Casual for a cause: Exploring the employment status of nursing in Australia and China.

This paper outlines obligatory nursing education and the registration process required to become a nurse in Australia, including nurses' workload, career structure and pay. It also provides an overview of the nursing workforce in Australia, with particular reference to casual employment, and its implications. The aim of this paper is to outline the development strategies that may assist with China's increasing need for nursing education, and how changes to healthcare policy and management are required to increase the recruitment and retention of nurses in hospitals worldwide.

Introduction

Australia's health system is facing significant challenges that will affect availability, demand and the cost of health service provision [1]. These challenges are the result of an ageing population, increasing demand for and expectation of services, as well as the cumulative burden of disease and increasing workforce shortages [2], [3]. These same challenges are also being experienced by China [4], [5], [6], [7], which is the third largest country in the world, with a population of 1.386 billion people [8] and on a fast-track of social and economic modernisation. However, China's internal progress is occurring post-revolution, and although adopting a western capitalist economic system, there remains an underlying Marxist communist ideology [9], that the nursing profession has to negotiate. Recent research suggests Chinese nurses are subject to job dissatisfaction and burnout [10], and that the Chinese nursing profession may need to observe how other countries are dealing with this world-wide occurrence to improve recruitment and retention rates of nurses in China.

Nursing education and registration in Australia

In Australia, nurses are protected by legislation and their practice is regulated by standards, ethics, and codes of conduct [11]. The Nursing and Midwifery Board of Australia (NMBA) is responsible for managing processes associated with registration and practice nationwide through authority delegated by the Australian Health Practitioner Regulatory Agency (AHPRA). To gain initial registration and become an RN, a person has to complete an accredited nursing program, demonstrate competency of NMBA Standards for Practice as a nurse, and meet the minimum English language requirements.

As shown in Table 1, there are three levels of nursing registration in Australia: 1) Enrolled Nurse (EN), 2) Registered Nurse (RN), and 3) Nurse Practitioner (NP). Training courses for EN, RN, and NP are accredited via an Australian Qualification Framework (AQF). In Australia, an EN requires 1–1.5 years full-time or part-time equivalent study for a Diploma of Enrolled Nursing; an RN requires 3–3.5 years full-time or part-time equivalent study for a Bachelor of Nursing, and an NP requires an expert RN to complete a relevant master's degree. An NP has been endorsed to work autonomously and collaboratively as an advanced clinical role in a specified nursing practice area [12], [13], [14], [15], [16].

Table 1

Comparison across three nursing levels.

Nursing registration level	Enrolled Nurse (EN)	Registered Nurse (RN)	Nurse Practitioner (NP)
Qualification requirement	Diploma of Nursing	Bachelor of Nursing	Master of Nursing
Clinical placement required for initial registration	Yes	Yes	Yes
Exam required for initial registration	No	No	No
CPD	At least 20 hours per year	At least 20 hours per year	At least 20 hours per year
National registration	Yes	Yes	Yes
Renew registration	Annually	Annually	Annually
Registration body	AHPRA	AHPRA	AHPRA

An EN provides care to patients across a range of clinical settings under the supervision of an RN. An EN can progress to an RN by way of further education; an RN works as part of a team and can supervise other staff such as ENs and unregistered healthcare workers. An RN is responsible for patient assessments and decisions regarding the delegation of care and assessments; the NP function as an advanced and extended clinical role to assess and manage patients' conditions including patient referral, prescribing and ordering diagnostic tests [12], [13], [14], [15], [16].

These three levels of nurse qualifications are required to meet Continuing Professional Development (CPD) standards to support the renewal and continuation of nursing registration. Nurses are required to participate in at least 20 hours of CPD per year [12], [13], [14], [15], [16].

Nurse/patient ratios, career structure and pay in Australia

In Australia, nursing workloads are measured by nurse to patient ratios. Generally speaking in hospital, one nurse to four patients is a ratio at ward level on the morning and afternoon shifts, and one nurse to a minimum of eight patients is allocated on night shift [17].

Career structure

In Australia, the nursing profession has numerous opportunities for advancement [18]. Generally, the positions attainable for nurses are:

Enrolled nurses

Graduate EN level 1

After initial registration with the NMBA of Australia, graduate ENs usually apply for a graduate program which is a 6–24 months paid position offered by hospital to support transition into the workforce.

EN level 1–4

ENs provide nursing care that are directly under supervision of the RN. Whilst answerable to the RN, they hold responsibility and independence for all delegated works.

Advanced Skill Enrolled Nurse (ASEN)

ASEN is an EN who has at least 4 years' experience and has demonstrated skills and knowledge that contained in the ASEN Competencies Workbook.

Registered nurses

Graduate RN – ANF level 1, increment 1

After initial registration with the NMBA of Australia, graduate RNs usually apply for a graduate program which is an 11–24 months paid position offered by hospital to support transition into the workforce.

