Many roles in nursing have a demanding, physical side and older nurses can find themselves less able to do the full mix of activities long expected of them. Many roles are immensely stressful, and this limits the capacity to have a long career. Given that only six percent of men are nurses, then the birth and upbringing of children more often break the career of nurses. Increasingly, nurses are the main breadwinner in families.
The nurse workforce fluctuates at high cost to nurses, particularly in the many parts of the country where employment options in the same field may be few.
Chart 9: Nursing workforce exit rates by age groups
Source: Health Workforce Information Programme
Note: this modelling is a work in progress, these are not final estimates
Nurses have experienced a significant change in roles in relationship to managers and other health professionals over the past two decades, often with a high degree of adhockery in the direction of change, and rarely with any consistency across health service as a whole.
There are an unknown number of nurses who have completed training and still hold, or have held nurse registration, and who could re-enter the nursing workforce. Recent increases in pay levels have seen a return to nursing of older nurses, and a continued growth in the share of nurses who now work part-time. New Zealand seems to have an unusually large share of nurses who work part-time, about which we have mainly anecdotal based understandings. A change in the terms of employment of registered nurses will have a huge impact on projections of the number of new BN graduates that might be needed in New Zealand, and this needs to be researched as a matter of some priority on a national basis.
Managing the contribution of overseas trained nurses in New Zealand
Overseas trained nurses play a significant role in meeting the need for nurses in New Zealand. Some particular ways they have been used include:
Enabling health services to continue in areas where vulnerabilities have the least visibility (e.g. intellectually disabled services) or where anticipating needs at a time of major change was poor
Enabling short term replacements for nurses as they retire from cohorts that have employed an unusually large number of nurses, in particular the post war baby-boomers
Meeting short term fluctuations in demand where population change far exceeds the more even annual graduate flow. This has been of major significance to the Auckland DHBs, as a consequence of comparatively large immigrant swings in migrant flows.
Providing professional resources when major one–off increases in health institutions or services occur (recently proposed theatre increase, primary care)
The short term responsiveness of the supply of overseas trained nurses has diluted the commitment to meeting long term labour force needs from the education of New Zealand men and women. Recruitment of overseas trained nurses has undoubtedly contributed to lessen the momentum to develop the Maori and Pacific nurse work force, and most importantly led to a more fragile age distribution in the nurse population, which now makes more critical the need to examine the existing levels of New Zealand men and women seeking to enter nursing. New Zealand has the highest level of its registered nurses who work in New Zealand and who are foreign trained, and the level of 23 percent in 2004 compared to 8 percent for both the UK and Ireland5.
In three of the past four years, registrations for overseas trained nurses have exceeded the number of first time registrations of New Zealand trained nurses.
Chart 10: Comparison of Annual Registrations of New Zealand Trained and Overseas Trained Nurses
Source: HWIP, Nursing Council
Note: these are all registrations from 2001 through 2008 regardless of where and when they started working.
Influencing the place of nursing as a preferred profession of New Zealand men and women
If we compare the teaching and nursing work force, they are both very large occupations, which have traditionally been lifetime vocations for many. Both occupations face huge discrepancies between where they are needed to work, and where they will work once trained. Maori and Pacific teachers make up a significantly larger share of the teacher population, but both nursing and primary teaching have comparatively few males.
The devolution of the responsibility for recruiting teachers has not changed the longstanding involvement of the Ministry of Education in the promotion of teaching as a career. No such comparable activity exists for nurses, yet the fact that nursing has experienced an extra-ordinary fall off in interest from younger people has been obvious for well over a decade.
It is unlikely that initiatives to increase the share of nurses who are Maori, or Pacific nurses, will be fully effective unless there are broadly based initiatives to quite significantly change the interest in nursing as career among young New Zealanders. An exercise to raise interest in nursing as a career would need to be based on sound research of attitudes of different cohorts to nursing, and what underpins the satisfaction nurses now obtain from the practice of their profession.
G.Leadership of the nurse education system
There are a comparatively large number of diverse institutions involved in nurse education. There are many alternative approaches to the system we have, ranging from retaining the current high degree of institutional independence, to having a high degree of collaboration, such as in developing nationally applicable programmes for some courses. For some groups such as Maori nurses, the opportunity to develop locally relevant ways is well supported by the current diversity, but then it appears that as in the health service, it is almost impossible to implement system wide change where that is well justified.
Nurse leadership exists through the Nursing Council of New Zealand. There is leadership through the College of Nurses Aotearoa, the Nurse Education in the Tertiary Sector (NETS), the Nurse Executives of New Zealand (NENZ), and the NZ Nurses Organisation which also has a number of professional nursing sections. There is a network of the District Health Board Directors of Nursing. Other relevant organisations include those focused on Maori, such as the NZNO group Te Rununga, and Te Rau Matatini, and Pacific nursing groups.
Nurses in practice operate within management structures that give varied recognition to the professional leadership of nurses. In all DHBs, there is now a Director of Nursing, as is the case in many large community and private sector organisations, such as Plunket and Pegasus Health. The DHB Directors of Nursing fit into a great variety of places in DHB management structures. Most do not have significant budget authority, or report direct to the DHB Chief Executive. The DON network has met regularly since 2007, and the Nurse Executive group has existed in various forms since it began as the Chief Nurses of New Zealand in 1984. In its current form it meets three times a year, has a cross sector professional leader membership and has a regional network. This forum has the strategic objectives of practice leadership, future workforce and practice effectiveness. As with all other collective groups in the health sector, the Directors of Nursing as a group draws authority and decision-making capacity solely from the impact of individual Directors of Nursing, as there is no distinct group mandate. Apart from the Nursing Council of New Zealand, there is no nation-wide body of nurse leaders that could give effect to system-wide decisions, were they within its brief.
NENZ and NETS have a working group that meets three times a year, on shared issues. A number of joint statements have been prepared in recent years by the Nurse Executives of New Zealand, and the Nurse Education in the Tertiary Sector (NETS) network (e.g. “Work Ready Graduate”, “Clinical Practice Experience for Undergraduate Nursing”, “Development of the Regulated and Unregulated Workforce: Creating a Consistent National Learning Framework”). These highlight the importance of collaboration in bringing sufficient authority to commonly agreed approaches on matters that can shift the integrity of the nurse education system as a whole. They would generate a strong momentum at the start of any more formalised collaborative arrangements.
There are not regular forums that have a nation-wide decision-making authority that bring together both those who lead the provision of nurse education, and those who lead the services that nurses enable. Given the diversity of perspectives that quite naturally pervade individuals who hold leadership roles, a number of significant choices about the education and training of nurses exist. While the existence of well articulated but divergent views on the place of nurses and their education undoubtedly reflects well on the vibrancy of thinking about the future of the profession, the ongoing lack of resolution is seen elsewhere in our fragmented national health service, most generally in the inability to influence nationally how things are done, regardless of the level of agreement in doing so.