ORIGINAL RESEARCH
Aged over 50 years and practising: separation and changes in nursing practice among New Zealand’s older Registered Nurses Nicola North, William Leung & Rochelle Lee Accepted for publication 15 March 2014
Correspondence to N. North: e-mail: [email protected] Nicola North PhD RN AFACHSM Associate Professor School of Population Health, University of Auckland, New Zealand William Leung MSc Research Fellow School of Medicine, University of Auckland, New Zealand Rochelle Lee MHSc Research Assistant School of Population Health, University of Auckland, New Zealand
N O R T H N . , L E U N G W . & L E E R . ( 2 0 1 4 ) Aged over 50 years and practising: separation and changes in nursing practice among New Zealand’s older Registered Nurses. Journal of Advanced Nursing 70(12), 2779–2790. doi: 10.1111/ jan.12426
Abstract Aim. To describe temporary and permanent separation patterns and changes in nursing practice over 5 years, for the 2006 cohort of nurses aged ≥50 years in New Zealand. Background. As ageing populations increase demand on nursing services, workforce projections need better information on work and retirement decisionmaking of large ‘baby-boomer’ cohorts. Design. Retrospective cohort analysis using the Nursing Council of New Zealand administrative dataset. Methods. A cohort of all nurses aged ≥50 years on the register and practising in 2006 (n = 12,606) was tracked until 2011. Results. After 5 years, a quarter (n = 3161) of the cohort (equivalent to 84% of all 2006 practising nurses) was no longer practising. There were no significant differences in permanent separation rates between the ages of 50–58; between 18–54% of annual separations re-entered the workforce. On re-entry, 56% returned to the same clinical area. Annual separations from the workforce declined sharply during the global financial crisis and more of those leaving reentered the workforce. In 2006, half the cohort worked in hospitals. After 5 years, the number of cohort nurses working in hospitals fell by 45%, while those in community settings increased by 12%. Over 5 years, weekly nursing practice hours declined significantly for every age-band. Conclusions. To retain the experience of older nurses for longer, workforce strategies need to take account of patterns of leaving and re-entering the workforce, preferences for work hours and the differences between the subgroups across employment settings and practice areas. Keywords: ageing, cohort design, nursing, nursing workforce, permanent workforce separation, temporary separation
© 2014 John Wiley & Sons Ltd
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Why is this research or review needed? • New Zealand’s Registered Nurse workforce is ageing, with those aged ≥50 years increasing from 33–41% in 2006– 2011. • Ageing of nurse workforces affects most developed countries and nursing service capacity is expected to be affected as large baby-boomer cohorts approach retirement. • Most previous research is cross-sectional; longitudinal studies of older nurses’ actual patterns of separation are lacking.
What are the key findings? • One-quarter of the 2006 cohort of nurses aged ≥50 years separated from the workforce in 5 years. Between 18–54% of separations each year were temporary; those nurses reentered the workforce by 2011. • Permanent separation rates between the ages of 50– 58 years were not significantly different and rose sharply at 64 years, as retirement fund-eligibility (at 65 years) approached. Half of the cohort who turned ≥65 years by 2011 continued to practise. • Redistribution across employment settings and practice areas and a decline in working hours were observed among those still practising in 2011.
How should the findings be used to influence policy and research? • Recognizing that a portion of nurses who separate will reenter the workforce highlights the need to identify factors to encourage re-entry. • Pinpointing the age of separation as retirement approaches and relationships with work characteristics, allows for targeting of retention strategies. • Highlights areas for future research to investigate factors related to employment and retirement decisions.
Introduction Registered Nurse (RN) workforces in developed countries are ageing numerically and structurally, as are populations generally. The anticipated retirement of large numbers of nurses coincides with increasing demand for nursing and health services (International Council of Nurses (ICN) 2008). This ‘fundamental structural shift in the RN workforce’ (Buerhaus et al. 2004, p. 531) is attributed to large numbers of young women entering nursing in the 1960s and 1970s, a substantial drop in new entries in the 1990s and a more diverse age range among new graduates. Since 2000, in the USA, a series of analyses have been undertaken using Current Population Survey data of all those aged 2780
21–64 years and stating their occupation as RN. Older women accounted for a large share of employment growth (1983–2003 data) with the ≥50-years age group growing faster than any other, driving up the median age (Buerhaus et al. 2004). This trend was confirmed in an analysis of 1973–2008 data (Buerhaus et al. 2009). In the USA, where nursing is one of 20 occupations identified as affected by ‘baby-boomer’ retirement (Sochalski 2002), the average age in years in 2008 was 438, expected to rise to 441 in 2014, before declining (Buerhaus et al. 2009). In Canada, nearly one-third of practising RNs was aged 50 years and over (Lavoie-Tremblay et al. 2006). Periodical surveys of UK nurses showed a rising average age, from 33 years in 1987 to 42 years in 2009, when 12% were aged 55 years and over (Ball & Pike 2009). The average RN age in years in Australia rose from 394 in 1993 to 441 in 2011 (Health Workforce Australia (HWA) 2013). Data modelling indicates 90,000 nurses will retire in the next two decades (Schofield 2007). In New Zealand (NZ), where the study took place, the modal age-band of RNs increased from 45–49 years in 2007 (North 2010) to 50–54 years in 2011, with 39% of RNs aged ≥50 years (Nursing Council of New Zealand (NCNZ) 2012). A series of reports have highlighted shortages and structural ageing, compounded by high levels of emigration and occupational detachment (Ministry of Health (MoH) 1998, Department of Labour (DoL) 2005, Zurn & Dumont 2008) and the age distribution seen as critical to the future resilience of the workforce (Cook 2009). Established in 2010, Health Workforce New Zealand (2012) has confirmed those concerns about ageing and the need to retain nurses in their 50s in the workforce. While numerous cross-sectional studies have demonstrated nursing workforce ageing, longitudinal analyses are lacking that determine older RNs’ actual patterns of separation (Nooney et al. 2010), hampering human resource strategies and workforce planning. For example, do older nurses leave because they are retiring? Or might they leave temporarily, then re-join, as Watson et al. (2003) suggest? Do nurses approaching retirement make changes to their employment (type and hours of work) to extend their working life or as a transition to retirement? The present study uses a cohort design to better understand the employment dynamics of older RNs. Based on a national administrative dataset, a cohort of all RNs aged ≥50 years in 2006, eligible to practise in NZ, was followed over 5 years. This allowed us to determine whether separation was permanent, or if some nurses who separated subsequently re-entered the workforce. It also allowed us to identify change in employment setting, practice area and hours of work for those who did not permanently separate. © 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
