C2001/1910, Transcript of Proceedings [2001] AIRCTrans 2883 (25 October 2001)

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TRANSCRIPT OF PROCEEDINGS

AUSTRALIAN INDUSTRIAL

RELATIONS COMMISSION

MUNRO J
SENIOR DEPUTY PRESIDENT O'CALLAGHAN
COMMISSIONER O'CONNOR

C No 2001/1910

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

10.04 AM, WEDNESDAY, 10 OCTOBER 2001

Continued from 9.10.01

PN1523

MUNRO J: Yes, Mr Ellery perhaps I should indicate, a couple of members of the Commission have on their bench lap tops, if - speaking for myself - I appear distracted, it should not be taken as discourtesy to any of the advocates, that's one reason I haven't used them much myself but we'll see how it goes. There has been a request, I think, for the parties to supply us with the electronic versions of witness statements and so on, and we would appreciate it if the ANF could make good, I think, with the initial documents, if they do have them, in that form - the original contentions order and witness statements, if they're still available in an electronic form they might be supplied to Mr Dudley.

PN1524

MS BURKE: Yes, your Honour, there's no problem with that.

PN1525

MUNRO J: And pass them on to his Honour, who has the mystique. Yes.

PN1526

MR ELLERY: Your Honour, before I call the first witness, if I could just talk about the scheduling witnesses that I hope to do. It occurred to me yesterday that we may be able to complete all the witnesses today and tomorrow, with a bit of re-shuffling, we may - obviously that would depend - and, of our witnesses, a number of them have limited timetables because there are other commitments - for example, Pat Tibbett is the Acting CEO of Royal Perth Hospital and obviously has various things on her plate at the moment.

PN1527

What I hoped and intended to do today was to call Ms O'Farrell first, as foreshadowed, Ms Di Twigg would be available from 10.45, Ms Pat Tibbett would be available today from 11.45, then I anticipated Dr Brian Lloyd could be made available today at 2 o'clock only - he couldn't be available at any other time and he does have a commitment at 3 pm he needs to get to, so, if it was possible I was going to ask the indulgence of the Bench to have resumption at 2 pm today?

PN1528

MUNRO J: Yes, I don't think there's any problem with that.

PN1529

MR ELLERY: Thank you. And then, for the remainder of the day there are a number of witnesses that I could slot in at various times, depending on how the day pans out, so Mr Alan Jones, Miss Cheryl Wolfenden and Mr Phil Della have relative flexibility so I can slot them in with some flexibility, depending on how long each witness takes. Tomorrow morning at 10 am I envisage calling Mr Kirkwood and, then following him, Mr Gilmore and that, subject to the order of those three "floaters" - if I can call them that - would be the order of events, I think, to allow us to complete within the 2 days rather than go through to Friday.

PN1530

MUNRO J: Very well. Well, I think, to some extent that program might be at the disposition of Miss Burke but we'll - the tight points in that are Ms Tibbett at 11.45?

PN1531

MR ELLERY: Yes.

PN1532

MUNRO J: Dr Lloyd is at 2 pm?

PN1533

MR ELLERY: Yes.

PN1534

MUNRO J: And perhaps if there are any other time constraints, you might enter Mr Kirkwood tomorrow at 10 am.

PN1535

MR ELLERY: Yes.

PN1536

MUNRO J: If there any other time constraints that are relatively inflexible you might just remind us as they go.

PN1537

MR ELLERY: Certainly, your Honour. Thank you. I'll call Miss Christine O'Farrell please.

PN1538

MUNRO J: Yes.

<CHRISTINE O'FARRELL, SWORN [10.08 am]

<EXAMINATION-IN-CHIEF BY MR ELLERY

PN1539

MR ELLERY: Thank you Ms O'Farrell. Just once for the transcript, can you repeat your name and address please?---It's Christine O'Farrell of the Department of Health, 189 Royal Street, East Perth.

PN1540

Thank you Ms O'Farrell. Ms O'Farrell, have you prepared two witness statements in these proceedings?---That's correct, I have.

PN1541

And are they true and correct?---Yes.

PN1542

I have nothing further, thank you.

<CROSS-EXAMINATION BY MS BURKE [10.08am]

PN1543

MS BURKE: Ms O'Farrell, if I could take you to your first statement, and specifically paragraph 4 of that statement.

PN1544

MUNRO J: We're looking at attachment 15, aren't we, to or tab 15 to WAGHI-1?

PN1545

MS BURKE: Yes, Tab 15 and folder 1 of the WAGHI submissions, yes, your Honour.

PN1546

In that paragraph you indicate that the government has decided to commit $69 million for 400 new nurses in the public health system in its first term in office and that is to be over a 4-year period. Could you tell the Commission how many nurses will be injected into the system each year?---The plan is to take the new nursing positions up into the system on roughly an equal basis each year so we would see the spread of those nurses in equal proportions generally across each of the years, bearing in mind that, in reality, it sometimes doesn't work that way.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1547

Given that there's a workload, immediate workload issue now, why aren't those nurses being, those positions being injected now?---The prospect of actually sourcing that many nurses in the short term was considered to be a little unrealistic in the current labour market. However, if the number of nurses was to become more immediately available, I believe there would be the flexibility to take up, to adjust the take up rate but it was really set and budgeted for, at least broadly at this stage, on the basis of the market availability of the nurses.

PN1548

Just in the earlier, in the background section of your statement you say that you are responsible for the executive management of the Principal Nursing Adviser, is that correct?---That's correct.

PN1549

Okay. And are you aware that Mr Della - who is the Principal Nursing Adviser - has submitted a statement in these proceedings?---I am.

PN1550

Okay. Are you aware that Mr Della has attached a number of reports that have been commissioned by the Health Department over the last 4 or 5 years?---Yes, I am.

PN1551

And I've had a look at Mr Della's evidence and what it tells me is that there has been a workload problem, or a concern by nurses with their workload since around 1997 and what I would like to know is how has the WA Government Health Industry actually dealt with the nursing workload problem over that time?---Yes, as you say, the reports do indicate and acknowledge that there is - has been a nursing shortage for quite some time and - - -

PN1552

Excuse me, Ms O'Farrell, I was actually saying that the evidence showed that there was a workload problem, that one of the reasons nurses were - - -

PN1553

MR ELLERY: Well, I've got to object to this line of questioning when we have a very broad summary of some hundreds of pages of reports that Ms Burke has chosen to characterise with the words that she's chosen but if the witness has a different understanding or interpretation of what is a great number of documents and a great number of reports, well then surely the witness should be allowed to proceed on that basis?

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1554

MS BURKE: Ms O'Farrell, in your opinion, do those reports show that there's a workload problem?---In my opinion, those reports focussed on a nursing shortage problem and the interaction between nursing shortages and workloads, I think, is pretty much a given - will I go on?

PN1555

That's enough, thank you. Okay. Just turning back to the $69 million in paragraph 4, how has that money been quarantined?---In this year's budget allocation process, the funding for this year's quantum of the uptake of 400 new nurses has been allocated to a costs centre which is being held in one of the divisions for which I have responsibility - that will be in the Health Workforce Division - and it is intended that through the process that we are establishing for implementation of the nurses EBA, the allocation mechanisms to health services will be done through that, through that process.

PN1556

Okay. Now in item 6, you talk about the 400 nurses are actually 400 FTE, as opposed to 400 in a body count, there are vacancies currently in the system, aren't there - your statement goes on to indicate that later on?---That's correct.

PN1557

Okay, so are the 400 new nurses going to be allocated once those existing vacancies are filled or are - do they form part of filling those current vacancies?---I think there's rather a dynamic between the vacancies that we have in the process of filling them and the business of increasing establishments and actually bringing more nurses in to fill those new positions and I think the best way for me to answer that is that both of those things will be happening at the same time. It is our intention in the EBA implementation process to work with nursing management to re-set establishments at a level which is sufficient, bearing in mind the workload that the patient activity and the acuity of patients that happens in a particular ward or unit, to then identify the level of vacancy and to work with management to ensure that there are sufficient measures in place, to attempt to fill those vacancies on a rather more sustainable basis than just bringing in ad hoc agency nurses on a shift-by-shift basis. And at the same time, when we are satisfied that there - those measures are established and in place, we will also look to allocating resources for new nurses where suitable nurses are able to be found to fill some of those new positions, so I think there will be a little bit of interaction between the two.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1558

So, if the Department is holding in a costs centre the $69 million, which is to be allocated, I understand, to the health services for the extra nurses, how will the Department know whether it's giving money for a new nurse or for filling a vacancy?---Well, we will establish a process where, when we allocate funding for a new nurse, it is on the basis of a certain understanding about that being for one of the designated new positions, we will allocate funding to that and we'll monitor the uptake of a nurse into that position and the retention rates and we will endeavour to keep the funding for those positions quarantined for those positions so that, if there is a turnover, the money is either used to fill the position or it is returned and is re-allocated. And I suspect that we'll be needing to do that at least for a couple of years, if not the life of the agreement, so that we are - we can all of us have a level of confidence that the new nurses have actually increased nursing establishments and are actually at a stage of reasonable sustainability that we no longer have to control and monitor that centrally. I think there is a point at which we can - we might all agree that we have achieved the target and it is now operating at a fairly sustainable level.

PN1559

There has been evidence submitted by Directors of Nursing from the major, from a couple of the major teaching hospitals and one from Esperance as well which says that, using the nursing hours per patient day model, there are currently significant requirements for additional nurses. So, for instance, at Kalgoorlie there's an indication that, using nursing hours per patient day, they need 22 additional nurses. Are you aware of that?---Mm hm.

PN1560

And at Sir Charles Gairdner Hospital there's a need for an additional 90 nurses to meet the nursing hours per patient day formula?---Mm hm.

PN1561

And at Royal Perth there's a need for an additional 127 nurses?---Mm hm.

PN1562

And at Esperance Hospital there's a need, using that - the nursing hours per patient day - for an additional 3 nurses, which adds up to - I've roughly added up - 342 additional nurses in 4 health services. How many health services are there in the WA Government health industry?---I don't have that number in, just on the top of my head actually, there's - there's a great number.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1563

I know - it wasn't meant to be a trick question, at least, you know, I think when we certified the agreement we knew - - - ?---There's a very significant number.

PN1564

Probably between 50 and 70, depending on the construction, of the service?---That's right, yes.

PN1565

Okay. So, if at 4 health services we need 342 nurses on the nursing hours per patient day model now, then 400 nurses over 4 years, and a commitment to $69 million to fund that, isn't going to meet the need, is it?---It will make a contribution to the need. I think the contribution by Government towards 400 new nurses was made well in advance of any of those sorts of figures being worked out so it is, it does need to be considered in the context of a range of strategies and a contribution towards resolving the problem. I would also point out that whilst there are a number of health services, as you have indicated, who against that measure require additional nurses, there are also a number of health services which against that measure require less, so yet another dimension of how we tackle the problem is to progressively look at some equalisation of staffing resources across the system.

PN1566

Okay. Turning to paragraph 8, you indicate that when new graduates, if they're retained by specific employers, come in they enter the system they will add to the general market of nurses available to be employed by the system, are you aware what that general market is in Western Australia, how many nurses there are available to work who are not working at the moment?---I have a rough idea, I mean we certainly know that there are - there is a specific number of nurses who are on the register and, when you compare that with the number of nurses who are actually participating in some way in the workforce, there's obviously a proportion of that market who - who are not participating.

PN1567

So the current - according to the most recent Australian Institute of Health and Welfare Report, there are currently 24,477 nurses on the WA register and would you say it would be correct that there are about 10,000 of them in body count as opposed to FTE working in the WA Government health industry?---I think that's correct, yes, it's 10,000 is the figure that, on a body count basis, that we're working with.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1568

Okay. And there's probably about 6000 in the private sector and around 3000 in aged care, which leaves about 6000 or so nurses who are on the register in WA but not working. Would that sound about right?---Probably in broad terms.

PN1569

Okay.

PN1570

MUNRO J: In that paragraph, Ms O'Farrell, you refer to graduate programs. A graduate coming fresh to hospital, what on-the-job experience, if any, would the typical graduate have?---It varies a little between the Universities who are training them but I think it's fair to say that they have relatively little practical experience, some a little more than others. But they come as new graduates into the system requiring a very high degree of supported entry for a period of time, several months, if not ideally about a year, of initially fairly heavily supervised and precepted work, easing off to - as their level of confidence and their capabilities to practice in solo gradually build up.

PN1571

Yes, so I think the evidence from Sir Charles Gairdner is referred to their intake being offered jobs permanently after a year so the rough rule of thumb is that the first year is an extension of training - - - ?---A learning year, that's correct.

PN1572

And, but when they arrive they're pretty wet behind the ears?---That's correct.

PN1573

Yes. Okay.

PN1574

MS BURKE: In paragraph 14 of your first statement, you talk about two extremes, one extreme being individual groups of nurses at the ward or unit level taking decisions about the eligibility to admit patients into a bed or ward or unit, which you say would create chaos and threats to patient safety, and then you refer to another extreme, which is for the system to continue to expose its nurses to unfair workload burdens. Have you seen the ANF alternative draft orders?---No, I haven't.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1575

Your Honour, could I show Ms O'Farrell a copy of the alternative draft orders?

PN1576

MUNRO J: Yes, is there one ready to hand?

PN1577

MS BURKE: I have, yes.

PN1578

THE WITNESS: Thank you.

PN1579

MS BURKE: If I read your comments in paragraph 14 correctly, what it seems you're saying is that there's one extreme and another, and perhaps there needs to be something in the middle that would resolve the issue of nursing workloads. Is that correct, a correct assumption?---Yes. I think so, yes.

PN1580

Okay. The ANF alternative draft orders have been submitted to the Commission in these proceedings to provide alternatives to what could be said as being two extremes in the form of workload management mechanisms. The first one is the ANF mandatory ratios, which you would be familiar with, and the other extreme is the Government's proposed order which - are you also familiar with that?---Yes.

PN1581

Yes. And what the ANF has presented here are certain principles of nursing staffing so if you have a look at the alternative draft order 1, it indicates that nursing staffing levels at each work place shall be determined on the basis of clinical assessment of patient needs. For instance, would that be something that you would consider nursing staffing levels need to be taken into account?---I would agree with that, yes.

PN1582

Yes. And would you agree that nursing staffing levels also need to be set, taking into consideration the demands of the environment, such as the layout of the ward?---Yes, I don't disagree with that.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1583

And, also, would you agree that consideration, such as workplace safety and health legislation and nursing regulatory legislation need to be considered in the determination of staffing levels for nursing?---Yes.

PN1584

And that the consideration of ensuring nurses don't have excessive workloads but have reasonable workloads needs to be considered when determining nursing staffing levels?---That's correct, I agree with that.

PN1585

So the principles are okay?---Don't have a problem with those, no.

PN1586

Okay. Now if you turn to the rest of that particular order, there's also a series of - - -

PN1587

MUNRO J: The document to which you're referring is ANF1 is it?

PN1588

COMMISSIONER O'CONNOR: B1.

PN1589

MUNRO J: Sorry it is?

PN1590

MS BURKE: No, it's not B1, Commissioner, it's alternative draft order ANF19.

PN1591

MUNRO J: It's the first draft, ANF19, yes.

PN1592

MS BURKE: Now, Ms O'Farrell, just turning to the grievance procedure which is contained within that same document, at the back of the document it contains a grievance procedure. Do you think that, if nurses on the wards have a concern about their workloads, they need to have some sort of mechanism to raise that concern in an appropriate way with their Director of Nursing and through to a process that can have a resolution at the end of it, if necessary?---I agree with that.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1593

You agree with that, okay. If I could take you to the second alternative draft order, which is alternative draft order 2 - ANF20, your Honour - this particular order, Ms O'Farrell, presents a mechanism for exploring a range of workload management mechanisms so it gives the - if it were issued by the Commission it would give the parties the opportunity to explore such things as the nursing hours per patient day model, nurse to patient ratios, responsibility allocations, trend care, software that's in use around the country, some of the bed containment strategies that are in place in the ACT, for instance - do you need to have a bit of time to look through it?---Probably would be a benefit if I did.

