Providing maternal and child care with scarce resources

Reports from the GNU meeting by NZNO president Grant Brookes

Delegates to the Global Nurses United (GNU) meeting in the Dominican Republic visited San Lorenzo De Los Mina, a hospital in a deprived suburb of the capital, Santo Domingo. There we talked with nursing and medical staff. 

Established in 1974, San Lorenzo provides advanced maternity and child health care through a range of secondary and tertiary services, with limited limited financial and human resources. 

The hospital specialises in the treatment of foetal alcohol spectrum disorder and maternal HIV transmission. Nurse-led programmes include post-discharge follow-up care for teenage mothers. 

The Dominican Republic is an indebted, middle-income country with a population of 10 million and a two tier, public/private health system. 

Last year, the government spent 2.2 percent of gross domestic product (GDP) on debt repayments and just 1.8 percent of GDP on public health services. There are only three nurses per 10,000 population, compared with more than a hundred for every 10,000 people in New Zealand. 

The Dominican nurses union, which hosted the GNU meeting, is campaigning to raise health spending to five percent of GDP. 

Despite the scarce health resources, the Republic’s public hospitals also provide healthcare to people visiting from its more impoverished neighbour, Haiti. 

First published in Kai Tiaki Nursing New Zealand, September 2019. Reposted with permission. 

Related coverage:

‘Building global ties’

‘Nurse/patient ratios under the spotlight at GNU’

Nurse/patient ratios under the spotlight at GNU

Reports from the GNU meeting by NZNO president Grant Brookes

Campaigns for minimum, mandated nurse-to-patient ratios were a key focus at July’s Global Nurses United meeting. 

Encouraging progress was reported in Canadian provinces and in central and eastern parts of the United States. 

California Nurses Association president Malinda Markowitz, who also conveyed a message on behalf of the Queensland Nurses and Midwives Union, explained that California is currently the only American state with legislated staffing ratios in its hospitals. 

“These vary by unit from 1:2 in ICU to 1:5 in med/surg wards. Violations are subject to civil penalties. 

“The ratio is the minimum. There must be improved staffing based on patient acuity. 

“The road to victory wasn’t easy”, she said. “Nurses organised rallies, protests and flexed their political muscle. One of the largest studies on nurse:patient ratios found that if the California law was implemented nationally, it would literally save tens of thousands of lives.”

In 2016 Queensland became the second Australian state after Victoria to implement ratios. “An exciting study by researchers at Queensland University of Technology confirms what nurses know to be true – more nurses save lives, save money and improve the work life of nurses. 

“These victories add fuel to the fire in the global fight for safe staffing. Nurses united will never be defeated,” Markowitz said. 

First published in Kai Tiaki Nursing New Zealand, September 2019. Reposted with permission. 

Related coverage:

‘Building global ties’

‘Providing maternal and child care with scarce resources’


Building global ties

Reports from the GNU meeting by NZNO president Grant Brookes

Nursing union leaders from around the world came together in the Caribbean in July for the annual meeting of Global Nurses United (GNU)

Founded in 2013 by representatives of 14 nursing unions, GNU now spans 27 countries. This year’s meeting meeting, attended by representatives from 19 countries, was hosted by the Dominican National Union of Nursing Workers, with the assistance from the United States’ (US) largest union for RNs, National Nurses United (NNU). 

Hosting this year’s GNU meeting was the Dominican National Union of Nursing Workers, known by its Spanish acronym SINATRAE.

Attending on behalf of NZNO were kaiwhakahaere Kerri Nuku and I, with Te Poari member Tina Konia also attending as a self-funded observer. 

Addressing the opening ceremony, NNU executive director Bonnie Castillo said that when nurses stand together in one hospital, they could hold their bosses accountable. 

‘Guardians of humanity’

National Nurses United executive director Bonnie Castillo addressed the opening ceremony, alongside SINATRAE general secretary Julio Cesar Garcia Cruceta.

