FOCUS: Learning & Leading
Nursing Review VOL 13 ISSUE 6 2013/$10.95
NEW ZEALAND’S INDEPENDENT NURSING SERIES
PRACTICE, PEOPLE & POLICY Cricket stars, privacy & ‘digital fingerprints’
EVIDENCE-BASED PRACTICE: Baby hopes and vitamins
A DAY IN THE LIFE OF
A NEW GRADUATE NURSE
WEBSCOPE
Health literacy
Q&A
Daryle Deering
EDUCATION
The science of storytelling “Hands-on” degree update
CNS to DoN CAREER PATH PROFILES
Leadership & Management FAST TRACKING LEADERS-TO-BE
GOOD NURSE = GOOD LEADER?
www.nursingreview.co.nz
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Inside:
LETTER FROM THE EDITOR Nurses and journalists – chalk and cheese? It has been interesting for the past decade writing about one of the most trusted professions as a member of one of the least trusted. Yet again in the recent Readers Digest poll, nurses came out as New Zealand’s fourth most trusted profession (just pipped by paramedics, firefighters, and rescue volunteers) while journalists came 43rd (falling between airport baggage handlers and real estate agents). I guess that just as not all journalists are unethical, scandal-mongering, sensationalists, nor are all nurses saintly, ministering angels. These stereotypes do neither profession any favours! I also suspect that journalists and nurses have more in common than their poles-apart reputations would lead you to believe. Most of us are smart, hardworking, and came into our professions with a belief in serving the public good. Both workforces sometimes struggle to hold onto those ideals under tight budgetary constraints. From my experience, nurses are also often good storytellers, and in this edition, we explore the use of storytelling in nurse education and have some nurses tell their own stories of their unique career paths. Nurses are also not all immune from the temptation of gossip … we have an article from a nurse-turned-lawyer on patient privacy breaches following the recent infamous “eel” x-ray and Jessie Ryder cases. And one of the areas I believe journalism as a profession has much to learn from nursing is the necessity to meet ongoing competency and professional development requirements. Jocelyn Peach looks back 25 years to the origins of the professional development recognition programmes (PDRPs) and what helped spur this very important work.
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Career Paths: the straight, the windy & the occasional u-turn
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SUE WHITE & the science of storytelling
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JACKIE McHAFFIE on telling tales at school
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EDUCATION: ‘Modern Apprenticeship’ 18 months on
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MANAGEMENT: SONIA GAMBLEN asks what gives you the right to lead?
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JOCELYN PEACH on fast-tracking PDRP in a decade of discontent
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Postgrad funding
RRR professional development activity (subscribers edition only) See subscription info at www.nursingreview.co.nz
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PEOPLE, PRACTICE & POLICY : Don’t read what you don’t need says ROBIN KAY
Regulars 2
Q & A Profile: DARYLE DEERING
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A day in the life of … new graduate nurse ROCHELLE PAICE
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Evidence-based practice: ANDREW JULL on fertility & vitamins
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Webscope: KATHY HOLLOWAY on literacy being everybody’s business
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College of Nurses column: Inspiring future Māori nurse leaders
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For the Record: News round-up
Connect with Nursing Review on Twitter www.nursingreview.co.nz
Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ
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Exclusive online content Nursing Review is a genuine multimedia publication. Our recently revamped website has content not found in the print edition, including exclusive online articles, live Twitter updates, social sharing, and the downloadable RRR professional development archive. Visit: www.nursingreview.co.nz COVER PIC: Rochelle Paice, a new graduate nurse at Waitemata District Health Board’s North Shore Hospital, shares a day in her life on p3. PHOTO CREDIT: Glenn McLelland, www.supersharpshooter.co.nz
Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
EDITOR Fiona Cassie @NursingReviewNZ ADVERTISING Belle Hanrahan EDITOR-IN-CHIEF Shane Cummings PRODUCTION Dan Phillips Aaron Morey PUBLISHER & GENERAL MANAGER Bronwen Wilkins PHOTOS Thinkstock
NursingReview
Vol. 13 Issue 6
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Errors and omissions: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.
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Q&A
Dr Daryle Deering
JOB TITLE: Senior lecturer, National Addiction Centre, University of Otago, Christchurch & President, New Zealand College of Mental Health Nurses Te Ao Māramatanga
Q A
and more broadly with nurses and other colleagues. The opportunities to contribute to influencing attitudes and practice, to develop national and international connections and networks, to work in partnership with consumers on projects and, in a university role, to advocate for change and support consumers to have a voice.
Where and when did you train? Sunnyside Hospital (psychiatric nursing) and Christchurch Hospital (general and obstetric training), 1975.
Q A
Other qualifications/professional roles? BA in nursing and psychology from Massey University. I did some postgraduate papers in health care management from Massey University before deciding operational health management was not for me and transferring to the University of Otago to complete a Master’s in Health Sciences in 1997. Then I completed my PhD, which looked at methadone treatment in New Zealand. There was little comprehensive research information on the nature of this long-term treatment for clients in New Zealand or client outcomes and perceptions of treatment.
Q A
When and why did you decide to become a nurse? I was curious about mental health and the impact of mental health issues and associated stigma on peoples’ lives. I saw an advertisement for prospective nursing trainees to have afternoon tea with the then matron of Sunnyside Hospital, Margaret Bazley (now Dame Margaret Bazley and patron of Te Ao Māramatanga New Zealand College of Mental Health Nurses). Talking with her was inspiring, and I subsequently commenced nursing training.
Q A
What was your nursing career up to your current job? I have spent over 35 years working principally in the area of community mental health and addiction. I have worked in paediatrics, a private psychiatric unit, adult mental health, community addiction services, family mental health, and youth mental health. I have been a staff nurse, clinical manager, regional manager, clinical tutor, clinical supervisor, and from 20002007, I was director of mental health nursing practice for the Canterbury District Health Board. I have been involved in community service developments, advanced nursing practice developments, service evaluations, policy development, and clinical research projects.
Q A
When have you felt particularly proud to be a nurse? When I see nurses contribute to making a difference to the lives of individuals and their families and whānau – for example, adolescents who have complex health issues returning to education and knowing that
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Nursing Review series Learning & Leading 2013
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What are the bits you love least? Being a citizen and a nurse in a society in which inequality is an increasing feature with associated negative health consequences for many families, particularly children.
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Have you ever wanted to give up nursing and why? No – while there have been many systems-related challenges, I have had amazing opportunities through nursing and worked with and got to know so many innovative nurses.
they have life options; people affected by addiction reclaiming their lives; people becoming aware about how they can improve their health and wellbeing; and people with mental health issues taking control and living fulfilling lives within their community.
Q A
What was your most embarrassing moment as a nurse? I am sure there were many – but I do remember receiving a leaving “present” that included a diary, key ring with a whistle etc. which brought attention to my habit of leaving a trail of “things behind me” and people knowing who they were likely to belong to.
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What is your current job all about? I work at the National Addiction Centre, University of Otago, Christchurch. The centre’s mission is to contribute to improving prevention and treatment in the area of substance use and addiction (and co-existing issues). It incorporates teaching, research, and promoting translation of research findings into practice – including addressing stigma. I also have a role in nursing practice developments with a national group of advanced practice mental health and addiction nurses and through Te Ao Māramatanga, New Zealand College of Mental Health Nursing.
Q A
What do you love about your current job? To combine clinical and academic work in a great interdisciplinary team
Q A Q A
Would you recommend your child/niece/ neighbour/grandchild to go into nursing? Definitely if they were interested in people and health and health behaviour change. What do you do to try and keep fit,healthy, happy and balanced? Enjoy the day, and like many people I know, put good intentions into practice and try to be mindful of health and positive psychology principles.
Q
Which book is gathering dust on your bedside table waiting for you to get around to reading it? Ratana: The Prophet by Keith Newman
A Q A
What have you been reading instead? Several other books – e.g. a Michael Connelly crime novel, Life after life by Kate Atkinson, and The Conductor, by Sarah Quigley
Q A Q A
What are three of your favourite movies of all time? Three of so many that come to mind are Annie Hall, Pulp Fiction, and Boy. What is number one on your ‘bucket list’ of things to do? I don’t have such a list, but I have yet to walk Milford Track and will be going with my partner to visit my daughter in Berlin in September.
A day in the life... of a new graduate nurse
NAME | Rochelle Paice JOB TITLE | New Graduate RN | LOCATION | Acute Orthopaedics, North Shore Hospital, Waitemata DHB
5.30
AM WAKE The alarm sounds. A quick change into a swimsuit makes for a cold start to the morning. Driving down to the local pool, I anticipate the plunge. After a 2km swim, I smile. I am mentally prepared for the day ahead.
be fine until I get back, can you just check on Mr J’s antibiotic? Antibiotics … a staple of nursing on the ward. I check my day planner. Two more antibiotics to give this afternoon.
1.00
PM VITAL SIGNS AGAIN A second set of vital signs to be taken and another round of analgesia thanks to the encouraging physiotherapists helping everyone to get back on their feet after surgery. It’s amazing what the body can go through.
6.45
AM WORK TIME After handover and patient allocation, the day begins. In the acute orthopaedic ward I’m in, we deal mainly with acute bone injury, spinal injuries, and cellulitis. The new graduate programme has been a perfect way to settle in and gradually integrate into the role of a registered nurse. Eight months into my first year and I love the work. You get to be a part of an extremely vulnerable stage in someone’s life and knowing you can make it that little bit easier is very rewarding.
7.30
AM Morning smiles, baseline observations, drain and epidural checks start the morning. A queue at the pyxis machines (medication dispenser) shows that everybody is waiting for pain relief. After morning washes and some analgesia administration, I call out to my nursing partner to help me turn Mr S. He was admitted a day ago with a neck of femur fracture. We turn him onto his side and check his back and other bony prominences for signs of pressure. We wash and moisturise. While he is on his side, I get him to take some deep breaths and have a cough – it is crucial we assist the prevention of bed-rest complications such as pneumonia. With a quick change of the sheets, we roll him back. He smiles as I pass him his cup of coffee. No surgery for him today, another day of waiting … It’s time for my own cup of coffee, but this morning will just be a quick break. Before I go, I need to run through a pre-op checklist with Mrs J. I have been notified she will most likely go down to surgery this morning, so it’s better to get it done now. You never know how the day will unfold.
10.00
AM BACK AFTER COFFEE BREAK We collect together in teams for a catch-up with the charge nurse. It gives the chance for an overview of the patients’ current condition and any new plans. Once up to speed, we head off in all directions to catch up on the workload. Whilst dressing a post-operative wound, I chat to Mr H and he shares stories about
2.00
PM I check on Mr C, who had a washout of his infected knee yesterday. He has spiked a temp of 38.7 degrees. His knee looks inflamed; it’s hot to touch. I send off a urine sample and some bloods. I page the house surgeon so they can review Mr C and decide on whether they want to get blood cultures or a chest x-ray.
‘back in our day’. Banter flies across the room from those who have been in hospital a while. It’s a really enjoyable atmosphere. I can hear my name being called from the nurses’ station – a phone call waits. With the dressing finished, my name is called again. Down the hallway to dispose of the dressing trolley, hands washed, then “Hello…”
11.40
PM THEATRE CALL My patient has been called to theatre, so time to get moving. Thank goodness I had a chance to go through the pre-op checklist this morning. A standard procedure on the ward but very new for Mrs. J; she is nervous. I talk to her about what it means to have a closed reduction of her fibula. Once I’ve finished going over the checklist with the pre-op nurse, I smile to Mrs J and with a short squeeze of the hand, I leave her on level one. Sometimes it takes a nervous patient to remind me that hospital processes that are now everyday to me are not familiar to them. It makes me think about their journey and the anxiety and fear that they are experiencing.
12.45
PM POST-LUNCH As I walk back on the ward after a bite to eat, patient bells are ringing as nurses pace up and down the hallways. I get a handover from my nurse partner so she can go on her lunch. Nothing major, she says, they should all
2.20
PM NOTES I need to get some time to do notes but a 2.30pm antibiotic has me back into the medication area, where I double check the fluid a colleague is getting ready and she checks my antibiotic. I draw it up, 2g flucloxacillin, it’s quite harsh on the veins, so I grab a burette and a bag of saline and go down the patient’s bedside.
3.00
PM SHIFT ENDING…NEARLY An account of the daily cares and a double check of all documentation. The afternoon staff enter the ward and we head to the hallway to begin the bedside handovers.
3.45
PM With the next shift up to date, it is time to leave work, a little late today… I’m knackered; don’t think I will squeeze in a run after work. Home to walk the dog instead.
