Ten years after introduction, nursing entry to practice (NETP) programmes are now seen as the established norm but demand for places outstrips jobs available. FIONA CASSIE reflects on a decade of NETP and talks to nurses about the very first NETP intakes.
So stated the 1998 Ministerial Taskforce on Nursing. The Taskforce report also noted many acute hospitals expected nursing graduates to “immediately take up a high workload and a high level of responsibility with little structured help or support”.
It’s been 10 years since the government gave the green light to funding new graduate programmes, bringing in the first nationally consistent clinical training support for novice nurses.
At the time, support for new graduates in their first year of practice varied considerably across the country with some fortunate new graduates securing a place in formal new graduate programmes and others, like the less fortunate casual pool nurses, being expected to be work-ready in any setting.
The gold standard then was the already long-established new graduate programme for mental health nurses (now known as the NESP or new entry to specialist practice programme). The Taskforce recommended NESP be the template for a national framework of funded new graduate programmes to support this “vital time in the development of a truly professional and effective nurse”.
After a pilot in 2002 and a positive evaluation report in 2004, the government in July 2005 finally announced funding for a national framework of nursing entry to practice programmes (NETP).
So in mid-2006 the first three district health boards to gain Nursing Council accreditation for their NETP programmes were given a subsidy of $6,000 per graduate to deliver the course – roughly 50 per cent of the estimated cost. The rest of the DHBs came on board in 2007 and in 2009 the first NETP places were offered in primary health and residential aged care.
Fluctuating supply and demand for NETP places
For many of the early years of NETP there were more funded places available than were ever filled, with a number of DHBs struggling to attract new graduates in a buoyant job market.
But this reversed when the global financial crisis saw nursing turnover stagnate and DHB budgets tighten, at the same time as record numbers were graduating from the country’s nursing schools in readiness to replace the country’s ageing nursing workforce.
It was a perfect storm that saw NETP numbers fall and plateau in 2010 and 2011 (see table) and then start to steadily climb, but not fast enough to match the growing graduate cohorts. Faced with keen new graduates struggling to find work – and the added fear they could be lost to the profession, which would ultimately need them to replace retiring baby boomers – the New Zealand Nurses Organisation (NZNO) last year launched a petition calling for the government to fund an NETP place for every graduate.
The petition reached 8,000 signatures and the then health minister, Tony Ryall, responded by announcing 1,300 NETP places would be funded in 2015. Unfortunately, with nearly 1,800 new graduates registered last year, this falls far short of NZNO’s expectations. Also, whether the sector will be able to step up and employ 300 more nurses than last year (see table) to fill those extra NETP places is yet to be seen.
Improved data is now available on graduate trends through the central clearinghouse for NETP and NESP applications known as ACE, which was first used for the February 2013 NETP intake. The February 2015 ACE round saw an increase in new graduates in NETP jobs and also saw places in the mental health NESP programmes swell from 152 last year to 175 this year. And for the first time NETP funding has been allocated to new graduates employed at private surgical hospital provider Southern Cross (see sidebar).
NETP: a year for clinical consolidation and/or postgraduate study?
“I don’t think anybody would argue that the NETP programme has been a tremendous asset to establishing people’s first year of practice in a safer way then we used to do,” says Professor Jenny Carryer, executive director of the College of Nurses.
“But there are still issues around the fact that we are not funded for every single graduate and so a number of graduates miss out on the NETP programme, therefore can fall between the cracks,” says Carryer.
While only a handful of DHBs at the outset included postgraduate papers as part of their NETP programme, this has expanded over the years until only a handful now do not. Some DHBs have taken this a step further and are offering top graduates an honours programme in their second year, with the option of progressing into studying for a health sciences doctorate.
Carryer, for one, sits in the camp that believes NETP should be a year focused on the consolidation of clinical skills. “It is a year they [new graduates] are under enormous pressure to think on their feet, time manage and take responsibility for decision-making – all of those first-year learning challenges. And personally I don’t think we should distract them with a postgraduate paper that year.” Also, graduates in their first year of practice usually haven’t yet decided on their likely career path or specialty.
Sitting in the other camp is associate professor Judy Kilpatrick, head of The University of Auckland nursing school, which offers postgraduate papers in partnership with many DHBs’ NETP programmes.
“What we actually found was that graduates were doing some quite high-level things in that first year and postgraduate study was a perfect way to give credit and shape up their thinking.” She said the paper involved a high level of clinical assessment but formal study did not commence until the second semester of the NETP year to give graduates a chance to adjust to working life.