“When we stand together in one city, one province or state, or one country, we can advocate for patient and nurse safety on a larger scale and with greater power. So it is incredible that nurses are building our solidarity to the highest level and strengthening our ties globally. I look around today, and I see advocates for the health and safety of everyday people. I see the guardians of humanity.”

The struggle for union rights in an age of authoritarian Right Wing government topped the meeting agenda. A spokesman for Guatemala’s National Union of Health Workers, Luis Alpirez Guzmán spoke about the international campaign to secure his release, supported by NZNO, after eleven of the union’s leaders were arrested in January. 

Filipino Nurses United general secretary Jocelyn Andamo reported that police agents had come to her offices and interrogated staff. A letter calling for an end to the attacks and signed by GNU affiliates, including NZNO, was later sent to Philippines president Rodrigo Duterte. 

But there were also success stories. Formed in 2011, India’s United Nurses Association (UNA) has now has 550,000 members. 

It has members in 23 overseas countries, including New Zealand, where they would be encouraged to join NZNO, UNA president Rince Joseph said. 

Speakers from NNU and the Canadian Federation of Nurses Unions shared their successful campaigns for stronger legal protections from workplace violence. We were all encouraged to lobby our governments to ratify and abide by the new Convention Concerning the Elimination of Violence and Harassment in the World of Work adopted by the International Labour Organisation this year. 

Other items on the agenda concerned safe staffing, universal health coverage, public health and the environment, disaster relief and retirement security. 

The environmental discussion focused on union campaigns for people’s access to clean water and to prevent and mitigate the effects of climate change. 

Underscoring our common cause, Maria Estela of Costa Rica’s National Association of Nursing Professionals spoke of the “creeping control” of water sources and the erosion of indigenous rights by multinational companies. “They’re bottling our water to sell it back to us”, she said. 

Kerri Nuku spoke on NZNO’s campaigns for health equity for Māori communities and pay equity for Māori nurses working for Māori and iwi health providers. 

NNU co-president Cathy Kennedy showed that disaster relief didn’t always happen overseas. This year, NNU members had provided humanitarian assistance to children and migrant families detained at the US-Mexico border. 

On behalf of NZNO, I thanked NNU for demonstrating the moral heart of nursing. This was also demonstrated by New Zealand nurses, along with other workers, who rallied outside the US embassy in Wellington in July, calling for an end to the inhumane treatment of children. 

The meeting concluded by passing a resolution supporting climate and immigrant justice

First published in Kai Tiaki Nursing New Zealand, September 2019. Reposted with permission.

Related coverage:

‘Nurse/patient ratios under the spotlight at GNU’

‘Providing maternal and child care with scarce resources’

Global nurses unite in Québec

At last December’s biennial meeting of Global Nurses United, NZNO leaders were able to bring some unique perspectives and gain fresh insights.

By NZNO president Grant Brookes

Nursing union leaders from 18 countries, representing more than one million nurses and health-care workers, gathered in Québec, Canada, in December for the biennial meeting of the Global Nurses United (GNU) executive committee.

GNU Executive Committee, 1.12.17
GNU Executive Committee meeting, Québec, 1 December 2017 (Photo: Linda Silas)

As a new GNU affiliate, NZNO was taking part for the first time, represented by kaiwhakahaere Kerri Nuku and myself. There we helped plan internationally-coordinated actions for 2018 and contributed a New Zealand perspective on global nursing and union debates.

We were also able to gain fresh insights into some of the issues facing NZNO, such as the need to grow advanced nursing practice in primary health and how to strengthen union democracy in an age of electronic voting (see articles, p29; listed below under “Related coverage“).

Collective bargaining discussed

The GNU meeting opened with a discussion on nurses’ rights to organise and bargain collectively. Although changes to the Employment Relations Act under our previous government have temporarily threatened multi-employer collective agreement (MECA) bargaining, some nursing unions in Asia, Africa and Latin America face bigger challenges.

The discussion in Québec laid the basis for a subsequent GNU joint approach to the government in Honduras, signed by NZNO.

