Australia s Health Workforce Series Nurses in focus. hwa.gov.au

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1 Australia s Health Workforce Series Nurses in focus hwa.gov.au

2 Health Workforce Australia This work is copyright. It may be reproduced in whole or part for study or training purposes. Subject to an acknowledgement of the source, reproduction for purposes other than those indicated above, or not in accordance with the provisions of the Copyright Act 1968, requires the written permission of Health Workforce Australia (HWA). Enquiries concerning this report and its reproduction should be directed to: Health Workforce Australia GPO Box 2098 Adelaide SA 5001 Telephone Internet Suggested citation: Health Workforce Australia 2013, Australia s Health Workforce Series Nurses in focus, Health Workforce Australia: Adelaide

3 Contents Introduction... 2 How many nurses?... 4 What sectors and settings do nurses work in? Where are nurses located? How many nurses is Australia producing? How many nurses are from overseas? Summary Technical notes... 48

4 Introduction This issue of Australia s Health Workforce Series brings together information from various sources to provide a picture of the nursing workforce in Australia. The National Review of Nursing Education 2002 Our Duty of Care noted that: Nurses are a vital part of the health, aged and community care systems in Australia. The work they do not only supports those who have particular care needs but also underpins much of the social structure in communities and care facilities. This is reinforced by the fact that nurses comprise a substantial proportion of the health workforce 1. The health environment nurses operate in is changing, and nursing roles have, and are, continuing to evolve to match the environment. There is an ongoing trend for increasing hospital admissions, reduced lengths of stay, increased acuity and greater use of technology. More care and more complex care is being provided in the community, additional aged care beds are being opened and nurses are taking on more roles and more diverse roles 2. As well as providing care, the nursing role encompasses health promotion and prevention, education and management and for nurse practitioners, extends to providing primary care by assessing and managing clients including providing referrals and prescribing medications. For the essential role nurses play in Australian society, combined with the fact they make up a substantial proportion of Australia s health workforce, it is important to understand the characteristics and the supply sources of Australia s nursing workforce. 1 Australian Institute of Health and Welfare Australia s health Australia s health series no. 12. Cat. no. AUS 122. Canberra: AIHW. 2 Australian Nursing Federation. Submission to the National Health and Medical Research Council (NHMRC) on the research program to address issues of Preventative Healthcare and Strengthening Australia s Social and Economic Fabric. Australia s Health Workforce Series - Nurses in focus 02

5 Structure of the nursing workforce There are two levels of regulated nurses in Australia Registered Nurses (RNs) and Enrolled Nurses (ENs). A RN is a person who has completed as a minimum, a three-year bachelor degree and is registered with the Nursing and Midwifery Board of Australia (NMBA). RNs practise independently and interdependently, assuming accountability and responsibility for their own actions and delegation of care to ENs and other healthcare workers. An EN usually works with RNs to provide patients with basic nursing care, doing less complex procedures than RNs. ENs must complete a also registered with the NMBA. To maintain registration, both RNs and ENs are subject to a recency of practice standard where they must development standards set by the NMBA. publication. In this publication, 2011 National Health Workforce Dataset (NHWDS) information is used to describe the most recent characteristics of Australia s nursing workforce. To examine the characteristics of Australia s nursing workforce over time, information from the 2003 to 2009 Australian Institute of Health and Welfare (AIHW) Nursing and Midwifery Labour Force Surveys is used. This is because the 2011 NHWDS was collected using a different survey methodology to previous nursing and midwifery labour force surveys (refer technical notes at the back of the publication), and comparisons with previous years is not recommended. Data sources The main data sources used in this report are: The National Health Workforce Dataset (NHWDS): nurses and midwives The NHWDS combines data from the National Registration and Accreditation Scheme (NRAS) with nursing and midwifery workforce survey data collected at the time of annual registration renewal. The nursing and midwifery workforce survey is administered through the national registration body, the Australian Health Practitioner Regulation Agency, on behalf of Health Workforce Australia. The NHWDS is collected using a different survey methodology to previous nursing and midwifery labour force surveys. Comparison with data from previous survey years is not recommended, and in this publication, 2011 data is presented on its own. The overall response rate to the nursing and midwifery workforce survey was 86 percent in 2011, the highest ever recorded. Further information on the NHWDS can be this publication. The Australian Institute of Health and Welfare (AIHW) Nursing and Midwifery Labour Force Survey. Before the introduction of the NRAS, this survey collected information about the demographics and employment of individuals registered in the nursing and midwifery professions. It was administered by the nursing and midwifery regulatory authorities in each jurisdiction, usually in conjunction with the registration renewal process. Response to the AIHW survey was voluntary and in 2009 the overall response rate was estimated to be 44 percent. The response rate was lower for ENs (41 percent) than for RNs (45 percent). In 2003, the Nursing and Midwifery Labour Force Survey underwent major revisions to the questionnaire design, data processing and estimation method. As such, the time series analysis incorporated in this publication is from 2003 to 2009 (noting the survey was not run in 2006). The Department of Industry, Innovation, Science, Research and Tertiary Education, (DIISRTE) Higher Education Statistics Collection, which provides data for enrolments and completions of students in general nursing courses required for initial registration as a registered nurse. National Centre for Vocational Education and Research (NCVER) VET provider collection (also known as the Students and Courses collection). This is an administrative collection of information on students, the courses they undertake and their achievement in the VET sector. The information is sourced from student enrolment records and it is an annual national collection. The scope of the collection has progressively widened over time and broadly covers the public VET system. Department of Immigration and Citizenship (DIAC) administrative data, which includes applications granted to RNs and ENs for the temporary business long stay (sub-class 457) visa type and for permanent migration outcomes. Australia s Health Workforce Series - Nurses in focus 03

6 How many nurses? The number of nurses in 2011 In 2011 the total number of registered and enrolled nurses was 328,817. Under the NRAS, people can register as nurses, midwives or both. Nurses who were also registered as midwives (dual-registered nurses and midwives) are included in nurse registration totals in this publication. Those registered as midwives only (of which there were 1,863 in 2011) are not included in 2011 totals in this publication (refer technical notes at the end of this publication). Of the 328,817 nurse registrations in Australia, the majority were registered as RNs (82 percent or 268,883), while those registered as ENs accounted for 18 percent (or 59,934) of total nurse registrations. In 2011, employed dual-registered nurses and midwives who reported their principal area of practice as midwifery are considered to be midwives, and are excluded from the employed nursing population (refer technical notes at the end of this publication). Most RNs (87 percent) and ENs (95 percent) were in the labour force. Of those in the labour force, most were employed in nursing (94 percent of RNs and 93 percent of ENs), with small percentages on extended leave or looking for work (Figure 1). Australia s Health Workforce Series - Nurses in focus 04

7 Figure 1: Registered and enrolled nurses by labour force status, 2011 Nurse registrations {328,817} Registered nurses {268,883} 81.8% Enrolled nurses {59,934} 18.2% In nursing labour force {290,899} Not in nursing labour force {39,917} 234, % 56, % 34, % 3, % Employed in nursing {271,996} 219, % 52, % On extended leave {14,446} 11, % 2, % Looking for work in nursing or midwifery (a) {4458} 2, % 1, % Employed elsewhere and not looking for work in nursing {6140} 4, % 1, % 174, % 14, % 9, % Clinician {214,321} Administrator {15,700} 39, % 1, % Teacher or educator {10,196} % Employed or on extended leave in midwifery {13,803} 13, % 4, % % Not employed and not looking for work {5134} 1, % Employed in nursing overseas {10,628} Researcher {2531} 10, % % 2, % 18, % Other {29,248} % 11, % Retired from nursing in Australia {2213} 1, % % (a) Includes 332 dual-registered nurses and midwives who may be looking for work in midwifery. It is not possible to identify which area people are looking for work in, therefore the 332 dual-registered nurses and midwives looking for work are included in both the nursing and midwifery labour force. Note: numbers in brackets are total registered and enrolled nurses, numbers in bold relate to registered nurses and plain to enrolled nurses. Nursing role is based on main nursing job. Source: NHWDS: nurses and midwives Australia s Health Workforce Series - Nurses in focus 05

