5.30AM WAKE

Wake to alarm, shower, eat breakfast while reading Stuff News online.

6.15AM ON THE ROAD

Travel to work, taking the car today instead of my usual motorcycle ride as it’s drizzling and cold. There’s minimal traffic on the motorway this morning because it is a public holiday and car parking is also easy, so I arrive 15 minutes early for work.

I trained as a registered psychiatric nurse at the former Sunnyside Hospital and have been nursing for Canterbury District Health Board mental health services for 33 years. For the past eight years I’ve been working alongside police custody staff in the Christchurch Police watch-house to assess people in custody for mental health issues, their risks to themselves and others, and for alcohol and other drug issues. In the 18 months prior to the watch-house initiative there were three suicides in the Christchurch Police cells. Since the initiative started in 2008 there have been no deaths in the cells due to suicide or medical issues. My colleague Neil McNulty and I were humbled last year to receive Police District Commanders’ Commendations for our work. Today I am on a 7am to 3.30pm shift.

7.00AM HANDOVER

I greet my nightshift colleague and receive a verbal handover. There is more than the usual amount of chaos in the custody unit today, with 30 detainees going from the cells to court, two of them requiring further review by the mental health service (MHS) teams at the courts. Two also require a review by me before leaving for court at 8.30am and one detainee needs a review once they are sober enough to be released from custody. There is also a juvenile detainee under youth mental health services, who will need to be notified that he’s in court this morning.

7.10AM WORK WHIRLWIND BEGINS

The next three hours are a whirlwind of activity, including assessments, the handover of risk issues to court escort staff, and arranging for two reviews by MHS at court for detainees with ongoing mental health and risk issues, as well as communicating risk and health information to the court liaison nurse and the prison health unit.
Unfortunately I missed the Police District Command Centre daily briefing meeting this morning due to the pressure of work. Today is particularly busy for a day shift – on average the watch-house nurse team sees 40–60 people a week, with the weekends usually being busier due to more intoxicated people.

Once the people head to court the watch-house calms down a little and I’m able to review another person, resulting in a referral to the DHB’s Single Point of Entry (SPOE) service for adult mental health services. I also fit in several consultations with police officers dealing with people in the community with mental health issues.
Then two more people are brought into custody requiring my attention. One is threatening suicide and my input is required to de-escalate him to the point where he can be received into custody. The other is a woman who appears to be psychotic, possibly due to methamphetamine use. I decide to observe her for a while in the cell to see whether she improves over time and see exactly what is happening for her.

10.00AM GRAB COFFEE AND BACK INTO IT

I manage to grab the first coffee for the day and drink this while discussing how best to assess the two new detainees. The next three and a half hours involve assessment of the woman with methamphetamine psychosis, who requires a referral to the DHB’s crisis team for further assessment under the Mental Health Act, plus the assessment of three other detainees not requiring further referrals.

The young man who was threatening suicide settles down rapidly and appears to have been decompensating (deteriorating) behaviourally, which had led to him catastrophising his situation. I also hold several more phone discussions with police on matters involving people with mental health issues in the community.

1.30PM HANDOVER AND LATE LUNCH

I provide a handover to the court escorts who are taking the man who had earlier threatened suicide to court. No follow-up is possible with this man as he intends to leave Christchurch this afternoon, has no phone or family to contact, and is declining further MHS input. I have a quick lunch and a coffee at my desk.

The crisis team arrives for a Mental Health Act assessment of the woman with methamphetamine psychosis, which requires handover and liaison. A further assessment of a detainee takes me up to 3.15pm, when the afternoon shift nurse arrives to take over. I provide handover for three people who require assessment, plus the ongoing Mental Health Act assessment. Today has been a particularly busy day so I leave 30 minutes late after catching up on documentation.

4.30PM HEAD HOME

I arrive home after mental de-stressing on the way home. I contemplate a number of concerns around some of the people I have seen today and think about some of the decisions I have made. The job we do carries a lot of risk, given the nature of the people we see, the environment we see them in and the pressure of police and court processes that determine the time available for the assessments we do.

I sit in the sun with a coffee and a book for an hour and say “hi” to my wife, Susie, when she arrives home. We then go for a walk together, and talk a bit about about our respective days at work. We cook dinner, have a couple of red wines and a general chat while we watch a movie on TV.

10.45PM BED

I head to bed, reflecting on what has been a very busy day for me and contemplating with some trepidation that tomorrow is New Year’s Eve, which is normally extremely busy at work. I wonder what that might bring.

JOB TITLE: Clinical nurse specialist, Anaesthetic Preoperative Assessment Clinic (APAC), Dunedin Public Hospital, Southern DHB

Nursing and other qualifications/awards:

• Bachelor of Nursing 2004 (Otago Polytechnic)
• Bachelor of Nursing (first class honours) (while completing new graduate programme at Dunedin Hospital)
• Toi Paematua Raranga (Diploma in Traditional Māori Weaving) 2009 (Te Wānanga o Aotearoa)
• Aoraki Bound 2012 (Kai Tahu and Outward Bound course)
• Level 4 Professional Development and Recognition (PDRP) portfolio 2013 (Southern DHB)
• Master of Nursing (with Merit) 2014 (Massey University, Albany)
• Ngā Manukura o Āpōpō Leadership Course 2015 (marae-based course for Māori nurses and midwives at Tuahiwi Marae, Christchurch)
• Southern DHB Nursing Excellence Award 2016 (plus recipient of Dunedin North Rotary scholarship for professional development)

Briefly describe your initial five years as an RN.

I started nursing in Older Person’s Health (medical/rehabilitation/psychiatric). I believe Older Person’s Health is a great platform to embed the fundamental skills taught in the nursing degree. I stayed on for six months after completing the new graduate programme for this reason, before transferring to general surgery. I worked in a number of areas within general surgery, including the surgical ward, surgical pre-admission, day of surgery admission, and as the follow-up coordinator.

Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career?

