TE PUAWAI The Blossoming
Whakatauki
Kia tiaho kia puawai te maramatanga
“The illumination and blossoming
of enlightenment”
This whakatauki highlights the endeavours of the College of Nurses as an
Organisation which professionally seeks enlightenment and advancement.
ISSN 1178-1890
College of Nurses Aotearoa (NZ) Inc
PO Box 1258, Palmerston North 4440
www.nurse.org.nz
© Te Puawai College of Nurses Aotearoa (NZ) Inc 1
Te Puawai
Contents
Editorial .............................................................................................................................. 2
“Deadly Medicines and Organised Crime: How big pharma has corrupted
healthcare” Book Review.................................................................................................. 6
Overdiagnosing Hypertension……………………………………………………………………………….7
HWNZ hosts workforce strategy day in partnership with NNO…….………….………..……10
Nurse Practitioners – Part of the Solution not the Problem… Jeff Symonds, NP……15
2013 Annual report ……………………………………………………………………………....………….18
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Editorial
Professor Jenny Carryer RN, PhD, FCNA(NZ) MNZM Executive Director
The health bureaucracy (probably just like all
bureaucracies) in its broadest sense has a
long-standing habit of trends, buzz words,
bandwagons, news ways of describing things
and catch phrases. It never ceases to surprise
me how very quickly they spread and how
earnestly they are taken up and shared or
spread.
Alongside the speed of spread goes a level of
thoughtlessness. Many adopters of the “ mots
du jour” seemingly give little thought to their
substance or veracity. In other situations the
same new terminology is used by all yet
simple investigation reveals that not all share
the same understanding of meaning.
The statement that has become apparent
lately is the one that suggests primary health
care (PHC) nursing leadership really needs to
“step up”. Cathy O’Malley (Deputy Director
General of Health) may have unwittingly
launched this at the Primary Health nurses
conference in Wellington earlier this year. I
am informed that she suggested or at least
was interpreted as saying that when PHC
nurses found obstacles in their way to
delivering better services they should “kick
some tires” “step up” and not just accept it.
Which is perfectly reasonable. What has
since stunned me however, is just how quickly
some Ministry of Health personnel now parrot
the statement about leaders needing to step
up, as new gospel, but if challenged are not
exactly sure why they said it and what it
means.
So let’s think about it in some depth. The first
irony is that nursing itself, since the launch of
the PHC strategy has noted the need for an
infra-structure of leadership in primary care
services from PHOs to General Practice and
through broader areas of primary health
service delivery. A revisionary read of
Investing in Health (MoH 2003) and the
updated document (NZNO, College of Nurses,
2007), shows that nursing has been very
cognisant and concerned by the paucity of
leadership structures and leadership
development in such settings. We have
argued for the need for specific leadership
development, and for the same professional
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practice model used elsewhere. By
professional practice model I mean one
whereby nurses report to nurses and nurse
leaders oversee professional development,
discipline and decisions about position
appointments and the appropriate deployment
of nursing staff.
The lack of such a model is painfully clear to
me when various primary health care nurses
from all over the country ring the College
office looking for support with employment
crises at work. It’s hard to summarise but my
impressions over the last many years are
firstly of fear, of intimidation, or oppression
and also very cavalier approaches to correct
HR procedures. Nurses in these settings often
express an almost unbelievable sense of
vulnerability and appear to lack any sense of
their own value, let alone rights. Ridiculous
myths about professional accountabilities are
sustained and being vocal or assertive is
almost always punished in one way or
another. Such environments destroy potential
leaders and only the hardiest rise above such
settings. Very rarely do they sound like
potential fearless “tire kickers”.
Back in 2003 when writing the blueprint for
PHC nursing development Investing in Health
we recognised that PHC nurses were largely
starved of access to post graduate education.
The implementation of scholarships (initiated
by Annette King and administered by the
MoH) brought forth a flood of applications.
Those of us in leadership positions saw this
as an exciting breakthrough and in many ways
it was. However as the years have dragged
by the comparative numbers of PHC nurses
who are accessing postgraduate education
remains a trickle and they consistently report
greater challenges with accessing the time
away from work and gaining genuine support
from employers. It is hard enough to do
postgraduate study when working full time but
to do it from a climate that begrudges the
support and belittles the value is sometimes
just too much.
As I have frequently argued, postgraduate
study fulfils a dual purpose. It is an essential
source of clinical skill and knowledge. It is also
a source of personal development in which
the nurse gains a much broader and more
strategic view of health sector issues and the
challenges facing all countries as they attempt
to sustain services against increasing demand
and diminishing workforce capacity. As such
it is a critical component of leadership
development. From my perspective as
someone who teaches these nurses every
year however, I am constantly reminded that
gaining strategic vision is more often a case of
increasing frustration for these nurses rather
than engendering or empowering action.
In summary thus far nursing efforts towards
leadership development have suffered from
working in a sector that largely does not see
or embrace any need for change. Powerful
voices in General Practice particularly, remain
resistant to real nursing leadership and
continue to pay lip service through partial
forms of team-work and paternalistic models
of power sharing. In addition we know that
behind the scenes if the GP lobby group has a
tantrum everyone from the Minister down
listens and acts. In nursing we could have all
the tantrums we like and nothing would alter
except probably even greater resistance to
our supposed “self-interest”.
So this brings me to the obvious question.
When as suggested nursing leadership “steps
up” more than it already does, what should it
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actually do differently. Believe me this is a
question I ask myself on a daily basis. In my
mind nursing leadership is about being highly
focused on patient and community health
outcomes and addressing what nursing can
do differently to meet those goals. As a
discipline we have carefully identified and
articulated those changes required to “release
the potential of nursing” (Ministerial Task
Force on Nursing, 1998). Our own internal
professional goals have been fulfilled. They
include (but are not limited to) radical changes
to postgraduate nursing education from a
social science focus to a clinical focus,
development of the Nurse Practitioner scope
of practice, a much more enabling and flexible
scope of RN practice to increase consumer
access to care, acceptance of registered
nurse prescribing, and well developed
collaborative processes across all nursing
groups and their leadership.
