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As with other countries, New Zealand is facing an ageing population, increasing prevalence of chronic conditions, and persisting health inequalities. Expanding the nurse practitioner (NP) workforce offers a solution to the general practitioner (GP) workforce crisis using a model of care that may be transformational in meeting local population health needs.1 Systematic reviews and meta-analyses of randomised controlled trials have confirmed that NPs provide care in a similar way to GPs, achieving at least equivalent clinical outcomes.2–4 Further, when compared to GP care, these reviews demonstrate that patient adherence and satisfaction is higher with NP care and some studies show reduced patient mortality.2,3 Internationally, NPs have tended to establish services for communities that are underserved, Indigenous, marginalised or rural.5,6 The opportunity that NPs offer the New Zealand health sector is how their work combines a biomedical and pharmaceutical approach with an advanced nursing practice approach that draws on principles of social justice and values relationship-oriented care.7–10

However, the development of the NP workforce in New Zealand has been described as ad hoc and lacking any consistent nation-wide approach.11,12 Since the inception of the role in 2001, the growth in the numbers of NPs, while initially slow, has accelerated more rapidly over the past five years, reaching a total of 455 NPs registered with the Nursing Council of New Zealand (NCNZ) at 31 March 2020 (Figure 1). There is considerable variation in the employment of NPs between the regions of New Zealand, ranging from 4.16 NPs/100,000 population in the Taranaki region to 16.44/100,000 population in the Manawatu-Whanganui region.13,14 From 2019, NCNZ workforce data13 showed employment settings for the largest NP workforces were primary healthcare (PHC)/community (42%) and acute settings within district health boards (DHBs) (32%), though 39% worked across multiple settings. Little is known about NPs professional activities, clinically and otherwise; their employment status; or the organisational factors enabling them to work to their scope of practice. The purpose of this survey was to provide further information on the NP workforce in settings broadly defined as PHC, including professional activities, clinical settings, employment status, and organisational limitations, to inform health sector policy and planning.

Figure 1: The number of NPs on the NCNZ Register showing annual increase since 2001.

Background

New Zealand has a robust educational, regulatory, and legislative framework for establishing the NP workforce that compares favourably to the US, Canada and Australia. Nurse practitioners are experienced, advanced nurses regulated by the NCNZ under the Health Practitioners Competence Assurance Act 2003.15 The NP scope of practice16 includes that NPs provide diagnosis and management for health consumers with common and complex health conditions; work autonomously and in collaborative teams; provide a wide range of assessment and treatment interventions; order and interpret diagnostic and laboratory tests; prescribe medicines; and admit and discharge from hospital and other health services.

To register as an NP, registered nurses (RNs) are required to have worked clinically as a RN in their area of practice for four years, complete a clinical Master’s in Nursing (or equivalent), that includes a clinical practicum, over an academic year and supervised by an authorised prescriber, to demonstrate advanced nursing competencies within the NP scope of practice. Following completion of their master’s, RNs are required to submit a portfolio to NCNZ which is assessed against the NP competencies.16 To maintain registration, NPs submit a three-yearly review to NCNZ demonstrating ongoing peer review, professional development, and clinical practice.

Changes to legislation over the past decade have seen NPs move from designated to authorised prescribers, with the same prescriptive authority as doctors under the Medicines Amendment Act 2013;17 are able to issue standing orders;18 and undertake work previously restricted to medical practitioners through the amendment of eight Acts in 2016.19,20 The Primary Health Organisation (PHO) Service Agreement between the district health board (DHB) and PHO allows NPs to enrol patients, receive capitation payments and claim General Medical Services in the same way as GPs.

Defining primary healthcare

For our research we used the definition adopted by the Primary Health Care Strategy21 and based upon the Alma-Ata Declaration of Health22 to include primary prevention and screening; health promotion; generalist first-level services from a range of health providers; and public health activities to improve the health of communities. The PHC Strategy sought to strengthen the PHC workforce with a central vision of reducing health inequalities. Nurse practitioners were proposed as a workforce able to deliver on the intent of the Strategy.23 We therefore included NPs who worked within general practice settings (often referred to as primary care) and NPs who worked in a range of other community settings, for example aged care; family planning and sexual health services; mental health and addiction services; child, youth and family; and DHB community nursing services.

Aim

The aim of this paper is to describe the demographics, distribution, clinical settings, and employment arrangements of the New Zealand nurse practitioner workforce in PHC settings; and organisational factors limiting their practice.

Methods

A survey method was chosen to efficiently reach NPs working in PHC settings across New Zealand. The survey, using Qualtrics©, was designed by the research team to provide workforce information drawing on knowledge gaps identified through previous research11 and international NP workforce surveys.24,25 Consultation included NCNZ; Nurse Practitioners New Zealand (NPNZ) (a subsidiary of the College of Nurses Aotearoa (New Zealand)); New Zealand Nurses Organisation (NZNO); and the National Council of Māori Nurses (NCMN). The survey was piloted on three NPs and revised accordingly, taking 20–30 minutes to respond.

The survey was emailed out, with the participant information sheet, to all NP members of their professional organisations, NPNZ (n=234) and the NZNO (n=150) in June 2019 (noting that some NPs have dual membership). Two reminders were sent. Nurse practitioners were asked to self-select if they identified their work as being PHC, general practice, community (including mental health and addiction, family planning/sexual health, district or public health nursing) or aged residential care.

Ethics approval for the study was granted by the University of Auckland Human Participants Ethics Committee (ref: 022814, 13/5/2019).

Results

The survey was completed by 160 respondents, representing 71.4% of NPs of the estimated 224 NPs registered and working in PHC settings at the time of survey.13 One hundred and fifty-one respondents stated they were working clinically, three were not and five did not record this information. Responses to individual questions varied, and the number of respondents (n) is given for each result presented. The results are presented under four main areas: demographics and location; professional activities and settings of clinical work; employment arrangements, salary and professional development; and organisational issues.

Demographics and location

We compared our sample of NPs working in PHC with the NCNZ 2019 workforce data13 of all registered NPs (n=365) working across all clinical settings; of which PHC is a subset. Overall, our sample aligned closely with the demographics of the total registered NP workforce in relation to gender, age and ethnicity (Table 1).

Table 1: Gender, age and ethnicity of NPs from our survey and all registered NPs.*13

The respondents were geographically spread across all regions of New Zealand. As a measure of rural-urban classification, 69.3% worked within 30 minutes of a major hospital; and for 14.2%, a major hospital was more than 60 minutes away.

Professional activities and settings of clinical work

Figure 2 shows the range of work that NPs were engaged with in addition to their clinical practice. Respondents were asked to identify their work as regular, occasional or never in these areas.

The responses (Figure 2) reflect the contribution of NPs to leadership and management; policy development; locum work; and research. Nearly half of all NPs provided clinical supervision for NP trainees and just under one third were involved with teaching at a tertiary education institute. Perhaps notably, 21 (13.9%) of the respondents were also working regularly or occasionally as a RN.

Figure 2: Respondents work across various professional practice domains showing frequencies for each type of work.

Just under half (73, 48.3%, n=151) of respondents working in clinical settings worked at least full-time hours (37.5–40 hours/week); 52 (34.4%) worked between 30–36 hours; and 24 (15.9%) worked 22.5–29 hours. Only three worked less than half time.

Respondents were asked to identify the clinical settings in which they worked (Table 2). Only 79 (52.3%) recorded that they worked in just one clinical setting. When asked to identify their “main” clinical setting, 34 (22.5%) responded to more than one setting, giving a total of 175 main clinical settings.

Table 2: Main clinical settings across which the 151 respondents worked.

*Of 151 NPs, 34 identified they worked in more than one “main” clinical setting. This resulted in a total of 175 main clinical settings being recorded by 151 NPs (the total adding to more than 100%).

General practice-type settings

General practice-type settings included general practice, health providers, DHB or PHO health centres or clinics, and accident & medical providers. While 68 NPs identified their main clinical setting as being in a general practice-type setting, several worked in two or more general practice employment settings, giving a total of 76 settings. These included general practitioner-owned practice (31, 40.8%); corporate-owned general practice (7, 9.2%); Māori or iwi provider (8, 10.5%); trust-owned general practice (4, 5.3%); DHB general practice clinic (7, 9.2%); PHO employed (4, 5.3%). Two worked in NP/RN owned practices, and 13 (17.1%) in other settings, such as accident & medical or Pacific health provider. Nurse practitioners in general practice-type settings were asked if a specific model of care was being used (n=63). Models included integrated family health centre (30, 47.6%); health care home (17, 27%); and whānau ora (10, 15.9%). Of 88 NPs who worked at least some hours in general practice-type settings, health centres and clinics, 38 (43.2%) were very low-cost access (VLCA) practices.

Aged residential care settings

A total of 41 NPs (27%) identified at least some of their work to include aged residential care. Nineteen NPs (13%) worked in both general practice-type settings and in aged care. Of 29 NPs (19.2%, n=151) who described aged care as their main place of work, seven were DHB employed; five were employed through general practice; two employed by PHOs and five through hospice; and four identified their main employment was through private contract. A further 15 NPs indicated they also worked under private contracts with aged residential care providers to deliver primary care services for at least part of their total clinical work.

Other clinical areas of practice

Nurse practitioners recorded working in other settings in addition to their main practice site across a wide range of other clinical settings with employing organisations including general practice-type settings, DHBs, PHOs, Māori health provider organisations and private contracts. While many of these numbers are currently small, they show the breadth of the NP workforce across the PHC sector.

Working with patients

Fifty NPs (38%, n=130) identified that they had their own caseload of patients enrolled with them; while a further 50 (38%) had their own caseload, but their patients were also enrolled with the GP or consultant of the service. The respondents were asked to estimate the average time they spent directly with patients and whānau. Figure 3 shows the variations between clinical settings.

Figure 3: The average time estimated that NPs spent with a patient by clinical setting (n=146).

Those working in aged residential care, sexual health/family planning, and mental health and addiction services, tended to have longer consulting times; while those in general practice-type settings and child/youth health had less time.

Employment arrangements, salary, and professional development

Most NPs (110, 75%, n=146) had been working in their main clinical setting for more than two years; 39 (27%) for more than 10 years; and 19 (13%) for up to one year. Of 137 NPs, 83 (60.6%) expected to stay in their clinical position for at least the next three years demonstrating a reasonably stable workforce.

