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Nurse and general practice co-owner KIM CARTER believes one of the biggest barriers stopping nursing from making a bigger difference in primary health is nurses' attitude to money.

Recently, I attended a workshop that bought together an eclectic group of nurse leaders in primary health care to discuss the current barriers to nursing (and nurse practitioners, more specifically) in the delivery of innovative services. It was a day filled with debate and a sense of justifiable frustration at the persisting legislative barriers that impact on the full expression of NP and RN scopes of practice – but also a day where a great deal of energy and willingness to support change was expressed.

On returning home, I pondered over our discussions that day and several things have kept me thinking.

Firstly, there are without a doubt a number of actual impediments to NP (and RN) practice that exist in legislation and clearly a lot of work is being (and has been) done to resolve this. However, it strikes me that there are a number of other barriers raised by the profession that are not in reality as big as we perceive them to be. Some of the barriers have been reiterated so many times that they are now seen as absolute fact and are believed to be one of the major causes responsible for the lack of innovation in the delivery of nursing services. One of the main culprits is the idea that the current funding model limits or impedes nursing service delivery in primary health care.

I feel the current PHO provider agreement provides a platform for all types of health practitioners to participate in the delivery of services, but I think we have seen a historical application of who gets to participate and access that funding. This is not inherent within the agreement itself and relates to an interpretation by DHBs and PHOs. The move to a flexible funding pool within alliance teams provides additional opportunities for nurses to contribute to the design and delivery of all kinds of services including collaborative and nurse led models. Clearly, there are still issues with gatekeeping, employment arrangements, alliance team memberships, and nursing leadership structures that come into play here. However, I refuse to accept that our thinking and our clinical and professional boundaries are defined by those, and nor should any of us accept that this is the case.

As a profession, we are the consummate masters of understanding systems and helping our patients navigate their way through our complex health machine. We know who to go to when something is required by a patient, and advocate for and facilitate the right things happening at the right time. We seldom let much get in the way of this and use our clinical muscles to make things happen. Yes we have frustrations, but ultimately we get it done.

In light of this, I feel we haven’t got to grips with the financial environment in the same way. After all, funding models and contracts by in large determine what happens, and can happen, by whom, to whom, and when. I don’t think we always see how an acute understanding of this could start to change our world view and help us be more strategic in our thinking.

Right or wrong, this is the environment we work within, and it would be to our patient’s advantage (as well as our own) if we could work the funding system as well as we work the clinical system and as well as our colleagues in other disciplines do. Nursing is based on a well-developed sense of social justice and a belief that the right things should happen because they are the right things. Despite seeing evidence to the contrary every day, the profession holds to this belief as a founding value, and we are right to do so – the alternative would be to lower our expectations and submit to the status quo. However, we cannot continue to sit back and trust things will change just because they should.

To start to move forward, the biggest barrier to overcome is changing our attitude and ignorance about money. I have found that as a profession our approach to money is inconsistent. We appreciate how important it is, but we can act, at times, like money is a dirty capitalistic notion that we should keep away from, given we are in a caring “people first” profession. We have a general understanding of the system, and perhaps a more in depth understanding of our small part within it, but seem loathe to get down to the nitty gritty and master financial language and concepts. However, it is in those details where I see huge possibilities for the primary care nursing workforce to meet the growing need for healthcare in our communities. It’s time we concentrated on developing our financial, business, and political muscles with the same zeal as we have developed our clinical ones.

We desperately need to have widespread detailed discussions about contracts and the possibilities they hold and about how we could look at models of care and new roles within a context of the current environment. But this requires all of us, including our leaders, to develop an intimate understanding of the financial environment so we can see the opportunities, the possibilities, and the scope for action. We need to see the funding model as an enabler and not an obstacle. We have to see the glass is actually half full!

Some barriers are there, but I don’t think they are as high, as tricky, or as oppressive as we believe they are. Walls are dismantled one brick at a time. We should use all of our muscles to remove the first brick so that we can start to see beyond the wall.