Thank you for highlighting the plight of rural health services in New Zealand.
When I worked at that very same location featured in your news item (Te Araroa on the East Cape*) for 12 years from the early 1990s there was also no resident doctor there for prolonged periods of time. And there were countless expensive locums who did little for consistency of care.
I stepped up to meet the health need. Initially I was on-call 24 /7 for 18 months working as a registered nurse at an advanced and expanded practice level. I also showed the local district health board a new model of care at the time.
So the shortage of rural doctors is not new information…more a reoccurring theme. The shrinking GP workforce in New Zealand is in crisis and it is an old ingrained model that no longer works.
I would like to inform you that there is a perfectly positioned response to helping with the ongoing crisis for areas such as these.
Nurse practitioners (NPs) are rapidly filling gaps where GPs have left or are over stretched to beyond safe capacity. Nurse practitioners provide virtually the same scope of practice as a GP; we diagnose, investigate with laboratory/ radiology tests, prescribe, treat and monitor patients’ care and provide a wider overview. Nurse practitioners are also owning and running health care centres.
We want to work alongside our GP colleagues in team work to provide a better model of care and prevent burnout, which happens all too often in the health sector, especially rurally. What works is using health practitioners more wisely…and well-funded team work with training of all health professionals to be working at the top of their scope.
Registered nurses can upskill to Masters’ degree level to become an NP. I began that process in Te Araroa. Fast forwarding to 2007 I gained my NP certification, continued to work in Tairawhiti/Gisborne, and then on the West Coast of the South Island for more than three years, so I have covered lots of the poorly-serviced GP regions. I have worked alongside GP colleagues in general practice in a newer model of care of team work, where nursing can work-up the patient who may or may not need to take a GP appointment. My current role is based in Blenheim where I locum across five general practices and afterhours care to provide ready access to care and appointments when individual GPs are on leave.
I’m not alone in providing this level of care – there are 256 practicing NPs nationwide, half of them in primary care and in regions such as your recent item showed. There will always be a need for the ambulance at the bottom of the cliff and hospitals. Health needs are expanding so rapidly and a GP is not necessarily the answer to every one of those needs. Access to early intervention can reduce the need and prevention is always better and more affordable than cure.
New models of team work including telemedicine, self-help on internet means that many of the old obstacles (to accessing health care) can be overcome to a large degree.
Nursing – alongside other allied professions such as social work, physiotherapy, pharmacists, counsellors as well as non-regulated health workers such as kaiāwhina and healthcare assistants – can provide much more care if funding is shared into other areas than purely another GP training school. I would support a new training school going ahead if it is a multidisciplinary school to the benefit of all who provide care in rural regions.
Small community trusts and health providers in provincial New Zealand are not supplied with deep pockets. NPs cost one-sixth of the cost of a GP to train and provide virtually the same level of service.
We are lobbying for a more equitable share of Health Workforce New Zealand (HWNZ) funding to fast track train more NPs from the 4000 RNs who currently hold a Masters’ degree, at present there is funding for only a very small number of up to 20 places in New Zealand to gain this training. Of note 55,000 nurses share $13 million in HWNZ funding, the remainder of $119 million goes to medicine.
I ask you to put some good news on your show. And challenge you to stop promoting the same old model that doesn’t work and keeps producing the same results, which is not good for health practitioners or the people of rural New Zealand.
We as Nurse Practitioners of New Zealand (NPNZ) implore you to interview Prof Jenny Carryer of the New Zealand College of Nurses on your show.
Regards
Diane Williams NP, Marlborough PHO
Nurse Practitioners New Zealand (NPNZ) executive member
PS Diane Williams – and other NP colleagues who contacted Seven Sharp – are as yet to have a reply.
*The Seven Sharp news item on October 17 featured an interview with Dr Tim Malloy, President of the Royal New Zealand College of General Practitioners, expressing concern about the shortage of doctors in rural communities saying it was “unacceptable, inequitable and a failure of the system”. It also featured an interview with people of the settlement of Te Araroa on the East Cape about their concerns at the lack of a local doctor.
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More than 130 rural nurses took part in the online survey held earlier this year by the newly formed Rural Nurses NZ working party.
