Counting nurses in his sleep

1 February 2013

Des Gorman, chair of Health Workforce New Zealand (HWNZ), says that he’s losing sleep worrying about the looming nursing shortfall. FIONA CASSIE talks to him about his disappointment at last year’s nursing criticism of HWNZ’s performance and why nursing will be a top priority in 2013.

“I’m not worried about the number of physios. I’m not really worried about the number of doctors. If you had to ask me what keeps me awake at night, it’s having enough nurses in 2020 to service the needs of the sick and ill of New Zealand,” says Des Gorman.

The University of Auckland medical school professor stepped into the job of executive chair for Health Workforce New Zealand at its creation in August 2009. HWNZ is the Ministry of Health business unit entrusted with leading the planning and development of the health workforce.

Gorman became infamous in nursing circles two years before then for labelling New Zealand’s nurse practitioner model as a “tragic” and “failed experiment” because of the lack of NPs and NP jobs.

Then late last year the leaders of the New Zealand Nurses Organisation, the College of Nurses, and the College of Midwives released a strongly critical open letter expressing “significant concern” about the HWNZ’s performance and calling on it to act now to restore confidence in the unit’s ability.

In particular the letter criticised HWNZ for its “poor focus” on its core business of workforce projections and planning, “very poor” engagement with health practitioner organisations, lack of transparency, and poorly planned innovations.

Disappointed and puzzled

Gorman’s response to the letter is a mix of disappointment and surprise.

“I think we’ve been very proactive in nursing since the day we were formed,” he tells Nursing Review.

“Admittedly we had some high profile medical burning platforms that took immediate prominence. That doesn’t mean we haven’t been absolutely focused on our nursing projects from the outset.”

He is “very disappointed” by the letter, and while not “depreciating the issues” raised, he believes they could have been raised a different way. He is particularly disappointed that the nursing champions group, formed at HWNZ’s request as the channel for communication back and forth with the nursing sector, appears to have failed to do its job.

He acknowledges it had underestimated the “huge challenge” of communicating with the health sector in general, with over 500 groups, committees, and colleges, all with a ‘genuine role’ in the workforce in some way. The response was a deliberate strategy to condense the sector down into champions groups as a way to engage, but the letter shows that a sizable portion of the nursing sector feels disengaged.

“Notwithstanding my surprise and disappointment, I want to hear about the issues that concern them,” he says. (The interview was held before nursing and midwifery leaders met with Gorman, HWNZ director Brenda Wraight and HWNZ board representatives in mid-February. Read more online at ‘What next for nursing & HWNZ’ at www.nursingreview.co.nz)

Nurses have not been alone in giving negative feedback, with district health boards having described HWNZ’s programme as “piecemeal”. “The fact is that they (DHBs) ignore most of what we put out until it affects their bottom line and then they react and say ‘you guys are piecemeal’.”

Gorman has declared that 2013 is the year that HWNZ will dedicate to the looming nursing workforce crisis.

Not that he believes that nursing has been forgotten in the interim.

“Our commitment to the nursing workforce and our anxiety about the nursing workforce has been at the forefront of our thinking for some time.”

He also thinks the letter’s criticism of poorly planned innovations and a fragmented approach is unfair.

“I think there is an absolute raft of nursing innovations. Some have been profoundly successful”, says Gorman. “The way we go about innovating may look piecemeal, but I can assure you that it is very, very strategic.”

He is particularly proud of the diabetes nurse specialist prescribing innovation (initiated by the multidisciplinary New Zealand Society for the Study of Diabetes under the championship of nurse practitioner Helen Snell) as a successful backdoor entry point for nurse prescribing in general. (Read Gorman’s additional comments on chauvinism, prescribing, physician assistant training and nurse practitioners in ‘More from Des Gorman’.)

The big picture: the looming nursing crisis

But what about the big picture: how many nurses do we need to recruit or retain to meet New Zealand’s health services in the future?

One could argue the lack of the big picture. A major concern raised in the open letter is HWNZ’s “poor focus to date on the core business of workforce projections and planning”.

Across the ditch Health Workforce Australia last year produced a major workforce projection document that, based on different demand and supply scenarios, predicts Australia could be short by anywhere between 17,000 and 147,000 registered nurses by 2025.

HWNZ doesn’t have a similar document and is unlikely ever to as Gorman says such plans and projections never work and just end up thrown in the bin. In defence of his position he asks who a decade ago would have predicted the recession leading to the current scenario of low nursing vacancies and turnover, which has resulted in new graduates struggling to find jobs.

(However, the Nursing Council has stepped in and commissioned its own report on New Zealand’s projected nursing supply from economic research firm BERL, which is due to be released shortly.)

Instead, HWNZ has opted for individual service forecasts looking at the workforce needs of various health services – from mental health and aged care to anaesthesia and eye health – rather than single professions. The ten forecasts to date have been disparate in approach, length, and answers.

Gorman agrees the forecasts are diverse but says, “interestingly they are telling us the same sorts of things.”

“First of all, there is a range of possibilities for the future. There is no single truth and we’ve got to make sure we plan in a way to cover a range of eventualities, not just one we hope and pray might come right.

