Nursing in New Zealand

Nursing Research Day, 28 April 2008

The theme of this day was 'Embedding the Ideas' - taking nursing research and putting it into policy and practice.

It provided a forum in which nursing researchers could present their work to leaders and decision makers.

The audience included representatives of the Ministry's senior management, directors of nursing, nursing organisations, ACC and GP representatives.

The presentations (where available), summaries, comments and questions and answers on the topics covered are provided below:

Speaker	Title of presentation
Mark Jones	Introduction
Mary Finlayson	Nursing Developments in the PHO Environment
Kathy Nelson	Findings from the Evaluation of Eleven Primary Health Care Nursing Innovations
Merian Litchfield	The Innovation Effort: The Turangi Integrative Nursing Service Scheme 2003 – 2006
Jeremy Mihaka-Dyer	Feeling the Nursing PHOrce at Lake Taupo PHO: Taking nursing research and putting it into practice
Michelle Day and Chris Masters	Comments and questions and answers
Eileen McKinlay	Primary Mental Health Initiatives: Nurses new roles in interdisciplinary health service delivery
Mary Finlayson	Teamwork in Practice
Jeremy Mihaka-Dyer and Helen Pocknall	Comments
Sue Buckley	Nursing Services in Schools: A Preliminary Analysis of Interviews with Nurses in Schools
Jean Ross	Awakenings for Rural Nurses
Jim Primrose and Jenny Carryer	Comments and questions and answers
Carol Boustead	Changing Role for Practice Nurses in Chronic Care Management
Various	Comments on key messages for shifting from research frame to policy and practice
John Marwick	Comments
Mark Jones	Conclusion
Karen Hoare, Margaret Horsburgh and Barbara Docherty	Presentations from speakers who were unable to attend

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Introduction
Mark Jones

Mark Jones, Chief Nurse, gave an introduction to the meeting.

View Mark's presentation - Nursing Research to Policy to Practice (PDF, 799 KB)

Mark explained how the day had evolved from the Ministry of Health’s Senior Research Advisor, Stephen Lungley’s idea about needing to look at how the large amount of research could be turned into policy and practice.

He was keen that we should be able to formulate policy with reference to existing research and that this in turn should be supportive of evolving practice. He indicated the importance of ‘closing the loop’ re research to policy to practice, indicating that all three elements were intrinsically linked.

Mark suggested the possibility of a new work stream, hosted within the Sector Capability and Innovation Directorate, which would concentrate on this theme.

The day was arranged to allow researchers to present their findings, then for identified key respondents to reflect back from their particular perspectives before moving to discussion involving all participants.

Mark explained that that there would be some departures from the programme because fog at Auckland Airport had meant cancelled flights and prevented some presenters from being in Wellington

Nursing Developments in the PHO Environment
Mary Finlayson

Mary spoke about the large amount of research that has taken place but the little amount of evidence that was coming through. This presentation is a small part of a bigger project.

Mary's presentation is not available however a summary is provided below:

Capability

• Māori nurses reported innovative approaches – possibly because of the shortage of GPs.
• Mental health did not come through as often as the researchers would have liked.
• Unable to directly access resources – particularly for further education.
• Where employers embrace the model, then there is significant difference in levels of support. Need some changing of attitudes.
• Need to look at nurses running own clinics.
• Access to education – not easy in remote areas.
• Not interested in up-skilling – needs to be worked on – some are not interested in up-skilling but the researchers challenge this – nurses are there to make a difference to the population.
• Work volume stopped them – nurses take on more and more that they don’t need to do as nurses.
• Lack of employment opportunities for NPs – funding – researchers intend to do more work on this.
• Business incentives – general practitioners ask why would we have NPs for work that practices can already do themselves.
• Post-graduate qualifications are needed for all Primary Health Care nurses.

Capacity

• Got to get smarter about how we use NPs. Some practices have no problem, others quite the opposite.
• Hard to get nurses who can speak Pacific languages

Recruitment and Retention

• Salary difference between 1 and 2 sectors.
• High stress, excessive workloads and lack of control over work environment. There’s more administration and more expectation but it is not doing much for the population of NZ.
• Infrastructure – especially space – are issues.
• Lack of work-life balance – 40% of nurses satisfied with work-life balance.
• Low number of Māori and Pacific Nurses. Lot of nurses wanting to come from Pacific but don’t have the language – surely this could be addressed.

