Care or cost-cutting: what is driving the push for health assistants

Health assistants are an emerging role in Australia’s public hospitals. Linda Belardi reports on the battle to ensure they support, rather than replace skilled nurses.

“OUR NURSES have three years’ education, experience and training and hundreds of hours of medical placement during that training. Health assistants with three months’ training cannot do the same role.”

– Lisa Fitzpatrick, Secretary of the Australian Nursing Federation, Victoria branch, February 24, 2012.
For months Victorian nurses have been campaigning against the introduction of health assistants into the Victorian public health system.

At the heart of their long-running industrial action is fierce opposition to the employment of unlicensed health assistants as a replacement for skilled nurses.

Yet as the only state without this new classification of worker, Victorian Health Minister David Davis has argued Victorian health services only want to be able to do what can be done everywhere else in Australia.

“There are thousands of assistants in nursing (an equivalent classification) in New South Wales and Queensland public hospitals … neither of these jurisdictions has specified how many they will employ,” a spokesperson for Davis told Nursing Review.

The government argues health assistants will free up registered nurses to carry out higher-level tasks and help attract future nurses into the system.

But leaked cabinet documents reveal the government considered a proposal last year to achieve $104 million in annual budget savings through role substitution and flexible nurse-patient ratios.

Last month, leaked confidential documents meant for Fair Work Australia from the Victorian Hospitals’ Industrial Association outline a plan to use nursing assistants as part of its obligations to meet staffing ratios.

While health assistants or assistants in nursing exist in other states the role has not been used to substitute registered nursing hours and staff.

The Queensland experience

Queensland Nurses Union secretary Beth Mohle says it is an issue that needs to be discussed.

“We haven’t seen any evidence in Queensland that there is a wholesale agenda [for substitution], but with the pressure on increasing productivity the first thing health departments are likely to do is to say ‘well you can actually substitute one for the other’,” she says. “It’s a debate that we need to have in nursing ... because if we don’t engage in the debate, substitution is at risk of happening.”

In Queensland, assistants in nursing make up a small component of the total nursing workforce and Mohle says effective processes are in place to control skill mix and models of care.

In July 2011, 2702 assistants in nursing were employed by Queensland Health, up from 1489 in 2005. This compares with 14,910 registered nurses and midwives and 3329 enrolled nurses out of a workforce that exceeds 32,000.

Queensland has also introduced a classification for undergraduate students in nursing, (a student nurse or midwife – grade 2), to recognise their skills and to help undergraduates to become “work ready”. There were 114 students employed in these roles by Queensland Health.

“Assistants in nursing have a role to play but it’s about the richness of the skill mix.”

NSW concerns

NSW Nurses Association’s Lisa Kremmer says nurses welcome the presence of health assistants as an addition to staffing levels. But there are concerns around substitution and the dilution of skill mix.

Concerns have already been raised in NSW about potential breaches to the Public Health System Nurses’ and Midwives (State) Award, which set out new staffing arrangements and appropriate staffing levels for safe patient care.

“While the association has agreed with NSW Health on a process to determine where assistants in nursing can be safely accommodated within a clinical unit, members are concerned the agreed process isn’t being followed and that AINs are being introduced as a way to save money,” she says.

Branches of the state union have voted to close vacant beds as a form of local action when the required staffing numbers and skill mix for safe patient care have not been provided.

“Having achieved a ratio based on nursing hours per patient day, what we are finding is that some health services are employing more assistants in nursing against those nursing hours,” she says.

“In the new award we have a provision for replacing absences ‘like with like’. If a registered nurse is off-duty then a registered nurse should be called in to replace them. However, what members tell us is that assistants in nursing tend to fill in a lot of those absences. Sometimes that’s because an AIN may be easier to bring in at short notice and sometimes members believe that it’s a budget-driven strategy.”

Kremmer says when these issues have been raised with local health services, management has referred to a lack of available staff to fill vacancies.

“Some branch members get to the point where they feel patient safety is at risk so they vote to take some form of local action, such as closing beds for example. This strategy was successfully used by nurses at Nepean hospital.”

As the state moves to implement a new rostering program, the NSW Nurses Association has been lobbying to include a mechanism in the new software to record every time an absence is filled with a lower classification.

While issues are being raised less frequently then they were when the new award was first introduced, Kremmer says there are ongoing concerns that a growing AIN workforce is diluting the skill mix.

