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Australian Industrial Relations Commission Transcripts |
AUSCRIPT PTY LTD
ABN 76 082 664 220
Level 2, 16 St George's Tce, PERTH WA 6000
Tel:(08)9325 6029 Fax:(08)9325 7096
TRANSCRIPT OF PROCEEDINGS
AUSTRALIAN INDUSTRIAL
RELATIONS COMMISSION
JUSTICE MUNRO
SENIOR DEPUTY PRESIDENT O'CALLAGHAN
COMMISSIONER O'CONNOR
C2001/1910
AUSTRALIAN NURSING FEDERATION
and OTHERS
and
MINISTER FOR HEALTH (WA) and OTHERS
Consent application pursuant to section 89(7) of the Act
as an exceptional matter re a dispute pursuant to
section 99 of the Act re nurses workloads referred to
a Full Bench under section 120A of the Act
PERTH
10.21 AM, TUESDAY, 9 OCTOBER 2001
Continued from 8.10.01
PN934
MUNRO J: Yes, Ms Burke.
PN935
MS BURKE: Thank you, your Honour. To continue with the proceedings the ANF witnesses who are required for cross-examination are here. They're not actually in the Court room and we seem to have reached agreement, Mr Ellery and I, that those witnesses who are to be cross-examined won't be present for hearing the evidence of those before them.
PN936
MUNRO J: Very well.
PN937
MS BURKE: The difference was with Mr Jones and Ms Mantell, I think, so then that procedure will apply with the employer's witnesses too. So, I would like to start by - you want to raise a preliminary issue?
PN938
MR ELLERY: Yes, sorry to interrupt. There's just one preliminary issue I wanted to raise as well which is Ms Burke and I were discussing the likely length of the cross-examination this morning and my view is that we are likely to finish all the ANF witnesses before lunch time today, that's obviously subject to any questions the Commission may have and any re-examination, but certainly I don't anticipate our cross-examination taking up a great deal of time this morning.
PN939
How we use the rest of the day would be up to the Commission. We would be able to open our case if we are able to have a short break between the closing of the ANF and our case. I would make a brief opening statement and then we would be in a position to call at least two of our witnesses today if time allowed for that, and so we could use the day that way. Alternatively, we obviously would be happy - - -
PN940
MUNRO J: I think we would generally prefer that, Mr Ellery, if that can be accommodated perhaps, especially if you can by lunch time give us an indication and perhaps Ms Burke an indication of which witnesses you will be calling.
PN941
MR ELLERY: Well, I can advise now in fact, that at least Ms Di Mantell and Mr Allan Jones would be available today. I don't at this stage anticipate any other witnesses would be available or will be required.
PN942
MUNRO J: Very well.
PN943
MR ELLERY: Certainly those two could be available and I would anticipate there would be some cross-examination of some length of both of those.
PN944
MUNRO J: Yes, and you might give us the batting order for tomorrow if you could too.
PN945
MR ELLERY: Yes, I can do that.
PN946
MUNRO J: There is no need to do that immediately, if it's not ready, but looking beyond today, do you yet have any idea how the time might be used? Is there any possibility of reaching addresses before Friday or is that something that you don't want to contemplate?
PN947
MR ELLERY: I would need an opportunity to properly prepare a closing address, your Honour.
PN948
MUNRO J: Yes, perhaps if the parties could get together or the applicants, I think there just seemed a general consensus I think that we are going to need to have the second bank of days in any event and we have ordered transcript in a way that assumed that we would be going through to that period. In addition there are WAGHI and HSUA I think have put themselves after those dates, so that may be the consensus. But if there's any likelihood of finishing earlier than Friday or some such thing it may be useful to indicate that, although I think it's of no practical moment because I gather that Western Australia is such a good place that nobody wants to find a way out of it.
PN949
MR ELLERY: No, that's quite right, your Honour. One other preliminary issue I should just raise is that yesterday we filed a witness statement of Mr Alex Kirkwood, that was the one that we foreshadowed.
PN950
MUNRO J: And that goes with Mr Spadaro's statement I take it, yes.
PN951
MR ELLERY: Yes. And the various parties have a copy of that.
PN952
MUNRO J: Yes, thanks Mr Ellery. Ms Burke.
PN953
PN954
MS BURKE: Mr Blinman could you please state your full name for the Commission?---Stuart Blinman.
PN955
And do you have a copy of your statement?---I do, yes.
PN956
PN957
MR ELLERY: Thank you. Mr Blinman, you've described that you work an 80-hour fortnight, can you just explain to us the actual roster that you work and the length of the shifts that you work?---I work - my roster varies from week - from fortnight to fortnight. I work usually one of two shifts, either an 8.15 to 4.45 or 12 till 8.30, however, I am on call at least once a week from 8 - from 8 o'clock until 8 o'clock the next morning and usually one day at a weekend, from 8 until 8 the following morning.
PN958
MUNRO J: When you say you are "on call', are you paid for that?---I'm paid - under the new EBA I'm paid for $3.40 an hour for that time, but that's over and above the 80 hours that I actually work.
PN959
Yes.
PN960
MR ELLERY: Just so we're clear, those various shifts that you've described starting and finishing times, what are the actual lengths of those shifts in hours?---They're and 8-and-a-half hour shift.
PN961
When you have been on call when was the last time you were actually recalled to work?---During the last week I was actually called in three times. I was called in at 9 o'clock on the Sunday morning, and I was there until 12 o'clock. I was called in again about - at 4 o'clock on the Monday morning of the next day and I was there until 7, and I was called - - -
**** STUART BLINMAN XXN MR ELLERY
PN962
MUNRO J: Seven - 4 am or 4 pm?---Four am.
PN963
Until 7 am?---Until 7 am, and then I was called in again on, let me think, Friday night at half past 11, and I was there until about 2.
PN964
MR ELLERY: And when you are recalled, what payment do you receive for the actual time you're working then?---I - I get paid for 3 hours at time-and-a-half, or double time, or double time-and-a-half, depending on - on the day. For a week day and a Saturday it's time-and-a-half, for a Sunday it's double time and for a Public Holiday it is double-time-and-a-half.
PN965
Okay. In your statement, you refer at paragraph 4 to a theatre course being implemented?---Yes. It's a - it's an informal course. There's no qualification at the end of it.
PN966
It's an on the job course, is it?---It is basically, it's basically an experience rather than a course.
PN967
Yes. Now, just so I'm clear, when you talk about graduate nurses, I understand that to mean nurses who have completed their undergraduate degree and are actually employees of the Health Service. Is that right?---That is right.
PN968
Okay. So these are employees who are employed on an indefinite basis, is that right?---Usually they're given a contract of - usually it's their first year out or with us it's their - or something like theatres, it's usually a second year graduate course, and they will be employed for 12 months and at the end of the 12 months then, depending on the requirements of the Department or what they feel like, they're either free to leave or the Health Department may offer them a job or they may go elsewhere.
PN969
Okay. But just so I'm clear; you refer to them as students but these are actually graduate nurses who are employed?---They have no experience in working in theatres.
**** STUART BLINMAN XXN MR ELLERY
PN970
No, because they've just finished their degree?---Yeah.
PN971
But they are actually employees?---They are employees.
PN972
Yes. Okay. You refer at paragraph 6 to new technology being introduced from time to time?---Mm hm.
PN973
Is it the case that the suppliers or manufacturers of that technology make training available to nurses?---Usually we get a half hour training session. It's not really a - we get the representative from the company comes along for a half hour, often in our own time so that we can learn how to use the equipment that's being used, or they may come and bring the equipment to an operating list so it's almost an on the job training. If we're using a particular - if a surgeon needs a particular new technology, new equipment for a particular case, then the representative will come along and during the course of the operation we will be instructed on how to use the - use the equipment.
PN974
You refer elsewhere in your statement at paragraph 9 to the recovery nurse in theatre?---Yeah.
PN975
Do you see that? And you've mentioned that on occasion this recovery nurse has worked a 15-hour shift?---Yeah.
PN976
When was the last time that that occurred?---A straightforward shift. It was probably a couple of months.
PN977
Okay. And just a final question. You mentioned the roster that you work on and the length of the shift times. Are those the standard shift lengths that full-time nurses at your Health Service work?---Standard shift length for our Department, yes.
**** STUART BLINMAN XXN MR ELLERY
PN978
Okay. For your Department?---Or even part-timers only work a standard shift length, though sometimes they do do half days.
PN979
Okay. Thank you, nothing further.
PN980
MUNRO J: Yes. I have a couple of questions. Do you know whether there are vacancies for nursing staff at Swan?---I believe there are?
PN981
Do you know roughly the numbers?---I don't - I honestly don't know. They're roughly about - - -
PN982
Is that a chronic position of there being vacancies?---Theatres in my Department, we've quite a stable Department. We don't have much change. A lot of the staff have been there quite a long time, though quite a few are coming up to retirement, so we are concerned for that. I think there is a chronic shortage within Swan Districts. Not so long ago, Swan Districts actually leafleted the entire area, Swan Districts area, requesting that any nurse that is currently registered or thinking about re-registered, apply to Swan Districts if they were looking for work. So I can only take it from that that they are actually quite short of staff.
PN983
So the shortage is not so much in the theatre area with which you're concerned?---We do have - we do have days when we are short. Our - because of the way our Department operates, we may have four surgeons operating in the morning, but we may only have two - two operating in an afternoon. Now we try and - because some staff only work on a half day, we try and alter the rosters to - to accommodate, but sometimes with holidays and things like that, we are often short for the morning session, whereas we may not be short for the afternoon session.
**** STUART BLINMAN XXN MR ELLERY
PN984
Yes. So there's a difficulty regulating the search capacity and presumably you also have difficulties where someone unexpectedly reports ill or has some personal problem?---Yes. Also because of the requirements of the on call, if somebody gets called in at 6 o'clock in the morning, we would get three people called in at 3 o'clock in the morning - 6 o'clock in the morning - they're not then required to be on shift until - until probably about 9 o'clock that - not 9 o'clock, sorry, about 5 o'clock that evening. Now it may be that those staff are actually needed in the afternoon because of the way the roster's been done. We don't all - we don't allow - there's not enough flexibility in the rostering or in the staffing numbers to allow for the extra staff to be available just in case they get called in at 6 o'clock in the morning.
PN985
Yes. The staff development you refer to in paragraph 8, that you had a staff development nurse who has a 50/50 clinical component. Is staff development normally able to be conducted on site during working hours?---We try and arrange with the surgeons to start operating half an hour later once a month, so that gives us in effect - and we come in a quarter of an hour earlier, though we don't often go home quarter of an hour earlier. We often go home at our normal time. We try and arrange for the surgeons to start operating later, which actually has a - you know, they then get a shorter list operating time and we try and arrange things during that time if we possibly can. But often there's other things that need to be discussed, such as unit meetings, things that have perhaps come up that we need to know about as far as the running of the hospital's concerned. Various housekeeping.
PN986
Yes. Perhaps I've not put the question very well, Mr Blinman. I think I'm really referring as much to a theoretical position as to the practical difficulties of having a staff development - perhaps if I put it this way. Is the staff development that would be appropriate for nursing staff in your area generally of a kind that could be delivered on site within working hours if the resources were available to spare the time?---If resources were available, then it would be, yes.
PN987
Yes. It's not one where you would ordinarily go as with teachers, for instance to, you've got to get away from the classroom. You might do it on site but you need to do it in a special manner?---No, because often the - no, often the staff development that we need, we need the equipment there or - we've got - we've got the facilities to do it, yes.
**** STUART BLINMAN XXN MR ELLERY
PN988
And you have the lecturing staff in the sense that's the staff development nurse who has the clinical component?---The staff development nurse actually will maybe bring somebody in if it's something specific, or there are - there are often courses available that we may need to go, if it's something specialised or for example, one of my colleagues went to Sydney last week for a conference on gastroenterology because that is one of her particular interests and a particular speciality that she looks after.
PN989
PN990
MS BURKE: Mr Blinman, you talked a little bit earlier about the student nurses or those graduate nurses who have just come from university. And the question that I have is; are those nurses who are inexperienced in working in a theatre placed on as a normal member of the roster?---Yes, they are.
PN991
And does that increase the workload for experienced nurses in theatre?---It does increase the workload because even though they are counted as a - as a normal member of staff, because of the specialised area that theatre is, they actually can do very little within the Department. They often don't know where equipment is. They often are unable to scrub for a majority of the operations or unable to assist the surgeons in the way that the surgeons require. They don't have the skills to do - to assist an anaesthetist with anaesthetic or anaesthetise a patient. They don't have the skills to work in a recovery unit. So their - - -
PN992
So who does the work or who supervises them?---You have a - you have a senior member of staff who's been working there and is competent to do so, so that senior member of staff is really doing two jobs. Their job and the job of the trainee.
**** STUART BLINMAN RXN MS BURKE
PN993
Thank you. And is it easy to get theatre nurses?---No, I don't think it is. Theatre nurse - because it's such a specialised - if you work on - on a ward, you can usually go from - from one ward to another and be useful. We can't take staff from the ward and put them into a theatre setting and for them - and they can be useful. It just doesn't work.
PN994
PN995
PN996
MS BURKE: Mr Paterson, do you have a copy of your statement?---Yes, I do.
PN997
And could you please repeat your name for the Commission?---My name is Derek Colin Paterson.
PN998
Thank you. Mr Paterson is available for cross-examination.
PN999
PN1000
MR ELLERY: Thank you. Mr Paterson, could you describe for us the normal roster that you work and the length of the shifts on your roster?---That I work?
PN1001
Yes?---That I work. I am on a 48-hours per week I work. Per fortnight, sorry. Per fortnight. And I - the day shift is an 8-hour shift and when I do work night shift, it's a - a 10-hour night shift.
PN1002
Okay. In your Department, is it correct that a staff development nurse has recently been appointed or recruited?---Yeah, that's correct. She works - her name's Kerry and she does - I think it's two shifts. I don't know exactly but I think it's two shifts per week. She does staff development which would be two 8-hour shifts.
PN1003
Okay. And is her responsibility entirely staff development, is it, or is it a combination of other things?---She also does then another day as a nurse on the floor.
PN1004
Okay. But there's two shifts in which she's staff development?---Two she is - she does - she is meant to do staff development. She is meant to. Unfortunately on occasion, as of last Friday, she - extremely busy. There was no help available elsewhere so I had to utilise her as a number on the floor. But ideally she does 2 days per week. Ideally.
**** DEREK COLIN PATERSON XXN MR ELLERY
PN1005
You've mentioned that a number of nursing staff have left your Department over the past few years. How many do you say have left?---What, just left?
PN1006
Yes?---Oh, probably a dozen or so have left.
PN1007
Over what period of time are you talking about?---Over - yeah, 3 or 4 years.
PN1008
Right. And I suggest to you that they would have left for a variety of reasons. Would that be correct?---Yes, that's correct. Yeah. Absolutely.
PN1009
The workloads would not be the reason why all of them have left. Is that correct?---That would be correct, yeah.
PN1010
For example, Carol O'Neill. Do you recall Carol O'Neill?---She left for personal reasons, yeah.
PN1011
Yes. Rosemary Lloyd?---She - again that was her health.
PN1012
Jenny Aunt?---She's not left. She's on - I understand she's on worker's comp.
PN1013
Sharon Morris?---Personal reasons.
PN1014
Bronwyn Pitter?---That was a combination of reasons for Bronwyn, yeah.
PN1015
Okay. But those people we've just mentioned, they didn't leave because of workloads, is that right?---Bronwyn would have been a combination of reasons.
**** DEREK COLIN PATERSON XXN MR ELLERY
PN1016
Any others?---Again that's personal and she had hassles - she wanted to do regular roster. Like she wanted to work these set days and being a shift worker it just wasn't possible, so it's sort of as you like it or you lump it and unfortunately with her children and family - and she had to leave.
PN1017
Okay. But it's clear to say, is it, that of those staff who have left, they did not all leave because of workload?---Oh yeah, that's true to say, yeah, yeah.
PN1018
Yes. Thanks I've got nothing further for Mr Paterson.
PN1019
MUNRO J: Mr Paterson, paragraph 6, the annual attendance stats sheet shows a huge increase in nursing workloads and this continues to escalate. Could you just flesh out the detail of what you mean by that?---I commenced at Swan Districts in February '95 and these are approximate figures, but close to the mark. The annual attendance of about 15,000 presentations per year. And that's risen to - to 25,000. That's the year - July 2001, which is an increase of roughly 66 per cent. And in the same time there has been an increase in the FTE, which is a full time employee, of 12 to 17, which works I think about 40 per cent. So the point I was trying to get at there, although there has been an increase in the number of nurses on the floor, it's not as great as the number of presentations.
PN1020
Yes. Is the operation of the Emergency Department, as I think it's called, affected by staff shortages? Are there vacancies there?---At the moment there's - in the Department there isn't any - any vacancies, no. Where we have a lot of problem is when a staff member goes off sick. There's a lot of problem trying to replace that staff member.
PN1021
Yes. The staff development member to whom you referred conducts staff development courses presumably on site and during working hours?---Yeah, the on site, and yeah, on site and in working hours, yeah. A lot of what she does is corporate induction type things, like you have to do - you have to do manual handling every year. You have to define safety every year, you have to do basic life support every year, which is for the whole - the whole hospital, so her work isn't purely staff development in Emergency. It's staff development for the whole hospital.
**** DEREK COLIN PATERSON XXN MR ELLERY
PN1022
Yes. Assuming resources are available, is the staff development function that would be appropriate for Emergency Department nursing able to be carried out generally on site and during working hours?---Yeah. Yeah, I would say yes to that, yeah.
PN1023
Yes. Thank you.
PN1024
SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Mr Paterson, in those situations of staff shortages due to, for instance, the illness of one or more nurses, is there a process that is followed to obtain additional staff in the Emergency Department?---So - to illness, so you know you've got a short - - -
PN1025
A staff member is absent through illness?---Oh, okay, yeah.
PN1026
What's the process that is then followed?---Yep. Initially they try to get regular staff. That's the ideal situation would be to get regular staff. That failing, you then would go to Agency. That failing, then you would have to - which has happened, I can give you examples of this, the manager, who is an office worker, 8 to 5, would be called in and I've called her in to work the shift. And if that failing, then - and this is also - the hospital would - the Emergency Department would go on bypass.
