The elements of whanaungatanga-Tapu, mana, Pono, Tiki and Aroha as described by Pa Henare Tate in his thesis, resonates deeply with the nursing philisophy of caring for self, respect, trust and restoration. If this basis of traditional Maori society was better understood and accepted by New Zealanders- not least politicians and funders and legislators, perhaps the growing inequality and inequity issues we are experiencing as a society may be arrested.

The benefits of utilising the triumverate of Pono- the reality, Tika- what is right, and Aroha- what is compassionate in all my connections with people in our mutual efforts to achieve Te Wa -the journey of life – appears to be self evident. The knowledge inherent in these concepts are simple and clear. Many of the values that our New Zealand society hold dear are expressed within the traditional Maori values system, within their definitions of roles and relationships.Perhaps if more Kiwis (including Maori) were to be open to learning and accepting these in a more overt formal way within our lives and our work, whanau/child poverty, whanau violence, alcoholism and other negative behaviours may be more readily rejected and eradicated.

Simple in purpose but rich in content. And deeply empowering.

In his efforts to examine the issues behind the reduced funding  of  PHC services, Professor Matheson describes the importance of distinquishing between higher order goals such as improved health outcomes and equity, and those that provide the more operational goals of how to provide the services within budget restraints.

Matheson has identified that the 40% of discretionary funding that a DHB had to fund PHC services has been chipped away by  increasingly tight budgets and the directive by the Ministry of Health (MoH) to focus funding to achieve targets that provide  little in terms of solutions to improving the health outcomes of people with complex health and social needs, or than narrow the ever widening inequity gap.

Targets such as ED waiting times and improved access to elective surgery are nonsensical in the face of burgeoning chronic conditions, increasing unemployment and all the social woes that follow a fiscally challenging time.

Better to identify targets that will truly measure how well we are providing the care, not how many surrogate markers we manage to collect from people who can barely afford prescriptions and medications as they struggle to pay higher power prices on minimum non livable wages. Providers and organisations are constantly distracted from providing quality evidence based care by having to reach targets that may not be at all relevant to the person sitting in front of them. To educate a patient on the benefits of having a low CVRA when they are struggling to breathe because of their emphysema or being diagnosed with a non curable illness is ludicrous, and yet if the box is not ticked, the ultimate penalty may be loss of income for the provider’s employer.

Best to have a system that rewards quality service by identifying improvement of quality markers such as patient satisfaction with a service, clinical competencies of providers, a multidisciplinary team approach and successful team components. Markers of a well functioning clinically integrated health system could also be utilised as targets to hasten the implementation of this throughout NZ.

Indeed this is what Cathy O’Malley – the Deputy Director of Health- has signalled will occur over time, as the PHO contracts are examined this year. DHBs and PHO will be asked to do more towards becoming  an integrated health system. Unfortunately whilst DHBs have so  little funding and influence over the PHC sector, with it’s privately owned and commercially driven business models, this work programme will be fraught with power struggles and political bargaining, with the biggest loser being the patient at the centre of a maelstrom rather than the calm epicentre of patient focused PHC!

And where are the nurses in this storm? At the bedsides in hospitals, and with people in their homes, but not at the top tables in any great numbers debating and developing the contracts and policies. It never ceases to amaze and frustrate that the largest  workforce in the health system, and thus potentially the  most affected by any structural, legislative or contractual changes is not included as of right, but must insist on being consulted.

Is it because we need to justify and prove the value of nursing because the financial benefits to an organisation from nursing are so difficult to prove?

Is it because we, as women, need to describe what we do as nurses, to describe the complexities of nursing and how it relates to the patient/human experience of health and illness?

According to this article, the patient experience is so intrinsically involved in the quality of a service, that the nursing gets dissected within the evaluation of that service. So what happens when the evaluation doesn’t show a great outcome for the service? Where does that leave the nurses? Is it so intrinsically incorporated with the service outcomes that the nursing role gets thrown out with the bathwater?

Is this one reason why nursing is struggling for financial and professional respect/recognition in specialist roles, or why it is often the first service to face budget cuts? With all the research on the value of effective nursing and the positive effect it has on overall quality in an organisation (see Magnet hospital research for example), what other conclusion can we come to about poor funding decisions made for, and on behalf of, nursing?

And yes, once again, this article’s summary states that the study described “clearly demonstrated the complexity and multiplicity of components of the CNS role and its impact on patients”.

Humpph -dont see “health” anywhere in that statement!

