THE CRITICAL CARE NURSE WORKFORCE IN AUSTRALIA

Transcription

1 Australian Health Workforce Advisory Committee THE CRITICAL CARE NURSE WORKFORCE IN AUSTRALIA AHWAC Report December 2002

2 Australian Health Workforce Advisory Committee 2002 ISBN X This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. Reproduction for purposes other than those indicated above requires the written permission of the Australian Health Workforce Advisory Committee. Enquiries concerning this report and its reproduction should be directed to: Executive Officer Australian Health Workforce Advisory Committee c/- New South Wales Health Department Locked Mail Bag 961 NORTH SYDNEY NSW 2059 Telephone: (02) [email protected] Suggested citation: Australian Health Workforce Advisory Committee (2002), The Critical Care Nurse Workforce In Australia, AHWAC Report , Sydney Publication and design by Australian Health Workforce Advisory Committee. Printing by Ligare, Sydney. ii

3 CONTENTS LIST OF TABLES...V LIST OF FIGURES...VII ABBREVIATIONS..VIII TERMS OF REFERENCE FOR AUSTRALIAN HEALTH WORKFORCE ADVISORY COMMITTEE AND THE AHWAC CRITICAL CARE NURSE WORKFORCE WORKING PARTY...VIII MEMBERSHIP OF AUSTRALIAN HEALTH WORKFORCE ADVISORY COMMITTEE...XI MEMBERSHIP OF THE AHWAC CRITICAL CARE NURSE WORKFORCE WORKING PARTY...XII EXECUTIVE SUMMARY AND RECOMMENDATIONS... XIV PART A: THE ADULT CRITICAL CARE NURSE WORKFORCE IN AUSTRALIA 1. INTRODUCTION, BACKGROUND AND DEFINITIONS PROVISION OF INTENSIVE CARE SERVICES CONSUMER PERSPECTIVES OF THE CRITICAL CARE NURSE WORKFORCE CRITICAL CARE NURSE DATA SOURCES METHODOLOGY OF THE CRITICAL CARE NURSE WORKFORCE PROJECT CRITICAL CARE NURSE EDUCATION THE CURRENT CRITICAL CARE NURSE WORKFORCE ADEQUACY OF THE CURRENT CRITICAL CARE WORKFORCE CRITICAL CARE NURSE REQUIREMENT PROJECTIONS CRITICAL CARE WORKFORCE SUPPLY PROJECTIONS CRITICAL CARE WORKFORCE PROJECTIONS: BALANCING SUPPLY AGAINST REQUIREMENTS RECOMMENDATIONS FOR THE CRITICAL CARE NURSE WORKFORCE PART B: THE PAEDIATRIC INTENSIVE CARE NURSE WORKFORCE IN AUSTRALIA PAEDIATRIC INTENSIVE CARE DESCRIPTION OF THE CURRENT PAEDIATRIC INTENSIVE CARE NURSE WORKFORCE ADEQUACY OF THE CURRENT PAEDIATRIC INTENSIVE CARE NURSE WORKFORCE FUTURE REQUIREMENTS SUPPLY PROJECTIONS iii

4 APPENDICES APPENDIX A: GLOSSARY APPENDIX B: RURAL, REMOTE AND METROPOLITAN AREAS CLASSIFICATION APPENDIX C: ANZICS RESEARCH CENTRE FOR CRITICAL CARE RESOURCES SURVEY APPENDIX D: MINIMUM STANDARDS AND STAFFING GUIDELINES APPENDIX E: 2003 AIHW LABOUR FORCE SURVEY APPENDIX F: DATA SOURCES AT THE STATE/TERRITORY LEVEL APPENDIX G: WILLIAMS AND CLARKE METHODOLOGY APPENDIX H: VAN KONKELENBERG MODEL APPENDIX I: NURSE EDUCATION (FRAMEWORK AND ARTICULATION) APPENDIX J: PROJECTIONS: NEW SOUTH WALES/AUSTRALIAN CAPITAL TERRITORY APPENDIX K: PROJECTIONS: VICTORIA APPENDIX L: PROJECTIONS: QUEENSLAND APPENDIX M: PROJECTIONS: SOUTH AUSTRALIA APPENDIX N: PROJECTIONS: WESTERN AUSTRALIA APPENDIX O: PROJECTIONS: TASMANIA APPENDIX P: PROJECTIONS: NORTHERN TERRITORY APPENDIX Q: PROJECTIONS: AUSTRALIA (TOTAL) REFERENCES BIBLIOGRAPHY iv

5 LIST OF TABLES TABLE 1: ADULT ICU BEDS BY SELF-DETERMINED ICU LEVEL, PUBLIC AND PRIVATE SECTOR, TABLE 2: PROPORTION OF VENTILATED AND NON VENTILATED AVAILABLE BEDS, PUBLIC AND PRIVATE SECTOR, BY LEVEL, TABLE 3: ICU TYPE AND BED CHARACTERISTICS, TABLE 4: ICU BEDS, PUBLIC AND PRIVATE SECTOR, BY ICU TYPE, TABLE 5: ICU BEDS AND ICU BEDS PER 100,000 POPULATION, PUBLIC AND PRIVATE SECTOR, BY STATE/TERRITORY, TABLE 6: ICU BEDS, PUBLIC AND PRIVATE SECTOR, BY BED CATEGORY AND STATE/TERRITORY, TABLE 7: ICUS: AVAILABLE BEDS AND VENTILATED BEDS, BY PUBLIC AND PRIVATE SECTOR, 1997, 1998 AND A TABLE 8: ICU ADMISSIONS, A TABLE 9: SUMMARY OF CONSUMER CRITICAL CARE ISSUES AND THEIR WORKFORCE IMPLICATIONS TABLE 10: NATIONAL NURSE LABOUR FORCE SURVEY, OVERALL RESPONSE RATES AND NON-RESPONSE STATUS TO INDIVIDUAL ITEMS, TABLE 11: SUMMARY OF STATE AND TERRITORY NURSE WORKFORCE DATA SOURCES TABLE 12: COMMENCING DOMESTIC UNDERGRADUATE PRE-REGISTRATION NURSING STUDENTS, BY STATE/TERRITORY, 2001 AND TABLE 13: UNDERGRADUATE PRE-REGISTRATION DOMESTIC NURSING STUDENT COMPLETIONS, BY STATE/TERRITORY, TABLE 14: CRITICAL CARE COURSES: COMPLETIONS (2001), POSTGRADUATE STUDENTS IN INTENSIVE/CRITICAL CARE COURSES (2002) AND PROJECTED COMPLETIONS (2002), BY STATE AND TERRITORY (UNIVERSITY ONLY) TABLE 15: NEW SOUTH WALES COLLEGE OF NURSING COURSE COMMENCEMENTS AND COMPLETIONS FOR INTENSIVE CARE AND CRITICAL CARE GRADUATE CERTIFICATES, TABLE 16: HOSPITAL BASED CRITICAL COURSES: COMPLETIONS (2001) AND COURSE COMMENCEMENTS (2002), BY HOSPITAL TABLE 17: REGISTERED NURSES WORKING IN INTENSIVE/CRITICAL CARE AS MAIN AREA OF WORK, BY STATE/TERRITORY, TABLE 18: REGISTERED NURSES WORKING IN INTENSIVE/CRITICAL CARE (HEAD COUNT AND FTE), BY STATE/TERRITORY, TABLE 19: PERMANENTLY EMPLOYED CRITICAL CARE NURSES (FTE) IN INTENSIVE CARE UNITS, PUBLIC AND PRIVATE SECTOR, BY STATE/TERRITORY, (EXCLUDES PICUS) v

6 TABLE 20: AGE PROFILE AND AVERAGE AGE OF CLINICAL CRITICAL CARE NURSE WORKFORCE, BY STATE/TERRITORY, TABLE 21: AVERAGE NUMBER OF HOURS WORKED BY REGISTERED NURSES WORKING IN INTENSIVE/CRITICAL CARE AS MAIN AREA OF WORK, BY STATE/TERRITORY, 1997 AND TABLE 22: PERCENTAGE OF MALE NURSES WORKING IN INTENSIVE/CRITICAL CARE, BY STATE/TERRITORY, 199 AND TABLE 23: REGISTERED NURSES: AVERAGE AGE AND AVERAGE NUMBER OF HOURS WORKED IN INTENSIVE/CRITICAL CARE AS SECOND JOB, TABLE 24: ICU REGISTERED NURSE VACANCIES (FTE), BY STATE/TERRITORY HEALTH DEPARTMENTS, 2000 AND TABLE 25: ICU REGISTERED NURSE VACANCIES AND VACANCY RATES, PUBLIC AND PRIVATE SECTOR, BY STATE/TERRITORY, TABLE 26: COMPARISON OF ESTIMATED TOTAL NUMBER OF CRITICAL CARE NURSES (1999) AND RECOMMENDED REQUIRED NUMBER OF CRITICAL CARE NURSES FOR CURRENT ADULT ICU BEDS ( ), BY STATE/TERRITORY (INCLUDES MANAGERS AND EDUCATORS) TABLE 27: PROPORTION OF QUALIFIED CRITICAL CARE NURSES (HEAD COUNT), STATE/TERRITORY, 1999 & TABLE 28: CASUAL SHIFTS ( 4 HRS) PER WEEK WORKED IN ICUS, PUBLIC AND PRIVATE SECTOR, BY STATE/TERRITORY, 2000 A TABLE 29: PROJECTED ICU BED REQUIREMENTS FOR NEW SOUTH WALES, PUBLIC AND PRIVATE SECTOR, TABLE 30: PROJECTED ICU BED REQUIREMENTS FOR VICTORIA, TABLE 31. NORTHERN TERRITORY ICU BEDS, 2002 AND 2005 (PROJECTED) TABLE 32: NEW (INITIAL) NURSING REGISTRANTS, BY STATE AND TERRITORY, TABLE 33: ESTIMATED ICU ATTRITION RATES, BY STATE/TERRITORY HEALTH, TABLE 34: NEW SOUTH WALES/AUSTRALIAN CAPITAL TERRITORY PROJECTED CRITICAL CARE WORKFORCE AND NEW ENTRANTS, TABLE 35: VICTORIA PROJECTED CRITICAL CARE NURSE WORKFORCE AND NEW ENTRANTS, TABLE 36: QUEENSLAND PROJECTED CRITICAL ARE WORKFORCE AND NEW ENTRANTS, TABLE 37: SOUTH AUSTRALIA PROJECTED CRITICAL CARE NURSE WORKFORCE AND NEW ENTRANTS, TABLE 38: WESTERN AUSTRALIA PROJECTED CRITICAL CARE NURSE WORKFORCE AND NEW ENTRANTS, TABLE 39: TASMANIA PROJECTED CRITICAL CARE NURSE WORKFORCE AND NEW ENTRANTS, vi

7 TABLE 40: NORTHERN TERRITORY PROJECTED CRITICAL CARE NURSE WORKFORCE AND NEW ENTRANTS, TABLE 41: AUSTRALIA PROJECTED CRITICAL CARE NURSE WORKFORCE AND NEW ENTRANTS, TABLE 42: PHYSICAL, AVAILABLE AND VENTILATED PAEDIATRIC INTENSIVE CARE BEDS, BY STATE/TERRITORY, TABLE 43: PAEDIATRIC CRITICAL CARE WORKFORCE, BY STATE/TERRITORY, TABLE 44: PAEDIATRICS INTENSIVE CARE NURSES: AVERAGE AGE, AVERAGE HOURS WORKED PER WEEK AND GENDER PROFILE, BY STATE/TERRITORY, TABLE 45: PAEDIATRIC INTENSIVE CARE COURSE COMPLETIONS (2001) AND PROJECTED COMPLETIONS (2002), BY STATE/TERRITORY TABLE 46: NUMBER OF PAEDIATRIC NURSES CURRENTLY ENROLLED IN POSTGRADUATE/TRANSITION PROGRAMS, BY STATE/TERRITORY, TABLE 47: SUMMARY OF ADEQUACY INDICATORS FOR REGISTERED NURSES WORKING IN PICU TABLE 48: ESTIMATED ATTRITION (%) PICU PERMANENT WORKFORCE, BY STATE/TERRITORY, LIST OF FIGURES FIGURE1: BASIC NURSING (UNDERGRADUATE BACHELOR) COURSE COMMENCEMENTS AND COMPLETIONS, AUSTRALIAN CITIZENS AND PERMANENT RESIDENT STUDENTS, FIGURE 2: COMPARISON OF THE AGE STRUCTURE OF CRITICAL CARE NURSES WITH ALL CLINICAL REGISTERED NURSES, FIGURE 3: CRITICAL CARE NURSES NATIONAL AVERAGE HOURS WORKED PER WEEK, BY AGE GROUP, FIGURE 4: NEW SOUTH WALES DEPARTMENT OF HEALTH REPORTING SYSTEM (DOHRS) SUPPLEMENTARY STAFF (AGENCY AND POOL) UTILISATION, REGISTERED NURSE POSITIONS ACTIVELY BEING RECRUITED, AND PAID OVERTIME, JULY 1999 TO DECEMBER vii

8 ABBREVIATIONS ABS ACCCN ACHS ACT AHMAC AHWAC AHWOC AIHW AMWAC ANZICS DEST DEWR DOHRS EIP EN JFICM FTE HC HCA HDU HECS ICU IPPV MET MMSS Australian Bureau of Statistics Australian College of Critical Care Nurses Australian Council on Health Care Standards Australian Capital Territory Australian Health Ministers Advisory Council Australian Health Workforce Advisory Committee Australian Health Workforce Officials Committee Australian Institute of Health and Welfare Australian Medical Workforce Advisory Committee Australian and New Zealand Intensive Care Society Commonwealth Department of Education, Science and Training Commonwealth Department of Employment and Workplace Relations Department of Health Reporting System (NSW) Evaluation and Investigations Program Enrolled Nurse (Division 2 Victoria, Division 1 Western Australia) Joint Faculty of Intensive Care Medicine formally FICANZCA: Faculty of Intensive Care, Australian and New Zealand College of Anaethetists Full time equivalent (38 hours/week) Head count Health care assistant High Dependency Unit Higher Education Contribution Scheme Intensive Care Unit Intermittent Positive Pressure Ventilation Medical Emergency Team Monthly Management Summary System (South Australia) viii

9 NHPPD NSW NT NUM PELS PICU Qld RN SA SPIS TAFE TISS Tas Terr THS VAED Vic WA Nurse Hours Per Patient Days New South Wales Northern Territory Nurse Unit Manager Postgraduate Education Loans Scheme Paediatric Intensive Care Unit Queensland Registered Nurse South Australia Staff Profile Information System (Queensland) Technical and Further Education Therapeutic Intervention Scoring System Tasmania Territory Territory Health Service Victorian Admitted Episode Dataset Victoria Western Australia ix

10 TERMS OF REFERENCE FOR AUSTRALIAN HEALTH WORKFORCE ADVISORY COMMITTEE AND THE AHWAC CRITICAL CARE NURSE WORKFORCE WORKING PARTY AHWAC Terms of Reference The Australian Health Workforce Advisory Committee (AHWAC) was formed in December 2000 to assist with the development of a more strategic focus to health workforce planning in Australia. AHWAC is a national advisory body which reports to the Australian Health Ministers Advisory Council (AHMAC), and through it to the Australian Health Ministers Conference. The prime focus of AHWAC is on national health workforce planning and analysis of information and the identification of data needs. AHWAC aims to provide advice to AHMAC on a range of health workforce matters, including: the composition and distribution of the health workforce in Australia; health workforce supply and demand; and the establishment and development of data collections concerned with the health workforce. AHMAC has asked AHWAC to consider the specialised nursing workforce as a first priority and in particular the specialty areas of critical care, midwifery, mental health, aged care and emergency. In developing its work program AHWAC will work closely with the Australian Medical Workforce Advisory Committee (AMWAC) and the Australian Institute of Health and Welfare (AIHW). Secretariat functions for AHWAC are co-located with the Australian Medical Workforce Advisory Committee Secretariat. At its first meeting in December 2000, AHWAC identified reviews of both the midwifery and critical care nursing workforces as the initial priority for its work. AHWAC Critical Care Nurse Workforce Working Party Terms of Reference The AHWAC Critical Care Nurse Workforce Working Party was established as a subcommittee of AHWAC and was asked to provide a report to AHWAC on the current adequacy, optimal supply and appropriate distribution of critical care nurses across Australia, including projections for future requirements. The Working Party held its first meeting in April The completed report was presented to the October 2002 AHMAC meeting. x

11 MEMBERSHIP OF THE AUSTRALIAN HEALTH WORKFORCE ADVISORY COMMITTEE Chairman Mr John Ramsay Secretary, Tasmanian Department of Health and Human Services Nominee of the Commonwealth Department of Health and Ageing Ms Mary Murnane Deputy Secretary Commonwealth Department of Health and Ageing Nominees of the Australian Health Ministers Advisory Council Mr Rod Bishop Director, Corporate Services Department of Human Services, South Australia Ms Sue Norrie Principal Nursing Adviser, Queensland Health Nominee of Australian Institute of Health and Welfare Dr Anny Stuer Head, Economics and Business Services Division, Australian Institute of Health and Welfare Nominee of the Australian Medical Workforce Advisory Committee Professor John Horvath Chairman Nominee of the Australian Vice Chancellors' Committee Associate Professor School of Nursing, Faculty of Health and Behavioural Sciences, Pauline Nugent Deakin University Nominee of the Commonwealth Department of Education, Science and Training Dr Tom Karmel Assistant Secretary, Higher Education Division, Department of Education, Science and Training (until July 2002) Observer Frances Hughes Chief Advisor (Nursing) Ministry of Health, New Zealand xi

12 MEMBERSHIP OF THE AHWAC CRITICAL CARE NURSE WORKFORCE WORKING PARTY Chair Ms Sue Norrie Principal Nursing Advisor, Queensland Health Nominees of State/Territory Health Departments Mr Ian Blight CNC Intensive Care Unit, Royal Adelaide Hospital Assoc. Prof. Ged Williams Principal Nursing Consultant, Territory Health Services. Nominee of Australian Nursing Federation Ms Victoria Gilmore Federal Professional Officer, Australian Nursing Federation Nominee of Australian College of Critical Care Nurses Ms Gabrielle Hanlon Nurse Unit Manager, Intensive Care Unit, St Vincent's Hospital, Melbourne Consumer nominee Ms Liza Newby Health Issues Centre, Melbourne Representative of Chair of AHWAC Ms Helene Delany (until July 2002) Ms Helen Townley (from July 2002) AHWAC Secretariat Ms Elizabeth O Brien AHWAC Senior Policy Analyst The report was prepared by Elizabeth O Brien. The Working Party would like to acknowledge the assistance of the following people and organisations for their role in providing data and information: Australian Institute of Health and Welfare (AIHW) Serge Christopoulos, Warwick Conn, Glenice Taylor Australian College of Critical Care Nurses (ACCCN) Australian Medical Workforce Advisory Committee Paul Gavel and Susan Jekel-Sadleir Australian and New Zealand Intensive Care Society (ANZICS) Research Centre for Critical Care Resources Therese Anderson Commonwealth Department of Education, Science and Training (DEST) Elizabeth McDonald Deakin University School of Nursing Robyn Ogle and Arlene Walker. New South Wales College of Nursing Lorraine Ferguson xii

13 The Working Party would also like to thank the Chief Nursing Officer/Principal Nursing Adviser in each Jurisdiction for information provided during this project. The Chief Nursing Officer/Principal Nursing Advisor in each jurisdiction is: New South Wales Judith Meppem (until September 1, 2002) Victoria Belinda Moyes Queensland Sue Norrie South Australia Deb Pratt Western Australia Phill Della Tasmania Fiona Stoker Northern Territory Ged Williams Australian Capital Territory Donna Mowbray xiii

14 EXECUTIVE SUMMARY AND RECOMMENDATIONS A nursing shortage is being experienced both in Australia and internationally. Until recently, there has been little quantification of the nursing shortage and little focus on nurse workforce planning in Australia (of either the overall nursing workforce or the specialist nursing workforces). Critical care areas traditionally draw relatively young nurses from the acute hospital sector. Shortages in specialist areas of nursing such as critical care are likely to be caused by a decreased pool of potential new entrants (in this case, new graduate and recently graduated nurses) and an increased rate of attrition from the workforce. Future demand for critical care services, and thus requirements for critical care nurses, is expected to increase with population growth and ageing. As well as expanded services (in terms of bed numbers), increased productivity of critical care nurses is expected, as the throughput of patients in critical care services increases (due to technological advances). This report provides an analysis of the current critical care nurse workforce, including the current supply, current requirements and the difference between the two. The current critical care nurse workforce is profiled in terms of numbers, average age, average hours worked per week, and gender. The Australian Institute of Health and Welfare (AIHW) provided much of the data for the workforce profile. Limitations associated with using the AIHW data included the age of the data (data from 1999 being the most recently available) and survey inconsistencies among jurisdictions. However, this source provided the only national workforce information. The Australian and New Zealand Intensive Care Society (ANZICS) was also a major source of data regarding the permanently employed critical care nurse workforce and vacant positions for critical care nurses, through its Review of Intensive Care Activity Report ( ). It also provided the necessary data to determine critical care nurse requirements, i.e., a description of intensive care bed provision in Australia. The Australian College of Critical Care Nurses (ACCCN) staffing standards were used as a basis for determining the critical care nurse requirement per intensive care bed. The staffing standards take into account accepted national minimum standards set by the Joint Faculty of Intensive Care Medicine (JFICM) and the Australian Council on Healthcare Standards (ACHS); evidence of the effect of nurse staffing from international studies; as well as best practice determined by consensus amongst critical care nurse leaders. The base-line requirement was applied to current available intensive care beds and was used to develop a measure of workforce adequacy when compared with the actual workforce. The JFICM and ACHS standards have not been reviewed since 1997, while the ACCCN staffing standards were developed in The total national critical care nurse workforce was estimated to be 9,869 using AIHW data. The estimated requirement for critical care nurses was 10, 386 (a net shortfall of 537 across the nation). The total permanently employed critical care nurse workforce (using ANZICS data) was estimated to be at least full-time equivalent (FTE) nurses, with estimated vacancies (FTE) totalling Baseline assessment of supply (under or oversupply) was factored into projection modelling. Because of a lack of data describing new entrants to the workforce and permanent exits each year, a number of scenarios were developed to provide an indication of new entrants xiv

15 required each year to balance the workforce from The required annual new entrants for workforce balance ranged from 722 to 1,356, depending on the workforce scenario used in the modelling. To achieve workforce balance the two ends of the workforce require adjustment. Firstly, an increased number of undergraduate nurses (who subsequently enter the nursing workforce) are required. Secondly, an increased rate of retention of experienced critical care nurses is required. The major limiting factor involved in this report has been the lack of recent, consistent, reliable and longitudinal data to describe the critical care nurse workforce. The following recommendations have been formulated by the Working Party in order to achieve a balanced workforce. The recommendations are based on the Working Party s view that there is unlikely to be a major change to critical care service provision within the defined projection period, including the model of critical care nursing. Highly specialist areas of healthcare require a highly specialist nursing workforce. Implementation of the following recommendations will require government (Commonwealth, State and Territory), the critical care nursing profession, the university sector, and public and private health services to work together. Recommendation 1: ensuring an adequate supply of registered nurses to work in critical care (quantity). That AHMAC coordinate action to improve the supply of critical care nurses in Australia by working with the health and education sectors to ensure sufficient adjustment in new entrants to the critical care nurse workforce, recognising that at least 722 (lowest requirement scenario) and at most 1,356 (highest requirement scenario) new entrants to the critical care nurse workforce are required nationally each year. Noting: That in putting in place these actions AHMAC should be guided by the state and territory scenario projections outlined in this report, and that these actions should be informed by the most recently available jurisdictional critical care nurse workforce data. Strategies to improve retention of the skilled critical care nurse workforce would ensure that the required new entrants to the workforce is minimised. Recommendation 2: ensuring an adequate supply of qualified critical care nurses (quality). State and territory health departments as part of ensuring an adequate supply of critical care nurses note the standards suggesting at least 50% of the critical care nurse workforce and desirably 75% of the critical care nurse workforce should hold critical care qualifications. That AHMAC note the desirability of a move towards greater consistency in postgraduate critical care courses and the development of a framework for accreditation for postgraduate critical care courses. xv

16 Recommendation 3: ensuring adequate data for ongoing and complete workforce supply analysis and requirement analysis. That AHMAC coordinate improvements to critical care nurse data collections, and overall nurse data collections, noting that reliable, timely data is essential to workforce planning. The following measures are required: AIHW surveys: the implementation of a consistent, timely national approach for the collection of nurse labour force surveys via nurse registration boards annually. Nurse registration authorities: AHMAC to encourage jurisdictions to work together to ensure a more consistent approach to registration data collection and reporting. ANZICS Intensive Care Unit Resource Surveys: AHMAC continue to support the work of ANZICS and ensure the enhancement of the surveys to include additional questions regarding the critical care nurse workforce. Improvement of information relating to the nursing education sector. Research to measure the relationship between critical care nurse staffing levels (and skill mix) and patient outcomes. Recommendation 4: monitoring the workforce That AHMAC coordinate the monitoring of supply and requirement projections of and for the critical care nurse workforce, and that the critical care nurse workforce be reviewed in five years time. xvi

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18 PART A: THE ADULT CRITICAL CARE NURSE WORKFORCE IN AUSTRALIA 1

19 1. INTRODUCTION, BACKGROUND AND DEFINITIONS A nursing shortage is being experienced both in Australia and internationally. A shortage of critical care nurses has been reported in Australia, with no quantification of the shortage. Reports suggest difficulty in both attracting and retaining critical care nurses. The current shortage is likely to be due to a diminished pool of younger-aged RNs (from which to recruit into critical care nursing), coupled with an increased attrition rate of critical care nurses. AHWAC was set up to assist with a national approach to workforce planning for nursing workforces, including the critical care nurse workforce. Other national bodies that recently examined nurse education and nursing workforce issues were the National Review of Nursing Education and the Senate Nursing Inquiry. There is little coordination between the university sector (providing the supply of nurses) and the health services sector (requiring the nursing workforce). Project Objective The goal of workforce planning for nurses is: To ensure the presence of the right nurse, with the right qualifications, in the right role, at the right time and in the right place, with the proper authority and the appropriate recognition. (International Council of Nursing, 1992) The Australian Health Ministers Advisory Council (AHMAC) identified 5 priority areas of the nursing workforce to be examined by the Australian Health Workforce Advisory Committee (AHWAC). These were aged care, mental health, emergency care, midwifery and critical care. Resources dictated that 2 projects would commence in As aged care and mental health were both subjects of reviews by the Commonwealth Department of Health and Ageing, AHWAC decided to begin work on the critical care nursing and midwifery reports. 2

20 In preparing this report, the Working Party s aim has been to identify an optimal supply and distribution of critical care nurses in Australia, including projections for future supply and requirements to The aim of this report, therefore, is to provide a description of current critical care nurse workforce (including current practice and models of care), assess the adequacy of the current workforce and to project future supply and requirements for critical care nurses. The report also aims to provide recommendations for achieving a balance between expected supply and projected requirements. Structure Of This Report The critical care nurse workforce report is divided into two parts. Part A refers to critical care nurses working in adult intensive care units, while Part B refers to critical care nurses working in Paediatric Intensive Care. The Working Party acknowledges the lengthy nature of this report but stresses the importance of providing a comprehensive report that addresses the complex nature of the workforce and its relationship with the overall nursing workforce. Part A is structured to provide the reader with an understanding of the context in which critical care nurses work. For this reason, chapters on consumer perspectives and the current provision of adult intensive care services are provided (chapters 2 and 3). A chapter devoted to describing data sources available is also provided to enable the reader to understand the complexity, inadequacies and useful sources of data available for the description of the critical care nurse workforce and related information (chapter 4). The methodology used in the development of this report is described in chapter 5. The following chapters then go on to describe critical care nurse education, the current critical care nurse workforce, the adequacy of the workforce and projection information. Recommendations for balancing of the critical care nurse workforce are made in the final chapter of Part A: Chapter 12. Part B is a relatively brief section of the report, providing an overview of the Paediatric critical care nurse workforce. Definitions Critical care For the purposes of the study, the Working Party defined critical care as adult intensive care units (ICUs) and their associated cardiothoracic, coronary care, neurosurgical and high dependency beds. Stand alone coronary care units, neurosurgery intensive care units (not under the direction of a medical intensivist), high dependency units and neonatal intensive care units (NICUs) are not included. However, where they are integrated into the ICU management, they have been taken into account. Paediatric intensive care units (PICUs) are examined as a separate entity within this report. The Working Party adopted the definition of an ICU used by the Joint Faculty of Intensive Care Medicine (JFICM) formerly the Faculty of Intensive Care, Australian and New Zealand College of Anaesthetists (FICANZCA), which defines an ICU as a specially staffed and equipped, separate and self contained section of a hospital for the management of patients with life-threatening or potentially life-threatening conditions. Such conditions should be compatible with recovery and have the potential for an acceptable future quality of life. An ICU provides special expertise and facilities for the support of vital functions, and utilises the skills of medical, nursing and other staff experienced in the management of these problems (FICANZCA, 1997). 3

21 Critical care nurse The Working Party defined a critical care nurse as a registered nurse (RN) working in an intensive (critical) care unit. This definition recognises the fact that many registered nurses currently working in intensive care do not possess a postgraduate qualification in the specialty area. Qualified critical care nurse A qualified critical care nurse refers to a RN with a specific postgraduate qualification in critical (intensive) care nursing. It may be a postgraduate certificate, diploma or masters degree. At present, there is no national accreditation of postgraduate critical care courses. Guiding Principle In compiling this report, the Working Party adopted the guiding principle that the Australian community should have available an adequate number of qualified and experienced critical care nurses, appropriately distributed to provide the intensive care services it requires. Background The intensive or critical care environment requires a highly specialised nursing workforce that can provide care to patients with life threatening or potentially life threatening conditions. The provision of intensive care services in Australia is dependent on highly skilled nurses working in ICUs. The last decade has seen the expansion of intensive care services and the increased throughput of patients using intensive care services. At the same time, there is a shortage of critical care nurses, reported both anecdotally and by the Commonwealth Department of Workplace Relations and Small Business (DEWR, 2002). Historically, critical care nurses have a relatively high attrition rate compared with other nursing specialities. The work is demanding both physically and emotionally and nurses are required to work a higher proportion of their time on night duty than other acute hospital nurses. However, nurse managers have reported that the attrition from the workforce has increased over recent times with the loss of experienced critical care nurses who have either left the workforce entirely or have left the permanent workforce to work casually with nursing agencies. Reports suggest that many remaining critical care nurses have chosen to reduce their regular working hours. Those remaining in the permanent full-time workforce are left with added responsibility, and a more rigid working life (for example more night duty). An increased attrition rate amongst experienced critical care nurses coupled with a deficit of new recruits leads to a shortage in the workforce, both in terms of numbers and proportion of qualified staff. There has been little analysis of the specialty nurse workforces in Australia. However work done by Buerhaus, Staiger and Auerbach (2000) on shortages of American hospital RNs in specialty care units suggests that younger RNs are normally clustered in ICUs. Therefore the shortage of RNs in ICUs relates to a sharp decline of younger-aged RNs from which ICUs have historically attracted staff. If the numbers of young nurses entering the labour force continues to decline, then specialty areas such as ICU will continue to face shortages. Having an adequate supply of critical care nurses means that new nurses must be recruited both into the nursing labour force in general and into the specialty, and nurses already in the specialty must be retained (Dracup & Bryan-Brown, 1998, Buerhaus, Staiger and Auerbach, 2000). It is likely that the current shortage is a product of the many RNs in their late 30s and early 40s who are either leaving the workforce or reducing their working hours, and are not 4

22 being replaced by the required number of younger aged RNs who tend to work more hours per week. The nursing shortage is not isolated to critical care areas. According to the Department of Employment and Workplace Relations (DEWR, 2002), across Australia there are shortages in operating theatre, accident/emergency, cardiothoracic, neonatal intensive care, neurology, paediatrics, aged care, midwifery, renal, oncology, palliative care, peri-operative, indigenous health, general registered nurse (RN) and mental health nurses. These shortages are defined by the DEWR as existing when employers are unable to fill, or have considerable difficulty in filling vacancies in an occupation, or specialised skill needs within that occupation, at current levels of remuneration and conditions of employment, and reasonably accessible location. Shortages are typically for specialised and experienced workers, and can coexist with relatively high unemployment overall in the occupation. The nursing shortage is not restricted to Australia. Other developed countries have reported nursing shortages and are grappling with a looming crisis to varying extents. A gloomy picture is emerging showing a collision between an ageing and shrinking nursing workforce and an increased demand for health care services as large numbers of baby boomers reach retirement age (Stienbook 2002, Beurhaus, Staiger and Auerbach, 2000). To date, there have been no studies carried out in Australia showing the overall changes in the nursing workforce and the impact these will have in terms of providing adequate health care services. A recent report from the United States (Kimball and O Neil, 2002) provides an overview of the American nursing shortage. It states the current shortage differs from shortages of the past because it is being driven by a broader set of factors than previous shortages. Most of these factors are also relevant to the Australian context: An ageing population. As baby boomers age, there will be an increased demand for nursing care. Fewer workers. There are fewer younger people entering the workforce in general. Ageing workforce. The average age of nurses is increasing while physical demands of work remain high. Many nurses will retire in the next decade. A mismatch on diversity. The racial and ethnic (and gender) makeup of current workforce does not reflect society. More options for women. Women are leaving nursing for other career options and women are choosing other careers rather than nursing. The generation gap. Generation X perceives nursing as unappealing. Work environment. Fewer resources, greater demands resulting in disillusionment and dissatisfaction among nurses. Consumer activism. Growing consumer empowerment, increasing awareness of medical errors. A ballooning health care system. Pressures on health care financing and a push for accountability are putting pressure on the nursing profession which lacks authority to create change. The nursing shortage in Australia entered the public domain via newspaper and other media reports over recent times. Headlines in newspaper articles such as Not enough nurses (SMH, 31 October 2001), Nursing staff ageing too fast (Weekend Australian, 22 September 2001), Nursing crisis ignored (The Australian, 26 July 2001) brought to the public s attention the current and potential problems of a nursing shortage. 5

23 Measures including encouraging non-working nurses back into the workforce, recruitment of nurses from other countries and recruiting school leavers into nursing courses are being actively pursued. However, it is widely believed that a national, broad sweeping and longterm approach is required to address the issues at the core of the nursing shortage. The initial preparation of nurses lies with the university sector. Each university makes independent decisions regarding course design, student intakes and postgraduate offerings. However decisions of universities impact directly on health services in terms of numbers of available graduate nurses to enter the workforce. There are few mechanisms in place to ensure university decisions impact positively on workforce requirements. A national coordinated approach is required (Duckett and Kenny, 2000). It is widely perceived that university decisions are likely to be influenced more by internal politics than assessment of demand for graduates. A national approach to nursing workforce issues, including education, is currently underway. The Australian Health Workforce Advisory Committee (AHWAC) was formed in December 2000 to assist with a more strategic approach to health human resources workforce planning in Australia. AHWAC identified the critical care nurse workforce and midwifery workforce as initial priorities for its work. Shortly after the establishment of AHWAC, two other national committees were set up to address issues related to the composition, supply and education of the nursing workforce. In 2001, a national review of nursing education was set up jointly by the Commonwealth Ministers for Education, Science and Training, and Health and Ageing. The terms of reference for the review included: models of nurse education and training, types of skills and knowledge required to meet the changing needs of the labour force, and mechanisms for both attracting new recruits and encouraging on-going learning of those already engaged in nursing (National Review of Nursing Education, 2002). In April 2001, the Senate Community Affairs References Committee established an inquiry into nursing. It covered issues such as the shortage of nurses in Australia and the impact this is having on health care service delivery, opportunities to improve current arrangements for the education and training of nurses, and strategies to retain nurses and attract nurses back to the profession. The report produced 85 recommendations related to these issues (Senate Community Affairs References Committee, 2002). Australian stakeholders involved with the nursing workforce include State and Territory health departments; private sector providers; education providers; nurses; nursing organisations; other health professions; and consumers. Nationally, Australia is in the early stages of dealing with the challenges of a nursing shortage, however, there are many initiatives taking place on local levels. According to Kimball and O Neill (2002), there are four stages of a response continuum to a nursing shortage that will eventually lead to the evolution of the profession. 1. Scramble: The nurse as commodity. Stakeholders collect data, debate issues, assess the situation and begin to chart a course of action. Actions include focusing on recruitment, which is generally highly competitive and not sustainable. Activities focus on monetary incentives. The nurse is considered a commodity, an expandable workforce element responding to traditional market incentives. Most activities in this early stage tend to be unilateral and stakeholders operate independently of others. This stage produces little change in the fundamental situation, as the focus is on numbers rather than people. The nurse as a pair of hands is the conceptual framework of this stage. 6

