Will we suffer a shortage of nurses too? - Australia - page 2

This article is written by anAmerican journalist and author Suzanne Gordon for an Australian Paper... We Americans like to think we're No. 1 in pretty much everything. But a lot of American... Read More

  1. by   talaxandra
    Quote from carm4502
    So where is the evidence that the NUM's gut feeling is accurate? How is the subjectivity of individual perceptions of what really is busy, removed?
    When we used a dependency scale, I never saw the results translated into staffing numbers. I certainly had my share of NUMs telling me that we were fully staffed, but it often didn't feel like it, and we had little or no discretion on a floor basis to make a change.
    Ratios are transparent and unarguable - if you have four staff and twenty patients then you're one nurse down. It doesn't matter how admin may try to wriggle, you're one down.
    Most of the wards at my hospital permanently staff above the ratio, at least on nights - although my NUM denies it. However, that doesn't mean that we don't ever employ extra staff - as well as allowing an extra person to work 1:1 when we have a transplant, we periodically employ an extra person.
    If one area is too heavy the allocation gets shuffled, but increased staffing needs are determined by the senior staff (ACN etc) in consultation with the floor staff. Although this gets run past the NUM, it's a clinical decision made by the floor staff, and admin are usually agreeable. After all, if we're not staffed adequately, people leave.
    I appreciate what you're saying about subjectivity, but I don't think that's really an issue in the acute setting - people can usually distinguish between an atypically busy evening and a dangerous workload, at least in my experience.


    Quote from carm4502
    Where is the model to allow the profession to independently review the ratios according to workforce and industry standards and apply as the service changes? The model is an acuity classification system that is maintained and analysed by nurses, not accountants. Without these things, ratios are nothing but a magic number pulled out of a hat that allows the employer to meet budget. Patient care is a minor irritation.
    I agree that this is a potential problem, but it's not inherent in the idea of a ratio model. The ANF want to incorporate regular reviews, so that the ratios can reflect the increase in acuity that we've all seen - every year more patients have short-stay ops, fewer patients have adequate GP care, inpatients come in sicker and stay for a shorter period of time... The problem, at least with this round of EBA, is that the State (Labor) government isn't interested - despite the fact that Victoria currently has no nursing shortage (a striking contrast with the situation pre-ratio).
    That said, the initial calculations of appropriate nurse : patient numbers were performed by nurses, based on nursing research. They are universal - every A grade hospital staffs 1:4 except in areas with a smaller ratio - and while the employer has input, that's 'employer' as in State, not hospital manager.

    I feel sure I could have articulated this more clearly - in my defence, it is almost 0400, and I'm a bit flu-y!
  2. by   pickledpepperRN
    Quote from talaxandra
    There isn't a specific acuity provision, except in so far as different categories of hospitals, and departments within those hospitals, having different ratios. All A-grade hospitals (tertiary metropolitan), for example, have 1:4 for the wards, 1:2 in HDU/PACU, 1:1 in NICU/ICU. If a ward or department finds its' acuity too high for this ratio to be safely applied, either on a per-shift basis or permanently, they can hire staff additional to the ratios; the ratios are designed to be a maximum number of patients (averaged), rather than a minimum. How does the Californian model differ?

    The actual wording of the Safe Staffing regulations:

    and a portion of the regulations that precede it and still apply.

    From the Department of Health Services

    The new language:

    http://www.dhs.ca.gov/lnc/pubnotice...lation_Text.pdf

    Statement of Reasons explaining the new regulations:

    http://www.dhs.ca.gov/lnc/pubnotice...-37-01_FSOR.pdf

    Frequently Asked Questions:

    http://www.dhs.ca.gov/lnc/pubnotice...R-37-01_FAQ.pdf

    From the California Code of Regulations:

    http://ccr.oal.ca.gov/cgi-bin/om_is...Section&record={605BF}&softpage=Browse_Fra me_Pg42

    TITLE 22. Social Security
    Division 5. Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
    Chapter 1. General Acute Care Hospitals
    Article 3. Basic Services
    70215. Planning and Implementing Patient Care

    (a) A registered nurse shall directly provide:

    (1) Ongoing patient assessments as defined in the Business and Professions Code, Section 2725(d). Such assessments shall be performed, and the findings documented in the patient's medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area.

