Celebrating the 101st nurse practitioner: a decade to reach a century

1 May 2012

It has taken a decade of hard work, lobbying, frustration and personal sacrifice to build a critical mass of 100 NPs.Nursing Review marks the milestone by asking nursing leaders to reflect on the role’s past and future and by profiling the work of some NPs.

DEBORAH HARRIS, the country’s first NP* celebrates the 100th NP registration by reflecting on the past decade and touching on two of the challenges remaining – creating and funding NP positions and preventing burnout.

I’d like to take the opportunity to reflect on the strength and courage of those who have made the nurse practitioner role a reality. I would also like to highlight two areas, which need careful attention as we approach the teenage years of implementing the nurse practitioner role.

Firstly, I wish to acknowledge the substantial contribution of Dr Frances Hughes, Marion Clarke, Judy Kilpatrick, Professor Jenny Carryer, and others who changed legislation and registration in order to create a unique role for Aotearoa. The persistence and strength of these nursing leaders in creating and leading this change – against considerable opposition both from within and outside the nursing profession – was outstanding. The realisation of the nurse practitioner scope within New Zealand has seen their vision become a reality.

I also wish to acknowledge and congratulate the Nursing Council of New Zealand for continuing to develop the NP registration and scope. While the process to become a nurse practitioner is difficult, and I believe it should be, the council process provides a strength that I have not seen in other countries’ registration processes. It is also reassuring to note that, while the registration process has become more streamlined, it still requires a high standard.

Finally, the nurse practitioners themselves – every nurse who has walked the NP registration path has seen the strength of nursing for their patients. I suspect that each and every one of us understands the responsibility we carry.

Role still needs nurturing

As the NP model approaches its teenage years, there are aspects of the role that need careful nurturing and attention.

Last week, I was invited to a morning tea, which was held to celebrate the employment of a new NP. I was delighted to be part of this celebration, which was the end point of a very long path. This nurse has been registered as a nurse practitioner for some time.

The morning tea illustrated the two areas that concern me. The nurse set a career goal of being a nurse practitioner. Her postgraduate education was demanding but also stimulating and challenging. The Nursing Council application and registration process was time-consuming and demanding, but she prepared well, and while challenged, flew though as many do.

The next part of the path was less easy – gaining employment. There was a significant mismatch. The service wanted the skills of an NP but was not really sure how best to use those skills. It was also struggling to find the funds to employ an NP. This is not an uncommon problem. How should we best solve this problem?

Furthermore, many colleagues at the morning tea were excited about the additional contribution this NP was going to provide. I was left feeling when on earth is she going to sleep?

I whispered in her ear, you don’t have to catch every ball thrown to you, and she smiled knowingly. The expectations of the role can be (but not always) too great, and frequently, the infrastructure to support the role expectations is not in place. Burnout and other consequences of stress are very real in advanced practice nursing roles.

I believe we need to address these issues in order to protect, grow, and shape our unique nurse practitioner model. I suspect before we reach 200 registered NPs, both these areas of concern will be successfully addressed.

Congratulations to all those who have been part of nursing journey and well done so far!

JANE O’MALLEY, Chief Nurse, Ministry of Health.

The milestone of the one hundredth NP and recent indicators of headway for the role are indeed reasons for celebration. Legislative barriers are being addressed and the scope of the role and pattern of employment is changing. While initially the role was more likely to be exploited by specialist services, the utility of the generalist NP role is recognised as ideal across broader populations in primary health, aged care, and mental health. This year, the majority of the district health boards’ annual plans acknowledge the potential of the role in addressing health need and its ideal ‘fit’ with emergent models of care. The future for the role is immense.

PROFESSOR JENNY CARRYER, Massey University and executive director of the College of Nurses Aotearoa.

I warmly congratulate the 101 brave souls who have got there against all of the odds. They are pioneering the role and are providing stunning leadership and superb clinical practice.

I issue a challenge to Health Workforce New Zealand to read the evidence, to truly understand the potential of having many more nurse practitioners, and to seriously support and actively facilitate the rapid increase in NP numbers. The many New Zealanders with unmet need for access, care, and attention deserve no less. 

Nurse practitioners are not an experiment or a pilot. Rather, years of evidence, now collected in a number of countries, show that they are a cost-effective and safe option for making the best possible use of nurses, many of whom already hold the requisite qualifications. Without appropriate high-level encouragement, this is a transformative workforce currently being wasted.

DR MICHAL BOYD, Aged care NP and chair of Nurse Practitioners New Zealand* (NPNZ).

NPNZ represents NP pioneers who have worked tirelessly over the last decade to develop innovative healthcare practices.

These clinical experts meet the health needs of thousands of New Zealanders across all types of healthcare settings. Outcome evaluations of NP practices have shown significant benefit to patients through prompt access to care and using a coordinated approach. This has resulted in decreased waiting lists and hospitalisations, as well as innovations for vulnerable populations.

We have achieved this by making changes happen within a health care system that has not always been ready for a new ways of providing care. Many adjustments have been needed and many more are yet to be resolved.

In the coming years, we envisage training programmes specifically for NPs, funding systems that will encourage NP practices, and supportive healthcare policies that will progress the full potential of this role.

We look forward to the continuing future development of the nurse practitioner workforce and integration within the multi-disciplinary team to provide high quality health care for all New Zealanders.

*NPNZ is a subsidiary of the College of Nurses Aotearoa

DR HELEN SNELL, Diabetes NP and chair of Nurse Practitioner Advisory Committee of New Zealand (NPAC-NZ).

