Healthcare is not in good shape. Decades of underinvestment by successive governments, have left our healthcare infrastructure woefully unprepared for the triple threat of a global pandemic, economic instability and the dramatic effects of climate change. The consequences are stark and widespread as we commonly hear stories of overstretched services where patients face missed or delayed diagnoses and treatment, with care quality varying by region. Our healthcare professionals, especially nurses, continue to provide the best care possible, but are battling against overwhelming odds, facing burnout and severe staff shortages.

The initial COVID-19 restrictions in 2020 were necessary to limit the spread of the virus in the absence of vaccines, limited hospital capacity and worrying international reports. While Aotearoa avoided the worst outcomes seen elsewhere, such as overwhelmed health systems and high death tolls, the ongoing pandemic response increased the burden on the health system, compounded by communities experiencing increased economic pressures and mental health issues, particularly for young people (Growing up in New Zealand, 2023). Throughout the time of the pandemic, we witnessed nurses going above and beyond their usual duties across the sector, from aged care facilities, communities, primary care, and hospital services (Hales et al., 2021; Hughes et al., 2021; Lockett, 2021; Popoola, 2021; Smith et al., 2021). Yet despite their efforts, postponed treatments, staff absences and persisting nurse shortages (from before COVID-19), created a backlog of patients, many of whom are now in a worse condition than when they were first diagnosed. Aotearoa saw a surge in internationally qualified nurses (IQNs) entering the country over the past two years. However, we also witnessed many of our colleagues head overseas for better pay and conditions. Additionally, hiring restrictions have been implemented, affecting nursing graduates. As a result, fewer than usual new nurses were employed into Health NZ roles, with just 50% of 1600 new graduates being offered employment for the cohort completing end of 2024. The result is a nursing sector facing uncertainty and frustrated by the undervaluing of their knowledge and expertise (see exemplars published in this issue of Nursing Praxis: Adams et al., 2024; Clubb et al., 2024; Taylor et al., 2024). Supporting a sustainable domestic workforce is essential to achieve pae ora and address equity and access.

The incoming National-led coalition government, in its first 100 days, responded to the healthcare crisis with sweeping reforms. These changes extended beyond health to education and included a range of legislative changes and budget cuts and have persisted into the first year of the term of the government. These actions directly affect the health and wellbeing of the people of Aotearoa, with anticipated adverse effects on equity (Pitama et al., 2024); as well as impacting workforces who are struggling to deliver healthcare under these adverse conditions.

A few of the key changes have been:

  • Te Pūkenga disestablished directly impacting nursing education, particularly the national unified BN Māori programme

  • Te Whatu Ora renamed to Health NZ

  • Te Aka Whai Ora reabsorbed into Health NZ, despite Pae Ora (Healthy Futures) Act 2022, having a dedicated entity to address serious disparities in Māori health outcome, access and equity

  • Reversal of equity-based funding to needs-based funding and the ACT party-led Treaty Principles Bill (see Loring et al., 2024)

  • Therapeutic Products Act repealed, returning to provisions of the outdated Medicines Act 1981, particularly Section 29 which impacts NP prescribing and patient care

  • Healthcare targets reinstated

  • Budget cuts for Whaikaha (Ministry of Disabled People), with the Ministry subsequently absorbed into the Ministry of Social development

  • Smoke free legislation repealed, a widely criticised move due to its negative impact on public health.

The latest setbacks are the budget cuts and austerity measures in Health NZ with the recent call for voluntary redundancy for people on individual employment agreements (IEA). and the subsequent proposal challenging clinical leadership, including nursing, medical, allied health and midwifery leadership roles, which support safe, quality patient care. For nursing leadership, these roles in particular are being drastically cut in both number and full time equivalent (FTE) allocated to the role. Four regions are proposed which at first glance seems to be very similar to that proposed by Gibbs back in 1988 (Gibbs, 1988).

