July 3, 2022

Royal Prince Alfred Hospital

Royal Prince Alfred Hospital nurses and midwives walk out

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Nurses and midwives at one of Sydney’s largest hospitals have walked off the job this afternoon in a two hour stop work action, frustrated their ongoing calls for safe staffing have been ignored by the NSW government.

NSW Nurses and Midwives’ Association (NSWNMA) Royal Prince Alfred Hospital Branch members voted in favour of the strike action to express their frustration at the many unresolved workplace issues and called on the NSW government to implement safe nurse-to-patient ratios.

NSWNMA General Secretary, Brett Holmes, said today’s action adds to the ever-growing number of members taking a stand for patient safety, and comes as a result of the desperate situation nurses and midwives are experiencing.

“Our members never take strike action lightly. In fact, many would not have experienced it in their working lives,” said Mr Holmes.

“Nurses and midwives at Royal Prince Alfred Hospital tell us they are under enormous pressures every day. Excessive workloads are affecting their psychological and physical well-being, leading to high levels of staff turnover and burnout.

“Unfilled vacant positions has resulted in chronic understaffing in the Intensive Care Unit (ICU), which is forcing many nurses to work an excessive amount of overtime. It’s a recipe for disaster when you’re dealing with critically unwell patients.

“We are also seeing more and more incidents of extreme aggression with not enough real-time support. The current situation is dangerous for staff and patients, and it’s just not good enough.

“They are working beyond what should be expected of any professional nurse or midwife.

“We need mandated nurse-to-patient ratios in our hospitals, like Queensland and Victoria. The NSW government’s current preferred staffing model is outdated, unsafe and frequently fails to deliver the right number of nurses needed on every shift.”

In recent weeks, thousands of nurses and midwives have walked off the job, closed beds or rallied at more than 30 public health sites across the state, highlighting the desperate need for safe staffing.

To date, the NSW government has refused to negotiate with the NSWNMA on introducing nurse-to-patient ratios.

RPA nurses and midwives rally for safe staffing

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Over 200 nurses and midwives from Sydney’s Royal Prince Alfred Hospital in Camperdown have rallied over the NSW government’s refusal to improve staffing levels.

NSW Nurses and Midwives’ Association (NSWNMA) members are calling for staffing to be overhauled across multiple wards and units at RPA, including mandated nurse-to-patient ratios of 1 to 3 in emergency, paediatrics and post-natal maternity wards.

NSWNMA General Secretary, Brett Holmes, said nurses and midwives felt ignored by the NSW government, after it refused to discuss their staffing concerns and the benefits of ratios currently operating in Queensland, Victoria and Canberra.

“On Monday, over 30 midwives and nurses specialising in emergency, critical care, mental health and rural health met with state politicians to highlight the unsafe staffing across our public hospitals – not one Liberal or National MP would talk to them,” said Mr Holmes.

“Our members are burning out and sick of feeling taken for granted by this government. Concerns for their professional registration and patient safety are very real.

“It is shameful how nurses and midwives are being treated across NSW. We desperately need ratios to ensure our hospitals are safe for everyone accessing care and for the staff trying to deliver care.

“Victoria and Queensland have had mandated nurse-to-patient ratios for more than five years. It’s time for NSW to catch up.”

Last week, around 500 nurses and midwives walked off the job across public health sites at Belmont, Blue Mountains, Bowral, John Hunter, Shoalhaven, Springwood and Waratah because of the conditions and pressures they are forced to work under. Five hospital beds were also closed at Yass on Monday.

Three nurses stabbed in RPA mayhem

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A vicious attack by a mental health patient while being specialled by an AiN highlights systemic deficiencies in managing violence in our hospitals.

Three nurses and an elderly patient were stabbed with scissors and attacked with air mattress equipment during an assault at Royal Prince Alfred Hospital on 4 May.

There had been clear escalating behaviour from the patient leading to the attack with two previous code blacks in the couple of hours before the incident.

