Forum 2019 - Enabling wellbeing

Budget 2019 unveiled Aoteroa New Zealand’s first Wellbeing Budget, which broadens the focus of the Budget beyond economic and fiscal impacts to include the determinants of wellbeing, such as the investment in human, social and environmental ‘capital’.

This session described the key functions of the Interim Mental Health and Wellbeing Commission, the increasing demand for mental health services and role of primary care, and the importance of a cohesive and resilient workforce.

Presenters

Hayden Wano, Chief Executive of Tui Ora health services and Chair of the Interim Mental Health and Wellbeing Commission

Video: Hayden Wano - Forum 2019 - Enabling wellbeing

[Hayden Wano presenting to an audience as part of the Enabling wellbeing session of Forum 2019]

[Hayden Wano's mihi]

When you get introduced for being involved in the health system for 40 years, you kind of wonder whether it's a recommendation or you've got a use-by date. And before I came in, we were just having a chat with a couple of people. And we were looking around at the number of people who are in the system. And we are in a very small sector, and we recycle ourselves.

And I think the positive spin I could put on being recycled-- because it's been about five or six years since I was last in Wellington-- is that you come back with different experiences. And so hopefully, that's something that I can bring to this new role. This is my first public engagement as chair of the initial commission. And it is a privilege to stand here today to represent the other members of the commission.

I want to acknowledge the political support, and I think that's important to acknowledge that. From the Prime Minister through to Minister Clark, this is clearly a government that is in reform mode and wanting to make a difference. I also want to acknowledge officials Ashley Bloomfield, Robin Shearer, and others across the system, for their support in getting this commission underway.

But ultimately, our goal is to set up the independent Mental Health and Well-Being Commission. And we are here as an interim stage to that outcome. So a little bit about the initial commission. We're establishing the Mental Health and Well-being Commission. It's an important pillar in getting the government's response to He Ara Oranga.

The initial commission has been established to maintain the momentum from He Ara Oranga while legislation is established for the permanent commission to progress. The initial commission will be in place from November 2019 to February 2021, give or take a matter of months, depending on how quick or slow we are to get to the work.

We will contribute to the transformation of New Zealand's approach to mental health and well . And we will see ourselves as a key contributor if not a catalyst for moving towards transformation. And that's a word I've picked up a lot on since I've been back in Wellington.

Our purpose is to provide independent scrutiny of the government's progress. And that's a pretty lofty goal to be given. It's something that brings with it its own unique challenges. So to monitor the government's progress in improving New Zealand's mental health and wellbeing. And just in case we didn't think our brief wasn't wide enough, we're here to promote collaboration between entities that contribute to mental health and wellbeing.

And finally, to provide advice to assist the permanent commission to hit the ground running when it is established in early 2021. That will involve us identifying some key priorities, and even more so, the resources that will need to be put in place to make this program work. Throughout our work, we're going to be mindful of Te Tiriti o Waitangi. And you'll be aware, or some of you will be aware, of the Waitangi claim, the 2575 claim, with over 200 claims underneath that mantle, and the enormous expectations that sit with Iwi, Urban Maori, and grassroots people.

We heard a lot from the minister this morning about the clear priority on equity. And I think it's an important part of the commission's role will be to identify what is working, but also to call out when it isn't working. And particularly, we should be looking for what is making a difference and what is making an impact. Finally, in terms of our purpose and principles, to work out how we can frame out what collaboration looks like, to encourage, to-- sorry. To foster and to reward behaviors that embrace collaboration.

The key functions and deliverables of the initial commission are to monitor the progress of the government system transformation in response to He Ara Oranga and to provide advice to the minister on a regular basis. We have been together as an initial commission for one meeting alone. And we had an initial meeting with Minister and we're-- We will continue to meet with the minister on a regular basis. Of course, he is very keen to see us make some progress. And our ultimate goal there in terms of reporting is to provide a final report sometime late in 2020.

We've also been tasked to develop a draft outcomes and monitoring framework for mental health and wellbeing that would be suitable for the permanent commission to consider adopting. And in this regard, we're in the process of setting up a secretariat to support the work of the initial commission. We're also tasked to begin to identify gaps in information required to monitor performance under the draft framework and to make recommendations on how these may be filled.