5.30
PM DINNER I love early dinners on work nights and especially pasta during winter. The dog is at my feet, hoping for a morsel to be dropped accidently. After a blob in front of the TV, I muster enough energy to squeak in a bit of postgrad work before heading to bed.
9.00
PM BED I climb into bed, trying to calm my mind. It never works, as I am quietly preparing for the next day ahead.
Nursing Review series Learning & Leading 2013
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Learning & Leading FOCUS: We look to nurses as learners, educators, and leaders in this edition. Read on about teaching fledgling nurses in the classroom and on the ward, fostering leadership skills, nurses sharing their career tales, and milestones past and future in the recognition of competence and professional development.
Career paths: the short, sweet, and roundabout Career paths can be straight, windy, or full of detours. Nursing Review asked five nurses from across the country in senior roles to tell us what path they followed to where they are today. They all share a common passion for nursing but none share the same path. Three of these stories appear in print and two appear online. One took a side trip to caregiving, another started their journey as an enrolled nurse, one literally grew up on hospital grounds, and others had career paths Intro ??????? that took unexpected u-turns. They each have a good tale to tell and tips to share on career planning, the skills and qualifications helpful in their roles, the value of ongoing education, and how important a good mentor can be.
From caregiver to aged care nursing director NAME: Kate Gibb JOB TITLE: Nursing Director, Older People – Population Health, Canterbury District Health Board
Hospital. After some time as a staff nurse, I returned to the aged care sector in various senior clinical roles, eventually becoming manager of a rest home, hospital, and retirement village.
NURSING QUALIFICATIONS: »» Caregiver* »» BN 2004 Christchurch Polytechnic Institute of Technology »» PGDip in Health Sciences (Gerontology Nursing) 2008 University of Otago, Christchurch »» PGDip in Health Management (in progress) University of Otago, Christchurch
Did you have a career plan (vague or definite) on becoming an RN? How did those first five years influence your subsequent career? I had the fortune of working with an amazing mentor who encouraged me early on to consider a leadership role within aged care, and who spent time and energy supporting my development through my few years as a RN. I continued to love working with older people, so I knew that this was the area of nursing I wanted to pursue. The nursing experience and skills gained from working with older people are significant – the level of autonomy, assessment skills needed in caring for people with such complex needs, and leadership skills gained in working in residential care are often undervalued.
*I first started my nursing degree in 1997 but soon realised I needed some time out to ‘grow up’ a little bit more. I had been working parttime as a caregiver while studying, so I decided to go full-time as a caregiver, which I loved. I later re-started my studies and focused on gaining clinical experiences that would support me in a nursing career for older people. Briefly describe your initial five years as an RN? Immediately after qualifying, I worked as an RN in the residential care facility I’d already been working in as a caregiver. I then gained a place on the new graduate programme with the Canterbury District Health Board, at Older Persons Health’s Assessment, Treatment, and Rehabilitation service at The Princess Margaret
What qualifications, skills, or stepping stone jobs do you think were particularly helpful and/ or necessary in reaching your current role? I initially completed a postgraduate diploma in gerontology nursing and have begun another postgraduate diploma in health management, which I should finish in a few months. I’ve also been fortunate to be a member of the New Zealand Palliative Care Council since 2008, and this has been a fantastic opportunity to better understand our health system and strategic planning to improve outcomes for our older people.
Kate Gibb
What personal characteristics do you believe are particularly important for nurses working in your role? A passion for nursing first and foremost! While I don’t work directly with older people currently, the ability to listen and form relationships is as important in my role now as it was when I was in previous more ‘hands on’ roles. What career advice would you give to nurses seeking a similar role to yours? I think ongoing education is so important for exposing nurses to a breadth of knowledge outside their workplace. I’m a firm believer too in the impact mentorship can make. I would highly recommend nurses finding someone whose career pathway you admire and asking for their support. Describe your current role and responsibilities? My role is to provide professional leadership, knowledge, and strategic advice to nurses and organisations working with older people throughout Canterbury and the West Coast, and to work with primary and community providers to promote and support collaborative nursing initiatives and developments. This means I get the opportunity every day to meet and work with passionate people working within our health system to make a difference to older people in the communities where they live – I’m very fortunate. Nursing Review series Learning & Leading 2013
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Guided by making a difference for Māori & Pacific NAME: Amio Ikihele JOB TITLE: Senior Lecturer at Manukau Institute of Technology’s Faculty of Nursing and Health Studies NURSING QUALIFICATIONS: »» BN 2004 Manukau Institute of Technology »» PGCert in Health Science 2009 University of Auckland »» Cert in Tertiary Teaching 2010 Auckland University of Technology (AUT) »» PGDip in Health Sciences 2012 University of Auckland »» MHSc (First Class Honours) 2012 University of Auckland Why nursing? My interest in nursing was brought about by my grandparents’ health; both suffered from long-term conditions (LTC), with my grandmother having serious complications from type 2 diabetes. My mother was caring for them, and I wanted to understand more so I had the knowledge to help my family and others. Briefly describe your initial five years as an RN? I worked for four years as a primary health care nurse in South Auckland with Mangere Health Centre and one other clinic. I then became a GP Intro ??????? liaison for Breast Screening with Counties Manukau District Health Board for one year before returning to Manukau Institute of Technology (MIT) in 2009 to work as a lecturer at the nursing faculty. How did those first years of nursing influence your subsequent career? As a student, I realised working in PHC was the area where the biggest impact could be made on improving the health of people with LTC. I worked with a lot of Māori and Pacific people in my first jobs and felt this was where I was needed most.
Māori and Pacific health has always been a passion for me because of the health disparities faced by these two groups and I want to help to improve this situation Being Niuean and Māori, I was able to relate to both Māori and Pacific people and their families and understand their needs. In my breast screening role, I worked to raise awareness of the need for breast screening amongst Māori and Pacific women, where there are a lot of disparities in screening rates and a higher incidence of breast cancer. Because the age for breast screening is 45 to 69, there were definite barriers with me being young. The role was all about building relationships and trust to enable them to feel safe when using the service.
career plan and that I was working towards my Master’s degree. I started my Master’s in 2010 and wrote a thesis about the sexual health behaviours and sources of information amongst New Zealandborn Niuean adolescent girls. During the writing of my thesis, I had my two children and completed my Master’s in 2012. I loved writing my thesis and am contemplating doing my PhD in 2014.
What led you into your current field or specialty? Lecturing was always a job that I wanted to do. A position came up and I thought I would go for it. When I was training to be a nurse, there were only ten Māori and Pacific nursing students in a class of around 80. I also have a big interest in workforce development, so I wanted to see more Pacific and Māori people training to become nurses, and I love teaching so I felt this was a way I could encourage others into the field. By teaching the student nurses about the health disparities faced by Māori and Pacific, I hope to enable them to be both clinically and culturally competent when working with Māori and Pacific individuals and their families.
What career advice would you give to nurses seeking a similar role to yours? Go for it! If you feel that teaching is something you want to do, then apply because there’s always a lot of support that will be provided in order to help you transition from being a clinical practitioner to a lecturer to help you succeed in this role.
What qualifications, skills, or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role? When I first started at MIT, I was completing my postgraduate diploma. To be a lecturer, I needed to show my
What personal characteristics do you believe are particularly important for nurses working in your role? A passion for nursing and a love of teaching, plus good time management, a sense of humour, and an ability to relate well with others from diverse cultural backgrounds.
Describe your current role and responsibilities? I work as a senior lecturer and teach on MIT’s new Bachelor of Nursing Pacific programme that started in 2011, which will see its first graduates at the end of 2013. I love teaching on this programme because it incorporates the importance of being both clinically and culturally competent when working with Pacific and non-Pacific people. Our students learn to work within two worlds, a skill which is strengthened by the experiences they bring with them from home and through their personal development within the course.
Amio Ikihele
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Career u-turn leads to rural specialist role NAME: Cathy Sampson JOB TITLE: Rural Nurse Specialist, West Coast District Health Board NURSING QUALIFICATIONS »» RN 1987 Nelson Polytechnic »» BN 1994 Otago Polytechnic »» PGDip in Occupational Health 1996 University of Otago »» PGCert (Child and Family Health Nursing) 2003 Otago Polytechnic »» Prof. Cert. in Allergy Nursing 2007 University of South Australia »» MN 2007 Otago Polytechnic »» PGCert (Advanced Clinical Nursing) 2010 University of Otago Briefly describe your initial five years as an RN? I held several staff nursing roles in Dunedin Public Hospital (gynaecology, mental health, and casualty) for two years after graduating. I then joined colleagues in the United Kingdom as an agency RN working in private hospital medical wards, homebased care for the disabled, and a community unit for people with AIDS. I returned to Dunedin’s ED on night shift while studying for my postgraduate diploma in occupational health. Did you have a career plan on becoming
Intro an RN? ???????
No, I didn’t have a clear plan. However, my time overseas did help to shape my path into primary care. My years as a hospital-based nurse were valuable in consolidating basic skills but I became aware that acute care and the constraints of secondary care were not a natural fit for me. My experience in the AIDS unit in London highlighted the value of prevention in primary care. Hence, my move to occupational health, then public health, and onto my clinical Master’s dissertation in paediatric allergy nursing. What led you into your current field or specialty? The move to rural nursing was completely by chance. I had been working hard at developing an allergy nurse specialist role in Dunedin. However, a series of family
and chance events caused me to take a bit of a u-turn. As it turned out though, rural nursing is a very good fit for me. It utilises all the skills and experience gained over the previous 20 odd years and still enables me to put energy into prevention and primary care. As a mother, wife, and daughter, it has also allowed me to work part-time, enjoy a rural lifestyle, and be near extended family in my hometown. What qualifications, skills, or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role? My rural nurse specialist (RNS) role encompasses seven separate nursing contracts including well child, mental health, and PRIME (Primary Response in Medical Emergency). Contracts and hours do vary but RNS usually work alone and are on call afterhours. You need to have experience, and ideally qualifications, in a variety of nursing specialties, as well as the ability to work independently and flexibly. Fortunately, most of my varied primary care roles were autonomous; however, it would be fair to say my learning curve in the first year was near vertical as I gained role specific skills and qualifications. My Master’s degree was not specific to rural nursing, but it did provide the discipline to up-skill quickly. Gaining a PGCert in advanced clinical assessment and applied pharmacology was especially useful. Regular clinical supervision has been equally vital to maintain safety when working and living in a small isolated community where your neighbours and friends are also your patients. There are no specific rural nurse organisations but monthly meetings with the region’s other rural nurses is important to keep up-to-date, debrief, and prevent professional isolation or burnout. What personal characteristics do you believe are particularly important for nurses working in your role? An ability to maintain professional and personal boundaries, while at the same time remaining approachable and credible within the community is important. Being the main health provider in a small remote community can be likened to living in a fish bowl, your every move is watched. A thick skin, broad shoulders, and a sense of humour are vital!
