Aged care nurses are working double and even triple shifts — 24 hours straight — to plug gaps, writes Nicholas Jones.
It took only a few nursing vacancies to close Wharekaka rest home and upend the lives of its elderly residents.
Aged care homes across the country are grappling with a severe nursing shortage that in recent months has forced 20 facilities like Wharekaka in the South Wairarapa to close all or some of their hospital-level beds.
The sector is short 1000 registered nurses out of a workforce that should number about 5000.
Covid-19 shut borders and created fierce competition for nurses, who can earn much more in public hospitals or working in other DHB roles, including as vaccinators.
The trust that runs Wharekaka, a 20-bed care home in Martinborough, can't replace three nurses, including two who left after refusing to get vaccinated against Covid-19.
As a result, it couldn't accept residents needing hospital-level care, and the associated loss of funding was a tipping point.
Elizabeth Kershaw, 91, was days away from moving in when news came of the closure.
Her son, Richard, scrambled to get her on the waitlist for a home in Greytown, but without other options in the area she will, in the meantime, keep living in a granny flat on his farm.
That's despite her needing someone close by around the clock, because of ill health that puts her at risk of falls.
"She needs to be there, and she wants to be there" says Richard of Wharekaka, a community mainstay where Elizabeth's own mother lived.
"We were taking her in twice a week for day visits. Singers come in to perform, they have exercise groups, that sort of thing. She loved that, she loved going in there and meeting up with people. They love that contact when they get a bit older.
"That's what a community is all about - babies, kindergarten, all the way through - you make sure that you provide. But unfortunately, we're not now. It's sad the way society has gone."
The Weekend Herald has obtained government documents and emails about the unfolding crisis, reviewed hundreds of rest home audits and reports, and spoken to frontline workers, unions and facility owners.
Even aged care homes that manage to stay open can do so with unsafe staffing levels.
Authorities were notified of 851 incidents last year when a facility didn't have enough nurses to ensure the safety of residents - a 227 per cent increase from 2020.
Nurses have worked triple shifts - 24 hours straight - because there's nobody to relieve them and they won't leave residents without cover.
Simon Wallace, the chief executive of the Aged Care Association, which represents most companies and owners, says staffing shortages are worsening by the day.
"I don't use the language that I am about to use very lightly at all. Quite frankly, we are on a precipice in aged care right now. We are on the verge of collapse."
A lack of nurses has caused more than 400 hospital-level beds to close in the past six months, he says.
"In Whanganui, an older person cannot get into an aged residential care facility, because there are no beds. In Taranaki, there are now only three rest homes that can take admissions. This is being repeated all over the country," Wallace says.
"We are going to close more beds and these people will start clogging up the public hospitals because there won't be anywhere else for them to go. The Government does not want to have that on their hands with Omicron."
Health Minister Andrew Little told the Weekend Herald he had instructed officials to work on a massive pay deal for aged care and other nurses that would, with other changes, ease staffing shortages.
"I accept there is a degree of urgency to it. And that is why I have been pressing officials to get on with it.
"All parts of the health sector are suffering a shortage of nurses. It has been a long-building problem but I am satisfied at the measures we are taking to address it."
Rest homes 'running out of options'
Aged care facilities provide different types of care, including more intensive hospital-level beds, for people who mostly need help to move and do daily tasks.
Funding contracts with DHBs stipulate that a registered nurse must work in hospital-level areas at all times.
However, documents obtained under the Official Information Act reveal multiple facilities recently breached that obligation. That occurred with the knowledge of DHBs, who accepted vacancies simply couldn't be filled.
The Government last September developed a "registered nurse risk assessment tool", to judge the risk of ongoing nurse shortages at an aged care facility, and agree on mitigations like nurses sleeping onsite to be roused if needed, and moving residents out.
Managers at greater Wellington DHBs worried "this situation of uncovered shifts is no longer rare but an ongoing sustained situation", emails show, and that not having a nurse working "may result in delayed access to required level of assessment and care" if a patient fell ill: "If an ambulance is called they would need a registered nurse to do assessments for them to help with triage … how will they manage controlled drugs/dangerous drugs?"
