Regional health under the pump 

8 August 2022

Article from July 2022 edition of INPractice

And in need of a serious patch-up. 

A major hospital without WiFi in 2022? Small wonder our country counterparts feel like a forgotten 'second cousin'.

The spate of emergency department closures during the pandemic has certainly highlighted the fragility of regional health services, beset by staff shortages and lack of doctors. 

The Barmera Hospital ED was closed for almost two years from April 2020 until February 2022 to decrease the risk of COVID transmission to co-located aged care facilities. 

Waikerie was forced to close their midwifery services due to lack of available staff. And there have been issues down the south coast as well with midwifery services in particular.

"You feel like a second cousin, absolutely, to the metros" said one Mid North nurse. "We took years to get swipe card doors on our wards, and then we find out they've been in metro for about 20 years and then they kept carrying on about the cost. 

"It's the same situation but they seem to think we're on a minor scale, but honestly it's the same stuff, just a different place with less back-up.”

Like so many other regional nurses around the state, she also says the violence and lack of security is "frightening". 

The Malinauskas State Government this year pledged to a raft of promising new policies in its pre-election pitch including measures to tackle violence. 

For four years the ANMF (SA Branch) has been running campaigns urging the former Marshall Government to stop the squeeze on the public hospital system and for urgent action on health. Our pleas repeatedly fell on deaf ears and what we got was largely inaction. 

Labor, by comparison, gave detailed commitments on each of the key policy asks of the ANMF. They committed to legislate for ratios. they promised and budgeted for additional beds (300 of them) and capacity, and they vowed to end privatisation and assure public ownership. 

In addition, Labor committed to 350 extra paramedics and ambulance officers, 300 extra nurses and 100 extra doctors and to implement a hospital occupancy target of 90% over the term of the new Government in order to address systemic issues such as ramping and dangerously long waiting times in emergency departments. 

They promised $24 million to upgrade Mt Gambier Hospital including emergency department security and capacity, $220 million for a new state-of-the-art hospital in Mt Barker and a review of security at the Port Lincoln Hospital. 

The latter move follows a campaign by the ANMF (SA Branch) for onsite security guards at Port Lincoln Hospital. 

In August 2019, a Port Lincoln registered nurse was attacked by a teenage boxer and suffered severe bruising, neck sprain and whiplash, facial scarring, intermittent pain, headaches, concussion, nausea from pinched nerves and post-traumatic stress disorder. 

"If one punch landed slightly in a different spot on my skull, I would not be alive today, I'm certain of that,” the nurse said in her victim impact statement. 

One of her colleagues recalls that during a meeting not long after the assault, staff at Port Lincoln Hospital were told "that under no circumstances would Lincoln be getting security guards". 

"I'm not sure why that statement was made and I have no idea what the agenda was. I often can't get my head around the way they think, they're very much focused on funding, and obviously not on staff safety".

She says regional communities and health care professionals "absolutely" feel abandoned by metropolitan-based authorities. "When we did our campaign for security to support nurses (an ANMF-led campaign to instate restraint-trained security guards 24/7), many local people could not believe that we did not yet have any sort of security in the hospital to protect us", the Port Lincoln nurse said.

Despite the alarming surge in Code Black incidents and widespread media coverage instigated by the ANMF (SA Branch), Port Lincoln, like so many other regional sites including Barmera, Port Pirie and Mt Gambier remains at the mercy of "psychotic patients and people who are just behaving really badly. Nurses feel really unsafe”.
The actual number of Code Black incidents is probably much higher than what's reported. “Staff under report, that's the other thing, they don't stop and think about it. Staff don't generally report everything, we are under the pump every shift. Staff are working double shifts, have dangerous and high patient loads/acuity and just lack time. Completing an SLS report often involves staying back another half hour just to complete. 

"The SLS system is really unwieldy. We actually have to put three reports in for every act of challenging behaviour or aggression. You can't just do it in one hit. The reporting system is set up that you have to complete one for you, one for the patient and one under a security event, so you actually have to complete three reports for one incident. 

"I know for a fact there have been plenty of things I haven't reported over the years, particularly around verbal aggression and abuse". 

A Mt Gambier nurse said it was a case of "wait and see" regarding Premier Peter Malinauskas's promise 10 pump $8 million to upgrade Mt Gambier Hospital's emergency department security and capacity.

"It's certainly something that's desperately needed. Assault or abuse against nursing staff at the ED occurs on a regular basis. Not a day goes past without a Code Black called. particularly in ED but also in the wards as well.”

