If Dunedin hospital was a patient, what would their status be?
The Otago Daily Times posed the question to Dunedin nurses and nursing assistants who went on strike and marched across the city earlier this week.
"Critical," answered one. "They would already be in the morgue," another said.
Nurses say they have been told not to talk to journalists, but are vocal anyway. Lives depend on it, they say.
They are clamouring for safe care. They talk of under-staffed shifts, slashed jobs, delayed recruitments, lack of medical equipment and broken computers. There are also suspicions the government is withholding important staffing data that would show under-resourcing.
Health New Zealand Te Whatu Ora (HNZ) said earlier this week that the government agency was "disappointed" that strike action was taken so early in the pay-bargaining process. Nurses say they are concerned more about patients than their pay packet.
The government announcement in September that the promised new in-patient building would be scaled back or scrapped in favour of a refurbishment of the ageing Dunedin Ward Block feels like the straw that has broken the camel’s back.
The refurbishment idea is intolerable to nurses. The recent refurbishment of the Intensive Care Unit on the fifth floor had caused "massive" noise and clinical disruption, one emergency department nurse said.
"Hope and goodwill is evaporating every day. We have soldiered on for so long — to be told now that there might be a refurbishment has left us feeling broken."
Many nurses, midwives, and people in important support roles such as healthcare assistants and IT roles were spoken to by the ODT for this article, both on the march and separately. They nearly all wished to remain anonymous to protect their jobs. The strike was organised by their union New Zealand Nurses Organisation (NZNO) and its chief executive Paul Goulter spoke for them.
The HNZ cuts are "piecemeal, random, they don’t make sense. It is very hard to work out what HNZ is trying to do."
Squeezed recruitment
Many nurses on the march said HNZ was making cuts to the frontline by stealth. There were delays getting permission for recruitment when a medic resigned, retired or went on extended leave.
"We are waiting weeks and weeks to readvertise roles," one Dunedin-based nurse said.
A union representative from the Public Service Association (PSA), representing Southland’s Allied Health staff, gave an example. It had not been possible for staff to help nine older people recently who had suffered fractures and left hospital requiring community care.
The care gap was due to a rehiring gap, they said. A physiotherapist and an occupational therapist had left but not been replaced in time. One of the departing staff had given eight weeks’ notice but approval to start advertising for a replacement didn’t happen until they left.
"It is a sneaky way of making frontline cuts. It is incredibly disheartening not to be able to provide services needed. . . staff feel terrible."
Graduate cutbacks
In July 2018, then director-general of health Ashley Bloomfield signed a safe-staffing accord with NZNO. It made a commitment to explore options for employment for all New Zealand’s nursing and midwifery graduates.
One ward nurse said they had provided work experience for four trainee nurses from Otago Polytechnic this year but only had permission to employ one.
Another hospital nurse with a training role said HNZ had turned its back on graduates and some were leaving for Australia. There was also the "tragedy" of nurses from overseas coming to New Zealand in hope of work, leaving their families behind but not getting a job despite nurses being "absolutely needed here".
An Otago Polytechnic spokesperson said that 2024 "has seen a more competitive job market in the wake of restructuring at HNZ alongside financial constraints flagged by the government".
This year, 120 nursing students graduated from the polytechnic and passed the final exam to qualify as a nurse. Initial results of a student survey found that 41 have got jobs within HNZ, most in HNZ Southern. Another 20 are in a HNZ "talent pool", hoping for a job. The remainder have either not replied to the survey yet or are working elsewhere, including in the private sector.
Lack of equipment
Lack of equipment leads to further inefficiencies and patient risk, say medics.
In the creaking Emergency Department, where there is limited ability to control the heating, there can be challenges keeping trauma patients warm, which is important while critical injuries are being assessed. Medics say they asked for a medical-grade heated mattress and the request was declined.
Other Dunedin nurses said there was significant time being wasted hunting around for basic equipment.
One nurse described commodes on their floor as being "like gold". Another nurse said it took "weeks and weeks" to get replacements when equipment broke, even things as basic as thermometers.
One long-serving nurse said that the hospital now sent round emails telling nurses to swap out drugs for alternate drugs, due to shortages. "I can’t remember a previous time when we had to use alternatives," they said.
A mental health nurse said it took three years to get approval for wrist restraints for a patient who became violent on a regular basis.
Many nurses talked about ageing and breaking laptops and the poor Wi-Fi connection in parts of Dunedin Hospital. A nurse said that whenever their laptop broke they had to go and look up a patient’s drug dose on a computer in a different room, leading to delayed care and error risk.
A general surgery ward nurse said at least two blood-pressure machines on her ward were broken. A request for replacements had not been granted yet.
Backroom staff cuts affecting frontline care
A hiring freeze for non-frontline roles was announced in June and HNZ announced last week that it plans to slash nearly half its data and digital workforce who provide IT support.