Along with the Australian Nursing and Midwifery Federation, we highlighted the health impacts of climate change in the Pacific. The GNU meeting adopted a consensus statement on “Global Nurses Leadership for Climate Justice”.

Next, we received an expert briefing from the Canadian Federation of Nurses’ Unions on the current state of trade negotiations, including those for the Trans-Pacific Partnership Agreement (now known as the “TPP-11”, or “Comprehensive and Progressive TPP”).

The original TPPA was vigorously opposed by NZNO. Strong Canadian opposition to the TPP-11 has ensured some of its harmful provisions have been suspended.

Actions against violence

The two final agenda items – on workplace violence and safe staffing – included proposals for action. The GNU meeting voted for global actions against violence towards nurses to be held on International Women’s Day (March 8), and for a week of action in May in support of safe staffing.

The NZNO board of directors later approved these two campaigns in principle, subject to operational contingencies.

Coinciding with the convention of the local nurses’ union, the Fédération Interprofessionelle de la Santé du Québec (FIQ Santé), five GNU affiliates were also invited to take part in a panel discussion. NZNO was among them. Our topic was how government policies affect the care union members provide, and what struggles we face.

NZNO’s bicultural framework

I explained to the 1000 convention delegates that all NZNO struggles are framed by bicultural relationships – highlighting struggles for the restoration of health funding, for safe staffing, new graduate employment, fair employment laws and for a health workforce that is culturally, ethnically and gender-representative, and that enacts Treaty of Waitangi articles.

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NZNO co-leaders Kerri Nuku (left) and Grant Brookes (right) took part in an international panel at the FIQ Santé convention.

On the TPP, Nuku said: “We will ensure no international agreements compromise New Zealand’s ability to control and lower the prices of pharmaceuticals and other medical supplies: to carry out public health programmes or maintain and expand the public funding and public provision of health on a non-commercial basis.”

Her description of NZNO’s 10-year battle for pay parity for nurses working in Māori and iwi health providers touched a nerve. Canada has embarked on its own truth and reconciliation process to address historic injustices suffered by indigenous people. After the panel discussion, nurses came up to Nuku to share stories about inequities experienced by indigenous health services on First Nations reserves.

The full text of our joint presentation is at https://nznogrant.org/2017/12/13/struggles-we-must-face-joint-nzno-presentation-on-the-global-nurses-united-international-panel-quebec-city/. •

 

Related coverage:

‘No fees at nurse-run service’

‘Do online votes aid union democracy?’

(First published as “NZNO brings its views to the world stage” in Kai Tiaki Nursing New Zealand, February 2018. Reposted with permission). 

No fees at nurse-run service

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Grant Brookes and Kerri Nuku were hosted by (from left) Coop SABSA coordinator Amélie Bédard, nurse practitioner Isabelle Têtu and registered nurse Maureen Guthrie.

By NZNO president Grant Brookes

Québec City, the venue for the GNU meeting (see Related coverage, below), is also home to Coopérative de Solidarité SABSA, a small, innovative primary health care (PHC) service with a growing reputation. When the nurses at Coop SABSA offered to give up their weekly staff meeting to show us around, Nuku and I eagerly accepted.

Established initially as a voluntary organisation in 2011, Coop SABSA is unique. Unlike other PHC services in Québec, the cooperative is a nurse-run, not-for-profit organisation that doesn’t charge consultation fees.

Canada is usually thought of as a country with universal health coverage. Canadian citizens, permanent residents and some temporary migrants are eligible for free health care (with certain exceptions) by presenting their health card.

For GP consultations, most doctors charge a fee for service. The card, however, ensures reimbursement under a public Medicare insurance scheme.

But among vulnerable populations, some do not have a health card. SABSA nurse Maureen Guthrie estimated the proportion of the population denied access to PHC as a result could be as high as 10 per cent. It’s this group, living in downtown Québec, who are cared for by her team.

The service has six staff and sees around 300 patients a month – either by appointment, at a walk-in clinic or through home visits.