A retrospective cohort analysis of a national administrative dataset 2006–2011
Background The nursing workforce reflects demographical ageing (ICN 2008). The median age of the NZ population was 359 years in 2006 (Statistics New Zealand 2007). Recent policy changes modify the rate at which the NZ labour market is being depleted by large-scale retirements, e.g. a compulsory retirement age was abolished in 1999 and eligibility for ‘universal superannuation’ (NZ’s retirement funding) increased from 60–65 years for men and women during the 1990s; raising it further is not currently planned (Khawaja & Boddington 2009, 2010). For most residents, entitlement is on reaching 65 years, irrespective of employment history and lifetime earnings and is not means-tested. Superannuation is inflation-adjusted, intended to give a sufficient income to allow participation in society (Rashbrooke 2009), but in reality provides for only a basic standard of living (Khawaja & Boddington 2009). To supplement superannuation, in 2007 ‘KiwiSaver’, a voluntary retirement savings scheme, was instituted involving employee and modest employer contributions. Like other such schemes, retirement funds will in the future reflect earning power and gender differences (Rashbrooke 2009). The predominantly female nursing workforce is thus not presently disadvantaged on reaching retirement by insufficient personal contributions because of career interruptions, as for example in the UK (Buchan et al. 2008), but in the future, as KiwiSaver becomes a major contributor, this may change. Eligibility for superannuation does not automatically lead to retirement. Labour market participation by the over 65years age group increased from 6% in 1991 to 171% in 2006, with more older men than women in work, many of whom work part-time. This is the highest in the developed world, after Japan (Khawaja & Boddington 2009). Nursing is among a small group of occupations where the age profile of the NZ workforce is older than the average (Alpass et al. 2007). As nursing workforces age, retirement ages, intentions and reasons and how older nurses may be retained, are focuses of many studies (e.g. Kovner et al. 2007). A survey of 3273 members of the NZ nurses’ union born before 1960 found that the intended retirement age increased with age: 65 years was the intention of 50– 55 year-olds, increasing to 70 years for 60–65 year-olds (Walker & Clendon 2012). Elsewhere, reviews of literature indicated that nurses were retiring younger (Moseley et al. 2008), in their 40s in Canada and the UK (Storey et al. 2009). Two small surveys in Canada and Belgium found respectively that 71 and 77% intended to retire by age 60– 65 years, mainly to enjoy their latter years (Blakeley & Ribeiro 2008, Boumans et al. 2008). However, retirement © 2014 John Wiley & Sons Ltd
and employment decisions depend on many issues including financial security, access to retirement funds (Buchan et al. 2008), health and ability and employer attitudes towards and support for older nurses (Camerino et al. 2006, Fragar & Depczynski 2011, Pike et al. 2011). To illustrate, in a sample of 1553 US nurses aged 20–75 years, the top three reasons encouraging retirement were: financial independence 75%; poor health 63%; and work intensity 48% (Cyr 2005). A UK study conceptualized retirement decisionmaking as ‘push’ factors towards retirement (rapid technological change and high work stress) and ‘pull’ factors (a perception they had value to employers reflected in flexible working conditions and pay) (Andrews et al. 2005). Some research on nursing workforce ageing links retirement of older cohorts and potential shortages. For example, in Australia, immediate shortages could be alleviated if nurses approaching retirement age were retained for longer (O’Brien-Pallas et al. 2004). Furthermore, RN employment patterns highlight that employers and sectors will be impacted differently, e.g. more older nurses worked in community settings than in acute settings in the UK (Royal College for Nursing (RCN) 2011) and in the USA (Norman et al. 2005). In Australia, rural nurses tended to be older than city counterparts and to retire significantly later (Schofield et al. 2006, Fragar & Depczynski 2011). Results are mixed about working hours: Kovner et al. (2007) reported there were no differences in hours worked between older and younger nurses. For nurses aged over 50 years in the UK, the proportion working full-time and weekly hours worked, progressively declined by age-band, although ethnicity was more important than age in accounting for variation in hours (Pike et al. 2011). Retirement is just one reason why older nurses separate from the workforce. Separation may also be because of voluntary or involuntary turnover as nurses leave an organization (Hayes et al. 2006), with Moseley et al. (2008) highlighting that older nurses are at higher risk of turnover. For nurses aged over 50 years, in addition to permanent separation due to retirement, Watson et al. (2003, p. 2) conceptualized pathways in and out of nursing for reasons such as taking and returning from a career break and retirement followed by re-entry.
The study Aims The aim is to describe, for the 2006 cohort of RNs aged ≥50 years, temporary and permanent separation patterns and changes in nursing practice. We address the following questions for the cohort: 2781
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• • • •
What are the permanent separation rates per age? What are the temporary separation patterns? What are their main employment settings and practice areas and relationships to separation and change? What are the trends in work hours?
Design Retrospective cohort analysis using the Nursing Council of New Zealand administration dataset.
