New Zealand Heart Failure Workforce Survey 2023

Heart disease remains one of the leading causes of death across many parts of the world, including Aotearoa New Zealand. Heart failure (HF), the end result of heart disease, affects 1–3% of the Aotearoa New Zealand population and remains a major public health problem, with high rates of hospitalisation and mortality.^1,2 HF is a clinical syndrome that spans a spectrum of ejection fraction (EF) and is broadly classified into three EF phenotypes.

HFrEF is regarded as the most severe of the three phenotypes and is prioritised for treatment due to robust evidence and the availability of effective medical interventions that yield positive clinical outcomes.^3–6 Furthermore, substantial evidence supports the use of specific medications that can enhance EF in this patient population.⁷

Patients with HFmrEF are classified as having an intermediate form of HF. The main objective in managing this population is to prevent any further decrease in EF. Diligent monitoring and prompt interventions are vital for preserving their current cardiac function and preventing a progression to HFrEF.⁷

HFpEF represents the most common type, especially among older adults and those with comorbidities like obesity, diabetes or chronic kidney disease. Options for pharmacological treatment are limited, leading to reliance on diuretic therapies that necessitate strict fluid management and routine monitoring. Patients with HFpEF often experience hospitalisations due to decompensated HF.^7–10

Over the past 40 years there have been significant advances in the diagnosis and management of HF, particularly HFrEF, with the introduction of complex imaging and pharmacological and device-based interventions that have improved both morbidity and mortality.^5,11–13 In Aotearoa New Zealand the demographics and incidence of HF are important factors influencing healthcare delivery and outcomes, especially in specific populations such as Māori and Pacific peoples, where recent studies have shown a widening incidence in health inequities over the last 13 years.^14,15

Research indicates that a multidisciplinary team approach, incorporating cardiologists and HF nurses, significantly reduces recurrent hospitalisations and enhances patient survival rates. Multidisciplinary teams centred around HF nurses are classified as a Level 1-A recommendation based on findings from randomised controlled trials and in alignment with international guidelines.^7,16

The British Society for Heart Failure recommends a minimum of two full-time equivalent (FTE) per 100,000 population.¹⁷ Furthermore, they report programmes that include HF nurses, particularly nurse practitioners (NP), are financially advantageous. For example, in the United Kingdom (UK), implementing such programmes could yield an estimated net economic benefit of £20,000 annually if implemented across 60 sites, and assigning one community HF nurse per 100,000 people, managing a caseload of 60 patients, could result in annual savings of £42,000, or £169,000 per 1,000 patients.¹⁷

The HF nursing workforce in Aotearoa New Zealand comprises NP, nurse specialists (NS) and registered nurses (RN), each differing in qualifications and experience. In addition, unpublished surveys on HF, conducted in 2011 and 2015 in Aotearoa New Zealand, revealed significant variation in this workforce across the country. NP, representing the highest clinical nursing level, independently assess, diagnose and prescribe treatments, thus driving clinical decision making. NS operate under standard operating procedures, and under supervision from NP or doctors.¹⁸ In Aotearoa New Zealand, an informal career progression pathway exists to support NS to advance their careers and qualify as NP. However, the existing systems do not allow for a seamless transition. To improve this, the career pathway should be aligned with the needs of the service using a systems-thinking approach. This would help standardise career progression and ensure robust workforce and succession planning across Aotearoa New Zealand.

Method

In March 2023, a survey was distributed to each district health board (DHB) across Aotearoa New Zealand, facilitated by the Cardiac Society of Australia and New Zealand and the New Zealand Regional Heart Failure Working Group. One team member from each of the 20 DHBs was asked to complete the survey. For DHBs without a dedicated HF team, respondents were asked to estimate the nursing FTE working in HF at their DHB.

The electronic survey, which consisted of tick-box questions for quick completion (approximately 15 minutes), was returned via email. Survey responses were then entered into an Excel spreadsheet and analysed using RStudio. The study questions addressed areas such as: nursing FTE dedicated to HF per 100,000 population, scope of practice, balance of clinical versus non-clinical time, clinical oversight (medical/nursing), nurse-led service components and delivery and performance/quality measures. The survey also asked if nurse-led clinics accepted all phenotypes, or HFrEF only (see Appendix for the full survey questions). The nursing FTE in HF was presented as the median and range, as well as FTE per 100,000 population.

The Aotearoa New Zealand DHB subpopulation data were obtained from Stats NZ.¹¹ Data from 2013 were used to estimate the 2011 populations, and data from 2022 were used to estimate the current 2023 survey population.

Statistical analysis was performed using RStudio. Results are presented as FTE and as numbers per 100,000 population.

Results

Responses were received from all 23 hospitals across the 20 DHBs, achieving a 100% response rate. The total number of FTE positions for HF nursing in Aotearoa New Zealand increased from 23.3 FTE in 2011 (range: 0–4.0 FTE) to 38.65 FTE in 2023 (range: 0.4–6.0 FTE). Over the same period, Aotearoa New Zealand’s population grew from 4,241,000 in 2011 to 5,124,100 in 2023, which led to a modest rise in FTE per 100,000 population from 0.52/100,000 in 2011 to 0.75/100,000 in 2023, representing a relative increase of 44% (see Table 1).

View Table 1–7, Figure 1.

The results highlighted variation in resource allocation across DHBs in Aotearoa New Zealand. Despite the overall increase in FTE nearly half of all DHBs had an HF nursing FTE rate of <1 FTE per 100,000 population, with only three DHBs reaching the recommended HF nursing FTE rate of ≥2 FTE per 100,000 population. These DHBs represent just 5% of Aotearoa New Zealand’s total population, indicating a disparity in resource allocation across the country (see Figure 1).

The total HF nursing FTE across Aotearoa New Zealand was 38.65, and of these less than a quarter were NP (see Table 2).

Proportion of clinical versus non-clinical time

The survey asked respondents to indicate the proportion of clinical versus non-clinical time for their service. Non-clinical time encompasses various meanings and can be categorised into three primary areas: patient-related activities (which are not face-to-face), specialty advancement (such as developing specialty guidelines and staying updated on relevant research) and professional development. This excludes educational activities, conferences and study days. The results indicated the majority of HF nurses had non-clinical time built into their clinical roles, with the proportion of time split 80–90% clinical and dedicated 10–20% non-clinical. For a full-time HF nurse (40 hours per week) the proportion of non-clinical hours were estimated to be between 4 and 8 hrs per week.

NP/senior medical officer (SMO) support

Of the 23 hospitals surveyed, three were managed by NP alone. While only six hospitals enjoyed specific SMO access and a dedicated HF team, the majority of hospitals reported good access to SMO and/or NP.

Referral-related data

The survey revealed variability in the HF nursing services provided across Aotearoa New Zealand. Most hospitals had written referral criteria and accepted patients across all EF phenotypes; however, three hospitals only accepted patients with HFrEF. More than half of the DHBs surveyed offered an inpatient nurse-led HF service. Additionally, all hospitals conducted follow-up care in the community, including outpatient clinics, home visits and rural area outreach clinics. Only five DHBs reported providing some form of exercise programme (see Table 3).

The survey report for nurse-led HF outpatient clinics covered three aspects: wait time to first nurse-led appointment (FSA), the length and subsequent wait to follow-up. The wait time to FSA varied across hospitals. Nearly half of patients were seen in a timely fashion, i.e., 2 weeks or fewer; however, more than half of all the hospitals reported a wait time of 3 weeks or longer, with the majority waiting more than 3 weeks (see Table 4).

The length of clinics also varied across hospitals, with FSA visits taking between 30 to 60 minutes compared with follow-up clinics at 20 to 60 minutes (see Table 5).

Time to follow-up

Time to follow-up after the initial FSA also varied. Although the goal for HFrEF patients to be reviewed is “better, faster, stronger”, within as short a time frame as possible, i.e., weekly/fortnightly, only a third of hospitals were able to achieve a fortnightly review.^5,12,13 Further, over half of all hospitals surveyed reported 4-weekly reviewing of patients, with two hospitals reporting wait times exceeding 4 weeks.

Guideline-directed medical therapy (GDMT)

The standard time to optimise GDMT for HF treatment varied across Aotearoa New Zealand. Recent evidence supports optimisation of GDMT to be achieved within a month.^5,7,19 However, the majority of patients in Aotearoa New Zealand are waiting longer than 6 months to have their GDMT optimised, therefore requiring at least an additional 3 months on optimal therapy before re-imaging can take place. This can delay crucial investigation and timely advanced therapies (see Table 6).

