EMERGENCY DEPARTMENT WOES
• Stressed emergency nurses at a key provincial hospital claim short-staffing made the ED unsafe for nurses and patients
• Tired, burnt-out nurses feared making fatal mistakes and were actively looking for new jobs
• The ED's health and safety rep issued a formal notice demanding change - but Worksafe cancelled the notice as the DHB was doing all it could
• The nurses' union says there have been improvements but ED still needs more permanent nurses
A dire staff shortage in one busy New Zealand emergency department left nurses stressed, burnt out and in tears, unable to "bounce back" from stressful events like patients dying, documents show.
At times there weren't enough nurses in Nelson Hospital's ED to resuscitate patients safely, while in one case a patient's suicide attempt was thwarted with only seconds to spare, according to documents released to the Herald through the Official Information Act.
Stretched nurses were working close to eight hours without breaks, and felt "coerced" into working overtime until they found someone to take over their patients.
Nurses were frequently texted to come to work early or on days off, and fatigued nurses feared making a serious mistake that could lead to a patient's death and see them struck off the register.
The resulting poor work-life balance crushed nurses' ability to cope with the daily stresses they faced on the job.
Worksafe has found the Nelson Marlborough DHB, which runs the hospital, is taking all reasonable steps to address the staffing shortage.
The DHB says it is working closely with the ED team to support them during "periods of high or complex activity" and has provided hundreds of hours of extra resources.
*SCROLL DOWN FOR MORE ON WHAT NELSON HOSPITAL IS DOING
But the nurses' union says while some conditions in the hospital have improved in recent months, the ED still does not have enough experienced, permanent nurses.
Nelson is one of many hospitals around the country struggling due to a national nursing shortage, made worse by high emergency department presentations and hospitals running at full capacity.
Last week a new report from senior doctors revealed acute admissions and emergency department use in New Zealand were growing more than twice as fast as the population.
In that report an ED specialist reported "exponential increases" in patient volumes over the past five years, but no extra staff.
"Effectively we're being asked to just work harder."
Many hospitals including Nelson had bed occupancy rates close to – and sometimes over – 100 per cent. The Ministry of Health says the ideal is 85 per cent.
The situation at Nelson Hospital was highlighted when the ED nurses' health and safety representative issued a provisional improvement notice (PIN) informing the DHB that as an employer it was breaching the Health and Safety at Work Act 2015.
The PIN, issued in July, accused the hospital of "failure to ensure, as far as it is reasonably practical, the health and safety of emergency department nurses, through sustained sub-optimal safe staffing levels."
Documents provided to Worksafe included notes outlining the situation nurses faced. They included one nurse who had no chance to take a break or debrief after a patient suddenly died - she was "expected to carry on with [the] next patient".
In another case, when a patient attempted suicide in ED - and almost succeeded - a nurse reported the near-miss as a high-risk incident so it would be reviewed by the chief executive. But the incident was downgraded and not reviewed because no harm had come to the patient, according to meeting notes.
Nurses were actively seeking work elsewhere, with a senior doctor reportedly saying the hospital had "the worst health and safety culture I have ever worked in".
• New Zealand's health system at 'tipping point' with doctors, surgeons reporting burnout
• Nursing 'crisis': 208 nurses needed at Counties Manukau DHB
• Hawke's Bay nurses ending shifts 'in tears', union claims
• Nurse deal: Accord signed to ensure safe staffing levels in hospitals
In May a letter from the ED's health and safety representative to the hospital's associate director of nursing said unsafe workloads had been increasingly reported to management and nurses were repeatedly required to endure "very heavy and stressful workloads".
Issues had been raised across the hospital since 2018, include "letters from senior doctors raising concern at workload and ED overcrowding".
Yet when issues were raised with senior management, they were minimised, nurses claimed. Senior management often didn't attend safety meetings and issues were resolved slowly, with minimal feedback.
The DHB asked Worksafe to review the "flawed" PIN, saying it did not accept staff levels were "suboptimal" and the "alleged breach is not ... capable of remedy required and in the timeframe specified".
"The NMDHB takes all steps so far as are reasonably practicable to ensure the health and safety of its patients and staff in the emergency department, and across the NMDHB," it said.
"This issue is extremely complex and staffing considerations across a hospital have to balance many factors. This is an issue that DHBs across the country face in best allocating the resources it has. In a nutshell adjusting staff numbers for one group of staff in one area can have negative and unforeseen impacts on another area."
Worksafe cancelled the notice in August because it found the DHB was doing everything "reasonably practicable" to address staffing levels and capacity issues.
But it did tell the DHB it was contravening the Act through inadequate communication and processes for engaging with workers around health and safety. An improvement notice issued by Worksafe requires this situation to be remedied by January 30, 2020.
The DHB says it has consulted with staff, unions and management about a new structure that it feels addresses all the requirements of the improvement notice. The NZ Nurses Organisation says there has been positive feedback about those changes.
WHAT THE HOSPITAL IS DOING
In June the DHB responded to the health and safety rep's initial concerns, thanking her for conveying the perspective of ED staff. There were plans to "focus on the barriers to patient flow both into and out of ED and the need to change the way we work together as a system going forward".
The DHB's director of nursing and midwifery, Pamela Kiesanowski, said in an emailed statement to the Herald there had been regular meetings with staff, and the DHB was working closely with the ED team to support them during "periods of high or complex activity".
"Hours of additional resource for Nelson Hospital ED have been added over past months as required. For example, 868 additional ED staffing hours were provided between 1 August and 31 October. This additional resourcing allocation continues as required."
A 10-bed Medical Admissions and Planning Unit opened in July, to take pressure off the ED and improving patient flow. Fifteen full-time equivalent positions have been added to staff this unit.
Variance Response Management - which matches staff and resources to wherever patient demand is greatest - was also used when needed across the hospital including in the ED.
Kiesanowski said a pilot was also being considered for an acuity tool, specific to the emergency department, that would measure staff requirements.
Daniel Marshall, the NZ Nurses Organisation's Nelson organiser, said members reported there were still not always nurses available when needed in the ED.
"It is disappointing that NMDHB do not permanently resource this department to ensure the best patient outcomes," Marshall said.
"Our members continue to work in an environment in which patients are cared for in corridors and other places which do not protect their privacy."
The continued stress on staff had an impact on long-term retention of emergency nurses, whose expertise was in immediately assessing and responding to patients with significant illness and injury, he said.
While nurses were being increasingly deployed from other parts of the hospital they often did not have the experience needed in the ED, he said.
"NZNO expects Nelson Marlborough District Health Board to uphold their responsibility to ensure there are enough staff in ED, and all clinical areas, to provide safe care and ensure the best possible patient outcomes."