July 2, 2022

royal prince alfred

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 The NSW government’s current preferred staffing model is outdated, unsafe and frequently fails to deliver the right number of nurses needed on every shift.”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.

It’s time to improve ratios

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Government-employed nurses across NSW have voted to campaign for greater quality and equality in public health services.

One hundred and seventy seven NSWNMA branches overwhelmingly voted ‘yes’ to endorse the union’s 2017 ratios and pay claim.

The claim puts nurse-to- patient ratios at the forefront of our 2017 campaign.

NSWNMA General Secretary Brett Holmes said the vote reflected NSW nurses’ deep concerns for patient safety due to understaffing.

“Our claim seeks to extend nurse- to-patient ratios to health services that still don’t have them,” he said.

“A lot of regional and rural hospitals were not included when the union’s first ratios campaign won mandatory ratios for many units of metropolitan and rural hospitals in 2011.

“Also not included were specialty areas such as emergency departments, units for paediatrics, intensive care, high dependency and neonatal intensive care, community nursing and community mental health nursing.

“All are crying out for a safer clinical working environment for both nursing staff and patients.”

“We aim to bring staffing levels in non-tertiary hospitals up to the same level as tertiary referral city hospitals.

“This would ensure patients receive the same level of care regardless of where they live or are treated.”

No improvements in hospital staffing since 2011

Brett said the campaign also focuses on services that have ratios but are being undermined by measures such as replacing registered nurses with lesser-qualified nurses and failing to allocate additional nursing hours to patients who require specialised one-to-one care.

“Short-sighted attempts to cut budgets by employing lower skilled staff result in higher rates of hospital-acquired infections, adverse events and failure to rescue. Evidence-based academic research has proved this repeatedly.

“Likewise, the pressure to make do without additional nurses is unacceptable and unsafe.

“Patients clinically assessed as requiring a special should not have their care compromised.

“Too often ‘specials’ are not provided, or lower-skilled classifications are used.

“It is clinically inappropriate for specialised care to be within rostered nursing hours because it takes time away from other patients.”

He said the government had done nothing to improve hospital-staffing ratios since the union’s 2011 win resulted in the employment of more than 1800 FTE nurses.

“Year on year, we have lobbied the NSW Coalition government for improved and expanded ratios, but the government has stubbornly sat on its hands.

“With budget surpluses forecast over the next four years the Berejiklian government can afford to give residents of NSW safer ratios.

“The evidence is clear that better ratios save lives and there is no reason why the NSW government should be lagging behind Queensland and Victoria.”

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Our ratio claims

Under the public health system award, Peer Group A medical and surgical wards are currently staffed at 6 nursing hours for each patient per day.

That is equivalent to ratios of 1:4 on morning shifts, 1:4 on afternoon, shift and 1:7 on night shifts, with some shifts including an ‘in charge’ nurse without a patient allocation.

This year we are calling on the state government to extend the same level of nursing care to patients at all Peer Group B, C and D hospitals, as well as the acute beds of Multi-Purpose Service facilities throughout NSW.

Ratios must also be extended to speciality units such as emergency departments, intensive care and high dependency units, paediatric and neonatal intensive care units. New staffing models must be introduced into community and community mental health nursing, drug and alcohol units and small birthing units.

Other states show the way

Victoria and Queensland have committed to minimum nurse-to-patient ratios in their public health awards.

They have also enshrined ratios in legislation.

Under the Queensland legislation and regulations, which take effect in July, medical, surgical and mental health wards must maintain a minimum of one nurse to four patients for morning and afternoon shifts, and one nurse to seven patients for night shifts.

Queensland Health expects to recruit an additional 250 nurses to staff these ratios and the government says it will consider whether ratios should be extended to other wards and facilities this year.

Ratios save lives

International research increasingly shows that lives are saved when hospitals employ more nurses.

Research, published in The Lancet, showed the greater the number of registered nurses, the lower the number of patient deaths.

When hospitals are understaffed, patients die, get infections, get injured, or get sent home too soon without adequate education about how to take care of their illness or injury.

The research shows:

– Every one patient added to a nurse’s workload is associated with a 7 per cent increase in deaths following common surgery.

– Every 10 per cent increase in university- educated nurses is associated with 7 per cent lower mortality.

– If all hospitals in nine European countries studied had at least 60 per cent university-educated nurses, with no more than six patients each, more than 3500 deaths a year might be prevented.

‘Special’ patients need special care

In 2017 we want the Berejiklian government to accept that staffing for patients clinically assessed as needing  a ‘special’ must be separate and in excess of mandated ratios or rostered staffing.

The pressure to make do without additional qualified nurses is unacceptable and unsafe.

Protect our skill mix

Our public hospital system badly needs a better skills mix to take some pressure off our most experienced registered nurses and registered midwives to guarantee patient safety. And there is an alarming lack of support for beginning practitioners in many areas.

The government can and must do more to help by funding more clinical nurse/midwifery educators – and not just on day shift.

As part of our 2017 claim we seek the employment of an additional 275 clinical nurse/midwifery educators working across seven days and all shifts.

That would help to keep transitional registered nurses in the system and working safely. It would also aid the retention of experienced nurses and midwives in the medium term.

Evidence based academic research has repeatedly shown that short-sighted attempts to cut budgets by employing lower skilled staff result in higher rates of hospital-acquired infections, adverse events and failure to rescue.

Assistants in nursing/midwifery should be used only where clinically appropriate.

Our claim calls for AiNs to be introduced only in accordance with the ministry’s own ‘2010 Health Service Implementation Package for AiNs in Acute Care’.

The government’s refusal to adopt these measures would erode the improvements nurses won in the 2011 introduction of ratios.

Things you can do

Download Ratios signs from our website http://www.nswnma.asn.au/get-involved/ratios-put-patient-safety-first/, fill them out, snap a photo of yourself or with colleagues, and send them to photos@nswnma.asn.au so we can post it on Facebook.

Like our Ratios put patient safety first Facebook page: https://www.facebook.com/safepatientcare?ref=hl

Sign up to get regular information about our ratios campaign: http://action.nswnma.asn.au/page/s/ratios-put-patient-safety-first-newsletter

Contact your NSWNMA organiser/branch official if there’s a staffing or ratios- related workplace issue you want to get active around