Nursing and midwifery in Queensland by Queensland Nurses and Midwives' Union

Nursing and midwifery in Queensland

Introduction

Nurses and midwives are carers, highly skilled and educated health professionals, patient advocates, managers and employees. We are regulated by law and bound by codes of ethics and practice. Our professions are also consistently ranked the highest for trust, honesty and integrity. This publication provides you with important information about the QNMU and our members, to give you a clear understanding of who nurses and midwives are and what we do. It is a briefing document that describes our values and mission, while also outlining our key concerns and tensions.

Beth Mohle

It also stands as an expression of our readiness to work collaboratively and productively with key health stakeholders, including the State Government, for the betterment of our health system and the people who need it. Nurses and midwives work in a variety of positions and settings throughout Queensland, but there are also significant opportunities for us to extend our roles and responsibilities, to draw on our skills and motivation to help address some of the critical issues facing our health system and make it safer, more efficient, and even more financially viable.

Sandra Eales

We have already seen some fantastic outcomes for Queenslanders in this respect over the past three years, with the introduction of legislated nurse/midwife to patient ratios, the implementation of the nurse navigator program, and a return to Interest Based Bargaining in the industrial space. While there is momentum for reform we want to be part of it. We welcome any questions or feedback you might have on any of the issues we identify in this book, or any other topic you may wish to discuss. The QNMU also has extensive information, research and resources available should you like to know more about any particular issue. We look forward to working with you to ensure we can deliver safe, high quality care for all Queenslanders and help build and grow a responsive and sustainable health system we can all be proud of. Sincerely

Beth Mohle Sandra Eales Secretary Assistant Secretary

Contents

Part 1: Nursing and midwifery in Queensland

■■ Nurses and midwives – who we are and what we do ■■ Categories of nursing and midwifery work ■■ Regulation of nursing and midwifery

Part 2: About the QNMU ■■ About the QNMU and ANMF ■■ Our values ■■ Our strategic plan ■■ What are our key goals? ■■ Nursing and midwifery leadership ■■ Our priority areas for attention ■■ QNMU and Queensland Health working together

Part 3: Governance and accountability

■■ Hospital and Health Services ■■ Transparency in private health services ■■ Public reporting ■■ Public Private partnerships ■■ Deficiencies in the regulatory framework for Health Practitioners

Part 4: Key issues for our professions

■■ Achieving safety and quality of care ■■ Nursing and midwifery excellence ■■ Workplace health and safety and occupational violence ■■ Primary and preventative health

NURSING AND MIDWIFERY IN QUEENSLAND (2018) 1

CONTENTS

Part 5: Social policy perspectives

Part 6: Federal concerns

Part 7: Other current issues as at March 2018

Appendix 1: Facts and figures

Appendix 2: Queensland Health nursing and midwifery classification structure

References

Where to go for more information

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PART 1:

NURSING AND MIDWIFERY IN QUEENSLAND

PART 1: NURSING AND MIDWIFERY IN QUEENSLAND

Nurses and midwives who we are and what we do Nurses and midwives are the largest occupational group in Queensland Health and one of the largest across the Queensland government. Nurses and midwives are the most geographically dispersed health professionals in Australia, working independently or collaboratively to provide professional and holistic care in a range of circumstances. We work to promote good health, prevent illness, and provide care for the ill, disabled and dying. Most nurses and midwives work in an area of clinical practice such as medical and surgical, aged care, critical care, perioperative, midwifery, emergency, general practice, community health, mental health, family and child health, rehabilitation and disability, rural and remote health and occupational health and safety. Nurses and midwives also work in other significant roles which include management, education, research and health policy development. The diversity of our work includes: ■■ emergency department care in Brisbane’s busiest, and regional Queensland’s smallest, hospitals ■■ indigenous health care in remote Aboriginal communities 4 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

■■ aged care in nursing homes, hostels, small private hospitals and large public hospitals ■■ midwifery, neonatal and paediatric care across the state ■■ coronary, mental health, intensive care, oncology, disability, surgical, palliative and renal care ■■ nursing in schools, prisons, general practice and large private businesses ■■ community nursing in people’s homes, outreach or mobile clinics. Nurses and midwives provide continuity of care for patients 24 hours a day, seven days a week. Nurses and midwives advocate for the patient as a whole person within a complex health system. At every site and level of the nursepatient relationship, nurses facilitate and mediate the competing demands of patients, families, carers, the environment at points of immediate care, the system and society to achieve the best possible outcomes.

We work to promote good health, prevent illness, and provide care for the ill, disabled and dying.

PART 1: NURSING AND MIDWIFERY IN QUEENSLAND

Categories of nursing and midwifery work Nursing and midwifery work is classified into seven main categories:

Nurse Practitioner A Nurse Practitioner is a Registered Nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. A Nurse Practitionerâ&#x20AC;&#x2122;s scope of practice extends beyond that of the Registered Nurse (RN). Their role includes assessment and management of clients using nursing knowledge and skills and may include, but is not limited to, the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. Nurse Practitioners must be registered with the Nursing and Midwifery Board of Australia (NMBA), the independent statutory body that regulates nursing in Australia

Registered nurse â&#x20AC;&#x201D; RN RNs must also be registered with the Nursing and Midwifery Board of Australia (NMBA). RNs in Queensland must complete an NMBA approved three-year bachelor degree at university. RNs plan, implement and evaluate nursing care and supervise the work of Enrolled Nurses and Assistants in Nursing. The RN is the constant presence in patient care 24 hours a day, seven days a

Throughout their career, nurses continually maintain and advance their skills through professional development. week, managing the relationships between doctors, specialists, administrators, loved ones and the patient.

Midwives with endorsement A Midwife with an endorsement on their registration has met specific requirements at a national level that enable them to prescribe scheduled medicines and Medicare rebatable maternity services. Midwives are endorsed to administer, obtain, possess, prescribe or supply specified scheduled medicines when they successfully complete a NMBA-approved program of study for prescribing medicines. They must also complete additional CPD hours and comply with regulatory and legislative requirements. Queensland has a significant number of Midwives with an endorsement who are not working in private practice and are unable to prescribe or provide Medicare rebatable maternity care (unless they are NURSING AND MIDWIFERY IN QUEENSLAND (2018) 5

PART 1: NURSING AND MIDWIFERY IN QUEENSLAND

in a 19(2) exemption site). QNMU is working closely with Queensland Health on removing these barriers to midwifery practice.

Registered Midwife Midwives are registered with the NMBA and bound by the NMBA Code of Conduct. A Registered Midwife may practise in any setting including the home, community, hospitals, clinics or health units. Midwives provide care to women during pregnancy and childbirth, and for the newborn up to six weeks of age.

Enrolled Nurse Advanced Skill – ENAS The Enrolled Nurse Advanced Practice (ENAP) category was introduced by Queensland Health following 2003 EB negotiations to recognise the complex clinical care and responsibilities of ENs working at an advanced level. It was renamed EN Advanced Skill during EB9. The QNMU believes the ENAS role is under-utilised and there are significant opportunities to advance the EN role in health care. Some facilities have created unreasonable obstacles for ENs working in an advanced capacity to progress to ENAS and we believe this needs addressing.

Enrolled Nurse — EN The EN must also be registered with the NMBA and must complete a NMBA approved Diploma at a TAFE or other approved vocational institution. The EN provides direct nursing care and observes and reports changes in an individual’s health status. ENs with NMBA authority to administer medication can administer prescribed drugs, under the supervision of an RN. 6 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

Assistant in nursing — AIN The NMBA does not currently licence AINs or Personal Carers/Personal Care Assistants, although for many years, the QNMU has campaigned to regulate their practice appropriately. AINs do, however, come under the jurisdiction of the Health Ombudsman who can investigate complaints against AINs and take action against AINs if deemed necessary. Many AINs/PCAs hold a Certificate III or IV qualification but this is not a mandatory requirement. The AIN/PCA assists with nursing care and works under the direction and supervision of a Registered Nurse. Throughout their career, nurses continually maintain and advance their skills through professional development.

In Queensland Health* nurses can progress through the following career structure: ■■ Assistant in Nursing ■■ Undergraduate Student in Nursing and Midwifery ■■ Enrolled Nurse ■■ Enrolled Nurse Advanced Practice ■■ Registered Nurse/Midwife ■■ Clinical Nurse ■■ Clinical Nurse Consultant/Nurse Unit Manager/Nurse Manager/Nurse Educator/Nurse Researcher/Public Health Nurse ■■ Nurse Practitioner ■■ Assistant Director of Nursing ■■ Director of Nursing ■■ District Director of Nursing ■■ Executive Director of Nursing * This is the QH structure — other sectors are different

PART 1: NURSING AND MIDWIFERY IN QUEENSLAND

Regulation of nursing and midwifery There are a number of laws, regulatory bodies and professional guidelines that govern the work of nurses and midwives.

The National Registration and Accreditation Scheme The National Registration and Accreditation Scheme commenced on 1 July 2010. The scheme provides nationally consistent legislation regulating the

registration and accreditation of 14 health group professions in Australia.

Health Practitioner Regulation National Law Act 2009 The law governing the National Registration and Accreditation Scheme is the Health Practitioner Regulation National Law Act 2009 (the â&#x20AC;&#x2DC;National Lawâ&#x20AC;&#x2122;). The Act was passed by the Queensland Parliament on 3 November 2009. The National Law provides the statutory framework for the

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registration and accreditation scheme for the regulated health professions which includes nursing and midwifery.

AHPRA is required under the National Law to discharge many of its functions in conjunction with the NMBA.

Since the introduction of the Health Ombudsman Act 2013 in Queensland, the National Law reference is to the Health Practitioner Regulation National Law (Queensland).

The Nursing and Midwifery Board of Australia

The National Law provides definitions for unsatisfactory professional performance, unprofessional conduct, and professional misconduct. These definitions are an attempt to consolidate the many and varied terms and phrases that previously existed under the numerous regulatory regimes.

Australian Health Practitioner Regulation Agency The Australian Health Practitioner Regulation Agency (AHPRA) is the organisation responsible for the implementation of the National Registration and Accreditation Scheme across Australia. Essentially, AHPRA is the body which supports, administratively and operationally, the Nursing and Midwifery Board of Australia (NMBA) and its state Boards.

The Nursing and Midwifery Board of Australia (NMBA) was established under the Health Practitioner Regulation (Administrative Arrangements) Act 2009. It is the board for nurses and midwives across Australia. The NMBA replaced the former Queensland Nursing Council (QNC). The functions of the NMBA include, among other things, the registration of nurses and midwives; determining the requirements for registration or endorsement of registration as a nurse or midwife; and developing or approving standards, codes and guidelines for nursing and midwifery. The NMBA also oversees the assessment and investigation of matters about nurses and midwives referred to it by AHPRA. and can refer disciplinary matters to the Queensland Civil and Administrative Tribunal or the Health Ombudsman.

The NMBA also oversees the assessment and investigation of matters about nurses and midwives referred to it by AHPRA. 8 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

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It can also establish panels to conduct hearings about health and performance, and professional standards matters involving nurses and midwives.

Registration standards The NMBA has developed a number of registration standards which were approved by the Ministerial Council and which came into effect on 1 July 2010. These registration standards include, but are not limited to, criminal history, having appropriate English language skills and professional indemnity insurance, and undertaking continuing professional development (CPD). These standards also include regulation around nurses and midwives administering scheduled medicines. All nurses and midwives across Australia are required to meet and comply with the standards relevant to their profession in order to be registered.

Health Panels and Performance and Professional Standards Panels Perhaps one of the most significant, yet so far rarely used, changes brought about by the National Law is the creation of Health Panels and Performance and Professional Standards Panels. A Health Panel can be established if the NMBA reasonably believes that a nurse, midwife or student has an impairment and the NMBA decides it is necessary or appropriate for the matter to be referred to a panel. The NMBA can also establish a Performance and Professional Standards Panel if it reasonably believes that the nurse or midwifeâ&#x20AC;&#x2122;s professional conduct, or the

way they practise their profession, is or may be unsatisfactory, and the NMBA decides it is necessary or appropriate for the matter to be referred to a panel. The NMBA has not published guidelines about the circumstances in which it may be deemed necessary or appropriate for the NMBA to refer a matter to a panel. The National Law does not provide significant guidance in relation to when National Boards should use a Health Panel or Performance and Professional Standards Panel. Both Health, and Performance and Professional Standards panels are required to include members who are nurses or midwives. The panels run independently from the NMBA. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 9

PART 1: NURSING AND MIDWIFERY IN QUEENSLAND

Office of the Health Ombudsman The Health Ombudsman is tasked with delivering a transparent, accountable and fair system for effectively and expeditiously dealing with complaints and other matters related to the provision of health services. The Health Ombudsman Act 2013 (Qld) varies how Part 8 of the National Law provides for the disciplinary arrangements for nurses and midwives. It has been the QNMU’s experience that the Health Ombudsman manages all serious allegations against Queensland nurses – namely, matters that indicate a nurse has engaged in professional misconduct or where grounds may exist for the suspension or cancellation of a nurse’s registration. Matters relating to performance (competence) and health impairment are usually referred to AHPRA by the Health Ombudsman.

10 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

Queensland Civil and Administrative Tribunal (QCAT) The Health Ombudsman has the power to refer a health service complaint about a nurse or midwife to the Director of Proceedings who will then decide whether to refer the complaint to the Queensland Civil and Administrative Tribunal (QCAT). The circumstances under which a matter may be referred to QCAT include: a. where a nurse or midwife has engaged in behaviour which the NMBA reasonably believes may constitute professional misconduct, or b. where the NMBA reasonably believes that the nurse or midwife’s registration was improperly obtained. The NMBA must also refer matters to QCAT as directed by a panel established through the NMBA.

PART 2:

ABOUT THE QNMU

PART 2: ABOUT THE QNMU

About the QNMU and ANMF

QNMU purpose The purpose of the QNMU is to grow power, confidence and capacity to improve the industrial and professional interests and wellbeing of nurses and midwives and the health of our community.

The Queensland Nurses and Midwivesâ&#x20AC;&#x2122; Union (QNMU) is the principal health union and the largest union in Queensland. The QNMU covers all categories of workers that make up the nursing and midwifery workforce in Queensland including Registered Nurses, Registered Midwives, Enrolled Nurses and Assistants in Nursing who are employed in the public, private and not-for-profit health sectors including aged care. Our more than 58,000 members work across a variety of settings from single person operations to large health and nonhealth institutions, and in a full range of classifications from entry level trainees to senior management. The vast majority of nurses and midwives in Queensland are members of the QNMU. In Queensland Health, membership density sits at more than 90 per cent. 12 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

PART 2: ABOUT THE QNMU

The QNMU promotes and defends the industrial, professional, social, political and democratic values and interests of members. In practice, this means the QNMU works to: ■■ establish and promote standards for nursing and midwifery practice, education and service by taking any action deemed necessary to do so including legal, industrial, political, professional and social activities ■■ stimulate and promote research designed to widen the knowledge on which the practice of nursing and midwifery is based ■■ obtain and maintain desirable conditions of work and just remuneration for all nurses and midwives and for this purpose to obtain awards or determinations from industrial tribunals and to enter into agreements or treaties with employers ■■ represent nurses and midwives and serve as their spokesperson before any tribunal, court, board, committee, or other authority and to present their cause ■■ obtain representation on boards, institutions and organisations as may be considered necessary to further the interests of nurses and midwives

making body of the union. As such it is rank and file membership that drives the agenda of the QNMU. In addition to the annual conference, the QNMU has an elected council and an elected executive, which in turn have decision-making responsibilities between conferences. Council is the governing body of the union. With the collective strength of more than 58,000 members the QNMU works with nurses and midwives to bridge the gap between the real and the ideal of nursing and midwifery at all levels.

The QNMU and the ANMF In addition to being a state-registered union, the QNMU is also a branch of the Australian Nursing and Midwifery Federation (ANMF). The ANMF is one of the largest and fastest growing unions in Australia with branches in each state and territory, and more than 260,000 members. Nurses and midwives who are members of the QNMU are also automatically full members of the ANMF.

■■ establish special funds to endow scholarships, promote research or conduct any activity which may be of general benefit to the members

While state interests naturally dominate the activities of the QNMU, our affiliation with our federal body means the QNMU is also active in promoting the interests of nurses and midwives on a national and international level.

■■ communicate effectively with members on all matters relating to nursing and midwifery.

Internationally the QNMU, through the ANMF, is also a member of the International Council of Nurses and Global Nurses United.

The union has a democratic structure based on its workplace and geographical branches. Delegates are elected from the branches to attend the QNMU Annual Conference which is the principal policy

The International Council of Nurses (ICN) is operated by nurses and leads nursing internationally. It works to ensure quality nursing care for all and sound health policies globally. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 13

PART 2: ABOUT THE QNMU

Our values

Our nursing and midwifery values, in concert with our union values, focus our activities around a common purpose, give us direction, and provide an anchor for our passion and the action we take.

Our nursing and midwifery values Understanding the core values of nursing and the underlying environmental tensions that are at odds with these values is the first step in building a culture of health for all, and ensuring an effective and sustainable nursing and midwifery workforce. Decision makers often do not fully recognise and value the things nurses value which can, on occasion, create obstacles to nurses and midwives maintaining autonomy with respect to professional practice, service delivery and health policy. The quality of nursing and midwifery we provide is central to our professional integrity. We are committed to person-centred care. We show this commitment by working in partnership with our patients, clients, residents and families, as well as the broader health team whose individual contribution and skills are vital to the best interests of those in our care. We care deeply and we are courageous in our commitment to caring. Every day, we stand up and speak out for what is right and necessary. 14 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

We do this as individuals, with and on behalf of those in our care. We do this together by engaging with those who have power to affect the way we provide quality care.

CARING Nursing and midwifery is indispensable, knowledgeable and human caring. We care with complex knowledge focused on the specific needs of the patient. Caring is physical, technical and interpersonal work. Caring is central to our identity as nurses and midwives.

PROFESSIONALISM Nurses and midwives are regulated by the community (through government) and is accountable to the community for its practice standards, conduct and education (through licensing, certification and codes of ethics and practice).

ADVOCACY Nurses and midwives keep the system safe. We are the critical link between the patient and the system.

PART 2: ABOUT THE QNMU

HOLISM

COLLECTIVISM

Nursing and midwifery provides continuity of care 24 hours a day, seven days a week. The time nurses and midwives spend with patients is critical to clinical decisions and co-ordination of care.

We are stronger when we work together. All workers have the right to a decent wage and to fair and safe working conditions. This is best achieved by joining and being represented by a union, and by bargaining collectively.

Our union values Our union values of fairness, collectivism, equality and opportunity unite us. As nurses and midwives we work together through our union and more broadly in our communities to champion our belief in every Australian’s right to a fair share of our nation’s wealth and health, especially through employment and a decent standard of living. Our union values support our efforts to advance a democratic, multicultural and sustainable Australia — one which values all citizens and their aspirations. Our union values draw on work done by the Australian and international union movements.

Our union’s collective aspirations are realised through our governance and democratic processes. As nurses and midwives, we are used to working together. We understand better outcomes are achieved when shared interests are identified and challenges addressed through teamwork and collaboration.

EQUALITY We believe all people should be treated equally and have the same rights under the law. We strive to ensure our society is free from discrimination, harassment, intimidation and violence.

We are committed to a fair society. We work day in, day out to give everyone a fair go in our workplaces and our broader society.

We recognise the role of unions in assisting the re-distribution of power in our society to deliver greater equality and we believe every Australian deserves equal access to free, quality public health care and education and other essential services, regardless of their socio-economic circumstances.

Democratic structures and institutions in our society, including in our unions, support fairer outcomes and enhance our capacity to share the wealth of our nation more equitably.

Nurses and midwives have a central role to play in addressing inequity in health care by actively recognising and helping to address the social and economic determinants of health.

FAIRNESS

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PART 2: ABOUT THE QNMU

OPPORTUNITY We seek to improve the quality of life of all Australians. Equality of opportunity is a core element of an egalitarian society. Universal health care, equal opportunity and investment in education, progressive and equitable taxation and a fair industrial relations system coupled with access to safe, secure and meaningful work all contribute greatly to our dignity and social cohesion. We believe the role and activities of government are central to ensuring opportunity for all. If we are to continue to improve the quality of life for all Australians, governments, unions, employers and civil society each have a role providing opportunities to address inequality.

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PART 2: ABOUT THE QNMU

Our Strategic Plan

Mission Statement The Queensland Nurses and Midwives’ Union promotes and defends the industrial, professional, social, political and democratic values and interests of members. Our members are Registered Nurses and Midwives, Enrolled Nurses, Assistants in Nursing and Personal Carers and student nurses and midwives. Our members are the union.

The landscape in which QNMU members live and work changes constantly and we can only meet the challenges this presents if our union is strong and well positioned. This is why every three years we review our priorities and performance, and draft a new Strategic Plan. Along with our rules, this Strategic Plan is a bedrock governance document that guides the QNMU. It defines what we stand for, and the union and nursing and midwifery values that underpin our actions. Strategic planning is vital for any successful organisation — especially a democratic and accountable memberbased organisation like ours. In the coming three years, our focus is on three critical success factors: ■■ Developing and practicing leadership at every level of our organisation through: ◆◆ encouraging workplace activism ◆◆ conducting workplace bargaining ◆◆ advancing professional nursing and midwifery practice ◆◆ influencing the political process ◆◆ advocating for legislative and policy change to advance the interests and values of members NURSING AND MIDWIFERY IN QUEENSLAND (2018) 17

PART 2: ABOUT THE QNMU

◆◆ facilitating social change consistent with QNMU values. ■■ Growing, supporting and developing our membership through: ◆◆ campaigning and communicating ◆◆ increasing membership ◆◆ educating members ◆◆ growing branches ◆◆ servicing members. ■■ Building our organisation’s capacity and ability to respond to our environment through: ◆◆ supporting and developing QNMU staff ◆◆ managing finances

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◆◆ supporting information and business systems. Drilling down to an operational level, this Strategic Plan also identifies a number of operational goals such as: ■■ addressing unsafe workloads ■■ campaigning for workplace health and safety improvements ■■ advancing member wages and conditions, and ■■ and facilitating positive social change. Our Strategic Plan is a multi-layered document which we believe anchors our organisation and gives us the wherewithal not only to manage challenges, but to embrace each year and thrive.

PART 2: ABOUT THE QNMU

What are our key goals?

DIRECTION AND FOCUS To promote the QNMUâ&#x20AC;&#x2122;s vision, mission and values in all aspects of its strategic operations.

ORGANISATIONAL To achieve union growth, influence and power through the provision of optimal infrastructure and support for both members and the union organisationally.

INDUSTRIAL To improve, maintain and enforce the industrial rights and aspirations of members.

PROFESSIONAL To advance and protect the professions and standards of safe practice of nursing and midwifery.

SOCIAL To facilitate positive and sustainable social change through directed activities, education and policy development.

POLITICAL To maximise the influence of the QNMU in political processes.

DEMOCRATIC To promote the participation of members in internal and external democratic processes.

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PART 2: ABOUT THE QNMU

Nursing and midwifery leadership There are untapped opportunities for nurses and midwives to make Queensland’s health system work better, smarter, and safer. Nurses and midwives, as individuals, and as a powerful collective of health professionals, have a wealth of knowledge and expertise we can bring to the table to keep the health system safe, achieve better outcomes, ensure sustainability and even reduce costs. But over the years nurses and midwives have often been sidelined and our contribution to the health system undervalued. Evidence of this was clearly seen in the cuts to nursing roles and the removal of nurses from decision making bodies resulting in declining influence during the Campbell Newman years. We certainly welcome the current Labor state government’s steps over the past few years to repair the damage but we believe more can be done across all health care sectors to harness the professional expertise and leadership capacity of nurses and midwives. Nurses and midwives are at the frontline of patient care and system safety, and many of us are leaders in research, 20 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

innovation, and training. But we must also lead nursing at the executive level. It is essential nurses and midwives represent their professions on executive boards and in centralised structures such as Department of Health, private health services and in senior management of Residential Aged Care Facilities. Rural and remote hospitals/health services have unique needs and also require on-site nursing leadership and management. To achieve this level of leadership, obstructions and potential roadblocks within the system must be addressed. ■■ We must ensure decentralising organisational structures do not strip nursing and midwifery voices from executive positions, and that executive, management and other leadership roles are sufficiently resourced and supported. ■■ Any organisational restructuring that affects nursing and midwifery must involve consultation and negotiation, and representation on any relevant groups or committees. ■■ Changes to nursing and midwifery roles, positions, titles, reporting lines and relationships must be negotiated, and effective risk assessments should be carried out to determine the impact on patient safety and care.

PART 2: ABOUT THE QNMU

■■ And there is a need to maintain a robust career structure with clear career pathways which reward increased responsibility and ultimately improve service outcomes. We know we are a powerful force for good and we have embraced this concept and made nurse power and midwife power part of our everyday language. We believe nurses and midwives must use their power to take control of their workloads and their work, to ensure safe workplaces, and to identify system deficiencies and achieve improvements. Nurses and midwives must be empowered and enabled to show leadership, to use their nursing and midwifery voice, to bring ideas to the table. Furthermore, we invite politicians, policy makers,

managers, and budget builders to tap into our power, listen to our nursing and midwifery voice, and collaborate with us. We know the issues, we know the state of play and we have the skills, professional knowledge and resourcefulness to help create a stronger, safer health system.

Nurse power fund At our 2013 Annual Conference, QNMU delegates from across the state passed a motion to set up a ‘power fund’ — a fundraising program dedicated to defending and advancing the interests of nurses and midwives as a profession. Through our Power Fund nurses and midwives now have the financial resources to publicly advocate for change and address critical issues such as patient safety and universal health care.

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PART 2: ABOUT THE QNMU

Our priority areas for attention

Safety and quality of health care Health care as a universal right

Innovation and

sustainability

22 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

Fairness at work for nurses and midwives

PART 2: ABOUT THE QNMU

HEALTH CARE AS A UNIVERSAL RIGHT Defend and advance universal access to quality health care based on need and not capacity to pay Identify current access gaps and establish a framework to ensure access to health care is consistently based on need. VIA

Undertaking care needs gap analysis and incorporate into HHS minimum community service obligations.

Improve health care co-ordination across the health and aged care system. VIA

Identifying and addressing blocks to improved care co-ordination across the system (e.g. through the expansion of the nurse navigator program, and establishment of continuity of midwifery care models).

Invest in health care infrastructure to service growing population and ensure public has access necessary health services. VIA

Ensuring timely delivery of planned program of works at Logan Hospital, Ipswich Hospital, and Caboolture Hospital; and of new health facilities including Rockhampton rehabilitation centre for ice users and replacement for Brisbaneâ&#x20AC;&#x2122;s Barrett Centre.

Invest in nursing and midwifery workforce to service growing population and ensure public health services are effectively resourced. VIA

Extending the nurse navigator program, maintaining the nurse and midwife graduate program and concerted focus on recruiting and retaining additional nurses and midwives.

Increase focus on promoting health, not merely treating illnessâ&#x20AC;&#x201D;reinvest in health promotion and prevention. VIA

Sustaining focus on primary and preventative health care and screening (e.g. through the expansion of the nurse navigator program, and establishment of continuity of midwifery care models).

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PART 2: ABOUT THE QNMU

SAFETY AND QUALITY OF HEALTH CARE Enhance confidence in the health and aged care system Improve implementation of legislated nurse/midwife to patient ratios and a skill mix framework in Queensland Health. VIA

Promoting consistent statewide adherence to legislative requirements and encouraging robust reporting across all HHSs (e.g. including KPIs in Service Level Agreements).

Support the appropriate and effective implementation of the Business Planning framework. VIA

Application of provisions within Queensland Health enterprise agreements and state legislation (particularly the Workload Management Standard).

Expand the nurse to patient ratios program. VIA

Extension of ratios to mental health services and state government nursing homes.

Legislate the establishment of minimum safety and quality datasets which would include the reporting of nursing/midwifery staffing numbers, skill mix, and quality outcomes across all sectors. VIA

Developing and establishing a “whole of health system” performance reporting framework that maps inputs (e.g. nurse/midwife to patient ratios) and outputs (e.g. enhanced patient safety and quality) to health outcomes (e.g. healthier Queenslanders).

Support a review into the adequacy of current staffing and skill mix arrangements in aged care facilities. VIA

Negotiating with federal government via health ministers’ meetings/CoAG.

Legislate and enforce minimum registered Nurse staffing 24/7 for Queensland aged care facilities. VIA

Negotiating with federal government via health ministers’ meetings/CoAG.

Refocus the health system to put the safety of patients first. VIA

Implementing a best practice approach to patient safety, including governance, frameworks, systems and processes, and generally including consumers in system design, implementation and evaluation.

Improve performance monitoring to drive systemic improvement in patient safety. VIA

Implementing a best practice patient safety and quality reporting framework solution (e.g. KPIs in Service Level Agreements).

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PART 2: ABOUT THE QNMU

INNOVATION AND SUSTAINABILITY Value the vital role nurses and midwives play as lynchpins for our health and aged care system Provide sufficient numbers of appropriately skilled nurses and midwives to deliver safe patient care. VIA

Promoting consistent and robust application of ratios legislation across HHSs including provisions around nurse and midwife professional judgement.

Support the sustainability of the nursing and midwifery workforce through optimal employment of new graduates. VIA

Continuing to implement ‘Refresh Nursing’ commitments, especially supporting the recruitment of additional new graduates.

Support and promote innovation through evidence. VIA

Developing and establishing a whole of health system performance reporting framework that maps inputs (e.g. nurse/midwife to patient ratios) and outputs (e.g. enhanced patient safety and quality) to health outcomes (e.g. healthier Queenslanders).

Establish, monitor and evaluate new models of care. VIA

Providing resources to establish a standardised evidence-based reporting and evaluation framework for new models of care.

Develop and implement a nursing and midwifery workforce plan. VIA

Investing in the development of holistic and integrated workforce strategies to support the demands of an ageing population and workforce.

Support nurses and midwives to work to their full potential/scope of practice. VIA

Identifying and removing barriers to nurses and midwives working to their full potential and scope of practice.

Ensure nurses and midwives have the necessary authority to control their resources. VIA

Identifying and addressing inadequacies in existing QH organisational structures that limit the ability of nurses and midwives to control nursing and midwifery resources and practice.

Acknowledge nurses’, midwives’ and other health care stakeholders’ responsibility to advocate for public policy around climate change that promotes and protects human health. VIA

Support nursing and midwifery engagement with established organisations such as the Climate and Health Alliance (CAHA – www.caha.org.au).

NURSING AND MIDWIFERY IN QUEENSLAND (2018) 25

PART 2: ABOUT THE QNMU

FAIRNESS AT WORK FOR NURSES AND MIDWIVES Provide job security, fair wages and conditions of employment, and industrial rights Provide a fair industrial relations framework to support innovation. VIA

Maintaining a fair and transparent industrial relations framework including an appropriate bargaining framework and fair government wages policy.

Maintain a culture of mutual respect and valuing. VIA

Implementing improvements to industrial relations arrangements that advance a culture of mutual respect and valuing via Ministerial Directives in Queensland Health.

Promote a culture that values the fundamental rights of workers. VIA

Support union encouragement provisions as outlined in the public sector Enterprise Agreement and having a genuine say at work.

Innovate to solve mutually identified problems. VIA

Maintain the interest-based problem-solving approach to negotiation and implementation of enterprise agreements, including appropriate consultative arrangements at the central and HHS levels.

Establish fair workloads to deliver safe patient care. VIA

Implementing legislated minimum nurse/midwife to patient ratios and skill mix and the proper implementation of the Business Planning Framework.

Address unresolved pay inequities including issues around multidisciplinary teams and Superannuation OTE. VIA

Enterprise Bargaining and whole of government negotiations.

Provide secure employment arrangements to support the provision of continuity of care. VIA

Promoting permanent ongoing employment arrangements for nurses and midwives.

Ensure the application of agreed provisions within the public sector Enterprise Agreement. VIA

Industrially mandated vehicles such as NaMIG and NaMCFs.

26 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

PART 2: ABOUT THE QNMU

QNMU and Queensland Health working together State of play The past three years have been a period of recalibration and reinvigoration for the QNMU. The 2012-2015 LNP regime left a deep gash in the health workforce and services in this state, and it is likely we will continue to feel the fallout from their devastating policy decisions for many years to come. Almost 5000 Queensland Health positions were slashed during that time, including more than 1800 nursing and midwifery jobs. The health system and the workforce that survived found itself stretched beyond acceptable levels. It was a time of great upheaval for our nurse and midwife members who in

addition to being deeply concerned about the safety of their patients, were made to feel undervalued and expendable. The election of the first term Palaszczuk government in 2015 saw a return to a more inclusive and consultative form of government, and within that, an acknowledgement that the health system needed focus. We have been reassured by the changes made so far to reinstate essential health services and personnel and have of course welcomed the opportunity to work with the government on initiatives such as nurse/ midwife-to-patient ratios and the nurse navigator program that go beyond merely repairing the damage and position us well for the future.

Health Minister Steven Miles met with QNMU Council in February 2018

NURSING AND MIDWIFERY IN QUEENSLAND (2018) 27

PART 2: ABOUT THE QNMU

But there is still much more we can do to advance a health system that is responsive to the growing and ever-changing needs of the Queensland population, and supports innovation and inclusiveness while remaining fiscally sound. We are particularly interested in to partnering with the Queensland government to explore opportunities around expanding clinical roles for nurses and midwives, adopting new digital technologies, and further development and deploy workload management practices.

Where to from here? The QNMU is keen to work with the government to help inform and facilitate electoral commitments that build on the health jobs growth record of the past three years. Of particular interest to our cohort is the commitment to employing more nurses and midwives, and specifically, the focus on creating more permanent employment opportunities for graduates, Nurse Navigators and Nurse Practitioners. The expansion of the ratios agenda is also of interest to our members and are keen to continue our engagement in this space as the government works to expand the program into acute public mental health wards and state-run aged care facilities. The QNMU has a significant body of evidence that can be drawn on to support the call for ratios and public reporting not only in the public sphere but also in privately run hospital and aged care facilities.

Funding fears At the time of going to print, a campaign is underway to recoup a Federal government 28 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

funding deficit of $979,000,000 from Queensland’s coffers. These missing funds are the result of the Abbott government’s unilateral decision to withdraw from the 2011 National Reform Agreement, in which the Commonwealth committed to meeting 45% of the growth in efficient hospital costs for the first three years and then increase the Commonwealth contribution to 50% thereafter. The current Turnbull Government has agreed to partially restore cuts and has reached a new agreement with State and Territory leaders for the Commonwealth to cover 45% of hospital funding with growth capped at 6.5% per annum for five years from 2020. But the Commonwealth government’s nearly $1 billion funding promise for the 2014/15 and 2015/16 financial years is still to be paid. This jeopardises not only the Queensland government’s ability to deliver on much needed election commitments such as 3000 new nurses and midwives over the next four years, extending the ratios program and implementation of the SWiM standard, but also affects current EB10 negotiations and investment in health infrastructure. At the most recent COAG meeting in February this year, Queensland, rightly, refused to sign up to the new agreement for Commonwealth funding, until the missing funds were restored. We will continue to campaign for Canberra to make good on its funding promise, but we are acutely aware that there remains the likelihood it will continue to refuse payment.

PART 2: ABOUT THE QNMU

It is our view that should this occur, the Queensland government must resist pressure reduce the health workforce in response.

Group) as the body responsible for the interpretation, application and implementation of the resulting EBA.

Our community is still recovering from the 2012-2015 job cuts, and all population and health workforce projections indicate the need for jobs growth in health to safely and effectively service future needs.

A collaborative forum for the QNMU and Queensland Health, NaMIG is the peak body for the advancement of the interests and issues of the Queensland Health nursing and midwifery workforce.

We would encourage the government to work collaboratively with health stakeholders, including the QNMU to find more innovative ways of managing funding shortfalls to ensure the health system is still able to meet the current and future service demands.

IBPS and NaMIG We welcomed a return to an interest based problem solving (IBPS) approach to EB negotiations last year. The QNMU is committed to the maintenance of a high functioning health service in Queensland and we know strong, mature partnerships will reap better rewards for Queenslanders than an outmoded adversarial approach. In our view, IBPS is the most effective approach to finding solutions to the challenges facing the health system, through work around critical areas such as ratios and workload matters, models of nursing and midwifery care, working arrangements and career structures, and around other strategic issues and productivity enhancements — such as the development of a productivity enhancement framework with an agreed performance indicator framework. We are encourage full utilisation of NaMIG (Nursing and Midwifery Implementation

A nursing voice through OCNMO The Office of the Chief Nursing and Midwifery Officer (OCNMO) is the Queensland Government’s principal advisor on all matters relating to nursing and midwifery with a particular authority and expertise in advancing, leading and advising on matters that promote a healthier Queensland. It is currently led by the Chief Nurse, Shelly Nowlan. OCNMO’s key areas of responsibility include: ■■ strategically advising and supporting the government in the delivery of health priorities ■■ developing policies and initiatives to support government health objectives ■■ undertaking high-level monitoring and responding to key state-wide indicators ■■ building state-wide capacity and sustainability. OCNMO is an important conduit between the state government and the state’s nursing and midwifery cohort. We support this role and have a keen interest in ensuring OCNMO and the QNMU maintain a strong and productive relationship. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 29

PART 3:

GOVERNANCE AND ACCOUNTABILITY

PART 3: GOVERNANCE AND ACCOUNTABILITY

Hospital and Health Services

The National Health Reform Agreement (NHRA) sets out roles and responsibilities for the Commonwealth and State governments in providing health services. Each State is responsible for establishing the legislative basis and governance arrangements of public hospital services, which includes the Hospitals and Health Services (HHS). In Queensland, the Hospital and Health Boards Act 2011 (the Act) and the Hospital and Health Boards Regulation 2012 form the legislative framework for the establishment of a public sector health system delivering high quality hospital and health services to the community. A major objective of the Act was to devolve governance functions, powers and decision-making to the boards and Chief Executives in charge of each of the 16 HHSs. The Act provides specific governance mechanisms in the form of committees and links with the Department of Health (DoH) as a state-wide system manager to maintain ‘balance’ between HHSs postdecentralisation. Theoretically, the new structure aimed to devolve decision-making to HHSs in order to be ‘closer to the patient’ while allowing the DoH to provide the overarching

consistency of service for patients, maintain standards of safety and quality, and provide transparency and funding sustainability. However, serious governance and performance failures demonstrate significant threats to achieving this objective. If no one party can be held responsible, there is clearly an inherently weak governance structure and ineffective strategy for aligning risk management processes with a single point of accountability. Although there are arrangements, processes and tools for managing risk at both the central and devolved levels, in practice, there is often ineffective correlation between the DoH and HHS. A decentralised health system such as Queensland’s creates a number of further challenges. The wide variation in service provision impacts upon nursing and midwifery workloads and thereby creates disparity in patient outcomes, which inevitably leads to organisational inefficiency. The risk of negative patient outcomes is further increased when some HHSs remove their executive nursing and midwifery leadership positions at a time when other state health entities are seeking to optimise the role of nursing in service provision. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 31

PART 3: GOVERNANCE AND ACCOUNTABILITY

There is further inconsistency in compliance across HHSs where some have failed to implement the prescribed safety and quality committees, a vital component for enhancing patient outcomes and the health of the Queensland community.

funding, where some HHSs are funded on an activity-based system, while others are funded through a fixed amount. The danger of such a varied funding arrangement is the creation of a health system that lacks equity and consistency.

The demographics of the state also create challenges and potential inequity in

A centralised clinical governance framework shared across all HHSs would improve access, equity, cost-effectiveness and consistency of all health services provided across Queensland. The QNMU recommends: ■■ the DoH commission an independent review of risk management procedures in the HHS and the DoH to determine specific, aligned points of accountability, and

TO RR ES AND CA PE

■■ HHSs undertake internal restructuring to provide nurses and midwives with more autonomy, authority and career paths.

CA IR N S AND D H IN TE RL A N

T N O RT H W ES

TO W N SV IL

LE M ACK AY

CE N TR A L ND Q U EE N SL A

ES T CE N TR A L W

T SO U TH W ES

W ID E BAY

DA RL IN G D OW N S

S U N S H IN E COAST M E TR O N O R TH M E TR O S O U TH

WEST M O R E TO N

32 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

G O LD COAST

PART 3: GOVERNANCE AND ACCOUNTABILITY

Transparency in private health services For a number of years, the QNMU has sought information on private health facilities from the Private Health Regulation Unit (PHRU) and through Right to Information processes. We have pursued this course of action as a means of remedying serious problems our members have identified in private health facilities. These measures have confirmed our initial belief that although the written regulations for private health are robust and the sector provides copious reports, a lack of transparency and an inability to obtain vital information that is in the public interest continues to impede our efforts.

We recommend Queensland Health: ■■ investigate whether the level of resources and independence of the PHRU is appropriate for it to carry out its statewide regulatory function properly ■■ requests the PHRU to provide more detailed information on private health facilities on its website ■■ publishes the outcomes of the PHRU’s audit reports ■■ publishes the process and outcomes the PHRU or the Department of Health (DoH) follows where there is non-

compliance with the Clinical Services Capability Framework (CSCF) ■■ includes the QNMU and other relevant stakeholders in compliance measures ■■ involves the QNMU and other relevant stakeholders in any review of the Private Health Facilities Act 1999, and ■■ seeks changes to the Right to Information Act 2009 to include the Mater Public Hospital as an entity to which the Act applies.

...although the written regulations for private health are robust and the sector provides copious reports, a lack of transparency and an inability to obtain vital information that is in the public interest continues to impede our efforts. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 33

PART 3: GOVERNANCE AND ACCOUNTABILITY

Public reporting

Public reporting affects the health system performance in two main ways. Increased knowledge of a healthcare providers’ performance can help consumers make informed choices, and increased knowledge of their own performance can inform healthcare workers’ quality improvement activities. Public reporting strengthens quality improvement and clinical outcomes. Success factors include: ■■ a centralised, independent agency to coordinate public reporting ■■ standardised measures ■■ evidence-based, culturally relevant reports ■■ transparent principles and methodology ■■ relevant and meaningful content, and ■■ public engagement. There are a number of initiatives across Australia which drive improved healthcare quality and patient safety outcomes and accessible information for stakeholders in the public and private sectors, including: ■■ Australian Charter of Healthcare Rights ■■ Australian Safety and Quality Framework for Health Care ■■ Australian Safety and Quality Goals for Health Care 34 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

■■ National Safety and Quality Health Service Standards, and ■■ Australian Institute of Health and Welfare’s (AIHW) various reports. In aged care, the Australian Aged Care Quality Agency (AACQA) accredits Australian Government-subsidised aged care facilities, conducts quality reviews of home care and Aboriginal and Torres Strait Islander flexible care services, provides compliance monitoring, information and training to providers and works with the community to promote quality care for older Australians (AACQA, 2017). Compared to the acute sector (particularly the public acute sector), there is a paucity of safety and quality data available from the predominately privately provided aged care sector. As regulatory control of the aged care sector is largely (though not exclusively) a role of the federal government, data sources are compiled at a national level. Reporting is clearly a priority across jurisdictions. Unfortunately, although standards and mechanisms abound there are still gaps, inconsistencies and a lack of transparency that is both costly and inefficient.

