The orthopaedics and rheumatology ward at Royal North Shore Hospital was among the first to implement ratios in NSW and despite teething issues they are delivering positive benefits for patients and staff.
For staff in Ward 9A at Royal North Shore Hospital, Sydney, the introduction of the new nurse-to-patient ratios, won last year, has brought increased capacity for improved care and enhanced staff education.
The nursing unit manager of the orthopaedics and rheumatology ward, Rose Hills, said ratios required her to find the equivalent of five full-time nurses and ‘that is quite daunting, but has been worth it’.
It was also a challenge, to change management of existing staff, with the initial elation followed by an adjustment period then another rise in mood.
‘The recruitment process is slow in hospitals. A big bonus for the ward is we have got a lot of permanent staff and didn’t have to use a lot of casuals,’ she said. The ward now has more than 39 staff for its 25 patients covering the 24/7 of shifts.
The ward has also hired assistants in nursing.
‘When the funding for the new ratios started in July, my ward was one of the first to transition to ratios. We thought it best to recruit in preparation for ratios, so we had our own staff rather than relying on casuals. We had quite a lot of staff meetings, to decide how to make Ward 9A a much better working environment and to determine how to utilize the extra staff to maximize the benefits.’
‘The problem before ratios was that on the evening and night shifts, the nurse in charge also had to take on patient load, as well as on the morning shift on Sundays,’ Rose said.
‘I’d come in on Monday morning and the staff would be stressed, as they felt they were unable to complete their work in a satisfactory fashion’.
‘The weekends were the tipping point. Senior staff were on, but they would be very stressed, due to being in charge, having a patient load and having very challenging patients. Staff would be unloading concerns on Mondays about the weekend, felt they were not able to adequately look after their patients. They were just barely getting by.
‘Because it’s a surgical ward, a lot of patients return from surgery on afternoon shift, so the evening shift is very busy and that flows on to the night shift,’ she said.
Before the new ratios, the ward had six nurses on the morning and afternoon shifts and three on the night shift. On Saturday morning seven staff, five on the afternoon shift and three at night. On Sundays there were six, five and three respectively. Morning shift starts at 7am, the afternoons at 1.30pm and, at night, with 10 hours instead of eight, three shifts start at 9.30pm and one at 11pm.
‘After recruitment, by early October, we had enough to start the new ratios,’ Rose said.
‘The ratios are calculated on the basis of six hours per patient per day, averaged over a week. Now we have a NUM and seven staff on the morning shift, seven on the afternoon and four on the night. At weekends we have seven, six and four.’
‘We’ve gone through a big change with highs and a bit of a low,’ Rose said.’We’ve had to look at how to work in a new environment. This experience has equipped us to change and it’s been made achievable by the new ratios. The increase in staff to accommodate patients means a safer, happier, less stressful workplace.’
Generally, Rose said, the staff are more satisfied with their work.’It is a much safer working environment and we are more likely to retain staff. We have only a 0.6 vacancy in our ward. We’ve got a lot of very good staff. Incidents and complaints have reduced. Before ratios the ward ran well but the frustration level was high.’
‘Since implementation everyone is happier, more positive and have noticed a positive change in the ward, such as things they could now do, that under the old staffing levels was not possible. For example, on the afternoon shift, the nurse in charge no longer has a patient load, so can help and support staff.
‘For the two permanent night shift staff, it has made an enormous difference. Previously they felt unable to complete their tasks satisfactorily. The ward is more organised now. They are able to attend to tasks in a more timely manner.’
Rose said other benefits aside from those relating directly to patient care were that there is more time for in-service, staff education, staff are now getting their breaks and there is more time to check equipment.
‘It’s a big change. Before, people were flat out. Now staff have more time and there is an increase in attendance at in-services.’
‘There was a short period where staff did not fully understand the nuances of the system. A few were under the impression that it was, 1:4 so it meant only four patients each. I think we had to go through that, and have people read the award.’
What the award actually allows is for the NUM to allocate patients depending on acuity and the experience of the staff on shift.
‘We slowly introduced team nursing in the process, and it is working really well, and team nursing has become embedded in our ward. 95 per cent are nursing in this way and finding it very beneficial.
‘I think with change, there is a high, then a bit of a low and then back up again.’
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