Listening to workers: the background of our Workers Inquiry
The first workers’ inquiry was conducted by Karl Marx in 1880 when he helped prepare and distribute a questionnaire consisting of 101 questions amongst the French working class. It progressed from purely technical questions concerning pay, work and lodging conditions, to political questions concerning ‘resistance associations’ of the workers. The point of the questionnaire was not simply to gather statistical data for the purpose of some abstract, academic investigation, but to use the inquiry method as a political tool, to help workers understand the social nature of the problems they experience as individuals and turn the latent struggle against the bosses that occurs in every workplace into a more generalized struggle against the system itself.
Since Marx’s original inquiry into the conditions of the French working class, the practice of the workers’ inquiry has been taken up by groups looking to understand the current state of the capitalist system, the working class, and the workers’ daily struggle against their masters. Although their methodology and conclusions have sometimes differed, the goal of those conducting a workers’ inquiry has always been to use the investigation as a means of further politicizing their fellow workers, building solidarity, and developing tactics appropriate to the current state of the class struggle. It’s with this tradition in mind that the Health Sector Workers’ Network has conducted its own inquiry into the conditions of those currently toiling in the health sector in Aotearoa.
In 2019, the Health Sector Workers Network (HSWN) carried out a Workers’ Inquiry to identify the experiences of health workers at our jobs. The information gathered identifies common threads in our working lives and supports our struggle for solidarity across the health sector. We had responses from administration, cleaners, district nurses, doctors, health care assistants, midwives, mental health support workers, occupational therapists, paramedics, residential care nurses and support workers, and registered nurses.
We asked questions about respondents’ role and working conditions, as well as the role of unions in the workplace. Although one of the principles of HSWN is the broad sense of ‘work’ which includes unpaid social reproduction and emotional labour, we needed to ensure the resulting data was manageable and comparable, so we limited this particular inquiry to investigating employment in any type of healthcare environment in Aotearoa New Zealand.
The design of our survey involved liaison with Notes From Below in the UK, an organisation which has developed inquiry to understand a range of different work. We used Marx’s original workers’ inquiry questionnaire as a reference, as well as contemporary examples. We created the final survey using Google Forms as our platform, and then shared the inquiry via our Facebook page, HSWN newsletter, personal email and word of mouth.
We received a total of 135 responses between March and June 2019 from a broad range of health workers. All quotations are taken directly from our participants’ anonymised responses. We have used a combination of qualitative and quantitative data from the inquiry to make our argument that feeling undervalued both financially and emotionally for the work we do, and the daily strain on the system due to under-resourcing and understaffing, has led to an increasingly stressed workforce often forced to practice unsafely and in ways that compromise patient care.
“Making do”: the daily reality of working in health care with not enough
The under-resourcing of healthcare in Aotearoa will come as no surprise to most readers. Not a week goes by in the media without a story related to budget over-spending in DHBs, or a plea for more funding in primary and community health care. What our inquiry aimed to capture was the testimonies of how this chronic under-resourcing plays out in the day to day lives of health care workers. The results show that over half of the respondents did not feel they had adequate resources to do their jobs properly.
The impacts that staff recognise in their workplaces when resourcing needs are not met are two-fold: pressure from staffing constraints and workload becomes overwhelming, and patient care is rationed and therefore compromised. Only 9.3% of respondents reported they always have the resources to perform their job as expected.
An almost unanimous response across every area of health care was a call for “more staff”. The consequences of understaffing whether it be in front-line medical care or the administration and support services that keep the health care system running ranges from “staff exhaustion and burnout” to “poor patient care”. In nursing this can look like poor skill mixes on the floor, “no time to actually get to know your patient, you can only do the basics and often leave work knowing you have not done all you wanted due to time constraints”. Due to a constant need to have the bare minimum required staffing to cut costs, hospital staff often have to move to other areas and departments to provide cover, with limited training and not knowing the team very well, some reported not feeling safe carrying out their work in these covering roles.
As healthcare workers we are used to being constantly told to maximise our efficiency, and effectively being “gaslighted” by management to make us feel it is our own individual incapacity to do our job properly, rather than a fundamental inadequacy of the system. One participant highlighted being “told it is my problem with time management. Actually [it is] under staffing and increased acuity of visits. Not enough hours to do the job properly, then [I am] pulled up for not doing something.”