PN1594

Sure. Okay. Do you think there would some merit in exploring some of the types of options that exist around the country in the Western Australian Government health industry?---In answer to that particular question, I think there would be merit in exploring a range of measures that are in practice or have been thought of or tried, yes.

PN1595

And do you think that, after exploring a range of measures and identifying one that seems superior to the others, an effective workload mechanism should then be introduced?---I have some reservations about the assumption underpinning that and that is that there is one best or one single mechanism that could be decided upon. I have a belief that, based on my own experience in nursing and nursing management, that there are many factors which impact upon the workloads of nurses and that there - it requires a rather more sophisticated set of solutions and constant attention to the balancing of patient activity, patient numbers, bearing in mind the acuity of those patients and the needs with nursing numbers and nursing workloads and I would just have a caution about steering down a path that aims to examine a range of things and pick one and then decide that that's the one that we're all going to try and that we're going to trial that and put it in place. I - I don't believe that would be very successful in managing workloads, I think we need to examine all of the various measures that need to be taken and observe and monitor the implementation and the testing of those measures until we - until we work towards getting the right balance of measures and some sort of sustainability in that all of the stakeholders are, at any given time, reasonably satisfied that workloads are reasonable and patient care is assured and safety is assured.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1596

MUNRO J: Ms O'Farrell, in that connection, I think, the point is one that arises at several stages, several points in your statement. Getting the stakeholders satisfied, how do any of the systems create a sufficient level of visibility of what the process is and what the outcomes are for staff at ward level to be satisfied that they've got some power, or even some knowledge, of how they think the extremes that you address in paragraph 14 of your statement are being coped with?---I think that that raises a very important issue of how you - how the stakeholders are enabled to participate in an exploration of the issues, the possible solutions, and the taking and implementation and testing of certain measures. So I think the formalisation of communication and participation mechanisms is very important and probably requires a rather structured arrangement whereby people have something tangible and visible that they can participate in and has a businesslike approach and there is adequate disclosure and adequate sharing of information.

PN1597

Yes, my impression is that nursing hours per patient day mechanism, at least, is developed to this point doesn't have much of that visibility about it, at least at ward level?---I think that is a valid statement and - and I believe that it is - it is now necessary to share with the nurses themselves how that model came about, how it worked and to enable them to have a view and input into the - those benchmarks and the modification or the testing and suitability of those benchmarks, and their views need to be given validity and they need - - -

PN1598

Yes, it might be capable of being adjusted, could it, to allow, at least, some monitoring or the movements in the various criteria over time to be exposed?---Very much so, yes. Yes, I think if there is a mechanism which enables nurses to gain a knowledge and an understanding and a legitimate participation and some ability to evaluate to have input into whether it is a sufficiently workable model, whether it is amongst other - provided other things are being - I mean they need to be able to evaluate all things that are being done - - -

PN1599

MUNRO J: Yes.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1600

THE WITNESS: - - - all factors, which impact on their workload and participate genuinely in that process and I think that's one of the reasons why we have, for this first time ever, put in place such a formal implementation process for this particular nursing agreement and taking a fair degree of central interest and monitoring role from the Department's perspective in it. Because I do believe that there are some rather complex and sophisticated issues here and there are a group of workers who, at this point in time, have a fairly limited understanding of some of those things. And it is now important to make sure that they are adequately informed and connected in with the processes of testing and evaluating.

PN1601

Yes, since I got you interrupted, yesterday - Ms Murphy's evidence I think it was, in which was put of the concrete understanding that nurses have as to the expectation where there are a particular number on a roster and the visible shortfall can be of presumably the same number of beds that are filled, but the roster is short for the day on which they're working - and that sort of visibility is relatively concrete and apparent. Similarly, I suppose that's one - at least it's advocated as one of the virtues of the nurse-patient ratio. But it's not a visibility that would be beyond possibility at least so far as outcomes by using the NH PPD model. Would that be your assessment?---That's correct. I think so.

PN1602

Yes. Could I just take you to the extreme that you mentioned at paragraph 14. I think you say as to have individual or groups of nurses taking decisions about admitted or eligible-to-be admitted patients entry into a bed or ward unit. Could I put this to you that to some extent that does occur regardless of the system. The suggestions that have been put to me that in some instances, for instance, we can discharge an inhibition on patients being discharged at the weekend is that if a patient's discharged, there's a bed vacancy and the whole process starts again. And to ease the workload, there is a quite pronounced tendency - this is more a New South Wales phenomenon, but it would appear to me to be likely to be universal - but so far as it is within the nursing staff's control, then they may not discharge. That is one way in which defacto there is an exercise of control, regardless of what the formal process is. Is that a strange thought to you or does it echo some experiential basis?---I think in the West Australian setting, there is the variation in discharge rates. In fact, week

**** CHRISTINE O'FARRELL XXN MS BURKE

days to weekends. And I doubt that it is something that nurses themselves have control over. I think that there is a very much more - a medical control over the lengths of stay for patients and when a patient is discharged. I could appreciate, particularly based on my own experience, that with lower staffing levels and generally lower activity on weekends, keeping patients you know in the bed, rather than starting the process over again, yeah, it might be a desirable outcome to have. And there may be some capacity for nurses to influence that. And I would think that there is probably a level of that happening. But I do think what we are aiming to try to achieve here is that if we are going to make - if we are having a patient ready for discharge, they ought to be discharged and the bed left empty if the staffing levels are, you know - - -

PN1603

Yes?---- - - have decided to be - - -

PN1604

Yes. I am not suggesting - - - ?---- - - kept low.

PN1605

- - - it is an optimal process. It is rather that - - - ?---Yes, I think it is always a matter of - - -

PN1606

- - - there is a measure of defacto control?---- - - trying to keep patient needs and staffing numbers - - -

PN1607

Yes?---- - - better balanced. I would just add too, just on a comment that you made earlier that the tangibility and the visibility, the measurability for nurses in something that they understand and that is simple, the number of nurses versus the number of patients, is one measure. But I think one of the things for you to consider in terms of how complex this is, is that you can have the right number of nurses by sourcing nurses that you need to match patient care on a particular shift. However, you can and most commonly these days, it is through agencies. But the use of a higher balance of agency nurses for that shift doesn't always eliminate the workload problems. For agency nurses bring with them a workload problem in that, okay, you might have a few more nurses to help with a bit more of the patient care duties but it places a burden on the permanent staff in the unit, particularly when those agency nurses haven't worked in that unit before. So there is a burden of orientation, a burden of constantly telling people where things are. So it is not just numbers.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1608

Yes, thank you. I interrupted you, Ms Burke.

PN1609

MS BURKE: Thank you, your Honour.

PN1610

In relation to the agency nurses, Ms O'Farrell, could you tell the Commission how much the WA Government health industry spends on agency and casual nurses roughly in a year?---No, I probably can't, off the top of my head give you that exact figure. But I can see that it is a considerable amount.

PN1611

Would it be around $40 million?---I couldn't say yes or no to that. I am sorry, I just don't have the precise figure in my mind. But just to reiterate, it is a substantial amount of money that we spend as a system per year on agency nurses.

PN1612

Okay. Just turning to your supplementary statement. At paragraph 8, you state that:

PN1613

The vast majority of FTE nursing positions are filled on a daily basis.

PN1614

And my question is what happens when the remainder aren't filled? What mechanism is in place to deal with that sort of situation?---In some places, that obviously causes a difficulty in that either the nurses are operating understaffed as it were and are, depending on patient needs of the day, going to have a somewhat more difficult time in managing that particular shift or as invariably happens and one would hope happens sufficiently is that the nurse's predicament is brought to the attention of management or is picked up by management and that there is some endeavour by management of the day to equalise the pressures either within the facility by shifting nurses about, to try to ease the priority pressure points or to try to modify patient activity by cancellations of admissions, cancellations of elective surgery. And in some cases, by trying to equalise the pressures between hospitals. So if you regard the metropolitan health system as a system, for example, if there are some

**** CHRISTINE O'FARRELL XXN MS BURKE

capacity, you know, in another place and another hospital is under some sort of peak pressure, then there may be some sort of capacity to move things around. I think between the hospitals, sometimes they are all placing significant demands upon the agencies to supply nurses and, for example, in very peak periods of demand a group of hospitals elects to cancel elective surgery for a period of time for anything other than category 1s, that will free up some demand upon the agencies to be able to channel nurses into where, you know, invariably sometimes a teaching hospital, for example, where there is peak levels of activity going on.

PN1615

MUNRO J: The hospitals are relatively autonomous in those decisions, are they?---Each hospital, yes. The way they are currently structured, does make them relatively autonomous. Although more and more we see and we encourage the metropolitan hospitals in particular to work collaboratively together to deal with these problems of - for example, the Winter crisis, the hospital system in the metropolitan area actually comes together and tries to deal with that problem on a systems level, rather than individual hospitals trying to grapple with that problem individually. Because it is beyond their capacity individually to deal with that type of problem. We are moving into a model where we will see metropolitan hospitals linked together in areas, geographic areas, so we are likely to see models where, for example, Royal Perth Hospital, Bentley Hospital, Swan Districts Hospital and Kalamunda become - are in an area and become linked together so the capacity for equalisation of pressures and staff mobility in and around that area system is going to be a feature which we have not seen before. So I think, again, probably creates some sort of potential to equalise workload and patient pressures in a way we haven't been able to do before, because of that autonomy of the individual institution.

PN1616

Thank you.

PN1617

MS BURKE: Ms O'Farrell, in paragraph 12 of your supplementary statement you say - you go on to say how the vacant positions are filled on a temporary basis. What is the - how do you know those are the figures?---We have been examining the experience in some of the hospitals and looking at their expenditure, for example, on nursing staffing FTE relative to their current budgeted establishment. And in some cases they are running over budget and

**** CHRISTINE O'FARRELL XXN MS BURKE

over FTE which is an indicator that they are actually making attempts to match staffing numbers to workloads. So where their workload pressures are going up and patient demands - levels of occupancy, acuity levels, are going up, irrespective of their budgeted FTE, they are actually on a shift by shift basis trying to adjust nursing numbers and they are drawing in higher and higher levels of agency nurses. And that is showing up as higher expenditure and higher FTE. So we also have looked and learned through other measures that by and large where there are vacancies on a roster, every attempt is made to fill all of those vacancies. Now, as you pointed out before, we don't think that they succeed in filling all of the vacancies. We do believe that from place to place, because of the demands one hospital might place on the agencies or a group of hospitals might place on the agencies for a week or two, some are going to miss out. But by and large, a lot of the vacancies that we have around the system on a shift by shift basis are being filled by nurses who are being drawn off casual lists or as fact would have it principally through agencies. Now, we don't think that that is satisfactory. And as I have pointed out, that brings with it its own workload implications so it doesn't really address the problem. But the nurses who we need to engage in employment with those health services are in fact coming to those health services, as you know, via agencies. So we have vacancies. We are filling them but not on a permanent basis. And the balance of that has come completely out of whack and that is really contributing another dimension to an already existing problem.

PN1618

What I was really getting at was do you have statistics that demonstrate the use of agency or how the vacant positions are filled or is it an estimate?---At a statistical level, all we have is the FTE and expenditure rates by various hospitals on nursing and comparing to their budgeted FTE. And knowing, as we do, how much - what is actually coming through by way of agency expenditure. So we can actually calculate the level of FTE and expenditure that is on agency nurses versus the permanent nurses. I just don't have those figures off the top of my head, I am sorry.

PN1619

Okay. Just going back to the question I asked earlier about the expenditure on agency nurses, if you have a look at your statement in paragraph 13, you talk about the document KBJ supplementary attachment 18 which was the document that was sent from the Government health industry to the ANF during the enterprise bargaining negotiations, that dealt with what the current number - a number of questions and the number of vacancies, how much is spent on agency - - - ?---I understand.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1620

- - - and casual and so on. So you are familiar - that document - - - ?---Yes.

PN1621

- - - came from your office?---Yep.

PN1622

And I just had a look at it now and noted that it actually says that it was about $43 million - - - ?---Right.

PN1623

- - - spent on agency and casual nurses. That you informed the ANF that there was about $43 million spent on agency - - - ?---Okay.

PN1624

So would that be correct or is it - - - ?---That was an our estimate at the time and I think that was probably a pretty reasonable estimate drawn off the data that we have. So, yes, I would agree with that.

PN1625

Okay. Right. Paragraph 16 of your supplementary statement, you talk about the 400 new nurses intended to progressively build up nursing capability. And the question I have is it does seem to be quite difficult to actually get nurses and recruit them and bring them back into the system. That is clearly a problem. So what happens if you can't get - if you can't fill those 400 new positions? How will the workload problem be dealt with?---I think, given that we have allowed ourselves a period of time to do that, we probably will fill them. But I understand the point of your question. And I think my answer is that because we have nursing shortages right now and we have nurses experiencing workload difficulties right now, we have a number of measures and strategies that we are already trying and we are going to explore a number more, to try to deal with the problem, but we have to deal with it today as well, as best we can. And apart from trying to source nurses through agencies, trying to run recruitment programs, get re-entry programs, and do everything we can to build up a more stable employed nursing workforce, we still have to look at the - managing the other side of the equation and that is the volume of patient work that we do. We need to accept that individual wards and units and individual hospitals do what they can but we have to try to look at equalising pressures and trying to balance things up and better match patient activity with

**** CHRISTINE O'FARRELL XXN MS BURKE

available human resources at a systems level where we can. And I believe that part of the rationale to moving towards the system of - the arrangement I described briefly earlier on with area management, is a big step in the right direction there. Because it does actually link various hospitals together and enable them to start to manage more as a system. And I believe that the nurses in the workforce will benefit from that because there can be decisions taken which can redirect patients which can change the way patient demands are managed and more adequately balance those against available human resources and skills than we are doing now. And those sorts of measures are available to us right now. And in fact in some cases and in many ways we are doing those things and should continue to do them more precisely. So I think we do need to manage patient and have a lot more regard for the workload demands we are placing on our workforce and we need to do that - take those measures in a variety of ways.

PN1626

So one of those ways that seems to be coming through from the Government health industry is the nursing hours per patient day model?---The nursing hours per patient day model I see as being a useful mechanism to enact at a ward or unit and at a hospital level and if that is applied fairly consistently across the industry, then everybody at those levels is trying to manage the problem in a fairly similar sort of way and, in that way, it becomes a fairly standardised strategy, everybody gets the benefit of trying to understand it and work with it. I think what I was referring to was at yet another dimension which is the higher and more systems level dimension and - - -

PN1627

I understand that but can I just go back to the ward unit or hospital level?---Mm hm.

PN1628

With the nursing hours per patient day, if that seems to be a model that sets a benchmark or a minimum standard of nursing care, and it's currently, as we know, it's indicating from the analysis that's been done, that a lot more nurses are needed to properly meet those benchmarks, why isn't that happening?---Yes.

PN1629

MUNRO J: I'm sorry, I missed the last part of the question, why isn't it what?

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1630

MS BURKE: Why isn't it happening, why isn't the hospital - say Charlie's for instance or any of them - why aren't they staffing to the nursing hours per patient day formula, which says they need a lot more nurses?---I would - I would go so far as to say that, in some cases, they actually do and I think, as I've pointed out, we've got some evidence to show that in some cases, by default, the hospital's nursing management are assessing patient demands and workload and they are doing everything they can to try to build up nursing numbers. Unfortunately, it's mainly through sourcing agency nurses which brings its own problems but they are actually trying to match the numbers of nurses to patient needs and that's, in some cases, beyond their budgeted nursing FTE so they are, if you like, by default, pushing up the establishment anyway. What's undesirable about that is, of course, that it isn't - it isn't done on a properly managed basis and they're not actually recruiting those people and getting them engaged as permanent employees. It's a much more chaotic arrangement for staffing.

PN1631

Yes. Okay.

PN1632

I don't have any further questions, your Honour.

PN1633

SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Ms O'Farrell, can I ask you to clarify paragraph 11 in your primary statement and, in particular, I refer to the sentence that reads:

PN1634

As a result of this, the Department of Health has funded a selection of additional re-entry programs which are free to subscribers.

PN1635

Can you explain to me exactly what that entails?---Yes I can. Re-entry programs for nurses are probably one of the best weapons we have because, as Miss Burke pointed out, there are a significant number of nurses who are registered to practice and who, for a variety of reasons, are not practising and we are actually aggressively targeting that market to try and attract them back into the nursing work force. Many of them need - have been out of practice for

**** CHRISTINE O'FARRELL XXN MS BURKE

a while, they are still registered and they need to do either a refresher course or, in some cases, they actually need to do a full re-registration course. Through my area in the Department, we - we do fund a number of those courses but up until fairly recently they've been on the basis of the subscriber paying a fee to participate. When we were embarking on the campaign, we actually advertised for 400 or put - ran an advert in the paper recruitment drive, saying that we were looking to bring 400 new nurses into the system on a progressive basis, asked people to contact us and one of the things we offered were re-entry programs because, by and large, the vast number of people who contacted us said they would be interested in coming back but they needed to do a refresher or they needed to do a re-registration and it's very difficult to get into those courses and it costs money. So we decided that we would set up some programs and run them on a subscriber-free basis and with a very, very good result. So, that is one of the strategies that I see us using more and more in the future because these are nurses who are trained, with a little bit of time and a little bit of effort and a little bit of money, they're actually very ready to hit the ground running and it seems that a barrier to them coming into these programs, which is the - is there a sufficient number of these programs available? Are they happening in convenient locations? Are they happening regularly enough and are they free to get into - is a way for us to actually tap into that market and bring nurses on stream fairly quickly, relatively - much more quickly than it's going to be for us to grow new graduates and go through their education program and then their training and there's relatively slow progression up to full solo practice capability.

PN1636

Now, these refresher programs, are they operated from hospitals or from where are they delivered?---There's a variety of models. We've been funding hospitals to run them for us.

PN1637

Do those hospitals then have any capacity to try to ensure that those staff who, or those personnel who undertake the program, then continue on as nurses within that particular hospital?---I would imagine that the hospital, that each of the hospitals running their program would probably try to influence the people going through that, to consider them first, but technically anybody coming through every refresher program or re-registration program is free to go wherever they like, it's a real seller's market at the moment, but if I was one of those hospitals I would be trying to have my first pick.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1638

Thank you. The role that you undertake within the Department, does it incorporate responsibility for involvement in the budget setting and finalisation process, particularly for rural hospitals?---To some extent.

PN1639

Has the budget then for the current year been set?---The budget for health has been provided by Government and the budget allocation process from the Department to the various budget holders, which includes hospitals amongst many others, has been done and is almost finalised.

PN1640

So hospitals know now what their budget is for the next or the current financial year?---Yes, they do.

PN1641

Then can you tell me a little bit more about the time frame for the budget-setting process? In your evidence and in your statement, you've referred on a number of occasions to full-time equivalent staff or staffing allocations?---Mm hm.

PN1642

You've also referred to budgeted full-time equivalent staff?---Mm hm.

PN1643

And what I'm interested to know about is how and over what period of time do you go about reviewing those budgeted full-time staffing allocations?---In a - in a normal cycle, budgets are brought down by Government prior to the commencement of an oncoming financial year and the Department's goal then is to - and the Government's expectation is generally to have budgets allocated to health services on or about at the commencement of the financial year. This year, because we've had a change of Government, that process has been a little slower and we didn't get the budget brought down until much later in the financial year. That's in fact happened a lot in years past and the way that works is that the hospitals continue to operate on an indicative budget. Governments always generally budget on a current and forward year basis, so the forward estimates become the indicative budget capability and in the main, budgets only change around the margins to the forward estimates. The process of budgeting, once the allocations are made, either indicatively or - or

**** CHRISTINE O'FARRELL XXN MS BURKE

substantively, to a health service and - and or a hospital, the internal budgeting process is commenced or finalised. So the process of - of looking at the year's activity, the contract for service, what the Government expects of the Health Service, what the health delivery strategy is going to be, what the patient work generation capability is going to be, what the work force needs are going to be. Really all of that determines how a hospital management team would - would allocate their internal budget to cost centres like the nursing one, setting - nursing establishments setting FTE, making provision for equipment purchases, staff development programs. They are very internal budgeting processes and they are usually - in the main they are fairly sustainable items. They don't change a great deal from year to year so they roll on across financial years in the main, maybe changed around the margin if a hospital says for example: well, this year we're going to run a new initiative or a program, so that might be a bit of a change in - in internal budgeting outcomes, but in the main the, you know, the nursing services and patient care services kind of jump over the - the roll on, the change from one financial year to another without any sort of tangible blip.

PN1644

Well, you see, can I test that a little further? There appears to be a great deal of material before us that indicates or goes to the significant shortage in nurses. There is material before the Commission that indicates that a commonly used mechanism to try to counter that problem is the use of agency nurses. And there is clearly material before us that indicates that agency nurses cost hospitals more than do staff employed directly by the hospital. So can you help me by telling me how a hospital that might be operating at the present time off its indicative budget, founded on the previous year's estimates but a hospital which then finds itself having to draw more heavily on agency personnel would not be prejudiced in terms of its financial position when the budget is confirmed?---I'm not quite sure I understand the question.

PN1645

I guess what I'm raising here is a question as to how the Department of Health take account of the potential that hospitals may have to incur significant additional costs - - -?---Ah, okay.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1646

- - - as a result of the use of agency nurses when we're in a time frame which takes us a little over a third of the way through a current financial year, and as I understand it from you, hospitals are just having their budgets confirmed now?---Thank you. I think I understand the question a little better. And I think - I think the budgeting process is not the key issue because hospitals continue to operate whether budgets have been finalised or not. In - in years gone by, hospitals have generally maintained a regular dialogue with the Department in the process of budget management and expenditure monitoring and clearly there are a number of cost factors which have been impinging on operations for quite some time and the high cost burden of agency nurses is one of those. And there has been the ability to provide additional funds to various health services throughout the year as that problem has - has become more exacerbated. In very recent years, the process of managing that situation has changed considerably, so the Department now is less inclined to keep aside a contingency fund, if you would, in anticipation of hospitals needing additional funds for various extra things. What is - what is now more normal in terms of budget management is for all of the funding to be allocated to the Health Service so that the Health Service then takes into consideration in its planning process and its internal budgeting processes just those sorts of contingencies. So hospitals know, for example, what their exposure has been in recent years to something like the cost of agency nurses. And they would make a budget provision for that. So - so in fact, in setting - in operating out of an indicative budget or a confirmed budget, it's - it's very - it would very much be the roll on of the strategy that they used the previous year. So yes, it is an impost upon them, but they have - they have what - they have all the money that is available to run their operation. I might just point out as well, it might help you just to understand that over the last several years, the - the mechanism for financing health services by the Department has ceased to be on the basis of historical spending and inputs such as FTE or - or other specific elements of expenditure. Health services are now financed on the basis of the range and volume and type of occasions of service for episodes of patient care that they are contracted to provide. And each of those episodes or sets of episodes has various production elements to it, staffing being one of those. So a Health Services contract these days is more likely to look at - to look like a contract which specifies a certain volume of certain types of activities which have a unit cost value to them, and the bottom line is, the sum total of all the activity-based unit costings. So it really puts a whole new dimension on it because the process of internal budgeting by the Health Service becomes a much more critical thing and they

**** CHRISTINE O'FARRELL XXN MS BURKE

are much more empowered to determine their own internal budgeting processes. The Department doesn't actually say: you can have X number of staff and here's the money for that and you can have this piece of equipment and here's the money and you can buy X amount of linen and here's the money. It says: we would like you to deliver this range of services, this volume and - and meet these sorts of performance targets for patient services and how you run your operations and allocate your internal budgets is a decision for you to make. So things have changed quite considerably in the last 7 or 8 years, I think, that process has been in train.

PN1647

Thank you. Two last brief questions. The first is that when Commissioner O'Connor and myself visited the Royal Perth Hospital, we were shown a newly developed Patient Management System that tracked patient movement and numbers through the hospital?---Yes.

PN1648

Given your evidence that there's a deal of effort being put into encouraging the metropolitan hospitals to work collaboratively, then is such a system potentially of benefit if it were to be applied on a consistent basis across hospitals that were working collaboratively and if so, then what role does the Department play in that respect?---Yes, we would see that as being an advantage and we would hope that sophisticated bed management systems like the one you saw might start to apply in a more consistent basis within systems, areas or even across the whole metropolitan area, because it's one really effective way to try to manage pressures and equalise pressures. The role of the Department of Health in matters like that is - is to influence the - the progression towards that sort of management of the system through strategic planning, through helping Government development policy, through its executive functions under legislation. It has certain delegations from the Minister through the Director General to be able to issue instructions and directives, set policy, set performance expectations. There are a range of measures by which the Department can decree or advise or instruct or influence, monitor, test, evaluate.

PN1649

Thank you.

PN1650

MUNRO J: Mr Walker?

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1651

MR WALKER: Thank you, your Honour.

PN1652

COMMISSIONER O'CONNOR: Sorry, just a minute. Ms O'Farrell, in paragraph of your supplementary, you say that:

PN1653

The 400 new positions are intended to progressively build up nursing capability so that rostered deficits related to consistently high patient volumes and acuity are covered in a more sustainable manner and ad hoc engagement of nurses through agencies.

PN1654

Now, given that you've got 750, according to your statement, FTE vacancies at this point in time, and that the FTE is determined by nursing hours per patient day, what's to stop those 400 additional positions just replacing the 750 FTE that you're currently filling from a current budget?---Well, technically that could - that could happen and that is a risk and that's why we've set up the - the sort of central control implementation process, if you like, to try and get documented every - every staff establishment and have a clear understanding about what the new benchmark is, so we can make a judgment on when employment is happening into these current vacancies versus one of the new positions. So we want to try to sort of clearly set up the differences between those two things and understand the dynamic between them and monitor the performance on both - both scores.

PN1655

Yes, because for it to truly be additional 400 staffing, and if you did get 400 permanent FTEs within the system, theoretically you would still have to be employing 750 FTES from outside the system?---We do need to. That's approximately the number of vacancies that we want to fill by permanent and part-time and - and casual nurses who are employed directly by the Health Service. That's right. And then we want to add 400 new ones to that.

PN1656

That's right?---So we've got quite a challenge in front of us.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1657

All right, thanks.

PN1658

MR WALKER: Ms O'Farrell, paragraph 3 of your first statement, you indicate that you are responsible for negotiations of the new agreement, but we understand that agreement covers mental health enrolled nurses?---That's correct.

PN1659

Could you indicate to the Commission where those mental health enrolled nurses are employed within the West Australian Health System?---I think predominantly Graylands although I'm not - I couldn't tell you exactly where all of them are employed, off the top of my head.

PN1660

Okay. Throughout your statement, you refer to new nurses, the 400 new nurses. Is that all levels of nursing that specifically include enrolled nurses?---It doesn't preclude the inclusion of enrolled nurses although I must - the initial strategy in setting up the 400 new nurses and the intention of Government was to predominantly aim or target senior nurses who were - senior registered nurses who are eligible to be operating at around about level 2, recognising that another set of factors in the workload issue is the impost of the preceptoring requirements upon nurses and the staff development requirements, particularly in areas where the uptake of new grads is fairly high. So if you - you know, if you're pretty busy and you're understaffed and you've got a new grad or two under your wing, it just - it's - yeah. So the idea was to try to get as many more senior nurses as possible who could come in and pick up those preceptoring roles and - and reduce the burden of that. But at the end of the day we have a workload problem to address for nurses, so we wouldn't rule out enrolled nurses as being a big part of the solution.

PN1661

Ms Burke referred to exploring a range of issues for nurses workload and you referred to the State levels. Would that include enrolled nurses or enrolled nurse representatives?---In my view, it would, because I actually see them as part of the nursing team. I think they're suffering part of the problem and they are part of the solution and they need to have adequate understanding and knowledge of what's happening. They need to be able to participate and they also need to be able to evaluate and judge what's being done and the adequacy of it.

**** CHRISTINE O'FARRELL XXN MS BURKE

PN1662

Okay. That's all I have.

PN1663

MUNRO J: Yes, thank you, Mr Walker. Mr Ellery?

PN1664

MR ELLERY: Thanks. Ms O'Farrell, Ms Burke took you to the draft alternative orders proposed by the ANF, which you looked at in the witness box, and took you to processes for resolving disputes, for want of a better word, under those draft orders. Do you recall that?---Yes.

PN1665

Now, your evidence is that you were one of the people responsible for negotiation of the certified agreement covering the ANF?---That's correct.

PN1666

That was recently certified. Are you aware of whether that agreement has any dispute resolution procedure in there?---I think it does.

PN1667

Are you aware of whether that procedure could not be used to deal with workload matters or workload problems?---In my view it could.

PN1668

Okay. Thank you. Nothing further.

PN1669

MUNRO J: Thank you, Ms O'Farrell. You're excused from further attendance?---Thank you.

<THE WITNESS WITHDREW [11.25am]

PN1670

MUNRO J: I think we have Ms Twigg, isn't it?

PN1671

MR ELLERY: Yes. I call Ms Diane Twigg. I believe she's outside.

PN1672

MUNRO J: Or is it Tibbett? I thought Tibbett - - -

PN1673

MR ELLERY: No, it's Twigg. Di Twigg is next.

PN1674

MUNRO J: Was that the 11.45?

PN1675

MR ELLERY: Di Twigg was here at 10.45, ready and waiting.

PN1676

MUNRO J: I see. Right, I'm sorry.

PN1677

MR ELLERY: And Ms Tibbett is scheduled for 11.45.

PN1678

MUNRO J: Yes. I have the wrong clock in mind.

PN1679

MR ELLERY: We may obviously run overtime a bit, but we'll just have to play that by ear, I suppose.

<DIANE ELSMAY TWIGG, SWORN [11.25am]

<EXAMINATION-IN-CHIEF BY MR ELLERY

PN1680

MR ELLERY: Thank you, Ms Twigg. Just once more for the record, could you state your name and address, please?---Diane Twigg, of Hospital Avenue, Nedlands, Western Australia.

PN1681

Thank you. And Ms Twigg, have you prepared a witness statement that was filed in this matter?---Yes, I have.

PN1682

And is that statement true and correct?---Yes, it is.

PN1683

Thank you, Ms Twigg. I have no further questions. Ms Burke will cross-examine.

<CROSS-EXAMINATION BY MS BURKE [11.26am]

PN1684

MS BURKE: Ms Twigg, if I could take you first of all to paragraph 4 of your statement, you say that the hospitals nursing service has run over budget to meet the existing nursing requirements. Is that correct?---Yes.

PN1685

Are you aware that recently in the West Australian, there was a report that Sir Charles Gairdner Hospital had a shortage of 40 nurses?---Yes, that's correct.

PN1686

MUNRO J: A shortage of how many?

PN1687

MS BURKE: 40. Sorry, your Honour, I must speak more clearly. Loudly.

PN1688

Can you explain how you have gone over budget, yet you have 40 vacancies?---The vacancies referred to relate to permanent appointments, so nurses that we would appoint permanently, if they were available, whereas the issue of running over budget is we've used casual or agency staff to supplement our permanent nursing work force, given that we can't find permanent nurses.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1689

And moving on to paragraph 5. In preparing the budgets each year, the hospital develops an estimate of the number of nurses required to operate the hospital if all staff were employed on a full-time basis. Is that correct?---Yes.

PN1690

And could you tell the Commission how that full-time equivalent profile is estimated?---We had a process in place several years ago. The original budget was built up, ward by ward, shift by shift. Any variation to those staffing requirements is now at the process where a business case is developed by the local area with their level 3 nurses and the nursing co-director, who's a member of the nursing executive. They then put that case to the nursing executive. The nursing executive discusses that and if that's supported through that process, it then goes into the hospital internal budget building process that identifies that we need whatever those resources are.

PN1691

Did you just that if it's supported by the hospital?---By the nursing executive.

PN1692

By the nursing executive. So are the nursing executive the group that determine what the FTE should be ultimately?---Yes.

PN1693

Now if you turn to paragraph 11. You talk in that paragraph about the 400 additional nurses and what I'd like to know is if the hospital has been provided with funding in its current budget for additional nurses from that 400?---No.