PN1027
And what happens when the Department does go on bypass?---You ring up St John's and say: you know, the hospital is on bypass and you no longer receive ambulance cases. It would still be open for - for patients to walk in the door, but you would call St John's - so you wouldn't receive those priority one, the really acute illness.
PN1028
Okay. Can I refer you to paragraph 7 in your statement?---Yeah.
PN1029
I will just ask you to clarify your statement that elderly patients are at risk of pressure sores due to the time they're required to remain on trolleys?---Yeah.
**** DEREK COLIN PATERSON XXN MR ELLERY
PN1030
Can I ask whether that statement specifically relates to the time that elderly patients may spend in the Emergency Department?---Absolutely.
PN1031
Or is it a more generic statement?---It is - it is due to the time they stay in Emergency Department and it's also due to the fact of probably - and it's not nice, but probably that the lack of care they get when they're in the Emergency Department. Unfortunately what happens in the Emergency Department, you prioritise very, very strictly, and if someone has a life threatening illness, they get attention immediately, whether it be trouble breathing or heart attack, severed limb, they get attention. And what happens in other illnesses are sort of, I suppose, are left, and the example I was thinking to there was the lady from a nursing home who's come in, had a fall. She's demented, she can't verbalise her complaint. She comes in, she's wet herself, she's soiled herself. She's lying on a trolley. It's not life threatening but unfortunately you have people in the Department who are life threatening illnesses and they get attended to. And that type of patient from a nursing home would unfortunately be - would be left. And their skin is exposed to moisture and your bony knees and your ankles which are very bony, they're rubbing and skin breaks down and they're prone to pressure areas.
PN1032
Thank you.
PN1033
MUNRO J: What time would that normally take for the onset of pressure sores?---2 hours. You normally should do pressure area care 2 hourly. So in 2 hours they should, you know, a pillow between the knees, rolled, a powder or a lotion applied to the area. So it should be - - -
PN1034
What, even from first admission?---Yeah. 2 hourly. 2 hourly care.
PN1035
Presumably the bypass to which you alluded may be due to a number of reasons, that you simply could be overloaded if you had had a truckload of patients come in?---Absolutely.
**** DEREK COLIN PATERSON XXN MR ELLERY
PN1036
And all the staff are there but you can't cope with any more, or it might be that you got a barrow load and you haven't got enough staff?---Yeah. The hospital's Emergency Department does bypass for a variety of reasons. You know, sometimes what you're saying, there's this huge inundation of patients all at once and you just can't cope any more.
PN1037
So the frequency of bypass is not necessarily an indicator of staffing overload so much, or staffing shortfall. It might be simply an indicator of capacity and the accident exigencies of workload?---Yes, true.
PN1038
Yes. Thank you. Anything arising out of that, Ms Burke?
PN1039
MS BURKE: No, your Honour, I have no further questions.
PN1040
PN1041
PN1042
MS BURKE: Ms Murphy, do you have a copy of your statement in front of you?---I do, thank you.
PN1043
And could you please state your full name for the Commission, please?---Loreta Veronica Murphy.
PN1044
Thank you.
PN1045
PN1046
MR ELLERY: Thanks. Ms Murphy, you've described in your statement that you work permanent part-time 6 hours a week and then casual hours in addition to that, is that correct?---Oh, it has actually changed of late.
PN1047
Oh, okay. What's it changed to?---I'm on a permanent part-time contract of 10 hours a fortnight but I do a lot of casual work on top of that so it's on a needs basis for both the hospital and myself.
PN1048
Okay. So, that new contract, that's by your choice, is that right?---Yes, it is. Yes, that's right.
PN1049
Okay. Have you worked full-time in the past?---Oh, certainly. I've been with the hospital 4 years and there are various times that I worked full-time. I'm a mother so it fluctuates around when I'm having children and what their needs are.
PN1050
Yes?---But at the same time I make myself very flexible. In November I've already booked into work full-time as Hospital Manager for that fortnight.
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1051
Right?---So, I fluctuate.
PN1052
Okay. So, you've chosen to work part-time because your personal family circumstances require that?---Absolutely. I could work double shifts every day if I wanted to, so.
PN1053
Yes. Are there other nurses you work with who have made similar choices based on their personal or family circumstances?---Certainly. That's one of - been one of the dramatic problems in the ward that I work on. I would say that in the last 2 years we had a stable permanent work force of full-time staff and we've had something like 12 babies in the last 3 years which has shattered a specialist Neurosurgery Ward because we now have lots of graduates, lots of students running through the place and lots of agency and we are so lean on the top for full-time experienced staff. They all hit their 30s and said, gee, I'm working a bit hard, better get on with the family side of things.
PN1054
Right?---So, we've - we've really been shattered so we've got a lot of people who have heaps of qualifications working one shift a week.
PN1055
Yes?---Or one shift a fortnight.
PN1056
Yes. So, the nurses on your ward are predominantly female, is that right?---Yes. We would have 2 RNs who are male, I think. That changes quite a bit too but at the moment I think we have 2. Now, if you ask me how many nurses, females, we've got?
PN1057
No, no. I'm just asking for general indications?---I - I think it would be - we - we probably have about 95 percent are female.
PN1058
Right?---Yep.
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1059
And in your experience is that type of percentage male to female poorly represented of the hospital that you work at?---Is has changed, depending on which hospital I've worked in. Another hospital I worked in took a large number of male nurses from the country and we tend to have a slightly higher rate but I think that that's probably fairly indicative of Sir Charles Gairdner Hospital.
PN1060
Okay. Have you worked at other hospitals prior to Sir Charles Gairdner Hospital?---Yes, I've been a nurse for 15 years. So, I've been at Charlies for 4 years.
PN1061
Have the other hospitals you've worked at, the male to female ratio, is it broadly similar to what you've just described for Sir Charles Gairdner or is it different?---Well, no. As I was saying, at another hospital I worked at which was a major public hospital, it had a slightly higher male ratio because they took a lot of male nurses from the country.
PN1062
Slightly higher, but clearly, the majority was female at that hospital also?---Yes, absolutely.
PN1063
Okay?---Absolutely.
PN1064
Right. You mention in your statement, Personal Care Assistants and Nursing Assistants, can you just describe to the Commission what those terms mean?---In - in nursing you have Registered Nurses, which obviously everyone's aware of. You have another group of nurses called, Enrolled Nurses, who have done a 12 - I could be - I can be - stand corrected on this, but I presume it's about a 12-month course.
PN1065
Yes?---And they can do a certain amount of nursing skills. They can wash, they can shower, they're allowed to give out certain - certain drugs.
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1066
Yes?---And then there is another group who have - for - from my own personal experience, a misleading sort of title which is, Nursing Assistants. And these people have done - my understanding is, like a TAFE course and they really can - they can make beds. They really have very little access to patients other than that. The tragedy is that - have they been creeping more and more into the system because we - we physically don't have enough nurses and I found it a terrible trauma when I'm working as Sir Charles Gairdner's Hospital Night Duty Manager. In July I was faced with a horrendous situation of knowing for 2 consecutive mornings, I had to find 45 and 43 nurses for the morning shift. We closed beds so that brought it back to 35 and 33. And I knew on the first morning that I - the first night I started, there was only 10 RNs in the State to fill those places. Now, that left me with a massive shortfall. The hospital's opinion at the time was knowing that there was no-one to get, that we would get Nursing Assistants in from the agencies but those Assistants could basically do nothing but make beds and a lot of wards actually rejected having them. They found that it was - it was just a hindrance to have someone just standing there saying, well what can I do? They could say, well, you can make a bed; they were from an agency, they didn't know the ward. Other staff were getting confused saying, oh, well can you go and shower this patient and the senior staff go, no, no, you can't have them do that. They're not a nurse, they have just basic sort of caring skills which I presume may be used in hostels but again, I'm not certain about where they're used. But in the public sector hospital they're very limited in what - what's capable - their capabilities are.
PN1067
You mention the Nursing Assistants could make beds. If they weren't able to be there to make beds, who would make the beds?---Well, you prioritise. That's what it comes down to.
PN1068
Well, I'm not sure that answers my question. Who would make the beds if the Nursing Assistant didn't do it?---Well if a Nursing Assistant doesn't make a bed and an RN doesn't have time to make a bed, it doesn't get made till the next shift.
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1069
Right?---And if it doesn't work in that shift, it only gets changed alternate day and - or it only gets changed when the patient's become incontinent of faeces or wee or vomits or has blood over it. One has to prioritise these days. When I started nursing we changed the sheets every day. We don't have time to do that. Someone said to me last week, "Do you actually run in your work," and I laughed. I thought, what a funny question to ask someone and then when I stood back from it I thought, well, no, I do run. That's how I prioritise my night duty. The - you know, I - I get paid 10 hours a night so I might be there 11-and-a-half, 12 hours and if I don't - I - changing a bed would be - be about the last thing I have time to do. I would always try and change a bed if it's soiled but again, I prioritise. If a patient's falling out of bed like last Saturday and they've got a tube hanging out of their brain, my priority is not to go and change the soiled patient. Unfortunately they may have to wait 2 hours until I get back to them. It's very sad but that's the nature of my nursing now.
PN1070
Right. So, I take it that the answer to my question was that subject to priority, a Registered Nurse would change the bed?---Absolutely.
PN1071
Okay.
PN1072
MUNRO J: Changing a bed though often entails getting the patient out of it, doesn't it?---Yes, it does, you Honour. I work - as I say, I - I have dual roles in the hospital being a senior staff member but I work mostly in neurosurgery and our patients are - the acuity of our patients now is such that most of them are - are quite seriously ill. They are confused or they are unconscious. Now, in order to change a patient like that, if you've got a patient that's 80, 90 kilograms and - and a dead weight, completely unconscious, you don't do it by yourself for fear of hurting yourself or hurting the patient so you have to be able to work your day around getting one of your colleagues to help you. They usually have, say, a dense hemiparesis, a dense weakness down one side, so if they are at a point where you can get them in a shower then you need to be able to get other staff to help you to transfer them, you know, in a hoist machine or - or transfer them sliding them onto a chair. So a lot of our care, unfortunately, isn't at a point of an independent area. It's not like where you can sit the patient up and say, oh, now you do so much. That's the nature of the ward that I work on. You - you have to have assistance.
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1073
COMMISSIONER O'CONNOR: Would you get a patient carer assistant rather than another nurse to assist you?---For my own personal preference, I wouldn't. That's only because again of the nature of my patients. If they're not used to someone with an ataxia, it - the brain's been affected so that they have no sense of balance, then they're quite like to fall over. You - if a patient has a hemiplegia, a weakness; if a Nurse Assistant goes to lift them up under the arm which would be a normal process, you normally lift someone up - hoist like that. You can't do that for our patients, they get what's called a, subluxation of the shoulder. You have to have been trained as a nurse to know to chock their - their shoulder, chock their feet. Unfortunately our patients are such that I can't say to a Nurse Assistant, can you go and feed that patient. That - patient may have a swallowing - due to their head injury, may have a dysphagia, a - an inability to swallow. They need a swallow assessment. That - that's where you run into huge risks and - and Nursing Assistants aren't registered. If that patient chokes and dies or anything happens to her, unfortunately I'm the one that - that's held responsible so as a professional I have to make a choice of - about the safety of my patients' care.
PN1074
MR ELLERY: In those sort of circumstances you've just described, would you get an Enrolled Nurse to help you?---Oh, certainly. Certainly.
PN1075
Right?---Yeah.
PN1076
Do you have many Enrolled Nurses working in your ward?---We have about 4. One of them we do not put in the hydropensy unit. She's new to the ward and she's unskilled in the area of neurosurgery. And we have 3 that have been with us quite a long time. Now, they've had to go through training programs and education.
PN1077
Right?---But they are still not allowed to do things like swallow assessments.
PN1078
No. So just to paint a picture, that's 4 out of a staff of how many Registered Nurses and Enrolled Nurses?---Well, see, I said to you you were going to get back to that, weren't you?
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1079
In broad terms. I don't want a precise number, just an estimate?---Oh, well look, I think we've probably got a staff of about 20 or 30.
PN1080
Right?---But I haven't done the rostering.
PN1081
Sure?---And I don't want to lead you astray.
PN1082
No, no. That's fine. So the 3 ENs that have gone through the further training?---Yeah.
PN1083
They are able to assist you in some of those - - -?---Oh, certainly. They're very good.
PN1084
- - - basic care tasks?---Yeah. They're very good.
PN1085
Yes?---They take their own patient load and they're capable of doing that because they now know things of, like, subluxation of shoulders and things like that.
PN1086
Right?---Yeah, absolutely. They need help with their drugs. I need to be able to assist them.
PN1087
Yes?---I need to find time in my workload, in my patient allocation.
PN1088
Yes?---To do their - you know, check their drugs and help them with certain drugs.
PN1089
So you have 3 Enrolled Nurses that are at that level of skill?---Yep.
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1090
That you can delegate to that level?---Absolutely.
PN1091
If you had another 3 who had a similar level of skill and ability to delegate to them, would that be of assistance?---Oh, see, you get into such challenging areas. It is - having someone with education like them is - is absolutely positively of help. If you start changing the nature of the skill mix on the ward so that you've now gone from 3 to 6, you've doubled that, well you're really starting to effect my workload. Not that they're not there to help me but I still have to help them so I have my allocation of 10 patients on night duty but I've got to be able to help them because, like, they - there are certain things they can't do. So, instead of me be there helping one or two on night duty to do their drugs, I've suddenly now got to find allocation of time to go and help the others and in the process my patients have wait, which means sometimes they're waiting, you know, one, two hours for pain medication or what ever because I - I have to keep spreading myself. So, yes. It is a physical help to have someone trained with a pair of hands but it also impacts on the skill mix on the ward. I - I've got work in a ward of 29 critically - generally critically ill neurosurgery patients. That has changed in the last 10 years. I used to have 5 critically ill neurosurgery patients and a range of people getting better. You can't change my skill mix that dramatically. Start throwing too many graduates in, how can I go and give them - the patient with tubes coming out of their brain to measure their CSF and haemovacs coming out of their brain and - and do they know how to do proper Glasgow Coma Scales. I can't have people who aren't skilled enough to do that or who I, then, have to give too much support to. It's not fair on the community, it's not fair to the patients and it's not fair to my colleagues.
PN1092
Thanks. I've got nothing further for Ms Murphy.
PN1093
MUNRO J: Your evidence at paragraph 4 is that Sir Charles Gairdner is currently not staffed to establishment figures and has a nursing bed crisis. In your section, is there an existing vacancy against establishment or number of vacancies against establishment levels?---I guess, you Honour, when - when I wrote that, it was from my role as manager in the hospital and that is because in July when I managed each night - as I said previously, I found myself that we were down for a - a.m. shift, like one shift up to 35 nursing staff of which I could only fill 10. Now, I can't give you exact hospital - - -
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1094
That was the hospital-wide figure?---That was a hospital-wide figure.
PN1095
Yes?---What was happening in my ward at that time and throughout the hospital is that we had beds closed as we do at the moment because it's school holidays. Our 29 bed ward has 5 beds closed and we're still struggling within my own roster in neurosurgery to cover that. We rely heavily on agencies throughout the hospital which has its own problems. I believe that we're down something like 90 FT but I'm not privy to that. But certainly as a manager, it is absolutely devastating to know that you're leaving a shift down over 20 staff throughout the hospital. For example, there's a ward called, G75, it's a very large ward and on the 25th of July they only had 4 of their own staff rostered on. They had been doing double shifts, people were sick. There were - they needed 10 of their own staff for the morning, well there was, you know, 25 or 35 vacancies in the hospital. I had to prioritise as manager as to just how many people I gave them. I think I gave them 2. So that meant patients have to go without care. You know, if you're down another, you know, 3, 4 staff - - -
PN1096
The figures you are giving, I think, 35 - - -?---On the first - - -
PN1097
- - - shortfall on a particular shift?---That's right.
PN1098
Or 35 to 33, I think, or 45 to 43?---Yep.
PN1099
Was that an isolated instance or was that a relatively recurring sort of problem?---Certainly for the shifts that I did throughout July, that was a recurring problem. I - without a doubt, your Honour, they were the hardest shifts of my life. Not just from a nursing perspective but as an RN. The hospital was full. On every one of those days we had no staff. We had no beds for the patients. We had about - ANE was overflowing. I had something like 7 codes in the night requiring me to run up to 17-hundred metres. We found someone unconscious in the Medical Library at the back of QEII, required me to run out of the building by myself in the dark to go down there. In the middle of an arrest, I had a phone call from a staff member that was committing
**** LORETA VERONICA MURPHY XXN MR ELLERY
suicide and I had to stand in the arrest throwing needles and - and look up the telephone book to - try and find out where she lived to send police there. They were very challenging shifts. But now that we're back into school holidays, I believe once again we're in that sort of dramatic cycle of having no beds and having no staff because people are taking holidays to be with their children.
PN1100
Was there any extraordinary about July and the surge that occurred other than it was a high work period? Was there something that would have - - -?---We - we - - -
PN1101
- - - explained if it was unusual?---Not unusual. Typical of winter. We know when we hit winter we have flu's go through the staff and that we also have school holidays and it's - it usually means a lot of trouble for us in order to find staffing. My own gut feeling is that this year, because we have had so many staff working double shifts, working a late and then continuing on through night duty, is that the staff's burn-out is quite high and be that they are more vulnerable then to picking up colds from patients or from fellow staff. I think that didn't help. But nursing is - does fluctuate. You know, there are times you go into work and it's - you know, it might be the holidays and surgeons aren't operating. Through that time, your Honour, the other thing the hospital did was, to try and manage it, that for at least - I'm aware for at least an 8-week period, perhaps it was longer, the hospital cancelled unofficially all level 2 and level 3 operations and all level 1 operations had to be prioritised. We have a full hospital, no empty beds, very few staff and we had to prioritise who actually went to theatre. And that's how the hospital's management chose to - to try and circumvent some of - some of the dangerous situations we were finding ourselves in.
PN1102
Yes, thank you. You refer in paragraph 7, "No time for any education." Is that education of the patient or education of the staff - this is with reference to swallow assessments in neurosurgery?---It's a good question. I - I actually probably - I was referring to staff but it probably - falls into both categories. You do have reduced time with your patients so therefore you do have a reduced education time with family. For - my own sake that I find now we will have a new piece of equipment come onto the ward and whoever's on the ward on that day will get a bit of education about it and then it becomes an ad hoc form of education that who ever's with you on the next shift or - might say to
**** LORETA VERONICA MURPHY XXN MR ELLERY
you, oh, I think this is the way it works and that's pretty much what happens. The education I saw when I started nursing where we were - formally educated on new equipment. We had sheets that were ticked off, you were assessed. There actually isn't time for that sort of education now.
