Nurse Practitioners in New Zealand

Case Studies

Working life as a Nurse Practitioner in Mental Health
Bernadette Forde

Background and training

I work as a Mental Health Nurse Practitioner for the Otago District Health Board. My nursing career started many years ago when I would take myself off to Calvary Hospital, which was located at the end of the street I grew up in, to help feed the oldies at tea time. From these early beginnings I decided to become a nurse at the age of ten. After my children (Rachael, Joseph and Ben) were born I opted for a nursing position in mental health because the roster system worked well for mothers with young children. Whilst the decision to move into the field of mental health was pragmatic it was also fortuitous as I quickly became very passionate about, and committed to, mental health.

After completing the Nursing Degree programme in 1994 at Otago Polytechnic I went on to commence my Masters Degree (Master of Health Sciences) through the University of Otago. After completing my Masters degree I studied part time at the Ashburn Clinic and completed a psychotherapy programme. During this period I also completed an additional course gaining a certificate in Cognitive Behaviour Therapy. This additional training gave me the skills that I consider crucial to my Mental Health Nurse Practitioner role. Throughout these years of study I took on a variety of leadership and education roles, including some post-graduate lecturing responsibilities with the Otago Polytechnics School of Nursing.

Dual diagnosis client group

In my clinical role I developed a special interest in working with people with intellectual (learning) disabilities who experience mental illness. It is this dual diagnosis client group who I predominantly work with now. Because this group of people are often in supported accommodation a large proportion of my work is dedicated to mental health education and promotion aimed at supporting health professionals and community providers to develop skills to better support this group of people. I have developed a variety of training packages, resources and workshops in this area.

Reducing inequalities and inequity in health

One of the guiding principles behind the development of Nurse Practitioner (NP) roles in New Zealand is to “reduce inequalities and inequity in health”. Nurse practitioner role development will inevitably be centred on patient and population health needs and improving health outcomes. People with a dual diagnosis of intellectual disability and mental illness have had a poor deal in terms of health care for years. The inequity in their physical and mental health status has been clearly identified. There are two major factors contributing to this: firstly, there is limited time given to this area in health professional training programmes in New Zealand e.g. medicine, psychiatry, psychology, GP training and nursing programmes; secondly, the health professional community tends to reflect society’s prejudices towards people with disabilities – the dual diagnosis population is often viewed as the least desirable client group for a mental health professional to serve. This has resulted in an extremely limited pool of clinicians skilled in this speciality area, which in turn has resulted in mental illness in this group generally being untreated because it is unrecognised and therefore undiagnosed. Consequentially many people with an intellectual disability lead unnecessarily difficult and unhappy lives. Given this background and history it wasn’t difficult developing a NP role within this area. The following outline is intended to provide an overview of how the role works clinically on a day-to-day basis.

Overview of Nurse Practitioner role

In the Otago District Health Board’s Mental Health Service I have primary/clinical responsibility for people who meet the adult mental health services criteria, i.e. major mental illness and an intellectual disability.

1. Following referral, I would conduct a comprehensive mental health assessment which includes ordering relevant laboratory tests etc.
2. I would then either:
   
   a) establish the diagnosis or differential diagnoses and then independently case-manage the client. An example, would be a person presenting with classical symptoms of depression without any additional health complications or
   
   b) consider diagnosis and then arrange a joint consultation with the client, the consultant psychiatrist (who I work collaboratively with) and myself. The outcome of this consultation will be a treatment plan which often includes Pharamcotherapy.
   
   
3. In my NP role I then case-manage the client autonomously consulting with the psychiatrist (and other disciplines) as necessary. I run an out-patient clinic as well as offering a domiciliary service to people unable to attend the clinic. I also offer a consult-liaison service to the Primary Health Care teams (GPs, and Practice Nurses) and other health professionals.
4. Mental health education, including drug education, also falls within my NP role, as does education for community support staff and other health professionals involved in the client’s care, for example the Primary Health Care Team.

Collaborative working and breadth of skills

Clinicians who work in the area of mental health understand that there is often substitution between professional groups allowing for efficiency and flexibility in the use of valuable resources to gain the complement of necessary skills needed within the team, e.g. nurses, social workers or psychiatrists with additional skills work as therapists and psychologists at times case-manage clients. The NP role requires the clinician to have a breadth of advanced skills. This includes some that for many years have been considered exclusive to medicine. Whilst in some ways it is a shame that the focus in NP roles is often on the incorporation of skills considered exclusive to the medical domain, the reality is that in terms of meeting the needs of a specified population these are the skills that today are often scarce. This is the case in the area I am working. In my NP role I work collaboratively with a psychiatrist, who I triage cases to – usually for confirmation of diagnosis or due to complexity of the case – therefore the psychiatrist’s role becomes one of “consultation”. My broad and advanced NP skills mean that the time I require of the psychiatrist is significantly less than that required in other teams (the time required/allocated with my medical colleague is approximately 1-2 hours per week).

Exciting and rewarding

Whilst gaining the necessary knowledge and skills to become an NP takes a significant amount of time, working in an NP role has been exciting and rewarding. This advanced clinical role offers an exciting clinical pathway for many nurses in New Zealand who are passionate about clinical work that brings with it a high degree of autonomy. I would encourage nurses working in advanced roles to think about the NP role as a very real possibility.

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