• •
• •
Sample and data Each year, RNs must apply for renewal of their Annual Practising Certificate (APC) by providing evidence of competence and fitness to practise (NCNZ 2008) and at the same time, voluntarily complete a survey to inform workforce policy; 95% do so (NCNZ 2012). The Nursing Council sets the survey questions, enters data from the surveys, maintains the dataset and periodically publishes reports on the nursing workforce. Anonymized workforce data from these APC application forms for 2006–2011 were supplied by the Ministry of Health. Each RN has a unique identifier, allowing us to track individual nurses. From the dataset, we extracted the study cohort using these inclusion criteria: on the register as an RN or Nurse Practitioner (NP – a gazetted scope of practice in NZ); aged ≥50 years (for rationale of 50 as the cut-off see Norman et al. 2005, Kovner et al. 2007); and eligible to practise in NZ in 2006. Those on the register reporting non-nursing roles or unpaid employment in 2006 were excluded. The authors, in consultation with expert nurse professionals, manually screened the cohort to exclude any not meeting the selection criteria. This 2006 cohort (n = 12,606) was tracked until 2011. The 2006 base year was selected for the following reasons. Prior to 2004, the register of nurses included midwives (a separate register was established for midwives in 2004) and any RN on the register could renew her/his APC on payment of a small fee, irrespective of whether she/he was practising. Since 2004, following implementation of the Health Practitioners Competence Assurance Act in 2003, APCs were contingent on competence to practise (active in a field of nursing, engaged in continuing education and complying with standards for the scope of practice) (Vernon et al. 2011).
Definitions
•
‘Separations’ are defined as those who left in any year (up to and including 2011) and were no longer practising in 2011.
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‘Permanent separations’ are those who left in 2007 and did not return in any year up to and including 2011, i.e. 5 years not practising nursing in NZ. ‘Temporary separations’ are those who for at least 1-year between 2007–2010 inclusive were not practising in NZ and who re-entered the NZ nursing workforce for a period by 2011. ‘Net separations’ for a specific year is equal to separations less re-entries (from temporary separations returning to practise nursing in NZ) for that year. ‘Cumulative net separations’ are the number of the 2006 cohort RNs who were not practising in NZ by the year in question. This is calculated by taking cumulative net separations for the previous year, adding all separations less all re-entries for the current year.
Ethical considerations Formal ethical review for an anonymized administrative dataset was not required.
Data analysis The variables of interest were: practising, age, gender, ethnicity, qualifications, locations, nursing practice areas, employment settings and working hours. Case-wise deletion was used for the analysis of all variables. Where missing data exceeded 1% in any question response, the percentage of valid responses is reported. Category labels were recoded so those that had changed (e.g. nursing practice area and employment setting) were consistent with the 2006 base year. To distinguish between permanent and temporary separations, data on whether the nurse was practising or not were analysed annually. A paired t-test (or Wilcoxon signed-rank test) was used to compare changes in continuous variables over time. The Shapiro–Wilk test was used to assess normality for the parametric tests. Chi-square tests were used to test for differences in categorical variables. All tests were two-tailed and statistical significance was at P < 005. Analyses were conducted using Stata SE v.11.
Validity and reliability Limitations involving the use of this secondary dataset included missing item response (the applicant did not respond to a question), respondent error (the wrong code was entered by the applicant), data entry error (on the databases) and changes made to the coded responses to the APC form questions. Implausibly high weekly hours were © 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
A retrospective cohort analysis of a national administrative dataset 2006–2011
manually screened. An upper boundary for weekly hours was set at quartile three plus the interquartile range. Crossvalidation using data from all other years was used to minimize errors in RN immutable attributes. Two of the authors (NN and WL) adjudicated on all data issues.
Results Between 2006–2011, the proportion of those aged ≥50 years increased from 333–414%. In 2006 the cohort of RNs aged ≥50 years (hereafter called the cohort) (n = 12,606) was: mean age in years 564, range 50–81; 94% female; 84% had a New Zealand registration qualification. For 83%, registration was through a Hospital Certificate (trained in a workplace-based programme before nurse education was transferred to the tertiary education sector); 16% had a postgraduate tertiary qualification; 81% practised in an urban area; 48% worked in the public sector for a District Health Board (DHB) in either their main or secondary employment; and 49% worked in a hospital (public or private) for their main employment. The majority, 90%, were of European ethnicity, with Asians the next largest group at 33%, then 28% Maori, 25% Other and 14% Pacific Islanders. Those aged ≥65 years comprised 85% (n = 1072) of the cohort.
Separations of older RNs from the workforce 2006– 2011 In 2007, there were 946 separations, of which 243 (26%) re-entered the workforce over the following 4 years. Thus, 74% of separations (n = 703) were permanent. Permanent separation rates per age are shown in Figure 1. There were no significant differences (v28 = 134, P = 0098) among the permanent separation rates of RNs between the ages of
50–58 years inclusive. Separation rates rose steeply from 64 years. Annual separations from the workforce declined sharply during the global financial crisis in 2008–2009, falling from 946 in 2007 to 246 in 2009. In addition, more of those leaving re-entered the workforce as the pattern of annual separations and re-entries on Table 1 shows. The number of the 2006 cohort RNs who were not practising in NZ by the end of the year, cumulative net separations, increased by only 34 from 2008–2009. In the following year, 1466 additional net separations were recorded, more than the 1323 net separations in the previous 3 years. After 5 years, a quarter (n = 3161) of the cohort (equivalent to 84% of the total 2006 practising RN workforce in NZ) was no longer practising.
Employment settings and nursing practice area of the cohort in 2006–2011 DHBs, that deliver public hospital and community health services (MoH 2013), employed 48% of the cohort in 2006 and 39% in 2011. Private, other government and non-government employers made up the balance. Being employed by a DHB was significantly associated with reduced separation: 5-year cumulative net separation rates were 21% for DHB employed vs. 29% for those employed outside of a DHB (v2 = 106, P < 0001). Of those employed by DHBs in 2006 and still practising in 2011, 86% stayed with a DHB. Across these employer types, the main employment settings for the cohort in 2006 and the redistribution that occurred in 2011 are shown in Table 2. The employment setting of temporary separators before they left closely resembles that of the whole cohort. On their re-entry to the NZ nursing workforce, approximately two-thirds of temporary separators returned to the same employment setting.
