FOCUS: eHealth / On the ward
Nursing Review December/January 2015/$10.95
New Zealand’s independent nursing Series
EVIDENCEBASED PRACTICE:
Smartphone steps up goals
Practice, people & policy
Being Māori ‘left at the door’
A DAY IN THE LIFE OF
A clinical nurse educator with 50 years nursing under her belt
Q&A
Lt Col Lee Turner
eHealth / On the Ward
Simulation answer to nurse shortage?
Work ethic & missed care
Bed chart to go electronic
Using data to relieve chaos
Smart moves from ED to ward bed
Burnout & wearing two hats
www.nursingreview.co.nz
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Letter from the Editor Every patient has a story
I started the year with a determination to start my sixth decade fitter than I had spent my fifth. Every Wednesday morning of that previous decade I’d heard, then seen, a group of chatting runners come past my office window. Determined to get fit enough to join them, I signed up to an eight-week “Get up to 10K” running course. The first two weeks were tough, and I didn’t identify much with my fellow runners, including two slim women I overheard discussing diets. One week later, I found that one of those slim women was literally half her former self as she had lost 65kg. Another week later, I found the other was wanting to lose weight so she could reduce her daily chemotherapy dose for a blood cancer she was living with. I reminded myself never to judge … I graduated and joined the Wednesday running club. As the weeks rolled by into winter, I struggled to make the weekly club runs as I became “too busy”, “too tired”, or “too sick” with winter sniffles. I eventually stopped making excuses and returned to find more of my fellow runners’ stories, including the 76-year-old who had stopped competitive running after his cardiac bypass surgery a few years ago, the 72-year-old with bronchiectasis who ran her last half-marathon on antibiotics fighting yet another lung infection, and the 65-year-old who declined a pin in her smashed pelvis as it would stop her dream (fulfilled this year) of competing in the Hawaii Ironman as a veteran. What has this to do with nursing? Probably not much – but maybe just like me, it is always good to be reminded that the patient/person in front of you always has a story and future dreams that at first glance you may never guess. Fiona Cassie editor@nursingreview.co.nz
www.nursingreview.co.nz Twitter@NursingReviewNZ
Wider distribution for Nursing Review
Some nurses have told us they are not receiving copies of Nursing Review, so we’ve done something about it. From this issue onwards, free copies of Nursing Review will be sent directly to every ward at every major hospital. If this is your first time reading Nursing Review, contact editor Fiona Cassie and tell her what you think (especially if you have news or ideas to share!). These free copies will have all the features and opinion Nursing Review is known for, but only subscribers will receive print and online access to the RRR professional development activity. To get your personal copy (including RRR), go to www.nursingreview.co.nz/subscribe
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: Theatre clinical nurse educator Thelma Glasgow started nursing at Rotorua Hospital in 1964. Check out a day in her life then and now on p.3. PHOTO CREDIT: Glenn McLelland, www.aerialvision.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).
Inside: Focus: eHealth/On the Ward
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SIMULATION: virtual patients halving student time on ward?
7
Southern insights: bed chart to go electronic & other SI initiatives
8
Mental health nurse’s pocket technology for outcomes
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Bye bye bed chart, hello electronic ‘obs’
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SHARING ELECTRONIC HEALTH RECORDS: update on who can view what &
shifting deadline for patient portals
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Smart moves from ED to ward & other Northern DHB initiatives shared by JODIE and PETER WOOD:
12
CLARE HARVEY on presenteeism and missed care
13
KERRI-ANN HUGHES on CNM burn out & wearing two hats
14
TrendCare founder CHERRIE LOWE on ward chaos & patient acuity data
RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe
Practice, People & Policy 18
A Te Kaunihera founder LINDA THOMPSON looks back three decades to first Māori nurse hui
20
Online Opinion ‘tasters menu’:
ROSEMARY MINTO: Health literacy & flicking the patient ‘switch’
LOUISE DAWSON: Challenging hand hygiene naysaying doctors
ANNE MORGAN: To feed or not to feed the dying?
