Growing public health nursing: Public Health Nursing Education Framework discussion document

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1 Growing public health nursing: discussion document July 2013

2 Funded by: The Ministry of Health Project managed and written by the Working Group, the Public Health Association of New Zealand and Head Strategic Limited Cover image from: Public health nursing: functions and activities, Department of Health, Wellington,

3 Contents Part 1: Context What is the purpose of this discussion document and who is it for? How can you provide feedback on this document? Who are public health nurses and what do they do? Why is a needed? What could be included in the? Workforce development challenges and opportunities for public health nursing What is the current public health nursing education pathway? Part 2: Isues and recommendations Step 1 Prior to starting a Bachelor of Nursing degree Step 2 Bachelor of Nursing Step 3 Nursing Entry to Practice Programme Step 4 First and subsequent PHN positions (after NETP) for registered nurses (with or without other nursing experience) Step 5 Advanced public health nursing roles Step 6 Nurse practitioner PHN Step 7 Nurse academic PHN Where to from here? Appendices Appendix 1: Te Uru Kahikatea objectives relevant to public health nursing Appendix 2: Individuals involved in this project Appendix 3: Public health nursing demographics Appendix 4: History of public health nursing by Elizabeth Farrell, Appendix 5: Short-, medium- and long-term visions for PHN workforce development Appendix 6: Generic Public Health Competencies Appendix 7: New Zealand Certificate in Public Health Appendix 8: Public Health Leadership Programme (PHLP) Discussion Document July

4 Part 1: Context 4

5 What is the purpose of this discussion document and who is it for? Public health nurses play an important role in supporting individuals, families, communities and populations to meet their own health and wellbeing needs. Future-proofing the public health nursing workforce by ensuring its competence in a changing society is essential to meet the population and personal health needs of New Zealand communities. At present, there is no national framework for public health nurses professional development. This discussion document is part of a nurse-led project to set a way forward. The purpose of this discussion document is to: summarise the current educational framework for public health nurses (PHNs) outline the key issues that PHNs experience on their educational journey ask for feedback on the proposed recommendations which will inform the development of the Public Health Nursing Education Framework. A framework could support the development of all registered nurses who work to change determinants of health such as infectious diseases or child protection. While it focuses on public health nurses, the framework also includes nurses who work in primary health care. Public health nursing is not about the role of a registered nurse, but about the essence of his/ her practice. Many primary health care nurses take a population health approach in their daily work, and play an important part in addressing the determinants of health. Who is this discussion document for? Public health nursing key stakeholders nurses, nurse leaders and managers are the main audience for this discussion document. However, we would also like feedback and comment from anyone interested in the development of public health nursing. This might include professional bodies, nursing and public health education providers, nursing school representatives, District Health Boards, public health doctors, community workers who work with public health nurses, and government agencies concerned with health service development and with population health. The Education Framework to come out of this discussion document will allow PHNs (and other registered nurses who undertake public health and population health work) to access education that develops both their public health and population health nursing knowledge and skills. The framework aims to be flexible and to have multiple entry and exit points. How did this discussion document come about? The need for this project was identified by a group of experienced public health nurses. It was strongly supported as a priority by a 2012 national meeting of representatives from public health disciplinary groups. The Ministry of Health has funded this project and provided advice and support. The project connects to Te Uru Kahikatea: The Public Health Workforce Development Plan , 1 which includes a number of goals and actions relevant to public health nursing (see Appendix 1). The major outputs for this project will be: 1. consultation on this discussion document with a range of stakeholders 2. a national Education Framework for public health nurses and other registered nurses doing public health and population health work 1. Te Uru Kahikatea: Public Health Workforce Development Strategy Ministry of Health, Wellington, Discussion Document July