Rhonda Johnson, chair of the Rural Nurses NZ working party, said the survey findings confirmed some of her hunches and provided a platform to help develop an action plan for the group that came into being after March’s National Rural Health Conference. She said the group also remained keen to get a better grasp of the total number of rural nurses and was looking to do its own census by directly contacting rural hospitals, practices and health providers
The group’s online survey found that 79 per cent of respondents had completed some form of postgraduate education and 21 per cent had a master’s degree or were nurse practitioners. About 91 per cent of respondents accessed professional development online and nearly 60 per cent faced non-physical barriers to accessing professional development including funding, travel and accommodation costs and lack of cover or time to attend.
“We’ve listened to rural nurses and what it is they need and they want – and professional development is one of those issues,” said Johnson. “Obviously location is a big part of accessing professional development, and we hope to establish links, networks and connections with each other so we support each with professional development as well.
“I was probably pleasantly surprised by the numbers who have completed some kind of postgraduate education – I thought that was a real bonus for rural nursing and shows the calibre.” She said it might also reflect a trend across the whole profession, with postgraduate education being seen as important for maintaining competency.
“Obviously it is an ageing workforce, but again that is true of nursing as a whole.” What she hadn’t expected was that – despite the largest group of respondents being in the 55-64-year-old age bracket (38 per cent) and 56 per cent having been registered for more than 25 years – that the largest group of respondents had only been practising rurally for up to five years (27 per cent) and only four per cent had worked rurally for more than 20 years.
“When I actually thought about my own working environment [Central Otago’s Dunstan Hospital], although there is a stable workforce of mature nurses there are also a number of younger nurses coming through.”
She said to her the survey findings confirmed the need for a group like theirs to be in existence to advocate for rural nurses, provide mentorship and connection between rural nurses working in other contexts and places, and influence other nurses to think about rural nursing as a career path. “We want to help influence recruitment and retention in these areas which are often hard to staff.”
The survey also indicated that the vast majority of respondents faced various difficulties in transporting patients to a base hospital due to inclement weather and lack of transport, and some required a boat or plane to transport patients.
Johnson said a list of working items had been collated following the survey findings and members suggestions and would be prioritised for action.
She said the RNNZ group was also working on a mission statement and how the group will fit with existing rural groups. “We don’t want to reinvent the wheel; connections with other rural groups, like the Rural Hospital Network (RHN) and Rural General Practice Network (RGPN), are important and we are working on those at the moment.” (See RNNZ’s term of references’ purposes and objectives below.)
As part of that work, the group remains keen to get a clearer picture of the number of nurses working rurally. Johnson said the Nursing Council does provide a setting category of ‘rural’ when gathering data during annual practising certificate renewals, but most rural nurses tick settings like ‘practice nursing’ or ‘hospital’.
“So the Nursing Council data shows only 257 rural nurses working in New Zealand, but that is grossly under-represented so we need to find out how many rural nurses there are. Which may sound quite easy, but actually it is not – because the term ‘rural’ is not adequately defined.”
Johnson said there is a research proposal on the table by rural hospital doctor Garry Nixon to define the term ‘rural’, which would help with establishing a rural health workforce database.
But in the interim, the working party was looking to do its own work to get a ‘ball park’ figure by contacting hospitals, general practices and other health providers in a rural setting to find out how many nurses they employ. She said at present the Rural Nurses NZ membership is open to any nurse who believes they practise in a rural context.
Currently the working party, which includes nurses from the Far North to Stewart Island (see bios below), meet via a monthly video conference. Johnson said the aim was for all working party committee members to attend the next Rural Health Conference in Auckland in March.
Purpose
To provide a regular forum that enables a diverse group of rural nurses from across New Zealand to develop models and/or strategies to support rural and remote nurses, including:
Objectives
Rural nurses work in a broad variety of environments, including, but not limited to: general practice, hospital, public heath, occupational health, district, PRIME, residential care, palliative care, nurse specialist or nurse practitioner roles, mental health, LMC, Plunket, wellchild, whānau ora, long-term conditions, and nurse-led clinics.
Rhonda Johnson: Chairperson
I have been immersed in rural nursing since 2002 and held the role of charge nurse at Dunstan Hospital for a total of 11 years. I recently moved into project planning and am now involved in the early stages of the Dunedin Hospital redevelopment project. I bring my rural knowledge and experience to this role.
