Centre for Palliative Care Research and Education, Royal Brisbane and Women’s Hospital
The recently released assessment of national and state skill shortages identifies that Australia has a national shortage of Registered Nurses (RNs), with oncology and palliative care registered nurses being listed as professional groups in shortage in all states and territories of Australia except the Northern Territory1. The recent National Review of Nursing Education in Australia report entitled Our Duty of Care identifies that a nursing vacancy rate of 30,000 is predicted between 2001 – 20062.
Cancer nurses today face major challenges in trying to provide quality patient care in a health care environment that is experiencing such widespread nursing shortages. Nursing workforce data from the Australian Institute of Health and Welfare (AIHW) indicate that despite a 1.2% increase in nursing workforce numbers since 1999, there has been a decrease in the average nursing working hours, thus affecting the overall supply of nurses3. In 1995 there were 1,127 Full Time Equivalent (FTE) nurses per 100,000 population, however this number had decreased to 1,024 FTE nurses per 100,000 population in 20013. Moreover, AIHW data indicate that nearly 48% of oncology nurses work part-time, employed an average of 32 hours per week.
A shortage of nurses compromises patient outcomes and safety4 and can impact on staff welfare5. A number of recent US studies report a significant inverse relationship between nurse staffing and adverse events such as thrombosis, pulmonary and urinary complications and medication errors in hospital surgical inpatients6,7. These studies report that an increase of RN hours per day is associated with a reduced rate of adverse events. The aim of this paper is to examine the factors contributing to workforce shortages in cancer nursing and discuss a range of potential solutions for addressing the current challenges.
The current shortage of cancer nurses exists in most countries, reflecting issues in supply and demand. The problem is complex, with several factors contributing to the shortage.
The demand for cancer services overall has increased as a result of the increasing incidence of cancer associated with an ageing population and earlier detection of many cancers. Changing treatment technologies have also had important implications for the health care needs of people diagnosed with cancer. The nature of cancer care has evolved, with the reorganisation of cancer services firmly on the agenda nationally and in many states of Australia. Specifically, current service reforms are seeing changes in models of service delivery, with an explicit emphasis on more responsive and person-centred systems of care. Nursing practice, with its central focus on addressing the supportive care needs for people with cancer, is integral to such reforms. Many Australian states are developing plans to guide the direction for cancer control over the coming years, highlighting the importance of the cancer nursing workforce to future cancer control efforts. For example, in the New South Wales Cancer Plan 2004 – 20068, cancer nursing has been acknowledged as playing an integral role in the support of patients. Moreover, patients are increasingly receiving treatment on an outpatient basis. The changing settings for care require staffing profiles that include professional nurses who have the skills, knowledge and experience to recognise an impending or actual problem in a timely manner and have the ability to act and mobilise resources to intervene as necessary9,10.
Patient numbers per FTE nurse have increased over the past years. The average length of stay has decreased from 4.6 days in 1993-1994 to 3.5 days in 2002 – 2003 and patient separations per FTE nurse continue to increase11. The reducing length of stay has contributed to increased nursing workloads as nurses care for higher acuity patients who require intensive nursing care while they are in hospital or the ambulatory setting. These changes in the nature of hospitalisation and treatment delivery have lead to a reduction in the amount of time that nurses can spend with patients12.
The increasing workloads have many consequences for nurses. Importantly, a number of recent studies suggest nurses are becoming increasingly distressed that they can no longer provide quality care as they do not have the time due to workload pressures13,14, with excessive workloads sometimes remaining hidden as nurses work unpaid overtime or through their meal breaks5,15, as nurses adapt their care and work harder and faster16. In 1999, a Victorian study indicated that workload was perceived as the most frequently occurring source of stress amongst nurses14. Similarly, a recent Queensland study of oncology/haematology nurses indicated that workload issues were a major dissatisfier for them, with nearly 50% reporting that they did not have the time to get through their work and that overall staffing levels were a concern for them12. The Queensland study further identified that cancer nurses were at high risk of burnout, with 70% of the sample categorised as experiencing moderate to high levels of emotional exhaustion on the standard burnout measures12.
The ability to recruit young people and career switchers into nursing is essential. Almost 40% of students applying for undergraduate nursing positions fail to obtain a place, showing that rather than a shortage of willing candidates, the problem lies with the number of places available13.
