School of Nursing
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How will the aging nurse workforce impact on rural healthcare and what can be done to address this issue?

Anja Koehler

Introduction

Sustainability of the rural nursing workforce is under threat. With an aging health workforce many clinical areas within nursing will experience shortages in the near future (New Zealand Nurses Organisation, 2018). Using the PECOT model, established by Jackson (2010), this practice issue from a clinical nursing setting has been defined into the question of: How will the aging nurse workforce impact on rural healthcare and what can be done to address this issue? This question guided the research and helped identify evidence based information relating to the issue (Whitehead & Maude, 2016). Through the use of evidence based literature I will explore the challenges and implications for rural healthcare of an aging nurse workforce and possible interventions that could be explored or implemented to alleviate the impact of this practice issue.

Rural New Zealand Background

The Ministry of Health (2002) identified that one in four New Zealanders live in rural communities. Living in rural New Zealand has its benefits such as close knit communities, open spaces and reduced cost of living but also its disadvantages such as reduced local amenities, isolation and reduced access to or lack of crucial resources and infrastructure (Howie, 2008b). Having lived provincially and recently had clinical experience within a rural healthcare facility, this has allowed me to understand the clinical and practice issues that rural healthcare facilities face. Particularly as a result of an aging nursing workforce, where there is the need to recruit new staff and retain experienced nursing staff in order to deliver services.

Rural as defined by Statistics New Zealand (2004) is related to population size, geographical location and overall dependence on urban areas. Rural communities usually refer to a small number of people living in relative isolation which can affect access to health services (Howie, 2008b). The National Health Committee (2010) believes the health needs of rural communities requires specific attention in order for them to access and receive the care and services needed. Often a particular level of health support and care is needed due to distance from secondary/tertiary healthcare, higher level of health needs and the socioeconomic status of many rural communities (National Health Committee, 2010).

One of the challenges, as identified by the National Health Committee (2010), faced by New Zealand’s health system is the provision of healthcare services that are accessible, appropriate, affordable, available and adequate for those living in rural communities. Adams (2017) noted the key to this is the health workforce and in particular rural nurses, however nursing as with other rural health professions is facing issues of an aging workforce.

The Clinical Issue

Howie (2008b) recognises that rural nurses in particular face unique and challenging barriers within their practice as compared to their urban counterparts. Rural nursing is variable and unpredictable, it’s a highly skilled clinical area that requires an advanced level of care, ability to adapt, enhanced knowledge of nursing research theory and its application to practice (Howie, 2008a). They must deal with additional challenges including lack of financial resources, more limited access to professional development and a diverse range of patients with a broad spectrum of health related issues (Howie, 2008a). All of which impacts on the attractiveness of rural nursing.

The Nursing Council of New Zealand (2018) notes that the nursing workforce has grown with 56,356 nurses practising as at 31 March 2018, an increase of 1,067 on 2017 figures. However it is unknown if this growth will counteract the aging nursing workforce or whether these nurses will be interested in working rurally given the recognised associated challenges (Nursing Council of New Zealand, 2018). Health Workforce New Zealand noted in 2015 that nurses had an average age of 46.3 years (this being higher in rural areas) and 45.2% were aged over 50, up from 40% in 2009 (Ministry of Health, 2016). This aging workforce coupled with potential shortages of new nurses moving into rural healthcare is a very relevant clinical issue for most of New Zealand’s rural healthcare facilities (Ministry of Health, 2016).

The broadness of knowledge required and skills needed, and access to a willing population are therefore among the challenges that rural healthcare facilities face. High acuity and load of patients coupled with a decreased and unsustainable level of staff is contributing to the inadequacy of services (Shaw, 2017). In addition, there is an apparent lack of resources, initiatives and access to professional development to educate and train inexperienced and new graduate nurses to take up positions in rural nursing (Ministry of Health, 2002). All impacting on the accessibility, availability and adequacy of healthcare in rural communities within New Zealand.