I love the diversity and challenge that rurality brings and am committed to supporting staff and guiding professional practice in our unique context. I completed my PG Dip through the Rural Institute of Health and University of Auckland in 2008 and am now working toward my Masters of Nursing. I see the benefits of increasing the rural nurse profile in New Zealand and a need to establish better connections across the country to develop initiatives key to rural nurses in all contexts. I am currently on the Rural Hospital Network (RHN) executive team and am enjoying the new challenge of working with our enthusiastic group of rural nurses on the working party.
Emma Dillon: Secretary
Up until this winter I was working in Colville, a small village 30 minutes north of Coromandel, for two years. With an enrolled population of 700 patients, the clinic is owned/operated by a sole GP and employs two nurses plus support staff. Working as a rural nurse here includes practice nursing, district nursing, public health, palliative care and after hours/PRIME nursing. I was born and raised on the south coast of the South Island, and graduated with a nursing degree from CPIT in Christchurch in 2010.
Currently I am studying at the University of Otago, Christchurch, doing my PG Dip specialising in rural nursing. In late August I moved back to the deep south to take on the exciting challenge of working as a rural nurse specialist based mostly on Stewart Island, and in Tokanui in the Catlins.
Kate Stark: Communication Liason
Currently I work as a nurse practitioner (NP) at Gore Health Centre, part of an IHCF in rural Eastern Southland. I also work as an NP/PRIME Practitioner in Twizel, South Canterbury, and Central Otago. Prior to this, I worked in Roxburgh and Tapanui in rural primary healthcare. I am currently on the RGPN executive committee and hold the following positions of external nursing representative on behalf of the CPHCN:
I believe it is crucial to improve the heathcare of rural populations and to reduce the barriers for the health of rural people while simultaneously working for rural nurses to promote the unique role that rural nurses carry out individually and in teams. I am delighted to be involved in RNNZ and look forward to making a difference to rural nurses working in all contexts.
Virginia Maskill
Since graduating as an RComp.N in 1992, I have worked in a variety of clinical settings including the Nelson-Marlborough District Health Board. During this time I gained significant experience working in rural settings, including a dual role as an ambulance officer/registered nurse in a busy accident and emergency department and after-hours general practitioner service. For six of these years I was also employed part-time at the hospital’s alcohol and drug outpatient clinic as a registered nurse/counsellor. These positions provided me with extensive experience of the challenges specific to rural nursing due to wide geographical regions and a dispersed population often under-serviced with health resources.
In 2009 I joined the Centre for Postgraduate Nursing Studies at the University of Otago, Christchurch and the Department of Psychological Medicine, University of Otago, Christchurch from 2006 to 2016. I have a special research interest in the rural nursing workforce, hence my keenness to contribute to the Rural Nurses New Zealand working party. I am currently a member of the Rural Health Plan Working Group for the future development of rural health, Division of Health Sciences, University of Otago.
Cathy Beazley
Tena koutou katoa. Ko Cathy Beazley toku ingoa.
I began working as a nurse practitioner in 2013 and currently work in primary health care for Hokianga Health (a Māori provider) in the remote north-west of the North Island. Hokianga Health provides health care for an enrolled population of about 6,350, plus the all-year-round visitors.
Having started work in rural practice in 2000, I have gained experience in a number of positions, including working as an inpatient RN on small acute ward, rural practice nursing and community nursing.
At a local level I am a member of our rural GP, Clinical Governance and Significant Event groups. Regionally I am a member of the Primary Options Programme Northland group and Manaaki Manawa Heart Care Clinical Governance Group. I am also involved in a new rural research project, focused on the impact of introducing a haematology analyser at a rural hospital. I believe we need to work collectively to inspire future growth of this particular area of specialist nursing and I look forward to being part of Rural Nurses New Zealand.
Rhoena Davis
I am a nurse practitioner working in the northern rural area of Whangaroa in Whānau Ora. I have been an NP for eight years, working in rural areas for approximately 25 years.
I have completed a Master in Clinical Advanced Nursing with First Class Honours through Auckland University and my Expert PDRP for Primary Health Care. I have completed a Postgraduate Diploma in Māori Business Studies through Auckland University, Postgraduate Certificate in Well Child Health through Whitireia Polytechnic, Graduate Certificate in Specialty Nursing Practice (Child and Family Health) and a Graduate Certificate in Nursing Practice (Public Health).