Respondents were asked about their employment contracts, and of 145 NPs who responded to this question, 121 (83.4%) were on permanent employment contracts (some with multiple employers) and 10 were on fixed-term contracts. Seven were self-employed and four were a business owner or practice partner. Of those who were self-employed, their income was generated through payment for the services they delivered to a patient group. The modal range for annual salary (based on one full-time equivalent) of 136 responders was between $100,000 and $109,999; 52% received a salary of $110,000 or more per annum; and 19% less than $100,000 (Figure 4).

Figure 4: Percentage of NP’s with an annual salary falling into each salary band.

Professional development

Ninety-three respondents (67.4%, n=138) stated their professional development needs were mostly or always met, with 22 (15.9%) stating occasionally or never. When asked about the funding received for professional development (Figure 5), many had no funding or less than $1,000 per annum with just under one fifth receiving $4,000 or more.

Figure 5: Annual funding available for professional development for NPs (n=114).

Organisational issues

Survey respondents were asked to identify what limited their ability to work to their full scope of practice as a NP on a four-point Likert scale (Figure 6).

Figure 6: Factors that limit NPs’ full scope of practice. Factors are ranked from the most to the least limiting (‘often’ and ‘very limiting’).

Nurse practitioners identified the factors least restricting of their work to be prescribing practice and their access to prescribing and medical advice. Those factors considered often or very limiting included the employment model and model of care used by the organisation; access to diagnostic tests; and organisational policies or processes.

Respondents were asked about their access to secondary specialists and diagnostic tests. A small number of NPs identified that they had at least some restrictions to referring to a range of medical specialities including general medicine (five respondents), general surgery (nine respondents), ear nose throat (eight respondents), ophthalmology (nine respondents), paediatrics (seven respondents), vascular or cardiac surgery (13 respondents). However, 47 NPs (38.8%, n=144) had difficulty or could not refer to radiology; 28 (19%) were unable to request an ultrasound; and 19 (13%) of NPs made additional comments that they were not able to request a pregnancy ultrasound, including for women requesting a termination of pregnancy. Other tests that NPs were unable to order included CT scans for ACC injuries. Further, 10 NPs commented that they still needed to request diagnostic laboratory testing under the name of the GP, meaning that the results would come back to the general practitioner.

Discussion

The Health and Disability System Review (HDSR) was tasked with ensuring the health sector is better balanced towards wellness, access, equity and sustainability. The Interim Report noted the widespread failure of the implementation of the 2001 Primary Health Care Strategy stating that:

“Continuing with the current model of care, based largely on a Western medical model, … will not only be ineffective in achieving the equitable outcomes we desire, it will not be sustainable” (p.2).26

Developing the health workforce and models of care to improve primary and community (Tier 1) services, using a networking approach to engage whānau and local communities, was identified as central in the HDSR final report.27 Expanding and optimising the NP workforce provides one potential solution to improving access to PHC services and meeting the needs of diverse communities.1,7

The number of NPs working in the health sector has risen steadily and will reach 500 by the end of 2020. Approximately 60% of all NPs work in clinical settings that can broadly be defined as PHC, including general practice-type settings, aged residential care, whānau ora, mental health, sexual health and family planning, and community nursing services. Further, many contribute to education, policy, research, and leadership. Nearly half of the NPs in our survey (48% compared with 39% of all registered NPs13) worked in multiple clinical settings with various employers or contracts; and many participated in a range of professional activities. While working across multiple clinical settings may be appropriate for local community health needs and indicate demand for the high level of expertise of the NP workforce, this high number of employment contracts may also speak to difficulty some NPs may have in gaining full-time employment with a particular health provider. Twenty-one NPs (14%) in this study continued to work regularly or occasionally as a registered nurse under a different scope of practice, and this confirms other findings that at least some NPs struggle to establish a full-time role as a NP.11,28

Perhaps surprisingly, only 38.9% of the 175 identified main clinical settings included general practice-type settings, despite the growing GP workforce shortage.29 Many worked in very low-cost access, indicating high deprivation communities. There have been recent challenges in New Zealand to the business ownership model of general practice, requiring user co-payments, as being fit for purpose, with cost to patients an unacceptable barrier.30,31 The GP workforce survey29 identified that 71% of GPs work in practices owned by one or more GPs, and of those who worked full-time, 42% earned more than $200,000. For GPs working in corporate-owned practices, 50% earned more than $200,000 per annum for full-time work. In our survey, 73% of NPs earned less than $120,000 (annual, full-time). However, the evidence from systematic reviews concludes that NPs deliver at least similar care compared to GPs (such as prescribing practice, diagnostic investigations, hospital referrals and hospital admissions) and achieve similar or improved clinical and health status outcomes.2–4 Further, there is some evidence that nurse-led primary care may lead to slightly fewer deaths; that patient satisfaction scores are higher as may also be quality of life scores.2 Given the shortage of GPs it would seem prudent to support the growth of the NP workforce.

While the majority of NPs in our survey reported that they were able to work to their full scope of practice, barriers, including organisational barriers continue to exist.9,11,24,25 The employment model (13.6%); model of care (11.8%); and organisational policies (8%) were limiting or very limiting to NPs’ work. While difficulties referring to medical specialists remained a problem for a just a few NPs, 47 NPs (38.8%, n=144) expressed they had difficulty or could not refer to radiology, including simple x-ray; and 10 NPs had to order diagnostic tests under the GP’s name. While some are legislative restrictions, such as ordering ultrasound in pregnancy, others are unnecessary limitations placed on scope of practice locally or regionally and do not reflect policy, legislation or regulation.

Our survey demonstrated the stability of the NP workforce, with three quarters of NPs having worked in the same setting for at least two years and 60% intending to stay for at least a further three years. New Zealand relies heavily on a locum GP workforce, particularly in rural areas where 39% of practices have a GP vacancy.29 Further, 36% of rural GPs intend to retire within the next one to five years.29 Our survey showed that 14.2% of NPs worked rurally, a similar proportion to 16.7% of GPs who self-selected they worked in rural practices.29 It would make sense to focus now on developing a permanent NP workforce in underserved and rural areas to support the diminishing GP workforce and improve access and continuity of care.

To achieve the mainstream establishment of NPs, there needs to be greater investment in the training of NPs; and particularly for Māori, and Pacific who are currently underrepresented and yet central to the endeavour of reducing health inequalities. The educational cost of training a NP is likely substantially lower than for a GP.6 The pilot NP Training Programme (NPTP) has annually trained 20 NPs since 2016 through their final clinical practicum year (just under one third of all NPs). This Programme provided 500 hours of supernumerary time to practice advanced clinical skills with supervision from an authorised prescriber and was positively evaluated.28 A nationwide NPTP, led by the University of Auckland with other partners, is now being funded by the Ministry of Health from 2021 increasing the number of training places and focusing on priority areas including PHC, and the Māori, and Pacific NP workforce. Delivering a nationally consistent training programme is essential for the long-term establishment of this workforce.

At the time of writing, there is no national guidance or agreement for NP salary, with each NP required to negotiate their own salary and terms and conditions. Those employed by DHBs may be under the DHB multi-employer collective agreement (MECA) at a senior nurse level. For ongoing registration with the NCNZ,16 NPs are required to undertake a minimum of 40 hours per year of professional development and ongoing peer review of their prescribing practice by an authorised prescriber to maintain registration. Of our respondents, 60% had $2,000 or less available annually for professional development. Establishing guidance and at least minimum requirements for employment, salary, and professional development is going to be a necessary step to protect this emerging workforce.

Limitations

Respondents self-selected with a reasonable response rate of 70%; however, the actual sample size was estimated as there was no definitive denominator available. Because of the multiple settings and currently relatively few NPs working across those many settings, in-depth analysis of variables has not been undertaken. Workforce data in New Zealand is variably collected and described, which does not allow for easy comparison.

Conclusion

The potential contribution of NPs in addressing health inequalities is well described in the literature1,7,32 and aligns with the WHO’s broader definitions of PHC.22,33 The New Zealand NP workforce is growing with an estimated 60% working in a range of settings broadly defined as PHC. This survey of 160 NPs has provided a stocktake of work, employment conditions, and barriers to optimising their scope of practice. With the GP workforce crisis looming large; the burgeoning of long-term conditions and mental health and addiction problems; a growing elderly population and frail elderly in aged residential care; and persisting health inequalities, it seems that now would be the time to facilitate the establishment of the NP workforce.

Summary

Abstract

Aim

The aim of the survey was to describe the demographics, distribution, clinical settings and employment arrangements of the New Zealand nurse practitioner workforce in primary healthcare settings; and organisational factors limiting their practice.

Method

An online survey was developed and sent to all NPs in mid-2019.

Results

The survey was completed by 160 nurse practitioners who worked in settings broadly defined as primary healthcare (response rate 71.4%). In addition to clinical work, nurse practitioners engaged in teaching and clinical supervision; leadership and management; policy development; locum work; and research; but 14% continued to do at least some work as a registered nurse. One hundred and fifty-one respondents were working clinically and 48% of these worked in more than one clinical setting. General practice-type settings (39%), of which over 40% were very low-cost access practices, and aged residential care (19%) were most commonly identified as the main clinical setting. Others included long-term conditions; mental health and addiction; sexual health/family planning; whānau ora; child/youth health; and various community nursing service roles. Seventy-three percent of nurse practitioners earned less than $120,000 per annum for full-time work; and 60% had $2,000 or less available for professional development. Three quarters had worked in the same setting for at least two years, and 60% intended to stay a further three years. Fourteen percent worked rurally. Employment models, models of care, and access to diagnostics, particularly radiology, were most limiting to their practice.

Conclusion

The nurse practitioner workforce offers stability and flexibility in working across multiple clinical settings in primary healthcare. They provide the potential solution to the general practitioner workforce shortage by improving access to primary healthcare and reducing health inequalities. As authorised prescribers able to enrol patients, receive capitation payments and claim general medical services, it is timely to facilitate the expansion of the nurse practitioner workforce in New Zealand.

Author Information

Sue Adams, Senior Lecturer, School of Nursing, University of Auckland, Auckland; Michal Boyd, Associate Professor, School of Nursing, University of Auckland, Auckland; Jenny Carryer, Professor, School of Nursing, Massey University, Palmerston North; Corinne Bareham, Postdoctoral Research Fellow, School of Psychology, Victoria University of Wellington, Wellington; Tim Tenbensel, Associate Professor, School of Population Health, University of Auckland, Auckland.

Acknowledgements

This survey was supported by funding from the School of Population Health, University of Auckland (PBRF funding) and School of Nursing, Massey University.

