“Regulation is a bit like watching paint dry – it’s never going to be fast and sexy,” says retiring Nursing Council chief executive Carolyn Reed.
But regulation needs to be done well. Council decisions can have a cascading effect on public safety, nursing education, nursing practice, nursing registration and the everyday lives of 57,500 nurses. Developing good, sustainable regulatory policy is also resource and time hungry.
Looking back on her ten years in the top job Reed is not surprised that she feels tired sometimes.
“I look back and see what the team is achieved (over those ten years) and I think no wonder I’m tired and I’m sure other people are too.”
It’s been a big decade for nursing. Back in 2008 there were only 50 nurse practitioners – and not all of those NPs prescribed let alone registered nurses. Enrolled nurses were controversially called ‘nurse assistants’. The largest source of internationally qualified nurses (IQNs) was the UK not the Philippines and India as it is today. And uncertainty reigned over whether expanded nursing practice roles, like the first surgical assistant (FSA), fell in or outside the existing scope of practice for registered nurses.
The Nursing Council staff and governance board during Reed’s time has consulted, discussed and negotiated itself a path forward that met its mandate to ensure public safety and also helped meet the nursing profession and sector’s wish to evolve new nursing roles. Along the way it faced its fair share of criticism and resistance from those who thought the Council too strict or too liberal in its regulatory role.
The consensus amongst nursing leaders is that Reed did a darned good job in her dual role as CEO and registrar. The announcement of her resignation brought praise both personal and professional of her vision, her leadership, her approach and the resulting ‘right touch’ regulation which kept the public safe but still allowed the profession to be forward-focussed. The Council chair for the past three years, Catherine Byrne, is to step into Reed’s job in the New Year and says she wants to continue Reed’s ‘right touch’ approach to the Council’s role.
Reed also says progress during her time is partly a matter ‘of everything in its time’ as often innovation and change – like the introduction of the nurse practitioner (NP) in 2001 – initially causes resistance that reduces over time.
“Sometimes you have to bring in new roles or policies with a tight rein on them to reassure the public and others (like some in the medical profession) that there is not a public safety risk. And then you can evaluate them after a few years and say we don’t need to have such high surveillance,” says Reed.
‘Initiation by fire’ into CEO role
Reed, a former paediatric nurse and dean of health and social sciences at NMIT, first crossed the Strait from her beloved Nelson to take up the role as the Council’s education advisor role in 2004 – the year that the Health Practitioners Competence Assurance (HPCA) Act 2003 came into effect under the stewardship of then registrar and CEO Marion Clark.
It was a heady time for regulation with the new onus on professional regulatory bodies to ensure the ongoing competence of registered health professionals leading to the introduction of the new competency, professional development and practising hour requirements (which may be reviewed in the near future) that saw thousands of inactive nurses stop renewing their annual practising certificates (APC). (Nursing Council statistics at the time show the number of APCs dropped from a high of 50,263 in March 2005 to 42,743 in June 2005 though the number of actively practising nurses stayed stable. )
“I have great admiration for the board and the staff who saw the registration through the change of the Act as it must have been enormous,” says Reed. Some of those respected colleagues are still there 15 years later like Strategic Programmes Director Pam Doole, Deputy Registrar Clare Prendergarst and Business Innovation Director Lindsay Hiener.
A political football at the time Reed stepped into the CEO shoes was the ‘return of the enrolled nurse’. It was a move first called for by Labour in the early 2000s and saw a one year, narrow-scope enrolled nurse (EN) programme offered for the first time in 2002.
Backlash against having a second-level nursing workforce saw the title for the new graduates changed to ‘nurse assistant’ in 2004 just before Reed arrived at the Nursing Council. Uncertainty ruled for a number of years over the role until 2008’s change of government saw the new Minister of Health Tony Ryall once again calling for the ‘return of the enrolled nurse’.