40% 35% 30% 25% 20% 15% 10% 5% 0%
50
Separate 2·7%
n
1275
51 2·6% 1208
52 3·3% 1129
53 3·5% 972
54 2·8% 862
55 2·5% 850
56 3·8% 780
57 4·5% 753
58 4·5% 748
59 6·9% 715
60 5·4% 666
61 5·2% 504
62 6·2% 389
63 64 65 66 67 68 69 70 7·4% 12·3% 21·9% 18·1% 21·1% 18·2% 26·6% 22·0% 351 332 319 227 147 110 79 50
Figure 1 Permanent separation rates in 2007. Values are mean and 95% CI. Data table: age and numbers practising in 2006; percentage permanently separating in 2007. © 2014 John Wiley & Sons Ltd
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Table 1 Annual separations and re-entries. Re-entries in year Separations in year
2007
2007 2008 2009 2010 2011
– – – – – – 946
946 496 256 1680 727 Total Cumulative net separations
2008
2009
2010
2011
153
49 173
24 82 108
17 14 22 302
– – – –
– – –
– –
–
153 1289
222 1323
214 2789
355 3161
Total 243 269 130 302 – 944
Proportion of separations temporary 26% 54% 51% 18% –
Table 2 Main employment setting for cohort and temporary separators. Employment setting
Cohort in 2006
Cohort in 2011
Temporary separators
% separators returning to same setting
Hospital Community Rest home/residential care Nursing agency Govt. agency/educational inst. Other* Total reporting
6226 3140 1498 139 515 987 12,505
3449 3513 1122 94 367 879 9424
385 261 102 19 39 113 919
63% 70% 67% 32% 62% 50% 63%
(50%) (25%) (12%) (1%) (4%) (8%) (100%)
(37%) (37%) (12%) (1%) (4%) (9%) (100%)
(42%) (28%) (11%) (2%) (4%) (12%) (100%)
*Includes: other, rural and self-employed.
Community settings (including general practice, district, public health, Maori and Pacific primary health providers and other public primary health services) and hospitals together accounted for three-quarters of employment of the cohort in 2006–2011. In 2006, hospitals were the main employment setting for half the cohort (four out of five in DHB-run hospitals): 5 years later the number of hospitalbased RNs had fallen by 45%. In contrast, by 2011 the number of community-based RNs had increased by 12% with the community (more than half in DHB community health services) now becoming the most frequent employment setting. Community-based cohort RNs had higher retention (63%) than hospital-based RNs (50%) over the 5 years and they also benefited from 19% of hospital-based RNs relocating to community settings. The top ten nursing practice areas, which together accounted for 74% of the cohort in 2006, are summarized in Table 3. These sub-cohorts were followed up 5 years later to track changes in practice areas as RNs aged. In 2011, 26% of those still practising had changed area. The results in Table 3 indicate that the sub-cohorts with least change, where RNs were still working in the same area, were mental health (69%), perioperative services (65%) and primary health care (62%). Markedly fewer RNs working in nursing administration and management (42%), 2784
assessment and rehabilitation (42%) and continuing care (mainly residential care of older people) (45%), remained in the same practice area compared with the other top ten specialties. For continuing care, this can be explained by the relatively older RNs working in that area (see Table 3 sub-cohort aged ≥ 60 years). Continuing care and primary health care accounted for 40% of all cohort RNs aged ≥65 years working in 2011. The clinical practice area of temporary separators before they left closely resembles that of the whole cohort. On their re-entry to the NZ nursing workforce, 56% of temporary separators returned to the same clinical practice area. Working hours The results in Table 4, grouped by age-band, track the change in weekly working hours in the main nursing practice area (excluding those reporting zero hours) for each individual RN from 2006–2011. All age-bands reported significantly less working hours per week after 5 years. Full-time RNs (defined by NCNZ as those working at least 35 hours a week), comprised 48% of the sample in 2006. Reasons for the remaining 52% of the cohort working part-time in 2006 were grouped into the following categories (each with greater than 100 individual responses): personal choice 131% of the cohort; working on a casual basis © 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
A retrospective cohort analysis of a national administrative dataset 2006–2011
Table 3 Changes in practice areas. On follow-up in 2011, numbers (%) Top ten sub-cohort practice areas, 2006
Sub-cohort aged ≥60
Practising in 2006
Practising in same area
Practising
Temporary separators, 2007–2010
Primary health care Continuing care Mental health Surgical Medical Perioperative care Admin & management Child health Assessment & rehab District nursing
267% 422% 183% 224% 196% 218% 202% 231% 257% 265%
1768 1725 1196 948 874 694 679 546 478 456
1103 778 827 564 405 453 286 328 203 252
1359 1100 931 765 680 536 538 427 359 342
126 115 75 68 51 52 70 25 31 26
(62%) (45%) (69%) (59%) (46%) (65%) (42%) (60%) (42%) (55%)
(77%) (64%) (78%) (81%) (78%) (77%) (79%) (78%) (75%) (75%)
On re-entry, percentage Practising in same area 68% 66% 75% 60% 39% 69% 34% 56% 32% 62%
Table 4 Change in main working hours and separation by full-/part-time status. 5-year separation rates
On 5-year follow-up
Age in 2006
Median (mean) hours/week, 2006
Median (mean) hours/week, 2011
Wilcoxon signed-rank statistic
Part-time RNs* in 2006 (% of cohort RNs)
Part-time in 2006
Full-time in 2006
Chi-square statistic
50–54 55–59 60–64 ≥65
35 32 32 24
34 32 30 22
37*** 121*** 145*** 102***
2508 1918 1325 806
163% 240% 500% 681%
136% 154% 285% 474%
79** 459*** 1034*** 369***
(327) (325) (318) (284)
(324) (308) (279) (234)
(46%) (50%) (59%) (75%)
*Part-time RNs are those working
Aged over 50 years and practising: separation and changes in nursing practice among New Zealand’s older Registered Nurses Nicola North, William Leung & Rochelle Lee Accepted for publication 15 March 2014
Correspondence to N. North: e-mail: [email protected] Nicola North PhD RN AFACHSM Associate Professor School of Population Health, University of Auckland, New Zealand William Leung MSc Research Fellow School of Medicine, University of Auckland, New Zealand Rochelle Lee MHSc Research Assistant School of Population Health, University of Auckland, New Zealand
N O R T H N . , L E U N G W . & L E E R . ( 2 0 1 4 ) Aged over 50 years and practising: separation and changes in nursing practice among New Zealand’s older Registered Nurses. Journal of Advanced Nursing 70(12), 2779–2790. doi: 10.1111/ jan.12426
