Nursing shortage cripples the regions

amanda-kennyAssociate Professor Amanda Kenny

An audio version (MP3 6.5MB) of this opinion piece read by Professor Amanda Kenny is also available.

For well over two decades there have been dire warnings of a looming crisis in the health care system due to the exponential increase in the ageing population, the burden of chronic disease and significant workforce shortages. In rural areas, we are now seeing the beginnings of catastrophic health workforce shortages that without action will cripple the health care system.   

Shortages in the rural medical workforce are well known and numerous strategies have been put in place to attract doctors to rural and regional Australia. While there are exceptions, largely these attempts have made little difference.  Alternative models of service delivery, with a strong emphasis on expanded roles for nursing and allied health professionals can no longer be contested. The reality is there is no choice.

The focus on rural doctors has detracted from planning for the catastrophic situation we now have in nursing. Nurses account for over 60% of the total health workforce and in rural areas these figures are much higher. The majority of rural hospitals have no onsite medical staff; nurses staff the hospital and are integral in first line care.

The average age of nurses in rural and regional areas is now over 50 years of age and a large percentage of the workforce will either retire or leave the profession in the next decade.

Alarmingly, there is a national trend toward falling interest in nursing as a career, with many universities seeing declining application numbers.

A problem of this magnitude is not easily solved; however, inaction or the piecemeal approach that has been characteristic of the last few years is not an option. Little will be achieved by offering more university places if they arent filled. A considerable amount of work must be done in creating more flexible models of education.

Generational research indicates that school leavers will change career direction frequently and often dont want to be locked in to three or four year degrees. It is difficult to ascertain how many prospective students delay or do not attend university as the lure of financial reward from employment is so much more attractive than incurring a HECS debt.

Transparent pathways that maximise credit for prior learning must be developed. Students want to clearly identify a pathway where they can work and complete small chunks and achieve qualifications that they can build upon. A person might start as a health care worker with a certificate from the VET sector; gain a qualification that provides division two nursing registration [enrolled nurse] and then progress to degree level studies. Strong linkages between industry, universities and the VET sector are crucial.

Leaders in universities must recognise that historical models of education do not fit with the needs of current and future students.  In Victoria, research has indicated that 80% of students enrolled in nursing programs work more than 15 hours per week. Many struggle to balance full time jobs with full time study.

There is evidence to indicate that increasingly mature age students will form a larger percentage of university student numbers. A recent study with mature age nursing students from all Victorian educational institutions indicated that inflexible, archaic timetabling was one of the major issues impacting upon students ability to study.

An important workforce strategy for building a sustainable nursing workforce is conversion of division two nurses to division one. Universities and health services must work together to design flexible programs to ensure these students can continue to work whilst they are upgrading their qualifications.

Rapid developments in technology provide the opportunity for students to study at a time and place that is convenient. There is no evidence that students learn more by sitting passively through a lecture conducted in a university than they do by having the opportunity to download and watch a lecture that they can repeat a number of times or engage in innovative technologically supported activities. Live with a group of young people and you will quickly realise this is the way they conduct their lives.  

Simply increasing nursing places in universities does not account for the major problems that exist in sourcing clinical experience placements for students. Professional placements have been identified by the National Health Workforce Taskforce as one of the major issues that impact upon workforce development.

Maximising professional placements is difficult and health services are faced with the relentless barrage of requests to take more and more students. It is a circular problem. Health managers dont have enough staff to adequately supervise students but unless they support student learning they will fail to recruit their future workforce.

Interestingly, there are still people who suggest a return to the apprentice style hospital training. This is not an option. Health care has changed and students require a strong theoretical university underpinning to prepare them for the complexity of their roles.

However, the transfer of nurse education to the university sector created a significant divide between education providers and the health care industry. Preparing a future workforce requires models where universities and health services view education as a joint responsibility. There are some very exciting models that have been developed where students gain paid health service employment while they study. Surely it is better to have a future health professional gain valuable experience in health rather than in a fast food chain.

The reality is that there are not enough nurses and nor will there be in the foreseeable future. The health workforce requires major restructure.  Roles for health care workers who provide some fundamental care attract opposition from industrial bodies and some sections of the nursing profession but there is little doubt that these roles will expand. The majority of people would prefer to be washed and fed by a properly prepared and supervised health worker than not receive this care. Nurses should provide high level nursing care but they must be supported by health workers who assist individuals with basic care needs. The challenge is to educate future nurses with solid delegation, supervision and leadership skills.

Central to a future sustainable rural health workforce is proper investment in rural and regional education. The evidence that students who study and live in rural communities are much more likely to work in those areas is irrefutable.

There are no easy answers, but maintaining the status quo is no longer an option. People are getting older, fatter, and unhealthier but the number one crisis in this country will be how to deliver services when you have no health workforce.