Disingenuous headlines have appeared in the national media in recent weeks indicating nurses have ostensibly turned down a half billion dollar pay offer.

The headlines talk of doubling the offer and other financial bells and whistles but given that district health boards (DHBs) have now been officially notified of strike action there seems to be something more to the story. So, why wasn’t the money enough?

For a start the NZNO, as the negotiating body for the majority of nurses employed within the public sector, crunched the numbers and the quantum, timing and distribution of cash has been questioned.

But aside from this it is likely other areas of discontent have not been fully acknowledged by DHB negotiators.

Safe Staffing Inquiry

I am not privy to NZNO negotiations, yet I would surmise a significant part of their claim harks back to the report of the Safe Staffing / Health Workplaces Committee of Inquiry published long ago in 2006; almost 12 years to the day from the start of the current dispute.

The inquiry was part of a commitment contained within the historic 2005 settlement between NZNO and the DHBs which gave rise to a 20 per cent increase in pay (colloquially known as the ‘pay jolt’) – suggesting more was to be had than just monetary incentive.

Nurses wanted to work somewhere safe and healthy and have the means of ensuring that.

As a government representative to the Inquiry I was initially sceptical and to admit turning up to my first meeting wondering whether it was going to be a good use of the day.

Well, how wrong I was. Ably chaired by former Retirement Commissioner Diana Crossan, the committee steadily worked through international evidence categorically indicating that ­– by accurately forecasting patient care needs and tailoring an available nursing workforce to suit ­– not only would nurses’ working environment improve significantly but so would health outcomes.

What I anticipated as another talkfest ended up being a year of effort by a dedicated group determined to report these findings to be the case.

My ‘full conversion’ was complete when I had the honour to present the recommendations within the report to the 2007 International Council of Nurses (ICN) Congress in Yokohama, Japan, with Jane O’Malley, then President of NZNO (and my successor as Chief Nurse) and Geoff Annals, the organisation’s then Chief Executive.

Such was my conviction as to the work of the committee of inquiry that I stated my belief in their suggested approach being the ‘new politick of industrial relations’.

So, what did the Inquiry Report actually recommend? Two stand-out elements are that NZNO and DHBs committed to developing:

  • a mechanism for nurses, midwives and employers to respond immediately if workloads exceed the determined levels
  • sustainable solutions to safe staffing issues, developed in a way that has the confidence of nurses and midwives

Underpinning this was an agreed recognition that nurses and midwives ‘understand the business of providing care 24 hours a day, seven days a week, and how organisations need to work in order deliver quality patient outcomes’.

This didn’t mean that just some senior nurses in a DHB were seen like this, rather the agreement stressed ‘the system needs to provide nurses and midwives with the authority and support to make decisions at the point nearest to where it is necessary’.

To make this work, a Safe Staffing and Healthy Workplace Unit (SSHWU) would be established. Contained within the unit’s remit was the task of developing a tool to forecast workload and tailor nursing and midwifery resources to suit. The resulting suite of tools developed is known as care capacity demand management (CCDM) system.

Note here the Committee of Inquiry intended this to be a means of determining the amount of nursing care that would be needed at any particular time, AND a means of nurses identifying when their ability to deliver that care was being jeopardised, being able to enlist additional providers of care – more nurses, and ultimately being able to restrict demand for that care until that resource is made available.

As evidenced by the NZNO ‘Care Point’ campaign, the implementation of CCDM hasn’t exactly going swimmingly well on a national basis.

Some DHBs have adopted the underlying software system – TrendCare, and some have developed their own bespoke system. However, CCDM is probably best characterised today as a means of determining how thinly care can be spread by the number of nurses DHBs feel they are able to recruit and afford to employ.

The notion of a ‘bedside’ nurse having the ability to use their professional judgement to suggest to a manager they are no longer able to give quality care due to demand – and that manager being able to follow some agreed escalation pathway that swiftly provides immediate additional sources of care – is but a pipedream in many clinical situations.

Admittedly an additional two per cent investment in more nurses is contained within the DHB offer. But how do we know that is anywhere near enough to guarantee high standards of care when we don’t have a nationally operated CCDM system? Nor an agreed means of determining what our nursing workforce should actually look like for that matter?

As Chief Nurse, somewhat embarrassingly, I had to answer the question from three different health ministers as to whether we had a nursing shortage with a simple ‘I don’t really know!’.

Not, I hasten to add, because I was inept, but because we didn’t have an agreed means of determining how many nurses we actually needed – some DHBs couldn’t even tell me how many nurses they actually employed or what their vacancy rates were.

We now have Health Workforce New Zealand to do this modelling, yet I still reckon a Chief Nurse would struggle to answer the same question in any real, definitive sense.

Of course, money is important; unfortunately for nurses they are a big-ticket item and their cost stands out like a sore thumb on a balance sheet, but it isn’t the be-all and end-all.

I would commend – as I did alongside Jane and Geoff back at that  2007 conference in Japan – the ever so sensible recommendations of the Committee of Inquiry. Contained within the 65 pages of the Inquiry’s evidence-based report is the solution for a revolution in DHB–NZNO industrial relations. Those parties agreed this over a decade ago and they can agree it once again.

A final thought on the dollars: If only a third of the nursing workforce strikes for two days there is a potential salary saving to DHBs of nearly $3.5M. I would be dismayed if anyone has done that calculation in a positive frame of mind…

Dr Mark Jones was Chief Nurse at the Ministry of Health from 2005-2010 and is also a former head of Massey University’s School of Nursing.

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