Nurse Coordination Project

Contents

Part One
Part Two
Part Three
Part Four
Part Five

Appendix One
Appendix Two
Appendix Three
Appendix Four
Appendix Five
Appendix Six

Introduction

The Nurse Project fell out of the disease management projects and the success of the management group that assessed problems associated with the Well Elderly project. Nurse managers and Jo Herbert voluntarily instigated the Nurse Management Group to manage the co-ordination of the nurses and allied staff in that project.

The nurse project group began initially with a meeting for all nurses. At this meeting the go ahead was given for a smaller group to look at the issues around changes concerning nursing politically, professionally and clinically. This smaller group met for several months with the intent of leaving employment issues out of discussions and focusing on nursing issues with the consumer as the focal point.

During this time it become apparent the common issues that draw nurses together were strong. These issues related to what it means to be a nurse in relationship to other providers and the role of nursing in professional clinical practice and the community. The Vision, Mission and Values, that have become part of our strategy plan, emerged from this group and have remained essentially the same.

When we got to the point of having to sort out how we were to pull together the project and encapsulate the discussions, the group decided that the five management personnel should continue with this aspect along with the consumer representative. The Nurse Management team was born, so to speak, consisting of:-

Pat Capon - Northland Health Ltd
Dianne Lawson - Te Ha o Te Oranga
Trish Crompton - DMC
Lynn Messervy - KCI
Jo Herbert Northland Health
Sarah Moran - Consumer Representative

Thus began a new era of co-ordination as the key management team worked together to promote the project and, by default, to co-ordinate the nursing services and effect change.

The nurse management team conducted a resource utilisation exercise that is attached to the main document. While these figures may not be as accurate as they could be, the HFA are looking at a financial tool to properly assess the nursing component of nursing in HHS contracts. This work will contribute to better planning of nursing services in the future.

The Nurse Project began with looking at the community nursing services. In the Kaipara District, this comprises the District Nurses, Practice Nurses, Public Health Nurses, Te Ha o Te Oranga Mobile Nursing Services, Mental Health Nurses and Nurses with a specific focus, ie diabetes educator.

For the purpose of the proposal the review and analysis covered District Nurses, Practice Nurses and Te Ha o Te Oranga. However, the ultimate strategy is inclusive of other nurses - the extent of which will be in the hands of the politicians.

A consumer survey and a survey assessing the educational needs of the nurses were also conducted. Results included in this document - See Appendix 1 & 2

While working on the project the nurse management team began to co-operate on various activities. They submitted a proposal for the Health Line, held a leadership day sponsored by KCI nurses and hosted a visit from Frances Hughes - Senior Adviser of Nursing to the Minister of Health - in the Kaipara.

The project had some specific outcomes that we believe have been achieved in some instances and the issues around achieving the remaining outcomes have been addressed in this document.

The approach taken to bring together the work of the nurse group into a coherent document and to give direction to the nursing services in the Kaipara was of a strategic planning focus. This approach has been highly successful and supports the evolutionary role of Kaipara Care Incorporated.

Strategy Situational Analysis

Setting strategy should constitute 20% thinking about the past and 80% thinking about the future. The nursing project group has done both, using the oral tradition of nursing. The task of committing the results of the dialogue of the nurses begins in this section and will cover:-

• A review of the documentation, relating to the nursing services in the Kaipara, over the past 6 years.
• A review of the main documents regarding nursing services in New Zealand during the last two years.

This review will provide the background from which the nurse's dialogue began, and future thinking developed.

Background

In 1994, a working party was established under the auspices of North Health (HFA) to examine nursing services in the Kaipara area. This working party was composed of key personnel representing a cross section of the services available and a representative of North Health (HFA). In the heady days of the then Health Reforms of 1992, it is evident the idea of co-ordinating nursing services under a single umbrella - managed and lead by nurses - had certainly emerged beyond academia and was discussed by nurses providing the services. The working group had identified issues around practice but do not seem to have worked out a formula for dealing with the issues. Current thought at the time (in the nursing culture) focused on nursing philosophy and this is apparent a philosophy developed from the work the working party achieved. There is also evidence of a resource audit, with each employment area listing the services they provided. There is no evidence of any task and time and or cost analysis. There is some evidence of future thinking, but little systematic planning - probably stymied by a clear indication of "patch protection" by some of the nurses involved.

However the first coming together of nurses occurred and discussions began. It is also worth noting that the nurses were paid as consultants for these meetings and that North Health (HFA) personnel contributed with extra resources. Once the funding ceased and North Health (HFA) personnel withdrawn, the work came to a halt.

Other Reading/Information

1) A report of the Ministerial task force on Nursing - Releasing The Potential of Nursing 1998

This task force was charged with making recommendations on strategies to remove the barriers that prevented Registered Nurses from contributing to a more responsive, innovative, effective, efficient, accessible and collaborative health care service for New Zealanders.

