HEALTH WORKFORCE PROJECTIONS MODELLING 2010

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HEALTH WORKFORCE PROJECTIONS MODELLING 2010

PRIMARY HEALTH CARE (PHC) NURSING WORKFORCE

Prepared for Health Workforce New Zealand by Health Workforce Information Programme (HWIP)

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1 PRIMARY HEALTH CARE (PHC) NURSING AT A GLANCE

Number of primary health care nurses

Growth in Supply Growth in demand

2009 8248 FTE 0.7% per annum

2031 8951 FTE 15.7% 37.3%

The Operational Capability and Information team (OC&I) at District Health Boards New Zealand (DHBNZ) has prepared these estimates of the size of the New Zealand Primary Health Care (PHC) nursing workforce for Health Workforce New Zealand (HWNZ).

Projections of the future balance of the primary health care nursing workforce supply compared with demand are made 20 years into the future using a forecast model based on a DHBNZ forecast framework.

The Nursing Council of New Zealand’s Annual Practising Certificate database provided the main source of data for the forecast.

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2 EXECUTIVE SUMMARY

This report has been written for HWNZ. It includes a forecasting model for PHC nurses in New Zealand.

The PHC nursing workforce as a subspecialty of nursing is comprised of 8248 full-time equivalents (FTE) (2009) and is estimated to grow to 8951 by 2029. Maintaining consistent nurse supply levels and accommodating changes in demand are issues for this workforce.

A major limitation to this demand forecast is the non-representation of 25 percent of the PHC nursing workforce. These providers including Non-government Organisations (NGOs) represented in the demand forecast. These providers are numerous and varied and data on their patients is either not collected or not available for this forecasting project.

Generally nurses tend are likely to transfer between areas of nursing several times over a nursing career. Few people (2.5 percent) enter PHC nursing without prior experience of working in New Zealand as a nurse. PHC also recruits significant numbers from other areas of nursing (more than 500 nurses each year). This means entry and exits rates for PHC nursing are lower than for the overall nursing workforce.

PHC nurses typically work longer hours than in their previous roles and the range of roles available within PHC nursing is expanding.

Nurses identifying as Māori or Pacific Island are leaving the PHC workforce faster than they can be replaced. Without intervention this is expected to continue over the forecast period, despite the rise in proportion of population in these two ethnic groups and in demand for Māori and Pacific health services.

The current government direction is toward redesign and redistribution of health care services. Particular emphasis is being placed upon the integrated family health care centre concept. The redistribution of PHC nurses in this role may be from hospital based services to the community. Although this will affect the location for service delivery, there will be little impact on changes to the

Assuming that current rates of nurses entering PHC nursing for the first time remains constant, baseline demand estimates indicate that demand for PHC nursing will expand at double the rate of both the population and nursing workforce growth rates over the next two decades.

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PHC nursing workforce. Nurses may work for another employer or from another location but the supply as PHC nurses is expected to remain the same.

PHC nursing supply numbers were determined from the Nursing Council of New Zealand (NCNZ) Annual Practising Certificate (APC) database. In particular, patterns of entry to (inflows) and exits from (outflows) the PHC nursing workforce and professional and educational qualifications have contributed to the forecast model.

Demand indicators included population growth projections, historical, current and anticipated demand for PHC nursing services and the way that PHC nursing services are delivered. Changing models of PHC nursing care delivery (Primary Care to PHC toward an integrated model of health care delivery), and the impact of current and emergent technologies also contributed to the model’s development.

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Entries to and exits from PHC nursing to 2031 ... 30

Analysis of current PHC nursing occupations ... 33

Education ... 37

PHC nursing education needs 2009-2029 ... 39

Methodology ... 42

Supply ... 42

Recommendations ... 44

Conclusion ... 45

Appendices ... 47

Appendix I – The team ... 47

Background of forecasting modelling process – Operational Capability and Information, DHBNZ ... 47

Stakeholder Reference Group ... 47

Expert Advisory Group (EAG) – PHC ... 48

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6 FIGURES AND GRAPHS

Figure 1: PHC nursing sub-specialties ... 11

Figure 2: PHC nurses and employer groups ... 12

Figure 3: Various PHC nursing roles according to main employment groups ... 25

Figure 4: DHBNZ Forecasting Framework ... 42

Graph 1: Well child ... 9

Graph 2: Domiciliary ... 10

Graph 3: Palliative Care ... 10

Graph 4: Sexual Health ... 10

Graph 5: Supply of Primary Health Care Nurses ... 13

Graph 6: Indexed growth in population based demand for PHC nurses ... 13

Graph 7: New Zealand population distribution 2009 - 2031 ... 15

Graph 8: Ethnicity population share change 2009-2029 ... 16

Graph 9: Accident patient age distribution ... 18

Graph 10: Accident patient likelihood ratios ... 19

Graph 11: DHB community service patient profile ... 20

Graph 12: Community service patient likelihood ratios ... 20

Graph 13: PHC nurses according to main and next main areas of practice ... 29

Graph 14: PHC nursing workforce age projection 2009 - 2031 ... 29

Graph 15: Overall nursing workforce age projection 2009-2031 ... 29

Graph 16: Inflows to PHC nursing ... 30

Graph 17: PHC nursing outflow ... 30

Graph 18: Returning nurses, new nurses, leaving nurses and retiring nurses 2009 – 2031 ... 31

Graph 19: Entry into PHC nursing ... 32

Graph 20: Previous experience of nurses entering into PHC nursing. ... 32

Graph 21: PHC nursing occupations ... 33

Graph 22: PHC nurse employers ... 34

Graph 23: PHC Providers not traditionally considered PHC providers but which employ PHC nurses34 Graph 24: Occupations of PHC Nurses who work for non-traditional PHC Providers ... 35

Graph 25: Employers of PHC nurses which have not traditionally been PHC providers ... 35

Graph 26: PHC nurses do everything – non-traditional roles of nurses employed by PHC Providers . 36 Graph 27: Māori nurses in the PHC nursing workforce 2009-2031 ... 36

Graph 28: Proportions per scope of nursing practice ... 37

Graph 29: CTA funded post graduate nurse numbers from PHC setting 2007 - 2009 ... 38

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7 BACKGROUND

PHC nurses work in a wide range of settings and roles including practice nursing, district nursing, public health nursing, well child or child health nursing, occupational health, family planning/sexual health, mental health, health education/promotion, and specialist PHC or community nursing. PHC nurses also work in areas of management of PHC or community services.