24 2. Improve: The nurse as customer. The depth of the situation sinks in, stakeholders realise that past solutions and the traditional supply/demand responses will not address fundamental issues. Front-line health services and educational providers initiate responses to symptoms of vacancies, turnover, declining enrolments and industrial action. Surveys, focus groups and forums are utilised to better understand nurses concerns. Types of actions include increasing the flexibility and improving working conditions, expanding educational opportunities and increasing diversity; recognising achievements and mentoring. Nurses feel they are being heard. 3. Reinvent: The nurse as valued asset. Leadership realises that a new paradigm will be required to address the core issues underlying the shortage. As the ongoing challenge of providing high quality care with fewer professional nurses escalates, leaders begin to examine a new vision for the nursing profession and its relationship with the health care system. Actions in the reinvent stage focus on creating new roles for nurses, career ladders and increasing the professional environment. 4. Start Over: The nurse as professional partner. Innovations that include new and most likely radical approaches are found at this end of the response continuum. Approaches include new models of care and professional practice. Approaches may challenge the current paradigm based on the medical or biomedical delivery of health care, including the organisation and training of nursing professionals. Actions at this stage are collaborative, interdependent, long term, complex and continually evolving. Start Over efforts are often the result of collaborative partnerships between various sectors and are defined by consumer needs. This stage requires enlightened and effective leadership and risk taking to facilitate change. The AHWAC critical care nurse workforce project is the first attempt to quantify the critical care nurse shortage and provide a national approach to workforce planning for critical care nurses. Being aware of the National Review into Nursing Education and the Senate Inquiry into nursing, AHWAC endeavoured not to duplicate information gathering exercises, rather, it remained informed of the progress of both inquiries and used information made available from the inquiries. The Working Party acknowledges that specialist nurse workforces, such as the critical care nurse workforce, cannot be viewed in isolation from issues affecting the overall nurse workforce. The number of undergraduate nurses and their subsequent entry into the pool of working registered nurses impacts on the front-end supply for specialist areas such as critical care. Shortages within critical care setting are not confined to nursing. In 1998, the Australian Medical Workforce Advisory Committee identified a need for additional intensive care medical specialists to be trained over the period 1998 to 2008 (AMWAC, 1999). 7

25 2. PROVISION OF INTENSIVE CARE SERVICES ANZICS data reveals there were 163 adult ICUs in Australia, 108 in public hospitals and 55 in private hospitals. There was a national average of 8.72 available ICU beds per 100,000 population and 6.19 ventilated beds per 100,000. There is a lack of data describing high dependency beds in ICUs, therefore non ventilated intensive care beds were used as a proxy measurement in this report. The provision of nursing care in Australian ICUs is predominately by registered nurses. Minimum standards suggest that a ratio of at least one RN to an intensive care patient (1:1) and one RN to two high dependency patients (1:2) be provided and that at least 50% of nursing staff have critical care qualifications. ACCCN staffing guidelines suggest a proportion of supernumerary RNs be available according to level of qualified staff, and that ideally at least 75% of staff should be qualified. Critical care services, including intensive care, are primarily delivered within the confines of a specialist unit within an acute care hospital. They were developed as a result of a number of factors. Firstly, it was recognised that acutely ill patients and those recovering from major surgery fared better by being concentrated in one area and being cared for by highly skilled nurses and doctors. Secondly, advances in anaesthesia and surgery produced patients requiring specialised care. Thirdly, the technological developments, which enabled the treatment and survival of critically ill patients, increased the need for specialist staff (both medical and nursing) who could manage the complex and intense therapy required by the patients (Clarke et al, 1999). Treating postoperative patients in a specialised single area, with expert doctors and nurses, began in the 1920s. During World War II modern intensive care facilities were developed to care for severely injured soldiers (Hilberman, 1975). The ICU as we know it today became a feature of major teaching hospitals during the early to mid 1960s. The Joint Faculty of Intensive Care Medicine (JFICM) defines an ICU as: a specially staffed and equipped, separate and self-contained section of a hospital for the management of patients with life-threatening or potentially life-threatening conditions. Such conditions should be compatible with recovery and have the potential for an acceptable future quality of life. An ICU provides special expertise and facilities for the support of vital functions, and utilises the skills of medical, nursing 8

26 and other staff experienced in the management of these problems (FICANZCA, 1997). The following information provides a description of both the current intensive care services available in Australia and the work practices particular to critical care nursing in Australia. Classification Of Intensive Care Units The level and range of services, and role of intensive care departments will vary according to the size, location and role of the hospitals within which they are located. ICUs are defined according to three main criteria: the nature of the facility, the care process and the clinical standards and staffing requirements. The JFICM (FICANZCA, 1997) defines three levels of adult intensive care units, including the recommended minimum nurse/patient ratios. Level 3 ICUs are principally located in metropolitan public tertiary referral hospitals, some metropolitan private hospitals and large regional hospitals. Level 3 ICUs provide a comprehensive range of services involving complex multi-system life support for an indefinite period. A level 3 ICU must be capable of providing mechanical ventilation, extra-corporeal renal support services and invasive cardiovascular monitoring, for an indefinite period. It should have extensive back up laboratory and clinical service facilities to support this tertiary referral role. At all times, level 3 ICUs are staffed by qualified intensive care specialists exclusively rostered and readily available to the ICU as well as experienced medical and nursing staff on site 24 hours. The nursing requirement of a level 3 ICU includes: a minimum of 1:1 nursing for ventilated and other similarly critically ill patients, and nursing staff available greater than 1:1 ratio for patients requiring complex management; a nurse in charge of the unit with a post registration qualification in intensive care or related specialty; the majority of nursing staff with a postgraduate qualification in intensive care or related specialty; all nursing staff responsible for patient care are registered nurses; and a nurse educator and formal nurse education program. Level 2 ICUs are located in metropolitan district hospitals and some rural base/regional hospitals. Level 2 ICUs have a separate and self-contained facility in the hospital capable of providing complex multi-system life support. They must be capable of providing mechanical ventilation, extracorporeal renal support systems and invasive cardiovascular monitoring for a period of at least several days. The nursing requirement is similar to that of a level 3 ICU, however, for selected patients, some may require less than 1:1 nursing. Access to a nurse educator should be available. Level 1 ICUs are mainly located in small rural or large remote centres. They generally have a separate and self-contained facility in the hospital capable of providing basic, multi-system life support usually for less than a 24 hour period. A level 1 ICU must be capable of providing immediate resuscitative management for the critically ill, including mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours. The nursing requirement for a level 1 ICU is similar to that of a level 3, except that a clinical nurse educator may not be available. A minimum of two registered nurses must be present at all times when there is a patient admitted to the unit, even if only one patient is admitted (this is a requirement of all levels). 9

27 Number Of Intensive Care Units And Number And Type Of Intensive Care Beds For workforce planning for critical care nurses, important factors to be considered are: number of ICUs and their distribution; number of ICU beds; and type of ICU beds (physical, available, intensive care and high dependency). These factors define the requirement for the critical care nursing workforce, as the number of nurses required is determined not so much by need within the population, but by resources available to provide intensive care treatment (infrastructure and funding). The number of ICU beds is dynamic and variable from one year to the next. Each year new units are opened, old ones decommissioned, while some are merged. The merging and reconfiguration of ICUs, which is currently taking place, is in response to the ageing of the units (most built in the 1960s) and the changing of work practices to allow more efficient and effective patient care. In recent years a number of super units have been opened which combine intensive care, cardiothoracic and coronary care beds, where in the past they were separate entities. The move within the private sector to open or up grade ICUs has also had an impact on the number and level of beds available. ANZICS (2001) reports the geographic distribution* of ICUs around the nation: 56.5% are in capital cities (n=96) 12.9% are in metropolitan regions (n=22) 29.4% are in rural regions (n=50) 1.2% in remote regions (n=3) *For definitions of geographic locations see appendix B. The Working Party decided the ANZICS Australian Research Centre for Critical Care Resources (ARCCCR) provides the most recent and reliable data describing ICUs in Australia. The following information is from the 2001 survey in which data was collected for the financial year (see appendix C for ANZICS questionnaire and definitions of physical, available and ventilated beds). ANZICS surveyed all critical care complexes in Australia and New Zealand. A critical care complex was defined as encompassing all intensive care services at individual hospitals. In previous surveys, ANZICS had recorded each ICU separately, but in the most recent survey data from hospitals with multiple ICUs was amalgamated. A critical care complex may include general and specialty ICUs, combined intensive care/coronary care units, paediatric intensive care units, high dependency units managed by ICUs or any combination of these. The term ICU has been used to describe all of the above (ANZICS, 2001). This definition sits well with the definition chosen by the Working Party to define critical care for the purposes of this report. ANZICS separated out paediatric intensive care data from general intensive care, which also suited the Working Party. Although this section of the report specifically describes adult intensive care services, a number of the following tables include paediatric data as it was difficult to remove. In , there were 163 adult and 7 paediatric ICUs (PICUs) in Australia. All PICUs were level 3 equivalents and within public hospitals. Of the adult ICUs, 67 were level 3, 64 were level 2 and 32 were level 1. Of the 163 Adult ICUs, 108 were public and 55 were private. Table 1 shows number and type of beds by ICU level for both the public and private sectors. 10

28 Physical, Available And Ventilated Intensive Care Beds Definitions used by ANZICS to describe intensive care beds are: Physical bed: A single patient care location fully configured to ICU standards, it is an actual bed, not a bed space. Available bed: An ICU bed in use or immediately available for use by admitted patients as required. In ICU this refers to a bed with advanced life support capability that is fully staffed and funded. Ventilated bed: a physical ICU bed plus ventilator Both available and ventilated beds are components of physical beds. Table 1: Adult ICU beds by self-determined ICU level, public and private sector, (paediatric beds not included) ICU level Physical beds a Available beds b Ventilated beds c Public sector units Level 3 (n=43) Level 2 (n=39) Level 1 (n=26) Total public (n=115) 1,275 1, Private sector units Level 3 (n=24) Level 2 (n=25) Level 1 (n=6) Total private (n=55) Total bed number 1,806 1,598 1,104 Note: a - physical bed: a single patient care location fully configured to ICU standards, it is an actual bed. b - available bed: a bed in use or immediately available for use as required, it is fully funded and staffed; c - ventilated bed: a physical bed plus ventilator (not necessarily available). Source: ANZICS High Dependency Units And High Dependency Patients The distinction between high dependency care and intensive care is often understood to be the requirement for mechanical ventilation (FICANZCA, 1997). ANZICS defines a high dependency unit (HDU) as a discrete unit within the hospital able to supply critical care expertise at less intensive resource levels, providing a level of care that falls between the general ward and the intensive care unit (ANZICS, 2001). Common definitions of HDUs have been summarised by Boots and Lipman (2002). These have been translated into the characteristics of high dependency patients. High dependency patients may: Be cared for in a specifically staffed and equipped section of an intensive care complex. Require an intermediate level of clinical care between a general ward and an ICU. Require invasive monitoring and support for, or be at risk of developing, acute (or acute on chronic) single organ failure. Require step-up or step-down care between the level of care in general wards and in intensive care. Be at high risk of clinical deterioration, or unknown risk. Not require mechanical ventilation. Require frequent specialist nursing interventions. 11

29 There is little data available to quantify high dependency patients within the intensive care environment (apart from a relatively small number of dedicated high dependency beds). In the absence of this type of information, available non-ventilated ICU beds were used as a proxy for high dependency beds in this report. Although this is not a completely accurate method to determine high dependency beds, as most ICU beds are flexible in their use (i.e., interchangeable, used for high dependency patients or ICU patients as required) it does describe the possible proportion of high dependency type patients within ICUs. The following information provided the working party with a description of the different bed characteristics by level and sector (private and public). It shows that as ICU level decreases, the proportion of available non-ventilated beds increases. The level 3 private ICUs have a lower proportion of ventilated beds than the equivalent level in the public sector, however the inclusion of paediatric bed data (public sector only) may have influenced the higher proportion of ventilated beds in the public sector. Table 2: Proportion of ventilated and non ventilated available beds, public and private sector, by level, Public sector Private sector Level 3 Ventilated beds 91.1% of available beds Non ventilated beds 6.9% of available beds Level 2 Ventilated beds 50.6% of available beds Non ventilated beds 49.4% of available beds Level 1 Ventilated beds 38.0% of available beds Non ventilated beds 62% of available beds Source: ANZICS 2001 Level 3 Ventilated beds 79.6% of available beds Non ventilated beds 20.4% Level 2 Ventilated beds 50.4% of available beds Non ventilated beds 49.6% of available beds Level 1 Ventilated beds 36.8% of available beds Non ventilated beds 63.2 % of available beds ANZICS identified 3 broad ICU types that are included in the definition of intensive care. They are the general ICU which includes cardiothoracic and high dependency beds, the combined ICU which usually includes intensive care, coronary care and high dependency beds, and the paediatric ICU which caters exclusively for paediatric intensive care patients. A number of bed characteristics were identified within broad types of ICUs. Table 3 shows those identified. They do not total all ICU beds in Australia. 12

30 Table 3: ICU type and bed characteristics, Public sector Private sector Of all general ICUs there were: Of all general ICUs there were: 61 HDU beds 53 HDU beds 77 interchangeable beds 36 interchangeable ICU/HDU beds 86 dedicated cardiothoracic beds (of no dedicated cardiothoracic beds which 35% were protected for cardiothoracic patient use) Of all ICU/CCU/HDU (combined) there were: 83 HDU beds 285 interchangeable ICU/CCU/HDU beds 85 protected CCU beds Of all paediatric ICUs there were: 4 interchangeable ICU/HDU beds Source: ANZICS, 2001 Of all ICU/CCU/HDU (combined) there were: 24 HDU beds 144 interchangeable ICU/CCU/HCU beds 23 protected CCU beds Specialty (neuro and caridothoracic ICU) no interchangeable ICU/HDU beds Table 4: ICU beds, public and private sector, by ICU type, (paediatric beds not included) ICU type Physical beds Available beds Ventilated beds Public sector General (n=48) ICU/CCU/HDU(n=60) Total public (n=108) 1,275 1, Private sector General(n=33) ICU/CCU/HDU(n=20) Specialty (n=2) Total private (n=55) Total beds 1,806 1,598 1,104 Source: ANZICS, 2001 Tables 5 and 6 show the distribution of ICU beds per population and the number and distribution of physical, available and ventilated beds for each State and Territory. There appears to be a disproportionate number of beds in South Australia and the Australian Capital Territory per population. This may be explained in part by the fact that these two jurisdictions draw patients from other States and Territories. For example, patients from the Northern Territory go to Adelaide for critical care services, and patients from southern New South Wales may go to Canberra for treatment. 13

31 Table 5: ICU beds and ICU beds per 100,000 population, public and private sector, by State/Territory, (paediatric beds included) State/Terr. Population Physical beds Available beds Ventilated Beds Available beds per 100,000 pop. Ventilated Beds per 100,000 pop. NSW 6,463, Vic 4,765, Qld 3,566, SA 1,497, WA 1,883, Tas 470, NT. 195, ACT 310, Australia 19,154,000 1,912 1,672 1, Source: Population: ABS: Estimated population 30 June 2000 (Australian Bureau of Statistics (2001) Australian Demographic Statistics. ABS, Canberra.); Beds: ANZICS 2001 Table 6: ICU beds, public and private sector, by bed category and State/Territory, (paediatric beds not included) Bed Category NSW Vic Qld SA WA Tas NT ACT Total Public sector Physical ,275 Available ,080 Ventilated Available non ventilated Private sector Physical Available ventilated Available non ventilated Total physical beds Total available beds available beds as a percentage of physical beds , , Av. = Total ventilated ,104 beds ventilated beds Av = as a percentage of physical beds Source: ANZICS

32 According to the data collected by ANZICS over recent years (table 7), there has been an increase in intensive care resources, particularly within the private sector. Table 7: ICUs: available beds and ventilated beds, by public and private sector, 1997, 1998 and a Item /2000 Hospitals ICUs Public sector ICUs Private sector ICUs Physical beds: private & public 1,589 1,646 1,912 Available beds: public & private 1,387 1,420 1,672 Ventilated beds: public & private 1,004 1,047 1,187 Level 3 ICU available beds: public & private Level 2 ICU: available beds: public & private Level 1 ICU: available beds: public & private Available beds/100,000 public Ventilated beds/100,000 public Available beds/specialist FTE public Nurse FTE b /available bed public Note: a & 1998 calendar year data; 1999/2000 financial year data; ICUs now grouped as critical care complexes; b - FTE = number of permanently employed RNs as reported by nurse managers. Source: ANZICS 2001 Differences Between Private and Public Sector ICUs It is generally agreed that ICU case mix in private ICUs differs from those in public ICUs (particularly level 3 ICUs). Patients admitted to private ICUs are more likely to be as a result of elective surgery. Therefore, these patients may have more predictable outcomes and lengths of stay. Nurse Managers of private hospital ICUs reported that the requirement for nurse staffing is not as constant as that in public ICUs. In many cases, beds are not fully occupied until mid-week and patients are often discharged from the unit by the weekend. Intensive Care Unit Activity Table 8 shows ICU activity for the year as a proportion of all separations (same day separations excluded). Note: there is a lack of reliable national longitudinal data available regarding ICU admissions. Data collected by AIHW (Australian Hospital Statistics) does not differentiate ICU admissions from other hospital admissions, as admissions are coded by diagnosis rather than type of facility in which patients are cared for. In Australia, other than the ANZICS Patient Database, there are no national databases available that identify ICU patients as a group. Some jurisdictions such as New South Wales and South Australia collect specific data related to public hospital ICU patients as part of their inpatient statistics collections. However, as a general rule case-mix data does not identify intensive care patients as a separate group. ANZICS collects data independently of State and Territory health departments. 15

33 Table 8: ICU admissions, a Region Number of ICUs ICU admissions AIHW separations a ICU admissions (% of separations) Public sector NSW 43/46 28, , Victoria 22/23 19, , Queensland 22/22 14, , South Aust. 9/9 8, , West. Aust. 6/7 5, , North. Terr. 2/ , Tasmania 4/4 1,471 41, ACT 2/2 2,792 29, Sub total 110/115 80,507 2,089, Private sector NSW 15/17 8, , Vic./Tas. 11/13 6, , Queensland 10/13 6, , South Aust. 6/6 3,517 81, West. Aust. 3/4 1, , ACT 2/ , Sub total 47/55 26, , Total 157/ ,913 2,975, a Same day separations excluded. Source: ANZICS 2001, AIHW Australian Hospital Statistics Intensive Care Unit Staffing, Work Practices and Minimum Staffing Standards The care of patients in intensive care is a collaborative effort involving a range of professional and support skills. This section describes the current work practices and skill mix in Australia, with comment on international work arrangements. Potential changes to the composition of the critical care nurse workforce and the impact of technology on the workforce will be discussed in chapter 9, Critical Care Requirement Projections. In general, and depending on size and level of the units, the intensive care workforce comprises: nurses (almost entirely RNs); medical staff (intensivists, registrars, residents, and other specialists); allied health professionals such as physiotherapists, social workers, pharmacists, and biomedical technicians; unlicensed health care workers such assistants in nursing (AINs, ward helps); administrative staff such as clerical assistants, data managers, equipment managers; & cleaning/housekeeping/catering staff. Critical care nurses in the Australian context Critical care nurses in Australia provide holistic care for patients in the ICU. The current standard clinical staffing arrangement of one RN to each patient allows the RN to provide 16

34 comprehensive care. Critical care nurses take all observations, provide respiratory care including physiotherapy and routine ventilator setting manipulations with blood gas analysis; comprehensively manage continuous renal replacement therapy and equipment; take and interpret electro cardiograms, blood samples and other diagnostic samples in consultation with medical colleagues. In many ICUs critical care nurses follow standard protocols for the administration of invasive and pharmacological treatments without direct input from a medical officer. The critical care nurse also provides all the personal care required by the patient, as well as providing support for the family and friends of the patient. Critical care nurses plan the care of their patients from admission and towards discharge, liaising closely with service providers beyond the boundaries of the ICU and the hospital (Williams & Leslie, 2001). ICUs in the UK and Europe use RNs in a similar way to Australia, i.e. RNs are the primary providers of nursing care on a 1:1 basis for ventilated patients (Audit Commission, 1999, Ferdinande, 1997). In other countries, notably the United States (US), the staffing skill mix differs from Australia. In the US, the nurse to patient ratio varies widely among ICUs, mostly due to attempts to reduce costs of care. The effect of the reductions of nurse to patient ratios on patient outcomes is the subject of recent evaluative studies. The results of such studies suggest that an increased ratio of critical care nurse to patient, produces in a decreased complication rate (Amaravadi, Dimick, Pronovost et al, 2000, Pronovost, Dang, Dorman et al, 2001, Robert, Fridkin, Blumberg et al, 2000) and decreased length of stay (Pronovost et al, 1999). The extended practice nurse The extended practice of critical care nurses in many ICUs in Australia is a result of the relationship between nurses and intensive care specialists with mutual training, learning and development of their respective disciplines. Critical care nurse roles are currently being developed within Medical Emergency Teams (METS), liaison roles and extended practice roles (performing some of the duties carried out by medical staff in the ICU). The numbers are small overall, but provide critical care nurses with opportunities to use their skills and expertise to the advantage of both patients and staff beyond the walls of the ICU. The use of enrolled (division 2) nurses in ICUs Currently, the use of enrolled nurses (division 2) in most jurisdictions is confined to supporting the roles of RNs with maintenance of equipment and assistance with procedures such as complicated dressings. However in South Australia, enrolled nurses play a role in direct patient care. In the public system they are allocated a full patient load under the supervision of an RN. They are generally allocated care of non-ventilated patients and there is usually no more than one enrolled nurse rostered on per shift. In the private sector, one organisation has piloted an education program entitled the Enrolled Nurse Critical Care Education Program. Graduates still practise under the supervision of RNs, but with extended roles. There is no published research evaluating the use of enrolled nurses Australian ICUs. The use of unlicensed health care workers in ICUs Australian ICUs do not currently employ unlicensed health care workers in direct patient care roles. Studies in the UK (Hind et al, 2000, Hogan, 2000 and Roberts and Cleary, 2000) have described the use of health care assistants (HCA) in ICUs. They may be able to support RNs by providing clerical support, housekeeping support and some direct patient care such as mouth care, eye care, urine measurement, feeding and bed changing. Other HCA involvement described includes some clinical monitoring such as the recording of vital signs 17

35 and blood sugar measurement. RNs have voiced their concern with HCAs performing some of these clinical roles, as the HCAs may not understand the clinical significance and therefore be unable to anticipate potential serious changes in patient condition. RNs argue that ICU patients are potentially volatile and therefore their condition must be monitored by qualified staff. The recommendations identified in the UK literature regarding the use of HCAs include the production of national guidelines for HCA use; the identification of all the indirect, non nursing activities that HCAs could perform; the production of specialised training programs for HCA who wish to work in ICUs; and the provision of a grading structure linked to levels of competency. The current minimum standards for ICUs in Australia (FICANZCA, 1997, ACHS, 1997) clearly state that RNs should be the primary providers of patient care in the ICU (Appendix D). Use of minimum standards and guidelines for staffing Using the current minimum standards and guidelines to ensure minimum staffing levels in the ICU, nurse managers then use their clinical judgement to allocate staff to care for patients according to need. For example, at times a high dependency patient may require more nursing care than a ventilated patient, due to instability of their condition, therefore requiring a nurse to patient ratio of 1:1 rather than 1:2. There is currently no nationally consistent approach to determining nursing workload by patient acuity or severity data in Australia. A number of systems have been developed to aid nurse managers determine staff allocations; the Therapeutic Intervention Scoring System (TISS) and Nine Equivalents of Nursing Manpower Score (NEMS), however, these are not widely used in Australia. There is currently little data available linking nurse staffing with ICU patient outcomes in Australia. One study (Beckman et al) reports a link between nursing staff shortage and undesirable patient outcomes such as major physiological change, patient/relative dissatisfaction and physical injury. In general, most ICUs do not operate with all physical beds open or available. This is not necessarily a measure of staff shortage, but is often due to budgetary constraints or fluctuating demand. For this reason, many ICUs operate with a certain number of beds open and staff to this number. To enable the ICU to respond to peaks in demand, casual or agency RNs are used as well as occasional overtime by regular staff. 18

36 3. CONSUMER PERSPECTIVES OF THE CRITICAL CARE NURSE WORKFORCE Consumers of critical care services are both the patients and their families and other supporters Consumers are in a vulnerable state, both physically and emotionally, while in ICUs. Consumers require nurses who are not only truly expert, but can also provide continuity of care, empathy, respect and information. Consumer requirements translate into workforce issues for critical care nurses. An adequate supply of competent, experienced nurses, having the time to pre-empt and provide all aspects of physical and emotional care is essential. The retention of nurses in the permanent workforce to allow continuity of care requires adequate career pathways and other mechanisms to encourage nurses to stay. This chapter highlights consumer issues and perspectives regarding the critical care nurse workforce and planning. The consumers of intensive care services are not only the patients, but also their families, friends and other supporters. A number of studies investigating consumer requirements and issues in critical care have been carried out. The issues brought to light by these studies are also reflected in the experiences presented in this chapter by the Consumer Representative on this project s Working Party. These issues are presented from both the micro (personal view) and the macro view for workforce planning. The Working Party acknowledges the subjective nature of the piece written by the Consumer Representative but believes it describes the experiences of many critical care patients, as supported by the literature. Hospitalisation for a critical illness or accident is seen as a crisis for both patients and their families and friends. Fear and uncertainty may overcome them as they grapple with uncertain prognosis, potential death or permanent disability. The vulnerability of patients in intensive care is related to their extreme level of dependency. An Australian study (McKinley S., Nagy S., Stein-Parbury J., Bramwell M. and Hudson J. 2002) reveals patients may experience feelings of security and safety even within their vulnerable state. Knowing what is happening to them, having their needs anticipated and acted upon, treated in a personalised manner, having a nurse nearby at all times and having family present contributed to feelings of security and safety. Such feelings underscore the importance of the presence of RNs in intensive care who are readily available to meet the immediate needs of patients and to provide assurance they are safe whilst in a vulnerable state. In contrast, patients may experience feelings of insecurity if they do not know what is happening, if their needs are not anticipated (particularly if they cannot communicate easily) or not met immediately and if their care is de-personalised. 19

37 Both nursing staff and medical staff concentrate on the technical aspects of saving lives and monitoring for complications or changes. At the same time they are relied upon to develop a therapeutic relationship with family members, and others, to provide support, information and hope (Bijttebier, Vanoost, Deelva, Ferdinande and Frans, 2001, Holden, Harrison and Johnson, 2002). This requires time, energy, understanding and patience on the part of staff to provide an adequate level of care to both the patient and their supporters. Research (Bijttebier et al 2001, Molter, 1979, O Malley, Favaloro, Anderson et al 1991, Coulter 1989) has found that needs identified as being most important for families of intensive care patients include: having questions answered honestly; to be assured that the best possible care is being given; to have understandable explanations given; to have hope; to help with the care of the patient; and to be involved with decisions making. O Malley et al (1991) suggest that less experienced critical care nurses tend to focus on the relationship between themselves and the patients and have reported feeling incompetent in meeting the psychological needs of the families, whereas more experienced nurses are more able to look beyond the patient to the family members who are also the consumers of the intensive care service. Strategies to meet the needs of families of intensive care patients include medical and nursing staff involving families in structured in depth information rounds, nurses actively involving families in the physical care of the patient and allowing time for families to express their fears and concerns. These strategies take time and effort. Consumer Representative : From my perspective As a consumer representative on the AHWAC Working Party on Critical Care Nursing I have thought long and hard about how I might contribute to this working group s deliberations and recommendations. All of the other members of the group have professional backgrounds in critical care nursing, nurse education, or work force research and planning. I have worked in the health industry for over fifteen years in policy development and health law, and with consumer issues as a former health care complaints commissioner and advocate for women s health. However, I feel ill equipped to comment from a stand-point which assumes an in-depth professional knowledge of the issues around work force planning. Additionally, consumer concerns often focus on the micro issues, based on experiences they, or others they know or hear about, have had within the health system. It is hard to connect the dots translate these micro concerns into more global issues such as work force planning. So I have decided to take a dual approach. First, I will focus on the micro level, based on my own, and others, experiences, and then endeavour to translate that into more relevant terms. This will likely not come up with anything new, but it will affirm that health care consumers share many of the concerns that professionals have about standards of care. I was reading an article in the paper today about nursing as a career the pluses and minuses of agency versus permanent employment, written by two nurses who worked in critical care. I was struck, once again, by the fact that the impact of their employment 20

38 conditions on the final product health care to a patient although it was implicit in much of their arguments about care standards never, at any point, referred to consumer preferences. Instead it focused on professional issues; working conditions, and a comparison of job satisfaction on the one hand, and on the other, the pros and cons of each type of employment on provision of professional, high quality care. Of whom was never mentioned! Consumer perspective: the micro view I do have frontline experience from a consumer perspective of critical care. I have listened to and reviewed hundreds, if not thousands of consumer complaints and concerns about their health care from the doctor never told me that, to the nurses are always too rushed to feed Mum / get the bed pan in time / be civil ; from what might seem trivial to professionals but are experienced as humiliating and unpleasant by consumers (e.g. being left inadequately clothed by a too small open nightdress on a trolley in a public corridor), to serious preventable adverse events leading to permanent injury or even death! As well, and perhaps more importantly, I have hovered between life and death myself, in a critical care neurosurgery ward, after a stroke, and then following major brain surgery. So perhaps that is what I can do; talk about what it feels like to be a consumer of critical care at the micro level, and then relate that to the larger macro issues (of which workforce planning is one) which, if we don t get them right, will directly impact on the micro experience of each and every patient. My experience in an intensive care neurosurgery ward, was by and large a positive one. For one thing, I survived! The nurses played a huge role in this. It is the nurses I remember, not the doctors really. I was drifting in and out of consciousness for several days. I remember that the nurses listened to me, and were there when I needed them. There were four beds in the ward, and two nurses on; so I was never, that I recall, left to wait if I pressed the buzzer for the bed pan or for pain killers etc. They were tolerant of visitors coming all hours of day and night, but firmly enforced rules to prevent non family when the patients needed rest. The atmosphere was quiet, and low key, the lighting subdued very important if your head hurts, and every noise sets off a clash of cymbals in your brain. I was helped to get up when I was ready, and to walk about even to break the rules ; the nurse was experienced enough to trust me as a patient to get it right as to how much I could be up, despite the doctor s orders that I was to be up so much per day. For the first 3 days (I was there 8 days) I was woken every 2 hours right through the 24 to test my blood pressure and brain functioning I hated that, I was so exhausted; but it was made bearable by the quiet competent way it was done. I liked seeing familiar faces a new nurse on a shift and my anxiety levels went up a notch would she know what she was doing; it was my life and health at stake here. I also, because of my background, was aware of the pressure they were under. They were short staffed and overworked, given the magnitude of the problems their patients suffered from. The standards of care they maintained was due to their commitment to their patients, and to going that extra metre more than should strictly have been required of them. There was one nurse in particular I remember she was the nurse manager on the ward. She was in her mid forties I think; she had been on the same ward for years and years, and she made sure she knew each and every patient and family that was there. Hundreds of them over the years. She exuded this air of competence, patience, and sensitivity to the suffering she saw every day. Some months later, when I felt well enough, I went back because I wanted to contact the patient who had been in the bed next to me we had talked quite a bit, and supported each other and, because of privacy and confidentiality, I 21

39 knew I needed to go through the hospital for him to be contacted and his permission sought for his contact details to be given to me. She remembered him and me, contacted him straight away, and within a few days, we were back in touch. She also reminds me of a non intensive care experience I had many years ago, when I was recovering from abdominal surgery. I was in great pain from gas bloating my stomach and pulling on the scar and stitches. The afternoon shift nurse told me to put up with it, and stop making a fuss. The evening shift nurse, when the rest of the patients had settled down for the night and she stopped being so busy, came in to talk to me; showed me exercises I could do to get the gas moving; brought a hot water bottle to lay on my stomach, and generally made me fell much better. The first nurse was right, I did have to just put up with it until it passed, but oh, what a difference the second nurse made! I also heard many tales of woe as Health Services Commissioner in Victoria. Although the majority of complaints were about doctors, some concerned nursing care. Even in the complaints of adverse clinical events focusing on doctors, one of the conclusions I came to is that nurses are a critical part of the safety net which prevents clinical adverse events. To do this there needs to be experienced nurses around; only then do they have the knowledge and the confidence to realise if a doctor makes a mistake, and then to stand up to him or her to correct it. Also, there needs to be enough nurses, so, for example, if a patient needs a bed pan to be helped to the toilet, a nurse can come immediately to do so; many adverse events, particularly for the elderly, occur when they try to get out of bed because they can t wait any longer. What is it then that we can learn about consumer needs of critical care nursing? Most of what we need is intangible. It focuses around notions of high quality care and feeling supported ; adequate follow up and general respect and sensitivity to the patient s non clinical as well as clinical needs in getting well. This is hard to quantify, or translate into health care planning. However, below, I have tried to synthesise my own observations. Trust Trust is critical. We need to be able to trust the professional and technical competence of the health care providers taking care of us. Our life is, literally, in their hands. We want to know that they are experienced, or, if less experienced, that they have adequate, and continuous, access to supervision. We want to know that less experienced staff will know their own limitations and call for help, which will be available. We want to know that the hospital has the capacity and systems to respond to all our needs not only the clinical ones, but the ones related to our sense of well being, which supports our capacity to recover. This is particularly so, in the pressure cooker of a critical care ward. Time We would like nurses to have time to talk to us, to explain to us what we want to know, and to comfort us when the pain is bad and no one else is around. For example, in the middle of the night when we can t sleep, we might like the nurse who comes to change our drip, to have a few minutes to talk to us as well, if we need that. We want to be helped when we ring the bell, not half an hour later. 22

40 Continuity We want continuity of care. We would like to see at least some of the same faces each day, as the shifts change. We hope that the nurse who changed our drip last night, and stopped to talk for three or four minutes, will be the same person who changes our drip tonight. We have a relationship of sorts, which we value, and want to continue while we are in the ward. Empathy, Respect, and Participation. When the pain is bad, we want someone to comfort us, and to call the doctor to get a drugs order for more pain relief. We want to be listened to when we say that our six year old son never makes a fuss; the fact he is crying now means something is wrong, not that he is naughty. We want not to be left on trolleys in public corridors with our bums hanging out! And we want to be treated with respect, consulted in discussions about our care (if we are up to it), and comforted when we feel low. All this as well as clinically getting the best care we can! How then, can we translate such concerns into something meaningful for macro workforce planning! Consumer perspective: The macro translation Below I have set out a table which attempts to move from these intangible qualities, to their macro implications. Table 9: Summary of consumer critical care issues and their workforce implications Consumer Issue Hospital Response Workforce Issue Trust Enough clinically competent critical care staff, Recruitment with a good mix of experienced and supervised learning; enough of them also to Retention enable time out for in-service training; plus working conditions that produce high morale. Continuity Time Empathy, Respect, Participation Shift rosters; mix of employed and agency staff; employment conditions. Enough appropriate staff to meet clinical and non clinical needs of patients in critical care Enough staff on duty with time and people skills; training; institutional philosophy & culture; interpreter services General, specialist, & inservice training Career paths / satisfaction Employment conditions Population Base None of this is new to the Working Party. Most are discussed in the report. What I have endeavoured to do is put the consumer into the picture as it is being drawn. The picture doesn t change very much, but we are reminded of what the final outcome of effective workforce planning should be enough well trained clinically competent critical care staff, who are good with patients, to provide optimum care to each and every one of us, if we need it. 23

41 Recommendation: Perhaps the report could consider the need to develop and then include, the value of consumer based data generated by complaints, as possibly providing a canary warning about inadequacies in the available workforce. Implications Of Consumer Issues For The Critical Care Nurse Workforce The ability of critical care nurses to provide the level of patient and family support required translates into a workforce issue very simply. Patients and their families and friends require experienced nurses who can anticipate and act upon needs quickly; have the time to talk with, provide information to and support them; are clinically competent and physically present at all times. A level of continuity of care is also required by consumers and this can only be provided by an increased proportion of permanent staff, rather than the current trend of increasing casual and agency staffing. Adequate staffing levels, educational support, and strategies to retain experienced staff are all important factors that relate directly to consumer needs. 24

42 4. CRITICAL CARE NURSE DATA SOURCES The AIHW provides the only national nurse labour force reports using surveys attached to the registration renewals in each State and Territory. Issues of lack of timeliness of reporting, question inconsistencies and response rates amongst jurisdictions have affected the usefulness of the data. ANZICS provides the most timely and consistent data on national critical care services and resources (medical and nursing). Systems for the collection of workforce data and monitoring data by State and Territory health departments range from centralised processes (easily accessed) to decentralised processes (difficult to access). The ability of the systems to report on workforce varies, but is generally poor at present. Data systems used by the various State and Territory nurses registration authorities differ, as do the categorisation of data collected and thus the ease with which the nurses registration authorities can report specific data. All jurisdictions are moving to improve their data collection and monitoring systems to enable more effective workforce planning. Data available directly from DEST to describe both undergraduate and specialist post graduate nursing courses is not adequate, requiring ongoing surveying of universities for the specific information required for specialist workforce planning. Direct surveying of universities also provides data that may not be accurate. Information from the private sector is difficult to obtain. Individual ICUs collect and analyse workforce data, however, in isolation of each other, thereby making it difficult to compare data. Improving national, state and territory and educational data sets is essential for accurate workforce planning. Selecting appropriate data to use for the description of the critical care nurse workforce was the first major task of the project. The resulting available data impacted on the approach taken in this project. The working party agreed to explore existing data sets prior to developing any further by surveying or other means. A wide variety of data sets were identified and utilised. This was of some concern to the Working Party, but a practical necessity given the general paucity of nursing workforce data suitable for specialist nurse workforce planning purposes. This reality reflects the historical lack of focus within 25

43 government and the profession on the establishment of nationally uniform and robust nursing workforce data collections. It also reflects the fact that the AHWAC national workforce planning projects undertaken on specialist nurse workforces in Australia (critical care and midwifery) in are the first of their kind. In parallel with these planning projects, AHWAC and the Australian Institute of Health and Welfare (AIHW) have been working toward improvement of the national nurse labour force surveys. The improved survey format and protocols should be in place for the 2003 survey. However, it is only one aspect of nurse workforce data and this report makes a number of recommendations related to other dataset improvements, including data held by State and Territory health departments. The Working Party acknowledges the increased attention to data collection by State and Territory health departments over recent times. At the time of writing this report, many jurisdictions were implementing improvements in the collection of data such as payroll and other systems to monitor the nursing workforce. The following is a detailed description of the potential data sets available for nurse workforce planning and critical care nurse workforce planning in particular. This section of the report is lengthy, however, it is important in context of the report as a whole, to understand the various data sources, the fragmented approach to collection of data and the impact this has on reporting and planning at a national level. National Data: Nursing Labour Force and Workforce 1. The Australian Institute of Health and Welfare (AIHW) The AIHW Biennial Nurse Labour Force Report The Australian Institute of Health and Welfare (AIHW) publishes the only national nursing labour force data every two years. The data originates from surveys conducted by the State and Territory health departments utilising the nurse registration authorities registration renewal process for distribution. Most States and Territories survey their nurses annually, however some survey biennially. Some survey at the same time each year, while some survey on the anniversary of the registrants initial registration. The surveys and their reporting have been the subject of concerns in terms of timeliness, consistency, and response rates. However, the AIHW with AHWAC and other stakeholders such as nurses registration authorities, health departments and the Australian Nurses Federation have been working toward addressing such concerns since November As a result of this collaboration, a newly standardised survey will be used for the 2003 nurse labour force surveys (Appendix E). The issue of timeliness of the biennial report is also of importance. Due to delays in processing, the time taken by the States and Territories to send their survey data to AIHW varies greatly. This has led to lengthy delays in reporting. For example the most recently available data (in 2002) from the surveys is derived from 1999 surveys. The AIHW and AHWAC recognise that this situation is not acceptable and actions to improve timeliness are under consideration. The response rates also vary in each state and from year to year. For example, in 1997 the national response rate was 78.7%. In 1999 it increased to 87%. However, the individual 26

44 jurisdictions varied greatly. There is also an element of non-response to specific survey items, which may impact on data for specialty workforces. The AIHW adjusts for the non-respondents of surveys by scaling the survey data up to the registrations in each State and Territory. This is done by distributing the non-response numbers on the basis that non-respondents are assumed to have the same labour force characteristics as respondents. This process may overestimate the numbers of nurses in the labour force in each State and Territory if non-respondents are more likely to be those with multiple registrations or are not actually working. This survey error is likely to be greater in the Northern Territory and the Australian Capital Territory where a higher proportion of RNs are registered in other jurisdictions but a lower proportion practises solely in the Territory (AIHW, 2001). Table 10 reports response rates for 1997 and 1999 and non-response rates to a number of key items used for workforce planning by survey respondents. Table 10: National nurse labour force survey, overall response rates and non-response status to individual items, 1999 Overall response rate 1997 % Overall response rate 1999 % Nonresponse to main area of practice* (1999) % Nonresponse to workfield* (1999) % Nonresponse to age* (1999) % NSW Victoria Queensland South Aust West. Aust Tasmania North. Terr ACT * % non-response to item, of those who responded to surveys. Source: AIHW 2. The Australian and New Zealand Intensive Care Society (ANZICS) Research Centre for Critical Care Resources Intensive Care Survey (ARCCCR). The ANZICS Research Centre for Critical Care Resources (ARCCCR) monitors critical care resources in Australian and New Zealand health care facilities. The focus is on resource issues, the critical care work force, demographic aspects, quality activities, processes of care and international trends and comparators. It aims to provide reliable information to clinicians, policy makers, health care providers and state and federal governments to improve critical care services. An annual survey is distributed to all Australasian critical care units (Appendix C). The most recently reported critical care resource survey was conducted in early 2001 by Anderson and Hart for ANZICS (referred to in this report as ANZICS 2001) and retrieved data for the financial year. The survey included a comprehensive list of questions related to nursing resources. The ANZICS survey is successful in that its overall response rate is very high (99%). It is useful to the AHWAC project as it asks enough questions 27

45 regarding critical care nurses to provide a national and timely picture of the number of RNs employed in intensive care (FTE) and the number of current vacancies for RNs in intensive care (FTE). At the same time it provides a source of information as the number and type of ICU beds and levels of units across the nation. Other data collected by the survey includes medical workforce data and data on equipment. Many of the key findings of the ANZICS survey are reported in this report. 3. Australian College of Critical Care Nurses (ACCCN) The Australian College of Critical Care Nurses (ACCCN) represents critical care nurses nationally. The college has strong professional links with other national peak nursing bodies and government agencies and individuals. ACCCN has braches in each state, with two members of each state management committee forming the Board of ACCCN. ACCCN National Nursing Workforce Survey of Intensive Care Units A national attempt was made in 1998 (Williams, Ogle and Leslie, 2001) to investigate the reported shortage and issues surrounding the shortage of intensive care nurses. All ICUs within Australia were mailed a questionnaire. The response rate (52%) does not allow general conclusions, however some of the findings are of interest. For example, the survey found that private sector ICUs used a greater proportion of agency staff than public ICUs (2.5 times more agency hours per patient day than public hospitals). Other findings included an average turnover rate for all ICUs of 18.2%. Of particular interest to the Working Party was the finding that the majority of managers indicated they adopted a 1:1 ratio for ICU patients and a 1:2 ratio for high dependency patients. Most nurse managers indicated they were experiencing difficulty recruiting suitably qualified staff. National Nurse Education Data In general, AHWAC found that the data to describe accurately both undergraduate and post graduate nursing course student numbers was difficult to obtain. It seems that processes in place for the reporting of such information as commencements, completions and attrition rates are not adequate. 1. Evaluations and Investigations Program (EIP) National Review of Specialist Nurse Education (Russell, Gethering and Convery, 1997) In 1997, the Evaluations and Investigations Program (EIP), Higher Education Division of the Department of Education, Science and Training (DEST) commissioned a project to review the specialist nurse education in Australia. It aimed to assess the quality and quantity of offerings in post registration specialist nurse education and determine future requirements. It produced recommendations for specialist post-registration nurse education in Australia. In seeking to quantify the number of post registration courses available at the time, questionnaires were sent to universities, Colleges of Nursing and organisations in the health sector (eg. hospitals). The courses were grouped into 15 categories. The critical care category included acute care, neurology, neuroscience, critical care, intensive care, cardiothoracic, cardiovascular, cardiology, coronary care, neonatal intensive care, perinatal intensive care and accident and emergency. The report provided the first national picture of post registration specialist nurse education with provider type, number of courses available for critical care courses and number of students and intakes per year. 28

46 One of the recommendations of the report was to develop a nomenclature for nursing specialties. It was suggested the nomenclature consist of a limited number of broad-band nursing specialities (7), each containing multiple sub-specialties. The broad-band of high dependency included critical care as a sub-specialty. Another major recommendation was for the development of a national database on the provision of specialist post-registration nurse education for future planning and collaboration between sectors. 2. Nursing Education and Graduates: Profiles for 1999, and 2000, with projections for (Ogle, Bethune, Nugent and Walker 2001) One of the DEST commissioned research reports for the 2001 Review of Nursing Education was Nursing Education and Graduates: Profiles for 1999, and 2000, with projections for 2001 (Ogle et al, 2001). This report provided valuable information on the number of undergraduate and postgraduate nurses in Australia. Of particular interest to the AHWAC report is the profile of postgraduate speciality courses. However, the authors have categorised critical/intensive care within the broad-band of high dependency nursing (based on the approach used by Russell, Gethering and Convey (1997) as outlined above). The High Dependency broadband incorporates 16 other specialties. According to the report, the ability of course coordinators to provide a more specific breakdown of course information may have been limited. The use of generic nomenclature for postgraduate courses is a response to both the philosophy of the broad-bands but importantly as a method of university administrators to enable funding for smaller specialty courses. For the purposes of the workforce planning for a sub-specialty within a broad-band category, this particular profiling report is of limited use. 3. Nursing Education and Graduates: Profiles for 2001, 2002 (Ogle, Bethune, Nugent, Walker and Wellman) This project was a follow up to the previous profiling report done in Like the above report, it was carried out by a team of researchers based at Deakin University in Victoria and was commissioned by DEST as part of the National Review into Nursing Education, with the purpose of mapping nursing education programs and nursing graduates for 2001 with projections for This follow-up project provided more useful data to the Working Party, as the high dependency category was broken down into sub-specialty categories, enabling critical care/intensive care, paediatric intensive care and other relevant specialties to be identified separately. This provided more useful data for inclusion in the critical care workforce report than the previous profiling report of DEST reports provided to AIHW DEST provides AIHW with numbers of commencements and completions for all nursing courses within the university sector. Postgraduate courses that contain intensive care or critical care in the title were identified by AIHW and reported to AHWAC in However, as Ogle et al found in their initial profiling exercise, using this method of identification leads to understatement of numbers of both courses and students in post graduate critical care courses. This is due to the large number of generically named courses, which may escape inclusion when examining specialty courses. State and Territory Health Department Data Collections Principally, State and Territory health departments collect data relating to public hospitals and other public health facilities. 29

47 The only consistent approach to nurse workforce data used by the States and Territories is via the nurse labour-force surveys. However, as described above, there are inconsistencies and issues of timeliness with these surveys. Apart from these, the other possible data collection is through the nurses registration boards, health department payroll, staffing systems or staff reporting systems. Some States and Territories have centralised systems that capture nursing data, other States have decentralised systems and there is no ability to capture this kind of data on a state-wide basis. Across the nation there is no consistent approach to payroll or staffing systems. This makes aggregation of the data for national workforce planning virtually impossible. With the writing of this report, most of the health departments were attempting to improve their workforce data collections via implementation of new systems. Nurses Registration Boards are a potential source of useful workforce data in terms of general supply information such as new registrants, overseas nurses and re-registrants. However, nurse registration data does not capture information about the specialist nurse workforces, unless they are required to have a separate authorisation to practise (such as midwifery). AHWAC sought data regarding initial registrations for the last five years from each of the jurisdictions to allow an analysis of trends. AHWAC also requested data on registration renewals and overseas nurses registration for the same time period. The ease or ability of each jurisdiction to provide AHWAC with this information depended upon the systems in place at the nurses registration boards. All were able to provide numbers of initial registrations (some with difficulty) and most were able to provide data on registered nurses from overseas. Some jurisdictions were unable to provide data on re-entry nurses or overseas nurses. Some data such as re-registrations was not reliable as an indicator of reentry to practice, as systems included late registration fee-paying registrants in these numbers. As AHWAC requested data, many of the registration boards were implementing new systems to enable better management of data, this should make future requests much easier to fulfil. Table 11 summarises the approaches and recent studies conducted by each State and Territory in regard to the nursing workforce in general and critical nurses in particular. To supplement this information with updated data, the Working Party requested data from each of the State and Territory health departments. The ability of the jurisdictions to provide the requested information was partly dependent on the systems in place for data collection, but also seemed dependent on the amount of time and effort each jurisdiction was prepared to spend on the request. Some jurisdictions surveyed their intensive care units to provide the information requested, while some drew from their most recently available nurses registration surveys. The Working Party acknowledges the recent approaches to improve data collection in all jurisdictions, most of which were not finalised at the time of writing this report. The information requested from the jurisdictions included: 1. RNs working in intensive care (both qualified and unqualified) number (FTE and headcount) number (FTE and headcount) with postgraduate qualifications in critical care nursing) number (FTE and headcount) currently enrolled in postgraduate qualifications in critical care nursing) Other descriptors: age profile gender profile 30

48 geographic distribution hours worked 2. Number of RN vacancies (being actively recruited) in intensive care 3. Attrition rates for RNs working in intensive care 4. Number of places available for postgraduate courses in critical care nursing 5. Number of subsidised or funded postgraduate courses in critical care nursing 6. Number of overseas registered nurses entering the intensive care workforce, either permanently or on temporary contracts 7. Use of casual staff (Agency and hospital pools ) in intensive care 8. Plans for future intensive care beds Information sought from the nurses registration boards included: 1. Number of initial registrations (registered/division one nurses) each year for the past 5 years. 2. Number of re-registrations of RNs for re-entry to practice each year for the past 5 years. 3. Number of new overseas registrations for the past 5 years (by region of possible) Information regarding nurses working in the private sector was not available from any payroll or staff reporting systems used by the State and Territory health departments. The following table attempts to summarise the current processes in place in the jurisdictions for the collection of nurse workforce data. It also highlights recent reports identified by AHWAC related to nurse workforce planning and intensive care service planning. For a full description of each of the state/territory processes, refer to Appendix F. AHWAC acknowledges that most jurisdictions are working toward improvements in workforce data collection and monitoring and at that some of this information may have changed since the writing of this report. 31

49 Table 11: Summary of State and Territory nurse workforce data sources State/Territory NSW Nurse Labour force Survey Annually, on anniversary of initial registration Payroll and Monitoring Systems Department of Health Reporting System (DOHRS): able to monitor vacancies in specialist areas. Recent workforce reports/ Intensive care planning reports The NSW Nursing Workforce Research project (2000) The Nurse Recruitment and Retention Project (2001) Intensive Care Service Plan - Adult Services (2001) Victoria Annually, in December Most public hospitals use one of three payroll systems. Qualitative Study of the Critical Care Nurse labour Force (1996). Daily tracking of agency and bank nurse utilisation in all public metropolitan hospitals (since mid 2002). Nurse Labour force Projections, Victoria (2001). Nurse Recruitment and Retention Committee: final Report, May 2001(2001). Nurse Recruitment and Retention Committee Government Response (2001). Nurse Workforce Planning (Auditor General Victoria, 2002). Queensland Annually April June State-wide payroll system: Staff Profile Information System (SPIS) for public sector health services. South Australia Annually August Monthly Management Summary System (MMSM) for all public sector health services Planning for Intensive Care Services in Victoria (MA International, 2001) Report of Critical Care Student Intakes Requirements (2000). Characteristics of the Specialist Nurse Workforces South Australia, 1998 (2000). Planning for intensive care report completed in 2001, but not released. 32

50 State/Territory Western Australia Nurse Labour force Survey Biennially November - December Tasmania Annually, July - August Payroll and Monitoring Systems Decentralised systems Centralised payroll system, but no collection of information of nursing specialties Recent workforce reports/ Intensive care planning reports Planning for intensive care services currently underway Specialist Nurse Labour force Requirements and Supply Projections (1994). Tasmanian Nurse Workforce Planning Project (2001). Northern Territory Annually, May - June ACT Annually April March (12 month collection period) Centralised payroll system, with centralised rostering system (ONESTAFF) No centralised payroll or workforce data collection Review of critical care nursing services (2001) Benchmarking of the Territory Nursing Workforce (2000) Nursing Recruitment and Retention Taskforce (2001). Data Sources At The Unit level Many ICUs have developed their own methods of rostering and reporting staffing on an ongoing basis. On the local level, there are many units that have developed their own spreadsheets, which describe their nursing workforce in great detail. Examples of some of the information captured in such systems are: over time hours, nursing hours per patient day (NHPPD), sick leave, casual staff usage. Some units also collect and store data regarding attrition from their units. Information from these databases is not available in any centralised form. Although these systems potentially provide useful data, comparisons and benchmarking should be done cautiously as they may differ in terms of interpretation of variables being measured. For example, one system measures NHPPD and includes direct and non-direct nurses, while another unit measures NHPPD by measuring direct care nurses alone. Private Hospital Data AHWAC requested information from the three main private hospital organisations in Australia (Mayne Health, The Australian Private Hospital Association and the Australian Catholic Hospital Association). The requested information was similar to that requested of the State and Territory health departments. While each of the directors of policy and planning and nursing services from the organisations were enthusiastic, only one response was received from an individual ICU. Although the response from the private sector was poor, ANZICS data was adequate to describe the current situation of the private sector ICUs for the report. 33

51 Improving Data Collections For Nurse Workforce Planning The Working Party developed a number of suggestions for the improvement of workforce data collections. These relate to national data sets, State and Territory data sets, data from the education sector and data to inform on quality. National data sets AIHW surveys: the implementation of a consistent, timely national approach for the collection of nurse labour force surveys via nurse registration boards annually. ANZICS ICU Resource Surveys: additional questions regarding the critical care nurse workforce should include specific questions to determine new entrants to critical care practice each year, and to determine attrition from the critical care nurse workforce each year. In the absence of national data informing all episodes of intensive care, continued support of the ANZICS Patient Database should be provided by the State and Territory health departments. However it is clear that this program needs to involve appropriate nursing bodies as well as AIHW to ensure national consistency and applicability of the results to prevent unnecessary duplication of effort and information. Consistent data definitions regarding critical care services and staffing should be developed for use both nationally, at the State/territory level, and the local level to allow aggregation of data and comparisons across various settings. State and Territory health departments Examination by State and Territory health departments of the options for adjusting payroll reporting systems to allow for the capture and reporting of workforce characteristics, participation, entrants and exists. A consistent approach for the collection and reporting of data by nurse registration authorities for the capturing new initial registrations (separating midwifery endorsements/authorisations, mental health nursing authorisations and overseas nurse registrations), and capturing re-entrants to the nursing workforce (separating re-entrants from late fee paying renewals) Monitoring adequacy of the critical care nurse workforce should include: cancellation of elective surgery due to insufficient critical care nurse staffing; closure of intensive care beds due to insufficient critical care nurse staffing; un-rostered over-time shifts (in excess of contracted hours) due to inability to staff beds; vacancies and use of agency and other casual nurses in critical care areas. Education sector Consistent nomenclature of critical care courses to enable clear definition from other postgraduate courses. Adequate data collection systems from universities to the DEST to enable efficient monitoring of both undergraduate commencements and completions and postgraduate commencements and completions. Processes for the monitoring of attrition from all nursing courses. Processes to monitor the gap between undergraduate completions and initial nurse registrations. Processes to monitor uptake of graduate nurses into the nursing workforce. Data to monitor and inform on quality Research to measure the relationship between critical care nurse staffing levels (and skill mix) and patient outcomes. Explore possibilities for consumer input into quality reports and dissemination of information 34

52 5. METHODOLOGY OF THE CRITICAL CARE NURSE WORKFORCE PROJECT Workforce planning is defined as a systematic assessment of future human workforce needs and the determination of actions required to meet these needs. The workforce planning process involves defining current supply and requirements, assessing current gaps in supply and service provision, considering future supply and requirement scenarios and developing agreed workforce plans for the future. The critical care nurse supply was analysed using AIHW data to provide an estimate of overall numbers, and profiling information such as age, gender and hours worked. ANZICS data was used to provide an estimate of the permanent critical care nurse workforce (FTE). There were many limitations to the data describing the critical care nurse workforce. These included a lack of data to describe annual new entrants to the workforce and little data to accurately determine attrition from the workforce. Measuring the adequacy of supply was by comparing the estimated critical care nurse workforce with an estimated required critical care nurse workforce using a method developed by Williams and Clarke (based on ACCCN guidelines and minimum standards). Adequacy of the permanent workforce was measured by examining FTE vacancies. Projecting requirements was carried out by applying a growth rate (based on population and ageing growth rates) to the baseline critical care nurse requirement. A no growth scenario was also provided. Two modelling calculation approaches were used. One was based on the total critical care nurse workforce and included age, gender and workforce participation (hours worked and attrition rates per 5 year age-group). An alternative simplified approach used the same base-line data, but did not use profiling information (5 year age and gender cohorts) rather, it was based solely on requirements, assuming consistent workforce participation across all age-groups. Both used the Williams and Clarke method to determine baseline requirements. 35

53 Generally, workforce planning may be defined as the systematic assessment of future human workforce needs and the determination of the actions required to meet those needs (Ripley 1995). In the case of health care, its fundamental purpose is to ensure the availability of sufficient staff with the right skills to deliver high quality health care to patients (Department of Health 2000a). Health workforce planning is generally considered to refer to the process of estimating the required supply of health care practitioners to meet an expected level of population health need or requirements in a future period of time; i.e. the planning process is concerned with determining the balance between the supply of labour and the need for labour. The planning process can be concerned with outlining supply in terms of numbers, mix, distribution and tasks, and need in terms of population health status, service requirements, or health outcomes goals. Ideally the defining of need should be linked back to optimal models of care or disease management. As far as is practicable an evidence based approach should be used in all analysis, but practicality will be determined by the availability of robust and reliable data sources. Workforce planning offers a practical guide to workforce policy. Health workforce planning is important in: identifying workforce shortage or surplus; defining (or redefining) workplace organisation, tasks and roles; establishing workforce education and training needs; providing knowledge and understanding of the workforce and its activities; and ensuring there is a process for systematically addressing the factors that are influencing workforce and workplace change. Health workforce planning is not an exact science, but rather an attempt to predict and determine the future on the basis of information available in the present. Reasons for health workforce planning being such an inexact science include: the long lead times involved; the influence of exogenous factors such as the economic cycle; and the impact that expectations can have. Given that workforce planning generally involves matching expected future workforce supply with expected future requirements the general approach used in health workforce planning is to: define current supply and requirements; assess current gaps in supply and service provision (generally referred to as assessing the adequacy of the current workforce); consider future supply and requirement (need) scenarios; and develop a workforce plan for the future. The general planning approach used in this report involved all of the above steps. However, the specific approach was dependent upon the quality of the data available to describe the critical care nurse workforce. Literature Review The first step of the process for this report was to identify recent approaches to critical care nurse workforce planning or assessment. In order to calculate the projections, a literature search and review of methods used both internationally and in Australia specifically related to the critical care nurse workforce was undertaken. A number of calculation tools were 36

54 identified and subsequently used for the projections. The following is a summary of the various potential assessment methodologies found. 1. Tarnow-Mordi, Hau, Warden and Shearer Tarnow-Mordi, Hau, Warden and Shearer (2000) published a report in the Lancet describing the relationship between nurse workload in ICU and mortality. Within the report a locally agreed formula for an appropriate level of staffing per ICU bed is described. The hospital in which the study took place was a Scottish medical and surgical intensive care unit servicing a population of 440, 000. The formula dictates how many beds will be adequately staffed given the actual numbers of FTE nurses available. Adequate nurse staffing was based on the assumptions that 7.0 FTE nurses are required for each bed (with allowance for handover time, holidays and sickness and an average nursing requirement of 1.3 per patient) and 4.3 FTE nurses are required for senior and basic administration and auxiliary duties. The number of appropriately staffed beds is: (total FTE nurses 4.3)/7.0 This approach is a potentially useful way to determine whether the number of ICU beds are adequately staffed depending on local agreed formulas. The authors assessed the relationship of increased nurse workload to patient mortality and found there was a relationship. That is, excess workload was related to increased mortality of ICU patients. 2. Miranda and Broerse Another method to determine ICU staffing was described by Miranda and Broerse (1999). The suggested formula is: Total number of staff = A x B x C x D x E F x G A = number of shifts per day B= total number of beds in unit C= number of days the unit operates D= desired occupancy rate (eg 85%) E= the staffing allocation to compensate for holidays and sickleave etc (1.25) F= the appropriate ratio of nurse to patient (eg 1:1) G= the total number of days each professional works (usually 5) The deficiency of the above model is its lack of calculation for supernumerary staff. However, these could be added in depending on the ratio of supernumerary required. It may be more useful for micro level planning than macro planning. 3. UK Intensive Care Society The UK Intensive Care Society as reported by the UK Audit Commission (1999) suggests a ratio of 6.3 nurse FTE per ICU bed, and half this for step down beds as a minimum. This ratio includes a nurse in charge and a runner/floater. There is no information in the document regarding the inclusion of other factors such as leave cover. 4. Task Force of the European Society of Intensive Care Recommendations on minimal requirements for intensive care departments (Ferdinande 1997) was published to inform the Task Force of the European Society of Intensive Care Medicine. It recommends a minimum of 6 RN FTE per bed for patients requiring the highest 37

55 level of care (level III), 4 RN FTE per bed for medium level of care (level II), and 2 FTE RN per bed for lowest level of care (level I). The Working Party considered this a potentially useful approach, however, may not be appropriate for use in the Australian context. 5. Rawinski and Brown A State-based study to determine critical care nurse requirements was carried out by the Department of Human Services in South Australia (2000). The purpose of the study was to determine the number of critical care nursing students entrants to meet South Australian Critical Care nursing requirements over the period Information required for this particular study was gathered by surveying individual ICUs. The current requirement for critical care nurses (FTE positions), headcount and attrition rates were determined by the surveys. The current total training numbers and course capacities were determined by surveying the course providers. This method determines training requirements by adding net loss (due to attrition) to growth in requirements. Data required for this method includes: FTE positions, actual headcount (including casual/agency staff), attrition rates (as expressed by average number of years spent working in critical care) and the actual numbers enrolled and course capacities of critical care nurse education providers. 6. Williams and Clarke Williams and Clarke (2001) provided a specific methodology to determine the number of nurses required to staff Australia s ICU and high dependency beds. The key questions considered by the approach include: What is the average number of full-time equivalent (FTE) nurses required to staff an ICU bed? How many FTE nurses are required to staff ICU beds in Australia? How many qualified and unqualified ICU nurses (FTE) are required to staff Australia s ICU beds? and What is the required replacement factor of ICU nurses per year (qualified and unqualified) to manage the attrition rate? The approach was based on accepted minimum standards determined by the Joint Faculty of Intensive Care Medicine (FICANZCA, 1997), the Australian Council of Healthcare Standards (ACHS, 1997) and consensus views of a panel of sixteen critical care nursing experts from around Australia. The methodology was developed using empirical data reported by Anderson & Hart (2000) for ANZICS, and the AIHW nurse labour force surveys. Where no empirical data was available, consensus was sought from a panel of sixteen critical care nursing leaders. There were two leaders from each State and Territory and included both clinical leaders and educational leaders from rural, metropolitan, paediatric, general and cardiac units. Consensus was gained in regard to staffing ratios (RN to ICU and HDU beds), use of Access (float/supernumerary) nurses, attrition rates, minimum and optimum qualified staff ratios, the number of nurse managers and number of nurse educators required. In determining an average FTE per bed, a number of variables were identified. These included the use of a ratio for RN to ICU patient and high dependency patients (based on the minimum standards of both FICANZCA and ACHS). Other variables used to determine average FTE per bed included number of nurse hours per week, number of supernumerary (ACCESS) nurse hours per week and award leave cover The number of required hours per 38

56 ICU bed per week was then derived. This was divided by 38 hours to provide an FTE requirement. In many ways it is similar to the approach outlined by Miranda and Broerse (1999). However the Williams and Clarke formula allows for supernumerary staff. For a detailed description please refer to appendix G. All variables described above were adjustable, particularly the ratio of ACCESS nurse per bed and leave cover ratio. The nurse hours per week were also adjustable according to the number of hours units operate on average. In the case of public hospital ICUs they are operational 24 hours per day, 7 days per week. Private hospitals may differ in terms of operational hours per week and occupancy rates. These factors can be incorporated to adjust the FTE requirement. Once an average FTE per ICU bed was calculated, this FTE was applied to the current number of ICU beds (using ANZICS data). The FTE required was then converted to a headcount by applying the average hours (based on AIHW nurses registration surveys) worked by critical care nurses to the FTE. The Williams and Clarke approach also included an estimation of the number of management and clinical educator RNs for intensive care. The number of nurse managers was estimated by applying one for each ICU, or by applying an agreed ratio e.g. one for every 12 beds. The number of clinical educator RNs was estimated by applying a ratio of one FTE educator to every 50 RNs (head count) or another agreed ratio e.g. one FTE for every ICU. A total number of RNs required was determined by adding the total number of bedside RNs to the total number of management and clinical educators. The total required headcount forms the basis for an assessment of the current supply by comparing it to the actual headcount (as reported by AIHW nurse labour force survey data). Estimating the required number of new entrants per year was possible by applying an attrition rate to the total headcount. The method also allowed the determination of numbers of qualified staff (by applying the desired ratio to overall required headcount) and the number of new qualified staff each year by applying the desired ratio to the attrition rate. In summary, the Williams and Clarke method may be used to determine current adequacy and/or to project future requirements (including new entrants each year) based on the same factors, by applying a growth rate to the base-line headcount or FTE requirements. Supply Analysis And Supply Projections The first step of the supply analysis was the estimation of the current critical care nurse workforce and the description of the workforce characteristics (profile) such as age, gender average hours worked, geographical distribution. Data from the AIHW was used to estimate the total critical care nurse workforce, including profiling information in 5 year age and gender cohorts. Data from ANZICS provided an estimation of the permanently employed critical care nurse workforce (FTE), but did not contain any profiling information such as age, gender, hours worked. The second step of the supply analysis was the determination of the adequacy of the workforce. This was done by two methods: 1. Using the AIHW data and comparing it with the agreed requirement assessment tool. Current supply was determined with the use of the AIHW nurse labour force data. The most recently available national data was from the 1999 surveys. Assessment of the 39

57 adequacy of supply was by using the Williams and Clarke approach. The required headcount of critical care nurses was calculated and compared with the estimated actual headcount (using AIHW data). This gave a baseline indication of undersupply, oversupply or balance. This assessment was made for each State and Territory. 2. Using ANZICS data to describe the permanent FTE workforce and assess the adequacy of the permanent workforce based on FTE vacancies. ANZICS reported the number of registered nurse FTE (permanent/rostered). This is a measurement of the permanent FTE critical care nurse workforce and does not include casual critical care nurses. An estimation of the adequacy of the permanent critical care nurse workforce is the reported number of vacant registered nurse FTE (positions funded but unfilled). There were a number of major limitations to the data describing the critical care nurse supply. Because of these limitations, a number of assumptions and scenarios were developed by the Working Party for the purposes of projecting supply. Limitations of data for supply projections: 1999 AIHW data was used to determine base year supply (2001); no data available on annual new entrants to critical care nurse practice; no reliable trend data on growth of the critical care nurse workforce. limited data on attrition from the workforce, not necessarily reflecting permanent exits from the workforce; no data on potential new entrants to the critical care nurse workforce (most RNs commence critical care nursing courses on entry to the workforce or subsequent to entry); no data available on re-entrants to critical care nurse workforce; and no data available regarding overseas migration into and out of the Australian critical care nurse workforce. Assumptions made due to data limitations: Two scenarios of total workforce loss were developed, of 10% and 15%. The attrition rate was applied to the 5-year age and gender cohorts according to most likely scenarios based on the age structure of the workforce (in general, a lower rate of attrition in the lower age groups and a higher level of attrition in the higher age groups). Average hours worked per week were assumed to remain constant within the agegroups. Requirement Analysis And Requirement Projections In order to determine future nursing requirements, the Working Party acknowledged that quality nursing practice is maintained with the continued adoption of current minimum standards and practice guidelines in relation to staffing, and that nursing requirements are determined by the intensive care infrastructure ie, number of available ICU beds. In essence then, two factors were considered to inform the requirements side of the workforce planning process: Critical care nurse practice and staffing; and Current and projected infrastructure (number of ICU beds). Critical care nurse practice and staffing The Working Party identified the current model of care in Australian ICUs. Critical care services are predominantly provided within the walls of ICUs. Critical care nurses apply a 40

58 total or holistic approach to patient care including the patient s personal care, therapies, monitoring, pathology and other sampling and investigations, equipment, and family support. Apart from the bedside nurse, other nurses play organisational, support and educational roles. Most ICUs have a nurse manager, a nurse educator and supernumerary nurses to provide support to the bedside nurses. The continuing ability to provide an holistic approach to patient care owes much to the adherence to minimum standards as set out by the Joint Faculty of Intensive Care Medicine (FICANZCA, 1997) and the Australian Council of Healthcare Standards (ACHS, 1997). The Working Party agreed to adopt these as minimum standards (Appendix D). Enrolled (division 2) nurses make up a small proportion of the critical care nurse workforce. They provide direct patient care in one State only and provide this to non-ventilated patients under the supervision of RNs. Patients who are critically ill require nursing staff able to provide complex care as well as a rapid comprehensive response to changes in their condition. The Working Party agreed to base planning on the assumption that the current model of care in Australian ICUs would remain stable in the foreseeable future, i.e., RNs would remain the main providers of critical care nursing. However, the Working Party acknowledges that alternative methods of staffing ICUs may be required if the supply of RNs is not able to meet requirements, and if the nature of intensive care service changes greatly with the introduction of new technologies. Using the Williams and Clarke (2001) methodology, an FTE per ICU bed was determined by applying a number of staffing factors including nurse to patient ratio, supernumerary staff ratios, and a ratio to cover leave entitlements (as suggested by the ACCCN staffing guidelines). An FTE of 6.5 for ICU beds and 3.7 for high dependency beds was determined (assuming at least 50% critical care nurses are qualified). This FTE was then applied to ICU bed numbers accordingly and a total FTE requirement was determined. Using average hours worked per week, the FTE requirement was converted to a headcount and provided a baseline critical care nurse requirement for bedside critical care nurses. An additional headcount requirement was determined for critical care nurse educators and managers as per the Williams and Clarke method. To account for the lower requirement in the private sector (due to a general lower occupancy), only 75% of the determined critical care nurse FTE for the private sector was used. The total critical care nurse requirement estimated was used to measure the adequacy of the current supply (see Appendix G for workings). The FTE per ICU bed determined by the Working Party was not developed for use at the micro (unit) level. It was developed to describe the overall number of RNs required to staff ICU beds on a statewide and national level. It is not to suggest that nurse managers must employ this number of nurses, rather to ensure that there is an adequate number of critical care nurses available on a macro level, whether permanently employed or casually employed who can staff ICU beds as required. The Working Party acknowledge that day to day staff requirements are determined by nurse managers depending on the clinical needs of patients and the number of beds occupied. 41

59 Projected critical care nurse requirements The Working Party recognised that growth in the underlying critical care infrastructure (i.e. the number and type of beds, equipment and funding available to support critically ill patients) will impact directly on the required growth of the critical care nurse workforce. By developing a baseline requirement using the Williams and Clarke method (critical care nurse FTE based on current intensive care infrastructure), it was possible to project future requirements by applying a growth rate to the baseline requirements. Because of insufficient data from State and Territory based planning for intensive care services, and for consistency, a population growth and ageing rate was developed for each jurisdiction and applied to the baseline critical care nurse requirements. These rates were based on the projected population change per annum (ABS 1998) plus an ageing factor. Ageing of the population is expected to add 0.4% to the demand for medical services (AMWAC, 1999). These rates were applied to the base-line headcount/fte requirements enabling a projected critical care nurse requirement over the 10 year projection period. The main assumption made by the Working Party in projecting in this way, is that the proportion of intensive care and high dependency beds will remain constant, and that the model of critical care nursing care provision will also remain constant. Limitations of data for requirement projections: Lack of national planning data available for future intensive care services; Little data available to describe average occupancy rates of the public and private sector ICUs; Little data available to describe fully the proportion of high dependency patients in ICUs; and Only two States and one Territory were able to provide planning reports for future ICU beds. The method used to determine future beds differed. Assumptions made to account for data limitations: Occupancy rates for public and private sector ICU differ, generally private ICUs have lower occupancy rates and a more elective type patient mix (therefore lower requirements). Occupancy rates of 75% were applied to private sector ICU beds to adjust overall FTE requirements. High dependency beds were estimated using available non-ventilated beds as a proxy. This was done by applying the average proportion of available non-ventilated beds to ICU level, by public and private sector. An average FTE requirement was then determined across all ICU levels for each State and Territory. Projections for growth in critical care nurse requirements (requirements growth) was based on population growth and ageing factors. The projected growth in population for each individual State/Territory plus an ageing factor of 0.4% (used for all States and Territories) was applied to the baseline requirement. Two scenarios related to requirements were used, one based on growth as determined by the population and growth estimates and the other based on no growth (assuming there will be no increase in ICU bed numbers over the next 10 years). Projection Modelling Due to the data limitations and the inability to reliably determine growth trends in the critical care nurse workforce, a requirements approach was taken. This entailed projecting the estimated requirements and then determining the number of new entrants required each year to balance supply and requirements. 42

60 Two modelling approaches were used. The first was developed by Von Konkelenberg. Data required for this model included the workforce in 5 year age and gender cohorts (available from AIHW nurses registration surveys), average hours worked per week by 5 year age and gender cohorts, entrants to the workforce in 5 year age and gender cohorts, losses to the workforce in 5 year age and gender cohorts, re-entry and migration and sample trainees (Appendix H). The assumptions developed were incorporated where no data was available and a number of scenarios were modelled. The baseline shortage, oversupply or balance was determined by comparing the Williams and Clarke determined requirements with the estimated actual headcount (as reported by AIHW). The second modelling approach used was developed by AHWAC and used Williams and Clarke derived base-line requirements (overall critical care nurse requirements and a measure of adequacy) expressed as both an FTE and headcount. This model did not require detailed supply information such as average hours worked per age-group or attrition rates per age-group. However, overall average hours worked per week as reported by AIHW, and an overall attrition rate was entered into the modelling. For both modelling approaches, a number of scenarios were used due to data limitations. These included supply side alternatives (10% attrition and 15% attrition). Requirement side alternatives included growing the requirements by population and ageing growth rates per annum; and providing a no growth scenario. 43

