Byrne has stepped down from her role as Council chair in anticipation of yesterday’s announcement that she will step into the shoes of retiring CEO Carolyn Reed as both chief executive and registrar of the regulatory body for the country’s about 57,000 nurses. Her appointment follows the recent announcement of Margareth Broodkoorn’s appointment as the country’s new Chief Nursing Officer.
Jane Bodkin, acting chief nursing officer, said the Office of the Chief Nursing Officer welcomed the appointment of the former chair and current director of nursing (DoN) for Taranaki District Health Board who was widely respected by the sector for her wealth of nursing operational and governance experience. She said the office had had regular contact with Byrne in both her DoN and chair roles and was looking forward to working closely with her in her new role.
“Taranaki’s loss is the Nursing Council’s gain. Catherine’s appointment ensures the Nursing Council will be in good hands following Carolyn Reed’s decision to retire,” said Bodkin.
The College of Nurses executive director Professor Jenny Carryer also welcomed the appointment saying Byrne brings a highly appropriate breadth of experience to the role.
“I am so glad the role has been taken by a New Zealander who understands our context and will build on the stellar work led by the Carolyn Reed.”
Likewise New Zealand Nurses Organisation chief executive Memo Musa said he was delighted at Byrne’s appointment as she brought to the role her wealth of nursing practice and leadership experience and her insight and understanding as a previous chair of the Council.
“I am sure that under her guidance the NCNZ will strive for great heights in ensuring public safety, whilst advancing professional nursing standards and practice; ensuring excellence in nurse education; and in continuing good stakeholder engagement practices.”
Byrne says she sees her new role as a great opportunity to combine her leadership experience, nursing regulation knowledge and her connection to the practice reality of nursing.
She said she was very much looking forward to working with the Nursing Council team and key stakeholders across the sector and continuing the work set out in the Council’s strong strategic plan.
“I intend to build upon the wonderful work that Carolyn and the team have achieved in regards to ensuring that our nursing regulatory practices are forward-focused, evidence-based, flexible and the right touch.
“The role of the Nursing Council is to protect the public by the regulation of nurses, however regulation also needs to be connected and relevant to the profession,” she said.
Byrne takes up the role in March and said as the Nursing Council’s business was complex she would be spending the first few months getting to understand that business better and building relationships across the sector.
The Taranaki-born and trained nurse – whose roles included being a charge nurse and nursing advisor at Starship Children’s Hospital before returning to Taranaki – said she would be sad to be leaving her DoN role.
“I am proud of the nursing achievements here at Taranaki. The nursing team is a strong team, with the best care to patients and families first and foremost in their sights. I have been astounded by the nursing team’s commitment and passion to their profession and the Taranaki community. They are a strong team of nurses and I will always hold them in the highest regard.”
]]>He said he was always looking for good CVs from people with governance experience and invited those in the room with such experience to send their CVs to him.
Clark made the remarks in his opening address to the New Zealand Nurses Organisation (NZNO) conference in Wellington this morning.
The conference, held at Te Papa museum, comes about a month and a half after nurses signed an accord at Parliament to implement a programme ensuring safe staffing at public hospitals.
It is also a little over a month since nurses signed the fifth pay offer from DHBs, bringing an end to nearly year-long negotiations.
The agreement includes three pay increases of 3 per cent, two of which took effect immediately. There are also two new steps at the top of the nurses and midwives scale to recognise the skill and experience in those roles.
Thousands of nurses around the country went on strike ahead of the pay agreement after successive negotiations had failed. It was the first nurses strike for almost 30 years.
In his speech today, Clark said 2018 would be a year remembered for a long time.
He said it was a year to listen to nurses’ concerns and address them.
“An agreement was reached that offered better pay, better conditions, and more support.”
Clark’s speech ran to the theme that access to healthcare is a human right.
“Every New Zealander should have the right to control their own health and make informed decisions with access to quality information, free from ambiguity and judgment.”
His priorities as minister were equity, child wellbeing, mental health, and primary health care.
“You, as nurses, are often a patient’s first port of call. You have the power to make an impact in all of those areas.”
The World Health Organisation estimated there would need to be 9 million more nurses and midwives in the world by 2030, he said.
Clark said nurses needed to be involved in health policy decision making and implementation.
“When nurses lead with their voice, there are a range of significant outcomes for people and communities.”
He recognised the “incredibly important and valuable role” nurses played in the system.
Clark wanted to see nurses represented in governance positions.
“I appoint a ridiculous number of people in my role. I’m always looking for good CVs from people with governance experience.”
He invited those in the room with such experience to send their CVs to him.
]]>Byrne joined other nursing leaders in paying tribute to her work saying she had been a “capable, visionary leader” for the organisation and thanked her for her years of service.
Reed first stepped into the role as acting chief executive in late 2008 and was appointed to the role in 2009. During her time she oversaw some major changes for New Zealand nursing including changes to the registered nurse, nurse practitioner and enrolled nurse scopes of practice and the introduction of registered nurse prescribing.
In announcing her retirement Reed said it had been an incredible privilege to work with the Council, nurses and people from across the country and internationally. “There hasn’t been a day that I didn’t want to come to work,” she said. She said she had been part of an amazing team and they had achieved success they all could be proud of.
Professor Jenny Carryer, executive director of the College of Nurses said Carolyn Reed has been an outstanding CEO for the Nursing Council.
“She has balanced the rigour and attention to detail needed to maintain public safety with a wonderfully warm and humane approach to everything she does,” said Carryer. “Under her leadership the Council has supported significant developments in the scope of registered nurse practice and the ongoing development of the Nurse Practitioner role. She is visionary and focused in the role and will be very sadly missed and very hard to replace.”
