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Community Affairs References Committee
Health services and medical professionals in rural areas

FRANCIS, Professor Karen, Chair, Rural Nursing and Midwifery Faculty, Royal College of Nursing

McLAUGHLIN, Ms Kathleen, Deputy CEO, Director, Operations and Professional Services, Royal College of Nursing

MILLS, Dr Jane, Advisory Committee Member, Rural Nursing and Midwifery Faculty, Royal College of Nursing

MALONE, Ms Gerardine, National Coordinator of Professional Services, CRANAplus


CHAIR: I welcome representatives of the Royal College of Nursing and CRANAplus.

CHAIR: I understand you have all had information on parliamentary privilege and the protection of witnesses and evidence. Is there anything you would like to add about the capacity in which you appear today?

Prof. Francis : I am Professor of Nursing at Charles Sturt University, and I am here in my capacity as chair of the Royal College of Nursing Australia Rural Nursing and Midwifery Faculty.

Ms Mills : I am here as deputy chair of the Rural Nursing and Midwifery Faculty of the RCNA.

Ms Malone : I am here representing CRANAplus and I am the national coordinator of professional services, based here in Canberra.

CHAIR: We have your submissions, numbered 82 and 26. I would like to invite whoever wants to to make an opening statement and then we will ask you some questions.

Prof. Francis : Thank you for allowing us to speak. Speaking from a professional nursing perspective in this opening statement I will summarise the issues that we would like to emphasise to the committee in relation to factors affecting the supply of health services in rural areas. There are professional, social and economic as well as health system factors limiting the supply of health services and nursing and midwifery professionals to small regional communities. These limiting factors are interconnected and there is no single solution to overcoming them.

The Royal College of Nursing Australia strongly argues that a comprehensive and overarching framework, in the form of a national nursing and midwifery workforce strategy, must be in place to steer the future direction of the professions and to ensure the supply of nurses and midwives into the future. As the peak representative body for nurses and midwives working and living in rural areas, RCNA is continually advised that the rural nursing and midwifery workforces are under great pressure in the professional environment and also experience many social and economic challenges.

Looking first at the overarching professional issues, there are now mandatory national registration requirements for demonstrating recency of practice and for maintaining continuing professional development, which of course we support. Meeting these requirements, however, is proving to be a significant challenge for many rural nurses and midwives. Poor access to continuing professional development programs and limited opportunities to obtain adequate and timely leave from employment, as well as financial and social barriers, are major concerns for the development and retention of the nurse and midwifery workforces in rural areas.

Of particular concern is the supply of dual registrants—that is, registered nurses who are also registered midwives. It is becoming increasingly difficult for dual registrants to maintain recency of practice specifically in midwifery. Due to low population demand for maternity services in some health services, dual registrants in these facilities are facing serious obstacles to accruing the requisite clinical practice hours to comply with the recency of practice standards. This presents a risk to the supply of midwives in rural areas and to maternity services in general.

RCNA highlights that there are few career or financial incentives to attract and retain rural nurses and midwives. There is no structured career pathway for rural nurses and midwives to aspire to, and no national financial incentive schemes to attract the best possible workforce to smaller regional communities. In relation to this, RCNA notes the great inequities between the level of national investment in the development of the rural medical workforce and that in the nursing and midwifery workforces. Given that we represent 60 per cent of the workforce, I think those inequities are not sustainable and should not be sustained.

These professional challenges are compounded by social and economic circumstances in rural areas. Other inhibitors to nurse and midwifery workforce development and effective supply include isolation, financial pressure, limited family supports and/or employment opportunities for partners, difficulties in transportation and a lack of access to technology. Inadequate professional development opportunities and supports also present challenges. We would like to highlight our concerns that the recently released Health Workforce Australia report, Health Workforce 2025: doctors, nurses and midwives, does not adequately examine current and future risks to the sustainability of the rural nurse and midwifery workforces. Given the information in this report will inform and underpin planning for our future workforces, it is important we note that the future geographic spread and distribution of the workforces need further analysis. It will be important to explore the potential impact on workforce geographic spread should shortages in metropolitan areas result in a workforce drain from rural areas. It is foreseeable that metropolitan nurse workforce attraction strategies could in future draw nurses out of smaller regional communities, thus increasing the workforce shortfall. This is particularly pertinent given that the nurse and midwifery workforces in rural areas are ageing and that comprehensive analysis of the skill mix of the emerging workforce is currently not available.

