Will we suffer a shortage of nurses too? - Australia

  1. 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 nurses and even some patients are beginning to recognise that where nursing care and patient safety are concerned, Australia is at the top of the hit parade. That's because of the pioneering action taken to implement safe nurse-to-patient ratios in public hospitals in Victoria.
    You've set a global record. Victoria is the first place in the world to make sure every patient gets high-quality care in a safe environment when they're in hospital. You've also taken a step that seems to be working. And let me tell you, that's more than most countries can say when dealing with the global nurse shortage.

    In my country, California has already copied the Australian model. Plus 30 other states including Massachusetts, where I live, have some form of safe staffing ratio legislation under consideration.

    So here's my question. Why is the Government of Victoria trying to curtail an experiment that is clearly so important? Why does it want to go back to the future by jettisoning staffing ratios and putting in their place the kind of corporate-designed .....

    Full Article:
    http://www.theage.com.au/articles/20...?from=storyrhs
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  2. 24 Comments

  3. by   carm4502
    Patient ratios would be great if they had some means of validation. The ratios are applied across a facility so a ratio of 1:4 sounds great until you take out the 1 for 1:1 patient care for each ICU patient, the 1:2 for all the HDU patients, the staff off-line doing professional development or other non-clinical duties and what are you left with? anything from 1:8 to 1:12. The next step the Government wants to take is to include in the ratios all non-clinical staff (the nurse managers Directors etc.)for a facility. Where will that leave nurses and their precious ratios? Ratios are fine if based in fact and are constantly evaluated and validated by Nurses.

    Historically Patient acuity systems have had bad press. My experience is that in facilities where there is a commitment to completion, accuracy and reliability of the data that goes in, and adherence to standards (so the facility can't fudge the figures) the acuity model works well. It gives ratios that are realistic within a unit not across a campus. It provides flags that tell when implementing a new policy has an impact on nursing workload. it can provide insight into priorities of care and establish and/or audit clinical pathways. I have just finished buuilding a budget using PDS data and can tell you that it is much preferred to the "historical" model or patient ratios.

    A major failing of patient ratios is that the don't keep up with trends in care. As we shortne length of stay to increase throughput, the physical bums in beds at any point in time does not change, but the acuity of those same bums increases. And remember the original ratios (before they were mauled by the finance guys) came from an acuity system. They were 1:3.56 for an acute med surg ward, 1:4.64 for a rehabilitation unit 1:4.92 for a residential unit, and applied only to clinical staff performing clinical duties.

    Wake up! Do yourself a favour and work for something that supports nurses not bureaucrats. Ditch ratios and give us a valid acuity measure controlled by and supported by nurses. Give a decent Auity system a go. :angryfire
  4. by   gwenith
    I agree with Carm - I would prefer we worked to a system such as Trendcare that actually measures acuity - it is not a perfect system by any stretch but it is better than the alternative.
  5. by   pickledpepperRN
    I would be all for using an acuity system IF as you state
    1. The acuity is determined by the needs of the individual patient as assessed by the bedside RN.

    2. All facilities use the same acuity system.Yearly changes may be made with the approval of direct care RNs.

    3. Enforcement of safe staffing by acuity is mandatory. Perhaps that will be possible in your public system.
  6. by   carm4502
    you're talking leadership here.
    In my world the bedside RN determines the patient acuity after working their shift. While not the best solution, it allows me to plan based on trends evident in the data. WE look at acuity for budget purposes but are then directedf by finance to staff to bums in beds. We need strong nursing leadership to turn this around. My analyses have shown that, left to our own devices, nurses are our own best critics and don't unnecessarily staff for comfort and would actually run more efficiently if allowed to staff to patient acuity fluctuations and maintain a reasonable casual force with in the facility. We have tried this but HR don't like paying for part shifts (the software doesn't support it and the entries have to be manual). Wouldn't it be nice if we had extra hands to help get things done then reduce down to a skilled core to maintain the quieter times?
    As for annual reviews, this is probably wasteful. Review every five years to validate the system but allow figures to be the same over time to facilitate honest trends. If a patient state is low acuity now it will still be low acuity in five years from now. What we need to capture is the change of acuity caused by shorter LOS, increased day surgery and more complex cases filling the empty beds created from the first two. Happy to chat about this any time.

    Quote from spacenurse
    I would be all for using an acuity system IF as you state
    1. The acuity is determined by the needs of the individual patient as assessed by the bedside RN.

    2. All facilities use the same acuity system.Yearly changes may be made with the approval of direct care RNs.

    3. Enforcement of safe staffing by acuity is mandatory. Perhaps that will be possible in your public system.
  7. by   pickledpepperRN
    Quote from carm4502
    you're talking leadership here.
    In my world the bedside RN determines the patient acuity after working their shift. While not the best solution, it allows me to plan based on trends evident in the data. WE look at acuity for budget purposes but are then directedf by finance to staff to bums in beds. We need strong nursing leadership to turn this around. My analyses have shown that, left to our own devices, nurses are our own best critics and don't unnecessarily staff for comfort and would actually run more efficiently if allowed to staff to patient acuity fluctuations and maintain a reasonable casual force with in the facility. We have tried this but HR don't like paying for part shifts (the software doesn't support it and the entries have to be manual). Wouldn't it be nice if we had extra hands to help get things done then reduce down to a skilled core to maintain the quieter times?
    As for annual reviews, this is probably wasteful. Review every five years to validate the system but allow figures to be the same over time to facilitate honest trends. If a patient state is low acuity now it will still be low acuity in five years from now. What we need to capture is the change of acuity caused by shorter LOS, increased day surgery and more complex cases filling the empty beds created from the first two. Happy to chat about this any time.
    Our complicated for profit "sick care non-system" (as I think of it) has MANY acuity systems. The nurse does the acuity for the next shift then a clerk enters them into a computer and tells us, "That is all you get." The program that determines how many staff are allowed is "proprietary".

