College of Nurses Aotearoa Submission on DHBNZ Nursing Workforce Strategy – 29 th August 2006

Introduction

The College of Nurses Aotearoa acknowledges that workforce development is critically important for reasons well known to the Nursing/Midwifery Strategy group. It is our sense that all groups involved in workforce action have become stuck in endless analysis of the issues whilst avoiding commitment to real strategies or innovation or even adherence to the vast body of evidence already collected.

We will largely confine our comments to primary health care, acute care, aged care and the Maori nursing workforce as our membership and expertise is concentrated in these areas. This is not to suggest that midwifery and the disability and mental health sectors are not important to us, rather we recognise that others have greater expertise in those areas.

Development of a national nursing strategy (Q. 13 & 16)

The development of comprehensive and effective workforce strategies should be based on good information, evidenced-based policy and research and the collective wisdom of a range of stakeholders. While this discussion document is the first effort of the strategy group to engage the sector, the scope or limitation of the discussion document as it stands largely reflects a DHB employer bias, not the wider sector, with a very low risk approach to innovation.

The College would support a principles-based approach to inform the strategy such as commitment to national self sufficiency, commitment to retention of the nursing workforce, or that the distribution of the nursing workforce should ensure equitable access to health care and recognise the specific requirements of people and communities with greatest need. Clearly articulated principles provide some rationale for decision-making and prioritisation and signal a direction for the future. While elements of these principles are scattered throughout the document, there is a major disconnect between the rationale and the recommended priority actions.

It goes without saying that a more inclusive approach to development of such an important document that not only canvasses the opinion of a wide range of stakeholders, but involves them in the planning and implementation is critical to future success. New Zealand is too small a nation to duplicate effort and a more inclusive approach will provide a better platform for future efforts. The College does not believe that this document or the strategy group have met this standard and recommend that the necessary time be taken to do so.

Nurse Practitioner role development (Q. 3, 4 & 5)

The NP scope is one of three registered nursing scopes. The development of the Nurse Practitioner (NP) role has been Government policy since 2002. Significant time and money has been invested by the Ministry, by the education sector and not least by nurses themselves towards the development of this role. It has become Government policy because the role directly addresses dwindling service provision and a strong evidence base supports the role as addressing unmet need safely and effectively. A prolonged volume of evidence has demonstrated that Nurse Practitioners have the potential to assist with improving the health of all New Zealanders and reducing the burden of chronic disease. The particular advantage of Nurse Practitioners is that they have the capability to lead service delivery and deliver services across the traditional boundaries of specialties and settings.

There is potential for Nurse Practitioners to be employed in boundary spanning roles across the following areas, in both under 65 and over 65 services; residential care; non-government organisations; PHOs; home based support services and acute services. These are areas of population need in which District Health Boards should have direct interest. Accordingly, a Nurse Practitioner could potentially have a mixed caseload of clients, with a range of needs based on their functional capacity. This nursing potential is far from realised.

In 2006 we should have moved well beyond the point of ten ill-defined pilots of the NP role as outlined in the DHBNZ discussion document. There is not time to move this slowly. Pilots suggest the role is being tested; there are already 25 NPs who have legitimate roles and should be evaluated for future learning. This is substantially different from piloting the role. Rather we need to focus on strategic challenges to the infrastructural issues which are inhibiting development. These barriers are mostly legislative and funding related and to a large extent a product of many sector opinion leaders neither understanding nor championing the role.

The barriers to establishing Nurse Practitioner positions are predominantly, although not exclusively, of a financial nature and there are three main reasons for this.

1. Nurse Practitioners may falsely be considered too expensive, particularly if funders or providers are not familiar with the advantages of employing an advanced practitioner who works across the traditional boundaries of specialties and settings and generates different outcomes.
2. Current funding mechanisms, or the conventions associated with them, reduce and sometimes remove DHBs' or providers' ability to use that funding in flexible and innovative ways. This is not only a problem in creating Nurse Practitioner roles, but in establishing any service that falls outside the historically accepted ways of delivering health care delivery.
3. Funding models differ in each geographical location and service delivery configuration, making a single approach to funding Nurse Practitioner roles impossible.