Development of Research Question

The practical issue of rural nurse shortages has been identified as problematic due to an aging workforce. The PECOT model, developed by Jackson (2010) and detailed in the Table 1 below, is a tool used to refine and restructure research ideas into a more formally defined and searchable question which is then used to guide the review of evidence based literature (Whitehead & Maude, 2016). Rural communities in New Zealand will face the challenge of sustaining and recruiting nursing resources. Addressing the health needs of people in rural areas is an important focus for New Zealand’s healthcare system. However, in order to do this rural healthcare providers need a sustainable nursing workforce.

Table 1:

Through use of the PECOT model I have developed my research question on the clinical issue of the aging workforce creating shortages in nurses in rural healthcare settings. I want to understand the barriers that rural healthcare providers are facing surrounding recruiting, educating and retaining new nurses and the effect that the shortage will have. In turn, I hope to identify effective ways nurses can be sourced and retained, and therefore allowing rural communities to continue to prosper from safe and sustainable healthcare. Therefore I have come up with the refined research question of: How will the aging nurse workforce impact on rural healthcare and what can be done to address this issue?

Critical Review of Literature

There is a multitude of evidence based literature that supports and recognises the potential for the aging nursing workforce to have an effect particularly on rural healthcare. Having a sustainable nursing workforce is vital to providing the care rural communities need and are entitled to (Shaw, 2017).

The Nursing Council of New Zealand (2017), has a focus on the numbers of nurses over the age of 55 with particular interest in nurses employed in the rural healthcare workforce. Statistics show the numbers of nurses, in a rural setting, in the over 55 age bracket is increasing over a five year period from 0.80% in 2012 to 1.57% in 2016 (Nursing Council of New Zealand, 2017). The clear aging trend in rural nurses is recognised by the Nursing Council of New Zealand and is alarming for the sustainability of the workforce. The Nursing Council of New Zealand additionally noted that due to the growth in numbers in the over 55 age bracket and employment region, these nurses now make up almost a third of all nurses. The number is far outweighing the incoming potential workforce replacements (Nursing Council of New Zealand, 2017).

With the aging nursing workforce in rural healthcare it is evident rural communities will face nursing shortages. It is predicted by Nana, Stokes, Molano and Dixon (2013) that over 50% of the present New Zealand nursing workforce will retire by 2035 and as researched by Adams (2017) 25% of rural health practices had a nursing vacancy. Shortages of nurses has been an issue recognised in many rural communities throughout New Zealand. It is clear that there is a need for a workforce development strategy to meet the increasing demand for rural nurses.

With the expected retirement of many rural nurses in the near future and the difficulties attracting nurses into rural healthcare facilities, the potential for a detrimental effect on rural healthcare will be evident. Mbemba, Gagnon, Paré and Côté (2013) found that rural areas are having increased difficulties in recruiting and retaining nurses in comparison to urban areas which provide greater opportunities in careers and prospects for work. There are additional barriers experienced by rural healthcare facilities in the recruitment and retention of nurses including; lack of specialised services and resources, geographical and professional isolation and the cost of traveling and living within rural communities (National Health Committee, 2010). Insufficient numbers of experienced nurses and the expected loss of a population of experienced nurses impedes rural communities ability to obtain adequate healthcare services.

The challenge for rural healthcare is therefore replacing a population that has had many years of experience, clinical growth and a level of knowledge and maturation in a rural clinical setting. Shaw (2017) recognises that currently many prospective new graduate or inexperienced nurses in the field of rural nursing are feeling underprepared and overwhelmed. The sheer knowledge and skill base that is needed to provide care for acute patients across the age spectrum that present at rural based healthcare facilities is unlike many other practical nursing settings (Shaw, 2017). Nurses are being turned away because of this lack of knowledge and skill, or many nurses are having to work beyond their scope of practice, particularly with some practices in rural settings now being nurse only due to issues in general practitioner recruitment as described in The New Zealand Nurses Organisation (2018). Goodyear-Smith and Janes (2008) confirm that with minimal exposure, education or training and role models, it is not surprising that few young nurses choose not to work rurally. This trend coupled with the aging workforce, will lead to New Zealand experiencing a shortage of rural nurses (Goodyear-Smith & Janes, 2008).

