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ADC - Nurse to patient ratios - ‘If we could do it so can you’

Judith Kieja rallied the ADC with a passionate account of how nurse to patient ratios were won in New South Wales. Tara Horan reports

“Safe staffing has been a huge issue for many years in Australia, just as in Ireland,” Judith Kieja, acting general secretary of the New South Wales Nurses and Midwives Association, told ADC delegates.

It took a decade for the association to achieve but in February 2011 mandated nurse to patient ratios were finally introduced in public hospitals in NSW, Australia. The state joined its neighbouring state of Victoria, and California in the US, as the only states in the world to achieve mandated nurse to patient ratios.

Addressing delegates, Ms Kieja drew many parallels between the campaign for safe staffing ratios fought in NSW and the campaign that the INMO is embarking on.

As well as the mandated staffing levels, the NSWNMA also won strong pay increases, following negotiations with an “intransigent government” that had said there was no money to fund any extras for nursing in the then economic climate.

In late 2009 the members had told the association through focus groups that staffing issues were hopeless, nothing could be done and there was no hope of any improvement. “I had never seen our membership so dejected”, she said.

“For the previous decade the association had tried many ways to deal with workload, including workload measurement tools, very strong award language, the committee approach, the documentation approach and, although there were small wins along the way, they weren’t consistent and they weren’t mandated.

“The union knew it was only member action that could change this dire situation. We commissioned academics to research the staffing situations, just as the IN MO is doing, and find out from nursing unit managers what staff they thought was necessary to provide safe care,” Ms Kieja said.

Following this, the NSWNMA formulated its claim, articulating what was needed to provide safe care in every healthcare setting. The claim was in three parts: pay; working conditions; and a comprehensive claim on nurse to patient ratio for medical and surgical units, palliative care and rehabilitation units, emergency departments, mental health, operating rooms, maternity units and community health services.

Once the claim was submitted, the campaign began in earnest. This included: a roadshow visiting as many facilities as possible across the state; information sessions; workplace lunchtime rallies; and postcards and leaflets to backup the campaign and to garner public support for the cause.

“It was very important to influence politicians. They needed to understand that this was a state-wide issue and therefore affected their constituents. We provided information packs and organised forums for MPs and backbenchers so that they could understand our claim and the necessity for it to succeed if NSW Health was to provide safe care,” Ms Kieja said.

The NSWNMA also ran radio, TV and newspaper advertisements. It encouraged members to write letters to the editor and to call talk-back radio programmes.

Delegates applauded one hard-hitting TV ad, with the voice-over: “In Victoria, hospitals have official ratios of one nurse to every four patients. But in NSW, hospitals have no mandatory nurse staffing levels at all. That’s bad for nurses and worse for patients.” Dubbed the ‘buzzer ad’ by the public due to its succession of unanswered hospital buzzers, this ad called on the public to join nurses in sending a message to State government.

Vote to strike
In October 2010 the government responded to the NSWNMA wages claim, but rejected the conditions claim and ignored the ratios claim, said Ms Kieja. “Members were incensed. They simply couldn’t understand the intransigence of the government. So they voted to strike.”

As they provide an essential service, nurses are not allowed to strike in NSW. The government went to the Labour Court, which made a strong recommendation to the NSWNMA not to strike. However, the association took the decision to defy the Labour Court recommendation. The court then ordered the NSWNMA not to strike and the association defied that also, Ms Kieja said to the applause of delegates.

On the strike day, nurses filled the state stadium to capacity. “They came from all over the state. At the strike, a resolution to escalate the campaign was passed because no one day of action is going to shift a government. We had to have a strategy that was really going to hit them,” she said.

Members passed a resolution calling for beds to be closed and community health services across the state to be reduced if government failed to make an offer worthy of member consideration.

“After the strike day the government finally understood that nurses in NSW were passionate about ratios and safe patient care, but even then the government would not give NSW Health the authority to make an offer,” Ms Kieja said.

Discussions dragged on and under the industrial system unions cannot negotiate while there is any threat of industrial action, she said. The association worked on training members how to close beds if there was not sufficient staff to provide safe care. “Members were getting very eager to put this into place,” she said.

Unimpressed at the tardiness of NSW Health and the government, the Industrial Relations Commission gave them a deadline to provide an offer covering all the demands, Ms Kieja said.