The law requires aged care homes to notify the director-general of health if a lack of registered nurses puts, or could put, residents at risk.
Last year those "Section 31" notifications more than tripled to 851.
The Ministry of Health called a crisis meeting with DHBs, who warned there was no easy solution because public hospitals were also short of nurses.
"DHB hospitals can't staff as well, so it is not possible to staff [aged residential care]," reported Auckland DHB, a position supported by Canterbury DHB's representative, who argued it was now time for "a strategy on what we stop doing and what we prioritise".
A survey of homes in Southern DHB found more than half didn't have enough nurses for safe staffing. "We're in strife down here," the DHB told the meeting, giving the example of a facility that wouldn't have an overnight nurse for the next three months.
Recent feedback from facilities gathered by the Aged Care Association and released under the OIA reveals despair and frustration.
It could take longer than half a year to fill vacancies, many said, and when overseas nurses finally got through the border DHBs poached them by exploiting a difference in government funding that means aged care nurses are generally paid less.
One home said its staff worked even when unwell because "they have a duty of care knowing there is no other person to do their work".
"We are down two nurses and I have multiple advertisements running for a month now with zero applicants," another facility reported. "We are just running out of options. It has been like this since Covid."
The Government "neglected us at the start of the pandemic and that cost lives," warned a manager who had nurses leave to become vaccinators. "What could happen if we have fewer staff working longer hours while tired and stressed?"
Awake and working for 24 hours
Those hours can be extreme: both the Nurses Organisation and Aged Care Association told the Weekend Herald that nurses are working double and even triple shifts - 24 hours - to plug gaps.
Lynda Boyd, an organiser for the Nurses Organisation (NZNO), which represents both aged care nurses and caregivers, says triple shifts are rare, but had been reported by workers at a South Island facility.
"They are not sleeping on shift. They are expected to be awake and working for 24 hours. These shifts are not rostered or preplanned and occur as a result of there not being enough staff coming on to shift to cover those who are leaving. Our members don't want residents to suffer so they stay on.
"It's horrifying. Employers are not meeting their health and safety responsibilities and they are breaking good practice guidelines. And, I would argue, common sense."
Aged care is heavily reliant on migrant workers, and Boyd says they are less likely to refuse unreasonable shifts because their residency can rely on their job.
Pay parity with DHB nurses is urgently needed, she says, as well as mandatory staff-to-resident ratios (presently there are only guidelines).
"Pre-pandemic there was a staffing crisis in aged care. Now we are in a pandemic - and we are about to see the worst of it in New Zealand - and there is a serious, serious problem."
Aged care workers and managers are finalising "life-preserving" plans, to be activated during a serious Omicron outbreak.
Christchurch nurse Natalie Seymour, who has worked in aged care for 26 years and chairs NZNO's College of Gerontology Nursing, says that includes calling on family members of residents to help with tasks like feeding and cleaning, so staff are free to deliver healthcare.
The workforce is already nearing "total burnout", she says.
"It is becoming pretty dire. Everybody is just trying to pull together … a lot of staff feel they are failing their residents at the moment because they are not providing the care that they feel the residents deserve.
"The resources are not available. We are having to split ourselves into three people to achieve daily routines."
Short staffing and suffering
Staffing pressure has been linked to substandard care in complaint decisions released by the Health & Disability Commissioner, the Government's health watchdog.
The Weekend Herald has read reports released since 2018 and found staffing and training problems identified in 27 cases when a resident died after substandard care. Investigators generally couldn't say whether or how that contributed to the deaths, given residents were often unwell with a range of health conditions and near the end of life.
In one example, proper checks weren't made on a dementia patient who fell repeatedly, and died soon afterwards. A nurse told investigators staffing levels meant "it was very difficult for the registered nurses to be as vigilant in attending to the needs of all 50+ residents as they ought to have been."