There is a need to maintain satisfactory provision of care and continued education to ensure the recruitment and retention of nurses into the rural healthcare profession in light of the aging workforce (New Zealand Nurses Organisation, 2011). Sources including Molanari, Jaiswal and Hollinger-Forrest (2011) acknowledge that new graduates and other nurses new to rural healthcare facilities are often unprepared as little is known about their role and perceptions of lifestyle changes and the education level needed to adapt to the role. Those that are new to rural nursing often have the willingness to learn but can feel unsupported and left to fend for themselves, due to the large workloads and needing to provide their own independent unsupervised professional development and learning in the rural healthcare profession (Molanari et al., 2011). Thus impacting on their retention and the supportive and nurturing environment that we want our nurses working in.

Limitations and Implications

With the aging workforce there are implications for the availability of experienced nurses to mentor and support new graduate nurses in rural areas. This is important given the more complex and unpredictable nature or rural nursing, as noted earlier. Mbemba et al. (2013) showed that mentoring, clinical supervision, and preceptoring are all valuable strategies in meeting the particular challenge of recruitment and retention of rural nurses. Therefore, losing a cohort of nurses equipped and experienced in educating on the provision of care of rural communities has significant implications.

Nixon et al. (2018) suggests that poor access to healthcare as a consequence of nursing shortages and inexperienced replacements in light of the aging workforce is a major limitation. It additionally is recognised by Nixon et al. (2018) to be contributing factor to the decline in health of the rural communities who are already experiencing significant health disadvantages. In addition in Statistics New Zealand (2004) geographical categorisation rural have the overall lowest socioeconomic status and therefore are our most vulnerable in terms of health status. It is also the residents of rural towns that additionally have the highest proportion of people identifying as Māori, who are known to have poorer health outcomes including a lower life expectancy, compared non Māori and those living in urban cities (Nixon et al., 2018). These communities are in need of particular level of healthcare that is adequate, appropriate, accessible, available and affordable.

As evidenced above through literature is the effect and implications on rural healthcare of an aging nursing workforce. Maintaining a sustainable population of nurses in rural communities is therefore challenging and an issue that needs to be addressed.

Recommendations

The recruitment and retention of nurses to maintain stability of the rural nursing workforce is complex, costly and a challenging process (Molanari et al., 2011). The implications of an aging health workforce means providers are needing to be; more aware of the challenges associated with rural nursing, embrace new models of care and roles, become innovative and flexible in the use of existing capacity (National Health Committee, 2010).

According to Bloomfield, Aggar, Thomas and Gordon (2018), those graduating from a nursing education facility typically commence careers in a professional practice which is hospital-based. Targeting nurses at an undergraduate level and introducing them to rural based practice is one strategy critical to resolving the shortage (New Zealand Institute of Rural Health, 2019). Evidence by Yeager and Wisniewski (2017) suggests that early nursing experiences have the potential to positively influence recruitment, selection, and retention. Providing rural placements allows undergraduates to better understand expectation of a nurse who practices in a rural community, fuelling their desire to work in such a setting (Yeager & Wisniewski, 2017). The Rural Health Interprofessional Immersion Programme mentioned in the Ministry of Health (2014) involves undergraduate students from several nursing institutions with a focus on gaining clinical experience in rural New Zealand. Applying learning to rural situations, thereby appreciating the challenges and opportunities in a rural health career (Ministry of Health, 2014). Expansion of institutions providing this programme and further undergraduate programmes offered to complement this may be a valuable strategy for developing the rural nursing workforce (New Zealand Institute of Rural Health, 2019).

Embracing nurse practitioners in all rural healthcare facilities is another crucial step in reducing the workforce shortage. Currently as evidenced by Ministry of Health (2018) there are approximately 300 nurse practitioners working within New Zealand, with minimal numbers working rurally. It is believed by Adams (2017) that rural healthcare facilities would greatly benefit from the employment of nurse practitioners, as they have the ability to provide a level of care similar to a general practitioner. MacQueen et al. (2017) acknowledges that nurse practitioners have expertise and in depth knowledge of the communities they work within, from previous practical experience and they are more likely to offer the community and provider a commitment to continuity of care. Therefore they are well equipped to alleviate the problem of the rural nursing staff shortage. Additional efforts to pursue measures in increasing the uptake of nurse practitioners in rural healthcare facilities to ensure they maintain an adequate service to their community is a priority (New Zealand Nurses Organisation, 2018).