“I think that postgrad study firstly helps retain the graduates; secondly, they are able to get new knowledge – at a sharper and higher level than undergraduate – that they can apply in the clinical area; and lastly, by the end of the first year they are already cementing themselves in the pathway of where they want to go.” She says rather than being burnt out, the graduates all complete and many will go on to pursue further postgraduate study (though quite a few take a break after completing their postgraduate certificate and look around before resuming study at the next level).
Sue Hayward, director of nursing for Waikato DHB, which offers the honours programme to leading second-year nurses and now has two recent graduates on the doctoral path, also believes postgraduate study in the NETP year consolidates what graduates have learnt in their undergraduate degree.
She says the Midlands region of DHBs have negotiated for graduates then to have a longer gap, if they wish, before they do the second paper of their postgrad cert but most have completed their certificate within three years. “It’s not arduous – though it’s not easy,” says Hayward. And retention, even taking into account the current economic environment, was very good, with 96 per cent of NETP graduates staying on and going into permanent positions.
Dr Kathy Holloway, national chair of nurse educator group NETS, was part of a team that evaluated the first three years of NETP and found the supported first year of practice programmes was enhancing trainees’ confidence and competence.
She says DHBs had always done some form of new graduate programme but they were very variable across the country and there needed to be some consistency and structure, which national funding enabled it to have. And expanding the scheme into primary health care, aged care facilities, some non-governmental organisations and some private surgical hospitals meant it could support graduates entering the wider nursing workforce.
“But we still have the goal of 100 per cent employment of nurse graduates into an NETP position if they seek one.”
Southern Cross joins NETP
Southern Cross this year became the first private surgical hospital group to get NETP government subsidies for its new graduates
Carey Campbell, chief nurse advisor for Southern Cross Hospitals, said Southern Cross first started working towards gaining NETP funding in 2010 but at the time Health Workforce New Zealand (HWNZ) specifications didn’t allow government funding for new graduates employed by private surgical hospitals.
But she says by 2013/14 the country’s private surgical hospitals were employing about 50 new graduates (25 of those by Southern Cross). “This was a significant contribution to the nursing workforce – the number being larger than many DHBs.”
Campbell said sharing this information with HWNZ and the Ministry of Health’s Office of the Chief Nurse at the same time as there was ministerial pressure over employing new graduates “certainly helped our cause”.
HWNZ spokesman Ruth Anderson said it considered Southern Cross’s application last year as part of its commitment to increase the number of new graduates employed in quality entry to practice programmes. It also followed the government’s July 2015 announcement to fund up to 200 additional new graduate places in 2015.
“HWNZ has a role to ensure the sustainability of all parts of New Zealand’s health workforce,” said Anderson. “To fulfill this role, funding support for training in both the public and private sectors must be considered.”
As a result, HWNZ agreed in October 2014 to fund Southern Cross for up to 25 new NETP new graduates in 2015 ($7,200 per graduate) dependent upon Southern Cross’s NETP programme getting Nursing Council approval.
Campbell said Southern Cross gained Nursing Council approval in April and currently has 20 new graduate RNs employed across the country, with 17 funded through NETP. Two further NETP places will be available in the September intake, making a total of 19 NETP this year.
For the first time, Southern Cross will also be added as an employer option for new graduates applying through the Advanced Choice of Employment (ACE) recruitment clearinghouse for the 2016 NETP intake. The number of NETP places Southern Cross will be funded for in 2016 is still under discussion and HWNZ says it also needs to consider existing training funding commitments to district health boards.
NETP places filled
2015: 777 (to date) – funding available for 1300*)
*NB The funded places for NETP have always exceeded the number actually filled. In the early days of NETP some DHBs struggled to attract new graduates into their programmes and then in more recent years low nurse turnover and tight budgets has meant more demand for places than DHBs were able to deliver.
- A maximum of two clinical placements/rotations within the maximum 12-month programme.
- Clinical preceptor support throughout the duration of the programme (sharing clinical caseload for six weeks in total).
- The equivalent of 12 group learning/study days (including any postgraduate papers).
- A sub-contract between the parent DHB and any other employer, i.e. general practice or residential aged care facility.
- Health Workforce New Zealand funds $7,200 per graduate towards six-week clinical caseload sharing by preceptor, 12 days release time for study days and 16 hours training for preceptors.
- Aged residential care providers meeting certain training criteria can receive an additional $12,800 to cover extra preceptorship and supernumerary release time.
