Te Puawai
List of Selected Articles

Editorial

Dr Jenny Carryer

What do we want for Christmas??

Hopefully by the time this edition is in your mailboxes the successful pay claim will have been announced, as it is long overdue and well deserved. There are of course some concerns about increased disparity between nurses in the acute and primary sector but at least some nurses will be more appropriately remunerated. My enormous preference would be to end the year 2004 on a very positive note, saluting the huge achievements and gains made by many brilliant nurses in varied locations. Such individuals continue to shine - in practice, in research, in teaching and in leading committees, networks, service development and many innovations. Congratulations and thank you to all of you.

Despite such individual brilliance I remain concerned that many of the fundamental structures needed to support the development of nursing services as a whole, rather than depending on the individual energy of the few, are still not adequately addressed as we end this year. In my view a number of key goals remain unmet despite a shared perception across the health sector that workforce development remains one of our greatest challenges in health. Let's look at those goals (the "what we might want for Christmas" goals) and their history and relationship to workforce development.

Goal 1 is the state-wide funding of first year of practice. This was a key recommendation of the Ministerial Taskforce on Nursing in 1998. Working groups, pilot studies and the intervening six years have all confirmed the value of graduate programme for increasing patient safety and aiding retention of the nursing workforce. The need for such programme acknowledges that no three year degree can prepare nurses for the wide range of different potential practice settings. Thus nurses once registered must learn to apply their skills to their chosen practice setting to be "work ready" whilst accommodating the ever increasing acuity of patients in many settings. This has been proven to be a key retention factor in job turnover and occupational health and safety research. Since the 1998 recommendation a number of DHBs have responded responsibly to the obvious need and constructed graduate programme of varying levels of quantity and quality largely depending on the presence of nursing advice and the degree of resourcing available. As such the funding for them remains continuously contestable and the programme is often a casualty of bed and staffing crises because it has no external protection through state-wide funding. With the exception of four to six places at Hutt Valley DHB, no programme that I know of offers entry to practice in primary health care, despite the obvious need for replenishment of this ageing work force.

Several years ago a representative working group agreed on behalf of the profession that the nature of these programmes should be at least nine months in duration, provide supernumerary time, reduced case load time and access to ongoing clinical education with educators working alongside the RN in the practice setting. It was agreed that the point of the programmes was to be clinical consolidation and that need is still strongly articulated by the clinical sector. There was never any intention that this year form the basis of a qualification let alone the equivalent of a masters paper as has been proposed more recently in some areas.

Existing programmes have demonstrated high retention rates (80-90%) and excellent transfer to continuing education and career goal setting. Indeed these programmes have demonstrated exactly the outcomes required in all assessments of workforce capacity and such results have been rigorously conveyed to policy makers. Yet as we end 2004 and despite obvious support from the Minister of Health there is still no announcement of state-funded first year of practice programmes and no certainty that if and when such an announcement is made it will include the primary health care setting.

A second goal is that of the development of stronger clinical leadership from within nursing. This is completely different from generic leadership of health organisations at any level and refers especially to critical clinical leadership at charge nurse and nurse team leader level. In the primary health care settings, despite some stunning individual exceptions, there is almost no widespread leadership at all as there has been no infrastructure to utilise leadership.

The attempt to rebuild nursing leadership positions has highlighted a significant gap in the numbers of nurses ready to take up such positions. There is now what has been described as a 'lost generation' in nursing and an urgent need to grow leaders from the cohorts who have graduated in the last four to six or more years. Retention and development of an acute services nursing workforce and the urgent need to build capacity in the primary health care nursing workforce both depend on strong clinical leadership within nursing. Some of this work is already being done really well by enrolment in clinical masters degrees but cost and access issues means this remains very ad hoc.

The third goal is implementation of the Nurse Practitioner role. At this point we have fairly well developed policy, based on sound evidence but very little clarity of the processes needed to create and sustain Nurse Practitioner roles. We still need an energetic attempt to locate and remove barriers such as ACC funding/charging and we must improve the ease with which NPs can order laboratory tests and X-rays (see the report on page ??). There also needs to be an end to the delay in clarification of the regulatory framework to support nurse prescribing.

Nationwide we need supported DHB trainee Nurse Practitioner positions which facilitate NP development and show an overt commitment to establishment of the role. Trainee positions would be held for three to four years whilst the nurse completes the masters degree and gains clinical hours and experience relevant to the area of specialty. Such positions are needed in both the acute sector and in PHOs.

Significant problems remain in this area of workforce development. There is a lack of workforce planning and economic modelling for new roles to meet health needs. If done, this alone would highlight the need to embrace Nurse Practitioners in the health environment as a key strategy to meet predicted demand in a number of critical areas. On a good note a number of rural nurses recently received full scholarships from the Ministry of Health in order that they can take a full year off work to complete their masters degree. And recently the College was able to work with ACC in order to arrange that six additional full time scholarships would be awarded for each of the next three years.

The fourth goal relates to Magnet Hospital Implementation. Recent international research from a prolonged six -country study has confirmed that a well supported and adequately staffed registered nurse workforce is essential on the grounds of both patient safety and cost effectiveness. RN staffing is a critical factor in determining patient safety, preventing surgical mortality and unexpected death during hospital admissions. It is also vital for preventing complications and reducing length of hospital stay. This is particularly important given the recent (2002) study by Peter Davis and others, showing that we currently spend one third of the health budget on adverse events!

For these and many other reasons, retention of a nursing workforce is so critical and we should remember Linda Aiken's recent publication showing that NZ currently obtains 24% of its workforce from international poaching or migration. In addition there are some early indicators of a marked reduction in applications to undergraduate nursing programmes for next year. Recruitment and retention of a stable nursing workforce is guaranteed in the magnet environment.

In support of the development of magnet hospitals, the evidence is compelling, the need is significant. It is no longer fiscally or ethically responsible at this point for DHBs not to make magnet hospital implementation a shared national agenda.

There is a great deal that nurses want for Christmas - much of it not covered here. It is an interesting phenomenon that, despite the presence of an exceptionally aware and supportive Minister of Health, these goals remain hard to meet. We have worked hard to provide consistent and compelling hard data to support these goals, we have political support and there is significant alignment with health need and key national strategy goals. Why is it so hard?

Merry Christmas everyone and very best wishes for a peaceful and safe summer.

Jenny Carryer

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