I am excited about what the newly formed Rural Nurses New Zealand working party can offer rural nurses and am already enjoying being involved.
Debi Lawry
I came to rural nursing late in my career after spending much of my nursing life working in Auckland. I have been a bedside (incubator side) nurse, a clinical nurse educator, a charge nurse and a nurse consultant. Along the way I also became a midwife. I completed an Advanced Diploma in Nursing and have since had a varied academic journey with a number of post graduate papers in neonatal science, health management, ethics and health policy. I moved to Dunedin in 2002 to help establish the newly created nurse director role. Five years later I achieved my dream of moving to Central Otago and working at Dunstan Hospital.
My eyes were opened to the complexities, challenges and joys of rural healthcare. Much of my career has been spent in nursing leadership roles where I strive to ensure nurses have the education, resources (human and consumables), skills and equipment to do their job well.
I am now very keen to be part of a working party to identify the issues for rural nurses, particularly hospital nurses (but not exclusively so) and to advance our cause.
Christine Dorsey
Kia ora. Ko Christine Dorsey toku ingoa.
I live in the Hokianga, in rural North Island. I am currently employed at Hokianga Health as the Hospital Services Manager for our small rural hospital. My roles include overseeing the 24/7 accident and emergency, acute inpatients, and residential care services.
My background is in emergency care and midwifery across both primary and secondary care.
At an organisational level I am a member of the executive team and co-ordinate internal meetings and ongoing professional development for staff. I am also currently the chairperson for the South Hokianga St John – an endangered service in the current climate.
With regards to rural nursing, my interests are in developing standardised clinical guidelines and standing orders for safe, effective use in rural New Zealand. In addition to this, I am supportive of further work and resources to improve easily accessible professional development options for rural nurses, something that is one of the aims for the Rural Nurses New Zealand group, hence I am very pleased to be involved.
Rachael Pretorius
My name is Rachael Pretorius and I am a nurse practitioner working in a rural general practice in Martinborough, South Wairarapa, where I have worked for the last two years. I am also PRIME trained. I am acutely aware of the issues that impact on rural living, nursing, and practice. Living and working in a rural area means working to the top of your scope, dealing with everything that comes through the doors, hoping your internet will work at home (or work) and that you might be able to do some online learning sometime, and hoping the roads aren’t flooded out so patients can get to the practice over gravel roads.
I am the College of Nurses representative for the Rural Health Alliance Aotearoa New Zealand (RHAANZ) and a RHAANZ council member.
I love working in a rural practice. Even though I haven’t lived in rural New Zealand for very long, I know what we miss out on compared with our city counterparts and I think a rural nurse working party is an excellent way for rural nurses to get their voices heard and ensure that rural nurses enjoy the same support that urban nurses do.
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Roberta Kaio, who is of Ngāti Kahu ki Whangaroa and Ngāpuhi Nui Tonu descent, says she will use the scholarship to complete her Master of Nursing at the University of Auckland.
She currently works as the primary mental health co-ordinator for Kaitaia-based Te Hiku Hauora’s mobile nursing team, which serves the Far North.
Kaio, who started nursing training later in life, said she was very grateful for the scholarship and the chance to continue her postgraduate study, after already gaining postgraduate diplomas in health management and nursing.
“I remember the days as a single mother with two children, knowing I had to do something better for myself and for my children,” says Kaio. “I became passionate about supporting people with mental health issues and those who experience abuse.”
After 22 years in Auckland, the mental health nurse moved to Ahipara with her husband and children to reconnect with whānau and the community. “We now have a better life balance, with time for fishing, being outdoors gathering kai, and time on the beach together.”
Her first job in the Far North was further south working for the Ngāti Hine Health Trust as the clinical lead and acting team leader for Mental Health and Alcohol and Addiction Residential and Community Services, until a position became available serving the Far North.
“I spend a lot of time travelling to clients across the rural Far North; however, I get a great deal of satisfaction seeing the work that I do make a difference to the community, and I enjoy being part of people’s journey in a positive way.”
“Community-based rural health services are essential for people living in remote areas,” says Fiona Gower, RWNZ National President. “It is heartening that health professionals like Roberta are passionate about working in regions such as the Far North, and undertaking further study to improve professional knowledge and experience for the provision of quality rural health services.”