The following three key points were identified in the report and are as follows:-

• emphasis on nurse led service development models
• evelopment of nurse practitioners
• the relationship of education and developing practice

The report emphasises the concepts of teamwork, collaboration and a multi-disciplinary approach to health care, where the responsibility for service does not necessarily remain with General Medical Practitioners. Co-ordination or Integrated Care Organizations are perceived as a way in which nursing services could develop more innovative management structures.

Issues related to funding were discussed and it is of note that a change to ACC has already opened up the opportunity for the nurse as an ACC provider.

Concern was noted in this report of the difficulties in gaining the true cost, let alone the value of nursing services. Many of the provider groups used different and complex formulas, which ensures that nursing costs are not clearly spelt out in contracts. This makes putting a financial assessment and budget together for innovative nursing services difficult. The report recommends that this is attended to and the Health Funding Authority had agreed to develop mechanisms for accurately assessing the cost of nursing.

Education at both an entrance and postgraduate level was discussed. Emphasis was put on the development of the specialist nurse practitioner role and the dearth of any nationally accepted educational courses for these roles.

It was recommended, in the report, that the Minister of Health require the Ministry of Health to design an over arching framework for occupational regulation to allow the requirements recommended in the review of the Nurses Act 1977, to occur. This recommendation is superceded by the need for the current limitations in the Nurses Act 1977 by Nursing Council to enforce competency based certificates as well as specialist and advanced competencies for practitioners.

It should be noted the changes to the Medicine Act has opened the way for nurses to prescribe at the completion of Masters Level Paper specified for this purpose.

While Governments and Ministers of Health may change, this report contains many of the issues that have been raised by nurses in the past and suggest changes in nursing services are inevitable at policy and funding levels.

2) National Health Committees Discussion Papers on Primary Health Care - Chapter Three

This lengthy discussion paper attempts to locate nursing in the delivery of primary health care. The initial sortie attempts to clear the throat on issues around the development of nursing practice historically, and politically through policy decisions.

The authors argue that, historically, decisions made cemented the position of nurses as employees with little recognition of their skills as nurses. Policy and decisions are being based on the focus of medicine.

Nowhere better is this illustrated but in the case of practice nurses. It is argued the practice nurse subsidy has been a barrier to the development of primary health care services. It was introduced in 1970 to improve the delivery of health services to rural areas. A 1997 review of practice nurse services noted the reason for the introduction of nurses in general practice has had a profound affect on how they work to day. The fact that they have remained employed by doctors for 27 years has meant that a nursing service has remained largely unaffected by the changes in the nursing profession over this time.

The report goes on to explain what happens to the resources that go into the delivery of primary health care. A significant amount of it is directed at the primary health care sector, which is mainly provided through the health and hospital services price volume contracts, although some services such as Well Child services are purchased through organisation such as The Royal Plunket Society and Iwi providers. The HHS community services related services are currently broken down into home health, which provides a range of domicillary nursing and other such services, and public health, which includes services such as communicable disease screening and management, well child services and health promotion. Purchasing services in this way not only fragments service delivery but results in gaps and over laps.

The authors note that a more prudent way of purchasing care services would, in all likely hood, be delivered in a more effective and efficient way with an ability to further develop primary health care initiatives with in existing resources. Many of these could be nurse led and managed.

There are only 5 nurse groups who hold contracts for service independent of employers. These are small groups or individual nurses and are meeting a need in areas which are not service by doctors, or are in areas which are better serviced by women - ie cervical smear taking.

The paper argues nurses need opportunities to have equal shares in provider organizations offering primary health care and the opportunity to take part in the governance of organizations.

References are made to evidence that supports the arguments that where nurses are utilized appropriately they are a value added and cost savings component of health care.

The final section of this discussion paper discusses and explains an approach to Primary Health Care - Community Orientated Primary Care (COPC). It is seen as being an answer to high cost, high acuity health care as well a way of expanding public health services whilst incorporating ecological considerations.

This approach adds community emphasis to existing primary medical care and acts as a change agent for the community. It is accountable for the health status of the community.

Community participation is central to the notion of COPC. It recognizes that no, one health professional working in isolation can produce a healthy society.

The COPC model identifies a key element in its success as a multi-disciplinary practitioner approach. Included in the team are physicians, nurses, social workers, administrators, social scientists and epidemiologists. Accountability for community health status resides with the entire practice not just one member. Health professionals are taught to work with communities, and to respect and value the knowledge, wisdom and expertise of the people they serve.

The available literature has focused on teaching doctors how to adjust to community partnership models they have not given any consideration on how to utilize, more appropriately, the already prepared nurses.

3) The Future Shape of Primary Health Care - A Discussion Document

This discussion paper foretells of the present government's thoughts on the delivery of primary health care. There are several points to made here which may have significance on the strategy adopted and has certainly propelled the Nurse Management Group into considering a model of nursing which may best align itself with the proposed changes.

