Twenty-five years on, JOCELYN PEACH looks back at the discontent, health reforms, and courageous leadership that prompted the speedy development of the first PDRP (professional development and recognition programme) and the legacy of that 1988 action.
Professional nursing today has been influenced by the foresight of nurse leaders in past decades.
Leaders such as Sally Shaw, Anne Murphy, Ron De Witt, Gay Williams, Nan Kinross and others were courageous, outspoken and – through horizon-scanning – promoted professional self-determination.
They modelled leadership and confident response to change and recognised that the profession needed to look globally at best practice. They empowered nurses to take charge of leading nursing practice, which is our mandate. They encouraged nurses to develop professionally through postgraduate education and introduced new advanced practice roles so that nursing contribution could be visible.
The beginning: growing discontent
New Zealand’s first PDRP was implemented in the late 1980s and was a response to the challenges of that decade.
The then-Auckland Hospital Board was experiencing difficulty recruiting and retaining registered nurses as the board transitioned from relying on students and hospital training to polytechnic-based comprehensive nursing programmes.
It had been assumed that the registered nurse (RN) graduates emerging from the schools of nursing would increase the professional leadership numbers at the bedside. Vacancies, however, resulted in closure of beds and wards in many areas. Centralised staffing, which saw nurses placed in vacant positions, regardless of the nurse’s specialty practice expertise or interest, compounded this. The continuation of the traditional hierarchal leadership system – with its recognition of years of service – also resulted in stalled career pathways for the new generation of nurses.
Nationally nurses marched as part of the “Nurses are Worth More” campaign. This was a time of discontent and frustration as registered nurses sought to be recognised, valued, and supported in their practice development.
Nurse leaders in New Zealand and internationally were grappling with similar issues of retention of registered nurses and development of practice expertise for new technologies. Two important works published in the early 1980s influenced professional and development frameworks internationally and in New Zealand.
The first was Margaret McClure’s 1981 publication Magnet Hospitals: Attraction and Retention of Professional Nurses, which examined the causes of the hospital nursing shortage and why some facilities were successful in creating nursing practice environments that were ‘magnets’ for professional nurses. In 1984 followed Patricia Benner’s From Novice to Expert: Excellence and Power in Clinical Nursing Practice, which described the five stages of skill acquisition, the nature of clinical judgement and experiential learning, and articulated the seven major domains of nursing practice.
These two publications were brought to the attention of Anne Murphy, chief nurse of the Auckland Hospital Board, through the board’s nurse advisor,
Sam Denny. That prompted Murphy to visit a number of the ‘magnet’ hospitals in the United States on her way to the International Council of Nurses (ICN) meeting in Geneva. The nurse leaders at the American hospitals generously shared their ideas and resources, and she returned with information, ideas, and a strong agenda for change.
Health reforms prompt urgency
In March 1988, Murphy and her deputy chief nurse, Ron De Witt, asked for the professional development and recognition concepts from these US programmes to be developed into a framework for all nursing and midwifery groups working in the Auckland Hospital Board area. Implementation was to be underway by July of that year.
Rapid work was done to create the framework and the evolving programme was called Professional Development and Recognition Programme – Towards Excellence. Implementation was similarly rapid with the programme launched just a few months later to the senior nurses across eight hospitals and community services and then on to many of the 5000 nurses and midwives working in a variety of settings across the region.
The timeline was so rapid as Murphy and De Witt had the foresight to realise that the 1988 State Sector Act would radically change the health system in the late 1980s and early 1990s. The urgency to get the processes in place was motivated by the anticipated change to area health boards and the shift to general management structures.
So they sought a way to address the major workforce and quality issues that would challenge health service provision under the management reforms.
As nurse leaders they wanted to ensure that nurses and midwives retained professional autonomy over their practice, whether they were managed by nurse and midwife managers or not. This proved to be a fortuitous decision.
The new PDRP framework (see sidebar) was supported by a clinical career pathway and change in nursing leadership roles. Clinical nurse educators, clinical nurse specialists, and nurse consultant roles were introduced, which brought forward enthusiastic nurses who were undertaking postgraduate qualifications and were eager to apply new learning. The career pathway ensured that nurses were supported to provide the best care possible by clinical management roles and clinical practice roles.
The programme was launched in the Auckland Hospital Board area in May 1988 and evolved over the following two years. As ‘project manager’, I was tasked with implementing the change with the principal nurses of the day, across the hospitals and community settings from Warkworth to Pukekohe. This was a challenging task and the initial ‘roll-out’ was achieved by the due date through the enthusiastic support of the professional leaders.
National adoption of many of the PDRP concepts
The PDRP was gradually later applied in a number of areas nationally, using the core concepts and adapting slightly to local conditions. Over time, PDRP became the professional development framework, supported by the New Zealand Council of New Zealand, New Zealand Nurses Organisation (NZNO), and other professional groups. Midwifery developed its own programme using similar concepts, with its distinct professional priorities.
In 1988 (for an article published in The Professional Leader) I looked back at the key issues (*see key issues box) that a decade before had provided the impetus for establishing the PDRP framework and found improvement across all issues. The PDRP had provided a framework for effective clinical and human resource support and for recognising excellence in professional practice. The programme had also provided structured support, had influenced learning programmes, and recognised proficient and expert practice and the supported development needed as nurses worked towards advanced practice roles.
