This article is a transcript of a Trans Tasman panel discussion on the topic of ‘Establishing effective long-term collaboration patterns with the providers of managed isolation and quarantine services and other non-healthcare organisations’.
Dr. Pete Rive (host),
Senior Advisor, S23M
Kaiwhakahaere (CEO), New Zealand Nurses Organisation
Thijs de Blok,
Senior Advisor, Buurtzorg (Japan / APAC / Netherlands)
Jorn Bettin (Q&A),
PR: I first would like to welcome our panelists for the second discussion in our series. Unfortunately a couple of our panelists couldn’t make it this evening and they had family and a hospital situation at the last moment so
are unable to join us.
But first of all, kia ora Kerri Nuku from the New Zealand Nurses Organisation, and Thijs de Blok from Burtzorg, covering Japan, APAC, and The Netherlands.
What I would like to do is to really keep the panel conversational. As you both come from nursing backgrounds but from different geographies and different contexts I thought that could be quite interesting. I was going to kick off with the following question:
To what extent you think that your organization either informally or formally establishes new collaborative partnerships with non-health
organizations? Obviously the pandemic and managed isolation and quarantine has pulled in a lot of people who are not healthcare professionals. I was wondering how you might be dealing with that.
TdB: well I can start if you like because I think it’s important to get some some context on the differences between New Zealand and Holland. New Zealand has a lot of difficulties with being an island far away from everything else, but there are also certain advantages. First of all I’ve been following the procedures and policies in New Zealand closely. I must say they’ve done an excellent job at stopping the virus from spreading in every way they can and also to be public about it, and then to let the public enjoy the success of this approach, so I think that’s really good.
In Europe this is slightly more difficult because it’s been since the 80s since we last had border closings. A lot of authorities and and police forces have been called in upon to make this possible, but it’s not airtight. In Holland they’ve decided to not impose a mandatory quarantine, so it’s an advised quarantine, and with this you have to collaborate with all the institutions that come with it, whether it’s a naturalisation and identification service, the police or the military police. Everyone has to be involved and everyone has to understand the benefits of restricting themselves from contact for two weeks.
Our nurses play their usual role in in this. In The Netherlands they are well known figures within the community and they try to advise the the formal and informal networks of clients and family members around them. We try to pull our weight in this and also give our nurses some education on this behalf. We hired an epidemiologist to give all our staff the proper education on how it can affect the public health if we don’t pull or pull our weight. This has led to the result that everyone wants to collaborate with us on this behalf and this has been very inspiring.
This is some background on how we’ve tried to do it. No system is perfect and there are always gaps and and things may happen. We’ve seen a certain surge in cases in Europe but also in The Netherlands. I think with with the information that we’ve gathered so far, we can prevent the public health from from a second spike in coronaviruses.
PR: Kerri maybe you could give Thijs and the audience a little bit of an overview of the members of your organisation.
KN: Sure. Our organisation is both a union and a professional body and we are the biggest nursing group in the country. We represent about 51,000 members that work across diverse areas, from primary health care, community aged care, to palliative care, and also in our big district health board structures. Our organisation also represents nurses, healthcare workers, students, and midwives.
Our representation is very wide, which is why when we went into COVID and level 4 restrictions under a national state of emergency, we were very forthright in coming forward to protect our central workers, because there was constantly the cry for lack of PPE gear. We mobilised quite quickly in response due to what we were seeing internationally months prior to actually getting here. On the 28th of February I think is when we had our first COVID case.
We had seen what was happening internationally and needed to prepare and respond, but in actual fact, going from nothing happening within the community to suddenly a level four complete lockdown happened really quickly. Seeing what happened overseas didn’t mean to say that our nursing workforce was any more prepared, because months prior we’ve been talking about the nursing workforce shortages the resource shortages and a tired and exhausted workforce.
So when we came in to respond to COVID we actually had to mobilise what was a really tired workforce. However what COVID has taught us is that as an island in the middle of the South Pacific we benefited in terms of the data and information that was coming out from places like the States, the places that were being hit hardest. We were able to use our international collaboration to ensure that we were front footing a lot of the research.
