No winter is easy in the health sector, but this winter brings the prospect not only of a tough flu season but also of a nurses’ strike.
So this season – when winter illnesses see the demand for acute patient beds go up at the same time as the staff available to nurse them goes down – could be tougher than usual.
Dr Jocelyn (‘Jos’) Peach, the director of nursing at Waitemata District Health Board since 1999 and a nurse for 44 years, is very conscious of the pressures that nurses are under and the need for DHBs to respond to nurses’ growing and very real frustration over pay and workloads.
But meanwhile, winter still comes.
“The challenge as a leader is to help the staff see the big picture,” says Peach.
The many pieces of the big picture for Peach include gathering accurate data to calculate safe staffing workloads, dealing with the staffing consequences of Auckland real estate prices, planning for the DHB’s population swelling by 100,000 or more in the next decade, and helping to refine systems to better manage demand and free up resources to fund more staff.
TransforMED – freeing up beds this winter
It is the initial success of one of those systems’ projects – called TransforMED – that Peach and the executive leadership team hope will help the DHB meet their winter goal of maintaining timely access to care and treatment for both acute and elective patients in its North Shore and Waitakere Hospitals (a goal post that, of course, could be dramatically moved if the flu season is unusually severe and nurses vote to strike in July).
One of the starting points for TransforMED was the reality that Waitemata’s population was growing rapidly and there was no space to expand at North Shore Hospital and no likelihood of getting a new hospital anytime soon.
Work began on system improvements to make better use of the beds and space the DHB has already got. Last spring the DHB launched TransforMED in North Shore’s Admission and Diagnostic Unit (ADU) first, then on through the hospital’s general medicine wards and beyond, with the aim of reducing unnecessary admissions and, whenever feasible, getting admitted patients home earlier with the appropriate aftercare in place.
“It’s had a huge impact on our hospital,” says Peach. A report to the DHB’s May Hospital Advisory Committee shows that TransforMED, ADUcare and a ‘Home Warding’ pilot initiative have combined to improve patient flow and shorten the average length of stay by 18 per cent since their inceptions.
The initiatives have also allowed North Shore Hospital to operate a ‘flexing bed’ programme by opportunistically closing beds if they are not needed. The combined bed savings of reduced length of stay and closing beds has to date has been just over $1 million, according to the DHB’s latest financial report.
The TransforMED project includes elements of the #endPJparalysis movement founded by Christchurch-based nurse and consultant Brian Dolan and his Irish colleague that encourages older medical ward patients to get out of their pyjamas and get dressed and mobile in order to maintain condition and return home sooner. Waitemata has developed its own variation – the ‘3G’ (Get up, Get dressed, Get moving) campaign.
Other elements of TransforMED are daily multidisciplinary board rounds, increased rounding in the ADU, daily bed management reviews, and doctors being assigned to patients in just one of the hospital’s six general medicine wards to help streamline patient care.
“We also have ‘red to green’ days,” says Peach.
“So no patient just sits around waiting for something to happen and every day is a green day. A green day is making sure patients get the treatment they need so they can get home – it’s about reducing length of stay but also reducing the risks of pressure injuries, falls, and deconditioning.”
Peach says the results to date have been fantastic and mean that the DHB – while, of course, they enter winter always concerned with what the season could bring – now has systems more responsive to patient needs and an ADU system that supports patients who can go home safely to do so, reserving beds for those patients who need to be admitted.
The hospital’s winter plan is also built on the assumption that TransforMED will continue to deliver a 10 per cent reduction in occupied medical ward beds, allowing those beds to be flexibly used to meet winter demand.
The first test was a much busier than expected summer and Peach says, while it was a very busy time, the DHB still managed to deliver clear care plans for patients and keep patient flows on track.
Another key requirement for TransforMED to work is, of course, a flexible nursing staff ready to respond not only to patient needs but to the ‘flexing bed’ policy of opening and closing beds in response to patient demand and staff availability.
“It means the staff are working under pressure – don’t get me wrong…” acknowledges Peach. “We’ve got more patients but fewer bed days. Our staff have been really amazing, they’ve been really flexible. Staff go from Waitakere Hospital to North Shore and vice versa to help out if beds are closed on their ward. We are very, very fortunate to have good, flexible nurses.”
And while Peach agrees that nurses “absolutely” face higher patient churn, she adds that nurses do not like seeing their patients languishing or having to face families frustrated because of the lack of an action plan.
Recruiting and retaining nurses in the Big Smoke
This year DHB nurses nationwide have been taking to social media to express pent-up frustrations at pay and workload issues and a result could be a national strike this winter if an independent panel does not result in an offer that the majority are ready to accept.
So how tough is it currently to recruit and retain nurses in the country’s biggest and most expensive city?
“It’s not perfect,” says Peach. “We still get raided every so often from Australia and the Middle East … everybody suffers from that.”
She says the DHB’s nursing workforce has good retention of long-serving staff and new graduates, but where it struggles most often with turnover churn is some of its internationally qualified nurses (IQNs). “We have had a lot of people who come from overseas, they do their time with us and then they go off to Australia.”
Improved pay may help reduce turnover, but Peach says there are several reasons why nurses leave, including IQN nurses crossing the Tasman because their husbands have been unable to find work in Auckland. Other nurses and their families leave Auckland for jobs in the provinces because houses are more affordable.
“So yes, dollars may help but they may not help enough because there are costs associated with living with Auckland – which are getting ridiculous.”
For example, she says, the DHB has a marvellous new graduate nurse with four children who has relocated to Auckland for a new start but is forced to spend nearly all her wages on rent.
“She’s having to go to WINZ saying she can’t afford to feed her kids – we are trying to help her as much as we can … but the new grad salary is the new grad salary …”
Likewise, Peach says the DHB tries so hard to recruit Māori and Pacific nurses from the provinces and other centres to work for Waitemata, but when they try and find a house to buy or rent they tell the DHB that they just cannot afford to take up the job.
Safe staffing and CCDM
Another major platform in the current stalled nursing pay talks is safe staffing and a commitment from all DHBs to fully implement the Care Capacity Demand Management (CCDM) safe staffing tools by 2021.
“I absolutely understand that we need to look at staffing and how our patient acuity has changed … it’s good work – nobody denies our patients are more complex and that we need adjustments around staffing,” says Peach.
Nonetheless, she says, the work involved to gather a year’s accurate acuity data from each of the 47 wards and units in which nurses are inputting daily information into the Trendcare acuity software – is “so huge, so massive” that it is “mind-boggling”.
Peach has taken on extra staff to help pull out the data from Trendcare, but says it will be a very tight work plan to deliver by the 2021 deadline. And once CCDM reveals the gaps between what is a reasonable workload and what is not, the next question is how DHBs will pay for the extra staff.
“Do we do the CCDM work? Definitely, but I don’t know how all DHBs will be able to afford the increases that are potentially there.”
Peach also doesn’t believe that CCDM is the ‘silver bullet’ and just one element – although a very important one – of her ‘big picture’ systems work to make nurses’ workloads more reasonable, fair and consistent.
“I understand the complexity of what nurses are facing … we’ve got to try and reduce the pressure by making the systems more efficient and effective.”
And all going well – although she acknowledges being concerned about what this year’s flu season might bring, and the chance of a July nurses’ strike in peak flu time “doesn’t bear thinking about” – Peach hopes that the big-picture systems will make a difference this winter.