61 6. CRITICAL CARE NURSE EDUCATION Undergraduate nurses are the front-end of the supply chain for critical care nursing. The lead-time from commencing undergraduate nursing studies to being available for the critical care nurse workforce is estimated to be at least 4 years. Therefore, a change in undergraduate numbers will have a major impact on new entrants to the critical care nurse workforce at least 4 years later. During the mid 1990s, there was a decrease in the number of undergraduate nurse commencements and completions. Since 1998, the national numbers have increased marginally, although not in all States and Territories. Data describing undergraduate commencements and completions may not be accurate, due to lack of adequate processes in place for reporting. Critical care nurses may enter the workforce without a formal postgraduate qualification related to the specialty. Many commence courses once employed. Minimum standards suggest at least 50% of critical care nurses should be qualified, whereas ACCCN guidelines ideally 75% should be qualified. Formal postgraduate education for critical care nurses is offered through the university sector, the NSW College of Nursing and by a small number of hospitals. Nurses may access courses based in States other than their own due to mixed mode or distance mode courses available. Accurately determining numbers of students commencing and completing postgraduate critical care courses via the university sector is difficult, due to the inconsistent nomenclature, generic nomenclature and inadequate processes for universities to report to DEST. Surveying of individual universities to determine postgraduate specialist numbers was carried out by Ogle et al (2001 and 2002), as adequate data was not available from DEST. An estimated total of 667 postgraduate critical care nursing completions are projected for Enrolled nurse education specific to critical care is actively being instituted in SA. 44

62 In Australia, the nursing component of critical care departments (ICUs) is almost exclusively registered nurses (RNs). Some ICUs employ enrolled nurses (division 2 nurses) predominately in support roles, and some in direct patient care. However, the numbers overall are very small. This chapter focuses on educational arrangements for RNs working in critical care, however a brief description of the educational arrangements for enrolled (division 2) nurses (ENs) will be provided. Critical care nurses are predominately registered nurses, many of whom have post graduate qualifications in intensive care, critical care or other related nursing courses. Undergraduate nursing courses provide the front-end supply for critical care nurses, while post graduate courses provide critical care nurses with their qualification. The education arrangements in Australia will be described in terms of undergraduate nurse education and critical care postgraduate nurse education. For workforce planning of a specialist nurse workforce such as critical care, there are two educational factors to examine in terms of numbers: 1. Undergraduate nurse education (bachelor degrees) 2. Postgraduate intensive/critical care nursing courses The framework for nurse education in Australia (for both RNs and ENs) and the articulation pathways for those involved in nursing work are provided in Appendix I). Undergraduate Nursing Education The entry requirement to provide direct and unsupervised patient nursing care in intensive care is to be a registered nurse. A nurse becomes registered by successfully completing a bachelor degree in nursing (equivalent to a 3 year full time university program). There are RNs in the workforce who hold a Certificate of Nursing gained from a hospital based training program prior to the introduction of university based undergraduate nursing degrees. All undergraduate nursing programs are now based in the university sector (since 1993). Undergraduate nurses and their subsequent entry into the pool of working RNs provide a source of recruitment for specialist nursing practice such as critical care. Any change in this supply chain will impact on the availability of RNs for recruitment into critical care nursing. The lead-time from commencing undergraduate education to becoming available for critical care nursing is four or five years on average. Therefore the effect of increased or decreased undergraduate commencements is felt in specialist nursing areas at least four or five years later. This section of the report refers only to pre-registration undergraduate nurses and does not include post-registration undergraduate nurses (RNs who convert hospital based registrations to bachelor degrees). Evidence from State and Territory health departments presented to the Senate Inquiry into Nursing (2002) highlights the difference between funded places available for undergraduate nurses and the number of undergraduate students required to provide an adequate frontend supply for the workforce. In most jurisdictions, the number of undergraduate commencements over recent years was considered to be inadequate in terms of workforce requirements. This may be due to a lack of funded places rather than lack of demand for nursing courses. Mechanisms for state health departments and universities to work together in determining the number of nursing places available appear to be lacking. University Deans 45

63 of Nursing stated that in 2000 and 2001 there were more applicants than available places for undergraduate nurses. A report commissioned by DEST for the National Review of Nursing Education (Ogle et al, 2001) provides profiles for 1999, 2000 and projections for 2001 for undergraduate and postgraduate nurses. In 2002 a follow up study was commissioned to further map nursing graduate numbers and project completions for 2002 (Ogle et al 2002). Without these two reports, such a detailed description of undergraduate pre-registration and postgraduate nursing numbers may not have been available. Data was collected directly from the universities via survey. The following information draws on the findings of both of these reports. As noted in the initial study, the authors acknowledged some discrepancies between data reported by DEST and data collected as part of their project and some difficulties respondents to the surveys had in obtaining data from universities. However, the authors were able to collect some data that was not available from DEST to provide a report with more detail than would otherwise have been achievable. Since 1994, the number of university schools of nursing offering undergraduate and/or postgraduate nurse education has increased from 28 to 31. At the undergraduate level, institutions have begun to offer combined degrees where students may complete a Bachelor of Nursing with another field of study such as Psychology, Arts or Public Health and this has been reported as being extremely popular. Ogle et al (2002) describe the variation in pre-registration undergraduate courses available in full-time years of study: Three-year bachelor of nursing. Four to five year combined degrees, which either consist of a bachelor degree in nursing with a bachelor degree in another field of study, such as psychology, commerce etc, or a bachelor degree in nursing with a bachelor degree in another nursing discipline such as midwifery or rural health. Two-year bachelor degrees in nursing for graduates of other disciplines or students with previous nursing studies such as enrolled nurses (division 2 nurses). One-year re-entry programs for nurses whose registration had lapsed. One-year conversion course for overseas qualified nurses seeking registration in Australia. Tables 12 and 13 provide the current number of pre-registration students and the number of pre-registration course completions for 1999, 2000, 2001 and projected completions for Completion rates for undergraduate nursing students has been found to be relatively high compared with other university courses. A DEST longitudinal study (Martin, Maclachlan & Karmel, 2001) examined completion rates on undergraduate nursing students from 1992 to It found that the average completion rate for undergraduate nursing students was 75% compared with 58% of Science and Arts students. There is no national data describing the uptake of graduate nurses into the nursing profession. However, the Auditor General, Victoria (2002) commissioned a report into nurse workforce planning. One of the studies within the report revealed that the uptake of graduate nurses into the nursing profession in Victoria was 75% in 2001 compared with 58% in

64 Undergraduate nurse commencements Data capturing overall (national) undergraduate pre-registration nursing commencements and completions (AIHW 2002 and Ogle et al 2001, 2002) show that from 1994 (the first year of all pre-registration courses in universities) commencements dropped in 1995, 1996 and 1997 and have gradually increased since then. Figure1: Basic nursing (undergraduate bachelor) course commencements and completions, Australian citizens and permanent resident students, Undergraduate bachelor nurse commencements and completions commencements completions Note: 2000 commencements estimated by AHWAC due to lack of available information Source: AIHW 2001, Ogle et al 2001, Data provided by Ogle et al (2001 and 2002) show an overall (national) increase in domestic undergraduate pre-registration student commencements from 2001 to However, some states and territories show a decreased number of commencements in 2002 (South Australia, Western Australia and the Northern Territory). Table 12: Commencing domestic undergraduate pre-registration nursing students, by State/Territory, 2001 and 2002 State/Territory New domestic preregistration students 2001 New domestic preregistration students 2002 Difference between 2001 and 2002 commencements NSW 2,163 2, Victoria 2,058 2, Queensland 1,651 1, South Australia Western Australia Tasmania Northern Territory ACT Total 7,597 8, Note: Pre-registration refers to those students who do not already hold a nursing registration. There are a number of RNs who convert their hospital certificates to a bachelor degree by undertaking a university based post registration degree course. Source: Ogle et al, 2001,

65 Undergraduate nurse course completions Domestic nursing students completing pre-registration programs by State are shown in the following table. For most states and territories there has been an increase in the number of domestic students completing pre-registration programs over the last 3 years. There has been an overall increase of completions from 1999 to 2001 of 370 completions. Projected completions for 2002 were provided by the universities, it is unclear if attrition rates and other factors influencing completions were taken into account. Table 13: Undergraduate pre-registration domestic nursing student completions, by State/Territory, State/Territory 1999 completions 2000 completions 2001 completions 2002 completions (projected)* NSW 1,504 1, Victoria 1,254 1, Queensland South Australia Western Australia Tasmania Northern Territory ACT Total 4,869 5,160 5,239 5,577 *Projected completions as reported by universities. Source: Ogle et al 2001, 2002 Postgraduate Nurse Education Australian Minimum standards (FICANZCA, 1997 and ACHS, 1997) suggest that the majority (at least 50%) of RNs working in ICU should hold a postgraduate qualification in critical (intensive) care nursing or their area of specialty practice. The ACCCN guidelines (2001) suggest that ideally 75% should be qualified (Appendix D). The completion of a postgraduate critical care course is not an entry requirement for practice as a critical care nurse. A large number RNs do not commence postgraduate study in critical care nursing until they are employed in the area. The commencement of a critical care course may be immediately upon beginning employment in an ICU or after a period of time (often 12 months). As a recruitment strategy, many hospitals and health departments are currently providing assistance with fees associated with courses. In the past, tertiary referral hospitals with ICUs offered their own post registration certificate courses in critical care nursing and thus were able to ensure an adequate number of trainees per year to meet requirements both in terms of staffing and qualifications. A number of critical care nurses currently working in ICUs hold hospital based post registration certificates (considered to be formal qualifications). Some have chosen to further their studies and gain postgraduate diplomas and Masters degrees. At least 3 hospitals in New South Wales and 1 in Western Australia have continued to run graduate certificate programs in intensive/critical care nursing. Overall, the numbers of nurses who gain a hospital based graduate certificate in critical care nursing are small, however, these courses articulate into local universities to encourage those undertaking them to further their studies with higher degrees. 48

66 Nationally, the majority of postgraduate education for nurses is offered through the university sector. Courses range from graduate certificates, graduate diplomas, masters degrees and doctorates. There is a wide range of postgraduate critical/intensive care courses available, producing graduates with varying levels of knowledge and skills (Aitken, Currey and Daly, 2001). The New South Wales College of Nursing provides a large number of graduate certificate courses in a range of nursing specialties, including critical/intensive care, paediatric and neonatal intensive care. It provides them to nurses in New South Wales predominately, but offers distance education and mixed mode courses to nurses in other States and Territories. Many hospitals and area health services are working with the tertiary sector to ensure the postgraduate courses are more successful in producing nurses who are truly expert in their field. Postgraduate courses are being offered with greater integration between the hospital and the university. There is an increasing number of joint appointments for nurse academics between their clinical and university settings. The total projected completions for postgraduate critical care nursing courses in 2002 is 677 (includes university, New South Wales College of Nursing and hospital based graduate certificate courses). According to the consultations carried out by AHWAC, access to and completion of relevant postgraduate education programs is problematic for many nurses. This may be due to the fees involved, difficulties being released from work, the length of some of the programs and the lack of recognition for prior learning and experience. Consultations with university staff suggest that attracting critical care nurses into postgraduate courses is highly competitive for the universities. Due to the cost (both financially and in terms of time), nurses are attracted to courses that are shorter in duration (more intense) and may have some kind of fee relief attached. In an attempt to recruit nurses and have more nurses qualified in critical care, hospitals, area health services and health departments offer a number of scholarship programs and other mechanisms for financial support. However, these vary from State to State and hospital to hospital. Recent trends indicate the cost of postgraduate education shifts from the university sector, to the nurse, and more recently onto health services and health departments, either directly or indirectly via hospitals or area health services. The approximate cost of a postgraduate certificate (4 credit points) is $4,000, a postgraduate diploma (8 credit points) is $8,000 and a Masters by course work (12 credit points) is $12,000. Fees for postgraduate courses often coincide with other financial commitments nurses have, such as repayment of HECS debts, housing and family commitments. As a response to the financial barriers to postgraduate education, in 2002 a Postgraduate Education Loans Scheme (PELS) was introduced for students in fee-paying courses. It is based on the Higher Education Contribution Scheme (HECS), which provides an interest free loan (DEST, 2001). Consultations with nurse managers suggest that a more clinical focus within the postgraduate courses is required and that competencies should be assessed as part of the courses. At the same time, there needs to be more support for clinical learning in the units. Currently, there is concern that there is a clouding of responsibilities between hospital-based clinical educators and senior staff and university-based educators. 49

67 When examining data from the education sector (both university and NSW College of Nursing), the student numbers may not reflect the home state of the postgraduate nursing students. Many courses are offered in mixed mode or distance education allowing students to access courses based outside their own home state. The results of the survey carried out by Ogle et al do not reflect the home state of the postgraduate students. For example, RNs in the Northern Territory access postgraduate courses based in both New South Wales and South Australia. RNs in the Australian Capital Territory access courses based in New South Wales. RNs in Queensland access courses based in New South Wales. University based postgraduate courses In general, most university based postgraduate nursing students were part time students. The mode of course delivery for postgraduate nursing education ranges from internal mode, mixed mode and external mode. The majority of postgraduate courses (41.8%) were offered by mixed mode (external and internal). Most university based graduate certificate programs for nurses are the equivalent of one full time semester, graduate diplomas are the equivalent of two full time semesters, while Masters degrees vary from two to four full time semesters, depending on the institution (Ogle 2001). Data used to describe university based postgraduate education of critical care nurses was provided by Ogle et al (2001 and 2002). Data was collected by surveying all universities offering postgraduate nursing education. Postgraduate courses by nursing specialty were profiled in terms of total number of enrolments, completions and projected completions for Projected completions were determined by the universities and it is unclear whether attrition, failures and changed timing was taken into account. The courses identified as relevant for the adult critical care nurse workforce are intensive care, critical care and cardiothoracic nursing. Table 14: Critical care courses: completions (2001), postgraduate students in intensive/critical care courses (2002) and projected completions (2002), by State and Territory (university only) State/Territory Completions of intensive/critical care courses 2001 Total number of intensive/critical care students 2002 Projected completions of intensive/critical care 2002 NSW Victoria Queensland South Australia Western Australia Tasmania Northern Territory* ACT Total *Northern Territory students currently undertake critical care courses via Flinders University (SA) and NSW College of Nursing. Source: Ogle et al 2001,

68 New South Wales College of Nursing courses The New South Wales College of Nursing offers postgraduate certificate courses in a range of critical care areas including cardiac, cardiothoracic, intensive care, paediatric intensive care, neonatal intensive care and emergency nursing. The critical care and intensive care courses cover the same content apart from the last subject. The courses are offered in a variety of modes, including distance education. Courses are therefore offered to rural nurses and nurses in other States (Northern Territory, Queensland and the Australian Capital Territory). The courses are fee paying (not HECS) and are tax deductable (average cost is $2,500). The New South Wales Health Department provides a large number of the courses free to employees of New South Wales Health Department (particularly in areas such as ICU). The courses are conducted by mixed mode (classroom attendance, self - directed study and distance education). They are part-time and run over 10 months. The New South Wales College of Nursing also provided information regarding commencements and completions of postgraduate certificate courses in intensive care and critical care to AHWAC, this is also reported by Ogle et al (2001 and 2002). Table 15: New South Wales College of Nursing course commencements and completions for intensive care and critical care graduate certificates, Commencements Completions * *Projected completions. Source: NSW College of Nursing, Ogle Hospital based postgraduate courses Three hospital based graduate certificate critical care programs were identified in New South Wales and one in Western Australia. All articulate with local universities to encourage the nurses to further their studies by entering graduate diploma or masters programs. They are generally 12 months duration; the nurses are employed on a 0.8 FTE basis to allow one study day per week. Table 16: Hospital based critical courses: completions (2001) and course commencements (2002), by hospital Liverpool Gosford John Hunter Charles Gardiner 2001 completions commencements Source: hospital critical care course coordinators Total projected completions for 2002 for all States and Territories (University, New South Wales College of Nursing and Hospital based courses) is

69 Transition Courses, Extended Orientation Courses, Mentoring Programs And Others There are many in-house courses offered by hospitals for critical care nurses that are not considered formal qualifications. These provide new recruits or existing staff with the knowledge and basic competencies to allow them to practise competently in critical care nursing. They are designed to attract new staff into the units as well as ensure a basic level of competency. The types of courses vary from hospital to hospital in most States and Territories. However, Queensland Health has moved to offer a consistent approach to all new recruits to critical care nursing across the State. The Transition program is provided to all new recruits. It is 12 months long and articulates into local university post-graduate programs. Nurses completing the Transition program are credited with 50% of a postgraduate certificate in critical care nursing. Other programs are available in other States and Territories, for example Westmead hospital in Sydney has a Mentor Program as part of a recruitment and retention strategy. It is a 3-month course aiming to provide a supportive environment to enable a smooth transition from novice to advanced beginner clinician. It also credits students with 50% of a postgraduate certificate. There are many other extended orientation or foundation courses available for new recruits to critical care nursing. Enrolled Nurse (Division 2) Education Although the overall numbers of enrolled or division 2 nurses (ENs) in ICU are small, they are a part of the critical care nurse workforce. Nationally, the role they play is predominantly supporting the work of the registered nurses. However, in some hospitals they provide direct patient care. Whether or not ENs are employed in ICU and the type of role they play, seems dependent upon individual unit management. Courses for ENs are provided mainly by TAFE institutes, in agreement with nurse registering authorities (however there are other providers of EN education). The emphasis on EN education has been on aged care and rehabilitation. However in more recent times, the emphasis has shifted to mental health, community health, maternal and child health and acute health care. This change in emphasis is providing more possibilities for EN practice. In most States and Territories, EN education is equivalent to 12 months full time study in a TAFE institute (or equivalent). However Western Australia has an 18-month course. In 2002, South Australia has introduced a hospital-based program (employment based) program for ENs. Most jurisdictions are increasing numbers of EN nurse education positions with a view to increase their numbers in both the non-acute and acute care settings (DEST 2001). South Australia is particularly active in increasing the role of ENs in the acute sector and ICU in particular. For example, in the private sector ENs are employed in ICU and undergo an extensive orientation program that enables them to provide direct patient care. One private provider of intensive care services has run a pilot program for ENs to work in ICU. It was a 26-week program, involving classroom education, practical experience and self-directed learning. It was a joint venture between a TAFE college and the hospital. The course enables ENs to extend their role within the current confines of their scope of practice. It is being proposed at an Advanced Diploma level and is pending accreditation with the Accreditation Registration Council and the Australian National Training Authority. Included in the overall emphasis in increasing the EN role in the acute sector is a career pathway incorporating progression in pay scales. 52

70 7. THE CURRENT CRITICAL CARE NURSE WORKFORCE The most recently available national data for profiling (average age, average hours worked and gender profiles) the critical care nurse workforce is 1999 data reported by AIHW. ANZICS provided national data on permanently employed critical care nurses (expressed as an FTE). AHWAC acknowledge the potential for inaccuracies due to data limitations. There were an estimated total of 9,869 critical care nurses working in Australia as their main job in An estimated FTE critical care nurses were permanently employed in adult ICUs in 1999/2000. The average age of critical care nurses increased from 34.9 years in 1997 to 35.7 years in Average hours worked per week has declined from 33.2 hours (1997) to 31.3 hours (1999). Average hours worked per week and average age are related. Average hours worked per week is lowest in the age group years. The majority of critical care nurses are female (86%). The majority of critical care nurses live and work in capital cities. The majority of critical care nurses are employed in the public sector. There is a lack of national data describing the number of critical care nurses who work on a casual (agency or casual pool/bank) basis. 53

71 There were three main sources of data available to describe the current critical care nurse work force. The AIHW nurse labour force survey data, data provided by individual state and territory health departments and ANZICS data. As described earlier in the report, the AIHW nurse labour force survey provides the most comprehensive national picture of the nursing workforce. However, the major limitations of the AIHW data are the lack of timeliness and inconsistencies between jurisdictions in some questions. The data provided to AHWAC from the individual State and Territory health departments varies a great deal. Some provided information from recent and direct surveying of units, while others have provided information from nurse labour force surveys from 1998 and 1999 and Some of the information from the States and Territories is useful to describe such items as attrition rates, average ages and use of casual staff. The data collected for ANZICS by the Australian Research Centre for Critical Care Resources provided an account of the critical care nurse workforce (permanently employed RN FTEs), vacancies for critical care nurses in (FTE) and related the nursing workforce to the ICU bed numbers and levels (see Appendix C for survey questions). The response rate for the ANZICS survey is 99%. Given the various strengths and limitations of the three main datasets, it has been necessary to utilise the best aspects of each in describing the current workforce. In a very real sense this means the following description is somewhat of a jigsaw, however the Working Party has been able to provide some conclusions on the size of the workforce and its main characteristics. Accordingly, in establishing the profile of the current critical care nurse workforce, the Working Party examined: head count of RNs working in critical care as their main job (AIHW data); number of critical care nurses permanently employed (FTE) employed in ICUs (ANZICS data); age and gender profiles of critical care nurses (AIHW and State/Territory data); average number of hours worked (AIHW and State/Territory data); average length of time in ICU/attrition rates (State/Territory data); educational arrangements for critical care nurses (DEST/NSW College of Nursing); and growth and distribution of critical care nurse workforce (AIHW/ANZICS data). In summary, AIHW provided profiling information such as age, average hours worked per week and a total number of RNs working in critical care as their main job. ANZICS provided information on the permanent critical care nurse workforce only (FTE in permanent/rostered positions). State/Territory health departments provided details to AHWAC on their critical care nurse workforces, but the collection methods were inconsistent. The Working Party decided to use the AIHW data for a total headcount (as it included all RNs whose main area of work was critical care nursing, regardless of work status). ANZICS data was chosen as the best estimate of the permanently employed critical care nurse workforce (expressed as an FTE). Although AIHW data was collected in 1999, it was the most recent national data available at the time of preparing this report. 54

72 Total Critical Care Nurse Workforce The most recently available national data from AIHW (1999 labour force survey data) reported the head count of RNs working in intensive/critical care. AIHW reports that in 1999 there were 9,466 registered nurse clinicians (including nurse unit managers) who indicated their main area of work as critical/intensive care. This figure includes nurses working with agencies as well a small proportion of nurses working in the tertiary education sector and other as work setting of main job. The change from 1997 to 1999 overall is small, an increase of 205 nurses working in critical/intensive care. However, there appears to have been substantial change in some States and Territories. NSW appears to have had an increase of 352, Victoria increased by 100, while Tasmania appears to have had an enormous decrease from 195 RNs to 44 RNs working in critical/intensive care. This apparent decrease in numbers in Tasmania is most likely due to a change in survey response rather than an actual change in numbers. Data reported directly to AHWAC from Tasmania s health department in 2001 stated there was a total of 197 RNs permanently employed in both the public and private sector ICUs, with 27 agency or casual critical care nurses who worked in the areas over the survey period. Due to the gross difference between the AIHW report and the direct survey report from the Tasmanian health department, the Working Party chose to disregard AIHW data (1999) for Tasmania and use data provided by the Tasmanian health department. Given this, the total number of critical care nurses (using Tasmania s direct data) and AIHW data for all other States and Territories was 9,869 (including educators). The 1999 AIHW nurse labour force surveys reveal that RNs working in intensive/critical care as clinicians make up 6.35% of all RN clinicians and 5.28% of all working RNs. Table 17: Registered nurses working in intensive/critical care as main area of work, by State/Territory, 1999 NSW Vic Qld SA WA Tas NT ACT Total 1997 a 3,285 2,124 1, , a 3,637 2,224 1, c , Total b 3,694 2,262 1, ,869 Note: a - clinical critical care nurses and managers only; b - includes nurse educators; c 2001, data supplied by Department of Health and Human Services (DHHS), Tasmania Source: AIHW 2001, 2002 Critical Care Nurse Workforce As Reported By States And Territories AHWAC requested data from all State and Territory health departments on both the FTE and headcount of RNs working in intensive care. Information from individual States and Territories to AHWAC was provided by a combination of direct work place surveys (Western Australia, Queensland, South Australia, Tasmania, Australian Capital Territory) and nurse labour force surveys (New South Wales 1999 data, Victoria 2001 data). The difficulties associated with inconsistencies between survey methods and years are obvious. Apart from those States/Territories that used nurse labour force survey results, the headcount and FTE refer to permanently employed staff only. 55

73 Table 18: Registered nurses working in intensive/critical care (head count and FTE), by State/Territory, 2001 NSW (1999) Vic (2001) Qld a (2001) SA a (2001) WA a (2001) Tas a (2001) NT a (2001) ACT a (2001) Total Public sector HC 1794 b 1,940 b ,851 FTE na 1,507 b na Private sector HC na na na na na FTE na na na na na Note: a - direct survey 2001; b - all nurses, public and private using nurse labour force surveys Source: State/Territory health departments Because of the inconsistencies of method and year, information collected from the individual States and Territories was deemed to be less useful than the information provided by AIHW (apart from Tasmania, where it is believed to be more reliable than data provided by AIHW). AHWAC requested similar data from the private sector via the three main private hospital associations: Mayne Health, Australian Catholic Hospitals Association and the Australian Private Hospitals Association. Of the 55 private hospital ICUs in Australia, one individual private hospital ICU nurse manager responded to the request. Permanently Employed Critical Care Nurses According to data provided predominately by ANZICS (2001) but supplemented by data from the Department of Health and Human Services (DHHS) in Tasmania, there were at least 5,047.1 full-time equivalent (FTE) critical care nurses permanently employed in both public and private sectors (table 19). These figures do not take into account RNs who work casually through commercial nursing employment agencies or with hospital casual pools. There is data missing from 9 units (154/163 ICUs provided information on RN FTE). Head count for nurses permanently employed in ICUs was not asked for in the ANZICS survey. ANZICS surveys conducted in 1997, 1998 and reveal that permanently employed RN FTE per available bed for public ICUs has gradually decreased. In 1997 there were 3.90 per available bed; in 1998 there were 3.26 and 3.21 in Table 19: Permanently employed critical care nurses (FTE) in intensive care units, public and private sector, by State/Territory, (excludes PICUs) Sector NSW Vic Qld SA WA Tas a NT ACT Total Public ,109.4 Private na Total ,047.1 Note: a data from DHHS due to unavailable data from ANZICS for private sector in Tasmania. Source: ANZICS 2001 Age Profiles According to AIHW, 1999 labour force surveys revealed the average age of all RNs was 41.4 years. This compares with the average age of nurses employed in intensive care as being 35.7 years in 1999 and 34.9 years in From 1994 to 1997 the average age of nurses employed in intensive care remained relatively constant (ranged from 34.2 years in 1994 to 56

74 34.9 years in 1997), although creeping up slightly each year (AIHW, 2001). The age structure of the critical care nurse workforce is different from all clinical RNs, having both a lower average age and skewed towards the younger age groups whereas the age structure of all clinical RNs is skewed towards the older age groups (figure 2). Figure 2: Comparison of the age structure of critical care nurses with all clinical registered nurses, 1999 percentage Age structure of critical care RNs compared with all clinical RNs < Critical care RNs All RN clinicians Source: AIHW

75 Table 20: Age profile and average age of clinical critical care nurse workforce, by State/Territory, 1999 Age (years) NSW Vic Qld SA WA Tas a NT ACT Aust Average age Average age Number Age groups 1999 < , , , , Total 3,637 2,224 1, ,466 % < Total Note: a as reported by AIHW (age profile not available from DHHS, Tasmania); - : totals included values less than 3 which were not included in table. Source: AIHW 2001, 2002 Hours Worked Per Week According to AIHW, in 1999 approximately 50% of critical care nurses worked full time (>35 hours per week) and 50% work part time (< 35 hours per week). This was the case in all State and Territories except the Northern Territory in which the greater proportion of critical care nurses work full time (76%) data reveals a decrease in average hours worked in each State and Territory and therefore a national decrease from an average of 33.5 hours worked per week in 1997 to 31.3 hours worked per week in

76 Table 21: Average number of hours worked by registered nurses working in intensive/critical care as main area of work, by State/Territory, 1997 and 1999 NSW Vic Qld SA WA Tas a NT ACT Aust AIHW AIHW Note: a data provided by DHHS, Tasmania Source: AIHW 2001, The average hours worked per week according to age group is of great significance. According to AIHW data for 1999, average hours per week were highest in the younger age groups (below 30 years of age); they then fell in the age groups between 30 and 44 years, and rose in the age group (although the actual numbers of critical care nurses in this age group is smaller than the younger age-groups). Nationally, the largest proportion of critical care nurses lies within the age group 30-34, with the second largest cohort in the age-group. Figure 3: Critical care nurses national average hours worked per week, by age group, 1999 Average hours per week by age group Hours per week < Age group 12 Source: AIHW 2002 Gender Profiles As with the total nurse workforce, the critical care nurse workforce is predominantly female. However, it has a higher proportion of males than all other nursing specialty areas apart from mental health nursing (AIHW, 2001). Table 22: Percentage of male nurses working in intensive/critical care, by State/Territory, 199 and 2001 AIHW (1999) NSW Vic Qld SA WA Tas NT ACT Aust 13% 14% 17% 8% 22% 10% 8% 2% 14% State/Terr. (2001) 16% 11.1% 16% na 10% 19% 18% 7% Source: AIHW 2001, State/Territory health departments

77 Casual Employment In Main Job Anecdotal evidence points to the fact that a large number of critical care nurses work on a casual basis in their primary nursing role. According to consultations with nurse managers and clinicians, this has been a growing trend. However, there is currently no national data to show this trend. The only State in 1999 that provided a question in the nurse labour force survey regarding casual or agency employment was New South Wales. Of the total critical care workforce in New South Wales (3,637), 257 reported they were employed casually (either with an agency or via a casual bank ). This appears to be a small proportion given the recent anecdotal evidence, highlighting the problems with relatively old data. At the time of writing this report a nationally consistent nurse labour force survey was being drafted, which will include an item to determine whether nurses are employed casually (and by what means) or permanently. Registered Nurses Working In Intensive/Critical Care In Their Second Job A substantial number of RNs worked in intensive/critical care as their second job. The 1999 AIHW nursing labour force surveys showed a total of 949 Australia wide. The average age RNs working in critical care as a second job was 36.5 and the average hours they worked was 8.9 hrs per week (about 1 shift per week). No RNs registered in the Northern Territory indicated they worked in intensive/critical care as a second job. Table 23: Registered nurses: average age and average number of hours worked in intensive/critical care as second job, 1999 NSW Vic Qld SA WA Tas NT ACT Total/ average Number Average age na Average hours worked na Note: - indicates less than three responses Source: AIHW 2002 Geographic Distribution Of The Critical Care Nurse Workforce The geographic location of RNs who worked in intensive care as their main job follows the service patterns seen in the previous chapter. Most ICUs are located in capital cities, metropolitan centres and large rural centres. Western Australia, Northern Territory and Queensland have remote centre ICUs. Data provided by AIHW showed that in 1999, 75.5% of critical care nurses lived in capital cities, 9.2% lived in other metropolitan areas, 7.9% lived in large rural centres, 4.6 % in small rural centres, 1% in other rural centres and 0.7% in remote centres. ANZICS (2001) reported RN FTE employment by geographic regions for 1999/ % were employed in capital cities, 11% were based in other metropolitan employment, 18.4% were employed in rural areas and 0.65% were employed in remote areas. These figures are reasonably consistent with where critical care nurses reside. 60

78 Public vs Private Sector Employment The majority of intensive care services are provided in the public sector. Therefore, the majority of critical care nurses work in the public sector. Nationally, 83.2% of critical care nurses work in the public sector and 16.8% in private sector in their main job (AIHW, 2002). Enrolled Nurses In Critical Care Enrolled Nurses or division 2 nurses (ENs) make up a small proportion of the nursing workforce in critical care (1.8%). In most ICUs, they are employed in roles to support the work of RNs, however, recently, in South Australia, their roles are extended to provide direct patient care. According to AIHW, in 1999 there was a total of 171 ENs working in critical care as their main job. New South Wales had 37, Victoria had 53, Queensland had 32, Western Australia had 34, South Australia had 4, Tasmania had 5, Northern Territory had 6 and the Australian Capital Territory had none. AIHW report that the majority of ENs in critical care work in the public sector (90.4%). 61

79 8. ADEQUACY OF THE CURRENT CRITICAL CARE WORKFORCE There were an estimated unfilled FTE positions for critical care nurses in Australia in 1999/2000 (ANZICS). The vacancy rate averaged 6.87% in public sector ICUs and 11.07% in private sector ICUs nationally. There is a difference between the estimated total number of critical care nurses and the required total number of critical care nurses, according to calculations based on an average of 6.5 FTE per ICU bed and 3.7 FTE per high dependency bed. Nationally, the required headcount was estimated to be 10,386, whereas the actual headcount was estimated to be 9,849: a shortfall of 537 critical care nurses nationally. A large proportion of this shortfall was estimated to be in Queensland and South Australia. Queensland and Western Australia fell below the minimum requirement of at least 50% qualified critical care nurses. The other States and Territories had between 50% and 63% qualified critical care nurses, except Victoria which had the highest ratio of qualified critical care nurses at greater than 75%. Although there is little data to show increasing use of agency nurses in ICUs, it is widely believed that it has increased dramatically over recent years and that many permanent nurses have left to work casually with nursing agencies. The amount of agency work available and the pay rates achievable suggest an underlying shortage in the workforce. Longitudinal data is required to assess changes in the adequacy of the critical care nurse workforce. Assessing the current adequacy of the workforce is an important aspect of workforce planning. Although there have been many studies attempting to discover reasons for nursing shortages, there has been little research conducted to determine the indicators of nursing shortages. Policy makers should carefully consider the definition of shortage used by both healthcare administrators and researchers. There are a number of possible indicators of shortage, ranging from the relatively subjective impressions of hospital administrators to detailed modelling using numbers of RNs, number of inpatient days, casemix and outcome information. In between these two methods lie the application of hospital staffing levels to patients (ratios), turnover rates, vacancy rates and RN supply per population (Grumbach, Ash, Seago, Spetz & Coffman, 2001). Other indicators of shortage include increased agency and nurse bank usage and increased overtime or excess hours. It is suggested that data used to measure adequacy or define shortage be collected over time, to show trends. (Buchan and O May, 1998). 62

80 Consultations carried out by AHWAC with nurse managers of ICUs both in metropolitan and rural hospitals suggest that changes in the workforce have taken place over the last 2 years in particular. In the past, RNs interested in working in ICUs were placed on a waiting list for employment in the ICU. Over recent times, these waiting lists are non-existent, leaving nurse managers to actively recruit staff to work in the units. Nurse managers also reported an increased rate of attrition from the units, with increasing numbers of nurses choosing agency work over permanent work or alternative jobs altogether. In other words, it has become more difficult to recruit new critical care nurses, and at the same time, there has been an increased rate of exit (attrition) from both the permanent critical care workforce and the overall critical care workforce. There is currently no national data available to show changes in movements in or out of critical care nursing. It is difficult to accurately define a shortage in the critical care nurse workforce when a significant proportion of the workforce is reported to have moved from the permanent workforce to the casual workforce (via agencies or casual pools). This clouds the issue of using vacancies as a measure of overall shortage. Many vacant positions have effectively been filled by the use of agency staff each day. However, the recent high demand for agency critical care nurses is likely to indicate an underlying shortage. In times of oversupply in the nursing workforce, there is less demand for agency nurses. The use of vacancy data is appropriate for use as an indicator of shortage rather than an accurate measure of shortage. Another method to determine adequacy of the critical care nurse workforce was to calculate the recommended levels of critical care nurses to ICU beds and compare this with actual headcount of critical care nurses, as reported in the previous chapter. Comparing the proportion of qualified critical care nurses as recommended by both minimum standards (FICANZCA and ACHS) and the ACCCN, to the actual proportion of qualified critical care nurses as reported was another method to determine adequacy of the critical care nurse workforce. The Working Party chose to use the following indicators of adequacy to measure if a shortage existed: intensive care vacancies for critical care nurses (FTE); intensive care vacancy rates for critical care nurses (FTE); critical care nurse requirement based on minimum standards and ACCCN guidelines compared with actual numbers of critical care nurses; and comparing the desired proportion of qualified critical care nurses with the actual proportion of qualified critical care nurses. The Working Party recognised the following indicators of shortage may have provided more reliable measures of adequacy, however these were not available nationally, or on a statewide basis (relating directly to the provision of critical care services) to AHWAC. This chapter does refer to any such information if it was available. increasing use of over time; increasing use of casual/agency RNs; increased workload to patient day; bed closures due to staff shortage; cancellation of elective surgery due to staff shortage; and measures of adverse patient outcome related to decreased staffing levels. 63