Cathy Sampson
What career advice would you give to nurses seeking a similar role to yours? Gain as much experience in a variety of nursing roles and then start applying and give it a go. Rural nursing is immensely rewarding. It is one of the few nursing roles where you get to provide wrap-around care to the whole age spectrum and be flexible to meet their needs in a meaningful way. You just need to be careful not to try to be everything, to everyone, all of the time. Describe your current role and responsibilities? I work in a remote rural community of approximately 650 people on the West Coast. The rural nurse role is shared between two RNs working seven days on and seven off, including after-hours on-call cover. We operate a nurse-led service filling those seven contracts. Clinical support is provided by a weekly GP clinic and regular video or teleconference contact with our GP for routine issues, and ED doctors and specialists for acute concerns. Read online-only career profiles of an aged care facility manager and emergency department nurse manager at www.nursingreview.co.nz
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Nutrition Update – Iron Iron deficiency in toddlers – The consequences of iron-deficiency anaemia (IDA) are more serious for children aged between six months and two years than for adults,1 yet nearly 8 out of 10 (78%) New Zealand toddlers don’t meet their recommended dietary intake (RDI) for iron.2 And with 14% of under-twos deficient in this vital nutrient,3 it’s important for parents and healthcare professionals to bridge the iron gap to ensure the healthy development of our next generation. The first three years of life is a period of rapid growth where iron is needed to support the development of the brain. During this time, toddlers need 7 times more iron per kg of bodyweight than an adult.4 However, in reality, about 8 out of 10 NZ toddlers under 2 years aren’t meeting the RDI for iron2 and recent research has shown that 14% are iron deficient.3 Iron deficiency in toddlerhood can adversely affect cognitive and behavioural development which may continue into later life.5,6,7 The first three years of life is a period of rapid growth where iron is needed to support the development of the brain. During this time, toddlers need 7 times more iron per kg of bodyweight than an adult.4 However, in reality, about 8 out of 10 NZ toddlers under 2 years aren’t meeting the RDI for iron2 and recent research has shown that 14% are iron deficient.3 Iron deficiency in toddlerhood can adversely affect cognitive and behavioural development which may continue into later life.5,6,7
Why aren’t toddlers getting enough iron? There are two key risk factors that can place toddlers at risk of iron deficiency: 1. A diet with low intakes of iron: Many toddlers do not consume adequate amounts of iron-rich foods,2,5 with most iron sourced from cereals, fruit and vegetables.2 These plant sources contain non-haem iron which is not as well absorbed by the body compared to the haem iron found in animal foods like red meat and chicken. 2. Over-use of cows’ milk: More than 500 mL per day of cows’ milk is associated with lower serum ferritin concentrations, a measure of iron stores.8 This may be due to low iron levels in cows’ milk and high levels of calcium and phosphorus, which can affect iron absorption.1
Iron deficiency in the toddler years can have an impact for life6 There are three critical roles for iron in the toddler years: 1. Cognitive development: Iron plays an important role in the formation of haemoglobin and the transportation of oxygen around the body,4 and iron deficiency can adversely affect cognitive and psychomotor development.5 2. Behavioural development: Lethargy, irritability and inability to concentrate are key signs of iron deficiency in children – and the effects on children’s behaviour and socioemotional functioning may continue into young adulthood, even if the deficiency/anaemia has been corrected.6,7 3. Healthy immune system: Iron deficiency adversely affects immune function,1,4 possibly due to a decrease in serum Interleukin (IL)-6, which may result in increased susceptibility to infections.9
What’s the association between iron deficiency and obesity? Paradoxically, about 8 in 10 NZ children under 2 years aren’t meeting their recommended daily needs for iron, yet about 1 in 3 NZ children are overweight or obese.2,11 This association between low iron status and obesity has been described both in children and adults.12 Genetic influences, physical inactivity and a limited intake of ironrich foods may all contribute to this phenomenon, although the exact cause is unknown.13 Foods rich in non-haem iron10,*
Foods rich in haem iron10,* 3.0
Haem iron (mg)
3.5 3.0
3.2
2.5 2.0 1.5
2.3 1.7
1.0
1.1
0.5 0
1 beef rump steak, grilled (70g)
3/4 cup beef mince, cooked
1 lamb cutlet, grilled
1 chicken drumstick, baked
0.2 1 snapper fillet, steamed
Non-haem iron (mg)
4.0
2.5
2.6
2.0
2.2
1.5 1.0 0.5 0
0.7 1 egg, hard boiled
1.0
0.9
0.8
0.1
3/4 cup 2 whole wheat 1 slice 1 cup fortified 1cup 1 cup baked breakfast wholemeal breakfast full fat toddler beans biscuits bread cereal cows’ milk milk drink
* The factors that determine the proportion of iron absorbed are complex and include: iron status of the individual (iron absorption increases as deficiency increases); the form of the iron in foods (i.e. haem iron from
animal foods is better absorbed than non-haem iron); and the presence or absence of nutrients (e.g. vitamin C increases the absorption of non-haem iron, whereas calcium and phytates can inhibit absorption).
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bridging the gap Educational development needs iron
“Iron deficiency (ID) has remained prevalent in NZ since it was first identified as a child public health issue in the1960s. If NZ truly desires to build a knowledge economy it must first secure the educational potential of its next generation. Reducing the proportion of its children exposed to the adverse cognitive, behavioural and educational consequences of ID is necessary if the nation’s intellectual capital is to be realised.”2 Dr Clare Wall, Senior Lecturer of Nutrition, School of Medical Sciences, University of Auckland
3 simple ways to help bridge the iron gap There are several practical tips health professionals can offer parents to help improve their toddler’s iron intake and make every mouthful count.
1. Encourage healthy eating habits
Compared to the cows’ milk control group, the study found: of iron stores) • a significant increase in serum ferritin (a measure in the iron-fortified milk group (44%; P=0.002)5 milk group • a greater increase in iron stores in the iron-fortified (p<0.001) and red meat group (p=0.033)5 • significantly higher dietary iron intakes in the meat and iron-fortified milk groups; however, there was lower compliance in the red meat group.5
Advise parents to: • offer toddlers iron-rich foods regularly (e.g. red meat 3–4 times a week) • include vitamin C-rich foods to help absorb the non-haem iron in plant foods • encourage solid foods at mealtimes and drinks after meals • ensure toddlers do not fill up on drinks between meals.
Percentage change in serum ferritin (µg/L)5
2. Aim to include iron-rich foods every day
3. Try toddler milk drinks as an effective and practical strategy to increase iron stores in toddlers Advise parents that toddler milk drinks, as part of a healthy balanced diet, can help a toddler meet their high nutritional requirements for iron in a way that is familiar. Toddler milk drinks are based on cows’ milk that is enriched with nutrients, including iron, critical for a toddler’s growth and development. A recent NZ intervention trial to determine the most effective way of improving iron status randomly assigned healthy, non-anaemic toddlers to one of three groups: a red meat group, an iron-fortified milk group (replacing cows’ milk with iron-fortified milk) or a control group (non-fortified cows’ milk).5
Percentage change in serum ferritin (µg/L)
50
Use the graphs above to help parents understand the iron content of commonly eaten foods.10,*
40
Iron fortified milk
30 20 10
Red meat
0 -10
Control
-20
“Encouraging the consumption of iron-fortified milk in place of non-fortified cows’ milk from the age of 12–24 months is an efficacious strategy to improve iron status in toddlers that does not require radical changes in dietary habits”5 Toddler intervention study
FOR HEALTHCARE PROFESSIONALS ONLY
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References: 1. NZ Ministry of Health. Food and Nutrition Guidelines for Healthy Infants and Toddlers (aged 0–2 years). A Background Paper, May 2008. 2. Wall CR et al. Public Health Nutr 2008 Dec; 12(9):1413–1421. 3. Grant CC et al. Paediatr Child Health 2007;43:532–538. 4. National Health and Medical Research Council & New Zealand Ministry of Health. Nutrient Reference Values for Australia and New Zealand. Canberra: Commonwealth of Australia, 2006. 5. Szymlek-Gay EA et al. Am J Clinc Nutr 2009;90:1541–1551. 6. Lozoff B et al. Nutr Rev. 2006;64(Suppl):S34–S43. 7. Lozoff B. Paediatrics 2000;105 (4):51–61. 8. Soh P et al. Eur J Clin Nutr 2004;58:71–79. 9. Ekiz C et al. Hem J 2005;5:579–583. 10. Food Standards Australia New Zealand. NUTTAB 2010 online searchable database [Online]. Available at: http:// www.foodstandards.gov.au/consumerinformation/nuttab2010/nuttab 2010onlinesearchabledatabase/online version.cfm Accessed June 2013. 11. NZ Nutrition Foundation. Maintaining a healthy bodyweight for children [Online]. Available at: http://www.nutritionfoundation.org.nz/nutrition-facts/maintaining-a-healthy-bodyweight/children. Accessed June 2013. 12. McClung For more information please visit www.nutricia4professionals.com JP et al. Nutr Rev 2009;67(2):100–104. 13. Nead KG et al. Pediatrics 2004; Nutricia New Zealand Limited, 37 Banks Road, Mt Wellington, Auckland, New Zealand. NBM1585-28/6/13-NZ. 11163-NRNZ 114(1):104–108. RESEAR
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Intro ??????? Sue White
Role-play a memorable
teaching formula
Turning science into stories and mini-dramas has won Unitec nursing school science lecturer Sue White a Tertiary Teaching Excellence Award for 2013. FIONA CASSIE talks to her about science, storytelling, and helping nursing students discover the scientist within.
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ne nursing student draped in paper towels, another playing Cupid, and a third flexing his fingers ready to grab and grope … What is the lesson here you might ask? If you answered ‘muscle contraction theory’, go right to the top of the class. Sue White has been teaching anatomy and physiology to nursing students for 25 years and for many of those years she has been pulling volunteers from the lecture theatre to act out role-plays to bring complex science concepts to life. Some of us may struggle to recall that when sacroplasmic reticulum releases calcium, it removes the blocking action of tropomyosin, allowing the thick filaments of myosin to bind with the thin filaments of actin so your muscle can contract. But call a female nursing student Actin and wrap her in paper towels (tropomyosin), add a male student called Myosin with grabbing hands, and then call on another student to play Cupid (calcium) to shift the towels allowing Myosin to
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“grab” Actin’s binding sites and pull her into his arms before abandoning her to grab another student called Actin and then another… well, you may never flex a muscle again without seeing your groping classmate. More importantly, White says if she can hook in students both emotionally and intellectually, they are more likely to leave the classroom and joke about the role-play with their classmates and maybe talk about it with their families. The more they talk about what they did in class, the repetition will help the scientific information imbedded in the lecture to stick. White also gets the whole 180-student class to stand-up and role-play being a bacteria to illustrate why you need to complete a whole course of antibiotics rather than just stop when a person feels better. So on ‘day one’ of the antibiotic course, she ‘kills off’ the most susceptible bacteria (asks them to sit down) and continues to ‘knock off more until about ‘day five’ just a few of the toughest ‘bacteria’ are left standing and the ‘patient’ is not surprisingly feeling chirpier.
The role-play brings home to the students that to stop antibiotics at that point allows the most antibiotic-resistant members of the bacteria population to live on and replicate to fight another day. You definitely remember being bacteria that was ‘snuffed out’ or lived on. “I have met students years later who still remember the stuff they acted out in class,” says White. “Even ten years down the track.”
Unexpected ‘nursing’ career
It is finding the key to help each student learn that keeps White excited about teaching nursing students more than 25 years since stumbling unexpectedly into the nursing arena. She had contemplated nursing as a career growing up but her Dad vetoed that option, saying nurses weren’t paid enough. He wasn’t keen on her being an archaeologist or a teacher, either, but was keen on the sciences, and she found herself training as a cardiopulmonary technician at Greenlane Hospital and gaining her New Zealand Certificate in Science. Returning from her OE to Rotorua, she applied
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“I wanted to introduce my students to the wonder and excitement that science offers them rather than to the scary Intro ??????? side of it.” for a technician job at Waiariki’s then-new school of nursing and found herself persuaded to teach science instead. Introduced to the world of care plans and nursing philosophy, she has never left it and made teaching science to nursing students her career, gaining an MSc in science education from Perth’s Curtin University via distance learning. In the early days of teaching, she feared being asked to move on as she wasn’t a “stuffy academic”. “Which sounds really stupid now, having won this award. “I think part of my success is because I have to make it very real for the students, and because I wasn’t a straight A student myself, I change complex concepts and simplify them for the students so everybody can track along with what I am saying.” White also loves what she does – and while the nursing school lecturer has taught students other than nursing students, it is the nursing students she is fondest of. “I think nursing students are a special group … they are there because they have a passion for nursing, they are motivated, and they are really nice people on the whole.” Once entering the lecture theatre, she tripped and fell after catching her toe in the hem of her skirt. “I know in most classes the students would just have laughed and giggled but in my class of nursing students they all came rushing over to help me and check out I was alright, and for me, that encapsulates the difference between nursing students and some other students.” But while nursing students often arrive with a strong sense of empathy for people, the predominantly female students don’t always
have a natural inclination towards science. Many arrive either having a poor, or little, experience of science. “I wanted to introduce my students to the wonder and excitement that science offers them rather than to the scary side of it.” Her philosophy is to try and apply the science to their lives, and as a teacher of anatomy and physiology, the big plus is that everybody has a body and most people are interested to find out more about how it works. “I’m on a winner there, really”. So she introduces and illustrates a concept – with role-plays or real life horror or funny stories of science in action in the clinical environment – while blending in the scientific knowledge they need to absorb.
Science as yet another language
This includes learning a myriad of new scientific terms. This creates another teaching challenge at Unitec, where 70 per cent of the nursing students already have English as an additional language, 60 per cent are new New Zealanders, 30 per cent have had their high school education overseas, and large numbers are the first in their family to go into formal tertiary education. “These students are already coming into nursing with potential cultural and language barriers.” Some science educators say starting learning science requires a student to learn as many new terms as learning French. “The language (of science) is a barrier anyway, if you add that to the barrier of having English as a second language it becomes incredibly difficult for these students.” She tries to get round any language barriers and finds that developing alternative ways of
presenting concepts to students with English as a second language – like role-plays – benefits all students. White also makes a conscious effort to establish a relationship with each of her students and to get to know their individual barriers to learning so she can help them overcome them. As what keeps teaching fresh after 25 years is the changing faces in front of her and their individual needs. “For me, they are not just the student cohort of 2013, they are a collection of individuals.” With 180 students in an anatomy and physiology class, it sounds a big ask, but in the first week, she photographs them all and works on getting to know them by name – helped by also doing small group teaching during the students’ two-hour science labs each week. “You don’t win them all over – some are resistant or don’t engage,” says White. Or study loses out when students try to juggle family, study and work commitments.