PN1103
Yes, and at paragraph 12, I think you refer to staff development being minimal. What are you referring to there when you speak of staff development? If resources were available, would the staff development that you have in mind be able to be delivered on site during working time in the unit with which you are most familiar, that's neurosurgery again, I take it generally?---I think two things would have to happen. I think that outside of the - the nursing crisis is there's been a change in economics and we used to have staff work, 7 until 3.30 and then the overlap started at 1 o'clock. And in that time, if you had sufficient staffing numbers, you had a - a couple of hours overlap where you could - you would, traditionally, take the staff aside and you would say, okay, we're having education on this topic today, who's been to it, who hasn't been to it. The nature of economics was such that they started to cut out the overlap time and that had a huge effect. One, it meant very poor hand-over, it meant agency shifts now leave at 1 o'clock and some of the other staff don't start till 2 or 3 o'clock. So that whole period where you had a good hand-over on your next patients and you had an opportunity to educate your staff. Either about the dynamics on the ward, to have ward meetings or to learn new equipment or to constantly refresh on education which is vital with neurosurgery with, you know, staff are a - a fluid lot. That doesn't really exist now. You have a quick hand-over and hope someone's around to tell you about your patients.
PN1104
But hand-over is a different notion, isn't it, from staff development hand-over would go more to patient care than - - -?---That was what that whole - - -
PN1105
No, not the staff development doesn't - - -?---Yeah, that's what that whole period was for, you combined a good hand-over and you usually had a staff-development team that would come into the ward and work with you or your senior nurses, your CNs would hold portfolios of education and - and they would use that time at the end of hand-over to say, right, now we're going to have education on subarachnoid haemorrhages. Who - who needs to listen to that, or we've got new ventricular drain tubes measuring the CSF fluid from your brain, let's have an education session on that at the end of hand-over.
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1106
I see. The method of hand-over now, you say, has an audio tape hand-over?---That's ward dependant, your Honour.
PN1107
Yes. How does that differ from an oral hand-over?---Some people like it. My preference is not to have an audio hand-over. You find that staff record the patient care on the - on the tape recorder, they may then leave and the leave one person on the ward to look after the ward while the new staff are listening to the hand-over. It means that there's no correspondence for you to interrupt and say, oh, you said that patient's blood pressure was high, well what did you do about it or what happened when you gave the drug. You can't then question the fellow nurse about her care.
PN1108
So, the tape is a single tape?---Absolutely.
PN1109
Where, for instance, with the 29 patients someone would run through and touch on the whole 29 or the 15 who seemed most critical?---Yep.
PN1110
And to get the hand-over you would have to start at the beginning of the tape and go right through to the end?---That's right. Now, that's the way they do hand-over in neurology. In neurosurgery, you have a different dynamic because the patients are so ill they actually don't have - everyone sit down and listen to all 29. They - you have a hand-over from the nurse who was looking after your 5 patients for the previous shift. Now, you regularly find that 2 or 3 people might have looked after the 5 patients you've been allocated. Some of them have already gone home because they're agency and finished at 1.00, so you hope someone has heard something about them or you have to read the history yourself. And then you have a different dynamic that when everyone goes on their tea break, you haven't had a general ward hand-over and a patient arrests in room 3, you know nothing about that patient and you're there grabbing the history trying to read and find out what's happening as you go along. It all comes down to just not enough time, I guess.
PN1111
Paragraph 16, you are on call Sunday to Thursday between 8.30 and 2 am, that's paid on-call duty is it, you're available to be called - - - ?---Your Honour, I've actually - I've actually stopped doing that now on the grounds that - - -
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1112
Let's just deal with the theory, if you were?--- - - - I would just like to explain, because I wasn't getting paid on-call. I knew the hospital was in a crisis, and they know me very well, so I live 10 minutes from Sir Charles Gairdner, they were phoning me at 8 o'clock at night. I would come in, they would give me push bike and I would ride around the hospital and trouble shoot on the wards. I was doing it a lot and I found that what was happening I was getting paid my basic rate, 4 hours, I was getting home at 2 am exhausted and then getting up at 6 o'clock when my kids got up and starting my next day, or going without sleep, being up for 38 hours having not had any sleep, and I eventually had to make a professional decision that if I could be paid no more than my basic salary, the feeling of the hospital was that since I was a general nurse there was no access for me to be paid an on-call re-call rate and that only specialist theatre Nurses and gastro-intestinal nurses would be paid that I would not be paid that and I made a professional decision to discontinue it. They still know if they're desperate I will do it, but I - I try not to now.
PN1113
And has that position, do you know, been changed by the recent agreement that there is an on-call availability, that's limited to specialist staff is it?---I was the only one - that's right. That's right.
PN1114
I see?---I did speak to the Manager about it recently and she said to me, "Loreta our hands are tied, you know what the agreement says, we can't do anything about it". And I said, "Well, if that's the case I really have to probably withdraw from doing it on a regular basis".
PN1115
Yes. Thank you.
PN1116
SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Ms Murphy, given the indication that you've given us that there is fairly heavy reliance placed on the use of agency staff, can I ask in that neuro-surgery and neurology area, how important is knowledge of the Sir Charles Gairdner Hospital in relation to the agency staff whom you might recruit?---The knowledge of the hospital in general or their specialist knowledge?
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1117
Or knowledge of that specialist area within the hospital?---It's - it's so vital. One of the things that I was really horrified about one night, as Manager, was I walked through neuro-surgery and I know it very well obviously, and I walked into the high dependency unit and there was two - one agency and one casual pool person. Now, neither of those staff are trained in neuro-surgery. And I glanced around the room, there were 7 critically ill neuro-surgery patients in there and one of the patients had this enormous bandage on their head, and I said to the Staff, "What on earth are you doing?" And they said, "Oh, he's come back from theatre, he's had" - what's called a sub-dural haematoma, a blood clot drain from the brain - "and he keeps - he keeps bleeding from the site, so oh don't worry about it, we've just put another bandage on top." And I just stood there for a minute absolutely aghast, I said, "What are you doing", I said, "take those bandages down we need to know what's happening inside this man's head, has he got too much pressure, and that's why the blood's bursting out? Does it need another suture?" And I stormed down to the person in charge of the ward and I said, "What are you doing?" And she said, "I hear what you're saying, but look at what I've got on the ward. I had to manage the ward, I'm the only person who knows neuro tonight, this is what I've had to do". Now, I said, "Well, you need to get in there and you need to treat this patient, you need to get the doctor up and we need to sort out what's happening". The two people in that room are excellent nurses, I've worked with them before. They are good general nurses but they were completely oblivious to the anatomy behind what was happening with that patient. They were giving good basic care, they were putting a bandage on top of his bleeding spot. Now, that patient ended up needing to go back to theatre because they had raising inter-cranial pressure and that's why they were bleeding out. And it really, really came home to me that night that we often are doing - we're just getting by, you know, we've got a pair of hands, so we go: okay, we will put them in that place. It's not the case. And then I thought to myself: well, what's happening in the rest of the hospital? I was able to find that because I know neuro-surgery so well; what's happening in the - the respiratory high-dependency unit? What's happening in the cardio-thoracic unit. Another night I came on and they told me there was no staff to manage the cardio-thoracic ward. So, one staff member had volunteered to stay back, she had been up since 7 am on the Sunday morning, she had worked the late shift. She stayed through the night completely with agency staff, none of whom knew anything about cardio-thoracic or the monitors, and at 3 am I found another staff member who said, "Please go up to the ward and make this
**** LORETA VERONICA MURPHY XXN MR ELLERY
girl lie down for 2 hours". Well, when they went up there three monitors went off. She was the only one who knew cardio-thoracics. So, we had agency staff there to kind of I guess make sure a patient doesn't fall out of bed or to give out the drugs or to help in whatever way they had. But if you don't have specialist knowledge I just think it's - it's fundamentally wrong. As a family member, if I had a patient in neuro-surgery I would darn well expect that someone with some sort of knowledge would be working in the high-dependency unit.
PN1118
So, can I just take that a step further. It's not simply a question of having a requisite number of registered nurses in a given ward - and for the sake of the example let's take the neuro-surgery area - it's a question of having both nurses with that experience - - - ?---Yes.
PN1119
- - - and then how important is experience within Sir Charles Gairdner Hospital, in addition to the neuro-surgery nursing experience?---Since I have only been at the hospital four years I would say that it is important because if you have experience within a hospital you know who to access, you know that if your patient's deteriorating if you ring this number you can get a clinical nurse consultant to run in to help you. So, it's understanding polices and procedures that Sir Charles Gairdner have, understanding that in that specialist ward there are those folders over there that might help you learn those things. It's knowing how to call the nurse Manager, it's knowing that in our hospital if a patient in neuro-surgery hits you over the head, which is not uncommon, that you can pick up the telephone, dial 91 and call the code "black" and have security and guards run and hold the patient down while you drug them so that you don't get physically abused. So, you're quite right, a good ward is run on skill mix, which is from having the highly educated to the less educated to your ENs who are there who can physically, awful as it sounds, give you a pair of hands or give love and care to the patients and yes, it is about trying to get as many of your own staff. As a Manager, if you see a good casual - a good agency nurse coming through, you regularly say: oh, come on, do you want to join our staff? Because you want someone who's a part of the whole hospital culture that understands how the hospital works and understands how to access the information.
PN1120
MUNRO J: Thank you, is there anything arising out of that, Mr Ellery?
**** LORETA VERONICA MURPHY XXN MR ELLERY
PN1121
MR ELLERY: Just one thing arising.
PN1122
The neuro-surgical wards, is it the case that there's only two of them in Western Australia, Royal Perth and Sir Charles Gairdner?---I believe so, but I think Fremantle care for some neuro-patients but I think they're usually transferred up to us, so I think you're probably right about that.
PN1123
MR ELLERY: Okay. That's all thanks.
PN1124
MUNRO J: Ms Burke.
PN1125
MS BURKE: I have no questions, your Honour.
PN1126
PN1127
PN1128
MS BURKE: Mr Clancy could you repeat your full name for the Commission, please?---Michael Barry Clancy.
PN1129
And do you have a copy of your statement?---I do.
PN1130
Thank you. Your Honour, that is ANF14.
PN1131
PN1132
MR ELLERY: Thanks.
PN1133
Mr Clancy, you work full time, is that right?---Yes.
PN1134
And could you to me the normal roster than you work and the length of the shifts on your roster?---I work at the moment on night shift, 10-hour shifts, usually Friday to Monday nights, 4 nights in a row.
PN1135
And does Royal Perth Hospital operate on the standard 8-hour 10 shift arrangement?---Yes, I would do a 10-hour shift. There are - are people who do work 7-hour shifts at the hospital still.
PN1136
Are they full time or part time employees?---I think they - it's a matter of - they're considered full time, but they're - I think they're paid as part time. They're not eligible to have RDOs and things because they're - they have their 7 - 7-hour shifts.
PN1137
Now, you refer in your evidence to events that occurred in January this year, when there was industrial action taken by nurses, do you recall that, bed closures in particular?---Bed closures, yes.
**** MICHAEL BARRY CLANCY XXN MR ELLERY
PN1138
Yes. Can you just explain to me firstly what actually happened when you say "bed closures" you describe simply that "bed closures occurred", what do you mean by that?---Well, the - certain beds were blocked at the time to make a one to four ratio. Notices were place on the bed to - to block the beds to what was considered a safe level at that time.
PN1139
And who would place the notice on the bed?---Usually the nurses who worked on the - on the ward would put them on there when - it was done with negotiation with the management as well, because I was as a job rep at the hospital not - not this time, but the previous EBA, we used to negotiate with them on allowing the - the beds to be closed.
PN1140
Well, in January 2001, did the management of Royal Perth Hospital agree with the bed closures?---I'm not quite sure exactly - they were closed, there was no objection to the managers on our ward to closing them.
PN1141
And when beds were closed was there any discussion or consultation with other wards as to the effect that that bed closure might have on other wards' operations?---Not on-going - well, there may have been on a previous - - -
PN1142
Are you aware of it?---I'm not aware of it.
PN1143
Okay, that's what I need to know. Do you have any idea what happened to patients who would otherwise have been occupying the beds that were closed?---Well, the beds were closed when a patient left, so the patient - I believe non-essential operations were cancelled because of it, to allow for the beds to be closed.
PN1144
Right, so the operations were cancelled and delayed, is that right?---Yes.
PN1145
Okay. How long did this period of bed-closures go on for?---It wasn't very long, it was only sort of a short time.
**** MICHAEL BARRY CLANCY XXN MR ELLERY
PN1146
Are we talking days, weeks, months?---There was days that I was involved in it.
PN1147
So, did you personally directly direct the beds be closed on your ward that you worked on?---I did when it was a night shift, yes.
PN1148
Yes, and before doing that did you discuss or consult with anybody else in other wards or with hospital management about that?---No. It was just - it was a matter of what was happening at that time, when a patient was left and there was a bed available to be closed.
PN1149
Right?---Most of the time - we actually had extra beds available anyhow that weren't occupied, it was like a symbolic thing, really, didn't really mean much.
PN1150
But some patients had their treatment delayed or cancelled?---Yes, mainly I think non - we had some video-monitor patients who were coming in to have their epilepsy video-monitored and they were cancelled and we don't have that many theatre patients on our ward, but they were placed in other wards because of - - -
PN1151
Okay. Thanks, Mr Clancy I have nothing further.
PN1152
MUNRO J: Mr Clancy, in paragraph 11 you are referring to your current ward I take it is straight neuro science?---Yes, that - that includes - - -
PN1153
That's what, people whose condition is relatively stabilised?---No, the acute strokes unit.
**** MICHAEL BARRY CLANCY XXN MR ELLERY
PN1154
But not surgical ones?---No, not surgicals, acute stroke, Parkinsons, motor neuron disease, multiple sclerosis, there's an odd patients there who are sort of newly diagnosed and sort of traumatised by the fact they've found out a condition, as well, so there's a very high dependency on the areas, a lot of patients aren't able to do any - any of their normal activities that they do for themselves so we have to do everything for them initially, and then gradually try and help them to rehabilitate so that they - you would actually stand by and allow them to do things and then when they fail you sort of step in and sort of encourage them and that - - -
PN1155
And some of them would be undergoing current treatment I take it would they, Warfarin and those various things that they use to - - - ?---Yes, they're usually Heprinised when they come in to dissolve any - any clots or reduce the chance of clots being thrown off by their heart - - -
PN1156
Yes, so it's active treatment as well as post-onset therapy of various kinds?---Oh yes, it is.
PN1157
What is the current level of staffing, I think you refer to there having been a shortage of nurses, are you up to your full time equivalent establishment at present or are there vacancies?---Well, there's - I think there's vacancies at the moment, but we normally have three nurses on at night time to look after 31 patients and during the day it's about 7 to look after them, so - - -
PN1158
And are those figures relatively stable and are all the positions filled?---No, we have a fair bit of agency staff as well, there's a big - usually a big turnover in our ward 'cause it is quite a heavy ward, a lot of people don't think of looking after stoke patients as a particularly exciting or - sort of type of nursing.
PN1159
Yes, so there is effectively day time when you say 7 there, that's what two day shifts?---Two day shifts, yes, from 7 - - -
**** MICHAEL BARRY CLANCY XXN MR ELLERY
PN1160
So, there are 14 and then 17 - 3 on the night shift to a total of 17, is that right?---Yes, there would be about - usually about 7 - yeah 14 and for the two day shifts, and yes 17, yes.
PN1161
And of those 17 some are agency staff, do you know roughly what proportion?---It varies all the time. We've had people coming and going all the time, people that are sick, people who have done their back in or on workers compensation, it fluctuates all the time. Sometimes it's quite good, we have the full complement of staff, but other times we don't. More often - usually in the winter months we're usually constantly running short.
PN1162
Do you know whether it's the aim ordinarily to fill all 17 of those positions or would the normal staffing practice be to have a number of them dealt with by casual or agency staff to give flexibility?---Well, I think they - I think they try to but they're not always able to attract the staff. They've increase the - we used to have a lot more registered nurses and they've replaced them with enrolled nurses lately that sort of usually means that the registered nurse has to do more medication of the - or the enrolled nurse is so that you've got a - it's an increase ..... they have less - there's less registered nurses to - ratio to the patients.
PN1163
And is that 31 patients a relatively constant figure or has that fluctuated a fair bit from week to week?---Most of the time we're full. Yes, as soon as the patient goes out we've sort of got another - they're ringing us to find out when the bed's available sort of there doesn't - get a chance to get cool usually.
PN1164
Yes, in paragraph 19 you referred to education sessions:
PN1165
Since the Departments took over responsibility, promised education days have not taken place -
**** MICHAEL BARRY CLANCY XXN MR ELLERY
PN1166
could you tell me about that, who promised the education days, what do they mean?---Well, we - we have actually had one education day where we were actually paid to come on to a day time to - a day shift to - since this time to do our basic education and fire manuals and a few other things that are important for the area, but that's the only one that we've had. We used to have a Friday night session where we would go off the ward for 2 hours. They would have a day shift person on for 2 hours and they would - to replace it they would say later and they would - so we could have like general education sessions on different diseases and things in the hospital, but that stopped. Our Managers told us that were - had them about a year and a half ago said that we were going to have them, and kept on saying they were going to be starting soon, and it kept, you know - - -
PN1167
And was there a particular quantum of education days or just that there would be one every now and again?---Well, they said: oh we're going to have all these education sessions for you. But so, far we've only had the one.
PN1168
And it was not part of any formal industrial agreement, it was hospital policy, managers being who?---No - it's - well I believe there's mandatory amounts that are spent on education is there for - is that part of the industrial - - -
PN1169
I don't know - - - ?--- - - - Industrial Act that you've - - -
PN1170
COMMISSIONER O'CONNOR: Training?---Training?
PN1171
Yes, there's a percentage - a percentage of the gross.
PN1172
MUNRO J: So, you understood that that was the purpose of it, to give effect to a training budget requirement?---Well, and the obligations for work - occupational health and safety that we had to do back - education to - that was mandatory, it's supposed to be every 12 months.