PART 3: GOVERNANCE AND ACCOUNTABILITY

The QNMU eagerly awaits the release of the report on consultations about public reporting commissioned by Minister Cameron Dick in 2017.

The QNMU seeks: ■■ legislated, mandatory participation of public, private and aged care sectors in the public reporting of contemporary, meaningful patient/resident safety and quality indicators ■■ the establishment of a Health Performance Commission, a specialist health data analytics and performance reporting body independent from Queensland Health responsible for:

◆◆ mapping and co-ordinating the collection, analysis and publication of health data across the public, private and aged care sectors to enable value-based health care ◆◆ managing end-to-end data, working from collection to publication ◆◆ linking hospital and health data with other economic and social data as an evidence base for value based health care and new health programs, and ◆◆ developing the quality of clinical performance indicators for valuebased health care.

NURSING AND MIDWIFERY IN QUEENSLAND (2018) 35

PART 3: GOVERNANCE AND ACCOUNTABILITY

Public Private Partnerships

Debate on the role of government and the private sector in funding infrastructure and service provision is long overdue. We accept there is a legitimate role for the private sector in infrastructure provision. However, the current policy framework for Public Private Partnerships (PPPs) is not transparent or consistently applied across jurisdictions in Australia. Patient-centred care must be the key focus of PPPs, not profit. Patient-centred care is respectful of, and responsive to, the preferences, needs and values of patients and consumers. Patientcentred care improves the patient care experience and creates public value for services.

health sector on future health service delivery, we contend Queensland Health should develop a standardised publicly available cost/benefit analysis tool so interested parties can make an assessment of each proposal and Queensland taxpayers receive value for money. Further to this, all future contracts with private providers to deliver public health services must maintain public sector standards on matters such as access to information by the public, especially in relation to adverse incidents and health outcomes. Transfer of funding between the federal and state governments and other contractual arrangements involving government spending must also be open and transparent to public scrutiny.

When healthcare administrators, providers, patients and families work in partnership, the quality and safety of health care rises, costs decrease, provider satisfaction increases and patient care experience improves. Patient-centred care can also positively affect business metrics such as finances, quality, safety, satisfaction and market share. Before embarking on partnerships or contractual arrangements with the private 36 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

Patient-centred care must be the key focus of PPPs, not profit.

PART 3: GOVERNANCE AND ACCOUNTABILITY

Deficiencies in the regulatory framework for Health Practitioners The QNMU supports an effective and efficient health complaints system that provides for protection of the community, and fairness to health practitioners. We recognise the need for a regulatory body to oversee the health system, however, the establishment of the Office of the Health Ombudsman (OHO) in effect created another regulator for regulated health practitioners when the Australian Health Practitioner Regulation Agency (AHPRA) and the Nursing and Midwifery Board Australia (NMBA) already have the power and resources to operate for this purpose. In our view, the OHO: ■■ has not improved the timeliness or consistency of decisions ■■ has led to duplication of effort, and ■■ may be a useful regulatory body for unregistered practitioners, but on current performance appears to be an unnecessary additional level of regulation for individual matters affecting registered health practitioners. While the OHO has an important role investigating complaints, we have a number of concerns.

We have recommended to the Queensland government that: ■■ All notifications related to individual registered health professionals should be made directly to AHPRA. Where AHPRA receives a complaint against a number of individual practitioners regarding the same incident or circumstances, it could simultaneously refer the matter to the OHO for investigation into a possible systemic failure. AHPRA should be fully resourced to carry out this function. ■■ AHPRA undertakes the regulation of all unregistered healthcare workers (however titled). Those who assist Registered and Enrolled Nurses in the provision of nursing care should be registered with the NMBA according to clearly defined NMBAapproved education standards and skill competencies which encapsulate relevant nursing professional standards and accountability. ■■ The OHO should retain responsibility for investigating systemic health matters. Failing implementation of these changes, we recommend: ■■ a more effective triage or assessment process to ensure matters are dealt with quicker and by the relevant body NURSING AND MIDWIFERY IN QUEENSLAND (2018) 37

PART 3: GOVERNANCE AND ACCOUNTABILITY

■■ there is consistency in the type of complaints being referred to AHPRA ■■ there is no duplication of resources in making assessments by both AHPRA and OHO ■■ the OHO should be empowered to grant extensions of time for response ■■ the OHO should be more diligent in observing its own timeframes for action, and ■■ the immediate action provisions should require that a practitioner be afforded an opportunity to respond before action is taken in relation to their registration.

Mandatory reporting The Health Practitioner Regulation National Law Act 2009 (Qld) (the National Law) as in force in Queensland compels health practitioners to notify AHPRA if they engaged in the treatment of other

38 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

health practitioners. In our view, it is not necessary for treating practitioners to make mandatory notifications where the health practitioner is engaged in and compliant with treatment. Mandatory reporting is punitive rather than compassionate. A focus on sanctions is weighted against the practitioner, particularly when they are aware of the need for help but fear retribution. Legislated, compulsory notification can therefore become counterproductive if it deters practitioners from seeking assistance. It is our position the National Law in Queensland should mirror the National Law provisions in Western Australia and provide treating practitioners with a complete exemption from making a mandatory notification of a nurse or midwife who has sought treatment for a health impairment.

PART 4:

KEY ISSUES FOR OUR PROFESSIONS

PART 4: KEY ISSUES FOR OUR PROFESSIONS

Achieving safety and quality of care While the core imperative of improving the safety and quality of health care is increasingly embedded at all levels of service planning, delivery and evaluation within the health system, failures continue to be exposed. Where efforts nationally and internationally have been focused, in part, on specific clinical governance for system safety, the QNMU is concerned the emphasis on safety and quality that has been so critical to producing better patient outcomes in recent times has waned in Queensland. While legislated nurse patient ratios have gone some way to addressing the impact of the significant job losses during the Newman government, these reflect minimum safe staffing levels. Recovery has been slow and workload issues remain, as do concerns about patient safety in the public sector.

SAFETY FIRST

The public reporting of safety and quality in the private sector requires urgent attention and the QNMU has strongly advocated for the state government to mandate robust safety and quality reporting for all sectors, public, private and aged care. Aged care continues to operate with a nursing workforce that is overworked and underpaid and where there is an accelerating trend of loss of Registered and Enrolled Nurses and increased employment of unregulated careworkers 40 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

PART 4: KEY ISSUES FOR OUR PROFESSIONS

to care for an increasingly frail residential aged care population. Currently, national health care worker regulation does not have a licensing regime for care workers who constitute the majority of the aged care workforce.

Patient and resident safety and quality in Queensland Within the Queensland Department of Health, the Clinical Excellence Division has core responsibility for leading and driving excellence in safety and quality across the health system in conjunction with Hospital and Health Services (HHS). Key elements of the division are: ■■ the Healthcare Improvement Unit which works with HHSs, Clinical Networks and other system elements to improve health access ■■ the Patient Safety and Quality Improvement Service which has monitoring role and works with HHSs to minimise patient harm and implement high quality care.

Action report was published in 2011 and believes that this, or similar, initiative should be revisited in the context of transparency and informing the public on the state of safety and quality in the public health system. Currently, patient safety and quality processes occur within a devolved model of health service delivery and governance as a consequence of the Hospital and Health Boards Act (2011). While this structure has been promoted as bringing health service decision making closer to the patient via the Hospital and Health Service Board structure, while allowing the Department of Health to take a system manager role of setting standards, monitoring and governance, the QNMU is concerned that this has not been the case in practice. Rather, the QNMU believes this is an inherently weak governance model which mitigates against effective correlation between the department and HHSs and ultimately against effective safety and quality processes.

Workload management

Examples of the key performance measures used at the state and HHS levels to monitor safety and quality performance include Variable Adjusted Life Displays (VLADS) which identify variation in performance, accreditation compliance, complaints and incident management and mortality.

Queensland Health and the QNMU developed the Business Planning Framework (BPF) in 2001 to address the areas critically important to the nursing and midwifery workforce including workloads, skill mix, patient acuity, and staff training and development.

The QNMU is extremely supportive of government proposals to expand public safety and quality in the private and aged care sectors.

The BPF is a comprehensive planning process that customises the workloads of nurses and midwives to suit the individual circumstances of their clinical environment.

However, the QNMU notes that the last annual Patient Safety – From Learning to

The framework takes into account a variety of environmental factors known to NURSING AND MIDWIFERY IN QUEENSLAND (2018) 41

PART 4: KEY ISSUES FOR OUR PROFESSIONS

affect nursing and midwifery workloads such as models of care, evidence-based practice and organisational policy. Over the years, the BPF methodology has been regularly reviewed and enhanced to ensure it remains applicable and relevant to nurses and midwives and the environment in which they work. A number of initiatives to improve consistency in the application of the BPF have been initiated via industrial processes. These include but are not limited to: ■■ the BPF refinement and enhancement project ■■ development of BPF addendums for speciality areas ■■ establishment of BPF Steering Committees ■■ appointment of BPF resource nursing positions in each HHS ■■ quarterly BPF compliance assessments/ reports, and ■■ development of the BPF 5th edition.

Despite the work undertaken to improve consistency in the application of the BPF, frontline nurses and midwives continued to raise concerns about unsafe workloads. Nurse/Midwifery Unit Managers reported dissonance between the staffing requirements determined by the BPF, and the staffing levels determined through macro-level financial frameworks. Fiscal constraints, limited knowledge/ understanding of the BPF and failure to apply agreed entitlements were noted.

Legislating ratios In 2015, the QNMU launched a major campaign, Ratios Saves Lives, to strengthen workload management methodologies for nurses and midwives across Queensland. The primary focus of this campaign was to seek the legislation of minimum nurse/ midwife-patient ratios in public health, private health and aged care services. The campaign was successful in the public sector with the passing of legislation that permitted the implementation of ratios in

QNMU Beth Mohle speaking at Parliament House after witnessing this historic moment for nurses and midwives when the ratios bill was introduced into parliament.

42 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

PART 4: KEY ISSUES FOR OUR PROFESSIONS

prescribed medical/surgical wards and two acute mental health wards from 1 July 2016. The implementation of ratios in Queensland is distinct from other jurisdictions using this methodology because the legislated ratios are used to underpin the BPF. The primary benefit of combining ratios with the BPF is that the BPF allows the number of patients allocated to a nurse/ midwife to be adjusted above the legislated ratio in accordance with variables such as patient activity/acuity and staff skill mix. Ratios and the BPF are complementary. This means they provide mutual benefits, which are capable of mitigating the known inconsistencies in the application of the BPF, particularly in relation to calculation of nursing hours required to meet service demand.

Improving workload management Statewide generic BPF review

In March 2017, following a formal request by the QNMU, the Director-General, Department of Health provided the authority for a statewide review of BPF compliance. HHS review teams were formed, which included QNMU organisers and workplace representatives. A variety of services participated in the review, which involved inpatient general wards, inpatient/ outpatient specialty services, community services and correctional services. The statewide generic BPF review delivered a variety of outcomes, both positive and negative. Significant variations in the application of the BPF were noted at both facility and service line level. A summary of key findings and outcomes of the statewide generic BPF review was

compiled from the feedback received from QNMU organisers and workplace representatives who participated directly in the statewide generic BPF reviews. The review revealed a number problems or inconsistencies in the calculation and application of the BPF including, but not limited to, the use of inconsistent/inaccurate methods to calculate productive hours and sick leave, problems translating skill mix requirements to actual hours and FTE, rostering gaps and failure to apply best rostering practices, insufficient backfill for certain positions, widespread non-compliance to proper application of multipliers, failure to approve service profiles within set timeframes, and inconsistent operationalisation of BPF Steering Committees. Poor application of the BPF significantly limits the ability of Queenslandâ&#x20AC;&#x2122;s public health services to deliver safe, high quality midwifery services on a consistent basis. Recommendations to improve the application of the BPF were developed during joint roundtable discussions with frontline users. These recommendations were endorsed by the Director General, Department of Health in October 2017. The Nursing and Midwifery Implementation Group (the peak central consultative committee for nursing and midwifery issues in Queensland Health) will work with local Nursing and Midwifery Consultative Forums to oversee the implementation of these recommendations across Queensland Health. The QNMU supports QH in undertaking regular statewide reviews of BPF compliance as a quality improvement and assurance activity. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 43

PART 4: KEY ISSUES FOR OUR PROFESSIONS

Ratios Save Lives Phase 2 National and international studies have irrefutably proven that the number, skill mix and work environment of nurses and midwives directly affects the safety and quality performance of health services. While most medical and surgical wards in Queensland Health now have legislated minimum ratios, there are numerous other nursing and midwifery services operating without this safety net. It is time to reflect upon the lessons of the first phase of ratios implementation to enable refinement and expansion of legislated ratios across Queensland. The Ratios Save Lives Phase 2: extending the care guarantee document clearly outlines the expectations that the QNMU have in relation to the refining and expanding legislated minimum ratios in a wide range of services based on reference sources such as the Safe Workloads in Midwifery (SWiM) standard for maternity services and the ANMF Aged Care Report on minimum staffing and skill mix levels. The SWiM standard has seven principles, one of which refers to the need for: ■■ 1:1 ratio in active labour ■■ 1:30-1:40 ratio for caseloads ■■ 1:4-1:6 ratio for inpatient units (counts mothers and baby as two) ■■ 1:5 ratio for postnatal home visits/day For residential aged care facilities, the ANMF research findings have concluded that the minimum care requirement is 4.30 resident care hours per day with a skill mix of 30% Registered Nurse, 20% Enrolled Nurse and 50% Assistant in Nursing/ Personal Care worker. 44 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

There is a definite need to improve the practical day-to-day application of ratios as well as improve compliance monitoring and the public reporting of safety and quality performance indicators to ensure the operational value of ratios is fully realised and acknowledged. The QNMU recommendations for refinement of the current ratios legislation include: ■■ All ratios must be applied in an absolute manner. ■■ Staffing requirements must be ‘rounded up’ not ‘rounded down’. ■■ Team leaders must always be excluded from direct ratios. ■■ Parameters for determining prescribed wards must be defined in the regulation. ■■ Minimum requirements for public reporting of ratios compliance and outcomes must be contemporary and represent the interest of the patient, staff and organisation. Improved compliance with the BPF is also expected to augment the effect of legislated ratios on nursing/midwifery workloads. The BPF allows the number of patients allocated to a nurse/midwife to be improved beyond the legislated ratio in accordance with variables such as patient activity and acuity.