8 How does Australia compare internationally? International comparisons provide a useful means for examining performance against the experiences of other countries. In 2009, there were 10.1 nurses per 1,000 population in Australia. This rate was higher than the Organisation for Economic Co-operation and Development (OECD) average (8.6). Different allocations of tasks between nurses and other health professionals may contribute to variations in rates across countries. Figure 2: Nurses, density per 1,000 population (headcount), OECD countries, 2010 (or nearest year) SWITZERLAND (a) DENMARK (a) BELGIUM (c) ICELAND (a) NORWAY (a) IRELAND (b) GERMANY (a) LUXEMBOURG (a) SWEDEN (a) UNITED STATES (b) JAPAN (a) AUSTRALIA (a) NEW ZEALAND (a) (a) Practising nurses, those providing care directly to patients, unless otherwise indicated. (b) Professionally active nurse, which includes practising nurses plus other nurses working in the health sector as managers, educators, researchers, etc. (c) All nurses who are licensed to practice. Source: OECD Health Data UNITED KINGDOM (a) FINLAND (a) CANADA (a) FRANCE (b) NETHERLANDS (a) SLOVENIA (a) CZECH REPUBLIC (a) AUSTRIA (a) ITALY (c) HUNGARY (a) ESTONIA (a) SLOVAK REPUBLIC (b) PORTUGAL (b) POLAND (a) SPAIN (a) ISRAEL (a) KOREA (a) GREECE (b) MEXICO (a) TURKEY (b) CHILE (c) Australia s Health Workforce Series - Nurses in focus 06

9 Changes in nursing numbers 2003 to 2009 for multi-state registrations). RNs increased by a greater percentage (up 19 percent from 218,615 to 260,121) than ENs (up 11 percent from 54,762 to 60,861) over the period (Figure 3). RNs accounted for approximately 80 percent of all nurses in each of the six years from 2003 to Figure 3: Registered and enrolled nurse registrations Registered nurses Enrolled nurses All nurses 350, , ,000 Number 200, , ,000 50, Source: AIHW Nursing and Midwifery Labour Force Survey 2003 to The employment status of nurses is similar over time and across the two workforces. For RNs in 2009: For ENs in 2009: Australia s Health Workforce Series - Nurses in focus 07

10 Changes in nursing role 2003 to 2009 management of clinical nurses. This was further categorised into clinical nurses (direct patient care) and clinical nurse managers and/or administrators (managing clinical nurses and midwives). > Lecturer, nurse/midwife educator, supervisor of new nurses/midwives: a person who teaches or trains people in nursing for their initial > Researcher: a person engaged in nursing research. > Other: not any of the above, for example, industrial relations or public health activities in nursing. In the NHWDS: nurses and midwives 2011, the distinction between clinical and non-clinical nurses is still made. However clinical nurses only comprise those providing direct patient care. Those involved in the supervision and management of clinical nurses (which were included as clinicians in the AIHW Nursing and Midwifery Labour Force Survey) are now counted as non-clinicians. The non-clinician role In 2011, most employed RNs and ENs worked in clinical roles, providing direct patient care (4 in 5 of all employed RNs and 3 in 4 of all employed ENs). Most non-clinical RNs and ENs reported a role of other (18,123 RNs and 11,126 ENs), followed by administrator (14,498 RNs and 1,202 ENs), teacher or educator (9,612 RNs and 584 ENs) and researcher (2,398 RNs and 134 ENs) (Figure 1). The number of employed RNs increased across all nursing roles from 2003 to Almost all were in a clinical role in 2009 (90 percent or 203,636), with 86 percent (174,962) of these providing direct patient care. While much smaller in number, non-clinical RNs increased by a greater percentage from 2003 to 2009 (up 69 percent) compared with clinical RNs (up 15 percent over the same period). Those reporting as a lecturer/educator and/or supervisor increased by over a third (37 percent or 2,448), however most growth was in those reporting other. This category, which includes roles involved in policy, industrial relations, regulation etc, more than doubled from 4,170 in 2003 to 10,153 in 2009 (Table 1). The number of employed ENs also increased overall from 2003 to 2009, with the greatest increase in number occurring in those reporting as clinical nurses. Employed clinical ENs increased by approximately 2,200 (5 percent) to be 45,852 in Similar to RNs, there was also a large increase in non-clinical ENs, both in number (up by 2,129) and percentage (up 88 percent). This was also a result of many more reporting other. The remaining EN categories experienced small reductions in numbers from 2003 to 2009 (Table 1). Australia s Health Workforce Series - Nurses in focus 08

11 Table 1: Employed registered nurses and enrolled nurses by role, 2003 and 2009 Number Percentage {%} Change 2003 to 2009 {%} Registered nurses Clinicians Clinical nurse 152, , Clinical nurse manager/administrator 24,042 28, Total clinicians 176, , Non-clinicians Lecturer/educator and/or supervisor of new nurses 6,591 9, Researcher 1,940 2, Other 4,170 10, Total non-clinicians 12,701 21, Total 189, , Enrolled nurses Clinicians Clinical nurse 43,647 45, Clinical nurse manager/administrator 1,495 1, Total clinicians 45,142 47, Non-clinicians Lecturer/educator and/or supervisor of new nurses Researcher Other 1,769 3, Total non-clinicians 2,432 4, Total 47,574 51, Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and Australia s Health Workforce Series - Nurses in focus 09

12 Nurse practitioners Since then, the number of nurse practitioners has increased, with 736 nurses holding a nurse practitioner endorsement in The National Competency Standards for the Nurse Practitioner 5 A registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The NP role may include, but is not limited to, the direct referral of patients to other healthcare professionals, prescribing medications and ordering diagnostic investigations. 6 and demonstrated competencies, to be endorsed by the NMBA as a NP. NP-led clinics now exist within Australia, and from 1 November 2010, NPs working in collaborative arrangements with medical practitioners are able to access Medicare arrangements demonstrated by: 7 Principal area of main job (clinical nurses only) user-pays basis. Completion is not recognised on a nurse s registration however it can be an employment requirement. Both the NHWDS and the AIHW Nursing and Midwifery Labour Force Survey reports nurses principal area of main job. This is the area nurses reported working the 3 Australian College of Nurse Practitioners website. Available at: Accessed 23 March Australian Health Practitioner Regulation Agency Annual Report Australian Nursing and Midwifery Council. National Competency Standards for the Nurse Practitioner. Available at: Accessed 16 November Ibid. 7 Collaborative Arrangements for Participating Midwives and Nurse Practitioners Fact Sheet. Medicare Finance and Analysis Branch. Australia s Health Workforce Series - Nurses in focus 10

13 Principal areas of main job from one area to another or work across areas. The question response options used in the 2011 Nursing and Midwifery Workforce Survey were different to those used in the AIHW Nursing and Midwifery Labour Force Surveys (2009 and previous years). The 2011 principal area of main job categories are outlined below. Aged care nurses provide nursing care to the elderly in community settings, residential aged care facilities, retirement villages and healthcare facilities. Community health nurses provide nursing care, health counselling, screening and education to individuals, families and groups in the wider community with a focus on patient independence and health promotion. Critical care and emergency nurses provide nursing care to critically ill patients and patients with unstable health following injury, surgery or during the acute phase of diseases, integrating new technological equipment into care in settings such as high dependency units, intensive care units, emergency departments or retrieval services. Education design, planning, implementation, evaluation and delivery of nursing education and staff development programs, and management of educational resources. Family, maternity and child health nurses provide nursing care to children from birth to school age and their families, with an emphasis on: the prevention; early detection of; and early intervention in; physical, emotional and social problems affecting children and their families. Care includes assistance with parentcraft, immunisation and developmental milestones. General practice/medical practice includes clinical care to patients, clinical organisation and practice administration, and the facilitation of communication within a general practice environment and between the practice and outside organisations and individuals. Management the management of a health service unit or sub-unit of a hospital, aged care or community healthcare facility, for a particular unit, and monitoring of quality, clinical standards and professional development of nurses. Medical nurses provide nursing care to patients with conditions such as infections, metabolic disorders and degenerative conditions, which need medical intervention in a range of health, aged care and community settings. Mental health nurses provide nursing care to patients with mental health illness, disorder and dysfunction such as schizophrenia, work in hospitals, community mental health services, residential mental healthcare services, welfare and aged care facilities, correctional services and the community. Maternity care (a) nursing care and advice to women during pregnancy, labour and childbirth, and postnatal care for women and babies in a range of settings such as the home, community, hospitals, clinics and health units. Mixed medical/surgical provide nursing care to patients with conditions such as infections, metabolic disorders and degenerative conditions, which need medical intervention in a range of health, aged care and community settings, as well as providing care to patients with injuries and illness that need surgical intervention. Paediatrics provide nursing care and advice regarding internal diseases and disorders in children from birth up to, and including, adolescence. Peri-operative nurses provide nursing care to patients before, during and immediately after surgery. They assess patients conditions, plan nursing care for surgical intervention, maintain a safe and comfortable environment, assist surgeons and anaesthetists during surgery, and monitor patients recovery from anaesthetic. Rehabilitation and disability nurses provide nursing care to patients recovering from injury and illness. They assist and facilitate patients with disabilities to adapt to their disabilities, achieve their greatest potential, and work toward productive, independent lives. Continues next page Australia s Health Workforce Series - Nurses in focus 11