The chronic nature of understaffing has led to a constant treading of water to keep things going: “we carry on… the best we can” and some services are forced to “stop clients from doing programmes if really short staffed”. Tragically, “people just go without… people are very used to being deprived in the community sector (especially in the mental health field), and have all sorts of coping strategies.”
There was a concern, in this case in primary health nursing, that an aging population and increasingly complex health needs was putting further demands on the system without any more funding or planning to reflect it. As one respondent put it, “we are rushed a lot of the time, our job has become more complex as more responsibilities are delegated to the nurses instead of the doctors and the appointment times are not increased to reflect this”. Essentially, it is a case of not enough butter spread over too much bread, with workers expected to “do more, with less, faster – don’t care how you do it, just do it”.
So how do workers survive day to day in a system that appears so overstretched and on the verge of breaking point? One of the key themes that came through in our findings was that of “making do”. One respondent put that: “We compromise. We find an innovative solution. We get told to improve but given no material way to meet needs.” It is a daily challenge and “we beg, borrow, hunt, improvise and explain”. With regards to lack of equipment and physical demands on the system: “We have to make do with whatever else we have in stock. A lot of stress and frustration builds up with colleagues as we don’t have all things needed.” In regards to responses or action that was being taken by management to mitigate such things, there was little to no hope from our participants, with one simply stating “You get told to do an incident report and hopefully this will create change.”
“Valued, but not worthy of value”
Feeling valued as a health worker is a complex and contradictory issue. Respondents to our inquiry felt a range of opinions of whether they feel their job is valued by society. A mental health nurse believed they had a “bad reputation” in society due to misunderstanding about the job and a deteriorating respect for the work they do. Another stated that while it is seen as “hard work”, with the common comment of “I couldn’t do your job”, there is also a stigma that comes with a wider lack of understanding of mental health. A number of responses highlighted the contradictions of value, for example being “Called ‘Angels’ by most, abused by some” or the troubling observation that “it is highly valued by the public, but perpetually underpaid and under valued by employers.” One respondent described it as “valued, but not worthy of value.”
Midwives in particular emphasised how their job is misunderstood both within and outside of the health sector. Due to being “frequently associated with nursing” by some, or viewed as “cuddling babies” by others, the misunderstanding of the crucial role that midwives play in the community, ensuring maternal health and the safe delivering of babies. Similarly, administration staff feel “that we aren’t really health workers, or that we are just an annoyance rather than a help.” Mental health workers reported feeling acutely the stigma attached to mental health service users, with work in the sector often also being misunderstood and stigmatised, “It is seen as hard work… ‘I couldn’t do your job!.’ There is stigma attached and a general lack of understanding about mental health.” Workers linked the low status of certain types of health work to underfunding and poor pay.
In 2017, the watershed Care and Support Workers Pay Equity Settlement Act was the first to legally recognise the undervaluing of women dominated paid labour. It was a substantial settlement that meant pay rises of up to 50% with the new minimum industry wage being $19.07 per hour. While not discounting the tangible change this made in the lives of many workers, the industry was far from ‘fixed’ as is clear from our care and support worker respondents. They write that they are still “being treated unfairly by their employers, we are subsidising the health system when we are not properly reimbursed for using our own cars to visit people, we have rosters that are not efficient and are impossible to keep time with, some workers still do not have job security and employers are not following legislation around the Care and Support Workers Settlement or Employment Law.”
A residential support worker stated that their job would be made easier if their employer treated them “like an intelligent, experienced person, who works with integrity and to a high standard.” Due to many health professions being seen as “women’s work” we are also financially undervalued, with one respondent believing that “I don’t think my income reflects nearly 10 years of hard work in this sector”. Fair pay was a strong theme that came out across the board, along with other aspects of feeling valued such as good communication and management listening to staff on the floor. Appreciation of the important work that is done is not always felt, and as one HCA articulated “some praise occasionally by boss and employer” would be nice.
In every profession, the response to the question of “what if no one did your job?” was overwhelmingly a catastrophic collapse of the public healthcare system, and the ultimate consequence would be that “people would suffer and die”. Those working on the frontline in hospitals predicted that “the community would suffer, longer hospital stays, unmonitored wounds becoming septic, bedridden patients would have to be taken elsewhere for their cares.” Those working in mental health in the community said that “clients suffering with mental health would be left unsupported, not advocated for, vulnerable and the suicide statistics would increase”. Midwives speculate there would be “a significant increase in mortality rates of women and babies.” Administration and support staff like cleaners thought that there “would be no operation or functioning of the wards” and “no one would get their appointments or surgeries, no one would get paid, and patients would have no point of call”. It is clear that we see our own work as deserving of respect, but this is not reflected in our pay and conditions. Only 13% of respondents answered that they were paid enough to not have difficulty in meeting their basic financial needs.