Our ministry of health relied heavily on information that was coming out of the WHO, which was a bit challenging to be quite honest. A lot of our policies and procedures that were set up from the ministry were based on what the WHO were sending out, which seemed to be inconsistent with some of the research that was coming out of frontline hospital workers. So we were needed to receive information, analyse it, and quickly advocate with or challenge the Ministry of Health around the development of some of their policies.
What we have learned is that we can no longer just think and inwardly, and that our external collaboration has to go further than just health workers, it needs to be broader than what we had previously been looking at. It has opened our eyes to the value of international collaboration within the healthcare sector, but also wider than. I mean we are a union, so we do need to make sure that we are advocating for our members rights during this process regarding access to health and safety legislation and protecting their interests. COVID has taught us that we can no longer just sit within a health realm, but we must look broader than that.
We must make sure that we’re a lot quicker in picking up relevant research, and respond in a timely way to be able to be better advocates for both our nurses and also our patients.
PR: Can I dig in a little bit deeper into that, because that sounds very interesting? I have a question here about to extent to which the pandemic has exposed knowledge gaps both within your organisations and other organisations. You’ve talked about the Ministry of Health, and we’re all sort of waking up to the fact of gaps in information, especially with so much fake news and other sort of nonsense coming out around the world. To what extent have you looked to rectify those gaps, and what are you doing, especially Kerri with your members, and Thijs with your nurses?
TdB: Thank you for that question. What we had was created scarcity in protective gear. Our government was was in charge of purchasing face masks and gloves and and aprons and all the materials abroad, and they were dividing it over the separate entities and organisations afterwards. We found that the home nurses, who are in our eyes the most vulnerable people, because you go in and out of people’s houses. We’re at the bottom of the list with cleaners and and teachers. The government made the simple statement “your nurses are just going to have to hold a meter and a half distance from their clients”. Anyone who has ever worked for a single day as a home nurse knows that this is completely impossible. So we reached out to an international organisation that helped us with purchasing our own our own protective wear. We bought over four million face masks in one month’s time, which had the result that we received large scrutiny from from the Ministry of Health, but all the independent organisations, especially in home nursing, wanted to collaborate with us, to share in this this wealth of protective wear, where there was scarcity on the backhand.
There have been questions at the Ministry and the House of Commons after this, and the Burtzorg way of working has has been since then been expanded internationally. We have a partner in Australia, and they’ve tried to do the same. Our partner in China is on the opposite side, so they have a lot of protective wear at their hands because of the local manufacturers, and and they’ve been helping us getting to the source of these masks and and dividing them over the European and Western countries. They can get a fair price, and we get our protective wear, and that is a large part of it. The process also involved non-health related professionals to raise awareness of the issue.
What I’ve seen in a lot of countries since then is the clapping appreciation for the healthcare workers, but it’s very quick forgotten about. I think the biggest problem here is that one time clapping or smacking on a pot with a with a spoon is not enough. There needs to be constructive improvements in the working environment of the nurses and other healthcare professionals and also in the payment system. I understand that for a lot of countries this this is a utopia and we have to get there slowly. But I hope with an international collaboration of unions of nurses like yourself Kerri, that we can create a movement that internationally would say this is what going on constructively around the planet, and it needs a solution now, before it gets even worse than this.
Those are some of the things that are on my mind these days. Sharing knowledge and ideas outside of the World Health Organisation, but specifically on the front of nursing, community nursing, and public health can be very important.
PR: Kerri, maybe tell us a little bit about your nursing members experience. You touched on it a little bit with PPE. A lot of this plays out in the media, and it’s it’s very apparent that some people have been playing politics with it. Maybe we can discuss the levels of trust and respect between the DHBs and frontline staff, who are feeling very exposed and mentally stressed.
KN: Yeah sure. What what connected with me was when I was on an international call with some nurses from the States and they were shattered, absolutely shattered, and from one nurse to another, your heart goes out when you can feel another colleague that feels powerless. What she said is that she sat in the tea room, and she looked across to another colleague, and they felt doomed, because they didn’t know how they can combat the virus when they don’t have access to adequate PPE gear. Now what this meant to us, is that the very first thing we needed to fight for was adequate PPE gear.