Contemporary public reporting Research has found that healthcare services with well-structured public reporting processes achieve better outcomes in clinical quality and overall organisational efficiency than those services using a penalty-based system alone.

PART 4: KEY ISSUES FOR OUR PROFESSIONS

While public reporting of ratios compliance is included in the current legislation, the lack of specific details about what, where and when the data should be reported has led to substandard reporting practices.

equip midwives, managers and executive level midwives with a framework for establishing safe work environments and sets out eight key principles for achieving a safe work environment for Queensland midwives.

The QNMU recommends the following quality indicators are used as a basis/ minimum for the public reporting of patient/ resident safety and quality indicators: ■■ nurse/midwife staffing numbers

We believe it should be used as a reference for the BPF during the development of service profiles and to establish the notional ratio in maternity services across Queensland.

■■ nurse/midwife skill mix levels

Why is it needed?

■■ nursing/midwifery process

The most prevalent model of maternity care in Queensland is a shift work medical model where midwives staff maternity units across the 24-hour cycle.

■■ nursing/midwifery workload concerns ■■ patient/resident health outcomes, and ■■ patient/resident/staff satisfaction. Further investment is required to develop linked minimum nursing/midwifery data sets to collect information about specific structure, process and quality outcomes of individual nursing and midwifery services. Consideration must also be given to the causal relationship professional judgement has with the structure, process and quality of outcomes within health services and how linked minimum data sets can be used to highlight this connection.

Safe workloads in midwifery (SWiM) A safe practice environment was one of the key concerns identified by participants at the 2016 Midwifery Summit and recognised as one of the main problems for midwifery workforce retention. As a result QNMU in consultation with midwives and supported by the Australian College of Midwives developed the SWiM Standard. The Standard is designed to

However, acuity in maternity care is increasing and intervention rates are skyrocketing, but the workforce has not grown to accommodate the heavier workload. As many as one woman for every three have undergone a caesarean section in public hospitals without any resulting improvement in the health and wellbeing outcomes of women and babies. The rates are higher in private hospitals. Increased surveillance during pregnancy, birth and the postnatal period also increases workloads. For example routine screening for diabetes in pregnancy leads to higher rates of intervention for both the mother and the baby and can result in heavier and more complex care provision. There is also an increasing burden on midwives through policy and guideline driven care, and the proliferation of paperwork and digital technologies leaves little time for being “with women”. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 45

PART 4: KEY ISSUES FOR OUR PROFESSIONS

Nursing and midwifery excellence

Nursing and midwifery excellence is a shared commitment of Queensland Health and the Queensland Nurses and Midwives’ Union (QNMU) as outlined within a number of Enterprise Bargaining Agreements including, EB8, EB9 and the pending EB10. Nursing and midwifery excellence provides the fundamental foundations for the delivery of safe, high quality consumerfocused care across healthcare services. The overarching objectives of nursing and midwifery excellence include: ■■ supporting and improving the delivery of safe, high quality patient care across Queensland ■■ developing and retaining high performing nursing and midwifery services ■■ leading and influencing nursing and midwifery’s contribution in health service delivery and design ■■ developing and progressing opportunities for interprofessional clinical collaboration, and ■■ positively contributing and growing organisational commitment to safety and quality. The framework for delivering nursing and midwifery excellence is based on seven individual components typically 46 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

found within strategic professional practice models — leadership, independent practice, collaborative practice, work environment, development and recognition, research and Innovation, and of course patient outcomes.

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These components can easily be used by local health services to assess, plan, implement and evaluate the progress of nursing and midwifery excellence in respect to achieving strategic directions and key performance outcomes. Nursing and midwifery excellence is an investment in an innovative, sustainable healthcare system that delivers safe services of the highest quality for all Queenslanders.

Positive practice environment Nursing and midwifery excellence significantly contributes to positive work environments. Research tells us that health services with positive work environments deliver care that is safer and of higher quality than those services with poor work environments — the better the work environment, the better the patient outcome. A positive work environment for nurses and midwives includes: ■■ having the right number and skill mix of nurses/midwives available to meet service demands ■■ collaborative/productive relationships with other health professionals ■■ participation in organisational policy and decision-making ■■ access to quality data relevant to nursing and midwifery services ■■ having a management team that is responsive to patient care problems identified by frontline staff ■■ participation in mentoring, clinical supervision and reflective practice, and ■■ ability to feel safe at work, speak out and ask for help — psychological safety.

Supporting and strengthening the work environment for nurses and midwives should be a major priority when developing policy, industrial agreements and legislation that affect the delivery of health services.

Expanded roles for nurses and midwives Nurse and midwife prescribing

The NMBA is currently facilitating the development of a nationally consistent model of prescribing for nurses and midwives. The NMBA is authorised to endorse the registration of RNs as qualified to administer, obtain, possess, prescribe, supply or use scheduled medicines if they meet the requirements of the respective registration standards. The NMBA proposes to expand the registration standard to include midwives and to enable RNs other than Rural and Isolated Practice Endorsed Nurses (RIPENs) to be able to supply medicines under protocol. RIPENs provide emergency and primary healthcare in an advanced and expanded clinical scope of practice to patients in rural and remote (isolated) areas. This may occur in isolation or in a collaborative environment with other health professionals. The NMBA aims to discontinue the RIPEN endorsement, as the relevant legislation and policies in the majority of Australian states (except Queensland and Victoria) facilitate the safe supply of medicines under protocol. In Queensland, the Chief Executive of Queensland Health gives authority for RIPENs to obtain, supply or administer NURSING AND MIDWIFERY IN QUEENSLAND (2018) 47

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medicines under the Health (Drugs and Poisons) Regulation 1996 Queensland (HDPR) conditional upon the RIPEN being ‘endorsed’. If the NMBA withdraws endorsement more than 800 RIPENs will not be authorised to carry out this function unless there are consequential changes to the HDPR. While we see there may be opportunities for new nurse-led models of care under the proposed prescribing regime, in effect, the QNMU cannot give support unless we have a level of certainty the HDPR will be amended to facilitate the seamless transition of RIPENs by November 2018, the proposed date of effect. We have requested the NMBA maintains a specific registration standard for RIPENs in Queensland until such time as the legislation is amended. However, we have not received any assurances this will happen. Therefore it is with urgency we ask the Minister to arrange amendments to the HDPR to ensure RIPENs are not deskilled and the communities they serve are not disadvantaged.

Nurse Navigators Nurse Navigator is a role that has been introduced into the Queensland public health sector to support patients with complex health conditions ‘navigate’ the health system as a whole, rather than focusing on any one aspect of the patients health service needs. Nurse Navigators play a coordinating role as patients move to and from primary to hospital care and across service providers with a focus on safety and quality of care. 48 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

The benefits of this approach are more integrated, and timely care, as well as supporting patients to more effectively manage their own health needs and equip them with the skills and knowledge to better use the health care system. Initially, 400 Nurse Navigators were funded in the 2015 state budget, with the government pledging permanent funding of these positions as part of 2017 pre-election commitments. Approximately 240 Nurse Navigator positions have been employed to date. Oversight of the Nurse Navigator program is via the Nurse and Midwife Navigator Reference Group and Navigator Network supported by the Office of the Chief Nursing and Midwifery Officer (OCNMO). The QNMU is a member of the reference group Again, the QNMU is concerned that the development and implementation of the navigator role is made more complex by the devolved Queensland health service delivery model and the need to negotiate with numerous statutory health services. A focus of the QNMU has been to ensure that all navigator positions are recruited in a timely manner and the role is consistently implemented across all Hospital and Health Services.

Midwifery models of care The QNMU Check in on midwifery report published in September 2016, highlighted a range of pressing midwifery matters in Queensland, particularly around workloads, skill mix and models of care which remain unresolved.

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It noted, among other things, that: ■■ only 10.3% of midwife respondents were able to satisfactorily complete their job always or nearly always in the time available ■■ 5.8% of midwives felt there were enough midwives available always or nearly always to meet the needs of mothers and babies, and ■■ 6.88% of midwives felt that the skill mix of midwives was always or nearly always sufficient to meet the needs of mothers and their babies. This indicates the current high intervention, high cost models of maternity care are not serving mother, child or midwives well and supports our long held belief that Queensland must: ■■ improve access to midwife-led continuity models that meet consumer demands by enabling positive practice change through legislative/regulatory reform, promotion of professional standards, modification of the cultural environment, better workforce planning and development of funding incentives, ■■ establish within OCNMO expertise specific to implementation, education and support of midwifery continuity of care models to support the expansion of models of midwifery care ■■ improve the ability of midwifery services to meet community needs by ensuring consumer involvement in all aspects of planning and evaluating maternity services.

Models of care Caseload care is a model of maternity care where women have a primary midwife

assigned to them throughout pregnancy, labour and birth and the postnatal period. Each midwife has an agreed number (caseload) of women per year and acts as a second or “back-up” midwife for women who have another midwife as their primary carer. Midwifery Group Practice means a number of groups of two three caseload midwives working together. Each pair or group of three may work with other pairs or groups of three to support matters such as emergent leave, periods of fatigue but this does not extend to routine on call. Primary midwife means the named midwife responsible for providing the majority of a women’s care. Women have direct contact with their primary midwife who is on call for them for the majority of the time. Team midwifery means a team of up to six to eight midwives who delivery care to a group of women. Team midwives work in shifts, and rotate across the antenatal, intrapartum and postnatal stages of care. On call periods are rostered across the whole team. Core midwifery are midwives within a maternity unit who do not participate in team midwifery or caseload/group practice models. Core midwives may be based in one area (antenatal, labour and birth, or postnatal) and may not necessarily follow the same group of women throughout the child bearing period. They work shift work and are most likely working under a medical model. Private Practice Midwifery means the midwife has achieved significant levels of legislative and regulatory imperatives NURSING AND MIDWIFERY IN QUEENSLAND (2018) 49

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that enable her to prescribe and access Private Indemnity Insurance. They have access to MBS/PBS, and may have access to visiting arrangements, credentialing and collaborative arrangements.

Midwifery: working to full scope Queensland Health has had a level of success in finding innovative ways of increasing women’s access to midwifery care. These include visiting rights for midwives, credentialing as a collaborative arrangement and midwives working in 19 (2) exemption sites attracting Medicare rebates for care for the facility. The QNMU is investigating strategies through EB10 negotiations to remove considerable barriers that prevent midwives working to their full scope of practice. This is especially problematic for midwives with notation (who gain MBS/PBS provider numbers), the vast majority of whom are employed by QH yet are denied the ability to work to their full scope. Through EB10 negotiations, an inprinciple agreement has been reached to address these barriers to enable midwives with endorsement to prescribe scheduled medications and order diagnostic investigations. We must increase the accessibility to midwives for women across all HHSs, which will also increase the ability to maintain an expert clinical workforce, improve the health and wellbeing of mothers and babies, and decrease health costs. If these EB10 strategies fail to address these significant issues, another option is to enable midwives’ rights to private practice (RTPP) in Queensland public hospitals. 50 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

This would be similar to the medical model of RTPP where a client can choose to be cared for as a public or private patient. If they choose private then the midwife continues care and the health service remunerates the midwife and retains the financial benefits (Medicare and health fund). The clients are very clearly informed of their choice and any costs therein. In both the National Health Reform Agreement and the Australian Health Care Agreements, the Commonwealth and States agreed that people can choose to be a private patient in a public hospital and that the public hospitals can charge for these private patients at a fee set by each State. Midwives with notation are well suited as public employees to provide public and private services in the same contractual and governance frameworks as Medical professionals can do within Queensland Health. Enabling midwives to work to their full scope in public hospitals will increase women’s access to midwifery services – a key objective of national Maternity reform measures. We propose that midwives be able to provide: ■■ outpatients clinics ■■ telehealth services ■■ private admitted inpatient services ■■ pharmaceutical services to non-admitted private patients, will be claimed against the PBS. Care provided by another midwife under the supervision of the PPM should also be Medicare rebatable.

PART 4: KEY ISSUES FOR OUR PROFESSIONS

Collaborative arrangements In order for a woman to be able to claim Medicare rebates for private midwifery, the midwife must have a collaborative arrangement in place. Until 2013, there were four processes that enabled midwives to meet this requirement: ■■ Being employed by an obstetric practice ■■ Having women are referred to them in writing by a medical practitioner ■■ Having a formal written collaborative agreement with one or more specified medical practitioners ■■ Having a written collaborative arrangement outlined in a specific way in the midwives’ notes. In 2013 an additional collaboration (hospital credentialing) was included. There was no evidence the legislative requirement for collaborative arrangements was needed. In fact there is strong evidence to indicate that it has decreased collaboration as medical doctors overwhelmingly refused to enter into collaborative arrangements with midwives. Doctors cite concerns around legal responsibility. It was clear in the US that insurers did not want doctors to sign agreements, and the language regarding liability and responsibility is peppered through Australian medical documents regarding collaborative arrangements. Doctors also see it as a form of supervision, and therefore concomitant legal responsibility. There are a raft of other reasons why requiring this in law is inequitable and overtly unworkable including the simple

fact that many medical doctors fail to understand the role of nurses and midwives. The end result is the professional midwife’s ability to provide private services becomes beholden to the medical practitioners’ beliefs or interest rather than professional collegiality. Furthermore, it means the communities that might benefit most from the services of these midwives are denied access. The QNMU believes that the National Health (Collaborative arrangements for midwives) Determination 2010; National Health (Collaborative arrangements for Nurse Practitioners) Determination 2010 and the National Health (Collaborative arrangements for midwives) Amendment Determination 2013 remain barriers to midwives in private practice being able to securely set up businesses to provide care to women. It is our view that collaborative arrangements be removed from legislation as a matter of urgency and that the established professional frameworks for collaborative collegiality instead be the criteria from which a midwife, Nurse Practitioner, medical officer or any health care professional can be mediated. Professional collaborative partnerships are already well defined and established across the regulatory bodies for nursing and midwifery, and defined and agreed upon by the key midwifery and nursing, and medical professional bodies at a national level (the National Health and Medical Research Council (NHMRC).