**** MICHAEL BARRY CLANCY XXN MR ELLERY
PN1173
Yes. Now, you made reference to - in paragraph 18 to:
PN1174
On Ward 8 and 8A there's been no clinical nurse on night shift for 3 years
PN1175
?---Yes.
PN1176
Do you know whether that position has been lost so far as a vacancy goes, or you say it's been transferred you think to some other part?---Well - well it's - another clinical position was made for the days, so a clinical nurse was put on to the day shift, so we assumed that that position was lost to the day staff.
PN1177
I see.
PN1178
SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Mr Clancy, can I ask you to assist me on the question of staffing mix in your current Ward 8A and can you advise me of what impact on your work would arise from the requirement that the Ward be staffed with a majority of agency personnel who would not be aware of or necessarily have experience in that particular hospital or, indeed, in that neuro-science area of nursing?---Even though we deliver a lot of basic nursing care, there's a lot of things with - special things with people with strokes. We do bladder scanning after they have a stroke to make sure that their - their bladder is working properly. I've seen a patient that wasn't - the nurse didn't realise that the - that the patient wasn't voiding properly. The patient was voiding about 300 mls at a time, had a 2 litre bladder - left in the bladder. The bladder was sort of expanded and damaged the muscles of the bladder, making that patient - rehabilitation would take another 3 months or something to - longer. Dysphasia screening. We've got to screen the patient for ability to swallow and we have a screen, a check list to do that. People unfamiliar with it wouldn't know what to look for in the swallowing processes. There's a tongue control, ability to - facial weakness, ability to cough. People can silently aspirate and they can develop pneumonia, which can lead to dire consequences later on. There's other mobility factors that people pulling on
**** MICHAEL BARRY CLANCY XXN MR ELLERY
shoulders and dislocating shoulders of the affected arm that a person's had a stroke in. Trying to lift them or transfer them improperly, whether they - the nurse damages their back because they don't know how to transfer them. There's a lot of things that do - can occur if the staff don't - are not aware of what - what's happening with the - the patient.
PN1179
And does that requirement that there be specialist knowledge of the neuroscience area extend to the enrolled nurses who work in that area too?---Yes. The staff development go through a procedure. We have a stroke unit manual. We're actually one of the best stroke units in the southern hemisphere. We've got a very good rehabilitation rate with our stroke patients and they're all taken through in the induction course to show them most of these procedures and I will guide them through usually with a preceptor to help them along in the initial stages. And then they're certified for every competency that they achieve. They're certified that they're competent to do - do them.
PN1180
Thank you.
PN1181
MUNRO J: Yes, Ms Burke? Do you have any - - -
PN1182
MS BURKE: I don't have any questions, your Honour.
PN1183
PN1184
MUNRO J: We will take a short adjournment.
SHORT ADJOURNMENT [11.44am]
RESUMED [12.08pm]
PN1185
PN1186
MS BURKE: Ms McNally, could you please state your name again for the Commission?---Yeah. My name is Raye Michelle McNally.
PN1187
And do you have a copy of your statement in front of you?---I do.
PN1188
PN1189
MR ELLERY: Thanks. Ms McNally, you explained that you were an enrolled nurse in Queensland prior to coming to Western Australia. Do you work with enrolled nurses in Western Australia?---Yes, I do.
PN1190
In your view, is the level of training of enrolled nurses in Queensland that you went through similar or different to that gone through by enrolled nurses in Western Australia?---The training of enrolled nurses here in Western Australia is 18 months and they actually go through a TAFE system over here which allows them more scope of practice than what Queensland enrolled nurses do.
PN1191
So enrolled nurses here are more highly trained, is that what you're saying?---In my experience, yes.
PN1192
Yes. Okay. What roster do you personally work on?---I work on a - I don't know. It's not a set roster. I work rostered shifts that I'm given. I work early duties. I work late duties. I work night duties. I'm not on a set roster. Currently I'm employed at a 76 hour a week contract - a fortnight contract.
PN1193
Fortnight. And what is the length of the shifts that you normally work?---Okay. I normally work an 8-hour early shift or a 6-hour early shift. I work either a 6-hour late shift or a 6-hour - or a 8-hour late shift and I work a 10-hour night duty shift.
**** RAYE MICHELLE McNALLY XXN MR ELLERY
PN1194
Right. Okay. Now, is it the practice of your Health Service to ask nurses whether they wish to be put on a list to be available for overtime?---I've never been asked whether I wish to be put on a list to do overtime. I have volunteered to do overtime on certain days if it suited in with my family.
PN1195
Right. Have you ever worked authorised overtime that you've not been paid for?---Have I ever worked authorised overtime that I've not been paid for? No, because any authorised overtime, I've been paid for.
PN1196
Yes. You say at paragraph 10 of your statement that too much time is spent on documentation. Is it your view that the level of documentation required has changed over time, or is it much the same as it always was?---The level of documentation has changed over time, yes.
PN1197
And do you understand why it has changed?---Just due to the legal ramifications of having to document as a nurse. There's also more in-depth assessment where you have to fill out more for the client. Documentation. We're also expected to do - as a permanent employee you're expected to do quality assurance activities. I also, on extreme circumstances, fill out incidence reports. There's a lot more documentation to do now. Even working in the Emergency Department in Port Hedland, we have to fill out every - all the demographic details for a client when they present to the triage window as well.
PN1198
Okay. Thanks. I have no further questions for Ms McNally.
PN1199
MUNRO J: Ms McNally, you refer in paragraph 4 and I think, 13, to an incident form. Could you tell me what that means, how does it operate, an incident form?---On that particular shift, I had come on the morning. It was a Saturday morning. I was working at the Medical and Surgical Ward and one of the senior registered nurses had called in sick. I was the only registered nurse working with two graduate nurses who were a week out of their training and I had an enrolled nurse on. The situation was at a dangerous staffing level,
**** RAYE MICHELLE McNALLY XXN MR ELLERY
whereas we had three acute psychiatric patients in the high dependency, one who had been sectioned under the Mental Health Act and was going to Graylands that day. I had a nurse manager of the night duty come on in the morning who sort of looked at me and said: what are we going to do? And I said: well, I need another couple of staff members. And she said: I don't know where you're going to get them from. So I had to actually ring and look through the roster and I actually called in staff from the afternoon shift to fill the morning shift. And because I was coordinating the shift as well that day, I just felt that - well, I knew that there was a lot of work that wasn't done. I had to tell the graduate nurses, who were quite unsure of themselves, that we just did basic nursing. We looked at - I just used the acronym and then the Danger Response Airway Breathing Circulation. I said: forget about bed making, forget about showers. If you can walk into the room and the patient is looking at you and talking to you, then they're fine. I had a psychiatric patient who had tried, on my shift twice, to kill themselves. I had to send the enrolled nurse with her and I said: you just stay with her until she gets transferred down. I did not feel supported by my nurse manager, who I will state was a agency nurse, at the time and didn't know the running of the hospital and so I needed to cover myself because we had one of the - an assault victim came in. They didn't have any neurological observations or any admission observations. I just needed to fill out an incident form to let people know what had happened.
PN1200
And what is an incident form?---An incident form is - it's an East Pilbara document. It just states - it's like an Occupational Health and Safety form that you fill out for actual incidents that have occurred. It's not so much for medication incidents as we have a separate form for that. It's for near misses that may have occurred. It's just when you identify an unsafe situation that you - - -
PN1201
And who does it go to?---I put it in. I got the other nurse who had called in to sign it with me and I would assume it would go to the Occupational Health and Safety officer or the Risk Management officer for the East Pilbara Health Service. And I assume the Director of Nursing.
PN1202
And is that peculiar to East Pilbara or is it the sort of thing that applies, do you think, right throughout - - -?---I have done it in - in other places.
**** RAYE MICHELLE McNALLY XXN MR ELLERY
PN1203
So they have a thing called an incident form for situations that are of concern related to occupational health and safety?---Yes, they do. Other places I have worked, I have filled out incident forms.
PN1204
The current staffing level, you work almost anywhere in the Pilbara Health Service, I take it?---Yes, I do.
PN1205
What's the total establishment there?---The total establishment for the - - -
PN1206
Yes, well, nursing staff?---I think - I think it's about 110.
PN1207
I see?---Yeah. I'm - I really don't know, to be honest.
PN1208
And is there a shortage there?---Most definitely. On that particular ward, I think just for registered nurses, they have a staff allocation of about 14 or 15. Permanent, we have four nursing staff. All the rest are agency staff that come out on contracts either 3 or 6 months.
PN1209
You're on a contract?---Mm hm.
PN1210
What's the duration of that contract?---I was only bound to the Health Service for a year because they relocated me, so my - it's a permanent contract after a year.
PN1211
I see, and you will be on permanency with them after a year or you will be free to - - -?---Well, my year is actually finished now so I can just give in my notice if I choose to.
PN1212
I see. And you would prefer to be not bound by contract or would you prefer to be a permanent member of staff?---I - I actually like being a permanent member of staff. I like having the stability there.
**** RAYE MICHELLE McNALLY XXN MR ELLERY
PN1213
Is that an option for you?---Yes, it is.
PN1214
So effectively, after the 1-year contract rolls over - - -?---I can be.
PN1215
- - - or you will be rolled over on to permanent staff if you seek it?---That's - that's correct.
PN1216
Yes.
PN1217
MR WALKER: Your Honour, could I please ask the witness a question? One of my witnesses that I had indicated, in my submissions.
PN1218
MUNRO J: Yes.
PN1219
MR WALKER: With enrolled nurses, in your third paragraph of your witness statement, you're referring to the staffing of the high dependency unit where it could be either 1 or 2 enrolled nurses. Do those enrolled nurses take on a full workload, a full caseload?---They do because - they - I don't fully quite understand your question. An enrolled nurse cannot man the high dependency unit by themselves, if that's what you're asking, because it's more specialised nursing.
PN1220
I understand?---On that day of the incident form, I had to put an enrolled nurse in there because of the psychiatric patient we had and I assessed the situation that it wasn't more specialist nursing where a registered nurse's skill is needed.
PN1221
You just refer to an either three or two junior RNs?---Yeah. That's to man the actual medical surgical ward, not the high dependency ward.
**** RAYE MICHELLE McNALLY XXN MR ELLERY
PN1222
So in that case, would the enrolled nurse take on the equivalent workload of a graduate registered nurse?---That's - that's a bit of a controversial question you're asking me, because an enrolled nurse can't take on the work of a registered nurse. An enrolled nurse, regardless of their training here in West Australia, still works under the supervision and direction of a registered nurse. So while they may be allocated their six patients, I am still responsible as a registered nurse for their nursing care.
PN1223
Would you also be responsible for the graduate RNs as well in a similar situation, similar circumstance?---That's where you're getting between - well, no, not really, because as a registered nurse, they're still a registered nurse. They're responsible and accountable for their own actions. They would take responsibility for an enrolled nurse, as a graduate, as a matter of conscience, because I love nursing and I - and I love training my junior registered nurses. I do look after them and I do allocate a workload to them that's acceptable or hopefully acceptable and so that I can follow up and help nurture them in their nursing career, otherwise they get frustrated and want to leave.
PN1224
Can you tell me the number of enrolled nurses at the Port Hedland Health Service?---I probably couldn't tell you the number of enrolled nurses actually working at Port Hedland Health Service. In the Emergency Department that I'm now working, we have about six enrolled nurses. In the Medical/Surgical Ward that I was working on when I filed this witness statement, there's say about four or five.
PN1225
Are there any mental health enrolled nurses working at - - -?---Not that I'm aware of.
PN1226
That's all I have, your Honour.
PN1227
MUNRO J: Mr Ellery?
**** RAYE MICHELLE McNALLY XXN MR ELLERY
PN1228
MR ELLERY: Nothing arising, your Honour.
PN1229
SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Ms McNally, just one question. In situations where there are staff shortages in specific wards, does the hospital relocate or endeavour to relocate nurses from other wards within the hospital to meet some of those specific skill shortages?---Usually they're - can I just explain how - - -
PN1230
Certainly?--- - - - the Port Hedland Hospital works? We have, in the Emergency Department there's usually a registered nurse and an enrolled nurse working for the morning shift, or two registered nurses. For the late shift you've got either two registered nurses or one registered nurse and one enrolled nurse. For the night duty shift, you have one registered nurse on all night and you have your enrolled nurse on until 1 or 2 o'clock in the morning. From then on it is the registered nurse only in the Emergency Department with - you have a night nurse manager who's expected to provide the backup. In the Maternity Ward they work on a two system as well, two in the morning, two in the afternoon, two at night and usually it is a midwife and an enrolled nurse. They have recently brought in an 11 to 7.30 shift in the Maternity Ward. We also have had that in the Emergency Department to cope with - - -
PN1231
MUNRO J: What, 11 am to 7.30?---Yeah, pm, to cope with meal relief and the extra workload we've been experiencing there, because in the paediatric ward we - we work on the two, two, two roster. Up in the Medical/Surgical, it's usually five, four and three. So there's not a lot of fat on the system if I can say that, so that if I needed help down in the Emergency Department, you either call in a nurse usually off the Surgical Ward to come down and help, or the nurse managers have actually had to do extra shifts to come in and help. Up at Port Hedland we're not - don't have easy access to a nursing agency, so we can't just call in shifts. The reality is that agency nurses do double shifts. I've actually had to do split shifts where the nurse managers have asked me to go home, say, from an early shift at 12, come back at about 6 o'clock at night and they work through till 9 o'clock till the night duty comes on.
**** RAYE MICHELLE McNALLY XXN MR ELLERY
PN1232
PN1233
MS BURKE: Ms McNally, Mr Ellery asked you about whether you were paid for overtime and the question I have is; do you ever perform any unpaid overtime?---Yeah. I answered correctly to Mr Ellery's question, because he asked me if I was paid for authorised overtime. I do participate in unpaid overtime, because in our Health Service, we actually have to - if there's a need to do overtime, if the workload's that great, in-between the overtaking of shifts, we have to get the nurse manager, contact her, get her to authorise the overtime before we actually get paid. And that would take at least a minimum of 20 to 30 minutes. And usually between 30 minutes to an hour is - sometimes all that they need is just that little bit of overlap so it's not worth contacting the nurse manager about it and going through the fights and the struggles to get the pay.
PN1234
Thank you. I have no further questions, your Honour.
PN1235
PN1236
MS BURKE: And with the exception of Ms Peggy Briggs, who as we indicated is on her honeymoon and in Thailand, that actually concludes our evidentiary material, your Honour, in this matter.
PN1237
MUNRO J: Yes, thank you, Ms Burke. I think it's in your court, is it, Mr Ellery?
PN1238
MR ELLERY: Yes, your Honour. We would be ready to proceed. I think in light of the time, I would propose rather than commence and then stop again for lunch, if we took an early lunch break and resumed earlier, if that was acceptable to the Bench, and then I would give a brief opening and then we would be able to call Ms Di Mantell and Mr Alan Jones. And if time allowed, I will just foreshadow that if we got through those witnesses quickly enough, Mr Della, Phil Della, would be available as well as a third witness. If we get to that today, and I would anticipate that it would be some considerable cross-examination of Mr Della so no doubt that would occupy the rest of the day.
PN1239
MUNRO J: We will resume at 2 o'clock? The Commission will adjourn until 2.
LUNCHEON ADJOURNMENT [12.28pm]
RESUMED [2.08pm]
PN1240
MUNRO J: Yes, Mr Ellery?
PN1241
MR ELLERY: Thank you, your Honour. Your Honour, I propose to give a brief opening statement. I am conscious that we have another listing of this matter for the purpose of closing submissions, so I don't intend to take up much time in my opening, but I think it's worth putting some things in broad context. We say firstly that one thing that is clear from all of the evidence from all the parties to this case is that there is a shortage of nurses in Western Australia and there is a shortage of nurses throughout the Western world. And there appears to be no dispute about that whatsoever. The reasons for the shortage, I think, are not clearly agreed.
PN1242
We say the reasons for the shortage are many and complex and the fact that those reasons are many and complex means that a simplistic superficial solution is not the answer. We accept that some nurses in the WA public health system have very high workloads and that that is not acceptable, and as is indicated in our written submissions, we have already undertaken a variety of measures to try and relieve that situation, but again we say a simplistic superficial approach will not solve what is a worldwide complex and difficult problem.
PN1243
A major concern we have with the proposal of the ANF, the primary proposal if you like, exhibit B1, and with the other alternative proposals that they put forward, is that those proposals ask the Commission to determine what is clearly an inherently complex political issue. Health is an issue in the current Federal election. It was an issue in the last State election. It is generally an issue in every State or Federal election in this country. How health issues are resolved, how they are determined, should be dealt with through the political process and the public policy process, and we say this forum, with respect, is not the appropriate place to resolve matters that are clearly foremost in the public's mind.
PN1244
We are dealing here with the public health system. It is public expenditure, public money, and the services are to the public and so it is the public that should determine, through the political process and through the public policy making process, how critical issues in the health system are dealt with and resolved, and we submit, with respect, that it is not appropriate for those matters to be resolved here. We refer to the Aran Private Nursing Home case, where the Full Bench in a section 170MX arbitration, found exactly that, that it - a matter of public policy shouldn't be determined through the Federal Commission.
PN1245
As you would be aware, that matter dealt with a claim for ratios. The evidence before you, in particular that of Mr Neil Purdy, is that the exhibit B1 proposal would provide an additional cost to the State Government of about 58 million per year. It is not an insignificant cost to the State Government. The ANF proposal is aimed at assisting, in their view, the needs of their members. Nothing wrong in that, nothing surprising in that, but the Government, and we would say, with respect, the Commission, doesn't have the luxury of looking at these issues solely through the perspective of nurses or solely through the perspective of registered nurses, I should - should specify.
PN1246
The Government has an obligation, obviously, to serve the needs of the public through providing health care. The Government has an obligation to spend money wisely and appropriately. The Government has an obligation to the various parties who are direct participants in the public health care system; doctors, allied health professionals, third level carers such as PCAs, orderlies, enrolled nurses, clerical and administrative staff. The Government has a very serious obligation to meet their needs and to consider them very careful in any policy developments. The ANF's evidence, the ANF's proposals, do not speak to those participants in the public health system whatsoever.
PN1247
They are very registered nurse specific. Now, as I say, there is nothing improper, obviously, in the registered nurses' union pursuing the interests of registered nurses, but we would submit that this body, the Commission, must take a broader approach, must consider the interests of other participants and parties and cannot simply determine an issue with reference only to the interests of one specific occupational group. The ANF in this State do not have award or agreement coverage of enrolled nurses, yet their proposal purports to control and limit the number of those enrolled nurses who may or may not be employed, and we say that simply is unworkable and is unrealistic.
