Bringing the family nurse practitioner role from Wisconsin to Martinborough: there are enormous differences between the United States and New Zealand health systems, and in how nurse practitioners are educated.
|Article Type:||Personal account|
Nurse practitioners (Personal narratives)
Nursing education (Methods)
|Publication:||Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 New Zealand Nurses' Organisation ISSN: 1173-2032|
|Issue:||Date: June, 2009 Source Volume: 15 Source Issue: 5|
|Topic:||Event Code: 200 Management dynamics|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
Making the leap from working as a family nurse practitioner (FNP)
in Oshkosh, I Wisconsin, in the United States (US), to initiating a
similar role in Martinborough New Zealand required a great deal of
courage and imagination. But in 2007 I had decided it was time for a
change, and when the opportunity presented itself, I realized my desire
to nurse in another country and experience life overseas was deep.
Before coming to New Zealand I had worked for 13 years in a large multi-specialty clinic in Oshkosh, a city of 60,000 located on Lake Winnebago in the upper Midwest, three hours north of Chicago. I worked for a corporation that had numerous clinics and ten hospitals in south east Wisconsin. Our clinic had more than 140 physicians, including a wide variety of specialists, and more than 20 advanced practice nurses. In my department, I worked with ten family practice physicians and three other FNPs.
The FNPs, nurse anaesthetists, nurse midwives and physician assistants were collectively known as mid-Level providers and, along with the physicians, we were ale considered to be primary care clinicians; all equal members of the primary care team. We were not considered part of the nursing structure per se. The nurses were integral to the delivery of care but in a quite different way from how they are in New Zealand.
Nurses and certified nursing assistants admitted my patients, took vital signs and determined the patient's concern s/he wanted me to address. They also assisted me by doing things such as tympanograms, electrocardiograms, returning patient phone calls, making referrals and managing my schedule. I would generally see 18-20 patients a day, four days a week, with my rote including prescribing, ordering all tests, interpreting and acting on test results and developing my patients' care plans. I would see whatever complaint a patient had, from a simple cold to acute abdominal pain and chest pain. I would also see complex patients with multiple chronic diseases. If I felt out of my depth, I simply had to discuss the case with one of the physicians or NPs. I was able to order my own x-rays, including computed axial tomography (CT scans) and magnetic resonance imaging (MRIs), with the complete support of our radiologists.
My job did not include policy development or research; the only focus was clinical practice. As a team we practised best practice and evidence-based care, but most of the indicators and policies pertaining to patient care were determined by senior committees at the corporate Level So compared to nurses in New Zealand, we were rarely involved with any research or Local or regional policy development; any policy development we might do pertained solely to our own organisation. NPs who teach at the university level have to do research as part of their employment contract, but it is not a part of their licensing requirements with the State of Wisconsin. To renew the annual license, all an NP needs is eight hours' continuing education in pharmacology and to pay a fee of $US74.
In our clinic, our main focus was to give the best care possible and to keep our patients happy. Our corporate office sent out surveys to a percentage of patients who came to see me, asking them about their care from the moment they walked through the clinic door until they Left. These survey results became part of my annual evaluation. The organisation took their reputation within the community very seriously. We weren't the only health care organisation in town, so if patients were unhappy, they could always go elsewhere.
The US health system is very complex compared to New Zealand's system. Patients have a variety of health insurance plans that health professionals have to be very familiar with. For example, when prescribing medication, I needed to know what drugs the patient's particular insurance company would pay for, or if ordering an MRI, whether the patient's insurance company required a prior authorisation before I could schedule the test. And to make matters more complicated, most insurance companies change their policies annually!
Educating nurse practitioners
Since being in New Zealand I have come to understand the many differences between our two countries, not only between our health systems, but also in the education of advanced practice nurses. My bachelor of science in nursing was a four-year university degree, followed by another three years to obtain my masters in nursing science. My masters programme was specifically to become a FNP, which is the most common type of NP in the US. Other universities may also have programmes for paediatric or adult NPs. In my masters programme, three of the semesters included clinical experience with either a family practice doctor or an experienced FNP. These clinical sites were always peaces other than where you were employed. That concept is very different from here, so I wilt explain the philosophy behind it.
Most of the students in my graduate class had worked for up to ten years in a hospital and had decided they wanted a career change to become an NP. When they were ready to start their clinical placements, they needed to find someone in family practice to be their preceptor. This preceptor taught them how to gather patients' histories, then how to do examinations. The following semester the student would be in charge of getting the histories and doing the examinations, then putting it all together to give a probable diagnosis. In the East semester they would have to build on what they knew and determine the treatment, including tests, prescriptions and teaching.