We're there to draft up a work program for the initial-- for the permanent commission. We literally are starting from a blank canvas. And so it's quite an interesting process of setting something up from scratch when there are such lofty and high expectations being put upon us. We're there to provide input into the establishment of the permanent commission, and we can expect some announcements from officials regarding the necessary legislation to set in place the permanent commission. So we could expect something regarding that bill sometime soon.

Finally, we're here to develop and maintain relationships with and between government and non-government entities that contribute to mental health and wellbeing. And as easy as that is to say, it is really difficult to achieve. And I think there are some experiences with the roll-out of the integrated primary mental health funding in some areas where this has in fact been the case.

Ultimately, I think it's important that, as a commission, we're able to build a sense of confidence within the system, acknowledge the good intent that is going on, and to elevate what is good, and importantly, to create some momentum for change. If the status quo is important to you, then this train is probably not one you want to be on.

Now, this core bunch of people here are part of the commission. And if I can just briefly introduce them. From your left to right, we have Kendall Flutey, who is the co-founder and chief executive officer of Banqer, an education program that teaches children concepts from income, interest on savings, tax, property, investment, and insurance. In 2018, Kindle won the title of Young Maori Business Leader of the Year, and earlier this year won Te Whetu Maiangi Award for Young Achievers.

Secondly, we have Kelly Pope. She is a mental health advocate, youth worker, and writer. She is founder of Crazy Young Things Consulting, which provides consumer advice relating to mental health and youth peer support. She is also a child support worker at Stepping Stone Trust and a research assistant at University of Canterbury.

Then we have Dr. Wharewera Julie Wharewera-Mika. And Julie is somewhere out in the audience. Sorry I didn't get a chance to see you before we got here. So Julie is a clinical psychologist and lead co-researcher, of Manu Arahi, the Flying Doctors. She has more than 20 years mental health experience, having occupied various roles within the sector, primarily as clinical psychologist and inpatient services, adult, child, and adolescent community mental health and district health board services. Doctor Wharewera-Mika's broader areas of research interest are focused on improving Maori mental health and well-being, mental health service delivery, support services for survivors of sexual violence, and Maori mental health workforce development.

And finally, most people I'm sure in this room will know Kevin Hague, who's a former Green Party MP and the current Chief Executive of Forest and Bird. He was previously the executive director of New Zealand AIDS Foundation and chief executive of the West Coast District Health Board. As I said we have had one session together. It was an intense session of induction and team building.

And what I can say from that initial meeting is that we are very strongly aligned in our values and in our drive and our reasons for being part of this work. And as I've said in the previous slide, we will bring energy to that, to this piece of work. Between us, we do bring diverse thinking and experience, including a broad range of lived experience.

So what we're building on. I'm a great fan of history in context. And if we go back to 1996, the Mason Report led to major step change in the mental health and addiction service system 23 years ago. The original commission lead to the establishment-- sorry. The original mental health report led to the establishment of the first Mental Health Commission. The commission was considered to be a strong, effective, and influential watchdog that improved public confidence.

The previous Mental Health Commission monitored and advocated for the interests of people who have experienced mental health distress and addiction, and promoted and facilitated collaboration and communication creation across the system. He Ara Oranga set the path for the next major step. And part of our role is to monitor the progress of the system transformation.

I just want to acknowledge that the system is under enormous pressure to roll out these rather ambitious programs that the government has set for us. And I think it's important that we are able to at least scale up, and I would say scale up in the short term, to acknowledge that there is a significant amount of work to be done across the system in regard to change management.

And I would like to think that there's that ability to not only scale up to meet that challenge for the change, but also to scale back when we know we're in a state of equilibrium and business as usual. What is our scope? So mental health and wellbeing is holistic. And for me, mental-- sorry, wellbeing means about person and place. You can't look at somebody's wellbeing when you just look at the person in their own context or the reason why they might be presenting in front of you.