The same cannot be said for the identified
barriers which are external and thus beyond
our control. As noted ad nauseum in many
workshops, publications and meetings with
Ministers and others, in primary health care
and beyond, nursing development remains
constantly stymied by a range of barriers and
legislative obstructions. It is indeed brilliant
that the Medicine’s Amendment Act is done
and dusted as of last week. But how tedious it
is to keep asking; Why is the Health
Practitioners Statutory Reference Bill still
sitting in Health Legal in the MoH? And why
has the Ministry never made it clear to all and
sundry that capitated payments for patients
are not an exclusive funding source for GPs?
Much more could be said and many more
subtle barriers identified. The point however is
that to me it is hard not to see the suggestion
that PHC nursing leadership should step up
as a strategy to distract. It aims to distract
from a complete failure to truly enable and
resource the very workforce that really could
and really wants to deliver on the goals the
Ministry constantly articulates. This is namely
a flexible responsive workforce that is able to
work differently, innovatively and responsively
to major areas of need, increasing disparities,
and what General Practice leaders have
themselves referred to as the ‘burning
platform”.
I am well versed in the mantra that as a leader
I should look for solutions rather than
articulate problems. Despite the best will in
the world I just cannot think of any more
solutions right now. Are there any ideas out
there?
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“Deadly Medicines and Organised Crime: How big pharma has corrupted healthcare”
Reprinted with the kind permission of the Auckland Womens Health Group Newsletter
This latest book by Peter Gotzsche was
published in August 2013. Professor Gotzsche
is a specialist in internal medicine, who co-
founded the Cochrane Collaboration in 1993
and established the Nordic Cochrane Centre
the same year. In 2010 he became Professor
of Clinical Research Design and Analysis at
the University of Copenhagen.
This refreshingly blunt book exposes the
pharmaceutical industries and their charade of
fraudulent behaviour, both in research and
marketing where the morally repugnant
disregard for human lives is the norm.
Professor Gotzsche convincingly draws close
comparisons with both the tobacco industry
and the mob, revealing the extraordinary truth
behind efforts to confuse and distract the
public and their politicians.
This book addresses, in evidence-based
detail, an extraordinary system failure caused
by widespread crime, corruption, bribery and
impotent drug regulations that are in
desperate need of radical reforms.
This book is as relevant to New Zealand as to
any other country; in fact it begins with a New
Zealand story – the story of how fenoterol
formerly used in asthma inhalers caused the
asthma death rates to go up in the same way
as the sales did. For the full story of how the
New Zealand Department of Health conspired
with the drug company and misinformed
doctors against the researchers who tried to
blow the whistle, read the book by Neil Pearce
“Adverse Reactions: the fenoterol story” which
was published in 2007.
The book also ends with a good news New
Zealand story – a description of the rock star
of our health system, PHARMAC.
In the introduction to his book Peter Gotzsche
states:
“The main reason we take so many drugs is
that drug companies don’t sell drugs, they sell
lies about drugs. This is what makes drugs so
different from anything else in life … Virtually
everything we know about drugs is what the
companies have chosen to tell us and our
doctors … the reason patients trust their
medicine is that they extrapolate the trust they
have in their doctors into the medicines they
prescribe. The patients don’t realise that,
although their doctors may know a lot about
diseases and human physiology and
psychology, they know very, very little about
drugs that hasn’t been carefully concocted
and dressed up by the drug industry … If you
don’t think the system is out of control, please
email me and explain why drugs are the third
leading cause of death.”
If you only read one book over the next six
months, then for the sake of your health and
your sanity this is the book you must read. It is
immensely readable, terrifyingly funny in parts
and just plain terrifying in others.
It is also worth noting that as soon as you start
reading the forewords in this book by Richard
Smith, former editor-in-chief of the British
Medical Journal, and Drummond Rennie,
deputy editor of the Journal of the American
Medical Association, you won’t be able to put
it down.
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Overdiagnosing Hypertension
Reprinted with the kind permission of the Auckland Womens Health Group Newsletter
According to Dr Gilbert Welch the beginning of
overdiagnosis began with the diagnosis and
treatment of a common condition –
hypertension (high blood pressure). (1)
In his book he states that hypertension was
the first condition for which regular treatment
was started in people without symptoms and
no complaints about their health. Such people
were suddenly turned into patients by being
given a diagnosis and then a prescription for a
drug.
While diagnosing hypertension in those who
had no symptoms provided the opportunity to
prevent symptomatic disease in some people,
it did so at the cost of making the diagnosis in
many others who would not develop any
symptoms or die from hypertension. In other
words, at the cost of overdiagnosis.
Like most conditions hypertension exists on a
spectrum, from very mild to much more severe
forms. Usually, the benefit of treatment rises
with the severity of the abnormality. Mild
abnormalities are less likely to cause
problems than severe abnormalities, and most
people are not destined to have anything bad
happen to them as result of their mild
abnormalities. However, they can be harmed
by being overdiagnosed and treated with a
drug that has side effects. And all drugs have
side effects.
The down side of drugs
The drugs used to treat people for
hypertension can cause fatigue, some cause
a cough, and others impair sex drive. All of
them can make your blood pressure too low,
leading to light headedness, fainting and falls.
For older people, major falls are often the start
of a chain of events that lead to death. (1)
Hypertension Guidelines
One of the presentations at the international
Preventing Overdiagnosis conference in
Hanover in September described how
applying the European hypertension
guidelines could destabilise the healthcare
system in Norway, one of the world’s most
long and healthy living nations. Norway also
happens to have very good physician
coverage. The hypertension guidelines
considerably overestimate the risk and/or the
amount of resources appropriate for the
healthcare system to spend specifically on
cardiovascular risk reduction. The presenters
concluded that “large scale, preventive
medical enterprises can hardly be regarded as
scientifically sound and ethically justifiable,
unless issues of practical feasibility,
sustainability and the social determinants of
health are considered.”