PN1694

You go on to say that using the nursing hours per patient day model, it's your understanding that the hospital would receive funding for an additional 90 FTE nurses? So is - - - ---Yes. Sorry.

PN1695

Is it the case that the nursing hours per patient day model determines that you should have an additional 90 nurses?---Yes. The work that was done on that model would mean around 90 more nurses for the wards at Sir Charles Gairdner Hospital. So it doesn't go to the critical care or Emergency Department, those sort of areas. That process is still in train.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1696

Okay. So it's likely that you'll need more than 90?---Yes. Overall.

PN1697

If you used the nursing hours per patient day model?---Yes. Or whatever model we use for those other areas.

PN1698

Okay. So is the nursing hours per patient day model actually in use now at the hospital?---No. We're between the state - we've let a tender to implement the program that we developed internally and that tender is in the process of implementation. So it's three quarters of the way there. But they had some sick leave so that did delay it, and that's the operational model.

PN1699

Okay. So how will you get funding for those additional 90 nurses that you need?---My understanding is that the 400 nurses that the Government has committed over 4 years, the funding for that has yet to be allocated at all. It is the work that the directors of nursing across the State, which started with the metro directors of nursing and now with rural areas as well, have agreed that this is the most appropriate model of allocating those resources.

PN1700

Now, the 400 new nurses, we've just heard from Ms O'Farrell that they are to be implemented over a 4-year period and that's across the whole State. So if you need 90, you're not likely to get them all now, are you?---No. I would imagine that they would be allocated over the 4-year period. In reality I don't think we could recruit 90 this financial year.

PN1701

But the nurses are - we have heard that there are nurses available who are registered with the Board but who are not working?---Mm hm. We have - and I think like most hospitals, we have two issues running concurrently. One is that we do need more nurses generally to address the nursing workload issue. The other is that we're covering a vacancy rate that we need to top up in the first instance in terms of our permanent nurses. Now, currently those nurses are coming through casual and agency but we would prefer that they were coming through part of your permanent working force except for those very short term unplanned absences.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1702

So as well as having a vacancy on the permanent work force, you also have a need for an extra 90?---Yes.

PN1703

So how many all up would you need?---I would estimate about 140.

PN1704

140. Okay. And so - - -

PN1705

MUNRO J: Well, that flows almost directly, doesn't it? I think you said that you have a shortfall of 39 or 40?---Yes.

PN1706

And on the NHPPD figures, you should get 90 out of the 400?---Yes.

PN1707

Well, when you run those together, that's 129 and you think you would be hard put to fill 90 in any event to overcome - well, you can't overcome the vacancy problem of 39. The chances at present of solving a vacancy problem of 130 would seem to be remote?---Yes. I think we'd have to put in some long term strategies to consistently focus on recruitment and retention.

PN1708

Yes. But to an extent the 130 figure or 129 figure reflects the quantum of the workload problem that you would have if you staffed up to the NHED level?---That - 90 is a truer reflection of the workload problem because we are filling those other vacancies. We're using up to a budget - - -

PN1709

But at present they're using your casual and - yes?---It's about 39 or 40 of those staff are through casual agencies which is an ideal way of doing it.

PN1710

Yes, thank you.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1711

MS BURKE: How do you manage workload difficulties for registered nurses at the hospital now?---We've established quite a few mechanisms to try and manage the situation on a shift by shift basis. We have reports that daily provide a view of the next 24 hours and where we're struggling and we have a variety of mechanisms from closing beds on an ad hoc shift by shift basis to deferring or cancelling surgery where we can as a last resort going on ambulance bypass, various mechanisms to manage the workload on a shift by shift basis. We have asked and relied heavily on the goodwill of our nurses to - if they're part-time to do extra shifts and on occasions have had to rely on overtime and double shifts. So there's a variety of mechanisms and several people who spend most of their day sort of trying to manage just on a day by day basis to get the balance between patient care needs and the pressure that nurses are under in terms of their workload.

PN1712

You have had a look at the ANF first order for mandatory nurse to patient ratios?---Yes.

PN1713

Have you seen any of the other alternatives represented by the ANF?---No, no, I haven't.

PN1714

Your Honour, could I show Ms Twigg a copy of a couple of things?

PN1715

MUNRO J: Yes.

PN1716

MS BURKE: Since the last date of the proceedings, Ms Twigg, the ANF has presented a number of other alternatives to the Commission for its consideration in trying to find an effective workload management mechanism. And if you'd just like to have a minute to have a look through those? Have you had the opportunity to have a brief look at those?---Yes.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1717

If I could draw your attention to alternative draft order 1? Do you see under the heading: Operative Provisions? It refers to a number of determinants of nursing staff levels such as clinical assessment of patient needs, the demands of the environment such as the ward lay out, the geography of the hospital, workplace safety and health legislation and the requirements of nursing regulatory legislation and professional standards and reasonable workloads. Would you agree that nursing staffing levels should be determined on those sorts of considerations?---Yes, they're reasonable.

PN1718

And if I could refer you to the back of the document, effectively the last page there is a dispute settlement procedure there. Do you think it's reasonable that dispute settlement procedure should be available if nurses have a workload issue, something that can follow through and be dealt with appropriately?---Yes. I think it's appropriate they have a grievance process.

PN1719

Yes. If you could turn to paragraph 16 of your statement? What you seem to be indicating there is that mandatory ratios would result in over-staffing or unnecessarily closing beds so there's a lack of flexibility? Is that what you're saying?---Yes, that's correct.

PN1720

Okay. So if there was some form of indicative guideline rather than a mandatory fixed ratio that took into consideration the principles that we've just had a look at, would that be a workable workload management mechanism?---If was geared towards of which you may use more or less, yes. But if it sets a minimum standard then you still have the same risk because depending on where you set the minimum standard you may set it too high.

PN1721

Yes?---And if you set it at a truly very low minimum standard then you probably set it too low also. So if you're talking about working around an average, I think that's a reasonable approach using those sorts of guidelines. But if you're talking about setting a minimum standard then I think there's still risks attached to that.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1722

Should there be minimum standards for nursing care?---For nursing care, yes.

PN1723

If you could turn to paragraph 36 of your statement?---Sorry, was that 36?

PN1724

Yes, 36? You talk about nursing hours per patient day model. Do you believe that that model presents safe practical and appropriate minimum staffing standards?---It produces a safe and practical average.

PN1725

If you could turn to paragraph 39? You talk about the development of the nursing hours per patient day and the principles and criteria to be used. Could you tell the Commission what the principles you're referring to there are?---They're those that are outlined in the dot points under that point. So do you want me to go through each one?

PN1726

I though those were the - I was looking for principles as opposed to criteria and I read those, the dot points as being the criteria. I was just wondering if you actually had some principles for nursing, staffing or the development of the model?---No, the basic, I guess, criteria and principles were tend to use loosely in this document.

PN1727

Could you tell the Commission how you have determined what the number of hours should be? How do you know that that is the right number of hours to deliver patient - safe patient care?---The work that the metropolitan directors of nursing did and which the rural and country directors of nursing also reviewed incorporated their requirements, was a mix of trying to - - -

PN1728

MUNRO J: Could you keep your voice up if you could? We're having a little bit of difficulty hearing?---Sorry. Was a combination of a clinical judgment and trying to use some criteria such as the number of emergency presentations on the ward, the mix between emergency and elective work, because one is planned and one is unplanned and that has an impact on nursing. On the turnover of the ward, because obviously if you have a 40 bed ward and half

**** DIANE ELSMAY TWIGG XXN MS BURKE

your patients are discharged in one day and another half are admitted, that's a significant workload in terms of volume for nurses. So it's looked at elements like that plus what is, I guess, generally accepted as the average requirements that you need for nurses. So it was a combination of the experience of senior nurses that have had to manage these issues for a long time, more measurable criteria that we could look at grouping wards into based on those sorts of things such as turnover, emergency occupation, that sort of thing and the types of patients. Whether or not wards had high dependency units within them or they had a regular requirement because of the nature of the work that was undertaken on that ward for more high levels of nursing. So there's a variety of things that were pulled together to try and create a band that a ward fell within that grouping that you on average required this sort of nursing resource and that's what you should build your budget and try and develop and recruit your staff to that level.

PN1729

MS BURKE: Yes. So if we can have a look at appendix 3? Do you have a copy of the attachments to your statement with you? Appendix 3 is the WA Public Hospital Target Nursing Hours Per Patient Day Guiding Principles?---Yes.

PN1730

Okay. If you look at category A which has - there are three columns in the table, category A. Is that the category of nursing hours per patient day? So you're saying that category A is this type of ward or unit in the third column?---Yes.

PN1731

And then the 7.5 in the second column is the number of nursing hours per patient day that should apply to a patient in those particular wards?---Yes.

PN1732

So what I'm getting at is: 7-and-a-half hours, is that based on an empirical evidence, clinical studies? Is there any material which demonstrates that 7.5 hours is the right number of hours? Or is it just the clinical?---It's based on experience, it's based on clinical judgment and it's based on the feedback received from the clinicians in those areas.

PN1733

Do you know of any studies or evidence that shows that 7-and-a-half hours is the right number of hours for - - -?---No.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1734

For a patient in a category A classification?---No. There's no direct empirical evidence.

PN1735

Okay. If we turn to paragraph 52 which again refers back to the appendix we just had a look at. What's happening with areas such as labour wards and delivery suites, closed mental health wards, intensive care units and coronary care units in terms of the development of the model?---This original work which was in the attachment was aimed at multi-day wards. So it was never intended to cover the areas you've just listed.

PN1736

Yes?---Currently again through the same process we used to develop this, the directors of nursing across the State are trying to work through areas, some guidelines to utilise in the areas you've just listed. So that's still work being developed.

PN1737

MUNRO J: What are multi-day wards?---Sorry?

PN1738

Multi-day bed or - - -?---Basically any ward where you expect the patient to stay for a period of time and certainly greater than 24 hours.

PN1739

I see?---So they're the tradition what we'd see as in-patient ward area.

PN1740

Yes. And I think earlier in your statement you distinguished the day beds, so to speak?---Yes.

PN1741

To effectively, what, short term, in and out. Yes?---Yes.

PN1742

MS BURKE: And Ms Twigg, have the DONs considered how nursing hours per patient day compares with other workload management mechanisms or models?---Such as?

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1743

Such as Trend Care, the computer software package that's used in South Australia or bed containment and redeployment arrangements that occur in the ACT or nurse to patient ratios?---Well, obviously we've considered it as an alternative to nurse to patient ratios. My understanding of Trend Care is basically that it is a nursing hours per patient model. It also has other measures - well, uses different measures of acuity that the nurses themselves rank each patient as opposed to perhaps some of the looser ones. We've suggested that you use in terms of turnover and acuity of patients whether the post ICU, those sorts of things. Obviously once these models are implemented we then can compare them to other models that are available. Or if this model was - and will be implemented at Charlie's.

PN1744

In terms of the analysis of the analysis of Trend Care, would you be able to tell the Commission what the nursing hours per patient day under that model would be for the category of wards or units that you've outlined in the attachment that we just looked at?---No, I can't.

PN1745

And if you turn to paragraph 62? You talk about the question of clinical judgment and how that's a very important consideration in determining nursing staffing levels?---Yes.

PN1746

What happens if a nurse in their clinical judgment believes they have an excessive workload and can't admit another patient onto the ward, for instance?---Generally speaking I don't think it becomes that specific in terms of what nurses report.

PN1747

The shift co-ordinator on a shift, if they have changes in patient acuity or requirements that changes their staffing requirements generally notify the nurse manager on. And there's 24 hour coverage who will then attempt to address those staffing changes. In the short term if there's a sudden change at least at Sir Charles Gairdner Hospital we have clinical nurse consultants that are available. During the day there's the ward clinical leader at level 3 and after hours there's a team of clinical nurse consultants and there's two on in all after hour period that can come to an immediate problem to help if they have patient

**** DIANE ELSMAY TWIGG XXN MS BURKE

who becomes acutely unwell suddenly which causes problems in terms of resourcing. And then both the nurse's assessment on the shift and the shift coordinator and the level 3 will work out what's the best staffing arrangement. Sometimes they will direct staff from other areas that are perhaps for various reasons have had several discharges and may have a quieter time to that area in the short term until sort of shift arrangements can be put in place for the next shift. Because obviously I mean over a shift of 8 hours a lot can change.

PN1748

Okay, thank you. I don't have any further questions, your Honours.

PN1749

MUNRO J: Yes, thank you. Mr Walker?

PN1750

MR WALKER: No further questions, your Honour.

PN1751

MUNRO J: I note the time. Could you just tell me, at paragraph 44 you refer to Mr Jones' work:

PN1752

He had a tool that incorporated all categories of staff including registered nurses, enrolled nurses, patient care assistants, clerical support and corporate services staff.

PN1753

Presumably those categories of staff aren't within the criteria for the NHPDDP?---No, the Nursing Hours Per Patient Day purely looked at nursing hours.

PN1754

Yes?---So it's only related to nursing resources and nursing resources in direct patient care.

PN1755

And nursing resources include for that purpose registered and enrolled nurses?---Yes.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1756

And clinical nurses?---Yes.

PN1757

Yes. The mix that you describe, I've just forgotten the paragraph number at Sir Charles Gairdner shows 28 per cent clinical nurses, 55 registered and 6 or 7 enrolled nurses. Is that a broadly satisfactory mix or is it one that just happens to be what's there at present?---In most areas it's reasonable. It's based on 30 per cent in our critical care areas and about 22 per cent in the ward areas. Some ward areas because they have a consistent group of higher acuity patients, do have a high level so it's somewhere between the two.

PN1758

Yes. You would presumably have a higher need for clinical nurses, sorry - yes, clinical nurses than other lower category hospitals in terms of the staffing mix, I assume?---Yes, we do.

PN1759

Yes. The PCAs, if that's the correct term, where do they feature in that requirement? Are they taken into account in any of the measures at present? Not directly in terms of the model or its development. As a hospital we - well, about 2 years did a major review of our support at that level at ward level and increased it quite significantly with the return of the service internally to the hospital that was contract and that's made, I think, a big difference. Certainly when nurses are under a lot of workload pressure, while they have concerns about what their sorts of roles should or shouldn't do, they do find that they can support them well on the ward. Just basic things like having someone else there to answer the phone is a lot of help and assist them with some of the heavier patients.

PN1760

But there's no formal mechanism at present for loading that factor in to assessment of nursing workload?---No.

PN1761

Yes. Thank you.

**** DIANE ELSMAY TWIGG XXN MS BURKE

PN1762

SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Ms Twigg, what does the Sir Charles Gairdner Hospital do when it does overrun its budget? What action does it take?---Well, obviously we have to try and pull it back in another area but we don't always do that. Last year we received additional funding from the Health Department, we balanced the budget at the end of the year, otherwise we would have overrun the budget.

PN1763

If you do not receive the additional funding what do you do then?---Fortunately that's not my problem because it means someone is not going to get paid.

PN1764

Right?---I honestly don't know. I mean, we've never been in that situation. I mean, we obviously regularly report the budgetary pressures that we're under and a significant one at the moment for the hospital is the high use of agency and casual nurses and also the high use of what we call HSA surveillance or orderly surveillance of patients that are prone to wandering, etcetera, and they are causing budget overruns. But it comes down to an assessment of quality of care and you often provide it and look for those resources in other areas to redirect.

PN1765

Thank you. Mr Ellery?

PN1766

MR ELLERY: Just one question in re-examination, Ms Twigg.

<RE-EXAMINATION BY MR ELLERY [11.57am]

PN1767

MR ELLERY: Ms Twigg, just to clarify, you were asked earlier in your evidence as to whether you'd be able to recruit 90 nurses as required this financial year. And you said as I recall, that that would be difficult. Can you just explain why do you think that that would be difficult?---Basically there doesn't appear to be that many nurses out there that wish to return. We have a variety of initiatives. As a hospital, I mean, 5 per cent of your total nurses is agencies, actually not that high in number in my view. The problem is that we seem to have an underlying vacancy rate that we haven't been able to top up.

