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Where Have All the Young Ones Gone: Implications for the Nursing Workforce

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Vicki Drury, PhD, RN, RMHN
Karen Francis, PhD, RN
Ysanne Chapman, PhD, RN

Abstract

The global nursing shortage, coupled with an ageing nursing workforce, has placed significant pressure on the Australian Government to implement strategies to meet future nursing demands as well as develop strategies to manage the current crisis. In response, the Australian government funded additional undergraduate places at universities between 2002 and 2008 and offered financial incentives for nurses who were not currently employed to return to practice. Many undergraduate places at the university (in all disciplines) have been taken up by mature-aged students. The high percentage of graduating, mature-aged nursing students is helping to alleviate the current nursing shortage, but runs the risk of exacerbating the shortage projected to occur around the year 2020. This article postulates that graduating this high percentage of mature-aged nursing students is making a significant contribution to nursing today, helping to alleviate the current nursing shortage. However, it runs the risk of exacerbating the shortage projected to occur around the year 2020. In this article the authors explore the current nursing shortage and the changing educational opportunities that affect recruitment of mature-aged students into tertiary-based nursing programs. Recommendations are provided for appropriate succession planning for the future.

Citation: Drury, V., Francis, K., Chapman, Y. "Where Have All the Young Ones Gone: Implications for the Nursing Workforce" (December 5, 2008) OJIN: The Online Journal of Issues in Nursing Vol 14 No 1.

DOI: 10.3912/OJIN.Vol14No1PPT03

Keywords: mature-aged students, nursing education, nursing workforce, undergraduate education

Globally the nursing workforce is ageing with fewer young people entering the profession to replace the large number of baby boomers due to retire in the coming decade (Erickson & Grove, 2007; Peterson, 2001b). Currently there is dissatisfaction amongst nurses who cite heavy workloads; shift work; minimal mentoring, supervision and support; low wages; poor working conditions; minimal professional opportunities; and limited autonomy as contributing to the number of nurses leaving the profession (Cline, Reilly, & Moore, 2003; Peterson, 2001a; Strachota, Normandin, Nancy, Clary, & Krukow, 2003). In 2004 the average age of a nurse in Australia was 43.2 years. The proportion of nurses 50 years or over increased  from 24% in 2001 to 35% in 2005 (Australian Institute of Health and Welfare, 2006; Rosenthal, 2008). Currently in the United Kingdom (UK) one in five nurses is over 50 (Buchan & Seccombe, 2003; Watson, Manthorpe, & Andrews, 2003). This pattern is the same globally with the United States (US), New Zealand, Canada, and European countries all reporting an ageing nursing workforce (International Council of Nurses, 2008; National Centre for Health Workforce Analysis, 2000; O'Malley & Annals, 2004a; United States Department of Health and Human Services, 2000). Buerhaus et al. (2000) asserted that by 2020 the largest cohort of nurses will be between 50 and 69 years, and that the retirement of these nurse will exacerbate the shortage of nurses at that time. If the present trajectory continues, it could be postulated that over the next two decades 75% of nurses working in these countries today are likely to retire.

Compounding the problem of an ageing workforce is the age at which undergraduate (pre-licensure / pre-registration) nursing students commence and complete their courses. There is evidence to suggest that globally fewer school leavers (people who have completed their high school education and are generally 17 or 18 years of age), who traditionally were the core of pre-registration nursing programs, are choosing nursing as a career (Aiken et al., 2001; Buerhaus & Staiger, 1999; Hopkins, 2001; O'Malley & Annals, 2004b; United States Department of Health and Human Services, 2000).

Historically, older workers who retired were replaced by younger workers. ...[but] nursing appears to have lost some of its attraction as a profession, especially for young people. Historically, older workers who retired were replaced by younger workers. This usual cycle, of younger nurses joining the workforce at the same time as older nurses retired and left the workforce, ensured that the numbers of workers remained reasonably static with an appropriate representation of all age groups in the workforce. The current, significant number of mature-aged nursing graduates, combined with an already aging nursing workforce suggests the potential for a future imbalance in the nursing workforce. This imbalance, coupled with the global shortage of trained nurses, has significant implications for recruitment and retention in the future (Malhotra, 2002).

