NZNO's Blog

Leave a comment

Getting the shift pattern right for nurses

Nursing Logo

DHB junior doctors are lobbying hard for shifts with fewer days in a row and fewer night shifts in a row. This is because they know fatigue leads to greater risk of mistakes. They also know that patient care and engagement is not as good when they are sleep deprived or not rejuvenated sufficiently between rosters.

Nurses are also on shifts, do overtime, work nights and need to have recovery time to be on form. A New Zealand research project about nurses shift work was launched earlier this month.

Studies in Australia and the United States of America show nurses get less sleep on work days than non-work days and how much less depends on the shift pattern they are on.

Massey University’s Sleep/Wake Research Centre and School of Nursing, in collaboration with the New Zealand Nurses Organisation, is running the project designed to take an evidence-based approach towards managing shift work and fatigue for hospital nurses.

The Safer Nursing 24/7 project, led by Professor Philippa Gander, aims to improve health service delivery by improving both patient safety and the safety, health, quality of life and retention of nurses.

Project manager Dr Karyn O’Keeffe says, “Less sleep is directly related to increased risk of clinical errors, struggling to stay awake at work, and drowsy-driving on the way home.

“The hours of sleep someone gets in the 24-hour period before their shift significantly affects their ability to remain awake at work, and is a significant predictor of errors and, near errors. Sleep-deprived nurses report a higher number of patient-care errors, and an American study found nurses struggled to stay awake on 20 per cent of their shifts,” Dr O’Keeffe says.

NZNO has worked collaboratively with the team from Massey University from the project’s inception, both sitting on the advisory board, and in helping with seed funding to support the Health Research Council funding bid. NZNO principal researcher Leonie Walker is a member of the study team and helped develop the study protocol and survey.

“There is a huge variety of shift patterns worked in New Zealand. We have different lengths of shift and different patterns of day and night rosters operating. We need to discover the pros and cons and practicalities of these to develop some evidence-based guidelines for safe and appropriate shift rostering,” Walker explains.

“It’s a bigger problem for some than others, depends on physiology, other life issues, age and also the nature of the work.”

Walker says a shift in an operating theatre for example might be more or less fatiguing than a shift in an outpatient clinic or a special care baby unit but we just don’t know at this stage.

The literature is clear about the risks of error increasing with fatigue. A recent systematic review by NZNO policy adviser Jill Clendon and Veronique Gibbons showed the errors for 12 hour shifts were higher, other things being equal, than for 8-10 hour shifts.

“Equally important to us is the risk to nurses of chronic fatigue – to their health, and for example driving home drowsy,” Walker said.

Walker suggests we need to research our hunch that there are factors other than shift length alone, particularly the pattern of the shift changes that will be just as important.

Safer Nursing 24/7 is a collaboration between the researchers and the nursing community, and is supported by an advisory group of key nursing representatives, as well as an expert in epidemiology and biostatistics.  Nurses and District Health Boards are being invited to participate in three main activities:

  1. Completing an online survey of the work patterns of nurses nationwide in six practice areas.
  2. Development of new education and training materials on how shift work affects fatigue and how to improve sleep, particularly when working shifts.
  3. Consultation on a new Code of Practice for shift work in hospital-based nursing.

Research funders: The project has received major funding from the Health Research Council, with additional funding from the New Zealand Lottery Grants Board, McCutchan Trust and Massey University.

Click here to watch a short video about the project.


A day in the life of a mental health nurse in New Zealand


This blog was sent to us by a NZNO member who works in mental health. We are choosing to keep their details anonymous because of the intense scrutiny that mental health services are currently under. This blog is a personal reflection on their own experience, rather than NZNO’s view, but we are sure it resonates with many of you who work in the sector. We really appreciate them sharing their story, and hope it gives some context to the recent media coverage of our mental health services. 

It is 7am and I am off to see a patient in the emergency department. It is a young man who has self-harmed overnight. This scenario is becoming all too common in today’s mental health setting. You see, mental illness is the invisible disease. Presenting to the emergency department in emotional distress, the only visible signs are an unkempt man with a frightened look on his face.

