Special Dangers

The specialling of mental health patients using staff without appropriate training is fraught with risk. 

The stabbing attack at RPA  highlights many of the safety risks to nurses and patients arising from the use of specials.

The use of nurses with insufficient training to care for patients with mental health issues and deficiencies in the documentation that would allow management to identify the appropriate skills needed for an aggressive patient requiring specialling are critical issues identified by the NSWNMA arising from the attack.

The Association also believes, more generally, that there needs to be a ban on the use of specialling within numbers, which pushes nurse-to-patient ratios into unsafe territory. 

NSWNMA General Secretary Brett Holmes says there is enough information in both Sydney LHD and NSW Health policies to demonstrate “that it is inappropriate for an AiN to be used as a special for an acute mental health patient with a risk of aggression”.

“The Association has serious concerns that the “special” allocated to provide care for the patient at RPA was an Assistant in Nursing from an agency,” he said. 

“The Association does not support the use of AiNs as patient specials where a risk of violence to others has been identified, particularly where this risk is arising from patients who are acutely mentally unwell, or have significant cognitive deficiencies including acquired brain injuries, intellectual disabilities, dementia or delirium.

“The use of an AiN as a special, in this instance, was highly inappropriate.”

LHD policy on specialling states that: “Consideration of nursing skills mix and relevant clinical competencies is required when selecting staff members to provide safe and effective observation and nursing care”.  

The NSW Health AiN job description refers to AiNs are only to be used for certain duties as outlined in the policy and in accordance with the acute care environment health service implementation package.

“It is difficult to see how the LHD can argue that an AiN has appropriate knowledge and skills to provide care for an acutely unwell mental health patient, particularly given that there is no requirement to undertake any mental health training as part of an AiN’s Certificate 3 course,” says Brett Holmes. 

He says there is a “glaring” problem with the form that is completed to request a patient special and for 
the daily review of the need for a patient special.

“The form does not clearly indicate aggression as a reason for requesting a special. This limits the information available to nursing administration to make the decision about the appropriate allocation of a person to this role.”

Specialling blows out nurse-to-patient ratios

The scale of specialling within numbers is also impacting on patient and staff safety.

According to data gathered by the NSWNMA, Royal Prince Alfred Hospital had 99,086.5 hours of specialling in the 2017-18 financial year.

52,364.5 hours were within numbers. Based on an 8.5 hour shift this means 6160.5 shifts were specialled within numbers in a year or around 16 shifts per day.

Tara, a midwife at a large Sydney hospital, says specialling within numbers becomes dangerous when the nurse-to-patient ratio blows out when a staff member is allocated as a special.

“Specials in numbers don’t work. You need an extra staff member to special the patient. If a patient requires one-to-one care they should be able to receive one-to-one care but not to the detriment of other patients.

“Often when we get an additional staff member it is someone who does not have the requisite training to be able to safely special a patient.”