More from Des Gorman: chauvinism, prescribing, nurse practitioners and physician assistants

1 February 2013

Des Gorman rejects nursing criticism that HWNZ’s innovations have been poorly planned and taken a fragmented approach.

He is particular proud of the diabetes nurse specialist prescribing innovation (initiated by the multidisciplinary NZ Society for the Study of Diabetes under the championship of nurse practitioner Helen Snell) as a successful backdoor entry point for nurse prescribing in general.

“The diabetes nurse prescriber is the biggest thing by far that’s extended the nursing role for probably the last decade or two,” says Gorman. “The failure to get nurses – short of nurse practitioners – the prescribing role has been because my profession has simply blocked it.”

He said the diabetes innovation succeeded because the potentially disrupted group, the doctors, were strongly in favour of an extended nursing role.

“Why has nurse prescribing not been on the books a long time ago?” he asks rhetorically.

“The answer is because they’ve tried to do it in a way that confronts the whole of the chauvinism of my profession. They’ve tried to do it across the board whereas what we’ve done is look for coalitions of the willing and work on low-hanging fruit.

“The NP, which I think is absolutely an essential and sensible model of care, has never had the traction in this country it deserves because the employers saw them as being too expensive and too long to train.

“Some innovations fail because you are disrupting a powerful lobby group or guild that chews you to death,” adds Gorman. “GPs, for example, so you’ve got to make sure you get the potentially most disruptive people on board …”

Physician assistants inevitable

The innovation that nurses have been most open in criticism of – for being poorly planned and lacking robust analysis ­– is HWNZ’s importing of the more doctor-friendly physician assistant role.

Gorman clearly sighs when the topic is brought up.

“The question we are addressing is not will there be PAs in New Zealand – there will be. It is what will be their best use? Where are they best employed? How do they add value?”

He reiterates the HWNZ philosophy that PAs and NPs are complementary, not competitive roles, and he has no concern that PAs will compete for jobs with NPs or specialist nurses.

“An NP can work with a high degree of autonomy and independence, all be it (within) an integrated health care model,” says Gorman. “A PA acts as an extension of a physician or whoever. They are very, very different beasts.”

But what about training? Most NPs report having to individually negotiate and battle to get time and support for their clinical training. Wouldn’t the introduction of PA training be competing for scarce clinical training resources?

Gorman says HWNZ was “absolutely” considering setting up a PA training programme in New Zealand, probably taking an existing model from Australia and relocating it to a local tertiary institute.

“I don’t see it competing for existing resources any more than the current workforce competes for resources ...The last thing we would do is introduce numbers of trainees that would exceed learning capacity.”

However, he believes there is a spare training capacity and the problem is DHBs not taking seriously enough their responsibility for training the future workforce. A major role of the new regional training hubs was to identify those training responsibilities and ensure DHBs didn’t “abdicate” them.

Gorman says HWNZ was also to use its training funding “as a lever to ensure we’re getting the right support for trainees, particularly nurse specialists and NPs, from the system”.

Already Gorman is threatening a financial stick against District Health Boards that don’t offer sufficient ring-fenced intern positions for new graduate nurses in 2014. (See online Jan 28 News Feed story