The patient’s family had also raised concerns about her agitated behaviour when they had seen her the day before.

In the third incident she assaulted three nurses and one patient with scissors. She grabbed the scissors, stabbed one nurse in the back when she was on the ground, and the other two in the chest and in the arm. She then went into another room and stabbed an elderly patient in the face.

The only duress button available was in the nurses’ station. The attacker was being specialled at the time by an agency AiN. The other staff on shift were new graduates.

An investigative report of the incident by Safework found that the nurses were “exposed to serious risk to their health and safety from patients displaying escalating violent behaviour such as attempting to strangle a nurse, accessing and swinging air mattress equipment, verbal aggression, grabbing nurses’ hair, accessing and using scissors to harm others”.

Safework issued an “improvement notice” and directed RPA to implement a safe system of work which should include:

  • the availability of suitably skilled staff for the patient’s medical needs
  • the selection and location of the room in which the patient is placed (should be visible) from the nurses’ station
  • the access to equipment and other objects which may be used as weapons towards others
  • the selection of control measures for managing the patient’s violent behaviour such as medication, restraint and/or the appointment of a security special.

An incident that was foreseeable

NSWNMA President O’Bray Smith, says: “You have to ask the question of whether the incident was foreseeable when there were two previous code blacks.”

“The special should have been someone who had done the training. I think at a very minimum you would have expected a nurse with mental health training to be looking after her. Someone who knows de-escalation, who is more aware of an escalating patient.”

O’Bray says the nurses deserve the highest praise for their bravery and selflessness during and after the attack.

“Once the incident was over the patient was banging her head against the floor. Even though she had just attacked them, they just turned around and went to help her and to stop her from harming herself.

“It’s a testament to how they coped that straight away afterwards they were looking after the patient,” she said.

O’Bray says there are many lessons to be learned from the incident.

“I’ve heard that at other hospitals they put patients like that on the mental health unit and have an RN with them from medical or surgical as the special rather than putting them on a medical ward and having an AiN special them.

“In a lot of incidents the after-hours management or the staff are blamed but when the ‘F’ word applies to recruitment and there are overtime bans how can we expect them to provide the necessary care?”

O’Bray says that since the then-health minister Jillian Skinner initiated a roundtable on hospital violence in 2016 the issue has been neglected.

“I think the initial response was really good. We had increased security. I’d have to applaud the security department at RPA. They are exceptional. They are fantastic with patients. They respond quickly. But I don’t think that has happened across NSW.

“As for training the staff – I haven’t done it and I don’t think many staff have. It has just fallen over. When you have a large hospital, with a large ED, mental health wards, plus a massive neuro and maternity – you have high-risk areas and just having extra security isn’t enough.

“I think the roundtable was good in theory but I haven’t seen what really came out of it apart from more security.”

The system failure that led to a multiple stabbing attack at RPA

After clearly escalating behaviour from the patient – with two code blacks – an AiN from an agency rather than an RN was allocated as a special.

  • Of the three nurses injured two were new graduates and one was an EN, which raises concerns about the level of experience and appropriateness of skills mix on the ward at the time.
  • Despite the known aggression risk, no personal duress devices were issued to staff working close to the patient, with only a fixed point alarm available on the unit, not readily accessible from the patient’s room.
  • The duress alarm only alerted security and not the other nurses working in the area.
  • There was insufficient training for the nurses working with patients with a high incidence of aggression: no practical de-escalation, breakaway or restraint training.
  • There was no appropriate system for managing scheduled mental health patients with physical 
health needs.

Special Dangers

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The specialling of mental health patients using staff without appropriate training is fraught with risk. 

The stabbing attack at RPA  highlights many of the safety risks to nurses and patients arising from the use of specials.

The use of nurses with insufficient training to care for patients with mental health issues and deficiencies in the documentation that would allow management to identify the appropriate skills needed for an aggressive patient requiring specialling are critical issues identified by the NSWNMA arising from the attack.