...graduating a high percentage of mature-aged nursing students is making a significant contribution to nursing today...However, it runs the risk of exacerbating the shortage projected to occur around the year 2020. Meachin and Webb  (1996) have argued that nursing needs mature students not only to widen recruitment, but also for the special qualities they bring. These authors noted that despite the additional roles and responsibilities that mature-aged students undertake, they have higher levels of motivation and are more committed. They also have lower rates of attrition, less sick time, above average academic performance, and more emotional maturity than their younger counterparts.

 This article postulates that graduating a high percentage of mature-aged nursing students is making a significant contribution to nursing today, helping to alleviate the current nursing shortage. However, it runs the risk of exacerbating the shortage projected to occur around the year 2020. In this article the authors explore the current nursing shortage and the changing educational opportunities that affect recruitment of mature-aged students into tertiary-based nursing programs. They recommend actions for appropriate succession planning for the future.

The Shortage of Professional Nurses

The global shortage of nurses has attracted much discussion in recent times. This shortage encompasses both recruitment and retention factors. Recruitment factors include limited capacity to accept new students, the cost of academic fees, and low salaries upon graduation. One retention concern relates to the fact that limited resources to meet the needs of more experienced nurses decreases the retention of these nurses, thus exacerbating the shortage both short term and long term. Another retention concern is the recruitment of foreign-trained nurses into Australia to meet the nursing shortage. These factors will be discussed below.

Recruitment into nursing programs in many countries is tied to government-funded places. In other words, the government funds a very significant proportion of the costs associated with study. In Australia this funding is provided to the university which then offers a specific number of ‘places’ in the undergraduate program. Further places are sometimes available for full-paying students who are usually international students. In a market where there are insufficient nurses, it would seem imprudent that potential students are turned away each year due to lack of government funding. Yet lack of funded places and lack of resources are cited as being two factors that impact on the recruitment of nurses into nursing  (Briggance, 2001; Hopkins, 2001; Productivity Commission, 2005).

In Australia the payment of tertiary (college) fees, may influence young peoples’ decisions to consider nursing as a career. Students are required to pay a part of the cost of their higher education. This fee, paid by the students, is called the Higher Education Contribution Scheme (HECS) fee. A student’s HECS contribution is a small percentage of the total cost of their higher education; the Australian Commonwealth government pays the major portion of their education. The money collected through these HECS fees is used to support the country’s higher education system. These fees, which currently equate to approximately $AUD700 ($US572, Euros 404) per unit (Editor's note: a unit of study is equivalent to a college course in the U.S. system) can be paid up front at the beginning of each semester or deferred and paid proportional to salary when the graduate commences work. A person entering an undergraduate nursing program in Australia can expect to pay approximately $AUD17,000  ($US13,890, Euros 9,800) for their total university study.

Additionally, graduate salaries need to be considered when questioning why school leavers are not attracted to nursing. Currently in Australia the graduate salary of a Registered Nurse is $AUD 37,149, which is equivalent to $US 30,280 and Euros 21,345, (Australian Nursing Federation, 2006). This is significantly less than graduate salaries in other disciplines such as teaching ($AUD 48,425) or policing ($AUD 48,462).

Retention, on the other hand, is about keeping nurses in the workforce once they graduate. Student nurses on clinical rotations experience first hand the deteriorating conditions, lack of resources, and minimal staffing in today’s healthcare settings; the deteriorating conditions include minimal mentoring, poor rates of pay, shiftwork, and a lack of structured career paths  (Hegney, 2000; Mahnken, 2003). Nursing may appear to be an overly altruistic career choice for potential nursing students given these conditions. Graduate (mentoring) programs, which are undertaken in the first two years after completion of undergraduate studies, need to be targeted to ensure that sufficient and competent mentoring is available during the graduate year(s). Graduate programs in Australia generally extend for a full year and involve rotation through different areas with clinical supervision and mentoring. Indeed Mills et al. (2008) have argued that competent mentoring during a graduate year can influence nurses’ decisions about future career aspirations and directions.