“So the Minister asked the Nursing Council to re-look at the role…that was a fascinating time really. And there was a lot of tensions. It was an initiation by fire for me really in my role,” says Reed. A consultation group called for a higher, generic scope EN and in 2009 the Council supported the call that lead to the development of the new 18 month EN diploma and a broader scope of practice.
“It is important that the scope is very open and enabling and it now just needs employers to get behind ENs and use them effectively.”
So what else is she proud of after a decade in such a key role in New Zealand nursing?
“I’m probably most proud of the way that nursing is working together much more effectively and respecting each other for the different roles we play. Because the regulator isn’t nursing – we are there for the public. But we need to participate in nursing discussions and we need to have the respect of the profession to do that effectively. Because we can never know all there is to know about nursing – it needs to be informed by the people at the frontline.”
She says she can’t take individual ownership of how nursing is working together as a profession. “But I’ve been part of it.”
Nursing leaders have praised her leadership as inspiring and made special mention of the personal warmth she brought to the role.
“I think I approach my role (believing) that anything or everything can happen if you come from a place of integrity and I really believe that everything is relational. I believe in the team really strongly and the team at the Nursing Council is pretty amazing – and I’m privileged to work with the people I work with. We’ve done a huge body of work for a small group.”
Reed says she’s also proud of the Council’s guidance around expanded practice. “I think that’s a good example of regulation being ‘light touch’. That is the Council providing the guidelines and the standards and then trusting the profession and the employers implementing the guidelines in practice to maintain those standards.
“Regulation is like the poor relation – it doesn’t get talked about a lot – but it sits behind things like nurses being able to do endoscopies and expanded roles like surgical first assistant and colposcopy.”
Another big innovation that has come in under her watch is registered nurse prescribing which was enabled under the Medicines Act.
“Everything we all do in health care is about better care and easier access for patients – and I think registered nurse prescribing is a perfect example of that. People who will get the most benefit from the various types of RN prescribing are the people who traditionally didn’t have the best access to health care.
“But they may have a nurse in their school, community or GP practice that who can attend to their needs relatively quickly. And from my perspective being able to prescribe is far better than having a standing order because the nurse is engaging (with the patient) and is much more accountable. Nurses are being responsible and working to the top of their scope and using their knowledge and skills”.
Also high on the list of the Council’s accomplishments in the past decade is the 2012 Code of Conduct and the related professional boundaries guidelines. Reed says the Code had high input from nurses across the country as the Council travelled to small places and large to “say what do you want in your Code of Conduct”. She says just that year she’s heard that the New Zealand Police are looking to use the Code as a ‘springboard’ for their own and nursing regulation colleagues in Ontario have asked whether they can adapt it for their nurses.
Building international relationships – particularly with a group of seven regulators from like-minded countries ranging from Singapore to the US – is something Reed is also pleased to have been part of during her time. “You can’t be isolated in regulation because we live in such a global economy where nurses are moving from country to country. So you can’t just sit down here with your doors closed and not take notice of what other people doing.”
Then of course there has been the reviewing and broadening of the EN, NP and RN scopes over that decade into a more open and enabling model.
The politics of regulation
People in politics, health and nursing not surprisingly can have different views on what nurses should and shouldn’t be able to do, and what they should learn, or know, to practise here and keep practising.
Reed says she has tried to do her best to avoid taking sides by keeping her focus firmly on what is the regulator’s role. “And the regulator’s role is to consult adequately and then to describe the scope of practise or the standards and not to get into the politics.
“…You have to keep a very open mind when working in regulation …I think listening and thinking independently are the big skills you need to ensure you can give good advice to the board… It’s not just a popularity vote or listening to the loudest voices.”
But occasionally you still get a ‘political prod’ in regulation and an example of that was Minister Tony Ryall pre-election promise about the ‘return of the enrolled nurse’.
“It is a matter of separating yourself and not allowing yourself to feel that political pressure because our role is clearly defined in the Act,” says Reed.
If the council delivered a recommendation to the board that was known to be politically unpalatable or not what the political powers of the day were seeking – then the board needed to be aware of that. But she said the decision-making then came down to good reasoning and having had a good quality policy and consultation process.