Statins
Peter Gotzsche, who co-founded the
Cochrane Collaboration in 1993 and
established the Nordic Cochrane Centre that
same year, says in his latest book that “statins
are currently intensively marketed to the
healthy population both by the industry and
some enthusiastic doctors, but the benefit is
very small when statins are used for primary
prevention of cardiovascular disease.” (2)
A Cochrane Database Systematic Review
published in 2011 urged caution in prescribing
statins for primary prevention among people
at low cardiovascular risk. (3) While previous
reviews of the effects of statins had
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highlighted their benefits in people with
coronary artery disease, the reviewers found
there is limited evidence to show that primary
prevention with statins is cost effective or that
they improve quality of life. They do however
turn healthy people into patients.
Totally biased drug trials
The problem with the statin trials is that “there
is often no blinding, no concealment of
treatment allocation (which means that the
randomisation could have been violated), poor
follow-up and no intention-to-treat analysis
(where the fate of all randomised patients is
accounted for, also those who drop out).
Funding from the test drug company rather
than the comparator drug company was
associated with more favourable results (odds
ratio 20) and more favourable conclusions
(odds ration 35). This is not surprising
considering that head-to-head statin trials are
not fairly designed, as the compared doses in
most of the trials are not equivalent.” (2)
Peter Gotzsche also points out in his book
which the above quote is taken from, the drug
industry’s many tricks make the impossible
possible, and their duplicity knows no bounds,
which is why he compares the industry with
organised crime.
This is important information for all those New
Zealanders who are being encouraged by the
current TV advertising campaign or by their
GP to get a heart check. Overdiagnosis is not
just a problem in America or in Europe, it is
also happening at your local GP practice. So
before you agree to go on a statin you need to
ask your doctor for the evidence from an
independent source that taking statins when
you have no symptoms of heart disease will
benefit you, or at the very least that it will not
harm you.
Prescription drugs are, after all, the third
leading cause of death after heart disease and
cancer. (2)
References
1. Dr H Gilbert Welch, Dr Lisa Schwartz
Dr Steven Woloshin “Overdiagnosed: Making
People Sick in the Pursuit of Health.” Beacon
Press 2011.
2. Peter Gotzsche “Deadly Medicines
and Organised Crime: How big pharma has
corrupted healthcare.” Radcliffe Publishing
2013.
3. http://www.ncbi.nlm.nih.gov/pubmed/2124
9663
Please remember to
update your contact
details if you have
not done so this year.
Email the College
office–
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HWNZ hosts workforce strategy day in
partnership with NNO.
The recent day (November 29th) hosted by Health Workforce NZ (HWNZ) was a tremendous
opportunity to see and understand the breadth of work currently being achieved by the combined
efforts of NZ Nurse leaders. The national nurse group (known as NNO) is a forum where leaders
of 9 national nursing organisations come together to find convergence of perspectives and to
clarify points of divergence so as to work together effectively on agreed key Nursing and health
service issues.
The NNO:
does not constitute another nursing organisation
does not speak as a collective voice for nursing and there is no NNO spokesperson – members comment to media in accordance with own organisational policy understanding that where consensus has been reached at NNO on an issue, individual organisational comment will express that consensus.
is not a decision making group
It is however excellent evidence of the
enormous collegiality, collaboration and
commitment to the greater good between all
of the major national nursing organisations.
Alongside the long overdue expansion in the
size and capacity of the nursing team in the
Chief Nurse’s office in the Ministry of Health
we are seeing a really strong focus and
combined expertise being brought to bear on
strategic challenges and direction for nursing.
A major issue for the health sector at the
moment is the ongoing development of a
workforce that is flexible, responsive and able
to respond to the escalating demand for
services. For this reason it is critical that there
be a respectful and active partnership
between NNO and HWNZ.
The health system is facing challenges
through a growing gap in demand for services
and supply of workforce. This has been
stated so often now that it risks losing impact
but is nevertheless an important signal to all of
us that workforce planning is extremely
important. Nursing leaders have led
considerable development of data intelligence
around new graduates, workforce planning,
advanced practice development, and care
capacity demand management in hospitals.
Nurse leaders also hold to the strategic vision
for the all-important goal of closely aligning
nursing services with community need.
Nursing, being a large, generalist and flexible
workforce is well placed to meet the changes
required but data indicates that this workforce
is not growing at the pace required to meet
the demand. Attention to the development of
the nursing workforce is essential if we are to
see both clinical and financial stability in the
New Zealand health system.
Nursing has previously argued that to date
HWNZ has paid insufficient attention to
nursing as the largest regulated workforce,
which also directly supervises the largest
unregulated workforce. At the end of last year
the College along with NZNO and the College
of Midwives wrote to HWNZ expressing our
concern about the progress HWNZ was
making in developing and implementing a
workforce strategy. In that letter we noted that:
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The changes required to build health workforce confidence in HWNZ and its mandated programme are
Open and transparent processes
Positive engagement with the sector including representative organisations
Sound problem identification and exploration of all options before developing and testing new models
Robust evaluation designs
Rigorous cost/benefit analysis of the introduction of new models and new health practitioners
Engagement with New Zealand health workforce researchers
Consultation with the sector on changes to models of delivery
The workforce strategy day held on November
29th could be seen as an eventual response to
our concerns and NNO approached this day
with enthusiasm. Approximately 50 nurses
from a range of locations and positions
attended the day as invited by HWNZ. HWNZ
staff had expended considerable effort to
arrange and host the day efficiently.
Chai Clua (Acting Director General of Health)
opened the day with an excellent and inspiring
address. He talked about his own journey to
leadership and about his interest in disruptive
innovations, which he sees as critical to
allowing the health system to respond to
demand in novel and sustainable ways. The
published works of Clayton Christenson on
this topic have been a particular source of
inspiration for him.
The bulk of the day was taken up by a
workshop aimed to elicit a range of goals
based on what we do know about nursing
workforce and identifying what is not known
and will require further data sourcing. The
day was characterized by a wonderful level of
cohesion and shared vision between senior
nurses present on the day who agreed that
issues of importance for the immediate future
include a number of key goals (summarized) ,
which included.
