July 3, 2022

Ratios put patient safety first

Overloaded emergency departments desperate for ratios

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The NSW Nurses and Midwives’ Association (NSWNMA) has renewed calls for a 1:3 nurse-to-patient ratio to be introduced in all emergency departments (ED), as the number of presentations continues to rise across NSW public hospitals.

According to the Bureau of Health Information (BHI) quarterly report released today, there were more than 749,500 ED presentations statewide in October to December last year, up 24,806 (or 3.4 per cent) from the same quarter in 2017.

The BHI quarterly figures show the pressure on EDs is not confined to the major metropolitan public hospitals and has continued to grow rapidly in regional areas.

General Secretary of the NSWNMA, Brett Holmes, said there was a clear need for a reliable nurse-to-patient ratios system, guaranteed in law, to help manage the ongoing demand being felt across the state.

“The strain that’s evident in our public hospitals has been taking a huge toll on nurses and midwives who do their best to deliver safe patient care at the bedside,” said Mr Holmes.

“Many regional hospitals continue to experience a higher volume of patients, yet under the current staffing model those patients receive less nursing hours compared to their city counterparts. It is unacceptable patients are disadvantaged simply for living outside of the city.”

Port Macquarie Base Hospital was one of the busiest sites, with a 12.9 per cent jump in ED presentations compared to the same period the previous year.

Other regional hospitals to experience increases in ED presentations for the quarter included Lismore (up 12.4%), Lithgow (up 12.3%), Deniliquin (up 12.2%), Wagga Wagga (up 11.8%) and Forbes (up 11.5%).

Across metropolitan Sydney, Campbelltown (10.5%) and Sutherland (10.1%) Hospitals reported significant increases in ED attendances for the quarter.

“Currently in NSW, there are no minimum nurse-to-patient ratios in our EDs or children’s wards, with no mandated ratio for each shift,” Mr Holmes said.

“We need a new, reliable shift-by-shift ratios system to provide a clear understanding of how many patients nurses have to care for,” Mr Holmes said.

In the lead up to the March 23 state election, the NSWNMA is campaigning for mandated nurse-to-patient ratios in every ward, on every shift, across all public hospitals.

Download this release: Overloaded emergency departments desperate for ratios

Labor supports nurses and midwives with major ratios offer

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More than 51,000 nurses and midwives across New South Wales have today been buoyed by NSW Labor’s pre-election announcement to fund a major nurse-to-patient ratios system, guaranteed in law.

Brett Holmes, General Secretary of the NSW Nurses and Midwives’ Association (NSWNMA), welcomed the extensive ratios commitment by Labor leader Michael Daley and called on the Liberal-Nationals government to match it.

“We’re looking at the details but Labor’s ratios announcement today shows they are seriously listening to public hospital nurses and midwives,” Mr Holmes said.

“Finally, NSW could join the likes of Victoria and Queensland with mandated nurse-to-patient ratios and ensure patients receive the level of care they deserve.

“This is the first time a major NSW political party has supported ongoing calls from nurses and midwives to guarantee ratios on every shift.

“Labor’s commitment to introduce mandated, minimum nurse-to-patient ratios will provide a clear and accountable system that patients can rely on and nurses can trust at all times.

“This is an historic recognition of the dedication nurses and midwives display day in, day out at the bedside. It will allow them to deliver safe patient care across city and country NSW.

“A patient’s level of care should not be determined by their postcode. This has to stop.

“The new ratios system offered by Labor means mandated nurse-to-patient ratios on every shift in metropolitan and regional public hospitals, creating a clear understanding of how many patients each nurse and midwife will care for safely.”

Mr Holmes said if elected, Labor’s commitment would deliver nurse-to-patient ratios of 1:4 on day and afternoon shifts; and 1:7 on night shifts to the majority of public hospitals.