Kaio’s most recent job in Auckland was as service manager for Mobile Community, Adult, Youth and Maternal Respite Services for Affinity NGO Services. She has also worked for Māori Community Mental Health Services for several district health boards in Auckland and at the Mason Clinic.
]]>The plan was to run a contestable business case process with currently two proposals in the running – the initial joint Waikato University and Waikato District Health Board proposal and the joint Otago and Auckland medical schools proposal.
Professor Jenny Carryer, executive director of the College of Nurses, said the Government committing to a new rural medical school with the specific intent of producing 60 additional doctors a year for rural health was “extremely disappointing”. She said training more doctors flies in the face of evidence and advice and a more cost-effective solution was to train more nurse practitioners who could deliver the same scope of service as GPs.
Dalton Kelly, the chief executive of the New Zealand Rural General Practice Network (RGPN), said establishing a new rural school of medicine would be “very, very good news” as the initiative would contribute “hugely’’ to ensuring rural New Zealanders had the best health services available. But RGPN wanted to ensure the new school was multi-disciplinary, and not just for doctors. Kelly said it wanted the school to be for nurses, pharmacists, midwives, physios and for all the health disciplines needed to ensure “the first-class delivery” of health services in rural New Zealand.
Carryer said New Zealand had tried for many years without success to provide GPs for rural areas and had spent millions of dollars on an endless rotation of locums. “Medical graduates move towards busy urban areas and specialist positions with higher incomes and status,” she said. “Nurses are resident in rural areas and evidence shows they remain there after becoming nurse practitioners”.
Professor Neil Quigley, the University of Waikato’s Vice-Chancellor, said the university was heartened that National’s election promise showed its proposal last year for a Waikato Graduate Entry Medical School had been recognised and acknowledged. He said that the international research in medical education indicated that the only way to address the rural primary health care shortage and “looming crisis” was through the creation of a third medical school with a dedicated graduate-entry programme focused on community-engaged medical education outside the main centres.
In March the University of Otago and University of Auckland medical schools, in association with the Royal New Zealand College of General Practitioners (RNZCGP) and the New Zealand Rural General Practice Network (NZRGPN), announced they were investigating creating a new National School of Rural Health as a joint initiative. A key part of the proposal was to have a rural component for all health professional students by building an “interprofessional” faculty with its own leadership, based at up to 20 sites located in rural communities across New Zealand, which the partners believed had the potential to begin to address the country’s chronic shortage of rural health professionals.
Goldsmith’s announcement did not mention nursing or allied health professionals but said the business case process for the new school would ensure it met the needs of rural New Zealand. Also that the Government was committed to growing the medical workforce to meet the needs of a growing and ageing population.
Carryer said producing an NP from a year 1 nursing degree student through to completion of a master’s cost about $120,000, compared with about $600,000 to train a GP. “We cannot afford to pour more money into a direction, which is not supported by evidence or good sense.”
(See earlier opinion piece by Carryer: Train more GPs, not NPs and one GP’s response.)
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In addition, what makes you think NPs are any more likely to live in rural areas than GPs? (Read Carryer opinion piece “Train more NPs not GPs” here)
In reality, they are more likely to have restrictions caused by their family role, their children’s schooling and social life and, dare I say it, their spouse’s occupation. These are the same for all individuals and not really discipline-related but may more affect women than men (rightly or wrongly).
Individuals must also address the limited social life, social isolation, educational opportunities for children and access to a range of consumables that many such urban individuals take for granted. This is inevitably more problematic for all who train in the city and who may have come from urban environments (the majority).
Rural medicine is indeed very rewarding but a challenging primary care environment with greater demands that even urban GPs need to adapt to. The scope of rural medicine is definitely wider, has more limited primary and secondary support and the ‘on call’ far more daunting. One cannot cherry-pick.
Being a 9–5 NP in COPD, diabetes, elderly Care – those NPs one mostly have contact with – certainly don’t have a scope remotely comparable to a GP. As for NPs whose scope is primary care, these are still extremely rare and in my experience could never work in isolation – at least for many years – in the post. One day this may change but at present this is a reality.
If NPs are so motivated to work in primary care, why are they not more present in AFTER HOURS? It is here that there is a really great need for NPs dealing with the worried well and minor illnesses. This is not a denegration of their training as it is here where the (quite uncommon) risks occur. Knowing when things are not quite right requires real experience when much of the time very limited skills are needed and the risks of getting things wrong are minimal.
