrated the shortage inthe area and welcomes the introduction of 50EFT positions. However, the AIRC did notaddress the need to review the definition andclassification of the CNC and its relationship tothe CNS position. The CNC, by definition,requires the nurse to reduce or be removedfrom a direct hands-on clinical role. The AIRCfailed to respond to what the Committee heardas a very strong position—the need for clinicalnurses to have a career pathway that retainedthem at the bedside. The Committee sees astrong need for the introduction of a CNSposition that recognises advanced and expertpractice rewarded at Grades 3 and 4.

Both groups agreed that the current CNSpositions should remain and that nurses whomet the current definition and the criteria (asidentified by the Committee), should beappointed to the position. The Committee,however, was made aware of the difficulties ofthe current definition, that is, its focus onexperience or qualifications and its failure torecognise advanced and expert levels of clinicalpractice. The Committee is firmly of the viewthat clinical nurses are more likely to remain inthe workforce if they have the opportunities ofpromotion beyond Grade 2 and their advancedand expert level skills, normally acquiredthrough both qualification and experience, arerecognised and rewarded through this pathway.The Committee was also of the view that ifsuch a pathway were introduced it wouldremove the need for a qualification allowance.The Committee saw the qualification allowanceas an interim measure only, with a longer termsolution of a strong clinical career pathway.

In the areas considered by both the Committeeand the AIRC, it would be appropriate tomonitor their impact on recruitment andretention.

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Recommendation 1:

That the Department of Human Services establishes mechanisms and strategies to ensure theimmediate implementation of the recommendations approved by the Minister of Health andthat there be effective nursing input into this process through consultation and establishmentof appropriate work groups.

That the Department of Human Services monitors the strategies in relation to workload, workingconditions, career structure, qualifications allowance and study leave as determined by the AIRCand evaluates their impact on recruitment and retention of nurses in the Victorian public healthworkforce.

Table 1: Comparison between Decisions of the AIRC and Recommendations of the Committee

a. AIRC Decision b. Committee Recommendation c. Comment

Workload Issuesa. Fixed nurse/patient ratios for Group A–D hospitals and other areas.b. Workload templates, range of ratios 1:3 to 1:5.

Department of Human Services monitors impact of workload.c. Committee recognises Nurse Unit Manager expertise and introduces flexibility.

Need for evaluation of strategy.

a. Working party to examine workload issues.b. Working party evaluate data and review dependency systems.c. Longer term strategy to determine basis for workload measurement.

a. Bed closure automatic local implementation Committee.b. Bed closure as last resort with local Committee.c. Recognition of Nurse Unit Manager expertise.

a. Fixed skill mix.b. Collect data.c. Not enough data to make recommendation.

Working Conditionsa. Return of Accrued Day Off (ADO) for full-time staff.b. Access to ADO by full-time staff taken in flexible manner.c. Flexibility important.

a. 8:8:10 rosters with secret ballot if alternative required.b. Flexibility, fairness and equity in rosters.

Restore overlap period.c. 8:8:10 too rigid and flexibility needed in overlap period.

a. Discussion locally re: part-time rosters.b. Rosters flexible, fair and equitable with no gaps.c. Need for flexibility re: short shifts and number of days worked.

a. Department of Human Services collects workforce data especially full-time/part-time toprovide to ANF.

b. Department of Human Services commissions regular payroll reports—agency, grade, service,full-time/part-time to feed into workforce planning.

c. Clear need for additional data.

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a. Increase night duty/permanent night duty allowances.b. Recognition of issues of rotating night duty and night duty culture.c. Committee comments on range of issues around night duty.

a. Encourage permanent staff, use bank staff in interim and agency for unexpected vacancies.b. Employ permanent staff, encourage nurse banks, agencies for unplanned absences only.c. Issues complex.

Career Structurea. Full-time Director of Nursing (DoN) each campusb.c. Encourage, but not enough data before Committee to make recommendation.

a. DoN on Exec Committee, hospital decision.b. DoN on Exec Committee.c. Essential strategy of resources to be adequate for nursing.

Not enough data available.

a. Deputy DoN, some >30 beds may appoint on each campus.ADoN collect data current situation. Appoint 50 FTE.

b. Department of Human Services investigate if a need.c. Data shows shortfall could be around 200 FTE.

a. Full-time NUMs necessary.b. Department of Human Services collects data for baseline figure and then appoints in areas of

need.c. Difficulty attracting full-time NUMs, joint appointments under principles needed.

a. Nurse educators—collect data, appoint 50 EFT.b. Rural/regional areas consider joint appointments for NUM positions.c. Survey established only a small need for nurse educators.

Also recommended a revision of definition and classification.

a. Remove restrictions on CNC role.b. Remove restrictions on CNC role.c. No recommendation made, but survey identifies need for small number of additional

positions.

a. Department of Human Services determines current situation, appoint 50 EFT.b.c. Being used as recruitment and retention strategy especially critical care.

a. Appoint Clinical Nurse Specialist (CNS) if meet definition and criteria.b.c. Rewards years of experience only. Does not extend clinical career path.

a. Increments grade 2 to year 7 and 8b. Department of Human Services establishes base line for all who meet definition and criteria

and ensures funding.c. Recognises value of qualified experienced clinical nurse. Retain at bedside. AIRC failed to

recognise CNC not direct clinical role and no progression available for nurse to stay atbedside. Long term retention strategy.

b. Extend CNS to grades 3 and 4. c. Recognition of qualification via a clinical career structure has higher potential of retaining

clinical nurses in longer term.

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a. Return of qualifications allowance.b. Interim qualification allowance and qualifications built into extended clinical career structure.

Leavea. 4 hrs for 26 weeks for postgraduate study.b. 4 hrs for 26 weeks for postgraduate study.

a. 2 days paid study/conference leave.

a. 3 days paid professional study leave.b. 2 hours per month clinical supervision time.

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As a result of a Government initiative toaddress the current shortage of nurses inVictoria, the Minister for Health established theNurse Recruitment and Retention Committee inFebruary 2000. The purpose of the Committeewas to provide advice to the Minister onworkforce matters in relation to the registerednurse workforce in Victoria.

Recommendation 1: That the Department ofHuman Services establishes mechanismsand strategies to ensure the immediateimplementation of the recommendationsapproved by the Minister of Health andthat there be effective nursing input intothis process through consultation andestablishment of appropriate work groups.

That the Department of Human Servicesmonitors the strategies in relation to workload,working conditions, career structure,qualifications allowance and study leave asdetermined by the AIRC and evaluates theirimpact on recruitment and retention of nursesin the Victorian public health workforce.

As part of its terms of reference, the Committeewas to provide a report to the Minister forHealth by 30 April 2000 and a final report by 31August 2000. The terms of reference areattached as Appendix 1.

1.1 Committee ProcessThe purpose of the Committee was to provideadvice to the Minister for Health on workforcematters and to address the shortage of nurses inthe short, medium and long term.

1.2 Committee MembershipThe Minister for Health appointed members tothe Committee. The membership was selectedfrom representatives of the unions: AustralianNurses Federation, Victorian Branch (ANF) andHealth Services Union Australia BranchesNumber 1 (HSUA) and 2 (Health &Community Services Union). In addition,representatives from the Royal College of

Nursing Australia (RCNA), Australian Collegeof Nurse Management Inc (ACNMI), Victorianand Tasmanian Deans of Nursing and theVictorian Hospitals Association (VHA) wereappointed, as were a number of nurse cliniciansfrom metropolitan and rural hospitals. Anindependent chair was appointed.

1.3 Establishment of Sub-CommitteesIn order to achieve the terms of reference in anefficient manner, three sub-committees wereestablished, namely Attraction andRecruitment; Education; and Retention.Members of the Committee were asked toindicate on which sub-committee they wouldlike to serve. The chair of the Committeeappointed chairs to the sub-committees, andeach sub-committee had the power to cooptother persons on either a permanent ortemporary basis. (A list of members andcoopted members are attached as Appendix 2.)

1.4 Information Collection andConsultationProcessThe Committee’s terms of reference includedthe requirement to engage in ‘a process ofconsultation with relevant bodies andorganisations in Victoria and withCommonwealth departments’. To this end, thefollowing processes were established:

A call for submissions from DoNs of health carefacilities in the public and private sectors, andfrom peak nursing (and medical) organisations.In the submission, information relating toissues of attraction and recruitment, educationand retention was called for, as was aninvitation to indicate strategies that wereproving successful in the three areas. A list ofthose organisations which providedsubmissions is attached as Appendix 7.

A number of individual current and formernurses made written submissions to theCommittee.

1. Introduction

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In addition to submissions, the Committeesought face-to-face meetings with several peakbodies—Australian College of Midwives Inc,Australian and New Zealand College of MentalHealth Nurses, Victorian Perioperative NursesGroup, Enrolled Nurses Special Interest Groupand Australian College of Critical Care Nurses(ACCCN)—as well as a specially convenedgroup of representative NUMs, to expand onissues raised in submissions and to discuss arange of professional workplace issues.

The Committee was keen to seek the views ofnurses who maintained registration with theNBV but who chose, for whatever reason, notto practise as a nurse. To this end, theCommittee commissioned Campbell Researchand Consulting to survey a sample of thisgroup of nurses. The reports resulting from thesurvey are attached (appendices 3 and 4).

The Committee also sought the views of nurseswho have allowed their registration to lapse. Acall for expressions of interest was made vialocal and statewide newspaper advertisements.

The Committee sought information on a rangeof professional issues pertaining to currentlyregistered nurses and ex-nurses. A series offocus groups were held in Melbourne andShepparton with participants from throughoutVictoria. The Committee commissionedResearch International to undertake this project.The report of the focus groups is attached asAppendix 6.

Public consultation forums for all Victoriannurses employed as grades 1 to 4 in Divisions 1to 4 were held at the following venues:

31 May 2000 Parkville Royal MelbourneHospital

5 June 2000 Traralgon Latrobe RegionalHospital

7 June 2000 Hamilton Western DistrictHealth Service

8 June 2000 Heidelberg Austin andRepatriationMedical Centre

14 June 2000 Bendigo Bendigo HealthService

15 June 2000 Clayton Monash MedicalCentre

19 June 2000 Prahran Alfred Hospital

28 June 2000 Mildura Mildura BaseHospital

6 July 2000 Benalla Goulburn OvensInstitute of TAFE

The Committee commissioned an independentfacilitator from the Union Research Centre onOrganisation and Technology (URCOT) to runthe forums. The report on the consultationprocess is attached as Appendix 5.

The Committee generated a number of surveysof hospitals, health care services and educationfacilities. The surveys sought a range ofinformation on such issues as vacancy data,refresher and re-entry course provision,postgraduate nursing course places, post-basicmodules for Division 2 nurses, Division 2articulation courses, senior nurse (grades 5, 6and 7) positions, paid study leave provision,clinical nurse specialist positions and agencynurse usage.

The Chair of the Committee and the Chair ofthe Retention sub-committee met with DoNsfrom rural and metropolitan Victoria. Inaddition, the Chair of the Committee addresseda recruitment and retention summit in Alburyat the request of Greater Murray Area HealthServices.

1.5 ContextDuring the lifetime of the Committee, severalenterprise agreements in the nursing sectorexpired. As a consequence, the ANF (VictorianBranch) and HSUA No 1 Branch lodged anenterprise bargaining claim for general nursesin the public sector, and HSUA No 2 Branch(Health & Community Services Union) andANF (Victorian Branch) lodged a claim onbehalf of nurses in the public mental healthsector. The Committee was mindful that someof the issues contained in these claims bore adirect relationship to its terms of reference. Acomparison of the Committee’srecommendations and the decision of theIndustrial Relations Commission in relation tothe ANF claim is in the executive summary.

In addition, during the lifetime of theCommittee, the Minister for Health released theVictorian Nurse Practitioner Project: Final Reportof the Taskforce December 1999 (Department of

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Human Services 2000), and announced thedevelopment of an implementation strategy toprogress the role of nurse practitioner inVictoria.

1.6 Report StructureThis report will be presented in two parts, assix chapters. Part 1 will outline the problemsfacing nursing in Victoria while Part 2 willpropose a range of strategies to deal with theproblems.

Part 1Chapter 2 of this report presents an overview ofavailable international and local literature onnursing supply and examines the supply ofnurses in Victoria through the tertiaryeducation sector, through migration, andthrough re-entry to the workforce. Indicators ofnursing shortage are critically examined andrecommendations are made on a range of issuesrelating to nursing workforce data.

Chapter 3 presents an overview of currentproblems in nursing, as relayed to theCommittee through its consultation process,and through recent literature. Issues relating toworkload, the working environment, ruralisolation, specialty issues and management arepresented.

Part 2Chapter 4 presents a range of strategiesdesigned to attract nurses into the workforce.Attraction of school students into Division 1and 2 training and attraction of nurses nolonger in the workforce back to nursing arediscussed.

Chapter 5 examines issues relating to nurseeducation. The T&D Grant, the StateGovernment’s education framework for publichealth facilities, is described, and strategiesrelating to Division 2, Division 1, graduate year,postgraduate and continuing education arerecommended.

Chapter 6 puts forward a range of strategies toaddress the problems raised in chapter 3. Theclinical career structure, workload,management issues, workplace safety and leaveentitlements are discussed, and recommendationsrelating to these issues are presented.

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Part 1—The Scope of the Problem

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2.1 The International ExperienceThere is a wide body of international literaturesuggesting a shortage of nurses in many partsof the world, including Africa, the UnitedKingdom, Denmark, Israel, Italy, Norway andthe Middle East, countered by a surplus insome Asian nations, such as the Philippines(Oulton 1998). Many national and stategovernments have instigated reviews ofnursing and have raised issues which arerelevant to the Australian context and areconcordant with submissions made to theCommittee. The key findings of relevantinternational studies are summarised below.

2.1.1 United KingdomWarnings about the impending shortage ofnurse supply in the United Kingdom had beensuggested since the mid 1980s (Reid 1986) anda steady decline in registered nurse numbersreached its nadir in 1998 (247,200). By the mid-1990s, the Government’s Audit Commissionhad highlighted the economic cost to the stateof preventable staff attrition and urged thatpolicies be put in place in National HealthService (NHS) Trusts to minimise staff turnover‘based on an understanding of the views andaspirations of staff’ (While & Blackman 1998).

Buchan & Edwards (2000) report that Britainhas a serious shortage of nurses, both in overallterms and in areas of specialty, with a decline innursing registrations of 6000 between 1990 and1998 (approximately 0.9%). Factors cited for thedecline included systemic issues such as greaterthan expected demand for nurses outside of theNHS, uncoordinated nurse training andworkforce planning, increased demand forhealth care and an ageing workforce, as well assubjective factors such as poor workenvironments. The paper noted that the BritishGovernment had called for the creation of15,000 new nursing positions and 6,000 newtraining places to address the current andanticipated shortfall, although the lack ofintegrated workforce planning in Britain meantthat it was unclear what specialist skills the

nurses should have, and into which worksettings they should be recruited.

The English Department of Health, in itsMaking a Difference Report (Department ofHealth 1999), identified the following issues asmajor problems in nursing:• Pay. Identifying problems with local pay

arrangements the Department’s firststrategy was to implement in full a payreview body recommendation for anunstaged cross sector pay rise.

• Safe workplace issues. The Departmentnoted increasing assaults against nurses byclients, and an increase in workplace relatedinjuries. It was noted that Englishmagistrates have been directed by the LordChancellor to treat assaults on nursesperforming NHS duties as an aggravatingfactor when sentencing offenders, and statedthat the view that assault is ‘part of the job’is no longer to be tolerated in health care. Inaddition, strategies to address back injuriesamongst nurses were recommended.

• Re-entry to the workforce. The Departmentidentified that 80% of non-working nurseswished to return to nursing and places for2,800 nurses on return to practice courseswere created as part of a nationalrecruitment campaign.

• Career structure. The Departmentconcluded that the existing career structurecreated barriers to promotion and jobsatisfaction, and was effectively under-funded. It recommended a simplified,articulated four-tier career structurecomprising health care assistant, registeredpractitioner, senior registered practitionerand consultant practitioner.

• Leadership. The report recognised problemswith nursing leadership, particularly at unitmanager level, and a direct relationshipbetween poor leadership and poorstandards of patient care. It recommendedsuccession planning, a framework forclinical supervision (statutory for midwives)and greater representation for ethnicminorities in leadership roles.

2. Nursing Shortages

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• Student preparation. The report identifiedproblems with the provision and quality ofclinical placements for student nurses. Itcalled for longer clinical placements in asupported learning environment (thecurrent curriculum requires 50% of thecourse be spent in clinical placements).

• Recruitment and retention. The Departmenthas established a permanent recruitmentand retention section within the NHSexecutive to oversee the nursing workforce.

The Department recognised, in its response tothe Health Committee in the Report on FutureStaffing Requirements (Department of Health1999), that a long term strategy to avoid futurestaffing shortage would involve abandoninglocal pay arrangements in favour of centralised,industry-wide pay reviews (p. 15), and wouldhinge on effective forward planning of theworkforce. The response also noted that, as aresult of a return to nursing campaign, theDepartment had received calls from 5,000nurses enquiring about returning to work in theNHS.

Although it is premature to fully evaluate theeffectiveness of the British campaign, it isapparent that there are many parallels to bedrawn between the problems encountered inthe NHS and the Victorian health care system.

2.1.2 IrelandThe Report of the Commission on Nursing (1998)dealt predominantly with the evolving role ofnurses in the overall management of healthservices, structural and work changes innursing and barriers to promotion. It includedan examination of the nurse manager role andan examination of the nurse educationframework, including professionaldevelopment. Although many of therecommendations are specific to the Irishcontext, it is noted that many submissions tothe Commission complained of bullying in theworkplace (s11.9–11.11), and the reportrecommended the introduction of formal andinformal workplace procedures to deal with theissue.

2.1.3 The United StatesIn the United States there is an estimated 2.55million registered nurses, of whom 83% areestimated to be working in nursing (Moses

1998). Several studies have indicated a loomingnational shortage of nurses due to the ageingworkforce, particularly in specialty areas suchas critical care where what is described as the‘baby boom nurse supply’ is waning (Buerhaus,Staiger & Auerbach 20001). In addition, careerchoices for women are expanding, therecontinue to be changes in technology anddisease patterns, and increasing demand fornurses is outstripping university supply(Buerhaus 1998, Buerhaus, Staiger & Auerbach20002). Others have indicated a potentialoversupply of nurses due to hospitaldownsizing and the inability of the communitysector to absorb redundant nurses (Pew HealthProfessions Commission 1995). Despite the lackof consensus on the national supply of nurses,most commentators agree on the need forinterdisciplinary workforce planning at bothnational and local level (American NursesAssociation www 1999).

Because of differences in health care deliveryand population patterns between states,nursing supply issues in the United States havebeen dealt with predominantly at a local level.In California, in an attempt to identify whetherthe state was facing an emerging shortage,Coffman & Spetz (1999) conducted alongitudinal analysis of the 230,000 registerednurses in that state. It was found that most ofthe nurses were working in nursing (77% full-time) and that, of the remainder, most werelikely to re-enter the labour market. With anestimated 23% growth in the state’s populationthe study concluded that 43,000 nurses wereneeded by 2010 and a further 74,000 by 2020.The study concluded that the labour marketwas unable to resolve the demand issuewithout government intervention and fundingfor basic RN programs (to educate beginningpractitioners). The study recommended thatefforts should be made to increase the ethnicdiversity of the Californian nursing workforceto reflect the state’s ethnic and racial diversity.

In the American context, recruitment andretention strategies have for many years beenlinked to the concept of magnet hospitals. Theconcept arose from the observation that, duringthe 1980s, a group of hospitals demonstrated nodifficulty in attracting and retaining staff,thereby being designated as ‘magnets’ (Scott,Sochalski & Aiken 1999). The designation is

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now formalised as magnet hospitals are subjectto a credentialing process by the AmericanNurses Credentialing Center, with the aim ‘toattract and retain professional nurses andthereby provide quality patient care throughnursing excellence’ (American NursesAssociation www 2000).

Research has identified common attributesshared by magnet hospitals, and the linkbetween the attributes and patient outcomes.The essential shared characteristics of magnethospitals are:• Autonomy of nursing practice. The nurses

in a magnet hospital have the ability tomaintain control over work, both in relationto decision making affecting patient careand organisationally in terms of practiceenvironment, such as staffing levels (Scott,Sochalski & Aiken 1999). This is deemed themost important single factor in the magnethospital model (Havens & Aiken 1999).

• Leadership. The role of nursing leadershipis emphasised in the magnet hospital model.Nurse leaders act as advocates for staff,maintain high educational and clinicalstandards and are accessible to staff, as wellas acting as role models. Nurse leaders havea formal role in organisational decisionmaking, within flat management structures(Havens & Aiken 1999).

• Interdisciplinary relationships. Goodworking relationships and communicationbetween nursing and medical staff are citedas a key element in nursing job satisfaction(Aiken, Smith & Lake 1994).

• Staff retention. Demonstrably lowervacancy rates and staff turnover rates haveconsistently been noted in magnet hospitals(Kramer 1990).

While research into magnet hospitals continues,and interest in adoption of the model spreadsoutside of the United States (Havens & Aiken1999), there is already sufficient evidence todemonstrate a direct relationship between theability of a nurse to organise his or her workand a variety of organisational and patientcentred outcomes. However, as Torrance &Wilson (2000) caution, any application of themagnet hospital model to Australia should becognisant of the fact that it is more than just aframework for industrial reform.

2.1.4 CanadaCanada has a similar health care structure toAustralia and has traditionally recruited from,and lost nurses, doctors and allied healthpractitioners to, Australia.

One study, which described the Canadiannursing workforce, showed that nearly 25% ofall nurses were aged over 50 years (CanadianInstitute for Health Information 1999), andfewer than 10% were aged below 29. Usingthese data, the Canadian Nurses Association(CNA) has predicted a shortfall in nurses inEnglish speaking provinces of between 59,000and 113,000 by 2011, with Quebec predicting ashortfall of 11,000 between 2001 and 2015(British Medical Journal 2000). The CNA alsopoints to the lack of available full-time work fornurses, coupled with downsizing of thehospital sector, as disincentives for newgraduates to remain in nursing as a career.

The CNA has responded with a call for theCanadian Federal Government to becomeinvolved in coordination of national nursingissues relating to population health and healthprotection (nursing is currently seen asprimarily a state responsibility), and iscampaigning for funding to support nursingresearch and development so that the publiccan be informed about what nurses contributeto the health care sector.

2.1.5 New ZealandIn 1998, the New Zealand Governmentestablished a ministerial taskforce on nursing torecommend strategies to deal with barriers tonursing. Although the taskforce dealt primarilywith a range of professional issues, the finalreport (Ministry of Health 1998) identified aseries of structural workforce barriers thatplaced stress on nurses. These included:• The inability of health care managers to

measure workload and skill mix. • Increasing patient acuity. The report

advocated the development of a nationallyconsistent system to recognise patient acuityand the corresponding nursing skill mixrequired to care for patients.

• Lack of recognition of nursing leadership.• Increased use of casual staff.• Increased difficulties in retaining nursing

staff.

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• The inability to provide services such aspreceptorship, mentoring and reflectivepractice in a crisis environment.

The New Zealand health system is reportedlyfacing chronic difficulties recruiting specialistnurses from within the country and overseas,while shortages of experienced mental healthand Maori nurses are noted to be particularlyproblematic. There are proposals within NewZealand to restore enrolled nurse training,which was ceased in the mid-1990s, in a bid toaddress current nurse shortages (Nurses.Cowww 2000).

In 2000, the New Zealand Ministry of Healthestimated that there was a pool of 10,000trained nurses not currently practicing in NewZealand (Nursing Review 2000), comparedwith 11,000 in 1998, and a sample was surveyedto determine what would bring them back toclinical practice. The survey revealed that 76%would consider returning to the workforce andthat flexible hours (19.5%), return to workprograms (16.2%), salary increases (12.7%) andchild care provision (11.5%) were factors thatwould influence return (New Zealand HealthInformation Service www 2000).

In addition, the Ministry reported that 1,200nurses left New Zealand to work overseas in1999 (compared with 500 in 1995), 200 of whichwere new graduates.

2.1.6 AustraliaSeveral State governments in Australia haveinstigated recruitment and retention enquires inthe last five years, either in response toperceived shortages or as part of routineworkforce planning functions. While difficultiesin recruiting specialist nursing staff underpinmany of the enquiries, there is a lack ofdefinitive data on the extent of shortages. Thisis discussed further in section 2.5.

2.1.6.1 New South WalesThe NSW Government released its NursingRecruitment and Retention Taskforce Final Reportin 1996 (NSW Health 1996). The reportidentified 32 issues affecting nursingrecruitment and retention including problemswith nursing management, lack of recognitionof experience and skill, access to educationalopportunities, organisational changes,

increasing patient acuity, flexible workinghours, child care and differing interpretation ofthe role of enrolled (Division 2 equivalent)nurses across the State.

The report recommended a range of humanresource management initiatives and structuralchanges including adoption of flexible workpractices, funded study leave and travel foreducation, professional recognition anddevelopment of professional networks. Thereport specifically did not identify or quantifyattrition from the NSW workforce or indicatewhat, if any, level of shortage the State wasexperiencing. However, recent press reportshave quantified the NSW shortage at 1300nurses, although the source of the data inunknown (The Australian, 20 July 2000).

As a result of the 1996 taskforce report, theNSW government is currently addressing thefollowing issues (NSW Health 2000):• A marketing and promotional campaign to

attract people to nursing as a career.• Reviews of workplace issues including child

care, study leave, flexible workingarrangements and access to education.

• The establishment of a standing ministerialCommittee on the Nursing workforce.

• Lobbying the Commonwealth on issuesrelating to the coordination of the nationalnursing workforce, postgraduate andundergraduate education.

• A career structure review, including the roleof the clinical nurse specialist, clinical nurseconsultant, enrolled nurse and nursepractitioner.

• State funded refresher and re-entryprograms.

• Hospital trained enrolled nurse conversioncourses (to Certificate IV in Health[Nursing] level).

• Clinical specialty orientation programs.

2.1.6.2 South AustraliaThe South Australian Nursing Recruitment andRetention Taskgroup Report (Department ofHuman Services 1998) identified problemsrecruiting and retaining specialist nursing staffin rural and remote South Australia. Itidentified problems in retention of nursesfollowing their graduate year (citing a 35%attrition rate), loss of nurses to the private

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sector, falling undergraduate intakes andchronic problems filling positions in the mentalhealth, midwifery, critical care, neonatal andrenal specialties. The report quantifiedshortages by citing vacancy rates in specificgeographical areas or health services (83 inrural South Australia, 40–60 FTE in specificmetropolitan health services) but did not offerany data on the extent of shortages across theState. The report identified hierarchicalmanagement structures, inflexible rostering,lack of child support and lack of role models asissues adversely affecting nurse recruitmentand retention.

Amongt its recommendations, the reportadvocated provision of funded refresherprograms, child care provision, exchangeprograms to facilitate backfill and allow ruralnurses to take study leave, rural financialincentives, professional development fundingand a campaign to market nursing.

A recent University of South Australia studyexamined recruitment, retention and roledevelopment of enrolled nurses in rural SouthAustralia (Bradley 2000). Amongst itsrecommendations are a view to expanding theskills, roles and professional development ofthe enrolled nurse, consideration of animproved career continuum from nursingauxiliary to nurse practitioner, and provision offlexible access to education for the enrollednurse.

2.1.6.3 QueenslandThe Queensland Government Report intoNursing Recruitment and Retention (QueenslandHealth 1999) reported growth trends in theemployment of nurses in the State and in theaverage length of service. Problems wereidentified in recruiting into specialist positions(critical care, perioperative, oncology,paediatric, mental health and midwifery) andspecific geographical locations, but overall thereport found that Queensland is not sufferingstatewide shortages experienced in otherAustralian States.

The report’s recommendations include acampaign to promote nursing as a career,improving the training infrastructure, facilitatingwork experience for school students andrecognising the role and value of enrolled nurses

(Division 2 equivalent) and assistants in nursing.

2.1.6.4 Western AustraliaThe Western Australian Governmentcommissioned the Attracting Nurses Back Intothe Workforce report to identify factors thatwould encourage non-practicing registerednurses to return to the clinical setting (BIZRAC1997), and to identify some of the principalreasons nurses leave the workforce. The reportfound that flexible hours, increased pay,affordable on site child care, refresher courses,part-time work and the availability of dayshiftonly rosters, are factors that would encouragenurses back.

In another supply-side initiative, and inresponse to falling nursing undergraduateintakes, the Health Department of WAcommissioned research (Donovan Research1998) to identify effective strategies to be usedin a campaign to promote nursing as a career.This resulted in a multimedia campaign topromote nursing as a career, entitled ‘Are yougood enough to be a nurse?’, targetedpredominantly at school students in Years 10 to12. The Committee understands that the WAGovernment is undertaking a preliminaryanalysis of the campaign.

2.1.6.5 The CommonwealthIn 1999, the Commonwealth Department ofHealth and Aged Care sponsored a nationalforum in Canberra entitled ‘RethinkingNursing’. The forum was held in response to arequest from the then Victorian Minister forHealth that the AHMAC address issues relatingto Commonwealth higher education policies, asthey related to nursing, and a national,coordinated approach to nurse workforceplanning. The forum, which includedrepresentatives from all national nursing peakbodies, considered a range of issues relating tothe nursing workforce including recruitmentand retention, education and the status ofnursing. A series of four recommendationswere made in the forum proceedingsRethinking Nursing (Department of Health andAged Care 2000):• That a national nursing workforce advisory

committee be established.• That a national nursing workforce strategy

be developed.

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• That each State, Territory and theCommonwealth develop a chief nurse/chiefnursing officer position.

• That coordination between educators andthe workforce is improved.

The recommendations were designed toaddress the lack of national coordination innurse workforce planning and the dislocationin supply of, and demand for, specialistpostgraduate nursing courses in the tertiarysector. The recommendations were twicesubmitted to AHMAC but were twice rejectedin favour of a workforce planning approachthat covered all health disciplines. As a result,the Health Workforce Advisory Council will beestablished and its first task will be to examinenursing sub-specialties such as critical care andmidwifery. At this stage the Council willcomprise membership from selected States only.Given the extent of work carried out onrecruitment and retention by the States andTerritories to date, the Committee believes it isimperative that all States and Territories arerepresented on the Council when nursingissues are considered, to ensure that adequatesharing of information takes place.

Recommendation 2: That theCommonwealth include all States andTerritories, and all relevant nursing peakbodies, in its new Health WorkforceAdvisory Council, when issues relating tonursing are considered.

In the Rethinking Nursing report, theCommonwealth acknowledges that while it hasa broad policy leadership role in health, it hasto date had little direct responsibility for thenursing workforce (Department of Health andAged Care 2000). Nationally theCommonwealth has sponsored research by theANZCMHN into the Australian mental healthnursing workforce (Clinton 1999). The report,Scoping Study of the Mental Health NursingWorkforce, recommended that Commonwealth,State and Territory responsibility for planningand development of the mental health nursingworkforce be delineated, and that theCommonwealth require the States andTerritories to improve nurse workforceplanning as part of the next Medicareagreement. In addition to mental health, theCommittee notes that the Commonwealth

Department of Health and Aged Care hasrecently engaged a consultant to report onstrategies to recruit and retain aged care nurses.

The Committee believes the Commonwealthcan play a key role in coordinating nationalnursing policy and workforce planning,through its broad policy leadership role inhealth. The Commonwealth has directresponsibility for higher education,immigration, and much of the aged care sector.In the higher education sector, access topostgraduate education places, the proportionof HECS funded university places,quarantining of nursing from postgraduatefees, undergraduate selection, the traineeshipmodel for enrolled/Division 2 nurse educationand the attrition from nursing courses (orsubsequent refusal to practice), are all matterswhich need to be addressed by theCommonwealth, States and Territories jointly.The Committee has identified these educationalissues as key impediments to maintaining astable nursing workforce.

Recommendation 3: That notwithstandinglocal initiatives, the Victorian Governmentcontinues to lobby the Commonwealth tocoordinate issues relating to nursingworkforce planning for which it hasresponsibility, including the tertiaryeducation of nurses, migration policy andaged care nursing.

2.1.12 SummaryIt is apparent that concerns over nursingshortages are a worldwide phenomenon, andthat many jurisdictions assume that suchconcerns will remain for the foreseeable future.Whilst there have been many enquiries into thestate of the nursing workforce, none appear tohave arrested the general decline in nursingnumbers or compensated for the ageingworkforce. The nursing workforce is a dynamicentity which is sensitive to changes in healthcare delivery patterns and which swings fromoversupply to undersupply in a relatively shortperiod of time (Department of Human Services19992, Buerhaus, Staiger & Auerbach 20001).

In reviewing the literature on the nursingworkforce, many common themes are apparent.The first, and probably most important, is thelack of a coherent workforce planning model

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which enables prospective adjustment ofnursing supply to fit demand. Many of thereports reviewed by the Committee for thisreport were written against the background ofan immediate or impending nursing workforcecrisis, and many coincided with significantchanges to health care structures, such as thetrend towards shorter patient stay episodes andthe shift to community care. While much of theliterature recommends an increase inlabourforce planning capacity at governmentlevel, it is by no means clear that a workforceplanning model exists which is universallyapplicable. Supply-side planning is evidentthrough strategies based on adjustment of basepractitioner supply, re-entry and migration,however, the issue of quantification of demandfor nurses (as well as para-nursing support),particularly in the face of changingtechnologies, patient acuity and health carestructures, has been markedly less evident inthe literature to date.

Coupled with the lack of workforce planning isthe underlying problem of paucity of workforcedata. In many jurisdictions the nursingworkforce has been held to equate with thenumber of nurses registered by the regulatoryauthority. While the trend towards recency ofpractice requirements and mandatoryprofessional development in many countriesmay force a closer relationship betweenregistered and working nurse numbers, it isclear that many jurisdictions, includingVictoria, still have large numbers of nurses whoare registered but are not prepared to practice.The Committee suggests that any improvementin Victorian workforce data capacity will haveto address the retrospective nature of currentdata, and that effort should be made to deviseprospective data sets that can take into accountcurrent and future workforce participationintentions of nurses. In support of this theCommittee notes the findings of the focusgroup research undertaken by ResearchInternational which found that, ‘when askedtheir future intentions, most (nurses) intend toeither scale back their participation, or plan toleave within the next 5–10 years’ (ResearchInternational 2000, Appendix 6).

The literature suggests that health plannershave paid insufficient attention towardsemerging career choices for nurses. In

particular, the trend towards casual work andself-employment (via nursing agencies) hasdestabilised the workforce in many countrieswith an effect on permanent staff and patientoutcomes (Snell 1997). Societal changes haveled to a greater diversity in career choices forwomen, as well as working pattern choices,leading to greater expectations in balancing acareer with life outside of work. The literaturesuggests that the nursing workforce is oftenstructured to accommodate the full-time‘career’ nurse rather than the increasingnumber of women and men who, for family,education, age, health or other reasons, chooseto work outside this structure.

2.2 The Victorian NursingWorkforce2.2.1 Nursing Supply

Division 1Nationally, the overall number of graduatesfrom the Bachelor of Nursing programs hasbeen steadily declining (AIH&W 1999). Figure 1shows this decline in the graduates fromundergraduate programs over a five-yearperiod. This decline is associated with a rise inpostgraduate numbers in 1997, in part as aresult of the recommendation of theCommonwealth Review of Specialist NurseEducation to increase specialist postgraduateplaces, based on projected workforcerequirements for more specialist nurses(Russell, Gething & Convery 1997). The totalnumbers and commencements have shownincreases above the 1997 figures for both 1999and 2000.

Figure 1. Australian Graduates fromUndergraduate and Postgraduate Courses duringthe Years 1993–1997 (AIH&W 1999)

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8000

7000

6000

5000

4000

3000

2000

1000

01997 1996 1995 1994 1993

Years

PostgraduateUndergraduate

In contrast to many other States, and forreasons that are unclear, Victoria has not faceddifficulties in filling undergraduate nursingplaces (Figure 2). Further, the attrition rate forthe undergraduate courses remains comparablewith the average undergraduate attrition rate.Figures from the Victorian Department ofEducation Higher Education Branch indicatethat, since 1996, the apparent completion ratefor nursing undergraduates has fallen by 3.8%to 63.3%, while in the same period the apparentcompletion rate as an average of allundergraduate courses has fallen by 2% to59.5% In contrast to nursing, occupationaltherapy, physiotherapy and radiographyapparent completion rates have all risen in thesame period by 15%, 8% and 18% respectively.

During the same period, the average ENTERscore for undergraduate nursing courses inVictoria has risen from 59 in 1996–97 to 70 in1999–2000 (the average ENTER score for allfields of study 1999–2000 is 76). It should benoted that ENTER scores are not the soledeterminant of entry to all nursing courses.

A concern put to the Committee in publicforums relates to the issue of undergraduatepreferences. There appears to be a widespreadperception that many students enter nursingcourses because they are unable to obtainplaces on preferred courses, or else enternursing to transfer during the course to adifferent discipline with a higher ENTER score,such as psychology. The Committee has no datato support this perception. Data supplied to theVictorian Department of Education by theVictorian Tertiary Admissions Centre (VTAC)shows that, for the last three years, theproportion of undergraduates with a place on afirst preference nursing course, that is thosewho obtained a place on their first choicecourse at their first choice campus, wasconsistently 20%. Overall, the first preferenceand total preference applications throughVTAC show a fairly stable pattern of demandfor places on nursing courses, with a slightincrease in demand evident in 1999–2000.

Figure 2: Victorian Undergraduate (Division 1)Students 1995–2000*

*Nurses Board of Victoria Annual Report 1999. NBV Melbourneand additional NBV data.

Division 2The total number of Division 2 students inVictoria has been increasingly steadily (Figure3). The data reflects the transfer of educationfrom the hospital-based system to the VETsector. The earlier years in this time period(1995–96) reflect the closure of the MelbourneSchool for Enrolled Nurses, which wasresponsible for the education of the majority ofEnrolled Nurses (now Division 2) in Victoria.There has been a steady increase in graduatesfrom the Certificate IV in Health (Nursing)course (full-time, part-time or traineeship) sinceDivision 2 education was transferred to theVET sector in 1997, although the number ofcommencements has reduced in 2000 since thepeak year of 1999.

The number of discontinuing students showedan increase in 1999. This may in part beattributable to the selection criteria adopted forthe traineeship model of training, criteria whichno longer apply, hence the lower number in2000.

32

6000

5000

4000

3000

2000

1000

02000 1999 1998 1997 1996 1995

Total CommencementsDiscontinued Completed

Figure 3. Victorian Undergraduate (Division 2)Students 1995–2000*

* Nurses Board of Victoria Annual Report 1999. NBV Melbourneand additional NBV data.

The Committee has had difficulty obtainingaccurate data relating to nurses in training, andhas noted discrepancies in several of the datasets supplied by various State andCommonwealth bodies. The Committeeconsiders it of crucial importance that numbersof students in training, and associatedcompletion and attrition, be accuratelymonitored to ensure a predictable workforcesupply.

Recommendation 4: That nurses ineducation courses be reported from theVictorian Department of Education,Employment and Training to theDepartment of Human Services annually(for Division 1) and six-monthly (forDivision 2).

2.2.2 Migration and ImmigrationIn Victoria in the 1999–2000 financial year, 112specialist nurses were granted temporaryresident visas for employment in the public andprivate sector (source: Department of HumanServices Workforce Branch). Of those, 16 wereemployed in mental health, one in aged careand 95 in the acute sector. Sixty-nine were fromthe UK, 13 were Irish and one was from NewZealand. To place the figure in context, 450temporary resident visas were issued in the1998–99 financial year for nurses nationally(AIH&W 2000) (1999–2000 figures areunavailable).

Nurses granted temporary residence play aperipheral role in the staffing of the Victorianhealth system. The use of such nurses has beenrestricted to areas of geographical and specialtyshortage where local candidates have not beenfound. It is argued by some that the cost ofbusiness sponsorship and migration agents hasled many health care facilities to view this as anoption of last resort. In global terms, the use offoreign nursing labour to address shortages hasled to an international ‘robbing Peter to payPaul’ syndrome that has been described as notbeing in the long term interest of the nursingprofession, and unsustainable (Glaessel-Brown1998).

In the same period (1999–2000) 168 nursessettled in Victoria as permanent migrants(Department of Immigration and MulticulturalAffairs).

2.2.3 Attrition from the WorkforceSince 1996 there has been a 3.14% decline in thenumber of nurses registered in Victoria. This isdue in part to the application of recency ofpractice provisions introduced into the NursesAct 1993, where nurses without sufficient recentclinical experience are removed from theregister. There has been a small increase in thenumber of Division 1 nurses but this should bebalanced with the closure of Divisions 3, 4 and5 of the register to new entrants.

Table 2 . Registration (Victoria) in 1996–2000*

Years

Division 2000 1999 1998 1997 1996 Diff 2000–1996

%

1 49,835 49,628 48,990 48,757 48,743 2.25

2 15,686 15,960 16,133 16,175 16,792 -6.59

3 1,710 1,763 1,802 1,836 1,924 -11.12

4 743 512 554 597 703 5.68

5 822 1,060 1,366 1,721 2,383 -65.5

Multiple 763 871 966 1,055 1,268 -39.83

Total 69,559 69,794 69,811 70,141 71,813 -3.14

* Nurses Board of Victoria Annual Report 1999. NBV Melbourneplus registration figures as at 31/3/00

33

1800

1500

1200

900

600

300

02000 1999 1998 1997 1996 1995

Total CommencementsDiscontinued Completed

Comparison between registration andworkforce data is of interest. According to thelatest Victorian figures, in 1998 there were69,811 nurses registered, and 56,350 of thesewere in the workforce (Department of HumanServices 19992). Thus, 13,461 nurses wereregistered, but not employed in nursing. Thisrepresents a significant number who might beable to be attracted back into the nursingworkforce. A sample of this cohort wassurveyed by the Committee to ascertainwhether they represent a source of futurenursing labour, or whether they are removedfrom nursing altogether. The survey is attachedas appendices 3 and 4.

Figure 4: Registered Nurses in Employment 1998

(NBV Annual Report 1999 and Department of Human Services1999)

2.3 National Data SetsThe AIH&W, established as a statutory body in1987, publishes nursing workforce data everytwo years. The data are based on informationcollected by the Nurses Boards in each Stateand Territory, and is processed by the State andTerritory health departments.

The AIH&W reports are calculated from avariety of data sources including AustralianBureau of Statistics (ABS), Department ofEmployment, Workplace Relations and SmallBusiness (DEWRSB) and Department ofEducation, Training and Youth Affairs(DETYA). The principle source of data is thesurvey distributed by the State and Territorynurse registration boards during the annualregistration renewal. The response rate to theAIH&W survey in Victoria is usually around80%, which compares favourably with alliedhealth (physiotherapy 92%, pharmacy 61%) and

medicine (74%). However, interpretation of theinformation is hampered by the fact that it isself-reported data which requires assumptionsto be made for the non-responding cohort.Despite these caveats, the data set remains themost consistent and widely used source ofnursing labourforce data for Victorianworkforce planning purposes.

The AIH&W data publication is subject tosignificant time delays, predominantly due totime taken in obtaining State and Territory data,and because of the relative status of nursing inthe Institute’s work plan priorities. This has theeffect of rendering these data outdated forworkforce planning purposes. As a result of therecent AHMAC meeting, the Commonwealth isundertaking a national review of nationalnursing data and the availability of these datafor use by key stakeholders.

The Committee noted that the then VictorianDepartment of Health and Community Servicespublished Victorian labourforce data bulletinson an annual basis as a service to assist keystakeholders in workforce planning. Thispractice could be reinstated by Department ofHuman Services in conjunction with the NBV.

Recommendation 5: That the Department ofHuman Services, in conjunction with theNBV, publish the Victorian proportion ofthe AIH&W labourforce statistics in ‘realtime’ as a separate report.

The Committee is concerned at the apparentdislocation between workforce data pertainingto specialist nursing workforce need, andprovision of postgraduate specialist nursingcourses through the higher education sector.The Committee advocates for regular workforcedata to the higher education sector so thatprovision can be made for specialist nursingcourses in areas of need. This is discussedfurther in section 5.2.1.

Recommendation 6: That the Department ofHuman Services makes available to theVictorian Department of Education,Employment and Training Victoriannursing labourforce statistics on a regularbasis, to assist in the provision ofpostgraduate and post-basic specialty nursecourse planning in the university andVocational Education and Training Sector.

34

60000

50000

40000

30000

20000

10000

01 2 3

Divisions

RegistrationEmployed

The most recent comprehensive AIH&Wnursing report (AIH&W 1999), using data from1996 to 1998, reported that the number ofregistered nurses in Australia remainedunchanged from a decade earlier. It didrecognise, however, that there was a steadydecline in the number of available hoursworked by nurses, with a corresponding rise inpatient numbers per FTE nurse. This wascoupled with an increased demand for nurseswithin the health care system.

Other features of the report were:• A low national unemployment rate for

nurses (2.4%).• An ageing of the nursing workforce. The

average age of nurses in Australia iscurrently 40.1. In 1986, 23.3% of nurses wereaged less that 25, in 1996 the percentage was9.9%. In 1986, 17.5% of nurses were agedover 45, in 1996 this had increased to 28.6%.

• An increase in temporary resident nursesworking in Australia.

• An increase in the age of students enteringundergraduate nursing programs (theaverage age of undergraduates is reportedas 24.5, compared to 21.8 five years earlier).See Figure 5, section 4.1.

• Australia continues to have a greaternumber of nurses per head of populationthan other English speaking OECDcountries with 962.3 per 100,000.

Other Commonwealth agencies also providenursing data. DEWRSB reports on nursingspecialty shortages, based on periodic phonesurveys of hospitals where information ondifficult to fill vacancies is obtained. These dataare not always consistent with thosemaintained by the Department of HumanServices (table 3 below) and are used by theCommonwealth to inform policy issues such asskilled migration and the granting oftemporary resident visas. Table 3 below showsnursing specialty shortage as interpreted byDHS and DEWRSB respectively.

In addition to the above, the Commonwealthreleases census data through the ABS after eachquinquennial census. The most recent censuswas conducted in 1996 and the data pertainingto nursing has been tabulated as a specialcommission for the Committee by the ABS. Thedata was sought primarily to establish the

sample size for the survey on currentlyunregistered nurses and correlates to thenumber of nurses on the NBV register (69,000).While the data is of historical interest, it isproposed that 1996 workforce figures bear littlerelevance to the 2000 workforce and, given thelead time the ABS requires to process Censusdata, it is unlikely that future Census data willbe of use in ‘real time’ workforce planning.

Table 3: Comparative Qualitative Nurse ShortageEstimates, Department of Human Services andCommonwealth

Department of DEWRSB

Human Services Shortage Shortage

Perioperative Y Y

Emergency Y Y

Cardiothoracic Y Y

Neurosciences N Y

NICCU Y N

Paediatric N N*

ICU/CCU Y Y

Renal Y N

Aged Care Y N

Oncology N N*

Midwifery Y (Rural) Y

Mental Health Y Y

Rural Generalist Y N (DESBWR 2000, Department of Human Services 1999)

* No Victorian shortage but shortages identified in other States.

2.4 Victorian DataIn 1998, the Department of Human Servicescommissioned a nursing workforce study(Department of Human Services 19992), toestablish labourforce projections for the period1999 to 2008. This followed previous studies in1991 and 1993, the latter of which predicted animpending oversupply of nurses. The 1993study resulted in a small reduction in thenumber of undergraduate nursing places and areduction in Division 2 training positions. Themethod used for the studies was a stocks andflow model using proprietary software. The1999 study found that, on current high demandprojections, Victoria would be facing a shortageof up to 5,500 nurses by 2008. This shortage isundifferentiated and does not quantify shortageby nursing specialty, grade, experience, divisionor geography.

35

Figure 5: Nurse Supply Requirements, Victoria1998–2008 (Department of Human Services 19992)

In addition, the Department of Human Servicescommissioned an evaluation of themethodology used in the studies of 1991 and1993. The study found that the assumptionswhich underpinned the Department of HumanServices labourforce studies were essentiallysound but that changes in the health caredelivery system, particularly the application ofthe casemix funding model, the increase indemand for health services (as calculated by theAcute Health Branch of Department of HumanServices), restructuring of aged care services,the establishment of health care networks andthe integration of mental health services couldnot be anticipated at the time of the studies(Department of Human Services 19991).

One essential difference between the study of1998 and the studies of 1991 and 1993, was adramatic increase in attrition rates, particularlyfollowing completion of Division 2 training.Losses to the labourforce in 1998 totalled 4,376nurses (7.41% of the workforce), which werenot balanced by the 1,682 nurses (2.85%)entering or re-entering the workforce.

In addition to the labourforce reports, theGovernment has commissioned periodicqualitative and quantitative studies that exploreissues in nursing specialties such as critical careand midwifery (Health and CommunityServices 1993, Department of Human Services1996).

While labourforce projections have definedoverall supply and demand issues, there is apaucity of data on workforce variation betweenstudies. Currently the Department of HumanServices has no consistent data on the numberof nurses working in the public hospitalsystem. It cannot establish the number of part-

time workers, the split between divisions, thenumber of casual nursing staff or the number ofagency staff employed by public hospitals withany confidence. Equally, the Department ofHuman Services cannot, with confidence,predict the number of nurses actually requiredin the public health system. This has majorimplications for monitoring the ongoingeffectiveness of any recommendationsproduced by the Committee relating to nurserecruitment and retention, as well as for theability to conduct routine labourforce planning.It also has major industrial implications for theGovernment, as individual grades of nursescannot be identified centrally. Labourforceestimates used in this report are based onreports commissioned by the Department ofHuman Services, Human Resources Branch,from Allegiance Systems, which has thecontract to manage the public hospital payrollin most Victorian public healthcare facilities.The report used data from March 2000.

Recommendation 7: That the Department ofHuman Services commissions regularpayroll reports (at least three-monthly),reporting total numbers and total EFT ofnurses by agency, by grade, by service andby full-time or part-time status.

In addition to difficulty relating to overallnursing numbers, the Department of HumanServices lacks any information about the post-basic qualifications held by nurses. While theNBV maintains a data set on nurses with aspecific qualification in post-basic midwiferyand maternal and child health, there is norecord of the number of nurses withqualifications in specialties such as critical careor oncology. Data exists on the number ofnurses with formal post-basic nursing courses(AIH&W survey Q17) but interpretation of thisdata is limited by several factors. The first isthat the data is self-reported, without anycorroborating information. The second factor isthat ‘post-basic’ is interpreted in surveyresponses to mean anything from informalcontinuing education to adult education andnon-nursing courses (such as massage andaromatherapy). While the respondent may useskills gained from these courses in everydaynursing care, the courses are not generallyconsidered ‘nursing’. The third factor is that thelevel of course is not recorded, so that a post-

36

70000

68000

66000

64000

62000

60000

58000

56000

54000

52000

500001998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Nur

ses

(Hea

dcou

nt)

ConstantDemographic Change HightDemographic Change Low

basic VET module, a graduate certificate and aPhD are recorded in the same context. Thefourth factor to consider is that the data doesnot identify nurses undertaking training.

The Committee was asked to examine changesthat may be necessary to the Victoriancomponent of the AIH&W annual survey (termof reference 2.7). It was noted that nursesworking in mental health were classified as onehomogenous group in the current survey.Given the current problems attracting mentalhealth nurses into the inpatient setting, and themigration of experienced nurses from inpatientto community settings, the Committee believesthat the question relating to area of clinicalnursing should differentiate ‘communitymental health’ and ‘inpatient mental health’ toassist workforce planning.

The Committee also notes the increasingly highprofile of palliative care nurses in Victoria. Asthese nurses work across setting boundaries(inpatient and community) they are notidentifiable in the current survey as a discreteclinical specialty. Again, the Committeeadvocates identification of this group withinthe survey.

Recommendation 8: That the Department ofHuman Services recommends the followingchanges to the AIH&W annual survey tool:

Q16: To assist workforce planning, mentalhealth be categorised by community mentalhealth and inpatient mental health, andpalliative care to be added as a clinicalspecialty in its own right.

Q17: Specify that the post-basicqualifications be graduate certificate(including hospital based courses whichpredate the transfer of nurse education tothe tertiary sector), graduate diploma,masters, PhD or post-basic TAFE/VETmodule. This is to exclude ‘informal’courses and in-service education whichconfound interpretation of Victorianspecialist nurses.

2.5 Indicators of Shortage inVictoriaAs previously discussed, there is a body ofinternational literature suggesting a worldwideshortage of nurses. Despite this, much of theevidence is anecdotal, descriptive and localised.Buchan & O’May (1998) review the evidence fornursing shortages and critically analyse the fivecommonly used indicators for shortage. Theseindicators will be applied to the Victoriancontext.

2.5.1. VacanciesThe inability of an organisation to fill vacanciesis often cited as an indicator of nursingshortage. Buchan & O’May contend thatvacancy rates, while a useful indicator, may infact underestimate shortage where, forexample, vacancies are not advertised, or wherevacancy data are collected at an atypical timepoint. Submissions before the Committeesuggest that many facilities no longer advertisehard to fill vacancies, using the rationale thatrepetitive advertising acts as a disincentive toprospective applicants, who may perceive lowmorale within the organisation. This hasimplications for any vacancy data collectionmethod that relies on published vacancies.

The Committee has been informed that at leastone large Melbourne hospital, when completinga vacancy survey, had no vacancies at thatpoint in time, yet were anticipating severeshortages during the winter. In addition, theCommittee has learnt that some hospitalsmaintain unfilled vacancies as part of theirstaffing profile, with no intention of fillingthem. It is concluded that vacancy data, to beuseful for workforce planning purposes, shouldbe collected on a regular basis and with aconsistent response rate, and should have thecapacity to reflect seasonal variations.

In Victoria, a statewide vacancy survey wasundertaken in 1999, in both the public andprivate sectors (ACNMI et al. 1999). Althoughthe response rate was relatively low (35% in theaged care sector, 41% in the acute sector) itrevealed that 58% of acute facilities and 57% ofaged care facilities had unfilled vacancies at thetime of the survey (February 1999).

37

The Committee, in its consultation process,sought data from public and private hospitalson current vacancy rates. Public sectorresponses on vacancies were obtained from 27health care facilities (20 rural) but this wascountered with a negligible response from theprivate sector. The number of vacanciesorganisation-wide ranged from 0.6 to 58 EFT.The data suggested that the majority ofmetropolitan hospitals were having difficultyfilling vacancies, particularly in specialist areassuch as critical care and inpatient mental healthservices, and suggested a shortage ofexperienced, qualified nurses. In rural facilities,the responses offered a greater variation. Somefacilities had no problems filling vacancies(with a waiting list for permanent positionsapparent in some hospitals) while others facedchronic problems filling rural generalist, agedcare, mental health and midwifery positions. Itshould be noted that the Committee viewedthis as indicative information only, and noattempt was made to aggregate the data.

2.5.2 TurnoverTurnover rates, and the ability of facilities toretain staff, have been suggested as a method ofmonitoring recruitment and retentiondifficulties (Kramer 1990). A distinction shouldbe drawn, however, between controlled anduncontrolled turnover as, during therestructuring of the Victorian health caresystem, anecdotal evidence suggests manynurses were offered retrenchment packages toleave the industry.

The Committee attempted to seek qualitativeand quantitative data on turnover rates but washampered by the lack of industry benchmarksin what is traditionally a highly mobileindustry. As one submission to the Committeestated, ‘(our) nursing service attrition ratefluctuates between 12–15% which could beconsidered low. There is no industrybenchmark…but I suspect that anything over25% would be an indication of organisationaldifficulties’.

Other submissions complained about a lack ofnursing turnover with one stating that, ‘somerural hospitals have little or no staff turnoverfor months, even years. This leaves little roomto permanently employ suitably qualified staffwho may be actively seeking work’.

2.5.3 OvertimeOvertime rates have been suggested as anotherindicator of nursing shortage. Interpretation ofdata in the Victorian context is hampered bythe fact that, according to both research(Considine & Buchannan 1999) and evidencefrom the Committee’s consultation process, thetrue extent of overtime in the public health caresector is significantly under-reported. Theindicators used to define overtime can rangefrom ad hoc additions to shift length, doubleshifts, work on days off, the use of on callarrangements to cover routine services andformal overtime arrangements (either paid orwith time in lieu arrangements). In addition,evidence from the consultation process suggestsa widespread expectation that non-clinicalwork tied to a specific role, such as CNS andANUM, be conducted outside of normalrostered working hours. The degree to whichsuch overtime represents shortages is unclearfor, as Buchan & O’May (1998) state, ‘unpaidclinical hours are cheaper than recruiting morepaid nursing staff, even if resources areavailable to meet the bill’.

Given the issues outlined above, a conservativeestimate of overtime in the Victorian publicsystem (Considine & Buchannan 1999) is thatbetween 300 and 450 full-time nursing positionsa week are being filled using unpaid labourthrough overtime. Considine & Buchannan alsoreport that 18.8% of overtime worked wasalways paid, 19% was unpaid, and that 30.5%of overtime worked was repaid as time in lieu(p. 4).

2.5.4 Unemployment RatesThe unemployment rate for nurses in Victoria isestimated to be 2% (ABS information line, July2000) compared with a statewide rate of 7.2%(DESBWR 2000). The former rate is identical tothat of United Kingdom nurses. According tothe British Government’s Ray Review Body, anunemployment rate of 2% is usually regardedas indicative of full employment (Buchan &O’May 1998).

The 2% unemployment rate in Victoria suggeststhat most of the pool of non-working nurses inVictoria described in section 2.2.3 is likely to beeither working in another industry, or out ofthe workforce altogether, rather thatunemployed and seeking nursing work.

38

2.5.5 Surrogate MarkersClinical indicators have been suggested as amethod of supporting data on staff shortages.In America, hospital infection rates (Fridkin etal 1996) and mortality rates (Aiken, Smith &Lake 1994) have both been correlated to staffinglevels. Such data need to be interpreted withcaution in the Victorian context. Increasingpatient acuity, changes in the pattern ofmicrobial infection and the trend towardsreduced length of hospital stay render the useof historical data relating to infection ratesdifficult to apply to the current context. TheCommittee notes that the VictorianGovernment has legislated that hospitals are tosubmit data on infection rates after specificsurgical procedures to the Department ofHuman Services Quality Council. Mortalitydata is subject to similar interpretationproblems relating to historical controls as thetrend continues for sicker patients to beadmitted to hospital while the less unwell aretreated in the community or on a day basis.

Other markers have been suggested asindicators of shortage, such as the number ofdays emergency departments spend onambulance bypass, patient satisfaction indicesor medication errors. However, as theirrelationship to understaffing, as opposed togeneralised systemic stress, is difficult todefine, these markers are not considered in thisreport.

The Committee sought information on sickleave rates in its call for submissions. Asexpected there was wide variation in themethod of sick leave reporting which did notassist in the aggregation of data. Of the facilitiesthat provided serial data for 1998 to 2000, nonedemonstrated trends towards significantincreases in sick leave, with most reportingannual sick leave rates in the range of 2 to 6%(sick leave hours taken as a percentage of allnursing hours worked).

2.5.6 SummaryWhile the data on shortages in Victoria ispatchy, there is strong evidence of uncertaintyof the supply of nurses in the workforce. At thisstage, the projection of statewide shortage in themost recent Department of Human Serviceslabourforce study (Department of HumanServices 19992) appears still to be relevant. Ofmore concern, the consultation process hasrevealed that many nurses currently workingare considering leaving the profession in thenear future (Research International 2000,Appendix 6). This may exacerbate projectedshortages with as many as 12% of nurses whohave already left the system indicating that theyare not prepared to return (Campbell Research& Consulting 2000, appendices 3 and 4).

While the data available to the Governmentrelating to nursing is acknowledged as sub-optimal, it should be noted that this is asituation experienced by Governments bothinternationally and within Australia. Thisshould be regarded as an opportunity toimprove and systematise the State’s datacollection policies to ensure accuratelabourforce planning capacity in the future.

39

40

As previously described in section 1.4, theCommittee undertook a consultation roundwhich comprised written and verbalsubmissions, focus groups and forums. Inseeking information, the Committee focused ontwo key issues: why people are leaving nursingand what would bring them back.

One of the features of the consultation processwas that the issues raised were usuallyconsistent across peak bodies, DoN andclinicians. The key issues are summarisedbelow, and are discussed in detail later in thereport.

3.1 WorkloadThe perception that workloads have increasedwas articulated by clinical nurses regardless ofclinical setting, geographic location or level ofpractice. This increase in workloads was givenas the most common reason for nurses leavingthe profession (appendices 3 and 4). A numberof factors appear to be contributing to this clearperception of increased workload.

3.1.1 Factors Contributing to IncreasedWorkloadsThe first of these contributing factors wasacuity of patients/residents. The level of acuityof patients has changed in acute areas, nursinghomes and in the community. Bed days havereduced over the past decade (ProductivityCommission 1998) and, with associatedspecialisation of services, there is generally nolonger the mix of short and longer stay patientswithin the acute wards. In addition, thecomplexity of care has increased, coupled witha trend towards community aftercare. The levelof care is, therefore, constant with high levels ofacuity for short stay patients. As was indicatedin the focus groups, there seems to be no‘downtime’ any more. In addition, patients aredischarged to aged care facilities and thecommunity in more acute phases of theirillnesses, often, it is claimed, without adequatedischarge planning.