The retention of older nurses in the workforce must also be acknowledged as a priority by organisations. Currently there is little evidence to show that health service managers are addressing the problem of the ageing nursing workforce (Levtak, 2002a). Mature workers have different needs than do younger workers, yet few organisations have structures in place to assist the older nurse to continue working (Levtak, 2002b; Watson et al., 2003). Contemporary research suggests that older nurses are less likely to work in acute care settings and prefer shorter shifts (Levtak, 2002a; Willis, Williams, Ulrich, & Dittus, 2005). Older nurses are beginning to experience some of the physical problems associated with ageing, and this must be taken into consideration by managers who want to retain them in the workplace (Fitzgerald, 2007). Flexible working hours; recognition and valuing of experience; the introduction of ‘new,’ paid roles, such as mentor and workplace trainer; greater autonomy; lighter (physical) duties; return-to-practice initiatives; and improved professional development opportunities, especially in relation to technology, have all been identified as strategies that can help keep older nurses in the workforce (Editorial, 2006; Trossman, 2006; Wright, 2006). Furthermore, there is evidence to suggest that as  large numbers of older nurses retire or leave the profession, there will be a loss of intellectual capital, which includes core competencies, accumulated experience and learning, organizational technology, relationships, and professional skills (Andriessen & van den Boom, 2006). Loss of this experiential wisdom may impact negatively on patient care and organisational performance (Hatcher, Bleich, Davis, O’Neill Hewlett, & Stokley Hill, 2006).

Mature-aged graduates enter an already ageing workforce. While they may not have the experience of the older nurses, it appears they have many of the same needs, for example flexible shifts, shorter shifts, and ongoing professional development. It is not yet known whether mature-aged graduates generally take up full-time positions or in what areas they choose to work. Collecting this information will be important, as it may affect future workforce planning.

In an effort to supplement the decreasing number of nurses, immigration of foreign nurses in Australia has been encouraged (Kline, 2003). Whilst developed countries, such as the UK and New Zealand, are the main sources of international recruitment of nurses in Australia, foreign nurses from other countries also contribute to the workforce. In the UK and US substantial numbers of immigrant nurses are now from the Philippines and other less developed nations (Chaguturu & Vallabhaneni, 2005; Simoens, Villeneuve, & Hurst, 2005). In Australia, foreign nurses who immigrate must often work in an area of unmet need, such as rural or remote Australia. Minimal research has explored how these foreign-trained nurses cope on arrival and in the ensuing first months. The challenging conditions, such as isolation and lack of staff that exist in rural Australia, make working there difficult for even the most experienced and culturally savvy Australian nurses, let alone for foreign-trained nurses with minimal understanding of life in the Australian bush. Hence the recruiting of foreign nurses is not an adequate solution to address the Australian nursing shortage.

Reasons for the Increasing Age of New Graduate Nurses: Changing Educational Opportunities

In most universities in Australia, mature students now account for one third to one half of all students enrolled in the university, both in nursing programs and other university programs (Tindle & Lincoln, 2002; White, 2002; Wright, Frew & Hatcher, 1998). Mature students return to study for many reasons including choosing a second career, second chancers (those students that didn’t have the opportunity to enter nursing when young), employment opportunities, and availability of courses within their home areas (Boughn, 2001; Collings, 1997). Furthermore, the changing economy may also contribute to an increase in mature-aged enrolment. Horn and Carroll  (1996) suggest that the diminishing number of unskilled jobs, coupled with an increasing number of women entering the workforce has contributed to the increase of mature students.

