Back in 2004 nurses withdrew a claim for mandated nurse-to-patient ratios to help win an historic pay ‘jolt’.

In place of ratios they were promised a committee of inquiry to develop a national safe staffing model with the aim for implementation to be underway “no later than July 2006”.

More than a decade later most public hospital nurses are still waiting for that safe staffing model to make a difference to the number of nurses on their ward (see full timeline below).  Safe staffing has been high on the agenda for all district health board collective agreement negotiations since 2004 but progress has been painfully slow.

Only one district health board, Bay of Plenty, has fully implemented the model’s Care Capacity Demand Management (CCDM) tools that calculate how many nurses are needed on each ward based, not on bed occupation, but on what level of nursing the ward’s patients require and the ward’s historic patient demand patterns.

For some wards this may mean no changes, occasionally it may find overstaffing but often CCDM data analysis reveals understaffing, like recently at Hawke’s Bay Hospital where a $1 million extra investment was announced in nursing staff after the analysis of the wards in its medical and surgical directorates found it was 17 registered nurses and 10 health care assistants short, particularly in intensive care and acute assessment as some staffing adjustments had already been done in its medical wards.

But in some DHBs nursing funding has not been increased, despite the analysis revealing understaffing, leading to disillusionment with CCDM and TrendCare – the acuity software that CCDM is built on. CCDM research has also confirmed that nurses working an understaffed shift, versus an appropriately staffed shift, were twice as likely to report care rationing – like not answering patient bells within five minutes – and less likely to leave the shift happy.

NZNO industrial organiser Cee Payne said the frustratingly slow implementation of CCDM around the country meant there was an acute unsafe staffing situation in many wards in many hospitals across the country which needed to be urgently addressed.

Strike starts a decade that ends with major safe staffing concerns

The first and to date only national nursing strike by public hospital nurses in 1989 was prompted by the first step in what was to be a decade of ongoing reforms for the health sector.

The first pay talks after the State Sector Act 1988 broke down over clawbacks to penal rates and employers call for a performance-based pay scale, leading to the then New Zealand Nurses Association agreeing for the first time that nurses could take strike action alongside fellow health union the Public Service Association. The strike went ahead on February 14.

The passing of the Employment Contracts Act 1991 saw the breakdown of national bargaining and regional strikes followed in 1992-93 in areas like Auckland and Nelson-Marlborough and the decade ended with a three day strike in 1999 by Waikato nurses. Restructuring and loss of clinical nurse leaders also permeated the decade and frustration continued to build with the last NZNO public hospital strike being held in Christchurch in late 2001.

By the start of the millennium nearly half of public hospital nurses taking part in a major international survey reported that their wards were understaffed. The momentum began to build for mandated nurse-to-patient ratios.

The decade of health reforms had eroded not only nursing morale but pay with a new graduate nurse with a three year degree starting on $10,000 less than a police graduate and pay gap grew to $20,000 at the top of their respective pay scales.

The Fair Pay campaign launched by the New Zealand Nurses Organisation in 2003 sought both mandated nurse-to-patient ratios and a major pay jolt to bring nurses back in line with police and teachers.

The public backed the campaign with a poll finding 73 per cent of nurses were underpaid and a 125,000 signature Fair Petition was delivered to parliament in June 2004.

Understaffing and pay both important

But pay – like now – was only part of the battle.

Dr Jane O’Malley – until recently the country’s Chief Nurse – was president of NZNO during the Fair Pay campaign and in 2004 expressed her concern that “far too many nurses were leaving nursing because of work overload”.  She also talked of nurses feeling demoralised because they could not deliver the care they entered into nursing to provide.

Roll over until 2017-18 and nurses’ continue to share similar stories of moral distress during the In their Own Words part of NZNO’s Shout Out for Health campaign and more recently the nurse-led New Zealand, please hear our voice social media campaign.

NZNO at the end of 2004 won a major pay jolt for nurses – equating to 20-30 per cent increases for public hospital nurses – but the nationwide implementation of a safe staffing model, which was not helped by a time of budget austerity for DHB funding, continues to be painfully slow.

The number of nurses employed by District Health Boards has continued to grow over the past decade but so also has the ageing population and the demand for patient services.

Hospitals are often running at full capacity leading to Auckland DHB chief executives to speak out this year about the unprecedented pressure on services. Recently Auckland emergency departments reported that even the once quieter summer months were now exceptionally busy and last year the demand for beds led to some DHBs cancelling elective surgery or putting up a “hospital full” sign.

So when DHB collective agreement talks got underway again in June last year industrial organiser Lesley Harry said the most “deeply and widely felt” issue raised by members was chronic short-staffing throughout the sector.  She said pay and professional development were also very important but the biggest issue was members’ workload and there was no trade-off for safe staffing.

