NURSING AND MIDWIFERY PRACTICE BILL

Second Reading

Adjourned debate on second reading.

(Continued from 28 October 2008. Page 433.)

The Hon. J.M.A. LENSINK (15:55): I rise to address this bill briefly. Much debate on this bill has taken place already in another place, so I do not propose to cover that ground but to make some general contributions and also raise some questions and concerns to which, I trust, the government will respond.

This bill was introduced in the House of Assembly on 23 September this year, so we seek to move it fairly expeditiously through both houses. In many ways, it reflects the other health practitioner bills which this parliament has been amending and updating following the Medical Practice Act 2004. It modernises the Nurses Act 1999 which, in relative terms, is fairly new legislation, and I think that reflects that in the health sector things move fairly quickly and, indeed, consumers have greater expectations which we welcome.

This bill has taken several steps to modernise the regime. The bill has a primary act to protect the health and safety of the public, and it does a number of things to ensure that properly qualified people are registered as nurses and/or midwives, or enrolled nurses or indeed students. It also provides that corporate providers of nursing and midwifery care can be held accountable for the services of their employees as nurses under this act and that decisions of the Nurses and Midwifery Board are to be more transparent. It allows for nurse practitioners—of whom we currently have some 28—to continue with adequate training. It provides for new definitions of nursing and midwifery, and that practitioners have to be personally capable of providing care to another 'without endangering the other's health or safety'.

It provides that seven of the 11 members of the board must be nurses or midwives; that terms on the board are limited to three terms or nine years; that a complainant is entitled to be involved in the proceeding on the hearing of any complaint; that registers of nurses' roles are to be kept by the registrar, including a student register; that the board can impose a condition if a professional has not worked for five years or more; that the board, with the approval of the minister, can develop codes of conduct; and that practitioners are required to answer questions but that that information can be used only for disciplinary purposes and not as evidence for criminal proceedings.

It provides for inspectors and offences in relation to hindering or obstructing them in the carrying out of their duties; that, in certain circumstances, a single board member can determine a complaint; that the board will have power to suspend or impose conditions prior to the hearing of a complaint; and that the appeal process changes from the jurisdiction of the Supreme Court to the Administrative and Disciplinary Division of the District Court.

Those are the general provisions. I think one of the things that has already been mentioned in the council has been the welcoming of the special recognition of midwifery as a specialised arm of nursing, and a number of comments have been made already which I do not propose to go over. I note that, in the debate in the other place, concerns were raised by our health spokesperson, the member for Bragg, that mental health nursing has been downgraded, if you like, in its recognition through this act.

Instead of having a separate register, there will now be an asterisk, and people then need to find out what the asterisk means to realise that that signifies a mental health nurse. There was much discussion about that, and I will not repeat it, but I think that we need to recognise that the mental health nursing profession is a very specialised area. Most people would agree that it is very hard work and often challenging at times, and that those nurses undergo very highly specialised training in order to practice in that area.

One of the areas for which the minister undertook to bring back some answers between the houses related to training. As is the case with all allied health practitioners, at least, if someone does not practise for five years then they must do some form of refresher course. Indeed, it is something about which I inquired in relation to my physiotherapy qualifications. I think there was a bit of a misunderstanding on the part of some other members who were not directly involved in the debate in the House of Assembly, and who talked about health practitioners being able to keep up their registration simply by reregistering. In fact, when we sign our registration form we must all sign a document declaring that we have practised within the 12 months.

A couple of years ago, when the physiotherapy legislation was changed, I was advised by the board that I would need to take out public liability insurance because the category of a non-practising physiotherapist no longer existed, so I have since dropped that. That is my long-winded way of saying that a person cannot continue to register unless they are actually working and have the relevant insurance, because it is not really worth it.

An issue has come up in relation to nursing. I think we all agree that if someone has not practised for five years they ought to do some form of refresher course—usually something in the order of 12 to 14 weeks. In relation to the Nurses Board, there is no actual legislative requirement for when someone has not practised for some 10 years; that is not prescribed in this legislation, and the minister has advised that the matter is dealt with by the board itself. The member for Bragg raised a couple of examples of people who had been out of the workforce for something like 10 or 15 years and who had been advised by the board that they would have to repeat the entire bachelor degree—something we think is quite unreasonable. The information the minister brought back provided us with a copy of the justification. In his letter he states:

I am pleased to be able to provide you with the attached response from the board in relation to:

the board's ability to report in detail the number of suspensions and/or removals from the registry per year in the annual report provided by the board;

justification of the 10-year rule that requires the nurse or midwife who has not practised for 10 years or more to undertake educational training

Then he says:

During the debate I referred to a copy of the Australian Nursing and Midwifery Council's Code of Professional Conduct for Nurses and Midwives in Australia.

So a number of documents have been provided, and I am grateful for that. It is a quite significant number of pages, but the pertinent part to which I would like to refer is from the Nurses Board of South Australia under the title 'Justification of 10-year rule to undertake educational training'. There is nothing in there that supports the individuals referred to by the member for Bragg having to undertake all the training again (it is a three or four-year bachelor degree), and I would like to read that into the record because I believe it is important to demonstrate that the Nurses Board does not seem to have that policy, yet people have been told that they do. It states:

The Nurses Board of South Australia (nbsa) does not have a policy that requires a nurse or midwife who has not practised for 10 years or more to undertake a re-entry program before being eligible for reinstatement to the register or roll.

Section 29(1) of the Nurses Act 1999 requires that where a registered nurse has not practised nursing for a period of five years or more, she/he must not practise nursing without first obtaining the approval of the board. This provision is to ensure that the public are protected and ensure that the person applying to return to the register can provide evidence that demonstrates they have the required contemporary knowledge and skills to demonstrate competence to practise nursing using the ANMC National Competency Standards for the Registered Nurse (2006) and can meet other relevant requirements for registration including medically fit and a fit and proper person.

An assessment is made by the board to ascertain whether registration can be approved or whether the person needs to undertake an approved Registered Nurse re-entry program. The assessment includes the length of time the person has been away from the practice of nursing, the breadth and depth of nursing experience the person acquired following initial registration, their continuing professional development in nursing and any nursing-related activities undertaken during the period of absence, as well as consideration of the changes in health care, particularly in relation to the use of technology, new medications and continuous improvement in therapeutic interventions and their impact on contemporary nursing care.

A board-approved RN re-entry program can be undertaken as a short continuing education course (with a minimum of 14 weeks' duration), including a theoretical component and clinical experience placement to demonstrate the National Competency Standards for the Registered Nurse 2006.

Alternatively, a board-approved RN re-entry program can be accessed as a pathway through the Bachelor of Nursing, whereby a person receives recognition of prior learning (RPL) for previous education and experience and completes the outstanding units of study, including a clinical experience placement to demonstrate the National Competency Standards for the Registered Nurse 2006. Commonly, this results in the person completing a minimum of two semesters of full-time study of the six-semester or three-year Bachelor of Nursing. The person is not only eligible to be registered with the board but also may have the added benefit of upgrading their existing nursing qualification to a bachelor degree. This concludes my comments on that aspect of the bill.

I have other issues I wish to raise which are not necessarily directly related to the provisions of the bill but which are relevant in other ways, including the national registration scheme through COAG arrangements that has been talked about. Through one of my Queensland colleagues, it has come to my attention that the Queensland government proposes to proceed with a national registration and accreditation scheme for health professionals. On 17 October 2008, the Queensland Minister for Health (Hon. Stephen Robertson MP) stated:

Australian health ministers have agreed that I should provide to you a copy of the first bill for your information prior to its introduction into the Queensland parliament. A copy of the Health Practitioner Regulation (Administrative Arrangements) National Law Bill is attached. Subject to Parliamentary priorities, I expect to introduce the Bill into the Queensland Parliament this month.

As the National Law Bill is based on the Intergovernmental Agreement signed by the Council of Australian Governments on 26 March 2008, a formal exposure draft process was not considered appropriate for this first stage of the legislative program.

This is the first formal information I have seen in a while about the new national registration scheme which, as I stated, has been talked about in relation to other health practitioner bills. Will the government advise whether this is a template bill, through the IGA process, that we will debate at some stage and, if so, when? Will the government also advise which aspects will come under the national scheme—whether it will be just the registration, in terms of contact details, or whether it will include disciplinary provisions and so forth? I think a number of health professionals will be interested to know about that matter.

The second matter I wish to raise, with some comments and questions for the government, is in relation to the Controlled Substances Act. This has been an issue particularly in aged care facilities, where a paper was circulated to the Nurses Board and so forth in relation to schedule 4 and schedule 8 medications and the level of qualification of workers (including care workers) and enrolled nurses, but not of registered nurses as they are allowed to administer those.

There are some different anomalies in low care facilities, with far fewer enrolled nurses, so they rely on their carers being able to administer some of these scheduled medications. In relation to low care facilities, enrolled nurses are permitted to administer S4 and S8 medications, while in high care facilities enrolled nurses are permitted to administer only S4, not S8 medications. That has been an ongoing issue for the aged care sector, so my question on that one is: will the government change the regulations and, if so, when?

My final issue is in relation to agency nurses, and I note from the member for Bragg's contributions on this bill that, when she made her general consultation—as we all ought to do—and she contacted all of the different stakeholders, she spoke to some of the agencies, and they had not been contacted by the government to gain their opinion on this bill. I think that is downright sloppy, but there you have it. A stakeholder has written to me as follows:

Agencies are a growing force in our market, which has brought with it several disadvantages to aged care providers:

1. The hourly cost of staff from agencies is significantly above the rates paid for staff directly employed by providers.

2. There is no incentive for agencies to curtail rates. Indeed, as they are paid a percentage of the rates, they have an incentive for rates to increase.

3. In an environment of workforce shortages, the agencies actually contribute to the shortage by offering a better-paid, less responsible and more flexible alternative to direct employment.

4. Our members consider agency staff less effective than those directly employed because they are often unfamiliar with the procedures etc and accept less responsibility for things than the direct staff.

He then says:

We understand that several years ago the Victorian Dept. of Human Services set up its own agency and instructed a public hospitals to use it exclusively. This immediately brought down costs to the government and to other organisations using agencies.

He asks whether the government would consider such an agency itself. I ask a numerical question for the government: what is the total quantum of expenditure on nursing agencies throughout our health system in South Australia? With those remarks I endorse the bill to the parliament.

The Hon. M. PARNELL (16:13): The Greens are very pleased to be supporting this bill, which will modernise the regulation of the nursing and midwifery professions in South Australia. We note that in its mechanical form the bill is very similar to other bills which we have considered and which seek to regulate various branches of the health profession. I am particularly pleased that this bill acknowledges the important and separate role of midwives, because as a branch of the health profession they deserve special treatment, and I think society is moving towards recognising their special and unique role.

In relation to nursing and midwifery—and, in fact, all the caring professions—the Greens believe that they are generally underpaid and undervalued in society. In fact, I would lump in with the caring professions the teaching professions; in fact, those professions that offer us health and knowledge are undervalued compared with those that offer us material wealth, but that is an aside.

Nurses and midwives are usually with us at our birth and, in many cases, nurses at least are with us at our deaths. Most of us try to avoid them between those two periods.

The PRESIDENT: I married one!

The Hon. M. PARNELL: Mr President, I am glad that you married one. My mother was one, and most of us would find that we have them in our families. We try to avoid them unless we want to have families, in which case very often we choose to engage with the midwives, in particular. Many of us, when planning the experience of birth (if we are, in fact, in a position to do so), will often say that we want midwives to play a dominant role. Many people say, 'Keep the doctors away. I just want to deal with the midwives if I can.' I think that is a reflection of the role they play and their level of importance.

Many people who have babies choose to do so in the context of a hospital and, in recognition of the fact that doctors are not always needed, many hospitals have special birthing units where the doctor might be around the corner but plays no particular role in the delivery. Increasingly, people are looking to have more natural births, whether it is at home, in hospital or in a birthing centre. People like to know that the doctors are there, but they do not necessarily want them to be involved unless it is absolutely necessary. In relation to nurses, if one was to take a straw poll in Rundle Mall, for example, and ask people who they would prefer to give them an injection, a nurse or a doctor—

The Hon. R.L. Brokenshire: Neither.

The Hon. M. PARNELL: —I am sure that most people would go for the nurse—except the Hon. Rob Brokenshire, who does not want either to give him an injection.

In relation to these two professions, we find in society that they are often at the forefront of other moves for social change, even outside the field of medicine and health. For example, I recently attended a rally calling for a better deal for aged pensioners, which was held a few weeks ago in a church in the city. Members of the Nurses Federation were there in some numbers. The issue did not relate to them in their role as health professionals but, clearly, in the package of measures that go to make up a just society, the nurses clearly felt that they wanted to support pensioners in their quest for a rise in the aged pension.

The Greens have no objection to any of the mechanical parts of the bill. We think it is a timely bill. The separation in recognition of the two professions, I believe, is well overdue, and I just want to put on the record my support for both these groups and my recognition of the high standards they have maintained until now. I am sure that this bill will provide the framework for those high standards to continue into the future.

The Hon. R.L. BROKENSHIRE (16:17): I am pleased to contribute to the second reading of this bill. I note that this is part of a sweeping set of reforms across the medical and health care professions, which are welcome changes for greater recognition of health care providers and their professionalism.

Midwifery has been added to this bill, and I see it as a very welcome inclusion. In fact, just for the history books, midwifery dates back to the 12th century BC (Mr President, I am sure you have studied this). It is recorded in the book of Exodus in the Bible that the Hebrew midwives were praised for their bravery in protecting Hebrew newborns from the state-sanctioned genocide of the Egyptian government under the pharaoh. Midwifery is not a new concept, and I doubt that it will ever go away.

In fact, I really appreciated the assistance of the midwives on the occasion of the birth of our two daughters and son—and particularly on the third occasion, when both the doctor and I were late getting there: we arrived just in time to see the midwife carrying out the delivery. Also, putting up with me on three occasions is enough to realise just how great they are at their job. It is hard enough looking after the mother to be, let alone the father who is next to hopeless and more nervous than anyone. However, new life is just a beautiful thing to behold, and I am sure that the midwives derive great pleasure from their work.

I understand that the 2007-08 annual report of the department reveals that there are 28,000 nurses and midwives, comprising roughly three-fifths registered nurses, one-fifth enrolled nurses and one-fifth registered midwives. I am also advised that some 7 to 9 per cent of nurses are now male, which is good to see. The 2006-07 Nurses Board of South Australia Annual Report indicates that there were 173 complaints against nurses, comprising 133 against registered nurses or midwives, and 27 against enrolled nurses, all of which complaints were reportedly investigated and none of which went to the District Court.

As the nursing profession becomes more professional it brings the inevitable question of whether nurses will need to engage in more professional development. At present I understand they are not required to do so, but I also understand that the profession nationally will be driving towards that as an outcome for the nursing profession. Matters of ethics are not contained in this bill, as is the case with a number of other professions, but I place on record my appreciation of the code of ethics to which the profession adheres and, in particular, the way in which that operates in allowing conscientious objection to participating in abortions. A great number of nurses quietly and politely decline to take part in abortion in city and country hospitals alike, and I believe this parliament should uphold and applaud their decision to do so.

I cannot conclude, however, without mentioning country hospitals and the terrible shame that faces us with respect to the country health changes. A number of hospitals no longer provide midwifery services, as we saw in version 1 of the Country Health Care Plan, and now version 2 has been tabled, which we are reviewing. Midwifery services were to be withdrawn from or no longer guaranteed in a number of country hospitals. To give some glaring examples, I cite the South-East, Yorke and Eyre Peninsulas and McLaren Vale. My wife and three children were all born in the McLaren Vale War Memorial Hospital, so I have seen the work done by the midwives, nurses, doctors and, importantly, the volunteers there in developing a new birthing unit, sadly to see it operating for only a couple of years. Through decisions of government, that birthing facility has been closed.

Family First does not agree with this sort of action being taken by any government. We do not want to see families faced with the prospect of births taking place by the roadside or wives relocating away in their last trimester to be nearer to hospitals where they can safely give birth. However, that is happening in country areas at the moment. It is an unfortunate and undesirable situation and I believe that women throughout the state deserve fair and equitable access to midwifery. With those general comments, for the reflection of the minister and others within his department responsible for the bill, Family First supports this bill.

Debate adjourned on motion of Hon. J.M. Gazzola.