Chris Wilson, the NZNO industrial advisor for Primary Health, said a major focus of the talks will be pay parity with the recently settled DHB MECA but it was also seeking coverage and appropriate pay scales for registered nurse prescribers and nurse practitioners (NPs).

A new regulation introducing RN prescribing in primary health and specialty teams came into force in September 2016* and the numbers have grown from 80 this time last year to nearly 210. To become an RN prescriber, a nurse has to complete a Nursing Council-approved postgraduate diploma in registered nurse prescribing for long-term and common conditions or equivalent.

“We are looking to have additional recognition for RN prescribers because this is an extended scope of practice and needs to be valued accordingly,” said Wilson. It was also wanting to discuss coverage of senior nurse pay scales in the PHC MECA, including nurse practitioners with Nursing Council statistics for 2016 indicating that 30 per cent of NPs practised in primary health care.

But a major focus of the talks would be the now 6 per cent pay gap between PHC and DHB nurses following the recent DHB NZNO pay settlement and the need to retain pay parity by also adding additional pay steps to the current PHC five-step pay scale to keep it in line with the DHB nurses new basic pay scale. The top of the current pay PHC pay scale is $32.44 an hour ($66,851 a year) and the new MECA would have to introduce a new step 7 of $37.10 an hour by May 2020 to retain parity with the new top step of the DHB basic pay scale (about $77,000 a year).

Asked whether she was concerned that practice and other primary health care nurses would seek jobs in the higher paid DHB sector – which won extra funding of $38m to take on the equivalent of 500 extra nurses to meet immediate safe staffing concerns – she said there was a “high level” of interest from members over how the upcoming negotiations went.

“From our perspective we are definitely looking to how we can shrink that gap,” said Wilson.

“It is so important in terms of recruitment and retention for primary health care.We want to retain a quality and effective workforce as PHC is a specialty. Nurses like to choose that specialty but if there is a significant pay difference – and we know there currently is – then that is going to be a major issues for medical centres and general practices in terms of being able to retain and also recruit.”

The New Zealand Medical Association (NZMA), which will represents the majority of practices covered by the MECA in the negotiations, said it would not comment while negotiations were underway.

At last month’s NZMA-supported South General Practice Conference, the Health Minister Dr David Clark was questioned from the floor about the ‘significant cost’ to primary care of practices having to match the recent DHB nurses’ pay increase.

Clark said he accepted that workforce costs were going up for the sector and the challenge was real.

He added that he had received Ministry of Health advice that the Labour Cost Index (which reflects movements in salary and wage rates and is used to fee into the funding formula for primary health care) had jumped significantly because of the pay equity settlement so primary care “has been getting the funding in advance of the cost increases coming”. He told the gathering that he was “not intending to stop that … you guys face plenty of pressures”.

Wilson said it was aware of Clark’s comments and was seeking to find out more about current funding levels.

*There are now more than 300 nurse practitioner prescribers (the top level and only autonomous nurse prescribers), and a group of nurses has been trialling a third and more limited level of RN prescribing in community health. 

Jane O’Malley says she’s often been asked about the conflict of wearing her two hats – one as the country’s nurse leader and the other as chief nurse, answerable to the Government.

Her answer was that it simply isn’t that difficult. If you have the hard data at your fingertips and keep patients and consumers at the heart of all you do, then it is very easy to give ‘free, frank and fearless’ advice to a health minister or her CEO, she says.

As a chief nurse, O’Malley says she’s always been keen on using data to tell the story but that first required getting the data so she knew what story to tell.

She says former Director General Kevin Wood used to tell her to stop focusing so much on the workforce because they now had Health Workforce New Zealand (HWNZ) to do that task. Her response was that she didn’t want people some time in the future facing a nursing shortfall to look back at her time and ask “so what was the chief nurse doing?”.

With concern rising about the ageing nursing workforce, getting a good grasp of where the nursing workforce was at was a high priority for O’Malley when she walked into the Office of the Chief Nursing Officer (OCNO) in late 2010.

Recruitment: ACE and the ‘ageing’ workforce

At the start of the decade, nursing turnover had fallen – an international phenomenon as nurses stepped up hours, put off retiring or returned to the workforce as the global financial crisis hit their families’ livelihoods. At the same time, anecdotal reports of new graduates struggling to find work started to emerge.