“The DHBs have had a long-time to budget for safe-staffing – they’ve had over a decade so we don’t expect to have to compensate. That really is a bottom-line issue.”

The revised DHB pay offer negotiated earlier this year includes tighter requirements for implementing safe staffing Care Capacity Demand Management (CCDM) tools with a date set for all DHBs to implement CCDM by 2021 and for all DHBs to have an implementation plan within six months of ratifying the agreement.

Whether nurses consider that safe staffing commitment – when combined with a 2 per cent per annum pay rise and the prospect of negotiating a new pay equity settlement that possibly could be paid out from July 1 next year – is enough or too little to late will be decided at the ballot closing this Friday (March 22).

Nearly 15 years after putting safe staffing at top of the agenda only nurses on the floor can make that call.

Timeline of NZNO nursing campaigns


“Nurses are worth More” campaign – first nurses’ march on Parliament


Public Hospital nurses hold first and only national strike


Employment Contracts Act (1991) breakdown of national bargaining


Auckland, Nelson-Marlborough and nurses in other regions take strike action on a region by region basis.


Waikato Hospital nurses strike


Christchurch Hospital nurses strike


NZNO launches Fair Pay campaign on Suffrage Day with aim of fair pay “jolt”, rebuilding a national DHB collective agreement and introducing a safe staffing model including mandated nurse-to-patient ratios

July 2004

National MECA negotiations begin between NZNO and DHBs

Sept 2004 

Talks stall. NZNO agrees to take mandated nurse-to-patient ratios off the table and talks progress on major pay increase for nurses.

Dec 2004  

A pre-Christmas deal bringing about a 20-30 per cent fair pay “jolt” is struck and in February 2005 is ratified by NZNO members and DHBs


Safe Staffing/Healthy Workplaces (SSHW) Inquiry –part of the national MECA agreement in return for dropping mandated ratios from the negotiating table – gets underway.


Safe Staffing Healthy Workplace Unit set up as joint NZNO/DHB initiative to implement 2006 SSHW Inquiry recommendations


Three demonstration sites set up for SSHW Unit’s Care Capacity Demand Management (CCDM) tools but only one, Bay of Plenty DHB, progresses


CCDM rolled out to three more DHBs while work continues on evolving the CCDM tools


Independent CCDM evaluation report gives the safe staffing initiative a firm thumbs-up but DHBs’ implementation rate a thumbs down with only 19 of 85 potential wards implementing recommended changes.

NZNO DHB nurses vote to accept a backdated 2 per cent raise in 2015 and a 2 per cent pay rise in 2016.

DHBs “reaffirm” their commitment to implementing Care Capacity Demand Management system including ‘timely’ response when data shows need to adjust staffing levels

June 2017  

NZNO/DHB MECA talks get underway. Only 14 DHBs are underway with implementing CCDM and only one has fully implemented the tools to ensure safe staffing levels on all wards.

Dec 2017    

DHB NZNO nurses vote to reject DHBs’ pay offer

Jan-Feb 2018

Mediation leads to new offer going to the vote with voting closing on March 23

Mar 27  

Outcome of ballot known – if deal rejected strike ballot is likely


*CCDM three core components

  1. Mix and Match Staffing(i.e. using patient acuity data analysis to calculate the safe FTE base staffing required for a ward or unit to meet patient demand patterns)
  2. Variance Response Management(i.e. capacity at a glance screen (CAG) and ‘traffic light’ system to alert when ward is in immediate need and systems of how to respond)
  3. Core data set(Using high-quality data to review and respond to safe staffing needs)


CCDM DHBs (at various stages of implementation)

  • Bay of Plenty
  • Northland
  • MidCentral
  • Nelson
  • Tairawhiti
  • Taranaki
  • Southern
  • Waitemata
  • Hutt Valley
  • Whanganui
  • South Canterbury
  • Auckland
  • Hawke’s Bay
  • Capital & Coast

Have validated patient acuity software and starting to implement CCDM

  • Wairarapa
  • West Coast  (starting when shift to new hospital)

Implementing validated patient acuity software

  • Lakes

Developed business case for validated patient acuity software

  • Canterbury
  • Counties Manukau

Progressing validation of another patient acuity system

  • Waikato


  1. Thankyou for this very comprehensive outline. It must be very frustrating trying to provide quality care within a supply limitation. I am an ancient retired nurse and I follow what’s happening in the provision of care environment with interest. Seems like the difficulties experienced over time do not change to any great extent. I won’t bore you with “in my time’ type comments but wish you all well in your endeavors and keep on reinforcing the need for nurses voices to be heard.


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