Editorial

Nursing Praxis in New Zealand, Nov, 2008 by Jenny Carryer

It is now ten years since we held the Ministerial Taskforce on Nursing (1998) and therefore timely to mark this edition of Nursing Praxis in New Zealand with some reflections on the journey since release of the report. I write this editorial as a former member of the Taskforce and as a purely personal review of the current challenges a decade later.

First there is some good news. I think it is fair to say that the climate and spirit of co-operation amongst nurse leaders and nursing groups is generally much easier and much more constructive than it was in 1998. There has been, one might argue, a political maturing of nursing in the intervening ten years, which has created a generally more thoughtful environment in which nursing politics occurs.

The notion of a nurse practitioner role in New Zealand as raised in the Taskforce report is now a concrete reality with almost 50 brave souls who have taken the leap of faith and completed the arduous pathway to attaining the role and title. Congratulations to each and every one of them. Much has changed about masterate education and we have finally largely left behind the preoccupation with the social sciences, ceased our endless condemnations of positivism and begun to focus much more closely on preparing nurses to be excellent clinicians at all levels. Our connections to the social sciences remain vital, our leadership in qualitative enquiry remains central but perhaps we have a greater sense of proportion now?

One burning issue for me in raising the possibility of a Taskforce with the then Minister of Health, Bill English, was huge concern about the "baptism by fire" of new graduates as they entered practice unsupported in any reliable way. Let us not forget that in 1999 graduate attrition had reached the unthinkable level of 60% during the first year of practice. Now, although it took forever, the entry to practice programme is well established in acute care settings and beginning to make inroads into primary health care environments. There is much more to be achieved here however and my personal view remains (as it did at the time of the Taskforce) that we badly need to reclaim the fourth year as a full time clinical year with registration only awarded at completion of that fourth year.

It is interesting to note that nursing education remains the only health professional group not to have its education delivered in the university setting. One value of university settings is the ready availability of experts in every field such as the sciences, the social sciences and also teaching faculty who are more reliably research active. Hopefully part of our maturity as a discipline is the ability to raise these potentially uncomfortable debates, put aside our personal positioning and conduct the discussion only with the goal of achieving the best outcomes and without personal angst. Just having the debate may lead to a completely different outcome but I strongly believe we should start the process.

Many indicators (see especially the recent Robert Wood Johnson Foundation report (Joynt & Kimball, 2008)) raise grave concerns for the maintenance of sufficient levels and quality of nursing faculty. The challenge of having sufficient nurse academics who combine research activity and clinical competence, without depleting the clinical workforce of much needed experts continues and will only increase. Multiple programmes increase the demand and spread our expertise very thinly.

Clinical placements remain unsatisfactory as a serious learning opportunity for many students and even if we were to reduce the number of nursing programmes delivered, reducing the number of areas in which placements are required is not possible. Perhaps we need to rethink the nature and distribution of clinical placements limiting them to less frequent but larger chunks of time held in students "home towns" and supervised by clinical experts. This would enable students to at least predetermine the choice of clinical area for a vital fourth year in which prolonged opportunity to practise in primary health or mental health, residential or acute care would really hone clinical competence. My sense has always been that our current approach in which the student experiences clinical practice in short bursts and is, each time, very focused on learning the culture, getting to know the people and finding their way around is a wasteful way of achieving our goals. I am also mindful of the expressed tension for registered nurses who find the presence of students is sometimes the final straw in a demanding day. In addition many students describe placements in some settings as insufficiently "hands on" to gain confidence and competence.

In essence I am saying that the Taskforce report started something which we have not finished. The issue of the review of the number of programmes was raised but not addressed through fear of offending delicate sensibilities. The nature of the programme was subsequently reviewed by the KPMG report; a document which seemingly no one found especially useful. Complacency is not compatible with professional rigour and the indicators for future workforce and health service challenges are strong enough to compel us to at least revisit these debates. Nursing student enrolments are increasing against many odds; our responsibility is to ensure that every single student becomes the best registered nurse they possibly can be, upon graduation.