The second contributing factor was availabilityof nurses. There appear to be fewer nursescurrently employed. According toCommonwealth figures (AIH&W 1999), patientseparations per FTE have increased by 8.1%and patient days per FTE by 9.3% in publichospitals. At the same time, there has been anoverall decline in staffing availability of 5.1%.This staff availability has been exacerbated bythe fact that only 68% of graduate nursesentered the Victorian workforce in 1998.Demographic trends appear to require 57,585 to57,645 nurses working in 2000. However, in1998, there appeared to be a net loss with 2,947entering and 4,394 leaving the workforce.

In addition, figures show that around 13,461nurses were registered but not working inVictoria in 1998. (NBV Annual Report 1999,Department of Human Services 19992). Thesurvey of a sample of this population hasindicated that 51% would be prepared to returnto work if, among other aspects, the workloadcould be reduced; while a further 32% wereunsure if they would return (appendices 3 and4). Coupled with this reduction of availability isthe reduction of experienced qualified nurses atthe bedside. From information before theCommittee, shortages have been identified ingeneral areas as well as the specialties of criticalcare, accident and emergency, mental health,aged care, neonatal intensive care and ruralmidwifery (Department of Human Services1999, ACNMI et al. 1999). The major shortageappears to be in experienced qualified nurses.In particular, the survey, forums and focusgroups identified the following as contributingto this loss:• Budget cuts and ‘an emphasis on cost

reduction by hospital management’(Appendix 6, p 20).

• Rounds of redundancy packages. • General dissatisfaction with working

conditions.

That third perceived cause of an increase inworkload is the casualisation of the workforce.Increasing numbers of nurses now work part-

3. Problems in Nursing

41

time (Department of Human Services 19992,AIH&W 1999). In some rural and metropolitanareas the ratio of part-time to full-time reportedto the Committee is as high as 80:20. Choice ofpart-time employment may reflect lifestylechoices in some instances, it may indicatebudget considerations in others, and in somecircumstances may represent an attempt bynurses to have some control over theirworkload. There is no doubt that greatercontinuity of care can be achieved with a higherfull-time workforce. The lack of continuity ofcare places an added strain on thoseexperienced nurses who must ensurecontinuous quality nursing care.

Where the number of staff is not sufficient forthe patient load, agency nurses tend to be used.In some instances, hospitals have contracts withonly one agency and the nurses becomefamiliar with the units in that hospital.However, this is not always the case. Hospitalsmay find themselves with nurses who do notknow the unit and in some instances do nothave the qualifications or experience necessaryto provide quality care for the patients in theunit. This increases the load on the full-timeexperienced nurses. Many nurses saw theorientation and supervision of agency staff asan additional burden in an alreadyoverstretched work environment, and there wasa widespread perception that many agencynurses were often being used in circumstancesother than of last resort by management. Theover award pay rates offered by agencies tocertificated specialist nurses was considered adestabilising factor by many nurses,compounding the difficulties facing health carefacilities in attracting permanent staff.

With the loss of experienced nurses fromwards/units, the concomitant increase in newgraduates and relatively inexperienced nursesresults in inordinately heavy workloads beingcarried by both the experienced and lessexperienced nurses. The former tend to suffer‘burn out’ and the latter may find themselvesunable to cope with the heavy demands.Therefore, both groups may choose to eitherleave the workforce, reduce to part-time or joinan agency. This situation has been described inthe focus group report as a ‘vicious cycle’(Appendix 6, p 22).

3.1.2 Control over WorkloadsNurses expressed a feeling of powerlessness incontrolling their workloads. Different methodshave been used to determine workload, one ofwhich is the nurse/patient ratio. Such ratiosappear to have increased in many areas. Thedata reported by Considine & Buchannan(1999) shows that, for acute wards, 66% of theresearch sample reported a current ratio of1:5–1:6. Of particular concern was the reportingby 22% of the sample of ratios in excess of 1:8.The issue of what is a desired nurse/patientratio for the acute wards is a matter of debate.When Considine & Buchannan posed thisquestion, 68 % of their sample who werecurrently working with ratios of 1:4–1:5indicated this as desirable.

Data before the Committee also show thatcurrent ratios vary considerably. For the acutemedical/surgical area, reports have rangedfrom 1:3 to 1:10. Those hospitals that haveattempted to address the ratio issue reportranges of 1:4–1:5 The focus groups referred toratios of 1:6–1:8 as the norm (Appendix 6, p 20),a view supported by nurses at the forums.

Where the workload was considered too high,and additional staff could not be provided, anobvious strategy to ensure reasonableworkloads was to close beds. Even where award/unit was successfully using a workloadmeasurement tool such as Trendcare, andtherefore had evidence that the ratio was toohigh, beds were rarely closed. This situationwas imputed to the use of the casemix fundingformula and budget allocation. Nursesfrequently recounted instances where, onrequest for bed closure, there were impliedthreats that such closure would result in moredrastic consequences for the hospital as awhole. Several NUMs expressed a feeling oflack of support from management in this area.

Other areas in which nurses expressed feeling alack of control over their workloads was in thehours worked. Discussion in the forums andfocus groups centred around: • Short shifts, resulting in shortages of staff

for periods of time during the day (forexample, a six-hour hour shift might leavetwo hours with insufficient staff).

42

• Rotation of shifts including compulsoryperiods of night duty.

• Time off during school holidays and time topick children up from school orchildminding services.

Several instances of successful self-rosteringwere cited and the resultant satisfaction withthis system. However, there were others whoindicated that this had either not worked, orwould not work in their clinical areas, becauseof the competing demands of school holidaysfor example.

There were several advocates for self-selectedpermanent night duty, especially where issuessuch as access to continuing education andnight duty culture were addressed. In allinstances, there was a suggestion that where itwas difficult recruiting permanent night dutystaff, added incentives were required, such as ahigher night duty loading.

3.1.3 Effects of High WorkloadsIn addition to the reported effect of experiencednurses leaving the workforce, there are anumber of other effects of high workloads. Thefirst, most worrying factor, has been a reductionin the quality of patient care. One nurse at aforum summarised this as a situation where thenurse was so busy, that they only had time toconcentrate on the tasks to be done, and wasconstantly working out how the remainder ofthe tasks were to be done. Thus there was littlecapacity to ‘be with’ the patients, listen to themand try to individualise their care. Time wasonly meeting immediate needs. For manynurses, this is a source of frustration and stress.Nurses consider that it is their role to be able toprovide quality, holistic care, not care that isbased only on tasks.

The demands of direct patient care were suchthat other areas of practice also suffered.Documentation and other administrativeactivities were given low priority. Conversely,the nurse managers (ANUM and NUM) foundthat they too were heavily involved in directpatient care, and that management activitieswere done with difficulty, often in their owntime. In addition it was reported that there waslittle time for research, quality managementprojects and teaching. The expectation toundertake these activities was considerable and

clinical nurses in particular felt that there wasan obligation for them to be involved in theseactivities. There was no time allocated and, asindicated above, research activities werecommonly undertaken in the nurses’ own time.The point was made repeatedly that otherhealth professions, because of their inherentability to control their own workload, did notface the same problems as nurses in beingreleased from the bedside for other professionalactivities. There was a position put before theCommittee at the forums that the increase inthese activities for clinical nurses was the resultof budget cuts, where Grade 5 positions thathad responsibility for quality management, forexample, were no longer employed, and thatresponsibility for these activities had ‘floweddown the line’. One person at a forumsuggested that nurses with the appropriateexpertise should be employed in these positionsto free the clinical nurse from such activities.However, a counter view is put for more timeto allow clinical nurses to undertake theseactivities, as they added value and variety totheir role.

For the experienced nurses who remain at thebedside, there has been an increase in the timespent on supervision of inexperienced nurses(new graduates and agency nurses). In general,experienced nurses accept that supervision andmonitoring are part of the role associated withclinical experience. However, with highnumbers of new graduates, and with agencynurses often unfamiliar with unit requirementsand sometimes lacking the experiencenecessary for the type of patient in the unit, theamount of time spent on this activity isperceived as excessive and detracts from theability to apply continuous quality care topatients. In addition, as new graduates do notreceive the support and mentoring required tohelp build their confidence, this contributes totheir attrition from the workplace.

For all nurses, irrespective of position, therewere reports of increased levels of overtime andunpaid work. This was reported by Considine& Buchannan (1999) and was reinforced at theforums. This was due not only to heavyworkloads, but also to a loss of ‘handover’time, as shift times frequently do not overlap atall. Particular references were made at theforums to the amount of time nurses at CNS

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grade and above were expected to spend in‘project’ work in their own time. Further, therewas an expectation that meetings would beattended in the nurses’ own time. Overtimewas a constant factor for which nurses werereluctant to claim, although entitled so to dounder the Award. It appears that claimingovertime is actively and/or passivelydiscouraged in some areas, and while therewere examples of staff being granted time off inlieu, these were the exception rather than therule.

Opportunities for undertaking postgraduatestudy reduced with a heavy workload, as didtime for continuing education. Nurses reportfinding it difficult to keep their knowledge andskills up-to-date. Further, there were fewopportunities for professional development,considered an essential part of the role of aprofessional. Not only were workloads suchthat these activities were curtailed, but therewas little availability of backfill for theirabsence.

Low staff morale and stress were constantthemes conveyed to the Committee. In additionto the factors indicated above, other aspectscontributing to low morale and stress were: • Lack of camaraderie-a situation exacerbated

by heavy workloads, no shift overlap timein which bonding and team building couldoccur and lack of strong nursing leadership.One person at a forum pointed out that theoutsourcing of services such as cleaning,catering and security had exacerbated thisproblem, as the feelings of loyalty andbelonging were no longer evident amonghospital staff as a whole.

• The feeling that nurses were not respectedand valued as professionals. Frequentexamples were given during the forums of aperceived lack of respect for nurses bycolleagues, other health professionals(particularly the medical profession), andnon-nursing management. This wasdemonstrated most clearly in the lack of anursing voice in clinical decision makingand in policy development. Severalsuggestions were made that could enhancethe feeling of value to the nurse. These werenot necessarily monetary, but rather theoccasional word of praise, the seeking of theopinions of the nurse and the involvement

of the nurse in policy making and clinicaldecisions.

• Few support services for nurses. Thecomplaints ranged from the lack of decenthot food in after hours shifts (not pre-dispensed machine food) through tocounselling services, child minding facilities,car parking facilities, access to the DoN,access to health services for all nurses andsabbatical leave for clinical nurses.

In summary, the effects of the increasedworkload are perceived as wide-rangingreductions in the quality of care, inadequatetime for effective supervision and monitoringof inexperienced staff, insufficient time forpursuing studies, continuing education,professional development, research and otherprojects necessary for the improvement ofquality care, the inability to balance betweenactivities and administrative functions, andincreasing levels of stress.

3.2 Unsafe Working EnvironmentThere was widespread concern that nurseswere increasingly bearing the brunt ofcommunity frustration and aggression in boththe hospital and community setting. TheCommittee received numerous complaints ofwidespread physical and verbal aggression inalmost all clinical settings, as diverse asemergency departments, aged care andcommunity paediatrics. Concern was raisedthat both hospitals and the community arebecoming more dangerous places to work andthat security precautions are inadequate. Therewas also concern at the perceived lack ofsupport from management for nurses subjectedto workplace violence. In addition, theCommittee received reports of open drugdealing in some public hospitals, accompaniedby harassment and intimidation of staff.

In the rural mental health sector the issue ofsole practitioners working in isolation withoutstaff and equipment back up was highlightedas a major workplace safety issue. This isdiscussed further in section 6.1.6.1.

In addition to violence from the community,there were widespread reports that nurses aresubject to ‘horizontal violence’, characterised bybullying, verbal harassment and ostracism,both by nursing colleagues and other health

44

professionals. It was observed that this is oftendirected at junior nurses and is cited as acontributing factor to attrition. This is discussedfurther in section 6.1.4.2.

Workplace injury was identified as anothermajor cause for concern, notwithstandinginitiatives to reduce the incidence of suchinjuries through appropriate patient handlingsuch as the Nurses Back Injury PreventionProject (Department of Human Services 2000).The Committee received numerous submissionsfrom nurses injured at work, both physicallyand mentally, who stated they were unable tofind suitable work or support to facilitate theirreturn to nursing.

3.3 Equipment AvailableA common complaint emerging from theforums was the lack of equipment in thenursing care of patients. It was suggested thatwhere adequate equipment is not available, thequality of care diminishes and the efficiency ofthe nurse is compromised. Shortages wereindicated not only in acute care hospitals, butalso the aged care sector and the community.Particular reference was made to the ‘no-lift’policy. Although this initiative has been fundedby the Government and preliminary reportssuggest it appears to be working well in areaswhere the funding has been utilised effectively,unsolicited examples were given of a lack ofequipment preventing the policy from beingimplemented. These examples were largelyfrom the public acute care and private agedcare sector. However, in addition, there wereanecdotes provided of lack of basic equipmentsuch as dressings, syringes, bed linen andventilators recounted by some of the hospitalnurses at the forums.

Both the community and aged care sectornurses related another common example oflimited equipment and resources. Patients werereported to be discharged with inadequateamounts of emergency medication anddressings, particularly at the weekend when itwas difficult to obtain either repeatprescriptions or equipment.

3. 4 Career StructureThe inability of the current career structure toretain nurses in clinical positions was a

recurring theme. Many cited the difficulty inmeeting the criteria for existing clinicalpositions, such as CNS, due to additionalrequirements being added at a local level, andapplied inconsistently. There was no clinicalcareer path beyond grade 2; many saw entryinto management and education as the onlyway of progressing a nursing career andcomplained of a glass ceiling syndrome in theclinical career pathway. This theme emerged asone of the strongest in terms of retainingexperienced, qualified nurses at the bedsideand within the nursing workforce.

3.5 Support for NursesTwo themes emerged in this area. The firstrelated to the need for assistance to the nurse inareas that were not direct nursing activities.Areas suggested were routine administrativeactivities not requiring the clinical judgment ofthe nurse, answering telephones on a 24-hourbasis and some housekeeping activities,including making of unoccupied beds. Therewas a suggestion in a small number ofsubmissions that delegated nursing activitiesshould also be undertaken by others, such asunregistered health care workers (UHCW).These suggestions were from the critical careand acute care areas.

The second area relating to support was anexpressed perception of lack of support bymanagement. This appeared linear in nature.Grade 2 and 3 nurses indicated a lack ofsupport from Grade 4 nurses, and Grade 4nurses a lack of support from levels above.NUMs in particular indicated that their rolehad changed, and that many duties had beendelegated downward, without requisite checksto ensure that the nurses had the skills ortraining to undertake these activities,particularly in relation to the management ofunit-based budgets.

The DoN (however titled) was singled out, insome instances, as having lost control ofnursing, particularly the nursing budget. Asindicated above this lack of support may haverelated to bed closure where workloads wereunacceptably high. A strong plea was madefrom the forums for strong nursing leadershipin areas such as control over workloads. Severalcomments were made at the forums of the lackof understanding of non-nurse management in

45

relation to issues around quality versusquantity of nursing care.

As discussed, there are a number of factors thatappear to be contributing to the frequentlyreported increase in workload: fewer nurses(particularly experienced nurses) in the publicsystem, casualisation of the workforce,increased patient acuity, equipment shortages,nurse to patient ratios, control over workloadand support for the nurse. There have been anumber of effects resulting from the higherworkloads expressed to the Committee.

3.6 Education Cost and Access3.6.1 Undergraduate PreparationThe Committee received criticism ofundergraduate preparation of nurses. Aspreviously discussed, there is a strongperception that the entry score requirement fornursing is too low, allowing unsuitablecandidates to enter nursing courses. In additionto concerns from specialist areas such as mentalhealth (sections 3.9.1 and 5.3.4) there werenumerous complaints concerning the clinicalaptitude of new graduates, particularly in theirability to handle patient caseloads and to workaccording to shift patterns. Much of the blamefor this is focused on the reduction of clinicalexperience hours during the undergraduatecourse, particularly the lack of appropriateclinical experience during the firstundergraduate year.

This should be balanced by concern fromclinicians in areas such as aged care who resenthaving first year students undertaking clinicalexperience in the specialty in the belief that it isan undemanding area to work, and by concernfrom clinicians in specialist areas thatundergraduates are often not offered specialistexperience, making it more difficult to recruitnew graduates to the areas.

3.6.2 Postgraduate EducationThere was widespread concern from all sectorsof nursing about the costs of postgraduateeducation, particularly under the full feestructure. Nurses were concerned that therewas unrelenting pressure to undertakepostgraduate qualifications in nursing (and toprogressively higher levels) without any

resultant increase in pay, opportunity forpromotion or assistance from management toundertake courses. Many nurses reportedhaving to drop from full-time to part-timeemployment to undertake study, with resultantloss of income. Some were employed at a lowergrade not only while studying, but oncompletion of study.

3.6.3 Professional DevelopmentIn addition to formal postgraduate education,some nurses were concerned with inequities inthe provision of professional development andcontinuing education. Many indicated that in-service education courses (including mandatorycompetency assessments such as resuscitationtraining) were conducted with no regard toshift patterns, requiring attendance on days off.Concern was also raised over the lack ofsupport from nursing management forattending conferences. Parallels were drawnwith other health professionals who weresupported and were able to attend suchactivities without concern over backfill. Ruralnurses stated that much of the education wasprovided in Melbourne, without provision fordistance education, requiring considerabletravel. Existing structures to facilitateeducation, such as the TeleHealth network,appear to be markedly underutilised.

3.7 Family IssuesThe inability of nurses to balance work withfamily life was raised in many contexts as areason nurses leave the industry. The lack offlexible, affordable child care facilities(particularly for unplanned or emergency care),the lack of flexible working arrangements, andproblems surrounding school holidays, werecited as important factors. One large facilityconducted a survey of child care needs andfound that 47% of respondents reported childcare problems as affecting their productivity,and 60% reported problems obtaining shortnotice child care when their child was sick.

Specialty areas with high demand for round theclock staffing, such a critical care, reportedgreater problems with attracting staff withfamily commitments because of the highprevalence of night duty.

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3.8 Specific Issues for RuralNursesSubmissions from rural facilities and cliniciansemphasised the difficulty in maintainingclinical skills in areas not serviced byeducational facilities. Difficulties in obtainingleave to attend metropolitan education meantthat many, particularly those with familycommitments, were unable to access externalprofessional development courses. The highrate of part-time work offered in rural hospitalswas cited as a disincentive for experiencednurses needing full-time work to move to ruralareas. Hospitals in tourist areas such as the SurfCoast reported particular difficulty attractingand retaining staff because of housing costs.

Isolation was frequently cited as an issueeffecting the rural workforce, in particular, lackof supporting networks and peer reviewmechanisms, especially for the sole practitioner.Sole practitioners were frequently on call, inaddition to their normal working week anddifficulties were identified in finding relief forthem in areas where there were no agencies ornurse banks.

Safety issues were indicated for all rural nurses,especially mental health nurses. Such issuesarose in relation to distances travelled,especially on unmade roads and through ‘blackspots’ in communication. Nurses working alonewhere there was inadequate securityequipment and personnel were also deemed atrisk.

3.9 Specialty IssuesThe Committee recognised that particular areasof nursing specialty are prone to recruitmentand retention problems that are not generallyapplicable to the nursing workforce as a whole,particularly the aged care, critical care, mentalhealth and midwifery workforce.

3.9.1 Mental HealthThere was considerable concern from all sectorsof mental health nursing that theundergraduate nursing curriculum offersinsufficient mental health training, both interms of theory and clinical experience. Thislack of preparation was contrasted with theincreasing profile of patients with mental health

problems in the general hospital environment,and the expectation that nurses educated underthe comprehensive curriculum are competent tonurse them.

The ANZCMHN informed the Committee thatthe most significant problem facing mentalhealth nursing is recruiting beginning levelpractitioners into mental health services. This ishaving a particularly detrimental effect on thepsychiatric service sector, as few new graduatesare entering the profession (Pante 1999,Department of Human Services 1998). TheCollege proposes a four-year degree as amechanism of achieving an adequate level ofmental health content in the undergraduatecurricula. The need to improve the input ofclinical services into curricula design isidentified and the college proposes that‘curriculum advisory boards’, with significantclinical agency representation, be established.

Retention issues are identified as a major issue,with an ageing nursing mental healthworkforce (the average age is 43) seen as anunresolved problem. The lack of qualified staffhas contributed to morale problems, sick leaveand resignations of the few remaining mentalhealth nurses.

The Committee was informed that there hasbeen a steady migration of staff from inpatientacute units into the community. As patientacuity in the inpatient setting rises (aggravatedby an increase in the number of behaviourallydisturbed patients with drug and alcoholproblems) and the number of experienced staffin the units decreases, there is concern that theundergraduate students undertaking clinicalplacements in the units are discouraged frommental health nursing as a career choice.

3.9.2 Aged CareThe aged care sector submissions citedparticular problems with the unregulatedworkforce, the perceived poor image of thespecialty in the profession, the physicallyarduous nature of the work, the undervaluedrole of Division 2 nurses in aged care, anddifficulties balancing care of clients with thedocumentation required for Commonwealthaccreditation. Other issues raised includefunding, postgraduate education, clinical careerpath, including a paucity of CNCs in areas such

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as dementia and continence management.Particular concern was also expressed about thefailure of the complete introduction of a no liftprogram.

3.9.3 MidwiferyThe Committee received numerousrepresentations about issues relating to ruralmidwifery. A key issue was that nurses withpostgraduate midwifery qualifications wereoften unable to practice in their chosenspeciality in rural areas. The principal reason isthat, in many hospitals, the number ofconfinements is insufficient to warrant full-timemidwifery practice, so that midwives areexpected to work in other clinical settings aswell. For those who do choose to practice therewas widespread concern that they wereeffectively being ‘deskilled’ through lack ofexposure to complex cases and lowconfinement rates. Conversely, new graduateswere reported to be reluctant to practise inrural areas as they were often expected to bethe sole practitioner on a shift, without thecollegiate and technological support availablein metropolitan facilities. Initiatives such astelephone support and clinical refresherexperience in metropolitan hospitals were citedas possible solutions to this problem.

In rural midwifery practice, conflict withmedical staff and the decline in the number ofgeneral practitioners (GPs) with obstetricpractices were raised as issues of concern.

The introduction of the casemix funding modelwas blamed by some midwives for theperceived fragmentation of midwifery care and,in particular, the inability of hospital-basedmidwives to offer quality postnatal carebecause of the trend towards short hospitalstay. Concern was also raised about thedifficulty facing midwives in private practice inobtaining admitting rights to hospitals.

The Committee received representations fromthe Australian College of Midwives Inc(ACMI), which highlighted its position onmidwifery training. In particular, the College isseeking introduction of direct entry midwiferycourses, in part to ensure that midwives areable to solely practice their chosen specialtywithout having to practice as generalists. Therewas insufficient information before the

Committee for it to recommend this as arecruitment strategy.

3.9.4 Critical CareCritical care nurses described major problemsin retaining staff and pointed to thecomparative rarity of experienced nurses in thespecialty. The high proportion of night dutyand the prevalence of burn out amongst staffwere cited as major contributing factors. Manynurses were critical of the Department ofHuman Services, pointing out that it hadpublished research (Department of HumanServices 1993, Department of Human Services1996) demonstrating problems in the specialty,but that no apparent remedial action had beentaken. The issues raised by this group havebeen considered in other areas of this report.

3.10 ManagementCriticism of nursing management wascommonly expressed. The criticism rangedfrom generalised problems with organisationalmanagement, and the way nurses were treatedand consulted in times of change, to issuesrelating to ward management. One of the mostcommonly cited opinions, both from juniornurses and nurse managers themselves, wasthat many nurse managers, due to workload,are unable to adopt leadership, mentorship andadvocacy roles in nursing, and that many nursemanagers lack basic human resourcemanagement skills or education.

A number of problems have been identifiedthat have contributed to the current problemsrelating to recruitment and retention ofexperienced qualified nurses in the Victorianworkforce. The major ones of these appear to beincreased workloads, and control overworkloads, fewer nurses (particularlyexperienced nurses) in the public system,casualisation of the workforce, unsafeworkplaces, equipment shortages, lack ofclinical career structure, support for nurses,education access, family issues, specific issuesfor rural nurses and those in specialty practiceand issues with management. Each of theseareas will be considered in detail in Part 2 ofthe report.

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Part 2—Strategies

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The Committee identified two areas ofrecruitment in which strategies need to beimplemented: • Attracting new people into nursing.• Recruiting back those nurses who have left

the nursing workforce.

In relation to attracting new people, the focus ison the image of nursing and undergraduateattraction.

4.1 The Image of NursingThe Committee coopted a representative fromthe Careers Education Association of Victoria(CEAV) to advise on strategies to improve theimage of nursing in schools. The rationale forthis was that other States are having difficultyfilling undergraduate places and data beforethe Committee indicated that manyundergraduate places were filled with studentsin second or third preference courses (seesection 2.2.1). The Committee, therefore,worked on the assumption that filledundergraduate courses could not be taken forgranted in Victoria in the long term.

The Committee was advised that informationaimed at influencing the career choice of schoolleavers should be targeted at students in Years9 and 10, and that current materials availableare sub-optimal. One issue of concern was thatcareers teachers are currently experiencingdifficulties in placing students for workexperience across all sectors of industry, and itwas noted that few hospitals are makingprovision for students to visit. Work experienceis cited as one of the most effective methods ofinfluencing the career choice of students.

The Committee was informed that nursing isnot effectively promoted in many schools as itis not considered prestigious because of itsrelatively low ENTER score. It was proposedthat one method of addressing this is toinstigate closer links between the Departmentof Human Services and the CEAV so thatteachers may gain a better appreciation ofnursing as a career option, and a greater

understanding of the wide range ofemployment settings available to nurses.

The Committee notes the recent expansion ofthe Victorian school nursing program, with 120nurses planned to be employed in Victoriansecondary schools. While the focus of theprogram is adolescent health, the fact thatnurses will be based in schools may be a usefulsource of information dissemination on nursingas a career.

Strategies will have to be developed to ensurethe nursing workforce better represents thecommunity it serves. Currently less that 8% ofAustralian registered nurses are male (AIH&W1999), and nurses from Croatian andVietnamese backgrounds are still markedlyunder-represented in the nursing workforce(Tang et al. 1999, Pitman & Rogers 1990). TheCommittee believes it is important to encourageculturally and linguistically diverse groups toenter nursing so that the composition of theprofession in Victoria can reflect the communityit serves.

4.2 Undergraduate RecruitmentIn addressing term of reference 2.8 (seeAppendix One) the Committee reviewedpublicity material available in other States toattract students into undergraduate programs.

The State Governments of Western Australiaand New South Wales were identified ashaving a coordinated package of publicitymaterial available for the wider community,and the South Australian and Queenslandrecruitment and retention reviews haverecommended similar approaches.

Western Australia has undertaken a recruitmentcampaign arising from research thatrecommended targeting school students(Donovan Research 1998). The theme of thecampaign is ‘Are you good enough to be anurse?’ and the campaign is based on a website (www.nursing.health.wa.gov.au),brochures, posters, cinema and radio

4. Attracting Nurses into the Workforce

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advertisements and the print media (Dolly andExpress magazines). Material has also beendeveloped for teachers. HealthWest (the HealthDepartment of WA) is currently evaluating theeffectiveness of the program and a request hasbeen made to supply Victoria with data whenavailable in order to inform the Department ofHuman Services’ deliberations concerning theneed for advertising campaigns.

The Committee reviewed representativematerial from other States to identify what typeof material should be developed for Victoria.The CEAV representative felt that none of theexisting material could be adapted for use inthe Victorian context without further research.

Any effort to attract nurses into undergraduatecourses will need to account for the changingdemographic of nursing undergraduates, as theaverage age of entrants is now 24.5 (AIH&W1999). While a proportion of this group arelikely to be Division 2 nurses undertakingDivision 1 programs there appears to be asource of nurses within an age group notpreviously targeted through recruitmentmaterial. The Committee believes further workshould be undertaken to identify thecomposition and information needs of groupsother than school leavers who may wish toconsider a career in nursing.

Figure 6: Undergraduate Profile by Age, Australia(AIH&W 1999)

Recommendation 9: That the Department ofHuman Services:

a. Liaises with the CEAV and VictorianDoNs (public and private) to increase theprovision of the number and quality ofwork experience places for Year 10secondary school students.

b. Explores the feasibility of using theschool nurse network as a method ofraising the profile of nursing amongstschool students.

c. Works closely with CEAV to ensure thatteachers have a better understanding ofnursing as a career.

d. Undertakes research to prepare a core setof materials to be made available for highschool students describing the role andeducation pathways for nursing. Thematerials should emphasise the variety ofclinical settings, should avoid gender andracial stereotypes and should give equalprominence to Division 1 and 2 educationpathways. The materials should also beavailable in both paper and electronicformats.

e. Seeks advice on materials and strategiesto attract people in age groups other thantraditional school leavers to considernursing as a career.

4.3 Attracting Nurses Back intoNursingThe Department of Human Services labourforceprojections indicated that, in 1998, there were13,461 nurses (or 19% of registered nurses) notworking in nursing. To attract these nurses backinto the workforce, the Committee needed toknow why they left and what theirrequirements were for returning

4.3.1 Registered Non-Working Nurse andUnregistered Nurse ReportsThe Minister for Health charged the Committeewith making recommendations on nursingrefresher and re-entry courses. The Committeemade interim recommendations for theexpenditure of funds committed by theGovernment for 2000 based on available data.The Committee commissioned CampbellResearch & Consulting to undertake a survey of

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> 399.5%

30–3917.4%

<2038.1%

20–2935%

nurses who had indicated, through registrationwith the NBV, that they were not currentlyworking in nursing. The survey was conductedaccording to NBV privacy guidelines and theresponses received were anonymous. Thesurvey yielded quantitative and qualitativedata, both reported separately (appendices 3and 4). The quantitative survey showed that51% of registered nurses not currently workingas a nurse planned to actively seek work as anurse, with a further 32% unsure. TheCommittee believes that this group, withcarefully managed and supported re-entrystrategies, represents an important source ofnursing labour.

During the promotion of public forums fornurses, the Committee advertised for nurseswho are no longer registered to complete asurvey on re-entry requirements and workingintentions. The response rate to the survey waslow (n<100), therefore, the Committee treatedthe data as indicative only. It was noted thatmuch of the material gleaned from the surveywas consistent with the findings of theCampbell Research & Consulting reports.

4.3.2 Framework for Re-EntryThe Committee drew a distinction betweenrefresher and re-entry courses. Refreshercourses are designed for nurses who are stillregistered, while re-entry programs (includingsupervised practice) are a NBV requirement fornurses who have allowed their registration tolapse and do not meet the recency of practice

provisions under section 14 of the Nurses Act1993.

Re-entry courses, including supervised practice,for unregistered nurses must be accredited bythe NBV, both for theoretical context andclinical experience.

The Committee sought information on thecurrent supply of refresher courses, both with(category 2) and without (category 1) a formaleducational component. In addition,information was sought on the supply of NBVaccredited supervised practice (category 3) andformal re-entry courses (category 4).

The results show that, of the public hospitalsaccredited by the NBV to conduct courses incategories 3 and 4, few actually run them. Infact, of the projected throughput for 2000 incategory 4, 50% will be through one hospital.

The Committee surveyed public hospitals onthe provision of refresher courses, with 58responses received. It found that only 21hospitals were running such courses, with orwithout a formal education component, and109 nurses undertook such courses in 1999. Theprincipal reason given by most hospitals for notrunning courses was lack of demand. Ofconcern to the Committee was that, of thehospitals offering refresher courses, none paidparticipants despite the requirement to do sounder section 6 (a)(6)(1) of the Nurses (VictorianHealth Services) Award 1992.

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Table 4: Supply and Demand—Public Sector Refresher and Re-Entry Programs, 1999–2000

Course Type Hospitals Nurses Projected Waiting Fees Any facilities

conducting through throughput list charged to offering free

courses in 1999 2000 nurse —range courses ?

Informal refresher courses (1) 8 38 43 5 $450–1500 Y

Informal refresher courses

with educational component (2) 13 71 45 3 nominal–$900 Y

Accredited supervised practice (3) 15 40 79 35 $650–1500 Y

Accredited re-entry courses (4) 5 45 83 19 $70–2500 N

4.3.3 Distribution and Cost IssuesThere is a marked maldistribution of re-entrycourses across the State. Mental health nurseswishing to undertake a course of supervisedpractice can only do so currently in Bendigo,Dandenong and Parkville, while Division 2nurses wishing to undertake re-entry coursescan only do so in regional Victoria. In addition,while a large number of facilities are accreditedto run supervised practice and re-entry courses,many have little or no throughput activity.

The survey of unregistered nurses informed theCommittee that there is unmet demand for re-entry courses where the clinical experience isprovided at a local level. Demand for courses isalso cost sensitive, both in terms of the coursecost and lost income and incidental expenses,such as travel. Nurses are ineligible forpayment by hospitals while undertakingcourses, as they are not registered.

The Committee argues strongly for theestablishment of a network of re-entry coursesand accredited supervised practicearrangements to service all areas of the State.This will ensure that nurses required toundertake clinical experience are able to do solocally, minimising transport costs anddisruption to family life.

The Committee recommends that all Group A,B and C hospitals (That is, the larger teachingand base hospitals, and smaller regionalhospitals) have access to supervised practiceand re-entry courses. This may involveconsortia arrangements with other hospitals,services or education providers, however, toaccess funding, such arrangements must notinvolve cost to participants. All courses willhave to be accredited with the NBV. It shouldbe noted that the NBV does not stipulateminimum clinical hours to be worked duringre-entry courses or supervised practice

programs, as the length of the program isdetermined by individual assessment of theknowledge and skills required.

The Committee reviewed the data onsupervised practice and re-entry courseprovision in relation to cost to participant. Itnoted that, while some facilities offered lowcost access, availability was often hampered byfactors such as other calls on clinical educatortime. In facilities with high throughput, the costof providing such courses ranged from $1,500to $2,500, while university based courses costup to $3,500. The Committee recommends thesum of $2,100 be offered to facilities for everynurse put through these courses on the basisthat this appears to represent the middle rangeof current fees charged. It is anticipated that thepayment will reduce the prevalence of high costcourses and will act as an incentive to facilitieswith little current activity to provide morecourse places.

Recommendation 10: That the Departmentof Human Services ensures that Group A, Band C public hospitals have access torefresher and re-entry programs forDivision 1 and 2 nurses, and that regionalmental health services have programs inplace for nurses in Divisions 1 and 3.

Recommendation 11: That Governmentprovides funding to participating hospitalsof $2100 for each nurse undertaking re-entry programs or accredited supervisedpractice programs.

The following criteria must be met:• Tailored nursing program must contain

clear learning and performanceparameters.

• Nurses participating in the re-entryprogram will not be charged fees or othercosts.

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Table 5: Distribution by Location and Division of Public Sector NBV Accredited Courses

Div 1 Div 1 Div 2 Div 2 Both Both Div 3 Div 3 TotalDiv 1 & 2 Div 1 & 2

(Metro) (Rural) (Metro) (Rural) (Metro) (Rural) (Metro) (Rural)

Supervised Practice 4 2 1 2 1 16 2 1 29

Re-entry 3 0 0 1 0 0 0 0 4

• The course must be accredited by theNBV.

• The educational component of the re-entry course may involve consortiaarrangements as appropriate to localneeds.

(NB this recommendation specifically excludes overseas trainednurses undertaking DETYA/Department of Human Services fund-ed conversion courses, as they are already funded jointly byDepartment of Human Services and the Commonwealth under adifferent model).

The Committee considers that nursesundertaking re-entry courses and supervisedpractice experience, who are ineligible forpayment, face severe financial hardship,particularly if they have been previouslyemployed. A notional payment, based on theminimum Austudy allowance, would assistparticipants to pay for costs incurred duringthe course, such as travel.

Recommendation 12: That Governmentprovides funding of $130 per week (FTE) toeach unregistered nurse undertaking a re-entry program or accredited supervisedpractice program, in line with currentAustudy arrangements. Rural nursesrequired to travel more than 100km eachway to undertake a program will attract$170 per week (FTE), to reflect the increasedburden of travel costs on rural nurses.

Information gathered through the focus groupconsultations highlighted a degree of ambiguityand dissatisfaction with the informationprovided by the NBV in relation to themaintenance of registration and re-entry to theregister. In addition, the focus groups raisedproblems with the NBV’s definition of‘sufficient nursing practice’ for registration, inthat the Board’s criteria were not felt to bewidely understood.

Recommendation 13: That the NBV reviewits current policies, procedures andpublications in relation to recency ofpractice requirements.

4.3.4 Refresher CoursesSkills update or refresher courses are not theonly means for nurses who hold currentregistration to re-enter the workforce after a

break of practice. Some negotiate orientationand supervision arrangements with employersas part of an employment arrangement, whileothers require minimal or no assistance at all.The degree of supervision and confidencebuilding required by nurses re-entering theworkforce, or changing clinical practice setting,should be a matter of individual negotiationand should result in mutually agreed learningoutcomes. The Committee views with concernsubmissions outlining complex, standardisedrefresher courses for nurses, of considerableduration and cost to the participant, that havebeen submitted to the Department of HumanServices.

It is the Committee’s view that refresher orreskilling arrangements should be consideredas a legitimate recruitment tool for healthservices rather than as a source of revenue, andthat hospitals should adopt a uniform approachto currently registered nurses wishing to re-enter the workforce or change practice setting.

Recommendation 14: That regionally-basedhealth services establish a uniformapproach to refresher programs thatconsider both education and clinicalrequirements of the individual nurse, andmay include consortia arrangements as amethod of program delivery.

The Committee is of the view that providingfunding to hospitals for short ‘return topractice’courses of three weeks duration, asapplied in the United Kingdom (Department ofHealth 1999), may assist in returning nurses towork. Providing such courses in each mentalhealth service, major teaching and base hospitalwill assist in retaining nurses, unlike thecurrent arrangements where a few facilitiesoffer courses and then lose participants tohospitals closer to the participant’s home. TheCommittee acknowledges that some nurses willneed more than three weeks to reach requiredcompetency and confidence, while others mayneed less. However, as submissions before theCommittee indicate that many nurses areprepared to return to work if reskillingarrangements are expedited, the Committee isof the opinion that funding based on a three-week model may go some way to facilitate theirreturn to work.

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The Nurses (Victorian Health Services) Award1992 section 6 (a) (6)(1) makes provision forregistered nurses undertaking refresherprograms to be paid, however, the commonpractice is that this program is undertaken inan unpaid capacity. The Committee believesthat registered nurses undertaking refreshercourses are contributing to the nursingworkforce and should be paid their legalentitlements under the Award.

Recommendation 15: That the Governmentpays $450 to each health service providingrefresher or reskilling programs for everyregistered nurse not currently practicingthat they place on a refresher or reskillingprogram.

The following criteria must be met: • Individual nursing programs must

contain clear learning and performanceparameters.

• Nurses participating in the refresher orreskilling program will not be chargedfees or other costs.

• Nurses undertaking refresher orreskilling programs are entitled to bepaid according to the provisions of theNurses (Victorian Health Services) Award1992.

4.3.5 Cost of RecommendationsThe preceding recommendations are predicatedon funding of $740,000 per annum beingavailable for refresher and re-entry courses, asper the Government’s policy commitment. TheCommittee advocates $500,000 being madeavailable for re-entry courses and $240,000 forrefresher courses. It is anticipated that fundingwould enable 533 nurses to undertake refreshercourses and 120–136 nurses to undertake re-entry courses under the recommendedarrangements.

The Committee cautions that the gains will beinitially modest due to the preference for manynurses to return to work on a part-time orcasual basis only. The Committee believes thatsome of the current arrangements for nurses tore-enter the workforce are cumbersome,expensive and act as a disincentive to thosewho are perhaps ambivalent about resumingtheir career. To this end it is proposed that a

formal campaign to encourage nurses back towork be considered.

Recommendation 16: That the Departmentof Human Services conducts a statewideadvertising program aimed at encouragingboth registered non-practicing andunregistered nurses to return to work.

4.4 Injured NursesOf concern to the Committee was theproportion of nurses responding to the varioussurveys that had left nursing because of illnessand injury. Of the unregistered cohort, 18%gave this as the principal reason, while thesurvey of registered nurses highlighted theissue of many nurses leaving the professionbecause of physical illness, such as back injury,or as a result of psychological stress.

The qualitative survey of registered non-working nurses shows that many injurednurses wish to return to work, but feel unableto do so because of lack of support frommanagement and colleagues, and because ofthe physically and mentally demanding natureof the work.

While the Committee believes that Governmentinitiatives such as the appropriate manualhandling initiatives will reduce the number ofnurses who leave the profession because ofinjury, there are still nurses who should besupported back into the workplace, boththrough the occupational health and safetyframework and through the support of fellownurses.

Recommendation 17: That the Departmentof Human Services explores the extent towhich return to work programs for injurednurses have been implemented in publichealth care facilities in Victoria.

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The Committee has received a range ofsubmissions in relation to the education of alldivisions of nurses in all education areas,namely undergraduate, postgraduate, graduatenurse year and continuing education. Inaddition, a number of submission werereceived regarding the education for mentalhealth nursing practice. Concern was alsoexpressed about the State Government’s T&DGrant. Education was, therefore, considered bythe Committee to be a major issue in relation toboth recruitment and retention of nurses in theVictorian workforce.

5.1 Undergraduate Education5.1.1 Division 1Three major themes emerged in relation to theundergraduate preparation of Division 1nurses:• Clinical placements• Preparation for speciality practice• Rural issues.

5.1.1.1 Clinical Placements

Access

Clinical experience is an essential part of theundergraduate curriculum as it enables theapplication and consolidation of theory and thedevelopment of the competencies required of abeginning nurse. A consistent theme raisedbefore the Committee was the readiness ofgraduates to practice as beginning levelpractitioners on completion of theirundergraduate course. In many instances it wasperceived that the quality and/or quantity ofclinical experience in the undergraduate coursewas insufficient, with the result that newgraduates were ill-equipped to cope with therealities of clinical practice in the clinicalsetting. The major factors contributing to thisperception were difficulties with access toclinical facilities, preparation of clinicalsupervisors and preceptors, and the learningenvironment in the clinical area.

To prepare the nurse for beginning practice,clinical placements are required in a widevariety of settings, in all years of the course.Both hospitals and universities have reported tothe Committee that obtaining clinicalplacements for students is an increasinglydifficult task. Changes in the health system inrecent years have reduced overall bed numbersand clinical placement opportunities, whileallied health and medical students seekplacements in the same diminished clinicalsettings. Some hospitals have indicated theywill take third year students only, while othersonly offer placements in a limited range ofclinical areas.

One way to guarantee clinical placements is fora university to affiliate with one or morehospitals. Under such arrangements studentsfrom a particular university are given firstchoice of the available clinical placements. Aswell as assuring clinical placements, thisapproach has the advantage of increasing thefamiliarity of the student with the hospital(potentially engendering a sense ofidentification), and consequently enhancingtheir learning opportunities. Hospital staff arebetter able to familiarise themselves with thelearning objectives of the university and canidentify to a greater degree with the students.These arrangements are generally not exclusiveand both universities and hospitals have acapacity to utilise other institutions ifcircumstances require. It may mean, however,that students from other universities becomelimited in the choice of clinical placementsavailable to them.

Currently , there is no data indicating whatclinical facilities are available statewide andhow they are being accessed by students ofnursing. In order to rationalise the scarceresources available to medical students, bothVictorian medical schools coordinate their useof clinical places. It would be advantageous tonursing if a similar approach were adopted.

5. Education of Nurses

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Recommendation 18: That the VictorianDeans of Nursing carry out a mappingexercise to ascertain both the availability ofclinical placements within the healthsystem and the requirements of thestudents for such placements. The results ofsuch a project should form the basis for theestablishment of a coordinated system tofacilitate bookings and placements of allundergraduate nursing students.

Funding

The Victorian Deans of Nursing have identifiedseveral issues associated with funding andsupport for the clinical component of theundergraduate nursing programs. The relativefunding model (RFM) for nursing does notadequately reflect the increasing costsassociated with clinical supervision of studentsat a ratio of one clinical teacher to eightstudents (a registration requirement).Additional problems exist within universitiesregarding the wide variation in the wayfunding is allocated to undergraduateprograms in nursing. The Australian Council ofDeans has raised with the DETYA the urgentneed for a review of the RFM disciplineweighting for nursing across Australia.

These funding issues are seen as one of thesignificant contributing factors to the problemspresented to the Committee in relation to theundergraduate nursing program, particularly inrelation to the commonly held view that newgraduates lack the practical skills required forclinical practice.

Recommendation 19: That the Minister forHealth, in conjunction with the VictorianMinister for Post Compulsory Education,Training and Employment, approach theCommonwealth to review the fundingmodel for the clinical learning componentof the degree programs leading to nursingregistration to ascertain if the current levelaccurately reflects the true costs of clinicallearning programs.

Preceptors

Those who act as clinical supervisors orpreceptors may be provided by either theuniversity or seconded from the health carefacility. The stated advantage of this latter

approach is that hospital staff know both thehospital environment and the nurses workingthere, and the nurses know them. This not onlypromotes the student’s acceptance into thehospital environment, but also contributes to asense of common purpose, leading to a morefulfilling educational experience.

Supervision/preceptorship of students is a skilland needs to be supported by education, yet inthe hospital environment the educationopportunities for nurses to take onpreceptorship roles may be limited. Nursestaking on these roles without adequateeducation may unwittingly contribute to anegative experience for students.

Funds are made available to hospitals, via theundergraduate teaching allowance componentof the T&D Grant, to support undergraduatestudents (section 5.6.1). Such funds should beaccessed for the education ofsupervisors/preceptors.

Recommendation 20: That nursesundertaking preceptorship roles haveaccess to suitable education to equip themto perform this role. Funding for theseprograms should be accessed through theundergraduate teaching allowance of theTraining and Development Grant.

Learning Environment

The quality of clinical experience is influencedby the capacity of hospitals to provide apositive learning environment for studentswhile on placements. Many factors impact onthis capacity. As indicated elsewhere in thisreport, workplace issues have hampered thecapacity of nurses to provide education andsupport to undergraduate students. Inparticular, the core group of experienced,permanent staff have increasingly had to takeon a disproportionately prominent role insupporting students, in addition to the otherfunctions required to maintain a hospital wardor clinical unit. As nursing workloads haveincreased, the capacity to support students hasreduced. In such an environment the support ofstudents is at risk of being perceived as anadded burden rather than a core professionalresponsibility. In order to address theseproblems, hospitals and universities haveadopted a number of strategies. The issue of a

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learning environment and acceptance ofstudents goes to the core of many of theproblems surrounding the undergraduatecourse. The extent to which students feelwelcome and valued is an important factor inachieving the goals of the clinical placementand their image of nursing.

Submissions before the Committee have raiseda number of issues relating to the clinicallearning component of the undergraduatecurriculum, not only in terms of access but alsoin relation to the supervision provided to thestudents and the learning environment of thehospitals. A review of clinical learning requiresinput from not only the Department of HumanServices and Victorian Dean of Nursing, butalso the Directors of Nursing.

Recommendation 21: That the Departmentof Human Services establishes a workingparty with the Victorian Deans of Nursing,Directors of Nursing and other relevantbodies to review the clinical learningprograms in the undergraduate programsfor Division 1 nurses to develop a statewidestrategy to maximise clinical learningoutcomes.

5.1.1.2 Preparation for Specialty PracticeThe issue of preparation for specialty practicewas a constant theme raised in relation tomental health nursing and these issues will beconsidered separately in section 5.1.2. However,the issue was also raised by a number of othergroups, in particular aged care, critical care,operating room, neurosciences and renalnursing. The perceived lack of theoretical andclinical learning in these areas was seen ascontributing to ongoing recruitment difficulties.

The foundation for fostering interest in clinicalspecialties begins at undergraduate level. TheCommittee recognises that additional specialtyplacements have the potential to placedemands on an already crowdedundergraduate curricula. The capacity toaccommodate increased specialty content islimited, particularly in the context of competingcalls for more areas of clinical practice. Thus,the current length of the undergraduate degreecourse is an issue that needs furtherexamination. A view put to the Committeeargued that a four-year undergraduate course

would allow these issues of specialty content tobe adequately addressed, especially though astreaming model. This approach is notuncommon in other health and human servicedisciplines; social work, physiotherapy,radiography, podiatry and pharmacy coursesare all of four-year duration in Victoria.Innovative curricula in nursing already existand evaluation of these programs and theimplementation of other programs should beencouraged.

Recommendation 22: That the VictorianDeans of Nursing through the Nurse PolicyBranch develop a group of relevantstakeholders (including the professionalcolleges) to review the place of the specialtycomponents within the undergraduatecourse. This review should investigate thedevelopment of innovative curricula whichtakes into account the accommodation ofspecialist areas through streaming and alsoconsider the appropriate length of fundeddegree programs leading to nursingregistration in the context of this issue.

5.1.1.3 Rural Undergraduate PlacementsIn its health policy, the Government made acommitment to provide resources to supportclinical placements for 400 undergraduatenursing students a year in rural hospitals(Australian Labour Party, Victorian Branch 1999).

Given the shortages of nurses who understandthe needs of rural communities, incentives arerequired to increase the number who accessrural placements during their undergraduatecourse.

The additional costs incurred by rural studentson placements have been well documentedover the years as a disincentive to undertakesuch placements. These costs can include travelcosts, often over significant distances;accommodation costs, which may relate to twoabodes as mortgage and rental expenses mustbe maintained; and child care costs.

This initiative should target those students whoare more likely to enter the workforce oncompletion of their undergraduate programs.Therefore, it should apply only from year twoof the course as it is in year one that the highestattrition occurs.

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The Commonwealth funded a one-off schemethat has now ceased: the approach used for thatprogram is recommended to be used inVictoria.

Process

The criteria for the Victorian incentive willexclude those who receive any other financialsupport. To this end, the scheme needs to beadministered centrally and the Department ofHuman Services is well placed to do this. Inorder to ensure equity and transparency, if thereare more applications than available funding,then a ‘first come’ basis would be used, onceequity across regions had been achieved.

The issue of a time limit was considered by theCommittee. In agreement with the formerCommonwealth scheme, the minimum was setat two weeks. The Committee believed thatsome students might be disadvantaged by theformer Commonwealth scheme’s upper limit offive weeks. Information before the Committeesuggested that some of the rural placementsexceeded five weeks. Consideration was givento extending the upper limit to 10 weeksHowever, more information needs to becollected and the Committee thereforerecommends that for the first year of thescheme the upper limit be five weeks. After theinitial uptake in 2001, the process will bereviewed with consideration given to theviability of introducing a 10-week upper limitfor some students.

Recommendation 23: a) That financial support of $100 per week

be provided to both metropolitan andrural undergraduate students in theirsecond and subsequent year(s) of theundergraduate course undertaking ruralplacements, where significant travel andaccommodation costs are incurred.

b) That Department of Human Servicesadministers this initiative using thefollowing criteria. That the student be:• An Australian permanent resident or

citizen undertaking a rural placementin the second or subsequent year(s) ofa Bachelor of Nursing program.

• Not in receipt of any other scholarshipor grant for this purpose.

• Required to travel in excess of 100 kmeach way from their usual place ofresidence to attend the ruralplacement.

• Required to provide supportingdocumentation from the universityacknowledging placement.

• Required to undertake a placement ofnot less than two or more than fiveweeks,

c) That the Department of Human Servicesadopts a ‘first come’ basis once equityacross regions had been achieved, for itsallocation, should the number ofapplicants exceed the available funding.

d) Department of Human Services reviewsthe initiative as a retention strategypaying particular attention to the lengthof the time of the placement.

5.1.2 Undergraduate Preparation forNursing in Mental HealthIssues relating to preparation of nurses formental health nursing have been highlighted tothe Committee. In essence, the concerns relateto attraction of nurses to the mental healthfield, and curriculum content, both theoreticaland clinical, relating to psychiatric nursing toensure that beginning nurses, whether in ageneral or specific mental health setting, areable to provide quality care for the mentally ill.

5.1.2.1 Attraction to Mental Health Area During the 1980s, Australia developed andimplemented the national mental health reformprocess. This process has had far reachingconsequences for the practice of psychiatricnursing. The key platforms of reform weredeinstitutionalisation and the mainstreaming ofmental health services into general healthsettings. The result of these changes has beenthe closure of the stand-alone psychiatrichospitals and the transition to a community-focused mental health service system, with onlya small number of inpatient beds remaining forthe acutely ill. The reform process has also leadto mental health consumers making greater useof health and other human services.

In the mid-1990s, university-basedundergraduate direct entry psychiatric nursingcourses were phased out. The Nurses Act 1993

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no longer required the separate registration ofpsychiatric nurses and the Division 3 registerwas closed to new entrants. Nurses successfullycompleting the undergraduate degree innursing were registered in Division 1 and thisbecame the entry-level qualification for nursesseeking to work in mental health settings. Theview was that the undergraduate degree wouldprovide an adequate mental health content toprepare nurses to practise as beginning levelpractitioners in mental health facilities, and allnurses would have some mental health nursingskills. Those nurses seeking to practice beyondbeginning level in mental health wouldundertake postgraduate studies.

Since this change, mental health servicesconsistently report significant difficultiesrecruiting nurses into their services, with sub-specialties such as psychogeriatrics reportingeven greater difficulties. This view was alsosupported by submissions to the Committeefrom professional and industrial bodies.

The Department of Human Services MentalHealth Branch, in its submission to theCommittee, described the current situation as a‘crisis in mental health nursing’. Itcharacterised the crisis as a situation wheredemand exceeds supply, and where pre-servicepreparation is inadequate, leading to a shortageof new graduates entering mental healthsettings. The Victorian group of theANZCMHN suggested it would support anyinitiative developed by the Department ofHuman Services to change the image of mentalhealth nursing and therefore attract nurses tothe area. Such an approach would need tocommence with programs aimed at schools.

Recommendation 24: That the Departmentof Human Services, together withANZCMHN, develop a marketing strategyto attract and recruit nurses into the mentalhealth areas.

5.1.2.2 Undergraduate Curriculum ConcernsFrom the submissions put to the Committee itcould be concluded that the preparation atundergraduate level has not been adequate. Inaddition to a failure to attract nurses to themental health area, nurses in general healthsettings do not have adequate mental healthskills. Nurses in mental health settings struggle

as beginning level practitioners and the uptakeof postgraduate studies has been poor.Attention needs to focus on the undergraduateprogram.

This concern is not peculiar to Victoria. A recentCommonwealth Department of Health reportinto the National Mental Health NursingWorkforce identified undergraduate nurseeducation as a key issue, stating that currentcourses provided an ‘inadequate theoreticaland clinical preparation for the beginning levelpractitioner of mental health nursing’ (Clinton1999).

Within the Victorian context, in 1995, the thenMinister for Health wrote to the heads ofschools of the Victorian universities and theNBV expressing concern about the psychiatricnursing content in the undergraduate degree.As a result, a survey of Victorianundergraduate curricula was undertaken,which reported considerable variation in theidentifiable psychiatric content, ranging from,at worst, no discrete content to, at best, 17.4% ofthe curricula (Department of Human Services1998). Mirroring this finding, a survey of newgraduates of the comprehensive curricula whohad chosen to work in the mental health sectorfound that they did not feel adequatelyprepared (Pante 1999). The currentGovernment, in its mental health policy, statesthat it would ‘examine ways of expanding theundergraduate training of nurses to moreadequately prepare them to work in mentalhealth settings’ (Australian Labor Party,Victorian Branch 1999).

Information from the forums confirmed theposition that undergraduate programs were notadequately preparing new graduates fornursing in mental health settings. A seniornurse highlighted this when she reported thatshe now employed allied health graduates inpreference to nursing graduates because oftheir better mental health knowledge.

The undergraduate program is also notadequately preparing graduates who work ingeneral health settings with people who havemental health problems. A key goal of thenational mental health reform process has beento increase the use of health and humanservices by people with mental health

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problems. Thus, there is a need for nurses tohave enhanced mental health skills in order tomeet the needs of these patients. The SecondNational Mental Health Plan, which identifiedthe role of health services in the provision ofservices to mental health consumers, sought topromote amongst health services an increasedknowledge and understanding of mental healthand mental disorder as well as an awareness oftheir additional needs (Department of Healthand Aged Care 1998).

The undergraduate curriculum not only hasproblems with the amount of theoreticalcontent included, but also with the clinicallearning component for mental health nursing.Two issues have been raised with theCommittee, firstly access to a range ofpsychiatric and mental health settings and,secondly, the clinical learning environment.

A broader range of placements not only allowsgreater numbers of students to experience thesector but leads to a more positive experiencefor the student. Some mental health servicesoffer students placements in all components oftheir organisation, including CAT teams.However, the Committee heard of some mentalhealth services that would not take students atall, others taking only third year students, andsome placements restricted to specificcomponents of the service. In somecircumstances only the traditional ‘placesstudents go’, such as inpatient units orcommunity care units, were offered. Othercomponents of the service capable of takingstudents, such as CAT teams or MobileIntensive Support Teams, are under either notoffered, or used only occasionally.

It has been reported to the Committee thatwhere a mental health service has a clearstrategy in place to provide clinical placementsand encourage educationally rewardingexperiences for undergraduate students, it canattract graduates into their services withoutdifficulty. This approach needs to be extendedacross the whole of the mental health sector.

Recommendation 25: That all area mentalhealth services offer placements,appropriate to the clinical learning needs ofstudents, at all stages of the undergraduatecourse. The requirement for agencies to

provide these placements, within theirservice capacity, be incorporated into healthservice agreements between theDepartment of Human Services and theindividual agencies.

As with all other clinical placements, how thestudents are welcomed and valued influencestheir commitment to the area. The learningenvironment must be a positive one for thestudent.

A view put to the Committee was that thereappears to be residual resistance in the mentalhealth sector towards the undergraduate‘comprehensive’ nursing course. This hascontributed to a less than enthusiasticwelcoming of students (and graduates) of thecurrent undergraduate course. The prevailingattitude in some parts of the mental healthsector appears to be that the nursing educationsystem has failed psychiatric nursing and that itshould therefore be ignored. This view is self-defeating and only serves to compound currentproblems.

As indicated above, the role of the clinicalsupervisor/preceptor is crucial in setting apositive learning environment for the student.This is equally true in the mental health sector.Clinical supervisors/preceptors requireeducation to prepare them for their role.Identifiable funds need to be available tosupport undergraduate placements: in the acutesector the ‘undergraduate teaching allowance’component of the T&D Grant is designed tosupport this activity. In the mental health sectoran appropriate proportion of training moniesneed to be identified for this purpose. SeeRecommendation 20, section 5.1.1.1.

It has been suggested to the Committee thatmental health services need to take a moreproactive stance in making placementsavailable and supporting students onplacements. To overcome the problem ofattracting nurses into the mental health sector,the sector must market itself more effectively toits potential future nursing workforce.

To address the curricula issues, guidelinesrelating to the mental health content of theundergraduate courses need to be developed.These guidelines should be adopted by the

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NBV as a requirement for the mental healthcontent in courses the NBV accredits as leadingto registration as a nurse. A group coordinatedby the Department of Human Services MentalHealth Branch comprising the Nurse PolicyBranch, the Centre for Psychiatric NursingResearch and Practice, the ANZCMHN,Victorian Deans of Nursing, relevant peaknursing bodies and service providers, togetherwith the NBV, should examine this issue. Thisreview will need to be completed mid-2001 inorder for the guidelines to be adopted by theNBV and the curricula modified in time for thefollowing academic year (2002). As some workhas already been completed in this area, thereport Undergraduate Nursing Education inVictoria: Psychiatric Knowledge, Attitudes and SkillRequirements for Beginning Level Division 1 nurses( Department of Human Services 1998) couldinform this process.

Recommendation 26: that the mental healthbranch of the Department of HumanServices coordinates a group of relevantstakeholders to review the mental healthcontent—both theory and clinicallearning—of the Bachelor of Nursingcourses and make recommendations to theNurses Board of Victoria as to theguidelines that should be adopted inrelation to mental health content. Thisprocess to be completed by June 2001 inorder that the guidelines developed can beadopted for the 2002 academic year.

5.1.3 Division 2 Nurse EducationThe report of the National Review of NurseEducation in the Higher Education Sector (1994)identified Division 2 nurses as an integralcomponent of the health care system, ‘...there isa move away from the role of the RN as ageneral broad based practitioner, with the ENtaking part of that role’. In order to fulfilgreater expectations, Division 2 nursingeducation needs to reflect current industryneeds. The contributions of the Division 2 nurseto the health care industry has been limited bya lack of awareness of their potential (Dunn1998).