Winning formula However, her strategy is working, with the vast majority of nursing students with her average pass rates comparing very well with international benchmarks of similar nursing science courses. White’s style has definitely won-over her students. Students have voted her best department lecturer every year bar one since 2005, along with winning best overall Unitec lecturer in 2006, 2009, 2010 and 2011. As one student put it: “I’m excited about science for the first time in my life.” White has shown that a little role-play can go a long way in making the driest of science fun. Nursing Review series Learning & Leading 2013
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I lived through it: teaching through telling tales Wintec nurse educator JACKIE McHAFFIE shares a tale or two about the role of storytelling in teaching nursing.
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hush went through the lecture theatre ... As an educator, I frequently question my purpose in the great game plan of nursing. I have forty years of nursing experience Intro ??????? in the profession. I became an educator to make a difference and inspire future generations of nurses with passion for the profession of nursing. Such noble thoughts were racing through my head as I gazed out at the 180 neophyte student nurses in the lecture theatre waiting eagerly for the word on the history of nursing as a profession. They had the timeline ‘from before to now’ on the screen above me. How do I make them want to listen and interact with the subject when the majority of them were not even born before the 1980s? Being of Māori and Irish descent, I draw upon my heritage to assist me in telling a personal story. I lived through some of this history, so who better to explain it to them than someone who lived through it? This would make me a relic from the past, so to speak. Story telling is an ancient technique used to educate, and therefore, empower, as well as to provide life lessons and hope. With the invention of writing and print, stories became books. The telling of stories to nurses who have no experience makes the reality seem closer for them. For example, when a question about “death and how do you deal with it?” rises from the lecture theatre it prompts me to share an oft-told tale of my own first experience: There I was with four months experience under my belt when my fellow student nurse and I went into wash and prepare the body of the deceased person for the relatives who were on their way in from home to see their dearly departed. This was the first time for the both of us. Coming from a religious and spiritual background, we both entered the room with reverence and no knowledge of what could happen. No one prepared us for the scientific fact that the lung space had filled with air so when we turned the body onto the left side, the inevitable WOOSH sound echoed from the deceased. My colleague flew down the five flights of stairs before someone caught her to explain. Me, I lost the power of speech and could only stammer and stutter out the words “b-b-b body WOOSH” and “not dead”.
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Nursing Review series Learning & Leading 2013
To this day, I have never let someone attend a dead body without mentioning the fact that when one dies nothing works anymore, so every space will fill with air if it can. These words of advice have now become known as the ‘Gospel according to Jackie’. Through sharing my stories, the students tend to relish them as one of their own and are more likely to remember the story’s lesson longer. We encourage students to use professional language but to use it with caution. I illustrate this by sharing the tale of the young girl quietly telling her best friend how the elderly neighbour had died. Encouraged by her educator mum from an early age to use the correct terminology, the daughter says “she died of an unstable vagina” . As the neighbour was in her nineties, I hasten to add it was actually “a case of an unstable angina”. Stories where we are the heroine always appeal to me, but I learned early on in my career that learning also comes from the good, the bad, and the ugly. It is the combination of all three that will guide student nurses in their learning. The awareness helps them to form a visual picture. Frequently students ask “how did you feel back then?” Which is my cue for another story, ‘My first injection’: Picture the nervous young student having checked and rechecked all her equipment and then walking to the bedside with her fellow student (I was a first year while she was a third year). The elderly gentleman was happy for me to do the injection. He said we all have to learn sometime, so it might as well be him I practised on. I went through the ritual of preparing the site and then prepared to insert the needle. In the back of my mind, I said the following words to myself: “be firm, don’t hold back, Jack, you need to breach the epidermial layer to reach the muscle”. In went the needle and bounced off the bone back to me. Forty years later, I can still feel the crunch like nails scrapping on a blackboard. The patient was not built like a muscle-bound beach guard. Rather, he was a thin elderly gentleman. Thank goodness for my colleague who quietly whispered “just do it with a different needle and insert it again, just not so far this time”. The patient then thanked me for my gentle technique. I just
Jackie Mchaffie
nodded and smiled because, in a rare moment for me, the power to communicate escaped me. The images from my stories may provide a note of caution or help to overcome fear, until the students have their own stories to tell that reflect on their own developing nursing practice. Whether spontaneous or planned, each story is a learning opportunity for students to further develop their scaffolding for nursing practice, knowledge, and experience. Storytelling is not new to nursing, with Pamela Wood analysing in 2009 a group of 16 kiwi nursing stories published between 1910–1914, which she refers to as backblock nurses’ stories. As nurses, we have a long tradition of folk tales, stories and narratives explaining what it is that we as nurses do. I will continue to tell my stories and hope this inspires others to include a piece of their history in their work for others to learn from. In the words of an Irish quote:
May you have the hindsight to know where you’ve been the foresight to know where you’re going and the insight to know when you’re going too far.
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Taranaki’s
Intro ???????
‘modern apprenticeship’ 18 months on, FIONA CASSIE checks up on Taranaki’s radical new ‘hands-on’ nursing degrees to see how the ‘modern apprenticeship’ is bedding in.
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utting nursing students at the patient bedside from just week two of their degree appears to be paying off. Eighteen months on from launching the new nursing degree, Taranaki’s nursing school is reporting higher student retention, and preceptors are reporting second year students appear more useful, confident and knowledgeable. The inaugural cohort of 54 students who started out in February last year is now down to 47 – an 87 per cent retention rate after five per cent attrition through family and personal issues and 8 per cent through failing academically. Which is less than previous years, says Diana Fergusson, head of the nursing school at Western Institute of Technology at Taranaki (WITT). Fergusson says placing students at the patient bedside from week two, so they can experience clinical theory in practice, is far from putting them off nursing. “Going into practice each week is actually keeping them highly motivated to keep studying and keep exploring the knowledge underpinning nursing – it was really quite motivating for them.” Gail Geange, associate director of nursing at Taranaki District Health Board with responsibility for professional development, agrees the early hands-on clinical experience is making a difference. She says the concern in the past was that students didn’t get out into clinical practice until the end of their first year and some students had never been in a hospital setting before starting training. “It’s very hard to hang theory on anything until you’ve been out there imbedded in the actual
clinical environment – understanding what it is like to be working with a variety of patients in different clinical areas,” says Geange. They also get an early understanding of what it is to be a nurse on the ward. “And that it’s not quite the same as you might see on TV,” adds Geange. First year students were now on the ward a day a week, seeing and putting in practice the nursing tasks and theory they are taught that week in the classroom. Geange says the benefits of having nursing students immersed early in nursing culture is paying off in the second year. She has been “really impressed” with the second year students links between theory and practice and preceptors were reporting the students had a “very good” knowledge base. “The preceptors are noticing their (2nd year students) knowledge is different than if they hadn’t been out experiencing what it is to be a nurse. Working those short hours in year one certainly pays off in year two, says Geange. “They’ve got the tasks they can go out and confidently do, while looking more holistically at the patients they are caring for with their preceptors.” They are also being introduced early to nursing culture, from observing RNs at work through to sharing the cafeteria.
Modern apprenticeship
It was the DHB, and other clinical partners, sending a strong message to WITT that they wanted a nursing curriculum centred on clinical practice that led to Fergusson developing the new degree. The programme
she wrote draws on US theorist Patricia Benner’s ‘modern apprenticeship’ philosophy and Christine Tanner’s case-based and concept-based learning theories. The total number of clinical hours offered to the students is similar to the old curriculum, but it is the timing and placement of those hours that is different. The first year sees the students starting the week with lectures on a concept, putting the concept into practice in the ward in the middle of the week, and then ending the week with tutorials, clinical scenarios, and labs to draw together and embed that week’s clinical knowledge. The students are placed into teams of four to six and each semester have a home base at either a medical or surgical ward and swap bases midway through the year. Each semester they also have a three-week placement in a mental health or paediatric ward, so by the end of the first year, they have experienced four different clinical settings. Whatever the concept they are learning that week – whether it is hygiene, vital signs, safe patient handling or fluid balance – they focus on it during their four to five hours on the ward with their clinical practice tutor. Fergusson says when they return to campus for tutorials, the student teams are reshuffled so that they get to hear and learn from the experiences of students in mental health and paediatric placements as well as medical and surgical. That first year was rounded of with a ‘consolidation Continued on page 14 >> Nursing Review series Learning & Leading 2013
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“They’ve also learnt that the night shift has actually got its advantages as well – in terms of having more time with the preceptor and being able to do a bit more learning and also caring for patients during a night shift.”
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Nursing Review series Learning & Leading 2013
week’ where students got to work four shifts with their preceptors in readiness for the second year curriculum of one week in the classroom, followed by one week on the ward. The second year kicks off with students experiencing the full reality of shift work, as the new degree was keen to have students ideally follow just one or two preceptors whenever possible. “Which means they are doing night shifts pretty much from beginning of year two,” says Fergusson. Night shift has been known to be a turn-off to hospital nursing for some young nurses. “It is a big shock to the system in transition to suddenly be working shift work,” says Geange. But both she and Fergusson say students have adapted well to being on rotating shifts. “They’ve also learnt that the night shift has actually got its advantages as well – in terms of having more time with the preceptor and being able to do a bit more learning and also caring for patients during a night shift,” says Fergusson. She adds that students largely having just one or two preceptors has made an “enormous difference” to their sense of belonging and achieving competence and the preceptors also prefer getting to know their student rather than having “different students every day”. “Because the students in year two have a much higher level of knowledge and skill base, they are actually working as part of the team because they can contribute to patient care pretty significantly now we’ve come to the end of the third semester (i.e. half way through degree).”
A work in progress
The second year introduces the concept of learning through case studies, in which a case study involving both physical and mental health concepts is gradually ‘unfolded’ to the students through lectures, teamwork, science and simulation labs, and online learning. The first semester’s learning was built around three case studies including one centred on a man with diabetes and depression which – by introducing a Māori cousin, a niece with type 1 diabetes, and an aunt with gestational diabetes – can be widened to look at depression and diabetes across the lifespan and taking in different cultural aspects. The second year clinical placements sees the students based in a medical or surgical ward for eight weeks of one 17 week semester. The other semester is split one-third between mental health and the remainder in new clinical areas like day surgery, the emergency department, and high dependency unit. With the new degree still a work in progress, it has been decided for the second half of the year to
shift from the previous one week in the classroom/ one week on the ward to trial a two weekly rotation. Geange says preceptors found that the on- week turnaround didn’t provide enough time to embed skills and knowledge and sometimes students had forgotten what they had learnt by the time they returned. “It was quite disruptive for both the clinical practice settings and the students.” Fergusson says another tweak the degree is undergoing is to improve the information flow to preceptors, including setting up a website on the DHB’s intranet for preceptors to access what the students are being taught. Meanwhile, both the nursing school and DHB are feeling confident that the skills built under the more hands-on degree programme means students are ready to be give IV (intravenous) drugs under supervision at the end of the second year. “That used to be purely a third year transition time skill,” says Fergusson. “Our feeling is that (IV management) can be done earlier as their knowledge is acceptable,” says Geange. “As long as they meet the theory and assessment requirements obviously,” she adds.
100% teaching staff turnover
Back on the WITT campus, the new degree is being delivered by a 100 per cent new teaching staff, with only Ferguson and her associate head of school still remaining from the old staff. “All of our eight lecturers are new in the last 18 months,” says Fergusson. She says rather than it showing a crisis of faith in the new curriculum, the 100 per cent turnover was largely due to a number of very experienced lecturers already close to retirement deciding to retire, believing it was time for new people to come on board. Fergusson says the new staff “really, really like” the new curriculum, with many of them coming to the school from clinical or non-education settings but with clinical education backgrounds. Next year will see the rolling out of the third year of the programme, which will concentrate on care in the community, including primary health care and residential aged care. The proof of the pudding of the new degree will be the successful passing of state finals and the ease in which the graduates transition into practice as registered nurses. Fergusson is confident to date that the first cohort will pass that transition with relative ease. “They (students) tell me that they feel like nurses and they feel like they belong and they are really contributing to patient care and they really feel like part of the team.”