14 Research the design, conduct and evaluation of nursing and interdisciplinary research projects, and promotion of the Surgical nurses provide nursing care to patients with injuries and illness that need surgical intervention. Other includes all other areas of nursing practice not covered above, such as nurses working in policy, industrial relations, regulation and other areas. (a) On the 2011 Nursing and Midwifery Workforce Survey, midwifery, rather than maternity care, was listed as an option for the principal area of main job. Most people who reported midwifery as their principal area of main job were dual-registered nurses and midwives, who are considered to be midwives, and are excluded from this report. A small number of people registered as a nurse only reported their principal area of main job as midwifery. It is assumed these nurses are providing maternity care as only people registered as midwives can provide midwifery services. As this publication provides information on nurses only, the principal area of main job has therefore been referred to as maternity care. For more information, see technical notes. Principal area of main job in 2011 The highest percentage of clinical RNs (14 percent or approximately 24,100) worked in critical care and emergency in Approximately one-quarter (26 percent or 44,654) of clinical RNs worked in medical, surgical and mixed medical/surgical areas (Figure 4). Almost one-third of clinical ENs worked in aged care (31 percent or approximately 12,300). This was more than double the size of clinical ENs second most popular principal area of main job medical with approximately 4,600 ENs. Figure 4: Employed clinical registered and enrolled nurses, by principal area of main job, 2011 Registered nurses Enrolled nurses CRITICAL CARE & EMERGENCY SURGICAL AGED CARE MEDICAL PERI-OPERATIVE OTHER MENTAL HEALTH COMMUNITY HEALTH MIXED MEDICAL / SURGICAL GENERAL PRACTICE / MEDICAL PRACTICE PAEDIATRICS REHABILITATION & DISABILITY FAMILY, MATERNAL & CHILD HEALTH OTHER AREAS (a) MATERNITY CARE Percent {%} (a) Includes the principal areas of management, education and research. Source: NHWDS: nurses and midwives Australia s Health Workforce Series - Nurses in focus 12

15 Changes in principal area of main job 2003 to 2009 For both RNs and ENs, the highest percentages of clinical nurses worked in medical/surgical in both 2003 (31 percent for RNs and 35 percent for ENs) and 2009 (31 percent for RNs and 39 percent for ENs). Medical/surgical is primarily hospital-based and covers many areas. Medical areas include cardiology, endocrinology, infection control and general medical nursing. Surgical areas include burns and plastics, ear, nose and (refer principal areas of main job box). The top two principal areas of practice most clinical RNs worked in were the same in 2003 and Medical/surgical, as noted above, had the highest percentage of the clinical RN workforce, followed by critical care, which increased from 14 percent of clinical RNs (22,732) to 19 percent (39,404). This increase was partially offset by a fall in the percentage of RNs working in aged care from 11 percent (or 18,313) in 2003 to 8 percent (or 16,431) in Similarly for ENs, the top two principal areas remained the same in 2003 and 2009 medical/surgical followed by aged care. However, the was offset by a substantial increase in the number of ENs reporting critical care as their principal area of main job, almost quadrupling from 1,079 in 2003 to 4,093 in 2009 (to be the third highest principal area of main job for ENs in 2009). Figure 5: Employed clinical registered nurses, by principal area of main job, 2003 and 2009 Figure 6: Employed clinical enrolled nurses, by principal area of main job, 2003 and REHABILITATION/DISABILITY FAMILY & CHILD HEALTH MENTAL HEALTH OTHER COMMUNITY HEALTH AGED CARE PERIOPERATIVE MIDWIFERY CRITICAL CARE MEDICAL/SURGICAL FAMILY & CHILD HEALTH MIDWIFERY COMMUNITY HEALTH PERIOPERATIVE REHABILITATION/DISABILITY MENTAL HEALTH OTHER CRITICAL CARE AGED CARE MEDICAL/SURGICAL Percent {%} Percent {%} Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and As highlighted above, both aged care and critical care experienced substantial changes in workforce numbers between 2003 and 2009, with the number of RNs and ENs in aged care falling, while the number in critical care rose. In 2011, the Productivity Commission publication Caring for Older Australians 8 included an examination of the formal aged care workforce. Findings in the report included that: compared with those performing similar roles in alternative settings and working environments, and Critical care involves the provision of care for the most seriously ill patients, often on life support, and working in a variety of settings such as coronary care, emergency, high dependency, and intensive care units 9. The changing nature of care and hospital admissions, with more patients needing more intensive nursing care, may have contributed to increased employment in this area. 8 Productivity Commission Caring for Older Australians, Report No. 53, Final Inquiry Report, Canberra. 9 Queensland Health. Nursing and Midwifery: A career in health fact sheet series. Available at: Accessed 23 March Australia s Health Workforce Series - Nurses in focus 13

16 Residential and community based aged care workforce The National Institute of Labour Studies periodically conducts a survey and census of the national aged care workforce. Results of the collection demonstrate that RNs and ENs form a minority of the direct care aged care workforce. Together, RNs and ENs comprised less than one-third (26 percent) of the direct care residential aged care workforce in 2012, with RNs accounting for a higher percentage than ENs. From 2007 to 2012, RNs and ENs declined slightly as a percentage of the total direct care residential aged care workforce (Table 2). Most RNs (61 percent) and ENs (75 percent) in the direct care residential aged care workforce were employed as permanent part-time (Figure 7). Table 2: Direct care residential aged care workforce, 2007 and Figure 7: Direct care residential aged care workforce registered nurses and enrolled nurses, by form of employment, 2012 No. % No. % Nurse practitioner n.a n.a Registered nurse 22, , Registered nurses Enrolled nurses Enrolled nurse 16, , % Personal care attendant 84, , Allied health professional 9, , Total 133, , Permanent full-time Permanent part-time Casual or contract In the direct care community-based aged care workforce, RNs and ENs account for a smaller percentage of workers than in the direct care residential aged care workforce, comprising approximately 12 percent of aged care community-based workers (Table 3). Similar to the direct care residential aged care workforce, most RN and EN community based aged care workers were permanent part-time (with permanent part-time workers accounting for 53 percent of all RNs and 67 percent of all ENs, Figure 8). Table 3: Direct care community-based aged care workers, 2007 and Figure 8: Direct care community based aged care workers registered nurses and enrolled nurses by form of employment, 2012 No. % No. % Nurse practitioner n.a n.a Registered nurse 7, , Registered nurses Enrolled nurses Enrolled nurse 2, , % Community care worker 60, , Allied health professional 3, , Total 74, , Permanent full-time Permanent part-time Casual or contract Source: DOHA and NILS. The Aged Care Workforce 2012 Final Report. Australia s Health Workforce Series - Nurses in focus 14

17 While many professions have experienced increases in female workforce participation, historically the main source of recruits for nursing has been, and continues to be, women. This is evidenced by the fact that males comprised approximately one-tenth (11 percent or 28,553) of employed nurses in 2011 (Figure 9). This trend is likely to continue, with females accounting for almost 90 percent of all commencing enrolments in courses for initial registration as a registered nurse in recent years (refer How many nurses is Australia producing?). Figure 9: Employed registered and enrolled nurses by gender, 2011 Male Female 100 Percent {%} Registered nurses Enrolled nurses All nurses Source: NHWDS: nurses and midwives The nursing profession is facing increasing competition for its future workforce supply. Australia s population is ageing, which will result in fewer people being available to enter the labour force. In addition, female workforce participation is increasing across a range of professions. Consequently, adequate numbers may not select nursing as their profession of choice. Strategies suggested to help ease supply issues have included increasing migration, changing skill mix or nurses roles and redesigning work 10. Another potential supply pool for the nursing workforce is males. However, as highlighted in Table 4, there has been little change in the overall percentage of male nurses over time. Reasons contributing to this may include: 11 Males account for approximately 10 percent of employed nurses overall and some areas do have higher percentages of male nurses (Figure 10). In 2011, almost one-third (5,725) of all nurses (both registered and enrolled nurses) working in the mental health clinical area were male. The clinical areas of critical care and emergency (with 15 percent or 4,074 male nurses) and rehabilitation and disability (with 12 percent or 1,046 male nurses) also had higher percentages of males than the overall nursing population. Of the non-clinical areas, management (with 14 percent or 1,084 male nurses) and education (with 11 percent or 551 male nurses) had higher percentages of males than the overall nursing population. A range of reasons may exist for this, for example: Australia s Health Workforce Series - Nurses in focus 15