    (2) The planning, supervision, implementation, and evaluation of the nursing care provided to each patient. The implementation of nursing care may be delegated by the registered nurse responsible for the patient to other licensed nursing staff, or may be assigned to unlicensed staff, subject to any limitations of their licensure, certification, level of validated competency, and/or regulation.

    (3) The assessment, planning, implementation, and evaluation of patient education, including ongoing discharge teaching of each patient. Any assignment of specific patient education tasks to patient care personnel shall be made by the registered nurse responsible for the patient.

    (b) The planning and delivery of patient care shall reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy, and shall be initiated by a registered nurse at the time of admission.

    (c) The nursing plan for the patient's care shall be discussed with and developed as a result of coordination with the patient, the patient's family, or other representatives, when appropriate, and staff of other disciplines involved in the care of the patient.

    (d) Information related to the patient's initial assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded in the patient's medical record.

    70217. Nursing Service Staff.

    (a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a licensed psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system.

    No hospital shall assign a licensed nurse to a nursing unit or clinical area unless that hospital determines that the licensed nurse has demonstrated current competence in providing care in that area, and has also received orientation to that hospital's clinical area sufficient to provide competent care to patients in that area. The policies and procedures of the hospital shall contain the hospital's criteria for making this determination.

    Licensed nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse at any one time. "Assigned" means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios.

    Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses, and other licensed nurses shall be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When a Nurse Administrator, Nurse Supervisor, Nurse Manager, Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the ratio. Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses who have demonstrated current competence to the hospital in providing care on a particular unit may relieve licensed nurses during breaks, meals, and other routine, expected absences from the unit.

    Licensed vocational nurses may constitute up to 50 percent of the licensed nurses assigned to patient care on any unit, except where registered nurses are required pursuant to the patient classification system or this section. Only registered nurses shall be assigned to Intensive Care Newborn Nursery Service Units, which specifically require one registered nurse to two or fewer infants. In the Emergency Department, only registered nurses shall be assigned to triage patients and only registered nurses shall be assigned to critical trauma patients.

    Nothing in this section shall prohibit a licensed nurse from assisting with specific tasks within the scope of his or her practice for a patient assigned to another nurse. "Assist" means that licensed nurses may provide patient care beyond their patient assignments if the tasks performed are specific and time-limited.

    (1) The licensed nurse-to-patient ratio in a critical care unit shall be 1:2 or fewer at all times. "Critical care unit" means a nursing unit of a general acute care hospital which provides one of the following services: an intensive care service, a burn center, a coronary care service, an acute respiratory service, or an intensive care newborn nursery service. In the intensive care newborn nursery service, the ratio shall be 1 registered nurse: 2 or fewer patients at all times.

    (2) The surgical service operating room shall have at least one registered nurse assigned to the duties of the circulating nurse and a minimum of one additional person serving as scrub assistant for each patient-occupied operating room. The scrub assistant may be a licensed nurse, an operating room technician, or other person who has demonstrated current competence to the hospital as a scrub assistant, but shall not be a physician or other licensed health professional who is assisting in the performance of surgery.

    (3) The licensed nurse-to-patient ratio in a labor and delivery suite of the perinatal service shall be 1:2 or fewer active labor patients at all times. When a licensed nurse is caring for antepartum patients who are not in active labor, the licensed nurse-to-patient ratio shall be 1:4 or fewer at all times.

    (4) The licensed nurse-to-patient ratio in a postpartum area of the perinatal service shall be 1:4 mother-baby couplets or fewer at all times. In the event of multiple births, the total number of mothers plus infants assigned to a single licensed nurse shall never exceed eight. For postpartum areas in which the licensed nurse's assignment consists of mothers only, the licensed nurse-to-patient ratio shall be 1:6 or fewer at all times.