PN1248
There is evidence before you that the nature of duties undertaken by registered nurses have changed significantly over recent years. The clear implication is that it will continue to change. There is evidence before you that technological devices and systems have changed also. Clearly we're not looking at a static system. The system will change. The roles and relationships of different occupational groups can and will change over time, yet if that is to occur, the ratios proposal would clearly inhibit and limit that. It would freeze the role of registered nurses and to a degree enrolled nurses, in a way that the ANF determines at this time and it would limit the ability to change and evolve those roles over time and to change and evolve the roles of other occupational groups who closely interact with and deal with registered nurses and enrolled nurses.
PN1249
The issue of provision of proper care to patients clearly requires clinical judgment. And again we say that, with respect, this is not the appropriate forum that can exercise that clinical judgment. Clinical judgment must be exercised by those in the workplace with the knowledge, the expertise and the training to properly do so. And to freeze in time the ratios or some form of ratios that the ANF proposes, obviously eliminates the ability to exercise that clinical judgment on an ongoing basis. Some of these issues that I've raised suggest how complex the issue and how complex the problem is, and in our view, they all support the view that managerial prerogative in this case and this circumstance should be respected and preserved.
PN1250
It is a dynamic situation, it is a difficult situation and those with responsibility to manage it must be left to manage it as best they can. That also leads to the issue of the role and the right of the State to determine its own functions. Health is clearly a major proportion of the State's expenditure. It's about a quarter of the State's total expenditure and that's broadly reflective of all the States of Australia. And clearly health is a core function of Government in this State. It's one of the core functions that the public of the State require the Government to carry out for them. Therefore it is not appropriate, in our view, for this forum, again with respect, to control or limit the ability of the State to properly that very important function.
PN1251
In addition, we have alluded to the principles of re AU; Victoria and the Commonwealth, and we say that all of the ANF proposals clearly impinge on those principles, and we will go to that in further detail, I suggest, in our closing submissions, but we say that re AU is very germane to this matter. While the issue is very complex and difficult, clearly the Government has already undertaken a variety of measures aimed at redressing it as best as can be done. There is the allocation of $69 million over 4 years for the recruitment of 400 new full-time nurse positions or the equivalent of. There is an additional commitment to refresher and re-registration courses, which has already had some success and there is evidence of that before you from Ms O'Farrell and Mr Della.
PN1252
There is additional advertising campaigns, which again have had some success and separately, and I don't think the State Government can take credit for this, but separately there are better retention rates at the universities who produce graduates in this State, and there is a new university course at Notre Dame University which is going to be producing graduates as of next calendar year. So various events have occurred and are occurring which will over time ease the problem. The problem will not be solved tomorrow, regardless of what happens in this forum. It is a long-term complex problem.
PN1253
It is a problem throughout the Western world, but this Government takes the problem very seriously and has implemented a number of measures to redress it. Not the least of those measures is the certified agreement that was reached recently, certified by this Bench. No trade offs, significant pay increases, additional pay increments for level 1 and level 2 nurses, the if you like, the hands on clinical nurses. Better allowances and so on. It's a significantly improved package of conditions and it is expected and hoped that this will help in recruiting more nurses to the work force and in bringing back some of the nurses who are registered but choose not to work for whatever reason.
PN1254
Now on that point, let me make this very strongly. The ANF simplify the problem of the shortage and say it's workloads, that's the only cause, and if you fix workloads you will fix the problem. Well, none of the evidence in our view supports that in any substantive detail. One simple illustration of it: you heard from one of the ANF witnesses, Loreta Murphy. Was a full-time nurse, currently working a part-time equivalent. I think about a fifth of a full-time workload from memory. Why? Because of her personal circumstances, not because of workloads. No doubt with every nurse who chooses not to work in the system or who chooses to work reduced hours, there are various reasons why they choose to take that step and it cannot be simply boiled down or simplified into saying it's workloads.
PN1255
The ANF evidence tried to suggest that in Victoria, studies there prove that workloads have caused a staff shortage. Objectively those studies do not. when challenged, it's clear that the studies referred to suggest that there has been a staff shortage and that has caused a workload problem, but not the reverse. They are confusing symptom with cause. We heard from Victoria that there had been numerous proceedings before Commissioner Blair in relation to nurse/patient ratios. Many other proceedings about other matters between the parties, but many about nurse/patient ratios. More than a year after Commissioner Blair's initial decision, there is still not a certified agreement in place in Victoria.
PN1256
There has been a significant amount of industrial disputation. There have been numerous other Commission proceedings and Federal Court proceedings about that industrial disputation, about the imposition of the ratios by the ANF in Victoria. It is hardly a commendation of the Victorian solution. And if the ANF's proposal in WA was adopted, then it's probably a good thing there's two new additional members of the Commission to be based in Perth in the near future because no doubt they would be needed extensively. Each of the ANF draft orders refer to a finding dispute resolution procedure requiring the exercise of the Commission's discretion and clearly no doubt that those draft orders, if any of them were adopted, would have the effect of the Commission being required to regularly intervene in and try to resolve concerns at particular workplaces as has happened in Victoria on a larger scale.
PN1257
The ANF have repeatedly suggested that basically getting the outcome that they seek is all that stands between nurses changing the status quo. That's a veiled but clear threat that there will be industrial action of some sort if the ANF do not succeed in these proceedings. As we have said in previous hearings, we say that that is totally improper and the Commission cannot and should not take account of that threat. The Commission should exercise its discretion properly on the basis of the evidence and the considerations before it and not on the basis of veiled threats. If it please the Commission, that concludes my opening statement. I now seek to call Ms Di Mantell.
PN1258
MUNRO J: Mr Ellery, while you're in opening, take you to what I understand you're saying, that the Commission should not intervene along any of the lines proposed by the ANF, and as I understand it, should not address the range of subject matter that goes to any linkage between workload and staff shortages or the fall off and recruitment or the declining supply caused by whatever are the changes in the profile of the labour force that provides nursing resources. Against that background of what you've put in the opening, what if any purpose are we to attribute to those you represent in having made joint application on exceptional matters order?
PN1259
Your advocacy seems to be: this is not an appropriate matter for the Commission. Don't trouble yourself with any of this material. Why are you here on your application?
PN1260
MR ELLERY: Well, with respect, your Honour, I wouldn't accept that characterisation of our position. The issue of workloads was, as is mentioned in our original submissions, was a matter of great moment between the parties and the negotiations that led to the enterprise agreement that was recently concluded as an element of the ANF's claim. It was an intractable one. It was the one that was not easily resolved by negotiation despite many efforts. And the parties agreed to jointly ask for the Commission to determine an application in the terms that we phrased. Essentially the only critical words are: the application deals with "nurses workloads".
PN1261
So we do agree and support the application that allows the Commission to hear this claim and to obviously exercise its discretion as it sees fit. So we have no difficulties with this forum hearing the claim, obviously, but we don't accept that the proposals outlined by the ANF are appropriate for the reasons that I've canvassed. And your Honour would no doubt be aware of the complexities and difficulties in establishing the prerequisites for an exceptional matter application.
PN1262
MUNRO J: Well, can that be shorthanded that you see the hearing as a process and that what your application boils down to, so far as its a joint application, is simply to provide a process, but it is a process which you think should not lead to any conclusive determination by the Commission about any aspect of workload?
PN1263
MR ELLERY: Yes, that is essentially correct, your Honour. Obviously by making the application, we expose ourselves to the process and obviously the possibility that the Commission would grant the ANF application in part or in whole and we have consciously adopted that course, but we don't support any such decision by the Commission, obviously. We have the difficulties that we've canvassed.
PN1264
MUNRO J: And is it unfair to say that while you have insisted upon that process, or the Commission as the process, you have also resisted relative to the ANF the commencement upon any alternative process?
PN1265
MR ELLERY: Well, a process did occur earlier this year during the EBA negotiations. It wasn't a quick or a superficial process. There was a lengthy and extensive effort to resolve the issue through negotiation and we have since that time resisted any further request for negotiation as the ANF has obviously canvassed, based on our experience of that process that we did go through earlier this year. We were of the view that that would be fruitless.
PN1266
COMMISSIONER O'CONNOR: Mr Ellery, I, as you well know, am pretty much involved in this whole thing.
PN1267
MR ELLERY: Yes, Commissioner.
PN1268
COMMISSIONER O'CONNOR: And my understanding was at all times that you accepted that it would be dealt with as an exceptional matter and there would be no argument from your side that it shouldn't be dealt with as an exceptional matter and indeed, if it hadn't ended up here, the union may well have achieved what it was seeking by protected action at that point in time. As a trade off for not exercising their protected action, the parties agreed to a process and this was part of that process and I can only think that your riding instructions have changed somewhat since that time.
PN1269
MR ELLERY: Well, with respect, Commissioner, I wouldn't accept that that's the case and our riding instructions have not altered. A couple of points. We contend, and the matter was never determined, but we contend that the ANF never undertook protected action, that they clearly didn't comply with the various requirements so they didn't waive - - -
PN1270
COMMISSIONER O'CONNOR: That was never - I mean, that was open to you, I suppose, at that point in time to argue that, but you settled on a conciliated settlement, having regard to the political pressures, and I accept that politicians sometimes change their minds but I doubt that in these sort of proceedings your mind should be changed, once you've reached an agreement to process the matter in a certain way.
PN1271
MR ELLERY: Well, I would accept that, Commissioner. I mean, the decision was reached at the time it was reached and you were involved in the conciliation that led to it. We support the application. We contend here and now that it is an exceptional matter and the Commission has jurisdiction to hear the application. What the Commission should then do is another question; and that's the distinction I would be making. We continue to support the right of the Commission to hear this application and it was open to us, as was canvassed in some of the earlier proceedings, to contest that, to contest that the Commission even had jurisdiction, because of re ..... etcetera. We didn't do that.
PN1272
We accept that the Commission can hear the application. What the Commission should do in response to the application is a matter for the Commission and we have our views about what it should do in response to the application. So, there are two separate elements to the decision-making process, if you like.
PN1273
MUNRO J: Just going back to an earlier point of your response, the utilisation of this process, for want of a better word, and I suppose one could add the order that you seek, which does have some extension of process involved, in that the evidence that was led by the ANF and indeed now the alternative orders that it seeks, encompass the possibility of I suppose alternative processes of the kind that are applied in other States, identifying principles and the like being in play before the Commission.
PN1274
Mr Jones's evidence included some detailed reference, which I can't claim to be across to the South Australian model, the Queensland model and I think even the New South Wales, as well as Victoria which has been the subject of much more comment. Has or is the case that you are to present gone to any refinement of the proposal for a mechanism that takes into account that line of evidence?
PN1275
MR ELLERY: In short no, it hasn't, your Honour. My understanding of how the outcomes have been reached in other States is that they have been reached partly on the basis of particular historical events and arrangements that were already in place in those States. For example South Australia, as I understand it already used a detailed computer modelling system that attempted to recognise patient acuity and I'm instructed that there were great concerns from the Department of Health here as to the validity of the model that they use in South Australia, but nevertheless, that's the course that the South Australian employer parties have taken.
PN1276
MUNRO J: I had particularly in mind and again I haven't looked at the extent to which perhaps people, other than the Department own some parts or other of those alternative models, what you have put to us in opening and to some extent the order you seek, if the ANF goes against what we put is that there shouldn't be much ownership at all of the workload problem, at least its management by the ANF as a representative of the employees. It's a matter for managerial prerogative and it's a matter of the politics of the day and the public of Western Australia on your approach.
PN1277
What I'm putting to you effectively is, do not the models in the other States allow a somewhat greater degree of participation in the answers to the workload problems and that which you contemplate?
PN1278
MR ELLERY: They do to varying degrees allow participation and I would say in some of those circumstances more than our proposal, I would accept that. I would need to look at those again to give you a response and I could take that up further in closing submissions, but I would accept that some of them certainly do allow for, if you like, greater ownership if we can use that phrase, by the ANF in those States of the matter. But let me say, I mean the proposal that we have put forward, clearly it's not accepted by the ANF, but it does require fairly detailed and onerous reporting which arms the ANF and other unions with the knowledge to pursue, through whatever forums or means that they choose, their desired outcomes on the question of workload and the model - - -
PN1279
MUNRO J: Yes. Nothing I'm putting should be taken in any sense to a pre-determination about that Mr Ellery. I'm really responding more to the way in which you've put your submissions in opening.
PN1280
MR ELLERY: No. Yes, and I don't interpret it as such your Honour, but let me say that the model we put forward does do that and explicitly ensures that it could not be taken to limit the rights of the ANF or other parties to pursue any concerns they may have of a workload, through any other forums or any other means.
PN1281
MUNRO J: Yes, the matter, as I understand it, that is the exceptional matters or the exceptional matter, was put as the workload of nurses employed in hospitals operated by the employer applicants.
PN1282
MR ELLERY: Yes, that's correct, your Honour.
PN1283
MUNRO J: That's workload generically.
PN1284
MR ELLERY: Yes.
PN1285
MUNRO J: In the submission that you have put on opening in broad terms you have put that as essentially a matter, to shorthand it, for managerial prerogative to be exercised having regard to public interest considerations, is that a fair summary?
PN1286
MR ELLERY: That's one element of our position.
PN1287
MUNRO J: Yes. I'm not trying to load you up with answers other than for the purposes of the question. One aspect that struck me about the evidence to this point, and to some extent I think is common ground in the way in which you put your submissions that you accept I think, that some nurses have high workloads. The question I'm going to is in terms of the effect of workloads on particular individuals where, given that the managerial prerogative is to insist that work be done, the context can sometimes cause workloads to be excessive to an individual.
PN1288
It seems to be at least not disputed that even if double shifts be permitted perhaps trebling up on the shift might be making it a little bit too rich, but management doesn't require that. To take it outside of the context in Western Australia, publicity has recently been given in New South Wales to, if you like, the predicament of resident medical officers, where particularly for A and E work there is probably no relief available in some facilities and I think the question was posed, I don't know for what purpose it is rhetoric, whether it was better to have a resident medical officer at the end of whatever it is, a double shift, trying to service people in the state of exhaustion or better to have sent them home and have nobody there at all.
PN1289
On the evidence in this case let's assume that high workloads or potentially excessive workloads can be a reality for some of the registered nurses who appear to have occasionally the only practical responsibility at a site, what protection is there at present for a registered nurse in that predicament - let's say it's similar to the resident medical officers' predicament - how does it work, how does what you propose that would be likely to assist them? And if there isn't any such mechanism why isn't it a matter of direct industrial concern and for industrial regulation?
PN1290
MR ELLERY: Well, let me - there is a number of elements to be put.
PN1291
MUNRO J: I know there are a lot of questions and if you simply want to take it on notice I'm quite happy to do that. I am basically trying to verbalise at this stage some fairly transient impressions, or perhaps transitory, whatever the word is, impressions formed from having read both your opening contentions and the like that are something that I want to formulate so as that you have really an opportunity to address it progressively and perhaps your witnesses likewise. It applies to both. It's got some negative elements, the questions I put for Ms Burke to deal with.
PN1292
MR ELLERY: Well, your Honour, I will take that opportunity, but let me also address at least part of it at this stage, yes, there is evidence that some nurses work for example double shifts. Is that a good thing or an acceptable thing, no. We don't dispute that nurses should not be working excessive hours and double shifts probably are excessive hours, we have no difficulty with that.
PN1293
The issue you raise about the debate about New South Wales RMOs and the question of whether it's better to have a doctor at the end of a shift or not at all in some ways is quite analogous to this case because the evidence is clear that if the ratios are granted beds will be closed, patients will be denied care, and that is what the ANF is arching, and asked for the reasons that they put forward and it will be up to the Bench to determine whether those are good enough reasons, but that is what they're asking. They are asking for this Bench to determine that patients will not get beds, or treatment will be delayed.
PN1294
We say that that is a difficult question. It's a complex question and that's why we think it should properly be dealt with through the public policy and the political process. It goes to fundamental value judgments, that society has to make about a range of competing interests and should be properly dealt with through a public process that takes into account the range of various stakeholders who are part of that process. So that, at least, is part of the answer to the question. There are a range of existing mechanism that are already in place and would not be changed if the ANF proposal was or was not granted.
PN1295
For example we have referred to in evidence the Nurses Code of Practice which requires a nurse to advise their superior if care is not or is not likely to be appropriate, for example because the nurse is too tired to give appropriate care. There is Occupational Health and Safety legislation, which the ANF has given evidence that they have already had access to, and which has in some circumstances issued improvement notices directly related to workloads, and that is already in place, whereas the Health and Safety - - -
PN1296
MUNRO J: That's what, the Incident Report?
PN1297
MR ELLERY: No, there is a procedure under the State Health and Safety legislation, which is very similar to the procedure in other States, as I understand it, where an inspector under the Health and Safety Authority, which is called Work Safe in WA can issue an improvement notice to an employer requiring them to take steps.
PN1298
COMMISSIONER O'CONNOR: And at least one witness here today attested that the Health Department had not acted, or the hospital in question hadn't acted upon the improvement notice.
PN1299
MR ELLERY: Yes, well Ms Tibbett is the Acting CEO and former Director of Nursing of that hospital will be appearing and we will be able to canvas that in detail.
PN1300
MUNRO J: Do Occupational Health and Safety complaints go to the Department of Health or is there another agency?
PN1301
MR ELLERY: No. It's an entirely separate agency, your Honour. Yes.
PN1302
MUNRO J: Perhaps I should make it as pointed as I can, and again not in any sense pre-determining any aspect of the matter. There are aspects of the case that strike me as parallel to the lengthy matter that I sat upon - and my colleagues had the good fortune not to have to do it - in relation to teachers, where the pressure on the Bench was to determine an application, in effect to re-instate class size limits that the AEU had succeeded in getting into agreements that were set aside by the Victorian Parliament upon the accession of the Kennett Government.
PN1303
There were two prongs, at least, to the application. One was to re-establish class sizes and another one, from recollection, was to limit teaching hours. The Full Bench decision rejected the class size determination aspect but did seize upon, for want of a better word, what appeared to be a reasonably solid stream of evidence to the effect that there could be excessive teaching hours, and I think it was around 18 or 20 at the high school level.