Much of the care involves long-term conditions management of non-communicable diseases or HIV-related conditions. There are regular clinics provided by a visiting psychiatrist and other specialists.

Two GPs are available on-call, but most of the prescribing is done by nurse practitioner Isabelle Têtu. Less than five per cent of consultations result in an onward referral to a doctor.

“If we did a survey of emergency rooms around here,” said Guthrie, “they would tell us there’s been a drop in presentations since we opened.”

Initial support to establish Coop SABSA came from the nurses’ union, FIQ Santé, which contributed C$300,000 in seed funding over two years. Today, one salary is paid by the government and the team receives small grants from pharmaceutical companies and donations from local GPs, but fundraising is an ongoing issue.

“Nurses need to take their place professionally,” said Guthrie. “It wasn’t easy at the beginning, but we just ignored what people said, because we knew we were doing it for the patients. Nurses have to trust themselves that they can do it.” •

 

Related coverage:

Global nurses unite in Québec

Do online votes aid union democracy?

(First published in Kai Tiaki Nursing New Zealand, February 2018. Reposted with permission) 

Do online votes aid union democracy?

Union Democracy and Electronic Vote

One of the FIQ Santé convention workshops Nuku and I attended was on a topical issue for NZNO members – Union democracy in the age of electronic voting.

NZNO has limited experience with online voting. It’s been used to elect board members since 2011. Turnout in these elections hasn’t topped 14 per cent. In 2012, 11.92 per cent of members voted in the online referendum on adopting the NZNO constitution.

A one-off, localised trial during multi-employer collective agreement bargaining in 2011 saw just 6.64 per cent of members at Capital & Coast DHB vote electronically to endorse the negotiating team and the claims – well below the national average.

Such limited experience meant the FIQ Santé workshop was valuable.

The facilitator defined union democracy as: “The opportunity for any member of a trade union to develop informed opinions on the objectives of their organisation and on the means to achieve them, on the one hand, and the opportunity to express these opinions in such a way that the union is governed by the majority of these opinions expressed, on the other hand.”

This requires a formal framework of power for the union’s administration, the ability for members to influence decisions, cohesion among members and transparency and responsiveness from administrators.

FIQ Santé research has found electronic voting can lift turnout in elections, as long as members know the candidates and the voting process.

In bargaining, meanwhile, the research found the participation rate was only slightly higher for the electronic vote.

Potential disadvantages with electronic voting were also identified – possible weakening of collectivity, confidentiality issues, increased cost and difficulties maintaining up-to-date email addresses.

The workshop concluded that while electronic voting can be considered a democratic tool, it does not replace the democratic process.

Opportunities will be sought to present the full findings to NZNO staff, to help inform future planning. •

 

Related coverage:

Global nurses unite in Québec’

No fees at nurse-run service

(First published in Kai Tiaki Nursing New Zealand, February 2018. Reposted with permisison).

‘Struggles we must face’ – Joint NZNO presentation on the Global Nurses United international panel, Québec City

Kaiwhakahaere Kerri Nuku and I represented NZNO at meetings in Québec from 27 November – 1 December. We attended a meeting of the Executive Committee of Global Nurses United, and spoke on an international panel hosted by the Québec nurses’ union, FIQ Santé. I spoke first, followed by Kerri, on the topic: “How do your government’s policies affect the care that your members provide and what struggles must you face? What will be your battles over the next few years?” Financial support from FIQ Santé, which enabled our attendance, is greatly appreciated. 


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Kia ora, koutou.

Greetings, to you all.

It is customary in our young country, when beginning a formal speech at a meeting, to start with an introduction which acknowledges one’s connection to the natural and spiritual world of your birthplace, to a shared experience of migration and to a collective identity based on ancestry. This custom has been adopted from the indigenous culture of the Māori, the tāngata whenua or people of the land.

Nō reira, ko wai ahau?

Ko Kapukataumahaka tōku maunga

Ko Owheo tōku awa

Ko Cornwall tōku waka

Ko te Tāngata Tiriti tōku iwi

Ko Grant Brookes taku ingoa, ā, ko te perehitene ahau ō te Tōpūtanga Tapuhi Kaitaiki ō Aotearoa.

