Decisions Behind the Mask

Opinion piece by a New Zealand nurse and HSWN member

“We are exhausted. Last night was brutal. We literally hit capacity … Just holding on. None of us have ever faced anything like it. Nothing in our studies ever prepared us for this, and not even the most experienced of us have ever seen anything like it” said Michelle Rosentreter a Sydney ICU nurse this week (The Sydney Morning Herald, 29/08/21).

In my New Zealand nursing training, less than a one hour lecture covered the Spanish flu and pandemic response. That lecture was 16 years ago, and I’ve not had any pandemic training since. I was asked to be part of the ICU surge nursing workforce; it’s false that nurses voluntarily signed up for this. Anyone insisting nurses knew the risks in the comments section of Facebook groups are wrong, only fooling themselves. 

The notion of nursing as a “calling” died last century, about the same time as massive student loans were introduced and housing became unaffordable. 

As highly educated professionals, nurses are weighing up the risks, benefits and ethical decisions in accepting COVID-19 assignments inside a fraught industrial relations and socio-political context. 

There is growing concern that the New Zealand health system is not prepared to cope with COVID-19 community outbreaks. We’ve had the last 18 months to prepare, plan, recruit, train and retain, and build bed capacity. Sadly, that time has been wasted. 

ICU staff at St Vincent’s hospital, Sydney. Source: https://www.theguardian.com/australia-news/2021/aug/13/sydney-hospitals-under-significant-strain-with-staff-shortages-as-covid-outbreak-grows

Hearing that Cabinet had budgeted 1.4 billion per week for four weeks in anticipation of another level four lockdown fell heavily around the nurse’s station last week. If the government budgeted and planned for four weeks of economic assistance why isn’t there any evidence of budgeting and planning for the increased demands on the health system? 

The decades of underfunding of the DHB system to the tune of billions has been well researched and documented. 

Surely a pandemic would change the government’s hands off DHB approach in order to protect New Zealanders. 

He aha te mea nui o te ao? He tangata. He tangata. He tangata. 

What is the most important thing in the world?  It is the people. It is the people. It is the people. 

In 2018 for the first time in over thirty years nurses took strike action, exhausted from propping up the health system with their good will and unpaid overtime. Across New Zealand, nurses’ loudest cry was for safe staffing. The DHBs nursing staffing levels had become so degraded nurses took to social media, media, and the streets to tell the New Zealand public their hospitals were unsafe. 

Three years on the nurse’s cry for safe staffing had been heard but left unanswered. 

Working on a contract that expired in July 2020 many nurses have lost faith in the Care Capacity Demand Management (CCDM) IT program that has failed to deliver minimum staffing levels after sixteen years. 

In 2021 nurses voted for another four rounds of industrial action, of which only one strike occurred. The health Minister Andrew Little has expressed frustration with the lack of recruitment by DHBs funded to hire additional nursing staff. 

It is shameful that in sixteen years, the time it took to raise a generation, our 20 DHBs haven’t implemented a patient acuity tool or hired adequate nursing staff to prevent harm to patients and employees. Nurses think this is something Worksafe and their labour inspectorates should have commented on long ago. Seemingly nurses Health and Safety at Work is worth less than employees working for other employers or industries. 

I used to commonly ‘rescue’ my colleagues crying in the toilets but last year I realised something had changed. Nurses silently cry at the bedside on my ward now. The patient is too complex, too sick, too unstable to leave. The nurse tries to hide red eyes by fixing a stare at the monitor, likely contemplating their horror and poor career choices. 

In the past ten years I have had six nurses tell me they are feeling suicidal. I’ve lost count of the number of colleagues who have left nursing for good.

There’s a worldwide nursing shortage, my Facebook feed is screaming at me. We had multiple lectures on the issue and I had to write an entire essay on it in my training. The main document cited was written by the government, they knew about the conditions and aging workforce decades ago. 

In reality there’s plenty of trained nurses in the world, there’s a shortage of people prepared to work under these terms and conditions, a shortage of respect, equity and good nurse employers. In any other industry you’d improve the terms and conditions to attract and retain skilled and experienced staff. In a shortage the market would decide and pay would have to increase. 

Not nursing.

Last week a section 70 notice was issued to permit nurses to return to work instead of self-isolating if a household member had been at a place of interest. 

DHBs won’t offer permanent contracts of less than 60 hours per fortnight and insist on employing nurses on rostered rotating contracts that allow them to be redeployed to specialist areas they are not trained in. 