PN1304
Essentially the point ran that although there were 38 hours in a teacher's week once you got beyond 18 or 20 or whatever the figure was - and the parties weren't agreed about what that figure was - then there were starting to be excessive workloads imposed, or there were excessive workloads imposed because the high school teacher had to mark the papers that were set and to prepare the lessons, had to probably do some supervision, had to liaise with parents, had to do a host of other matters that probably occupied an equivalent amount of time to the face-to-face teaching.
PN1305
The Bench agreed to or determined that there should be a limit to face-to-face teaching and if it was exceeded then there would be a grievance process through a Board of Reference, the aim being to say that if there was an excess then individuals had a right to say: this is too much, and it wasn't purely a matter of managerial prerogative. While this is a long question, the contrast that strikes me with nursing is that it's not quite the same, in that assuming you've got 38 hours then that's what people are supposed to work, subject to whatever is the period of unpaid overtime, or whatever they might be brought back later.
PN1306
There is also an element which is typified I suppose again, by the mythical resident medical officer, that if they're consistently the only person in the A and E area they might be only, even assuming they are only working the 38-hour week, almost nobody would assume a 38-hour week is going to be occupied by a surfeit of patients day after day calling for skills that are beyond the individual capacity.
PN1307
It comes back to: what is an excessive workload? Is there no common ground about what point you get to where - take one of the witnesses earlier, they're actually using the bicycles in the corridor to get from one disaster to another - if the resident medical officer - or there isn't one there - has gone home, when can this be said to be an excessive workload in the eyes of the managers; and what protection do you give at present or should you give, and I've given you the parable if need be of the high school teacher who was really being asked to fill in for the extra shift, take on the history lesson because the kids are going to fail their tertiary exam this year if we don't have a decent history teacher when they're already coordinating half the school. That's the background to the question that I earlier asked. I don't expect a response to it but I want you to focus in on that aspect rather than think that it's only just about hours. It's what is excessive workload and how do you define it?
PN1308
MR ELLERY: Yes.
PN1309
MUNRO J: And I think I asked some witnesses earlier about that. But I have interrupted, did you want to - opening someone?
PN1310
MR ELLERY: That's fine.
PN1311
SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Mr Ellery, much of your opening address and indeed a significant proportion of the content of the witness statements provided appears to address the initial ANF Draft Order and logically also then, the alternative Draft Order 1. Alternative Draft Orders 2 and 3 are, and I hasten to say these are my words, not necessarily the ANFs, oriented more toward a process rather than necessarily a definitive set of ratios. Can I presume that the witnesses who you will be calling this afternoon, will also be able to provide advice to us on their view on the more process oriented Draft Orders, being Draft Orders 2 and 3 in addition to the specific ratios that are contained in the original proposal and draft alternative one?
PN1312
MR ELLERY: Some of the witnesses will be thoroughly familiar with all the alternatives and some will only be familiar with exhibit B1. I know the ANF have provided some of the alternatives to some of the witnesses. I think Ms Tippet in particular who was present at the inspection that yourself and Commissioner O'Connor were at. And I understand that she has had some opportunity to look at what was provided to her but we're not taking it on ourselves to provide a detailed copy of the alternative to each and every witness. So, in short, the answer to your question is, some will and some will not. Ms Mantell will, she will have some familiarity with some of it.
PN1313
MUNRO J: I think you're allowed to get on with your case, Mr Ellery.
PN1314
PN1315
MR ELLERY: Thanks, Ms Mantell. For the record can you just state once again your name and address, please?---Yes. Diane Christine Mantell of Unit 3, 46 Killarney Street, Kalgoorlie.
PN1316
Thank you. And, Ms Mantell, have you provided a detailed written witness statement in these proceedings?---I have.
PN1317
Is that statement true and correct?---It certainly is.
PN1318
Thank you. I have no further questions.
PN1319
PN1320
MS BURKE: Thank you, your Honour.
PN1321
Ms Mantell, if I could take you to paragraph 3 of your statement, you indicate that you've had over 18 years of experience in nursing management and the question that I would like to ask is, what workload management mechanisms have you utilised in your experience?---Okay. In - at - I will work from what I did originally up to now if that's okay. When I worked in New South Wales I was initially - I was originally in charge of a critical care unit which was a combined intensive care unit. In that unit we had a workload management system for intensive care ventilated patients where we had a one on one ratio. We, for the coronary care patients, we basically worked it on a 1:2 or a 1:3, depending on the illness and the acuity of the patients and that was determined by clinical assessment. For what - for a short period of time we tried the PACE Dependency System which is an acuity system but it was found that whilst it was applicable in some areas, initially at that point of the general wards, it was applicable to the critical care areas so it was mainly based on a clinical judgment decision. When I went to Tumut Hospital, Tumut is a 26-bed
**** DIANE CHRISTINE MANTELL XXN MS BURKE
hospital in the Snowy Mountains in New South Wales. We had a system where our maternity unit was isolated and separate and had been staffed on a 2 nurses for the number of patients that we had in there which fluctuated. In the general wards, it was based on a nursing profile that had been established over time which was then adjusted up and down depending on acuity as the workload fluctuated significantly because it was a holiday resort, being near the snow and also the - the water skiing area. And then when I went to Kalgoorlie, the practice there in the past had been that nursing hours allocated to the patients had been recorded over time against the occupancies and nursing profiles had been established for the rosters there which was what was used when I had arrived there.
PN1322
Thank you. Moving onto item 4 of your statement, you played a role in the enterprise bargaining process, is that correct?---That's correct.
PN1323
And what was your role in the process?---A decision was made by the Government Health Industry this year that for the - the EBA process, they would have a - a representative from both the rural sector and the metropolitan sector as well as a Government Health Industry. There are 20 rural health services in W.A. and I was chosen by the - the General Managers Council from that to represent the rural sectors on the EBA.
PN1324
And were you a representative to the workload working party that was formed during the enterprise bargaining negotiations?---Yes, I was.
PN1325
Turning to paragraph 5 of your statement, you talk about the ANF ratios?---Mm.
PN1326
And you also refer in your statement elsewhere to the nursing hours per patient day concept. Could you tell me what the difference is between nursing hours per patient day and nurse to patient ratios?---Okay. Can I first just apologise if my throat gives out. I'm afraid I'm still struggling with it.
PN1327
Okay?---The ANF - - -
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1328
MUNRO J: Have you got a glass of water there?
PN1329
THE WITNESS: Yes, I've got one, thanks. I've had it checked this morning but it's been sprayed now so it keeps giving up. The ANF ratios, the concern that I have and - and this was voiced at the working party when I was representing the rural sector there as well and it wasn't only my opinion. I was actually representing the whole of the rural sector so it was actually in a large case, the opinion of several of my peers as well. The concern was that it was a very inflexible system which basically indoctrinated what would occur and didn't appear from the information that we were given at the working party and my other readings that that actually was flexible enough to actually consider fluctuations in workload at the work site and considered the way that actual rural health services managed the way they - they ran their workload now. The fact that it was - there was a - a distinction made between Group B and Group C hospitals was of concern, as was addressed later. And mainly the fact that when - even speaking to my staff, which I did, and several other nurses around, there was a concern that if - if it was set at that level it - it wouldn't be sufficiently flexible to allow for different variations in workloaded times because it didn't ever consider the actual acuity of the patients. It only looked at the actual number of the patients in any of those areas that were defined.
PN1330
So have you had an opportunity to have a look at the ANFs alternative Draft Order 1?---Yes.
PN1331
Which contains indicative responsibility allocations and a series of principles for nurse staffing. So do you think that there is the flexibility provided by a non mandatory minimum staffing level is more appropriate than a mandatory nurse to patient ratio?---I think anything that is more flexible is a preferred option. I'm just not sure that there is a whole lot of benefit in determining that. The hospitals have to be graded and divided across the State and that it actually has to be indoctrinated to make it work because I think there are a lot of places where we are currently functioning on the - on the rosters that we've got where we're actually working above some of those - what you would perceive as ratios now.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1332
Have you had an opportunity to have look at alternative Draft Orders 2 and 3?---Yes.
PN1333
And do you think it would be useful to have exploration of the various types of workload management mechanisms that are in place around Australia?---Oh, I think it's always beneficial to look at what everybody is doing.
PN1334
With a view to selecting an appropriate mechanism for use in Western Australia?---Yes. But I think we need to be very cautious. Having looking at what's gone on in Victoria and having spoken to some people from South Australia and having come from New South Wales, I think it's important that we accept that whilst - while we've all acknowledge and all the parties on the workload working party acknowledge that - that nurses workloads are of concern, I don't think that one system that fits in certain sectors can automatically be transferred to another health service. There is no doubt that - - -
PN1335
No. Sorry, just to cut you off, what I was asking was, would it be useful to explore some of the other options?---Yes.
PN1336
Okay, thank you. Going back to paragraph 8 of your statement?---Mm.
PN1337
What you say in the first sentence is that the Kalgoorlie Hospital's FTE profile has decreased over the last 2 years?---Mm.
PN1338
Could you give the Commission an idea of what that FTE - and I imagine you're talking about nursing profiles?---Yes.
PN1339
Could you tell the Commission what the profile was in, say, the last couple of years, '98, '99 and '99, 2000?---Yes. When I took over in - 12 months, 2 years ago almost now, it was originally 183.5 approximately. And it's now currently 174.65.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1340
So you've reduced the number of nurses at Kalgoorlie Regional Hospital?---Mm.
PN1341
Turning to paragraph 11, you're talking about the particular model of nursing hours per patient day?---Mm.
PN1342
And you say that the nursing hours per patient day is used as an indicator of past performance to assist in future projections of need?---Past staffing?
PN1343
Past staffing problems, yes?---Mm.
PN1344
Okay. How do you actually make that prediction of future need?---What we've done is, since having been there we've now - accumulated a fair bit of data to do with the actual nursing hours that are allocated on any of the rosters. The number of occasions of service through the Emergency Department, the actual attendances as in-patients and the - the bed occupancies at the ward level. Would you like me to expand on that?
PN1345
Yes?---When - when I went to Kalgoorlie, what was evident in the past is, Kalgoorlie had always been staffed to numbers that would basically provide for 100 percent occupancy of the wards and when we went to look back at the data and the Director of Nursing who was there before me had started it when she was there for 12 months, it was evident the Kalgoorlie Regional Hospital is actually rarely fully occupied in the beds. So whilst we had been staffing to 100 percent occupancy or attempting to staff to 100 percent occupancy, it was actually rare that we actually got to that level on the wards. So, what we tended to do was start looking at what the occupancy - actually was and then staffing closer to that amount. So we now and try staff around 85 to 90 percent occupancy which still gives us a fair bit of leeway in what we actually experience as a given.
PN1346
And can you tell the Commission what the occupancy figures have been?---Yeah.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1347
Over the last couple of years?---When I first went there, certainly the rehabilitation unit which is a 16-bed unit, which is also restorative care unit, its occupancy had, in a large number of cases, been around 45 to - up to 65 percent occupancy. And in the medical ward, it tended always to have been up around 80 to 85 percent occupancy and the surgical ward fluctuated throughout the year depending on which surgeons were away and what our trauma numbers had been. Our paediatric unit works - has a capacity of up to 20 beds but basically tends to run around 12 because that's what we use. It's occupancy varied around the summer months from anything as low as 35 percent up to 100 percent during winter or endemic sort of periods when we had had children in from some of the Aboriginal Communities outlying.
PN1348
MUNRO J: Could I just ask you to tell me, the nursing hours in that indicator, how is that calculated? Is that subdivided at all or is it the gross hours that you've got on staff?---You look at the - for the nursing hours is that we actually look at the - the number of hours that have been rostered and allocated to a ward at any one time. So the total number, it's Enrolled Nurses and Registered Nurses including the managers of the wards, so it's the total - - -
PN1349
And are they subdivided at all? It's Enrolled Nurses, Registered Nurses?---No. We do that as a total number. Yes.
PN1350
As a total number of hours?---Yep.
PN1351
And so it's a gross number comprised of those 2 staff mixes?---Yes. Yes.
PN1352
And the patient days, how's that assessed?---The patient days are - registered at midnight each night. You look at how many occupant - what occupancy is actually in there but it also takes account of discharges and admissions during the day.
PN1353
And that assumes, I suppose, that the out-patients or they would be factored in for - how are they dealt with for A and E?---They're kept separate - they're kept as occasions of service so the actual total number of - patients that comes through, each time they come, it's counted as one.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1354
I see. So, they're in for the day even if they're not there at midnight, are they?---Um, usually you hope for - they're not there for the day but yeah, it's - it's - - -
PN1355
No. I mean, but they count as - - -?---No. It's just counted as a number, yes. So it's basically like a head count.
PN1356
Just run that by me again. For purposes of dealing with, let's say it is the - well, it could be an oncology unit if you had one, but the patients come in but you've still got a nursing need as you have in accident and emergency. How does the midnight reference - - -?---Oh, they're count - they're count - - -
PN1357
How do they enter into it, do they - because they're only in and out during the day, do they feature in your patient count?---They're not counted as an occupancy but they're accounted as occasions of service which is still recorded through the admissions process.
PN1358
I see?---But it's not counted as an in-patient occupancy, no. But we still keep records of them.
PN1359
And it feeds into working out the nursing need?---We look at the number of occasions of service that they have for the number of staff that we allocate.
PN1360
I see?---Yes.
PN1361
COMMISSIONER O'CONNOR: Do you add up the number of hours that they're being attended to, the out-patients?---You can get that off the triage and the emergency department data, yes.
PN1362
And then that, so if there were say, 4 patients doing 6 hours, they're assessed as one?---Yep.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1363
Is that right?---No. We count each one of them - when you allocate the staff to the department you still - you can accept that a lot of the patients that come in may be GP type of patients but still you have to provide the service so you don't provide any less nursing hours for them in principle. I mean - and that, I guess was one of the concerns - - -
PN1364
So they don't go into the assessment of nursing hours per patient day?---No.
PN1365
No, that's what I'm trying to find out?---Which is one of the concerns, I guess, from the Victorian - some of the Victorian information where they were actually allocating - there was a suggestion that you would allocate a certain number of nurses depending on the number of presentations into an emergency department and there was no break down in that at all of what sort of category they may have been. Whether they were 4 people who had a cold, or 4 multi trauma patients.
PN1366
MUNRO J: In the nursing hours per patient day, a model with which you're familiar, is there any sensitivity to acuity of patients in that?---Yes.
PN1367
Or is it a gross measure?---Yes - no. It considers the - the number of hours increase depending on the acuity or complexity of the patients, the type of interventions that you would need to do.
PN1368
I see, so when you look at it on the past basis then that's really just based upon the historical practice?---Mm.
PN1369
But when you're applying it perspectively, there is an attempt to build in, I suppose, a quality control factor for acuity?---Yes. You look at the type of patients that you get on the ward and you can tell that from talking to the clinicians who are there who are caring for them and they know the type of patients that they get and whether they're more complex now or with the decreased length of stay, the complexity may have still increased. So we've - we've built that into them to - consider.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1370
So there would be some rating of the patient days as well by a reference to acuity?---Yes.
PN1371
Yes?---Yes.
PN1372
Yes, I suppose that it would pretty automatically follows that the ICU patient almost by definition would have to have a much higher acuity equation than the kids wards?---Yeah.
PN1373
Yes.
PN1374
MS BURKE: Ms Mantell, with the nursing hours per patient day formula, how does it provide flexibility on a day to day level?---Because when the - the way the hours are worked out, you work out an hours for a total roster period, so it's worked out over a 7-day roster. Then at the actual ward level, the clinical managers may look at what they're doing and their activity. If it was a surgical ward, for example, you may know that you get your major surgery early in the week. You may know that you only do day type cases part of the week and at the end of the week, towards Friday and Saturday, you may actually have some degree of quietening down, certainly in a regional centre, and then you may get your day of surgery patients back in again, starting Friday. There's the opportunity there for the total number of rostered hours to be used as to suit the workload that fluctuates on the ward. So for instance, in our surgical ward, they staff more during the week and then they actually have some reduction of hours to - on the Saturday shift because - on a Sunday morning shift, sorry, where they actually know that on the whole they have a lesser workload. And the agreement is that if they then find they have got a lot more workload in, then we would float someone to that Department from either the pool, the casual or an area that was actually quiet.
PN1375
Okay. I would like to come back to nursing hours per patient day shortly, but just another question on the - on the use of agency nurses. In paragraph 13 you talk about accessing agency staff depending on your need and availability?---Mm hm.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1376
Could you tell the Commission what percentage of your nursing staff are agency nurses?---When we're fully operational, about 10 to 15 per cent. I think the highest we've ever gone has been 20 per cent.
PN1377
And you say that the cost of agency staff is very high?---Mm hm.
PN1378
So in fact, you say that if you were to employ agency - well, 2000 and 2001, the use of agency staff cost $1.5 million but if you were to have employed those nurses, rather than using them through an agency, the cost would have been 1.07 million, which is quite a lot less?---Absolutely.
PN1379
So agency nurses are an expensive option?---Oh, absolutely.
PN1380
MUNRO J: Your reference there to 80 hours; are the nurses on a 40-hour week? That's what, an award standard or an agreement standard?---Oh, 38-hour week.
PN1381
38-hour week?---Yes. Yep.
PN1382
But you draw a distinction between agency staff who are employed on 76-hour full-time contracts whereas permanent are on full-time 80 hours?---Yeah, those who are getting ADOs.
PN1383
I see, yes, yes.
PN1384
MS BURKE: In paragraph 14 you talk about it being very difficult to attract and retain nurses in Kalgoorlie and that it's imperative that you use agency if you are to maintain contractual and community expectations in terms of levels of service. And I'm just interested to know if you are referring there to the Kalgoorlie/Boulder Health Service Agreement with the Health Department. Would that be the contractual expectation you're talking about?---Yes. Yes.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1385
And what sort of contractual expectation is there of the Kalgoorlie/Boulder Health Service?---The expectation is that we will provide a certain range of services to the community. Kalgoorlie is a referral centre that services about 1 million square kilometres. We're the largest referral centre in - in our area and we are responsible for providing services as well to Leonora and Laverton and to some extent also we get patients up from Norseman and Esperance. What we provide is a full range of services so we're expected to provide surgical services, renal dialysis, paediatric, emergency, obstetrics. And we're about to provide in-patient psychiatric services as well as community mental health and community and public health services.
