Walker in 2010 at age 32 became New Zealand’s youngest nurse practitioner and the first to specialise in kidney care.  She was last month awarded her PhD by the University of Sydney for her research into patient and whānau preferences for dialysis treatments.

Walker will lead EIT’s registered nurse prescribing diploma programme.

Pam Doole, strategic policy manager for the Nursing Council, said in May that most of the about 15 RN prescribers had authorised to date under the new regulations had completed masters degrees. Four nursing schools enrolled students in the diploma prescribing practicum at the start of the year though, so the first diploma graduates should be seeking authorisation in around July.

Doole said there had been some fears expressed that the introduction of the registered nurse (RN) prescribing role might impact negatively on the nurse practitioner role.  But she said a number of the RNs that had been authorised to prescribe since September last year had indicated that they saw it as a stepping-stone to becoming an NP. (A third and more limited level of nurse prescribing – to be known as registered nurse prescribing in community health and aimed at nurses currently using standing orders – is also being trialed at present by nearly 70 primary health and family planning nurses.)

The seven nursing schools offering NP programmes, that are now offering or intending to offer a prescribing diploma, told Nursing Review that a number of the students on the prescribing diploma pathway still planned to pursue their clinical masters after becoming RN prescribers. A number of schools believed that a combination of the type of practice settings and their employers’ willingness to create NP positions were likely to influence on how many of the first cohorts of RN prescribers chose to see

Victoria University’s head of nursing Dr Kathy Holloway said it enrolled about nine students in the diploma’s final paper – the prescribing practicum – in semester one. She said an issue for some workplace settings and employers was meeting the Nursing Council’s clinical supervision and mentoring requirements for the RN prescribing practicum and the school supported them, like it had in the past for nurse practitioner practicums, to develop the necessary policies.

Jennifer Robertson, head of EIT’s school of nursing said it had five nurses undertaking the prescribing practicum in semester one – four currently working as nurse specialists at district health boards and one in a GP practice.  She said it also a number of nurses on its database either already started or keen to start the prescribing diploma pathway with the strongest support to date from district health boards and less so from primary care.

Also starting in semester one was the University of Auckland, which enrolled ten students in the prescribing practicum and likewise said the majority were from district health boards but some were in general practice.  It had about 40 nurses who indicated they would be starting the diploma in 2017 or 2018.

The fourth nursing school to get underway with the diploma at the start of the year was Wintec with one nurse on a prescribing practicum and it expected a further four, predominantly in primary care, to follow in semester two.

Massey University’s director of postgraduate nursing programmes Dr Jill Wilkinson said its prescribing diploma was getting underway in semester two and it had about ten students in line for the prescribing practicum with most working in the primary health sector but also in public health

Dr Philippa Seaton, director of the University of Otago’s Centre for Postgraduate Nursing Studies said it had students enrolled on the pathway to RN prescribing and was also planning to start its diploma this year.  She said interest to date was from across the South island in diverse settings including general practice, aged care and outreach roles.

Associate Professor Stephen Neville of AUT University said it was planning to get its diploma underway in 2018 and had significant interest expressed in the programme.

Since 2011 the Nursing Council has been authorising ‘second level’ prescribing by diabetes nurses but applications under the diabetes health regulations will close in November this year and future applications will come under the new RN prescribing in primary health and specialty teams regulations.

The first and most longstanding form of nurse prescribing, independent prescribing by a nurse practitioner, has been carried out by nurse practitioners since 2003.

The new level of community health RN prescribing requires experienced nurses to undergo a period of supervised practice and a Nursing Council-approved recertification programme to allow them to collaboratively prescribe from a much more limited list of medicines targeted at treating common ailments like sore throats and common sexually transmitted infections. The first and most longstanding form of nurse prescribing, independent prescribing by a nurse practitioner, has been carried out by nurse practitioners since 2003.*

A trial and evaluation of the new RN prescribing level started in April with 33 primary health nurses at Counties Manukau Health and 24 nurses from Family Planning beginning a recertification programme to meet the Nursing Council competency requirements in readiness for the new community health RN prescribing level coming into force in July.

Nursing Council chief executive Carolyn Reed said both organisations serve populations that would benefit from easier access to medicines required by “normally healthy people” and were supportive of the proposal to extend RN prescribing in the place of standing orders. A decision of when in 2018 to further rollout the new prescribing level will follow a full evaluation of the six month trial that is looking at both the recertification programmes and the trial nurses’ prescribing practice.

Reed said this new prescribing level would improve access to health care for people in vulnerable communities – including children at risk of skin and throat infections that could lead to more serious complications and hospitalisation.

Emphasis on antimicrobial stewardship

Karyn Sangster, chief nurse advisor for primary and integrated care at Counties Manukau Health, said antimicrobial stewardship, through responsible use of antibiotics, is an important focus for the recertification education programme developed by the district health board.  “We have been challenged (over whether) we going to have nurses accessing antibiotics inappropriately.”

But she said analysis of nurses treatment of skin infections under the region’s existing Mana Kidz programme found that only four per cent of the nurses had used standing orders for antibiotics.  “What the research is indicating is that nurses are very judicious in their use of antibiotics and most of the treatments for skin infections have been around cleaning wounds and applying dressings.”

The nurses on the Counties Manukau trial are all currently using standing orders and includes 16 primary health care nurses working in general practice, 11 public health nurses and six secondary school nurses.  Sangster said it had received very good support from GPs ready to provide clinical supervision of the nurses at their practices. Clinical supervision of the public health and school nurses in the trial, would be provided by nurse practitioners and clinical nurse specialists.