There is a clear indication that the predominance of the primary medical model of health and the imbalance between doctors and other providers - ie nurses - is now seen as an issue to be addressed.

District Nursing and health promotional type services will be devolved to the District Health Boards. This may be perceived as a way of opening up the direction for nurses to take on a nurse organisation focus rather than being employees of Doctors. New organisations may develop. These organisations are very unlikely to be accepted by funders if they are doctor or hospital driven.

Primary care organisation may take on many forms. There is a clear indication that these are not to be dominated by GPs, therefore arrangements for nurses to take on an equal role will have to be developed. Practice Nurses, District Nurses and other Primary Care Nurses will not continue to be funded the way they currently are.

4) The College of Nurses Primary Health Care Strategy Paper

This paper is to be launched by the Minister of Health in August this year. It is currently in draft form. However, it gives an excellent background paper to the nursing issues and this document will be available to those who wish to read it when published.

Innovative Nurse Practices visited 1999 and 2000 by Pat Capon and Lynn Messervy
Company: OPINS LTD - Opotiki

History
Business has been in existence for 3 years. One of the nurses had done the INP Course at Wairaki Polytechnic. Change had occurred in the health sector generally, and this change had to happen. The CHE had a high need and everyone came together at once.

The developing of the business was easy - it was the convincing of colleagues that was the most difficult. In the end they bit the bullet and went with it. One of the directors was going to go it alone if the others did not come to the party. They started with 6 directors and now there are 3, a good workable cohesive group. It was apparent good strong business and nursing leadership was present.

The CHE was made to clean up its act regarding long service leave, etc. It was a fire and hire scenario. All contracts are individual and confidential between the CHE in regard to their settlements with the nurses and those who got contracts with OPINS.

A new culture was in the development. NZNO would not have a bar of it. All employees now belong to the College of Nurses.

The service arrangements
Background
Serves a population of 9,000 -13,000 people. Rural and isolated. Limited availability of staff in the area. No midwives.

The GPs are all solo practices. A disparate group who do not work together and don't like the idea of working for a "bunch of nurses". The CHE contract them to provide the medical services to the hospital.

There are 5 inpatient beds and 3 maternity beds. One full time RN on 24 hours a day. There is an on call system and support arrangements available.
Not an A&E - but an assessment service.
No diagnosis and no treatment. Assess and report procedure only.
Have developed a real trusting relationship with Doctors with supporting policy and procedures for drug and narcotics.
They have existing plans and standard criteria for known re-admits of people with chronic illness - there is a written Dr's letter that is reviewed 3 monthly.

They have a limit on the nature of the patients they will accept.

• Palliative care
• No children
• No detox
• No psych
• Post op patients who are mobile
• MI for rehabilitation

Maternity
Midwife is lead provider.
Nurses are not second pair of hands.
Do not do antenatal as a rule of thumb. Do not have complicated postnatals.

Retrieval helicopter service.

No OT or Physio available.

They have a very clear idea of what they are contracted to do and the outcomes of that contract. They are at times pressured to take unsuitable patients but defend the rules applying to admission.

Run the lab contract using same day courier. Nurses take the bloods on the wards.
The CHE do the laundry and stores. They would like to take over both. They believe they could do it better and cheaper.
Very keen to, and are now beginning to, negotiate the taking over of the community nursing service.

Inservice Education
Link in with CHE as they can and as appropriate.
IV certification.
"How To" manual.
Have staff members doing a variety of studies at postgraduate and undergraduate level as well as at a clinical skills level.

Staffing
12 staff members.
12 1/4 hour shifts with 4 on 4 off, but usually 3 shifts on a run then 2 days off.
No penal rates.
Rotated shifts that are allocated fairly.
Shift rate allowance.
Increased base rate.
No weekend capture.

Performance incentives and can move to higher salary scale.
On going peer review.

Conclusion
This group believes it saves the CHE half a million dollars a year. Their success lies in five areas

• Use of sound business principles.
• Clear vision and nursing leadership for the future.
• Population and outcome focus.
• Good employee relationship.
• Ongoing education and staff development.

Eketahuna and Takapau Nurse led Health Centres in Rural New Zealand.
Visited by Lynn Messervy and Di Lawson

The then Department of Health instigated both of these nursing services several years ago. In the case of Eketahuna and the Health Funding Authority in the case of Takapau - because there were no general medical practitioners in the areas.

Both centers are funded through a Trust established for the purpose. The Trust arrangement not only brings in a community perspective but also resolves a myriad of employment issues that would have been opposed by NZNO. It also maintains the provider and funder split.

The arrangements for funding and revenue activities are similar in both cases. The HFA partially funds the clinic and wage of the nurse. The trust and nurses earn more revenue where ever possible. Both rent out rooms to other travelling health personnel. Changes in ACC now allows nurses to claim third party insurance for patients seen which has increased their revenue. Both services are ACC registered. There is a small fee charged or a Koha accepted. At Takapau a table with sellable goods is maintained.

