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When the numbers don’t add up

New research says Australia is ignoring evidence that improvements in nurse staffing is a cost-effective investment for the health system. Annie May reports.

The push for mandated staffing levels in all Australian hospitals has been further backed by new research that directly links an increase in nurses to patient safety.

However, even with these findings, and those of similar past studies, the researchers say Australia continues to ignore the evidence.

Looking at the impact the introduction of the nursing hours per patient day (NHPPD) staffing method in Western Australia hospitals had on patient outcomes, the study found a 25 per cent decrease in the rate of patient deaths.

It also found that surgical patients had a 54 per cent drop in central nervous system complication rates, a 17 per cent decrease on pneumonia and a 37 per cent reduction in ulcer, gastritis and upper gastrointestinal bleed rates.

This evidence shows that it is now time to act and implement mandated staffing, said the study, published in new edition of the Australian Health Review.

Led by Professor Di Twigg, the head of ECU’s School of Nursing, it is one of the first studies to examine NHPPD staffing policy. Currently the method has been implemented in WA, Northern Territory and Tasmania. Victoria also has nurse-to-patient ratios.

“The research reveals that nurses play a vital role in providing a continuous surveillance system, enabling the early detection and prompt intervention when patients’ conditions deteriorate,” Twigg said.

“The ability of nurses to initiate actions that minimise adverse events and negative outcomes for patients is directly linked to the hours of care and the skill mix.”

However, despite evidence that improvements in nurse staffing is a cost-effective investment for the health system, Twigg said Australia’s hospital staffing policies were moving in the opposite direction.

“Calls for greater workforce flexibility and skill mix changes have resulted in substitution of more highly skilled workers with assistant type roles rather than maximising use of the skills and expertise of the RN workforce to enhance patient safety,” she said.

“An evidence-based policy response would reflect the findings of extensive research that patient safety is linked to nurse staffing. This means that policy makers must ensure there are sufficient registered nurses to guarantee patient safety.”

At the same time as the study was released, NSW nurses again called for minimum nurse-to-patient ratios, saying the health system had been plagued by nurse shortages for too long, and that if other states could do it, “so could we”.

“Over the years we have tried a number of mechanisms to deal with the problem of escalating work pressure, but the evidence from Victoria, California and other places with minimum nurse-to-patient ratios is now in and they work better than any other system, NSWNA general secretary, Brett Holmes said.

The NSWNA have called for a one-to-four nurse to patient ratio at most metropolitan hospitals to be included in the new award, which expired in June 30 this year.

“Nurse-to-patient ratios have existed in Victoria for 10 years and have greatly improved the health system in that state, and attracted many former nurses back to the profession. If Victoria can do it, NSW can do it. If it is good enough for the people of Victoria, it is good enough for the people of NSW,” Holmes said.

While the NHPPD method doesn’t address skill mix, the proposed NSW ratios include the establishment of a minimum registered nurse component of 85 per cent RNs for each shift.

“All the research shows there is a direct link between RN numbers and patient outcomes,” Holmes said.

Implementing mandated staffing levels will be difficult given that Australia is facing a nursing crisis, Twigg concedes.

Current workforce projections indicate that by 2012 there will be a shortfall of 61,000 registered nurses in Australia. Adding to this problem is the ageing of the nursing workforce, with more than one third of the Australian nursing workforce likely to retire over the next decade.

These trends indicate Australian heath care services will face significant challenges in securing adequate nursing resources to provide safe and effective patient care. Addressing this needs to be a shared responsibility between policy makers and the nursing profession.

“In addition, the number and diversity of key players at both state and federal levels involved in health workforce planning, education, training and accreditation make it difficult to achieve a coordinated policy response,” Twigg said.

“This diversity of stakeholders results in fragmentation of responsibilities, ineffective coordination between sectors and inefficiencies in funding and payment arrangements. Effective and efficient policy responses in this climate are difficult, for example coordination of the number of university places made available for nurse education.

“If governments are serious about reducing the number of patient deaths, then government policy should focus on initiatives aimed at maximising the number of RNs at patients’ bedsides. Models of care that maximise the use of less skilled workers to assist in patient care should be rejected. Policy responses should also support the determination of safe levels of nurse staffing, including the mix of nurses, by funding studies to empirically examine specific nurse staffing methods.

“If we care about patient safety, we need to ensure our workforce policies reflect the evidence that more nurses means better outcomes for patients.”

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