Not really, a wise nurse once said we do not know the jobs we will be doing in the future as they are yet to be created. When I graduated with my BN degree, my philosophy of nursing practice had three parts under the kaupapa of cultural safety (kawa whakaruruhau). These aspirations still resonate with me today:

• Reflective practice (i ngā wā ō mua), we take our experiences with us into the future, so we must take time to reflect.
• Professional development (te ao marama), we all have a responsibility to continue learning as nursing practice continually changes.
• Self-determination (tino rangatiratanga), to work in a patient/whānau-centered, respectful and appropriate manner with all patients coming into this (foreign) environment. This concept also extends to tino rangatiratanga as a nurse and to value others in the multi-disciplinary team.

What led you into your current field or specialty?

I saw an opportunity to improve the patient’s elective surgery experience. I wanted to provide an opportunity to optimise patient health and ensure patients felt informed prior to elective surgery.

What skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role?

• Knowledge and understanding of pre and post-op care of the surgical patient, including discharge planning. Preoperative assessment is a valuable time to walk through the elective surgical experience, while ensuring patients feel informed and supported during a potentially vulnerable time.
• The follow-up coordinator role was an autonomous position that required a critical lens to review patient progress and promote optimal post-op recovery. It was also the avenue to oversee complex, long wait cases that needed intensive management.

What personal characteristics do you believe are particularly important for nurses working in your role?

A positive attitude, great communication skills, flexibility, patience, being proactive, organised and always looking to improve.

What career advice would you give to nurses seeking a similar role to yours?

• Know yourself and work to your strengths.
• Have good support and mentors.
• Be self-caring and have a good work/personal life balance.

Describe your current role and responsibilities.

• I take care of the operational aspects of APAC at Dunedin Hospital, including:
• running APAC at Dunedin Hospital, including day-to-day rostering and organising leave cover
• being a resource person by providing leadership, mentoring, training and support to staff in APAC
• working alongside a team of registered nurses, a healthcare assistant, and the consultants and registrars rostered to clinic, with accountability to the APAC manager
• providing presentations about APAC
• problem-solving any operational issues and ensuring APAC processes are robust
• working closely and collaboratively with the consultant clinical leads to manage quality issues
• working closely with the surgical specialties
• maintaining the APAC electronic database and initiating quality improvements
• ensuring collaboration between Dunedin and Southland sites via the Anaesthetic Preoperative Assessment Governance Group.
• I am a member of the Perioperative Nurses College and the Gerontology Section of NZNO.

JOB TITLE: Plunket Society national educator

Nursing qualifications:

• Diploma in Nursing 1984 (Wellington Polytechnic)
• Plunket Certificate 1989 (Plunket)
• BA Social Sciences (nursing) 1999 (Massey University)
• Postgraduate Certificate in Professional Nursing Practice 2003 (Otago Polytechnic)
• Master of Nursing 2005 (Massey University)
• Further postgraduate papers 2013 (University of Auckland)

Briefly describe your initial five years as an RN.

In my early nursing career I worked in several roles at Hutt and Wellington Hospitals including medical, general surgical, paediatrics, cardiothoracic surgery and radiology before moving to Christchurch to work in the neonatal unit and then a general medical ward.

Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career?

On graduating I had no particular career plan as I was bonded, which meant on gaining a hospital placement I was routinely rotated between areas. Focusing on a particular practice area as a result was not possible but I had the opportunity to have a wide variety of experiences. Each experience provided me with growing skills in nursing care and communication, working as a team member and developing an interest in quality and innovation.

What led you into your current field or specialty?

One of my rotation placements was paediatrics; at the time it seemed like a daunting area of practice for a new graduate but it started my passion for working with children and their whānau. The vulnerability of children and disparity in health outcomes was apparent with many children with preventable infectious diseases and injuries admitted to the ward.

In the paediatric ward and NNU I saw the considerable stress that hospitalisation places on whānau. This gave me the drive and passion to want to work in the community to improve child health through prevention and early detection. On returning to Wellington from Christchurch an opportunity to undertake the Plunket training became available, leading to an amazing career change. I was provided with opportunities to work with whānau to share in their challenges and delights and to work in nursing leadership and education.

What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role?

Undertaking professional development and postgraduate study has been vital to my practice, leading to my current role as a Plunket educator. My BA and MN degrees are the foundation that further professional development has built on.

I have developed a passion for learning about health disparity and its impact on communities and vulnerable children. More recently I have become increasingly interested in education on nurse client partnership, parenting and infant mental health. Last year I was awarded the Margaret May Blackwell Travel Fellowship to explore how child vulnerability could be reduced by strengthening caregiver infant relationships. The opportunity to travel to meet international experts in the field of infant mental health, community child health, training and research was invaluable to my role and the potential to lead change in practice and service delivery.

What personal characteristics do you believe are particularly important for nurses working in your role?

In my role as an educator I see the important personal characteristics as being empathy for nurses in their complex role, to be open-minded, reflective and innovative. As a Well Child nurse, I believe there is a need to be passionate to work within communities, to be hopeful that adverse child experiences will be reduced, to have a belief in the capacity of parents and the role of the Well Child nurse to support the reduction of disparity.

What career advice would you give to nurses seeking a similar role to yours?

I would suggest that nurses wanting to have a role in community practice and education talk to colleagues and nursing educationalists about their passion and career pathway. This includes how to gain clinical experience and which education pathway to take. This is not only nursing postgraduate education but also opportunities to attend conferences, short courses and seminars. Reflecting on current practice and evidence will help identify gaps and potential for innovation and change. Talking to clients and community groups about their current and future needs will help to keep relevant and client focused. Nurses also need to surround themselves with passionate people and mentors.

Describe your current role and responsibilities?

Currently I am a national educator working for Plunket. This role includes supporting Well Child/Tamariki Ora nurses undertaking the Postgraduate Certificate in Primary Health Care Speciality Nursing (Well Child/Tamariki Ora) and supporting ongoing professional development within Plunket.