“However, they defied the order. Enough was enough. Our members decided if the government wouldn’t provide enough nurses to deliver safe care then they would close inpatient beds and reduce community health services so that the resources they did have would provide safe patient care. On January 4, 2011 facilities right across the state, from major tertiary referral hospitals to tiny health outposts, started to close beds as patients were discharged.”

Within a week, 600 beds were closed across the state, along with some community health service reductions. There was a huge media response.

The bed closure strategy was a big risk, said Ms Kieja. The NSWNMA supplied a handbook to every member so that they understood all the rules on bed closures. The idea was to have enough staff to care for patients properly. There were exemptions – beds could not be closed on oncology or palliative care wards, dialysis units, maternity or paediatrics wards, EDs, ICUs, CCUs and HDUs.

One in four non-urgent community health home visits or clinics, and one in four elective surgeries, were also cancelled. “The handbook detailed everything about how to close a bed, including how to handle management intimidation, of which there was a fair bit,” Ms Kieja said.

“The members loved it. They went from not thinking they could do anything, to not wanting to stop, because they were able to give the care that patients needed.

“The government was adamant there would be no ratios. They couldn’t even say the ‘R’ word. They said ratios were too inflexible, too expensive and too hard. We were equally insistent that we needed a staffing mechanism that was simple, transparent and enforceable. Nurses needed the certainty that when they arrived on duty, the staff that they required to deliver the care that was traditionally needed on that particular unit was already rostered on. And if a staff member was sick, they were replaced because mandated staffing means that you have to have the whole number there before the patients are there.

“After long negotiations, the government finally made an offer built on nursing hours per patient day, which converted to a ratio. They told us how many hours they wanted us to have and we kept upping them until we got to the ratio that we wanted of one to four,” she said. The negotiating committee designed a tool to convert ‘nursing hours’ to the ratio of one to four.

However, this wasn’t good enough. The nursing hours/ratios had been granted for medical and surgical wards, palliative care and rehabilitation. Nothing was granted for ED, mental health or community health. “So it was back to the table. Members were champing at the bit to close beds again. But we were now on a timeline to get it resolved before the looming state elections,” Ms Kieja said.

Final offer
Following more protracted negotiations, there was finally an offer to put to the membership, which ultimately got a 90% yes vote from members. This offer included:

  • 9.7% pay increase over three years, backdated to July 2010
  • 1,600 FTE nursing posts, required to meet the new ratios
  • A ratio framework for medical, surgical, palliative care, rehabilitation, operating theatres, mental health, maternity and some parts of ED.

“A big thing we got was very strong language and commitment around likefor- like. So that if an RN is off sick we get an RN replacement; if an assistant is off, we want it replaced with an assistant. And if it isn’t we want to know why. That has really made a difference – having to replace like with like,” Ms Kieja said.

Unfortunately, there were disappointments for community health, nurse education and staffing in smaller, non-acute hospitals

The campaign has continued for these areas with the new conservative government, however it has been falling on deaf ears.

“The reality is that the government is intransigent on this issue and we are now making it an election issue for the 2015 campaign. The good news is the (opposition) Labour Party has agreed to make nurse to patient ratios in ED at least, part of their election manifesto,” she said.

“Members have vowed to keep fighting for ratios as long as it takes because they know, and research backs this up, that there is no other way to ensure that patients get the care that they deserve. “

One event that we use to keep the ratio campaign in the public eye was the signing up by 14 countries, including Ireland, to a charter for an international union of nurses called Global Nurses United. Securing minimum mandated nurse to patient ratios is one of the main aims of this movement.

“While we didn’t win everything we asked for, we had a really valuable win. We organised and mobilised traditionally timid members – members who thought nothing could be done, that they just had to go to work and cop it. Well you don’t have to cop it. If you stand together and use your collective power, you can make a difference.

“In this battle to hang on to the ratios and improve and extend them, we have already planned for the next phase, leveraging on the strength already built. So watch this space.

“Embedding these ratios in an enforceable award means safe staffing is now regulated in NSW and no longer subject to management whim. Ratios give nurses control, backed by law, to manage their workloads and patient safety. This new award shifts a lot of power away from management and back to nurses.

“Our union is stronger and more active because of the action members took in this campaign. You can do it,” she said, wishing the INMO every success in achieving similar advances for safe patient care.

“Remember you are doing this for your patients. A nurse’s job is to advocate for those in their care. You will succeed as no politician, try as they might, can argue against safe patient care.”

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