Abstract Aim. To describe temporary and permanent separation patterns and changes in nursing practice over 5 years, for the 2006 cohort of nurses aged ≥50 years in New Zealand. Background. As ageing populations increase demand on nursing services, workforce projections need better information on work and retirement decisionmaking of large ‘baby-boomer’ cohorts. Design. Retrospective cohort analysis using the Nursing Council of New Zealand administrative dataset. Methods. A cohort of all nurses aged ≥50 years on the register and practising in 2006 (n = 12,606) was tracked until 2011. Results. After 5 years, a quarter (n = 3161) of the cohort (equivalent to 84% of all 2006 practising nurses) was no longer practising. There were no significant differences in permanent separation rates between the ages of 50–58; between 18–54% of annual separations re-entered the workforce. On re-entry, 56% returned to the same clinical area. Annual separations from the workforce declined sharply during the global financial crisis and more of those leaving reentered the workforce. In 2006, half the cohort worked in hospitals. After 5 years, the number of cohort nurses working in hospitals fell by 45%, while those in community settings increased by 12%. Over 5 years, weekly nursing practice hours declined significantly for every age-band. Conclusions. To retain the experience of older nurses for longer, workforce strategies need to take account of patterns of leaving and re-entering the workforce, preferences for work hours and the differences between the subgroups across employment settings and practice areas. Keywords: ageing, cohort design, nursing, nursing workforce, permanent workforce separation, temporary separation
© 2014 John Wiley & Sons Ltd
2779
N. North et al.
Why is this research or review needed? • New Zealand’s Registered Nurse workforce is ageing, with those aged ≥50 years increasing from 33–41% in 2006– 2011. • Ageing of nurse workforces affects most developed countries and nursing service capacity is expected to be affected as large baby-boomer cohorts approach retirement. • Most previous research is cross-sectional; longitudinal studies of older nurses’ actual patterns of separation are lacking.
What are the key findings? • One-quarter of the 2006 cohort of nurses aged ≥50 years separated from the workforce in 5 years. Between 18–54% of separations each year were temporary; those nurses reentered the workforce by 2011. • Permanent separation rates between the ages of 50– 58 years were not significantly different and rose sharply at 64 years, as retirement fund-eligibility (at 65 years) approached. Half of the cohort who turned ≥65 years by 2011 continued to practise. • Redistribution across employment settings and practice areas and a decline in working hours were observed among those still practising in 2011.
How should the findings be used to influence policy and research? • Recognizing that a portion of nurses who separate will reenter the workforce highlights the need to identify factors to encourage re-entry. • Pinpointing the age of separation as retirement approaches and relationships with work characteristics, allows for targeting of retention strategies. • Highlights areas for future research to investigate factors related to employment and retirement decisions.
Introduction Registered Nurse (RN) workforces in developed countries are ageing numerically and structurally, as are populations generally. The anticipated retirement of large numbers of nurses coincides with increasing demand for nursing and health services (International Council of Nurses (ICN) 2008). This ‘fundamental structural shift in the RN workforce’ (Buerhaus et al. 2004, p. 531) is attributed to large numbers of young women entering nursing in the 1960s and 1970s, a substantial drop in new entries in the 1990s and a more diverse age range among new graduates. Since 2000, in the USA, a series of analyses have been undertaken using Current Population Survey data of all those aged 2780
21–64 years and stating their occupation as RN. Older women accounted for a large share of employment growth (1983–2003 data) with the ≥50-years age group growing faster than any other, driving up the median age (Buerhaus et al. 2004). This trend was confirmed in an analysis of 1973–2008 data (Buerhaus et al. 2009). In the USA, where nursing is one of 20 occupations identified as affected by ‘baby-boomer’ retirement (Sochalski 2002), the average age in years in 2008 was 438, expected to rise to 441 in 2014, before declining (Buerhaus et al. 2009). In Canada, nearly one-third of practising RNs was aged 50 years and over (Lavoie-Tremblay et al. 2006). Periodical surveys of UK nurses showed a rising average age, from 33 years in 1987 to 42 years in 2009, when 12% were aged 55 years and over (Ball & Pike 2009). The average RN age in years in Australia rose from 394 in 1993 to 441 in 2011 (Health Workforce Australia (HWA) 2013). Data modelling indicates 90,000 nurses will retire in the next two decades (Schofield 2007). In New Zealand (NZ), where the study took place, the modal age-band of RNs increased from 45–49 years in 2007 (North 2010) to 50–54 years in 2011, with 39% of RNs aged ≥50 years (Nursing Council of New Zealand (NCNZ) 2012). A series of reports have highlighted shortages and structural ageing, compounded by high levels of emigration and occupational detachment (Ministry of Health (MoH) 1998, Department of Labour (DoL) 2005, Zurn & Dumont 2008) and the age distribution seen as critical to the future resilience of the workforce (Cook 2009). Established in 2010, Health Workforce New Zealand (2012) has confirmed those concerns about ageing and the need to retain nurses in their 50s in the workforce. While numerous cross-sectional studies have demonstrated nursing workforce ageing, longitudinal analyses are lacking that determine older RNs’ actual patterns of separation (Nooney et al. 2010), hampering human resource strategies and workforce planning. For example, do older nurses leave because they are retiring? Or might they leave temporarily, then re-join, as Watson et al. (2003) suggest? Do nurses approaching retirement make changes to their employment (type and hours of work) to extend their working life or as a transition to retirement? The present study uses a cohort design to better understand the employment dynamics of older RNs. Based on a national administrative dataset, a cohort of all RNs aged ≥50 years in 2006, eligible to practise in NZ, was followed over 5 years. This allowed us to determine whether separation was permanent, or if some nurses who separated subsequently re-entered the workforce. It also allowed us to identify change in employment setting, practice area and hours of work for those who did not permanently separate. © 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
A retrospective cohort analysis of a national administrative dataset 2006–2011
Background The nursing workforce reflects demographical ageing (ICN 2008). The median age of the NZ population was 359 years in 2006 (Statistics New Zealand 2007). Recent policy changes modify the rate at which the NZ labour market is being depleted by large-scale retirements, e.g. a compulsory retirement age was abolished in 1999 and eligibility for ‘universal superannuation’ (NZ’s retirement funding) increased from 60–65 years for men and women during the 1990s; raising it further is not currently planned (Khawaja & Boddington 2009, 2010). For most residents, entitlement is on reaching 65 years, irrespective of employment history and lifetime earnings and is not means-tested. Superannuation is inflation-adjusted, intended to give a sufficient income to allow participation in society (Rashbrooke 2009), but in reality provides for only a basic standard of living (Khawaja & Boddington 2009). To supplement superannuation, in 2007 ‘KiwiSaver’, a voluntary retirement savings scheme, was instituted involving employee and modest employer contributions. Like other such schemes, retirement funds will in the future reflect earning power and gender differences (Rashbrooke 2009). The predominantly female nursing workforce is thus not presently disadvantaged on reaching retirement by insufficient personal contributions because of career interruptions, as for example in the UK (Buchan et al. 2008), but in the future, as KiwiSaver becomes a major contributor, this may change. Eligibility for superannuation does not automatically lead to retirement. Labour market participation by the over 65years age group increased from 6% in 1991 to 171% in 2006, with more older men than women in work, many of whom work part-time. This is the highest in the developed world, after Japan (Khawaja & Boddington 2009). Nursing is among a small group of occupations where the age profile of the NZ workforce is older than the average (Alpass et al. 2007). As nursing workforces age, retirement ages, intentions and reasons and how older nurses may be retained, are focuses of many studies (e.g. Kovner et al. 2007). A survey of 3273 members of the NZ nurses’ union born before 1960 found that the intended retirement age increased with age: 65 years was the intention of 50– 55 year-olds, increasing to 70 years for 60–65 year-olds (Walker & Clendon 2012). Elsewhere, reviews of literature indicated that nurses were retiring younger (Moseley et al. 2008), in their 40s in Canada and the UK (Storey et al. 2009). Two small surveys in Canada and Belgium found respectively that 71 and 77% intended to retire by age 60– 65 years, mainly to enjoy their latter years (Blakeley & Ribeiro 2008, Boumans et al. 2008). However, retirement © 2014 John Wiley & Sons Ltd
and employment decisions depend on many issues including financial security, access to retirement funds (Buchan et al. 2008), health and ability and employer attitudes towards and support for older nurses (Camerino et al. 2006, Fragar & Depczynski 2011, Pike et al. 2011). To illustrate, in a sample of 1553 US nurses aged 20–75 years, the top three reasons encouraging retirement were: financial independence 75%; poor health 63%; and work intensity 48% (Cyr 2005). A UK study conceptualized retirement decisionmaking as ‘push’ factors towards retirement (rapid technological change and high work stress) and ‘pull’ factors (a perception they had value to employers reflected in flexible working conditions and pay) (Andrews et al. 2005). Some research on nursing workforce ageing links retirement of older cohorts and potential shortages. For example, in Australia, immediate shortages could be alleviated if nurses approaching retirement age were retained for longer (O’Brien-Pallas et al. 2004). Furthermore, RN employment patterns highlight that employers and sectors will be impacted differently, e.g. more older nurses worked in community settings than in acute settings in the UK (Royal College for Nursing (RCN) 2011) and in the USA (Norman et al. 2005). In Australia, rural nurses tended to be older than city counterparts and to retire significantly later (Schofield et al. 2006, Fragar & Depczynski 2011). Results are mixed about working hours: Kovner et al. (2007) reported there were no differences in hours worked between older and younger nurses. For nurses aged over 50 years in the UK, the proportion working full-time and weekly hours worked, progressively declined by age-band, although ethnicity was more important than age in accounting for variation in hours (Pike et al. 2011). Retirement is just one reason why older nurses separate from the workforce. Separation may also be because of voluntary or involuntary turnover as nurses leave an organization (Hayes et al. 2006), with Moseley et al. (2008) highlighting that older nurses are at higher risk of turnover. For nurses aged over 50 years, in addition to permanent separation due to retirement, Watson et al. (2003, p. 2) conceptualized pathways in and out of nursing for reasons such as taking and returning from a career break and retirement followed by re-entry.
The study Aims The aim is to describe, for the 2006 cohort of RNs aged ≥50 years, temporary and permanent separation patterns and changes in nursing practice. We address the following questions for the cohort: 2781
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What are the permanent separation rates per age? What are the temporary separation patterns? What are their main employment settings and practice areas and relationships to separation and change? What are the trends in work hours?
Design Retrospective cohort analysis using the Nursing Council of New Zealand administration dataset.