81 Intensive Care Unit Registered Nurse Vacancies The Working Party defined a vacancy as: a position available for a RN in intensive care, which is funded and undergoing active recruitment or for which recruitment action has recently occurred and has been unsuccessful. There is currently no national ongoing monitoring of nursing vacancies in hospitals. New South Wales appears to be the only state that has ongoing monitoring of its nursing vacancies by specialty. AHWAC asked each of the state and territory health departments to provide information based on their best estimate of current vacancies during August and September Most jurisdictions were able to provide information to AHWAC on RN vacancies in their ICUs by either directly surveying the units or extracting information from hospital reporting systems. At the time, the Department of Human Services in Victoria was not able to provide information on ICU vacancies. Queensland Health was unable to ascertain the number of vacancies in ICU with confidence. Upgrading of monitoring systems in some jurisdictions is currently underway and will make the centralised collection of such data possible. DEWR monitors occupational labour markets and assesses whether skill shortages exist. However it does not quantify the skill shortages identified. It has identified a national shortage of critical care nurses (DEWR 2002). The most useful data for national vacancies for critical care nurses was supplied by ANZICS (2001). It reported the number of RN FTE vacancies from both public and private ICUs. The ANZICS definition of a vacancy was a position which was funded but unfilled. ANZICS identified FTE ICU vacancies as at 30 June 2000 (PICUs excluded). The following table summarises vacancy data from both State and Territory health departments and ANZICS. Due to issues of consistency, timing and the availability of private and public data, the ANZICS data was chosen by the Working Party as the most reliable indicator of shortage (as expressed as FTE vacancies). Table 24: ICU registered nurse vacancies (FTE), by State/Territory health departments, 2000 and 2001 Source NSW Vic Qld SA WA Tas NT ACT Total State/Territory health departments (2001) b Public na na 52.1 c na Private na na na na na na ANZICS (2000) d Public Private e na ANZICS Total Note: a na: the health departments were not able to provide data; b - paediatric ICUs not included; c - public and private hospitals; d - ANZICS data is as at 30 June 2000; the public sector data was retrieved from 104/108 respondents and private data from 50/54 hospitals; e - includes Tasmania Source: ANZICS 2001, State/Territory health departments

82 Vacancy Rates The vacancy rate is the number of vacancies as a proportion of the number of positions available (both filled and unfilled). The ANZICS data was used to determine the vacancy rates by State and Territory and nationally (except for Tasmania). The private sector appears to have higher vacancy rates than public sector ICUs, particularly in Western Australia. Data from future ANZICS surveys will be useful in showing vacancy rate trends. Table 25: ICU registered nurse vacancies and vacancy rates, public and private sector, by State/Territory, NSW Vic Qld SA WA Tas a ACT NT Aust Public sector RN FTE ,110.3 Vacant RN FTE Total ,421.7 RN FTE Public 8.48% 6.78% 6.28% 4.07% 6.28% 9.58% 5.71% 7.79% 6.87% vacancy rate Private sector RN FTE ** Vacant RN FTE Total RN FTE Private vacancy rate Pub/Priv vacancy rate ** , % 9.33 % 7.8 % 7.29 % % 8.27 % % 7.72 % % % 12 % % % 7.98 % 7.79 % % % Note: a - Tas figures as reported by DHHS Tasmania (2001) as they include private sector. ** ACT underestimate - data from one of two ICUs only Source: ANZICS 2001, DHHS Registered Nurses To Intensive Care Unit Beds In Australia, Victoria is the only jurisdiction that has determined the minimum level of nurse staffing to patient numbers within the acute hospital setting. However, these ratios do not extend to intensive care. Intensive care has its own minimum standards (FICANZCA and ACHS) to ensure that at the least one critical care nurse is available for each intensive care patient and one critical care nurse to every two high dependency patients. These have been discussed previously within the report. Using the Williams and Clarke methodology an FTE per ICU bed of 6.5 and per high dependency bed of 3.7 was used to measure the adequacy of the current critical care nurse workforce. This was done by converting the required FTE into a headcount (using average hours worked per week). The required headcount was then compared with the actual headcount as reported by AIHW. This measure of adequacy was 65

83 chosen by the Working Party to represent best practice. It is based on available beds, rather than physical beds. Table 26: Comparison of estimated total number of critical care nurses (1999) and recommended required number of critical care nurses for current adult ICU beds ( ), by State/Territory (includes managers and educators) Registered NSW Vic Qld SA WA Tas NT ACT Aust nurses Actual 3,694 a b ,849 headcount Recommended 3, ,386 headcount Difference Notes - a. NSW data includes critical care nurses working in specialty units including Burns and Neuro-surgery ICUs; b. Data provided by DHHS, Tasmania (2001) due to gross underestimation in 1999 labour force survey data. Source: AIHW 2002, ANZICS 2001, DHHS 2001, AHWAC. Proportion Of Qualified Registered Nurses To Non Qualified Registered Nurses Working In Intensive Care Units The minimum standards for ICU (FICANZCA and ACHS) state that the majority of critical care nurses should be qualified (at least 50%). The ACCCN guidelines suggest that ideally 75% should be qualified. The number of ACCESS nurses should be tailored to the proportion of qualified staff, i.e. less qualified staff means a higher number of ACCESS nurses to support them. AHWAC requested information from the State and Territory health departments in an effort to obtain information on the proportion of qualified critical care nurses to non-qualified critical care nurses. The responses revealed that in 2001, Queensland and Western Australia fell below the 50% recommended staffing benchmark. Although Victoria did not provide information directly to AHWAC on the proportion of critical care nurses with relevant qualifications, a report commissioned by the Victorian health department was released in time for this report. The Planning for Intensive Care Services in Victoria report (MA International, 2001) surveyed each Victorian ICU to determine the proportion of qualified critical care nurses. The results of the survey showed that of a total of 25 units, 1 fell short of 50% qualified staff, 7 had between 50 to 75%, and 17 had 75% and over qualified staff. Given this information, 68% of Victoria s public and private ICUs meet the optimum standard set by ACCCN (at least 75% qualified), while 96% meet the minimum standard (at least 50% qualified) nurse labour force survey data provided by AIHW was also used to determine the proportion of qualified critical care nurses. The proportions were similar to those reported by the individual States and Territories, apart from Western Australia, where the AIHW data provided a better picture than the State reported data. 66

84 Table 27: Proportion of qualified critical care nurses (head count), State/Territory, 1999 & 2001 NSW a Vic a Qld SA WA Tas b NT ACT State reported na na 43.0% 60.3% 39.0% 63.0% 60.0% 50.0% (2001) AIHW reported 50.4% 80.4% 46.1% 61.5% 50.1% 60% 54% 51.7% (1999) Note: a - New South Wales and Victoria provided data from labour force surveys and it was not possible to determine whether those RNs with ICU/critical care qualifications were working in ICU at the time; b - public and private hospitals Source: AIHW and State/Territory health departments In summary: Victoria is the only jurisdiction which meets the ACCCN best practice staffing guidelines (75% of RNs with relevant post graduate qualifications); New South Wales and the Australian Capital Territory are just above the minimum standard level (between 50 51%); South Australia, Tasmania and the Northern Territory appear to have a majority of RNs with postgraduate qualifications (between 54 63%); Queensland falls short of the minimum standards (43 46%); and Western Australia is reported to be below minimum standards by Western Australian Health Department (39%), but just on 50.1% by AIHW. In many hospitals, programs are in place to address the deficiency of unqualified and inexperienced staff in critical care areas. For example, in Queensland all new recruits to critical care units in public hospitals are provided with a transition program which provides the nurse with the knowledge and experience to practise in the area competently. The transition programs articulate with a number of universities by providing the equivalent of 50% of a graduate certificate. Nurses are therefore encouraged to continue their development by enrolling in further studies. Other states have extended orientation programs, mentor programs, foundation programs etc all of which attempt to provide novice critical care nurses with the support and knowledge to function adequately. Use Of Agency And Casual Nurses In Intensive Care Units Traditionally agency and casual RNs have been used in ICUs to enable the units to flex up or down in their staffing according to demand for beds. However, over the last 18 months, there has been much talk and limited data available describing the increased use and associated costs of agency staff usage in specialty areas such as critical care. Agency and casual RNs are filling the gaps of vacant positions rather than just the peaks in demand for beds. The inadequate supply in the permanent workforce is due partly to the overall shortage, but also to the disenchantment of nurses in the permanent workforce with working conditions (a retention issue). Anecdotal evidence from interviews with nurse managers reveals that many nurses have left the permanent workforce over recent years. They have left in pursuit of more flexible working arrangements for study requirements, family and personal needs, as well as increased rates of pay. This apparent exodus has left the permanent staff with an increased burden in terms of responsibility and more rigid rosters, resulting in even more permanent staff leaving to work with agencies. In many cases, critical care nurses leave the permanent workforce and come back to the same unit on a casual basis, earning more 67

85 money and having a flexible working life. Nurse managers in ICUs are in a difficult position, trying to meet budgets while keeping beds staffed. There is no national data to describe the increased use of agency and casual staff in critical care areas, nor the move of the permanent workforce to the casual/agency workforce. NSW collects data on an ongoing basis on the overall usage of agency and casual staff in public hospitals, but not for specialty areas. Victoria publicly released information describing the increased costs of agency utilisation for the last half of 2001 (Minister for Health, Media Release, March ). The nurse agency costs in one health service increased from $2.8 million to $4.1 million for the same 7 month period. A snapshot survey of ICUs was conducted on July It revealed an average of 160 hours of agency nurses per unit per week (2,193 hours in total) at a cost of $141, 000. Monitoring systems are now in place to provide ongoing monitoring of agency use in Victorian public health facilities. These were not in place at the time of AHWAC requesting data. Tasmania was also able to provide data to AHWAC on the use of agency/casual staff in critical care. Data was collected as part of a survey of critical care nurses in When examining the headcount, 197 were permanent and 27 were agency or casual (13.7%). ANZICS provided a cross sectional description of the average use of casual shifts per week nationally for both the public and private sector ICUs. This data also includes un-rostered overtime shifts. Until longitudinal data becomes available, an increasing trend cannot be confirmed. Table 28: Casual shifts ( 4 hrs) per week worked in ICUs, public and private sector, by State/Territory, 2000 a Sector NSW Vic Qld SA WA Tas NT ACT Public Private b na 10.0 Note: a % of ICUs surveyed were unable to provide information on the number of casual shifts worked per week; b - includes Tasmania; na not applicable Source: ANZICS 2001 Figure 4 shows New South Wales data for the use of casual staff, as well as use of overtime in relation to RN positions being actively recruited from July 1999 to December The graph illustrates the steady increase in vacant positions and slight increases in use of agency and paid overtime in the public hospital system overall. 68

86 Figure 4: New South Wales Department of Health Reporting System (DOHRS) supplementary staff (agency and pool) utilisation, registered nurse positions actively being recruited, and paid overtime, July 1999 to December Jul-99 Sep-99 Nov-99 Jan-00 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Casual Pool Agency Paid OverTime RN Positions Actively Being Recruited Source: NSW Health Overtime, Bed Closure And Cancellation Of Elective Surgery The inability to staff an ICU bed leads to the use of overtime (extra time worked by critical care nurses), closure of beds and the cancellation of elective surgery. These three factors are potentially excellent indicators of an inadequate supply. Apart from the New South Wales DOHRS information (paid overtime), there is little available national or state/territory data describing such actions. However, according to consultations with nurse unit managers (NUMS) the use of overtime is an increasing occurrence. There is no national data collected describing bed closures and deferment of elective surgery due to staff shortages. 69

87 9. CRITICAL CARE NURSE REQUIREMENT PROJECTIONS Two States provided AHWAC with planning information for intensive care services. Demand for critical care services is expected to increase with population growth and ageing. AHWAC used a population growth and ageing factor to project growth in critical care nurse requirements The requirement for critical care nurses is expected to increase proportionally with growth in critical (intensive) care service provision Growth in demand for both specialist intensive care services (quartenary services) and high dependency care is expected to increase in the future with the advent of new technologies and treatments. An increase in critical care throughput is expected due to technological advances. This will effectively increase the productivity of critical care nurses. The impact of technology on the critical care nurse workforce is not easily predicted. It may reduce the workload, but at the same time is likely to increase the throughput of patients. Future critical care nursing requirements may alter in terms of skill mix due to new technologies available for monitoring and treating patients. Future critical care nurse requirements will be determined by the future critical care infrastructure. In other words, the number and type of ICU beds available for patient use will determine how many RNs will be required to staff them. Projecting growth in future ICU services will determine growth in the critical care nurse requirement. Two main factors are expected to impact on the demand for critical/intensive care services in Australia: population growth and ageing; and technological advances. These are both expected to increase the demand for intensive care services, and thus impact on the required number of intensive care beds in the future. Assuming the model of care for critical care nurses does not alter drastically, the growth in critical care nurse requirements will be in proportion to growth in intensive care bed provision. It is also assumed that there will be increased productivity within the intensive care environment as the throughput of patients increases due to advances in technological and surgical appliances and techniques. Trends identified in terms of provision of intensive care services may also impact on the critical care nurse requirements. 70

88 Population growth and ageing People of all ages become critically ill or injured, however, people over the age of 65 use a larger number of critical care services than those in the younger segment of the population. In the US over half of all ICU days were incurred by patients older than 65 years. Individuals between the ages of 65 and 74 years use critical care services 4 times as much as those under 65 years, and those 75 to 84 years use critical care services 6 times as much as those under 65 (Society of Critical Care Medicine, 2001, Angus et al, 2000). The structural ageing in Australia is mainly due to the sustained decline in fertility rates that followed the post-war baby boom. In 1961, the total fertility rate was 3.6 babies per woman. By 1999 it was 1.75 babies per woman. In 2001, the proportion of the Australian population aged over 65 was 12.4%, by 2011 it is expected to be 14%. This compares with 8.3% in Based on assumptions of continued low fertility and increased life expectancy, Australia s population is projected to continue to age over the next 50 years (ABS 1999). A large number of people entering into the older age groups (>65) are expected to greatly increase the demand for all health services, including critical care services. Technology: the impact of technological advances While technology has decreased the length of stay in hospital for some conditions, total age specific use rates for hospitalisation has actually increased. Although technological advances might theoretically reduce the need for specialist care, the usual pattern is for technology to increase demand, particularly in intensive care (Angus et al, 2000, Gipe, 1999). Technological advances in critical care environments are also likely to allow an increased throughput of patients, thereby increase the productivity of critical care nurses. The following is a description of some of the potential changes in the critical care environment which are likely to impact on service provision. In terms of information technology, there are a number of potential changes that may impact on the critical care workforce. For example, advances in networking are likely to redefine the organisational boundaries of the critical care unit. The increasing use of wireless technology will enable many devices to quickly reconfigure bedsides to suit the needs of patients. The level of intelligence in clinical instruments will increase and these when combined with advances in instrumentation, automation and decision support will mean more point-of-care work (carried out by critical care staff). The critical care unit will be a more self-sufficient organisation, reducing delays of interdepartmental dependencies. The use of electronic patient records that are automatically updated and systems capable of providing predictions of next steps in care are a future potential. Trends toward fully interoperable (all system components able to work together), fully computerised critical care units will facilitate better mechanisms for quality measurement and therefore further evidence based care (Craft 2001). The effect on the work of critical care nurses may be that less time will be spent on documentation, setting up equipment and decision making. The above advances are likely to translate into further increases in patient throughput (by more efficient information systems, reduction in testing delays and the quick assembly of equipment to configure bed spaces). The role of the critical care nurse may in fact increase with point-of-care testing. 71

89 Trends in intensive care service provision Current and future trends in terms of intensive care service delivery include the intensive care without walls. One of the most likely changes, which are already taking place is the provision of intensive care expertise to the hospital wards outside intensive care unit. The outreach or medical emergency team (MET) originates from the intensive care unit to provide assessment and support of unstable patients in the hospital wards in an effort to avert potentially fatal scenarios, admission to ICU or to admit patients requiring ICU treatment prior to adverse events/effects. The MET is a trained team of resuscitation doctors and nurses who attend hospital in patients with clinical instability. It is usually made up of a senior critical care nurse, an ICU registrar and a medical registrar (Buist, Moore, Bernard et al, 2002). In the UK, most Outreach teams are nurse-led 24 hours services providing early intensive care support for ward-based patients requiring critical care interventions (Department of Health 2000b). In Australia, the role of critical care liaison nurse or Clinical Nurse Consultant is being developed, such as at the Royal Melbourne Hospital in Victoria. The aim of such a role is to follow up all ICU patients discharged to the wards, offer clinical support to ward staff, facilitate access of patients from the ward to ICU, and to provide psychological support to patients and their families. Anecdotal evidence suggests it results in a reduction of readmissions to ICU. Quaternary services (specialist ICU services for spinal cord injury, burns, heart/lung transplantation, liver transplantation and pancreas transplantation) have increased over recent years. These are low volume, highly specialised services centralised in particular ICUs to retain the required level of expertise of medical, nursing and paramedical staff. Data gathered by the Intensive Care Implementation Group in NSW, 2000 shows an increase in all quarternary services over recent years, measured in bed days. Demand for these types of highly specialised intensive care services are expected to increase into the future. At the other end of the intensive care spectrum, there is likely to be growth in high dependency services as a response to a number of factors. These include the increasing acuity of patients and complexity of surgical interventions; a shortage of senior and experienced nursing staff on hospital wards to manage complex care; an inadequate level of care by junior doctors on the wards, due to inexperience and lack of supervision; and a shortage of ICU beds. The structure of these services may range from a Central Closed service (managed by and located adjacent to intensive care services) to a peripheral service functioning independently of other critical care services. It is believed that patient outcomes will improve with the establishment of high dependency units with defined admission criteria (Boots and Lipman 2002). There is limited information available from the states or territories regarding plans for HDU beds or units in the future. The Working Party assume they would be in addition to existing and future ICU beds rather than a replacement of ICU services. Provision of nursing services may alter in future years. It is possible that enrolled nurses with specialist training to work in critical care may become a larger proportion of the critical care nurse workforce. It is possible that non-nurses may provide more supportive roles within the critical care environment. However, nationally there appears little support for their use in direct patient care. 72

90 State/Territory Health Department Future Planning For Intensive Care Unit Beds AHWAC s preference was to seek planning information from the States and Territories on which to base projections. However, of all jurisdictions, only New South Wales and Victoria provided AHWAC with intensive care planning reports and the Northern Territory provided projected ICU bed numbers. New South Wales The New South Wales Government Action Plan for Health: intensive care service plan Adult services (2001) provides a guide to bed spaces rather than actual beds (physical or available beds). ANZICS (2001) reports New South Wales currently has a total 643 physical beds, 564 available beds and 358 ventilated beds (excluding paediatric beds): 9.05 available beds per 100,000 and 5.86 ventilated beds per 100,000 population. It has a higher number of physical beds, available and ventilated beds per 100,000 than most other States and Territories. The projected bed spaces outlined below are actually less than the current provision of physical ICU beds (reported by ANZICS) in New South Wales. The following requirements are projected for NSW: Table 29: Projected ICU bed requirements for New South Wales, public and private sector, Year Maximum intensive care bed space requirement for peak demand (includes private sector) Intensive care beds per 100, /100, /100, /100,000 Source: NSW Health 2001 Victoria The Victorian health department recently released its planning document for intensive care services (MA International, 2001). The report suggests that the distribution and construction of new beds should consider: population requirements and trends; relative benchmarks; adequacy of current ICU services and availability; current and future supply distribution of specialist acute hospital services; functional requirements of new capital developments or re-developments; efficiency and critical mass of bed configurations across units; and current capital program for metropolitan hospitals. It also suggests a two stage approach to planning be adopted, that is, demand (based on population and epidemiological factors) and the best way to supply services. A number of methodologies were used to determine future bed requirements (demand) in the report. The following table summarises the findings of the determination methodologies for the year 2006, 2011 and It highlights the wide variation resulting from the different methodologies used. 73

91 Table 30: Projected ICU bed requirements for Victoria, a b C D e f g H i j k : Physical beds a: survey ratio, b: ANZICS ratio, c: age adjusted, d: Australian ratios, e: NSW ratios, f: SA model, g: WA model, h: UK base, i: UK occupancy adjusted, j: occupancy adjusted, k: VAED Source: MA International, 2001 As a result of the MA International Report of 2001, the Victorian government provided funding for 12 additional ICU beds in October The report recommends that the total number of available ventilated ICU beds increase by at least 25 beds to meet the national average for ventilated beds. Queensland No planning information available South Australia South Australia recently undertook a review of its critical care services. However, the report is not yet available. Western Australia Intensive care service planning is currently underway Tasmania No planning information made available. Northern Territory Table 31. Northern Territory ICU beds, 2002 and 2005 (projected) Physical beds Ventilated beds HDU beds 0 10 Available ICU/HDU beds 11/0 16/10 Source: Territory Health Services 2002 Australian Capital Territory No planning information made available. Estimation Of Growth in Critical Care Nurse Requirements In the absence of planning information from all States and Territories, the Working Party agreed to apply a growth rate to base-line critical care nurse requirements. These requirements were based on the baseline requirement as determined by the William and Clarke method, which was in turn based on the current number and type of intensive care beds. 74

92 The estimated increase in requirements was calculated for 2001 to 2011 using the projected population change per annum plus an ageing factor. Projected population growth rates plus an ageing factor (0.4%) were applied to the baseline requirements for each State and Territory. An alternative scenario was provided, which assumed that there would be no growth in actual bed numbers over the ten-year projection period. 75

93 10. CRITICAL CARE WORKFORCE SUPPLY PROJECTIONS No data available to show trends in annual new entrants to the critical care nurse workforce Undergraduate nurse completion may provide an indication of frontend supply trends for specialist areas of practice such as critical care In recent years there has been a gradual increase in total (national) undergraduate nurse commencements and completions, however, in some States and Territories there has been a decline (e.g. South Australia, Western Australia and the Northern Territory). Available data from nurse registration authorities describing trends in initial nursing registrations (new registered nurses each year) suggests a decline in overall (national) initial nurse registrations over recent years. However, a number of States and Territories reported increasing, others reported decreasing and others reported fluctuating initial registrations. No data available on overseas migration into critical care nursing. No data available on re-entrants to critical care nursing. Reports from nurse managers suggest an increased rate of attrition (permanent exits) from the critical care nurse workforce and increased attrition from the permanent workforce into the casual workforce (agency nursing) over recent years. There is no reliable data to determine the actual attrition rate from the critical care nurse workforce. The Working Party assumed attrition rates of 10% and 15% for projections. Ensuring a balanced supply of critical care nurses depends upon replacing critical care nurses who leave the workforce with younger-aged nurses (who work more hours per week on average). Increasing retention (reducing attrition) results in a lower number of new entrants required each year. Entry To The Workforce In considering supply projections of the critical care nurse workforce, information on the number of new entrants to the workforce was sought. However, the Working Party found there was no data available on new entrants to critical care practice. There is currently no nationally available data to determine how many RNs enter practice as critical care nurses each year. The AIHW nurse labour force survey reports do not identify new practitioners to critical care nursing. 76

94 As explained previously in this report, a postgraduate qualification is not an entry requirement to practise as a critical care nurse. Rather, it is a desirable quality and many critical care nurses embark on such a qualification once employed in an intensive or critical care unit. Therefore the use of commencements of postgraduate critical care courses was not considered to be an adequate proxy for new entrants to the critical care nurse workforce. Front-end Supply It was hoped that a trend in front-end supply would be identified to provide information on growth of potential new entrants to critical care practice. New additions to the overall registered nurse workforce (via undergraduate nurse programs) provide the front-end supply for the specialty nurse workforces such as the critical care nurse workforce. There is an average lead-time of between 4 and 5 years from the beginning of an undergraduate nursing program to entry into a specialist nursing area such as critical care. Trends in undergraduate completions and new nurse registrations are potential indicators of growth in the front-end supply for specialist nursing practice such as critical care. Data capturing overall (national) undergraduate pre-registration nursing commencements and completions showed that there was a drop in undergraduate commencements in 1995, 1996 and Since then overall (national) numbers have gradually increased. However, in the last year (2002) commencements have dropped in South Australia, Western Australia and the Northern Territory. (AIHW 2002 and Ogle et al 2001, 2002) For most states and territories there was an increase in the number of domestic students completing pre-registration programs over the last 3 years. There has been an overall increase of completions from 1999 to 2001 of 370 completions. Each State and Territory nurses registration authority was asked to provide AHWAC with the number of initial registrants each year for the last 5 years leading up to The jurisdictions provided data on the number of new registrants who completed undergraduate nursing courses in their own State/Territory. One nurse registration authority was not confident in the accuracy of the data supplied (Northern Territory), one could not separate midwifery and mental health nurse endorsements from the overall nurse registrations (Australian Capital Territory), and one was not able to separate initial nurse registrations from overseas nurse registrations in 2001 (Western Australia). It was hoped that a pattern would emerge to inform the Working Party of the trend in the growth at the front end of the nursing workforce. The total numbers for 1998, 1999 and 2000 reveal a gradual drop in initial new registrants. Two jurisdictions show a trend of increasing new registrants: Victoria and Queensland. South Australia shows a downward trend (table 32). Because of the fluctuating student and registration numbers in most jurisdictions, the Working Party was not confident to project a national growth trend in the front-end supply of registered nurses. 77

95 Table 32: New (initial) nursing registrants, by State and Territory, Year NSW Vic Qld SA WA Tas NT a ACT b Total ,521 1, na ,625 1, ,597 1, ,376 1, ,698 1, na a : may not be accurate, b: include midwifery registrations and mental health nurse registrations. Source: Nursing registration authorities for each State and Territory There is no national data available linking undergraduate completions to initial registrations or entry into the nursing workforce. The Victorian Auditor General s report on nurse workforce planning (2002) reported that there was a 75% uptake of nurse graduates into the nursing profession in 2001, compared with only a 58% uptake in A UK study reports that 34% of new graduate nurses are not registering to practise, contributing to a continuing shortage (Finlayson, Dixon, Meadows and Blair, 2002). Overseas registered nurses entering the critical care workforce (permanent and temporary) Two potential sources of data were identified to determine how many overseas nurses begin work in critical care, the Commonwealth Department of Immigration and Multicultural and Indigenous Affairs, and nurse registration authorities of each jurisdiction. However, no data was available specifically relating to critical care nurses. Re-entry to the registered nurse workforce Due to the shortage of nurses experienced across all States and Territories, many initiatives have been launched to encourage nurses whose registration has lapsed or who have not practised recently to re-enter the nursing workforce by completing re-entry (re-registration) or refresher programs. The programs vary greatly and are funded differently among and within jurisdictions. Refresher programs are currently offered by the public hospital sector, the private sector, the aged care sector and educational sector. Re-entry programs are offered in a variety of ways depending on the requirements of the particular nursing registration boards. However, there is no accurate measure of the total number of RNs re-entering workforce, nor is there a measurement of those who return to the critical care nurse workforce. Expected changes in work hours There has been a decrease in average number of hours worked per week by critical care nurses between 1997 and The 1997 AIHW nurse labour force data shows the average hours worked by nurses in intensive care is 33.5 hours per week, while the 1999 data reveals a the national average hours worked per week was During consultations with critical care nurses the following reasons were given for the reduction in working hours: lifestyle preferences; study commitments; family considerations; and stress of workplace (personal health considerations). Effect Of Ageing The overall RN workforce is ageing. At the 1986 ABS Census, 23.3% of nurses were aged under 25 and 17.5% were aged over 45 years or more. At the 1996 census, the proportion of nurses aged under 25 had fallen to 7.7%, while the proportion of nurses aged 45 years or 78

96 more had increased to 30.3%. The average age of RNs increased from 39.1 years in 1994 to 41.6 years in 1999 (AIHW, 2001). When examining the age structure of the critical care nurse workforce, it is younger than the overall clinical registered nurse workforce. AIHW 1999 data reveals the average age of the critical care nurse workforce is only marginally older than it was in There is a clear relationship between average hours worked and age-group. On average, younger aged critical care nurses worked more hours per week than those in the higher agegroups (over 30 years). The maintenance of an adequate supply of critical care nurses is dependent on the recruitment of younger aged registered nurses into the specialty. Recruiting nurses who on average work more hours per week, effectively reduces the headcount requirement, but maintains an FTE. Female: male participation The representation of females in the workforce is high (between 80 93%) in each jurisdiction. It is not expected that these ratios will change as the proportion of female: male undergraduate nurses remains relatively constant. Therefore, the attrition from the workplace due to family considerations is expected to remain constant. There is no indication to suggest that male participation in nursing is increasing. Losses To The Critical Care Nursing Workforce The nursing workforce is particularly fluid. Registered nurses may move from one specialty area to another, from one sector to another, from the permanent workforce to the casual workforce and in and out of the overall workforce a number of times in their working lives. Permanent exits from a specialty are difficult to determine for these reasons. Some information regarding losses to the critical care nurse workforce was available from the State and Territories health departments. In most part they were unable to specify if the attrition rates referred to permanent exits from the critical care nurse workforce, or exits from rostered positions in units. There is no consistent monitoring of where critical care nurses go when they leave an intensive care unit. Attrition rates in critical care The attrition rates for critical care nurses vary across jurisdictions. In response to AHWAC s request for information, jurisdictions provided the following information. Table 33: Estimated ICU attrition rates, by State/Territory health, 2001 NSW a Vic Qld SA WA Tas NT b ACT b Attrition rate % 16% 10% 24.8% 29.0% 30% 14.5% 40% 90% 3.5% 20% Note: a - all nurses; b - attrition rates from two hospitals Source: State/Territory health departments Due to the inability of the AIHW nurse labour force surveys to identify individual movements over time, the actual attrition from the critical care nurse workforce cannot be determined (ie. the number of critical care nurses who leave the critical care nurse workforce permanently) According to Williams and Clarke (2001) consensus was gained amongst leading ICU nurses across Australia that the average time spent working in ICU is 5 years, therefore the attrition rate is 20% annually. The Working Party agreed that although individual units may have 79

97 higher attrition rates, many critical care nurses do not leave the workforce altogether, but may work in other units or work with nursing agencies. The Working Party assumed more likely scenarios of attrition rates (permanent exits) are 10 to 15%. According to consultations with nurse managers, attrition rates have increased over the last two years. However, there is no longitudinal data to show trends. The increase in attrition may be due to a number of factors, including the movement of the bulk of the critical care nurse workforce into the age-groups in which they tend to leave for life-style reasons; dissatisfaction with working conditions; and the usual reasons for leaving, such as burnout. It is likely that the attrition rate of critical care nurses is less in the lower age-groups and more in the higher age-groups. This assumption is supported when examining the age structure of the critical care nurse workforce. The numbers drop significantly in the years and years age groups. The Working Party identified a number of strategies to reduce attrition from the workforce (increase retention). Increasing retention will directly reduce the requirement for new entrants to the workforce each year. Strategies include: the development of an improved career structure that recognises the skills for clinical roles in critical care (and remunerated accordingly); provision of financial incentives for night duty; the establishment of work practices that allow more flexibility; the establishment of work practices to prevent burn-out ; implementation of management practices that enhance genuine valuing of nursing staff in the workplace; and implementation of management development and training to enhance the ability to manage nurses and workforce issues better than has been done so to date. Projected retirements Due to the relatively young age of most critical care nurses, attrition due to retirement from the workforce is not considered to be a major factor. In any case, no data was available on workforce retirements from critical care. Migration of nurses from Australia to another country It is well known that many Australian RNs leave Australia temporarily to work overseas. There is no data describing how many critical care nurses leave the Australian workforce to work in other countries. 80

98 11. CRITICAL CARE WORKFORCE PROJECTIONS: BALANCING SUPPLY AGAINST REQUIREMENTS Two approaches were used to calculate workforce projections, both used a base-line estimation of required critical care nurses for current ICU bed infrastructure (available ICU beds). Base-line supply estimates included total workforce estimate (based on AIHW data) and base-line requirements were estimated by using the Williams and Clarke approach for determining critical care nurse requirements. The estimated national critical care nurse workforce was 9,849 (headcount). The estimated national base-line requirement for the critical care nurse workforce was 10,386 (headcount), with an estimated net undersupply of 537 (headcount). Current total available ICU beds (nationally) were estimated to be 1,598. By applying a population growth plus ageing factor, total (public and private) available ICU beds are projected to be 1,806 in Four scenarios were used in the projections. These ranged from a high scenario of 15% attrition and growth in underlying requirements by a population growth and ageing factor, and a low scenario of 10% attrition and no growth in underlying requirements. For a balanced workforce, AHWAC estimates that at least 722 new entrants (low scenario, ) and at most 1,356 new entrants (high scenario, ) are required nationally. To meet minimum standards (50% qualified critical care nurses) at least 361 postgraduate critical care completions per annum are required (low scenario, ), and at most 678 completions are required (high scenario, ). To meet ACCCN standards (75% qualified critical care nurses) at least 541 postgraduate critical care completions per annum are required (low scenario, ), and at most 1,017 completions are required (high scenario, ). This chapter draws together information outlined in previous chapters and, using the models described in the methodology chapter (Chapter 5), projects both the total critical care nurse workforce required and the required number of new entrants to the critical care nurse workforce annually for each year from and for each State and Territory, in order to have a balanced workforce (that is, one where supply matches the requirements). 81

99 The Working Party acknowledges the potential impact the data limitations may have had on the following projections. A number of scenarios have been provided to allow planners options according to what they can determine about the workforce (particularly in terms of new entrants and attrition rates) and the critical care services in their particular jurisdictions. AHWAC strongly recommends monitoring of the workforce to enable a more informed process. Available (open) ICU beds (beds that are immediately available for use i.e., funded and staffed) provided the base-line requirements for all projections. If jurisdictions plan on increasing available ICU beds, by opening (funding and staffing) more physical beds or equipping bed spaces greater than by the population growth and ageing factors AHWAC applied, then this must also be altered in any further workforce planning. Scenarios were based on 4 potentialities: Workforce attrition of 15% and growth in requirements by population and ageing factor (scenario A: highest requirements scenario); Workforce attrition of 15% and no growth in requirements (scenario B). Workforce attrition of 10% and growth in requirements by population and ageing factor (scenario C); Workforce attrition of 10% and no growth in requirements (scenario D: lowest requirements scenario). The results of the base-line assessment and projections are related to average hours worked per week. A required FTE related to bed numbers and types was determined. The FTE was converted to a headcount by factoring in average hours worked per week (as reported by AIHW) The average hours worked per week effects the overall headcount requirements directly, ie. the lower the average hours worked per week, the higher the headcount to meet the required FTE. In jurisdictions with reported low average hours worked per week, this has a major impact on required headcount (eg South Australia). If data related to hours worked per week or estimated total workforce (from AIHW) is not accurate, then this impacts on the accuracy of the underlying measurement of adequacy. Due to possible inaccuracies in data reported by AIHW, it is possible the results of the projections are not accurate. They should be used as a guide and AHWAC strongly suggests that when more reliable, up to date data becomes available, it is used to update the following projections. The above scenarios were applied to the two modelling approaches used (Van Konkelenberg and the AHWAC approach based on Williams and Clarke). To simplify the results of the projections, only the highest requirements scenario (A) and lowest requirement scenario (D) are reported in this chapter. All scenario summaries are provided in the Appendices K - R. The summary tables in this chapter report a number of items: Total workforce: The actual number (FTE and headcount) projected for a balanced workforce in the given year under the given assumptions. New entrants: The required number of new entrants required for the year. % under/oversupply: Indicates the balance between the projected supply and requirements (as measured in headcount and FTE), where a negative (-) percentage 82

100 indicates supply exceeds requirements (oversupply) and a positive percentage indicates requirements exceeds supply (undersupply). The results of the two different modelling approaches are displayed in the summary table for each jurisdiction. Method 1 refers to the Van Konkelenberg model, which incorporates workforce participation (hours worked per week and attrition rates) in 5-year age and gender cohorts. Method 2 refers to the AHWAC method based on a requirements only approach (where assumptions of adequacy are not made). It uses average hours per week over the total workforce and a total workforce attrition rate. In essence, it holds the workforce participation constant, regardless of potential influence of the age of new entrants. Both approaches base the required workforce on a recommended headcount determined by the Williams and Clarke methodology. Because the underlying base-line information is similar, it is expected that the balanced workforce FTE displayed in method 1 will be similar to that of method 2. Because of the increased sensitivity of the Van Konkelenberg method to changes in overall workforce participation due to the input of younger-aged new entrants, the headcount projections are expected to differ (i.e. less than those projected in method 2). 83

101 Projections critical care nurse workforce: New South Wales/Australian Capital Territory Current workforce headcount: 3,909 (AIHW) Current headcount shortage: 143 oversupply (using Williams and Clarke) Current permanent workforce FTE: 1,674.1 (ANZICS) Current FTE shortage: FTE (vacancies, ANZICS) Average age: 36.4 (AIHW) Average hours worked: 32 (AIHW) Initial registrations: fluctuating. Population/ageing growth rate: 1.11% per annum Table 34 summarises the results of scenario A (high: 15% attrition, growth in requirements) and D (low: 10% attrition, no growth in requirements) projections for New South Wales/Australian Capital Territory. In modelling method 1, an assumption was made that the workforce was in balance at the base year. The new entrants required to maintain a balance ranged from at least 275 per year (scenario D, ) to at most 460 per year (scenario A, ). If the base-line headcount was an oversupply (143), then the rates of new entrants may result in a 4% oversupply at most. Method 2 reveals at least 377 (scenario D) new entrants and at most 631 (scenario A) new entrants are required each year to balance supply with requirements. Method 1 is used to determine numbers of postgraduate critical care completions to ensure the workforce meets minimum standards (50% qualified) and ACCCN suggested standards (75%). This is determined by applying the desired percentage of qualified staff to estimated new entrants. For a 50% qualified workforce, will need to complete postgraduate critical care courses annually. For a 75% qualified workforce, postgraduate critical care course completions are required annually (depending on scenario of workforce requirements). See appendix J for detailed spreadsheet summaries. 84

