How far have we really come in New Zealand nursing?

1 November 2011

American Academy of Nursing “living legend” Professor Donna Diers was guest speaker at a recent College of Nurses and Waiariki Institute of Technology function.

The following is an abridged version of her lecture, looking at some of the good, the bad and the ugly of New Zealand nursing in the past two decades.

I first encountered New Zealand nursing in 1993, not a good vintage year for this discipline. That was right in the middle of the worst of your health reforms.

How could anyone have believed that by removing the senior leadership from nursing in hospitals there would be anything other than the chaos that ensued? And the removal did not save money.

Nurses left New Zealand for Australia or other places. Potential nursing students declined to enrol for nursing education. Substitution of nurses by unregulated caregivers occurred.

And yet the research and writing that describes that period in the reforms does not mention nursing at all – it’s all economics, that most rationally irrational of sciences.

Time passed and my work in health services research and policy increasingly focused on measuring nursing making a difference. So over a dinner in Wellington in 2000 hosted by then chief nursing advisor Frances Hughes, I met Angela Pidd, now a very senior data person in NZ Health Information Services (NZHIS).

I learned that, unusual for any country, New Zealand’s HIS maintains the annual survey of nurses that goes along with recertification. Suddenly the possibility of studying the relationship between health policy and patient outcomes through nursing sprang fully formed in my head. It would be a study that could not be conducted anywhere else that I knew of because it required simultaneous joining of nursing resource data as nursing hours or full-time equivalents (FTEs) with discharged patient data. NZHIS could do this.

I went home and laid the idea on a perfect doctoral student – Barbara McCloskey – who seized upon it with glee. We both had utter confidence that there would be a discernible relationship between impoverished nursing resources and increased adverse patient outcomes. With Angela Pidd’s help and with appropriate permission, we acquired 18 years of ‘de-identified’ data on both nurses and patients in all New Zealand public hospitals. We had 12 million or so patient records and about 250,000 nursing records.

When the statistics were run, sure enough, nursing resources as hours and FTEs fell in the early years of health policy reform and began to rebound about 1998. At the same time, the adverse outcome rates (pressure ulcers, confusion/delirium, wound infection, sepsis and so forth) began climbing and reached peaks that began to flatten out about 2000 when Barbara’s data stopped.

The work was strong, methodologically and statistically sophisticated and it was published in a US health services research journal in 2005. (McCloskey and Diers, 2005). It has been cited in reviews of nursing health services research and, I learned only recently, has been among the works that are used to argue against mindless re-engineering of hospital services.

Ah, but in New Zealand, what happened?

Precisely nothing that we ever heard about. Nevertheless, being stubborn if not demented, we persevered and under Jenny Carryer’s leadership, replicated the study by adding eight more years of data, refining the methods and statistical treatment, and anchoring the study more firmly in the New Zealand policy context. We published an article on this second study in January of this year. (Carryer, Diers, McCloskey and Wilson, 2011). It’s too early to see if it’s being picked up in nursing health services research literature, but I am told that once again in New Zealand, the silence has been deafening.

This time around, we found exactly the same patterns in even more prominence: when nursing resources decline, adverse outcomes for patients increase, sometimes by more than 1000 per cent. Even when nursing resources were restored, adverse patient outcomes did not fall back to baseline. We think that is because the professional authority of nurses in hospitals has not been restored and the damage to hospital operations (most of which is nursing) has not been healed. That line of inquiry is being pursued with renewed vigour by Jenny and one of her doctoral students, Kerri-Ann Hughes. The first part of that study has just been published and it identifies the anomalous position nursing occupies in New Zealand hospitals and DHBs and the fact, astonishing to us in the US without a national healthcare system, there is no consistency across DHBs. Further, the reporting relationships of chief nurses to CEOs, the organisational charts and nursing structures are “not readily aligned”, the authors say in a monumental display of understatement (Hughes and Carryer, 2011).

And yet, despite the traumatic past, in New Zealand nursing has arisen like the phoenix from the ashes. Last summer, with the sponsorship of the College of Nurses, a qualitative study was conducted of nursing’s political and policy development here. One of my graduate students conducted interviews all over the North and South Islands using a framework developed by Cohen and her colleagues (1996). Respondents were asked to rate the policy/political development of nursing in New Zealand along a four-point continuum from internal navel-gazing to ‘leading the way’ in health services and population health. You should be pleased to note that most respondents rated nursing at the higher end of the scale most of the time – an achievement I do not think any other country can claim.

You have brought nursing back – oh, perhaps not all the way, there is always more work to do – but you have brought nursing back from invisibility and victimhood to recognisable, palpable and visible leadership. The College and the leadership of its fellows, board and founding (and only) executive director, have been responsible for much of this, in partnership of course with others, most especially NZNO and the College of Mental Health Nurses.

You have the advantage (to my American eyes) of being a small country without the layers of political and policy levels we have to contend with. You have the disadvantage of being a small country, somewhat isolated (though less so with the internet). Your story is not well known beyond your own country and even when it is told, it is difficult to believe it all happened to you with such ferocity and speed.

You have managed to achieve a remarkable degree of ‘speaking with one voice’. An inability to do so is the curse of nursing in many countries. I believe you have done this by getting beyond nursing’s parochial internal interests in public discourse and associating nursing’s interests with wider agendas in the health of the public and its public institutions. There will always be intra-professional differences of opinion, tactic and strategy but they are to be ironed out away from public view: it’s no-one’s business but our own. The College has provided astonishing leadership both in front of and behind the scenes – in spite of the geographic distance between the North and South Islands and the impossible professional workloads of all nurses in this country – and from the bedside to the boardroom.

You have also addressed an aspect of contemporary health services around the world that is barely mentioned in either the UK or the US: cultural safety. In the US, we are still stuck in “cultural competence” when, and if, ethic, racial or cultural differences and disparities are even recognised. I wish the world would pay more attention to New Zealand’s history and progress in this respect, while at the same time I hope we would all leave you alone to develop your very special, Treaty-based style and attitude so that we do not despoil it. We in the US have much to learn from how progress has been made in honouring the Treaty, when we cannot even seem to remember that American Indians have had their own treaties violated. And a good bit of that leadership has been provided by nurses, by Māori nurses specifically.

So, this evening, I join you to celebrate the discipline of nursing in all its complexity as you plan for even greater contributions to human service, compassion and civility.

Donna Diers PhD, RN, FAAN is the Annie W. Goodrich Professor Emeritus and lecturer in the nursing management, policy and leadership specialty at the Yale School of Nursing. To view a full podcast of professor Diers' address and for references, go to the College of Nurses website: www.nurse.org.nz