Correspondence

Sue Adams, Senior Lecturer, School of Nursing, University of Auckland.

Correspondence Email

s.adams@auckland.ac.nz

Competing Interests

Dr Tenbensel, Dr Boyd and Dr Carryer report grants from Faculty of Health & Medical Sciences, University of Auckland, during the conduct of the study. Dr Carryer reports personal fees for Statistical Advice during the conduct of the study.

1. Carryer J, Adams S. Nurse practitioners as a solution to transformative and sustainable health services in primary health care: A qualitative exploratory study. Collegian. 2017; 24:525–531.

2. Laurant M, van der Biezen M, Wijers N, et al. Nurses as substitutes for doctors in primary care (Review). Cochrane Database Syst. Rev. 2018 (Issue 7. Art. No.: CD001271).

3. Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: A systematic review and meta-analysis. BMC Health Serv. 2014; 14(214):1–17.

4. Swan M, Ferguson S, Chang A, et al. Quality of primary care by advanced practice nurses: A systematic review. Int J Qual Health C. 2015; 27:396–404.

5. Auerbach DI, Chen PG, Friedberg MW, et al. Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Aff. 2013; 32:1933–1941.

6. Carter M, Moore P, Sublette N. A nursing solution to primary care delivery shortfall. Nurs Inq. 2017; 25(e12245):1–7.

7. Browne AJ, Tarlier DS. Examining the potential of nurse practitioners from a critical social justice perspective. Nurs Inq. 2008; 15:83–93.

8. Xue Y, Intrator O. Cultivating the role of nurse practitioners in providing primary care to vulnerable populations in an era of health-care reform. Policy Politics Nurs Pract. 2016; 17:24–31.

9. Wolff-Baker D, Ordona RB. The expanding role of nurse practitioners in home-based primary care: Opportunities and challenges. J Gerontol Nurs. 2019; 45(6):9–14.

10. Ploeg J, Kaasalainen S, McAiney C, et al. Resident and family perceptions of the nurse practitioner role in long term care settings: A qualitative descriptive study. BMC Nurs. 2013; 12(24):1–11.

11. Adams S, Carryer J. Establishing the nurse practitioner workforce in rural New Zealand: Barriers and facilitators. J Prim Health Care. 2019; 11:152–158.

12. Gagan MJ, Boyd M, Wysocki K, Williams DJ. The first decade of nurse practitioners in New Zealand: A survey of an evolving practice. J Am Assoc Nurse Pra. 2014; 26:612–619.

13. Nursing Council of New Zealand. The New Zealand Nursing Workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2018-2019. 2019. [Available from: http://www.nursingcouncil.org.nz/Public/Publications/Workforce_Statistics/NCNZ/publications-section/Workforce_statistics.aspx?hkey=3f3f39c4-c909-4d1d-b87f-e6270b531145 accessed 20 April 2020].

14. [http://www.health.govt.nz/new-zealand-health-system/my-dhb accessed 20 April 2020].

15. Health Practitioners Competence Assurance Act. New Zealand Government. [Available from: http://www.legislation.govt.nz/act/public/2003/0048/latest/DLM203312.html?src=qs accessed 20 April 2020].

16. Nursing Council of New Zealand. Nurse practitioner. n.d. [Available from: http://www.nursingcouncil.org.nz/Public/Nursing/Scopes_of_practice/Nurse_practitioner/NCNZ/nursing-section/Nurse_practitioner.aspx?hkey=1493d86e-e4a5-45a5-8104-64607cf103c6 accessed 20 April 2020].

17. Medicines Amendment Act. New Zealand Government. 2013. Available from: http://www.legislation.govt.nz/act/public/2013/0141/latest/DLM4096106.html

18. Ministry of Health. Amendment of the Medicines (Standing Orders) Regulations. 2016. [Available from: http://www.health.govt.nz/our-work/nursing/developments-nursing/amendment-medicines-standing-orders-regulations accessed 20 April 2020].

19. Ministry of Health. Changes to health practitioner status. 2017. [Available from: http://www.health.govt.nz/about-ministry/legislation-and-regulation/changes-health-practitioner-status accessed 20 April 2020].

20. Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. New Zealand Government. 2016. [Available from: http://www.legislation.govt.nz/bill/government/2015/0036/23.0/versions.aspx accessed 20 April 2020].

21. King A. The Primary Health Care Strategy. Wellington: Ministry of Health; 2001.

22. World Health Organization. Declaration of Alma-Ata. Alma-Ata, USSR: International Conference on Primary Health Care, 6–12 Sept; 1978.

23. Hughes F, Carryer J. Nurse practitioners in New Zealand. Wellington: Ministry of Health; 2002.

24. Poghosyan L, Chaplin WF, Shaffer JA. Validation of Nurse Practitioner Primary Care Organizational Climate Questionnaire: A new tool to study nurse practitioner practice settings. J Nurs Meas. 2017; 25:142–155.

25. Scanlon A, Murphy M, Tori K, Poghosyan L. A National Study of Australian Nurse Practitioners’ Organizational Practice Environment. J Nurse Pract. 2018 ;14:414–418.e41

26. Health and Disability System Review. Health and Disability System Review - Interim Report. Hauora Manaaki ki Aotearoa Whānui – Pūrongo mō Tēnei Wā. Wellington: HDSR 2019.

27. Health and Disability System Review. Health and Disability System Review: Final Report - Pūrongo Whakamutunga. Wellington: HDSR 2020. [Available from http://systemreview.health.govt.nz/assets/Uploads/hdsr/health-disability-system-review-final-report.pdf accessed 18 June 2020].

28. Malatest International. Evaluation report: Evaluation of a nurse practitioner education programme. 2018. [Available from: http://www.health.govt.nz/system/files/documents/publications/evaluation-nurse-practitioner-education-programme-feb18.pdf accessed 20 April 2020].

29. Royal New Zealand College of General Practitioners. 2018 general practice workforce survey: Part 1. 2019. [Available from: http://www.rnzcgp.org.nz/RNZCGP/Publications/The_GP_workforce/RNZCGP/Publications/GP_workforce.aspx?hkey=a7341975-3f92-4d84-98ec-8c72f7c8e151 accessed 20 April 2020].

30. Gauld R, Atmore C, Baxter J, Crampton P, Stokes T. The ‘elephants in the room’ for New Zealand’s health system in its 80th anniversary year: General practice charges and ownership models. N Z Med J. 2019; 132(1489):8–14.

31. Goodyear-Smith F, Ashton T. New Zealand health system: Universalism struggles with persisting inequities. Lancet. 2019; 394(10196):432–442.

32. Poghosyan L, Carthon JMB. The untapped potential of the nurse practitioner workforce in reducing health disparities. Policy Politics Nurs Pract. 2017; 18:84–94.

33. World Health Organization. Declaration of Astana: Global Conference on Primary Health Care. In: Astana Kazakhstan, 25-26 Oct: World Health Organization; 2018. [Available from: http://www.who.int/primary-health/conference-phc accessed 20 April 2020].

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As with other countries, New Zealand is facing an ageing population, increasing prevalence of chronic conditions, and persisting health inequalities. Expanding the nurse practitioner (NP) workforce offers a solution to the general practitioner (GP) workforce crisis using a model of care that may be transformational in meeting local population health needs.1 Systematic reviews and meta-analyses of randomised controlled trials have confirmed that NPs provide care in a similar way to GPs, achieving at least equivalent clinical outcomes.2–4 Further, when compared to GP care, these reviews demonstrate that patient adherence and satisfaction is higher with NP care and some studies show reduced patient mortality.2,3 Internationally, NPs have tended to establish services for communities that are underserved, Indigenous, marginalised or rural.5,6 The opportunity that NPs offer the New Zealand health sector is how their work combines a biomedical and pharmaceutical approach with an advanced nursing practice approach that draws on principles of social justice and values relationship-oriented care.7–10

However, the development of the NP workforce in New Zealand has been described as ad hoc and lacking any consistent nation-wide approach.11,12 Since the inception of the role in 2001, the growth in the numbers of NPs, while initially slow, has accelerated more rapidly over the past five years, reaching a total of 455 NPs registered with the Nursing Council of New Zealand (NCNZ) at 31 March 2020 (Figure 1). There is considerable variation in the employment of NPs between the regions of New Zealand, ranging from 4.16 NPs/100,000 population in the Taranaki region to 16.44/100,000 population in the Manawatu-Whanganui region.13,14 From 2019, NCNZ workforce data13 showed employment settings for the largest NP workforces were primary healthcare (PHC)/community (42%) and acute settings within district health boards (DHBs) (32%), though 39% worked across multiple settings. Little is known about NPs professional activities, clinically and otherwise; their employment status; or the organisational factors enabling them to work to their scope of practice. The purpose of this survey was to provide further information on the NP workforce in settings broadly defined as PHC, including professional activities, clinical settings, employment status, and organisational limitations, to inform health sector policy and planning.

Figure 1: The number of NPs on the NCNZ Register showing annual increase since 2001.

Background

New Zealand has a robust educational, regulatory, and legislative framework for establishing the NP workforce that compares favourably to the US, Canada and Australia. Nurse practitioners are experienced, advanced nurses regulated by the NCNZ under the Health Practitioners Competence Assurance Act 2003.15 The NP scope of practice16 includes that NPs provide diagnosis and management for health consumers with common and complex health conditions; work autonomously and in collaborative teams; provide a wide range of assessment and treatment interventions; order and interpret diagnostic and laboratory tests; prescribe medicines; and admit and discharge from hospital and other health services.

To register as an NP, registered nurses (RNs) are required to have worked clinically as a RN in their area of practice for four years, complete a clinical Master’s in Nursing (or equivalent), that includes a clinical practicum, over an academic year and supervised by an authorised prescriber, to demonstrate advanced nursing competencies within the NP scope of practice. Following completion of their master’s, RNs are required to submit a portfolio to NCNZ which is assessed against the NP competencies.16 To maintain registration, NPs submit a three-yearly review to NCNZ demonstrating ongoing peer review, professional development, and clinical practice.

Changes to legislation over the past decade have seen NPs move from designated to authorised prescribers, with the same prescriptive authority as doctors under the Medicines Amendment Act 2013;17 are able to issue standing orders;18 and undertake work previously restricted to medical practitioners through the amendment of eight Acts in 2016.19,20 The Primary Health Organisation (PHO) Service Agreement between the district health board (DHB) and PHO allows NPs to enrol patients, receive capitation payments and claim General Medical Services in the same way as GPs.

