The Health Sector Workers Network put out a press release this week stating that Plunket planned to cut all of its nine clinical nurse consultant (CNC) positions following a PricewaterhouseCoopers (PwC) review.

Bram Kukler, Plunket’s Acting Chief of Operational Transformation, in a response to Nursing Review said it had told affected CNC staff this week that following “strong advice” it had agreed to “look more broadly at our system before making any decisions” but the “motivations” for the review still remained.

The CNC review is one of two Plunket reviews underway with the second a review of services and staff in Plunket’s Central region involving disestablishing 53 positions and replacing them with 34 positions. Well Child nurses are not involved in the Central review but NZNO has said the proposal does including moving from four clinical services manager (nurse leader) positions to two. Decisions are due on the Central review at the end of the month.

Kukler said both reviews were about “making sure we can deliver what families across New Zealand have told they need – today and into the future”.

“Like any organisation, and especially a charity that relies on donations from the generosity of New Zealanders, we have to make sure that our resources are used wisely and ultimately help to deliver on our future vision.”

Plunket appoints three high-flier nurse leaders

Meanwhile Plunket has recently taken on three high-flier nurse leaders into its executive team – including former Ministry of Health Chief Nursing Officer Dr Jane O’Malley who started this month as Plunket’s first chief nurse.

She will be working again with Dr Paul Watson, a former principal advisor in the Office of the Chief Nursing Officer, who left his most recent position as manager of workforce strategy and policy at Health Workforce New Zealand (HWNZ) to start last month as a national advisor in Plunket’s advisory and advocacy team.

Also just started with Plunket is Jane MacGeorge who has left her role as NZNO’s manager of nursing and professional services to become Plunket’s head of organisational capability.  MacGeorge has previously worked for Plunket as its National Clinical Advisory Manager for 14 months in 2010-11 and was director of nursing for Healthcare New Zealand for six years and clinical services director at Mary Potter Hospice for three years.

Claim that CNC review ‘superficial’

The Health Sector Workers Network press release said anonymous Plunket sources had described the CNC review process as “superficial and insincere”.

It had lead to PWC advising Plunket that there was “significant role overlap” between the CNC roles – leadership positions responsible for mentoring nurses and maintaining quality service standards – and other positions.

Kukler said the original CNC proposal had looked at the scope of the consultants role and a potential reduction in the number of roles.

“However, during the consultation strong advice emerged from staff that the interdependencies across our clinical system go further than we had originally anticipated and we needed to take a step back,” he said in a statement.

“We’ve listened to this advice and agree that we need to look more broadly at our system before making any decisions.

“The motivations for the change still exist so we will be working with our Clinical Nurse Consultants and other staff to work out the next steps.”

Kukler said PWC had provided Plunket with some support at several points in the clinical nurse consultant (CNC) review but Plunket was leading the review and consultation process.

He said that staff involved in the Central review had also given Plunket “plenty of well-considered feedback” on the original proposal and it was taking extra time to work through that feedback. A decision is expected at the end of March.

The interim chief executive at Waikato District Health Board has spent most of his career in health managing broken situations back to repair.

As the replacement for Dr Nigel Murray, who resigned in October amid an expenses scandal, Wright is arguably tasked with his biggest challenge yet.

That is; change the culture, create a workplace people are proud of, get Waikato Hospital to the top of its game, and turnaround the DHB’s financial problems.

The 63-year-old has set himself a one year deadline to achieve the transformation.

He doesn’t want to commit for too much longer than that for two reasons – he gets bored easily which turns to “mischief”, and he wants the next chief to hunker down for five years and lead the embattled DHB into a period of stability, security and ultimately, growth.

And it should be noted, Wright – previously the health board’s mental health and addictions executive director – was given the seal of approval for the important interim job by the senior doctors at Waikato Hospital.

This is no mean feat, particularly given the dysfunctional relationship Murray created with clinicians during his three year tenure, and the loss or partial loss of training accreditation in different units at the tertiary hospital.

Wright says there’s no secret to being a good leader.

“It’s not rocket science. I think it’s about having that focus, having that visibility. I’m really clear that I make decisions everyday that impact on the work that staff do and unless I’m informed then I might be making the wrong decisions.”

Relating to people from all walks of life comes naturally to Wright.

Born in Scotland and raised in Fife, north of Edinburgh, Wright fell into health at 19 when his neighbour offered him a job at the local hospital as an orderly.

“I started at the bottom basically.”

The football-mad teenager earned just 10 pounds per week, about $200 by today’s standards, graduating to 15 pounds a week after he trained to be a nurse.

That was 1978. He specialised in surgery and crossed into mental health, working his way up from a staff nurse to a charge nurse.

He moved to Newcastle in 1984 at the time when major health reforms were underway with an emphasis on turning clinicians into managers.

Wright was offered a spot at Birmingham University to study health management and moved into general management shortly after.

By then he was married to Elizabeth – who he met in the nurses’ home of a psychiatric hospital – and together with their two children in 1992 the couple upped-sticks and moved to New Zealand on a health industry exchange for one year.

Wright swapped jobs with the manager at Auckland mental health services based at Waitemata.

“During that year I also got asked if I would take on the role of project manager for the closure of Kingseat [Hospital] and Carrington [Hospital].

“I think it was because, ‘new guy, if it doesn’t work then he’s out of here and if it does then he’s out of here anyway and we can take the credit’.”

Wright closed the two former mental hospitals – Kingseat took longer than a year – and back in the UK he and Elizabeth decided, thanks to a bitterly cold winter, they would make New Zealand home permanently.

He managed mental health and drug and alcohol services at Waitemata from late 1993 before becoming general manager of North Shore Hospital for four years.

That was followed by a stint as the first mental health regional director for the northern region before Wright was headhunted in 2007 to be director of operations in South Australia.

“The day I arrived, they had 74 psychiatrists and 40 of them resigned. Nothing to do with me. It was all to do with pay negotiations they were having with the state but that was my introduction to South Australia.”

Five years later Wright returned to New Zealand. He worked for a non-government organisation and was made redundant.

He set up a consultancy, doing strategic planning, restructures and service reviews, including a mental health review for Northland.

Wright initially turned down the opportunity to apply for the mental health director role at Waikato, but eventually succumbed to a persistent recruitment agent.

He joined the DHB in February 2016, during the middle of a Ministry of Health Section 99 review of its mental health unit, following the death of patient Nicky Stevens.

Among other things, the review identified the need for an experienced senior executive in the DHB’s mental health team, a position left vacant during a restructure of the executive leadership by Murray.

The DHB had also been in the spotlight for allowing fake psychiatrist Mohamed Siddiqui to work there for six months in 2015 on a salary of $165,000.

“There was lots to do but there was a really good team and me never having worked in Waikato before, I came in with fresh eyes. We made lots of changes. There was already lots happening – I just hopefully provided some leadership to the team.”

Wright has already been outspoken on some issues. He previously said he believed New Zealand had too many district health boards.

Twenty for a population of 4.5 million is out of kilter he reckons, and he believes there should be one linked IT system for all DHBs so that health records follow patients.

He also wants to see real change come from the ministerial mental health inquiry launched last month, not just “a tinker and throwing money” at the problem because as it stands our mental health system is unsustainable, Wright says.

Plus there’s room for better training, Wright suggests. Much of his training was on the wards compared to today’s student nurses, some of whom get all the way through a nursing degree only to find the profession is not for them once they get properly into a hospital.

“I think the pendulum has gone too far. I think probably when we trained in the ’70s we were a cheap workforce. I think here there’s too much of the academic side of it and not enough of how do you deal with people.”

Nowadays Wright says there are lots of expectations from health that didn’t exist 40 years ago.

“In the early ’70s, if you were a patient and you needed a hip replacement and you were 65, you didn’t get it done.

“Whereas we operate on 90 year olds now because the expectation is you get it done.”

For now though Wright will concentrate on the job at hand – restoring public confidence in Waikato DHB.

He has set about doing this with a number of initiatives including recently proposing to trim his executive leadership team, to dismantle the 18-strong group Murray put in place and re-assemble it so only 11 executives report directly to him.