18 Figure 10: Percentage of employed male nurses by principal area of main job, 2011 MENTAL HEALTH CRITICAL CARE & EMERGENCY MANAGEMENT REHABILITATION & DISABILITY EDUCATION MEDICAL RESEARCH PERI-OPERATIVE OTHER SURGICAL COMMUNITY HEALTH AGED CARE MIXED MEDICAL / SURGICAL PAEDIATRICS GENERAL PRACTICE / MEDICAL PRACTICE MATERNITY CARE FAMILY, MATERNAL & CHILD HEALTH Percent male {%} Source: NHWDS: nurses and midwives While the number of males in the nursing workforce increased from 2003 to 2006, they accounted for less than 10 percent of the registered, enrolled and total nursing workforces in each year (Table 4). Table 4: Employed registered nurses and enrolled nurses by gender, Registered nurses (no.) 189, , , , , ,040 % Male % Female Enrolled nurses (no.) 47,574 48,577 46,044 50,990 50,263 51,711 % Male % Female All nurses (no.) 236, , , , , ,751 % Male % Female Source: AIHW Nursing and Midwifery Labour Force Surveys 2003 to Australia s Health Workforce Series - Nurses in focus 16

19 Average age (years) Percent aged 55 and over Registered nurse Enrolled nurse All nurses Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and from the imminent retirement of older nurses. 12 increasing percentage of those aged 55 years and over. The average age of all nurses increased by approximately one year, from 43.1 in 2003 to 44.3 in 2009, with RNs and ENs experiencing similar increases in average age over the same period (Table 6). A greater percentage of RNs were aged 55 years and over compared with ENs in both years. The percentage of RNs and ENs aged 55 or more also increased (44,823) and employed ENs (3,491) were aged 55 or more. Average age (years) Percent aged 55 and over Registered nurses Enrolled nurses All nurses Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and Most nurses commence their career in the hospital sector. Anecdotally, as nurses become older they move out of this area, with suggested support the view that nurses do move out of the hospital sector as they become older. Figures 11 and 12 show those principal areas where nurses average age is less than the national average. For RNs and ENs this included the principal areas of surgical (RNs 39.3 years, ENs 42.5 years), critical care and emergency (RNs 39.1 years, ENs 43.3) and paediatrics (RNs 38.5 years, ENs 43.1 years) all primarily hospital-based areas. This indicates there are greater numbers of younger nurses working in these areas. Aged care has the highest average age for RNs (49.8) indicating higher numbers of older RNs work in this area. 12 Australia s Health Workforce Series - Nurses in focus 17

20 Figure 11: Employed registered nurses, average age by principal area of main job, 2011 NATIONAL AVERAGE AGE {44.1yRS} AGED CARE FAMILY, MATERNAL & CHILD HEALTH MANAGEMENT COMMUNITY HEALTH RESEARCH EDUCATION MENTAL HEALTH OTHER GENERAL PRACTICE / MEDICAL PRACTICE REHABILITATION & DISABILITY MIXED MEDICAL / SURGICAL PERI-OPERATIVE MEDICAL SURGICAL CRITICAL CARE & EMERGENCY PAEDIATRICS MATERNITY CARE Average age {years} Source: NHWDS: nurses and midwives Figure 12: Employed enrolled nurses, average age by principal area of main job, 2011 NATIONAL AVERAGE AGE {45.5yRS} MATERNITY CARE MENTAL HEALTH MANAGEMENT REHABILITATION & DISABILITY EDUCATION COMMUNITY HEALTH AGED CARE OTHER RESEARCH MIXED MEDICAL / SURGICAL FAMILY, MATERNAL & CHILD HEALTH PERI-OPERATIVE GENERAL PRACTICE / MEDICAL PRACTICE MEDICAL CRITICAL CARE & EMERGENCY PAEDIATRICS SURGICAL Average age {years} Source: NHWDS: nurses and midwives Australia s Health Workforce Series - Nurses in focus 18

21 percent of all RNs aged less than 25 reported their principal area of main job as medical. A further 20 percent of all RNs aged less than 25 reported their principal area as surgical. For both medical and surgical, approximately 5 percent of RNs aged 55 or more reported working in these areas. For ENs, this pattern was not as pronounced. Approximately 11 percent of all ENs aged less than 25 reported their principal area of main job as medical in 2011 (12 percent surgical), which fell to 9 percent of those aged 55 or more (5 percent surgical). Figure 13: Employed registered nurses, selected principal areas of main job by age group, 2011 Figure 14: Employed enrolled nurses, selected principal areas of main job by age group, 2011 Medical Surgical Medical Surgical % of all nurses in age group < Age group % of all nurses in age group < Age group Source: NHWDS: nurses and midwives Source: NHWDS: nurses and midwives Hours worked 2011 In 2011, RNs average weekly hours worked were greater than ENs. Males average weekly working hours were higher than females. As males account for only a small proportion of the nursing workforce, this had little impact on overall average hours worked (Table 7). Table 7: Average weekly hours, employed registered and enrolled nurses, 2011 Male Female Persons Registered nurses Enrolled nurses All nurses Source: NHWDS: nurses and midwives Average weekly hours worked also varied according to principal area of main job. In 2011, RN average weekly hours worked ranged from 28.5 for those working in general practice/medical practice to 39.1 for those working in management. For ENs, average weekly hours worked ranged from a low of 27.5 in family, maternal and child health, to 37.7 in management (Figure 15). Of the clinical principal areas of main job, mental health had the highest average weekly hours worked for both RNs (36.7) and ENs (35.0). areas. Australia s Health Workforce Series - Nurses in focus 19

22 Figure 15: Employed registered and enrolled nurses, average weekly hours worked by principal area of main job, 2011 Registered nurses Enrolled nurses MANAGEMENT MENTAL HEALTH EDUCATION CRITICAL CARE & EMERGENCY MEDICAL REHABILITATION & DISABILITY OTHER AGED CARE SURGICAL RESEARCH PERI-OPERATIVE PAEDIATRICS COMMUNITY HEALTH MIXED MEDICAL / SURGICAL MATERNITY CARE FAMILY, MATERNAL & CHILD HEALTH GENERAL PRACTICE / MEDICAL PRACTICE Average weekly hours Source: NHWDS: nurses and midwives Australia s Health Workforce Series - Nurses in focus 20

23 Hours worked 2003 to 2009 Average weekly working hours of both RNs and ENs experienced little change over the period 2003 to RN average weekly working hours were 32.8 in 2003, rising by less than one hour to 33.6 in For ENs, average weekly working hours in 2003 were 31.2, also increasing by less than one hour to be 32.0 in Male nurses average weekly working hours were consistently higher than females for both RNs and ENs over the same period: As male nurses account for only a small proportion of the nursing workforce, this had little impact on total average weekly working hours (Figures 16 and 17). Figure 16: Employed registered nurses, average hours worked per week, 2003 to 2009 Average weekly hours worked Male Female Persons Source: AIHW Nursing and Midwifery Labour Force Survey 2003 to Figure 17: Employed enrolled nurses, average hours worked per week, 2003 to 2009 Male Female Persons 38 Average weekly hours worked Source: AIHW Nursing and Midwifery Labour Force Survey 2003 to Australia s Health Workforce Series - Nurses in focus 21

24 Average years worked 2011 worked (15.6 years). Average years worked 2003 to 2009 AIHW survey) and For RNs, there was a slight increase, from 16.4 years to 17.6 years, while the average years worked as an EN was the same in both 2004 and 2009 (15.4) Years Registered nurses Enrolled nurses midwife? The national average calculation excludes the Australian Capital Territory. Source: AIHW Nursing and Midwifery Labour Force Survey 2004 and Australia s Health Workforce Series - Nurses in focus 22

