1986 – 2000: from The Strike to ratios
In 1986 Victorian nurses went on strike for fifty days – it was only the second time nurses here had done so – the first time, for five days in 1985, was part of the same campaign, though nurses didn’t realise it at the time. I was in my final year of high school and, though I was aware of the Strike at the time, it wasn’t until I began my training in mid-1989 that I began to understand it – the Strike formed a substantial part of our history of nursing studies, and it was recent enough that many of my instructors, Charge nurses, registered nurses and advanced students had taken part or been affected. There’s an excellent overview of the Strike here.
When I began on the wards our staffing was based on a daily patient dependency score that weighted factors like the age of the patient, linen changes, frequency of observations, and complexity of dressings to arrive at an aggregate that measured patient care hours over a full day – an 18 bed ward might have a couple of category 1s (essentially ambulant and self-caring), seven or eight each category 2s (some IV medications and a dressing) and 3s (ambulance with assistance or a hoist, four-hourly observations, an extensive dressing) and one or two category 4s (bed-bound, full care, a tracheostomy, frequent medications, incontinent).
The scoring was unavoidably retrospective, and staffing was based on scores from the month before. If your ward was particularly light you could be sent to another ward with heavier needs, sometimes mid-shift but usually at the beginning of the shift (students were almost always sent over registered nurses, and the individual was determined either by who arrived last or, on fairer wards, by consulting the sent book to see who’d had longest without being sent).
After I was registered the dependency calculation slowly faded away, and effective full-time (EFT) staffing was based on an opaque assessment of the ward specialty and typical patient load – when the ward seemed particularly heavy and we were missing tea breaks or running relentlessly we’d be told that we were “at EFT” however it felt on the floor. Sick leave wasn’t always replaced, and I clearly remember a night in the late ’90s where another RN and I, along with an agency enrolled nurse (pre-medication endorsement, who had only ever worked in an aged care facility, and could only help with bed turns and changes) cared for 26 patients without a break and without even enough time to check drugs with each other – something that was then against hospital policy, if not illegal. It was purely thanks to good luck there wasn’t a tragedy.
In 2000 the then-secretary of the Australian Nursing Federation, Belinda Morieson, spearheaded a campaign that resulted in the world’s first nurse/midwife: patient ratios – instead of flawed patient dependency systems determining how many patients nurses were allocated, a transparent ratio (based on hospital status, ward type, and shift time) meant that a maximum safe number of patients could be allocated to nurses or midwives.It’s often simplified to “1:4 – one nurse for four patients” but that’s not quite the case. On the general wards of a class one hospital (like the Royal Melbourne or the Austin) plus a supernumerary in-charge nurse and five nurses are rostered for twenty patients (six for twenty-four etc) on a day shift, but the actual allocation of patients is dependent on skill mix and patient acuity, so one nurse might have six stable patients while another has one very sick patient and an ambulant, self-caring patient (this last is something of a unicorn in the current system).
That means that a tertiary metropolitan hospital has different ratios than a small rural hospital, that nurses on a rehabilitation unit have more patients than nurses in coronary care, and that there are fewer nurses on night shifts (and, in some places, afternoon shifts) than on mornings.
Instead of feeling overloaded and unable to meet patient needs, but being told that we were adequately staffed, it was now easy to see if we had sufficient nurses for our area. The dramatic fall in nursing numbers precipitated by the Kennett government’s health care “reforms” took some time to reverse, but eventually Victorian nurses and midwives came back to full strength – wards were no longer reliant on casual bank and agency staff to meet daily staffing shortfalls, which resulted in more consistent standards, less cost, and continuity of care.
Thanks to ratios Victoria does not have a nursing shortage, experienced nurses have been retained and even returned tot he system, and our patient outcomes have improved, but it has not come without a cost – as I will discuss tomorrow