Community Nurses Report.indd

NSW Nurses and Midwives’ Association PROFESSIONAL ISSUES | 7

PROTECTING THE HIDDEN GEM

Community Healthcare in New South Wales

ContentsIntroduction 3

What do we know about community nursing in NSW today? 4

Discussion 8

What needs to be done? 11

2018 Claims for Improved Staffing 12

Recommendations 13

References 14




3

Excessive workloads and stressed, overworked nursing and midwifery staff have become the hallmark of many parts of the NSW health system. The Association has made some progress in responding to this crisis with the establishment of an award entitlement for a reasonable workload in 2003 and the limited introduction of the nursing hours per patient day system in specific wards and hospitals in 2011. However, there remain unacceptable workloads in many parts of the system, none more so than for community nurses and midwives.

New research conducted among community nurses by the NSWNMA suggests community health services are struggling to cope, and government strategies to deliver savings in public hospitals will exacerbate the problem. The population of New South Wales is predicted to grow by 25% by 2031. With an ageing population and government health strategies trending to an earlier discharge from public hospitals, the state’s demand for community nursing, particularly in primary health and chronic care is expected to skyrocket.

The purpose of this paper is to provide feedback on the most recent survey of community nursing and midwifery issues and identify useful information from the research literature.

BackgroundThe New South Wales Nurses and Midwives' Association (NSWNMA) is the registered union for all nurses and midwives in New South Wales. The membership of the NSWNMA comprises all those who perform nursing and midwifery work. This includes assistants in nursing (who are unregulated), enrolled nurses and registered nurses and midwives at all levels including management and education. The NSWNMA has approximately 64,000 members and is affiliated to Unions NSW and the Australian Council of Trade Unions. Eligible members of the NSWNMA are also deemed to be members of the New South Wales Branch of the Australian Nursing and Midwifery Federation.

Our role is to protect and advance the interests of nurses and midwives and the nursing and midwifery professions. We are also dedicated to improving standards of patient care and the quality of health and aged care services.

NSWNMA is committed to the notion of health as a public good with shared benefits and shared responsibilities. We believe that access to adequate healthcare is the right of every Australian and a crucial element of the Australian social compact. We are committed to publicly funded universal health insurance as the most efficient and effective mechanism to distribute resources in a manner that generally ensures timely and equitable access to affordable healthcare on the basis of clinical need rather than capacity to pay.

4 | Community Nurses Report

What do we know about community nursing in NSW today?

Australia and the rest of the developed world is facing a major chronic disease burden in the future and it is well-understood that it will become increasingly important to find more efficient ways of managing chronic illnesses. It will be increasingly important that people with chronic diseases avoid expensive hospitalisations through easy access to early intervention, prevention, maintenance and education about self-management from community health nurses and midwives. This will require more emphasis on care in the community and better integration of healthcare.

There are 280 community health centres in NSW and the Association has close to 4000 members who have indicated that they belong to a community branch or are working in a community service.

Community nurses and midwives provide comprehensive nursing and midwifery care that allows recipients of care to remain in their communities. Services are diverse and wide ranging and include palliative care, wound care, hospital in the home, mental health assessment and support, pre and post-natal care, child and family care, complex, aged and chronic care, women’s and men’s health services, immunisation services and indigenous health.

Identifying and isolating budget allocations relevant to the work of community nurses and midwives is difficult. NSW Budget Estimates 2018-19 papers1 indicate that of the $25.1 billion health budget, the ‘mentally healthy communities’ outcome receives 9% of recurrent spending and ‘healthy, resilient communities’ receives 7% of recurrent spending. For perspective, public hospitals receive 83% of the recurrent budget.

Community nursing in NSW exists within a global focus on more integrated person-centred health services that are provided in a way that are coordinated around their needs, respects their preferences, and are safe, effective, timely, affordable, and of acceptable quality2. In NSW, this focus has been expressed through the NSW Integrated Care Strategy which aims to develop models of care involving greater focus on a person’s needs, better communication and connectivity between health care providers in primary care, community and hospital settings, and better access to community-based services close to home3.

In 2013 NSWNMA conducted research among community nurses which found that community health services are struggling to cope. In a substantial survey of almost 400 community health nurses, 70% of respondents disagreed with the statement “the service would be able to cope with an increase in clients without additional staff”.

‘Mentally Healthy

Communities’

How the $25.1 billion health budget spread out

9%7%

‘Healthy, Resilient

Communities’

83%

Public Hospitals

5

For many, patient care was already going backwards with current resources. Thirty-six percent of survey respondents thought the quality of care had deteriorated, while 50% said there was no improvement.