The waste of medical expertise here in a world of diminishing ageing doctors in New Zealand is a travesty. If NPs could show that they could tackle such a workload (15 minutes a patient) I might be impressed.
Despite these negatives, I do sincerely support the evolution of nurses to NPs by broadening their scope but cherry-picking narrow spectrum specialities cannot really be seen as being a GP.
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The conference will be held in Auckland from April 5-8 2018 and the New Zealand Rural General Practice Network is calling for abstracts in the four themes of clinical, nursing, community and management. Abstract submissions close on August 31, 2017. Abstracts can be submitted by clicking HERE.
]]>The New Zealand Doctor article went on to say that very few medical graduates want to live and work in towns with a population under 10,000, but rural health advocates point out these communities have increasing health needs as residents age.
The statistics were drawn from the latest Medical Schools Outcomes Database (MSOD) report* that shows only 1.6 per cent of New Zealand medical graduates in 2015 saw small towns as places they wanted to practise.
New Zealand has a long history of trying to incentivise doctors to remain and practice in small towns and rural areas. Many continue to call for incentives (for doctors) despite the historical and demonstrable failure of the many forms of incentives tried.
Alongside the increasing struggle to recruit GPs to many parts of the country is the huge amount spent on GP locums over the years. I personally have no idea exactly how big that spend is, but I can confidently suggest that over our history it has run into many millions of dollars.
Currently there is a push to try and increase GP numbers by establishing a new medical school at Waikato University that will produce rurally oriented GPs. It seems to be based on a similar model at Flinders University in Adelaide which has had success at providing GPs for rural areas.
My questions in response are outspoken and provocative:
These are challenging questions but they need answering if we are to really deliver on the goals of the New Zealand Health Strategy.
We should be very concerned that more and more New Zealanders are experiencing diminished access to health services – or poor quality, poorly co-ordinated care – with different health outcomes for Māori and Pacific, poor or no rural access, rising mental health problems and many other concerns.
We are in danger of becoming inured to such reports as they come so frequently. Whichever way we look, there is a system under severe and growing pressure. Those working in hospitals dealing with the consequences of poor primary health care are under even more pressure.
At least half a million people can no longer afford general practice visits. Many such people in desperation, are currently putting emergency departments under intolerable pressure. At the same time GPs are reporting that their practices are not viable with current funding levels. This situation should not be allowed to continue as it can only worsen under the pressures of an ageing population, increasing levels of long term conditions such as diabetes and kidney disease and the impending threat of anti-microbial resistance.
I feel like a stuck record in noting that one answer is hiding in plain sight.
In New Zealand it costs approximately $600,000 to produce a general practitioner (GP) and $100,000 to produce a nurse practitioner (NP) yet the scope of service is the same.
Registered nurses are widely distributed around the country in rural, remote and urban areas. Evidence shows they are inclined to remain in the areas where they begin practice. Evidence now shows that approximately 4000 nurses have a clinical masters degree and many would not be far off seeking NP registration if encouraged with minimal further investment.
There is a long overdue need to stop the repeated calls to educate more GPs and instead divert substantial investment towards developing some of the existing nursing workforce to nurse practitioner level. Doing so would provide a rapid, cost effective, completely safe and highly accessible solution to the problem.
There are already nearly 300 NPs in New Zealand, half of whom are providing primary health care services.
I would urge more careful consideration of this health workforce solution which is right under our noses.
*National report on students graduating medical school in NZ in 2015, NZ MSOD Steering Group
Author: Professor Jenny Carryer RN PhD is executive director of the College of Nurses. This article will also be published in the next print edition of Nursing Review.
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Nominations were called for in April for a working party to up the profile of rural nurses after the idea was first mooted at the National Rural Health Conference in March.
Nineteen nurses put themselves forward for the election and the successful candidates were recently announced (see list below). The election, which was combined with a survey to gather some demographic data on the rural nursing workforce and the challenges it faced, had 136 participants.
Rhonda Johnson, one of the group instigators and now an elected member, said the group was likely to hold its first meeting next week by video conference.
On the agenda for the first meeting would be electing officials including a chair, discussing the survey results and deciding first priorities for the group.
