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Legislative Council - Fifty-Fifth Parliament, First Session (55-1)
2025-10-28 Daily Xml
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Nurse and Midwife to Patient Ratios Bill

Second Reading

Adjourned debate on second reading.

(Continued from 14 October 2025.)

The Hon. J.M.A. LENSINK (16:09): I rise to make some comments in favour of this piece of legislation. There is no question that nurses and midwives are the backbone of our health system, and we are all grateful for the support, kindness, care and professionalism that we have received from nurses and midwives when we and our family members have needed their help. I think we all have personal experience in that regard, whether it is in our emergency departments or in maternity wards. Mr President, I think it is probably appropriate for us to pause and acknowledge.

The PRESIDENT: The Hon. Mrs Henderson is on the floor with a guest. Nice to see you, the Hon. Mrs Henderson.

The Hon. J.M.A. LENSINK: I was just saying, as I was talking about nurses and midwives, how we all have a range of personal experiences where we are just so grateful for everything they do. Nurses and midwives provide care in every part of South Australia, from our tertiary hospitals to small regional facilities and in the community sector as well, and they do so with professionalism, skill and compassion. Their work is vital, and their voices are rightly heard in shaping the future of health care in this state.

This bill enshrines nurse and midwife to patient ratios in law, which aligns South Australia with Victoria and Queensland, where similar legislation has been in place for some time. It sets minimum staffing requirements across different types of care and categories of hospitals. The ratios are detailed in schedule 1 of the bill and vary according to the shift and clinical setting. The legislation also includes a two-year implementation period, after which hospitals can face civil penalties of up to $10,000 for noncompliance.

The Liberal Party supports this bill. Safe staffing levels are essential to patient safety, clinical quality and the wellbeing of our nursing and midwifery workforce. But, as my colleagues in the other place have said and I will repeat here today, ratios alone are not enough. Just having this bill legislate a ratio does not actually directly translate to new nurses or midwives, nor does it fill rosters or solve the workforce shortages that continue to affect hospitals across South Australia, particularly in our regional and rural areas. The challenge for this government is not just to legislate but to deliver and to ensure that the workforce is there to meet targets without compromising services or closing beds.

We know how stretched our system already is, and we know that a lot of nurses and midwives are really feeling the strain. In many metro and regional hospitals, wards are operating under significant strain. Some sites have been forced to temporarily close emergency departments or reduce capacity simply because they cannot recruit staff. In my own discussions with country members and local health networks, this story is repeated again and again. The ratios in this bill must not come at the expense of accessibility for regional patients.

The minister has assured members that it is not the government's intent for any wards or beds to close as a result of the bill, which we welcome, but we will be holding the government accountable for it. The bill demands a serious and coordinated workforce plan, one that includes meaningful incentives for nurses and midwives to work in regional communities and support them to stay. That means relocation assistance, career development opportunities and proper support for experienced staff to mentor the next generation.

We are also concerned that penalties under this bill will be paid directly to Treasury rather than being ring-fenced for reinvestment back into health. If fines are to exist they should go back into supporting the nursing workforce, not disappear to the Treasurer. We believe that is a missed opportunity to strengthen the sector in a constructive way.

I note that the government has allowed a two-year phase-in period, which is sensible but it must be used wisely and cannot be used as just a waiting period. Those two years require action behind the scenes to recruit and to train and to plan. They will determine whether this reform is symbolic or not. I reiterate that we support this bill because safe staffing is good for patients and it is good for staff. Every South Australian, regardless of where they live, deserves access to high-quality care, and we long to see long-term investment in our workforce. I commend the bill.

The Hon. C. BONAROS (16:14): I rise to speak in support of the bill before us, which deals with nurse to patient and midwife to patient ratios. It is somewhat of a no-brainer in the sense that we know these things provide safe outcomes for patients and their carers, reduce nurse and midwife fatigue and enhance nurse and midwife wellbeing. We know that these sorts of measures improve efficiency of care and make nursing and midwifery, which are really the heartbeat of our hospital systems, a more attractive career option.

There is strong evidence that the number of patients allocated to a nurse or midwife directly relates to patient safety and, indeed, mortality rates. New South Wales' ratios have been modelled on those of Victoria. The Victorian branch of the ANMF says that since the implementation of nurse and midwife to patient ratios in 2000 that the health outcomes for the state's patients have radically improved and thousands of registered nurses and midwives have returned to work in the public health system.