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Sample and data Each year, RNs must apply for renewal of their Annual Practising Certificate (APC) by providing evidence of competence and fitness to practise (NCNZ 2008) and at the same time, voluntarily complete a survey to inform workforce policy; 95% do so (NCNZ 2012). The Nursing Council sets the survey questions, enters data from the surveys, maintains the dataset and periodically publishes reports on the nursing workforce. Anonymized workforce data from these APC application forms for 2006–2011 were supplied by the Ministry of Health. Each RN has a unique identifier, allowing us to track individual nurses. From the dataset, we extracted the study cohort using these inclusion criteria: on the register as an RN or Nurse Practitioner (NP – a gazetted scope of practice in NZ); aged ≥50 years (for rationale of 50 as the cut-off see Norman et al. 2005, Kovner et al. 2007); and eligible to practise in NZ in 2006. Those on the register reporting non-nursing roles or unpaid employment in 2006 were excluded. The authors, in consultation with expert nurse professionals, manually screened the cohort to exclude any not meeting the selection criteria. This 2006 cohort (n = 12,606) was tracked until 2011. The 2006 base year was selected for the following reasons. Prior to 2004, the register of nurses included midwives (a separate register was established for midwives in 2004) and any RN on the register could renew her/his APC on payment of a small fee, irrespective of whether she/he was practising. Since 2004, following implementation of the Health Practitioners Competence Assurance Act in 2003, APCs were contingent on competence to practise (active in a field of nursing, engaged in continuing education and complying with standards for the scope of practice) (Vernon et al. 2011).
Definitions
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‘Separations’ are defined as those who left in any year (up to and including 2011) and were no longer practising in 2011.
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‘Permanent separations’ are those who left in 2007 and did not return in any year up to and including 2011, i.e. 5 years not practising nursing in NZ. ‘Temporary separations’ are those who for at least 1-year between 2007–2010 inclusive were not practising in NZ and who re-entered the NZ nursing workforce for a period by 2011. ‘Net separations’ for a specific year is equal to separations less re-entries (from temporary separations returning to practise nursing in NZ) for that year. ‘Cumulative net separations’ are the number of the 2006 cohort RNs who were not practising in NZ by the year in question. This is calculated by taking cumulative net separations for the previous year, adding all separations less all re-entries for the current year.
Ethical considerations Formal ethical review for an anonymized administrative dataset was not required.
Data analysis The variables of interest were: practising, age, gender, ethnicity, qualifications, locations, nursing practice areas, employment settings and working hours. Case-wise deletion was used for the analysis of all variables. Where missing data exceeded 1% in any question response, the percentage of valid responses is reported. Category labels were recoded so those that had changed (e.g. nursing practice area and employment setting) were consistent with the 2006 base year. To distinguish between permanent and temporary separations, data on whether the nurse was practising or not were analysed annually. A paired t-test (or Wilcoxon signed-rank test) was used to compare changes in continuous variables over time. The Shapiro–Wilk test was used to assess normality for the parametric tests. Chi-square tests were used to test for differences in categorical variables. All tests were two-tailed and statistical significance was at P < 005. Analyses were conducted using Stata SE v.11.
Validity and reliability Limitations involving the use of this secondary dataset included missing item response (the applicant did not respond to a question), respondent error (the wrong code was entered by the applicant), data entry error (on the databases) and changes made to the coded responses to the APC form questions. Implausibly high weekly hours were © 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
A retrospective cohort analysis of a national administrative dataset 2006–2011
manually screened. An upper boundary for weekly hours was set at quartile three plus the interquartile range. Crossvalidation using data from all other years was used to minimize errors in RN immutable attributes. Two of the authors (NN and WL) adjudicated on all data issues.
Results Between 2006–2011, the proportion of those aged ≥50 years increased from 333–414%. In 2006 the cohort of RNs aged ≥50 years (hereafter called the cohort) (n = 12,606) was: mean age in years 564, range 50–81; 94% female; 84% had a New Zealand registration qualification. For 83%, registration was through a Hospital Certificate (trained in a workplace-based programme before nurse education was transferred to the tertiary education sector); 16% had a postgraduate tertiary qualification; 81% practised in an urban area; 48% worked in the public sector for a District Health Board (DHB) in either their main or secondary employment; and 49% worked in a hospital (public or private) for their main employment. The majority, 90%, were of European ethnicity, with Asians the next largest group at 33%, then 28% Maori, 25% Other and 14% Pacific Islanders. Those aged ≥65 years comprised 85% (n = 1072) of the cohort.
Separations of older RNs from the workforce 2006– 2011 In 2007, there were 946 separations, of which 243 (26%) re-entered the workforce over the following 4 years. Thus, 74% of separations (n = 703) were permanent. Permanent separation rates per age are shown in Figure 1. There were no significant differences (v28 = 134, P = 0098) among the permanent separation rates of RNs between the ages of
50–58 years inclusive. Separation rates rose steeply from 64 years. Annual separations from the workforce declined sharply during the global financial crisis in 2008–2009, falling from 946 in 2007 to 246 in 2009. In addition, more of those leaving re-entered the workforce as the pattern of annual separations and re-entries on Table 1 shows. The number of the 2006 cohort RNs who were not practising in NZ by the end of the year, cumulative net separations, increased by only 34 from 2008–2009. In the following year, 1466 additional net separations were recorded, more than the 1323 net separations in the previous 3 years. After 5 years, a quarter (n = 3161) of the cohort (equivalent to 84% of the total 2006 practising RN workforce in NZ) was no longer practising.
Employment settings and nursing practice area of the cohort in 2006–2011 DHBs, that deliver public hospital and community health services (MoH 2013), employed 48% of the cohort in 2006 and 39% in 2011. Private, other government and non-government employers made up the balance. Being employed by a DHB was significantly associated with reduced separation: 5-year cumulative net separation rates were 21% for DHB employed vs. 29% for those employed outside of a DHB (v2 = 106, P < 0001). Of those employed by DHBs in 2006 and still practising in 2011, 86% stayed with a DHB. Across these employer types, the main employment settings for the cohort in 2006 and the redistribution that occurred in 2011 are shown in Table 2. The employment setting of temporary separators before they left closely resembles that of the whole cohort. On their re-entry to the NZ nursing workforce, approximately two-thirds of temporary separators returned to the same employment setting.