The news has alarmed IT workers and frontline medics in equal measure, who say the IT workers are already stretched and firefighting ageing, inadequately-funded computer systems.
One health worker in Invercargill described the proposed IT cutbacks as "terrifying".
A PSA member within the data and digital team in the Southern region — which has about 60 staff — said the team was already understaffed "beyond any limit you would find in any other IT department".
About 90% of them had now received letters saying their roles were being disestablished and they would have to reapply for new roles. There was an expectation only about half would get the new roles.
The PSA member said the functioning of health services was reliant on the IT staff who developed and maintained multiple software systems for different medical uses. Drastically cutting back IT specialists posed a "massive" frontline risk. The IT helpdesk would be useless if it couldn’t point health workers to an expert to fix their problem.
"It’s all pretty dire. . . I think things will break, quickly," they said.
PSA change delegate Mel Orchard said many of the larger IT systems, particularly a new patient administration system, had "serious performance issues" and yet "many digital staff who maintain in-house-developed applications providing critical visibility of patient flow to clinicians are flagged to go".
An Emergency Department nurse gave an example of digital inefficiency. To electronically log a photograph of a patient’s wound they had to take a photo, email it to themselves, print it out, put a patient label on it, put it into a paper record, then send it to a clinical records department to be scanned into an electronic records system.
"How can that be efficient? It is disempowering and affects my ability to work. I am not an admin or IT specialist, and yet my job requires me to work in those spaces and I don’t have the support available to assist me with that."
Staffing data
The 2018 safe-staffing accord between the government and NZNO had committed to data collection to identify HNZ staffing shortfalls.
Nurses on the march frequently mentioned a software system called TrendCare that enables nurses to log patients’ needs on a ward and consequently calculate the required staffing levels on a shift. The system flags if more staff are needed than rostered.
Marching nurses also said shifts frequently remained under-staffed. TrendCare would flag that more staff were needed but none were available.
The system also has a strategic planning purpose. TrendCare data is loaded into a central Care Capacity Demand Management (CCDM) programme, overseen by a unit called Safe Staffing Healthy Workplaces. The CCDM can help identify consistent staffing shortfalls in a hospital and, in theory, enable government to address these shortfalls through recruitment to ensure safe care.
The data is clearly in the public interest. NZNO has found that getting hold of it has been like pulling teeth. After the union repeatedly asked for the data last year it was released for 2022 and 2023. It showed staff shortfalls that NZNO describes as "crisis level".
In Dunedin Hospital, 2023 data showed around half the shifts in the neonatal intensive care unit and the Queen Mary antenatal units were understaffed.
More than a third of the shifts in the refurbished ICU — Te Puna Wai Ora-Southern Critical Care — were understaffed.
Just over half the shifts in the forensic mental health ward at Wakari hospital were understaffed.
In Southland hospital, nearly a third of the shifts on the surgical ward were understaffed.
NZNO has asked HNZ for any CCDM data from 2024 and, so far, not got it.
One nurse on the march slammed any pause in data provision as "absolutely farcical". Not publishing information was a "case of putting your head in the sand intentionally".
NZNO president Anne Daniels agrees: "If you don’t have the data then you can say there is nothing to see here and no problem and it is just completely untrue. It disempowers the unions and the people that we care for. We don’t go on strike just for a pay rise, we have been striking since the early ’90s for safe staffing."
The impact on nurses
Nurses say the upshot of cuts is they are doing more than they should, creating fatigue and risk. "Everyone is just tired and burned out," said one marching nurse.
One nurse, who has been in the job for decades, said nurses on medical wards were sometimes expected to look after double the number of patients compared with 10 years ago.
"It is unrealistic. Nurses don’t have the time to provide the care they were trained to do. It creates patient risk and they are going home sad and angry."
A healthcare assistant said the problem of lack of staff was particularly problematic if patients, for example dementia patients, became violent and there were no colleagues to help. "We have been hit, kicked and spat on."
Healthcare assistants were being asked to work extensive overtime, leading to fatigue and some were "too scared to say no".
Multiple nurses also pointed to the potential for nurses to make mistakes when working tired and being over-stretched, and then be blamed. "If a nurse doesn’t give a drug in the right way, they are held accountable, not the doctor."
HNZ responds
HNZ Southern Group director of operations Hamish Brown acknowledged there were vacancies across the workforce "and we are working urgently to recruit for these positions".
He said staffing in the Southern district had increased over the past 14 years from 3083 full-time equivalents in 2010 to 4672 in June 2024.
"There has been no reduction in clinical roles," he said.
HNZ also said that "most" wards at Dunedin Hospital were at or near "budgeted staffing levels for nurses" and would be "boosted" by newly qualified graduates in early 2025 to fill "existing vacant positions".
In response to the complaints about lack of medical equipment, Mr Brown said a recently-announced $12m fund was being split equally among HNZ regions, meaning "requests for local capital equipment are now beginning to be processed".