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Workplace health and safety and occupational violence The QNMU remains focussed on the management of Occupational Health and Safety within Queensland’s Hospital and Health Services, particularly the ongoing high levels of exposure to occupational violence in the workplace. We acknowledge significant efforts in managing this specific problem since 2015 and broader changes to health and safety legislation. These efforts are focussed on the rollout of recommendations from the May 2016 Occupational Violence Prevention in Queensland Health’s Hospital and Health Services Taskforce report and the 2017 Best Practice review of Workplace Health and Safety Queensland. The former report’s recommendations are being overseen by the State Wide Occupational Violence Implementation Committee and a number of working groups sitting beneath this committee. Despite these efforts, QNMU members continue to be injured as a result of assaults perpetrated by patients/aged care residents and families of same. We therefore seek to reinforce our view that all the recommendations of the taskforce report need implementation and commensurate funding. 52 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

One barrier identified by the QNMU in a consistent widespread rollout of the recommendations is difficulties exposed by the status of prescribed health services that, in practicality, means each Hospital and Health Service can choose whether to adopt the work of the implementation committee or not. Whilst acknowledging significant progress in different clinical environments, the tension between clinical professional practice and their rights around health and safety remains. This is of particular concern in Aged Care and Mental Health Services. In a broader examination of legislative changes introduced in 2017 which reinforced the role of Health and Safety Representatives and provide for increased training opportunities, the QNMU and its members look to progress health and safety improvements. This, combined with an increased focus of the inspectorate on the wider healthcare and social assistance industry sector. We believe this will lead to improvements in health and safety outcomes for the health workforce.

PART 4: KEY ISSUES FOR OUR PROFESSIONS

Primary and preventative health

Mental health The success of national and state mental health funding and care models hinge, wherever possible, on the recovery and reintegration of people with mental illness into their communities. The key principles of the National Standards for Mental Health Services 2010 are fundamental to providing mental health care, and note that the treatment, care and support of the mentally ill should be tailored to meet the specific needs of the individual consumer.

These principles are complemented by the Australian Governmentâ&#x20AC;&#x2122;s National Practice Standards for the Mental Health Workforce 2013 which recognise the importance of the practitionerâ&#x20AC;&#x2122;s empathy, understanding and expert knowledge as being critical to successful outcomes. They also recognise the growth of mental health care provision in the nongovernment and private sectors, along with an increased focus on the role of the primary care sector. They apply to all disciplines working within mental health,

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including nurses, who make up the bulk of the mental health workforce. These Practice Standards are listed in Queensland’s Clinical Services Capability Framework as a non-mandatory standard. The view of QNMU is that the Practice Standards should be listed in the mandatory standards in the CSCF’s Mental Health module that includes the National Standards for Mental Health Services 2010.

Workforce When it comes to providing a mental health nursing workforce for clinical care, Queensland is well below the national average and has the second lowest number of mental health nurses per capita of any state or territory, ahead of only the ACT. This has been a consistent trend for several years, despite marginal increases in Queensland’s figures. The Australian Institute of Health and Welfare figures from 2015 (latest available) show that Queensland’s clinical FTE for mental health nurses was 71.4 per 100,000 population, whereas the national average was 77.2. Western Australia, which has similar rural and remote communities to Queensland, has 88 clinical mental health nursing FTE per 100,000 population. The AIHW data defines a mental health nurse as one who indicates that their principle area of work is mental health. It is unknown how many of those nurses are qualified in mental health or psychiatric nursing. Anecdotal information from our members indicates that the number of nurses working in mental health without any qualifications 54 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

or formal education in mental health is increasing at an alarming rate. They are being put on the floor with responsibility for a number of mentally ill patients after only a few days’ training. In our members’ view, undergoing a mental health first aid course alone is not sufficient for successfully nursing in the mental health inpatient setting. The QNMU recommends a lengthy period of supernumerary supervised practice is essential for a successful transition into the mental health nursing workforce. We will be happy to work with Queensland Health on the development of a mentoring and preceptorship program for generally trained nurses wishing to work in mental health. Of further concern is that almost 60% of nurses working in mental health are aged over 45 and more than half of them have reached preservation age for accessing their superannuation (55+ in 2015). Many of these nurses are likely to be mental health qualified. The Queensland Government’s recently released document Advancing health service delivery through workforce: a strategy for Queensland 2017-2026 does not contain any strategies specific to the mental health workforce, despite Queensland consistently lagging behind most of the country in this area. The QNMU implores the Department of Health’s Workforce Strategy Branch to scrutinise the current mental health nursing workforce and develop strategies that are specific to this ageing cohort that is becoming increasingly de-skilled as qualified mental health nurses steadily leave the workforce.

PART 4: KEY ISSUES FOR OUR PROFESSIONS

The QNMUâ&#x20AC;&#x2122;s current Ratios Saves Lives campaign has a focus on Mental Health nurse staffing in both the public and private sectors. This staffing profile has been developed by experienced nurse clinicians and managers. The Department of Health is strongly advised to refer to this staffing ratio and methodology when considering its workforce needs for mental health services now and into the future.

Young persons The closure of the Barrett Centre by the Newman Government in 2014 resulted in tragic outcomes for three of its former patients. However, Queensland is still awaiting the provision of a purpose-built centre for the rehabilitation of severely mentally ill young persons. Funding for a new centre was announced in 2016 with a construction commencement date of late 2017. Preliminary works on the new centre were announced in January 2018, with a proposed completion date of January 2020. The new centre is sorely needed and it would be disappointing to see any phase of the construction delayed. In the interim, Queensland Health should be considering the highly-skilled workforce that will be required for such a modern unit with contemporary models of care and any training that staff will need to therapeutically engage their clients. Regarding children and young personâ&#x20AC;&#x2122;s mental health, it is imperative that there are sufficient inpatient, outpatient and day and residential programs and units available with sufficient capacity to meet demand.

It is widely recognised that early intervention in mental illness is a key to long term quality of life and reduced need for services. Providing best practice mental health services for children and youths is essential for the patient, the family and the community as a whole, and could have long term benefits for adult mental health cost efficiencies through significantly reduced presentations.

Occupational violence Occupational violence is a serious concern for many mental health nurses in Queensland. Nurses are assaulted by patients at an alarming rate and thus far the Departmentâ&#x20AC;&#x2122;s response has been less than adequate. Of major concern is that Hospital and Health Services across the state have no formal policy on how staff are to be supported after being assaulted by a patient. Generally, the only avenue nurses have for assistance with their injuries, both physical and psychological, are WorkCover processes. Further, our members report that there is very little training being provided in deescalation techniques for when presented with a potentially aggressive situation. Such techniques are essential in minimising the occurrence of seclusion and restraint, one of the aims of the new Mental Health Act. We strongly encourage the Department of Health to ensure that all nurses working in a mental health setting receive best practice, competence-based training in the deescalation of aggression on a regular basis. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 55

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Mental Health Commissioner When the concept of establishing a Mental Health Commissioner role was first floated, the QNMU was hopeful the role would have the scope and capacity to work collaboratively with mental health stakeholders, including the QNMU, to drive mental health reform in this state. In our submission in support of establishing the role, we stated that the scope and functions of the commission should provide a unique opportunity to influence policy development in the area of research for evidence-based care, to encourage cooperation and collaboration across agencies and departments and to monitor the impact of evidence-base practice on patient outcomes.

disease, type 2 diabetes, some musculoskeletal conditions and some cancers (AIHW, 2017). 63% of Australians are now overweight or obese (ABS, 2015). Consumption of highly processed and energy-dense food such as sugar-sweetened drinks is a major factor driving this condition. The QNMU supports urgent examination of a tax on sugar-sweetened beverages as a means of curbing obesity. In conjunction with this we recommend governments consider the full range of available measures to improve nutrition including education, food literacy and restriction on advertising to children.

However, the eventual model selected for the role of the Mental Health Commissioner and the operating practices so far have failed to meet these expectations. We strongly urge the Mental Health Commissioner to consider the QNMU and its members as significant stakeholders in ensuring that mental health services are capable, sustainable and engaging best practice principles.

Sugar tax Good nutrition is an important public health issue. Well balanced, adequate food intake contributes to growth and development in infants and children and good health in adults. Poor nutrition can reduce immunity, increase susceptibility to disease and impair physical and mental development. Excess weight, especially obesity, is a major risk factor for cardiovascular 56 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

The QNMU supports urgent examination of a tax on sugar-sweetened beverages as a means of curbing obesity.

PART 5:

SOCIAL POLICY PERSPECTIVES

PART 5: SOCIAL POLICY PERSPECTIVES

Social policy perspectives

Value-based health care and the social determinants of health Value-based health care is a framework for restructuring health care systems with the overarching goal of value for patients. It places the consumer at the centre. Internationally in the shift from fee-forservice to value-based care, stakeholders are recognising the need to integrate data on the social determinants of health for better clinical decision support, quality measurement, care co-ordination, and population health management. The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities — the unfair and avoidable differences in health status seen within and between countries. In Queensland, one significant difficulty with implementing value-based health care lies in the medicalised system that has been perpetuated and reinforced through funding models. There needs to be a shift in funding methodology and the support systems 58 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

around funding for value-based healthcare to be successful (consumer versus medical practitioner focused).

Medicinal cannabis There is a growing body of evidence that certain cannabinoids are effective in the treatment of chronic pain, particularly as an alternative or adjunct to the use of opiates. The major therapeutic benefits include relieving nausea and vomiting in patients with cancer, stimulating appetite in patients with cancer and AIDS, and relieving acute and chronic pain, often in combination with other analgesics such as opioids. Controlled trials have also shown the positive effects of cannabis preparations on bladder dysfunction in multiple sclerosis, tics in Tourette syndrome and involuntary movements associated with Parkinson’s disease. In our submission to the inquiry into the Public Health (Medicinal Cannabis) Bill 2016 we stated our support for the licenced and controlled use of medicinal cannabis in Queensland. The Bill was enacted in March 2017, but since then only 11 medical practitioners – all doctors – have been licenced to prescribe medical cannabis.

PART 5: SOCIAL POLICY PERSPECTIVES

There are reports of patients in need being unable to access treatment because of a lack of licenced practitioners and perhaps more prevalent, frustration within the community that the treatment is only available for a small group of patients who conform to a narrow criteria. While we appreciate the need to regulate the use of this treatment we believe there is scope to expand it to a broader range of conditions, and to include Nurse Practitioners (NP) among the medical personnel licenced to prescribe. The framework in the original bill provided a pathway allowing certain specialist practitioners to prescribe medicinal cannabis to patients suffering specific

conditions without the need to obtain any further state approval. We believe NPs should be considered part of this cohort. Furthermore, if the Therapeutic Goods Administration opts to reschedule medicinal cannabis products from a schedule 9 prohibited poison to a schedule 8 medicine then a NP may be authorised under Queensland law to prescribe schedule 8 medicinal cannabis products within their scope of practice as a matter of course. As stated in our submission, NPs are already educated and authorised to prescribe schedule 8 drugs. They are Masters degree level practitioners and their scope of practice is built on the platform of the RN scope of practice. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 59

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We also envisage a role for Rural and Isolated Practice Endorsed Nurses (RIPENs) in the supply and administration of medicinal cannabis in rural and remote areas, particularly where an ‘approved pharmacist’ is unavailable. RIPENs are authorised, educated and competent to practice. The RIPEN provides emergency and primary healthcare to an advanced and expanded clinical scope of practice to patients in rural and remote (isolated) areas. This may occur in isolation or in a collaborative environment with other health professionals.

Assisted dying The QNMU supports legislative reform enabling persons who have an incurable physical illness that creates unrelieved, unbearable and profound suffering to choose to die with dignity in a manner acceptable to them and is not compelled to suffer beyond their wishes. Where a person expresses a wish for assistance to die, nurses should be educationally prepared to discuss the legal and medical parameters of this request as well as other options available to the person or seek the assistance of knowledgeable health care professionals. Nurses and midwives have the right to conscientiously object to participation or involvement in assistance with dying.

Abortion law reform The QNMU believes women should have access to: ■■ legal and safe abortion ■■ reliable, safe and affordable contraception 60 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

■■ information and services to support adoption or maintaining a pregnancy, and ■■ appropriate sexual and reproductive health and information. As Queensland is one of only two states in Australia where abortion is still a criminal offence we support removal of sections 224, 225 and 226 of the Criminal Code 1899 (Qld) (the Code) so that women and those who assist them are free of prosecution. The Code is not the appropriate mechanism for regulating a medical procedure. Abortion provisions should be removed from this legislation and remain subject to appropriate health regulations. Nurses and midwives have the right to conscientiously object to participation or involvement in abortion.

The QNMU supports legislative reform enabling persons who have an incurable physical illness that creates unrelieved, unbearable and profound suffering to choose to die with dignity

PART 6:

FEDERAL CONCERNS

PART 6: FEDERAL CONCERNS

Federal concerns

Aged care system failures The aged care system is failing older Australians. This is not the fault of the overworked nursing staff who deliver the best possible care under very difficult circumstances. There are simply not enough of them. Recent research demonstrates aged care facilities need: ■■ an average 4.3 hours of nursing per resident per day ■■ a skill mix requirement of 30% RNs, 20% ENs and 50% AINs/PCs ■■ 1 Registered Nurse rostered 24/7 (ANMF National Aged Care Staffing and Skills Mix Project Report). These standards must apply in state government and private aged care facilities. The QNMU together with various other aged care peak bodies and representatives are lobbying the federal government to: ■■ legislate minimum staffing and skill mix levels ■■ implement a transparent aged care funding process that covers the real cost of resident care and ensures taxpayer funding is directed to nursing and direct resident care ■■ require aged care providers to publicly report how government funding is spent.

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Cost shifting in health and aged care Cost shifting in health care is a considerable concern for Australian consumers. It results in higher private health premiums and longer waiting lists for certain clinical procedures. When Activity Based Funding (ABF) models are added to the mix, the potential for financial benefit is an incentive for public facilities to give specific categories of patients preferential treatment. A recent report from Ernst and Young, titled Private Patient Public Hospital Service Utilisation, commissioned by the Independent Hospital Pricing Authority (IHPA) found there had been a 10% per year increase in the number of private patients treated in public hospitals over the past seven years. The report also noted that there was significant evidence that state/territory governments are actively recruiting private patients as a revenue source. While the states argue this is necessary because the Commonwealth has neglected health funding, the Federal Government claims states consistently underfund public health services, failing to pass on funding increases delivered through Australian Health Care Agreements — which eventually leads to veiled suggestions that if the states can’t be trusted, perhaps the Federal Government should assume responsibility for the whole health system.