The survey also revealed that community nurses and midwives were carrying large caseloads, with negative consequences for patient care. Over half of respondents thought that increasing requirements of administration and documentation constrained the time available for client care. Travel time was seen as an additional pressure.

Factors such as travel time, administration demands and lack of replacement staff, produce an environment where the care needs of an appropriate number of patients cannot be met. In order to cope with workload demands community nurses and midwives are working unpaid overtime, suggesting a system that is under stress.

Five years later has anything changed?In 2018 we again surveyed members working in community settings and found that workloads continue to undermine the capacity of community nurses to provide quality care.

Less than half of respondents indicated that on a typical day their workload allows them to complete their work at a professional level of which they are proud. The demands of documentation and electronic medical records were cited by 70% of respondents

The biggest issue is relief for annual

leave, sick leave or long service leave

and recruitment and retention of

nursing staff to the country.

Rural General Community RN

Equipment available to you

Lack of resources

Poor staffing

Time

Documentation/ paper/ computer work

What are the barriers that prevent you from being able to effectively complete your work?

57.64%

69.21%

73.89%

Too many clients

31.77%

35.96%

Other(NSWNMA survey)

29.06%

19.95%

Extensive waiting list 3.69%


A very high percentage indicated that

improved staffing and skill mix is the priority for improvement in their service.

as undermining the standard of care as well as issues such as poor staffing (49%), lack of resources (26%), time (64%) and excessive workloads (31%).

Only 6% of respondents indicated that annual and sick leave are backfilled resulting in work being either reallocated (”passed on to already busy colleagues”) or left undone if non-urgent until the staff member returns.

When asked what factor would be the priority for improvement in their service a very high percentage indicated improved staffing and skill mix. Other issues raised include service fragmentation and the need for better integration within the system.

The nurses who responded to this survey identified a wide variety of barriers to service improvement. These included: staffing

Are all occasions of annual leave and sick leave backfilled at your facility?

NO 90.27%

9.73%YES

(NSWNMA survey)

No allocated desk – sometimes

90 mins wasted finding desk and

setting up.

RN, Community Mental Health

I care for about 200 clients

by myself.

RN, Community Mental Health

7

and workloads, bullying, budgets, lack of management support, culture and lack of understanding of the value of the work of community nurses.

It was also evident from some responses that there is some concern that services are being allowed to decline in preparation for privatisation. Half of respondents indicated that there are private sector services offering parallel services in the LHD and roughly a third of responses indicate that aspects of their services are being transferred to NGOs or other private providers. The nurses who responded to our survey were overwhelmingly of the view that privatisation would not improve their services.

Do you think privatisation would improve your service?

(NSWNMA survey)

In the Palliative Care Team there is a strong commitment to providing

high quality patient care and the service has had a long history of this high

quality care, however it has been at the expense of the health and wellbeing

of the staff. Many hours of unpaid overtime have been worked over a long

time and is still done in order to provide the quality of care that the staff

have the skills and knowledge and dedication and desire to provide. There

is such a commitment to high quality care that changing priorities and

ensuring that the health and wellbeing and professional development needs

and mandatory requirements of staff is as high a priority as patient care, is

difficult to achieve, but we are working on this very slowly.

RN, Palliative Care

Disagree

Strongly disagree

20.17%

62.98%

Unsure 9.67%

0.83%Strongly Agree

1.10%Agree

5.25%Neutral


While we recognise there are substantial reforms that can be made in order to improve the system, we believe that the principles on which Medicare was founded must be preserved: equity, efficiency, simplicity and universality. We absolutely reject the suggestion that asserting market based mechanisms will preserve or support these principles.

While goals such as innovation, cost effectiveness, choice and consumer responsiveness are worthy and relevant, in the healthcare sector the primary performance measures are quality, safety, equity of access and affordability.

The Association rejects the orthodoxy that privately delivered services will always be more efficient than publicly provided services. This is particularly so in the healthcare sector where it is well understood that market mechanisms do not drive quality and efficiency.

Competition must not be an end in itself but a means to achieve improved performance. Experience in Australia, the US and the UK suggest that competitive markets in healthcare are often imperfect—the effects of information asymmetry, natural monopoly, vertical service integration, service co-dependencies, costs of market entry, and so on can make it difficult to realise the benefits of competition and can instead produce a range of adverse and unintended consequences such as excessive complexity, patient selection by providers, overtreatment, and lower clinical quality.

Further, fragmentation of care is a precursor to poor outcomes and inefficiency. With the growing burden of chronic and complex conditions, system reform must seek to address fragmentation whereas the proposed establishment of a market of multiple and competing providers will serve only to exacerbate this problem.

