Like many countries, Aotearoa New Zealand is in the midst of a health workforce crisis.[[1–4]] Long-term staff shortages across health professions have been exacerbated by the COVID-19 pandemic, which has significantly increased stressors experienced by the workforce, both here and globally.[[5–7]] COVID-19 response strategies continue to evolve in response to new variants of the virus and to the shifting societal attitudes related to acceptability of restrictive public health interventions. The ongoing impact of the pandemic on the healthcare system and the health workforce should not be underestimated.

Recently published research shows the extent to which healthcare workers experienced anxiety and increased stress in the workplace due to inadequate access to personal protective equipment (PPE) during the first COVID-19 surge in New Zealand.[[8,9]] The inadequate state of New Zealand’s PPE stockpile and distribution system at the beginning of the pandemic may be a far cry from our current situation, where masks are ubiquitous and supply chains restored. However, it remains a critical signal, a “canary in the coalmine”, of broader ongoing challenges within the healthcare system—particularly related to healthcare worker wellbeing, stemming from persistent staffing shortages, high workloads, under-resourcing and burnout.[[2–4]]

The shortages of PPE during the first COVID-19 surge reflected inadequate stock, inequities in distribution and complacency in preparedness and planning, as well as other ethical and practical concerns.[[10,11]] A survey of over 1,400 healthcare workers, representative of a range of regions and specialties in New Zealand, showed that many healthcare workers were adversely affected by shortfalls in PPE provision, viewed as further demonstrating their perceived lack of value in the system and the extent to which their safety and wellbeing is compromised even when their skills are most needed. Unsurprisingly, respondents’ comments showed links between feeling safe and protected in the workplace and feeling valued and respected as workers and as people.[[ 8]]

Public health emergencies force re-examination of moral commitments and obligations, both public and private. Like the SARS epidemic of 2003 and the HIV/AIDS epidemic before that, ethicists have used the COVID-19 pandemic as an opportunity to re-examine the nature of healthcare workers’ duties to continue to work and care for patients in situations of increased personal risk. While most ethicists (and health professionals) accept some form of the “duty to treat”, the inadequate supply of PPE during the first surges of COVID-19 clarified why that duty has limits. Some scholars have argued that the duty to treat is contingent on the provision of adequate PPE, and that where suboptimal PPE is a result of “avoidable allocation decisions,” healthcare workers are justified in refusing to provide care.[[12]] Others have emphasised that insofar as healthcare workers have a duty to treat, healthcare institutions and governments have a reciprocal obligation to provide adequate PPE.[[13,14]] Crucially, other forms of affirmation for the contributions of healthcare workers during a public health emergency, while important for morale, are not substitutes for fulfilling this reciprocal obligation.[[13]]

Findings of the recent survey conducted with New Zealand healthcare workers show that just over one quarter did not receive adequate PPE from their organisation to enable them to do their jobs, and a similar proportion were told by their organisation not to wear PPE due to stock levels during surge one in 2020.[[9]] Reusing was also common, with just under half reporting they personally reused PPE.[[15]] These findings indicate the extent to which healthcare workers are expected to assume personal risks when their organisations are either unwilling or unable to meet their responsibility to mitigate those risks.

Failure on the part of healthcare organisations to meet this responsibility left many workers feeling expendable and under-valued. Past research has highlighted the interweaving of pre-existing tensions within the health system and the “extreme work” required during the pandemic response.[[5]] The “reality gap” between health management and frontline staff was amplified, with the tension of the moral aspects of frontline healthcare provision and adhering to changing workplace guidelines at times incompatible with staff wellbeing laid bare.[[8]]

Failures in the provision of PPE were not the only factors contributing to these feelings of a reality gap, as healthcare workers also experienced increased levels of stress and anxiety related to uncertainty. A lack of transparency and honesty about stock levels and the reasoning behind PPE allocation decisions were key indications for many healthcare workers that their organisations did not trust them to use either the information or PPE appropriately.

Alongside this negativity, positive experiences of communication were reported and recognised as critical to building trust and unity in a given organisation.[[8]] These findings are particularly relevant as Te Whatu Ora – Health New Zealand begins its leadership as the national organisation to deliver health services nationally.[[16]] One of the stated goals of this reform is to better support healthcare workers.[[17]] This is critical given the high rates of healthcare worker burnout reported in recent surveys across Australasia.[[3–5]]

The new knowledge gained from the PPE survey[[8,9,15]] allows us to draw robust conclusions about the impact on healthcare workers of the shortage of PPE, as well as the wider health system deficiencies that this shortage, and the organisational response to it, draws attention to. The reduction in “organisational slack” in public health services as a result of increased demand and the need for efficiency within austere funding environments already had the potential to negatively impact on healthcare worker health and wellbeing pre-pandemic.[[5,18]] The inability of healthcare workers to provide the care they perceive as needed—to patients for whom they have responsibilities—results in moral distress and ultimately burnout.[[5,8]] In a system in which unmet need has been normalised, healthcare workers were expected once again to carry on, assuming the risks of extreme staff shortages and unexpected workload surges, just as they have done with the risks of COVID-19, of pre-existing staff shortages and other long-standing challenges of under-resourcing.