6 Public health/population health Public health has been described as the science and art of promoting health, preventing disease and prolonging life through the organised efforts of society. Public health work focuses on improving the overall health of populations, such as children, through interventions such as immunisation, health screening checks, or safer housing. Population health focuses on the health outcomes or status of population such as groups, families and communities. A population health approach takes account of all the influences on health (the determinants of health) and how they can be tackled to reduce inequalities and improve the overall health of the population. 3. an implementation plan to identify next steps, roles and responsibilities and timelines to bring the Education Framework to fruition. How the project is being managed and supported This project is led by the Public Health Nursing Education Framework Working Group, a group of experienced public health nurses, nurse leaders and nurse educators. The Public Health Association is providing project and administrative support to the working group. The working group is supported by an advisory group of people with expertise in public health nursing, Māori health, Pacific health, public health workforce development, project management, and professional nursing practice. The advisory group includes members from Health Workforce New Zealand, Nursing Council of New Zealand, District Health Boards Directors of Nursing, the New Zealand Nurses Organisation and the Public Health Association (see Appendix 2). The Ministry of Health s Chief Nurse Business Unit and the Public Service Association have also expressed support for this project. The working group would also like to acknowledge the very experienced and highly skilled public health nurses who have spent many years committed to making a significant difference in the lives of many in their communities. Whether or not they choose not to travel the journey along the Education Framework, they can play a vital role in supporting the next generation of PHNs to pursue continuing education. Appreciation is extended to this group in anticipation of the encouragement they offer to members of the nursing workforce following in their footsteps. 6

7 How can you provide feedback on this document? There are several ways you can provide feedback on this document and its recommendations. Hard copy You can provide comment on the hard copy, and mail it to us at: Public Health Association of New Zealand PO Box Wellington 6142 By You can comments to Leona Head at Online discussion forum We invite you to share in the online discussion about the issues at the user-friendly Loomio discussion space. You ll find links to the online discussion at Currently, there is no continuous or coherent professional and educational development pathway for public health nursing in New Zealand. Discussion Document July

8 Case study 1 While visiting her assigned school, Rachel was told by the school that Josef, a nine-year-old Tongan boy with whom Rachel had been working with for a number of months, had not been at school for the past three days. Rachel decided she would home visit on her way back to the office. On arriving at Josef s house she could see preschool children playing on the doorstep and a dog running around the yard. Rachel asked for the dog to be tied up and after this was done she spoke with Josef s mum, Anna. Josef had been off school unwell. When she was talking to Josef he told Rachel he had a wicked sore throat. Rachel immediately arranged to take a throat swab to screen for Group A Streptococcus the cause of rheumatic fever. Rachel also assessed the health status of other family members and provided education regarding sore throats and rheumatic fever. Anna told Rachel that her nephew had rheumatic fever and was on injections. Rachel also assessed and discussed the early childhood education needs of the preschoolers with Anna along with their immunisation status. Who are public health nurses and what do they do? Public health nurses (PHNs) are registered nurses who use their nursing expertise, alongside their wider knowledge of communities, to promote health and wellbeing. 2 They play an integral role in delivering public health services in New Zealand. PHNs work in many settings, such as schools, homes and community health services. They operate across many sectors for instance some public health nurses are based at Work and Income offices. PHNs work with complex population and personal health issues, such as those described in Case Study 1. PHNs have a range of competencies that are important to the health sector in Aotearoa New Zealand. As a relatively small workforce there are only public health nurses nationwide 3 their core work is often not visible to the public, except in the event of a national public health crisis such as H1N1 border screening and communicable disease outbreaks. Appendix 3 provides known demographic information about the public health nursing workforce from To gain insight into the unique contribution PHNs have made to improve the health of communities both locally and internationally, you can read about the historical development of public health nursing from the late nineteenth century to the present day in Appendix 4. Most PHNs are involved in co-ordination and case management between families/whānau and communities, and the health, social and education sectors. Their wide-ranging work may include: health assessments and treatment, for instance treating children with skin diseases 2. Working for a better future: Careers in Public Health, Ministry of Health, 2006 at page The New Zealand Nursing Workforce. Nursing Council of New Zealand

