THE HON. MINISTER FOR HEALTH
Government Hospitals
Omitting Wooroloo, now staffed independently, Government hospitals are 41 trained nurses short and 52 trainees short. As a set-off to the deficiency of trainees, an additional 84 nursing assistants have been appointed, effecting an excess in untrained staff of 32.
The Government is giving close attention to the provision of facilities for the training of these nursing assistants.
Wooroloo Sanatorium.
Wooroloo Sanatorium is short 9 trained and 8 untrained staff. Discontinuance of the employment of general nursing trainees at Wooroloo for some time created a serious staff shortage in untrained categorises. This has now been largely made good by the appointment of 52 persons training as tuberculosis nurses, of whom 38 are males.
Country Board Hospitals.
Country Board hospitals are short 59 trained and 15 untrained nurses.
The over-all figure for untrained personnel reflects practically complete elimination of the shortage existing three months ago – a deficiency of 1, compared to a deficiency in March of 101. Distribution, however, is irregular and a shortage of 15 exists through country Board hospitals.
For your information, 60 general nurses have passed their final examinations and are expected to be approved for registration by the Nurses’ Registration Board this afternoon. 16 midwives will sit for their final examination as midwifery nurses towards the end of July.
C. E. Cook
COMMISSIONER OF PUBLIC HEALTH for W.A.
18.6.1947
Nursing Shortage in Western Australia – 1947
The following is an attempt to analyse the factors concerned in the current shortage of nurses, a study of which will, it is hoped, indicate the measures necessary to solve the hospital staffing problem.
- TRAINED NURSES
Hospitals other than Private Hospitals in Western Australia are 217 trained nurses short of the number necessary to maintain adequate staffing on the basis of a 44-hour working week.
Factors operating to produce this deficiency include:-
(a) Increased demand by the public for admission to hospital:
In 1911 public hospitals in Western Australia provided accommodation for only 31 per thousand of the population compared to 108 per thousand in 1946.
In 1911 the ratio of nurses to patients in Public Hospitals was 1 to 24 compared to a ratio of 1 to 48 in 1946.
It is apparent that the demand for hospital beds has far out-stripped the provision of trained staff for hospitals.
Factors contributing to this increased demand include:-
(i) Elimination of Home Nursing.
The Nurses’ Registration Act, 1921, and the Midwives Registration provisions of the Health Act, who was formerly available to nurse patients in their own homes whilst the urge for employment outside the home has removed therefrom the bulk of those members of the family who formerly would have been available to care for its sick.
(ii) Elimination of the Private Nurse.
In the earlier years after the Registration Acts a considerable number of registered nurses engaged in private practice nursing cases at home. Several factors have since operated to eliminate this class of nurse:-
Depletion of domestic assistance in the home which has induced nurses to avoid a type of practice which inevitably involved performance of menial household tasks.
Increasingly exacting demands for proficiency made by medical practitioners. Under the influence of advances in medical practice, medical practitioners found it preferable to admit cases to private hospitals.
Realisation by the private nurse that hospital practice offered better conditions and remuneration. The increased demand by hospitals for staff consequent upon the increasing demand for hospital accommodation has gradually diverted the private nurse from home to hospital practice.
Greater facility of nursing the same or a greater number of patients in hospital as compared to nursing them in their several homes or flats.
(iii) Increased use of Tenements and Flats as Dwellings.
In 1911 the ration of the population occupying flats and tenements to those occupying private homes was 1 to 20. At 1933 census this ration had become 1 to 12. The discomfort and disabilities of nursing under flat and tenement conditions has driven increasing numbers of sick into hospital.
(b) Reduction of Working Hours.
In 1911 working hours were considerably longer than they are today, most nurses working without question 54 to 60 hours a week. The statutory nursing week in 1947 is 44 hours.
(c) The low output of graduates from Western Australian training schools in 1943, when there was a reduction of 36% on the figure for the previous year.
Factors associated with the outbreak of war in 1939 doubtless contributed to this fall.
Factors contributing to the diversion of Trained Nurses from hospital practice after graduation include:-
(a) Incompatibility of Temperament.
Nursing as an avocation is not one carrying an enduring appeal to most women.
A successful nurse today must attain a high proficiency in an extremely technical training, annually becoming more specialised and intricate with the advance medicine and surgery and with the delegation to the nurse of many procedures formerly regarded as exclusively the proper field of the medical practitioner.
In addition to being trained to allay suffering she must possess a personality which will enable her to dispel fear and anxiety and inspire confidence in the patient.
The exacting nature of nursing practice nowadays with its demand for relentless elimination of waste time and for high pressure attention to more specialised duties in the absence of even untrained assistance tends to eliminate that contact with the patient that psychologically is of such value both to the nurse and to the patient. Furthermore nursing under these conditions frays the nerves of the nurse and in many induces an irritation and exasperation which destroy that spirit of idealism which characterised the nurse in the early years of the profession’s development.