The PPE survey allowed healthcare workers to express their recognition that such expectations are wrong, both morally and practically. We depend on the health workforce to continue contributing their skills during crises; those skills make them instrumentally valuable. But healthcare workers are also human beings, and this makes them intrinsically valuable; their welfare is as important as that of the patients for whom they care.[[19]] We cannot continue to depend on the contributions of healthcare workers unless we (the public, our institutions and our government) meet our obligations to ensure the health system provides a safe, supportive and well-resourced working environment. It is important to acknowledge that these issues are not confined to one country, with studies published internationally showing similar findings.[[5,7]]

As New Zealand reforms its health system with the aim to improve access to and equity of care for patients, an opportunity is available to prioritise the wellbeing of the healthcare workers we depend on to deliver that care. The analysis of survey responses from healthcare workers highlighted four critical values they hold: trust, transparency, respect and safety. These four values have been organised into the Nurture Framework, a set of recommendations for ensuring that healthcare institutions and organisations exhibit these values in their relationships with health professionals. The Nurture Framework clearly reaches beyond the pandemic.[[8]] Trust, transparency, respect and safety are fundamental for all workers who contribute their skills, knowledge and time to our healthcare organisations.

One key strength of the Nurture Framework is that its demands are straightforward and achievable—for example, inclusion of healthcare workers in decision making, honest communication, commitment to appropriate occupational health and safety standards, availability of wellbeing services and listening and responding to healthcare workers’ concerns. A commitment to this Framework at all levels of healthcare delivery, management and governance would help ensure that the health system can deliver the best outcomes for our communities.

While healthcare has, rightly, become increasingly patient-focussed, a nurturing model encircles healthcare workers with support and care just as healthcare workers encircle patients. While the immediate crisis over PPE has passed, this important research highlights the need for a shift in mindset moving forward: from a top-down, linear model of healthcare delivery to a circular model, with patients supported by the healthcare workforce, the workforce supported and nurtured by the organisations within which they provide healthcare, and the patients actively contributing to improve the ways in which healthcare is delivered to them. Patient-centred care is not possible without a nurtured, engaged and valued healthcare workforce. Simply put, the health and wellbeing of New Zealanders depends on the health and wellbeing of healthcare workers. We should not wait for another health emergency to recognise their importance.

Like many countries, Aotearoa New Zealand is in the midst of a health workforce crisis.[[1–4]] Long-term staff shortages across health professions have been exacerbated by the COVID-19 pandemic, which has significantly increased stressors experienced by the workforce, both here and globally.[[5–7]] COVID-19 response strategies continue to evolve in response to new variants of the virus and to the shifting societal attitudes related to acceptability of restrictive public health interventions. The ongoing impact of the pandemic on the healthcare system and the health workforce should not be underestimated.

Recently published research shows the extent to which healthcare workers experienced anxiety and increased stress in the workplace due to inadequate access to personal protective equipment (PPE) during the first COVID-19 surge in New Zealand.[[8,9]] The inadequate state of New Zealand’s PPE stockpile and distribution system at the beginning of the pandemic may be a far cry from our current situation, where masks are ubiquitous and supply chains restored. However, it remains a critical signal, a “canary in the coalmine”, of broader ongoing challenges within the healthcare system—particularly related to healthcare worker wellbeing, stemming from persistent staffing shortages, high workloads, under-resourcing and burnout.[[2–4]]

The shortages of PPE during the first COVID-19 surge reflected inadequate stock, inequities in distribution and complacency in preparedness and planning, as well as other ethical and practical concerns.[[10,11]] A survey of over 1,400 healthcare workers, representative of a range of regions and specialties in New Zealand, showed that many healthcare workers were adversely affected by shortfalls in PPE provision, viewed as further demonstrating their perceived lack of value in the system and the extent to which their safety and wellbeing is compromised even when their skills are most needed. Unsurprisingly, respondents’ comments showed links between feeling safe and protected in the workplace and feeling valued and respected as workers and as people.[[ 8]]

Public health emergencies force re-examination of moral commitments and obligations, both public and private. Like the SARS epidemic of 2003 and the HIV/AIDS epidemic before that, ethicists have used the COVID-19 pandemic as an opportunity to re-examine the nature of healthcare workers’ duties to continue to work and care for patients in situations of increased personal risk. While most ethicists (and health professionals) accept some form of the “duty to treat”, the inadequate supply of PPE during the first surges of COVID-19 clarified why that duty has limits. Some scholars have argued that the duty to treat is contingent on the provision of adequate PPE, and that where suboptimal PPE is a result of “avoidable allocation decisions,” healthcare workers are justified in refusing to provide care.[[12]] Others have emphasised that insofar as healthcare workers have a duty to treat, healthcare institutions and governments have a reciprocal obligation to provide adequate PPE.[[13,14]] Crucially, other forms of affirmation for the contributions of healthcare workers during a public health emergency, while important for morale, are not substitutes for fulfilling this reciprocal obligation.[[13]]

Findings of the recent survey conducted with New Zealand healthcare workers show that just over one quarter did not receive adequate PPE from their organisation to enable them to do their jobs, and a similar proportion were told by their organisation not to wear PPE due to stock levels during surge one in 2020.[[9]] Reusing was also common, with just under half reporting they personally reused PPE.[[15]] These findings indicate the extent to which healthcare workers are expected to assume personal risks when their organisations are either unwilling or unable to meet their responsibility to mitigate those risks.