More than a decade on from the first registration of nurse practitioners in New Zealand, we now have reached the 100th nurse practitioner.

Through innovative service delivery, nurse practitioners are making a significant contribution towards the health and well-being of people throughout New Zealand, resulting in real health gains. Whilst we now have 100 NPs working across our health care system, this is few given the size of the overall nursing profession.

NPAC-NZ believes part of the reason for this is the absence of a formal NP education and clinical training programme where the nurse completes his/her advanced practice training in a practice environment that offers both adequate opportunities to apply and practise advanced knowledge and skills. The appropriate level of clinical oversight is also lacking. The nurse practitioner candidate requires chances to extend their clinical leadership and scholarship capabilities.

To date, much of this preparation has been driven by the nurse only and is reliant on employer goodwill. In 2011, NPAC-NZ consulted on an NP education and training programme with the view of informing the Nursing Council’s postgraduate education review.

Over the past ten years, we have seen some of the barriers to practice removed, such as applying for special authority applications, and there is currently an omnibus Bill in progress to address other barriers – although a significant number of legislative barriers remain to impede practice on a daily basis. Attitudes towards employing NPs also remain an obstacle in both primary health care and secondary care settings, but the resilient nature of nurses see many push on and make space for their services in the health care sector.

Over the next five to ten years, NPAC-NZ sees a healthy future for the NP scope of practice and role in New Zealand. We expect we will see changes to the education and training of NPs, to the registration process, and I hope, to employment options for NPs.

SUSANNE TRIM, professional services manager for the New Zealand Nurses Organisation.

The significant struggle to reach this milestone needs to be recognised, says Trim. “NPs had to forge and fight for their positions to be established and that’s been incredibly frustrating,” she says.

The sector was slow to adopt the new role for a number of reasons, including lack of understanding by employers and funders of NPs’ potential, the legislative and policy barriers, and some uncertainty from nursing itself about the career pathway and assessment process.

Improvements over the last decade have included positive developments in the Nursing Council registration process and the cases where NP employment positions have been established and consolidated.

Trim says her real regret is that the potential for NPs to make a huge difference in primary health and aged care is being held back by funding and purchasing models that need to be reformed to allow NP numbers in those sectors to rise. She is also disappointed that pilots continue for the physician assistant role and are not widened to also look at the impact of nurse practitioners.

“I think the reality is that the next five years will continue to see slow development, but once we get a critical mass of NPs and their work is really seen and valued, then I imagine we will see an escalation of the number of NP positions.”

TONY RYALL, Minister of Health

It is a significant milestone that there are now 101 nurse practitioners in New Zealand. I am very pleased that the number of nurse practitioners continues to increase, and that in the past two years, the number has doubled. Nurse practitioners have a crucial role in helping New Zealand meet the challenges facing its health service and improving the health our communities, in partnership with other health professionals.

BRENDA WRAIGHT, director of Health Workforce New Zealand

We welcome the growth in numbers of nurse practitioners and the achievement of this important milestone. Nurse practitioners make an invaluable contribution to health care in New Zealand and HWNZ looks forward to helping to support and develop the role further for the benefit of both patients and the profession.

NURSE PRACTITIONER TIMELINE

1998

• Ministerial Taskforce on Nursing promotes the advanced nursing NP role.

1999

• Amendments to Medicines Act 1981 allows nurse prescribing.

2001

• New NP scope of practice launched by the Ministry of Health and Nursing Council.

Late 2001

• Deborah Harris registered as New Zealand’s first NP (neonatology).

2002

• NP Advisory Committee of NZ (NPAC-NZ) established.

2003

• Paula Renouf approved as first prescribing NP (child family health).

• First rural NP scholarships offered (about 40 awarded over next four years).

• 10th NP registered.

2005

Medicines (Designated Prescriber: Nurse Practitioners) Regulations 2005 gazetted.

• $500,000 grant to NP Employment and Development Working Party leading to DHBNZ NP Facilitation programme

• Nursing Council stats show only 17 out of 35 NP applications to date had been successful.

2007

• New Zealand has 39 NPs. 21 of those have prescribing privileges.

• Des Gorman, now chair of Health Workforce New Zealand (HWNZ), calls current NP model a “tragic” and “failed experiment” that needs to be relaunched. Strong backlash from nursing.

• Physician assistant model raised.

• Work begins to identify and remove legislative barriers to NPs working to top of their scope (resulting omnibus, Health Practitioners (Statutory References) Bill due in parliament in 2012).

• 50th NP registered.

2010

• HWNZ backs 12-month pilot of US-trained physician assistants (PAs) to support Middlemore Hospital surgical services.

• NPAC-NZ starts advocating for NP “registrar” or “intern” training programme.

2011

• 100th NP registered.

• Long-awaited Medicines Amendment Bill 2011 enters parliament. If passed, will give NPs same authorised prescribing status as midwives, dentists, and medical practitioners.

2012

• HWNZ announces proposed trial of three US-trained primary health physician assistants to go ahead in Midlands Health Network

• New Zealand has registered 101 NPs – about two-thirds are prescribers. More than one third of all NPs are working in primary health.

NURSE PRACTITIONER SCOPES

Primary Health Care/ Whānau ora 33

Aged care 11

Cardiology/cardiac care 9

Neonatal/paediatrics 8

Child Health/Adolescent/Youth health 6

Mental Health 5

Palliative care 4

Emergency nursing 3

Respiratory 3

Wound care 3

Diabetes 2

Intensive care/high dependency 2

Pain management 2

Urology 2

Other 7