In 2001, the Government introduced its Primary Health Care Strategy (PHCS)i_{, to strengthen the role} of PHC, in order to improve health and reduce inequalities in health. Whereas primary care was previously seen as the first point of contact for individuals, the emergence of Primary Health Organisations (PHOs) with enrolled population-based responsibilities became the catalyst for change to PHC as a concept that emphasises population health, health promotion and preventative health care. This broadened the scope of PHC nursing from a focus on delivery of individual care to one centred on population health needs.

Primary health care relates to the professional health care received in the community.... Primary health care covers a broad range of health and preventative services, including health education, counselling, disease prevention and screeningii

i

Ministry of Health, (2001). The Primary Health Care Strategy. Retrieved 15 August, 2009. Available at:

http://www.moh.govt.nz/moh.nsf/0/7bafad2531e04d92cc2569e600013d04?OpenDocument

ii

Ministry of Health, (2010). Primary Health Care. Available at www.moh.govt.nz/primaryhealthcare

PHC nurses are nurses with knowledge and expertise in PHC practice. PHC nurses work autonomously and collaboratively to promote, improve, maintain and restore health. PHC nursing encompasses population health, health promotion, disease prevention, wellness care, first-point-of-contact care and chronic disease management across the lifespan. The setting and the ethnic and cultural group of the people determine models of practice. Partnership with people – individuals, whänau, communities and people – to achieve the shared goal of health for all, is central to primary healthcare nursing

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8 Describing PHC nurses

As part of the survey requirement for the Nursing Council of New Zealand’s (NCNZ) Annual Practising Certificate (APC) nurses within the regulated nursing workforce choose the ‘main’ and ‘next main’ practice areas that they think best describe their job. They also choose ‘main’ and ‘next main’ employment codes, that best describe their employment situation.

Supply of PHC nurses involves eliciting nurses who have a PHC role as their main area of practice from within the NCNZ data collection. For supply measures the following were counted as PHC nurses:

• Nurses who selected the ‘Primary Health Care (including Practice Nurses)’, and ‘District Nursing’ area of practice categories regardless of employment code.

• Nurses who selected PHC as employer regardless of area of practice code (excepting Intellectual Disability, Mental Health and Continuing Care (refer to exclusions below)

• Nurses who selected the Family Planning/Sexual Health, Child Health, Public Health, Palliative Care, Assessment and rehabilitation, Nursing administration/management, Occupational health or Other categories as their main area of practice were counted as PHC nurses when they also chose one of the following as their main employer:

o Primary Health Care/Community service (non-public) o Public community service

o Māori Health service provider o Pacific Health Service Provider

Nurses who selected the educational institute employment code (as main employer code) but did not choose ‘education as a area of practice code, were counted in order to distinguish between nurses working in educational institutes and nurse educators in the tertiary sector.

In this way nurse specialists who work mainly in a DHB hospital environment such as renal, diabetes and cardiac nurse specialists and who outreach into the community are not counted unless they work from within a community service such as a District Nursing service.

Practice areas within the employer category ‘government agency’ were examined for specific PHC nursing groups such as defence and prison nurses, who were then included in supply numbers

Exclusions

Nurses who work specifically in Continuing Care (Elderly) are excluded from this workforce.

Also excluded from this workforce were nurses who selected Intellectual Disability and any Mental Health categories, regardless of employer.

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9 Scope of the forecasting project

As PHC nursing has developed over the past decade the workforce has grown and nursing roles have diversified to include a greater range of PHC service delivery. Results of a studyiii_{in 2009 identified 13} different work types of PHC and Community Nurses. Each work type is highly likely to provide services to specifically defined populations with regard to age and gender. Each of these work types could be considered a sub-specialty of the generic PHC workforce. No single work type can be identified to represent a client base that typifies all of the work types. Therefore, the first part of this report focuses on a macro view of the PHC nursing workforce using the general population as the basis for demand factors. For example, graphs one, two, three and four show the diversity of age groups within four different DHB PHC nursing services.

Graph 1: Well child

iii Finlayson, M., Sheridan, N., Cumming, J. 'Nursing developments in primary health care since 2001, Victoria University of Wellington, Wellington, 2008. Available at: http://www.victoria.ac.nz/hsrc/reports/NURSING%20Developments%20in%20Primary%20Health%20Care%20EDITED%20F INAL%20ExMF14%2001%2009%20ExWS%20Feb%2009%20(2).pdf

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Graph 2: Domiciliary

Graph 3: Palliative Care

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There are 15 sub-specialties identified within the generic PHC nursing specialty. Of these 12 were identified as PHC nursing work types identified by Finlayson, Sheridan and Cumming (2009), with three further groups identified as a result of analysis of the NCNZ workforce data (DHB Community Nurses, who are not District Nurses, School Nursing and out-of-hospital palliative care nursing)1_{. PHC} nursing sub-specialty will have discrete demand factors that are relevant to the specific sub-specialty. However, forecasting of each sub-specialty is beyond the scope of this project.

Figure 1: PHC nursing sub-specialties

Therefore a macro-view PHC nursing workforce forecast model is presented in this report.

Not all of these work types are with traditional PHC providers (e.g. public hospitals) but are work types comprised of nurses who traditionally have been considered PHC nurses. Subsequently there are three main groups of PHC nurses2_,3_{(figure 2).}

• Nurses who work in traditional workforce roles and are employed by PHC providers (60 percent)

• Nurses who selected PHC as their area of practice and who have selected employers other than those traditionally considered as PHC employers (18.8 percent)

• Nurses who selected PHC as an employer but did not select one of the traditional PHC areas of practice such as critical care and emergency (21.7 percent)

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13 FORECASTS

Main results

The baseline demand estimates indicate that demand for PHC nursing service delivery will grow twice as fast as the population over the next 20 years, and twice as fast as the nursing workforce growth over the same period.

Supply

Based on current workforce dynamics the primary health care workforce is set to expand by 1754 nurses (15.7 percent) in the 20 years to 2030, an average growth rate of approximately 0.7 percent each year. Full-time equivalents will grow to 8951, including 336 working in primary health care as a second job.

Graph 5: Supply of Primary Health Care Nurses

Demand

Overall population driven demand for PHC nurses is estimated to grow 37.3 percent by 2031. This growth will be constantly and steadily driven by an ageing population.