In the past six to eight months, she says, assistants in nursing have been introduced into new areas outside of the general acute-care environment including mental health.

Developing the evidence

Mohle says more Australian evidence is needed to demonstrate how nursing contributes to quality outcomes. But unfortunately this is an area where the research agenda is still playing catch up to the policy, says Professor Di Twigg, Head of School at Edith Cowan University. Twigg, who is undertaking a three-year study to evaluate the AIN role in Western Australia, says local research is still in its early stages.

“However, what we do know from the international evidence is that when you have a richer skill mix or more registered nurses in the total number of hours of care provided, you do get better patient outcomes,” she says.

Twigg says more research needs to be conducted almost at a ward-by-ward level to work out the appropriate resources to deliver the best level of care in a cost-effective way.

“While funding is always limited, what concerns me is the evidence around safety isn’t getting the same air play as the view that we can substitute nurses with less skilled workers and not have any impact on the quality or safety of patient care,” Twigg says.

She has just completed an unpublished analysis in WA that has shown a richer staffing mix is also more cost effective.

“The biggest issue is that governments still view nursing as a major expenditure on their hospital and health bill.

“Policy makers don’t see that getting your nursing workforce right in terms of the number of nurses, the skill mix and educational preparation to do the job is actually either a cost minimisation or a revenue enhancer,” she says.

While the overall size of the AIN workforce is significant, Twigg says what’s more important is how the assistant in nursing role is implemented.

Where AINs can be most effective, she says, is in helping to manage the workload of registered nurses on the ward.

“The AIN role can be a really welcome addition on the ward if they work with the registered nurse to provide care for quite physically demanding patients.

“If you don’t have AIN-type roles you may have to call on registered nurses all the time to help with the physical needs of patients and that’s not the best use of resources,” Twigg says.

Supportive role

Dr Michael Roche, senior lecturer with the Faculty of Nursing, Midwifery and Health at UTS, says if used as an addition to existing staffing numbers, assistants in nursing may even have a positive impact on patient outcomes.

A report commissioned by the Victorian government to evaluate a two-year trial of health assistants at Austin Hospital found the AIN role was well-received by staff and supported nurses in the context of high nursing vacancies.

The evaluation released in February shows patients enjoyed the one-on-one contact with health assistants and complaints decreased by almost 50 per cent over the pilot period.

However, the ANF’s Lisa Fitzpatrick says these roles were implemented in addition to current nursing staff levels, which is not part of the Victorian government’s agenda.

In a letter to the Australian Nursing Federation, Victorian Chief Nurse and Midwifery Officer Alison McMillan rejects claims the evidence linking staffing with patient safety is clear and unambiguous.

McMillan says health assistants will free up nurses’ time to focus on the tasks they are specifically trained to do.

In the letter dated February 23, McMillan says there have been no studies conducted in the Victorian context, nor did studies specifically examine the risks of moving away from the 1:4 nurse to patient ratio.

“Clinical risk is a complex area of investigation and I refute your comment that I could be seen to be championing an issue that puts patients at risk of increased morbidity and mortality,” she writes in the letter.

Tasmanian trial

This month, Tasmania became the last state to trial the assistant in nursing role in acute care.

On March 5, Tasmania launched a sixth-month trial of the AIN role at the Royal Hobart Hospital, following an agreement between the ANF (Tasmanian branch) and the state health department to introduce the classification into the state award agreement negotiated in 2010.

Fiona Stoker, Chief Nursing Officer, Department of Health and Human Services, says the AIN role will operate in a support role for nurses.

The ANF Tasmania says it only agreed to the trial on the condition that all current nursing staff positions remain and an evaluation process is conducted.

National policy

At a federal level, the government has committed to “exploring the regulation of the personal care workforce”.

In the 2010-2011 Budget, the government committed $3.5 million over three years to explore a national scope of practice and competency framework for personal care workers and assistants in nursing, including those employed in aged care facilities.

Budget papers say this money will provide a “basis for a proposal” to consider regulating Australia’s more than 120,000 personal care workers and healthcare assistants as part of the National Registration and Accreditation Scheme.

Already PricewaterhouseCoopers has been undertaking an ‘Overview of the Personal Care Worker and Assistant in Nursing Workforce’ and is due to report this month.

As part of this project, PwC is assessing the use of these workers in three main employments areas – aged care, disability support and acute/sub- acute health.

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