Strategies

• Some practices actively encourage recruitment and retention.
• Some large PHOs and some DHBs promote PHC nursing as an exciting career

Overall Finding

Where practices and PHOs embrace the intentions of the strategy to improve the health of the population, nurses’ role have expanded.

Policy Implications

• Funding
  • Single baseline funding stream with incentives
  • Avoid ad hoc short-term funding streams
  • Offer incentives of PHOs to establish NP positions
  • Enable NPs to access Vote Health funding
    
    
• Education
  • Advocate for all PHC nurses to have a postgraduate qualification to develop necessary knowledge and skills – it is a specialty area and need to come through with some sound core knowledge and ensure skills that are needed are there.
  • Continuing scholarships and funding for postgraduate education.
  • Promote quality of clinical placements for undergraduates.
    
    
• Leadership
  • Appoint directors of PHC Nursing in DHBs to provide leadership
  • Appoint nurse leaders in PHOs
  • Mentoring programmes
  • Include and mentor PHC nurses in governance roles
  • PDRPs for all PHC nurses
  • Develop and implement nurse sensitive patient outcome indicators – need to prove how nurses make a difference. (Audience - As teamwork increases, it is difficult to identify the outcomes by the individual nurse.)
    
    
• Recruitment and retention
  • Instigate a national advertising campaign to increase awareness of PHC nursing as a career choice and PHC nurses as providers of health care.
  • Target Māori students through schools, workplaces and hui/marae
  • Target Pacific students through schools, workplaces, churches and fono.
  • Provide incentives to establish NP positions
  • Develop nursing-sensitive patient outcomes

Questions and answers

Q: I am reminded of what was written in “Investing in Health” in 2003 and updated in 2007 – how much more do we have to find out before we make some responses?
A: It was not long ago that we were talking about getting funding for nursing research and now have to get nursing in policy and practice.

Q: Did study look at level of understanding of practices around role of Nurse Practitioners.
A: No, not specific questions but it looked at ways of increasing access and found that NPs are really important people to come into all levels – PHO, GP. We need them, but haven’t got enough although 82% of nurses say that they want to be Nurse Practitioners.

Q: Smear-taking funding will stop in June – what’s going on? (No answer)

Findings from the Evaluation of Eleven Primary Health Care Nursing Innovations
Kathy Nelson (presenting on behalf of Trish Wright whose flight was cancelled)

View Kathy's presentation - Findings from the Evaluation of Eleven Primary Health Care Nursing Innovations (PDF, 40 KB)

The Innovation Effort: The Turangi Integrative Nursing Service Scheme 2003 – 2006
Merian Litchfield

View Merian's presentation - The Turangi Innovation Effort: The Integrative Nursing Service Scheme 2003 – 2006 (PDF, 207 KB)

Feeling the Nursing PHOrce at Lake Taupo PHO: Taking nursing research and putting it into practice
Jeremy Mihaka-Dyer

Jeremy discussed the interdisciplinary team and case review, using the Healthright model, quality plan and performance management programme.

View Jeremy's presentation - Feeling the Nursing PHOrce at Lake Taupo PHO: Taking nursing research and putting it into practice (PDF, 860 KB)

Comments and questions and answers
Michelle Day (Practice Nurse) and Chris Masters (GP)

Michelle and Chris were invited to reflect and comment on the above presentations from the perspective of a Nurse-GP team.

Chris' comments

The research Mary presented is reflected in our general practice – we have a large group practice with 19,000 patients and have moved to encourage nurses to have some specialty roles. There are obviously variable opinions from doctors in practices to having nurses working independently including the training issues.

Michelle's comments

We work on the basis that all nurses are offered the opportunity to start post grad papers – chronic disease first and then look at funding further education. We believe we have two groups – specialty Practice Nurses and Wellness Team. Wellness team nurses work part time in that and part time as Practice Nurses.

It has been difficult in that our practice is a PHO in its own right – developing this has been time consuming and we don’t have large resources. We have tried to get the mix right in various programmes to give what patients need and nurses can deliver. We are responsive but don’t feel we’ve got it quite right yet.

Nurse led with GP supported – our nurses deliver across all funding silos. We have a flat management structure; we have 13 nurses and operate the team across that management structure on which there are 2 nurses of which Michelle is one.

