The cover of Ivor Popovich's A Dim Prognosis with a red background behind it.
A Dim Prognosis by Ivor Popovich gives and insider’s view of New Zealand’s health system. Image design: Tina Tiller.

BooksJune 21, 2025

‘Punitive and suffocating’: a doctor’s view of the working environment for nurses

The cover of Ivor Popovich's A Dim Prognosis with a red background behind it.
A Dim Prognosis by Ivor Popovich gives and insider’s view of New Zealand’s health system. Image design: Tina Tiller.

In this excerpt from his memoir, A Dim Prognosis: Why our health system is on its knees, Ivor Popovich gives an example of why we need more nurses; and why their working conditions are less than ideal.

Some years ago I was on a night shift looking after a patient who had just had open heart surgery. Having someone stop then restart your heart is a big deal, and patients can get really sick before they get better. As a result, these patients often end up with tubes and lines sticking out of every orifice.

One of these is a catheter that runs through the jugular vein in your neck and sits inside your heart, where it measures the amount of blood your heart pumps around your body per minute. This is your cardiac output. In an average healthy human it is about 5 litres per minute but it varies a lot, depending on how much blood flow your body needs. When you exercise, your heart can pump more than 20 litres per minute.

Halfway through my shift I was walking around, checking up on patients. The ICU can be strangely peaceful at night, the gentle rhythmic hiss of a roomful of ventilators pushing air in and out soothing your nerves. The patients were all sedated and asleep, which meant there was no chance of a confused patient running around butt-naked (which was not uncommon in the ICU at night). One of my friends once told me that the first time he questioned his career choice was when he was about to inject a sedative into the butt cheek of a naked man who was pinned down by four security guards after spending half an hour being chased around the hospital.

Ms Jones was doing well after her surgery. Her numbers all seemed satisfactory, except her cardiac out-put was a little low, at 3.5 litres per minute. I frowned. This wasn’t quite good enough, and the supervising specialist wouldn’t be happy with me if I let it stay at that all night. I prescribed her half a litre of intravenous fluids. Hopefully this would fill up the heart more, allowing it to pump more blood around. I came back half an hour later, expecting the problem to have gone away. Instead, the cardiac output now read 3.4 litres per minute. I prescribed another half-litre of fluid. The patient’s blood pressure went up, but still the cardiac output wouldn’t budge. Now I was getting irritated. Why wasn’t my therapy doing what it was supposed to do? Time for something more heavy-hitting. I prescribed a drug infusion to stimulate the heart muscle to squeeze harder.

Within minutes the cardiac output had increased to 4.5 litres per minute. Quite pleased with myself, I went for a rest. In the morning the specialist came around, and tore me a new one.

“What the fuck did you prescribe that for?”
“Well, the . . . the car . . . cardiac output was low,” I stammered.
“Are you a doctor or just someone who reads numbers?”

I didn’t understand. I had just wanted to make the patient better. Why was I in trouble?

He looked at me and shook his head like a disappointed dad. “It doesn’t matter what the cardiac output is, only whether it is enough for the needs of the patient. Whatever cardiac output you have right now is enough for you, but it wouldn’t be enough for someone running a marathon. Did Ms Jones, a sedated patient not doing any activity, have any signs that 3.5 was too low for her? Cold arms and legs, low urine output, was she unstable?”

“No.”

The lesson: absolute numbers are not the full picture. And so it is with numbers of nurses. It matters not how many we’ve employed; it only matters whether we have enough to meet the needs of the system. The answer, for anyone who has eyes and ears and has set foot in a hospital lately, is no.

In 2024 a multimillion-dollar extension was built in a major hospital, designed to increase elective surgery capacity, with thousands of extra surgeries promised. It opened six months late, and for even longer was bereft of patients — there were not enough nurses to staff it. Operating theatre staff as well as nurses were simply transplanted from the old building to the new. So much for extra capacity.

Nurses go on maternity leave, they retire, they resign, and the gaps they leave go unfilled. Local hospital managers no longer have the power to advertise or fill gaps. They have to go up the chain for approval. But of course we are “over-budget”, so nothing happens. Numbers alone do not reflect experience. There is a huge difference between a pool of battle-hardened veterans and a pool of rookies. The loss of experienced and skilled nurses over the years has not gone unnoticed by the medical profession. One contributing problem, aside from overwork, is the erosion of nursing independence.

The cover of medical memoir A Dim Prognosis by Ivor Popovich shows Ivor, a young male doctor, sitting and looking at the camera.

