Review of Australian Government Health Workforce Programs

7.3 Nursing and midwifery workforce sustainability

Page last updated: 24 May 2013

As indicated above, a general concern persists that with the current increase in the number of nursing graduates, there are not sufficient opportunities to provide employment for new graduates up until 2016, when the modelling suggests that the balance of those entering and leaving the workforce is likely to be in equilibrium. Vacancies are currently lower than normal as retention rates have increased for nurses (and anecdotally midwives). It is currently unclear whether this is a short-term phenomenon or an indication of a longer term trend. As noted earlier, the assumptions used in HWA’s modelling of the nursing and midwifery workforce need to be revalidated in the future.

A number of jurisdictions have recently reported significant difficulties with the placement of nursing graduates. In Tasmania, it has been asserted that many new registered nurses may be forced to move to mainland Australia to seek employment, as a result of the Tasmanian Government’s budget situation. Queensland and Victoria have also noted concerns that they will not be able to find positions for all new nursing graduates, while SA has considered an option to offer older nurses a retirement package to open up positions for nurse graduates.

HWA has undertaken a short-term project to address recruitment issues for graduate nurses and midwives. Subsequently a web-based information portal has been established which provides links to existing graduate programs in the public, private and NGO sectors. The portal is designed to complement employers’ usual recruitment processes by offering a site to post information about recruitment processes and vacancies.

During the course of this review, there was some discussion regarding mature age entrants to nursing education programs. These new entrants to the nursing and midwifery workforce are more mature, have qualifications and careers in other sectors, and have chosen a career change to the health professions. This group are different from those choosing nursing and midwifery as school leavers and by making this active choice at an older age, are more likely to remain within the profession until retirement. The educational pathways that facilitate this activity should be further investigated, as this may enable older applicants in regional and rural areas to consider nursing as a career option.

Overseas nurses and migration issues

There has been an increasing trend internationally to employ overseas qualified nurses to fill nursing shortages. This has become a practice of countries such as Canada, the UK, the US and Australia. Approximately 15% of all nurses and midwives currently practising in Australia were either born overseas or obtained their initial nursing qualification overseas. Australia is a signatory to a number of global and regional codes of practice relating to the recruitment of internationally trained health professionals. Under the codes, Australia must refrain from actively recruiting nurses and midwives in those countries that are experiencing a lack of trained health professionals.

A number of countries, including Malaysia and the Philippines, have developed university courses which have direct application and skills matched to those required in developed countries, such as Australia.

Conversely, it needs to be pointed out that the globalisation of the nursing profession has also facilitated a large number of Australian nurses moving overseas to work. It is likely that this helps balance the impact of migration flows. For example, the Nursing and Midwifery labour force survey, published by the Australian Institute of Health and Welfare (AIHW), provides data on the nursing labour force (those employed, on extended leave or looking for work). In 2009 there were estimated to be 3,233 nurses who were overseas and not in the nursing labour force. In 2011, this number was 10,166, an increase of 214% in two years.167

This data may be indicative of a trend emerging in Australia whereby Australian educated registered nurses are choosing to migrate overseas to find work. It is also possible that the apparent trend is an artefact of improved data collection, given the response rate for the 2011 survey was over 86% compared to around 44.4% for the 2009 labour force survey.168 While this is unlikely to be become a large scale trend (given recent downturns in nurse employment in countries like the UK) this issue has some potential to add an additional element of complexity to workforce planning.

Re-entry arrangements

Nurses who have had significant years out of the nursing workforce are required to undertake refresher or re-entry programs to gain registration. After ten years, this may require nurses to enrol in a new entry qualification at university. Many of these nurses will be given some credit for previous studies, but nevertheless, those who have been out of the workforce for a long period may have to undertake a full three year program. This has caused particular concern for nurses in New South Wales where previously jurisdictional registration did not specify or mandate continuous professional development or recency of practice.

Guidelines for accreditation of these programs are being reviewed and updated by the Australian Nursing and Midwifery Accreditation Council. At this stage there is clearly an issue for rural nurses who are unable to access requirements locally. Costs of re-entry courses are also reported to be prohibitive for some nurses, with costs reputedly as high as $16,000. Those rural and remote students, who are unable to access courses locally, also incur additional living away from home expenses.

One proposal which seems to have merit would be that the Commonwealth should provide flexible financial support (covering, for example, tuition fees, travel, accommodation and living expenses) of up to $10,000 per recipient under the NAHSSS initiative for supervised re-entry courses for those registered nurses in regional, rural and remote locations, seeking to return to the workforce after extended periods away, until satisfactory flexible delivery or e-learning options are available in all states and territories.

As there is some limited scholarship assistance provided by some jurisdictions for this activity, care must be taken to ensure equity and fairness and systems put in place to avoid multiple scholarships being provided to an individual to undertake the same activity. Any such scheme would also need to be carefully designed and monitored, as there is some history of well-meaning schemes failing to achieve significant outcomes. Financial assistance to undertake re-entry and refresher courses is also discussed in the scholarship section of Chapter 3.

Further credentialing issues

Under NRAS, there are only two categories of nurse, enrolled nurse and registered nurse. There are several endorsement processes available for both registered nurses and midwives, such as nurse practitioners and eligible midwives, which allows these clinicians to work in situations of increased autonomy and at higher levels of scope of practice and may provide access to prescribing rights. Part of the requirement is to have collaborative arrangements in place with medical practitioners. For those working in private practice, clients of nurse practitioners and eligible midwives can access MBS and PBS benefits for services provided.

In clinical practice, many senior clinical nurses hold postgraduate qualifications in areas of specialty such as acute care, intensive care and emergency nursing, rehabilitation and cancer care. Although jurisdictional industrial awards vary, some jurisdictions require formal qualifications to hold positions at senior clinical levels. These roles can provide advice and leadership for generalist nurses working in specialty areas, and may provide consultancy services for clients with complex needs. These additional skills can also provide opportunities for vertical career pathways as a clinician.

There is growing interest in increasing formal nurse credentialing. The Australian College of Mental Health Nurses has led this move and has a well-developed process requiring a certain level of qualification, years of current experience, professional development requirements and referee support. In 2011, under the auspices of the Coalition of National Nursing Organisations (CoNNO), a project was completed that provides guidance for other nursing organisations to develop credentialing processes.

In some situations this process has some merit, where a nurse may be working in relatively autonomous areas of practice, for example, a private mental health nurse working in a community setting who sees clients on a one-to-one basis. However, there is increasing concern that this amount of ‘specialisation’ is not essential for most clinical positions and may become an unnecessary formal requirement. This poses the risk of limiting horizontal career pathways, reducing recruitment pools and developing a requirement for formal education and training that is not necessary to perform the duties of a position competently and safely.

The issue of sub- or super-specialisation is most often raised in the medical workforce context, but the core issue potentially applies to the nursing workforce as well. If specialisation becomes an issue, there is a real possibility that some flexibility in the workforce, particularly in rural and remote areas will be reduced. There is a need in both the medical and the nursing and midwifery professions to encourage generalist roles, while still ensuring there is an appropriate balance of specialist and generalist skills.

It is important that the concept of on-the-job informal training and mentoring is not lost to formal processes which may limit access to service for clients and limit employment opportunities and choice for nurses and midwives. In the same vein, assessment of use of VET-trained assistants (enrolled nurses and assistants in nursing) to provide support to registered nurses with routine tasks within the clinical setting must be a consideration.

Assistants in nursing workforce

The introduction and usage of an assistant workforce to support registered nurses and midwives to work to the top of their scope of practice has been identified by some stakeholders as a priority activity to address the predicted nursing and midwifery shortage. This needs careful consideration in consultation with the professions and will need to be done in conjunction with the VET sector and a variety of health service delivery providers to ensure adequate numbers of participants are employed to ensure this training and employment option is viable into the future. In parallel, investigation of new and innovative models of care designed to increase productivity of the health workforce should be developed and piloted before consideration of a wider rollout of these activities is considered.

There are a number of terms used to describe individuals performing duties to assist nurses and midwives in delivering patient care, for example Nursing Assistants, Assistants in Nursing, Health Assistants in Nursing, Personal Care Workers and Personal Care Assistants. For convenience for the purposes of this paper, the term ‘Assistants in Nursing’ (AINs) is used.

During the course of the review, nursing stakeholders and private health care providers noted that a significant percentage of the private aged care sector workforce is made up of enrolled nurses and assistant level staff. There are a number of programs and activities managed by DoHA and by HWA that are aimed directly at new models of care and service delivery for all levels of staff in the aged care sector. This includes nurse practitioners, registered and enrolled nurses and the assistant workforce.

The lessons learned and outcomes of these activities should be analysed with a view to transferring relevant learning or models of care to other health service delivery settings. This must be done in consultation with the nursing and midwifery profession leaders.

