A clearer solution to workloads

Despite the workloads tool, nurse workloads continue to intensify in the NSW public health system. The Lamp looks at how other nursing unions have tackled this chronic problem with the use of mandated minimum staffing ratios.

The global nursing shortage is hardly news. Despite interminable discussion and policy debate no effective remedies have been found to the relentless intensification of nurses’ work that flows from this shortage.

California and Victoria have adopted minimum staffing ratios to provide a baseline for nurses’ workloads.

In both California and Victoria ratios were won after long, hard-fought battles and they appear to have given nurses more control over their working days.

Victoria’s victory

Victorian nurses won ratios during their pay and conditions bargaining campaign in 2000.

Prior to the introduction of ratios, ANF Victoria research had found nurses were stressed to the point of exhaustion. In one survey an overwhelming majority of nurses (87%) felt a high level of work-related stress.

The researchers found that nurses made a direct link between their rising workloads and staff shortages and concluded that nurses often acted as a personal buffer between quality patient care and workload pressures to uphold their duty of care.

Life in Victoria’s hospitals became very tough after the election of the Kennett Liberal Government in 1992.

Within two years of being elected, Kennett slashed permanent employment in the public sector. About 16% of the health workforce lost their jobs. Incredibly, the Kennett Government argued there was an over-supply of nurses and eliminated 2,000 nursing positions.

This slash and burn of nurses’ positions occurred during a period of steep increasing demand in the hospitals.

A report commissioned by the Victorian State Government found that the average life expectancy of men in Victoria increased from 68 years in 1971 to 77.5 years in 2001. For women, the average life expectancy increased from 75 years to almost 83 years in the same period. People were living longer without necessarily being healthier and required higher levels of nursing care.

A major impact of the Kennett blitz was a reliance on agency nurses and a distortion of the nursing labour market.

Belinda Morieson, Secretary of ANF Victoria at the time, argued that the use of agency nurses created a vicious spiral in Victoria’s hospitals.

‘Agencies were paying their nurses three times the amount of money permanent staff were getting. So more and more nurses left permanent work in the hospital and went and worked agency,’ she said.

The Government paid for these agency nurses, who ended up costing a great deal of extra money.

By the late 1990s Victorian nurses had tried for over seven years to preserve patient care and protect individual patients from the consequences of inadequate staffing by working unpaid overtime, working through rest and meal breaks and foregoing equipment and professional training in order to stay on the ward.

Formation of the 2000 ratio claim

Victorian nurses passed a motion to include award-appropriate nurse-to-patient ratios as a centrepiece of bargaining.

The ANF argued that ratios were a worker retention issue that had positive financial ramifications, citing the cost to the system of hiring agency nurses.

The ANF said the use of agency nurses was driving committed permanent nursing staff to leave the health sector completely and this would undermine the professional integrity of nursing and the supply of nurses overall.

The ANF included a cap on the use of agency employment across the sector in their campaign.

When the ANF put its case to the Australian Industrial Relations Commission, the testimony from nurses about their workloads was so dramatic and compelling that even employers began to acknowledge the need to address the issue of workload and its influence on nurse professionalism and patient safety.

The ANF convincingly argued that a system-wide problem of work intensification called for a system-wide solution.

The ANF also developed a strong economic argument: if you don’t resolve the workload issue you’ll have nothing but agency nurses in this State and they are costing you three times as much. You put in ratios and it will cost you less and you’ll get a more stable workforce.

Even a key witness for the employer conceded that, ‘It is a source of some concern that in the year 2000 we still have not come to grips with a proper measurement of workload at the patient level so that we can’t bring those sort of facts to the debate.’

Walsh essentially acknowledged that hospitals had changed the work environment without seriously considering the impact of these changes on their largest workforce: nurses.

The ANF campaign was underpinned at all times by ongoing industrial action and work bans to continually remind the public and employers of the importance of staffing and workload issues (see box on page 22).

On 31 August 2000, the AIRC ruled that nurse-to-patient ratios represented the most effective response to both the workload and staffing crises facing the Victorian health sector.

Belinda Morieson said the decision gave back to Victorian nurses much of what they had lost during the Kennett years and more.

‘We got additional nurse educators, we got additional senior nurse clinicians, we got qualification allowance if you went back to university and got additional qualifications. We got additional night duty allowance. We got study leave paid, and seminar leave. It was extraordinary.’

The political context

The election of the Bracks Labor Government in 1999 created the political opening for the introduction and implementation of ratios.

The newly-elected Victorian Government agreed to fund the nursing positions required to comply with the outcome of the arbitration proceedings. Once wages and benefits were settled, the Government had to set aside money to pay for enough staff to fill the ratios.

This money is earmarked for nursing and nursing alone and cannot be raided by other hospital departments or other clinical disciplines.

In 2000, therefore, the Government allocated $198 million to fund the ratio positions. In 2001 it became clear the Government had not set aside sufficient funds to meet the ratios. The Government then set aside another $300 million to fund the ratios.

The advantages of ratios 

  • They remove uncertainty: management can no longer keep beds open on the promise of getting more staff when needed.
  • Nurse to patient ratios ensure there are adequate numbers of nurses on the roster six weeks in advance.
  • Nurse-to-patient ratios were fully funded by the Victorian Government so they gave DONs the budget to provide safe staffing levels.
  • They help break the reliance on expensive nursing agencies. Ratios mean nurse numbers are compulsory but they still have flexibility for judgement in determining appropriate levels of care.
  • Ratios mean better patient care and the ability to recruit and retain nurses.

A tough, organised, disciplined campaign

There was a perfect storm of factors in Victoria that led to the winning of ratios. There was the backing of key stakeholders. The Steve Bracks-led Labor Government was necessary to fund the staffing of ratios; the media also played a key role as did the general public.

A critical fact that influenced the ratio outcome was the degree of public despair over the failing health system. Another key factor was the nursing labour market conditions in Victoria with a nursing shortage in every part of the Victorian health system.

But by far the decisive element was the campaign waged by Victorian nurses through their union.

Victorian nurses can now control their workload and regain their sense of pride in their ability to deliver highly-skilled care to the community. This revolution is in part due to the solidarity of Victorian nurses who committed themselves to the ANF campaign and fought strongly for mandated staffing numbers.

In short, the campaign was about creating a sustainable public health system and promoting professional renewal.

ANF Victoria Secretary Lisa Fitzpatrick says nurses used ongoing industrial action and work bans to continually remind the public and employers of the importance of staffing and workload issues.

The campaign was structured around preserving the integrity and renewing the professional aspirations of the nursing profession.

Bed closures as an effective tactic

During the Kennett years, ANF Victoria honed its tactic of bed closure as a weapon of industrial action.

‘It’s an easier way of taking industrial action than it is to strike. You still achieve an outcome – it certainly brings the message home to the management. But it doesn’t put nurses or the community through the terrible emotional trauma of having to take the ultimate [strike] action,’ said Hannah Sellars, Assistant Secretary ANF in the 1990s.