Questions and answers

Q: Is funding apportioned equitable?
A: There is some merit in us looking at a single funding mechanism – from a business point of view, you’re employing a Care Plus nurse but funding is risky and therefore a business risk – would be good to combine in a single funding model. All our nurses are smear-takers – it is the patient’s choice. With the limited GP workforce we must have nurses taking on those roles.

It has been useful to have nursing leadership within the PHO – we can guarantee there is support for our Practices Nurses.

Q: Leadership; - we only have one PHO and 16,000 are enrolled. We have just scoped the job of lead Practice Nurse and adopted Core Clinical Nurse Manager – this has met with resistance by some people because of the title – the bestowing of authority – and the challenge has come from the Clinical Director but more so from the Practice Manager. How have you coped?
A: From a doctor’s point of view, it has enabled us to continue us to see patients that we need to. It has also allowed insights into some patients that I wasn’t aware of. We have one-on-one meetings to discuss patients and this has improved communication.

Q: How do you see you will target special population groups in the current boundary type environment?
A: Working on set project across PHOs. We are starting to develop inter-PHO services.

Q: The level of unmet need is a concern is paramount to the provision of relevant services.
A: Finding out what patients want is a huge challenge for us. We are looking at ways such as IT-use to increase access.

Q: How do you change the attitudes of people who are entrenched and focused on the pocket.
A: It is difficult but having a champion keen to work with the nursing team is great. And providing plenty of opportunity for discussion is important. We are happy to share with anyone how we work.

Comment: Being capitated means you already have a team philosophy.
Comment: Start the conversations and important to follow them up as I have found there is huge willingness for dialogue to follow.

Q: I am interested that you have been in the role for 5 years – what’s different for the people?
A: We’ve had a lot of development and build up – we’ve built our team from 7 to 13. The model is starting to work and patients are getting benefit. Our patients with chronic disease are showing benefit but we are not at the point where we can adequately survey our patients.

Q: I am in a Youth Health Practice – when we added a new contract concentrating on employment and career, we found a lot of people with unmet need who needed to be referred into the Health Service.
A: We are working with our DHB to see how we can access their results/letters etc and looking at the reverse also to ensure everyone is working for the patient.

Primary Mental Health Initiatives: Nurses new roles in interdisciplinary health service delivery
Eileen McKinlay

View Eileen's presentation - Primary Mental Health Initiatives: Nurses new roles in interdisciplinary health service delivery (PDF, 358 KB)

Comment

One way of increasing expertise available in community is to upskill people in a structured way as many such as RGONs are getting involved in mental health area.

Questions and answers

Q: Do you see any scope for entrepreneurial health nurses beyond the GP setting? Could they set up as individual practitioners and tender for services?
A: Nurses working in the community health area are entrepreneurial – they created a role and definitely there is an opportunity to work in that way.

Q: It appears there is a movement to pull mental health out from the general health silo. But the mental health scene is so tied up with every aspect of health, are we re-embedding something we have tried to break out from?
A: There has been a gap in services – Primary Mental Health Care within general practice settings - so care has been limited to prescribing medications and not around other therapies or a coordinated approach.

Teamwork in Practice
Mary Finlayson

Mary's presentation is not available however questions and answers and comments following her presentation are provided below:

Questions and answers

Q: There seems to be a lack of clarity around what teamwork is – need to put more emphasis on this and work towards this.
A: You are right – total variability in terms of definition.

Comments

Comment: We have the idea there is a shared vision but need team work to get the shared vision – there is an assumption around what we’re there for.

Comment: Something missing from team practice is Practice Manager – they are the conduit through which the two teams can get together and work – education and taking out the patch protection.

Comment: Teams last only for the time it takes for them to achieve what they want to achieve. You build a team for what you want to achieve. The idea of Primary Health Care teams means designing what we want and the right recipe for the product at the end and then the team dissolves. Maybe if we want to talk about ongoing teamwork, what we mean is team spirit.

Comment: Teamwork delivered in Primary Health Care would take on more significance if driven by what community says it needs. However about Practice Nurse confidence, you can see in the courses delivered the nurses who have the opportunity to come away from the practice environment – they are confident as potential team members. Without that sense of self and confidence there will not be a team.

Comment: We asked Practice Nurses what it would take to get them into postgraduate study – they did not want to leave Westport, they wanted time off for study and they wanted help with their study. We delivered this but it required a funding shift and a whole lot of change to long standing structure.

Comments
Jeremy Mihaka-Dyer (CEO Lake Taupo PHO) and Helen Pocknall (Director of Nursing Wairarapa DHB)

Jeremy and Helen were invited to reflect and comment on the above presentations from the perspective of a PHO and DHB respectively.