In Barmera, they had nine police callouts in one month alone last year. A surge in attacks on nurses - 22 assaults in a 4 and a half week period - finally prompted the Whyalla and Port Augusta Hospitals to instate 24/7 security guards in June last year. with very positive results for reduced incidents and staff peace of mind. 

In addition to our anti-violence campaigning, the ANMF (SA Branch) is calling for urgent incentives to address nurse shortages and burnout in regional South Australia. 

"There are extreme pressures on country nurses and midwives, and there has been significant concern for a long time, with many hospitals running short staffed or relying very heavily on people working double shifts or overtime. And there is a lot of reliance on people working on call and recall, which leads to a significant issue of fatigue,” ANMF (SA Branch) CEO/Secretary Adj Associate Professor Elizabeth Dabars AM said.
"We do believe there should be recruitment and retention allowances specifically in country South Australia, so we have made specific requests for that. Again, the former government rejected them, they are back on the table with the current Government".

“If those (incentive) strategies are put in place then we will be in a much better position to be able to provide appropriate care and services to the community and to actually provide appropriate resources and support to those who are delivering that care.”

"From our perspective we have been advocating and lobbying for workforce improvements and workforce changes for many, many years," Ms Dabars said.

“We have had some degree of successes. last year, for instance, we did manage to convince the then government to employ the entire cohort of the graduating nurses and midwives.

"That was a great coup and a great win for us all. However, we are now again on the bandwagon with the new Government, advocating and arguing very strongly for the employment of all of the next lot of graduating nurses and midwives and indeed the full employment of those who are finishing their Transition to Professional Practice Placements".

Ms Dabars said the ANMF (SA Branch) was designing a new TPPP in conjunction with SA Health, aimed at addressing the workforce demand surge and support the accelerated transition of graduate nurses to professional practice. 

"It is so important that we contribute and we offer solutions to these issues. We know workforce shortage is local. national and international. We have again been trying very hard to put forward solutions. This 1s one of those solutions.” she said.

Mt Gambier Hospital was in late April placed under a Code White rating (no beds available) for three days in what was believed to be a first for the site. The local network said the shortage was caused by furloughed staff due to COVID. It was also claimed that up to 60 FTE positions at the Mt Gambier hospital were vacant. 

Says the Mt Gambier nurse: “I heard we were 20 to 30 shifts short a fortnight ago, a lot of them being filled by staff doing extra shifts and I think the wards are actually worse." 

"We need between 20 to 30 per cent more nursing staff to be able to staff the hospital adequately, which is a huge figure." 

"I think country nurses have got the same problems as metro nurses but for some reason they won't fund us." says the Mid North nurse. 

"We need extra numbers for the type of clients we've got. Whether that's going to come through in the new EB, whether there's going to be some recognition, when you're too tired to think about the next shift - that's really bad. 

"There's no sort of downtime. Previously during Christmas and January, the number of surgeries went down and you could get off on time and you weren't rung up on your days off. That doesn't happen anymore, it's just like a continuous flu season."

She cited an example of the extreme pressures nurses are under. 

"The other day an RN had to deal with a Code Black, a guy screaming at the door, trying to kick it in for meds, they had an elderly patient who had a cardiac arrest and were resuscitating him and then they had another man that was an acute abdomen, and they couldn't get the on-call doctor to come over. 

"She was having to make decisions on retrievals and resuscitations, and she said: 'I'm not a nurse practitioner'."

The Port Lincoln nurse said investment in infrastructure at her site is "shocking". "We still don't have WiFi or electronic patient management systems.

There is no hospital WiFi, so money is wasted on installing additional cabling to relocate computers and phones to meeting increasing clinical demands in previously unused areas, because they haven't invested in modern infrastructure. Everything's connected via cable, which seems like madness in this day and age. You don't need to have cabling everywhere now, it's just crazy. The issues are endless”.

She said skilled staff shortages and antiquated staffing methodologies were exacerbating the crushing workload, resulting in poor retention of fed-up staff.

“Port Lincoln hospital's role has changed and grown significantly in the last 10 years. We are the only hospital in the region with resident surgeons, physician, GP obstetricians and we service the whole of lower Eyre Peninsula plus a large influx of tourists during peak seasons for these specialist services.

“We're the regional maternity service and that's all come about with the withdrawal of those services and the changes to hospitals like Cummins and Tumby Bay. They used to birth their own babies and provide minor surgery, but that doesn't happen anymore and it hasn't happened for quite some time now.