But when then Health Minister Tony Ryall asked O’Malley a question (which she says he did a lot) about whether new graduate nurses were getting jobs, she, shamefaced, had to answer that they just didn’t know.

At that time the OCNO had to wait a whole year until new graduates renewed their APCs with the Nursing Council to get an accurate picture of employment rates, or wait three months after graduation for partial information when the NETS (Nursing Education in the Tertiary Sector) graduate destination survey results arrived.

Getting better new graduate job data quickly went to the top of the list for the new chief nurse, leading to nursing in 2012 adopting medicine’s ACE one-stop-shop clearing-house system for new graduate job placements.

“Now we have a good five to six years of strong data about the new graduates applying through ACE, their specialty preferences and their regional preferences,” says O’Malley.

They also know that, despite people’s ongoing concerns that only 50–60 per cent of applicants get jobs in the ‘first flush’, within five months 60–70 per cent will have nursing jobs and by the end of 12 months only around 3–5 per cent are still job-hunting.

Thanks to work done by her then advisor Dr Paul Watson, the office also had data on the skill mix and turnover of the nursing workforce in DHBs and knew that the largely experienced DHB workforce had the capacity to replace experienced staff nurses with new graduates from the ACE talent pool.

O’Malley says HWNZ analyst manager Emmanuel Jo recently presented her with a graph that shows the nursing workforce now has a “dip in the middle” between the new generation of young nurses and the ageing generation of nurses nearing the end stages of their career.

“The concern when we first started this work was that the young weren’t coming in, but what we are seeing is a nice wave of our new graduates steadily coming in each year.”

Based on that data trend, Jo was predicting a steady number of nurses across the age spectrum into the future.

“So the ageing workforce people were worrying about is now going to be a ‘youthening of workforce’ over the years, if we continue to do what we are doing at the moment. So that’s really good.”

ACE and Nursing Council statistics are also showing that 86–88 per cent of nurses gaining places in either of the new graduate programmes are still nursing five years on. It’s some encouraging news on which to end her term.

Retention: safe staffing and the slow adoption of CCDM

But the news has not always been good about nursing over the past near-decade. Nurses are often reported feeling under the pump as patients get sicker, bed turnover faster and budgets tighter.

So retention has been another one of the ‘three Rs’ that has preoccupied her time, with much of the focus being on ensuring good working conditions, in particular safe staffing.

O’Malley’s own career has been closely aligned with safe staffing. She was president of the NZNO when the 2004 historic ‘pay jolt’ deal for DHB nurses set up the Safe Staffing Healthy Workplace (SSHW) Inquiry.

She was also director of nursing for one of the early SSHW demonstration sites, the West Coast DHB, and a member of the SSHW Unit governance group, which oversaw the development of the acuity-based, safe staffing suite of tools known as CCDM (Care Capacity Demand Management).

But she admits the pace of rolling out CCDM across DHBs has been so slow and so fragmented that it risked putting the whole programme under threat.

“Nurses might be tempted to say CCDM doesn’t work. And chief executives might fail to realise the potential for CCDM to impact on patient and staff outcomes and actually improve hospital productivity if they don’t see the full scale roll-out.”

So it was great news to her, and one of her career highlights, that late last year the DHB chief executives agreed that the national rollout of CCDM will be “over the line” across all 20 DHBs by July 2021.

She emphasises that ‘over the line’ means not only introducing the tools, but DHBs also building into their budgets the funding to boost nursing numbers if CCDM analysis reveals that a ward or unit is understaffed to meet patient demand.

O’Malley acknowledges that CCDM at the moment is very much focused on DHB inpatient settings “but it’s a good place to start”.

The national rollout will also provide good national data and O’Malley reiterates that it is good data that should be driving decisions about workforce and skill mix.

“If we know we have a need for care, we must staff for it,” she says.

While supporting specialist and advanced nursing practice, O’Malley is also a champion of the generalist nurse working to the fullest extent of their scope. Generalism is a nursing attribute that comes to the fore in a CCDM environment, which encourages wards to plan and be ready to transfer or receive a nurse if a crisis arises.

“The truth is that registered nurses (RNs) are generalists – they can move from one ward to another and not do the specialist part of nursing in that ward but the generalist part,” says O’Malley.

