KEY POINTS:
It's tough, thankless work with high dropout rates - and the sexy uniforms are long gone - so why is nursing more popular than ever? It's the magical allure of compassion.
Nursing has always been the dream job for little girls: the nurse who listened to your heart beat, tapped your knees and peered down your throat was the model of what was most interesting about life. And the uniform of the 50s, with its cinched-in waist and pert white hat, was pretty cute, too. Since Florence Nightingale, nurses have consistently topped our "most trusted professionals polls" - plus they get to hang around with all those McDreamy doctors.
Now, nursing has a decidedly unglamorous reputation - but why? Long gone are all those problems our mothers warned us about: the heavy lifting ("ruins your back, dear"); smelly bedpans; boring menial work and doctors treating you like servants. Today's nurses have bachelor's or master's degrees; a "pay jolt" in 2005 brought their salaries into the real world; they have hoists and sliding sheets to lift patients and move them from bed to bed. Undergraduate enrolments are higher than ever, and nursing schools are even seeing the return of students who previously dropped out of courses, but are now newly excited about better pay and improved job prospects.
Yet statistics show that 40 per cent of nurses leave the profession every year, exhausted, disillusioned - or simply because their shiny New Zealand Registered Nurse badges are tickets to better-paid jobs almost anywhere in the world. The way it goes, say new graduates, is you work a year to get that essential ward experience, then take off to the country of your choice; experience a new lifestyle and pay off your student loan at the same time. Right now New Zealand nurses are staffing hospitals in London, Edinburgh, Dubai, Cape Town, Sydney - the world. Some don't come back.
Others move into primary community care, working as midwives, nurse practitioners, practice nurses, workplace nurses with companies such as Fisher and Paykel, private hospital nurses - or like former nurse, Julia Morris, become highly paid drug-company reps.
But, says Kristina Cassels-Brown, one of the last intake of Greenlane hospital-trained nurses, nothing compares with the deep satisfaction of "being at the bedside" - working on the public wards with patients and their families. She's not kidding. Back in 1990 when my father was rushed into hospital with a stroke, he was treated by a wonderful nurse. Sometime later, as we sat at his bedside, tense, silent, horrified as his oxygen mask filled with blood, she must have gone off duty. I remember calling for help and someone else arrived, looked after the crisis, then left us in peace while Dad died.
By some amazing chance, I meet Cassels-Brown again while interviewing nurses for this story and she tells me she was that first ministering angel. To my shame, I had not recognised her until this moment - even though she helped us through one of the most traumatic times in my life, and after 17 years has never forgotten my father, or me.
How many people, I wonder, has she supported through a death? How much of an emotional load does she carry on her slim shoulders? Plenty, she says. That's part of the job - the most rewarding part. "It's not just about death. We're present at really huge times for patients and help them with the enormity of it."
New graduate Laura Doorish has yet to find the deep satisfaction of dealing with the raw human emotions that surface when people are critically ill or dying. "I'm 22 and I'm dealing with death. But I always have this rule. I let myself think about work until I'm on the Northwestern Motorway. Then I take a deep breath, think about dinner, and let it go.
"I love it here," she continues. "Here" is Ward 81, one of Auckland City Hospital's two specialist neurology wards, where Doorish, in her blue and white pinstriped blouse, blue pants and lip gloss, works alongside Cassels-Brown. They deal with the medical and surgical sides of brain or spinal disease or injury (strokes, accidents, brain tumours, galloping MS or Parkinsons that needs stabilising). The nurses' station is studded with computer screens showing cross-sections of patients brains. Consultants stride round, flanked by house surgeons and students while the patients lie there, speechless, often paralysed - and the nurses hold the whole thing together.
Admittedly, Auckland Hospital, especially in its tertiary specialist wards, is different from other hospitals and other wards. Patients stay longer, the work is complex and challenging, staffing is adequate, nurses work more satisfying 12-hour (rather than eight-hour)shifts - and nurse turnover is a low 14 per cent.
At North Shore Hospital, where wards run at 100 per cent capacity throughout winter and nurses have to care for critically ill people in hospital corridors because there are no beds for them in the wards, almost half the nursing staff leaves each year: 73 per cent of them to be replaced by new graduates or overseas-trained nurses.
But how do we get New Zealand nurses to stay home? "Tell us we're doing a great job, show us we're appreciated, give us more money," says Joanne Clements, who graduated last year after a career in the corporate sector. People don't appreciate how good New Zealand nurses are."