The Ministry of Health’s Office of the Chief Nursing Officer congratulated Carolyn Reed on her retirement and acknowledged the outstanding contribution she had made to nursing throughout her career.
Dr Jill Clendon said as acting Chief Nursing Officer she had personally enjoyed working with Carolyn and would miss her dedication and contribution to nursing and the sheer passion she has for the sector. She said Reed had worked tirelessly to strengthen the nursing profession in areas like nurse prescribing and enhancing the scope of practice for nurse practitioners which enabled nursing to contribute more holistically to the wellbeing of all New Zealanders.
“Carolyn leaves the Nursing Council in as strong a position as ever to advocate for the safety and competency of the workforce.
Byrne said Reed had worked with the profession to ensure right touch regulation and is widely respected for her nursing leadership in the sector. “She has been instrumental in the forging of national and international links between regulatory authorities. Byrne said Reed had also worked hard to transform the organisation’s operations to improve efficiency.
Former Ministry of Health chief nurse and now Plunket chief nurse Dr Jane O’Malley said Carolyn Reed had probably been the finest registrar the country had ever had.
“She’s always been at the forefront of regulatory change for nursing – not just here in New Zealand or Australasia but internationally,” said O’Malley. She said during Reed’s time she had overseen tremendous changes in nursing scope of practices, prescribing, the new Code of Conduct and much more. “She’s been marvellous, has a great way with people and is a smart woman,” said O’Malley.
The Council has begun recruitment for a new Chief Executive/Registrar and expects to recruit a suitable candidate in due course.
]]>Williams is studying for her Doctorate in Health Sciences, with her research project examining the relationship between health services and education in primary schools from an education perspective.
She says the ICN leadership programme arrived at an exciting time for her doctorate and her current role, as its aim was to help enhance nurses’ effectiveness in influencing policy change as well as building competence and understanding of the health policy process.
Montayre, who trained in the Philippines before moving to New Zealand in 2011 and gaining his PhD in 2015, said he hoped the programme would help equip him with skills and confidence to bring the nursing voice to the policy-making tables.
“Nursing has reached significant milestones as a profession, however in this age of tight funding, emerging government priorities, and socio-economic challenges in a global scale, It is high time for nurses to be well-equipped in understanding how policies are made, be actively involved in policy-making,” he said.
“There is no such thing as being too ambitious around this or being too involved in policy. Our day-to-day nursing practice tells us nurses that something needs to be changed in our practice with the policies that govern these practices and within the environments we are currently working in.”
He said nurses being involved in government policy and strategy consultations was really important, for example the national health strategy, as well as supporting submission by professional bodies on areas like the End of Life Choice bill, the healthy ageing strategy and being involved in translational nursing research that informs future policies.
“I strongly uphold what Oestberg said: ‘As nurses, we need to think of policy as something we can influence, not just something that happens to us’.”
The five-month programme includes a week-long residential workshop in Geneva in mid-September with the aim of building nurses’ professional, political and policy leadership skills so they can help shape, influence and implement policy decisions. Participants are from across Africa, Australasia, North America, Asia and Europe.
Williams leads Whare Hauora initiative for primary school health services
Sarah William’s doctoral research follows on from her previous role running the DHB’s nurse-led Mana Clinic at Wellesley Primary School.
When Williams left Mana Clinic to become a nurse educator for Starship’s Community Child Health service, she continued to believe in the importance of having physical spaces for nurses in high need primary schools in order to provide health services.
Working in collaboration with others, she initiated a project three years ago that led to the opening this month of Starship’s first ‘Whare Hauora’, a partnership between health and education made possible through the support of the Starship Foundation. The Whare Hauora is an in-school, semi-permanent health clinic that provides a fit-for-purpose space for nurses to deliver health care to children at Panmure Bridge School.
“Experience had shown us that having a nurse available in the primary school space greatly supports children who have health issues that are preventing them attending school or engaging in learning activities,” said Williams. “This approach works even better if there is an appropriate facility for our nurses and others to use.”
Williams said the Starship Community Nurses are working from the school three or four times a week and previously had to work from whatever space was available, which might not have been child or nurse friendly.
“In schools where you have a lot of referrals you need an appropriate space – if you are asking a nurse to work there for a full day, it needs to be a pleasant place to work in and an inviting place for children to come to as well.”
She said Starship and its partners hoped to roll out two more Whare Hauora next year, working in collaboration with other high-needs primary schools.
The Whare Hauora contains a small waiting area, a private treatment space where patients are seen and office space at the rear for administration. It measures around 7.2 metres long and 3 metres wide and is similar to a shipping container, making it easily relocatable.
]]>Pauline Fuimaono Sanders-Telfer, the Nurse Leader for Auckland-based the Alliance Health Plus primary health organisation recently received her Master’s in Professional Practice (Leadership) for her leadership research.
Her research was prompted by wanting to know why there were so few Pasifika nurse leaders – particularly in her own area of primary healthcare. She said more Pasifika nurses has been identified as a key enable to improving Pacific health outcomes but there were very few formal nurse leadership roles in primary health care, and variable access to nurse leadership development, which impacted on the number of Pasifika nurses. Currently Pacific nurses make up about three per cent of nurses compared to Pacific people making up about seven per cent of the population.