To date the trial nurses have had two face-to-face teaching days from clinical experts including a clinical microbiologist and a nurse practitioner.  The recertification programme also includes the nurses completing six online education modules covering areas including pharmacology and clinical assessment.  Sangster said the modules have been developed with the aim of rolling them out nationwide if the trial and evaluation is successful. The education programme is also linked to the HealthPathways support system (developed by Canterbury Health and used by Counties Manukau) which provide a ‘care map’ for consistent patient care of a range of conditions including, for example, a child with scabies.

The Counties Manukau recertification programme is focused on educating nurses to be able to treat common skin conditions, ear infections, low-level pain, sore throats and provide preventative and ongoing treatment for rheumatic fever. Sangster said on completion of the Counties Manukau programme it had arranged with Family Planning for ten of the trial nurses to also complete further training on contraception and treating common sexually transmitted diseases.

Sangster said standing orders has been a great enabler but believed RN prescribing would be much safer, particularly as training of nurses to use standing orders was left up to the discretion of the prescriber.

“They are getting much more training around medicines and antimicrobial stewardship doing this programme.”

She said a focus of the community health prescribing trial was ensuring there  enough rigour in the training process to ensure nurses were safe as it was all about patient safety.  As prescribers the trial nurses accountable for any prescribing decisions they made. But she said the key outcome hoped for was that having community nurse prescribers would enable easier and more convenient access to medicines for common complaints which would free up doctors time and improve access to health care.

Family planning trial also underway

Rose Stewart, National Nurse Advisor for Family Planning, said 24 of its about 70 nurses were involved in the prescribing trial.

She said its recertification programme differed from Counties Manukau’s as when first recruited all Family Planning nurses underwent an extensive training programme on the treatment protocols and specialised range of medications currently supplied by Family Planning nurses under standing orders.

All the nurses who volunteered for the trial were already working at a level where their standing orders were audited monthly, rather than requiring countersigning, but under the recertification programme they had been assigned prescribing mentors to supervise and support them meet the recertification competency requirements which included a series of workbooks. The trial nurses were spread from Invercargill to Whangarei with all of the nine South Island nurses involved being supervised by nurse practitioners.

Stewart said becoming community health prescribers would allow the nurses to take full responsibility and accountability for the care they offered and also changed the relationship between the nurse and the authorising prescriber.

Stewart, who has completed a clinical masters and works clinically two days a week and, said late last year she was approved by the Nursing Council to prescribe at the registered nurse prescribing in primary health and specialty teams (postgraduate diploma) level and was currently the only nurse working at that prescribing level in Family Planning and one of still very few in the country

*Nurse practitioners (who require a clinical masters degree) can work autonomously and can assess, diagnose and treat patients using the same authorised prescriber status as doctors and dentists. 

Karen Jones was authorised last month by the Nursing Council of New Zealand as a registered nurse (RN) prescriber under regulations that came into force on September 20 allowing suitably qualified RNS to prescribe a limited list of medicines used in long-term and common conditions

The primary health nurse works fulltime for the Te Manu Aute Whare Oranga clinic at Manurewa Marae as part of an “extremely supportive” team of three part-time GPs and, more recently, a part-time nurse practitioner.

Jones says one of her GP colleagues told her when she applied for prescribing rights that it was likely that her first prescription would “feel like a let down” as it would be for something like paracetamol.

But she says it still felt “awesome” as a patient had rung up late on a Friday needing pain relief for the weekend and, with no doctors on site, she was able to meet the patient’s needs. She had also talked to the local pharmacy about the new regulations and shown them proof of her new status on the Nursing Council website so her first prescription went smoothly.

Jones, who trained at Manukau Institute of Technology graduating in 1992, recently completed her clinical masters degree through Massey University including her prescribing practicum. She says she has been working in primary health for 15 years, with a particular interest in diabetes, and had began work towards becoming a diabetes nurse prescriber when the new regulations came into force allowing her to apply to be an RN prescriber.

The main pathway to RN prescribing rights will be through the new postgraduate diploma in prescribing being offered next year but some nurses, like Jones, who have already completed a prescribing practicum as part of their clinical master’s degree, have been able to apply since October 1.

The community clinic Jones works for has 1400 patients enrolled, 90 per cent Māori, and Jones says long-term conditions is a major focus of the clinic’s work with her own special interests being diabetes and lung disease.

She says as she spends a lot of time working with people with diabetes it had been “wonderful” to be able to titrate insulin for her patients, which was saving time for both patients and the team’s GPs and NP.  Jones believes the new regulations will be good for the whole health system with GPs and NPs able to focus more on the acutely unwell or those with complicated conditions while RN prescribers like herself could see patients coming in for routine review appointments or needing repeat medications that are covered by the list of medications she was authorised to prescribe from. In her first few weeks of prescribing she says the most common medications she is prescribing are diabetes medications.

Jones, who thanked her husband, two teenage daughters and mentor Dr Rod Wynne-Jones for their support in gaining her new status, says her next step will be looking at become a nurse practitioner.

The first nurse practitioner prescriber was authorised in 2003 and NPs now have the same autonomous prescribing status as dentists and doctors.

Diabetes clinical nurse specialists have been prescribing as part of a collaborative team for the past five years but the new regulations opened the doors to suitably qualified nurses working in a general practice to district nursing and specialist outpatient clinics to rural nurse specialists to become prescribers as long as they are working collaboratively and have access to a prescribing mentor (see full requirements below)

Reed said the passing of the regulations was a “source of great excitement to the Council and we hope it makes a big difference to patients”.

Health Minister Dr Jonathan Coleman said he welcomed the new regulations, which fit with the government’s approach to improving access to health care and to making the best use of the health workforce. He also added that patient safety remains a top priority.