Failure on the part of healthcare organisations to meet this responsibility left many workers feeling expendable and under-valued. Past research has highlighted the interweaving of pre-existing tensions within the health system and the “extreme work” required during the pandemic response.[[5]] The “reality gap” between health management and frontline staff was amplified, with the tension of the moral aspects of frontline healthcare provision and adhering to changing workplace guidelines at times incompatible with staff wellbeing laid bare.[[8]]

Failures in the provision of PPE were not the only factors contributing to these feelings of a reality gap, as healthcare workers also experienced increased levels of stress and anxiety related to uncertainty. A lack of transparency and honesty about stock levels and the reasoning behind PPE allocation decisions were key indications for many healthcare workers that their organisations did not trust them to use either the information or PPE appropriately.

Alongside this negativity, positive experiences of communication were reported and recognised as critical to building trust and unity in a given organisation.[[8]] These findings are particularly relevant as Te Whatu Ora – Health New Zealand begins its leadership as the national organisation to deliver health services nationally.[[16]] One of the stated goals of this reform is to better support healthcare workers.[[17]] This is critical given the high rates of healthcare worker burnout reported in recent surveys across Australasia.[[3–5]]

The new knowledge gained from the PPE survey[[8,9,15]] allows us to draw robust conclusions about the impact on healthcare workers of the shortage of PPE, as well as the wider health system deficiencies that this shortage, and the organisational response to it, draws attention to. The reduction in “organisational slack” in public health services as a result of increased demand and the need for efficiency within austere funding environments already had the potential to negatively impact on healthcare worker health and wellbeing pre-pandemic.[[5,18]] The inability of healthcare workers to provide the care they perceive as needed—to patients for whom they have responsibilities—results in moral distress and ultimately burnout.[[5,8]] In a system in which unmet need has been normalised, healthcare workers were expected once again to carry on, assuming the risks of extreme staff shortages and unexpected workload surges, just as they have done with the risks of COVID-19, of pre-existing staff shortages and other long-standing challenges of under-resourcing.

The PPE survey allowed healthcare workers to express their recognition that such expectations are wrong, both morally and practically. We depend on the health workforce to continue contributing their skills during crises; those skills make them instrumentally valuable. But healthcare workers are also human beings, and this makes them intrinsically valuable; their welfare is as important as that of the patients for whom they care.[[19]] We cannot continue to depend on the contributions of healthcare workers unless we (the public, our institutions and our government) meet our obligations to ensure the health system provides a safe, supportive and well-resourced working environment. It is important to acknowledge that these issues are not confined to one country, with studies published internationally showing similar findings.[[5,7]]

As New Zealand reforms its health system with the aim to improve access to and equity of care for patients, an opportunity is available to prioritise the wellbeing of the healthcare workers we depend on to deliver that care. The analysis of survey responses from healthcare workers highlighted four critical values they hold: trust, transparency, respect and safety. These four values have been organised into the Nurture Framework, a set of recommendations for ensuring that healthcare institutions and organisations exhibit these values in their relationships with health professionals. The Nurture Framework clearly reaches beyond the pandemic.[[8]] Trust, transparency, respect and safety are fundamental for all workers who contribute their skills, knowledge and time to our healthcare organisations.

One key strength of the Nurture Framework is that its demands are straightforward and achievable—for example, inclusion of healthcare workers in decision making, honest communication, commitment to appropriate occupational health and safety standards, availability of wellbeing services and listening and responding to healthcare workers’ concerns. A commitment to this Framework at all levels of healthcare delivery, management and governance would help ensure that the health system can deliver the best outcomes for our communities.

While healthcare has, rightly, become increasingly patient-focussed, a nurturing model encircles healthcare workers with support and care just as healthcare workers encircle patients. While the immediate crisis over PPE has passed, this important research highlights the need for a shift in mindset moving forward: from a top-down, linear model of healthcare delivery to a circular model, with patients supported by the healthcare workforce, the workforce supported and nurtured by the organisations within which they provide healthcare, and the patients actively contributing to improve the ways in which healthcare is delivered to them. Patient-centred care is not possible without a nurtured, engaged and valued healthcare workforce. Simply put, the health and wellbeing of New Zealanders depends on the health and wellbeing of healthcare workers. We should not wait for another health emergency to recognise their importance.