Regulars 2
Q & A Profile: Defence Force nursing director Lt Col LEE TURNER
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A day in the life of … clinical nurse educator THELMA GLASGOW with 50 yrs nursing under her belt
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Evidence-based Practice: Stepping out with a smartphone
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College of Nurses column: JENNY CARRYER on ‘second class’ citizen school nurses
Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ Editor Fiona Cassie Advertising Belle Hanrahan editor-IN-CHIEF Shane Cummings production Aaron Morey Publisher & general manager Bronwen Wilkins Photos Thinkstock
Nursing Review
Vol 14 Issue 6 2014
NZME. Educational Media Level 1, Saatchi & Saatchi Building 101-103 Courtenay Place Wellington 6011 New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 © 2014. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014
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
Lieutenant Colonel Lee Turner
JOB TITLE | Director Nursing Services and Director Health People and Processes, New Zealand Defence Force
Q A Q A
Q A
Name three things that you get to do nursing in the army that you would never get to do in civvy street? Weapon training, parade commander for a 100 man (person) Royal Guard of Honour, and your patients are also your work colleagues (therapeutic relationships and professional boundaries galore).
Where and when did you train? I trained in the UK at Southampton, 1987–1990.
Other qualifications/professional roles? BSc(Hons) in Military Nursing Studies, PGDip in Defence and Strategic Studies and a Masters’ in Health Service Management.
Q A
What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt? Wow, if I had the answer to this, I’d be worth a few dollars! There’s a plethora of books and articles on leadership. However, it’s a bit like a diet where there isn’t one solution for all. There are the obvious, like honesty, being a good team builder, strategic thinker, and leading by example. However, a leader should know their strengths and weaknesses and have the ability to adapt their approach to different situations/people. Leaders don’t always get it right, but when they don’t, they need to own the mistake, and if possible, fix it. Born or bred is another huge topic; I’d argue there’s definitely a bit of both.
Q A
When and/or why did you decide to become a nurse? I came to nursing after a few years of doing other jobs; I was influenced by volunteer work with various charities. I still remember asking my mum for guidance/ advice on applying to do nurse training and getting a “well, why don’t you?” – not quite what I expected!
Q A
What was your nursing career up to your current job? After completion of training, I worked as a staff nurse on the regional cardiothoracic unit in Southampton. The first Gulf War occurred, which sparked the idea of military nursing. So for the last 23 years, I’ve been in uniform in various clinical and management roles. Two years ago, I was appointed as Director Nursing Services for the New Zealand Defence Force.
Q A
So what is your current job all about? My current role has me based in Wellington, in Defence Headquarters, providing senior nursing input to policy, governance, career management, remuneration, and anything else that I’m asked to do. The role now has a broader health outlook, rather than just nursing. Being the only military nursing leader in New Zealand, there is a fair amount of international liaison as many of the issues are unique to the military environment so a wider network is needed.
Q A
What have been amongst your most rewarding experiences as a military nurse? Too many to name. I believe it’s rewarding just being a nurse, but to add on to that, being in the military, representing your country, and making a difference, both overseas and within country, has given me variety and a really rewarding career. Next year (2015) is the centenary for the Royal New Zealand Nursing Corps so I’ve been meeting more and more nursing veterans, which has been not only rewarding but also quite humbling.
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Q A
What do you do to try and keep fit, healthy, happy and balanced? Exercising regularly is a military pastime. It certainly helps to get rid of some of the daily stresses and contributes to being healthy. I’m sure wine can contribute too!
Q A
What were your toughest nursing postings? While we were deployed in Kosovo, an old farmer and his sister were admitted after being shot while tending their crops – they were shot because of their ethnicity. These were just two of many but I remember trying to comprehend why and find some logic. I quickly realised that I just had to get on with the job in hand. Professionally, some of the biggest challenges were in Northern Ireland. I was the sole nurse and senior clinician providing primary health care and emergency care to the base and the surrounding region. There was a significant risk of going beyond your abilities and/or scope but also having to make the decision on where your sick/injured went, balanced against the ongoing military operational limitations. These postings, along with the likes of Afghanistan and Banda Aceh, were also some of the best experiences. These postings are also hard due to missing out on your children growing up, but home support is essential for all defence personnel.
Q A
Helping to keep me sane, busy or on task outside of work are? Living on a lifestyle block, there’s always something to do and animals are great for keeping you levelled, although my wife and children are good at that, too!