Johnson said one issue raised at the conference in March was the lack of accurate data on the number of rural nurses actually working in the secondary and primary health sector. So she said one thing she may raise at the first meeting is approaching rural hospitals, like the one she works for, to gather nursing numbers and to look at how best to capture data for primary health nurses working in rural or remote settings.
Rural Nurses NZ Facebook page
https://www.facebook.com/groups/440474582969538/
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The West Coast District Health Board nurse was presented the Health Quality & Safety Commission award last month by the HQSC chief executive Dr Janice Wilson after being nominated by the DHB for her commitment to establishing lasting relationships with her patients and advocating on their behalf.
Gibbens says district nurses on the Coast are big advocates for their patients including work closely with Canterbury DHB and ensuring patients have a good experience and understand what is happening.
“If someone has just been discharged from the ward and something isn’t going well, I advocate for them and make sure a specialist sees them,” says Gibbens. “If they need to talk to the team in Canterbury, we try to set this up by video conference instead of the patient needing to make the long trip to Christchurch.”
Wilson said Gibben’s exemplary leadership in a rural community – including ensuring patients receive the same quality care as patients living in the big cities made her an “extremely deserving recipient”.
The HQSC Open for Leadership awards are to recognise health professionals who demonstrate excellent practice, quality improvement and leadership skills. They are part of the Commission’s work building capability and leadership in the health sector.
]]>Within minutes, clinicians can have blood test results to help them assess whether or not a patient’s chest pain is a heart attack, manage a diabetic patient with ketoacidosis, or decide whether a blood transfusion is required.
Patients can also have peace of mind that they can be treated close to home in Hokianga and a decision made whether the two-hour trip to Whangarei or four-hour trip to Auckland by road is warranted.
Point-of-care testing (POCT) devices allow blood tests to be carried out at the bedside or in a clinician’s room; tests that were once only available at a central laboratory.
Using POCT for acutely unwell patients is now well-established at Hokianga Hospital in Rawene. The community-owned, trust-run hospital includes 10 acute beds (along with long-stay and maternity beds) serving the predominantly Māori, socio-economically deprived communities located around the beautiful but isolated Hokianga Harbour.
Residents of these remote communities have high rates of long-term conditions such as heart disease, diabetes and renal disease. Being cut off by flooding is part of life in this region and, with no on-site laboratory, even in the best of conditions blood test results could take from eight hours to as long as 72 hours over a weekend, so pioneering the use of POCT analysers, which return results in two to 10 minutes, has had a particular appeal.
Nurse practitioner Catherine Beazley is one of two ‘super-users’ of POCT at Rawene – the other is fellow nurse and hospital services manager Christine Dorsey.
In the 16 years since Beazley began working at Rawene, she has gone from using a simple glucometer for measuring blood sugar to being the quality control guru for ‘half a shelf’ of increasingly sophisticated POCT technology, ranging in size from the handheld to a haematology analyser roughly the size of an Auckland telephone book.
Beazley says the big game-changer in being able to keep and treat patients locally was the trust’s purchase of the iSTAT analyser in 2008. The handheld device supported clinicians to assess suspected heart attacks to heart failure, and diabetic ketoacidosis to acute renal failure, by being able to carry out urgent blood tests for levels of blood gases, chemistries, troponin and BNP. Also on the shelf is an on-the-spot coagulation checker (Coaguchek), an HbA1C analyser (DCA Vantage) and a more recent addition is the haematology analyser (Emerald 22).
A 2010 study, led by Dr Kati Blattner of Hokianga Health, found that with having prompt access to POCT results patient transfers to Whangarei Base Hospital reduced by 62 per cent and patient discharges increased. Clinicians reported substantial (75 per cent) changes in the treatments that were offered.
Beazley reported another spinoff for the nursing staff, apart from the comfort of test results to support their clinical judgement and care plan, was fewer call backs to escort ambulance transfers. Before iSTAT, patients with undiagnosed chest pain were often transferred by ambulance to Whangarei, with urgent escorts adding a minimum of five hours to a nurse’s working day.
At the outset nurses and doctors received comprehensive ‘herd’ training in using POCT with these clinicians keen to get on board, even offering their own blood.
However, as the novelty wore off, using the devices increasingly became part of the nurses’ role and now the majority of the 23 active users on the main POCT analysers are nurses. Adding amateur lab technician to a nurse’s job description could be viewed as stretching multi-tasking a little too far.
