Safe staffing--getting it right now: ensuring safe staffing across all health sectors is a significant challenge. NZNO is meeting the challenge with a long-term, organisation-wide approach.

NZNO, along with other nursing organisations worldwide, has wrestled with "safe staffing" for many years. In the 1990s, NZNO predicted a nursing and midwifery shortage before 2010. Being right is no comfort. The current "condition" is a legacy of the competitive business model promoted in health during the 1990s. This model saw New Zealand enduring major health reforms, consequences of which were the disestablishment of nursing leadership roles, the cessation of enrolled nurse (EN) education, and the stealthy and systematic removal of EN positions in hospitals. Reduced hospital stays, higher patient acuity, decreased permanent staffing numbers and the move away from publicly provided aged-care services shifted workload pressures to the community and primary health care settings. Add to this picture, a caregiver staffing crisis directly linked to the undervaluing of their work and low pay and what we have is a recipe for a very unsafe environment for carers and those cared for. This is a condition from which we have never fully recovered.

During negotiations for the inaugural NZNO/ district health board (DHB) national multi-employer collective agreement (MECA), safe staffing was identified as the biggest issue after pay. The DHBs agreed the issue was valid and to achieve a sustainable outcome a significant approach was needed. An independently chaired bipartite Safe Staffing Healthy Workplaces Committee of Inquiry (CoI) was set up to investigate the issues, identify solutions and make recommendations. It was agreed that a more sophisticated solution was required than the Australian model of legislated or mandated nurse/patient ratios.

Seven interdependent elements

The CoI's solution included seven interdependent elements that must be present to achieve a safety staffed and effective health care environment. These seven elements are: the requirement for nursing and midwifery care (ie right people, fight place/time, with the right skills delivering the right care); the cultural environment (ie genuine partnerships); creating and sustaining quality and safety; nursing authority and leadership; acquisition and use of knowledge and skills; the appropriate deployment of the wider health care team; and genuine involvement in decision making about the physical environment, technology, equipment and work design.

The CoI also recommended the establishment of a safe staffing/healthy workplaces unit and this has been achieved with funding provided through the Ministry of Health and is a joint NZNO/DHB initiative. Unit director Vicky Brewer was appointed in September 2007 to facilitate the implementation of the CoI recommendations, with the work overseen by an advisory board of two NZNO and two DHB representatives.

Three-pronged approach in aged care

The strategy in our aged-care campaigning has been a three-pronged approach aimed at addressing wages, staffing and training. Understaffing in aged-care facilities is an end result of employers attempting to maximise profits by paying low wages and employing fewer qualified staff. Until 2000, legislation provided for a regulated number of registered nurses (RN) per beds in aged-care hospitals and rest-homes. But numbers often fell below acceptable standards and the law was poorly enforced. On repeal of this legislation, an expert advisory group recommended to the then Minister of Health that minimum levels of qualified nurses, based on patient dependency, should be attached as a schedule to the Health and Disability Services Act. This was opposed by the Ministry of Health and employers. Further consultation resulted in non mandatory clinical indicators for patient safety. Essentially, this is recommended RN, EN and caregiver hours per patient, based on patient dependency. NZNO is seeking mandated minimum staffing levels in aged care.

At this stage, NZNO's safe staffing solutions for the primary health, community and private hospital settings are less well developed.

Across all settings, NZNO members continue to identify safe staffing as a significant issue. In response to members' concerns, NZNO's board of directors included safe staffing as one of the nine priorities in NZNO's 2008 annual plan. A number of reports--from the Health and Disability Commissioner, to Coroners' Reports, to Accident Compensation Corporation treatment injury and patient safety reports--have high-lighted that unsafe staffing is systemic in health services and is detrimental to patient outcomes.

All these reports have contained recommendations to address patient safety and include safe staffing and healthy workplace initiatives. The fallout from the Belhaven Resthome gagging incident has also highlighted the gravity of short staffing in aged care.

So, how are we going to "get it right now"? NZNO is developing an organisation-wide safe staffing plan. It is a tong-term project focused on delivering sustainable outcomes. A steering group has been working on the project framework, which includes designing processes that will ensure all NZNO members and staff understand what is planned and who is responsible. Effective and regular communication and opportunities for participation are also essential ingredients of the plan. The plan will enable members in all settings to play a part, establish links with other related work and will include a detailed communications, media and campaign strategy. The effectiveness of the plan will be monitored against realistic time-frames, key deliverables and achievement of milestones.

The objective of this project is to use whatever tools, skills, knowledge and experience within NZNO and our allies, to address members' staffing concerns in a sustainable, tangible way. The work will feed into the work of the safe staffing unit. The time for getting it right is now. Steering group members are: organising services manager Cee Payne (project sponsor); industrial adviser, Glenda Alexander (project manager); private hospital organiser Mark Lennox; aged-care organiser Lorraine Lobb; campaign adviser Lyndy McIntyre; DHB organiser Blair O'Brien; professional nursing adviser Suzanne Rolls; and co-ordinating organiser--primary health care, Chris Wilson.

By industrial adviser Glenda Alexander