‘Health For All means Health For Nurses, too’ – Speech to NZNO Greater Wellington Regional Convention

These notes of a presentation to NZNO Greater Wellington Regional Convention on 30 April 2019 were amended on 4 June 2019, to clarify the current position of CCDM implementation at Hutt Valley DHB. I wish to apologise that I did not make this sufficiently clear at the Convention.

Photo courtesy of Shammi Kumar.

E ngā reo, e ngā mana, e ngā karangarangatanga maha o te rohe – tēnā koutou. 

Ka tū ahau ki te tautoko i te karakia timatanga. Ka mihi anō ki ngā maunga, ngā awa me ngā wāhi tapu o te mana whenua. 

E ngā mate, haere, haere, haere. Rātou te hunga mate ki a rātou. Tātou te hunga ora e huihui mai nei, tēnā tātou. 

E te tiamana, ko Rerehau, me te mangai-ā-rohe o Te Rūnanga o Aotearoa NZNO, ko Lizzy, tēnā kōrua. Kei te whakawhetai ahau ki a kōrua mō tā kōrua pōwhiri. 

E te rangatira kua hoki mai nō tāwhiti, tēnā koe Kerri. E ngā kaimahi, me ngā kaiārahi nēhi e huihui nei, tēnā koutou. 

Ko wai ahau? 

Ko Kapukataumahaka te maunga. Ko Ōwheo te awa. Ko Cornwall te waka. Nō Ōtepoti ahau, engari kei te noho ināianei ki Pōneke. Ko Don rāua ko Helen ōku mātua. Ko Tangata Tiriti tōku iwi. Ko Grant Brookes tōku ingoa.

Ka maumahara ahau ki tēnei whakataukī i tēnei wā: “Te Amorangi ki mua, te hapai o ki muri”. 

Nō reira, tēnā koutou, tēnā koutou, tēnā koutou katoa. 

——

To the authorities, the voices, all the many alliances and affiliations of this region, greetings.

I stand to support the greetings to the Creator, to whom belong all things. I also acknowledge the mountains, rivers and sacred areas of the indigenous people with authority over this place. 

I greet those who have passed on, and the living gathered here. 

To the Chair, Rerehau, and the Rūnanga rep, Lizzy, thank you for your invitation. 

To the chief returned from afar, greetings to you Kerri. For those who may be unaware, Kerri is just back from New York where she addressed the UN Permanent Forum on Indigenous Issues and is due to arrive at this Convention very soon. 

To the staff and all the nursing leaders gathered here (which is all of you), greetings. 

Who am I? 

Although I now live in Wellington, I hail originally from Dunedin. I grew up at the foot of Mt Cargill and by the Water of Leith. 

My ancestors arrived in Dunedin on board the ship Cornwall in 1849. The son of Don and Helen, my name is Grant Brookes.

For reasons I will soon explain, at this time I recall the saying: “The leader at the front and the workers behind the scenes”.  

So greetings, greetings, greetings to you all. 

So many old familiar faces. It’s wonderful to be back here with you again. 

——

The theme of today’s convention is the one set by the International Council of Nurses (ICN) for the upcoming International Nurses Day on the twelfth of May. “Nurses: A voice to lead – Health for all”. 

In keeping with this theme, the topic I’ve been asked to speak on is the following (it’s a long one!):

“Nurses, HCAs and Midwives face a number of issues on the shop floor on a daily basis, while working for the health of New Zealand… we ask that you speak with the aim of motivating and inspiring our members to harness/channel their momentum, energy and input into health for us as members. 

In doing so, please include information on anticipated changes off the back of the MECA, a summary of the current campaigns, how the various health sectors can communicate with and support each other with these campaigns, and any plans around the organiser structure to support this.”

It was this suggested topic that made me think of the whakataukī, “Te Amorangi ki mua, te hapai o ki muri”. Literally, “The leader at the front and the workers behind the scenes”, this saying expresses the general idea that everyone is of equal importance. 

Or as former Minister of Māori Affairs Te Ururoa Flavell has explained, the late Wiremu Tawhai “provides a far richer meaning [for this whakataukī] which is expressed in terms of sustainability and survival. He suggests the mana of the whole group is dependent on the support and guidance provided by ‘te hapai o’.”