PN1386
And does that Health Service Agreement contain any particular requirements of the Kalgoorlie Boulder Health Service? I imagine that the arrangement is that the State Government through the Health Department provides a certain amount of money to Kalgoorlie Boulder to provide the health service in exchange under the purchase or provider model for a particular range of performance - are they performance indicators?---It's a particular range of services but there's key performance indicators showing that we actually meet our obligations, yes.
PN1387
And are there Human Resource Management or staffing performance indicators in the Health Service Agreement?---No.
PN1388
Okay. Now, if we move to paragraph 18. 17 and 18 we go back to the nursing hours per patient day model?---Mm hm.
PN1389
And you're referring to the 400 - there's a question of the 400 additional nurses that the Government say is an initiative that it's committed funding to?---Mm hm.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1390
And you say that you have - you've calculated on the nursing hours per patient day model that Kalgoorlie would receive funding for 22 additional nurses, is that correct?---It is. There's probably one overriding point that's not in that statement. When we have looked at the nursing hours for patient day model across the metropolitan we've stated that in the metropolitan area we've not yet finished doing the critical care areas. Plus we were still working with critical car specialists both through the Emergency Department Association, Emergency Nurses Association and the critical care nurses, so there may still be some minor flexibility to that but at that point, yes.
PN1391
So what you're saying is that the - by using the nursing hours per patient day model, Kalgoorlie actually should be staffed with an additional, give or take 22 nurses depending on that final analysis?---Yes.
PN1392
Okay. So can I ask why the Kalgoorlie Regional Hospital is not staffing to what this nursing hours per patient day model says in an optimal nursing staffing profile?---Yes, okay. At the moment we have some beds closed because of shortages of people, staff out there. We've had a lot of discussion and it's been well documented in the media over the last few weeks, we've had some withdrawal of services from one of our obstetrics - from our obstetric - - -
PN1393
MUNRO J: Sorry, could you - just do your best to, I know you've got a sore throat but perhaps if you could look a little bit this way we will hear you?---Okay. We currently are trying to work on a - we've reduced our beds marginally at the moment because we have a shortage, we have one less, our obstetric service has been withdrawn by the doctor. And we're also coping - several of our mines, a couple have closed recently who had had other people in town with them and also we've moved - some of the mines have moved more to a fly-in, fly-out system. So we've actually reduced our beds to the - to match the available staff at the moment. We are attempting significantly to try and recruit to get our numbers up and we are budgeting. As I've said, our FTE is 174.65 and that's the target that we're working towards which will be in line with the nursing hours per patient day model.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1394
MS BURKE: Has the Kalgoorlie Hospital been given an allocation of funding for additional nurses from the money set aside for the 400 new nurses?---Not yet, no.
PN1395
When will that happen?---That will be allocated dependent on the outcome of this and negotiations and still refining the nursing hours per patient day model.
PN1396
Has the budget already been allocated for the financial year that we're in now?---There's a lot of discussion about the current budgets. The budgets have had - have been in principal have been agreed upon. There is still negotiations between the chief executives and certainly the general managers for the rural sector. There are no budgets that have actually formally been handed down yet. We're currently doing cash flow statements on a weekly basis and being funded accordingly. So they've not actually fully been handed out as yet, no.
PN1397
So is it the case that at this stage you have no commitment to any money from the Government for any extra nurses?---It's - the commitment has been that the money is being held centrally at this point. But no, it hasn't been divided up and circulated out, no.
PN1398
MUNRO J: Are you effectively funded subject to those qualifications which I suppose are pretty major for 174 FTE for the year, or were you last year, for instance, to about the same level? And even though I think you've set your - what is 20-odd positions below the FTE is 30. How many are below FTE at present?---Last week there were 36.
PN1399
36?---Mm hm.
PN1400
So if you were to carry that shortfall for the year apart from dissipating a fair bit of on agency staff or all of it, you would be that far ahead you would have a budget surplus I take it. Is that the theory?---In principle that's the theory, yes.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1401
Yes. So if you can fill the positions you do?---Yes.
PN1402
You've got the budgetary enablement to do so provided you can find the bodies to put in?---Yes.
PN1403
Yes. Subject to there also not being a great shortfall in patients, I imagine?---Mm.
PN1404
Yes.
PN1405
COMMISSIONER O'CONNOR: Other than your contracted agency staff, is agency staff readily accessible in Kalgoorlie for - - -?---No. We get most of them from Perth of which we use - for us to access the number of staff we need to top up our own permanent staff, we do contact up to 15 to 18 agencies at any one time to get enough staff to get out there. The majority of those are based in Perth but we also use agencies out of Adelaide and Sydney and Northern Territory.
PN1406
MUNRO J: Yes.
PN1407
MS BURKE: At the moment, Ms Mantell, you say in your statement that your staffing to - was it 85 per cent occupancy?---Yes, occupancy. Yes.
PN1408
So what happens when you exceed 85 per cent occupancy with the difficulty of getting agency nurses in?---Okay. (1) It's rare that that would occur across all of the wards at any one time and that's historically been shown in the data that we've collected since I've been there in the 12 months before that. If it does get to that point we've got a few options. We have a casual pool, be it small, but we have a casual pool where staff can be called in. We have the opportunity for agency staff to do additional hours at casual rates. We have part-time staff who may wish to do additional hours which they can do. And as an absolutely last resort we do overtime.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1409
And what happens if you can't get anyone? If you've gone through those mechanisms of trying to get an agency, trying to get a casual from your regular casual pool and then, you know, you may have a couple of nurses sick and just no one is around, what happens then? Do you restrict access to the hospital via patients or - - -?---We can't restrict access we're the only hospital in Kalgoorlie, so there is nowhere else to go. There is no private institution in Kal. We may consider flying patients out but the RFDS are not enthusiastic to transport people out if it's a factor resource shortage that we have. I can say openly that I have never got to the point in any of the places that I've worked that I've actually got to that circumstance where those things haven't worked. We did have a plan in place a couple of weeks ago when it was looking very tight at Kal where the girl who was the After Hours Supervisor actually had the skills that we were going to use and if it had got to that point she was actually going to go and work on the ward and I was coming in to be the After Hours Manager. But we didn't have to do it, the staff - we filled the spots we had with those measures that I've mentioned.
PN1410
Is elective surgery offered at Kalgoorlie Hospital?---Yes, it is.
PN1411
So is that one mechanism that can be used if there is - if you're at 100 per cent occupancy you can cancel elective surgery?---Yes.
PN1412
And that would happen sometimes in the school holidays and Christmas, would it?---Not so much the school holidays. In the Christmas holidays we have a planned wind down and most hospitals across Australia that's something they do. And that's not to consider the workload of nurses at any point, it's actually to recognise that a lot of the doctors take leave. It also allows you to roster nurses on leave so they can take holiday periods. But we do sometimes wind elective surgery back if our emergency numbers have gone up, yes.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1413
So you talk a lot about the nursing hours per patient day model, is there any empirical evidence to suggest that the nursing hours per patient day model is reliable, valid to your knowledge?---I've read several papers on it when I've done the same sort of searches that obviously Ken did. There's quite a bit of evidence that it's been used in a variety of settings and I think that it's very difficult to compare some places. And I guess one of the difficulties I've got is that - and it's been raised in some of the discussions before and at the workload meeting that comparing different facilities is very difficult in this setting. But yes, I think there is certainly some data out there that supports that type of model because of its flexibility and the fact that it is responsive to what - to fluctuations in the workplace.
PN1414
And have you, just in this case and as an instructing witness to Mr Ellery, have you had a look at Mr Jones' statement and the attachments to it?---I have.
PN1415
There was an article in there which indicated that the nursing hours per patient day model should be retired. Are you aware of that?---Mm hm.
PN1416
If you can return to item 29 - paragraph 29 of your statement. You outline a fairly detailed scenario of what would happen if ratios came in. Have you ever experienced that? Have you ever worked with nurse to patient ratios such that that type of scenario would arise?---Probably mainly in the critical care setting where we had ventilated patients and they were basically again - we were a referral centre. I have to change the places I go to work, I think, where you rely on a one to one system and certainly we managed to have a car accident and ended up with four people in who couldn't speak English and you've suddenly got a whole lot of ventilator patients. That would be my main experience of using the closest to a ratio.
PN1417
So this scenario is your - you imagine that's what may happen if ratios came in?---Yes. Can I say why?
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1418
Go ahead?---I think if we go to the point of developing a ratio and the expectation of nurses out there is that that's what's actually put in place, whilst it's been mentioned that you know, it would be flexible and that people wouldn't expect that it would need to be varied on that sort of thing. I think if nurses are given the ruling by whatever group that that's what is accepted practice now, then they should have an understanding that that's accepted practice for them at any point and that there shouldn't be a lot of: well, no, not now or - you know, in this situation and it's just a one off. So I think that's my basic concern that it won't be flexible and that the nurses' expectation will be that it should be consistently like that across a given number of exercises, I guess.
PN1419
So if you, just going back to the ANFs alternative draft order 1 which says that those particular allocations of work to each individual nurse are almost a bench mark or a minimum standard there would be flexibility in that, wouldn't there?---There should be, yes.
PN1420
Okay. And that flexibility would allow for patient acuity considerations, occupancy?---Potentially, yes.
PN1421
And even things such as ward lay out or the geography of the hospital. I think that's very difficult to say that you're going to have something that is that flexible knowing the different layouts of hospitals across the country let alone WA. I think it's a big statement to make to say that we will set the ratio up as this but we will actually flex it to do a lot of these things. I think the expectations of nurses is they either get a ratio or that they can expect to be endorsed and supported all along or that they basically stick to a nursing profile as they know on a roster now that fluctuates depending on what their workload is.
PN1422
And do you think nurses know what that profile is now?---Yeah. And the reason I say that is ever since I've been nursing which has been quite a while now, you always know on a ward that you go on that you will either seven people on in the morning and five on in the afternoon and night, or whether it goes to 9 on the morning. And you don't have to be very clever to figure out that if you're supposed to have 9 on in the morning and they're not there that you've been short changed.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1423
MUNRO J: I'm sorry, then you've - - - ?---Short changed. You know the issue about nursing hours per patient day has been made to sound very difficult and very involved. In fact, you convert it to a roster profile where you know that you get seven nurses in the morning and five in an afternoon and three on night duty or whatever it is. That's what nurses know and that's what nurses will expect on any given day. They don't mind whether the ratio is one to four or one to six, or the fact that you've got a workload, a nursing hours per patient day model that's 4.5. What they want to know is how many nurses that converts to on the ground at any one time. So the roster profiles that have been around for quite a while is what nurses know and understand.
PN1424
How does that roster profile allow for variance in the patient load? That happens through the nursing hours per patient day model what, in anticipation or historically?---A degree of both. The roster is set up based on what they know is the planned level of activity through the week and obviously on a surgical ward, a ward that has surgical intervention or some structured interventions you can build that in knowing that you may have a lot of surgery on a couple of days in the week or certain things that happen and you can staff it up. In addition to that, well either you have access to either a nursing pool or a casual pool, the clinical judgment on those wards at any one time can then ask for additional staff to be given. And 9 times out of 10 I would think it's actually provided.
PN1425
Yes. So the profile could be bolstered to meet those surges?---Mm.
PN1426
And presumably also blend down a bit where the numbers have attenuated?---Yes.
PN1427
Yes.
PN1428
MS BURKE: Well, just carrying on from that, the profile can be bolstered if you can get nurses to fill the profile?---If you have nurses, yes, and your nurses may come from a variety of centres, yes.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1429
Okay.
PN1430
MUNRO J: Could I perhaps if it's convenient, you said 9 times out of 10 the need would be met. I put some fairly long winded questions to Mr Ellery that you perhaps heard although you might have been thinking about what you were saying but the gist of them really went to perhaps someone in the 10th of those 9 positions that you're alluding to and it was canvassing the possibility of someone, a registered nurse encountering the workload that borders on the frantic. Is that a real life possibility in your experience?---Yes.
PN1431
Or is it fanciful?---No. It's very possible.
PN1432
And are there measures of a practical kind to alleviate or to provide some redress against it?---Yes, there are. I think the thing that we certainly, I've always told my nurses: if you've got any issue about the workload it is absolutely paramount that you report it and that you don't just stay there working through it and then say afterwards that it was an issue or a problem. The reason that the issue of - - -
PN1433
To whom do they report it?---They report it, if they're a ward nurse then they would report it to the in-charge person on their shift. If they then can't - - -
PN1434
Is that normally the NUM, is it or - - -?---During office hours basically it's the NUM or the clinical managers over here or the coordinators.
PN1435
Yes?---After hours it would be a shift coordinator on the ward, like an in-charge person of the shift. Outside of that they then report it to the person who's responsible for the hospital at that time and during days it's either a clinical coordinator or a hospital coordinator depending on what time of day it is. And if they've got an issue then they report it and it depends how big the structure is but certainly in the rural sector then it would then be reported up to the Director of Nursing if it was still remaining an issue and unresolved and
**** DIANE CHRISTINE MANTELL XXN MS BURKE
that occurs at my place. If you've not been able to resolve it at ward level then it's the responsibility of the coordinator when they've had it reported then to look at the set of circumstances, see if there's any way the workload on the ward itself can be adjusted, whether patients should be moved to another ward area or whether other resources should be brought in be them either nursing resources or some clerical support for someone to answer the phone while it's busy or a PCA to help maybe clean up or just help move patients and assist under the supervision of nurses. If then it still remains a problem, one of the reasons this is a management issue is because the care delivery at any hospital at any point in time, the Director of Nursing is ultimately responsible for the care provided. So we can't walk away from the fact that we have to have a say in what goes on about how the service is run.
PN1436
Well, I suppose what occurs to me the process might be a bit intimidating let's say for an enrolled nurse that they might be out of date but in some hospitals whingeing about that mightn't attract all that sympathetic a response from the people who used to be matrons?---Oh, sure. And there is no doubt there probably still remains a varied response across the country I think to people doing it. I think it's important that we certainly ad Directors of Nursing have a really good relationship with our staff and that they do know that we're accessible and that certainly the people in between are accessible. And I think it is really important that we do respond, I think. I've told people who volunteered to do overtime that no they shouldn't do it because I think they're too tired and I've sent them home. We've reorganised who's actually been on the ward or we've put other measures in place to try and protect them but it is imperative that they know that they have to report it up and that you can't just grumble about it at ward level because that's not going to resolve the issue.
PN1437
It doesn't need to be a written report or - - -?---No. No.
PN1438
It doesn't?---No.
PN1439
Thank you.
PN1440
MS BURKE: Ms Mantell, are you familiar with the statement of Alan Jones?---I've briefly looked at it.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1441
Okay. Mr Jones submits an interesting document which is an analysis using the nursing hours per patient day of the Kalgoorlie Regional Hospital which actually indicates, and it was dated July - I think it was either July or February this year, depending on whether it's the American or the English date formula but what - - -
PN1442
MUNRO J: Ms Burke, I will have to ask you to keep your voice up.
PN1443
MS BURKE: Oh, I beg your pardon.
PN1444
MUNRO J: I'm only a little bit deaf.
PN1445
MS BURKE: Sorry about that.
PN1446
This particular analysis uses the nursing hours per patient day model or formula and what is shows is that there needs to be a cut in nursing numbers, a reduction by 15 FTE which would save the hospital $574,000. And can you remember when you worked with Alan Jones on an analysis of Kalgoorlie how it would have arrived at a reduction in nursing staff of 15 and now, when you analyse the model again, it shows that you need 22 additional nurses?---Mm. When the - when Alan did the - Mr Jones did the initial report last year which was in about April last year, 2000, what we did was, we - the benchmark was applied as - as he had applied it across regional and - rural New South Wales and then several Western Australian regional centres and the benchmark he was using then was a nursing hours per patient day of around about 4.5 nursing hours per patient day. That was applied across the whole site. He actually looked at the whole site, not just nurses and did an overall review of what the benchmark was from his Eastern States experience and rural - W.A. And then put up what - he also looked at what the current actual figures were on our rosters and at that point Kalgoorlie did come up as appearing to be over staffed, certainly for nursing. And we looked at that because at that point the nursing FTE that he came up with including everybody's leave and the whole lot was somewhere around the vicinity of a - an FTE of 192. Now, the reason that
**** DIANE CHRISTINE MANTELL XXN MS BURKE
we're now saying that we would - an increase, because of looking at the nursing hours per patient day focus group that we've had where I've worked with the Metropolitan Directors of Nursing, we have revisited the nursing hours per patient day because we believe it should be a flexible tool that's reflective of - of the workload. And in one of the attachments to my statement, it actually states now what the nursing hours per patient day are for a variety of wards. And instead of having one fairly stable static figure for a medical surgical ward we've actually expanded that out and put more detail to it and given our range of nursing hours, those nursing hours per patient day have now been applied to the Kalgoorlie situation and that's why now, there's an increase of staff on his - working on his analysis.
PN1447
Is it the case that the nursing hours per patient day model provides a way of fitting nursing FTE into the budget for the hospital. So, if you've got a particular budget amount you can flex your nursing hours to fit into that budget by using the nursing hours per patient day formula?---You could but that's not what we've done.
PN1448
And if we go to paragraph 63 of your statement, you refer to appendix 3. Perhaps if you turn to appendix 3 of your statement, this provides a W.A. public hospital target, nursing hours per patient day guide in principles?---Mm.
PN1449
Can you tell the Commission when this document was developed?---Yes. It was - we commenced on it early in the year. When I was involved with the - the workload working party as part of the EBA, one of the sub committees, Ms Di Twigg and myself were involved as the representatives of the Government Health Industry on that. I became aware during those discussions that the Metropolitan Directors of Nursing have been doing some - some work on it and we talked about what we had done at Kal and where we were standing currently and then we worked through this. So basically from early in the year till about July.
PN1450
And I notice that the document has a date on it, 9 July?---Mm.
PN1451
2001?---Yes.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1452
So this document was never presented to the workload working party?---The document in that form was never presented. The issue of nursing hours per patient day modelling was presented to the workload working party.
PN1453
But this document wasn't?---No.
PN1454
So the Metropolitan ..... Council started working on the nursing hours per patient day concept after the working party concluded?---No. They had been working on it for about 12 months before that but they had been doing - getting a lot of data collected, some work for a starter and that behind it. But, no. They had been doing it for about 12 months.