“When working rurally you have to have a generalist attitude,” says Beazley. Being trained to use POCT devices is now perceived as business as usual for nurses at this hospital.
Routinely, when a diagnostic test is ordered, a nurse not only takes the blood sample from the patient’s vein but usually carries out the test. For iSTAT the testing procedure involves inserting two or three drops of blood into the appropriate test cartridge, entering the required information (including the nurse’s council number as a user ID) and inserting the cartridge into the handheld analyser. Within two to 10 minutes (depending on the test) the results are ready.
Initially, nurses would stand anxiously waiting for the test results but now carry on with normal duties, returning to take a quick look at the results as they deliver them to the requesting doctor or NP (post-haste if they show elevated troponin results). While registered nurses don’t order or usually interpret POCT – senior nurses may take the initiative while inserting an IV line into an acutely unwell person to also take a blood sample in anticipation that POCT tests may be wanted.
Point-of-care testing may be fast but it is not cheap so the preferred approach remains waiting for a traditional lab test result. Last year clinicians ordered between 80–130 iSTAT tests a month and 35–60 haematology tests a month. As Beazley emphasises, POCT tests don’t replace good quality clinical assessment and care but do support clinicians to decide on the best management plan for an acutely unwell patient and can give increased peace of mind to both patients and clinicians.
“Sometimes it might be used to help adjust medication for someone such as renal or heart failure,” says Beazley. “Or you might be trying to determine whether a person has a chest infection/pneumonia-related shortness of breath/cough or whether it is heart-related.”
The New Zealand Society of Pathologists in a letter to the Ministry of Health last year acknowledged that modern medicine was impossible without POCT, but said that alongside the advantages of speedier access to diagnostic testing came challenges – including that POCT can appear to be “deceptively simple to use” but was not without risk and needed consistent quality control and risk management processes.
When the Hokianga team presented to the Rural Health Conference in March, Blattner spoke of the positives of POCT but also watching the nursing staff “working harder and harder” at making it work and to meet the ongoing treadmill of quality standards. She believes that funding and policy work is needed to make the benefits of POCT sustainable for settings like Hokianga.
Beazley acknowledges that carrying out quality control (working in tandem with Northland District Health Board’s point of testing coordinator Geoff Herd and the DHB’s medical laboratory), looking after the shelf of POCT devices plus the training and annual testing of users has become a routine part of her role. The organisation is reviewing this workload as part of a current research project and recommendations may be made in the near future about formal FTE hours being allocated to manage POCT devices at Hokianga.
Meanwhile, working at 9pm on a Monday night wearing her POCT ‘hat’ is not unknown for Beazley. The rural NP says what motivates her is the benefits that POCT testing brings to the hospital’s staff, patients and wider community by being able to provide a modern acute care service to an isolated population.
Should other nurses be ready to follow or wary of following the POCT path?
“I think it [POCT] is something to be embraced as a way forward in rural practice but it has to be done with the right supports in place and the right funding,” says Beazley. She suggests that nurses seek answers about who is going to do the ongoing training, fund the test supplies, coordinate quality control and be responsible for the day-to-day maintenance of devices.
While the diagnostic comfort that the shelf of devices in Rawene’s drug room can provide doesn’t come without costs, Beazley adds that along with the increased peace of mind also comes a great sense of community pride in what the hospital can deliver to the people of Hokianga.
A project to roll out point-of-care testing to rural practices from Great Barrier Island to Warkworth is also underway. The Rural Point of Care Testing (R-POCT) project aims to provide general practices in the Auckland Waitemata Rural Alliance with POCT analysers.
So far the Waitemata DHB has committed $1.02 million for the project over the next two and a half years. The alliance’s practices serve a rural population of nearly 60,000 people – mostly in rural north and west Auckland, including Great Barrier Island, Waiheke Island, West Rodney, Wellsford and Warkworth.
The project will make rapid on-the-spot blood test results available to help diagnose and decide whether acutely unwell rural patients can be cared for at their general practice or need hospital referral. It is being led by Waitemata DHB, whose POCT team will provide quality assurance and training for practice ‘champions’ in using the selected analysers.
The R-POCT project has identified that more than one analyser will be needed to carry out the required tests for troponin, D-dimer, INR (international normalised ratio) and a full blood count with a three-part differential.
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