Views from nursing specialists on: Staffing and nurse ratios

The NSWNA has been busy undertaking research and consultation to inform the development of nurse-to-patient ratio models for eight specialty areas of nursing  an important inclusion in our claim for the new Award for public health system nurses. The Lamp spoke with senior nurses about staffing in their specialty areas and how mandated staff ratios would impact on nurses’ capacity to deliver safe patient care.


More time for specialist nursing  

With current staffing levels, rehabilitation nurses are struggling to meet the requirements for this specialist nursing area, according to Marc Johns, CNC. Marc works in the Rehabilitation Units at David Berry Hospital, Berry, and Shoalhaven District Memorial Hospital.

‘Staff are flat out providing basic nursing care and striving to meet competency standards. Good specialist nursing takes time and without adequate staff, specialties such as rehabilitation are in jeopardy.

‘Staff report feeling so stretched that their rehab roles are not fulfilled. Usually, the only time available for professional development is during the afternoon shift change and this is consumed by clinical handover and ward communication. It’s difficult providing staff with the professional development they require.

‘Rehabilitation nursing is a very important part of a patient’s care and preventative health. It impacts on the quality of life at home and aims to reduce the risk of re-admission to hospital. Patient and carer education is an important element of rehabilitation nursing and at the moment we are limited in what we can offer.

‘With the current staffing  patients are not getting the rehabilitation support they require. For example, nurses are hard pressed to spend the right amount of time with patients and end up “doing” for the patient rather than allowing the patient to focus on developing skills to increase independence.

‘These problems are not unique but are faced by all rehabilitation wards.

‘Patients have noticed the nurses’ workloads and feedback indicates the impact on patient care. The nurses succeed in providing good quality care, but have difficulty in ensuring that all the rehabilitation needs are met.’

Marc says a mandated staffing ratio would provide professional development opportunities and enable nurses to meet the basic requirements for rehabilitation nursing.

‘We would also have more time for communication with allied health workers, and family conferences,’ says Marc.

Medical wards

Skill mix is crucial 

Peg Hibbert currently works as a CNS in the medical unit at Hornsby Hospital ED, and previously worked in the hospital’s medical ward for 21 years.

Peg explains that staffing in the medical unit is based on patients having a 48-hour stay in the unit but in reality ‘it doesn’t work out like that’. ‘Our patients have complex medical problems. The majority are elderly or developmentally delayed from nursing homes, hostels or group homes and they’re in hospital for problems that are symptomatic of their conditions.

‘Our work is cut out dealing with very complex care needs. Nurses here have an incredible workload. They’re tearing their hair out.

‘The current staffing model doesn’t consider these complex medical needs. It is based on the number of patients staying 48 hours.

‘Mandatory staffing ratios would at least ensure we have the right number of nurses for the right number of patients.

‘The NSW ratio model would consider skill mix. This is crucial. An extra pair of hands is not the only solution; we need extra hands with the right skills. On the medical ward we need more appropriately skilled staff to deal with the care requirements of patients with multiple and very complex care needs,’ says Peg.

Palliative care

Ratios very positive for palliative care 

Paul Baddock, Nurse Manager, Palliative Care, participated in the NSWNA expert panel on palliative care to help develop a mandated nurse-to-patient ratio model for this specialty area of nursing.

‘Palliative care is not just about how many patients you have; a lot of nurses’ workload is associated with families. When you admit a patient, you’re admitting the whole family. You may have 16 beds but you are caring for more like 30 patients when you take in to account the number of people you’re dealing with.

‘We need to be thinking in broader terms than just safe staffing levels. Whatever happened to best practice? Striving for best practice needs to be a priority when looking at developing a mandated staffing model.

‘Care goals in palliative care are different to other areas of nursing. A lot of satisfaction comes from providing relief to patients and families.

‘With current staffing nurses are struggling with their workloads. Workloads have increased with increased patient acuity and intervention.

‘Mandated ratios would provide a more balanced staffing model and enable best practice to be achieved as well as safe nursing care.

‘Mandated ratios would be very positive for palliative care. At a recent statewide palliative care meeting, there was a buzz in the air about mandated ratios. It’s seen as very positive. It takes us back to the patient being at the centre of care,’ says Paul.

Inpatient mental health

Staff ratios safer for patients 

Angela Pridham, RN in the High Dependency Mental Health Unit at Shellharbour Hospital, says it is difficult to assess staffing needs for inpatient mental health, and a mandated nurse-to-patient ratio would more equitably respond to fluctuating patient needs.

‘With mental health patients, acuity can change quickly, so it’s very hard to assess staffing needs. In other nursing areas, if a patient has xyz, then you’ll need so many hours nursing care. But mental health patients don’t follow a pattern. Sometimes they get worse before they get better. There is no tool for working this out.

‘A mandated nurse-to-patient ratio for inpatient mental health would deliver the right numbers and skill mix to provide safe patient care.

‘If a mandated nurse-to-patient ratio is in the Award, management will have to stick to it. At the moment, if there are 15 patients at the beginning of the day, then this is the basis of staffing for the day. If another five patients are admitted during the day, you won’t get an extra nurse. But if we had a mandated nurse-to-patient ratio this would be automatic. You’d have a more equitable ratio,’ says Angela.

Emergency Department

Flexibility is important for ED staffing 

Brad Marney, Nurse Manager at a major referral hospital, says a staff ratio model for ED would be great in terms of equitably matching staff with patients but it would need to be flexible and able to adapt to fluctuating patient requirements.

‘The modern ED environment requires flexibility, so the model should not be too generalised. ED is a constantly changing environment, which means you need to continuously upgrade your staffing requirements, and within ED there are several units that have different staffing requirements,’ says Brad.

‘A staff ratio model should also be able to adapt to the particular needs of each hospital ED, and the different units within an ED. For example, Westmead ED is different to any other hospital ED in the State.’

Brad says a number of recent factors impact on staffing in ED. ‘The State Trauma Plan released in March has led to increased trauma presentations, which has increased staff workloads.

‘The introduction of electronic records has enabled intense scrutiny of staffing levels. We’re able to measure the care and time spent with each patient down to the last minute.

‘Management likes to look at how KPI targets are met in ED as a benchmark or indicator of a hospital’s performance. There can be quite a difficult tension between ED KPI and staffing,’ says Brad.

Community Health

Staffing based on case management

Jayne James, NUM, Community Health, says staffing in community health needs to be based on case management size.

‘We need a degree of flexibility with staffing in community health. Caseloads are managed proactively on a week-to-week basis to allow for flexibility in workloads and staffing, but daily workloads are managed on a day-to-day basis.

‘We have daily team meetings where clinical caseloads are reviewed and monitored. We have a simple straightforward system to work out staffing and manage nurse workloads. Each case is assessed and patients are given a certain number of points based on acuity and the degree of care required. A nurse’s daily workload will be according to a certain number of points rather than the number of patients visited.

‘A nurse-to-patient ratio model for community care would need to have a degree of flexibility, with the ratio developed around case management size rather than a certain visits per day.’