1. The need for a professional practice
model of leadership in every setting in
every nurse practice setting
2. The need to align the investment in
nursing education with strategic nurse
workforce development -determined by
consumer voice
3. The importance of policy support for
expanded nurse roles and prescribing
4. Interdisciplinary models for rural health
and other communities
5. The importance of a whole of integrated
system approach
6. The need to develop and resource
alternative approaches to clinical nurse
education in the undergraduate degree
7. All the NetP funding to go on NETP
nurses inclusive of a vision of 100%
employment for new graduate nurses
Professor Des Gorman closed the day by
acknowledging the sterling work of Nursing
Council of NZ in developing superb systems
of data collection for the nursing workforce.
He also conceded that HWNZ had been
wrong to address medical workforce issues
first and largely ignore nursing as he now
realised that nursing workforce issues were of
critical importance to the sustainability of the
health system. He was less gracious in noting
that he had heard nothing disruptive, tactical
or strategic all day in terms of listening to the
discussions that had occurred.
On that point we will need to differ. Nursing
holds to a focus on attending to community
need for services as guidance for aligning
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nursing development. This may not be short
term or exciting or gain “easy runs on the
board” but we believe it is the ethical,
sustainable and long-term approach that is
needed. And were we to reach the point
where all legislative, policy and the many
other more subtle barriers were addressed, so
that the full potential of nursing was released?
Well that, all by itself, would be a remarkably
disruptive innovation!!
Wellington 13th February 2014
Christchurch 14th February 2014
(Check the website, more dates & venues scheduled soon)
Covering the requirements for Nursing Council’s Code of Conduct training for 2014
Schedule of dates for 2014 will be available on the website soon.
Friday 4th April 2014 East Tamaki Campus University of Auckland.
Thursday 28th August 2014 Massey University Wellington.
Friday 29th August 2014 Massey University Wellington.
Saturday 30th August 2014 Massey University Wellington.
All events are advertised & registration can be made online via the College website
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Tobacco Control Seminar Series 2014
In February 2014, the Health Promotion Agency (HPA) and partners are hosting a series of
regional tobacco control seminars. You can access more information here.
To ensure we get all the right people along to these seminars - HPA, ASH, Cancer Society, Heart
Foundation, Smokefree Coalition, Tala Pasifika and Te Ara Ha Ora - are providing scholarships.
These scholarships are open to people working within smokefree/auahi kore sector. Primary
consideration will be given to those working in the NGO and community sector, Maori and Pacific
Island kaimahi, and those working in services helping young people and pregnant women.
Applicants cannot be employed or affiliated with the tobacco industry. Special consideration will be
given to those that were not able to attend the Oceania Tobacco Control Conference,
The scholarship includes the full registration cost for the seminar, with some additional funds
available for those requiring travel and/or accommodation assistance.
If you think this is you, we would love to hear from you in the New Year. An application will be
available from smokefree.org.nz. More information to follow, if you have any questions please
email Donna Harding on [email protected]
Please note the closing dates for applications are:
Auckland, Rotorua seminars - closing date Friday 24th January, 3PM
Wellington, Christchurch seminars - closing date Friday 30th January, 3PM
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Nurse Practitioners – Part of the Solution
not the Problem
Article by Jeff Symonds, NP, Bay of Plenty DHB
Recently the Ministry of Health (MoH) published its future mental health & addictions remit
for 2012-2017 called “Rising to the Challenge”. I tried not to think “oh no not another vision
and sets of goals to aim for”, at least until the next lot comes along…. Notwithstanding this I
actually took the time out to read the document and I was pleased I did. As I was going
through the information and gathering in the subliminal messages I couldn’t help but think of
Josser Hughes in “Boys from the Black stuff” when he used to say “gizza a job I can do that”.
(Google it?).
I was impressed that this above
mentioned report, at least from my point of
view, appeared to have an immense
amount of potential opportunity for
advanced practice nurses and in particular
Nurse Practitioners who practice in Mental
Health & Addictions services. For example
a renewed focus on earlier and more
effective responses, improved outcomes,
better system integration and
performance, increased access to
services, effective use of resources and
stronger whole-of-government
partnerships.
Or:
Therefore, to achieve the changes
needed, our major focus must be on using
our current resources more effectively and
increasing productivity. This will enable us
to focus our attention on early intervention
and strengthening primary–specialist
integration.
Rising to the Challenge, MoH 2012 p. 3
The Rising to the Challenge document
gave me a sense of direction as to where
the Ministry wants to go and made me
ponder on how I as an NP can fit in or out
of this future view. Clearly NPs are part of
the solution to help achieve these goals.
The Ministry want clinical services to
provide high quality services and improve
delivery in a more timely and accessible
way that is both efficient for the health
budget and effective for the health needs
of the community. When I write this I
sense the catch cry of Josser Hughes is
out there in the thoughts and aspirations
of most advanced practice nurses and
NPs.
If we as NPs use this Ministry document
ethically to incorporate the philosophy and
direction into our professional strategies
we may be able to, at the very least, lobby
more effectively with the view to establish
ourselves as integral components of this
future.
The area of main interest for me as a
practicing prescribing NP is the
secondary/primary interface:
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In addition, they (DHB Providers) will need
to use their knowledge and capability to
support primary care providers and the
wider health workforce to identify and
address mental health and addiction
issues.
Rising to the Challenge, MoH 2012 p 6
Nurse practitioners such as myself,
working in secondary services, are ideally
positioned to work across traditional
boundaries and integrate with primary
health services. By remaining in the
secondary service I am (at least
potentially) able to support both worlds in
my practice. For example with secondary
services I have good administrative and
clinical back-up, along with
supervision/support from my multi-
disciplinary colleagues. I am also able to
access clinical pathways more efficiently
and effectively. This ability to improve
timeliness and accessibility has direct
benefit for the clinical needs of patients
and the educational and attitudinal needs
of primary health care staff.