Retention of nursing staff is arguably a more urgent concern, with recent workforce analyses undertaken by the Department of Education, Science and Training noting that it will be difficult to maintain and grow the nursing workforce as exit rates increase13. A recent survey of 243 oncology/haematology nurses in Queensland highlighted that nearly 48% of the sample indicated that they could not commit to remaining in the specialty for the next 12 months8. While the reasons for turnover were multifaceted, workload issues were identified as the most common reason given for considering leaving the specialty8.
The Department of Education, Science and Training has reported that the ageing nursing workforce will bring about high exit rates from the profession over the next decade2. The proportion of nurses less than 35 years is only 30 percent of the total workforce2. The Oncology nursing workforce is slightly younger, with an average age of 38.5 years, compared with the average age of employed clinical nurses being 41.8 years3. The ageing nursing workforce will influence recruitment in the future, as employers compete in a tighter employment market.
Postgraduate education is well established in most university schools of nursing. However, Yates17 argues there is an ambivalent relationship between nursing and postgraduate education that is manifested in the differing levels of qualification, and the substantial variation in the length and mix of clinical practice and theory in postgraduate specialty courses18. Yates suggests that the lack of clarity about many aspects of the location, design, delivery and outcomes from postgraduate education typically results in confusion for students, employers and academics as to which course to choose or recommend. Other reports indicate that the cost of higher education for nurses is a major barrier to entry into specialist postgraduate courses in areas such as cancer nursing, especially as completed qualifications do not necessarily result in increased remuneration and career advancement19. Without a clearly defined and accepted pathway for development of specialist skills in cancer nursing, the development of a skilled workforce is likely to be compromised.
In 2002, the Cancer Nurses Society of Australia (CNSA) indicated their concern that the nationwide shortage of cancer nurses would worsen and published a position statement on this issue19. CNSA argued that, given the contribution that nurses make to reducing the burden of cancer in this country, coordinated national strategies need to be implemented to recruit and retain cancer nurses to meet future workforce needs9. These strategies need to address workforce needs across the cancer continuum, including health promotion, screening detection, treatment, rehabilitation and palliative care.
Workloads are a source of emotional exhaustion and a dissatisfier for oncology/haematology nurses12. The literature suggests that oncology nurses who believe they work on adequately staffed units report they are better able to care for patients and ensure quality of care when compared to nurses who work on inadequately staffed units20. Furthermore, fully staffed units report less difficulty retaining staff, work less overtime and do not have to rely on supplemental staffing20.
The management of workloads will, however, continue to be a challenge for clinicians and managers alike. Currently, few validated models exist to determine current workloads, care planning and staffing requirements in the oncology setting, especially in ambulatory care. In the cancer care setting it is essential that any such workload models factor in the complex clinical components and the support and education roles of the nurse to ensure that these essential components of patient care are incorporated into workload calculations12. Moreover, the pressures of finite resources demand efficiency in the workplace and in some cases a re-evaluation of current practices. Work redesign programs are needed that focus on developing models of care centred on addressing the needs of the person with cancer, within the context of a flexible multidisciplinary team approach to care.
Flexible team approaches to care are likely to be critical to future cancer service delivery, in order to most effectively respond to complex patient needs and increasing demands on resources. Currently the predominant model used to organise nursing work is patient allocation. The patient allocation model arguably has the potential to isolate staff from one another and result in reduced communication and co-ordination of human resources. Models of care that develop a culture of teamwork that foster the sharing of knowledge and expertise may assist in the formation of supportive professional relationships. For example, the Department of Education, Science and Training has indicated that the workforce will have to adjust structurally to distribute the work across registered nurses, enrolled nurses and health carers and articulate arrangements between health care workers of various skill levels2. While such approaches may be an appropriate response to the complex challenges faced by today’s health systems, some nurses have expressed concern that they may shift RNs away from hands-on care to serve as ‘team leaders’ and that they may return nursing to a fragmented, task oriented discipline.