It occurs to me that the same is true for health and wellbeing. The health of the whole group is dependent on the health of those who do the work of delivering healthcare. So when we talk about “health for all”, we must consider health for us. 

As ICN President Annette Kennedy put it last year: 

“All over the world, there are individuals and communities who are suffering from illness due to a lack of accessible and affordable health care. But we must also remember that the right to health applies to nurses as well! We know that improved quality and safety for patients depends on positive working environments for staff. That means the right to a safe working environment, adequate remuneration, and access to resources, and education. We must add to this the right to be heard and have a voice in decision making and policy development implementation!”

I have opted today to talk in detail about a handful of key developments, rather than offer a broad brush overview. If you miss any of the facts and figures in my talk and want to find them later, my speech notes will be available on my blog at nznogrant.org. 

So firstly, what can we anticipate off the back of the DHB MECA? 

‘Immediate relief’?

When the collective agreement was ratified in August last year, it came with $38 million in extra funding from the Ministry of Health for “immediate relief on staffing and workloads” and a promise of “500 extra nurses”. Without this movement on positive working environments in DHBs, this access to resources, then improved quality and safety for patients will be very hard to achieve. 

Eight months on, where are we at? 

According to the latest update issued by the Ministry of Health, as at 13 March, 222 FTE registered and enrolled nurses, 19 FTE midwives and 42 FTE Health Care Assistants have been employed as a result of the additional $38 million.

“A further 118.04 FTE are… in recruitment processes… Some DHBs have recruited all their allocated FTE, others have recruited most of it and some have asked to defer a portion of their funding to the 2019/20 financial year.”

So about half the extra nurses promised “immediately” have been employed, with job ads out for a further quarter. Although all DHBs got their share of the extra funding last year, some of them don’t want to (or can’t) spend it all on employing extra staff – or at least, not this year. 

In summary, off the back of the DHB MECA we can anticipate what I predicted in Kai Tiaki last December: “It will take more struggle to clear away all the dark clouds over our public health system – and the deeper chill still lying across the rest of the sector”. 

To get what we’ve been promised by employers, we’re going to have to hold their feet to the fire. This struggle will require a whole-of-organisation effort. But crucially, the struggle will now take place under conditions which are more favourable than before the DHB MECA settlement. 

This is a theme that will run through the remainder of my talk. 

Safe Staffing Accord 

Also off the back of the DHB MECA, of course, was the Safe Staffing Accord between the Ministry of Health, NZNO and the DHBs. The Accord contains three commitments. The first of these is the one where we may anticipate the biggest and fastest progress. It says the parties will “explore options for providing employment for all nursing and midwifery graduates…” 

The latest available report on the Advanced Choice of Employment Nursing intake, dated November 2018, shows that 85.7 percent of the 468 mid-year applicants received a place in the Nurse Entry to Practice (NETP) or Nurse Entry to Specialist Practice (NESP) programmes.

This compares with a new grad employment rate of 54.6 percent in 2016 and 64.8 percent in 2015. 

Preliminary data for the 2018 end-of-year intake show that as of January 2019, 71.3 percent of the 1,253 applicants had been placed. This number will rise when the final report is released in July. 

CCDM

The second commitment in the Safe Staffing Accord links directly to the Terms of Settlement for the DHB MECA – to “develop any accountability mechanisms the Parties believe are necessary (over and above those already agreed) to ensure DHBs implement the additional staffing needs identified by CCDM within the agreed timeframe” of 30 June 2021. 

Hand on heart, I cannot say I expect all DHBs to achieve this, if left to their own devices. I base this on some information which I’m not at liberty to share but also on past experience, which will be very well known to some of you here today. 

Hutt Valley DHB commenced implementation of CCDM back in 2013. In March 2014, Board meeting minutes record that “The Coronary Care Unit was selected as the Pilot Ward for Part 1 of the CCDM Programme… There was excellent buy-in to and engagement with this from all staff; nurses, doctors, allied health, clerical and health care assistant staff. The data is still being entered and then will be analysed.”