9 Case study 2 Margaret works in a community health centre providing a range of services to support health and wellbeing among community members. Because the health centre is located in school grounds, Margaret is able to work closely with the local school and their families as well as with other community members. Margaret provides the following types of services for community members and their families: general health checks, diabetes support, hearing checks, B4 school checks, quit smoking support, cervical screening smears, housing, income and welfare support, counselling, access to dietary advice, respiratory guidance, and/or referral to any other health or social service as required. A common scenario is a child identified by the school who is not managing their asthma. Margaret is able to visit the home, provide education and support for the family and child regarding asthma, and support the school through education and information for teachers about children with asthma. As part of the home visit, Margaret is able to assess any housing, social or financial needs with the family and arrange for appropriate support. disease prevention refugee health child protection communicable disease control, such as primary prevention of rheumatic fever working with teachers to promote health programmes in schools facilitating multidisciplinary strengthening families meetings developing one-stop-shop health services for young people playing a major part in implementing schoolbased immunisation programmes advocating for healthy home environments with families and communities. Within this work, PHNs have an important role establishing partnerships and communication strategies with Primary Health Organisations to improve health outcomes for communities. Discussion Document July

10 Why is a Public Health Nursing Education Framework needed? In response to changing needs and in some cases due to reduced funding and changes in government strategies public health nursing and public health nursing roles have changed significant over the last 20 years. Accessing opportunities and funding for professional development in public health nursing has become increasingly challenging. Currently, there is no continuous professional and educational development pathway for public health nursing in New Zealand. Individually, PHNs may choose to undertake qualifications after completing their undergraduate nursing degree, but those qualifications are not specific to public health nursing, and may not even be related to public/population health. There is some regional or organisational public health nursing education; however, national consistency is an issue, and what is available is not linked to any professional development pathway. High quality, consistent public health nursing services in New Zealand demand national public health nursing education. This will increase the opportunity for nurses to develop population health knowledge and skills, and could be available to other RNs who work in the community. The Education Framework is intended as a conceptual framework that organises the hierarchy of qualifications relevant to public health nursing in New Zealand. It will frame the education pathway from beginner to expert, with multiple entry and exit points. This pathway aims to help those involved in public health nursing to advance towards the top of their scope of practise, using advanced competencies and clinical skills. It may also allow PHNs to gain recognition as a highly skilled nursing workforce, and could help attract registered nurses into public health nursing. Over time the Education Framework could, for example: increase the number of highly qualified PHNs who can provide evidence-based public health nursing services to vulnerable communities lead to better population health outcomes, as PHNs increase their clinical expertise and better understand the effect social determinants of health have on inequalities, chronic health needs and unmet community health needs lead to health cost savings through PHNs initiating preventative measures and early interventions for vulnerable populations. This could avoid costly hospital admissions and long-term health problems: for example, the earlier detection and treatment of skin infections, oral health issues and hearing loss enable nurses to advocate for better access to services for Māori, Pacific, and other populations with particular needs improve collaboration with multidisciplinary teams and build coalitions with a range of services increase the number of PHNs who can successfully lead the management of complex health issues influenced by poor housing, inadequate social support and poverty. 10

11 What could be included in the Public Health Nursing Education Framework? The Education Framework could: 1. set a direction for the development of the public health nursing (see Appendix 5) 2. align professional development (PDRP), registration pathways and education pathways 3. set out a pathway for the stages of qualification, and enable career progression 4. create a platform for a public health competencies framework 5. provide a platform for positive change. Workforce development challenges and opportunities for public health nursing Current challenges Expectations on the primary care sector to reach vulnerable communities have not been fully realised, and may require a skill set that is not widely available. Other areas of the health sector have been given greater priority than public health. Structural changes in the health sector may have marginalised the relatively small public health nursing workforce in some areas. While many younger nurses are coming to the PHN workforce, the workforce is still an ageing one. There is very little information available about New Zealand s public health nursing workforce to guide workforce development planning. Due to financial constraints, employers are often unable to arrange release time for study and provide backfill arrangements. There is little or no financial recognition for gaining additional qualifications. There is a perception that new graduate nurses lack practical experience, which can inhibit organisations from employing new graduate nurses and PHNs. Health Workforce New Zealand (HWNZ) does not currently fund non-clinical graduate nursing courses, creating a barrier to nurses wanting to work towards the Nurse Practitioner level. Opportunities There is strong interest among public health nurses in taking a greater role in improving health gains in both personal and population health. Public health nursing is gaining visibility Discussion Document July