Defining primary healthcare

For our research we used the definition adopted by the Primary Health Care Strategy21 and based upon the Alma-Ata Declaration of Health22 to include primary prevention and screening; health promotion; generalist first-level services from a range of health providers; and public health activities to improve the health of communities. The PHC Strategy sought to strengthen the PHC workforce with a central vision of reducing health inequalities. Nurse practitioners were proposed as a workforce able to deliver on the intent of the Strategy.23 We therefore included NPs who worked within general practice settings (often referred to as primary care) and NPs who worked in a range of other community settings, for example aged care; family planning and sexual health services; mental health and addiction services; child, youth and family; and DHB community nursing services.

Aim

The aim of this paper is to describe the demographics, distribution, clinical settings, and employment arrangements of the New Zealand nurse practitioner workforce in PHC settings; and organisational factors limiting their practice.

Methods

A survey method was chosen to efficiently reach NPs working in PHC settings across New Zealand. The survey, using Qualtrics©, was designed by the research team to provide workforce information drawing on knowledge gaps identified through previous research11 and international NP workforce surveys.24,25 Consultation included NCNZ; Nurse Practitioners New Zealand (NPNZ) (a subsidiary of the College of Nurses Aotearoa (New Zealand)); New Zealand Nurses Organisation (NZNO); and the National Council of Māori Nurses (NCMN). The survey was piloted on three NPs and revised accordingly, taking 20–30 minutes to respond.

The survey was emailed out, with the participant information sheet, to all NP members of their professional organisations, NPNZ (n=234) and the NZNO (n=150) in June 2019 (noting that some NPs have dual membership). Two reminders were sent. Nurse practitioners were asked to self-select if they identified their work as being PHC, general practice, community (including mental health and addiction, family planning/sexual health, district or public health nursing) or aged residential care.

Ethics approval for the study was granted by the University of Auckland Human Participants Ethics Committee (ref: 022814, 13/5/2019).

Results

The survey was completed by 160 respondents, representing 71.4% of NPs of the estimated 224 NPs registered and working in PHC settings at the time of survey.13 One hundred and fifty-one respondents stated they were working clinically, three were not and five did not record this information. Responses to individual questions varied, and the number of respondents (n) is given for each result presented. The results are presented under four main areas: demographics and location; professional activities and settings of clinical work; employment arrangements, salary and professional development; and organisational issues.

Demographics and location

We compared our sample of NPs working in PHC with the NCNZ 2019 workforce data13 of all registered NPs (n=365) working across all clinical settings; of which PHC is a subset. Overall, our sample aligned closely with the demographics of the total registered NP workforce in relation to gender, age and ethnicity (Table 1).

Table 1: Gender, age and ethnicity of NPs from our survey and all registered NPs.*13

The respondents were geographically spread across all regions of New Zealand. As a measure of rural-urban classification, 69.3% worked within 30 minutes of a major hospital; and for 14.2%, a major hospital was more than 60 minutes away.

Professional activities and settings of clinical work

Figure 2 shows the range of work that NPs were engaged with in addition to their clinical practice. Respondents were asked to identify their work as regular, occasional or never in these areas.

The responses (Figure 2) reflect the contribution of NPs to leadership and management; policy development; locum work; and research. Nearly half of all NPs provided clinical supervision for NP trainees and just under one third were involved with teaching at a tertiary education institute. Perhaps notably, 21 (13.9%) of the respondents were also working regularly or occasionally as a RN.

Figure 2: Respondents work across various professional practice domains showing frequencies for each type of work.

Just under half (73, 48.3%, n=151) of respondents working in clinical settings worked at least full-time hours (37.5–40 hours/week); 52 (34.4%) worked between 30–36 hours; and 24 (15.9%) worked 22.5–29 hours. Only three worked less than half time.

Respondents were asked to identify the clinical settings in which they worked (Table 2). Only 79 (52.3%) recorded that they worked in just one clinical setting. When asked to identify their “main” clinical setting, 34 (22.5%) responded to more than one setting, giving a total of 175 main clinical settings.

Table 2: Main clinical settings across which the 151 respondents worked.

*Of 151 NPs, 34 identified they worked in more than one “main” clinical setting. This resulted in a total of 175 main clinical settings being recorded by 151 NPs (the total adding to more than 100%).

General practice-type settings

General practice-type settings included general practice, health providers, DHB or PHO health centres or clinics, and accident & medical providers. While 68 NPs identified their main clinical setting as being in a general practice-type setting, several worked in two or more general practice employment settings, giving a total of 76 settings. These included general practitioner-owned practice (31, 40.8%); corporate-owned general practice (7, 9.2%); Māori or iwi provider (8, 10.5%); trust-owned general practice (4, 5.3%); DHB general practice clinic (7, 9.2%); PHO employed (4, 5.3%). Two worked in NP/RN owned practices, and 13 (17.1%) in other settings, such as accident & medical or Pacific health provider. Nurse practitioners in general practice-type settings were asked if a specific model of care was being used (n=63). Models included integrated family health centre (30, 47.6%); health care home (17, 27%); and whānau ora (10, 15.9%). Of 88 NPs who worked at least some hours in general practice-type settings, health centres and clinics, 38 (43.2%) were very low-cost access (VLCA) practices.

Aged residential care settings

A total of 41 NPs (27%) identified at least some of their work to include aged residential care. Nineteen NPs (13%) worked in both general practice-type settings and in aged care. Of 29 NPs (19.2%, n=151) who described aged care as their main place of work, seven were DHB employed; five were employed through general practice; two employed by PHOs and five through hospice; and four identified their main employment was through private contract. A further 15 NPs indicated they also worked under private contracts with aged residential care providers to deliver primary care services for at least part of their total clinical work.

Other clinical areas of practice

Nurse practitioners recorded working in other settings in addition to their main practice site across a wide range of other clinical settings with employing organisations including general practice-type settings, DHBs, PHOs, Māori health provider organisations and private contracts. While many of these numbers are currently small, they show the breadth of the NP workforce across the PHC sector.

Working with patients

Fifty NPs (38%, n=130) identified that they had their own caseload of patients enrolled with them; while a further 50 (38%) had their own caseload, but their patients were also enrolled with the GP or consultant of the service. The respondents were asked to estimate the average time they spent directly with patients and whānau. Figure 3 shows the variations between clinical settings.

Figure 3: The average time estimated that NPs spent with a patient by clinical setting (n=146).

Those working in aged residential care, sexual health/family planning, and mental health and addiction services, tended to have longer consulting times; while those in general practice-type settings and child/youth health had less time.

Employment arrangements, salary, and professional development

Most NPs (110, 75%, n=146) had been working in their main clinical setting for more than two years; 39 (27%) for more than 10 years; and 19 (13%) for up to one year. Of 137 NPs, 83 (60.6%) expected to stay in their clinical position for at least the next three years demonstrating a reasonably stable workforce.

Respondents were asked about their employment contracts, and of 145 NPs who responded to this question, 121 (83.4%) were on permanent employment contracts (some with multiple employers) and 10 were on fixed-term contracts. Seven were self-employed and four were a business owner or practice partner. Of those who were self-employed, their income was generated through payment for the services they delivered to a patient group. The modal range for annual salary (based on one full-time equivalent) of 136 responders was between $100,000 and $109,999; 52% received a salary of $110,000 or more per annum; and 19% less than $100,000 (Figure 4).

Figure 4: Percentage of NP’s with an annual salary falling into each salary band.

Professional development

Ninety-three respondents (67.4%, n=138) stated their professional development needs were mostly or always met, with 22 (15.9%) stating occasionally or never. When asked about the funding received for professional development (Figure 5), many had no funding or less than $1,000 per annum with just under one fifth receiving $4,000 or more.

Figure 5: Annual funding available for professional development for NPs (n=114).

Organisational issues

Survey respondents were asked to identify what limited their ability to work to their full scope of practice as a NP on a four-point Likert scale (Figure 6).

Figure 6: Factors that limit NPs’ full scope of practice. Factors are ranked from the most to the least limiting (‘often’ and ‘very limiting’).

Nurse practitioners identified the factors least restricting of their work to be prescribing practice and their access to prescribing and medical advice. Those factors considered often or very limiting included the employment model and model of care used by the organisation; access to diagnostic tests; and organisational policies or processes.

Respondents were asked about their access to secondary specialists and diagnostic tests. A small number of NPs identified that they had at least some restrictions to referring to a range of medical specialities including general medicine (five respondents), general surgery (nine respondents), ear nose throat (eight respondents), ophthalmology (nine respondents), paediatrics (seven respondents), vascular or cardiac surgery (13 respondents). However, 47 NPs (38.8%, n=144) had difficulty or could not refer to radiology; 28 (19%) were unable to request an ultrasound; and 19 (13%) of NPs made additional comments that they were not able to request a pregnancy ultrasound, including for women requesting a termination of pregnancy. Other tests that NPs were unable to order included CT scans for ACC injuries. Further, 10 NPs commented that they still needed to request diagnostic laboratory testing under the name of the GP, meaning that the results would come back to the general practitioner.

Discussion

The Health and Disability System Review (HDSR) was tasked with ensuring the health sector is better balanced towards wellness, access, equity and sustainability. The Interim Report noted the widespread failure of the implementation of the 2001 Primary Health Care Strategy stating that:

“Continuing with the current model of care, based largely on a Western medical model, … will not only be ineffective in achieving the equitable outcomes we desire, it will not be sustainable” (p.2).26

Developing the health workforce and models of care to improve primary and community (Tier 1) services, using a networking approach to engage whānau and local communities, was identified as central in the HDSR final report.27 Expanding and optimising the NP workforce provides one potential solution to improving access to PHC services and meeting the needs of diverse communities.1,7

The number of NPs working in the health sector has risen steadily and will reach 500 by the end of 2020. Approximately 60% of all NPs work in clinical settings that can broadly be defined as PHC, including general practice-type settings, aged residential care, whānau ora, mental health, sexual health and family planning, and community nursing services. Further, many contribute to education, policy, research, and leadership. Nearly half of the NPs in our survey (48% compared with 39% of all registered NPs13) worked in multiple clinical settings with various employers or contracts; and many participated in a range of professional activities. While working across multiple clinical settings may be appropriate for local community health needs and indicate demand for the high level of expertise of the NP workforce, this high number of employment contracts may also speak to difficulty some NPs may have in gaining full-time employment with a particular health provider. Twenty-one NPs (14%) in this study continued to work regularly or occasionally as a registered nurse under a different scope of practice, and this confirms other findings that at least some NPs struggle to establish a full-time role as a NP.11,28

Perhaps surprisingly, only 38.9% of the 175 identified main clinical settings included general practice-type settings, despite the growing GP workforce shortage.29 Many worked in very low-cost access, indicating high deprivation communities. There have been recent challenges in New Zealand to the business ownership model of general practice, requiring user co-payments, as being fit for purpose, with cost to patients an unacceptable barrier.30,31 The GP workforce survey29 identified that 71% of GPs work in practices owned by one or more GPs, and of those who worked full-time, 42% earned more than $200,000. For GPs working in corporate-owned practices, 50% earned more than $200,000 per annum for full-time work. In our survey, 73% of NPs earned less than $120,000 (annual, full-time). However, the evidence from systematic reviews concludes that NPs deliver at least similar care compared to GPs (such as prescribing practice, diagnostic investigations, hospital referrals and hospital admissions) and achieve similar or improved clinical and health status outcomes.2–4 Further, there is some evidence that nurse-led primary care may lead to slightly fewer deaths; that patient satisfaction scores are higher as may also be quality of life scores.2 Given the shortage of GPs it would seem prudent to support the growth of the NP workforce.

