Feature Article

Challenges for Australian
Nursing in the International
Year of Older Persons
Rhonda Nay, PhD, Sally Garratt, MScN, and Susan Koch, MN

Abstract: Some of the major issues challenging gerontic nursing in Australia
are addressed in this article. The broad context of change that has been introduced by successive Australian governments is presented briefly. The
problems of attracting and keeping qualified nurses in aged care exacerbated
by a trend toward employers actively seeking to replace qualified nurses with
unregulated staff are discussed. Education and work practice changes are
proposed as minimum responses required from nursing if the profession is to
remain relevant and central to aged care into the 21st century.
(Geriatr Nurs 1999;20:14-7)

A

s is the case internationally, most elderly
people in Australia are living in the community, they report their health to be
good, and required care is given by a
spouse or family member. However,
older people are relatively heavy users of acute hospitals. Although constituting around 12% of the population, people older than 65 in Australia take up 56% of
acute hospital bed days.1 In addition, on any given day in
Australia, approximately 20% of people older than 70
are receiving long-term formal health care support.
Table 1 indicates where this care is received.
Before 1997, nursing homes housed the people who
required high-level care,2 and low-level care was delivered in hostels. Although this article focuses on the concerns of elderly people who require high-level care, most
of the nursing issues are relevant to the care of elderly
people in any context.
Aged care in Australia has been in a state of change
since 1984, when the government initiated the first

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major reforms of the nursing home industry. The main
changes included:
• Strategies to reduce the number of nursing home
beds from around 67 per 1000 to 40 per 1000 people older than 70 and increase the extent to
which care was provided in the community
• The introduction of nursing home standards,
monitoring, and sanctions
• The establishment of aged care assessment teams
(originally known as geriatric assessment teams)
• The introduction of new funding arrangements
that were tied to resident dependency and had to
be allocated from specific funding categories
The most significant funding category, the care aggregated module, could be used only for nursing hours,
and this restriction encouraged the employment of qualified nursing staff. Despite an emphasis on nursing
hours, the low status of aged care made it difficult to attract qualified nurses, and more than 50% of people employed as nurses had no qualification or license to

Geriatric Nursing Volume 20, Number 1

Table 1: Long-Term Care for People Older than 65
Receiving formal support 20%

Community care 11%

Residential care 9%

Low care 4%

High care 5%

practice. Nevertheless, nursing home care improved
enormously between 1984 and 1997.
A change in government in 1996 brought a move to
introduce further major changes in aged care. Of particular relevance to this article were:
• The collapsing of the boundaries between hostels
and nursing homes and the merging of the two
into what now are called aged care facilities
• The removal of the budgetary divisions and requirement that a set proportion of the budget be
spent on nursing hours
• The replacement of standards monitoring with
self-regulation and accreditation
Ongoing funding is tied to achieving accreditation;
however, exactly what form the accreditation will take
and how strong the will of government might be to sanction “failed” facilities remain to be seen.
Two parallel developments have the nursing sector
concerned for future quality of care and the role of nursing in delivering that care. On one hand, many nursing
homes appear to have taken this opportunity to eliminate nursing positions and increase the proportion of
unlicensed, unregulated workers. These workers are
seen to be more flexible, cheaper, and untrammeled by
legislation that can limit the scope of practice. For example, enrolled nurses are not permitted to administer
medications, yet people with no training are not regulated and therefore can administer medications.
(Enrolled nurses in Australia are similar to LPNs in the
United States: they typically have between 1 and 2
years’ training through the Technical and Further
Education Sector and are required to work under the
supervision of an RN.)
On the other hand, the recognition that workers
should have some level of education is increasing, and
the result is a national push to develop competencies
and an articulated educational framework that supports
career progression of aged care workers. Although some
people would argue that these workers are being taught
nursing by nurses, they are developing in a parallel track
to nursing rather than under the nursing umbrella.
The reduction of qualified nurses in aged care is occurring within the context of shorter hospital stays and

Geriatric Nursing Volume 20, Number 1

higher acuity and complexity of need in the nursing
home population. This shortage appears to have a circular effect by increasing the pressures on registered
nurses to the extent that many are leaving the workforce, thus exacerbating the qualified nurse shortfall.
The Victorian state government and the Australian federal government have responded to nursing concerns by
funding studies and workshops to investigate the extent
and nature of these problems. The results of these initiatives are not yet completely available, but clearly nursing is facing major challenges to maintain quality care
for elderly people. Many of the identified challenges can
be clustered under the themes of image, education, and
work practices.3,4