There are, however, possible changes which have been identified. These may, if implemented, create flexibility in existing funding mechanisms, allowing a greater range of options for the funder or provider to choose from when establishing new services or reshaping existing ones. A true strategy would look to address the following structural challenges:

• Legislative: The Ministry of Health has a comprehensive analysis of the remaining legislative barriers. We would anticipate that a workforce strategy document would align with this work and outline processes for reducing the barriers, many of which are significantly inhibiting the desired workforce flexibility.
• Attitudinal or knowledge based limitations: There has been considerable effort made to educate the sector on NP roles and their potential. It is doubtful if all sector leaders, funders and planners fully understand the role. The role is still often understood as a simple substitution for medicine which engenders reaction and backlash. That the role can replace ‘tasks' performed by medical practitioners is indeed true, but the role is clearly a new way of working as it spans an expanded task repertoire provided from a nursing perspective thus focusing on improving client or patient capacity to function optimally and live well with whatever disease or chronic disability they have.
• Capacity limitations: In relation to NP pilots, ‘building on successful models coming out of Nursing Innovation projects' is recommended on page 7 of the discussion document. This is misleading as it was not the goal of the primary innovations to produce Nurse Practitioner roles. Interestingly it was argued at the time by nursing that innovation projects should look to develop capacity not service models as preferred by the Ministry of Health. Consequently, the primary health care sector still has a significant capacity deficit as indicated by the problematic role out of Care Plus funding and other initiatives.

The College strongly recommends more detailed actions to implement Nurse Practitioner role development in any future strategy as a critical priority.

Advanced practice nursing roles (Q. 3)

The College agrees that work is required to clarify the role of expert nurses in specialist areas who are not Nurse Practitioners. The multitude of titles for advanced practice nursing roles has created significant confusion amongst nurses, employers and the public on what an advanced practice role is, and what as a health care consumer could be expected in terms of skills and competency from such a role. It is timely that there is national debate that moves beyond ‘titles', employers and unions to seek clarification and consistency of the role of expert nurses in health care services.

Competencies now and into the future (Q.1)

While the discussion document describes the predicted health care need of the New Zealand population in the future, it does not offer any analysis of what the perceived deficits or gaps are in terms of nursing competencies. The College suspects that the discussion document may be confusing tasks and skills that are shared with other health professionals with nurses working in ‘expanded' roles, with ‘competencies' and/or ‘competence'.

The College argues that the competencies for a Nurse Practitioner were largely developed in response to future health care need. Competencies such as critical thinking, diagnostic enquiry, and clinical assessment, the application of advanced nursing knowledge in a number of health care settings, cultural safety, health promotion or prescribing are all within the current registered nurse and Nurse Practitioner scopes of practice. As stated previously, attention to the barriers that prevent nurses from achieving their full potential may go some way towards addressing future population need.

Nurses already have a broad undergraduate education and the foundational knowledge required for any nursing area in health care. The health sector has yet to create an environment that reliably allows nurses to transfer their preparation into practice and then develop and consolidate their practice as intended. The College agrees that the New Graduate Nurse Entry to Practice programme may go some way to supporting this transition. However, the focus should not be on developing ‘new' competencies, but understanding, marketing, and harnessing the ‘current' potential, assisting nurses to achieve the expectations set in their socialisation into the profession in their undergraduate nursing programme – that is, holistic people centred health care.

No discussion on maintaining or expanding nursing competencies can be considered in isolation from adequate and appropriate investment in training and education programmes. Investment in professional development and post-graduate education so that nurses are able to function at an optimal level of competence is critical. For example programmes to support advanced nursing practice in priority areas such as Older Peoples Health, chronic care management, primary health care or palliative care are all key priorities; however there is no match in the document's recommendations to reflect this requirement.

Recommendations in the discussion document do however place a disproportionate weighting on Professional Development Programmes (PDRPs) as a strategic initiative. The College is supportive of all programmes that contribute to nursing competency development. However, in the College's opinion PDRPs contribute to this broader outcome, but are not a total solution.

Finally we note that the registered nurse competencies were reviewed in 2005 by the sector through the NCNZ submission process and in relation to the definition of a registered nurse in the HPCA Act. DHBNZ had an opportunity to respond through that process.

