How safe are our hospitals?
Five takeaways from our investigation into unsafe staffing
A hospital system pushed to the brink by the Covid-19 pandemic is now confronting another crisis. Alex Spence highlights the impact it is having on staff and patients.
In Wellington, an overworked community psychiatrist became so exhausted and disillusioned about his working conditions that he quit and moved back to the United States. “If I’m going to work in a s***show, I might as well do it closer to home,” he said.
In Palmerston North, the head of the local hospital’s emergency department wrote a desperate letter to the chief executive of Te Whatu Ora-Health New Zealand saying he didn’t have enough junior doctors left to provide a safe acute medical service.
And in Auckland, more than 150 nurses in one of the city’s busiest emergency departments signed a health and safety notice warning that chronic understaffing was constantly putting them and patients in danger.
Across the country, staff in public health services ranging from EDs to radiology to mental health are working in increasingly difficult conditions. A system that was pushed to the brink by the Covid-19 pandemic is now confronting another crisis compounded by desperate shortages of doctors, nurses, and other essential frontline workers.
In recent months, an investigation by the Herald, based on previously unreported data and internal documents and interviews with dozens of clinicians and officials, has examined the growing concerns among these workers about the impact this crisis is having on them and their patients.
In a series of exclusive articles, we have revealed how staff are stressed, demoralised, and increasingly worried about the quality — and safety — of the care they’re providing.
Here are five key themes that emerged from our reporting.
‘Everyone’s getting burnt out’
It has become a cliche to say that the health system is in crisis. Clinicians have run out of ways to express the gravity and urgency of their situations.
“We’ve gone beyond desperation,” said Anne Daniels, president of the New Zealand Nurses Organisation (NZNO) and a practising emergency nurse.
Emergency departments are a canary in the coalmine, reflecting pressures on other parts of the system including primary care and hospital wards.
Our investigation uncovered numerous documents in which nurses and doctors warned their bosses that their departments were chronically understaffed because of resignations, illness, recruitment problems, and other challenges.
Crippling shortages have resulted in clinicians carrying unmanageable workloads. Representatives say the stressful conditions are impacting on workers’ physical and mental health, depressing morale, and causing “moral injury” because they cannot always provide the level of care that they aspire to. Many have quit and moved overseas or retired.
“Everyone’s getting burnt out,” said Dr Amanda Rosenberg, a consultant in emergency medicine at Auckland City Hospital. “We’re exhausted.”
In a rare move for a senior doctor, Rosenberg gave an on-the-record interview without the permission of her bosses at Te Whatu Ora because she was so concerned about the state of emergency medicine. For the first time in her career, Rosenberg told the Herald, she had considered leaving the field.
It is not just stress and exhaustion that frontline staff are dealing with. In this strained environment, many are concerned that they will be involved in a serious incident that causes irreparable harm to a patient or even death — which could also damage their careers.
Senior executives at Auckland City Hospital took the extraordinary step of writing to employees to assure them they will be supported if they become embroiled in an investigation or complaint arising from hospital pressures. “Like you, we cannot remember a time when the system has been under so much strain,” said the letter from the Auckland health authority’s chief nursing officer.
Medical staff are also facing increasing violence and hostility in their workplaces. In April, we reported that hospitals recorded 22,870 incidents of violence, aggression, or harassment against staff in the last three financial years — a rate of more than 20 incidents per day around the country. Clinicians and union representatives say this underestimates the scale of the problem and that it is getting worse.
In September, the Australasian College for Emergency Medicine (ACEM) called for security guards to be posted around the clock in every ED. “This is the worst that we have ever seen,” said Dr Kate Allan, the organisation’s New Zealand spokesperson.
Understaffing is not the only problem
Workforce shortages are usually cited as the reason for the troubling state of our health services, with good reason, but they are far from the only contributor. In many places, the staffing issues are colliding with systemic and cultural problems arising from years of poor planning and processes.
This was starkly illustrated in the radiology service at Hawke’s Bay Hospital. In August, we obtained a damning 35-page review that Te Whatu Ora had previously refused to release that detailed a host of serious technical, cultural, and governance problems that had harmed patients.
For more than a decade, medical workers in the department — which also had its share of staffing shortages — had to deal with a defective information system that crashed frequently, mislaid vital patient reports, and forced them to adopt risky workarounds. It made it harder to do their jobs, depressed morale, and fostered a culture of “learned helplessness”, the reviewers found.
