Public Hospitals had matrons, but publicly funded, privately owned general practices have no such nurse leadership tradition. In 2014, more than a decade on from the Primary Health Care (PHC) Strategy launch, nursing leadership in the sector remains ad hoc. FIONA CASSIE finds out more and why there are calls for PHC nursing to have a consistent leadership structure across the country – and soon.
There are a lot of leading nurses in primary health care, but not so many leaders with a capital ‘L’ … or the word ‘nurse’ in their job title.
Instead, there are clinical directors, quality managers, programme facilitators, practice liaison leaders, clinical service managers, integration facilitators, and a host of other combinations and permutations of health monikers. Some of these titles have professional responsibility for nursing in their job descriptions, others do not.
The PHC philosophy is to provide collaborative and interdisciplinary care that puts the patient at the centre. But many in nursing argue that this doesn’t mean that nurses – typically the under-represented half of the health professional workforce in general practice – shouldn’t have a professional and clinical leader with a capital ‘L’ batting on behalf of them and their patients.
For this reason, earlier this year, the College of Primary Health Care Nurses went to the National Health Board and requested the board work with nursing bodies to speed up the development of a nursing leadership structure for primary health care.
Rosemary Minto, former president of the College of Primary Health Care Nurses and a primary health nurse practitioner, says the college has been arguing for a long time that there is no consistent leadership structure for nursing in the primary health care sector.
She says district health board DoNs (directors of nursing) already have very wide briefs and can only do so much.
“A lot of the primary health organisations (PHOs) don’t have the capacity or capability to maintain a formalised PHC leadership structure.
Minto thinks the time is not only ripe but also overdue to have a nurse leadership structure with expectations for alliancing between DHBs and PHOs and integrated health services.
“If you don’t have strong (nurse) leaders leading that change nationally, regionally, and at a local level, then the change isn’t going to happen as fast as it needs to,” believes Minto.
She says despite all the best efforts of nurses on the ground, they can only get so far in building a leadership structure without help from the key organisations involved.
Pioneering leadership role
Back in 1997, when Shelley Frost took up her role as nursing facilitator for Canterbury’s Pegasus Health, she had few role models to turn to.
“When I began, I can’t remember any equivalent roles nationally. It was a blank sheet of paper, really,” says Frost of her pioneering role at Pegasus (which was initially an independent practitioner association but is now also Canterbury’s largest PHO).
Her role kept stepping up the ranks until in 2002 she became director of nursing – a role she only recently resigned from.
Frost continued to be a ‘poster girl’ for practice nurses, rising through the ranks by becoming first the deputy chair of General Practice New Zealand, which represents 14 general practice networks across the country, with about 2,000 GPs and 2,000 nurses – then its first executive director of nursing, and finally, she added the role of chair in 2012.
“There’s always been (PHC) nurses who have assumed leadership roles,” says Frost. “Though perhaps [leadership] with a small ‘l’.”
“It took some time for the IPAs (former independent practitioner associations) to move from being quite medically dominated organisations to taking that team approach,” she adds, along with her thanks to former Pegasus leader and GP Paul McCormack, whom she says “very much modelled” the doctor/nurse team approach in Pegasus.
Frost acknowledges that not all IPAs-turned-PHOs have followed.
“We still have a significant amount of variation in the PHOs in terms of how nursing is acknowledged and developed … not necessarily all have nurses at governance level or at the executive management team level.
“But those nurse (leaders) that are there in primary care are quite visible, they are strong leaders, they are bringing about significant change, and they are well thought of in the primary care world.”
Frustration surfaced last year, which led to a letter to the Ministry of Health from the College of PHC Nurses NZNO and the College of Nurses Aotearoa about the lack of nurses around the table during the negotiations of the new PHO agreement. Some nurse leaders have argued that one barrier to more nurses on executive teams and governance boards in the primary health care sector is the funding model and the predominantly GP or private ownership of general practices.
Frost says it probably comes as no surprise that she has never subscribed to the view that the ownership model is holding back nurse leadership development or nursing innovation.
