NSW nurses and health workers are heading for the exits as an epidemic of bullying, harassment and violence takes hold in the hospital system.
A report commissioned by the NSW Nurses and Midwives’ Association (NSWNMA) in 2023 found that 15 in every 100 nurses and midwives surveyed are suffering symptoms of post-traumatic stress at clinical levels. Overwork, exhaustion and burnout were identified as key contributors.
A NSW Health employee survey, which had 81,815 respondents, found 16 per cent of respondents claimed to have experienced bullying, 12 per cent had experienced threats or physical harm, and 7 per cent had experienced sexual harassment. Nurses and midwives made up 33 per cent of respondents.
According to data obtained by the Sydney Morning Herald under freedom of information laws, more than 33,500 NSW Health employees have also claimed they are burnt out, while 21,000 workers say they have witnessed bullying in the workplace.
The 2023 NSW Inquiry into Rural, Remote and Regional Health found a "culture of fear" among healthcare staff around speaking out about under-resourcing, mismanagement, bullying or harassment.
But does it need to be like this? Like the NSW Government, the Healthy Communities Foundation Australia employ nurses, administrators, allied health workers, social workers, policy makers, doctors and managers. But in a recent survey, 96 percent of its staff expressed positive satisfaction working for the Foundation because it strives to create a culture that reflects the values of its staff.
Culture has consistently been identified as the single most important reason why nurses and other health workers are leaving the health system. And a positive culture that is supportive of staff, and aligns with their values, has been shown to increase recruitment and retention of staff, and improve organisational productivity.
That is why the utterance of a single word by the NSW Premier, Chris Minns, is so important and might suggest that the NSW Government has finally worked out the cause of the problem.
At a recent Community Cabinet meeting in Orange on 17 May 2024, the NSW Premier talked about public service as a ‘vocation’, not just a ‘profession’.
For many this might have been seen as a throw-away line - a statement of the obvious. But for me it was like a breathe of fresh air. When is the last time a Premier of NSW has talked about public service as a ‘vocation’.
A vocation is an occupation that one feels compelled to engage in on a personal level, which is augmented and strengthened by a professional or vocational qualification. It amounts to a sense of calling. Vocation is work that is meaningful to the person who engages in it. Nursing, teaching, social work and policing roles are typical examples.
A profession is an occupation or employment obtained after having received training, and being professed as an expert in a particular field.
Vocationalists are professionals, but professionals are not typically vocationalists. Vocationalists tend to find joy in work that fulfils their innate purpose in life, while professionals tend to enjoy work that delivers the greatest amount of money, status and power over the life course.
Research suggests that those who feel personally connected with their jobs and attach to it a sense of purpose, typically exhibit greater physical health and emotional well-being.
I see every day the critical difference between a vocational professionals and non-vocational professionals, and the importance of a health and social care organisation aligning its organisational culture to its role as a vocational services provider to vulnerable people.
Why is this important to me? I rely on the public education and health system just like every other citizen of NSW. I want it to work, and I want it to be able to attract and retain good people that it needs to do its work. As a citizen, and taxpayer, I want to contribute to finding a solution to the cultural challenges besetting our health services.
However, to solve a problem we need to be able to name it, understand it and address it. This is why the single word ‘vocation’ uttered by the NSW Premier, and the single word that has flowed out of myriad inquiries and surveys into our caring professions ‘culture’, are so important.
It is also why we all need to be concerned that neither word, excluding the statement of the Premier on 17 May 2024, is at the top of the public policy and reform agenda of the NSW Government.
Despite the importance of culture to a strong and sustainable health system, and the numerous findings that a misaligned culture lies at the heart of the problems in our health system, the Government launched a Special Inquiry into Health Funding that focuses on money (the perennial cost-shifting game that has distracted Ministers from the main challenges of our health system) and not on its people or the community.
The Minns’ Labor Government has announced new incentive payments for nurses, made more temporary staff permanent and commenced a program to build nursing accommodation near local hospitals, to address some of the identified sources of concern. It has launched a committee of rural MPs to examine the “culture of fear” in rural and remote hospitals, but significantly not the wider health system.
But despite the recognition of public service as a ‘vocation’ by the Premier, and the centrality of culture to the ability of government to recruit and retain staff, and deliver services, the word ‘culture’ is not publicly at the front of the Minns’ Government’s policy agenda.
So what does a vocation look like? Let me share some examples from the Foundation.
