July 3, 2022

RPA

RPA nurses and midwives rally for safe staffing

by Leave a Comment

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

by

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

by

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.”

It’s time to improve ratios

by

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.”

ratios2 600

 

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

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

by

‘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.”

_61R5585

‘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.”

_61R5741

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.”

_61R5623