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2011 – the issues
In the run up to an enterprise bargaining agreement each side creates a log of claims – the ANF’s claims are based on motions from representatives at the preceding years’ Delegates conferences, where job reps from around the state meet, raise, discuss and vote on proposals. These might centre on a need to change staffing to reflect a change in acuity, or the addition of a new or revised condition – for example, the option to gift sick leave to a colleague. Periodically a proposal that job reps pay reduced membership fees is raised, and voted down – we want to retain reps who are primarily interested in the best interests of the membership as a whole.

The government has its own log of claims, which are usually submitted three or four months prior to the expiration of the agreement and  which are generally less expansive than ANFs’ both in terms of content and form. That said, this time around they were more bald than I’ve seen previously, with such useful entries as “review ratios”. This was part of a larger strategy (see “duplicity” below).

I imagine that ANF was prepared to defend the ratios yet again. What was new were the proposals to introduce minimally trained staff, and to dramatically reduce staff hours – the refrain to which VHIA (the government’s negotiating agent) continually returned was ‘flexibility’. So why were these aspects important?

Ratios
I’ve previously discussed the significance of ratios in terms of both improved patient outcomes (fewer complications, better care, shorter hospital stays) and workforce benefits (less burnout, lower turnover, improved overall retention, the return of former nurses to active practice). I don’t expect governments to care about happiness, job satisfaction or professional development, though it would be nice if they were considered important. However, on both fronts these results mean cost savings to government.

The nursing budget comprises a significant portion of all hospitals’ running costs, and therefore a source of temptation for governments looking to reduce operating costs. The nursing budget is high because nursing care is the primary reason for admission – patients who can manage without nursing care are treated as outpatients. There is a 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 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. For a broader view of the benefits of ratios see here; Curtin provides a great overview of the research around improved outcomes and a skilled workforce, which brings me to the second spear in the government’s attack.

Skill mix
The government strongly endorsed the introduction of aides (variously titled health care workers, patient care attendants or nurse aides) into Victoria’s acute hospitals, and would count them in the ratios. While the government publicly professed that they would retain current ratios, even going so far as to state that they aimed to employ additional nurses across the state, including the acute care sector, and to invest in retention and recruitment programs, this was quite clearly in the name of public relations rather than a statement of intent.

As I wrote to the Health Minister’s Executive Director during the campaign, I suspected we had quite different ideas about what the retention of ratios means in practice, and possibly their understanding of the definition of “current”. At present the ratios, which I will for the purposes of clarity and brevity 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.

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. I have been privilege in my career to thrice been the sole recipient of a disclosure that my elderly patients were the victims of childhood sexual abuse – each disclosure was made while I assisted the patients with hygiene care, and each time it was some way in to the therapeutic relationship, after the development of a strong rapport. This does not happen when care delivery is fragmented – such as 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.

That’s the patient side of things – for practitioners, the other key sticking point was that we would be legally responsible for the actions of these people who had a few months training and no accountability.When I supervise a student, she or he is responsible for their scope of practice – I have some accountability and oversight, but if Jo decides on her own and without my consultation to give Mr Brown paracetamol he wasn’t prescribed then she is responsible for his anaphylactic reaction or worsening liver function, not me. Under the VHIA proposal, if an aide did the same thing, I would be legally held responsible. So to that members said, with one voice, no.

Hours and staff deployment
The final ‘flexibility’ measure was a joint proposal – first that nurses could be redeployed, without notice, and even in midshift, not just to other wards and departments but also to other hospitals within the same network. We can set aside the effect this would have on patient continuity (which in itself increases the likelihood of avoidable complications), on the workload of the colleagues who would be taking over our abandoned patients, and on nursing satisfaction.

This proposal clearly demonstrated that the VHIA, with whom we were negotiating, saw nurses as interchangeable pieces with minimal specialist skill, and I believe this explains a lot about the opposition we received throughout. I received a comprehensive general education – the change in education in the interim means that few if any recent graduates would have the same breadth of experience, because I rotated through every ward and department at my hospital, as well as specialty rotations in pediatrics, midwifery, ICU, theatre, emergency, psychiatry, community health, and district nursing.

These experiences were invaluable for two reasons – they informed my cureent practice, and they allowed me to know early on which areas I enjoyed (medical nursing) and which I did not (theatre, pediatrics). They did not equip me to work in those areas twenty years later. Yes, I could provide care for a child, a burns patient, or an emergency patient. But those people would not receive the same care as they would from a nurse who specialised in those areas, and in some cases my lack of expertise and knowledge could result in death or avoidable complications – I don’t know how to read variations in cardiac telemetry, what to look for in a patient fresh from neurosurgery, or how to delivery cytotoxic chemotherapy.

In addition, VHIA proposed the introduction of unlimited short shifts (as little as four hours) and split shifts – where a nurse might work for four hours in the morning, go home (or somewhere) for two, four or six hours, then return to the ward for another few hours. Split shifts were outdated in the seventies, when nurses still predominantly lived onsite.

Duplicity
The Health Minister, David Davis, denied in December that split shifts were suggested , but he had little believability – in May 2011 he submitted a Cabinet-in-confidence document, later leaked to The Age, where he and his department recommended trying to force ANF into compulsory arbitration – under the current industrial relations legislation that meant there would be no possibility of shift length, work load (the ratios) or skill mix (the introduction of aides) into the EBA.

Two months later he told nurses that the Liberal government was committed to fair negotiations, and to ratios; six months later he was telling the public the same thing, though his recommendations included slashing $104 million dollars from the states nursing budget  – the equivalent of over 1700 full-time jobs.

Other proposals in the document included a suggestion that the government’s log of claims be “publicly presented in a broad manner so as to be as small a  target as possible for inevitable ANF criticism, but still position employers for any arbitrarial proceedings that might eventuate” (point 18).

Lisa Fitzpatrick can articulate the nursing position far better than I – here’s a clip of her address to a group of nurses and community members in Colac: