The findings indicate a ‘culture change’ is needed to reduce public hospital nurse fatigue and improve nurse and patient safety, says the code co-author Professor Philippa Gander, as the majority of nurses reported usual sleep shorter than what’s recommended for health safety and wellbeing.
Gander says fatigue resulting from shift work and extended hours can degrade patient care, also increase the risk of clinical error, workplace injuries to nurses, and drowsy driving accidents, as well as increasing nursing turnover and health care costs.
The draft code out for consultation is part of the major Health Research Council-funded Safer Nursing 24/7 project. The three year project, led by Gander in league with nurses’ union NZNO, was launched in 2016 with an online survey of shift working nurses as the first step to better managing nurse fatigue.
The 2016-17 survey of public hospital nurses – working in six practice areas chosen for having a high likelihood of fatigue – attracted 1885 registered nurse and enrolled nurse participants.
The full survey findings are yet to be released but the 43-page draft code document released by Gander, Dr Karyn O’Keeffe and the rest of the research team includes findings that:
The survey findings have been used – along with advances in knowledge about the impact of shift work on the circadian ‘master’ body clock, the associated health risks and improvements in safety management systems – to develop a code to help DHBs better identify, manage and mitigate nurse fatigue and the resulting safety hazards.
Gander and fellow Massey Sleep/Wake Centre researcher Dr Karyn O’Keeffe, say fatigue is inevitable in hospital nursing because of the requirement to provide care 24/7 but – with a culture change and the new draft code – district health boards could develop a fatigue and shift work management system that reduces the risk of fatigue being a safety hazard for both nurses and their patients.
The draft code does not recommend absolute restrictions on nurses’ work patterns, for example set maximum safe shift lengths, numbers of consecutive shifts, or minimum breaks between shifts. Instead it provides a fatigue hazard assessment matrixfor evaluating weekly work patterns, based on six variables relating to work patterns and two variables relating to sleep.
The matrix was developed and validated using the 2016-2017 national survey of DHB nurses to check how accurate it was at predicting fatigue levels of nurses and the three main fatigue-related outcomes: excessive sleepiness, having felt close to falling asleep while driving in previous 12 months and recalling a fatigue-related clinical error in the last six months.
The matrix and draft Code of Practice are now out for consultation until March 10 to get wider nurse expertise feedback on refining the code to make it as useful as possible. Gander and O’Keeffe said once it had received feedback and finalised the Code it hoped to pilot it in a major public hospital.
The document can be downloaded and feedback provided at the project’s website www.safernursing24-7.co.nz along with information on fatigue, sleep, shift work, the body clock and fatigue management.
Table 1: Fatigue hazard assessment matrix for DHB nurses (from draft Code of Practice)
| Risk Factor | Lower fatigue
Score O |
Significant fatigue
Score 1 |
Higher Fatigue
Score 2 |
| 1. Total hours worked | ≤ 40hr | 40hr to 48hr |
>48hr
|
| 2. Shift extensions ≥ 30 min | None | ≤50% of days
worked
|
>50% of days
worked
|
| 3. Breaks <9h between shifts | 0 | 1 | >1 |
|
4. Number of nights
|
0 | 1-2 | >2 |
| 5. Number of breaks ≥ 24h between shifts | ≥2 | 1 | 0 |
| 6. Roster change | no | Roster change requested | Roster change not requested |
| 7. Number of nights sleep (2300-0700) | 6-7 nights | 4-5 nights | 0-3 nights |
| 8. Number of nights got enough sleep to be fully rested | 6-7 days | 4-5 days | 0-3 days |
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The DHB multi-employer collective agreement (MECA) ratified by NZNO members in early August included a $38m Government fund towards the immediate, short-term relief of nursing and midwifery workload pressures.
As of late last week seven of the 20 DHBs had submitted the required ‘brief plans’ to the Ministry of Health’s Chief Nursing Officer on ‘why, where, who and how’ workforce capacity would be increased at their DHB.
For DHBs to receive their share of the $38m funding pool their plans need to first be approved by the joint DHB-NZNO Safe Staffing Healthy Workplace (SSHW) governance group. To date three out of the seven submitted DHB plans have been approved or partially approved.
Hilary Graham Smith, NZNO associate professional services manager, when asked whether she was concerned at the DHBs progress said she would much prefer DHBs to take their time to work through their plans thoroughly. She said it was ‘all good positive work’ between DHBs, NZNO staff and NZNO members at the bedside to determine the ‘hot spots’ with major staffing needs or gaps. “Some of these gaps are pretty substantial,” says Graham-Smith. She said the $38m was agreed to not be enough but it was a “launch pad” to start filling those gaps while the safe staffing Care Capacity Demand Management (CCDM) system* was being fully implemented.
The $38m is the funding equivalent of employing 500 extra nurses across the country – which is acknowledged as just providing some short-term relief to areas under the most pressure while DHBs meet their MECA commitment to roll-out and implement the CCDM system to ensure they have evidence-based safe staffing levels for each ward and unit.
The fund can be used for whatever nursing staff skill mix is agreed to by each DHB’s joint union-DHB CCDM Council or equivalent; so it can be used to employ additional registered nurses, health care assistants, enrolled nurses or midwives but it can’t be used to fill existing vacancies or to staff planned new services.
The latest workforce statistics for the 20 DHBs show that nursing numbers increased by 1096 nurses or 981 full-time equivalent (FTE) positions between June 30 2017 and June 30 2018 – about a 4.5% increase. Most of these positions would be to meet demand for new services and population growth as well as absorbing more new graduates. The 20 DHBs financial reports to the Ministry of Education indicate that the growth in nursing numbers was higher than budgeted for with the DHBs taking on 549 more nursing and midwifery personnel than planned for in the year to June 30 2018.
Graham-Smith, who is on the SSHW governance group, said mostly the DHB plans she had seen to date to relieve the pressure staffing points were good – as they were required to be signed off by nurses at the ‘coalface’ before being submitted – but some required a “little tweaking”. “It’s been a good process and in the end you get the right result”. She says all DHBs are using different methodology to work out their pressure points and submitting different plans with some using the opportunity to resolve some longstanding issues.
Dr Jill Clendon, the Ministry of Health’s acting Chief Nursing Officer said the work between the Ministry, NZNO and DHBs was progressing well. She said most DHBs were distributing the new positions fairly evenly across the workplace and no particular trends had been identified yet about what skill mix was being employed.
*CCDM three core components
When the DHBs and NZNO management began negotiations last year, only 14 of the 20 DHBs were signed up to implementing the CCDM tools built on the validated acuity software TrendCare. And four of the remaining six – Lakes, Canterbury, Waikato and Counties-Manukau – did not have TrendCare.
But an update from the joint DHB-NZNO Safe Staffing Healthy Workplace (SSHW) Units show that all DHBs are now starting or about to start on the CCDM path (see details below) and with all but one of the DHBs – Waikato – also looking to use TrendCare.
Hilary Graham-Smith, NZNO’s associate professional services manager and a member of the SSHW Unit governance board, welcomed all DHBs coming on board as NZNO had always sought for CCDM to be implemented for all members.
“We want them to have that safe staffing environment right across the board so it was never satisfactory for us that some of our members had that opportunity but a significant portion of others didn’t,” said Graham-Smith.
She said given time DHBs would have come on board as it was the “right thing to do”. “But negotiations and subsequently the Accord has pushed that along a bit more – and that’s a good thing.”
Trust also had to be rebuilt with nurses at DHBs where CCDM had already been introduced and nurses were yet to see DHBs respond by putting more staff on the ward floor.
“If nurses do all that work trying really hard to get their TrendCare data right – and then they see nothing for that – it is no wonder that there’s a complete lack of trust and confidence in the programme and in TrendCare,” said Graham-Smith. She strongly believed CCDM would deliver but nurses now needed NZNO and the Unit to work with DHBs to ensure boards were transparent and open about what the data analysis was showing about understaffing and when and how they would respond with extra staff.
“That’s what they need to see – the outcomes – and the other thing they desperately need of course is to see that they are working in a safe environment and able to give the kind of care they want to give.”
DHBs spokesman Jim Green said he was no apologist that CCDM had not been consistently introduced across all the DHBs which had led to the implementation deadline being set for 2021 to allow time for the late-starting DHBs to catch-up.
“However, I don’t see that we (the other DHBs) won’t be making progress much, much faster – with greater degrees of progress already at many DHBs.”
CCDM requires nurses to input patient acuity data for 12 months to ensure accurate trend data is available to calculate the FTE staffing to meet patient need – so it can take up to three years to fully implement.
Both Green and Graham-Smith believed that the additional money and resources being put into CCDM through the ratified deal would accelerate the process.
“Others who haven’t yet begun – or only just begun – have got a much bigger journey to make within that time frame but what the package has done has given them the ability to increase the implementation resource and obviously NZNO will get in right behind that and support that right alongside the SSHW Unit,” said Graham-Smith.
Post-quake Canterbury and Counties-Manukau on board, Waikato going different path
Mary Gordon, executive director of nursing for Canterbury DHB, has confirmed that the DHB would be working with the SSHW unit to implement CCDM and was putting together a business case for purchasing an ‘appropriate acuity tool’ (understood to be TrendCare).
She said she very proud of how Canterbury nurses had coped with the disruptions the health service has faced since the 2010-11 quakes – particularly the population growth being well above any forecasted predictions.
“We are now seeing the impact of this growth on our environment both in terms of service capacity across our primary, community and hospital services but also in our constrained physical environment,” said Gordon. She said the impact had been “unrelenting” especially for staff on its Christchurch, Hillmorton and The Princess Margaret sites “however nurses and their colleagues continue to provide high quality care to patients”. Gordon added that she and her fellow Canterbury directors of nursing were committed to engaging with staff on ongoing staffing improvements and development of the nursing workforce, including dedicated education units that had increased the number of nursing students able to be trained.
Another late sign-up to a CCDM agreement was Counties Manukau with Head Nurse Jenny Parr saying it signed in late July and it had recently developed a business case for purchasing TrendCare.
She said Counties Manukau had for a number of years, been using the principles of CCDM using an alternative acuity assessment tool. “Once approved, TrendCare will provide an opportunity to benchmark with other DHBs by using the same tool.” Parr said while implementation had not taken full effect it did have a full-established CCDM Council and co-ordinator to provide assistance with implementing the core components of the CCDM programme.
Waikato DHB deputy Chief Nurse Deborah Nelson said it signed up to CCDM about 18 months ago and was “well on the way to rolling it out” to ensure safe staffing levels on its wards but using another acuity tool called Assignment Workload Manager, which measured skills and numbers in each ward. “The MECA does not stipulate that TrendCare is required, we believe our acuity tool meets the requirements of CCDM.”
She said it would be working with NZNO and nurses to ensure there were enough people to deliver patient care in its hospitals. “We are actively working on recruitment strategies which include enticing New Zealand nurses back home from across the globe, increasing NETP intake spread across the year and investigating more active employment of enrolled nurses as they graduate.”
UPDATED PROGRESS LIST of CCDM IMPLEMENTATION (as at August 8 2018)
CCDM DHBs (at various stages of implementation)
Have validated patient acuity software and starting to implement CCDM
Implementing validated patient acuity software
Developed business case for validated patient acuity software
Progressing validation of another patient acuity system
This week the 20 District Health Boards, New Zealand Nurses Organisation and Director-General of Health signed a Minister of Health brokered safe staffing Accord to address growing concern over unsafe nursing levels impacting on both nurses and patients.
Primary school teachers and principals this week also voted to follow DHB nurses in taking strike action in support of the teachers’ claim for a pay rise of about 16% over two years to help address a current teaching recruitment crisis, particularly a 40% drop-off in the number of teachers training over the past six years.
At the same time the NZNO’s DHB members started voting on a 5th offer from the DHBs which includes a commitment to pay equity, pay increases of between 9-15.9% over three years (plus a $2000 pro rata lump sum in lieu of backpay), along with calculating and funding the extra nurses required to ensure safe staffing by implementing the long sought-after care capacity demand management (CCDM) system. The agreement includes $38 million to be immediately spent employing up to 500 extra nurses across the 20 DHBs in areas of most concern but some nurses say this will not be enough to address understaffing – particularly if the nurses taken on are new graduates needing mentoring and support.
Job statistic trends for nurses and teachers
Job vacancy trends on the major internet job boards – SEEK, Trade Me Jobs, the Education Gazette (where nearly all teacher jobs are advertised) and Kiwi Health Jobs (where nearly all DHB jobs are advertised) – are monitored by the Ministry of Business, Innovation and Employment (MBIE) as an indicator of different industries demand for staff.
On Tuesday MBIE released its latest Jobs Online summary report for the three months up to June 30 and noted that, year to date, the increasing number of health sector job ads made it one of the two sectors with the strongest total growth in vacancies (the other being the business/legal/administration sector).
The report shows registered nurses job vacancies were up 39% on the same quarter last year and nurse manager jobs by 16% with both increases described as being “statistically significant” because of the number of vacancies involved. (Enrolled nurse vacancies were also up by 29% but because of the small numbers involved the increase was not regarded as statistically significant.) Other health professions also had major increases with the highest statistically significant increases including occupational therapists (77%), psychologists (49%) and non-GP medical practitioners (53%).
In the education sector there was a very steep increase in the number of school principal ads (90%), and increases in ads for ‘other’ education managers (34%) and early childhood teachers (2%). But for primary school teachers there was a 15% decrease in online job ads compared to the same period last year and a 17% decrease in secondary school teacher advertisements.
These trends were also reflected in current ads on the Education Gazette website which was dominated by 433 ads for early childhood teachers compared to 208 for primary school teachers and 173 for secondary teachers. Of the about 101,000 teachers with current practising certificates about 37,000 are primary school teachers, 26,000 secondary teachers and 21,000 early childhood teachers.
On the Kiwi Health Jobs website about 320 of the 878 DHB clinical jobs being advertised this week were for nurses – and roughly a third of the nurse jobs were for mental health positions. At present there are more than 55,000 nurses with annual practising certificates with roughly half (about 27,500) working for district health boards.
Nurse sick leave and accrued annual leave trends
The average number of sick days being taken by district health board nurses is on the way up and the days of annual leave down, according to DHB statistics.
One of the staffing issues voiced by DHB nurses during the current pay talks is short staffing making it difficult to take annual leave as well as leading to the cancelling of study days and leave.
For the last 18 months the DHBs have been reporting in their quarterly workforce reports.on trends in sick leave hours and annual leave accrual over the previous 12 months by occupation grouping and DHB by DHB.
The latest quarterly statistics to March 31 this year appear to show that the majority of nurses are increasingly taking all their sick leave but at the same time are struggling to take their annual leave – with on average nurses having outstanding annual leave equivalent to 95 per cent of their year’s entitlement. Also that staff at nine of the 20 DHBs had on average accrued more annual leave than their annual leave entitlement.
The report also shows that the average annual sick leave hours taken by nurses were 68.6 hours (8.5 days) which was up on the same period the previous year but less than the peak in last year’s winter quarter report of 83 hours (10.3 days) over the previous 12 months. The occupation sector taking the most sick leave hours on average was the care and support workforce and taking the least was the junior doctors.
The DHBs most recent nursing workforce trend report was published in 2015 and looked at nursing data trends from 2007-2014 which had started to show a consistent increase in nurse numbers of about 2% a year – roughly the same as the average national population growth. (The New Zealand population’s highest growth in recent years was 2.1% in 2016-17 with the greatest growth being in the Auckland region which grew by 2.6%).
Whether the 2% growth in nurses matches the growth in clinical need of an ageing population with increasingly complex co-morbidities and higher patient turnover will not be known until the CCDM calculations are made on what nurse levels are required to deliver safe patient care. The March 2018 report does confirm a continuing trend of higher ratios of DHB nurses per 100,000 people in recent years but also shows that ten of the country’s DHBs had nurse ratios less than the national average – including the two fast growing DHB regions of Waitemata and Counties-Manukau.
The 2015 workforce trend report also found the mean annual turnover rate for registered nurses has fluctuated between 9% and 10.5% over the previous five years. (NB the period 2009-2014 included the impact of the global financial crisis which saw a worldwide trend of improved nursing retention and recruitment.)
Since that report the mean length of time nurses have served at DHBs has increased from 8.8 years in 2014 to 9.2 years in 2018 and the average age has decreased from a peak of 45.7 years old to just under 44 years old.
]]>Betty is a New Zealand resident.
Betty returned to India in 2016 and was married to Nidhin Mathews on September 12, 2016. It was an arranged marriage, but they had known each other for some considerable time.
Nidhin came to New Zealand on a Partnership Based Visitor Visa on May 28, 2017. Betty and Nidhin are living together as husband and wife in a very supportive, genuine and stable relationship.
Nidhin made an application for a Work Visa on the December 12, 2017. He received a letter by email from New Zealand Immigration on March 2, 2018 advising him that his application for a Work Visa has been unsuccessful and that he will be unlawfully in New Zealand as of March 4, 2018 and liable for deportation. He was asked to leave the country in two days.
Betty and Nidhin made an Urgent Section 61 application to New Zealand Immigration to ask them to review their decision. Unfortunately that application was also declined.
It seems that NZ Immigration was still not accepting that he and his partner were in a genuine and stable relationship.
We have a very good employment relationship with Betty, she is a highly valued and experienced RN, who is an essential part of our team. We decided to talk to the Member of Parliament for Northland, Matt King. He and his office has been most helpful.
I wrote to the Associate Minister of Immigration Kris Faafoi on the April 4, 2018 to request that he personally review Nidhin’s application for a Work Visa under the Partnership Category.
The Claud Switzer Memorial Trust provides residential aged care for older New Zealanders. We are the only home in Kaitaia in the Far North. We provide a range of services including, rest home, hospital and dementia level care for 92 frail older people who live in this rural community.
In 2010, this community was at risk of losing the services we provide because of the shortage of RNs who were available and willing to work in aged care.
At the time, and despite wide advertising in the local and national media, and approaching Northland Polytechnic to offer placements and positions for new Bachelor of Nursing graduates and offering wage rates similar to those offered by district health boards, we were unable to recruit or retain the numbers of RNs required to maintain our services.
We made the decision to recruit overseas RNs and fortunately we have had a stable RN workforce since then. We have been able to maintain this extremely valuable essential service for the Kaitaia community. We have a good reputation for the standard of care we provide and we are regarded as a good employer.
We consider that we have been most fortunate in that we have recruited RNs from Kerala in India. Their nurse education is very similar to that of New Zealand and the United Kingdom.
They are usually very sound people who are reliable, committed and eager to do well. Diversity in workplaces is not merely a question of ethical consideration, it also improves employee wellbeing, productivity and business performance.
If Nidhin was not granted a Work Visa, I could see that it would be difficult for his wife Betty to remain in New Zealand and we would lose her, together with her skills, knowledge and experience.
This Trust understands the importance of providing employment opportunities and jobs to New Zealand Citizens.
However, if the aged care sector is unable to provide the appropriate standards of care, and retain the right skill mix knowledge and experience we are required to provide, we will once again be considering the loss of this essential service.
If the NZ Government does not actively support diversity in aged care then we will lose other RNs and overseas RNs will then apply to other countries instead of NZ. Without overseas RNs there is no doubt that we would have to close our hospital and many other organisations throughout NZ would follow.
This at a time when the Government has made a decision to provide more RNs for a health system that is struggling. It really makes no sense.
During the time that the Associate Minister of Health was considering Nidhin’s application (three months).
Nidhin and Betty were extremely upset, extremely anxious, concerned that Nidhin was staying in a country that did not want him. They worried that he would be arrested and forcibly made to leave. His driving licence expired, he was housebound, he became depressed.
Finally, the Minister decided to grant the Work Visa in July. So for now Nidhin and Betty can resume life, until the next time that they are required to apply.
I fail to see how NZ Immigration can justify this approach when all the evidence they have in relation to the ageing population, the tsunami of older people on their way towards aged care, demands an increase in RNs.
RNs won’t come to or stay in New Zealand without their families.
]]>The Independent Panel, set up to try and resolve the pay impasse without a winter strike released a series of recommendations yesterday on pay and safe staffing to the New Zealand Nurses Organisation and the 20 district health boards. The pay rise recommendations have fallen short of nurses and NZNO’s expectations but NZNO said it was pleased to see “a significant number of recommendations that reflect their concerns about the immediate staffing crisis”.
The panel report noted the lack of recognition by DHBs of the impact on nursing workloads of the “significant increases” in patient acuity over the past decade due to both the ageing population and the number of patients with multiple co-morbidities.
“This has increased the complexity of nursing care in hospitals and related settings, requiring a more skilled, knowledgeable and experienced workforce,” said the panel. It said the lack of recognition of these changes had led to “a sense of grievance that underlies both workloads and remuneration”. It added that the panel recommendations reflected that the “fundamental workload issues” could not be addressed through remuneration alone.
The recommendations include the 20 DHBs – on ratification of a new NZNO DHB agreement – receiving funding equal to two per cent of the total national cost of the DHB employed nursing and midwifery workforce for DHBS to ensure it has enough nursing staff to “deliver the required patient services”.
Cee Payne, the NZNO’s industrial advisor said this was a “significant recommendation” that had not been previously seen for nursing and midwifery.
The panel also noted that DHB representatives were aware of the need to address the workload issues but “resource constraints” meant that measuring nurse workloads was not a priority for many DHBs.
“This is even though the instruments and mechanism to accurately assess patient acuity and staffing required has been available to DHBs through a validated patient acuity tool and the Care Capacity Demand Management (CCDM) programme for many years.”
The panel recommended that “high-level commitment needs to be made to improving the nurse workforce planning strategy, and to ensuring compliance with commitments agreed in the MECA” including implementing CCDM across all DHBs”.
Ensuring that nurses felt they had a “voice” within the workplace was also seen as important and the parties agreed to a national framework requiring DHB chief executives to “review how the nursing perspective can, and does, influence clinical and business decisions within their DHB, initially focusing on nursing workloads, escalation pathways and incident reporting”.
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Metcalfe, chair of the Enrolled Nurse Section of the New Zealand Nurses Organisation, was speaking during a panel discussion on growing the EN workforce at the section’s recent conference in Christchurch. Currently the EN workforce numbers are still falling, and some district health boards are reluctant to employ ENs, despite the 18 month enrolled nurse diploma now being offered by seven nursing schools.
“I think we need our health leaders to champion the role of enrolled nurses as part of the wider health team,” said Metcalfe. “We need to ensure that employers are including enrolled nurses in their workforce planning so they are developing models of care that include the EN role.”
She said currently ENs can work across the whole spectrum so should not be restricted from practising in any setting including primary care and mental health. “We need to dismiss the myths as it is easy to say enrolled nurses can’t and it is harder for them to say enrolled nurses can.”
Suzanne Rolls, NZNO professional advisor for the EN section, set the scene for the panel by saying the enrolled nurse diploma qualification, offered by seven nursing schools across the country, was well-placed to create an enrolled nurse workforce to help meet the future health needs of the ageing population. “And employers need to make the opportunities to make the best use of opportunities now – before health service demands increases any further and there are fewer nurses available.”
She said there had only been 1052 graduates enter the workforce supply since starting re-training enrolled nurses in 2001 which had not been enough to replace ENs retiring in the ageing workforce.
Nursing Council statistics show there were around 6,500 enrolled nurses in 1993 when hospital-based EN training ended. This had dropped to just over 4000 in 2002 when the first EN training programmes re-commenced but controversy over titles, scopes and qualifications continued during the 2000s. The current 18 month diploma was not launched until 2011 by which time EN numbers had fallen to around 3000 and have continued to fall and in 2017 were down to 2,648.
“So we’ve got a long way to go to ensuring that we get back to 2011 levels and actually increase those numbers,” said Rolls.
Also on the panel was Mary Gordon, executive director of nursing for Canterbury District Health Board has been one of the most supportive DHBs of enrolled nurses since training recommenced in 2001.
She told the conference that back in 2001 people were saying ‘what are we going to do with all these people once we train them’. “And I remember thinking at the time – and looking at the age profile of the enrolled nurse workforce we had at the time – and I said we’ll be lucky if we can replace those are due to retire and keep ahead of that.”
Gordon said 7.5 per cent of Canterbury workforce was enrolled nurses but “we could easily do with doubling that, if not more, and there would be employment.” She believed a starting point to building the EN workforce was to make nursing more attractive as a career to prospective nurses across the population and age spectrum.
Dr Cathy Andrew, head of the Ara Institute of Canterbury school of nursing, said one of the barriers to rebuilding the EN workforce was her generation of registered nurses who were lead to believe in the 1980s and 90s that the “only nurse was a registered nurse” and that ENs were being phased out.
She said when the first training programmes were about to be introduced in Northland and Christchurch in 2001-02 she was a very new head of school. “At the time I was a meeting in Wellington and I was bailed up – for want of a better word – by the then chief nurse, the chair of the Nursing Council and the chief executive of the Nursing Council,” recalls Andrew. “I was young, I was new in the job and I was told I had to find a way of stopping enrolled nursing being brought back in by Canterbury DHB and CPIT as it was then.”
Andrew said her generation had been told that patients would do better under a totally RN workforce but she said this was based on actually “quite flawed” research as often it was comparing a total RN workforce to an RN workforce supported by unregulated assistants rather than a regulated enrolled nurse style workforce. She said she was now a convert to the EN role – and with the EN scope of practice now broadened – she believed that now the barrier to employing ENs was the ‘artificial’ barrier of the attitude of her generation of nurse managers rather than regulatory barriers.
Dianne Martin, chief executive officer of the Registered Practical Nurses Association of Ontario, told the conference that unlike New Zealand in Ontario the EN workforce equivalent – the Registered Practical Nurse (RPN) – was actually increasing and was a very young workforce. She said it was the registered nurse workforce in Ontario that was the oldest and the net number of RNs were actually decreasing as a proportion of the nursing workforce so all nursing groups had agreed it needed to work on resolving the RN shortage.
But she said Ontario’s RPNs were also facing a lot of pushback from RNs who saw RPNs as taking their jobs but she said RNs should not feel threatened by an EN/RPN workforce if they are doing a job that only an RN can do.
Metcalfe also told the conference that new graduate ENs, like their registered nurse (RN) colleagues needed support to safely enter into practice so they could fully utilise their nursing skills to meet the needs of health consumers. She said the section was working with the Ministry of Health on a generic orientation programme and also on a living document on addressing the barriers to ENs being employed
Enrolled Nurse Timeline
1993 Hospital-based enrolled nurse programmes end.
2000 Labour government initiates return of EN programmes.
2002 First one-year, narrow-scope EN programmes start.
2004 Title changed to nurse assistant.
2008 Advisory group calls for higher, generic scope EN.
2009 Nursing Council backs call for broader scope and agrees on EN title.
2011 Current 18 month diploma of enrolled nursing begins
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The New Zealand Nurses Organisation leader is just back from addressing the United Nations Permanent Forum on Indigenous Rights in New York for the third year running to support the case of Māori nurses.
Nuku requested a UN interventionto ensure Māori women’s voices were included in health policy decision-making and for the health system to support having a nursing workforce that matched the Māori population. And on her return to New Zealand has called for the Government’s ‘full commitment” to developing and planning a growing Māori nursing workforce.
“An aspirational Māori nursing workforce goal with no further commitment, funding or implementation strategy is unacceptable,” said Nuku.
In November 2015 the Health Workforce New Zealand’s (HWNZ) Nursing Governance Taskforce for Nursing set a date of 2028 to meet a goal of “significantly increasing” the number of Māori nurses (currently 7%) to better match the proportion of Māori in the population (15.6%), with the aim of improving access to care and the quality of care for Māori.
Nuku said recruitment and recruitment of Māori nurses was vital for the future health and wellbeing of whānau, hapū and iwi and a Maori Nursing Strategy was “urgently needed to address this”.
“Whilst commitment has been made to form some regional partnerships to achieve the goal of a Māori nursing workforce that matches the percentage of Māori in their population by 2028, there is no supporting operational strategy to make this happen.
Health Minister Dr David Clark was unavailable for comment but the Ministry of Health’s acting chief nursing officer Dr Jill Clendon said theNational Nursing Organisations group’s (NNOg)MāoriCaucus – which included Nuku – was providing leadership on developing a strategy to meet the goal, with the support of the Ministry’s Office of the Chief Nursing Officer (OCNO).
“We currently fund a number of operational initiatives to grow and support the widerMāorihealth workforce, including scholarships, cultural support and leadership programmes, and initiatives in secondary schools, undergraduate and post graduate education,” said Clendon. “There are also two Bachelor of Nursing (Māori) programmes based on kaupapa Māori perspectives supporting Māori nurses to work in their communities”.
Nuku also drew attention to the ongoing pay parity issue for nurses working for Māori and iwi health care providers who were paid up to 25 per cent less than their counterparts in district health boards.
An 11,000-plus petition was presented to Parliament back in July 2008, pointing out the inequity and calling for the Government to work with NZNO and Māori and iwi PHC employers so that pay equity could be funded and delivered to their nurses and other health professionals.
“This situation, although complex could be remedied by different contractual arrangements, if there was the political will to do so,” she said. The Ministry said it could not comment, saying DHBs funded Māori and iwi providers to provide primary health care services and that nurses pay was dependent on negotiations between the nurses and their employers.
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Nigel Fairley, general manager of the region’s Mental Health, Addictions and Intellectual Disability Service (MHAIDS) says as Wellington becomes more diverse and multicultural so are the services nurses.
Currently, 35 graduate registered nurses are undertaking MHAIDS’ New Entry to Specialist Practice (NESP) programme to support them to specialise in mental health, addictions and intellectual disability.
The graduates come from a range of cultural backgrounds – including Māori, Pasifika, Filipino, New Zealand European, Chinese, South African, and British – making it one of the most diverse groups the programme has seen, said Fairley.
“People from different backgrounds and cultures view and experience mental health issues and treatments differently and, so, have different needs,” he said.
“If we are to properly support them, we must understand that – which is why it is so important to build an ethnically diverse workforce that is conscious of people’s cultures and needs.”
“Nurses are a significant part of our workforce and are vital in the delivery of health services – both in a hospital and community setting. They often work closest with the people we support, and work hard respect and understand their cultures and beliefs.
“The more we can nurture an ethnically diverse and culturally-conscious staff – including nurses, mental health support workers, doctors, therapist and others – the better equipped we will be to continue supporting our ever-changing communities into the future.”
]]>Safe staffing levels have been high on the agenda in the current pay impasse between New Zealand Nurses Organisation (NZNO) and the 20 DHBs, with the DHBs’ spokesperson Ashley Bloomfield acknowledging the pressure many nurses are currently working under on the ward floor.
The Ministry of Health released its latest DHB financial performance update to the Minister last month which was predicting worsening DHB deficits – partly due to unusually high patient volumes over summer – and that DHBs were carrying more than 400 vacancies. The breakdown of DHB staffing showed that allied health was the area with the greatest full-time equivalent (FTE) vacancies and DHBs were employing 260 more nursing FTEs then budgeted for.
Sixteen of the 20 DHBs were employing more nurses than budgeted for in their annual plans, with in total 28,297 FTE nurses, midwives and health care assistants being employed as at the end of February. This was up more than 900 FTE on the same time last year. Medical staff were also over budget by more than 100 FTEs and had 382 more FTEs than the same time last year.
Pressure has been on district health boards for the last couple of years to absorb more of the record number of new nurses graduating each year (more than 1900 in 2016-17) to ensure New Zealand’s ageing nursing workforce was being replenished – with many new graduate programmes starting in February.
DHBs were also reporting higher than expected patient volumes in recent months contributing to escalating deficits through increased personnel costs and the need to outsource staff and clinical services.
Cee Payne, NZNO industrial services manager, said nursing FTEs might be higher than DHBs budgeted for but that didn’t mean the budgets were sufficient to deliver safe, quality patient care.
“We are aware that people are sicker coming into hospital and there is increased consumer demand so the volume of people and the acuity of patients is impacting on how many nurses are actually needed,” she said.
But she said at present the number of nurses required to meet patient needs was not being accurately calculated by DHBs because of the slow implementation of the Care Capacity Demand Management (CCDM) system process that began nearly a decade ago.
“Even though they (DHBs) might be over budget, basically nurses are not being able to manage the work…and they are not making that up. And yes they may have a budget for nurses but it is not based on any evidence of what is actually happening in the hospital.”
Speeding up the implementation of CCDM has been a major platform in the NZNO collective agreement talks with the DHBs agreeing in the rejected offer for all DHBs to fully implement CCDM – including funding and filling nursing shortfalls revealed by the CCDM analysis – by 2021.
Only one district health board, Bay of Plenty, has fully implemented the safe staffing CCDM tools that use acuity software to calculate how many nurses are needed on each ward based, not on bed occupation, but on what level of nursing the ward’s patients require and the ward’s historic patient demand patterns.
“If they had implemented CCDM ten years ago they would be able to measure and tell us whether they’ve got the right number of nurses based on patient acuity…but they have never done that,” said Payne. “That’s why we are concerned because they can say ‘this is the budget’, but the budget is made to fit whatever money they have got. It’s not based on what are the actual patient and nursing needs.”
She said the fact that hospitals were strained over summer was a warning sign with the winter peak still to come which this year – if the flu season is as severe as it was in the northern hemisphere winter – could be a particularly challenging one. “I do think we are in for a bit of a crisis – and we are going to have to bring people into work ..and the budget is going to probably blow out even further. But patients deserve decent care.”
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