Rees Dart tramp triggers Angela's goal to become a nurse practitioner

Handover | Issue 38 – March 2017 – Nurse profile

"Become a nurse practitioner so you can round your career up… pull all your skills and practice experience together into a tidy bundle” were words from a friend whilst tramping that ignited Angela Bleach’s desire to become a nurse practitioner (NP).

Six years later, with support from the growing swell of NPs in the Southern DHB, Angela was endorsed by the Nursing Council as a nurse practitioner: adult mental health. She is one of 15 NPs supporting people experiencing mental health problems in New Zealand. Angela now works as an NP in mental health services for older people.

She is just one of six NPs to be “hatched” (in Angela’s words), by Heather Casey, director of mental health nursing. The first being Bernadette Paus-Forde who in 2004 became New Zealand’s first NP, mental health, intellectual disability and prescriber. Followed by Liz Langer, Mark Baldwin, Christine Maxwell and Jenni Topliss who also works in mental health services for older people.

Support is high for NPs to develop in this DHB which offers nurse practitioner candidate roles as pathways towards an NP role. Angela followed in the footsteps of Liz Langer and Christine Maxwell, NPs in older people’s mental health. Liz was profiled in Issue 20 of Handover and retired in 2014 however returned for a four-month locum early 2015 to provide support to the service and mentorship for Angela.

Although Liz returned to the US she continues to provide mentorship to Angela via Skype or phone. Couple this support with; weekly meetings with Bernadette, monthly meetings with the other Southern DHB NPs in mental health, bi-monthly meetings with all NPs working in Otago and Southland and throw in very supportive nursing leaders and psychiatrists then a clear picture of how a nurse practitioner can be ‘hatched’ and supported to grow from a novice NP to an experienced NP is painted.

Preparation 

Although Angela had completed a Master in Nursing in 2006 she was required to complete further study. She undertook a postgraduate diploma via the University of Auckland over a three-year time period. This was funded by Skills Matter. These papers were: Advanced assessment and clinical reasoning, biological science for practice, principles of pharmacology, pharmacokinetics (15 points), principles of therapeutics for advanced nursing (15 points) and prescribing in advanced nursing practice.

Being on a supported NP pathway enabled Angela to build on her existing skills as an experienced mental health nurse and integrate new knowledge into practice. During this time she also worked alongside Bernadette in Balclutha fulfilling the practice requirements for the physical health assessment and prescribing practicum paper.

The NP portfolio took Angela about five months to prepare. Following an accident Angela had a period of enforced rest to allow a serious leg injury to heal. This was just six weeks out from appearing before the Nursing Council panel, but it was “a blessing in disguise,” says Angela. Up until then she had been juggling full-time work, study and preparing her portfolio. The break from work gave her time to fully prepare. It was hard work but she says well worth it in the end. Angela said her panel consisted of two NPs and a Nursing Council staff member. “It was not too stressful, they were all really supportive,” she said.

NPs meeting a need

The population served by the Southern DHB is New Zealand’s highest in terms of ageing. Of the 365,000 people in this DHB area there are around 51,000 who are over 65 years of age. This equates to around 14 per cent of the population and the aged population will continue to increase. NPs can play a key role in improving the quality of life for people living in residential care facilities who often experience multiple co-exiting problems – mental health, physical health and loneliness to name but a few.

Although many staff working in the residential care facilities have some basic knowledge about how to recognise and respond to people with mental health problems there remains a high demand for further training, says Angela. “My work also includes spending time with managers and delivering educations sessions for staff. In some areas the turnover of staff is high so this is a continual process. Despite good intentions of most staff, stigma and discrimination about mental health conditions exists and this can be a barrier sometimes in enabling older people to receive the care that they need.”

By providing support to older people where they live, it not only helps ease their distress but reduces the need for hospital admissions. Shortly after Liz Langer took up the role as NP six hospital beds were closed. Angela says this trend in reduced hospital admissions has continued as the NP roles develop. The mental health services for older people now has two NPs which cover the Otago area. Angela will also cover the Oamaru area and Jenni the Balclutha area, with both covering Central Otago in the future. The role is busy and demand ever increasing with capacity for a third NP to be introduced.

Learning to prescribe 

Angela sees herself as a novice nurse practitioner and really values the support by others. “Becoming a prescription writer is a big learning curve and the responsibility is huge. To get the best outcome, you need to carefully assess the person, consider what medication they are on, what they have been on before and what may benefit them most now. Many of the people I support experience physical health problems and are often on a range of different medications. I need to consider how all these interact with any new medication. I have good support from Dr. Seifert around prescribing and can also consult with other NPs and psychiatrists,” explained Angela.

A typical day

  • Arrive at work, check emails.
  • Complete documentation from previous day and prepare for today.
  • Complete any notes related to previous days’ work.
  • Check lab reports/clinical information for new referrals.
  • Make calls to family members. 
  • Attend a referral meeting twice a week. 
  • Around 10am start to venture out to visit people in rest homes, including three D6 hospital level care facilities and five D4 level rest homes.

Angela enjoys spending time with the people who have been referred to her. “Listening to stories about their lives and gently drawing out information about their health problems is the part of the job I lovs the most,” says Angela. 

Key highlights from the early days of getting through the NP process

  • Becoming a NP – yeah!!
  • Getting out there and being able to practice autonomously. 
  • Having the freedom to practice clinically. 
  • Spending time with older people, listening to their wonderful stories and gently unravelling what their health problems are.
  • Helping to provide respite from symptoms.
  • Enabling people to improve their quality of life.
  • Working with family members or significant others. 
  • Enabling staff to better respond to older people. 
  • Feeling a huge sense of job satisfaction. 

Key messages for aspiring NPs

  • Put your head down and work hard. 
  • The hard stuff doesn’t last forever.
  • It’s worth it! 
  • Engage in good clinical supervision and mentoring.
  • Don’t think that your learning will ever stop.
  • Seek out support to develop your portfolio. This takes a few months to develop if you are working full-time but the process is much more streamlined now. “Lean and green I call it.”

Career pathway 

Angela graduated in 1982 as a registered general and obstetric nurse, and then in 1985 as a registered psychiatric nurse. Over the last 30 odd years Angela has worked in a variety of clinical settings in general health care and mental health, both as a manager and clinician. A brief summary of these areas are: community mental health service including rural teams, community therapeutic programmes, forensic service, acute mental health inpatient units, programme coordinator for new graduate nurses programme, duty manager role, acute mental health inpatient unit in London, general nursing in Maniototo and Dunedin Hospital and two years voluntary service as a general nurse in Papua New Guinea.

Attributes

In summary Angela's NP journey is characterised by these attributes.

  • Desire and resolve to become an NP. 
  • Commitment to lifelong learning. 
  • Dedication to supporting people experiencing mental health problems. 
  • Determination to succeed.
  • Diligence to produce a portfolio and courage to face a panel of experts.
  • Courage and ability to articulate the skills and knowledge of being a nurse practitioner to others.
  • Contagious sense of adventure and humour.

If you have any queries please feel free to contact Angela via email.