On another of those fateful house officer night shifts early in my career, I had just lain down for a little rest when I got a message on the on-call phone app. “Hi, Doctor, patient’s chest drain suction has been prescribed in mmHg [millimetres of mercury], protocol says it needs to be prescribed in cmH2O [centimetres of water].”

I stared at the message through droopy eyelids, daring it to be a joke. After a few minutes, with no follow-up message of “Haha, gotcha!”, I fired back: “You can google the conversion factor.” It was 1.36. As soon as I shut my eyes, another beep wrenched them open.

“OK, have googled. Is 600 cmH2O of suction correct?”

I tore out of bed so fast I practically teleported down to the ward. In the nurses’ station a nurse was standing waiting for me.
“600 cmH2O of suction?” I said as I filled out the correct prescription on the chest drain protocol. “Are you trying to suck his lungs out of his body? It’s 25!”

He just smiled calmly at me. “OK doc, thanks for coming.”

He took the paper protocol and walked off. I stared after him in incredulity, then started to laugh and shake my head as I realised I’d been played. He knew full well how to convert between the two units. At the end of the day, though, if it wasn’t prescribed on the protocol, it would be him that got in trouble for using his initiative, and the fastest way to get me down there was to seem incompetent.

This is the punitive and suffocating environment that nurses have to work in. The protocols and guidelines and forms that were designed to help, now enslave us all. People worry that not following a protocol to the letter means putting the patient at risk. There are always cases where the standard protocol is not appropriate, and you will not learn to recognise these situations and use your initiative if you always blindly follow the protocol. Nurses’ experience and judgement are being told to take a hike — the mighty protocol rules all.

When the Office of the Health and Disability Commissioner publishes its periodic case findings, nurses are always getting into trouble for this, regardless of whether or not their actions actually made a difference to the outcome of the case. Instead of encouraging independent thinking and problem-solving, our system punishes it. The result is enormous “time rot”, because now the nurse will page me when the patient complains of an itchy bum, because they are afraid to use their own judgement.

A Dim Prognosis: Our health system in crisis – and a doctor’s view on how to fix it by Ivor Popovich (Allen & Unwin NZ) can be purchased from Unity Books

Keep going!
Three book covers with stars behind them.
Your bestseller chart for this Matariki long weekend.

BooksJune 20, 2025

The Unity Books bestseller chart for the week ending June 20

Three book covers with stars behind them.
Your bestseller chart for this Matariki long weekend.

The only published and available best-selling indie book chart in New Zealand is the top 10 sales list recorded every week at Unity Books’ stores in High St, Auckland, and Willis St, Wellington.

AUCKLAND

1 A Different Kind of Power by Jacinda Ardern (Penguin Random House, $60)

Spot New Zealand’s former prime minster on this week’s New York Times bestseller list.

Jacinda Ardern’s memoir on this week’s NY Times bestseller list.

2 The Book of Guilt by Catherine Chidgey (Te Herenga Waka University Press, $38)

The un-put-downable alternate history that explores some of life’s biggest questions, including what does it mean to have a soul? Can a human ever not have one?

3 Eurotrash by Christian Kracht (Serpents Tail, $30)

Auckland really loves this hectic mother-son roadtrip novel.

4 James by Percival Everett (Picador, $38) 

Everett’s biggest book yet is his stunning, funny and profound retelling of Huckleberry Finn.

5 Welcome to the Hyunam-Dong Bookshop by Hwang Bo-Reum (Bloomsbury, $25) 

Cosy and charming and perfect for a long Matariki weekend.

6 The Safekeep by Yael van der Wouden (Penguin, $26) 

This year’s winner of the Women’s Prize for Fiction. One of the most exquisite novels you’ll read this year: it is moving, sexy and surprising.

7 Butter by Asako Yuzuki (4th Estate, $35)

The smash hit novel based on a true crime story of a serial killer who lured her victims in with stunning food.

8 A Dim Prognosis by Ivor Popovich (Allen & Unwin, $38)

An utterly gripping, energetic memoir from Dr Popovich. Revealing! See The Spinoff this weekend to read an excerpt from this brilliant book.

9 Emperor of Gladness by Ocean Vuong (Penguin Random House, $38)

Vuong’s second novel.

10 King of Ashes by S. A. Cosby (Hachette, $38)

A fiery crime novel. Here’s the blurb:

“Roman Carruthers left the smoke and fire of his family’s crematory business behind in his hometown of Jefferson Run, Virginia. He is enjoying a life of shallow excess as a financial adviser in Atlanta until he gets a call from his sister, Neveah, telling him their father is in a coma after a hit-and-run accident.