Job title: Charge nurse manager, Assessment and Diagnostic Unit, North Shore Hospital, Waitemata DHB

Nursing qualifications:

• Diploma of Nursing 1991 (Auckland Institute of Technology – now AUT)
• Health Assessment papers 2001 (Christchurch Polytechnic Institute of Technology – now Ara Institute of Canterbury)
• Master of Health Science still in progress (Auckland University of Technology)

Briefly describe your initial five years as an RN.

New graduate nurse positions in New Zealand were limited when I gained my nursing registration in 1991. Due to this I applied across the Tasman and gained a new graduate post at the Princess Alexandra Hospital in South Brisbane. New graduates at Princess Alexander rotated between three types of specialties to gain experience, including four months on a general medical ward and four months on a general surgical ward. This opportunity allowed me to gain valuable experience, skills and knowledge.

For the last four months I chose to move to the emergency department (ED) and that was the commencement of my 20-year journey in ED throughout Australia and New Zealand.

After completing my new graduate year I was fortunate enough to be offered a permanent position and spent a further four years consolidating my knowledge and skills in trauma with emergency nursing. After spending five years at the Princess Alexandra I wanted to develop my skills and moved to Darwin, Northern Territory, to work at the Royal Darwin Hospital in the ED for a further five years.

Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career?

My initial career plan was focused on getting a job after I qualified. The lucky opportunity to move to Australia and gain the post at Princess Alexandra gave me the opportunity to experience different nursing specialties. I always had an underlying dream to do emergency nursing. The chance to experience the adrenaline and environment of a normal day of an emergency nurse during my new graduate year sparked my interest in emergency nursing into a passion and gave me the drive to follow my dream.

What led you into your current field or specialty?

After a further five years in Royal Darwin Hospital I moved back to New Zealand to be closer to family and worked at the ED at the North Shore Hospital for 10 years. During this time I was lucky enough to progress through the senior ranks and worked as a clinical charge nurse for five of those years.

This experience gave me my first taste of leadership and management and started my current journey of management and has led me to where I am today.

I progressed to team leader at a large rural GP service north of Auckland and then as clinical learning leader at AUT for the undergraduate nursing degree before settling in my current role.

Throughout my career three mentors assisted with my career path and without their inspiration, direction and guidance I would not be where I am today.

What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role?

My personal stepping stones for progression were the ability to lead a team in the emergency department. This progressed with relevant courses, e.g. preceptorship, leadership and management courses, and the ability to develop leadership experience by hands-on experience, mentoring, clinical supervision and reflection.

What personal characteristics do you believe are particularly important for nurses working in your role?

The ability to lead a team must coincide with individual ownership and partnership for all team members. Communication, meeting team expectations and being a visible leader who both listens to staff and is approachable is imperative. Keeping staff fully informed and included with the change process allows a joint ownership and partnership for moving forward to achieve best optimum results.

What career advice would you give to nurses seeking a similar role to yours?

Set your goals, get a mentor and start to be the leader you want to be.

Describe your current role and responsibilities.

My current role is charge nurse manager in the Assessment and Diagnostic Unit at North Shore Hospital. This unit is a 50-bed unit, which works alongside the emergency department and is an acute, fast-paced environment with a high turnover of patients. My responsibilities include managing:

• the quality of nursing care to meet patient needs
• the culture to deliver excellent customer service for positive team relationships
• the environment, equipment and systems that delivery cost effective service of the highest standard
• professional development, applying learning to enhance clinical leadership and patient outcomes.

A mental health nurse with an empathetic air for all has been nominated as Southern DHB’s unsung nursing hero.

Julie Coverson is a very modest person and needed some assistance to recognise her hero qualities.

A nurse for 25 years, Julie started her nursing career in the United Kingdom, where she specialised in mental health nursing. She has spent the past 15 years working in Dunedin in various mental health roles and now works as a psychiatric liaison nurse as part of a small team working with a consultant psychiatrist and a registrar.

Her broad role encompasses taking care of the mental health needs of patients within general hospital settings as well as the support and education of nursing staff.

Heather Casey, the Southern DHB’s nursing director for the Mental Health Addictions and Intellectual Disability Directorate, says that Julie does a wonderful job as the psychiatric liaison nurse. “She has a wonderful ability to work alongside all disciplines in a way that supports and builds their knowledge and confidence when working with people who have mental health needs. Additionally, she is an extraordinary teacher and an empathetic ear to all.”

Julie has a particular interest in maternal and infant mental health and after completing several papers in this area has just commenced a postgraduate diploma in infant mental health through an Australian university. She says she always knew she wanted to do a job that involved looking after people. She loves her role and feels humbled by what human beings can tolerate. She says her job keeps her mindful and appreciative of what she has.

Why do we do it x way? What would happen if we did y way instead? How about if we did both x and y ways? With the pool of nurses who have pursued or are pursuing postgraduate study ever growing, more and more nurses are carrying out research in diverse topics using a broad spectrum of research methodologies for their master’s and PhD degrees. Some of these nurses won’t want to stop there and will go on to pursue research as a career, which prompts further questions like: Why do research? How do you get to do research? And what types of research are a ‘force for change’?

Why do it?

Ask researcher Jane Koziol-McLain why she pursued a research career and she says she’s always had a questioning mind, from her early says nursing at an emergency department in Chicago.

She was curious when each time a new registrar was rotated to her ED they brought with them their own variation on ED practice.

“I wondered, why is it there are these different ways of doing things? Don’t we know which way is better?” says Koziol-McLain, whose questioning mind eventually led her to Auckland and her current position as professor of nursing at AUT.

Likewise, Dr Kathy Nelson, acting head of Victoria University’s Graduate School of Nursing, says she had a questioning mind and recalls wanting to know why mental health clients appeared to have insight into their illness the second time they were admitted but not at their first. That was back in the late 1970s when nurse researchers were few and far between and she was unable to find a supervisor for her curiosity-driven research. But curious she remained and she sought jobs that brought her research experience until she made it up the research ladder to become a researcher herself.

