There has been inadequate capacity for building up a good understanding of the drivers of the future New Zealand-wide level demand for nurses. This has limited the potential for national oversight and cohesion in the planning of educational institutes. It also reduces the information base available to governance bodies including the Tertiary Education Commission and the Ministries of Education and Health when they have a need to challenge the strategic implications of locally made tactical decisions that have been unconstrained by any common national reference point. There is only now developing a regular, systematised process for maintaining any such New Zealand-wide understanding, through the work of DHBNZ. Indeed, the competitiveness among institutions, both DHBs and tertiary education providers, has led to some obscuring of information about current trends, and reluctance to exchange insights and experiences. The lack of national oversight has a variety of consequences, in particular:
Nurse education will not be as immediately responsive to delivery needs as overseas recruitment without strong service provider links with educators at local and New Zealand-wide levels
The national training of nurses has usually been below long term needs, as recruitment overseas is more immediately responsive, and generates fewer commitments past the current financial year.
The high costs of recruitment and a high turnover of overseas trained nurses raise the long term costs of the nursing workforce
Clinical training capacity may limit the size of future nurse intakes, reducing the capacity to “catch up”
The limited capacity to rebuild a stable age distribution in the nurse workforce after any period of under-provision may well be poorly understood
The number of nursing students from communities including Maori and Pacific Islands will not get close to national needs without national oversight and national support of initiatives
The large cohort of nurses recruited in the 1960s and 1970s are reaching retirement age
The managing of a reduction in nurse numbers during the 1990s by significantly reducing enrolment in nurse education has left a significant void in the size of the age cohort that is under 35 years, and some return to earlier lower levels of nurse numbers aged between 35 and 45 years.
While the recruitment of overseas trained nurses has enabled the number of nurses to grow even with near static enrolment in nurse education over the last decade, their older ages compared to new graduates means that during the next decade, they too will expand the numbers retiring compared to those being trained.
The nurse educator work force faces even greater problems of ensuring its replacement over the next decade.
These problems are not common to New Zealand. In the United States, the United Kingdom and Australia similar issues exist, which is why these places also remain as attractive places for New Zealand trained nurses to work, often quite soon after receiving registration in New Zealand. Buchan and Calman4 noted
High-income countries are also reporting nursing shortages. In a recent report on health systems, the OECD highlighted that, “There are increasing concerns about nursing shortages in many OECD countries”. The OECD noted: “Nursing shortages are an important policy concern in part because numerous studies have found an association between higher nurse staffing ratios and reduced patient mortality, lower rates of medical complications and other desired outcomes. Nursing shortages are expected to worsen as the current workforce ages”
Some recent examples of OECD country assessments of nursing shortages include Canada, where the shortfall of nurses was quantified at around 78,000 nurses by 2011, and Australia, which projects a shortage of 40,000 nurses by 2010. HOPE, the standing committee of hospital employers in the European Community, has also recently reported on nursing shortages in many European countries.
Many high-income countries in Europe, North America, and elsewhere are facing a demographic “double whammy” – they have an ageing nursing workforce caring for increasing numbers of elderly. For these countries, the pressing challenge will be how to replace the many nurses who will retire over the next decade. Some of these countries face shortages due to marked reductions in the numbers of nurses they trained in the 1990s as well as reduced numbers entering the nursing profession today. Attractive alternative career opportunities are now available to the young women who have been the traditional recruits into the profession.
Buchan and Calman identified four components of a policy framework to address nursing shortages that are highlighted in their 2004 international survey:
It is difficult to develop consistently applied measures of vacancies for nurses. Some of this reflects the operational nature of responses to vacancies in the health sector, in that one way or another, through stretching cover by another person, locum arrangements or otherwise managing, services continue in some form. DHBs have released measures of vacancies based on systematic approaches, and these enable us to regularly assess gaps in availability of nurses. The effective analysis of these measures is needed to inform the long term evolution of skills and roles, both across professions and within them.
Balancing DHB financial arrangements and graduate flows
Nurses are some 40 percent of the workforce in DHBs across New Zealand. As the financial fortunes and pressures on DHBs vary, one of the more immediate impacts is on the nurse workforce. Inevitably, from the short term perspective of any individual DHB, it is simplest in the short run to limit the recruitment of new graduates, as there are no industrial considerations, the saving is immediate, and the loss of more experienced staff is avoided. From the point of view of the newly graduated nurse, the need to recover the cost of training is at its highest, as is the need for experience. The new graduate will have achieved nurse registration, and for most they will have reached the peak in their qualifications. The market for nurses is international, and for nurses as with all New Zealanders, looking elsewhere increasingly involves an overseas job. Even now there are nurses trained in localities who will not find jobs in their local DHB, although training numbers at the time of enrolment in a nurse programme would have been set to meet expected needs of the DHB. While this will always be a difficult match, more can be done to ensure that the DHB system as a whole becomes the preferred employer of each new graduate, particularly as over the next few years the annual financial fortunes of even the most financially viable DHBs will fluctuate significantly. Given the comparatively small size of current BN graduating cohorts, compared to our need for nurses over the next decade, some DHB wide focus on retention is needed.
The education of a nurse takes three years to graduation and registration, with the NETP programme year then providing a structured introduction to practice, and further experience to support being fully effective in most work areas. Positions for the NETP programme now involve almost all new registered nurses. The limits on the number of new graduate placements at this stage are financial, although in the medium term the capacity to increase the number of enrolments for nurse education will be constrained by the willingness of nurses now in practice to enter educational institutions to become nurse educators. At present, educational pay levels are not comparable with practice incomes, and the variability in student numbers over the past decade has reduced the viability of some nurse programmes. More significantly, across the 17 tertiary institutions as a whole, there seems insufficient attention to the retirement profile of the nurse educator workforce. DHBs are accountable individually for how they manage the financial implications of the volatility in demand for nurses that they face, yet it is unlikely that all DHBs face the same pressures. The education system will never have the immediacy of response to the demands that DHBs place on the supply of nurses, yet in the medium term the inability to train the required share of each cohort of students in nursing exacerbates the longer term instability of the nurse workforce. Individually, DHBs can freeload on collective actions taken in the short term to increase the certainty of the future nurse workforce, unless there are processes to inform such balancing, and justify the judgments that underpin it. In the near future, with more nurses returning to work, as well as people returning from Australia, some alleviation of demand pressures will not avoid having to think now about the long run structural instability of the New Zealand nursing workforce.
Developing roles in Nursing
The development of new skills and roles across health professionals may be somewhat constrained by some industrial agreements, and more particularly by the licensing processes that result from self regulation. The development of coherent pathways across roles has long been important in nursing, as the large share of people that enter the profession start with greatly differing backgrounds and understandings of their own abilities and aptitude. Given the size of New Zealand, there is a need for a locally relevant balance between the adoption of skills and roles that are well proven elsewhere, and the wider application of locally valued approaches. This is particularly so for Maori and Pacific initiatives. The capacity to explore, evaluate, accept and implement change in roles seems unnecessarily fraught in nursing, particularly where the skills and roles overlap with other professions, particularly medicine. A body that can bring together the wider community of health professionals to engage on the evolution of roles as skills develop may well significantly increase the current limited capacity to trigger progress in these difficult issues.