In addition, she says that more care could be provided by enrolled nurses (ENs) – a workforce she believes could easily be grown to support RNs – and some by healthcare assistants (HCAs).

“We have to be ready to look at our own practices rather than always blame the funding, or the operations manager,” says O’Malley. “My challenge to registered nurses would also be to not assume that all that care needs to be RN care.”

Removal of barriers: prescribing and law changes

The third ‘R’ – removing legal barriers to practice that were creating ‘road blocks’, particularly for nurse practitioners, but also RNs and other health practitioners with advanced skill sets – was another major ongoing task for O’Malley’s office.

Pulling together an omnibus law to amend and remove ‘doctor’ and ‘medical practitioner’ from eight Acts where other suitably qualified practitioners could now safely carry out the roles was a complex and convoluted process. But O’Malley says the triumvirate of Alison Hussey (OCNO), Mary Louise Hannah (HWNZ), and legal advisor Jane Hubbard successfully shepherded the bill through and the amended Acts were finally enacted on 31 January this year.

Under O’Malley’s watch the Nursing Council and Government also brought in two new levels of registered nurse prescribing, amended standing orders regulations and tweaked a number of other regulations to ease the way for nurse practitioners.

Nursing leadership – particularly under the DHBs – is another area that has been in the spotlight during O’Malley’s watch.

“I’ve heard people saying that nursing leadership is under pressure and restructuring is taking out nurse leaders,” she says. “I’ve actually looked at the last five DHB restructures and I can’t see evidence that nursing has been restructured out of the decision-making.”

During her behind-the-scenes discussions with chief executives over restructuring, she says the CEOs “really listened” and while restructuring is stressful and some nursing leaders have gone, others have been appointed to take their places.

She also can’t see evidence that nursing clinical advice is not being listened to – though she acknowledges “you will have pockets of it”.

Morale, frustrations and rewards

What about the toughest and most difficult-to-measure test of her tenure – how has nursing morale changed in the time she has been the country’s chief nurse?

“I don’t think morale is any worse or better than it was seven years ago … I’m an optimist,” says O’Malley. “I always think it’s not bad but it could be better.”

“I think if we utilise nurses well; if we make sure that we deliver them predictable workloads that allow them to do the work they need to do for patients; if we make sure that every nurse is accountable for their practice in an environment where they are free to make good decisions; and if we value people as people and give them time to grow, then we will always get better patient and nurse outcomes.”

O’Malley leaves the Ministry – a place in which it has been a pleasure to work, she says, as there are so many intellectually smart people with a passion for health in one space – in March to become Plunket’s first chief nurse. Will she leave any frustrations and regrets behind her?

“There’s always frustration and always more that you could do.”

Only time will tell whether people will look back at her time and ask “what was the chief nurse doing?”. Jane O’Malley leaves knowing that she did a lot.

Yesterday’s announcement of Fitt’s appointment follows Pharmac announcing on Monday that current chief executive Steffan Crausaz was stepping down after six years in the post to take up a new role in the private sector.

Fitt is currently Pharmac’s director of operations and has worked in executive positions at Pharmac for more than five years.  Previously she was Chief Pharmacist at Auckland Hospital and also worked as a clinical pharmacist in the United Kingdom, where she specialised in the management of patients with liver disease.

Pharmac board chair Stuart McLauchlan in announcing her appointment said Fitt was “one of the most outstanding clinical leaders in New Zealand”.  “Her experience is going to be vital for the continuity of Pharmac and we wanted to ensure that we retained that talent”.

Fitt will take up the position from January 6 next year.

Outgoing CEO Crausaz was with Pharmac for more than 14 years and during his tenure as CEO he led the extension of Pharmac into hospital medicines, vaccines and medical device.  He said he had been a passionate advocate for building on the “evidence-based and commercially astute” reputation of Pharmac while also making the organisation easier to engage with and “developing its more approachable character”.

“When Pharmac does its job well more patients are able to benefit from medicines and health services that otherwise would not be available to them,” said Crausaz.

McLauchlan said Crausaz had made a huge contribution to Pharmac and the New Zealand health sector, and was sad for the board that he had decided to take up a new role.

World Antibiotic Awareness Week 2017 (November 13 to 19) is a World Health Organization global event around one of the most pressing challenges to health care – including the risk of relatively common infections developing resistance to the antibiotics usually used to treat them.