What we heard on the regular one o’clock public announcements in the afternoon from the Prime Minister and Director General of Health and the police was that there is adequate PPE gear, that nurses have to be safe and feel safe, that we have to mobilise and move fast, that if we want to contain the virus we need to move quickly.
So what we were doing is we were sending nurses into a healthcare system, and what they were reporting back to us is that they didn’t feel safe. They couldn’t feel safe because they didn’t have access to adequate PPE gear. This is within district health boards, which is usually the second line of defense. Primary health care and community care nurses were the ones that were out there doing a lot of the initial COVID screening, and they didn’t have enough PPE gear.
We had palliative care nurses that were going into homes, who needed to go back to the office and make up their own masks out of laminate paper. What we were hearing was inconsistent with what the Director General for Health was telling us. So we kept on saying there needs to be something, there is something not quite right here, when you’ve got frontline essential workers and a Prime Minister that’s saying we need to be kind to people. Well, kindness is also about protecting the interests of the healthcare workers, and we kept pushing at this issue. Then we had cluster outbreaks happening in aged care, and still reports of lack of PPE gear.
What we did is we elevated the issue and called for the Director General to have an independent review of access of the supply and demand to PPE gear. Once we got the Auditor General in and the ombudsman to look at the aged care clusters, that exposed what we had identified, and the concerns of nurses were vindicated. There were certainly PPE issues, there were certainly issues with supply and demand, there were certainly issues with adequate storing, and quality and access to PPE gear.
So what the review did is that it empowered nurses to ask more, and to come out stronger, because certainly what was being projected outwards to public was different to what the experience was for nurses, and it was also inconsistent with what the Ministry of Health was sending out. The review did create a little bit of mistrust distrust, and what we saw all of a sudden was an increase in PPE gear, a different way in access to N95 masks and the fitting of those, and we saw more readily available PPE gear.
What we had were nurses that wanted to go to work and wanted to help the communities. But they were coming home at night and their husband or their partners had set up the garage of their house, or a tent, or the shed, or the caravan for them to self-isolate, so they didn’t re-infect or infect the family, and they didn’t bring the virus home.
We had nurses doing some extraordinary things to ensure the protection, so they could go to work the next day, but also remove themselves immediately from the family, so they didn’t bring any of the virus home. This actually meant that the nurses didn’t feel safe, and they weren’t, because why would you go through those extraordinary things if you actually had a degree of comfort that you’re going to be well protected.
We saw a lot of health care workers needing to go into isolation because they had been in contact with the virus and had become COVID positive. What we needed to do then is look at the legislation that protects healthcare workers when they are at work (the Health and Safety at Work Act). The unfortunate thing that we’re still challenging is a weakness in the legislation, and the obligation of Health and Safety at Work crew to protect and to investigate any outbreaks, and the impact that outbreaks had on the nursing workforce, to ensure its protection and safety.
What COVID has done is it has unpacked a lot of the issues that we kind of knew we had. We now know that we were never prepared for a pandemic of this size. When we’d had previous epidemics and pandemics, our Ministry of Health prepared for a pandemic based on the population size back in 2005, but we’re 19% more of a population since then. We’ve grown up since then. We weren’t able to respond to the current needs of the current population, and we had no way of future forecasting what would PPE gear look like, and how would we need to measure and monitor its supply and demand, to ensure the safety of both community and essential workers, remembering that essential workers aren’t just nurses and healthcare workers.
What we had were some gaping holes around our level of preparedness. But in saying that, what we did have, is a government that realised its shortfalls, and was prepared to remedy and make steps towards remedying the problem.
TdB: May ask a question Kerri, because you’re from a union perspective, very involved in this. Was it difficult in your situation to get all the companies that work in primary healthcare and that employ your nurses to get on the same page, or was it a natural movement after the first weeks of the pandemic?
KN: What we never did is we never identified the workplaces, but the way that our health system works in New Zealand is that a lot of the services are devolved out in the community sector and aged care sector, so the distribution of our PPE gear actually went from the Ministry of Health to our larger District Health Boards, and it was their role to disseminate out to the communities. What we had is a blockage and the flow down to these providers. When we went out we spoke in general terms. Certainly where there were cluster outbreak and in some of the aged care facilities, we were able to focus in on some of the relevant issues, but generally we spoke broader, so it didn’t make identifiable some of the providers, and we were able to put nurses up.
