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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

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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


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Editorial 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.

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 © Te Puawai

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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Te Puawai 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 © Te Puawai

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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Te Puawai 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

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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 cofounded 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.

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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. © Te Puawai

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.

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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. 9663

Please remember to update your contact details if you have not done so this year.

Email the College office–

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HWNZ hosts workforce strategy day in partnership with NNO. The recent day (November 29th) hosted by Health Workforce NZ (HWNZ) was a tremendous opportunity to see and understand the breadth of work currently being achieved by the combined efforts of NZ Nurse leaders. The national nurse group (known as NNO) is a forum where leaders of 9 national nursing organisations come together to find convergence of perspectives and to clarify points of divergence so as to work together effectively on agreed key Nursing and health service issues.

The NNO:  

does not constitute another nursing organisation does not speak as a collective voice for nursing and there is no NNO spokesperson – members comment to media in accordance with own organisational policy understanding that where consensus has been reached at NNO on an issue, individual organisational comment will express that consensus. is not a decision making group

It is however excellent evidence of the enormous collegiality, collaboration and commitment to the greater good between all of the major national nursing organisations. Alongside the long overdue expansion in the size and capacity of the nursing team in the Chief Nurse’s office in the Ministry of Health we are seeing a really strong focus and combined expertise being brought to bear on strategic challenges and direction for nursing. A major issue for the health sector at the moment is the ongoing development of a workforce that is flexible, responsive and able to respond to the escalating demand for services. For this reason it is critical that there be a respectful and active partnership between NNO and HWNZ. The health system is facing challenges through a growing gap in demand for services © Te Puawai

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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Te Puawai The changes required to build health workforce confidence in HWNZ and its mandated programme are  

issues of importance for the immediate future include a number of key goals (summarized) , which included.

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

1. The need for a professional practice model of leadership in every setting in every nurse practice setting

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.

5. The importance of a whole of integrated system approach

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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 © Te Puawai

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

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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Te Puawai 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 More information to follow, if you have any questions please email Donna Harding on

Please note the closing dates for applications are:  Auckland, Rotorua seminars - closing date Friday 24th January, 3PM  Wellington, Christchurch seminars - closing date Friday 30th January, 3PM

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Nurse Practitioners – Part of the Solution not the Problem Article by Jeff Symonds, NP, Bay of Plenty DHB Recently the Ministry of Health (MoH) published its future mental health & addictions remit for 2012-2017 called “Rising to the Challenge”. I tried not to think “oh no not another vision and sets of goals to aim for”, at least until the next lot comes along…. Notwithstanding this I actually took the time out to read the document and I was pleased I did. As I was going through the information and gathering in the subliminal messages I couldn’t help but think of Josser Hughes in “Boys from the Black stuff” when he used to say “gizza a job I can do that”. (Google it?).

I was impressed that this above mentioned report, at least from my point of view, appeared to have an immense amount of potential opportunity for advanced practice nurses and in particular Nurse Practitioners who practice in Mental Health & Addictions services. For example


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.

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.

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.

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.

Rising to the Challenge, MoH 2012 p. 3

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The area of main interest for me as a practicing prescribing NP is the secondary/primary interface:

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Te Puawai 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 multidisciplinary 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.

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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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Te Puawai 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.

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.


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



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. 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. 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.

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 © Te Puawai

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Annual Report 2013

College of Nurses Aotearoa (NZ) Inc. Presented at the AGM 23rd October 2013 Massey University, Wellington 06 358 6000

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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

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Contents Foreword




College Executive


Executive Directors Report 2013


Appendix 1. Strategic Plan 2013 - 2016 11 Appendix 2. NPNZ Annual Report 2013 13

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Board Members

Te Puawai Maori Caucus 

Taima Campbell – Co Chairperson Margareth Broodkoorn Ngaira Harker-Wilcox

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Non Maori Caucus 

Judy Yarwood – Co Chairperson

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Angela Bates Nicola Russell

Executive Director 

Professor Jenny Carryer

College Patrons

Prof Marilyn Waring

Putiputi O’Brien QSO

College Censors Prof Nan Kinross

Putiputi O’Brien QSO

Cathy Cooney

Te Miringa Huriwai

College Administration Staff Kelly Rotherham

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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.

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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.

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Activity  Consortiums terms of reference and documents have been reviewed and endorsed. They are accessible along with endorsed standards on the following website  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.

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 

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

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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

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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. © Te Puawai

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Appendix 1.


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.

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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 socioeconomic 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.


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. 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. 2. 3. 4.

Promote excellence in advanced clinical nursing through practice, education and research Enhance capacity of the Nurse Practitioner practice in New Zealand Provide Nurse Practitioner leadership for legislation, regulation and policy development Provide resource and consultation for healthcare practice in New Zealand.


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 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. Auckland.

Last one held April 2013 held in

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.


2013 Activity: 3A. Alison Pirret and Bernadette Paus worked with CNA(NZ) re-develop NPNZ Website to be more userfriendly 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.


Te Puawai December 2013  

College of Nurses Aotearoa (NZ) Inc Journal for Registered Nurses in NZ

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