Coming into the cubicle I see a young man in obvious distress. A feeling of hopelessness comes from him. I walk in and introduce myself. We begin to talk. Eyes downcast, feeling somewhat embarrassed as he shares his story with me. He talks to me in a quiet voice. He knows he needs help but does not know where to obtain the help he needs. His relationship with his family has become strained. They have tried to help, but are unable to provide the support he requires.

This man begins to articulate his struggle with schizophrenia. His self harm is due to despair: a belief that life holds nothing for him.  By the end of the interview I know I have several options open to me as a clinician:

  • We could send him home to his parents. But evidently his parents are unable to cope anymore with his distress.
  • We could suggest his GP follow up and maybe a visit from the already over-stretched crisis team.
  • Another option is to find a community respite bed for a few days. But we know that these are few and far between. I will have to telephone and “sell” his case to the respite coordinator if I am to make this happen.
  • Another option is to try and organise for him to be admitted into the inpatient ward. But I know they are nearly always full or over capacity. This is yet another hard sell to find this young man a place to be safe and be supported.

I go to discuss treatment options within the consult liaison team and the decision is made to admit the young man to the inpatient unit. I call the ward coordinator.  “What are his risks they ask?” Not, ‘who he is’, but, what logistical problems might he bring to the unit.

This is mental health nursing today. There is now a ‘risk adverse’ culture that always errs on the side of organisational safety: a system characterised by a lack of choices due to limited resourcing.

This is the young man’s first time in an inpatient unit. I try and reassure him, but as soon we get to the unit the door closes.  People are busy. I try and find a nurse. They are few and far between. I eventually find the nurse assigned to my client. A brief introduction is shared, but I know the nurse is trying to get the paperwork done. Admission note, risk assessment, interview with the psychiatrist, place them on the observation board and a host of other tasks. This leaves little time to begin getting to know, understand and work alongside my client to better support them.

I leave my client and return to the ED, there is another case on the board.

This time another young person in a self-harm situation – they were bullied at school and decided to end their life.

Nurses do care, but we are not being given the time or resources to provide the level of service and care that I would want or expect if it was my family member presenting to mental health services.

We do not want to restrict or deny the people we care for their freedoms. Too often the concept of least restrictive practice is sidelined by lack of resources.

The organisations we work for are worried. Worried about risk and what could be in the papers tomorrow. So much so they seem to have forgotten about the core reason we are here – we are here to help.

I as a clinician welcome the reviews and public scrutiny. The current structure needs looking at so we mental health professionals are able to provide the service, care and support that our clients deserve.



Leave a comment

Suffrage Day – vote for great health leaders




Pictured- NZNO Senior Policy Analyst, Marilyn Head with CTU Equal Pay campaigner Camilla Belich, outside parliament today.

By NZNO Chief Executive, Memo Musa

Today, NZ Suffrage Day, provides an opportunity to celebrate New Zealand’s suffrage achievements and look for ways to make further progress on gender equality issues in the health sector.

With the local government elections open for voting, now is a good time to think about how to use the hard-fought right to vote wisely.

The election of new District Health Boards (DHB) is a very important arm of our democracy. The New Zealand Nurses Organisation (NZNO) has provided its members with an election issues guide sheet with key questions for DHB candidates.

Nurses, caregivers, healthcare assistants, kaiāwhina and midwives need to be supported in their work with great leadership and governance.

A living wage, safe workplaces, good faith collective bargaining and collective agreements, and equal pay for work of equal value are fundamental aspects of a fair and healthy society. We do not have access to all of these things yet for all workers in the health sector in New Zealand.

The nursing team’s first priority is improving health outcomes and patient safety. Nurses need the right tools and enough staff to deliver best care. Nurses have developed Care Capacity Demand Management (CCDM) for safe staffing in public hospitals, but not all hospitals are making full use of this tool yet. Aged care does not have mandatory minimum safe staffing levels. Safe workplaces are not nationally consistent for all health staff.

This morning we supported the ongoing call for the government to support the Equal Pay Principles. At parliament steps the Council of Trade Unions delivered white roses for women MPs to encourage them to endorse the principles.