Turning now to health service delivery, flexible funding arrangements are required to improve the supply of health services in rural areas to give the community easier and greater access to a range of healthcare professionals. The decision to provide nurse practitioners and eligible midwives access to the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme has been a strong step in this direction but does not go far enough. These MBS and PBS arrangements for nurses and midwives should not be limited by regulations that tie nurses and midwives to medical practitioners or any other unnecessary restrictions that potentially limit public access to their services, particularly in rural areas.

In relation to Medicare Locals, it is acknowledged that their introduction is at various levels of implementation. At this point it is too early to determine the effect they will have on the provision of health services in rural areas. RCNA continues to endorse Medicare Local partnerships, inclusive membership and skill based corporate governance arrangements and engagement with health service users. Achieving the goals of improving Australia's primary healthcare infrastructure and better integrating service delivery requires broad engagement with health professionals working in the sector. Given the centrality and potential of nurses within primary health care in rural communities, it is paramount that nurses are actively and positively engaged with Medicare Locals at all levels, and that is at the practice nurse as well as the nurse practitioner levels.

To ensure a sustainable rural nurse and midwifery workforce into the future, the issues I have outlined must be addressed through a nationally coordinated approach supported by substantial funding investment. RCNA recommends that the Australian government action the following recommendations: that funding be allocated for the development of a national nursing and midwifery workforce strategy; that funding be allocated for a national rural nursing and midwifery work environments and lifestyles assessment; that incentive packages and tax relief arrangements be developed to attract and retain rural nurses and midwives; that research be commissioned to explore structured, specialist-generalist career pathways for nurses and midwives; that financial schemes be urgently implemented to support rural nurses and midwives meet mandatory registration requirements; that funding incentives be provided to establish an increased number of specialist advanced practice nurse and nurse practitioner positions in smaller regional communities; that undergraduate clinical placements in small regional communities be promoted and financially supported as a key nurse and midwifery workforce attraction strategy; that resources be allocated to provide structured, flexible and dedicated mentoring support mechanisms for graduates and early career nurses and midwives in smaller regional communities; that a national funding initiative be developed exclusively for nursing and midwifery research; and that funding be allocated to scope the establishment of a national research repository for the nursing and midwifery professions. Thank you.

CHAIR: Thank you. Ms Malone, do you have a statement?

Ms Malone : Yes, a short one. As the peak body for remote health we would like to clarify our position with regard to the nature of this inquiry. As we acknowledged in our submission, the terms of reference focused on the rural sector, but it is incumbent on us to ensure that the remote sector is considered in any deliberations. Whilst there is some overlap from rural to remote and they are often considered in tandem, the remote sector is unique in its particular challenges: specifically, in the first instance, the nature of the communities themselves, the models of health service delivery and the health professionals who comprise a significant majority of the health workforce. These remote health services are staffed predominantly by Aboriginal health workers and remote area nurses. Some communities have permanent medical officers, but more commonly they have the fly-in, fly-out variety, such as is provided by the Royal Flying Doctor Service, and we know this trend of fly-in, fly-out is increasing at perhaps an alarming rate.

The implication for supporting the health professionals and the opportunities to build on models of health care that are not in the tradition of GP models need to be considered in the best interests of these remote communities. We would like these models to receive greater acknowledgement as they work well, with highly skilled staff who work collaboratively with their health professional colleagues through telephone and video communication in spite of the fact of being inequitably supported.

We welcome the opportunity to appear before you and we are happy to expand on any issues raised.

CHAIR: Thank you. We will go to questions now.

