Nurse and Midwife to Patient Ratios Bill

Second Reading

Adjourned debate on second reading.

(Continued from 16 September 2025.)

Mr DIGHTON (Black) (16:01): I will continue my remarks. The legislation is another example of the Malinauskas government's continued commitment to ensuring the safety of our nurses and midwifery workforce within the Public Service.

Some of the benefits of having ratios include that mandated ratios help to ensure that our nurses are not overburdened, allowing them to provide timely and attentive care. The ratios also help to reduce nurse workloads and prevent burnout and stress fatigue, which are major contributors to staff turnover. A more manageable workload improves job satisfaction, helping to retain experienced nurses and attract new ones.

The ratios will help to achieve consistency in our health system by creating clear, enforceable standards across all public hospitals, ensuring equity and care regardless of the location. Ratios are tailored to different settings—general wards, coronary care and antenatal units—ensuring there is context-appropriate staffing. The ratios will also support planning and workforce development and will include a two-year rollout period, allowing local health networks to recruit and restructure as needed. It will also encourage long-term workforce planning and investment in nurse education and training.

Nurses and midwives are critical to the South Australian public health system and collectively comprise nearly 50 per cent of the state's healthcare workforce. They play a vital role in promoting health, preventing illness and delivering care across acute and chronic settings. The bill provides an important opportunity to pay tribute to the nurses and midwives in our community, and more broadly in our society, who provide such an important service.

My sister and brother-in-law, Danni and David, are both nurses and they live in my electorate as well; they are both constituents. Their dedication to their profession is so important. David, in particular, is an emergency services nurse and will often regale me with the challenges of working in our emergency departments. I have seen firsthand the impact their profession can have on them in terms of illness, in terms of being away from their family and in terms of working through shiftwork and managing the complex needs of their patients, and so I want to pay tribute to them and the many nurses in my electorate who do fantastic work.

I also want to take the opportunity to reflect on and again acknowledge the nurses and midwives, in particular, who have helped bring my two children into the world and helped care for them and for my wife Claire. As I spoke about in my very first speech, my family spent more time in a hospital than we would want for anyone, particularly through the birth, life and death of my son Clancy. There was a high level of care that Clancy received, and that we as parents received, both from the midwives who brought him into the world and the nurses who cared for him in the special care unit at Flinders and from the PICU team at the Women's and Children's Hospital.

Whilst losing Clancy was and is a devastation for our family, we feel so blessed that we had the opportunity to spend time with him. That was due to the amazing and wonderful work of the nurses who kept him alive so that doctors and specialists could try to determine the cause of his illness. Our experience demonstrated why it is so important that we have a well-funded healthcare system that includes ratios for the appropriate minimum number of nurses and midwives for the needs of our patients.

I want to emphasise that, over the past three years, the state government has already recruited more than 1,460 additional nurses and midwives. These additional nurses and midwives will help to ensure that there is the additional staff required to meet the ratios as provided in this legislation. I want to acknowledge the Australian Nursing and Midwifery Federation for their work in advocating for these ratios and this legislation. This bill complements the significant commitment that the Malinauskas government is making to our public hospital system. I commend this bill to the house and thank all our fantastic nurses and midwives.

Mr BASHAM (Finniss) (16:06): I rise today to speak on the Nurse and Midwife to Patient Ratios Bill and to highlight how its implementation may affect health services in the southern Fleurieu. There is no question that nurses and midwives are the backbone of our health system. They work long hours under immense pressure and provide compassionate care to our communities.

The intent of this bill to ensure safe and sustainable workloads is commendable. However, we must carefully consider what it means for regional services like the Southern Fleurieu Health Service. Victor Harbor and Goolwa, along with the surrounding communities, are experiencing rapid growth. Many retirees are moving into the region, adding to the demand placed on the hospital and aged-care services. The Southern Fleurieu Health Service is already stretched in meeting this demand, with recruitment and retention of nurses being a constant challenge.

The mandated ratios in this bill may have unintended consequences. If we cannot recruit enough nurses to meet the legislated minimums, the only option available to management may be to reduce the number of available beds. In practice, that would mean fewer patients can be treated locally and more families would be forced to travel long distances to Adelaide for care. For an older population, often without transport, that is not just inconvenient, it is unsafe.

