On November 20th last year I sent the Health Minister an email, expressing my concern about the lack of progress toward a mutually agreeable EBA. This morning I received a (generic) response from the Executive Director of Finance and Corporate Services. In this response I was assured that the government’s committed employing more nurses and midwives, that they “support nurse-to-patient ratios in their current form” and is investing in programs to recruit, retrain and attract nurses into the public sector (one assumes midwives, too, but they weren’t mentioned).

I don’t expect to hear back a second time, but I did want to express my concerns about the specific issues we have with the government’s proposal – if nothing else, at least someone may read it in cyberspace:

Dear Ms Kalcovski,

thank you for forwarding the Executive Director’s letter responding to my email to Minister Davis regarding the Victorian nurses’ EBA. As Mr Wallace did not include his email address I ask that you forward my response to him.

I am delighted to learn that the Victorian Government’s aim is to employ additional nurses across the state, including the acute care sector, and to invest in retention and recruitment programs. I am also overjoyed to read that the Government supports the current nurse: patient ratios. I suspect, however, that we have quite different ideas about what the retention of ratios means in practice, and possibly your understanding of the definition of “current”. At present the ratios, which I will for the purposes of this email assume to be 1:4 (while recognising that different hospital categories, clinical areas and shifts have different ratios), apply to the number of patients each nurse has. Maintaining the current ratio system therefore means the retention of six clinical nurses, plus a supernumerary nurse in charge, for every twenty-four patients. Any proposed alteration to that – be it the replacement of one nurse with a minimally-trained worker, or the removal of a single nurse for a portion of the shift – does therefore not support current ratios.

I certainly understand that the nursing budget comprises a significant portion of all hospitals’ running costs. This is because nursing are is the primary reason for admission – patients who can manage without nursing care are treated as outpatients. I am sure you are aware of the large, overwhelmingly unanimous body of local and international research that clearly links a decrease in the education and experience level of bedside care with an increase in falls, pressure injuries, iatrogenic infections, pneumonia, medication errors, clinical errors, failure to escalate care in the deteriorating patient, ICU admissions, preventable re admissions, morbidity and mortality.

In one study (Aiken et al, 2002) each additional patient assigned to a nurse resulted in a 7% increase in both 30-day patient mortality and failure-to-rescue rates, a 15% increase in job satisfaction and a 23% increase in nurse burnout. Increasing nurses’ workload for four patients to eight increased the likelihood of death within 30 days of admission by 31%. Atencio et al (2003) estimate a cost of US$92,000 to replace a general nurse and up to US$145,000 to replace a specialist nurse – these figures are nine years old, but even ignoring inflation and differences between the US and Australian systems, that’s a lot of money that could be saved by reducing burnout and dissatisfaction.

Patient care workers are not nurses. Perhaps 80% of the tasks that I do could be performed by someone with minimal training – I could, for example, teach you how to perform a bed bath in around an hour. However, the tasks are less than 50% of my role; the rest is assessment and the utilisation of education and experience. When I perform a bed bath I am not just washing my patient – I am assessing their skin, the condition of their heels and occiput, looking at the integrity of dressing, whether there is a positional increase in flow from drains, assessing ease of movement and non-verbal indicators of pain, comparing how well the patient is able to assist in their care now versus last week, noting positional orthopnea and exertional dyspnoea, assessing affect, and watching for postural hypotension when the patient is returned to a sitting position. I am, at least as importantly, also creating a unique space for the patient to talk – washing is a time of vulnerability and intimacy, often the only uninterrupted time the patient has, and very often when patients will ask questions or disclose information essential for their care and recovery. This does not happen when care delivery is fragmented, when the hygiene is performed by an aide as a task rather than by a nurse as part of holistic care.

Though the aspects I’ve discussed are important for the comfort and well-being of the patient, they are also of significant clinical use. For example, observing pain on repositioning means better analgesic coverage, which means an increased ability to move, which in turn reduces rates of deep vein thrombosis and chest infection, both of which significantly affect length and therefore cost of stay.

Nursing is not about tasks, though there are certainly tasks that need to be performed. Good nursing care – care that promotes patient welfare, shortens hospital stays, reduces preventable re-admissions and meets patient needs – is holistic and coherent. It meets the physical, clinical, psychosocial and spiritual needs of the people at the centre of our health care system. Patients who are critically ill, and that’s an increasing percentage of acute sector inpatients, need frequent assessment by skilled staff who are able to detect small but significant indicators of deterioration. In acute care there is no such thing as a low-priority task that can be performed by someone without the necessary background and education.

I have trouble believing that a Government that doesn’t understand this can truly respect the work we perform. I also have difficulty believing that VHIA is interested in negotiating in good faith when the Minister’s Cabinet-in-confidence document from last May unambiguously stated an aim of driving us to mandatory arbitration rather than a mutually agreeable, negotiated outcome. I truly hope that my concerns are misplaced, and that the new year sees a change in approach from VHIA, the Minister, his Department and the Government – one that acknowledges the work we do, and that recognises the undeniable evidence that reducing ratios, introducing minimally-trained aides, fragmenting care and altering hours will not only negatively affect patient outcomes but also increase health care costs. I will be watching the return to negotiation next week with interest, and close attention.

Sincere regards,

Tara Nipe
Clinical Nurse Specialist
Grad. Dip. BioEth (Monash), MHlthEth (Melb.), MSocHlth (Melb.), PhD candidate (Melb.)
Alfred Hospital