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The predicted overall growth in demand has been drawn from an index for PHC nurses based on three components including two PHO components (accident and non-accident) and DHB community nursing. The other providers in the PHC landscape (which employ about 25 percent of PHC nurses) are not explicitly represented in the demand forecast. These providers are numerous and varied and data on their patients is either not collected or not available for analysis.

Demand for Primary Health Care Nurses

The demand for PHC nursing over the next 20 years is determined by considering several demand indicators such as:

• Population growth projections further determined by age, gender, and ethnicity • Population health needs

• Historical, current and future changes to the way PHC nursing services are configured • Anticipated development of and changes to the way PHC nursing is offered as models of

PHC nursing care delivery

• The impact of current and emerging technologies

Given the shift toward population based health care delivery, total population health needs and achievements are particularly pertinent to this forecast. At a total population level New Zealand’s health continues to improve. Longevity gains include a current life expectancy at birth of 82.2 years for females and 78.0 years for males (a rise of 6.8 years for females and 9.2 years for males since 1971-1977).

Population Growth

According to the 2006 census New Zealand had a population of 4,143,279 of which 2,062,328 were women. There are about 104 women for every 100 men. The median age was 35.4 years for men and 37.2 years for women. In keeping with international trends, New Zealand’s population is ageing. As demonstrated in graph seven most of the population growth between 2009 and 2029 will be in the age groups over 55 years with the fastest growth rate in the 85+ age group. This 85+ group will more than double in size in the next 20 years, whereas the population age group of less than 55 years will remain almost static over the same periodiv_.

iv

World Health Organisation (2010) Country Health Information Profiles: New Zealand. Available at: http://www.wpro.who.int/countries/2010/nez/

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Graph 7: New Zealand population distribution 2009 - 2031

Population growth highlightsv_include:

• By mid-2020s people aged 65 and over will outnumber those aged 15 and under • A population of five million by the late 2020s

• The growth rate will slow steadily due to the narrowing gap between births and deaths • Sometime in the 2050s deaths will exceed births

• Population structure will continue to include more older people and further ageing • Fertility rates will continue to decrease

• Life expectancy at birth will continue to increase

• From 2010 a long-run annual net migration gain of 10,000 people is anticipated

• Population growth will occur predominantly in main urban areas, with some rural area populations declining

The percentage share of European within the population is expected to decrease over the next 20 years as other ethnicities increase (graph 8)4_.

• The Māori population will increase by 1.7 percent of the total population by 20295 • The Pacific population will increase by 1.4 percent of the total population by 2029

• The Asian population will remain reasonably constant based upon current immigration policy That is, the groups with the greatest health disparities (Māori and Pacific) are expected to undergo the highest population growth.

v _{World Health Organisation (2010) Country Health Information Profiles: New Zealand. Available at:}

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Graph 8: Ethnicity population share change 2009-2029

Although the Asian proportion share of the population is expected to remain reasonably stable, immigration policy is likely to favour increased Asian immigration as the European general labour workforce ages. The growing international trend indicates that the pattern of migration will alter, with people moving between countries for shorter term contracts rather than permanently immigratingvi

Population health needs

Primary Health Organisations (PHOs) are based upon enrolled populations for the provision of PHC. Currently 95 percent of the New Zealand population is enrolled with a PHO service provider. Therefore PHO service data can be used to determine population-based demand estimates. For the purposes of this forecast PHO patient data is further divided into ‘non-accident6_{’ patients and} ‘accident7_{’ patients.}

However, not all PHC nursing services are delivered through PHO service providers. A significant number are delivered by DHB community services under the umbrella of publically funded DHB services not associated with PHO enrolments. Therefore when examining demand patterns of patients based on those receiving PHC nursing services data about the health needs for DHB community services patients is also examined.

Currently little demand-based data is available from the NGO sector. This precludes consideration of NGO demand.

vi

Department of Labour (2008) Workforce 2020: Forces for change in the Future Labour Market in New Zealand. Available at: http://www.dol.govt.nz/PDFs/forces‐for‐change.pdf

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17 PHO NonAccident

Based on the assumption that fertility, as projected will remain static or reduce and that immigration patterns8_{will remain at a medium level of increase, the PHO enrolled population is expected to grow} by 19.5 percent (about 0.9 percent per year) by 2031.

The proportions of the different age groups enrolled with PHOs are quite similar and therefore do not provide any useful insight into the levels of resources used to provide PHC nursing care delivery. In particular, no insight can be gleaned about how much nursing time is devoted to specific groups of the population.

The health needs of the population increase according to age growth as much of the population growth occurs in older age-groups. One indication of the varying levels of PHOs future demand comes from differential funding applied to patients of different age, gender, ethnicity and socioeconomic status, which comprises about 85 percent of the Vote Health funding directed to PHOs. This excludes categories relating to pharmaceuticals, laboratory, radiology, PHO management and performance payments, which are not easily associated with demographic proportions. Care Plus payments are also excluded as there is insufficient information on patient demographics to predict the level of future demand. Similarly, very low cost access payments are not included in this analysis as there is little confidence in the accuracy of predicting delivery of low cost services.

Capitation Based Funding of PHOs is tied, in part, to the age, ethnicity and deprivation scale of the enrolled patient. Chart one illustrates the distribution of the part of these payments that can be associated with (and for future years predicted by) demographic characteristics. Each cell shows how many people of the specified age receive an associated level of funding9_{. This shows that the very} youngest age groups (children under 5 years) receive the highest level of funding, followed by the oldest (over 65 years).

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The chart illustrates the two tiers of funding - the smaller (dark blue) band indicates patients with High-Use Health Cards (HUHC), who receive a higher tier of funding at all ages. The four striations (for non-HUHC patients) represent four demographic groups, those with Māori/Pacific ethnicity and/or living in areas with a deprivation index of nine and ten, with male and female splits of each group. The yellow areas mark the bulk of New Zealand’s population. This group will age over the forecast period. As they move into the over-65 age group they will place considerable demands on health services.

This portion of PHO funding is used as a proxy for part of the demand on PHC nursing services. By 2031 population growth, weighted for age, gender, ethnicity and deprivation will produce a 27.2 percent increase in demand. This growth is higher than overall population growth, since the growth areas (patients over 55 years) receive higher payments. On the other hand this part of PHC growth is lower than predicted for the other PHC areas (PHC associated with accidents and DHB community nursing), since these latter areas are subjected to even greater demand from the older age groups.

PHO Accident Patients

This forecast draws on nurse consultation data from ACC to provide information about the demand for primary health care nurses from ‘accident’ patients. The age distribution of ACC-funded patients seeing PHC providers is relatively flat, and children and young adults place the highest demand on the service (graph 9).

Graph 9: Accident patient age distribution

When compared with the relative sizes of the population groups it becomes clear that older age-groups are disproportionally highly represented. Patients in the 75-85 year age band are twice as likely to need accident-related treatment, and patients over 85 are four times as likely (graph 10). The

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result of this weighting, combined with the rapid growth of these population groups, contributes 30.6 percent, which is a significant amount of the forecast.

Graph 10: Accident patient likelihood ratios

DHB Community Services Patients

Patients who receive PHC from DHB community services usually interact with a variety of health care practitioners as well as nurses. As specific health practitioner data related to patients receiving community services from DHBs is not yet recorded and reported on, these services cannot be assumed to be specific to nursing. The DHB community services that were analysed included:

• Well-child services

• Family planning and sexual health services

• Occupational therapy and community-based assessment treatment and rehabilitation services (AT&R)

• Palliative care • District nursing

It was found that younger age groups have a high demand on DHB community nursing, as use is made of the well-child and family planning services. The populations of these age groups, however, are static and will have little impact on the growth of future overall demand (graph 11).

Like the other two PHC patient population groups, those aged over 55 years provide most growth in demand for DHB community services. Nevertheless, when directly compared with the PHO ‘accident’ and ‘non-accident’ patient groups of PHC patient populations, the DHB community nursing services are the most heavily weighed towards the oldest age groups.

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Graph 11: DHB community service patient profile

People aged over 85 are nearly seven times more likely to use these services than the average New Zealander, in the form of district nursing, occupational therapy, AT&R and palliative care (graph 12).

Graph 12: Community service patient likelihood ratios

With the highest weighting of demand concentrated in the oldest, fastest growing age groups, demand for these services will grow 54.0 percent by 2031.

Burden of disease

Chronic conditions

Diseases of the circulatory system, including heart disease and cerebral vascular accidents (CVA), were the major mortality causes in 2006 (38 percent of all deaths). Cancer was the next biggest cause of mortality (29 percent of all deaths).

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Chronic conditions are the leading cause of preventable morbidity, mortality and unequal health outcomes. These include diabetes, cardio-vascular disease (CVD), cancer, respiratory conditions, mental health conditions and arthritis. Cardio-vascular disease and diabetes together account for a significant burden of chronic illness and premature death. About 10,500 people die from cardio-vascular disease each year (40 percent of all deaths) and 7000 people sustain a CVA event each year. Over 700 people are newly diagnosed with diabetes each year, with 4.5 percent of the population living with diabetes. It is predicted that the number of New Zealanders with Type II diabetes, which is associated with obesity, will double by

2028 to almost 10 percent of the adult populationvii_. Currently just over half of chronically ill New Zealand adults live with multi-morbid (more than one) chronic illness and this is expected to increase. However, people with multi-morbid chronic illnesses tend to have each condition treated in isolation.

Unequal health outcomes can largely be attributed to the disproportionate burden imposed by chronic conditions, especially CVD and Type II diabetes on Māori and Pacific people and those on low incomes10_.

Between 1999 and 2004 absolute inequality in all-cause mortality decreased, more so for Māori than Pacific ethnic groups. The decline in mortality over this time is substantial.

Major contributors to inequalities in health include:

• Smoking - the rate of smoking is higher in the most deprived areas according to deprivation indices.

• Obesity and being overweight are the major risk factors for Type 2 diabetes, CVD and CVA. Increasingly sedentary lifestyles and high energy diets, combined with an ageing population and improvements with acute CVD, such as early cardiac intervention, means more people are living with CVD. Gains from reduction of CVD risks, however, appear to be off-set by increased incidence of obesity and Type 2 diabetes.

vii

National Health Board, 2010. Trends in service design and new models of care: a review. Available at: http://www.nationalhealthboard.govt.nz/sites/all/files/trends‐service‐design‐new‐models‐care‐jul2010.pdf

The implications of the increasing burden of chronic conditions for PHC nursing include: • Greater levels of chronic disease management, including acute exacerbations based on proactive care planning and best practice clinical guidelines • Increased promotion of patient and/or whānau‐led care • Increased demand for nursing services within an integrated team model • Greater participation in coordination and shared care • More emphasis on educative role for healthy lifestyles

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As the likelihood of developing co-morbid chronic disease increases with age, the prospect of an older population requiring greater use of PHC services, risk identification, preventative strategies and chronic care management have become progressively the domain of PHC nursing care.

Communicable disease

New Zealand has a relatively high incidence of waterborne disease including campylobacter, giardiasis and cryptosporidiosis. The Ministry of Health has strategies to cope with possible emergency communicable disease events such as severe acute respiratory syndrome, (SARS), avian and swine flu, by the development and implementation of a National Health Emergency Plan for Infectious Diseaseviii_{. The management of notifiable communicable disease contact tracing processes} is included within community nurses’ roles, as a means of preventing spread of communicable disease.

The national health target for childhood immunisation is for 95 per cent of all children at two years of age to be fully vaccinated. Current coverage is 85 percent, which is a nine percent rise since 2007. Immunisation rates are also disparate between ethnicities with Māori and Pacific five and four percent respectively lower then European.

The national ‘flu’ vaccine coverage target set by the Ministry of Health is 75 percent. This is monitored by immunisation benefit claims by PHOs as part of PHO performance monitoring and applies to people over 65 years.

The model of nursing care has changed over the past decade from the delivery of individual care mostly as nurses within medical practices, to a PHC nursing role supported by the capitation funding model of Primary Health Organisations. As a result nurses have become more involved in illness prevention, health promotion, risk identification, chronic disease management and screening/immunisation recall processes as autonomous practitioners.

First line prevention in the case of global infectious disease has become the domain of nurses, who implement emergency screening plans as required, e.g. screening incoming passengers at airports.

Population based Primary Health Care initiatives

PHOs get a set amount of funding from the Government to subsidise a range of health services using a capitation funding model. The funding is based on the numbers and characteristics (e.g., age, sex, and ethnicity) of people enrolled with PHOs. PHC providers are funded by PHOs for:

• Providing care and treatment when people are ill (optimal use of PHC services)

viii

Ministry of Health (2010) National Health Emergency Plan: Infectious Diseases. Available at:

http://www.moh.govt.nz/moh.nsf/0/A7C725C02E537849CC256EE50004C1B2/$File/nationalhealthemergency plan.pdf

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• Helping people stay healthy (improved primary care prevention of long term conditions and other health care priorities)

•

Reaching out to those groups in their community who have poor health or who are missing out on primary health care (reduction in health disparities)

Additional PHC provider funding to improve the management of people with chronic conditions has been available since 2002. This aims to develop innovative services, improve patient access to reduce health inequalities and to support nurses to develop new services. The funding has been available through Care Plus, Reducing Inequalities Contingency Funded (RICF), and Services to Improve Access (SIA). A specific PHC nursing innovation fund has also been available.