Late last year New Zealand’s Council of Medical Colleges facilitated the local launch of the global Choosing Wisely initiative in partnership with the Health Quality and Safety Commission and Consumer. The initiative – targeted at both health professionals and consumers – aims to avoid unnecessary clinical interventions including inappropriate prescribing of antibiotics.

Dr John Bonning, from the Council’s executive, said a growing number of infections, such as pneumonia, tuberculosis, and gonorrhoea, are becoming harder to treat as the antibiotics used to treat them become less effective. He said as part of the Choosing Wisely campaign the Council worked with Australasian and New Zealand Colleges and specialist societies to develop specific recommendations about antibiotic use.

“These recommendations include situations when antibiotics should not routinely be used – such as for upper respiratory tract infections, the use of topical antibiotics on surgical wounds, and for the treatment of fever in children without a bacterial infection.” (See list of recommendations and links below.)

The  Ministry of Health’s Director of Public Health, Dr Caroline McElnay, says New Zealand this year presented its Antimicrobial Resistance Action Plan as part of the commitment to tackling the global challenge.

Michael Baker, spokesperson for the College of Public Health Medicine said it was essential that New Zealand implemented the plan and echoed that antibiotic resistance was a global issue in which New Zealand “absolutely has to play its part”. “We need widespread commitment and leadership from medical, veterinary and agricultural sectors in New Zealand, working together.”

Hilary Graham-Smith of the New Zealand Nurses Organisation said nurses are in the frontline of helping patients around proper use of antibiotics. “Nurses have an integral part to play. Some nurses are prescribers now and more will come. Education about the importance of taking antibiotics as recommended by a health professional, not sharing them, and reporting adverse effects, is key to managing the use of antibiotics well.”

Wellington GP Dr Cathy Stephenson said it’s crucial to work out whether or not a person really needs an antibiotic.

“It’s partly about explaining to patients why antibiotics won’t help. But it’s also about giving them some practical advice that will help them, or their child, feel better – getting good rest, ensuring adequate fluid intake, and advising on proper pain relief. Often when you explain all this, people are actually very happy to avoid antibiotic use.”

Dr John Wyeth from Pharmac says they are charged with getting the best possible health outcomes for New Zealanders from the public medicines budget – and antimicrobial resistance could undermine that.

“We often forget that things we take for granted, like chemotherapy and surgery, would not be possible without antibiotics.”

Choosing Wisely antibiotic use recommendations

• Do not use antibiotics in asymptomatic bacteriuria.http://choosingwisely.org.nz/professional-resource/asid/#1
• Do not take a swab or use antibiotics for the management of a leg ulcer without clinical infection.http://choosingwisely.org.nz/professional-resource/asid/#2
• Avoid prescribing antibiotics for upper respiratory tract infection.http://choosingwisely.org.nz/professional-resource/asid/#3
• Do not use antimicrobials to treat bacteriuria in older adults where specific urinary tract symptoms are not present.http://choosingwisely.org.nz/professional-resource/anzsgm/#3
• Don’t use oral antibiotics for the treatment of atopic dermatitis unless there is clinical evidence of infection.http://choosingwisely.org.nz/professional-resource/nzds/#4
• Don’t routinely use topical antibiotics on a surgical wound.http://choosingwisely.org.nz/professional-resource/nzds/#5
• Do not routinely prescribe oral antibiotics to children with fever without an identified bacterial infection.http://choosingwisely.org.nz/professional-resource/pchd/#1
• Consider antibiotic de-escalation daily for intensive care patientshttp://choosingwisely.org.nz/professional-resource/anzics/#5

Choosing Wisely also encourages health professionals to share the campaign’s resources for consumers including:

• Antibiotics for sinusitis
• Antibiotics for your skin
• Coughs, colds & sore throats – manage symptoms without antibiotics
• Ear infection – treatments

‘WISE’ questions to help avoid unnecessary prescribing/interventions

• Why? What will this test, treatment or procedure change?
• Is there an alternative? Less invasive, less resource intensive?
• Seek clarification. Clarify why the doctor ordered this test
• Explore/explain. Be the patient’s advocate. Explore concerns, take time to explain why a test, treatment or procedure is/isn’t necessary

Source: From resources developed by the New Zealand Medical Students Association to support the Choosing Wisely campaign: choosingwisely.org.nz/professional-resource/nzmsa/

Encouraging conversations between health professionals and health consumers about their medications was chosen by the Health Quality & Safety Commission as the focus for this year’s Patient Safety Week. The aim is to try and prevent the harm caused by patients taking the wrong medicines, the wrong combination of medicines, the wrong dose and other medication safety issues.