But remember, as you’d well know, that nurses don’t actually like to take the public limelight and talk about how hard they’re done by their employer. We took that role away from them and provided that sort of distance and anonymity, but we’re really strong advocates around access to PPE gear. We called upon the Auditor General to do their work and the ombudsman, and at the same time we worked with the McGuiness Research Foundation to actually research our members, as quickly as we could, to see whether or not what they were saying was consistent with what the broader research was telling us, and certainly it all matched up.
I think it was really a critical time, and a lot of the radiologists and doctors were stepping back, and letting the nurses take not the limelight, but make the charge, because they were the ones that were actually out there doing a lot of the frontline swabbing and testing. It really was a respectful kind of way in which we collaborated with the doctors and other health unions.
PR: To what extent you both think that what the pandemic has exposed is actually the knowledge flows. We’ve got two different examples, one is the Buurtzorg model, which I should get Thijs to explain a little bit about, and how that’s different from collaboration in a hospital situation, and the other is the healthcare system in New Zealand, where typically we follow a very hierarchical approach to knowledge flows. It doesn’t surprise me that that the information coagulated at the top, and that if the DHBs are not at the front line themselves, that the information isn’t getting to the one place. I guess i’d like to make this comment into a question to you both about how you see the difference between a decentralised versus a hierarchical and centralised system.
TdB: Absolutely. I don’t know how familiar you are with our model Kerri, but I will I will give a brief explanation. We started in 2006 with with two or three self-steering teams in The Netherlands, and and today we’re market leader in The Netherlands in home nursing, with a lot of international ventures as well. We focus on self-steering, so all the little nursing teams from eight to twelve nurses are all their own little companies. They make decisions themselves, but they benefit from generic intelligence from the Burtzorg company. We have a framework that is pretty wide, and within their team nurses can make their own decisions on how they implement this framework. As long as it’s financially sustainable and as long as they keep the quality of care in mind and keep their focus on the client.
This has been very successful, because for a lot of nurses is a very challenging and fun way to work in, because you’re in the center of the community again. In the 80s and 70s the healthcare system in Holland already used to work like this, and then through the 90s and the 2000s, it got privatised, fragmented, and segmented. Then a lot of commercial companies wanted to improve on efficiency and productivity and started working “production driven” rather than “client focused”, and didn’t have any outcomes on how many hours of care you’d actually need to cure someone.
In the pandemic this had as a result that we had to be very careful about what can we integrate within the framework, what is non-negotiable for us as a company, and what is up to the teams themselves to make a decision. Even in a small country like The Netherlands there was a big difference between the cases in the north and the south. The south was heavily impacted by Corona, and in the north there were barely any cases.
In our view the Buurtzorg model could still work in that the teams in the different areas can make their own anticipation on the guidelines and the regulations that would be given from the government, but also from us as a company. We started a Corona team, so one team that would have a meeting every day on the new information that we got from the government and from our partners internationally. We got some information by the WHO, but we also have partners for example in Taiwan, who are not part of the WHO and who have been very successful in keeping the virus out. We would all have webinars and calls with these people. How have you been successful? How have you been dealing with it and what is the response of your frontline staff?
We’ve involved all the teams in this, we gathered the information, and provided them with the information to make the right decision themselves. Most teams started collaborating with other teams to make one Corona COVID route, so you would only have a couple of nurses exposed to the possible cases of COVID in the area. You’d minimise the risk of a lot of nurses getting affected. We would look at the personal situation of the nurses. If a nurse is a father or a mother of three little children there is a big chance that if the virus gets taken home, it will spread over the entire family, and then to the informal networks around it. That is obviously not desirable, so we tried to pick nurses that volunteered for the job, for example nurses that have just finished their studies, that live alone, and that are naturally in solitude after work anyway, for whom it makes the most sense to pick up this route.
We actually had more volunteers for these Corona routes than we needed, because the they felt committed to the safety of their colleagues. This was the largest scale of of the impact. Some of our nurses got sick, as people did everywhere, but the people that got sick were aware of the risk before they signed up to it, and their colleagues in the other teams and in their own team were extremely grateful, because it could have been them.