Reviewing undergraduate & postgraduate nursing programmes (Q. 8 & 12)

Possible changes signalled in the tertiary review in terms of the Clinical Training Agency (CTA) role and funding of degree programmes will have significant implications for nursing which currently straddles the university and the polytechnic sector. The rationale for the review of the undergraduate degree is not provided in the strategy document as presented. Whilst we are not averse to a review per se we believe there needs to be careful balancing between determining the goals of such a review and desired workforce development goals. We do also note that the sector had an opportunity in 2005 through the NCNZ submission process to comment on both standards for educational programmes and the competencies of an RN. We do not need yet another undirected review process resulting in yet another review document which sits on shelves. Again we draw your attention to our points in Q 1. We need to address the working environment, not the process of preparation.

We do not support a review of postgraduate programmes as suggested. Postgraduate nursing programmes have undergone extensive development in the last few years in direct response to workforce demand for example in primary health care, to government policy such as NP programmes and in response to extensive calls for leadership development. Development is still required in clarifying links between the academic programme and consolidation of clinical skill development in the practice environment.

The National Nursing Workload Measurement Project (Ministry of Health, 2000) which was conducted in 15 wards in six hospitals across New Zealand indicated access to education and ongoing learning processes were compromised regardless of location in the country. Nurses were not able to access learning because of workload, casualisation, or turnover. In the Safe Staffing Committee of Inquiry report (DHBNZ/ NZNO Safe Staffing / Healthy Workplaces Committee of Inquiry, 2006) nurses clearly articulated the value of education and reported that attendance was extremely compromised by workload. Provision of programmes was not the issue. We argue that people keep looking at the programmes because it seems an easier option than addressing the practice environment.

The major problem which does require review is Tertiary Education Commission (TEC) funding of nursing education at all levels. We attach a brief review document prepared by Prof Jenny Carryer and Dr Susan Jacobs which outlines the nature of the problem (Appendix 1). DHBNZ should be very concerned that the funding processes for preparation of a critical workforce are so flawed. DHBNZ might well ask what processes allowed the apparent decisions to be made. There is a clear policy disconnect.

The role of the CTA in funding nurse training is clearly set to change. We can only say that the process by which it is set to change has not been transparent or consultative. We are aware that an advisory group is being formed and await further news of this process with interest. We are not opposed to greater DHB involvement in the purchase of post entry clinical training but of course wish to see that the allocation of money between nursing and medicine is based on health gains rather than traditional inequitable patterns. We are also concerned that these changes may further limit access to funding for nurses in private employment, such as general practice, aged care or Non-Government Organisations.

Priority areas: Primary health care; older peoples health (Q. 2)

The College has advocated extensively for strategies to improve primary health care nursing workforce development. We acknowledge that the discussion document has attempted to integrate some of the work undertaken by the Primary Health Care Nursing Expert Advisory Group into the recommendations.

However it is not made sufficiently clear that the goals set out in the pivotal document ‘Investing in Health: A framework for activating primary health care nursing in New Zealand' (Expert Advisory Group on Primary Health Care Nursing, 2003) remain critical. These goals resulted from substantial analysis which does not need to be repeated. Leadership development remains unaddressed to any significant extent. Scholarships have represented a welcome but token attention to the complete dearth of education for primary health nurses which has also yet to be taken seriously. Nurse Practitioner development continues to struggle against attitudinal and structural barriers which have not been seriously addressed.

The registered nurse workforce in aged care is in crisis. It remains invisible, atrociously undereducated and significantly ageing itself. The acute sector bears the brunt of preventable admissions which are a direct result of inadequate nurse staffing in the residential care sector. The implementation of Nurse Practitioner roles in gerontological settings would assist directly with:

• Prevention of unnecessary transfer to acute hospitals.
• Demonstrating a meaningful career path for nurses in aged care.
• Having better onsite education available.
• Saving scarce GP resource.
• Improving links to primary health care and improving the primary health care of aged residents.

With the expected changes in the NZ population, particularly the effects of an ageing population and those with chronic illness, the complexity and acuity of the people being cared for in the community has increased. This will require an investment in primary health care, rehabilitation and older people's health services to ensure people are supported to live independently in their own home/community. Developing the specialist skills of nurses across health care settings will provide a more seamless, integrated model of care for this part of the population.

Flexibility – what is the problem we are trying to fix? (Q. 5)

The discussion document makes several references to improving or increasing flexibility within the nursing workforce. The document seems to suggest a persistent tendency to regard nursing roles as inflexible. The College would argue based on considerable analyses and published literature that it is not nursing roles per se but adherence to limited contractual models of service purchasing, traditional employment processes e.g. GP employment of practice nurses and the persistence of funding barriers which limit flexibility and inhibit new ways of working. In addition, barriers to education for many groups of nurses severely limit the development of their full potential.

We argue that nursing is by its very nature, diversity and span of practice locations a generic health workforce of huge potential. We ask, as did the Ministerial Taskforce in 1998, that we focus on the barriers to full utilisation rather than tinkering with the creation of new roles and titles. We recommend that the strategy group undertake similar analysis on the actual and perceived barriers to ‘flexibility' to advance the rhetoric around this debate so that all parties are clear on what problems we are trying to fix?

Nursing workforce retention (Q. 9)

The College agrees with the Department of Labour analysis that nursing supply at this point in time is sufficient to meet workforce demand. The key issue is the poor attention to retention of nurses in the health workforce. The College asks why the DHBNZ discussion document is so silent on the research based on Magnet hospitals yet talks about critical need for retention. Again we have an evidence base which is lengthy and comprehensive so why would we look for other strategies? A bibliography outlining some of the research undertaken is in included in Appendix 2 for the strategy group's reference. Additional literature and research is available on request. The Health Workforce Advisory Committee has also made recommendations for establishing a healthy workplace as a strategy to support not only retention but productivity.

In addition, the College recommends that the strategy group familiarise themselves with some of the national nursing workforce research. In particular:

• The National Cost of Nursing Turnover and Impacts on Nurse and Patient Outcomes Study (including mental health units). The study aims to determine the direct and indirect cost of nursing turnover. Principal Investigator: Dr Nicola North, University of Auckland .
• The National Survey of New Zealand Hospital Nurses (2001 & 2004). The survey was part of the Hospital Restructuring: Patient Outcomes and Nursing Workforce Implications study which examined hospital restructuring in New Zealand from 1988 - 2004 (Finlayson & Gower, 2002) . The study is associated with the International Hospital Outcomes Study led by Professor Linda Aiken and colleagues from the University of Pennsylvania . It is currently being undertaken in 16 countries including New Zealand (Aiken et al., 2001; Gower & Finlayson, 2002) . Principal Investigator: Dr Mary Finlayson, University of Auckland .
• Nurses and midwives e-cohort study. Nurses and midwives e-cohort is a longitudinal population-based study that examines factors associated with both workforce and health outcomes in a cohort of nurses and midwives within Australia , New Zealand and the United Kingdom . It is anticipated that the study will provide important information to inform education and workforce policy for the nursing and midwifery professions. Study outcomes will also focus on factors influencing the physical and mental health of nurses and midwives. Principal Investigator (NZ): Dr Annette Huntington, Massey University . See http://www.e-cohort.net .

Second tier roles (Q. 3)

The College agrees that these roles are critical and acknowledges that nursing is divided on this point. The College position is that we do need a regulated second tier person who works under the direction of a registered nurse in a range of areas. We do not understand why we have given this person the title nurse (nurse assistant) thus allowing confusion and misuse as has occurred in many instances previously. 

Whilst there is no reason to change the title of existing experienced enrolled nurses we see no need to create this role again for the future workforce. In doing so we would be assuming that all the previous problems with enrolled nurses regarding employment issues, cost issues, blurring of scope and inappropriate use will not reoccur.

We believe there should be a nationally standardised training for a second tier health worker to ensure that RNs who will supervise and delegate to them can have clear ideas of their capability.

The College also notes with interest an emerging debate about the possibility of physician assistant roles. It is of interest that this can be considered when the role of Nurse Practitioner has barely been established and no evaluation of its impact on service provision has yet occurred. In addition we note much evidence suggesting that health gains and reduction in disparities will be derived from increased health care rather than increased medical care. Better utilisation of nurses would negate the need to create a new position such as physician assistants.

Maori nursing and health workforce development strategies (Q. 7)

The health sector already faces a shortage of health professionals with a deep understanding of Maori and Pacific health perspectives and cultures. The College considers that increasing the absolute and comparative numbers of Maori and Pacific people working in health would effectively contribute to addressing both problems. There are three broad approaches to increasing the number of Maori and Pacific people working in health. These include:

• Measures to retain and develop existing workers.
• Removing barriers to Maori and Pacific people entering the health workforce.
• Actively attracting Maori and Pacific people into the sector.

The College supports accelerated efforts to develop the current Maori nursing workforce. The College acknowledges that the National Council of Maori Nurses, the Health Workforce Advisory Committee – Maori Subcommittee, and Te Kete Hauora have all recommended a range of strategies to this effect.