The regulations allow suitably qualified registered nurses (RNs) who meet Nursing Council prescribing standards to prescribe from a limited list of commonly used medicines (see also prescribing article published in the June edition of Nursing Review for more details on training and qualification requirements).

Coleman said NPs have been prescribing for the past 14 years and for the past five years approved diabetes clinical nurse specialists had been prescribing under the same designated prescriber provision of the Medicines Act 1981 that was now being extended to approved registered nurses.

“Designated RN prescribers will, from mid-September, be able to prescribe a number of commonly used medicines and also provide continuation prescriptions for some medicines started by nurse practitioners or doctors,” said Coleman. “The changes have the potential to reduce double handling and improve access to medicines, particularly for people living in rural or remote regions.”

He added that the Nursing Council had “listened and responded to health groups’ concerns about ensuring patient safety by strengthening the educational requirements on prescribing nurses and revising the list of eligible medicines able to be prescribed”.

“We know from the emerging evidence from other countries, such as Australia, Canada, and the United Kingdom, that registered nurse prescribing is increasingly seen as safe, acceptable to consumers and improves access to medicines.”

Reed said the Council expected to announce before the end of the month the assessment process for nurses who may already meet the education and prescribing practicum requirements to become RN prescribers. “We can be ready to go if there are nurses who are ready to go (on 20 September).” It had also been working to inform pharmacists of the upcoming changes and preparing information to share with the public about RN prescribing via the Council’s website.

A further final step is for Pharmac to consult on extending medicine subsidies to the patients of RN prescribers as they currently are for NPs and approved diabetes nurse specialists.

“It [RN prescribing] has got government support so it is highly unlikely that that won’t occur,” said Reed.

The first patient to receive a prescription written by an asthma, cardiac or practice nurse prescribing in their own right and in their own name should happen this year.

The right for suitably qualified registered nurses (RNs) working in primary health and specialty teams to be able to prescribe from a limited list of commonly used medicines has been a long time in anticipation, but is now in sight.

“We are optimistic that we will have our first nurse authorised this year,” says Nursing Council strategic policy manager Pam Doole.

The first prescribing nurse practitioner (NP) was authorised in 2001 and the first registered nurses (RNs) to prescribe followed a decade later in 2011 with the demonstration trial of prescribing diabetes nurse specialists.

That same year then-Health Minister Tony Ryall invited the Nursing Council to apply to widen prescribing rights for other suitably qualified RNs. A consultation document followed and at the end of 2014 the Nursing Council submitted its application for RN prescribing rights.

This culminated late last year in the Cabinet signing off the proposal and in June one of the last steps – enacting the government regulations required – is expected to happen and regulations  expected to come into force in September.

Then there is just one last hurdle to jump before the Nursing Council can set a date to start assessing and authorising applicants who may already meet the education and prescribing practicum requirements to become RN prescribers. (From next year approved nursing schools will start offering the new postgraduate diploma in RN prescribing for long-term and common conditions but in the interim the Nursing Council is gearing up to consider case-by-case applications.)

That hurdle involves Pharmac, which is understood to be waiting for the regulations to be enacted so it can consult on amending its own prescribing regulations so medicine subsidies are extended to the patients of RN prescribers like they currently are for NPs and approved diabetes nurse specialists.

The Ministry of Health’s Office of the Chief Nursing Officer said in April that it is working with Pharmac to ensure that subsidies are applied to the medicines on the RN designated prescriber list.

Plus, it said, it is working with the Nursing Council and Pharmac to ensure that the diabetes nurse specialists currently prescribing under the 2011 regulations (set up to allow the diabetes nurse specialist prescribing demonstration) retain their prescribing status and ability to prescribe subsidised medicines when the wider regulations come into force.

Jane O’Malley, the Chief Nursing Officer, says RN prescribing will improve access to medicines for people with common and long-term conditions and make the best use of the health workforce by RNs with appropriate experience, education and skills being able to work to the full extent of their scopes of practice. She says it also creates a pathway for RNs to advance their practice including steps along the way to becoming an NP.

How many RN prescribers are in the wings?

It is estimated that there are around 1000 nurses who may have completed a clinical master’s degree, but it is uncertain how many of these have completed a prescribing practicum and are waiting in the wings to seek prescribing authority from the Nursing Council. Of specific uncertainty is how many have been able to keep their prescribing knowledge current and have the backing of their workplaces to become prescribers – as, once authorised, RN prescribers are required to complete a further 12 months of supervised prescribing practice.

Doole says they intend to distribute guidance on what nurses need to consider before they seek prescribing authorisation. “We really want to set nurses up to succeed and also it has to be prescribing within a collaborative
healthcare team.”

She says the emphasis of the regulations is on nurses being able to give patients better access to medicines in primary health care and in those specialty teams where nurses have a significant role in managing long-term conditions such as respiratory, cardiovascular and diabetes.

When it comes to which specialties can be covered under the regulations, Doole says the Council is suggesting that nurses take a good look at the medicines schedule, when finally approved as, while there are medicines there for most common conditions, some of the smaller specialties are not covered.

The 15-page initial medicines schedule lists drugs covering from heart failure and hypertension to treatments for acne, warts and common infections; plus contraceptive pills to antidepressants and painkillers to bronchodilators. Also listed are drugs for which RN prescribers cannot initiate prescriptions, but can approve a repeat prescription.

Sandilands has a clinical master’s degree and has been a diabetes nurse specialist for the past 15 years – training at Nelson Hospital before the keen skier shifted five years ago to take up her current position based at Dunstan Hospital in Central Otago.

She supports the more than 300 people with type 1 and type 2 diabetes across an area stretching from Queenstown and Wanaka in the west to Ranfurly in the east and down to Roxburgh in the south. In 2012 – despite of and because of the isolation – she became the first prescribing diabetes nurse specialist in the South Island, which has reduced the barrier of travel for people.