    (5) The licensed nurse-to-patient ratio in a combined Labor/Delivery/Postpartum area of the perinatal service shall be 1:3 or fewer at all times the licensed nurse is caring for a patient combination of one woman in active labor and a postpartum mother and infant The licensed nurse-to-patient ratio for nurses caring for women in active labor only, antepartum patients who are not in active labor only, postpartum women only, or mother-baby couplets only, shall be the same ratios as stated in subsections (3) and (4) above for those categories of patients.

    (6) The licensed nurse-to-patient ratio in a pediatric service unit shall be 1:4 or fewer at all times.

    (7) The licensed nurse-to-patient ratio in a postanesthesia recovery unit of the anesthesia service shall be 1:2 or fewer at all times, regardless of the type of anesthesia the patient received.

    (8) In a hospital providing basic emergency medical services or comprehensive emergency medical services, the licensed nurse-to-patient ratio in an emergency department shall be 1:4 or fewer at all times that patients are receiving treatment. There shall be no fewer than two licensed nurses physically present in the emergency department when a patient is present.

    At least one of the licensed nurses shall be a registered nurse assigned to triage patients. The registered nurse assigned to triage patients shall be immediately available at all times to triage patients when they arrive in the emergency department. When there are no patients needing triage, the registered nurse may assist by performing other nursing tasks. The registered nurse assigned to triage patients shall not be counted in the licensed nurse-to-patient ratio.


    http://ccr.oal.ca.gov/cgi-bin/om_is...Section&record={605BF}&softpage=Browse_Fra me_Pg42

    TITLE 22. Social Security
    Division 5. Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
    Chapter 1. General Acute Care Hospitals
    Article 3. Basic Services
    70217. Nursing Service Staff.

    Hospitals designated by the Local Emergency Medical Services (LEMS) Agency as a "base hospital", as defined in section 1797.58 of the Health and Safety Code, shall have either a licensed physician or a registered nurse on duty to respond to the base radio 24 hours each day. When the duty of base radio responder is assigned to a registered nurse, that registered nurse may assist by performing other nursing tasks when not responding to radio calls, but shall be immediately available to respond to requests for medical direction on the base radio. The registered nurse assigned as base radio responder shall not be counted in the licensed nurse-to-patient ratios.

    When licensed nursing staff are attending critical care patients in the emergency department, the licensed nurse-to-patient ratio shall be 1:2 or fewer critical care patients at all times. A patient in the emergency department shall be considered a critical care patient when the patient meets the criteria for admission to a critical care service area within the hospital.

    Only registered nurses shall be assigned to critical trauma patients in the emergency department, and a minimum registered nurse-to-critical trauma patient ratio of 1:1 shall be maintained at all times. A critical trauma patient is a patient who has injuries to an anatomic area that : (1) require life saving interventions, or (2) in conjunction with unstable vital signs, pose an immediate threat to life or limb.

    (9) The licensed nurse-to-patient ratio in a step-down unit shall be 1:4 or fewer at all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio in a step-down unit shall be 1:3 or fewer at all times. A "step down unit" is defined as a unit which is organized, operated, and maintained to provide for the monitoring and care of patients with moderate or potentially severe physiologic instability requiring technical support but not necessarily artificial life support. Step-down patients are those patients who require less care than intensive care, but more than that which is available from medical/surgical care. "Artificial life support" is defined as a system that uses medical technology to aid, support, or replace a vital function of the body that has been seriously damaged. "Technical support" is defined as specialized equipment and/or personnel providing for invasive monitoring, telemetry, or mechanical ventilation, for the immediate amelioration or remediation of severe pathology.

    (10) The licensed nurse-to-patient ratio in a telemetry unit shall be 1:5 or fewer at all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times. "Telemetry unit" is defined as a unit organized, operated, and maintained to provide care for and continuous cardiac monitoring of patients in a stable condition, having or suspected of having a cardiac condition or a disease requiring the electronic monitoring, recording, retrieval, and display of cardiac electrical signals. "Telemetry unit" as defined in these regulations does not include fetal monitoring nor fetal surveillance.