“Because there’s a degree of independence in the regulator and that’s how it should be. But you also have to make sure that you are listening to the public voice as well in your consultation process and meeting health need.”
Challenges and changes
One of most challenging and tough times as CEO and registrar was when the then Government instructed the regulatory bodies to explore combining into a single body – similar to the Australian model. She says the advice given to the board was that under the existing legislation nurses had to be consulted and nurses gave the concept a “resounding no”.
Another major change in the past decade has been the source of New Zealand’s historically always high percentage of internationally qualified nurses (IQNs make up 27 per cent of the current workforce) with most IQN nurses now coming from the Philippines and India
“We need those nurses – they are a vital part of our healthcare system and they bring valued difference to us. Our role as a regulator is not to make a decision about how many or where they come from but to set the standard – and it has to be the same standard you set for New Zealand nurses to enter the workforce. I think you’ve got to guard against setting standards that are unnecessary barriers but you’ve also got to question every standard and ask ‘is this necessary to protect the public?’.
Questions over the education level of some Indian nursing qualifications saw frustrated would-be New Zealand nurses taking hunger strikes in 2012 and a major audit of Indian-diploma qualified NZ registered nurses in 2013-14 which found the vast majority were ‘really good nurses’ doing a ‘really good job’.
What level of English proficiency IQN nurses should have has also been an ongoing issue for much of the decade including whether theInternational English Language Testing System (IELTS) or the Occupational English Test (OET) are appropriate tests and whether the pass levels required by Council are the appropriate levels for nurses coming from the Pacific or the Philippines and India.
Reed says the Council recently commissioned the University of Melbourne to research language level requirements and that was due to go to the Board in February. She says there are questions over whether they current tests are the only tests available but also that language testing alone does not test nurse communication in practice. “And the critical thing for people to be in safe care is good communication in practice. So we are toying with how best to manage that.”
Meanwhile nurses’ growing frustration at workload pressures and safe staffing boiled to the surface this year with public hospital nurse strikes and a social media movement that attracted tens of thousands of nurses keen to voice their concern about barriers to giving consistent, safe nursing care.
Reed heard those concerns with empathy.“I just want to acknowledge that nurses work in just the most incredibly difficult environments. And just in the last three days I think I’ve read about three really significant violent attacks against nurses…Its bloody hard work.
“From a regulator’s perspective we can’t regulate systems. That’s not in our brief. But I guess I just want to reassure nurses that we are able to take context into account when we are dealing with issues that come before the Council,” says Reed.
“When you get a nurse, for example, making a drug error…and the nurse is the only registered nurse with 50 residents to dispense drugs to and they getting interrupted all the time, or somebody falls over, then it’s hardly surprising that they make a mistake.”
“We’re very conscious of the nurses practice (setting and context) when we are considering matters that come before the Council.” She is also keen to point out that the percentage of the country’s 57,5000 nurses that do end up before the council on disciplinary or competence issues is “miniscule”. “They are just tiny, tiny figures really.” She also adds that the Council works very hard to take a rehabilitative approach to managing nurses with competence or health issues. “We always want them to get back into practice. We’re not about punishing nurses. We’re about keeping the public safe.”
Retirement – a time for rest
Keeping the public safe has dominated Carolyn Reed’s life for 10 years and now feels the right time to retire.
The role as CEO and registrar has had a major impact on her family life – her husband and family are based in Nelson – and her time regularly hopping across the Cook Strait was never envisaged to be so long.
“I’ve been commuting for 14 years to Wellington so it’s time we (her and her husband) spent some time together and do the things we’d like to do,” says Reed.
High on the list is yoga, some biking and “hopefully looking after myself a bit better than I have been lately”.
She says she will miss Wellington terribly as well as the Council people and friends that have made her able to say that there hasn’t been a day she hasn’t wanted to come to work.
But after a decade of putting the public first she is ready to hand over the reins and have a rest. “I don’t want to go anywhere – I’m always somewhere – and I just want to be at home.”