Takapau Nurse has a contract with the Hawkes Bay HHS to carry out the district nursing requirements for 5 hours a week. This arrangement allows the nurses to have access to the Hospital and Health services resources and ongoing education and professional development activities.

The nurses have a special dispensation to carry some medication and sell some pharmaceuticals and are looking forward to being able to prescribe.

The clinics are well stocked and have various pieces of equipment to assist them in their practice. For example the Takapau clinic boasts of a mini laboratory and an EEG machine. Both clinics are computerized and hold the patient's records.

The nurses estimate that 80% of their patient base, who would have gone to a doctor had there been one available, were able to be attend to successfully - only 20% of their patients are referred to a doctor. These figures are similar to those other European countries where nurses are actively promoted to work in similar ways.

The staffing of these clinics rely on one nurse at the clinic at any one time. Some voluntary work by the community was also done to keep the clinics functional.

Both clinics link in with other local service groups and health agencies with in their localities. There is a Maori health provider who works out of Takapau, but is struggling. There was a doctor who was attending half a day a week but eventually gave up, as the attendance was so low. Attempts have been made by the Takapau nurses to encourage the Maori provider to work from their premises, in order to better co-ordinate services and support each other. This has not well received from the provider who prefers to work alone.

The services of these two nurse led clinics are attached in the appendix of this document. See Appendix 4 & 5

The Lakeland Health Community Health Service
- Taupo/Turangi District Nurse Case Management Model

The interest of this model for the Kaipara is two fold. It is a rural and co-ordinated model of case management and it evolved from a review of the district nurse's services. This review identified several issues that needed resolving.

• The misallocation of time and resource to the Turangi area in relation to the Taupo area given the population and need.
• Over service of individuals and under service of others.
• No control who accessed the services.
• Reluctance to allow people to exit the service.
• Individuals slipping through the gap in the community service as a whole.
• High re-admission rates of some patients to hospital.
• High variation in provider skill.

A case management model was commenced in July 1998. The case manager was a district Nurse seconded to the position. This Nurse had considerable experience in the fields of community health and the skill to implement the model.

• The staffing time had been created from the re-allocation of resources in the Turangi area.
• Stream lining access to the services. Referrals from the GPs and self-referrals were no longer accepted.
• A review of the District Nurse patient lists.

The objective of the Case Management Model was to gauge the effectiveness of the model in relation to the performance indicators:-

• Repeat re-admissions.
• Average length of stay.
• Duplication of services.
• DNA's (to out patients).

The reaction from the district nurses, initially, was tremendous opposition because they no longer had the control of who entered the service and how long patients stayed in their service. Also they were forced to confront their own practice standards. However the major opposition came from the medical Social Workers who saw the co-ordination of health services as their role.

After a year the benefits of the pilot and the Case Management model were:

• Most appropriate discipline becomes key-carer.
• Care streamlined.
• Services co- ordinated - no duplication.
• Resource utilization rationalized.
• One point of contact (particularly useful for GPs and physicians).
• Higher client satisfaction.
• No gaps in client education/information - evidence based - one source.
• Contractual obligations met and monitored effectively.

The pilot was evaluated and is now proceeding beyond the pilot. The issue of buy in from the district nurses and medical social workers were noted, as was the need to demonstrate alignment with Lakeland Health Mission and values.

References and Bibliography:
Any of the documents listed below are available from Lynn's office.

• Report on the Ministerial Taskforce on Nursing - Releasing the Potential on Nursing: August 1998. Ministry of Health.
• National Health Committee Report - Primary Care Models for Delivering Population Based Health Outcomes - Chapter 3.
• A Primary Health Care Strategy Document for Nursing: College of Nurses (Aotearoa) NZ. May 2000 (First Draft).
• The Future Shape of Primary Health Care - A Discussion Document: Hon Annette King, 2000.

Other:

• BMJ Doctors and Nurses: No.7241 15th April 2000.

The Strategic Management Process
Strategic management process involves strategic analysis, strategic choice and strategic implementation

Strategic Analysis
Strategic analysis is concerned with the key influences on the present and future well being of an organisation and is considered here under the headings environment, resources, competencies and purpose.

1) Environmental Analysis
The four techniques used in this analysis is the PEST analysis which considers the political, economic social and technological environment nurses work in combined with the SWOT analysis which considers the strengths, weaknesses opportunities and threats nurses are subjected to.

Porters five forces which focuses on whether there are factors in the community that might enable the nurses to achieve and retain a competitive advantage.

Scenario Planning
This technique is used to put together the scenarios that build plausable veiws of different and possible futures for medium to long term organisational change, based on key environmental influences and drivers of change.

• Identify the high impact, high uncertainty factors in the environment
• Identify different possible futures by factors
• Build scenarios by plausible configurations of factors

Resources and competencies
A resource Audit considers the physical, human financial and intangible resources that are either owned or accessible to nurses.