Sanders-Telfer used the Talanoa interview method to interview Pasifika nurses with the findings highlighting that nurses’ life priorities significantly impacted on their participation in leadership roles. She said her research also found fundamental differences between the Western and Pacific view of how leaders were selected which also impacted on leadership participation; coupled with the variable support from the nurses’ employers and a lack of confidence in their own leadership skills and experience.
The lack of research literature into Pasifika nursing leadership also became clear. “My research was challenging due to minimal literature in my area of focus. This highlighted the need for more Pacific leadership research in nursing and health in general”.
“As Pasifika people, we can improve the health of our community,” said Sanders-Telfer. “We need to be part of the decision making conversations otherwise, someone who thinks they know our community will do it for us. As Pasifika women who are healthcare workers, we need to use our expertise and opportunities to provide quality care, at all levels of the health system, for our community. My journey has started, come and join me”.
Her research project was supported by the Aniva Pacific Nurse Leadership Programme, Whitireia school of nursing, Alliance Health Plus and the Ministry of Health.
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By Kate Blackwood
Reading the article Do nurses eat their own? Identifying and managing workplace bullying and undertaking this learning activity is equivalent to 60 minutes of professional development.
This learning activity is relevant to the Nursing Council of New Zealand competencies: 3.3, 4.1, 4.2.
Reading and reflecting on this article will enable you to:
Workplace bullying is a known problem in the nursing profession internationally.
If findings from research conducted in the New Zealand healthcare sector1 are applied to the nursing workforce, it is estimated that approximately 10,000 of New Zealand’s nurses have experienced workplace bullying in the past six months (about one in five), and that over 40,000 (87 per cent) have been exposed to occasional negative behaviours.
The detrimental consequences of workplace bullying extend well beyond those directly exposed. Bullying targets, witnesses, and individuals accused of bullying may experience harmful consequences, such as stress, depression, difficulty sleeping, low self-esteem, post-traumatic stress disorder, and suicidal ideation. Workplace bullying lowers morale, job satisfaction, commitment and productivity, and increases the likelihood of staff absenteeism and turnover.
In the nursing profession in particular, workplace bullying has detrimental impacts on workforce productivity and negatively impacts the quality and safety of health services provided to the public.
Bullying in nursing is enabled or encouraged by a range of work environment conditions, such as physical and emotional stress, high workloads, limited resources and community expectations.
A politicised climate is also said to exist in nursing, leading to a lack of collegiality and a climate of nurses “eating their own”2.
Bullying is often passed down from experienced nurses, with nurses commonly reporting being exposed to bullying during their training and induction years3. Such exposure to bullying throughout socialisation processes normalises bullying behaviours from the point of entry into the profession, encouraging and embedding a perpetual culture of bullying4.
Research in New Zealand shows that newly registered nurses are subjected to bullying behaviours, such as having learning opportunities blocked, being undervalued, suffering emotional neglect, being distressed about conflict, and being given too much responsibility without appropriate support5.
However, it is not only junior nurses who are at risk of bullying: bullying can occur anywhere in an organisation.
Although a range of definitions exists, it is generally agreed that bullying consists of systematic and persistent behaviours directed towards an individual over a period of time. The definition used by WorkSafe in their good practice guidelines Preventing and Responding to Bullying at Work6 is:
“Bullying at work is repeated and unreasonable behaviour directed towards a worker or a group of workers that can lead to physical or psychological harm” (p. 14).
There is a range of behaviours that constitute bullying. These are generally categorised as being work-related, person-related, or physically intimidating behaviours and are outlined in Table 1. (See Table 1 at end of article)
Because of the covert nature of many of the behaviours that can constitute bullying, bullying is often difficult to identify at first.
Also, the definition of bullying is such that it is not until the behaviours have been going on for some time (official measurements of bullying prevalence use a six-month duration7) and an individual has been frequently and persistently targeted that an experience would constitute bullying. Hence, the nature of workplace bullying is such that targets of bullying are often unable to identify an experience immediately.
However, as bullying behaviours continue over time, a cycle of demoralisation develops where the individual begins to doubt themselves and their confidence is undermined. In the initial stages of a bullying experience, they will often struggle to make sense of whether they are being targeted or whether they are misinterpreting the behaviours.
A common response by nurses when reflecting on the initial stages of their bullying experience is: “I thought it was all my fault”. At this stage of an experience, the targeted nurse will often seek to re-establish a sense of safety and security, rebuild comfort, and validate their value in their work team.
While a number of studies point to a struggle by those who are bullied to identify that what they are experiencing is workplace bullying, in some cases, the perpetrators may also struggle to identify cases of workplace bullying. Cultural norms can cause individuals to behave in such a way that they believe their behaviour appropriate in their work context, and bullying perpetrators may claim to have little insight into the impact their behaviour is having on the other person.
There are a number of strategies that an individual experiencing bullying can use to try to deal with the situation. These strategies can include:
Research indicates that junior or low-status employees are more likely to respond by trying to please the perpetrator and not giving them an opportunity to bully than they are to respond assertively8.
It is recommended that targets of bullying should be more assertive in dealing with perpetrators to avoid being perceived as easy targets of mistreatment. Several cases of effective coping by responding assertively to the bully have been reported by New Zealand nurses9, as in the following quote:
“I decided I wasn’t going to let her bully me. Every single time I spoke back to her nicely, no matter how bad she was, no matter what she said. And from my point of view, it worked. I was amazed. Her attitude towards me started to change.”
It should be noted, however, that targets of bullying who have success using this approach generally also have validation from their managers that they are not in the wrong and are well supported by colleagues.
For many targets of bullying, responding assertively is often easier said than done, particularly when the bully is at a senior level in the organisation or when the experience has escalated and the target has become demoralised and lost confidence.
