December 6, 2024

Royal North Shore Hospital

Ratios rollout gets underway

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Our decade-long campaign to ease workloads and make public hospitals safer takes a big step forward.

Shift by shift ratios are being rolled out in the emergency departments (EDs) of two Sydney hospitals – the first in the state to benefit from the union’s safe staffing ratios campaign.

About 70 additional full-time equivalent (FTE) nurses are being recruited for the EDs of Royal North Shore  and  Liverpool  hospitals to meet a minimum ratio of 1:1 in resuscitation bays, and 1:3 in ED “generally occupied treatment spaces”.

This is the start of a phased rollout in five clinical areas of the public hospital system, agreed between the state government and the NSWNMA.

Between now and July 2027, ratios will extend to other EDs, and then intensive care units (ICUs), adult in-patient wards, maternity services and multiple-purpose service sites.

The rollout is being overseen by the Safe Staffing Levels Taskforce, made up of state health officials and the NSWNMA.

NSWNMA General Secretary Shaye Candish said the union has been working with the government on the implementation of ratios as part of the Taskforce since May 2023.

“This has been a lengthy process, but we are starting to see this hard- fought campaign come to fruition,” she said.

“After more than a decade of fighting to have our voices heard, this is a key moment in our efforts to ensure patient safety is given the priority it deserves.

“It is also a step in the right direction to help rebuild the workforce and retain nurses and midwives in the public health system.

“We look forward to seeing ratios expand into other EDs, and then ICUs, adult in-patient wards, maternity services and multiple- purpose service sites.

“The government has committed 2480 FTE nurses and midwives to help deliver this, but we know more must be done.

“Your union is fighting for more funding from the government, to ensure these five clinical areas receive ratios.

“We know current funding won’t cover all wards and units in every hospital, and the government must do more to ensure this, because our public health system cannot afford to be shortchanged on this vital reform.”

Working with the community for positive change

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Nurses, midwives and the community all have a common interest in improving the public health system.

 For some time now pressure has been building in maternity services throughout NSW due to a significant shortage of midwives in our major hospitals.

Recently there were 28 midwife vacancies at Westmead, Wollongong had just under 10, Royal North Shore Hospital 16 and Blacktown Hospital 23.

Midwives working in these units are constantly stretched and this creates a situation that is a lot less than optimal for the mothers and babies who depend on their care.

Because there are shortages of midwives in post-natal areas mothers and babies are being discharged as soon as possible. This means there is a risk that mothers are not getting the assistance they need to establish breast feeding and to avoid complications that can lead to mothers returning to hospital if their baby is dehydrated and unwell.

NSW Health has been claiming publicly that there is no significant shortage of midwives, that there are merely “challenges” in some districts due to population growth.

This complacent analysis jars strongly with the real life experience of midwives on the ground. They are telling the Association that there are not enough midwives to deliver the care to be able to adequately support the mothers and babies they have responsibility for.

The intense workloads that midwives are working under often compound the problem. Working extra shifts – often double shifts – has led some midwives to reduce the number of hours they work in order to manage this pressure. Some seek alternative employment. In many cases vacancies are being filled by non-midwifery staff.

The Association is very concerned about how these vacancies and the subsequent stress they put on maternity services impact on the quality of care for mothers and babies.

In post-natal wards it is imperative that the mother can successfully breastfeed and their baby is well fed, that they can go home safely and won’t suffer from complications.

Our concerns about the state of maternity services are shared by many mothers who use these services and who can see for themselves that midwife numbers are frequently inadequate.

In this issue of The Lamp we talk to mothers from the NSW south coast who have formed their own group – Better Birthing Illawarra – to lobby the local health district for improved maternity services. 

Through admirable persistence this group has established regular meetings with the chief 
executive and have also met with local MPs.

The group supports our campaign to include babies when calculating Midwife to patient numbers and has raised the need for more staff at meetings with the hospital executive.

Like us, they want to “hold the executive to account and improve the service with more staff and models of care that work in line with what the community wants”.