It is important to acknowledge the person and their place. And that means sometimes where it's really important to acknowledge the place of whanau and the place of community. We heard Heather this morning talking about devolution to communities. And I think that's an important part of the conversation, that the system should not look to achieve all that needs to be done on its own. In fact, it's just not possible, particularly when you bring place into the context.

So it is important that we take as part of our role into account the broad factors that impact on the social and-- sorry, on the wellbeing of our people. And they include the social and economic determinants of health, everything from housing, employment, poverty, and that very challenging and confronting issue, the pervasive effect of institutional racism.

Further, both the initial commission and the permanent commission will look at the wider contributors to mental health and wellbeing. The initial commission will hold the government accountable-- it's a big task-- for delivering on the commitments made in response to He Ara Oranga. So this process of accountability is going to be a very public one.

It's important, though, that we maintain-- that this support is maintained politically, because political support through change, through the whole process of change until we [INAUDIBLE] the new way of doing things, is important. We intend to work with the new suicide prevention office being set up as part of the response to He Ara Oranga, and we want it noted that addiction will be part of the initial commission's scope of mental health and wellbeing.

What's not in our scope? The initial commission won't advocate for individuals or investigate individual cases. There are some tasks that the initial commission won't do and that the permanent commission will ultimately do, and these are for pragmatic reasons. For example, we won't be reporting publicly on the state of New Zealand's mental health and wellbeing beyond that which is in the He Ara Oranga Report.

The focus will be on the rollout of the government's program and to gain momentum. And because the time frame that we have to achieve this important milestone of setting up the permanent commission, it's appropriate for that scope to be limited to what it is. Communication and engagement. The commission members are very clear in their own minds and have embraced a different approach in wanting to approach community engagement and engagement across stakeholders in a very different way.

We want to acknowledged that people who are included in this slide, whānau, Maori, people with a lived experience, families, disabled people, Pacific people, rainbow people, and other communities that are disproportionately affected by mental health and wellbeing outcomes need to be part of designing and developing the new system, adding onto what is already-- has already been-- is going in what we are doing well, but engaging in a different way and being prepared to be open in our approach to the design of the way we do things in the future.

So some final thoughts. The initial commission is committed to ensuring accountability, integrity-- and I think integrity of the system as a whole is probably an important part for us as a commission to get our head around-- as well as transparency across the system. We want to ensure that people in New Zealand understand what the government is doing for mental health and wellbeing and how it is being done.

We want to build a sense of confidence from the sector and from the public. We want to instill that sense of confidence that we are heading in the right direction.

[Hayden Wano's farewell]

[APPLAUSE]

Dr Samantha Murton, GP and President of The Royal New Zealand College of General Practitioners

Video: Dr Samantha Murton - Forum 2019 - Enabling wellbeing

[Dr Samantha Murton presenting to an audience as part of the Enabling wellbeing session of Forum 2019]/p>

[Dr Samantha Murton mihi]

I'd like to thank the Ministry of Health for inviting me here today. And I'm pleased to be speaking to you today on behalf of the Royal New Zealand College of General Practitioners. We represent more than 5,000 general practitioner fellows or specialists-- "#specialisttoo" is our new hashtag-- and trainees and from across the country.

Although I've been president for less than a year, I've been working in general practice for more than 20. And I've gained valuable insight into how our health system and the demand for care and the high quality of health services in New Zealand have also managed with my previous work in the college to see many other health services around the globe.

Although our health system performs well compared to many countries, there's a lot more we can do. And today, I'll be speaking to you about mental health and general practice from two perspectives, caring for our patients and caring for ourselves.

I've been reading a book recently called Range by David Epstein. I hope someone's read it because it's a great book. It has discussion and insights into how broadening your skills helps to develop expertise. GPs in New Zealand are expert at range and truly use a variety of skills every day. We are also expert in specific things, and mental health is one of them.

I've also read some of He Ara Oranga, the government report on mental health and addiction. And every general practitioner would applaud the first two recommendations, to give more people more access to services and more choice and to transform primary health care. General practitioners are all for increasing access, but transformation sometimes feels a bit scary.