Indeed, targets of bullying are often forced into positions where they have little power to deal effectively with their own experiences of workplace bullying and, unless the organisation steps in, an unfortunate and all too common outcome is that once the targeted individual’s personal coping resources are depleted they will leave the organisation.
Hence, early identification and reporting is essential for resolving cases of workplace bullying.
Most anti-bullying policies will outline the channels for reporting within the organisation.
Generally, nurses who believe they are being subjected to workplace bullying are encouraged to report to their direct line manager in the first instance, if they feel safe to do so. Other reporting channels include other managers, a harassment contact person (if the organisation has them), a union representative, or a human resources manager (HR). Some organisations also encourage reporting by way of lodging an incident report; however, experiences of bullying do not often involve a single major incident and instead the harm experienced is a result of a build-up of subtle behaviours over time. In such cases, incident reporting may not be appropriate.
However, despite being aware of policies and reporting channels, research shows that many targets of bullying do not formally report their experiences10.
Under-reporting may be due to:
When a target has previously seen other complainants being blamed or seen as troublemakers and having their problems deflected with little or no support, they too become reluctant to complain. In organisations where there is a culture of bullying and it is perceived to be tolerated, encouraging reporting is particularly problematic.
If a target of bullying makes a formal complaint to HR, they will respond by conducting an investigation into the complaint, interviewing both parties and witnesses, and provide recommendations based on the outcome.
However, targets of bullying often find this process overwhelming and emotionally draining. By the time a bullying experience has escalated to a point that a target believes a formal complaint is warranted, the targeted individual will often feel highly demoralised, having experienced numerous unsuccessful attempts to resolve the situation.
Due to the historical nature of many of the behaviours (with some experiences having continued for years prior to a formal complaint being made), and the contextual nature of the harm experienced (i.e. the build-up of behaviours, rather than a major incident), targets often have little evidence to support a bullying complaint. In addition, perceptions of right and wrong are usually strongly embedded by this stage and neither party is able to compromise on their views. As such, the outcome of workplace bullying investigations is rarely accepted by both parties and for these reasons a number of early, low-level interventions are strongly recommended.
The preliminary findings of current research into the competencies required for managing bullying show excellent practice by some New Zealand nurse managers, including providing perpetrators with insights into their behaviours and coaching them in effective communication with colleagues. Coaching the targets in effective responses to bullying can also increase their resilience; however, managers should be aware that relying solely on target-focused responses is rarely sufficient to resolve a case of workplace bullying and is unlikely to be suitable in escalated cases or when there is a power imbalance between the target and the alleged perpetrator.
Mediation is also a commonly used strategy for resolving cases of workplace bullying and can be conducted formally by an external mediator or by a manager or organisational representative. The efficacy of mediation for resolving cases of bullying is debatable; however, it is generally agreed that in escalated, highly destructive cases of bullying or where the alleged perpetrator is a manager, mediation is less appropriate due to the power imbalance that exists between the two parties. Although mediation is not recommended in such cases, if such a case does go to mediation, encouraging the target to bring a support person or advocate is advised.
Although there is evidence of good practice by managers and organisational representatives in responding to workplace bullying, ineffective intervention in workplace bullying is common. If the bullying intervention is not effective, the target is often left with little choice but to leave the organisation. Research indicates that unsuccessful resolution is often due to:
In cases where the alleged perpetrator is a manager, managers have been found to be able to justify their behaviours as performance management, and HR may often side with management. That said, however, staff may also use the term ‘bully’ in an allegation of managerial bullying as a response to legitimate performance management that they deem is unfair.
It is well-documented that effectively resolving escalated cases of bullying is near impossible, and therefore it is strongly recommended that early identification of potential cases of bullying and early reporting and intervention is encouraged.
Although line managers hold the role with most influence on the immediate work environment – and are often heavily relied upon to address behavioural issues within their team – the support of the organisation is also required to address an underlying culture of workplace bullying. While it is commonly recommended that an anti-bullying policy is developed and implemented by organisations, research indicates that a policy alone is unlikely to have a significant impact on the prevalence of workplace bullying and multi-level interventions are required.
Organisations should work to minimise work-related causes of bullying, such as role conflict and ambiguity, poor leadership, and institutionalised processes and practices that encourage bullying.
A strong zero tolerance for bullying should be communicated and enforced by senior leadership and commitment to this policy demonstrated through frequent communication and resourcing of interventions. Organisation-wide culture change programmes aimed at fostering dignity and respect in the workplace are also encouraged11.
Bullying intervention recommendations include:
Risk factors for workplace bullying include:
Witnesses to bullying have been acknowledged as playing an influential role in shaping the bullying experience and its resolution.
Witnesses can influence a bullying experience in a number of ways12. Those who associate themselves with a nurse clique may be more inclined to assume an instigating, manipulating, collaborating or facilitating role, whereby they encourage the bully or create situations for the perpetrator to go after the target, often for their own personal benefit. Alternatively, a witness may take an intervening, defusing, empathising, or defending role, whereby they actively support the target.
Unfortunately the most common role assumed by witnesses is one of abdicating or avoiding, whereby they allow the perpetrator to continue bullying, or simply walk away from the situation. Witnesses to bullying often fail to speak up at the time of an incident, often choosing to support the target behind closed doors instead, for fear of retaliation from the bully.
Although the prevalence, causes and consequences of workplace bullying are reasonably well documented, the search continues for effective strategies for prevention and intervention. Therefore the problem continues to persist and cases of bullying are rarely resolved effectively.