Of course, the situation in Victoria is one that this legislation is modelled on. It says one of the immediate outcomes for the public healthcare system were reduced waiting times in Victoria's 87 public hospitals; improved recruitment and retention of nurses and midwives as a result of better, safer working environments; capability to meet demands on hospitals; and improved economic performance of public hospitals. All these things are quite logical. They also cited evidence in support of ratios from studies primarily by world ratios authority Professor Linda Aiken, from the University of Pennsylvania, who has led ratio studies in 30 countries. The findings of Professor Aiken include:

every extra patient per nurse over four patients is linked with a 7 per cent increase in the likelihood of that patient dying within 30 days of admission;

each additional patient per nurse over four patients is associated with a 7 per cent increase in likelihood of failure to rescue. Failure to rescue means death from complications such as pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis, or even deep vein thrombosis;

each additional patient per nurse over four patients was also directly linked to a 23 per cent increase in the likelihood of the nurse burning out; and

every extra patient added to a nurse's workload increases a medically admitted child's chance of being readmitted within 15 to 30 days by 11 per cent.

In July 2016, Queensland Health enacted legislation for nurse to patient ratios in public facilities—at the time only the fourth government in the world to make those ratios law. The Australian Nursing and Midwifery Journal stated that a subsequent study in Queensland found legislated nurse to patient ratios had positive effects on nurse staffing and patient outcomes, including mortality, readmissions and length of stay. As we have heard and as we know, when we talk about ratios, we are inevitably talking about safety. We are talking about dignity. We are talking about the difference between a nurse having time to comfort a patient in pain, look out for warning signs, and a nurse rushing between six beds hoping not to miss a critical patient, a critical change in someone's condition.

I say that, acknowledging the sentiments that have just been expressed by the Hon. Michelle Lensink, which I agree with overwhelmingly. Patient to nurse ratios, in and of themselves, do not fix the problem. Legislating ratios does not fix the problem, especially in our rural and regional communities. This has been an ongoing issue for some time now in this jurisdiction and across other jurisdictions. As alluded to by the honourable member, the proof will really be in the pudding in terms of whether this succeeds in South Australia, because above all else we need some real political will here to make this work. A piece of legislation enshrining those ratios, in and of itself, will not do the hard yards in terms of what needs to be done to get the outcomes we need.

I want to end by asking the Attorney one question. I am trying very hard to figure out where this question or concern was raised and whether it was during processes which we cannot talk about here in committee or whether it was in discussions. I have racked my brain and I cannot remember. What I do know everyone in this place will remember is the passage of Gayle's Law and the subsequent bunfight that occurred in this place about ratios in our rural and remote communities.

For those of us who were not here at the time, we know that Gayle Woodford died in the most tragic circumstances, having worked as a nurse in remote areas of the state, ultimately resulting in her rape and murder. We know that as a result of those laws and the regulations and the bunfight that resulted from those regulations in this place under the former government, it is an absolute requirement under law that there be a second responder when attending an out-of-hours or unscheduled call-out in those communities.

The question that I have for the Attorney is: has there been discussion of moves to change regulation or consideration of exemptions from those requirements? That is a suggestion that has been put to me. Given that we are dealing with this issue here today, I would like some clarity on that to rule out, I am hoping, the prospect of having exemptions where the legislative requirement to have a second nurse responder is potentially being undermined by some move that would, I imagine in very difficult circumstances, allow a nurse to go into those workplaces alone.

Certainly, the legislation and regulations are quite clear around what is required in those sorts of scenarios, but if there is any such move afoot or if there have been discussions that have taken place around that, I would care to know before voting on this bill.

The Hon. T.A. FRANKS (16:23): I rise with great pleasure to support the Nurse and Midwife to Patient Ratios Bill 2025. This bill has been a long time in the making and certainly the result of a lot of years of work by many, particularly within the Australian Nursing and Midwifery Federation. I want to thank in particular Jackie Wood and Elizabeth Dabars for their briefing on this bill.

This bill will establish minimum nurse and midwife to patient ratios per shift across key clinical areas, including general medical and surgical, coronary care, high dependency, oncology, stroke, rehabilitation, birthing and labour, neonatal intensive care and palliative care wards. It will ensure that the appropriate minimum number of nurses and midwives are available on a shift-by-shift basis, enabling staff to meet patient care needs in a working environment that supports our dedicated nurses and midwives.

Many times in this place we have extolled the virtues of our nurses and midwives and how important they are to our health system and to our community and society. It is almost a no-brainer that we would ensure they have the best workplace possible to provide us with the best care possible. I will have a few questions at the clause 1 stage, and I will flag those in just a second.

This bill will have a great outcome of better patient safety, increased quality of care, better nurse workload and job satisfaction, a reduction in adverse events and consistency across the various workplaces and facilities. While many may be concerned that perhaps we are enabling a layer of bureaucracy, I would say that, in fact, this does change the current nursing midwifery hours per patient day, the very sexily titled NMHPPD. 'Nurse to patient ratios' certainly rolls off the tongue a little easier and I think it will be much easier for workplaces and those who are doing the rosters and providing that care to be able to manage the best environment.

I would say, in particular, of course, that this does not apply to mental health nurses and private hospitals. One of my questions is about how smaller hospitals will be reviewed and what the process is for that in coming years and months and I am hoping that is more about a six-month review, rather than something that drags out to years.

Given the Hon. Laura Henderson was just in the chamber with a young stranger, I was hoping to also raise a question while she was here but did not quite get there. I am interested to know how this legislation currently treats babies in those maternity wards and whether or not they are included in the nurse to patient ratio and whether there are plans to include them in the future if they are not.

With regard to my briefing, they were two of the issues that we did particularly discuss, if the government would be able to provide further information on what their future plans are with this legislation. I know that it is also timely in terms of the enterprise bargaining situations and negotiations, and that that will be part of this process. With that, I commend the bill to the chamber and look forward to its speedy passage.

The Hon. T.T. NGO (16:26): In September 2025, the state government introduced the Nurse and Midwife to Patient Ratios Bill to parliament. The bill marks an important milestone for South Australia's health system and for every nurse, midwife and patient who depends on it. The legislation is designed to ensure that our hospitals are staffed safely, fairly and sustainably.

For the first time in history, minimum nurse and midwife to patient ratios will be set in law across all public hospitals in South Australia. These ratios will apply on every shift and in every ward so we can have the right level of care for patients as well as the right level of support for staff. This reform recognises a simple truth: safe staffing saves lives. We know that when nurses and midwives have manageable workloads patients recover faster, safety improves and the quality of care rises.

Under the new legislation, ratios will vary according to hospital size and clinical area. In our busiest metropolitan hospitals, the Royal Adelaide, Flinders, Lyell McEwin and the Women's and Children's, there will be one nurse for every four patients by day and one for every eight at night. In the regional hospitals at Mount Gambier, Port Augusta, Port Pirie, the Riverland, Murray Bridge and others, staffing levels will reflect local needs but still ensure safety and fairness. For critical areas like neonatal care, stroke and maternity, ratios will be even safer, with one midwife for every woman in labour and one nurse for every two babies in intensive care.

An important fact about this legislation is that it not only protects patients but also strengthens our nursing and midwifery workforce. Recognising their workload and giving certainty that every shift will be safely staffed will enable the continued delivery of the compassionate and professional care South Australians have come to rely on.

Planning for implementation is already underway. SA Health is working closely with the Australian Nursing and Midwifery Federation (SA Branch) and hospital networks to make the transition as smooth as possible. If passed, the new laws will come into effect from early 2026 with a two-year rollout period to allow for recruitment and adjustments. During that time there will be a moratorium on noncompliance; however, hospitals will begin to comply with the new legislation as soon as it is practical to do so.

Over the past three years, South Australia has already recruited more than 1,460 additional nurses and midwives. This has strengthened our workforce and put us in a good position where we are ready for this transition. Importantly, the reforms in this bill are modelled on proven systems in Victoria and other jurisdictions, but tailored to South Australia's unique needs. The proposed improvements demonstrate this government's absolute commitment to patient safety, staff wellbeing and the long-term sustainability of our public health system.

The Malinauskas government is very aware that our nurses and midwives are not just the backbone of our health system, they are its heart. To every nurse and midwife across the state, we thank you. This legislation is about you and for you. It recognises the extraordinary care you provide, the pressures you face and the difference you make in people's lives every single day.

This bill will help to ensure that the South Australia public health system remains one of the safest, most trusted and most compassionate in the nation. To members in this chamber, I hope you give this bill your full support.

The Hon. J.S. LEE (16:32): I rise today to speak in support of the Nurse and Midwife to Patient Ratios Bill. The bill introduces mandated minimum staffing ratios for nurses and midwives across South Australia's public hospital system with the goal of improving patient care and supporting the wellbeing of our dedicated healthcare workforce.

The proposed legislation would see a transition from the current nursing hours per patient day model to specific minimum staffing numbers required for each shift. Currently, SA Health operates under a minimum staffing framework that is set out in the Nursing and Midwifery Enterprise Agreement. The bill will enshrine in legislation minimum staffing numbers for each shift in certain patient care areas in all public hospitals. These care areas include general, medical and surgical, coronary care, high dependency, oncology, stroke, rehabilitation, birthing and labour, neonatal intensive care, and palliative care wards. I note that emergency departments and intensive care units are not included in the proposed legislation, with private hospitals and aged-care facilities also excluded.

Hospitals will be categorised according to size and complexity, from category 1, including the Royal Adelaide Hospital, Women and Children's Hospital, Lyell McEwin and Flinders, down to category 4, Naracoorte and Wallaroo, and then all other small hospitals. The bill ensures that ratios meet the requirements of different wards and patient care areas based on hospital category while preserving any pre-existing higher staffing levels set out in the enterprise agreement.

This model is based on the Victorian legislation, I understand, which has been in effect for more than a decade, and evidence shows that legislated nurse and midwife to patient ratios enable greater transparency and accountability. Local health networks found to be deliberately or systematically in breach of the legislation by the South Australian Employment Tribunal could face civil penalties of up to $10,000 per breach. I note that transitional provisions, including a two-year moratorium on noncompliance penalties, allow for local health networks to plan recruitment and staffing reconfigurations to implement the bill.

Nurses and midwives are truly the backbone of our health system, making up 50 per cent of South Australia's healthcare workers. I have family members and good friends working in the health sector, so I have a deep appreciation of their compassion, care and professionalism. Safeguarding minimum staffing numbers on a shift-by-shift basis will help improve quality of care and patient outcomes, reduce staff burnout and improve job satisfaction and retention.

I understand that the South Australian branch of the Australian Nursing and Midwifery Foundation (ANMF) has been instrumental in drafting this bill and is a staunch advocate for the proposed changes. I also understand the ANMF has asked the government to assess how small hospitals are categorised under this new model. The minister has indicated that the government is undertaking work in this area, which is a welcome step.

Under the proposed legislation, small hospitals are required to be staffed with at least one registered nurse and one other nurse or midwife on all shifts. Concerns have been raised regarding the potential impact the bill may have on small country hospitals across South Australia, which are already struggling to attract and retain nursing staff and GPs. Reports suggest that the Tanunda War Memorial Hospital has had to reduce bed capacity due to ongoing nursing staff shortage, and the Angaston District Hospital often relies on locum doctors and has turned away patients from its emergency department on 23 occasions over the last two years due to staffing issues.

While the bill sets minimum staffing levels, it does not solve the underlying workforce challenges faced by regional health networks. Without sufficient staff to meet the mandated ratios, there is a risk that services may be scaled back or suspended. The prospect of their local hospitals facing fines or reductions in services or bed capacity is understandably of great concern to residents in regional communities. We must ensure that we are doing everything we can to attract and retain healthcare workers in our regional communities so that all South Australians have access to high-quality care, no matter where they live.

Overall, I support the intention of the bill and am pleased to see minimum staffing numbers enshrined in legislation to support better health services for patients and better workplace conditions for our incredible nurses and midwives. We ought to give them our special attention and appreciation.

The Hon. S.L. GAME (16:37): I rise to speak briefly in support of the Nurse and Midwife to Patient Ratios Bill 2025. The stated aim of this bill is to enshrine minimum nurse and midwife to patient ratios in legislation. The bill will only apply to South Australia's public hospitals in certain patient care areas and a very small number of state-funded aged-care beds across the system. While minimum patient to staff ratios in our public hospitals is a measure worthy of support, it is doubtful whether this bill alone will deliver the high-quality hospital care and best patient outcomes this government has been spruiking.

Much needs to be done to improve the quality of patient care in our hospitals, and to be fair this bill largely duplicates the patient to staff ratios that already exist under enterprise agreements in commonwealth legislation. The new penalty to be imposed against hospitals for breaching these ratios is only $10,000, which is unlikely to offer any further deterrence to hospitals already struggling to meet staffing requirements. There is also a two-year moratorium on the application of these penalties. We should provide hospitals with enough time to meet the new ratios before facing the possibility of a $10,000 fine.

This scheme is almost identical to the Victorian model, which has been in place for several years without any hospital receiving a penalty for breaching nurse to patient ratios. Improving health care in this state should always be at the forefront of any new policy or legislation in this area, and the government's commitment to these ratios is welcome and should be supported. However, at the same time, we should not pretend that this bill will achieve anything beyond the codification of standards of care that should already exist. With that, I offer my support of the bill.

The Hon. R.A. SIMMS (16:39): I also rise to indicate my support for this bill on behalf of the Greens. Isn't it nice when we all agree. It is good to hear everybody in this chamber indicating their support for this reform, which I think is an important step forward for our hospitals.

The legislation before us today will provide the minimum safe number of nurses and midwives required to care for patients across key clinical areas in our public hospital system, ensuring safe workloads and quality patient care. We know that understaffing is dangerous for patients and dangerous for nurses and for midwives. When each nurse or midwife has too many patients, they cannot monitor each one closely. This increases the risk of complications, missed signs of deterioration, medical errors, falls, infections and even death.

One review by the Royal College of Nursing found that increasing a registered nurse's workload by one additional patient raised the odds of a patient dying by about 7 per cent—7 per cent. When staffing levels are poor and there are too many patients per nurse and midwife, it not only reduces safety for patients but also leads to high workload, stress, fatigue and burnout for nurses and midwives. High turnover further contributes to staffing shortfalls, something that our health system simply cannot afford. Better ratios help retention and lead to a healthier workforce.

In recent years, other jurisdictions around Australia have moved to implement nurse and midwife ratios, including Queensland and Victoria. I note that the model outlined in this bill is based on the model that has been successfully implemented in Victoria. The results interstate speak for themselves. In Queensland, the establishment of nurse and midwife to patient ratios has not only saved lives but also reduced costs, with patients receiving better care and being less likely to be readmitted.

A study by The Lancet found that, with the introduction of nurse to patient ratios in Queensland between 2016 and 2018, ratios had saved $69 million in two years, more than twice the cost of hiring new staff. They had reduced 30-day mortality rates by 7 per cent. They had reduced readmissions within seven days by 7 per cent and they had seen patients leave hospitals 3 per cent faster, so pretty strong results. Lower patient ratios also allow for more individualised care, including through thorough assessment, rapport, education and emotional support. This improved patient satisfaction allowed for better continuity of care and has resulted in better outcomes for patients.

I also note that the state government has collaborated closely with the Australian Nursing and Midwifery Federation to develop this legislation. I commend the union for their advocacy and might I also commend the health minister, Chris Picton, for his leadership on this issue. I also acknowledge the ANMF's persistent advocacy over many years, which I think has been critical to achieving this outcome.

Appropriate nurse and midwife to patient ratios lead to safer care, faster recovery times and improved job satisfaction for frontline staff. It is also an important recognition of the vital role nurses and midwives play in safeguarding the health of South Australians, and it is vital that South Australian governments continue to improve their pay and conditions. I see this as being a significant step in the right direction. I believe it was part of an election commitment that the Malinauskas government made. Indeed, it was something the Greens also committed to during the last election, and so I am very pleased to see that being implemented during this term of parliament. With that, I conclude my remarks.

The Hon. K.J. MAHER (Deputy Premier, Minister for Aboriginal Affairs, Attorney-General, Minister for Industrial Relations and Public Sector, Special Minister of State) (16:43): I thank all members for their contribution. I think I can respond to the Hon. Connie Bonaros's question that she raised during the second reading debate by saying I am advised that the scheme and regime around Gayle's Law is separate from what is being considered here, but there is no intention from the government to change the scheme that is set up under the regime that has Gayle's Law. I am happy to put that on the record for the Hon. Connie Bonaros to make that as clear as I can, and I look forward to the committee stage.

Bill read a second time.

Committee Stage

In committee.

Clause 1.

The Hon. K.J. MAHER: At clause 1, having received some advice in relation to something the Hon. Tammy Franks raised, I might respond in relation to babies and how that interacts with ratios. The issue of counting babies always and automatically in patient ratios is not something this piece of legislation does; I am advised, though, that it is something that has been raised, and it is in discussion with the Australian Nursing and Midwifery Federation of South Australia.

The Hon. T.A. FRANKS: Thank you. I also had a question in regard to the review for small hospitals.

The Hon. K.J. MAHER: I am advised that there is a commitment to review small hospitals within six months to see if their categorisation is correct or whether they should move into another category.

The Hon. T.A. FRANKS: My final question was: at what point will mental health be considered for patient to nurse ratios?

The Hon. K.J. MAHER: My advice is that the South Australian model is based on the Victorian model, which does not include mental health. However, it is something we are not opposed to considering in the future.

Clause passed.

Remaining clauses (2 to 21), schedules (1 and 2) and title passed.

Bill reported without amendment.

Third Reading

The Hon. K.J. MAHER (Deputy Premier, Minister for Aboriginal Affairs, Attorney-General, Minister for Industrial Relations and Public Sector, Special Minister of State) (16:48): I move:

That this bill be now read a third time.

Bill read a third time and passed.

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