Nurses and midwives should take heart that we have such strong and influential support from members of the community who, like us, have seen and understand what is happening in our maternity services.

In our campaign for better ratios we need to build and nourish our relationships with such like-minded people in the community. It will be critical to the success of our campaign.

Also in this issue of The Lamp we talk to an energetic group of aged care nurses on the NSW north coast who are taking our campaign for ratios in aged care to their community.

They have been holding stalls in shopping centres, engaging local MPs and spreading our message 
through local media.

I understand how many nurses in aged care find it difficult to put their head above the parapet in their workplace. The aged care nurses who have thrown themselves into this sort of community campaigning have found it a safe and rewarding way to improve conditions in aged care.

I would urge you to get involved in this engagement with the community and politicians so we can make aged care a safer and better environment for elder Australians.

Mums matter, babies count

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Midwives at Royal North Shore Hospital have run an innovative campaign to educate the public about the need for appropriate staffing levels in birthing wards.

Corrine Cakebread has worked as a midwife for more than 15 years. Over that time she has seen increased numbers of mothers and babies with complicated health needs coming into the wards.

“We get a lot more women with complex health issues now. More women are being induced earlier,” she says.

There are a number of factors that have changed the birthing environment: the rising numbers of older mothers, more IVF births to women with complex health histories and higher rates of gestational diabetes. Babies being born at 35 weeks are now being cared for in regular maternity wards, rather than in intensive care.

But these increasingly complex care needs haven’t been matched with increased staffing levels says Corrine, a registered nurse and midwife at the Royal North Shore Hospital.

“We have the same level of staffing, the same hours as when I started,” she said.

The RNSH’s birthing ward – which also takes referrals for complicated cases from surrounding regions – averages 220–230 births per month. “We don’t get the time to help everyone who needs help,” Corrine says.

Compounding the problem is the pressure to “discharge babies earlier than ever means that many are coming back and being treated for jaundice”.

As a long-time union member, Corrine was happy to pay her fees knowing the union was representing nurses and midwives in the workplace. But last year Corrine’s growing concerns about patient safety led her to become active in the union for the first time.

“At the end of the day, if something happened to one of our patients it comes down to the midwife looking after the mother and baby and the team leader. And that is a huge responsibility. I was concerned that something would have to happen before something changed.”

Fighting to give mothers better care

After a couple of near misses last year, Corrine and other midwives worked with the union to create a campaign called ‘Mums Matter, Babies Count’.

The campaign slogan highlights both the staff’s desire to give every mother the best possible care, and to improve Birth-rate Plus®, which currently doesn’t count babies as patients, a key issue for calculating appropriate staffing levels.

NSWNMA Acting General Secretary Judith Kiejda says, Birth-rate Plus®, can be a clunky tool for calculating appropriate staffing numbers.

“When our organisers first sat down with RNSH staff to discuss staffing levels and workload pressures, midwives were crying. They were devastated they couldn’t provide the kind of holistic, woman-centred care they would like to,” she said.

Corrine explains that unlike nurses, who can have a four-to-one patient-nurse ratio, midwife loads can be much higher.

“On a good day you have five women to look after. On occasions there can be one midwife for up to eight mothers. But babies need to be cared for too, and embedded in Birth-rate Plus® is the assumption that babies don’t count as patients.”

She says management have been making up staffing shortfalls with assistants in midwifery (who are usually student midwives) but they are still learning and can’t be expected to do observations.

“Some babies [born pre-term or to diabetic mothers] need their blood sugar levels monitored for at least 24 hours,” Corrine says. “The only people who can do that are midwives.”

For Corrine, the bottom line for safe staffing levels is that “anyone who walks onto that ward should be able to resuscitate a neonate or a mother”.

In the post-natal ward, midwife shortages are being filled with RNs, who can’t be expected to have the expertise to get a woman breastfeeding correctly, Judith says.

“When baby and mother thrive, readmissions rates are lower.”