Q A
Which book is gathering dust on your bedside table waiting for you to get round to reading it? The Penguin History of New Zealand by Michael King, I got about a quarter of the way through when I first arrived in New Zealand but never got back to it.
Q A
What have you been reading instead? The most recent read is Exit Wounds by John Cantwell but most recently listened to (whilst painting – incredible, I know, but yes, a man doing two things at once!) is Great Expectations by Charles Dickens.
Q A
What is your favourite meal? good hot curry!
A day in the life of a ... nursing veteran
NAME | Thelma Glasgow JOB TITLE | Clinical Nurse Educator (CNE 0.4FTE) and Coordinator Sterile Services Unit (SSU – 0.5FTE) LOCATION | Rotorua Hospital, Lakes DHB
6.00
AM WAKE I wake up by the alarm clock, I am not a morning person, so this is always a shock. My cat is waiting outside the bedroom door to be let in and fed! I feed the three Shaffer hens waiting at their run gate; I enjoy this little chore as they leave me three golden brown eggs every day. I pack the lunch I prepared the evening before into my chilly pack and head out the door.
7.00
AM LEAVE FOR WORK I like to leave for work by seven before the traffic builds up – also so I can stop at Nando’s for a flat white. The staff are very friendly and have my regular coffee ready and waiting. My husband, who is retired, often takes me to work on the excuse of partaking in an early coffee, too.
7.30
AM START WORK I always start work in the sterilising unit to perform the warm-up cycle of the autoclaves and organise the daily Bowie Dick checks and heat sealer checks. Then it is all ready for the morning staff who arrive at 8am to continue with the reprocessing and sterilisation of reusable instruments and equipment used the evening before. I check the theatre lists and discuss with the clinical nurse coordinators (CNC) of each theatre specialty whether there is any need for turning around equipment for the list. Today I check and authorise timesheets for the SSU staff ready for payday on Thursday.
9.30
AM COFFEE MEETING Before the rush of the day, I have a coffee and some yoghurt with my SSU team and the theatre clinical nurse manager (CNM). I check that the in-service training flyers for the next three weeks (that I had sent to the theatre support person) have been typed and are ready for display. I also see that I'm scheduled to attend an unexpected meeting at 1.30pm. I started my nursing training at the Rotorua Public Hospital in 1964 alongside my twin sister. I really did not know what I wanted to do when I left school, so my dad thought it might be a good idea to join my sister and go nursing too. Training with my sister reduced my homesickness. It also allowed me to play tricks on my twin like quickly repinning shift change notices from my hostel bedroom door to hers.
After graduating in 1968, I was assigned to the operating theatre until asked to transfer to the isolation ward. This was a ward for all infectious diseases and all ages – so infants and children as well as male and female adults. In the ward, we had all surgical site infections, otitis media, gastroenteritis, childhood infections, meningitis, tuberculosis, as well as osteomyelitis. Often these patients were hospitalised for many months, even up to a year. The men with tuberculosis were housed outside in small rooms referred to as the TB huts. During the 9pm medications round, these men were often absent – they had walked down the hill to the Lake House Hotel for a few beers. I hope they didn’t cough too much. After one year, I was transferred to the 40-bed paediatric ward, where I worked as first a staff sister then ward sister. I nursed there for fifteen years until I felt I was in a bit of a rut, so I asked in 1986 to be transferred to the operating theatre. From a new theatre staff member learning the ropes, I progressed to a leadership role in general surgery and endoscopy. In 2003, I became the operating theatre clinical nurse educator while continuing to be responsible for the endoscopy service. Then in 2011, I became the manager of the sterile services unit while continuing with the educator’s role.
1.00
pM LUNCH BREAK I eat the salad I brought from home in the staff lounge. It is a good opportunity to meet up with theatre staff and discuss how their day is progressing.
1.30
pM BUSINESS PLAN MEETING The meeting is to discuss a business plan for the post-anaesthetic care unit (PACU). As a senior nurse, I am often involved in meetings on improvement strategies and planning nurse education, including in my roles as an assessor for the PDRP (professional development recognition programme) and as a national hand hygiene auditor. Fifty years sounds like a long time to be working in the one workplace. However, it just seems like yesterday that I started on this journey. I am still enjoying my work and sharing nursing experiences and stories with my colleagues.