She also refutes that nurses weren’t involved in last year’s negotiations, pointing out that there were nurses involved in supporting and advising the provider representatives put forward by the General Practice Leaders Forum, which includes the PHC nurses college, GPNZ and the rural nurse and GP organisation Rural General Practice Network.
“GPNZ is one of the negotiating bodies of the contract, and as you know, their chair is a nurse.
“I absolutely believe there should be dedicated nursing leadership positions and an infrastructure that sits beneath that role,” says Frost.
She believes nurses need to be proactive to achieve this.
“Nurses need to not sit back and (wait to) be invited to the table,” says Frost. “They need to be articulating what contribution they can bring and not be afraid to do that.
“Where there are nurses able and willing to step up and make a meaningful contribution, I think by and large they are welcomed into the fold.”
Frost says that each of the 14 PHO or network members of GPNZ is encouraged to bring their nursing leaders to the GPNZ Council meeting. Currently, up to half-a-dozen nursing leaders attend.
Where are the missing leaders?
When Rachael Calverley in 2011 went in search of the nurse leaders of nine primary health collectives for her Master’s research, she found it no easy task.
The Waitemata director of nursing wanted to see what influence nursing leadership had on primary health innovations underway under the nine Better, Sooner, More Convenient (BSMC) business cases.
In some cases, it was simple – there were known and titled nurse leaders. But other leading nurses in BSMC were nurse leaders only of the inverted commas variety and not by job title or description; these she had to track down through the PHO CEO and other mechanisms.
“One of them couldn’t do the interview because her position was subsequently disestablished, which I felt was quite telling in itself,” says Calverley.
The ad hoc nature of the nurse leadership roles left her convinced that work needs to be done on developing PHC nursing leadership, particularly in the current alliancing climate.
“If we are going to have a number of services devolved or integrated into primary healthcare or the community, we need to have nurse leaders helping to steer that direction.”
Her research showed that nursing leaders needed to be resilient and ready to fight to be visible, and unfortunately, they still faced “tall poppy syndrome” from some nursing colleagues. She identified that challenges and issues facing the leaders included variable investment in nursing leadership infrastructure, interdisciplinary relationship issues, limited training for nurse leaders, and that most were working in a generic management model rather than a professional practice model.
“There’s no point in having a director of nursing if it’s a tokenistic DoN and they aren’t able to influence funding and planning.
“Having nurses sitting at the strategic table being able to influence service planning is really critical if we are going to get it right for our patients over the next five to ten years,” she says.
Filling the leadership gaps in some big PHOs
Nursing leadership models in primary health care have progressed and improved in recent years but continue to be fluid.
An example of this is trying to find a nurse spokesperson for two of the country’s largest PHOs – Waikato-based Midlands Health Network (Pinnacle) and Auckland’s ProCare.
Midlands’ former director of nursing Lindsey Webber has moved on and Midlands CEO John Macaskill-Smith responded to Nursing Review queries, saying the PHO had taken the opportunity to review how best to support nursing development across the network’s 400 nurses.
He said the ongoing review had highlighted a “range of key areas” requiring different approaches – including professional development, clinical management, and development of new models of care – and it was unlikely it would follow the “more traditional route of appointing a DoN” and instead appoint a number of nurse leaders to lead the key areas. In the meantime, he said the PHO had three experienced nurses step up to form a nursing leadership team.
Seeking out a nurse spokesperson for ProCare, with its 500 GPs and 600 nurses, was also not easy, with its website listings for executive and senior management team members not including a named nurse leader. A spokesperson said that ProCare’s COO Denis Baty and newly appointed medical director Allan Moffitt (both away at time of going to press) were – as part of moves to continue strengthening its clinical leadership – to make new nursing appointments; these were to include a new strategic nursing role, which would be a senior management role, on the clinical directorate working alongside Dr Moffitt.
The news of ProCare’s impending new nursing appointments is welcomed as fantastic news by Karyn Sangster, a long-term nurse leader in primary healthcare who was last year appointed to become Counties-Manukau DHB’s first PHC nurse director.