25 What sectors and settings do nurses work in? Employment sector The Australian health system is a mix of public and private sector service providers. This includes: and psychiatric hospitals) and maintaining relationships with most healthcare providers. 13 In 2011, most registered nurses and enrolled nurses were employed in the public sector (Table 8). Table 8: Employed registered and enrolled nurses (a) by employment sector of main job, 2011 Sector Number Registered nurses Public sector 132,741 Private sector 70,549 Enrolled nurses Public sector 26,527 Private sector 21,207 (a) Excludes 16,064 registered nurses and 4,908 enrolled nurses who did not state their sector of employment. Source: NHWDS: nurses and midwives Accessed 23 March Australia s Health Workforce Series - Nurses in focus 23

26 In 2003 and 2009, the percentages of RNs and ENs employed in the public and private sectors were similar. Approximately two-thirds of both workforces were in the public sector with the remaining third in the private sector (Table 9). Table 9: Employed nurses by work sector, 2003 and 2009 Registered nurses Enrolled nurses All nurses Number 189, ,040 47,574 51, , ,751 % public sector % private sector Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and Employment setting Historically, nurses have primarily been employed at hospitals, most of which are publicly funded. Even with an increased emphasis on care in of RNs (63 percent or 137,526) and almost one-half of ENs (48 percent or 25,476) worked in a hospital setting (Figure 19). Most other ENs (31 percent or 16,328) worked in a residential healthcare facility. Figure 19: Employed nurses by work setting, 2011 Registered nurses Enrolled nurses 100 Percent {%} Hospital Residential health care facility Community health-care services Private practice All other settings (a) Source: NHWDS: nurses and midwives Australia s Health Workforce Series - Nurses in focus 24

27 Where are nurses located? State and territory distribution 2011 In 2011, three-quarters of RNs worked in New South Wales (29 percent or 63,936 RNs), Victoria (26 percent or 57,275) and Queensland (20 percent or 43,635). This was the same for ENs, with approximately one-third (34 percent or 17,696) working in Victoria, 23 percent (12,276) in New South Wales and 18 percent (9,368) in Queensland. In examining the number of nurses per 100,000 population, the Northern Territory had the highest number of employed RNs (1,263.8 per 100,000 population), and South Australia had the highest number of employed ENs (413.5 per 100,000 population) (Figures 20 and 21). Figure 20: Employed registered nurses, number and number per 100,000 population, states and territories, 2011 Number of registered nurses Number 70,000 60,000 50,000 40,000 30,000 20,000 10,000 Registered nurses per 100,000 population 1,400 1,200 1, Number per 100,000 population 0 NSW VIC QLD SA WA TAS NT ACT 0 Source: NHWDS: nurses and midwives Australia s Health Workforce Series - Nurses in focus 25

28 Figure 21: Employed enrolled nurses, number and number per 100,000 population, states and territories, 2011 Number of enrolled nurses Enrolled nurses per 100,000 population Number 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2, Number per 100,000 population 0 NSW VIC QLD SA WA TAS NT ACT 0 Source: NHWDS: nurses and midwives State and territory distribution 2003 to 2009 Between 2003 and 2009 Queensland experienced the largest increase in the number of employed RNs (10,119). This was the third largest percentage increase (of 30 percent), behind Western Australia and the Northern Territory (both with a 33 percent increase in their number of population. Despite the large increase in employed RNs in Queensland, they had one of the lowest ratios of employed RNs per 100,000 population (979) in South Australia and New South Wales were the only two states with lower ratios (960 and 928 respectively). The Australian Capital Territory and Western Australia had the highest ratios of employed RNs per 100,000 population (1,665 and 1,379 respectively). Other characteristics of employed RNs were similar across the states and territories, with low percentages of males and minimal change in hours worked. The average age of employed RNs in Queensland, Western Australia, the Australian Capital Territory and the Northern percentages of new entrants into the Queensland, Western Australian and the Northern Territory RN workforces. Australia s Health Workforce Series - Nurses in focus 26

29 Table 10: Employed registered nurses, selected characteristics by state and territory, 2003 and 2009 (a) NSW VIC QLD SA WA (b) TAS NT ACT AUS Number of employed registered nurses ,855 49,089 33,218 16,703 16,800 5,425 2,792 3, , ,110 57,940 43,337 21,540 22,407 6,233 3,707 3, ,040 Number of employed registered nurses per 100,000 population ,097 1, , , ,379 1,238 1,052 1,665 1,025 Percent male Average age (years) Average weekly hours worked (a) State and territory estimates for 2009 should be treated with caution due to low response rates in some jurisdictions. (b) Estimates for Western Australia for 2003 should be treated with caution due to the low response rate (19.0%) in the 2003 survey. Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and Australia s Health Workforce Series - Nurses in focus 27

30 Similarly for ENs, as for RNs, from 2003 to 2009, Queensland had the highest number and percentage increase (2,168 and 35 percent respectively) in employed ENs of all the states and territories. The Queensland increase contributed to more than half of the national increase in employed ENs (which was 4,137 between 2003 and 2009). Table 11: Employed enrolled nurses, selected characteristics by state and territory, 2003 and 2009(a) NSW VIC QLD SA WA (b) TAS NT ACT AUS Number of employed enrolled nurses ,625 17,446 6,245 5,180 4, , ,017 17,536 8,412 6,272 4,210 1, ,711 Number of employed enrolled nurses per 100,000 population Percent male Average age (years) Average weekly hours worked (a) State and territory estimates for 2009 should be treated with caution due to low response rates in some jurisdictions. (b) Estimates for Western Australia for 2003 should be treated with caution due to the low response rate (19.0%) in the 2003 survey. Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and Australia s Health Workforce Series - Nurses in focus 28

31 Regional distribution 2011 While having enough health professionals is essential in being able to provide health services, so too is equitable, needs-based distribution National Health Workforce Strategic Framework 14, which provides a set of principles to guide Australia s future health workforce policy and planning. Key to achieving good health outcomes is access to health professionals. In current service delivery models, the primary mechanism for access is through personal contact. Mechanisms such as telehealth, which uses video consultations to reduce barriers such as geographic location to accessing medical services, are also in use. One measure used to determine workforce availability is the ratio between the number of health professionals and an area s population. In 2011, the ratio of RNs to population was highest in major cities (1020.7) followed by very remote areas (1,003.0). Outer regional areas had the lowest ratio of RNs to population (832.0). The opposite was observed with ENs. The highest number of ENs per 100,000 population were found in outer regional areas (311.2) and the lowest in very remote (172.2) followed by major cities (206.6). Figure 22: Employed registered nurses and enrolled nurses, number per 100,000 population by Remoteness Area, 2011 Registered nurses Enrolled nurses Number per 100,000 population 1,200 1, Major cities Inner regional Outer regional Remote Very remote Australia Source: NHWDS: nurses and midwives Remoteness Area the Australian Bureau of Statistics, is used to present regional data for nurses. This structure is based on the Accessibility/Remoteness Index of Australia, where the remoteness index value of a point is based on the physical road distance to the nearest town or service in each of population size classes based on the 2006 Census of Population and Housing. These classes are: 14 Australian Health Ministers Conference National Health Workforce Strategic Framework. Sydney. Australia s Health Workforce Series - Nurses in focus 29

32 Regional distribution 2003 to 2009 Figures 23 and 24 show the distribution of RNs and ENs by Remoteness Area in 2003 and The ratio of RNs per 100,000 population increased across all Remoteness Areas from 2003 to 2009, with the highest increase in remote (from 825 to 988) followed by outer regional (798 to 940). Major cities experienced the smallest increase, from 920 to 950 per 100,000 population. Figure 23: Employed registered nurses, number per 100,000 population by Remoteness Area of main job, 2003 and Number per 100,000 population 1,200 1, Major cities Inner regional Outer regional Remote Very remote Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and The number of ENs per 100,000 population fell across all Remoteness Areas from 2003 to 2009, with the largest falls experienced in very remote (from 250 in 2003 to 202 in 2009) and outer regional areas (from 327 to 295). In both 2003 and 2009, major cities had the lowest number of ENs per 100,000 population (184 and 181 respectively). Figure 24: Employed enrolled nurses, number per 100,000 population by Remoteness Area of main job, 2003 and Number per 100,000 population Major cities Inner regional Outer regional Remote Very remote Source: AIHW Nursing and Midwifery Labour Force Survey 2003 and Australia s Health Workforce Series - Nurses in focus 30