She is employed as part of the Southern District Health Board diabetes specialist team and works in collaboration with her supervisor, Dunedin-based endocrinologist and associate professor Dr Patrick Manning, with whom she holds regular case reviews both in person and by email.

She offers clinics in Queenstown and Wanaka and most of the general practices across Central so she gets to mentor practice nurses in diabetes care. This means that most of the 18 practices she works with now have a nurse competent to start and titrate patients on insulin – though she is always only a phone call away – compared with  only two or three when she arrived in 2011.

Since last year she has been involved in offering up to monthly paediatric diabetes telemedicine clinics.

A big screen has been set up in Dunstan Hospital so Central Otago families can skip the six-hour-plus return trip to Dunedin and instead join Sandilands and the local dietitian at Dunstan for a video link consultation with paediatrician Dr Ben Wheeler in Dunedin. The children arrive with their downloaded insulin pump information to see “TV Dr Ben” who is larger than life on the big screen and she can do the physical examination and HbA1c tests while Wheeler from Dunedin can discuss test results, ongoing management and any other issues. And Sandilands can write any prescription needed there and then.

Amongst her rural diabetes patients are those keen on smartphone apps with quite a few using an app to download results from their blood glucose meter to share with her and others using apps recommended by the dietitian as being good for carb-counting. While she is concerned about the lack of validation of the many apps on the market she says with so many patients really keen the key was to work alongside the patients who want to use them.

New blood glucose sensor technology to avoid finger pricking (yet to be released in New Zealand) is also appealing to some of her younger clients who are bringing it in from overseas.

Frustration was expressed after the government’s Budget in May that the successful Waitemata District Health Board bowel screening pilot was extended rather than funding announced for a national rollout of screening for bowel cancer, which is New Zealand’s second biggest cancer killer. Health Minister Jonathan Coleman in his Budget announcement said that the largest constraint on rolling out screening nationwide was the lack of workforce to meet the increased demand for diagnostic colonoscopies.

Professor Jenny Carryer, a former nurse representative on Health Workforce New Zealand’s (HWNZ) nurse endoscopy advisory group, argued at the time that the money spent on extending the Waitemata pilot would be better invested in training the expanded colonoscopist workforce.

In late June HWNZ uploaded on the Ministry of Health website the first framework for the “Nurses performing endoscopies” project and said training would be available from 2016 involving two specialist papers and a practicum.

The training is to be subject to identical standards and under the same governance as the training currently provided for gastroenterology and general surgery registrars working in endoscopy.

Nursing Review was declined an interview by HWNZ staff over the delayed start to nurse training but in answer to written questions HWNZ group manager Ruth Anderson said development of the nurse endoscopy training programme was “on track”.

She said some nurses had completed or were close to completing postgraduate papers that would be ‘creditable’ to the programme (which has a prerequisite of a postgraduate diploma in nursing and at least three years specialist experience working in gastroenterology or a related specialty).

Anderson said, in late July, that meetings were scheduled over the next two months with DHBs that are either already supporting or have expressed interest in supporting the training of nurse endoscopists.

“We anticipate that subject to employer support and funding availability, nurses will be undertaking papers specifically designed for nurse endoscopy early in 2016,” said Anderson.

The project website, uploaded in late June, says next steps for the project includes finalising the education framework and it was “in discussion” with the Australian and New Zealand College of Anaesthetists with “respect to conscious sedation requirements”.

Associate Professor Judy Kilpatrick, the current nurse representative on the HWNZ advisory group and head of the University of Auckland nursing school, said Auckland had agreed to develop the two specialist papers required.

She says the specialty papers, focused on gastroenterology and colonoscopy (including conscious sedation) were now ready to go but work was ongoing by HWNZ and the advisory group on finalising the clinical training practicum.

“It is a training programme that requires getting agreement from the DHBs, agreement from the existing gastroenterologists to provide the training and also requires working with the anaesthetists for a satisfactory arrangement,” said Kilpatrick.

She says she was not surprised that training did not get underway at the start of 2015. “I think to be fair that’s because you’ve got to find enough theatres, enough lists, with enough surgeon availability to be able to do the training to grow the numbers.”  She understood meetings were being held in August to finalise the development of training practicums.

“But we fully expect to start offering the first paper at the start of semester one in 2016 and the second paper in the second semester.

“We would expect the clinical hands-on (training) to commence with the second paper (i.e. second semester) as it goes hand-in-hand with the focused colonoscopy paper.”

Kilpatrick say it is expected between six to ten nurses would have met the prerequisites to start the course in early 2016.  “It’s not swamping the field as you just can’t do that…and when you start a new programme clearly you are looking towards taking the nurses who have reasonably significant experience in the area already.”

For more background on the issue see last year’s Nursing Review article, Nurse Endoscopists: the evolution of a new nursing role 

International evidence indicates that screening can reduce annual bowel cancer mortality by at least 14–16 per cent annually. The Waitemata screening pilot underway since 2011 has so far detected cancers in about 180 people before symptoms emerged.

Along with finding the approximately $60 million a year it would cost to screen all 50–74-year-olds, and ensuring the laboratory capacity to test for blood in faecal samples, more endoscopists would be needed to provide the possibly 50–75 per cent increase in demand for colonoscopies to diagnose whether cancer is present.

How can that increased demand be met? With nurse endoscopists already established in the UK, and training soon to be underway in Australia (see more online), training our own nurse endoscopists was soon bandied around as one possible answer.