12 through the current focus on emergency preparedness and response. The Public Health Generic Competencies (see Appendix 6) provide a strong foundation for public health knowledge and skills. There is growing recognition of the need to fund non-clinical post-graduate nursing qualifications, and interest in expanding the criteria for HWNZ funding to include, for example, post-graduate Public Health Diploma and Masters degree programmes. Distance learning is making study more accessible. There are well-developed communication and consultation mechanisms such as the PHA conference, NZ College of Primary Health Care Nurses conference, the PHN leaders national tree and the regional managers meetings, the publichealthworkforce.org.nz website, and the nzno.org.nz website, etc. National strategies and policy documents, including Te Uru Kahikatea, NCNZ Scopes of Practice, NZNO Colleges and Sections Nursing Knowledge and Skills Framework (e.g. respiratory, diabetes, primary health nurses), and the DHBNZ Career Framework for the Health Workforce provide direction for public health nursing. International frameworks and models of public health nursing practice, such as the USA Minnesota Wheel and the UK Career and Development Framework for health visiting and school nurses are influencing practice. What is the current public health nursing education pathway? Table 1 (opposite) summarises the current career steps and education for PHNs. This is the starting point for the Education Framework. The sections that follow Table 1 review the relevant issues for each of those steps and make recommendations for change. Please provide your feedback on the issues and recommendations. Your comments will inform the final framework. 12

13 Table 1: Current career, education and registration pathways for public health nurses in New Zealand Aotearoa 4 NETP: Nursing Entry to Practice Programme provides graduate registered nurses with support and development during their first year of practice. PDRP: Professional Development Recognition Programme advances professional development in nursing and supports nurses to demonstrate competency to the NCNZ Step Career Progression Education Pathway National Health Careers Framework Registration PDRP Pathway 5 1 Various options Secondary education NA NA 2 Nursing related Bachelor of Nursing Support/Advanced support (i.e. supervised as a student) Registered Nurse 3 NETP NETP NETP Beginner 4 First and subsequent RN/PHN positions Orientation to PHN Short courses, Nursing Knowledge and Skills; e.g. vaccination, Cervical Smear taker certificates, etc. (prescribing courses) 6 Transition RN Competent Proficient RN Proficient NZ Certificate in Public Health (see Appendix 7). Level 5 but relevant to public health nursing 5 Advanced PHN roles Designated roles (e.g. nurse educator, nurse manager, nurse specialist) PG Certificate PG Diploma Master s degree (prescribing courses) 7 Advanced PHN roles Designated roles RN with prescribing (optional) Expert/expert with expanded practice 6 Nurse Practitioner Master s that meets NP requirements Expert Nurse Practitioner Nurse Practitioner 7 Nurse Academic PhD Nurse Academic/clinician 4 The Nursing Council of New Zealand s 2010 nursing workforce data report indicated there were only a very small number of enrolled nurses (ENs) in public health less than 23. ENs are not included in this pathway, but will be considered within the workforce required to support the RN PHN workforce. 5 Once initial registration is gained, a nurse maintains registration by meeting the Nursing Council of New Zealand s Annual Practising Certificate (APC) requirements. 6 NCNZ is currently consulting on community nurse prescribing once approved, this could be a useful model for PHNs. 7 NCNZ is currently consulting on specialist nurse prescribing. Discussion Document July

14 Part 2: Issues and recommendations This section presents the seven steps of the proposed pathway. It outlines the current situation and issues, and asks for your comment about the recommendations. Providing feedback We invite you to comment as much as you would like on the recommendations for each step. You can also provide general comments on the framework. Your feedback will inform the development of the Education Framework and its recommendations. As well as providing feedback by or hard copy, we also invite you to share in an online discussion about the issues. You ll find links to the online discussion at along with other ways to provide feedback. 14