33 While the ratio between the number of nurses and an area s population is a useful measure, it should be noted there is no nationally agreed workforce to population ratio. It also does not account for a number of issues, including: professional providing health services within the community. The distribution illustrated in this publication does not take this differing role into account. 15. This indicates that while the current distribution is relatively even, the ageing of the nursing workforce may lead to a maldistributed workforce in the future. 15 NHWDS: nurses and midwives Australia s Health Workforce Series - Nurses in focus 31

34 How many nurses is Australia producing? There are many aspects to nursing education in Australia today, including: impact on nursing education was the move away from hospital-based to higher education-based training for RNs. This transformation occurred over a period of approximately ten years, from the Commonwealth providing in-principle support for nursing education to move to higher education in 1984, to 1994 when the shift of all RN training to the higher education sector across all states and territories was complete. This transformation occurred within a period of great change within the higher education sector itself, where colleges of universities was created. With the shift in RN training, the Commonwealth assumed responsibility for funding RN training, while state and territory governments are primarily responsible for EN education through the VET sector. Australia s Health Workforce Series - Nurses in focus 32

35 Clinical placement pressures Nursing is a practical discipline. Nursing education is comprised of theoretical and work experience components. Work experience provides the link between theoretical knowledge and practical application, and this is obtained through clinical placements where a nursing competencies in students 16 and that a supportive clinical learning environment decreases attrition rates due to culture shock and competence in readiness for beginning practice as a registered nurse. 17 RN and EN education accreditation standards (developed by the Australian Nursing and Midwifery Council), specify a minimum number of clinical placement hours a course must provide for it to be accredited as a course leading to initial registration as a nurse. These are: 18. Most health profession courses require some clinical placement hours and with increases in enrolments across a range of courses, there is increasing competition and pressure in obtaining clinical placements. Reasons cited as barriers to increasing clinical placements include: institutions gaining access to larger providers who are well established in providing clinical placements. health workforce or differences in organisational culture regarding training the future health workforce. 19 Despite increasing pressures on obtaining clinical placements, the number of clinical placement days for undergraduate courses in nursing increased 8 percent from 2009 (856,175 days) to 2010 (931,202 days). Most clinical placements days occur within the public sector. In 2010 approximately two-thirds (68 percent or 632,588) of clinical placement days were in the public sector, compared with 32 percent (298,614 days) in the private sector. Figures 25 and 26 demonstrate most clinical placements occur in acute settings across the public (473,366) and private sectors (170,646) Clare et al. (2003). Evaluating Clinical Learning Environments: Creating Education-Practice Partnerships and Clinical Education Benchmarks for Nursing, p Health Workforce Australia 2011: Mapping Clinical Placements: Capturing Opportunities for Growth Supply (Clinical Training Provider) Study. Australia s Health Workforce Series - Nurses in focus 33

36 Clinical placement pressures Figure 25: Number of clinical placements days for undergraduate courses in nursing in the public sector, by type of setting, 2009 and , ,000 Clinical placement days { number } 400, , , , , , ,000 50,000 0 Acute Aged care Mental health/ alcohol & other drugs Setting Primary/ community health Other settings Figure 26: Number of clinical placements days for undergraduate courses in nursing in the private sector, by type of setting, 2009 and , ,000 Clinical placement days { number } 140, , ,000 80,000 60,000 40,000 20,000 0 Acute Aged care Mental health/ alcohol & other drugs Setting Primary/ community health Other settings Source: HWA, Mapping Clinical Placements Census, Clinical placement days 2009 to 2010 Australia s Health Workforce Series - Nurses in focus 34

37 Registered nurse students and graduates Nursing as a national priority The Higher Education Support Act 2003 relating to the provision of higher education are to be achieved. An example of a national priority is to increase the number of people undertaking a particular course of study. Nursing was included as a national priority under this Act, and in 2005 this saw price caps for Commonwealth-supported places (CSP) in undergraduate nursing courses frozen at 2004 Higher Education Contribution Scheme (HECS) levels. For other courses of study (except teaching which is also a national priority), price caps for CSP were increased 25 percent above the 2004 HECS charge. Price caps for CSP are primarily the student contribution payment (and for domestic and international fee paying students, are the tuition fees set by the university). By freezing the student contribution amount, this measure was designed to encourage students into nursing. The 2008 Review of Australian Higher Education highlighted that with changes in government funding not compensating fully for are considering ceasing to offer the courses. As a result, the review recommended that the maximum student contribution amount for nursing be increased to the Band 1 rate from 2010, and that a reduction in Higher Education Loan Program (HELP) debt be used nursing students pay the Band 1 student contribution amount, with those graduates that go on to work in nursing having their Overall, commencing enrolments of students in general nursing courses required for initial registration as RNs almost doubled (up 90 incentives for nursing as a priority education area. While domestic commencing enrolments increased 68 percent from 2002 to 2011 (from 8,188 commencing enrolments to 13,749), particular increases occurred between: freeze in student contribution rates for nursing at 2004 HECS levels. of reduced compulsory HELP debt repayments for graduates going on to work in the nursing profession. Strong growth also continued from 2009 to 2010, with commencing domestic enrolments increasing a further 11 percent (to 13,827). The number of overseas commencing enrolments (full-fee paying students) increased substantially over the period 2002 to 2011, rising more than 500 percent (from 397 to 2,579 commencing enrolments). This has resulted in overseas students accounting for almost one in seven (15 percent) of all commencing enrolments in general nursing courses required for initial registration in 2011 (increasing from 5 percent in 2002). Australia s Health Workforce Series - Nurses in focus 35

38 Figure 27: Commencing enrolments, students undertaking general nursing courses required for initial registration, 2002 to 2011 Number of commencing enrolments 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Domestic Overseas Source: DIISRTE Higher Education Statistics Data Cube (ucube), based on the student and staff data collections. The continuation of nursing as a female-dominated profession, as highlighted earlier in this publication, is set to continue. Across the period 2002 to 2011, females accounted for almost 90 percent of all commencing enrolments in courses for initial registration as a nurse (Table 12). Table 12: Commencing enrolments, students undertaking general nursing courses required for initial registration, by gender, 2002 to Commencing enrolments (number) 8,585 8,533 9,289 11,046 12,045 13,436 13,580 15,210 16,626 16,328 % Male % Female Source: DIISRTE Higher Education Statistics Data Cube (ucube), based on the student and staff data collections. In the past, universities were funded by a system that capped the number of places for which public funding was provided, restricting the number of students admitted to courses. From 2012, as a result of the 2008 Review of Australian Education, this has changed. The Higher Education Support Act 2003 currently is not), a provider can enrol as many eligible students as they wish and receive corresponding government subsidies. The impact this change will have on nursing enrolments is yet to be seen. Consistent with the increase in commencing enrolments, the number of course completions for initial registration as a nurse has also increased from 5,571 in 2002 to 9,950 in 2011 (up 79 percent). Within this, domestic completions rose 48 percent (from 5,269 to 7,806) while overseas completions increased more than seven-fold, from 302 to 2,144 (Figure 28). Australia s Health Workforce Series - Nurses in focus 36

39 Figure 28: Students completing general nursing courses required for initial registration, 2002 to 2011 Domestic Overseas 10,000 Number of completions 8,000 6,000 4,000 2, Source: DIISRTE Higher Education Statistics Data Cube (ucube), based on the student and staff data collections. Australia s Health Workforce Series - Nurses in focus 37

40 Nursing student attrition Nursing students represent the major supply source for the future nursing workforce. Student attrition, that is, students commencing but then not completing a course, impacts on future supply. Student attrition is inevitable, with many reasons what the course meets students aspirations), quality of teaching, and social factors such as language background and socioeconomic status. 20 A crude examination of attrition trends is to compare the difference between numbers of students commencing and completing a course over time. Figure 29 shows commencing enrolments in courses leading to initial registration as a nurse against course completions lagged by three years (the general length of a RN course). For courses leading to initial registration as a nurse, the gap between commencements and completions has increased slightly over time, particularly in recent years (for those commencing in 2007 to 2009). Figure 29: Students commencing and completing courses for initial registration as nurses, Completions Commencements Commencing year 16, ,000 14,000 14,000 12,000 12,000 Number 10,000 8,000 10,000 8,000 Number 6,000 6,000 4,000 4,000 2,000 2, Completion year Source: DIISRTE Higher Education Statistics Data Cube (ucube), based on the student and staff data collections. 20 Australia s Health Workforce Series - Nurses in focus 38