To translate: The sacred mountain overlooking my birthplace is Kapukataumahaka, and the sacred river is Ōwheo. My ancestors arrived on board the ship, Cornwall. My tribe is known as the People of the Treaty, which means I am not indigenous. I reside on the land by right of the 177-year old Treaty of Waitangi between the Māori peoples and the British Crown. My name is Grant Brookes and I am the co-president of the New Zealand Nurses Organisation.

It is then customary to pay respects to the tribe on whose land we are meeting. So I would like to acknowledge that the land on which we gather is the traditional and unceded territory of the Abenaki and Wabenaki Confederacy and the Maliseet.

This biculturalism – embracing the twin perspectives of the of the indigenous and non-indigenous peoples – is today reflected (to a greater or lesser extent) across New Zealand’s health sector. And it is embedded in the structures of our union, as reflected in the two co-presidents you see before you.

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It hasn’t always been customary for non-indigenous people to start speeches this way. New Zealand is a colonial settler society. After signing the Treaty of Waitangi in 1840, the British Crown and colonists proceeded to ignore it. Māori land, cultural treasures and authority were alienated over following decades through military force and other means. Respect for Māori customs is being restored today through reconciliation for these Treaty breaches.

The initial health impacts of colonisation were devastating. A pre-contact Māori population of up to 150,000 was reduced to 42,000 in little over a century. Our other co-president, Kerri Nuku, will speak shortly about our union’s current battles to improve Māori health status and about government policies affecting the care that our Māori members provide.

Before I turn to the set questions, I would like to briefly explain the structure of the New Zealand health system.

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Since 1938, the system has been organised around a core of “socialised medicine”, which resembles the UK National Health Service. The government owns and funds most inpatient and outpatient hospital services, including mental health facilities, and all emergency, intensive care and preventive health services.

Care rationing and waiting lists for non-urgent procedures have become a feature in recent decades, leading to a small private health insurance market. During the period of neoliberal ascendancy in the 1980s and 90s, parts of the public health system – such as elder care and some disability support services – were privatised.

General Practice was excluded from the state-owned system at the outset, and it has largely remained a private business ever since – along with dentistry. Government subsidies, however, fully fund free access for children and part-fund GP visits for adults. Prescription drugs are also subsidised.

Total health spending is 9 percent of GDP. Public spending, generated through general taxes, accounts for 80 percent of this total (Mossialos et. al., 2017).

From this overview it can be seen that government is the ultimate employer of the majority our members and that government policies greatly affect the care that all our members provide.

Two months ago, the New Zealand general election delivered a change of government. Many of the policies of the former conservative government are being reversed. In some cases, where the new Labour-led coalition government has pledged to adopt our policy priorities, we may face struggles to ensure they deliver on their promises in a timely fashion.

Current rapid change means it is difficult to see what our battles may be over the next few years. So I will briefly mention five of the immediate priorities we have raised with the new government.

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1. Reinstate health funding to levels able to provide the same quality and quantity of health services for our population as at 2009/2010.

Under the previous conservative administration which took office at the end of 2008, government health funding failed to keep pace with population growth and inflation, leading to a cumulative funding shortfall of $1.4 billion. Effectively a 9% cut in operational funding over 8 years, this has meant that our members have been providing care to more people with no corresponding increase in workforce size. The new government has pledged to restore funding. We will battle to make this happen sooner, rather than later.

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2. Ensure safe staffing levels and workloads throughout… all health care services

Nurses comprise half of New Zealand’s health workforce. As the largest single group, our members have borne the brunt of the funding cuts of the last 8 years. Unsafe staffing levels, unmanageable workloads and long hours have become the norm in the care our members provide.

We have collaborated in developing a unique local model to ensure safe staffing levels, called Care Capacity Demand Management, as an alternative to legislated ratios used overseas. CCDM relies on a tripartite approach to calculate and adjust staffing levels in the public health system based on patient acuity. Our big battle now is to get this model implemented.

