Nurses at Middlemore Hospital say they are facing burnout and worry about putting patients at risk due to a staff shortage as the hospital tries to fill more than 200 full-time nursing positions.
Their experience is echoed by nurses around the country, as a national nursing "crisis" is exacerbated by a rise in emergency department presentations.
Ambulances had to be diverted to Auckland Hospital last month when 16 Middlemore nurses rang in sick, sparking suggestions the army should be brought in to provide cover.
Counties Manukau DHB accepts nurses are distressed but says staff levels are improving. Vacancies are down by a third, from 302 in July 2018, DHB chief nurse Jenny Parr said.
More patients were streaming in the front door, especially in winter, putting "relentless" pressure on staff, so nurses who had previously coped were becoming distressed, Parr said.
Increasing ED pressures and nursing shortages were not unique to Counties Manukau but were a national problem, Parr said.
A Middlemore nurse told the Herald her colleagues were "at their wits' end" and felt this winter had been their worst.
She had seen nurses crying and others hiding in bathrooms trying to calm themselves. "Some of them didn't want to turn up to work the next day."
Some feared risking patients' lives, and their careers, because unsafe staffing levels increased the risk of dangerous mistakes.
Nurses reported serious incidents but felt little had improved, she said.
Counties Manukau DHB said there were 208 full-time-equivalent nursing vacancies at Middlemore, from 2982 roles - a 7 per cent vacancy rate. Vacancies didn't include staff on parental leave, casual or fixed-term contracts.
By comparison Waitematā DHB has a 4 per cent vacancy rate, with 131 nursing vacancies from 2820 roles.
Parr said Counties Manukau DHB was fully committed to safe staffing. The improvements were "really positive" but she aimed for 100 vacancies.
A safe staffing tool called is to be fully rolled out at all DHBs by 2021 as part of the Safe Staffing Accord, an agreement between the NZ Nurses Organisation, DHBs and the Ministry of Health . The tool matches capacity to demand to ensure patients are safe and the organisation runs efficiently.
Middlemore was still implementing the tool but obvious gaps already needed to be filled, Parr said.
The DHB had recruited 46 extra nurses into immediate demand areas through the accord's funding. New graduate nurses were also hired twice a year but the pool was small and CMDHB's September intake would not be as high as hoped.
Parr received all incident reports related to unsafe staffing so was aware of nurses concerns.
"We would like to be in the position of being able to provide more staff right now but these things do take time."
Meanwhile the DHB was introducing a wellbeing programme for staff.
"We absolutely acknowledge that there are some people who are feeling very distressed about it but we are aware and are doing a huge amount to try and address the gap."
Massey University school of nursing Professor Jenny Carryer said the entire sector was "struggling desperately", with additional nursing shortages in aged care and public health.
The deficit would not be easily fixed, she said.
Thousands of nurses who held practising certificates were not working because of conditions, while other stressed-out nurses could only cope with part-time work.
Past failures to hire all new graduates meant many nurses had gone overseas. This was being resolved but the historic shortfall still had an effect, Carryer said.
In 2018 the NZNO reached a multi-employer collective agreement with DHBs , including improved pay scales.
But NZNO organiser Justine Sachs said more pay and better conditions were still needed to entice nurses to New Zealand amid international competition for nurses.
Entry-level DHB nurses can expect to start on $47,000 per year, according to the Government's careers website .
On July 22 Middlemore diverted ambulances to Auckland Hospital after 16 nurses called in sick before an evening shift, just as demand surged in the emergency department.
At the time the NZNO said Auckland DHB had suggested Middlemore call in the army. Both DHBs have rubbished those claims.
But Sachs said the incident was a symptom of the ongoing "understaffing crisis".
A statement from CMDHB said it would only ever call in the defence force if authorised by central Government in a national emergency.
Health Minister David Clark said the Labour government had "only ever funded more nurses".
"After years of neglect, DHBs are now having to play catch up with their workforces, including nursing, but we are funding them to do so. This will take time but progress is being made."
The Ministry of Health's chief nursing officer Margareth Broodkoorn said New Zealand's nursing workforce was the biggest it had ever been, with 58,200 enrolled nurses, registered nurses and nurse practitioners, up from 56,356 last March.
The Ministry later confirmed that number included nurses who held practising certificates but were not currently working.
An extra 500 nurses were to be employed as part of last year's collective agreement. Most were now in jobs, Broodkoorn said.
The Safe Staffing Accord was trying to ensure all nursing graduates secured jobs. It also aimed to retain existing staff and reemploy those who had left the profession.
An international recruitment campaign aimed at UK and Ireland nurses had also seen strong interest, she said.