While the majority of NPs in our survey reported that they were able to work to their full scope of practice, barriers, including organisational barriers continue to exist.9,11,24,25 The employment model (13.6%); model of care (11.8%); and organisational policies (8%) were limiting or very limiting to NPs’ work. While difficulties referring to medical specialists remained a problem for a just a few NPs, 47 NPs (38.8%, n=144) expressed they had difficulty or could not refer to radiology, including simple x-ray; and 10 NPs had to order diagnostic tests under the GP’s name. While some are legislative restrictions, such as ordering ultrasound in pregnancy, others are unnecessary limitations placed on scope of practice locally or regionally and do not reflect policy, legislation or regulation.

Our survey demonstrated the stability of the NP workforce, with three quarters of NPs having worked in the same setting for at least two years and 60% intending to stay for at least a further three years. New Zealand relies heavily on a locum GP workforce, particularly in rural areas where 39% of practices have a GP vacancy.29 Further, 36% of rural GPs intend to retire within the next one to five years.29 Our survey showed that 14.2% of NPs worked rurally, a similar proportion to 16.7% of GPs who self-selected they worked in rural practices.29 It would make sense to focus now on developing a permanent NP workforce in underserved and rural areas to support the diminishing GP workforce and improve access and continuity of care.

To achieve the mainstream establishment of NPs, there needs to be greater investment in the training of NPs; and particularly for Māori, and Pacific who are currently underrepresented and yet central to the endeavour of reducing health inequalities. The educational cost of training a NP is likely substantially lower than for a GP.6 The pilot NP Training Programme (NPTP) has annually trained 20 NPs since 2016 through their final clinical practicum year (just under one third of all NPs). This Programme provided 500 hours of supernumerary time to practice advanced clinical skills with supervision from an authorised prescriber and was positively evaluated.28 A nationwide NPTP, led by the University of Auckland with other partners, is now being funded by the Ministry of Health from 2021 increasing the number of training places and focusing on priority areas including PHC, and the Māori, and Pacific NP workforce. Delivering a nationally consistent training programme is essential for the long-term establishment of this workforce.

At the time of writing, there is no national guidance or agreement for NP salary, with each NP required to negotiate their own salary and terms and conditions. Those employed by DHBs may be under the DHB multi-employer collective agreement (MECA) at a senior nurse level. For ongoing registration with the NCNZ,16 NPs are required to undertake a minimum of 40 hours per year of professional development and ongoing peer review of their prescribing practice by an authorised prescriber to maintain registration. Of our respondents, 60% had $2,000 or less available annually for professional development. Establishing guidance and at least minimum requirements for employment, salary, and professional development is going to be a necessary step to protect this emerging workforce.

Limitations

Respondents self-selected with a reasonable response rate of 70%; however, the actual sample size was estimated as there was no definitive denominator available. Because of the multiple settings and currently relatively few NPs working across those many settings, in-depth analysis of variables has not been undertaken. Workforce data in New Zealand is variably collected and described, which does not allow for easy comparison.

Conclusion

The potential contribution of NPs in addressing health inequalities is well described in the literature1,7,32 and aligns with the WHO’s broader definitions of PHC.22,33 The New Zealand NP workforce is growing with an estimated 60% working in a range of settings broadly defined as PHC. This survey of 160 NPs has provided a stocktake of work, employment conditions, and barriers to optimising their scope of practice. With the GP workforce crisis looming large; the burgeoning of long-term conditions and mental health and addiction problems; a growing elderly population and frail elderly in aged residential care; and persisting health inequalities, it seems that now would be the time to facilitate the establishment of the NP workforce.

Summary

Abstract

Aim

The aim of the survey was to describe the demographics, distribution, clinical settings and employment arrangements of the New Zealand nurse practitioner workforce in primary healthcare settings; and organisational factors limiting their practice.

Method

An online survey was developed and sent to all NPs in mid-2019.

Results

The survey was completed by 160 nurse practitioners who worked in settings broadly defined as primary healthcare (response rate 71.4%). In addition to clinical work, nurse practitioners engaged in teaching and clinical supervision; leadership and management; policy development; locum work; and research; but 14% continued to do at least some work as a registered nurse. One hundred and fifty-one respondents were working clinically and 48% of these worked in more than one clinical setting. General practice-type settings (39%), of which over 40% were very low-cost access practices, and aged residential care (19%) were most commonly identified as the main clinical setting. Others included long-term conditions; mental health and addiction; sexual health/family planning; whānau ora; child/youth health; and various community nursing service roles. Seventy-three percent of nurse practitioners earned less than $120,000 per annum for full-time work; and 60% had $2,000 or less available for professional development. Three quarters had worked in the same setting for at least two years, and 60% intended to stay a further three years. Fourteen percent worked rurally. Employment models, models of care, and access to diagnostics, particularly radiology, were most limiting to their practice.

Conclusion

The nurse practitioner workforce offers stability and flexibility in working across multiple clinical settings in primary healthcare. They provide the potential solution to the general practitioner workforce shortage by improving access to primary healthcare and reducing health inequalities. As authorised prescribers able to enrol patients, receive capitation payments and claim general medical services, it is timely to facilitate the expansion of the nurse practitioner workforce in New Zealand.

Author Information

Sue Adams, Senior Lecturer, School of Nursing, University of Auckland, Auckland; Michal Boyd, Associate Professor, School of Nursing, University of Auckland, Auckland; Jenny Carryer, Professor, School of Nursing, Massey University, Palmerston North; Corinne Bareham, Postdoctoral Research Fellow, School of Psychology, Victoria University of Wellington, Wellington; Tim Tenbensel, Associate Professor, School of Population Health, University of Auckland, Auckland.

Acknowledgements

This survey was supported by funding from the School of Population Health, University of Auckland (PBRF funding) and School of Nursing, Massey University.

Correspondence

Sue Adams, Senior Lecturer, School of Nursing, University of Auckland.

Correspondence Email

s.adams@auckland.ac.nz

Competing Interests

Dr Tenbensel, Dr Boyd and Dr Carryer report grants from Faculty of Health & Medical Sciences, University of Auckland, during the conduct of the study. Dr Carryer reports personal fees for Statistical Advice during the conduct of the study.

1. Carryer J, Adams S. Nurse practitioners as a solution to transformative and sustainable health services in primary health care: A qualitative exploratory study. Collegian. 2017; 24:525–531.

2. Laurant M, van der Biezen M, Wijers N, et al. Nurses as substitutes for doctors in primary care (Review). Cochrane Database Syst. Rev. 2018 (Issue 7. Art. No.: CD001271).

3. Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: A systematic review and meta-analysis. BMC Health Serv. 2014; 14(214):1–17.

4. Swan M, Ferguson S, Chang A, et al. Quality of primary care by advanced practice nurses: A systematic review. Int J Qual Health C. 2015; 27:396–404.

5. Auerbach DI, Chen PG, Friedberg MW, et al. Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Aff. 2013; 32:1933–1941.

6. Carter M, Moore P, Sublette N. A nursing solution to primary care delivery shortfall. Nurs Inq. 2017; 25(e12245):1–7.

7. Browne AJ, Tarlier DS. Examining the potential of nurse practitioners from a critical social justice perspective. Nurs Inq. 2008; 15:83–93.

8. Xue Y, Intrator O. Cultivating the role of nurse practitioners in providing primary care to vulnerable populations in an era of health-care reform. Policy Politics Nurs Pract. 2016; 17:24–31.

9. Wolff-Baker D, Ordona RB. The expanding role of nurse practitioners in home-based primary care: Opportunities and challenges. J Gerontol Nurs. 2019; 45(6):9–14.

10. Ploeg J, Kaasalainen S, McAiney C, et al. Resident and family perceptions of the nurse practitioner role in long term care settings: A qualitative descriptive study. BMC Nurs. 2013; 12(24):1–11.

11. Adams S, Carryer J. Establishing the nurse practitioner workforce in rural New Zealand: Barriers and facilitators. J Prim Health Care. 2019; 11:152–158.

12. Gagan MJ, Boyd M, Wysocki K, Williams DJ. The first decade of nurse practitioners in New Zealand: A survey of an evolving practice. J Am Assoc Nurse Pra. 2014; 26:612–619.

13. Nursing Council of New Zealand. The New Zealand Nursing Workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2018-2019. 2019. [Available from: http://www.nursingcouncil.org.nz/Public/Publications/Workforce_Statistics/NCNZ/publications-section/Workforce_statistics.aspx?hkey=3f3f39c4-c909-4d1d-b87f-e6270b531145 accessed 20 April 2020].

14. [http://www.health.govt.nz/new-zealand-health-system/my-dhb accessed 20 April 2020].

15. Health Practitioners Competence Assurance Act. New Zealand Government. [Available from: http://www.legislation.govt.nz/act/public/2003/0048/latest/DLM203312.html?src=qs accessed 20 April 2020].

16. Nursing Council of New Zealand. Nurse practitioner. n.d. [Available from: http://www.nursingcouncil.org.nz/Public/Nursing/Scopes_of_practice/Nurse_practitioner/NCNZ/nursing-section/Nurse_practitioner.aspx?hkey=1493d86e-e4a5-45a5-8104-64607cf103c6 accessed 20 April 2020].

