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Nurses leaving--should we be worried? Nursing Council research reveals the attrition rates for nurses who registered eight years ago and those who registered two years ago.

An attrition rate of 42 per cent after eight years of nursing and an attrition rate of 10 per cent after the first year of practice--should the profession be concerned? The answers from a range of nursing leaders are, seemingly, equivocal. But there was more unanimity about what's important to keep nurses nursing.

Data gathered and compiled from annual practising certificates (APCs), by head of Massey University's nursing school Annette Huntington and reported by Nursing Council in its Nursing Cohort Report 2014, reveals these attrition rates. Of the 1323 New Zealand qualified registered nurses (NZRNs) who first registered in the year ending March 31, 2006, 67 per cent were still practising eight years later. Of the 1273 internationally qualified nurses (IQNs) who gained New Zealand registration that same year, 47 per cent are still in practice. That's an attrition rate of 42 per cent across the two cohorts. (1)

Of the 1639 NZRNs who first registered in the year ending March 31, 2013, 93 per cent (n=1528) are still practising. Of the 1257 IQNs who registered that year, 89 per cent (n=1115) are still practising and of the 150 New Zealand-qualified enrolled nurses (ENs) who registered, 74 per cent (n=111) meet the requirements to practise and 107 (71 per cent) are still practising.

Introducing the report, council chief executive Carolyn Reed said following these groups over time would provide a valuable resource for planning, policy development and research.

A number of nursing leaders posited similar reasons for the 42 per cent attrition among the 2005/2006 cohort--pregnancy, parenting, other family considerations, overseas travel, further study, another career choice and, for the IQNs, a return to their own countries or another country to work.

While the nurses may not be practising, they have not necessarily left nursing. The report showed the vast majority of the cohort--96 per cent since 2009--had retained their APCs. (1)

National chair of Nursing Educators in the Tertiary Sector Kathy Holloway said, while the attrition rate seemed high, she would like to see how it compared with previous decades and other professions. The context of the last few years also had to be considered. "Is there a possible link with the global financial crisis? Did this create an exodus 'bulge', as jobs were downsized? Or is it related to policy changes, eg more care being moved to the community?"

The report of the 2005/06 cohort shows a steep decline in the number of NZRNs between 2009 and 2010 and a slight increase in 2011. Apart from those exceptions, the rate of decline in nurses actively practising declined steadily over the period. In 2007, 84 per cent of the cohort was still actively practising. (1)

In terms of retention, the nursing leaders agreed a combination of factors would help, including better pay, conditions, staffing and nursing leadership. Holloway said support for ageing nurses, eg meaningful part-time work and retirement support, would also help.

The attrition rate reinforced the need for sound orientation and support for both new graduates and new "hires", she said.

Nursing workforce researcher and NZNO's principal researcher Leonie Walker thinks better shift choices and more manageable workloads would help retain nurses.

Director of nursing and midwifery at Waikato District Health Board (DHB) Sue Hayward said many of the earlier cohort were in the childbearing and raising age group. "While they may not be currently practising, we may see them coming back after a period of parental leave and this can sometimes be a number of years, as opposed to months," she said.

Of the 1323 NZRNs in the 2005/2006 cohort, 55 per cent (n=727) were under 30 when they first registered. Of the IQNs, 25.6 per cent (n=326) were under 30 when they first registered.

While the attrition rate seemed high, Hayward said it might not be that much different from past cohorts. A wonderful aspect of nursing was its flexible employment options. "Having periods of leave and then coming back into the profession, can be accommodated."

Referring to implications of the attrition rate for undergraduate nursing education, Walker said some older nurses felt the degree education did not adequately prepare nurses for the more emotional aspects of nursing "and that, in particular, they don't build the social support structures necessary to carry them through the tough times at work".

Also, degrees were more transferable than vocational training, so degree-trained nurses had more career options, she said.

Chief Nurse Jane O'Malley said the report on the two cohorts provided "valuable workforce intelligence". She drew a distinction between "temporary attrition", where nurses were not practising but still held an APC, and "longer-term attrition", where nurses no longer held an APC. Thus, she said, the longer-term attrition rate for NZRNs in the 2005/06 cohort was four per cent over eight years. That was important to know from a workforce planning perspective "but it is likely to have few implications elsewhere".