We have already seen this story play out in aged care. When federal mandates required a registered nurse to be on duty 24/7 in residential facilities, many small regional homes struggled to comply. In some cases, beds were closed, services scaled back or facilities placed under financial stress because the staff were simply not available. Rather than improving care, those mandates sometimes left vulnerable residents worse off, forced to move away from their communities or waiting longer for a replacement. That is exactly the risk we run if hospital ratios are imposed without a workable plan to grow the workforce.

We must also remember that regional hospitals require flexibility. A smaller hospital like Victor Harbor does not operate in the same way as a major metropolitan hospital. Patient flows are different, staffing pools are smaller and there are far fewer options to bring in agency staff at short notice. Imposing the same rigid ratios across facilities risks tying the hands of local managers who know their communities best. Instead of a one-size-fits-all mandate, what the Southern Fleurieu Health Service needs is support to grow its workforce, to invest in training, for incentives to attract nurses to the regions, and for housing solutions to help staff live close to where they work. Safe workloads are essential, but we cannot legislate them into existence if the workforce simply does not exist to deliver them.

I urge the government to ensure this bill does not unintentionally reduce the health services in the Fleurieu. The people of Victor Harbor, Goolwa and the wider region deserve safe staffing levels, yes, but they also deserve accessibility care close to home. Let us make sure that this bill supports our nurses without compromising the services our communities rely on.

The Hon. C.J. PICTON (Kaurna—Minister for Health and Wellbeing) (16:10): I want to thank all of the speakers who have contributed to the second reading debate. As I said in my second reading speech, this is a landmark piece of legislation that we have introduced here in South Australia for the first time. While we have previously had nursing hours per patient day, which in some regards could be regarded as a ratio, it has not been exactly a ratio, it has not been as clear as that and it certainly also has not been legislated. So with the passage of this bill, hopefully through this house and the other place, we will be making this the law—the law of the land—that these ratios are in effect. This all comes back to patients, this all comes back to making sure that we have the appropriate care for our patients in our acute care system.

There is a lot of evidence that, having safe staff ratios, having the appropriate number of nurses per patient per bed helps to ensure safety, helps to ensure that we are delivering better care, helps to reduce the number of people who are readmitted to hospital, therefore reducing pressure on the system overall. This is a timely moment for us, as many speakers in this debate have done, to thank our nurses and midwives for the incredible work that they do caring for the patients of South Australia day in, day out, around the clock in our busy public health system.

This bill ensures that we as the parliament are saying that we support you, that we know the pressure that you are under and that we want to make sure that we have safe staffing—ultimately for patients, but also to make sure that we can manage the pressure on our nurses and midwives across the state as well. Ultimately, we need to make sure that we have a well-supported workforce so that they can care for their patients as well.

I mentioned a number of people in the beginning of this debate in the second reading stage. I would like to reiterate that in terms of thanking the Australian Nursing and Midwifery Federation, particularly the Secretary/CEO Associate Professor Elizabeth Dabars for her very strong advocacy to get us to this point, as well as the many other officers who work in the ANMF, and one who has within the past year or so left the ANMF, Mr Rob Bonner, who was a particular advocate of this to the now government before the last election. He has even been coming out of retirement to be part of several meetings, to make sure that we could get to this day of having this debate in the parliament.

I want to thank, in particular, a number of people in my department who have worked very hard to ensure that we could get to this stage including, obviously, all the nursing and midwifery team led by Jenny Hurley. I also really want to give a shout-out to the workforce team, led by Judith Formston and Gabrielle Starr, who have put in a huge amount of work to solve the puzzle of making sure that we can get this to this point where we have addressed the concerns of the ANMF, and also that we can make sure this is a workable legislation for SA Health. This has been successfully rolled out in Victoria and Queensland for some years. There are other states in a non-legislative way who are implementing ratios, and I am confident that it will be successful here in South Australia as well.

I would also thank Georgia Phillips in my office, senior adviser, who has done a lot of work on this legislation to get it to this stage. Just as we left here after the second reading stage, I had the opportunity to thank Kath Thomas who worked on this legislation in the Department for Health and Wellbeing. This is her final piece of work after a very long career in the public sector. She was joined by her niece who is just starting and has just got a job as a TPPP, as we call it—a Transition to Professional Practice Program nurse—next year in SALHN. It was particularly exciting to have her, as part of the future of our profession in South Australia, hear the debate and hear that this legislation is going forth.

This has been something that so many nurses and midwives in this state have fought a very long time for, and we are delighted that this will be a situation where for nurses in the future this will be part of standard practice of operation. I thank the opposition for indicating their support—of course, with their usual reservations, to put it mildly.

Mrs Hurn interjecting:

The Hon. C.J. PICTON: I heard some of the contribution from the member for Finniss, which raised a few concerns, but we thank the opposition for their support for this. I understand we are going to have some committee stage discussion about this, and I am hopeful that we achieve passage through this house. I commend the bill to the house.

Bill read a second time.

Committee Stage

In committee.

Clauses 1 to 6 passed.

Clause 7.

Mrs HURN: Minister, in relation to the application of ratios more broadly, how many additional nurses are required to meet the ratios?

The Hon. C.J. PICTON: We have done some detailed work looking at where this applies across the system, and that modelling has come out at 86 nurses and midwives.

Mrs HURN: As part of this proposed bill, is there any associated plan to put in more money to recruit nurses to meet the ratios?

The Hon. C.J. PICTON: Yes. We have a very significant budget for SA Health that increases every year. Obviously, in the context of the 50,000 people who work for SA Health, 86, while being significant, is also not an overbearing percentage of the 50,000 people who work for SA Health, so we are confident that we have the funding provisions to enable us to acquire those 86 extra people. Let's also bear in mind that over the past three years we have recruited over 1,400 additional nurses and midwives above attrition, full-time equivalent, so in that context as well that is a very small percentage of the nurses and midwives we have already recruited.

Mrs HURN: If the minister could clarify: is that 86 additional nurses and midwives who would be required now to meet the ratios, or is that at the end of the two-year moratorium?

The Hon. C.J. PICTON: As per the legislation, the aim is to achieve that full compliance at the end of the two years.

Mrs HURN: Clause 7(2)(c) provides that a ratio may be applied in a flexible way. Can you explain or give a practical example of what that means?

The Hon. C.J. PICTON: Very helpfully we have been able to sneak into the drafting some examples. Parliamentary counsel are no doubt listening and I know that they hate these being in here, so kudos to us for getting them through the legislation. If you look at the examples, they provide:

1. In a ward with 20 patients and a 1:4 ratio, plus a required nurse or midwife in charge, a total of 6 nurses or midwives (as the case requires) are required for the shift to comply with the relevant ratio.

2. For the purposes of paragraph (c) [which is what the member is referring to], in a ward with 8 patients and a 1:4 ratio, if 3 patients require a higher level of care and 5 patients require a lower level care then one nurse may be assigned to care for the 3 patients requiring the higher level of care and the other nurse to the other 5 patients.

What this is saying is that within a ward, while meeting that overall ratio, it is up to the trained clinical staff to make sure that there is the appropriate allocation of those resources for the patients who are in that ward—so meet the ratio overall but also make sure that we have the best deployment of those resources to meet the clinical needs that there are.

Mr ELLIS: I refer back to the answer to the first question that referenced modelling that had been done to uncover the fact that there would be 86 extra nurses. Does that extend to a hospital-by-hospital basis and could you answer what the net impact will be on nurse numbers at Wallaroo, Maitland and Yorketown hospitals?

The Hon. C.J. PICTON: We will have to take that on notice, member for Narungga.

Mr PEDERICK: In regard to the patient-nurse ratios, minister, does that mean with fewer nurses for patients in country areas we expect a lower level of care in country areas?

The Hon. C.J. PICTON: No, I certainly would argue not. What it reflects is a change in acuity. Obviously the member would be aware of the fact that our tertiary and quaternary sites are based in the metropolitan area and obviously, as has been the case for many, many years under successive governments, they have had a higher level of nursing hours per patient day and that translates to a higher ratio, or a lower ratio, I guess, if you put it that way, in terms of the number of patients per nurse. That is obviously based on the acuity of patients.

As the member knows, people who require a higher level of care do need to be transferred to those major tertiary settings and that is why obviously, as has been the case forever, there will be country people who are in metropolitan hospitals because they need that higher level of care.

Mr PEDERICK: So out of the 1,460-plus nurses that you have hired since the last election, how many of them are placed across country hospitals?

The Hon. C.J. PICTON: We have those figures, and if we are able to get those figures for you before the end of the debate I will be very keen to do so. I am looking at my team and we will try to get those exact figures for you.

Mr PEDERICK: Obviously, agency nurses make up some of that mix. I would be interested in that breakdown as well, unless it is specifically to nurses you have hired. A specific question in regard to Murray Bridge hospital is: how many houses does SA Health rent to agency nurses from New South Wales?

The Hon. C.J. PICTON: Firstly, I can reassure the member for Hammond that, as part of the 1,400 staff, they are not agency staff. These are people who are employed by SA Health. They are on our payroll as SA Health employees, not as agency employees. In terms of how many homes we rent for agency staff, I will have to take that question on notice.

The CHAIR: You have had your three questions. Is it a supplementary maybe?

Mr PEDERICK: Thank you, sir, I will run with a supplementary. Is the minister able to give us a ratio across the state of how many agency staff are required to back up the nurses that are in place by SA Health?

The Hon. C.J. PICTON: I will see what we can find, but there is certainly not a ratio. It is where there are gaps that need to be filled. Obviously, part of the intent of the fact that we have been trying to increase our workforce and recruit record numbers of graduate nurses over the past three years, not to mention other recruitment activities that we have got underway, is because we would like to have staff working for SA Health rather than agency staff.

Mr ELLIS: Following on from my previous question, obviously my concern lies in the fact that we will be left with fewer nurses than are there currently. While I have asked for the net increase or decrease of nurses, how does the ratio that is planned for the Wallaroo hospital, for example, compare to the ratio that would be in place under the enterprise bargaining agreement that currently exists?

The Hon. C.J. PICTON: The first thing to say is that I understand they are specified as a category 4 hospital in the legislation, so that has requisite ratios that are in place there. The other thing to say is that there is essentially a savings provision here whereby, if there are any higher levels of requirements under the existing enterprise bargaining agreement in place for nurses and midwives, then they are retained. So no-one will be worse off because of this legislation. I think there will be a much clearer scenario for staff in Wallaroo hospital, as per other hospitals, in terms of what that actual ratio looks like, as opposed to what can be a very complicated arrangement of the nursing hours per patient day.

I will quickly use this opportunity as well to answer the member for Hammond's previous question, which is, as part of our recruitment and part of our over 1,400 additional nurses and midwives above attrition full-time equivalent that we have recruited in three years, 210 of those are in country areas. That is 210 more country nurses and midwives than was the case three years ago full-time equivalent. Obviously, we would have recruited a lot more than that to deal with attrition as well, but there are 210 extra nurses working for SA Health, not agency nurses, in the country full-time equivalent than was the case three years ago.

Mr ELLIS: This is my last question, I believe. The savings provision that you just referenced that would prevent lower numbers of nurses being replaced under the ratio than currently exists under the enterprise bargaining agreement, is that in perpetuity or is there an end date on which that will lapse?

The Hon. C.J. PICTON: In perpetuity. Well, as long as parliament deems that to be the case.

Clause passed.

Clause 8.

Mrs HURN: Clause 8(2)(b) makes reference to any known or anticipated factors. Can you talk the parliament through what an anticipated factor is? For instance, is it the Winter Demand Plan, etc.?

The Hon. C.J. PICTON: The emphasis here is to try to make sure that we are protecting nurses and midwives, to try to protect and to better plan. In terms of a short answer to the member's question, no, it is not trying to suggest a particular type of winter demand, etc., here. It is more about if we anticipate that we are going to be changing the service profile of what is happening in a mixed ward, that we are giving appropriate notice for that, that there is appropriate planning for that.

There could be any number of reasons why that is the case, but this protects the nurses and midwives, and then ultimately the patients, in terms of the provision of this clause. The emphasis, the pressure, is then on hospital management to make sure they are planning for those changes well in advance.

Mrs HURN: Just for further clarification on the winter demand, it is broadly known that there tends to be a bit of an uptick in demand on the system. So that is not an anticipated factor? If there are additional beds, additional patients that come in to wards, etc., surely that is something SA Health and the hospitals would be predicting that would therefore require more nurses.

The Hon. C.J. PICTON: No-one is suggesting that there is not pressure in terms of winter—and we are certainly seeing that with our record flu season around the country at the moment—but this is about mixed wards. This whole section is about mixed wards, where you have a different variety of patients within the one ward. I think what the member is referring to is where we may be adding additional wards or additional capacity.

This is in terms of what the cohorts of patients are within the one ward. I would not necessarily expect that it would be a winter demand reason why there would be proposed changes in terms of the cohort of patients that would be in a mixed ward. However, for whatever reason, as I said, this obviously puts the finger on hospital management to make sure they are appropriately planning for that, rather than if this clause were not there it would be last-minute decisions.

Clause passed.

Clause 9.

Mrs HURN: Clause 9(1)(a) makes reference to an emergency situation that could not reasonably have been anticipated. Can the minister just confirm that an emergency is only as per the definition at the start of the bill; that is, under the Emergency Management Act or the Public Health Act, and does not extend to an internal Code Yellow or ED dashboards on Code Red or Code White, etc.?

The Hon. C.J. PICTON: I refer the member to the definitional section that she has alluded to and that we have already passed, which makes it clear that this is either that statewide emergency, as was put in place under the Emergency Management Act during COVID, or a public health emergency, which I think was in place for three days at the start of COVID before the state emergency was declared.

Mrs HURN: Clause 9(1)(b) makes mention of staff. It says, 'the hospital has determined that the staffing level is safe'. Can you explain who is it within the hospital who determines that the staffing levels are safe? Who has that responsibility?

The Hon. C.J. PICTON: This is a clinical decision that happens on a case-by-case basis. If we are talking about one ward, it may well be the local clinical leadership involved there. However, given the context of this section, where we are talking about either a public health emergency or a state emergency being declared, it is likely to be quite a serious emergency that the state is confronting, in which case, if you look at what was put in place during the COVID pandemic as an example, there was quite a high cadence in terms of the decision-making around our allocation of resources. That would be at quite a senior level within emergency operations, if not of the state then certainly of that particular local health network. Through COVID, all the local health network sites had emergency coordination and decision-making protocols to manage such a serious incident.

Mr BASHAM: I have a question in relation to breach. If there happened to be a sudden illness within the nursing cohort of a particular hospital, particularly in a country hospital where numbers are smaller, would they be in breach under those circumstances, where a shift may not have enough nurses, particularly at the start of a shift?

The Hon. C.J. PICTON: I am not sure that is of relevance to clause 9 that we are talking about. I am happy to answer that later when we get to other sections. This is only in relation to a state emergency or a state public health emergency. The circumstances outlined by the member in his question are certainly not provisions that would apply here.

Clause passed.

Clauses 10 to 16 passed.

Clause 17.

Mrs HURN: Clause 17 is in relation to the civil penalty for breaching a ratio. It mentions that the civil penalty must not exceed $10,000. Can you talk us through how that figure was arrived at, and is that comparable to what is in place in Victoria?

The Hon. C.J. PICTON: This was not exactly the same, but similar to the Victorian provision, and therefore that was what was adopted here and proposed to the parliament.

Mrs HURN: On the same clause, subclause (7), that civil penalty needs to be paid to the Treasurer and credited to the Consolidated Account. Has the minister given any consideration to ensuring that Treasury ring fences the $10,000 fines (or up to $10,000 fines) for the purposes of health recruitment campaigns, given that any breach would probably speak to a lack of nurses or a problem within the system somewhere—so ring fencing that money for the purposes of health recruitment, not just in the general Treasury realms?

The Hon. C.J. PICTON: I do not want to speak on behalf of the Treasurer, but he probably regards health as ring fencing a fair amount of his state budget, as the case is already. Health is almost now $10 billion of the state budget, so in that context a $10,000 penalty is not a significant variance to the budget. What we are attempting to do here is to make sure there is a penalty, make sure that a breach does not go without appropriate penalty. I do not think anyone would regard this as being an exercise that is going to lead to an overall detriment to the health system. It certainly will put pressure on us to make sure that we achieve improvements in the healthcare system.

I am not sure that doing what the member is suggesting would be beneficial either, given that we are hoping that none of these penalties occur. We are hoping, similar to what has happened in Victoria, we are able to make sure that we meet this legislation. We certainly would not want to make our budgets for health recruitment dependent upon civil penalties taking place. No doubt the process of prosecution in itself would probably cost more than what the penalty is, so I think this is to be avoided at all costs. It is not something that I want to plan for being part of our system, where we rely on this for the recruitment of staff, and therefore I am not supportive of what the member is suggesting.

Mrs HURN: To clarify, it is not about the workforce package being reliant on any fines being paid to the Treasury. Surely the minister would recognise that if there is such a penalty that is being paid it is because of a failure in having enough nurses, and it is a failure of the system somewhere, so ring fencing this for further investment is a good idea—but clearly not. Can you just confirm: have you had that conversation with the Treasurer about ring fencing?

The Hon. A. Koutsantonis interjecting:

The Hon. C.J. PICTON: As the Minister for Infrastructure says, we speak as one. This is not something that we are considering. As I said in my previous answer, this is very small in the context of our $10 billion budget and also something where we are hopeful that we are not going to have any of these penalties. Certainly, that has been the experience in Victoria, where there have not been any of those penalties that have taken place.

Mr TEAGUE: The minister has answered perhaps a couple of aspects. There is no example interstate of this being applied, and it is a minimal amount in the context. I think the minister has given the example of the court proceedings themselves. I would perhaps go further and say that the deliberate course of conduct that is required to be proved to establish the $10,000 offence would itself be an extraordinary kind of endeavour. It is really a sort of naming and shaming potential, is it not? The minister is going to be in receipt of advocacy from the union much more effectively than the results of this process. Is there actually any worked example of it doing some sort of actual work beyond what might be actually much larger consequences of other associated action if the sort of conduct that is required to be proved was actually going on?

The Hon. C.J. PICTON: Far be it from me to speak on behalf of the ANMF, but I think one of the reasons they are advocating for ratios and for ratios to be legislated is because it is clear. It is clear whether you have that many people on the ward at the same time, whereas it is not clear when there is a mathematical calculation of nursing hours per patient day, because that is a variance that happens averaged over the course of a week or a month, etc. Hence, this is actually sort of a prevention mechanism in the first place in having this legislation in place.

Secondly, I kind of agree with the member for Heysen—I find myself worried—in terms of having an action under this has a sort of name and shame aspect. I suspect the media coverage that would ensue from something like this happening would be disincentive enough for everybody to try to prevent that from happening to begin with.

Mr TEAGUE: Perhaps just to bookend that, and in all seriousness, this is not unlike the sorts of civil penalties that we have seen ordered in recent times that run to the millions or the tens of millions, and we can have the same sort of analogy to where those moneys get paid. You might think, 'Hang on, there's a government windfall coming out of a penalty order.' Is there not—to go the shadow minister's point—a case for saying, 'Well, why not actually beef it up, and then have it going back to the minister's budget to be able to remedy this egregious, deliberate conduct that's been proved as a result of this process'?

The Hon. C.J. PICTON: It is open for you to advocate what you like. I guess the argument would be that it is coming from the minister's budget to begin with, so if it is then sort of going back to the minister's budget we should have sorted it out to begin with. I think this is a step towards making sure that we put in place preventative measures rather than a cure, and I think this will set the standard by which the system will be incentivised to try to avoid us heading down this path.

Mr PEDERICK: In regard to the civil penalties, what leeway does a hospital have in filling ratios if, for whatever reason, the nurses hired full-time under the SA Health banner or agency nurses cannot fill shifts? I am thinking of hospitals like Murray Bridge or Strathalbyn. If they have exhausted every avenue they can to fill shifts—it may be at short notice, there may have been illness, as the member for Finniss was indicating—how much leeway do they have so that they do not end up with a penalty and being named and shamed when they have exhausted every avenue to make sure they can staff all the shifts at the appropriate ratio level?

The Hon. C.J. PICTON: The provision in terms of the civil penalties is 'systemic and deliberate,' so the circumstances that you are describing I do not think would fit in that regard. Obviously, we have, as I have described, nursing hours per patient day at the moment. We do work incredibly hard to make sure that we can fill those shifts right across the state, and that is something that our staff are very used to doing and make sure that they can pull every lever to ensure that we can provide care for the patients who need it.

Progress reported; committee to sit again.