Senator NASH: Just to start, Ms Malone, I think the title being 'rural' certainly did not exclude remote. We probably should have thought of that. When we looked at 'rural' it was about being 'non-urban' and so everywhere falling in that non-urban zone.

Ms Malone : We always feel the need to clarify that.

Senator NASH: Point made.

CHAIR: We should also say we have already been up to Alice Springs and Darwin and had some really valuable evidence.

Senator NASH: Point well made and well taken. Can I start with the issue about freeing up of the funding arrangements to give the community easier and greater access to healthcare professionals. How does it work now? What sort of flexibility do you want to see that is going to improve the situation?

Prof. Francis : I am happy to start. What happens at least at the primary care level is that we have the general practitioners offering services, community health and public sector funded, and a range of NGOs. I think the issue is that there is such demand on services that are at no cost, so no fee for service, that they become so stretched they cannot service the communities properly. I do not think there is effective networking between what services are out there. I know part of the brief of Medicare Locals is to make those networks happen a little bit easier. I am not seeing evidence of that as yet but, as we stated, it is early days.

One of the things is that there seems to be ad hoc development of services rather than any real planning around what should we do and how do we work? I guess some of the clinical placement networking stuff that is happening through HWA may make the networks develop over time. But I think it is about adhocness, the access of the communities to it and the whole strategy of supporting at-risk services for people at risk. I think what that has actually done is stigmatise people to the point that those people that really need access to the services do not access them because they have become so highly visible, particularly in rural communities where everyone is highly visible.

Senator MOORE: For example?

Prof. Francis : Mental health services is the one that is in my mind at the moment. If you have a mental health problem and you are identified as at risk—let us say through school systems or you might have had some call to go to an ED or something like that—as soon as you become visible and people see you going into services, then you just do not access them. Given that we have such a high mental health problem in rural Australia, we cannot afford that.

The other one that is in my mind is around maternity care services, antenatal and postnatal care particularly, where we have at-risk clinics for women who might be substance abusers, that sort of thing. The people that we really want to go into the services and use them go away from them because all of a sudden they become in limelight for having mandatory reporting occur, the removal of your children and all that kind of stuff. That then creates an even greater risk. When we had a system that was much more about publicly funded services being available to everyone and no prioritising—and I know the problems around that—the maternal-child health services were on basically every corner of each town, everybody went through and there was none of that stigma that is attached to it. So I think we have actually lost the plot a little bit. And I think it is even more problematic with our Indigenous populations, particularly in communities where the Indigenous population is probably a smaller proportion than the non-Indigenous.

Senator NASH: Imagine that you are the health minister and that tomorrow you get the chance to do whatever you want to improve, I guess, the sustainability of nurses and midwives and improve the future for them. What would be the priority?

Prof. Francis : I think the real problem is about how to provide a career structure for nurses and midwives that keeps them in the system.

Senator NASH: This is the structured specialist and generalised pathways you were talking about?

Prof. Francis : Yes. Let us look at the career advancement pathways for nurses: there has always been an administrative pathway, there is an academic pathway and there is an extremely limited clinical pathway. If you couple that with the fact that it is a female dominated workforce, it is a part-time workforce—we know that from around 25 to 45 it remains part time, probably around 0.4 FTE. Think about how many nurses and midwives we need just to cover the ordinary full-time equivalent workforce.

CHAIR: You need double, don't you.

Prof. Francis : Three times, actually, by the time you cover shifts. What are we doing that keeps people there? We are not doing much. Even for stuff around providing a more flexible workplace for people with young children et cetera: some places do that all right; others do not address it at all. It is not something we are going to get away from. The workforce will remain female, I think. If it had a better career structure we might get a better gender balance than we currently have—it is currently 91 per cent female and nine per cent male. I am most concerned about the clinical pathway. In midwifery it is even worse; there is hardly anywhere to go.

Senator NASH: When you say 'clinical pathway', what do you mean and how would that look? If I am a young woman in a regional area and I am a part-time nurse, what is the clinical pathway now and how should it look?