Core Competencies
These are what Hamel and Prahald have described as the connective tissue that holds together a portfolio of seemingly diverse businesses. They see high performing organisations as those who adopt the concept of synthesis as the underlying premise upon which an operation operates.

2) Purpose
The following techniques are used to assist in the issue of nursing governance and are stakeholders, ethical stances and mission statement.

Stakeholder mapping
Will be used to identify stakeholders and establish political priorities for managing stakeholder relationships.

Ethical stance considers whether the governance of nurses should include short term share holder interest or be extended to include longer term share holder interest, multiple stake holder obligations or, further more, be a shaper of society.

Mission statement
This should be the most generalised statement of organisational purpose and contain the following elements:

• Be visionary
• Clarify main intentions and aspirations of the organisation
• Animate and challenge
• Describe the organizations main activities
• Help determine strategy

Objectives and Values
Objectives will be identified for a nursing service and used as a criteria for determining strategy.

Strategic Choice
The strategic choice builds on the strategic analysis stage where matters of environment, resources and purpose were considered. These elements are used to developed strategic options and then evaluated against weighted criteria. This exercise is termed: Performance Index Analysis

Framework for the Evaluation and Selection of Strategy

3) Strategic Implementation
Organisational Structure and design choice for a nursing service in the Kaipara has basically three options.

• Employee based by many other service providers meeting contract requirements
• Nurse led service employed and managed by other service providers
• Nurse lead owned and managed nursing organisation

Alignment of Strategy with Existing Resources and Competencies

Control mechanisms to implement new strategy

Administrative control which includes planning, supervision, and performance targets

Social/Cultural control

Training and development, with introduction of best practice quidelines.

Self Control

Management shaping the right context for self motivation. This approach may include resource support, personal support, and success to good information about the job and the organisation.

4) Managing Strategic Change
There are five characteristics demonstrated by organisations that manage change successfully.
Environmental assessment. The environment in which nurses work is well understood by nurse management groups.

Leading Change
The change is lead by a change agent that establishes the context upon which to achieve support for change.

Linking Strategic and Operational Change
Link between the critical success factors, resource plans and key tasks. Change is better if it is incremental.

Strategic Human Resource Management
Strategy is integrated with human resources management policies.

Coherence in Managing Change
Change needs to be feasible with respect to the resources it requires, organisational structuring and the change to organisational culture and operational routines.

Strategic Analysis
Table One PLEETS/SWOT

The Key Strengths, Weaknesses, Opportunities and Threats

Strengths
KCI Board umbrella
Essential part of work force (contracts)
Co-ordination activities now the norm
Community support
Weaknesses
Lack of input into nursing contracts
Funding held by other professional and management groups
Captured Workforce
Opportunities
To become a coherent and co-ordinated nursing unit
Negotiating for nursing service contracts under KCI umbrella
Improved outcomes and reduced costs.
Be part of a centralized information system
Bicultural nursing services
Threats
Vested interests of current contract holders
Competition from other provider groups for the nursing dollar.
Understanding about the changing role of the nurse and the nurse project

Porters 5 Forces

Figure Two

Threats of Entrants
The threat of entry into the Kaipara health market of independent nurse groups, depends on the barriers to entry. The barriers are, possibly, lower than any other major provider in the district though not likely. Contracts for nursing services are held by the three major players in the market, all of whom are Society Board Members and are represented on the KCI Board. There is now an historical precedent for GPs and Hospitals to hold Primary Health Care Nursing Contracts.

Threats of Substitutes
The threats of substitutes to the existing nursing services are small. However, both changes to the Medicines Act allowing nurse prescribing, and access to ACC subsidies are indications change is on its way. The changes to the law that freed midwives from being a captured workforce should not go unheeded by nurses in the Kaipara. It should also be noted that community nursing services do not depend on a hospital from which to function, thus, this would not be a barrier to new entrants. In terms of relationships, nurses are also held in high esteem by the community and substantial research has demonstrated that the community do not personalise nurses ie - practice nurse, district nurse , public health nurse - (despite the belief practitioners have of themselves) - rather they see nurses as a homogeneous group. It should also be noted that nursing is not the fat under belly of medicine but a service which exists in all societies whether or not doctors are present. This is a continuing phenomenon in rural areas through out the Western world where there are no doctors, but there are nurses.

In time, it is inevitable in the political environment that the existing nursing groups and arrangements will be threatened by other groups of nurses or organisations. The Pilot Nurse Help Line is perceived, by some, to be one such service.

Buyers Bargaining Power
Currently the Health Funding Authority is the principle purchaser of primary health nursing Services in the Kaipara. They continue to bargain with the existing major providers for these services. There have been few alternative operators for them to bargain with. The extent to which the new administration (Coalition Government ) will be strapped to the history of the past and be prepared to initiate pilots for co-ordinated and focused primary health care nursing services, may increase the buyers bargaining power as it did with the midwifery situation.