Fourteen residents died with infected bedsores and wounds that weren't treated or monitored properly, with investigators finding staffing issues including high turnover, heavy workloads for nurses and lack of training. In one case, nurses claimed they were ordered to complete care plans and other assessments in their own time if necessary.
A man had maggots hatch in his wounds after dressings were changed infrequently, and a nurse told investigators her workload was "impossible".
A woman died after her 6cm deep ulcer wasn't treated properly, and a nurse working as the clinical manager revealed she was on call 24 hours, seven days a week and the "fulcrum point of the natural tension between the owners' interests and their financial constraints, and maintaining nursing standards".
Another home was ordered to review nursing levels after no action was taken when a man complained of stomach pain. He died the next day from a perforated intestine.
The HDC investigates only a fraction of complaints, and can take more than a year to do so, meaning there is a significant lag-time before events turn up in reports.
Aged care homes are also regularly audited by companies contracted by the Government. Most are found to be in good shape, but staffing issues are being noticed, including at an Auckland rest home that had 15 occasions over a single month when a nursing shift was instead worked by a healthcare assistant, which resulted in call bells not being answered quickly enough.
A high rate of falls among residents was linked to short staffing at a Taranaki home. Staff at another facility were increasingly working double shifts and extra days, and they and families were concerned about workload.
Wallace, of the Aged Care Association, told the Weekend Herald the vast majority of the 37,000 people in aged care were well looked after.
"[But] going forward, I think it is inevitable that we will have more cases of substandard care. And that is regrettable. It is not through any lack of effort to try to get help on this stuff. It does come down to the nursing workforce."
Aged care nurses are generally paid about $10-15,000 less than a hospital nurse, Wallace says. That will widen to as much as $20,000 when a DHB nursing pay equity deal rolls out in July, at which point, "none of our nurses will want to stay … rest homes will just close."
Some larger companies can pay their nurses more using income from retirement villages often located on the same site, he says, but most in the sector cannot.
Aged Care Association is 'catastrophising'
Little recently met with Wallace and other aged care representatives, and told the Weekend Herald he's made it clear "the pathway to [pay] parity" for all nurses "is now being intensively worked on".
Wallace is "utterly wrong" to say the Government isn't responding, says Little.
He also took issue with the statement that aged care is on the verge of collapse.
"I think when Simon says those sorts of things he is catastrophising, and he puts his own credibility at risk. I met with him as recently as a few weeks ago [and] he didn't catastrophise in the way he seems to be to you."
(Wallace says Little told an aged care conference in 2020 that pay parity was a top priority, but nurses needed certainty. "The minister may say I'm catastrophising the situation but if the sector is not able to provide aged care services for our most vulnerable, I have no hesitation in saying so.")
Little couldn't give a timeframe for when pay parity would happen, or what it might cost (the Aged Care Association says previous government modelling indicated about $113 million a year).
One complication, Little says, is that aged care is made up of large companies as well as "charitable and small family-owned facilities who are in genuine need of additional support".
Extra funding shouldn't "line the pockets of the large corporates who just use it to pay an extra dividend to their shareholders".
"There's a difference between the big corporate players and the rest, and we have to have a policy that distinguishes between them."
The nursing workforce grew in the past three years. The ministry says measures to boost numbers include a voluntary bonding scheme, funding for study, a one-off residency pathway, and major recruitment campaigns.
DHBs have also been told to stop hiring nurses allowed into NZ to specifically work in aged care, by supporting the alteration of visa conditions.
That message was delivered late last year by Southern DHB chief executive Chris Fleming, who leads aged care work for the country's 20 health boards.
However, poaching continued.
"I've had to remind my [chief executive] colleagues on a number of occasions, because individual events do get flagged with me," Fleming says.
"DHBs are quite large, complex organisations, so sometimes it takes a period of time for what had been agreed to get all the way through."
Southern has more than 200 nursing vacancies and, like elsewhere, is trying to clear elective backlogs and cope with rising demand from an ageing population.