**** DIANE ELSMAY TWIGG RXN MR ELLERY

And that's the main driver and so that's why we've gone overseas and it is an - I mean, the nursing shortage is known to be an international problem. So it's not like this State is doing something different in isolation from the rest of the world.

PN1768

Okay. Thank you. Nothing further.

PN1769

MUNRO J: Yes, thank you, Ms Twigg, you're excused.

<THE WITNESS WITHDREW [11.58am]

PN1770

MR ELLERY: Thank you. Your Honour, the next witness was to be Ms Pat Tibbett. I did take the liberty earlier of asking someone to let her know that she wouldn't be likely to be required before midday, so I assume if she's not in the immediate vicinity she's very - I don't think she's in the immediate vicinity I've just been told. So I wonder if it would be possible to take a short adjournment.

PN1771

MUNRO J: Very well. The Commission will adjourn for a short time.

SHORT ADJOURNMENT [11.59am]

RESUMED [12.23pm]

PN1772

MR ELLERY: Thank you, your Honour. I call Ms Patricia Tibbett to the stand.

<PATRICIA TIBBETT, SWORN [12.23pm]

<EXAMINATION-IN-CHIEF BY MR ELLERY

PN1773

MR ELLERY: Thank you, Ms Tibbett. Just once more for the record could you state your name and address, please?---Patricia Tibbett, 203 Grand Prom, Doubleview.

PN1774

And Ms Tibbett, have you filed a witness state in these proceedings?---Yes, I have.

PN1775

And is that statement true and correct?---Yes, it is.

PN1776

Do you have a copy of the statement with you or - - -?---No, it's my bag.

PN1777

Okay. I can provide you with one. Thank you. I have no further questions.

PN1778

MUNRO J: I think the witness statement is at tab 4, isn't it, of the document?

PN1779

MR ELLERY: Yes, I apologise, your Honour. It's tab 4, yes.

PN1780

MUNRO J: Yes. Ms Burke?

PN1781

MS BURKE: Thank you, your Honour.

<CROSS-EXAMINATION BY MS BURKE [12.26pm]

PN1782

MS BURKE: Ms Tibbett, do you have a copy of your statement there?---Yes.

PN1783

Okay. Just turn to paragraph 4 of your statement. You say that:

**** PATRICIA TIBBETT XXN MS BURKE

PN1784

The hospital develops an estimate of the number of nurses to determine a full-time equivalent or FTE profile.

PN1785

Could you say how that estimate is developed?---It's developed every year using a zero based budgeting approach. So you look at the ward that you wish to staff, the size of the ward, the number of beds, the environment of the ward, they type of case mix that would generally apply to the ward, the specialty of patients that you would put in there and the type of support staff that you would also be employing to provide a service to the ward albeit that it would be maybe non-nursing staff. You would then develop a ward based coverage profile of the usual expected workload for the ward given, as I said, all those indicators that you take into consideration. You would then work out the number of nurses on each shift, the number of hours that the nurses would need to cover over the 24 hour 7 days a week, if that's the sort of ward. It might be a 5 day ward or it might be a day ward. So you look at the number of hours that you wish to cover over the week, over the day and then over the week and then you add in a leave component to cover the expected leave entitlements that the nurses have and then you add that up. You get a ward profile, a ward FTE, then you just add up the whole hospital in relation to the wards and any other support services that nurses work in. You would add all those in in terms of your management structures, your staff development support structures, your clinical support structures and it rolls up to be your total hospital FTE requirement for nursing.

PN1786

Okay. And in paragraph 5 you say that for the 2000/2001 financial year that FTE profile came out at 1281.44 FTE?---Yes.

PN1787

But the actual FTE usage was 1290.16 FTE?---Yes.

PN1788

So the hospital's nursing costs were the equivalent of 8.72 nurses more than were budgeted for?---Yes.

**** PATRICIA TIBBETT XXN MS BURKE

PN1789

So is it the case that the budget failed to provide enough nurses to meet demand?---Well, I wouldn't put it like that. I was suggesting to you our forecast workload and case mix was not correct. What happened over the year we would have had on different shifts and different wards, a patient acuity higher than we anticipated a year ago. We would also have not anticipated maybe because Royal Perth Hospital system - Royal Perth Hospital works in a metropolitan health system, it has an emergency department. It also has to actually respond to demands, emergency demands by the State and the metro. So there are times whereby we forecast that we would only budget to run a certain amount of beds, that we would have to increase the beds to meet the overall system demands and nursing FTE would be required. Nurses would be employed to meet those demands and our budget, of course, went up.

PN1790

If you could turn to paragraph 11 of your statement? You say that:

PN1791

The Government is committed to providing funding for the extra 400 nurses.

PN1792

?---Yes.

PN1793

And that if you were to use the nursing hours per patient day model, Royal Perth would receive funding for an additional 129.7 FTE?---Yes.

PN1794

So the nursing hours per patient day model is telling you that you need 129.7 more nurses in your FTE profile?---Yes.

PN1795

Okay. So effectively what you're saying is that if that model was used there should be right now 129.7 more nurses in the hospital?---Yes.

PN1796

Okay. What do you think the impact of that is on the nurses who are in the hospital?---Currently? Oh, I think it's - the issue of nursing workloads as I also said in my statement, we recognise and that's why we're here.

**** PATRICIA TIBBETT XXN MS BURKE

PN1797

So I recognise there is an issue of nursing workloads that has to be addressed?---Yes. But there are a number of ways that it has to be addressed and the ways that it has to be addressed has to be sustainable for the long term.

PN1798

Okay. I suppose I was wondering what the impact is on - the practical impact for nurses in the hospital?---I guess - I'm not quite sure what you're asking me but I guess if - where you had those nurses, those 129 nurses are not available at the moment, they're not there to be employed in a permanent basis.

PN1799

So even if the Government gave us enough money, quarantined to our nursing budget to employ those nurses they're not there. The hospital isn't restricting itself on the employment of nurses based on its budget or what it thinks its workload is, the nurses aren't there. So if there were more nurses Royal Perth Hospital would employ more to meet what they believe the workload demands are.

PN1800

MUNRO J: In relation to the workload problem that you're referring to, I think it was for the current year you gave the figures where you're about 8.72 FTE over - for budget of FTE, the NHPPD comes up with a figure of 129 more FTE that you would get. Is that a broad indicator what you see as the extent of the workload problem. Can it be taken as a rough measure? I suppose I can contrast it to the 129 with the plus 8 that, in fact, was your experience over the last year. Was your experience over the last year one where you were effectively unduly pinched and if you were able to expand to the full 129 that is predicted would that remove the pinch on workloads?---Yes.

PN1801

Yes.

PN1802

MS BURKE: Have you requested additional funding for the additional FTE?---Yes. Not the 129 at this stage.

PN1803

I did mean the 129?---No.

**** PATRICIA TIBBETT XXN MS BURKE

PN1804

Right. Do you know how that money is going to be made available from the Health Department. We're not - we're told that there is money available but we're not actually sure how it's going to be distributed. We - I guess I haven't had anything in writing from the Health Department to say that the model nursing hours per patient day will be used but there's - I guess it's the only thing that we've been led to believe that the distribution will be made upon.

PN1805

Okay. In terms of the fact that there aren't enough nurses in the hospital what do nurses at Royal Perth Hospital do when they are experiencing the workload increase?---They certainly, on a shift-by-shift basis, request extra staff to meet what they believe is the patient needs on the wards and the Nurse Managers staffing the wards either on a long term basis, in terms of the acute levels and adjustments or a short term, which can be a shift-by-shift or a week-by-week basis, do endeavour to meet those - the needs that are believed to be needed. There is, of course, conflict between what a nurse believes - at ward level believes that they need and another assessment would indicate that that is not required. As you know workload assessments are fairly complex in terms of it's a skill mix as well as just a patient acuity issue. So there are individual professional judgments made by people in terms - so once the identification of the need for the workload is identified there is a staffing request and the staff are employed. Where the staff can't be employed there are other alternatives put in place to try and make sure that the nursing resources that we have will certainly maintain patient safety, and they are issues of where possible if we can limit the amount of patients the ward receives, the number of patients in the ward, if there is any discretion, we will do that or any other support staff that we can bring in to support that particular ward on that particular shift and we would go into our support staff, who don't normally work on that shift, actually going to work on that shift on that day and those people are Clinical Nurse Specialists or Staff Development Nurses or whatever. So if it's a shift-by-shift issue we tend to meet the needs by that. We also look at our staffing trends and acuity trends over a long term and adjust where necessary.

PN1806

In paragraphs 19 and 20 you talk about the development of the nursing hours per patient day model and I just would be interested to know if you believe that nursing staffing should follow principles that take into account certain considerations such as the clinical assessment of the needs of the patient. Would you say that would be a reasonable consideration as a principle for nursing staffing?---Yes.

**** PATRICIA TIBBETT XXN MS BURKE

PN1807

The environment, such as the ward layout, the geography of the hospital is important?---Yes.

PN1808

What about such things as safety and health legislation and nursing regulatory legislation, they should be considered too?---Yes. Yes.

PN1809

Also trying to manage reasonable workloads for nurses, so as a set of principles you wouldn't object to anything along those lines?---No.

PN1810

Have you had an opportunity to have a look at any of these alternative orders presented by the ANF in this matter?---Yes. I have.

PN1811

Okay. Have you had a look at alternative draft order 1, which provides an indicative responsibility allocation as opposed to a mandatory ratio?---Yes. I have.

PN1812

Do you understand that the nurse to patient responsibility allocations in that order are not mandatory?---Yes.

PN1813

They are flexible to accommodate the considerations that we just talked about?---The way that I read them, they can interpreted as mandatory, a person could read them and say: this is what this says and that is what I must have, regardless of applying the principles that you just previously said. So I guess in terms of having a document that people would really understand and apply in a reasonable sense, I would suggest it was lacking.

**** PATRICIA TIBBETT XXN MS BURKE

PN1814

Have you considered any other workload management mechanisms, such as Trend Care or bed containment strategies as exist in the ACT?---We have certainly - Royal Perth Hospital in the past has had an acuity system. I think we would go back in the early '90s, late '80s early '90s we had an acuity system and it was resource intensive to maintain, it wasn't actually well supported by the nurses in terms of what came out in terms of reflecting what their patient acuity was as well as management not really accepting it as a - well valid added tool, so we actually took it out of the organisation. I have been looking at the implementation of nurse hours per patient day at Royal Perth and other hospitals. I have looked at the private sector because they use nurse hours per patient day to manage their nursing workloads and I have seen Trend Care at Hollywood, yes, as an acuity system.

PN1815

Do you know how the actual nursing hours per patient day are derived?---Yes.

PN1816

So if we had say, for instance, in a category A ward of the nursing hours per patient day, which you say is 7-and-a-half hours is the appropriate number of nursing hours per patient day, is there any evidence to support 7-and-a-half being the appropriate number of hours?---You mean 7.5?

PN1817

Yes?---What do you mean "evidence" to support?

PN1818

Is it based on the study of that number of hours in any other place? Is there any empirical statistical evidence that would prove that that is the right number of hours?---I would have to say that there isn't any statistical evidence to say that it was the right hours. It's probably, as a lot of judgments in terms of nursing workloads, based on good professional judgment and previous experience based on the case mix. So that you build the nurse hours based on that sort of a profile, but I haven't actually heard or read that there is actually in-depth studies and the difficulty with that is comparing it from State-to-State and even hospital-to-hospital because the nurse hours in one award is different to the nurse hours in another award - or the nurse available hours are different.

**** PATRICIA TIBBETT XXN MS BURKE

PN1819

In paragraph 23 and the following paragraphs you talk about a range of recruitment and retention initiatives?---Yes.

PN1820

The intention of those is to attract more nurses to Royal Perth Hospital?---Yes.

PN1821

But in themselves they don't deal with the workload issue right now, do they?---No. No.

PN1822

No. So they are more long term initiatives to try and fill the numbers?---Medium and long term strategies, yes.

PN1823

But is there currently an immediate mechanism to deal with workloads?---Well, we have our staffing requirements on a shift-by-shift or basis, but I think that the recruitment of permanent staff will assist in impacting on nursing workloads because the nurses find it easier to work with staff who know the hospital than maybe replacement staff. So, in a sense, it does - will assist with the here and now workloads.

PN1824

Are you aware that evidence in these proceedings has included material about workload concerns in the Emergency Department at Royal Perth Hospital?---Yes.

PN1825

Are you aware that there have been improvement notices issued by Worksafe for the Emergency Department?---Yes.

PN1826

Are you aware - or you may not be aware that the ANF has received correspondence from its members to say those improvement notices haven't been complied with?---I wasn't aware of that, but the improvement notices that I have had an opportunity to read, which were last October, the Worksafe have lifted those and were satisfied at the outcome that the hospital - what the hospital put in place to address the issues raised and the work orders were

**** PATRICIA TIBBETT XXN MS BURKE

addressed. So we don't have anything at the hospital at the moment, improvement notices by Worksafe, in respect to our Emergency Department and I think that the document that you are referring to actually didn't go through our normal hazard process alert - hazard alerting process at all in respect to management being given an opportunity to address staff concerns.

PN1827

I don't have any further questions for this witness.

PN1828

MUNRO J: You made reference to I think the form of grievance process, Ms Tibbett, whether it is concerned about a particular staffing problem on a ward that goes to the NUM then to Level 3 I think you said. In that process at present is the NHPPD system used at all in a formal way?---The nurse hours per patient day is used at Royal Perth Hospital. It is being implemented - or has - it is still being implemented, I would say, and it is used in conjunction with our normal staffing systems that we have had historically but in terms of the workload dispute on a shift-by-shift basis, where a nurse says: I need more staff and the area is assessed, we don't do it. We don't actually have an ability to use the nurse hours per patient day on a shift-by-shift basis, it's actually a retrospective analysis of our hours over the previous month.

PN1829

I see?---It's a monthly report at this particular time.

PN1830

That is what the NHPPD does, it looks retrospectively and the shift problem you deal with more as a matter of clinical judgment?---Yes. Yes. There is a nurse hours per patient day system in the private hospitals where you can access it, shift-by-shift, but the public sector has not got the information systems to get it on a shift-by-shift basis, but we are working towards it.

PN1831

Well, that leads to the question that I was coming to, it is practical, it is possible in your view to make something like the NHPPD available on the basis that would make it visible to the staff on a shift?---Yes. It is possible.

**** PATRICIA TIBBETT XXN MS BURKE

PN1832

It could be converted so as it would be visible as to how the system operated?---It is possible, whether it would need to be - our information systems would need to be improved, but it is possible because it's already used in the private sector. On top of the nurse hours per patient day you have to add a factor for a patient acuity, nurse hours per patient day doesn't - is only a ratio between patient hours and nurse hours and doesn't actually bring in an issue of acuity which still could require an extra nursing resource put in, but we currently at Royal Perth have a few other mechanisms to retrospectively and look at - and shift-by-shift look at the issues of patient acuity and record issues of patient acuity.

PN1833

I take it from the general tenor of your evidence that you would agree that the visibility of the system for allocating ward staff is a desirable value in any system?---Yes. I would.

PN1834

So that those on the wards know roughly what the system is and what it should be providing if there is any issue about it?---Yes. I think that would help.

PN1835

Thank you. Mr Walker?

PN1836

MR WALKER: Thank you, your Honour. Could I show the witness a document.

<CROSS-EXAMINATION BY MR WALKER [12.48pm]

PN1837

MR WALKER: Ms Tibbett, can you identify the document?---Yes.

PN1838

Can you tell us what it is?---I think it's the Enrolled Nurses and Nursing Assistants Enterprise Agreement 1999.

**** PATRICIA TIBBETT XXN MR WALKER

PN1839

Your Honour, can I tender that as an exhibit.

EXHIBIT #ALHMWU3 COPY OF ENROLLED NURSES AND NURSING ASSISTANTS ENTERPRISE AGREEMENT 1999

PN1840

MR WALKER: Ms Tibbett, can you tell the Commission who the agreement is between?---It's between the Australian Liquor, Hospitality and Miscellaneous Workers Union and the Metropolitan Health Service Board.

PN1841

Does this agreement apply in your hospital?---Yes.

