Will safe staffing review be a turning point at last?

Having spent eight years at NZNO advocating alongside my colleagues for the implementation of safe staffing programme Care Capacity Demand Management (CCDM), I wondered if at last this would be the turning point. Would this be an opportunity to move forward with CCDM and make a difference for nurses and nursing?

Years of negotiating for safe staffing by NZNO, changes in relevant clauses in the DHB multi-employer-collective-agreement (MECA) – even the signing of a safe staffing accord – had not achieved the right number of nurses with the right skills in the right place at the right time – the crucial elements of safe staffing.

‘Understaffing is the new normal’ – DHB RN

The Minister of Health Andrew Little commissioned the review to:

Review implementation of CCDM including programme components and success factors.
Compare outcomes in DHBs where CCDM is fully implemented with those at the early stages of CCDM implementation.
Examine the impact of CCDM on safe staffing, patient care and work environments in DHBs where it is fully implemented and
Make recommendations for the next steps of this national programme.

I was fortunate to be joined by three other nurse colleagues familiar with the CCDM programme:

Dr Jill Clendon – formally NZNO policy advisor now associate director of nursing and operations manager for ambulatory care at Nelson/Marlborough DHB.

Kapua Quinn – nurse manager of the integrated operations centre at Capital and Coast DHB.

Dr Rhonda McKelvie – previously a programme consultant with the Safe Staffing Health Workplaces Unit and now a senior lecturer at the Massey University School of Nursing.

Together we formed the Nursing Advisory group with the apt acronym of NAG.

The task was substantial and the timeframe short – we had three months to prepare a report for the Minister. Thankfully we were well supported by the Hauora team at KPMG consultants as our secretariat and staff at the Ministry of Health (MoH) provided project management support.

Approach and Methodology

The journey began with a session with KPMG and the MoH to discuss who we needed to talk with, how we would do that and what data did we need to request from the DHBs. The NAG was in agreement from the outset that this review was about safe patient care and hearing the voices of nurses – their work environments, their experience of the CCDM programme and whether or not it was working for them.

Hearing how nurses coped, their resilience, commitment and professionalism was awe-inspiring.

The focus for this review was on medical, surgical, mental health and asessment, treatment & rehabilitation wards across the 20 DHBs. Emergency Departments were added to the scope of the review at the request of the NZNO College of Emergency Nurses. DHB Midwifery and community nursing services were out of scope of the review however it is acknowledged in the report that these areas need to be included in a system-wide approach to safe staffing

Sources of information

We connected with nurses (all scopes including registered and enrolled nurses, charge nurses, nurse managers and Directors of Nursing) in focus groups, interviews and through an online survey.
We requested Core Data Set data (care hours variance and shifts below target) and TrendCare data from all DHBs
We reviewed international literature on other approaches to Safe Staffing. The review examined ratios as an approach closely and determined that CCDM remains the most effective tool for the New Zealand context if implemented effectively.

What we found

CCDM does not recognise Te Tiriti O Waitangi responsibilities in its design, implementation or outcomes.

CCDM has given visibility to the work of nurses and the historic under-investment in growing the nursing workforce which has led to nursing shortages across Aotearoa. This has been exacerbated by the COVID-19 pandemic but that is not the root cause of the prevailing staffing issues.

Nurses are working longer hours and extra shifts to cover staffing shortages. The impact of this on nurses and their whānau is severe.

There is agreement amongst the workforce that CCDM is the right tool to determine safe staffing however there are some fundamental issues with its current configuration which create unnecessary complexity.

In its current form CCDM has limited impact on patient outcomes.

The delay in implementing the results of FTE calculations has caused widespread distrust in the programme and contributed to the staffing deficit.

What did we recommend?

There are eight recommendations: (a summary of these is on page 13 of the report and are provided in more detail on pages 68-77)

Review the design, operation, implementation and governance of CCDM and TrendCare to recognise and uphold the articles of Te Tiriti
Redesign key components of the CCDM programme to ensure it is fit-for-purpose
Strengthen leadership and accountability for the CCDM programme
Invest in the infrastructure which enables and underpins CCDM
Increase nursing supply immediately and in the long-term
Review the role of the Safe Staffing and Healthy Workplaces Unit
Establish a national work programme to oversee the delivery of the changes to CCDM
Complete development work on the ED module

The NAG has suggested that work on these recommendations begins immediately with those that have a significant impact on safe staffing, patient outcomes and the work environment be prioritised for implementation in the next twelve months.