So mental health-- why are GPs so good at it? Mental health never turns up in isolation. I'll explain this with a story. Now, I did notice that Anthony Hill's here. This isn't really about a patient, but I'll try and be discreet.

Grandma never found a life partner and so had many. She had also never been taught to parent, so did not do it very well. Her cluster of children were generally neglected and brought up by each other. Now, I think my children would both say the same.

These children have their children, their own children and grandchildren. And some of them struggle with the same issues as grandma. But nearly all of them are determined to do better. This is not easy. And when things get tough, it's easy to turn to alcohol, drugs, get anxious and depressed.

Each of the children, grandchildren, and great-grandchildren have had a moment when they've seen their GP as things are unraveling. They can't tell the full story in 15 minutes. They won't tell their story to anyone they don't trust.

Fortunately, this whanau has a long relationship with their GP. One day, Jay comes in-- didn't miss the appointment this time. Jay says they're the black sheep of the family and not very well-connected. Sleep has been really bad, and Jay has been drinking heavily to nod off.

Jay works in the postal service, and the poor sleep affects their work. And so does drinking. The GP knows that sharing a bit of themselves often helps people open up.

The GP starts chatting about the postal service and losing things in the mail. And the GP explains how they had to stay in a house once where the owner had died. Their ashes had been sent by post and got lost.

And then jokingly, the GP wondered if the creaking floorboards was the chap walking the floors. Jay suddenly lights up. Do you believe in ghosts, Jay says. Now, would they say that to someone they don't trust?

Being open to spiritual health, the GP says, yes. And it turns out Jay uses alcohol to sleep because they dream about grandma coming to take them away and stealing things from them and feel like it's the spirit or ghost of grandma in their dreams. It feels so real that Jay does not want to dream. And alcohol stops that.

Jay agrees to attending alcohol and addiction services, but has no one to support them to go. The GP goes with them. Jay also confesses to being involved with a drug deal and agrees with the GP to stop doing that. The GP provides guidance and support for counseling, as well as medication as needed.

The relationship with Jay carries on. Jay gets a bigger job, employs staff, is now well-integrated into the whanau, and nurses grandma to the end. A life is transformed, a whanau is impacted, and a generation is changed.

Many GPs see this every day. They look after large whanau, and they know that their intervention early on in the patient's life based on a trusted relationship with a skilled wide-ranging expert has transformed the patient's outlook, opportunities, and mental well-being.

So what does transformation mean in practice? I have a counselor in my practice. I employ a social worker, funded through grants and donations. And we have a psychiatrist who comes in every two months to talk through our patients. So we have the skills and guidance to deal with the complex top 20% that we deal with every day.

In a recent survey, we went out to our members and asked them to tell us about their daily mental health and addiction consults. Unsurprisingly, the results overwhelmingly indicated that GPs are in high demand for mental health services. We ran the survey as an idea of the volume of mental health that GPs deal with.

We had 183 responses. Those 183 GPs saw 3,486 patients in one day. That's an average of 19 appointments per GP. Of the total consultations done, 1,089-- that's 31%-- included a component relating to mental health or addiction.

Of those consultations, 522-- that's 48% of them-- resulted in a prescription for medication related to mental health or addiction. And 217-- that's 20%-- were referred on to other services for mental health and addiction issues. Many of the comments were that this in no way reflects the amount of time that each of these consultations take.

Clearly, GPs are very busy in the mental health space, and this is only a snapshot of one day. It's an ever increasing demand for mental health services, and GPs are generally the first port of call. They also provide care at the extreme end of mental health care. Until recently, funding was the most risky top 3% who had a mental health condition. And He Ara Oranga recognizes the need is closer to 20%.

We see that in our 30% we see every day. As much as we are the first port of call for many of our patients' mental health concerns, GPs are not immune to mental health issues themselves. Working is extremely challenging, and the obstacles to overcome throughout a career in general practice are numerous.

I've already touched on the sheer pressure we are under to provide mental health care to patients, and the demand for these services is only increasing. I mentioned our psychiatric visits. I remember some years ago, I was berated by a patient that if anyone committed suicide, it was the doctor's fault.