The people making governance decisions for DHBs hugely affect the health and wellbeing of families, workers and communities. In New Zealand although women have had the vote for over a hundred years, not enough women are standing for election or being elected into governance roles. There is a gender imbalance in the board room. Local body and DHB elections are therefore also an opportunity to bring more capable women onto the board as well as more board members with the requirements of our great nurses in mind. Seizing the right to vote leads to a healthier New Zealand.


Any DHB candidates who want to answer all the questions we have asked on the guide and have it published online can email their full names as on the ballot, contact details and answers to

Voting in DHB elections and more information on the voting process is available online here: 

Leave a comment

It’s time to shout out for health

Shout out banner blog rsz

I’ve spent a long time working in health, and have seen a lot of change. Governments come and they go, budgets change, policies shift. But what doesn’t change is the reason we are attracted to health careers- it comes from a deeply felt desire to make a difference, and change the lives of others for the better.

What you’ve been telling us over the last few years is that it’s becoming harder to connect to that feeling in your everyday working life.

Of course, we still do good. Nursing, like all people-centred jobs is about getting creative, working with what you’ve got and accepting what you can’t change. But the more workarounds our members have to do to give good care, the less time they actually have to provide that care. Nursing SHOULD be a job where you can go home at the end of the day with a satisfied feeling that you were able to make the difference, not frustrated about what you couldn’t do. Nursing is a job we should be able to love.

You have told us you want:

  • “A health system we can be proud of, where everyone can get the healthcare they need when and where they need it.”
  • “To feel proud of the care we provide, and be confident that we have the resources to provide safe, quality care at all times.”
  • “We want satisfying careers with pay that values our work and is enough to thrive on, and ongoing professional development.”

And that’s what NZNO is also pushing for. But we need your help!

Right now, the effects of healthcare funding are all around us- on the ward, in the community, and in the news. In just the last few weeks, we’ve seen news reports about

And the list could go on. The best management and policy in the world can’t make 1+1 = 3. Healthcare underfunding affects almost every aspect of our working lives, and is starting to impact on patient care. I know we all want better. That’s why we are running a campaign programme led by YOU, our members, called Shout out for health. Shout out for health will take action on health funding to push for a health system we are all proud of. Sometimes it will be about a particular service, like our petition on funding for Smokefree services.

Social share3.2

And sometimes it will be about a local issue, that you let us know is happening. The important thing is we need confident, passionate members to make it a success.

If you are an NZNO delegate or NZNO champion, you should have received an email inviting you to a special Shout out leadership training programme. You need to let us know now if you are in- so check your emails please!

If you are ready to stand up and take action to make health funding a priority for all politicians, sign up to be a supporter of the campaign here.

This slideshow requires JavaScript.

We are a professional association and union of 47,000 people who care deeply about others. If we use our voice to say ‘health matters’, we have the power to make it better for patients, but also for ourselves.

Memo Musa

NZNO Chief Executive


Leave a comment

Don’t block good health

By NZNO President, Grant Brookes.

Housing protest Grant

NZNO President Grant Brookes at ‘The Block’ housing protest in Auckland.

This might be a strange way to begin a nursing blog, but Season Five of The Block NZ is drawing to a close.

The top-rating programme has gripped viewers for the last two months. As eight young New Zealanders in their twenties and thirties competed for a chance at home ownership, we shared their yearning.

But this season has also attracted controversy, screening at a time of heightened awareness about the growing housing crisis.

In hindsight, it’s odd that it took five seasons. The appeal of the programme has been so strong all along because the goal of home ownership – or even a secure, affordable tenancy – is increasingly unattainable.

Last weekend I joined a protest at The Block NZ Open Home in the upmarket suburb of Meadowbank. I went along to support a group from NZNO.

It might sound shocking, but rising house prices mean that NZNO members are now starting to join the ranks of the “working poor” – people who don’t have enough left over, after accommodation costs, to pay the bills and feed the kids.

Hamish Hutchinson 13920350_10153658016692601_4644016310309070721_o (2)

NZNO delegate and RN Hamish Hutchinson at ‘The Block’ housing protest.