Given the low number of Maori and Pacific people in all health professions, we have chosen to focus on attracting new workers to the sector either through removal of barriers or active recruitment. We believe that there are synergies between these two approaches and that some proposed programmes may contribute to both aims.

We were saddened that Maori are less likely than students generally to take high school science subjects and, when they do, are less likely to pass. Without high school science qualifications Maori are prevented from proceeding into tertiary health science training and enter the health professions. This situation is not sustainable either in terms of providing the targeted health services needed by the Maori community, or (given the growth of Maori as a proportion of the New Zealand population and future labour force) for the provision of health services to the general community. If DHBs are to make a true commitment to addressing Maori and Pacific health needs and having a sustainable workforce now and in the future the College recommends that DHBNZ advocate for the following:

• Improving the teaching of science generally
• Improving the teaching of Maori and Pacific students.

International comparisons have found that New Zealand high school students are doing well at science , in particular they are able to apply the approach and concepts. Therefore, to date, the Ministry of Education has not given science teaching the same level of professional development resourcing as generic literacy and numeracy.

However, good teaching is key to students' success in science and other subjects. Up to 59% of the variance in student performance is attributable to differences between teachers and classes and the Ministry of Education is aware of concerns that the way science is being taught may be causing students to find it “boring or irrelevant”. To this end the science curriculum should be revised to better relating science to daily life and future careers.

There is little to be gained in removing barriers to Maori entering the health professions, if those professions and the associated training do not appeal to them or if Maori secondary students are not adequately prepared. Maori stakeholder forums suggest that, currently, the professions and courses are not exercising such an appeal. There are several options to changing this:

• Showing health careers to be worthwhile, strongly contributing to the wellbeing of Maori communities.
• Providing role models/teachers and education programmes for individual Maori students to improve maths and science achievement.
• Recruitment programmes that promote health careers to students, their whanau, and communities to influence students' study and career decisions. It is recommended that local communities and schools, parents and employers are active participants in these programmes given Maori students do not readily access careers advice and that the most influential sources of careers advice are, in order; peers, whanau, teachers and then careers advisors. The College considers that Maori could best be encouraged to enter the health professions through a programme of ambassadors based on the IPENZ ‘FutureinTech' programme (see www.futureintech.org.nz ) backed by a carefully targeted marketing campaign.

Conclusion

The College would like to acknowledge and restate the many valid recommendations made by nurses previously as part of numerous working parties . A number of documents, reports and strategies have been developed previously and implemented with varying degrees of commitment. These strategies should provide a platform and a context for the strategic activities proposed by DHBNZ. However, documents alone cannot be the basis for a progressive nursing workforce strategy. Visible, accountable and consultative nursing leadership is also a prerequisite to success. The College would welcome all opportunities to be more involved in developing a comprehensive nursing strategy for the future.

Appendix 1: Funding issues in Nurse Practitioner education - August 2006

Introduction

This paper outlines the funding problems for institutions offering a clinically-focused Master of Nursing programme as required to meet Nursing Council of New Zealand criteria for Nurse Practitioner education.

Currently clinically-focused postgraduate nursing education is funded via a number of bodies: the Tertiary Education Commission (TEC), the Clinical Training Agency (CTA), and supported through a range of Ministry of Health scholarships. This paper examines TEC funding for the Master of Nursing programmes preparing nurses for advanced practice roles, including Nurse Practitioner registration.

The essential course work for a clinically-focused masters includes advanced clinical assessment and diagnostic reasoning, advanced pathophysiology, advanced pharmacotherapeutics, clinical specialty courses, research theory and design, and advanced practicum. The curriculae enable nurses to develop the advanced practice competencies through balanced, clinical programmes.

The required clinically-focused course work outlined above equates to 6 or 7 papers, or 3/4 of a two year full-time-equivalent masters. Therefore a thesis/independent scholarly project of “1 or 2-paper size” is the largest research component which can be included. This is in contrast to a research masters thesis, which provides a 4-paper thesis.

Master of Nursing programmes to prepare Nurse Practitioners therefore fall into the TEC-funding category of “taught postgraduate programmes” as opposed to “research postgraduate” programmes. Research postgraduate funding requires that the programme includes a thesis/research component of 3/4 to 1 EFT-equivalent – a 3 or 4-paper thesis.