102 Table 34: New South Wales/Australian Capital Territory projected critical care workforce and new entrants, Total Workforce Method 1. Scenario A Available beds Total workforce 3,364 3,322 3,476 3,615 3,699 3,780 (FTE) Total workforce 3,909 3,861 3,935 4,159 4,298 4,393 (headcount) New entrants % under/oversupply if base-line balance % if base-line oversupply Scenario D Available beds Total workforce 3,364 3,314 3,344 3,366 3,371 3,385 (FTE) Total workforce 3,909 3,851 3,885 3,912 3,917 3,934 (headcount) New entrants Under/oversupply Total Workforce Method 2. Scenario A Available beds Total workforce 3, , , , ,475 3,552.5 (FTE) Total workforce ,114 4,206 (headcount) New entrants Scenario D Available beds Total Workforce 3, , , , , ,181.3 (FTE) Total workforce 3,776 3,776 3,776 3,776 3,776 3,776 (headcount) New entrants Method 1: Van Konkenlenberg Method 2: AHWAC based on Williams & Clarke (requirements only) 85

103 Projections critical care nurse workforce: Victoria Current workforce headcount: 2262 (AIHW) Current headcount shortage: 33 undersupply (using Williams and Clarke) Current permanent workforce FTE: 1,178.6 (ANZICS) Current FTE shortage: 88.2 (vacancies, ANZICS) Average age: 33.6 (AIHW) Average hours worked: 31.0 (AIHW) Initial registrations increasing. Population growth/ageing rate: 0.96% per annum Table 35 summarises the results of scenario A (high: 15% attrition, growth in requirements) and D (low: 10% attrition, no growth in requirements) projections for Victoria. In modelling method 1, an estimated undersupply of 33 was applied (base-line undersupply of 1.4%) for a balanced workforce, at least 175 (scenario D, ) and at most 300 (scenario A, ) new entrants are required each year. Method 2 reveals at least 230 (scenario D) new entrants and at most 379 (scenario A) new entrants are required each year to balance supply with requirements. Method 1 is used to determine the numbers of postgraduate critical care completions to ensure the workforce meets minimum standards (50% qualified) and ACCCN suggested standards (75%). This is determined by applying the desired percentage of qualified staff to estimated new entrants. For a 50% qualified workforce, completions are required annually. For a 75% qualified workforce, postgraduate critical care course completions are required annually (depending on scenario of workforce requirements). See appendix K for detailed spreadsheet summaries. 86

104 Table 35: Victoria projected critical care nurse workforce and new entrants, Total Workforce Method 1. Scenario A Available beds Total workforce 1,845 1,841 1,947 2,000 2,046 2,076 (FTE) Total workforce 2,262 2,257 2,386 2,451 2,508 2,545 (headcount) New entrants under/oversupply Scenario D Available beds Total Workforce 1,845 1,837 1,872 1,876 1,876 1,882 (FTE) Total workforce 2,262 2,252 2,294 2,299 2,300 2,306 (headcount) New entrants Under/oversupply Workforce Method 2. Scenario A Available beds Total workforce 1, , , ,059.9 (FTE) Total workforce 2,295 2,339 2,384 2,430 2,477 2,525 (headcount) New entrants Scenario B Available beds Total workforce 1, , , , , ,872.2 FTE Total workforce 2,295 2,295 2,295 2,295 2,295 2,295 New entrants Method 1: Van Konkelenberg Method 2: AHWAC based on Williams & Clarke (requirements only) 87

105 Projections critical care nurse workforce: Queensland Current workforce headcount: 1621 (AIHW) Current headcount shortage: 339 (using Williams and Clarke) Current permanent workforce FTE: (ANZICS) Current FTE shortage: 84 FTE (vacancies, ANZICS) Average age: 35.8 (AIHW) Average hours worked: 32.5 (AIHW) Initial registrations increasing Population growth/ageing rate: 1.97% per annum Table 36 summarises the results of scenario A (high: 15% attrition, growth in requirements) and D (low: 10% attrition, no growth in requirements) projections for Queensland. In modelling method 1, an estimated undersupply of 339 was applied (base-line undersupply of 17.3%) for a balanced workforce, at least 135 (scenario D) and at most 288 (scenario A) new entrants are required each year. Method 2 reveals at least 196 (scenario D, ) new entrants and at most 357 (scenario A, ) new entrants are required each year to balance supply with requirements. Method 1 is used to determine the numbers of postgraduate critical care completions to ensure the workforce meets minimum standards (50% qualified) and ACCCN suggested standards (75%). This is determined by applying the desired percentage of qualified staff to estimated new entrants. For a 50% qualified workforce, completions are required annually. For a 75% qualified workforce, postgraduate critical care course completions are required annually (depending on scenario of workforce requirements). See appendix L for detailed spreadsheet summaries. 88

106 Table 36: Queensland projected critical are workforce and new entrants, Total Workforce Method 1. Scenario A Available beds Total workforce 1,335 1,481 1,683 1,839 1,909 1,978 (FTE) Total workforce 1,621 1,798 2,043 2,220 2,318 2,402 (headcount) New entrants under/oversupply Scenario D Available beds Total workforce 1,335 1,436 1,558 1,621 1,628 1,634 (FTE) Total workforce 1,621 1,744 1,892 1,968 1,977 1,984 (headcount) New entrants Under/oversupply Workforce Method 2. Scenario A Available beds Total workforce 1, , , , , ,968.5 (FTE) Total workforce 1,960 2,038 2,119 2,203 2,291 2,382 (headcount) New entrants Scenario D Available beds Total workforce 1, , , , , ,619.6 (FTE) Total workforce 1,960 1,960 1,960 1,960 1,960 1,960 (headcount) New entrants Method 1: Van Konkelenberg Method 2: AHWAC based on Williams & Clarke (requirements only) 89

107 Projections critical care nurse workforce: South Australia Current workforce headcount: 873 (AIHW) Current headcount shortage: 289 undersupply (using Williams and Clarke) Current permanent workforce FTE: (ANZICS) Current FTE shortage: 41.5 (vacancies, ANZICS) Average age: 36.6 (AIHW) Average hours worked: 26.2 (AIHW) Initial registrations decreasing. Population growth/ageing rate: 0.65% per annum Table 37 summarises the results of scenario A (high: 15% attrition, growth in requirements) and D (low: 10% attrition, no growth in requirements) projections for South Australia. The average hours worked per week (as reported by AIHW) impacts greatly on the underlying determination of base-line critical care nurse headcount requirements. South Australia has the lowest reported average hours worked per week (26.2) compared to the other States and Territories. In modelling Method 1, an estimated undersupply of 233 was applied (base-line undersupply of 24.9%) for a balanced workforce, at least 67 (scenario D, ) and at most 158 (scenario A, ) new entrants are required each year. Method 2 reveals at least 116 (scenario D) new entrants and at most 186 (scenario A) new entrants are required each year to balance supply with requirements. Method 1 is used to determine the numbers of postgraduate critical care completions to ensure the workforce meets minimum standards (50% qualified) and ACCCN suggested standards (75%). This is determined by applying the desired percentage of qualified staff to estimated new entrants. For a 50% qualified workforce, completions are required annually. For a 75% qualified workforce, postgraduate critical care course completions are required annually (depending on scenario of workforce requirements). See appendix M for detailed spreadsheet summaries 90

108 Table 37: South Australia projected critical care nurse workforce and new entrants, Total Workforce Method 1. Scenario A Available beds Total workforce (FTE) Total workforce ,127 1,214 1,234 1,247 (headcount) New entrants % under/oversupply Scenario D Available beds Total workforce (FTE) Total workforce ,104 1,167 1,170 1,170 (headcount) New entrants Under/oversupply Workforce Method 2. Scenario A Available beds Total workforce (FTE) Total workforce 1,162 1,177 1,193 1,208 1,224 1,240 (headcount) New entrants Scenario D Available beds Total workforce (FTE) Total workforce 1,162 1,162 1,162 1,162 1,162 1,162 (headcount) New entrants Method 1: Van Konkelenberg Method 2: AHWAC based on Williams & Clarke (requirements only) 91

109 Projections critical care nurse workforce: Western Australia Current workforce headcount: 861 (AIHW) Current headcount shortage: 6 undersupply (using Williams and Clarke) Current permanent workforce FTE: (ANZICS) Current FTE shortage: 44.4 (vacancies, ANZICS) Average age: 36.9 (AIHW) Average hours worked: 30.2 (AIHW) Initial registrations fluctuating. Population growth/ageing rate: 1.8% per annum Table 38 summarises the results of scenario A (high: 15% attrition, growth in requirements) and D (low: 10% attrition, no growth in requirements) projections for Western Australia. In modelling method 1, an estimated undersupply of 6 was applied (base-line undersupply of 21.1%) for a balanced workforce, at least 54 (scenario D, ) and at most 100 (scenario A, ) new entrants are required each year. Method 2 reveals at least 87 (scenario D) new entrants and at most 155 (scenario A) new entrants are required each year to balance supply with requirements. Method 1 is used to determine the numbers of postgraduate critical care completions to ensure the workforce meets minimum standards (50% qualified) and ACCCN suggested standards (75%). This is determined by applying the desired percentage of qualified staff to estimated new entrants. For a 50% qualified workforce, completions are required annually. For a 75% qualified workforce, postgraduate critical care course completions are required annually (depending on scenario of workforce requirements). See appendix N for detailed spreadsheet summaries. 92

110 Table 38: Western Australia projected critical care nurse workforce and new entrants, Total Workforce Method 1. Scenario A Available beds Total workforce (FTE) Total workforce ,006 1,045 (headcount) New entrants Under/oversupply Scenario D Available beds Total workforce (FTE) Total workforce (headcount) New entrants Under/oversupply Workforce Method 2. Scenario A Available beds Total workforce (FTE) Total workforce (headcount) New entrants Scenario D Available beds Total workforce (FTE) Total workforce (headcount) New entrants Method 1: Van Konkelenberg Method 2: AHWAC based on Williams & Clarke (requirements only) 93

111 Projections critical care nurse workforce: Tasmania Current workforce headcount: 224 (DHHS, includes casual staff) Current headcount shortage: 32 shortage (using Williams and Clarke) Current permanent workforce FTE: (DHHS) Current FTE shortage: 16.5 FTE (vacancies, DHHS) Average age: 37.6 (DHHS) Average hours worked: 30.7 (DHHS) Initial registrations fluctuating. Population/ageing growth rate: 0.17% per annum Table 39 summarises the results of scenario A (high: 15% attrition, growth in requirements) and D (low: 10% attrition, no growth in requirements) projections for Tasmania. In modelling method 1, an estimated undersupply of 32 was applied (base-line undersupply of 21.1%) for a balanced workforce, at least 12 (scenario D, ) and at most 41 (scenario A, ) new entrants are required each year. Method 2 reveals at least 26 (scenario D) new entrants and at most 39 (scenario A) new entrants are required each year to balance supply with requirements. Method 1 is used to determine the numbers of postgraduate critical care completions to ensure the workforce meets minimum standards (50% qualified) and ACCCN suggested standards (75%). This is determined by applying the desired percentage of qualified staff to estimated new entrants. For a 50% qualified workforce, 6-20 completions are required annually. For a 75% qualified workforce, 9 30 postgraduate critical care course completions are required annually (depending on scenario of workforce requirements). See appendix O for detailed spreadsheet summaries. 94

112 Table 39: Tasmania projected critical care nurse workforce and new entrants, Total Workforce Method 1. Scenario A Available beds Total workforce (FTE) Total workforce (headcount) New entrants under/oversupply Scenario D Available beds Total workforce (FTE) Total workforce (headcount) New entrants Under/oversupply Workforce Method 2. Scenario A Available beds Total workforce (FTE) Total workforce (headcount) New entrants Scenario D Available beds Total workforce (FTE) Total workforce (headcount) New entrants Method 1: Van Konkelenberg Method 2: AHWAC based on Williams & Clarke (requirements only) 95

113 Projections critical care nurse workforce: Northern Territory Need to update with new projections Current workforce headcount: 99 (AIHW, includes 8 educators) Over supply of 19 (comparing AIHW data with base-line requirements) Current permanent workforce FTE: 71.0 (ANZICS) Current FTE shortage: 6 FTE (vacancies, ANZICS) Average age: 39 (AIHW) Average hours worked: 35.9 (AIHW) Initial registrations fluctuating Population growth/ageing rate: 2.24% per annum Table 40 summarises the results of scenario A (high: 15% attrition, growth in requirements) and D (low: 10% attrition, no growth in requirements) projections for Northern Territory. A balanced workforce was assumed in the modelling process, although AIHW data suggested a total critical care nurse workforce of 99 (base-line requirement of 80). In modelling method 1, to maintain a balanced workforce, at least 4 (scenario D) and at most 9 (scenario A) new entrants are required each year. Method 2 reveals at least 8 (scenario D) new entrants and at most 15 (scenario A) new entrants are required each year to balance supply with requirements. Both of the above methods are based on 10% and 15% attrition rates. The Northern Territory may have a higher attrition rate, due to many nurses working in the Territory on a temporary basis. Method 1 is used to determine the numbers of postgraduate critical care completions to ensure the workforce meets minimum standards (50% qualified) and ACCCN suggested standards (75%). This is determined by applying the desired percentage of qualified staff to estimated new entrants. For a 50% qualified workforce, 2-7 completions are required annually. For a 75% qualified workforce, 3 11 postgraduate critical care course completions are required annually (depending on scenario of workforce requirements). See appendix P for detailed spreadsheet summaries. 96

114 Table 40: Northern Territory projected critical care nurse workforce and new entrants, Total Workforce Method 1. Scenario A Available beds Total workforce (FTE) Total workforce (headcount) New entrants under/oversupply Scenario D Available beds Total workforce (FTE) Total workforce (headcount) New entrants Under/oversupply Workforce Method 2. Scenario A Available beds Total workforce (FTE) Total workforce (headcount) New entrants Scenario D Available beds Total workforce (FTE) Total workforce (headcount) New entrants Method 1: Van Konkelenberg Method 2: AHWAC based on Williams & Clarke (requirements only) 97

115 Projections critical care nurse workforce: Australia Current workforce headcount: 9,849 (AIHW & DHHS) Current headcount shortage: 537 shortage (using Williams and Clarke) Current permanent workforce FTE: 5,047.1 (ANZICS & DHHS) Current FTE shortage: FTE (vacancies, ANZICS) Average age: 35.7 (AIHW) Average hours worked: 31.3 (AIHW) Initial registrations decreasing nationally Table 41 summarises the results of scenario A (high: 15% attrition, growth in requirements) and D (low: 10% attrition, no growth in requirements) projections for all Australian States and Territories. Method 1: The total undersupply of critical care nurses was estimated to be 537 (base-line undersupply of 6.6%). Required new entrants each year ranged from 722 (scenario D, ) to 1,356 (scenario A, ) to achieve balance. In total, method 2 shows required new entrants to range from 1,038 (scenario D) to 1,764 (scenario A). Method 1 is used to determine the numbers of postgraduate critical care completions to ensure the workforce meets minimum standards (50% qualified) and ACCCN suggested standards (75%). This is determined by applying the desired percentage of qualified staff to estimated new entrants. For a 50% qualified workforce, completions are required annually. For a 75% qualified workforce, 541 1,017 postgraduate critical care course completions are required annually (depending on scenario of workforce requirements). See appendix Q for detailed spreadsheet summaries. 98

116 Table 41: Australia projected critical care nurse workforce and new entrants, Total Workforce Method 1. Scenario A Available beds 1,598 1,637 1,678 1,719 1,762 1,806 Total workforce 8,087 8,258 8,891 9,346 9,604 9,829 (FTE) Total workforce 9,830 10,057 10,844 11,406 11,719 11,992 (headcount) New entrants 1,356 1,356 1,306 1,051 1,031 1,031 under/oversupply Scenario D Available beds 1,598 1,598 1,598 1,598 1,598 1,598 Total workforce 8,087 8,193 8,492 8,642 8,658 8,688 (FTE) Total workforce 9,830 9,978 10,361 10,553 10,573 10,608 (headcount) New entrants Under/oversupply Workforce Method 2. Scenario A Available beds 1,598 1,637 1,678 1,719 1,762 1,806 Total workforce 8, , , , , ,589.6 (FTE) Total workforce 10,384 10,240 10,492 10,752 11,019 11,293 (headcount) New entrants 1,558 1,596 1,636 1,678 1,720 1,764 Scenario D Available beds 1,598 1,598 1,598 1,598 1,598 1,598 Total workforce 8,461 8,461 8,461 8,461 8,461 8,461 (FTE) Total workforce 10,384 10,384 10,384 10,384 10,384 10,384 (headcount) New entrants 1,038 1,038 1,038 1,038 1,038 1,038 Method 1: Van Konkelenberg Method 2: AHWAC based on Williams & Clarke (requirements only) 99

117 12. RECOMMENDATIONS FOR THE CRITICAL CARE NURSE WORKFORCE The following recommendations were formulated by the Working Party in order to achieve a balanced workforce. The recommendations have been based on the Working Party s view that there is unlikely to be a major change to critical care service provision within the defined projection period, including the model of critical care nursing. Highly specialist areas of healthcare, require a highly specialist nursing workforce. Implementation of the following recommendations will require government (Commonwealth, State and Territory), the critical care nursing profession, the university sector, and public and private health services to work together. Recommendation 1: ensuring an adequate supply of registered nurses to work in critical care (quantity). That AHMAC coordinate action to improve the supply of critical care nurses in Australia by working with the health and education sectors to ensure sufficient adjustment in new entrants to the critical care nurse workforce, recognising that at least 722 (lowest requirement scenario) and at most 1,356 (highest requirement scenario) new entrants to the critical care nurse workforce are required nationally each year. Noting: That in putting in place these actions AHMAC should be guided by the state and territory scenario projections outlined in this report, and that these actions should be informed by the most recently available jurisdictional critical care nurse workforce data. Strategies to improve retention of the skilled critical care nurse workforce would ensure that the required new entrants to the workforce is minimised. Recommendation 2: ensuring an adequate supply of qualified critical care nurses (quality). State and territory health departments as part of ensuring an adequate supply of critical care nurses note the standards suggesting at least 50% of the critical care nurse workforce and desirably 75% of the critical care nurse workforce should hold critical care qualifications. That AHMAC note the desirability of a move towards greater consistency in postgraduate critical care courses and the development of a framework for accreditation for postgraduate critical care courses. Recommendation 3: ensuring adequate data for ongoing and complete workforce supply analysis and requirement analysis. That AHMAC coordinate improvements to critical care nurse data collections, and overall nurse data collections, noting that reliable, timely data is essential to workforce planning. The following measures are required: AIHW surveys: the implementation of a consistent, timely national approach for the collection of nurse labour force surveys via nurse registration boards annually. Nurse registration authorities: AHMAC to encourage jurisdictions to work together to ensure a more consistent approach to registration data collection and reporting. 100

118 ANZICS Intensive Care Unit Resource Surveys: AHMAC continue to support the work of ANZICS and ensure the enhancement of the surveys to include additional questions regarding the critical care nurse workforce. Improvement of information relating to the nursing education sector. Research to measure the relationship between critical care nurse staffing levels (and skill mix) and patient outcomes. Recommendation 4: monitoring the workforce That AHMAC coordinate the monitoring of supply and requirement projections of and for the critical care nurse workforce, and that the critical care nurse workforce be reviewed in five years time. 101

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120 PART B: THE PAEDIATRIC INTENSIVE CARE NURSE WORKFORCE IN AUSTRALIA 103

121 PAEDIATRIC INTENSIVE CARE Initially, paediatric critical care nurses were not included within the scope of this study. However, the Working Party felt that due to the similarities of the workforce (in type of work and qualifications) that they should be included. It is a relatively small workforce and it was feared that because of its size, it would be overlooked in any further studies of nursing workforce planning. However, as will be explained, the availability of nationally consistent data describing the workforce is limited. This section of the report is therefore limited, but it is hoped that the current situation of the paediatric critical care nurse workforce will be highlighted and that further study will be undertaken when better data becomes available. In Australia, specialist paediatric ICUs (PICUs) are located in tertiary referral hospitals in a number of capital cities. They provide complex multi-system life support for an indefinite period for children needing intensive care and have extensive back up laboratory and clinical service facilities to support this tertiary role. A paediatric ICU must be capable of providing mechanical ventilation, extra-corporeal renal support services and invasive cardiovascular monitoring, for an indefinite period to infants and children less than 16 years of age. Information for this section of the report was provided directly to AHWAC via telephone interviews with the nurse unit managers of each of the 7 PICUs. Number of Paediatric Intensive Care Units Paediatric intensive care services in Australia are highly regionalised. The vast majority of critically ill children are cared for in tertiary paediatric ICUs in the major capital cities. In most instances, critically ill children are transferred to these units by specialised retrieval units. A small number of critically ill children are cared for in large regional, adult ICUs. When prolonged care of such children is required, most are transferred to the specialised tertiary paediatric ICUs. Such practices are consistent with the recommendations of the National Health and Medical Research Council (1981, 1983). In 2000, there were seven paediatric ICU facilities in Australia. These were located in New South Wales (2 units), Victoria (1 unit), Queensland (2 units), Western Australia (1 unit) and South Australia (1 unit). Tasmania, the Australian Capital Territory and the Northern Territory do not have stand alone PICUs. They have level 3 adult ICUs which may care for paediatric patients on a short term basis. There are a number of level 3 ICUs in Australia that have dedicated paediatric beds and care for a significant number of paediatric patients. Table 42: Physical, available and ventilated paediatric intensive care beds, by State/Territory, State/Territory Number of units Physical beds Available beds Ventilated beds NSW Victoria Queensland South Australia Western Australia Australia (total) Note: Available beds refer to beds currently open and available for immediate patient use (staffed). Source: AHWAC 104

122 DESCRIPTION OF THE CURRENT PAEDIATRIC INTENSIVE CARE NURSE WORKFORCE Paediatric Intensive Care Nurses Similar to critical care nurses who work in adult intensive care units, paediatric critical care nurses are required to be RNs. New paediatric critical care nurses commence postgraduate education once employed in a PICU. The majority of new entrants to paediatric critical care nursing are recruited from the pool of RNs working within acute paediatric hospitals. There is no national data to describe the paediatric critical care nurse workforce. Of all the State and Territory AIHW nurse registration surveys, only New South Wales and Western Australia have provided specific categories for paediatric intensive care to indicate their main area of practice as paediatric intensive care. The other States and Territories provide an intensive care category and a paediatric category. In these other States and Territories, nurses working in PICUs must then decide whether they indicate their main practice area is paediatrics or intensive care. They cannot indicate paediatric intensive care. Six of the States and Territories provide a category for post registration paediatric intensive care qualifications. The AIHW nurse registration surveys are therefore not able to provide a national picture of the paediatric intensive care workforce. For this reason, AHWAC surveyed each of the 7 PICUs to determine the numbers of RNs employed in PICUs. However, this data did not reveal the number of RNs who work in these units via agencies. Interviews with nurse managers suggested a relatively large number of rostered RNs had recently left to work with agencies. Table 43: Paediatric critical care workforce, by State/Territory, 2001 NSW Vic Qld SA WA Total Head count FTE Vacancies (FTE) Source: AHWAC survey of nurse managers Profile of the Paediatric Intensive Care Nurse Workforce The following information was provided by the nurse managers of each of the seven PICUs located in New South Wales, Victoria, Queensland, South Australia and Western Australia. Table 44: Paediatrics intensive care nurses: average age, average hours worked per week and gender profile, by State/Territory, 2001 NSW Vic Qld SA WA Average age Average hrs/week 34 na 32 na 28 Female to male % 94.4% 97% 82.5% 95% 88.2% Source: AHWAC 105

123 Education in Paediatric Intensive Care Nursing The types of postgraduate education programs available for nurses who wish to specialise in paediatric intensive care nursing are similar to those for other critical care nurses. Nurse managers consider postgraduate studies in intensive care, paediatric intensive care or neonatal intensive care as being appropriate for qualification as a paediatric critical care nurse. In the past paediatric critical care nurses gained their postgraduate qualifications from hospital-based programs. In recent years post graduate programs have been provided by the university sector in association with hospital units. The New South Wales College of Nursing is also a large provider of postgraduate paediatric intensive care and neonatal intensive care courses (both of which are considered appropriate qualifications). Queensland has instituted transition programs for paediatric critical care nurses. Although these are not regarded as formal qualifications, they are considered to provide the new entrants to practice with core skills and knowledge. In one Queensland PICU, they have replaced the New South Wales College of Nursing courses. Table 45: Paediatric intensive care course completions (2001) and projected completions (2002), by State/Territory NSW* Vic Qld SA WA * includes NSW college of Nursing courses which are provided to nurses in other states/territories. Source: Ogle et al 2002 The nurse managers of the PICUs were able to provide AHWAC with numbers of RNs currently enrolled in postgraduate courses. The NSW college of Nursing was also able to provide AHWAC with the number of commencements and completions of paediatric intensive care courses over the last few years. The issues for nurses entering postgraduate programs are the same for adult critical care nurses, such as costs involved and the need to take study days on a regular basis. Table 46: Number of paediatric nurses currently enrolled in postgraduate/transition programs, by State/Territory, 2001 NSW Vic Qld SA WA RNs currently enrolled 20 a 6 18 b 5 3 a: NSW College of Nursing course b: Transition course Queensland Health Source: AHWAC survey of nurse unit managers 106

124 ADEQUACY OF THE CURRENT PAEDIATRIC INTENSIVE CARE NURSE WORKFORCE In interviews with the nurse managers of the PICUs, concern was expressed in regard to the supply of paediatric critical care nurses. In the past PICUs had waiting lists for interested RNs to work in the units; now the opposite is happening, with PICUs having to wait for RNs to become available to work. One nurse manager said it was not unusual to have to wait 8 months before a nurse could leave the ward to work in the PICU. Over the last two years, it has been more difficult to fill vacant positions. Advertisements have had little or no response in some states. There has been an increased attrition from the workplace as staff have left to work with agencies or to jobs with regular hours such as research jobs, and many have left to work overseas. Recruiting from the pool of RNs working in the hospital wards is more difficult, as the wards are experiencing a shortage. There is also a perceived lack of experience on the wards, leading to more pressure on the PICUs to manage patients with complex care needs. High dependency patients, who would previously have been managed in the wards, are more commonly being managed in the PICUs, placing pressure on beds. Indicators of Adequacy in Paediatric ICUs The Working Party agreed to use the following indicators of adequacy: RN FTE vacancies; proportion of qualified RNs: non qualified; use of agency nurses; overtime worked; and turnover and attrition rates. Table 47: Summary of adequacy indicators for registered nurses working in PICU State (no. units) Proportion of qualified RNs RN FTE Vacancies Average overtime worked in month (hours) Average use of agency per week (hours) NSW (2) 57.5% a hrs/week a Vic (1) 75% ,008 hrs (6 agencies per shift) Qld (2) b 66.6% hrs/week 60 hrs/week SA (1) 50% 5 Each RN: 1 overtime shift per week 168 hrs/week (1 agency per shift ) WA (1) 34% hrs/week (1 agency per shift) a : NSW Paediatric Intensive Care Data Collection January 2001 September 2001 b : the two units details given separately as large difference between them in terms of adequacy indicators. Source: AHWAC 107

125 Table 48: Estimated attrition (%) PICU permanent workforce, by State/Territory, 2001 NSW Vic Qld SA WA Attrition rate for last 12 24% 55% 20% 26% 18% months Note: Attrition rate given as an actual percentage of RNs who have left. Where this information was not available the average number of years RNs stay was converted to an annual percentage. i.e. average of 5 years = 20% annual attrition rate. Source: AHWAC It must be noted that the attrition reported from the workplace refers to those critical care nurses who have resigned from their rostered positions. They may not have left the PICU workforce entirely but may have joined an agency and will work in the PICU casually. One nurse manager reported a large loss of staff to competing private sector hospitals that have upgraded their adult intensive care facilities. They have also lost staff to a major adult public hospital that provides paediatric care in its adult ICU. There is currently no national data set which can detect individual movements in and out of the nursing workforce specialties, therefore there is no way of knowing who and how many have actually left the workforce. FUTURE REQUIREMENTS A number of factors will increase the demands on paediatric intensive care services. These include population growth, surgical initiatives, family expectations and technological advances. Surgical initiatives include those associated in particular with cardiac surgery for congenital heart disease, craniofacial surgery, transplantation and epilepsy surgery. The cohort of children that have had palliative procedures for complex congenital heart disease will require additional surgical procedures. Expanding oncological services also places demands on paediatric ICUs. Changing expectations of parents and caregivers in certain groups of children with chronic disabilities are already impacting on paediatric intensive care services. Particular examples relate to the care of children with end stage neuromuscular diseases and children who are severely intellectually and physically handicapped (AMWAC, 1999). Downward trends for some intensive care services have occurred as a result of immunisation programs, eg. haemophilus immunisation, and safety measures such as car restraints, the use of bicycle helmets and swimming pool fencing. It is anticipated that some of these trends will continue, particularly in the area of immunisation. In terms of service provision, nurse managers highlighted problems associated with the lack of experienced staff in general paediatric wards. This had led to the use of PICU beds for the treatment of patients who would otherwise have been cared for outside of the PICU. It could therefore be expected that demand for PICU beds will continue to rise. Like adult ICU critical care nurse requirements, paediatric critical care nurse requirements will be determined by infrastructure and resourcing. The number of PICU beds available for patient use will provide an indication of the number of critical care nurses required to staff them. 108

126 Similar ratios of RNs to patient are required in PICUs as public level 3 adult ICUs. For this reason, the requirement projections for paediatric critical care nurses will be included with adult critical care nurses. SUPPLY PROJECTIONS Due to the inconsistency of data related to paediatric critical care nurses available in the AIHW nurse labour force surveys, projecting supply is difficult. Although there is a major gap in the data to describe fully the paediatric intensive care nurse workforce, it is clear that the workforce is currently facing a shortage and this is expected to worsen due to the highly specialised nature of the work and the increasing difficulties of recruiting nurses into this area of practice. 109

127 110

128 APPENDICES 111

129 APPENDIX A: GLOSSARY Critical Care: In this report critical care refers to Intensive Care Units (ICUs) and their associated cardiothoracic, coronary care, neurosurgical and high dependency beds. Stand alone coronary care, neurosurgery, high dependency and neonatal intensive care units are not included. However, where they are integrated into the management of the ICU, they have been taken into account. Paediatric intensive care units (PICUs) are examined as a separate entity within this report. Intensive Care: An ICU is defined as a specially staffed and equipped, separate and selfcontained section of a hospital for the management of patients with life-threatening or potentially life-threatening conditions. Such conditions should be compatible with recovery and have the potential for an acceptable future quality of life. An ICU provides special expertise and facilities for the support of vital functions, and utilises the skills of medical, nursing and other staff experienced in the management of these problems (FICANZCA 1997) Available Beds (open): Beds in use or immediately available for use by admitted patients as required. They have advanced life support capability, are fully staffed and funded. Physical Beds: Actual beds which are fully configured to ICU standards. They may or may not be fully staffed. Occupancy Rate: the average overall occupancy of intensive care beds, expressed as a percentage Ventilated Beds: Physical beds plus ventilators Critical Care Nurse: A registered nurse employed to work in critical (intensive) care, with or without a specialist qualification. Post Graduate Qualification: Postgraduate Certificate, Postgraduate Diploma or Masters degree in Critical or Intensive Care Nursing. Qualified Critical Care Nurse: A registered nurse who holds a postgraduate certificate, postgraduate diploma or Masters degree in the area of specialty (ie, critical care). Non Qualified Critical Care Nurse: A registered nurse working in the area of specialty (ie, Critical Care), but does not hold post graduate qualification such as a post graduate certificate, post graduate diploma or Masters degree related to the specialty. Short in house courses do not count as formal qualifications. Attrition: permanent exits from the workforce, not turnover or changing workplace or workforce status (permanent or casual). 112

130 Net Attrition: The decrease in the size of the workforce if those who retire or resign are not replaced. Attrition rate: The rate of attrition, usually expressed as a percentage of the size of the workforce per annum. Full Time Equivalent (FTE): The number of positions if work was carried out by full-time employees (ie 38 hours per week). Headcount: The total number of registered nurses working in ICUs, including full time and part time and casual staff. Vacancy: A position available for a registered nurse in intensive care, which is funded and undergoing active recruitment or for which recruitment action has recently occurred and has been unsuccessful. The difference between funded FTE positions and actual FTE staffing. 113

131 APPENDIX B: RURAL, REMOTE AND METROPOLITAN AREAS CLASSIFICATION The Commonwealth Departments of Health and Aged Care and Primary Industries and Energy, Rural, Remote and Metropolitan Areas classification, has been used to classify the geographic location of the job of responding medical practitioners in the following seven categories. Metropolitan areas: 1. Capital cities consist of the State and Territory capital cities of Sydney, Melbourne, Brisbane, Perth, Adelaide, Hobart, Darwin and Canberra. 2. Other metropolitan centres consist of one or more statistical subdivisions which have an urban centre of population of 100,000 or more in size. These centres are: Newcastle, Wollongong, Queanbeyan (part of Canberra-Queanbeyan), Geelong, Gold Coast-Tweed Heads, Townsville-Thuringowa. Rural zones: 3. Large rural centres are statistical local areas where most of the population reside in urban centres of population of 25,000 to 99,999. These centres are: Albury-Wodonga, Dubbo, Lismore, Orange, Port Macquarie, Tamworth, Wagga Wagga (NSW); Ballarat, Bendigo, Shepparton-Mooroopna (Vic); Bundaberg, Cairns, Mackay, Maroochydore-Mooloolaba, Rockhampton, Toowoomba (Qld), Whyalla (SA); and Launceston (Tas). 4. Small rural centres are statistical local areas in rural zones containing urban centres of population between 10,000 and 24,999. These centres are: Armidale, Ballina, Bathurst, Broken Hill, Casino, Coffs Harbour, Forster-Tuncurry, Goulburn, Grafton, Griffith, Lithgow, Moree Plains, Muswellbrook, Nowra-Bombaderry, Singleton, Taree (NSW); Bairnsdale, Colac, Echuca-Moama, Horsham, Mildura, Moe-Yallourn, Morwell, Ocean Grove-Barwon Heads, Portland, Sale, Traralgon, Wangaratta, Warrnambool (Vic); Caloundra, Gladstone, Gympie, Hervey Bay, Maryborough, Tewantin-Noosa, Warwick (Qld); Mount Gambier, Murray Bridge, Port Augusta, Port Lincoln, Port Pirie (SA); Albany, Bunbury, Geraldton, Mandurah (WA); Burnie-Somerset, Devonport (Tas). 5. Other rural areas are the remaining statistical areas within the rural zone. Examples are Cowra Shire, Temora Shire, Guyra Shire (NSW); Ararat Shire, Cobram Shire (Vic); Cardwell Shire, Whitsunday Shire (Qld); Barossa, Pinnaroo (SA); Moora Shire, York Shire (WA); George Town, Ross (Tas); Coomalie, Litchfield (NT). Remote zones: These are generally less densely populated than rural statistical local areas and hundreds of kilometres from a major urban centre. 6. Remote centres are statistical local areas in the remote zone containing urban centres of population of 5,000 or more. These centres are: Blackwater, Bowen, Emerald, Mareeba, 114

132 Moranbah, Mount Isa, Roma (Qld); Broome, Carnarvon, East Pilbara, Esperance, Kalgoorlie/Boulder, Port Hedland, Karratha (WA); Alice Springs, Katherine (NT). 1. Other remote areas are the remaining areas within the remote zone. Examples are: Balranald, Bourke, Cobar, Lord Howe Island (NSW); French Island, Orbost, Walpeup (Vic); Aurukun, Longreach, Quilpie (Qld); Coober Pedy, Murat Bay, Roxby Downs (SA); Coolgardie, Exmouth, Laverton, Shark Bay (WA); King Island, Strahan (Tas); Daly, Jabiru, Nhulunbuy (NT). 115

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134 APPENDIX C: ANZICS RESEARCH CENTRE FOR CRITICAL CARE RESOURCES SURVEY ANZICS RESEARCH CENTRE FOR CRITICAL CARE RESOURCES CRITICAL CARE RESOURCE SURVEY: FINANCIAL YEAR (1/7/ /6/2000) Please complete all details, place in the pre-stamped / addressed envelope and submit by 30 th March Please refer to enclosed glossary for data definitions. See page 4 for list of abbreviations. Tick one box only unless otherwise specified. Please write clearly. 1. Hospital Name: 2. Number of Acute Hospital Beds: 3. Number of Hospital Separations: (exclude day cases, endoscopies, same day dialysis, chronic/rehabilitation patients) 4. Hospital Type: Public Hospital Private Hospital Other (specify type) 5. ICU Type: General ICU (combined medical/surgical) ICU/CCU (combined intensive care/coronary care) Cardiothoracic ICU Paediatric ICU High Dependency Unit / Step Down / Special Care Unit Other (specify type) 6. Functional ICU Level: Level 3 Level 2 Level 1 (short term ventilation only) High Dependency Unit / Step Down / Special Care Unit (no ventilatory capacity) 7. Does the ICU have: (tick all that apply) JSAC-IC specialist(s) 6 ventilated beds Nurse Unit Manager Nurse Educator Medical Practitioner in unit at all times 350 ventilated patients per annum Nurse with ICU qualification in charge of each shift Active research program 117

