In this series of articles about the new Dunedin hospital, the prime focus has rightly been on the experience of patients in our current hospital and how a new hospital could substantially improve that.
However, patients are not the only group suffering as a result of the inadequacy of the current facility. Staff are too, and this not only causes distress to those staff, but greatly increases the rate at which they leave and impacts on behaviour and interactions to the ongoing detriment of patients.
The main focus of this article is the nursing workforce, while acknowledging that there are serious problems with the medical, allied health and administrative workforce as well.
After 40 years of battling for improvement in Dunedin Hospital, it became pretty discouraging for me as a consultant surgeon and intensivist, despite being in what one would think was a reasonably influential position.
For nurses and other staff, who feel comparatively powerless, working in understaffed and often unsafe situations and seeing patients getting a raw deal, their experience has been incredibly distressing, and it is amazing to me that even more have not left the profession or gone across the Ditch. The morale of those who remain is at a very low ebb.
Three features of the nursing world are of grave concern. One is that we continue to lose our older, most experienced, skilled and wise nurses at an alarming rate. The second is that we are not employing all of our newly graduated nurses without hesitation and this plays right into the hands of Australian healthcare bodies who are targeting them quite deliberately with offers of better pay and conditions.
It is critical to note that despite nursing students paying substantial tuition fees, the taxpayer has funded around two-thirds of the cost of their education (and the same issue applies to medical graduates, but at an order of magnitude bigger). There needs to be some return on that investment.
The third is that we are employing large numbers of foreign nurses (mostly from the Philippines and India) which creates various problems, not the least of which is the moral issue of fleecing poorer countries of their talent and training, just as Australia is doing to us.
While the ongoing flow of talent from poor to richer countries is mostly driven by money, there are ways of limiting it, so that all of the talent and skill does not overwhelmingly end up in the richest countries. The obvious one is to compete by matching wages and salaries, (which is difficult when our neighbour Australia is significantly richer and spends more on healthcare) or at least keep the gap as low as possible, but the other is to make the job or the living environment so attractive that people are prepared to forgo the income difference.
Social, community, geographic and other lifestyle factors come into play here, but most important of all is whether our staff are happy and want to come to work. If they are not happy, fulfilled and feel they are making a difference, they will not stay unless they are trapped by other circumstances.
The two main generators of distress.
For nurses working in our hospital there are two potent causes of distress; one is seeing one’s patients’ urgent and serious needs not being met in a timely fashion, and the other is not having sufficient staff working alongside you to deliver a safe and decent level of care. Having to constantly apologise for inadequate care and not being able to rectify the problems is utterly soul-destroying for anyone in a caring profession and creates disintegrative stress which leads to either burnout or maladaptive self-protective behaviours.
Nursing shortages
For many years nurses in our hospital, particularly in the ED and on surgical wards, have been saying that they are understaffed and overstretched and struggling to deliver safe, let alone optimal care. Often this was treated dismissively. Now, however, there is an increasing amount of robust data which is able to measure workloads and nursing capacity.
Programmes like Care Capacity Demand Management using tools that provide a measure of patient acuity and nursing workload such as TrendCareO have been well validated, and they do support what nurses have been saying for a long time.
However, this all too often is ignored. Arm’s length imposition of blunt instruments like global hiring freezes create a massive disconnect between those at the coalface and upper level managers, bureaucrats and politicians, the anger level rising exponentially when the latter lie about the existence of such a freeze yet will not even replace people in essential roles.
What are the effects of chronic resource deficits?
When resources are inadequate this produces frustration and distress for the staff who can see what the patients should be getting but aren’t, and are also personally stressed and chronically tired trying to provide even basic care. When these problems are allowed to become chronic, this produces a deep-seated anger with the system and those who run it. Most staff are initially willing to be involved in quality improvement initiatives to try to fix faulty processes but when the root cause is a lack of facilities or not enough staff and this is not remedied, then sooner or later they stop trying.
If they keep striving for change in the face of constant frustration the inevitable result is burnout, so a number of protective behaviours emerge which all too often are counterproductive and may further exacerbate the problems.
I have seen many examples in overworked and frustrated nursing staff where they simply stop caring to limit personal distress. They become resigned to the inevitability of badness and reach a level of sullen acceptance of clearly unsatisfactory situations. They may become passive-aggressive and even when an opportunity presents to improve a process or patient journey they do not try to take it.
All too often they just leave, either to a job offshore or by exiting the profession. These are often our most experienced nurses with still a good deal of working life and contribution left in them, if only the conditions were tolerable.
Those who remain often do so only because they are anchored by family commitments and they need a job, but that hardly makes them enthusiastic about their work; in fact they are often quite resentful and cynical.
The final very destructive effect of resource shortages, both facilities and staffing, is that groups start fighting over the available resources, and are turned against each other, which can lead to serious deteriorations in relationships, further damaging morale and impacting patient care.
We have to do better by them.
— Mike Hunter is a retired consultant general surgeon and consultant intensive care specialist.