    (11) The licensed nurse-to-patient ratio in medical/surgical care units shall be 1:6 or fewer at all times. Commencing January 1, 2005, the licensed nurse-to-patient ratio in medical/surgical care units shall be 1:5 or fewer at all times. A medical/surgical unit is a unit with beds classified as medical/surgical in which patients, who require less care than that which is available in intensive care units, step-down units, or specialty care units receive 24 hour inpatient general medical services, post-surgical services, or both general medical and post-surgical services. These units may include mixed patient populations of diverse diagnoses and diverse age groups who require care appropriate to a medical/surgical unit.

    (12) The licensed nurse-to-patient ratio in a specialty care unit shall be 1:5 or fewer at all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio in a specialty care unit shall be 1:4 or fewer at all times. A specialty care unit is defined as a unit which is organized, operated, and maintained to provide care for a specific medical condition or a specific patient population. Services provided in these units are more specialized to meet the needs of patients with the specific condition or disease process than that which is required on medical/surgical units, and is not otherwise covered by subdivision (a).

    (13) The licensed nurse-to-patient ratio in a psychiatric unit shall be 1:6 or fewer at all times. For purposes of psychiatric units only, "licensed nurses" also includes licensed psychiatric technicians in addition to licensed vocational nurses and registered nurses. Licensed vocational nurses, licensed psychiatric technicians, or a combination of both, shall not exceed 50 percent of the licensed nurses on the unit.

    (14) Identifying a unit by a name or term other than those used in this subsection does not affect the requirement to staff at the ratios identified for the level or type of care described in this subsection.

    (ACUITY SECTION)
    (b) In addition to the requirements of subsection (a), the hospital shall implement a patient classification system as defined in Section 70053.2 above for determining nursing care needs of individual patients that reflects the assessment, made by a registered nurse as specified at subsection 70215(a)(1), of patient requirements and provides for shift-by-shift staffing based on those requirements. The ratios specified in subsection (a) shall constitute the minimum number of registered nurses, licensed vocational nurses, and in the case of psychiatric units, licensed psychiatric technicians, who shall be assigned to direct patient care. Additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient classification system for determining nursing care requirements, considering factors that include the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan, the ability for self-care, and the licensure of the personnel required for care. The system developed by the hospital shall include, but not be limited to, the following elements:

    (1) Individual patient care requirements.

    (2) The patient care delivery system.

    (3) Generally accepted standards of nursing practice, as well as elements reflective of the unique nature of the hospital's patient population.

    (c) A written staffing plan shall be developed by the administrator of nursing service or a designee, based on patient care needs determined by the patient classification system. The staffing plan shall be developed and implemented for each patient care unit and shall specify patient care requirements and the staffing levels for registered nurses and other licensed and unlicensed personnel. In no case shall the staffing level for licensed nurses fall below the requirements of subsection (a). The plan shall include the following:

    (1) Staffing requirements as determined by the patient classification system for each unit, documented on a day-to-day, shift-by-shift basis.

    (2) The actual staff and staff mix provided, documented on a day-to-day, shift-by-shift basis.

    (3) The variance between required and actual staffing patterns, documented on a day-to-day, shift-by-shift basis.

    (d) In addition to the documentation required in subsections (c)(1) through (3) above, the hospital shall keep a record of the actual registered nurse, licensed vocational nurse and licensed psychiatric technician assignments to individual patients by licensure category, documented on a day-to-day, shift-by-shift basis. The hospital shall retain:

    (1) The staffing plan required in subsections (c)(1) through (3) for the time period between licensing surveys, which includes the Consolidated Accreditation and Licensing Survey process, and

    (2) The record of the actual registered nurse, licensed vocational nurse and licensed psychiatric technician assignments by licensure category for a minimum of one year.

    (e) The reliability of the patient classification system for validating staffing requirements shall be reviewed at least annually by a committee appointed by the nursing administrator to determine whether or not the system accurately measures patient care needs.

    (f) At least half of the members of the review committee shall be registered nurses who provide direct patient care.