The two designations of Taught postgraduate and Research postgraduate do not recognise the unique differences of a programme that includes theory, research and clinical practice components.

The funding for Taught postgraduate programmes has been steadily decreasing, meaning generally that student fees have, or will be increased. The TEC funding per EFTS (one year full-time student) for “taught postgraduate” nursing programmes decreased from $11,852 (GST exc) per EFTS in 2005, to $10,190 (GST exc) in 2006 .

This level of funding for a postgraduate programme with the three critical components of theory, clinical practice and research is only marginally greater than that of an undergraduate nursing degree which is funded at $9,790/EFTS. (Refer to table below.)

Additionally, institutions offering postgraduate programmes that are categorised as “Taught”, have been doubly disadvantaged. Institutions which apply for Performance-Based Research Funding (PBRF) receive some of their PBRF funding for “Research Degree Completions”. Up to 25% of the total funds allocated through PBRF (~$20million is the total PBRF funding) is allocated on the basis of Research Degree Completions. However, only those theses of 3/4 to 1 EFT may be counted. So again, the clinical masters programme, structured to meet NP competencies, does not draw PBRF funding for research degree completions.

The costs associated with clinical education and training have been managed to some extent for many undergraduate programmes, e.g. undergraduate programmes with high clinically-related costs have received TEC “add-on” funding, for example:

Clinical Master of Nursing programmes have not received any “add-ons”. The whole situation which significantly undervalues the “Taught” postgraduate clinically-focused Master of Nursing programmes is set to worsen in 2007. The add-on rates shown above have been added to the base rates and new funding categories created as a consequence.

Nursing is moved to a funding category “L” in which undergraduate and all postgraduate programmes are funded at the same level - $9,469/EFTS, GST exc. The concept of clinical add-ons has been eliminated. “Research” postgraduate programmes will receive “top-up” funding via PBRF. Comparison of 2007 funding of programmes is shown below.

The 2007 funding regime seriously further undermines the viability of the programmes preparing registered nurses for Nurse Practitioner roles. It is unclear what analytical process, if any, was carried out to assess costs of clinical programmes.

A further challenge is created because nursing programmes need a proportion of faculty who are clinical experts and therefore ideally will be in joint teaching and practice roles. In addition managing clinical practice programmes produces administrative demand not experienced by schools and departments with no such component. This means that such staff are unlikely to generate high research outputs and thus the onus of generating PBRF generated income for the school falls on a small number of faculty. Nursing's scores in the first PBRF round demonstrated the consequences of this and this is now leading to even greater funding restrictions.

The problem is being further compounded because the ability to attract appropriate clinical faculty is now seriously challenged by the comparison between academic salaries and those of senior clinical nursing staff. A Nurse Practitioner commands appropriately a salary of 80-90k and this places them on the most senior levels of academic employment. The professorial salary range begins at approximately $100k (there are variations between tertiary institutions).

Summary statement

By our calculations there is a decline of 20% in income per EFT for clinical post graduate nursing between 2005 and 2007. There is no incentive for tertiary institutions to support programmes to prepare nurse practitioners - TEC (through PBRF) provides financial rewards for completion of research based programmes MA, MPhil, PhD which nurses do, but clinical masters are the predominant programme now. It is hard to work out why a workforce “product” which compares so closely to Medical Specialists and General Practitioners in terms of level of services provided, is required to be produced from such a constrained funding stream. It is becoming increasingly difficult for postgraduate schools of nursing to survive on the current regimen.

Prepared by Professor Jenny Carryer and Dr. Susan Jacobs, 18 August 2006.

Appendix 2: Selected articles reviewing the relationship between patient outcomes and the quality and configuration of registered nurse staffing.

Collecting the NZNHIS data from all medical and surgical discharges 1989-2000 revealed a close connection between declining registered nurse staffing and nurse sensitive negative patient outcomes. As nursing skill mix and staffing levels declined through the health restructuring of the 1990s there was a sharp and highly statistically significant increase in 11 negative and costly patient outcomes.

McCloskey, B. and Diers, D. Effects of New Zealand's Health Reengineering on Nursing and Patient Outcomes. Medical Care 43(11) 1140-1146

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A study of nurse staffing and patient outcomes in 799 US hospitals found relationships between nurse staffing and UTIs, DVTs, length of stay, upper gastrointestinal bleeding and shock in medical patients and with UTIs, Pneumonia and failure to rescue in major surgery patients. The ‘failure to rescue' refers to deaths occurring in hospital patients where it could not be expected as a reasonable outcome of the admission. Higher RN staffing was associated with a 3-12 percent reduction in rates of OPSNs (outcomes potentially sensitive to nursing) depending on the OPSN tested and the regression model examined.