Helen's comments

While DHB-land may not use research well overall, DHBs may not be made aware of all the research that is done. Working together as a team is crucial but so is strengthening nursing practice in that context. We develop skills to meet our populations’ needs but do we ask the community? We would like a group of researchers to show us what communities need.

How do we find out what research is available – is it being shared as widely as it could and should be. DHBs are not good at supporting nurses into research – the funding, the time to get involved in group research.

Jeremy's comments

Themes from this morning – from a PHO perspective.

• Teamwork – what is the purpose of the team – the GP doesn’t have to be the leader - is the whole team involved, is the practice manager involved. Just because it has been done for a long time doesn’t mean that it is right. It’s important to get the team to voice what the community needs.
• Need to have research and evaluation built into projects at PHO level. Sharing research and practice.
• Lake Taupo is looking at leadership, wider than the Practice Nurse role. Workforce is a major problem – look at Pinnacle paper – and we are trying to address that e.g. mentor roles. Have awarded 9 PHC scholarships – some of which have been picked up by nurses.
• Looking at infrastructure investment – we have loaned money to advance new nursing practice, or have provided seed funding to get new initiatives off the ground.
• Good change management takes a lot of time – 2 years to come up with model and 2 years to roll out – and that’s just phase 1. Have to get people along on the journey and general practice to work out how they use their nurses differently. Then getting other general practices to look at the models and see they are working and go down this track too.

Comment: Concur with community engagement – let us not underestimate our populations and let them develop their own relevant models, and this includes Maori. There is room for borrowing but room for creativity and innovative models of care too. Let us not ignore our own contextual arena and not underestimate the nursing capacity within that arena to deliver our capacity. ‘Everyone else’s stuff is better’ appears to be the norm - let us not forget our own.

The ability to profile a population and identify its needs is a wide bit of research – you can contract such services and this is something that needs to be done by both DHBs and PHOs. Local management groups feed through information from grass roots which gets turned into projects, researched and rolled out.

A critique of needs analysis could be done by the DHBs to ensure they work better at the local end of the DHB level.

Nursing Services in Schools: A Preliminary Analysis of Interviews with Nurses in Schools
Sue Buckley

View Sue's presentation - Nursing Services in Schools: A Preliminary Analysis of Interviews with Nurses in Schools (PDF, 231 KB)

Comments

Comment: A number of people who are not nurses are employed as School Nurses. Schools are only obliged to provide someone with First Aid qualifications but they are often working with issues such as mental health and sexual health.

Comment: Isolation – nurses are working in different places – nurses were concerned they had no clinical oversight.

Comment: First AGM for national network of doctors and nurses working in this area will be held in July. There is quite a lot of work going on around competencies for school based health professionals.

Awakenings for Rural Nurses
Jean Ross

View Jean's presentation - Awakenings for Rural Nurses (PDF, 734 KB)

Comments and questions and answers
Jim Primrose and Jenny Carryer

Reflections on the day.

Jenny's comments

• How often we limit discussions on health care to general practice environment and how much bigger it is than this. The notion of continuum of care is needed. People are the same regardless of who is seeing them.
• Capitation has been the trigger to allow people to do things differently. However, capitation also means that people who would most benefit from using funding differently have the least power to decide how this is used – patients and nurses.
• There are a number of key recurring themes: identified in 2003 and re-identified – leadership, education, infrastructure. Can’t leave education.
• Language: we talk about “Primary Care” when we mean “Primary Health Care”. We have to consistently mirror the changes by speaking about them and educating the public.

Jim's comments

• Thanks to the organizers and presenters. Things are changing but not fast enough and it is variable across the country. Attitudes, team spirit, and we spend too much time on structural things and contracts and not on human values and what is required for successful change management. What is required for a better spread of innovative ideas? What could the Ministry do differently that would create the sort of environment for ideas to spread more easily. Has a single PHO contract passed its use-by date? To achieve results in a community, is a single contract suitable? Also there was a deliberate decision to not have a thick reference book on what a PHO was but a few minimum requirements. They were great for the establishment but not fit-for- purpose for continued PHO development. Do we now need to revisit those and see the design principles for the continued development of PHOs?

Comment: To say that attitudes and values are the things that create innovation – they are – they are ad hoc because the structure needs to free up a good deal to free up innovation.

