July 2007

Jenny Carryer

People have written endlessly about “Vision”.  It has been said that the power of a vision is the ability to unify people to strive towards a common goal.  When the shared vision is clear enough and strong enough it allows people to rise above their personal concerns and rise above simply considering what implementation of the vision might mean for their own lot in life.

Sharing a vision embodies some notion of holding out for excellence or the greater good and also it supports the establishment of a focus for activity so that actions are purposeful and directed.  Much more has been said about the impact of having a vision on creating passion, commitment and the ability to keep striving for particular goals even when the obstacles seem huge or even insurmountable.  History is full of people or groups of people who have struggled on against immeasurable odds because their commitment to the vision is big enough to sustain them through the challenges.

It seems therefore useful to ask the question: Does nursing have a vision that is shared by all nurses and is it the nature and substance of that vision which is strong enough to keep us plugging away even when it seems so difficult to persist in the face of continued obstacles?  I think the answer is both yes and no.  There is no way that a group of over 40,000 people could ever share a vision and it is inevitable that given the nature of women’s lives (and nurses are still predominantly women) that the working aspect of their lives is just one of their many preoccupations.  However there are certainly some shared concepts of both what nursing is and what it could be if we did not have to struggle so endlessly against structural and attitudinal barriers to progress.  There must be something which keeps so many of us so endlessly preoccupied!!

There are multiple definitions of nursing and many of us have grown tired of the perennial question as to “what is nursing?”.  Many of us however would, I think, loosely agree that people need, or are entitled to, an informed nurse partner who will:

1. support them to make healthy choices in the context of their own personal challenges at all stages of the life span and in all locations from well child services, through schools and through various community health services.
2. provide appropriately delivered education and information to support a high level of self management
3. support them to negotiate the access of services effectively when needed
4. care for them in a manner which respects their individual and family circumstances when they are ill, injured or dying and ensures that their care is technically expert and based on up to date evidence.

The degree to which we are able to achieve this shared vision of nursing is of course supported or impeded to various degrees depending on the level of supports and barriers present in various practice locations.  Barriers can include a whole range of issues such as lack of education, restrictive contracting, employment structures, inadequate staffing, the quality of leadership and many others.  Sometimes the barrier is our own lack of vision!  But more commonly it is not so.

Have you ever thought about how much of nursing’s energy is directed towards trying to cast off the barriers and impediments rather than simply addressing the ongoing directive towards updating and ensuring good quality practice and safe care of people and communities?  I remember that the title of the 1998 Ministerial Taskforce on Nursing was “Releasing the potential of nursing” and it aimed to address structural, educational, legislative and attitudinal barriers to releasing the full potential of nursing services.

Nearly 10 years on we could well have a taskforce with exactly the same title and whilst some of the focus would indeed be different, and certainly many things have been achieved, there would still be some striking similarities.  Structural barriers remain in primary health care where the national funding formulae and processes continue to impede the deployment of nursing as effectively as we could.  In particular, I think of the limited ACC reimbursement of nurse services, the continued misuse of capitation funding to PHOs, and the difficulty in funding the training and employment of NPs.  In the acute setting we know that the characteristics associated with Magnet hospitals ensure recruitment and retention and patient safety (which in itself makes nurses happier) yet only one DHB now has a Magnet hospital (see this edition re Hutt Valley Health).

Our current educational barriers are actually stronger than ever.  Nursing education per se is grossly under-funded especially in the area of EFT funding of postgraduate courses for advanced practice roles.  There is no nationally guaranteed funding stream for NP development and the pool of money released to DHBs from the Clinical Training Agency is insultingly low for the size of the nursing workforce.  Nurses in the critical areas of primary health care, aged care and disability (especially the NGO sector) continue to report major barriers to education despite being at the front line of managing chronic illness and disability.

The legislative barriers (63 in all) identified some years ago as impeding NP practice are once again being addressed by a working group.  Given the Ministry of Health’s tireless rhetoric about the importance of new ways of working, it is indeed hard to grasp why these barriers have remained so firmly entrenched for so long.  The inability to easily create NPs as authorised rather than designated prescribers is yet another legislative frustration.

Perhaps we must conclude that it is the attitudinal barriers which impact on all of the other barriers.  Clearly nursing’s vision for releasing its own potential is not shared by non-nurse decision makers in the health sector who remain intimidated and paralysed, seemingly, by fear of offending medical lobby groups.  Recently the College has worked with the NZNO Primary Health Care Council to attempt a revision of the recommendations of Investing in Health in line with developments (or lack thereof) since the original document was first written in 2003.  Nursing has confidently addressed the expected divisions of opinion and successfully negotiated a shared position on all of the recommendations (see page?).  It has however been interesting and very disappointing to see the Ministry (through the Director General) ensure that the Ministry’s distance from that work is made clear.  I have been privately advised that this distancing occurred as a result of a letter to the Ministry from the NZMA.  I do look forward to the day when a letter from a nursing group invokes such concern at the highest levels of health bureaucracy.  Only then will our vision and potential be fully released.  Only then will “new ways of working” truly be enabled.