17. Medicines Amendment Act. New Zealand Government. 2013. Available from: http://www.legislation.govt.nz/act/public/2013/0141/latest/DLM4096106.html

18. Ministry of Health. Amendment of the Medicines (Standing Orders) Regulations. 2016. [Available from: http://www.health.govt.nz/our-work/nursing/developments-nursing/amendment-medicines-standing-orders-regulations accessed 20 April 2020].

19. Ministry of Health. Changes to health practitioner status. 2017. [Available from: http://www.health.govt.nz/about-ministry/legislation-and-regulation/changes-health-practitioner-status accessed 20 April 2020].

20. Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. New Zealand Government. 2016. [Available from: http://www.legislation.govt.nz/bill/government/2015/0036/23.0/versions.aspx accessed 20 April 2020].

21. King A. The Primary Health Care Strategy. Wellington: Ministry of Health; 2001.

22. World Health Organization. Declaration of Alma-Ata. Alma-Ata, USSR: International Conference on Primary Health Care, 6–12 Sept; 1978.

23. Hughes F, Carryer J. Nurse practitioners in New Zealand. Wellington: Ministry of Health; 2002.

24. Poghosyan L, Chaplin WF, Shaffer JA. Validation of Nurse Practitioner Primary Care Organizational Climate Questionnaire: A new tool to study nurse practitioner practice settings. J Nurs Meas. 2017; 25:142–155.

25. Scanlon A, Murphy M, Tori K, Poghosyan L. A National Study of Australian Nurse Practitioners’ Organizational Practice Environment. J Nurse Pract. 2018 ;14:414–418.e41

26. Health and Disability System Review. Health and Disability System Review - Interim Report. Hauora Manaaki ki Aotearoa Whānui – Pūrongo mō Tēnei Wā. Wellington: HDSR 2019.

27. Health and Disability System Review. Health and Disability System Review: Final Report - Pūrongo Whakamutunga. Wellington: HDSR 2020. [Available from http://systemreview.health.govt.nz/assets/Uploads/hdsr/health-disability-system-review-final-report.pdf accessed 18 June 2020].

28. Malatest International. Evaluation report: Evaluation of a nurse practitioner education programme. 2018. [Available from: http://www.health.govt.nz/system/files/documents/publications/evaluation-nurse-practitioner-education-programme-feb18.pdf accessed 20 April 2020].

29. Royal New Zealand College of General Practitioners. 2018 general practice workforce survey: Part 1. 2019. [Available from: http://www.rnzcgp.org.nz/RNZCGP/Publications/The_GP_workforce/RNZCGP/Publications/GP_workforce.aspx?hkey=a7341975-3f92-4d84-98ec-8c72f7c8e151 accessed 20 April 2020].

30. Gauld R, Atmore C, Baxter J, Crampton P, Stokes T. The ‘elephants in the room’ for New Zealand’s health system in its 80th anniversary year: General practice charges and ownership models. N Z Med J. 2019; 132(1489):8–14.

31. Goodyear-Smith F, Ashton T. New Zealand health system: Universalism struggles with persisting inequities. Lancet. 2019; 394(10196):432–442.

32. Poghosyan L, Carthon JMB. The untapped potential of the nurse practitioner workforce in reducing health disparities. Policy Politics Nurs Pract. 2017; 18:84–94.

33. World Health Organization. Declaration of Astana: Global Conference on Primary Health Care. In: Astana Kazakhstan, 25-26 Oct: World Health Organization; 2018. [Available from: http://www.who.int/primary-health/conference-phc accessed 20 April 2020].

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As with other countries, New Zealand is facing an ageing population, increasing prevalence of chronic conditions, and persisting health inequalities. Expanding the nurse practitioner (NP) workforce offers a solution to the general practitioner (GP) workforce crisis using a model of care that may be transformational in meeting local population health needs.1 Systematic reviews and meta-analyses of randomised controlled trials have confirmed that NPs provide care in a similar way to GPs, achieving at least equivalent clinical outcomes.2–4 Further, when compared to GP care, these reviews demonstrate that patient adherence and satisfaction is higher with NP care and some studies show reduced patient mortality.2,3 Internationally, NPs have tended to establish services for communities that are underserved, Indigenous, marginalised or rural.5,6 The opportunity that NPs offer the New Zealand health sector is how their work combines a biomedical and pharmaceutical approach with an advanced nursing practice approach that draws on principles of social justice and values relationship-oriented care.7–10

However, the development of the NP workforce in New Zealand has been described as ad hoc and lacking any consistent nation-wide approach.11,12 Since the inception of the role in 2001, the growth in the numbers of NPs, while initially slow, has accelerated more rapidly over the past five years, reaching a total of 455 NPs registered with the Nursing Council of New Zealand (NCNZ) at 31 March 2020 (Figure 1). There is considerable variation in the employment of NPs between the regions of New Zealand, ranging from 4.16 NPs/100,000 population in the Taranaki region to 16.44/100,000 population in the Manawatu-Whanganui region.13,14 From 2019, NCNZ workforce data13 showed employment settings for the largest NP workforces were primary healthcare (PHC)/community (42%) and acute settings within district health boards (DHBs) (32%), though 39% worked across multiple settings. Little is known about NPs professional activities, clinically and otherwise; their employment status; or the organisational factors enabling them to work to their scope of practice. The purpose of this survey was to provide further information on the NP workforce in settings broadly defined as PHC, including professional activities, clinical settings, employment status, and organisational limitations, to inform health sector policy and planning.

Figure 1: The number of NPs on the NCNZ Register showing annual increase since 2001.

Background

New Zealand has a robust educational, regulatory, and legislative framework for establishing the NP workforce that compares favourably to the US, Canada and Australia. Nurse practitioners are experienced, advanced nurses regulated by the NCNZ under the Health Practitioners Competence Assurance Act 2003.15 The NP scope of practice16 includes that NPs provide diagnosis and management for health consumers with common and complex health conditions; work autonomously and in collaborative teams; provide a wide range of assessment and treatment interventions; order and interpret diagnostic and laboratory tests; prescribe medicines; and admit and discharge from hospital and other health services.

To register as an NP, registered nurses (RNs) are required to have worked clinically as a RN in their area of practice for four years, complete a clinical Master’s in Nursing (or equivalent), that includes a clinical practicum, over an academic year and supervised by an authorised prescriber, to demonstrate advanced nursing competencies within the NP scope of practice. Following completion of their master’s, RNs are required to submit a portfolio to NCNZ which is assessed against the NP competencies.16 To maintain registration, NPs submit a three-yearly review to NCNZ demonstrating ongoing peer review, professional development, and clinical practice.

Changes to legislation over the past decade have seen NPs move from designated to authorised prescribers, with the same prescriptive authority as doctors under the Medicines Amendment Act 2013;17 are able to issue standing orders;18 and undertake work previously restricted to medical practitioners through the amendment of eight Acts in 2016.19,20 The Primary Health Organisation (PHO) Service Agreement between the district health board (DHB) and PHO allows NPs to enrol patients, receive capitation payments and claim General Medical Services in the same way as GPs.

Defining primary healthcare

For our research we used the definition adopted by the Primary Health Care Strategy21 and based upon the Alma-Ata Declaration of Health22 to include primary prevention and screening; health promotion; generalist first-level services from a range of health providers; and public health activities to improve the health of communities. The PHC Strategy sought to strengthen the PHC workforce with a central vision of reducing health inequalities. Nurse practitioners were proposed as a workforce able to deliver on the intent of the Strategy.23 We therefore included NPs who worked within general practice settings (often referred to as primary care) and NPs who worked in a range of other community settings, for example aged care; family planning and sexual health services; mental health and addiction services; child, youth and family; and DHB community nursing services.

Aim

The aim of this paper is to describe the demographics, distribution, clinical settings, and employment arrangements of the New Zealand nurse practitioner workforce in PHC settings; and organisational factors limiting their practice.

Methods

A survey method was chosen to efficiently reach NPs working in PHC settings across New Zealand. The survey, using Qualtrics©, was designed by the research team to provide workforce information drawing on knowledge gaps identified through previous research11 and international NP workforce surveys.24,25 Consultation included NCNZ; Nurse Practitioners New Zealand (NPNZ) (a subsidiary of the College of Nurses Aotearoa (New Zealand)); New Zealand Nurses Organisation (NZNO); and the National Council of Māori Nurses (NCMN). The survey was piloted on three NPs and revised accordingly, taking 20–30 minutes to respond.

The survey was emailed out, with the participant information sheet, to all NP members of their professional organisations, NPNZ (n=234) and the NZNO (n=150) in June 2019 (noting that some NPs have dual membership). Two reminders were sent. Nurse practitioners were asked to self-select if they identified their work as being PHC, general practice, community (including mental health and addiction, family planning/sexual health, district or public health nursing) or aged residential care.

Ethics approval for the study was granted by the University of Auckland Human Participants Ethics Committee (ref: 022814, 13/5/2019).

Results

The survey was completed by 160 respondents, representing 71.4% of NPs of the estimated 224 NPs registered and working in PHC settings at the time of survey.13 One hundred and fifty-one respondents stated they were working clinically, three were not and five did not record this information. Responses to individual questions varied, and the number of respondents (n) is given for each result presented. The results are presented under four main areas: demographics and location; professional activities and settings of clinical work; employment arrangements, salary and professional development; and organisational issues.

Demographics and location

We compared our sample of NPs working in PHC with the NCNZ 2019 workforce data13 of all registered NPs (n=365) working across all clinical settings; of which PHC is a subset. Overall, our sample aligned closely with the demographics of the total registered NP workforce in relation to gender, age and ethnicity (Table 1).

Table 1: Gender, age and ethnicity of NPs from our survey and all registered NPs.*13

The respondents were geographically spread across all regions of New Zealand. As a measure of rural-urban classification, 69.3% worked within 30 minutes of a major hospital; and for 14.2%, a major hospital was more than 60 minutes away.

Professional activities and settings of clinical work

Figure 2 shows the range of work that NPs were engaged with in addition to their clinical practice. Respondents were asked to identify their work as regular, occasional or never in these areas.

The responses (Figure 2) reflect the contribution of NPs to leadership and management; policy development; locum work; and research. Nearly half of all NPs provided clinical supervision for NP trainees and just under one third were involved with teaching at a tertiary education institute. Perhaps notably, 21 (13.9%) of the respondents were also working regularly or occasionally as a RN.

Figure 2: Respondents work across various professional practice domains showing frequencies for each type of work.