15 Step 1 Prior to starting a Bachelor of Nursing degree Current situation Students have little information about public health nursing as a career. Issues High school students should be exposed at an early stage to information on careers in public health, nursing and public health nursing. This could increase their uptake of science-related subjects, and improve the pool of young people who could progress into nursing. People should understand what their options are before they start a programme of study. Not promoting career opportunities may mean that opportunities to grow the potential workforce pool for nursing and public health are lost, reducing graduate nursing numbers and causing future workforce shortages. Issues and recommendations Issue 1.1 Opportunities to grow the potential workforce pool may be lost if career opportunities are not promoted at an early age to high school students. Recommendation 1.1 PHN stakeholders actively support initiatives to encourage secondary students and secondchance learners to meet entry requirements for nursing. Agree / Disagree Comment (please circle) Discussion Document July

16 Step 2 Bachelor of Nursing Current situation Public health nurses complete a generic Bachelor of Nursing qualification from one of 16 nursing schools in New Zealand. All schools of nursing are monitored and audited against the Nursing Council New Zealand (NCNZ) nursing education standards, which outline broadly the requirements for curriculum content and clinical experience. Nursing students complete placements as part of their nursing training. Issues The education standards that guide nursing schools are not prescriptive. There is relatively little on population health, with only a reference to primary health care and community settings in the expectations for clinical experience. 8 The curriculum content standard is focused on matching theory with the national registered nurse competencies. The language used to describe the indicators of competence focuses on personal health and nursing care of the individual, with only occasional reference to nurses working with individuals and their whānau and wider communities. 9 However course information on four nursing schools websites clearly reflects that the concepts of population health, public health, and primary health care, the role of the nurse in community settings or the role of the nurse in population health are embedded in various courses within their Bachelor of Nursing programmes. 10 In addition, related theory from the disciplines of sociology and epidemiology are also evident. The Generic Public Health Competencies are the foundation knowledge and skills expected of all people working in public health. These competencies (shown in Appendix 6) could be used as a guide for the NCNZ education standards. Recognising the unique context of Aotearoa New Zealand, nursing education aims to prepare nurses to understand their Treaty of Waitangi responsibilities to address inequalities between Māori and their fellow New Zealanders. 11 Despite the best efforts of the NCNZ, this concept remains unfamiliar and relatively misunderstood. A barrier for students who wish to do a public health placement as part of their training is that many organisations have insufficient capacity to offer placements to students. Students may decide not to look for public health placements as there are relatively few job opportunities compared to other areas of nursing. 8. Nursing Council of New Zealand. (2010). Education programme standards for the registered nurse scope of practice. Wellington: Nursing Council of New Zealand. 9. Nursing Council of New Zealand. (2007). Competencies for registered nurses. Wellington: Nursing Council of New Zealand. 10. UNITEC. (2013). Bachelor of nursing: Programme summary. Retrieved from ED52FB43859F. Southern Institute of Technology. (2013). Bachelor of nursing: Course content. Retrieved from courses/invercargill/bachelor_of_nursing. Auckland University of Technology. (2013). Bachelor of health sciences: Nursing. Retrieved from 11. Nursing Council of New Zealand. (2011) Guidelines for cultural safety, the Treaty of Waitangi, and Māori health in nursing education and practice. Wellington: Nursing Council of New Zealand. 16

17 Issues and recommendations Issue 2.1 The education standards guiding nursing curriculum content and clinical experience do not specifically require the inclusion of concepts of population health and community settings. Recommendation 2.1 Negotiate to increase the required level of knowledge and skills in population health and community settings in the Education Standards, using the GPHCs as a guide and including a reducing inequalities focus. Agree / Disagree Comment (please circle) Issue 2.2 The indicators of competence in the national registered nurse competencies, appear to focus on personal health and nursing care of the individual. Recommendation 2.2 Negotiate a review of the registered nurse competencies using the GPHCs as a guide to include population health and community settings content. Agree / Disagree Comment (please circle) Issue 2.3 Variable population health and reducing inequalities content in schools of nursing curriculum content. Recommendation 2.3 Encourage or incentivise schools of nursing to review the levels of public health nursing knowledge and skills in the curriculum content in their nursing programmes, using the GPHCs as a guide and including a focus on reducing inequalities. Issue 2.4 Agree / Disagree Comment (please circle) There are few placements available for students who wish to work in population health and community settings. Recommendation 2.4 Facilitate partnerships between schools of nursing and public health nursing employers to offer and promote PHN student placements. Agree / Disagree Comment (please circle) Discussion Document July