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You trained to be a nurse:
what gives you the right to lead? Director of nursing SONIA GAMBLEN asks whether being a good nurse qualifies you to become a manager and leader, and she reflects on what characteristics and skills that nurse leaders need to foster or acquire.
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ver the years, managers and health professionals have had a turbulent past. To ease the warring factions, contemporary healthcare policy encourages managers to foster an understanding of the constraints in which public health systems have to operate. So does being a good nurse qualify you to become a manager and leader? Whether you manage few staff or many staff, you will be responsible for a variety of equipment, Intro ??????? resources, buildings, contracts, and budgets. You collectively endeavour to deliver a complex service to your customers. I would suggest that there is no other service that operates across such diverse and complex organisational structures as health services. But you trained to be a nurse; what gives you the right to practice management and leadership? Unlike most other services, we all have a vested interest in the end ‘product’ of the health service. The demand for our service is increasing: technology, biomedicine, and expertise has revolutionised quality of life and life expectancy – and will continue to do so. In such an explosive and dynamic environment you are required to manage competing demands from the community you serve, the health professionals within your teams, and the budget afforded you by your accountant. Today there is growing debate around the management style required to effectively manage such dynamic and complicated services. The term leadership has become synonymous with management. I suggest that management and leadership are different and that both are necessary attributes for all health service managers in different amounts at different times. Can leadership be taught? I am not so sure. I think leadership is an innate gene which for some, given the right circumstances, is awakened, while for others, it remains dormant (mindful that in some circumstances leadership can be narcissistic or maleficent!). Do not underestimate your influence; be it good or not so good, you will be copied! The attributes depicted on the table (see sidebar) are by no means exhaustive, but they do demonstrate the differences between management and leadership. I believe some of the characteristics are more easily learned while others require insight, reflection, and collegial altruism. Traditionally, management preparation has included in-depth study and analysis of finance,
Can leadership be taught? – I am not so sure. marketing, operational management, management science, strategy, organisation management, and information technology. This knowledge is indeed an asset in managing present and future healthcare services. I would stress the need to become acquainted with such phenomena if you are to fully interpret financial reports, outcomes data, structural changes, and organisational strategy in a meaningful way to the people who look to you for guidance and support. Leadership, however, entails good working relationships, including regular communication, trust, and mutual respect between you and your teams. These characteristics are crucial to ensuring work satisfaction for you and your staff and to ensuring a quality service results. Integral to any unit, department, or organisation is the distribution of power and authority; both are dangerous if not used constructively and yet necessary to stimulate creativity and achieve desirable results. You cannot achieve this by sitting in an office or reading it from books – an important part of your education is to understand how each person contributes to the service and to ensure that full potential is optimised. You understand the importance of evidencedbased practice – you need to apply this to managing and leading. This will require you to engage, research, and communicate with others in the field before proposing any changes to equipment, working
patterns, organisational structure or resource allocation. What I am trying to make you understand is that you must continue to learn throughout your management career. You may have acquired a set of competencies in your practice thus far; you will need to develop these further as the context of health care shifts between settings, between markets, and between professionals. As you progress through the next chapter of your career, unless you take the time to reflect upon your decisions, successes, and sometimes, failures, you will not accrue experience. Experience is gained through a process of reflection. Do not be confused: length of service does not equate to experience nor necessarily expertise! So you are a manager and a leader; you need to decide where your knowledge gaps are and what type of education, training or learning will help fill that gap. This requires you to acknowledge your strengths and weaknesses and to remedy deficits during a process of continuous reflection and career long learning. A mix of academia, placement practice, and reflection throughout your careers would to me seem a balanced diet on which to feed. Sonia Gamblen is director of nursing for Tairawhiti District Health Board. Her research for her Masters of Management degree looked at the leadership and management requirements to be a clinical nurse manager.
Characteristics of management and leadership Management (Fayol, 1949)
Leadership (Kouzes & Posner, 1987)
Forecast & Plan
Inspiring a shared vision
Organise
Modelling the way
Command (making sure tasks are completed)
Challenging the process
Coordinate
Encouraging the heart
Control
Enabling others to act
From: Wedderburn Tate, C. (1999). Leadership in Nursing. London, Churchill Livingstone p. 32 & 41
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First PDRP fast-tracked
in response to decade of discontent
Intro ???????
Twenty-five years on, JOCELYN PEACH looks back at the discontent, health reforms, and courageous leadership that prompted the speedy development of the first PDRP (professional development and recognition programme) and the legacy of that 1988 action.
P Jocelyn Peach
They modelled leadership and confident response to change and recognised that the profession needed to look globally at best practice.
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rofessional nursing today has been influenced by the foresight of nurse leaders in past decades. Leaders such as Sally Shaw, Anne Murphy, Ron De Witt, Gay Williams, Nan Kinross and others were courageous, outspoken and – through horizonscanning – promoted professional selfdetermination. They modelled leadership and confident response to change and recognised that the profession needed to look globally at best practice. They empowered nurses to take charge of leading nursing practice, which is our mandate. They encouraged nurses to develop professionally through postgraduate education and introduced new advanced practice roles so that nursing contribution could be visible.
The beginning: growing discontent
New Zealand’s first PDRP was implemented in the late 1980s and was a response to the challenges of that decade. The then-Auckland Hospital Board was experiencing difficulty recruiting and retaining registered nurses as the board transitioned from relying on students and hospital training to polytechnic-based comprehensive nursing programmes. It had been assumed that the registered nurse (RN) graduates emerging from the schools of nursing would increase the professional leadership numbers at the bedside. Vacancies, however, resulted in
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closure of beds and wards in many areas. Centralised staffing, which saw nurses placed in vacant positions, regardless of the nurse’s specialty practice expertise or interest, compounded this. The continuation of the traditional hierarchal leadership system – with its recognition of years of service – also resulted in stalled career pathways for the new generation of nurses. Nationally nurses marched as part of the “Nurses are Worth More” campaign. This was a time of discontent and frustration as registered nurses sought to be recognised, valued, and supported in their practice development. Nurse leaders in New Zealand and internationally were grappling with similar issues of retention of registered nurses and development of practice expertise for new technologies. Two important works published in the early 1980s influenced professional and development frameworks internationally and in New Zealand. The first was Margaret McClure’s 1981 publication Magnet Hospitals: Attraction and Retention of Professional Nurses, which examined the causes of the hospital nursing shortage and why some facilities were successful in creating nursing practice environments that were ‘magnets’ for professional nurses. In 1984 followed Patricia Benner’s From Novice to Expert: Excellence and Power in Clinical Nursing Practice, which described the five stages
of skill acquisition, the nature of clinical judgement and experiential learning, and articulated the seven major domains of nursing practice. These two publications were brought to the attention of Anne Murphy, chief nurse of the Auckland Hospital Board, through the board’s nurse advisor, Sam Denny. That prompted Murphy to visit a number of the ‘magnet’ hospitals in the United States on her way to the International Council of Nurses (ICN) meeting in Geneva. The nurse leaders at the American hospitals generously shared their ideas and resources, and she returned with information, ideas, and a strong agenda for change.
Health reforms prompt urgency
In March 1988, Murphy and her deputy chief nurse, Ron De Witt, asked for the professional development and recognition concepts from these US programmes to be developed into a framework for all nursing and midwifery groups working in the Auckland Hospital Board area. Implementation was to be underway by July of that year. Rapid work was done to create the framework and the evolving programme was called Professional Development and Recognition Programme – Towards Excellence. Implementation was similarly rapid with the programme launched just a few months later to the senior nurses
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across eight hospitals and community services and then on to many of the 5000 nurses and midwives working in a variety of settings across the region. The timeline was so rapid as Murphy and De Witt had the foresight to realise that the 1988 State Sector Act would radically change the health system in the late 1980s and early 1990s. The urgency to get the processes in place was motivated by the anticipated change to area health boards and the shift to general management structures. So they sought a way to address the major workforce and quality issues that would challenge health service provision under the management reforms. As nurse leaders they wanted to ensure that nurses and midwives retained professional autonomy over their practice, whether they were managed by nurse and midwife managers or not. This proved to be a fortuitous decision. The new PDRP framework (see sidebar) was supported by a clinical career pathway and change in nursing leadership roles. Clinical nurse educators, clinical nurse specialists, and nurse consultant roles were introduced, which brought forward enthusiastic nurses who were undertaking postgraduate qualifications and were eager to apply new learning. The career pathway ensured that nurses were supported to provide the best care possible by clinical management roles and clinical practice roles. Intro ???????was launched in the Auckland The programme Hospital Board area in May 1988 and evolved over the following two years. As ‘project manager’, I was tasked with implementing the change with the principal nurses of the day, across the hospitals and community settings from Warkworth to Pukekohe. This was a challenging task and the initial ‘roll-out’ was achieved by the due date through the enthusiastic support of the professional leaders.
National adoption of many of the PDRP concepts
The PDRP was gradually later applied in a number of areas nationally, using the core concepts and adapting slightly to local conditions. Over time,
PDRP became the professional development framework, supported by the New Zealand Council of New Zealand, New Zealand Nurses Organisation (NZNO), and other professional groups. Midwifery developed its own programme using similar concepts, with its distinct professional priorities. In 1988 (for an article published in The Professional Leader) I looked back at the key issues (*see key issues box) that a decade before had provided the impetus for establishing the PDRP framework and found improvement across all issues. The PDRP had provided a framework for effective clinical and human resource support and for recognising excellence in professional practice. The programme had also provided structured support, had influenced learning programmes, and recognised proficient and expert practice and the supported development needed as nurses worked towards advanced practice roles. In 2003, the Health Practitioners Competence Assurance (HPCA) Act was enacted and required regulatory authorities, such as the Nursing Council of New Zealand, to set the continuing competence requirements nurses had to meet to receive their annual practising certificate (APC). In September 2003, the Nursing Council approved a framework for recognising professional recognition programmes that met those APC continuing competence requirements. The Nursing Council used the existing frameworks that had been used for over a decade in PDRPs nationally. The PDRP process became the recertification programmes under section 41 of the HPCA Act for the purpose of ensuring nurses were competent to practise. This created a continuing competence framework (CCF) as a quality assurance mechanism and allows nurses to demonstrate annually that they remain competent and fit to practice.
Measuring PDRP’s contribution to practice and organisational effectiveness It was acknowledged from the beginning that it would be a challenge for nurse leaders to quantitatively measure and present evidence of the contribution and impact of the PDRP.
“Towards Excellence” – the 1988 Professional Development and Recognition Programme [PDRP] The programme framework was developed around four quadrants: Recruitment Selecting the right people with the right qualifications placed in the right position/ specialty, selected by the charge nurse manager to fit the team. This was an innovation at the time and required the charge nurse manager to learn about human resource management. Development This includes orientation of all new staff to the organisation and settings by a preceptor; familiarisation to the specialty practices and competencies for a ten week period; appraisal at ten weeks and annually thereafter. Education, learning, and coaching developed for each level of practice from new practitioner through to competent, proficient, and expert.
Administration Clear policies and procedures guide practice, support practice decisions, and support career progress. Emphasis was placed on retaining nurses at the bedside to provide the best care possible. Portfolios were introduced. Senior nurse roles changed from supervisors to other career roles in recognition that registered nurses needed less supervision and more support for their development. Review Monitoring and audit of practice by proficient and expert nurses was introduced. This included review of contemporary and evidence-based practice and encouragement of proficient and expert nurses to learn skills to lead change in clinical practice.
Few researchers have considered measuring the PDRP outcomes using quantitative and qualitative measurement, relying anecdotally instead on descriptive analysis of ‘before and after’. The PDRP Coordinators group plan to work with key organisations on analysis of the PDRP on professional development, retention, the benefits of levels of practice on skill mix, retention, and practice safety and organisational effectiveness. In conclusion, over the past 25 years the PDRP concepts and framework have been applied to nursing nationally and integrated by the Nursing Council into the Continuing Competence Framework. The programme has become part of the professional practice of nurses in New Zealand. As a legacy, the PDRP has supported generations of nurses to develop their practice and also influenced the career development of many nurses. Tawhiti rawa i to tātou haerenga atu te kore haere tonu, maha rawa o tātou mahi te kore mahi tonu. We have come too far to not go further, we have done too much to not do more [Sir James Henare] About the author: Dr Jocelyn Peach, RGON, ADN, BA [Soc Sci], MBS, PhD is director of nursing and midwifery at Waitemata District Health Board. She was the original project leader for PDRP development and implementation in Auckland and remains passionate about the value of the programme. NB References for this article will be available online at www.nursingreview.co.nz or by emailing editor@nursingreview.co.nz Read an online-only article on NZ plans for ‘certifying’ mental health nurses at www.nursingreview.co.nz
Some of the key issues in 1988 prompting PDRP development »» shortage of experienced nurses and fewer RNs with a reliance on a student workforce and enrolled nurses »» high turnover of nurses and midwives (40 per cent) »» centralised employment of nurses with nurses placed where there was a vacancy rather than because of expertise or interest »» new graduates from comprehensive programmes did not receive structured orientation and familiarisation »» no consistent performance management processes »» no preceptor processes or peer review processes »» no mechanism for recognising and rewarding excellence and performance »» no mechanism for differentiating skill and expertise »» poor integration of quality systems with staff practice – e.g. an emphasis on rules rather than recommended best practice »» poor clarity of expectations and minimal awareness of risk management »» minimal reflection on practice »» limited post-registration education linkage »» minimal succession planning.
