Emeritus Professor Christine Duffield FACN
Australian College of Nursing President
There are many reasons why a nurse may leave our profession. Family obligations, pursuit of educational opportunities or a different career path, retirement, to attain work-life balance or simply taking time out are a few that spring to mind. Some nurses may decide to return after a period of absence, but as many have found, getting back into our profession is not easy.
Employers may be reluctant to take on someone who has not practised recently which is understandable. New drugs enter the market, different nursing techniques are introduced (proning is a good example of this), and treatment regimens change. An employer has a responsibility to ensure that a nurse is practising according to current evidence and guidelines and that there is not a knowledge and/or skills deficit. For a nurse returning to the workforce, this can entail additional training and/or supervision of practice for a period of time.
Generally, a nurse who has previously held registration in Australia but does not meet the requirements for recency of practice, for example, someone who has had a lapse in practice of five years or more, must complete a Nursing and Midwifery Board of Australia (NMBA) approved re-entry to practice pathway (NMBA 2022). This may consist of supervised practice for a set time or completion of an NMBA approved re-entry to nursing program. The process is more complex for those who have been out of the workforce for more than five years.
While this process affords a degree of security in ensuring safe practice, there are resource implications in terms of time and financial costs for the nurse and the employer. Turnover of staff is costly – estimated in 2015 to be $48,790 for each nurse replaced in Australian hospitals (Roche et al. 2015). More cost-effective is retaining staff, but some might say this is easier said than done in today’s current employment market.
Alarming data from the USA indicate that in 2021 hospital turnover increased by 6.4% to 25.9% (NSI Nursing Solutions 2023). Australia is also facing another shortage of nurses. This comes off the back of a 5.8 per cent per annum increase in the number of nursing students graduating from Australian universities (2004-2018) and, a 26 per cent unemployment rate of new graduates from 2004–2019 six months after graduation (Doleman et al. 2022). Since then, absolute numbers of nursing school enrolments declined in 2019, and the number of visas granted to immigrating nurses has dropped by almost 25 per cent (Australian Government 2022).
National data show the number of nurses and midwives who are registered but not practising has increased by 63 per cent in the five years to 2021, and about 20 per cent of Registered Nurses (RN) say they are likely to leave their current position in the next 12 months (McKinsey 2022). Aphra data from December 2022 indicate that there were 10,177 non-practising enrolled and registered nurses. This may not sound like many. However, in the context of a projected shortage of 20,000 to 40,000 nursing positions left unfilled by 2025, assisting these nurses to re-enter the workforce reduces the shortages by 50 to 25 per cent respectively.
In a survey across all sectors including health, McKinsey found that the top three factors employees cited as reasons for quitting were not feeling valued by their organisations (54 per cent), not feeling valued by their managers (52 per cent), or not feeling a sense of belonging at work (51 per cent) (McKinsey 2021). These are all aspects of a positive work environment very much under the control and influence of organisational managers as are workload, understaffing, inappropriate skillmix and skillsmix. All of these factors lead to burnout, intention to leave, turnover and increasingly, a labelling of nurses as lacking in resilience. The work conditions all health professions have faced during the past few years with the pandemic would challenge anyone’s resilience!
The growth in industrial action overseas and across Australia would seem to indicate that our profession has had enough of being overworked, underpaid and undervalued. We need to conceptualise nurse staffing differently. Zaranko et al. (2022) found that an extra 12- hour shift by an RN was associated with a reduction in the odds of a patient death of 9.6 per cent (skillmix) but more significantly, adding an additional senior RN (in NHS pay band 7 or 8) had 2.2 times the impact of an additional band 5 RN (skillsmix). Retaining staff not only saves money but saves lives.
Perhaps more importantly, Saville et al. (2022) have found that staffing to average demand with low numbers of permanent staff risks care quality and safety. A reliance on temporary staff is costly, and results in more understaffing than setting staff establishments at higher levels. They recommend that contrary to current practices, overstaffing is cheaper financially and results in more positive patient and staff outcomes.
Recruiting more nurses is a short-term solution. We cannot continue to ‘shed’ nurses – constant recruitment and retraining is costly and time consuming. Overwhelmingly the evidence suggests that decreasing workloads, ensuring an appropriate number and mix of staff (skillmix and skillsmix), is a much more cost-effective investment. Perhaps as important, if not more important with today’s workforce, is valuing the role of nurses and the work they do, rewarding them appropriately in financial and non-financial terms, and enabling them to work to their full scope of practice.
With the International Council of Nurses (Buchan et al. 2022) predicting that 13M more nurses will be needed in the coming decade, nearly half of the current nursing workforce, I am reminded of the often-quoted words by Professor Margretta Styles (2003),
“Imagine a world without nurses. Think of a world without persons who know what nurses know; who believe as nurses believe; who do what nurses do; who have the effect nurses have on the health of individuals, families, and the nation: who enjoy the trust that nurses enjoy… imagine a world without nurses.”
References
Australian Government (2022). Australian Migration Statistics, 2020–21, Australian Government Department of Home Affairs, January 17, 2022.
Buchan J Catton H Shaffer F (2022). Sustain and Retain in 2022 and Beyond: THE GLOBAL NURSING WORKFORCE AND THE COVID-19 PANDEMIC. ICNM, Philadelphia:
https://www.icn.ch/system/files/2022-01/Sustain%20and%20Retain%20in%202022%20and%20Beyond-%20The%20global%20nursing%20workforce%20and%20the%20COVID-19%20pandemic.pdf
Doleman, G., Duffield, C. Li, l. and Watts, R. (2022) Employment of the graduate nursing workforce: A retrospective analysis. Collegian: The Australian Journal of Nursing Practice Scholarship and Research. 29(2), 228 – 235.
McKinsey & Company (2021). ‘Great Attrition’ or ‘Great Attraction’? The Choice is Yours, McKinsey Global Publishing
McKinsey & Company (2022). Should I stay or should I go? Australia’s nurse retention dilemma, McKinsey Global Publishing
NMBA (2022). Re-entry to practice for nurses and midwives, Nursing and Midwifery Board of Australia, Australian Health Practitioner Regulation Agency
NSI Nursing Solutions (2023) NSI National Health Care Retention & RN Staffing Report, NSI Nursing Solutions, Inc.
Roche, Duffield, C., M., Homer, C., Buchan J. and Dimitrelis, S. (2015) The rate and cost of nurse turnover in Australia. Collegian: The Australian Journal of Nursing Practice Scholarship and Research. 22(4), 353-358.
Saville, C., Monks, T., Griffiths, P. and Ball, J.E., (2022). Costs and consequences of using average demand to plan baseline nurse staffing levels: a computer simulation study, BMJ Quality & Safety 2021 Jan; 30(1): 7-16
Styles, M.M (2003). The Gretta Foundation: Our mission and history. https://grettafoundation.org/who-we-are/our-mission-history/
Zaranko, B., Sanford, N.J., Kelly, E., Rafferty, A.M., Bird, J., Mercuri, L., Sigsworth, J., Wells, M., Propper, C. (2022) Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study, BMJ Quality & Safety 2023 May; 32 (5): 254-263