But it wasn’t an easy answer. It raised questions about how willing and able our already pressured endoscopy services were to train nurse endoscopists on top of training more traditional gastroenterologist and general surgeon endoscopists. A survey in 2011 of the 84 medical endoscopists then working in public hospitals found just 30 per cent of respondents had a positive attitude towards introducing nurse endoscopists. A survey at the same time of the about 190 nurses working in public endoscopy services found that only 35 per cent of respondents were willing to consider training as nurse endoscopists.

New Zealand was also lacking a national quality and auditing programme for endoscopy and no competency framework for nurses working in the field (which didn’t help the proposal to recruit a UK-trained nurse endoscopist for a New Zealand pilot – the proposal eventually fizzled out).

Uneven quality and lack of national standards in endoscopy services

Things were not moving fast when Jenni Masters – now the National Endoscopy Service improvement lead – was appointed in 2010 with clinical director Dr David Theobald to the National Endoscopy Quality Improvement programme (NEQIP). The first focus of the programme was gauging the quality of endoscopy services already on offer as the Ministry of Health geared up to begin the Waitemata bowel screening pilot in 2011.

Masters’ own nursing background included gastroenterology and being a charge nurse manager in gerontology and committee member of the NZNO Gastroenterology Nurses Section.

She says NEQIP began by carrying out a national stocktake of public endoscopy services that found a wide variation in the way endoscopy services were being delivered across the country. Likewise, endoscopy nursing roles varied greatly, with some nurses assisting physician endoscopists with manipulating auxiliary equipment down the endoscope and others not (see sidebar and online only sidebar at www.nursingreview.co.nz).

The lack of consistency was further highlighted when NEQIP trialled in four DHBs – now rolled out nationally – the United Kingdom-based quality assurance system known as the Global Rating Scale (GRS) that has a set of quality standards for endoscopy services to be working towards, including workforce standards.

One need identified was for national consistency in assessment, education and training for endoscopy nurses and a project was set up, initially led by Megan Buckley of Tauranga Hospital, to develop a knowledge and skills competency framework for endoscopy nurses.

A competency framework was seen to improve not only the quality of endoscopy nursing but also the quantity, by providing a career path towards senior nursing roles – such as clinical nurse specialists in areas from hepatology to irritable bowel syndrome, and in time, nurse endoscopist and nurse practitioner roles – that could attract more nurses into the field.

Pro or anti-nurse endoscopist?

Difficulties in recruiting and retaining endoscopy nurses, along with the need for more gastroenterologist endoscopists, was noted in the 2011 report to Health Workforce New Zealand (HWNZ) by the Gastroenterology Workforce Service Review.

The review report noted not only the ageing endoscopy nurse workforce and the lack of appeal to younger nurses but also “major concerns with nurses currently performing extended roles with no recorded job description, no title, no competencies programme, and no reimbursement structure”.

In addition, there was “high awareness” that some within the medical profession were anti-nurse endoscopist.

With only an estimated 50 full-time equivalent gastroenterologists and general surgeons (a number work across both the public and private sectors) currently delivering endoscopy services in public hospitals, and with only a handful of gastroenterologists graduating each year, the report noted that there was only a limited pool of endoscopy training places available for gastroenterology registrars and general surgical registrars before adding trainee nurse endoscopists to the mix.

“In addition, doctors need to agree to training and overseeing nurse endoscopists, which is a barrier currently,” said the 2011 review document.

The workforce service review recommended that HWNZ work with the Nursing Council and other relevant bodies to set in place the means for RNs to train to become “nurse endoscopists in supervised roles in larger centres”.

In the wake of that recommendation, the New Zealand Society of Gastroenterology surveyed its membership and reported “more than half” supported the appointment of nurse endoscopists and “most” would be willing to train nurse endoscopists. In November 2012, the society came out with a revised position statement supporting the introduction of nurse endoscopists but said first an agreed practice framework had to be established and issues of safety and competencies had to be addressed.

Knowledge and skills framework for endoscopy nurses

By this time, work was well underway on the knowledge and skills framework, with good input from public and private sector endoscopy nurses keen to help.

Masters said this led to the first iteration of the framework, with ongoing development work picked up by Christchurch endoscopy nurse leader Gendy Bradford, who was employed last year by NEQIP as nursing workforce development lead (she was joined this year by MidCentral DHB gastroenterology clinical nurse specialist Anne Cleland).

To ensure the framework is practical and usable in the endoscopy workplace, it was decided some directly observed practical skills (DOPS) assessment tools for different types of endoscopies and pre- and post-procedural care were needed.

Feedback on how effective the assessment tools will be was gathered at a meeting with gastroenterology charge nurse managers in August, along with further discussion on when and how to launch the knowledge and skills framework.

The framework does create a path for endoscopy nurses from competent through proficient to expert but competencies and training standards for nurse endoscopists will not be just nurse-specific.

NEQUIP says its strategic goal is for New Zealand to train endoscopists and “not surgeons, physicians, or nurses who perform endoscopy”.

“Everyone should be trained in exactly the same way because they are doing exactly the same procedure,” says Masters.

So along with refining the endoscopy nursing framework, NEQIP has other work streams in enhancing endoscopy training overall and the setting up of a national governance body to oversee a new competence-based training and assessment platform for all endoscopists

Masters says the interdisciplinary governance body – with representatives from the relevant medical and nursing professional groups – would be a first for New Zealand.

The Nursing Council has now also approved processes for the credentialing of expanded practice in specialty nursing areas – though there were quibbles by some over whether endoscopy fitted the criteria and whether it was more a technical skill than expanded practice.

But others argue that nurse endoscopy is much more complex than skilfully inserting an endoscope into somebody.

Masters says nurse endoscopists need not only expert technical skills but also knowledge of histology and pathophysiology, along with high-level clinical decision-making abilities to ensure patient safety and good care. The next step is deciding on an education and training programme.