Participating in this review has been both humbling and distressing. Hearing first hand from nurses about the difficulties they face on a daily basis, the concern they have for their patients and the exhaustion they are feeling was distressing. Hearing how they coped, their resilience, commitment and professionalism was awe-inspiring.

Kia kaha, kia māia kia manawanui

Hilary Graham-Smith was NZNO’s associate professional services manager 2012-2020.

Uncut – news briefs

3 Dec	Health NZ end-of-year deficit confirmed In publishing its annual report, Health NZ has confirmed it ended the financial year with a deficit of $722 million, against a target surplus of $54 million.
2 Dec	ICN says COP29 climate finance shortfall threatens the planet’s health The International Council of Nurses (ICN) has expressed profound disappointment with the outcomes of COP29, held in Baku, particularly the New Collective Quantified Goal (NCQG) on climate finance that was passed despite significant objections from developing countries.
29 Nov	Minister reminds public health officials of priorities Minister of Health Dr Shane Reti says the National Public Health Service should concentrate its focus on prioritising serious public health issues facing New Zealanders.
29 Nov	Community providers rally to protect hapū māma and pēpi as national whooping cough case numbers surpass 1,000 for 2024 Hapū māmā are being urged to get immunised, and parents and caregivers are encouraged to get their babies immunised on time, as whooping cough case numbers continue to climb across Aotearoa New Zealand.
28 Nov	Govt ignores health crisis, plans to axe 1500 public health roles The health of New Zealanders will suffer because of the Government’s plan to axe nearly 1500 roles at Te Whatu Ora, coming at a time when the public health system is already under severe pressure.
27 Nov	Health New Zealand Establishes Technical Advisory Group to Lead Transformation in Maternity Care This team of experts and community representatives will play a key role in the development of the Maternity Commissioning Framework, a core element of the wider Kahu Taurima programme, which aims to make maternity and early years services more equitable, accessible, and whānau-centered.
22 Nov	Whooping Cough epidemic declared across Aotearoa New Zealand Health agencies have confirmed today that Aotearoa New Zealand is now in the early stages of a Whooping Cough epidemic, with a nationally coordinated response now in place.
20 Nov	A Global Map of Winter Depression Healthnews has released an extensive study that ranks 194 countries based on their winter-pattern Seasonal Depression Disorder (SAD) risk.
18 Nov	Potential travel disruption expected with Tuesday’s national Hīkoi Health New Zealand \| Te Whatu Ora urges those with an appointment scheduled at Wellington Regional Hospital on Tuesday morning or early afternoon, to please allow extra time to get to appointments.
15 Nov	ICN’s calls on G20 leaders to address international health worker migration crisis Ahead of the G20 Leaders Summit in Rio de Janeiro next week, the International Council of Nurses (ICN) welcomes the Declarations recently adopted by the G20 Health Working Group and health ministers.
13 Nov	Measles case confirmed in Tāmaki Makaurau Health New Zealand \| Te Whatu Ora has confirmed today that a new case of measles has been identified on Waiheke Island in Auckland. The case and their household are being supported by the National Public Health Service (NPHS), with those most at risk now in quarantine to help reduce the chance of further spread.
5 Nov	Safety fears ahead of changes to mental health 111 calls Mental Health Nurses have serious concerns about the safety of their patients, the public, their colleagues and themselves when police changes to emergency 111 calls come into effect on Monday, New Zealand Nurses Organisation (NZNO) Tōpūtanga Tapuhi Kaitiaki o Aotearoa says.
31 Oct	General practices welcome fast-track approvals process A new fast-track approval process is a good start, but more is needed to fix New Zealand’s chronic GP shortage, says the General Practice Owners Association (GenPro)
24 Oct	International Council of Nurses Bucharest Declaration priorities for the future of nursing The International Council of Nurses (ICN) marked the 125 years since its founding in 1899 with an anniversary conference held in Bucharest, Romania and hosted by the Order of Nurses, Midwives, and Medical Assistants of Romania.
10 Oct	Call to immunise now as New Zealand at high risk of whooping cough outbreak Pregnant people, babies, children and others at high risk from whooping cough are urged to get vaccinated as soon as possible, as Aotearoa New Zealand stands at high risk of an outbreak.