By January 2015, staffing methodology (which at that time was called the “Part 2 mix and match calculation”) had been completed for three inpatient areas, setting their base nursing FTE requirements, and was under way in a fourth ward as well. 

But then, after changes in the Executive Leadership Team during 2015, a full external review of CCDM was commissioned by the DHB (see this link). The FTE calculations, which had showed that extra nursing staff were needed, got shelved. 

“Recalling this history is not to make any comment about HVDHB now. HVDHB is in fact well on track to have CCDM fully implemented by June 2021, with support from across the DHB and Board and an excellent relationship with NZNO and the Safe Staffing Healthy Workplaces Unit. Rather, it is to remind us what to look out for elsewhere, and what we need to do to help make sure all DHBs follow through on their CCDM commitments.”

So I anticipate that winning increases in baseline staffing off the back of the MECA is another change that will require a whole-of-organisation effort – from nurses on the floor entering their Trendcare data, to delegates pressing for oversight through local data councils for their ward. Delegates must blow the whistle, for instance, on any manager who alters Trendcare data after it’s been actualised. And they must have paid release time to do this and other CCDM work. 

Organisers, Professional Nurse Advisors and senior delegates on the DHB’s CCDM council must demand adherence to the programme and to timelines. FTE calculations must be accurate and acted upon, even if it means cost increases. And people like me and Hilary Graham-Smith must ensure DHB accountability through the Safe Staffing Unit Governance Group, while Chief Executive Memo Musa does the same there and in the Health Sector Relationship Agreement Steering Group and the Safe Staffing Accord Operational Group. 

The pace and scale of implementation means I expect workloads to increase over the next two years. But again, we’ll be working under conditions more favourable than before. At last, there is a deadline for CCDM implementation. The Minister of Health himself has requested regular progress reports. 

Pay equity 

The final development off the back of the DHB MECA which I’ll discuss is pay equity. 

NZNO raised a pay equity claim as part of the MECA negotiations. DHBs acknowledged that nursing has been undervalued. A pay equity process with an implementation date of 31 December 2019 was agreed.

Soon, expressions of interest will be sought from NZNO delegates at the DHBs chosen to participate in the assessment process. 

After that, claimant (our) data will be gathered through interviews with job holders, including senior nurses, registered nurses, public health nurses, nurse practitioners, enrolled nurses karitane nurses, obstetric nurses and health care assistants including psychiatric assistants. This part of the process will take through to late September/October. The pay equity claim for NZNO’s midwifery members will be progressed in a concurrent but separate process. The interviews will be conducted using pay equity assessment tools that have been purposefully developed to be gender-neutral. 

Finally, an NZNO bargaining team will be democratically selected. The union team will use the assessment data and comparisons to negotiate and conclude a pay equity claim. Ratification will happen when an agreed outcome has been identified based on the evidence, between the DHBs and union negotiating team. I expect this work will occur between early November and late December.

At this stage I anticipate that the deadline will be met, but I am also aware that the timeframe for completing the work in time for implementation by 31 December is very tight. 

In Safe Hands 

Regarding current campaigns, and how the various health sectors can support each other, last month saw the launch of what will be NZNO’s flagship campaign for 2019. “In Safe Hands” is calling on the government to review and update the Aged Care Safe Staffing Standards, to set minimum staffing levels based on residents’ needs. 

Stage one of the campaign seeks to sign up NZNO members from all health sectors as activists and asks them to send an initial message to the Government. You can get involved at www.insafehands.co.nz

Without this campaign, I would expect that trends of reducing care hours and increasing workloads – identified in new research from Dr Julie Douglas and Associate Professor Katherine Ravenswood of AUT – are likely to continue across the aged care sector.

Based partly on initial reactions when we raised it with the Minister of Health, I anticipate that achieving the goal of this campaign is going to be hard. But together, with the whole organisation behind us, we can do it. 

PHC MECA

The Primary Health Care Sector is another where we will have to struggle to achieve the ambitious goals around positive working environments, adequate remuneration and health for us as members, within very tight timeframes. 

