There is naturally a mix of views on what will make up the nurse of the future. Such differences can impede progress in a system such as we have in New Zealand where there are few ways of developing a consensus for action in the face of diverse views, so that decisions risk being made by default, slowing innovation and making change more erratic than it need be. Establishing common pathways is critical in nursing, and the necessary cohesiveness across programmes is fraught without a clear “world view” of the system we are moving towards.
The Nursing Council of New Zealand is a critical anchor for the nurse education system, in its requirements for registration, and statement of curricula that result in BN graduates from all education institutions being most likely to meet Nurse Registration requirements. This places huge expectations on those institutions to retain a degree of diversity, innovation and challenge while what they teach that is consistent with rigid national expectations.
Where those in nurse practice and in nurse education are able to have joint appointments (e.g. University of Auckland), there is undoubtedly a strengthening of linkages between the tertiary education system and the health services it prepares people for. The intangible and tangible benefits of such linkages can be huge, as they vastly increase the level of interactions that raise the responsiveness of the education institutions to how practice is changing. They also increase the capacity to introduce scientific study of nurse practices and health services that can have considerable impact over the next two decades of change.
There needs to be some system wide leadership of development initiatives for future nurse leaders. Nurses make up a significant number of the leadership and management positions in health. Currently there is no formal structure for identifying and preparing for these types of roles. There needs to be a process for education and practice organisations to identify individuals with leadership/management potential and provide opportunities to develop these skills through managed education and career opportunities. A similar system runs in the United Kingdom National Health Service. The experiences of the New Zealand public sector in investing in early leadership development confirm that there are successful models working in New Zealand, and the ideas behind them may well fit the health sector. A recent study by Dr Jocelyn Peach6 highlighted the disparate and continually changing position on nurse leaders across the New Zealand DHB system, and the lack of coherent approaches to advance the leadership capability of those with aptitude and experience at almost all levels, as well as the most senior.
The Ministerial Taskforce on Nursing in 1998
Barriers to releasing the potential of nursing and strategies to address these were identified and published in the Report of the Ministerial Taskforce on Nursing in 1998. Implementation of such a comprehensive array of proposals from a review of this sort is unlikely to be achieved as intended unless there is the capacity to persist with the system wide focus such reviews often involve. These task force proposals have been variously adopted, by and large without the impact intended at the time. The summary by nurse educators of its key conclusions focused on:
Including nursing leadership in management structures and decision making
Strengthening collaborative nursing input to policy making
Developing consistent processes for measuring the work of nursing and for resourcing nursing services
Preparation of nurses for top level management and leadership in clinical practice
Profiling nursing/nurse led initiatives and encouraging a wider range of provider organisations
Clinical career planning for nurses
Better links between education and health service providers
A similar taskforce today might repeat many of these conclusions.
Why structured collaboration is necessary
Perhaps the most vital achievement of any whole of system body in the New Zealand health system of 2009 is to establish some momentum on obtaining resolution to a good number of festering issues where inaction has slowed progress in nurse education more generally. The evolution of nurse roles as skills change, the tie up between gaining post-graduate qualifications and receiving workplace recognition and advancement, and the development of clinical places for training are among such issues raised with this committee.
While the local connections between DHBs and local tertiary institutions are often very good, at a national level there needs to be an ongoing process by which the market expectations and workforce plans of DHBs overall, are matched against the accumulated plans of tertiary educators in nursing. Given that the linkage between the demand for nurses in New Zealand, and the supply of New Zealand trained nurse graduates is now quite loose, it is even more critical that national oversight of nurse training exists to enable judgments about the long run sustainability of the nurse work force. Bottom up planning at the local DHB/Tertiary Institute level needs increasingly to be tempered by leadership and decision making at a system wide level, as local demands for nurses by DHBs may be simultaneously affected by resource constraints, the severity of which, necessitates short term adjustments that add up to change that is unsustainable at a national level. The accumulation of these decisions at a national level can result in inconsistencies in how short and long term benefits are compared. They usually ignore the relative scale of local and national capacities to manage change, and the considerable differences in the capacity of single institutions to influence system change compared to national organisations. Some actions are only viable at a national level, such as a national campaign to promote nursing, and some concerns such as the needs of local Maori and Pacific communities can be submerged at a local level through paucity of information and constrained voices, in a way that is less likely nationally. DHBNZ strategy groups have been building a capacity to bring national leadership the DHB wide initiatives, and cohesiveness to strategic thinking about health workforce issues. The DHBNZ Future Workforce Group and the Workforce Strategy Groups are in the process of establishing the wider strategic context for Nurse education and would enable a Nurse Education and Training Board to focus on its more specific role, with a high degree of cohesiveness with related health service initiatives.
The NETP programme development in clinical training for BN graduates typifies the scale of access to clinical experiences that nurses need in their education. The vital importance of linking education and training with service delivery may lead to a need to include students in the model of care. Not only innovation in this important area, but the sustaining and scaling up of existing opportunities would be greatly advanced by much more unified views between education and delivery about clinical placements. As in other fields of health education, there is a continued tension between theory and practice. We need to find constructive ways of ensuring that not only are nurse educators able to be periodically challenged in how this balance is established, but also that across the many participants in the tertiary education service nurse leaders are exchanging good practice and sharing innovation. The recent collaboration between Massey, Auckland, and Otago on developing a single curriculum on long term care management is a good example of this happening now. A common approach to innovation is essential, as many initiatives in one field of health may have systemic consequences (nurse assistants/enrolled nurses), and the capacity to engage collaboratively and constructively with other health sector education and training bodies would be strengthened by this board.
Quite naturally, even in a country of just 4.2 million people, nurse leaders and other health leaders have quite diverse aspirations that have vastly differing implications for the development of nurse education. A Nurse Education and Training Board would be one vehicle for effectively channelling this diversity into some commonality of expectations that can shape the path of nurse education, ensuring its relevance for an uncertain diversity of future needs. In this, such a board would not replace existing networks, but would seek to extend their capacity to contribute.
The funder/provider split in public sector management has been further complicated by the limited reach of existing collaborative bodies in nurse education and in the practice of nursing. Opportunity rarely exists for all parties to engage in reaching deliberations on how resources are allocated to particular fields or levels of education and training, and consequently there is a strong perception that resources could be applied in better ways.
The enrolment of students into nurse education courses, their later success and eventual recruitment are seen as critical stages in the building up of the nurse workforce. In the micro-management of these processes by individual DHBs, universities and tertiary institutes, quite inadequate attention has been given to influencing the attitude and expectations of each cohort of girls and boys into seeing nursing as their career. A strategic approach to the place of nursing as a significant career could be modelled on what is done for teaching. Investigating this could be one of the initial projects for the proposed board.