Reducing the stress of independent practice.

Can nurses pull together more to establish independent practices within primary health organisations (PHOs), work creatively as a team and so reduce the stress and isolation of working alone?

This was a possible way ahead for primary health care (PHC) nurses suggested by New Zealand's fourth nurse practitioner (NP) Jenny Phillips, who specialises in wound care, during a keynote address on the conference's second day. Phillips, who has been in nursing for over 40 years, established her own business as an independent NP in 2003, having been endorsed an NP the previous year. She described getting onto the NP pathway as almost an accident, after working for two years as a clinical nurse specialist in wound care at Palmerston North Hospital She had previously worked as programme manager of the BN programme at the then Taranaki Polytechnic. In her native United Kingdom, she was known as a tissue viability nurse. Being able to go down a clinical rather than an academic pathway, she said, was ideal for her, though being somewhat of a trailblazer and having to develop a portfolio on her own was not easy.

"If you are going to apply to become an NP, you must get over any hang-ups about being a 'tall poppy'", she advised. "You have to be able to tell Nursing Council why you can make a difference to patients. We need more tall poppies in nursing; people who are prepared to push boundaries and to make a difference in their practice and to their clients. But we also have to be clear about what we can't do. There are many things I can't do in nursing that other professionals can."

Phillips was also clear that going down the NP pathway is not right for everyone. "There are many excellent nurses out there, eg clinical nurse specialists, people working part-time. We are all here to complement each other in the skills we bring."

Finding service gaps and opportunities

Phillips was prompted to set up her own wound care business after realising she was making little impact in primary health care (PHC) while she remained "sitting in the DHB". Nurses who wanted to set up their own businesses needed to ask where the service gaps in the community were, what the needs were and what funding was available. Phillips began working with the new Manawatu PHO, finding allies with practice nurses and GPs to set up a three-days-a-week wound care clinic in the community. "One GP did the hard graft at board level to get me a contract. I wasn't that savvy about contracts. There is PHC funding available, though some of it has tags on it, eg for Maori health initiatives or chronic disease prevention. But I discovered that 70 percent of my patients were in the low socio-economic band and I was meeting a real need."

One of the challenges was getting enough data about wounds, and being able to prove the benefits and calculate the costs of establishing a nurse-led initiative. "Wound care is not on anyone's radar. You need to become politically aware and active if you are going to succeed in your own business."

Identifying strengths and weaknesses

Doing a "SWOT" analysis proved useful, as a way to increase her self-knowledge, and to identify her strengths, weaknesses, opportunities and threats to set up a viable business. "You need to calculate how much it is going to cost to set up a service. This includes everything from running your car and giving yourself a salary, to paying your ACC levy, your GST and tax. I didn't know what was involved initially, so it was a steep learning curve for me. "My advice to nurses considering setting up their own business is to get a small business account Like MYOB [mind your own business]. Prepare reports from day one. I prepared quarterly reports, which I presented to the PHO. This included details about my client population, the wound dressings used etc. Often at the weekends, I would be catching up on my paperwork, but that was my fault. Eventually I learnt to say 'no'. I had to be realistic about what I could do. It took me six months to get over feeling guilty about not doing any more than my contract stated.

"The first year I was very stressed, partly because of the long hours I had to work to get the business started. Now I have a better relationship with the doctors; they trust me and can issue the prescriptions I recommend. I now have no desire to gain prescribing rights."

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At the end of her first year, Phillips made a small profit, which she ploughed back into some new equipment and attending a conference. For the last six months of the three-year contract, she also employed a practice nurse to assist with the workload.

Getting her contract renewed, however, proved extremely difficult. Phillips presented a huge report on her work and gave the PHO plenty of warning that she would have to close the business if it did not renew the contract in time. "I do not think the PHOs and DHBs are really ready for small independent businesses," she said. "I was forced to tell my clients I could not continue with the service the following year, as my contract was not renewed in time."

Phillips now works two days a week for HealthCare New Zealand and one day a week teaching at Massey University. Her business Central Wound Service is contracted one day a week to MidCentral DHB to provide strategic leadership for wound services in both the hospital and the community. She is also available to run study days or help with wound policies for other DHBs or employers.

"Setting up a business on one's own is hugely lonely and isolating. You need to set up good support networks and ensure you get stress relief. Certainty independent practice offers the best potential for innovation in some areas and the time is right for initiatives in PHC, but it is a slow process and there are many challenges along the way. Nurses pulling together and working collectively within the PHO might well be the best way to go," she said.