Te Puawai December 2013

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

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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–

[email protected]

http://www.ncbi.nlm.nih.gov/pubmed/21249663

http://www.ncbi.nlm.nih.gov/pubmed/21249663

mailto:[email protected]


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http://ow.ly/rN1ML


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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

http://smokefree.org.nz/tobacco-control-seminar-series-2014

mailto:[email protected]


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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

http://www.nurse.org.nz/


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

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

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


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.


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.


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.

http://www.hiirc.org.nz/section/15221/national-nursing-standards/?tab=6850


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

http://www.smokefreenurses.org.nz/

http://www.nzcmhn.org.nz/

http://www.ruralwomen.org.nz/


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


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.


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.

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