The Terms of Settlement for the PHC MECA, which was ratified last month, contained an agreement that employers and NZNO will undertake a joint exercise to scope the nature of Health Care Assistant, Nurse Practitioner and Designated RN Prescriber roles within PHC by 31 August 2019. That’s just four months away. 

It also said: “NZNO and NZMA have agreed to jointly lobby government as soon as is possible and no later than April 2019 to increase funding to the sector to enable the sector to be able to recruit and retain nurses and to meet expectations regarding nursing salaries following the DHB settlement”. 

In particular, increased funding will be essential to securing new steps 6 and 7 in the next PHC MECA negotiations, as in the DHB MECA, and any pay equity process that might be agreed in future. I probably needn’t remind you that today is the 30th of April 2019. 

Also within the PHC Sector are Māori and Iwi providers. Here I am optimistic enough to finally predict – after more than a decade of work led by Kerri and Te Rūnanga – movement this year on the issues of inequitable funding models and pay disparities. 

Violence in the workplace 

A second campaign will address one of the six Global Health Challenges highlighted in the ICN Guidance Pack for International Nurses Day: “the effects of violence on health care and all of us”. 

“Violence is an everyday occurrence around the world for health workers”, says ICN. “This includes violent physical, sexual and verbal assault from patients and potentially their families. The issue is so bad that across the world, nursing is considered more dangerous than being a police officer or a prison guard…

“Violence against nurses threatens the delivery of effective care and it violates their human rights. It damages their personal dignity and integrity. It is an assault on the health system itself.”

Health for us as members means freedom from violence at work. To this end, NZNO is producing a “Position statement: Violence and aggression towards nurses”. This will serve as the basis for a campaign. A project team has been established, with leaders drawn from across our organisation. 

Through the Council of Trade Unions, NZNO is also participating in the creation of a new legally enforceable convention on gender-based violence at work under the auspices of the International Labour Organisation.

Organiser structure 

Before I finish, I was also asked to speak about any plans around the organiser structure to support these efforts and campaigns. I take this to mean the structure of the organising work performed and supported by by NZNO staff. 

The annual, weekly and daily planning of this work is an operational matter, under the direction of NZNO management. But I can report on some discussions around resourcing and strategic planning at the Board level. 

First of all, earlier this month the Board of Directors approved business cases to increase the number of NZNO organisers by 2.0 FTE during the current financial year. What does this number mean? 

This represents a 6% increase in the existing organiser workforce of 35.95 FTE. The last increase in the number of organisers was in 2017, when an extra 1.5 FTE was approved. The increase before that was back in 2007. That year, total NZNO membership sat at 39,000. It is now 52,000. A planned review of organiser resource in 2011 was deferred in favour of setting up the Member Support Centre. 

So in the last 12 years, we have seen the establishment of MSC, while the number of members has grown by 33 percent and the number of organisers has been boosted by 10 percent. 

To address this mismatch, and current workload issues such as those arising from rapid nationwide implementation of CCDM (noted previously), the initial business case put to the Board in February this year sought an extra 5.0 FTE for the organiser workforce, plus 1.0 FTE for casual or “relief” organising. 

The Board decision to approve a lower number than six full-time equivalents was based on the need for a break even operating budget. But clearly, there are issues with sustainability and pressures are building. These pressures could be resolved in a number of ways. 

Firstly, business cases declined this year could be funded in the future. Alternatively, the pressures could also be addressed by reorganising the way we work. On a part of the NZNO website you may not have visited, it says:

“Wherever possible, we use the “organising” model which simplistically means, an approach to working with members that empowers them to act in their own interest, with NZNO’s elected leadership and staff on a team basis. This approach is distinctly different from that where a staff or elected member “fixes” things for members.”

“Wherever possible” depends on factors like the number of delegates in a workplace and their skills, confidence, engagement and their resourcing, including the amount of their paid release time, along with the nature of member issues. It also depends on how staff work to empower and educate members. 

Clearly, addressing growing pressures on our organiser structure is not a case of “either/or”. A combination of more staff and changing the way we work is possible. 

This concludes my talk. Thank you for listening. I will be available to answer any questions now and throughout the day. 

Nō reira, tēnā koutou, tēnā koutou, tēnā koutou katoa. 

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