For patients requiring repeat cardiac imaging following GDMT optimisation, access to imaging services was variable. Less than a quarter of the hospitals surveyed reported always having timely access to imaging, with the majority reporting difficulty, and over a quarter reporting a significant problem (see Table 7).

Audit and data collection

To ensure HF treatment in Aotearoa New Zealand is equitable, accountable and evidence-based, standardised data collection, regular auditing and ongoing review of DHBs are essential. Although over half of the hospitals surveyed reported conducting audits of their services, less than half have conducted an audit within the last 3 years. More importantly, only two DHBs across Aotearoa New Zealand reported participation using the data collection of the National Heart Failure registry with others reporting local data collection, which is not linked to the national registry.

Discussion

Opening summary

This foundational study provides a national overview of the HF nursing workforce in Aotearoa New Zealand and reveals considerable regional variation in staffing and service delivery. Despite an overall increase in the total number of HF nursing FTE positions from 2011 to 2023, nearly half of the DHBs still report a rate of less than one FTE per 100,000 population, with only three DHBs meeting the minimum of two FTE per 100,000 population as recommended by the British Society for Heart Failure.¹⁷

Key findings underscore the urgent need for targeted policy interventions, enhanced workforce planning and a stronger commitment to reducing health disparities. Findings also highlight challenges in the timely optimisation of GDMT and access to repeat cardiac imaging, both of which disproportionately affect patients from Māori, Pacific and rural populations, exacerbating existing health inequities.^14,20,21

Interpretation of findings

This survey highlights significant disparities in HF nursing services across Aotearoa New Zealand, reflecting systemic weaknesses within the current health framework.

While HF nursing FTE has increased since 2011, nearly half of the DHBs still report less than one FTE per 100,000 population, well below the recommended two FTE. Even where targets are met, geographic isolation limits access. These disparities point to broader issues of inequitable workforce distribution and underdeveloped service delivery structures.

The current health framework causes variability in service delivery and restricts NP from fully utilising their advanced clinical training. Examples include clinic availability, wait times, implementation of GDMT, repeat imaging and inconsistent national data collection.

Reforming the health framework to support independent NP practice, alongside standardised care pathways and national coordination, could reduce variability and improve access. A multidisciplinary approach, supported by international evidence, demonstrates that NP-led care improves outcomes and reduces hospital admissions, yielding both clinical and economic benefits.^4,7,17 Such measures are critical to evaluating the country’s performance to meet international benchmarks and to addressing the prevalent health inequities in HF management.²²

Addressing regional inequities, increasing NP FTE and supporting professional development within a structured framework are critical steps toward sustainable, high-quality HF care across Aotearoa New Zealand.^20,21

Comparison with previous literature

This study highlights the persistent regional disparities in the availability of specialised HF nursing staff. Internationally, studies have shown that disparities in HF care are often exacerbated by inequitable resource allocation, resulting in poorer outcomes for marginalised populations. This study reinforces those findings, demonstrating that while the overall HF nursing workforce has increased, inequities in staffing levels persist, particularly in regions where the population is less likely to access timely care. The evidence is consistent with research from the UK, which suggests that increasing nurse-led services, particularly those involving NPs, can reduce disparities.¹⁷

Strengths and limitations

A key strength of this study is its national scope and high response rate, with data collected from all 23 hospitals across the 20 DHBs in Aotearoa New Zealand. This comprehensive participation provides a robust and representative overview of the current state of the HF nursing workforce. The study also offers valuable longitudinal insights by comparing current findings with data from 2011, highlighting trends in workforce growth and distribution over time. Importantly, the survey extended beyond workforce numbers to examine service delivery models, clinical roles, access to multidisciplinary support and the timeliness of care, yielding a detailed picture of the operational landscape of HF nursing. The inclusion of NP roles and the differentiation of scope of practice across nurse classifications further enhances the relevance of findings to workforce planning and policy development.

However, this study also has several limitations. The data are self-reported and rely on individual respondents’ knowledge and interpretation of their local services, which may introduce inconsistencies, particularly in DHBs without formal HF teams. The absence of qualitative data limits contextual understanding of the barriers faced by HF nurses and patients, which may be critical to addressing service variation and inequities. Additionally, the lack of ethnicity-stratified data constrains the ability to assess the extent to which HF services are meeting the needs of Māori and Pacific peoples, populations disproportionately affected by HF. Finally, the limited engagement with the National Heart Failure Registry among most DHBs reduces the capacity for national benchmarking and coordinated quality improvement, underscoring the need for more integrated-data systems.