In 2003, the Health Practitioners Competence Assurance (HPCA) Act was enacted and required regulatory authorities, such as the Nursing Council of New Zealand, to set the continuing competence requirements nurses had to meet to receive their annual practising certificate (APC). In September 2003, the Nursing Council approved a framework for recognising professional recognition programmes that met those APC continuing competence requirements.
The Nursing Council used the existing frameworks that had been used for over a decade in PDRPs nationally. The PDRP process became the recertification programmes under section 41 of the HPCA Act for the purpose of ensuring nurses were competent to practise. This created a continuing competence framework (CCF) as a quality assurance mechanism and allows nurses to demonstrate annually that they remain competent and fit to practice.
Measuring PDRP’s contribution to practice and organisational effectiveness
It was acknowledged from the beginning that it would be a challenge for nurse leaders to quantitatively measure and present evidence of the contribution and impact of the PDRP.
Few researchers have considered measuring the PDRP outcomes using quantitative and qualitative measurement, relying anecdotally instead on descriptive analysis of ‘before and after’. The PDRP Coordinators group plan to work with key organisations on analysis of the PDRP on professional development, retention, the benefits of levels of practice on skill mix, retention, and practice safety and organisational effectiveness.
In conclusion, over the past 25 years the PDRP concepts and framework have been applied to nursing nationally and integrated by the Nursing Council into the Continuing Competence Framework. The programme has become part of the professional practice of nurses in New Zealand. As a legacy, the PDRP has supported generations of nurses to develop their practice and also influenced the career development of many nurses.
Tawhiti rawa i to tātou haerenga atu te kore haere tonu, maha rawa o tātou mahi te kore mahi tonu. We have come too far to not go further, we have done too much to not do more [Sir James Henare]
About the author: Dr Jocelyn Peach, RGON, ADN, BA [Soc Sci], MBS, PhD is director of nursing and midwifery at Waitemata District Health Board. She was the original project leader for PDRP development and implementation in Auckland and remains passionate about the value of the programme.
Aiken, L. H. (2002). Superior outcomes for magnet hospitals: the evidence base. In M. L. McClure & A. S. Hinshaw (Eds.), Magnet hospitals revisited: attraction and retention of professional nurses. (61-81). Washington, D.C.: American Nurses Publishing.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.Journal of the American Medical Association (JAMA), 288(16), 1987-1993.
Armstong, E.G. (2007). An Outcomes Approach to Evaluate Professional Development Programmes for Medical Educators. Annals Academy of Medicine. Vol 36, No 8.
Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice, Menlo Park CA, Addison-Wesley.
Clarke, S., Aiken, L. (2003). Failure to rescue: Measuring nurses' contributions to hospital performance. AJN: American Journal of Nursing, 103, 42-47.
McClure, M.L. (1981). Magnet Hospitals: Attraction and Retention of Professional Nurses. American Nurses' Association (Kansas City 64108).
McClure, M.L., Hinshaw, A.S. (2002). Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses, American Nurses Association.
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., Zelevinsky, K. (2002) Nurse Staffing Levels and Quality of Care in Hospitals. New England Journal of Medicine, Vol. 346, No 22, May 30.
Nursing Council of New Zealand. (2008). Framework for the approval of professional development and recognition programmes to meet the continuing competence requirements for nurses. Revised June 2008.
Nursing Council of New Zealand. (2011). Guidelines for Competence Assessment February 2011.
Peach, J. (1998). The Professional Development Programme: achievements and outcomes. The Professional Leader, Vol 5, Number 1.
Vernon, R., Chiarella, M., Papps, E., Dignan, D. (2010). Evaluation of the Continuing Competence Framework Report prepared for the Nursing Council of New Zealand October 2010.
“Towards Excellence” – the 1988 Professional Development and Recognition Programme [PDRP]
The programme framework was developed around four quadrants:
Selecting the right people with the right qualifications placed in the right position/specialty, selected by the charge nurse manager to fit the team. This was an innovation at the time and required the charge nurse manager to learn about human resource management.
This includes orientation of all new staff to the organisation and settings by a preceptor; familiarisation to the specialty practices and competencies for a ten week period; appraisal at ten weeks and annually thereafter. Education, learning, and coaching developed for each level of practice from new practitioner through to competent, proficient, and expert.
Clear policies and procedures guide practice, support practice decisions, and support career progress. Emphasis was placed on retaining nurses at the bedside to provide the best care possible. Portfolios were introduced. Senior nurse roles changed from supervisors to other career roles in recognition that registered nurses needed less supervision and more support for their development.
Monitoring and audit of practice by proficient and expert nurses was introduced. This included review of contemporary and evidence-based practice and encouragement of proficient and expert nurses to learn skills to lead change in clinical practice.
Some of the key issues in 1988 prompting PDRP development
- shortage of experienced nurses and fewer RNs with a reliance on a student workforce and enrolled nurses
- high turnover of nurses and midwives (40 per cent)
- centralised employment of nurses with nurses placed where there was a vacancy rather than because of expertise or interest
- new graduates from comprehensive programmes did not receive structured orientation and familiarisation
- no consistent performance management processes
- no preceptor processes or peer review processes
- no mechanism for recognising and rewarding excellence and performance
- no mechanism for differentiating skill and expertise
- poor integration of quality systems with staff practice – e.g. an emphasis on rules rather than recommended best practice
- poor clarity of expectations and minimal awareness of risk management
- minimal reflection on practice
- limited post-registration education linkage
- minimal succession planning.
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