The current crisis goes back to the nursing renaissance of the early 1970s, which replaced apprentice-style, hospital-based training in favour of a three-year tertiary Bachelor of Nursing course. Nurses, who had once cheerfully emptied bedpans, became medical professionals with a highly specialised university degree behind them and were underpinned by enrolled nurses (a one-year hospital-based course) who did much of the washing, panning and basic nursing under the care plans and supervision of the RNs.
The new system was based on the "primary nursing model" which meant that nurses, rather than working in a team under a matron, now worked independently. Each nurse was responsible for the total care of, say, six patients on each shift.
But, explains Susanne Trim, of the New Zealand Nurses Organisation, the nursing reforms became unworkable after a new set of wide-ranging health reforms rolled in two decades later. "The Gibbs Report meant bed numbers were reduced, bed occupancy increased, rapidity of turnover increased - and all of it put more pressure on the nurses' workload," she says. Gibbs' system also led to the increasing use of part-time staff, pool and bureau nurses - and in some parts of the country, unqualified workers to replace enrolled nurses.
Over the following 20 years, despite successive governments, and much tinkering, the system has remained roughly the same, but with an increased emphasis on treating people at primary-care level - in other words, out of hospital. Despite increasing population growth only 0.8 per cent of new nursing positions were created over the past decade. (The number of doctors increased 2.3 per cent.)
Meanwhile, second-tier nurse training was phased out of hospitals in 1993, putting even more pressure on RNs, and did not re-start in polytechs until 2000. They now turn out nurse assistants, and courses are based, surprisingly, only in Northland and Christchurch with Southland about to begin one and Rotorua looking at offering another. In Auckland, student nurses are filling the gap by working as paid nurse assistants on weekends.
And the work gets harder. By the time people arrive in hospital they are sicker, probably older and have several different conditions or illnesses. Modern nurses must work with high-tech monitors and computers. The drugs they administer are powerful and complicated. The paperwork trail that surrounds their patients is rigorous, time consuming - and most of it designed to cover the hospital's back. The average ward nurse has to complete about 20 minutes paperwork for each patient. If she has six to look after that's two hours out of an eight-hour shift. And although some nurses are plainly not interested in the washing and bedpan end of the job, most simply have no time to do it.
The nursing hierarchy has managed the situation by making on-going education a huge part of the Registered Nurse's career structure - and it starts the day of graduation. Much is dictated by the Health Professionals Competency Assurance Act. Cassels-Brown, who spent years tutoring students, says: "You have to have attended lectures, put together case studies and conducted teaching sessions and it's examined by an educator who sits alongside you every day."
She says the programme is too tough for new graduates. "They're on a ladder, like mice on a wheel. They haven't had the on-ward experience we had and it's a pretty responsible job to just walk in and start doing - without studying at the same time. All jobs that are advertised now have the caveat: 'you must be working towards a post-graduate degree."'
The downside of that Master's degree is that it doesn't mean a wage increase.
But although New Zealand-trained nurses have this Rolls-Royce education system, the reality is that a large slice of our nurses are overseas trained. "A good New Zealand nurse is an excellent nurse," says another who has moved to the private sector. "They take account of your feelings much more than some other cultures."
Others complain that nurses trained in the primary model don't work together enough. "They'll finish their patients and sit down at the nurses' station, rather than helping a colleague who is rushed off her feet."
And for all this - and after the famous "pay jolt" - the average inpatient registered nurse earns around $54,000 a year, plus penalty payments.
"The jolt boiled down to a 4 per cent pay rise for three years in a row, followed by a four-year freeze," says Clements. "I left corporate work on $55,000 nine years ago. Now [as a junior paediatric intensive care nurse] I'm on $50,000. The work's hard, the pay's not great, we work very anti-social hours and there's continual study.
Trim says it's a wonderful career but one that is under pressure. "When you're short of staff it can be soul-destroying."
Amid the gloom there are glimpses of light: a move back towards team-based nursing; nurse assistants arriving on the wards; the introduction of more satisfying 12-hour shifts and fixed shifts where nurses work the same hours every day.
"The pay increases have made a big difference," says Cathy Andrew, head of the nursing school at Christchurch Polytechnic Institute of Technology, where bachelor enrolments have risen 16 per cent in the past year. "We're seeing many more school-leavers taking an interest in nursing, and there's much more confidence now about the job market."