I had had three people take their own lives in the six months prior to that. Two were in a mental health facility already, and one of them had been drinking alcohol. I was feeling particularly vulnerable that day, and I told my rather aggro patient that I could not have this discussion with them.

And as soon as they walked out the door, I rang my friendly psychiatrist and said, I think I need help. But we all do need help at some stage. General practitioners are quite deeply invested in the care of their patients and want to do the best.

I talk to my depressed patients a lot about how frustrations and not being able to fix things is a common cause of depression and anxiety. And GPs deal with frustrations and inability to fix things every day.

There are a range of factors that make caring for not only our patients but for ourselves particularly difficult-- a dearth of GPs in New Zealand, a retiring GP workforce, and a lack of GPs in practices in rural areas, underfunding, complexity of health need, and a complex health system and many, many more constraints.

GPs are under immense and increasing pressure to see more patients, to manage more complicated health issues, and to work after hours and to forgo more breaks for paperwork. We did another survey in 2018 on our workforce. This showed that 26% of respondents rated themselves as being burnt out. This had increased from 22% in 2016. More significantly, in our older age group from 54 to 60, the numbers were between 30% and 31% or 33%.

On a positive note, doctors in general are made of tough stuff. But we cannot rely on that completely. During Mental Health Awareness Week, we again surveyed members-- they love our surveys. And we asked what things they do to help themselves stay well.

And the responses were wide and varied-- gardening, tramping, playing the guitar, lots of walking dogs. "I knit so I don't unravel." "I knit so I don't kill people"-- yoga, organizing stuff, spending time with family.

"A day off while children are in childcare"-- this is a real novelty. Mountain biking, "encouraging my three-year-old to grow vegetables so one day, he might eat one," menial admin around the house while singing loudly, reading and walking, just reading, cooking, "clucking at chickens"-- one would concern about the mental health here-- scuba diving, "eating the crayfish your patients give you because they go scuba diving."

So GPs agree that there needs to be a bit of access and changes and transformation in primary health care. GPs welcome the mental health initiatives, the well-being budget, and the opportunities that are rising.

But GPs would remind you that mental health never occurs in isolation. Patients have complex social and physical health needs, along with mental health issues. GPs deal daily and well with this higher end of the mental health spectrum, but the pressure is on.

Although personalized health care may feel like a luxury, how many of you would want to go to see your doctor, talk to your GP? How many of you have turned up to your GP to discuss your sole time but really wanted to talk about the dark parts of your heart and soul and then tell them that you would tell no one else?

I'm not saying that no one else can do some of this work. But general practitioners' wide-ranging scope of practice makes them expert in both mental and physical health. And they're integrally related. Having access to other services within the practice is essential and beneficial to the patient, but also mitigates the frustrations of general practitioners and patients.

I've employed people that are appropriate for the community I work in. But what I have may not work somewhere else. The services that are being funded through the health and well-being budget need to be wide and varied. Thank you.

[APPLAUSE]

Dr Jenny Parr, Chief Nurse and Director of Patient and Whānau Experience at Counties Manukau District Health Board

Video: Dr Jenny Parr - Forum 2019 - Enabling wellbeing

[Dr Jenny Parr presenting to an audience as part of the Enabling wellbeing session of Forum 2019]

[Dr Jenny Parr mihi]

I'm Jenny Parr. I'm the Chief Nurse and Director of Patient and Whaanau Experience, as Robin's just said, at Counties Manukau. And, even though I have a bit of an English twang to my accent, I am actually from South Auckland. And I was brought up and did my training at Middlemore.

Achieving well-being requires positive social exchanges and action between staff and patients, between staff themselves, and staff and leaders. I mean, at the end of the day, we're going to get what we give and give what we get. The response of our staff to the way we support them in practice will totally reflect what we invest in them, for better or for worse.

Investment in social and environmental capital and human capital, such as the well-being funding, needs to deliver on culture, which includes excellent relational leadership, clinician engagement in governance and leadership, valuing evidence-based practice with the right number, the right skill, and the right demographic of staff. It needs to provide for their physical safety with an unwavering stance on zero tolerance for workplace violence and supporting personal resilience through opportunities for recovery and development.