IMAGE
Many Australian writings have identified the devalued image/status of elderly people and aged care as deterrents to nurses choosing this field of work; 3-7
Australia is no different from other Western countries in
this regard. The consequences of this devaluation have
included limited recognition of elderly care in undergraduate nursing curricula, inappropriate placements of
student nurses in aged care facilities that lacked positive
role models, insufficient positive role models among university faculty, and pitying responses to new graduates
who have gained a placement in aged or extended care.
A growing number of nurses, passionate about
gerontic nursing, are fighting to change the image and
status of the specialty. Some strategies that have been
introduced and or are being developed include:
• Establishment of clinical chairs and professorial
units in gerontic nursing
• Appointment of senior staff who can model positive attitudes and practices
• Development of promotional videos to “sell”
aged care
• A national government-funded workshop to
identify contributory issues and offer suggestions
for change
• A national conference conducted under the auspices of the Royal College Nursing Australia
(RCNA) to advance the discussion and development of positive strategies
• Establishment of clinical development units in
aged care environments
• A national government strategy to promote positive aging and similar state strategies

EDUCATION
Perhaps because aged care has been perceived to
lack status and require few skills beyond those inherent
in any “good mother,” postgraduate specialty courses
have been poorly subscribed. Clearly, quality care of
older people demands sufficient numbers of specifically
prepared and qualified nurses.8 However, in addition to

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the lack of pressure on nurses to acquire advanced skills
in gerontic nursing, increasing pressure is being placed
on universities to charge student fees (traditionally university nursing courses are subsidized by the government) and on the health
care system to cut budgets and reduce education support for nurses—
Like all other major disincentives to
study.
specialty areas,
In Australia, a gerontic nursing subject is not
gerontic nursing mandatory in the undergraduate nursing curricshould be taught ula; however, universities
do claim that aged care is
by those who integrated across nursing
subjects or is offered as
have the passion an elective. The problem
with the so-called “integration” model is that
and credentials aged care may be taught
by academics who have
and not merely little interest or expertise
in the area or it simply is
the inclination to referred to occasionally
within a context that
teach the subject. clearly values acute care
of younger people. The
difficulty of offering
gerontic nursing as an
elective is that the devaluation of old age and aged care generally results in few
students choosing a gerontic nursing elective.
If gerontic nursing is included in the curriculum, it
often is placed in the first year of the student’s program,
and many nursing students experience their initial clinical placement within a high care residential facility.
Many reasons are given to justify selecting this area as
most appropriate for the novice’s introduction to nursing, including:
• Skills related to assisting with activities of daily
living typically are taught in first year, and nursing homes offer the greatest volume of experience
in this area.
• Caring for elderly people is “easier” and more
suited to students in their first clinical experience.
• Whether students make mistakes in this area is
not critical; after all, old people are waiting to die
anyway.
• Because nurses will spend most of their careers
working with elderly people, they should be introduced to gerontic nursing as early as possible.
Unfortunately, what the novice usually experiences
is a population of frail elderly people with complex
health needs far beyond the novice’s knowledge level or

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practical experience. This interaction often occurs in contexts in which most staff members are unqualified and
the care provided inappropriate. Such experience simply
serves to confirm negative views of aged care.9
Clinical experience in complex aged care should be
left to the latter part of the curriculum when students can
use their knowledge and clinical experience gained
throughout the program to inform their practice. Older
people with complex health needs deserve care from students who are capable, knowledgeable, and confident in
their practice—not by students who are unprepared,
frightened, and disillusioned with gerontic nursing.
Symbolically, placing aged care early in the course
also reinforces the view gained from the public that aged
care is easy and devalued, whereas acute care in hightech settings is placed in the most senior year of study,
reflecting the opposite values. Where academic staff
teaching aged care lack specific expertise, specialist
qualifications and research experience in the area also
can reinforce the notion that specialist qualifications are
not required. Like all other specialty areas, gerontic
nursing should be taught by those who have the passion
and credentials and not merely the inclination to teach
the subject.
In Australia, most aged care is undertaken by
women who have no qualifications. Around 8% to 10%
of qualified nurses are enrolled nurses, and another 30%
to 35% are registered nurses. Most of these nurses have
not formally upgraded their qualifications since obtaining their enrollment or registration. Many women see
gerontic nursing as a way to supplement the family income rather than as a serious career choice. Therefore
they are not self-directed toward further education, especially if they have to pay for it. For some people, education is attractive, but other factors mitigate against
commitment. A major factor is the accessibility of education. Face-to-face classes often prove impossible because
of staff shortages, the inability to be released for class
during work hours, and family commitments after work.
In an attempt to address the need to provide further
education to nurses working with older people, the
School of Nursing at La Trobe University developed a
postgraduate diploma major in gerontic nursing that is
offered in a variety of learning modes. The course of
seven subjects may be taken as individual continuing education subjects; a group of four subjects that allow the
student to exit with a postgraduate certificate; or the full
postgraduate diploma, which can be undertaken during 1
year full time or 2 years part time. These seven subjects
cover professional and policy issues in gerontic nursing
and issues related to healthy aging, biopsychosocial issues of aging, care of the ill and disabled older person,
geropsychiatric nursing, research, philosophy and nursing, and an elective. Packages that include directed readings, activities, guided clinical learning, and assessments
are supplemented with optional face-to-face workshops