In particular, the Commission is highlighting the ‘triple whammy’ – the potentially dangerous combination of taking the wrong off-the-shelf or prescribed pain killers when already taking heart pills and diuretics – that can lead to serious kidney damage. New data shows that about 22,000 older New Zealanders are being prescribed the combination of the three medicines each year.

Commission medication safety clinical lead Dr Alan Davis says the ‘triple whammy’ risk often arises when people who are taking heart failure or blood pressure medicines plus diuretics (water tablets) then start on a non-steroidal anti-inflammatory (NSAID) to treat pain or swelling.

Some NSAIDs – like ibuprofen and diclofenac (voltaren) – are available to buy from pharmacies and supermarkets as well as by prescription. Used together, the combination of heart/blood pressure medication (i.e. ACE inhibitors / angiotensin receptor blockers), diuretics and NSAIDs can cause significant harm.

Dr Davis said the triple whammy combination was involved in more than half of reported cases of treatment-related acute kidney failure.

Data released by the Commission’s Atlas of Healthcare Variation this week shows that in 2016 about 22,000 New Zealanders aged over 65 were dispensed the ‘triple whammy’ of these medicines in the same quarter. It does not include the people who bought an NSAID over-the-counter or were prescribed NSAIDs on an earlier occasion.

New Zealand’s Centre for Adverse Reaction Monitoring (CARM) received 119 reports of kidney adverse reactions from January 2000 to December 2012 that were associated with the use of pain relief or anti-inflammatory medicines. These included four deaths and 12 cases that were considered life-threatening. Most of the reports were in adults over 50 years of age.

Davis said health professionals are advised not to supply the combination of the three medicines to people with risk factors for kidney failure – such as older adults, people with some kidney failure already, people at risk of dehydration (vomiting, diarrhoea, inadequate fluid intake), and hypotensive patients.

“Heart and blood pressure medication and pain relief medication affect blood flow in the kidneys, while diuretics can cause dehydration, which can also affect kidney function,” said Davis. So it was important that patients taking heart/blood pressure medicines and diuretics were told not to take over-the-counter NSAIDs and that health professionals checked what medication patients were already taking before prescribing or dispensing NSAIDs for pain relief.

Between 2011 and 2016, ACC accepted over 5,800 treatment injury claims related to medication errors and reactions. ACC’s chief clinical advisor Peter Robinson said while many of these injuries were minor, a small number were severe, with long-term effects on patients, and were a priority for ACC to prevent.

During Patient Safety Week (Nov 5-11) health professionals are being encouraged to consider:

• the importance of giving consumers time – their questions are valid
• what is common for you may be unusual, confusing and challenging for consumers
• knowledge is power – the more a consumer knows, the less likely they are to make a mistake with their medicines
• cost could be a barrier to consumers filling prescriptions and continuing to take medication – talk to them about this
• practising the three steps to better health literacy: find out what people know, build health literacy skills and knowledge, and check you were clear.

Consumers are being encouraged to ask clinicians questions about their medication including:

• What is my medicine called?
• What is it for?
• When and how do I take it?

Patient Safety Week resources are available here

The woman, who had told the dermatologist she was in a relationship and using condoms, found out she was pregnant after taking the drugs – known to cause birth defects – and the pregnancy was terminated.

Health and Disability Commissioner Antony Hill, in a report released today into the 2015 incident, found the dermatologist in breach of the Code for Health and Disablity Services for failing to test for pregnancy prior to prescribing isotretinoin. Isotretinoin is teratogenic and known to cause birth defects in an unborn child. Guidelines recommend pregnancy tests prior to starting the drug as well as ‘strict birth control procedures’.

The woman saw the dermatologist in July 2015 about severe acne, which had been successfully treated by isotretinoin when she was 16. But the acne had gradually recurred and had not responded to antibiotics or oral contraceptives. The young woman had visited the same dermatologist in 2011, but had decided not to proceed with isotretinoin at that time.