“Our overcrowded emergency departments and children’s wards have been crying out for nurse-to-patient ratios, finally these critical areas would have specific minimum staffing, mandated in law,” said Mr Holmes.

“Importantly, under Labor’s commitment of one midwife caring for three mothers in postnatal maternity wards, mothers and babies will finally get the support and education they need in those critical first few days.

“This would be a first for NSW and it is desperately needed. Many public hospital maternity wards are in crisis with not enough time for midwives to ensure all mothers feel confident and supported following the birth of a newborn.

“Labor’s nurse-to-patient ratios system goes further than what the Liberal-Nationals government has put on the table to date.

“Nurses and midwives across NSW call on the Liberal-Nationals government to change their policy and match today’s announcement by Labor,” concluded Mr Holmes.

Download this media release: Labor supports nurses and midwives with major ratios offer

The role of the Reasonable Workload Committee

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I am a registered nurse working in a public hospital. When talking to my colleagues and the Branch, it is often said that the Reasonable Workload Committee at the hospital is dysfunctional. What is the intended role of the committee?

Under Clause 53 of the Public Health System Nurses’ and Midwives’ (State) Award 2017, the intended role of the committee is to “…provide a structured and transparent forum for all nurses to be genuinely consulted about workload matters through an appropriate mechanism; contribute to the decision-making process; and have the ability to resolve disputes about workloads, should they arise, through the committee process and provisions in this Award”. It includes but is not limited to discussing and resolving issues about “… nursing workloads generally, the provision of specialist advice, training, and planning for bed or ward closures or openings as they relate to nursing workloads”. 

Ratios a boost for NUMs

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The NSWNMA’s award claims aim to give NUMs in the public health system more control over unit staffing.

The NSWNMA claim for improved ratios would help nurse unit managers to staff their units with the nursing numbers and skills they need, says Nepean Hospital NUM Kerry Rodgers.

Kerry, who is NUM of the Operating Suite (Clinical) and a NSWNMA councillor, says if successful, the union claim would give NUMs “more autonomy and greater capacity to staff units the way they should be staffed, with the right skill mix depending on patients’ acuity.”

She says recent Industrial Commission cases brought by the NSWNMA have revealed how upper management in some local health districts have manipulated the existing nursing hours per patient day (NHPPD) system.

“The current Award says NHPPD should be considered as the minimum standard but NUMs find it difficult to make that argument.

“At a lot of hospitals, including Nepean, NUMs have been hamstrung in their efforts to advocate for their wards and obtain the correct NHPPD, including like for like replacement of absent staff.

“For some senior management, as long as you’ve got a beating heart you are an adequate replacement for any staff member regardless of your qualifications and skills.

“Wards have also been short-changed via the use of shorter shifts for replacement staff and the direction to manage ‘specialling’ patients within staffing numbers.

“The 2018 award claim will strengthen the capacity of NUMs to say they need extra appropriately qualified staff due to the high acuity of their patients.”

Equal ratios for all NSW hospitals

The union’s award claim includes equal ratios for all adult medical/surgical wards in all NSW hospitals.

“It is unfair that a ward in a country hospital has to work with fewer NHPPD than a ward caring for the same type of patients in a tertiary hospital,” Kerry says.

“People should receive the same level of nursing care regardless of which hospital they attend.”

The current award says operating theatres should be staffed according to ‘ACORN’ 2008 standards and the NSWNMA 2018 claim seeks to have staffing levels continually updated in line with the release of ACORN standards.

Kerry says applying current ACORN standards would boost staffing of indirect roles such as NUMs and clinical nurse educators.

It would also help non-theatre procedural areas undertaking procedures requiring sedation such as endoscopy units and imaging departments, to gain safe staffing levels.

Hours-based staffing needs reform

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Our public hospitals need a simpler, more accountable ratios system.

Public hospital staffing based on nursing hours per patient day (NHPPD), must be improved to account for skill mix and daily fluctuations in patient numbers, says nurse unit manager Darryl Petersen.