“We mostly work in isolation”: the emotional toll of health work
Many responses to our inquiry highlighted the various ways that health sector work can impact negatively on their wellbeing, both physically and emotionally, leading to heightened stress and burn out. Health work is often shift work, which involves working unsociable hours or “flexi rostering” which is erratic and precarious. One participant disliked how this caused “stress and impact of stress on my well-being and time with family”. Having erratic shift changes makes it extremely difficult to get a healthy sleep or develop a routine outside work, an example of this would be “working 3 different shifts in a 4 day roster eg. Arvo day day night.” Some workers on penal rates described having to “work a lot of nights and weekends to earn penal rates, just so that I can meet my bills, still don’t have money for extras like holidays, dentist, new clothes.” Shift length and working overtime was another common concern in the responses, with one support worker describing what they saw as problematic rostering practices that are clear evidence of understaffing: “People working over 130 hours a fortnight, people working 16 hours plus continually.”
Under the strain of short staffing, many responses highlighted not being able to take breaks or annual leave as examples of employers not meeting their contractual obligations by law. For some this looks like being “unable to leave my unit for meal break in spite of it being unpaid”, or working “unpaid overtime and meal breaks not taken due to heavy workload”. Some participants in our inquiry, particularly in midwifery talked about being on call 24/7 and the impact this has on their own health and wellbeing. Lead Maternity Care (LMC) midwives contracted by the Ministry of Health (MoH), find that “being on call all the time is demanding and intrusive to my family life and enjoyment of activities.” Additionally, they must pay from their own pocket for their ongoing costs and to get cover as they are not entitled to annual leave or sick leave. As a result, LMC midwives feel the weight of an underfunded health system as “there is a cost to myself (both financial, emotional and physical) to fill gaps when needs are not met”.
Other workers reported a similar feeling of not being able to ‘escape’ from work, and the emotional pressure to keep giving and giving until there is nothing left. Leave and time away from work is not safeguarded when staffing is so short; as one support worker put it: “we are called at any time they want. Txts, phone, emails. While on annual leave, sick leave, family emergencies.”
The nature of healthwork takes its toll both physically and emotionally, especially if resourcing and staffing is over-strectched or there is no access to adequate support. Home care workers often work individually, and while they enjoy the contact and relationships with their clients, they report finding it hard to cope with “the isolation we feel with not seeing other staff members.” This is made worse when staff do not feel supported by management in their job, as another support worker said: “We have little social or other support from colleagues or managers as we mostly work in isolation. We depend on good communication from our managers but this is rarely forthcoming.” A widely experienced problem is that resources are so stretched in so many of our workplaces, staff are pushed harder and harder to keep the system going, resulting in burn-out, exhaustion, and people leaving the profession. One nurse described “ending a shift feeling so physically and emotionally drained that I just want to cry”; this is not the kind of healthcare system or work environment we deserve.
On the path to organising: “Work is hard right now”
Nearly 84% of respondents belonged to a union. However, just over half (56 of the 108 responses) noted union activity present in their workplace. In some cases there were barriers to this “because management refuse to let [union organisers] on site to hold meetings or talk to existing union members.” However, many workers commented that unions were only visible during bargaining or that union related activities failed to address workers’ issues or were unproductive, “There really are no union related activities in my workplace. As a delegate we have monthly WOC (workplace organising committee meetings). These meetings discuss issues but rarely action anything to solve them.” There was a sense of frustration that some unions were not responding to the reality of those working at the coalface, and when workers attempted to push issues, they encountered barriers. “I have been involved in various roles in my union. However, union officials kept control of activities and members are not permitted to do what we’re capable of” said one respondent. Others had also put in hard mahi as active union members and stated they expect more from paid officials: “[I’ve been a] delegate and been in the union for 40 odd years…. Not impressed with union presently and they will have to up their game.”