9 Oct	New pilot with Plunket to deliver childhood immunisations To increase access and boost immunisation rates, Health New Zealand \| Te Whatu Ora and Whānau Āwhina Plunket will pilot the delivery of childhood immunisations at a select number of sites across the country.
8 Oct	Health NZ Begins Development of National Perinatal Bereavement Care Pathway As Baby Loss Awareness Week shines a light on the heartbreak faced by many, Health NZ is taking a compassionate and hopeful step forward in transforming the support available for whānau who experience the loss of a baby.
7 Oct	Govt takes the scalpel to regional health budgets At Labour’s insistence, Te Whatu Ora financial documents have been released by the Health Select Committee today showing more cuts are on the way for our health system.
2 Oct	Orion Health and Streamliners form strategic partnership Orion Health, a global leader in digital health solutions, has announced a strategic partnership with Streamliners, creators of HealthPathways which provides an online manual used to assist with clinical assessments.
1 Oct	Rollout of new medicines across New Zealand begins Today marks the first day a range of new medicines, including cancer medicines, will start to become available in hospitals and health centres across the country.
27 Sept	New Dunedin hospital: Southerners deserve better The Government’s announcement today that it will scale back the new Dunedin hospital will negatively impact patient care, the New Zealand Nurses Organisation (NZNO) Tōpūtanga Tapuhi Kaitiaki O Aotearoa says.
26 Sept	Govt not addressing health workforce crisis The National Government is hiding the gaps in the health workforce from New Zealanders, by not producing a full workforce plan nearly a year into their tenure.
25 Sept	New programme offers step up for jobseekers seeking a career in health and wellbeing Local jobseekers have an exciting new opportunity to begin a career in Health following the launch of a new community-based kaiāwhina programme in the Hutt Valley.
23 Sept	Ministers oblivious to cuts’ effect on families The National Government is oblivious to the impact cuts to services will have on New Zealanders who are doing the hard yards caring for mentally ill family members.
19 Sept	Wānaka community to benefit from new overnight health service Health Minister Dr Shane Reti says an Overnight Acute Care Service opening in October will provide people in Wānaka and the surrounding area with the assurance of quality overnight care closer to home.
17 Sept	Dr Le Heron takes title of 2024 Alzheimers NZ Fellow Distinguished neurologist and cognitive neuroscientist, Dr Campbell Le Heron, has been made the 2024 Alzheimers NZ Fellow for his work researching and managing cognitive disorders.
11 Sept	Aged care will be worse off if redesign rushed New Zealanders needing aged care support and the people who care for them will be worse off if the Government pushes through a flawed and rushed redesign of dementia and aged care.
11 Sept	Govt takes action on mpox response, widens access to vaccine The Government is taking immediate action on a number of steps around New Zealand’s response to mpox, including improving access to vaccine availability so people who need it can do so more easily, Health Minister Dr Shane Reti and Associate Health Minister David Seymour announced today.
10 Sept	ICN launches new position statement and discussion paper setting out a revolution in the delivery of Primary Health Care The International Council of Nurses (ICN) is launching its new position statement and a discussion paper on Primary Health Care (PHC) at its Nurse Practitioner/Advanced Practice Nursing Network (NP/APN Network) Conference in Aberdeen, Scotland.
9 Sept	First cancer medicine decision following Pharmac funding boost Pharmac has decided to widen access to two medicines for several types of cancer. Pembrolizumab (branded as Keytruda) will be funded from 1 October 2024 for eligible people with advanced triple-negative breast cancer, head and neck cancer, colorectal cancer, bladder cancer, and Hodgkin lymphoma. Nivolumab (branded as Opdivo) will be funded from 1 November for eligible people with kidney cancer.
6 Sept	Health agencies working with Police on rebalancing roles for mental health responses Health New Zealand \| Te Whatu Ora and the Ministry of Health - Manatū Hauora are working with Police to change some of the ways agencies respond to mental health. The change will see an increased health-led response, supporting Police to focus on core Policing.
4 Sept	Nurses’ bargaining starts with action for safe staffing Nurses are kicking off their collective bargaining with Te Whatu Ora by taking action for safe staffing on Friday, New Zealand Nurses Organisation Tōpūtanga Tapuhi Kaitiaki o Aotearoa (NZNO) says.