As the largest group of health care worker, nurses have considerable opportunity to shape the system itself21. A significant challenge for nurse leaders is to create positive work environments in which staff feel valued. Constructive leadership behaviour can influence the culture of the work unit and the morale and retention of employees, which in turn improves patient satisfaction and outcomes22. Studies suggest that nurses’ trust in their managers has been linked to improved productivity, improved patient care, job satisfaction and commitment23. Clinical leadership roles should be developed to mentor and develop new cancer nursing practitioners and promote innovative practice in cancer care, thereby contributing to the retention of experienced and motivated cancer nurses. Nurses with leadership potential should be identified and supported, to shape and lead our profession in the future24.
Education is an essential component for the preparation of new professionals and specialist nurses. The provision of appropriate funding, flexible and responsive education and the building of collaborative relationships across academic and clinical settings are key to building the capacity of the nursing workforce18. Immediate strategies that may be implemented include relief from Higher Education Contribution Scheme and other course fees to overcome the financial barriers nurses face in undertaking postgraduate cancer nursing courses4.
The recently released NSW Cancer Plan8 identifies that cancer nursing education is required to develop a workforce that can provide optimal patient care. Specifically, the plan states that advanced practice positions need to be developed, providing clinical experts and leaders. Such initiatives may provide excellent opportunities to recruit and retain cancer nurses and also to evaluate the efficacy of specialist nurse models in improving outcomes for patients with cancer.
Three important national initiatives are currently underway that have the potential to set the agenda for future directions in nursing workforce planning. Firstly, the 2002 National Review of Nursing Education18, and Senate Inquiry into Nursing25 made many recommendations emphasising the importance of nationally coordinated approaches to addressing nursing workforce and education issues. In November 2003, state/territory and Australian Ministers for Health and Education announced the establishment of a National Nursing and Nursing Education Taskforce (N3ET)26. N3ET has been set up to implement the recommendations of the report Our Duty of Care18, including issues such as the skill mix and work organisation of nurses, augmentation and retention of the current workforce, training of care assistants, funding of clinical education and national education standards. This is the first time there has been national collaboration on these issues.
Secondly, the Nursing Workforce Planning in Australia document has recently been published to guide the Australian Health Workforce Advisory Committee (AHWAC), the National Health Workforce Secretariat and members of nursing workforce working parties established by AHWAC27. It provides a set of principles to guide health workforce planners. This report highlights that workforce planning for the nursing specialties is highly complex and poorly understood and suggests that planners need to examine work practices, changing roles and scopes of practice as part of workforce redevelopment.
Thirdly, an Australian study is currently being undertaken to reveal what influences nursing workloads and how this affects patient care. The effect of patient acuity and decreased length of stay on nursing workloads will also be assessed, in an attempt to match staffing to workloads13. It is expected that the results will be available in 2005.
The complex nature of cancer and its treatment and the increasing population of people living with this disease requires a workforce of nurses that can provide care across the cancer continuum. Cancer nurses possess the specialised knowledge and skills to provide treatment, education and emotional support to patients with cancer and their families, however recent reports have identified that the cancer nursing workforce is in shortage, suggesting that patient outcomes may be compromised. Strategies which facilitate the development of a sustainable cancer nursing workforce include increasing the future supply of nurses, increasing the capacity of the current workforce through education and providing an infrastructure that supports nurses at the workplace and promotes retention. Nursing workforce issues have become increasingly prominent in policy agendas, suggesting that the impact of the nursing shortage of Australia’s health care system is becoming more visible. This is an ideal time for nurses to discuss nursing and patient care issues that are important to their practice and to provide solutions to enhance the cancer nursing workforce.
11. Australian Institute of Health and Welfare. 2004 Australian Hospital Statistics 2002 – 2003, Health Services Series. No 22, AIHW Cat. No. HWL 32, Australian Institute of Health and Welfare, Canberra.
21. Courtney M, Nash R, Thornton R, Leading and managing in nursing practice: Concepts, processes and challenges. In Daly J, Speedy S, Jackson D. 2004 Nursing Leadership. Sydney: Churchill Livingstone.
27. Australian Health Workforce Advisory Committee 2004, Nursing Workforce Planning in Australia – A Guide to the Process and Methods used by the Australian Health Workforce Committee, AHWAC Report 2004. 1, Sydney. www.healthworkforce.health.nsw.gov.au accessed 12/9/04.