    (g) If the review reveals that adjustments are necessary in the patient classification system in order to assure accuracy in measuring patient care needs, such adjustments must be implemented within thirty (30) days of that determination.

    (h) Hospitals shall develop and document a process by which all interested staff may provide input about the patient classification system, the system's required revisions, and the overall staffing plan.

    (i) The administrator of nursing services shall not be designated to serve as a charge nurse or to have direct patient care responsibility, except as described in subsection (a) above.

    (j) Registered nursing personnel shall:

    (1) Assist the administrator of nursing service so that supervision of nursing care occurs on a 24-hour basis.

    (2) Provide direct patient care.

    (3) Provide clinical supervision and coordination of the care given by licensed vocational nurses and unlicensed nursing personnel.

    (k) Each patient care unit shall have a registered nurse assigned, present and responsible for the patient care in the unit on each shift.

    (l) A rural General Acute Care Hospital as defined in Health and Safety Code Section 1250(a), may apply for and be granted program flexibility for the requirements of subsection 70217(i) and for the personnel requirements of subsection (j)(1) above.

    (m) Unlicensed personnel may be utilized as needed to assist with simple nursing procedures, subject to the requirements of competency validation. Hospital policies and procedures shall describe the responsibilities of unlicensed personnel and limit their duties to tasks that do not require licensure as a registered or vocational nurse.

    (n) Nursing personnel from temporary nursing agencies shall not be responsible for a patient care unit without having demonstrated clinical and supervisory competence as defined by the hospital's standards of staff performance pursuant to the requirements of subsection 70213(c) above.

    (o) Hospitals which utilize temporary nursing agencies shall have and adhere to a written procedure to orient and evaluate personnel from these sources. Such procedures shall require that personnel from temporary nursing agencies be evaluated as often, or more often, than staff employed directly by the hospital.

    (p) All registered and licensed vocational nurses utilized in the hospital shall have current licenses. A method to document current licensure shall be established.

    (q) The hospital shall plan for routine fluctuations in patient census. If a healthcare emergency causes a change in the number of patients on a unit, the hospital must demonstrate that prompt efforts were made to maintain required staffing levels. A healthcare emergency is defined for this purpose as an unpredictable or unavoidable occurrence at unscheduled or unpredictable intervals relating to healthcare delivery requiring immediate medical interventions and care.
  3. by   talaxandra
    So how does this translate in practice? Have you had any problems staffing when demand increases? Also, it may just be that my eyes were starting to glaze over (I could never be a lawyer!) but I couldn't see an objective acuity assessment tool there, either.
  4. by   pickledpepperRN
    Quote from talaxandra
    So how does this translate in practice? Have you had any problems staffing when demand increases? Also, it may just be that my eyes were starting to glaze over (I could never be a lawyer!) but I couldn't see an objective acuity assessment tool there, either.
    You honed right in on the problems! Clearly you are not only smart but experienced with hospital administration.

    In critical care we are listened to when we say our patient needs 1:1 nursing care. Other hospitals have managers that place rules such as "Only one vasoactive drip does not constitute a 1:1."

    YES there are problems when patients are admitted or become sicker. At my hospital two medical-surgical unite have very different staffing. One has a charge nurse without patients, a clinical nurse specialist, and a 4 hour nurse to provide meal break relief. The staff documents unsafe staffing due to hugh acuity patients, broken or lacking equipment, and attends meetings to present possible solutions to management.
    They will not leave their patients for a break or to transport one to a test unless a competent RN takes report and responsibility for nursing care.

    The other unit begins the shift with the minimum number of nurses the ratios require, admit patients later, eat on the run, "watch" anothers patients when one is off the floor to MRI or other test. No matter the acuity they don't document. They just complain to each other.