On the downside, the average age of nurses is now 45, just over half of them work part-time and the turnover is huge. "It's worrying," says Trim. "I think it's a real signal of a growing crisis." Nicola North, associate professor at Auckland University's School of Nursing, agrees. "It can be very hard for an older body to keep up with the physical demands."
But the underlying problem, says Cassels-Brown, is that the district health boards simply don't employ enough nurses. "It's important to audit, but that takes people away from the jobs they should be doing - and leaves a gap at the 'gold standard', caring, end of the equation. The thing is, washing someone not only makes them feel better, but also provides important diagnostic time. Brushing a patient's teeth, rubbing his back, washing, showering, always observing."
I think back to the professional, meticulous care she showed my father - and the instinct in all of these nurses who have chosen to look after people during the most traumatic times of their lives. How frustrated they must feel when low staffing levels mean they cannot do the job properly.
As several nurses told me off the record, the Nursing Council, by its failure to stand up to the constant pressure from the DHBs to keep nurse numbers and salaries down, and its emphasis on higher education and auditing performance at the expense of basic nursing, is not looking after its own people well enough.
And if anyone deserves to be looked after, surely it is these people, these angels of the bedside upon whose compassion, in turn, we all rely.
Laura Doorish, 20s, new graduate
Doorish is one of those girls who stuck with a childhood dream of being a nurse that goes back to when she was 5. "Mum's mother and father were both mental health nurses, Mum would have loved to have done nursing," she says, "and I always wanted to." And no, real-life nursing is not like ER even though the entire ward used to watch it and discuss the programme furiously in the morning. "True-life nursing is not as fast-paced," she laughs. "In ER they don't show the preparation, the on-going education, the drawn-out things like preparing patients for stitches that takes 20 minutes."
Doorish came to neurology on a six-weeks placement segment during her training and applied to come back after she graduated because she enjoyed the complexity and rhythm of the ward.
Now, after a year, she is a Level Two Registered Nurse, working towards a Masters degree at Auckland University and routinely looking after four patients for 12-hour stretches. She has an easy way with patients. They open their eyes and smile for her. Mentors and co-workers, including Cassels-Brown, greet her with jokes and gentle joshing.
Nathan Tuuta, 30s
Tuuta, the only man on his ward, trained in Taranaki and moved to Auckland as part of a Maori nurse development scheme. Like all our nurses, his family had a big part in his career choice. "My sister and I went on a trip to Arkansas to see my mum," he says. "And we thought, why don't we give this a go? These girls [friends of his mother] were nurses, too. They were travelling, having a good time ..."
Thirteen years later Tuuta, now 32, is a prized nurse in Neurosurgery's High Dependence Unit while his wife, Marlene, works in anaesthetics. They met on the ward. "Mum's a nurse, my sister's a nurse and my wife's a nurse."
"It's changed a lot since I started," he says. "There was definitely a homosexual stigma when I decided to go into it. We had 15 guys start and nine graduate out of a class of 55. Of those, a couple left to become musicians, one became a medic then a ski instructor, one went into nursing management and another works for the Flying Doctor service. And quite a few went to the UK, the States and Canada to do their OE - it's definitely a career you can travel with."
He and Marlene work opposing 12-hour shifts three or four days a week so they can look after 18-month old Kereama, and juggle to get Mondays off together. Between them they pull in pretty good money - and with a new baby expected in late August are planning take their talents back to Taranaki. As Tuuta says, "I'd love to stay in neurosurgery. Auckland Hospital is good to work for, but in Taranaki there are four or five sets of family within a kilometre ... It's just for the kids - more space to run around."
Joanne Clements, 30s, late bloomer
From the time she was 18, Clements wanted to work in medicine. Her problem was she didn't stay long enough at school to qualify for the nursing course. Only after several years of travelling and high-end PA work, she took the plunge. "I went and saw my parents and asked if I could please move home, and enrolled at Manukau Institute of Technology."
Half her colleagues were school leavers and the rest in their late 30s. "They'd had their children and were looking at getting back into the workforce." Six years on she doesn't see that happening: "Older women with young kids don't want to do it and I don't blame them."
Clements is now a paediatric intensive care nurse at Auckland Hospital. "I do it because I like the shift work and days off during the week," she says. "I love the actual job - the autonomy, the challenge of it, the way it's changing all the time."
She handles everything from her patient's ventilation and IV medication, to wound dressing and making them comfortable. "We're very focused on our speciality," she says. It's getting harder and harder to move around [to other wards]."
