Australia entered the COVID-19 pandemic with a nursing shortage already on the books and left it with the problem sharpened. Health Workforce Australia (2014) projected a national shortfall of approximately 85,000 nurses by 2025, rising to 123,000 by 2030, if prevailing exit rates and training patterns continued. A decade later, the successor modelling tells a similar story, anticipating a gap of around 70,000 full-time equivalent nurses by 2035, concentrated in aged care, mental health and rural services (Department of Health and Aged Care, 2024). What the projections obscure is that the register keeps growing: more than 470,000 nurses and midwives hold current registration with the Nursing and Midwifery Board of Australia, and the employed workforce has expanded almost every year for a decade (Australian Institute of Health and Welfare [AIHW], 2024). Australia’s problem, in other words, is not chiefly a failure to produce nurses. It is a failure to keep them in the wards, sectors and rosters where they are most needed.
This essay argues that retention should sit at the apex of post-pandemic nursing workforce policy, ahead of both domestic pipeline expansion and international recruitment. The argument proceeds in four steps: an account of why nurses leave; a review of what the evidence shows keeps them, including ratio legislation in Victoria and Queensland, magnet-style practice environments and graduate transition programs; an assessment of the ethical limits of international recruitment; and a proposed hierarchy of retention strategies. The essay then addresses the strongest counterargument, that supply-side pipeline growth deserves priority, and explains why it fails.
Why Nurses Leave: The Drivers of Post-Pandemic Attrition
Attrition is best understood through the job demands-resources model, which holds that a sustained excess of demands over resources produces exhaustion, disengagement and, eventually, turnover intention (Bakker & Demerouti, 2017). The pandemic inflated demands faster than any resource could compensate. Australian primary healthcare nurses reported inadequate personal protective equipment, constantly shifting guidance, expanded infection-control responsibilities and hostility from anxious patients, all layered onto pre-existing workloads (Halcomb et al., 2020). Acute settings experienced the same dynamic through redeployment, furloughed colleagues and surge rostering. By 2022, the Australian Nursing and Midwifery Federation’s national survey found a majority of respondents reporting exhaustion and a depleted capacity to care, with roughly one in four indicating an intention to leave the profession within five years (Australian Nursing and Midwifery Federation [ANMF], 2022). Burnout of this kind is not a wellbeing deficit to be managed with resilience seminars; it is the predictable output of a system run above safe capacity.
Workload is the demand that matters most. Where staffing falls below need, nurses ration care, absorb unpaid overtime and carry the moral distress of tasks left undone, and each departure deepens the deficit for those who remain. The resulting churn is expensive as well as corrosive. In a comparative international study, Duffield et al. (2014) estimated Australian nursing turnover at approximately 15 per cent per annum, with a replacement cost close to A$49,000 per departing nurse once recruitment, orientation and lost productivity were counted. Every dollar spent replacing a nurse is a dollar unavailable for retaining one, which is the fiscal signature of the leaky-bucket problem to which this essay returns.
Two further drivers deserve explicit naming: pay and violence. Nursing remains a feminised profession and, in parts of the sector, a demonstrably undervalued one. In the aged care work value case, the Fair Work Commission (2023) concluded that award rates had not kept pace with the skill and responsibility of direct care work and ordered a 15 per cent interim increase, with further staged rises to follow, an institutional admission that low pay had been structural rather than incidental. Occupational violence compounds the injury. The ANMF (2022) survey found that most respondents had experienced aggression or abuse at work in the preceding year, much of it unreported because it had come to feel routine, particularly in emergency, mental health and aged care settings. Nurses rarely leave for a single reason; they leave when accumulated demands outstrip every available resource, and the pandemic accelerated exactly that accumulation.
What Keeps Nurses: The Retention Evidence
The strongest Australian retention evidence concerns legislated minimum nurse-to-patient ratios. Victoria codified minimum ratios in the Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Act 2015, and Queensland followed in 2016 with amendments to its hospital legislation prescribing one nurse to four patients on morning and afternoon shifts, and one to seven at night, in prescribed medical and surgical wards. The Queensland policy received a rare prospective evaluation. McHugh et al. (2021) found that hospitals subject to the ratios improved staffing relative to comparator hospitals, and that mortality, readmissions and length of stay all fell; the savings from avoided readmissions and bed days were roughly double the cost of the additional staff. Evidence from California’s earlier mandate points the same way for the workforce itself, with nurses in the ratio state reporting lower burnout, less dissatisfaction and weaker intention to leave than peers elsewhere (Aiken et al., 2010). Ratios are usually defended as patient-safety policy; the retention dividend is the under-advertised half of the case.