I'm going to cover three tenets to enabling well-being in our health sector. And I think it will balance nicely what we've already heard. It's important. I'm going to cover the use of evidence in practice to target specific care needs, knowing our workforce and their specific needs, and providing a practice environment that fosters personal resilience and great care. At the center of all the work we do must be the patient, consumer, and their whaanau, establishing and preserving effective relationships with them to enable great care and achieve excellent outcomes.

New Zealand nurses were asked in 2013 about the factors that influence their ability to thrive at work and enjoy working as nurses. A key driver was altruism, based on being able to engage with patients and make a real difference. Nurses want the lived reality of nursing to meet this expectation so they feel positive about the work they do and avoid the negative stress that leads to compassion, fatigue, and burnout.

At the end of the day, they want to be able to function in the way depicted in this picture, a mutually invested relationship reflecting reciprocated commitment, which results in obligations to provide and participate in care. Our organizations are the context in which this altruistic behavior occurs. And an organization either enables it or creates barriers that nurses perceive as hindering their ability to relate to and support patients.

We've already heard how practice is complex. It's challenging, emotionally draining, and also rewarding at the same time. The work requires specialist knowledge, and skills, and the use of evidence-based practice. Understanding that a range of events can lead to a trauma response, which can have potentially negative effects on behavior, mental, and physical health, we need to also appreciate that adverse events have been shown to negatively impact on brain development, physiology, behavior, and relationships across their lifespans and through generations.

They might come from adverse child events. Or adults who've experienced some form of abuse-- partner violence, violence by non-partners, crime, active hostility, workplace, physical violence, and bullying-- are also at risk of developing mental health issues. In fact, 50% of the general population is impacted by trauma, 70% of Maori and 80% of our prison population. 90% of the people accessing mental health and addiction services have some form of trauma.

So this requires a care model informed by evidence about responses to trauma. So providing trauma-informed care, on the right of the screen, is critical. And you can find out more about that from the exhibition outside. Trauma-informed carers, strengths-based service delivery that's grounded in an understanding and responsiveness to trauma and the impact of that that emphasizes a physical, psychosocial, and emotional safety for both providers and survivors.

And there's a real alignment with this to ensuring that fundamentals of care are also practiced. That is, the relationships are established reflecting a commitment to care, providing a platform for mutual trust, anticipation, and focus on relational, physical, and psychosocial care needs. As an example, mental health nurses focus on engagement with the consumer, the tangeta whaanau, and developing trust is critical to supporting a person's return to wellness.

And more and more, the return to wellness includes an acknowledgment of a person's spirituality, their family whaanau, and recognizing what's important to them, what matters to them the most. Supporting patients to engage with their condition and learn self-management requires relational energy. It's not about task and time, but about thinking and linking in the moment-- knowing, anticipating, and evaluating the care that's provided.

The balance between managing necessary tasks and the emotional challenges in providing great care for patients needs to be valued by us, as leaders, or the tasks will take over. It's clear that, to be successful, we need to provide a culture and environment that is truly patient outcome-centered, rather than task-focused. Everyone who works in mental health, or in any area, needs to be highly attuned to the need for better outcomes for Maori.

There's a focus on doing more and understanding our own potential biases. We need to invest in a workforce that can professionally respond to the complex needs for patients, for people's well-being in areas that include addiction, disability, and corrections, and mental health, and across the entire health system.

Te Tiriti o Waitangi, in its purest context, is about and informs relationships, and must inform all approaches to care. We need to realize a demographic workforce, which reflects our population. This is critical to the nature of nurses and other clinical professionals' work.

You might wonder why I put a picture up of a whole bunch of students not at school. Well, I guess what I'm trying to reflect here is that our workforce is made up of a number of groups. And millennials are a really key part to that, as is those in middle age. In fact, we're overrepresented in health when you compare our employed staff across New Zealand.