PN1455
Was there any reason why this document wasn't presented at the working party?---Yes. It wasn't formalised and finished. The workload working party went for approximately 5 weeks, commencing from the 5th of February. During the discussions at the working party, we, as the representatives of Government Health Industry, raised the points of the nursing hours per patient day. We also talked about the bench-marking that had occurred in the rural sector that Mr Jones had undertaken and we presented some annualised data that was - that we thought was worth discussing and exploring. That data was rejected out of hand at the working load working party. We also asked to extend the workload working party by a couple of meetings to explore some issues a bit further and it was - and that was also rejected on the grounds that we weren't actually - there wasn't a lot of gain and it was probably more productive to put up independent suggestions from the workload working party to the Commission for some ruling instead of trying to pursue this further because it was thought by the reps and certainly from the ANF side, I think that we weren't actually gaining a lot of ground.
PN1456
Okay. I don't have any further questions, your Honour.
PN1457
MUNRO J: Yes. Could you just tell us what a, neonates are?---Tiny babies.
**** DIANE CHRISTINE MANTELL XXN MS BURKE
PN1458
It's new births, is it?---Tiny babies. New borns.
PN1459
PN1460
MR WALKER: Your Honour, I have a few questions for the witness. If I could, could ask the witness to be shown this document?
PN1461
MUNRO J: Shown? Right.
PN1462
MR WALKER: Ms Mantell, can you identify the document for the Commission?---Should I read it? West Australian Industrial Relations Act - - -
PN1463
It's probably easier on the second page?---
PN1464
This agreement is the Enrolled Nurses and Nursing Assistants Kalgoorlie Boulder Health Service Enterprise Agreement 1999. This agreement.
PN1465
PN1466
MR WALKER: Are you aware of the document?---Yes, I am.
**** DIANE CHRISTINE MANTELL XXN MR WALKER
PN1467
Do you know who the document is between?---Is Kalgoorlie Boulder Health Service and the - also the Miscellaneous - the Liquor Hospitality and Miscellaneous Workers Union.
PN1468
Correct. Who does the document cover, industrially cover?---Enrolled Nurses and Nursing Assistants.
PN1469
So does it cover all the Enrolled Nurses at the Kalgoorlie Boulder Health Service?---Yes. We don't have any Enrolled Mental Health Nurses at this point.
PN1470
Okay. Could I ask you to turn to clause 11 on page 7? Now, this is the wages clause?---Mm.
PN1471
Do you use all the levels of wages at your Health Service?---We have Enrolled Nurses and we have Advanced Skills Enrolled Nurses. We don't employ Nursing Assistants.
PN1472
Okay. So the 5 levels there, they're the only levels used for Enrolled Nurses at the Health Service?---That's right.
PN1473
Could I ask you about the ANFs exhibit, the Draft Order B1 where it refers to the staffing mix and there's a reference there to Enrolled Nurses, level 1 to 5?---Mm.
PN1474
In your Health Service, would these be the levels that that is referring to?---Yes.
PN1475
Okay. Could I also ask you to turn to the dispute settlement procedure which is found - - -?---Page 12.
**** DIANE CHRISTINE MANTELL XXN MR WALKER
PN1476
Page 12, thank you.
PN1477
MUNRO J: It's of LHMWU2, you're referring to of your exhibit or of - - -
PN1478
MR WALKER: Of the exhibit.
PN1479
MUNRO J: Yes.
PN1480
MR WALKER: Yes. Page 12, it's clause 19, Disputes Resolution.
PN1481
In the event there was a dispute with Enrolled Nurses, I will put it to you this would be the dispute settlement procedure used at the Health Service?---That's right.
PN1482
And in the event the union and the employer couldn't resolve the issue, where would the matter be referred to?---Industrial Commission.
PN1483
Do you know which Industrial Commission?---No.
PN1484
Okay?---West Australian Industrial Commission?
PN1485
That's right, thank you.
PN1486
That's all I have, your Honour.
PN1487
MUNRO J: Mr Ellery?
**** DIANE CHRISTINE MANTELL XXN MR WALKER
PN1488
MR ELLERY: I have no re-examination.
PN1489
SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Ms Mantell, in your evidence you outlined a sequence that would be followed in the event the 85 percent occupancy estimate was exceeded and that sequence went through from relocation of nurses within the hospital?---Mm.
PN1490
And ended up with provision of overtime for existing permanent staff. When you follow that sequence, are the nursing staff who are currently working in the hospital, who would by that time quite possibly be facing increased workloads, informed of the process that has been followed?---Yes. Yes, often it's not myself down there. This usually tends to be an issue certainly after hours so on a - evening shift is probably one of the - the most variable issues that we've got so it's generally the Hospital Coordinator goes down and liaises with the Shift Coordinator on that ward and then she would be telling the staff on the ward whether they were either going to provide someone to another ward if - if their workload was okay or that they would - what we were going be trying to do to get them some additional assistance.
PN1491
And if staff were to be asked to work overtime, presumably they would be aware of the earlier steps then that had been taken, albeit unsuccessfully?---Yes, yeah.
PN1492
Within the Kalgoorlie Hospital, who is responsible for assessing patient nursing needs?---On individual wards the - the nurses that care for the patients certainly have responsibility themself but the ultimate - the - the responsibility generally for each ward is the Clinical Manager or the Shift Coordinator and ultimately it sits with the Director of Nursing.
**** DIANE CHRISTINE MANTELL XXN MR WALKER
PN1493
And if you reach a point where the hospital is not able to support various elective surgery, for example, then how is that information conveyed to the doctors who might ultimately otherwise have conducted the surgery?---We ring their rooms as soon as the decision's made. We actually currently have a meeting every afternoon at 20-to-2 where we sit down and - and the managers from theatre and her booking clerk, my two senior coordinators and there's a medical director meet and we look at what the list is for the next day and we look at what our bed availability is currently and what we're anticipating is coming in. If the decision's made that we can't accommodate the patients, we look at two things. Whether if they're actually supposed to be coming in that afternoon whether they can possibly be put off and come in on the day of surgery. If, however, we believe we can't accommodate them we either say that we will - we will let it hand but we will ring the doctor and tell them and let the patient know that we - ask them to ring in the morning and check that there may be a bed. And alternatively, we ring the doctor and tell them that the case has been cancelled and we ring the patients, the doctors don't ring them.
PN1494
So, when you use the word, "We," can you be a little more specific for me?---Yeah. The clinical - - -
PN1495
Whose task is that?---The Clinical Coordinator.
PN1496
Thank you. Now, can you tell me how the nursing hours per patient day ratio takes account of ward layout?---Mm.
PN1497
And whether or not ward layout becomes a significant factor in terms of the efficiency of delivery of nursing services?---With the - the way that the nursing hours per patient day model has been established, it's looked at a variety of settings across the country. It mainly looks at the actual complexity of the patients and the amount of interventions that are required for them. Then at a - at a site level you may decide that you need some additional hours to actually accommodate site specific issues. As I stated in my statement, we don't have a possibility, our wards aren't - at Kalgoorlie there was - there's like a hub-and-spoke model and unfortunately the hub is a rotunda in the middle of the facility
**** DIANE CHRISTINE MANTELL XXN MR WALKER
and then the wards go out down concrete corridors from there so they're - they're not co-located. If we want to we can then allocate additional hours on top of what's in the nursing hours per patient day for allowing for things such as transfers from the Emergency Department to the wards which are quite some distance apart. Not as distance apart as what Royal Perth is but in a Regional Centre, significantly distanced apart. There's also potential for us to add in additional hours to accommodate things such as our patient mix which, in our zone, the issue of Aboriginality and cultural issues are a concern where we actually tend to keep the patients in longer. So, we can actually accommodate that in the nursing hours per patient day model if we want. We tend to keep, for instance, we keep patients in who are - who may deliver babies from up in the deserts. From up - from us, the only time they actually get antenatal care is when they come down to us so you try and keep them in - you bring them in 2 weeks earlier potentially; you keep them in for the time and then you keep them in for a bit of time afterwards knowing that that's the only actual time you're going to get to do any interventions with them. So, the model is sufficiently flexible that you can allow additional hours in to accommodate those type of patients. Even though, in the metropolitan setting, that may not be the case.
PN1498
When Commissioner O'Connor and myself went to the Royal Perth Hospital?---Mm.
PN1499
We were shown a new or very recently developed, it's a computer based system, that endeavoured to monitor patient demand and potentially, I guess, assist in workload assessments. Does the Kalgoorlie Hospital have a comparable sort of system?---No. We don't. Unfortunately the regional centres in W.A. haven't been linked to - to any of the - the systems such as the EDI System with is the Emergency Department Information System where you can actually get information about patients coming in and the relay it to other sites. We don't have access to that at this point. I guess the advantage for Kalgoorlie as - as most of the regionals - as one of the largest regional centres is, the distance isn't that large to go and actually tell people and let them know about what the information is. We're currently working on a system to get our doctors to actually provide us with more information about the patients coming in which is - which has been a new challenge for them in the last few months. And we believe once we've got that up and running then we will actually be able to provide more information about what we've got. We've currently got a
**** DIANE CHRISTINE MANTELL XXN MR WALKER
system called, OSCAR which is a Theatre Operating Suite Management System where you can put the information into it and then record and follow where the patients actually are, whether they're in theatre or in recovery or - or going back to the ward. So you can actually do some tracking there about what patients need, what wards and when. But there's no integrated system in the rural sector for bed management, no.
PN1500
Thank you. Finally, as I understood your evidence, you're over a third of the way through the current financial year?---Mm.
PN1501
But do not, as yet, have an approved budget?---We've had what appears to be a budget allocated to us which has been the subject of much discussion, both at the General Manager's level and both through the media. The budgets have been negotiated to some point but they haven't actually been handed down to the Health Services. Well certainly not when I left on Friday night.
PN1502
Can you tell me what impact that has on managerial decision making within the hospital?---It's very difficult because at the moment - well certainly for the budget this year. A lot of the expenses have been incorporated into an operational budget where previously there was definitive other amounts come in later on. The problem we've got at the moment is that we have to put up an estimated cash flow each week of what it is and then the department actually allocates us funding according to that, close hopefully, to what we've actually asked for. One of the issues we've obviously got is with our use and fluctuation of agency nurse usage. We - we had planned out roughly what we thought it was going to cost us and in the last few months - couple of months, the nursing agencies have actually increased their fees by 20 percent. Now, there was minimal notification of that and it's interesting they've actually already put up the EN rates but the Nurses - the ENs EBA is not till later in the end - start of next year. So trying to work out a budget based around those sort of parameters, yeah, it's fairly demanding at this point in time.
PN1503
Is there the potential that an increase then, for instance, in the charges levied on you by the agencies, might mean that you have a significantly reduced expenditure budget for the latter part of the current financial year?---Oh, potentially, yeah. Absolutely.
**** DIANE CHRISTINE MANTELL XXN MR WALKER
PN1504
And what would you do in that event?---We - we've had quite a discussion about it already. We've said that we would probably - currently we're anticipating that we would be closing elective surgery over Christmas for about a period of 5 to 6 weeks and part of that for us this year - well actually we've got to do an upgrade on one of our theatres so we're coinciding that with it. The potential is that you may have to look at extended periods of reduction of - of surgery such as - elective. Because of the situation we're in, there is not a lot of our other work we can actually control because we're a referral centre. There's very few other things we can reduce. We also reduced the Procedural Clinic activity before when we got really - had a shortage of nurses, not a shortage of money. So, potentially we may have to reduce those services.
PN1505
So if you were to cut elective surgery, for instance, for a prolonged or extended period, then on the basis of previous experiences, where do those patients go?---I guess in our situation we're probably fortunate that we actually don't have a waiting list at Kalgoorlie so if the patients had to wait, we would still do emergency surgery, but if the patients had to wait for a designated period then it - it shouldn't be that bad. Obviously any delay in surgery at any point in time is not a desired outcome because whilst it may not be earth shattering for us, it obviously, personally, is very upsetting for the individual. The alternative is that patients would be transferred to another metropolitan centre. It would be unlikely we would refer to another regional centre. But patients would be made aware of where waiting - where they may be able to get that treatment done earlier.
PN1506
MUNRO J: Ms Burke referred you to an article that had been incorporated in Mr Jones' evidence and I think asked whether you were familiar with it, in which the author had suggested that the NHPPD system should be retired. She didn't ask you what you thought of that article. Do you share that view?---No, I don't. I don't think there is any absolutely perfect system out there for nursing, for actual managing of the workload. I still think there is a lot of merit in the nursing hours for patient/day model and I think - I think if you have adopted it as a set benchmark where there has been no flexibility and no utilisation as part of the management plan on the ward level, so a clinical management plan, then I think if it's structured and it's sort of embedded in concrete, then no, it shouldn't be used. I think it's a tool that needs to be flexible. I think it needs to be reviewed on an ongoing basis in line with changes in - in practice both in nursing and in medicine and - and certainly in the way hospitals are doing the business that we now do.
**** DIANE CHRISTINE MANTELL XXN MR WALKER
PN1507
Yes. Mr Jones' material also included an exhibit KBJ5 in which I think as at January this year, he contrasted the ANF then proposed nurse/patient ratios with actual data on a full-time equivalent basis. Are you familiar with that exhibit, broadly?---Yes.
PN1508
I think I did put to Mr Jones a question about the relative consistency of the actual data at present for full-time equivalents, for instance, when you run through surgical wards, Kalgoorlie is slightly out but not that much. It's 1 to 6. Geraldton is 1 to 6 and then looking on the second page, there are a lot of 1 to 7s. Could you suggest whether there's a reason for that apparent relative consistency through all those hospitals? Is it purely an accident? Could it be attributable to the years of something like the NHPPD or is there some other reason?---Certainly over my time, variations of the nursing hours for patient/day model has certainly been used. I think it's been well accepted that for a general medical or surgical ward that you know, depending on what type of elective and emergency interventions you do whether you focus one way or the other, that you have a fair idea that you need somewhere between 4 and a half and 5 nursing hours per patient day and that converts across on - on a ward around 30 patients, to have about 7 people on in the morning. So it's been something that's been established over a long period of time and with a lot of clinical expertise added to it and the wards have been able to develop and then modify that to suit their own personal needs. I think there are a lot of very clever people out there who spend a lot of time trying to get it right for nurses and I think the different types of sites that we run, whether they're a multi-purpose service or a bigger regional centre, I think we've got a pretty fair idea of what the workload actually is on the wards and try very hard to put numbers there that actually match. I mean, you're silly to understaff your ward. There is no gain in it. If you want to spend a lot of your time agonising over trying to find staff on an ad hoc measure afterwards, then that's not a productive use of your time. It's much better to staff a ward properly at the start and provide the resources there and then manage it as it goes. I think that's a much better use of time both at the clinical level and certainly as a manager at the management level.
**** DIANE CHRISTINE MANTELL XXN MR WALKER
PN1509
So the use of the NHPPD over time has extended beyond Kalgoorlie or the single instances to be something of a rule of thumb?---Yes. Yeah. And certainly people - there's probably more transient population in Western Australia than I think on the Eastern States. There are people who have come from a variety of circumstances. I mean, some people will abuse the Trend Care System or Excel Care System or Apace Acuity System and I think you will use all of those together to come up with what you believe is a reasonable and acceptable workload tool to assist in managing the workload at your sites.
PN1510
Yes. So there may be individual variations between the different, what are they called, districts, are they?---Health Services, yes.
PN1511
Health Services. But there would tend to be a relative consistency regardless of what measure was used? Is that putting it too high?---No.
PN1512
Yes, thank you. Anything arising out of that, Ms Burke? Mr Ellery?
PN1513
MR ELLERY: Nothing arising, your Honour.
PN1514
PN1515
MR ELLERY: Your Honour, I'm conscious of the time. Mr Alan Jones is available if you wish me to call him. Otherwise we could leave it till tomorrow or the day after.
PN1516
MUNRO J: I think the vote might be in favour of adjourning.
PN1517
MR ELLERY: Certainly, your Honour.
PN1518
MUNRO J: The people at that end of the bar table, is the temperature a bit elevated?
PN1519
MR ELLERY: It is a bit warm here, yes. So it's not just me?
PN1520
MUNRO J: Yes, I thought from the complexions. It is at this end too but ours might have been alleviated. We will see what we can do to correct it.
PN1521
COMMISSIONER O'CONNOR: If you can do that, Judge, you are very brilliant. We've been trying for years.
PN1522
MUNRO J: I see. I thought it had got better simply because his Honour's associate had done something. I react to the placebo effect, I think. I felt cooler but I thought you were looking hot. Very well, the Commission will adjourn till 10 am tomorrow morning.
ADJOURNED UNTIL WEDNESDAY, 10 OCTOBER 2001 [4.02pm]
INDEX
LIST OF WITNESSES, EXHIBITS AND MFIs |
STUART BLINMAN, SWORN PN954
EXAMINATION-IN-CHIEF BY MS BURKE PN954
CROSS-EXAMINATION BY MR ELLERY PN957
RE-EXAMINATION BY MS BURKE PN990
WITNESS WITHDREW PN995
DEREK COLIN PATERSON, SWORN PN996
EXAMINATION-IN-CHIEF BY MS BURKE PN996
CROSS-EXAMINATION BY MR ELLERY PN1000
WITNESS WITHDREW PN1041
LORETA VERONICA MURPHY, SWORN PN1042
EXAMINATION-IN-CHIEF BY MS BURKE PN1042
CROSS-EXAMINATION BY MR ELLERY PN1046
WITNESS WITHDREW PN1127
MICHAEL BARRY CLANCY, SWORN PN1128
EXAMINATION-IN-CHIEF BY MS BURKE PN1128
CROSS-EXAMINATION BY MR ELLERY PN1132
WITNESS WITHDREW PN1184
RAYE MICHELLE McNALLY, SWORN PN1186
EXAMINATION-IN-CHIEF BY MS BURKE PN1186
CROSS-EXAMINATION BY MR ELLERY PN1189
RE-EXAMINATION BY MS BURKE PN1233
WITNESS WITHDREW PN1236
DIANE CHRISTINE MANTELL, SWORN PN1315
EXAMINATION-IN-CHIEF BY MR ELLERY PN1315
CROSS-EXAMINATION BY MS BURKE PN1320
CROSS-EXAMINATION BY MR WALKER PN1460
EXHIBIT #LHMWU2 ENROLLED NURSES AND NURSING ASSISTANTS KALGOORLIE BOULDER HEALTH SERVICE ENTERPRISE AGREEMENT 1999 PN1466
WITNESS WITHDREW PN1515
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