The Nurse Practitioners New Zealand (NPNZ) (2015) website states:
You can’t guarantee a job unless you have prepared the way, and you
can’t do that in isolation, you must include people who can help with service delivery, funding strategies, business cases, job descriptions and team development. Becoming an NP is only one aspect of increasing the NP workforce, the workforce must also change shape to accommodate and embrace this new opportunity.
The advice instructs nurses on the activities they need to do in order to become a NP, and identifies that the health workforce must itself “change shape”. This is the extraordinary tension that NPs experience. Firstly, the work processes behind each of these activities - service delivery, funding strategies, business cases, job descriptions and team development – is enormous, and requires the involvement of others. Evidence from research where change in practice is implemented identifies the commitment and time involved in supporting a team to make changes in practice (Belanger & Rodríguez, 2008; S. Morgan, Pullon, & McKinlay, 2015). Secondly, to be accommodated in practice requires not only practical changes to work processes, but also changes to the discourses regarding NPs delivering services that are at the very least equivalent to a general practitioner. Research has identified the necessity of an organisational climate that promotes collegiality and professional visibility to successfully implement NPs (Poghosyan, Nannini, & Clarke, 2013). Practice staff and patients are all required to accommodate the new workforce.
Liz was an advanced nurse, near to completing her master’s and hoped to become a NP. She understood the necessity of working in a clinical setting that supported the development of NPs. Liz’s journey over a three-year period is mapped.
163 The map45 (overleaf on page 164) shows the key actions that Liz took, and identifies some of the texts known to her that were organising her journey. Those texts that could not be identified at interview are marked with a “?”. The map portrays her efforts to gain employment in a position which would support her completing her master’s, prescribing practicum, and registering as a NP (S4-S5 of the scaffold map).
At the time shown as the start of the map, Liz was employed by the DHB to work with patients who had long term conditions and lived mostly rurally. She was an experienced, advanced nurse with a postgraduate diploma. She asked both the DoN and the CEO about the development of the NP workforce:
And I didn’t get a very clear answer that there was any kind of plan. There was a lot of talk about NPs coming in the future, and I think our CEO at the time was Chair of one of the NP Development Groups [nationally]. But no real guidance, so I shook my head and said “Well, I’ll carry on in long term conditions – politically for me, long term conditions seems to be the hot topic, that’s where the attention is, where the resources come in. That’s where the need in our community is – it’s not going to steer me wrong”, and so I continued on my pathway with long term conditions. By the time I was completing my master’s, probably finishing my thesis and about to start on my practicum, the DHB quite clearly said “No, we’re not looking at NPs in the DHB, we’re looking for Primary Care to lead the way”. (Liz)
164 Map 9 : Liz: Three y ear jo urney
165 District health boards have a dual role both as a provider of secondary (and tertiary) health services, and as the planner and funder of primary health care services. Local PHOs are contracted by the DHBs through the PHO Services Agreement to deliver services including through general practices. However, the division of functions between PHOs and DHBs has often led to tension and the inability to implement population health strategies, such as reducing health inequalities (Cumming, Mays, & Gribben, 2008; Tenbensel, Cumming, Ashton, & Barnett, 2008).
Liz was unsure of the texts leading to this decision, though was aware of the tensions between the DHB and PHOs in the sector. She was somewhat bemused at the contradiction of the CEO’s commitment at a national level to the NP project, yet those texts were not being enacted at a local level.
Liz searched to find a new position, where she would be supported to become a NP. She was offered a job by a manager of a PHO who had previously employed a NP, and who allocated rural and long term conditions funding to enable Liz’s employment. Liz described the manager as:
Incredibly visionary, proactive, wanting the best for the community, and [she] felt that NPs and nurse-led services were the way forward. (Liz)
Liz established her work through rural general practices. However, a change in government policy resulted in a major restructure and consolidation of PHOs beginning in 2010, at the request of the Minister of Health, Tony Ryall46. The PHO, where Liz was employed, merged with another larger PHO, with its head offices out of the area. The result was that contracts were reviewed and a new manager employed. Liz lost her “champion”, and was told that the PHO would not be in a position to support a NP. While Liz found that some general
46 The National-led government came to power in 2008 with a commitment to reduce health
166 practitioners seemed to be keen on employing a NP, the question was always “Where’s the money going to come from?”
Liz returned to the DHB. She was told by her DHB manager:
“We think that it [becoming a NP] is important. We’d like you to do it. Come on back and we can support you in your practicum and the rest of your pathway”. So I came back. I swapped my prescribing mentor for one of the physician’s here, and had a really great prescribing practicum. Then after a short period of time was told: “No, it [becoming a NP] is not going to happen. We’re not ready. Sorry.”
Liz was unsure exactly where this decision came from, but believed there was concern about the logistics of employing a NP and securing ongoing funding. She believed that the decision had been blocked by the CEO, who, at a national level, was seemingly an advocate for NPs. There was no change during this time to the national texts that described the need to develop the advanced nursing workforce and reduce health inequalities through primary health care provision. However, other texts were entering into the CEO’s local environment and being enacted instead, resulting in his change in decision. Textually, the CEO was giving priority to other texts and discourses. The hierarchy afforded to the texts in this complex climate was in a state of flux. Liz re-explored options to work in general practice, but there seemed to be no opportunities.