135 8. ICU Bed category: (as bed status may vary, state average number of beds) Number of Physical Beds Number of Available Beds Number of Ventilated Beds 9. For Combined ICU/CCU only: Number of protected ICU Beds Number of protected CCU Beds Number of interchangeable ICU/CCU Beds 10. For HDU only: Number of High Dependency Beds managed by ICU Are these HDU beds included in the total number of beds in Q8? Yes No Number of HDU beds interchangeable with ICU beds 11. For General ICU with Cardiothoracic activity only: Number of dedicated cardiothoracic beds within the ICU Are these cardiothoracic beds included in the total number of beds in Q8? Yes No Are the cardiothoracic beds protected or do other ICU patients access them? Protected Access occurs 12. Funding Allocation for Opened/Closed Beds: 1/7/99-30/6/00 Number of additional beds opened: 180 days (6 months) 181 days Number of beds closed: 180 days (6 months) 181 days 13. Admission / Ventilation Data: Number of ICU / HDU admissions (including readmissions) Number of ICU / HDU readmissions (all readmissions including multiple readmissions for same patient) Number of CCU admissions (for combined ICU/CCU) Number of CCU readmissions (all readmissions including multiple readmissions for same patient) Number of ICU Bed Hours +/ or Number of ICU Bed Days Number of Ventilator Hours +/or Number of Ventilator Days 118

136 14. Paediatric Admission Data: Number of admissions < 16 years of age Number of ventilated patients < 16 years of age Number of patients transferred to paediatric ICU Number of deaths < 16 years of age 15. Senior Medical Staff Profile as at 30/6/00: Number of intensive care specialist FTE* Number of intensive care specialists on roster* Number of non-intensive care specialist FTE Number of non-intensive care specialists on roster Number of vacant specialist FTE (position(s) funded but unfilled) 16. Does the ICU director hold an intensive care specialist qualification*? Yes No * (fulfils criteria for JSAC-IC / NZJSAC-ICM specialist recognition) 17. Registrar Profile as at 30/6/00: Number of Registrar FTE in JSAC-IC training positions Number of other Registrar FTE (not in JSAC-IC training positions) 18. Resident / House Officer / Career Medical Officer Staffing as at 30/6/00: Number of FTE 19. Registered Nurse Staffing Profile as at 30/6/00: Number of Registered Nurse FTE (permanent / rostered positions) Average Number of shifts ( 4 hours) per week worked by casually employed Registered Nurses (include nurse bank / pool / agency / non-rostered overtime shifts) Number of permanently employed Registered Nurses with a post-registration critical care qualification Number of rostered hours per week of ICU nurse educator(s) (includes clinical / lectures on site but not at university/other educational facility) Number of post-registration critical care course students Number of vacant Registered Nurse FTE (position(s) funded but unfilled) 119

137 20. Total Number of hours of employment per week for dedicated ICU data collector(s). 21. Severity of Illness Scoring Systems used by the ICU (tick all that apply): APACHE II/III SAPS II MPM PIM PRISM other (please specify) 22. Severity of illness data collection software: AORTIC STATIC Other (please specify) 23. ACHS indicators collected by the ICU (tick all that apply): Contributor to National Database / ANZPIC Yes No Would like to contribute Inability to admit to ICU Pneumothorax following central venous cannulation Inadvertent extubation Readmission to ICU / HDU 48 hours post discharge 24. This survey has been completed by (tick all that apply): ICU Director Medical Staff Nursing Staff Administrative / Clerical Staff Other 25. Contact Details: Name of ICU Director: address: ICU Telephone Number: ICU Fax Number: Thank you for completing the survey - Please return by 30 th March 2001 Please direct any queries to: Therese Anderson Project Officer ANZICS Research Centre for Critical Care Resources 233 Rathdowne Street CARLTON VIC 3053 Tel/Fax: thereseanzics@oz .com.au Abbreviations: ACHS ANZPIC APACHE FICANZCA FTE (EFT) HDU ICU ICU/CCU JSAC-IC / NZJSAC-ICM MPM PIM PRISM RACP SAPS Australian Council on Healthcare Standards Australian and New Zealand Paediatric Intensive Care Registry Acute Physiology and Chronic Health Evaluation Faculty of Intensive Care, Australian and New Zealand College of Anaesthetists Full Time Equivalent High Dependency Unit Intensive Care Unit Combined Intensive Care / Coronary Care Unit Joint Specialist Advisory Committee Intensive Care Mortality Probability Model Paediatric Index of Mortality Paediatric Risk of Mortality Score Royal Australasian College of Physicians Simplified Acute Physiology Score 120

138 APPENDIX D: MINIMUM STANDARDS AND STAFFING GUIDELINES ACCCN: Position Statement on Intensive Care Nursing Staffing (2002) ACHS: Guidelines for Intensive Care Units (1997) JFICM: Minimum Standards for Intensive Care Units (1997) 121

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153 This document is an extract from the Joint Faculty of Intensive Care Medicine policy Document IC-1 Minimum Standards for Intensive Care Units 1997 and is copyright and cannot be reproduced in whole or in part without prior permission. Extract reproduced with permission for distribution with the AHWAC report: Australian Critical Care Nurse Workforce in Australia , November

154 APPENDIX E: 2003 AIHW LABOUR FORCE SURVEY Nursing & Midwifery Labour Force Census 2003 (State) The following information about practising and non-practising nurses and midwives is being collected by the government authority h lthin your State/Territory, with the cooperation of your registration board. The data from all jurisdictions will be collated Australian b th Institute of Health and Welfare (AIHW) into a national data set.the information will be only to compile statistics for the purposes d of d national, state and regional planning. Your cooperation in completing this form will greatly contribute to building an t picture of the nursing profession in your State/Territory, and A t li Queries regarding There this are survey no identifying can be directed features on to this the form, Dept and of Human your confidentiality Services, South is assured. Please return your completed survey form to: The Nurses Board of South Australia PO Box 7176 Hutt Street, ADELAIDE SA 5000 To look at summary statistics from previous Nurse Labour Force Surveys, or to browse through the full range of health statistics held by the AIHW, visit the Institute s Internet Home Page at NOTE: Unless otherwise indicated, when answering the questions, please use a black pen to place a tick in the appropriate boxes or print your answers clearly where written responses are required. 1a. Note: Please answer each part of Are you a Registered nurse? Yes 1 2 No 1b. Are you an Enrolled nurse? Yes No 1 2 1c. Are you authorised by your nurses' board to practise as a Midwife? Yes No 1 2 1d. Are you a Mothercraft nurse? Yes No 1 2 1e. Are you authorised by your nurses' board to practise as a Psychiatric nurse/mental health nurse? Yes No 1 2 1f. Are you authorised by your nurses' board to practise as a Nurse Practitioner? Yes 1 2 No 2. In what year did you first become a registered or enrolled nurse or midwife in Australia? Where did you receive your first nursing qualification? Australia Overseas 1 2 (please specify State) (please specify country) For how many years since you first registered/enrolled have you worked as a nurse or midwife in Australia? ( I.e. the number of years worked, either full-time or part-time, since first regstered or enrolled, less youtime spent not working as a nurse or on unpaid leave. Answer to the nearest ) year Sex Male 1 2 Female 6. Year of birth Are you of Aboriginal or Torres Strait Islander origin? (For persons of both Aboriginal and Torres Strait Islander origin, tick both 'yes' boxes) No Yes, Aboriginal Yes, Torres Strait Islander Are you an Australian citizen? (please tick one box only) Yes, Australian citizen No, Permanent Resident No, Temporary Resident What is the postcode and location of your usual residence? (if in Australia) Location (suburb/town) or country, if overseas Have you completed, or are you currently undertaking, any postregistration/enrolment courses of study relating to nursing or midwifery? No 137

155 10. Have you completed, or are you currently undertaking, any postregistration/enrolment courses of study relating to nursing or midwifery? Please insert code(s) from the following list that best describe any such courses of study you have completed or are currently undertaking. Include hospital-based certificates and tertiary qualifications in nurse management or clinical nursing. Do not include in-service/continuing education sessions, refresher/re-entry courses or courses of less than 6 months duration. Courses completed Courses currently studying No Yes 1 2 Go to question 11 Continue with this question High Dependency 01 Anaesthetic & recovery 02 Cardiac 03 Cardiothoracic 04 Critical care 05 Emergency/Trauma 06 High acuity (ward care) 07 Intensive care 08 Neonatal intensive care 09 Paediatric critical care 10 Perioperative 11 Neuroscience (including spinal injury) Medical/Surgical 12 Acute/clinical care 13 Burns and plastics 14 Gastroenterology 15 Infection control 16 Medical nursing 17 Oncology/palliative care 18 Orthopaedic 19 Renal/nephrology 20 Surgical nursing 21 Wound management Family and Child Health 22 Family, child, & adolescent health 23 Lactation & infant feeding 24 Neonatology/Neonatal 25 Paediatric & child health 26 Parenting education 27 Women s health Midwifery 28 Midwifery 29 Midwifery continuity of care 30 Midwifery practice in riskassociated pregnancies Mental Health 31 Child and adolescent mental health 32 Community psychiatric 33 Mental health/psychiatric nursing practice 34 Rural and remote mental health Indigenous health 35 Indigenous health Community Health 36 Alcohol & other drug studies 37 Asthma education 38 Clinical forensic nursing 39 Community health 40 Correctional nursing 41 Corrections health & forensic nursing 42 Diabetes education and management 43 Health education 44 Health promotion 45 Infertility & associated reproduction 46 Occupational health & safety 47 Public health 48 Rural & remote health 49 School health 50 Sexual health 51 Substance abuse 52 Transcultural nursing Aged care 53 Aged care 54 Continence 55 Gerontology Rehabilitation and Habilitation 56 Developmental disability 57 Other disability 58 Rehabilitation 59 Respiratory Management 60 Applied management 61 Health services management 62 Nursing administration 63 Nursing leadership Education 64 Clinical education 65 Clinical teaching 66 Nurse education Generic and other courses 67 Nurse practitioner 68 Bachelor of Applied Science/ Health Science/ Nursing (Post Registration) 69 Other (please specify) NOTE: For the following questions, employed includes: 1. worked for a total of one hour or more LAST WEEK in a job or business (including own business) for pay, commission, payment in kind or profit; 2. usually work, but away from work on leave (with some pay) for less than 3 months, on strike or locked out, or rostered off. 11. Which of the following best describes your work status LAST WEEK? (Answer questions in box A or box B or box C) A. Employed in nursing/midwifery (includes the practice of nursing/midwifery, or work that is principally concerned with those disciplines, e.g. nursing/midwifery research, nursing/midwifery administration or teaching of nursing/midwifery) : 1 only in ('this' State) Go to question 12 mainly in ('this' State) but also in another State(s) 2 Go to question 12, but answer all further questions only in respect of your work in ('this' State) LAST WEEK only or mainly in another State(s) overseas 3 4 There are no further questions. Thank you very much for your time. Please return this form to the address at the top of the form. B. Employed in nursing/midwifery in ('this' State), but on extended leave for 3 months or more 5 Go to question 12, but answer all further questions only in respect of your usual job(s) in a typical week in ('this State) prior to leave C. Not employed in nursing/midwifery currently not working at all currently working, but not at all in nursing/midwifery 6 7 If you have ever worked as a nurse or midwife, in what year did you last work in nursing or midwifery? Have you taken active steps to look for work in nursing/midwifery? (Active steps include: applying for work in nursing or midwifery, answering an advertisement, enquiring about a job, checking noticeboards, registering with Centrelink or an employment agency, advertising for work or contacting people in the profession about a job) No No, because about to start working in nursing/midwifery Yes, looked for part-time work Yes, looked for full-time work There are no further questions. Thank you very much for your time. Please return this form to the address at the top of this form. 12. Have you returned to work in nursing in the last 12 months, after a period of unpaid absence? 1 Yes (please specify how many months' absence) 2 No 138

156 Please answer the rest of the questions with reference to your nursing/midwifery job last WEEK (or a typical week, if you were on leave, on higher duties or on secondment) in (this state). If you had more than one job last week in the field of nursing/midwifery, please answer for both your main job (in which you worked the most hours) and your 2 nd job (in which you worked the next most hours), where indicated. (Answer to the nearest hour.) 13. What sector were you working in last WEEK? Public Private 14. Was your job Permanent Casual Fixed term or temporary contract Own business or other Main job nd job Were you employed through, or paid by, a nursing agency last WEEK? Yes No Approximately how many hours did you work in your job(s) last WEEK? Main job Paid (regular hours) Paid (overtime hours) Unpaid (extra hours) Total (including paid and unpaid overtime nursing work) nd job Approximately how many hours did you spend last WEEK performing the following core roles? (Include paid and unpaid overtime.) Main job 2nd job 1 Clinical (direct patient care) 2 Clinical management (managing clinical nurses/midwives ) 3 Supervision/support for students or new nurses/midwives Nurse/midwifery administration/management (incl. meetings) 4 Lecturing, Nurse/midwifery education, Clinical 6 Research 7 Other nursing/midwifery activity (please specify activity) Other activity related to nursing/midwifery (please specify activity) Which of the following best describes the classification or level of your job(s) last WEEK? (please tick only one box for each job) Main job Division 2/Enrolled Nurse 01 Division 3 Nurse 02 (Please specify classification) Registered Nurse Grade 1 03 Registered Nurse Grade 2 04 Clinical Nurse Specialist 05 Registered Nurse Grade 3 06 Registered Nurse Grade 4 07 Registered Nurse Grade 5 08 Registered Nurse Grade 6 ( beds) 09 Registered Nurse Grade 6 (400+ beds) 10 Registered Nurse Grade 7 (up to 100 beds) 11 Registered Nurse Grade 7 ( beds) 12 Registered Nurse Grade 7 (501+ beds) 13 Higher Education or TAFE Lecturer 14 Professor/Academic 15 Non-Nursing Award (please specify) Other (please specify) nd job

157 19. Select the category that best describes the principal place where you worked, last WEEK (please tick only one box for each job) Psychiatric hospital Other hospital Mental health facility Day procedure centre Residential aged care service Domicilliary care Hospice Community health centre Multipurpose service Developmental disability service Doctors Rooms/Medical Practice School Tertiary institution (higher education or vocational education & training) Other (please specify) Main job nd job What was the postcode and location (suburb/town) of that place of work? (i.e. the postcode and location (suburb/town) where the premises are located, not the postcode of the P.O. Box.) Main job 2nd job postcode location (suburb/town) 21. Please enter the code from the list below that best describes your principal area of activity in your job(s) last WEEK (please enter one code only for your main job and one code only for your 2nd job, if any) Main job 2nd job (if any) Medical nursing 01 Cardiology 02 Endocrinology 03 Gastroenterology 04 Medical nursing 05 Neurology 06 Oncology/Haemotology 07 Palliative care 08 Renal medicine 09 Respiratory 10 Across all above areas Surgical nursing 11 Burns 12 Cardiothoracics 13 Ear, nose & throat 14 Gastro-intestinal nursing 15 Neurosurgical 16 Opthalmology 17 Orthopaedic 18 Plastics 19 Surgical nursing 20 Urology 21 Vascular 22 Across all above areas Perioperative 23 Anaesthetic 24 Perioperative 25 Recovery 26 Across all above areas Critical care 31 Cardiac/Coronary care 32 Cardiothoracic 33 Critical care 34 Emergency 35 High dependency 36 Intensive care 37 Neonatal intensive care 38 Paediatric critical care 39 Retrieval 40 Across all above areas Midwifery 27 Antenatal 28 Labour 29 Postnatal 30 Across all above areas Family and Child Health nursing 41 Family planning 42 Family, youth and child health 43 Infertility & assisted reproduction 44 Men's health 45 Paediatric and child health 46 School health 47 Women's health 48 Across all above areas Community health nursing 49 Community health 50 Health promotion 51 Indigenous health 52 Medical Practice nurse 53 Public health 54 Sexual health 55 Across all above areas Aged care 56 Aged care 57 Gerontology 58 Across all above areas Mental health nursing 59 Adult mental health 60 Child and adolescent mental health 61 Forensic 62 Psychogeriatric 63 Across all above areas Rehabilitation disability 64 Disability 65 Rehabilitation 66 Across all above areas Other 67 Alcohol & other substance abuse 68 Health education/disease management (eg stomal therapy, diabetes, asthma, continence) 69 Infection control 70 Informatics 71 Management 72 Nurse education 73 Nurse practitioner 74 Occupational Health And Safety 75 Policy 76 Quality management 77 Research 78 Rural and remote health 79 No one area of practice 80 Other (please specify) There are no further questions. Thank you very much for your time. Please return this form to the address at the top of the form. 140

158 APPENDIX F: DATA SOURCES AT THE STATE/TERRITORY LEVEL New South Wales Over recent years, the New South Wales Health Department has focused on the recruitment and retention of the nursing workforce. The main source of data New South Wales uses to describe its workforce is the nursing labour force survey collected with registration renewals via the Nurses Registration Board. New South Wales surveys annually. The Department of Health Reporting System (DOHRS) is used to collect information on nursing positions being actively recruited by Area Health Services and by clinical specialities. It also collects information on use of casual staff (pool and agency) and overtime, as well as part-time and full time positions. This information is collated monthly and is therefore useful data. The management of the health system in terms of service provision and staffing, is generally decentralised into local area health services. These health services have their own payroll and staff reporting systems. The New South Wales Nursing Workforce Research Project (NSW Health, 2000) focussed non-working nurses who were registered or enrolled at the time. It aimed to identify a range of incentives or conditions required to encourage the study population back into the workforce. In terms of specific workforce projects for critical care nurses, the Government Action Plan for Health Intensive Care Implementation Group Intensive Care Nursing Workforce Report is currently in draft form. It is unclear what data is being used to describe the work force. The Government Action Plan for Health has recently released its Intensive Care Service Plan Adult Services (2001). This provides useful projections for future ICU bed requirements. However, bed spaces rather than number of ventilated and non-ventilated beds have been projected. In response to the AHWAC request for data, the New South Wales Health Department provided data from the 1998 and 1999 nurse labour force survey. This was supplemented by information collected by DOHRS. Victoria As with most other jurisdictions, Victoria collects labour force data annually, in December, using the nurse labour force survey sent with the registration renewals. It has been stated that the Victorian Department of Human Services does not hold consistent data on the number of nurses working in the public system. It cannot establish the number of part time workers, number of casual or agency nursing staff with confidence. Nor can it confidently predict the number of nurses actually required in the public sector (Human Services, 2001). 141

159 The payroll systems vary from hospital to hospital, however, almost all Victorian public hospitals use one of three payroll systems. Each ICU has its own method of staff management (spreadsheets, rostering systems). A number of workforce studies have been commissioned over the last 5 years. The latest workforce study (Department of Human Services, 1999) projected for the period It found that Victoria would be facing a nursing shortage of up to 5,500 by However the shortage projected does not differentiate between nursing specialty, grade, experience, distribution or division. In 2000, the Victorian State Government commissioned a review to examine an appropriate response to the nursing shortage. The Nurse Recruitment and Retention Committee (NRRC) Final Report (May 2001) was a product of the review and made many recommendations to address the issues identified. The subsequent Nurse Recruitment and Retention Committee Government Response (June 2001) outlined the strategies to be adopted by the Victorian state government in response to the findings of the NRRC. In 2002, a report entitled Nurse Workforce Planning commissioned by the Victorian Auditor General was produced (Auditor General Victoria, 2002). The objective of the report was to determine whether effective and efficient arrangements were in place for planning and manageing the supply of and demand for qualified nurses in Victoria. It found that the Nurse Recruitment and Retention Strategy had the desired effect of increasing the number of nursing staff within public hospitals and in hard to fill specialities. However, initiatives such as refresher and re-entry programs will have reducing effects over time. It also revealed an ageing workforce with a significant proportion of nurses over 40 years. At the same time the total number of entrants to nursing places at university has reduced marginally over recent years. Much of the report relates to the lack of reliable and up to date data on the nurse workforce. Its recommendations regarding data include a review of hospital payroll systems in terms of their capacity to meet workforce planning requirements, and Victoria retaining the option of publishing Victorian results of the nurse labour force surveys as soon as they are available if publication of AIHW data continues to be delayed. It also recommends the Department of Human Services work with non-public sector employers for comprehensive workforce data. It recommends that data related to the nursing workforce should include the capacity for analysing trends over time, including the destination of graduates. Of particular interest to the Working Party, the report also details information not reported elsewhere, such as proportion of nursing graduates who enter nursing. It also provides some useful recommendations in terms of workforce data requirements for planning. In relation to the critical care nurse workforce and critical care services, two reports were identified. Firstly, a qualitative study was commissioned in 1996 (Ogle & Ferguson, 1996) examining the critical care nurse labour force. It explored issues of attraction and attrition of critical care nurses. Secondly and more recently, a report commissioned by the Victorian Department of Human Services Planning for Intensive Care Services in Victoria (MA International Pty Ltd, 2001) was released. It provides a comprehensive review of intensive care services as well as projection for intensive care services in the future. Part of the report addressed the intensive care nurse workforce. Most of the information on the intensive care workforce is derived from AIHW data as well as direct surveys of the Victorian ICUs. It is not clear from the report what the response rate to the survey was. The report gives useful projections for future bed requirements, however, these are not disaggregated into ventilated and non-ventilated beds. 142

160 Recent measures to improve the collection of data related to and monitoring of the nursing workforce include: daily tracking of agency and nurse back utilisation in al metropolitan and 3 of the largest non-metropolitan health services; the piloting of a new Nurse Workforce Minimum Data Set; investigation of new patient dependency systems for trial in 20 public hospitals; and the implementation of all recommendations of the Victorian Auditor General s audit on nurse workforce planning. In response to the AHWAC request, Victoria used information collected from its 2001 labour force survey and supplemented this with snapshot survey data on use of casual staff. Queensland Queensland surveys its nursing labour force annually via nurses registration survey. Queensland has a statewide payroll system used to collect data from each public health facility (Staff Profile information System: SPIS). The employee details available on the system which may be used for workforce planning purposes are: Demographic information such as gender, date of birth; Facility at which employee works; Date commenced; Employment category (permanent, casual, temporary); Employment basis (full time, part time); Job code, classification and level; Service type; Full time equivalent (FTE); Employment status; Over time worked; Extended family leave; and Termination date and reason. Although Queensland has the above system in place, in response to the AHWAC request, information was produced by directly surveying the public hospital intensive care units. However, at a later date, Queensland Health provided data to AHWAC on turnover rates using the above system. South Australia South Australia has a centralised system called the Monthly Management Summary System (MMSS). Each public health unit submits monthly returns to the Department on workforce, expenditure and activity relating to their unit. Using the MMSS system, South Australia is able to provide regular nurse labour force bulletins. The bulletins compare the actual supply of nurses with forecasted numbers and monitors factors considered important in determining future nursing demand. The information in the bulletins relate only to nurses in the public sector. In 1997, the pre-registration student nurse intake requirements were projected. The estimation for the report was based upon the health system requirements, net RN attrition, changes in the FTE of the nursing workforce and the student nurse attrition rate. South Australia has also produced reports related to specialty nurses such as midwives and critical care nurses. For example, the report of critical care student intake requirements

161 2004 collected information by surveying each provider of critical care courses and each critical care unit in the state. In 2000, South Australia produced a report entitled the Characteristics of the Specialist Nurse Workforces South Australia, It was produced using the information from the 1997/98 labour force surveys attached to the registration renewal notices. South Australia has recently conducted a clinical services review of intensive care services, however has not released the report publicly. In response to the AHWAC request for data, South Australia used data gathered by direct phone survey from each ICU (both private and public) and supplemented this by the use of information from the 1998 data used in the report of the Specialist Nurse Workforce. It was not able to provide information on use of casual staff or the number of overseas RNs entering the intensive care workforce. Western Australia The health system in Western Australia is also decentralised. Information other than that from the nursing labour force surveys must be gathered directly from the services in question. However, since December 2001, a process of developing a single health service has been progressed and this will result in centralised processes. A review of intensive care beds is currently underway. In response to the AHWAC request for data, the health department of Western Australia directly surveyed both private and public hospital ICUs. Tasmania The Nurse Labour Force Survey has been the principal means of gathering nurse workforce data in Tasmania. Tasmania has a centralised health service with central labour force statistics. However, it does not collect information on the different specialties as yet. The Final report of the Tasmanian Nurse Workforce Planning Project was completed in November The data to inform the project was collected by the Nurse Labour Force Survey attached to the year 2000 practicing certificate renewals. In 2001, the Tasmanian health department reviewed its critical care nursing services and was therefore able to provide information to AHWAC that was collected directly from hospitals for the review. Northern Territory The Territory Health Service (THS) has established a database for workforce planning purposes. It has approximately 18 months worth of data. The database has the capacity to examine the composition, structure and service settings of the current THS workforce. However, there are some gaps in the information it can provide, eg. qualifications of nursing staff. The THS has also commenced a nursing workforce supply model. Therefore, in terms of collecting data regarding the critical care workforce, it should be straight forward in terms of numbers of RNs working in critical care, however, whether or not they are qualified is not as easily determined. Also, as there are only two hospitals providing 144

162 intensive care services in the Northern Territory, accessing data related to the critical care workforce is not difficult. The Northern Territory has a rostering system (ONESTAFF) rosters and provides information on the nursing workforce. It is in all the hospitals and some other nursing work units. It interfaces with a payroll system. The THS have released 2 relevant reports on the nursing workforce in general: the Nursing Recruitment and Retention Taskforce (Jan 2001) and Benchmarking of the Territory Nursing Workforce (December 2000). The information provided to AHWAC from the THS was collected by surveying the units directly. Australian Capital Territory The Australian Capital Territory currently relies primarily on the labour force surveys collected by the Nursing Registration Board on a biennial basis. However, in terms of measuring the current critical care nurse workforce, the small number of hospitals providing intensive care services make it relatively easy to access data. In response to the AHWAC request, data was provided by directly surveying the public hospitals in the Australian Capital Territory. 145

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164 APPENDIX G: WILLIAMS AND CLARKE METHODOLOGY The Williams and Clarke (2001) methodology can determine: RN FTE and head count requirements for intensive care beds (ventilated and non ventilated) The support RN FTE and head count requirements for intensive care beds The required head count for qualified ICU RNs The required head count of newly qualified RNs each year to meet current standards These requirements are determined for each State and Territory, for public hospitals and private hospitals separately and for public and private hospitals combined. The following variables can be changed to provide different scenarios: Number and type of ICU beds RN FTE: ICU bed ratio Qualified RN ratios Ratio of educators: RN head count Ratio of NUM: ICU bed Attrition rates For example, a scenario of increased number of ventilated beds, an increased attrition rate and a decrease in average hours worked/week would show an increased requirement for newly qualified RNs. A scenario with a decreased ratio of RN FTE: bed and decreased attrition rate and increase in hours worked, would show a decreased requirement for newly qualified RNs. However, if it is projected that ratios, average hours worked/week and attrition rates are changing, then these also need to be adjusted in the model. The following is a description of the methodology used by Williams and Clarke to determine critical care nurse requirements for ICUs in Australia. 147

165 A consensus driven method to measure the required number of critical care nurses (Williams and Clarke, 2001) ICUs require nursing staff at constant levels 24 hours per day, 7 days per week. To determine the number of RNs required to staff ICU beds and HDU beds in ICU, the following assumptions and calculations were used: 1. An ICU bed (ventilated) requires a nurse to patient ratio of 1:1 (FICANZCA) 2. A high dependency bed (in ICU) requires at least a 1:2 ratio of nurse to patient ratio (FICANZCA) 3. The ratio of access* nurse to patient for national measurement is 1:5 (consensus) 4. A full nursing day adds up to a 26 hour day (to allow for handover periods/shift changes) 5. Industrial award leave entitlements require staff replacement of 1:6; one nurse on leave for every six currently working (for every 6 FTE positions, an extra 1 FTE is required to cover leave entitlements) 6. A FTE RN works 38 hours per week RN FTE per Intensive care bed: 1 nurse/bed x 26 hours x 7 days = 182 ICU nurse hours/week 0.2 access nurse/bed x 26 hours x 7 days = 36.4 ICU nurse hours/week therefore: hours = hours Award 1:6 staff = 36.4 hours Required nurse hours: = 255 hours per ICU bed/week = 6.7 FTE/ICU bed Step Down (high dependency) patient beds are non ventilated beds in ICU for critically ill patients. Because they are not ventilated, they may not require one on one nursing care at all times, but may require this level of care if particularly unstable. For calculation purposes, a nurse to patient ratio is 1:2 has been used. Because of the potential for instability, the ratio of access nurse to patient is the same for high dependency patients as for ventilated patients.: RN FTE/ step down bed: 0.5 nurse/bed x 26 hours x 7 days = 91 ICU nurse hours/week 0.2 Access nurse/bed x 26 hours x 7 days = 36.4 ICU nurse hours/week therefore: hours = 127 hours Award 1:6 staff = 21 hours Required nurse hours: = 148 hours per ICU bed/week = 3.89 FTE/step down To determine the number of nurse managers and educators required, the following calculations were used: 1. A single nurse unit manager is required per ICU (minimum standard: FICANZCA) 2. At least one clinical nurse educator (for clinical, unit based education) is required in each ICU (minimum standard: FICANZCA), with a ratio of no more than 1:50 (consensus, ACCCN recommendation) To determine the total number of RNs required to work in intensive care the following calculations were used; 1. The average hours worked per week (AIHW) x RN FTE 2. One nurse unit manager x number of ICUs (minimum standard: FICANZCA) 3. Clinical nurse educators x 1:50 nurses (ACCCN recommendation) 148

166 To determine the number of qualified and unqualified ICU nurses required to staff ICU beds the following assumptions were used: 1. 75% for optimal proportion of qualified staff (consensus and ACCCN recommendation) 2. 50% for minimum proportion of qualified staff (minimum standard: FICANZCA) To determine the required replacement factor for ICU RNs per year the following assumption was made by panel consensus: 1. The average time spent by a nurse working in intensive care is 5 years i.e. 20% attrition rate per year. Use of Williams and Clarke in this report The Williams and Clarke methodology was used to determine the required critical care nurse workforce according to underlying intensive care services available. The Working Party agreed to base planning on a ratio of 6.5 to an intensive care bed and 3.7 to a high dependency bed (assuming at least 50% of the critical care nurse workforce is qualified). As there was no information available describing accurately high dependency beds available for use in intensive care, the proportion of non- ventilated beds were used as a proxy measurement. A required FTE per ICU level was estimated for each Jurisdiction and for private and public sector beds, using the appropriate proportion of ventilated and nonventilated beds in each (supplied by ANZICS). The overall requirement for the private sector was reduced by 25% to allow for lower occupancy rates than those in the public sector. The FTE determined by the above method was then converted to a headcount requirement, using the average hours worked per week (supplied by AIHW). This gave a required number of bedside critical care nurses. Additional headcount requirements were determined for educators and nurse unit managers. Educators were determined by applying a ratio of 1:50 critical care nurses, and unit managers were determined by applying one for every intensive care unit. A total headcount requirement was then determined. The adequacy of the actual workforce was then determined by comparing the AIHW headcount with the headcount requirement. The following spreadsheets detail the workings for the requirements for each jurisdiction. 149

167 Australian Capital Territory: Determining current critical care nurse requirements ACT Level 1 Level 2 Level 3 Total public hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) public bedside RNs (including ACCESS) RN FTE: ICU bed = 6.5: RN FTE: HD bed = 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total bedside@ 85% occupancy private hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) private bedside RNs (including ACCESS) RN FTE: ICU bed= 6.5: RN FTE: HDU bed= 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total 85% occupancy(avail beds) RN FTE total 75% Occupancy (avail beds) RN FTE total 60 % occupancy (avail beds) public and private RN FTE total required public & private RN FTE total 85% occupancy public& private RN FTE total 75% occ private public and private RN FTE total head count RN bedside head count (public&private) based on 30.6 hrs per week RN bedside head count (public&private@75%) hrs per week 1:50 head count (100% occupancy) 1:50 head count (75% priv.occupancy) 1:unit 4 1:12 beds 2.75 total RN headcount (bedside,educators, NUMs)100% occupancy total RN headcount (bedside,educators, NUMs)75% private occupancy AIHW head count with no educators 208 educators 7 AIHW 1999 total headcount 215 Oversupply 5 150

168 New South Wales: Determining current critical care nurse requirements NSW Level 1 Level 2 Level 3 Total public hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) public bedside RNs (including access) RN FTE: ICU bed = 6.5: RN FTE: HD bed = 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total bedside@ 85% occupancy private hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) private bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HDU bed= 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total 85% occupancy(avail beds) RN FTE total 75% Occupancy (avail beds) RN FTE total 60 % occupancy (avail beds) public and private RN FTE total required public & private RN FTE total 85% occupancy public& private RN FTE total 75% occ private public and private RN FTE total head count RN bedside head count (public&private) based on hrs per week RN bedside head count (public&private) 32.9 hrs per 75% occupacy private 1:50 head count :50 head count (75% occupancy private) 1:unit 61 1:12 beds 47.5 total RN headcount including bedside and support total RN headcount (bedside,educators, NUMs)75% private occupancy AIHW head count with no educators 3637 Educators 57 AIHW 1999 total headcount 3694 Oversupply

169 Victoria: Determining current critical care nurse requirements Victoria Level 1 Level 2 Level 3 Total public hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) public bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HD bed = 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total bedside@ 85% occupancy private hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) private bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HDU bed= 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total 85% occupancy(avail beds) RN FTE total 75% Occupancy (avail beds) RN FTE total 60 % occupancy (avail beds) public and private RN FTE total required public & private RN FTE total 85% occupancy public& private RN FTE total 75% occ private public and private RN FTE total head count RN bedside head count (public&private 100%) 31.1 hrs per week RN bedside head count 31.1 hrs per week 1:50 head count (100% ocupancy) :50 head count (75% ocupancy private) :unit 34 1:12 available beds 28 1:12 phsyical beds total RN headcount (bedside,educators, NUMs)100% occupancy total RN headcount (bedside,educators, NUMs)75% private occupancy AIHW 1999 headcount with no educators 2224 Educators 38 AIHW clinical and educators 2262 Undersupply

170 Queensland: Determining current critical care nurse requirements Queensland Level 1 Level 2 Level 3 Total public hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) public bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HD bed = 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total bedside@ 85% occupancy private hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) private bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HDU bed= 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total 85% occupancy(avail beds) RN FTE total 75% Occupancy (avail beds) RN FTE total 60 % occupancy (avail beds) public and private RN FTE total required public & private RN FTE total 85% occupancy public& private RN FTE total 75% occ private public and private RN FTE total head count RN bedside head count (public&private 100%) hrs per week RN bedside head count hrs per week 1:50 head count (100% ocupancy) :50 head count (75% ocupancy private) 1:unit 33 1:12 available beds 26 1:12 phsyical beds total RN headcount (bedside,educators, NUMs)100% occupancy total RN headcount (bedside,educators, NUMs)75% private occupancy AIHW 1999 headcount with no educators 1578 educators 43 AIHW clinical and educators 1621 Undersupply

171 South Australia: Determining current critical care nurse requirements South Australia level 1 level 2 level 3 total public hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) public bedside RNs (including access) RN FTE: ICU bed = 6.5: RN FTE: HD bed = 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total bedside@ 85% occupancy private hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) private bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HDU bed= 3.7: RN FTE total bedside Av RN FTE per bed by level #DIV/0! RN FTE total 85% occupancy(avail beds) RN FTE total 75% Occupancy (avail beds) RN FTE total 60 % occupancy (avail beds) public and private RN FTE total required public & private RN FTE total 85% occupancy public& private RN FTE total 75% occ private public and private RN FTE total head count RN bedside head count (public&private) based on 26.2 hrs per week RN bedside head count (public&private@75%) 26.2 hrs per week :50 head count (100% occupancy) :50 head count (75% priv.occupancy) :unit 14 1:12 beds total RN headcount (bedside,educators, NUMs)100% occupancy 1286 total RN headcount (bedside,educators, NUMs)75% private occupancy total RN headcount:bedside and support (NUM 1:12 available beds) total RN headcount: bedside and support (NUM 1:12 physical beds) 1999 AIHW head count with no educators 859 educators 14 AIHW 1999 total headcount 873 shortage

172 Western Australia: Determining current critical care nurse requirements Western Australia Level 1 Level 2 Level 3 Total public hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) public bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HD bed = 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total bedside@ 85% occupancy private hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) private bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HDU bed= 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total 85% occupancy(avail beds) RN FTE total 75% Occupancy (avail beds) RN FTE total 60 % occupancy (avail beds) public and private RN FTE total required public & private RN FTE total 85% occupancy public& private RN FTE total 75% occ private public and private RN FTE total head count RN bedside head count (public&private 100%) hrs per week RN bedside head count (public&private hrs per week 1:50 head count (100% ocupancy) :50 head count (75% ocupancy private) 1:unit 10 1:12 available beds 9 1:12 phsyical beds total RN headcount (bedside,educators, NUMs)100% occupancy total RN headcount (bedside,educators, NUMs)75% private occupancy AIHW 1999 headcount with no educators 831 educators 30 AIHW clinical and educators 861 Undersupply 6 155