Nurse endoscopist training underway soon?

Laying the groundwork to build the quality and quantity of public endoscopy services has been steady to date but the training of nurse endoscopists now appears to be on the fast track.

The pace stepped up in March when Tony Ryall announced an April symposium looking at ways of boosting the colonoscopy workforce–and nurse endoscopists were definitely on the agenda.

Ruth Anderson, HWNZ’s manager of Workforce Education Intelligence Planning, says out of the symposium came several “pieces of work” around the “role of nurses performing endoscopy” i.e. nurse endoscopists – including establishing an advisory group which Anne Cleland of NEQIP and gastroenterologists group, of which are amongst the members.

Anderson says amongst advisory group purposes are finding the best ways of increasing the number of nurses able to do endoscopy and establishing education and training requirements.

“The development of that role (nurse endoscopist) and performing gastrointestinal procedures will be considered in a wider context of developing advanced nursing roles so that it contributes to a career pathway for nurses,” says Anderson.

But any training is also to come under the national governance body and training standards that are consistent and identical whether they are doctor or nurse endoscopist trainees.

“From the viewpoint of the patient, they will be able to have the same level of confidence in the endoscopic procedure, regardless of who carries it out, but recognising that follow-up work from nurse endoscopy would then be undertaken by a gastroenterologist.”

Anderson wanted to stress that the training of nurse endoscopists was to complement and not replace gastroenterologists and general surgeons carrying out endoscopy, with registrar training numbers in the two medical specialties also to be increased.

Nursing Review spoke to Anderson in early July prior to the Minister’s July 29 announcement that the first nurse endoscopists were to start training next year.

She said at the time that training processes were still under development and it was hoped to have an agreed training by the end of the year.

The aim for the theory side was likely to develop a postgraduate diploma with an endoscopy focus that was “professionally recognised, credentialed, portable, reflected best practice and absolutely demonstrated inter-professional learning”.

Asked when it was likely that a training programme was likely to be available to trainee nurse endoscopists, Anderson said at the time they were not certain and to get tertiary education providers on board could “take another year beyond next year” but the pace could depend on government decision-making.

She indicated that initial nurse endoscopist trainees are likely to be senior nurses who have already undertaken significant postgraduate study relevant to endoscopy.

Following the Minister’s announcement, his office was asked whether the qualification and training programme for nurses was now to be fast-tracked and give the go-ahead prior to setting up the national governance body.

His office declined to comment and referred all questions to HWNZ. Anderson said in a written response that “while final specifics such as available places are currently being developed, Health Workforce New Zealand expects to have nurses beginning postgraduate training to perform endoscopy from early 2015”.

So it looks like a matter of “watch this space”, but nurse endoscopists are on the way.

DHB: Counties Manukau

Job: Nurse practitioner (adult intensive and high dependency care), Middlemore Hospital

Dr Alison Pirret is a nurse practitioner whose vision has taken critical care nursing beyond the walls of the traditional ICU and into the ward setting.

Last year, the adult intensive and high dependency care NP successfully completed her PhD comparing the diagnostic reasoning of NPs and medical registrars. She is the author of a 390-page acute care nursing textbook that is into its second edition.

“Alison is the epitome of what it means to be a hero role model,” says Counties Manukau acute care clinical nurse director, Annie Fogarty.

“Like how the media portrayed (super) heroes, on the surface, Alison appears incredibly normal and unassuming. However, this highly intelligent, passionate, professional, and empathic educator, team player, and visionary leader in her field doesn’t suddenly need to change her personality, shape, or form to bring her skills to the fore in a time of crisis.”

Pirret developed her NP role to meet an identified ICU outreach need and works in Middlemore’s critical care complex as an outreach NP and in support of the Patient At Risk team.

Fogarty says Pirret’s role is pivotal in supporting nursing and medical staff to identify and successfully manage patients at risk, within the ward setting.

“Alison would maintain this is nothing special, it’s what she does every day; we would argue that it takes a special type of hero to do this.”

Name: Anamaria Watene

DHB: Bay of Plenty

Job: Clinical nurse manager, Kaupapa Ward, Tauranga Hospital

Anamaria Watene has turned her Kaupapa ward from one that has faced complaints to one that regularly receives compliments.

An intentional rounding pilot was introduced into the ward at Tauranga Hospital in 2011, leading to a dramatic rise in the frequency of times patients are checked every hour. The raw data collected in 2011 showed the lowest daily hourly rounding was 46 per cent, which increased to 100 per cent in 2012, and has remained at this high level through 2013 and the first two months of 2014. Watene, charge nurse manager of the ward, attributes the dramatic improvement to her staff buying into intentional rounding and all disciplines working as a team. Her major goal with intentional rounding has been to reduce harm from falls by minimising the risk of falls by patients by meeting the patient’s fundamental care needs.

The mantra of the ward is now A for aid mobility; B for bell, pain, position; C for clutter; D for drink; E for elimination (toileting), and signs reminding staff and patients are found throughout the ward.

“The systems introduced include mobilisation recommendations, rounding checks, signs in every patient’s room, all actions recorded in the Care Plan, and audited twice a month, with an intentional rounding audit once a month,”says Watene.

Additional prompts Watene has introduced include rounding checks on computer screensavers and coloured 3D rounding checks ticker-taping across computer screens.

Name: Anna Reed

DHB: Wairarapa

Job: Nurse practitioner, Masterton Medical

Anna Reed is a nurse practitioner creating wrap-around care for the high needs elderly in the community with often complex health needs.

She works for Masterton Medical Centre,

New Zealand’s largest general practice, with 23,000 patients. About half of her patients are in the community and the other half in residential aged care facilities.