Working in close liaison with primary care
GP’s, NPs and other clinical staff would
help shift the ambulance closer to the top
of the cliff not towards the bottom where I
consistently see clients now. I could more
effectively provide clinical input for the
mild to moderate mental health and
addictions problems with which people
present. This reduces the pressure on
primary health by providing a much
needed resource for primary health care
staff, significantly mitigates against stigma
by not referring onto secondary mental
health & addictions services and limits the
overall demand on secondary mental
health & addictions services.
It seems to make sense for the Ministry to
actually walk the talk and influence if not
direct funders, planners and providers of
health services to change for the better.
By “the better” I suggest as just one
example, incorporating Nurse
Practitioners into key roles within the
health system rather than either not using
them at all or using them to do what does
not interest medical staff. I am sure the
bean counters out there can see the
benefit as systems and processes can be
recharged to achieve productive outcomes
and quality improvement.
Nurse practitioners still face fundamental
barriers in working to their full extent.
There are a number of regulatory
restrictions to NP practice to still work
through with government departments,
i.e., signing authority of benefits
applications and ACC, authorised
prescribing of medications, and in mental
health not being able to do certain
sections of the Mental Health Act which
are reserved for medical officers. These
regulatory restrictions are being worked
on with dogged determination by nursing
representatives around the country but the
progress is as one NP described recently
“glacial”.
Some of the bigger restrictions to practice
can come from within the health service
itself. I have talked about the glass
ceilings before (see Editorial Kia Tiaki
Sept 2013) and how these are formed
essentially from the attitudes of our
colleagues influencing national, regional
and local health organisations on how
services are delivered and who delivers
them. Yes NPs with prescribing are
moving into other clinician’s traditional
settings but that is how the human race
adapts, evolves and improves otherwise
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we would still be in our shelters and caves
somewhere in Africa.
Rising to the Challenge (MoH) suggests
that services need to think again about
how they can be creative and improve
effectiveness and efficiencies. These
words may sound old and clichéd but that
is only because they have been used
again and again but not yet actually
implemented. Nurse practitioners have
years of experience, advanced training
and the ability to apply their skills and
knowledge in a practical if not user friendly
way to improve health outcomes. That is
what we are designed to do; the NP scope
of practice embodies clinical integration. It
is not that anyone wishes to undermine
medical officers or be tall poppies with our
colleagues. The fact is we have skills and
knowledge that can be better utilised in
ways other than just “filling the gap” or
worse still qualified but not employed as
NPs. As the evidence demosnstrates for
health administrators and regulators over
and over again NPs especially are a
highly flexible and very cost effective
solution to workforce challenges.
Jeffrey Bauer (2010), an internationally
recognised medical economist and health
futurist, states:
Consistent findings about comparable and
acceptable quality have been reported in
studies focused on different institutional
settings, including emergency
departments,1
Nurse practitioners as an underutilized
resource for health reform, rural clinics,2
and nursing homes.3 Many more studies
that reach the same conclusion are
identified in the footnotes of these
publications. A highly significant
observation about the breadth of
comparative studies in this area is the
absence of any studies that reach a
contrary conclusion. Of more than 100
published, post- OTA reports on the
quality of care provided by both nurse
practitioners and physicians, not a single
study has found that nurse practitioners
provide inferior services within the
overlapping scopes of licensed practice.
My final statement to readers of this article
and in particular to decision makers who
influence health service development in
the New Zealand health sector is to
please read the evidence and incorporate
the roles of advanced practice nurses/NPs
into your service delivery plans. In regard
to the MoH base document that I have
referred to in this article “Rising to the
Challenge”, Nurse Practitioners have
already risen to the challenge! “Gizza job”
we are ready and able. It is time for the
furniture to be re-arranged to allow us into
the room.
1. Carter, M. W., & Porell, F. W. (2005). Cited in Bauer J (2010). Nurse Practitioners as an underutilised resource for health reform. Evidence base demonstrations of cost-effectiveness. American Academy of Nurse Practitioners.
2. Lemley, K. B., & Marks, B. (2009). Cited in Bauer J (2010). Nurse Practitioners as an underutilised resource for health reform. Evidence base demonstrations of cost-effectiveness. American Academy of Nurse Practitioners.
3. Aigner, M. J., Drew, S., & Phipps, J. (2004). Cited in Bauer J (2010). Nurse Practitioners as an underutilised resource for health reform. Evidence base demonstrations of cost-effectiveness. American Academy of Nurse Practitioners.
Annual Report 2013
College of Nurses Aotearoa (NZ) Inc.
Presented at the AGM 23rd October 2013
Massey University, Wellington
www.nurse.org.nz
06 358 6000
© Te Puawai College of Nurses Aotearoa (NZ) Inc 18
Te Puawai
Foreword
It is my pleasure to present this report to the 21st annual general meeting of the College.
As always this report notes the outcomes of considerable work and dedication to the College’s vision; that in health there will be one hundred percent access to services and zero disparities in health status. We recognise the contribution of those who extend their practice or organisational contribution to also working for the discipline of nursing, for health service quality and for the consumers of our services. It is a considerable demand to provide both positional leadership and discipline based leadership and those who do make an enormous contribution.
Nursing continues to make extensive and highly collaborative efforts towards “working differently” but cannot do it alone. As noted last year workforce reform needs a whole of sector approach and political and policy leadership that supports and fosters the nursing endeavour rather than ignoring or obstructing such projects. I continue to anticipate the day when health sector leadership and nursing leadership are working in a genuine partnership that places patient and community need ahead of professional power and traditional patterns of privilege.
Acknowledgements
As always my thanks are extended to the Board who make sacrifices in their personal lives to contribute to the College. In particular I want to acknowledge the dedication of our co-chairs Taima Campbell and Judy Yarwood. Both have now served a long term of office providing vital continuity and expert advice and guidance to the Board and to the Executive Director.
In addition I acknowledge the work of the College Censors and thank them for their continuing attention to college applications for Fellows.
Kelly Rotherham as College Administrator and her assistant Andrea Bond have again provided dedicated and skilled assistance to me, to the Board and most importantly to the College membership. Last year we reported that their absolute dedication and skill saw the College in the strongest position it has ever been with vital and vibrant workshops running all over the country and membership at an all-time high. This year has seen the continuation and growth of that strong position.