The Commonwealth (AIH&W 1998) identifieda 37% decrease in enrolled nurse numbers inthe workforce between 1991 and 1996. As

discussed in 2.2.1, a shortage of Division 2nurses developed through the 1990s followingthe closure of the Melbourne School forEnrolled Nurses (Bassett 1993). Thecombination of decreasing student numbers inthe years preceding 1992 and the closure of thelargest enrolled nursing school contributed to asignificant shortage of Division 2 nurses in themetropolitan area. This shortage was temperedin regional Victoria as a small number ofeducation programs continued in this setting.

The Nursing Workforce Survey (ACNMI et al.1999) identified that, despite educationrecommencing in the tertiary sector in 1995, ashortage of Division 2 nurses still exists,particularly in the aged care sector. TheVictorian data reinforces this finding showingin 1998 a net loss of 5% of the Division 2workforce (Department of Human Services19992). In addition, registration figures havereduced by 6.59% since 1996 (Table 2).

The current pre-registration course for Division2 nurses, the Certificate IV in Health (Nursing),was developed with an emphasis on aged care.In contrast, the previous hospital certificateprepared the graduates for a wider range ofsettings, including the acute care sector andmental health.

The Department of Human Services labourforcestudy (Department of Human Services 19992)showed that of the current Division 2workforce, 53% worked in aged care, 26% inacute care and associated specialties and 7% inmental health. A position frequently put beforethe Committee was the need to revise thecurrent scope of practice of the Division 2 nurseand, in particular, prepare the graduate for awider range of practice areas. The question ofwhether the preparation for extensions ofpractice for the Division 2 nurse should be atpre-registration or post-basic level is not onethat the Committee can answer.

An area identified as important in extendingthe scope of practice for the Division 2 nurse isthe administration of medications. In 1998 thethen OTFE funded a research project into theissues surrounding assistance with medicationadministration required by clients ofcommunity services and health organisations,and consequent training implications (CSHITB

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1999). In 1999 the then Minister for Healthrequested that the NBV undertake a study intothe expansion of the role of the Division 2 nursein relation to medication administration. TheNBV report is currently before the Minister forHealth. If the role is expanded in this direction,then the education underpinning such a changewill need to be considered at either pre-registration or post-basic level.

In addition, given the emphasis oncompetency-based curricula in the VET sector,it is important to note that the ANCI iscurrently reviewing the enrolled nursecompetency statements in the light of changesin current curricula and industry requirements.

The Committee has heard concerns expressedabout the quality and quantity of clinicalexperience within the Certificate IV in Health(Nursing) course. As with the Division 1program there have been concerns expressedabout both access to appropriate venues andthe learning climate. In particular, theCommittee’s attention has been drawn to thelimitations of clinical experience in areas suchas acute care and mental health. Problems havebeen identified in relation to the aged caresector, a situation exacerbated by the shortageof Division 1 nurses in the aged care sector andworkload issues. Further, as indicated in section6.3.2, Division 1 nurses do not alwaysunderstand the role of the Division 2 nurse.This may also impact negatively on the qualityof the clinical earning environment.

The Committee recognises that Division 2 is acareer path in its own right. However, one pathopen to the Division 2 nurse is articulation intothe Division 1 undergraduate program.Currently, in Victoria, between 15–25% ofentrants to the Division 1 undergraduate courseare Division 2 nurses. VET coordinators reportthat 23% of their graduates enter such aprogram immediately and a further 13% enterwithin three years. The amount of credit forCertificate IV in Health (Nursing) programsinto degree courses leading to registration as aDivision 1 nurse was also an issue boughtbefore the Committee. The amount of creditoffered varied between universities. The rangewas between two months to a full year. Itwould appear that universities that alsoprovide VET sector courses are more likely to

give a full year credit to a Certificate IVgraduate. There is no doubt that moreconsideration needs to be given to credit andrecognition of prior learning in the universitysector.

It is essential that the Division 2 curriculumreflects the demands of the health care industry.Revision of the pre-registration curriculumshould include the revised ANCI competenciesas well as increased scope of practice issues. Itshould examine the clinical experience and thearticulation arrangements in a Bachelor ofNursing (BN) program. A steering committeecomprising representation of all keystakeholders is essential to avoid duplication ofeffort, confusion and potential exploitation ofthe Division 2 nurse.

Recommendation 27: That the Departmentof Human Services convenes anintersectoral steering committee comprisingrepresentatives from vocational educationand training sector, the health care industry,the higher education sector, professionalorganizations, NBV, and the IndustryTraining Board. The role of this group willbe to address the educational issuesassociated with the developing role andexpanded scope of practice of the Division2 nurse. In particular, but not limited to, theCommittee should pay attention to:• The need to revise the Certificate IV in

Health (Nursing) curriculum, includingthe clinical practice component, to reflectrelevant changes flowing from changes inthe scope of practice, new modes ofservice delivery and current areas ofpractice, that is, acute care and itsspecialties, aged care, mental health andcommunity settings.

• The current credit transfer arrangementsbetween Certificate IV in Health(Nursing) course and undergraduatedegrees leading to registration inDivision 1

Funding of the clinical component of theCertificate IV in Health (Nursing) course hasbeen an issue since the program was firstimplemented. As with the Division 1undergraduate course, the funding modelappears inadequate. Prior to the course beingaccredited by the NBV, a request was made and

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granted by the then OTFE that additional hoursof clinical experience be added to thecurriculum. VET coordinators consider that thelevel of funding was not adjusted toaccommodate this change.

Recommendation 28: That the Minister ofHealth recommends to the Minster for PostCompulsory Education and Training thatthe level of funding for the Certificate IV inHealth (Nursing) reflect the requirementsfor registration.

5.2 Postgraduate Education5.2.1 Divisions 1 and 3Throughout the submission and consultationactivities of the Committee, issues relating topostgraduate education featured prominently.Clearly the most significant issue related to thecost of postgraduate education and the negativeeffect this is having on the nurses undertakingsuch studies. Access and the modes of deliveryof existing courses were also significant issues.For further discussion of issues associated withpostgraduate education and recommendationssee sections 5.5 (study leave), and 6.2.3(qualification allowance).

5.2.1.2 Cost of Postgraduate CoursesThe HECS course fee is $3,200 while the rangefor full fee paying places is $8,000–10,000. It isthe Committee’s view that the allocation ofadditional HECS places to postgraduatenursing would be a key strategy in addressingshortages in specialty areas.

The Committee undertook a survey on thesupply of, and demand for, postgraduatenursing places in Victorian universities. Thesurvey identified a disparity between availablepostgraduate places and those filled. In 2000,there was a total of 75 postgraduate nursingcourses offered. Of the 1,008 postgraduateplaces available across the range of specialistnursing courses, only 725 (72%) places werefilled. However, all of the 176 HECS placeswere filled, with the vacancies occurring in thefull fee paying places. Thus, the comparativelyhigh cost of undertaking postgraduate courseswas cited as a significant disincentive to furtherstudy and has contributed to the under-subscription to courses in 2000. If the numberof HECS places were to be increased, then the

uptake into such courses would be enhanced.As places in universities are a Commonwealthmatter, the issue needs to be addressed with theCommonwealth Minister for Education,Training and Youth Affairs to make more HECSplaces available for nursing nationally. Withinuniversities the available HECS places areallocated according to university profiles. TheMinister of Health should discuss with the ViceChancellors the matter of increased allocationof HECS places within the universities as arecruitment and retention strategy for nurses inVictoria.

Recommendation 29: That the Minister ofHealth:• Approach the Commonwealth

government to increase the number ofHECS places allocated to nursing.

• Approach the university Vice Chancellorsto increase the number of HECS placesallocated to nursing within Victorianuniversities.

A Government initiative had been to providescholarships for additional places for post-graduate education for nurses. However, inview of the low uptake of places, attentionneeds to be focused in the first instance onattracting nurses to undertake qualifications inthe identified areas of nurse shortages, namelyacute medical/surgical (metropolitan), agedcare, critical care, emergency mental health,perioperative and renal nursing (metropolitanand rural) and midwifery (rural). For futureyears the areas of need would be identified byboth the Department of Human Services on itsworkforce data and the hospitals with specificneeds. Given the disproportion of full feepaying to HECS places, it is recommended thatthese scholarships be 50% of the fee, but that acap be set at $4,500 in the first year. The healthfacilities may offer other financial incentives,such as a matched scholarship, or an up frontloan for the remaining 50%. In the allocation ofscholarships the ratio of rural to metropolitanwould need to be taken into consideration.

Recommendation 30: To increase uptake ofpostgraduate places:• That the Department of Human Services

a) funds scholarships to a maximum of50% of the fee (HECS or Full Fee) forpostgraduate courses in areas of

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identified need over the next three years,and b) establishes an equitable,transparent process and providesfeedback to the profession on the numberof places funded.

• That heath care facilities consider ways toprovide financial support to nursesundertaking such courses in identifiedareas of need.

• That a minimum of 25% of thesescholarships be allocated to regional/ruralareas.

• That the Nurse Policy Branch monitorsthis strategy and evaluates itseffectiveness as a recruitment andretention strategy by December 2003.

Access to Postgraduate Courses

Four issues were raised in relation to access tocurrent postgraduate courses. The first of theserelated to the mode of delivery of the courses.Concern was expressed about those coursesthat were offered at Master level only and didnot provide for exit points at graduatecertificate (six months FTE) and graduatediploma (one year FTE) level. The argumentput to the Committee was that the courses ofshorter length prepared the nurse to functionwithin the specialty area and would be anattractive option for some nurses, giving themthe choice of being able to continue theireducation at a later time. It also was viewed asa useful way of building confidence in thosenurses who considered that they might not besuccessful at postgraduate level and thereforewould not enrol in the more daunting higherlevel courses. Other universities offer singlesubjects as a way of easing students into themore extensive course. In this way, newknowledge and skills are learned in specificareas and the nurse may then gain theconfidence necessary to continue with apostgraduate course.

The second concern expressed was that somecourses were offered in full-time and on-campus mode only. The loss of earnings wascited as a disincentive to full-time study andthe need for more flexibility in mode of studywas urged. Some universities are alreadyoffering considerable flexibility and informationabout such courses should be disseminatedwidely.

The third issue raised was the availability ofrecognition of prior learning provisions by theuniversities to allow maximum credit intopostgraduate courses. Learning should be seenas a lifelong venture, with the ability toarticulate into programs at different entrypoints. Currently a diverse range of clinicallyfocused nursing education is offered either as aone-off session or an extended module todevelop an in depth understanding of the topicarea. These modules are an efficient way tooffer skill development in areas of needidentified by the health service. The continuingeducation unit might offer them in a healthfacility, a university or in a collaborativeundertaking. A collaborative review of thecontent of such continuing education modulescould result in a system whereby thecontinuing education modules are granted ascredit to appropriate postgraduate courses. Inthis way, modules are developed that not onlymeet the need for knowledge and skillenhancement in clinical areas, but enable asystem to be established that gives maximumrecognition of prior learning, to make learningseamless.

Some universities have established their ownprofessional development units. Students inthese units are not required to have enrolled ina postgraduate course but can undertake studyin particular disciplines. This has madepostgraduate education more manageable for anumber of staff in terms of both financial andtime commitments.

Ease of access to postgraduate courses andmaximum recognition of prior learning areconsidered by the Committee to be strategies tofacilitate uptake of postgraduate places andthus enhance the further development ofqualified nurses in the nursing workforce.

Recommendation 31: That the VictorianDeans of Nursing develop options tofacilitate easier access to postgraduatestudy, especially through theencouragement of multiple entry and exitpoints, a variety of modes of delivery andsystems that enable maximum recognitionof prior learning, especially learningachieved through continuing educationmodules.

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The final area of concern about access topostgraduate courses related to the difficultiesof individual universities meeting the needs ofsmall numbers of nurses wanting to study inspecialist areas. For example, courses in renal,neonatal and neuroscience nursing were offeredin 2000 by more than one university, but in totalattracted comparatively small numbers ofapplicants. A renal nursing course was offeredby two universities but one discontinued thecourse as it could not attract sufficientapplicants to make the course viable. Withinthe range of postgraduate courses availablethere will always be a proportion of coursesthat will attract small numbers. This howeverdoes not obviate the need of the health industryto receive graduates from such courses. In fact,renal nursing is a current area of shortage.Offering courses for small numbers of studentsis not a financially viable option anduniversities will chose not to offer thesecourses. This effectively reduces access forstudents to their university of choice. Whilealternative modes of delivery can be beneficialin such circumstances this approach does notovercome the problem. This decreased access inturn can decrease demand for the course andfurther exacerbate the problem. The option foroffering such courses rests with the VictorianDeans of Nursing to develop collaborativearrangements across the State to ensure that theneeds of the health industry are met throughpostgraduate education.

Recommendation 32: That the VictorianDeans of Nursing develop collaborativearrangements that maximise postgraduatecourses for smaller specialties and smallcohort courses.

5.2.2. Division 2As indicated above, submissions and formaldiscussions with stakeholder groups expressedthe need to consider some expansion of the roleof the Division 2 nurse. The health careindustry suggests that it needs second levelnurses with increased knowledge and skills andDivision 2 nurses require a clear professionalpathway in which to apply their expertise. Thepotential advent of an expanded scope ofpractice will place greater emphasis on both therevision of current post-basic modules and thedevelopment of new units of study. In this

context the current AQF classification mayrequire re-examination.

Currently, the range of post-basic modulesincludes those in dementia, continence, mentalhealth rehabilitation, perioperative and acutecare nursing. However, to meet industryrequirements, additional post-basic modulesshould be examined closely andrecommendations made by the intersectoralworking group indicated in Recommendation27. In addition, the career path for Division 2nurses needs to be examined to ensure thatthere is maximum recognition of prior learninggiven by the VET sector for continuingeducation and for articulation into the Division1 degree program for post-basic studies.

Recommendation 33: That the intersectoralgroup in Recommendation 27 also payattention to the:

Effectiveness of current post-basic modulesand the need for additional modules tomeet industry requirements.

Recognition of prior learning arrangementsbetween post-basic and continuingeducation undertaken and for post-basicmodules and the Division 1 degree program.

The interim report of this committeerecommended that scholarships be provided forDivision 2 nurses undertaking post-basicmodules in areas of shortage over a three-yearperiod. The use of these scholarships as arecruitment and retention strategy should beevaluated after three years.

Recommendation 34: That the Departmentof Human Services evaluates theeffectiveness of the provision ofscholarships for Division 2 nurses toundertake post-basic modules as arecruitment and retention strategy byDecember 2003.

5.3 Graduate Nurse Programs5.3.1. Division 1 The issue of the educational preparation of thenew graduate was frequently raised throughthe submission and consultation processes. Thetransition from undergraduate student toregistered nurse is key phase in the professional

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development of a nurse as knowledge andskills are consolidated in the process ofbecoming members of the clinical team. Thegraduate year program is intended to facilitatethis transition during this important phase oftheir professional development. Researchdemonstrates that new graduates feeloverwhelmed and unprepared for the rigoursof practice (Beeman 1999), while graduatesstate that they have difficulty fitting in anddoubt their own ability to acquire the necessaryskills.

In 2000, a total of 109 hospitals (public andprivate) offered approximately 1,223 graduatenurse program places (Victorian MedicalPostgraduate Foundation Nursing ComputerMatch booklet 1999). Reports to the Committeeindicated that hospitals, both rural andmetropolitan, were not able to fill all of theseplaces. The places in public hospitals(excluding mental health services) aresupported by the Department of HumanServices T&D Grant, and must comply with theDepartment of Human Services GraduateNurse Program Guidelines (Department ofHuman Services 1997). A number of issues havebeen bought before the Committee in relationto the way in which graduate nurse programsare conducted,the support for the graduate, andthe models of rotation used during theprogram.

Support is provided to the new graduatethrough either a designated clinical teacher oran experienced nurse who undertakes apreceptor role. The capacity of clinical teachersto provide the support to graduate nurses issignificantly influenced by the ratio of teachersto graduates. Feedback to the Committeeindicated that the numbers of clinical teachersin the health system is insufficient to fulfil thisrole.

In the absence of sufficient clinical teachers, thepreceptor role is delegated to the experiencednurse. A number of issues were raised inrelation to clinicians acting as preceptors.Firstly there was little recognition of this rolewithin patient/workload allocations. It wasindicated that in some circumstances, apreceptor and a graduate nurse were notrostered on the same shifts. The Department ofHuman Services Graduate Nurse Program

Guidelines indicates that a preceptor should beavailable for the first six to eight weeks of aclinical rotation. The impact on the clinical loadof both the preceptor and the graduate shouldbe recognised in workload allocation(Department of Human Services 1997).

Secondly, the capacity to successfully carry outa preceptor role requires considerable skill: thiseducation was not always available. Thegraduate nurse focus group (ResearchInternational 2000, Appendix 6) reported theneed to ‘provide in service training to othernurses imparting basic teaching skills (such ashow to ‘show’ rather than ‘do’ when workingwith graduates) and tolerance for graduateswithin particular nursing segments’.

It is essential that the new graduate is given thesupport and guidance necessary for them todevelop confidence in their skill and abilities. Ifthis support is not provided, the new graduatestend to leave the profession and a vicious cycleis set up within the profession where the newleave, the experienced become more stressedand they too leave in turn. There is a variety ofmodels of preceptorship being used in Victoria.There is little data to indicate what is bestpractice.

Recommendation 35: That the Departmentof Human Services commissions and fundsa research project to evaluate differingmodels of preceptorship within GraduateNurse Programs in order to identify bestpractice.

Issues relating to workload, staffing levels andskill mix all need to be addressed to ensure thatthe graduate nurse year can be effectivelyimplemented. These are considered elsewherein this report. The graduate nurse year isfunded from the T&D Grant (section 5.6) andthere are guidelines associated with itsimplementation. These guidelines need to bereviewed (Recommendation 41) .

The other areas of concern raised with theCommittee, both by its members and throughsubmissions, is the place of specialtycomponents such as aged care, critical care,renal and mental health, within graduate nurseprograms. The lack of a rotation in specialtyareas was seen as contributing to therecruitment difficulties in the specialties,

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especially in mental health and aged care. Bymaking a rotation more widely available tograduates who have an interest in one of theseareas, beginning level nurses will have anopportunity to gain some experience andconfidence in these specialties.

Currently some aged care services, and to alesser degree mental health services, offer a fullgraduate year program based in theserespective service sectors. While the numbers ofpeople accessing these programs is small, ademand exists. In many professions a smallpercentage of people will decide during theirinitial education as to which particular areathey wish to work in.

A variation on this phenomenon is particularlyevident in mental health, with some nurses’primary interest being in the mental healthservice sector. Nursing is seen as a way ofqualifying to work in that sector (ResearchInternational 2000, Appendix 6).

Given the significant difficulties aged care andmental health face in attracting new graduatesto their service systems, graduates should beencouraged into these areas, either through arotation or a full graduate year. SeeRecommendation 41, section 5.6.5.

5.3.2 Division 2The consultation and submission processundertaken by the Committee identified lowlevels of confidence amongst new graduatesfrom Certificate IV in Health (Nursing). It wassuggested that a lack of consolidated clinicalexperience during the education course limitedthe ability of nurses to achieve realistic andeffective work expectations.

The same arguments that support a graduateyear program for the Division 1 nurses apply tonew Division 2 graduates. Both nursingDivisions require assistance, support,acknowledgment and education during thetransitional practice phase to promote acommitment to nursing. The provision of asupportive graduate practice setting willprovide a secure environment for the beginningsecond level practitioner that will ultimatelyfoster best practice.

It is the Committee’s view that these issues oftransition have not been readily acknowledged

by the health industry in relation to Division 2nurses.

Recommendation 36: That the intersectoralgroup (Recommendation 27) should look todeveloping programs to assist Division 2nurses make the transition from theeducational to industry sector during thefirst six months of practice. These programsshould reflect the principles adopted forthe Division 1 graduate nurse program andinclude a preceptor component.

5.4 Continuing Education 5.4.1 FundingContinuing education has been defined as‘planned educational activities developed tobuild upon and enhance the professionalpractice of nurses’ (Alspach 1995). For thepurpose of this section, continuing educationwill refer to both updating programs for newknowledge and skills in in-service and otherprograms, and other professional educationacquired through attendance at conferences,seminars and workshops, commonly referred toas study days. Formal postgraduate educationis not included in this definition.

It is a requirement of the ANCI Code ofPractice that all nurses keep up-to-date withnew knowledge, skills and technologies:participation in continuing educationcontributes to achieving this requirement.Responsibility to undertake continuingeducation is shared—it is the nurses’responsibility to undertake the learning and theresponsibility of employing health care facilitiesto support this endeavour. However, in anenvironment of declining revenue, downsizing,rapid patient throughput and other constraints,the ability of health care facilities to providesupport for continuing education is restricted.

There are costs associated with continuingeducation. These include the conduct of in-service programs, attendance and back fill.There are also costs associated with theattendance at courses or conferences notconducted on site. In some instances, there areadditional costs for travel and accommodation.

Issues of distance and diseconomies of scalefurther exacerbate these problems in ruralsettings. There continues to be a strong

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consensus among health care professionals thataccess to continuing education and training forrural health workers is inadequate. This, inturn, leads to long term workforce retentiondifficulties (Blue & Howe-Adams 1992, Malko1992, Harris 1992, Hope 1993, Buckley & Gray1993, Cramer 1994, Duffy 2000). The barriers tomeeting the educational needs of rural healthcare professionals have been well documented,as have the preferences for mode of deliveryand content. The barriers most frequentlymentioned are related to costs, time,replacement staff, resources and support wheneducation cannot be provided on site (Handley1996, Spencer et al 1998).

The submission process, public forums andfocus groups have supported the publishedstudies above. Seminars, short skill-basedcourses and conferences are generally held inMelbourne or to a lesser degree in majorregional centres. In order to access suchcourses, nurses from rural and regional servicesmust travel, often considerable distances. Thisadditional travel has multiple additional costs.The back fill or loss of a staff member is longer,travel costs are higher and accommodationcosts are commonly incurred. While regionaluniversities and other education providers areincreasing the flexibility of their deliverysystems the reality of rural practice is that,currently, a significant proportion of continuingeducation can only be undertaken by accessingMelbourne-based programs.

Information before the Committee wouldsuggest inadequate expenditure on continuingeducation is a significant causative factor in thecurrent nursing shortage and the provision ofcontinuing education would act as a significantincentive to attract and retain nurses. TheConsidine & Buchannan (1999) survey indicatedthat the inability to take up educationalopportunities was a significant problem in theworkplace. Although paid study leave wasavailable to almost 70% of their sample, lessthan half of the 47% who applied for it weregranted it. Budget constraint was the reasongiven to 60% of these nurses. Professionaldevelopment and training opportunities wereincluded among the five most important factorsinfluencing a return to work by those nurseswho were registered but not working(Campbell, 2000). From the forums, a theme

related to the ‘imbalance between a clearexpectation and pressure for nurses to bepursuing on-going education and the minimalsupport provided in relation to leave or money’(URCOT 2000, p i, Appendix 5).

Access to continuing education is hampered byworkload and shift arrangements. This themewas frequently identified in the variousconsultation processes undertaken by theCommittee. While these issues are dealt withmore fully in Chapter 6, it is evident that theseissues have a significant impact on access tocontinuing education. High workloads andshift arrangements that eliminate ADOs andreduce shift overlaps, have a negative impacton the capacity of nurses to pursue continuingeducation.

Information before the Committee indicatesthat expenditure on continuing educationvaries between facilities. In some instances, theamount of budget expended on this activity fornursing is clearly transparent. However, thistends to be more the exception than the rule.There needs to be a more level playing field inrelation to continuing education expenditure. Aposition was put firmly to the Committee thatan additional 1.5% of nursing budget formetropolitan and 2% of rural budgets shouldbe clearly allocated to continuing education fornurses. However, at this time, it is not knownwhat is being expended and the Department ofHuman Services needs to gather the data on thecurrent situation and then ensure that allfacilities have a level of funding allocated as aline item in their budgets to 1.5% or 2% asindicated above, according to their FTE nursingnumbers. The Committee recognises that theT&D Grant also provides $4 million forcontinuing education, money that is allocatedto submitted proposals on an annual basis. ThisGrant should continue in addition to thebudget allocation.

Recommendation 37: That the Departmentof Human Services collects data relating tocurrent expenditure on continuingeducation for nurses in each facility.Through its health services agreementswith health care facilities, Department ofHuman Services ensures that funding isprovided for continuing education to alevel of 1.5% for metropolitan and 2% for

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rural facilities based on the budget for thetotal nursing EFT across the facility. Thesefunds to be shown as a separate line item.The Training and Development Grant forcontinuing education should be continuedin its present form.

5.4.2 Mode of DeliveryThere is a wide range of interactive and self-directed educational programs and resourcesthat could be of benefit to the continuingeducation needs of nurses across the State. Inmany instances awareness of these resources islow. Should the availability of such programsbe more widespread, resource allocation couldbe focused on areas of need, rather thanduplicating existing programs.

The lack of knowledge regarding the contentand availability of further education is notrestricted to continuing education. The variousuniversities that teach nursing offer a wide rangeof postgraduate courses from graduate certificateto doctorate level. They also offer modules thatare often specifically geared to particular needsand attract credit points for postgraduatequalifications. An efficient system of informationdissemination is required in terms of the contentand availability of these courses

The Minister for Health, the Hon JohnThwaites, has endorsed the implementation ofthe Clinicians Health Channel, a medium thatprovides Web-based access to an electronichealth library for all Victorian acute publichospitals. The project is currently in trial stages,after which it is anticipated that a statewidelicense will be negotiated.

The Clinicians Health Channel is divided intoseveral main categories comprising:• Clinical news and views• Electronic health library• Guidelines and protocols• Training and support• Contributions to the channel• Links.

The Clinicians Health Channel (or similar Web-based services) would provide an excellentresource for access to the wide range ofmultimodal continuing education programsand postgraduate education that are currentlyoffered in Victoria.

As indicated above, access to continuingeducation for rural nurses is inadequate andcostly. Both access and cost can be reduced ifthe education is delivered on site. Blue &Kirkbright (1998), in citing the Project for RuralHealth Communications and InformationTechnologies Report (1996), note that 82% of thehealth professionals surveyed believed thatinformation and telecommunications wouldhelp reduce their feelings of isolation.Utilisation of a variety of teaching modalities,including multipoint video, CD Rom and self-directed learning packages, offers a means toreduce professional isolation and providerelevant educational programs for rural nurses.

It is recognised that several avenues currentlyexist for rural health care facilities to increasetheir access to funding resources foreducational purposes: these include the ruralhealth support, education and trainingprograms (RHSET or SETR). It would appearthat, despite these programs, problems withcontinuing education for nurses remain.Indeed, only 23% of the Duffy (1999) sampleindicated that they had access to computertechnology and network.

While there is a range of education providers,the benefits to the overall health system arelimited because health care facilities and nursesare either unaware of what is available orunable to access it.

The costs of continuing education in rural areascould be reduced if tele/video facilities wereused at least for some continuing education.Currently, there are 32 teleconferencing facilitiesaround Victoria, used for the delivery ofTelehealth services. These facilities are mainlyused by physicians for diagnosis and treatmentof rural and regional patients. Potentially, thistechnology could be used to deliver continuingeducation to rural/regional nurses to enableincreased access to ongoing education.

The delivery of such services has a cost and thiswould need to be balanced against the time,travel, accommodation, and back fill costs forboth the facility and the nurse. Informationbefore the Committee indicates that ongoingcosts have been a issue, but as this is now beingboth subsidised and promoted by Departmentof Human Services and VHA, this will

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potentially increase its viability as a means ofdelivering distance education.

Recommendation 38: That the Departmentof Human Services: a. Ensures information on existing

multimodal education products andpostgraduate modules and courses bedisseminated to health care facilities andtheir nurses via the most appropriatemethod, such as the Clinicians HealthChannel.

b. Reviews existing multimodal educationproducts with a view to identifying whatis currently available, the product’sability to meet current industry needs,and to identify unmet needs. The reviewshould also evaluate, as well asrecommend, appropriate products formultimodal education, such as tele/videoconferencing, distance education andCD-ROMs, to fill identified gaps incontinuing education.

c. Explores what is currently available intele/video conferencing facilities inVictoria and that a strategy be developedto make effective use of these as a meansof delivery of continuing education inrural and regional Victoria.

5.5 Study Leave The Committee was asked to makerecommendations regarding the Governmentinitiative to ‘provide paid study leave to 1000nurses undertaking postgraduate courses inareas of specialist expertise’.

The aim of the initiative was to help overcomethe shortage of nurses in the public sector,especially in specialist areas, by providingsupport to those undertaking postgraduatecourses. As indicated earlier, shortages ofnurses have been identified in a number ofareas for which postgraduate courses areavailable for Division 1 and 3 nurses. Inaddition, submissions before the Committeeindicate shortages of Division 2 nurses, notonly in the aged care area, but in areas forwhich post-basic modules are available, such ascontinence, dementia, mental health,perioperative, acute and rehabilitation nursing.

The committee was guided by a number of

principles in the operationalisation of thisinitiative.

5.5.1 Principles• Paid study leave be applied to nurses in all

Divisions of the register in the metropolitan,regional and rural areas of Victoria.

• Paid study leave be applied to all nurses,employed full-time or part-time throughoutVictoria in the areas of need currentlyidentified not only in the acute care, but alsoaged care, mental health, communitynursing and midwifery.

• Paid study leave be granted to allpostgraduate courses, graduate certificates,graduate diplomas, masters or PhD forDivision 1 and 3 nurses, and post-basiccertificates/modules for Division 2 nurses,irrespective of mode of delivery.

• Department of Human Services processes betransparent and communicated to thenursing profession.

• Processes used to implement study leave bematched to the tertiary sector timelines toallow for planning of rosters andreplacements.

5.5.2 DefinitionTo ensure equity across Divisions of theregister, the term ‘place’ will be used. A placeequates to 104 hours of study leave, that is, fourhours per week for two semesters (26 weeks).As Division 2 modules tend to be of onesemester equivalent duration, two Division 2nurses may share one place.

5.5.3 Allocation of FundingThe Committee undertook a survey of healthservices to ascertain the extent of study leaveprovision. The survey returned 51 responses(43%). Of the respondents, only 19 hospitals(two metropolitan and 17 regional/rural)provided paid study leave. From the 51respondents it was revealed that there were 750nurses reported to be undertaking studies andonly 179 (24%) received study leave. Themetropolitan hospitals paid only 19% of their594 nurses while regional/rural hospitals paid44% of their 69 nurses. Six of these respondentsconsidered the payment of study leave as anessential element to recruit qualified staff. Ofthe remaining 32 respondents, budget

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constraints were given as the reason why studyleave was not paid.

Data from a survey of universities indicatedthat currently there are 1,322 studentsundertaking postgraduate clinical courses in2000 (including continuing students). It must benoted that this number includes those nurses inthe private sector.

Data before the Committee from the VET sector(coordinators of Certificate IV in Health[Nursing] course) suggested that there was apoor uptake rate of post-basic modules byDivision 2 nurses.

The recommendation to provide scholarshipsfor extra places in both universities and theVET sector, makes the need for assistance tonurses who are upgrading their qualificationsat a postgraduate and post-basic level a matterof urgency.

5.5.4 QuotasTo overcome current shortages, paid studyleave should be directed at areas of need. Thoseidentified in this report are acutemedical/surgical (metropolitan), aged care(metropolitan and rural), critical care(metropolitan and rural), emergency(metropolitan and rural), mental health(metropolitan and rural), midwifery (rural),perioperative (metropolitan and rural), renal(metropolitan and rural). Attention should alsobe paid to the metropolitan-rural distributionof 75:25. In addition, registration data indicatesthat 75% of nurses are registered in Divisions 1and 3 and 25% in Division 2. The allocation offunding in this initiative should reflect theproportion of nurses in each Division.

At this stage, it is unclear what the take up ratefor places will be, especially in relation to themetropolitan,rural and Division 2 quotas.Where quotas are not met in one area,Department of Human Services will distributeplaces to areas where applications are in excessof quota to ensure that the full amount offunding is allocated in this first year ofimplementation.

5.5.5 ProcessThe Government initiative was funded at $2.08million per annum for a full year effect. At an

average of $2,080 per place this would enable1000 places to be taken up in any year. Toensure equity of distribution, the funds need tobe managed centrally and therefore theDepartment of Human Services is theappropriate body to implement therecommendation. Criteria must be establishedto reflect this principle of equity. Such criteriamight include identified areas of need andstatewide and hospital EFT as a guide tooverall distribution of places. To ensuretransparency of process, a reporting mechanismneeds to be developed to inform the professionabout the allocation of places and theirmonitoring and evaluation.

Recommendation 39: That Department ofHuman Services allocates places for paidstudy leave for four hours per week perplace for nurses undertaking postgraduateand post-basic courses by any mode ofdelivery. Such allocation to be based onareas of identified need and EFT with aminimum of 25% of the total placesallocated to the regional/rural areas and25% of total places allocated to Division 2nurses. Department of Human Services toensure a mechanism for reporting back tothe profession on its process.

In addition, health facilities will need toestablish processes internally. Such processesneed to apply a number of principles to ensureequity and transparency where the applicationsexceed the allocation.

Recommendation 40: That nurses apply forstudy leave to their health service or areamental health service. Where applicationsexceed allocations, a ranking system beused incorporating the following principlesas guides: length of service, results ofperformance appraisal where available and,if not available, their contribution to theservice, and service priority for its areas ofneed/shortage, including aged care andmental health nursing.

5.6 The Training andDevelopment GrantThe T&D Grant for nursing was established asa part of the acute casemix funding formula. Itis a specified grant similar to those made for

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medical and allied health. The nursingcomponent of the Grant was established fortwo reasons: firstly to recognise and providefunding for specialist hospital post-registrationprograms already in existence and, secondly, tocompensate hospitals for employing newgraduates whose contribution to patient carewas less than that of an experienced registerednurse. It is the single largest training specificfunding mechanism available to the Victorianhealth system. There is also a continuingeducation grant and an undergraduate teachingallowance.

Each hospital receives funding for specialistand graduate nurse programs based on itsnumber of students. This per capita grant hasbeen adjusted over time to reflect moreaccurately the costing information available. Incontrast, the continuing education grant isallocated on the basis of a business plansubmitted by the hospital outlining continuingeducation or professional developmentprograms. The undergraduate teachingallowance is allocated proportionally tohospitals that have nursing and medicalundergraduate students.

The Grant is for the acute care setting only. Theaged care and sub-acute sectors have aseparate, similar grant. The mental healthsector has a different method of funding itstraining and, because of the global nature ofthese funding arrangements, the nursingcomponent is not identified.

Information before the Committee stronglysuggests there are problems with the overallT&D Grant. These are outlined below for eachof the components of the Grant.

5.6.1 Undergraduate Teaching AllowanceThis allowance is combined for both nursingand medicine undergraduates. The Committeehas received reports that accessing this granthas been difficult. It is not transparent in thebudget and, more often than not, is notallocated to nursing. Further, it has beenindicated to the Committee that the currentsystem does not reflect the actual numbers ofstudent placements offered, rather the primarydeterminant of funding is the amount ofcasemix the hospital receives. Given the issues

of transparency and acquittal of funds, theCommittee is of the view that combiningfunding in this manner does not facilitate theirdistribution to nursing undergraduate clinicalexperience—the problems of which are outlinedabove (section 5.1.1.1).

5.6.2 Graduate Nurse ProgramsAs indicated above, the success of the graduatenurse program depends on the quality of theclinical supervision/preceptorship available tothe new graduate. Problems were identifiedabove in relation to the numbers of clinicalteachers available and the clinical nursesproviding the preceptorship. Attention was alsodrawn to the current apparent limitation of thegraduate nurse year to allow for experience inspecialty areas, particularly the special needs ofaged care and mental health services. The needfor a Division 2 graduate nurse program wasalso indicated.

Each of these areas needs to be considered inrelation to the guidelines for graduate nurseprograms. The current guidelines need to bereviewed to more closely reflect the needs ofindustry and ensure that new graduates are notlost from the workforce.

5.6.3 Postgraduate ProgramsCurrently there are no guidelines for thepostgraduate grant other than the generalcriteria published in Victoria—Public HospitalsPolicy and Funding Guidelines 2000–2001(Department of Human Services 2000).Information before the Committee indicatesthat the grant is used differently by differentfacilities. In some instances it is used to providethe student with clinical teaching support, inother cases the money is provided to theuniversity to reduce the cost of the fees chargedto the student. In other cases it may be used toprovide for back fill. The Committeerecommends that guidelines should bedeveloped to include similar principles to thosein the graduate nurse program guidelines.Guidelines need to be developed as a matter ofurgency, in order to ensure that there is equityin the system. The guidelines may also need totake into account the recommendations madein this report relating to assistance with fee costthrough scholarships.

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5.6.4 Continuing EducationCurrently continuing education grants areallocated on the basis of submissions made byhospitals, based on standard guidelines. Thereis a requirement that hospitals mustdemonstrate that they have consulted withnursing staff and have a comprehensive needsanalysis underpinning their submission. Thereis also a requirement that hospitals mustevaluate the program, according to criteria theythemselves develop. While every effort is madeto assist hospitals to apply for funds, thelimited pool available (currently $4 million) andthe increasing number of hospitals accessingfunds, means that hospitals usually receive lessthan they request. This is complicated by manyhospitals including a self-confessed ‘ambit’component in order to achieve a greater level offunding. Currently all acute Victorian hospitalsapplying for the continuing education grantreceive funds although the administration ofthe program is burdensome in terms of staffand time, both from the Department’sperspective and from the hospital’s.

The Committee considers that this grant shouldcontinue in its present form, as it providesadditional monies for an important area ofeducation, however its administration needs tobe simplified.

5.6.5 Training and Development GrantRecommendationsThe T&D Grant provides needed support forfour areas of nurse education and it is essentialthat this support continues. However, in viewof the problems outlined above, there wouldseem to be a need for specific review of thenursing component of the T&D Grant. TheCommittee notes that the Government policystates that ‘Labor will also require publichospitals to make transparent their expenditureon clinical nursing training and to account forthat expenditure against agreed benchmarks’(Australian Labour Party, Victorian Branch1999) and applauds this approach. Further, itnotes that recent concern was expressed aboutthe detailed acquittal and recall of funding forpostgraduate courses in the Ministerial Review ofHealthcare Networks (Department of HumanServices 2000, p.141), suggesting that this bedevolved to the universities. The Committee

interprets this to mean that data on clinicalplacements, such as student numbers andduration of placement, should be provided byuniversities (as is currently the case with theallied health undergraduate component of theT&D Grant) and not that the universitiesprovide financial acquittals. The rationale forthis interpretation is that universities are notprivy to information about how the grant isused by hospitals. The Committee also notesthat the T&D Grant is currently under reviewby the Department of Human Services. TheCommittee supports this action, but points thereview to the specific matters outlined in therecommendation below.

Recommendation 41: That the Departmentof Human Services reviews the T&D Grantin relation to the undergraduate teachingallowance, the graduate nurse program, andthe postgraduate program (includingmidwifery) The review should ensure that: a) The manner in which the Grant is made

available to the hospitals is transparentand acquittal processes ensure the fundsare used for their intended purpose.

b) The funding for undergraduate nursingbe allocated according to studentnumbers undertaking placements in ahospital.

c) The medical and nursing components areseparated and the nursing component isshown as a line item in the budget.

d) A nursing reference group is establishedto review the graduate nurse programguidelines paying particular attention to:• How the funds are used to support the

new graduate through supervision andpreceptorship

• The capacity to provide for rotations inspecialty areas such as critical care,renal, perioperative nursing

• The provision for both rotations in andseparate programs for aged care andmental health as a positive recruitmentstrategy

• Provide for Division 2 nurses.e) Establish a nursing reference group to

develop guidelines for postgraduatecourses along the lines of the graduatenurse program, ensuring that thedistribution of the monies provides forequity between facilities.

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f) That allocation to the aged care T&DGrant be increased as a positiverecruitment strategy.

g) That the mental health funding beanalogous in structure to the acute T&DGrant.

h) That the continuing education grantcontinue as it is.

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As indicated in Chapter 3, several themes wereraised with the Committee that wereconsidered important to retain nurses in theworkforce, particularly the experienced,qualified nurses. The first of these themesrelated to the workplace itself—workload, workconditions and the work environment. Thesecond, equally strong theme, related to thelack of recognition and valuing of the clinicalnurse—lack of a strong clinical career structure,management and other support for the clinicalnurse, and recognition for qualifications andexperience in clinical practice. In additionspecific issues were raised in relation to theretention of nurses in rural and regionalVictoria, Division 2 nurses and those nursesworking in speciality areas including the publicaged care sector.

6.1 The Workplace6.1.1 WorkloadAs discussed in section 3.1.2, from the viewsstrongly put to the Committee it is apparentthat nurses will not be recruited back into theworkforce, or sufficient numbers of experiencednurses retained, unless the issue of workload isaddressed as a matter of urgency. TheCommittee takes the position that research hasclearly shown that restoring workloadmanagement and clinical decision making tothe nurse has demonstrable benefits in terms ofrecruitment and retention (Kramer 1990, Scott,Sochalski & Aiken 1999, Havens & Aiken 1999).Research has also shown that current flat rateformulas for funding nursing staff, such asthose based on diagnostic related groups, doesnot allow for individual variability in theamount and quality of necessary nursing care itis possible to offer patients (Shamian, Hagan,Fu & Foggarty 1994).

What is a reasonable workload? The number ofpatients allocated to each nurse depends on avariety of factors including patient acuity, theskill mix of the nursing staff, time of day andother support services for the nurse. Thesefactors may vary both within and between units.

Fundamental to the discussion relating toworkloads is determining how many nurses arenecessary to provide quality care to patients,and how these numbers are controlled.

6.1.1.1 Measurement of Workload

Nurse/Patient Ratios

The NUM assumes primary responsibility forcontrol of workload in the ward or clinical unit.The NUM needs to have some measure of howmany nurses are required on a shift, with thecapacity to recruit more staff on some days andless on other days. In most instances this is aprofessional judgment by the NUM based onclinical experience, as there is a paucity ofreliable data on what constitutes a reasonableworkload.

In the absence of a validated and reliablemeasure, the decision of what is a comfortableworkload is often left to the NUM, to whomthree objective measures are generallyavailable:

Nurse hours per patient bed day

A rule of thumb used for nurse allocation insome units is the number of nurse hoursrequired per patient bed per day. Where theacuity level and skill mix is fairly stable thisappears to be an adequate measure.

Nurse/patient ratios

The use of nurse/patient ratios is also a guideto level of workload. There are, however, noclear indicators as to what is a standard ratio,given the variability in acuity and skill mix. TheANF is advocating a ratio for the acute generalmedical and surgical wards of 1:4 for morning,and evenings, and 1:8 for night (in addition tothe nurse in charge of the ward). A number ofassumptions underpin these ratios. Firstly, thatthe level of acuity for acute wards is similar.Secondly, that wards contain patients withcomparable acuity levels. Thirdly, that the levelfor acute care can be determined relative toother areas of care. Fourthly, that the skill mixcan be maintained at a similar level, and that

6. Retaining Nurses in the Workforce

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the skill mix is adequate. Finally, it assumesthat clinical activities are the same in themorning and evening, and that there is asignificant change for the night shift. Supportfor the position of fixed nurse/patient ratios isclaimed to have emerged from the Considine &Buchannan data (1999) where a 1:4 to 1:5 ratiowas regarded by the majority of the researchsample to be the desired ratio for acute wards.However, these were subjective data, and thereis a need for more objective data to support anargument for fixed nurse/patient ratios.

It is claimed that a fixed ratio will providesome guide for what could be considered to bea reasonable workload for the acute care areasand then allow for adjustment up or down,accordingly in other areas of care. The criticalcare areas tend to run 1:1 ratio and the sub-acute and nursing home areas run on ratioshigher than 1:5.

Many Directors of Nursing have indicated tothe Committee that they do not support a fixedratio. They claim that in some acute care areas a1:3 is more appropriate, but not at all times andrural Directors of Nursing, in particular, claimthat the mix in their units varies in level ofacuity, and hence a given ratio would bedifficult to achieve. They also indicate that ifratios are fixed, this does not allow for theflexibility of adjustment in workload that isinherent in the professional judgment of heNUM.

There is a paucity of information about an idealskill mix. There is no doubt a need for sufficientnumbers of experienced qualified full-time staffto ensure a continuity of quality care. Moreinformation needs to be collected on skill mixas part of the case for fixed nurse/patientratios.

Dependency tools

An alternative to fixed ratios is a measurementtool for patient dependency. A tool commonlyused in many hospitals, predominantly in theprivate sector, is Trendcare. Some hospitalshave indicated that Trendcare does giveaccurate prospective workload figures thatallow reasonable workloads to be determinedfor each shift. Others are sceptical, indicatingthat if it is not introduced or applied with anadequate education program, it can be

manipulated in undesirable ways. There wouldappear to be a need to evaluate Trendcare, andother available tools, in terms of validity,reliability and applicability to the Victorianpublic sector. If such a tool were found to be aneffective measure of workloads for the varietyof areas in which it is applied, then the need forfixed ratios would no longer be necessary.

In the absence of consensus on the effectivenessof measuring tools or other accurate workloadmeasures, there would appear to be some valuein suggesting that fixed ratios be applied in theacute medical/surgical wards only as ameasure to avoid excessive workloads.However, there are many difficulties with afixed ratio, while a range of ratios would allowfor some degree of flexibility. Further,wards/units that have sound reasons forworking outside set ratios should have theopportunity to provide the rationale for theirchosen ratios. It is, therefore, necessary that theDepartment of Human Services has thecapacity to review the impact of ratios on theworkload until satisfactory measures areintroduced.

6.1.1.2 Adjustment of WorkloadAs indicated above, it is up to the NUM or, intheir absence, the ANUM to facilitatereasonable workloads. A suggestion put beforethe Committee was that each ward/unitdevelop a template for an appropriateworkload in their area. Such a template wouldbe developed in consultation with theward/unit staff and reviewed weekly. Thehospital would also convene a group reviewingsuch templates and the NUM would expectsupport from management when workloadswere in excess of the template and bed closureshad to be considered.

The issue of bed closure is an important one.An experienced NUM, with or without atemplate, will know the optimum workingconditions for the skill mix on the unit.Whether working to fixed ratios or Trendcare if,in the professional judgment of the NUM, theworkload is too high, more staff are notavailable, and they are unable to control theflow of patients, then an automatic closure ofbeds should occur, with the explicit support ofmanagement. Thus, there should be clearpolicies and procedures, based on best available

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information about the ward/unit, to facilitatesuch closures. Casemix funding may need to beadjusted to ensure that such contingencies areaccounted for without diminution of care.

Recommendation 42: That in the absence ofstatewide workload data, each ward/unitestablish a template for an appropriateworkload for that ward/unit consistent witha ratio ranging from 1:3 to 1:5, excluding thenurse in charge of the am and pm shifts, forthe acute general medical/surgicalwards/units and the Nurse Policy Branchreviews the impact of ratios on workloadsuntil more explicit data are collected andanalysed.

Recommendation 43: That the Departmentof Human Services convenes a workingparty comprising relevant stakeholdersincluding ANF, HSUA and Directors ofNursing to jointly:• Determine the data that are needed to

evaluate nurse/patient ratios and skillmix across the State.

• Review available dependency systemsand, if needed, commission furtherstudies on such systems to evaluate theireffectiveness and report back to theMinister for Health.

Recommendation 44: That policies andprocedures should be in place to enable theNUM and ANUM to control workloads byadjustment of staff numbers as appropriateand where workloads are unreasonablyhigh, additional staff are unavailable andpatient flow cannot be controlled, thatadequate support be given to enable bedsto be closed as a last option in the controlof workload.

There are times of the year when it is knownthat there will be a shortage of nurses, such asduring school holidays. There is no reason whyplanning could not ensure that the amount ofelective surgery is reduced during this time.This would ease the burden on nurses at a timewhen resources are limited. With carefuladjustment of such surgery lists, there shouldnot be a corresponding increase in waiting lists.

Recommendation 45: School holidays areknown periods of nurse shortages and thathospitals minimise the amount of electivesurgery during such times.

6.1.1.3 Assistance to the NurseIn order to reduce the workload of the nursethere are many activities that the nursecurrently undertakes that could be taken by a‘ward assistant’ or ‘ward clerk,’ howevernamed. These activities include answering thetelephone, preferably on a 24-hour basis, but atleast from 8am to 8pm (at the completion ofofficial visiting hours), many clerical activitiesthat are routine and repetitive, as well as somehousekeeping tasks such as making unmadebeds. Such a role should be seen as an assistantto the nurse and not as a replacement. TheCommittee is of the view that such assistanceshould not include the provision of nursingactivities including those that tend to beclassified as ‘personal care’, but are in fact thevery basis of the activities of daily living whichform an integral part of nursing (Henderson1996). In the view of the Committee, nurses, asdefined in the Nurses Act 1993, should be theones to undertake nursing. This is particularlyso not only in the acute care area, but also inthe sub-acute and nursing home environmentwhere the complexity and acuity of care isincreasing. Experience from the USA wouldsupport the view that the use of personal careattendants is problematic in these sectors(Shindul-Rothschild, Berry & Long-Middleton1996).

Recommendation 46: That each facilityundertakes a review of activities such astelephone answering, routine clericalactivities and some housekeeping activities,such as unmade bed making, andrecommends to the Department of HumanServices strategies that will either introducesuch positions in addition to nursingpositions that assist the nurse at ward/unitlevel, or extend the hours of such assistanceas necessary.

Recommendation 47: That health facilitiesestablish a policy that nursing activities beundertaken only by those nurses registeredunder the provisions the Nurses Act 1993.

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6.1.2 Working Conditions

6.1.2.1 RostersThere are a number of areas where theconditions of work can be considered to meetboth the needs of staff as well as therequirements of the workplace. Nursesindicated to the Committee that they needed tohave some control over their conditions ofwork.

Full-Time and Part-Time Work and Rostering

A constant theme in forums and focus groupswas that of flexibility, particularly in relation toshift length and rostering. It is generallyaccepted that continuity of care can be achievedmore easily where there are permanent staff,either full-time or part-time. It has been madeclear to the Committee, particularly in theforums, that there is little attraction for somenurses to work on a full-time basis. With thecurrent shortages of experienced qualifiednurses, those who remain in a full-time capacitycarry a heavy burden. Therefore, many opt foragency work where they can not only chose theshifts that they work, but also do not have tobecome involved in the daily management ofthe unit. There are a number of strategies thatcan be used to attract nurses back to permanentfull-time or part-time positions.

The areas identified by the nurses included:

Shift rosters

Nursing, like many other professions, mustprovide a 24-hour service. The ability to ensurethat all nurses receive the shifts that suit theirlifestyle is not easily achieved, particularly inrelation to school holidays and the collection ofchildren from school and child care. Whatnurses need to feel is that that they have somecontrol over the situation and that there is thereis flexibility, fairness and equity in rosteringarrangements. Flexibility can be achievedthrough means such as self-rostering and jobsharing. The Committee heard of bothsuccessful and unsuccessful self-rosteringarrangements. Such a system requires thesupport of all staff and a willingness to sharethe hours to be worked with colleagues.

Job sharing

This is recognised by the Committee as animportant way to achieve more flexibility in theworkplace. The Committee considered jobsharing using these guiding principles:• nurses sharing the position are at the same

grade of employment;• each employee is clear about the job

requirements;• each employee is clear about replacement

arrangements for sick leave and holidays,and entitlements are accrued at a part-timerate;

• processes are in place for termination of thejob sharing arrangement.

Shift length

This was a matter of some discussion andvaried according to the area concerned. Theissue of short shifts and the ability to work afew days per week was an issue that was seenas attractive to those with young families. Theargument was put that working for shortperiods not only maintained skills andknowledge, but encouraged nurses to return topermanent positions once family circumstancesallowed this to happen. Many nurses perceivedsuch flexibility as a measure of the value inwhich their experience was held. Oppositionwas expressed to short shift arrangements fromsome nurses on the basis of continuity issues,and gaps in the roster. The length of shiftwould appear to depend on local needs andshould be considered at that level, however agoverning principle would appear to be theproviso that no gaps should be left in the rosteras a result of short shifts.

Night duty

The issue of rotating versus permanent nightduty was raised in the forums. Strong viewswere expressed about rotations of night duty,and it was seen as a reason why some nurseswere leaving the profession, particularly fromthe critical care areas. There were many whoadvocated voluntary permanent night duty.However, the dangers of not keeping up withcurrent changes in knowledge, skills andtechnologies and the possibility of thedevelopment of a negative night duty culturewere put forward as concerns. Measures tocounter these problems included access to

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education during the night or at times duringthe day convenient for the night nurse, in somecases a period of time on day duty andsufficient overlap period. In some instances,incentives were offered for permanent nightduty, including (but not limited to) a hot meal.

Recommendation 48: That attention be paidto rostering and that the followingprinciples be implemented:• Flexibility, fairness and equity of

rostering, through such means as self-rostering and job sharing.

• No gaps in the roster caused by shortshifts.

• Encouragement of voluntary permanentnight duty, but with access to continuingeducation, periods of day duty andstrategies to avoid a ‘night duty culture’.

Overtime

During the forums the issue of overtime wasfrequently raised. As indicated in section 3.1.3,the amount of unpaid overtime worked hasbeen estimated at 300–450 EFT per week(Considine & Buchanan 1999). The Committeeis of the view that each health facility shouldhave in place strategies that reduce the amountof overtime worked. Every nurse is entitled,under the Award, to claim legitimate overtimeworked and it would appear that some healthfacilities need to be reminded of theirobligations in this area. The reward forovertime can be either remuneration or time offin lieu, whichever suits the hospital, theward/unit and the individual nurse.

Recommendation 49: That strategies be putin place by each hospital to reduce the needfor excessive overtime, but where it isrequired, hospitals be reminded of theiraward obligations regarding overtimeprovisions.

One problem that was frequently alluded to inthe forums and focus groups was a prevailingculture in which nurses were discouraged bothovertly and covertly from claiming overtime.Budgetary constraints were commonly used asa reason why overtime was not to be claimed.Some NUMs appear to have contributed to thedevelopment of this culture by not claimingovertime themselves, and by either actively orpassively encouraging others not to claim. It is

proposed that one way to reverse this negativeculture would be for the NUM to ensure thatthey claim overtime when this is worked.

Recommendation 50: That managementencourage NUMs to claim legitimateovertime to ensure that a negative culturedoes not develop in relation to payment ofovertime.

As the nurse workload becomes morereasonable as a consequence of the measuresrecommended in this report, the amount ofovertime both claimed and rewarded could beused as a measure of the success, or otherwise,of a facility’s ability to recruit and retain nurses.

6.1.2.2 Overlap PeriodThe Committee has been informed that one ofthe major causes of overtime relates to absenceof an overlap between shifts. The ANF hasindicated that the 8:8:10 roster is necessary toprovide a two-hour overlap period, howeverthis was not supported by a number ofsubmissions, both written and verbal. It wasfelt that different needs of different units wouldnot be met with such a prescriptive roster.However, the principle underlying this, namelythat an overlap period is necessary betweenshifts, is one that is supported. The overlapperiod is not only necessary for reduction ofovertime, but also enables the handover to beachieved effectively, allows for double dutiesduring this period, meal breaks and providestime for education and team building.

Recommendation 51: That all health carefacilities restore an overlap period betweenshifts. The length is to be determined bylocal need and the requirement forsufficient hand-over time, meal relief,undertaking of double duties and provisionof some in-service education and teambuilding.

6.1.2.3 Accrued Day OffAs discussed in Chapter 3, associated with theissue of an overlap period is that of length ofshift and its relationship to the ADO. Somehealth care facilities have retained the ADO fornurses and others have removed it. The ADOhas tended to be retained by allied health careprofessionals as the issue of back fill is not amajor concern.

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Australian data (AIH&W 1999) havedemonstrated that while there has been littleoverall decline in the number of nursesnationally during the last ten years, there hasbeen a decline in full-time equivalent (FTE)nurse employment, as more nurses choose towork part-time. The Committee considers thatthe linking of the ADO with full-timeemployment is one strategy that may facilitatethe return to full-time employment. TheCommittee notes that the strategy is dependanton the willingness of employers to offer full-time work. Submissions from the consultationprocess suggest that some rural hospitals havesignificantly reduced opportunities for full-timeemployment, in part as a cost saving measure.Forums held in regional hospitals suggestedthat the inability to obtain full-time work is amajor disincentive to specialist nursesrelocating to rural areas.

The return of the ADO for nurses needs to beconsidered in conjunction with the issues oflength of shift and the overlap period.Consistent with the rostering principles insection 6.1.2.1, there should be sufficientflexibility to meet the needs of individuals aswell as the ward/unit. Therefore, the length ofshift for full-time staff seeking access to anADO should be based on local needs, withnursing staff working a roster pattern thatallows them to work full-time. This shouldresult in an increase in the shift overlap in themiddle of the day (under most rosterconfigurations) thus reducing the amount ofunpaid overtime currently being worked.

The cost of the ADO lies largely in therequirement for back fill. Information before theCommittee suggests that the ADO wasremoved by changing the hospital rosterconfiguration, so that nurses continued to worka 38 hour week but reverted to reduced shiftlengths. As a result nurses were present for thewhole 20 day, four-week cycle, and as such thereplacement cost of these staff was eliminated.While it is difficult to accurately cost thereplacement of nurses taking an ADO, the VHAhas estimated that the cost would be in therange of $15–20 million per annum. This maybe an overestimate, however, as a number offactors influence costing, including the numberof facilities already providing an ADO, thenumber of full-time staff requiring back fill,

length of shifts, requirements for part-timestaff, reduction of overtime and the migrationof part-time staff to full-time employment.

Restoration of the ADO is seen as a strategy toencourage nurses to return to full-timeemployment to enhance continuity of qualitynursing care. Further, increasing the length ofthe shift will help alleviate the issue of unpaidovertime, allow nurses to take breaks from theworkplace once a month, and provide forgreater satisfaction and retention of nurses.Submissions before the Committee fromconsultation forums suggested that manynurses regarded their work as mentally andphysically exhausting, while the survey of non-working registered nurses (appendices 3 and 4)indicated that workload was the primarybarrier to re-entry to nursing. Thus, return ofthe ADO could be considered as a powerfulrecruitment strategy to full-time employmentand a retention strategy for those alreadyemployed full-time.

Recommendation 52: That full-time nursingstaff have access to an ADO, to be taken ina flexible manner suitable to the nurse andthe local facility circumstances, and that theDepartment of Human Services adjusts thecasemix funding formula to allow for thefull implementation of ADOs.

6.1.3 The Casual Workforce

6.1.3.1 Agency Nurses Agency nurses have traditionally beenemployed in hospitals to cover ad hoc orunplanned periods of absence of permanentstaff, for example due to sick leave, familyleave or unpaid leave.

Over recent years the use of agency nursesappears to have increased significantly,although this was unable to be quantified dueto lack of historical workforce data. Throughthe forums and focus groups the Committeewas informed that the reasons for nursesleaving permanent employment and joiningagencies included increased workloads,reduced flexibility with rosters, and freedom towork in a clinical setting without addedadministrative burdens. The Committee hasalso been informed that two important factorsrelating to agency nursing as a primary career

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choice are certainty of work, with agencies ableto offer regular preferred shifts to many of theirstaff, at times suitable to the nurse’s lifestyle,and differential pay rates offered to nurses withpostgraduate qualifications. For example, it iscommon for nurses with critical carequalifications to be paid at grade 4 or 5 level,and some agencies augment pay withenticements such as loyalty reward programsand professional development courses.Although attempts have been made to containdifferential pay rates through preferredprovider contract arrangements, and despitewidespread concern over the sustainability ofthese remuneration levels, it appears that thecurrent structure continues to flourish in whathas become a sellers’ market.

It was also reported through both the hospitalsubmissions and the nurse forums that theincrease in use of agency nurses has beenlargely due to an inability of hospitals to recruitnurses to permanent positions.

Department of Human Services figuresindicated that agency nurses (nurses workingfor an agency as their principal form ofemployment) comprised 3.5 % of the Division 1nursing workforce, while a further 14% workedfor agencies as a second or third means ofemployment. In total 7,133 working Division 1nurses were estimated to engage in some formof agency work (Department of HumanServices 19992). The workforce percentages aresimilar for nurses in Divisions 2 and 3.

As indicated in Chapter 3, there are a numberof problems associated with the employment ofagency nurses. An individual agency nurse’slevel of competence is not necessarily knownwhen attending a shift and the nurse in chargeis likely to allocate the less acute or complexpatients to the agency nurse. As Snell (1997)notes, ‘such staff are, in most cases, competentbut their skills may not always match those ofpermanent staff, particularly if they areworking in an area they are not totally familiarwith’. As a result, permanent staff will berequired to nurse patients on an ongoing basis,again causing increased pressure and stress onthose staff. This is further supported byresearch that identifies the problem that, onmost occasions, agencies are unable to supply anurse who is adequately experienced and

appropriately qualified to fill the vacancy(ACNMI et al. 1999), which has resulted infurther stress for permanent staff. In addition,agency nurses are often only present for oneshift and the permanent staff report that theyshoulder more responsibility for ensuring thatthere is continuity of care from one shift toanother, as well as responsibility for orientationand supervision of agency nurses.