Supplier Bargaining Power
There are few current contract holders for nursing services in the Kaipara and lack of innovation in proving services all contracts based on the aged old, largely unevaluated, systems of the past. Therefore the bargaining power of the suppliers is unlikely to change in the foreseeable future. Any new players with innovative and co-ordinated arrangements in the future ie the iwi provider groups or other IPA groups capturing the nursing budget, will further decrease the current suppliers bargaining power.

Scenario Development

Identification of High Uncertainty factors in the Environment

Identification of Different Futures by Factors Identified.
1) Government policy regarding nursing innovation and integration.

2) Commitment to Change

3) Nursing Leadership

4) Employment Issues

Scenario Development
The optimistic, the pessimistic and the medium future scenario.

Scenario 1: The Optimistic Scenario
There are continuing changes to the law and to Government policy regarding nursing services and the integration of primary health care services. Nursing education institutions begin to offer a post basic degree in Primary Health Care Nursing which will lead to recognised qualification to practice such.

Nurses are employed as Primary Health Care Nurses and not identified by the employer tags. The contracts for these services are based on the health needs of specified communities. The governance and budget is the responsibility of a nursing based organisation ie A Nursing Trust. The "Nurse Management Group" is legitimised and provides both the management and leadership of the new nursing service. Good relationships are established with all stake holders and co-ordination of services continues. The nurses are able to work through employment issues in good faith. There is active consumer support and the population's health improves as a result.

Scenario 2: The Pessimistic Scenario
The policy encouraging changes in nursing, instigated by the previous government, are halted and there is little change in education. Integration of health services is rejected as a policy issue. National initiatives, which have little regard for local communities, are implemented and decision making put into the hands of larger authorities. The opportunity for KCI to progress with their business plan is lost, nursing leadership fails to consolidate and the historical employment of nurses remains the same. There will be little change and possibly a fall in the health status in the community.

Scenario 3: The Medium Scenario
The co-ordination and integration of health services continues and the government is supportive of KCI. However the KCI Board is reluctant to ruffle the feathers of current contract holders of nursing services, but prepared to accept the "Nursing Management Group " as having responsibility for determining the way the nursing services will function - according to the community's need and an input into contract content. A nurse management group representative becomes a member of the Board. The communities' health status may show some improvement.

Core Competencies
The core competency of nurses is their professional, managerial and clinical nursing expertise.

Critical Success Factors
Leadership and Governance in the Nursing Workforce.

• Deployment of vision, mission and values for an integrated nursing service
• Measuring the success and outcomes of that direction

Building a Knowledgeable Workforce.

• understanding the nursing needs of the community
• know the educational and skill mix of the nursing community
• support and foster educational opportunities
• careful selection of nurses for available positions

Building Relationships.

• Iwi
• consumers
• all provider groups
• crown and crown agencies
• employment relationships

Information and Analysis.

• value chain analysis for a base line
• inter-provider electronic links for the collection and the sharing of patient data
• documented evidence of patient/nurse information
• consumer feedback
• Nurse feedback

Process and Operational Management.

• core co-ordinated nurse management group
• quality services/and standards/ best practice guidelines
• population focus and individual need requirement
• human and financial resources

Stakeholder Mapping for the Nursing Service

The nurses are the only stakeholders with a high interest and low power in moving toward a nurse led service.

Wherever a provider holds a contract for nursing services, and are also the employers of nursing services, there is high interest and high power.

Nurses, as a main provider of primary care and community services, represent an inbalance between power and interest. This is because they are employed by other high power, high interest groups.

This situation has a history, and when critically reviewed, can be seen not to be a natural process but a process of influence by employers, the dominance of medicine in the political arena and the status of nurses as women in general.

The Community Health Trust and community do not hold power over the nursing service. Their interest is that a nursing service be provided which meets the needs of the community.

Are strategies required to reposition nurses in relationship to interest and power?
The strategies required are at both national and local levels, to align the level of interest and degree of power nurses have over their position as a major health provider.

The national strategies have begun with ACC provider registration available to nurses, prescription rights for nursing will come on stream in 12 - 18months for child care and the elderly. An extension to these areas is being examined by the Ministry of Health.

Capitation - funding for all primary health services with the development of Primary Care organisations will begin to put pressure on all current contract holders to examine the resource allocation to nursing services, including HHS, district and other nursing services. A nurse led service will be able to develop a PCO - a possibility for the Kaipara. The basis for funding will be enrolled patients to the service - this is not an impossible task.

All the nurse categories continue to work together closely, developing the relationship and the trust required to build a co-ordination nursing service which will challenge existing practices.

Representation on the KCI Board should include nurses as an identity, not as a representative of the employing agency. Although well represented at the moment as employees, this may not endure.

The current holders of contracts for nursing services confront the issues related to multiple employers and work with the nurses to find the solutions for providing the method of co-ordination which improve a wide variety of health issues for the Kaipara.