    The usual acuity is similar but on average the number of licensed nurses, clerks, and aides is much more on the first unit. Usually they have at least two additional licensed nurses, an aid, and a clerk at night. They get more aides if patients are very large, incontinent more often.
    The second unit barely gives adequate care when the acuity is high, nurses begine charting after the next shift arrives.
    There is a high turnover except for the long time "martyrs".
  5. by   talaxandra
    Oh, I am indeed familiar with hospital politics, management etc!
    It doesn't sound that different from the system here - like I said in an earlier post, most of the other wards at my hospital have a higher than mandated night staffing level. On my ward we just struggle along, making do, though we have one of the highest levels of combined acuity and heaviness.
    On the plus side, that can work in our favour - one night I came on to find it was me, a second year RN (second year by 2 months), and a div 2 bank (which I think is the equivalent of your LPN) who'd been booked to special a BiPap. The PM ACN hadn't realised he was a div 2 and when the other booked nurse rang to say she wasn't coming in they liased with the resident, who agreed the BiPap pt would be okay without.
    So I rock up and find that I'm supposed to run a 24-bed ward one down. I paged admin and opened with "How are you?"
    In response I got "I'd be better if you people would stop ringing me all the time."
    O-kay then. I explained the situation, and was told that there were no agency staff available in the city. Not happy. I said "I don't care if that means one of you comes and works here. None of my PM staff can work a double, and I'm not accepting this load."
    I got the whole no-agency thing and said that they knew we put up with a lot, manage without if we can, so if I'm saying we need another person we d-mn well need another RN.
    They said they'd see what they could do, and ten minutes alter I got a call that someone was coming in. When she got to the ward half an hour or so later I thanked her profusely for coming. She told me that she and her roommate had been available all week, and her roommate was at home in front of the TV. (that's my eyes popping in amazement, BTW)
    I'm not quite sure how this turned into a rant - sorry! My point - wait, let me scroll back through the bile - ah yes, my point was that while the ratios provide a theoretically safe minimum staffing level, staffing for increases in acuity in dependant on pressure from the floor staff. I still like it better than dependancy systems, though.
  6. by   pickledpepperRN
    OH YES!
    We have an "Assignment Despite Objection" (ADO) form. Funny how when the staff of both oncoming and offgoing shifts fills one out agency nurses become available. A miracle!

    I never tell the nursing office if I am available for an emergency because they would use me to avoid the expense of agency nurses. My fellow staff nurses, especially trusted charge RNs know.
    One exception is the one and only trusted night supervisor. She always helps with patient care too.
    ---------------------------------------------------------------------------------
    IDIC "And the way our differences combine to create meaning and beauty." (Hope i got the quote correct)
    Live long and Prosper
    Peace and Long Life
  7. by   talaxandra
    I wish administrators were far-sighted enough to realise that this kind of blatant lying (or, more accurately, getting caught blatantly lying) means that any trust that was there evaporates. And not just from the nruses involved - as we all know there's no rumour mill faster than the hospital system! From now on, instead of thinking "poor coordinator, having to ring a zillion agencies, feeling bad because there are wards left short" I'll now be thinking "no staff. Uh-huh, I'm sure"
  8. by   bukko
    Quote from talaxandra
    So how does this translate in practice? Have you had any problems staffing when demand increases? Also, it may just be that my eyes were starting to glaze over (I could never be a lawyer!) but I couldn't see an objective acuity assessment tool there, either.
    If I may comment at this late date, I'd like to give another perspective about how California's ratio law works in practice. Space, who's always got a lot of detailed information at her fingertips to forward, posted the law, but it is tedious to read. Here's my take on how it is at the hospital where I work.

    Unlike Space's place, the bosses at my hospital start each shift with MORE nurses than they need to comply with the ratio law. They realize we will get admissions. I'm on a cardiac unit where by law, each RN can only have five patients. We usually start with four. It's similar in the med-surg and oncology floors I float to. This is a management decision -- they're not trying to do things on the cheap.

    The charge nurse does not take any patients and is not counted in the ratio number. My hospital also has a "resource nurse" who goes from floor to floor to relieve staff for breaks, do admission questionnaires, perform special procedures, etc. This person is not counted in the ratios. Licensed professional nurses, a lesser-trained category who cannot do as much as RNs (I don't think you have that classification in Oz) ARE part of the ratio. Usually the charge nurse "covers" them, hanging the IV antibiotics and doing other tasks the LPNs are legally forbidden to do. But overall, the administration at my hospital does not try to game the ratio. It sounds like hospitals in your province do.