Nursing budgets are often targeted for cuts as they represent the largest cost category in healthcare yet are mission critical for delivering safe healthcare to the people of Aotearoa. We know, from our own experience as well as strong research evidence, that rationing of nursing reduces patient safety (Uchmanowicz et al., 2024). It is high time the nursing budget was viewed as an asset rather than merely a cost to be restructured at will. Budget cuts to meet nationally imposed financial targets often fail to consider the local impact on patients and staff. We must recognise that investing in nursing is essential for maintaining and improving healthcare quality across Aotearoa.

The current situation feels very reminiscent of the significant health reforms of 1990s. Perhaps the government would do well to remember that “health cuts don’t heal”. Patient outcomes suffered as a result of those reforms (Carryer et al., 2010), and there is a high risk of this happening again as fiscal prudence takes centre stage. Decision-making driven primarily by budget constraints sets the scene for financially motivated choices rather than patient-centred ones.

Anecdotal evidence suggests a rise in hospital acquired infections, patient falls and an increasing length of stay. These are failure markers that weigh heavily on nurses who are unable to deliver high standard care in a system increasingly designed not to support it. Budgets that bear no relation to the delivery of safe patient care, acuity and complexity are frankly dangerous and will lead to poor outcomes. The Francis report, into the failings of NHS Mid Staffordshire, highlighted stark findings - a focus on fiscal imperatives can have serious and often fatal consequences for patient care (Francis, 2013).

Nursing workforce investment

Legislative barriers continue to limit nurse practitioner (NP) effectiveness with much healthcare legislation predating the development of the NP role in Aotearoa. Section 29 of the Medicines Act 1981 allows the prescribing of ‘unapproved’ medicines (not on the pharmaceutical schedule or prescribed for a use not specified) to registered medical practitioners only and not NPs. Through the pandemic and since, there has been limited availability of some approved medicines, requiring alternatives to be sourced and prescribed. This has disrupted routine care for patients, especially those living rurally, and priority and vulnerable populations, served by an NP who must seek physician-provided prescriptions. The new Therapeutic Products Act 2023 addressed many issues, including Section 29 of the Medicines Act. Yet the repeal of the Therapeutic Products Act is underway posing ongoing risk to disrupting care and disadvantaging patients. Careful use of language around health practitioner (not medical practitioner) is crucial. Meetings with the College of Nurses Aotearoa (NZ), NPNZ and Minsters Reti and Seymour have emphasised this point and sought assurances that this anomaly will be swiftly addressed. We continue to await news.

A record number of NP candidates entered the Nurse Practitioner Training Programme (NPTP) in 2024, with 121 places funded by Te Whatu Ora/Health New Zealand. However, while 141 have applied for the 2025 programme, funding remains uncertain. Despite having nearly 80,000 nurses in Aotearoa, only 800 are registered as NPs. Given the value of the NP role and their ability to work independently it is logical to support more experienced registered nurses to complete their NP educational and clinical training to address unmet health need. NPs have the potential to transform health services, meeting local community health needs and advancing health equity (Adams et al., 2024). They are key to developing a sustainable, highly skilled, workforce that could significantly facilitate the delivery of accessible healthcare across Aotearoa.

To ensure sustainable, equitable healthcare, we must invest in our domestic workforce at all levels. This includes undergraduate programmes for nursing registration and enrolled nursing qualifications, postgraduate education pathways, and the NP programme. We need to create incentives that ensure rural and remote areas have access to health professionals. A recent Earn As You Learn programme for kaimahi to complete their EN diploma was highly successful in supporting Māori, and Pacific peoples, into the registered health workforce in primary healthcare settings serving priority and rural communities (Wiapo et al., 2023). Nurses are the cost-effective solution to many of our healthcare challenges and should not be substituted by new and emerging cadres of workers with narrower scopes of practice.

To secure a healthier future for Aotearoa, we must prioritise investment in our nurses. Nursing leadership must remain staunch in holding to the values of nursing and to Te Tiriti o Waitangi, actively resisting governmental drives which negatively affect the workforce and the population. A well-supported and highly valued nursing workforce is the foundation for robust communities and a thriving healthcare system that serves all the people of Aotearoa.

Kate Weston
Executive Director, College of Nurses Aotearoa (New Zealand)