41 Enrolled nurse students As noted earlier, ENs are trained through the VET system, which is primarily managed and funded by state and territory governments. VET providers include the state and territory TAFE systems, adult and community education providers, agricultural colleges, the VET operations of some universities, schools, private providers, community organisations, industry skill centres, and commercial and enterprise training providers 21 while VET system students enrol in courses, in some instances they only do so for the purpose of completing particular modules of that the intention of qualifying as an EN. Enrolled nurse accreditation/education changes To be able to register as an EN, a person must have completed an accredited EN training course. Accreditation, carried out by the Australian Nursing and Midwifery Accreditation Council, ensures the training courses produce graduates considered as competent for beginning level practice, with foundational knowledge, professional attitudes and essential skills that are both transferable and 22 The course accreditation standards state that the course length and structure is determined primarily by the National Health 23 In the National Health Training Package there are currently three approved programs of EN study: being phased out. This primarily affects Victoria and New South Wales, as other states and territories have already moved to the diploma. The NMBA has a goal that all ENs practicing in Australia will, as part of their education program, have completed study enabling The above changes mean the EN workforce, particularly in Victoria and New South Wales, have mixed education levels and consequently mixed scope of practice responsibilities. Data available shows EN commencing enrolments rose steadily from 2002 (6,347) to 2008 (12,238), almost doubling (up 93 percent) over the period. Some variability has occurred since then. A substantial fall (of 19 percent or 2,315) occurred in commencing enrolments between 2008 and 2009, however most of this was recovered from 2009 to In 2011, commencing enrolments continued to increase, reaching 12,232 (Figure 30). Similar to RNs, males form a small percentage of commencing EN enrolments, ranging from a low of 12 percent across 2004 to 2007 inclusive to a high of 16 percent in NCVER glossary. Available at: Accessed 23 March Australian Nursing and Midwifery Accreditation Authority. Standards and Criteria for the Accreditation of Nursing and Midwifery Courses Leading to Registration, Enrolment, Endorsement and Authorisation in Australia with Evidence Guide, Enrolled Nurses Ibid. Australia s Health Workforce Series - Nurses in focus 39

42 Figure 30: Enrolled nurse commencing enrolments, Number of commencing enrolments 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Females Males Note: ASCO code 341 Enrolled Nurses and ANZSCO code 4114 Enrolled and Mothercraft Nurses. Source: NCVER data request, VET provider collection. completed over the period 2002 to 2010 occurred in 2004 (2,175), with the highest in 2007 (4,598). In 2010, the number of enrolled nurse to ,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Females Males Note: ASCO code 341 Enrolled Nurses and ANZSCO code 4114 Enrolled and Mothercraft Nurses. Source: NCVER data request, VET provider collection. Australia s Health Workforce Series - Nurses in focus 40

43 How many nurses are from overseas? part of the NRAS registration data, however it was not able to be reported for 2011 due to issues with data migration from some of the previous jurisdiction-based systems. It is expected to be able to be reported in future years. Migration plays an important role in the supply of Australia s nursing workforce. 24 The AIHW Nursing and Midwifery Labour Force Survey 2009 were similar: overseas-trained ENs may include: applicant Australia s Health Workforce Series - Nurses in focus 41

44 The immigration process for overseas trained nurses To apply to work in Australia as a nurse, applications need to be submitted to two organisations: 1. The NMBA for registration as a nurse. 2. DIAC, for a visa to work in Australia. Applying to the NMBA for registration because every nurse who wants to practice in Australia must be registered with the NMBA by law. The NMBA Framework against which overseas nurses are assessed: 1. The applicant must establish their identity. professionals must be able to communicate effectively in English with their clients and other health professionals. 3. The applicant is assessed as meeting current Australian nursing and midwifery education standards. of time preceding the application. As part of their assessment, the NMBA can request that overseas nurses undertake a bridging program prior to gaining registration, for which temporary visa options exist (the occupational trainee and business short-stay visas). Applying to DIAC for a visa Permanent and temporary visa options exist for overseas nurses who wish to work in Australia. To be eligible for the permanent skilled independent migration pathway, an applicant must be applying for an occupation that appears on the Skilled Occupation List (SOL, see separate box). To be eligible for the nominated or sponsored permanent migration pathways, an applicant must be applying for an occupation that appears on the Consolidated Skilled Occupation List (CSOL, see separate box). RNs appear on both lists, ENs on the CSOL only. Overseas RNs applying for a permanent migration pathway have a skills assessment conducted by the Australian migration. This determination forms part of their visa application. ENs and nurses (RNs or ENs) applying for working holiday or temporary visas are not assessed by ANMAC, and apply directly to the NMBA for registration or enrolment. While an overseas nurse may apply to DIAC for a visa prior to gaining registration, a visa will not be approved until nursing registration is obtained. In addition to the previous steps, nurses also need to pass a health examination, including a chest x-ray, to work in a hospital or other healthcare area. Australia s Health Workforce Series - Nurses in focus 42

45 Visas granted A range of temporary and permanent visa options exist that nurses wishing to work in Australia can choose. Of the temporary visa options, the 457 business (long-stay) visa is the most common temporary visa used by employers (Table 13). Almost all 457 business (long-stay) visas granted over the last seven years have been to overseas RNs. The highest number of ENs this visa type was granted to, was 47 in For overseas RNs, 457 business (long-stay) visa grants reached a peak of almost 4,000 in The two years following this peak saw a substantial fall, with grants almost halving, to 2,146 in However in , temporary visa grants increased again, rising by 44 percent (Table 13). The 442 occupational trainee visa allows people to complete workplace-based training in Australia on a temporary basis. This visa option is often used when the NMBA requests an overseas nurse complete a bridging program prior to gaining registration. Few of these visas are granted compared with 457 business (long-stay) visa grants (Table 13). Table 13: Number of 457 temporary business (long-stay) visa grants to nurses, to Registered nurses (a) 457 Business (Long Stay) 2,609 3,011 3,375 3,977 2,624 2,146 3, Occupational Trainee Total 2,697 3,028 3,390 4,057 2,632 2,149 3,118 Enrolled nurses (b) 457 Business (Long Stay) Occupational Trainee Total (a) ANZSCO code 2544 Registered nurse. (b) ANZSCO code Enrolled nurse. Source: Department of Immigration and Citizenship administrative data. Australia s Health Workforce Series - Nurses in focus 43

46 Nursing, the Skilled Occupation List and Consolidated Sponsored Occupation List The Skilled Occupation List (SOL) was developed by Skills Australia (now the Australian Workforce and Productivity Agency or AWPA) for DIAC as part of the reforms to the general skilled migration program. The SOL is used to determine eligible occupations for long-term skill needs of the Australian economy. 26 The SOL is drawn from the Specialised Occupation List (SpOL), also developed by AWPA. To be on the SpOL, occupations must satisfy two of the following three criteria: long lead-time; high use; high risk. In addition, the occupation must satisfy a fourth criterion of high information. RNs are included on the SOL. This means overseas RNs can apply for a permanent visa through the skilled independent pathway (which does not require sponsorship). Enrolled nurses, although on the SpOL, are not currently on the SOL. Reasons documented by AWPA for this decision are that labour market and education data indicates that the occupation is likely to be in oversupply in the medium term and: below average. percent in the past 2 years (NCVER Provider Collection, 2010). 27 By not appearing on the SOL, ENs are not eligible to apply for a permanent visa through the skilled independent migration pathway. the Employer Nomination Scheme and the Subclass 457 Skilled Occupation Lists. The CSOL now determines occupations that applicants can nominate for under the permanent sponsored migration pathways, and the temporary 457 Business (Long Stay) pathway. Both RNs and ENs appear on the CSOL. RNs appear on the Skilled Occupation List (SOL, see separate box), which means overseas RNs can apply for a permanent visa in Australia without sponsorship. Other permanent migration pathways needing employer or state/territory government sponsorship are available to both RNs and ENs. Permanent visa grants to RNs almost doubled (up 91 percent) from to reach a peak of 4,133 in From to , this trend reversed and permanent visa grants fell almost one-quarter (24 percent) to 3,160 (Table 14). It should be noted that permanent visa grants are likely to include people who initially arrived on a temporary visa. Table 14: Permanent visa grants, to Registered nurses (a) 2,161 2,174 2,478 3,492 4,133 3,400 3,160 (a) ANZSCO code 2544 Registered nurses Source: Department of Immigration and Citizenship administrative data. 26 Australian Workforce and Productivity Agency. Available at: Accessed 7 November Australian Workforce and Productivity Agency. Available at uments/4114enrolledandmothercraftnurses.pdf. Accessed 23 March Australia s Health Workforce Series - Nurses in focus 44