Wright also returned the executives to Waikato Hospital after Murray moved them to an ivory tower in the city, away from the coalface clinicians felt.

There’s a 10-year plan being developed focusing on prevention and working smarter, and staff at the $1.4 billion organisation have rallied behind it.

He’s confident of regaining the lost training accreditation in obstetrics and gynaecology and is working on creating a workplace free of bullying and where targets feel they can speak out.

Wright will continue visiting the DHB’s 7000 staff including those at hospitals in Taumarunui, Tokoroa, Te Kuiti and Thames, and he is tackling the way the DHB communicates, both internally and externally.

It’s undoubtedly damage control after the DHB was accused of keeping information secret during the Murray affair, but making himself available to the media and sending out fortnightly intranet updates to staff, complete with jokes, is a good start.

“I’ve hopefully brought some consistency to the organisation. I do a lot of management by walkabout. It’s a slightly different culture I’m trying to bring to the organisation. I guess I’m just trying to humanise management.”

Erin Kennedy, lead delegate for the New Zealand Nurses Organisation and a staff nurse at Wellington Hospital, said the survey results showed only 19 per cent of nurses and midwives responding felt safe or supported at the DHB. Kennedy said NZNO believed this was a direct result of underfunding causing financial deficits and the “sick health funding system” was hurting everyone.

Andrea McCance, the DHB’s executive director nursing and midwifery, acknowledged the survey identified that many staff “are feeling under pressure, are emotionally drained and are experiencing or witnessing unwarranted behaviour”. “This is unacceptable and we are committed to addressing this,” said McCance.

She said nurse and midwives were the backbone of the DHB’s workforce and the wellbeing and safety of staff was of paramount importance. “We strive to provide a safe and supportive environment for all staff, and inappropriate behaviour of any kind is unacceptable,” said McCance.

Kennedy believed the survey results highlighted that there were “simply not enough dollars” to deliver the care patients needed and deserved. She said this made a “huge impact” on nurses and midwives who were “leaving shifts exhausted, and stretched beyond capacity due to short staffing, insufficient resources and a system strained beyond coping”.

The staff engagement survey was carried out in March-April this year and had just under 3000 clinical and non-clinical participants – just over half of the DHB’s workforce. NZNO organiser Georgia Choveaux said about 39 per cent of nurses and midwives responded – approximately 800 people.

The DHB shared the survey results for all staff at its June 28 meeting which indicated 69 per cent of staff felt positively engaged with the DHB, 70 per cent felt motivated in their work and 65 per cent agreed or strongly agreed they would recommend the DHB and the work that it does.

It also reported that the areas required the most focus for improvement included supporting staff to “cope with the demands of their work”, “eliminating bulling and unwarranted behaviour” in the workplace and ensuring “quality communication”.

McCance said the board was committed to working for change, and had initiated a range of activities to address safety issues and to nurture a positive work environment.

NZNO Organiser Georgia Choveaux says that NZNO supports CCDHB’s acknowledgment that urgent work needs to be done. “We are confident that no nurse and no manager would want to see such poor results as this survey has returned,” said. “We know staff and the board alike want the best outcome for every patient in Wellington.”

However, Choveaux said the Government needed to “fix the broken funding model” to ensure CCDHB was resourced to provide a safe workplace. “Instructing the DHB board to find further efficiencies or saving costs at this point can only come at the detriment of patients and staff alike.”

Labour’s health spokesman David Clark told Radio New Zealand on August 4 that Samuel was one of three senior staff to resign within 48 hours at the DHB and the loss of experience was ‘unfortunate timing’ as the DHB struggled with understaffing and resourcing issues. The DHB’s board was sacked two years ago by the Health Minister Jonathan Coleman and replaced by a Commissioner.

Fleming said Samuel’s expertise and knowledge of the health system, passion for nursing and midwifery practice and leadership in nursing and midwifery would be missed and he wished her all the best for her future endeavours.

The DHB had announced on June 30 a new management structure that involves disestablishing 11 nursing leadership positions, including Samuel’s executive director role, and replacing them with seven roles including the new role of Chief Nursing and Midwifery Officer.

The initial proposal had been to disestablish 13 nursing leadership positions and replace them with only four but this had been revised after 136 submissions opposing the changes and after discussions between the chief executive, Samuel and the New Zealand Nurses Organisation.

Samuel was finishing with the DHB on Friday and new Chief Nursing & Midwifery Officer Jane Wilson is to start in her new role on Monday August 14.

Wilson has been based at the DHB’s Commissioner’s officer where she was appointed implementation manager in late 2015 but prior to that was acting director of nursing operations and had been a nursing director for the DHB since 2010 and a charge nurse manager in Dunedin since 1997.

Samuel was director of nursing and midwifery at the former Southland District Health Board prior to the merger with neighbouring Otago District Health Board. She became first the regional chief nursing and midwifery officer in 2009 than executive director of nursing and midwifery at the creation of the merged Southern District Health board in 2010. In all Samuel has worked within the merged Southern District Health Board for more than 30 years as a nurse, lead maternity carer midwife, charge nurse, service manager, general manager and nursing director.

Fleming said the process of appointing the other six new nursing leadership roles was progressing well with interviews due to take place over the next two to three week period.

NEW NURSING ROLES ESTABLISHED (to replace 11 disestablished roles)

• Chief Nursing and Midwifery Officer
• Director of Nursing Southland
• Director of Nursing Surgical, Dunedin
• Director of Nursing Medical, Women & Children, Dunedin
• Director of Nursing Strategy, Primary & Community, DHB wide
• Associate Director of Nursing Southland
• CNM Perioperative, Southland)

NAME CHANGES ONLY

• Director of Midwifery
• Director of Nursing Mental Health & Addictions and Intellectual Disability
• Associate Director of Nursing Surgical Dunedin – Perioperative & ICU
• Associate Director of Nursing Medicine – Southern Blood & Cancer

The DHB late last week announced its new leadership and management structure that includes 11 nursing leadership roles being disestablished, to be replaced with seven.  It also changes reporting lines for nurses.

In its initial consultation document the DHB was proposing disestablishing 13 nursing leadership positions and replacing them with a chief nursing and midwifery officer and three other senior nursing leadership positions.

But chief executive Chris Fleming said the proposed nursing changes raised the greatest concern including 141 submissions of which 136 opposed the proposed changes (that did away with dedicated nursing directors for areas like medical and surgical services and a number of senior nurse management roles).  He said a major theme of the submissions was the value of nurse managers and the roles they played in quality improvement, culture and patient safety.

After discussions with the executive director of nursing and midwifery, Leanne Samuel, and the New Zealand Nurses Organisation he decided to review the nursing proposal leading to the final decision announced at 5pm on June 30.

The positions being disestablished include Samuel’s executive director of nursing and midwifery position which is to be replaced with a chief nursing and midwifery officer role.  The new role will split off operational responsibility for nursing and midwifery staff and change the reporting line for the new tier of nursing leaders. But the role will still be part of the executive leadership team and report directly to the CEO

Currently five nursing directors and the midwifery director report directly to Samuel and 715 fulltime equivalent (FTE) nurses.  This will change to four nurse leadership roles reporting directly to the chief nursing officer and 14 indirect reports

Most charge nurse managers will report to the five directors of nursing who will report to the operations manager or executive director of the section. Most of the new inhouse positions will be internally advertised this month. Across the DHB 55 leadership positions are being disestablished and replaced with 42.

NEW NURSING ROLES ESTABLISHED (to replace 11 disestablished roles)

• Chief Nursing and Midwifery Officer
• Director of Nursing Southland
• Director of Nursing Surgical, Dunedin
• Director of Nursing Medical, Women & Children, Dunedin
• Director of Nursing Strategy, Primary & Community, DHB wide
• Associate Director of Nursing Southland
• CNM Perioperative, Southland

NAME CHANGES ONLY

• Director of Midwifery
• Director of Nursing Mental Health & Addictions and Intellectual Disability
• Associate Director of Nursing Surgical Dunedin – Perioperative & ICU
• Associate Director of Nursing Medicine – Southern Blood & Cancer

The new Health and Safety at Work Act puts the onus on employers to eliminate or minimise risks to their workers’ health and safety – including their mental health.

Studies both here and overseas show that caring for others – who are often at their most vulnerable – in today’s fast-paced, high acuity, high workload health sector can come at a cost to the mental health and wellbeing of the carers.

It can lead to unhealthy stress levels, fatigue, emotional exhaustion, cynicism, compassion fatigue, moral distress and burnout. It can also be a trigger for anxiety and depression disorders.

But while nurses may talk about stress or feeling emotionally drained at the end of a day, it appears that few are likely to share that they have a mental health disorder like anxiety and depression.

Nursing blogger Barbara Docherty last year described depression as nurses’ “best kept secret” in a blog that went viral, attracted many social media comments and led to nurses taking the opportunity to confidentially share their stories.

It should not be a surprise that nurses suffer depression and anxiety as the 2012–13 New Zealand Health Survey found that one in six New Zealand adults (16 per cent) had been diagnosed with common mental health disorders (including depression and anxiety) at some time in their lives, and one in five New Zealand women.

Literature reviews also indicate that mental health issues are more prevalent in nursing and the other health professions than they are in the general population – probably because of the high stress and emotional demands of the work.

For example, a major review of the health and wellbeing of Britain’s NHS staff by Dr Steve Boorman released in 2009 found that sick leave taken by NHS staff was 50 per cent higher than in the private sector. About £1.3 billion of the £1.7 billion estimated annual cost could be attributed to mental health problems.

A recent study of nearly 3,500 Chinese nurses found an estimated 38 per cent had depressive symptoms. A 2012 study of 1,171 American nurses funded by the Robert Wood Johnson Foundation found that nurses had twice the rate of depressive symptoms of the general public (18 per cent, compared with 9.4 per cent).

An Australian retrospective study found elevated rates of suicide amongst nurses and female doctors, compared with other occupations, with one explanation raised being greater exposure to work-related stressors.

These are stark statistics. What are the possible reasons behind them and how could the mental health and wellbeing of nurses be better supported?

Emotional work

“I think we should work with the assumption that all nurses at some time are going to struggle because of the emotional work we do,” believes Dr Jacquie Kidd, a researcher in the field of nursing and depression.

Kidd’s PhD research drew on the experiences of 18 Kiwi nurses experiencing mental illness while practising. She believes that if both the profession and sector acknowledged that nursing is a vulnerable workforce under high emotional stress they would be more open to providing the early intervention and support required.

“I think we would be much healthier,” says Kidd, who is also a Waikato-based senior lecturer for the University of Auckland and teaches and coordinates a mental health new graduate programme.

She says programme leaders tell nurses starting out in their first mental health jobs that after a honeymoon period all of them will hit the wall and think they are hopeless nurses and wish they’d never chosen mental health nursing as a career. But the programme leaders also reassure them that when that happens they will be supported with whatever help they need, and that they will come through it.

Kidd thinks this type of approach should be extended to nurses throughout their careers because not only does the public place “huge” expectations on nursing as a caring profession, but the profession also puts high expectations on itself.

The fear of letting their colleagues or ‘the badge’ down may be one reason few nurses are ready to speak up when they are struggling, believes Kidd.

“In the beginning, depression and anxiety can feel like you are doing something wrong … you feel you’re not quite as good or as fast as everybody else and you are struggling to cope with patients and families that your colleagues just seem to be sailing through with.”

Kidd says by covering up and putting on a brave front of ‘coping’, struggling nurses can miss the early warning signs and the opportunity for early interventions to prevent mental health issues affecting their work. Pushed nursing colleagues may also struggle to feel compassion for a struggling colleague because they are worried about the impacts on their own workloads and mental health if they offer support and help.

Dr Stacey Wilson, a mental health nurse with a research interest in emotional competency, says there is also a sense that nurses should know better, as depression is somehow seen as “quite self-absorbing or selfish” and “nurses aren’t really allowed to be like that”.

Wilson acknowledges the irony that as a profession nurses encourage clients to seek help for mental health or addiction issues and are positive about mental health recovery. But personally it may be a different story because there is still a stigma attached to disclosing mental health issues as a nurse.

“I don’t know many nurses who would say that they are off on leave because of a mental health or a drug or alcohol issue,” says Wilson. “Some might say they are on stress leave.”

Both Kidd and Wilson believe that contributing to nurses’ stress and distress is the disjoint between what draws many nurses to the profession in the first place and the reality of the modern workplace.

“My impression is that what makes us resilient is the time we spend engaging with patients and families – because that’s where we get the sense we are doing a good job,” says Kidd. But working at full capacity can leave nurses little time to foster the relationships that give them energy.

“I think we are in an ever-decreasing circle – we’ve got less and less soul-feeding happening and yet we are giving more and more.”

Wilson says constant change in the health sector is another factor, along with nurses trying to juggle the demands of work with the pressure to do postgraduate work, look after families and attempt a semblance of work/life balance.

So what steps could be taken to better care for the carers?

Healthy workplaces

“If we expect the healthcare workforce to care for patients, we need to care for the workforce.”

This quote from the National Patient Safety Foundation’s Lucian Leape Institute is one of the philosophical drivers for nurse Janice Riegen’s work.

The clinical nurse specialist in occupational health and safety is passionate about the urgent need to create healthy workplaces in the health sector, including reducing the risk factors for anxiety and depression.

“What the literature is telling us is that anxiety and depression are going to be the leading cause of workplace absence for everybody in the next five years – not just in healthcare,” says Riegen. Contributing factors to this include psychosocial risks which Riegen says are becoming one of the biggest health and safety challenges in the modern day workplace worldwide.

Riegen’s master’s research was into what contributes to a healthy workplace and she has presented on the topic internationally. Waitemata District Health Board, who Riegen works for, has created a Healthy Workplace steering group – inclusive of the main unions. Last year the DHB’s board and senior management gave the go-ahead to a Healthy Workplaces Strategy for the organisation and its staff.

The three-year programme lists 15 actions ranging from developing an age-friendly working environment to offering mindfulness and wellbeing sessions, and from supporting best practice workload management to promoting good shiftwork and fatigue management practices.

Riegen says that any healthy workplace strategy needs to be holistic and look at all work aspects that can impact on staff health and wellbeing. “Because what the evidence tells us is that one-off things are no good.” The DHB have used the World Health Organisations ‘Healthy Workplace’ (2010) definition and action model as a basis for the work, along with New Zealand’s Te Whare Tapa Whā model.

So, for example, offering mindfulness and wellbeing sessions is good – but a strategy needs to permeate an organisation’s culture and address psychosocial risks as well.

Riegen says that doesn’t mean you shouldn’t do anything in the interim – she points out that Waitemata’s strategy has been five years in the making and is still a work in progress – but that the bigger picture should always be kept in mind.

Including that there is a very good business case for investing in healthy workplaces as having healthy staff – both physically and mentally – results in less absenteeism, ‘presenteeism’ and staff turnover and leads to greater productivity.

“Also in the last few years the research about the inextricable link between staff health and wellbeing and the safety and quality of the experiences and outcomes for the patients has nearly doubled,” says Riegen.

Safe staffing is definitely one part of a healthy workplace, Riegen says, and if you talk to nurses anywhere their main safety focus is on workload pressures. Excessive workload is a psychosocial risk (according to European Agency for Safety and Health at Work) that can contribute to mental health issues, along with a lack of involvement in decision-making and a lack of support from management or colleagues.

“I used to do bureau work and I could tell how healthy the workplace was straight away after walking in – just based on how I was greeted and welcomed.”

Teamwork and managers

The nursing literature agrees that teamwork – and good managers who foster it – is a very important component of nurse wellbeing in the workplace.

For instance, the Magnet Hospital research, which distilled the common characteristics of hospitals able to attract and retain satisfied nurses during nurse shortages, found that these hospitals not only had adequate staffing, but also offered professional autonomy, participatory management styles, well-prepared leaders and teamwork.

Alison Ogier-Price, who leads the Working Well programme for the Mental Health Foundation and has been working for a number of DHBs to help develop wellness programmes, sees training and supporting managers as crucial

“I see teams that function so well,” she says, “and the heart of it is always that manager who gets it – someone who likes people and gives people a sense that they are participating in decisions that are happening around them.”

But sometimes charge nurse managers (CNMs) are in the role due to seniority or their clinical skills and don’t have the skills to run a team of people. Or they are scared to raise mental health concerns with staff because of uncertainty around what is okay to ask about and what is not. Sometimes managers themselves are affecting the mental wellbeing of their staff because of their communication styles and, on occasions, bullying behaviour.

“Sometimes bullying issues arise through lack of training – they don’t realise what they are doing,” says Ogier-Price. She says that is why it is important to invest in training managers to listen to what’s going on, acknowledge it and respond by using positive and communicative management styles. Training should include communication skills, conflict resolution and team-building skills to create cultures where teams work well together and feel free to raise issues of concern.

Kidd suggests that charge nurse managers may do well to have the ongoing support of HR, rather than HR stepping in when things go pear-shaped.

Riegen says the evidence indicates that line managers should also be trained in supporting staff at risk of mental health issues because if staff have trusting relationships with their managers then they will turn to these people first when they are struggling at work. But line managers, who can be the meat in the sandwich between staff and senior management, also need the skills and the tools to take care of themselves.

“It seems to me it doesn’t matter what position you are in the hierarchy of nursing – the level of stress and the potential for developing a mental health problem that is work-related is pretty high,” says Wilson, who provides professional supervision for nurses, from new graduates to charge nurses. “I don’t think because [managers] are at the top of the food chain that they are any more resilient to the work pressures – maybe they are even more vulnerable.”

Everyone who Nursing Review spoke to agreed that in an ideal world one-on-one professional supervision would be more widely available to help both managers and their nursing staff to critically reflect on their practices, plan their careers and work through some of the challenges facing them in their work.

Wilson says it could also help to defuse anger and conflict in a team if an issue could be resolved by confidential supervision rather than “spreading around like a virus” and infecting everybody.

Stress management, emotional competence and building resilience

So in the real world what can you do, as a nurse, to contribute to the mental wellbeing of yourself and your colleagues in a pressured work environment?

For a start, be kinder and more compassionate to yourself and be kind to your colleagues, who may be struggling around you.

“We’re a highly educated workforce that works in very difficult and challenging situations in some of the most dire times in people’s lives,” says Wilson. “We need a little reminding that nurses are valuable people and it is worth spending a little time being a little compassionate to yourself and working on your emotional competency so you are in good shape for work.”

Ogier-Price, who specialises in applying positive psychology to organisational wellbeing, agrees, saying that nurses generally don’t take good care of themselves and – strangely enough – don’t always have the information or skills to recognise when and how much support they need.

She has been offering wellbeing workshops in collaboration with the quake-challenged Canterbury DHB for the past three years, and after being called in to support other DHBs has come to believe that ‘care for the carers’ information is lacking in the health sector. In her role with the Mental Health Foundation she was commissioned to write a white paper for the Ministry of Health on the topic – something like a ‘working well’ guide for the health sector.

Ogier-Price says a health and wellbeing culture should permeate an entire organisation and include reducing the stigma of mental health illness so that people struggling with anxiety and depression feel more able to speak up.
In larger organisations this can include having access to EAP (Employee Assistance Programmes) that typically offer three free and confidential sessions with a counsellor or psychologist about personal and work issues that may be affecting workers’ productivity.

Kidd, for one, thinks that nurses could be making much more use of EAP. “Just having somebody who is paid to listen to you and talk about your woes … can really help to crystallise what you might need to do to help yourself feel better.”

Ogier-Price says organisations should also promote or offer programmes that help people to maintain and sustain their mental wellbeing.

Encouraging exercise is one example, as there is a growing body of evidence that physical exercise can be effective for people with mild to moderate depression. Programmes that can help people to relax, such as yoga, meditation or mindfulness, are also available, plus others that focus on the other important components of wellbeing, such as nutrition and sleep. Wellbeing workshops such as those offered at Canterbury DHB can teach nurses how to better care for themselves as carers.

Ogier-Price says an absolutely ‘core concept’ that she emphasises in her workshops is the need to build social networks at work, as this is where people spend so much of their lives. This includes creating a work environment where socialising can occur, such as a lunchroom, which she acknowledges can be challenging in busy wards with little private space. Finding a way for staff to get together regularly should be a priority, she says, even if it is just getting together for special morning teas once in a while.

After listening to nurses offload during wellbeing sessions, Ogier-Price is also interested in whether the idea of facilitated support groups, similar to those offered by Alcoholics Anonymous, could be helpful.
Another approach that Ogier-Price encourages in her workshops is for nurses to boost their wellbeing by “basically doing the stuff you enjoy doing”. She says that to avoid chronic stress nurses need to routinely and frequently de-stress during the working day.

“People need five minutes off every hour to de-stress so for the next hour they can function that much better.”

This may be as simple having a laugh or an enjoyable conversation. In a particularly busy day it may be just grabbing a minute to go into the corner and take some deep, calming breaths. In longer breaks it could be grabbing a chance to take a walk outside, knit or do a Sudoku puzzle – whatever helps them to relax.
Apart from stress management, Ogier-Price says other training programmes that could benefit nurses include assertiveness training and boundary setting to help them deal with both difficult patients and colleagues (see p.8 for some stress management tips).

Wilson and Kidd also believe that pre-entry and ongoing nurse education should acknowledge that nursing is emotionally draining work and help them to build the self-awareness and emotional competency skills needed to be resilient and care for themselves and others.

But it is not up to nurses alone to care for themselves – what is also needed is a health sector that cares for its carers. Creating a healthy workplace for carers – to paraphrase the World Health Organization’s healthy workplace motto – is the “smart thing, the legal thing and the right thing to do”.

Winter can be a challenging time to be nice on the ward. Demand for beds can go up and staff numbers go down as winter illnesses hit.

It is the second winter for Mikaela Shannon as nurse manager of inpatient services at Kenepuru Hospital, which is 18 months into a ‘Care with Dignity’ project that morphed from focusing on staff being kind to patients to nurses being kinder to each other.

Shannon says this winter, when wards are short-staffed and flag they need help, it may well be a team manager who arrives to work on the floor beside them.

“All my managers are in uniform now. They used to be in their own clothes. At the end of the day we are all nurses and we are slowly getting that culture that we are all there to help. And I too can make a bed and take a patient to a toilet.”

Shannon believes “absolutely” that if you want culture change you need to “get on the floor and role model it”.

And when she arrived nearly two years ago to take up the post of managing around 100 nurses and healthcare assistants in Kenepuru’s five inpatient wards, a culture change was being called for by Capital & Coast District Health Board’s head office. There was concern about some ‘unpleasant’ online patient feedback and a series of complaints to the Health and Disability Commissioner, says Shannon.

Working with the director of nursing’s office, it was decided to adapt the United Kingdom’s ‘Dignity in Care’ approach and the Royal College of Nursing’s related ‘Dignity: At the heart of everything we do’ campaign to form the basis of Kenepuru’s Care with Dignity programme, which was held last year and underwent an independent evaluation by Whitireia New Zealand.

Shannon says the campaign started simply with wearing name badges and taking a “Hello my name is” approach to communicating with patients. It then moved on to an education workshop looking at dignity, patients’ rights and ideas for improving patient care, which were supported by appointing ‘dignity advocates’ in each ward to highlight and champion putting the improvements into action.

The project focused on treating patients with dignity and respect but it got some staff questioning how respectful staff were of each other. And amongst the Whitireia evaluation report recommendations – including management providing the resources, time and environment to put the Care with Dignity philosophy into action – was a call for all healthcare workers themselves to “model a culture of care with dignity”.

“Over 18 months we probably had four or five events where people had not been very nice to each other … really harsh, ‘eat your own’ type stuff,” says Shannon.

Some events involved new graduate registered nurses or new enrolled nurse staff being snapped at when asking a question or for help, leaving them in tears.

The dignity training meant staff were ready to speak up about unkind behaviour, including one healthcare assistant reporting, “Yes, I’m under direction and delegation, but I don’t need to be shouted or screamed at.” “People can have a bad day,” says Shannon. “But they still need to communicate respectfully to each other.”

Some staff also expressed concern about patients having to hear the “silly banter” of staff being disrespectful to each, including the incoming shift’s nurses sniping about what the previous shift had left undone.

The result is that this year there is a follow-up pilot Care with Dignity project for fostering respect and dignity between nursing staff that got underway in April to build on the groundwork of last year’s patient-focused programme.

It’s early days yet but Shannon says things are changing and nearly 60 per cent of staff are on board, with feedback indicating that the dignity advocates, focus groups and ward teams are working on developing a ‘culture for caring’ and a zero tolerance for bullying-type behaviour (see sidebar).

All her senior team staff are trained and supported in conflict management, including giving staff feedback and assessing ward culture. Work has also been done with staff whose actions prompted the call for more kindness, including using a ‘coach and buddy’ system, role reversal discussions and peer mediation, plus making sure that staff have the appropriate professional language and strategies to use when things go wrong. They are also encouraged to come to meetings with not only problems but also possible solutions.

Shannon says she once had new grads and ENs coming to her in tears but now she believes that the former ‘I’m not helping you’ or ‘we’re not working as a team’ vibe is very much gone.

Work pressure and rostering stress

Shannon acknowledges that the stresses and strains of the modern health system also take their toll on a nurse’s capacity to be caring.

“Most people don’t come to work to be unprofessional – they come because they want to do a good job but they get stressed and snap or say the wrong thing.”

She believes what is helping is having the dignity advocacy groups where people can talk about some of the pressures and issues that make them act unprofessionally.

“It is not perfect yet by a long shot – don’t get me wrong.” But she feels Kenepuru is now on the right track.

Part of the move to “being nicer to each other” is Kenepuru’s new approach to rostered and rotating shifts. Shannon says the roster may have been a source of tension before but there is now a push towards a ‘self-rostering’ model with the aim of allocating shifts fairly and “looking after each other like a team”.

“It is no longer ‘my way or no way’. [For example] we had an awful lot of nurses who had had their families and worked mornings but their families had now left home and they were still working mornings – that kind of thing.”

Roster discussions start at ward meetings and while some people request shifts online there is still a paper roster in the staffroom where people can negotiate and swap shifts before the roster is finalised and published.

Conclusion

Shannon says it can be hard work role-modelling a culture change and she needs to be mindful that she may not always get it right.

But while it may take longer to get some staff on board with the new philosophy than others, she says a Dignity Week in March was a turning point for her as positive things happened on wards not just because she or her senior managers were around or had initiated them.

“We now have a platform where dignity is business as usual,” says Shannon. And, “touch wood”, after 22 months in the job, staff turnover is very low and she has not had to deal with any serious patient complaints. “Which, for me, says volumes.”

Expecting bullied nurses to toughen up is not the answer, says workplace bullying researcher KATE BLACKWOOD.

The Massey University management lecturer interviewed 34 bullied hospital nurses for her PhD thesis and was shocked by the impact bullying can have. The majority of nurses had reported the bullying but she spoke to only one nurse whose complaint had been successfully resolved. Less than a handful had managed to stop or control the bullying by directly addressing the bully themselves while the remaining interviewees were either still being bullied or had resorted to changing jobs (see full research findings in sidebar below).

“The unfortunate reality is that at the moment targets (bullying victims) leaving is the best chance of getting away from workplace bullying,” says Blackwood.

Bullying an organisational problem

Blackwood’s research followed on from a 2009 workplace bullying study which found high levels of workplace stress (75%) and workplace bullying (18%) in the New Zealand health and education sectors.

A number of health sector respondents in that research noted that bullying was a “big problem” within nursing – specifically ‘manager-to-nurse’ and ‘consultant/doctor-to-nurse’ but also ‘peer-to-peer’ bullying.

The focus of workplace bullying research has moved on from looking at the personality traits to seeing bullying as a product of the work environment and placing the onus on organisations – like health sector employers – to do something about it.

“Bullying wouldn’t be as rife in health care as it is right now if there wasn’t a culture of tolerance for bullying,” says Blackwood. “If there wasn’t a culture of nurses being expected to harden up and cope with these behaviours.”

She says while resilience is important it is not the answer to workplace bullying and there needed to be a culture change from the top to create a workplace environment where responding to bullying is taken seriously.

“As when bullying is still tolerated and normalised, managers aren’t following it up because they don’t have to.”

Leadership training for managers essential

The culture change needs to include training and support for direct line managers, like charge nurse managers, who are often the first port-of-call for nurses reporting bullying, says Blackwood.

Particularly as one of her key research findings is that bullied nurses’ reports of bullying are often snubbed or trivialised so they are put off reporting again.

Blackwood says poor leadership skills is one of the workplace factors that heightens the risk of bullying and is not helped by nursing’s tradition of often promoting managers based on clinical rather than leadership abilities.

This can leave managers not only struggling to respond appropriately to bullying reports but also with handling performance management issues which – if done badly – can be perceived as bullying by the nurses involved.

So this is why leadership training in areas like identifying bullying and conflict management skills are very important, believes Blackwood, so fewer managers’ default action is little or ‘no action’.

A lot of the behaviours that can constitute bullying can be subtle and appear almost petty or trivial – like being ignored or having your work criticised – but when they are targeted and happen over and over again they can become really harmful, says Blackwood.

On the other hand, a one-off incident, like a colleague losing their temper, is not bullying and neither is undergoing performance management. There also can be a fine balance between identifying bullying too early and creating a greater issue than actually exists, and identifying it too late when the bullying has escalated and low level interventions like mediation are less likely to be effective.

Focus groups that Blackwood held with managers, and others at the receiving end of bullying complaints, expressed how very difficult they find dealing with bullying cases – often taking the strain home with them at night. They spoke of sometimes being hamstrung from intervening by the bullied nurse not wanting the ‘bully’ to know about the complaint for fear of repercussions; and also the difficulties of dealing with a generation more accustomed to praise than criticism, which could make it very difficult to performance manage some staff.

Blackwood says different strategies were also needed for dealing with, for example, the ‘known bully’ who gets away with it as they are thought irreplaceable; than were needed for the ‘teacher-student’ bullying of a new graduate nurse too scared and inexperienced to realise they are being targeted.

Bullying reporting channels also needed to be clear, well known and reflect the complexities of bullying. So expecting nurses to report bullying via a DHB’s incident reporting system was “extremely problematic”. It could also be a “huge problem” if the only informal reporting channel is a nurse’s direct line manager, when it is the manager they are alleging is the bully.

Funding constraints one bullying barrier

Blackwood is keen to emphasise her research is “not about hauling DHBs across the coals”.

She says the dilemma is not a lack of DHB awareness of bullying as an issue but having the tools and knowledge to change the workplace culture and reduce the risk of bullying and bullying going unchecked.

At the same time funding constraints help not hinder the risk of workplace bullying – because as one nursing leader put it, a funding ‘sneeze’ at the top can impact like ‘pneumonia’ on front line staff. And Blackwood says stress is definitely one channel through which bullying develops and some of that stress also definitely comes through underfunding and the pressure that can place on frontline nurses.

“One of my key strategies (for addressing workplace bullying) is the need to work on organisational culture change but that can take a huge amount of time and resources – both of which DHBs have very little of.”

But Blackwood doesn’t believe this means change can’t happen –she has heard examples of simply the change of DHB leadership making a difference to a hospital’s readiness to intervene on bullying. She is also keen to contribute herself by investigating tools that could make a difference including seeking research funding to implement and evaluate a bullying intervention.

Because leaving their job should be the last resort, not the only option, open to a bully’s victim.

Be nicer to each other

A lack of kindness and courtesy is as much or more of an issue than bullying, believes Sue Hayward.

The director of nursing at Waikato District Health board said her fellow nursing director colleagues are aware of concerns about bullying and she personally investigates any that come to her attention.

“Many things are not at all bullying – just someone who has had a bad day and has interpreted somebody’s action in a different way,” says Hayward.

“But I think, with the increasing pressures placed on individual nurses and nurses as a whole, we have stopped being quite as kind to each other as we should be.”

She adds that in society as a whole she sees a real lack of courtesy.

“Standards of good behaviour just don’t seem to exist or don’t seem to be embedded in society to the degree that they once were.”

Hayward says nurse managers wanting to create a caring environment for their nursing staff need to “role model, role model, role model”.

“Role model, listen to staff, acknowledge their concerns, never minimise them or never marginalise an individual because of what they are saying – that’s my mantra.”

That was then and this is now

Bullying is cruel and destructive, wastes energy, causes nurses to leave the workforce and creates untold misery, says Jenny Carryer.

The Massey University professor and executive director of the believes nursing should be very concerned about it.

But whether bullying as it is defined today has always been a factor in nursing she finds hard to say. Back in the early 1970s, when she trained, nursing was so hierarchical and militaristic that she doubts many recognised they were being bullied although they almost certainly were. The difference was that it was not individualised bullying and “there was a sense we were all in it together”.

“We used to do ridiculous things like a first-year student had to stand up when a second-year student came into the room.

“And you had to turn sideways when the matron was walking down the corridor – the most extraordinary, antiquated, bizarre behaviours that we took as normal.”

That type of behaviour was in its dying days in the early 70s but student nurses still had to accept they were at the bottom of the pecking order and senior people would be “very, very hard on them” or they left. And leave they often did. “The attrition rate was huge.” It was also one of the reasons that training was shifted from the hospital model to polytechnics.

Carryer says individualised bullying between nursing colleagues today is “absolutely an oppressed group behaviour” with the sociological literature describing it as horizontal violence. “So where nurses feel hugely valued – and hold appropriate power and control over their own destiny – I suspect that bullying decreases markedly.”

No magic answer

Bullying is a reality in all workplaces, says Anne Brinkman.

Add to the mix hospital nurses working under the everyday challenge of rostered and rotating shifts and the pressure of constant change and it is no surprise that there is bullying in nursing, believes the professional nursing advisor for the New Zealand Nurses Organisation.

Brinkman says there is no magic answer to the systemic and human factors that lead to some people bullying and being bullied. But probably not helping was the constant push for change, calls to do more with less, stress caused by rostered and rotating shifts, and a lack of mental health skills and political awareness in many nurses.

“We might clinically be able to help someone with blood pressure but we don’t necessarily get it right when it comes to helping ourselves be more resilient and less bullied as a profession in an increasingly stressful environment.”

Brinkman says though there is no single answer to solving bullying, nurses should remember standard 1.1 of the Nursing Council Code of Conduct – which says treat people with kindness and consideration.

Also a “skilled, experienced and balanced charge nurse manager (CNM) who can lead, manage and inspire is worth their weight in gold” believes Brinkman. Though she echoes Karen Blackwood in saying too many CNMs are promoted because of their clinical expertise, and historically and nationally there was “very inadequate orientation” for CNMs who need leadership education and support to do their job well and create a caring environment for their staff.

But meanwhile nurses can be aware of their own strengths and weaknesses, work on having a balanced life and strive to be kind, considerate and supportive of each other.

The publishing of the Francis Report in 2013 on the tragedy at Mid-Staffordshire NHS Foundation Trust rang alarm bells in healthcare around the world.

The report showed that a hospital could appear to meet performance targets while concealing appalling standards of care.

One of the problems identified by the Francis Report was that senior management at Mid-Staffordshire was not listening to patients and their families, or to staff. Despite continual signs of dissatisfaction in staff and patient surveys, no action was taken. Leaders were distanced from what was happening on the front lines and did not fully understand the reality of care being provided to patients.

Leaders at Counties Manukau District Health Board (CMDHB is also known as Counties Manukau Health or CM Health) were left wondering if a similar tragedy could happen in their organisation. CM Health routinely gathered quantitative data under its Patient Safety Framework – including the incidence of falls and pressure injuries and hand hygiene compliance rates – but the Francis Report proved that this sort of data didn’t tell the whole story. CM Health decided it needed to gather different information about safety in its wards and units, and this information needed to be from the points of view of staff, patients and patients’ families.

In early 2014, a collaborative team led by clinical nurse director Jacqui Wynne-Jones created the Patient Safety Leadership Walk Rounds. In the fortnightly Rounds, a team of six staff, including at least one member of the executive leadership team, visits a Middlemore Hospital ward or unit. (There are plans to expand the Rounds into CM Health satellite clinics.) The Rounds team uses three qualitative tools to assess how safe the ward is and capture the experience of staff and patients on that ward (see ‘Qualitative Safety’ box).

Tools to help assess patient safety

The first of the tools used during the fortnightly Rounds is ‘First 15 Steps’, adapted from a National Health Services (NHS) toolkit called ‘The 15 Steps Challenge’ that assesses how safe a ward is based on first impressions of the ward environment. The development of the NHS toolkit was sparked by a comment from the mother of a young patient in an NHS hospital: “I can tell what kind of care my daughter is going to get within 15 steps of walking onto a ward.”

The other two tools are a patient experience questionnaire and a staff experience questionnaire that each comprise 10 questions. The patient experience questionnaire also contains a scale to measure how patients feel about ward processes, routines and interactions with staff.

Wynne-Jones brought together a range of leaders and advisors to co-design the questionnaires. Further staff and patient input was also sought.

Keeping leaders in touch with the front line

The Francis Report warns of the dangers of healthcare strategic and operational leaders becoming distanced from the reality of everyday care. Patient Safety Leadership Walk Rounds are regarded as a mechanism for CM Health leaders and other staff to see first-hand the care provided on the wards, and to hear the voices of staff and patients.

Wynne-Jones’s team contacts charge nurses the week prior to the visit to inform them about its purpose and background. The visiting team of six is made up of a consumer, clinical leaders, heads of departments, clinical directors, senior medical officers and members of the executive leadership team. During the Rounds two of the leaders assess the ward using the First 15 Steps, while two interview patients and two interview staff. Leaders typically interview about three people each per visit.

The team tries to speak to a cross-section of medical, nursing and allied staff and does not collect personally identifiable information during interviews. The Rounds were developed using PDSA (plan, do, study, act) cycles, with the aim of being perceived positively rather than as a specific mechanism for ‘checking up’ on staff.

Celebrating what’s great and improving what isn’t

At the end of each walk round, leaders produce a summary identifying what they saw or heard that was great about the ward, and what could be improved. The summary, along with a copy of the completed tools and notes, is supplied to the ward charge nurse, head of department, service manager and clinical nurse director within 24 hours. Also supplied is a facility for wards to track improvement actions and to request support. Wynne-Jones’s team also keeps in touch with wards.

Sometimes intervention to resolve problems is more direct. “We feel very responsible when we interview patients. We have to be careful that we don’t just open up an emotional wound and then walk off and leave them. So if there is a specific complaint, we discuss this with the charge nurse or help the person to access the complaints process if they prefer this option,” says Wynne-Jones.

The Rounds also often help staff to identify and address isolated problems. For example, one Rounds visit provided traction for a charge nurse to obtain some long-needed documentation privacy cupboards that the ward’s budget could not cover. With assistance from the director of nursing, Denise Kivell, surplus cupboards were located elsewhere in the hospital and moved to the ward that needed them.

However, responses are often broader. Clutter was noted as a problem in a number of ward environments during Rounds. As a consequence, Kivell made a formal request for refresher training in 5S Workplace Organisation methodology for these wards to improve their environment. Interestingly, clutter was less of a problem in wards with strong leadership.

Strong leadership, good communication and systemic issues

The Rounds repeatedly reinforce the importance of leadership development on wards. “We are seeing best practices where there is strong leadership,” says Wynne-Jones. This has led to the creation of a new programme for charge nurse managers on clinical quality leadership that is informed by learning from the Rounds.

Patient Safety Leadership Walk Rounds act as a vehicle for spreading good practice and new ideas, particularly around communication, with the need to improve communication being one of the strongest themes to have emerged.

There is also helpful evidence about the effectiveness of communication tools, such as hourly vigilance rounds, huddles and bedside handovers involving the patient in the plan of care. This feedback was given to a rehabilitation ward that had changed its model of care to accept post-op orthopaedic patients earlier due to the ERAS (Enhanced Recovery After Surgery) Programme. This patient population is at high risk of falls. Following recommendations by the Rounds team, the ward’s charge nurse manager developed a team nursing model that included a walk-round handover and huddles to improve safety.

Some issues identified, such as after-hours staff shortages, are systemic. Kivell informs the CM Health board of systemic issues emerging in the feedback across wards. In this way, qualitative input from patients and staff complements other evidence used to guide the development of CM Health policies and processes. For example, feedback from the Rounds is helping to inform the development of a workload planning and acuity tool for CM Health (see box 1 for more information).

The approach with staff is one of ‘appreciative inquiry’ – Rounds aim to learn, support and encourage, not to find fault (see box 2 for staff feedback).

“All the charge nurses have fed back afterwards that staff appreciated us listening to them,” says Wynne-Jones. “And the patients love it, because they love someone to talk to them about these important aspects of care. People are asking us when we’re coming to their ward!”

The Rounds link with other initiatives at CM Health designed to improve the design and delivery of services. Most importantly, the Rounds complement the Patient Safety Framework, providing qualitative feedback from staff and patients on the wards.

“If there is a mismatch between what the data tells us around safety and what the narrative from patients and staff tells us, then that is an alert to us,” says Bev McClelland, organisational development consultant. The aim is to ensure no tragedy like Mid-Staffordshire happens at CM Health. ✚

Authors:

• Jacqui Wynne-Jones is clinical nurse director, surgical and ambulatory care services, at Counties Manukau Health (CMH).
• Dr Lynne Maher is director for innovation at CMH’s health education and improvement hub, Ko Awatea.
• Bev McClelland is an organisational development consultant at Ko Awatea.

References:

Francis R. (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry: Report of the Mid Staffordshire Foundation Trust Public Inquiry. Available at:
http://webarchive.nationalarchives.gov.uk/20150407084003/
www.midstaffspublicinquiry.com/report
NHS Institute for Innovation and Improvement. The 15 Steps Challenge. 2006–2013.

The Church is looking for someone just like you to…

An elderly Samoan man has just turned up, can you translate…

Auntie is sick, can you just pop round after work…

We are looking for a Māori nurse for this working party, you’d be great…

Sorry to wake you up, but Mrs Toleafoa from down the street has had a turn…

Few nurses see their profession as just a job. But the expectations placed on Māori and Pacific nurses by themselves, their employers and their communities can make an already demanding profession even more challenging.

This is particularly true now, when health strategies stress the need for more Māori and Pacific nurses to help counter poor Māori and Pacific health statistics, while the percentage of Māori and Pacific nurses still lags far behind the actual populations (see statistics sidebar).

So there are too few nurses and too much need. How does this impact on Māori and Pacific nurses? And how do they cope?For her PhD thesis, organisational psychologist Dr Lisa Stewart looked at whether the occupational stress experienced by Māori health workers was different from their mainstream counterparts.

She says two themes emerged, one being the cultural expectation from Māori communities – shared by Pacific communities – that Māori nurses and other health workers give back to the community in some kind of service. The second was institutional racism – often caused by misunderstandings and a lack of cultural competence – which added to Māori health workers’ stress loads.

Community expectations

Māori and Pacific are not the only cultural groups where community and family expectations outside of work are important, says Stewart. But that cultural expectation is very real.

She recalls as a young university student in the 1980s being told by Māori student association leaders that, on graduating, Māori students like herself should help their whānau, hapū and iwi in some way, be it serving on the marae committee or helping out at kohanga reo.

Kerri Nuku, kaiwhakahaere of Te Rūnanga o Aotearoa NZNO, agrees and says being a nurse within a whānau group can lead to additional expectations.

“You will be the contact person for aunty down the road who is not really sure whether she should rock on down to the doctor’s or just put a bandage on it,” says Nuku. “We hear stories of nurses, particularly who work in rural communities with high population Māori, that in the supermarket people come up to you when you are trying to do your shopping at the weekend and ask you for your advice because you are whānau, because you are Māori and because you are approachable.

“Then if you’ve got somebody sick within the whānau, you go to work, do your work and then come home and take over your shift caring for the sick whānau member. You build your own roster around them so that caring doesn’t stop when you leave the hospital grounds or workplace.”

This sense of duty begins as nursing students, believes Jackie McHaffie, who is in charge of the Tihei Mauri Ora stream of Wintec’s bachelor of nursing programme and has been involved with the programme for around 15 of its 25 years.

“There’s a cultural component that is always going to be there and will add to your duties above and beyond being a registered nurse.
They try and give as much as they can back and in doing so they often burn out.”

Dr Sione Vaka, Tonga’s first male nurse, who is now a lecturer for Massey University’s School of Nursing, says likewise there is an expectation from the Pacific community for nurses to deliver as much support as they can. For him this means that in addition to his day job he is on the executive of the Tongan Health Society; he’s also vice-president of the Pacific Island Mental Health Professional organisation, chair of his church’s health committee, a member of both the Tongan Nurses Association of New Zealand and the Aotearoa Tongan Health Workers Association, informal mentor to Pacific postgraduate students from a variety of institutions, feedback provider on Pacific mental health research – and he also holds various other community service positions. And this is all after cutting back his out-of-work commitments to fit his targeted areas of expertise.

Workplace expectations and institutional racism

Then there are the workplace expectations that can be placed on a scarce and already stretched thin Māori and Pacific nurse workforce.

Stewart says one of the stress issues unique to Māori that emerged as a theme during her research (which assessed the work stress levels of 130 Māori health workers, including nurses) was institutional racism; for example, workplaces playing lip service to the Treaty of Waitangi and related policies aimed at improving health outcomes for Māori.

And Stewart says when organisations do recognise bicultural responsibilities – like holding a powhiri to welcome new graduate nurses – non-Māori managers can see this as a Māori-only role, adding an extra layer to Māori nurses’ workloads.

She says it doesn’t have to be that way. A positive example was an organisation she worked at where it was clearly expected that a Māori staff member would lead the karanga but all ethnicities and nationalities were invited to be part of the waiata group that performed support songs and helped set up the powhiri, including food if that was involved.

McHaffie adds that Māori nurses who work for organisations where they may be one of the few or only Māori can find themselves approached for advice on all things Māori, as well as being expected to say the karakia or sing a waiata. But there are also high cultural expectations placed on Māori who are working for Māori providers, which can extend the working day and week for Māori if they need to attend hui or practice for iwi cultural events. Then on top can come expectations for postgraduate study. McHaffie says that over the years she has seen some graduates burn out after struggling to cope with the pressure to be not only a good nurse but also a good Māori nurse.

Nuku says she’s also heard of hospitals placing Māori new graduates in particular units or wards well known to be “not conducive to Māori … oh I will just put it out there… they are areas known to be racist” in the hope of trying to change the behaviour of the staff. “So these are conscious decisions that are being made that put our nurses in unsafe places because nobody has dealt with the issue of racism.”

Nuku and her NZNO colleague Eseta Finau, who heads the Pacific Nursing Section (PNS), also both receive reports of interview processes and panels that are seen as discriminatory and demoralising for Māori and Pacific nurses.
Finau says an ongoing issue for many Pacific-trained registered nurses is being used as “cheap labour” by rest homes while struggling to afford time off to attend the English language training they need to become registered in New Zealand.

Another workplace expectation often adding to the stress loads of already stretched nurses is the belief that Māori and Pacific nurses should be allocated the Māori and Pacific patients, without the workload impact being considered.

“Why are Māori patients the sole domain of Māori nurses and why are Tongan patients the sole domain of Tongan nurses? Aren’t all patients the domain of all nurses?” asks Stewart.

Vaka echoes this, saying sometimes non-Pacific nurses are keen to transfer the care of a Pacific patient to a Pacific nurse, saying they would do a better job.

He believes it is important to encourage other nurses to be comfortable and confident in working with Pacific people, rather than trying to refer all patients to a potentially already overloaded Pacific nurse or Pacific health service.

Not a burden

Community, and employer, expectations may be high of Māori and Pacific nurses but often so are the nurses’ expectations of themselves in doing their best to improve the health outcomes of their people.

Stewart says Māori and Pacific nurses don’t usually see this work as a burden but more a natural extension of being part of a community. “I find when I’m giving back to a really good cause – and I’m helping the whānau in some way – as much as that’s work, it also feels really, really good and has a way of energising you too.”

So giving can be good – it’s over-giving that can be the issue.

Finau says family upbringing is also a major influence, with multitasking just something you do when you’re from the Pacific. “Because at home you grow up with so many kids around, there are family things and church things … and you just learn to juggle and cope with things. Giving back to the community is just another thing you take on and being a nurse you manage your time.”

Stewart’s research found that occupational stress was not lower in kaupapa Māori health providers than in mainstream providers – on the contrary, role overload and organisational constraints were all higher. But the coping strategies were better, which matched earlier research findings (see retention sidebar) that the top factors encouraging Māori health workers to stay with a health provider included being able to make a difference to Māori health and to their iwi or hapū, and that Māori practice models and approaches were valued.

Nuku agrees, saying Te Rūnanga o Aotearoa used to see nurses shifting from Māori provider groups to DHBs because of the money, but, despite pay parity being an ongoing issue (see sidebar), she says the reverse is also happening. “What we are feeling is that there is a trend that they are going back because they can’t cope with the amount of racism that is happening in workplaces.” There is also a frustration that poor Māori health statistics are used as “a patu [weapon] against ourselves”; innovative strategies that do work don’t get sustainable funding; and the Māori nursing workforce is still static, despite strategies aimed at boosting recruitment and retention.

“I don’t think we have looked enough at how we support Māori and Pacific nurses in the workplace,” she says.

Cultural competence of all staff important

One step in the right direction, believe many, is placing value on cultural, as well as clinical, competence in the workplace.

“If all of our nurses were culturally competent to deal with all of the cultural groups that they see in their practice, then the burden of being responsible for Māori patients becomes everybody’s responsibility – not just Māori nurses’ – and Tongan patients are not only the responsibility of Tongan nurses,” says Stewart.

Vaka says he is aware, through non-Pacific nursing friends, that some have a fear they will do something wrong when caring for Pacific patients, so they look to transfer them when possible. He agrees a better approach is for all nurses to upskill themselves culturally, seek advice and “have a crack” themselves in looking after Pacific people.

“If we are able to learn more about one another and how to work with different cultures – it is such a diverse community that we are living in at the moment – it would be improving our overall health care as well,” he says.

Stewart also believes the handover of patients to Māori or Pacific nurses is not intentionally malicious but more a lack of understanding and a lack of confidence in being able to work effectively with those client groups. “The reality is that as a Māori when I go into a health service would I prefer to work with a Māori member of staff? Sometimes I would, but I know the reality is that I won’t. But what I do expect as a Māori health user is that when I use the health services I get treated with dignity and respect in the same way that every other cultural group would expect to be.”

Nuku says there are expectations that registered nurses be culturally competent and clinically competent “but time and time again clinical competency outweighs the need for nurses to be seen to be culturally appropriate.” She says, as an example, that nurses must undergo ongoing professional development to be deemed clinically competent, whereas it is accepted that nurses will be still culturally competent after attending, though not necessarily participating in, a Treaty of Waitangi workshop five years previously. “It’s almost like a default that we sanction ignorance around working in Aotearoa and the unique relationship we have as tangata whenua.”

Mentoring and supervision

Having strong support mechanisms for Māori and Pacific nurses in hospitals and other organisations is also seen as key to recruiting and retaining nurses.

Nuku says strong mentoring programmes are needed not only for new graduates but also for Māori nurses throughout the continuum of nursing until retirement.

McHaffie also recommends that her graduates find a cultural advisor or mentor from whom they can obtain advice or talk to about situations that may arise. Nurses can also seek support from the Māori health units that are often within larger DHBs.

What is needed and wanted by many Māori nurses, believes Stewart, is cultural supervision, just as clinical supervision is offered to nurses in the mental health sector, to support best practice.

Networking with other Māori health professionals also emerged as an important coping strategy for stress, says Stewart,
but this was often seen by non-Māori managers as a social activity, rather than a chance to share ideas, download and support each other. “There seems to be a lack of understanding about what organisational conditions need to exist in order for Māori nurses and other health professionals to be most effective at their job.”

Likewise, Pacific Nursing head Eseta Finau says one of the most important roles of the country’s various Pacific nurses associations – such as the umbrella NZNO Pacific Nursing Section, the Samoan Nurses Association, the Tongan Nurses Association (which she also leads), and other Pacific nursing groups – is the support and mentoring they provide for members.

But when she invites nurses to join the NZNO Pacific Nursing Section and help to train a new generation of leaders, she says employers often won’t allow them to attend in work time. “Yet this is all towards the wellbeing and the future of our Pacific people in the communities that we live in.” With many Pacific nurses being the breadwinners for their family, it is a big ask to take a day off to attend a meeting, but committed nurses will use precious annual leave to attend, which Finau says is “just not fair”.

She says one way to deal with stress and burnout is by supporting people to be trained to fill leadership positions such as in the PNS to share the load.

Learning when to say ‘no’

An important skill for preventing burnout is the art of when to say ‘no’. Culturally, this is not always simple for Māori and Pacific nurses.

Stewart says it is actually harder for Māori and Pacific nurses to say ‘no’ to their cultural communities then it is to say ‘no’ to people at work.

Finau acknowledges saying ‘no’ can be an issue for Pacific nurses. “Some of us are just too polite and say ‘yeah’, ‘yeah’, ‘yeah’ and don’t say ‘no’ to anything. And commit and commit and you can tell they are over their limits. It’s a cultural thing – just trying to be nice and serve others rather than thinking about what you can do and what you can cope with.”

The result is that nurses can learn to cope and over-cope, but Finau says she can say ‘no’. “I know when to say ‘no’ and tell them when this is enough and when things are rubbish.”

Vaka says he used to overcommit to a lot of community projects and, combined with his PhD study, this left too little space for family time. “No wonder my wife would call my PhD the ‘other woman’,” laughs Vaka. He realised he had to be very selective in what extra commitments he said ‘yes’ to and now, unless he believes his expertise in health and research is going to be well-used, he will recommend another person. But it is still not easy.

“At the moment I am still struggling to say ‘no’ to people. But I think I know now how to say ‘no’ nicely,” laughs Vaka. “And I think for us Pacific people we need to know when to say ‘no’, as we need to reassess when we have enough on our plate already if we want to deliver a good quality service [to our work and our community]. Don’t be scared of saying ‘no’.”

Stewart agrees that it helps if nurses prioritise which goals are most important to them and decide how to make the best use of their time and expertise to meet those goals. This includes being aware of their own capabilities and when they are at risk of burnout “rather than just blindly saying ‘yes’ to everything.”

Conclusion

With its small numbers of nurses and high population needs, the Māori and Pacific health workforce is unfortunately at real and ongoing risk of burnout. Helping the existing workforce look after itself seems essential if that workforce is to have the rapid growth required to meet government targets and community needs.

One part of the equation is for funders and employers to keep working at better supporting and fostering this scant workforce. Another may be for communities to be realistic in the expectations they place on their nursing members. The last is for nurses themselves to do their best to look after themselves (see sidebar for some ideas).

“Nurses are no strangers to reflective practice – it is just a matter of reflecting on themselves rather than their work,” says Stewart.

“The reality is that if we aren’t looking after ourselves, how can we do our best to look after our communities? The best way we can serve our communities is to make sure we are well ourselves.”