When Roman goes home, he learns the accident may not be what it seems. His brother, Dante, is deeply in debt to dangerous, ruthless criminals. And Roman is willing to do anything to protect his family. Anything.

A financial whiz with a head for numbers and a talent for making his clients rich, Roman must use all his skills to try to save his family while dealing with a shadow that has haunted them all for twenty years: the disappearance of their mother when Roman and his siblings were teenagers. It’s a mystery that Neveah, who has sacrificed so much of her life to hold her family together, is determined to solve once and for all.

As fate and chance and heartache ignite their lives, the Carruthers family must pull together to survive or see their lives turn to ash. Because, as their father counselled them from birth, nothing lasts forever. Everything burns.”

WELLINGTON

1 A Different Kind of Power by Jacinda Ardern (Penguin Random House, $60)

2 Towards Modernism: Walter Cook Collection at Te Papa by Justine Olsen (Te Papa Press, $75)

This handsome new publication celebrates the Walter Cook Collection of Decorative Arts (held at Te Papa) and the ceramic, glass and metal objects therein.

3 The Book of Guilt by Catherine Chidgey (Te Herenga Waka University Press, $38)

4 It’s A Bit More Complicated Than That by Hannah Marshall (Allen and Unwin NZ, $25) 

A brilliant new YA novel from a huge new talent. Here’s the blurb:

“Zelle and Callum used to be best friends, but they haven’t spoken in three years: not since the tragedy that wrenched them apart, and Zelle moved away. But now Zelle is back, and their lives are about to get a whole lot more complicated. Zelle is in denial about her alcohol use that threatens to spiral out of control, and she’s deeply annoyed at having to leave the city. Callum’s future is thrown into jeopardy after both a disastrous uni interview and his budding romance turning sour. But they can’t keep running from the past forever, and circumstances force them to examine their grief and guilt and find a way through.”

5 A Beautiful Family by Jennifer Trevelyan (Allen and Unwin NZ, $37)

“Trevelyan’s narrator is 10 years old. She’s unnamed until the very end of the book (I won’t reveal it here: best to find out for yourself). It’s this naive perspective that makes A Beautiful Family both easy to read and impossible to put down. The narrator’s innocence is pitted against several disturbing factors, all orbiting her summer in various shapes and shades, and it’s that persistent dance of disturbances that creates the sustained and unrelenting tension in the novel.” Read more of Claire Mabey’s review on The Spinoff, right here.

6 The Safekeep by Yael van der Wouden (Penguin, $26) 

7 Delirious by Damien Wilkins (Te Herenga Waka University Press, $38)

“I don’t want to say that Delirious is the pinnacle of what Damien can do because that would be like putting a curse on his future work. But I am going to say it’s almost impossible for me to imagine how he could do better. I think this is a great book – Great with capital G.”

Even before Delirious won this year’s Jann Medlicott Acorn Prize for Fiction, Elizabeth Knox was rapturous about Wilkins’ beautiful novel.

8 Heart Lamp by Banu Mushtaq (Scribe, $37)

Shortlisted for the 2025 International Booker Prize. “In the twelve stories of Heart Lamp, Banu Mushtaq exquisitely captures the everyday lives of women and girls in Muslim communities in southern India. Published originally in the Kannada language between 1990 and 2023, praised for their dry and gentle humour, these portraits of family and community tensions testify to Mushtaq’s years as a journalist and lawyer, in which she tirelessly championed women’s rights and protested all forms of caste and religious oppression.

Written in a style at once witty, vivid, colloquial, moving and excoriating, it’s in her characters – the sparky children, the audacious grandmothers, the buffoonish maulvis and thug brothers, the oft-hapless husbands, and the mothers above all, surviving their feelings at great cost – that Mushtaq emerges as an astonishing writer and observer of human nature, building disconcerting emotional heights out of a rich spoken style. Her opus has garnered both censure from conservative quarters as well as India’s most prestigious literary awards; this is a collection sure to be read for years to come.”

9 James by Percival Everett (Picador, $38) 

10 The Māori Millionaire by Te Kahukura Boynton (Penguin, $35)

“Te Kahukura Boynton is Māori Millionaire, and her debut book is here to help. Learn how to make money by clearing debt, saving for an emergency, finding work and increasing your salary, and even starting your own business and investing in shares and yourself. With tips on building better habits with your money and your life, Māori Millionaire is the positive mindset change you might be missing.” So goes the blurb.