“Port Lincoln Hospital has picked up all of that workload, but there's never been a change to the staffing methodology or funding model. We're still under the country staffing methodology which hasn't changed for 30 years and we cover a really broad area and patient cohort, which has never really been reflected in the funding model for the hospital”.

"Staff get incredibly frustrated and stressed. We've got eight cardiac monitors and only leave one special care nurse on, which is a HDU nurse essentially". 

"Patients in this area can be critically unwell, awaiting transfer to a tertiary facility. In a metro hospital, these patients would be cared for 1:2 or 1:3 at worst. You've also got Maternity in the same geographical area. When these areas are busy, and due to the staffing methodology, direct entry midwives are expected to look after general med-surgical patients, which clearly is not within their scope of practice". 

All the nurses the ANMF spoke with stressed the need for incentives. "For people who stay here long term it's really fulfilling but really the current model is not sustainable, it's frightening. They've got to make it worthwhile coming up here," says the Mid North nurse. 

"You get to know your health community, you build up relationships, you do have an excellent network of community nurses, you know the allied health staff, you really get to know the team. 

"I think teamwork is the best thing about being country. Nurses do have to take a really frontline role and manage when there's no doctors on the ward. They (doctors) come in and do their rounds in the morning and then that's it, they only come back 1f there's an emergency sort of thing. 

"I think there's personal satisfaction, you work to your full scope. I think regional nurses should receive an incentive payment, to say we recognise you're going above and beyond. I think we should be rewarded for being pseudo nurse practitioners".

The Mt Gambier nurse said incentives to attract staff to the South-East were desperately needed "because at the moment there are none”. 

However, she believes improved workplace conditions could help retain and attract staff. 

"I'm really hoping with the team we’ve got now that's going to change, she's (the new Director of Nursing) certainly interested in changing the culture of the whole hospital, which is fantastic. 

"The previous administration, two lots of administrations ago, had basically cut the staff to the bone. There was more concern about saving money. The staffing is just at such a low level that the minute you have anyone sick or even on annual leave, the place is short. 

"It's something I think our new Director of Nursing will be able to address in the next few months because she has been an absolute godsend, she's just really focused on staff welfare and staff safety and all those things. In all the years I've worked at Mt Gambier I've never seen that happen before, so it's a wonderful, wonderful change." 

"One of the reasons we have trouble retaining staff is when staff get down here, there are very few places available to rent. The hospital has got a few places, a couple I know are like Housing Trust-type houses, I think they are pretty basic to say the least". 

The Port Lincoln nurse says government needs to “get serious about the level of investment in regional and what it actually means to be a regional service". 

"I'm not going to lay blame at the regional executive's door, as I do feel successive governments have ignored regional services”.

“I don’t think it's Liberal, I don't think it's Labor, I think it's just a successive focus on metro services, 'Oh well, county, it's a small population base, too bad, how sad' sort of thing.

"People in this region are geographically very isolated. It's a seven-hour drive to Adelaide, it's a 45-minute flight and costs are prohibitive for a lot of people. There's a lot of people of low socio-economic status".

"They've increased the range of chemotherapy service available here, some of which require a recognised HDU, but again we don't have a, recognised HDU or the staff for it at this point in time.

“I think if it was a better place to work, not quite so stressful, we'd probably retain some of the staff we attract, because Port Lincoln's a beautiful place to live, I love being here".

"In saying that I'm also very proud to be part of the nursing team in Port Lincoln - the staff do amazing work, but they are exhausted and it's time all regional nursing staff across the state are meaningfully supported with good infrastructure. funding and staffing models". 

The ANMF (SA Branch) in regular consultation with the State Government on health issues in this state. In addition to our calls for incentives and full employment, we have long advocated for a total commitment to the SA Health Prevention of Fatigue Policy Directive and Challenging Behaviour Strategic Framework to address issues of fatigue and aggression and will continue to do so with the new Government.

We believe the SA Health framework addresses the criteria identified in our 10-point Plan to End Violence and Aggression (including improved security, risk identification. workplace design and the integration of legislation, policies and procedures).

"All the indications we have currently from the new Government is that they are committed to implementing all their promises on health,” Ms Dabars said.

"While we applaud the new Malinauskas Government's commitments to health and believe they will go a long way to addressing the needs of the health system, we will also monitor developments very closely and hold the Labor Party to account - to deliver their pre-election promises.

"If we need to take action to highlight a lack of action or failure to live up to pre-election pledges then we will not hesitate to do so”.

Click here to read the July 2022 edition of INPractice.