Apparently they want a model that estimates the financial impact of task substitution between nurses and GPs. Now there is the first problem I have. This is suggesting that nursing and medicine is able to be “measured” by “tasks”. Have they not learnt anything from the massive amount of research done in the States around quality of health care services, health outcomes  and magnet hospitals. Every time a bean counter tries to measure health we end up in a morass of money saving cuts,and no proven benefits to patients or services.

Then if you read the limitations of the study it essentially makes the study rather pointless to my mind. Because it hasn’t been able to capture the complexity of the practice nurse and the team role in general practice. It doesn’t take into consideration the patient at all- older and high needs populations will change the picture markedly in terms of consultation times and team involvement costs etc. A scary implication is that if you make nurses more expensive and shorten their consultation times (see 6.5) they will make you more money- boom,there goes accessibility and quality out the door, right there!

What it does do is provide a good overview of literature around nursing-PN’ s and NPs in general practice and the issues therein. So I guess it is watch and wait time to see what sort of model gets spewed out. As we all should know- cheap does not necessarily= better! Penny wise, pound foolish….

Not sure I like the quote that NP’s are “just like doctors without the pay”. I kinda like the idea that I work differently and add value rather than the competitive model that this quote represents…..but it would be great to reduce what Peter Pronovost calls the toxic heirachy. Suzanne Gordon, on her blog, has a great expose on this concept

“….the lecturer mentioned the nursing diagnosis and that it differed from medical diagnosis, in that it could only cover what we as nurses could treat. The example she gave was that instead of giving a diagnosis of diabetes, we should instead say something like abnormal blood sugar or abnormal regulation of insulin.”

Wikipedia suggests that “ A nursing diagnosis is a standardized statement about the health of a client (who can be an individual, a family, or a community) for the purpose of providing nursing care. Nursing diagnoses are developed based on data obtained during the nursing assessment”

North American Nursing Diagnosis Association now known as NANDA-International suggests that the difference between a medical diagnosis and a nursing diagnosis is that the medical one deals with the pathophysiology of a disease whereas the nursing diagnosis is about the human response to the actual or potential health problems.Further more…..

“Using a medical diagnosis alone does not provide enough information to accurately diagnosis a patient from a nursing perspective. A holistic nursing assessment is critical for you to identify the potential nursing diagnoses. A medical diagnosis may be a related (or etiologic) factor for a nursing diagnosis, but you must identify defining characteristics of a nursing diagnosis during your assessment; it is impossible to make an accurate nursing diagnosis strictly from a medical diagnosis.”

Never heard so much piffle in my life! So all my study of pathophys and pharmacotheraputics etc goes to waste because I should be using a nursing diagnosis that ignores all that information I have garnered or calls it medical? I include the “defining characteristics” in my SOAP.  Is nursing so obessedwith having their own identity, separate from medicine that they will persist with this dumbing down of nursing practice? Nursing in this age is complicated enough without confusing nursing students even more with an obsolete language. Nursing so needs to get over the medical vs nursing debate and get on with what we are good at and let’s use a common language– the medical one works well as long as we include our extended assessments…..

Out of the mouths of virtual babes-the author of the blog writes:

“This seems to me to be a way to work around the fact that nurses are not supposed to give medical diagnoses, when in fact that is what they are doing. I mean abnormal blood sugar or abnormal insulin production IS diabetes, isn’t it? It just seems silly to me”.

Brings to mind The Emperor’s New Clothes,eh what?

.

Excuse me, but care assistants may “pop in”, tea ladies may “pop in”, but nurses do planned assessments of their patients state of health whenever they see them. This is a clear case of poor use of language that continues to perpetuate the dumbing down of nursing. It brings to mind the 1997 British Columnia Nurses Union campaign:

“He thinks he’s having a conversation about the hospital Jell-O. She’s actually midway through about 100 assessments. In the seconds it takes to reach the bedside, a Registered Nurse will have made over 100 assessments. Any one of which could mean the difference between recovery and tragedy. Take away direct patient care from Registered Nurses and vital knowledge affecting the health of the patient is lost. Nurses are doing vital work. It’s that simple…..”

New research from the New Zealand Nurses Organisation (NZNO) reveals a snapshot survey of caregivers working in residential aged care which indicates that caregivers are frequently undertaking clinical tasks more appropriately performed by Registered Nurses (RN). A “well, dhuh!” comes to mind. This issue is such an old and complex problem in terms of the stakeholders involved that, like funding streams for nursing roles in PHC or nurse prescribing, it may take even longer to untangle. Unless of course the large conglomerates that own resthomes take the ethical, moral and intelligent option of leading the way with complying with  sector standards, adopting career and clinical pathways, providing more RN hours and the money to grease the way. For this we will need the carrot and the stick.