Prof. Francis : When registered nurses come through the system there is a graded salary until about year eight, I think. You get a minimal wage rise. If you stay as a clinical nurse and do nothing else that is it. You can expect a wage rise other than CPI for eight years.

Senator NASH: Regardless of where you work.

Prof. Francis : Regardless. You could decide that you want to take on a more managerial role, so you might decide to aim towards becoming a nurse unit manager or an assistant nurse unit manager, whatever they are called. You can step up that pathway, but you get to a point after nurse unit manager where the next role is assistant director of nursing or director of nursing, or something like that—a supervisory role of some description—but there are not many of them, and you have taken the clinical nurse away from the clinical work. That is one of the things we have not done well. Partly, that is the profession's fault, because we have not pushed it. The medical profession set up a pathway for the progression of every student that they bring through the system—about how they will pass through. We do not do that with nursing or with midwifery.

Senator NASH: Would they pick a stream or a strand of the path they want to head down, whether it be into the bureaucracy or the actual clinical work?

Prof. Francis : Do they actually pick it? I think some people do, but, on the whole, most people do not. The career pathway is not something that is really talked about and there are basically no options. In rural nursing it is even more complicated, because even though we are in a workforce shortage, the most stable workforce out there is nursing. That is basically because it comprises women, they are usually married, they have a family and they tend to stay in the same places. But that is not taking us forward in planning for the future for a progressive, innovative health-care system that is responsive and thinks about what is going to happen with the population over time. One of the concerns we have is about the future workforce. How do we get the best and the brightest? How do we make a career pathway that is attractive and that keeps them in it, so that they are responsive and are looking forward and create new ways of managing population health?

Senator NASH: What are the barriers for people looking to go into nursing in a rural area? What are the things that stop them choosing that as a career?

Prof. Francis : A career pathway. I have worked in rural universities most of my academic life, and Jane has too. Most of our students, when you talk to them about where they are thinking about going as they move through their career, and once they register, say, 'I am going to Sydney—or Melbourne or somewhere—because that is where all the action is.' That is where the big intensivist opportunities are and that is where the career pathways are for the advanced practice nurse et cetera. In rural areas, other than in the regional hospitals, which have limited opportunities for specialist practice, there is very little out there. So that whole idea of valuing being a generalist—we do not do that. In medicine they do not do it either.

Ms Mills : Well, they do in Queensland now. And I think that the Rural Generalist Pathway that they have established in Queensland is actually a very good model. It probably could provide some sort of pathway for nursing to go down as well, but of course that would require external funding because it is outside of state government remit.

Prof. Francis : I think it is even worse for midwives in rural practice. We know there has been an absolute downturn in maternity service across the board because of the issue about women being at risk. But even for an experienced, very competent, midwife it is becoming increasingly difficult to maintain their currency, and therefore their registration, under our current system. In fact, with this round of registrants that is just going through the board, we will be waiting to see how many of the rural midwives drop off the register. I am expecting a significant number. Even though the hospitals that they might be working at, or the services that they might be working at, may not have birthing services, they do provide ante-and postnatal care. As soon as there are no midwives to do that, what then happens to that service? It goes.

Ms Mills : They also do emergency obstetrics, and that is also problematic if they are not registered as midwives any longer and somebody comes to the door.

Senator NASH: Yes, what do you do? It is interesting. It really reflects the GP concern that we have had this morning where we have got the doctors going through university in Sydney and they see the bright lights of being a specialist as what they want, as that is where all the dollars are and where all the opportunities are—compare that to being a rural GP in the bush! What you are saying, if I am right, is that it is a similar structure for nursing.

Prof. Francis : It is.

CHAIR: Except they have not got so much of an ability to do the specialties.

Ms Mills : There is also a real dearth of graduate programs in rural Australia. Obviously, we both teach at university and so we are quite concerned with what happens to first year graduate nurses. There are very few graduate programs in rural Australia. A lot of that is around cost and cost-cutting by state governments. But that is also not attracting students to go back out into country Australia. Many of our students come from country Australia and that is why they are enrolled in regional universities. But if they are looking for a graduate program, for us, they will often end up going to Brisbane; for Karen, it would be Sydney.