The Association also believes, more generally, that there needs to be a ban on the use of specialling within numbers, which pushes nurse-to-patient ratios into unsafe territory.

NSWNMA General Secretary Brett Holmes says there is enough information in both Sydney LHD and NSW Health policies to demonstrate “that it is inappropriate for an AiN to be used as a special for an acute mental health patient with a risk of aggression”.

“The Association has serious concerns that the “special” allocated to provide care for the patient at RPA was an Assistant in Nursing from an agency,” he said.

“The Association does not support the use of AiNs as patient specials where a risk of violence to others has been identified, particularly where this risk is arising from patients who are acutely mentally unwell, or have significant cognitive deficiencies including acquired brain injuries, intellectual disabilities, dementia or delirium.

“The use of an AiN as a special, in this instance, was highly inappropriate.”

LHD policy on specialling states that: “Consideration of nursing skills mix and relevant clinical competencies is required when selecting staff members to provide safe and effective observation and nursing care”.

The NSW Health AiN job description refers to AiNs are only to be used for certain duties as outlined in the policy and in accordance with the acute care environment health service implementation package.

“It is difficult to see how the LHD can argue that an AiN has appropriate knowledge and skills to provide care for an acutely unwell mental health patient, particularly given that there is no requirement to undertake any mental health training as part of an AiN’s Certificate 3 course,” says Brett Holmes.

He says there is a “glaring” problem with the form that is completed to request a patient special and for 
the daily review of the need for a patient special.

“The form does not clearly indicate aggression as a reason for requesting a special. This limits the information available to nursing administration to make the decision about the appropriate allocation of a person to this role.”

Specialling blows out nurse-to-patient ratios

The scale of specialling within numbers is also impacting on patient and staff safety.

According to data gathered by the NSWNMA, Royal Prince Alfred Hospital had 99,086.5 hours of specialling in the 2017-18 financial year.

52,364.5 hours were within numbers. Based on an 8.5 hour shift this means 6160.5 shifts were specialled within numbers in a year or around 16 shifts per day.

Tara, a midwife at a large Sydney hospital, says specialling within numbers becomes dangerous when the nurse-to-patient ratio blows out when a staff member is allocated as a special.

“Specials in numbers don’t work. You need an extra staff member to special the patient. If a patient requires one-to-one care they should be able to receive one-to-one care but not to the detriment of other patients.

“Often when we get an additional staff member it is someone who does not have the requisite training to be able to safely special a patient.”

‘Every patient deserves the right to excellent, timely and safe nursing care.’

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‘Specials put a huge load on what is already a very busy, high-stress department.’

“Every patient deserves the right to excellent, timely and safe nursing care. As a senior nurse I sometimes feel we are letting people down due to staffing constraints,” says Sabrina Sharp, NSWNMA delegate at Royal Prince Alfred Hospital.

An emergency nurse, currently on secondment to another department, Sabrina strongly supports the union’s push to introduce nurse-to-patient ratios in hospital emergency departments.

“The union’s claim is for a 1:3 ratio in EDs, plus a triage nurse and an in-charge nurse. We feel our patients are entitled to that level of care,” she says.

“Currently the ED can have two nurses looking after over 30 people in the waiting room. Some of them should be in beds on monitors but because of bed block there is nowhere to take them.

“The ED never closes its doors. When we are full we are still taking ambulances and attending to increasing numbers of walk-ins. Inadequate staff numbers force us to prioritise people who are in pain, distressed, and need timely treatment and other interventions. It seems like we’re juggling a lot of the time.

“Elderly people could be sitting in the waiting room for hours because of the acuity of other patients who don’t stop coming through the door. And if we don’t have appropriate staff numbers those patients can face lengthy delays to treatment.”

Sabrina says ratios would help to protect the ED skill mix by reducing high staff turnover partly due to some staff leaving in search of less stressful roles.

