Nursing and the nursing workplace in Queensland, 2001–2010: What the nurses think
The purpose of the study was to inform policy for reform in nursing. A survey mailed to members of the Queensland Nurses' Union four times between 2001 and 2010 elicited views on their employment and working conditions, professional development and career opportunities. Results across years and sectors of nursing consistently showed dissatisfaction in many aspects of employment, particularly by nurses working in aged care. However, views on staffing numbers, skill mix, workload, work stress, pay and staff morale all showed significant improvements over the decade. For example in 2001, 48.8% of nurses believed that their pay was poor, whereas in 2010, this had reduced to 35.2%. Furthermore, there was a significant rise throughout the decade in the opinion of the value of nursing as a good career. In light of the need to address nurse workforce shortages, the trends are encouraging; however, more improvements are required in order to support recruitment and retention.
Nursing workforce shortfalls are forecast to last for some years with the situation in Australia a prime example of this global phenomenon. After a decade of decline at the end of the last century, nursing supply in Australia increased by 12.5% from 1999 to 2004 and by 6.2% between 2005 and 2009.[2-4] The increases have resulted in part as a result of Australian Government bonuses to attract retired and non-working nurses back to the workforce, and in part by increases in universities places for students of nursing.
It is predicted, however, that despite these increases, demand for nurses will well exceed supply. The shortfall will be driven by the increased burden of disease, the ageing nursing workforce and ageing Australian population, changes in service delivery and the expectations of both community and workforce.
Over the past decade, various predictions for national shortfalls have been reported.[6-8] Most recently Health Workforce Australia modelled scenarios of increased productivity or reduced demand and predicted shortfalls of enrolled and registered nurses (RNs) of between 13 000 and 20 000 in 2016 and between 31 000 and 109 000 in 2025. These figures do not include the largest workforce element of the aged care workforce, namely the Assistants in Nursing, which constitute ≈ 65% of direct care employees in the sector. Their inclusion would paint an even gloomier picture, resulting in a 50% increase in the patient to nurse ratio over the current value.
In Queensland, the health department's Workforce Analysis and Research Unit suggested a statewide deficit of RNs of up to 5000 in 2017. Increasing demand is driven by the same factors as the other seven Australian states and territories, namely, the older and retiring workforce and the ageing population with a greater burden of chronic disease. However, in Queensland, this is compounded by the large population rise. With more than a third of nurses already over the age of 50 at least half of the State's current workforce could be lost to retirement in the next 20 years. Over the same period, the Queensland's population is predicted to be at least 50% higher and the number of persons over age 65 to double.
In some jurisdictions, the current shortfall of nurses in Australia is being mediated through the employment of overseas trained nurses; however, as a National Health Workforce report recognizes, this trend is unsustainable in the longer term. It is becoming increasingly recognized that although the previous focus has been on recruitment, there is a growing recognition that there need to be better strategies focusing on retention.[9, 14] As Graham and Duffield concluded in a recent paper (p. 47) ‘one strategy for resolving the shortage of skilled nurses is to focus on their continued participation in the workforce. To do so requires understanding what will motivate them to continue…’.
In 2001, a study of Queensland's nurses was designed around the research question of what factors create opportunities or present constraints to nurses in their nursing career. The aim of that original study was to determine the views of nurses about their roles, their careers and their workplaces in order to inform the union and, through publication, nursing management. Since 2001, policy changes by employers have affected working conditions, particularly parity in areas such as remuneration. In order to determine from the nurses' perspective the effect of those changes, the study was replicated in 2004, 2007 and 2010. Some of the results from individual years of study have been reported variously.[16-20] This current paper provides detail to the research question ‘from the nurses' point of view what has changed in nursing over the past decade?’
Each study polled current members of the Queensland Nurses' Union (QNU) who were employed as nurses in the public, private and aged care sectors. ‘Nurses’ included both regulated (RN and enrolled nurse (EN)) and unregulated providers of nursing care (Assistants in Nursing (AIN, also known as Personal Care Assistants)). Three quarters of EN and RN in Queensland are members of the QNU, whereas membership for the AIN is estimated ≈ 50% of the AIN workforce.[10, 21]
Detail of the methodology has been reported previously.[15-20] In summary, data were collected through a self-reporting postal survey of financial members of the QNU. A stratified random sampling design was used of (i) aged care (non-government and government); (ii) public (government acute hospitals and community nursing); and (iii) private (non-government acute hospitals and community nursing) sectors.