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Postgraduate funding for 2014 unknown An announcement is expected soon about the funding and priorities for nurse postgraduate study in 2014 – and possibly, change is afoot.
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n recent years, the funding pool available for nurses wanting to pursue postgraduate study has stayed static at around $12 million a year and training priorities have continued to be aged care, rehabilitation, and mental health and addiction. For the past two years, Health Workforce New Zealand (HWNZ, which has administered postgraduate training funding since 2011) has indicated in advance that the status quo would continue for funding and training priorities for the following year. But when Nursing Review asked in mid-August this year whether the same funding and focus were likely to ??????? continue in 2014, an HWNZ Intro spokesperson said postgraduate nurse funding for 2014 had not yet been approved and the HWNZ board had also yet to agree on postgraduate training priorities for 2014, including nursing. “But HWNZ would expect to continue to support nurses seeking to undertake postgraduate study,” the spokesperson said. When HWNZ was asked further whether any major restructuring or changes to postgraduate nursing funding were being considered for 2014, it declined to answer. Last year, the former director of HWNZ, Brenda Wraight, said HWNZ was to carry out a full review of postgraduate nursing funding in 2013, but no review is known to have taken place.
Ring-fence ‘stick’ on its way?
In January this year, HWNZ chair Des Gorman indicated a “financial stick” could be used from next year if district health boards did not start providing ring-fenced jobs for nursing new graduates. HWNZ administers the funding for the new graduate NETP programmes, as well as postgraduate training, and Gorman first mooted ring-fencing new graduate ‘intern’ places in 2010, when new graduate nurse unemployment started to emerge as a problem. The call was taken up by Ministry of Health Chief Nurse Jane O’Malley in 2011, but few DHBs have made the full shift to ring-fenced 12-month contracts for new grads. Gorman told Nursing Review that HWNZ had been clear since it set up regional training hubs that DHBs needed to provide ‘proper internships’ for nurses, including ring-fenced jobs, and training money could be at risk if they didn’t. “The money is a dry run this year. But in the financial year 2013-14, there will be money at risk. In the financial year 2014-15, it won’t just be money at risk, it will be the entire funding at risk,” he said Sue Hayward, head of the Nursing Education Advisory Team (NEAT), said in mid-August that she had yet to hear anything about postgraduate funding changes for 2014. “I had assumed it would stay at the same level. We are all hoping the requests we have made to allow a little more flexibility around the areas we can focus on will be supported by
Graduate School of NurSiNG aNd Midwifery Wherever you want to take your career—clinical practice, leadership, education or research—we can help you get there. Expand your knowledge with a postgraduate qualification in nursing from Victoria University of Wellington. Find out more at victoria.ac.nz/nmh or by calling 0800 108 005
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HWNZ,” said Hayward, who is also director of nursing and midwifery for Waikato District Health Board. “I think HWNZ would look at the success of both the funding levels and the processes for allocation and see there is nothing to be gained from a workforce development prospective if changes were made, especially with no dialogue with the sector,” said Hayward. Kathy Holloway, chair of nurse educator group NETS, said she was unaware of any proposals to change funding for 2014. She recently attended a HWNZ central regional training hub meeting with the region’s directors of nursing as an education representative. “There is support in the group for a regional approach to workforce development and a commitment to meet collectively more often but no specific actions as yet,” said Holloway. Skills Matter, the training funding arm of mental health workforce agency Te Pou, has been advised that it will continue to manage HWNZ training funding targeted for the mental health and addiction workforce. Fiona Hamilton, the Skills Matter programme lead, said actual HWNZ funding levels for programmes like its clinical leadership in nursing practice
programme were yet to be confirmed, but the organisation hoped to maintain the same level of funded places.
Support for new role training
Hayward said one area where DHBs were experiencing barriers was using their HWNZ funding to support the clinical training for new expanded practice roles like registered nurse first surgical assistant (RNFSA) and nurse colposcopists. “In expanded practice, there’s a requirement not only for postgraduate study but also for having those nurses taken off the roster to spend time working alongside a nurse already qualified in the field or a consultant. “DHBs are saying they don’t have the FTE capacity to fund supernumerary time while that nursing is learning a different scope,” said Hayward. “We are wanting to know whether we can negotiate with HWNZ to use our existing funding in a different way.” HWNZ said it did propose to provide support for new roles for nursing, including RNFSA, “and other roles that contribute directly to addressing government priorities and health targets”
HWNZ-funded postgraduate study statistics HWNZ postgraduate nurse training units* 2010 1753 units 2011 1526 (projected) 1428.7 (actual) 2012 1442 (actual)** 61% (DHB), 32% (Primary & Aged Care), 7% (Rural) 2013 793.3 (first semester only) *A training unit is the equivalent of a two paper PGCert or one year of a PGDip or Master’s degree programme (with or without clinical mentoring). The cost of a unit can vary from $7,374 per annum to more than $28,000 per annum. **DHB postgraduate training coordinators reported to HWNZ that overall 2426 nurses were supported in 2012 (through HWNZ or DHB funding) to study postgraduate papers.
Te Pou Skills Matter (targeted mental health nurse postgraduate funding) 2012 42 funded places in Clinical Leadership in Nursing Practice (CLNP) programmes for mental health & addiction nurses who are current or emerging clinical leaders. (Equated to 50 nurses receiving some level of funding for postgraduate study at the three contracted university providers) 2013 40 funded places on CLNP programmes. (50 nurses)
EVIDENCE-BASED PRACTICE
Baby hopes and vitamins Does taking vitamin supplements help women with fertility problems? CLINICAL BOTTOM LINE:
PubMed clinical queries (Broad): Antioxidants AND subfertility
were searched, reference lists from retrieved articles checked and a Google search conducted. There were no language limitations. Risk of bias – two reviewers independently screened and selected included studies and extracted data. Disagreements were resolved by discussion or a third reviewer – authors were contacted for additional information if data was not described. Only where clinical heterogeneity was sufficiently low were studies combined in meta-analysis. Quality assessment – Methodological quality in each study was independently assessed by two reviewers. Elements assessed were randomisation generation, allocation concealment, blinding of intervention, incomplete outcome data reported, selective outcome reporting and other sources of bias. Publication bias – was assessed using funnel plots. Overall – a high quality review of generally low quality studies.
CITATION:
RESULTS:
Showell MG, Brown J, Clark J, Hart RJ. Antioxidants for female subfertility. Cochrane Database Sys Rev 2013, Issue 8. Art No.: CD007807. DOI:10.1002/14651858. CD007807.pub2
Twenty eight trials involving 3548 women were identified. Nine trial compared antioxidants to placebo, nine trials compared antioxidant to no treatment or standard treatment, two trials compared antioxidant to antioxidant, two trials compared pentoxifylline to placebo, one trial compared pentoxifylline and vitamin E to no treatment, four trials compared antioxidants and a co-intervention with placebo and a co-intervention, and in one trial the control was not specified. Nine trials did not report randomisation sequence, twenty-two trials did not adequately report allocation concealment, Eleven trial studies were not blinded or did not report blinding and eleven trials used incomplete outcome data. Antioxidants did not increase live birth rates or pregnancy rates (Table). Adverse events included miscarriage, multiple pregnancy, gastrointestinal disturbances and ectopic pregnancy. There were no significant differences on each of these types of adverse event.
Taking oral antioxidants is unlikely to improve the chances of getting pregnant for subfertile women.
CLINICAL SCENARIO: You and your partner have been trying for more than one year to get pregnant. You are increasingly worried that you might have fertility problems. Friends have told you that vitamin supplements (antioxidants) may increase your chances of getting pregnant. You decide to have a look at the literature.
QUESTION: Among women with fertility problems, does taking antioxidant supplements increase rates of pregnancy?
SEARCH STRATEGY:
STUDY SUMMARY: Systematic review of oral antioxidants compared to placebo, no treatment, standard treatment or another antioxidant. Inclusion criteria were: [1] type of study was randomised controlled trials; [2] Patients were subfertile women attending a reproductive clinic that may or may not be using assisted reproductive technology. Subfertile was defined as couple trying to conceive for more than one year without success; [3] Interventions: any type of antioxidant supplementation including pentoxifylline used in addition to subfertility treatment; [4] Outcomes were live birth, rate of pregnancy and adverse effects. In all 2197 study titles were screened, 67 were retrieved for further review and 28 trials were included.
STUDY VALIDITY: Search strategy – electronic searches were made of Cochrane Menstrual Disorders and Subfertility Group Specialised trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS and OpenSIGLE. Conference abstracts and citation lists on ISI Web of Knowledge
COMMENTS: Overall the trials were considered low quality because of the number of smaller studies included, the high risk of bias within the studies, and amount of statistical heterogeneity in the main analyses.
Reviewer: Dr Andrew Jull, RN PhD, Associate Professor (School of Nursing, University of Auckland), Nurse Advisor – Quality & Safety, Auckland District Health Board.
Table. Results with 95% confidence intervals Antioxidant
Control
Odds Ratio (95%CI)
% heterogeneity (I2)
Live birth (2 trials, n=97)
48% (23/48)
37% 18/49
1.25 (0.19 to 8.26)
75%
Pregnancy (13 trials, n=2441)
25% (343/1383)
23% (244/1058)
1.30 (0.92 to 1.85)
55%
Think outside the box! Want to be your own boss?
Nurses in Business Seminar
Wellington, 7th November 2013 Many nurses have left public healthcare to be involved in healthcare businesses. Some run nursing homes or nursing services; some have set up companies or social enterprises that provide services, education or consultancy. Changes in the healthcare system, and the increasing scope of professional practice, mean their numbers will grow. This seminar is for nurses who are interested in combining their professional skills with business opportunities and who would like to know more about how to get started. This seminar will provide vital information for nurses interested in entrepreneurship, self-employment, consulting, or an RN/ health business. Share learning and insights by networking with experienced nurse entrepreneurs and receive advice from a variety of business advisors from planning & insurance to marketing.
RN Professional Portfolio Development Workshop All regions around NZ. Be prepared for a Nursing Council audit. This enjoyable & invaluable day provides you with all the skills & information required to complete and maintain your Professional Portfolio with ease as required under the HPCA(2004).
Professional Boundaries & Relationships Workshop All regions around NZ. Being involved in caring and advocating for other people can involve complex and challenging personal and professional situations. Attendees will gain an in-depth understanding and knowledge of the current Nursing Council Professional Boundaries, Code of Conduct and the Code of Ethics guidelines. Beneficial for all registered nurses and highly recommended for Nurse Managers especially if supervising nursing staff.
www.nurse.org.nz Dates, information & registration on our website ‘workshops’ tab
WEBSCOPE
Health Literacy – everyone’s business Today’s patients and families have a myriad of health information just a click, a phone call, or an appointment away. The challenge is understanding and processing all that information to meet their health needs. KATHY HOLLOWAY calls on nurses to step up their health literacy skills.
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recently attended the International Council of Nursing’s 25th Quadrennial Congress in Melbourne. The congress brought together almost 4,000 nurses from more than 100 countries and every region in the world to discuss nursing’s key role in improving equity and access to healthcare.
A key message from the ICN congress for me was that health is the foundation for development rather than merely the outcome. One of the significant challenges identified for consumers is the multiple sources of information available to them about health and healthcare from the internet. A key concept identified in enhancing informed consumer choice is health literacy. Health literacy is defined by the US Department of Health and Human Services as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”.