The World Health Organisation (2009) Country Health Information Profile reports significant improvement in inequality measures in New Zealand, such as smoking and diet coupled with control of blood cholesterol and blood pressure. Case fatality rates for CVD and CVA have also reduced significantly.

Service delivery and outputs

Most but not all PHC providers are funded by PHOs, supported by additional funding (as outlined above). The Accident Corporation Commission (ACC) also funds most, but not all, PHC providers. The ACC model of payment is fee-for-service and is unrelated to the capitation funding model of PHOs. Other PHC nursing services providers include District Health Boards (DHBs), NGOs, the Ministry of Education, and the Ministry of Defence.

Although PHO performance is measured against the above goals nursing services are measured only on the number of patient consultations. The PHO Performance Programme reports annually against a variety of indicators relevant for nursing, including:

• Cervical and breast cancer screening • Age appropriate vaccinations

• 65+ year old vaccinations

Indicators recorded but with insufficient history to provide trend analysis include: • Ischaemic CVD reporting

• CVD risk assessment

• Diabetes Detection and follow-up

The care associated with vaccinations, risk assessment, education and ongoing management, of chronic and co-morbid disease are already delivered by PHC nurses as vaccination nurses, diabetes nurse specialists, cardiac nurse specialists, breast care nurses, public health nurses and district nurses. This is likely to increase over time as ongoing and preventative care shifts from DHBs to PHOs.

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24 Technology developments

There is every reason to believe the PHC strategy will expand to provide integrated health service delivery, giving PHC nurses greater and more direct access to funding for the delivery of nurse-led clinics, targeted prevention and promotion

activities. As the population-based model of care gains traction, PHC nurses will perform more home visits, mobile clinics, electronically manage individual health needs, and high technology nurse led clinics, which enable transmission of clinical measurements and findings to centralised integrated health speciality centres.

There are a number of changes in technology that may affect PHC nursing. For instance:

• electronic personal health record online11 • e-referral12

• multi-disciplinary care pathways • online health management13 • digital photography14 • telehealth15

• cardiac16_{, diabetes}17_{and asthma}18 monitoring

• defibrillator availability19

• Healthline and the Well-Child Telephone Advice Services20

PHC Nursing Service configuration

The way PHC nursing services are delivered depends upon overall health service configuration and delivery. The role of PHC nursing in New Zealand’s health care system is constantly changing and evolving. Recognising the rise in chronic and co-morbid conditions, aging populations and increasing costs, governments

globally are placing greater emphasis on integrated models of service delivery.

In particular, the PHC strategy (2001) brought about a shift in the way PHC nursing services may be configured. Whereas in the past primary care was seen as the first point of contact for individuals, the emergence of PHOs, with a responsibility for the health of the enrolled population became the catalyst

The electronic personal health record, tele-health and other technologies are tools that will enable better sharing of information, and clinical decision making without the need for patients to travel long distances. These technologies are supported by the Better, Sooner, More Convenient paper released by the Minister of Health, 2010. Realising the potential for such technology requires careful service planning and allocation of resources. To date information and communication technologies that could benefit PHC nursing have been applied erratically, often funded only for a pilot as a seeding innovative grant by a major commercial systems or software developer/vendor. Funding following such successful pilots for sustainable development has not been forthcoming from heath service providers in the past. At the moment broadband capability in the some areas is well below the standard required to enable adequate ICT implementation. However, the Government has approved implementation of fibre networks that will supply high speed broadband access. This will enable capability for these technologies.

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ng to main e w offered to ices, accord g services in ategy resulte urses in the ere is more in change in dir and respons sion and nur o this day nated fee-for ach. This ha er driven med nity. ng roles is p se where nur llow shaded mployment g include heal ding to nee nclude diabet ed in increas community. ntegration of rection, with sibility, with e rse led servi

some small r-service fund as changed dical centres presented ac rses could n roles were groups th prevention ed based o tes, asthma sed PHC nu Primary sec f services. some servic expanded an ces. Conver ler traditiona ding model, r the traditiona s to the broad ccording to t ot be discer actively sou n and promo n populatio and cardiac ursing auton ctor nurses a ces trailblaz nd extended rsely others p al general p remain. al role of der more the main ned from ught from otion, risk n health c nurses. omy and are more ing ways roles for preferred practices,

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The change of government and establishment of the National Health Board (NHB) has furthered the notion of integrated service configuration driven by the emergence of four major trends for health service to underpin service re-design for the futureix_{. This aims to address current pressures on the} system including resource scarcity, population changes, health inequality, public expectations, workforce shortages and emerging technologies.

The four major concepts for service re-design include:

• Greater home based care delivery, support and self management, including more targeted prevention for healthier lifestyles, maximising information technology to improve communication coupled with greater staff mobility to enable more services in the home setting.

• Integrated family health centres, partnerships and teams in the community that: strengthen the primary health care sector,

improve patient access,

support improved health outcomes,

make the best use of the available workforce,

use multi-disciplinary teamwork to co-ordinate care delivery, improve access to specialist diagnostic testing

deliver some services that have been traditionally delivered as secondary services to relieve hospital pressure

• Greater emphasis for secondary hospitals to enhance core clinically viable services and strengthen relationships with close, larger metropolitan hospitals. This aims to address workforce and quality issues, with an emphasis upon delivering services from community settings. Hospital and/or institutionalised services will be used where necessary.

• Consolidation of specialist/tertiary services into a smaller number of centres (regionally and nationally) that offer greater specialisation with better communication and shared information by electronic interaction within the sector.

These plans for reconfiguration of national health care service delivery have the potential to change current models of PHC nursing care delivery. In particular, the emergent Whānau Orax_{model is based} upon integrated service delivery.

ix _{National Health Board (2010). Trends in Service Design and New Models of Care: A review. Available at:}

http://www.hiirc.org.nz/page/21269/trends‐in‐service‐design‐and‐new‐models‐of/?section=9097&tab=27

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27 Models of care

Models of nursing care delivery describe the purpose and shape of nursing care in a particular contextxi_{. In this case, the models of care refer to anticipated changes to the ways in which PHC} nursing may be delivered. These changes depend upon the rate at which a re-designed health care service is implementedxii_{. The re-design has major implications for the shape of PHC nursing care} delivery.