    As for acuity, when I started working there, we were instructed about a computer program which evaluated how much care each patient would need. That was supposed to tell the bosses how to plan the staff assignments. Our union made them accept the computer program during contract bargaining. But the program was not working when I started there, and has never been used during my time. The union could make an issue of it, but you can't fight everything. At least not in the U.S. I've heard the unions in Aus are more militant.

    The American medical system is more fragmented than I think it is in Australia. Instead of a national or province-wide health system with across-the-board standards, each hospital here has its own culture. I work for a hospital run by the Catholic church, which is not as money-conscious as those run by corporations that are trying to make a profit. So my experience is not universal. But I love the ratio law. By the way, the ratios are the same on midnight shift as they are on day shift, so the owls get a break!

    I'm always interested in reading about nursing in Australia. We might be moving there if George Bush steals another four years in office. (My wife favors New Zealand because of the climate, but the Kiwis I've known tended to be more priggish than you bonzer Aussies.)
  9. by   talaxandra
    Hi Bukko,
    I agree that it's interesting to see how different places practice. We staff to open beds, rather than to patient numbers, to allow for admissions, and in any case a vacant bed rarely stays that way for long. In fact, in the last week or so, we've tried to close beds because my hospital is over its WIES (the government allocates a certain amount of money per patient, treatment, condition etc, and if we're over the WIES then the hospital isn't reimbursed for treatment), but have had to keep opening them as Cas keeps going on by-pass.
    Where was I?! Oh yes, how things are done differently. So a 20-bed general unit in an acute hospital has five RNs (division 1 or 2 - I think div 2's are the rough equivalent of an LPN), plus a resource nurse (an ACN or other senior nurse), plus a NUM (on the AM), regardless of actual patient numbers. We also have an ADON for every couple of floors, and out of hours a clinical coordinator (who organises bed assignment, sick leave replacement, ICU transfers and general dramas). Night duty is 1:8, including resource nurse, with no div 2s.
    The union here is opposed to an acuity program, primarily because of moves to have it replace, rather than augment, the ratio system.
    If the commander in thief does regain office we'd love to have you - although our own PM isn't that different! If your wife's concerned about the climate, tell her that there's a climate here to suit everybody, from the desert to the mountains to the coast! NZ is beautiful, though, and I wouldn't use 'priggish' to describe the NZ'ers I know!
  10. by   pickledpepperRN
    Thank you both. I am VERY glad to hear your hospital does'nt try to "game" the system Bukko.
    Talaxandra:
    It is good to get one nurses perspective. We were reading about heaven when your down to earth struggle goes on.

    GLAD to have ratios!

    Does anyone know this?
    I was told flight attendants have ratios based on the number of seats on the plane, not the number of passengers.
    TRUE?
  11. by   penguin2
    Someone told me that an LPN in Australia functions as an RN does here in the US. If this is true, what do Australian RNs do??
  12. by   talaxandra
    Just like in the US, what nurses do differs on the clinical area and scope of practice of the individual nurse. Where I work (a thirty-two bed mixed medical specialty unit in a tertiary metropolitan trauma hospital) our thirty-six ward staff includes five division two nurses.

    All the Div 2's can: assess patients, monitor and record vital signs and BSL's, liaise with allied health, check lab results, remove drain lines/IVs/vascaths etc, write notes, suction, insert NGs, perform CPR, call MET calls...

    Four of them are medication endorsed, which means they can give regularly-prescribed oral medications, including narcotics; they are in the process of being endorsed for subcut and IM injections.

    Div 2's cannot: single check injectable or schedule 8/11 (narcotic/potentially addictive) drugs, take phone orders, insert IVs, act as a primary nurse, act as in-charge, nurse initiate drugs, prescribe peritoneal dialysis regimens, give telephone advice to patients...

    That's a start, anyway. I certainly seem to find enough to do to fill my shifts...

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