3.30
pM MEETING ENDS I usually manage a morning tea break but never take an afternoon tea break as I try to finish work by 4pm because I prefer to complete the work for the day on time, if possible.
4.00
pM HEAD HOME On the way home, I manage a 30-minuteplus walk in the redwood forest. Once home, I feed the waiting hens again and walk around the garden, which is especially highly perfumed and colourful at this time of year.
8.00
pM POST-DINNER After dinner, I usually read, watch television, or play a few games on the computer. I also check any emails from the trainer of the racehorses my husband and I have a share in.
10.00
PM TO BED I generally like to be in bed by ten and read until I start getting sleepy, takes about 20 minutes …
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FOCUS n eHealth
eHealth Again we look at health with a small ‘e’ ... and report on stepping up simulation in nursing training, an update on sharing electronic health records and some eHealth projects from the north and the south.
Simulation the answer to relieve pressured nurses? Can you halve the time student nurses spend on the ward or with a nurse in the community and still train a clinically competent nurse? A major US study has proven you can by replacing half the traditional clinical placement hours with quality simulation scenarios. With a nursing shortage looming, FIONA CASSIE finds out whether New Zealand sees simulation as one way of training student nurses without placing more demands on busy working nurses.
I
t's always been a bit of a Catch-22. Busy nurses finding the time to train a new generation of nurses so – hopefully – they are less busy. With the Nursing Council and Health Workforce New Zealand predicting a need to start training more nurses very soon to meet a shortage* hitting from 2020 onwards – when baby boomer nurses start to retire in greater numbers – the pressure for clinical training placements will only increase. (*Of course this predicted shortage is cold comfort to the already increasing cohorts of new graduates right now struggling to find jobs.) Is one answer for nursing students to spend less time on the ward, or on the road with community nurses, and more time in high-tech simulation laboratories? A major longitudinal study funded by the National Council of State Boards of Nursing (the NCSBN is the closest US equivalent to our Nursing Council) found no difference in the clinical competence of nursing graduates trained traditionally and those trained by replacing up to 50 per cent of traditional clinical placement time with high quality simulation scenarios (see sidebar one for details of study). New Zealand currently allows no simulation training hours to be included in the minimum 1100 clinical experience hours required to become a registered nurse – though some simulation hours can count towards the enrolled nurse diploma and may shortly be allowed in the midwifery degree (see sidebar two for details and definitions).
Something's got to give
With traditional clinical placements in hospitals and other settings already stretched, something's got to give if New Zealand is to train more nurses. Steps are underway for standardised and quality simulation scenarios like those used in the US study to be part of the solution. "What we (nursing schools) are very clear about is that we can't increase the numbers coming through nursing programmes without a change in our clinical learning model," says Kathy Holloway, national chair of nurse educators group NETS. This is the conclusion schools came to at an education workshop in 2013 that also discussed a simulation collaboration project (led by CPIT's 4
Nursing Review series 2014/2015
Karen Edgecombe and funded by tertiary teaching agency Ako Aotearoa) that came up with teaching and learning guidelines for effective clinical simulation in undergraduate nursing training. Holloway says moving towards the recognition of clinical simulation hours is just part of changing the clinical learning model, which also includes using dedicated education units (DEUs) and other ways of ensuring clinical learning experiences are quality learning experiences. Of course, clinical simulation is already very much part of nursing training in New Zealand. It has come a long way from just repetitive technical skills training to detail scripted and researched simulation scenarios using highfidelity mannequins or role-playing 'patients', followed by very sophisticated debriefing processes to maximise the learning. If New Zealand is going to eventually replace some of the traditional hours on the ward with clinical simulation hours, there needs to be standards and consistency across the country in what counts as a clinical simulation experience. Holloway says NETS has stepped in to fill that gap by developing some standard simulation scenario resources. First, nursing has to agree what should and could be taught by simulation.
FOCUS n eHealth
This year, NETS has been working on just that by asking a group of 37 nursing school and clinical practice leaders to come to a consensus on the key learning outcomes it wants students to demonstrate in simulation scenarios. It has now come up with ten learning outcomes, with the two coming out top being demonstrating clinical reasoning in assessing and managing nursing care and demonstrating clinical judgement. The next step is to develop a set of standardised simulation scenarios drawing on scenarios that nursing simulation experts across the country have already created so, as Holloway puts it, they are not reinventing the wheel, just retreading it.