PN1842

Does it apply to all the hospitals in the metropolitan area?---Yes.

PN1843

I will ask you just to turn to page 7 the wages clause. In your hospital, Royal Perth Hospital, do you pay under the levels shown for enrolled nurse?---Yes.

PN1844

That is four pay points and advanced skill enrolled nurse?---Yes.

PN1845

That is all I have thanks.

PN1846

SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Ms Tibbett, when Commissioner O'Connor and myself visited the hospital we were shown a new system recently developed to try to track patient movement within the hospital. Does that system relate at all to the work that is being done on the nurse hours per patient day ratios?---Was it the bed management system?

PN1847

That is right?---Yes. It relates a little bit in the fact that that bed management system is fed by TOPAS, which is our management system, and it's out of - TOPAS is where the patient hours are and it's where - out of TOPAS where you would get the patient hours for a nurse hours per patient day system.

**** PATRICIA TIBBETT XXN MR WALKER

PN1848

Thank you. Secondly, you outlined the various steps that the hospital takes in situations where there is a specific nursing shortage, how do the nurses working in a given ward get to be advised of the success of indeed the undertaking of those steps, so that if you have a situation where a ward is understaffed how are the various efforts the hospital has made to minimise the impact of that communicated to the staff and when does that communication occur?---It's communicated on a shift-by-shift basis, so when the workloads, the staffing requirements are made known and the issues to find the appropriate staffing replacements are made, a nurse who is the shift co-ordinator is in liaison with a Nurse Manager and it could be also a Clinical Nurse Specialist in respect if it's the patient acuity. So that shift co-ordinator is in liaison with both those, either the Nurse Manager or the Clinical Nurse Specialist attempts to get the required either skill mix for the ward or the number of nurses required for that shift and we have a Nurse Manager on 24 hours a day 7 days a week and also a Clinical Nurse Specialist cover 24 hours a day 7 days a week. So those are the choices that the Nurse Manager has in relation to meeting - the ward staff's needs are discussed and options discussed. In terms of the long term issues pertaining to a ward, there is discussions - ward based meetings, and discussion with the senior nurses, the Clinical Nurses and the Nurse Managers looking after the ward over a long term recruitment, a strategy discussed at those sorts of meetings, those meetings might be every 2 weeks, they might be once a month, so a long term resource planning, I guess. Discussions are held in terms of how many new staff are coming, what is the vacancy rate like, what are the issues pertaining to the skill mix in terms of that ward. So they are also discussed.

PN1849

Thank you.

PN1850

MUNRO J: Yes?

<RE-EXAMINATION BY MR ELLERY [12.53pm]

PN1851

MR ELLERY: Thanks. Ms Tibbett, a couple of things just to clarify, one you mentioned Trend Care at Hollywood. Can you just explain, particularly for the Members of the Commission who aren't from Perth, what is Hollywood that you are referring to?---Hollywood is a private hospital.

**** PATRICIA TIBBETT RXN MR ELLERY

PN1852

Okay, and that is in the suburbs of Perth?---Yes.

PN1853

Can you explain for the Commission, are there any differences between the types of patients that Hollywood would service and the types of patients that your hospital services?---Well, one big difference is Hollywood doesn't have an emergency centre where the workload is unpredictable both in terms of the amount and the type of patient that they would - so they have a more predictable forecast of their workload. So that would be one difference and in terms of the types of patients that we would have as against what they would have would be the acuity. In general terms, we would take a more acute patient than Hollywood.

PN1854

Okay. Thank you. Now, Ms Burke took you to ANF alternative draft order 1 and she described a number of factors that could be considered under that provision in terms of assessing staffing or nursing levels, she mentioned clinical assessment and some others. Would they be all the factors that you think would be relevant in assessing nursing staffing requirements?---Well, they are now and as I said when we set the budget we take all those into consideration when we do the forecast budget, then on a shift-by-shift in terms of the assessment of the workload they are taken into consideration.

PN1855

Now, in terms of the nurse hours per patient day model, you were asked to discuss that. Is it your understanding that that model takes into account acuity or does not take into account acuity?---It takes account of acuity in the sense of the type of case mix a hospital would have. It lacks the sensitivity, I think, on the shift-by-shift basis issues but you would expect more greater nurse hours per patient day in an intensive care than you would on a general ward. So in that sense it is sensitive to those, that acuity, but not necessarily on a shift-by-shift.

PN1856

Okay. You were asked about strategies to address workloads and you were asked about recruitment. Is the hospital endeavouring to recruit nurses now as we speak?---Yes.

**** PATRICIA TIBBETT RXN MR ELLERY

PN1857

What is the hospital doing to achieve that?---Well, all our strategies are in place as in my evidence, we certainly advertise, we have the refresher programs going, we have educational programs where we try and attract and retain nurses, we have - I haven't been in my substantive position for 2-and-a-half months but there was an expectation that we would advertise in New Zealand and attract nurses. I also, I guess for Royal Perth Hospital in terms of its ability to - we are under the Labour Agreement, so international recruitment of nurses and I guess in respect to the metro hospitals, what we want to do is to make sure the pool of nurses that is available to us all in terms of either replacement staff or permanent recruitment staff is there so every hospital, and I understand Sir Charles Gairdner Hospital is - has gone to England, as Royal Perth Hospital did the year before to recruit, and I think they are planning to go to England again, so Royal Perth Hospital will not go, we just hope that Sir Charles Gairdner Hospital recruit on the system's behalf to get nurses in Western Australia and then we will compete to employ them at our different hospital.

PN1858

Just, finally, you said you haven't been acting in your substantive position for some time, why is that?---I'm the Acting Chief Executive at Royal Perth at the moment.

PN1859

Okay. Thank you. I have got nothing further, your Honour.

PN1860

MUNRO J: Thank you. You may be excused from further attendance?---Thank you.

<THE WITNESS WITHDREW [12.55pm]

PN1861

MR ELLERY: Your Honour, I note the time. There is probably not much benefit in calling another witness now.

PN1862

MUNRO J: We will resume at 2 pm with Dr Lloyd, is it?

PN1863

MR ELLERY: That is correct, your Honour.

PN1864

MUNRO J: Yes. Very well.

LUNCHEON ADJOURNMENT [12.55pm]

RESUMED [2.06pm]

PN1865

MUNRO J: Yes, Mr Ellery?

PN1866

MR ELLERY: Thank you, your Honour. Just to confirm the order for this afternoon, I intend to call Dr Brian Lloyd and Allan Jones and then Sheryl Wolfenden. I anticipate that will take the rest of the afternoon but if we do finish earlier there may be a possibility of calling one of the other witnesses as well.

PN1867

MUNRO J: Yes. We will need to adjourn at 4 o'clock or very shortly thereafter, I have another matter on.

PN1868

MR ELLERY: Thank you. I call Dr Brian Lloyd.

<BRIAN LLOYD, SWORN [2.07pm]

<EXAMINATION-IN-CHIEF BY MR ELLERY

PN1869

MR ELLERY: Thank you, Dr Lloyd. Just once again for the record could you state your name and work address please?---Yes. Brian Lloyd, Sir Charles Gairdner Hospital, Nedlands, Western Australia.

PN1870

Thank you. Dr Lloyd, have you filed a witness statement in this matter?---I have.

PN1871

Is that statement true and correct?---Yes.

PN1872

Do you have that statement with you?---Yes.

PN1873

Thank you. Nothing further.

PN1874

MUNRO J: The statement is tab 20 to WAGHI1.

<CROSS-EXAMINATION BY MS BURKE [2.08pm]

PN1875

MS BURKE: Turning to paragraph 4 of your statement, you refer to the fact that you are aware that there is an application in relation to nurses workloads and I would like to know if the medical staff at Sir Charles Gairdner Hospital always have adequate nursing support on a normal day in the hospital?---That's a difficult question to answer. In a stable ward situation it would generally be adequate although I imagine there would be peaks and troughs in that, where there would be increased demand and occasionally troughs where there is perhaps an excess supply. So that is in general terms but in some areas there may be greater demands at peak times, such as in emergency.

PN1876

So in those times where there are peaks it would be the case that there isn't always enough nursing support?---No. What I meant was relatively in that in any position we have in the hospital there will be peaks of work so that often there will be doctors who would prefer to have had four more hands but they need to deal with the issues in a prioritised manner, so in a similar manner to that.

**** BRIAN LLOYD XXN MS BURKE

PN1877

I would like you to turn to paragraph 10 of your statement?---Yes.

PN1878

You say that there are approximately 25 to 30 beds closed at any one time during the action of January 2001. Were all of those beds closed because of the action nurses were taking or would any of them have been closed for other reasons?---No. These were beds that were being closed because of the industrial action, that wordage may not be strictly as clear as it should be.

PN1879

Does the hospital ever close beds for other reasons?---Yes.

PN1880

What would those other reasons be?---Generally, it will be because of staff shortages or predicted staff shortages such as school holidays, for example, when there would be an increased number of people wishing to take leave and that is attempted to be accommodated.

PN1881

Now, if we turn to paragraph 14, you say there were instances of category 1 surgery being cancelled. Could you please tell the Commission what category 1 surgery is?---Yes. Category 1 surgery is that which we deem to generally require to be done within 30 days of a decision being made to operate on somebody. It is not emergency surgery, such as somebody who is in hospital having something go wrong and needs urgent surgery, it is people who electively need an operation and it can be done within a month. So it will be things like cardiac surgery to do bypass surgery, might be to replace a valve, it might be for somebody who has got severe pain related to some event, it might be where there is a stone blocking a kidney and it needs to be done before the kidney gets too far damaged, those sorts of things.

PN1882

Are there reasons why category 1 surgery may be cancelled in the normal running of the hospital? Is it ever cancelled?---It - category 1 may occasionally be cancelled but very uncommonly and after a lot of decision but it may occur if there is a marked shortage of beds on a particular day or, for example, if the intensive care unit is required and doesn't have beds to bring the patient back to, so that a cardiac procedure can't go on if there is not a clear cut supply of intensive care beds, but they are uncommon, we don't routinely cancel category 1.

**** BRIAN LLOYD XXN MS BURKE

PN1883

In paragraph 18 you say that the well-being of patients was being placed at risk. Do you believe that patients risk would be minimised if there were more nurses in the hospital?---That is a separate question from what I was saying there. Are you relating it to that sentence?

PN1884

Yes?---What I was making the point, was that because we were cancelling procedures we were putting patients at risk so that, for example, one of the cases I cancelled in that period was somebody who needed a leg amputation. We had to cancel that person and not bring them into hospital and I couldn't guarantee when I could bring them in, so for that period of time that person was at some risk. Cardiac surgery cases, likewise. If you cancel an already arranged slot you can't guarantee when the next slot that you can bring them back in, so in that setting they were placed at risk.

PN1885

Turning to paragraph 23, you say that it is well known that there is currently a shortage of nurses in Western Australia. I make the suggestion to you that it's actually a shortage of nurses willing to work in the system at the moment. Would you agree with that?---There are nurses, I don't know whether they are willing or not willing to work, to be honest, but the issue is they haven't signed up to work.

PN1886

Right. Okay. So there are nurses available but they are not in the system?---Yes.

PN1887

Okay. Do you believe that the recruitment of nurses would be facilitated if nursing workloads were reduced?---I don't know, to be honest, I'm not expert in that.

PN1888

That is all, thank you, your Honour.

**** BRIAN LLOYD XXN MS BURKE

PN1889

MUNRO J: Yes, doctor, the batting order for bed closures, I take it, would be category 3 where you have any choice would be the first sacrifice, would it?---Yes. Yes. Category 3 and category 2, most of us are not necessarily concerned about because there it's more an inconvenience issue. Category 1, by definition, does suggest that the patients can get into an urgent situation if something goes wrong with their condition. So the difference being, if somebody has got a painful hip it by and large can't cause them a problem in terms of death if you put them off, but if you cancel a patient an angina and cardiac surgery pending it is quite possible that they could have a heart attack and either die or do badly from it and so on. Similarly, with cancer cases.

PN1890

The Emergency Department, that is really I suppose independent although perhaps the flow through from the Emergency Department might also be a consideration, that if you can't take them out of the Emergency Department if you haven't got beds elsewhere in the hospital and there is no point in taking them in presumably?---Absolutely. It certainly inconveniences how you manage the hospital, in that you can't in an orderly manner use beds how you need to to manage the elective work and the urgent work.

PN1891

But the Emergency Department closures to which you have referred, have they been matters of demands on staff in the Emergency Department or are there ones right throughout the system have influenced that?---The current system in emergency bypass is usually where too many patients have presented and the department is cluttered, for want of a better word, and making conditions unsafe for everybody, where not enough patients are being seen in a timely manner and staff are battling to cope with the more urgent of the patients there. So the usual plan is to put the hospital on - or the Emergency Department on bypass so that the department can catch up with its workload, but if there is an exit block and you can't get the patients out it is harder to clear that problem.

PN1892

What process would be associated with a decision to put emergency on bypass or for that matter to close or to shut down, for instance, on category 3 surgery?---Yes.

**** BRIAN LLOYD XXN MS BURKE

PN1893

Who would take that decision and what would be the preliminaries to it being made?---Yes. Currently, in each of the teaching hospitals, those decisions are taken generally by the Director of Medical Services, that is my position, to co-ordinate it across the hospitals where you appoint one of us to be the co-ordinator for a given week, so that if I am not the co-ordinator for this week but my department looks overcrowded and becoming a bit stressed then I assess that and ring the co-ordinator, explain the circumstances, we look at what is happening in the other two hospitals, trying to balance the risks against people who are in ambulances and the other departments and then make a co-ordinated decision, whether we will or will not close the Emergency Department. In terms of category 3 surgery, that decision is generally taken in Charles Gairdner by me after consultation with a variety of people, including the Nurse Managers who look after the bed stock.

PN1894

One view we've been putting to several of the witnesses concerns the way in which a registered nurse at ward level might have access to a process where there is a perception that the workload is unduly onerous, that for instance, the number of acute patients are higher than normal or there's a shortfall of the number of staff on roster that are becoming chronic. What is your perception of the process that might be available to the nurse in that circumstance to bring that matter under attention to essentially avoid what the individual might consider to be an onerous or perhaps unsafe workload?---I'm not expert in that, sir, but I would have thought they take it to their immediate superior, who would examine the workloads across the hospital and if possible, alleviate it from somewhere else if the problem were real, or help that person in strategising - prioritising the workload.

PN1895

So it would be normally dealt with through the Director of Nursing and below, subordinate positions?---Yes. I would have thought, mm.

PN1896

Okay. All done? Mr Ellery?

PN1897

MR ELLERY: No re-examination, your Honour.

**** BRIAN LLOYD XXN MS BURKE

PN1898

MUNRO J: Thank you, Doctor, you're free to go?---Thank you. Thank you.

<THE WITNESS WITHDREW [2.20pm]

PN1899

MR ELLERY: I call Mr Allan Jones, who's just outside. Mr Jones is tab 19 of our second volume.

<ALLAN SIDNEY JONES, SWORN [2.22pm]

<EXAMINATION-IN-CHIEF BY MR ELLERY

PN1900

MR ELLERY: Thank you, Mr Jones. For the record once more, could you state your name and your work address, please?---My name is Allan Sidney Jones and my work address is 15 Moondale Close, Tamworth, New South Wales.

PN1901

Mr Jones, have you filed a witness statement in these proceedings?---I have.

PN1902

Do you have that statement with you?---Yes, I do.

PN1903

And is the statement true and correct?---Yes, it is.

PN1904

Thank you. Nothing further.

<CROSS-EXAMINATION BY MS BURKE [2.23pm]

PN1905

MS BURKE: Mr Jones. Paragraph 1 of your - beg your pardon - paragraph 3 of your statement, you talk about your qualifications in health administration?---Yes.

PN1906

And I would just be interested to know if that diploma contained any nursing units of any sort?---It did, yes.

PN1907

What were they?---Medical terminology, industrial nursing law. It's a long time ago. And management skills associated with the running of health institutions etcetera.