The use of permanent staff adds to the level ofcontinuity of care and reduces the stresses onother nurses in the ward/unit for the reasonsoutlined above. However, what is unknown iswhether nurses will return to permanentpositions if workload is ameliorated andworking conditions made more attractive.Agency nurses have had a role in the healthcare industry for the cover of unplanned leaveof permanent staff but it is now suggested thatthey are being used to fill EFT vacancies, ashospitals are pressured to keep beds open dueto casemix funding imperatives. By recruitingpermanent nurses, the health care industry willreduce its reliance on agency nurses, so thatthey will be used to cover ad hoc or unplannedabsences only. It is hypothesised that, as aresult, permanent staff satisfaction will beincreased and a reduction in the attrition rate ofpermanent staff may be achieved. Further, aspermanent positions are filled, the need foragency nurses reduces and the attractiveness ofagency work as the principle source ofemployment diminishes.

It can be anticipated that minimising agencyuse will offer significant financial benefits forhospitals. It is difficult to calculate the cost tohospitals of employing agency nurses in placeof permanent workers. A complicating factor isthat charges to hospitals by agencies do notonly reflect staff replacement, but also on costsand the cost of differential payment rates forcertificated staff. For example, one majormetropolitan hospital reported that it has tobudget 60% on costs for agency staff.Nonetheless, significant savings could beanticipated as more permanent staff areemployed. This strategy for recruitment andretention of permanent staff will be effectiveonly if adequate funding is provided forpermanent staff, full-time employment isencouraged as appropriate (particularly insome rural areas), and the procedures for filling

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vacancies are streamlined within health carefacilities.

Recommendation 53: That health carefacilities ensure that:• Strategies are being implemented to

employ nurses on a permanent basis tofill permanent vacancies.

• Recruitment procedures for replacementof permanent positions are developed toensure that such vacancies are filledwithin eight weeks of notice ofresignation.

• Use of agency nurses is restricted tounplanned absences only.

Recommendation 54: That the Departmentof Human Services monitors statewidetrends in agency usage in the public healthcare industry on a quarterly basis.

Recommendation 55: That casemix fundingbe adjusted so that hospital funding issufficient to ensure that ward/unit budgetsand permanent staffing profiles includeprovision for leave relief such as annualleave and ADOs.

6.1.3.2 Nurse Bank ModelsMost hospitals have at one time operated nursebanks. Bank nurses are employees of a hospital,employed on a casual basis only, unlike ‘pool’nurses who are offered regular work. Thenurses notify the hospital when they areavailable and as vacancies in rosters exist, theyare ‘booked’ for those shifts. It was reportedthat many have allowed their banks to lapse infavour of contract arrangements with nursingagencies.

There are advantages to operating a nursebank. As bank staff are employees of the healthcare facility, they have usually undertaken anorientation program and are conversant withhospital policies and procedures. Over timethey also become familiar with the differentwards or units and require less orientationwhen commencing a shift. They are known bythe permanent staff and are more likely todevelop a sense of organisational loyalty.

A further advantage of the bank system to thecasual nurse is that they are able to accessservices offered to permanent staff, such asprofessional development and continuing

education activities. Submissions before theCommittee highlighted the importance ofcontinuing education to casual nurses as arecruitment and retention strategy.

One disadvantage of the nurse bank is that theshifts available might not suit the nurse,whilethe agency nurse has access to a greaternumber of health care facilities and canexperience clinical work in hours that suit.However, it could be argued that theadvantages of the nurse bank outweigh thesedisadvantages.

In summary, the Committee sees nurse banks asa way of meeting ad hoc staffing needs withnurses whose experience and qualifications areknown and who are familiar with theward/unit and type of nursing required.

Recommendation 56: That health facilitiesare encouraged to (re)establish Nurse Banksto meet the ad hoc staffing needs of thefacility and that these nurses have access to the ongoing education program of thefacility.

6.1.4 The Working Environment

6.1.4.1 Physical and Verbal AbuseNursing is recognised internationally as adiscipline that exposes workers to occupationalviolence. A UK study showed that nearly 33%of all nurses surveyed had been violentlyattacked or abused by patients or by friends orrelatives of patients (Trade Union Congress1999). In Sweden occupational violence againstnurses is described as commonplace (Arnetz,Arnetz & Soderman 1998). In Australia, theAustralian Institute of Criminology hasreported that the health industry is the mostviolent in Australia (Perrone 1999). It should benoted that while the incidence of violenceagainst nurses appears to be rising, it isestimated that such violence remains seriouslyunder-reported (International Council ofNurses 1999).

Physical, psychological and verbal violenceperpetrated against nurses by clients and theirrelatives is subject to sanctions under commonlaw, as well as occupational health and safetyand equal opportunity legislation. It is also thesubject of active campaigns by many Stateindustrial bodies and statutory authorities.

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The Committee notes that work is currentlybeing undertaken by Victorian WorkcoverAuthority and the ANF to address the issue ofviolence directed at nurses from clients andtheir families. The Committee also notes thatVictorian occupational health and safetylegislation places a clear responsibility onemployers to protect staff from workplaceviolence. However, given the current level ofestimated under-reporting of workplaceviolence and the clear relationship betweenviolence and attrition (Hastie 2000), theCommittee proposes that current strategies bereviewed in order to assess whether a formalstatewide strategy needs to be adopted.

Recommendation 57: That the Departmentof Human Services, in conjunction with keystakeholders, evaluates work currently inprogress in the health care industry toassess the prevalence and control ofworkplace violence (physical and verbal)both directed at nurses, and from withinnursing, and to consider whether acoordinated statewide campaign isrequired.

6.1.4.2 Horizontal ViolenceEvidence before the Committee suggests thatviolence in the nursing workplace is not onlyperpetrated by clients and their families. Thespecific concept of horizontal violence, and themore diffuse concept of ‘workplace culture’, hasbeen described as a major cause of nursingattrition and a major barrier to re-entering theworkforce. In the quantitative survey ofregistered non-working nurses, 12% stated thata negative work environment was a reason fornot returning to nursing, and in the youngercohort (20–29 years old) 22% of nurses citedthis reason (Campbell Research & Consulting2000, Appendix 3).

It is the Committee’s view that it should beacknowledged that horizontal violence is afactor in the attrition of nurses from theVictorian public health care system and that thenursing profession should review andimplement strategies to address the endemicworkplace culture issues that contribute tohorizontal violence.

Horizontal violence has been widely describedin recent literature (Hedin 1986) and appears to

have captured the imagination of many nursesworking in the public sector. Intra-disciplinaryviolence cannot be described as a newphenomenon, and there has been a degree ofacceptance of nursing ‘eating its young’ (Spring& Stern 2000). However, there has been a recentrecognition of both its impact on individualsand on the health care industry as a whole.

Horizontal violence can be described as a sub-category of harassment and is more insidious inits effect, particularly as its perpetrators maynot recognise it as such as it is usually low key,long term and difficult to quantify. It rangesfrom professional discourtesy (failure to returnphone calls and rumour spreading) toprofessional degradation (ridicule of other’swork, negative performance appraisals andcondescension) to overt harassment (physicaland verbal intimidation). Anecdotal evidencesuggests new graduates are particularly proneto such abuse.

Recommendation 58: That the Departmentof Human Services review of the GraduateNurse Program addresses the issue of thevulnerability of new graduates to physicaland horizontal violence in the workplace.

To healthcare organisations the effects can beincreased absenteeism, displacement, reducedproductivity and efficiency, poor industrialrelations, hasty decision making and increasedstaff turnover (Irish Health & Safety Authority1998). British research (Quine 1999) has shownthat nurses subject to horizontal violence havestatistically significant lower levels of jobsatisfaction and higher levels of job inducedstress, depression, anxiety and intention toleave the job. The research concludes thatbullying is a serious problem and that systemsfor supporting staff and dealing withinterpersonal conflict may have benefits foremployers and staff alike.

The Committee notes that several hospitalshave in place formal counselling services fornurses, predominantly for critical incidentdebriefing. The Committee’s attention wasdrawn to the counselling service offered toPeninsula Healthcare staff and the criticalincident protocols adopted by the EarlyPsychosis Intervention Centre as goodexamples of such services.

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Recommendation 59: That provision offormal independent counselling for victimsof bullying and interpersonal conflict, beavailable for all nurses working in thepublic system. In addition the Committeerecommends that all nurses working in thepublic system have access to criticalincident debriefing services.

Recommendation 60: That the Departmentof Human Services, in conjunction with keystakeholders (which should includerelevant industrial and professional bodies,as well as human resources professionalsand the Victorian Workcover Authority),establish a review of workplace culturewith the aim of ensuring that each healthcare facility has in place a formalmechanism for dealing with workplacebullying.

The Committee believes that measurement ofstaff satisfaction is an important indicator oforganisational difficulties or success, and willassist in the evaluation of the effectiveness ofmany of the strategies put forward in thisreport. Staff satisfaction surveys are commonlyused in private enterprise and the publicservice to monitor organisational climate andworkplace attitudes on an ongoing basis, andthe Committee proposes that such an approachbe undertaken with the nursing workforce.

Recommendation 61: That the Departmentof Human Services encourages all publiclyfunded agencies to undertake anappropriately recognised and validatedstaff satisfaction survey on a regular basis,and that these agencies demonstrate to theDepartment of Human Services changesthey have initiated as a result of surveyfindings.

6.1.4.3 EquipmentWorking conditions are made more difficultand inefficient when adequate equipment is notprovided. Several hospitals reported a lack ofequipment ranging from major items such asventilators, to pillows andsphygmomanometers, to consumables such assyringes. Such a situation is unacceptable. It isincumbent upon management to ensure thatthe nurses have all the equipment necessary toprovide not only safe, but also quality nursing

care and to do so in an efficient manner. It isalso a Department of Human Servicesresponsibility to ensure that available funds areexpended wisely in relation to the total hospitalequipment budget.

Recommendation 62: That all hospitalsreview their budget allocations for medicalconsumables and equipment for nursingcare and where the budget is inadequate, inorder to avoid the inefficiencies of practicethat results from such inadequacies, torequest that the Department of HumanServices consider additional finances torestore and maintain medical consumablesand equipment level.

6.1.5 The Nurse Friendly Workplace

6.1.5.1 Child CareEvidence before the Committee fromunregistered nurses and registered non-working nurses has highlighted the issue ofchild care as a major factor influencing whetherto remain in the workforce. The Committee wasgranted access to internal research from a majormetropolitan teaching hospital where staff werecanvassed on their child care use and needs.The majority of staff were reported as happywith their current child care arrangements, andthose unhappy with current child carearrangements had predominantly preschoolchildren. The report indicated:• 64% of nurses using child care reported

sickness of a child as the principal reason forwork absence.

• Around half the nurses surveyed felt theirwork had been affected by child careproblems of other staff.

• 70% would return to work earlier frommaternity/paternity leave if employerprovided child care were available.

Evidence from forums suggests that whilemainstream child care services are routinelyused by nurses, there are major problemsencountered when a child is sick, during schoolholidays and outside of office hours. Inaddition, the inflexible pre-booking approach ofsome child care facilities negates the ability ofsome nurses to offer short notice workplaceflexibility.

The Committee, in common with the findingsof other States, views the issue of appropriate

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and flexible child care as a key factor inattracting and retaining nurses.

Recommendation 63: That the Departmentof Human Services, as a matter of urgency,undertakes a review of nurses’ child careneeds across all sections of the nursingworkforce, with a view to formulating astrategy to best meet assessed needs.

6.1.5.2 Other IncentivesOther issues that have been raised through thefocus groups and forums as incentives fornurses to return to nursing and or to work atparticular hospitals are:• Car parking—increased availability and at

lower cost.• Incentive schemes—such as private health

cover, access to fitness training and on sitehealth care.

• Counselling services.

The Committee has made no recommendationsfor these areas as it will depend on localcircumstances and individual assessments byhospitals as to whether these would be usefulincentives

6.1.6. Support for Rural Nursing PracticeAs outlined in section 3.8, submissions from therural sector highlighted major concerns aboutisolation, deskilling and support.

Submissions to the Committee offered specificsuggestions to address some of the problemsattracting nurses to rural areas. They included:• Exploring State-funded scholarships for

rural students to undertake the Bachelor ofNursing course, with an expectation of theirreturning to the local area for a graduatenurse year.

• Offering work experience (as personal careattendants) to undergraduate students in thelocal area during university vacations.

• Exploring payment options, such asassistance with living expenses andrelocation expenses.

• Considering bonus payments (such as $1000at the end of each year of service) to allnurses working in a regional and ruralsetting.

• Using low cost hospital-ownedaccommodation where available.

The Committee noted that many of theseinitiatives paralleled existing schemes alreadyin place for medical practitioners and fundedby the Commonwealth Government.

Isolation was also frequently cited as an issueaffecting the rural nurse workforce. Somesubmissions drew attention to the lack ofsupporting networks and access to peer reviewfor their nurses. Given that all rural andregional health facilities are associated with aRegional Department of Human ServicesOffice, it is essential that the needs of theisolated nurse and the sole practitioner areconsidered carefully and strategies put in placeto provide support and peer review.

Sole rural practitioners are frequently on call inaddition to their normal weekly working hours.This has the capacity to cause stress and theinability to plan for and enjoy leisure time, withthe consequent risk of burnout. In addition,there were several submissions indicating thedifficulties in providing relief or leave for thesole practitioner, particularly in areas wherethere are no nurse banks or agencies. Onesuggestion to the Committee was to introducelocum nurse banks in a similar manner to theGP locum relief service. To achieve this, itwould be necessary to develop a successfulmarketing strategy to promote the concept of alocum nurse bank and to provide incentives,such as travelling time, accommodation andeducation opportunities, to assist recruitment.Such an initiative would need to be formallyevaluated and the outcomes of the evaluationreported to the Department of Human Services,so that best practice can be encouraged andimplemented more widely as appropriate.

In both mental health and general communitynursing, there are safety issues associated withthe sole practice in rural areas. Having to traveldistances on unmade roads and pass through‘black spots’ in telecommunication servicescreate unnecessary risks for the nurse. The riskis heightened where suitable transportation(four-wheel drives) and telecommunicationsdevices (two-way radios) are not available. It isimportant that appropriate equipment issupplied and that, where possible, two nursesattend calls in places of risk. Similar risks applyto nurses who are alone in places such asemergency departments in rural and regional

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areas. The Committee believes it is essentialthat adequate security equipment andpersonnel support are provided in places wherenurses may be at risk.

Recommendation 64: That Department ofHuman Services, in conjunction with itsregional offices, establishes work groups ofrelevant stakeholders to: • Develop strategies to provide support

and peer review opportunities for nursesin rural hospitals.

• Explore the establishment of a locumnurse bank in rural areas where relievingnurses are not available and developmarketing strategies and an incentivescheme for the bank.

• Examine the security risks for nursesworking in both the hospital andcommunity in rural regions and developa statewide policy with strategies such astraining programs, use of two staff whereappropriate, suitable vehicles,telecommunication devices and safetyequipment and personnel for securitymanagement and risk minimisation

Policy and strategy implementation andtheir outcomes to be reported toDepartment of Human Services NursePolicy Branch.

6.1.6.1 Rural Mental Health and CommunitySafety IssuesIt has been reported to the Committee that,under some circumstances, mental health nursesin rural areas are at times required to practice inan unsafe manner in order to compensate forlow staff numbers. For example, in addition tothe safety issues outlined above, it was reportedthat mental state examinations to assess,amongst other things, danger to self or others,are being performed by solo practitioners. Suchpractices put the client, the nurse and thecommunity at risk and the industry standarddeems that such practices should be explicitlyprohibited (Department of Human Services1994). Standard operating procedure for CATteams direct that all new assessments, and anyassessment where there is a possibility of danger,are to be carried out by two practitioners.Assessments where a danger is identified areusually performed in a secure environment orwith police presence. While the Committee hasno evidence to indicate such practices are

widespread, it is of considerable concern thatreports of such practices occur at all.

Another example of inappropriate cost controlmeasures impacting on retention of nursesreported to the Committee relates to theclassification of some community positions inrural services. It has been argued that theprofiles of some community teams in ruralareas are at a lower level than theirmetropolitan counterparts. In community-basedmental health services the entry level positionsare graded at RPN3, more senior clinicalpositions at RPN4. Teams that have a greatercrisis assessment function have a higherloading of RPN 4s. While the ratio between theRPN3s and 4s vary, it is not uncommon onsome CAT teams for the majority of nurses tobe RPN 4s. While rural services do notnormally have CAT teams, they neverthelesscarry out the same crisis assessment functions,usually through an integrated team structure.

The issue brought before the Committee is thatthese situations create disincentives to work inrural settings. As with the issue of solo visits indangerous circumstances, it is difficult toquantify such practices. Again it is thought thisproblem is not necessarily widespread,however it has been brought before Committeein the context of retention issues.

It could be argued, in the context of many ruralpractitioners working in isolated environmentsin a manner not dissimilar to that of a solepractitioner, that such classifications be higherthan their metropolitan counterparts.

Recommendation 65: That regional andrural health facilities ensure thatclassification structures in rural areasadequately reflect the levels ofresponsibility associated with the isolatedenvironment in which nurses practice andis on no less than comparativeservices/functions in the metropolitanareas.

6.2 Working Conditions6.2.1 Clinical Career StructureThe following section examines the issuessurrounding the current CNS position, thelimitations of the CNC position and the needfor a progressive career path for the CNS whois at advanced and expert level.

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6.2.1.1 Clinical Nurse Specialist (CNS)

History of the CNS Position in Victoria

The position of CNS was established in Victoriawith the advent of the nurses’ career structure,defined in clause 3 (aa) of the Nurses (VictorianHealth Services) Award, 1992. The awarddefinition of the CNS is:

A registered nurse appointed to the gradewith either specific postbasic qualificationsand 12 months experience working in theclinical area of his/her specific post basicqualification and is responsible for clinicalnursing duties; or minimum of four yearspost registration experience, including threeyears’ experience in the relevant specialistfield.

The aim in creating the position was to retainexperienced clinical nurses at the bedside,within their area of clinical expertise. Theposition was introduced as a 1989 amendmentto the Registered Nurses Professional Pay RatesAward 1988 which saw the abolition of thequalification allowance. Criteria for the positionwere trialled in four Victorian hospitals and,until the implementation of the CNS position inMarch 1990, qualification allowance ratescontinued to be paid to grade 2 registerednurses (Health Department of Victoria Circular,March 1990). The rates of pay were set at a levelbetween the highest grade 2 classification(grade 2 year 6) and grade 3A year 1. Fundingwas allocated in line with the professional payrates agreement, but the difference in paybetween the grade 2 positions and that of CNSwas funded directly by the then Department ofHealth and Community Services (DH&CS) as,unlike other positions in the career structure,there were no designated numbers. Theposition was designated one of personalappointment, not incremental progression andapplicants were assessed according toguidelines agreed to by the DH&CS andVictorian ANF.

The guidelines indicated the details of thedefinition and outlined a process forapplication, interview, notification, appealmechanisms and ongoing applications. It didnot specify criteria other than those implied bythe definition. An applications package wasdeveloped as a result of the trial of the criteria

and was intended to have widespreadapplication across the State. With separatefunding, the appointment of a CNS positionwas not a budget consideration and, therefore,it was relatively easy for nurses to access thisposition.

Following the introduction of the casemixfunding formula, the CNS position wasabsorbed into the budget allocation and was nolonger funded as a separate entity. Since then,many health care facilities have introducedtheir own tailor-made criteria that are appliedin addition to the award definition. Informationbefore the Committee indicates that, in manyinstances, appointment to CNS positions hasbeen difficult, even when the award criteria aremet. Conversely, some health care facilitieshave used the CNS position as a tool to retainexperienced nurses in specialist areas, such ascritical care. Thus across the State, the ability togain access to the CNS position is not equitableand the eligibility criteria vary markedlybetween health care facilities.

The current CNS position rewards those nurseswith experience and qualifications who want tostay at the bedside. It has been used as asuccessful strategy by some hospitals forretaining such nurses at the bedside, especiallyin critical care nursing. The Committee viewsthe CNS position as an important strategy toretain qualified experienced nurses in theworkplace. As a matter of urgency, health carefacilities need to accept the principle that thisposition does offer value and status to qualifiedand experienced nurses, and therefore shouldbe used widely as a retention strategy.

Recommendation 66: That the CNS positionat Grade 2 year 7 be maintained in thehealth care sector and be used as a strategyfor retaining experienced, qualified nursesat the bedside.

6.2.1.2 Criteria for CNS PositionAt present, the criteria used to appoint nursesto the CNS position vary across the Victoria. Aspreviously described, there were a set of criteriapiloted in four hospitals, but not subsequentlyadopted across the State. The criteria forapplication reflect the expectations of theposition. During the open consultation forums,a theme that emerged frequently was the

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demands that management placed on the CNS.For many, there was an expectation that theCNS would provide not only clinical leadershipand teaching, but also undertake research andproject activities, often in their own time.Further, they had to demonstrate a level ofpersonal continuing education not required ofother nurses. One CNS indicated that he hadgiven up the CNS position and reverted to hisformer grade 2 position because of theunrealistic demands of management. TheCommittee considers that this may be a notuncommon situation. Others expressed theview that they did not even consider applyingfor the position, as both the selection criteriaand the application process were toodemanding.

A selection of the criteria currently being usedin NSW and Victorian metropolitan (major andnon-major) and regional hospitals was collectedby the Committee and analysed. The criteriavary widely in terms of function, and allinclude the requirement for the CNS to act asrole model for clinical practice. All but oneincludes a preceptor and/or mentorship role,particularly for graduate year nurses. Half theVictorian sample set the level higher than thatexpected of other grade 2 nurses, while theremainder set the level at that of expert, and anexpert recognised as such by colleagues (acriterion used by Benner [1984] in her definitionof the highest level of clinical practice). Onehospital used the ‘higher’ and ‘expert’ labels,another ‘higher’ and ‘complex’ and anotherboth ‘advanced’ and ‘expert’. One used‘advanced’ only. Clearly there is variation in thecriteria applied to the level at which the CNSshould operate: over half the sample consider itto be at the level of expert, but of thosehospitals, only one had a criterion relating to aresource function, and none emphasised theleadership role.

In terms of the demonstration of commitmentto the specialty, the hospital and the profession,all included a criterion for involvement inquality improvement projects, while half alsospecified involvement in research projects. Allbut one of the sample had a criterion relating toinvolvement in teaching, even specifying thenumber of sessions that the CNS should beinvolved in (the range was one to four wherespecified).

Two of the sample required the CNS tocontribute to conferences or forums, with onerequiring a paper to be delivered. Fourhospitals expected the CNS to demonstratehow their own professional development wasprogressing and six expected the CNS to belongto a professional organisation.

Four of the hospitals included other criteria:membership of the occupational health andsafety committee (1), demonstrating hospitalvalues (2), assisting the NUM (1), involvementin critical incident documentation (1), meetingbudget targets (1), orientation of staff (3), andassuming management in the absence of theNUM (1). One hospital specified that a CNSshould mainly be appointed in an area where amedical specialist was involved.

The application and selection process in thesample varied; in some instances it wasrelatively simple while in others extremelycomplex. In some instances, the requirementsfor the CNS were in excess of those of othernurses, particularly in relation to demonstrationof continuing competency and performanceassessment.

The Committee recommends that a range ofcriteria are adopted and that hospitals publishtheir own set of criteria that meet their specificneeds, but which are consistent with thegeneral principles outlined below.

Recommendation 67: a. That for candidates applying for CNS

positions, hospitals adopt the followinggeneral principles: • Recognition of the Registered Nurses

(Victorian Health Services) Award 1992definition.

• Level of clinical practice reflects thelevel of remuneration i.e. higher levelof skill than would be expected ofother grade 2 nurses but less than grade3 positions.

• The primary focus of the position isclinical.

• Criteria for CNS must be achievable innormal paid rostered hours.

• Criteria for performance reviewprocesses be consistent with the reviewprocess of all nurses in the facility.

• Publish criteria for the CNS position.

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b. Applicants must show a commitment todevelopment of area of specialty, theirown development and the hospital inwhich they are employed and mustdemonstrate one of criterion in each ofthe three sections.Clinical Skill• Higher levels of skill demonstrated in

clinical decision making, in particularin problem identification and solution,and analysis and interpretation ofclinical data.

• Maintenance and improvement ofclinical standards.

Professional Behaviour• Positive role modelling.• Act as mentor or preceptor to less

experienced nurses, including graduatenurses.

• Support of, and contribution to, qualityimprovement and research projectswithin the area of practice andward/unit.

• Acting as a resource person to others inrelation to clinical practice.

Professional Development• Membership of relevant professional

body. • Contribution to the education of other

professionals e.g. being willing toprovide at least one in-serviceeducation program each year.

• Undertaking own planned professionaldevelopment and competence throughvarious forms of continuing education,such as conferences, study days, formalstudy, reading.

c. Department of Human Services to reviewall criteria and ensure statewideconsistency of application of criteria.

6.2.1.3 FundingCurrently there are 1,185 full-time equivalentCNS positions in the public health sector inVictoria, which account for 15.6% of all grade 2positions. A number of submissions before theCommittee indicated the difficulties in fundingthe number of grade 2 positions eligibleaccording to the Award definition. A surveyrequesting information on the additionalnumber of CNS positions that health careservices would require if funding were

available yielded a figure of 170.16 EFT (64%response rate).

The current distribution of these places is ofinterest (Figure 7). The majority of the currentplaces are in critical care (including cardiaccare) and midwifery. In critical care, somehospitals have been using this classification as aretention strategy and none of the facilitiessampled argue the need for additional places inthis area. However, in other areas of identifiedneed, such as emergency, medical/surgical andperioperative nursing and midwifery, moreplaces were required. Of particular interest wasthe aged care sector. In the sample surveyedthere were no CNS classifications, but a needwas established for 20.6 EFT classifications.Likewise, there appeared to be few mentalhealth classifications and these were consideredsufficient. However, given that mental healthnurses enjoy a better clinical career structurethan general nurses, this is not a surprisingfinding.

Figure 7: Distribution of CNS ClassificationsCurrently and Desired if Funding Were Available

It appears that the number of CNS positionscurrently available would be increased if morefunding were available. The issue of fundingneeds to be addressed, as the casemix fundingformula does not currently meet the demandsfor CNS positions. Therefore, in the short term,the Committee argues that additional fundingneeds to be provided to meet the immediateshortfall of CNS positions. More data needs tobe collected to establish what is a realistic anddesirable level of CNS positions in the public

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health sector, preferably prior to the end of2000. In the meantime, a review of casemixfunding is required to ensure that it does allowfor adequate funding for the CNS contributionto patient care, and in adequate numbers.

Data also need to be collected to establish whatis a realistic number of places required. Thisdata should be collected by April 2001 toensure that the baseline is taken intoconsideration for the 2001–2002 budget.

Recommendation 68: That as a matter ofurgency Department of Human Servicesrequests that facilities indicate the numberof CNS positions that are needed for theimplementation of Recommendation 67above. That the Department collects dataregarding the number of CNS positions inthe public sector, following implementationof this recommendation, and uses thisnumber as a baseline for the funding ofCNS positions across the public sector.

Recommendation 69: That Department ofHuman Services recommends a mechanismto ensure that adequate funding is providedfor the CNS classifications according to thebaseline figures as established inrecommendation 68 above, for the2001–2002 financial year and beyond.

If the CNS position is to be used as a strategyfor retaining experienced, qualified nurses inthe workforce, then implementation of theabove recommendations is required as a matterof urgency.

Costing

As indicated above, when the concept was firstintroduced, in the pre-casemix era, the CNSclassifications were funded separately. Theclassification is now a matter of budgetallocation.

As the casemix funding formula does notcurrently meet the demands for CNS positions,additional short term funding needs to beprovided to meet the immediate shortfall ofCNS classifications. On the figures extrapolatedfrom the survey, it is calculated that a total of260 EFT new CNS positions would be requiredas a retention strategy. As the majority of thesewould already be classified as grade 2, theirintroduction would require only the salary

difference between the present grade 2classification and CNS. On current salaries thedifference between the mid-range of grade 2year 3 and CNS is $172.00 per week. A full yeareffect of this additional number of CNSpositions would be in the vicinity of $3.32million.

6.2.1.4 Title of Clinical Nurse SpecialistThere is some ambiguity about the title ‘ClinicalNurse Specialist’. The definition used inVictoria was consistent with that of NSW, withthe exception that the latter specifies that theCNS must ‘satisfy the local criteria’ (PublicHospitals Nurses’ [State] Award NSW, 1997).

These definitions are not consistent with thetitle as used in the international literature(emanating predominantly from the USA andthe UK). Castledine (1995) summarised the roleof the CNS in the UK as:

a nurse who is able to demonstrate higherlevels of clinical decision making, able tomonitor and improve standards of care,through supervision of practice; clinicalaudit; the procession of professionalleadership and the development of practicethrough research, teaching and the supportof professional colleagues (p. 265).

Castledine also indicated that the CNS’s workwith patients must be ‘systematic, reflective,analytical, innovative and dynamic’. Theoverseas literature addresses the issuesassociated with the terms ‘clinical nursespecialist’, ‘advanced practice nurse’, ‘nursepractitioner’ and ‘expert nurse’ (Castledine1995). In a recent article on specialisation in theAustralian context, Fairweather & Gardner(2000) highlight the semantic ambiguity ofterms by demonstrating that the ANF (1996)definition of ‘advanced’ level equated with theUK ‘specialist’ level and that the Australian‘expert’ level shared some characteristics of theUK ‘advanced level’. There is no equivalent ofthe Victorian CNS in the overseas literature.

Australian specialist nurses were asked toreflect on their specialist practice in focusgroups. Two distinct concepts emerged fromthe groups: the ’nursing-in-a-specialty’ and the‘specialist nurse’. The former more closelyresembled the Victorian CNS role. Of interestwas the observation that not all nurses working

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in a specialty would become specialist nursessimply through working in the area(Fairweather & Gardner (2000), p.31). Thespecialist nurse was closer to the advancedpractice nurses described by Casteldine in theUK.

There is no doubt that the current VictorianCNS position does not reflect the commoninterpretation of the role. While it does reflectsome expertise in practice, it does not capturethe advanced level of specialty, nor is itappropriate that advanced practice berewarded at this level. In order to avoid theambiguity of title, the Committee recommendsthat the title be changed to ‘Senior ClinicalNurse’. This would be consistent with otherhealth disciplines, where progression accordingto specified criteria give recognition and statusaccording to qualifications and experience, butdo not require advanced levels of practice.

Recommendation 70: That the partiesrespondent to the Registered Nurses(Victorian Health Services) Award 1992work towards a consent award variation,whereby the title CNS be changed to SeniorClinical Nurse (SCN) to more accuratelyreflect the expectations of the position.

Introduction of CNS within the ExtendedCareer Path

Thus with the development of criteria andchange of title, recognition is given to thoseexperienced, qualified nurses and their work isvalued by both monetary reward and status.However, the issue is raised as to the long termeffectiveness of this position as a retentionstrategy.

Several written and verbal submissions beforethe Committee identified three issuesassociated with the CNS as part of the currentcareer structure. Firstly, the use of the term‘experience’ in the definition. As Fairweather &Gardner (2000) stated, specialists need notnecessarily develop ‘just by working in thearea’ (p.31). The part of the existing Awarddefinition placing time limits on experienceneeds to be reviewed in the light of the changesthat have occurred in nursing practice since1992. Secondly, as outlined above, the CNS roleneeds to be examined against specialist andadvanced practice, concepts that have been

continually developing over recent years. Thethird issue to emerge, particularly through theforums, is the need for ongoing recognition ofthe CNS position. The Committee has learntthat the common practice is for annual re-application for the position, and there appearsto be no transportability of the position acrosshospitals. The issue of transportability, as wellas increments, needs to be examined to assist along term retention strategy.

The criteria developed above reflect a particularrole defined for the CNS. In 1997, NSWreviewed the CNS position and concluded thatthe classification should be maintained, but toupdate and clarify the role description to reflectcontemporary practice (NSW Health DepartmentCircular, 28th February 1997). Strangely, the roleof the CNS was described as ‘performing(identified functions) at an advanced levelcompetently and consistently’. The criteria setby NSW are at a higher level than the Victoriancriteria proposed previously.

South Australia is currently undertaking areview of its career structure with moreavenues for the CNS, where progression isbased on increased skill and competence, notexperience. It has also included the nursepractitioner in its career structure.

The career structure of Victorian mental healthnurses already includes the equivalent of theSCN and CNS, and offers clear clinicalprogression (Registered Psychiatric NursesClassification Standards 1997).

Victoria has not reviewed the CNS positionsince its inception, nor has it addressed theissue of advanced and expert practice.

The Committee believes it is time for a revisionof the clinical career pathway. The pathway,and its associated remuneration bands, needs torecognise the clinical contribution of the currentCNC and CNS and to offer a path that willcontinue to reward the higher levels of clinicalexpertise developed by clinical nurses,expertise that adds considerably to the qualityof care. The CNS, at advanced and expert levelsof practice, needs recognition at grades 3 and 4with the appropriate remuneration. In addition,the career structure should build in arequirement for qualifications in order topractise at these higher levels.

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Under any review, the interface between theclinical specialist and consultant and theevolving roles of Clinical Chairs needs to berecognised and articulated. The current CNCdescriptions are ambiguous and confuse theroles of specialist and consultant. This reviewmust ensure that the profession ‘owns’ the newstructure if it is to be successfully implementedand should have a wide consultation processbuilt into it.

Recommendation 71: That VHIA, ANF andthe Department of Human Services develop aCNS stream within the Registered NurseAward which ensures that there are CNSpositions at grades 2, 3 and 4, and that thedefinition of the responsibilities of the Grade3 and 4 be completed by the end of 2001.

Costing

At this stage, the number of those eligible forpromotion to grades 3 and 4 is unknown.Working on the assumption that around halfwould be suitable, the amount of fundingrequired would be based on the differencebetween the CNS salary and that of a nurse atgrade 3A ($10.00 per week), 3B ($43.80 perweek) 4A ($89.70) and 4B ($138.2). If the base ofCNS were established at 1,450 EFT, assumingthat half would be eligible for such aprogression, initially to grade 3 year one, theadditional finding required would be between$0.37 and $1.6 million in the first full year, withincrements each year thereafter through bothgrades 3 and 4.

It is anticipated that the initial cost of increasingthe number of CNS positions to moreaccurately reflect the current level of experienceand qualifications at grade 2 level, and theintroduction of CNS positions at grade 3,would require initial funding of $2.7 to 3.9million.

Summary

Recognition of experience and qualifications isan essential factor in the recruitment andretention of such nurses to the workforce andthe CNS classification is currently being usedfor this purpose by some health care facilities.The Committee sees this as an importantstrategy. The CNS classification is one ofpersonal appointment and it is essential that

the principles and criteria for appointment beconsistent across the State. The CNS criteriacurrently relate to the expectations of a nurse atthe upper level of grade 2 but there is a need toextend the career path for experienced qualifiednurses beyond this level. To this end it isrecommended that as a medium term strategy,consideration be given to changing the title ofthe current CNS to SCN and that a newclassification of CNS, which recognisesadvanced and expert levels of practice, beintroduced at grades 3 and 4. In this way,recognition is given to the experiencedqualified nurses who have been leaving theprofession, which is essential if quality nursingcare is to continue to be provided to the peopleof Victoria.

6.2.2 Clinical Nurse Consultants The CNC is defined under section (3)(l) of theNurses (Victorian Health Services) Award 1992 as:

a registered nurse who is appointed as suchto provide a clinical resource, clinicaladvisory/development role on a full timededicated basis and undertakes relatedprojects and research and developmentactivities to meet specific nursing needs inone of the following disciplines of infectioncontrol, diabetes education, chemotherapy,stomal therapy.

The specialty areas defined in the Awardreflected the clinical nursing environment in1992. Since that time there has been greatdiversity in clinical specialisation. NSW hasaddressed this issue by naming the variousspecialties in which nurses currently practice.However, identification of specialties does notallow for future diversification and theCommittee argues that facilities should havethe flexibility to appoint CNCs in areas that areconsidered necessary for the enhancement ofnursing practice, and that restriction onspecification of specialist areas removed as amatter of urgency.

Recommendation 72: That in order toensure an appropriate clinical career pathfor nurses in Victoria, the partiesrespondent to the Registered Nurses(Victorian Health Services) Award 1992remove the current award provision which

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restricts CNCs to chemotherapy, stomaltherapy, diabetes education and infectioncontrol to ensure that the CNC position canbe appointed in any clinical area.

The current definition focuses on consultation,rather than a direct clinical function. Therelationship between a specialist with apredominantly direct clinical care role and theconsultant role that has wider consultationresponsibilities must be considered by thegroup established in Recommendation 71. Thedescriptions in the current award for CNC weredeveloped at a time when the CNS, as definedin the literature, was not considered. Therefore,the description appears to be a mixture of boththe specialist and consultant role. The two rolesneed consideration and their responsibilitiesneed careful definition.

The Committee notes that the Government hasnow endorsed the role of Nurse Practitioner,and that funding has been allocated for theimplementation strategy. This role is seen asone that further extends the options for theclinical nurse. It will not only contribute toimproved nursing care, but by extending theboundaries of nursing, will act as an incentivefor strengthening the image of nursing andretaining experienced, qualified nurses in theworkforce.

By considering the career path open to clinicalnurses at specialist, consultant and nursepractitioner levels, recognition is given to thosenurses who wish to develop at an advancedlevel of practice and to not only to share theirexpertise, but develop the profession in anextended role, as the need arises.

6.2.3 Qualifications AllowanceThe issues surrounding the qualificationsallowance are complex. At their core is arecognition of and reward for the effortrequired to gain a qualification in an area ofpractice. The options available for suchrecognition of reward are a qualificationsallowance or the position that professional ratesof pay should build in the necessity forqualifications for certain levels of practice andshould therefore reward in this way. In additionthere is a perceived need for non-monetaryreward as well. Those advocating aqualifications allowance consider that

completing a postgraduate qualificationrelevant to their area of clinical practice willkeep qualified experienced nurses at thebedside. However, the survey of nursesregistered but not working showed that 48%had completed a formal postgraduate nursingcourse. Thus, the acquisition of the qualificationalone appears not to be sufficient incentive toretain nurses at the bedside. In the sectionbelow, the arguments for and against aqualification allowance are presented.

6.2.3.1 The Case for a Qualification Allowance A qualification allowance, paid to nurses whohave completed a postgraduate qualificationrelevant to their area of clinical practice, isviewed by the ANF (Vic Branch) as a strategythat will keep qualified experienced nurses atthe bedside. The arguments are based on thehistory of the qualification allowance for nursesin Victoria, parity with other health professionsand the cost of postgraduate education.

Qualification allowance, at 4.5% of the base ratefor a certificate and 7% for a diploma (butcapped at $47.50 per week), was paid toVictorian nurses until 1988 when professionalrates of pay were introduced into the nurses’award. It is claimed by the ANF (Vic Branch)that nurses were informed at this time that theirprofessional rates of pay would ensure paritywith the other health professionals who wouldalso lose their qualification allowance.Currently, the health disciplines still receivingqualification allowance in Victoria are Division2 Nurses, audiologists, clinical perfusionists,dietitians, pharmacists, medical scientists,speech therapists, occupational therapists andphysiotherapists. It is also of interest to notethat the current entry salary for nurses is lowerthan other health professionals who still receivequalification allowance (Figure 8). Currently, noother State or Territory in Australia pays nursesa qualification allowance.

The arguments for the restoration ofqualification allowance also relate to the currentcost of postgraduate courses. The cost ofacquiring postgraduate qualifications hasaccelerated over recent years. In the 1970s,scholarships were provided for nursesundertaking postgraduate courses at theCollege of Nursing, Australia. These coursesincluded administration, ward management,

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education, public health, operating theatre andcritical care. Other clinical courses were offeredby the hospitals where the students were alsopart of the workforce and were thus receivingsalary while studying.

Figure 8: Graduate Entry Level Salaries (ANF 2000)

As previously described, during the 1980s therewas a gradual transfer of postgraduateeducation to the higher education sector. Theclinical courses were developed largely asresult of collaboration between the universitiesand health facilities. The programs that wereoffered required the students to reduce to part-time and sometimes to work at a lower grade.Initially places in these courses were funded atthe HECS rate. However, reflecting changes inthe higher education sector, many became fullfee paying places. Data before the Committeeshows that currently only 33% are HECS places.The HECS fee is set at $3,200 and full fees rangefrom $8,000–10,000. Thus, the students incurtwo costs, a reduction to part-time employmentduring the course and the fees—either HECS orfull fees. It is, therefore, clear that the cost ofpostgraduate education has risen over the pasttwo decades.

Those advocating a qualifications allowance seeit as a strong motivator for nurses to return tothe workforce and to retain those already there.It would reward individual effort, encouragenurses to undertake such qualifications andhelp offset the cost of the education.

6.2.3.2. The Case against the QualificationAllowanceDoubts are raised as to whether thequalification allowance is a strategy that will

attract and keep nurses at the bedside in thelonger term. The arguments against thisallowance can be summarised as those relatingto equity, cost, career structure and value.

Equity

There are two issues relating to equity—clinicalnurses without qualifications, and nurses withqualifications other than clinical.

The major issue addressed by the Committee isthe recruitment and retention of experienced,qualified clinical nurses within the Victorianpublic health sector. The issue of experienceversus qualifications is an important one. Asdescribed in section 6.2.1, experienced nursesmay reach the CNS classification within theaward with or without qualifications, and theyare rewarded equally. In some cases, the lack ofa qualification may be due to the paucity ofopportunities for postgraduate study. Forexample, in the area of acute medical/surgicalnursing there is a limited number of coursesavailable (three were offered in 2000), and theytend not to be attractive to nurses. Knowledgeand experience may have been acquiredthrough other means, such as short courses,reading and mentoring. In some instances thismay have been at considerable cost to thenurse. A qualification allowance woulddiscriminate against those nurses who coulddemonstrate the competencies of anexperienced nurse, but who had not had theopportunity to undertake formal postgraduatequalification or who have acquired theknowledge and skills through other means.

In some disciplines, where qualifications are aprerequisite for a position (as in academia),there is usually a provision for a personwithout the appropriate qualification todemonstrate the knowledge and skills requiredfor the level—a qualification allowance wouldnot allow for this flexibility.

If the aim of the Committee is to recruit andretain qualified, experienced nurses at thebedside, should the qualification allowance bepaid only to clinical nurses? This raises thequestion of the value of postgraduatequalifications in such areas as management,education and information technology, areasthat provide support to experienced qualifiednurses at the bedside. The cost to the nurse in

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obtaining these qualifications is similar to thatof their clinical counterparts. What is the valueof these qualifications to the profession? Interms of equity, the qualification allowanceshould apply to all nurses who haveundertaken postgraduate qualificationsrelevant to their area of practice. Although theprimary focus of the Committee is on clinicalnurses, consideration should also be given toareas that the support the clinical nurse.

Cost of Undertaking PostgraduateQualifications

As indicated above, there is considerable costassociated with undertaking postgraduatestudies. However, there are both HECS and fullfee scholarships available for nursing courses,therefore not all nurses have to pay these costs.It is of interest to note that most universitiespay the HECS fees for PhD and most Mastersby research students, yet the ANF claimsuggests a higher qualifications allowance forthese qualifications. This rewards the effort andtime to undertake such qualifications, butcannot be argued on a financial cost to thenurse basis. An alternative to a qualificationallowance would be to ensure that all nursesreceived assistance with payment of feesthrough Department of Human Services andhealth facility scholarships, and that paid studyleave be provided while undertakingpostgraduate courses. If the qualificationsallowance were to be introduced the questionshould be asked as to whether it is appropriateto divert the monies currently allocated asscholarships to the qualifications allowance,given that a major argument for thequalifications allowance is the cost of theeducation.

6.2.3.3 Qualification Allowance and CareerStructureA view strongly expressed by the nurses at theforums was the need for recognition ofqualifications. The only reward being offered tothe nurses was the qualifications allowance. Asthe alternative of a clinical career structure wasnot put, the strength for a qualificationsallowance is understandable.

Currently, any nurse who undertakes apostgraduate course in a clinical area has theopportunity to apply for the CNS position

when s/he meets the criteria. As indicatedabove, the definition for this position stipulatesboth ‘postbasic’ [sic] qualifications and twoyears experience, or four years experience inthe relevant area. Thus, in theory, under thecurrent award the qualified and experiencednurse could attain a higher pay level in twoyears less than the unqualified experiencednurse. A qualification allowance would furtherreward those who have undertaken a coursebut, as indicated above, would not rewardthose who were unable to so do and who haveacquired their competence in other ways.

As was indicated above, there are no furtherincrements for the CNS; it is a personalappointment to one pay point, currently $70.80per week more than the highest Grade 2 level.As is argued in section 6.2.1.4, there is a need torecognise the advanced and expert levels ofclinical practice by extending the clinical careerpathway to grades 3 and 4. Practice atadvanced and expert level requires the nurse todemonstrate certain competencies, andqualifications are necessary for such positions.Thus, as suggested earlier, there should berecognition of the advanced and expert clinicalspecialist with rewards up to grades 3 and 4and a process established for recognition ofqualifications in these positions. In this way,recognition would be given for individual effortand expense associated with the acquisition ofa qualification. It would also reward the clinicalnurse who wants to remain at the bedsideproviding a high level of quality care andclinical leadership Although not all qualifiednurses may reach these levels, it would,nonetheless, provide a clear incentive forclinical nurses to remain at the bedside. Thereward of incremental progression may have abetter chance of keeping qualified experiencednurses at the bedside than qualificationsallowance and one pay point. Even ifincrements were introduced to the grade 2level, this would not be sufficient to keep thenurse at the bedside in the longer term.

Value of Clinical Role

Another strong theme emanating from thenurses who attended the forums was that theirqualifications and expertise be valued not onlyin a monetary way, but also in less tangibleways. Suggestions given were:

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• Input into decision making in the clinicalarea.

• Respect for their position by management(both nursing and general) and by otherhealth professionals.

• Time to teach, undertake research and beinvolved in the professional development ofother nurses in the unit.

• Time for personal ongoing education.• Control over personal workload and

conditions of work.

Conclusion

Within the Committee there was considerabledebate over the issue of qualification allowance.Overall, the arguments were not in favour of aqualification allowance. The issues associatedwith the current need for a qualificationallowance were addressed through thefollowing means. Firstly there was agreementthat there should be financial assistance givento nurses undertaking postgraduate courses, asthe cost was prohibitive. As indicated inChapter 5, this cost was given as a reason whynot all postgraduate places were filled in 2000.

Secondly there was agreement that the careerstructure should be changed to allow forprogression of a CNS to grades 3 and 4. Withthis change the qualification allowance wouldno longer be an issue, as higher salaries andstatus would offset the cost of such educationand also demonstrate clearly the value andrecognition that was given to the experienced,qualified clinical nurse. It would also give alonger career pathway. Clearly, a mechanismneeds to be established for recognition ofqualifications at these levels.

Such a process will take time. Given the debateabout a qualification allowance, an interimmeasure could be introduced to allow thepayment of a qualification allowance, until thecareer structure mechanism is implemented.There was debate in the Retention sub-committee as to the form that such an interimmeasure should take. Two forms were debated,a bonus payment for one year, paid on afortnightly basis at $20 per week (which wouldmean a bonus payment of around $1000 pernurse), or the alternative of a payment at a levelcomparable to other health professionals. Thelatter option was accepted by the sub-

committee and this option was put to the mainCommittee (and subsequently accepted).

Recommendation 73: That ANF, HCSUA,VHIA and Department of Human Servicesestablish a suitable mechanism forrecognising postgraduate qualifications fornurses within areas of nursing at specificlevels within the context of the careerstructure (the work to be completed by June2001). Until this mechanism is establishedand qualifications are recognised in thisprocess, an interim qualifications allowancefor nurses should be introduced, similar tothat of other health professionals inVictoria for qualifications relevant to thearea of current practice.

According to Access Economics, the estimate ofnurses with qualifications in the public sectorwas 11,517. However, the question must beasked as to how many of these qualificationsare relevant to the current area of practice. Forexample, figures from the NBV indicate thatonly around 25% of midwives who hold thisqualification are in current practice. It couldtherefore be assumed that, with thequalifications allowance restricted to‘qualifications relevant to current practice’, thenumber of eligible recipients would be lowerthan estimated.

In relation to other health professional groupswho currently receive qualifications allowances,Division 2 nurses receive 7.5% for a one-yearcourse and 4% for a six-month course;audiologists, clinical perfusionists, dietitians,pharmacists and medical scientists receive6.5%; and speech therapists, occupationaltherapists and physiotherapists receive 7.5%.Thus if the figure of 11,517 were taken, thefunding required for a full year effect would bebetween $22.7 million and $24.5 million.However, as indicated above, this is an estimateonly as the exact number of potential recipientsis not known accurately.

6.2.4. ManagementMany nurses, through the various consultativeprocesses, expressed concern aboutmanagement in the Victorian public health caresector. The Committee considers theeffectiveness of nurse managers a critical factorin the recruitment and retention of qualified

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nurses in the Victorian public health system.During the progressive restructuring of thepublic health system in the last decade, the roleof the nurse manager has changed asmanagement structures have been generallyflattened, with a trend towards erosion ofsenior level positions and expanded roles atunit level. Unit managers have been givengreater budgetary and human resourceresponsibility while senior nurse managershave commonly lost responsibility for majorareas of hospital management.

6.2.4.1 Senior Nurse Management (Grade 7)—Director of Nursing or Chief Nursing OfficerThe Committee has heard that the human,capital and fiscal resources have not beensufficient to prevent the situation whereunremittingly heavy staff workloads, excessiveunpaid overtime, restricted access to education,violent and unsafe workplaces, staff shortages,and the loss of experienced and qualifiednurses have become commonplace. TheCommittee believes it is the responsibility ofmanagement to ensure that resources areprovided for quality nursing care byexperienced, satisfied staff. Fiscal responsibilityis essential and the needs of the entire healthsystem must be carefully balanced. However,the aim of any health system is to providequality care to the community in which itoperates. Nurses, which constituteapproximately 48% of the public healthworkforce in Victoria (Department of HumanServices Human Resources Branch, March2000), provide a large proportion of thatservice.

The erosion of senior nurse managerresponsibilities during the restructuring of theVictorian health care system in the 1990s led theVictorian Council of Peak NursingOrganisations (VCOPNO) to issue a positionstatement to the then Victorian Government onthe role of the Director of Nursing in theorganisational structure of health services,particularly in relation to budget management(VCOPNO 1997).

There are a number of factors that havecontributed to the erosion of the position ofnurse manager.

1. The philosophy of some organisations thatthe generic manager is more effective thanone who has experience of the context of themanagement decisions.

Generic managers are attractive to someorganisations because they are perceived tomake management decisions with a degreeof objectivity, without jeopardisingprofessional loyalties. A counter view is thatthe nurse manager understands the ways inwhich the clinical environment is affected bydecision making and is more likely tounderstand the resources required tomaintain quality of care and staffsatisfaction. However, understanding of theclinical environment alone is not sufficientin the current climate of output-basedfunding models.

2. Insufficient training/education in modernfinancial and human resource managementtechniques of some nurse managers.

Some nurse managers have not had theadvantage of education/training to enablethem to fully understand modern financialand human resource management issues.This has resulted in the nurse managereither not being directly involved indecisions about resources for nursing, or inmaking decisions that have shown a lack ofunderstanding and resulted in disadvantageto the nursing workforce. Nurse managerswho do possess such knowledge and skillshave tended to remain in control of thenursing budget, and have been moresuccessful in achieving the dual aims ofquality nursing care in a fiscally responsibleclimate and high levels of staff satisfaction.One issue brought to the Committee’sattention is the tendency of hospitals tomanage budgets in the short term to meetspecific financial targets, rather than in thelonger term. While this is understandable,given the financially precarious state ofmany hospitals identified in the MinisterialReview of Health Care Networks(Department of Human Services 2000), it hascommonly led to a culture of staff attritionwhich, when resultant recruitment,orientation and agency costs are taken intoaccount, have exacerbated the financialdifficulties of many health services.

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3. The lack of clear succession policies.

The nurse manager needs to be a mentor tothose with whom s/he works. Mentoringand succession planning become difficultwhen the pool of eligible staff identified forsuccession diminishes. There is clearevidence that in many facilities, the numberof positions at grade 6 and 5 has beenreduced. Without a deputy position,succession must be sought from the pool ofgrade 5 positions that have a managementfocus. However, after hours supervisorswho may not have an interest in a career inmanagement, occupy many of the remaininggrade 5 positions in hospitals. Carefulattention should to be given to this aspect ofmanagement.

If nursing management is to be effective inproviding the resources necessary for thequality of nursing care that the public isentitled to, then they must have control ofthe nursing budget and form an essentiallink in the chain of decision making withinthe public health facilities. The Committeehas heard instances where grade 7 nursemanagers (Directors of Nursing) wereunable to access information about thebudget for the nursing service and were notconsulted about budgetary decisions. Onesubmission before the Committee commentsthat senior nurse managers take on theexecutive role of dealing with day-to-dayissues but are excluded from the high leveldecision making issues, or are included onlyas token participants.

American research has demonstrated that whennurse managers are included as decisionmakers with hospital executives, a range ofclinical and human resource indicators showoverall benefit to the organisation, particularlyimproved nurse recruitment and retention rates(Scott, Sochalski & Aiken 1999). The positioningof the nurse leader within the decision makingframework of a health care institution is one ofthe characteristics of the magnet hospital model(see section 2.1.3). In the Australian context,some submissions before the Committeesuggest that there is a strong correlationbetween the management and leadership skillsof nurse managers and the health of thehospital, ward or unit team.

Recommendation 74: That the senior nursemanager (however titled) be a member ofthe hospital executive and have recognisedinput into resource allocation andutilisation appropriate to the nursingservices of the facility.

Little attention has been paid to the educationand professional development of nursingmanagers at top level. There are manypostgraduate courses available in financial andhuman resource management and theCommittee believes it is essential in the currentclimate that nurse managers have suchqualifications.

6.2.4.2 Unit ManagersWhile the role of the top level nurse managerhas often been eroded, that of the nurse unitmanager (NUM) has been expanded.Devolution of financial and human resourcesmanagement to the unit level, where thedecisions have most impact, is now an acceptedpart of health system management. The role ofthe NUM is the lynch pin in any health facility.The workloads, working conditions and moraleof the unit depend in large measure on theability of the NUM, as is the way theirmanagement decisions are supported bymanagement at higher levels.

The Committee heard both positive andnegative feedback about the NUMs. Where awell educated, caring, committed NUM was incontrol and was adequately supported by othermanagement, staff were extremely positive.However, the converse was also true and theCommittee was told of the difficulty of fillingthe NUM positions and thus the appointmentof nurses who did not have the experience,knowledge and skill to fill the positioneffectively. The discontent with such NUMswas clear at the forums.

In order to obtain more information on thechanging role of the NUM, and to expandfurther on some of the NUM issues raised insubmissions (section 3.10), the Committeeconvened a representative group ofmetropolitan and rural unit managers toascertain their views on the devolution of manymanagement decisions to unit level. The NUMsthemselves indicated that the position was a

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demanding one. Largely because of thereductions of experienced clinical leaders in theunit, they were required to have a direct clinicalrole as well as manage the unit and be involvedin other professional activities such as qualitymanagement projects and research. Some hadlearned to cope with their workload byallocating ‘management days’, thus creating anartificial separation in their role.

Most NUMs indicated that they were workingexcessive unpaid overtime, although theyrecognised that the position did require sometime commitment outside the ‘normal’ hours.One of the major contributors to excessiveworkload for NUMs is the lack ofadministrative support available. In anenvironment where many clinical units havescant resources allocated to support staff toanswer phones, NUMs described thefrustrations of routine clerical work such asupdating policy and procedures, filing,maintaining an in-tray and answering phones,compounding the already heavy workload.

Those NUMs who were educationally preparedin management and were actively involved inthe recruitment and retention issues in thefacility were more likely to have established areasonable workload and skill mix on theirunit. They were also more likely to haveinvolved their staff in the unit decisions, tohave established clinical leaders and allowedflexible systems such as self-rostering to beadapted to their particular needs. They werealso effective in controlling the workloads,particularly through their understanding of theclinical requirements of their unit. They wereable to allow time off and reallocate staff whenthe unit was not busy, and to call in additionalstaff when workloads increased. For theseinitiatives, successful NUMs often had supportfrom senior management. These NUMs werealso viewed by peers as financially responsible,fighting for more resources where required andwith reasoned arguments, yet endeavouring toremain within budgets, without compromisingthe quality of care. They also consideredthemselves part of the management team of thefacility and had regular contact with othermanagers.

Such NUMs tended to occupy their position asa result of succession planning, where their

abilities were recognised, and their professionaldevelopment reflected their chosen career path.

The Committee also heard reports of NUMswho had tried to institute reform in their unitsbut had been stopped by (non-nursing)management.

The Committee considers the role of the NUMto be pivotal in relation to many of the issuesthat appear to be the cause of discontent andattrition in nursing currently.

As previously indicated, the issue of adequateremuneration for this position was raisedfrequently as a matter of major frustration.Many NUMs compared their role tomanagement positions in private industrywhere levels of managerial responsibility werecomparable, but where remuneration was not.One issue difficult to resolve is that of theANUM receiving more than the NUM becausethe latter commonly work shifts which attractpenalty rates, whilst NUMs generally workwithin core business hours. In a professionwhere shift work is essential, such issues willremain. A position frequently put before theCommittee was that the ANUM positionshould be redefined and that a deputy unitmanager be reintroduced with more clearlydefined roles and functions, although therewere contrary positions advocating the statusquo.

Recommendation 75: That all health carefacilities ensure that strategies are in placefor succession planning for all levels ofnursing management.

Recommendation 76: That nurse managershave input into the budget setting processand have responsibility for its ongoingimplementation.

Recommendation 77: That all nursemanagers be encouraged to:(a) Participate on a regular basis in in-

service education in general, financialand human resource management.

(b) Pursue postgraduate management andhave access to paid study leave.

Submissions from rural and regional facilitiesdrew attention to the difficulty of attractingnurses to become grade 4 NUMs. Several

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contributing factors were proposed. Manynurses in rural areas prefer to work on a part-time basis, because of lifestyle factors such asfarm commitments (one submission estimatedthat 80% work part-time). Convention dictatesthat the NUM position needs to be full-time.While the Committee was made aware of someNUM positions occupied in job sharingarrangements it was put to the Committee,from a variety of sources including the speciallyconvened NUM group, that the positionrequires a full-time incumbent and should notbe offered as a part-time position. However, theCommittee is of the view that, in somecircumstances, using the principles outlinedon113, job sharing arrangements areappropriate for NUM positions.

Those nurses who may wish to work full-timemay not have the necessary education orexperience to undertake the NUM role. Further,few opportunities appear available for ANUMpositions; hence the potential for successionplanning could be limited. In order to recruitnurses into NUM positions and ensure thatthey are retained, a number of strategies needto be considered. Incentives such as a bonus, ahigher salary or salary packaging, training inmanagement and additional funded continuingeducation opportunities have been proposed aspotential strategies. In addition, nurses withpotential need to be identified and successionplanning and professional developmentdiscussed and implemented.

Recommendation 78: That rural andregional hospitals explore strategies toensure that there is training anddevelopment for ANUMs to facilitatesuccession planning to NUM positions, andthat, where appropriate, consideration begiven to job sharing within the NUMposition.

6.3 Special Issues6.3.1 Clinical Supervision

BackgroundClinical supervision is not a newphenomenon—it has a long history in mentalhealth with conceptual origins inpsychoanalytic theory. Since then the model hasbeen adapted to support professional practicemore broadly.

In a position paper on clinical supervision,Faugier & Butterworth (1995) note that in socialwork, counselling and psychotherapy, clinicalsupervision is understood as a means ofprotecting the client ‘by ensuring thatpractitioners develop the highest level of skilland the most professional attitudes within thecontext of a trusting supportive professionalrelationship’.

In the paper they draw upon a definitiondeveloped by Wright which, they claim, is themost useful for the purposes of examining thevalue of clinical supervision in nursing practice.Wright defines clinical supervision as ‘ameeting between two or more people who havea declared interest in examining a piece ofwork. The work is presented and they willtogether think about what was happening andwhy, what was done or said, and how it washandled—could it have been handled better ordifferently, and if so, how?’ (Faugier &Butterworth 1995).

Nevertheless, it is worth noting the cautionexpressed by Ryan (1998) that clinicalsupervision ‘is a multidimensional, dynamic,developing process (that) defies absolutedefinition’.

The literature on clinical supervision identifiesa range of models. However, most makereference to three dimensions of clinicalsupervision: formative (teaching or facilitatinglearning); restorative (giving emotional supportand identifying successes); and normative(directing the supervised person and advisingon action, with client safety in mind). It isworth noting that the word ‘supervision’ hasbeen used widely in management literature andin practice to describe managerial control. Thisdefinition of supervision concerns only oneelement of this tripartite model, the normative.