In privatised sectors such as aged care, where a tripartite approach cannot be guaranteed, we will push for mandatory standards for minimum safe staffing levels and skill mix in residential facilities.

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3. Full employment for all new nursing graduates

Research shows that employment experience in the first few years post-graduation is a critical factor in retaining nurses in the profession long-term. The New Zealand health system offers a supported Nurse Entry to Practice programmes (NEtP), with enhanced mentoring and educational opportunities. Last year, however, only 62 percent of nursing graduates secured NEtP positions. Many of the others were reduced to voluntary, part time or casual jobs ie. precarious work. We will battle for a NEtP place for every new grad.

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4. Fair employment laws

The previous government amended New Zealand’s industrial relations law seven times in 9 years – each time reducing union rights and workers’ rights.

These changes have reinforced structural barriers to fair and balanced employment relationships that, in the rapidly changing labour market, have led to increased job insecurity and persistent low growth in wages, despite growing productivity.

The struggle we will wage, along with the other affiliates of the New Zealand Council of Trade Unions, is not only to roll back these changes – which the new government has agreed to – but to strengthen the pre-existing framework.

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5. Health workforce planning

It is projected that half of all nurses will retire over the next 10 to 15 years. An improvement to long term workforce planning is urgently needed to meet projected shortages and to ensure that the workforce is culturally, ethnically and gender representative, enacts Treaty of Waitangi articles, and meets international obligations for ethical recruitment and self-sustainability.

I will now hand over to Kerri to speak more about our struggle for workforce planning – especially to ensure that it is culturally representative of the population.

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There are many workforce issues due to funding constraints and I want to focus on one specific area, identify the impact funding constraints has on community and our responsibility as advocates and finally trade agreements

1. Pay inequities

Significant pay disparities of up to approximately 25% exist for nurses working with Primary Health Organisations, especially with Indigenous Health Care services. These disparities occur even in cases where staff have professional qualifications and affect the workforce predominately working within Indigenous service providers who are predominately female.

Pay disparities seem to be the unintended consequence of how the government funds healthcare, which fails to address the differences in infrastructure and investment required specifically within indigenous healthcare service providers versus other larger health providers. This issue affects an indigenous workforce.

These entrenched pay inequities are now affecting the retention and recruitment of nurses in these areas. We will continue to lobby within Aotearoa New Zealand government and raise a complaint to the interventions to the Human Rights Commission and United Nations in New York and challenged the application of our government to ILO Conventions 169 and 149.

2. Community impact

Health funding is imperative to ensure that the we are responsive to the changes in population health needs. Our population (like others) is constantly in a time of change demographics, health demand. However what we have seen is the opposite that is systemic barriers to access health services, escalating social, economic and health disparities has seen an increase in poverty, homelessness and over the years we have seen the emergence of diseases of poverty.

As a union we must ensure that health is central to all government policies and that these policies are integrated to address the global challenges of climate changes antimicrobial resistance and unfair work, trade and immigration patterns.

3. Trade agreements

Achieving the UN Sustainable Development Goals, including reducing inequality within and between countries, requires international trade and economic integration agreements to be free of provisions that have the potential to erode government’s rights to act in the best interest of the population and environmental health.

In Aotearoa we promote a coherent system of global health law to further multilateral cooperation in advancing global health equity, by developing and implementing strategies to achieve the sustainability development goals.

We will ensure that no international agreements compromise New Zealand’s ability to control and lower the prices of pharmaceuticals and other medical supplies: to carry out public health programme or maintain and expand the public funding and public provision of health on a non-commercial basis.

To conclude, we cannot estimate that nursing is in a crisis, nurses are overworked and under respected and appreciated. Health is a human right and not a privilege and we have an important role to play in advocacy for our populations. Our challenge as a union is to progress policies, while bringing along the public, to keep alert to the changes in the environment, remain relevant and ensure as a union we continue to engage and grow members in solidarity. Be brave and courageous to take action.

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