Implications for practice and policy

This study reveals significant variation in the allocation and utilisation of the HF nursing workforce across Aotearoa New Zealand, underscoring the urgent need for more consistent and equitable workforce planning at a national level. Despite an increase in total FTE positions since 2011, nearly half of all DHBs still fall below the recommended minimum of two HF nurse FTE per 100,000 population, with only three DHBs meeting or exceeding two FTE per 100,000. These disparities contribute to delays in patient care, prolonged optimisation of GDMT and limited access to advanced clinical oversight and imaging services. Policymakers and health system leaders should prioritise the development of a national HF nursing workforce strategy, with clear benchmarks for FTE per population, a focus on increasing the NP FTE and dedicated funding for under-served regions.

At a practice level, expanding the scope and accessibility of nurse-led HF services could alleviate pressures on secondary care, reduce hospital readmissions and improve patient outcomes, particularly when services extend into the community through outreach and home-based care. The integration of structured clinical pathways and performance audits into HF nursing practice can also enhance accountability and ensure alignment with international best practice guidelines. Finally, consistent participation in the National Heart Failure Registry should be mandated across all DHBs to enable real-time monitoring of service delivery and outcomes. A more standardised, data-driven and equity-focussed approach to HF nursing services will be essential to improving both the quality and consistency of care nationwide.

Implications for future research

The findings of this study highlight several key areas where future research is warranted to support the development of a more equitable and effective HF care model in Aotearoa New Zealand. First, there is a need for qualitative research to explore the lived experiences of HF nurses and patients, particularly in under-resourced regions. Such insights could help identify systemic barriers to service delivery, workforce retention and timely access to care, while informing strategies to strengthen multidisciplinary collaboration and community-based models.

Further research should also focus on evaluating the impact of different HF nursing models on patient outcomes, including hospital readmission rates, medication optimisation timelines and health-related quality of life. Comparative studies between DHBs with varying nurse-to-population ratios and service structures could provide valuable evidence to support workforce investment and redesign. Additionally, research that specifically investigates equity outcomes, particularly among Māori and Pacific peoples, will be essential to addressing persistent disparities in HF management and outcomes. Integrating ethnicity-stratified service utilisation data and embedding equity-focussed metrics into national audits and registries will be critical to this effort. Finally, there is scope for economic evaluation studies to quantify the cost effectiveness of increasing NP FTE and community-based HF services to guide policy and funding decisions at both regional and national levels.

Conclusion

This study delivers the first comprehensive, nationwide assessment of Aotearoa New Zealand’s HF nursing workforce, exposing systemic challenges in staffing, service delivery and equity. While workforce numbers have grown modestly, persistent regional disparities continue to undermine timely access to care and contribute to variable patient outcomes. These issues are symptoms of deeper structural fragmentation that cannot be resolved through isolated initiatives.

Addressing these complex challenges demands a proactive, systems-thinking approach, recognising the interconnectedness of service delivery, workforce planning, digital infrastructure and community needs. Strategic investment must be paired with interdisciplinary collaboration—spanning nursing, medicine, Māori health providers, data analysts and policy experts—to co-design equitable and sustainable models of care.

Strengthening the role of HF nurses, especially NP, and embedding consistent national standards will be critical levers in transforming service delivery and ensuring high-quality, accessible care for all New Zealanders living with HF.

Recommendations

1.       Standardise service delivery models through the implementation of national guidelines.

2.       Improve access to GDMT and imaging.

3.       Strengthen data infrastructure and audit participation by mandating regular participation in the National Heart Failure Registry for all DHBs.

4.       Address health equity and regional disparities by providing targeted support to under-resourced DHBs.

5.       Expand community-based services led by nurses to improve care access.

6.       Establish a national benchmark for HF nursing FTE, setting a minimum standard of ≥2 HF nursing FTE per 100,000 population, flexible enough to accommodate regional variability.

7.       Expand and support the HF NP workforce, particularly in under-served areas.

8.       Invest in workforce sustainability and development to build a sustainable and skilled HF nursing workforce.

View Appendix.