However, early identification and low-level interventions prior to escalation are vital if cases are to be resolved.
All staff within an organisation should be encouraged to familiarise themselves with the behaviours that can constitute bullying, report behaviours early, and stand up for colleagues experiencing bullying. Organisational support and a zero-tolerance culture of bullying are also required to put a stop to this pervasive problem.
Work-related
Person-related
Physically intimidating
Source: Negative Acts Questionnaire – Revised7
Kate Blackwood PhD is a lecturer and a member of the Healthy Work Group at Massey University, Palmerston North. Her recent research projects include exploring target experiences of workplace bullying complaint resolution, the efficacy of mediation in bullying cases and management competencies for fostering healthy work.
If you are interested in reading further on the research that informed this article,
email [email protected].
Stacey Wilson RN PhD is a senior lecturer at Massey University’s School of Nursing. Her research expertise includes mental health, crisis interventions and emotional competence.
Mikaela Shannon RN BN MN is a nurse manager at Capital & Coast District Health Board. She has a special interest in fostering respect, kindness and dignity between nursing staff and initiated and leads a Care with Dignity project at Kenepuru Hospital.
The simple act of nurses greeting each other at the start of a shift can be the source of cultural confusion.
“My staff still call me ‘ma’am’ – why don’t they just call me by my first name?”
“My charge nurse manager jokes she’ll fire me if I don’t call her by her first name, but I’m just being respectful.”
As New Zealand’s nursing workforce becomes increasingly multicultural, so does the potential for cultural misunderstandings at the nurses’ station, the bedside and the tearoom.
Kiwi-born nurses can feel uncomfortable when new migrant nurses chat in the corridor in a language other than English. And new migrant nurses can struggle to understand Kiwi-born nurses’ informality, jokes and jargon. Both can struggle to understand each other’s accents.
Integration is definitely a two-way street. New migrant nurses need help and time to adjust to Kiwi nursing culture and Kiwi-trained nurses need help to understand and respect the cultural differences that their new workmates bring to the ward or rest home. But integrating nurses from diverse cultures into a cohesive and collegial nursing team can be a challenge.
Nearly a decade ago Sue Lim, national director of eCALD, and her team developed courses, and eventually a free online toolkit, to help do just that. The courses were developed initially to meet the needs of the migrant nursing workforce but the Toolkit for Health Workforce Working in a Culturally Diverse Workplace is also aimed firmly at helping Kiwi nurses and nurse managers (and others in the health workforce) to better understand, appreciate and work with their culturally diverse workmates and build a collegial team culture (see more about eCALD at the bottom of this article).
“It’s important for all staff because everyone – regardless of whether you are migrant or New Zealand-born – needs to understand the cultural context that they are working in and needs cultural competencies,” says Lim.
Her colleague Dr Annette Mortensen, who is a nurse and eCALD’s research and development project manager, also points out it is not just migrant nurses from Asia and other CALD (culturally and linguistically diverse) countries who can face issues in adjusting to nursing in New Zealand, but also migrant nurses coming from the UK, North America and Europe.
NZ reliant on migrant nurses
New Zealand has long had a reliance on overseas-trained nurses, with more than a quarter of New Zealand’s nursing workforce being trained overseas. But the makeup of that migrant workforce has increasingly changed over the past decade, with the numbers of migrant nurses from the traditional sources of the UK and Ireland falling away and the number of migrant nurses from Asia, particularly the Philippines and India, steadily growing. Those two countries alone were the source of 1,047 of the 1,433 overseas-trained nurses registered in New Zealand last year.
As New Zealand becomes more culturally diverse – Asian people made up nearly 12 per cent of the population in 2014 and nearly one in four Aucklanders – so does the Kiwi-trained nursing workforce. Just under 20 per cent of newly registered New Zealand qualified nurses in 2012–13 identified as being from an Asian ethnic group, compared with 11 per cent identifying as Māori and six per cent as Pacific.
This increase in cultural diversity in the nursing workplace is not all smooth sailing. A major survey in 2012 of new members of the New Zealand Nurses Organisation (NZNO) – both New Zealand qualified nurses (NZQNs) and internationally qualified nurses (IQNs) – found evidence of cracks in the multicultural nursing workforce.
Researchers Drs Leonie Walker and Jill Clendon reported some NZQNs commenting on “too many IQNs”, expressing stereotypes about particular cultures and making negative comments about some IQNs’ training, cultural awareness or English skills.
Both NZQNs and IQNS reported witnessing racism towards Asian and Indian nurses – particularly from patients – including very high numbers reporting patients refusing to be cared for by a “foreign nurse”. IQNs themselves reported feeling discrimination, frustration and disappointment at their career opportunities in New Zealand.
Mortensen says the NZNO research illustrates what can go wrong in a multicultural workforce when integration is not successful. She also recognises that for some long-standing Kiwi-born nurses the changing makeup of the workforce also comes with a feeling of loss of community and collegiality.
“I’m in a workforce that isn’t like me and it’s not like it used to be”, is how some Kiwi nurses are feeling, believes Mortensen. “There’s a confusion and sadness about not knowing how to change with the times.”
Leadership needed to nurture multicultural teams
Bringing together new migrant nurses and Kiwi-born nurses into a multicultural team that works well together takes good leadership skills.
Lim offers a face-to-face programme for frontline managers, like clinical nurse managers, on managing culturally diverse teams, which is now embedded into the management training programmes offered at all three DHBs in the Auckland region. (Also available are courses targeted at helping migrant nurses adjust to the Kiwi workplace and a workshop designed for culturally diverse healthcare teams.)