Time with real patients is very important
Denise Kivell, chair of nurse executives group NENZ, says simulation is a great tool for learning new skills but the quality of the simulation is critical. "It does not represent a complete substitute for practice hours in undergraduate training." She says Kathy Holloway has spoken to NENZ, which was aware that NETS was working on simulation standards. The Nursing Council had also indicated it was involved in the work around developing simulation standards. "There are many very well constructed research-based programmes that we would support," says Kivell. She adds that simulation is no longer just about "resus Annie" on the floor and clinical simulation experiences need to be as real as possible and include high quality feedback from the ‘patient’. Kivell, who is director of nursing for Counties-Manukau District Health Board, says there also needs to be a balance between simulation and hands-on clinical time. “The value of learning and developing how to have an effective therapeutic relationship with the ‘real' individual patient is so important, especially now with the decreased contact time and length of stay in many of the settings." Continued on page 6 >>
NELSON
Nurse Consultant - Education and Development We’re seeking a vibrant, energetic leader in nursing education, who is highly motivated and committed to the development of contemporary nursing services, to join our Nurse Education and Development team based in Nelson. If you’re looking for an exciting career development opportunity, then look no further. You will work as a key professional nursing leader influencing our staff to achieve high quality clinical outcomes and clientcentred care across the Nelson Marlborough District Health Board. This is a permanent, full time position. Please visit our careers site for more details. Closing date: Monday, 12 January 2015 Ref: N14/322 Online applications, CV and cover letters are required before your application can be processed. Enquiries can be made to Human Resources Nelson telephone: 03 546 1274 or email vacancies@nmdhb.govt.nz Register for job alerts/view full details on jobs @ www.nmdhb.govt.nz
New Zealand clinical experience training requirements Registered nurse
Nursing schools must provide a minimum of 1100 clinical experience hours for all students and all students are entitled to up to 1500 clinical experience hours to prove competence. Simulation hours cannot be included in clinical experience hours (Nursing Council of New Zealand).
Enrolled nurse
Students are required to complete 900 clinical experience hours during the programme, which can include up to 200 hours of simulation (Nursing Council of New Zealand).
Midwife
Currently analysing feedback on new education standards that include a proposal to allow 10 per cent (i.e. 240 hours) of simulated practice to count towards the 2400 midwifery practice hours required. A decision will be made in the New Year and the earliest the new standards may be introduced is 2016. Currently some clinical skills – childbirth emergencies like undiagnosed breech and neonatal resuscitation – can be assessed through simulation (Midwifery Council of New Zealand).
Nursing Council definition of simulation: Activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision-making and critical thinking through techniques such as role-playing and the use of devices such as interactive videos or mannequins. A simulation may be very detailed and closely simulate reality, or it can be a grouping of components that are combined to provide some semblance of reality. Definition from US nursing academic Pamela Jeffries Midwifery Council definition of simulation: Simulation is a technique for practice and learning that can be applied to many different disciplines and types of training. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often ‘immersive’ in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. ‘Immersive’ here implies that participants are immersed in a task or setting as if it were the real world.