It is a rural mental health nurse who had patients without access to transport, and were in the line of the bush fires in southern Queensland, who got in her car in NSW and took them to an evacuation centre. It is the young graduate nurse who is mentoring Aboriginal people to become Aboriginal Wellness Workers so that they have meaningful employment and remote communities have access to the services they need. It is the nurse practitioner who told her Mum that she had young female patients experiencing ‘period poverty’ who then worked together to secure a donation of tampons to be distributed freely to young women in a small remote town. It is the deputy principal of a primary school who spends hours on the phone trying to find a paediatrician to formalise a diagnosis of ADHD so a child has a chance of a positive life. It is the Aboriginal Health Workers who travel to the furthest reaches of the State to screen kids for Fetal Alcohol Spectrum Disorder so that they can get early access to treatment. It is the manager who gives the boss a call to let him know that a colleague is doing it tough, to make sure that the organisation wraps around the support they need.
These are people driven by a vocation. They live in vulnerable communities because that is where they can do the most good. They talk to members of the community every day because they know that the community needs to be heard, and often have answers to challenges that we would not otherwise find. They work collaboratively as a team with other people because arguments about ‘my scope of practice’ are irrelevant if it impedes a patient getting the care or help they need. They argue at times ferociously for the right to health for the people whom they serve, even if it makes their boss shift in his chair.
Professionals can develop a vocational driver as they experience the impacts of decisions on the life of others. Others adopt the language of vocational professionals, but have never been to a small rural town off their own bat, talked to a remote Aboriginal person at a pub just for fun, gone to a nursing home to chat with older people to provide them with some company, sat holding the hand of a young man dying or AIDS because he had no one else to provide comfort, taken a homeless person on the street out to lunch, or asked a teacher if they could sit in a classroom to understand the pressure on our teachers of undiagnosed neurodiversity disorders. Vocationalism is bred-in-the-bone, and manifest by unprompted engagements with real people with lived experiences.
The culture of the Healthy Communities Foundation Australia reflects the vocational values of our staff. We are not perfect, but we do strive to do our best every day and I think our staff value that we are trying.
A focus on vocational values is not easy, and comes with challenges. Encouraging staff to speak up means bosses and boards must have the temperament to listen and act, rather than command and deflect. We must be prepared to hear uncomfortable truths and respond, rather than try to bury the things or punish people for telling us the truth. It means that bosses and boards must genuinely embrace the full and beautiful diversity of people, including their frailties and idiosyncrasies, rather than demand a uniform set of people who all think the same and act the same. It means that strategies must be less about ‘what we can do’ and more about ‘how we can help’.
Many areas of the NSW Government demonstrate a commitment to a culture of vocationalism in public service. A recent experience doing collaborative co-design with NSW Transport demonstrates an organisation that acts on its values, and values the vocation of its people. The NSW Human Services Framework as a document, and our work with a group of staff from NSW Communities and Justice to find ways to ensure remote area foster kids have access to appropriate care, demonstrates that there are people in government right now that have the capacity teach others about how a culture of vocationalism can transform public services, attract a new cadre of employees and deliver care that communities value where they need it.
The amazing things about nourishing a vocational culture is that it leads to better health outcomes for people, and that means fewer preventable illnesses, few avoidable hospitalisations, fewer unnecessary deaths and significantly lower costs for taxpayers of running our health system.
But to achieve reform we need to reject the argument that a vocational culture is antithetical to the cost-effective delivery of public services. This is nonsense. The escalating costs of our health system gives the lie to this assertion, as does the irrefutable evidence that place-based, needs-based, community-led service design and delivery leads to lower costs and better outcomes for people.
At the heart of the problems in our health system (and I use the word ‘our’ deliberately because the system belongs to us as citizens) is the imposition of a managerial professional culture on people driven by a vocation, and who crave to work in organisations with a vocational purpose and culture. That is why the recognition of ‘vocation’ by Premier Chris Minns is so important.
But recognition is not enough.
Things like incentives, housing and other monetary changes sound like solutions, but we know from the last 20 years that increasing incentives and other rewards is a temporary solution at best, and only increases the price of health care to taxpayers while exacerbating the problems at the heart of our health system. It is a managerial professional response to a vocational values problem.
When you respond to someone who has a problem with your culture by offering them only money, you are telegraphing how little you value the things that of central importance to them. It’s a short term solution that plays to electoral cycles, and not to the deeper needs of communities and the people who staff our health system.
At the end of the day, people driven by a vocation do not go to work just to earn an income (a fair day’s pay for a fair day’s work should be an assumption, not be a demand), but to do what their heart tells them is important in their lives.
The shift to a managerial professional culture in health was intended to standardise service delivery, reduce costs, streamline processes, improve quality - all at a lower cost. But what it produced was health inequity, fragmented services, higher costs, red tape and the loss of critical skills and knowledge.
If we want a solution to the crisis engulfing our vocational professions and services, then we need to look to elevate discussion of communities, culture and values and stop looking for easy, short-term wins.
The challenge for the NSW Premier is to take this word ‘vocation’, and turn it into a mantra for fundamental reform of public and health services.
For more information contact Mark Burdack on 0418974988.
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