Providing incentives increasing the desire to work in harder to staff communities will attract more nurses. Mbemba et al. (2013) examined the effects of financial incentives for service in undesirable areas, an example being healthcare workers in rural areas. Identifying that financial incentives for rural health institute potential strategies that could positively influence the retention of nurses in rural areas (Mbemba et al., 2013). The Ministry of Health (2019) shows how such initiatives are in place within New Zealand for example Health Workforce New Zealand’s Voluntary Bonding Scheme, which focuses on attracting health professionals including nurses too hard to staff communities. Incentives of annual payments, to help alleviate student loans or to top up income, are used as means of attracting new health professionals to work in specific communities (Ministry of Health, 2019). Further expansion through increasing the number of eligible communities and nurses partaking in such a scheme would help to ensure a more sustainable rural workforce (New Zealand Nurses Organisation, 2018).

The New Zealand Nurses Organisation (2018) has a ‘Strategy for nursing 2018-2023’, it includes current actions that support the above recommendations in maintaining a sustainable rural workforce. The New Zealand Nurses Organisation focuses on the continuation, evaluation and further development of the voluntary bonding scheme and the inclusion of nurse practitioner roles within rural nursing. Additionally, through acknowledging the challenges that will occur within rural nursing due to the aging workforce the New Zealand Nurses Organisation will focus on combating this through professional development and better work conditions (New Zealand Nurses Organisation, 2018).

Utilising Existing Resources

Focusing on solely recruitment may however not be the only way to address shortages. Retaining existing older rural nurses would provide a short term solution to the issue. Uthaman, Chua and Ang (2016) discussed how older nurses have essential advanced skills and experience that is useful in a multitude of situations, a level of responsibility, scope of practice and professional boundaries that is crucial to retain in a rural setting. However they identified many older nurses face issues including personal health concerns relating to their mental and physical ability to continue, limitations associated with advancing technology and unmanageable workload. Uthaman et al. (2016) found factors which lead to the retention and longer employment of older rural nurses such as greater flexibility in work arrangements, improved employer practices and attention to factors that could influence and lead to early retirement or conversely assist in retention.

Better use of technology has many positive effects including enabling rural nurses to better access professional development and support, reducing the stress on healthcare facilities and aiding in the delivery of healthcare in the face of nursing shortages. Identified by Marcin, Shaikh and Steinhorn (2016) telemedicine is a new emerging initiative to address the barriers and projected increase in shortages of the rural health workforce. Telehealth uses information, communication techniques and other technologies to deliver healthcare to patients that are in hard to reach areas an example being rurally (NZ Telehealth Forum and Resource Centre, 2019). Continued input through supporting and complementing initiatives already in place for example mobile health are key. Additionally, improving communication of information to communities on other ways to access healthcare will reduce the strain on nurses, healthcare facilities and be an effective means to sustaining a rural healthcare workforce (NZ Telehealth Forum and Resource Centre, 2019).

Ongoing professional development and relevant education, greater employment flexibility, monetary incentives and use of technology and changing scopes of practice will help to assist in attracting, preparing and retaining rural nurses (Ministry of Health, 2002). Thereby ensuring more sustainable, safe and adequate practice of nurses and healthcare for those in the rural communities.

Conclusion

A sustainable workforce and effective healthcare for rural communities is paramount. However, as with a number of other health professions, the nursing workforce is aging and soon New Zealand’s healthcare system will be experiencing a large percentage of their nursing workforce retiring. The implications of this for rural communities and rural healthcare providers, given the unique and often broad scope of practice and recognised barriers to recruiting and retaining staff rurally, are key challenges that need to be addressed. Strategies and initiatives such as better use of resources, enhanced education and incentives will help to ensure a sustainable rural nursing workforce that meets the healthcare needs of rural communities.

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