And the job does not stop there. Nurses deal with family tensions, parents who want their child any way they can have that child - including seriously disabled. "We deal with family dynamics: not just the kid in the bed."
But even she sometimes wonders how long she will be able to keep going at this pace. "I've got 30 years of nursing left. Nursing responsibility has become a lot bigger, there are fewer nurses and more patients - and I can understand why young women don't want to do it."
Kristina Cassels-Brown, 50s
When Cassels-Brown trained in the early 1980s, nursing was one of the preferred jobs for school leavers. Unlike modern students, who pay to learn, student nurses were paid for their time. And unlike her mother, who was obliged to leave nursing when she got engaged, Cassels-Brown got 12 months' maternity leave after both her children. When they were small she had the option of working night-duty, which meant she could still look after the children during the day. "That didn't last long," she remembers, "I didn't tolerate it".
After "retiring" in 1994, she landed a job in Neurosurgery - and the pressure to upskill was enormous. "I was out to Manukau Tech one night a week doing a paper a term, ending up with bachelor of health science." This turned into tutoring on the bachelor of nursing course at AUT and completing her clinical masters in nursing. She finished last year then moved "back to the bedside" where she loves it best.
"Neurology is a really challenging area because you're often looking after people who've lost some ability to move. And it's good for [someone wanting to do] gold-standard nursing too."
Even with a master's degree, Cassels-Brown gets around $54,000 a year plus shiftwork margins. "I don't find the money much different from the university pay ... and I like it better."
Julia Morris, 30s, drug-Company Rep
Three years ago Julia Morris was struggling with a student loan, an injured shoulder and a busy ward at Auckland Hospital. Today the 33-year-old former nurse drives a new Ford Mondeo, works days, makes appointments to suit her schedule and is making inroads into her loan.
Although she enjoyed nursing, after eight years the stress was showing. "I loved being a nurse," she says now. "I enjoyed the huge challenges and variety. And I loved working with the people, helping the people."
On the other hand, "nursing school offers a really good foundation, but it's only when you're actually in the job that you really start to learn things. They were very understaffed, and especially in the acute, fast-paced areas it was challenging. Every day we had bureau nurses, pool nurses, resource nurses and student nurses who needed to be oriented. You do have the responsibility and are trying to juggle all these things."
She started at $35,000, which was barely enough to pay her rent and food. Then, three years into her career, she lost most of the use of her right arm with a nerve problem. Although there was no known cause for the condition, Morris, who chose to do a lot of afternoon and night shifts, personally linked it to stress, overwork, and shift work.
"There was no health care, no medical insurance and it was against hospital policy to pay me out annual leave," says Morris, who spent 21 months on the Invalids' Benefit, followed by six months part-time. Still in pain, she moved to Recovery, working as clinical charge nurse.
And then she ran into someone leaving a pharmaceutical company who encouraged her to apply for the job. She now works for Australia-based Abbott Immunology, selling a new drug for rheumatoid arthritis and other auto-immune diseases to specialist doctors. She travels abroad a lot, works nine-to-five, sets her own schedule, makes more money and belongs to the company's generous superannuation and medical insurance schemes. But the most important change, she says, is being recognised for what she does. "You get reward, acknowledgment, recognition. You're treated like a professional and get to do really exciting things."
Meg Ayrton, 60s, Practice Nurse
When she started at the Herne Bay Medical Centre, 23 years ago, the busy suburban practice had no recall systems for things such as vaccinations, smear tests and blood tests, and was not on computer. Now, thanks largely to Ayrton, who worked as a practice nurse for 10 years in England before arriving here, the place runs like a well-oiled machine.
This is primary care at a gallop. Many of the practices 19,000 patients call for Meg, with her unflappable smile, before their family doctor. She masterminds the recall system. She and the team of four nurses administer vaccinations for everyone from tiny babies upwards, monitor blood pressure, the practice's diabetics, people on blood thinners and those with heart problems, take cervical smears, administer ECGs, cut out verrucas, plaster broken arms, suture wounds, give advice about illness, diet and cholesterol, fax prescriptions to chemists all over the city, chase up doctors and generally provide an excellent service. She gets between 60 and 80 phone calls a day.
"Our nursing role and our patient roll has increased enormously since we became a PHO [Primary Health Organisation]", she says. "When I arrived from England we were seeing many more patients because it was free. Now we're seeing as many here - and it's free for children under 6."
She finds this kind of nursing busy but satisfying: "It's almost impossible to get to the phone now," she says. "But babies I immunised are now coming in with their babies to be immunised."