The dermatologist and patient in July 2015 agreed to try another course of isotretinoin and the doctor ordered some pre-treatment blood tests, but not a blood or urine pregnancy test. The patient told the dermatologist she had a long-term partner but had infrequent intercourse, and when she did they used a condom. The dermatologist told the HDC that she did not consider the patient a pregnancy risk as she had been using a barrier method of contraception for five years and had not fallen pregnant.

Medsafe advises not to prescribe isotretinoin in “women of childbearing potential” unless they had been on an “effective contraception without any interruption” for one month before beginning isotretinoin and had had a negative pregnancy test within two weeks of starting the drug. It was recommended that, while on the drug, two complementary forms of contraception, including a barrier method, should be used.

Mr Hill said whether the patient was pregnant or not at the time of the consultation was not relevant to the findings. The patient told the commissioner that the dermatologist had explained the risks associated with becoming pregnant while taking isotretinoin and given her a booklet, but she had not been made aware during the consultation that she should have been on two forms of contraception.

Mr Hill considered that by prescribing the woman isotretinoin without carrying out a pre-treatment pregnancy test, the dermatologist failed to provide services to the woman with reasonable care and skill. He also found the dermatologist’s company liable for the dermatologist’s actions.

The dermatologist said following the complaint she carried out a pre-treatment pregnancy test before prescribing isotretinoin to women of childbearing potential, required them to be on a secure form of contraception and had introduced a consent form, along with a handout for all patients.

The dermatologist had provided a written apology to the woman and arranged to enrol in a communication skills course.

The full report can be read here.

New Zealand pharmacists were joining pharmaceutical colleagues around the world in celebrating their roles in health care and research to mark the day on September 25. An animated video is also on its way to inform the public who pharmacists are and what services they can provide.

Smith, head of the society that represents about 4000 pharmacists, said the Government recognised pharmacists as an “untapped resource”, given their five years of professional training, and this was reflected in the Pharmacy Action Plan launched in June last year.

“The Action Plan aligns with the New Zealand Health Strategy and aims to make greater use of the skills and training of the pharmacist as a member of an integrated healthcare team,” said Smith.

Enhanced services that pharmacists may now provide include:

• medication reviews
• Warfarin monitoring
• range of vaccinations
• treatment (antibiotics) for urinary tract infections
• treatment for erectile dysfunction
• (soon) repeat prescriptions for the contraceptive pill.

“Already this year we have seen pharmacists able to administer subsidised flu vaccinations to pregnant women and people aged over 65,” said Smith. He said the next section of the plan under consideration was a Minor Ailments Scheme provided by pharmacists to targeted populations.

In 2013 new regulations were also introduced to allow suitable trained specialist pharmacists to be designated prescribers (similar to the regulations under which registered nurse prescribing was introduced last year) after completing a postgraduate certificate in prescribing and meeting the clinical experience requirements. In August 2016 there were 18 pharmacist prescribers, of which about half were working in primary care or across primary and secondary care.

Smith said recent research indicates that the public was largely unaware of how pharmacists were trained, their ongoing professional development requirements or the range of services they could provide. With this in mind, the Society has created an animated video to show patients how their pharmacists can help them. “The video will explain in a simple and entertaining way who we are as pharmacists and what we do,” Smith said. The Society expects to release the video in early October.

Pharmacist facts

• New Zealand has more than 3500 practising pharmacists.
  • Around 75 per cent of these work in community pharmacies.
  • About 13 per cent are hospital pharmacists.
  • About 2 per cent work in primary care teams.
• There are close to 1000 community pharmacies.

Source: Pharmacy Action Plan 2016-2020, Ministry of Health (2016)

The regulation introducing RN prescribing in primary health and specialty teams came into force on September 20 last year, with the aim of improving access to medicines for vulnerable populations.

The 29 new RN prescribers authorised to prescribe from a schedule of common medicines for common and long-term conditions join 53 diabetes nurse specialists authorised to prescribe in diabetes health, making 82 RN prescribers in total.

Pam Doole, the Nursing Council’s Strategic Policy Manager, shared the updated statistics on the new second level prescribing at the Clinical Nurse Specialist Society NZ conference in Christchurch earlier this month.