The approach created a larger empathy to each other’s roles within the team and I think in the end it made us as a company stronger because the shared entity of working for Buurtzorg and identity is greater and greater. This is how we successfully navigated the pandemic in Holland. Internationally we are active in 26 countries now, and in all these countries and partnerships we we try to engage in what is successful in which culture, and understand how can we move forward helping each other out without interference of of a local government or an international body of power.
It’s all about information. We have 15,000 employees and I think that with 15,000 employees you also have 15,000 highly educated good opinions on what is a possible way to approach this and we’d like to use most of them at least.
KN: It is quite a different structure than what we operate here in New Zealand, and as you said Pete, it is a more of a hierarchy, at the pinnacle of which is our Ministry of Health, which determines policy. Then we have:
- Large District Health Boards, which are situated across the regions. We have 20 of those across the whole of the country, and each of those come with their own unique way of administering and their unique priorities and direction.
- Our aged care sector, which has largely evolved or devolved down into private business model arrangements.
- Primary health care organisations, which are also private businesses on a bigger scale.
- And then we have peppered out throughout that, palliative care services, and Plunket services (early childhood services).
We have a lot of services that are run by the different structures within our health system. A lot of the criticism within the reviews that we’ve had and from nurses themselves, have been the poor, inconsistent and varied communication. This meant that what might have been been sent from the Ministry of Health or Director General as a directive, gets translated depending on which area you work in, and there wasn’t the consistency necessarily of infection prevention controls.
There were inconsistencies around when masks can be worn, when head gear gets worn, etc. That created a whole lot of discontent amongst health professionals, because there was not one clear direction coming out. I know that when we went into level four, which was basically a complete lockdown, with just essential workers going about their business, the healthcare providers, doctors and healthcare workers were all still feeling very uncertain about what was happening.
It took us almost two weeks into that lockdown until we started to see clearer policies and guidelines coming out of the Ministry of Health. But in that really critical time, when there’s a state of emergency, and you’re wanting some clarity and some really clear direction, to have to wait for 10 to 14 days for some policies to come out, or some WHO directors eventually to come out, it meant that we were dealing with the unknown.
What we were seeing every night on the six o’clock news was how many deaths were happening around the world. Health professionals felt they were putting themselves at risk with not really getting any clear direction, and not really knowing the transmission of the virus, or how to deal with it, or what was best practice.
This created a lot of tensions amongst the providers, but the complexity of the way that our healthcare system works, within such a small country, is what created a lot of the challenge.
TdB: I sort of get what you’re saying, with with the fragmentation comes a lot of uncertainty. If there are too many players around, the health support system around one individual makes it very very complex to find out how do we stop spreading this virus.
This is one of the key pillars of of the Buurtzorg model, and this is where I think our success has also shown in a pandemic, that we try to minimise the amount of health professionals that visit a client each day or each week. This approach also has very important benefits in terms of mental health. Before we started in Holland there were some clients that received 30 to 40 health professionals in their own house on a monthly basis. For someone with dementia or cognitive issues the benefits that you get in terms of physical improvement from the interventions by health professionals all goes over board with with the detrimental effect on mental health.
This was one of our motivations to change the entire system around. We really focused on the goal of ensuring that a suspected case of of COVID-19 would only ever see one professional in their home with the right protective gear. This approach really takes the risk down. If the virus spreads through a client, we know exactly the one nurse who is the only one who can be infected in our company, and all the clients that this nurse cared for afterwards, who may have been impacted, who were already suspected cases, because they were on a “Corona route”. Within our company we have proven that our approach successfully minimises the exposure of everyone.
So maybe, for New Zealand in in the future, moving forward, this can also be a good way of restructuring the public health system.
PR: I’d be really interested to know Kerri, what you’re doing to try and solicit information coming back upstream, especially from rural communities etc. in terms of nurses, who are the frontline staff where contact with the virus is actually happening. Are there current facilities or abilities to communicate information to where it where it actually counts, and back up stream through the DHBs into the to the Ministry, or is it a problem of the whole structure?
KN: I think it’s a problem with the structure and the funding formula that is set, and how that is fed down through the system to get out to the rurals. There were stories of people that lived in rural communities. Once we went into lockdown and we were servicing the central business areas, who was going out to the rural communities?
