Rural nurses are often isolated from their colleagues. The low number of registered NPs in rural primary health care has meant that nurses often have not experienced working with a NP. This, of course, is inevitable with the introduction of a new workforce role when they are, in essence, pioneers (Brown & Draye, 2003). The lack of such experience, however, was problematic for nurses as they worked to finalise their NP portfolios and be assessed by the Nursing Council.
I don’t actually think you get a real understanding of the importance of the role and the level, the senior level of the role, if you don’t have that collegial support and [the opportunity] of studying with a group that is going to carry you through that journey. (Carol)
Primary informants identified the value of having colleagues and nursing leadership, and acknowledged that completion of a Master’s in Nursing was just another stepping stone. An experienced NP involved in mentoring others stated:
It’s another ball game. They’ve finished their master’s; phew, leave that behind. Now the next lot of hard work begins. And we’re going to set you up ready for [the Nursing] Council. (Informant 3: Group 2014)
In a group interview, the NPs discussed how there were two distinct roles for support and mentoring:
Well are there two roles here? I mean the clinical oversight for making clinical decisions which a GP can absolutely do around case review; but then there’s that other mentoring role around the leadership and the articulating of the nurse practitioner role, which maybe is not the GP - we don’t look to GPs for that. We look to our colleagues (Informant 6, Group 2014)
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Just some of the nurses, some inspirational nurse that you can sit down with, you can review “How do I manage this? Where am I going?” That leadership - I see that’s two quite different types of roles... (Informant 4, Group 2014)
Informants gave two examples of formal mentoring and support programmes provided. One PHO had identified a nurse leader who particularly supported nurses on their pathway from nurse to NP. This included helping with access to education pathways, HWNZ funding, requirements for NP portfolio, and support in accessing NP mentors. Jane described the support when she completed her portfolio:
And what drove [the portfolio] was the help through the PHO and the leadership group…. Then there was some funding available to help me to get a portfolio together. I suppose it was more like a semester again. There was a time frame with it and some goals. [The nurse leader] was put in place to be my mentor, I suppose my supervisor, to get me through to Nursing Council and that was the bit that made it happen. (Jane)
Another group reiterated the importance of both the PHO and the DHB’s DoN being involved in the process:
One thing that from the very time we started the NP [programme] was the effort to make the relationships that count, that were going to assist the nurse practitioner pathway, was really important. We’ve got the key stakeholders to me in this room. We do. We’ve got our PHO members... (Informant 5, Group 2014)
Our DoN. (Informant 6, Group 2014)
We’ve got our DoN. You know, she’s our DHB voice. (Informant 5, Group 2014)
She’s our mentor. She’s our... (Informant 6, Group 2014) Champion. (Informant 1, Group 2014)
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Champion for going into those areas and making the negotiations with people who develop the contracts with the DHBs. (Informant 5, Group 2014)
And we’ve got two clinical leaders in the PHO that absolutely support us and the NP pathway. (Informant 1, Group 2014)
The experiences of this group of NPs was in complete contrast to another NP candidate who described her support as “zilch” from both PHO and DHB.
A PHO chief executive officer (CEO) described the unfairness of the situation and how the environment differed considerably from one place to the next. She described the work that nurses intending to become NPs needed to do. She stated:
I’m aware of other places where it isn’t as easy for a nurse practitioner to move through that whole pathway, because there is quite active sabotage of what’s happening. You know you need the commitment of your employer, of your manager, you need a sense of where you’re heading. You’ve got to really have an analysis of what you’re doing and why you’re doing it, you need to align with service goals and know where you fit in the scheme of things… You need to have conversations with key people, and you may need to talk to the Director of Nursing. It’s complex. (PHO CEO)
The CEO went onto describe how she had aimed to create a culture of professional development, where nurses were supported to develop their career pathways in response to the population needs of their communities. The development of NPs for the PHO was a part of their strategic plan, and in turn this was supported by the DoN and the manager of the Planning and Funding team at the DHB. The result was that the PHO could appropriately use funding to provide mentorship for the nurses through to submission of their portfolio and attendance at the Nursing Council for their NP assessment panel. Further, they supported authorised NPs to share their knowledge with NP candidates to develop their own practice, and had established a successful NP forum.
161 When I asked the CEO essentially about how she managed the ruling relations and the variety of texts regarding NPs, she identified the report by the Ministerial Taskforce on Nursing (1998) as a significant text. She stated:
There was a group that actually brought together a whole lot of nurses from different areas of practice and organisational levels and talked about how to position nursing strongly, and there was a document that came out as a result of that group working together. This was a good document in terms of positioning nursing and nurse practitioners. So we took that and ran with it when we went back to our home ground. (PHO CEO)
Different individuals and organisations engage with and enact the same texts in different ways over many years. The CEO demonstrated how she gave power to those texts that promoted reducing health inequalities and developing the nursing and NP workforce over a fifteen-year period. She engaged with a social justice discourse and believed that all communities should have access to a NP. However other nurse leaders of PHOs and DHBs have failed to engage with the texts to establish a NP workforce. Instead, they have been subjected to other authoritative knowledge, including the necessity to continue the general practitioner-led model of care, discussed in the next chapter. Despite the availability of texts to advocate for the NP workforce, as well as the regulatory, educational, and legislative framework, there is no single text governing the implementation of the NP workforce in New Zealand.
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