There are now also 254 nurse practitioner prescribers (the top level and only autonomous nurse prescribers), and a group of nurses are currently trialling a third and more limited level of RN prescribing in community health. The first NP prescriber was authorised in 2003 and a pilot followed in 2011 of RN-designated prescribing in diabetes (applications under the diabetes regulations close in November).

Doole said to date most of the 29 RN prescribers in primary health and specialty teams have come through the alternative pathway of having first completed a clinical master’s degree. But the first graduates of the council-approved postgraduate diplomas in registered nurse prescribing were now starting to seek prescribing approval.

RN diploma prescriber

Hawke’s Bay’s Rachael Engelbrecht is one of the first RN prescribers to come through the diploma model.

The former practice nurse specialising in diabetes said she finished a postgraduate diploma in health sciences in 2015 at EIT and spent 2016 waiting for the new prescribing diploma path to be finalised and approved so she could do the EIT diploma’s prescribing practicum.

Engelbrecht began her practicum at the start of this year at the general practice where she had worked for eight years and had become the lead diabetes nurse after developing an interest in diabetes. She said she had a very supportive GP mentor and they envisaged that while her main prescribing focus would be diabetes, it would be useful for her to also have the potential to prescribe for conditions like urinary tract infections and other long-term conditions apart from diabetes.

But midway through her prescribing practicum she changed roles and took up a new post as a diabetes nurse specialist for Hawke’s Bay District Health Board’s diabetes service and completed her diploma practicum under an endocrinologist.

The new RN prescriber believed the role was more clear cut in secondary services and was still evolving in primary care where some issues, like what to charge for an RN prescriber consultation, needed to be worked through.

At the DHB she is one of seven diabetes nurse specialists, with five of them now prescribers – four through the diabetes prescribing regulations and herself through the primary health and specialty team regulations. She said a sixth was currently following the diploma pathway to prescribing.

Changes afoot to regulations controlling RN prescribing

Pam Doole told the clinical nurse specialists’ conference that developing the RN prescribers’ medicines list of commonly used medicines for common conditions had not been a simple process.

Including the Council needing to respond to concerns raised by doctors and pharmacists, which led to it removing some medicines from the final list that was approved and gazetted by the Ministry of Health under the Medicines Act 1981.

Doole said she was aware that medicines used by some nursing specialties, and some new medicines, were not covered by the list. She said the medicines list, gazetted in 2016, was unlikely to be reviewed for a couple of years and in the interim nurses could develop a case for adding additional medicines that could make a difference to their patients.

Meanwhile, work was underway on a new regulatory regime to replace the Medicines Act 1981 and regulations, which could see controls on prescribing shifted to the Health Practitioners Competence Assurance Act and authorities like the Nursing Council. Doole said she was not sure yet whether that meant control of the medicines list would also come under Council’s control, but it could be simpler to make changes in the future if it did.

BACKGROUND INFORMATION

The specific common and long-term conditions that nurses authorised to prescribe in primary health and specialty teams can prescribe for include:

• diabetes and related conditions
• hypertension
• respiratory diseases including asthma and COPD
• anxiety and depression
• heart failure
• gout
• palliative care
• contraception
• vaccines
• common skin conditions and infections.

Examples of primary health and specialty team settings that RN prescribers can work in include:

• general practice
• outpatient clinics
• family planning
• sexual health
• public health
• district and home care
• rural and remote areas.

The requirements for registered nurses who wish to prescribe in primary health and specialty teams are:

• a minimum of three years full-time practice in the area they intend to prescribe in with at least one year of the total practice in New Zealand or a similar healthcare context
• the completion of a Council-approved postgraduate diploma in registered nurse prescribing for long term and common conditions or equivalent as assessed by the Nursing Council
• a practicum with an authorised prescriber, which demonstrates knowledge to safely prescribe specified prescription medicines and knowledge of the regulatory framework for prescribing
• satisfactory assessment of the competencies for nurse prescribers completed by an authorised prescriber
• RN prescribers in primary health and specialty teams must work in a collaborative team with a doctor or nurse practitioner available for consultation if the patient’s health concerns are more complex than the RN can manage.