NETP pioneer inspired to nurture today’s new nurses
Sharon Fisher was not new to her first ward but still recalls those first few weeks as a ‘real’ nurse as “absolutely terrifying”.
The mature student and mother of two had had a student placement at the Waitakere Hospital medical ward that became her nursing home as a new graduate nurse in Waitemata DHB’s first official NETP cohort (also one of the country’s first) back in 2006. The ward was familiar and friendly but being a new nurse was still testing to the nerves.
“I can recall around week four doing a blood pressure on a patient and it was something ridiculous like 80/60 when I knew that 120/80 was normal,” recalls Fisher with a laugh.
“I wasn’t panicked as such but I was certainly perturbed and can just remember the clinical coach being on the floor at that stage and calming me down by making me aware that you look at the patient as a whole, rather than as a set of numbers. So when I took that into account I realised she was a tiny little dot of an old lady… and I recall feeling really, really supported by my ward staff and the NETP people.”
Fisher had applied to both Auckland and Waitemata DHBs and been accepted by both but chose Waitakere as she had enjoyed her placement and lived ‘out west’.
But another factor was Waitemata’s NETP at that stage did not include a postgraduate paper and after three years of study with two preschoolers, she didn’t want to do any more study for a while. “I really felt that a year of just learning to be a nurse – without the pressure of more study [was what she wanted].” (Though she has since done the assessment paper now offered in the NETP year and thinks it may not have been as hideous as she had feared as a new graduate.)
Looking back, Fisher can recall near the end of her NETP year an incident when she had the confidence to test her nursing wings. “I had a patient who was dying in a little windowless treatment room and I had the opportunity to move her into a single room with a view over our little pond – so I did.
“Our charge nurse questioned me, as the patient died within hours, about the cost of the moving, extra cleaning etc – and I can recall feeling very much that I was able to justify why I’d done it. I really felt that for the family to have their family member die in a room with a nice view and some sunshine rather than a poky internal room was an important part of that patient’s death. I thought it was the ethical, right thing to do … and I certainly wouldn’t have done that at the beginning of my new grad year.”
Fisher went on to become a district nurse, still based at Waitakere Hospital. She completed her postgraduate diploma and has started her Master of Health Science research thesis looking at new graduates’ interest in placements with older adults.
She herself also became a preceptor and recently successfully applied for a clinical coach position within the NETP programme, which she sees as playing a vital role in nursing.
“I think if we can get in and shape our new grads at the beginning and give them an experience like I had – I’m still nursing 10 years down the track and I’m still at Waitakere.” She says being able to spend time with fellow new graduates in the same position as herself made a “huge impact” as that year can be “overwhelming” and she definitely sees herself long-term working as a nurse educator to help nurture new nurses.
Supportive new grad year sealed love for ED nursing
Lola Brownlee’s new grad year in ED was so positive she is still there a decade later.
Another of Waitemata DHB’s first cohort of NETP graduates, she started in North Shore Hospital’s emergency department (ED) in 2006. She has now completed her clinical master’s in emergency medicine and is one of the ED’s team of clinical charge nurses.
The former bookkeeper and mother-turned-nurse recalls being excited just being on the floor doing what she had chosen to be her new career – nursing, though it was also quite daunting coming from nursing school straight to ED as you initially thought you didn’t know anything. “But you quickly learn, with support, to trust what you’ve learnt and to trust the people around you … and with NETP you’ve got somebody you can trust to ask the silly questions to make sure everything is okay.”
She says her pioneering ED NETP programme may not have included postgraduate papers but did include intense learning of the ED training manuals for each area and training in areas like cardiac assessment skills and resuscitation. “I think to do postgrad study in the first year in ED would have been too much because we had so much learning to do on the floor that year but they’ve revamped our ED programme and now they start postgrad study in the second semester. I think some new grads find it difficult to try and learn what they need for working on the ED floor, as well as postgrad study.”
Brownlee thinks ED is possibly slightly different from nursing in other acute areas. Just consolidating newly learnt skills in the first year could be a good thing, she says, then starting postgrad study in the second year when nurses better “know what they don’t know”.
“I think the support I got from the coaches in the new grad programme was really amazing. So I never felt scared – though there were times I felt challenged… like the first time you see a death.”
Brownlee says in time, and with support, you can tell from the data and your observations that the patient in front of you is not just sick but really sick and you realise you are really nursing.
“It boosts your confidence that you’ve developed that critical thinking where you can tie things together and when you go to the doctor there is a reaction and they start trusting you as a nurse – it’s quite exciting.”