Cost shifting in health care is a considerable concern for Australian consumers.... This blame game does not serve the community well. These measures represent cumulative savings to the federal budget of over $80 billion by 2024-25 — but the $80 billion represents funding withdrawn from the states. The federal government’s retreat from the agreed funding arrangements with the State and Territory governments under the National Health Reform Agreement (NHRA) was ostensibly to drive productivity and efficiency improvements in public hospitals that would rein in expenditure growth (see also page 28 Funding fears). Through Activity Based Funding (ABF) hospitals are funded according to the number and mix of patients they treat.

This blame game does not serve the community well.

Funding based on medical activity is likely to drive outcomes that are not in the patient‘s interest, particularly in maternity care.

From 2017-18 the federal government introduced revised funding arrangements that remove funding guarantees.

If a hospital treats more patients, it receives more funding. Because some patients are more complicated to treat than NURSING AND MIDWIFERY IN QUEENSLAND (2018) 63

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others, ABF also takes this in to account. ABF should be fair and equitable, based on the same price for the same service across public, private or not-for-profit providers of public hospital services. The NHRA determined agreed roles and responsibilities between the different levels of governments. Funding design should recognise the complementary responsibilities of each level of government in funding health services. This is why the QNMU has long argued the need for a collaborative approach between state and federal health stakeholders. We recognise service delivery models are not static and there is plenty of scope to introduce innovative, nurse and midwiferyled models of care. Ongoing arguments over federal/state funding waste time and effort that is better spent on developing more effective health services for patients. Cost shifting in aged care is a variation on the theme, in which residents are transferred from aged care facilities to hospitals for treatment, thus shifting the cost into the public system. Media investigations late last year suggest that in Victoria alone this practice has reached record levels with a 25 per cent jump in the number of residents being transported from nursing homes to hospital in the previous 12 months. Our Federal branch, the ANMF, is on record as saying the jump in residents being sent to hospital was a symptom of the sharp reduction in qualified nursing staff at residential aged care facilities. The QNMU will continue to work both with the ANMF and at a state level to advocate 64 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

for aged care reform which includes the application of ratios and staffing models in aged care so as to reduce the need for hospital transfers. We will also advocate for an overhaul of the funding models for aged care and increased transparency with regards to staffing levels, funding distribution and adverse events

Penalty rates The Fair Work Commissionâ&#x20AC;&#x2122;s 2017 decision to roll back Sunday and public holiday penalty rate payments to employees in hospitality, retail, fast food and pharmacies effectively reduced the pay of thousands of Australian workers. Although employers claim otherwise, we see this as just the start of a general cutback that could flow on to other industry sectors. For nurses and midwives it would have a devastating effect, particularly those who rely on penalty rates to make up a substantial portion of their take-home pay. We believe penalty rates are fair compensation for nurses and midwives having to work unsocial, irregular hours and sacrificing personal time with family and loved ones to care for the sick and vulnerable around the clock. Reducing penalty rates would undermine and undervalue the contribution nurses and midwives make to the health of all Australians. It would also fail to acknowledge the very real physical and emotional strain of working long shifts, continuous night shifts and irregular rosters. It will act as a disincentive to staff working beyond regular hours.

PART 6: FEDERAL CONCERNS

Australian workers and businesses share a common understanding of weekends, public holidays and ‘after hours’. That is our family, social and community engagement time. Penalty rates compensate workers who miss out on that. Businesses, not workers, drove the extension of working hours to the point where they encroach upon traditional ‘down time’. It is in their interests, particularly those businesses affected by the penalty rates decision, to maximise their profits by trading when most people are not at work. Penalty rates are the premium placed on labour when employees are required to work outside normal hours.

The QNMU will continue to strongly oppose any moves to reduce penalty rates for nurses, midwives and all other workers.

Superannuation The Australian superannuation system is among the best in the world. Its overall performance is based on ‘all profit to members’ funds, including industry and public sector funds. The hallmark of such funds has been the equal representation trustee model. Unions must be involved in the management of industry and other not-for profit superannuation funds. Equal worker and employer representation on boards has been a

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PART 6: FEDERAL CONCERNS

notable feature of these funds since their establishment. Superannuation is a system of deferred wages designed in the first instance to benefit workers. It must stay as an item within awards and other industrial instruments to ensure workers and their representatives are able to negotiate improvements during enterprise bargaining and to protect those who remain award reliant.

Women and superannuation Women face unique challenges when it comes to retirement savings. Lower pay, time out of the workforce to raise children, caring for elders, running a single-parent household, illness and divorce are some of the many hurdles they face throughout their lives. However, despite these factors, women do not form a ‘niche’ market. They are a powerful consumer group that makes significant contributions to the nation’s economic and social wealth. Women’s long-term economic disadvantage lies in the assumptions underpinning superannuation where its key feature is protracted, continuous periods of employment over which employers and workers make contributions. It is a grand design, but one ultimately failing women and those with interrupted employment. Women’s disadvantage is exacerbated by the gender wages gap currently standing at 15.3%, the fact that women live longer than men and other structural factors that effectively reduce women’s lifetime earnings and their superannuation contributions. We support measures such as a lowincome superannuation contribution to 66 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

address the particular difficulties women and low income earners face in contributing to and benefiting from superannuation. More can be done by the Queensland government to close the retirement savings gap of its female employees. We call upon the government to closely consider this issue when undertaking further examinations of gender-based bay inequities.

University funding The Federal Government has recently decided to freeze university funding for 2018 and 2019 university placements at 2017 levels. This move will significantly affect prospective students for rural and regional universities which are less likely to absorb the cost of funding new placements. Potentially this will create a shortage of nurses and midwives in regional Australia as nursing students often return to work in their communities. The decision to freeze funding could force many prospective nurses and other students to abandon their career plans and may impact on the long-term health and wellbeing of rural and regional communities.

...women do not form a ‘niche’ market. They are a powerful consumer group that makes significant contributions to the nation’s economic and social wealth.

PART 7:

OTHER CURRENT ISSUES AS AT MARCH 2018

PART 7: OTHER CURRENT ISSUES AS AT MARCH 2018

Other current issues as at March 2018 Carparking policies Safe and affordable car parking at Queensland public hospitals remains an ongoing problem for our members. Queensland Health does not have a consistent approach or strategy for car parking, so over the past few years QNMU and its members have been working on solutions with management on a site-bysite basis. The progress, however, has been slow and unsatisfactory. The QNMU welcomes Queensland Healthâ&#x20AC;&#x2122;s recent focus on undertaking a review of the adequacy and appropriateness of existing parking arrangements across the state. Appropriate carparking facilities are workplace safety and workforce retention issues. Members frequently raise safety concerns over poorly lit, poorly secured parking areas, some members noting that a lack of suitable facilities forces them to park a considerable distance from their workplace. In addition of the risk to their personal safety â&#x20AC;&#x201D; particularly those who work late or on night shift, many members have also reported vehicle damage and vandalism as a result of inadequate parking provisions. Having to struggle to find a car park even before a shift begins is also a source 68 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

of considerable stress for our members and the availability of adequate, safe and affordable car parking is often a consideration in determining whether to seek work at a particular health facility. Rockhampton, Ipswich, Sunshine Coast, Nambour, Lady Cilento and Townsville Hospitals are some current hotspots.

PART 7: OTHER CURRENT ISSUES AS AT MARCH 2018

Digital health and hospitals Digital technologies and information systems such as telehealth, integrated electronic Medical Records (ieMR), patient dependency systems and patient databases are permeating our work places in an ever-expanding way, and it is affecting the way nurses and midwives practice. The rapid growth of digital technologies and electronic information systems in health and aged care settings requires nurses and midwives not only to understand the importance and potential usefulness of digital technologies and information systems in their practice, but also have the appropriate knowledge, skills and

competency in the manipulation of data to support safe and informed practice. The QNMU believes it is imperative that technological changes are managed in a way that ensures nurses and midwives are professionally supported and given every opportunity to upskill to the use of new systems and protocols. We also maintain that nursing and midwifery practice and models of care must continue to inform the development, implementation and maintenance of digital technologies and information systems for nurses and midwives. It is also paramount that digital technologies and information systems complement, maintain and enhance, and NURSING AND MIDWIFERY IN QUEENSLAND (2018) 69

PART 7: OTHER CURRENT ISSUES AS AT MARCH 2018

not compete with or restrict a nurse and midwife’s practice. These measures will allow nurses and midwives to meet their professional obligations under the NMBA while continuing to deliver safer, better integrated and evidence-based care, which will result in positive health and aged care outcomes for the community in the digital age.

Workforce planning The Health Workforce 2025 report released in 2012 predicted a nation-wide shortage of some 109,000 nurses, unless state and federal governments worked co-operatively to find ways to recruit and retain them. This is in line with Queensland’s Department of Health’s data of 2016, which predicted a potential undersupply of RNs of up to 4,090 by 2025. The QNMU has consistently advocated for a nursing and midwifery workforce plan for Queensland that is linked to a national plan. The solutions need to be both state and national given the overlap in educational preparation. A nursing workforce plan must be situated within an overall health workforce plan. In our view, responsibility for developing the plan in consultation with key stakeholders lies with the Office of the Chief Nursing and Midwifery Officer (OCNMO). Unfortunately it remains the case that duplication of effort occurs alongside inadequate consultation about workforce strategies affecting nursing and midwifery when these are being driven by areas outside OCNMO. 70 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

As it stands, the QNMU remains extremely concerned about the lack of integration of workforce planning across the HHSs and the absence of appropriate nursing and midwifery input into workforce planning processes. There exists a distinct lack of consistency around workforce planning strategies and implementation across HHSs working in silos separate from a central authority. This has been most acutely visible in relation to the employment of graduate nurses and in the rollout of nurse navigators.

A national workforce plan Planning nursing and midwifery infrastructure is more complex than merely counting nurses/midwives or their hours, their qualifications, shifts, or job preference.

The QNMU has consistently advocated for a nursing and midwifery workforce plan for Queensland that is linked to a national plan. The solutions need to be both state and national given the overlap in educational preparation.

PART 7: OTHER CURRENT ISSUES AS AT MARCH 2018

It is the interaction among these variables in the process of care delivery that influences the number and type of nurses/midwives required and related outcomes. Some elements critical to informing a national workforce plan include, but are not limited to: ■■ focussing on primary health care model, recognising that there will still be a requirement to provide direct clinical care both within the hospital and the community. ■■ including strategies that will enhance service delivery such as the incorporation of nurses and midwives into multidisciplinary teams, recognition of advanced clinical skills and judgement, access to professional development opportunities and ensuring nursing and midwifery roles are not substituted by unlicensed/non-nursing employees. ■■ using effective tools such as the Business Planning Framework that matches workloads to workforce capability. ■■ harnessing targeted strategies that allow flexibility in recruitment and retention that comply with relevant industrial instruments.

Support for NUMs and MUMs It is generally accepted across both public and private health sectors that the Nurse or Midwife Unit Manager role is critical to ensuring the proper functioning of health service delivery. The fundamental reason for this is that this role is a single point of co-ordination for the service delivery across the myriad of disciplines involved in that service delivery. That is, the

NUM’s role is to coordinate the provision of care and is the point of contact for making enquiries in relation to the provision of that care. The NUM position is also, in most cases, the cost centre manager for the unit or service. In the wake of the HHS restructure and the LNP job cuts, a number of tasks once performed centrally (for example, undertaking criminal history checks), were pushed down to the Team Leader or NUM to do. The workload implications were significant and the NUMs received little financial, human resource or IT support from Queensland Health to alleviate the burden. During EB8 negotiations the QNMU did initially secure additional support for NUMs by way of funding for immediate administration support, and longer term solutions around direct entry rostering, but the agreed outcomes were never implemented during the life of the agreement. Since then, however, there has been renewed focus on support for NUMs through EB9 and we hope to continue and build on this under EB10. The reinvigoration of the Nurses and Midwives Implementation Group (NaMIG), the peak consultative forum for nurses and midwives, was particularly pleasing, as was the $12 million allocated for workplace initiatives to reduce the administrative burden on NUMs and MUMs. The NUM/MUM summits at the end of last year also signalled a shift in approach, and provided a much needed opportunity for this important nursing cohort to raise issues and solutions. NURSING AND MIDWIFERY IN QUEENSLAND (2018) 71

PART 7: OTHER CURRENT ISSUES AS AT MARCH 2018

The progress made so far has been very constructive and we look forward to continuing a positive relationship with Queensland Health to ensure our member NUMs and MUMs continue to be leaders of patient and women centred care and are not weighed down by administrative work.

care facilities. For example, a person who seriously assaults a nurse employed in the Mater Emergency Department cannot be prosecuted under this provision. We see this as a serious anomaly and seek amendment of the Code to ensure nurses and midwives in all sectors have the same protections.

Changes to Section 340 of the criminal code

Inductions

Section 340 of the Criminal Code Act Qld 1899 provides penalties for serious assaults to police, corrective services and public officers. It applies to nurses and midwives employed in the public sector. However, it does not cover private and aged

An important aspect of union growth and renewal is the ability to discuss the benefits of membership and a collaborative approach to industrial relations with new employees. The QNMU seeks the allocation of 30 minutes in all nurse/midwife induction programs for this purpose. Orientation session at GCUH

72 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

APPENDIX 1:

FACTS AND FIGURES

APPENDIX 1: FACTS AND FIGURES

Facts and figures

National ■■ According to the Australian Health Practitioner Registration Authority (AHPRA) as at December, 2017 nursing and midwifery are the health professions with most practitioners, with 351,455 nurses, 27,159 nurse/midwives and 4691 midwives nationally registered (general registration only)* (AHPRA Nurse and Midwife Registrant Data: December 2017)#. This includes: Registered Nurses (RN) 282,412 Enrolled Nurses EN) 61,992 RN and EN (dual registration) 7051 Midwife and RN 27,030 Midwife and EN 68 Midwife, RN and EN 61 Midwife 4691

RN EN RN/EN MW/RN MW

■■ Females make up the largest proportion of the nursing and midwifery labour force. Nurses^ Female

310,011

Male

41,441

Nurses and Midwives^ Female Male

26,692 467

Midwives^ Female Male

4674 17

The largest number of nurse registrants (general registration) was aged 30-34 years (47,627). For nurse and midwifery registrants it was the 55-59 years age bracket (5730) and for registrants solely as midwives the largest number was in the 25-29 years age bracket (869)

Working arrangements According to data published in the Australian Institute of Health and Welfare’s 2015 Nursing and Midwifery Workforce report: ■■ The average weekly hours worked by employed nurses and midwives in

74 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

APPENDIX 1: FACTS AND FIGURES

Australia increased slightly from 33.4 hours in 2012, to 33.5 hours in 2015. ■■ Almost half (149,867 or 48.8%) worked less than 35 hours per week. ■■ Nurses and midwives in very remote areas worked the greatest number of hours, 40.1 hours per week compared with the national average of 33.5. ■■ The principal area of nursing and midwifery with the largest number of workers in 2015 was aged care. ■■ There were almost twice as many Registered Nurses working in the public sector (156,528) compared to the private sector (88,675) ■■ Nurses employed in the public sector worked more hours on average than those in the private sector. ■■ In 2015, there were 3,187 nurses and midwives employed in Australia who identified as an Aboriginal or Torres Strait Islander.