Needleman, J., Buerhaus, P.I., Mattke, S, Stewart M., Zelevinsky, K Harvard School of Public Health February 2001.

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A review of articles addressing the link between a number of hospital characteristics and inpatient mortality rates identified a higher number of RN hours per patient day to be a major contributor to lower mortality rates. The proposed reasoning underlying this is that hospitals employing more RNs also have a high teaching status, and use advanced technology.

Van Servellen, G., & Schultz, M.A. (1999). Demystifying the influence of hospital characteristics on inpatient mortality rates, JONA 2994), 39-47.

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Using month by month data in a large university hospital (880 beds), correlations among staffing variables and outcome variables were determined and multivariate analyses, controlling for patient acuity were completed.

With average patient acuity controlled, the proportion of hours of care delivered by RNs was inversely related to the unit rates of medication errors, decubiti and patient complaints. Total hours of care from all nursing personnel (including assistive roles) was also associated with decreased mortality.

Blegen, Goode and Reed (1998) Nursing Research 47(1) 43-49

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Nursing presence, whether measured as RN hours to a patient ratio or as RN hours relative to other nursing personnel hours, is significantly correlated to mortality. The relationship can be explained as an outcome of the hospital environment. Hospitals which are known to deliver good nursing care and have positive mortality outcomes may also have distinct organisational characteristics whereby nurses experience greater professional autonomy, more control over the practice environment and better relationships with doctors.

Aiken, L., Smith, H.L., Lake , E.T. (1994). Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care 32(8), 771-785.

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A comparison of quality of central venous catheter placement service by specially trained CNS versus pre-existing service provided by junior medical staff was performed. With the advent of the CNS system, rate of failed insertions decreased from 20% to 3% with a concomitant reduction in medical referrals. In addition line infection rates in the 30 days following insertion fell from 10 episodes per 72 lines inserted to 2 episodes per 200.

Fitzsimmons, C. L., Gilleece, M.H., Ransom, M. R. Wardley, A., Morris, C., & Scarffe, J. H. (1997). Central venous catheter placement: extending the role of the nurse. Journal of the Royal College of Physicians of London , 31(5), 533-5.

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The odds on dying within 30 days of hospital admission were significantly lower in hospitals with dedicated AIDS units and in magnet hospitals, net of differences in the severity of illness of the patients. Higher nurse-to-patient ratios and AIDS specialty physician services account, in large part, for these better outcomes. Net of all other factors, an additional nurse per patient day reduces the odds on dying by one-half.

Aiken, LH, Sloane, D. M., Lake , E. T., Sochalski, J., & Weber, A. L. (1999). Organization and outcomes of Inpatient AIDS Care. Medical Care 37(8), 760-772.

This finding is consistent with several other recently published studies showing that higher nurse-to-patient ratios account for lower hospital mortality and fewer medical and surgical complications. References for this are:

Kovner, C., & Gergen, P/J. (1998). Nurse staffing levels and adverse events following surgery in US hospitals. Image, 30, 315-21. (see below)

Blegen, M.A., Goode, C.J., & Reed, L. (1998) Nurse staffing and patient outcomes. Nursing Research 47, 43-50.

Czaplinski, C., & Diers, D. (1998). The effect of staff nursing on length of stay and mortality. Medical Care, 36, 1626-38.

Aiken, L. H., & Sloane, D. M. (1997). Effects of organizational innovations on burnout among urban hospital nurses. Work Occupation, 24, 453-77.

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A hospital organisational structure and orientation that devolves a level of authority to nurses that is consistent with their high level of responsibility should enhance the outcomes of patients. In settings where nurses' authority is consistent with their responsibility nurses would exercise their professional judgement in a timely fashion exert control over the practice setting to focus resources as required for good patient care establish good relations with physicians that facilitate exchange of important clinical information. Our theory predicts that organizational models, whatever their particular form, that result in greater nurse autonomy, more control by nurses of resources at the unit level, and better relations between nurses and physicians will yield better patient outcomes (p. NS9)

Aiken, L. H., Sochalski, J., & Lake , E. T. (1997). Studying outcomes of organizational change in health services. Medical care, 35 (11), NS6-NS18, Supplement.