Sangster is not a DoN by title but is in role, as she sits on the DHB’s executive team, which she says is “vitally important” to translate the strategic direction for PHC nursing to and fro between the DHB and community. She has a broad brief including hospice and district nurses, along with the five PHOs – ProCare amongst them –working in the DHB’s region.
“There’s no one (nursing leadership) model across all the PHOs, so it’s about trying to find where you need to go to influence nursing activity and nursing roles.”
Sangster agrees there definitely needs to be nurse leadership in PHOs to not only influence the clinical direction of nursing services but also to take professional responsibility to ensure nurses have the right resources, skills, capacity, and knowledge to deliver those services to patients.
She believes it is also important for PHO nursing leaders to form a broader network with the community nursing (and other health professionals, such as, increasingly pharmacists) that also support patients in their community, so they can provide connected care and not duplicate each other’s work. In Counties-Manukau, PHC nurses across the region, from PHOs to youth health centres, have been meeting for over a decade.
A leading leadership model
Another region with a strong history of promoting nurse networking is MidCentral DHB, where nursing leadership is well embedded into primary healthcare.
So much so that the DHB’s longstanding PHC nursing leader Chiquita Hansen has for just over a year now held the dual roles of PHC DoN and executive director (basically CEO) of the region’s Central PHO.
Hansen says her DoN role was created in 2003, as the region recognised that if nursing wanted to respond to opportunities under the recently released Primary Health Care Strategy then it needed the infrastructure to grow and develop PHC nursing capacity.
She says where MidCentral was fortunate and different from other regions was that it won funding from both the Ministry (see What models are out there, page 7) and the DHB that allowed her to employ a “fantastic team” of nurses to support her in the work.
“We have now morphed into something called Health Care and Development and we have 19 FTE (full-time employees) jointly funded and working across the PHO and DHB in service development-type work (like developing knowledge and skills frameworks) and they happen to all be nurses at the moment … oh no, there is one doctor.”
She also laughs and adds that having trained management well over the past decade, she is also fortunate to work in a “nurse-centric” PHO. It is also a PHO that – with a DHB DoN as its CEO equivalent and many nurses in leading roles – doesn’t feel the need to have its own director of nursing and its senior clinical advisor is a pharmacist.
“I go to many, many meetings now, and I don’t have to utter the word ‘nurse’ as I’ve got GPs saying nursing is the answer, which four or five years ago, we didn’t hear quite so often.”
She also acknowledges that not all PHOs are at the same point, and for PHOs still trying to develop nursing capacity and capability, “good strong nursing leadership is vital”, including nurses at the PHO board table.
Hansen says they have hosted visits over the past half-a-dozen years from many DHBs and PHOs keen to find out more about the model and there’s no lack of willingness to replicate it elsewhere.
“People leave with a lot of passion and commitment to go back to their own places … but they don’t have access to the resources to make it happen.”
How to build leaders?
Some DHBs, such as MidCentral, Counties-Manukau, and Canterbury, have had a decade or more of building a primary healthcare culture where nurse leadership is increasingly the natural and accepted norm – but other regions are further back in the evolutionary chain.
So how do you ensure that a new generation of leaders is ready and able to fill the current gaps in the ad hoc and uneven PHC nursing structure across the country?
“GPNZ can and does play a role in supporting and developing nurses to be able to step up into those more governance and leadership and influencing roles,” says Frost.
The organisation recently had more than 90 current or aspiring nursing leaders attend a leadership development day, and she works with a small executive team of six general practice network nursing leaders – not all directors of nursing but all with influencing roles.
Frost emphasises again her belief that nurses have to be proactive and prepared to advocate what nursing has to offer and not just wait for opportunities to be offered to them.
“Absolutely. I just didn’t sit back and wait to get invited to a number of tables,” she laughs.
Calverley agrees that nurses need to stand up and be accountable and says her research made it clear that nurses needed to be more politicised if they want to leverage a key place for nursing at the leadership table.
“It would be great to see more education and training into strategising, how to negotiate, and how to be confident in strategic forums and the political arena.”