Talking to the community

Last year Corrine and other midwives, with NSWNMA support, met with the hospital’s reasonable workload committee to discuss possible solutions, including increased ward clerk hours and changes in ward layout.

While the committee was sympathetic, when the midwives’ concerns were put to management they “fell on deaf ears”.

As part of the campaign, they also held a rally outside the hospital last October. “Some of the doctors came and supported us,” Corrine says.

“We’ve also been wearing ‘Mums Matter, Babies Count’ badges, and talking to mothers and visitors when they ask us about it.”

Corrine has seen some small improvements in staffing levels since their action started, but more needs to be done.

“We would like at least five midwives on the maternity ward and at least five on the birthing unit every night.”

As part of the campaign, RNS midwives counted missed meal breaks: they found 96 missed meal breaks on the birthing unit over two weeks.

“Midwives will work through their lunch; we are not going to leave a birthing mother,” Corrine said.

Judith Kiejda says midwifery shortages are impacting maternity units everywhere, with the units at the RNSH down the equivalent of 15 FTE, while at least 40 FTE positions are missing at Westmead. She says long-term issues still remain unresolved in Wollongong Hospital maternity unit.

Corrine is also concerned that the work pressures are making it harder to retain new midwives coming through.

“We have at least 10 student midwives coming through every year. We don’t get the chance to educate them the way we should educate them. My fear is so many of our midwives are going to leave because they don’t get the support they need.”

She’s worried she doesn’t have time to sit long enough with mothers either as she bounces between patients.

“The main thing for me is trying to make sure we are working in a safe environment for staff and patients. That is our aim in having babies count.”

Members of the NSWNMA… share your thoughts on articles in the Lamp or anything else important to you as nurses and midwives by sending a Letter to the Editor. Four letters are published in the Lamp each month and the letter chosen as Letter of the Month will win a gift card. Please include a high-resolution photo along with your name, address, phone and membership number. You can submit your letter by emailing the Lamp: lamp@nswnma.asn.au

Midwifery hours fall well short at RNSH

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Extra maternity beds at Royal North Shore Hospital not staffed properly.

RNSH midwife and NSWNMA branch member Sue Bullmore says midwives are committed to providing a safe birth environment and the best possible care for new mums and babies.

“However, when the workload is as heavy as it is now we are not able to give the women that optimal care,” she says.

RNSH maternity services are housed in a new building designed with future expansion in mind.

“We have more birth rooms and maternity beds than we are funded for. We go over census quite often and use those extra beds but we are not staffed accordingly.

“On top of that, vacancies in the maternity ward are often filled by AiNs, RNs and student midwives instead of qualified midwives.

“Under the nursing award if we accept anyone in the maternity unit who isn’t a midwife we are saying that we are covering for the work they do.

“If something were to go wrong the midwives would ultimately be held responsible.”

“Maternity staff often miss meal breaks and finish work late. We have a high staff turnover, which is largely a result of understaffing.”

BirthRate Plus doesn’t count babies

Sue says the failure of Birthrate Plus to take babies into account when determining staff numbers is a particular problem for a high-risk referral centre such as RNSH.

“We have a lot of women with high-risk pregnancies and we often have babies who need special care.

“They include late pre-termers, babies requiring phototherapy for jaundice, babies who are poor feeders or need to have their blood sugars monitored.

“None of that work is counted in Birthrate Plus because babies are not counted as patients.

“If these babies were moved up to the neo-natal unit they would be counted as patients. But because they are down with their mothers in the maternity ward the belief is that the mothers are caring for them, which is not necessarily the case.”

She says inadequate staffing is largely to blame for the number of babies who have to be readmitted due to weight loss.

“We think their mothers did not get the amount of input they should have got before they left hospital, especially with feeding.”

In the birthing unit, midwives are often pushed to complete inductions and elective caesareans when staff numbers are short.

On their own initiative, RNSH midwives have started four projects to look at ways of improving efficiency to alleviate the staff shortage.

“These initiatives have the support of the director of midwifery services and midwifery unit managers. They are open to suggestions so it’s not an ‘us against them’ situation.