PN1908

MUNRO J: Mr Jones, there's a natural tendency to address Ms Burke and we're having a bit of difficulty hearing the witnesses, so perhaps you could either speak ahead if you can, but keep your voice up and that will help her to keep her voice up?---Yes, sir.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1909

MS BURKE: Okay. Turning to paragraph 8, you say that your services include the provision of benchmarking and computer modelling to address work force requirements and facilitate structural efficiency methods in health institutions?---That's correct.

PN1910

Yes. I just wonder if you could explain what you mean by facilitating structural efficiency methods?---Part of my work in benchmarking is to - to look at the whole of the hospital and not just nursing as such, in the work that I've carried out across various states in Australia. It has been to - to look at whole of institutions and then look at the staffing in each area to be able to then put together a model. If you want me to elaborate a little bit more on that, how that started, I could, but depending on - - -

PN1911

I'll get to some specific questions on the modelling in a minute. Are you referring to looking at the size of the work force in relation to certain considerations?---Yes. It came about in regards to working in Queensland, looking at the redevelopment of hospitals across the State and at that time there was a process called DRG costing and case mix funding etcetera, and that was a lot of figures, but not relating to the work force and how it operated, and I was commissioned by the Queensland Health then to put that into some type of perspective, to be able to see what DRG costing, which is diagnostic-related group costing in hospitals and see what we could come out in dollars, and the work force associated with that.

PN1912

So the model that we're talking about is the nursing hours per patient day?---That is a part of it.

PN1913

That's a part of it?---Yes.

PN1914

Okay. And it's used - it could potentially be used to fit your work force into your budget.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1915

It could potentially do that. In regards to the work that I did, was to be able to identify the activity of the units and the complexity of the units and then put a profile together and see whether that did come to the funding and not about matching the funding initially. That was what I was commissioned to do initially with the Queensland Government.

PN1916

MUNRO J: Was the nursing hours per patient day model a creation in effect of yours, or was it something that was in existence that you developed and, as it were, developed into a program?---Sir, it was developed in regard to working in the institutions and hospitals and looking at what was the commonsense approach of staffing in those areas. And it's been a moving and a developing thing based on technology and what has happened over the years. It was quite raw to start with but over the period of time we've been able to refine it by working with the people within the industry in different areas, and you know, I deal with catering and cleaning and all those other things.

PN1917

So it's a sort of variant on a program budgeting notion that you've applied in your own context?---Yes.

PN1918

Yes. But it's not something which you have a peculiar property yourself?---It's something I developed myself as a property to use as a consultant and it's just developed from there, yeah.

PN1919

I see.

PN1920

MS BURKE: Turning to paragraph 11, Mr Jones, you say that you were engaged by the Health Department in 2000 to develop a benchmark staffing profile. Was that as a consultant to the Health Department?---Yes, it was.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1921

Okay. And if we turn to paragraph 13, this is the question of the tool for assessment based on activity and the type of service to be provided. Has this tool been tested for reliability and validity?---It has been tested in regards to validity and the reliability of that, because the initial stage of any type of benchmarking that I undertook was to then - to identify exactly what - how the actual institution or hospital did operate and then apply the benchmarking models against that and detailing those benchmarkings that I used in different areas to come up with a model. And in regards to the question of whether it's been tried and proven, the model has identified in some cases where there's been under-funding as well as over-funding, yes, so that is a fair indication that, you know, the model is quite appropriate. But no model is unique. You need to take some considerations in and part of that is taking those considerations in based on the, you know, the complexity of the hospital, the size of the wards and things like that because at some stage you can't use benchmarks because of the volume that goes through, and the size of the wards or the buildings that are actually worked in.

PN1922

So when and where was it tested for the reliability and validity?---Well, it's been tested in a number of States and it's been used in Queensland as a base. It's also funding that has been successful in remodelling and developing hospitals across Queensland. That was the initial state where it was tested and used as - as a reliable model and basically it was used in regards to constructing a hospital so that you get your right-sized wards and things like that, which you'd be familiar with. If you haven't got that, you really have got problems in using benchmarks.

PN1923

Just going back to the question about the identification of under-funding and over-funding. Through the evidence that we've heard so far, Ms Mantell from Kalgoorlie Regional Hospital has in her statement identified that using the nursing hours per patient day model, she needs an additional 22 nurses, but I notice that in your statement you have an attachment, exhibit 1 to your statement is a Kalgoorlie summary of actual and revised benchmark profiles?---Yes.

PN1924

And that was dated July 2001?---Correct.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1925

Yes, and that indicates, if I'm correct, that there needs to be a reduction in the number of nurses?---Yeah. There was two studies done at Kalgoorlie, if you want me to elaborate on that to be able to identify the differences. The first study was using the basic benchmarks that I developed and have been used across Australia. Following that, I was then asked if I could be involved in the nursing hours per patient day within the metropolitan hospitals, and what we were able to do then is to sit down and revisit the benchmarks because basically with technology moving the acuity wards, the shorter length of stay and things like that, we needed to address that and the way that I approached that was being involved with a group of people who are peers in the nursing services as such, to then come up with - which there is an attachment there in regards to the categories of wards and the acuity and things like that. And I then took on their views in regards - because they were nurses and peer in their - their industry, to be able to then revisit my - my information because of the way things have changed and that's how it came that we increased the number of - or decreased the excess staffing numbers that were at Kalgoorlie from one number to another.

PN1926

Okay. So does that mean that the average nursing hours for each category have changed?---They have, after doing the work with the Directors of Nursing Metropolitan Perth, which was enlightening to me and also being able to support the actual concept of nursing hours per patient day, because if we go back to nursing hours per patient day, in initial cases it was quite raw and it wasn't used in an appropriate way and the same as staff ratios to patients. You know, it all evolved around the patient as such and the opportunity to revisit this and be able to then categorise with peers, to be able to say: well, we all acknowledge that there is a work force problem out there. We now need to address that in a way that it would be appropriate and create the most efficiencies, but also reduce the pressure in the work force. So that we did that and we came up with these categories which I must confess would be more advanced that any other area in Australia at this point in time.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1927

And can you tell me how you determined what the number of hours that you need, say for a category A you need 7.5 hours per patient day. How do you know that you need 7.5 hours?---Well, it wasn't me to make that decision. Not being a nurse, as you've indicated, and having worked in management, it was more to getting that knowledge from the peer group as such. And that was determined by those people in regards to being able to put the categories down in some type of commonsense form to be able to be used in a commonsense way across the industry and I - I accepted what they were saying in regards to those hours per patient day without challenging them, even I thought that they were a little bit excessive in the way that I had previously done that work.

PN1928

Okay. So the DONs told you that you needed 7.5 for those types - - -?---They classified the classifications and then they attached the hours to those classifications, yes.

PN1929

Okay. And your modelling allows for whatever you feed in in terms of, if the DONs had told you you only needed 6 or 4.5 hours per day, the model could accommodate that?---Yes, as well. Following that, I was then able to model all the metropolitan hospitals using that criteria, which then really didn't highlight areas where you had massive workload problems and areas where you didn't have massive workload problems, and it really did set out some really good principles. And the other thing I was able to do was able to identify ward by ward in regards to where your major problems were, with a commonsense approach.

PN1930

Have you assessed any other workload management mechanisms for nursing, as opposed to nursing hours per patient day or that formula?---Yeah. We have - we looked at further ways of assessing nursing workloads because nursing hours per patient day only really relates to a ward - ward area. We looked at trying to develop nursing hours per patient in regards to accident-emergency and being able to categorise that and we're in the process of doing that, which I think is quite unique, and I was able to identify the acuity of the patients that are going through accident-emergency, which is, you know, another high area of where there are workload problems. And if you use - - -

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1931

MUNRO J: You said you were in the process of doing that?---Well, we've got the broad outline of that set out and using categories of triage in the accident-emergency wards, and if you go to country hospitals, your triages are a lot less so then you can then identify not by pure volume but the acuity of the people who are going through accident-emergency at that point in time.

PN1932

MS BURKE: So the model is a useful management tool to inform management of how to staff appropriately?---It is a common sense tool to be able to get you to the first step. To be able to then make a valued judgment using activity and acuity of that area, to be able to say: well, if we assume that we're going to run at 85 percent occupancy and we assume the acuity is going to be XYZ, that we would know that we would need 6 hours per patient day in that ward, if we're running at that. And if you use that as your base it - it gives you a good starting point. In any case of nursing ratios or modelling or whatever, it has to be used in the contents of being a base to be able to have a starting point and then developing what you need outside that base to say: we can't do that because of. You know you might say that's an eight bed ward, therefore you need X amount of patients, you need X amount of staff regardless because of the legality of having, you know, so many nurses on the ward at that particular time. That's a good starting point.

PN1933

Okay. It has its limitations though?---Any system has its limitations and if you don't apply common sense to any of them you won't get anywhere in my personal view as a consultant.

PN1934

Yes. It has limited visibility to the nurses on the ward as a model?---It has limited feasibility but - - -

PN1935

Sorry, I said "visibility", I must be mumbling, I'm sorry?---Sorry. It has its limits but it's probably the best system that I've seen in the work that I've done across Australia in the last 20 years. This has been the best developed system that has generated from the initial approach of staff to patient ratio to then look at and re-visit nursing hours per patient day. In my view maybe the term "nursing hours per patient day" is not the right thing to be using for this type of model that's been approached by, you know, what we're doing at this point in time.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1936

But it's not very visible to nurses, is it? In the ward? They wouldn't - - -?---Well, I can be visible to nursing because if you're used to nursing and someone says it's a 1 in 6. Well, you know that's 4 hours per patient day. So if you got six nurses on you know you've only got 4 hours per patient day. So you can visually count the people that are there to be able to then give you a feel whether you've got your 6 hours or your 8 hours or whatever in the 1 in 4, 1 in 6, 1 in 8 or whatever.

PN1937

So are you saying you can convert the nursing hours per patient day into a ratio, for instance?---It's quite simple.

PN1938

And how would you do that?---It's all tied together in regards to your 1 in 6, your 1 in 4 or 1 in 8 per shift.

PN1939

So how would you actually convert - what would 7.5 nursing hours per patient day be if you turned it into a nurse per patient ratio?---About 1 in 3.

PN1940

So 1 nurse to 3?---1 to 3 is eight. So it's a - you know, if you work in the industry - - -

PN1941

MUNRO J: I'm sorry, Mr Jones, you're leaving me well behind?---Sorry, I - - -

PN1942

What 1 to 3 what - is a - - -?---Well, there's 24 hours in a day. So that if you have three patients for one nurse they are actually getting 8 hours of care per day.

PN1943

I see?---You use that as a simplistic - - -

PN1944

So 7.5 is a little bit higher than 1 in 3?---Yes.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1945

Yes.

PN1946

MS BURKE: Okay, how would that compare to something like Trend Care? What does that say you need?---Well, Trend Care is another system that I'm not totally familiar with but it's quite complicated and what you need is something visible and something to be able to work out on a time basis of when you're dealing with the patient at that point in time. Now a lot of the systems I've seen previously have been after the event, that you can do the measurements which is no good for the actual time of the service, you know, at the ward level at that point in time.

PN1947

Right. So you haven't done an analysis of the comparison between something like Trend Care and this model?---I've not conversed with it enough to be able to make a valid comment.

PN1948

Okay. That's all for the moment, thank you.

PN1949

MUNRO J: Yes. Could I just take you on much the same theme. In paragraph 10 I think you're broadly outlining the work performed by AJA. My question is going more specifically though to the development of that work as it's occurred with the nursing hours per patient day model in Western Australia. To what extent is there value given in the development of that model to perceptions of the visibility of the operation of the model from a ward level nursing staff member, the simplicity of it?---I believe the simplicity is there in regards to being able to do a quick calculation back. If you're saying: this ward is going to be running at 6 hours per patient day it's a 1 in 4, that you could do a quick calculation on that. And I think they compliment each other and people who are working in the system could work - look at, you know, using the nursing hours per patient day and do a quick calculation there to say: well, that equates to a 1 in 4 or 1 in 6 or 1 in 5 roster.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1950

So that would require management to communicate it was adopting the model to arrive at that sort of conclusion about the particular ward?---Yes, what we've found was we initially had to - if we use for an example, Royal Perth Hospital, where there is something like 21 wards. What we had to do initially was then to categorise those wards on the information made available from the management end and the people working on those wards to say: well, 99 per cent of the time that ward would be running at that category 6. You know 6 nursing hours per patient day or 7, category A, B, C or D, and it would be running at an occupancy of such. Now that basically if you use that as your starting point to say: well, that's - and everyone would agree to say: well, that's what we staff to. Then you can then address where you've got your highs and lows in regards to your staffing problem. Because my experience previously was we used to just categorise a ward as medical or surgical ward but in some cases where you had high dependency beds it was a high dependency medical ward. And what we've been able to do now is to break down, say four or five categories within a hospital, medical, surgical, paediatrics, maternity, into a category of, you know, one of those seven. And then say: well that is what it is and be able to come up with appropriate staffing to decrease the problems in regards to workloads in those areas.

PN1951

So the simplicity would translate eventually if the staff understand that the ward was classified at that particular level, to totalling up the number of patients and the number of staff available at a particular time and say: well, there's something amiss?---Yes, sir.

PN1952

Or this is broadly informative. It should be understandable that way?---I believe so but having worked in the industry and doing all that myself maybe though I have a feeling that I could understand it very quickly but other people might need to have a little bit more knowledge given to them in regards to how it is set out and - you know.

PN1953

Yes. Thank you. Paragraph 31, the criteria have been accepted and endorsed by the MDONs, I take it that's Metropolitan Directors of Nursing. When was that done? Is there a particular date when it happened or - - -?---The date was in March/April. There is a particular date, yes. But I haven't got it, we've just - on my statement it's just got a date and not the actual date written there. It was around March/April but I could get it back to you with a firm date if you want one.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1954

No. It's provided, about March/April this year and that's how it is finalised in that sense. Those are the criteria at attachment 1, is it the same ones?---Yes, that's one to seven starting at 7.5 and going down to 6.1, 5.7, 5.5, 4-and-a-half, 4, 3 - something like that.

PN1955

Down to 3, yes?---Yes.

PN1956

And do the criteria operate in a way that are common to all services both metropolitan and rural?---When we put it together we believed so. That is about draft 7 and it could be, you know, regardless - anything like that can be fine tuned just to make it a little bit more understandable but it's certainly a great starting point.

PN1957

Yes. I know your evidence says that it's a framework not a rigid answer to everything but broadly it applies across all services and then the fine tuning of adaptation would come according to the nature of the acuity and various other local factors?---Yes. We tried to keep it simple but understandable and fair.

PN1958

Yes. And there would be no reason why once it was being implemented the framework at least could be explained in a way that would translate to ward level?---I believe so.

PN1959

Yes?---And the other thing that I believe that it does is it's able to identify from hospital to hospital where instead of funding a hospital because of A, B, C, you could fund it because of the acuity and the type of wards that you have in that area and be able to come up with appropriate funding right across the industry instead of some - in some cases being fat and others not being so fat. You know, that's basically was my modelling from day 1 anyway.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1960

Does the model build into it any differentiation between clinical, registered and enrolled nurse or are the hours basically homogenous?---No, they can be adjusted in regards if there was - the next step would be to say: well, in regards to an acuity, a ward with acuity of needing 6 hours that the level 2s and 1s and the enrolled nurse should be, you know, 70 per cent, 20 per cent, 10 per cent or whatever. Then you could then accordingly put a roster together which would be appropriate for the acuity of that ward. It also identifies that there is a level 3 that is not based in regards to the nursing hours per patient day, that is a pure management decision.

PN1961

I see. So the assumption is this is the measure of the nursing timed that as available without necessarily any qualification built into it as to the standard?---Yes.

PN1962

Although obviously there would need to be a decision made - - -?---A decision about that in regards to it. But if you look at it and one of the things that I - the modelling that I've done is if you put a roster together most nurses or any person working in the health care system would understand the roster better than understanding a lot of figures. And my modelling is based on a visual roster in front of you to be able to then come up with the hours per patient day after you've put the visual roster together. So it then identifies the level of people and how the roster works.