A colleague of mine said that she made a really incredibly long trip to go out to a rural community that she knew was pretty much isolated. This was a small community that she referred to as almost living in a shanty town, a makeshift town. We have to remember that some of those people that live out in the community are our most vulnerable and are not necessarily have the same access to running water or electricity in the same way you might have in a town situation. She told me the story about how they’ve been trying for a long time to get a needs assessment done, and to get services for a woman that was quite debilitated, but once we went into level four lockdown, services came like that.
We’ve got to find a mechanism that we don’t complicate access to services and diminish the quality of life, just because of bureaucracy. We’ve got to make sure that we’re living a pandemic all the time and we free up services to get to where they’re needed. But at the moment, we haven’t been able to have that really robust conversation with the Ministry to say, just because of COVID, we shouldn’t have to open up the floodgates. We should actually be enabling access to services at all times, to ensure that everybody has access to quality of life.
Those really challenging conversations are the things that we haven’t actually had yet, and our disability system is under review. We’ve got a Heather Simpson report that’s out, a document that’s still out for consultation. So we’ve got to take the time to look at doing things different and not just doing more of the same thing – bad.
PR: An observation on the Simpson report is that while it’s sort of addressing these these long-term problems that we have had, it still seems to be slanted towards a highly bureaucratic solution and approach. There’s all this talk about strong leadership. Even the Māori health authority as you would know is problematic in itself, and once again it seems like rather than enabling and empowering the communities to help themselves, there’s still quite a paternalistic approach to community health.
KN: Definitely. I think what’s obvious through the Simpson report is that the power and control doesn’t shift or change. It still remains within the structures. It might just have a different name. I we’re really going to embrace change, especially on the tail of COVID, then we should look at different models of care and not just the same models of care.
But I take the point that you make, we’ve been talking a long time now, that nurses scopes and practices are limited by the policies that are put out from government. So we don’t just need a clap, we don’t just need a minister to say nurses are the backbone of a healthcare system – and then turn around and actually put in structures that oppress the voice and freedom of nurses, to be able to work to their fullest potential.
We do need to recognise that nurses are the front line in the combat to COVID. How do we create it, so that we can ensure that they respond, that they have their own autonomy, and maybe work in smaller teams that are more patient-focused or patient-centric? And how do we recognise the skill and expertise that they bring, and pay them what they are worth? We have such a huge workforce that we underpay. This huge workforce can make a big difference.
TdB: I think you touch the spot there. What I think is important is, if you decrease the hierarchy, money will become available to pay the frontline staff accordingly, and and I think that’s the essence of this entire story. Keep the quality and the knowledge where it is, with with the frontline staff, and and pay them accordingly so they actually get paid to care.
JB: It’s a cultural issue that requires cultural evolution to acknowledge that you can’t substitute knowledge with power and control. Actually knowledge and local expertise is much more valuable than power and control. If you look at the language that we encounter in the media and from the government, whenever that is about “getting things under control”, it’s actually an acknowledgement that there’s a complete lack of understanding of the role of knowledge and expertise in in this context here.
KN: That’s right.
PR: I wanted to just put one idea in your in your mind before you go. Jorn and I we are working on on a project around a community co-designed healthcare solution, and we’re not we’re not prejudging it, but we we would like to get your help and Kerri’s help, in terms of like trying to find a new way that we can seed a community driven health solution, especially in rural and Māori communities. I think we need a totally new new approach that that is led by and co-designed by the people. I don’t know if you are both interested in this, but we would like to get your help on it.
TdB: I’m always willing to help and and give advice. If there’s a certain structure to it, please let me know, and then I’ll do what I can. I thoroughly enjoyed speaking to you Kerri and hearing your ideas. If that means that the New Zealand Nurses organisation also involved it’d be very persuasive for me to join it.
KN: Fantastic. It’s been great catching up. I’m happy to be involved and to suggest people that might also help advance that work. It’ll be great to catch up one day and connect up organisations.
PR: Thank you all very much. It’s been it’s been fascinating we’re we’ll we’re putting together recordings of this discussion and transcripts, because we think there’s valuable information for people in the future. Thank you very much to both of you for giving us your time.
Facilitated by S23M in association with