Dr Andrew Jull of The University of Auckland remembers emerging from his first foray into university studies without a degree, but with a strong desire to do research and to be of service. He eventually combined the two with nursing; first as an early ‘adopter’ of the Cochrane approach of using evidence to ensure best practice and then by becoming a researcher himself to help fill the gaps in evidence about what is best practice and what makes a difference to patients.

Honouring the special insight that nursing provides into illness and health is another driver for nurse researchers, believes Massey University’s professor of nursing Jenny Carryer.

“If think about a lot of the PhDs that have been done – there’s a desire to actually [honour and reflect] an alternative or more people-centred way of how people experience health and illness. And how they experience health service delivery.”

Koziol-McLain would agree, saying nurses have so much to offer research based on the knowledge they gain from working alongside clients. “It really is quite a privilege to be with people and support them in gaining health during those difficult times… Along with that privilege really does come a responsibility to do the best that we can.”

In the case of Koziol-McLain – whose major research focus for more than two decades has been family violence – this sense of responsibility saw her volunteering at women’s refuges so she could gain a wider perspective on domestic violence than the limited view she got as an ED nurse.

How do you do it? Getting the skills and finding the time

The question to follow ‘why’ nurses pursue research is ‘how do they do it?’ Perseverance and tenacity seem to be important qualities, as even now – when there are dedicated postgraduate paths for nurses and funding for course costs is more widely available – it is no easy task to pursue a research career.

“When I think back to my own time doing a PhD – actually working full-time with small children – it was a mad time of life. You’d never do it twice,” says Carryer.

Many nurses still come to postgraduate study later in life so nursing PhD students can often be juggling children, mortgages and demanding senior nursing roles. And the very few full-time PhD scholarships available to clinical nurses are highly contestable and may not be viable if the nurse is the family’s principal breadwinner. So part-time study is often the only option – stretching a PhD from the usual three years into six.

“But it is interesting how many nurses actually soldier through that process,” says Carryer.

Gaining the research skills that studying for a master’s and a PhD will provide is an essential step for nurses who want to pursue a full-time research career and ultimately lead their own research teams.

Established researchers say that potentially all nurses can play a role in research projects making a difference to clients, be it simply helping recruit participants or right through to being lead investigators for million-dollar-plus research projects. Nurses also work in research teams as clinical research nurses carrying out a variety of clinical and research roles and others work as research managers coordinating and managing research trials.

“Nurses have incredible skills and knowledge and the respect of clients and an understanding of clients and communities,” says Koziol-McLain. “So nurses, I think, are very well positioned to make an important contribution to research.”

Nurses interested in becoming more actively involved in research can just start small by volunteering for improvement projects or putting their hands up to assist in local research (see ‘Tips’).

Finding a mentor at work or in the local nursing school can also help nurses get a foot in the door by joining a research project and building skills, experience and gradually building that all-important research track record.
Koziol-McLain says being a principal investigator for a small nurse-led research project as an ED nurse, prior to even starting her master’s degree, was an important stepping stone to her next job and more research opportunities. “When I was interviewed for the job they were impressed that we had started the study, conducted it safely, finished it and reported on it.”

Gaining a PhD is also not always essential – as associate professor of nursing Andrew Jull points out – to winning major research grants if you build the right research team around you and gain a reputation in your research niche.

After completing his master’s degree – a systematic review of evidence on an aspect of venous leg ulcer (VLU) care – he identified a gap in nursing research as “very few folk” doing quantitative research had a nursing background and he was keen to fund and run his own quantitative research.

Jull says there was a perception that it was necessary to have a PhD first, but he wasn’t convinced as he knew that very few of his medical colleagues had PhDs and they still won funding. “So I thought, ‘Why can’t I do that?’
“And it seemed to me that the key to getting funding was having the right kind of team – so if you had skills gaps then you had the team around you to support those skills gaps.”

This philosophy helped him eventually win a Health Research Council grant for a multi-centre research trial that also helped build a network of nurse research collaborators around the country with whom he continues to work nearly 15 years later. “It is the people working at the study centres who really make me look good. They do all the hard work when it comes to turning trials into reality.” This research also ultimately led to his PhD.

How do you fund it? Getting the funding to answer your research question

Getting the funding to release your time and meet the costs of a research project is rarely simple.

For nurses who join academia, the Performance-Based Research Fund (PBRF), which divvies up a substantial pool of government funding to universities and participating polytechnics based on the research performance of individual academic staff, has led to increased pressures and rewards for doing research, says Carryer. (Nursing, which is still regarded as an emerging research field, compared with established academic disciplines like medicine, has not fared well in the initial PBRF rounds, coming in at 41 out of 42 disciplines in 2012, but it was noted that nursing scholars had improved their average score “markedly” since the first bruising results in 2003.)

Carryer says while it is hard enough for nursing academics with high teaching loads to find the time and money to do research, it is “very, very difficult” for nurses to do so in clinical practice.

“So the bulk of the research being done by nurses in practice is being done by people engaged in a master’s or doctoral programme.” That hasn’t prevented nurses from completing prizewinning PhD research ‘on the job’, including Waikato neonatal nurse practitioner Dr Debbie Harris’s “Sugar Babies Study” and Auckland intensive care nurse and senior research fellow Dr Rachael Parke, who last year was the first nurse to receive The University of Auckland’s Vice Chancellor’s Award for best doctoral thesis of 2015 for her work investigating the effect of nasal high flow oxygen in patients following cardiac surgery. And some district health boards have created nurse-focused research positions – like that of Dr Sandy Richardson, who is based at Christchurch Hospital as the country’s only emergency nurse researcher, as well as being a senior lecturer for the University of Otago’s Centre for Postgraduate Nursing.

Dr Beverley Burrell, a senior lecturer and researcher at Otago’s Centre for Postgraduate Nursing, believes that the more young or early career nurses who obtain PhDs, the more likely nursing as a profession and discipline will succeed in building long-term research collaborations and teams and in winning those elusive major research grants.

Nurses are not alone in their frustration around winning funding grants to support research. With limited funding pools available for health research – for example, of the 321 research funding applications to the Health Research Council last year just 33 were successful – rejection is more common than not.