Privatisation of services can also occur by what is termed a social impact investment or bond. In NSW we have seen the introduction of a social impact investment in healthcare which saw the transfer of a particular line of service in a Local Health District to a private operator. ‘Social impact bond projects claim to transfer risk from government to the private sector. They monetise public services through the payment by results model…’4 Another method whereby private operators are profiteering from the care of vulnerable people.

The objectives for healthcare delivery in the public sector are clear: quality, safety, efficiency and universal access. For private providers seeking to deliver the same services, the objectives are different: undercut the public service’s price and deliver a profit5. So where will this profit margin come from?

Discussion

Fragmentation of care is a precursor to

poor outcomes and inefficiency.

9

We know from experience in Australia and abroad that nursing and midwifery services are the single biggest cost in running a hospital and they will most certainly be a key area targeted for cutting costs. This could be achieved through reduced staffing, diminution of skill mix, lower pay and conditions or a combination of these. Not only does this affect nurses and midwives but the evidence shows a very clear correlation between staffing ratios and quality and safety of care.6, 7, 8, 9, 10

Despite these concerns, we see the community care sector in Australia is undergoing a paradigm shift with the embedding of a demand driven model of service delivery in the disability and aged care service sector under consumer directed care (CDC).

Community care packages have been traditionally provided in a block funded, case-managed model (HACC). This approach enabled LHDs to deliver care to groups of recipients, with some recipients with less intense packages essentially cross-subsidise those who need more intensive care. By creating individual

budgets in the Commonwealth Home Support Program (CHSP), this cross subsidisation is no longer possible and some recipients will not have enough funding to retain their previous level of services.

Undoubtedly these reforms are creating a more consumer driven, market orientated system. For many recipients of care who are well-informed and well supported, there will certainly be advantages associated with this shift, particularly in terms of flexibility and autonomy.

However, not every care recipient has the resources required to ensure that they get the care they need in this new system. The market orientation assumes that consumers have adequate information to make informed choices. As we well know, the neoclassical assumption of information symmetry cannot be applied effectively to health care. As will be discussed later in the paper, a system predicated on this assumption will inevitably exacerbate risks to quality, safety and equity.

... the community care sector in Australia is undergoing a paradigm

shift with the embedding of

a demand driven model of service delivery

in the disability and aged care service sector under

consumer directed care (CDC).

11

What needs to be done?

A very substantial body of research and evidence linking nurse staffing with patient outcomes has emerged in the literature however specific research relevant to the question of what is a safe workload for community nursing and midwifery staff is limited.

In an evidence-based culture, this raises a tough question: do we do nothing until evidence is gathered or do we take some action to tackle the known district nurse staffing problems? From a patient perspective, the ‘do nothing’ option does not sit comfortably – I do not believe we can wait for years searching for definitive evidence.

Instead, a balance between pragmatic common sense and puritanical evidence based, risk-averse inactivity must be struck – and the unearthing of evidence should continue.11

Further research is required to draw evidence based conclusions, however our members working in community health have reported consistently for many years that their workloads are not sustainable so it is time for some common sense solutions from the frontline.

Evidence from this review suggests that community nursing environments vary considerably across populations and locales and that continued development of such tools could be more beneficial than searches for more generalizable offerings, which may never be able to take account of the wider complexity across healthcare settings and environments. Much of community nursing work involves in-the-moment autonomous decision-making and a good deal of emotional input that cannot easily be quantified, measured or predicted, it remains to be seen whether it is entirely possible to capture both the complete complexity and qualitative nature of the work.12

The NHS has recently published a substantial improvement resource to help standardise safe, sustainable and productive staffing decisions in their district nursing service. While NSW community nursing operates in a different context, the resource provides a reasonable framework within which staffing and workloads can be further discussed and considered.

For some time now, the NSWNMA and it’s members have been fighting for safe nurse to patients ratios in NSW. Community Health and Community Mental Health needs a time based face-to-face patient contact model as outlined below to ensure staffing levels are meeting patient needs.


2018 Claims for Improved Staffing

Community Health and Community Mental Health services require a limit of 4 hours of face to face client contact per 8 hour shift, averaged over a week to be applied in order to provide safe patient care.

The nature of the work of Community Mental Health Services Acute Assessment Teams requires them to have a limit of 3.5 hours of face to face client contact per 8 hour shift, averaged over a week to provide such care.

Work that is not included in this ‘face to face hours’ claim includes travel, meal breaks and administration (eg. phone calls to other health professionals or suppliers, paperwork), otherwise known as ‘indirect care’. ‘

Face to face hours may also be known as ‘direct care’.

