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Peace…well, for three years

Victorian nurses have saved nurse-patient ratios but the long, bitter dispute shows the state should not leave workforce planning to be decided in such a heated environment, writes Pauline Stanton.
There is little doubt that the outcome of the 2011 enterprise bargaining round for nurses in the Victorian public hospital sector was a success for the Victorian branch of the Australian Nursing Federation.

The final agreement included not only an acceptable pay increase but avoided the introduction of health assistants and importantly the protection of nurse-patient ratios. Questions remain, however, as to why the acrimonious bargaining process took so long and are we likely to see a repeat of the same scenario in three year’s time?

The antecedents of this dispute go back to the 1990s and the election of the Bracks Labor government. The Victorian healthcare sector was in poor shape after years of budget cutbacks and consequent work intensification under the previous Kennett Coalition government.

The nursing workforce was tired, demoralised, angry and in short supply. In opposition the ALP had wooed the nurses with promises of increased funding and once in power, as the 2000 enterprise bargaining round approached the last thing the new government needed was a stoush with the ANF.

This was especially the case as other public sector workers were waiting in the wings. The process was very quickly handballed to the Australian Industrial Relations Commission who handed down an outcome that included a beneficial total remuneration package for nurses and the first legally enforceable nurse-patient ratios in the world.

However, the ratios were always going to be a problem. From the start they were not properly costed, and hospital managers believed that centrally determined nurse-patient ratios were a crude measure, not sensitive to patient acuity and not allowing for discretion by nurse unit managers.
In the 2004 and the 2007 enterprise bargaining rounds the Bracks Labor government tried to dismantle the ratios without success. Nurse patient ratios are highly popular with Victorian nurses who believe that they provide some protection and control over their workloads in a continuing culture of cost saving and doing more with less.

They are also a symbol of what can be achieved by collective action. Nursing in Australia is a female dominated workforce and like many female dominated professions is often undervalued. The profession has had a long and at times bitter history as nurses have had to struggle for their professional and tertiary qualification status, to improve their wages, conditions and career structures, and to enhance their skills and roles.

The ANF has been at the forefront of many of these struggles and is a union that has grown against a background of international union decline. The Victorian branch credits its growth to the fact that it believes it listens and acts on the concerns of its members and in the interests of patient care. Its resistance to the introduction of less skilled and lesser paid health assistants instead of registered nurses is also part of this philosophy.

In the 2011 bargaining round the new Ballieu Coalition government tried yet again to dismantle the ratios. The government’s strategy, contained in leaked cabinet documents, was to grind the nurses into submission through a long campaign. Nine months is a long time to sustain industrial action and the Victorian branch had a lot to lose but stood firm. Memories of the 1987 dispute which ended in abysmal failure for the ANF and a huge loss of members were revived. The ABC’s Stateline interviewed Irene Bolger who had led this previous doomed dispute and who cast doubt on the tactics of the current leadership and predicted failure.

The employers also appeared to stand firm and while professing sympathy for the predicament of nurses saw the opportunity to abolish ratios and introduce health assistants more widely as a much needed boost in their constant struggle to manage limited resources much more effectively.

However, the union utilised social media to build community support around quality patient care and keep the dispute in the public eye. No health minister likes the spectacle of ward closures and the cancellation of elective surgery on the front page of newspapers and in the end the government’s strategy backfired. The unfortunate arrogant gesture to a group of protesting nurses made by the Premier’s cousin, Marshall Baillieu, became a circuit breaker and forced the government back to the bargaining table. The final outcome was heralded by the ANF as a great victory.

The question remains: are we likely to see a repeat in 2014? Unfortunately the answer is likely to be yes unless there is a change of strategy from both sides. It is time to move the issue of labour utilisation in healthcare outside of the bargaining process.

Good long-term outcomes are rarely decided in the heat of an industrial dispute and there are no real winners in such a strategy. If the ANF had been seen to back down and the ratios weakened there was a real risk that Victorian public hospitals would have been left with an angry and demoralised nursing workforce and the danger of more nurses leaving the industry – creating even more work for those left behind.

While it can be seen to be a positive step that eventually the state government took charge and found a resolution to the dispute before more irreparable damage was done, many employers felt that yet again an opportunity was missed. They will continue to be expected to do more with less with little support from those who provide the resources. Trust on all sides has been undermined in this process.

The reality is that public healthcare is still a system under pressure due to increasing healthcare demand and a shortage of skilled professionals, in particular nurses. The state government and hospital employers do have to act; they have to find new ways to organise healthcare work that is efficient, effective, provides a quality outcome for patients and creates a healthy working environment for their staff.

In other countries governments are looking at different approaches to skill mix and skills escalation between the professions. This can only be done through long-term engagement and collaboration.

Many hospitals in Australia are currently experimenting with different approaches to work process change some of these imported from other industries such as “lean production” techniques. At the coalface multidisciplinary teams are working together to find better ways to provide good quality care for patients. These bottom-up approaches are essential and need to be recognised and valued.

In reality we need commitment from both sides to take responsibility to provide leadership that involves working together in identifying innovative ways of creating a responsive and sustainable healthcare workforce for the 21st century. This cannot be achieved in an adversarial climate – only in one based on trust and mutual respect. There is much to be done to build this trust and respect and prevent the same scenario in the next enterprise bargaining round in Victoria.

Professor Pauline Stanton is head of the school of management and information systems at Victoria University. This an extended article of an opinion piece first published in The Conversation online.

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