In order to provide adequate levels of precision in estimating key measures, 1000 nurses from each of the three sectors were invited to participate in 2001, 2004 and 2007. In 2010, this was raised to 1250 per sector to reflect an increase in QNU membership. In each of the four studies, surveys were mailed in October with two reminders sent to non-respondents 2 and 4 weeks after the initial mail-out.
To ensure anonymity of respondents, eligible QNU members were allocated an ID code by the QNU, and codes were randomly selected by the researchers to achieve the desired number for each sector. The QNU then mailed out the surveys after matching the ID back to their members' list. Surveys were returned to the research team in reply-paid pre-addressed envelopes. Data were hand-entered into spread sheets in 2001 but scanned into the software program Verity TeleForm (Verity Inc., Sunnyvale, CA, USA) in all subsequent years.
The questionnaire contained questions divided into eight sections – current employment, working hours, working conditions, responsibilities outside of work, professional development, views of nursing, nursing career and about you. The vast majority of questions were dichotomous, multiple choice or required selection on rating scales. A few additional questions provided opportunity for short free text commentary.
Over the years, the number of questions ranged from 72 to 77 reflecting specific interest of the day. For example, two additional questions requiring open-ended qualitative responses were added to in 2007 to gather information on nurses' views of external socioeconomic, environmental and political factors. Additional questions were pretested by independent experts and a sample of nurses from the different sectors.
Each of the four studies was approved by the university Human Research and Ethics Committee. Informed consent was implied by return of the completed questionnaire.
Comparisons were undertaken across sectors both within and among years. Nominal and parametric data comparisons were made on an item-by-item basis, using descriptive and inferential statistical tools (SPSS v14-18, IBM, St. Leonards, NSW, Australia) as appropriate to the scale of measurement. Cross-tabulations with χ2 tests for significance were used for dichotomous and categorical variables and the t-statistic for independent groups for continuous variables. Post hoc tests were employed to identify differences. A level of .05% was used to support inferences.
Free text responses were analysed thematically by two researchers using the framework of Pope; one researcher was constant over all four studies. Following the first analysis, notes were compared and agreement reached on themes and subthemes prior to final collation of the results.
Response rates fell from 46.6% in 2001 to 36.4% in 2010. Returns each year across the three sectors remained consistent and equal (33 ± 2%). Participants ranged from 40% to 45% AIN, 15–20% EN and 40–45% RN. Over 90% of the AIN were employed in the aged care sector. Other characteristics of the respondents are provided in Table 1.
Table 1. Characteristics of the sample
|Response rate|| ||46.6||41.3||39.7||36.4|
|Employment status||Perm full-time||33.1||29.4||29.0||28.0|
|Second job||In nursing||12.1||11.2||11.1||10.8|
|Not in nursing||5.9||4.8||6.3||4.7|
Age and length of time in nursing
The age of respondents within each sector across the studies increased (χ2 = 183.559, degrees of freedom (d.f.) = 15, P < 0.001). There was a dramatic decline in the 30–39 year age group in favour of older nurses. There were marked sector differences; for example in the aged care sector in 2010, 65% of respondents were over 50 years of age compared with 48.5% in 2001. In the private and public sectors, although the number of nurses over 50 years of age in 2010 was < 45%, this constituted a doubling since 2001.
The length of time in nursing also reflected the increasing age (χ2 = 49.456, d.f. = 27, P < 0.001). For example, the proportion of nurses with > 25 years of experience increased at every survey (35.7, 2001; 38.2, 2004; 40.3, 2007; 43.7, 2010).
Between 15.5% and 18% of nurses had more than one job, and this was not different across years (P = 0.451). Variety or diversity, followed by insufficient income, maintaining clinical skills and lifestyle choice were the principal reasons.
Employment status changed over the survey years (χ2 = 29.758, d.f. = 12, P = 0.003) with a trend for full-time employment to decrease and part-time employment to increase. Shift patterns also changed across the survey years (χ2 = 92.871, d.f. = 18, P < 0.001) with a reduction in the proportion of nurses doing rotating day, evening and night shifts in favour of day shifts (Table 2).
