A Nurse Education and Training Board for New Zealand
Report to the Minister of Health: An evaluation of the need for a Nurse Education and Training Board for the oversight of nursing education and training in New Zealand
29 June 2009
A. The Committee on Strategic Oversight for Nursing Education 3
Terms of reference 3
The review process 3
B. Summary of findings and recommendations 4
C. The Place of Nurses in the Health service 8
Nurses work wherever health care and prevention exists 8
Nurses in the health work force 9
D. The Education and Training of Nurses 13
The Nurse Education system 14
Post-graduate education and post-entry clinical nurse training 16
Maori and Pacific Island nurses in the health workforce 18
E. Meeting the demand now for Nurses 20
Recognising the current demand for Nurses 20
Significant trends, constraints and risks 21
F. Future demand for Nurses in New Zealand 25
The nature of the general uncertainty about the size and mix of the nurse work force 25
The projected demand for health services 26
Influencing the future working life of nurses 27
Managing the contribution of overseas trained nurses in New Zealand 28
Influencing the place of nursing as a preferred profession of New Zealand men and women 30
G. Leadership of the nurse education system 31
Nursing leadership structures 31
Leadership issues 32
The Ministerial Taskforce on Nursing in 1998 33
Why structured collaboration is necessary 33
A proposal for structured collaboration across the nursing workforce 35
Strengthening collaboration across the various health workforces 37
H. The Terms of Reference set by the Minister of Health 38
I. Statistical Appendix 40
A.The Committee on Strategic Oversight for Nursing Education
Terms of reference
The Committee on Strategic Oversight for Nursing Education was established by the Minister of Health in March 2009 to explore whether a formal Education and Training Board would add value in overseeing and improving the leadership and responsiveness of nurse education in New Zealand. The Committee was established by the Minister to ensure the nursing profession has access to strategic education and development opportunities comparable to those now established for medicine through the Medical Training Board.
The Committee of Len Cook1 was to report to the Minister of Health in June 2009, after consultation mainly focused on New Zealand’s nurse organisations and nurse leaders.
The review process
Some 20 meetings and several less formal discussions were held with nurse leaders, educators and others in the health service. These discussions were essential to the review, adding insights that underpin the conclusions of the report. Every group was unstintingly helpful, and they often added leads for further thought. The Tertiary Education Commission (TEC), District Health Boards New Zealand (DHBNZ), Ministry of Health and Statistics New Zealand gave invaluable assistance in obtaining the statistics used in this report.
In carrying out this review, I was most ably supported by Christine Andrews (Senior Policy Analyst – Nursing, Ministry of Health), Robert Heyes, (Principal Technical Specialist, Ministry of Health), and Kerry-Ann Adlam (Director of Nursing, Taranaki District Health Board). I am most grateful to those who later reviewed parts of this report during its preparation, after being interviewed.
This review provides an assessment of the ways that we could better make decisions about the appropriate number and mix of types of nurses we need each year, to inform and provide a national focus to their education and training. Such decisions are of vital importance to our health, health services and nursing. This is not a review of any aspect of the nature of nursing as a profession.
There have been many initiatives that further the development of the nursing workforce, and in more recent years District Health Board initiatives have paid particular attention to developing information about the nursing workforce, structured pathways for building up the clinical experience of newly registered nurses, and increasing the share of nurses who are Maori or from Pacific communities. This review has not enumerated these initiatives, nor have any initiatives been evaluated for endorsement or criticism. Many of the comments received have sought to build on initiatives that already exist, or have been a stimulus for a more fundamental challenging of existing received wisdom.
B.Summary of findings and recommendations
New Zealand competes against the world to retain the nurses we train. Because we have tended to train fewer nurses each year than there is work for, New Zealand DHBs also recruit nurses from overseas, in addition to those that seek to come here. Since 2004, the Nursing Council of New Zealand has registered more overseas trained nurses than newly educated New Zealand nursing graduates. To some degree, the flow of overseas trained nurses can more quickly react to unplanned demands. Many overseas nurses work in roles and areas where New Zealand has failed for some time to develop staff with the required interests and skills. In doing this, the age distribution of the nurse workforce in New Zealand is being significantly changed, with downstream consequences for recruitment in later years. We have not been well enough organised in looking ahead at where national needs are not being met, or to give a lead to individual tertiary education providers and to local DHBs to consider national needs as well as those locally. The committee has had access to work now in hand2 among DHBs that will strengthen the basis for this in the future. The varied collaboration we have locally is a weak substitute for a nationally shared view of the issues we face and preferred options to resolve them. Many of the opportunities in the future require collaboration among health professionals, and nursing too needs to be more effective in establishing clear paths. Nursing, like most of the health sector, is clearly capable of developing thoughtful strategies, but then mobilising to achieve change effectively can be rather difficult, most particularly in change that involves joint action among professions.