How health literate is your organisation? Health literacy is as relevant for health professionals and healthcare organisations as much as for the populations we serve. An Institute of Medicine (IOM) report last year identified the Ten Attributes of Health Literate Health Care Organisations as: 1. Has leadership that makes health literacy integral to its mission, structure, and operations. 2. Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement. 3. Prepares the workforce to be health literate and monitors progress. 4. Includes populations served in the design, implementation, and evaluation of health information and services. 5. Meets the needs of populations with a range of health literacy skills while avoiding stigmatisation. 6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact. 7. Provides easy access to health information and services and navigation assistance. 8. Designs and distributes print, audiovisual, and social media content that is easy to understand and act on. 9. Addresses health literacy in high-risk situations, including care transitions and communications about medicines. 10. Communicates clearly what health plans cover and what individuals will have to pay for services.
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How confident in health literacy do you feel you are? A 2010 report suggested that over 50 per cent of New Zealand adults are likely to experience health literacy difficulties. Poor health literacy affects people’s ability to navigate the healthcare system, provide a clear health history, engage in self-management of health and understand concepts of probability and risk.
The Waipuna Statement 2011: Health Literacy is everyone’s business (http://bit.ly/169pJsD) calls upon all health professionals in New Zealand – this means you – to recognise that health literacy is your responsibility. You need to develop your communication skills to meet the varied needs of all your patients and communities; to always check that you have understood the needs and concerns of the patient correctly and always check that your message has been understood by using techniques such as summarising and ‘teach-back’ (also called ‘closing the loop’); and to develop teams with communication and health literacy in mind. Health literacy has been reported to be one of the strongest demographic factors associated with health outcomes, greater than age, ethnicity and socioeconomic factors. Awareness of the individual and systemic factors that affect the levels of health literacy is therefore important. One of the key elements identified is the clinicianpatient communication from what is being discussed at the point of care, how it is conveyed, whether it’s understood and so on. So it is our job to make sure that we can support health literacy through developing our own skills in accessing and using information appropriately. Nurses are often the initial point of contact for questions and requests to assist in clarifying information found on the internet or given out by other health professionals. Studies show that people who understand health instructions make fewer mistakes when they take their medicine or prepare for a medical procedure, which means better safer patient outcomes. They may also get well sooner or be able to better self-manage a chronic or complex health condition – so it is our job to be prepared to facilitate health literacy as with awareness comes informed choice. View or download full document at: http://bit.ly/PkXONh Kathy Holloway is dean of the Health Faculty at Whitireia Community Polytechnic
CHECK THESE OUT
Effective Communication Tools for Healthcare Professionals http://www.hrsa.gov/publichealth/ healthliteracy/ The Health Resources and Services Administration (HRSA), is an agency of the US Department of Health and Human Services. The role of this agency is to improve access to health care services for people who are uninsured, isolated or medically vulnerable. This free online course is recommended by our own Health Navigator New Zealand site. The stated aims of the course are to assist the health professional to: • Acknowledge cultural diversity and deal sensitively with cultural differences that affect the way patients navigate the health care system, • address low health literacy and bridge knowledge gaps that can prevent patients from adhering to prevention and treatment protocols, and • accommodate low English proficiency and effectively use tools that don’t rely on the written or spoken word [Site accessed 28 July 2013 and last updated May 2013]
Workbase - New Zealand Health Literacy http://www.healthliteracy.org.nz/ This site was developed to support health professionals, managers and policy makers in New Zealand by providing comprehensive free information about health literacy, and easy access to some very interesting resources for both clinicians and educators. There are additionally excellent links on the site to presentations from last year’s Workbase and Health Navigator New Zealandhosted “From Discussion to Action” conference in Auckland. [Site accessed 28 July 2013 and last updated July 2013]
COLLEGE OF NURSES
Nurses blossoming through leadership programme
MARGARETH BROODKORN shares some inspiring stories of how the Ngā Manukura ō Āpōpō programme is building a new generation of much-needed Māori nursing and midwifery leaders.
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ecent workforce data indicates that while the Māori health workforce has improved in some health professions, overall, there is still a significant under-representation of Māori. The proportion of Māori registered nurses doubled from 1991 to 2001 to six per cent. By 2009, there were 2803 active Māori nurses in the health workforce. 2011 data notes 3,487 nurses who identify as Māori (7.1 per cent), of which seven nurse practitioners are Māori (7.8 per cent). It is well documented that clinical education and leadership make a difference in health care provision. This is of paramount importance to the Māori workforce if we are to make a difference to Māori health disparities. A national Māori nursing and midwifery workforce programme, Ngā Manukura ō Āpōpō, aims to make a difference by supporting the retention, recruitment, and continuous development of Māori nurses and midwives. The programme, known as NMoA for short, commenced in 2010 and focuses on three key work streams: clinical leadership, professional development, and recruitment and profile-raising. NMoA, as well as Kia Ora Hauora, earlier this year profiled two inspirational new graduate nurses from Te Tai Tokerau. Cheryl Turner and her daughter Karen Turner were driven by a desire to care for others and successfully graduated as registered nurses from NorthTec in April. WHĀNAU INSPIRING SUCCESS Education is key for this family. “I have two daughters, and I told them from a young age they were going to university and to university they went,” shares Cheryl Turner. “Karen has a diploma and two degrees, and her younger sister Denise also has a diploma and a degree.” “I am the first of my brothers and sisters to earn a degree and my mother was able to take part in our graduation ceremony which was extra special. After our graduation, we went for a meal. We were all seated around the table when my 5-year-old grandson said, ‘I can’t wait for my graduation’.” Family is also important to France Badham, a Northland public health nurse who credits her successful journey through nursing, a journey of hardship and self-doubt, to her children. “They are the people who have supported me most,” says France. Having left school with no formal qualifications France completed adult education classes at a local high school, bridging from the EN to the RN diploma then to a degree qualification. While France has had to work hard on her confidence both clinically and culturally, she has recently completed the Ngā Manukura ō Āpōpō leadership course and the Poutama NMoA initiative that is being piloted in Northland and Rotorua. The Poutama initiative supports Māori registered nurses, over a 12-month period, to become workplace assessors and mentors. Completing the NMoA leadership course has added to France’s
Cheryl Turner, daughter Karen Turner and whānau
confidence and encouraged her to embark on postgraduate study. France is now inspiring others by achieving nothing less than As and Bs on her postgraduate papers. LEADERSHIP COURSE BOOST CONFIDENCE Since the first cohort in 2010, 114 participants have completed the Ngā Manukura ō Āpōpō Clinical Leadership programme. Each cohort complete four marae-based wānanga. The sixth cohort was recently completed in Christchurch with a further two cohorts to be delivered by the end of December 2014. Phyllis Savage, a public health nurse in Wellington, was part of the sixth cohort. She says she can finish her nursing career when she retires knowing the sector is in good hands because Māori leaders are being cultured through Ngā Manukura ō Apōpō. “I’m very confident that Māori are looking pretty good at the moment. If we continue along that vein and support each other and Ngā Manukura ō Āpōpō gets the funding to be able to increase that network of leaders, that’s about having the autonomy to do what needs to be done”. Judith Hapi was part of the fourth cohort that was delivered in Whangarei, and she hasn’t looked back. Since completing the NMoA leadership programme, Hapi presented at a national Care Capacity Demand Management forum in late 2012 – a first for someone who lacked confidence with public presentations. Six months on, Hapi has also achieved another milestone: being appointed to the associate clinical nurse manager role in the local paediatric ward. Judith credits her accomplishments over the last year to the NMoA leadership course. For further information about the Ngā Manukura ō Āpōpō, visit www.ngamanukura.co.nz. Margareth Broodkoorn is the sponsor of the Ngā Manukura ō Āpōpō programme, a board member of the College of Nurses, and Director of Nursing and Midwifery at Northland District Health Board.
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Articles, profiles and opinion pieces from across the nursing spectrum
People, practice & policy Robin Kay
DON’T READ WHAT YOU DON’T NEED: UNAUTHORISED ACCESS OF CLINICAL RECORDS
Patient privacy breaches have been hitting the headlines. The infamous ‘eel’ x-ray in Auckland led to staff dismissals, and spying on cricket star Jesse Ryder’s clinical notes resulted in four clinicians facing disciplinary action. Nurse-turned-lawyer ROBIN KAY looks at the legal and ethical issues for nurses around accessing patient records – particularly now that unauthorised reading of a file leaves an ‘electronic fingerprint’.
“I can resist everything except temptation” – Oscar Wilde, Lady Windermere’s Fan NURSES’ AND OTHER clinicians’ inability to resist the temptation to unlawfully access high-profile patients’ records has been given significant media coverage recently. According to a recent Official Information Act release reported in The Press in July, district health boards have dealt with 20 reported breaches of privacy already this year. Some of those involved were nurses and were dismissed by their employer. This behaviour has highlighted a worrying lack of understanding by staff of the regulatory framework surrounding access to clinical notes, and of the serious consequences of breaching that framework. In the modern era, where most records are in electronic form and are accessed via the employer’s database, there is an electronic fingerprint left when a member of staff opens clinical records. This makes it very easy for an employer to see who has accessed the patient’s clinical records, when they did so, and what they looked at.
Why may having a look at someone’s notes be a problem? Your contract of employment Firstly, you and your employer have entered a contract of employment. Most clinicians’ contracts will have a clause that relates to confidentiality and protection of information obtained during your employment. If you access the notes of a 22
Nursing Review series Learning & Leading 2013
patient who you are not providing care to, you are very likely to be in breach of your contract of employment and find yourself subject to disciplinary action taken by your employer. Your professional code of conduct Secondly, you are very likely to be in breach of your professional code of conduct. Principle 5 of the Nursing Council of New Zealand’s Code of Conduct for Nurses states that nurses should respect health consumers’ privacy and confidentiality. As a nurse, you have a professional duty under the code to access an individual’s health records, be they clinical notes, test results, x-ray records, or any other type only for the purpose of providing care. If you are not involved in the individual’s care, you are breaching your professional code of conduct when you access those notes. The Health Information Privacy Code 1994 Accessing an individual’s notes when you are not involved in their care is also a breach of the Health Information Privacy Code 1994 (HIPC). The HIPC applies to health information relating to identifiable individuals and applies to all agencies providing personal or public health or disability services; an ‘agency’ includes an individual clinician. The HIPC protects clinical information about the health of the individual, any disabilities that the individual has or has had, any current or historic treatment provided to that person, and information obtained prior to, during or incidental to the provision of health services to that person. Accessing an individual’s clinical notes when you are not involved in their care and do not have their authority to do so could constitute a breach of rule 10 and/or 11 of the HIPC. Rule 10 provides that when an agency
collects information for one purpose, it must not use that information for a different purpose. For example, information obtained for clinical purposes should not be accessed for mere curiosity by a clinician not directly involved in that person’s care. The courts and various tribunals have considered whether “browsing” through information constitutes “use” under this rule, and the legal authorities suggest that one perhaps needs to do something more with the information than merely reading it. However, this point is not decided, and in light of the current uncertainty about the legal status under this rule of reading notes without authorisation, it would be a foolhardy nurse who decided to take the risk. Rule 11 provides, in basic terms, that an agency that holds personal information should not disclose it to a person or body or agency unless it is disclosure of information that is: »» in a publicly available publication; or »» to the individual concerned; or »» authorised by the person concerned; or »» for maintenance of the law, including safety of others or the conduct of proceedings before a court or tribunal; or »» in a form that does not identify the individual. If you access and then disclose that information, by any means, to another party, without any of the justifications listed in a) to e) above, you are likely to be in breach of rule 11.
What can happen if you breach your employment agreement, or your professional code of conduct, or the HIPC? As already mentioned, you will undoubtedly find yourself answering some very tricky questions posed by your employer. Your employer could take disciplinary
People, practice & policy PRACTICE action against you in the form of a warning, verbal or written, or if sufficiently serious, dismissal. Finding another nursing job with a reference that explains why you lost your previous position or without a reference at all will not be easy. Furthermore, any person can make a complaint to the Nursing Council about unauthorised access of clinical notes. The council must promptly forward a copy of the complaint to the Health and Disability Commissioner. The commissioner decides whether they have jurisdiction and whether they will investigate the complaint. In any event, the council can refer the complaint to a professional conduct committee (PCC) in situations where there was no health provider/health consumer relationship between the parties. In the case of a nurse accessing an individual’s clinical records without authority where they do not have a health provider/ health consumer relationship, it is highly likely that the complaint will be considered by the PCC. If there are sufficient concerns about your practice, your registration can be suspended while the complaint is processed. The PCC can decide that no further action be taken against you; or that the matter be referred for conciliation; or that the matter be referred to the Health Practitioners Disciplinary Tribunal. For breaches of privacy and confidentiality, it is likely that you will find yourself appearing before the tribunal. If you have any doubt about this, visit http://www.hpdt.org.nz and search using the words ‘confidential’ or ‘privacy’, to find examples where clinicians have inappropriately accessed and used clinical records.