Just under half (73, 48.3%, n=151) of respondents working in clinical settings worked at least full-time hours (37.5–40 hours/week); 52 (34.4%) worked between 30–36 hours; and 24 (15.9%) worked 22.5–29 hours. Only three worked less than half time.

Respondents were asked to identify the clinical settings in which they worked (Table 2). Only 79 (52.3%) recorded that they worked in just one clinical setting. When asked to identify their “main” clinical setting, 34 (22.5%) responded to more than one setting, giving a total of 175 main clinical settings.

Table 2: Main clinical settings across which the 151 respondents worked.

*Of 151 NPs, 34 identified they worked in more than one “main” clinical setting. This resulted in a total of 175 main clinical settings being recorded by 151 NPs (the total adding to more than 100%).

General practice-type settings

General practice-type settings included general practice, health providers, DHB or PHO health centres or clinics, and accident & medical providers. While 68 NPs identified their main clinical setting as being in a general practice-type setting, several worked in two or more general practice employment settings, giving a total of 76 settings. These included general practitioner-owned practice (31, 40.8%); corporate-owned general practice (7, 9.2%); Māori or iwi provider (8, 10.5%); trust-owned general practice (4, 5.3%); DHB general practice clinic (7, 9.2%); PHO employed (4, 5.3%). Two worked in NP/RN owned practices, and 13 (17.1%) in other settings, such as accident & medical or Pacific health provider. Nurse practitioners in general practice-type settings were asked if a specific model of care was being used (n=63). Models included integrated family health centre (30, 47.6%); health care home (17, 27%); and whānau ora (10, 15.9%). Of 88 NPs who worked at least some hours in general practice-type settings, health centres and clinics, 38 (43.2%) were very low-cost access (VLCA) practices.

Aged residential care settings

A total of 41 NPs (27%) identified at least some of their work to include aged residential care. Nineteen NPs (13%) worked in both general practice-type settings and in aged care. Of 29 NPs (19.2%, n=151) who described aged care as their main place of work, seven were DHB employed; five were employed through general practice; two employed by PHOs and five through hospice; and four identified their main employment was through private contract. A further 15 NPs indicated they also worked under private contracts with aged residential care providers to deliver primary care services for at least part of their total clinical work.

Other clinical areas of practice

Nurse practitioners recorded working in other settings in addition to their main practice site across a wide range of other clinical settings with employing organisations including general practice-type settings, DHBs, PHOs, Māori health provider organisations and private contracts. While many of these numbers are currently small, they show the breadth of the NP workforce across the PHC sector.

Working with patients

Fifty NPs (38%, n=130) identified that they had their own caseload of patients enrolled with them; while a further 50 (38%) had their own caseload, but their patients were also enrolled with the GP or consultant of the service. The respondents were asked to estimate the average time they spent directly with patients and whānau. Figure 3 shows the variations between clinical settings.

Figure 3: The average time estimated that NPs spent with a patient by clinical setting (n=146).

Those working in aged residential care, sexual health/family planning, and mental health and addiction services, tended to have longer consulting times; while those in general practice-type settings and child/youth health had less time.

Employment arrangements, salary, and professional development

Most NPs (110, 75%, n=146) had been working in their main clinical setting for more than two years; 39 (27%) for more than 10 years; and 19 (13%) for up to one year. Of 137 NPs, 83 (60.6%) expected to stay in their clinical position for at least the next three years demonstrating a reasonably stable workforce.

Respondents were asked about their employment contracts, and of 145 NPs who responded to this question, 121 (83.4%) were on permanent employment contracts (some with multiple employers) and 10 were on fixed-term contracts. Seven were self-employed and four were a business owner or practice partner. Of those who were self-employed, their income was generated through payment for the services they delivered to a patient group. The modal range for annual salary (based on one full-time equivalent) of 136 responders was between $100,000 and $109,999; 52% received a salary of $110,000 or more per annum; and 19% less than $100,000 (Figure 4).

Figure 4: Percentage of NP’s with an annual salary falling into each salary band.

Professional development

Ninety-three respondents (67.4%, n=138) stated their professional development needs were mostly or always met, with 22 (15.9%) stating occasionally or never. When asked about the funding received for professional development (Figure 5), many had no funding or less than $1,000 per annum with just under one fifth receiving $4,000 or more.

Figure 5: Annual funding available for professional development for NPs (n=114).

Organisational issues

Survey respondents were asked to identify what limited their ability to work to their full scope of practice as a NP on a four-point Likert scale (Figure 6).

Figure 6: Factors that limit NPs’ full scope of practice. Factors are ranked from the most to the least limiting (‘often’ and ‘very limiting’).

Nurse practitioners identified the factors least restricting of their work to be prescribing practice and their access to prescribing and medical advice. Those factors considered often or very limiting included the employment model and model of care used by the organisation; access to diagnostic tests; and organisational policies or processes.

Respondents were asked about their access to secondary specialists and diagnostic tests. A small number of NPs identified that they had at least some restrictions to referring to a range of medical specialities including general medicine (five respondents), general surgery (nine respondents), ear nose throat (eight respondents), ophthalmology (nine respondents), paediatrics (seven respondents), vascular or cardiac surgery (13 respondents). However, 47 NPs (38.8%, n=144) had difficulty or could not refer to radiology; 28 (19%) were unable to request an ultrasound; and 19 (13%) of NPs made additional comments that they were not able to request a pregnancy ultrasound, including for women requesting a termination of pregnancy. Other tests that NPs were unable to order included CT scans for ACC injuries. Further, 10 NPs commented that they still needed to request diagnostic laboratory testing under the name of the GP, meaning that the results would come back to the general practitioner.

Discussion

The Health and Disability System Review (HDSR) was tasked with ensuring the health sector is better balanced towards wellness, access, equity and sustainability. The Interim Report noted the widespread failure of the implementation of the 2001 Primary Health Care Strategy stating that:

“Continuing with the current model of care, based largely on a Western medical model, … will not only be ineffective in achieving the equitable outcomes we desire, it will not be sustainable” (p.2).26

Developing the health workforce and models of care to improve primary and community (Tier 1) services, using a networking approach to engage whānau and local communities, was identified as central in the HDSR final report.27 Expanding and optimising the NP workforce provides one potential solution to improving access to PHC services and meeting the needs of diverse communities.1,7

The number of NPs working in the health sector has risen steadily and will reach 500 by the end of 2020. Approximately 60% of all NPs work in clinical settings that can broadly be defined as PHC, including general practice-type settings, aged residential care, whānau ora, mental health, sexual health and family planning, and community nursing services. Further, many contribute to education, policy, research, and leadership. Nearly half of the NPs in our survey (48% compared with 39% of all registered NPs13) worked in multiple clinical settings with various employers or contracts; and many participated in a range of professional activities. While working across multiple clinical settings may be appropriate for local community health needs and indicate demand for the high level of expertise of the NP workforce, this high number of employment contracts may also speak to difficulty some NPs may have in gaining full-time employment with a particular health provider. Twenty-one NPs (14%) in this study continued to work regularly or occasionally as a registered nurse under a different scope of practice, and this confirms other findings that at least some NPs struggle to establish a full-time role as a NP.11,28

Perhaps surprisingly, only 38.9% of the 175 identified main clinical settings included general practice-type settings, despite the growing GP workforce shortage.29 Many worked in very low-cost access, indicating high deprivation communities. There have been recent challenges in New Zealand to the business ownership model of general practice, requiring user co-payments, as being fit for purpose, with cost to patients an unacceptable barrier.30,31 The GP workforce survey29 identified that 71% of GPs work in practices owned by one or more GPs, and of those who worked full-time, 42% earned more than $200,000. For GPs working in corporate-owned practices, 50% earned more than $200,000 per annum for full-time work. In our survey, 73% of NPs earned less than $120,000 (annual, full-time). However, the evidence from systematic reviews concludes that NPs deliver at least similar care compared to GPs (such as prescribing practice, diagnostic investigations, hospital referrals and hospital admissions) and achieve similar or improved clinical and health status outcomes.2–4 Further, there is some evidence that nurse-led primary care may lead to slightly fewer deaths; that patient satisfaction scores are higher as may also be quality of life scores.2 Given the shortage of GPs it would seem prudent to support the growth of the NP workforce.

While the majority of NPs in our survey reported that they were able to work to their full scope of practice, barriers, including organisational barriers continue to exist.9,11,24,25 The employment model (13.6%); model of care (11.8%); and organisational policies (8%) were limiting or very limiting to NPs’ work. While difficulties referring to medical specialists remained a problem for a just a few NPs, 47 NPs (38.8%, n=144) expressed they had difficulty or could not refer to radiology, including simple x-ray; and 10 NPs had to order diagnostic tests under the GP’s name. While some are legislative restrictions, such as ordering ultrasound in pregnancy, others are unnecessary limitations placed on scope of practice locally or regionally and do not reflect policy, legislation or regulation.

Our survey demonstrated the stability of the NP workforce, with three quarters of NPs having worked in the same setting for at least two years and 60% intending to stay for at least a further three years. New Zealand relies heavily on a locum GP workforce, particularly in rural areas where 39% of practices have a GP vacancy.29 Further, 36% of rural GPs intend to retire within the next one to five years.29 Our survey showed that 14.2% of NPs worked rurally, a similar proportion to 16.7% of GPs who self-selected they worked in rural practices.29 It would make sense to focus now on developing a permanent NP workforce in underserved and rural areas to support the diminishing GP workforce and improve access and continuity of care.

To achieve the mainstream establishment of NPs, there needs to be greater investment in the training of NPs; and particularly for Māori, and Pacific who are currently underrepresented and yet central to the endeavour of reducing health inequalities. The educational cost of training a NP is likely substantially lower than for a GP.6 The pilot NP Training Programme (NPTP) has annually trained 20 NPs since 2016 through their final clinical practicum year (just under one third of all NPs). This Programme provided 500 hours of supernumerary time to practice advanced clinical skills with supervision from an authorised prescriber and was positively evaluated.28 A nationwide NPTP, led by the University of Auckland with other partners, is now being funded by the Ministry of Health from 2021 increasing the number of training places and focusing on priority areas including PHC, and the Māori, and Pacific NP workforce. Delivering a nationally consistent training programme is essential for the long-term establishment of this workforce.