PN1963

SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Mr Jones, does your approach to the consulting functions that you undertake generally involve discussions with staff?---Certainly. One of - having worked in the industry one of the things I found most appropriate in regards to being a consultant was to be able to get the people that you are doing the assessment on, being able to sign off and say the initial information you've collected is correct and the initial information you've put together is correct on the understanding of what other activity is there. If you don't do that, you might as well not be a consultant because you can walk out the door and they'll blame the consultant as people normally do because they haven't consulted. And I make it a point in all the work that I did to be able to sit down and sign off where our starting point is so that we've got a starting point and then you can go to the next point.

**** ALLAN SIDNEY JONES XXN MS BURKE

PN1964

I wonder whether I might draw on that: contact with staff, and ask you just a couple of questions drawing on your experience in states other than Western Australia? In that regard can you confirm to me that nursing shortages exist in the other states?---Based on what we've developed here in Western Australia, I believe so.

PN1965

Can I then ask whether you're aware of regional nursing recruitment activities that have been undertaken in other parts of Australia?---I'm not familiar enough to be able to comment on that, sir.

PN1966

Can you give me some observations then on the different hospital specific strategies that are adopted to try to recognise and deal with nursing shortages?---I don't think I'm in a position to comment on that quite frankly because every one does their own thing and one could be as good as the other.

PN1967

Thank you. There are no common themes or approaches that you can draw in that regard?---No, because each State is very different in regards to the size and, you know, the complexity of the states.

PN1968

Thank you.

PN1969

MUNRO J: Mr Ellery?

PN1970

MR ELLERY: No re-examination, your Honour.

PN1971

MUNRO J: Okay. Mr Jones, you're free to go back to Tamworth?---Thank you very much.

<THE WITNESS WITHDREW [2.51pm]

PN1972

MR ELLERY: Your Honour, I call Ms Sharon Wolfenden who I believe is outside the Court.

PN1973

MUNRO J: Yes.

PN1974

MR ELLERY: Her statement is at tab 5 of the volume 1 documents.

<SHERYL DIANE WOLFENDEN, SWORN [2.52pm]

<EXAMINATION-IN-CHIEF BY MR ELLERY

PN1975

MR ELLERY: Thanks, Ms Wolfenden. Just once more for the record, could you state your name and your work address, please?---Sheryl Diane Wolfenden and I work at Esperance Health Service.

PN1976

Thank you. And Ms Wolfenden, have you filed a witness statement in these proceedings?---Yes, I have.

PN1977

Is that statement true and correct?---Yes, it is.

PN1978

Do you have that statement with you?---Yes, I do.

PN1979

Thank you. Nothing further.

<CROSS-EXAMINATION BY MS BURKE [2.53pm]

PN1980

MS BURKE: Ms Wolfenden. Just moving to, in paragraph 6 of your statement. You say that the Esperance Health Service employed 43.09 FTE nurses?---That's correct, yes.

PN1981

And the vacancy rate was three?---Yes, that's correct.

PN1982

And you had to fill those three positions with casual staff?---Yes, those positions were filled with casual staff.

PN1983

How does the hospital determine how many nurses it needs?---We work on the situation that the acuity of the patients, the layout of the hospital and experience of the staff in charge of those two areas work out the staff that they require. But basically there are two ward units, because of the way the hospital is built, and it's difficult to share staff across those two spaces safely and so they're actually staffed as two identifiable units.

**** SHERYL DIANE WOLFENDEN XXN MS BURKE

PN1984

Ms Wolfenden, when you answer, could I ask you to turn to face His Honour?---Sorry.

PN1985

MUNRO J: It keeps your voice up and we can hear you?---Sorry.

PN1986

MS BURKE: Okay. So how do you know that 43 is the right - you budget for 43, do you?---Yes. The budget basically covers about 43 staff, yeah.

PN1987

And can you tell the Commission what the occupancy rate is, the patient occupancy at Esperance Hospital?---The occupancy rate is about, I think, 76 per cent. 80 per cent.

PN1988

Has that stayed the same over the last few years or has it gone up or down?---It - it varies depending on - on budgetary constraints and the booked activity of the Health Service. If we're able to actually have visiting surgeons, then the activity goes up a little bit and we staff accordingly and if visiting surgeons are unable to come for some reason, then the activity goes down slightly.

PN1989

And have nursing numbers gone up or down over the last few years?---They - they rise and fall according to the actual need of the in-patient occupancy, but there's a basic standard of staff, once again because of the layout of the hospital.

PN1990

If you turn to paragraph 8 of your statement, you say that if the ANF ratios were implemented, you would need an additional 27 FTE nurses?---That's correct.

PN1991

Whereas if the nursing hours per patient day was introduced, you'd only need an extra three. Is that correct?---That's correct.

**** SHERYL DIANE WOLFENDEN XXN MS BURKE

PN1992

It seems like quite a big difference between them, isn't it?---It's a huge difference.

PN1993

Because we've looked at some other evidence from witnesses, DONs at other hospitals, where it would seem that the nursing hours per patient day model would require about half the number of nurses that the ratio model provides. So I'm just wondering what - if there was some reason why yours would be so much higher?---The reason is that we have actually three casualty bays but they - and they would have to be staffed on a fixed basis according to the ANF ratios and likewise, with the labour ward, which is situated in the post natal ward area. And those areas would have been identified as specifically staffed places on the ANF ratios, which is quite - slightly different to the situation with the - with the nursing hours per patient day. And that's what took the numbers up so high. There certainly would be an increase in the ward areas but the large amounts of numbers over the three shifts go in - in those other areas rather than the ward areas themselves.

PN1994

So you think that the mandatory ratios are not flexible enough to accommodate the needs of the hospital?---No, I believe the - the fixed ratios will be very inflexible and very difficult to manage from a budgetary point of view for a rural health service.

PN1995

So they'd be expensive?---Extremely.

PN1996

Would they assist with patient care?---I don't - personally I don't think so, because a lot of the time you would have staff actually staffed in areas like the accident-emergency area or the labour ward, who actually wouldn't have patients there to - to keep them occupied.

PN1997

Okay. Ms Wolfenden, are you aware that the ANF has presented a couple of other alternative solutions to the workload problem to the Commission?---Yes, I have viewed those.

**** SHERYL DIANE WOLFENDEN XXN MS BURKE

PN1998

Have you seen them?---Yes.

PN1999

Okay. Can I show you - have you got a copy with you or - - -?---No, I haven't.

PN2000

Can I hand one up, please?---Thank you.

PN2001

If you could just have a look at the first one, which is called: Alternative Draft Order One?---Yes.

PN2002

And you'll notice that under the heading: Operative Provisions, it actually sets some principles on how nursing staffing should be determined. Do you agree with those principles?---In principle, they're the parameters that we've based our staffing levels on, so yes, I do agree with them.

PN2003

Okay. And at the back of that, the last page of that order is a grievance procedure. So if a nurse on the ward has a workload concern, they can follow a grievance procedure. Do you agree that that's an appropriate thing?---I thought it was somewhat cumbersome and the fact that the Commission was seen as sort of a place for these sort of issues to be finally dealt with seemed somewhat cumbersome and probably an inappropriate place for a local workplace issue to come up in.

PN2004

Hopefully, though, following a grievance procedure, you would resolve matters at the earliest opportunity. That would be the best way of managing a grievance procedure, wouldn't it?---Certainly, yes.

PN2005

Okay. And have you had a look at Alternative Draft Order 2?---Yes. That's the committee process.

**** SHERYL DIANE WOLFENDEN XXN MS BURKE

PN2006

Yes. What that order provides is a way of assessing a number of different workload management mechanisms such as nursing hours per patient day or ratios or something like the computer software packages that are in use in other states. Do you think that it would be worth exploring an appropriate workload management mechanism for the WA Government Health Industry?---I once again felt that this was possibly not as good as - as the Draft Order 3. I felt that once again this was a slow process and not necessarily in the best interests of individual health services.

PN2007

Draft Order 3 doesn't actually deal with the workload problem, though, does it?---I thought it - it reflected, sort of, the same type of thinking as the nursing hours per patient day.

PN2008

Okay. In terms of the extra nurses that you would require under the nursing hours per patient day model, have you received - do you know if you've received funding for those extra positions?---No, we haven't.

PN2009

You haven't. Do you know how you'll get funding for them?---I don't think that's been decided yet, but I'm certainly not privy to that information at this point.

PN2010

Okay. That's all I have, your Honour.

PN2011

SENIOR DEPUTY PRESIDENT O'CALLAGHAN: Can you tell me whether your budget, hospital budget for this year is currently finalised?---I understand it's not completely finalised yet. It's my understanding that the general manager is still in the process of negotiating final details. There's a general understanding of a basic starting point, but I don't think the detail has actually been finalised.

**** SHERYL DIANE WOLFENDEN XXN MS BURKE

PN2012

Now, Ms Wolfenden, when the Esperance Hospital has an immediate nursing shortage, for example when one or more nurses in a given ward are away ill, can you tell me what steps are taken to address that problem?---Yes. We - in my statement earlier it says that we keep - we've had a vacancy factor of three and that vacancy factor was generally agreed, was the difference between coverage of wards, implying staff to coverage of wards to the full-time equivalent and that allows for staff to take holidays in a much more flexible way in the Health Service rather than being told when to take holidays, which suits country people, and the other issue of keeping a vacancy factor and casual staff moving through the hospital and other parts of the Health Service is so that we can maintain a well-skilled and knowledgeable group of casual staff that we can call on from varying times. Esperance is fairly isolated. We don't have access to agencies and so we really - it's - it's fairly important that as managers, we make sure that our casual pool is a safe pool of people to be accessing, and so that's why we've done it that way. So if somebody - if two or three people rang in sick, we have a list of casuals. We would work out the seniority of the staff required and then we may have to rearrange certain senior staff on one ward or the other and then we can maybe put in a more junior staff member under them to - to fill in the gaps for the sick leave. If we're unable to access enough staff from the casual pool, then our level 3 staff would be required to look at maybe working some overtime or doing a double shift. If that wasn't appropriate for them to do that, then the level 4 or myself would fill in the gap. Most of my senior staff don't have midwifery and so it's fairly incumbent on me to fill in that gap if it's a midwifery requirement.

PN2013

And when and how would the staff who would be directly affected by those absences, in terms of their workload, be advised of the steps that you've taken to try to obtain alternative staff?---I'm sorry. I'm not - not sure.

PN2014

So you've got a ward with two nurses who've called in sick and you've gone through a process of first of all seeking to fill those vacancies using the casual pool and you've fallen back on re-organising workloads within the ward or within the hospital. What's the process whereby staff are advised of why this is occurring and what steps might have been taken in terms of the attempt to utilise that casual pool?---Our hospital's the size that we actually all talk to each other and we would actually go and tell each other what we've done. It's

**** SHERYL DIANE WOLFENDEN XXN MS BURKE

only a very small hospital and so it's a very personal communication with the situation. Often staff come up with - with suggestions of how we could get around the situation rather than one of the senior staff having to come back and work a double shift. Or for example, myself coming back and working night duty. The staff are very - also the staff ringing in for illness are very considerate in the fact that people ring in as early as they possibly can and let us know.

PN2015

Thank you.

PN2016

MUNRO J: Having some vacancies is almost a desired management tool I take it in the context in which you operate? It wouldn't follow that even if you could make permanent appointments you necessarily would for the three positions?---That's correct. And that was something that was taken to staff some 10 or more years ago when we were restructuring, when our nursing home type patients moved into a community nursing home. We sat down and looked at all those things at a general staff meeting and people went away and thought about it because the option is if we employ to full-time equivalents it means that you have to roster people on holidays. And for country people there's no point in a mother and children going on holidays when their father happens to be on a tractor seeding. So those things are a big issue to be considered in a rural health service.

PN2017

They would have probably parallels in many health services, though, would they not, in that with occupancy levels fluctuating plus or minus 5 per cent say the availability of vacancies up to 10 per cent below FTE provided you can find the casuals, give some flexibility in avoiding over-staffing? So some vacancies would be almost a desirable thing if hospital services are similar to other work intensive organisations?---I would think that any manager would be looking to have some vacancy factor, yes.

PN2018

Yes. For flexibility purposes?---Yes.

PN2019

Is there anything? Yes. Mr Ellery?

**** SHERYL DIANE WOLFENDEN XXN MS BURKE

PN2020

MR ELLERY: Just one issue.

<RE-EXAMINATION BY MR ELLERY [3.08pm]

PN2021

MR ELLERY: Ms Wolfenden, you've been asked a bit about occupancy levels and you've suggesting that they generally are about between 76 and 80 per cent, I think that was your evidence?---Yes.

PN2022

Do they vary much from week to week or month to month?---They can depending on visiting services as far as surgical procedures.

PN2023

Right. So it's doctor driven to some extent the variations?---Yes.

PN2024

Okay. And the doctors we're referring to would not be employees of the hospital, is that right?---No, they're not.

PN2025

Okay. Thank you. Nothing further.

PN2026

MUNRO J: Thank you. Ms Wolfenden, you're free to go.

<THE WITNESS WITHDREW [3.10pm]

PN2027

MR ELLERY: Thank you. Your Honour, that concludes the witnesses we're able to call today. We did make inquiries as to whether we could get any other witnesses here for the rest of the afternoon and the only one who could be available was Mr Della. And having discussed that with Ms Burke it's clear that he will be needed for quite some time so we wouldn't be likely to finish by 4. So accordingly we don't have any further witnesses to call today unfortunately.

PN2028

MUNRO J: So tomorrow we have Mr Della, Mr Kirkwood?

PN2029

MR ELLERY: Yes. We intend to call Mr Kirkwood first, then Mr Gilmore second and then Mr Della as the final witness.

PN2030

MUNRO J: And what do we do then. We're free to go, are we? So to speak, for the time being.

PN2031

MR ELLERY: I would anticipate so.

PN2032

COMMISSIONER O'CONNOR: Would we be finished by lunchtime do you think?

PN2033

MR ELLERY: That's my guess. I mean, it's probably more in Ms Burke's hands than mine but that would be my guess.

PN2034

MS BURKE: Yes. I believe we would be finished by lunchtime.

PN2035

COMMISSIONER O'CONNOR: It will enable us time to attend to some of our other clients.

PN2036

MR ELLERY: Yes, Commissioner.

PN2037

MUNRO J: Very well, we will resume at 10 am tomorrow morning.

ADJOURNED UNTIL THURSDAY, 11 OCTOBER 2001 [3.11pm]

INDEX

LIST OF WITNESSES, EXHIBITS AND MFIs

CHRISTINE O'FARRELL, SWORN PN1539
EXAMINATION-IN-CHIEF BY MR ELLERY PN1539
CROSS-EXAMINATION BY MS BURKE PN1543
WITNESS WITHDREW PN1670
DIANE ELSMAY TWIGG, SWORN PN1680
EXAMINATION-IN-CHIEF BY MR ELLERY PN1680
CROSS-EXAMINATION BY MS BURKE PN1684
RE-EXAMINATION BY MR ELLERY PN1767
WITNESS WITHDREW PN1770
PATRICIA TIBBETT, SWORN PN1773
EXAMINATION-IN-CHIEF BY MR ELLERY PN1773
CROSS-EXAMINATION BY MS BURKE PN1782
CROSS-EXAMINATION BY MR WALKER PN1837
EXHIBIT #ALHMWU3 COPY OF ENROLLED NURSES AND NURSING ASSISTANTS ENTERPRISE AGREEMENT 1999 PN1840
RE-EXAMINATION BY MR ELLERY PN1851
WITNESS WITHDREW PN1861
BRIAN LLOYD, SWORN PN1869
EXAMINATION-IN-CHIEF BY MR ELLERY PN1869
CROSS-EXAMINATION BY MS BURKE PN1875
WITNESS WITHDREW PN1899
ALLAN SIDNEY JONES, SWORN PN1900
EXAMINATION-IN-CHIEF BY MR ELLERY PN1900
CROSS-EXAMINATION BY MS BURKE PN1905
WITNESS WITHDREW PN1972
SHERYL DIANE WOLFENDEN, SWORN PN1975
EXAMINATION-IN-CHIEF BY MR ELLERY PN1975
CROSS-EXAMINATION BY MS BURKE PN1980
RE-EXAMINATION BY MR ELLERY PN2021
WITNESS WITHDREW PN2027