173 Tasmania: Determining current critical care nurse requirements Tasmania Level 1 Level 2 Level 3 Total public hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) public bedside RNs (including access) RN FTE: ICU bed = 6.5: RN FTE: HD bed = 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total bedside@ 85% occupancy private hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) private bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HDU bed= 3.7: RN FTE total bedside Av RN FTE per bed by level RN FTE total 85% occupancy(avail beds) RN FTE total 75% Occupancy (avail beds) RN FTE total 60 % occupancy (avail beds) public and private RN FTE total required public & private RN FTE total 85% occupancy public& private RN FTE total 75% occ private public and private RN FTE total 60% occ private public & private RN FTE total 85% public, % priv public and private RN FTE total head count RN bedside head count (public&private) 30.7 hrs per week RN bedside head count (public&private) 30.7 hrs per % occupacy private RN bedside headcount(pub&private) 30.7 hrs per % occupancy private RN bedside headcount (pub 85%, priv 60%) 30.7 hrs per week RN bedside headcount(pub&priv 85%) 30.7 hrs per week 1:50 head count :50 head private occupancy % 1:unit 5 1:12 beds total RN headcount(bedside, educators, NUMs) 100% occup total RN headcount (bedside,educators, NUMs)75% private occupancy total RN headcount (bedside, educators, NUMs) 85% pub and priv total RN headcount including bedside and support (NUM 1:12 beds) Tasmanian survey headcount (2001) 224 Undersupply

174 Northern Territory: Determining current critical care nurse requirements Northern Territory Level 1 Level 2 Level 3 total public hospital ICUs Physical beds av ventilated (physical) av non ventilated (physical) Available beds av ventilated (avail) av non ventilated (avail) public bedside RNs (including access) RN FTE: ICU bed = 6.5:1 (physical beds) RN FTE: HD bed = 3.7: RN FTE total bedside (physical beds) Av RN FTE per physical bed by level RN FTE: ICU bed = 6.5: RN FTE: HD bed = 3.7: RN FTE total bedside (available beds) Av RN FTE per available bed by level RN FTE total bedside@ 85% occupancy private hospital ICUs Physical beds Available beds av ventilated (avail) av non ventilated (avail) private bedside RNs (including access) RN FTE: ICU bed= 6.5: RN FTE: HDU bed= 3.7: RN FTE total bedside Av RN FTE per bed by level public and private RN FTE total required (available beds) public and private RN FTE total required (physical beds) public and private RN FTE total headcount (bedside) RN bedside 35.9 hrs/week (physical beds) RN bedside head count@ 35.9 hrs per week (avail beds) :50 head count per unit 2 1:unit 2 1:12 beds total RN headcount (avail beds) 77 total RN headcount (physical beds) AIHW head count with no educators 91 Educators (AIHW) 8 AIHW 1999 total headcount

175 158

176 APPENDIX H: VAN KONKELENBERG MODEL The Projection Model A computer simulation calculation tool (based in Microsoft Excel) was developed in 1995 by Dr Ron Van Konkelenberg from the consulting firm Fresbout Consulting Pty Ltd. It models the workforce and projects supply and requirements forward for up to a 12 year period, on the basis of five year age/gender cohorts. The model defines current requirements as the baseline workforce plus any existing shortages/oversupply, measured in hours worked per week. Future requirements are determined by applying a compound growth factor to the baseline requirements. Baseline supply (i.e., the current workforce) is input into the model in five-year age/gender cohorts which incorporate workforce participation in terms of hours worked per week, entry and loss (attrition) rates. Future supply is estimated by ageing the cohorts, adding gender and cohort specific entrants, and then subtracting losses from the workforce. Losses are permanent exits from the workforce. The modelling process uses head counts and conversions to full time equivalents and hours worked for measuring supply and requirements. Using hours worked (broken down by five year age/gender cohorts) to measure supply and requirements, allows the model to take into account variations in working patterns and entry and loss rates among different age/gender groups. The model assumes that the behavioural pattern of the current workforce, including hours worked and entry and loss rate by age/gender cohort, remains the same throughout the projection period. For example, if those in the lower age groups work, on average, more hours per week than those in the higher age groups, this would be retained in the projection. In addition, the age/gender specific loss rates (attrition rates) remain the same throughout the projection period. However, the total losses in each age cohort in the workforce will vary because the workforce ages throughout the projection period. Thus, while the loss rates for each age cohort remains constant, the total number leaving the workforce can also vary. For example, if it is assumed that the majority of losses are in the higher age groups, and the ageing process and entry of students is not sufficient for replacement, the total losses will decrease and the workforce becomes younger. The impact of this is most prominent in the first year of the critical care projections because the loss rate for the older age-groups is assumed to be very high. The growth in those age-groups is only a small proportion of the previous age cohort and there is no intake new entrants in these age-groups. After the first year the total number in the age cohort has dropped significantly and the losses for the cohort and in total is smoothed out. 159

177 160

178 APPENDIX I: NURSE EDUCATION (FRAMEWORK AND ARTICULATION) Overview of models of education and training related to nursing and midwifery and the Australian Qualifications Framework Australian Qualifications Framework Title Models of Education and Training Doctorate Doctor of Philosophy/Professional Doctorate Doctor of Philosophy Doctor of Nursing Research Postgraduate Masters Diploma Certificate Registered Midwife (on completion of Diploma or Masters) Masters by research or course work Courses embedded - Cert/Diploma/Masters with exit points at each level if desired Free standing courses at each level Bachelor Registered Nurse / Division 1 Nurse Registered Midwife (programme to begin in 2002 Double Degrees Six semesters courses (2-3 years) Eight semester courses (with or without Honours) Graduate entry programmes Enrolled Nurse entry programmes One year entry for registered hospital trained nurses with lapsed registration Hospital trained(1 year) Diploma upgrade (1 semester) Diploma Enrolled Nurses (Queensland) Level V Certificate (Advanced Certificate) Enrolled Nurse (Advance Certificate) Level IV Certificate Enrolled Nurse/Division 2 Nurse Employment contact with TAFE course (eg NSW traineeship) VET course with clinical placement (TAFE or private provider) Level III Certificate Health Care worker Assistant in nursing Personal care worker Aged carers Disability carers New Apprenticeship - on and off job training Traineeships for school students Traineeships post-school On Job training Course with clinical placement (full or part time Source: National Review of Nursing Education Discussion Paper (2001). 161

179 Articulation pathways for those involved in nursing work Source: National Review of Nursing Education Discussion Paper (2001). 162

180 APPENDIX J: PROJECTIONS: NEW SOUTH WALES/AUSTRALIAN CAPITAL TERRITORY Notes For Reading Spreadsheets Based On The Van Konkelenberg Method (Method 1) 1. Attrition Rate is the percentage of the total exiting the workforce in the base year. The attrition rate within each age/gender cohort is assumed to be constant throughout the projections period. 2. Hours worked per week by age/gender cohort are assumed to be constant throughout the projection period (i.e., based on 1999 AIHW data on average number of hours worked per week by critical care nurses within the State/Territory) 3. Growth in requirements is assumed to be either 0% or to be equivalent to the projected growth in population plus the impact of ageing of the population during the projection period (source: ABS) 4. Balancing the workforce shows the estimated number of new entrants required to ensure a balanced workforce by 2005, and to maintain a balance from 2005 onwards. 5. Entrants are the assumed number of new entrants to the workforce (as required for balance). 6. Workforce is the number of critical care nurses (supply); requirements are the estimated number of critical care nurses required; and difference is the difference between supply and requirements. The base-year supply (2001) is based on 1999 AIHW data (with the exception of Tasmania, where 2001 data as provided by DHHS, Tasmania was used). Base-year requirements are the recommended headcount as determined using the Williams and Clarke methodology. For New South Wales/Australian Capital Territory where an initial surplus was estimated, for projection purposes, a balanced workforce was assumed in the base-year. 7. Workforce % under/over indicates the balance between projected supply and requirements (as measured in total headcount) where a negative (-) percentage indicates supply exceeds requirements (oversupply) and a positive (+) percentage indicates requirements exceed supply (undersupply). 8. FTE figures are calculated based on a 38 hour work week. The headcounts are translated into FTE numbers by multiplying the projected headcount by the average hours worked per week in New South Wales and ACT (32.7 hours, source: AIHW) and dividing by 38 hours (assumed to be an FTE). 163

181 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce NSW + ACT 1 15% constant 0% entrants workforce 6 3,909 3,763 3,759 3,786 3,846 3,925 3,915 3,914 3,919 3,927 3,936 requirements 6 3,909 3,909 3,909 3,909 3,909 3,909 3,909 3,909 3,909 3,909 3,909 difference % under/over % constant 1.11% (pop'n+ageing) entrants workforce 6 3,909 3,815 3,861 3,935 4,039 4,159 4,201 4,248 4,298 4,347 4,393 requirements 6 3,909 3,952 3,996 4,041 4,086 4,131 4,177 4,224 4,271 4,319 4,367 difference % under/over % constant 0% entrants workforce 6 3,909 3,842 3,851 3,862 3,885 3,917 3,912 3,913 3,917 3,925 3,934 requirements 6 3,909 3,909 3,909 3,909 3,909 3,909 3,909 3,909 3,909 3,909 3,909 difference % under/over % constant 1.11% (pop'n+ageing) entrants workforce 6 3,909 3,891 3,947 4,003 4,070 4,143 4,188 4,236 4,285 4,334 4,383 requirements 6 3,909 3,952 3,996 4,041 4,086 4,131 4,177 4,224 4,271 4,319 4,367 difference % under/over

182 Projected Critical Care Nursing Workforce Supply and Requirements, (FTE) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce NSW + ACT 1 15% constant 0% entrants workforce 6 3,364 3,238 3,235 3,258 3,309 3,377 3,369 3,368 3,372 3,379 3,387 requirements 6 3,364 3,364 3,364 3,364 3,364 3,364 3,364 3,364 3,364 3,364 3,364 difference % under/over % constant 1.11% (pop'n+ageing) entrants workforce 6 3,364 3,283 3,322 3,386 3,476 3,579 3,615 3,656 3,699 3,741 3,780 requirements 6 3,364 3,401 3,439 3,477 3,516 3,555 3,595 3,635 3,675 3,716 3,758 difference % under/over % constant 0% entrants workforce 6 3,364 3,306 3,314 3,323 3,344 3,371 3,366 3,367 3,371 3,377 3,385 requirements 6 3,364 3,364 3,364 3,364 3,364 3,364 3,364 3,364 3,364 3,364 3,364 difference % under/over % constant 1.11% (pop'n+ageing) entrants workforce 6 3,364 3,348 3,396 3,445 3,502 3,565 3,604 3,645 3,687 3,730 3,772 requirements 6 3,364 3,401 3,439 3,477 3,516 3,555 3,595 3,635 3,675 3,716 3,758 difference % under/over

183 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount+FTE) [ Method #2: Williams and Clarke] NSW/ACT 15% attrition available beds:public available beds:all growth rate headcount av hrs/week FTE % attrition, growth % attrition growth rate headcount av hrs/week FTE % attrition, growth % attrition growth rate headcount av hrs/week FTE % attrition, no growth % attrition growth rate headcount av hrs/week FTE % attrition, no growth

184 APPENDIX K: PROJECTIONS: VICTORIA Notes For Reading Spreadsheets Based On The Van Konkelenberg Method (Method 1) 1. Attrition Rate is the percentage of the total exiting the workforce in the base year. The attrition rate within each age/gender cohort is assumed to be constant throughout the projections period. 2. Hours worked per week by age/gender cohort are assumed to be constant throughout the projection period (i.e., based on 1999 AIHW data on average number of hours worked per week by critical care nurses within the State/Territory) 3. Growth in requirements is assumed to be either 0% or to be equivalent to the projected growth in population plus the impact of ageing of the population during the projection period (source: ABS) 4. Balancing the workforce shows the estimated number of new entrants required to ensure a balanced workforce by 2005, and to maintain a balance from 2005 onwards. 5. Entrants are the assumed number of new entrants to the workforce (as required for balance). 6. Workforce is the number of critical care nurses (supply); requirements are the estimated number of critical care nurses required; and difference is the difference between supply and requirements. The base-year supply (2001) is based on 1999 AIHW data (with the exception of Tasmania, where 2001 data as provided by DHHS, Tasmania was used). Base-year requirements are the recommended headcount as determined using the Williams and Clarke methodology. 7. Workforce % under/over indicates the balance between projected supply and requirements (as measured in total headcount) where a negative (-) percentage indicates supply exceeds requirements (oversupply) and a positive (+) percentage indicates requirements exceed supply (undersupply). 8. FTE figures are calculated based on a 38 hour work week. The headcounts are translated into FTE numbers by multiplying the projected headcount by the average hours worked per week in Victoria (31 hours, source: AIHW) and dividing by 38 hours (assumed to be an FTE). 167

185 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce Vic 1 15% constant 0% entrants workforce 6 2,262 2,182 2,187 2,212 2,254 2,306 2,297 2,294 2,293 2,295 2,297 requirements 6 2,295 2,294 2,294 2,294 2,294 2,294 2,294 2,294 2,294 2,294 2,294 difference % under/over % constant 0.96% (pop'n+ageing) entrants workforce 6 2,262 2,218 2,257 2,313 2,386 2,416 2,451 2,490 2,508 2,527 2,545 requirements 6 2,295 2,316 2,338 2,361 2,383 2,406 2,429 2,452 2,476 2,499 2,523 difference % under/over % constant 0% entrants workforce 6 2,262 2,237 2,252 2,270 2,294 2,303 2,299 2,298 2,300 2,303 2,306 requirements 6 2,295 2,294 2,294 2,294 2,294 2,294 2,294 2,294 2,294 2,294 2,294 difference % under/over % constant 0.96% (pop'n+ageing) entrants workforce 6 2,262 2,257 2,292 2,329 2,371 2,417 2,440 2,464 2,488 2,513 2,537 requirements 6 2,295 2,316 2,338 2,361 2,383 2,406 2,429 2,452 2,476 2,499 2,523 difference % under/over

186 Projected Critical Care Nursing Workforce Supply and Requirements, (FTE) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce Vic 1 15% constant 0% entrants workforce 6 1,845 1,780 1,784 1,804 1,839 1,881 1,874 1,871 1,871 1,872 1,874 requirements 6 1,872 1,871 1,871 1,871 1,871 1,871 1,871 1,871 1,871 1,871 1,871 difference % under/over % constant 0.96% (pop'n+ageing) entrants workforce 6 1,845 1,809 1,841 1,887 1,947 1,971 2,000 2,031 2,046 2,061 2,076 requirements 6 1,872 1,889 1,907 1,926 1,944 1,963 1,982 2,001 2,020 2,039 2,059 difference % under/over % constant 0% entrants workforce 6 1,845 1,825 1,837 1,852 1,872 1,879 1,876 1,875 1,876 1,878 1,882 requirements 6 1,872 1,871 1,871 1,871 1,871 1,871 1,871 1,871 1,871 1,871 1,871 difference % under/over % constant 0.96% (pop'n+ageing) entrants workforce 6 1,845 1,841 1,870 1,900 1,935 1,972 1,990 2,010 2,030 2,050 2,070 requirements 6 1,872 1,889 1,907 1,926 1,944 1,963 1,982 2,001 2,020 2,039 2,059 difference % under/over

187 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount+FTE) [ Method #2: Williams and Clarke] Victoria 15% attrition available beds:public available beds:all growth rate headcount av hrs/week FTE % base year shortage headcount 33 10% attrition growth rate headcount av hrs/week FTE required 10% % attrition growth rate headcount av hrs/week FTE required 15% % attrition growth rate headcount av hrs/week FTE required 10%

188 APPENDIX L: PROJECTIONS: QUEENSLAND Notes For Reading Spreadsheets Based On The Van Konkelenberg Method (Method 1) 1. Attrition Rate is the percentage of the total exiting the workforce in the base year. The attrition rate within each age/gender cohort is assumed to be constant throughout the projections period. 2. Hours worked per week by age/gender cohort are assumed to be constant throughout the projection period (i.e., based on 1999 AIHW data on average number of hours worked per week by critical care nurses within the State/Territory) 3. Growth in requirements is assumed to be either 0% or to be equivalent to the projected growth in population plus the impact of ageing of the population during the projection period (source: ABS) 4. Balancing the workforce shows the estimated number of new entrants required to ensure a balanced workforce by 2005, and to maintain a balance from 2005 onwards. 5. Entrants are the assumed number of new entrants to the workforce (as required for balance). 6. Workforce is the number of critical care nurses (supply); requirements are the estimated number of critical care nurses required; and difference is the difference between supply and requirements. The base-year supply (2001) is based on 1999 AIHW data (with the exception of Tasmania, where 2001 data as provided by DHHS, Tasmania was used). Base-year requirements are the recommended headcount as determined using the Williams and Clarke methodology. 7. Workforce % under/over indicates the balance between projected supply and requirements (as measured in total headcount) where a negative (-) percentage indicates supply exceeds requirements (oversupply) and a positive (+) percentage indicates requirements exceed supply (undersupply). 8. FTE figures are calculated based on a 38 hour work week. The headcounts are translated into FTE numbers by multiplying the projected headcount by the average hours worked per week in Queensland (31.3 hours, source: AIHW) and dividing by 38 hours (assumed to be an FTE). 171

189 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce Qld 1 15% constant 0% entrants workforce 6 1,621 1,634 1,709 1,788 1,875 1,964 1,963 1,963 1,964 1,965 1,966 requirements 6 1,960 1,960 1,960 1,960 1,960 1,960 1,960 1,960 1,960 1,960 1,960 difference % under/over % constant 1.97% (pop'n+ageing) entrants workforce 6 1,621 1,680 1,798 1,918 2,043 2,168 2,220 2,270 2,318 2,362 2,402 requirements 6 1,960 1,999 2,038 2,078 2,119 2,161 2,204 2,247 2,292 2,337 2,383 difference % under/over % constant 0% entrants workforce 6 1,621 1,663 1,744 1,817 1,892 1,964 1,968 1,972 1,977 1,980 1,984 requirements 6 1,960 1,960 1,960 1,960 1,960 1,960 1,960 1,960 1,960 1,960 1,960 difference % under/over % constant 1.97% (pop'n+ageing) entrants workforce 6 1,621 1,708 1,831 1,946 2,060 2,170 2,220 2,268 2,313 2,356 2,396 requirements 6 1,960 1,999 2,038 2,078 2,119 2,161 2,204 2,247 2,292 2,337 2,383 difference % under/over

190 Projected Critical Care Nursing Workforce Supply and Requirements, (FTE) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce Qld 1 15% constant 0% entrants workforce 6 1,335 1,346 1,407 1,472 1,544 1,618 1,616 1,617 1,618 1,619 1,619 requirements 6 1,615 1,615 1,615 1,615 1,615 1,615 1,615 1,615 1,615 1,615 1,615 difference % under/over % constant 1.97% (pop'n+ageing) entrants workforce 6 1,335 1,384 1,481 1,580 1,683 1,786 1,829 1,870 1,909 1,945 1,978 requirements 6 1,615 1,646 1,679 1,712 1,746 1,780 1,815 1,851 1,888 1,925 1,963 difference % under/over % constant 0% entrants workforce 6 1,335 1,370 1,436 1,497 1,558 1,618 1,621 1,625 1,628 1,631 1,634 requirements 6 1,615 1,615 1,615 1,615 1,615 1,615 1,615 1,615 1,615 1,615 1,615 difference % under/over % constant 1.97% (pop'n+ageing) entrants workforce 6 1,335 1,406 1,509 1,603 1,697 1,787 1,829 1,868 1,906 1,941 1,973 requirements 6 1,615 1,646 1,679 1,712 1,746 1,780 1,815 1,851 1,888 1,925 1,963 difference % under/over

191 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount+FTE) [ Method #2: Williams and Clarke] Queensland 15% attrition available beds:public available beds:all growth rate headcount required av hrs/week FTE % base year shortage headcount % attrition growth rate headcount required av hrs/week FTE % % attrition growth rate headcount av hrs/week FTE required 15% % attrition growth rate headcount av hrs/week FTE required 10%

192 APPENDIX M: PROJECTIONS: SOUTH AUSTRALIA Notes For Reading Spreadsheets Based On The Van Konkelenberg Method (Method 1) 1. Attrition Rate is the percentage of the total exiting the workforce in the base year. The attrition rate within each age/gender cohort is assumed to be constant throughout the projections period. 2. Hours worked per week by age/gender cohort are assumed to be constant throughout the projection period (i.e., based on 1999 AIHW data on average number of hours worked per week by critical care nurses within the State/Territory) 3. Growth in requirements is assumed to be either 0% or to be equivalent to the projected growth in population plus the impact of ageing of the population during the projection period (source: ABS) 4. Balancing the workforce shows the estimated number of new entrants required to ensure a balanced workforce by 2005, and to maintain a balance from 2005 onwards. 5. Entrants are the assumed number of new entrants to the workforce (as required for balance). 6. Workforce is the number of critical care nurses (supply); requirements are the estimated number of critical care nurses required; and difference is the difference between supply and requirements. The base-year supply (2001) is based on 1999 AIHW data (with the exception of Tasmania, where 2001 data as provided by DHHS, Tasmania was used). Base-year requirements are the recommended headcount as determined using the Williams and Clarke methodology. 7. Workforce % under/over indicates the balance between projected supply and requirements (as measured in total headcount) where a negative (-) percentage indicates supply exceeds requirements (oversupply) and a positive (+) percentage indicates requirements exceed supply (undersupply). 8. FTE figures are calculated based on a 38 hour work week. The headcounts are translated into FTE numbers by multiplying the projected headcount by the average hours worked per week in South Australia (26.2 hours, source: AIHW) and dividing by 38 hours (assumed to be an FTE). 175

193 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce SA 1 15% constant 0% entrants workforce ,028 1,096 1,166 1,167 1,168 1,169 1,168 1,167 requirements 6 1,162 1,162 1,162 1,162 1,162 1,162 1,162 1,162 1,162 1,162 1,162 difference % under/over % constant 0.65% (pop'n+ageing) entrants workforce ,051 1,127 1,204 1,214 1,225 1,234 1,241 1,247 requirements 6 1,162 1,170 1,177 1,185 1,192 1,200 1,208 1,216 1,224 1,232 1,240 difference % under/over % constant 0% entrants workforce ,043 1,104 1,165 1,167 1,169 1,170 1,171 1,170 requirements 6 1,162 1,162 1,162 1,162 1,162 1,162 1,162 1,162 1,162 1,162 1,162 difference % under/over % constant 0.65% (pop'n+ageing) entrants workforce ,064 1,132 1,199 1,210 1,221 1,231 1,240 1,247 requirements 6 1,162 1,170 1,177 1,185 1,192 1,200 1,208 1,216 1,224 1,232 1,240 difference % under/over

194 Projected Critical Care Nursing Workforce Supply and Requirements, (FTE) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce SA 1 15% constant 0% entrants workforce requirements difference % under/over % constant 0.65% (pop'n+ageing) entrants workforce requirements difference % under/over % constant 0% entrants workforce requirements difference % under/over % constant 0.65% (pop'n+ageing) entrants workforce requirements difference % under/over

195 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount+FTE) [Method #2: Williams and Clarke] South Australia 15% attrition available beds:public available beds:all growth rate headcount required av hrs/week FTE % shortage headcount 289 South Australia 10% attrition growth rate headcount required av hrs/week FTE % base year shortage headcount 289 South Australia 15% attrition growth rate headcount av hrs/week FTE required 15% base year shortage headcount % attrition growth rate headcount av hrs/week FTE required 10%

196 APPENDIX N: PROJECTIONS: WESTERN AUSTRALIA Notes For Reading Spreadsheets Based On The Van Konkelenberg Method (Method 1) 1. Attrition Rate is the percentage of the total exiting the workforce in the base year. The attrition rate within each age/gender cohort is assumed to be constant throughout the projections period. 2. Hours worked per week by age/gender cohort are assumed to be constant throughout the projection period (i.e., based on 1999 AIHW data on average number of hours worked per week by critical care nurses within the State/Territory) 3. Growth in requirements is assumed to be either 0% or to be equivalent to the projected growth in population plus the impact of ageing of the population during the projection period (source: ABS) 4. Balancing the workforce shows the estimated number of new entrants required to ensure a balanced workforce by 2005, and to maintain a balance from 2005 onwards. 5. Entrants are the assumed number of new entrants to the workforce (as required for balance). 6. Workforce is the number of critical care nurses (supply); requirements are the estimated number of critical care nurses required; and difference is the difference between supply and requirements. The base-year supply (2001) is based on 1999 AIHW data (with the exception of Tasmania, where 2001 data as provided by DHHS, Tasmania was used). Base-year requirements are the recommended headcount as determined using the Williams and Clarke methodology. 7. Workforce % under/over indicates the balance between projected supply and requirements (as measured in total headcount) where a negative (-) percentage indicates supply exceeds requirements (oversupply) and a positive (+) percentage indicates requirements exceed supply (undersupply). 8. FTE figures are calculated based on a 38 hour work week. The headcounts are translated into FTE numbers by multiplying the projected headcount by the average hours worked per week in Western Australia (30.2 hours, source: AIHW) and dividing by 38 hours (assumed to be an FTE). 179

197 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce WA 1 15% constant 0% entrants workforce requirements difference % under/over % constant 1.8% (pop'n+ageing) entrants workforce ,006 1,026 1,045 requirements ,002 1,020 1,038 difference % under/over % constant 0% entrants workforce requirements difference % under/over % constant 1.8% (pop'n+ageing) entrants workforce ,006 1,024 1,043 requirements ,002 1,020 1,038 difference % under/over

198 Projected Critical Care Nursing Workforce Supply and Requirements, (FTE) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce WA 1 15% constant 0% entrants workforce requirements difference % under/over % constant 1.8% (pop'n+ageing) entrants workforce requirements difference % under/over % constant 0% entrants workforce requirements difference % under/over % constant 1.8% (pop'n+ageing) entrants workforce requirements difference % under/over

199 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount+FTE) [ Method #2: Williams and Clarke] WA 15% attrition available beds:public avaialable beds:all growth rate headcount av hrs/week FTE % base year shortage headcount 5 10% attrition growth rate headcount av hrs/week FTE % % attrition growth rate headcount av hrs/week FTE required 15% % attrition growth rate headcount av hrs/week FTE required 10%

200 APPENDIX O: PROJECTIONS: TASMANIA Notes For Reading Spreadsheets Based On The Van Konkelenberg Method (Method 1) 1. Attrition Rate is the percentage of the total exiting the workforce in the base year. The attrition rate within each age/gender cohort is assumed to be constant throughout the projections period. 2. Hours worked per week by age/gender cohort are assumed to be constant throughout the projection period (i.e., based on 1999 AIHW data on average number of hours worked per week by critical care nurses within the State/Territory) 3. Growth in requirements is assumed to be either 0% or to be equivalent to the projected growth in population plus the impact of ageing of the population during the projection period (source: ABS) 4. Balancing the workforce shows the estimated number of new entrants required to ensure a balanced workforce by 2005, and to maintain a balance from 2005 onwards. 5. Entrants are the assumed number of new entrants to the workforce (as required for balance). 6. Workforce is the number of critical care nurses (supply); requirements are the estimated number of critical care nurses required; and difference is the difference between supply and requirements. The base-year supply (2001) is based on 1999 AIHW data (with the exception of Tasmania, where 2001 data as provided by DHHS, Tasmania was used). Base-year requirements are the recommended headcount as determined using the Williams and Clarke methodology. For NSW/ACT where an initial surplus was estimated, for projection purposes, a balanced workforce was assumed in the base-year. 7. Workforce % under/over indicates the balance between projected supply and requirements (as measured in total headcount) where a negative (-) percentage indicates supply exceeds requirements (oversupply) and a positive (+) percentage indicates requirements exceed supply (undersupply). 8. FTE figures are calculated based on a 38 hour work week. The headcounts are translated into FTE numbers by multiplying the projected headcount by the average hours worked per week in Tasmania (30.7 hours, source: AIHW) and dividing by 38 hours (assumed to be an FTE). 183

201 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce Tas 1 15% constant 0% entrants workforce requirements difference % under/over % constant 0.17% (pop'n+ageing) entrants workforce requirements difference % under/over % constant 0% entrants workforce requirements difference % under/over % constant 0.17% (pop'n+ageing) entrants workforce requirements difference % under/over

202 Projected Critical Care Nursing Workforce Supply and Requirements, (FTE) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce Tas 1 15% constant 0% entrants workforce requirements difference % under/over % constant 0.17% (pop'n+ageing) entrants workforce requirements difference % under/over % constant 0% entrants workforce requirements difference % under/over % constant 0.17% (pop'n+ageing) entrants workforce requirements difference % under/over

203 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount+FTE) [ Method #2: Williams and Clarke] Tasmania 15% attrition available beds:public available beds: all growth rate headcount av hrs/week FTE % base year shortage headcount 32 10% attrition growth rate headcount av hrs/week FTE % % attrition growth rate headcount av hrs/week FTE required 15% % attrition growth rate headcount av hrs/week FTE required 10%

204 APPENDIX P: PROJECTIONS: NORTHERN TERRITORY Notes For Reading Spreadsheets Based On The Van Konkelenberg Method (Method 1) 1. Attrition Rate is the percentage of the total exiting the workforce in the base year. The attrition rate within each age/gender cohort is assumed to be constant throughout the projections period. 2. Hours worked per week by age/gender cohort are assumed to be constant throughout the projection period (i.e., based on 1999 AIHW data on average number of hours worked per week by critical care nurses within the State/Territory) 3. Growth in requirements is assumed to be either 0% or to be equivalent to the projected growth in population plus the impact of ageing of the population during the projection period (source: ABS) 4. Balancing the workforce shows the estimated number of new entrants required to ensure a balanced workforce by 2005, and to maintain a balance from 2005 onwards. 5. Entrants are the assumed number of new entrants to the workforce (as required for balance). 6. Workforce is the number of critical care nurses (supply); requirements are the estimated number of critical care nurses required; and difference is the difference between supply and requirements. The base-year supply (2001) is based on 1999 AIHW data (with the exception of Tasmania, where 2001 data as provided by DHHS, Tasmania was used). Base-year requirements are the recommended headcount as determined using the Williams and Clarke methodology. 7. Workforce % under/over indicates the balance between projected supply and requirements (as measured in total headcount) where a negative (-) percentage indicates supply exceeds requirements (oversupply) and a positive (+) percentage indicates requirements exceed supply (undersupply). 8. FTE figures are calculated based on a 38 hour work week. The headcounts are translated into FTE numbers by multiplying the projected headcount by the average hours worked per week in Northern Territory (35.9 hours, source: AIHW) and dividing by 38 hours (assumed to be an FTE). 187

205 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce NT 1 15% constant 0% entrants workforce requirements difference % under/over % constant 2.24% (pop'n+ageing) entrants workforce requirements difference % under/over % constant 0% entrants workforce requirements difference % under/over % constant 2.24% (pop'n+ageing) entrants workforce requirements difference % under/over

206 Projected Critical Care Nursing Workforce Supply and Requirements, (FTE) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce NT 1 15% constant 0% entrants workforce requirements difference % under/over % constant 2.24% (pop'n+ageing) entrants workforce requirements difference % under/over % constant 0% entrants workforce requirements difference % under/over % constant 2.24% (pop'n+ageing) entrants workforce requirements difference % under/over

207 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount+FTE) [ Method #2: Williams and Clarke] Northern Territory 15% attrition available beds growth rate = headcount av hrs/week FTE required 15% base year shortage headcount 35 Northern Territory 10% attrition growth rate = headcount av hrs/week FTE required 10% Northern Territory 15% attrition available beds growth rate = 2.24% headcount required av hrs/week FTE % base year shortage headcount 10% attrition growth rate = 2.24% headcount av hrs/week FTE required 10%

208 APPENDIX Q: PROJECTIONS: AUSTRALIA (TOTAL) Notes For Reading Spreadsheets Based On The Van Konkelenberg Method (Method 1) 1. Attrition Rate is the percentage of the total exiting the workforce in the base year. The attrition rate within each age/gender cohort is assumed to be constant throughout the projections period. 2. Hours worked per week by age/gender cohort are assumed to be constant throughout the projection period (ie., based on 1999 AIHW data on average number of hours worked per week by critical care nurses within the State/Territory) 3. Growth in requirements is assumed to be either 0% or to be equivalent to the projected growth in population plus the impact of ageing of the population during the projection period (source: ABS) 4. Balancing the workforce shows the estimated number of new entrants required to ensure a balanced workforce by 2005, and to maintain a balance from 2005 onwards. 5. Entrants are the assumed number of new entrants to the workforce (as required for balance). 6. Workforce is the number of critical care nurses (supply); requirements are the estimated number of critical care nurses required; and difference is the difference between supply and requirements. The base-year supply (2001) is based on 1999 AIHW data (with the exception of Tasmania, where 2001 data as provided by DHHS, Tasmania was used). Base-year requirements are the recommended headcount as determined using the Williams and Clarke methodology. For New South Wales/Australian Capital Territory where an initial surplus was estimated, for projection purposes, a balanced workforce was assumed in the base-year. 7. Workforce % under/over indicates the balance between projected supply and requirements (as measured in total headcount) where a negative (-) percentage indicates supply exceeds requirements (oversupply) and a positive (+) percentage indicates requirements exceed supply (undersupply). 191

209 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requirements 3 Balancing the Workforce Total 1 15% constant 0% entrants 5 1,205 1,204 1,205 1,204 1, workforce 6 9,830 9,586 9,744 9,960 10,249 10,574 10,551 10,546 10,553 10,564 10,577 requirements 6 10,528 10,529 10,529 10,529 10,529 10,529 10,529 10,529 10,529 10,529 10,529 difference % under/over % constant pop'n + ageing entrants 5 1,356 1,355 1,356 1,355 1,306 1,051 1,051 1,031 1,031 1,031 1,031 workforce 6 9,830 9,746 10,057 10,419 10,844 11,248 11,406 11,573 11,719 11,860 11,992 requirements 6 10,528 10,658 10,790 10,923 11,058 11,195 11,334 11,475 11,618 11,763 11,911 difference % under/over % constant 0% entrants workforce 6 9,830 9,784 9,978 10,157 10,361 10,555 10,553 10,560 10,573 10,589 10,608 requirements 6 10,528 10,529 10,529 10,529 10,529 10,529 10,529 10,529 10,529 10,529 10,529 difference % under/over % constant pop'n + ageing entrants 5 1,078 1,078 1,078 1,078 1, workforce 6 9,830 9,924 10,254 10,563 10,893 11,227 11,378 11,530 11,680 11,827 11,967 requirements 6 10,528 10,658 10,790 10,923 11,058 11,195 11,334 11,475 11,618 11,763 11,911 difference % under/over

210 Projected Critical Care Nursing Workforce Supply and Requirements, (FTE) [ Method #1: Van Konkelenberg Model] St/ Terr Scen - ario Att. Rate 1 Hours Worked per Week 2 Growth in Requiremen ts 3 Balancing the Workforce Total 1 15% constant 0% entrants % constant workforce 6 8,087 7,878 8,000 8,170 8,400 8,659 8,640 8,637 8,642 8,651 8,662 requirements 6 8,622 8,623 8,623 8,623 8,623 8,623 8,623 8,623 8,623 8,623 8,623 difference p p % under/over ageing entrants 5 1,108 1,107 1,108 1,107 1, workforce 6 8,087 8,010 8,258 8,548 8,891 9,216 9,346 9,484 9,604 9,720 9,829 requirements 6 8,622 8,730 8,838 8,948 9,060 9,173 9,287 9,404 9,522 9,642 9,763 difference % under/over % constant 0% entrants % constant workforce 6 8,087 8,042 8,193 8,332 8,492 8,644 8,642 8,648 8,658 8,672 8,688 requirements 6 8,622 8,623 8,623 8,623 8,623 8,623 8,623 8,623 8,623 8,623 8,623 difference p p % under/over ageing entrants workforce 6 8,087 8,157 8,420 8,667 8,931 9,199 9,323 9,448 9,572 9,693 9,809 requirements 6 8,622 8,730 8,838 8,948 9,060 9,173 9,287 9,404 9,522 9,642 9,763 difference % under/over

211 Projected Critical Care Nursing Workforce Supply and Requirements, (Headcount) [ Method #2: Williams and Clarke] Australia % attrition, growth available beds:public 1,080 1,093 1,106 1,119 1,133 1,147 1,160 1,175 1,189 1,203 1,218 available beds:all 1,598 1,618 1,637 1,657 1,678 1,698 1,719 1,741 1,762 1,784 1,806 FTE 8,449 8,554 8,660 8,768 8,877 8,988 9,101 9,215 9,331 9,448 9,567 headcount 10,386 10,117 10,240 10,365 10,491 10,619 10,748 10,880 11,013 11,148 11,285 new entrants 1,558 1,577 1,597 1,616 1,636 1,657 1,677 1,698 1,719 1,741 1,762 10% attrition, growth FTE 8,449 8,554 8,660 8,768 8,877 8,988 9,101 9,215 9,331 9,448 9,567 headcount 10,386 10,514 10,643 10,775 10,908 11,044 11,181 11,320 11,461 11,604 11,749 new entrants 1,039 1,051 1,064 1,077 1,091 1,104 1,118 1,132 1,146 1,160 1,175 15% attrition, no growth FTE 8,449 8,449 8,449 8,449 8,449 8,449 8,449 8,449 8,449 8,449 8,449 headcount 10,386 10,386 10,386 10,386 10,386 10,386 10,386 10,386 10,386 10,386 10,386 new entrants 1,558 1,558 1,558 1,558 1,558 1,558 1,558 1,558 1,558 1,558 1,558 10% attrition, no growth FTE 8,449 8,449 8,449 8,449 8,449 8,449 8,449 8,449 8,449 8,449 8,449 headcount 10,386 10,386 10,386 10,386 10,386 10,386 10,386 10,386 10,386 10,386 10,386 new entrants 1,039 1,039 1,039 1,039 1,039 1,039 1,039 1,039 1,039 1,039 1,

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