1. The potential to relocate nurses, in particular, nurse specialist roles from the DHB environment to a community base

2. A shift from hospital stay to home management for higher acuity, sicker patients

3. Progressively more acute nursing services delivered from an Integrated Family Health Centre 4. Greater participation within an integrated health practitioner team as autonomous

practitioners

5. Expanded and extended nursing roles in the PHC environment

6. Case management roles, especially in chronic disease monitoring and management - nurses refer patients to doctor when issues are identified or medical opinion needed.

7. Greater role in preventative strategies and risk management, such as triage, screening, monitoring and recall

In 2008 the NCNZ discussed a range of issues related to nurses working in roles which extend the Registered Nurse scope of practice. This included a colposcopy role for nurses working in the community-based national screening programme. The implications of this role include a greater expectation that PHC nurses will expand roles to include some minimally invasive procedures especially in screening and chronic disease management.

Nurse Practitioners (NPs) have some minimally invasive procedures within their scopes of practice. These are likely to increase within the Integrated Family Health Centre concept as NPs develop greater roles. In particular, recent developments have included authorising NPs to complete medical certificates for sickness beneficiaries. Most NP-approved scopes of practice indicate that all or a significant component of practice is either in (or could be) PHC practice.

Other development of NP roles may include:

• Legislative change that enables NPs to enrol patients into PHO providers • Increasing case management roles including patient referral

• Potential for private business, receiving funding and the capability to charge patients

xi

Walsh, K. & Moss, C. (2007). Blending practice development methods with social science research: An example of pushing new practice research boundaries. Journal of Research in Nursing.

xii

National Health Board (2010). Trends in Service Design and New Models of Care: A review. Available at:

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Subsequently there is a need for greater numbers of NPs in PHC with nursing capability of autonomous practice.

The emergence of new occupational groups may affect the model of care for PHC nursing. These include:

• Expanded and extended Registered Nurse scope of practice • Increase of minimally invasive procedures by NPs

• Reintroduction of Enrolled Nurse training, which may provide a greater proportion of the PHC workforce in a Registered Nurse support role

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29 Supply

Current supply

Based on the 2009 NCNZ APC there are 8248 full-time equivalent (FTE) nurses in PHC. Nurses whose main area (or only) area of practice was PHC accounted for 7907 FTE, while nurses for whom PHC was entirely their ‘next main’ area of practice accounted for only 341 FTE21_.

Graph 13: PHC nurses according to main and next main areas of practice

Age distribution of PHC nurses (20092031)

The median age of the PHC nursing workforce is 49.2 years, and this grows to 49.9 years by 2031. This is two years older than the overall nursing workforce where the median age of all nurses in 2009 was 47.2, increasing to 48.4 in 2031 (graphs 13 and 14).

Graph 14: PHC nursing workforce age projection 2009 - 2031

Graph 15: Overall nursing workforce age projection 2009-2031

The PHC nursing workforce has proportionately fewer nurses aged under 40 than the overall nursing workforce. This reflects the traditional trend for nurses to enter the PHC workforce after gaining experience in other areas of nursing. Graduate nurses are less likely to consider PHC nursing for their

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first nursing positions post training. Because nurses usually enter the nursing workforce in positions other than PHC, the age of entry to PHC nursing is older.

In line with nursing trends elsewhere the PHC nursing workforce will age in the next 20 years, and will increasingly depend on a greater proportion of nurses aged over 50.

Entries to and exits from PHC nursing to 2031

The diverse nature of the PHC nursing workforce complicates analysis of the flow of PHC nurses. The analysis of inflows, outflows, and transfers in the workforce needs to consider that nurses in this particular workforce often hold multiple positions with multiple employers in both the public and private sectors. Many nurses work as PHC nurses and also do work that has not traditionally been regarded as PHC roles. Entry to the PHC nursing workforce may be as a second and/or part-time job, which means that the resultant inflow may be less significant than a nurse already working in the sector who takes on additional hours. However, there are some general observations that can be made about changes to the PHC workforce.

The PHC supply model begins with a constant baseline inflow of new nurses22_{based on historical} averages. The proportion of new nurse inflow to PHC nursing is quite small (about 270 nurses each year, or 2.5 percent of PHC nursing workforce) as PHC in the past has not been a popular first job destination for new nurses.

Graph 16: Inflows to PHC nursing Graph 17: PHC nursing outflow

PHC nurses who permanently leave the nursing workforce will grow to 670 nurses per-annum by 2030, outnumbering new entrants by 2.5 to 1. PHC draws a significant number of nurses from other areas of the nursing workforce – a net inflow of more than 500 nurses per-annum, although this will shrink in the next 20 years to about 425 nurses per-annum as the relative sizes of PHC and other sections of the nursing workforce change.

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As the PHC workforce grows and ages the number of nurses retiring will increase, contributing to a growth in the number of nurses leaving nursing permanently (graph 18).

As the overall nursing workforce grows the number of nurses who return to nursing and take up positions in PHC nursing will increase (graph 18). PHC is an area that attracts a relatively high number of returning nurses.

The proportion of PHC nurses who are leaving nursing permanently (and retiring) will grow during the forecast period. PHC is affected more than the general nursing workforce with this exit rate because it has a more experienced workforce and has historically attracted fewer new nurses.

Graph 18: Returning nurses, new nurses, leaving nurses and retiring nurses 2009 – 2031

The PHC nursing workforce benefits from an increase in the size of the overall nursing workforce, which supplies the recruitment pool for PHC nursing. Although numbers of nurses returning to PHC and transferring into PHC nursing can be expected to increase, that increase is negated to some degree by the nurses leaving and retiring from PHC nursing. The resultant increase is therefore quite small.

The proportion of PHC nurses retiring grows from 3.4 percent per annum of PHC FTE in 2009 to 12.1 percent per annum of PHC FTE in 2031.

New nurses and nurses returning to the nursing workforce contribute only a small portion of the inflow to PHC nursing. The largest inflow of PHC nurses comes from nurses leaving other nursing positions or nurses taking on additional work as a PHC nurse (graph 19). The smallest inflow at 10 percent is from new nurses.