Professor Jenny Carryer Executive Director
© Te Puawai College of Nurses Aotearoa (NZ) Inc 19
Te Puawai
Contents
Foreword 2
Contents 19
College Executive 4
Executive Directors Report 2013 5
Appendix 1. Strategic Plan 2013 - 2016 11
Appendix 2. NPNZ Annual Report 2013 13
© Te Puawai College of Nurses Aotearoa (NZ) Inc 20
Te Puawai
Board Members
Maori Caucus
Taima Campbell –
Co Chairperson
Margareth Broodkoorn
Ngaira Harker-Wilcox
Non Maori Caucus
Judy Yarwood –
Co Chairperson
Angela Bates
Nicola Russell
Executive Director
Professor Jenny
Carryer
College Patrons
Prof Marilyn Waring Putiputi O’Brien QSO
College Censors
Prof Nan Kinross
Cathy Cooney
Putiputi O’Brien QSO
Te Miringa Huriwai
College Administration Staff
Kelly Rotherham Andrea Bond
© Te Puawai College of Nurses Aotearoa (NZ) Inc 21
Executive Directors Report 2013
This report is a summary of College activities and
achievements written against the core goals of
our strategic plan.
GOAL 1. ALIGN NURSING WORKFORCE DEVELOPMENT WITH COMMUNITY NEED.
Community need for health services is
recognized as being at risk from predicted
workforce shortages and deficits. The College
remains committed to all activities which support releasing the full potential of nursing services to
address disparities and to ensure that people have full access to competent and safe care from a
health professional who is working at the “top of their license”. It is becoming ever more critical that
nursing consider its social justice commitments as a basis for our decision making. This is especially
important in terms of workforce development which is not about enhancing the position of nurses
but about ensuring we can provide the best possible service.
We begin with activities towards development and maintenance of a viable Nurse Practitioner
workforce.
NPNZ (Nurse Practitioners of New Zealand)
The College makes a significant commitment to Nurse Practitioners on the basis of strong and
long standing evidence that Nurse Practitioners provide a transformational health service and
are a solution to many workforce shortages. We continue to work in partnership with NPNZ
to address the on-going issues underpinning implementation of the Nurse Practitioner role.
At this stage the Health Practitioner Statutory Reference Bill remains seemingly lodged
somewhere in the Ministry of Health and although pivotal to workforce flexibility it is taking a
very long time to become an agenda item. This despite its first iteration beginning in 2005. As
noted last year, for a Government committed to “better sooner more convenient” health care
this seems an extraordinary state of affairs.
Similarly much time and effort has been devoted to lobbying for changes to primary health
care funding and ACC reimbursements. We were delighted to see the announcement that
GMS payments would become available to RNs, pharmacists and NPs but as always “the devil
will be in the detail” and implementation details are as yet unclear. NPNZ annual Report
attached as Appendix 2.
© Te Puawai College of Nurses Aotearoa (NZ) Inc 22
Prescribing
Whilst the Health Select Committee have now agreed that NPs should have authorised
prescriber status we still await the final reading of the Medicine’s Amendment Bill. At the
time of writing it is unclear what exactly constitutes the delay in the passage of this Bill. We
have recently received assurance in writing from the Associate Minister of Health , Hon,
Todd McClay that he has asked Parliament to consider the Bill soon in order to ensure
passage before July 2014.
The same Bill also paves the way for nursing to begin work on a model of RN prescribing to
utilise the designated prescriber category. Nursing Council has completed consultation on this
development. We were disturbed this year to see PHARMAC extend special authority
prescribing to GPs whilst overlooking NPs. Interestingly despite many requests for
consultation coming to the College and other organisations this year, this announcement
came as a surprise. Currently the Chief Nurse’s Office in the MoH is chasing this up.
Nursing Workforce in General
o Consumer Alliance Work
Judy Yarwood has continued to maintain a relationship with Rural Women and with the
Rural Health Alliance Network.
o Report on National Nursing Consortium 2014
Membership
Maureen Morris (Chair, NZNO) Di Roud (College of Nurses) Maureen Ager, Daryle Deering
(NZCMHN), Susanne Trim (secretary, NZNO) David Warrington, Angela Bates (College of
Nursing)
Hemaima Hughes who represented Te Kaunihera resigned in February due to personnel
reasons. Replacement pending.
The National Nursing Consortium is a collaborative, national process for overarching
endorsement of nursing standards and knowledge and skills frameworks by the wider
nursing profession in New Zealand. It establishes a mechanism by which nursing retains
authority over standards and frameworks for areas of practice developed within New
Zealand. The process does not replace the processes representative nursing organisations
use for the development and approval of standards frameworks, but is a validation from
the wider nursing profession in New Zealand of standards meeting criteria set by the
profession. Neither individual nurses nor education programmes would be endorsed
through this process. Procedural standards are not eligible.
© Te Puawai College of Nurses Aotearoa (NZ) Inc 23
Activity
Consortiums terms of reference and documents have been reviewed and endorsed.
They are accessible along with endorsed standards on the following website -
http://www.hiirc.org.nz/section/15221/national-nursing-standards/?tab=6850
National Youth Health Nursing Knowledge and Skills Framework was submitted in
June, endorsement is pending as they have been asked to submit more evidence.
National Pain Management Knowledge & Skills was submitted and endorsed in
September.
o NNO (National Nurse Leaders Meetings)
This remains an excellent forum for informally bringing together the Chief Nurse and the
leaders of NZNO, College of Nurses. College of Mental Health Nurses, Council of Maori
Nurses, Nursing Council, Council of Deans, Nurse Educators in the Tertiary Sector,
Directors of Nursing and Nurse Executives. The forum is used to discuss topical issues, to
move towards consensus positions or determine both agenda setting and responses to
groups such as Health Workforce NZ.
Conferences, Workshops & Seminars
Dr Michal Boyd, Bernadette Paus and Diane Williams have made an excellent contribution on
behalf of NPNZ and the College in conducting a number of workshops specifically designed to
support intending NP candidates towards portfolio completion.