Table 2. Shift patterns of nurses from 2001–2010
|Continuous (am, pm, night) shift||Count||461||436||290||330|
|% within year||32.6||35.4||29.5||25.2|
|% within year||21.3||20.2||25.8||29.3|
|% within year||3.8||3.4||6.8||6.0|
|% within year||7.3||7.9||7.3||7.6|
|Morning and evening shift||Count||370||303||253||335|
|% within year||26.2||24.6||25.8||25.6|
|Evening and night shift||Count||31||34||16||25|
|% within year||2.2||2.8||1.6||1.9|
|% within Year||6.6||5.7||3.2||4.3|
|% within Year||100.0||100.0||100.0||100.0|
Sufficient staff and skill mix
There was a statistically significant change to the question asking if the nurses perceived there were sufficient staff employed in their work unit to meet the needs of patients (χ2 = 78.168, d.f. = 12, P < 0.001; Table 3). This result was consistent in all three sectors. For example, in the aged care sector the seldom, very seldom or never choices had reduced steadily from 53.7% in 2001 to 36.4% in 2010 (χ2 = 38.674, d.f. = 12, P < 0.001).
Table 3. Sufficient staff to meet work unit needs
|Never or very seldom||Count||187||157||121||136|
|% within year||13.2||12.2||12.1||10.4|
|% within year||24.9||20.0||20.3||15.7|
|% within year||26.7||25.6||26.5||24.9|
|% within year||28.8||33.3||32.0||35.9|
|% within year||6.4||8.9||9.0||13.0|
|% within year||100.0||100.0||100.0||100.0|
Similar results across the four studies were seen for the question whether there was a sufficient skill mix in the work unit (χ2= 40.628, d.f. = 12, P < 0.001). The main effect was a trend for the perception of increased sufficiency in all sectors, although aged care sector nurses over each study were more likely to indicate that skill mix was the least adequate.
Overall almost half of the nurses had experienced workplace violence from other staff or clients and visitors in the previous 3 months. Across sectors there were differences in each study with the lowest incidence of workplace violence reported in the private sector. Over the years, there was a statistically significant effect (χ2 = 30.412, d.f. = 3, P < 0.001). The main effect was the reported increase in workplace violence between 2001 and 2004. The cause of this might have been to greater employee awareness and a more inclusive definition of workplace violence in the 2004 study. In 2007, the incidence dropped from the 2004 level and remained constant in the 2010 study.
From 2004, nurses were asked if they had access to training through their workplace. In each study, there were sector differences (χ2 = 27.546, d.f. = 4, P < 0.001) with public sector nurses most likely to say they had access to training and professional development opportunities and those nurses in aged care least likely. Overall access to training tended to rise (χ2 = 65.952, d.f. = 4, P < 0.001).
Your views of nursing
Views on nursing were elicited using a semantic differential seven-point rating. Nurses were provided with 20 opposing statements about working in nursing and requested to indicate within the range of the two extreme positions, how they felt about each aspect. For most factors, the overall view fell on the negative end of the scale (Table 4).
Table 4. Mean responses to apposing statements about nursing
|Factors with significant (P < 0.05) effect across studies|| |
|Work is emotionally challenging||2.18|
|Workload is heavy||2.16|
|The work in physically demanding||2.42|
|Pay rate is good||3.93|
|Work hours are convenient||4.19|
|Career prospects are good||3.84|
|Nursing is seen as a high status career||3.78|
|Work stress in high||2.09|
|Workplace is safe||2.95|
|Nursing staff morale is good||4.11|
|Nursing staff morale is deteriorating||3.41|
|Factors with no significant effect across studies|| |
|Workplace is well equipped and supplied||3.42|
|Nursing work is valued by the community||2.63|
|Nursing work is valued by the health system||3.75|
|The work I do matches my professional expectations||2.91|
|The purpose of nursing is understood in the workplace||2.78|
|The purpose of nursing is promoted in my workplace||3.05|
|Lacks teamwork and support from colleagues||3.99|
|Skill and experience is not rewarded||3.33|
|Autonomy is encouraged||3.38|
Across the four studies, the views of nurses were significantly different for 11 of the 20 statements. These included views on workload, pay, career and morale. Chi-square ranged from 40.96 to 182.41 (d.f. = 18; P < 0.001), and in all cases, there was a positive trend with the negative aspects of the statement tempered. Table 5 illustrates one of the factors (pay rate) where the ‘quite poor’ and ‘extremely poor’ responses fell from 34.5% to 26% between 2001 and 2010.
Table 5. Effect of study in response to views on pay rate
|% within year||1.1||1.1||1.5||2.0||1.5|
|% within year||19.1||17.0||20.0||24.9||20.2|
|% within year||18.2||22.4||22.0||24.9||21.8|
|% within year||12.8||12.9||14.3||13.1||13.2|
|% within year||12.3||10.2||10.3||9.2||10.5|
|% within year||19.1||17.8||16.4||13.5||16.7|
|% within year||17.4||18.5||15.4||12.5||16.0|
|% within year||100.0||100.0||100.0||100.0||100.0|
Limitation of the studies
Response bias and non-response bias are potential limitation to the studies. Contributing factors to response bias might include small sample size, limited distribution of the survey tool and using only females or one age group or level of nurse. All these aspects were addressed by the adopted methodology that polled the most appropriate population to provide a valid answer the overriding research question.