NELSON
Charge Nurse Manager – Out Patient Department If you are a dynamic and driven nursing leader with a clear vision and focus on quality patient-centred care, then this permanent, full time position is an ideal platform to enhance your career trajectory. You will be an innovative clinical nursing leader with superior clinical skills and knowledge, a commitment to quality, determination and a professional nursing focus to manage our Out Patient Department at Nelson Hospital. You will have: • Extensive (5 years plus) management/leadership experience preferably at Charge Nurse Manager level. • A Masters level qualification or be working towards this. • Demonstrated leadership skills, a vision for clinical achievement in new and innovative ways, and excellent interpersonal and relationship building skills. • A mixture of contemporary nursing knowledge and management ability, as well as professional credibility to the team. • A commitment to the ongoing development of the Out Patient service and staff. Enquiries can be directed in confidence to Kerri Shaw Acting Associate Director of Nursing/Operations Manager via kerri.shaw@nmdhb.govt.nz. For full details please visit our NMDHB Careers website. Closing date: Thursday, 29 January 2015. Ref: N14/324 Register for job alerts/view full details on jobs @ www.nmdhb.govt.nz
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FOCUS n eHealth
"Simulation is not just about machines that go ‘ping’ and ECGs that go flat," agrees Holloway. She says it is replicating real life situations and giving students the opportunity and time to practice and test their skills in a safe environment and to debrief afterwards and learn from the experience. Jane O'Malley, the Ministry of Health chief nurse, points out that the supply of New Zealand-educated nursing graduates is already increasing, having risen from around 1300 a year in 2010 to around 1800 in 2013. A major focus for her office is ensuring that as many of those nurses as possible are employed when they graduate. She says her office is aware of the NCSBN simulation study and the work that NETS and the Nursing Council are doing around it. "There is a push to improve the quality of nurses' clinical learning experience and a recognition that simulation is a part of that," says O'Malley. She adds that clinical experience hour requirements are primarily an issue for the Nursing Council. Her office and Health Workforce New Zealand were working with the National Nursing Organisations' group (of which NETS and NENZ are a part) on a broader workforce programme to address the workforce and predicted shortage issues identified by the Ministry and the sector.
Where to next?
Intro ???????
<< Continued from page 5 Kivell says, looking to the future, the increased nursing student intakes necessary will need to be accommodated using both clinical training methods. "It is so important we all work together to ensure the simulation standards for the RN programme, and development of the simulation units and associated teaching methodologies, have robust quality measures that result in quality clinical learning." She adds it would be prudent for NENZ members as directors of nursing and nurse leaders to work closely with nursing schools to ensure that the outcomes are acceptable.
So how close is New Zealand to including any clinical simulation hours towards the required clinical experience hours, let alone 50 per cent? "We're still at the beginning of the process," says Holloway. For some simulation hours to be counted as clinical experience hours, the Nursing Council has to change the current education standards for registered nurses. Last year, Nursing Council chief executive Carolyn Reed said the council was working with NETS on looking at simulation standards for undergraduate RN programmes and was awaiting with interest the NCSBN simulation study findings. As Nursing Review went to press, she was unprepared to comment on the simulation study and its implications for New Zealand, as the council was due to further discuss the topic and study findings in 2015. Holloway says she has been keeping the Council and sector briefed with NETS progress in developing simulation standards. "In order for the Council to be confident that there is a standard that is shared across the sector in terms of simulation, we need to do this work." The NETS report is due to be signed off and published in 2015 and will then be presented to Council. The steps beyond that are not known, but Holloway believes it will take time to bring some nursing colleagues onside so is not pushing for a tight timetable. NETS is aiming to have its first standardised simulation scenarios completed by the end of 2015 – possibly just concentrating on scenarios for first-year students – so it would be at least 2016 or 2017 before nursing schools would be ready to look at offering some standardised clinical simulation hours. Maybe it won’t be that far away when the nurse beside you has developed and proven their clinical competence and confidence by caring for both real and virtual patients?
US study on replacing up to half of traditional clinical experience with simulation STUDY DETAILS
Control: No more than 10% of clinical hours spent in simulation 25% group: 25% of traditional clinical hours replaced by simulation 50% group: 50% of traditional clinical hours replaced by simulation
SIMULATED CLINICAL EXPERIENCES
»» A standardised simulation curriculum was developed and provided to the 10 selected nursing schools to ensure that quality simulation scenarios were used at all study sites. »» The study team staff members from each school were required to attend three mandatory training sessions in the NLN/Jeffries Simulation Framework and were taught the Debriefing for Meaningful Learning method. »» Simulation scenarios involved: medium or high-fidelity manikins, standardised patients, role-playing, skills stations, and computer-based critical thinking simulations. »» Students were assigned roles during the simulation scenarios, including Nurse 1, Nurse 2, family member, and observer. Clinical instructors stayed with the remaining students in the clinical group to observe the scenario. All students in the simulation group participated in the debriefing. »» Examples of simulation scenarios worked through in a clinical practice day could include, in bed one, a paracetamol overdose patient with depression, and in bed two, an appendectomy patient one day post-surgery with pain, nausea, and vomiting.