RN– ANF level 1, increment 1 to 8

RNs act as role models and undertake a teaching role in nursing practice for ENs and other junior staff.

Nurse practitioners

An NP is usually an experienced specialist RN who has completed a relevant master's degree. An NP functions autonomously as an advanced role practicing in a designated nurse practice area.

It is worth mentioning though, nurses' each state has their own way of naming the nurses' position classifications, and for example, the nurse position classification systems are different between Victoria and Queensland.

Salary

Pay levels for nurses in Australia are depending on their position and years of nursing experience. Their salary usually increase yearly in line with the increased cost of living. An RN earns an average wage of $75,000 per year.

Added payment is also received for working particular shifts, around 10% of superannuation contributed by employer, and ability to salary package their mortgage, rent, childcare, health insurance, car, laptops etc. for which decreases their taxable income [18].

Again, there are differences in nurses' salary and availability of salary packaging across states and hospitals in Australia. For example, accessibility of salary packaging in private hospitals might be different compared to public hospitals.

Nursing in China

Nursing education in China comprises of five levels including Diploma, Advanced Diploma, Baccalaureate, Masters, and Doctoral [11]. The Diploma consists of a three-year nursing program designed to teach clinical skills, and the Advanced Diploma consists of a three-year associate nursing degree program offering general clinical training alongside nursing theory and skills. The Baccalaureate consists of a five-year Bachelor of Nursing program providing a broad nursing foundation with associated sciences, and the Master of Nursing programs aim to prepare experts in either clinical practice that emphasises advanced clinical practice or in research that focuses on research training. The Doctoral nursing programs aim to instruct nurses in education, research, and leadership and management skills [3].

China aims to develop its own specialised and advanced nursing programs, however, inconsistent with clinically focused both Masters and Doctoral programs at universities, there are no such advanced clinical practice available for students in hospitals [11].

As shown in Table 2, there is only a single level of registration, which is that of an RN despite the fact that nursing education comprises of five levels [11]. Chinese nurses are required to renew their registration with their local Nursing Registration Board every five years however there is no clear CPD requirement when renewing nursing registration. In China, because of the lack of a national registration, a nurse cannot move easily from one city to another. A registered nurse who wishes to work in another state or city is required to apply for current nursing registration to be transferred to that state or city before being able to practice in that geographical area [11].

Table 2

Similarities and differences of Australian and China's nursing registration systems [7].

	Australia	China
Nursing registration level	EN; RN; NP	RN
Qualification requirement	Diploma of nursing (EN)Bachelor of Nursing (RN)Master of Nursing (NP)	Diploma of NursingAdvanced Diploma of NursingBachelor of Nursing
Clinical placement required for initial registration	Yes	Yes
Exam	No	NNLE exam
CPD	At least 20 hours CPD per year	No
National registration	Yes	No
Renew registration	Yearly	5 yearly
Registration body	AHPRA	Local Nursing Registration Board

In China, most nurses are female. Their average is 29 years old and their mean work experience is 8 years [19].

Nursing staffing levels and workloads vary considerably among hospitals, as well as across states. The average workload is 6.8–7.9 patients per nurse per shift overall [20].

Hospital managers often employ fewer nurses whenever possible to meet budget constraints, and Chinese hospitals are currently experiencing serious nursing shortages [4], [5], [6], [7]. More than 50% of nurses in China are contract nurses [19]. Contract nurses are employed by the hospital, to solve staffing shortages, but with lower salaries and fewer opportunities for promotion compared with nurses whose positions are allocated by the government [19]. These factors contribute to increasing burnout, job dissatisfaction, and nurses' intention to leave.

Permanent full-time and causal work (hospital pools and agencies) in Australia

Historically, the employment system in many countries mainly centred on standard employment contract which is the permanent full-time work with a single employer. Women especially unhappy with the inflexibility of the contract, and employers looking for greater privilege, have aided to wear away the supremacy of permanent full-time employment in Australia. Non-standard forms of employment, such as causal work through hospital pools and agencies, have become more prevalent. The current employment system in Australia lies anywhere between the US and Europe, with marginally less than half of all jobs being permanent and full-time [21].

In Australia, casual contracts usually absent of annual leave, sick leave, and public holiday payment. However, adequate recompense for wage loading is added and it usually between 15% and 25% which is set by a collective agreement [22]. Nursing agencies and hospital pools are familiar with outsourcing casually employed nurses. A casual nurse is either employee of a labour hire agency or a hospital pool. The nurse is therefore either paid through the labour hire agency or the hospital pool. The nurse can register with multiple hospital pools and/or labour hire agencies at one time. The agency sets the casual nurse's pay rate and a fee of finding the nurse.

