Safe staffing?
Asked if she believes Te Whatu Ora is now completely safely staffed with nurses — contrary to what frontline nurses are saying — Gray says there are still some shortfalls in mental health and addictions.
A revamped version of safe staffing tool care capacity demand management (CCDM) has now rolled out nationally — ahead of the mid-year budget cycle — after its staffing calculations were paused to iron out inconsistencies across 20 regions.
While cautious to discuss CCDM in detail, as safe staffing is a part of NZNO–Te Whatu Ora collective agreement bargaining currently underway, Gray says it’s a key tool and there are no plans to get rid of it. “CCDM’s not going anywhere, and I’m really excited to think about its future direction.”
“The negotiation is around how decisions are made with the FTE [full-time-equivalent staffing] uplifts and I know that’s where the rub has been,” she said.
“There is absolute need for quality improvement around the processes we’ve been using now we are one organisation, and adherence to one SOP [standard operating procedure] around calculating FTE.”
But certain environments — like emergency departments, mental health and addiction units — had different staffing mixes to other inpatient wards CCDM was designed for.
“So we needed to do this [pause] to have assurance that we are calculating what we require in our health services.”
Chief nurse Nadine Gray, (Te Whakatōhea), is surprisingly honest about the challenges of working at Te Whatu Ora.
Having come from Te Aka Whai Ora, where she was also chief nurse before its dissolution last June, she is still mourning the loss of its targeted approach to improving Māori health.
‘We know that what’s required is addressing Māori health need. Although it has probably become more silenced than when we were at Te Aka Whai Ora.’
However, Gray says she won’t stop raising Māori health inequities — despite a Government directive to the public service to take a needs-based, rather than ethnicity-based, approach.
“We know that what’s required is addressing Māori health need. Although it has probably become more silenced than when we were at Te Aka Whai Ora – because that was a once in a generational opportunity,” she told Kaitiaki in a face-to-face interview recently.
“There may never be anything like it again and, from my own challenge of going through that — a grief for something that could have been — you can’t not continue to talk about the kaupapa.”
Māori endure a life expectancy seven years lower than non-Māori, and have higher disease rates across the board including for cancer, diabetes, cardiovascular and asthma.
As chief nurse at Te Whatu Ora, Gray says she remains as driven as ever to improve Māori health. Asked how, given the political brief, she says she will keep the kōrero going.
“I think you talk about it. You raise it. And I’m surrounded by amazing Māori and non-Māori leaders currently who do raise it so I’m in a clinical leadership team where equity matters — although it may be languaged differently around need and addressing need in vulnerable populations.”
‘Te Aka Whai Ora. . . was a once in a generational opportunity — there may never be anything like it again.’
Gray acknowledges, too, the ongoing voice of NZNO-Tōpūtanga Tapuhi Kaitiaki o Aotearoa in “banging the drum” on the need for more Māori nurses. “I couldn’t agree more,” she says.
Nursing DNA
Born into a strong nursing family in Ōpōtiki, Gray started her nursing career in aged care — as she noted last year when hundreds of new nursing graduates missed out on hospital jobs.
She went on to work in different specialties, such as medicine and neurosurgery, before finding her “clinical home” in emergency nursing.
Married to a military man, she’s moved around a lot over the years, working at emergency departments (EDs) around the country including Auckland and Hutt Valley. She’s been a duty nurse manager, patient flow coordinator and worked in community urgent care before moving into specialist cancer care for Māori.
“What led me there, [is that] I wanted to give back because I cared for my mother who passed away from cancer.”
Her mother was Janet Maloney-Moni, the country’s first Māori nurse practitioner (NP) and trailblazer in primary care advanced practice, who died in 2014 at just 62.
“Unfortunately she got cancer and it was very rapid so I basically left Wellington overnight and cared for her till she passed away,” Gray says.
“So when that [cancer] role came available, it just really appealed to me in terms of improving outcomes for Māori in cancer care.”
Gray says her desire to tackle Māori inequities hasn’t waned.
‘It doesn’t waver my drive for ensuring that we improve outcomes for Māori, within the sphere of control and influence that we have.’
“I think because I could channel that empathy, having known what could have been different within my own whānau – not just mum but we’ve had cancers in my whānau. So I think there’s a driver.”
Cancer is an area of particular inequity — Māori are 20 per cent more likely to get cancer and twice as likely to die from it.
So being a nurse leader in an organisation instructed not to recognise evidence-based ethnic population health statistics — especially when the inequities affect her and her whānau personally — she acknowledges is a challenge.
“It doesn’t waver my drive for ensuring that we improve outcomes for Māori, within the sphere of control and influence that we have,” she said. “Because it is never going to go away. The kaupapa actually endures no matter whether I’m on the frontline of clinical practice or whether I’m in the bureaucratic arm of health.”