Dr Patricia McClunie-Trust has made an enormous contribution to the College and the
profession in conducting 7 Professional Boundary workshops in the past year with more to
come. Alongside the release of the Nursing Council Code of Conduct these have been a timely
and vital contribution to nursing professional development. I cannot sufficiently express our
gratitude for the enormous contribution that Patricia has made and continues to make.
Feedback from the workshops is consistently superb and we are very grateful to Patricia for
this major contribution of her time and energy.
Primary Health Care Nurses (including school and youth health nurses) This is another area of key engagement for the College. We remain committed to ensuring
that there are no funding, employment, post graduate education or infrastructural
impediments to ensuring that nurses in all primary health care settings can offer the full range
of possible services.
We continue to look forward to the day when we can work in true partnership with GP leaders
in order to overcome the barriers to full utilisation of primary health care nurses. As GP leader
Dr Tim Malloy has noted, primary health care and General Practice is a “burning platform”:
requiring rapid change in traditional ways of doing things if services are to be even maintained.
© Te Puawai College of Nurses Aotearoa (NZ) Inc 24
GOAL 2. INFLUENCE POLICY/ HEALTH LEADERSHIP
Consultation with key sector leaders continues; Regular meetings with health sector and nursing leaders
Strategic partners
Member of the Rural Health Alliance
Member Smokefree Coalition of New Zealand
Submissions
The following submissions have been completed in the previous year. Thanks go to the
College Board, NPNZ Executive and those members who have contributed to submissions on
for the very concerted effort that goes into this work. These submissions represent a
substantial body of work and a major contribution to influencing health and nursing policy.
All Submissions are available to view on the website www.nurse.org.nz/submissions-2013
© Te Puawai College of Nurses Aotearoa (NZ) Inc 25
The above submissions by the College of Nurses Aotearoa (NZ) Inc and NPNZ (A division of
the College of Nurses) are all available on the College Website
www.nurse.org.nz/submissions
© Te Puawai College of Nurses Aotearoa (NZ) Inc 26
GOAL 3. DEVELOP A SUSTAINABLE FUTURE FOR THE COLLEGE
Marketing 2013 has seen the College using increased marketing strategies. This year we have used a combination of direct marketing, print advertising and email marketing of workshops and events as well as College membership to practice nurses, aged care facilities, private hospitals and PHO’s, nursing groups and past attendees of workshops.
Website
The website continues to be a great resource for our members and nursing throughout NZ, with information updated and emailed to members on a regular basis. Membership applications and event registrations are almost all now received via the website. The website is now also generating some advertising revenue with the positions vacant and advertising of selected events.
Expertise data The expertise database is constantly updated and available. This is a valuable resource, listing all College members and their fields of expertise. Members should note that when this resource is kept up to date we are greatly assisted in calling the right people to provide expertise.
College Symposium 2014 It is my hope that in 2014 we might revisit our theme of 2008 by continuing to explore critical approaches to addressing the issue of obesity, nutrition and poverty. Plans for 2014 conference will be discussed at the October Board Meeting and AGM.
Scholarships
We are pleased to be able to offer a variety of scholarships in October 2013/14 from $500 -
$2000 each.
Nursing Praxis in New Zealand Nursing Praxis continues in contract with the College office managing the administration and accounts with the intention of moving to a publisher with international marketing expertise.
Financial Status The College continues its positive growth for 2013, with further extension of the business arm including workshops and events etc. securing the financial stability of the College and enabling development of additional member services and scholarships for members. Copies of audited financial statements are available at the AGM and also available on request from the College office.
Insurance The College will renew our membership indemnity insurance policy this year underwritten by NZI at an anticipated increase of aprox 5% in line with current insurance trends, also taking into account the increase in membership numbers.
Appendix 1.
© Te Puawai College of Nurses Aotearoa (NZ) Inc 27
COLLEGE OF NURSES AOTEAROA (NZ)
STRATEGIC PLAN 2013 - 2016
Purpose:
The College of Nurses Aotearoa (NZ) provides a forum for critical inquiry into professional, educational and research issues relating to nurses and to the achievement of equitable outcomes for health consumers. The College of Nurses Aotearoa (NZ) acknowledges Te Tiriti o Waitangi as the foundation document of this nation and this, therefore, underpins all activities undertaken by the College of Nurses Aotearoa (NZ).
Vision:
The College of Nurses Aotearoa (NZ) aims for professional excellence in nursing practice and health care delivery, underpinned by negotiated relationships. This will be achieved through the support of nurses and their ongoing professional development to enable: 1) innovation and health service delivery and 2) the development of regional, national and strategic consumer alliances with the aim of creating 100% access and zero Disparities. How does this plan work? Nurses as the key members of the health care team, work in diverse community and hospital settings delivering numerous health services to different population groups and cultures. The many challenges and opportunities inherent in the current health care environment demand a planned and tactical approach. Building on from previous strategic plans, the current 3 year plan outlines directions the Board considers important to members, policy makers and health care consumers. Each of the three strategic directions has an objective, which can be measured and reported to members on an annual basis. Implementation of the plan is reliant on the College Board and membership being committed to proactively and creatively engaging with each objective. COLLEGE STRATEGIC DIRECTIONS 1. ALIGN NURSING WORKFORCE DEVELOPMENT WITH COMMUNITY NEED
Rationale Workforce development is a critical challenge for the health sector. An effective nursing workforce is essential for delivering health care to New Zealanders and for reducing inequalities in health. Outcome: Competent and effective registered nurse / nurse practitioners working at the top of their licence. Key objectives: a. Support primary health care nursing workforce development and implementation of the framework for
activating primary health care nursing in New Zealand. b. Support ongoing Nurse Practitioner role development c. Address the elimination of all barriers to full use of RN/NP workforce. d. Identify and nurture emergent leaders amongst College membership and elsewhere within the profession. e. Foster and support the aspirations of Maori nurses.
