Will the new pay deal deliver more nurses?
With the ink dry on their new deal, nurses finally have pay certainty. But deep scepticism remains over safe staffing. Cate Broughton reports.
Jessica has worked as a nurse in a busy children’s unit in a large public hospital for nine years. She is on maternity leave, but the prospect of returning to work fills her with dread.
Constant demands coupled with inadequate staffing levels made it almost impossible to do justice to her profession, she says.
‘‘When you look at your patients you’re thinking, I’m not caring for you as well as I should be – because I physically can’t.’’
She struggles to even describe her job as nursing. ‘‘It’s not nursing, it’s . . . I don’t know what it is but it’s not nursing.’’ She didn’t want her last name used.
Nurses are forced to reduce care for vulnerable and sick patients, Jessica says.
‘‘I’ve had to leave parents sobbing in the corner of a room because I can’t talk to them because I’ve literally got to keep babies alive.’’
Nurses should not have had to fight for something as basic as safe staffing, she says.
‘‘Most people don’t have to do their pay negotiations and advocate for patient safety, but for some reason that got lumped into our agreement.’’
Jessica has little faith the new settlement will make a difference to staffing levels and is perplexed as to why it will take so long.
‘‘Everyone already knows how many staff you need on a shift, I think it’s pretty obvious.
‘‘I honestly don’t think [the agreement] means anything.’’
Successive employment agreements since 2006 have committed to safe staffing through a programme called Care Capacity Demand Management (CCDM). It has become synonymous with safe staffing in New Zealand hospitals.
CCDM involves a range of measures and ‘‘tools’’ that have the aim of ensuring sufficient nurses are working to meet patient demands.
Key to the staffing model is knowing how sick the patients are, their sheer numbers, and in which wards.
To figure this out, nurses use a software program to track data on patient numbers and sickness levels. Armed with this data, the program then calculates optimal staffing needs.
The only ‘‘validated’’ nurse staffing program is TrendCare, designed by former nurse and nurse manager Cherrie Lowe. At a cost of about $83,000 for a midsized district health board, plus an annual licensing fee of $16,500, the system represents a significant investment.
The New Zealand Nurses Organisation (NZNO) and Lowe say it is the only proven way to ensure safe staffing, but acknowledge it is not simple to implement, and progress has been slow. It could take up to three to four years to roll out CCDM in any one DHB.
Which may be why the current agreement has committed all DHBs to full implementation by 2021.
Three DHBs have not bought TrendCare, and three DHBs are in the process of implementing it, despite having signed up to CCDM years ago, says NZNO associate professional services manager Hilary Graham-Smith.
‘‘Nurses have been entering that data and then the calculations are done – and nothing happens as a consequence of that calculation.
‘‘They are, quite rightly, disenchanted,’’ Graham-Smith says.
She acknowledges ‘‘fiscal constraints’’ on DHBs have prevented follow-through. ‘‘If the system says you need another seven [nurses] and you don’t have the money to employ them, that’s enormously difficult.’’
Under previous employment agreements, DHBs were required to report on progress to a Safe Staffing and Healthy Workplaces unit (SSHW).
SSHW, made up of representatives from the Ministry of Health, DHBs and NZNO, conducted site visits to monitor how hospitals were using the system.
But Graham-Smith, who represents the NZNO on the group, says their power to influence staffing decisions has been limited.
‘‘What I’m really hoping now is that with the new agreements built into the [settlement] and now with the [safe staffing] accord, we have sufficient levers to drive this programme forward.’’
A commitment by DHBs to employ one staff member for every 600 nurses to train and monitor staff in using CCDM is ‘‘huge’’, Graham-Smith says.
DHBs will also have to provide a plan for implementation of CCDM within six months, under the new agreement.
The accord on safe staffing, initiated by the minister of health, and twice-monthly progress reporting instead of quarterly, would increase accountability, she says.
An immediate injection of an extra 500 nurses is a good start but probably not enough across 20 DHBs.
Graham-Smith knows she and her colleagues have an uphill battle ahead to get members on board.
‘‘While our members have lost trust and confidence, we
‘‘I’ve had to leave parents sobbing in the corner . . . I can’t talk to them because I’ve literally got to keep babies alive.’’
know it’s the right thing to do.’’
Lowe says her experience as a nurse, midwife and nursing manager motivated her to design TrendCare. The program now sets staffing levels in hospitals in Queensland, Ireland, Britain, Singapore and New Zealand, she says by phone from Britain.
She acknowledges it is a complex system, but insists the results are worth it. ‘‘Without this evidence, there is nothing else. If we just go on the number of patients, that doesn’t tell you the complexity of the patients.’’
If TrendCare was being used by 17 DHBs, why had the discontent about staffing brought nurses into the streets in protest?
‘‘You can measure something and people are using TrendCare . . . but it doesn’t spit nurses out of the computer. It only says you are minus 10 today and then they just have to make the best of it.’’
The three DHBs that have not bought TrendCare are Canterbury, Counties Manukau and Waikato.
However, all say they have signed up to implement CCDM and are committed to the safe staffing accord.
Waikato DHB is not planning to buy TrendCare ‘‘at this stage’’, as it uses an alternative tool that measures skills and numbers needed in each ward, a spokeswoman says.
Counties Manukau DHB has been using ‘‘the principles’’ of CCDM with an alternative tool to TrendCare for ‘‘a number of years’’. Chief nurse and director of patient and wha¯ nau experience Jenny Parr says it has recently developed a business case for a new tool
which would enable it to benchmark with other DHBs.
Canterbury DHB executive director of nursing Mary Gordon says Canterbury has many ‘‘elements’’ of CCDM in place but does not have an acuity tool and therefore was not eligible for the CCDM programme.
Canterbury has a ‘‘high-level plan’’ to implement CCDM by 2021 and a validated tool has been budgeted for.
‘‘We will meet our commitment in the accord as we will implement an appropriately validated acuity tool,’’ Gordon says.
Ministry of Health acting chief nursing officer Jill Clendon says the three DHBs are ‘‘in the process of purchasing the software’’.
Jim Green, a spokesman for the DHBs during the pay negotiations and Tairawhiti DHB chief executive, says he has been a fan of TrendCare and CCDM since 2006.
The systems help wards build a picture of demand and capacity on every shift on every day.
Having detailed and accurate information about patients and nursing capacity is incredibly valuable, he says.
Clinical managers could respond by reallocating nurses to different wards to keep staffing levels within acceptable levels.
Green says DHBs have taken longer to implement the systems because they are complex and require funding support from the government.
Nursing staff could be reluctant to use TrendCare, seeing it as yet another administrative task to fit in around patient care.
Tairawhiti has used TrendCare for 10 years and it had led to an increase in nursing staff, Green says. The DHB still struggled ‘‘a lot’’ to respond to increased patient demands and volumes at times.
He says the TrendCare information gives managers confidence to make ‘‘tough’’ decisions, including cancelling elective surgeries, to ensure staffing for acute patients is adequate.
An increase in funding by the Government enabled the DHBs to make a stronger commitment to safe staffing and CCDM in the current settlement, Green says.
‘‘I don’t think it’s right to suggest that DHBs don’t understand the relationship between the appropriate staffing levels and good outcomes for patients. I think they understand that very well.’’