The formative and restorative dimensions ofclinical supervision have, by contrast, beenpromoted widely in the education literature,drawing upon notions such as reflectivelearning and adult learning. The literatureseparates clinical supervision from performanceappraisal and most authors cite the value ofclinical supervision as a support mechanism forhealth professionals. The nature of this supportincludes prevention of burnout, increasing thepractitioner’s sense of confidence and security,

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supporting employee personal growth andsupporting employees in dealing with jobrelated stress (Ryan 1998). Some authors alsoraise the issues of horizontal violence andprofessional rivalry, which can negativelyimpact on the success of clinical supervisionbecause it requires a collegial culture. However,Ryan argues that ‘quality clinical supervisionwill in itself assist in moving the culture inwhich it exists toward a more cooperative,learning environment’.

This report makes recommendations about theintroduction of clinical supervision forregistered nurses in health service delivery inthe Victorian public health sector.

Principles Underpinning Implementation ofClinical Supervision• The purpose of clinical supervision is to

help the nurse increase skill in working withpatients/residents.

• Clinical supervision is concerned withprofessional development and support forindividual registered nurses and is to bedistinguished from performancemanagement and review.

• Clinical supervision is dependent on thequality of the supervisory relationship andrequires the supervisor to have undergonetraining for clinical supervision.

• The supervisor may be either in a moresenior position or may be a peer of thesupervisee and they may be external to orwithin the organisation in which thesupervise practices.

• The relationship is premised on trust,support, confidentiality and professionalism.

• Participation in clinical supervision is on avoluntary basis.

• The function of clinical supervision is toexamine work practices and personalresponses of the supervisee to ensure skilldevelopment and enhancement ofprofessional attitudes.

• The process of the relationship isdevelopmental, ongoing and includesintegration of feedback into practice.

Recommendation 79: a) That clinical supervision for registered

nurses be introduced into the publichealth system as a strategy for retainingexperienced, qualified nurses in clinicalsettings and that each nurse, regardlessof full-time or part-time status, willreceive two hours per month of clinicalsupervision time.

b) That funding be provided for theintroduction, implementation andevaluation of clinical supervision forregistered nurses and that theDepartment of Human Services takeresponsibility for the allocation of fundsand establish a process for the allocationto health services.

c) That the Department of Human Servicesevaluate the implementation of clinicalsupervision.

The Cost of the InitiativeThe manner in which clinical supervisionwould be organised would be highlydependent on local circumstances, such asroster configurations and overlap time. It isconceivable that most clinical supervision willbe performed in the context of current or futureavailable hours, therefore this initiative has thecapacity to be cost neutral, depending on theoutcome of recommendations related toworkload for nurses (section 6.1.1).

6.3.2 The Division 2 NurseWhile the educational issues relating toDivision 2 nurses have been discussed insection 5.1.3, in considering the recruitment andretention issues relating particularly to theacute hospital sector, it became apparent to theCommittee that there was confusion in thehealth workforce as to the role of the Division 2nurse and the employment settings relevant totheir training. The Committee acknowledgesthat the NBV report on medicationadministration by Division 2 nurses, currentlybefore the Minister for Health, will influencefuture employment and education trends. TheCommittee also believes that there is adiscrepancy between the aspirations of manyDivision 2 nurses, who wish for extendedpractice and to be employed in the acutesetting, and the aged care industry, which

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perceives the Certificate IV in Health (Nursing)as preparation for nurses solely to enter theaged care sector.

Submissions before the Committee indicate thatthe image of the Division 2 nurse has fairedpoorly in the past decade. The relatively lowprofile of Division 2 nursing in the communityand in schools, the lack of exposure to Division2 nurses by undergraduates and Division 1nurses, issues surrounding the early applicationof the traineeship training model, and the trendtowards employment in the aged care sectorhave all contributed to a poor understanding ofthe role and capabilities of the Division 2 nurse.The Committee is concerned at the apparentunder-utilisation of the skills and experience ofDivision 2 nurses in a variety of settings, andnotes the efforts of organisations such as theVictorian Perioperative Nurses Group topioneer new roles for Division 2 nurses withinthe acute sector

Recommendation 80: That health agenciesbe encouraged to consider whether thereare opportunities to employ Division 2nurses in the acute sector in positionscurrently not filled by Division 2 nurses.

Recommendation 81: That the Departmentof Human Services considers a campaignamongst Division 1 nurses, undergraduatesand the wider health care industry, topromote a better understanding of the roleof Division 2 nurses.

6.3.3 The Aged Care Sector

6.3.3.1 Aged Care Funding IssuesPrior to 1987, the public aged care sectorreceived State Government funding to provideshort and long term residential care in additionto a variety of rehabilitation services. The latterincluded long term rehabilitation for patientswho had been involved in traffic accidents,those who suffered strokes or those withmyocardial infarctions requiring cardiacrehabilitation prior to discharge. The fundingallowed hospital management to provideappropriate staffing levels that were adequateto meet the clinical needs of patients.

In 1987, the Care Aggregated Module/StandardAggregated Module funding model wasintroduced into the private nursing home

sector. This model was subsequently applied toall public aged care facilities for residential careservices including short term respite care,following a State and Federal agreement totransfer responsibility for residential aged careto the Federal Government. The VictorianGovernment provided a funding top-up topublic sector aged care facilities and retainedresponsibility for rehabilitation servicesincluding post-acute care.

Since the advent of the Aged Care Act 1996, thefunding levels have diminished in real termsdue to the ‘treasury measure of underlyinginflation’ formula being applied. This hasmeant that aged care sector funding is nolonger indexed for both wage movements andinflation, which was the case under theprevious CAM/SAM funding formula.Workloads in the aged care sector havecontinued to increase commensurate withincreasing resident acuity while the fundingcontinues to decrease in relative terms.

Further, the public sector has traditionallyprovided services for patients whom theprivate sector has been reluctant to accept, suchas those residents with exceptionallychallenging behaviours. This factor has servedto place additional demands on nursesemployed in these facilities.

Aged care nursing, until the mid-1980s, wasoften viewed as the ‘Cinderella’ of theprofession. However, with the increase ofpostgraduate aged care nursing educationopportunities and the development of the roleof clinical nurse consultants in areas such ascontinence management and dementia care,aged care nursing became an attractive clinicalarea for nurses to work in. It was alsorecognised that the advantage for nurses inaged care nursing was the ability to havegreater autonomy of practice in comparison toother specialist areas. However, due to thefunding issues outlined above, theseadvantages have largely been lost, so that agedcare nursing is currently a specialty that hasgreat difficulty in attracting a sufficient numberof committed and qualified nurses (Nay &Closs 1999).

While most public sector nursing homes andhostels receive some form of State Governmenttop-up funding, the delivery of care services is

104

essentially managed under the currentarrangements provided for by the FederalGovernment through the ResidentClassification System (RCS) funding tool.

The application of available resources does notnecessarily allow for any overlap during theday shift to enable nurses to attend in-serviceeducation, and many facilities have reduced thenumber of nurse educators they employ.

If the aged care sector is to offer nurses theopportunity to practise quality nursing care,then aged care specific education programsneed to be provided, to ensure that nursesemployed in these health care facilitiesmaintain their skills and engage incontemporary aged care practices.

Recommendation 82: That ongoing in-service education be provided in the publicaged care sector (nursing homes andhostels) and that resources be sufficient for this activity.

6.3.3.2 Specialist Positions in the Aged CareSectorAged care nursing is recognised as a specialistarea of nursing, however it does not attract thesame monetary support or interest as otherareas of nursing specialty. It is noted that theCommonwealth Government has recentlyannounced its interest in nominating aged carefacilities in each State as Tertiary EducationCentres.

Whether or not this initiative is finally realised,there are opportunities for the Department ofHuman Services to identify some of the largeraged care facilities as Teaching Centres ofExcellence. The Department of Human Servicesalso has the opportunity to enhance the clinicalcareer pathway for aged care nurses to not onlyimprove the quality of care, but also retainexperienced qualified nurses in the clinical area.The Committee’s survey of current and desiredCNS positions (section 6.2.1.1) showed thatthere were no CNS positions in the public agedcare responses. However, 20.6 EFT positionswere identified in response to the question ofhow many places could be appointed iffunding were available. There is, therefore, aneed to fund some positions and to establishthe number of positions that are required in theaged care sector, consistent with

Recommendation 68 in section 6.2.1.3.

Recommendation 83: That the Departmentof Human Services collects data relating tothe staffing mix in the public aged caresector and, in particular, identifies:• The number of CNS positions required

following the implementation ofRecommendation 68 and ensures that thisnumber be used as a basis for the fundingof CNS positions.

• The number of CNC positions, especially,but not limited to continencemanagement, and dementia care.

• Nurse Practitioner roles as they areimplemented and evaluated as part of theGovernment’s funding of NursePractitioner projects.

In addition, recognition needs to be given tospecific areas of aged care nursing through theappointment of CNC positions and, as theydevelop, Nurse Practitioners.

6.3.3.3 Documentation in the Aged Care SectorOne of the criticisms of Federal Governmentpolicy both pre- and post-1997 legislativechanges, has been the increasingdocumentation requirements in aged carefacilities.

Nurses employed in aged care complain aboutthe time they are required to spenddocumenting care that has been providedwhich, they argue, diminishes the amount oftime they have to spend on actual resident care.

As these excessive demands appear to be acontributing factor in lowering morale, otheralternatives to current documentationrequirements should be explored.

Recommendation 84: That the StateGovernment recommend to theCommonwealth Government that thedocumentation required for ResidentialClassification Index Tool currently beingused in the aged care sector be simplified,so as to reduce the documentation requiredto allow more time for nurses to deliverdirect patient care. The Committeerecommends that the Victorian Minister forHealth raise this issue at AHMAC to seekthe support of other State Governments.

105

6.3.3.4 Capital Funding in the Aged Care SectorThe Victorian Back Injury Project (Departmentof Human Services 2000) is undertaking a datacollection exercise to ascertain whetherdemonstrable savings can be made throughimplementation of no lift policies. The StateGovernment provided $2 million in December1998 and a further $1.2 million in May 2000 forthis initiative. While some aged care facilitieshave gained access to these funds to introducea no lift policy in specific areas, further fundingis required to allow all facilities to adopt thepolicy across the entire industry.

While there is an up front cost, particularly forthe purchase of new equipment, these costsmay be recouped within a three to four yearperiod through reduction in time lost, reductionin WorkCover claims, reduction in sick leaveand reduction in agency costs as back injuriesdiminish, although further data will need to becollected to confirm this.

Recommendation 85: That Department ofHuman Services provides specific fundingfor the complete implementation of a no liftprogram in the public aged care sector.

6.3.4 Midwifery As discussed in section 3.9.3, rural midwiferypractice faces specific problems in terms ofpractitioner support, retention and deskilling.The Committee believes more data needs to becollected on the rural midwifery workforce, inorder to monitor overall recruitment andretention trends and the impact of strategiessuch as the Commonwealth’s rural midwiferyupskilling program.

Recommendation 86: That Department ofHuman Services, together with keystakeholders, collects data relating to therecruitment and retention of midwives inrural areas and the implemented strategiesbe evaluated by Department of HumanServices.

This concludes the report of the Committee’sdeliberations. The remainder of this reportcontains the various research projectscommissioned by the Committee andundertaken by consultants.

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The purpose of the Committee is to provideadvice to the Minister for Health on workforcematters in relation to the registered nurseworkforce (including general nurses,psychiatric nurses and the Division 2 nurses)and, in particular:

I. To review local, national and internationalexperiences and measures to addressnurse recruitment and retention.

II. To consider a range of strategies forimproving recruitment and retention ofnurses, through a process of consultationwith relevant bodies and organisations inVictoria and with CommonwealthDepartments. Areas to include:A.Undergraduate recruitment.B. Undergraduate educational programs

and clinical practice opportunities.C. Access to continuing education.D.Access to refresher courses.E. Particular needs for rural and regional

Victoria.F. Workplace reform.G.Work role reform opportunities.

And without limiting the generality of theabove to:• Examine the effectiveness of other State

Government’s publicity programs toattract students into undergraduatenursing programs with a view tointroducing similar media campaigns intoVictoria.

• Examine any recent research availableregarding nursing shortages and toconsider any additional questions thatmay be included in the annual researchconducted by the Australian Institute ofHealth and Welfare.

• Ascertain what is appropriate healthagency support, monitoring andsupervision for new graduates.

III. To examine the impact of the currenteducation and registration frameworks onavailability of specialised nurses.

IV. To identify and prioritise effective short,medium and longer term strategies toremedy the current situation and preventshortfalls in Victoria in the future.

V. To develop costed action plans in thecontext of government policy for priorityareas.

VI. To advise the Minister for Health onmatters requiring attention to be taken tothe Victorian Minister responsible forEducation and Post CompulsoryEducation, and to the CommonwealthMinister for Health and Aged Care.

VII. To establish sub-committees, workinggroups as necessary.

VIII. To prepare an interim report for theMinister for Health by 30 April 2000,which should give special consideration topostgraduate education, and a final reportby 31 August 2000.

Appendix One—Terms of Reference

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Nurse Recruitment and Retention Committee Coopted Sub-Committee Members

Emeritus Professor Retention Sub-committee Ms Naomi Corlett Attraction and Recruitment

Margaret Bennett—Chair Sub-committee

Ms Jan Brownrigg Education Sub-committee Ms Donna Dunn Education Sub-committee

(from July 2000)

Ms Andrea Dennis Attraction and Recruitment Ms Kate Gray Education Sub-committee

Sub-committee

Mr Alwin Gallina Attraction and Recruitment Ms Wendy Lewis Retention Sub-committee

Sub-committee

Ms Denise Guppy Retention Sub-committee Ms Cheryl Nicholson Education Sub-committee

Ms Jill Linklater Chair—Retention Sub-committee Professor Judith Parker Retention Sub-committee

Ms Belinda Morieson Retention Sub-committee Ms Leanne Raven Retention Sub-committee

Associate Professor Chair—Education Ms Hannah Sellers Attraction and Recruitment

Pauline Nugent Sub-committee Sub-committee

Ms Margaret Ormerod Attraction and Recruitment Ms Kylie Smith Attraction and Recruitment

Sub-committee Sub-committee

Associate Professor Retention Sub-committee Ms Kim Sykes Education Sub-committee

John Rasa

Ms Victoria Southgate Retention Sub-committee Dr Sue Turale Education Sub-committee

Ms Ann Turnbull Chair—Attraction and Mr Dan Weeks Attraction and Recruitment

Recruitment Sub-committee Sub-committee

Mr Paul Waterson Education Sub-committee Ms Sue Williams Retention Sub-committee

Ms Kairsty Wilson Education Sub-committee

Ms Sue Wylie Education Sub-committee

(to July 2000)

Project Team

Ms Karen Carmichael

Mr Geraint Duggan

Mr Peter Carver

Mr Gerard White

Mr Graeme Doidge

Appendix Two—Committee Membership

114

Nursing Return to Work SurveyFINAL REPORT

A report of 2,089 self-completion surveys

with nurses who are registered but currently not working.

Prepared for

Nurse Recruitment & Retention CommitteeDepartment of Human Services

Melbourne Victoria

June 2000

Appendix Three—Quantitative Survey ofRegistered, Non-Working Nurses

115

Contents

1. Executive Summary ............................................................................................................................................119

1.1 Key Characteristics ......................................................................................................................................119

1.2 Workforce Status ..........................................................................................................................................119

1.3 Reasons for Not Working as a Nurse ....................................................................................................119

1.4 Barriers to Return to Work ........................................................................................................................120

1.5 Factors Influencing Return To Work ......................................................................................................120

2. Conventions Used in This Report ..............................................................................................................121

3. Background ............................................................................................................................................................121

4. Research Objectives ........................................................................................................................................121

5. Methodology ..........................................................................................................................................................122

6. Results ......................................................................................................................................................................122

6.1 Division of Registration ..............................................................................................................................122

6.2 General Background Information ............................................................................................................122

6.3 Employment Attitudes ..................................................................................................................................125

6.4 Seeking Employment as a Nurse ............................................................................................................129

6.5 Returning to the Nursing Profession ......................................................................................................136

116

Index of TablesTable 1: Terms and Acronyms................................................................................................................................121

Table 2: Division of Registration ........................................................................................................................122

Table 3: Division of Registration by Age Group ............................................................................................123

Table 4: Type of Nursing Course by Division of Registration ..................................................................125

Table 5: Division of Employment ........................................................................................................................125

Table 6: Current Work Status by Division of Registration ........................................................................126

Table 7: Current Work Status by Age ................................................................................................................127

Table 8: Factors for Leaving Nursing by Division of Registration (Average Score) ........................128

Table 9: Factors for Leaving Nursing by Age (Average Score) ................................................................128

Table 10: Factors for Leaving Nursing by Current Work Status (Average Score) ..............................129

Table 11: ‘Other’ Factors for Leaving Nursing by Age ..................................................................................129

Table 12: Active Employment Seeking by Current Work Status ................................................................130

Table 13: Reasons for Not Seeking Employment as a Nurse ......................................................................131

Table 14: Reasons for Not Seeking Employment as a Nurse by Current Work Status ......................132

Table 15: Influential Factors for Not Seeking Employment by Division of Registration ..................133

Table 16: Influential Factors for Not Seeking Employment by Age ..........................................................133

Table 17: Influential Factors for Not Seeking Employment by Current Work Status ........................134

Table 18: Factors Rated as Important in Returning to Work by Division of Registration ................136

Table 19: Factors Rated as Important in Returning to Work by Age ........................................................137

Table 20: Area of Nursing Likely to Work by Division of Registration ....................................................137

Table 21: Area of Nursing Likely to Return to Work by Age ........................................................................138

Table 22: Area of Nursing Likely to Return to by Current Work Status ..................................................139

Table 23: Desired Area of Nursing by Division of Registration ................................................................139

Table 24: Desired Area of Nursing by Age ........................................................................................................140

Table 25: Desired Area of Nursing by Current Work Status ........................................................................141

117

Index of FiguresFigure 1: Registered Nurses by Age Group ......................................................................................................122

Figure 2: Place of Residence ................................................................................................................................123

Figure 3: Registrations in Other States ............................................................................................................123

Figure 4: Average Years Since Graduation ....................................................................................................124

Figure 5: Formal Post-Basic Nursing Courses across All Divisions ......................................................124

Figure 6: Nursing Courses by Division of Registration ..............................................................................124

Figure 7: Employment of Registered Nurses ..................................................................................................125

Figure 8: Current Work Status ..............................................................................................................................126

Figure 9: Influential Factors for Leaving the Nursing Profession ..........................................................127

Figure 10: Seeking Employment as a Nurse ......................................................................................................130

Figure 11: Seeking Employment by Divison of Registration ........................................................................130

Figure 12: Influential Factors for Not Seeking Employment ........................................................................132

Figure 13 Influential Factors for Not Seeking Employment by Geograhical Location ....................134

Figure 14: Factors Rated for Importance in Not Finding Employment in Nursing ..............................135

Figure 15: Factors Rated Important for Not Successfully Obtaining Employment by Division of Registration ........................................................................................................................135

Figure 16: Factors Rated as Important for Not Obtaining Employment by Age ....................................136

Figure 17: Factors Rated as Important in Returning to Work ......................................................................136

AppendixAppendix A Return to Work Nursing Survey

118

1. Executive SummaryThis report summarises survey information onthe attitudes, beliefs and behaviour of registerednurses who are currently not working in thenursing profession.

A total of 3,626 surveys were mailed.Altogether 2,089 responses were received by 23May 2000. The response rate of 58% isexceptionally high for a mail survey indicatingthe high level of interest by nurses.

1.1 Key Characteristics• Nearly all (96%) nurses who are registered

but are not currently working are women.• Most (71%) have worked as a Division 1

nurse for an average of 19 years.• Seven in ten (68%) are middle aged (30–49

years).• There was a high proportion from non-

metropolitan Victoria (46%) and a smallproportion resident (4%) or registered (6%)in other states.

• These are nurses with substantial experiencein the nursing workforce. The majority (60%)have completed some post basic nursingtraining. Most commonly (22%) the trainingwas in midwifery. There is a wide spectrumof other specialities but less than 10% of thesample reported qualifications in critical care,advanced nursing, community health,gerontology education and management.

1.2 Workforce Status• Nearly all Division 1 and Division 3 nurses

had worked full-time while only 73% ofDivision 2 nurses had worked full-time.

• Fewer than one in five (16%) nurses whoindicated they were not working at the timethey completed the registration surveyindicated that they were working in May2000. This suggests that a segment of thenon-working registered nurse population hasa dynamic or flexible relationship with theworkforce.

• The finding that a substantial minority (close toone in three) of nurses not currently workinghad also worked part-time during their careersupports the dynamic relationship. The relativehigh proportion of this population who haveworked part-time suggests that, over theirsubstantial workforce experience, part-timework was an option for nurses.

• Most commonly the population of nurses

who reported not working at the time ofregistration had abandoned the nursingworkforce, at least temporarily, or wereworking in an area other than nursing.– 40% were not working in May 2000.– 20% were working in an area other than

nursing.– 11% were on extended leave.

• Only 12% indicated that they would not seekemployment as a nurse again.

1.3 Reasons for Not Working as a Nurse• The most important reasons given by those

not working were:– Increased workload.– Conditions of work.– Satisfaction with nursing.

• Family commitment also received a highrating.

• Working conditions and lack of experiencewere important for younger nurses as werefinding a job in another area and returning tostudy. Sickness, injury and redundancypackages were more important for oldernurses who also rated organisationalrestructure and inadequate hospital fundinghigher than their younger counterparts.

• Just over one in ten (12%) indicated theywould not return to the nursing workforce.The reasons differed by age group.

• Registered nurses, excluding those alreadyworking as a nurse, were asked to rate theimportance of a list of influential factors fornot seeking employment. The four highestrated factors included: – The workload is too heavy.– Commitments in other areas (family). – Lack of recognition.– Working conditions are poor.

• Older nurses were most likely to giveretirement (33%) or injury/illness (19%) as areason.

• Middle-aged nurses were most likely toidentify working/studying in another area(34%), poor career satisfaction (23%), familyresponsibilities (17%) and a negative workenvironment (16%).

• Younger nurses were most likely to identifypoor career satisfaction (39%), working/studying in another area (28%), negative workenvironment (22%) and poor salary (22%).

• Registered nurses in Division 1 and Division2 reported different influential factors for notseeking employment than registered nurses

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in Division 3.Division 1 and Division 2 rated:– No access to child care.– Commitments in other areas (family).– Employment prospects are better elsewhere.– Opportunities for promotion are limited.– Pay is inadequate, higher in importance

than respondents in Division 3.• Conversely, Division 3 rated ‘working

conditions as poor’ and ‘difficulty in findinga job’ higher in importance thanrespondents in Division 1 and Division 2.

• Non-metropolitan Victorian registerednurses rated higher on factors, including:– Commitments in other areas.– My practical experience is inadequate.– Difficult to find a job.

1.4 Barriers to Return to Work• The two most important factors for not

finding successful employment in nursingwere:– There are limited job opportunities.– It is difficult to find a job in my locality.

• Division 1 nurses rated higher importancefor ‘difficult to find a job in my preferredspeciality’, than both Division 2 andDivision 3.

• Division 2 nurses rated higher importancefor ‘inadequate hospital funding’ than bothDivision 1 and Division 3.

• Younger registered nurses rated ‘I lackpractical experience’ higher than middle-aged and older registered nurses.

• Older registered nurses rated ‘there arelimited job opportunities’ higher thanmiddle and younger registered nurses.

1.5 Factors Influencing Return To Work• The five most important factors influencing

return to work for those not working as anurse were:– Working conditions.– Flexible rosters.– Employment opportunities.– Professional development.– Training opportunities.

• The main types of nursing identified as

likely areas for return to work were:– Gerontology (27%)– Agency/Casual (27%)– Mixed medical and surgical (21%).

• These were closely followed by communityhealth (18%), surgical (13%), and midwifery(12%).

• Area of work was analysed by Division ofregistration which found that:– Division 1 nurses are likely to work in

community health (20%)– Division 2 nurses are likely to work in

gerontology (44%)– Division 3 nurses are likely to work in

mental health/psychiatric (85%).• Age differences were evident for the area of

nursing the participants would return to, forinstance:– Younger and middle-aged nurses were

likely to work in agency/casual (30% and30%)

– Older nurses were more likely to work ingerontology (38%).

• Respondents who were working in thehealth arena were more likely to report thatthey would return to work in the‘community health’ area (24%).

• Respondents working in other areas (nothealth related), reported that they wouldlikely return to work in the agency/casualarea (32%).

• Registered nurses on leave were also likelyto return to work as a nurse in theagency/casual area (25%).

• Respondents who are not working at allreported they would most likely return towork in the area of gerontology (30%).

• Respondents were asked what area ofnursing they would like to work in ifappropriate training were accessible. Thethree main areas reported were:– Community health (26%)– Midwifery (18%)– School children’s health (16%).

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2. Conventions Used in ThisReportThe results of the Nursing Survey have beenanalysed by Division, region and age.

Only statistically significant differences at the95% confidence level have been reported.

2.1 Reading the Tables• The tables identify the relevant survey

question in the header.• The base for each table is identified under

the left-hand column of the table.• The base on which percentages are

calculated for each column is given inparentheses under the column header.

• Alphabet letters in lower case representssignificant levels at the 5% level (95%), andletters in upper case represent significantlevels at the 10% level (90%). Thecorresponding capital letters for comparisonmay be found in the column header(example table below).

Category DIV 1 DIV 2 DIV 3A B C

Yes 45B 3 46B

Don’t Know 42c 67C 6

In this example above, respondents whoanswered:

– ‘Yes’, Division 1 (column A) and Division3 (Column C) was significantly differentat the 95% confidence level than Division2 (Column B).

– ‘Don’t know’, Division 1 wassignificantly different at the 90%confidence level compared to Division 3.

• ‘n/a’ means that the particular cell is notapplicable and no result can be reported.

• ‘-‘ means that the responses for the cell weretoo low to provide a percentage.

• Subtotals are right justified and printed inparentheses.

• Percentages are rounded to the nearestwhole number.

2.2 Reading the Graphs• The relevant survey questions are identified

in the graph header.• The base for each graph refers to the total

number of responses upon which thepercentages have been calculated. This isidentified under the left-hand corner of thegraph.

The following terms are used in this report:

Table 1: Terms and Acronyms

NBV Nurses Board of Victoria Division 1 Nurses registered in Division 1 Division 2 Nurses registered in Division 2 Division 3 Nurses registered in Division 3 AIHW Australian Institute of Health & Welfare Younger Nurses aged between 20 years of age to 29 years of age Middle Nurses aged between 30 years of age to 49 years of age.Older Nurses aged 50 years and older CR&C Campbell Research and Consulting NRRC Nurse Recruitment & Retention Committee

3. BackgroundThere is currently a shortage of registerednurses in Victoria. The Victorian Governmenthas established a task force to identify factorsthat can address the shortfall of nurses. Thereis a substantial number of nurses who areregistered but not working. To identify factorsthat can encourage registered nurses to rejointhe workforce, the Nurse Recruitment andRetention Committee (NRRC) commissionedCampbell Research & Consulting (CR&C) toconduct confidential self-completion survey ofnurses who indicated they were not working atthe time of last registration.

4. Research ObjectivesThe objectives of the research are to identify:1. Characteristics of the estimated 14,000

registered nurses who are currently notworking.

2. The reasons to why registered nurses haveleft the nursing profession.

3. The factors that will influence registerednurses to return to the nursing profession.

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5. MethodologyThe sample was drawn from the responses to asurvey distributed by the NBV on behalf of theAustralian Institute of Health & Welfare(AIHW). Strict protocols were developed toensure the confidentiality of respondent details:

– The survey was mailed by the NBV tonurses who, when renewing registration,indicated they were not working as anurse.

– No names, addresses or personalinformation was provided by the NBV toCR&C.

– A passive consent process was used—refusal was through non-response.

Respondents were advised that no identifyinginformation was reported, however somerespondents specifically asked to be identifiedand attached lengthy detailed responses.

A total of 3,626 surveys were mailed. Thissample included a proportion of nurses onextended leave which will act as a de factocontrol group, and understand thepreconceived notion that nurses on maternityleave do not always return to nursing.Altogether 2,089 responses were received by23d May 2000. The response rate of 58% isexceptionally high for a mail survey indicatingthe high level of interest by nurses.

6. ResultsAn initial 3,626 surveys were posted toprospective participants. Response rate wassuccessful with a total return rate of 2,089surveys.

6.1 Division of Registration Most respondents (71%) were Division 1 nurses(Table 2).

Table 2: Division of Registration

Division (2,089) %

Division 1 171 Division 2 225 Division 3 32 No response 2

6.2 General Background InformationThe majority (96%) of the sample were females.This did not differ across age groups, Divisionof registration or geographical region. Thisfinding is consistent with the nurse register as awhole.

The sample was analysed by three age groups,younger, middle and older (Figure 1Figure 1),with:1. The majority of the sample (68%) from the

middle age group (30-49).2. Two in ten (20%) respondents aged 50 years

of age and over (older). 3. One in ten (10%) respondents aged between

20 and 29 years of age (younger).

Age was calculated from year of birth.

Figure 1: Registered Nurses by Age Group

Q5 Your year of birth?

Base: 2,089

The majority of nurses (71%) wereregistered in Division 1.

Older nurses were more likely to be registeredas Division 1 (Table 3).

Eight in ten (81%) of older nurses wereregistered in Division 1 compared to seven inten (72%) of the younger, middle age group.

A very small proportion of all age groups wereregistered as Division 3 (Table 3).

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80%

70%

60%

50%

40%

30%

20%

10%

0%

Younger

Middle

Older

Not answered

Younger Middle Older Not answered

Table 3: Division of Registration by Age Group

Q2: In which Division of the Registermaintained by the NBV are you currentlyregistered?

Division Younger Middle Older(20-29yrs) (30-49yrs) (50yrs & Over)

(203) (1,416) (432)% % %

Division 1 72 68 81 Division 2 23 29 16 Division 3 2 2 1

Note: Of the total sample, 38 respondents did not respond.

Note: The small proportion of participants in Division 3 is consis-tent with the total number registered by the NBV.

Place of residence is relatively distributedthroughout Victoria (Error! Reference sourcenot found.Figure 3), with:• Five in ten (52%) respondents residing in the

Melbourne metropolitan area.• Four in ten (39%) respondents residing in

non-metropolitan Victoria.• A small proportion (4%) of respondents

living in other states of Australia. • A small proportion (5%) of respondents not

indicating their permanent place ofresidence.

Figure 2: Place of Residence

Q7: What is the postcode of your permanent place of residence?

Base: Total sample (2,089)

Victorian registered nurses are unlikely tobe registered in another state.

Nine in ten (91%) respondents were notcurrently registered in another state or territoryother than Victoria (Figure 3). A smallproportion (6%) indicated that they wereregistered in another state, and 3% ofrespondents did not answer this question.

Figure 3: Registrations in Other States

Q4: Are you currently registered in anotherstate or territory?

Base: Total sample (2,089)

6.2.1 Years of RegistrationNurses registered but not working had beenregistered on average for 18 years.

Years of registration is a function of age, with:• Younger nurses registered for an average of

six years. • Middle aged nurses registered for an

average of 15 years. • Older nurses registered for an average of 33

years.

Division 1 nurses have more years ofregistration than nurses in Division 2 andDivision 3.

Overall, Division 1 nurses (average of 19.1years) report having more years of registrationthan both Division 2 (average of 16.1 years) andDivision 3 (average of 16.1 years) nurses.

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MelbourneMeltropolitan

Rest of Victoria

Other States

Not answered

Not answered

Other States

Rest of Victoria

Melbourne Metropolitan

0% 10% 20% 30% 40% 50% 60%

YesNoNot answered

3% 6%

91%

Figure 4: Average Years Since Graduation

Q6 What year did you first register as anurse?

Base: Total sample (2,089)

6.2.2 Completion of Formal Post-Basic NursingCoursesFive in ten (48%) nurses had completed aformal post-basic nursing course and four inten (41%) nurses had not (Figure 5).

Figure 5: Formal Post-Basic Nursing Coursesacross All Divisions

Q12 Have you completed any formal postbasic nursing courses such as Grad Dips,Grad Certs, Masters?

Base: Total sample (2,089)

Division 1 nurses are more likely to completeformal nursing courses than Division 2 andDivision 3. Division 2 (65%) and Division 3(52%) nurses were more likely to have notcompleted formal post-basic nursing courses(Figure 6), than Division 1 nurses (31%).

Figure 6: Nursing Courses by Division ofRegistration

Q12 Have you completed any formal post-basic nursing courses such as Grad Dips,Grad Certs, Masters?

Base: Division 1 1,478Division 2 531Division 3 33

Note: Of the Division 1 nurses, 29% had completed at least amidwifery course.

Completion of formal nursing courses was afunction of age, where:• Three in ten (34%) younger registered

nurses reported the completion of a formalnursing course.

• Five in ten (54%) middle age nurses hadcompleted a formal nursing course.

• Six in ten (62%) older nurses had completeda formal nursing course.

6.2.3 Type of Formal Post Basic Nursing CourseMidwifery is the most commonlycompleted post-nursing course.

The most common formal nursing coursereported by the total sample was midwifery(22%), this was followed by critical care (6%).Midwifery remained the most common nursingcourse for all three age groups.

Midwifery also remained the most commonnursing course (Table 4) for Division 1 (29%)and Division 2 (4%)(sic), however mentalhealth was the most common nursing coursefor Division 3 (18%).

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20

18

16

14

12

10

8

6

4

2

0Division 1 Division 2 Division 3

Year

s of

Reg

istra

tion

YesNoNot answered

41%

11%

48%

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0$

Yes

No

Not Answered

Division 1 Division 2 Division 3

9%

31%

60%

17%

63%

18%

15%

52%

33%

Table 4: Type of Nursing Course by Division ofRegistration

Q12: Have you completed any formal postbasic nursing courses such as grad dipsetc?

Course Type Total Division 1 Division 2 Division 3(2,089) (1,478) (531) (33)

% % % %A B C

None 36 31 65A 52AMidwifery 22 29BC 4 6 Not Answered 11 9 17A 15 Critical Care 6 8bC 1 0 Advanced Nursing 5 6B 2 3 Education 4 5B 1 9B

Community Health 3 5B 1 3 Administration/ 3 4B 1 3 Management Maternal & 3 4B 1 0 Child Health Gerontology 3 4 2 3 Perioperative 3 4B 1 0 Coronary Care 2 3B 0 0 Accident & 2 2b 1 3 EmergencyMental Health/ 2 2 1 18AB

Psychiatric

Note: Percentages add up to more than 100% because of multi-ple responses.

Note Alphabet letters A, B, C represent significant levels.

6.2.1 Employed as a Registered NurseNearly all respondents (98%) indicated thatthey had been employed as a registered nurse,while a very small proportion (1%) respondedthat they had never been employed.

There was no difference by age or Division.

Division 2 nurses are less likely to work ona full-time basis than Division 1 andDivision 3 nurses.

Some nurses indicated that they had worked asa registered nurse on a full-time and/or otherthan full-time basis. Division 2 nurses (73%)were less likely to work on a full-time basisthan both Division 1 (92%) and Division 3(97%). However, Division 2 nurses (42%) aremore likely to work ‘other than full-time’ (forinstance part-time, casual) compared toDivision 1 (32%) and Division 3 (27%).

Figure 7: Employment of Registered Nurses

Q9: Have you ever been employed as a registered nurse?

Base: Division 1 (1,478)Division 2 (531)Division 3 (33)

6.2.2 Division of EmploymentNurses who had been employed as registerednurses were asked to indicate which Divisionthey were employed in. Most nurses worked intheir Division of registration, however somedid work in other Divisions (Table 5).

Table 5: Division of Employment

Q10 In which Divisions were you employed?

Registered Division 1 Division 2 Division 3Division (1,473) (628) (42)

% % %

Employed in Division 1 97 5 25Employed in Division 2 9 97 0 Employed in Division 3 1 0 91

Note: Percentages add up to more than 100% because of multi-ple responses.

Note: Some respondents have been employed and registered inmore than one division, which illustrates multiple responses.This is due to the previous structure of the nursing training sys-tem where Division 1 students could work as Division 2 nursesas part of their education.

6.3 Employment AttitudesA key objective of the current study was toidentify the reasons why registered nurses leftthe nursing profession. In this section of thereport, survey information will identify specificcharacteristics of the nurses who have left theprofession and reasons that led them to their

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100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Division 1

Division 2

Division 3

Yes (Fulltime) Yes (Other than full time) No (Never employed)

decision. This section begins by analysing thetotal sample by current work status.

6.3.1 Current Work StatusWhile the sample was drawn from nurses whoindicated they were not working as a nurse inthe registration survey, a substantial proportion(16%) were in fact working.

Four in ten registered nurses were notworking at all.

Of the total sample (Figure 8):• 16% of respondents were working as a

registered nurse.• 11% of respondents were on extended leave.• 12% of respondents were working in the

health industry, but not as a nurse.• 20% of respondents were working in an area

other than nursing.• 40% of respondents were not working at all.

Figure 8: Current Work Status

Q1: Which of the following best describesyour current work status?

Base: Total sample (2,089)

Note: The sample included respondents who were on extendedleave in order to determine the preconceived notion that nurseson maternity leave do not always return, and secondly to act asa de facto control group.

Division 1 and Division 3 registered nursesare more likely to be working as a ‘nurse’than Division 2 registered nurses.

‘Current work status’ was analysed by Divisionof registration (Table 6) and it was found that:• Division 1 (17%) and Division 3 (21%)

nurses were more likely to be working asregistered nurses than Division 2 nurses(13%).

• Division 1 nurses were also more likely to beon leave (14%) than both Division 2 (7%)and Division 3 nurses (3%).

• Division 2 nurses (27%) were more likely tobe ‘working in another area other thannursing’ than Division 1 (18%) and Division3 (21%).

• Across all Divisions of registration there isconsistency between respondents reportingthat they were not working.

Table 6: Current Work Status by Division ofRegistration

Q1 Which of the following best describes yourcurrent work status?

Current Work Division 1 Division 2 Division 3Status (1,478) (531) (33)

% % %A B C

Working as registered nurse 17B 13 21 Working in health, but not as a registered nurse 11 15A 9 Working in an area other than nursing 18 27A 21 Not working (on leave) 14BC 7 3 Not working 40 37 45

Note: Alphabet letters A, B, C represents significant levels.

Younger registered nurses are more likelyto be working as a nurse than middle agedand older registered nurses.

‘Current work status’ was also analysed by age(Table 7), which found that:• Younger nurses (25%) are more likely to be

working as a registered nurse than bothmiddle (17%) and older (8%) registerednurses.

• Younger nurses were also more likely to beworking in a ‘health-related field but not asa registered nurse’ (16%) and ‘takingextended leave’ (17%), than older registerednurses.

• Older nurses (57%) are more likely to be notworking at all compared to younger (19%)and middle (37%) aged registered nurses.

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Not answered

Not working

On extended leave

Working in an area other than nursing

Working in health industry,not as reg. nurse

Working as RegisteredNurse

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

1%

40%

11%

20%

12%

16%

Table 7: Current Work Status by Age

Q1 Which of the following best describesyour current work status?

Current Work Younger Middle OlderStatus (203) (1,416) (432)

% % %A B C

Working as registered nurse 25BC 17C 8 Working in health, but not as a registered nurse 16C 12 11 Working in an area other than nursing 23 20 20 Not working (on leave) 17C 13C 4 Not working 19 37A 57AB

Note: Alphabet letters A, B, C represents significant levels.

Registered nurses in non-metropolitanVictoria are less likely to be workingcompared to registered nurses inmetropolitan Victoria.

There are small differences between registerednurses residing in metropolitan Victoria andnon-metropolitan Victoria for current workstatus. Registered nurses residing in non-metropolitan Victoria (42%) are significantlymore likely to be ‘not working’ thanmetropolitan registered nurses (38%).

6.3.2 Reasons for Leaving NursingThe three main reasons why nurses stoppedworking in the nursing profession (Table 8)were:• Job satisfaction• Working conditions• Increased workload.• These were closely followed by family

commitments and lack of support.

Figure 9: Influential Factors for Leaving theNursing Profession

Q15 Thinking about why you left work innursing, how important were thefollowing factors?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Base: Sample 1,790 (excludes participants working as a nurse)

Key differences between Divisions ofregistration for reported ‘factors’ for leavingnursing (Table 9) included:• Across all Divisions of registration, factors

such as ‘increased workload’ and ‘workingconditions’ were rated as the mostimportant factors for leaving the nursingprofession.

• Division 2 nurses significantly placedgreater importance on many factorscompared to Division 1.

• Factors such as family commitment, lack ofsupport, and organisational restructure wererated consistently across all Divisions.

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Increased workload

Working conditions

Job satisfaction

Family commitments

Lack of support

Inadequate hospital funding

Pay

Limited career path

Found a job in another area

Staff conflict

Sickness/injury

Organisational restructure

Lack of practical experience

Returned to study

Reduncy package

1 1.5 2 2.5 3 3.5 4 4.5 5

Average Score

Table 8: Factors for Leaving Nursing by Divisionof Registration (Average Score)

Q15: Thinking about why you left work innursing, how important were thefollowing factors?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Factor Total Division 1 Division 2 Division 3(1,760) (1,227) (461) (27)

Average Average Average AverageA B C

Working conditions 3.7 3.7 3.8A 4.1 Increased workload 3.7 3.7 3.9A 3.6 Job satisfaction 3.7 3.6 3.8A 3.8 Family commitments 3.6 3.6 3.6 3.6 Lack of support 3.3 3.3 3.3 3.5 Pay 2.9 2.8 3.2A 3.0 Inadequate hospital funding 2.9 2.8 3.1A 2.9 Limited career path 2.8 2.5 3.3A 2.8 Sickness/injury 2.3 2.3 2.5A 2.2 Staff conflict 2.3 2.2 2.3A 2.7 Found a job in another area 2.3 2.1 2.6A 2.7 Organisational restructure 2.2 2.2 2.3 2.7 Lack of practical experience 2.1 2.0 2.4A 2.2 Returned to study .8 1.8 1.9A 1.8 Redundancy package 1.6 1.5 1.7A 2.0

Note: Alphabet letters A, B, C represents significance levels.

‘Job satisfaction’, ‘working conditions’ and‘increased workloads’ are factors rated ashighly important for leaving the nursingprofession across all age groups. Withinparticular age groups:• Older registered nurses rated factors such as

sickness/injury, redundancy package,inadequate hospital funding andorganisational restructure higher than bothmiddle and younger nurses.

• Younger nurses rated ‘lack of practicalexperience’, ‘working conditions’, ‘return tostudy’ and ‘found a job in another area’higher than both middle and olderregistered nurses as contributing factors forleaving the nursing profession.

• Younger and middle registered nurses ratedfamily commitments, pay and limited careerpath higher in importance for leaving thenursing profession than older registerednurses (Table 9).

Table 9: Factors for Leaving Nursing by Age(Average Score)

Q15: Thinking about why you left work innursing, how important were thefollowing factors?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Factor Total Younger Middle Older(1,760) (152) (1,176) (400)

Average Average Average AverageA B C

Job satisfaction 3.7 3.8 3.7 3.7 Working conditions 3.7 4.0BC 3.7 3.6 Increased workload 3.7 3.8 3.7 3.9B

Family commitments 3.6 3.3C 3.9AC 2.6 Lack of support 3.3 3.4 3.2 3.4B

Pay 2.9 3.1C 3.0C 2.5 Inadequate hospital funding 2.9 2.7 2.8 3.1AB

Limited career path 2.8 3.0C 2.9C 2.2 Sickness/injury 2.3 2.3 2.1 3.0AB

Staff conflict 2.3 2.3 2.2 2.5B

Found a job in another area 2.3 2.9BC 2.3C 1.9 Organisational restructure 2.2 1.9 2.1 2.9AB

Lack of practical experience 2.1 2.6BC 2.1 2.0 Returned to study 1.8 2.1BC 1.8C 1.5 Redundancy package 1.6 1.4 1.5 1.9AB

Note: Alphabet letters A, B, C represent significance levels.

There are some significant differences betweenregistered nurses residing in metropolitanVictoria and non-metropolitan Victoria. Nursesresiding in metropolitan Victoria placed moreimportance on the following factors for leavingthe nursing profession than registered nursesresiding in non-metropolitan Victoria:• Lack of support• Job satisfaction • Working conditions• Increased workload• Pay • Limited career path • Returned to study • Organisational restructure• Inadequate hospital funding.

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6.3.3 Factors for Leaving Nursing by CurrentWork StatusThe main factor (Table 12) rated as importantfor respondents who are not working wasfamily commitments (average score 4.0). Thiswas also the main factor for people on leave(average score 4.4). The main factor for leavingnursing for people working in a health job (butnot as a nurse) was ‘job satisfaction’ (averagescore 4.0). This was the highest rated factor interms of importance for people working inanother area (average score 3.9).

Table 10: Factors for Leaving Nursing by CurrentWork Status (Average Score)

Q15: Thinking about why you left work innursing, how important were thefollowing factors?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Working Not Working

Factor Total Health Other Leave Not(1,760) (249) (422) (225) (826)

Average A B C D

Job satisfaction 3.7 4.0CD 3.9CD 3.5 3.6 Working conditions 3.7 3.9D 3.9D 3.7D 3.5 Increased workload 3.7 3.7 3.9ACD 3.7 3.6 Family commitments 3.6 2.6 3.0A 4.4ABD 4.0AB

Lack of support 3.3 3.4D 3.4D 3.4D 3.1 Pay 2.9 3.1E 3.0E 3.0e 2.8 Inadequate hospital funding 2.9 2.9CD 3.3ACD 2.6 2.7 Limited career path 2.8 3.3BCD 3.1CD 2.7D 2.4 Sickness/injury 2.3 2.1 2.2C 2.0 2.5ABC

Staff conflict 2.3 2.3C 2.2 2.0 2.3D

Found a job in another area 2.3 3.7BCD 3.2CD 1.6D 1.4 Organisational restructure 2.2 2.3C 2.4CD 1.9 2.2C

Lack of practical experience 2.1 2.2C 2.2C 1.9 2.1C

Returned to study 1.8 2.2CD 2.0CD 1.7 1.5 Redundancy package 1.6 1.6C 1.5C 1.4 1.7BC

Note:Alphabet letters A, B, C & D represents significance levels.

Note: In table headers ‘Health’ refers to nurses working in thehealth arena but not as a nurse, ‘Other’ refers to nurses workingin an area other than nursing, ‘Leave’ refers to nurses who areon leave from nursing and ‘Not’ refers to nurses not working.

Two in ten respondents who identified ‘other’factors for why they left the nursing professionwere related to: • Structural change • Other employment functions • Retirement • Factors not related to nursing (Table 11).

Table 11: ‘Other’ Factors for Leaving Nursing byAge

Q15: Thinking about why you left work in nursing, how important were thefollowing factors?

‘Other’ Factors Younger Middle Older(152) (1,176) (400)

% % %

Structural change 7 6 14 Other employment functions 5 5 4 Retirement 1 1 1 Unrelated to nursing 3 3 3 No other factor mentioned 84 84 76

6.4 Seeking Employment as a Nurse Three in ten registered nurses were unsurewhether they would seek employment as anurse.

Of the total sample:• Four in ten (42%) respondents will seek

employment as nurse.• Three in ten (27%) respondents were unsure

whether they would seek employment.• One in ten (12%) respondents indicated that

they would not seek employment as a nurse. • 15% of respondents indicated that they

would not seek employment as a nursebecause they were already working.

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Figure 10: Seeking Employment as a Nurse

Q11 Do you think you will actively seekemployment as a nurse?

Base: Total sample (2,089)

Seeking employment as a nurse did not differbetween Divisions of registrations for ‘total yes’(Figure 11). There were significant differencesfor:• ‘Not sure’ between Division 2 (31%) and

Division 1 (26%) • ‘No’ between Division 1 (12%) and Division

2 (8%).

Figure 11: Seeking Employment by Divison ofRegistration

Q11: Do you think you will actively seekemployment as a nurse?

Base: Division 1 (1,478), Division 2 (531), Division 3 (33)

There was some age differences for seekingemployment, which included:• Older registered nurses (19%) are less likely

to seek employment than younger (43%)and middle (49%) aged registered nurses.

• Older (40%) and middle (24%) agedregistered nurses are more likely to be ‘ notsure’ about seeking for employment thanyounger registered nurses (18%).

No differences were found between registerednurses residing in metropolitan Victoria andregistered nurses residing in non-metropolitanVictorian in terms of seeking employment as anurse.

6.4.1 Intentions To Seek Employment by CurrentWork Status Nearly two in ten (16%) registered nurses whoare currently working as a registered nurse(16%) reported that they were seekingemployment as a nurse (Table 12).

Five in ten (51%) non-working registerednurses will at some stage seek employment as anurse. Three in ten (32%) non-workingregistered nurses were unsure whether theywould seek employment (Table 12).

Respondents who were:• working in a health related field, but not as

a nurse (16%);• working in a other area (14%); and • not working at all (15%);

were more likely not to seek employment as anurse, compared to respondents on leave (6%)(Table 12).

Table 12: Active Employment Seeking by CurrentWork Status

Q11 Will you actively seek employment as anurse?

Working Not Working

Total Nurse Health Other Leave No(2,089) (333) (253) (425) (240) (827)

% % % % % %

Total Yes 42 23 32 34 67 51 Not sure 27 2 35 42 12 32 No 12 0 16 14 6 15 No, currently working 15 60 16 9 10* 0

* Respondents do not intend to seek employment because theyconsidered themselves on leave from their current employment.

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100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%Total Yes Not sure No No, currently

working

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Division 1

Division 2

Division 3

Total Yes Not sure No No, currently Not answeredworking

42%46%

33%

26%31%

36%

12%8%

12%16%

11%15%

4% 4% 4%

6.4.2 Reasons for Not Seeking Employment as aNurseThe main reasons for not seeking employment(Table 13) included retirement (18%), poorcareer satisfaction (17%), working in anotherarea (19%) and family responsibilities (12%).

Table 13: Reasons for Not Seeking Employment asa Nurse

Q11b: If you DON’T INTEND to seekemployment, please tell us why?

Factor Total Younger Middle Older(242) (18) (100) (121)

% % % %A B C

Working/studying in other area 19 28 34C 7 Retirement 18 0 0 33AB

Poor career satisfaction 17 39 23C 8 Family responsibilities 12 17 17C 7 Negative work environment 12 22 16C 8 Injury/illness not work related 11 6 3 19B

Excessive work load 9 6 9 9 Poor salary 7 22 12C 0 Work related stress/burnout 5 0 4 5 Heavy workload 5 0 6 4 Not answered 5 11 3 7 Hours of work 4 11 8 0 WorkCover injury/illness 4 0 2 7 Age 4 0 1 7B

Lack of staff 3 6 4 2 Child care 2 0 4C 0 Stress/burnout not work related 2 0 3 1 Lack of suitable/available positions 1 0 1 2

Note: Percentages add to more than 100% because of multipleresponses.

Note: Alphabet letters A, B, C represents significance levels.

Previously, it was discussed that older nurseswere more likely not to seek employment thanyounger and middle aged nurses. As Table 13suggests older nurse do not seek employmentbecause of:• Retirement (33%) • Injury/illness (19%) • Excessive workload (9%).

Middle and younger nurses do not seekemployment for reasons such as:• Poor career satisfaction (23% and 39%)• Poor salary (12% and 22 %)• Negative work environment (16% and 22%) • Family responsibilities (17% and 17%).

One in ten (12%) of the total sample reportedthat they would not actively seek employment(Table 13). These respondents mainly consistedof registered nurses who were already workingbut not as a nurse and registered nurses whowere not working at all.

Influential factors (Table 14) for registerednurses who are not looking for work included:• Retirement (30%)• Injury/illness (17%)

Registered nurses working in the health arenabut not as a nurse reported the influentialfactors to be: • Poor career satisfaction (33%)• Working/studying in another area (40%).

The factors reported for nurses working inanother area included:• Negative work environment/conditions

(24%)• Working/studying in another area (36%).

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Table 14: Reasons for Not Seeking Employment asa Nurse by Current Work Status

Q11b: If you DON’T INTEND to seekemployment, please tell us why?

Working Not Working

Factor Total Health Other Leave No(242) (40) (59) (14) (127)

% % % % %A B C D

Working/studying in other area 19 40D 36D 7 7* Retirement 18 0 3 7 30AB

Poor career satisfaction 17 33D 20 7 12 Family responsibilities 12 3 5 50 14Ab

Negative work environment 12 2 24BC 0 11 Injury/illness not work related 11 3 3 14 17AB

Excessive workload 9 8 10 0 9 Poor salary 7 5 15D 0 4 Heavy workload 5 5 0 4 Not answered 5 5 8 0 5 Work related stress/burnout 5 3 2 7 6 Hours of work 4 8D 8D 0 2 WorkCover injury/illness 4 5 2 14 4 Age 4 0 5 0 6 Lack of staff 3 5 3 0 2 Child care 2 0 2 0 2 Stress/burnout not work related 2 0 3 0 2 Lack of suitable/available positions 1 5bD 0 0 1

Note: Percentages add to more than 100% because of multipleresponses.

Note: Alphabet letters A, B, C & D represents significance levels.

* Respondents are studying in an area other than nursing.

6.4.3 Important Factors for Not SeekingEmployment in NursingRegistered nurses, excluding those alreadyworking as a nurse, were asked to rate theimportance of a list of influential factors for notseeking employment. The four highest ratedfactors included: • The workload is too heavy• Commitments in other areas (family) • Lack of recognition• Working conditions are poor.

Figure 12: Influential Factors for Not SeekingEmployment

Q17 How important are the following factorsfor you not actively seeking employmentin nursing?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Base: Sample 1760 (excludes participants working as a nurse).

Registered nurses in Division 1 and Division 2reported different influential factors for notseeking employment than registered nurses inDivision 3 (Table15).

Division 1 and Division 2 rated:• No access to child care• Commitments in other areas (family)• Employment prospects are better elsewhere• Opportunities for promotion are limited• Pay is inadequate, higher in importance

than respondents in Division 3.

Conversely, Division 3 rated ‘workingconditions as poor’ and ‘difficulty in finding ajob’ higher in importance than respondents inDivision 1 and Division 2.

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Workload is too heavy

Commitments in other areas

Lack of recognition

Poor working conditions

Hospital funding is inadequate

Change in HealthCare structure

No access to funded refresher programs

Inadequate pay

Opportunities for promotion too limited

Lack of confidence

No access to child care

Employment prospects better elsewhere

My practical experience is inadequate

Difficult to find a job

1 1.5 2 2.5 3 3.5 4 4.5 5

Table 15: Influential Factors for Not SeekingEmployment by Division of Registration

Q17 How important are the following factorsfor YOU not actively seekingemployment in Nursing?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Factor Total Division 1 Division 2 Division 3(1,760) (1,227) (461) (27)

Average Average Average AverageA B C

The workload is too heavy 3.7 3.6 3.6 3.9AB

Commitments in other areas (family) 3.6 3.4C 3.9AC 2.6 Working conditions are poor 3.5 3.5 3.5 3.7B Nurses do not receive enough recognition for the work they do 3.5 3.7C 3.5 3.5 Hospital funding is inadequate 3.3 3.1 3.3A 3.5AB

Change in the health care structure 3.2 2.7 3.1A 3.6AB

No access to funded refresher programs 3.1 3.0 3.1 3.1 The pay is inadequate 3.0 3.3C 3.1C 2.7 Opportunities for promotion are limited 2.8 3.2BC 2.9C 2.5 Employment prospects are better elsewhere 2.5 3.0BC 2.5C 2.1 No access to child care 2.5 2.6C 2.9AC 1.2 Lack confidence 2.5 2.8BC 2.5 2.4 My practical experience is inadequate 2.4 2.7BC 2.4 2.4 It is difficult to find a job 2.3 2.3 2.3 2.5B

Note: Alphabet letters A, B, C represents significance levels.

Registered nurses from the middle age grouprated most influential factors higher than bothyounger and older registered nurses (Table 16).

Table 16: Influential Factors for Not SeekingEmployment by Age

Q17 How important are the following factorsfor YOU not actively seekingemployment in Nursing?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Factor Total Younger Middle Older(1,760) (152) (1176) (400)

Average Average Average AverageA B C

The workload is too heavy 3.7 3.6 3.8A 3.3 Commitments in other areas (family) 3.6 3.6 3.5 3.4 Working conditions are poor 3.5 3.5 3.6 3.4 Nurses do not receive enough recognition for the work they do 3.5 3.5 3.7A 3.6 Hospital funding is inadequate 3.3 3.3 3.5A 3.4 Change in the health care structure 3.2 3.1 3.4A 3.2 No access to funded refresher programs 3.1 3.0 3.3A 3.3 The pay is inadequate 3.0 2.9 3.3A 2.6 Opportunities for promotion are limited 2.8 2.7 3.2A 2.8 Employment prospectsare better elsewhere 2.5 2.4 2.7A 2.2 No access to child care 2.5 2.5 2.5 2.1 Lack confidence 2.5 2.5 2.4 2.6 My practical experience is inadequate 2.4 2.4 2.6A 2.1 It is difficult to find a job 2.3 2.2 2.5A 2.4

Note: Alphabet letters A, B, C represents significance levels.

Registered nurses residing in metropolitanVictoria significantly rated higher on thefollowing factors (Figure 13) than registerednurses residing in non-metropolitan Victoria:• Workload is too heavy• Lack of recognition• Poor working conditions• Hospital funding is inadequate• Inadequate pay• Opportunities for promotion are limited.

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However, non-metropolitan Victorian registerednurses rated higher on factors, including:• Commitments in other areas• My practical experience is inadequate• Difficult to find a job.

Figure 13: Influential Factors for Not SeekingEmployment by Geograhical Location

Q17 How important are the following factorsfor YOU not actively seekingemployment in Nursing?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Base: Metro (908), Non-Metro (695).

Respondents who are working rated differentfactors higher in importance than respondentswho are not working (Table 17). For instance,registered nurses who are working, but not as anurse, rated factors higher, including:• Pay is inadequate• Working conditions are poor• Employment prospects are better elsewhere.

However, respondents who are not workingrated higher on factors such as, commitmentsin other areas (family) and no access to childcare, than respondents who are working.

Table 17: Influential Factors for Not SeekingEmployment by Current Work Status

Q17 How important are the following factorsfor YOU not actively seekingemployment in nursing?

Working Not Working

Factor Total Health Other Leave No(1,760) (249) (422) (225) (826)

Average A B C D

The workload is too heavy 3.7 3.8 3.7CD 3.5 3.6 Commitments in other areas (family) 3.6 2.6 3.1A 4.2ABD 4.0AB

Working conditions are poor 3.5 3.8CD 3.7CD 3.3 3.4 Nurses do not receive enough recognition for the work they do 3.5 3.8CD 3.7CD 3.5 3.4 Hospital funding is inadequate 3.3 3.4C 3.6CD 3.1 3.2 Change in the health care structure 3.2 3.1C 3.3AC 2.8 3.2C

No access to funded refresher programs 3.1 3.0 3.2AC 2.7 3.2C

The pay is inadequate 3.0 3.3CD 3.2D 3.0 2.8 Opportunities for promotion are limited 2.8 3.3BCD 3.0CD 2.7 2.5 Employment prospects are better elsewhere 2.5 3.1CD 3.0CD 2.2 2.1 No access to child care .5 1.9 2.2A 3.6ABD 2.7AB

Lack confidence 2.5 2.3 2.4C 2.1 2.6ABC

My practical experience is inadequate 2.4 2.5C 2.5C 2.0 2.5C

It is difficult to find a job 2.3 2.2C 2.3CC 1.9 2.4ABC

Note: Alphabet letters A, B, C & D represents significance levels.

One in ten registered nurses mention ‘other’important factors for not actively seekingemployment. These important factors includedhealth and safety, employment conditions,negative attitudes and the redundancy process.

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Workload is too heavy

Lack of recognition

Poor working conditions

Commitments in other areas

Hospital funding is inadequate

Change in HealthCare structure

Inadequate pay

No access to funded refresher programs

Opportunities for promotion too limited

Lack of confidence

No access to child care

Employment prospects better elsewhere

My practical experience is inadequate

Difficult to find a job

1 1.5 2 2.5 3 3.5 4 4.5 5

Average Score

Non-Metro

Metro

6.4.4 Barriers to Obtaining Employment inNursingAll respondents, except those employed as anurse, were asked to rate the importance of alist of factors relating to the barriers inobtaining successful employment.

The two most important factors for not findingsuccessful employment in nursing were:• Limited job opportunities• It is difficult to find a job in my locality.

Figure 14: Factors Rated for Importance in NotFinding Employment in Nursing

Q18 If you have been seeking employment innursing but have not been successful,please circle the number that identifieshow important the following factorsare:?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Base: Sample 1760 (excludes participants working as a nurse)

There were only two significant differencesbetween Division of registration for the factorsrated as important in not finding employmentin nursing (Figure 15). These included:• Division 1 nurses rated higher importance

for ‘difficult to find a job in my preferredspeciality’, than Division 2.

