Do we have safe and healthy workplace yet? Are the recommendations of the Committee of Inquiry into Safe Staffing and Healthy Workplaces making a difference in district health boards? They should be, as they encourage positive practice environments.

Almost a year on from the completion and endorsement of the NZNO/District Health Board New Zealand (DHBNZ) Safe Staffing/Healthy Workplaces Committee of Inquiry (CoI) report and recommendations, has it made any difference?

The CoI was established as an outcome of collective bargaining for the first national NZNO/DHB multi-employer collective agreement in the public sector. Nurses and midwives believed they were being required to work in environments that wereunsafe both personally and professionally, and did not always ensure optimum outcomes for patient and clients.

Nurses in most of the private health sector also struggle to deliver quality patient care because lack of funding limits the number of staff able to be employed and what they are paid.

Three-year implementation

So what were the report's recommendations supposed to do? The CoI identified seven elements that, if present in any workplace, should provide the basis and/or mechanisms to deal with unsafe situations. The implementation of the recommendations was time-framed over the next three years.

The first phase of implementation--the establishment of the Safe Staffing Healthy Workplaces Unit (SSHWP Unit) within DHBNZ--was to happen within three months of the endorsement of the report. There has been some time tag, as NZNO members and DHB chief executives endorsed the report last July. The unit will be dedicated to the implementation of the "action plan" The unit will be overseen, monitored and evaluated by a joint advisory board of two NZNO representatives, chief executive Geoff Annals and NZNO member representative and director of nursing at West Coast DHB Jane O'Malley, and two DHB representatives, Tairawhiti DHB chief executive Jim Green and MidCentral DHB director of nursing Sue Woods. Health Minister Pete Hodgson has approved funding for the unit.

However, implementation of other recommendations was also supposed to be underway and making a difference in workplaces by now. Some nine months on from the endorsement, differences in nursing and midwifery clinical leadership should now be apparent. DHBs should by now be ensuring that nursing and midwifery staff have adequate access to clinical leadership 24/7 at all levels of the organisation. Processes should be in place to support nurses and midwives when they believe their workloads have reached the Emits of safe practice. There should also be agreed mechanisms to preserve standards of care, while meeting patient throughput requirements.

By now, we should have been working with the DHBs to agree on processes to support and guide nurses and their managers when it is deemed staffing is unsafe. These processes should be tools that are applied to monitor and evaluate the effectiveness of the strategies put in place. The escalation process was also to be standardised and strengthened to include some principles about reasonable expectations of what should be clone when workloads or the work environment is unsafe, or when the standards of care could be compromised. Good incident reporting systems should also have been put in place by now.

So why are we still hearing of situations where things have not improved? Why have some DHBs been reluctant to implement the report's recommendations? Why are some DHBs still blaming staff when an adverse event occurs, rather than focusing on the systems and processes the CoI recommended to help prevent such events?

Nurse and patient at risk

NZNO was recently advised of a situation in a recovery room where a nurse and the patient were both exposed to an unsafe situation. The rest of the recovery team was involved in a procedure with another patient in the adjacent operating room, and the nurse was left alone with a patient emerging from anaesthetic. The theatre assistant/orderly had been sent off to collect some equipment. On emerging from the anaesthetic, the patient became agitated and was thrashing around quite violently on the gurney. The nurse attempted to restrain the patient to prevent them coming to harm but was unable to reach the alert bell or summon assistance in any other way. The nurse resorted to giving the patient a chemical restraint, which calmed the patient and protected them from harm, with no adverse outcome. This nurse is now facing disciplinary action for administering a drug that was not ordered.

This example clearly shows up a number of issues that contributed to a nurse and a patient being put at risk. The right people were not in the right place at the right time to deal with this contingency; the environment and technology did not facilitate alerting others that assistance was required. Team work was not evident, as no one from the team in the adjacent room checked to see if their colleague was okay. Following the incident, there was no opportunity for processes to be put in place to ensure the situation wouldn't be repeated. Instead, the staff member was put through disciplinary action when the incident should have been viewed as a critical incident debrief.

Was this an example of the "system" failing? Should there have been more staff and should the next procedure have continued before there was adequate personnel to safety cope with all contingencies? Was this a positive practice environment?

We hope the SSU will facilitate the development and implementation of a range of initiatives that will contribute to more positive practice environments, improved standards of care and quality outcomes for patients.

By industrial adviser Glenda Alexander