Comparison of the demographics of respondents against the QNU database indicated no differences. This suggested minimal non-response bias and supports the contention that the data are representative of QNU members. Furthermore, as three quarters of all nurses in Queensland are QNU members, they are widely representative of the overall nursing workforce.
Another potential limitation to the results is the reliability and generalizability of the survey tool. The survey was presented in a consistent format with consistent instructions and explanations and during development had been face and content validated by a panel of experts. Taking issues such as this into account we see little threat to the internal validity.
Generalizability, or external validity, of results to situations with similar parameters, populations and characteristics is evidenced by the citations received from prior papers from the study and the fact that the instrument has already been requested and used by a number of researchers in Australia and worldwide.
The strategy was to distribute the surveys equally between the three sectors based on the nurses' classification within the QNU's database. A limitation of the sampling method is underrepresentation of nurses in the public sector and an overrepresentation of nurses from the private and aged care sectors.
This paper reports on studies to determine changes in the workplace and views of the nursing profession that impact on job satisfaction and ultimately workforce recruitment, retention and attrition.
The originality of the study is in its longitudinal nature of gathering workforce data over 10 years from nurses within the same jurisdictions. We believe that the data collected over this period provide the first clear information on the changing perceptions of Queensland nurses with regard to their working life.
The study is also unique that it reports the same data across the public, private and aged care sectors in Queensland. It identifies that differences have not eroded over time and the areas of need. Results that illustrate that a ‘one size fits all’ resolution to the nursing workforce is unlikely to be successful, will inform further strategy for further action (e.g. pay in aged care).
The overall objective of this and other studies into the nursing workforce is, of course, to improve employment conditions for the individual and collective such that they are able to meet their intrinsic work values and thus are retained within the nursing workforce. The results of these studies will not only be informative to the union but also employers, teaching institutions and governments nationally and internationally.
Reasons for leaving any profession are likely to be complex, and some of these influences can have nothing to do with satisfaction with working conditions per se.[9, 23] For example, a nurse might be perfectly satisfied with the profession and leave for other reasons such as family commitments or other individual and personal reasons.[9, 24] Additionally, there is evidence that the factors that nurses perceive would decide their remaining in the workforce while employed in nursing are quite different to the factors that nurses cite as the reason for leaving nursing once they have exited the workforce.[23, 24]
Nevertheless, the views and perceptions that nurses do hold about nursing and their nursing job are of great significance. Considerable literature exists on job satisfaction and its relationship to staff turnover and patient outcomes and to dissatisfaction with nursing which is associated with retention and loss to the profession.[25-28] Satisfaction is a multifactorial phenomenon that is highly subjective and most aspects of any employment can contribute to job satisfaction or dissatisfaction in its broadest sense.
Although our studies did not specifically address job satisfaction, they did collect many facets of information about nursing and nurses' views that have been used previously to be indicative of satisfaction in nursing. These included perceptions of morale, exposure to workplace violence (and therefore the safety of the workplace), workload, perceptions of the adequacy of staff and skill mix, remuneration and working conditions.[9, 24-26, 28-35]
Our results show continued dissatisfaction in many aspects of nursing and employment conditions and major differences among the sectors, particularly between the aged care sector and the public and private sectors. However, there have been positive changes across the decade in many parameters and of particular note were the significant trends for the improvement in perception of the nursing workplace and nursing as a career. We believe that the results of the studies have played a small part in influencing arguments supporting change in workplace conditions. The consequences of change in pay, staffing, shift and employment flexibility are reflected in these views.
Provision of effective and cost efficient health care is a primary function of Australian Governments. Nurses represent the largest group of health professionals and are fundamental to service provision. Workforce data indicates that there is a shortage of nurses that will continue to impact on Government's capacity to deliver health care. Longitudinal data that provide demographic information and insight from the perspective of the nurses are invaluable to informing workforce planning initiatives. These data contribute to the understanding of factors that influence nurses' perceptions about their workplace and that might affect retention. Our findings help to identify those issues that will improve the job conditions and where interventions could be targeted to improve nurses' job satisfaction.
We wish to thank the QNU for providing the funds for the studies. Their foresight has ensured that this, the first workforce study in Queensland with long-term comparative data, has provided such an important resource. Most importantly, we also wish to thank the members of the QNU who took the time to respond to the surveys.