O'Malley referred to a range of initiatives that should contribute to retention. These included care capacity demand management, funding of $13 million for postgraduate nursing education and moves to eliminate some of the barriers limiting nurses' ability to practise to the full extent of their scope. These include a ministerial commitment to designated nurse prescribing for RNs in primary health and specialty teams; introduction of a bill to the House that will enable nurse practitioners (NPs) and some other nurses to do some activities previously restricted to doctors; and guidelines that will enable NPs and RNs to verify death.

Chair of Nurse Executives of New Zealand (NENZ) Denise Kivell said the 42 per cent attrition rate represented five per cent attrition rate per year over eight years. The annual attrition rate in the Auckland region was between eight and 10 per cent.

Kivell said loss of nurses meant a loss of knowledge but it did create positions for new graduates. Knowing the attrition rate would help with workforce planning, but it needed to be monitored. "If you educate to meet a certain attrition rate, you could be caught out when it changes. Staff skills and skill mix also need to be monitored accordingly," she said.

'Dreadful waste of vital resource'

Executive director of the College of Nurses Aotearoa Jenny Carryer said any nurses leaving was a "dreadful waste of a vital resource that we can ill afford to squander". Her research and her exposure to postgraduate nursing students revealed deep-seated and long-standing levels of frustration.

"Nurses in both acute and primary settings are often considered and spoken of, as a cost item rather than a vital and productive resource. The well-known connection between RN staffing levels and patient safety, and the work around missed care, should be receiving far more attention," she said.

A well-prepared and appropriately-deployed nursing leadership structure greatly increased nurses' sense of job satisfaction and helped both recruitment and retention, she said.

An initial qualitative study on nursing attrition in the United States revealed three key themes in nurses' decision to leave clinical nursing: unfriendly workplace; emotional distress related to patient care; and fatigue and exhaustion.

Referring to the 2012/13 cohort, Holloway said 10 per cent attrition across the three groups meant 90 per cent had remained in nursing. "It's total speculation without accurate information on why 10 per cent left--travel, a change in family circumstances, nursing not being what they expected, inability to get a job in preferred practice area or location--these could all be factors."

Referring to the 10 per cent attrition rate overall for the later cohort, Walker said some of the reasons nurses left in their first year of practice could include changing expectations of work, emotional unpreparedness, that nursing was very hard work, the impact of shift work on social life and having other opportunities.

Holloway believes the 26 per cent attrition rate among ENs could, in part, be related to the numbers who enrol in a bachelor of nursing post-graduation. It could also reflect the challenges some face in getting employment. Kivell agreed. "I think it highlights the need to give them jobs. The consensus among NENZ was the importance of comprehensive orientation," she said.

O'Malley said during the 17 years when there was no New Zealand EN training, many employers changed their models of care away from using ENs. "However, this is starting to change and DHBs and other employers are developing news models of care that incorporate ENs."

Hayward believes the EN situation reflects a problem in understanding how ENs fit in acute, chronic or primary care.

The nursing leaders were grateful to the Nursing Council for the cohort reports and all agreed further research was needed to find out why nurses left the profession.

The person ultimately responsible for ensuring the country has enough nurses is head of Health Workforce New Zealand (HWNZ) Graeme Benny. He believes medium and long-term employment prospects for nurses are good and is confident HWNZ's nursing workforce programme will ensure career pathways for all New Zealand nurses, graduates and experienced nurses. "The programme will take full account of any anticipated future shortage of nurses, the ageing nursing workforce and the need to ensure an increase in the number of nurses working in both primary and aged care," he said.


(1) Nursing Council of New Zealand. (2015) The Nursing Cohort Report 2014. Wellington: Author.

(2) MacKusick, C.I. & Minick, P. (2010) Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. MEDSURG Nursing; 19: 6,pp335-340.

By co-editor Teresa O'Connor
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Title Annotation:news focus
Author:O'Connor, Teresa
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Jun 1, 2015
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