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Graph 19: Entry into PHC nursing

As PHC nursing mostly gains nurses from other nursing areas, PHC nursing benefits from a larger nursing workforce as a pool from which to draw recruits. Nurses moving into PHC roles come from the entire range of nursing areas of practice. The likelihood of a nurse coming from another area of nursing depends more on the number of nurses in that practice area than any tendency for particular nursing areas to contribute more PHC nurses. That is, the larger the numbers of nurses working in a particular area of practice, the more likely nurses are to enter PHC nursing. For instance, 17 percent of PHC nurses are from the continuing care (elderly) area of practice. Rather than being a trend from continuing care (elderly), this is because that workforce is the largest nursing workforce (graph 20).

Graph 20: Previous experience of nurses entering into PHC nursing.

Nurses moving into PHC roles tend to take on extra hours. On average a new PHC nurse works 5.4 percent longer hours than they did in their in their previous role(s) in the previous year of practice

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Conversely, nurses leaving PHC nursing, but remaining in nursing in another area of practice, reduced their average working hours by 2.6 percent.

Overall the average hours worked by all PHC nurses have increased by 4.3 percent since 2005. The net inflow to the PHC nursing workforce is not a one-way flow of nurses. It indicates a tendency for nurses to migrate towards PHC. This tendency is a fraction (13.5 percent) of the nurses moving between PHC and other sectors of the workforce, or moving between jobs in the PHC nursing workforce. Nearly 3700 active nurses (i.e. those already in the nursing workforce) entered a new PHC position in 2009. Some of these nurses will have left or remain in a previous PHC position). This ‘churn’ is about one third of the PHC nursing workforce each year. When coupled with new and returning nurses this motility in the workforce results in rapid turnover of PHC nurses in any single position.

Analysis of current PHC nursing occupations

Overall, 11,881 nurses are engaged in PHC nursing service delivery, with their main or next main (and sometimes, both) areas of practice. Nurses within the ‘Primary Health Care (including Practice Nursing)’ area of practice category make up the largest group, of the total FTE count of PHC nurses, with more than 40 percent, (graph 18).

Graph 21: PHC nursing occupations

The employers of PHC nurses are primarily engaged with Primary Health Organisations/General Practices and the community services arms of the DHBs. Many work for employers that have not traditionally been considered PHC providers, including private hospitals, agency nurses, and self employed nurses (graph 19).

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Graph 22: PHC nurse employers

Together Practice Nurses/other PHO provider nurses, DHB nurses and non-traditional PHC providers make up 89.6 percent of the PHC nursing workforce. Of the employers, which are not traditionally PHC employers and hospitals, (both public and private) make up 43.9 percent (graph 12).

Graph 23: PHC Providers not traditionally considered PHC providers but which employ PHC nurses

The largest PHC nursing occupational group working for non-traditional PHC providers are Palliative Care nurses at 47 percent. Together with PHC nurses (20.7 percent), Occupational Health Nurses (15.1 percent) and District Nurses (6.8 percent) they make up 89.6 percent of this group (graph 21).

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Graph 24: Occupations of PHC Nurses who work for non-traditional PHC Providers

Within the group of nurses working for a PHC provider but who do not have an occupation traditionally considered as PHC nursing) forty percent are employed as DHB community service nurses, another 40 percent work in practices/PHO providers, and the rest work for various other primary care providers (graph 14).

Graph 25: Employers of PHC nurses which have not traditionally been PHC providers

These non-traditional PHC nurses working for PHC providers have a variety of areas of practice ranging from critical care, research, management and administration to assessment and rehabilitation. This broadening of roles for PHC nurses is likely to intensify within the planned service re-design and shift toward community services as the hub for care delivery.

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Graph 26: PHC nurses do everything – non-traditional roles of nurses employed by PHC Providers

Of concern is the small number of nurses who identify as Māori within the workforce. The current rate of recruitment of Māori to the PHC workforce is insufficient to replace those leaving. Over the next 20 years this will reduce the Māori percentage proportion in the workforce. PHC Māori FTE will decline in absolute and relative terms over the period of the forecast.

Graph 27: Māori nurses in the PHC nursing workforce 2009-2031

Already Māori nurses are in lesser proportions in the general nursing workforce than within the population. This disproportion is intensified by the number of new nurses who enter the nursing workforce in New Zealand from overseas rather than emerge from undergraduate programmes. This means that the area of most need will have the least supply provided to meet demand.

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37 Education

The undergraduate pre-registration programme for nurses in New Zealand provides graduate nurses with a comprehensive set of beginning practice skills. Beginning Registered Nurses, who have been trained in the New Zealand tertiary education sector, have completed some PHC courses as part of their undergraduate education.

Enrolled Nurses and Nurse Assistants currently comprise seven percent of the overall nursing workforcexiii_{. The proportion in the PHC nursing workforce is two percent less, totalling five percent of} the PHC nursing workforce. However, Enrolled Nurses are being reintroduced. The NCNZ has released education programme standards for the new Enrolled Nurse scope of practice. The structure of the programme provides for an 18 month diploma in Enrolled Nursing at level five on the New Zealand Qualification Authority – National Qualification Frameworkxiv_{. To date there is no specific} PHC nursing module within that.

Graph 28: Proportions per scope of nursing practice

In-house, on the job training may or may not be supported by formal education for PHC nurses. Historically nurses have had to pay for their studies, secure external scholarships or have their employer’s support in order to study. It is not possible to measure how many PHC nurses have undertaken post-graduate study in a post-operative related course funded by these means. From 2006-2009 post graduate PHC nursing courses have been supported by the Clinical Training Agency (CTA). In particular, CTA funded PHC post graduate courses have been supported from a targeted

xiii_{HWIP Macro view}

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fund specific to PHC nurses. The funding has been available to nurses who work in a primary health care setting as defined by CTA.

The number of nurses from PHC settings has increased over the three years, indicating increasing interest for PHC post graduate education amongst nurses.

Graph 29: CTA funded post graduate nurse numbers from PHC setting 2007 - 2009

That is, less then one percent (about 0.6 percent) of the total PHC nursing workforce has participated within the HWNZ (formerly the Clinical Training Agency) targeted courses in the last three yearsxv_. The past decade has seen a progressive broadening of PHC nursing practice in the area, with nurses now functioning in areas of practice across the spectrum of care. In particular, in tandem with increased patient acuity in the community, practice has become increasingly acute, including emergency, perioperative and critical care roles. The future supply of PHC skilled nurses for an increasingly complex service delivery will depend on access to and availability of ongoing post graduate related courses, not confined to PHC based education but including acute and specialist services as the roles develop.