Evidence provided in Aiken, L.H., Smith, H. L., & Alke, E. T. (1994). Lower medicare mortality among a set of hospitals known for good nursing care. Medical Care, 32, 771 (see above).

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Patients cared for on short-staffed units, experienced more complications than comparable patients cared for on adequately staffed units.

Flood, S. D., & Diers, D. (1988). Nurse staffing, patient outcome and cost. Nurse Management, 19, 34-43.

Taken from the abstract… “A large and significant inverse relationship was found between full-time-equivalent RNs per adjusted inpatient day (RNAPD) and urinary tract infections after major surgery (P<.0001) as well as pneumonia after major surgery (p<.001). A significant but less robust inverse relationship was found between RNAPD and thrombosis after major surgery (P<.01), as well as pulmonary compromise after major surgery (p<.05).

Kovner & Gergen (1998) Image – Journal of Nursing Scholarship 30(4) 315-320

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“Failure to rescue” is a term used to describe the death of a patient during an admission where death could not be reasonably expected to occur. A study concluded that failure to rescue is more closely associated with hospital characteristics than patient characteristics. This study is interesting because it lends support to other work by Linda Aiken's team in the five country study that finds that the hospital characteristics associated with Magnet hospitals are associated with reduced levels of failure to rescue.

Silber, JH, Williams, SV , Krakauer H, and Schwartz, S ( 1992) Medical Care, 30(7) 615-629

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The current nursing shortage, high hospital-nurse dissatisfaction and reports of uneven quality of hospital care are not uniquely American phenomenon. A study of 43,000 nurses across five countries ( U.S. , Canada , England , Scotland and Germany ) and in 700 hospitals found that despite organisational differences and funding structures, nurses reported similar shortcomings in their work environments and in the quality of care. Generally nurse and physician competence and nurse-physician relationships appear satisfactory but there are core problems in the design of work and workforce management that impede or threaten care provision.

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Aiken, Clarke, Sloane, Sochalski, Busse, Clarke, Giovanetti, Hunt, Rafferty and Shamian (2001) Health Affairs, Spring

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An extensive review of the impacts of hospital restructuring, generic management, cost shifting practices and many other features of the previous decade has been undertaken by the Milbank Memorial Fund, led and reported by Professor Claire Fagin. This extensive and well referenced report entitled “When Care becomes a burden: Diminishing access to adequate nursing” is available at www.milbank.org

Jenny Carryer: Professor of Nursing - August 2001

References

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J. A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A. M., & Shamian, J. (2001). Nurses' reports on hospital care in five countries: the ways in which nurses' work is structured have left nurses among the least satisfied workers, and the problem is getting worse. Health Affairs, 20 (3), 43-53.

DHBNZ /NZNO Safe Staffing / Healthy Workplaces Committee of Inquiry. (2006). Report on the Safe Staffing/ Healthy Workplaces Committee of Inquiry . Wellington: District Health Boards New Zealand / New Zealand Nurses Organisation.

Expert Advisory Group on Primary Health Care Nursing. (2003). Investing in health: Whakatohutia te oranga tangata. A framework for activating primary health care nursing in New Zealand. A report to the Ministry of Health from the Expert Advisory Group on Primary Health Care Nursing . Wellington: Ministry of Health.

Finlayson, M. P., & Gower, S. E. (2002). Hospital Restructuring: Identifying the impact on patients and nurses. Nursing Praxis in New Zealand, 18 (1), 27-35.

Gower, S. E., & Finlayson, M. P. (2002). We are able and artful, but we're tired: Results from the Survey of New Zealand Hospital Nurses. Paper presented at the College of Nurse Aotearoa, Nelson.

Ministry of Health. (2000). The National Nursing Workload Measurement Project . Wellington: Ministry of Health.

They are in the second-best tranche of countries for 15 year olds along with Canada and Australia . It was noted that the first tranche in these studies often consists of only one or two countries. PISA OECD study

Primary Health Care Nursing Expert Advisory Group, Mental Health Nursing Advisory group, the Nurse Practitioner Working Party, etc

2006 Tertiary Funding Guide at http://www.tec.govt.nz/funding_guide/2006/

Category L funding also includes agriculture, and horticulture non-degree programs and osteopathy.