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Jenny Carrier, RN, PhD, FCNA(NZ)
Recently the College has been working closely with NPAC-NZ to move forward
the issue of NP employment and NP training processes in New Zealand. A
paper authored by Jenny Carryer, Frances Hughes and NPAC-NZ was presented
to Annette King, Minister of Health, in April. The paper outlined two
options for progressing the development of Nurse Practitioner training
and employment and met with significant enthusiasm and support from Annette
King.
The following is some of the content of the paper presented to the Minister.
“Over the last decade Nurse Practitioners (NPs) have been identified
all over the globe as a key role in addressing health priorities. In New
Zealand, since the late 1990s, we have had government policy developments
which have identified the position as vital to assisting reduction in
health disparities, improving access and also as a means of cost and quality
efficiency as health costs continue to grow. Over the last few years,
hundreds of nurses have commenced preparation to fulfil this role, but
the key barrier to implementation of this role to deliver on government
policy and service directions is lack of structured implementation. When
NPs were first developed in New Zealand, it was thought that services
themselves would take the initiative and create positions according to
their workforce plans. Despite information in the form of documents and
road shows to all areas of New Zealand, it is now clear that many DHBs
have not established workforce plans to develop these roles or where they
have, they are taking too long. We believe that central government has
a role to assist this development as they continue to do for other professions
such as medicine in the development of registrars.
In summary there are 4 major imperatives facing the health sector:
- Results indicate the sector needs to achieve more and achieve it
more effectively.
- There are forecasts of unprecedented growth in demand for health care
because of lifestyles and the aging population.
- Labour demand will outstrip supply by 2011.
- Costs keep accelerating without obvious increase in outputs.
“If the health and disability services maintain their share
of the New Zealand working age population, demand for labour will outstrip
supply by 2011. Again depending on which scenario is used, the excess
of labour demand over supply is projected to be equivalent to between
28% and 42% of the 2001 workforce by 2021 (NZIER, 2004).
Government policy has already recognised that development of the NP role
is a key response to the imperatives facing the health sector (Ministry
of Health, 2002).
- This brief paper outlines a critical issue now confronting the next
stage of development of NP roles in the New Zealand health system and
offers a range of possible solutions to that issue. There has been considerable
investment, from both the Ministry of Health and the various professional
nursing organisations, in supporting individuals to develop in the role.
Across the five approved education programmes there are at least 100
nurses in the completion phase and, at the very least, 200 nurses in
the earlier stage of preparation.
- Although NPs have been identified in several government policies
and strategies as a key vehicle to deliver on health goals, the development
to date has been around individuals, not services or environments for
them to deliver their practice once registered as a NP. Incentives for
both creation of NP posts in training and also NP positions for registered
NPs have not yet occurred.
- DHBs are now responsible for population-based approaches to health
provision (includes provider arm services and also NGO through funding
and performance areas). Both these environments need an integrated approach
to developing NP roles to deliver on health service goals, thus allowing
greater effectiveness and efficiency with current health outcomes. To
date no integrated workforce approach has consistently delivered on
this.
- Current DHB workforce (primary and secondary) is structured around
existing workforce configurations and defined by existing funding streams.
This has created organisational barriers to developing new roles and
models of delivery as NP positions have to come out of existing nursing
budgets and are not configured out of total workforce budgets. Thus
an incentive is required to encourage development of NP positions to
allow for the role to become established, thus allowing time and resource
for DHB to create more flexible mechanisms for the total workforce.
- New models and innovations require a catalyst to allow for critical
mass to develop; without such a catalyst, NP positions will be created
in a continued ad hoc manner. We cannot leave key Government strategies
for reducing inequalities and improving health gains to a state of serendipity.
Every other innovation in health has required an implementation strategy
and supportive funding to embed the innovation. The planned establishment
of NP positions will allow for visibility, evaluation and role modelling
of the position, thus supporting the needed culture change to encourage
sustained development.
- Medicine has recognised this issue for their profession and has received
Government support for development of registrars.
- A recent NPAC-NZ survey showed that only 2 DHBs have any emerging
plan for NP utilisation.
- There is a systemic inertia that often arises when innovations begin
as to how to best utilise and foster them, and who takes the lead. This
has been experienced internationally in the establishment of similar
positions (Hughes, Clarke, Sullivan-Marks, & Fairman, 2003).
The paper concluded by suggesting a number of options.
1. The Status Quo.
To do nothing represents something of a ‘market’ approach,
whereby an ‘invisible hand’ will eventually create the most
appropriate outcomes. Given the size and nature of the challenges facing
new and innovative initiatives such as this, many likely outcomes may
not be positive. Those that are positive could take considerable time
to eventuate. Given the investment already made by government in establishing
the NP role, this could result in a loss of considerable potential gain
from that investment both in financial and health terms.
2. The provision of funding to develop Nurse Practitioner positions
within DHBs.
The funding is used to create positions across the country in as many
DHBs as possible and, importantly, to professionally support the people
appointed to the positions. The paper outlined a strategy for achieving
this.
Approaches to structuring such funding could include:
i. A contestable fund, centrally managed, which evaluates
initiatives proposed by DHBs/PHOs on an annual/six monthly basis. Applications
could be judged on/monitored against:
a. Government health priority areas
b. Key DHB/PHO measures
ii. Additional funding that is tagged or ring-fenced,
within key government health priority areas for the development of NP
positions.
3. The development of a Nurse Practitioner Training Scheme based on
new CTA funding.
The preferred long-term response was argued as Option 3 because:
- Incentives are needed on a sustainable pathway that is not service
funding.
- This is a model that already works internationally and nationally
as the registrar training programme.
- Medical resistance would lessen, using this model, as they understand
and cannot then debate the efficacy.
- It allows for centres of excellence in a small country.
- It allows for small services i.e. NGO and small PHOs to have access
to this service without affecting their budgets as payment is via central
fund.
- It allows for development of resource of NPs in key population areas.
Option 2 was also considered to have significant merit as a short-term
response because it:
- Allows early establishment of employment positions for those who have
self funded their career development in good faith.
- Gives DHBs Incentives to have such positions.
- Will create roles quickly for purposes of evaluation of health outcomes.
- Will create positions quickly which will then be able to influence
further demand for the positions.
The paper recommended the establishment of a NZ steering committee or
working group comprising representation from MoH/CTA, DHBNZ, and appropriate
nursing membership. The outcome has been a directive from the Minister
to form this working group and the allocation of half a million dollars
to progress an exploration of the above objectives.
References
Ministry of Health, (2002). Nurse Practitioners in NZ. Wellington: Author.
NZIER, (2004). Ageing New Zealand and Health and Disability Services:
Demand Projections and Workforce Implications, 2001–2021. A discussion
document. Wellington: Ministry of Health.
Hughes, F., Clarke, S., Sullivan-Marks, E., & Fairman, J. (2003).
Research in support of Nurse Practitioners. In M. Mezzy; D. McGIvern &
Sullivan-Marks. (Eds.). Nurse and Nurse Practitioners, Boston; Little,
Brown.
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