Lim says managers have to understand that for migrant nurses the process of adjusting and adapting to the New Zealand workplace can be difficult.
“A lot of migrant nurses can feel full of anxiety, discomfort and resentment at being asked to integrate because it is a difficult process.”
Mortensen adds that NZ-born managers, coming from the host culture, have to be conscious that the power balance is in their favour, so need to be ready to go the ‘extra mile’ to be welcoming and friendly.
What eCALD advises clinical nurse managers to do is to help new migrant nurses adjust with small changes, take time to engender trust and be transparent about their expectations. This includes being aware that many migrant nurses are coming from different and often more hierarchical workplace cultures where speaking up at a meeting without being asked – or calling your manager by their first name – would be considered rude and disrespectful. Lim says as a new migrant from Malaysia 30 years ago it took her three months to feel comfortable calling her manager by her first name.
Managers need to give new migrant staff time and, if possible, mentor them or give them a buddy to guide them as they adapt. Managers also need to be ready to be a role model, to risk making mistakes and learning from them, and to accommodate difference. (Mortensen says she knows of one rest home manager who modified the uniform for her Muslim staff so it met both health and safety standards and was culturally appropriate.)
Lim stresses that team ground rules need to be set by managers, including zero tolerance for discrimination and stereotyping and setting clear, fair house rules on what can be a common cause of tension – new migrant staff talking together in their native language. She says this risks offending some patients and some staff, because they worry that the person talking in the native language may be talking about them. She says when managing a team of Korean and Chinese staff she allowed staff to chat in their own language in the lunchroom but they needed to make a friendly acknowledgement of anybody else who entered the room.
Developing cultural awareness and competency
Once again, multiculturalism is a two-way street.
For all nurses to be culturally safe practitioners, they need insight into their own culture and acknowledge how that influences their interactions with other nurses in the team – as well as patients – from cultures or ethnicities other than their own.
Along with being aware of New Zealand’s bicultural heritage stemming from the Treaty of Waitangi, nurses also need to accept the reality that nursing, like New Zealand, is becoming increasingly culturally and ethnically diverse.
A major section of the eCALD toolkit is aimed at all staff in a multicultural team and places a strong emphasis on building cultural competence, being self-reflective about any prejudices they might hold and how to work through any cross-cultural issues they encounter.
This includes thinking about what culture is, the dangers of stereotyping people, and of being ethnocentric and viewing one’s own culture as the only right way to do things and viewing all others as inferior. It also includes increasing understanding of how different cultural values can impact on communication – such as different attitudes about making eye contact, saying ‘no’, speaking up and interpreting body language and facial expressions.
The toolkit also emphasises that it is a myth that food, music, dance or other visible aspects of culture are the best way to better understand cultural diversity: “It is the invisible and unstated differences that present the most challenges and violations of trust and respect. These [differences] are held largely in the values, and in the expectations, goals and styles of communications.
“In fact, many cultures have values and styles that are almost opposite to each other. If we assess meaning based on patterns in our own culture, we are likely to misinterpret, misunderstand and be confused.”
Lim and Mortensen also stress that while offering cultural competency education is important, it isn’t enough without an organisation-wide cultural diversity and inclusion policy in place. Countries with similar and even less migration and cultural diversity than New Zealand already have such policies in place in their health organisations.
Such a policy here could help to reduce the risk of those cultural misinterpretations and confusions that can get in the way of good teamwork and good patient care.
About CALD and eCALD
CALD refers to culturally and linguistically diverse groups who are migrants and refugees from Asian, Middle Eastern, Latin American and African backgrounds.
Since 2010 eCALD has been providing a variety of free, accredited e-learning courses for health professionals working with culturally and linguistically diverse (CALD) groups in New Zealand – including their fellow health professionals.
The Ministry of Health-funded eCALD service is based at Waitemata District Health Board’s Institute for Innovation and Improvement. Around 24,000 learners have completed a CALD course since 2010, with more than a third of those being registered and enrolled nurses.
Find more information on free e-learning CALD courses and resources at www.ecald.com.
]]>The interim chief executive at Waikato District Health Board has spent most of his career in health managing broken situations back to repair.
As the replacement for Dr Nigel Murray, who resigned in October amid an expenses scandal, Wright is arguably tasked with his biggest challenge yet.
That is; change the culture, create a workplace people are proud of, get Waikato Hospital to the top of its game, and turnaround the DHB’s financial problems.
The 63-year-old has set himself a one year deadline to achieve the transformation.
He doesn’t want to commit for too much longer than that for two reasons – he gets bored easily which turns to “mischief”, and he wants the next chief to hunker down for five years and lead the embattled DHB into a period of stability, security and ultimately, growth.
And it should be noted, Wright – previously the health board’s mental health and addictions executive director – was given the seal of approval for the important interim job by the senior doctors at Waikato Hospital.
This is no mean feat, particularly given the dysfunctional relationship Murray created with clinicians during his three year tenure, and the loss or partial loss of training accreditation in different units at the tertiary hospital.
Wright says there’s no secret to being a good leader.
“It’s not rocket science. I think it’s about having that focus, having that visibility. I’m really clear that I make decisions everyday that impact on the work that staff do and unless I’m informed then I might be making the wrong decisions.”
Relating to people from all walks of life comes naturally to Wright.
Born in Scotland and raised in Fife, north of Edinburgh, Wright fell into health at 19 when his neighbour offered him a job at the local hospital as an orderly.
“I started at the bottom basically.”