“The ED gives nurses great opportunities for education and our senior nurses are highly trained.

“The nurses in ED are very passionate about their work and are motivated by their desire to help people.

“Losing them is so wasteful because it’s a huge cost training people to a high level.

“And our junior nurses can’t properly learn if there are too few senior nurses to guide them.”

Sabrina says ED nurses now perform certain tasks previously attended only by medical staff. This was aimed at improving both the flow of ED and outcomes for patients.

“We enjoy working at a high level and it benefits the whole department, but if we’re getting bogged down by sheer numbers we’re not able to do that.”

The NSWNMA claim calls for additional nursing hours to be allocated when a department provides ‘specials’ for patients who require one-on-one care.

“Specials are needed every day and if we have 20 nurses at the start of a shift and three end up assigned to specials, it puts a huge load on what is already a very busy, high-stress department.

“Our staffing claim is based on achieving positive nursing environments where nurses feel they can always deliver the safe and timely care our patients deserve.”

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‘It’s not right that smaller country hospitals are still fighting to get what we have.’

Westmead Hospital’s midwifery service benefited from staffing increases achieved through Birthrate Plus, a staffing tool for maternity services won for major hospitals in the union’s 2011 award negotiations.

In 2014, Birthrate Plus achieved a 29 per cent staff increase across the birthing unit, maternity ward, antenatal clinic, and home visits service of Westmead, the state’s second biggest maternity hospital.

Westmead midwife Joanne Robertson, the hospital’s branch secretary and delegate, says it is now time to support the union’s current award claim for guaranteed staffing arrangements at non-Birthrate Plus maternity services.

“The state government must fund smaller hospitals and services to employ adequate staff so that all women and babies across NSW get the care and education they need,” she says.

After 2014 Westmead’s staff ratios and skill-mix gradually eroded until the gaps were filled by recent recruitments based on Birthrate Plus calculations.

“Before the recent intake it wasn’t uncommon to find three or four assistants in midwifery under the supervision of one midwife looking after 41 women and babies.

“Due to the shortage of midwives we had to get assistants in nursing, endorsed nurses and registered nurses from the casual pool to replace people on sick leave.

“A lot of our recent recruits are new midwives and 3rd year bachelor of midwifery students employed as AiMs.

“So it’s quite common to be the only senior midwife on afternoon shift in a full ward.

“Fortunately, the hospital has just employed an after-hours educator to cover the maternity and antenatal wards on afternoon shifts, which will help take a bit of pressure off the staff.”

“The increasing acuity of patients makes it more important to guarantee safe staffing of all hospitals across the state. It’s not right that smaller country hospitals are still fighting to get what we have.”

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Government neglecting the bush

“Our patients should be entitled to the same level of care as patients in the big city hospitals, but the state government doesn’t seem to care about the bush,” says Gunnedah District Hospital registered nurse Heather Franke.

Heather, acting secretary of the hospital’s NSWNMA branch, says the government’s refusal to extend nurse-to-patient ratios to small regional hospitals disadvantages her patients.

“Extended ratios would help to overcome the serious, long-term under-staffing that puts the safety of both patients and nurses at risk.”

The hospital serves Gunnedah’s 10,000 residents plus workers at area mine sites. Heather works in the emergency department and 25-bed general ward.

“In ED we only ever have one RN on each shift and at night that person has to cover both the ED and general ward. And sometimes you’re designated in charge of the hospital as well.

“When you’re working in ED at night you might not get down to the ward until 3am. Usually that leaves just two endorsed enrolled nurses unsupervised on the general ward.”

“When we ask for another RN for night shift, management offers to reassign someone from elsewhere, which is not what we want. We want to gain a staff member, not lose one from some other part of the hospital, which is also understaffed.

“Morale here is pretty low but the situation is not well known in the community. We are about to start a campaign to tell local people what’s going on. It’s important to get them onside.”

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