Having stepped into a CEO role, Hansen believes it is vital for nurse leaders to understand how the health system works, including how capitation and health target funding flow.
“If you’ve got your eye on the ball (on how the system works), there is nothing to stop you maximising what a nurse can do in a general practice environment.”
Sangster believes a weakness in nursing education both before and after graduation is a lack of knowledge about the business side of health – particularly for PHC nurse leaders.
“As nurses doing training, the cost of the care we deliver isn’t often discussed.”
She believes being able to draw up the business case for a new service or find a revenue stream to meet an untapped clinical need are all very useful skills for PHC leaders in the making.
From ad hoc to accepted
Firstly, however, nurse leadership roles to need to be filled. A decade on from the roll-out of the PHC strategy, dedicated PHO and DHB PHC nurse leadership roles on the executive team or around the board table is in some cases still the exception rather than the norm.
With 20 DHBs and 32 PHOs of varying sizes, structures, and geographical structures, it is admittedly not easy to have a one-size-fits-all approach to PHC nursing leadership (let alone adding in all the other community nursing services, from Plunket to prison nurses).
But most agree that the PHC sector could do a lot better for half of its workforce, and Minto and Calverley argue that they also need to do it much quicker – particularly if the country is to maximise the benefit from the push for alliancing and integrated health care.
Hansen believes the answer lies in being smart as a small country and, where possible, investing resources in PHC nurse leadership role that can work across the DHB and PHO.
“Absolutely ideally, it would make very good sense to have a nurse leader within each PHO who works in collaboration with their nurse leaders within the district health board.”
Calverley believes that having some level of PHC nursing leadership role in both PHOs and DHBs is important. “The remit of the DHB director of nursing is huge, so having somebody who can also liaise as PHC director with PHO nurse leaders is critical.”
Minto believes the best approach is to start with the DHBs.“A commonsense approach would be to have a PHC DoN or associate DoN in each DHB and build it from the ground upwards,” says Minto.
The college is still waiting for a response from the National Health Board to its call, but in the meantime, nurses will continue advocating for more nurse leaders with a capital ‘L’.
What models are out there?
DHB and PHO PHC DIRECTORS OF NURSING (DoNs)
Three district health boards have PHC nursing leaders on the DHB’s executive team.
Capital and Coast DHB has Vicky Noble (director of nursing, PHC & integrated care), MidCentral DHB has Chiquita Hansen (director of nursing PHC and executive director of the region’s Central PHO – see more below), and more recently Counties Manukau DHB has appointed Karyn Sangster (nurse leader PHC).
Waitemata and Auckland DHBs have a shared primary healthcare nursing director, Jean McQueen, who isn’t on the DHBs’ executive teams.
Some DHBs such as Waitemata and Southern, have one main PHO each with a PHO nurse leader reporting directly to the PHO chief executive. Waitemata has Rachael Calverley (director of nursing) and Southern has Wendy Findlay (nursing director).
Other partnership models
MidCentral Chiquita Hansen has the novel dual role of being the DHB’s director of nursing PHC and the Central PHO’s executive director. The DHB won Ministry of Health PHC nursing innovation funding in 2003 to build primary healthcare nursing capacity and leadership, and Hansen was appointed PHC DoN in September 2003. A PHO and DHB proposal also was selected in 2008 as one of the nine Better, Sooner, More Convenient business cases, and the board and PHO are now closely intermeshed.
Northland has a partnership model between Northland DHB and the region’s main PHOs. It has two associate directors of nursing, primary healthcare – Mary Carthew at Manaia Health PHO and Hemaima Reihana-Tait at Te Tai Tokerau PHO.
Canterbury was an earlier adopter of the whole-of-system approach to health, so the DHB’s executive director of nursing Mary Gordon heads the region’s nursing structure, underneath which are hospital directors of nursing and longstanding primary care directors of nursing out in the community, such as like Shelley Frost (and her successor) at Pegasus Health PHO and Sheree East at Nurse Maude. All the nursing directors meet once a month.
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