The excerpt from Liz’s map (p. 164) indicates the complexity of texts that are controlling the process, and her experiences and actions, many of which were outside of her awareness. The change around, or U-turns, in the policy of the employing organisations left her feeling “frustrated and disappointed”. Her embodied experience indicated a reality gap between the expected action of the organisation, the needs of the local community, and what actually happened. The overall message of the organisations are marked in orange text as ‘maybe’, ‘yes’, or ‘no’ to her becoming a NP within that organisation. However, she did recognise that
167 her NP pathway had been caught up in wider political issues, particularly through the National government policy requiring the consolidation (reducing the numbers) of PHOs:
I could see when we had [named] PHO in control of a lot of our practices, that NPs would have come, and would have come quicker in the practices, because we had someone innovative controlling the funding, and they would have been much more-able to say to the GPs “OK, I’m going to give you this funding, but I’ve ring-fenced it for the NP position; we’ll evaluate it as a model, and let’s see how you go”. And once they’d got it established, that would’ve been have been fine. Now that we’ve got such a disparate group of PHOs, the GPs have actually built up a kind of wall of resistance to anything new. It’s all changed so much, and they’re being managed by people from so far away, who don’t understand [our rural area] that they’ve almost built up this kind of barrier to further change. “We will do things at our pace, thank you, when we’re ready for them, and when it’s our idea.” (Liz)
Further, through the interview Liz recognised that the poor relationships between the PHOs and DHB had reduced the priority of establishing NPs in their area:
I feel like I did blame [the CEO] for the NP slow-down, and it’s true, it was his fault, but he is still trying to work on building relationships between primary and secondary care. (Liz)
Ultimately, Liz reflected:
I’ve never been bitter about what happened. I was frustrated at the time, but I’ve never been bitter about it because there’s absolutely no point in it in an area this size. If you get annoyed with the organisation you work for, there’s going to be nowhere else for you. So you learn to make your peace with it, and you move on. (Liz)
In her new position, Liz has continued to advocate for NP services in rural areas, and believes that increasingly the idea of NPs is being accepted by rural general practitioners. She is reconciled to not becoming a NP in the foreseeable future.
168 The map (shown on page 164) depicts a summary of Liz’s journey. Each sequence of her journey would have been organised through multiple text-work-text sequences. However, by mapping in this way, the complexity of the frequently changing environment becomes visible, as well as how different texts are perhaps foregrounded at different times. Liz did a vast amount of work to prepare the way and endeavour to become a NP. She identified the unmet health needs of people with long term conditions living in a rural community and how NP services could address those needs. She proactively engaged with employers and managers who at the outset appeared to promote and be supportive of the NP workforce. She completed the clinical and educational work to meet the Nursing Council requirements to be registered as a NP. She has not yet become a NP.
Summary
The journey to become a NP is arduous, requiring tenacity, dedication, and some luck. While it is perhaps an essential part of who those NPs are today, others, such as Liz, were subjected to frequent changes in policy, health service structures, organisational priorities, and the commitment of individuals. Through this chapter I have used data, mainly from the primary informants, to identify the key texts that were enacted by the RNs on their pathway to become a NP.
The scaffold map was used to show the pathway from RN to NP, identifying the key stages as described by the Nursing Council, tertiary education institutions, and HWNZ. What lies behind the scaffold map, as described by the primary informants, is a considerable work process to become registered as a NP, both for the development of their advanced clinical practice and decision-making, and their educational pathway in order to be in a position to apply to be registered as a NP.
169 The primary informants demonstrated how the ruling relations of rural health provision imposed an onus on nurses to provide a full range of primary health care services in isolated situations. In turn this has driven and organised their work and actions to become NPs. The nurses described their abilities to work within the system and engage with texts in a way that enabled them to provide services, although at times stretched the boundaries of their competence. Innovations in rural health, such as standing orders and PRIME, and working in out of hour’s services, provided an opportunity for the nurses to work at the top of their RN scope of practice, further developing their advanced skills.
Alongside their clinical practice, the nurses were navigating their way through a clinical Master’s in Nursing programme, including undertaking extensive work processes to apply for and secure funding on an annual basis. There is ad hoc access to HWNZ funding for primary health care nurses which is administered by the DoNs for each DHB. While I have not explored explicitly those texts organising the selection of nurses to fund for their postgraduate education, there is variation between the DHBs. It may be that some DoNs are more powerfully coordinated by the ruling relations organising service delivery within their own DHB services, rather than enacting the texts that advocate and regulate for primary health care NP workforce development.
The NPs identified how a nursing leadership discourse that supported the growth of NPs, whether through direct activities such as funding, mentoring, or professional development, enabled their progress to become a NP. The NPs recognised the actions and work of nurse leaders and managers at the PHO and DHB to establish such a robust infrastructure. For one particular PHO, it was evident that certain texts had been strongly engaged with and enacted, and while the CEO acknowledged difficulties over the fifteen-year journey, she determinedly drew on the texts advocating for a NP workforce, and reducing health inequalities.
170 Finally, I mapped Liz’s journey as she repeatedly tried, though ultimately did not succeed in becoming a NP within her locality. The complexity of the health environment, and the multiple and frequently changing texts, was evident. There is no national policy regarding the implementation of NPs. Ultimately, the decision to develop the NP workforce is taken at a local level, whether DHB, PHO or local general practice. For RNs wanting to develop their practice there is an element of ‘pot luck’, and despite actions to ensure there is commitment from organisations, their success is dependent upon the alignment of texts supporting NP practice. The next chapter explores the contested space of general practice.
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