Caught between violent and management pressure

Staff concerns were disregarded when they tried to warn of mounting aggression in an understaffed mental health unit.

In Hornsby Hospital’s understaffed mental health intensive care unit (MHICU), nurses are caught between the risk of violence from aggressive patients and a management that disregarded staff concerns.

A unit nurse was brutally assaulted on 1 June – one day after management pressure led staff to reopen a bed they closed three days earlier due to safety concerns.

MHICU nurses closed the bed on May 28 in line with a resolution by Hornsby Hospital’s NSWNMA branch that called on management to close three of the 12 beds to match the available trained staff.

The unit was dangerously understaffed by 9.4 FTE (full time equivalent) vacancies out of a total of 29.5 FTE nurses.

 Staff were doing excessive overtime and untrained contingency staff were being placed in the MHICU, said branch president Michelle Rosentreter.

The bed closure was also preceded by  a “riot” which saw patients barricade themselves inside the unit, she said.

“Experienced senior nurses on duty at the time were able to manage that episode without injury to staff.

“However, the assault on 1 June happened when permanent staff had to rely on irregular casuals who were not trained to manage such a serious incident.”

Warnings were disregarded

She said the branch held Northern Sydney Local Health District management responsible for the June 1 assault because the LHD had failed to help MHICU nurses deal with serious understaffing since at least September.

“Staff told the branch that senior nurses who raised safety concerns with hospital executives and advocated for bed closures were threatened with reprisals and verbally intimidated.

“MHICU staff are distressed about it because they tried to avoid a foreseeable danger.

“Their warnings were disregarded and they were made to feel that their judgement was poor and their risk assessment worthless.

“To be told by people who aren’t in that clinical setting that there isn’t a problem is just irresponsible.”

She said that following the recent violence, the MHICU was given its own security team separate from general hospital security.

“We asked for this as long ago as 2016. Management trialled it for a few weeks then stopped it.”

Michelle said the branch and Reasonable Workloads Committee (RWC) tried to identify risks and put strategies in place to avoid injury to staff.

“However, the LHD and hospital executive don’t see the need to do anything until something bad happens.

“We acknowledge that the LHD has now escalated recruitment of staff to fill vacancies.

“The branch and RWC are auditing all mental health units to establish staff numbers and skill mix.”

Situation remains volatile

NSWNMA Assistant General Secretary Judith Kiejda said the Hornsby MHICU incidents highlighted the desperate need to improve staffing of mental health units across the state.

She said that by last September, nine of the 26 positions at Hornsby’s MHICU were vacant and the number of reportable near-misses increased.

“The unit was forced to rely on overtime and irregular casual and agency labour including nurses who lacked minimum training in violence prevention.

“They were not trained to take down a violent patient or deescalate a potentially violent situation, which prolonged the incident on 1 June.

“While recruitment is now being fast-tracked, the unit will continue to rely heavily on contingency labour for the next month or so and the situation will remain volatile.”

Last year, nurses from all Hornsby Hospital units held a rally to warn the public about unsafe staffing practices throughout the hospital.

The rally followed the release of data obtained by the NSWNMA which revealed that 142 eight-hour shifts went unfilled in just four wards over the previous 10 months.

In the aged care and rehabilitation wards, unfilled shifts represented a total of 752.2 hours below award minimum staffing levels. Understaffing below the legal minimum at Wards 3A and 3B amounted to 214.8 hours and 170.8 hours respectively.

Michelle said the staffing situation had improved across hospital units subject to nursing hours per patient day (NHPPD) ratios since the NSWNMA took the issue 
to the Industrial Relations Commission.

“The NHPPD units are now mostly staffed in accordance with the award,” she said.

“Our biggest problem is with non-NHPPD units, such as specialist wards like paediatrics, theatres and maternity and the mental health ICU.”