The call for innovation and reform of the nursing and midwifery professions in Australia has led a number of jurisdictions to commission work to investigate the role of assistants in nursing in the health workforce. It appears clear that such a role is not embraced by parts of the nursing profession. Others hold the view that assistants can potentially be a productive, efficient, innovative and viable workforce model. This is supported by the recent findings of a number of pilot projects in Victoria and NSW.

From 2005 to 2011, Victoria’s Better Skills Better Care (BSBC)169 strategy explored and trialled innovations that sought to improve workforce capacity, utilisation and the sustainability of service delivery, while maintaining and improving quality of outcomes, efficiency and worker satisfaction. The objective of the strategy was to ensure “that the right people with the right skills were in the right place at the right time to deliver quality care to patients. The strategy sought to extend the skills in nursing and allied health together with building an assistant workforce.

Box 7.4: Better Skills, Better Care strategy

Through the BSBC strategy, Austin Health ran a pilot project to introduce six Health Assistants in Nursing (HANs) across three wards. The evaluation of the strategy found that the model would be replicable and scalable in other health services with similar demographic and regional characteristics. Some of the findings from the pilot included a reduction in overtime hours worked and satisfaction by registered nurses who, through the use of HANs, were able to work on more clinically orientated tasks. Patient complaints decreased by 50% and overall, patients felt they benefited from the one-on-one contact provided by HANs. Perhaps most notable to the success of the trials was that, in all three pilot sites, there was strong executive and managerial support for the implementation of HANs.170

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Similarly in NSW, the Healthcare Assistant Initiative entitled Assistants in Nursing working in the acute care environment171 supported the employment and clinical allocation of AINs. AINs are defined in the document as “a health care provider who assists health care professionals in the provision of nursing care to patients in acute care settings”.

Box 7.5: NSW Assistants in Nursing working in the acute care environment initiative

The resource provides a series of guidelines through which AINs may most successfully be utilised in the care environment. It consists of processes to assess and evaluate AINs in clinical environments, the education and development needs of AINs, components of establishing the scope of practice of AINs, and delegation and supervision guidelines. The initiative is a model of innovative service delivery through the refinement of policies, protocols and guidelines to suit individual health services.

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The potential inclusion of AINs within NRAS was one of the major topics of discussion amongst nursing stakeholder groups during this review. The Australian Nursing Federation (ANF), for example, expressed a firm view that AINs should become registered in order to enhance the quality of services for patients and to ensure their scope of practice is clearly defined.172 The ANF appears to be resistant to any increased use of AINs within the workforce until they become a registered professional group, with clear lines of responsibility between registered nurses and assistants.

The potential for greater acceptance of an expanded role for AINs by other health professionals, along with the development of more consistent educational standards and subsequent improvements in patient safety, appear to be the main arguments in favour of adopting registration requirements. In addition, registering this group would enable better monitoring of workforce data through linkages with AHPRA systems.

However, other review consultations have provided a note of caution in terms of this proposal. AINs are a major part of the private sector health workforce, particularly in aged care settings, and private sector stakeholders expressed reservations about the imposition of greater regulation upon this workforce. This was primarily on the basis of concerns about reduced flexibility, with AINs often performing different roles in a variety of settings. Potential cost implications, both for employers and individual health workers, were also expressed as key concerns.

While making recommendations for the inclusion of new professional groups within NRAS is outside the scope of this review, this issue clearly needs further informed debate amongst stakeholders that is focused on reaching agreement about what are the appropriate costs and benefits of AIN registration from the perspective of professional groups, employers (public and private) and individual health workers. Given the challenges of ensuring the community has access to sustainable nursing and midwifery services in the future, it is important that the efficient use of this workforce group is not restrained by a continuing unresolved professional debate around registration and accreditation issues.


Nurse and midwives are the largest professional group in the health workforce. There are a variety of both public and private employers of nurses and midwives in Australia, each offering different industrial arrangements and employment conditions, which further varies between states and territories. There are a range of embedded cultural issues within the profession that differ between settings and nursing teams.

While the notion of nursing retention as a lever for reducing the predicted nursing workforce shortfall is not new, the enormity of the challenge appears to have hampered momentum in this area. Nursing workforce retention is recognised internationally as the key to addressing the nursing workforce shortage and HWA has been contracted to conduct a series of projects in this area.

The predicted nursing workforce shortage crisis is well recognised, both within health and the broader labour market and there is an agreed need for change. All Australian Governments have agreed on the need for coordinated, long-term reforms by Governments, professions and the higher education and training sector to ensure Australia has an affordable and sustainable health workforce to meet the future health needs of the community.