The combination of flexible university access, recognition of prior learning, and an increase in mixed-mode delivery, i.e., a combination of on-campus, off-campus, and online delivery of course content, have undoubtedly also contributed to an increase in mature-aged students returning to formal study (Ryan, 2001). Whereas once a nursing student needed to be present at all lectures and study full time, students are now able to choose modes of study that suit their lifestyles. The mixed-mode delivery style is a format that has become increasingly popular especially with mature-aged students who work.

Recommendations

...organisations and mangers need to focus on appropriate succession planning. The declining number of young people undertaking nursing will have a significant effect over the next two decades as the current, older nurses start to retire. With fewer younger nurses to “take over from them,” the profession is vulnerable. In order to maintain a sustainable number of nurses in the coming decade, organisations and mangers need to focus on appropriate succession planning. whereby organisations develop the skills and knowledge of younger nurses, and prepare them to replace older nurses planning to retire (Bolton & Roy, 2004). Concerted efforts need to be made to attract school leavers to nursing. This section will discuss several of these efforts, such as enhancing the image of nursing, improving the work environment, studying the effect of the ‘gap year’ on school leavers’ entering nursing, and assessing the effect of encouraging Enrolled (Licensed/Practical) Nurses to become Registered Nurses.

The issues associated with the poor image of nursing that are commonly held by school leavers include poor pay, high workloads, and less autonomy and professional standing than other health professions (Foong, 1999a, 1999b; O'Malley & Annals, 2004b). These issues  need to be addressed through a collaborative approach that includes government policy to establish improved pay and conditions; industry innovations, such as changes to shiftwork patterns; and marketing a positive image of nurses as professional and autonomous healthcare team members. Strategies to address these issues need to be nationally focused, rather than state focused, and should concentrate on the positive aspects of nursing. Positive marketing of nursing as a profession needs to capitalise on the public’s perception of nursing. Recently in Western Australia, a campaign titled, 'Have You Got What It Takes To Be A Nurse,’ was launched. This campaign used real nurses in real situations and portrayed nurses as professional, well educated, people orientated, and caring. It also explained the diversity of career paths available to nurses. Furthermore, nurses who are currently working clinically can speak positively about nursing at school career days and represent nursing at career forums with the goal of encouraging school leavers to consider nursing as a profession.

Concerted efforts need to be made to attract school leavers to nursing. Retention, particularly of new graduates, requires improving the work environment by providing appropriate mentoring as well as implementing interventions to assist with high nurse-patient ratios and poor conditions. Such interventions include a supportive work environment, empowered leadership, appropriate remuneration, and ongoing professional development and continuing education opportunities(Gillis, Jackson, & Beiswanger, 2004).

Research is needed to identify the factors that attract young people to nursing so that future recruitment strategies are evidence based. Many young people now take a year off between completing high school and commencing their university education. This time off, routinely termed a ‘gap year,’ is a period of transition between high school and university for young people. During this period many students work to finance future tertiary studies. Research needs to be done to determine whether a gap year influences a school leaver’s choice of career and whether students who defer nursing studies and have a gap year actually take up nursing studies on completion of the gap year. This research may demonstrate that a person working in a health-related area in their gap year can actually be attracted to nursing by their work-based experiences.

Research is needed to identify the factors that attract young people to nursing so that future recruitment strategies are evidence based. In Australia programs have been developed to attract experienced Division 2 Nurses (also called Enrolled Nurses or Licensed Practical Nurses) to the university to undertake accelerated courses to become Registered Nurses. In Australia, the Division 2 Nurse has undertaken a one-to-two year nursing course at less than the baccalaureate level. Division 2 Nurses retain responsibility for their own actions while being accountable to the Registered Nurse (Division 1 Nurse). As most qualification-advancement programs require registration in Division 2 in-order-to gain exemptions or credit for previous study and qualifications, it could be assumed that these nurses are already in the workforce. In addition to the Division 2 Nurses who have been working and want to upgrade qualifications are the Division 2 Nurses who are newly graduated from nursing programs. There is anecdotal evidence to suggest that some students enrolled in Division 2 courses use this qualification to gain entrance to the university and the Division 1 qualification. This group of Division 2 (Enrolled) Nurses only plan to work in this category to self support as they go through the Registered Nurse (Division 1) program. Although these measures are worthwhile in buffering the current number of nurses in the system, they do little to alleviate the future problem of an ageing workforce. Research has shown that the majority of these students are already mature aged (McKenna, Sadler, Long, & Burke, 2001). Additional research studies, investigating whether the initiative to attract Division 2 Nurses has increased retention and whether programs for Division 2 Nurses have had any impact on Registered Nurse staffing levels, are essential to future workforce planning.