The football-mad teenager earned just 10 pounds per week, about $200 by today’s standards, graduating to 15 pounds a week after he trained to be a nurse.
That was 1978. He specialised in surgery and crossed into mental health, working his way up from a staff nurse to a charge nurse.
He moved to Newcastle in 1984 at the time when major health reforms were underway with an emphasis on turning clinicians into managers.
Wright was offered a spot at Birmingham University to study health management and moved into general management shortly after.
By then he was married to Elizabeth – who he met in the nurses’ home of a psychiatric hospital – and together with their two children in 1992 the couple upped-sticks and moved to New Zealand on a health industry exchange for one year.
Wright swapped jobs with the manager at Auckland mental health services based at Waitemata.
“During that year I also got asked if I would take on the role of project manager for the closure of Kingseat [Hospital] and Carrington [Hospital].
“I think it was because, ‘new guy, if it doesn’t work then he’s out of here and if it does then he’s out of here anyway and we can take the credit’.”
Wright closed the two former mental hospitals – Kingseat took longer than a year – and back in the UK he and Elizabeth decided, thanks to a bitterly cold winter, they would make New Zealand home permanently.
He managed mental health and drug and alcohol services at Waitemata from late 1993 before becoming general manager of North Shore Hospital for four years.
That was followed by a stint as the first mental health regional director for the northern region before Wright was headhunted in 2007 to be director of operations in South Australia.
“The day I arrived, they had 74 psychiatrists and 40 of them resigned. Nothing to do with me. It was all to do with pay negotiations they were having with the state but that was my introduction to South Australia.”
Five years later Wright returned to New Zealand. He worked for a non-government organisation and was made redundant.
He set up a consultancy, doing strategic planning, restructures and service reviews, including a mental health review for Northland.
Wright initially turned down the opportunity to apply for the mental health director role at Waikato, but eventually succumbed to a persistent recruitment agent.
He joined the DHB in February 2016, during the middle of a Ministry of Health Section 99 review of its mental health unit, following the death of patient Nicky Stevens.
Among other things, the review identified the need for an experienced senior executive in the DHB’s mental health team, a position left vacant during a restructure of the executive leadership by Murray.
The DHB had also been in the spotlight for allowing fake psychiatrist Mohamed Siddiqui to work there for six months in 2015 on a salary of $165,000.
“There was lots to do but there was a really good team and me never having worked in Waikato before, I came in with fresh eyes. We made lots of changes. There was already lots happening – I just hopefully provided some leadership to the team.”
Wright has already been outspoken on some issues. He previously said he believed New Zealand had too many district health boards.
Twenty for a population of 4.5 million is out of kilter he reckons, and he believes there should be one linked IT system for all DHBs so that health records follow patients.
He also wants to see real change come from the ministerial mental health inquiry launched last month, not just “a tinker and throwing money” at the problem because as it stands our mental health system is unsustainable, Wright says.
Plus there’s room for better training, Wright suggests. Much of his training was on the wards compared to today’s student nurses, some of whom get all the way through a nursing degree only to find the profession is not for them once they get properly into a hospital.
“I think the pendulum has gone too far. I think probably when we trained in the ’70s we were a cheap workforce. I think here there’s too much of the academic side of it and not enough of how do you deal with people.”
Nowadays Wright says there are lots of expectations from health that didn’t exist 40 years ago.
“In the early ’70s, if you were a patient and you needed a hip replacement and you were 65, you didn’t get it done.
“Whereas we operate on 90 year olds now because the expectation is you get it done.”
For now though Wright will concentrate on the job at hand – restoring public confidence in Waikato DHB.
He has set about doing this with a number of initiatives including recently proposing to trim his executive leadership team, to dismantle the 18-strong group Murray put in place and re-assemble it so only 11 executives report directly to him.
Wright also returned the executives to Waikato Hospital after Murray moved them to an ivory tower in the city, away from the coalface clinicians felt.
There’s a 10-year plan being developed focusing on prevention and working smarter, and staff at the $1.4 billion organisation have rallied behind it.
He’s confident of regaining the lost training accreditation in obstetrics and gynaecology and is working on creating a workplace free of bullying and where targets feel they can speak out.
Wright will continue visiting the DHB’s 7000 staff including those at hospitals in Taumarunui, Tokoroa, Te Kuiti and Thames, and he is tackling the way the DHB communicates, both internally and externally.
It’s undoubtedly damage control after the DHB was accused of keeping information secret during the Murray affair, but making himself available to the media and sending out fortnightly intranet updates to staff, complete with jokes, is a good start.
“I’ve hopefully brought some consistency to the organisation. I do a lot of management by walkabout. It’s a slightly different culture I’m trying to bring to the organisation. I guess I’m just trying to humanise management.”
]]>But workplace and incivility is less common in hospitals where line managers show ‘authentic leadership’ behaviours, reported researcher Professor Stephen Teo at this month’s Australian and New Zealand Academy of Management Conference.
He reported that 59 per cent of the 230 nurses surveyed recounted witnessing bullying in their workplace, while 48 per cent reported being a target. Of the bullying targets, 39 per cent experienced bullying now and then, while 12 per cent went through the ordeal several times a week.
Teo, of Cowan University’s Centre for Work and Organisational Performance, said the high level of bullying partly reflected the healthcare sector where people were often promoted primarily based on their clinical skills and the soft skills, such as managing people and relationships, were considered secondary.
“The pressure of the medical field can expose weaknesses, so a manager may react abruptly and be snappy, and if that isn’t addressed, it can become normal,” said Teo. “This has a trickle-down effect on how those around them act.”