Patients are being harmed
While the medical professionals we spoke to are worried about the impact the staffing crisis is having on their own health and careers, they say it is concern for the wellbeing of their patients that is motivating them to speak up.
The risk to patient safety is not just theoretical, they say. With services becoming harder to access, waiting times increasing, hard-pressed clinicians juggling excessive caseloads, and inexperienced staff being put into positions they’re not qualified to handle, the chances are increased of a patient falling through the cracks or getting substandard treatment.
Staff say corners are being cut and mistakes made because of the strained conditions. An elderly dementia patient falls because there is nobody to keep watch. An inexperienced nurse dispenses the wrong dose of medication. A person with severe mental illness waits 94 hours in Auckland City Hospital’s ED, in extreme distress, because there are no free beds in the psychiatric ward.
In many instances, clinical errors are picked up before it is too late, but the nurses and doctors we spoke to all said they had seen preventable incidents that resulted in serious consequences for patients.
“We know that harm is being done,” said Dr David Prisk, the head of emergency medicine at Palmerston North Hospital, in a letter to the chief executive of Te Whatu Ora warning that he didn’t have enough staff to run a safe acute medicine service. “We feel powerless to prevent or address that harm, and we are all aware that we are at increased risk of making a mistake in our always fraught environment.”
Rosenberg, the emergency doctor at Auckland City Hospital, told the Herald: “If I didn’t think there were knock-on effects for my patients, I wouldn’t be talking to you today.”
Staff don’t feel they’re being heard
Adding to the clinicians’ fatigue and moral injury is a sense that the people above them — hospital executives, government officials, politicians — aren’t responding to the crisis with the urgency it demands. Many of the staff we spoke to said they or their colleagues had escalated problems up the chain repeatedly, over many years, but little had changed.
One psychiatrist in Wellington said he perceived an “abject level of indifference” among health executives to the views of doctors on the front line. And an ED nurse in Whanga¯rei described trying to get executives to understand their daily reality as “like trying to explain to someone who hasn’t got children how exhausting it is to be a parent”.
By our count, more than 23,000 reports had been filed by hospital personnel when staffing reached unsafe levels in the past three financial years. But union representatives say this substantially undercounts the extent of the problem because harried staff often don’t have time to go through a cumbersome reporting process or don’t feel there’s any point.
Staff said they were frustrated with ministers and health officials downplaying the crisis, saying the system was improving, or failing to inform the public of serious problems because they did not want people to stop seeking treatment. It has fostered deep mistrust between clinicians and managers and prompted some clinicians to take extreme steps.
Among them was Dr Bryan Wolf, a senior radiologist in Hawke’s Bay, whose disclosures resulted in the damning review. After Wolf alerted Te Whatu Ora’s senior leadership and board to serious safety risks that had harmed patients, he became so exasperated by the organisation’s response that he alerted various watchdogs.
In one letter to Chief Ombudsman Peter Boshier, Wolf accused Te Whatu Ora of a “conspiracy” to conceal the safety risks from the public and asked him to investigate. Te Whatu Ora denied deliberately withholding information but Wolf ’s actions reverberated explosively across the organisation, prompting meetings with its chief executive and top medical officer and promises of reform.
There’s no end in sight
Health officials say they’re “pulling every lever” to address staffing shortages, but are limited in how much they can do in the short term. As they often point out, New Zealand isn’t the only country experiencing a health workforce crisis; it is a global problem.
Providers are actively trying to recruit replacement doctors and nurses from overseas but New Zealand is competing with other countries, including Australia, that offer higher pay. Training new doctors and nurses takes years.
During the election campaign, we spoke to National’s Shane Reti, the new Health Minister. Reti had recently accompanied 19 ambulance crews on night shifts around the country.
His “ride-alongs” caused tension between Te Whatu Ora and Hato Hone St John Ambulance, because Te Whatu Ora wasn’t aware he would be entering its hospital EDs, but Reti said the experience confirmed his belief that the system was in crisis.
“I’ve been saying for ages, our health system is gonna break at some point,” he said.
In our interview, Reti admitted previous National governments did not do enough to improve hospitals and develop the workforce, and said he was committed to preserving a public health system accessible to all New Zealanders. National’s campaign manifesto promised a handful of incremental health policies — a new medical school in Waikato, the return of targets for ED waiting times — rather than a transformative alternative vision.
Reti said the sector was exhausted and couldn’t tolerate more sudden change after the Te Whatu Ora restructuring. This will be a long, hard slog.