11
2. INFLUENCE POLICY/ HEALTH LEADERSHIP Rationale Nurses contribute to policy development through their roles as analysts, researchers, academics, consumer advocates and clinicians The goal of this activity is elimination of disparities in health status and improvement in health service delivery. Outcome The College, through its members provides health leadership, critical advocacy, and contributes to national health and socio-economic policy. Key objectives a. Maintain and build strong strategic relationships and participate in cross disciplinary communication. b. Promote the use of evidence and research to inform policy decisions addressing health disparities. c. Identify and support College members on key decision making and policy development forums. d. Foster strong consumer alliances.
3. DEVELOP A SUSTAINABLE FUTURE Rationale The College of Nurses is committed to being responsive within a dynamic health environment.
Outcome The College resources are effectively utilised. The College continues to utilise its strength and maximise its growth. Key objectives a. Engage Fellows and Members in the implementation of the strategic activities of the College. b. Work towards the employment of a policy analyst. c. Market and promote the College. d. Develop the College’s political and media profile. e. Recruitment of new members. f. Plan for a viable future.
Appendix 2.
12
A division of the College of Nurses Aotearoa (NZ) Inc
2013 Annual Report
NPNZ has had another very active year. Michal Boyd will be stepping down as chair in October 2013 and
Jane Jeffcoat will be taking up the position. Rachel Hale kindly served as secretary in 2013 but unfortunately
resigned due to work commitments and we are now in the process of re-appointing the secretary. The NPNZ
executive members include:
Alison Pirret, secretary (nominations for a replacement have been accepted and will be voted on at
the October NPNZ meeting)
Elizabeth Langer, treasurer
Helen Topia, conference facilitator
Diane Williams, primary healthcare and ACC expert
Michal Boyd – past chair
Mary Jo Gagan
Rachel Hale
Mission:
Nurse Practitioners New Zealand (NPNZ) is an organization that provides a collective voice to advance Nurse
Practitioner (NP) practice and enable high quality integrated and accessible healthcare throughout New
Zealand.
Values:
Excellence in health through service delivery, research and policy
Closing the gaps in healthcare
Honest and respectful partnerships
Nurse Practitioner leadership for New Zealand Nurse Practitioners
The Treaty of Waitangi is the foundation for nurse practitioner practice
Aims:
1. Promote excellence in advanced clinical nursing through practice, education and research
2. Enhance capacity of the Nurse Practitioner practice in New Zealand
3. Provide Nurse Practitioner leadership for legislation, regulation and policy development
4. Provide resource and consultation for healthcare practice in New Zealand.
14
2013 NPNZ STRATEGIC Plan, Activities and Future Plans
Aim 1: Promote excellence in advance clinical nursing through practice, education and research
2013 Activity:
1A. Currently collaborating with Health Workforce New Zealand to develop a funded NP training programme
in collaboration with employers and NZ Nursing Council
1B. MJ Gagan et al. NZ authored 10 year NP summary article based on NPNZ member survey and it has
been submitted for publication in AANP journal.
1C. Sylvia Meijer’s Aged Residential Care NP practice (through MidCentral DHB and Central PHO) was
evaluated with HWNZ funding by University of Auckland. The evaluation was very positive and supported the
“triple aim” philosophy. Report available on-line at
http://healthworkforce.govt.nz/sites/all/files/Evaluation%20of%20the%20NP%20in%20Aged%20Care%20Apr
il.pdf
Aim 1 2014 Plans: 1A: Helen Topia organising NPNZ prescribing conference for mid-2014
Aim 2: Enhance the capacity of the Nurse Practitioner profession in New Zealand
2013 Activity;
2A. NPNZ actively linking with Chief Nurse Jane O’Malley and her office.
Jane O’Malley attended April 2013 meeting and chief nurses office representative will attend October 2013
meeting.
2B. Regularly provide NPNZ Nurse Practitioner Development days. Last one held April 2013 held in
Auckland.
2C: NPNZ chair met with Tony Ryall along with Chiquita Hansen and Yvonne Stillwell from Midcentral Health
to discuss Central PHO NP evaluation report and future NP development.
2014 Plans:
2A. Develop the processes to implement an NPNZ Associate Membership category.
2B. Re-develop NZNC information pack for new NPs.
2C. National NPNZ prescribing conference planned for 2014
Aim 3: Provide Nurse Practitioner leadership for legislation, regulation and policy development to identify
and actively advocate for removal of barriers to NP practice.
14
2013 Activity:
3A. Alison Pirret and Bernadette Paus worked with CNA(NZ) re-develop NPNZ Website to be more user-
friendly and easier to navigate.
3B. Correspondence to MOH in collaboration with NZNO and CNA(NZ) to encourage the third reading of the
legislation to change NPs from designated to authorised prescribing. The third reading is now expected
before Christmas 2013.
3C. Consulted with NZNC regarding Misuse of Drugs act for NPs. NZNC & CNO support no lists or time
limits for controlled drugs when NPs become authorised prescribers.
3D: Advocating for standardised approval for ordering imaging tests across DHBs and PHOs. – NPNZ
representative – Margaret Colligan on national imaging task force. Agreement that NPs will have the same
imaging privileges as GPs in PHC.
2014 Plans:
3A: Continue to work toward NP authorisation to sign WINZ disability and sickness benefit applications.
3B. Continue to work with MoH to remove the barriers to accessing Section 88 for primary healthcare
practitioners
Aim 4. Resource and consultant for health practice in New Zealand.
2013 Activity:
4A. Promote Nurse Practitioner authorisation of Life Extinct form and Death Certificates. The Chief Nurse is
actively developing a plan to expand this authority to nursing currently.
4B. Consulted with ACC to ensure access to NP service provision is included in ACC contracts, fee
structures, treatment claims and referral processes. ACC did include NPs in their latest payment schedules,
however not at the payment level NPNZ had strived to achieve.
4C: NPNZ member – Rosemary Minto interviewed on 9 to noon about NPs in PHC.
4D: Diane Williams and Anna Dawson – developed NPNZ submission document for the Pharmac policy
consultation request.
2014 Plans: Yet to be developed.