Q: The only way we can change is to revisit the PHO contract – have you looked at this to see how PHOs can be incentivised. Is it possible?
A: It’s possible.

Q: How can you stop the vested interests that developed in the last contracts?
A: Environment is different and if you want a contract that everyone will sign up to it’s a different issue to developing a contract that’s acceptable to 60%. Lakes have innovative and different practices from the same contracts – how can we spread this?

Comment: All communities have moved dramatically, there has been a significant shift in thinking and we need to recognize this and help those who have moved faster to influence others who are moving more slowly.

Comment: Change is happening and people are willing to work closer together. DHBNZ is looking at what general practice will look like but this work has not been brought up today.

Comment: the Primary Health Care strategy has been going for three to four years, but GPs tend to be conservative as small business owners. Now that PHO multidisciplinary team working is becoming more visible there will be more engagement of innovative ways of working than there has been over the past five years.

Changing Role for Practice Nurses in Chronic Care Management
Carol Boustead

View Carol's presentation - Changing Role for Practice Nurses in Chronic Care Management (PDF, 442 KB)

Questions and answers

Q: Would it be useful to have ongoing monitoring.
A: We are hoping there will be evaluation of the roll out.

Q: Re collection of data and the variability, what are the recommendations to improve the data?
A: We recommended practice manager training and giving nurses permission to be more involved in Practice Management Systems.

Key messages for shifting from research frame to policy and practice

Comments

• What do we need to do differently or more of – it’s a learning environment that allows knowledge and learning. If you have nurses doing Masters then it allows them to come back and pass on knowledge. If you have the leadership that allows this then you have a network that allows knowledge spread across the PHC. Job descriptions that value these things and allows the release of nurses. Practice influences research, its not just research influencing practice.
  
  
• There needs to be information on the models that are developing and the success stories need to be given to the people employing the people coming through.
  
  
• Endorse the suggestion that it’s time to redraft the contract for PHOs. We know it needs to be different. PHOs are key and let’s have a go at taking them the next step. Look at whether they are willing – a policy phase where we take those PHOs who are willing and able to the next stage.
  
  
• In the restructuring, it would be interesting to see how NGOs can be involved.
  
  
• Some of the tools that we develop around teamwork and team practice might allow us not to all ask the same questions i.e. around housing.
  
  
• Some NGOs have innovations worth noticing too. And we have to look beyond NGOs, because we have an increasingly privatized Primary Health Care workforce….
  
  
• There are a number of DHBNZ project activities that are coming to a fruition which will continue to inform discussions like this. Also, language: re Practice Nurses not wanting to up-skill and liking to pour the coffee – we need to be careful that if we use that language ourselves we will use it elsewhere – need to push that the profession is exciting and fulfilling.
  
  
• Sustainability of Primary Health Care workforce. There are different kinds of nurses and the workforce is aging, so we have to be mindful of bringing the next generation in.

John Marwick

John, Manager (Workforce) Health & Disability Systems Strategy Directorate, Ministry of Health, speaking on behalf of Deborah Roche, Deputy-Director General, said that:

• PHC is still an absolutely crucial central strategy and the emphasis on it is a priority for the Health & Disability Systems Strategy Directorate of the Ministry.
• Future workforce questions apply to the whole of the sector and Minister wants a more strategic approach.
• The Workforce Taskforce is looking at the barriers in Primary Health Care that are standing in the way of delivering the Primary Health Care Strategy. Draft report is due end of this month.
• Research – needs to be supported and then used and disseminated and we need to see it put in place in policy.
• We have Health & Disability Intelligence unit which makes sense of the data gathered about the health sector.
• There is a long term systems framework being developed for the sector – it looks at service delivery and models of service across a national picture and how going forward you can get thinking across 21 DHBs about how service is delivered differently. There is a key role for nurses in leading services and disseminating good ideas.

Conclusion - Mark Jones

In conclusion, Mark said it is essential to ensure that policy is based on evidence. He said that the Ministry would post the notes of the meeting on its website, to inform work going forward. He thanked the people who had put the day together.

Presentations from speakers who were unable to attend

Presentations from presenters who were not able to attend are provided below:

• The use of two evidence-based websites by Practice Nurses - Karen Hoare (PDF, 198 KB)
  
  
• Nursing initiative in Primary Health Care: An approach to risk reduction for CVD and diabetes” - Margaret Horsburgh (PDF, 566 KB)

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