Nurses are the largest group of health care professionals

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Nurses are the largest group of health care professionals providing direct patient care in hospitals, and the quality of care for hospital patients is strongly linked to the performance of nursing staff, according to an Institute of Medicine report. There is a severe shortage of nurses in Australia. Policy makers and researchers are especially concerned that retention levels of nurses in the health workforce have worsened over the last decade. There are also concerns that rapidly growing private sector hospitals are attracting qualified nurses away from the public sector. To date no systematic analysis of trends in nursing retention rates over time has been conducted due to the lack of consistent panel data.

In 2004, there were 100,372 nurses either registered or enrolled with the Nurses Registration Board of

NSW over the calendar year, a growth of 4,261 from the 96,111 nurses either registered or enrolled in

2002. This includes 84,034 registered nurses on the Register of the Nurses Registration Board of NSW and 16,338 financial enrolled nurses on the Roll of the Nurses Registration Board of NSW. The majority of this growth was in registered nurse numbers (4,109) compared to enrolled nurse numbers (152).(Ahwo, 2004)

Key Characteristics and impact on the future planning and management of the workforce group.

Nursing characteristics in the WA State-wide level:

The proportion of enrolled nurses across WA Health has decreased from 15.1% in 2001/2002 to 13.4% in 2007/2008

The average age of nurses/midwives has increased from 41.8 in 2001/2002 to 43.4 in 2007/2008

The overall proportion of males in the nursing/midwifery workforce has dropped from 10.1% in 2001/2002 to 9.8% in 2007/2008

As of 2007/2008 42% of nurses/midwives were full time, which has decreased from 44.5% since 2001/2002

Over 70% of males nurses/midwives are full time employees, compared to 38.8% of female nurses/midwives (WA Department of health, 2008)

As an outbreak of nursing shortage approaches health care systems must aim to retain the employment of nurses requiring employment.. Management should focus on enhancing elements of job satisfaction and job embeddedness that will motivate nurses to remain both in the workforce and with their employer. (Cohen, 2006) Although much of this responsibility falls on the nurse manager, nurse managers are often not provided the necessary support by top management and are neither recognized nor held accountable for nurse turnover. Other retention initiatives can include altering working conditions to reduce both physical and mental stress and addressing issues of employee health and safety. As for compensation, organizations may be well-served by offering senior nursing staff flexible working hours, salary structures that reward experience, and benefit programs that hold value for an aging workforce. (Cohen, 2006)

Key issues, supply, adequacy of the workforce, future approaches to planning.

The analysis of recent Australian nurse workforce studies highlights a number of important

factors. These include:

- the general inadequacy of numbers of nursing graduates produced over recent years to

meet demand (in terms of both replacement and growth in demand for health services);

- the ageing of the nursing workforce (and projected retirements), decreasing hours worked

and turnover will have an effect on the ability of the nursing workforce supply to replace


- growth in demand for health services is also expected to increase especially in the aged

care sector but also across acute care sectors;

- the need to increase the intakes into nursing (university and VET sector) to provide new

entrants to the nursing workforce (for both replacement and to meet growth in demand). A

number of studies were carried out examining requirements for new graduate nurses

(RNs). The projected new graduate nurses required for 2006 range between 10,182 and

12,270; and between 10,712 and 13,438 for 2010. One study projected required new

enrolled nurses and found that between 5,734 and 6,565 will be required each year

between 2006 and 2012.

- the need to better align workforce requirements with nurse education; and

- the continued need for improvements in nursing workforce data collections and processes

so as to improve timeliness in data availability and to ensure that the information

considered in Australian nursing workforce planning studies covers all key projection data

items in terms of both supply and demand. (Ahwo, 2004)

With national nursing shortages expected to climb from their current level of 6 percent to 29 percent in 2020 (HHS 2002), healthcare organizations are growing increasingly competitive with one another over their largest segment of employees. While successful recruitment into the field of nursing would help alleviate staff shortfalls, organizations ought to target retention of their current nursing staff as well. The average age of the registered nurse (RN) workforce, which has risen steadily since the mid-1980s, was 42.1 years in 2002. This number is projected to reach 45.4 years in 2010. In 1983, half of the RN workforce was under age 35; by 2002, however, only 22 percent of the RN workforce was under 35 (Buerhaus, Staiger, and Auerbach 2004). As the nursing workforce ages, organizations that are able to both retain their aging nursing staff and attract older nurses from outside their organization will be best suited to continue to operate successfully in an increasingly challenging labor marketplace. (Cohen, 2006)

Evidence implies that current job satisfaction for nurses has significant room for improvement, Jaros (1997) discovered that 50 percent of employed nurses have considered leaving nursing as a profession in the last two years, primarily because of low satisfaction with their job. Whereas older nurses are more likely to leave the hospital workforce for other positions, older nurses who do not leave are more satisfied with and committed to their employer than are younger nurses (McNeese-Smith 2000). Yet, job satisfaction is not necessarily the most accurate predictor of employee turnover. Other common predictor variables include organizational commitment, perceived job alternatives, job-search behavior, and job embeddedness (Holtom and O'Neill 2004). In comparing these variables, Holtom and O'Neill found job embeddedness to be a more effective predictor than a combination of perceived desirability of movement measures (job satisfaction and organizational commitment) and perceived ease of movement measures (job alternatives and job search). As a result, healthcare organizations would be best served by focusing their retention strategies on the elements of job embeddedness. (Cohen, 2006)