Senator NASH: Can I just ask where you are all from?

Ms Malone : I am currently working in Canberra, but I have worked predominantly in remote Australia in flying doctor services and as a midwife.

Ms Mills : James Cook University in Cairns.

Prof. Francis : Wagga.

Ms McLaughlin : I am Canberra-based.

Prof. Francis : I was listening to the medicos who were talking before when they were talking about locum relief. One of the things that we know is happening in rural and remote services is the increasing use of—and need for—locum support. In some ways that is great, it is a gap-filler and that is all it is. But if our hospitals and other services are only being supported by locum services, then I think there is a real issue for the communities, because the lifeblood of a lot of communities is their health services. It is a real issue. I know at Wagga Base Hospital, which is a fairly large regional hospital provider, the need to fill the nursing and midwifery vacancies with locum staff is increasing all the time. And that is with a university on the doorstep that puts out 1,700 undergraduate nurses per year and they still cannot staff it.

CHAIR: How do they find locums? Are there people who are already in the community who are employed as locums or who choose to be locums?

Ms Malone : In the nursing world we have always been called agencies, rather than locums. Locum tends to be a medical term but it is the same thing really. Generally they are flown in from more populated areas.

Prof. Francis : From the cities.

CHAIR: Like fly-in fly-out?

Ms Malone : For a period of time, yes. With NAHRLS, which is the latest Commonwealth initiative in terms of supplying nursing and allied health to rural services, again, it is the same. Although they say they have a bit of a commitment to using locums, if you like, who have experience in rural and remote, but that is not the norm with agencies. So, as Karen said, it has huge implications for communities. Just recently we heard about staff going into remote who have no context, particularly culturally, and the impact that has on the community. It also has a big impact on the Aboriginal health workers, who are the real core to those communities. Unfortunately, there is not a good understanding by people who do not work in these areas of the absolutely pivotal role, the essential role, that Aboriginal health workers have. So they are feeling even more disengaged through a lot of these processes. It is becoming more common.

Prof. Francis : And a level of resentment from communities when they get the fly-in fly-outs, because there is no continuity.

CHAIR: No-one knows them or their history—

Ms Mills : Especially when they come from overseas. I know that in Cape York Peninsula, which is obviously in my backyard, a lot of them are New Zealand locums.

Senator MOORE: Massive problem.

Ms Mills : I really support Gerry's statement about the cultural inappropriateness of the nursing care provided. The lack of ability to provide mental health care is also a really big issue in an awful lot of those communities, and there is no service provision because of that.

Senator MOORE: I am interested to hear what you thought of the evidence of the previous witness about the nurses in the young practice and how he could use his nurses better if the system were different.

Ms Mills : Interestingly both Karen and I are very active researchers in the area of general practice nursing. We have a lot of publications between us about that, so we know a lot about it. The big issue is the funding model in general practice. While the funding model continues to be a small business model where general practitioners have to generate income out of item numbers, nurses will continue to be inappropriately utilised and their scope of practice will continue to be constrained. That comment is quite common. I think the sad bit is that a lot of the time they do not actually realise what the general scope of practice of a registered nurse is. Certainly the way the Medicare item numbers used to be set up—and of course the PIP payments—there is still this belief that doctors have to sight every single patient and, in many ways double-dip.

Senator MOORE: It is just really sad that the understanding is not there.

Prof. Francis : And I think that is the big issue. I am currently doing some work and all the practice I have been involved in there is that misunderstanding that that is how they have to operate the payment system. Regarding that whole notion of 'not having a nurse practitioner; they are not supportive', there are models where that actually works really well; it divides the work up and they provide a much better service to the community. It is just turf war.

Ms Malone : Unfortunately there is a lack of understanding in the medical community about the role. They use the phrase 'independent nurse practitioners' almost as this notion they are going to be off doing their own thing, which is really far from the truth and absolutely against the whole notion of it. I don't know what you guys think, but I think there is real lack of good understanding by the medical profession of what nurse practitioners do. There are a lot of myths out there, and that is really unfortunate because there are some great models of nurse practitioners in general practice.