We also had classes during each semester, one of those being a clinical management class where we discussed our cases, including discussion of the rationales behind our diagnoses, tests, prescriptions and teaching. The beauty of this type of programme is that you are able to "practise" under the supervision of someone who is very witting to take the time to teach you all the "ins" and "outs" of being a primary care clinician. Practising in a setting where I wasn't employed allowed me to "practise" my new rote, while at the same time being treated by the staff as if I already were an NP. This is very important for rote development.
The physician or NP the student did their clinical with, along with their instructor for that semester, were the ones who determined whether or not the student was competent to practise. The student was not allowed to move on to the next semester if deemed incompetent, therefore they would not graduate. The State Board of Nursing was in charge of issuing annual licenses and for revoking them when statutes or laws were broken. The American Nurses Credentialing Center administers the certifying national examination after we graduate and also determines the criteria for renewal, required every five years. To renew, you need to meet two of five categories or double one of them: continuing education (75 hours), five presentations, one publication of an article or research project, or have 120 hours of preceptorship. In addition, you need to have a current registered nurse license and have practised 1000 hours in your certification area. So, as you can see, preparing a portfolio to apply for registration as a primary NP in New Zealand was something entirety new to me.
Another difference in the US is that NPs are considered "rookies" when they graduate and start working in their new rote. In New Zealand, an NP is considered an expert and within the context of this system, they are, because they are expanding their rote, rather than going into a new one.
'How in the world did you end up here?'
The first question most people in Martinborough asked me when I arrived 15 months ago was "How in the world did you end up here?" When I decided to make a change in my tile, I initially was going to move to a town one and a half hours from where I lived. However, when I was on line looking for a job in that town I stumbled upon an advertisement for a job in New Zealand. I had been to New Zealand two years previously to visit my son Matt, who was doing a semester abroad at the University of Canterbury in Christchurch. We travelled around the South Island together and I absolutely loved the country and the people, hoping to come back again for a longer visit. The ad I found was seeking a US family FNP to model the rote for GPs and practice nurses, and to mentor a nurse to become an NP. I thought, "I could do that!" so applied. My two sons were grown and seemed years away from marriage and children. If I was going to go overseas, now was the time.
The job I applied for had been developed by the Wairarapa Primary Health Organisation and District Health Board (DHB) with funding from the Rural Innovations Fund. The proposal was to bring an NP to the south Wairarapa to improve access to primary care in an area short of GPs.
I am currently half way through my three-year contract. Wairarapa DHB director of nursing Helen Pocknall has played a big part in helping me through my transition into the New Zealand health system.
I feet very lucky to have ended up in Martinborough. Not only is it a lovely rural area, but the residents have been very welcoming and have made my adjustment here an easy one. I am also extremely lucky to be working with a wonderful group of people at the medical centre. GP Steve Philip had worked with NPs in Africa years ago, so he understood the concept and what I could offer. He has been very supportive in my goal to become a prescribing NP and has taught me a lot about the intricacies of the New Zealand health system. I also work with two very experienced practice nurses and a great office staff. They have all been a huge help in teaching me the cultural differences and we have had many laughs over my mispronunciation of New Zealand words.
Doing a two-day workshop on the Treaty of Waitangi through the DHB has also been very enlightening, as the understanding of cultural safety is quite different here. I appreciated the welcome I received onto the Hau Ariki marae in Martinborough and the fact the local Maori people have been so accepting of me and wilting to see me.
I see patients with a large variety of acute needs and also those with tong-term conditions. During harvest time, we also get to see large numbers of seasonal workers. Part of my role has been to develop a project to have all Maori women over 45 and Maori men over 35 complete their cardiovascular risk assessments. I succeeded in getting g5 percent of the women and about half the men to compete these assessments. I referred the rest of the men to the Maori health centre Whaiora Whanui, because of its programme targeted at hard-to-reach patients. Since then, another 25 percent of the men have had their assessments done.
I am in the process of submitting my portfolio with prescribing rights to the Nursing Council. This is proving a longer and more complicated process than I or anyone else expected, so I am looking forward to having more time, especially at the weekends, for relaxation and exploring, once this process is completed.
Over the' last 15 months I have teamed so much. Now that the community knows me welt and I understand the New Zealand health sector that much better, I expect the next 15 months to be even more satisfying and enjoyable than the first.
Nancy Williams, RN, FNP (US), is half way through her three-year contract working at an advanced level at the Matinborough Medical Centre.
|Gale Copyright:||Copyright 2009 Gale, Cengage Learning. All rights reserved.|