It is also a case of nothing ventured, nothing gained, and Kathy Nelson for one believes nurses don’t apply often enough for funding to explore nursing research questions. She says most people applying to the HRC have to apply a couple of times and sometimes three to win funding for a project.

Jull well knows this and says funding his current aspirin trial (see related article) was a matter of perseverance. The team first applied for an HRC grant back in 2010 and got to the second round before being declined; the second application didn’t even make it to the second round. The third time they just applied for pilot funding and were still declined and then finally on the fourth attempt – after a related small trial had been published – they gained enough traction to be awarded a grant.

Burrell says it never hurts to apply for research grants. “Don’t be put off as you learn a lot from applying, even if it’s a rejection, as you learn how to shape-up applications and become more successful. And you do have to keep applying for money in different sources.”

Knowing the research priorities of funders is also important and Burrell says new researchers applying for major research grants need to be mindful of what funders are seeking.

What research should you choose?

So what type of research can create a ‘force for change’? What sort of research are funders looking for? And how much should nurse research be influenced by such funding drivers?

Answering these questions could probably generate several research projects alone as research philosophy is a field in its own right.

But the pragmatic answer to the middle question is that on the whole funders, like the HRC, generally favour research that can be translated into evidence-based practice. “Funders definitely favour studies that can show effectiveness and research that just doesn’t sit on a shelf but is rolled out and utilised,” says Burrell.

So funders largely, but not exclusively, favour quantitative over qualitative research. As in the international hierarchy of evidence-based practice, it is the randomised controlled trial (RCT) that sits at the top. Which, as Jull noted earlier, is an area that nursing research was traditionally not strong in; but with the nursing sector fostering of collaborative research teams – sometimes interdisciplinary and increasingly international – this is changing and nurse-led RCT trials are becoming more common (see examples next page).

On the other hand, the research form that nursing has been strong in for longer, qualitative research has gained more legitimacy over time. “When I did my PhD in 1997 qualitative work was considered relatively radical,” recalls Carryer. “That is no longer the case at all. And major funding bodies now consider qualitative research quite realistically.”

She acknowledges, though, it is still a challenge to get research funding for the “highly experiential, lived-experience type” of qualitative research, which she says many nurses still tend to gravitate towards. “Because at the end of the day that’s what fascinates nurses – it’s what informs what we do.”

Which brings us back to the opening question – what type of research can create a ‘force for change’?

Burrell thinks a primary driver of nurse research should be what is good for patients. “I think we’ve had an introspective view in the past of looking at the profession a lot. I don’t think you can neglect that, but really our business is about better patient outcomes and improving healthcare delivery for the population – that is our main purpose, isn’t it?”

Koziol-McLain says another driver is nursing’s sense of justice and concern about health inequalities that makes nursing research often focus on improving systems to promote wellbeing and health. Carryer agrees there’s a critical need to do research that may influence policy, though she adds that policy is too often “insufficiently and infrequently” informed by research.

Her own experience of policymakers’ readiness to be informed by a major quantitative research project she led (published in 2011 with the late Professor Donna Diers of Yale University) was mixed. The research team looked at the impact of registered nurse staff levels on nurse-sensitive patient outcomes following the 1990s health reforms and, after analysing 12 million discharges from New Zealand hospitals, showed that there is a clear relationship between declining RN staff levels and rising nurse-sensitive negative indicators. “I didn’t have a sense really that that work was taken particularly seriously,” says Carryer. “Even though it was based on huge numbers and had quite significant findings.”

What the nurse researchers all agree on is that there is no ‘one-size-fits-all’ research approach that can answer the many research questions that could make a difference to the health outcomes and experiences of the populations that nurses serve.

Koziol-McLain believes the research method should be driven by the practice issue or health challenge the researcher wants to tackle and then by establishing the best way to address those issues in a way that will be heard by the target audience and help create change.

“It is also important to have the ears of the policy-makers and sometimes that’s the nurses you work with, sometimes the interdisciplinary team and sometimes the Government.”

She says that means sometimes the best method is a randomised controlled trial and other times it may be qualitative research that tells stories – as stories can be very powerful in engaging people. Burrell agrees that RCTs have their place but there are other important research questions that need qualitative work; for example, interviews that ‘drill down’ and elicit people’s pattern of thinking that influences and motivates their health behaviour.

Others add that sometimes a mix of quantitative and qualitative research is the answer and that there should always be room for pure, serendipitous research and for research that gives voice to philosophical and ethical debates. “We can’t neglect any of them,” says Burrell.

Because questioning minds are a force for change in whichever direction their curiosity may take them.

Hutton said she has been Franz Josef’s sole nurse since February 2014 offering health services to the isolated South Westland region with the support of a visiting GP one or two days a week and nurses in nearby communities.

Being the oncall 24 hours a day means she has to be ready to for “whatever lands on her doorstep” including being called out to treat people injured in car accidents, glacier incidents or flown in from offshore fishing boats.

She has also set up an exercise and healthy lifestyle group for Franz Josef residents and, after working with a lot of new parents, she has organised a mothers and babies group to bring them altogether.

Hutton said the role was massive but very exciting and diverse and her job was made easier by having a “really supportive community”, including working alongside a very supportive St Johns volunteer team.

NZNO spokesperson, Dr Jill Clendon described Gemma as “a nurse with the X factor”. “She see the needs in the community, and gets to work straight away putting goals in place and achieving positive health outcomes.”

“I echo Gemma’s nominator when I say I believe Gemma to be an excellent role model for young nurses entering the profession. Nursing is in good hands.” Clendon said.

Hutton said had been very surprised and humbled to have been nominated and win the award. “Being acknowledged for doing something I love feels awesome.”

She initially trained at Otago Polytechnic and spent her new graduate year in Dunedin Hospital’s emergency department before taking on a private nursing job in Central Otago and then working in a small hospital in the Lakes District.

Hutton is close to completing her postgraduate certificate in nursing and in the long-term hopes to complete a masters degree and maybe looking at becoming a nurse practitioner.