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RESEARCH FINDINGS
At graduation: A total of 666 students graduated from the 10 selected nursing schools. Clinical preceptors and instructors reported no statistically significant differences in clinical competency, nursing knowledge, or pass rates between the three groups. Six months into first job: The new graduates' managers at their first jobs reported on overall clinical competency and readiness for practice at six weeks, three months, and six months and found no difference between the traditional and simulation trained graduates. Conclusion: "The results of this study provide substantial evidence that substituting high-quality simulation experiences for up to half of traditional clinical hours produces comparable end-of-program educational outcomes and new graduates that are ready for clinical practice." Reference: HAYDEN J, SMILEY R, ALEXANDER M, KARDONG-EDGREN S & JEFFRIES P (2014). The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education. Journal of Nursing Regulation 5(2) July 2014 supplement.
FOCUS n eHealth
Southerners sticking together It is 750 kilometres from Farewell Spit to Bluff (as the crow flies) but the five South Island district health boards are getting closer by the day. NURSING REVIEW looks at two South Island-wide health information systems projects: one designed to improve patient and data flow, and the other an electronic risk management system that brings speedier incident reporting, analysis, and feedback. Patient Safety 1st
P
utting pen to paper to report patient falls to unsafe staffing on the ward will soon be a thing of a past across all South Island DHBs. No longer will paper reports and responses have to travel through people's ‘in’ and ‘out’ trays before feedback gets to the people at the bedside. Currently, only two of the five DHBs – Southern and Nelson-Marlborough – have some form of electronic risk management system, and in the case of Southern DHB, their Invercargill site is still paper-based. But before the end of 2015, all Intro DHB sites??????? will be using Safety 1st – an electronic incident management system using the updated RL6:Risk software by RL Solutions. An earlier version of the same software is already being used by eight DHBs across the country, including Nelson-Marlborough. Sue Wood, the quality and patient safety director at Canterbury District Health Board and a former nurse leader, has been closely involved in the South Island project. She says it is safe to say that currently the majority of incident reports are filed by nurses, but the projects team hopes there will be more reporting by doctors and other health professionals once electronic reporting is possible using a smartphone app. The electronic incident report will go directly into a hospital’s server and alert the relevant person, such as a charge nurse manager of a ward. Some DHBS are choosing to let the software calculate
the SAC (severity assessment code) for the incident, and others, the manager, but in both cases, it is the manager who confirms the code level given and what further action is needed. SAC 1 and 2 incidents – the most serious adverse events – need to be reported to the Health Quality & Safety Commission. The commission also encourages boards to consider reporting ‘near misses’ and SAC 3 or 4 events that could help prevent similar incidents from occurring nationwide. Wood says under Safety 1st, investigating an incident should be easier and smarter as witnesses, managers, and experts can view and add comments or input to the same electronic report file. People making the report, like a nurse reporting unsafe staffing levels, can also request direct feedback on the outcomes of the investigation. Electronic reporting and processing will also mean that trends in reporting, incidents, and responses can be viewed and analysed at a ward, service, hospital, and South Island level, from pressure injuries to falls and patient complaints to equipment failure. The island-wide system includes incident management reporting as
well as modules for root cause analysis, patient feedback (complaints or compliments), hazard register, patient restraint incident register, and a risk register. "This (new system) will be slicker, faster, and more people will be able to see (information), so there is more transparency," says Wood. With the system, a nurse, for example, who reports an unsafe staffing incident will be able to see whether their report has been investigated, closed, and ask for electronic feedback. Wood hopes the system will not only make it easier for people to report incidents but also more likely to do so once the streamlined system leads to more direct feedback and more change happening as a result. "It is all about learning, isn't it – and changing the underlying systems (to reduce the risk of incidents)."
Ironing out the hiccups in patient flow
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ntiquated patient data systems can struggle to keep up with both the expectations of patients and the demands of health professionals. A new patient management and administration system, to be known as SI PICS (the South Island Patient Information Care System), is to be rolled out across all five South Island DHBs over the next few years – starting with some locations at Canterbury DHB at the end of 2015 and followed by the whole of Nelson-Marlborough DHB in 2016 – with the aim of providing a more flexible and responsive system*. One of the South Island clinicians involved in helping develop SI PICS is Peter Twamley, who is now Nelson-Marlborough District Health Board quality control coordinator but was the charge nurse manager of outpatients when first invited to join the project team. Twamley says he was keen to get involved as he and his colleagues live with the daily challenges of a system that doesn't work. He says the problem is outdated technology that causes gaps in inter-departmental communication and difficulties in managing patient appointments. These all affect the patient experience.
