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Four years on, Christchurch’s nurses are still driving on bumpy roads to workplaces that are often temporary or under repair before returning to a home that may still be cracked or leaking. And with a $650 million rebuild, redevelopment and reshuffle of hospital services underway over the next four years and increasing demand for mental health services, it seems there is little relief in sight.

FIONA CASSIE looks at efforts to boost and maintain the wellbeing of Christchurch nurses and considers the take-home lessons for nurses under stress anywhere in the country.

 

Toni Gutschlag	Heather Grey

 

The ‘heroics’ are all behind us, the ‘honeymoon’ is well and truly over and it feels like we’ve been stuck in the ‘disillusionment’ phase for quite long enough, thank you.

Four years on from the most devastating quake, and nearly four and a half years after the first and largest quake, Christchurch is very much ready to climb out of the ‘disillusionment’ doldrums into the fourth and final ‘reconstruction’ phase of the psychosocial recovery model for a disaster.

With new and glistening buildings popping up in the city – and the cranes on the skyline now there to construct rather than destruct buildings – there is a feeling that the city’s ravaged inner city is on the up.

Christchurch isn’t quite there yet though and its citizens largely feel the same. Many are still on an emotional rollercoaster – buoyant and optimistic at the peaks and frustrated to downright cantankerous in the troughs. And many are tired, increasingly tired, according to the 2014 survey carried out for the Canterbury District Health Board’s All Right? campaign in which 65 per cent of respondents reported feeling tired, compared with 55 per cent in 2012.

That figure doesn’t surprise Heather Gray, director of nursing for Christchurch Hospital.

“Last year just seemed to be a long, hard year for many of us… many people have said it was the hardest year for some reason.”

She agrees that maybe it was because by 2014 people thought things would be getting easier. “We should be over this by now,” is a common comment, says Gray.

And while many more people now have new or repaired homes, others are only now requesting quake leave in 2015, having finally got the green light for their repairs. Others are still waiting – sometimes caught up in complicated wrangles over initiating first-time repairs or rejecting sub-standard repairs and sometimes still camping in garages or campervans.

 

Stats show 2014 a tough year

The DHB’s mental health services had a particularly hard time last year, with extra demand across the spectrum forcing the board into a one million dollar deficit, as cited by the DHB’s finance general manager in The Press late last year.

General manager mental health services Toni Gutschlag says that in the past three years demand for community mental health services has increased by 30 per cent, acute emergency mental health services by 37 per cent, and rural mental health services by 65 per cent.

There has been an upsurge in children and teenagers presenting for specialist help for depression and anxiety (up by 56 per cent – 28 per cent in rural Canterbury) and admissions to the DHB’s 15-bed specialist child and youth inpatient unit at Princess Margaret Hospital has risen by 91 per cent.

Gutschlag is also chair of the DHB’s Staff Wellbeing Action Group (SWAG) that was created after its own staff wellbeing was found to be floundering in the DHB’s first staff wellbeing survey in 2012 (see SWAG story on this page).

The follow-up 2014 survey found that around a third of staff still had earthquake claims that were only partially resolved and a quarter of homeowners still had unresolved issues. On top of that, 13 per cent of staff reported being directly impacted by the three record floods that hit the city in quick succession in March and April last year.

It is probably not surprising then that the DHB survey found that the emotional wellbeing of 35 per cent of its male staff and 37 per cent of female staff respondents rated ‘poor’, according to the World Health Organisation wellbeing index. This was a slightly better result for men than that of the 2012 survey but slightly worse for women. Once again lack of sleep and feeling fatigued was a very common theme.

That feeling of post-quake fatigue is also likely to be shared by many of the nursing community working around roadworks, building repairs and rebuilds across general practices, rest homes, community nursing services like Nurse Maude and Health Care New Zealand, private surgical hospitals, community mental health providers and Plunket.

 

2015: the best year yet? Working amongst traffic cones and orange vests

After a bright, hot summer many Cantabrians have returned from holidays optimistic that 2015 could just be the year that the city turns the corner.

“It is only lately that I’ve started meeting people who are more hopeful that we are going forward,” says Heather Gray. “We’re building a few buildings rather than ripping them down… it’s quite nice to see that.”

“I think though there are still some challenges ahead – particularly on this campus,” says Gray of the central city Christchurch Hospital. “We’ve got a building construction site out back and road construction out front and we have business as usual – sort of – in the middle,” she laughs.

“All our access-way roads have been moved. Our two-way streets have become one-way, our one-way street has become two ways and one street is cut off entirely. So all of the flow past the hospital is different.”

The construction site out the back is a new acute services hospital building – already in the pipeline, pre-quake – which got under way in late 2014. Out front the City Council is carrying out a major transformation of the roading network.

Sandwiched between the road cones to the north and the jackhammers to the south are the ongoing repairs to the existing acute services building, with virtually every room having experienced quake damage. To the east, work is under way on the new green belt along the Avon River – a long-term plus for hospital staff but currently yet another disruption.

All this construction also means that from late October last year all car parking around Christchurch Hospital – except for limited mobility parking sites – has ceased. Staff parking is not directly affected but hospital visitors are now encouraged to park on the site of a demolished brewery (earmarked for a new sports facility) and take a free shuttle to the hospital.

It’s no wonder that patients and visitors can present as more than a little harried when roads, car parks, entrances and facilities may have been closed, shifted or changed between visits.

“We have certainly found that over the last four years people are less tolerant,” says Gray. “There’s a shorter gap between coping and not coping than perhaps there was before the earthquake.

“I think we’re developing a phobia for orange cones in Canterbury. People almost run them down on purpose, it seems,” she adds, with a laugh.

Across town in the north-east of the city at the Burwood Hospital campus, major new facilities are being built to house the team at the CDHB Older Person’s Health Specialist Service. The big shift, scheduled for 2016, will take them from their current home at The Princess Margaret Hospital, which is in the opposite, south-west corner of the city. The completion date of the project, originally set for 2018, is now looking more like 2019.

 

High demand for MH services yet to peak?

In the midst of these rebuilds and reshuffles the mental health service is becoming seriously stretched, with increased demand driven by those with mental health issues triggered by the quakes’ aftermath.

Toni Gutschlag is not sure whether this increase in demand, particularly the “extremely concerning” rise in child and youth presentations, has yet to reach its peak.

She says previous international disaster research has indicated that mental health needs increase a couple of years after the main event. “We were lucky we had a reduction in demand for the first 12 months – things dropped off as people were preoccupied with other things.”

As a result, the DHB was able to action some plans already in the pipeline before the quake and make some quick changes in readiness for the expected increase in demand “which for us has been in the last 18 months.”

Gutschlag believes one of the reasons for the increased demand is Cantabrians’ greater awareness, post-quake, of mental health and wellbeing and how to get access to professional help. “I think some of the stigma has reduced so it’s okay now to get help, because mental distress has been experienced by so many more people.”

But it was also worrying that the upsurge in post-quake demand meant parts of the community were under such pressure that it was impacting on their mental health.

The demand has come at the same time as mental health staff turnover and sick leave has increased, however, as mental health staff are all part of that same pressured community. Recruitment has also been “really challenging”, Gutschlag says, particularly with Christchurch’s limited and increasingly expensive housing stock.

One successful response has been to invest heavily in the DHB’s nursing and allied health new graduate programmes to help meet the ongoing high demand for mental health services.

“It (the upsurge) was predicted and what we are experiencing is consistent but we don’t know when it’s going to end…”

 

Maintaining and building nursing resilience

‘Challenging’ may be somewhat understating the trials that many Christchurch nurses will be facing in their professional lives for possibly another four years, on top of an already tough four years.

So how do you keep nurses ‘keeping-on’ in the ongoing aftermath of a major disaster that at times has tested the resilience of even the most buoyant?

“I don’t think there is one formula for that,” says Gray. She believes the accumulation of some really simple intangibles can help make a difference. Things like ensuring people take their holidays, sensitive rostering and making sure they are aware that their work is appreciated. “Because it is easy to forget to appreciate the quiet ones,” says Gray. Also giving people a vision of where the service is headed, as vision and teamwork is a priority.

Then there are the more tangible things like the programmes offered by SWAG and the All Right? campaign (see related story) posters plastered on the walls of hospital corridors and wards. “Just asking people ‘are you okay?’ is also really important,” adds Gray.

Nurses are learning to pace themselves too, if the trend noted by postgraduate nursing education coordinator Jenny Gardner is anything to go by.

She says funding applications last year exceeded supply, leaving a waiting list of nurses who were eager to begin studying and were not letting the quakes hold back their careers. But this year there has also been a noticeable trend of nurses with approved funding for two papers deciding over the summer to settle for one paper or take a break before launching into their dissertation year. “I think the drive and the want and the intention is definitely there – that hasn’t waned at all – but it’s just been tempered with reality really,” says Gardner.

The most common reason for postponing study is house repairs, with nurses reporting that they’ve just been notified by their insurers that they need to shift out next month so repairs can begin. “It’s hard to study when you’re living out of boxes.”

 

Seeing the silver lining

Taking a breather is a sensible approach but it can be challenging when you are part of the mental health service, which is facing increased demand, increased staff turnover and recruitment challenges.

“At the end of the day it is tough going,” acknowledges Gutschlag, when asked how mental health services staff deal with the pressure.

Though, she adds, there was also a positive side to being so in demand, particularly in the early days post-disaster. Gutschlag says staff told her that in their personal lives they had felt a lack of control over what was happening to their homes, their children’s schools and their local community. “But they could come to work and get on with their jobs and be involved in change and making things better,” recalls Gutschlag.

 

Givers need to take time for themselves

‘Giving’ is one of the five ways to mental health wellbeing, and the strong ‘giving’ trait is also fundamentally why most health professionals are there in the first place.

But givers and carers also need to care for themselves.

“We can be very good at providing care for others and not prioritising ourselves, and that is a challenge not only for the mental health workforce but the whole (health and social service) workforce,” says Gutschlag.

CDHB chief executive David Meates is keen for his staff to get the take-home message of doing something for themselves. In his September CEO update he signed off by saying: “Remember that to care for others you need to look after No. 1 first”.

Gray says ‘looking after yourself’ can sound a little glib but the worth of it was brought home to her personally last year. Bogged down with a range of work projects, she had hardly seen the sun for five months and not surprisingly found her mood was flat.

“In a way I think you have almost got to fail at that (looking after yourself) before you realise you’ve got to do better. Looking after yourself is something that doesn’t come easy for nurses. I think they look after other people first before looking after themselves.

“But it’s like the airline safety messages, isn’t it? ‘Put on your own oxygen mask first before assisting others’.”