If the average Staff Nurse, working full time was somehow able to save a 20% deposit, then to buy an average-priced house in Meadowbank they’d need to spend about 90% of their income on mortgage repayments. So buying one of The Block NZ houses is clearly not an option.

But sadly, things are heading the same way across other parts of the country. A mortgage on an average-priced house anywhere in New Zealand would consume over half of a Staff Nurse’s income. And as house prices rise, so of course do rents.

But I also went along to the protest because adequate housing is essential for health.

Skyrocketing house prices (and rents to match) have recently put the issue of homelessness into the spotlight. But they also cause the less visible problem of household overcrowding.

Researchers at He Kainga Oranga, the Health and Housing Research Programme at Wellington’s Medical School, have been looking at the health impact.

In one study, they found that one in 10 hospital admissions to treat infectious diseases are the direct result of household crowding. For Māori and Pacific peoples, the figure jumps to one in five.

The researchers examined nine major categories of infectious disease — gastroenteritis, hepatitis A, Helicobacter pylori infection, pneumonia and lower respiratory infections, upper respiratory infections, Haemophilus influenzae disease, bronchiolitis, meningococcal disease and tuberculosis. They estimated that household crowding causes more than 1,300 hospital admissions a year, and even some deaths.

“Most of the diseases in the study have especially high rates in children”, said lead investigator Professor Michael Baker. “Children are more susceptible to meningococcal disease, gastroenteritis, pneumonia and most other infectious diseases, and our analysis shows that their risk is strongly associated with exposure to household crowding”.

The Block NZ is about houses as money-making opportunities, rather than homes for people to live in. Even as it appeals to us, it glamorises the competitive race which is shutting more and more people out of a warm, dry and affordable home.

But the show is not responsible for the housing crisis, or the toll it is taking on health. That responsibility lies with the Government.

The protest at their Open Home was a chance to again send the message that everyone – whether they can afford a $1m house or not – needs somewhere dry and safe to live.


Not so ACE

Yesterday, about 600 new graduate nurses had their hopes raised and then dashed when the ACE system malfunctioned badly.

Graduate nurses were mistakenly sent an email congratulating them on gaining a Nurse entry to practice (NETP) position at Auckland DHB.

If you were one of those nurses, we feel for you, it must have been a tough day.

ACE assures us this is a one-off and that’s good to hear because NZNO believes the system is a really good way of matching new grads with jobs.

We can’t help noting that this mistake wouldn’t have happened if the Government funded a NETP position for every new grad nurse. We believe this is the only answer for a fair, well-supported and sustainable nursing workforce that can take us into the future, and you can count on us to keep pushing for that.


You can find out more about our campaign for 100% NETP here:

Leave a comment

CCDM from a Charge Nurse Perspective

By Caroline Dodsworth, charge nurse, Palmerston North Hospital


As an NZNO member working in a DHB, I know that getting Care Capacity Demand Management (CCDM) working in all our DHBs is a priority in our multi-employer collective agreement (PDF pg 66).

I know that it has been started in most DHBs and I think the implementation has actually been completed in only one so far. It is good work to be doing and it’s important to do it right – better to take the time to get every step correct than to rush it and not get the benefits.

We all want patients to have the best possible outcome. This is most likely to be achieved when patients have the care they need when they need it.

CCDM is the programme that has been developed by the Safe Staffing Healthy Workplaces Unit, NZNO and district health boards (DHBs) to make sure we can actually do this every day (not just on those random, lucky days…).


Working in partnership is the key to CCDM’s success; NZNO members and staff working together with DHBs to make safe staffing a reality. It’s about making sure base staffing is right every day. It’s about making sure there are workable strategies in place if the match between demand (what patients need), and capacity (our resources) is not right. And to do that there has got to be good quality data available to everyone so we can see on the day and over time if the programme is working. The whole system depends on the information we provide.

You can find out more about CCDM here:


I thought I’d share my experience of CCDM at Palmerston North Hospital, so you can get an idea of what to expect when your DHB gets the programme (if it hasn’t already).

In 2012 I was charge nurse manager of an acute 32 bed medical ward. TrendCare showed that we consistently didn’t have enough staff to complete the care required; often between 20 and 30 hours short over a 24 hour period! Rosters were pretty much set in concrete and didn’t (and couldn’t) respond to the peaks and troughs in workload. We knew care rationing was happening but there was no way to “see” it or prove it.