The challenge is made even more difficult by the variability of current forecasts for future workforce need. The key to driving change in this area will not only be in ensuring engagement and collaboration of all necessary stakeholders, but in all parties agreeing to a course of action for the future and taking ownership of the issues and solutions.

Recommendation numberRecommendationAffected programsTimeframe
Recommendation 7.1The Commonwealth should work with the profession and across jurisdictions to establish a National Nursing and Midwifery Education Advisory Network (NNMEAN) that would develop five year rolling nursing education plans across the whole training pipeline from enrolled and undergraduate nurse training to advanced scopes of practice and nurse practitioner candidates.

These plans will be based on the best possible nursing workforce data and take into account health service delivery requirements (both in the public and private sectors) and consider both the supply and demand issues.

HWA, support through the Health Workforce FundMedium term – formation of the network and the development of consensus on its role would take some time.
Recommendation 7.2As part of the wider NNMEAN work, an appropriate organisation should be tasked with identifying and analysing the issues related to a perceived reluctance by employers to employ newly graduated nurses.

Further, they should identify actions that could be taken in the undergraduate program to allay these issues and provide advice and options on how professional groups and employers could best support nurses to ensure they are retained within the profession upon graduation.

HWA, support through the Health Workforce FundMedium term – linked to the establishment of NNMEAN.
Recommendation 7.3The Commonwealth should consider providing seed funding for a feasibility study of a national rollout of leadership courses to mid-level nurse and midwife managers, based on the New South Wales Government sponsored Essentials of Care program.

This would build on work that Health Workforce Australia (HWA) is doing in its Health LEADS Australia health leadership framework. The Australian College of Nursing should lead this work and the resulting education activities should be considered eligible for support under various scholarship schemes until these courses are well established and sustainable under a user pays system.

New funding – Health Workforce FundShort term – work on this project could commence immediately post-Review, subject to available funding.
Recommendation 7.4The Commonwealth should consider providing flexible financial support under the Nursing and Allied Health Scholarship and Support Scheme (NAHSSS) of up to $10,000 (per recipient) for supervised re-entry courses for those registered nurses in regional, rural and remote locations, seeking to return to the workforce after extended periods away, until satisfactory flexible delivery or e-learning options are available in all states and territories.

The University Departments of Rural Health (UDRH) program could potentially provide a platform for delivering this education in some rural and remote areas.

NAHSSSShort term – redirection of NAHSSS priorities, existing funding.
Recommendation 7.5The Commonwealth should continue its investment in the Practice Nurse Incentive Program (PNIP) but the Nursing in General Practice Program (NiGP) should be integrated with the activities of Medicare Locals.PNIP, NiGPShort term – NiGP activities to be integrated with Medicare Locals from 2013-14.
Recommendation 7.6The Commonwealth should develop a model based on the Remote Vocational Training Scheme (RVTS) model to allow distance education and supervision. This will allow highly qualified nurses working in rural and remote areas to access clinical experience and supervision while still delivering services in those areas.

Additionally, the scheme could be modified to include education and supervision requirements associated with nurses undertaking extended scope of practice, such as advanced practice nurses or nurse endoscopists. These activities could support increased access to services for rural and remote communities.

RVTSMedium term – subject to available funding and engagement with the profession.
Recommendation 7.7The Commonwealth agencies involved in nursing education need to investigate the availability and cost of VET sector training as it relates to enrolled nurses. There are a declining number of enrolled nurse places/courses being offered and a reason raised within consultations was cost (approximately $16,000 for an enrolled nursing course). Enrolled nursing students/courses should be eligible for scholarship support. Research and policy development across DoHA, DEEWR and DIICCSRTE, scholarships.Longer term
Recommendation 7.8The Commonwealth should undertake an analysis of activity in other similar countries, such as the United Kingdom, New Zealand and Canada where enrolled nurse positions (and therefore training) have been reduced or removed entirely. This work would inform policy development in this area. Recently these countries have revised the enrolled nurse role in response to community needs and workforce pressures.Nil – research and policy developmentLonger term

167 Australian Institute of Health and Welfare 2012 Nursing and midwifery workforce 2011. National health workforce series no. 2. Cat. No. HWL 48, Canberra: AIHW.

168 ibid.

169 Price Waterhouse Coopers, Evaluation of three Better Skills Better Care (BSBC) pilot projects, Department of Health, Victoria 2011.

170 ibid.

171 NSW Department of Health, Assistants in nursing working in the acute care environment – Health Service Implementation Package, NSW Department of Health, 2009, accessed at

172 ANF Position Statement: Assistants in Nursing (however titled) Providing Aspects of Nursing Care, June 2011, accessed at