A second body of evidence concerns the organisational features popularised by the American magnet-hospital program: visible nursing leadership, shared governance that gives nurses real authority over practice, sustained investment in professional development and adequate support services. Kelly et al. (2011) found that nurses in magnet hospitals reported significantly lower burnout and higher job satisfaction than matched non-magnet peers, with correspondingly lower intention to leave. The transferable lesson for Australian health services is not to purchase an accreditation badge but to replicate the active ingredients. A ward where nurses help govern their own practice, can see a credible clinical career ladder and are backed by functioning support services retains staff for reasons that no one-off bonus can imitate.
Third, retention effort should concentrate where attrition concentrates: the transition from university to practice. Newly graduated nurses who enter understaffed wards without structured support are disproportionately likely to leave the profession within their first years. A systematic review led from Australian institutions found that structured transition-to-practice programs incorporating supernumerary time, preceptorship and protected education days consistently improved new graduates’ satisfaction and retention, although program quality varied widely between health services (Missen et al., 2014). Guaranteeing every graduate a funded, properly supervised transition year, including in aged care and rural services, is among the cheapest retention purchases available, because it protects the career stage at which the workforce is most fragile.
Pay completes the picture without dominating it. Remuneration operates as a threshold condition: conspicuously unfair pay drives exits, as aged care demonstrated, yet pay rises layered over unsafe workloads purchase little loyalty. In job demands-resources terms, a salary increase is a resource that cannot buffer a chronically excessive demand load (Bakker & Demerouti, 2017). The policy implication is sequencing rather than dismissal: repair conditions first, pay competitively, and target premiums at the points where retention is weakest, such as night duty, rural postings and the early career years.
The Ethical Limits of International Recruitment
Confronted with vacancies, Australian governments have reached reflexively for international recruitment. Roughly one in five practising nurses gained their initial qualification overseas, and in the years since the pandemic internationally qualified nurses have made up a majority of some new-registrant intakes (AIHW, 2024). Globally, however, the pandemic deepened a worldwide need for millions of additional nurses this decade, concentrated in low- and middle-income countries whose health systems can least afford further losses (Buchan et al., 2022). The World Health Organization’s Global Code of Practice discourages active recruitment from countries facing critical health workforce shortages and calls for bilateral arrangements that return genuine benefit to source health systems (World Health Organization, 2010). An Australia that fills its rosters by thinning the nursing workforces of the Philippines or Nigeria is not solving a shortage; it is exporting one to systems with far less capacity to absorb it.
There is also a self-interested reason for restraint. Internationally qualified nurses recruited into the same understaffed and unsafe conditions that are driving domestic attrition will, in time, leave those conditions too, after Australia has paid the recruitment, migration and orientation costs. Ethical international recruitment, conducted through government-to-government agreements and supported by fair qualification recognition and deliberate workplace inclusion, has a legitimate supplementary role. It cannot be the strategy, because it treats the symptom, imports the new workforce directly into the disease, and does so partly at other nations’ expense.
A Retention Hierarchy for Australian Health Services
The evidence reviewed above supports an explicit hierarchy for governments and health services. The first tier is safe work: legislated minimum ratios extended beyond Victoria and Queensland, and beyond general medical and surgical wards, together with enforceable occupational violence prevention. These interventions attack the chronic demand overload that generates burnout, and they carry the strongest outcome evidence, including the Queensland finding that ratio compliance substantially offsets its own cost (McHugh et al., 2021). The second tier is the practice environment: shared professional governance, visible nursing leadership, credible clinical career structures and a guaranteed supported transition year for every graduate (Kelly et al., 2011; Missen et al., 2014). The third tier is targeted remuneration: full flow-through of the aged care work value increases, and retention premiums aimed at early-career, rural and night-duty nursing (Fair Work Commission, 2023).
Only beneath these tiers do supply measures belong: expanded domestic training places and ethically governed international recruitment. The ordering is not rhetorical. Tier-one measures are preconditions, because resources added on top of a broken demand structure simply leak away, which is why wellbeing programs and recruitment campaigns conducted amid unsafe staffing have so little to show for their expense. The job demands-resources logic runs in one direction: reduce demands first, then build resources, then reward (Bakker & Demerouti, 2017). The sequence is the strategy.