    On our telemetry unit night shift we assigned all patients acuity 2 for a week.
    The next week we assigned all acuity 4, the sickest possible.
    Guess what? We got the same staff based on census both weeks. Each licensed nurse had 5 or six patients to start going up to 7 when we admitted from the ER.

    Now at least there is a maximum of five telemetry patients, four step-down (on a ventilator or having unstable vital signs). They are still required to staff by acuity, but unless all staff are willing to enforce it they don't.

    Evren our finest, supportive managers are evaluated on keeping to the budget rather than quality of care. They are glad to have the ratio law to justift a higher budget for nursing staff.

    I think truly the best is a combination of core staffing you never go below and required increases for higher than usual acuity.

    Oh, some hospitals have nurses come in for four, six, or eight hours to provide break relief and admit patients. If there are no admits two hours before the next shift we call the ER asking if there are probable admits. If not we send the relief nurse home. One works four hours Monday through Friday only on school days. What a blessing! Uninterrupted lunch break!
    They will also send a nurse home if there are many discharges.
  8. by   pickledpepperRN
    Quote from gwenith
    I agree with Carm - I would prefer we worked to a system such as Trendcare that actually measures acuity - it is not a perfect system by any stretch but it is better than the alternative.
    Would it be possible to briefly explain Trendcare?

    Carm:"In my world the bedside RN determines the patient acuity after working their shift. While not the best solution, it allows me to plan based on trends evident in the data. WE look at acuity for budget purposes but are then directedf by finance to staff to bums in beds. We need strong nursing leadership to turn this around. My analyses have shown that, left to our own devices, nurses are our own best critics and don't unnecessarily staff for comfort and would actually run more efficiently if allowed to staff to patient acuity fluctuations and maintain a reasonable casual force with in the facility."

    Sounds like a good world for nursing work!
  9. by   talaxandra
    Quote from carm4502
    Patient ratios would be great if they had some means of validation. The ratios are applied across a facility so a ratio of 1:4 sounds great until you take out the 1 for 1:1 patient care for each ICU patient, the 1:2 for all the HDU patients, the staff off-line doing professional development or other non-clinical duties and what are you left with? anything from 1:8 to 1:12. The next step the Government wants to take is to include in the ratios all non-clinical staff (the nurse managers Directors etc.)for a facility. Where will that leave nurses and their precious ratios? Ratios are fine if based in fact and are constantly evaluated and validated by Nurses.
    I've worked with old-style dependency scales, been involved with a Trendcare trial, and worked with the Victorian ratios, and the latter are my preference by far.
    The description above is an inaccurate portrayal of the ratio system - the 1:4 applies to general wards in A class hospitals (in Melbourne that's The Royal Woman's, The Royal Children's, Royal Melbourne, the Alfred etc).
    ICU's are staffed 1:1, HDU's are staffed 1:2 etc, and there has never been a suggestion that non-clinical staff are counted in the numbers. In fact, ACN's are specified as being supernumary, so a twenty-bed unit in a A class hospital has five clinical nurses, plus an ACN, plus a Unit Manager, Clinical Support and Development Nurse, plus any non-clinical nurse specialists.
    Also, the ratios are supposed to be a minimum safe staffing level - the night-time ratio in A hospitals in 1:8 (including ACN), but most wards on my hospital staff 1:5 or 1:6, depending on acuity.
    One key advantage of the ratios is that it is a transparent system - any one can come on and see if there are enough staff for the shift. This has meant that this morning, for example, I was able to close three empty beds because admin weren't able to replace a sickleave, and without that we'd be working over the ratios. No need to involve admin, get approval from my NUM - we don't have 1:4 so those beds are closed until the PM.
    It's also supposed to be flexible - you can deploy those five nurses any way you like among 20 patients: team two nurses with ten stable patients, have a 1:1 special, whatever works for that shift on that ward.
    The ratios have meant that Victoria hasn't got a nursing shortage, and we're not giving them up!
  10. by   Token Male
    My view of nurse/patient ratios is the simple view. I look after my 5 patients land assist my peers look after their five patents and the RN in Charge looks after us all. Then the admin staff have their meetings and coffee.
  11. by   carm4502
    But how do you determine acuity?
  12. by   pickledpepperRN
    Keep informing us!

    We have acuity written into our ratio law.
    I want to know in Victoria how YOU determine acuity.
  13. by   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?
  14. by   carm4502
    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?
    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? I have worked in some areas with 1:4 where they consider themselves busy if the don't get their afternoon tea break, and in areas where 1 RN and 3 ENs cared for 60 patients on a night shift and called it an easy night.

    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.

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