• Division 2 nurses rated higher importancefor ‘inadequate hospital funding’ thanDivision 1.

Figure 15: Factors Rated Important for NotSuccessfully Obtaining Employment by Divisionof Registration

Q18 If you have been seeking employment innursing but have not been successful,please circle the number that identifieshow important the following factorsare:?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Base: Division 1 (1,227), Division 2 (461), Division 3 (27)

Note: Division 3 consists of a relatively small sample, thereforeinterpret this finding with care.

There were only two significant differencesbetween age groups for the factors rated asimportant in not finding employment innursing (Figure 16). These are:• Younger registered nurses rated ‘I lack

practical experience’ higher than middle ageand older registered nurses.

• Older registered nurses rated ‘there arelimited job opportunities’ higher thanmiddle and younger registered nurses.

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There are limited job opportunities

It is dificult to find a job in my locality

Hospital funding is inadequate

It is difficult to find a job in my preferred speciality

I lack practical experience

1 1.5 2 2.5 3 3.5 4 4.5 5

Average Score

Hospital funding isinadequate

It is dificult to finda job in my locality

It is difficult to find a job in my preferred speciality

I lack practical experience

There are limited job opportunities

1 1.5 2 2.5 3 3.5 4 4.5 5

Average Score

Division 3Division 2Division 1

Figure 16: Factors Rated as Important for NotObtaining Employment by Age

Q18 If you have been seeking employment innursing but have not been successful,please circle the number that identifieshow important the following factorsare:?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Base: Younger (152), Middle (1176), Older (400)

Two significant differences were noted betweenmetropolitan respondents and non-metropolitan respondents with factors rated asimportant for not obtaining employment as anurse. These include non-metropolitanregistered nurses rating higher importance on:• There are limited job opportunities.• It is difficult to find a job in my locality.

6.5 Returning to the Nursing ProfessionOne of the main objectives of the currentresearch was to determine the factors that willinfluence registered nurses to return to thenursing profession. This section exploressurvey information regarding this objective,and begins by analysing the important factorsthat contribute to respondents’ decision toreturn to work in nursing.

6.5.1 Influential Factors in Returning to WorkRespondents regarded all factors highlyimportant (Figure 17), however the three ‘standout’ main factors rated as important inreturning to work as a nurse included:• Working conditions• Flexible rosters• Employment opportunities.

Figure 17: Factors Rated as Important in Returningto Work

Q16 If you decided that you wanted to returnto work in nursing, how important arethe following factors?

Base: Sample 1760 (excludes participants working as a nurse)

Division 1 and Division 2 nurses rated mostfactors relating to returning to work assignificantly higher in importance thanDivision 3 (Table 18). Division 1 nurses did rate‘organisational structure’ higher in importancethan both Division 2 and Division 3.

Table 18: Factors Rated as Important in Returningto Work by Division of Registration

Q17 If you decided that you wanted to returnto work in nursing, how important arethe following factors?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Factor Total Division 1 Division 2 Division 3(1,760) (1,227) (461) (27)

Average Average Average AverageA B C

Working Conditions 4.5 4.5 4.5 4.4 Flexible rosters 4.2 4.4C 4.4C 3.7 Employment opportunities 4.1 4.2C 4.1C 3.9 Training opportunities 4.0 4.1C 4.0C 3.8 Professional development 4.0 4.1C 4.0C 3.7 Funded refresher courses 3.9 3.9 3.9 3.8 Hospital funding 3.9 3.9 3.9 3.9 Pay and benefits 3.9 4.2C 4.0 3.6 Organisational structure 3.7 3.5 3.7 3.8AB

Funded supervised practice 3.6 3.8C 3.6C 3.5 Funded post graduate courses 3.4 3.6C 3.5C 2.9 Career path 3.4 3.8BC 3.5C 2.6 Childcare facilities 2.9 2.9 2.8 2.8

Note: Alphabet letters A, B, C represents significance levels.

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Hospital funding isinadequate

It is dificult to finda job in my locality

It is difficult to find a job in my preferred speciality

I lack practical experience

There are limited job opportunities

1 1.5 2 2.5 3 3.5 4 4.5 5

Average Score

OlderMiddleYounger

Working conditions

Flexible rosters

Employment opportunities

Professional development

Training opportunities

Hospital funding

Pay and benefits

Funded refresher courses

Organisational structure

Funded Supervised Practice

Career path

Funded Postgraduate courses

Childcare facilities

1 1.5 2 2.5 3 3.5 4 4.5 5

Average Score

Middle aged registered nurses placed higherimportance on many factors compared toyounger registered nurses (Table 19). Theseinclude:• Training opportunities• Employment opportunities• Funded refresher courses• Pay and benefits• Career path.

Table 19: Factors Rated as Important in Returningto Work by Age

Q17 How important are the following factorsfor YOU not actively seekingemployment in Nursing?

1 = Not at all important, 2 = Not too important, 3 = Important, 4 = Very important, 5 = Extremely important.

Factor Total Younger Middle Older(1,760) (152) (1176) (400)

Average Average Average AverageA B C

Working conditions 4.5 4.5 4.5 4.5 Flexible rosters 4.2 4.2 4.3 4.5 Employment opportunities 4.1 4.0 4.3A 4.2 Training opportunities 4.0 4.0 4.1A 4.1 Professional development 4.0 3.9 4.0 3.8 Funded refresher courses 3.9 3.8 4.0A 4.3 Pay and benefits 3.9 3.9 4.1A 4.0 Hospital funding 3.9 3.9 3.9 3.9 Organisational structure 3.7 3.7 3.7 3.6 Funded supervised practice 3.6 3.6 3.6 3.9 Funded postgraduate courses 3.4 3.4B 3.2 3.3 Career path 3.4 3.3 3.6A 3.7 Child care facilities 2.9 2.9 2.8 2.8

Note: Alphabet letters A, B, C represents significance levels.

6.5.2 Area of Nursing Likely to WorkParticipants were asked which area of nursingthey would like to work in if they returned towork as a nurse. The three most reported areaswere:• Gerontology (27%)• Agency/casual (27%)• Mixed medical and surgical (21%).

These were closely followed by communityhealth (18%), surgical (13%), and midwifery(12%).

Area of work was analysed by Division ofregistration (Table 20), which found that:• Division 1 nurses are likely to work in

community health (20%)• Division 2 nurses are likely to work in

gerontology (44%)• Division 3 nurses are likely to work in

mental health/Psychiatric (85%).

Table 20: Area of Nursing Likely to Work byDivision of Registration

Q13 If you were to RETURN TO WORK ASA NURSE, in which area of nursingwould be likely to work?

Area of Work Total Division 1 Division 2 Division 3(1,760) (1,227) (461) (27)

% % % %A B C

Gerontology 27 21 44A 15 Agency/casual 27 26 34A 26 Mixed medical and surgical 21 20 27A 7 Community health 18 20B 13 33 Surgical 13 14 12 0 Midwifery 12 15B 5 0 Medical 11 10 15A 4 Rehabilitation 9 6 17A 4 Management 8 10B 2 15 Perioperative (including operating theatre and recovery) 7 8B 3 0 Not answered 7 8B 5 0 Accident and emergency 6 7B 4 0 School children’s health 6 7B 4 4 Paediatric 5 5 6 0 Mental health/psychiatric 5 4 6A 85 No specialty 5 3 10A 0 Oncology 4 4 4 0 Critical care/intensive care 4 5B 2 0 Maternal & child health 4 4B 2 7 Coronary care 3 4B 1 0 Gynaecology 3 3 3 0 Net Mixed medical & surgical, surgical, and medical* 45 44 54 11

Note: Percentages add up to more than 100% because of multi-ple responses.

Note: Alphabet letters A, B, C represents significance levels.

* Response consists of three combined categories namely med-ical & surgical, medical, and surgical

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Age differences were evident for the area ofnursing the participants would return to (Table 13), for instance:• Younger and middle aged nurses were likely

to work in Agency/casual (30% and 30%)• Older nurses were more likely to work in

gerontology (38%).

Table 21: Area of Nursing Likely to Return to Workby Age

Q13 If you were to RETURN TO WORK ASA NURSE, in which area of nursingwould be likely to work?

Area of Work Total Younger Middle Older(1,760) (152) (1176) (400)

% % % %A B C

Gerontology 27 15 24A 38AB

Agency/casual 27 30CC 30C 20 Mixed medical and surgical 21 25C 24C 11 Community health 18 13 18 18 Surgical 13 22BC 15C 6 Midwifery 12 5 14AC 10 Medical 11 16C 12C 8 Rehabilitation 9 9 9 10 Management 8 5 8 9 Perioperative (including operating theatre & recovery) 7 7 7 6 Not answered 7 5 7 11AB

Accident and emergency 6 10BC 6C 4 School children’s health 6 8 6 5 Paediatric 5 9C 5C 3 Mental health/psychiatric 5 9C 6C 3 No specialty 5 7 5 5 Oncology 4 4 5 3 Critical care/intensive care 4 5C 6C 1 Maternal and child health 4 5 3 4 Coronary care 3 3C 3C 1 Gynaecology 3 1 3 3 Net Mixed medical & surgical, surgical, and medical* 45 63 51 25 Note: Alphabet letters A, B, C represents significance levels.

Note: Percentages add up to more than 100% because of multi-ple responses

* Response consists of three combined categories namely med-ical & surgical, medical, and surgical

Some notable differences of area of work werereported between metropolitan and non-metropolitan nurses. These included registerednurses residing in metropolitan Victoria: • To work in surgical (15%) and

agency/casual (31%) more than registerednurses residing in non-metropolitan Victoria(11% and 24%).

• To work in community health (16%) andgerontology (21%) less than registerednurses in non-metropolitan Victoria (21%and 34%).

Differences between respondents who areworking and not working, in terms of thenursing area they would likely return to workto, were evident from the survey information(Table 22). These included:• Respondents who were working in the

health arena were more likely to report thatthey would return to work in the‘community health’ area (24%).

• Respondents working in other areas (nothealth related), reported that they wouldlikely return to work in the agency/casualarea (32%).

• Registered nurses on leave were also likelyto return to work as a nurse in theagency/casual area (25%).

• Respondents who are not working at allreported they would most likely return towork in the area of gerontology (30%).

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Table 22: Area of Nursing Likely to Return to byCurrent Work Status

Q13 If you were to RETURN TO WORK ASA NURSE, in which area of nursingwould be likely to work?

Working Not Working

Area of Work Total Health Other Leave No(1,760) (249) (422) (225) (826)

% % % % %A B C D

Gerontology 27 24C 27C 17 30AC

Agency/casual 27 24 32AC 25 27 Mixed medical and surgical 21 17 24AD 16 23AD

Community health 18 24BCD 19C 11 18C

Surgical 13 12 14 11 15 Midwifery 12 7 12A 12 14A

Medical 11 12C 11C 6 13C

Rehabilitation 9 12C 9C 3 10C

Management 8 16BCD 10CD 4 5 Perioperative (including operating theatre & recovery) 7 7 7 9D 6 Not answered 7 8BD 3 23ABD 5 Accident and emergency 6 9D 7D 7D 4 School children’s health 6 4 8C 4 6 Paediatric 5 4 6C 3 6C

Mental health/psychiatric 5 9BCD 5 4 4 No specialty 5 6C 7C 2 6C

Oncology 4 4 8ACD 3 3 Critical care/intensive care 4 6D 5D 8D 2 Maternal and child health 4 2 3 2 4AC

Coronary care 3 3 3 2 3 Gynaecology 3 2 4 2 3 Net mixed medical & surgical, medical, and surgical* 45 41 49 33 51

Note: Alphabet letters A, B, C & D represents significance levels.

Note: Percentages add up to more than 100% because of multi-ple responses

* Response consists of three combined categories namely med-ical & surgical, medical, and surgical

6.5.3 Desired Area of Nursing Respondents were asked what area of nursingthey would like to work in if appropriatetraining were accessible. The three main areasreported were:• Community health (26%)• Midwifery (18%)• School children’s health (16%).

The main areas reported by Division ofregistration (Table 23) included:• Division 1 and Division 2 nurses would like

to work in community health (25% and30%).

• Division 3 nurses would like to work inmental health/psychiatric (30%).

Table 23: Desired Area of Nursing by Division ofRegistration

Q14 If appropriate training were accessible toyou, which of the following areas wouldyou consider working in?

Area of Work Total Division 1 Division 2 Division 3(1,760) (1,227) (461) (27)

% % % %A B C

Community health 26 25 30A 22 Midwifery 18 19 18 19 chool children’s health 16 16 18 11 Not answered 16 19B 9 11 Mixed medical and surgical 13 9 25A 22 Maternal and child health 12 13 12 7 Gerontology 11 11 13 19 Surgical 10 7 18A 7 Accident and emergency 10 10 11 4 Agency/casual 9 8 11A 19 Cardiothoracic 9 9 11 11 Management 9 11B 5 15 Oncology 8 7 11A 4 Rehabilitation 8 6 15A 7 Perioperative (including operating theatre & recovery) 8 7 13A 4 Paediatric 8 6 15A 7 Medical 6 5 10A 7 Mental health/psychiatric 6 5 8A 0 No specialty 6 5 7 15 Coronary care 5 5 4 0 Critical care/intensive care 5 6 4 0

Gynaecology 4 4 6A 4 Neonatal/intensive care 4 4 5 4 Renal 3 3 3 7 Net Mixed medical & surgical, surgical, and medical* 29 21 53 36

Note: Alphabet letters A, B, C represents significance levels.

Note: Percentages add up to more than 100% because of multi-ple responses

* Response consists of three combined categories namely med-ical & surgical, medical, and surgical

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Younger nurses would like to work inmidwifery (26%), middle aged nurses wouldlike to work in the area of school children’shealth’ (20%), and older nurses would like towork in the area of community health (24%)(Table 24).

Table 24: Desired Area of Nursing by Age

Q14 If appropriate training were accessible to you, which of the following areas would you considerworking in?

Area of Work Total Younger Middle Older(1,760) (152) (1,176) (400)

% % % %A B C

Community health 26 23 27 24 Midwifery 18 26BC 20C 10 Maternal and child health 16 1 9BC 14C 5 Not answered 16 1 15 23AB

Mixed medical and surgical 13 14C 15C 8 Cardiothoracic 12 9 11C 5 Gerontology 11 8 9 21AB

Surgical 10 14C 11C 4 Accident and emergency 10 21BC 10C 4 Agency/casual 9 8 9 10 Neonatal/intensive care 9 10BC 5C 2 Management 9 7 10 9 Oncology 8 8 9C 5 Rehabilitation 8 9 7 10 Perioperative (including operating theatre & recovery) 8 13C 9C 5 Paediatric 8 15BC 9C 3 Medical 6 8 7 5 Mental health/psychiatric 6 10BC 5 5 No specialty 6 5 5 8B

Coronary care 5 5C 6C 2 Critical care/intensive care 5 11BC 6C 2 Gynaecology 4 1 5AC 3 School children’s health 4 13 20AC 8 Renal 3 5C 3C 1 Net Mixed medical & surgical, surgical and medical* 29 36 33 17

Note: Alphabet letters A, B, C represents significance levels.

Note: Percentages add up to more than 100% because of multi-ple responses

* Response consists of three combined categories namely med-ical & surgical, medical, and surgical

There were only two differences betweenmetropolitan and non-metropolitan nurses inreporting the area of nursing they would like towork in. This included:• Non-metropolitan nurses (15%) reported

higher on gerontology than metropolitannurses (9%).

• Metropolitan nurses reported higher formanagement (10%) than non-metropolitannurses (7%).

Registered nurses who are:• Working in the area of health (but not as a

nurse) (31%) and those working in otherareas (27%) would like to work incommunity health.

• Respondents who are not working (21%)would like to work in the area of midwifery.

• A proportion of nurses who are on leave(32%) did not indicate what area they wouldlike to work in (Table 25).

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Table 25: Desired Area of Nursing by CurrentWork Status

Q14 If appropriate training were accessible toyou, which of the following areas wouldyou consider working in?

Working Not Working

Area of Work Total Health Other Leave No(1,760) (249) (422) (225) (826)

% % % % %A B C D

Community health 26 31CD 27C 21 25 Midwifery 18 12 16 16 21ABC

School children’s health 16 8 15A 16A 19AB

No specialty 16 8C 6C 3 6C

Not answered 16 17B 11 32ABD 14 Mixed medical and surgical 13 11C 17AC 6 15C

Maternal and child health 12 7 10 14AB 15AB

Gerontology 11 12C 3C 7 12C

Surgical 10 10C 9C 5 12C

Accident and emergency 10 13D 12D 10 8 Agency/casual 9 7 10C 5 10C

Cardiothoracic 9 11 11 8 9 Management 9 15CD 13CD 7 7 Oncology 8 5 13ACD 6 7 Rehabilitation 8 10C 9C 4 8C Perioperative (including operating theatre & recovery) 8 10C 9 6 8 Paediatric 8 7 10C 4 9C

Medical 6 8C 7C 2 8C

Mental health/psychiatric 6 8C 5 3 6 Coronary care 5 3 5 5 5 Critical care/intensive care 5 7 6 5 4 Gynaecology 4 2 5C 2 5AC

Neonatal/intensive care 4 2 4A 6A 5A

Renal 3 2 3 2 3 Net Mixed medical & surgical, surgical, and medical* 29 29 33 13 35

Note: Alphabet letters A, B, C & D represents significance levels.

Note: Percentages add up to more than 100% because of multi-ple responses

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Nursing Return to Work SurveyQualitative Report

A Qualitative Report of Nurses’ Responses to

Open-Ended Survey Questions

Prepared for

Nurse Recruitment & Retention Committee

Department of Human Services

Melbourne Victoria

June 2000

Appendix Four—Qualitative Survey ofRegistered, Non-Working nurses

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Contents

1 Executive Summary ........................................................................................................................................145

1.1 Family ..........................................................................................................................................................145

1.2 Injury and Illness ....................................................................................................................................145

1.3 Work Conditions and Remuneration ................................................................................................145

1.4 Employment Opportunities and Training ........................................................................................145

1.5 Professional Recognition ....................................................................................................................145

1.6 Job Satisfaction and Other Careers ..................................................................................................146

2 Background and Objectives ....................................................................................................................146

2.1 Research Design ......................................................................................................................................146

2.2 Reading this Report ................................................................................................................................146

3 The Common Themes ..................................................................................................................................147

4 Family ....................................................................................................................................................................147

5 Injury and Illness ............................................................................................................................................148

6 Work Conditions and Remuneration ....................................................................................................149

7 Employment Opportunities and Training ............................................................................................150

8 Professional Recognition ..........................................................................................................................152

9 Job Satisfaction and Other Careers ....................................................................................................152

10 Conclusion ..........................................................................................................................................................153

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1. Executive Summary• This report summarises the qualitative

component of a survey of 2,089 registerednurses, currently not working in the nursingprofession, to better understand reasons forleaving, as well as barriers to returning tonursing.

• A detailed report of the quantitative resultsis reported separately.

• Responses to six open-ended surveyquestions are analysed here according tocommon themes. These questions askedinclude:Q11. If you don’t intend to seek employment,

please tell us why?Q15. Thinking about why you left work in

nursing, how important were the followingfactors?

Q16. If you decided that you wanted to return towork in nursing, how important are thefollowing factors?

Q17. How important are the following factors forYOU not actively seeking employment innursing?

Q18. If you have been actively seekingemployment in nursing but have not beensuccessful, please circle the number thatidentifies how important the followingfactors

Q19. Is there anything else you would like to sayto the Nurse Recruitment RetentionCommittee that you think could influencenurses to return to the workforce?

• This report summarises six key themesidentified by the 2,089 registered nursesresponding to the survey.

1.1 Family• Combining family with nursing is a serious

concern for registered nurses who have theresponsibility to care for family members.

• Nurses do not perceive that their professionprovides flexible shifts and appropriatechild care facilities to accommodate familycommitments.

1.2 Injury and Illness• Respondents reported both work related

and non-work related injuries as barriers toreturning to work.

• Work related injuries and illnesses areperceived to be a result of poor workingconditions (heavy workloads andunderstaffing).

• A lack of support by management wasnoted when injuries and illnesses occurred.

• After an injury or illness has incurred,nurses often feel unable to return to workdue to the lack of alternative duties.

• Injured and sick registered nurses want tonurse but feel the inflexibility of theworkplace and their employers are barriersto gaining suitable employment.

1.3 Work Conditions and Remuneration• Registered nurses reported that work

conditions and their duties were notrewarded with adequate remuneration.

• Many respondents feel exploited becausethey do not receive their entitlements, suchas meal breaks and overtime.

1.4 Employment Opportunities and Training• Division 2 nurses reported a sense of

displacement with the introduction ofPersonal Care Attendants (PCAs), and thereis a lack of opportunities to increase theirqualifications.

• Division 1 nurses feel that Division 2 nursesare being employed before themselvesbecause they have a lower salary.

• Most registered nurses reported that theywant to attend further training andeducation, but not at their expense,especially when salaries do not increasewith further training.

• Both hospital trained and university trainednurses feel that university graduates lackpractical experience, thereby compromisingtheir ability to work on the ward or obtainemployment.

1.5 Professional Recognition• Nurses perceive they receive little respect

and recognition for their skills.• Respondents believe a lack of respect is

evident by the poor remuneration theyreceive.

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1.6 Job Satisfaction and Other Careers• Job dissatisfaction is created by overlapping

factors such as non-family friendlyenvironment, lack of flexibility of workinghours, poor working conditions, injury,illness, displacement and lack of recognition.

• In addition, job dissatisfaction is enhancedwith the lack of time available to ‘care’ forpatients, as well as increased administrationworkloads.

• Due to continued poor job satisfaction,many registered nurses have changed careerdirection.

2. Background and ObjectivesCampbell Research & Consulting wascommissioned by the Nurse Recruitment andRetention Committee to develop a profile ofregistered nurses who are currently notworking as nurses.

A survey instrument was developed to providedetailed information of why nurses continue toregister as nurses, but not work as nurses. Inaddition, nurses were asked what would enticethem to return to the nursing profession. Aseparate report provides a detailed analysis ofthe survey implementation and quantitativereporting of the survey information as at May2000.

The current report intends to provide aqualitative account of six open-ended questionsfrom 2,089 returned surveys and detailed lettersreturned by respondents with the survey.

2.1 Research DesignThe survey research design is described in theNursing Return to Work Survey, QuantitativeReport.

For this qualitative report, six open-endedsurvey questions asked registered nurses fortheir thoughts on leaving and returning to thenursing profession:

Q11. If you don’t intend to seek employment,please tell us why?

Q15. Thinking about why you left work innursing, how important were the followingfactors?

Q16. If you decided that you wanted to return towork in nursing, how important are thefollowing factors?

Q17. How important are the following factors forYOU not actively seeking employment innursing?

Q18. If you have been actively seekingemployment in nursing but have not beensuccessful, please circle the number thatidentifies how important are the followingfactors

Q19. Is there anything else you would like to sayto the Nurse Recruitment and RetentionCommittee that you think could influencenurses to return to the workforce?

Survey respondents provided extensivecomments to these questions, and manyprovided additional letters, several pages long.The nurses were grateful to be given theopportunity to speak and their responses havebeen coded into similar groups to providesummaries. These summaries will be presentedas separate common themes that became evidentwhen responses of each question were coded.

2.2 Reading this ReportVerbatim responses of registered nurses weredetailed and broad ranging. Quotes arereported to illustrate the breadth and depth ofresponses to particular survey questions.Verbatim responses are not reported forcategories where percentages are less than 5%unless the response holds importance forunderstanding the current issues at hand.

This report provides details of the quotesillustrating the context of the responses toprovide depth of understanding of the nurses’point of view.

DisclaimerPlease note that in accordance with ourCompany’s policy we are obliged to advise thatneither the Company nor any member noremployee undertakes responsibility in any waywhatsoever to any person or organisation inrespect of information set out in this report,including any errors or omissions thereinarising through negligence or otherwisehowever caused.

3. The Common ThemesThe responses to the open-ended questionshave provided a rich pool of data generatedfrom the realms of the nursing profession. Insummarising this data it became apparent thatno matter what question was asked somecommon themes prevailed. These themes arecentral to providing insight to the two researchobjectives, namely, why registered nurses leftthe nursing profession and what wouldencourage them to return.

This report has been written to tell a ‘story’about respondents’ views, and has beengenerated from nurses’ verbatim responses. Asummary at the end of each theme will give aclear understanding of the areas that need to beaddressed in the nursing arena.

The common themes discussed are:• Family• Injury and Illness• Work Conditions and Remuneration• Employment Opportunities and Training• Professional Recognition• Job Satisfaction and Other Careers

4. FamilyWhen respondents were asked why theystopped working in the nursing profession oneof the main responses was familycommitments. The additional informationprovided in the open-ended questions clarifiesthe problem nurses’ face combining family withtheir profession.

Concerns about combining family with nursingare determined by the family as the mainpriority in the nurses’ life. This may be youngchildren or ill family members:

I would love to return to nursing but familycommitments make it impossible.

I intend to be a full-time mother to my 12-monthold baby. She comes first.

Disappointed with the nursing profession and Iam a full-time mother

Illness in the family, too difficult to maintainwork commitments.

Employment conditions, in particular hours ofwork, are problematic to registered nurses withfamily commitments:

I do not want to leave my children home atnight.

Inflexible and unsympathetic rostering of thenursing workforce undermines the importance offamily commitments.

I left nursing to have my two children and tocare for them at home. I would like to returnpart-time but there are no available positions andmost workplaces are not family friendly.

As well as a lack of ‘family friendly’ shifts, theabsence of suitable child-care, especially forsingle parent families is frequently discussed.Hours of work are not flexible and havedetrimental affects on mothers who need toseek out care for their family:

Nurses with young families, particularlymothers, need permanent part-time rosters inorder to organise child care.

Hated working different shifts all the time.Can’t raise a family like that. Child-care has tobe a permanent arrangement.

I have children, and there are a lack of positionswhere I can work one to two shifts a week on aregular basis.

The importance of this rather complexrelationship between family, shift work andlack of suitable child care in the nursingprofession becomes particularly problematicwhen registered nurses with familycommitments actually want to nurse. Theyfind that the barriers are too overwhelming:

More shifts or mother friendly opportunitiesshould be available. If I could I would be back atwork now, but I can’t see how I can do it withmy children and no spontaneous care. My familycomes first, so I am rapidly losing my skill, mycareer.

Regular evening and weekend ‘on call’, frequentovertime and low staffing levels were a regularpart of my working life. However, with twosmall children at home, despite a desire to returnto part-time theatre work, I really desired a morefamily friendly position.

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The fundamental problem for registered nursesis that the nursing profession does not cater forthose employees or potential employees whohave families. This is a serious concernconsidering that the majority of respondents areof child bearing age. Some nurses offersuggestions to rectify the problems discussed.

Be aware that job sharing would be appealing fornurses with school age children. A lot of womendon’t want to work full-time and raise a family.

Provide a better package for nurses returningfrom Maternity leave, for instance thecombination of shorter working hours, flexiblehours to fit in with child care, and the ability tomaintain a career path.

No ‘on call’ and minimal over-time.

The solution is provision of child care and moreflexibility in rosters:

I think child care and flexible rosters are soimportant as most women are mothers and someare single parents.

Flexible hours of work to cater for single parentswith school aged children.

Unfortunately some feel that the nursingprofession is no career choice for individualswho wish to have a family in the future. This issummarised by one respondent:

It seems ludicrous in the extreme that nursinginvests so much time, money and resources inthe training of motivated and dedicated youngnurses, predominantly female. These nursesusually consolidate their practice and then seekfurther education, experience and qualificationsbefore ultimately taking leave from work to havea family. So, here, we have a very valuable assetbeing allowed to deteriorate due to difficulties inreturning to a system that does not allowflexibility and support for those trying tomaintain professional standards, and juggle thedemands of a busy family. Trying to findconsistent and reliable child care becomes toodifficult at times and at the end of the struggle,it does not seem worth it as the cost of child careultimately takes most of the wage. There seemslittle incentive for those once motivated, qualifiedand experienced to persist in their chosen career.

The responses for this theme captured arevolving problem felt by many registerednurses. These nurses indicated that poorflexibility in rosters and lack of suitable childcare or the effects of rosters on child carecommitments made nursing an impossiblecareer path to follow. Many respondents wishto nurse, but could not perceive how tocombine nursing with family commitmentsunder the current nursing health care system.

5. Injury and IllnessMany respondents reported injuries or illnessesthat were both work-related and non-workrelated. The reasons why nurses leave work anddo not return reflects an inflexible professionthat does not allow nurses to continue to workby attending to alternative duties.

While some injuries did not occur at theworkplace, most did. This raises many issuesabout the working conditions of the nursingprofession:

What nurse doesn’t end up with a crook back forthe rest of their lives.

I am burnt out after ten years ... fed up withdeplorable hours.

I love nursing, but it seemed that every nurse Iknew had a back injury from excessive andphysically demanding workloads.

I sustained a permanent work injury contributedfrom poor equipment, staff shortages, heavy workload and poor working conditions.

If nurses’ workloads were less and hospitalresources were increased (staffing andequipment) perhaps nurses would not feel soexhausted and ‘burnt out’. This has put me offnursing all together.

Older nurses especially feel that the demandsof nursing are too excessive. Some of theserespondents have decided to retire early ratherthan risk injury or continue working in astressful industry:

I am close to retirement and do not wish for anymore injuries.

Too tired and drained from nursing, decided toretire.

I am 64 years of age and tired.

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Respondents who had work-related injuriesand illnesses reported that there was a lack ofsupport from their employer when they wereinjured:

In my first year of nursing, I hurt my back. Ireported this to my employer, however nothingwas done about it. I was not aware of my rightof WorkCover. I am disappointed and I doubt I’dever go back.

A lack of support was also reported by manyrespondents after the injury or illness hasoccurred (irrespective whether work-related ornot). These registered nurses would like tocome back but feel the workplace is notprepared for them and the managers are notwilling to offer alternative duties:

I was very disappointed at the treatment by myemployer after I sustained my injury. I am surethat after receiving such a permanent injurythere must be something I am capable of doing.However, I was told not to come back to work.We have been through the courts and it has beensettled, but still I am not welcomed back at work.

As I use a walking stick it is very hard to findemployment to suit my qualifications andexperience. I am a disabled nurse, ex-nurse.

There is no support or program for a personreturning to work after a injury.

I have cystic fibrosis and I am presently unableto work due to this health condition.

The combination of excessive workloads and theinability to provide adequate duties for injuredor sick workers have sent some registered nursesinto other non-nursing careers:

I am now in a job which is much more gentle onmy body and stress levels.

Work-related injuries are a by-product of theduties expected of nurses. Once injured or sick,there are few support mechanisms to aid theirrecovery and return to work. Respondentsreport problems potentially leading to injury(work conditions) which dissuades them fromcontinuing work. Also, nurses report a lack ofsupport if injured as a barrier for them toreturn to nursing.

6. Work Conditions andRemunerationUnsatisfactory work conditions andremuneration were important factors forleaving the nursing profession. Remunerationrefers to the tangible benefits gained fromworking (for example, salary and leaveentitlements). ‘Work conditions’ is a broadterm used to refer to:• The duties performed by the nurse• The environment in which the duties are

performed • The management under which the duties

are conducted.

Together, work conditions and remunerationhave a dynamic relationship, which ultimatelycontributes to nurses leaving the profession andnot returning.

Some nurses reported the current climate of thenursing profession is very discouraging:

I would never return to work whilst the publichealth system is in such a mess.

I have had a gutful of being treated asinexperienced or obstructive when my advice isignored because I am only a nurse.

When the Standards Monitoring Team visitedthe Nursing home at which I worked everyresident was given or made sure that they had atoothbrush, hair brush, soap, shampoo etc. Theseitems were then taken away and put back intostorage after the visit at the management’srequest.

No amount of money or pay increase is worthhaving to work in such discouraging andunsupported conditions. When care andcompassion for workers and patients is dispensedwith, the term ‘nursing’ becomes obsolete.Robots will do the job quite adequately.

I was told by my boss in the last restructure thatnurses are overpaid. He was a professor onabout $180,000 pa.

Many respondents believe that theremuneration received is not adequate for thework conditions they endure:

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The amount of money earned does not fit the jobdescription. We get physically, mentally andverbally abused and come away with less than atelephone company employee who sits on theirbottom answering phones. It’s ludicrous.

Physical and emotional demands of nursing aretoo high when compared to the low wages andlack of professionalism in the industry.

I have come to realise how suppressed youropinions become and how low your remunerationis for such a physical and mentally demandingposition.

Registered nurses reported that they were notgiven appropriate compensation for doingovertime, excessive workloads and sometimesnot receiving their award benefits:

I would stay back at least half an hour overtimeevery shift due to the heavy workload. I wasnever paid for these extra hours, nor was Ioffered any remuneration.

Nurses are treated like slaves. There is norecognition of our right to a meal break. We areexpected to work a full day, then be on call andforced to work the next even though we werecalled out during the night. My employerstopped paying penalty rates for working the dayfollowing overnight call-outs.

As usual a female dominated industry receiveslittle recognition and the rewards are poor.

One respondent suggests work conditions andremuneration in the nursing profession havenot moved with the times like otherprofessions:

I am unable to understand why conditions fornurses do not resemble those of the police, whoalso do shift work and deal with the public, butwith conditions (holidays, superannuation),which are light-years ahead of those in place fornurses.

Work conditions and remuneration seems to bean inverse relationship ... the pay for theamount of responsibility, hard work, pressureand risk to personal happiness (mental health)do not balance the equation. Registered nursesbelieve they do not receive benefits from theiremployers that reflect the work they do.

7. Employment Opportunities andEducationNurses’ responses highlighted a tensionbetween employment and education acrossDivisions. Division 2 nurses reported that thereis no accessible education path to increase theirtraining to the level of Division 1. Additionally,Division 2 nurses felt that their career is beingtaken from under their feet with theintroduction of Personal Care Assistants(PCAs).

Division 2 seems to be an unwanted registration.Pseudo caring certificates are underminingDivision 2. There is also a lack of recognition ofDivision 2 registration when applying toupgrade (sic) to Division 1 nursing courses.

Lack of education for Division 2 nurses tobecome Division 1 nurses.

Lack of opportunities for Division 2 nurses towork out of the nursing home structure.

Funded refresher courses for Division 2 nurseswill become extinct with PCAs taking theirpositions.

In the aged care sector nurses are being replacedby PCAs.

As a Division 2 nurse, there are not many jobsavailable as the PCAs can do the same job.

Conversely, Division 1 nurses feel they have toaccept less money because Division 2 nursesare being employed for jobs originally done byDivision 1. A similar situation is evident forDivision 2 nurses and PCAs:

Division 1 nurses jobs are not being protected,therefore we receive lower pay due to thecompetition with other divisions.

Most Division 2 positions go to PCAs for lessmoney.

We are leaving nursing (Div 2 Nurses) becausethere is no chance to advance nor is our abilityrecognised and our pay is less than a factoryworker or a PCA yet we have a qualification.

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Some nurses feel discouraged from furtheringtheir education as it is a personal expense anddoes not result in a salary increase. This leadsto less experienced staff working on the wards:

Lack of funded staff training results ininexperienced staff. Staff want to learn more butshould not have to pay for it from their ownmoney.

An inadequate quota of qualified and experiencedstaff results in stressful and unsafe workenvironment, especially in critical care.

Lack of support with regard to education. Nonurse educators for nursing staff especially fornew and junior staff. Therefore the workload onexperienced staff is excessive.

I am required to work some days in areas where Ihad little or no training.

Unrealistic/unreasonable expectations of nursesknowledge, expertise and skill with the absence ofcontinuing education.

Nurses feel their employment opportunities arelimited due to either a lack of practicalexperience and/or preferred employmentpositions:

I have spent five years at university and receivedexcellent results. However, I have found itimpossible to find a permanent position in mychosen field because I lack practical experience.This has destroyed my self-confidence. I work inmostly agency positions, which has not beensatisfying. Now I am at home with a baby and Iam concerned where my future in nursing is.

The only work available is in aged care nursing,which I do not find challenging enough.

Because of PCAs, Division 2 positions are nowonly available in aged care.

Agency is the only option for someone of mypractical experience.

Further, registered nurses living in rural areasreport limited access to job opportunities andtraining:

Living in isolated area, no job opportunities.

Rural women have limited opportunities andmany expenses.

There are no courses for Division 2 nurses tobecome more educated, especially in rural areas.

The rural area I’m now living in appears to havea policy of ‘in house jobs’, therefore jobs that maybe appropriate to me are not advertised publicly.I have no knowledge of vacant positions.

A tension between hospital and universityeducated nurses appears in nurses’ comments.Both parties are dissatisfied with the lack ofpractical experience of university trainednurses:

After doing my graduate year, I vowed never toreturn to nursing. Apart from earning moremoney as a telemarketer, I did not want to beabused for my lack of practical experiencebecause I was university trained.

Lack of self esteem caused by ridicule of hospitaltrained nurses, I am university trained.

In some institutions there is undue pressure forhospital trained nurses to get their nursingdegree. There has to be a balance of the twotraining systems.

Nurses who completed hospital-based traininghave double or triple certificates and many years’of experience should not be discriminated, justbecause they do not have a diploma or degree.They are all registered nurses and that is all thatmatters. This issue is a major factor for manynurses leaving the profession and must beaddressed.

I would suggest that serious consideration begiven to undergraduate nurse education—thereneeds to be much more time spent on clinicalplacements as I have worked with a number ofnew graduates who have discovered after theirthree years at university that they dislikenursing. This is not a matter of apportioningblame, but simply of giving undergraduatesmuch more “hands-on” experience, so that theydevelop practical ability along with theoreticalknowledge.

Registered nurses want to be educated andlearn more practical skills. In turn, workloadsmay be decreased and employmentopportunities may be available for others:

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Emphasise free refresher courses and on-siteeducation. Have ‘hands on’ nurses as managersbecause they understand the practicalities.

Training and education is an issue for furtherinquiry. Funded courses would be desirable asmost nurses wish to learn and improve theirskills. However, nurses do not want to pay forthese courses unless they perceive it will lead toincreased remuneration. In addition, nurseswant to be able to work in their chosen nursingarea after the completion of these courses.

8. Professional RecognitionNurses perceive they receive little respect andrecognition for their skills. Nurses’ commentsabout this issue reflect a great degree ofdisappointment:

Lack of opportunity to practice nursing withautonomy. Nurses are capable of making theirown nursing judgement. We are not justdoctors’ handmaidens or hospital dogs.

Listen to what the nurses tell you, not the CEOand certainly not the government, none of whomhave any grasp of the true needs of ongoinghealth care.

My career adviser in high school summed it upperfectly–—if you want to be a professional andtreated as one, do occupational therapy, notnursing.

Nurses need to have professional recognitionwith continuous opportunities for furthereducation and professional status, remunerationmake us independent practitioners not a slave.

Nurses over the age of 50 years have been treatedbadly in the last 8–10 years. They feelunwanted, lack respect from senior staff andtheir experience is not valued.

Morale is very low amongst nurses, and the waythe workload is organised, staff tend to have to“compete” to access resources/equipment ratherthan working as a team.

The devaluing of nursing, as a profession is apart of economic rationalism. Nurses feel thathumanity has been removed from theirprofession:

Employers should be recognising their nurses forthe valuable work they do, and begin to treatstaff as people, not just numbers on a computer.

Nurses need to be valued more for what they dowith better pay conditions and improvedmanagement (very poor quality at the moment).The economic rationalist approach has taken theheart out of the health care settings.

Nurses are turning away from their professiondue to lack of respect, money and support fromgoverning bodies, such as the Nursing Board.Other professional areas are attracting nurses’attention away from nursing because of the waythey are treated.

As a solution, nurses are asking for increasedrespect, support and remuneration:

Nurses provide essential service in thecommunity for very little return and support.Look after nurses and they will look after you.

Nurses will come back to work when it is seenthat people are more important than money.

9. Job Satisfaction and OtherCareersA non-‘family friendly’ occupation, lack offlexibility, poor working conditions, injury,illness, displacement and lack of recognition willultimately lead to poor job satisfaction. In effectpoor job satisfaction will lead registered nurses‘who were once inspired’ to begin careers inareas that offer more than a career in nursing.

Job dissatisfaction is created by a multitude offactors previously discussed but also clearlylinked to understaffing, inability to spend time‘caring’ for patients, and increasedadministration workloads:

There is very little job satisfaction due to poornurse/patient ratios, impossible cost cuts anddifficult rosters. It is not possible to give goodcare any more.

I have lost what little faith I had left in themedical profession to actually help sick andinjured people to help themselves. Nursing isnow a job for conformists, scapegoats and non-questioners. I no longer fit into these categories(thankfully!). I thought that nursing wasunethical.

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Nursing now seems to be orientated aroundadministration. There is more emphasis on whatis written than what is actually done for thepatient. Give us the time to put caring back intonursing.

Nursing now seems to be so administrativelyimportant, there is more emphasis on what iswritten than what is actually done for thepatient. I know reports are very important. Itseems that the solution is more nurses perpatient—give us time to put the caring back intonursing.

I didn’t know the culture of loving care had beenreplaced by a culture of pseudoentrepreneurialism.

More emphasis required on basic nursing careand documentation to be kept to a minimum toenable the care to be carried out.

More clinical staff may help unnecessaryduplication of paper work. If I wanted to be asecretary, I wouldn’t have chosen a career I haveloved—Nursing.

Many nurses feel patient care now comes secondto paperwork. Originally, nursing was a handson job. These days, patients lose valuable time oncare because staff are busy filling in forms to getthe much deserved funding we need.

In summary, registered nurses are lookingtoward other careers due to poor jobsatisfaction and stressful working conditions inthe nursing profession. The feelings expressedidentify overlapping problems:

It is very tempting to abandon nursing for otherprofessions where stress is lower andmanagement support is higher.

I’m now in a job which is much more gentle onmy body and stress levels. Work conditions areexcellent in comparison, and my trainee wagewith this job is more than I ever earned in my 10years of nursing. I have no desire to return tonursing. I kept my registration just on the offchance that if conditions change I might nurseagain.

I have undertaken studies in a completelydifferent field, for a job which gives me fargreater personal satisfaction and pleasure than Ifound in nursing.

My current job is so much better.

I have no desire to nurse again. I have kept myregistration on the off chance that I may nurseagain, but I doubt it very much. There are toomany better opportunities out there for women.I can see that there will be a huge shortage ofnurses in the future.

10. ConclusionThe themes discussed are the most prominentlyexpressed opinions of the respondents. Manycomments reflect a combination of themes,especially respondents who attached additionalletters to their survey.

Many registered nurses expressing discontentand frustration with the nursing arenacommented that this survey was long overdue.Nurses were also thankful for the NurseRecruitment and Retention Committee fortaking interest and allowing them to ‘speakout’:

Thank-you for the opportunity to comment onthe survey. I would volunteer more informationif needed.

I feel very concerned about the current nursingconditions and was very grateful that this surveyarrived in the post last week.

Others articulated that the survey was notenough to make change, and what was requiredwas a further in depth account of personalexperiences in the nursing domain.

I really do not think that this type of survey willprovide sufficient information to developprofound change in the recruitment andmaintenance of the nursing profession.

There is no singular reason why nursescontinue not work, but rather a multitude offactors that seem to be common to mostparticipants. The consensus of respondents’opinions are that nursing no longer has a focuson ‘caring’ and interacting with those who arein need.

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Many survey participants believe that nursingis now an unsatisfactory profession because ofexcessive workloads, physical and mentalstrain, unpleasant work environment, poorsalaries, and lack of compassion. For thesereasons nurses choose not to work until theycan begin to refocus on caring for patients witha more humanistic approach.

Keeping registration is largely seen as afinancial safety net. If conditions change in thenursing arena, many would consider returningto work as a registered nurse.

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155

Nurse Recruitment and Retention Committee

Issues Arising from

Public Forums in June 2000:

An Overview

Prepared by URCOT,

July 2000

Appendix Five – Report of the Open ConsultationForums

156

Contents

Executive Summary ....................................................................................................................................................157

Introduction ....................................................................................................................................................................158

Issues Affecting Recruitment and Retention ................................................................................................158

1. Education..........................................................................................................................................................158

2. Resources and Workloads ........................................................................................................................159

3. Workplace Change ......................................................................................................................................160

4. Nursing Management ..................................................................................................................................160

5. Pay, Role and Career Issues......................................................................................................................160

6. Balancing Work and Life Priorities........................................................................................................161

7. Quality Issues and Community Perceptions........................................................................................162

Conclusion ......................................................................................................................................................................163

Acknowledgements

This report has been prepared by Dr Bruce Wilson, URCOT. It is based on data gathered at PublicForums of nurses, which were facilitated by Bruce Wilson and Robyn Dale. Thanks are due to themembers of the Project Team who assisted with the organisation and the conduct of the forums, toProfessor Margaret Bennett and Ms Ann Turnbull, members of the Committee who chaired theForums, and to all the nurses who attended and contributed to the Forums, or otherwise submittedtheir feedback in writing.

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Executive Summary• This document reports on the issues arising

from the public forums targeted at nursesemployed at Grade 4 and below, conductedat four metropolitan and six rural sites onbehalf of the Nurse Recruitment andRetention Committee.

• Compared with the reports from each of theindividual forums, this report presents amore thematic and interpretative account,seeking to understand some of theunderlying issues that shaped the commentsmade in the forums.

• The Committee obviously faces aconsiderable challenge in addressing theissues of concern to nurses. There are arange of complex factors that shape thestructure and resourcing of the healthindustry, as well as the social context fromwhich its workforce is drawn.

• The economic and cultural forces shapingnurse recruitment and retention will bedifficult to address through public policyalone, especially when resources are limited.However, recognition of the complexitieswill be important in gaining support fromthe various stakeholders for the morespecific initiatives that governments cantake.

• In every forum, participants raised aconsiderable number of issues about nurseeducation, including undergraduate,

postgraduate and refresher programs.Underpinning many of these comments wasa fairly deep-seated resentment at theimbalance between a clear expectation andpressure for nurses to be pursuing ongoingeducation, and the minimal supportprovided in relation to leave or money.

• Nurses have been affected very severely bythe reductions in resources for generalpatient care in the health care environment.

• Workplace change in the health care systemappears to have been driven by alterationsto funding arrangements, rather than a focuson work processes.

• At several forums, there was substantialcriticism of nurse management. Put simply,nurses believed that there was a lack ofsupport and respect from management.

• Nurses felt that they were underpaid andaccordingly undervalued.

• Nursing is a highly gendered occupationand many of the women who participated inthe forums raised issues that reflected theirconcerns about balancing work and otherresponsibilities.

• Many nurses have suffered a crisis of identityand loss of faith in their capacity to deliverwhat is expected. Questions about theunderlying issues of leadership, identity andquality of care also need to be addressed.

IntroductionThis document reports on the issues arising fromthe public forums targeted at nurses employedat Grade 4 and below, conducted at fourmetropolitan and six rural sites on behalf of theNurse Recruitment and Retention Committee.The forums were introduced by members of theCommittee, and attended by between 27 and 165people. Nurses from all Divisions and all Gradeswere represented at one or the other of theforums. Evidence was recordedpublicly on awhiteboard; and participants were invited torespond to a set of questions in writing duringthe forum, and to hand them to the facilitator ifthey felt that their views were not expressedadequately during the forum.

On a few occasions the forums were taped.Reports were prepared from each of theforums, summarising the issues and theirimplications for recruitment and retention.

While most of the forums were held in healthcare environments, nurses from variouslocations attended. These included nurses frominpatient and from community health settings,from agencies and from the Royal DistrictNursing Service. Quite a few nurses droveconsiderable distances from other centres orhealth care environments to attend the forumsconducted in rural settings.

This document presents an overview of themajor themes and issues that have emergedfrom the forums. While the reports from each ofthe individual forums has been organisedaround the particular Terms of Reference of theCommittee which had featured prominently inthe forum, this report presents a more thematicand interpretative account, seeking tounderstand some of the underlying issueswhich shaped the comments made in theforums.

Issues Affecting Recruitmentand RetentionThe forums were conducted in an open manner,with participants being encouraged to take upany aspect of the Committee’s Terms ofReference. Where possible, the discussion wasmanaged to bring some coherence to thedialogue and, on other occasions, people wereprompted to address particular topics that had

not yet been considered. Specific promptingquestions were used to explore apparentcontradictions or ambiguities and to bringgreater depth to the insights being generated.At times, the forums generated considerablepassion, even anger, and a sense almost ofdesperation in relation to the need for change.At other times, the mood was quieter and morequestioning about possibilities for change.

Another perhaps tentative observation aboutthe forums might be that the geographiclocation and the quality of the health careenvironment seemed to influence the nature ofthe discussion and the positive or negativenature of the contributions. In general, nursesin the rural and more modern health careenvironments had more to say about theprofessional issues under consideration by theCommittee, whereas industrial issues tended tohave more prominence in the metropolitan andolder sites.

The Committee obviously faces a considerablechallenge in addressing the issues of concern tonurses. There are a range of complex factorsthat shape the structure and resourcing of thehealth industry, as well as the social contextfrom which its workforce is drawn. Theeconomic and cultural forces shaping nurserecruitment and retention are difficult toaddress through public policy alone, especiallywhen resources are limited. However,recognition of the complexities will beimportant in gaining support from the variousstakeholders for the more specific initiativesthat governments can take. Some of thesecomplexities are raised in the followingdiscussion of the issues.

1. EducationIn every forum, participants raised aconsiderable number of issues about nurseeducation, including undergraduate,postgraduate and refresher programs. Many ofthe issues were quite specific, referring topractical problems such as the costs of variouscourses, geographical access, number of places,and difficulties in getting study leave.

Underpinning many of these comments was afairly deep-seated resentment at the imbalancebetween a clear expectation and pressure fornurses to be pursuing ongoing education, and the

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minimal support provided in relation to leave ormoney. It was not uncommon for nurses toindicate that undertaking a postgraduatequalification had cost them up to $20,000, incourse fees, foregone income and travel costs, withone nurse claiming as much as $50,000 had beenspent in obtaining her qualifications. Theirresentment was exacerbated by the lack of anyacknowledgement by their employers, monetaryor even professional, once they had completed thequalification.

Balancing the resentment about costs was therecognition that the health industry was subjectto rapid change, especially in relation tomedical research and the introduction of newtechnologies. Many nurses were positive aboutthe importance of continuing to build theirexpertise, so that they were well equipped tosupport new forms of treatment for patients.

It seemed that this situation was more difficultfor rural nurses rather than metropolitan. Ruralnurses were concerned about the quality ofcontinuing education in rural areas (did theyget educational support equivalent to those inthe city), and the general commitment toproviding continuing education.

Undergraduate education was a source ofconsiderable angst, manifesting itself in twokey issues. Firstly, the general lack of clinicalexperience available to student nurses, with theconsequence that they were clearly unpreparedfor employment as independent nurses on thewards. The second issue was the implicationsof students undertaking broadly-basedcurricula, rather than offering the opportunityfor specialisation through a specialist directentry model.

These two issues reflect a continuingunderlying tension between the commitment touniversity-based programs which provide thetheoretical base for nurses to develop anindependent professional identity, and healthcare-based experience, which provides a muchmore practical grounding for nurses to workwith patients. It reflects different visions aboutthe role of nursing in the health industry.

Much of the criticism of university-trainednurses was based on their lack of readiness totake a full load immediately they wereemployed as graduate nurses. In the current

circumstances of limited resources, health careproviders find it difficult to provideappropriate supervision and support forgraduate nurses. Even though they might beready to learn how to apply their expertise,once employed in a health care environment,they still need a phased period of inductionand support. This can be a source of additionalpressure on established nurses, given thedemands of the current working circumstances.There was some concern that new graduatesare too much at risk of encountering incidentsthat would undermine their confidence forever.

A similar philosophical difference arose inrelation to psychiatric nurses, who wereconcerned about the lack of opportunity forstudents to experience psychiatric clinicalsettings during their undergraduate studies.They felt that it meant that graduate nurseswere completely unprepared to work inpsychiatric settings, threatening the supply ofnurses to what they regarded as a quite distinctfield, requiring specialist training.

2. Resources and Workloads All the forums provided evidence that nurseshave been affected very severely by thereductions in resources for general patient carein the health care environment. There were anumber of dimensions to this issue.

Firstly, the cost constraints meant that therewere simply not enough nurses to provide adecent quality of patient care. Nursesrepeatedly told stories about how they wereunable to do the little things, such as helppatients to eat, to clean their teeth, to wash, thathad always been part of the care provided.Secondly, in some cases, there were insufficientresources to supply basic equipment ormedicines, such as pillows or ventilators.

Unit managers are seen sometimes to bepreoccupied with containing costs rather thanaddressing quality of care issues. Perhaps moreseriously, in the absence of there being enoughstaff, junior staff were being pushed to seniorlevels without the education or the experiencerequired to respond appropriately to thecircumstances which they might have to dealwith.

While some health care environments have

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adopted particular strategies designed toprovide a more strategic and objective basis forallocating nurse workloads (such as theTrendcare patient dependency tool), they didnot appear yet to have won the confidence ofnurses. While there were some who felt thatthese technologies were a step in the rightdirection, they did not provide acomprehensive framework for assessing therange of tasks expected of nurses.

3. Workplace ChangeBased on the views expressed in the forums,workplace change in the health care system hasbeen driven by alterations to fundingarrangements, specifically casemix, rather thana focus on work processes. This has meant thatcost containment has been the focus, withwards being merged and spans and layers ofmanagement being restructured so thatworkplace relations are being reordered. Itappears that much of this change has beenundertaken without recognition of theimportance of the ward relationships to nurses,and without any consultation or otherinitiatives to draw on their expertise..

As workplace reform has had this focus, therehas been a corresponding failure to review evensimple work practices (such as basicobservations) that might have been in place formany, many years. While there have beenoccasional experiments with various kinds ofstaffing structures, there has not been anyserious commitment to the kind of processredesign which might significantly improvenurses’ working environment, and achievegreater efficiencies in health care systems.

From comments made in some of the forums,workplace change has not typically involved achallenge to the underlying power relations inthe health care systems. This has meant that themedical dominance of doctors continues tocontrol nurses’ working environment andprofessional practice, without adequaterecognition of the potential role which nursescould fulfil (as independent practitioners, forexample), given the benefit of their increasededucational standing. In some rural settings, inparticular, nurses expressed some concernsabout the ways in which their services wereused by doctors, given an ambiguity in the

management of public and private healthprovision.

In these circumstances, it seems that manynurses are saying that they can see few benefitsfor them emerging from the kind of workplacereform that has occurred over the past decade.It seems that the love of nursing is notsufficient to balance the consequences of all ofthe forced changes in the profession.

4. Nursing ManagementAt several forums, there was substantialcriticism of nursing management. Put simply,nurses believed that there was a lack of supportand respect from management. This wasexemplified in comments about the lack ofconsultation by management with nurses overproposed changes in the workplace. It was feltthat nurses’ expertise was often simply ignored.There was little open communication fromhealth care management, and nurses regularlyencountered decisions which, in their view, didnot demonstrate an understanding of the valueof bedside nursing.

Increasingly, it was felt that even thosemanaging the nursing workplace hadinsufficient understanding of the pressuresnurses were experiencing, and failed torepresent nurses’ interests adequately inmanagement forums. Many nurses felt thatmanagement had unrealistic expectations ofnurses, given the resources available.

Given the kinds of changes that have occurredin the health system over the past decade, itwould seem that a range of managementdecisions and strategies have been poorlyfounded. Irrespective of the pressures thatmanagers have been under themselves (andmany of these were noted also in the forums,especially workloads), some key principles inmanaging staff constructively appear to havebeen neglected.

5. Pay, Role and Career IssuesAt the core of the consultation process, nursesfelt that they were underpaid and accordinglyundervalued. The pay issue was raised indifferent ways and terms. For example, oneparticipant made the blunt assessment that therelativities had declined, making other careersmore attractive. Another view was that the way

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in which pay and career options werestructured gave nurses no incentive to pursue anursing career.

Even more simply, the pay was not enoughcompensation for the work nurses wereexpected to put in. There was a widespreadview that nurses had been expected to assumeincreased responsibilities that had beenmatched by little or no financial recognition.

There was some discussion about theeffectiveness of the restructured professionalcareer structure, specifically the opportunitiesassociated with Clinical Nurse Specialists(CNS). In most cases, the CNS positions werevalued as a tangible means of providing acareer option for nurses who wished to stay atthe bedside. However, a number of issues hadarisen in almost all sites. These included thedifficulties in gaining access to CNS positions.In some cases, it appeared that appointmentshad been curtailed as a means of reducing coststructures, while in others, there was aperception that some parts of the health careenvironment were neglected in the allocation ofCNS positions.

For those who were successful in gaining theappointments, it was sometimes felt that theworkload was excessive, and that they wereexpected to give up too much of their own timeon project activities. There was some ambiguityalso about how decisions about project topicswere made, and about the use of the projectresults. Another constraint was that if a nursewished to change their employment, he/shewould have to reapply for a CNS position inthe new organisation. While the CNS positionswere accepted as a positive step in the rightdirection, there was still a widespread view thatthere needed to be a clearer career structure forclinical nurses.

As mentioned previously, there was significantconcern about the lack of recognition ofpostgraduate qualifications, especially giventhe investment that nurses, and sometimes thehealth care environments, had to make inacquiring the qualifications. It was generally asource of considerable disquiet that nursescould not gain any direct career benefit fromtheir studies.

There do appear to be a range of tensionsunderlying these discussions. Many nursesappear to have views about career structuresthat imply a clear maintenance of a hierarchy inpay and status, even in bedside nursing, at atime when most organisational change ispromoting flatter structures and forms of careerplanning which involve lateral movement asmuch as vertical.

On the other hand, nurses’ expectations thatthey should get additional compensation forgaining additional qualifications is quiteconsistent with the implementation of flatterstructures, providing that they are relevant to anurse’s work performance. Perhaps a morethoughtful approach to resolving these tensionscould be promoted within the context of a moreopen and inclusive discussion about workplacereform.

One other dimension of the debates over careerstructures again concerns different views on thebalance between general and specialist nursing.While psychiatric nurses were the most vocal inpromoting the need to recognise the specialcircumstances of that nursing field, there was amore general debate about the extent to whichnurses should be encouraged to specialise,especially given the pace and increasingly(technologically) sophisticated dimension ofmedical treatments.

Rural nurses were alert to this debate, but feltthat in many rural health care environments,nurses had to be generalists. While they mightstill develop specific areas of expertise, theyhad to be able to deal with any circumstancesthat presented themselves.

6. Balancing Work and Life PrioritiesWhile balancing work and life is anincreasingly important issue in manyindustries, it has particular significance fornurses. Nursing is a highly genderedoccupation and many of the women whoparticipated in the forums raised issues thatreflected their concerns about balancing workand other responsibilities. This was especiallyimportant in rural areas, where a very highproportion of the nursing workforce wasemployed part-time.

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There were some important consequences. Formany participants, it was apparent that nursingwas their second priority, possibly beingundertaken to add a second wage to the familyincome. They suggested that improved accessto child care, and to car parking, would make areturn to nursing after having had children thatmuch easier.

They also raised issues about the structure ofshifts, showing some interest in shorter shifts,and greater flexibility in shift times (morechoices that the standard eight or ten hourshifts). It should be noted, however, that thequestion of shift structures was debated in avery heated fashion. Many participants felt thatthe various modifications to shift structuresalmost always meant that an additional burdenfell on the shoulders of the ongoing full-timenurses, especially in relation to paperwork, andother less desirable tasks. There was somediscussion about the potential value of self-rostering. While some small, stable teams hadmanaged their rosters themselves, the generalmood about these arrangements was cautiousand most participants were inclined to expectdifficulties in self-management amongst largergroups of staff.

Many nurses clearly experienced considerablestress in combining a commitment to their paidemployment with the flexibility to spend timein caring for their children. On severaloccasions, it was apparent that it was verydifficult for some nurses to resolve these issues.One particularly moving response was givenwhen the following question was asked:

Facilitator: ‘When I asked about working andthe stresses affecting your life,there was energetic nodding; tellme what that was about?

A nurse: ‘I’ll tell you. I’ve got a nine-year-old who won’t go to schoolbecause he hasn’t done hishomework. He hasn’t done hishomework because I’m not thereto help him. I’m not there becauseI am here, working. I am staying atwork later—there are fewer staffand other things need to be done.When I ring work from home, mykids say that I would rather be at

the big house than the little house.I need to ring the big housebecause I am worried about adying patient. I feel the tensionsfrom both houses. I can’t give mychildren what they need because Iam here.’ (Ballarat).

These tensions need to be managed, and thereare very few resources available in health careenvironments to provide the extra support forthose people who struggle with these kinds ofuncertain responsibilities. It would be mucheasier for this nurse if she could leave thehospital knowing that her patients wouldcontinue to be cared for with the same attentionthat she herself would provide. However, shecannot, partly because of a lack of otherexperienced nurses, and partly because ofstaffing levels.

This issue is a very good example of thecomplex interaction that can occur between theprofessional domain of nursing and the broadersocial context from which the predominantlyfemale workforce is drawn.