From a whānau of Ōpōtiki Māori nurse leaders — past president of Te Kaunihera o ngā Neehi Māori (National Council of Māori Nurses) Hemaima Hughes is her aunt — Gray trained at the Waikato Institute of Technology (Wintec). She went on to do a Masters of Health Science at University of Auckland, where she researched the importance of mātauranga Māori in for students at Te Whare Wānanga O Awanuiārangi. That work that led her to Manatū Haoura (Ministry of Health) as clinical chief advisor. She then became principal advisor nursing at Te Aka Whai Ora / Māori Health Authority in 2022, before taking up her current role in mid-2024.
It’s not been smooth sailing.
Amid mounting financial pressures last year, Te Whatu Ora implemented a hiring freeze which commissioner Lester Levy swore would not impact frontline staff.
But when just three in five mid-year nursing graduates and a little over half the year’s end cohort were employed by Te Whatu Ora (compared to the normal 90+ per cent intake) NZNO student leaders accused Te Whatu Ora of failing its most basic duty — protecting New Zealand’s future nursing workforce.
Fronting the issue, Gray blamed fewer vacancies and low turnover after employing nearly 3000 nurses over the previous year — something former CEO Margie Apa publicly blamed for blowing the organisation’s budget.
Later, a release of internal emails to Kaitiaki showed Gray arguing for placing new graduates, especially Māori and Pasifika.
By November, she was urging nearly 800 jobless graduates to consider roles in primary, community and aged care, saying “all roles will offer valuable work skills and experience”.
Te Whatu Ora is also offering incentive payments of $20,000 for rural, provincial or Māori and Pacific providers to hire and mentor new graduates; or $15,000 for urban primary health practices.
With enough funding for 200 such placements, there have been 127 applications from nurses and 191 potential vacancies identified so far, she said.
“My role is to look beyond this year — how do we continue to drive that? How do we get funding in outer years to continue to really stimulate graduates going into primary, community and aged care?”
Today, there are still about 530 graduates from 2024 in the talent pool looking for work — including 19 who turned down their Te Whatu Ora offers.
Gray says an extraordinary set of circumstances are behind the lack of jobs. Internationally-qualified nurses now make up nearly half the nursing workforce after being fast-tracked into New Zealand amid a global nurse shortage post-COVID.
‘Naturally a graduate wants to work in a hospital where there are all the specialties . . . but we also need our nurses right across the health system to deliver care.’
“There are unintended consequences of that [now], where we have more nurses than we do jobs, so that has impacted our supply — which is our new grads,” she says. “The economic climate right now is also not helping as our turnover is extremely low [1.9 per cent].”
But there are other opportunities here — and Gray says she wants to do some “myth-busting in nursing that ‘thou shalt not be a nurse unless you’ve worked in a hospital’.”
“Naturally a graduate wants to work in a hospital where there are all the specialties . . . but we also need our nurses right across the health system to deliver care.”
As a new graduate in the early 2000s herself, she got turned down for a hospital role and applied for a position in aged care instead “and it was fine”.
Aged care, along with primary and rural health, needs nurses — but those sectors can pay up to 20 per cent less than hospitals, which she acknowledges: “Yes, that’s a work on”.
“There’s an appetite to want to grow graduates in those spaces . . . but they’ve got to be in the right places, with supervision. It’s not just a job, it’s a supported space.”
Those new graduates in community roles were also welcome to join Te Whatu Ora’s nurse-entry-to-practice (NETP) programmes in their district for further support, she said.
“The first step is never the wrong one – even if you’re part-time. Your first year is around gaining clinical experience and being supported in your first year of practice.”
The future of nursing in Aotearoa?
Nursing, says Gray, is still a “great career” — in fact she’s keen to spend more time in community clinical practice this year because “nursing brings me joy”.
New Zealand is world-leading in advanced nursing practice such as nurse prescribing and NP scopes of practice, says Gray. Taking some Australian state chief nurses and midwives on tour last year, she visited some “amazing practices where there was integrated practice humming”.
‘For me, I really want to make space for celebrating the work that nurses do . . . the magic nurses bring every day.’
“I’m talking about new graduate, RN, community prescriber, NP and GP — and that’s the transformational model we require when we think about putting patients and whānau at the centre of why we’re here.”
“It’s to deliver care and access to care to patients of whānau when and where they need it, by the right people. So I firmly believe that nursing is the transformation that the health system needs, because we’re in every corner, at every touch point and we can do a lot within our scopes,” says Gray.
“For me, I really want to make space for celebrating the work that nurses do. We need to lift up and give positive stories about the magic that nurses bring every day to the health system. We get a lot of negative.”