We face a considerable shift in the mix of health care demands, as people live longer, in particular the nature of the conditions people have, their acuity and persistence. There will be a larger group of people who place quite massive demands on health services. Because we know a lot more about the causes of poor health, and have seen huge advances in treatments and diagnostic capability, we can also influence health outcomes much more now than was previously possible, and to a greater extent than we can ever afford. We do not know how all these influences will come together, leaving us with a need to prepare for many eventualities. Nurses work in many areas of practice, with only a half now being based in hospitals, a significant change from 25 years ago when six out of seven nurses worked there.
The central focus of more recent initiatives in health services, structures and systems, is to ensure that we can achieve the scope and scale of services for all New Zealanders that our national income leads us to expect.
Almost universally, nurses met during the last three months endorsed the general idea of a Nurse Education and Training Board, as a critical vehicle for advancing the leadership of nurse education and workforce development. A good many placed considerable value on the consequential benefit of a regularly organised leadership forum among medical, nurse, midwifery and allied health bodies involved in education and development of professional health workers, to confront and advance matters which needed collective understanding to proceed at a reasonable speed. An end point of collaboration in this form would be the establishment of a health education and training authority.
Many of the nurse leaders interviewed expressed very strong concern about the limited analysis of the long term demands on nurse numbers of New Zealand’s health services, and had a variety of concerns about preparedness to meet these demands. In particular, not only the age distribution of the current nurse work force, but the significant reduction in younger trained nurses will have serious consequences for our ability to maintain even the current level of New Zealand-trained nurses in the health service. Concern about the age distribution of nurses is more significant when looking at the age distribution of nurse educators. We have already reached high levels of overseas trained nurses, in particular nearly one quarter of nurses have been trained overseas, and of nurses aged under 45 years, three of every ten have been trained overseas.
Overseas trained nurses have a different age distribution to those that graduated in New Zealand, as they have tended to be recruited as New Zealand graduate numbers became insufficient to meet demands, although at correspondingly later ages. As the early post war baby boom cohort of nurses retires, the retirement will then start of overseas nurses now in the largest age group, between 35 and 45 years. Their concentration in particular roles and places will continue to exacerbate the impact of the ageing of the total nurse work force.
We already see that the needs of people, as they live longer than ever before, have led to a compounding of the number with multiple chronic conditions, so much so that demands on health services are unlikely to be met within New Zealand’s national income without either significantly increasing inequalities of access or changing how our health services operate. Nurses will play a critical part in any such inevitable change, and in extending the options we have for the overall nature of our heath service. Over the past twenty years the nursing workforce has changed in size, place of work, skills and qualifications ethnicity and national origin. With further change expected of the nurse workforce over the next two decades, more effective leadership at a national level will be needed to ensure that the many forces for change are responded to in a coherent manner that reinforces their fit with the longer-term needs of the health service. While the analysis in this report is mainly focused on Registered Nurses, it is expected that a Nurse Education and Training Board would have that responsibility for all nurses.
Fundamental to bringing about significant change will be:
A need to consider how to affirm the place and significance of nursing among the population in each age group, as a significant career choice
A need to understand and give attention to the current attrition rates across the seventeen tertiary institutions that grant degrees in nursing, and the retention of registered nurses in the health service.
A need to consider the service wide consequences of the accumulated decisions each education institution makes every year about the size of its student intake
A need to ensure that the availability of clinical placements does not limit nurse education
A need to systematically arrange for the development of the leadership capacity of those in each birth cohort with the most aptitude for wider health service leadership, at an appropriate time during their career
The New Zealand health service is highly decentralised, and once performance goals are set and financial allocations have been made, there is little basis for nation-wide direction or leadership of decisions about the health workforce. Training is not included in the performance goals of DHBs. Tertiary education operates in similar ways. More recently, we have seen a long overdue recognition that all parts of the health service share many common concerns about the nature of the leadership and management of the future health workforce. A strong focus on the development of the future medical workforce led to the workforce taskforce chaired by Dr Robert Logan, which in early 2007 recommended the setting up of the Medical Training Board. Len Cook has been the Chair of the Medical Training Board since it began in November 2007.