If a nurse is found guilty of professional misconduct by the tribunal, in that the nurse’s conduct amounts to malpractice, negligence, or brings discredit to the profession, the tribunal can cancel the nurse’s registration or suspend it for a period of no more than three years; censure the nurse; order that the nurse pay a fine of up to $30,000; and order the nurse to pay legal and other costs, which can run into thousands of dollars.
Some really bad news As if the outcomes just outlined are not serious enough, the person whose privacy has been breached may decide to sue the nurse in person, on the basis that the nurse has breached the common law (law that is made by judges rather than the legislature) of confidentiality and/or privacy. It is often better for the injured party to sue the nurse’s employer for the actions of the nurse rather than the nurse themselves – because the employer usually has more money. However, it is possible that a nurse’s acts are such that the employer is not responsible for what the nurse did, and in such a case, the injured party may decide to sue the nurse in person. This process is invariably long, very stressful, and can lead to the nurse having to pay damages.
How to avoid falling foul of the privacy framework Despite the somewhat alarmist portrayal of what can happen to a nurse who reads records that they have no right to read, avoiding trouble is very easy:
Develop a working knowledge of the HIPC. For further guidance, have a look at the excellent On the Record – A Practical Guide to Health Information, produced by the Privacy Commissioner and available at http://www.privacy.org.nz/assets/Files/Healthtoolkit/On-The-Record.pdf If you are not directly involved in an individual’s care, stay away from their clinical records! If you are involved in that individual’s care, access only those parts of the clinical records that you require in order to provide the care necessary; and Use the information that you are allowed to access only for the purpose(s) that you need it. Just be mindful of why you are accessing someone’s notes, and hopefully, you won’t ever need to contact a lawyer to assist you. www.stuff.co.nz/the-press/news/8870143/ Nosy-Jesse-Ryder-clinicians-disciplined The author: Robin Kay RMN, Dip. Health, LL.B (Hons) and LL.M (Health Law) was a mental health nurse for more than 20 years before becoming a Christchurch solicitor. He has a keen interest in the legal aspects of nursing practice, particularly professional conduct and is an associate member of the College of Nurses Aotearoa.
Read an online-only PPP article on the evaluation of first rest home NP Sylvia Meijer at www.nursingreview.co.nz
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A round-up of national and international nursing news
For the record NURSING AT RISK OF LOSING REGULATORY VOICE THE NURSING COUNCIL is consulting on whether nurses want the status quo or to ‘merge’ and reduce the ‘voice’ of the largest profession to just one of 16. The council has been open about its “concerns” at the Government’s controversial and stalled proposal to merge the administrative and regulatory roles of the 16 regulatory authorities from January next year. In mid-July, there was a new twist to the shared services organisation (SSO) proposal, with the Director-General of Health writing in mid-July to the 16 authorities suggesting working together to combine “back room” functions as stage one of a two stage process to forming an SSO. Council chief executive, Carolyn Reed, has said that the stumbling block for many authorities was the combining of regulatory roles and the council’s concerns about the SSO proposal were not alleviated by the proposed compromise as it still sought to ultimately create an SSO. The council, just about to finalise its SSO consultation document, considered the last minute proposal and added it as ‘option two’. The option is only given two paragraphs as the council was unclear what the model involved, but as the option was still “intended to lead to an SSO”, the benefits and risks were similar to those outlined in the SSO option. In the consultation document, the council says the PricewaterhouseCooper (PwC) report* that outlines the SSO proposal identifies the benefits of forming an SSO was that it would “better protect public safety” over time; increase coordination across RAs, which would lead to more efficient and consistent processes and a stronger unified voice; and it was expected to increase public confidence in the sector. Under the proposal, the RA’s governance boards and councils would remain but all staff carrying out the regulatory and administrative functions would work for the SSO limited liability company. The transition cost to form an SSO was estimated to be $4.8m over three years funded from RA reserves and lead
by FIONA CASSIE
to an estimated overall saving of $3.5 million across all 16 RAs from 2017 onwards. The Nursing Council commissioned a report on the SSO proposal from KPMG consulting* and says this identified no empirical evidence that the SSO would improve public safety. The council said it was concerned that the loss of a direct governance relationship between it and its staff could see it “lose its flexibility” and become unresponsive to change. “Additionally, there is a risk of loss of momentum on a strategic direction for the nursing profession as other profession’s strategic projects may take precedence,” says the document. It also noted that nursing made up more than half of the regulated health workforce but the proposed model would reduce the council’s ‘voice’ to just one of 16. The Director General had wanted authorities to get back to the Ministry of Health by August 31 but the Nursing Council is seeking submissions on its consultation document up to September 27. *The consultation document, PwC SSO proposal, and KPMG critique are all available to download at the Nursing Council website: www.nursingcouncil.org.nz
Summary of Consultation Options »» Option 1: Maintain status quo. »» Option 2: Combine back office functions of 16 regulatory authorities (RAs) as stage one of developing a shared services organisation (SSO). »» Option 3: Combine back office and regulatory functions of the 16 RAs to form SSO.
NURSES: TOO MANY COMPLAINTS AND NOT ENOUGH PLANS? A CHALLENGE WAS thrown to the nursing sector to be more pro-active and solutions-focused if it wants greater influence on the direction of primary health care. Cathy O’Malley, the Ministry of Health deputy director general for sector capability and implementation, threw the challenge during her speech to last month’s College of Primary Health Care Nurses NZNO conference in Wellington. O’Malley told the conference that when she looked back on those who had “knocked on her door” in her first year of the job, and now had regular spots in her diary, there were “very few nursing organisations”. “I’ve had a few letters – most of those were complaining letters about what committees or not I had put nurses on.” She said while she was aware that the Ministry’s chief nurse, Jane O’Malley, had regular interaction with nurses, she questioned nursing’s influence on the wider ministry – including her directorate, which was in charge of implementing the primary health strategy. “So the presence of nursing leadership across the health system needs looking at – and the way you apply your influence.” Cathy O’Malley asked the audience to consider nursing 24
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leadership’s strategy and agility to respond and influence the decision-makers in the system to advance not only the “interest of nursing” but also better outcomes for populations which were also sustainable “win-wins” for all stakeholders. She said her “offer” to the nursing sector in response to her challenge was to help do something about it including fostering “pro-active proposals from nursing on how they can really make a difference”. “I haven’t had a single one since I’ve been in the role. I’ve had letters; I’ve had requests for participation, but nothing in terms of what actually is the solution … so bring them on!” Marion Guy, NZNO president, said O’Malley indicated “all she was hearing was complaint letters” and, though Guy did not believe this was the case, the organisation would certainly work to rectify that perception. Rosemary Minto, chair of the College of Primary Health Care Nurses, said O’Malley’s speech had been a good challenge to “bring us back to the fact that we need to be solutions-focused”. “The College has been trying to do that since our inception really … since we began we’ve been in the solutions game and not the whinging game.”
NEWS BRIEFS Appointments Update Denise Kivell, the director of nursing for Counties-Manukau District Health Board, has been elected the new chair of Nurse Executives New Zealand (NENZ). Margareth Broodkoorn, the director of nursing for Northland DHB, has been elected to take Kivell’s place as NENZ’s Northern region chair. Former chair Gary Lees of Lakes DHB is treasurer and Leanne Samuel of Southern DHB is secretary. Sue Wood the long-standing director of nursing for MidCentral District Health Board, has left to take up a new appointment as director of quality and patient safety at Canterbury DHB. John White is acting director of nursing at MidCentral DHB until a permanent appointment is made.
Did you miss… Check out these stories on our online News Feed at www.nursingreview.co.nz/ news-feed: »» Survey confirms high numbers of mid-year new grads still job hunting (Aug 13) »» Rural general practices and NZNO welcome extending GMS funding to nurses (Aug 8) »» Minister dampens NP hopes and GP fears about GMS subsidy (Aug 5) »» NZ nursing shortfall projected to hit by 2020 (July 4)
Some upcoming events »» 6 Sept 2013 College of Nurses’ Professional Boundaries Workshop, New Plymouth »» 24 Oct 2013 College of Nurses’ Professional Boundaries Workshop, Wellington »» 9–11 Oct 2013 Australasian Nurse Educators Conference, Wellington »» 6–8 Nov 2013 NZ Urological Nurses Society Conference, Bay of Islands »» 7 Nov 2013 College of Nurses’ Nurses in Business Seminar Wellington »» 16 Nov 2013 College of Nurses’ Professional Portfolio Workshop, Auckland
ONLY PREVENAR 13 PROVIDES COVERAGE AGAINST THESE 3 STRAINS. 1-3
29% of IPD cases in NZ children <2 years are caused by the strain 19A.4
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Offer your patients the choice. References: 1. Prevenar 13® Approved Data Sheet, 9 March 2011. 2. Prevenar Approved Data Sheet, 1 November 2010. 3. Synflorix Approved Data Sheet, 21 September 2011. 4. Heffernan H, et al. IPD Q4 2011 ESR Report. Before prescribing, please review Data Sheet available from Medsafe (www.medsafe.govt.nz) or Pfizer New Zealand Ltd (www.pfizer.co.nz) or call 0800 736 363. Prevenar 13® (pneumococcal polysaccharide conjugate vaccine, 13-valent adsorbed) suspension for I.M. injection minimum data sheet. Indications: Active immunisation against disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F (including sepsis, meningitis, pneumonia, bacteraemia and acute otitis media) in infants and children from 6 weeks up to 5 years of age. Dose: 0.5 mL I.M. Do not administer to the gluteal region or intravascularly (see also Precautions). Infants: 6 weeks of age: 3 doses at least one month apart. A single booster should be given in after 12 months of age, at least 2 months after the primary series. Previously unvaccinated infants 7 to 11 months of age: 2 doses approx. 1 month apart, followed by a third dose after 12 months of age, at least 2 months after the second dose. Previously unvaccinated children 12 to 23 months of age: 2 doses at least 2 months apart. Previously unvaccinated children 24 months of age or older should receive a single dose. Contraindications: Hypersensitivity to any component of the vaccine, including diphtheria toxoid. Allergic reaction or anaphylactic reaction following prior administration of Prevenar. Precautions: Do not administer intravenously, intravascularly, intradermally or subcutaneously. Avoid injecting into or near nerves or blood vessels. Do not inject into gluteal area. Postpone administration in subjects suffering from acute moderate or severe febrile illness. Prevenar 13 will not protect against Streptococcus pneumoniae serotypes other than those included in the vaccine nor other micro-organisms that cause invasive disease, pneumonia, or otitis media. Prevenar 13 may not protect all individuals receiving the vaccine from pneumococcal disease. Infants or children with thrombocytopenia or any coagulation disorder. Appropriate treatment must be available in case of a rare anaphylactic event following administration. Safety and immunogenicity data in children with sickle cell disease and other high-risk groups for invasive pneumococcal disease are not yet available for Prevenar 13. Prophylactic antipyretic medication recommended for children receiving Prevenar 13 simultaneously with whole-cell pertussis vaccines, or children with seizure disorders or prior history of febrile seizures. Antipyretic treatment should be initiated whenever warranted as per local treatment guidelines. The potential risk of apnoea should be considered when administering the primary immunisation series to very premature infants. Adverse Effects: Very common: Injection site erythema, induration/swelling, pain/tenderness, fever, decreased appetite, drowsiness, restless sleep, irritability. Common: Vomiting, diarrhoea, rash. Uncommon: Urticaria or urticaria–like rash, seizures, crying. Rare: Hypersensitivity reaction including face oedema, dyspnoea, bronchospasm.V10111. Contains: 30.8 micrograms of pneumococcal purified capsular polysaccharides and 32 micrograms of CRM197 protein. The decision to administer Prevenar 13 should be based on its efficacy in preventing IPD. Risks are associated with all vaccines, including Prevenar 13. The frequency of pneumococcal serotypes can vary between countries and could influence vaccine effectiveness in any given country. Otitis media and pneumonia can be caused by various organisms and protection against otitis media and pneumonia is expected to be lower than for invasive disease. Prevenar 13 is a fully funded prescription medicine for children meeting the high-risk criteria or pre- and postsplenectomy criteria (Immunisation Handbook 2011). For children not meeting these criteria, Prevenar 13 is an unfunded prescription medicine – a prescription charge may apply. Pfizer New Zealand Ltd, PO Box 3998, Auckland, New Zealand 1140. DA1212SW. BCG2-H PRE0123. P5786.
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