The Supply-Side Counterargument
The strongest objection to this position holds that the shortage is ultimately arithmetic. Demand growth is being driven by population ageing, the expansion of the National Disability Insurance Scheme and aged care reform, so no plausible retention dividend can close a projected gap of 70,000 full-time equivalents; the rational response is therefore to expand university places, clinical placements and skilled migration pathways, and to treat retention programs as marginal refinements. On this view, ratios and practice-environment reform are expensive, slow and administratively heavy, whereas supply expansion is scalable and certain.
The rebuttal begins with arithmetic of its own. With an employed nursing workforce in the hundreds of thousands, each percentage point of annual turnover avoided retains several thousand experienced nurses, a yield comparable to the entire annual output of multiple nursing schools, delivered immediately and without the 3-5 year training lag (Department of Health and Aged Care, 2024; Duffield et al., 2014). Second, the pipeline is not independent of retention. Clinical placements and graduate supervision depend on experienced nurses, so attrition shrinks training capacity at precisely the moment the counterargument needs it to grow, and graduates poured into understaffed wards leave fastest of all (Missen et al., 2014). Third, the affordability objection is weakened by the Queensland evaluation, in which the ratio policy roughly paid for itself through avoided readmissions and shorter stays (McHugh et al., 2021). The concession the counterargument earns is real but limited: demographic demand growth means pipeline expansion is genuinely necessary. It is simply not sufficient, and it belongs second in the sequence, because filling a leaking bucket faster has never been a workforce strategy.
Conclusion
Australia’s post-pandemic nursing shortage is retention-shaped. The register grows while wards stay short because burnout, unsafe workloads, compressed pay and normalised violence push nurses out faster than universities and migration programs can push them in. The evidence assembled in this essay, from Queensland’s evaluated ratio legislation to magnet-style practice environments and structured graduate transition programs, shows that the levers that keep nurses are known, Australian-tested and in some cases largely self-funding. International recruitment can supplement an ethical strategy but cannot substitute for one, and supply-side expansion, though necessary, inherits its value from the retention system into which it feeds. Health Workforce Australia (2014) issued its warning more than a decade ago, and the successor modelling now extends the horizon to 2035 (Department of Health and Aged Care, 2024). Projections, however, describe trajectories rather than destinies. Whether the projected gap materialises will be decided less by how many nurses Australia trains than by how many it manages to keep.
References
Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., Spetz, J., & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health Services Research, 45(4), 904-921.
Australian Institute of Health and Welfare. (2024). Health workforce. Australian Government.
Australian Nursing and Midwifery Federation. (2022). ANMF national COVID-19 survey report.
Bakker, A. B., & Demerouti, E. (2017). Job demands-resources theory: Taking stock and looking forward. Journal of Occupational Health Psychology, 22(3), 273-285.
Buchan, J., Catton, H., & Shaffer, F. A. (2022). Sustain and retain in 2022 and beyond: The global nursing workforce and the COVID-19 pandemic. International Centre on Nurse Migration.
Department of Health and Aged Care. (2024). Nurse supply and demand study 2023-2035. Commonwealth of Australia.
Duffield, C. M., Roche, M. A., Homer, C., Buchan, J., & Dimitrelis, S. (2014). A comparative review of nurse turnover rates and costs across countries. Journal of Advanced Nursing, 70(12), 2703-2712.
Fair Work Commission. (2023). Aged care work value case: Summary of decision. Commonwealth of Australia.
Halcomb, E., McInnes, S., Williams, A., Ashley, C., James, S., Fernandez, R., Stephen, C., & Calma, K. (2020). The experiences of primary healthcare nurses during the COVID-19 pandemic in Australia. Journal of Nursing Scholarship, 52(5), 553-563.
Health Workforce Australia. (2014). Australia’s future health workforce: Nurses overview report. Commonwealth of Australia.
Kelly, L. A., McHugh, M. D., & Aiken, L. H. (2011). Nurse outcomes in Magnet and non-Magnet hospitals. Journal of Nursing Administration, 41(10), 428-433.
McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of hospitals. The Lancet, 397(10288), 1905-1913.
Missen, K., McKenna, L., & Beauchamp, A. (2014). Satisfaction of newly graduated nurses enrolled in transition-to-practice programmes in their first year of employment: A systematic review. Journal of Advanced Nursing, 70(11), 2419-2433.
World Health Organization. (2010). WHO global code of practice on the international recruitment of health personnel.