CHAIR: Can you give us some examples where it is working well?

Prof. Francis : There is a practice in Cootamundra, with a very innovative medico as their practice principal. I think that practice stands out as an exemplar. I think it is a whole-team approach, and everybody on the team, the nurses included—I can't remember if the nurse practitioner is endorsed yet or still in train—provide a comprehensive service, a much better arrangement than other practices that I know of.

Senator MOORE: And accessing Medicare to its full extent?

Prof. Francis : Yes. A solid understanding of it.

Ms Mills : Ironically, general practitioners have been working with community nurses for years. Community nurses work to the full scope of the registered nurse practice. They happily go out and visit people in their homes. They undertake dressings, they deliver care, they make decisions, they case manage and they case manage palliative care clients—all of those things GPs have worked in a team operation with for a long time. But, as soon as you put a practice nurse into their practice and they are responsible for paying their salary, it changes the dynamic.

Senator MOORE: And it changes the relationship as well.

Ms Mills : Totally.

Senator MOORE: They are used to a relationship.

Ms Mills : They are.

Senator MOORE: Has the issue around careers changed? You are identifying all the issues about the lack of career opportunity in rural areas at the moment being a disincentive. Was it different 10 or 20 years ago?

Prof. Francis : Was it different? I would probably have to say no.

Senator MOORE: That is my view.

Prof. Francis : Having said there are no career structures, there are but they are limited—which is the point. We are seeing more nurses as CEOs than we saw in the past. But that is the whole argument though—it is an administrative pathway. If you are trying to career advance, there is not the clinical type of pathway. The nurse practitioner, advance practice nurse scenario was the way forward but there is a big gap between the registered nurse and the nurse practitioner. We do have clinical nurse specialists and clinical nurse consultants—although the consultant is a more administrative leader type person. There is just not anything that fills the ladder—the steps up.

Senator MOORE: There never has been.

Prof. Francis : No. Underpinning all that, you need to have some strategies that support people to be able to move through that, recognising that the majority of the workforce is part time. So the structures have to actually take that into account as well.

Ms Malone : It has been there informally for a long time, if we think about the advance nurse practice role. Many different words have been used for that. I think it is there but it has not actually ever been well or formally acknowledged.

Senator MOORE: Or paid.

Ms Malone : Yes, or paid or supported in terms of education, although we have made some big inroads in that. In the remote sector, remote area nurses certainly are in positions of advance nurse practice—not all of them because, again, there are levels within that. We have some really good opportunities in that vein for clinical pathways and as a bit of a stepping stone to get to nurse practitioner. There are opportunities but we have not been very good at advancing that until now.

Ms Mills : I think it would support the diversity of service provision in rural and remote areas of Australia if there was a stronger career pathway for nurses, if there was a stepping stone somewhere between a registered nurse and a nurse practitioner. You could then look at nurse-led clinics and nurse-led models of care with somebody who has undertaken a structured pathway of education and training and to gear them up to be able to deliver that.

Senator MOORE: There has been a lot of talk in most of the conditions-specific organisations about the wonderful work that could be done by having nurse-led teams or a nurse-only team in regional areas with arthritis, Alzheimer's, heart and diabetes, for example—and breast nurses of course which get a lot of publicity. I know that in regional towns sometimes a nurse with one of those guises, through specialist funding often—which is not government—could well be the centre point of lots of community care anyway. They may have the title 'breast care nurse' but everybody knows her and, if they have got other medical problems, they are more likely to chat to her than they would be to anyone else. Do they fit within the system that you are describing—that kind of specialist care?

Prof. Francis : Yes, absolutely. Whilst we recognise that chronic and complex care are the major issues facing the population at the moment, I like to think that the difference between nursing and maybe a medical practice is that we have always used a wellness framework. It is about maintaining optimal health and working from a preventative rather than intervention perspective. That is how I see nursing complements especially general medical practice, which is really interventionist. I know they do not think it is, but I think it is. The work that we do is about maintaining and promoting wellness and working with allied health people around how to work with people that require cardiac rehabilitation—or even before that—in order to keep them at a level where they are functioning and can live independently. That is where I think there is scope for advancement and new roles for nurses that will add value.