18 Step 3 Nursing Entry to Practice Programme (NETP) Current situation Once graduated, most nurses enter the nursing workforce through the national, DHB- managed NETP programme. NETP provides graduate registered nurses with support and development during their first year of practice. The programme offers a range of placements, including placements in public health nursing. Issues The content of the NETP programme has variable amounts of population health knowledge and skills. Some PHNs believe that the NETP programme does not fully prepare graduates to work effectively in population health settings. Graduates who want PHN placements as part of the NETP programme have trouble accessing placements, with the result that many end up working in other nursing areas. Resource constraints also affect the investment in graduate nurses who wish to be on the PHN career pathway. PHNs often work in small teams, which have limited time and capacity to support newly qualified nurses who wish to be PHNs. The result is that new nurses who gain placements do not always have a positive experience of the NETP programme. It is beneficial to expose high school students to careers in public health, nursing and public health nursing. This could potentially increase their uptake of science-related subjects, and improve the pool of young people who could progress into nursing. 18

19 Issues and recommendations Issue 3.1 The content of the PHN NETP programmes delivered at DHB level have variable amounts of population health knowledge and skills. Recommendation 3.1 Work with DHBs to review NETP, and to increase the national consistency of public health knowledge and skill content, using the GPHCs as a guide. Agree / Disagree (please circle) Comment Are there other existing programmes that you believe might improve NETP? What suggestions do you have to help nurses have positive NETP programme experiences? Issue 3.2 Graduate nurses seeking PHN placements on the NETP programme have difficulty securing positions. Recommendation 3.2 Encourage or provide incentives for organisations to invest in newly qualified PHNs and to offer NETP programme placements. Agree / Disagree Comment (please circle) Discussion Document July

20 Step 4 First and subsequent public health nursing positions (after NETP) for registered nurses with or without other nursing experience Current situation While some registered nurses choose public health nursing from the beginning of their nursing career, many more work in a variety of other nursing settings before starting public health nursing practice. Often these registered nurses have gained life experience that deepens their nursing knowledge and skills, which can be invaluable to their public health nursing work. New PHNs, with or without previous nursing experience, complete in-house orientation programmes, professional development training to meet Annual Practising Certificate requirements, and other in-service short courses, or graduate/ post-graduate education. While these training opportunities have different degrees of relevance, few are specific to public health. Issues New PHNs Public health nurses are offered local or regional orientation programmes, which may vary in content, length and learning expectations. These programmes often focus on the particular local/ regional requirements of the organisation, role, and community, and may provide limited opportunity for participants to strengthen their population health and public health knowledge and skills. Registered nurses with other experience Nurses moving into PHN roles with previous nursing experience often do not receive any orientation to population health concepts and practice. Nor is it usual for them to receive tailored orientation suitable to their existing experience. They are also unlikely to receive any recognition of the valuable prior learning and expertise they bring to their PHN role. Nurses doing public health nurse work in primary health care settings Orientation programmes are usually specific to PHNs, so there are only ad hoc opportunities for registered nurses with a population health approach in primary health care settings to receive any orientation to public health. Ongoing education after NETP After orientation to public health nursing, apart from the PDRP programme, ongoing education is not coordinated. Training is often specific to areas of an individual s work, such as immunisation, child wellness, or housing, and may not even relate to public health. There is no formal education pathway upon which PHNs can structure their career development, or where nurses doing public health nursing related work can access programmes to meet their knowledge and skill needs. Continuing quality education is a cost to employers. However, if public health nursing education is not given priority, nurses may not receive the training needed to equip them to be safe and effective practitioners. A lack of investment in nursing development can reduce job satisfaction, and a nurse s sense of achievement, of being valued and having a vision for one s future, which in turn affects public health nursing recruitment and retention. The public health generic competencies provide a solid foundation in public health. However, these competencies have largely not yet been used as a basis for local/regional PHN orientation programmes or for PHN education. 20

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