Queensland ■■ The total number of Registered and Enrolled Nurses^* as at December 2017 was 70,339 and the total number of midwives nationally registered as both nurses and midwives was 5611. ■■ The number of midwife-only registrants was 950. (AHPRA Nurse and Midwife Registrant Data: December 2017) #. ■■ Females also make up the largest proportion of the nursing labour force in Queensland.

Nurses and Midwives^ Female

5,524

Male

Midwives^ Female Male

949 1

Aged Care workforce An estimated 366,037 people are aged care workers in Australia (The Aged Care Workforce, 2016, Australian Government Department of Health) – defined as workers who provide care services to older Australians as a key part of their work. Includes unregistered carers as well as nurses registered with AHPRA. 87% of residential direct care workers are female with a median age of 46 years. 70% of residential direct care aged workers are PCA/AINs. 53% of residential aged care facilities report skills shortages, most commonly for Registered Nurses. ^ General registration * The National Board recognises four nursing and midwifery registration types: general registration, limited registration, non-practising registration and student registration # AHPRA figures include re-entry nurses and overseas trained nurses but do not include Assistants in Nursing because AINs are currently unregulated and not required to register with AHPRA.

Nurses^ Female Male

62,349 7,989

NURSING AND MIDWIFERY IN QUEENSLAND (2018) 75

APPENDIX 2:

QUEENSLAND HEALTH NURSING AND MIDWIFERY CLASSIFICATION STRUCTURE

APPENDIX 2: QUEENSLAND HEALTH NURSING AND MIDWIFERY CLASSIFICATION STRUCTURE

Queensland Health nursing and midwifery classification structure This table should be read in conjunction with the full Generic Level Statements found at Schedule 2 (pages 64-113) of the Nurses and Midwives (Queensland Health) Award - State 2015. You can view the Award at http://qirc.qld.gov.au/qirc/resources/pdf/awards/n/ nurses_and_midwives_swc17.pdf The Generic Level Statements articulate what all the positions entail within the five (5) key domains of: ■■ ■■ ■■ ■■ ■■

Direct comprehensive care or provision or direct care Support of systems Education Research Professional Leadership.

Classification

Pay Point Level

Nurse Grade 1 Assistant in Nursing

Nurse grade 1 – Band 1 1 to 6 (Pay point levels relate to years of experience)

Nurse Grade 1 Assistant in Nursing – Sterilising Services

Nurse grade 1 – Band 2 1 to 3 (Pay point levels relate to years of experience)

Nurse Grade 2 Undergraduate Student Nurse/Midwife

Nurse Grade 2 1 to 2 (Pay point levels relate to year of study)

Nurse Grade 3 Enrolled Nurse

Nurse Grade 3 1 to 5 (Pay point levels relate to years of experience)

Nurse Grade 4 Enrolled Nurse Advanced Skill

Nurse Grade 4 1 to 2 (Pay point levels relate to years of experience)

Nurse Grade 5 Registered Nurse Registered Midwife

Nurse Grade 5 Re-entry to 7 (Pay point levels relate to years of experience)

NURSING AND MIDWIFERY IN QUEENSLAND (2018) 77

APPENDIX 2: QUEENSLAND HEALTH NURSING AND MIDWIFERY CLASSIFICATION STRUCTURE

Classification

Pay Point Level

Nurse Grade 6 Clinical Nurse/Midwife

Nurse Grade 6 – Band 1 1 to 4 (Pay point levels relate to years of experience)

Nurse Grade 6 Associate Clinical Nurse/Midwife Consultant Associate Nurse/Midwife Unit Manager Associate Nurse/Midwife Associate Educator Associate Nurse/Midwife Manager Associate Nurse/Midwife Researcher

Nurse Grade 6 – Band 2 1 (Pay point levels relate to years of experience)

Nurse Grade 7 Clinical Nurse/Midwife Consultant Nurse/Midwife Unit Manager Nurse/Midwife Educator Nurse/Midwife Manager Nurse/Midwife Researcher

Nurse Grade 7 1 to 4 (Pay point levels relate to years of experience)

Nurse Grade 8 Nurse Practitioner

Nurse Grade 8 1 to 2 (Pay point levels relate to years of experience)

Nurse Grade 9 Director of Nursing/Midwifery - Rural or Remote

Nurse Grade 9 1 to 3 (Pay point levels relate to years of experience)

Nurse Grade 10 Assistant Director of Nursing/Midwifery

Nurse Grade 10 1 to 2 (Pay point levels relate to years of experience)

Nurse Grade 11 Nursing/Midwifery Director Director of Nursing/Midwifery

Nurse Grade 11 1 (Pay point levels relate to years of experience)

Nurse Grade 12 Nursing/Midwifery Director Director of Nursing/Midwifery

Nurse Grade 12 1 (Pay point levels relate to years of experience)

Nurse Grade 13 Health Service Director of Nursing/Midwifery Executive Director of Nursing and Midwifery

Nurse Grade 13 1 (Pay point levels relate to years of experience)

Nurse Grade 13 Executive Director of Nursing and Midwifery

Nurse Grade 13- Band 2 1 (Pay point levels relate to years of experience)

78 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

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Safety and quality of care Aiken, L., Cimiotti, J., Sloane, D., Smith, H., Flynn, L., & Neff, D. (2011). The effects of nurse staffing and nurse education on patient deaths in hospitals with different work environments. Med Care, 49(12), 1047-1053. Aiken, L., Sloane, D., Bruyneel, L., Van Den Heede, K., Griffiths, P., Busse, R., . . . Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet, 383(9931), 1824-1830. Boxall, A. (n.d.). What are we doing to ensure the sustainablity of the health system? Research paper No.4. Retrieved from http:// parlinfo.aph.gov.au/parlInfo/ download/library/prspub/1234561/ upload_binary/1234561. pdf;fileType=application/ pdf#search=%222010s%20boxall,%20 anne-marie%22

KPMG. (2017). Through the looking glass: a practical path to improving healthcare through transparency. KPMG International . Lindrooth, R., Yakusheva, O., Fairman, J., Weiner, J., Naylor, M., & Pauly, M. (2015). Increasing the valur of health care: the role of nurses. Philadelphia: University of Pennsylvania. Ministerial Taskforce. (1999). Ministerial Taskforce - nursing recruitment and retention. Brisbane : Queensland Government. Nurses and Midwives (Queensland Health Agreement (EB8). (2012). Nurses and Midwives (Queensland Health) Certified Agreement (EB7). (2009). Brisbane. Nursing and Midwifery Implementation Group (NaMIG). (2017). Governance of the BPF and ratios legislation in Queensland Health. Brisbane : Nursing and Midwifery Implementation Group (NaMIG).

Brodie, P. (2013). ‘Midwifing the midwives’: addressing the empowerment, safety of, and respoect for, the world’s midwives . Midwifery , 29(10), 1075-1076.

Queensland Government. (2012). Delivering continuity of midwifery care to Queensland women - a guide to implementation. Brisbane: Queensland Government.

Dekker, S. (2017). Just culture: restoring trust and accountability in your organisation (3rd edition). Boca Raton: FL CRC 2017.

Queensland Government. (2016). Hospital and Health Boards Act 2011 - Part 6, Divsion 4. Brisbane: Queensland Government.

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Harvard Business School. (n.d.). Value-based health care delivery . Boston: Harcard Business School.

Queensland Health. (2015). Business Planning Framework: a tool for nursing and midwifery workload management. Brisbane: Queensland Health.

Queensland Nurses and Midwives’ Union. (2015, January). Ratios Save Lives: a care guarantee for the delivery of safe, high quality nursing and midwfery to all Queenslanders. Brisbane: Queensland Nurses and Midwives’ Union. Retrieved September 8, 2015, from https:// www.qnu.org.au/__data/assets/ pdf_file/0020/541406/Ratios-SaveLives-Claims-Jan15-WEB.pdf Queensland Nurses and MIdwives’ Union. (2016). Submission to the health and ambulance services committee. Brisbane: Queensland Nurses and MIdwives’ Union. Queensland Nurses and Midwives’ Union. (2017). Safe Workloads in Midwifery Standard. Brisbane: Queensland Nurses and Midwives’ Union. Slatyer, S., Coventry, L., Twigg, D., & Davis, S. (2016). Professional practice models for nursing: a review of the literature and synthesis of key components. Journal of Nursing Management, 24(2), 139-150. Twigg, D., Geelhoed, E., Bremner, A., & Duffield, C. (2013). The economic benefits of increased levels of nursing care in the hospital setting. Journal of Advanced Nursing , 69(10), 2253-2261.

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observational study to identify risk attributable to staff deployment, training and updating opportunities for midwives. British Midwifery Journal. Vol 32, no 7. pp 584a-586A. Australian Institute of Health and Welfare. (2015). Australia’s mothers and babies 2013 - in brief. AIHW. Canberra. Australian Institute of Health and Welfare. (2016). National Core Maternity Indicators stage 3 and 4 results from 2010–2013. AIHW, Canberra. British Columbia Nurses Union. (2016). Position statement: Mandated Nurse to Patient ratiios. Available: https://www.bcnu.org/AboutBcnu/ Documents/position-statement-nursepatient-ratio.pdf, Burnaby. Brodribb, W., Zadoroznyi, M., & Dane, A.(2012). Evaluating the implementation of the Universal Postnatal Contact Services in Queensland: Experiences of Health Care Providers and Mothers. Queensland Centre for Mothers & Babies. University of Queensland. Brisbane. California Nurses Association. (2004). California RN Staffing Ratio Law. Available: https://www.cga. ct.gov/2004/rpt/2004-R-0212.htm. Commonwealth of Australia. (2010). Improving Maternity Services: Report into the National Review of Maternity Services. Commonwealth of Australia. Canberra. Cummins, A., Denney-Wilson, E., & and Homer, C. (2015). The experiences of new graduate midwives working in continuity of care models in Australia. Midwifery. Vol 31, no 4. pp 438-444. Dixon, L., & Tumilty, E. E. A., (2014) Stepping forward into life as a midwife in New Zealand/Aotearoa: An Analysis of the Midwifery First Year of Practice Programme 2007 to 2010. New Zealand College of Midwives. Christchurch. Forster, D., et al. (2006). Staffing in postnatal units: is it adequate for the provision of quality care? Staff perspectives from a state-wide review

of postnatal care in Victoria, Australia. BMC Health Services Research. Vol 6, no 83. Hartz, D., et al. (2011). Australian maternity reform through clinical redesign. Australian Health Review. Vol 36, no 2. pp 169-175. Hegney, D., Francis, K., & Eley, R. (2013). Your work, your time, your life. Queensland Nurses’ Union, Brisbane. Hegney, D., Plank, A., & Parker, V. (2003). Nursing workloads: the result of a study of Queensland Nurses. Journal of Nursing Management. Vol 11. pp 307-314.

National Institute Clinical Excellence. (2015). Safe midwifery staffing for maternity settings. Accessed 5 September 2016: www.nice.org.uk/ guidance/ng4. National Institute of Clinical Excellence. (2015). National Institute of Clinical Excellence Quality Standard. Retrieved 9 September 2016 from www/.nice.org.uk/guidance/qs105/ chapter/Quality statement-2-One-toone-care.

Hirst, C. (2005) Re-birthing. Report of the review of maternity services. Queensland Government. Brisbane.

Nursing and Midwifery Board of Australia. (2016). Safety and Quality Guildeline for Privately Practicing Midwives. 2016. Accessed 8 September 2016 www.nursingmidwiferyboard. gov.au/News/2016-02-01-revisedmidwifery-standards.aspx.

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Kruske, S., et al. (2015). A retrospective, descriptive study of maternal and neonatal transfers, and clinical outcomes of a Primary Maternity Unit in rural Queensland, 2009-2011. Women Birth. Vol 28, no 1. pp 30-39.

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Lankshear, A., et al. (2005). Nurse staffing and healthcare outcomes: a systematic review of the international research evidence. Advances in Nursing Science. Vol 25, no 2. pp 163-174. Mate, J., Washbrook, M., & Ball, J. (2011). Birthrate Plus: methodology for NSW Health. NSW Department of Health. Sydney. McHugh, H., et al. (2013). Hospitals with higher nurse staffing had lower odds of readmission penalties that hospitals with lower staffing. Health Affairs. Vol 32, no 10. pp 1740-1747. Miller, S., et al. (2016). Beyond too little, too late and too much, too soon, a pathway towards evidence-based, respectful maternity care worldwide. The Lancet. Miller, S., et al. (2016). Beyond too little, too late and too much, too soon: a pathway toward evidence-based, respectful maternity care worldwide. The Lancet.

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NURSING AND MIDWIFERY IN QUEENSLAND (2018) 81

WHERE TO GO FOR MORE INFORMATION?

Where to go for more information

This document includes a reference list and the QNMU has extensive information and research about nursing and midwifery available, which we will provide on request. Many resources are also available on our website at www.qnmu.org.au Please contact the QNMU for any other information you may require â&#x20AC;&#x201D; we are only too happy to assist. Contact QNMU on (07) 3840 1444 or (toll-free outside Brisbane) on 1800 177 273.

82 NURSING AND MIDWIFERY IN QUEENSLAND (2018)

www.qnmu.org.au

03/18