In addition, Community Mental Health nurses will be provided Clinical Supervision which includes:

• 2 hours face to face paid clinical supervision leave per fortnight; and

• Paid face to face training in specialised mental health including de-escalation and responding to mental health emergencies.

It’s a matter of LIFE or DEATH

NSWNMA claim for 2018 Award

13

RecommendationsBased on the results from our survey of members and from industry research, the NSWNMA makes

the following recommendations:

1Permanently maintain CHSP funding

(HACC funding)

2Commit to ensuring publicly owned

and run community health services to ensure sustainable healthcare for all

3Cessation of privatisation of services in CH –

there is no evidence that it works

4Implement the 2018 Award Claim for Community

Health and Community Mental Health


1. SW Budget Estimates 2018-19, https://www.budget.nsw.gov.au/sites/default/files/budget-2018-06/4._Health_cluster-BP3-Budget_201819.pdf

2. Framework on integrated people-centred health services, World Health Organisation http://www.who.int/servicedeliverysafety/areas/people-centred-care/framework/en/

3. NSW Health, Integrated Care Plan, http://www.health.nsw.gov.au/integratedcare/Pages/integrated-care-strategy.aspx

4. Whitfield, D. (2015). Alternative to private finance of the welfare state: A Global analysis of social impact bond, pay-for-success and development impact bond projects. Adelaide: Australian Workplace Innovation and Social Research Centre, The University of Adelaide

5. Ross Gittins, Think twice before throwing open the government coffers, SMH, 16 July 2016, http://www.smh.com.au/business/the-economy/think-twice-before-throwing-open-the-government-coffers-20160715-gq6dkw.html

6. Twigg, D. E., Geelhoed, E. A., Bremner, A. P. and Duffield, C. M. (2013). The economic benefits of increased levels of nursing care in the hospital setting. Journal of Advanced Nursing, 69(10): 2253-2261

7. Kalisch, B. J., Tschannen, D. and Lee, K. H. (2011). Do staffing levels predict missed nursing care? International Journal for Quality in Health Care 23(3), 302-308

8. Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244-255

9. Twigg, D., Duffield, C., Bremner, A., Rapley, P., and Finn, J. (2011). The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: a retrospective analysis of patient and staffing data. International Journal of Nursing Studies, 48(5), 540-548

10. Cho, E., Sloane, D. M., Kim, E. Y., Kim, S., Choi, M., Yoo, I. Y. Yoo and Aiken, L. H. (2015). Effects of nurse staffing, work environments, and education on patient mortality: an observational study. International journal of nursing studies, 52(2), 535-542

11. Safe, sustainable and productive staffing – An improvement resource for the district nursing service, National Quality Board, January 2018, pp 6. https://improvement.nhs.uk/documents/816/Safe_staffing_District_Nursing_final.pdf

12. Jackson, C., Wright, T., Martin, A. 2016 Safe Caseloads for Adult Community Nursing Services – An Updated Review of the Evidence, NHS Improvement, pp 6. https://improvement.nhs.uk/documents/817/Final_Version_Managing_Safe_Caseloads.pdf

References

NSW Nurses and Midwives’ AssociationAustralian Nursing and Midwifery Federation NSW Branch

50 O’Dea Avenue Waterloo NSW 2017

PHONE 8595 1234 (metro)

1300 367 962 (non-metro)

www.nswnma.asn.au


NSWNMA/ANMF NSW Branch Legal Disclaimer

This publication contains information, advice and guidance to help members of the NSWNMA/ANMF NSW Branch. It is intended to use within New South Wales but readers are advised that practices may vary in each country and outside New South Wales.

The information in this booklet has been compiled from professional sources, but it’s accuracy is not guaranteed. While every effort has been made to ensure that the NSWNMA/ANMF NSW Branch provides accurate and expert information and guidance, it is impossible

to predict all the circumstances in which it may be used. Accordingly, the NSWNMA/ANMF NSW Branch shall not be liable to any person or entity with repect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out

of this information and guidance.

Publised by the NSWNMA/ANMF NSW Branch, 50 O’Dea Avenue, Waterloo NSW 2017, Australia.

© 2018 NSWNMA/ANMF NSW Branch. All rights reserved. Other than as permitted by law no part of this publication may be produced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or

otherwise, without prior permission of the Publisher. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is publised, without the prior consent of the Publisher.

ISBN: Print 978-1-921326-21-9 Ebook – 978-1-921326-22-6 (Australia)

Issued November 2018. Authorised by Brett Holmes, General Secretary, NSWNMA and Branch Secretary, ANMF NSW Branch, November 2018



ISBN: Print 978-1-921326-21-9 Ebook – 978-1-921326-22-6 (Australia) I Issued November 2018




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