"It wasn't even a term I knew two years ago," veteran Tamworth nurse Jill Telfer said.

"This is looking at capacity for the hospital, that we're working beyond capacity, or that we are beyond capacity, whether it's a staffing shortfall or a bed shortfall, or worse, both.

"It's certainly worse this year, which I wouldn't have thought that was possible."

NSW Nurses and Midwives' Association branch secretary Ms Telfer, a nurse of 30 years said winter is normally the "surge" period for the health system, with staff asked to work extra overtime to meet the peak illness period.

But the health workforce is already surging.

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NSW Nurses and Midwives' Association New England organiser Nola Scilinato said a Hospital Code Black is called when "bed block" at the hospital's wards forces the organisation to keep patients in the emergency department [ED].

Nurses are ordered to attempt to discharge anyone who can be safely sent home.

There have been four this month, she said.

"[Code Blacks,] they're happening weekly, and usually on a Monday, Tuesday. That would be because over the weekend, I would think that there's very little discharge of patients from the wards," she said.

"Or just everyone that's there needs to be in hospital. As people come through the front door in ED if there's no real bed for them to go to, they stay in ED."

The health service has already opened an entire new 26-bed ward in order to accommodate for the additional demand - but she said it has yet to hire enough staff to fill it despite advertising the positions. That means more overtime and less time off for an already exhausted workforce.

"They're concerned how we're gong to manage in the winter months," Ms Telfer said.

"There's been a lot of overtime. The overtime in April throughout the facility was the highest that I can recall - and the sick leave was extraordinary as well."

Tamworth hospital's general manager, Yvonne Patricks, said a project team is currently looking at streamlining ED and hospital processes.

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"Tamworth hospital provides an excellent standard of care, staffed by highly skilled and dedicated nurses and clinicians," she said.

"We are currently looking to increase staffing over the winter period with additional new graduate nurses and offers of short term rural placements. We have also increased the numbers of assistants-in-nursing working across a number of wards, including the ED."

Ward 2 is staffed according to the NSW Nurses and Midwives award.

A major blockage of the hospital system like bed block has knock-on effects.

With a full hospital, ambulance "ramping" is happening "every day", according to Health Services Union sub branch delegate Brian Bridges, who represents paramedics in the New England branch.

An ambulance becomes "ramped" when it can't unload a patient into the ED, because the ED can't shift patients to wards because the hospital is full. The whole system is clogged up.

That can even happen with a patient transport job, where a smaller hospital is forced to send a patient to a bigger one due to the complexity of their complaint. Despite the advance warning, sometimes the ambulance can still be kept waiting, he said.

"There's been up to 12 [ambulances ramped at once]. Anywhere from six, to eight, to 10. Even if there's one there they could be ramped for up to two to three hours," he said.

"The hospital is basically at lockdown. There's no beds anywhere. There's no staff anywhere anymore, we've lost staff out of ED, they've closed beds down in ED. God bless the nurses and the doctors, they're doing the darned best. But unfortunately we come out at the back door and go 'sorry I've got nowhere to put you'."

Union organiser Nola Scilinato blamed two factors for contributing to the constant bed block.

On the one hand, the system has been battered by staff shortages caused by both record numbers of staff either infected by COVID-19 or furloughed as a close contact. Meanwhile, the institution continues to have unfilled positions.

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Tamworth hospital also has seen an increase in presentations and more complex and severe presentations, ever since the pandemic.

"I think nurses and midwives are really worried that they're exhausted and they don't how long they can keep up the intensity of what's happening," she said.

"Anecdotally, I'm hearing that people are resigning. Because one they're exhausted and they feel fearful that something bad will happen."

She said the only solution was for the government to give nurses hope by committing to nurse-to-patient ratios.

Hunter New England Health (HNEH) did not respond to questions from the Leader asking how many times the hospital has gone into Code Black in 2022, how many instances of ambulance ramping have occured this year, or how many hours of overtime the hospital has paid this year.

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General manager Yvonne Patricks acknowledged that Tamworth hospital "like all hospitals", experiences periods of increased activity and these fluctuations can be difficult to predict.

Very busy periods are managed through "short term escalation plans, which include measures such as opening surge beds and redeployment of staff to areas with the highest demand", she said.

"We work very hard to avoid asking staff to take overtime, however a surge in activity coupled with staff being furloughed due to COVID-19, has meant there are times when this has been required.

"We acknowledge and appreciate the hard work of staff in these circumstances and are supporting them in many ways including through regular check-ins and daily safety huddles."

She said the hospital revises its winter plan on a yearly basis, taking into consideration such things as workforce requirements and the availability of additional beds that can be surged when required.

From 2012 to 2021, Hunter New England Health increased its workforce by an additional 1633 full-time equivalent staff - an increase of 15.5 per cent including 400 more doctors, 905 more nurses and midwives and 156 more allied health staff.

The 2021-22 budget for the HNEH district is nearly $2.54 billion, an increase of almost $95 million, or 3.9 per cent more, on the previous year's budget.

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