Geriatric Nursing Volume 20, Number 1

across the semester. The gerontic nursing subjects include 52 hours of related clinical experience.
Students are expected to keep a journal of this experience. This journal allows students to reflect on
everyday nursing practices, question what they do in
their work practice, and increase evidence-based practice. In the major assignments, students are encouraged
to submit their work in a form suitable for publication in
a refereed journal. Students are able to choose a topic in
which they have an interest, an issue that relates to their
practice or currently is debated within the profession, or
an area of nursing practice that requires discussion or
investigation. This form of assessment is useful in developing the skills and confidence to publish.
Nursing subjects have been developed in collaboration with representatives from the clinical field and
professional and consumer organizations, such as the
RCNA and the Alzheimer’s Association–Victoria. The
course, now in its second year of delivery, uses the variety of learning modes described. Student feedback indicates that the course is well received and the positive
experience is based on the course’s flexibility, relevant
and recent content, strong links with industry, and interaction with academia.

tice. To encourage younger staff, a career pathway that
rewards clinical skills and encourages specialization and
innovation needs to be developed.

CONCLUSION
Australian aged care is facing a crossroads in the
continuing role of qualified nurses. Despite overwhelming evidence that qualified nurses positively influence
quality of care, perceptions that unqualified staff yield
cost-savings and aged people do not require qualified
care are driving nurses away from this field. Traditional
nursing education and work practices no longer are appropriate for contemporary demands, and new models
must be developed and sold to the broader nursing profession, employer bodies, and government. The aged
care reforms of the past 14 years have substantially improved the quality of life for older people in nursing
homes. Nursing has been proactive but must continue to
demand a central place in aged care if quality is to be
ensured. Nurses will maintain that place only if they are
prepared to strive for excellence, relevance, flexibility,
efficiency, and effectiveness. This preparation necessitates postgraduate education; partnerships between
clinicians, managers, universities, industry, and government; and major changes in work practices.

CHANGING WORK PRACTICES
In Victoria, the classification and awards that guide
the aged care industry are derived from the public acute
care sector. Aged care facilities, which largely are privately owned, have limited ability to pay for both manager positions and clinicians. The result is the
employment of a higher grade RN who tries to do both.
In reality, management functions leave little time for
self and/or staff development of advanced clinical skills.
While the emphasis remains on management in residential care settings, promotion of a clinical career
pathway is difficult. Very few career incentives exist,
such as salary increases or positions created to foster advanced gerontologic nursing practice. The profession
justifiably is determined not to lose the director of nursing positions currently built into the structure. Clinical
care requires a nurse manager to develop quality outcomes for residents and lead other nursing staff. How
many more managers are required, especially in small
aged care facilities, remains to be ascertained.
Facility budgets no longer cover the ideal staffing
mix. The hiring of higher paid “management” RNs often
precludes the employment of lower paid, beginner “clinical” RNs. If a range of RN levels is not employed, the
opportunity to develop a career pathway will not materialize and best clinical practice will not be possible.
The time is ripe for lateral-thinking employers and
others interested in the development of gerontologic
nursing expertise to propose solutions that will engage
RNs in a positive attitude toward work in the field and
develop a level of competence that meets specialist prac-

Geriatric Nursing Volume 20, Number 1

REFERENCES
1. Duckett S, Jackson T. Do the elderly cost more? Casemix funding for elderly
patients in acute inpatient settings. In: Nay R, Garratt S, editors. Nursing
older people: issues and innovations. Sydney: MacLennon and Petty. In
press.
2. Commonwealth Department of Health and Family Services, Aged and
Community Care. Available from: http://www.health.gov.au/acc/. Posted
1997 Dec.
3. Howe A. Nursing workforce in residential aged care workshop [draft report].
Melbourne: National Aging Research Institute; 1998.
4. Nay R, Closs B. Recruitment and retention of qualified nursing staff in longterm care of older people [interim report]. Melbourne: Gerontic Nursing
Professorial Unit; 1998.
5. Nay R. Contradictions between perceptions and practices of caring in longterm care of elderly people. J Clin Nurs 1998;7:401-8.
6. Nay R. Benevolent oppression: lived experiences of nursing home life [dissertation]. Sydney: University of New South Wales School of Sociology;
1993. p. 158-87.
7. Stevens JA. A career with old people: do nurses care for it? [dissertation].
Sydney: University of New South Wales; 1995.
8. Wunderlich GS, Sloan FA, Davis CK. Nursing staff in hospitals and nursing
homes: is it adequate? Washington (DC): National Academy Press; 1996.
9. Burke M, Sherman S. Gerontological nursing: issues and opportunities for the
21st century. New York: National League for Nursing; 1993.

RHONDA NAY, PhD, is a professor of gerontic nursing and the head
of the School of Nursing at La Trobe University in Melbourne,
Australia. SALLY GARRATT, MScN, is an associate professor of
gerontic nursing and the director of residential care for the Association for the Blind Elanora Nursing Home. SUSAN KOCH, MN, is the
director of postgraduate studies and senior lecturer at La Trobe
University.
Copyright © 1999 by Mosby, Inc.
0197-4572/99/$5.00 + 0

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