Primary Health Care Nursing Leadership

On June 8th 2018 a group of nurses from across the primary health care sector met to discuss a range of issues and concerns in relation to primary health care nursing in New Zealand. The intended purpose of the day was to identify a set of key messages to support a series of conversations with funders, planners and sector leaders about the value and contribution of primary health care nursing to improving health outcomes.

The following outlines a set of principles, core questions that nurse leaders should be asking themselves, and the key messages arising from the day.

Further activity is underway to identify a set of action points arising from the key messages. We encourage you to use this document to guide your discussions and statements in relation to primary health care nursing in the various forums you attend.

Principles underpinning the key messages

  • Nurses should create opportunities for listening to consumers and consumer groups formally as well as informally
  • The basis for any service design or redesign should be to ask how closely will it align with patient needs as understood
  • Nursing services should be led by nurses working within a professional practice model of leadership (i.e. line accountability for nursing)
  • Nursing services should at all times closely integrate the fullest aspects of primary health care delivery working towards a continuum with the patient or person at the center.

Core questions that nursing should be asking

  • What is it patients want/need from nursing/nurses (can we align better)?
  • How can the most vulnerable people start to better understand what nursing/a nurse can offer to support their health and wellbeing and/improve their patient experience?
  • How can the services we provide better meet the needs of people, family/whānau (context/environment/funding/upskilling).

Key messages from the PHC Nurse Leaders Workshop June 8th 2018

Health of Maori

  • Nurses have identified that all heath care organisations need to actively monitor and proactively attend to the health needs of Maori, utilising the nursing workforce to optimal effect
  • The health needs of Māori are a priority across every level of the integrated framework for change. The nursing sector actively works to increase access to health services and positively contributes to improving health outcomes for Māori
  • The nursing workforce provides culturally relevant, quality care through therapeutic and engaging relationships with Māori. Cultural safety/kawa whakaruruhau training should be more readily accessible to all nurses working in primary and community care.

Full utilisation of nursing workforce

  • The nursing workforce is agile, flexible and responsive. Nursing has the capacity, with nurses working to the full extent of their scope, to move practice further into the community, to work across teams and the health system, to lead the provision of care where appropriate, and meet many of the health programme requirements previously allocated to other health professionals
  • It is expected that working to the full extent of scope becomes the norm across the profession
  • Opportunities for better use of delegation to others in the workforce should be more fully explored.

Collaboration across the community and across professions

  • Healthcare should be delivered using an integrated, whole-of-team approach. Nurses work collaboratively across the health system, proactively with communities, across professions and with a range of cross-sector agencies. As such, nurses are ideally placed to contribute to service design to achieve optimal patient care and population health
  • Nurses are professionally connected, involved in their communities and actively advocate for change.

Changing models of care

  • Nursing has a responsibility to re-invent and develop integrated care models to align with the shift to patient focused health care. Changing models of care, service design and new roles will enable innovative care delivery through optimal use of the nursing workforce. System infrastructure needs to shift to support this innovation
  • Nurses can practice in a range of settings and this flexibility should see nurses identified as designated providers and funded directly
  • Nursing embodies the focus on patient/consumer self-management in their own care and disease prevention. Nursing influence on these behaviours is greater than many other health professionals.

Funding models

  • Nursing is a fundamental investment for health care organisations, as well as a fundamental driver of outcomes.These outcomes must shape the funding decisions that are made to benefit the patient. As such, funding models need to shift to match much needed change to models of care or service provision to build on the value nurses bring to improving health outcomes, including examples such as linking the funding to the patient, not the practice, or pooling funding out of DHBs to provide care to communities based on need. Direct funding models need exploring and testing
  • Nurses often cannot afford to or do not necessarily want to become a business/practice owner (although this should be enabled where it is desired). This should not preclude them from access to more flexible funding models to enable them to meet individual and population health need.

Nurse leadership and engagement in policy and education

  • Legislation, regulation and policy drive health care provision and nursing practice. Nurses have already completed significant work to ensure the fit for purpose flexible workforce that nursing when fully utilised has become
  • Policy has lagged behind and nurses need to be more actively engaged in this process taking a central role in policy development, identifying barriers, lobbying for change, advocating for equity and providing feedback
  • The outcomes of legislative, regulatory and policy change need to be clearly communicated across the health sector to ensure change is embedded in a timely way. Nurses can take a lead role in proactive communication but so must the Ministry of Health, DHBs, PHOs and other health and disability providers and organisations. Ignorance of change continues to cause considerable waste of time and effort
  • Mentorship for leadership roles, including for nurses new to business structures, will add value if appropriately resourced
  • Nurses often cite their lack of knowledge around contractual arrangements and how the health dollar is allocated across the highly complex hospital and primary and community care system. To have optimal input into service design and delivery, nurses need to have a sophisticated understanding of funding allocations and contracts. Nurses should control their own budgets through clear nursing leadership structures (see next section). Nurse leaders are indicating the need for preparatory, practical education in this area. This should become a priority focus.

MoH role

  • The Ministry of Health should actively and visibly increase its support for nurses and implement change in a way that enables optimal use of all health workforces.The Ministry must in all correspondence and public pronouncements socialise understanding of the workforce by referring to Nurse Practitioners (NPs) and General Practitioners (who provide similar services).

Workforce

  • A comprehensive database on nurses who work in primary and community settings is required to enable a workforce strategy to be developed
  • A workforce strategy which encompasses the breadth of the Registered Nurse (RN) scope and integrates innovative models of care is needed. There is low confidence in Health Workforce New Zealand’s current ability to achieve this
  • Roles across primary and community care are fragmented and there are inconsistencies between RN and NP roles in some settings. HWNZ workforce funding contracts lack transparency, are cumbersome and slow to change. A review focusing on supply and demand to meet community need is required.

Value of nurses

  • The value and contribution of nurses is not consistently or accurately understood by the public, the professions, employers or funders. As a result, system barriers remain in place and services are established without exploring whether a different workforce model may be a more appropriate option. Nurses recognise that to change perceptions and social constructs, nurses must change the narrative. Nursing needs a value proposition and a profile which changes the public, employer and funder perception of nurses and what services nurses can now provide
  • There is poor pay parity between DHB employed RNs and those employed outside of DHBs.

Clinical placements/learning

  • To maximise nursing in primary and community care, we must continue to work on opening up learning opportunities for new graduate nurses and student nurses. Work is still to be done with education providers to support a curriculum focus on primary health care
  • There should be a clear integrated leadership structure within nursing that can ensure that NETP placements are linked to strategic workforce planning across the sector rather than ad hoc primary health care and aged care placements that frequently occur now.

Data on primary health care nursing

  • Evidence-based change needs good data. Data on nursing activity in primary and community care is currently lacking and significant change and improvement is required. Activity to support data collection needs to occur at all levels (from Ministry to practice).
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