40% 35% 30% 25% 20% 15% 10% 5% 0%
50
Separate 2·7%
n
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51 2·6% 1208
52 3·3% 1129
53 3·5% 972
54 2·8% 862
55 2·5% 850
56 3·8% 780
57 4·5% 753
58 4·5% 748
59 6·9% 715
60 5·4% 666
61 5·2% 504
62 6·2% 389
63 64 65 66 67 68 69 70 7·4% 12·3% 21·9% 18·1% 21·1% 18·2% 26·6% 22·0% 351 332 319 227 147 110 79 50
Figure 1 Permanent separation rates in 2007. Values are mean and 95% CI. Data table: age and numbers practising in 2006; percentage permanently separating in 2007. © 2014 John Wiley & Sons Ltd
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Table 1 Annual separations and re-entries. Re-entries in year Separations in year
2007
2007 2008 2009 2010 2011
– – – – – – 946
946 496 256 1680 727 Total Cumulative net separations
2008
2009
2010
2011
153
49 173
24 82 108
17 14 22 302
– – – –
– – –
– –
–
153 1289
222 1323
214 2789
355 3161
Total 243 269 130 302 – 944
Proportion of separations temporary 26% 54% 51% 18% –
Table 2 Main employment setting for cohort and temporary separators. Employment setting
Cohort in 2006
Cohort in 2011
Temporary separators
% separators returning to same setting
Hospital Community Rest home/residential care Nursing agency Govt. agency/educational inst. Other* Total reporting
6226 3140 1498 139 515 987 12,505
3449 3513 1122 94 367 879 9424
385 261 102 19 39 113 919
63% 70% 67% 32% 62% 50% 63%
(50%) (25%) (12%) (1%) (4%) (8%) (100%)
(37%) (37%) (12%) (1%) (4%) (9%) (100%)
(42%) (28%) (11%) (2%) (4%) (12%) (100%)
*Includes: other, rural and self-employed.
Community settings (including general practice, district, public health, Maori and Pacific primary health providers and other public primary health services) and hospitals together accounted for three-quarters of employment of the cohort in 2006–2011. In 2006, hospitals were the main employment setting for half the cohort (four out of five in DHB-run hospitals): 5 years later the number of hospitalbased RNs had fallen by 45%. In contrast, by 2011 the number of community-based RNs had increased by 12% with the community (more than half in DHB community health services) now becoming the most frequent employment setting. Community-based cohort RNs had higher retention (63%) than hospital-based RNs (50%) over the 5 years and they also benefited from 19% of hospital-based RNs relocating to community settings. The top ten nursing practice areas, which together accounted for 74% of the cohort in 2006, are summarized in Table 3. These sub-cohorts were followed up 5 years later to track changes in practice areas as RNs aged. In 2011, 26% of those still practising had changed area. The results in Table 3 indicate that the sub-cohorts with least change, where RNs were still working in the same area, were mental health (69%), perioperative services (65%) and primary health care (62%). Markedly fewer RNs working in nursing administration and management (42%), 2784
assessment and rehabilitation (42%) and continuing care (mainly residential care of older people) (45%), remained in the same practice area compared with the other top ten specialties. For continuing care, this can be explained by the relatively older RNs working in that area (see Table 3 sub-cohort aged ≥ 60 years). Continuing care and primary health care accounted for 40% of all cohort RNs aged ≥65 years working in 2011. The clinical practice area of temporary separators before they left closely resembles that of the whole cohort. On their re-entry to the NZ nursing workforce, 56% of temporary separators returned to the same clinical practice area. Working hours The results in Table 4, grouped by age-band, track the change in weekly working hours in the main nursing practice area (excluding those reporting zero hours) for each individual RN from 2006–2011. All age-bands reported significantly less working hours per week after 5 years. Full-time RNs (defined by NCNZ as those working at least 35 hours a week), comprised 48% of the sample in 2006. Reasons for the remaining 52% of the cohort working part-time in 2006 were grouped into the following categories (each with greater than 100 individual responses): personal choice 131% of the cohort; working on a casual basis © 2014 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
A retrospective cohort analysis of a national administrative dataset 2006–2011
Table 3 Changes in practice areas. On follow-up in 2011, numbers (%) Top ten sub-cohort practice areas, 2006
Sub-cohort aged ≥60
Practising in 2006
Practising in same area
Practising
Temporary separators, 2007–2010
Primary health care Continuing care Mental health Surgical Medical Perioperative care Admin & management Child health Assessment & rehab District nursing
267% 422% 183% 224% 196% 218% 202% 231% 257% 265%
1768 1725 1196 948 874 694 679 546 478 456
1103 778 827 564 405 453 286 328 203 252
1359 1100 931 765 680 536 538 427 359 342
126 115 75 68 51 52 70 25 31 26
(62%) (45%) (69%) (59%) (46%) (65%) (42%) (60%) (42%) (55%)
(77%) (64%) (78%) (81%) (78%) (77%) (79%) (78%) (75%) (75%)
On re-entry, percentage Practising in same area 68% 66% 75% 60% 39% 69% 34% 56% 32% 62%
Table 4 Change in main working hours and separation by full-/part-time status. 5-year separation rates
On 5-year follow-up
Age in 2006
Median (mean) hours/week, 2006
Median (mean) hours/week, 2011
Wilcoxon signed-rank statistic
Part-time RNs* in 2006 (% of cohort RNs)
Part-time in 2006
Full-time in 2006
Chi-square statistic
50–54 55–59 60–64 ≥65
35 32 32 24
34 32 30 22
37*** 121*** 145*** 102***
2508 1918 1325 806
163% 240% 500% 681%
136% 154% 285% 474%
79** 459*** 1034*** 369***
(327) (325) (318) (284)
(324) (308) (279) (234)
(46%) (50%) (59%) (75%)
*Part-time RNs are those working