Coming from a rural background she said she always intended to move into rural nursing at some stage and spent some time in Haast as a child. Hutton said rural nursing would appeal to young nurses who want variety in their work, are ready to cope with being on-call and want to live in a rural community. She says she has met some really cool people in Franz Josef and finds plenty to do in her free time.

Name: Jinsu Shinoy

Job title: Clinical Services Manager, Ellerslie Gardens Home and Hospital, Auckland

Nursing qualifications:

• Bachelor of Science (Nursing) 2008 (SNDT University, Mumbai, India)
• Preceptorship of Nurses in Practice 2013 (Wintec)
• Postgraduate Diploma in Leadership and Management in progress (AUT)

Briefly describe your initial five years as an RN

I worked in a variety of settings during my training. After graduating I worked in the intensive care unit as a registered nurse for three years in Lilavati Hospital, Mumbai, before moving to New Zealand in 2011.

Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career?

I always wanted to work in a very challenging area, gain experience, improve my knowledge and complete higher studies overseas. My first three years of nursing were very interesting and the knowledge gained was worthwhile. So yes, my initial years as a nurse did influence my career in many ways.

When I moved to New Zealand my initial goal was to understand the New Zealand health setting, gain my New Zealand registration and start working as a nurse.

What led you into your current field or specialty?

To be honest, the current field I am working in is by chance. My first choice was always intensive care. But as I had moved to a new country, and needed experience in the healthcare system, I accepted a job in aged residential care (ARC). As I started working in ARC I found my job very challenging, fulfilling and rewarding so I continued to invest more of my time in training to enhance my career in ARC.

What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role?

I am very thankful to my previous employer and manager who provided opportunities to enhance my ARC knowledge by sending me to training courses, conferences, workshops etc. I am passionate about gaining knowledge so have also attended a lot of courses in my own time.

 A stepping stone for my career was my previous employer, and the senior management team, trusting me and offering me a position as a clinical manager. I accepted as I always had a passion to be a leader and this gave me a chance to work towards my passion. After accepting the role, I saw the need to support my role with postgraduate education. I am grateful for all the support I received from my previous employer and Waikato DHB, who encouraged and helped me to walk the education road once again.

I personally think education and experience are both equally important to fulfil the needs of my current role. I am really fortunate to come into a new company and receive management backing to complete my postgraduate study.

I would also like to acknowledge my family, my loving husband, and my friends, who supported me in every possible way and provided guidance in time of need. Above all, I thank God Almighty, who opened up the way and showered his blessings on me in this beautiful country, New Zealand.

What personal characteristics do you believe are particularly important for nurses working in your role?

I think as nurses we should have empathy, compassion and a caring attitude towards our residents/patients. Other attitudes and attributes I feel are important are commitment to excellence in the care of the elderly population, a good sense of humour, common sense, honesty, integrity, our own values, a desire to find solutions and a ‘can do’ attitude.

It is vital as a clinical lead to have a conscientious and industrious work ethic. Keeping an open mind to change and learning as practice changes is essential. Communication and listening skills, plus patience, are indispensible attributes to have.

What career advice would you give to nurses seeking a similar role to yours?

• Make a short-term and long-term goal for your career with some flexibility as this will help to put things into perspective (and help to develop and extend yourself to move out of your comfort zone)
• Actively take opportunities to keep up to date with best practice
• Develop the needed skills by experience and education
• Work in different roles to understand, learn and grow as a nurse
• Acknowledge the importance of communication and building relationships
• Dedication, hard work and honesty.

Describe your current role and responsibilities

My role’s main aim is providing a high level of clinical leadership and support to clinical and care staff.

The key objectives of my role are to:

• provide leadership, supervision and direction to staff with active and applied knowledge and practice (as per the Health Practitioners Competence Assurance Act)
• assist and support the facility manager in effective facility management by having extensive knowledge of relevant legislation and codes of practice (including Health & Disability Commissioner standards and code of rights, ARRC contracts etc.)
• actively participate in the facility’s quality and risk management programme by seeking continuous improvement of all services
• monitor the provision of care to residents to ensure the highest standards are achieved and maintained
• coordinate the provision and the use of clinical supplies within the facility ensuring resources are allocated and utilised cost-effectively
• provide the oversight of resident clinical records and recordings to ensure they meet organisational and legislative requirements
• participate in the implementation of an effective education programme
• be actively involved in all aspects of human resource management
• demonstrate commitment to the provision of a safe environment for residents and staff
• assume the responsibilities of the facility manager in their absence
• undertake additional responsibilities as required (infection control officer, restraint coordinator, health and safety officer etc.)

So stated the 1998 Ministerial Taskforce on Nursing. The Taskforce report also noted many acute hospitals expected nursing graduates to “immediately take up a high workload and a high level of responsibility with little structured help or support”.

It’s been 10 years since the government gave the green light to funding new graduate programmes, bringing in the first nationally consistent clinical training support for novice nurses.

At the time, support for new graduates in their first year of practice varied considerably across the country with some fortunate new graduates securing a place in formal new graduate programmes and others, like the less fortunate casual pool nurses, being expected to be work-ready in any setting.

The gold standard then was the already long-established new graduate programme for mental health nurses (now known as the NESP or new entry to specialist practice programme). The Taskforce recommended NESP be the template for a national framework of funded new graduate programmes to support this “vital time in the development of a truly professional and effective nurse”.

After a pilot in 2002 and a positive evaluation report in 2004, the government in July 2005 finally announced funding for a national framework of nursing entry to practice programmes (NETP).

So in mid-2006 the first three district health boards to gain Nursing Council accreditation for their NETP programmes were given a subsidy of $6,000 per graduate to deliver the course – roughly 50 per cent of the estimated cost. The rest of the DHBs came on board in 2007 and in 2009 the first NETP places were offered in primary health and residential aged care.

Fluctuating supply and demand for NETP places

For many of the early years of NETP there were more funded places available than were ever filled, with a number of DHBs struggling to attract new graduates in a buoyant job market.