That requires hiring more staff, Fleming says, but, "we have made a call we are not going to do that at the expense of seeing an aged residential care facility fall over, or face even more significant risk issues."
About 60 aged care beds have already closed in his region alone. That has caused "bed block", when an older person who needed ongoing and professional care stayed in hospital with nowhere to go.
Facilities brace for Omicron outbreaks
Rest homes accounted for most Covid-19 deaths during earlier outbreaks, and staffing became a major problem at some facilities.
At Rosewood rest home in Christchurch, which had 12 deaths, staff went into isolation and for three days there weren't enough DHB volunteers to replace them, meaning residents received only basic care. "Skin integrity issues developing," stated one DHB document summarising problems. "Medication adherence issues."
Many of the patients were bed-bound, incontinent and couldn't talk. If a person needed changing, three workers donned new PPE and then, together, hoisted the patient into bed and cleaned them carefully - to manage the infection risk, and to not cause distress by appearing rushed.
A nurse later said there were days when half a dozen patients needed changing, hourly - she could change PPE 50 times on those shifts.
"Patients' symptoms would spring up left, right and centre like holes in a dam ... diarrhoea, back pain, dry cough, delirium, the occasional high temperatures, lungs filling up fast with thick mucus, and plummeting oxygen saturations . . . for some, positioning became a matter of life and death."
During an outbreak at an Auckland rest home some of the DHB nurses who replaced stood-down facility staff reported being brought to tears by floors dirtied with "stinking" urine and faeces and overflowing bins. Residents suffered falls and waited too long for feeding and toileting.
The Aged Care Association in April 2020 called for the Government to develop a surge workforce plan to be used in case of future outbreaks.
That doesn't appear to have happened, Wallace says. Up till now that hasn't mattered, including because aged care staff and residents are triple vaccinated (the association lobbied for a vaccine mandate, with which 98 per cent of workers complied).
However, Wallace has watched as Omicron outbreaks in Australia have claimed hundreds of lives in aged care. The army has been sent into some rest homes to help with workload.
"I'm worried about what's going to happen," Wallace says of the situation here.
"We were told at a recent meeting of ministry and DHB officials that, 'we will literally just have to manage ourselves'."
That's strongly rejected by Little - "DHBs have been planning for months" - and by Fleming, who says his and other DHBs are working with aged care homes on contingency planning.
"Is it enough? I think it would be fair to say, no. It is never going to be enough, because nobody knows exactly where the peak of Omicron will occur," Fleming told the Weekend Herald of Southern's contingency planning.
"[But] if DHBs don't respond and a care facility does fall over, the end result will be that the residents will turn up at the hospital anyway."
Feedback from people in aged care made clear that staffing was "absolutely" a concern as Omicron threatens, Fleming says.
"The sector is in a much more tenuous position than they were in 2020 with the original lockdowns. They were much better staffed. The staffing shortages were not as acute as they are now."
A distressing closure
The first resident moved out of Wharekaka on Wednesday and the doors will shut for good by March 31.
"Somebody sent me an angry email saying, 'Why didn't you announce the closure six months ago, it would have given the community time to find a solution,'" says Joy Cooper, chair of its governing board.
"Well, six months ago we were doing fine. We were fine up until early November, when we suddenly realised we were going to lose nurses."
Two left over the vaccine mandate and another for more money at another rest home similarly desperate for staff.
Job advertisements had no response. Wairarapa DHB (which has nearly 20 nursing vacancies itself) is sympathetic and gave extra money, but the home is losing up to $40,000 a month.
Wharekaka was built as a maternity home and since the 1970s has been used as an aged care facility, run by a community not-for-profit. Villas for independent living will continue and the trust hopes to keep doing meals on wheels.
The DHB expects to find aged care beds for the 13 residents remaining. Some will go to Wellington, others to Masterton.
"It's very distressing for the residents. The nearest places are some distance away," Cooper says.
"The community is very upset, because it serves a need. But we just can't keep it going. It's a model that's not supported in the current system."
• We want to hear about your aged care experience. Contact nicholas.jones@nzherald.co.nz