After completing her clinical Masters in 2009, Anna was Wairarapa DHB’s clinical nurse specialist in aged care before moving to general practice to train as an NP.

“Once I worked with older people, I never wanted to do anything else,” she says.

“Most have had such a remarkable journey and have so many stories to tell. Many are lonely, anxious, and some are angry. Their families may have gone away, their friends are dying, and some struggle to care for themselves in their own homes.”

Their health issues can be complex and many of her referrals are for people in the early stages of memory impairment or dementia.

“Ensuring support packages are in place such as access to day activities, respite and carer-relief is essential to protecting the valued carer role.”

Anna’s role includes assessment, diagnosis, and treatment, including prescribing, of acute and chronic illness in consultation with GPs, DHB physicians, and other members of the multidisciplinary team involved in coordinating care of older people. She also does the three-monthly reviews of rest home patients, looking at their mobility, medication, and wellbeing, and talking to family members.

Name: Anne Cleland

DHB: MidCentral

Job: Gastroenterology lead clinical nurse specialist

Anne Cleland is in the forefront of helping build a endoscopy nursing skills framework, which may lead to the development of the nurse endoscopist role in New Zealand.

Cleland, who has a Master’s degree in nursing, has a background of 25 years of endoscopy nursing, mostly at MidCentral Health, but including some years in America. She has recently been appointed to a

part-time position with the National Endoscopy Quality Improvement Programme (NEQIP) as a nursing workforce development lead. In this role, her focus will initially be on the continued development of an Endoscopy Knowledge, Skills and Competency Framework for endoscopy nurses, which may include the development of a nurse endoscopist role in New Zealand. She will also be supporting the national implementation of the NZGRS (a patient-centred quality improvement tool) and other NEQIP activities.

In addition to these roles, Anne has been treasurer on the New Zealand Nurses’ Organisation Gastroenterology Nurses Section and is also a member of the National Bowel Cancer Working Group. Recently she was awarded a travelling scholarship and visited England to view hospitals that have implemented the Global Rating Scale and viewed workforce development initiatives and efforts to improve the patient journey.

Gastroenterology charge nurse Lynley Morton says that Cleland’s work is helping put gastroenterology in the spotlight.

“Not only is her experience helping us develop our service here at MidCentral Health, but it’s helping nurses and patients around the country.”

Name: Brenda Baird

DHB: Auckland

Job: Staff nurse, respiratory ward, Auckland City Hospital

Brenda Baird is a staff nurse who made up to two litres of Milo a shift for a vulnerable long-term patient and is seen as a nursing hero for consistently going the extra mile.

Each month, one member of the Auckland DHB team is selected as a local hero with nominations coming in from patients, their families, and from staff alike. Earlier this year, Brenda Baird, a staff nurse of 30 years at Auckland City Hospital, was nominated by her charge nurse, Sarah Wilson. Wilson says Baird consistently goes the extra mile for patients.

“The effects of her care and attention were recently demonstrated when she was looking after a very vulnerable, long-term patient. Every shift, Brenda would make this patient up to two litres of hot Milo, one cup at a time. She led the team to manage his pressure sores, improving his health and enhancing his experience of being in hospital. This patient now smiles and communicates – he is a completely different man.”

Wilson says Baird works tirelessly for patients to ensure that they get the best out of life.

“She really listens to them, understands what they want for their life, and then she works closely with them and their families to help them achieve their goals.

“Brenda is well-known and loved by our patients who comment they feel better when she walks in the room.”

Name: Delia Williams

DHB: Whanganui

Job: Clinical nurse specialist diabetes

Becoming Whanganui’s first diabetes nurse specialist prescriber has enabled

Delia Williams to make a big difference to her patients.

Williams, who has been in nursing since 1984 and a diabetes nurse for 13 years, is one of only 27 nurses in the country employed in the prescribing diabetes role.

“Being a designated diabetes prescriber is a small but very exciting aspect of my role because it gives me the opportunity to advance my clinical practice while offering an efficient and comprehensive service for those with diabetes,” Delia says.

“Prescribing can make a significant difference for the patient by simplifying the processes involved for them and by influencing their continuity of care.

“Unfortunately, the number of patients with diabetes has almost doubled in the last 10 years, so it’s important we extend the scope and skills of our healthcare team to help us manage the increase.

Williams see patients on the hospital ward, outpatients, and also hold clinics in rural health centres. She also provides education and support to nurses working at the hospital and in general practices.

Williams supports a collaborative approach by the DHB’s diabetes service to strengthening the partnership between primary and secondary care with the aim of maximising available resources for the management of diabetes. Her vision is to bring about change by empowering nurses through their knowledge and skills, working alongside them to build confidence and foster a seamless service for people with diabetes.

Name: Fiona Unaç

DHB: Hawke’s Bay

Job: Acute care nurse practitioner (radiology and vascular services)

Fiona Unaç is the only nurse practitioner in Australasia working in the acute care specialties of radiology and vascular services.

Hawke’s Bay DHB chief nursing officer Chris McKenna says Fiona is a real nursing hero because she is “innovative, positive, and goes the extra mile to improve patient outcomes”.

“Fiona carries out technical skills traditionally performed by doctors, such as ultrasound guided paracentesis and thoracentesis, and she has a core responsibility of delivering advance nursing care across radiology and vascular services from first specialist assessment to post procedural follow-up.

“She is the only nurse practitioner in Australasia working across these specialties and has a special interest in peripheral vascular disease (PVD) management, particularly as people with PVD are a high risk but neglected disease population.”

McKenna credits Unaç with working to make sure this group of patients is better integrated into the system and not forgotten.