Casual employment contracts are also seen to be part of a cost saving strategy by employers. Casual contracts proposition employers with budget management, more versatility, and ease of termination. Contrasting to temporary contracts in other countries, casual nurses in Australia advantage from state-stipulated securities of minimum salary and equal rights policy and are eligible to compensation for work-related injury and disease. They are also entitled to receive superannuation contributions from employer, long-service leave, maternity leave, and are able to claim for unfair dismissal. Furthermore, a continuing optimistic Australia's economy, and a nursing market characterized by low unemployment, have reduced job insecurity. Thus nursing in Australia provides a unique and favourable context to this phenomenon.

The extent that nurses chosen casual employment in Australia, and the reasons they give are varied. Many nurses have made a deliberate choice of casual employment for reasons of improved quality of life, reduced responsibility, less workplace politics, decreased work life conflict through control of working schedules, reduced job stress, and greater remuneration. The casually employed nurse receives a better pay rate to counterweigh for the loss of access to an increased hourly rate of pay to compensate for the loss of access to advantages such as paid holiday and sick leave, which are typically inherent in full-time positions. Casual employment allows nurses to mingle paid work with family obligations, to study and seek other interests, to ease out of the labour force as they near retirement, and to supplement the family earnings [23]. Many nurses who wish to take a break from working within nursing, but taking on casual employment at some future time just to maintain nurse registration. Nurses who have good financial, educational, social resources and good health, are able to exercise greater decision-making power over their employment status.

Some of the pitfalls associated with casual employment centre on the fact that non-standard employment may give nurses a lack of control over working schedules, cause job insecurity, and perceived reduced power and respect at work [21]. It is also believed that non-standard employment generally presents conditions lesser than the ideal position of permanent full-time work. Advantages such as access to training, knowledge of health hazards at work, paid holidays, sick leave, and unemployment compensation are absent or less common in casual employment, with some cross-national variation [21].

Discussion

The shift away from standard full-time work to more accommodating ways of non-standard work has essentially been driven by deregulation of the labour market, the need for greater flexibility in organisational structures, competitive and economic stress [24]. Non-standard employment are likely to be an ongoing feature of the modern nursing workforce and necessitates strategies to warrant it positively to staff and patients experiences.

Continuance of a central full-time workforce, together with the capacity to ‘top up’ as demand dictates, is a powerful human resource strategy. Causal employment is a way to rise the flexibility of the workplace; casual nurses not only fill shifts for sick leave or seasonal demands, but are also used to assist with any staff nursing shortages [25].

Nurses perform best when they have some in control of their work hours and are able to work within their full scope of practice. Flexibility around work schedules and working hours is a key factor to increase staff participation. More casual positions are therefore needed to achieve this and it is especially important for women and mature-aged nurses, Nurses can work their preferred hours and schedules have been found to demonstrate greater satisfaction and thereby it can be used to address nursing retention [26]. Displeasing or underutilising capable and experienced nurses is potentially disadvantageous to patient outcome and to the nursing profession. Employers and government body need to consider strategies to keep these employees in meaningful work.

Many agency nurses are female who have chosen family commitments over commitments to a career [23]. Job satisfaction and workforce commitment demand employers to support casual employment choice where possible and employer commitment should not be influenced by the type of employment chosen.

Retaining and updating clinical skills within contemporary clinical practice can be challenging for nurses who work as casuals due to a variety of reasons which include poor integration into organisations' staff development opportunities, high turnover rates of casual staff, and difficulty maintaining mandatory annual competencies [27]. Therefore, issues concerning continuing education and training are a genuine concern. Hospital organisation's strategies and policies require revision, enabling casual employees the same opportunities to continuing and training as nurses employed on permanent contracts. This would ensure that despite casual nurses working in different nursing environments, quality patient care and outcomes would be maintained.

Another initiative, that could be implemented to accommodate employment flexibility needs of staff, are the variety of length of shifts available within clinical environments. Shifts could comprise of differing hours (four, six, eight and 12 h shifts), that would improve work/life balance for many nurses [23]. This flexibility may provide employers with valuable options in how staff may be utilised within the varied clinical environments, including periods when patient/nurse ratios are increased or decreased.

Conclusion

Within the nursing profession, flexible employment options offer increased opportunities and an improved work/life balance, to retain women in the workforce. Being able to work within chosen employment preferences attracts casual nurses, particularly mature nurses who wish to reduce their hours in preparation for retirement, or nurses managing young families. Casually employed nurses have an important contribution to make in patient care and outcomes, and should be recognised and valued when strategies are being considered by organisations when regarding future employment. Inclusion of contemporary research and the promotion of innovations and evidence-based strategies should be considered to ensure inclusion of casual nursing employment opportunities. This will be a contributing factor in hospital organisations' commitment in the provision of safe patient care and optimal patient outcomes.