“They also tell us that extended nursing roles are essential, irrespective of what scenarios we see.”

Training and retaining more

Coming back to the big picture, how can nursing leaders and HWNZ ensure we have enough nurses to meet demand, whether it be for traditional, new, or extended roles in 2025?

Gorman may not have projection statistics at his fingertips, but he says he is losing sleep about having enough nurses to carry out core nursing duties.

In particular he is “hugely worried about three things”.

Firstly, that the health sector is complacent about nursing numbers because the recession has led to low turnover and unemployed new graduates.

Secondly, that the average age of nursing is reaching 50 when nurses in particular “traditionally increasingly become part-time or stop working”.

Finally, while Gorman may doubt the worth of Health Workforce Australia’s projections, he doesn’t doubt that Australia is about to face a major nursing shortage that will have a flow-on effect to nursing supply this side of the Tasman.

In response to the first concern he says that he jumps on anybody who argues that nursing student numbers should drop because of graduate unemployment. “That would be the single worst thing you could do at the moment.”

Instead he says “absolutely” nursing intakes should increase but in a “responsible” way.

“You don’t have to say that if there are 4000 nursing graduates then there have to be 4000 nursing jobs [waiting]. But if you have 4000 nursing graduates, you can’t have a 1000 first-year nursing jobs, either.”

Asked what steps were being taken to make bigger intakes a reality, Gorman says it is in “close quarters” with the Tertiary Education Commission “regularly” on what needs to be resolved. “And this is the year for resolving it”. Already Gorman is threatening a financial stick against District Health Boards that don’t offer sufficient ring-fenced intern positions for new graduate nurses in 2014. (See online Jan 28 News Feed story www.nursingreview.co.nz).

When it comes to his second point, there is debate whether statistics back Gorman’s concern that nurses in particular retire or go part-time in droves at 50. Nursing Council and Medical Council statistics for 2011 show the demographic breakdowns by age are virtually identical for doctors and nurses.

What there is no debate over is that nursing is an ageing profession (see Focus story on older nurses) and retaining more nurses at all ages – not just young or old – is going to be increasingly important as baby boomer nurses start to retire in large numbers five years from now.

Feast, famine, and burnout

Strategies to retain nurses are high on the agenda this year, says Gorman.

“That is the very project to challenge both the academic nursing groups and the nursing champions group,” he says.

The challenge is to identify strategies (to both discourage nurses from leaving and encourage them to extend or change roles) that can be deployed quickly to help meet the demands of 2025.

The open letter likewise challenges HWNZ to up its own performance in workforce projections and planning, if it wants to regain the sector’s confidence.

So what action is HWNZ taking itself to plan for the expected nursing shortage?

“We’ve funded research at the University of Auckland, for example,” says Gorman.

Last year HWNZ funded a PhD student to commence a research project into strategies to keep nurses nursing.

“But it’s been beyond that,” adds Gorman. He says HWNZ has joined the International Health Workforce Collaborative and will be working closely with Health Workforce Australia as any response needs to be in synch with its equivalent across the Tasman.

HWNZ was approached for more detail on New Zealand’s research involvement with the collaborative. A spokeswoman replied that it was a “relatively new relationship” so “it is too early to provide specifics about the exact nature of our contribution at this stage”.

Gorman says he’s been made aware of existing nursing research into retention, like the Magnet Hospital principles. In return, he asks why, if nursing knows what influences nurses to stay in the workforce, nobody has managed to break the “feast or famine” cycle that the nursing workforce is in internationally.

“The answer is that the nursing workforce is following general labour market conditions and general economic conditions. Health has not broken into that cycle and imposed some more regularity to it,” believes Gorman.

Another possibility is that nurse leaders and researchers know the answers but why aren’t their voices heard or their research acted on?

“That might be true. What we don’t want to do is pull a series of levers that we think will fix the nursing workforce problem and then discover they make no difference at all.”

Another key could be finding what causes burnout – is it shift work, lack of autonomy, collegiality, or the impact of funding?

“The fact is that over the last 20 years, every time nurses have shown a productivity gain, the system has said ‘you beauty! we need less nurses to do the same work’… so there’s never been a shift in the work/life balance. (Nurses) just end up doing more and more,” says Gorman.

2013 year of action

Meanwhile the sector over the next decade is about to face a demand/supply gap too big to be met by simply productivity gains and recruitment drives, believes Gorman.

“It will require a profound shift in behaviour.”

Gorman agrees that it is definitely now time to act on a plan for nursing and to increasingly engage with the nursing community – to find what out what the “big themes” are.

“What we are saying is that this is the year that those concerns and that anxiety has to end up coalescing into some coherent responses. By the end of this year, those responses have to be in place.”

“Fortunately the crisis we face is sufficiently down the road that we can spend some time getting this right. We don’t need to rush in to some knee-jerk reaction that we will regret in 10 minutes time.

“2013 is the year we’ve dedicated to getting some of these big pictures right.”

If HWNZ succeeds, maybe everybody will be sleeping more soundly?