7. Quality Issues and CommunityPerceptionsTaken together, many of the difficulties facedby nurses in the current environment lead toconsiderable concern about their capacity toprovide the quality of care which they want togive, and community perceptions about thehealth system and the nursing profession. Thegreat majority of the written responsesprovided in the forums indicate the extent ofnurses’ commitment to caring for people, andto serving the community. Many entered theprofession because they saw it as a respectedrole.

The current crisis in health care has generated amuch deeper problem for nurses than isreflected in the obviously practical problemsthat result from a lack of resources. When youput the following problems together, manynurses are left wondering whether they canprovide the level of care they had alwaysunderstood, from the earliest days of theirtraining, to be their obligation, and to whichthey still aspire. These problems include:

• Fewer nurses to share the workload.• Roster allocations which mean that nurses

have more disjointed connections withparticular wards.

• A structure of funding which has lead tomany patients being in hospital for shorterstays (and leaving before they are clearlywell).

An important dimension of nursing ismanaging relationships with patients,responding to their social and personal needsand offering a measure of dignity in spite of theconsequences of illness. This is very hard tomanage in the current environment, with theconsequence that many nurses have suffered acrisis of identity and loss of faith in theircapacity to deliver what is expected.

This tendency is reinforced for many nurses bytheir experiences with community reaction.This is not just their sense that theircontribution to health is not adequatelyrecognised or valued in community opinion, itis manifest in their very direct experience ofaggression and abuse on the wards (especiallyin accident and emergency situations). Bothpatients and family members blame nurses forhaving to wait for treatment, or for any otherreason that has disrupted their expectations inregard to immediate ‘customer’ service. Andthis might come when nurses are alreadyexhausted from their workloads, perhaps evenat the end of a double shift that they haveworked because there are simply no othernurses available. These circumstances seem toresult from a pattern of unrealistic expectationsand to reflect a lack of respect from thecommunity, even in rural areas.

The workplace violence which results frompublic aggression are matched to a significantdegree by ‘horizontal’ aggression amongstnurses themselves. While this is much lesslikely to be physical, it can nevertheless be justas demanding on the personal resources ofnurses who are already stretched to the limit.

ConclusionThe issues that emerge in the discussion aboutproviding an appropriate quality of care doreflect a significant under-resourcing of healthservices. However, it is also the structure ofhealth care that has changed. Nurses have beenalmost systematically excluded from making aneffective contribution to the direction of change(the lack of consultation in the workplacereform process), and have suffered also from avery significant lack of leadership inunderstanding and exploring how the role ofnursing is changing. What are the professionalexpectations of nurses in providing anoutstanding quality of care in the contemporaryhealth system, and how can they be resourcedto deliver? This question appears to be centralto the challenge facing the Committee.

The great majority of respondents said thatthey would not encourage people to enter orreturn to nursing until there had beensignificant changes made. Some did supportincreased promotion of nursing in order toinfluence public opinion about nursing. Otherswere prepared to offer quite specific andpractical suggestions that would enhance theprospect of remaining in nursing, and ofattracting nurses to return. Some of thepractical suggestions unquestionably offersound ideas about career structure, education,nursing management and, fundamentally,about pay.

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Nurse Recruitment and Retention Review

Appendix Six – Report of the Focus GroupConsultation

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Executive SummaryQualitative focus group research was conducted in July 2000 among nursing students and thecurrent and lapsed nursing workforce. The research sought to gain, first hand, issues andconsiderations impacting on recruitment and retention of nurses.

There is a perception among nurses that it is, quite simply, becoming harder to do their job. Thepressures of increased acuity of care, inadequate staffing numbers and lack of support systems havebecome the realities of nursing. Added to this is perceived inadequate remuneration and limitedcareer paths. Not surprisingly, a high proportion of nurses report that, within the next 5–10 years,they will either leave or scale back their participation in the profession. This intention is expresseduniformly across the various nursing segments researched.

There is a clear sense by many of being ‘trapped’ in their jobs. We suspect departure rates from theprofession may in fact be higher if perceived exit barriers (or barriers to switching) were lower.Many nurses are clearly dissatisfied, but stay in the profession simply because they see no way out(that is, they are unsure of what else to do or earning potential elsewhere).

Finally, there is a feeling among nurses of being isolated in term of their grievances:• Nursing management does not champion their cause for improved conditions and recognition

for their contribution.• The public generally has limited understanding or appreciation of nurses’ role/working

conditions.• Government continues to cut health funding, with any shortfalls expected to be ‘picked up’ by

nurses.• The issues/concerns expressed in the groups have all been said before and there has been no

resolution.

Each of the above reinforces the strong perception among nurses of being undervalued. It is clearfrom this research that the current levels of departure from the industry are only likely to increase ifmeasures are not taken to address the range of issues outlined above. In particular, the issues thatimpact on nurses’ fundamental ability to perform their jobs is a clear priority for action.

Remuneration is the tangible recognition of your contribution to the workplace. Thus, whendiscussing remuneration, the issue for nurses is bigger than just a salary gap. The concern is thefundamental belief that nurses are undervalued.

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Contents1. Introduction ..........................................................................................................................................................168

1.1 Background ..................................................................................................................................................168

1.2 Research Objectives ................................................................................................................................168

1.3 Research Method ......................................................................................................................................168

1.4 Respondent Profile ....................................................................................................................................169

2. Detailed Findings ............................................................................................................................................170

2.1 Role of Nursing ..........................................................................................................................................170

2.2 Overall Satisfaction with Nursing as a Career ..............................................................................171

2.3 Key Reasons for Departure from Nursing ........................................................................................178

2.4 Nursing Advocacy......................................................................................................................................178

2.5 Future Intentions ........................................................................................................................................179

3. Segment Findings ............................................................................................................................................180

3.1 Grades 2/3 Nurses......................................................................................................................................180

3.2 Division 2 Nurses ......................................................................................................................................182

3.3 Midwives ......................................................................................................................................................184

3.4 Mental Health Nurses ..............................................................................................................................186

3.5 Graduate Nurses ........................................................................................................................................189

3.6 Undergraduate Students..........................................................................................................................191

3.7 Community Nursing ..................................................................................................................................194

3.8 Agency Nurses ............................................................................................................................................195

3.9 Unregistered Nurses ................................................................................................................................197

3.10 Rural vs City Nursing ................................................................................................................................200

4 General Recommendations ........................................................................................................................201

5. Appendix—Discussion Guide

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1. Introduction1.1 BackgroundThe number of nurses working in Victoria hasbeen declining at an increasing rate, with thenett loss in 1998 alone being some 2,700 nurses(source – Department of Human Services Nurselabour force projections 1998–2009). While theactual numbers are at a sufficient level to meetcurrent demands, there are very realdistribution problems in some geographic andspecialty areas.

In response to concerns relating to practicepatterns and supply projections, the VictorianGovernment has introduced a number ofinitiatives to bolster the industry.

These include:• An extra $26.9 million spent over four years

on a recruitment and retention package toaddress the shortage of nurses in thehospital system.

• The establishment of the Nurse Recruitmentand Retention Committee (NRRC) tourgently report on issues contributing to thecurrent shortages.

In preparing their submission to the Ministerfor Health, the NRRC is seeking direct inputfrom nurses on issues perceived to be havingan impact on the industry. Hence, this proposalis in response to a request for target marketresearch focusing on the areas of education,attraction and recruitment and retention ofnurses in the State.

1.2 Research ObjectivesThe overall objective of this study was toprovide the NRRC with specific andcomprehensive feedback on nursing issuesacross the State as perceived by existing andundergraduate nurses.

The research was required toidentify/understand, across all nursingcategories, the:

• Drivers (or motivations) for becoming anurse.

• Ongoing motivations to stay in nursing.• Expectations (or needs) from a career in

nursing— what role do they play incommunity, what value does the communityplace on their profession?

• Satisfaction with the nursing profession.• Appeal of, and/or satisfaction with,

specialty areas.• Perceptions of differences in practising in

metropolitan and rural areas.• Perceptions of reasons for leaving the

profession; and• Specific actions or steps required to increase

retention rates (probe beyond remunerationand working conditions).

1.3 Research MethodQualitative focus groups were conducted onthe basis that they were the most suitableavenue for covering the breadth of issuessurrounding nurse recruitment and retention.

In total, eight categories were identified forinclusion in the study:1. Grade 2/3 nurses (Divisions 1 & 3)2. Division 2 Nurses3. Mental health nurses4. Midwives5. Graduate nurses (mid-graduate year)6. Undergraduate students7. Agency nurses (metropolitan only)8. Unregistered nurses (metropolitan only)

Given the focus on both metropolitan and ruralissues, each of the above segments (with theexception of agency and unregistered nurses)were covered in both regions to enablecomparison and contrast on the range ofnursing issues.

Given the skew in nursing numbers towardsDivisions 1 to 3 (and in particular, Division 1)the numbers of groups among this segmentwere boosted relative to other categories.

The table below summarises the groupstructure:

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Number Category Location

1. Grade 2/3 nurses Metropolitan

2. Grade 2/3 nurses Metropolitan

3. Division 2 nurses Metropolitan*

4. Mental Health nurses Metropolitan

5. Midwives Metropolitan

6. Graduate nurses Metropolitan

7. Undergraduate students Metropolitan

8. Agency nurses Metropolitan

9. Unregistered Metropolitan

10. Grade 2/3 nurses Rural

11. Division 2 nurses Rural

12. Mental Health Rural

13. Midwives Rural

14. Graduate nurses Rural

15. Undergraduate students Rural

* Two separate mini-groups were conducted – One group withhospital educated Division 2 nurses and another with TAFE edu-cated Division 2 nurses

Metropolitan groups were conducted at aResearch Facility in Elwood, Melbournebetween 12 – 27 July 2000. Rural groups wereconducted in Shepparton between 18–19 Julyand in Ballarat on 25 July with undergraduatenurses.

Each group lasted approximately 1.5–2 hoursand contained up to nine respondents. Anincentive was paid to each respondent forattending.

Key Recruitment Criteria for each segment was:1. Grade 2/3 nurses (Divisions 1 & 3):

50:50 Grade 2 vs 3, 50:50 community vshospital-based.

2. Division 2 Nurses: 50:50 community vs hospital-based. Mix ofhospital educated and TAFE educated.

3. Mental health nurses:Work predominantly as mental health nurse.50:50 community vs hospital-based.Mix of those who were initially educated asmental health nurse vs specialised later.

4. Midwives: Practicing midwives only. 50:50 communityvs hospital-based.

5. Graduate nurses (mid-graduate year): In 1st year of study.

6. Undergraduate students: In 3rd year of study.

7. Agency nurses: Work full-time as agencynurse. Mix/ cross-section of nursingcategories.

8. Unregistered nurses: Have allowed nursingregistration to lapse (either consciously orby default).

1.4 Respondent ProfileA total of 107 nurses participated in the focusgroups across Melbourne, Shepparton andBallarat. The majority of nurses were female(n=95), with just over one in ten respondentsbeing male (n=12).

Division 1, 2 and 3 nurses worked in a spreadof organisations, including:• The Alfred Hospital• Goulburn Valley Health• Mercy Hospital for Women• Monash Medical Centre• Royal Children’s Hospital• St George’s Hospital• St Vincent’s Hospital• Wangaratta and District Base Hospital• Western Hospital, Footscray

Mental health nurses worked in the followingorganisations:• Doveton Community Care• Dandenong Hospital• St Vincent’s Hospital• Melbourne Health – Royal Melbourne

Hospital• Goulburn Valley Base• Numurkah District Hospital

Midwives worked in the followingorganisations:• Moorabbin Birthing Centre – Monash

Medical Centre• Frankston Hospital

Undergraduate nurses attended the followinguniversities:• Monash University• LaTrobe University• University of Ballarat

Agency nurses worked with the followingagencies:• Medistaff• Care Nursing Agency• Code Blue• Staffing Australia

Participants came from a broad geographicalsection of Melbourne (and surrounding areasfor the rural groups). Where available, suburbof residence can be separately supplied.

Drop-Out RatesInitial recruitment for the groups targeted ninepeople per session, in order for eight to attend(an expected drop-out rate of one per group isthe norm in market research). However, afterthe first few sessions, the drop-out rate for thisproject was significantly higher than the norm,with early groups averaging only sixattendants.

When later investigated, the vast majority ofrespondents who failed to attend reported lastminute changes to rosters or having to stayback and work overtime as the reason for non-attendance. Of note, this encroachment of workinto private life is widely mentioned in thegroups as an issue for nurses.

A few were unable to attend due to unforeseenfamily circumstances. Specifically, two peoplecontacted had sick children and another had afamily member in an accident.

2. Detailed Findings2.1 Role of NursingInitially in each of the groups an understandingof motivations to become a nurse are probed.This section provides interesting insights intothe extent to which people are aspirationallyattracted to the profession (as opposed to ‘it’s ajob’).

The research reveals that nursing is more likelyto be an optional career choice (that is, chosethis in preference to something else, but notparticular desire to become a nurse), rathervocational.

Why Are People Attracted to Nursing?

The majority of people fell into nursing ratherthan actively selecting it as their career choice.For most it was ‘something to do’ and appealedon the basis of not being a desk job. For thosewho had been in nursing longest, it is oftendescribed as one of limited options available tothem (most in their peers either becameteachers or nurses). There was at least oneperson in each group who had family innursing (often a mother) which influenced theirchoice.

More recently, since nursing has become adegree, there are those who choose nursing asan entry point to another profession (that is,had the university entrance scores for nursing,but not their preferred profession).

Nursing initially appeals for a variety offactors:• Portability—you can travel within Australia

as well as worldwide and will always findwork as a nurse

• Security—perception that there are alwaysjobs available in nursing. Additionally, thereis a perception of transparent entry and exitbarriers to nursing (that is, can leave forperiods of time, for example to have afamily, and can easily return).

• Flexibility—in terms of shiftwork (althoughit is also a negative aspect of nursing).

• Rewards of helping people.• Being paid from the first day of training in

the hospital system.

Why Do People Remain in Nursing?When discussion of ongoing motivations forstaying in nursing is explored, it is clear thatthe ‘shine’ has gone off many of the factorsdetailed above. Significantly, many nursesdescribe themselves as being ‘stuck in a rut’and lacking vision or motivation to changecareers. Additionally, there is a perceived lossof income (at least for a transition period) whenyou change careers.

Hence, for a majority of nurses, retention todate is more to do with barriers to exit ratherthan satisfaction with or commitment to theprofession.

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VOCATIONAL”want to be a nurse”

OPTIONAL”fell into it”

Specific barriers to exit include:• While base salaries in nursing come under

criticism, there is still an expectation that tochange careers they will need to return to‘entry level’ salaries. These are expected tobe significantly less than current salaries(this is typically a barrier for nurses whohave been in the profession for 5–10+ years).

• The cost of education (both in terms offinancial outlays and loss of income whilestudying) is also a significant barrier tochanging careers, hence they stay in currentroles.

• Many are unsure what else they would do(most are not interested office/ desk jobs orworking in a shop).

The discussion at this stage in the groups is notall negative, participants are able to suggestvarious upsides to a career in nursing whichhas sustained them during the years. These areexplored in more detail in the following section(that is, positives of nursing).

What Are Perceptions of Nursing Among theCommunity?Many feel that there is a general lack ofunderstanding of nursing. This is not justamong the general public but even amongfamilies and friends. ‘How can you do that job?’is a common reaction people receive. It isacknowledged that once people have been inhospital or had a close friend/ relative inhospital they are much better at understanding.

A number still feel that nurses are perceived as‘Florence Nightingale’ types. Although this is apositive impression for people to have, it isincreasingly unrealistic in today’s environment.Nursing is no longer about personal care—there is no time to rub backs or sit chatting onbeds. It is felt that older generations in thepopulation, in particular, have this image,which makes them more demanding patientswho are typically dissatisfied when theyexperience the nature of care in hospitals today.

Those who see the image of nurses to bepositive overall still acknowledge the potentialof the media to report on negative incidentsand harm this image. An incident inShepparton a couple of years ago was raised asbeing heavily reported by the media and thenursing profession is still recovering from it.

Most feel that expectations of nurses are high,and rising. The public is becoming moredemanding as knowledge about health issuesand awareness of patient rights increases. Thisis not just confined to nursing, however,comment is also made that doctors are nolonger perceived by patients as God.

More demanding stakeholder expectations ismentioned across all segments of nurses, withthe main issues raised being:• Management deliverables (that is, making

more demands on nurse outputs).• Patient ‘rights and responsibilities’ creating

a potentially adversarial environment. Theconcern for nurses in this regard is theperception that emphasis is placed onpatients rights (to the detriment of nurserights), rather than their responsibilities.

• General increase in public’s assertiveness(translating to more difficult and demandingpatients to care for).

Some feel that the low entry mark for nursingdegrees is harming its image. Although traininginvolving a degree is seen as positive in termsof raising the profile of nursing, the low entrylevel creates a public perception that: ‘It’s aneasy way to get a degree’.

There was some feeling in the rural groups thatthe community, in fact even other nurses, maysee nurses from the country as less skilled,particularly if someone has only ever worked atone hospital. Specific issues include:• Less exposure to acuity of care (and hence

capacity to manage high acuity patients isless).

• Unless utilised, ‘advanced’ skills tend tolapse.

• Typically more generalist than specialist.

2.2 Overall Satisfaction with Nursing as aCareerOverall there are low levels of satisfaction withnursing. There are a number of positive aspectsof nursing and it is these positives which tendto attract people to the profession initially.However, the positives of nursing are offset bythe reality of the daily grind of working as anurse. Overall, the positives are clearlyoutweighed by the negatives.

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2.2.1 Positives of NursingThe reported positives of a career in nursingreflect many of the initial motivations forentering the profession. Portability andflexibility are the most commonly mentionedbenefits. Significantly, while both attributesare perceived benefits of the profession, bothalso have an impact on the ‘stability’ of theworkforce (in terms of staffing levels and skillsmix).

The following key positives of nursing areraised spontaneously across all groups:• Flexibility of hours: shiftwork and the

ability to work part-time.• Portability: nursing is a transferable skill

(both within Australia and worldwide).Australian nurses also feel that they aregenerally well respected worldwide.

• Job security: it is perceived that nursing is aprofession where there will always be jobs,providing security for trained nurses(particularly important for those withfinancial responsibilities).

• Personal contact and interaction: workingwith people (this is one of the keyattractions of nursing over otherprofessions).

• Making a difference: using your skills tohave a positive impact on people’s lives.

• Appreciation: when you receive thanks(note: gratitude and positive reinforcementis mentioned in the context of patients;management are criticised for their lack ofencouragement).

Other less frequently mentioned positives:• Interesting and varied work (‘no two days

are the same’).• Nursing can be exciting or pose a challenge,

for example in emergencies, or when youdiagnose a condition before medical staff.

• Teamwork is also mentioned in mostsegments as a positive aspect of working innursing, that is working towards a commongoal and pulling together to help oneanother out. At the same time, there is aconcern that the teamwork approach hasbecome more fragmented in recent years.

• There are a number of different specialityareas from which nurses can select. – Some see this as a positive as individuals

should be able to find something they

like among the options available.– Those with a speciality tend to feel more

skilled and confident in their roles• Some mention that health knowledge and

access to health information can be usefulfor situations outside the work setting, forexample if children are sick.

• Grade 2/3 city nurses comment on in-service hospital training as a positive. Newproduct training and updates ontherapeutics, in particular, are mentioned asthe most beneficial forms of training.

2.2.2 Negatives of NursingPoor remuneration and burdensome workingconditions are main areas of dissatisfactionhighlighted across all groups. Coupled withthese is the ‘bigger picture’ issue of limitedcareer path (particularly in the clinical setting).

Overlaying these concerns is the perceivednegative attitude of nursing management.

There was a great deal of discussion about thenegatives of nursing in the groups. Whenspecific reasons for departure from the industryare later probed, it is clear that the majority ofnegatives raised also act as drivers fordeparture. Hence, each of the areas of concerndetailed in this section is also applicable to thelater section on departure rates.

RemunerationRemuneration is typically one of the firstissues raised when the negatives of nursing areprobed. It is the ‘yardstick’ by which theymeasure their value. Nurses are quite vocal inexpressing a perceived mismatch between theircontribution to health care and theircompensation. Perceived poor remunerationprovides yet another indication to nurses thatthey are not valued by management.

Specific areas of dissatisfaction withremuneration are summarised below:• Numerous references are made to other

professions (mainly business) to contrast thedisparity between nurses remuneration andother ‘professions’. Salaries for nurses areseen to be significantly lower than theearning potential of other professionals(beyond the initial graduate level transition).

• To the same point, nurses’ salaries areperceived to be ‘capped’, with remuneration

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based solely on salary. It is the perceivednorm in other professions for remunerationto comprise each of the following:– Base salary (fixed rate of pay regardless

of on-the-job performance orcontribution)

– Skills recognition (an additionalcomponent to base salary reflecting skillset and skills upgrades)

– Performance review (recognition ofcontribution to the working environmenteither by way of salary increase, bonusesor some other tangible incentive).Nurses perceive that not only are theydenied skills recognition andperformance reviews, but that basesalaries do not meet workplace demands.

• It is also felt that salaries in nursing do notreflect the level of responsibility nurseshave. Nurses feel that they work with theconstant pressure of having people’s lives intheir hands but receive no recognition for it.

• Without shiftwork, nurses salaries arecommented as being very low. Nursesbegrudge having to make long term lifestylesacrifices (shiftwork) to earn a liveablesalary.

• There are seen to be insufficient taxdeductions available. Uniforms can nolonger be claimed, child care and parkingcosts are also mentioned (should bedeductions)

• Many have high levels of unpaid overtime.Nurses are often ‘expected’ to finish shiftslate but are not recognised for this extratime (this may be half an hour extra pershift, which quickly adds up over time).

• Once a certain level of experience is reached,salaries do not shift, regardless of additionaltraining or expertise brought to theworkplace. As commented by oneMelbourne nurse ... ‘I’ve been on the same payfor 10 years’

• The ANF public sector claim is referred to asaddressing specific pay issues among nurses(although specific elements or details of theclaim are not discussed).

WorkloadsAlthough there are clearly issues withremuneration in nursing, it is not unexpectedthat salaries would be a focal point when areasof dissatisfaction are probed (regardless of

industry). While nurses are clearly concernedabout compensation, the more compelling issuefor them is workload (and the associatedstress).

When explored in the groups, nurses reportvarious contributing factors to increasedworkloads and stress levels in the workplace:• The emphasis on cost reduction by hospital

management has resulted in lower stafflevels and higher patient ratios. All groupsrefer to patient loads of at least six, eveneight patients to one nurse (where four isseen as an acceptable level).

• All nurses felt that their hospitals wereshort-staffed (some commented on beingparticularly short-staffed at night). Therewere also some comments that skill mixeson shifts were often poor. Agency nursesand/ or graduates replacing full-time staff,in particular, put extra burden on units.

• Increased acuity of patients is a significantissue. Turnover and earlier discharge ofpatients has resulted in higher maintenanceinpatient care, while nurse to patient ratioshave not decreased commensurately (and infact have reportedly increased).

• There is also recognition that problems willcontinue into the future as a result of theageing community (it will place increasingpressure on already limited beds).

• Nurses feel that they can no longer do theirjobs properly. They often leave feeling thatthey did not do as much as they could have,or should have, done. This results in feelingsof disappointment and low job satisfaction.

• There is seen to be no downtime anymore. Ifit is a slow shift someone will be sent home(to save costs). On the other hand, ifsomeone is sick the others are oftenexpected to just cope with one less staffmember.

• A concern from Division 1 and 3 nurses isthe increasing use and reliance upon agencyand nurse bank to top up low staff numbers.Specific issues include:– a resentment that management regularly

pays the higher rates required for bankand agency nurses, when they are socost-focused in all other aspects

– a belief that agency nurses are lessproductive then hospital staff since theyare not familiar with the ward

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– a perception that agency nurses have a‘pick and choose’ mentality, positioningthemselves as elitist

– Hence, some permanent nurses feel thatagency nurses have an adverse impact onthe morale of permanent staff on theward and would prefer that bank nursesare used instead.

• Rosters are seen to regularly change andworking overtime is common (and oftenunpaid). As mentioned earlier in the report,a number of the respondents reported achange in shift or having to stay on at theend of a shift as reasons for being unable toattend the groups. This lack of control overhours adds to nurses’ feeling of not beingrespected by management.

• There is also an issue with time in-lieu andannual leave. Time in-lieu, in particular, isfelt not to be encouraged or easy to take.Annual leave may even be refused (onerural participant hadn’t had leave in twoyears despite claiming she had asked for itseveral times).

• Working conditions are seen to have a veryreal and detrimental impact on nurses overtime (and with age). The physical nature ofthe job and the demands of shift work arecommonly spoken of as wearing nursesdown. Burn-out is regarded as inevitable.

In summary, workloads have increased inreality while staffing levels have not kept pacewith on-the-job demands. As stress levels inthe workplace increase, burn out ratesaccelerate, either forcing nurses out of theindustry or to scale back their participation(that is, work part-time).

The concern for longer term maintenance ofstaffing levels is that as participation ratesdecrease, workloads for incumbents willincrease thus resulting in the vicious cycle asillustrated below.

Management Attitude (Lack of Support)Nurses frequently referred to ‘management’during the groups. They were generallyreferring to Nurse Unit Managers and Directorsof Nursing. It is acknowledged thatGovernment funding and CEO support isessential in implementing change, but the day-to-day responsibility is seen to lie with UnitManagers and Directors of Nursing. Nurse UnitManagers in particular are perceived not to befighting hard enough for better workingconditions for nurses—they are seen to be on‘management’s’ side.

There is a general feeling that research has beendone before and nothing has changed as aresult. Management is seen not to listen oradmit the problems that exist in the nursingindustry. Hospital managers are seen to havebecome businessmen who are focused on costsand are puppets to government.

There are a number of elements that areperceived to contribute to inadequate supportfrom management:• Managers are seen to now follow an

academic stream and have become removedfrom the reality of nursing today. Even thosewho started out as nurses act in a waywhich makes current nurses think that ‘theyseem to have forgotten what it was like’

• Hospital management is perceived to careonly about money and cutting cost. Thistranslates into high patient ratios and highlystressful working conditions (as discussedpreviously).

• It is felt that there is no people focus bymanagement. This lack of focus applies toboth patients and staff, as neither isreceiving adequate treatment/ support inthe current environment.

• There is seen to be no recognition of thestress staff are under and denying of basicrights, such as the opportunity to take timein-lieu or annual leave.

• There are no formal performance appraisalsin place for nurses. Hence, no feedback orencouragement mechanisms along with nobasis for which to reward high performancelevels.

• There is no support on a day-to-day basis,let alone in more serious situations. Nursesfeel isolated in circumstances where they

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INCREASINGWORKLOADS/STRESS

NURSES LEAVING/SCALING BACK

A VICIOUS CYCLE

would expect to have the support of nursingmanagement. Examples cited includemanagement siding with patients with noregard for the nurse’s perspective if there isa complaint. Mention is also made ofexpecting no support if more serious matters(for example, litigation) arise.

Higher Expectations• It is felt that expectations of nurses from the

public have increased in recent years.Consumers are generally more informed,including in health matters. More informedpatients are increasingly demanding interms of the standard of care they expect.

• This is contrary to the lower standard ofcare that nurses feel that they are able tooffer in current working environments.Patients easily become impatient with whatthey believe to be hospital inefficiencies andblame nurses for a lower standard of care.

Working conditions and the lack ofmanagement support, combined with higherexpectations from the public, contribute toconsiderable stress in the workplace.

Lack of Career Path• Bedside nurses in particular feel that their

career options are limited. It is felt by somethat there is a perception in the industry thatbedside nurses are under-achievers andthere is thus no career path for them.

• There is a common perception that once youreach clinical nurse specialist there isnowhere to go except ‘management’.Similarly with some specialities it isperceived that after five years the onlyadvance you can make is into management.

• Many seem unclear about exactly whatmanagement does (one group mentionedthat roles should be more clearly defined sothat management is not so ‘alien’/ separate).However, it is generally associated withadministration, which does not appeal to amajority of nurses. Interaction with peopleis a positive aspect of nursing for most; thereason they are nurses is because they don’twant a ‘desk job’. ‘The further up in nursing you move the furtheryou move away from patients’

• Many of those who had been nursing formore than a few years, felt that they had lots

of rotations and exposure to different areaswhen they were training but since then theyhave been ‘stuck’ in one area/ role.

• Division 2 nurses are clearly seen by all tohave a limited career path, with fewer andfewer options outside of aged care (seeDivision 2 section).

• There is some feeling among those whohave been nursing for some years thatnursing was once a good career choice butisn’t any longer.

Perceived lack of career opportunities is anissue, as nurses do not have a long term viewof their future in nursing. In particular, amongbedside nurses, there is a perception that thereare deliberately limited opportunities. A senseof reaching a ceiling early in careers (eg 5–10years) leaves many considering options outside(bedside) nursing.

EducationEducation is another key area ofdissatisfaction, evoking much comment in thegroups. There is not a particular issue in termsof courses being available with a number ofcourses/options for further education seen toexist (except for Division 2 nurses—see sectionbelow). However, there is clearly an issue withnurses accessing education due to both cost andtime barriers. In particular, lack ofmanagement support is regarded as a primarybarrier to further education.

• Lack of support consists of three mainfacets: 1. No assistance towards the cost of courses

(actual course cost is significant and timeoff required to study means a loss ofincome).

2. Minimal study leave available (nursesexpect that they will not get study leave.Shepparton Div 2 nurses pointed outthere is one day/ fortnight study leavefor their unit, which covers 50 staff.

3. Lack of recognition at the end (nothanks/congratulations, not recognisedin review processes, no monetaryrecognition, no promotionalopportunities).

• Although concerns are raised about the costof study, it is generally the unpaid time offwork that is seen as the greatest cost.

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Vocational-based education appeals tonurses on the basis of not having to taketime off (minimise loss of income).

• Study leave is mentioned in terms of a perunit allocation of only one day/fortnight.Where a unit has someone who is studyingthey can take the allocation for the entireunit. There is a perception of issues of accessto this leave (not equally awarded todifferent levels).

• There is a clear perception that otherprofessions receive assistance, both time andcost outlays, to do further education, as wellas being financially rewarded once theyhave completed education.

• There is a further barrier to education inrural areas as many courses are inMelbourne. Travel to Melbourne requirestime and cost (particularly when at nightand overnight accommodation is required).

• The paradox is that, in spite of offering nosupport for education, management isperceived to put pressure on nurses to up-skill.

• Midwives differed from other groups interms of having a greater number who hadpursued further education, as midwifery isnow a postgraduate qualification. Midwives,as a group, appeared more motivated thatother nurses (see midwife section below).We believe that generally higher levels ofon-the-job satisfaction may help to reduce orovercome the perceived barriers to furthereducation.

Respondents are quite specific in saying thatthey want to pursue further education and thatthe barriers that exist are a real concern forthem. While access to education is clearlydesirable, it is possible that its aspirationalappeal is elevated due to difficulty of access.Specifically, education acts to bolsterindividual confidence as well as provideevidence of recognition when sponsored (evenin a small way) by management.

Hence, it is potentially an ‘easy target’ toprovide more evidence of management lack ofsupport for nurses. Having said this, it is quiteclear from the groups that current access istotally inadequate to meet the needs anddemands of the nursing workforce.

In-Service Education

Hospital-based education was raised initiallyby some groups when discussion turns toeducation. There is typically positive feedbackon this level of education. There were, however,a few access issues raised across the groups:

• Night shift workers are not catered for aseducation is typically during the day (andneither are night shift staff compensated toattend day time sessions). This is seen todemonstrate a basic short-sightedness ofmanagement, that is, not catering to theneeds of a sizeable segment of theworkforce.

• Sometimes not everyone in the hospital ismade aware of education sessions(mentioned by Division 1 nurses inparticular; seemed to be a result of hospitalhierarchy/politics).

• Training for new equipment/technology isoften by the equipment’s manufacturer,meaning nurses receive only a positive view(not warned of possible problems ).

Lifestyle Cost• The hours of nursing are unsociable (nights

and weekends) and impractical for motherswith children as child care facilities do notoffer extended hours for shift workers.

• Nursing is seen to become more difficult withage. It is felt that as you get older the physicalnature of the work and the hours (particularlynight shift) have a greater impact.

Age aside, the lifestyle cost of shiftwork is seento wear nurses down and is reported in thegroups as a major reason for leaving theprofession or working fewer hours.

University Educated Nurses• There is clearly a feeling among current

nurses that graduates are ill-prepared whenthey come out of the nursing degree. Theyare seen by many to be a stark contrast tothe ‘old hospital trained’ nurses:‘We were value for money from Day 1…weexpect them to have more practical skills’

• Expectations are that graduates shoulddeliver from day one. This is clearly an issueas expectations are not in line with what thecourse delivers (the course is not structuredto do this).

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• The reality is that graduates are having todeliver from day one due to staffingshortages on most wards (graduates reportinconsistent access to supernumerarystatus). This creates problems as wards orunits feel the strain of having graduates whoare clearly not able to act in that capacity.This is further compounded by theknowledge many nurses have of the‘graduate levy’ (reportedly $15,000) paid tohospitals while graduates are in transitionfrom study. The current scenario providesfurther evidence to nurses of management’slack of respect for staff (that is, disregard forprotocols and an expectation thatexperienced staff will cope with any skillsgap).

• Many of the more experienced nursesbegrudgingly work with graduates. There isa feeling that ‘graduates can’t do anything’.There can also be problems if it becomesobvious that graduates are unsure aboutwhat they are doing, which subsequentlyupset patients. The extra burden graduatespose in their first year is causing genuineconcern, even animosity among some moreexperienced nurses.

• Undergraduate courses are seen to be tooacademic by existing nurses. Although theydo include clinical training, it is not seen toadequately prepare graduates for their firstday in the ward. Many request a return tothe hospital-based ‘training’ regime.

• Graduates themselves agree that there aregaps in their preparation for the workforce.(See graduate section for more detail.)

• Undergraduates also feel unprepared for theclinical placements and request moreplacements to better prepare them for theirgraduate year. However, they have anexpectation that support will be forthcomingin the wards if required (as things stand, thereality is likely to be very different).

Risk of LitigationLitigation is mentioned by a number of nursesas something which is constantly ‘hanging overtheir heads’. There is felt to be an increased trendtowards it as well as an increased risk ofmistakes with the pressure they are now under.One nurse commented ‘You are being judged allthe time’.

There was a heightened sense of litigation inShepparton groups where there had beenlitigation at the local hospital.

Lack of FacilitiesHospitals are seen to offer inadequate facilitiesfor their nursing staff. Specific shortcomingsinclude:• Lack of child care facilities generally and

also the hours of operating are inadequate tomeet the needs of shift workers.

• Parking around hospitals can be quiteexpensive and is regarded as unsafe forwomen leaving hospitals late at night.

• Poor staff kiosks/canteens, however this is areasonably low priority.

• Access to facilities is reportedly limitedoutside business hours. This is regarded asdemonstrating management’s lack ofunderstanding (or care) regarding the needsof afternoon and night shift workers.

Health Risks• Back injury is mentioned by many as a

relatively common injury among nurses.Support in the instance of injury is felt to bepoor. WorkCover is seen to be inadequateand there is no post-injury support.

• There is also a perceived risk of infectiousdiseases (relatively minor issue).

• There was some mention of physicalviolence in the workplace in emergencycare, psychiatric and community nursing.

Horizontal Violence• Comments relating to horizontal violence

are isolated across the groups, but exist. Theterm was referred to in one group (grade2/3 nurses) to describe segregation orbreakdown in working relationshipsresulting in inequitable treatment. Specificreferences include:

• A feeling by a small number of nurses thatthere were hierarchies within hospitalsbased on where you had trained.Information was not felt to be shared by all(believed that some withhold informationon the basis that it is power). Lines ofcommunication were also not seen to opento everyone.

• One example given was ‘selected’ access toinformation about in-service educationsessions.

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• Some other groups raised a general lack of‘togetherness’ among nurses. It is felt thatthere is a clear hierarchy in hospitals,particularly the gap between medical staffand nursing staff, but in addition to thissome perceive there to be a real sense ofrivalry among nurses at the same level. Thatis, ‘rivalry among people who should beyour peers’ (comments about this weremade across different nursing segments).

• There is also recognition of intolerance bysome older nurses towards graduates andundergraduates. The observation was madein one group that ‘we eat our young’ tohighlight the attitude of some nurses.

• Mention is also made of instances wherestaff will call in sick to avoid particularindividuals, placing undue burden on otherstaff members.

• Some acknowledge that bitchiness andrivalry is the nature of a predominantlyfemale based industry, however it is also feltthat the way nursing works today iscontributing to this (people are assignedtheir patients and have to focus on gettingeverything they need done for theirpatients). Hence, there is no time to considerthe needs of co-workers when workingunder these pressures.

• Doctors having a lack of respect for nurses issomething mentioned in several groups.This attitude has improved over time asdoctors ‘status’ with the public has changed(public now more questioning) but it is stillan issue. Nurses feel frustrated whendoctors won’t acknowledge their views orare subject to patients trusting the doctor’sword over their own.

• Some do still feel that there is a sense ofteamwork and that people do offer to helpeach other out (for example at the end of ashift). This image is certainly an appealingaspect of nursing but the reality today seemsto be that nurses are becoming increasinglyfragmented and somewhat isolated in theirroles.

Rate of Change• The pace of technology and other changes

was mentioned. Change itself is seen as apositive but some felt that change was notmanaged well—you have to make the effortto keep up you get left behind.

2.3 Key Reasons for Departure from NursingAs mentioned previously, all of the negativesdiscussed above can be reasons for peopleleaving nursing. It is most likely that it is acombination of negative factors that causenurses to leave the profession.

Overall, when asked to prioritise negatives,poor remuneration and working conditions arethe two factors named most often as reasonsfor departure from nursing. As stated earlier,working conditions appear to be the morepowerful motive to adjust work status or leavethe profession.

One Shepparton respondent summarised thereason for people leaving by commenting ‘It isthe powerlessness of it’. This powerlessness is acombination of poor working conditions,higher and higher patient loads with norecognition or support from management, andincreasingly difficult patients to deal with. Thatis, higher levels of stress combined with norecognition or support. All these factorscombine to make nurses feel under-valuedand unsatisfied with their careers.

Barriers to entering nursing in the first placewere also discussed. Overall, nurses(particularly those who have been nursing forsome time) felt that there were many morealternatives out there for women these days.Nursing does not compare well when youcompare the pay and the hours to otherindustries. They also feel that when theyselected nursing it was a good career choice butthese days it lacks a career focus.

2.4 Nursing AdvocacyWhen responsibility for dealing with departureissues is probed in the groups, the over-ridingresponsibility, or lack of advocacy, is assignedto nurse management. Additionally, nursesthemselves believe they need to take more ofthe initiative.

The point is well summarised by a comment inthe groups that nurses ‘ are their own worstenemies’. The fact that they continue to put upwith conditions and continue to ‘cope’ underpressure and in times of short-staffing (most ofthe time) sends the wrong messages back tomanagement.

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At the same time they also believe that therehave now been a number of investigations intoconditions in nursing and as yet they have seenno tangible outcomes. There is cynicism thatthis project will be any different. It is generallyfelt that there is a reluctance to admit the issuesin the industry and until this admission ismade it is unlikely that any improvements willbe seen.

It is felt that there needs to be a change in theattitude of ‘management’. When discussingmanagement during the groups, nursesgenerally refer to Nurse Unit Managers andDirectors of Nursing. Nurse Unit Managers inparticular are seen to have a responsibility forspeaking up for nurses and in most cases arenot living up to this responsibility. It is felt thatthose beyond Unit Manager level are out oftouch with the reality of today’s wards. Theyneed to become closer to the coalface and gaina true understanding of nursing. It is felt thatonly then will they be able to offer genuinesupport.

For change to occur it is acknowledged thatGovernment must lead the way (with anincrease in funding an obvious requirement).Change will also have to be supported by alllevels of hospital management.

2.5 Future IntentionsOf concern, the proportion of nurses who arepositive about their future in nursing is small(less so for midwives and psychiatric nurses).When asked their future intentions, mostintend to either scale back their participation,or plan to leave altogether within the next 5–10years.

This point is illustrated in the graphic belowdepicting the current sentiment, or attachment,of nurses to their profession. While nursing hasbeen, or is, relevant to their context today for amajority of nurses, the trend is to be divestingresponsibility within the next five years and tobe somewhere else (that is, disconnected)within the next ten years.

There is a high proportion of nurses who expectto be working part-time within the next fiveyears. The bulk of nurses we spoke to fall intothis category. In reality not all will have thisoption available to them (mainly due tofinancial considerations). However, the extentof desire to scale back participation in thenursing workforce is obviously a concern. Webelieve it is clear evidence of the dissonancethat currently exists with the profession.

Nurses seem no longer prepared to give somuch of themselves. The lifestyle cost ofnursing full-time is not worth it when there islittle or no perceived reward. Some feel thatthey will physically be unable to handle theworkload in the future, others feel emotionallyburnt out.

Some nurses intend to move to agency nursingin the next few years. Although it is recognisedthat it doesn’t have the same job security,agency is perceived to have the key advantagesof higher salaries and control of your workinghours (including the ability to work part-time ifdesired).

There is a segment of nurses who intend toremain in nursing but move away from thebedside. Becoming community nurses is themost logical option for this group to pursue.Being out of the wards, having more autonomy,working one-on-one with patients and havingmore regular hours are the appeals ofcommunity nursing.

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DISCONNECTING

DIVESTING

RELEVANT

NURSING

TODAY 5 YRS 10 YRS

LEAVINGPROFESSION

There is a segment that intends to leave nursingto move into an associated health profession.There is a general perception among nursesthat they have a transferable skill; many seemto believe this skill extends into other healthareas. Some who have tried moving into whatthey see as an associated health field havediscovered that this may not be as easy as itsounds.

Psychiatric nurses and midwives are less likelythan other nurses to report an intention to leavenursing. There is some trend towards part-timenursing, as in other segments, but the majoritysee themselves in the same role, or at least stillin their specialty, in the future.

Some of those who intend to leave nursingaltogether plan to move into totally differentroles. Business is mentioned several times as analternative.

Those leaving intending to leave altogetherincluded a few of the males we spoke to. Webelieve that there could be an issue wherenursing is being depended on for sole incomein a household. Current salaries areencouraging breadwinners to look elsewhere.

Amongst the agency nurse group there were acouple who were sales representatives forpharmaceutical companies and worked agencynursing only part-time for extra money.

There could possibly also be a negative imageassociation with men and nursing which makesthem less likely to continue to ‘put up with’ thepoor conditions. (One respondent mentionedthe surprised and disparaging reactions he gotwhen saying he was a nurse to other males).

3. Segment Findings3.1 Grades 2 / 3 NursesThree focus groups (two in Melbourne and onein Shepparton) were conducted among Grade2/3 nurses. In total, 23 Grade 2/3 nurses acrossa range of speciality areas were included in theresearch.

Compared with other segments, the toneamong Grade 2/3 nurses is relatively negative.There is a real issue with bedside nurses whoare fed up with their roles and lack of careerprogression. There is a clear issue with

maintaining the interest and motivation ofbedside nurses.

On the whole, the views of Grades 2/3 nursesare reflective of the range of issues covered insection 2 of this report. Many of thecharacteristics of, and issues for, Grades 2/3nurses applied across segments, that is tonursing as a whole. Any issues specific toGrades 2/3 nurses are covered in this section ofthe report.

Career Progression When career prospects are raised in the groups,the focus is on clinical or ‘bedside’ nursing.Clinical nurses feel particularly strongly. Thelack of perceived career path for clinical nursesis seen to send the message that you are notambitious if you stay bedside. There is a veryreal sense that if you are career-oriented, youwill regard clinical nursing as transitory. Thatis, you won’t go far by staying at the bedside.

Additionally, it is felt that there is nothingbetween the wards and management(administration). Most do not want to moveaway from the wards as they do not want tolose the people aspect of their jobs.Management is essentially seen by Grades 2/3nurses as to shuffle paper. There is a generallack of understanding of exactly whatmanagement does but it is seen as verydifferent and unappealing by most.

Beyond career path, there is the issue of jobstimulation if you have been in the one role fora long time. Grades 2/3 nurses feel that whenthey first start out as a nurse, a number ofrotations occur which provide exposure todifferent areas. However, once they have beennursing for more than a few years they get‘stuck’ in one area or role.

Clinical nurses are feeling stale and bored as aresult of limited variety in their role andopportunities for progression. This is clearly anissue as it is a reason for leaving the industry.

Speciality AreasThose who had specialised tended to feelsomewhat more satisfied than others. Overallspecialties are seen to have the advantage ofproviding a sense of security (nurses feel moresecure when they have a particular skill). Some

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also feel that there is a greater sense oftogetherness among specialist staff, bound by acommon interest and ‘membership’ to a skillset.

It was also generally acknowledged that youcan reach a ceiling within specialities ‘Five years in a speciality and there is nowhere to go’

When motivations for choosing differentspecialties are probed, reasons are varied anddependent on someone’s particular interest. Forsome, being in a specialty was more by accidentthan design. The comment is made severaltimes that they chose the first specialty thatcame along in order to get out of what theywere doing. A few examples of specialty basedappeals include:• Intensive Care was seen to have the

advantage of being fast paced, exciting andan area where you were able to focus more(fewer patients, often one-on-one). Thechallenge of working with technology ismentioned by a number of the youngernurses in this field.

• Surgical/Theatre was seen as a less intensearea, which appeals to some (others find itless exciting/ stimulating). It is appreciatedfor having more ‘normal’ hours, particularlyday surgery.

Beyond these two specialties, it was difficult todraw out particular drivers or attractions to therange of specialty areas in nursing.

Key Issues Facing the IndustryAs highlighted in Section 2, working conditionsis a key issue facing nurses today. Grades 2/3nurses are especially vocal about workingconditions, with the range of concerns raisedreflecting those outlined earlier.

Grades 2/3 nurses feel that there has to be ageneral change in the attitude of managementto improve the situation. There is a perceiveddistance between management and the realityof nursing today. It is felt that managers nowfollow an academic stream and that even thosewho were once nurses ‘have now forgottenwhat it was like’. Management is seen to offerno genuine support to nurses ‘they don’t give adamn’.

Interestingly, Grades 2/3 seemed very aware ofone another’s income. While other nursingsegments complained about remuneration, theydid not discuss pay amounts. Grades 2/3nurses seemed to know rate of pay and incomelevel associated with all positions in nursing($50,000 was most commonly mentioned as theceiling for salaries for bedside nurses). Thistransparency in salaries is a frustration forsome nurses who feel that regardless of on-the-job performance or commitment, ‘you are paidthe same as the person working with you’.

The Way ForwardWhen actions or steps to retain more nurses inthe profession are probed, the immediatefocus is on increased remuneration. When weexplore remuneration more fully, it becomesclear that salary is an issue, but recognition ofperformance is the underlying need.

Of similar importance are poor workingconditions, which are perceived to haveescalated as a result of management’s actions(and inaction). There is widespreadendorsement that management needs tobecome more in touch with the reality ofnursing today and stop being ‘puppets togovernment’. Nurses would like to see the focusrevert from a focus on costs back to people(patient and staff). Lowering patient ratios isthe most immediate step that needs to occurhere.

Other, less widely recommended, steps oractions arising from the Grades 2/3 nursegroups include:• Clinical nurses would like more exposure to

different areas. They would like to have anumber of rotations providing them withthe opportunity to work in different areasand on different wards.

• Reduce working hours to a maximum 32hours a week. This is commented as morefeasible for shiftworkers.

• Some claim that they should have eightweeks annual leave. The current six weeksmakes up for missing public holidays butdoes not compensate for the extra stress ofnursing compared to other professions.

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The FutureAlmost all Grades 2/3 nurses included in theresearch intend to scale back their participationin the nursing workforce in some way over thenext 5–10 years. For many, this means hopingto work part-time. Those nursing for more thanfive years perceive that there is a limit to theirfuture in nursing (boredom is a key factor afterfive years, with no prospects for change). Quitesimply, they are unprepared to keep givingthemselves (at least full-time) to a professionthat gives them little back in return.

3.2 Division 2 NursesOverall, the views of 19 Division 2 nurses wereincluded in the research. The research wasconducted across three groups: one rural andtwo metropolitan mini-groups. The mini-groups were split by type of education, withone group comprising TAFE educated hospitalnurses and the other comprising nurses whohad been educated in the hospital system.While the mindset across the two Melbournegroups was quite distinct (with TAFE educatednurses more likely to be seeking or activelystudying for Division 1 registration) there is aconsistent perception of how this segment ofnurses is treated in the system. Hence, theviews of Division 2 nurses are reportedtogether in this section. Additional comment ismade towards the end of the section referringspecifically to views of TAFE educated nurseswhere they are atypical from other Division 2nurses.

The mood among Division 2 nurses was,largely, depressed. They have a low feeling ofself-worth due to the perception that they arebeing ‘squeezed out’ of the profession, at leastfor areas outside aged care. Nurses as a wholefeel under-valued, however Division 2 nursesfeel even more so than others. The issues arethe same for both metropolitan and ruralnurses.

Perceptions of Division 2There is a general feeling among some Division2 nurses that public perception is more negativethan for nurses as a whole. For example, whenpatients realise the limits of theirresponsibilities they reportedly behavedifferently towards them: ‘…they know you

don’t give out medication…therefore believeyou must be less qualified in some way’.

There is a feeling among some Grades 2/3nurses that Division 2 nurses are generallyrespected by other nurses but not by otherhealth care workers. A comment made by aGrade 2/3 nurse is that Division 2 nurses are‘seen as the working class of nursing’.

Some Grades 2/3 nurses are positive aboutDivision 2 nurses and point out that there aresome very experienced Division 2 nurses whoare good to work with. At the same time,however, there is the perception amongDivision 2 nurses that some Division 1 nursesare not happy having them on the ward.Division 2 nurses regard this disposition aseither stemming from an elitist attitude, in thecase of some graduates, or purely territorial forothers. The fact that Division 2 nurses cannotadminister medication (and hence add to theDivision 1 nurse’s workload) is also expected tobe a frustration driving Division 1 nurses’attitudes. This frustration is equally shared byDivision 2 nurses.

Limitations of the Division 2 Role The nature of the responsibilities that Division2 nurses have is recognised as a limitation byall (Division 1 and Division 2 nurses). The factthat they are not able to administer any drugs,even a panadol, is seen as ridiculous by some.Not being able to check medications is alsofrustrating. Division 2 nurses report having tointerrupt workflows to find a Division 1 nurseto administer medications as a frustration whenboth nursing divisions are under pressure to fiteverything into their work day. This latterconcern is most potent in situations whereDivision 2 nurses are called in from nurse bankor agency to replace a Division 1 shift.

The role of Division 2 nurses regardingmedications is not consistent across Australianstates. Victorian Division 2 nurses believe thatDivision 2 nurses in other states are able toadminister medication. This causes confusionand some resentment.

Limitations of the Division 2 role areexemplified by the following comments madewithin Grades 2/3 groups:

• ‘I continually have to find things for them to do’• ‘I feel sorry for them’• ‘It’s becoming harder and harder for them to be

of help given the more acute nature of patientsthese days.’

The Future of Division 2 Nurses There is a perception among all nurses thatDivision 2 nurses seem to be being ‘squeezedout’, with the only opportunities being in agedcare. For some, this is a highly unattractivelonger term option. Division 2 nurses largelyfeel they are being forced out of (moreinteresting) general nursing and are alsoexcluded from most courses that allow them togain additional skills. This means that there isno incentive for them to develop themselves. Itis felt that they have no career path or direction,which is resulting in low motivation levels andpoor attitudes among some. There is a minoritywho report working in environments that aremore progressive and stimulating in terms ofdifferent work tasks and wards. This has moreto do with the attitude of management andequality of access to resources in their specificworkplace

Division 2 nurses see no career path to exist forthem, with fewer and fewer opportunitiesoutside aged care available to them. Forexample, midwifery had been taken away as acourse option. There are still some courses theycan do, such as a diabetes course, but the costis a barrier, study leave is almost impossible toget, and there is a feeling of ‘what is the pointreally?’ (no recognition at the end).

Those already working in nursing homes arefeeling particularly frustrated. They believehospitals offer greater diversity, job satisfactionand higher remuneration. The aged careenvironment is generally described as‘depressing’, especially for younger nurses.

On the whole, Division 2 nurses feel that ‘theyare phasing us out’ and as a result(management) offer no support. Rural Division2 nurses felt that there were even feweropportunities for them in the country.

The Threat Posed by PCAsPersonal Care Attendants (PCAs) are regardedas a threat to Division 2 nurses, particularly incommunity-based nursing in the aged care

sector. There is resentment that PCAs come outafter an eight-week training course able toperform most of the functions, and indeed withgreater job responsibilities, than Division 2nurses who are educated for 12 months.

Other segments of nurses are also concernedabout the level of responsibility that PCAs haveafter such a short training period, particularlythe ability to administer medication. MelbourneGrade 2/3 nurses commented that they wouldrather Division 2 nurses were performing theroles that PCAs are taking on ‘we’re gettingPCAs doing things they shouldn’t’.

One recently trained Division 2 nurse feltfriction with older PCAs when she began workas they seem to view her and any new ideas orknowledge as a threat. It was noted that it willbe more difficult to attract people to Division 2these days as PCAs are out there with moreflexibility and responsibility, earning the samemoney after an eight week course.

The Way ForwardDivision 2 nurses raise the key issues ofremuneration and workloads (as discussed inthe main section of the report). However, theydo have some very specific issues to do withtheir responsibilities and future in nursing, asdiscussed below.

Ideally Division 2 nurses want a career path.They are resentful that management is ‘payingthem no attention’ and continues to further limittheir options, for example, taking courses away.As the situation stands today, Division 2 nursespoint out that it is obviously a segment indecline, which is unlikely to attract newentrants.

They at least want to be given more scope inthe areas they work in. For example, the abilityto administer simple drugs like panadol, or theauthority to check medications on their own.Victorian nurses are seeking clarity on theissue, particularly from the perspective thatthey believe this is already permitted in otherstates.

In addition to increased responsibility, Division2 nurses say they would like moreopportunities to work in different areas and tofeel like they are actually working as a nurse.Working as a perioperative theatre nurse was

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suggested by one, where they could function asa theatre technician. There is resentment thatthey are being forced into aged care and theyclearly want the option to remain in otherareas, such as acute care.

There needs to be clarification of the role ofPCAs. Division 2 nurses would like PCAs to beprevented from performing the same tasks ‘theyare taking our jobs!’

Division 2 nurses would like to see a reductionin the amount of paperwork they have toprocess so that they can get back to a focus onpatient care.

The Nurses Board of Victoria is suggested ashaving primary responsibility for addressingthe issues discussed above (seen as responsiblefor all sectors of nursing).

The FutureFor some Division 2 nurses becoming aDivision 1 nurse is aspirational, but the barriersto change are perceived to be excessive: loss ofincome while training being the greatest.

When asked about their futures, most of thosewho have been nursing for some time are likelyto stay as is. There is almost a sense ofresignation about their futures.

A small, more ambitious, segment is activelyseeking opportunities outside clinical nursing,for example community nursing.

TAFE Educated Division 2 Nurses ‘Upgrading’ toDivision 1The attitude of TAFE educated nurses is quitedifferent from hospital educated nurses. Formany of the former, Division 2 is a transition toDivision 1 (a function of representation at ourfocus groups possibly). For some, thelimitations of Division 2 nursing had forcedthem to take up further study. For others,Division 2 was always going to be part of theirprogression to Division 1. These nurses weretypically much younger than hospital educatednurses.

TAFE CoursesOverall, among all Division 2 nurses there is astrong sense that TAFE courses are focusing onaged care. It is believed that the course has very

few weeks in hospitals and much more time innursing homes. This makes it very difficultinitially when Division 2 nurses come on to thewards. Division 2 nurses identify that atransition period would be very useful, ideallyin the acute sector to expose them to more thanaged care.

Nurses would expect to be educated during thetransition period (less than full salary may beacceptable) and would like to besupernumerary throughout this period.

3.3 MidwivesWe spoke to 10 midwives in total, with onemetropolitan and one rural group. Overall,midwives were clearly the most positive of allsegments towards nursing. They did still raisegeneral industry issues, such as workloads andremuneration, but their tone was much morepositive and their intentions for the future wereto remain in midwifery.

There were some issues that came upspecifically among rural midwives (see below).

A Positive SpecialityThe positive views appear to be due to thenature of midwifery. Unlike general nursing,midwifery is not about helping people who aresick, to the contrary, most patients are typicallyexcited about having a baby. Essentially,midwifery is a much ‘happier’ environment towork in. Midwives cite this as a key positive ofthe speciality and something which keeps themin the speciality.

As well as working in a more positiveenvironment, the midwives we spoke to alsofelt privileged to witness new lives and guidewomen in such an important part of their lives.In addition, and importantly, they feel that theyhave more autonomy and greater decisionmaking power than general nurses. They havetheir own patients who they look afterthroughout the birth (without a doctor lookingover their shoulder). Midwives clearlydistinguish themselves from general nursingand the consensus is that they would never goback to general nursing.

Midwifery is seen to be an emotional area inwhich to work, related to the protractedintensity of care during labour. However, the

emotional benefit or satisfaction associated witha successful birth was seen as greater thansatisfaction achieved in general nursing. Thissatisfaction was seen to offset the emotionalstrain of the job.

Undergraduates and graduates also perceivemidwifery in a positive light with many hopingto specialise in it eventually. There was somemention of it being quite difficult to get into todue to its popularity.

The metropolitan midwives seemed to have agreater sense of teamwork and togethernessthan other nursing segments (Moorabbin birthcentre in particular seemed to emit this feeling).This was not the case in the rural group, wherethere were issues with some feelinguncomfortable with other members of the team(sense of competition etc).

Doctor Relationship IssueNurses generally say that there were someissues with the relationships with doctors ifasked. They generally believe that doctors thinkthey are superior and treat them with a lack ofrespect. However, relationships with doctorsseemed to be somewhat more of an issue tomidwives and was raised spontaneously bysome as a negative of their roles. Midwiveswith many years of experience, in particular,find it frustrating when a young doctorcontradicts their treatment approach. Both therural and metro groups felt that doctors, on thewhole, do not give them the respect theydeserve. Specific examples include:• Metropolitan midwives mentioned that

doctors can place things in a different wayand tend to focus on all possibleabnormalities (fear of litigation), which cancause confusion and concern amongpatients.

• There was an issue among rural midwivesas they felt that they have autonomy onlyup until the birth itself, at which point adoctor steps in and takes over. They clearlyfind this unsatisfying as they feel they do allthe hard work along the way but are deniedresponsibility at the end, for the keymoment of birth.

Access to EducationFurther education is more common amongmidwives than other sectors. They seem lessconcerned with the barriers of time and cost.They acknowledge there is no tangiblerecognition of further qualifications; for themself-satisfaction is enough motivation.

Additionally, rural midwives are clear that theywould like the general patient overflow intomidwife wards to stop altogether. If it is tocontinue, perhaps some internal generalnursing refresher courses would help them feelmore confident with general patients.

Rural De-Skilling Issue?Rural midwives did not feel disadvantaged interms of the births that they were exposed to. Ifa birth was known to be difficult in advance,the patient may be sent to Melbourne, but thishappens rarely. Goulburn Valley Hospital is alarge hospital and receives most of the births inthe surrounding area so they experience a widerange of situations.

Midwives also point out that experience goesbeyond the birth itself. Goulburn ValleyHospital has rotations every two monthsbetween the three areas of antenatal, deliveryand postnatal care, which provides midwiveswith variety and exposure to the different areas.

There is a lack of exposure to critical care ofyoung babies in rural areas. This is an issue forone rural midwife who is considering movingto pursue this (she is one of the few who doesnot have family ties in the area, which willmake it easier for her to leave).

Midwifery units in some smaller countryhospitals have been closed due to a problemattracting staff. This hasn’t been an issue forany of the midwives we spoke to, however,they mention it. It is not perceived as a threat tothem given the size of Goulburn Valley Health.

The Way ForwardIn spite of having a relatively positiveperspective, midwives still mention a consistentset of concerns driving nurses from theprofession. Their views, for the most part, arereflected in Section 2 of this report.

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One concern going forward for rural midwivesis the ability to feel empowered in all aspects oftheir role. This means preventing doctors fromperforming tasks that midwives can (mostnotably delivery of babies).

The FutureIn line with the higher levels of motivation andjob satisfaction among midwives, few areintending to leave the speciality. Many talkabout doing further training and specialisingwithin midwifery.

Their career is in midwifery.

3.4 Mental Health NursesTwo focus groups were conducted amongmental health nurses from three Melbourne-based and one Shepparton mental healthfacility.

Mental health nurses are passionate about theirarea of specialty, with reported intentions toremain in the specialty higher than retentionamong the general nursing workforce.Significantly, however, burn-out is becoming akey driver for leaving the clinical area.Additional to this is the accelerating pace ofburn-out in the inpatient setting.

Perception of SpecialtyMental health nurses regard themselves firstand foremost as being in the field of psychiatry,commonly referring to themselves as ‘psychnurses’.