At the time of writing, there is no national guidance or agreement for NP salary, with each NP required to negotiate their own salary and terms and conditions. Those employed by DHBs may be under the DHB multi-employer collective agreement (MECA) at a senior nurse level. For ongoing registration with the NCNZ,16 NPs are required to undertake a minimum of 40 hours per year of professional development and ongoing peer review of their prescribing practice by an authorised prescriber to maintain registration. Of our respondents, 60% had $2,000 or less available annually for professional development. Establishing guidance and at least minimum requirements for employment, salary, and professional development is going to be a necessary step to protect this emerging workforce.

Limitations

Respondents self-selected with a reasonable response rate of 70%; however, the actual sample size was estimated as there was no definitive denominator available. Because of the multiple settings and currently relatively few NPs working across those many settings, in-depth analysis of variables has not been undertaken. Workforce data in New Zealand is variably collected and described, which does not allow for easy comparison.

Conclusion

The potential contribution of NPs in addressing health inequalities is well described in the literature1,7,32 and aligns with the WHO’s broader definitions of PHC.22,33 The New Zealand NP workforce is growing with an estimated 60% working in a range of settings broadly defined as PHC. This survey of 160 NPs has provided a stocktake of work, employment conditions, and barriers to optimising their scope of practice. With the GP workforce crisis looming large; the burgeoning of long-term conditions and mental health and addiction problems; a growing elderly population and frail elderly in aged residential care; and persisting health inequalities, it seems that now would be the time to facilitate the establishment of the NP workforce.

Summary

Abstract

Aim

The aim of the survey was to describe the demographics, distribution, clinical settings and employment arrangements of the New Zealand nurse practitioner workforce in primary healthcare settings; and organisational factors limiting their practice.

Method

An online survey was developed and sent to all NPs in mid-2019.

Results

The survey was completed by 160 nurse practitioners who worked in settings broadly defined as primary healthcare (response rate 71.4%). In addition to clinical work, nurse practitioners engaged in teaching and clinical supervision; leadership and management; policy development; locum work; and research; but 14% continued to do at least some work as a registered nurse. One hundred and fifty-one respondents were working clinically and 48% of these worked in more than one clinical setting. General practice-type settings (39%), of which over 40% were very low-cost access practices, and aged residential care (19%) were most commonly identified as the main clinical setting. Others included long-term conditions; mental health and addiction; sexual health/family planning; whānau ora; child/youth health; and various community nursing service roles. Seventy-three percent of nurse practitioners earned less than $120,000 per annum for full-time work; and 60% had $2,000 or less available for professional development. Three quarters had worked in the same setting for at least two years, and 60% intended to stay a further three years. Fourteen percent worked rurally. Employment models, models of care, and access to diagnostics, particularly radiology, were most limiting to their practice.

Conclusion

The nurse practitioner workforce offers stability and flexibility in working across multiple clinical settings in primary healthcare. They provide the potential solution to the general practitioner workforce shortage by improving access to primary healthcare and reducing health inequalities. As authorised prescribers able to enrol patients, receive capitation payments and claim general medical services, it is timely to facilitate the expansion of the nurse practitioner workforce in New Zealand.

Author Information

Sue Adams, Senior Lecturer, School of Nursing, University of Auckland, Auckland; Michal Boyd, Associate Professor, School of Nursing, University of Auckland, Auckland; Jenny Carryer, Professor, School of Nursing, Massey University, Palmerston North; Corinne Bareham, Postdoctoral Research Fellow, School of Psychology, Victoria University of Wellington, Wellington; Tim Tenbensel, Associate Professor, School of Population Health, University of Auckland, Auckland.

Acknowledgements

This survey was supported by funding from the School of Population Health, University of Auckland (PBRF funding) and School of Nursing, Massey University.

Correspondence

Sue Adams, Senior Lecturer, School of Nursing, University of Auckland.

Correspondence Email

s.adams@auckland.ac.nz

Competing Interests

Dr Tenbensel, Dr Boyd and Dr Carryer report grants from Faculty of Health & Medical Sciences, University of Auckland, during the conduct of the study. Dr Carryer reports personal fees for Statistical Advice during the conduct of the study.

1. Carryer J, Adams S. Nurse practitioners as a solution to transformative and sustainable health services in primary health care: A qualitative exploratory study. Collegian. 2017; 24:525–531.

2. Laurant M, van der Biezen M, Wijers N, et al. Nurses as substitutes for doctors in primary care (Review). Cochrane Database Syst. Rev. 2018 (Issue 7. Art. No.: CD001271).

3. Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: A systematic review and meta-analysis. BMC Health Serv. 2014; 14(214):1–17.

4. Swan M, Ferguson S, Chang A, et al. Quality of primary care by advanced practice nurses: A systematic review. Int J Qual Health C. 2015; 27:396–404.

5. Auerbach DI, Chen PG, Friedberg MW, et al. Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Aff. 2013; 32:1933–1941.

6. Carter M, Moore P, Sublette N. A nursing solution to primary care delivery shortfall. Nurs Inq. 2017; 25(e12245):1–7.

7. Browne AJ, Tarlier DS. Examining the potential of nurse practitioners from a critical social justice perspective. Nurs Inq. 2008; 15:83–93.

8. Xue Y, Intrator O. Cultivating the role of nurse practitioners in providing primary care to vulnerable populations in an era of health-care reform. Policy Politics Nurs Pract. 2016; 17:24–31.

9. Wolff-Baker D, Ordona RB. The expanding role of nurse practitioners in home-based primary care: Opportunities and challenges. J Gerontol Nurs. 2019; 45(6):9–14.

10. Ploeg J, Kaasalainen S, McAiney C, et al. Resident and family perceptions of the nurse practitioner role in long term care settings: A qualitative descriptive study. BMC Nurs. 2013; 12(24):1–11.

11. Adams S, Carryer J. Establishing the nurse practitioner workforce in rural New Zealand: Barriers and facilitators. J Prim Health Care. 2019; 11:152–158.

12. Gagan MJ, Boyd M, Wysocki K, Williams DJ. The first decade of nurse practitioners in New Zealand: A survey of an evolving practice. J Am Assoc Nurse Pra. 2014; 26:612–619.

13. Nursing Council of New Zealand. The New Zealand Nursing Workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2018-2019. 2019. [Available from: http://www.nursingcouncil.org.nz/Public/Publications/Workforce_Statistics/NCNZ/publications-section/Workforce_statistics.aspx?hkey=3f3f39c4-c909-4d1d-b87f-e6270b531145 accessed 20 April 2020].

14. [http://www.health.govt.nz/new-zealand-health-system/my-dhb accessed 20 April 2020].

15. Health Practitioners Competence Assurance Act. New Zealand Government. [Available from: http://www.legislation.govt.nz/act/public/2003/0048/latest/DLM203312.html?src=qs accessed 20 April 2020].

16. Nursing Council of New Zealand. Nurse practitioner. n.d. [Available from: http://www.nursingcouncil.org.nz/Public/Nursing/Scopes_of_practice/Nurse_practitioner/NCNZ/nursing-section/Nurse_practitioner.aspx?hkey=1493d86e-e4a5-45a5-8104-64607cf103c6 accessed 20 April 2020].

17. Medicines Amendment Act. New Zealand Government. 2013. Available from: http://www.legislation.govt.nz/act/public/2013/0141/latest/DLM4096106.html

18. Ministry of Health. Amendment of the Medicines (Standing Orders) Regulations. 2016. [Available from: http://www.health.govt.nz/our-work/nursing/developments-nursing/amendment-medicines-standing-orders-regulations accessed 20 April 2020].

19. Ministry of Health. Changes to health practitioner status. 2017. [Available from: http://www.health.govt.nz/about-ministry/legislation-and-regulation/changes-health-practitioner-status accessed 20 April 2020].

20. Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. New Zealand Government. 2016. [Available from: http://www.legislation.govt.nz/bill/government/2015/0036/23.0/versions.aspx accessed 20 April 2020].

21. King A. The Primary Health Care Strategy. Wellington: Ministry of Health; 2001.

22. World Health Organization. Declaration of Alma-Ata. Alma-Ata, USSR: International Conference on Primary Health Care, 6–12 Sept; 1978.

23. Hughes F, Carryer J. Nurse practitioners in New Zealand. Wellington: Ministry of Health; 2002.

24. Poghosyan L, Chaplin WF, Shaffer JA. Validation of Nurse Practitioner Primary Care Organizational Climate Questionnaire: A new tool to study nurse practitioner practice settings. J Nurs Meas. 2017; 25:142–155.

25. Scanlon A, Murphy M, Tori K, Poghosyan L. A National Study of Australian Nurse Practitioners’ Organizational Practice Environment. J Nurse Pract. 2018 ;14:414–418.e41

26. Health and Disability System Review. Health and Disability System Review - Interim Report. Hauora Manaaki ki Aotearoa Whānui – Pūrongo mō Tēnei Wā. Wellington: HDSR 2019.

27. Health and Disability System Review. Health and Disability System Review: Final Report - Pūrongo Whakamutunga. Wellington: HDSR 2020. [Available from http://systemreview.health.govt.nz/assets/Uploads/hdsr/health-disability-system-review-final-report.pdf accessed 18 June 2020].

28. Malatest International. Evaluation report: Evaluation of a nurse practitioner education programme. 2018. [Available from: http://www.health.govt.nz/system/files/documents/publications/evaluation-nurse-practitioner-education-programme-feb18.pdf accessed 20 April 2020].

29. Royal New Zealand College of General Practitioners. 2018 general practice workforce survey: Part 1. 2019. [Available from: http://www.rnzcgp.org.nz/RNZCGP/Publications/The_GP_workforce/RNZCGP/Publications/GP_workforce.aspx?hkey=a7341975-3f92-4d84-98ec-8c72f7c8e151 accessed 20 April 2020].

30. Gauld R, Atmore C, Baxter J, Crampton P, Stokes T. The ‘elephants in the room’ for New Zealand’s health system in its 80th anniversary year: General practice charges and ownership models. N Z Med J. 2019; 132(1489):8–14.

31. Goodyear-Smith F, Ashton T. New Zealand health system: Universalism struggles with persisting inequities. Lancet. 2019; 394(10196):432–442.

32. Poghosyan L, Carthon JMB. The untapped potential of the nurse practitioner workforce in reducing health disparities. Policy Politics Nurs Pract. 2017; 18:84–94.

33. World Health Organization. Declaration of Astana: Global Conference on Primary Health Care. In: Astana Kazakhstan, 25-26 Oct: World Health Organization; 2018. [Available from: http://www.who.int/primary-health/conference-phc accessed 20 April 2020].

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