But this reversed when the global financial crisis saw nursing turnover stagnate and DHB budgets tighten, at the same time as record numbers were graduating from the country’s nursing schools in readiness to replace the country’s ageing nursing workforce.

It was a perfect storm that saw NETP numbers fall and plateau in 2010 and 2011 (see table) and then start to steadily climb, but not fast enough to match the growing graduate cohorts. Faced with keen new graduates struggling to find work – and the added fear they could be lost to the profession, which would ultimately need them to replace retiring baby boomers – the New Zealand Nurses Organisation (NZNO) last year launched a petition calling for the government to fund an NETP place for every graduate.

The petition reached 8,000 signatures and the then health minister, Tony Ryall, responded by announcing 1,300 NETP places would be funded in 2015. Unfortunately, with nearly 1,800 new graduates registered last year, this falls far short of NZNO’s expectations. Also, whether the sector will be able to step up and employ 300 more nurses than last year (see table) to fill those extra NETP places is yet to be seen.

Improved data is now available on graduate trends through the central clearinghouse for NETP and NESP applications known as ACE, which was first used for the February 2013 NETP intake. The February 2015 ACE round saw an increase in new graduates in NETP jobs and also saw places in the mental health NESP programmes swell from 152 last year to 175 this year. And for the first time NETP funding has been allocated to new graduates employed at private surgical hospital provider Southern Cross (see sidebar).

NETP: a year for clinical consolidation and/or postgraduate study?

“I don’t think anybody would argue that the NETP programme has been a tremendous asset to establishing people’s first year of practice in a safer way then we used to do,” says Professor Jenny Carryer, executive director of the College of Nurses.

“But there are still issues around the fact that we are not funded for every single graduate and so a number of graduates miss out on the NETP programme, therefore can fall between the cracks,” says Carryer.

While only a handful of DHBs at the outset included postgraduate papers as part of their NETP programme, this has expanded over the years until only a handful now do not. Some DHBs have taken this a step further and are offering top graduates an honours programme in their second year, with the option of progressing into studying for a health sciences doctorate.

Carryer, for one, sits in the camp that believes NETP should be a year focused on the consolidation of clinical skills. “It is a year they [new graduates] are under enormous pressure to think on their feet, time manage and take responsibility for decision-making – all of those first-year learning challenges. And personally I don’t think we should distract them with a postgraduate paper that year.” Also, graduates in their first year of practice usually haven’t yet decided on their likely career path or specialty.

Sitting in the other camp is associate professor Judy Kilpatrick, head of The University of Auckland nursing school, which offers postgraduate papers in partnership with many DHBs’ NETP programmes.

“What we actually found was that graduates were doing some quite high-level things in that first year and postgraduate study was a perfect way to give credit and shape up their thinking.” She said the paper involved a high level of clinical assessment but formal study did not commence until the second semester of the NETP year to give graduates a chance to adjust to working life.

“I think that postgrad study firstly helps retain the graduates; secondly, they are able to get new knowledge – at a sharper and higher level than undergraduate – that they can apply in the clinical area; and lastly, by the end of the first year they are already cementing themselves in the pathway of where they want to go.” She says rather than being burnt out, the graduates all complete and many will go on to pursue further postgraduate study (though quite a few take a break after completing their postgraduate certificate and look around before resuming study at the next level).

Sue Hayward, director of nursing for Waikato DHB, which offers the honours programme to leading second-year nurses and now has two recent graduates on the doctoral path, also believes postgraduate study in the NETP year consolidates what graduates have learnt in their undergraduate degree.

She says the Midlands region of DHBs have negotiated for graduates then to have a longer gap, if they wish, before they do the second paper of their postgrad cert but most have completed their certificate within three years. “It’s not arduous – though it’s not easy,” says Hayward. And retention, even taking into account the current economic environment, was very good, with 96 per cent of NETP graduates staying on and going into permanent positions.

Dr Kathy Holloway, national chair of nurse educator group NETS, was part of a team that evaluated the first three years of NETP and found the supported first year of practice programmes was enhancing trainees’ confidence and competence.

She says DHBs had always done some form of new graduate programme but they were very variable across the country and there needed to be some consistency and structure, which national funding enabled it to have. And expanding the scheme into primary health care, aged care facilities, some non-governmental organisations and some private surgical hospitals meant it could support graduates entering the wider nursing workforce.

“But we still have the goal of 100 per cent employment of nurse graduates into an NETP position if they seek one.”

Name: Safaato’a (To’a) Fereti (born in Samoa, raised and educated in Dunedin)

Job title: Clinical Nurse Director, Medicine & Clinical Support Services, Counties Manukau District Health Board

Nursing qualifications:

• RN 1989 (Christchurch Polytechnic)
• Postgraduate Certificate in Specialty Care (Pacific Health) 2012 (Whitireia Community Polytechnic/Aniva Pacific Nursing Leadership Programme)
• Master of Nursing (MNurs) 2013 (University of Auckland)
• Postgraduate Diploma in Specialty Care (Pacific Health) in progress (Whitireia/Aniva)
• Postgraduate Diploma in Business (Healthcare Management) in progress
• Master of Nursing (Pacific Health) beginning in 2016 (Whitereia/Aniva)

Postgraduate study and Aniva Pacific nursing leadership programmes

I started postgraduate study in 2006 as it was expected of me on taking up a senior nursing role at Counties Manukau DHB. In 2012 I also did my Postgraduate Certificate in Specialty Care Pacific Health as part of the Aniva Pacific Nursing Leadership Programme. This programme – funded from next year to master’s level – is special and unique as the focus is specifically on the issues of Pacific peoples’ health and wellbeing and the challenges and opportunities these provide for Pacific nurses. It is delivered by some of the most pre-eminent Pacific health professionals, including Fuimaono Karl Pulotu-Endemann and Dr Margaret Southwick, with the support of Aniva director Dr Debbie Ryan. They have become my mentors.