Darryl, the NUM of Blacktown Hospital’s aged care ward, believes the NHPPD system is “open to wide interpretation” and can be manipulated to reduce effective staff numbers.

He supports the NSWNMA’s 2018 award claim for a simpler, more accountable ratios system.

“We need ratios that ensure we have enough staff with the required skills to care for our patients. The current system gives us staff numbers only,” he says.

Blacktown’s aged care ward has 12 patients plus one flex bed and is staffed by three nurses plus the NUM on morning shift.

“Our staffing is often one RN, one EN and one AiN – the lowest skill mix we can possibly have,” Darryl says.

“This morning I had two RNs and an EN on the roster, but one RN was moved to another ward and replaced with an AiN.

“Replacing RNs with AiNs reduces the level of care available to my patients without a doubt. It means we can’t always attend to their clinical needs in a timely manner.

“Recovery care is sometimes delayed because there are not enough skilled nurses available.”

Darryl says the practice of counting patients at midnight understates the true number to be cared for.

“We quite often use the 13th bed during the day with the number of occupied beds dropping to 12 by midnight.”

He supports the union’s award claim for the in-charge nurse not to be allocated a patient load.

“On mornings I am the team leader for three other staff who carry patient loads. As team leader I manage ward activity such as admissions and discharges.

“However, on afternoon shift, the senior nurse acts as team leader and also has a patient load. That significantly reduces the level of care that can be provided compared to morning shift.

“The same problem applies on nights and weekends to varying extents.

“In order to maintain an equal standard of care for our patients 24/7 we need a dedicated in-charge nurse without a patient load for every shift.

“I would be open to some flexibility about the NUM being the team leader in the morning. But I would definitely advocate a team leader without a patient load for afternoon and night shifts.”

Darryl says inadequate staffing often causes delays in non-clinical care and management of patients.

“In the aged care ward we are very involved with patients’ families. We may be trying to maintain a person’s ability to continue to live safely at home. Or, we are working with a family to make plans for their relative to go into some level of care or service provision at home.

“These decisions require intensive interaction between patient, family and staff and it’s very difficult to do that when we are spread so thin.”

Rallies for ratios

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NSWNMA members have been connecting with their local communities about the importance of ratios.

Blacktown Hospital, Maureen Buckley, Aged Services Emergency Team, clinical nurse consultant

“When we started to discuss the ratios campaign, our branch members came up with this idea of asking nurses here to write on an egg what their issues were. There were dozens of eggs and people put all sorts of things on them. Then we had to stand on a plank of wood balanced on bricks and put the egg on the end. Invariably the eggs got broken, and the broken eggs with the messages on it symbolised the current broken system without improving ratios. We had a rally at the beginning of May with around 100 people, just outside Blacktown Hospital. We drew attention to the fact that we support all our colleagues throughout NSW public health facilities in this new campaign to increase ratios. At Blacktown we have areas that don’t have any mandated ratios, such as the Emergency Department and the special care MAU (Medical Assessment Unit). Usually when ratios are employed they are a minimum. Skills mix is still an issue: like for like are rarely replaced.”

Campbelltown Hospital, Melissa Vowell, Emergency Department, NUM

“I work at Campbelltown emergency as a NUM and I’m concerned about ratios in ED. We don’t actually have ratios in ED, so the best ratios we probably have are one to four, and that can blow out to one to five. One to three would be a reasonable workload in the acute area, and speaking to staff they would fight more for the ratios than for a pay rise. If we had ratios in ED, it will just make it safer for the staff and safer for the patient. Other parts of the hospital have worse ratios; in sub-acute it is one to six, and in some areas there are no ratios. At the end of April we wore red tape around our arms just to highlight the issue of ratios for 24 hours, then we gathered at Park Central for a rally. Everyone is supportive of having ratios: they know it means they are going to get better care in the emergency department.”