Unaç’s nursing achievements have also been recognised by her peers firstly as a recipient of the DHB’s Innovation in Nursing Award in 2010, and then as a recipient of a New Zealand Nurses Organisation Award for Services to Nursing and Midwifery in 2013. She is the current chair of the Perioperative Nurses College (NZNO) and is a technical expert in medical imaging nursing for International Accreditation New Zealand.

Name: Helen Lloyd

DHB: Canterbury

Job: Community clinical nurse specialist (older people’s health)

Helen Lloyd is passionate about helping older people stay well in their own homes and has been key to a number of post-quake Canterbury initiatives aiming to do just that.

“I have a huge passion for older people in terms of helping them to live the way they want to live.” Lloyd is a key member of the Community Older Persons Health Team and has been instrumental in a number of innovations in the Canterbury Health System for older people in the community including a lead role in launching the Community Rehabilitation Enablement and Support Team (CREST).

“If it was not for the amazing team of people I work with, then this job would be impossible. We have the best clinical leaders and multidisciplinary teams I have worked with anywhere in the world; that includes the 20 years I spent in England,” Lloyd says.

Kate Gibb, the DHB’s nursing director for older people’s health, says Lloyd continues to work closely with CREST along with filling gaps across a multitude of other roles including managing clinical teams and supporting gerontology nursing colleagues in Canterbury and the West Coast.

“Helen manages to fit an enormous amount into her working week … amidst all of this she still manages to support and regularly visit her own clients.”

Post-quake, Lloyd was part of the team supporting vulnerable aged residential care facilities, providing practical support to facilities, which had lost vital services and infrastructure such as power and water. She was also part of the team that led to the development of a Motor Neurone Disease facilitator role within the Canterbury Initiative.

Helen is an assessor and advocate for the Professional Development Recognition Programme (PDRP) and has also led the introduction of nursing students and Nurse Entry To Practice (NETP) into the community team, which is now a Dedicated Education Unit (DEU). She also established a team to develop Older Person’s Health Specialist Service education days, which are attended widely by nurses across the DHB, community, and residential care sectors.

Name: Nikita Fleming

DHB: Nelson-Marlborough

Job: Mental health nurse (second year)

Nikita Fleming’s career has moved from beauty therapy to building therapeutic relationships with her mental health clients.

The 24-year-old came to nursing via a roundabout route, as after leaving school at 16, she worked in her father’s factory and completed a beauty therapy diploma before deciding she wanted a career with more substance. As a nursing student, Fleming did a placement at Nelson Hospital’s mental health acute unit and was hooked.

“Building a therapeutic relationship with mental health consumers is both critical to develop, as well as a challenge, but that is what I enjoy about mental health nursing,” says Fleming.

“Developing rapport and trust with a person to allow you to provide care is the most important part of my job.”

Last year, while working full-time during her Nursing Entry to Practice (NETP) new graduate programme, she completed a Postgraduate Certificate in Nursing (Mental Health) through Whitirea Community Polytechnic. She says she really enjoyed study at this level and will continue to study to keep her practice current and to create a body of knowledge that reinforces “why we do what we do”. She is nominated by NMDHB as a young nursing hero who has embraced both the academic and therapeutic aspects of nursing.

Name: Sara Best

DHB: Capital & Coast

Job: District nurse (wound care management)

District nurse Sara Best’s enthusiasm and humour has helped introduce 60 of her colleagues to using a high tech, handheld laser camera to measure and monitor wounds.

Best has been named Capital & Coast’s nursing hero for her pivotal role in training the DHB’s district nursing workface in the use of the innovative wound care technology across the board’s Kāpiti, Kenepuru, and Wellington bases.

The Silhouette system comprises a 3D laser camera that captures dimensions of length, area, depth, height, and volume of a patient’s wound at home or in a clinic. That information is then logged on a secure database, from which reports can be generated to assist district nurses in the management of surgical wounds, pressure sores, and leg ulcers.

“It’s motivating for staff and patients – the graphs that we can produce make it clear for people to understand if their wound is progressing or not, and provides objective, robust data when we’re liaising with clinicians.”

Now just one paper shy of her Master’s in Nursing, Best has educated district nurses of all ages, backgrounds, and computer skill levels with humour and enthusiasm, on top of her regular role providing lower limb Doppler assessment and complex wound care management. She’s been a district nurse for around 15 years and has tried other roles but always gone back to district nursing, specialising in her passion of wound care management.

“Now we can track an ulcer. If it’s not improving, we can assess the aetiology of an ulcer and intervene proactively with best practice treatment to ensure a faster healing rate.”

Her colleagues praise Best’s compassionate and inspiring manner and speak highly of the way she challenges their thinking to encourage evidence-based best practice.

Name: Kirstin Unahi

DHB: Southern

Job: Oncology nurse educator and nurse-led oncology assessment clinic.

Kirstin Unahi is helping cancer patients by identifying early potential side effects of their chemotherapy and offering timely intervention.

Southern DHB says Unahi is a dedicated oncology nurse educator for the Southern Blood and Cancer Service in Dunedin. She is also on the nurse practitioner pathway and is working on expanding her clinical skills and knowledge by running nurse-led oncology clinics for the board’s oncology assessment unit.

This unit provides a proactive service to patients having chemotherapy treatment by phoning patients post-treatment with the aim of promptly identifying potential side effects and providing early intervention. Patients can also come into the unit for a nursing assessment, after which nurses liaise with the medical teams in developing treatment plans. The DHB says the unit’s service is reducing the number of patients requiring admission to the oncology in-patient ward, enabling patients to stay in their own homes.

Unahi’s motivation and positivity is admired by her colleagues and nursing leaders and is seen as a role model to younger members of the nursing team of what can be achieved through hard work and a ‘can do’ attitude.