Pioneer prescriber looks back

1 April 2013

Paula Renouf became the country’s first nurse prescriber in June 2003. Nursing Review caught up with her on travelling sabbatical in the United States’ Pacific North West and asked her to reflect back on the decade that’s followed.

For the country’s first nurse prescriber being the pioneer was a mix of the good, the bad and the frustrating.

Paula Renouf may have been New Zealand’s first nurse prescriber but on her endorsement in June 2003 she already had ten years prescribing experience under her belt.

The New Zealand-trained nurse gained her masters degree in the United States before working as a certified paediatric nurse practitioner in an inner city community clinic in San Francisco meeting the needs of high need, mostly Latin American, children and youth.

Returning to New Zealand in 2001 she had to prove herself all over again by first successfully applying for nurse practitioner status in New Zealand. Then ¬– after completing a one semester prescribing practicum (under paediatric consultant Teuila Percival at South Auckland’s Ta Pasefika practices and Kidz First emergency department) – she became the first prescriber under the narrow regulations of the time that only allowed for nurse prescribing in either child family health or aged care.

Once finally endorsed she sought clinical work as a prescribing NP. “Two years had lapsed since I left my vibrant practice in San Francisco. Initially this meant returning to the world of the hospital as there was really no mechanism to practice or be accepted in the primary care world at that time... and there was still a great deal of opposition to NP prescribing.”

So her first NP clinical work was at Kidz First emergency department working with the paediatric registrar team.

By 2005 she was ready to launch into the community – a move she says would not have happened without the support of the Ministry of Health and then chief nurse Frances Hughes subsidising her first clinical position, the innovative spirit of the Counties Manukau DHB’s nurse and primary health care leaders, and the willingness of the doctors in Manurewa’s GP Faculty practice to employ the first prescribing nurse practitioner. “Which they did with some excitement.”

She remembers at first the GPs would call her in and quiz her on the spot about her prescribing and diagnosing decisions but within just a few days she felt welcomed as part of the clinician team.

“I felt one hundred percent supported in my prescribing clinical practice and enjoyed a collaborative spirit of bi-directional consulting with the GPs. I zipped around introducing myself to the local pharmacists and found them all to be helpful and very happy to have a professional relationship with a NP prescriber. It took very little time to establish a practice, a clientele who sought me out, and a rhythm of work which I loved, but sadly after a year that practice was dismantled…”

She went on told hold various clinical positions as an NP while working forty per cent of the time as a lecturer at the University of Auckland school of nursing. One of those roles was for an Auckland primary health organisation (PHO) with a ‘brilliant philosophy and funding’ for specialist paediatric care beginning with assisting community-based paediatrician clinics. But with one of the paediatricians “sadly opposed to working collaboratively with an NP”, her chances to practice at an NP level were limited to a few hours a week working in the PHO’s general practices.

“This situation was untenable in the long run because I could barely keep up with diagnosing and prescribing skills and never really felt part of a team. There was enormous potential for the role, especially in linking the PHO practices with NP school-based clinical care but I could see that it would take a few years to evolve.”

Renouf also went on to provide “GP’ care in residential youth justice and providing ‘GP’ clinics in secondary schools for the then HealthWest PHO.

“Both of these roles involved prescribing for common acute and chronic conditions and sexual and reproductive health. The PHO valued and fostered NP development and paid a salary equivalent to the GPs for what I did.”

She says the main difficulty she had prescribing in these roles was not with Pharmac or legal barriers but finding someone to endorse her prescribing practice to meet Nursing Council recertification every year. The difficulty was she was not working side-by-side with other prescribers but doing solo half-day or full day clinics. She not only missed out on the opportunity of gaining professional endorsement from prescribing colleagues she worked with daily but also the ‘buzz’ of professional collaboration and further building her prescribing competence.

“When you work in a collaborative practice, whether in the community or inpatient care settings, there is a wave of energy and knowledge you ride every day with case conferences, practice audits and door-knocking consultations to ask ‘come and see this interesting case…what do you think?’ or ‘I've tried this, what would you do next?’.”

Instead she found herself periodically heading back to San Francisco “just to get a burst of good clinical experience”.

“Also throughout the early years of NP practice in New Zealand, I found great collegiality with pharmacists in the community, and sometimes found myself asking them to help complete my competence assessments.”

Meanwhile Renouf is pleased to hear New Zealand is taking the next step with nurse prescribing as she has always believed NP endorsement was a “barrier for a whole cohort of RNs who should be able to prescribe”.

“The real question is how does attaining NP status which involves demonstrating leadership, teaching, consultancy and national or local policy-making (which may or may not evolve over the natural course of a professional life) make one a more competent prescriber? Is it not adequate and safe to be an expert clinician with a clinical master’s degree (including all diagnosing and prescribing requirements) and endorsement by a preceptor/prescribing colleagues?”

NB Since leaving New Zealand Renouf has recertified with the American Nurses Credentialing Center (ANCC) as a paediatric nurse practitioner and has been keeping up to date clinically during her recent sabbatical including some volunteer NP work. She hopes in the future to return to New Zealand regain her NZ prescribing status and work again as an NP”.