In 2010 the Nurse Entry to Practice (NETP) programme was expanded to include PHC nursing, with providers funded by Vote Health. This gave DHB PHC nurses an impetus for PHC nursing as a first entry to practice. New graduate nurses within the NETP programme undertake post graduate education as part of the programme.

A usual pathway for specific skill level acquisition in a nursing specialty is on entry to the sub-specialty orientation programmes, which develop the new entry to a stage of usefulness (advanced beginner). Clinical experience and ongoing education within a professional development and recognition programme (PDRP)23_{provide skill level acquisition to the recognised level of} ‘competence’24_{. The entry of new nurses to PHC, who require this level of education, is quite small}

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(about 2.5 percent each year) and will remain so until PHC becomes a popular place for new graduates’ entry to practice.

Formal post-graduate sub-specialty specific education is crucial to the provision of optimal patient care delivered by a workforce with skills that match the complexity of demand. Each sub-specialty expects that some of the workforce will have completed post-graduate clinically-based study at level eight. Opinion from the sub-specialty Expert Advisory Group (EAG) indicates across the sector that about two years experience plus a completed specific post graduate course is desirable for development to the stage of advanced practitioner or the level of a ‘proficient’ nurse. However, there is a gap between what is perceived as desirable and the reality in a climate of scarce resources to support study.

The National Framework for Nursing Professional Development and Recognition Programmes and Designated Role Titles Report (2005) recommends that a pre-requisite to becoming an expert nurse is the need to be engaged in post graduate study.

PHC nursing education needs 20092029

One of the objectives of workforce forecast modelling is to identify future training needs for each of the workforce sub-specialties that are undergoing predictive forecasting. A key question then is how many nurses will require post-graduate education to sustain nursing service provision in each nursing subspecialty in the future?

In most health workforces this can be predicted as when people make a career change between sub-specialties, it is likely to be for a lengthy period of their remaining career time. That is, the flow between sub-specialities is slow. For instance, when doctors decide to enter a sub-specialty, such as General Practice, they do the required training and are likely to remain in General Practice for a long time. Consequently one can predict how many trainees need to be trained for General Practice based on historical averages and predicted supply to meet predicted demand for General Practice services. The same can be applied to other health practice areas such as physiotherapy, and pharmacy.

In nursing, the picture is different. The median career length in the nursing workforce is 12 years, unlike other professional groups who may have a life span in the same profession. This means that half of all nurses in the current cohort25_{of nurses will spend more than 12 years in the nursing} workforce and half will not. Regardless of specialty nurses change their jobs within nursing several times over the course of their careers. Half of all nurses now in nursing will stay for the next five to six years. This is referred to as the half-life of nursingxvi_.

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The PHC nursing workforce has a greater ‘churn’ of nurses within the sub-specialty than others. This is related to the diversity of roles within a single sub-specialty, which enables nurses to change jobs within PHC, and also have more than one job with either both within PHC or with one outside PHC. Due to the internal churn of entry into, exit out of and internal shifting between PHC positions and the lack of NGO nursing sector information, estimation of training numbers for the PHC nursing workforce would not be meaningful. Few nurses who are now nursing (as part of the general workforce) will remain in the workforce for 20 years (the tip of the green area in graph 27), and fewer still of the nurses who are in a particular field of nursing will still be in the same field.

Graph 30: Career length of nurses

The nurses who have been in the workforce for the least amount of time need to be engaging with post graduate study now to ensure adequate skill mix for the future. However, those with the least experience also need to complete in-house and experience based skills acquisition programmes. If all the PHC nurses who have been in this specific workforce for less than 3 years obtained a post graduate certificate in the next two years, only half of them would still be in the PHC nursing workforce at the end of that time. Added to this would be the training needs of new entries to the workforce each year until 2029, which rises exponentially in comparison with supply numbers.

The complexities of the PHC nursing workforce highlighted in this report suggest that there is a need for a strategic approach toward greater retention. Nurses need to be encouraged to enter PHC nursing earlier and remain within the workforce. Provision of education including short courses, on-the-job support and post graduate education as well as a defined and a career pathway may be the lever to grow the required expertise.

There are considerable barriers to the provision and uptake of education for PHC nurses including: • Level of inflow to PHC nursing by nurses new to the area. Although these nurses are provided

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entry. Because the level of new nurse entry is low, this is less likely to impact upon more senior PHC nurses time that could otherwise be spent on study, than other subspecialties • As nurses who enter the PHC nursing workforce will have had limited exposure to population

based preventative care and chronic disease management prior to entry the emphasis for the first two years is upon gaining experience in PHC and skills acquisition. Post graduate study as an added extra is difficult during this time

• Expense. Nurses are less likely to study when self-funded. Although funding may come from scholarships, employers and Health Workforce New Zealand, some nurses may see self funding as the only option. When self funded, questions arise about the potential for increased remuneration and to what extent this will offset the costs of study. The issue of expense is particularly pertinent during the current economic climate.

• Backfill. The supply of nurses is often insufficient to provide backfill for nurses to have leave for post graduate study

• High proportion of nurses working part time of in multiple jobs.

• Travel distance to post graduate courses in main urban areas with compulsory on-campus attendance is an issue

• Existing heavy workloads may preclude choice to study

• Capacity for tertiary educational facilities to provide courses. Most tertiary educators require a minimum number of nurses to establish a financially viable cohort for specific education that is sustainable.

One of the major issues facing nursing is the overall supply of new nurses to the workforce. In 2009 nurses entering from overseas outweighed the number of new graduates emerging from nursing schools in New Zealandxvii_{. Operating in an environment of capped numbers for undergraduate study} and rising demand for nursing services suggests that the gap between supply and demand will continue to widen as the population, including the health workforce, ages.

Although nurses emerging from New Zealand based undergraduate programmes have some PHC nursing as part of their course work, the sub-specialty has not been a preferred entry to practice area in the past. However, the ‘end of education’ survey of graduate nurses suggests this is changing. Nurses are now entering PHC nursing as graduate nurses in greater numbers. This has been supported by the availability of the PHC NETP programme for new graduates.

xvii _{Ministry of Health (2009), Current status of the national regulated nursing workforce. Available at} http://www.moh.govt.nz/moh.nsf/pagesmh/6795/$File/current-state-nursing.pdf

HEALTH WORKFORCE PROJECTIONS MODELLING 2010