Lesley Harry, NZNO industrial advisor, said a second facilitated forum was being held today on addressing chronic understaffing and implementing the safe staffing Care Capacity Demand Management (CCDM) tools with DHB, Ministry of Health and New Zealand Nurses Organisation representatives

Chief Nursing Officer Dr Jane O’Malley confirmed she is attending the meeting on how to hasten the roll out of CCDM as the Ministry’s executive representative and as “an observer and support”.

Harry said today’s (16 August) CCDM safe staffing forum was a follow-up to an earlier forum held on July 18 to help inform the multi-employer collective (MECA) negotiations which got underway between the DHB and NZNO in June.

During the 2015 negotiations the DHBs ‘reaffirmed’ their commitment to implementing the safe staffing CCDM system* including making a ‘timely response’ when CCDM analysis showed that more nursing positions were needed to meet patient acuity and demand trends. But by midway through this year only 14 DHBs were underway with implementing CCDM and few had completed full implementation.

Harry said in negotiations earlier this month NZNO had reiterated issues relating to its pay equity claim and intended to discuss Australian comparators when negotiations resumed on August 23.

In early August NZNO negotiators had also held discussions with DHB directors of nursing over plans for registered nurse (RN) prescribers and how the RN prescriber role might fit into the current employment agreement’s senior nurse framework.

The MECA negotiations cover about 27,000 registered nurse, enrolled nurse, midwife and health care assistant members of NZNO. The current MECA expired on 31 July.

In its latest MECA bargaining update the NZNO said it had also agreed to refer discussions about support for victims of domestic and family violence to a joint forum on 5 September with fellow health unions, the Public Service Association (PSA) and E tū.

*CCDM three core components

1. Mix and Match Staffing (i.e. using patient acuity data analysis to calculate the safe FTE base staffing required for a ward or unit to meet patient demand patterns)
2. Variance Response Management (i.e. capacity at a glance screen (CAG) and ‘traffic light’ system to alert when ward is in immediate need and systems of how to respond)
3. Core data set (Using high-quality data to review and respond to safe staffing needs)

CCDM DHBs (at various stages of implementation)

• Bay of Plenty
• Northland
• MidCentral
• Nelson
• Tairawhiti
• Taranaki
• Southern
• Waitemata
• Hutt Valley
• Whanganui
• South Canterbury
• Auckland
• Hawke’s Bay
• Capital & Coast

Have validated patient acuity system and CCDM under discussion

• Wairarapa
• West Coast

Progressing validation of another patient acuity system

• Counties Manukau
• Waikato

Considering acuity system options

• Canterbury
• Lakes

The action plan, published online at the weekend, is New Zealand’s contribution to fighting the global risk that increased antimicrobial resistance will see people needlessly die from infections and diseases that are currently treatable.

Better monitoring and reporting on antibiotic and other antimicrobials being used in hospitals and the community will be part of a national surveillance programme of antimicrobial resistance and antimicrobial use in humans, animals and agriculture to be established.

This will include analysing the dispensing of antibiotics to identify “prescriber types” with the data used to “develop and target interventions” to promote “appropriate” prescribing.  It will also examine the differences between the prescribing of antimicrobials in the community and hospitals.

Educating consumers about appropriate antibiotic use and developing resources to support better prescribing, including the possibility of prescriber targets, are priority actions.  Along with improving infection prevention and control in health facilities, schools and community-based services including promoting a “one-team” approach to infection prevention and control in health facilities.

Health Minister Dr Jonathan Coleman and Food Safety Minister David Bennett launched the finalised plan that was first aired at the 70th World Health Assembly in Geneva earlier this year.

Bennett said as a major food producer, New Zealand must manage antimicrobial resistance in animals and plants effectively.

You can view and download the plan here

The 18 action areas are built around the plan’s five objectives:

1. Awareness and understanding: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training.

2. Surveillance and research: Strengthen the knowledge and evidence base about antimicrobial resistance through surveillance and research.

3. Infection prevention and control: Improve infection prevention and control measures across human health and animal care settings to prevent infection and the transmission of micro-organisms.

4. Antimicrobial stewardship: Optimise the use of antimicrobial medicines in human health, animal health and agriculture, including by maintaining and enhancing the regulation of animal and agriculture antimicrobials.

5. Governance, collaboration and investment: Establish and support clear governance, collaboration and investment arrangements for a sustainable approach to countering antimicrobial resistance.