His research considered the impact of civility – which included not just traditional workplace bullying but also behaviours like rudeness, creating feelings of exclusion, unfair work distribution and negative body language or tone.
He said nurses that witnessed or experienced incivility were 52 per cent more likely to report psychological stress, which had been linked to increased health problems, turnover and decreased efficiency.
But in workplaces were line managers, like charge nurse mangers, demonstrated ‘authentic leadership’ characteristics like honesty than nurses’ perception of incivility was 37.5 per cent lower, which in turn reduced stress.
“Authentic leaders model positive social behaviours while being self-aware and open and honest,” Teo said. “They embody the organisation’s professed values, even if they aren’t perfect.”
His research also found that nurses who felt they and their organisation had shared values, experienced lower levels of workplace incivility and psychological stress.
“Overall, our research suggests healthcare organisations need to put more emphasis on training to provide line managers with skills and tools to navigate the human side of work,” Teo said.
BULLYING RESOURCES
Victoria University researcher Dr Helen Rook’s recently completed PhD research found Kiwi nurses felt conflicted and anxious at being unable to deliver care true to their nursing values because of pressures on the ward to discharge patients quickly, keep-up the paper work and keep costs down.
She said the nurses’ response– sometimes conscious and sometimes not – was to focus on essential duties like documentation and nursing tasks as a coping strategy. Sometimes this also lead to nurses cutting short patient conversations, ignoring call bells and in other ways withdrawing from their patients to protect themselves emotionally.
Rook’s PhD research – prompted in the wake of the inquiry into patient neglect in Mid-Staffordshire – involved spending 300 hours observing nurses on medical wards in three district health boards, multiple interviews, checking nurse sensitive indicator statistics (like falls and pressure injuries), and measuring burnout levels. She concluded that the conflict that the nurses felt – between their personal and professional values and how they actually were able to practice nursing because of the constraints of modern healthcare – caused anxiety, exhaustion, cynicism and burnout.
Building and supporting nursing leadership at the ward level upwards was one recommendation by Rook to help nurses speak up and act on their concerns. Another was for district health board and other healthcare providers to put in place strategies to help mitigate the organisational dysfunction and financial constraints that lead to nurses feeling unable to consistently deliver compassionate, clinically competent care.
Withdrawing from patients a coping strategy for conflicted nurses
“In all of the wards the nurses said they were practising team nursing and yet there was very little evidence of that,” said Rook. Instead they were observed to be mostly focussed on tasks and “getting things done”. “They are very skilful at that,’ said Rook. “In order to protect themselves they use defensive strategies to protect themselves from anxiety.”
She said the conflicted nurses also used the coping strategy of withdrawing a little bit from the patients they were caring for. So they tried not get caught in conversations with patients by using strategies like giving a quick smile. “Or say ‘I’ll be with you in a minute’ and then pull themselves away as they know they have all this other stuff they need to get done.”
Rook said she also observed more overt withdrawal by busy nurses. “I watched nurses walking past patients who were calling out for help, and call bells that were unanswered, not because nurses were uncaring but because they had so many other things to do, to comply with.”
When she spoke to nurses about the organisational values at their DHBs – and the DHB’s strategies for improving patients care – she said a number expressed cynicism that while DHBs talked about focusing on partnership and respect most improvement projects were actually about discharging patients quicker, balancing the budget and ensuring the required documentation was done. She said there was also a sense that the DHB’s emphasis on economics and managerialism was becoming more prevalent not less.
But she added that for her Phd she drew on the iconic nursing research carried out in a London hospital in the late 1950s by Isabel Menzies, who wrote about how nurses de-personalised patients to protect themselves from the anxiety of their work.
“That’s a long time ago – we’re 2017 now – but a lot of things that she found in that research I also found in my research. Not a lot has changed in healthcare in the intervening years really…”
Be consciously present not emotionally numb
“Nurses go into the profession with an assumption that they will be caring for people who are sick, taking a moment to talk with them and build caring relationships,” said Rook.
But said the current culture didn’t allow for that and DHB’s managerial imperatives to get patients out of hospital quickly, combined with financial constraints, meant that it just wasn’t possible. So nurses often responded by focussing on doing the essential nursing tasks.
“I think there is a bit of guilt in that we focus on tasks,” said Rook. “I don’t think it’s such a bad thing if we do. Because that is what the public expect – they expect us to be able to do things for them.”
Rook said if the reality was that nurses’ coping strategy for pressured workloads was to focus on tasks, then nurses should take ownership of this new reality. They needed to be vocal about the type of nursing care they were able to deliver, and why, and then deliver the task excellently.
“We need to be very clear that ‘okay we are going to focus on a task but we are going to be excellent in that task and in our interactions with people….even if is only a minute or two.”
She said nurses need to aim to be fully present with their patient even if “just doing a task” as that would be much more beneficial therapeutically.
“We need to be consciously present rather than emotionally numb in our patient interactions.”
But in the long-term she said it was imperative that nurses on the frontline were supported to build leadership skills and find their voice so the culture was changed and they could provide the nursing care that matched their personal and professional values. Also organisations had to introduce strategies that removed the constraints currently preventing nurses from delivering that care.
Rook, who is currently the Programme Director at the Graduate School of Nursing, Midwifery and Health at Victoria University of Wellington, graduates next week with her PhD in nursing.
She has a background in critical care nursing in the United Kingdom, Ireland and New Zealand, and has worked as a nursing academic in New Zealand and Ireland delivering undergraduate and post-graduate education.
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