A nurse Education and Training Board for New Zealand

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It is recommended to the Minister of Health that he:

  1. Notes that in considering proposals from the current reviews of the health system and health workforce, there would be considerable benefits in building up high level governance of the system we have for nurse education and training.

  2. Notes the high level of commitment among nursing groups that were consulted as requested about a nurse education and training body

  3. Notes the need to bring health professionals together more effectively in the oversight of the whole health workforce, in training and in the establishment of roles and evolution of skills needed for the treatment and care of New Zealanders

C.The Place of Nurses in the Health service

Nurses work wherever health care and prevention exists

Nurses lead the care of patients and the delivery of health services through young to old in public institutions, private organisations, community organisations and the home. Across these places, the structures that nurses work in vary considerably. Nurses may work autonomously, without a support structure, as part of teams within structured work groups, or some in between arrangement. We have few studies of the way in which the work of nurses has evolved, and the extent to which education and training is relevant for the demands placed on nurses across so many different settings.

Chart 1: Where nurses work in the New Zealand health service, 1986 to 2006

Source: Statistics New Zealand, 1986, 1996, 2006 Census of Population and Dwellings

We have seen considerable change not only in the scale and nature of the demands of people in New Zealand for health services, but the health system in New Zealand has undergone three major transformations in the last two decades. These transformations have either stimulated or followed shifts in the demands placed on nurses, and they have not always increased the capacity of nurses or other health professionals to meet peoples’ needs for health services. Nurses have had to adapt as the health system itself has evolved. As hospital stays have reduced, from a mean stay of seven days in the mid 1990s to around three days now, the acuity of patients in hospital has increased considerably. Over this period, in general, health practitioners have become more specialised, perhaps doctors more so than nurses and allied health professionals, while the share of patients with multiple chronic conditions has increased. Some 40 percent of acute patients are people with multiple chronic conditions, a large minority of who are usually resident in some form of aged care institution. Nurses working with people with acute conditions fill an increasingly complex role. We have little measure of the impact of the increased acuity on the demands we place on health services, and as a consequence we are less able to anticipate further shifts in workforce needs.

The Director-General of Health needs to develop a regular assessment of how DHBs identify and meet their collective obligations for training of health professionals, and should require the DHBs to provide each year to whatever new governance body is established, their collective strategies for raising the retention rates of nurses in the New Zealand health service

Whether they work as a Plunket nurse, in a ward of a major hospital, mental health nurse or as a specialist practice nurse in a medical centre, nurses are most often the constant element in the care and oversight of the variety of conditions and treatments faced by patients, the culmination of which may regularly require other support services. A stable nurse service is fundamental to both the resilience and the managed adaptability of the health service.

Nurses in the health work force

DHBNZ reports that the total regulated active nursing workforce working in nursing in New Zealand is now 40,616. Nurses make up approximately half of the registered health professionals in DHBs, and are just under 40 percent of the hospital workforce. Whereas until the mid 1980s, some 80 percent of nurses worked in a hospital setting, this share has continually fallen over the last two decades, so that now about half of all nurses in the health sector work in hospitals. Other major places where nurses increasingly work are in general practice, primary care and in the community sector, where there are generally fewer support structures for nurses in the field. In primary care, nurses comprise some 22 percent of the total paid primary care workforce of approximately 29,000.

Chart 2: Trends in the significance of nurses in the health workforce

Source: Statistics New Zealand, 1986, 1996, 2006 Census of Population and Dwellings

Nursing has long held a significant place in the occupational expectations of women. There has more recently been a huge shift in the composition of the younger nurse workforce. Although some of this shift reflects deliberate efforts to recruit older students into nursing, it also suggests that in the last 10-15 years New Zealand women do not now see nursing in the same light as did earlier birth cohorts. If this shift is not addressed by some mix of policy, managerial and operational initiatives, there will be a significant decline in the resilience of the nurse workforce, as the capacity to educate future cohorts with the necessary academic and clinical competence may well decline at a time when we expect to have more being trained. Nurse numbers fell from 1986 to 1996 by some five percent, and in the decade since 1996 they increased by nearly 18 percent. The number of nurses in employment over this same time has risen from over 36,300 in 2002 to 40,600 in 2008. The increase in the share of registered nurses who are currently in the workforce has been attributed to the pay adjustment several years ago. Over the last decade, the mean age of the nurse population has risen, with the share of New Zealand trained nurses aged under 35 years at its lowest ever level. The age composition of the nurse workforce is now a matter of serious concern, as the capacity to influence the number of New Zealand trained nurses through traditional means has been seriously eroded. These concerns have been apparent for some time, yet there seem to be insufficient national levers to influence change and reinforce the mix of localised initiatives.

Chart 3: Ratio of overseas trained to NZ trained nurses by age, 2001 to 2008

Source: Health Workforce Information Programme, Nursing Council Registration Database

Note: an upward slope indicates more overseas trained nurses relative to the NZ trained

Chart 4: Comparison of age distribution in 2008 of NZ trained and overseas trained nurses

Source: Health Workforce Information Programme, Nursing Council Registration Database

Note: excludes nurses younger than 21 years and nurses whose age is unknown
Nursing and teaching are two professions that employ many people, mainly women, where recruitment and retention can have profound long term effects. There are over 30,000 women teachers in New Zealand, leaving nursing with some 40,000 as the largest single occupation employing women, and the largest professionally trained workforce in the country. The significance of nursing as a key occupation for New Zealand women has been on the wane for nearly two decades, as can be seen in the analysis of the age of nurses as reported in the five yearly census of population. Teaching has not experienced this decline. Whereas in teaching, there have been regular national campaigns to encourage people into teaching, for nursing there have been no national campaigns. Local initiatives such as the Inzone bus and local DHB programmes cannot substitute for this.

Chart 5: Females reporting occupation as nurse as a percentage of the population in age group, for given birth cohort, 1942-51 to 1972-81

Source: Statistics New Zealand, 1986, 1996, 2006 Census of Population and Dwellings

Nursing is the largest occupation women take on. The consequences of being a large share of the health workforce, means that nurses most often bear the brunt of financial pressures on DHBs and on other health services. This can affect nurses by

  • Necessitating a change in employment or vocation

  • Influencing the advice given to local nurse education universities or polytechnics on the current demand for nurses

  • Determining the share of each graduate cohort that has local employment opportunities, on graduation.

  • Amplifying the fluctuations in job opportunities when nurses seek to change jobs, return to nursing, or seek promotion

The number, place and composition of the nurse workforce in New Zealand has undergone one of the most marked transformations over the last two decades of any key workforce that continues to have considerable relevance to New Zealand. Nursing will continue to experience a high rate of change, although we remain uncertain about the future level of need for nurses, the mix of skills they will have and the roles they will fulfil. Factors which are most critical to the future resilience of the nurse work force include:

  • The means of influencing the flow, ethnicity and age of those who seek entry into the Bachelor of Nursing (BN) courses

  • Increasing the retention of nursing students during degree studies

  • The capacity to find positions for nurses during training and immediately after graduation

  • The age distribution of the current nurse work force

  • The retention or return of registered nurses to nurse occupations

  • The age distribution of the nurse education workforce

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