The nurses keep the relationship with the community and consumers of the nursing services open, honest and enduring.

Act and think political strategies that involve MOH, RHA and Professional representation.

Key Blockers
General Medical Practitioners
Northland Health Ltd
Ministry of Health policy variations

The response offers a choice for nurses and the other stakeholders. There is a chance to evolve a new structure for a nursing service in an evolutionary manner, with consensus that the nurses will respond to the inevitable changes independently, then reconcile toward co-ordination.

Resource Audit
See Appendix 3

Ethical Stance Identification

Short term Interests of Shareholders:
This stance involves the current contract holders as the shareholders with the consumers or the nurses as stakeholders. It takes the position that maximising shareholders' wealth is the only position any organisation should be concerned with. This approach is not compatible with either the nurses or the consumers.

Long term Shareholder Interests:
The stance takes the same position as the short term interests and the players remain the identical. Now there are other stakeholders to be considered, given that all the current shareholders are members of Kaipara Care Incorporated, it is assumed they have committed their organisation's to supporting co-ordination of health services. The ethical stance should be broader than this and is not sufficient in itself to be accepted by the nurses when doing nothing but more of the same is not necessarily going to improve the populations' health.

Multiple Stakeholder Obligations:
This stance takes the position that stakeholder interests are wider than the shareholder interests and should be explicitly incorporated into the organisational purpose. This is currently the position nurses find themselves in today, and subsumed by managers, executives and employers in decision making and organisational visions, missions and values. While this may suggest an ethical stance it is a stance that works better for some stakeholders and shareholders than it does for nurses.

Shaper of Society:
The stance takes the position of organisations shaping society. A cursory examination into the history of nursing, which few people outside of nursing bother with, will find a wealth of evidence demonstrating how nurses have been shapers on society. As early as the Crimean war nurses where able to turn the toll from infection around when, and only when, Florence Nightingale convinced a Military General that putting nurses in to care for the troops was his idea and not hers. The history of nursing is full of such controls on their practice. How many lives have been lost that could have been saved - and how much better could a populations' health have been improved if the full potential of nurses had been granted them decades ago?

Conclusion:
The nurses in the Kaipara are in no doubt they wish to be shapers of society - a model for other groups to emulate.

Options

Acceptability/Feasibility Audit for a Nursing Service

The above analysis indicates a there would be difficulty in achieving options 2 & 3 without considerable movement on behalf of the current budget holders and change in funding options by Government.

The Performance Index Analysis Model (PIA)
The PIA analysis aids the systematic preparation of information necessary for decision making, where there are complex project alternatives. It enables alternative evaluations to be carried out with little practical difficulty as well incorporating a multitude of objective criteria to suit individual circumstances.

The characteristic features of PIA are:

• Any number of options may be compared
• All variables relevant to the decisions can be considered
• The relevant importance of these variables or criteria can be determined - preferably by a team of experts.

The PIA model evaluates the four options selected by the Nurse Project team. These models are as follows:-

Model 1
Co -Operative

Based on

• Co-ordination of current nursing services
• Identified community need
• Agreed joint Management between current service providers
• Negotiated arrangement through KCI

Co-operative Model

Main Characteristics

1. Developmental in establishing the key relationships and responsibilities with KCI Board and all stakeholders
2. Community input to identify outcomes and community needs
3. Commonly held bicultural mission, vision and values by all nurses
4. Agreed systems for a working management team, by current contract holders
5. Short term - no change in employer, but agreed changes to job descriptions and performance reviews
6. Co-operation to develop best practice guidelines for nursing services
7. Change - Mechanism, Compelling Rationalization and Negotiated Agreement

Model 2
Co-Ordinated Model

Based On

• KCI be delegated contract approval and administration
• Nurse management team has the delegated responsibility for the planning of nursing services
• Nurse reference group and consumer reference group
• Employment remain the same but is examined for future developments
• Planning for a nursing service, based on the populations' need, commences

Co-ordinated Model

Main Characteristics

1. KCI delegated responsibility for the contract relating to nursing services
2. Moral imperative of doing good for consumers.
3. Nurse/allied team manages will projects human and other resources in away that shares resources and aligns incentives
4. Planned approach to nursing and allied service development based on Value Chain Analysis, strategic planning and shared vision for an integrated service
5. Operational Team focuses on driving the business plan
6. Nurse and other provider reference group, takes on the responsibility of a monitoring provider role
7. While employers may or may not change job descriptions, performance reviews will change.

Model Three
Nursing Trust Model

Based On

• Kaipara Care Incorporated becoming a Primary Care Organisation and a Nursing Trust is established. Shaping (rather than being shaped) the Primary Health Care Services required in the Kaipara.