In such situations minor disabilities of accommodation, lack of amenities and social intercourse in leisure hours to which the individual might have been tolerant or adaptable at other times are magnified into major disabilities and the nurse speculates enviously upon the advantages enjoyed by her sisters in less exacting occupations with equivalent salary and a more regular roster or limited hours.
By providing the nurse with a choice of domicile in the metropolitan area where she can choose her own accommodation and provide her own amenities they compare favourably to hospital service particularly where the daily routine is beset by minor irritations increasing each day in number and in important as the nurse broods upon them.
(b) Exacting Standards.
The rising standard of technical proficiency required by medical practitioners of nurses tends further to eliminate some who formerly would have passed muster as trained nurses of average quality.
(c) Migration.
There is no opportunity for training in Infant Health in Western Australia. Nurses who wish to take the third certificate must leave the State for the purpose.
Opportunities for training in midwifery are limited in Western Australia. There is only one training school for midwives (King Edward Memorial Hospital, Subiaco) and its training capacity is limited by the restricted number of public beds. Pressure by private practitioners unable to obtain accommodation for their patients in private hospitals is constantly being directed towards reduction of the public bed allocation. King Edward Memorial Hospital cannot provide instruction for all the general nurses graduating from the general training schools of Western Australia in any one year and nurses who are not prepared to wait until called up proceed to the Eastern States for training.
The opportunities offered ex-service nurses to undertake refresher and post-graduate courses without expense to themselves, have been frequently used as a means of travel to the Eastern States where influences towards diversion from nursing operate even more strongly than they do in Western Australia.
RECOMMENDATIONS:
Little indication for practicable immediate action emerges from study of the forces causing the current shortage of trained nurses. For the future guidance of policy, however, it may be concluded that:
(a) Reversion to home nursing should be facilitated and encouraged. This may be attempted by the training of girls in elementary nursing before they leave school. The curriculum should include Anatomy, Physiology, Hygiene, Asepsis, elementary surgical and medical training and the general care of the bed ridden.
Girls as part of their training should serve some weeks in the district hospital and on passing an examination should be issued with a Certificate of Competency in home nursing by the Nurses’ Registration Board.
The service of these girls in country hospitals will in some measure relieve staff shortage and might be recommended at Nursing Assistant rates.
Many who otherwise would not have considered nursing as a career might under the influence of this training be attracted to the profession.
(b) The appointment of trained nurses, particularly of double and triple certificated nurses to Departmental administrative duties is unsound policy.
(i) It diverts trained nurses from hospital practice.
(ii) It virtually involves waste of a vacancy in a training school during the currency of their training.
When nurses are selected for these appointments they should be drawn from the ranks of those who for any reason are unsuitable for hospital practice. For the rest consideration might well be given to providing a special training for these appointments.
Further reference will be made to this suggestion at a later stage.
- TRAINEES
The known deficiency of trained nurses in public hospitals in Western Australia is 217, and the estimated deficiency in private hospitals 83 – a total of 300.
Public hospitals require a trained staff of 540 and licensed private hospitals 250.
It is estimated that not less than 10% of trained nurses are lost to hospital nursing each year by death, marriage, retirement, migration, and diversion to extra hospital practice – a total annual wastage of approximately 80 for Western Australia, when hospitals are fully staffed.
Before the deficiency of 300 can commence to be overtaken the training schools of Western Australia must produce sufficient nurses annually to make good this 10% wastage.
Training schools in Western Australia can, as at present constituted, produce 180 trained nurses per year. It is estimated that within twelve months of graduation 20% of these will be lost to hospital nursing by marriage, migration, or diversion to commercial practice. Their nett annual yield therefore approximates 144.
After providing for the normal average wastage an annual yield of 144 will not reduce the existing deficit of 300 under four years.
The output of existing training schools is not likely to be materially supplemented by immigration from the Eastern States or from elsewhere in the world. Of nurses registered in Western Australia only 10% were not trained in this State, and this number will be little more than offset by migration from Western Australia. It has become, therefore, an inescapable necessity to increase the output from training schools by augmenting the numbers passing through existing schools, by extending training to other hospitals, or by both of these methods.
Meantime major country hospitals formerly partially staffed by trainees who served a portion of their training at Wooroloo, are short-staffed to the extent of 191 untrained nurses. This deficiency must be made good either by expanding training or by substituting nursing assistants.
(a) Decrease in output from existing training schools.
The present effective capacity of West Australian hospitals is 144 trained nurses per annum. This may be doubled with occupation of the new Perth Royal Hospital, but cannot be materially increased for at least three years. Actually owing to poor recruiting at recent years it may not be approached in 1947.
Trainees entering during the current year at Perth Royal Hospital are expected to total 144, but earlier classes show that this is the impassable maximum for the existing building.
The effect of increased training in Perth Royal Hospital will not be felt for another three years. Meanwhile country hospitals remain unstaffed unless some other source of nursing supply is tapped.
(b) Part-time training in Country Hospitals:
Persons in opposition to full-time training in country hospitals have suggested that girls in training at metropolitan training schools should serve portion of their time, say, three months, in country hospitals. It is submitted by the protagonists of this plan that such a period would not materially interfere with their training in a major hospital and at the same time staff would be provided for the country hospitals.
This suggestion does not survive critical examination. Omitting Kalgoorlie hospital, the qualifications for which as a full-time training school are beyond dispute, 120 nurses are required for country hospitals. If these girls are drawn from metropolitan hospitals to serve one-twelfth of their training time in the country it follows that 1440 will be required to supply the demands of a 3 months term. Similarly a six months term will need 720 and a twelve months term of 360.
The total personnel of the metropolitan training schools to-day is 450. If 120 girls for country hospitals be added a maximum of 570 is required. Unless the accommodation and nursing material in the metropolitan hospitals is to be subjected to excessive demand these girls would require to serve nine months each in the country.
Whilst this may be found practicable it is apparent that the suggestion for a three months’ training period in country hospitals is not.
It must further be considered that this rotation assumes that country hospitals will be staffed by girls drawn from all years in the metropolitan training schools. As far as the latter are concerned this would facilitate necessary movement of personnel but inevitably for the first three years of the operation of the scheme country hospitals would be principally staffed by girls in their first year and would not be fully staffed until the third year.
It may be possible later to evolve a system whereby trainees at country hospitals obtain one year’s experience at Kalgoorlie or at a Metropolitan Hospital, but the reverse – movement of metropolitan trainees to country hospitals is not practicable.
(c) Full-time training in Country Hospitals:
It is estimated that the 10 major country hospitals – Kalgoorlie, Northam, Bunbury, Geraldton, Callie, Narrogin, Albany, Merredin, Katanning and Busselton could provide for the training of 200 nurses provided suitable residential accommodation is available.
Provision of training facilities in country hospitals may be expected to increase the number of applicants for training.
Many parents will refuse their consent to a daughter leaving home before 21 years of age. Under necessity of choosing an occupation such a girl will be restricted to those opportunities offering in her home town. Half the available labour pool is resident outside the Metropolitan Area and the loss of recruits incurred in this way must be considerable.
Kalgoorlie, Northam, and Geraldton with a three year course should complete the training of approximately 40 nurses per year, and the remainder, with a four year course, 20 per year – an annual output of 60.
Objection to the use of these hospitals as training schools may be taken in certain quarter on the following grounds:-
(i) Some of the hospital provide such inferior accommodation for staff that nurses will become discontented and terminate their training before graduation.
(ii) Country hospitals are usually so badly designed and constructed that they do not facilitate efficient nursing. This will impair the quality of training and contribute towards discontent precipitating termination of service.
(iii) Equipment in these hospitals is out-moded, defective, or deficient. Nurses cannot, therefore, be adequately trained in modern practice, will learn bad habits, and cannot be expected to achieve a standard of practical proficiency acceptable to the Registration Board.
(iv) The supervising and tutorial staffs of Government hospitals are more or less permanent Officers of the Public Service who over a period of years have served in small rural hospitals where the standard of practice is low. Many were trained in a period since which there have been considerable advances in nursing practice with which their country service has not made them familiar, and they have remained in the public service under influence operating towards the natural selection of the least efficient. Many may not be competent to serve as instructors for trainees aspiring registration.
(v) The low bed average in the smaller hospitals reduces the amount of nursing material available to trainees thereby depriving them of experience to be gained in larger hospitals and impairing the quality of their training.
The first four of these objections must be met by appointing competent persons to ascertain how true these charges are and to make recommendations, which should thereafter be promptly implemented to correct any defects to which attention is called.
The fifth is based upon the fallacies assumption that the hospital of 300 beds offers a girl 10 times the material that is offered by a hospital of 30 beds.
In point of fact a girl nursing in a hospital of 300 beds will serve, throughout her training, in wards of 40 beds or less and will share the patients in that ward with three or more other trainees. The patient material available to her, therefore, day by day, is in fact not greater than is available to her in the smaller hospital.
It is true that in the larger hospital a trainee during any given period, nursing as she will be in a ward exclusively devoted to a certain type of case, may during that period receive more intensive training in that particular field, but on transfer to another ward accommodating a different category of patients she will cease to be concerned with the first category.
In a small hospital, on the other hand, she will be likely to nurse a wider variety day by day and in the aggregate over the longer period of training will gain as much experience in the basic fundamentals of nursing as she would in the larger hospital.
The advantage usually claimed for the larger hospitals is the wider experience gained in the special and more infrequent types of cases – more particularly surgical. This advantage, though real for the medical student, is illusory for the nurse.
The fundamentals of nursing training are the same in each category of nursing activity, and although the girl in the small hospital may not see the rarer cases seen by the girl in the larger metropolitan hospital, she will in the aggregate nurse as many cases of that general category. In any event, the vast majority of trained nurses will ultimately not be employed in the Metropolitan hospitals and their competence for nursing elsewhere can only reasonably be measured by the demands made upon them in their field of service.
Too much emphasis it is felt can be placed upon the value of the training of a nurse in metropolitan hospitals. Fifty per cent of the cases nursed in Western Australia are nursed in country hospitals and comparatively few of the nurses trained in any year will ultimately serve in the major hospitals of the metropolitan area.
It cannot be disputed that country hospital can efficiently train nurses to the standard necessary for their efficient service in the country.
There is an increasing tendency to delegate to nurses in the greater hospitals more and more work of a highly technical and specialised character which was formerly regarded as the exclusive prerogative of the medical practitioners. Whilst theoretically the standard of nursing is raised by the assumption that the trained nurse must be competent to undertake these functions, the fact remains that a great majority of nurses registered by the Nurses Registration Board in earlier years could not pretend to possess this competence, and the vast majority of nurses in nursing practice will, and can never exercise it.
Meantime the mass of the sick public in country hospitals must be nursed by women who have and can hope to secure no training whatever.
It is fallacy to argue, as many do, that the training of nurses in smaller hospitals will involve the lowering of the standard of nursing. In point of fact the standard of nursing is determined by the competency of nursing practice throughout the State and in other States.
In other States of the Commonwealth with which this State has reciprocity nurses may be trained in hospitals with a daily average of ten beds These women may apply for and receive registration in Western Australia as trained nurses and thereafter be appointed to positions as sisters or matrons of country or even of metropolitan hospitals. It is ridiculous under these circumstances to suggest that girls should be refused the opportunity to train in 20 and 40 bed hospitals in their own State in order that the standard of nursing may not be lowered.
A serious obstacle confronts country hospitals at present in an effort to maintain a bed average qualifying for approval as training schools. In a hospital with a normal daily average of 25 beds, for example, the shortage of trained nurses may have reduced the trained staff to 50% of requirements. In order to relieve the strain upon the staff it is necessary to limit admissions so that the daily average is maintained in the vicinity of 15 to 18.
Because the hospital is not, and with that daily average cannot be a training school it is not possible to recruit or retain for the assistance of the trained staff girls of a type qualified to train as nurses. The hospital therefore must have recourse to staffing by nursing assistants. These are untrained and under present conditions untrainable, so that the more highly specialised duties of nursing and the responsibilities still remain with the trained staff. Hours worked by the latter cannot be shortened and their work in the wards is not materially reduced, except at the expense of the patients’ welfare. It is still therefore not possible to raise the daily average to a level permitting approval as a training school.
There is yet another serious difficulty here involved. Where the staff of a hospital is less than 80% normal strength its members are paid a Disabilities Allowance. Sisters in a hospital such as that under discussion, therefore, will receive additional emoluments as long as the shortage of staff continues.
If, however, it is possible to appoint a number of nursing assistants sufficient to raise the total staff to over 80% of normal irrespective of the proportions of trained and untrained individuals, the Disabilities Allowance will cease.
Trained nurses working in a hospital staffed by 20% of the normal trained staff but with sufficient untrained assistants to make the numerical strength of the whole staff, over 80% of normal, are not entitled to the Disabilities Allowance. Nevertheless by virtue of their being trained they must still perform most of the nursing and remain on duty as supervisors for tours of duty no less than if there were no untrained assistance.
The tendency therefore is for the trained staff to discourage the appointment of nursing assistants, who do not relieve them materially in the wards either of nursing duty or responsibility and to limit hospital admissions retaining the Disabilities Allowance as some recompense for overwork.
Consideration should be given therefore to re-drafting the conditions of the Disabilities Allowance so that it refers to the proportion of trained staff and untrained staff severally, rather than the total staff indiscriminately.
SUMMARY:
- It is necessary to increase the number of trainees by at least 200.
- This cannot immediately be implemented by existing training schools but could be effected by commencing training in major country hospitals.
- Such an extension may be expected to attract girls who at present for any reason will not leave country towns to train in Metropolitan Training Schools.
- Unless major country hospitals are constituted training schools, they must remain unstaffed, or unsatisfactorily staffed for at least three years.
- There is no reason why major country hospitals should not be training schools provided the standard of nursing practice, equipment, instruction and accommodation is assured beforehand.
- In order to facilitate rehabilitation of hospitals fallen below critical bed average the Disabilities Allowance should be revised to relate to the proportion of trained to untrained staff severally and not collectively.
- NURSING ASSISTANTS
In all hospitals which are not training schools it is necessary to supplement the trained staff by women who undertake minor nursing duties and duties of a semi-domestic character to relieve the trained staff for more special and technical procedures.
These women are especially employed by private hospitals and by country hospitals which are not training schools. Originally little more than Ward Domestics they have of necessity, during the period of nursing shortage, more and more invaded the field of the trained nurse and of the senior trainee.
Several Government hospitals which were formerly part-time training school and which now have no trainees, have been partially staffed with nursing assistants. A few country hospitals retain only their Nursing Assistant staff.
If these girls can comply with the age and educational requirements of the Nurses’ Registration Board they may ultimately transfer to training schools and become qualified nurses. For the most part, however, they lack the educational standard upon which the Nurses’ Registration Board insists.
Latterly the demand for trainees by training schools having been roughly commensurate with the number of girls offering, most of the eligible nursing assistants have transferred to training schools.
Nursing Assistants, therefore, usually comprise girls who have not yet attained the age of 18 years entitling them to train, or who do not possess the educational qualifications required by the Board.
Application is not infrequently made to the Board for the recognition of part of the service of these girls towards their training for registration. The difficulties confronting the Board in considering these applications are principally:-
(a) The educational standard of the application:
It is felt that nursing in its higher branches has become such a technical occupation that the educational standard cannot be safely lowered without admitting girls who will be unable successfully to complete the more specialised training in their later years and comprehend the more intricate details of nursing practice in relation to modern medicine. On the contrary it is felt that the educational standard might well be raised.
This difficulty does not appear to be insuperable. If the Nurses’ Registration Board will accept attainment of the educational standard at a date before final examination, or at least defer the test until two years after commencement of training instead of insisting upon its application before commencement of training is approved, it might be possible in many cases by arrangement with the Education Department to have the educational standard of the girls substantially raised during the period of their training.
Alternatively, where a girl commences nursing in a country hospital at the age of 15 or 17 she might devote that time to bringing her educational standard up to the level of that required by the Board.
(b) The age of the applicant:
Quite frequently nursing assistants commence service in hospitals at the age of 16. Ordinarily it is not possible for a girl to obtain the approval of the Board to train until she has attained the age of 18 years. It is, however, discretionary for the Board to lower the age of entry within narrow limits. Since a girl cannot be registered as a nurse until she is 21 no great hardship is involved in her being refused to the right to train until she is 18, provided she can be subsequently enter a three years’ training school. If, however, she is unfortunate enough to be posted to a four year’s training school she will be anxious that part of her time in a small country hospital should count as training time for purposes of the Board.
The Board’s objection to crediting a girl with time served as a Nursing Assistant is based on:
(i) Country hospitals are usually so ill-equipped that the girl in her formative years learns bad nursing practice which her subsequent training may not eliminate.
(ii) They may be staffed by senior nurses who through defects in their own training, apathy, or lack of interest, are not competent to train girls as nurses, so that the value of the time served is largely lost.
(iii) The bed average of the hospital may be so low that the nursing material available to the trainee is inadequate.
(iv) The medical practitioner may be incompetent or unwilling to undertake his share of the girl’s training.
It is felt that none of these difficulties are insuperable provided they are energetically attacked with the will to overcome them.
A number of girls must be lost to nursing owing to the interval between leaving school and attaining 18 years of age. The age limit for entry to a training school may well be lowered to 17. Particular is this so in the case of a girl who has already served some months in the wards of a hospital.
Whilst it may be true that poor equipment in one institution will impair the training of a nurse it may reasonably be advanced that in a small hospital where this objection is not sustained a nurse should not be penalised by application for the generalisation. Similar comment may be made concerning objections in respect of nursing staff and medical practitioners.
The Board might well, in the interests of extension of training, not only ascertain how far these objections actually exist in an individual country hospital, but make representations to the proper authority to have them remedied. Once remedies to the satisfaction of the Board a girl might reasonably be credited with a portion of her time of service.
This may indeed be advanced as a responsibility of the Nurses’ Registration Board, for the girls are in fact nursing for remuneration and it is, or should be, of viral concern to the Board to see that wherever employed, they are properly trained.
The standard of nursing may be regarded as bad in direct proportion to the nursing assistant – trained nurse ratio. Nursing Assistants must be trained whether for registration or not.
SUMMARY:
(a) Nursing Assistants should be encouraged to train. This will require in certain cases:
(i) Assistant to attain the educational standard.
(ii) Modification of a minimum age limit for entry.
(b) Consideration should be given to inspection and training supervision in hospitals employing Nursing Assistants so that the Board may satisfy itself they are receiving a proper grounding whether or not they intend to train for registration.
- MIDWIVES
Legislation to provide for the training and registration of midwives was introduced under the Health Act in 1911. Previously it had been permissible for any woman to assist at childbirth and it was usual for even the smallest township to have a number of women who for reward attended mothers during labour and the puerperium with or without the advice of a medical practitioner.
Some of these women under the tuition of medical practitioners with whom they worked attained a certain degree of efficiency as midwives, even judged by modern standards; others learned little or declined to be taught refusing to admit that they were not fully competent.
Some merit, in many of these midwives, attached to their confidence in leaving the progress of their cases to nature. “First do no harm” – may not have been their acknowledged slogan, but it was commonly in fact their guiding principle.
It was believed that most of these women were a fruitful source of obstetric calamity and puerperal infection and in order to raise the standard of obstetric nursing “The Protection of Life” sections of the Health Act provided for the registration of practising midwives, the prohibition of practice by unregistered midwives, and the approved training of all women thence forward aspiring to become midwives.
A feature of obstetrics nursing practice in those days which was possibly not important at the time but which has become of first important since, was the function of midwives in rendering domestic and housekeeping service to the patient’s family during the lying-in period. With the reduction in the number of midwives as a result of the training requirements and insistence upon an educational standard, it was impossible for registered midwives to spare the time for this service even if they were prepared to suffer what they came to regard as the indignity of performing it. When there was ample domestic assistance for the family in the home or nearby this may have been a small consequence, but more recently the extreme difficulty in obtaining domestic help has made confinement in the home a matter of acute embarrassment.
There has, therefore, been an inevitable trend towards maternity hospitalisation, a trend which has been sedulously fostered and financially assisted by successive Governments until today it is the rule rather than the exception and there are few who do not use the maternity allowances for the purpose of ensuring confinement in hospital, private or public.
In common with the public hospitals in Western Australia private hospitals have been seriously embarrassed by the shortage of trained nurses. A total of 256 private maternity beds, sufficient to accommodate 7000 mothers per year are licenced in W.A. Returns show that these beds during the past year together with a number of unlicensed beds introduced to meet the unprecedented demand for admission, have been consistently fully occupied.
Births in 1946 exceeded 12,000 of which 3,500 took place in major public hospitals.
There is only one training school for midwives in Western Australia – King Edward Maternity Hospital, which is capable of completing the training of some 60 midwives each year. It is probably impossible for this number to be exceeded even if the number of trainees is increased, because the Nurses’ Registration Board requires that each trainee shall deliver not less than 20 cases personally.
The inability of medical practitioners to obtain nurses to attend mothers in their own homes, the progressive reduction in the number of maternity beds consequent upon the closing of maternity homes and private hospitals unable to secure staff, and the persistence of mothers in demanding admission to private beds in King Edward Maternity Hospital so that they may retain the services of a medical practitioner whom the Commonwealth maternity benefit enables them to pay, all operate towards a reduction in public beds in the State’s only training school.
The contentious question arises whether the average medical practitioner, particularly when busy and in a hurry, is a preferable accoucheur to a properly trained midwife. If he is not, the enlightened course would appear to be to eliminate the medical practitioner from obstetric practice in the training school, except to the extent necessary for the training of midwives, the training of medical practitioners, and the retention of a specialist staff for abnormal cases.
If on the other hand it is premised that the medical practitioner is the best accoucheur or is the accoucheur of preference, it would seem unnecessary to demand that standard of manipulative dexterity in the midwife which present practice implies to be necessary. Midwives could then be trained in the actual nursing of obstetric cases more expeditiously than is possible now.
An even more acute embarrassment will attend the development of a Medical School in Perth, when the limited number of public beds available will require to be shared between the obstetric nurse trainees and medical students.
The availability of midwives is reduced by the appointment of women holding double certificates to hospitals and other appointments where they will not practise midwifery.
There offers no opportunity of expanding the current system of training for midwives in this State. The only public hospital with a bed average of obstetric cases adequate to meet the requirements of the Nurses’ Registration Board is Kalgoorlie. Here practically all patients are under contract agreements with local medical practitioners who expect, and who are expected to attend the mother at the time of delivery. Admissions to the maternity ward at Kalgoorlie Hospital, therefore, are not available for the training of nurses.
The present tendency is for General Nurses to proceed to the “double certificate” by undertaking nine months training after obtaining the general certificate. Previously untrained girls served 18 months in their obstetric training. The number of General Trained girls available during the next two years will be unusually small. If the number of midwives is to be increased it will be necessary to admit for training to King Edward Hospital a larger number of untrained women.
Meantime sheer necessity will, in country areas, increase the number of wholly untrained women attending maternity cases and inexorable forces are compelling reversion to the pre-1911 Sarah Gamp type of midwife.
As the annual member of births has risen beyond the normal obstetric provision, so the still birth rate has increased disturbingly. It is significant that this increase in the still birth rate is a feature of urban practice rather than of rural.
In the first six months of 1946 the still birth rate for the Metropolitan Area reached 30.78 per thousand confinements compare to 17.52 in country districts.
The respective rates for 1942 were 21.35 and 19.81. During the same period the State maternal mortality fell from 2.76 to 1.83 per thousand births. Once cannot but be feared to the conclusion that the overloading of reduced hospital accommodation, to which there is no alternative, the strain upon depleted nursing staffs and the haste and pre-occupation of busy city medical practitioners, has led to a serious deterioration in obstetric practice resulting in a deplorable wastage of infant life.
SUMMARY:
The Health Authority and the Nurses’ Registration Board must consider whether:
(a) The imposition of restrictive standards upon private buildings whilst reducing maternal mortality has imposed upon the licensed a burden of overwork which they cannot safely perform.
(b) Raising of the standard required of midwives, by preventing the normal case obtaining reasonable safe partially trained attention, has restricted obstetric practice to a few midwives who cannot safely cope with the volume of work now thrust upon them so that medical practitioners are driven to expedients which have raised the still birth rate by 50%.
(c) The training of medical practitioners who propose to practise obstetrics should not be made to conform to a higher standard and whether the competence to practise obstetrics should not cease to be implicit in the right to general practice carried by Medical Board registration.
(d) The standards required in the training of midwives should be lowered to permit the more rapid training of women competent to assist the medical practitioner at delivery, or whether it should be raised so that midwife may be available to displace the less competent general practitioner.
CONCLUSION:
All expectations of the probable success of measures designed to facilitate the training of nurses must be tempered by appreciation of the available labour pool.
It would be an advantage therefore, briefly to study the salient factors affecting the labour pool of females (aged 15-19) at different periods. Expressed as a percentage of general population this group has shown persistent decline in the last two decades.
In 1911 the birth rate in Western Australia was 28.2 per thousand of population. By 1931 it had dropped to 19.8 so that there must be proportionately much fewer girls of 16 years of age in 1947 than there were in 1927. Subsequently to 1931 the birth rate continued to fall until 1935 when it was 18.23. It varied between 18.84 to 19.87 until 1941 when it rose to 21.35.
The trend in the female age group 15 to 19 years between 1936 and 1950 as calculated from birth rates in relevant years is graphically shown on the attached chart (not attached). This reveals that during 1946 the number of females aged 15 to 19 was slightly greater than the mean between 1939 and 1944 and appreciably greater than in earlier years.
Subsequently to 1946, however, the graph falls steeply until in 1949 and 1950 the figure is well below any in the previous decade. This suggests that the pool from which female labour may be drawn in the next few years is rapidly shrinking and calculations regarding the availability of girls to undertake nursing must be modified accordingly.
The high birth rate of recent years must be expected to swell the school age groups after 1950, and the available labour pool for trainee nurses will be increasingly taxed by extra demands for teachers.
Certain it is that expansion of training has better prospects in 1947 than in any later year before 1951 and that each successive year will provide less and less raw material.
Nevertheless at 30th November, 1946, 285 vacancies were offering for female juniors in all branches of industry in Western Australia. For these vacancies there were only 49 applicants, a number which would have been inadequate even to supply the requirements of hospitals.
Again the influence of the marriage rate of miners in reducing the number of girls likely to be immediately available to commence training is of interest.
In 1938 the marriages of 775 females under the age of 21 were registered. In 1944 this number had increased to 1,327. The estimated number for 1946 is 1,332.
Recent figures for the employment of females it has not been possible to obtain, but the percentage of females employed in gainful occupations rose from 18% in 1911 to 24% in 1933. 1933 was a post-depression year and the proportion of females since entering industry is probably even greater so that the field of choice available to girls has extended even while the number of girls available to supply the labour demands has been limited by a falling birth rate and by the increased juvenile marriage rate of the last few years. Maintenance of the current juvenile marriage rate in synchronization with the falling population in the age group 15 to 19 will materially reduce the potential nursing labour pool during the next few years.
It will be necessary, therefore, to attack this problem in several ways:
(a) The number of training schools must be increased immediately.
(b) Encouragement must be given to nursing assistants to train as nurses. Consideration should be given to their being credited with the service period in approved minor country hospitals. Suitable supervising and assistance should be given them to attain the educational standard desired by the Board.
It is worth of notice that the girl who undertakes work as a Nursing Assistant under the present trying and frustrating circumstance may in fact be the most desirable type to train as a nurse and every opportunity, therefore, subject conservation of the nursing standard should be given her to train.
(c) Hospital administrations must be reconciled to an enduring nursing shortage and steps must be taken to modernize equipment and modify nursing practise for the purpose of conserving effort and reducing the waste of labour to a minimum. Influences attracting girls away from nursing should be, as far as possible, eliminated by improving accommodation, amenities, working and domestic conditions.
It will be impossible under the influence of persisting nursing and labour shortage and a competitive call of less arduous avocations to eliminate all these factors which destroy the will to nurse in a girl who is not a nurse at heart, but the less impatient at least may be retained.
(d) Increased use of Male nurses. Male nurses may train under the same conditions as female nurses. The employment of Male nurses though more costly has the advantage that marriage does not, with them, as it does with girls, involve retirement from nursing.
(e) Consideration may well be given to meeting the impending emergency by assisting return to home nursing so that the strain on hospitals may be eased. This might be achieved in a variety of ways:
(i) Girls before leaving public schools should be trained in the elements of general nursing, aseptic routine, the administration of drugs and application of dressing. This may inspire in a proportion, who otherwise would give the matter no thought, a call to adopt nursing as a profession.
(ii) The licensing of sick attendants by the Nurses’ Registration Board. This licence should permit the holder to nurse for reward ailments not requiring the more highly specialised procedures of modern medicine and surgery. Further reference will be made to this suggestion later.
It would be well, therefore, if the Nurses Registration Board of Western Australia, in association with analogous boards in other States, gave close consideration to the following:-
(a) Legislation designed to improve nursing service for the public has produced a situation where it prevents 50% of the sick obtaining even moderately competent nursing attention. Some method of relating the supply of non-specialised nurses to the demands of the community must be solved. The present problem is not less serious than that which this legislation was intended to correct and the time has obviously arrived when the legislation itself must be reviewed and where necessary recast. Reform is inevitable and it will be better if it be unhurried.
(b) The assistant nurse, originally a ward domestic has become, untrained, the mainstay of rural nursing staffs.
These women nurse for gain and it is impossible for Nurses’ Registration Boards longer to exclude them from the ambit of registration legislation.
(c) The labour pool from which trainee nurses can be drawn is rapidly shrinking owing to social trends beyond control.
If the deficiency of trained nurses is to be made good the numbers in training must be immediately increased and measures to this end could not safely be deferred another year.
(d) The high standard of training demanded for nurses under the influence of advancing surgical practice in the great public hospitals, reduce the yield of trained nurses from training schools.
(i) By excluding many incapable of attaining it.
(ii) By restricting the number of training schools to the few hospitals capable of providing it, thereby reducing the annual yield below the minimum required.
(e) At the same time many registered nurses, trained in earlier years, cannot claim the proficiency of modern practice developed since their training days and now demanded of trainees. Nevertheless registration is afforded them without question.
(f) Many nursing assistants at present unqualified for training are in fact suitable for training and should be trained.
To meet this situation Boards should consider the following suggestions:
(a) All hospitals complying with present requirements of bed average should be constituted as training schools. All deficiencies of structure, equipment and professional staffing calculated to impair training should be rectified immediately so that recruiting may comment at once.
(b) Hospitals employing nursing assistants and of a bed average insufficient for the present requirements of the Board should be subject to inspection by the Board so that defects may be eliminated. After the elimination of defects the Board should prescribe a source of training for the nursing assistants there employed.
(c) Consideration may well be given to re-constituting the nursing profession and its training. It is suggested, for example, that there may be established two grades of nurse:
(i) A licensed sick attendant or junior nurse who may train to a special curriculum determined by the Board in an approved Hospital however small, and who may be licensed to practise for reward privately or in hospitals. Such a nurse would fill the role originally intended for practising nurses by the Act, and it is suggested that the training period should be three years in a hospital up to 40 beds and two years in a hospital of 40 beds and over.
(ii) The Nursing Sister who may be a nurse trained for three years in an approved major public hospital or one who after completion of the training for a licenced nurse has undergone a further two years’ training approved by the Board in a major public hospital. During at least one year of this training, opportunities should be given for specialisation.
(d) In association with Medical Boards, Nurses’ Registration Boards should consider the relative role and status of medical practitioners and obstetric nurses deciding whether priority in training and function is to be given to the one or to the other and how adequate training material for both is to be secured under a National Health Scheme entitling all mothers to delivery by a medical practitioner.
(e) Consideration might also be given to the establishment of two grades of obstetric nurse:
(i) A licensed nurse qualified to attend maternity cases in charge of a medical practitioner. In large training schools associated with public hospitals the training period for such a nurse might be somewhat shortened.
(ii) The Obstetric Sister – one who has completed an advanced training qualifying her to attend Obstetric cases independently or with an obstetric consultant.
C.E. Cook.
COMMISSIONER OF PUBLIC HEALTH