Although most respondents were union members – reflecting the high unionisation of certain health worker groups – there was more enthusiasm for participation in furthering workers’ rights outside of official union structures. Respondents reported: working with their colleagues to identify issues and bring management together; helping other workers interpret their contracts and support them to address issues when obligations are not met; and organising lunches to discuss workplace issues and other supportive actions. One delegate responded that they “attend other workers’ strikes, eg burger king, the teachers. Try and find out about what I can do to help ward clerks in hospital.” However, unsurprisingly, given the stress that many workers reported, some had become too tired to fight: “I and my colleagues are TIRED and demoralised. It looks like apathy, but we’ve been beaten up over and over and many have given up…and many have left.”
In almost every area of the health system we see people and resources stretched to the point of crisis, and yet the voices of those who are on the front line of the problem are not being listened to. The participants of this inquiry come from vastly different professions and occupations, but there is a unity in our calls for change. We entered this industry because we are empathetic and compassionate, and wanted to make a positive difference in our work. Many of us become burnt out, leave, or get worn down and disillusioned by the way circumstances never seem to improve. When we go on strike or speak out about our work and the state of the health system, it is not because we don’t care. It is because we care immensely for the health of people in Aotearoa and the meaningful and valuable work we do. In the media and particularly during industrial action, our issues are siloed and attempts are made to pit workers against each other to decrease the power of the working class. However in this report we have deliberately woven together everyone’s responses with a focus on the commonalities we share in order to build solidarity and power. We are all health sector workers, and in this report we have unapologetically told our story.
Compromised care: fight or fate?
We live in an era where NGOs battle over funding fluctuations beholden to political whims, community health services are struggling to stay operating especially in rural areas, hospitals have CEOs, aged and disability care work is being privatized – the list of attacks on the public health system goes on and on. Our current health system compromises both workers’ health and patient care. Despite government claims of investment and change, many workers’ experience is that conditions are worsening.
Hospitals are a hierarchical reflection of our wider society. There is a huge pay disparity in the hospital with Māori, Pasifika and women making up the majority of those at the lowest rungs of the employment ladder. Cleaning, laundry and hospitality services in the hospital are contracted out, and are paid less than a living wage. Administration, security and other non-clinical support work is often not acknowledged or valued for the vital role it plays in holding the system together. Nurses, midwives, health care assistants and lab and imaging technicians are chronically understaffed and overworked, with a staggering rate of burn out, stress leave and staff turnover.
Outside the hub of the hospital, primary and community based health care is crucial to providing both emergency and preventative healthcare, but this work is often invisible. LMC midwives work on contracts that circumvent basic workers rights like holiday and sick leave. Mental health services struggle with the increasing demands on their system. Home-based care workers in the disability and aged-care sector are subjected to long, erratic and unguaranteed shifts. Paramedics struggle with industrial action against employers and – at times – an hostile public, just to get a living wage.
At HSWN, our aim is to unite a diverse workforce across the health sector and beyond, in solidarity against the shared struggles we all face as a result of a hierarchical, colonial, and capitalist healthcare system. The majority of the respondents to our inquiry see their core work as valuable and rewarding, but are often unable to deliver safe care due to lack of resources and decision-making processes that are disconnected from those delivering health services. The findings lead us to believe that it is necessary to make connections and build networks across health unions and sectors as ordinary workers. These networks would cooperate and organise to assist and extend concrete solidarity for all health workers. We know our work best, know what is needed, and what action we need to take. Through the process of self activity we hope that workers will strengthen our resolve to stand up and fight for collective and inclusive control over our workplaces, communities, and lives.
A note from the authors
This report was collaboratively written by HSWN members across the country remotely using a shared Google Doc. The main contributing members were: Maire Christeller, Siobhan Lehnhard, Annabel Bennett, Olly Hill, Al Dietschin, and Sam Ritchie. We also acknowledge the advice and knowledge of Achille Marotta in the UK and cover art by Lauren Christeller. In the final revisions before publication in March 2020, the Novel Coronavirus Covid-19 was taking hold in Wuhan, China, and proceeded to rapidly spread across the world causing chaos in healthcare systems wherever it went. This report shows that the crisis in the health system is not new, and has been forewarned by the struggles of health workers keeping it afloat for many years – Covid-19 is pushing it beyond the brink and laying bare the inequities, injustices, inefficiencies, and absurdities of a system that was already very damaged after decades of neoliberal attacks. The government’s response over and over again has been “there’s no money.” Now, when politicians, officials, and management realise the depth of their neglect, it is already too late for our broken system to cope with an outbreak of Covid-19. We feel this is an apt time to release a document that is based on responses given in March-June 2019, that seem to foreshadow many of the national and global issues we face now, a year later.