Primary Care Organisation

Main Characteristics

1. Kaipara Care Incorporated becomes a PCO
2. Board has a wider representation and has a nurse as a Board Member
3. KCI membership reflects the wider community, not just the provider groups
4. Ngati Whatua representation on board as well as a Deed of Partnership with the PCO
5. Nursing becomes an integrated nursing service
6. The PCO negotiate the primary and community health contracts required and holds the budget
7. Negotiated relationships with all provider groups and stakeholders
8. Service based on need, value and compelling rationalisation
9. Employs the staff with skills required to meet the service needs
10. Negotiated secondary services links with NHL

Model Four
Progressive Evolutionary Model

Based On
Proceeding from Model One to Model Three

Main Characteristics

1. The nursing service can evolve in tandem with KCI's development to a PCO in an uncertain political future
2. Nursing will be informed by the Value Chain Analysis - (cost analysis, value added analysis, care pathways, critical path analysis)
3. The process is inclusive of stakeholders
4. Time is given to understand and formulate responses to sensitive issues such as staff concerns and organisational change
5. Establishes organisational form, process and control features that will optimise the value chain
6. Formation of a suitable structure for nursing services - ie Trust

Performance Index Analysis

The strength of the performance index analysis lies in the team discussion that results in order to achieve consensus on a numerical score for each of the criterion.

Each criterion is rated out of 100.

Description of the Values selected by the Nurse project group

1) Facilitate Nursing Leadership and Vision
Model 4 scored highest on this criterion because it lends itself to a common vision for all nurses in the Kaipara and the model allows for this vision to be implemented over time. Leadership skills can be developed throughout nursing service at all levels of delivery. Model three also scored relatively well because it concentrates on an integrated nursing service with a common vision. Governance of nursing will be in the hands of nurses.

2) Increase Nursing Input into Service Contract
Model 4 scored the highest on this criterion because the input to the nursing services would be based an individual and population needs, rationalisation of services informed from the value chain analysis, needs assessment and community input. It allows for increased flexibility, innovated and monitored approaches to providing a nursing service. Nurse organisation will be responsible for negotiating the contracts and their administration.

3) Current Contract Holders of Nursing Contracts are not Overly Threatened
Models 1 and 2 scored highest on this criterion because control of the contracts at all levels of operation remain in the hands of the current employers.

4) Facilitate Motivation for Change
Model 4 scored highest on this criterion because it gives time for change. Also, the political indications are that changes will happen to nursing services and a pilot nursing service may be acceptable to the funding sources. It allows time for the current contract holders to take on board the suggested changes and allows for time in negotiating and planning.

5) Optimises the Integration and Delivery of Nursing Services
Model 4 scored the highest on this criterion because the model brings nursing services firstly under the governance of nurses, and secondly it brings all nurses together who are currently employed by different employers. Thus, the vision and planning can incorporate models of a nursing service such as:- case management, generalist, expert nurses and maximise the skill mix.

6) Prepares for the Worse Case Scenario
Model 4 rates the highest on this criterion - the worst scenario being that KCI is no longer funded and collapses as an organisation. This model allows for a pilot to be developed and for nurses to proceed with integration.

7) Improvement in Maori Health
Model 4 scores highest on this criterion because the integration of the nursing services demands a focus on population, as well as individual health needs. Moreover, best practice guidelines and education opportunities would facilitate referral practices and the best use of available resources. (It is conceivable that the Mobile Maori Nursing Service remains as a separate entity. Issues around this have time to be teased out and solutions found to ensure Maori needs are met and health gains made).

8) Strong Iwi Nursing Service
As No. 7.

9) Optimises the Use of Resources for a Nursing Service
Model 4 scores highest on this criterion. The integration of the nursing services firstly allows for one administration point, planning for all resource and utilisation of those resources. This would come about through the development of innovative ways to deliver the service which have found to be effective in the utilisation of nursing services elsewhere - ie Great Britain nursing pilots and other NZ nursing initiatives.

10) Enhances Core Competency Development
Model 4 rated highest on this criterion. It is the model that offers the greatest opportunity for both professional and clinical development because it is over time, and suggests a role of governance for nursing at a level currently unavailable.

11) Produces Equitable Stakeholder Governance
Model 4 rated highest on this criterion. This is because the role of nurses is targeted at the highest governance level and there is time allowing for the changes that are now apparently on the Government's agenda.

12) Nurses have Independent Governance of Nursing Services
Models 3 and 4 rated highest here. Both would give nurses a direct governance role, but 3 does not incorporate the factor of time and evolution. Model 4 suggests flexibility in development and the opportunity to work in a close relationship with other stakeholders to develop into a service which is flexible and innovative.

Conclusions and Recommendations

The strengths of the current nursing service is in the clear leadership in nursing, and for nursing, in the Kaipara. For this leadership to endure, it must be fostered and allowed to move nursing forward, the purpose of which is, to ensure the consumers in the Kaipara receive a nursing service which is:-

• appropriate and relevant to individual needs
• is based on best practice guidelines
• is a quality service and well evaluated