Next year I am planning to continue my postgraduate business diploma, as well as start my second master’s through the Aniva Fellowship programme. (I’m looking at whether I can cross-credit some of this towards a Doctorate in Health Sciences). Yes, everyone has called me crazy!

Briefly describe your initial five years as an RN

My first job as a new graduate in 1990 was in Coronation Hospital, Christchurch, which was a long-term geriatric hospital. I believe this instilled in me the foundations and essence of nursing. It closed down in December 1991 and I was redeployed to Princess Margaret Hospital AT & R ward until I moved to Auckland in 1993, motivated by wanting to work more with our Pacific people. I got a job pretty much straightaway in Middlemore Hospital’s Ward 8, which was the renal/medicine ward. Back then, there was only a handful of Pacific nurses. It is good to see this number has grown; however, there is still work to be done to increase the Pacific health workforce to reflect our population demographic. In 1995, renal was given its own dedicated ward (ward 15) where I became the ward-based acute haemodialysis nurse and basically remained in the ward until 2001.

Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career?

My path to date has been ‘accidental’ – a phrase coined by Matafanua Hilda Faasalele. It was being at the right place, at the right time; however, it was also about having great friends behind me who recognised my potential and my strengths (even when I didn’t) and who pushed and supported me to go for the senior nurse roles – thank you.

In 2001 I felt I needed a new challenge. I applied for senior nurse roles within the renal service but was unsuccessful as I lacked the required qualifications. But as they say, where one door closes another one opens. The ‘new door’ was at Auckland DHB where one of my best friends encouraged me to apply for the renal transplant coordinator role. It was the best thing that happened to me – a new DHB brought new knowledge, skills and networks. It was probably the turning point of my nursing career.

I knew then that my pathway was more leadership/managerial rather than clinical. I returned to Middlemore Hospital as renal services nurse educator at the end of 2006 to be closer to home for my children. I was in this role for 10 months and then became charge nurse manager of the Acute Dialysis Unit, taking up my current role in April 2012.

What led you into your original specialty?

It is ironic that my specialty background has been renal for more than 20 years – this was my worst subject at nursing school. But on seeking a job at Middemore (as I was told it served the most Pacific people) I was given the choice of a job in AT & R or renal and chose renal as I’d come from AT & R in Christchurch.

I soon learnt that Pacific people had a high incidence of diabetes and hypertension leading to renal failure. I loved working with and caring for our renal patients who became like my second family as the hospital was like their second home. I learnt a lot about the different cultures, values and beliefs. From this my understanding of my own cultural values has grown and how these values are translated into and through my nursing practice.

What qualifications, skills or stepping-stone jobs do you think were particularly helpful and/or necessary in reaching your current role?

To best answer this question, I need to quote the ‘3 C’s’ from
Dr Margaret Southwick:

• Courage: the courage to take the first step into the unknown; stepping out of your comfort zone and getting uncomfortable
• Credentials: you need to have qualifications behind you to get into the more senior nurse roles.
• Credibility: standing up and doing what is right, even when everyone thinks you shouldn’t.

It’s also about relationships – maintaining and sustaining good relationships with everyone.

In June I accepted a Ministerial appointment to the Nursing Council of New Zealand, for a three-year term. I am proud to say I am the first CMDHB nurse appointed to the Nursing Council and only the second Pacific person (the first was Dr Margaret Southwick, who was chairperson from 2009–2013).

I was an independent consultant to the Ministry of Health, Samoa, in 2014 and undertook a review of the National Kidney Foundation of Samoa. I also undertook a review of the Lakes Satellite Dialysis Unit, Rotorua, in 2010.

I have a passion for Pacific health and to increase the Pacific health workforce, in particular nurses. Definitely my journey through the Aniva Pacific Nursing Leadership programme with the guidance of my mentors has enhanced my leadership skills within my current role.

And I remember the journey of how I got to where I am now, and those who helped and supported me along the way. Now it’s time for me to give back and help others pave their way.

What personal characteristics do you believe are particularly important for nurses working in your role?

Definitely the first three would be Dr Southwick’s ‘3 C’s’: courage, credentials, and credibility. Leadership is a key skill in this role, balanced by self-confidence and humility (and a great sense of humour).

Excellent communication and interpersonal skills are a must as you are providing professional leadership and governance over the practice of nurses. Also you need to have a strategic lens, to provide coaching, mentoring, and positive role modelling, and have emotional intelligence, critical thinking, and energy.

For myself, being a Pacific nurse leader in a mainstream role and having a two-world view lens, it is also important to me that I remain authentic and infuse my own Samoan cultural values of faaaloalo (respect), alofa (love), tautua (service) and humility into my role and into my nursing practice.

Also being caring, kind and compassionate towards all people – that’s what I believe nursing to be and why I chose this profession.

Describe your current role and responsibilities

My current role is clinical nurse director of Medicine & Clinical Support Services and I have been in this role for over three years. I am proud to say that I am the first Pasifika nurse to get this role in Counties Manukau Health. I am part of my director of nursing’s (Denise Kivell) leadership team. She is an awesome and fabulous boss and I am proud to be under her leadership.

• I have over 600 nurses within my division for whom I:
• provide professional governance and leadership for at a strategic level
• ensure all nurses perform and conduct themselves in accordance with the DHB vision and values, and Nursing Council requirements
• ensure strategic and operational plans are successfully implemented with a strong professional nursing and clinical focus
• ensure patient and family safety and quality agendas within the service are championed as part of Counties Manukau’s quality focus
• provide clinical advice, coaching and mentorship for all nursing staff within the division to manage complex and difficult professional/clinical situations
• contribute to the strategic planning process for the workforce, ensuring that nursing professional issues and impacts are considered.

My career to date has not been achieved on my own. I am here because of all the support and love from my four children, my family, friends, my director of nursing and my mentors. So it is only fitting that they are also recognised for their contribution to who I am, what I am doing and where I am today. As a Pacific nurse leader in a mainstream role my vision for the future is for the Pacific health workforce to make positive changes in the health status of Pacific people in New Zealand.