“One project is looking at the role of discharge planning because our mothers are in hospital for longer than average.

“Another project is looking at whether team nursing or midwifery would work better than patient allocation.

“However, our main need is more midwifery hours to reach the minimum recommended by Birthrate Plus.”

 

Maternity workloads untenable

Royal North Shore Hospital midwives say the public need to know about staffing issues affecting midwifery services around the state.

The NSWNMA branch at Royal North Shore Hospital has called for a community campaign for adequate staffing of maternity services.

The branch issued the call after spending a year trying to resolve staffing issues through the reasonable workloads process of the nurses and midwives award.

Assistant General Secretary Judith Kiejda said RNSH management had made some positive changes but more should be done to ease untenable workloads.

She said Birthrate Plus, the work tool used in conjunction with the award to determine required midwifery hours, had failed to solve the problems.

This was mainly because the hospital had filled midwifery vacancies with unqualified staff and Birthrate Plus did not count babies in a midwife’s ratios.

The 7-bed birthing unit surges up to 9 when busy and pulls midwives away from the maternity unit, leaving it
short staffed.

The 32-bed maternity ward surges up to 41 when busy and vacancies are often filled by nurses and assistant nurses not qualified in midwifery.

“A statewide trend towards higher gestational diabetes and women having babies when they are older has increased the need for close monitoring of mothers and babies.

“RNSH is a tertiary referral hospital that admits high-risk mothers, and babies that traditionally would have been
in special care now stay with the mother on the ward.

“These factors contribute to unsustainable workloads, which have contributed to some midwives leaving the hospital. Midwives hold concerns for women’s safety if things don’t improve.”

Big back pay win at Royal North Shore

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Fifteen nurses at Sydney’s Royal North Shore Hospital will get back payment of the in charge of shift allowance they were denied for more than four years.

Hospital management finally agreed to the back payment after the NSW Nurses and Midwives Association filed an industrial dispute in the NSW Industrial Relations Commission.

The 15 nurses worked in the post-anaesthesia or recovery unit on the afternoon shift. Back payments for some of them will total several thousand dollars.

A member of the unit, Michelle Keith RN, said nurses were very happy with the result.

“Some people don’t even know it’s coming, so they might get a nice surprise when they see their pay slips,” she said.

“The union staff did amazing work – they were so supportive of us.”

Michelle and Edward Makepeace, the RNSH branch secretary, were on the NSWNMA team that negotiated with management over the back payment.

The public health system award for nurses and midwives says a registered nurse who is designated to be in charge of a ward or unit when the Nursing Unit Manager (NUM) is not rostered for duty, shall be paid an allowance – currently about $30 per shift.

The award also says the allowance must also be paid when the NUM is rostered on duty but the day to day clinical management role for the shift is delegated to a designated registered nurse/midwife.

Staff pressure pays off

The hospital paid an in-charge allowance for the afternoon shift until August 2010 when a second NUM was appointed to the anaesthesia and recovery units.

“We desperately needed a NUM in each department but we were told we would have to sacrifice our in-charge allowance for the afternoon shift in return,” Michelle said.

“However, despite the appointment of a NUM, management continued to designate a RN to be in charge of the afternoon shift.

“At meetings with management over the years we questioned the non-payment and were told it wasn’t up for negotiation.

“It was finally reinstated in February 2015 after a lot of pressure from the staff. But we were told back payment was out of the question.

“When a manager tells you it’s not up for negotiation you tend to accept it. But there was a strong feeling among the staff that it wasn’t right.”

Michelle took the problem to the hospital’s NSWNMA branch, which approached management and got an offer of three years back pay.

Edward said the branch believed members were entitled to full back payment and “tried to negotiate a local solution. But we weren’t able to agree so we got the union head office involved and went into dispute.

“The hospital finally agreed to full back payment when the case went to the Industrial Relations Commission.

“It was a good outcome but it was ridiculous that it had to get to that point.”

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