This doesn’t work for returning to work parents, fixed childcare bookings, nurses mentally harmed by their career and the huge proportion of nurses over fifty years old. 

DHBs are cutting off their nose to spite their face, turning away nurses wanting to work part time but burning out full time nurses pressuring them to work overtime. This approach is not financially savvy or sustainable. 

Most employees want to feel valued, safe and respected. 

The DHBs have been harsh employers denying discretionary sick leave for nurses receiving cancer therapy, having surgery and caring for dependents, cancelling annual leave and bombarding nurses on days off with texts begging for overtime workers. There are no Christmas holidays, no bonuses, no superannuation, no parking, no hazard pay, no mileage or shoe allowance, most nurses work rostered and rotating shifts that start or finish outside public transport options and wages are so low workers often cannot afford to live in the same city as the hospital they work in. 

DHB workers are the final government workers awaiting Holiday Act pay error remediation. 

Many nurses have gone to Australia where they can earn tens of thousands more annually and in some areas have mandated nurse patient ratios. 

New Zealand nurses echo Michelle Rosentreter’s comments ‘nothing has prepared us for what we are about to face’ and workers don’t trust DHB employers to protect their safety. DHBs haven’t protected healthcare workers’ mental or physical health up to this point. 

There are ED department staff being issued masks that expired ten years ago and many staff are yet to be fit tested with N95 particulate masks. DHBs have only just acknowledged COVID-19 is airborne, previously ignoring World Health Organisation advice and the precautionary principle deeming droplet Personal Protective Equipment (PPE) adequate. 

Watching the first, second, third and fourth waves overseas nurses here fear the border breaches. Our hospitals are operating in excess of 100% capacity daily without COVID-19 community transmission. This means patients are bed blocked in waiting rooms, emergency departments, ambulances, interventional suites and theatre departments unable to reach specialist medical and nursing teams, potentially delaying discharges and contributing to poorer outcomes. 

We had eighteen months to build negative pressure rooms, refit unused wards, offices, reconfigure services, recruit additional staff and liaise with private providers to continue elective surgery and health screening services. 

The excess capacity could have reduced elective surgery wait times, increased primary health chronic condition management, planned for split rosters and teams and crucially, supported training for advanced critical care respiratory nursing skills and increasing ICU capacity and staff. 

This hasn’t happened. Instead we have seen unprecedented demand for acute services. 

Without any additional staffing and resources we have burnt out our nursing workforce before COVID-19 really gets a foothold in New Zealand. 

Nursing staff have been disrespected and forced to continue working in conditions so unsafe seven Provisional Improvement Notices (PIN) have been issued by DHB health and safety representatives in the past two months. 

When nurses consider working with COVID-19 patients they will be balancing complex demands. Most healthcare workers’ household members are unvaccinated. Nurses fear exposing their families to COVID-19. 

Some DHB’s have begun advocating for ringfenced vaccination sites specifically targeted at DHB workers and their households. This sends a clear message to workers “we care, we care about the people in your household”. 

Workers asking about testing regimes have been met with blank stares. Lack of planning in this area does not say “we care” it says “we don’t know what we’re doing”.

Nurses typically will take a challenge on, we don’t shy from hard mahi and are proud advocates for the vulnerable and disadvantaged. Most of us would like to say we would have volunteered in the HIV/AIDs crisis in the 1980’s. We know COVID patients need skilled expert nursing care regardless of the prognosis. We know we will spend the longest time at the bedside. 

The ethical decision making to volunteer for COVID-19 hot areas is occurring inside an industrial relations and socio-political context that could force more New Zealand nurses to leave the profession rather than accept a COVID-19 assignment. 

Nurses feel unsafe now, there’s not enough nurses the majority of shifts we work, leading to care rationing, we do not feel safe with droplet PPE, our hospitals are overcrowded, we are forced to return to work when everyone else self isolates by government decree, our employers have no testing regime, our household members are largely unvaccinated, we are facing increasing levels of abuse and violence and working on an expired contract. 

Nurses are expecting a new offer for the NZNO/DHB Multi Employer Collective Agreement (MECA) in the next week or so. This is a critical moment for our employers and the government to demonstrate real respect through fair remuneration and acknowledgment of the desperate staffing shortage. It is vital they use this chance to not only retain but grow our current workforce in order to face the difficult years ahead.