Senator MOORE: This committee is also working on palliative care

Prof. Francis : Absolutely.

Senator MOORE: It certainly has come out that it is often the nurse community that is working with people through that process, and the community organisations are focused on that.

Prof. Francis : Absolutely.

CHAIR: They were talking about the need for a case manager and there were a number of suggestions saying it would be better—

Prof. Francis : I can give you an example of a really good response by a small MPS, not in this jurisdiction—I mean not in New South Wales. This happens quite regularly It is a small service. It does not have any local medical officers at all, so it is serviced by a medical officer from another town who comes in once or twice a week. The local service identified a number of people coming through their A&E department, which is basically a nurse-led department, with various stages of cancer and no localised support—so people were having to travel 100 kilometres to the nearest oncology services. What the nursing staff at the MPS did was set up a roster for people to go out into the community and provide in-home support for palliative care—off the roster. That is staffing an MPS, which is a very small acute care, and a very large aged-care, service.

Senator MOORE: They were doing their own community nursing.

Prof. Francis : Basically, yes—but they were actually ward staff, not community nurses. It was in response to the community need. I think that is an indication of the innovation that is out there if we can somehow provide the support that allows them to do it and recognition through career pathway options.

Senator MOORE: And this is an option for them.

Prof. Francis : Yes.

Senator MOORE: Do all the graduates of both your schools get employed?

Prof. Francis : Yes, but every nurse gets employed.

Ms Mills : Actually, I have to say we did not end up with all our graduates gaining employment in Queensland. We had quite a lot of our graduates having to leave regional Far North Queensland and head down to Sydney and Melbourne to get jobs.

Prof. Francis : When I said they all get work, I did not necessarily mean they all got work in surrounding areas. They got jobs, but whether they got a graduate placement is another question.

Senator MOORE: That is the dichotomy. That is what I have heard: we have now built up nursing schools throughout the country which are highly regarded, and places are taken every year. That is my understanding as well, but I have heard over the last couple of years that in Queensland people do all that work and graduate, but there is no work. I would have thought that would be the worst result.

Ms Mills : It has only been in the last two years, and I think it is a result of the GFC. That really did put pressure on Queensland Health from reduced retirements; that is my understanding.

Senator MOORE: With the superannuation figure, yes.

Ms Mills : Yes. That was what happened, and the squeeze was on. Queensland Health, to give them their due, have offered fractional appointments, so a lot of our graduates got employed at 0.7 of 0.8 of full-time and ended up picking up casual shifts to fill up to a full-time salary. It is not ideal, but still—

Senator MOORE: The same thing has been recorded in Toowoomba and also some of the other colleges.

Ms Malone : One of the issues about graduate placements—I think Jane mentioned it—is that often, unfortunately, a lot of rural and remote programs do not offer graduate placements. That is really about lack of resources and lack support to do it. There is a willingness there for a lot of the remote and regional centres to do that, but unfortunately there is not much support, either financially for the students to undertake those placements or for the health services themselves to have the resources to be able to support and supervise graduate roles well.

Senator MOORE: They want people with more experience.

Ms Malone : They often go for people with more experience. It is a bit of a catch-22. We all support the fact that you can have a really good graduate program in a rural or even, we might argue, a remote area, but it is about the lack of support and resources they have to provide that, if that makes sense. There are some very good models in the medical world where they do that support very well, which are funded. There are some good lessons to be learnt there, but unfortunately we do not have those at the moment. I think we would then get more nurses in undergraduate studies in regional areas who would like to do those placements in those places, but unfortunately the support and the structure is not there to allow that to happen.

CHAIR: Okay. Thank you. We are on 3:00. I do not think we gave you any homework, did we? No. You are lucky. Get out while the going is good, before we dream something up! Thank you very much for your time.