47 Within the permanent migration options, the employer sponsored visa and the skilled independent visa were the most popular for RNs. Together, these two visa types accounted for more than 80 percent of permanent visas granted over the period to The two visa types experienced opposite trends over the period: Figure 32: Permanent visa grants to registered nurses by type of visa, to Skilled Australian sponsored State/Territory sponsored Skilled independent Employer sponsored % Source: Department of Immigration and Citizenship administrative data. While few ENs are granted a permanent visa, there has been a substantial increase in EN visa grants in recent years, rising from 6 in to 59 in As noted earlier, low numbers of EN visa grants is likely due to a combination of ENs not appearing on the SOL and many countries not educating to the EN level. Those that were granted a permanent visa would have arrived through a sponsored pathway, either state/territory, employer or regional sponsored. Table 15: Permanent visa grants, to Enrolled nurses (a) (a) ANZSCO code Enrolled nurse Source: Department of Immigration and Citizenship administrative data. Countries of origin Table 16 shows the citizenship countries overseas RNs with a 457 temporary business (long-stay) visa grant were most commonly sourced from in and India, the United Kingdom and the Philippines accounted for three-quarters of all overseas RNs in Both India and the Philippines recorded large increases in the number of RNs granted a 457 visa from to India more than quadrupled from 207 to 1,108, while the Philippines more than tripled, from 144 to 476. In contrast, the number of 457 visa grants to overseas nurses from the United Kingdom was almost the same in the two years. Australia s Health Workforce Series - Nurses in focus 45

48 Table 16: Number of 457 Temporary Business (Long-stay) Visa grants to Registered nurses, by citizenship country Citizenship country no. % no. % India , United Kingdom Philippines Ireland Nepal Zimbabwe China (excludes SARs and Taiwan) United States of America Canada South Africa Korea, Republic of (South) Singapore Other countries (a) Total 2, , Source: Department of Immigration and Citizenship administrative data. It should be noted a substantial number of New Zealand nurses enter Australia. 28 New Zealand citizens do not have the same visa requirements as other countries. The 1973 Trans-Tasman Arrangement has allowed New Zealand citizens to visit, live and work in Australia without the need to apply for authority prior to travelling. From 1 September 1994, all non-citizens in Australia must hold a visa, and the Special Category Visa (SCV) was introduced for New Zealand citizens. With the SCV, as long as a New Zealand citizen wanting to enter Australia presents a valid New Zealand passport for immigration clearance, they are considered to have applied for, and will receive (subject In recent years, there have been increasing global concerns about the impact of international health professional recruitment on developing countries workforce supply. This coincides with the change in magnitude of migration from different source countries, as outlined above. In recognition of such concerns, Australia: (Commonwealth Secretariat, 2003). large origin countries such as India or Russia albeit large in absolute terms remains low compared with the size of their total workforce. In addition, some countries with a percentage of their health personnel abroad manage to maintain relatively high numbers of health workers at home. This is the case notably for countries that train nurses for export, such as the Philippines, some Caribbean states and increasingly, China. 29 These countries referred to by the OECD (India, the Philippines and China) all have substantial levels of nursing migration to Australia and 9 August 2011, and were employed as a RN. 29 OECD. International Migration of Health Workers: Improving international co-operation to address the global health workforce crisis. Australian Policy Online. Australia s Health Workforce Series - Nurses in focus 46

49 Summary NHWDS. Future surveys collected on the same basis as 2011 provide a great opportunity to better understand this essential workforce. In 2011, the nursing workforce: Over 2003 to 2009, the number of RNs and ENs increased. Characteristics of the workforces remained similar in many aspects. Most RNs and ENs were clinical nurses providing direct patient care, male nurses continued to form only a small percentage of the workforce and average weekly working hours changed minimally. Average age is slowly increasing and, particularly for RNs, the proportion aged 55 and over increased substantially from 2003 to The ageing nursing population raises concerns for the future, particularly in combination with: Education and immigration, the primary supply mechanisms for the nursing workforce, are experiencing change. The number of students commencing and completing courses for initial registration as a nurse in the university sector have both increased. In the VET sector, the permanent visa grants have fallen in recent years for RNs, while temporary RN visa grants have varied, and EN migration numbers are minimal with little impact on the overall workforce. Altogether, there are a number of challenges facing this essential component of Australia s health workforce into the future. Australia s Health Workforce Series - Nurses in focus 47

50 Technical notes Revisions to NHWDS: nurses and midwives 2011 Nursing and midwifery workforce Revisions have been made to the data since publication. Data presented in this publication will not match AIHW published totals. NHWDS: nurses and midwives 2011 delineation between nurses and midwives The NHWDS: nurses and midwives 2011 combines data from the NRAS with nursing and midwifery workforce survey data. The data set contains information on the demographic and employment characteristics of nurses and midwives who were registered in Australia in Data was collected via registration forms and a survey instrument administered by the Australian Health Practitioner Regulation Agency, in conjunction with the annual registration renewal process for nurses and midwives. to 2011 data to delineate the nursing and midwifery workforces. Nurse registrations Under NRAS, a person can be registered as a: This publication focuses on nurses. Those people that were registered as a midwife only are excluded from all data in this publication. Table 17 shows the breakdown of nurse only, dual-registered nurse and midwife, and midwife-only registrations in Total nurse registrations of 328,817 is reported in this publication. Table 17: Nursing and midwifery registrations, 2011 Category Number Registered nurse only 229,336 Midwife and registered nurse 39,547 Enrolled nurse only 59,912 Midwife and enrolled nurse 22 Total nurse registrations (including dual-registered nurses and midwives) 328,817 Midwife only 1,863 Total nurse and midwife registrations 330,680 Source: NHWDS: nurses and midwives Australian Institute of Health and Welfare Nursing and midwifery workforce National health workforce series no. 2. Cat. no. HWL 48. Canberra: AIHW Australia s Health Workforce Series - Nurses in focus 48

51 Employed nurses Dual-registered nurses and midwives can work in nursing and/or midwifery. The NHWDS collects information on principal area of main job, and in 2011, dual-registered nurses and midwives were only able to report one principal area of main job. The options in 2011 were: For the purposes of this publication, dual-registered nurses and midwives who reported a principal area of main job of midwifery are considered to be midwives, and have been excluded from the nursing population. As principal area of main job is only reported for nurses who were employed or on extended leave at the time of the survey, these two categories, and consequently the category in the nursing labour force, are affected. Dual-registered nurses and midwives who reported a principal area of main job of midwifery are shown as not in the nursing labour force employed or on extended leave in midwifery in Figure 1 in this publication. Table 18 shows the number of dual-registered nurses and midwives who reported midwifery as their principal area of main job. Table 18: Dual-registered nurses and midwives excluded from the nursing population, 2011 Registered nurse and midwife Enrolled nurse and midwife All dual-registered nurses and midwives Employed in nursing or midwifery 13, ,136 On extended leave Total 13, ,805 Source: NHWDS: nurses and midwives 2011 There were a small number of nurses without dual registration who reported their principal area of main job as midwifery in With national registration, a person must be registered as a midwife to provide midwifery services, and it is assumed these nurses were providing principal area of main job for these nurses. In the 2012 nursing survey, the principal area of main job options have been updated and maternity care has replaced midwifery. In the 2012 NHWDS: nurses and midwives, dual-registered nurses and midwives were able to report hours worked as a nurse and hours worked as a midwife, along with a separate principal area of main job for their nursing and midwifery work. The business rules to be applied available. A midwifery-focused publication will be developed after the release of NHWDS: nurses and midwives 2012, to examine the characteristics of the midwifery population. Nurses and midwives in the 2003 to 2009 AIHW Nursing and midwifery labour force surveys Until 2010, a separate register of practitioners did not exist for midwives. This means that it is not possible to separately identify nurse and midwife registrations in data that predates In this publication, the 2003 to 2009 AIHW Nursing and Midwifery Labour Force Survey data includes midwives in the category of registered nurses. This is consistent with AIHW Nursing and Midwifery Labour Force publications. Comparisons between 2011 data and data from previous years are not recommended. Australia s Health Workforce Series - Nurses in focus 49

52 Enquiries concerning this report and its reproduction should be directed to: Health Workforce Australia GPO Box 2098 Adelaide SA 5001 Telephone Internet Health Workforce Australia 2013 HWA13IAP002 Published March 2013 ISBN: