A nursing crisis in Hawke’s Bay and no cavalry to the rescue

[As published in July/August BayBuzz magazine.]

“I love my job, but I am feeling sad right now because I can’t provide the nursing care I want to. I don’t have time to tend to patients, checking in to see if they need a cup of tea, or if they’re warm enough. 

“We would always go above and beyond when I started in this job. But now we’re so worried about the emergency bells going off, about the patients waiting 6-plus hours to see specialists. 

“This hospital just hasn’t grown with the HB population. There are shortages right across it.” 

This is the impassioned voice of a senior nurse who has worked for more than 10 years in Hawke’s Bay hospital’s emergency department (ED).

“I feel terrified about what’s going to happen as we go into winter,” she continues. “We start each day in ED with a lack of space and a lack of nursing staff.

“We are meant to be part of an ‘escalation plan’, so when we are not coping we can move into Code Red, signalling we need help. But we’re always in Code Red and no one comes to help. We’re left to drown.

“Management talk about safe staff patient ratios. For us in ED that’s 1 nurse to 3 patients. But I can’t remember the last time I was able to work to a 1:3 ratio, it’s usually 1:4 and having to keep an eye on people in the corridors as well.

“I do 12-hour shifts 7pm-7am pretty much all the time to cover the gaps. I do get paid more for it yes … but 12 hours is not recommended, that’s when fatigue sets in and mistakes happen … Every night one or two nurses are having to do 12-hour shifts.

“A lot of nurses from ED [there’s a staff of about 70] have gone to Aussie recently. We’re losing such valuable skills all the time. 

“I am weighing up whether to move my family to Aussie. We would be a lot better off financially. But I get upset at the thought of leaving. We have such a great team and we prop each other up.

“We want to provide good care, but we can’t and I see nurses in tears daily. ED nurses are strong and hold it together very well but more recently nurses have been breaking down. We’re suffering from abuse too: physical and verbal. People get sick of waiting. They don’t understand why someone is triaged ahead of them, so they lash out.

“It is what it is. There’s nothing we can do! It’s rough and nurses are scared to speak out.

“We feel like numbers in a system.”

The numbers

The nurse above is one of 2,300 Hawke’s Bay nurses (working in both primary and secondary health care) who are members of the New Zealand Nurses Organisation Tōpūtanga Tapuhi Kaitiaki o Aotearoa (NZNO) Union. She was one of 340-odd who attended a well-subscribed union stopwork meeting in Hastings on 30th May. A few days later votes from that meeting and thousands from 55 meetings around the country (a 98% majority) voted to reject Te Whatu Ora Health NZ’s latest employer offer of a $4,000 pay rise this year across all rates and a further 3% next year.

“We haven’t had a new contract since bargaining began last September,” a Hawke’s Bay Union delegate told me soon after the meeting. “This is as much about staff retention as anything. We’re all concerned about the staff shortages.”

The delegate told me the Union’s view is that a pay rise to equal inflation is an important effort to retain and recruit nurses by offering conditions and pay on a par with Australia – “so our nurses are not jumping over there”.

Since early 2022, the NZNO has been running the ‘Maranga Mai’ Rise Up campaign calling for its members, whatever sector they work in, to come together and take united action to win the political and resourcing commitments needed to address the nursing shortage crisis permanently – and across the whole health sector.

“We know nurses, midwives, health care assistants and kaimahi hauora are facing increasing demands and significant shortages in workforce supply,” says chief executive Paul Goulter. “We all know, too, that Māori have relatively very poor health outcomes due to systemic racism and failures to honour Te Tiriti in Health.”

The NZNO bargaining, which has been continuing as I write, also aims to address unresolved, historic issues around pay equity, promised back pay and pay relativity for Senior nurses. There are also issues around Health & Safety and how to measure, retain and enforce safe patient/staff ratios.

I will come back to the above, but for now, let’s start with the bald fact that there are as many as 5,000 vacancies for nursing staff right across the country – not just in hospitals but in primary care such as private doctor’s surgeries, Māori and other independent providers and NGOs including aged care facilities.

As we go into the General Election, shortages across the whole health sector will be targeted over and over in the media and thrashed out by politicians.

In Hawke’s Bay, nurses across all settings make up one of our single biggest workforces. I have heard anecdotally that it is getting harder to attract nurses and other health staff to Hawke’s Bay because of our accommodation shortage, highlighted in the aftermath of Cyclone Gabrielle. Specialist roles including nurse management roles are apparently also getting harder to fill as are vacancies in the Hawke’s Bay Fallen Soldiers Memorial Hospital and private Aged Care facilities.

Getting to the truth

I was brought up on stories of Florence Nightingale, ‘The lady with the lamp’, and on the many colourful memories of a mother who had trained as a nurse in the early 1950s, then worked at Kawakawa Hospital in the Bay of Islands, overseas at the private London Clinic, and as a Ward Sister at Napier Hospital.

So, I have an innate respect and interest in nursing and hoped to write a positive story in HB in cooperation with Te Whatu Ora Te Matau a Māui (Health NZ, HB) media and nursing management. I wanted to focus on and spend time with three nurses working in different roles under Te Whatu Ora’s umbrella, and I wanted to hear about ‘creative initiatives’ underway to recruit more nurses.

I also wanted to look at nursing today and how much it differs from my mother’s day, in particular the role of nurse practitioners who have completed a Master’s degree and are authorised to prescribe medicines to the same level as GPs, and registered nurses who have undertaken postgraduate study and can prescribe as nurses working within primary care and specialty teams settings.

Last year the Nursing Council of New Zealand endorsed Te Whatu Ora – Te Matau a Māui to run a programme, piloted in Counties Manukau, to get nurses prescribing as they worked in the community. This equips and trains nurses across many settings to prescribe from a list of about 80 medications including for contraception and sexual health, infections (ear, throat, skin etc.), eczema, headlice, rheumatic fever and other conditions.

As the plan for my story unfolded, additional questions presented themselves. Just how many nurse vacancies do we have here in Hawke’s Bay? And what is the local official response to the 30th May stop-work meeting that by chance coincided with my research on this story.

But when I sent a list of questions via the media team, I received a quick return email from Regional Communications & Engagement Lead/ Executive Director Communications Emma Horsley: “ … Your original intent was to steer clear of ‘strikes and shortages’ to instead focus on nursing as a whole and what makes nurses do their jobs and the different aspects and opportunities of nursing.

“As the angle has now obviously changed we have made the decision to respectfully decline the offer to take part. The questions highlighted can be answered by the national office hnzmedia@health.co.nz”

If the hospital authorities have a ‘stay calm’ story to tell, why refuse to discuss it?

“We’re being gagged because it is election year,” one nurse manager told me. 

BayBuzz sent an Official Information Request (OIA) to Te Whatu Ora Health NZ asking how many nursing vacancies there are within Hawke’s Bay, among other questions. We are still awaiting the standard 20-day response.

In the meantime I contacted Labour MP for Tukituki (and ex Hawke’s Bay DHB member) Anna Lorck.

“HB Hospital is the region’s largest employer with over 3,280 staff and more than half are nurses,” she replied. “Nursing numbers have been increasing with at least another 30 more recently employed I understand and there is more budget provided to keep employing more and there is an active recruitment drive.

“We need more nurses, we need to also train more. I have full admiration for the work they do, I am always hearing praise from people about the professional and high quality they provide in HB. They work incredibly hard in a health system that has been under significant pressure, especially during and after Covid.”

But on this point, Sue Revell, a Nurse Practitioner, who has worked for Te Whatu Ora at the hospital since 2005 and been the Union co-convenor for the last four years, has a different view.

“There were already staffing and health & safety issues before Covid,” she says. “Covid just exposed a broken health system.” Before we go on, let’s note that nurses, many returning from retirement especially, have played a key and leading role, and continue to do so, in HB’s Covid and vaccination response. And that nurses too have been at the frontline during and after Cyclone Gabrielle providing emergency care in cut-off rural communities.

In fact Te Whatu Ora Te Matau a Māui Hawke’s Bay has produced a booklet Celebrating our Nurses and Midwives In honour of the International Day of the Nurse and Midwife 2023 which tells many great stories of nurses and midwives.

Inspiring, but not the full story.

Unsafe conditions

Sue Revell counters that despite having very skilled and dedicated nursing staff within Hawke’s Bay hospital, “The risks of doing harm are increased everyday, due to trying to provide care within a system that is under pressure and working in facilities that are old and inadequate.”

In April, the NZ Herald published a report titled, ‘NZ hospital workers file 23,000 reports warning of unsafe staffing.’ Full article here. Figures obtained under the Official Information Act (OIA) revealed that some New Zealand hospital wards and departments had racked up hundreds of unsafe staffing reports as workers repeatedly alerted their bosses to critical shortages.

In the Herald article, the incidents of “Unsafe Staffing” reported in Hawke’s Bay from 2019 – November 2021 were high with 1,655 incidents reported, close behind the five biggest former DHBs in the country. There was no reporting in HB for the 21-22 period because of “staffing issues”, though apparently these are now being collated.

“As a delegate we know these are under-reported,” says Sue Revell. “After finishing an understaffed shift all nurses want to do is go home, not sit down and spend half an hour writing a report.”

“There are unsafe incidents virtually every shift in ED,” the nurse in my opening paragraphs told me. “But the reporting of them is so much lower than it should be.”

Back in April, I had sent the NZ Herald report to Te Whatu Ora HB media and asked what was being done about the high levels of “incidents relating to unsafe staffing” in Hawke’s Bay hospital. Karyn Bousfield-Black, Chief Nursing Officer and Director Patient Safety & Quality replied: “With Care Capacity Demand Management (CCDM) for nursing and Allied Health, Hawke’s Bay uses Variance Response Management to move resources where they are most needed. Escalation processes are also in place to manage resourcing to any increased demand. (Remember what my source said above about ‘Escalation’.) We also continue to actively recruit to vacancies.”

As I understand it, CCDM is about better matching staff resources to patient demand. The system allocates resources based on patients’ needs, not according to raw patient numbers. CCDM is an acuity tool. This identifies the amount of nursing care needed for each patient on a unit based on the level of intensity, nursing care and tasks needed for each patient.

Revell says CCDM works well in identifying the required nursing numbers per shift and has led to uplifts in budgeted staffing levels (FTE) in many areas where it is in place. “However, due to daily gaps in the roster, safe nurse to patient ratios are exceeded every day. When we try to escalate there are no extras.

“We can’t call the Cavalry in because there is no Cavalry.

“Many staff are burnt out,” she says. “They are picking up extra shifts to help their colleagues out, but also because there is a cost of living crisis. 

“People are tired, morale is low and we’re sick of fighting for everything from health & safety, to our collective agreements and pay equity.”

Back in 2018 the Minister of Health Andrew Little started the Equal Pay Review promising completion by the end of 2019. When it took longer than a year to complete, he then promised that any agreed pay uplift for nurses would be backdated to Dec 31st 2019.

But it didn’t work out like that. The Equal Pay Review resulted in a 19-20% uplift in wages for many nurses, midwives and healthcare assistants based on proven historic sex-based underpayment. But designated Senior Nurses only received a 7% uplift resulting in loss of relativity with their junior colleagues and Little’s promise of backpay was reneged on. Both these issues are currently before the ERA and Employment Court.

“The old disrespect for nursing still exists,” says Revell. “We’re seen historically as a female caring workforce of mostly women, underpaid, and not as important as doctors. This disrespect bleeds everywhere.

“Look at Kiwisaver for example, Te Whatu Ora employer contributions are 6% percent for doctors and 3% (same employer) for nurses, midwives and healthcare assistants.” So what needs to happen?” I ask Sue Revell.

“We need the government and Te Whatu Ora to acknowledge the seriousness of these issues,” she says.

“To not say: ‘It’s not a crisis’.”Because it clearly is!

It gets worse

And while BayBuzz has focused on the hospital for this story, a quick scan of Seek NZ online shows there are currently about 30 vacancies for registered nurses across its site for Hawke’s Bay. In particular our 28-plus Aged Care facilities are suffering.

“It’s an ongoing challenge for us to get registered nurses,” says the region’s representative from the National Aged Care Association, Greg Pritchard. He hasn’t done a tally of vacancies since the cyclone. But when we spoke to him last year, he estimated at that time there were 50-60 vacancies for registered nurses across HB Aged Care facilities.

State of the art medical centres such as the new Kaweka private hospital, as well as some primary care practices, are offering nurses good pay and conditions and are undoubtedly benefitting from nurses wanting to leave the public hospital, but not the region.

CEO of Kaweka Hospital Colin Hutchison says Kaweka didn’t have any trouble getting nursing staff (they employ about 70) and that while their pay rates are within range of the general hospital staff, conditions offered are likely better.

Likewise Dr KJ Patel of Te Mata Peak Practice says, “My nurse head of department is excellent so we’ve been able to get fantastic and motivated nurses, some of whom have left the hospital.

“I suspect we’ve been attractive due to the culture we’ve fostered at the practice.”

All the more reason to be mighty appreciative of the hospital nurses we have, who clearly deserve better conditions!