Summary

Nursing continues to top the list in most countries as being the most trusted profession (Briggance, 2001; Illiffe, 2004; Wells & McElwee, 2000). Despite this accolade, nursing appears to have lost some of its attraction as a profession, especially for young people.

Mature-aged students become mature-aged graduates and have a shorter working career than school leavers. To reverse this trend nursing needs to attract more young people. Nursing and all of society need to look at what needs to be done to make nursing a career of choice for school leavers. Australia is not alone in its plight, the nursing shortage is an international issue. To establish and maintain an appropriately prepared, nursing workforce, worldwide, we believe marketing strategies and initiatives that advance nursing as an appealing career choice need to be implemented. This implementation should be collaborative in nature, involving both educational institutions and healthcare organizations.

This article has argued that the high percentage of mature-aged nursing students may exacerbate the current ‘greying’ of the global nursing workforce. It will be essential that succession planning and workplace conditions are addressed soon, to ensure that nursing has a sustainable future as the baby boomers prepare to retire.

Authors

Vicki Drury, PhD, RN, RMHN
E-mail: vdrury@educareconsulting.com.au

Vicki Drury is a Project Officer working in the Centre for Research into Disability and Society at Curtin University in Australia. She is also the founder and Principal Consultant for Educare Consulting, a health education and research consulting firm. Previously she was a Senior Lecturer at Murdoch University undertaking research into the ageing workforce in regional mining organisations. A graduate of Charles Sturt University (MCN) and Monash University (PhD) her career has included clinical work in rural and regional Australia in addition to Curtin University. She is known for her commitment to nurse education and has published numerous papers on nurse education and mature students in nursing. She is a member of the Royal College of Nursing, Australia, the Australia and New Zealand College of Mental Health Nurses, and Sigma Theta Tau Upsilon Eta Chapter, Singapore.

Karen Francis, PhD, RN
E-mail: Karen.Francis@med.monash.edu.au

Karen Francis is Professor of Rural Nursing and Head, School of Nursing and Midwifery, Gippsland campus, Monash University, Australia. She is recognised nationally and internationally for her contribution to the development of the discipline of rural nursing. Her research and publication agendas have focussed on exploring the realities of nursing in rural environments, health workforce, and rural population’s health issues. Professor Francis contributes to the development of nursing, in particular rural nursing, through her role as an executive member of the International Network of Rural and Remote Nurses. In addition, she seeks to influence the direction of nursing and policy formation through membership of the Royal College of Nursing, Australia, and the National Rural Health Alliance. Professor Francis holds a ministerial appointment with the Nurses Board of Victoria which is responsible for the regulation of nursing in Victoria. She is also a board member of the Institute of Regional Studies, Monash University, which aims to undertake high quality research that is of interest to regional communities in both Victoria and beyond.

Ysanne Chapman, PhD, RN
E-mail: Ysanne.Chapman@med.monash.edu.au

Associate Professor Ysanne Chapman works at Monash University, Gippsland campus, and holds the portfolio of teaching and learning. Her scholarly focus is researching and developing creative and innovative teaching and learning techniques that assist both students and academics in their pursuits in higher education. Ysanne has worked as an academic in Australia and the Middle East.

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© 2008 OJIN: The Online Journal of Issues in Nursing
Article published December 5, 2008


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