The opportunity to become the first ward to undertake work analysis and data collection to inform the CCDM programme was floated and our application was successful.

There was excellent communication during the process; ward staff were included and actively involved. It was a great example of working in partnership with close collaboration between charge nurse, NZNO and ward staff. Ward staff were given every opportunity to express their concerns and listened to in a non-judgmental manner. Facts and figures were explained and we were given time to digest and seek clarification if we weren’t sure about anything. Unfamiliar data was explained in language that we could all understand. Charge nurse, associate charge nurses, management and NZNO delegates were professional and supportive, and assisted with propelling the process forward – staff joined in at “grass roots” level.

The data collection process was difficult and hard work, as I had anticipated; ironing out teething problems, ensuring everyone was on the same page, encouraging the negative staff and the fence-sitters, keeping the momentum going when enthusiasm flagged.

The data collection process was generally seen as “just another data gathering exercise”. But as the process developed it was an eye-opener to be able to quantify the many interruptions during each shift. It also highlighted and reinforced what nurses already know; many interruptions means less time for patient care. We also gained further insight into the peaks and troughs of ward work.

By the end of the two weeks we had become quite attached to our diaries! Finally, we were able to show care rationing – especially the missed nursing care that had become “business as usual”.

It took quite a while for the information we collected to be analysed and some wondered if their hard work had all been for nothing. During this time we implemented Releasing time to care which helped keep a sense of momentum.

As soon as the results were confirmed we swung into action and developed a new model of care. The entire nursing team got together, and with butchers paper and models, felt pens and timetables, we arranged and rearranged the FTE and the roster to meet workload over the entire 24 hour day and seven day week.

We divided up the available FTE into the most efficient and effective spread of regulated and un-regulated staff, thinking outside the square and breaking down traditional shift time barriers. Our new model of care implemented a new role of “admission and discharge nurse” who straddles the morning and afternoon shifts without a patient load, but instead focuses on timely discharges and active “pulling” of patients from MAPU and ED.

This means less pressure on the qualified staff, especially on the morning shift. Discharges happen in a more timely manner, and the discharge of complex patients requiring a lot of registered nurse time is now smoother. Patients feel more informed and new admissions are seen and assessed early without having to wait for a busy nurse.

The model of care for patients with delirium also changed – instead of being staffed by a ward RN and a bureau Health Care Assistant (HCA) we have our own ward HCA who knows the patients and provides continuity of care for them. To have our own HCA caring for these patients is amazing. The benefits to the patient outcomes, and working relationships between the team are invaluable.

The staffing numbers across all three shifts are well thought out. Patient safety has improved significantly with an extra registered nurse at night.

The difference to staff morale and motivation as a result of CCDM has been immense! While the ward remains very busy it now operates efficiently and effectively.  Complaints, incidents, falls and medication errors have reduced, staff turnover is practically zero and productivity has improved.

Since then we have developed a hospital-wide response to variance in collaboration with NZNO. The CCDM variance response management (VRM) tool is a visible and user-friendly process. It still cannot produce nurses out of thin air, but it raises awareness of areas under pressure to all the right people and allows an organisation-wide approach to pooling resources and to providing support where it is needed. Everyone is talking the same language and the tool triggers a response at the top of the cliff instead of the bottom.

I’ve heard a lot of feedback about CCDM over the last couple of years but the comment that has had a lasting impression, and the thing that I think CCDM stands for above all else for nurses is: “Since CCDM it feels like I’ve actually met the patients and I don’t go home with that horrible feeling that I’ve missed something”.

As the charge nurse for that ward I take pride in the fact that I was responsible for making that happen. We need senior managers to influence change at the executive table, but the charge nurse is responsible for driving change at ward level with enthusiasm and passion, leading from the front and never giving up.

If you are involved with CCDM in your ward or unit, I’d love to hear how it’s going. You can leave a comment by clicking the “leave the comment” link to the left of this article.


If you would like to know more about CCDM please talk with your local NZNO delegate or organiser, or visit or