• And within this field … they are nurses.• For many in the groups, mental health

nursing was their career choice (rather thannursing per se).

• Having said this, there are still a reasonablenumber who entered via the general nursingstream and then specialised. Over time, theytoo have come to regard their specialty areaas offering them something different to,/ ormore than, general nursing.

When perceptions of the specialty among thebroader community are probed, there isconsensus that the public largelymisunderstands mental health and that thesegment is suffering general image problems.The media is highlighted as fuellingmisinformation. Additionally, the role of nurses

in this segment is also regarded asmisunderstood, with public perceptionsranging from ‘martyrdom’ through to ‘nurseRatchett’ (from the movie ‘One Flew Over TheCuckoo’s Nest’).

Motivations to Nurse in Mental HealthA majority of mental health nurses in theresearch cite an interest in the field ofpsychiatry as an initial motivation for becominga nurse (that is, the initial attraction is not tothe general field of nursing).

In both metropolitan and rural mental healthgroups, teamwork is reported as an appealingaspect of mental health nursing. The emphasison teamwork is stronger in this specialty thanother nursing segments included in theresearch. The strength of relationship, orbonding, with co-workers is perceived to befuelled by the stress of working conditions intheir specialty.

Another appealing aspect of nursing morewidely mentioned in mental health than othergroups is the sense of personal reward orresults. Mental health nurses see themselves asbeing responsible for longer term care andmaintenance of patients and results can be slowand hard won. Hence, a strong sense ofsatisfaction when positive outcomes areevidenced. Community/case managers inparticular comment on the personal reward feltfrom making a difference in people’s lives.

Nursing IssuesIn the main, mental health nurses report asimilar set of issues and workplaceimpediments as the broader nursing populace(that is, work load, remuneration, career path,shift work, access to education ).

There are, however, a few particular areaswhere discussion in the mental health groupswas more emotive than in other groups. It isworth re-stating these issues.

Workload

As with other nursing segments, the increasingworkloads and acuity of care are significantissues that have an impact on the ability ofmental health nurses to effectively deliver thelevel of care deemed appropriate.

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Respondents cite many examples of increasingworkloads beyond manageable levels, while atthe same time the administration content oftheir work is rising relative to patient contacthours. This is resulting in greater levels ofdissatisfaction with job content and role.Specifically, the quality of time that can bespent with any one patient suffers as theworkload increases. Typical comments amongmental health nurses include:

• ‘You simply don’t have time … you feel asthough you are going from crisis to crisis’

• ‘Ideally a case manager’s load should be 20 cases.We manage up to 37’

• ‘The contact you have with patients gets less andless while you try to manage the admin stuff andpaperwork while also negotiating with otheragencies and referrals’

Increased workload is seen to be the largestcontributor to burn-out in the workforce, whichis also reported as the major cause for nursesleaving the bedside (and leaving theprofession). Mental health nurses perceive thatburn-out and stress levels are higher in theirspecialty than in general nursing, due to:• Patient conditions more emotionally

draining.• Can be more physically demanding.• Changing nature of patient

illnesses/increased complexity (beyondtraditional mental health areas into drugaddiction, homelessness, and so on).

A few comments typifying burn-out within thespecialty include:• ‘I love psych nursing, but I just can’t handle the

stress levels I have been carrying for the last fiveyears anymore. I feel that I am tired of life beingso tough. I live to work at the moment and Iwant to get on with my life’

• ‘I think psych nursing is actually depressed. Inow just go to work and do my job – stufftraining, stuff politics.’

While workload is widely mentioned across thegroups as a very real barrier to accessingeducation, mental health nurses feel especiallystrongly about taking time off in the knowledgethat co-workers will be under additional stress.As commented in the Melbourne group ‘youfeel guilty about abandoning the ward’.

Career Path

A flat and diminishing career path wasmentioned in both mental health groups. Theclosure of larger psychiatric institutions andtheir absorption into the community is singledout as a contributing factor in lack of careerpath. Specifically:• Loss of a career structure previously

accessible in the hospital setting (aperception that more opportunities/layersare available to nurses in this setting).

• Flattening of levels within the specialty. • Coupled with a breakdown of nursing

responsibilities, with aspects of their jobnow being absorbed by allied healthprofessionals and non-governmentorganisations.

This ‘de-skilling’ leaves many mental healthnurses with a strong feeling of being under-valued by the system. Typical commentsreflecting attitudes towards de-skilling include:• ‘The landscape looks very different now … we

direct traffic rather than drive cars’• ‘It has made it less attractive. You start to think

‘why should I come to work’’• ‘There are things we used to be able to do, now

you can’t – or you can’t do them easily.Everything is being referred out, so we lose theskill’ Psychotherapy is a specific example cited.

As with general nursing, a flat career structurefor clinical nursing is also identified, along withunnecessarily heavy workloads being deemedthe ‘reward’ for promotion in the currentenvironment:• ‘There is no promotional structure for someone

who wants to pursue a clinical channel … Theyintroduced the clinical nurse consultant, but youare expected to carry a 0.5 case load, which is 20clients in our setting, as well as be accountablefor the professional standards of 90 nurses forthe other half of your time. It’s ridiculous.’

• ‘If you want to progress, you need to move intodirect care.’

• ‘The really good nurses move onto communitybecause of the structure and job satisfaction.Here (in the ward) you burn out very quicklyand there is no incentive to stay in terms ofcareer structure’

• ‘There is no mobility within the structure’

Entry Level Requirements

For some, the feeling of being under-valued isfurther reinforced by recent changes to theentry requirements for mental health nursingvia the bachelor of nursing program (ratherthan a specialist psychiatric nurse training).Specific comments include:• ‘It took me three years to train for this job. Now

a student does a few weeks clinical and they’reexpected to be ready to handle patients’

• ‘The new system genericises patient treatmentand de-values the patient experience … doing aunit in communication skills in a degreeprogramme is useless if it’s with a non-psychoticperson’

• ‘The majority of graduates are in their early tomid-twenties. They have no life experience …psych is all about people intervention’

• ‘This triggers a shift … psych nursing was oncea specialty, but it’s not anymore. Anyone with abasic comprehensive degree can walk in and do itafter a few weeks of psych exposure’

Interestingly, undergraduates have a perceptionthat the mental health component of theircourse is high (possibly to the detriment ofother, ‘more useful’, areas such aspharmacology). At the same time, there isrecognition among undergraduates that even ifthey don’t go into the mental health specialty,they still need a certain set of skills to handleand diagnose patients who come through themainstream system.

Dilution of Specialty

A significant concern among longer servingnurses (10+ years) is the perceived dilution(and hence devaluing) of their specialist roleover time. Specific examples of this include:• Decreased input into patient care (due to a

combinations of other professions takingover aspects of their role as well asincreasing workloads making it impracticalto spend time with patients).

• Aspects of their role are being contracted tonon-government organisations.

• Increased role of allied health in theirprofession.

• Less time allocation per patient (forexample, time pressures to have assessmentsdone in short time frames—expected thatpatients will be ‘stamped with a condition’in one hour).

Leadership

While also raised in other segments, the issueof leadership and a united front for nurseissues seems to be more strongly championedamong mental health nurses. Part of this maybe due to the skew in the Melbourne grouptowards more experienced specialist nurses,who have had longer to consider the macroissues facing the profession (rather than a focuson micro issues that can be all-consuming).Specific reference is made to the profession and,in particular, mental health nursing, as:• Having no solid leadership • Rudderless• Fragmented • Impotent (no one taking particular interest

in nursing issues within psychiatry).

The comment is made in the groups that thenext level of reporting for mental health nursesis a social worker. Without a Director ofNursing to champion nursing issues, many feelthere is inadequate consideration being given tonursing issues, contributing to thedisintegration of their specialty. Furthermore,the absence of a dedicated senior nurse isperceived as devaluing the role within thespecialist field. Interestingly, while mentalhealth nurses perceive a Director of Nursingwould make a difference in fighting for therights of nurses, in other focus groups, thislevel of management comes under direct attackfor the lack of their commitment to the nursingworkforce (that is, seen as siding withmanagement and bureaucracy).

These factors are said to stem from the de-institutionalisation of mental health and a shiftaway from working in large hospitals. Theinstitutions at least provided a career path.

As with many other nursing segments, thecompromises outlined in this section translateto a disintegration of patient care, thusimpacting the degree of fulfilment nurses havewith their job (that is, left with a feeling thatthey could do more for the patient if differentaccess to resources).

The Way ForwardWhen prompted, mental health nurses suggesta number of courses of action to address issuesraised. Some of these are listed below:

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• Graduate placements in acute inpatientunits to be supernumerary. This wouldprovide graduates with greater opportunityto learn and foster a more supportiveenvironment from co-workers (that is, moreinclined to take the time to help withdevelopment).

• Solid leadership—to address the perceivedsetbacks since de-institutionalisation. Whatis sought is someone to ‘hold the reigns andfight for the nursing cause in a very competitiveenvironment’

• The creation of dedicated nursemanagement positions is to be a step in theright direction in terms of the value ofnurses in the new organisational structures.

• The HACSU Public Sector claim ismentioned in the groups as addressing therange of issues that have an impact onmental health nurses and desirableoutcomes.

When responsibility for dealing withdeparture issues in the profession is probed,mental health nurses are more likely than othersegments to attribute blame to hospital CEOsand the Minister for Health. That is,responsibility for policies that impact onworking conditions and patient care is aimedhigher than the nursing hierarchy (which iswhere blame tends to rest among other nursingsegments).

The FutureAs with other nursing segments, mental healthnurses are also looking for working options inthe future that reduce stress levels and givethem access to better quality of life. Unlikeother segments, there is less reported intent toscale back hours of work (although this iscertainly aspirational), with expectations beingof a move away from bedside to roles that givethem greater autonomy and control over theirworking lives. Some areas they are pursuing forthe next 5–10 years include:• Community nursing• Academia (in mental health area)• Early retirement (at 55 years).

3.5 Graduate NursesTwo focus groups of graduate nurses wereconducted: one in Melbourne, with graduatesrepresenting five different hospitals and

covering a range of specialist rotations (frompaediatrics to psychiatric); one in Shepparton,with graduates employed at the local hospital.Of the 15 graduates spoken to, three hadpreviously been Division 2 nurses.

Overall, graduate nurses are pleased to finally‘be out there’ working, but are now discoveringthe realities of being a nurse: long hours,physically demanding, mentally challenging,pressures of time and resource management.

Significantly, after a relatively short exposure toclinical practice, their reported intent is in linewith other nursing segments researched interms of expectations for the future: for themajority, their career beyond the next five yearsis out of bedside nursing!

Perceptions of a Career in NursingGraduates’ reasons for entering nursing are notdissimilar from the various motivationsreported across the spectrum of nursingsegments. Essentially, the main drivers are: • Career benefits (for example, portability,

flexibility, security).• Vocational (for example, always wanted to

be a nurse; family heritage).• By default (for example, unsure of what

direction to take, ended up in nursing; byaccident, not what originally intended todo).

Regardless of initial motivation for becoming anurse, there is a common thread in terms of itbeing ‘bigger’ than they expected (that is, abigger commitment). For some, there was asense coming into the graduate year that theyhad ‘made it’ and were now nursing. The realityhas been ongoing study and a heavy scheduleto meet workplace expectations (that is, fullpatient load).

When prompted, the perceived downsides andreasons for departure rates from the profession,as volunteered by graduates, is on par withother more experienced nurses. After sixmonths of working, they have begun toexperience first-hand some of these down-sides, including:• Lack of social recognition (the community is

regarded as still not giving nurses the samedegree of recognition as graduates’ peers inother industries).

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• Remuneration (the comment was made by aprevious enrolled nurse that, after threeyears of study, she now earns three cents anhour more than before study).

• Physical working conditions (long days,busy, heavy work).

• Mental stress (dealing with peoples livesand with death).

• Shiftwork (and the impact on social life).

Graduates have already come to the conclusionthat you can only do this for so many years.

Perceptions of Preparation for NursingReinforcing the views held by moreexperienced nurses, graduates (in hindsight)regard themselves as being ill-prepared forclinical placements. Graduates included in theresearch were all mid-year. Hence, by this timethey feel they have gained confidence and arestarting to appreciate what it is to be a nurse(that is, it’s stressful, hard work and shift-based).

Specific comments regarding preparation forwork include:• ‘Uni doesn’t prepare you for working or the

realities of being a nurse … I didn’t realise itwould be such hard work’

• ‘When you do your clinical placements at uni,you work day shift. That’s nothing like the wayyou actually work when you’re a nurse. Youreally need to be exposed to shift work soonerthan grad year’

• ‘I didn’t think it would be such physical work …it is, after all, a female dominated industry’(comment by Melbourne-based male)

Perceptions of Graduate Year

Nursing Support

On balance, the perception of workingrelationships is of a cooperative, supportiverelationship between graduates and othernursing staff. However, there are a number ofgrievances raised across both groups that arespecific to graduates. Namely:• A perception that they ‘get the butt end’ of

the roster (Saturday night and Sundaymorning). The rationale is argued thatgraduates are cheaper to pay to do theseshifts than other staff.

• Decreased staff on wards results in potentialfor graduates to be given menial tasks

(perceived as easier than investing time intraining when under pressure).

• Some perceive that graduates (and agencynurses) are given the more high acuitypatients.

• Younger staff are regarded as more‘sympathetic’ (that is, they know what it’slike to be a grad), but some older staff areperceived to judge without getting to knowyour skill level, for example: ‘you’re a grad …you’ll do pans!’

• The term ‘nasty nurse’ was used in theMelbourne group to describe the demeanourof nurses worn down by the ongoing stressin the workplace (that is, cranky,unsupportive). The consensus is that stepsneed to be taken, since none of them wantsto become a nasty nurse!

At the end of the day, there is a sense that theonus is on the graduate to make the most oftheir transition year and to seek support andassistance when needed. To do so requires acertain level of confidence (that is, to not beafraid of asking).

Rotations

When satisfaction with career choice is probed,it is clear that graduate placement (institution)and choice of specialties can have an impact onperceptions. It is noted that some hospitals (andunits/staff within them) are better equippedthan others to manage graduate needs andprovide appropriate support for theirdevelopment.

About one-quarter of graduates expressdissatisfaction with the program to date, withnegative feelings stemming from a combinationof choice of specialties as well as a difficultywith staff and management. Specific commentsinclude:• ‘I don’t feel I’m getting enough exposure to

different areas of nursing’• ‘On my first placement they didn’t know what to

do with me … I tidied up pamphlets’

In the main, graduates are satisfied withplacement and optimistic that at least one oftheir rotations will have longer term appeal tothem. The program at the Royal Children’swas singled out in the Melbourne group (bothby those in the program and other attendants atthe group) as being innovative and supportive

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of graduates’ needs. Specifically, the programappeals because it has:• Three rotations, each of four months (rather

than two rotations of six months each).Preference drivers include: opportunity tobe exposed to another specialty area; sixmonths can be a really long time if discoverdon’t like the specialty; four months isenough time to determine how you feelabout the specialty and to consolidate skillsin the area of practice.

• A mentoring program.• Generally supportive staff.

There is strong support for more than tworotations in the graduate year. A fear of being‘boxed’ into a specialty area early in their careeris mentioned several times. As discussed in thegroups, the graduate year is important in termsof consolidating nursing skills, but also gainingexposure to and choosing a specialist area. Theaccess to only two areas in Shepparton (generalward and rehabilitation) is seen as not offeringenough stimulation or choice. A concernspecific to the rural group is the perceivedlimited options in rural areas (you can study aspecialty area, but may not get a position in it).

Third year placements during theundergraduate program are also commented onas playing a role in choice of specialties (andsubsequent graduate placements).

The Way ForwardAddressing issues contributing to workload is amajor target in terms of actions or steps toretain nurses in the workforce. Graduates can‘see the writing on the wall’ in terms of burn-out and lifestyle sacrifice as they progressthrough their career.

Specific suggestions are also made in terms ofbetter preparation for the workplace. Theemphasis is on longer clinical placementsthroughout the undergraduate degree, both toconsolidate workplace skills and to greaterappreciate the physical and emotional demandsof the job and shift work.

Options described in the groups include:• Longer placements (a four-week minimum

to consolidate specialty and to generally ‘fit’into the ward).

• Requirement to work shifts duringplacements (from 1st year) to appreciate

sooner, rather than later, the impacts of shiftworking on the body and lifestyle.

• Blocks of ‘permanent’ employment, working2–3 days a week for approximately sixmonths. The suggestion is made that theseshifts be paid.

In a similar vein, graduates would like to seeinitiatives to assist both the candidate and thehospital deciding if they are right for the jobearlier on. For example, placements sooner during1st year along with interviews with hospital.

Graduates are also seeking strongercommitment from hospitals participating ingraduate year programs to support theirtransition to the workforce. Specific suggestionsinclude:• Strict application of supernumerary status

(not just on their first rotation).• Provision of in-service training to other

nurses imparting basic teaching skills (howto ‘show’ rather the ‘do’ when working withgraduates) and tolerance for graduateswithin particular nursing segments (nursestrained in the old system).

The FutureAcross both groups, a majority of respondentsexpect to have left bedside nursing within thenext 10 years. Barriers to bedside nursinginclude:• Physical fatigue or burn-out. • Mental burn-out or need a change.• Opportunities for promotion lie outside of

bedside.• Salary cap (especially for the few males who

felt compelled to earn higher incomes ‘tosupport a family’. One was proposing tofollow a career path into academia).

3.6 Undergraduate StudentsTwo focus groups of undergraduates in thenursing program were conducted: one withstudents from La Trobe and Monash inMelbourne and another with students fromBallarat University. Of the 13 students spokento, three had previously been Division 2 nurses.

Undergraduates are optimistic about careerprospects, although, a majority do not seethemselves in the clinical environment beyondan initial consolidation of skills period (up tofive years).

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Students are anxious and excited about startingtheir graduate year, however they believe theirnervousness and questioning of ability to ‘cope’is not dissimilar from that of any other studentfinishing an undergraduate degree and about toenter the unknowns of the working world.

Overall, the undergraduate degree program isregarded as having provided students with anacademic framework and principles of nursing.However, they are vocal in their call forincreased clinical contact throughout the courseto consolidate skills learned in the curriculumand better prepare them for the realities ofworking as a nurse.

Perceptions of a Career in NursingThe primary motivation for studying nursing isfairly evenly split among three key drivers:1. Nursing is a vocation or a career of choice,

as typified in the following comments: • ‘want to give something back’• ‘I’ve always wanted to be a nurse – I love

helping people’2. Nursing is an option (no particular desire to

be a nurse, but a convenient and reasonablyattractive option at the time). Typicalexplanations of this motive include: • accessibility (entry score)• know people who are nurses (family or

friends) so ‘just fell into it’• it was a choice between nursing or

teaching or some other career.3. Nursing as a stepping stone to something

else. • These students entered the nursing

undergraduate program as a means ofincreasing their university eligibility toother degree programs that they did notqualify for. Significantly, the intent onentering the program was to switch atthe end of first year, but all subsequentlydecided to see the degree through oncethey had some exposure to theprofession.

Undergraduates’ expectations of a career innursing are not dissimilar to graduates andother nursing segments and include:• Career benefits (portability, diversity,

options).• Flexibility (day-to-day flexibility, shiftwork

as well as lifestyle, taking time off forchildren / travel etc).

• Desirable skill set (for own benefit or familyas well as attractive to employers if want tochange careers).

When perceptions of the expected downsidesare probed, undergraduates are typically awareof the range of working concerns voiced byother nursing segments. Of note, Melbournerespondents appear to be slightly more awareor familiar with the range of issues and theintensity of impact on future nursing work life.

There is a sense among undergraduates that thecommunity’s perception of nursing is slowlychanging for the better. The degree qualificationis believed to be elevating nursing status to a‘profession’. Although, undergraduatesacknowledge that there is still a gap betweenthe regard held for degrees in medicine andlaw as compared with nursing (which is morelikely to be paralleled with teaching).

Despite this, undergraduates are quick todefend the robust academic format of thedegree, commenting that nursing is in fact oneof the more difficult undergraduate programs (work load, degree of content difficulty), furthersupported by the high drop-out rates in firstyear.

Perceptions of CourseAs eluded to above, students rate theundergraduate nursing degree as being highlyintensive in its academic content, with acommensurate drop-out/failure rate by thetime someone graduates.

Specific feedback on a year-by-year basis isprovided below, however, some overallobservations of the course are worth notingfirst. Specifically:• The most widespread criticism of the

program is the limited clinical content andthe lag in making ‘first contact’ with thehospital environment.

• The intensity of study throughout theprogram is criticised, especially in secondyear.

• Off-campus educators are also mentioned asnot necessarily providing as much support(or encouragement) as sought.

• Generally speaking, however,undergraduates believe they haveappropriate support mechanisms when onclinical placements.

• In terms of curriculum, there are severalsuggestions requesting increased emphasison pharmacology and pathology. A numberof students felt that there was an imbalancebetween these subjects, which are seen tohave important and widespread applicationin all fields of nursing, compared withpsychiatry, which is a specialist field, buthas greater weight of content.

• There is mixed reaction to the ‘holistic’ focusadopted in the degree programs.Specifically, the course philosophy isreported as ‘treating the whole patient’. Whilethis approach is endorsed by students, manyare coming to realise that this is not thereality of how nursing is practised. Thesuggestion is made that either the focusneeds to shift, or at least a more balancedrepresentation of how nursing isadministered in practice needs to bepresented. In practice, it is perceived thatnursing is task-focused rather than patient-focused. Excessive patient loads are seen tobe a major contributor relating to thenecessity for a task-oriented approach inpractice.

First Year

When reaction to the program is probed, theinitial discussion is consistently about the levelof clinical contact. Within this context, the firstyear of study comes under most attack.Specifically, undergraduates’ perceptions offirst year are:• High drop-out rates (especially after the first

clinical placement; but also during othertimes of the year as some students come torecognise that nursing is not the career forthem).

• It is generally regarded as the ‘lightest load’,hence suggested opportunity to includesome of second year curriculum in first yearto lighten the load in subsequent years.

• Timing of clinical placements is too late inthe year (that is, three months into thecourse). They want to get out andexperience nursing sooner.

• Clinical placements in aged care facilities aremet with mixed reaction. While it is seen asa ‘safe environment to let undergraduates loosein’, it is also regarded as potentiallymisrepresenting the challenges and diversityof nursing. The comment is also made that

some students may drop-out in first yearbecause they get the ‘wrong impression’ ofnursing after this first placement.

• Drop-outs in first year are also attributed to theusual undergraduate motives, such as don’twant to put the effort into study; want a yearoff to experience life before further study; wantto earn money; academic failure.

Second Year

Second year is regarded as the toughest year inthe program due to the volume of subjects toget through. It is also when the majority ofstudents really embraced nursing and becamemore focused in their studies. Factors drivingthese perceptions include:• First ‘acute care’ placement and sense of

excitement regarding placements.• A chance to consolidate learning (put the

theory into practice).• The failure rates in second year are

perceived to be high (with three respondentsout of 13 having repeated second year).These are regarded as testimony to theintensity of the program.

• In spite of the heavy on-campus work load,there are still calls for longer placements insecond year as well as a preference forplacements to in some way relate to thecurriculum (although recognise this isimpractical for the number of studentsaround the State).

Overall, second year is regarded as the year ofempowerment (albeit via a ‘sink or swim’philosophy).

Comments typifying reactions to second yearinclude:• ‘I’m in it now … I’m a nurse’• ‘Everything fell into place for me in second year

.. it was much more nursing focussed’• ‘It was difficult, full-on and unnecessarily

stressful’• ‘It’s much more intense than first or third year ..

it’s probably also heavier than a lot of otherdegrees’

• ‘A lot of people fail second year’

Third Year

There is an almost self-congratulatory feel tohaving made it to third year. As summed up byone Ballarat participant: ‘if you make it to third

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year you really want to be a nurse – you’re awinner’. While continuing to be a fullworkload, there is a sense of the pressureeasing off compared to second year, with moreof an emphasis on consolidating learning.

On balance, third year is regarded as the yearof responsibility; when you begin to feel areadiness to take on nursing in practice.

Next Year

When expectations of their preparedness for theupcoming graduate year is probed, the majorityexpress some apprehension. The apprehensioncentres around:• The unknown.• Being fully responsible for a human life.• Accountability for 6–-8 patients. • Support mechanisms are not in place to the

extent of the undergraduate program. • Will they retain theory in a practical context

(time lag from studying subject to actuallyhaving to implement learning).

While apprehension is reported as not specificto nursing (that is, all final year students feelsome anxiety about going into the wide world),there is a definite question in students’ mindsabout their capacity to ‘get the job done’. This isnot so much related to the demands of the job(such as workloads or shift work), but refers totheir ability to apply their nursing skills. Hence,the repeated calls for more clinical contactthroughout the course to exhibit to themselves(and the nursing workforce) that they areprepared and able to nurse as well as toconsolidate skills as they are learned in theory.

When the computer match list is explored inthe groups there is limited discussion, butgeneral endorsement of the recruitmentprocess. While some regard it as a ‘bonus’ (thatis, other professions don’t get this sort of entreeto the workforce), others comment that thereality is you still need to go through thenormal job interview process anyway, so it haslimited appeal. Additional comments includethe possibility of completing more than fouroptions, especially if you are applying to highlysought after positions.

The Way ForwardThere is widespread endorsement in the groupsfor earlier exposure to the clinical environment

as well as earlier detection of ‘fitness’ for acareer in nursing. Some suggestions for earlierdetection of ‘fit’ with nursing included:• Work experience before going to university. • Interviews or briefings by hospital staff to

give a grounding in ‘nursing’ (including dayto day tasks; career prospects ).

• Open days and hospital tours to get a feelfor the work environment.

• Earlier placements in first year (as early asthe first week on campus).

• Exposure to ‘real’ wards (not just aged care,which can be deflating andmisrepresentative of what nursing has tooffer).

The FutureSimilar to graduate nurses, the expectationsamong undergraduates is that bedside nursinghas a limited shelf life. Many are expecting tospend no more than the required period of timeto consolidate their skills before exploring otheroptions, such as:• Nurse management• Academia• Related health.

Having said that, there is less of an expectationof leaving the profession or scaling backparticipation (part-time) in the medium term(five years) for undergraduates compared withother nursing segments.

3.7 Community NursingAcross the groups, there was representation ofcommunity nurses in each of the segmentsresearched. While community nurses alsoacknowledge and support the views ofinstitutional nurses, there appears to be agreater sense of on-the-job satisfaction amongthis segment of nurses.

Both institutional-based and community nursesperceive a number of advantages to working incommunity. The key benefit to most is anincrease in autonomy. Community nurses seethemselves as sole nurse practitioners whomake their own decisions. They enjoy thechallenge of being responsible for their ownactions. Doctors are involved only in abnormalcircumstances, which gives community nursesa sense of autonomy and independence: ‘Thereis no one looking over your shoulder’

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Another significant benefit is perceived to bethe one-on-one relationships they have withpatients. They feel that they spend more timewith patients (in their own home), whichallows them build greater rapport and trust. Atthe same time, patient loads are alsocommented as prohibitive to spending time.Mental health nurses working in communitywere most vocal about this issue.

Community nursing also appeals on the basisof not being ‘stuck on the ward’. They are outand about, usually with a car provided forthem. The more regular hours are alsoappreciated: ‘It feels more normal’

There are some downsides mentioned tocommunity nursing. Autonomy also meansaccountability. Having sole responsibility forpatients means being accountable (and solelyliable) in the case of any mishaps.

For some, community nursing is also regardedas lonely, from the point of view of notestablishing close working relationships withcolleagues.

Another negative mentioned was the threat ofphysical violence. This is seen as a potentialrisk for female nurses working alone in thecommunity and entering people’s homes (thishas been experienced by one communitynurse).

The concern was also raised regarding someneighbourhoods being dangerous whentravelling in a vehicle brandishing ‘communitynurse’. As commented by on nurse, ‘this is anadvertisement saying ‘drugs on board’.’

On balance, community nursing is clearlyaspirational to a large number of nurses, withthis being one of the more widely mentionedpreferences for the future. For those feeling (orexpected to be) burnt-out from time spent onwards, community nursing is regarded assomewhat of a panacea.

3.8 Agency NursesThe research included one group of agencynurses, comprising nine respondents whocurrently live and work in Melbourne.

The decision to work for an agency is based ona greater level of flexibility and financialreward. Nurses who register with agencies also

appear to find permanent nursing positionsunappealing due to politics, rosters, workloads,stress levels and the inability to combine workwith study and family commitments.

Attractions to NursingAgency nurses report similar initial attractionsto the profession as other nursing segments.Agency nurses have a real desire to care forpeople, and appear to enjoy the level of contactthey have with their patients. Nursing is alsoseen to offer flexibility for those who relocate(intra or interstate), and offers vast and variedemployment opportunities. Gainingemployment does not seem to be an issue forthe profession generally, as it is well knownthat shortages exist.

Many nurses report joining the profession as amatter of default, having received a lowTertiary Entrance Rank at the completion oftheir secondary education.

Overall the profession is seen to be rewarding,with nurses taking pride in being able to ‘makea difference’.

Attractions to Agency NursingNurses are generally attracted to Agencynursing for four main reasons:• Greater flexibility• Greater remuneration• Dissatisfaction with permanent nursing

positions• Perception of decreased stress levels.

There are many facets to the flexibility ofagency nursing. Agency nursing is flexible forthose with family or study commitments, andallows nurses to ‘escape the roster’. There is astrong sense that agency nurses can ‘pick andchoose’ between shifts, with as many as sixshifts being offered at any one time. Enrollingwith multiple agencies appears to be the norm.

Agency nursing allows those who are studyingthe ability to gain experience (undergraduates)or ‘keep skills up’ (Division 2 nurses studying forDivision 1, or those doing Masters). Forinstance, when studying their undergraduatedegree, students are able to join an agency andwork as a nursing assistant. During the studyyears, agency nursing is viewed as being ‘goodfor the CV’ and there is a sense that it ‘helps toprepare you’ for the realities of nursing. This is

seen to be particularly beneficial given thatmany undergraduate nurses worry about theresponsibilities of nursing. For these nurses,agency nursing is an avenue for exploringdifferent areas and to ‘test the water before gettinga permanent job’. Many undergraduates reportthat they are likely to stay with an agency forthe duration of the graduate year and beyond(in addition to full-time employment at thecompletion of study).

Consistently, agency nurses state that salariesare higher within the agency structure. There isseen to be a hierarchy in pay rates, with agencytopping the list, Bank coming in second, andregular nursing at a distant third. There is alsoa perception that different agencies offerdifferent rates of pay, whereby pay is equatedwith reliability (some agencies that pay highlyare perceived to be somewhat unreliable, withlast minute cancellations of shifts).

Many nurses are attracted to agency nursingdue to dissatisfaction with regular permanentnursing positions. Nurses are frustrated by therigid rostering systems adhered to bypermanent staff, increased stress levels and theexposure to internal politics. Permanent nursesalso have to contend with staff shortages, highexpectations, unpaid overtime and constant‘running around’. In most cases thesefrustrations can be avoided or felt to a lesserextent in an agency position.

For those nurses with personal commitmentssuch as family or study, agency is clearly thepreferred employment option. Examples weresighted, whereby changes in the employment ofa spouse resulted in the family re-locating. Incases such as this, agency employment allowsfor fast reinstatement in employment, whileavoiding lengthy interviewing processesassociated with permanent positions.

Agency nurses also claim to have beenattracted to agency nursing due to theperception of lower stress levels. Agency nursesgenerally believe they feel much more incontrol of their shifts, and take pride in the factthat they can choose not to go back to ahospital if they dislike the patients or staff – ‘wecan walk away at the end of a shift and never goback if we don’t want to’. Agency nurses alsobelieve they can reduce stress simply by

managing their own hours. By managing theirown hours they are able to avoid becomingoverworked and worn out.

It should be noted that while there are manyattractions to agency nursing, many nursesrefrain from this type of employment due to apreference for stability and continuity of care.

Issues for Agency NursesWhile agency nurses easily identify theadvantages of agency employment, there areissues, however, that remain. These can besummarised as follows:• Instability• Lack of team environment or support

structure• Working conditions • Agency nurse reputations within the

profession• Barriers to continued training and

education.

The instability of agency employment is feltinitially by graduate nurses, however this isseen to subside as graduates learn to enjoy thegreater flexibility that agency nursing offers. Insome instances, graduate nurses choose Bankover agency for added stability. Moreexperienced agency nurses have the view thatnew graduates shouldn’t work for agencies—they believe the transition is hard enoughwithout moving around hospitals.

By the very nature of agency nursing, nursesacknowledge that there is a lack of exposure toa team environment. Given that a particularplacement may only be (at the very least) forone shift, agency nurses are unable to formcloser working relationships with other staffmembers and patients (‘friends on the ward’). Formany this is seen to be beneficial (that is,leaving problematic colleagues/patientsbehind), but others miss peer group support orcontinuity of patient care.

The working environment that agency nursesare exposed to is very much ‘fend for yourself’.Agency nurses find that orientations arevirtually non-existent, simple introductions arenot given and generally very little assistance isoffered by the permanent staff. The overallfeeling that is derived from this is that ‘nursesdo not care for each other’. Many agency nurses

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talk about how they need to introducethemselves and ‘pick out someone who isresourceful and helpful’.

Agency nurses appear to be somewhatconcerned about the reputation they havewithin the profession. There is a concern thatthe interviewing process is not stringentenough within the agencies themselves, and theactions of a few nurses are ruining thecredibility of the group as a whole. Division 2nurses in particular talk about the difficultiesthey face working within the agency structure;they believe there is a perception that ‘they donot know what they are doing’.

While it is generally accepted that furthereducation and training is available, agencynurses believe that barriers do exist. Furthereducation is seen to be expensive, both inmonetary terms and in the opportunity cost oftime away from work. Many also report thatthere is very little incentive to undertakefurther education when it is not recognised inremuneration. Agency nurses believe thatfurther education is both expected andencouraged by the profession (and many arewilling to participate), however, there is ageneral consensus that the barriers (that is,costs) are too great.

While there are issues for agency nurses asmentioned above, it is important to note thatthe positives of agency nursing far outweighthe negatives.

How Agency Nurses See the NursingProfessionThere are many issues facing the nursingprofession generally, as identified by agencynurses. These include:• Problems in aged care• ‘Disgruntlement’ in profession• Nurses leaving the profession.

The problems identified with aged care relatelargely to privatisation. Agency nurses believethat cost cutting is contributing to heavierworkloads (‘only need one registered nurse for60 beds’). There is a perception that Division 1nurses have been forced to leave, while ‘cheaper’PCAs are being hired. This is clearly an issuefor Division 2 agency nurses.

Agency nurses are also aware of‘disgruntlement’ within the profession. It is feltthat nurses do not stick together and bitchinessand rivalry is rife. Many believe this is a factorof a predominantly female-based industry,while others believe it is a factor of the workingenvironment, that is high levels of stress, highworkloads and insufficient pay rates.

Agency nurses recognise that nurses areleaving the profession. It is generally believedthere are many contributing factors for theincrease in departures from the profession.Burn-out due to staff shortages and associatedstress levels, coupled with disgruntlement anddissatisfaction with pay rates, appear to be themain contributing factors as seen by agencynurses.

The Way ForwardThe issues facing agency nurses are quitesimilar to the general issues facing theprofession as a whole. The way forward as seenby agency nurses, involves the followingactions: • Increased funding • Reduce workloads—staffing on patient

numbers is ineffective, when differentpatients require different levels of care.

• Recognition of study—encourage furtherstudy by paying accordingly.

• Bonuses/rewards—to keep staff motivated.• Tax deductions—previously available tax

deductions have been taken away. Should beallowed to claim shoes, stockings anduniforms as tax deductions.

• Need professional recognition.

The FutureQuite clearly, the future for agency nurses is notback in health institutions, it is largely awayfrom nursing, with many actively studying forentry into other professions, such as business,travel industry and information technology.

3.9 Unregistered NursesThe research included one group ofunregistered nurses, comprising sevenrespondents who currently live and work inMelbourne. There was a mix of unregisteredDivision 1 and Division 2 nurses in the group.

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Unregistered nurses appear to have eithermade a conscious decision to exit the professionentirely (a minority) or they have movedhorizontally into related fields, such aspharmacy, pathology, community or research.In spite of this career decision to leavetraditional nursing, many nurses state that theyinitially did not wish to forfeit theirregistration. However, due to confusionregarding registration requirements, and littleguidance from the Victorian Nurses Board,there is wide belief that unregistered nurses arein some ways ‘forced’ to lose their registration.While not all unregistered nurses wish toreapply for registration, there is a proportionthat do wish to reapply at some point in thefuture—these nurses identify barriers toreapplying and claim to be uncertain about thenecessary requirements.

Attractions to NursingDespite making a conscious decision todiscontinue registration or losing registrationdue to circumstance, unregistered nurses speakfondly about initial attractions to theprofession. Many describe a natural want tocare for people, and the flexibility of workinghours, such as nights and weekends. It is,therefore, not surprising to find that manyunregistered nurses remain in a nursing relatedfield, such as pharmacy assistants, pathology,research nursing, drug therapy, communitywork.

Reasons for Discontinuing RegistrationVarious reasons are given for discontinuingregistration. Of those who have made a choiceto leave, many speak of being dissatisfied withthe quality of care given while nursing, and thefrustration of not being able to give the level ofcare required due to time shortages and costcutting (‘no time to sit on the bed’). Other nursesdescribe wanting regular ‘9 to 5’ jobs, or simplya change of pace and describe theirderegistration as a conscious decision. Of thosewho did not actively decide to leave, the loss ofregistration appears to be the result of movinginto a related field, and experiencing one of thefollowing:• Related field not recognised for registration,

for example, research nursing.

• Difficulty in completing minimum numberof shifts to maintain registration (whileworking in another job).

• Confusion over what is required to maintainregistration.

Unregistered nurses appear to display a level of‘sadness’ that they no longer hold theirregistration – ‘one part of your life is over whenyou let your registration go’. At the same time,however, there is a perception that unregisterednurses remain nurses and ‘they can’t take it awayfrom me’.

The general view of unregistered nurses is thatthey would prefer to maintain theirregistration, to have nursing to fall back on.There are, however, cost barriers to maintainingregistration.

Many unregistered nurses talk about thefinancial cost of registration. There appears tobe some discontent with the fact that nursing isthe only profession that requires compulsoryregistration. There also appears to be issueswith the fact that registration is not transferablebetween states. For those unregistered nurseswho are working in related fields (whereregistration is not required) maintainingregistration is ‘paying for something you’re notusing’.

Generally, the belief of unregistered nurses isthat the Victorian Nurses Board does not makeit clear what is required to maintainregistration, or reapply for registration. There isa strong sense that the Board does not stipulatethe hours required (to maintain registration)and there is a widespread belief that the Boardis reluctant to send information. The overallattitude of these nurses towards the Board is‘thanks for nothing’.

As most unregistered nurses are working inrelated fields, many have tried to maintainregistration while working in new positions fora period of time. However, during this time,nurses encounter difficulties in completingshifts when working full-time. Some nursesalso describe being hesitant about doing oddshifts due to concerns about their own skilllevels (‘…concerned that my skills aren’t up todate’).

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Factors Contributing to Career Move out ofNursingWhether a conscious decision to leave, orsimply a desire to move into a related field,there is a common set of drivers that appear tobe contributing to a career move out of nursing.These can be summarised as follows:• Internal politics• Working conditions• Working conditions in nursing homes• Career development issues.

Possibly the most often mentioned contributingfactor for nurses leaving the nursing professionis internal politics. This is typically described attwo levels: politics between nurses and politicsbetween nurses and other medical staff, such asdoctors and surgeons. The former wouldappear to be of greatest concern within theprofession. In a similar way to other segmentsof nurses, unregistered nurses take the viewthat nurses do not support nurses. This can besummarised by the following quote ‘…we are ina caring profession, yet we do not care for eachother’. There is also a widely held belief thatnurses themselves are contributing to theretention issues within the profession – ‘nurseshave a lot to answer for nurses leaving’ (that is,lack of mutual respect and support for oneanother). The main issues appear to be highlevels of stress, no recognition or support and‘dictation from the hierarchy’. To a lesser extent,unregistered nurses describe a ‘power play’with doctors and other medical professionals.

Unregistered nurses also see working conditionscontributing to nurses leaving the profession.This covers a spectrum of problems, includingremuneration (unpaid overtime and generalperceptions of low pay rates compared to otherprofessions), budget cuts and staff shortages,increased workloads and burn-out. Unregisterednurses also report the fact that they are caringfor ‘sicker patients’, a factor of high patientturnovers and shorter hospital stays. This againcontributes to levels of exhaustion. Overall theissues facing unregistered nurses with regard toworking conditions are relatively consistent withother nursing segments.

Remuneration is also seen to be contributing tothe retention issues in nursing. Unregisterednurses believe that the salaries in nursing donot reflect the level of responsibility required orthe workloads.

Many unregistered nurses report the workingconditions in nursing homes as a reason toleave the profession. As quoted by anunregistered nurse: ‘…in aged care you work likea dog, get treated like a dog and get paid like a dog’.Many nurses cite examples of heavy workloadsas the result of cost cutting or ‘cutting corners’.As quoted by another unregistered nurse:‘…one nurse may be required to give 40 showers ina morning’. Unregistered nurses believe theseworking conditions are quite common in agedcare.

Finally, unregistered nurses believe that careerdevelopment issues are also contributing tonurses leaving the profession. There is a generalperception that the nursing career path leadsaway from patient care and towardadministration (an unfavourable direction asseen by many, and particularly by Division 1nurses). This career path is perceived byunregistered nurses to be limiting for thosewho want to continue in ‘hands on nursing’.Further, unregistered nurses do not see thissituation improving. It is believed thatdocumentation will become more and moreimportant, and nurses in management will berequired to take on more administrative duties.One unregistered nurse said that this will leadto ‘…stagnation in career development andincreased resentment’. Those nurses who werehospital educated prior to deregistrationbelieve that their careers are even more limited.That is, ‘…there is nothing in between wardnursing and administration, unless you docommunity work’.

What Would Entice Unregistered Nurses Backto Nursing?Despite the majority of unregistered nursesworking in related fields, it is quite clear thatthese nurses are not interested in returning toconventional nursing at least in the short term.In spite of this, however, many are interested inreapplying for registration either to providethemselves with work cover in their currentposition, or as a back up should they decide toreturn to more traditional nursing at a laterdate. Those nurses not interested in reapplyingfor registration (minority) stated that theywould ‘like to have the choice of a flexible refreshercourse’.

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What Is Known about Reapplying forRegistration?Generally unregistered nurses are not entirelyclear on what is required to reapply forregistration. One unregistered nurse wasquoted saying ‘…I would like to go back tonursing, but I don’t understand what is required’.

Those unregistered nurses who havepreconceived ideas about what is involved,believe it very much ‘depends on yourcircumstances’. Generally unregistered nursestalk about a refresher course with a ‘combinationof hands-on and theory’, with the ratio dependingon past experience and how long you havebeen unregistered.

Barriers to Completing a ‘Refresher Course’All unregistered nurses acknowledge that realbarriers exist to completing the required‘refresher course’ for registration. These barriersinclude:• Expensive• Time consuming• Not suited to everyone• Limited access to information regarding

refresher courses and costs.

When unregistered nurses describe the expenseof refresher courses they talk about both themonetary expense, ‘$3,000’, as well as the paysacrificed, that is, perception of some nursesthat refresher courses involve unpaid trainingor ‘slave labour’.

Time also appears to be a barrier forunregistered nurses completing a ‘refreshercourse’ for registration. One unregistered nursewas quoted saying ‘13 weeks full time isdemanding’. Those nurses with familycommitments appear most likely to see time asa barrier – ‘…a big inconvenience for my family’.

There is a strong sense among unregisterednurses that currently refresher courses are notrelevant or suited to everyone. For example, ‘ahospital placement is not relevant to everyone’, thatis, those not wanting to return to ward nursing.

Access to information and costs on refreshercourses is a barrier for many consideringregistration. Nurses report instances of phoningthe Victorian Nurses Board only to receive verylittle assistance – ‘…they don’t send youinformation’.

How Unregistered Nurses View Training(Generally) in the Nursing ProfessionIt is perceived by unregistered nurses thateducation and training is not readily availablein hospitals, however they also state that it ‘doesvary by hospital’. Those nurses who have beenexposed to training comment on ‘having to payfor it’. The overall view is that a nurse’sprofessional development is left to theindividual. That is, there is ‘no appraisal, noguidance as to what you are best suited to, not muchsupervision and no debriefs’.

The Way ForwardUnregistered nurses believe many actions arerequired to prevent nurses leaving theprofession. These actions include:• Increase funds to hospitals, increase staff

numbers and reduce the patient ratio. Allowfor greater flexibility, that is, shorter shifts.

• Attempt to change attitudes and encourageteamwork. Run courses to encouragebonding and communication. Encouragebrainstorming and conduct a SWOTanalysis.

• Need to clearly define roles. Nurses need tounderstand the ‘hierarchy’ and theopportunities for career development.

• The profession needs to acknowledge thatthere are problems.

• Education needs to be available, accessible(cost and time) and recognised inremuneration.

Unregistered nurses believe that implementingthese actions should be a ‘collaborative effort’among stakeholder groups.

The FutureUnregistered nurses see their future in health-related fields rather than in a clinical setting.These nurses have essentially ‘moved on’ fromthe clinical. Removal of barriers to re-registration is unlikely to entice them back intonursing.

3.10 Rural vs City NursingOverall there were remarkably few differencesbetween the city groups (Melbourne) and therural groups (Shepparton and Ballarat).

Living outside the city is referred to as alifestyle choice. Rural nurses are there becausethat is where they want to be. Nursing is

secondary to that; it is a job that they can dowhere they have chosen to live. Almost all thenurses we spoke to in Shepparton andsurrounding areas were there due to ties withthe area. Many were born and bred there andhad family still in the area.

There were some issues with rural midwives.They were frustrated with having to take ongeneral patients and felt a lack ofempowerment when doctors step in fordelivery of babies. (See Midwives section forfurther detail).

De-Skilling IssuesOn the whole nurses in rural settings feel thatthey receive exposure to a wider range ofsituations and in that sense have a wider skill-set (certainly a broader working knowledge)than their city counterparts. Few felt that theirskills were less than city nurses, more soslightly different in nature.

There was some feeling among nurses inShepparton that nurses from the country maybe seen as less skilled. This view is thought toexist among nurses and even among ruralnurses themselves. If someone has only everworked at one country hospital people tend tothink of them as less experienced than othernurses.

There were some isolated comments about alack of exposure to certain areas:• One woman had done an IV course and

needed to do a certain number of IVs permonth as a post-course requirement (shewas finding keeping that number updifficult).

• One midwife would like to specialise in neo-natal care but neo-natal units are limited tobigger cities.

• One feels that she has become less skilled inpaediatrics in a rural setting.

There is a perception among graduates andundergraduates that opportunities are greaterin Melbourne in terms of exposure to thediversity of nursing.

4. General RecommendationsFor all recommendations outlined in thissection, there is also the fundamental issue offunding. Many raise this as a prerequisite forimprovements in the future. There must begreater funding available as well as awillingness to spend it ‘fixing’ some of theissues. This willingness is seen to rely on anadmission of the issues that exist in theindustry by the Government and hospitalmanagement.

When discussing issues, nurses tend to ‘blame’those closest to the ‘grass roots’ (Nurse UnitManagers in particular). However, when askedwho is responsible for implementing changes,most believe that changes must come from thetop (government) and then need to filter downthrough levels of management. This meanshospital CEOs, Directors of Nursing, down toNurse Unit Managers, who must be acting onbehalf of their staff (generally not perceived tobe the case currently).

Although remuneration came up clearly in allgroups as a priority, we believe that there is aneed to recognise nurses in many dimensions,as the issues extend far beyond just pay. Otheractions, such as improving working conditions,facilities and career opportunities are lesstangible forms of recognition than money. (Wefeel that remuneration is likely to reduce insignificance once other factors have beenimproved).

This final section of the report makesrecommendations based on the proposedactions raised in the groups. There is noconsideration given in this section as impacts ofthese recommendations on other segments ofhealth care or for funding initiatives.

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ISSUE RECOMMENDED ACTION Remuneration is raised by all nursing segments as a majorarea of dissatisfaction and opportunity to increase industryretention.

In terms of specific actions, the current ANF public sectorpay claim is generally viewed positively, particularly for itsrecognition of the need to achieve parity betweenremuneration for nursing and other professions (acting on itwould be appreciated by the industry).

Salary ‘packaging’ is recommended as a way of bothrecognising nursing for its professional status (that is,compensation is based on more than just wages) and toprovide incentive for nurses to up-skill. Specifically,consideration should be given to the following areas ofremuneration:

• Review base salary movements for nurses who choose toremain at bedside (specifically, create more levels/tiers forsalaries to increase after more than five years—perceivedto be the cap).

• Introduce a skill recognition where nurses upgradequalifications. This should extend beyond specific skillsrelated to specialist area (but remain relevant to nursing).

• Performance reviews should be introduced (or enforced ifthey do already exist) with an emphasis on providingsupport and motivation to develop careers (rather thanjust focusing on evaluating delivery of day to day tasks).

Lower patient ratios should be a priority. They are attributedto high levels of job dissatisfaction (stress levels, feeling thatyou’re not keeping pace or performing job adequately, con-cern for patient care etc) and regarded as a key factor inburn-out and subsequent departure from the industry.

Nurses request a ratio of one nurse to every four patients(perceived by some as the recommendation in the ANF payclaim).

If this is not realistic, there should at least be an attempt toensure no more than six patients (up to eight is currentlyquite common).

There needs to be a clearer career path for nurses. In particu-lar for bedside nurses. Revisit the number of levels for bed-side nurses (consider increasing them).

There should be more opportunities to move around depart-ments/ wards if possible. Many request this as a means ofmaking their roles more interesting.

Remuneration

Workloads

Lack of career path

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As highlighted in the remuneration recommendations, for-mal performance reviews are worth implementing.

Division 2 nurses require special attention. Clearer communi-cation of career opportunities and strategic intent (vis a visthe role of Division 2 nurses) needs to be clarified.

Both of the initiatives above should increase motivation,which may increase intentions to remain in nursing.

While paid study leave is clearly attractive, simply being ableto access education, even without paid leave is the greaterbarrier to not pursuing more study.

Where funds are made available, equitable access to fundsshould be put in place. We would recommend a set amountof paid study leave per person (not per hospital unit) toensure all staff members have equal access.

Some sort of additional financial incentive is required forrural nurses who need to attend Melbourne courses, forexample, amount towards travel and accommodationexpenses.

In-service training also needs to be reviewed to ensure thatthere is equal access to all staff (including permanent nightshift workers).

Multiple entry points to graduate degree should be consid-ered:

• Tertiary entrance score • Hospital-based interview • Observation/ work experience (ideally).

There needs to be an accurate impression given about nurs-ing to applicants and they need to be interviewed to assesstheir suitability and commitment to the degree.

Within the degree there should be more clinical placements,starting from early in first year, and less time between each(consider 2 days/ week).

Set in place education programs:

• To manage expectations hospital staff have of graduates’capabilities at different stages of transition.

• To ensure staff are trained in basic teachingcommunication to develop (rather than suppress)graduates on-the-job.

Ensure graduates are given the supernumerary time that theyshould be during their first year working. This should helpimprove attitudes of more experienced nurses towards grad-uates.

Acess to Education

Graduate preparation

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Provision and appropriate access to facilities:

1. Parking (secure parking)2. Child care (hours matched to shifts)

There is opportunity to improve the working environmentfor some nurses who feel tension between nursing staff andtowards management.

Clearer role definition of management function may assist.

It is suggested in the groups that staff development daysmay also be of value to improve team bonding in a non-stressful environment.

A public education campaign to address the misinformationabout nurses is also recommended within the groups.

Facilities

Fragmentation

Community perception

1. Organisation SubmissionsAlfred HospitalAngliss Health ServiceAustralian Association of Maternal & Child Health Nurses Australian & New Zealand College of AnaesthetistsAustralian & New Zealand College of Mental Health NursesAustralian Diabetes Educators Association LtdAustralian College of Critical Care NursesAustralian College of Midwives Inc (Victorian Branch) Benalla & District Memorial HospitalBallarat Health Service Barwon HealthBendigo District Nursing ServiceBendigo Health Care GroupBox Hill Hospital Caritas Christi Palliative & Aged Care ServicesCasterton Memorial HospitalCaulfield General Medical Centre Colac Community Health ServicesDay Surgery Special Interest GroupDjerriwarrh Health ServicesDunmunkle Health Services East Gippsland Institute of TAFE East Wimmera Health ServiceEchuca Regional HealthEnrolled Nurses Special Interest Group (Victoria) Far East Gippsland Health & Support ServiceFreemasons HospitalGippsland Southern Health Service Goulburn Ovens Institute of TAFEGoulburn Valley HealthKerang & District HospitalAustralian Medical AssociationKyabram & District HospitalLa Trobe University (Mildura Campus) LaTrobe Regional Hospital Lorne Community HospitalMansfield District Hospital Maryborough District Health ServiceMaryvale Private Hospital Masada Private HospitalMayfield Education CentreMelbourne ClinicMildura Base HospitalMildura Private Hospital Mount Alexander Hospital Mount Alvernia Mercy HospitalNorth West Health Mental Health Program

Appendix Seven – Submissions Received

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North Western HealthOtway Health & Community Services Palliative Care VictoriaPeninsula Health Care NetworkPeninsula Private HospitalPeter James CentreRoyal Australasian College of General PractitionersRoyal District Nursing ServiceRoyal Talbot Rehabilitation Centre Royal Victorian Eye & Ear HospitalRural Northwest HealthSouth Gippsland Hospital South West Healthcare Southern Health Care NetworkSt George’s Health ServiceSunraysia Institute of TAFESwan Hill District Hospital Swinburne University of TechnologyTallangatta Health ServiceTerang & Mortlake Health ServiceVictorian Association of Health & Extended CareVictorian Healthcare Association Ltd Wangaratta District Base HospitalWestern District Health ServiceWodonga District Hospital Wodonga Institute of TAFEYarram & District Health ServiceYarrawonga District Health Service

2. Individual Submissions A Johansson-Wong A FergusonA Watts K Greig L Cassar M Smyth P Mayne S Kernaghan M Lees D Shillabeer M Henshaw I Royce M Buschmann

During the life of the Committee, severalsurvey instruments were generated. Due tospace constraints these instruments will bemade available on request. Please direct suchrequests to:

Geraint DugganNurse Policy BranchPolicy & Strategic Projects DivisionDepartment of Human ServicesGPO Box 4057Melbourne Vic 3000

Appendix Eight – Survey Instruments

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The Training and Development (T&D) Grantwas established as a part of the acute casemixfunding system. It is a specified grant andsimilar grants are made for medical and alliedhealth. The Grant for the acute sector is brokendown as follows:

Table A: Acute Training and Development Grant

Medical $62 million

Nursing $23 million

Allied Health (including undergraduates) $5.5 million

Medical and Nursing Undergraduates $9 million

Table B: Acute Training and Development Grant—Nursing Component Breakdown

Program Total Nurses Per Capita

Allocation Supported rate (2000)

Graduate Nurse $11.4 million 903 $12,626

Program

Postgraduate

Program $6.5 million 562 $11,573

Postgraduate

Midwifery $1.4 million 121 $11,573

Continuing Education $4 million N/A N/A

Aged Care and Sub-Acute GrantThe aged care and sub-acute T&D Grant issimilar in structure to the acute grant and theoverall funding allocation is around $5.1million. Although the nursing streams broadlyconform to the criteria used in the acute grantoutlined above, and is used in public sectorfacilities, the overall emphasis of the grantreflects the strategic priorities of the aged careand sub-acute workforce (particularly agedcare, palliative care and rehabilitation).

Table C: Aged Care and Sub-Acute Training andDevelopment Grant

Medical $2.1 million

Nursing $1.9 million Allied

Health $0.59 million

Table D: Aged Care and Sub-Acute Training andDevelopment Grant—Nursing ComponentBreakdown

Program Total Allocation

Graduate Nurse Program $1.2 million

Postgraduate Program $0.78 million

BackgroundThe nursing component of the Grant wasestablished for two reasons: the need torecognise and provide funding for specialisthospital post-registration programs already inexistence, and the need to compensate hospitalsfor employing new graduates whosecontribution to patient care was less than thatof an experienced registered nurse.

Initially, a ‘best guess’ estimate of the cost ofthe specialist programs was made and a percapita amount established. Each hospitalreceived funding for specialist and graduatenurse programs based on its number ofstudents. The graduate nurse per capitaamount was based loosely on the cost of half asalary for a new graduate plus on costs. Overtime, these per capita grants have been adjustedto reflect the more accurate costing informationavailable.

In addition to the above allocations, ‘A’ and ‘B’hospitals—those with the most beds—allreceive an additional allocation of 10% of theirT&D Grant for supervision of medical andnursing students. Allied health student supportis paid to all hospitals, based on student clinicalplacements for the previous year.

The funds available in the nursing T&D Grantremain constant with the addition of any CPIadjustments. However, changes within theallocation of the funding are made from time totime. In summary, changes to funding since theinception of the Grant have been an increase inthe per capita allocation for specialist programs,a decrease in the per capita allocation for

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Appendix Nine – Training and Development GrantDetails

graduate nurse programs, and the creation ofthe continuing education program.

Programs

Graduate Nurse ProgramIn September 1997, the Department of HumanServices published the first in a series of papersreviewing components of the nursing T&DGrant. This led to the establishment of agreedguidelines for the provision of graduate nurseprograms in Victoria, and apply to Victorianacute care and aged care public institutions(Department of Human Services 1997). Pilotschemes have also been run in the communitysector, while there is no government fundingprovided for programs run in the mental healthand private sector, including nursing agencies.Graduate nurse programs remain popular withnurses and competition for places is strong.

Criteria

The programs must be offered full-time withpro rata payment during 2000 for thoseprograms not full-time. The intent is not tofund part-time positions in 2001 unlessapproval is granted by the Department ofHuman Services. Hospitals introduced part-time programs as a cost saving means and full-time work was found generally to beunavailable to graduates. Part-time programsare considered by the Department of HumanServices to be a disincentive to undertakenursing, that is, to have a negative impact onattracting persons into nursing if full-time workis not available on completion of studies.Department of Human Services does notsupport the underemployment of graduateswhile a nursing shortage exists.

Courses must adhere to the graduate nurseprogram guidelines (Department of HumanServices 1997).

Hospital must participate in the computermatch program.

No fees are to be charged to graduatesapplying, undertaking or completing graduatenurse programs.

Clinical educator to be dedicated to program.

Postgraduate ProgramsWhile this program is currently under review ithas been designed to compensate hospitals forthe clinical experience component of studentsundertaking postgraduate nursing courses. Inaddition, the program funds a residualhospital-based critical care course.

Criteria

Course must be at postgraduate level.

Hospital must provide clinical component ofpostgraduate course. Course must require aminimum of 24 hours per week clinicalcomponent with a dedicated nurse educator (orpart-time equivalent).

Funding is provided for equivalent of full-timecourse.

Where students are undertaking courses on apart-time basis over two years, fundingequivalent to that for full-time will be paid inthe first year of the course. No funding will beprovided in the second year of the course.

Midwifery (Postgraduate) ProgramThe criteria are broadly the same as thepostgraduate program above. In addition, thereis a fixed number of hospitals receiving anallowance of $9,995 per student due tohistorical agreements reflecting old coursestructures.

In another funding model, funding wasintroduced at $3000 per student midwife towhom a minimum of 50 days clinical placementper academic year is provided by hospitals. Prorata payment may be provided to hospitalsproviding placements of less than 50 days to alarge number of students.

Continuing Education ProgramThis program is a submission-based fundinground where business plans are submitted tothe Department of Human Services forcontinuing education and professionaldevelopment. All submissions are funded froma fixed $4 million pool, so that the morehospitals apply the less funds are available forindividual hospitals. Rural and regionalhospitals are assisted in business plansubmission development by Department ofHuman Services Regional offices and they are

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encouraged to form consortia or jointprograms. Many of the programs seek to teachnurses functional skills acquisition in areassuch as information technology, customerservice and management. Others run courses inspecialties such as critical care, oncology andrenal nursing in variable forms from workshop-based formats to short courses with exitexaminations.

The program imposes a considerableadministrative burden on hospitals and theDepartment of Human Services. The currentfunding split is metropolitan hospitals $2.2million and rural and base hospitals $1.8million.

Criteria

Business plans are assessed centrally and arejudged on set criteria such as a needs analysis,evaluation methodology and financial acquittalstatements.

All Victorian acute hospitals have submittedbusiness plans or have been covered byconsortia arrangements with other hospitals.

Undergraduate Teaching AllowanceThis allowance is allocated proportionally toteaching hospitals according to casemix, that is,the greater the casemix funding the larger theteaching allowance. This allowance is onlyallocated to hospitals that have undergraduatenursing and medical students (as allied healthundergraduate funding is separately funded onan output-based model) and is not tied to anyother criteria (such as the number of studentsor the number of clinical placement days).

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