Sources of Job Dissatisfaction In addition to enhancing elements of job satisfaction and job embeddedness, the organization should address those dissatisfiers that lead to deflated morale, low job satisfaction, and increased employee turnover. A plethora of staff surveys have been published that identify those issues that most often lead to low job satisfaction among nurses.(Cohen, 2006) In a study by Hart (2001), low morale in the workplace was reported by approximately 68 percent of working nurses and by 81 percent of nurses considering changing careers

According to Hart (2001), the top reason, besides retirement, that 56 percent of nurses leave patient care is to seek a job that is less stressful and less physically demanding. High levels of job dissatisfaction have also been attributed to scheduling, unrealistic workloads, mandatory overtime, and hospital administrators' perceived lack of responsiveness to nurses' concerns (Gerson and Oliver 2005). According to Reineck and Furino (2005), the most frequently reported work-environment issues identified by RNs are increased paperwork (82 percent), increased severity of illness (70 percent), government regulations (64 percent), RN turnover (61 percent), need for second-language skills (58 percent), voluntary overtime (53 percent), and pressure to reduce time on the clock (51 percent).

Extent to which redesign strategies have been proposed.

In July 2004 the Australian Government announced additional nursing places for 2005. Total

additional places, based on data supplied by the DEST, are estimated to be 1,494 nationally

(including midwifery and aged care nursing places). The estimated total number of

undergraduate nurse commencements (based on 2003 commencements) with these additional

1,494 places is 9,382. These figures assume no current nursing places are lost and refer to

commencing nursing students rather than completing nursing students. Not all entrants to

undergraduate nurse education complete their courses and enter the nursing workforce. It is

therefore important that completion and entry to the nursing workforce rates are high to ensure

maximum benefit of increased intakes into undergraduate nursing courses are felt in the

workplace, and that new entrants to the workforce are retained. This will require monitoring over

coming years. Most recently available data specifically for nursing estimated a 78% retention

rate in 1999 for undergraduate nursing courses (Nursing Education Review, 2002). The results

from the 2003 graduate destination surveys show that 95% of nursing graduates in full time work

are working as registered nurses and 90% of nursing graduates in part-time work are working as

registered nurses (note: this survey had a 62.7% response rate of all graduates) (Graduate

Careers Council of Australia 2003 and 2004). (Ahwo, 2004)


This report has analysed the current nursing workforce characteristics, key issues, strategies, trends and possible solutions to provide a better service in future..

Throughout all reviewed sources, a number of consistencies are found. These include: the ageing of the nursing workforce and subsequent expected retirements over the next decade; and the inadequacy of recent past and current new registered and enrolled nurses to meet projected replacement needs as well as growth in demand for health services in the future.

As highlighted in this paper, the total projected required number of new graduate nurses (RNs)

by 2006 ranges from between 10, 182 (Preston 2002) and 13,438 (Access Economics 2004). By

2010 an estimated 10,712 (AHWAC analysis of Karmel and Li 2002) and 13, 438 (Access

Economics) new graduate nurses will be required. These are in effect new RNs who have

completed their undergraduate nurse education and have entered the nursing workforce. The

additional nursing places (for new entrants to undergraduate nursing courses in 2005)

announced by the Australian Government will contribute to increasing the supply of new

graduate nurses, but will not be sufficient to meet projected demand based on replacement

(turnover and retirements), population growth and ageing and increasing demand for health


This means a range of further policy responses will be required to ensure Australia has an

adequate supply of nurses entering, and remaining in, the Australian nursing workforce. From

the estimates provided in the national workforce planning reports considered in preparing this

paper, this will need to include further increases in nurse undergraduate intakes. However,

issues around the support of student nurses in the clinical environment, retention of nursing

students, the subsequent support of new graduate nurses and the retention of nurses in the

nursing workforce also need to be addressed. In this context, the National Nursing and Nursing

Education Taskforce has been established by the Australian Health Ministers Conference and

the Taskforce will be overseeing recommendations dealing with such additional issues in the

context of implementing aspects of the 2002 National Review of Nursing Education.

In the short term, there is no need to commission any further national nursing workforce planning

projects for the nursing workforce as a whole. The national nursing workforce planning projects

reviewed in preparing this paper have contributed sufficient advice on future nurse workforce

supply and recommended levels of undergraduate nurse intakes. The scope of the challenge is

quite clear, what is now required is implementation. In turn this will require all stakeholders to act

cohesively and decisively to further boost nursing workforce intakes and to put in place

suggested reforms within the education and clinical environment to ensure the nursing workforce

is trained, retained and supported. (Ahwo, 2004)