Millennials need, from us, a deep sense of meaning. They want to make a difference. They want a work-life balance. They want positive workplace cultures and rely heavily on integrity and values. They want to work on complex problems, and they also want to have a real connection with visible leaders. Team cohesion is really important to them. And they need that in order to be able to be fully present at work, in order to be able to engage with patients, but also to be able to engage fully with their families at home.

Work-life interference and conflict won't be tolerated by our staff, and we cannot afford to ignore it as an issue. In a complex, stretched, and stressed health system, opportunities to recover from stressful work situations are becoming more scarce, but ever more important. Younger nurses have lives and families outside of work. And 50% of nurses over 50 are now thinking about retirement. And this accelerates with age.

To retain both groups, and allow them to thrive and want to work, we, as leaders, need to understand their issues and engage with them in developing workforce management approaches that support their lives. Staff need effective, supportive leaders who possess integrity and approachable, can tap into their motivations, and create and sustain positive, fulfilling practice environments where they have the knowledge and skills to provide the complex care and enable them to make a difference to society.

Nurses are in demand due to their problem-solving skills, professionalism, and sense of clinical duty. They have highly developed interpersonal skills. And we're very easy to work with as well. For that reason, we must ensure that nurses look after their own well-being and that we provide them support to enable that to happen.

Thriving at work is shaped by the context in which they are embedded, as I've said before. It's a feeling of being alive and energized at work. When was the last time you felt like that-- feeling absorbed in your work, feeling that you're making a positive difference, and that you're always learning how to become more effective? High workloads and work-life interference can lead to stressed managers being more demanding than supportive and colleagues being driven by their own demanding work.

We need to finish the job of achieving safe staffing to be able to deliver the nature of care that's required, which is complex, that takes time to achieve, that is relationally competent care. We need to develop the skills and confidence of staff to support people accessing services with experience of trauma. We also need to maintain cultural connections and understand frameworks towards healing and recovery.

Above all, nurses need to feel valued. Support and recognition from colleagues is a major factor in enjoyment of work. Managers and supervisors need training to understand how to develop supportive teams and reduce bullying. We need to focus on strengths and focus on how and why things go right more often than not. This requires that we all demonstrate respect for each other with each profession, knowing their role and place in the delivery of health care.

But a culture of wellness starts with how we behave towards each other, both when it's going well and when we're under pressure. Emotional hindrance demands need to be minimized. These factors, such as bullying in the workplace and violence and aggression from patients, are really problematic. Workplace safety is a legislative responsibility that we hold in any organization, which basically means that we have an obligation to develop and support nurses to thrive, rather than just survive, their demanding jobs.

I doubt any of us in this room would say it was OK to come to work and feel either psychologically unsafe or physically unsafe. However, increasingly, it's becoming more difficult to assure physical safety of our staff. I remember the impact on my own well-being when I was in two armed robberies in the 1980s. Well, I was brought up in Papatoetoe and running a pizza delivery shop at the time. You might say I was unlucky or perhaps I shouldn't have put myself in that position where I could be subject to this type of crime.

However, in our health care, staff are at risk every day. I was told recently of a conversation with a research team who were trying to determine how much violence was tolerable for their project, in ED until they realized that, actually, no violence is tolerable. We already understand the impact on society from trauma, and this extends to our staff. We have a responsibility to provide them with the skills and expertise to deescalate beyond those in mental health and generate a culture of zero tolerance to workplace violence. And that's down to us.

In summary, we need to enable and expect positive relationships at work within teams, across teams, and throughout systems. We need to support staff by taking a stand for zero tolerance of violence and aggression towards health care staff. We need to achieve safe staffing, which enables nurses to have time and energy to invest in emotional engagement with patients and recovery time for themselves.

We need to use evidence-based practice, such as trauma-informed care and fundamentals of care, enhancing confidence and capability in our staff to support people's returns to wellness. And, finally, leadership is critical to enabling well-being. We cannot achieve mental health well-being for patients or staff if we do not expect or equip leaders to prioritize this with authenticity across the system.

No rera a aku ho mahi. Tena kotou, tena kotou, tena tatou katoa.

[APPLAUSE]

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