“For example, a patient gets a new hip, but what they will remember is that they had to wait hours in the hospital between appointments when it could have been avoided. If we improve systems, we improve quality and safety, and we improve a patient’s experience.” He says having a system that can quickly and easily reschedule appointments between specialists is important, as is the access and movement of patient information between departments. "These are all part of the current patient administration solution, but it’s just not keeping up with our demands as staff, nor with health demands and expectations of patients in the 21st century world," says Twamley. “Antiquated systems constrain many innovations that will have potential to improve capacity and increase operational facility on the whole.” The new PICS system will eventually integrate with other health information technology initiatives like eMeds (electronic prescribing), Safety 1st (see related story), HealthOne (formerly eSCRV, which is the Canterbury & West Coast system of sharing patient information across general practices, community pharmacies, and public hospitals), and the clinical workstation Health Connect South (that will be a single repository across the South Island of patient clinical records). *Source: From article supplied by Frederique Gulcher, communications advisor for South Island Alliance.
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FOCUS n eHealth
Mental health Bye bye nurse's pocket bed chart, technology hello for outcomes electronic 'obs' MARK SMITH* outline's a new app to help address an old problem in mental health
I
t is sometimes said that there is nothing new under the sun. Certainly in mental health care, we see problems and use treatment approaches that have been used many times over many years. While that may be true, the role of information technology does offer potentially new ways of addressing age old problems. As I have written previously in Nursing Review, HoNOS (health of the nation outcome scale) data is required to be collected by mental health services in New Zealand. Nationally, we have seen collection rates for inpatient services at over 80 per cent but community services have struggled to get over 60 per cent. This is partly because it is simply harder Intro to collect??????? outcome scores in the community. Part of the problem for community clinicians is that they are mobile and on the go, therefore accessing and recording their ratings becomes something they do when they return to the community base at the end of the day. Hopefully at that point, they will be able to access the desktop computer in the base office, but this isn’t always the case. The new app that Te Pou have developed may address some of these problems. The HoNOS app can be downloaded (simply write ‘HoNOS app’ in Google play and the IOS version for iPhones and iPads is soon to be released). The app enables clinicians to collect and use any of the five mandated HoNOS measures (HoNOS, HoNOSCA, HoNOS 65+, HoNOS LD, HoNOS secure) and produce a simple dashboard of their own caseload. This represents the first device to routinely provide mental health clinicians with a dashboard of their own caseloads in New Zealand. While this new app should help clinicians to collect the five mandated measures, and hence lead to better collection rates for the community, it will also enable clinicians to have conversations with their service users about their recovery and progress. It is this direct and easy access to information by clinicians that is potentially the most important. This current version 1 of the app will hopefully be superseded by a version 2 that is fully integrated into district health board systems. This is very much a work in progress, with no clear idea when it will be achieved. Nothing new under the sun? Or is it simply a case of old wine into new skins? I’ll leave you to judge.
*Mark Smith is clinical lead for mental health workforce agency Te Pou and is an independent nurse practitioner.
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The country's first public hospital is a step closer to farewelling the paper chart at the end of the bed and replacing it with electronic recording of nursing observations and automatic alerting of a high-risk early warning score (EWS). FIONA CASSIE finds out more.
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ne of the keystones of nursing practice – recording vital signs and other observations – is going electronic. Rather than deciphering somebody else's handwriting, the Canterbury DHB is looking to be the second public hospital system in Australasia to farewell paper charts at the end of the bed. Not only will nurses be able to electronically record vital signs via a tablet or smartphone at the bedside, but the software system can also calculate an early warning score and automatically alert clinicians if the score indicates that patient is starting to deteriorate. Sue Wood, director of quality and patient safety and former director of nursing at MidCentral DHB, says after getting expressions of interest they sought tenders for a software platform to enable electronic nursing observations and selected an Australian/New Zealand partnership as their preferred provider. The next step is working with the provider to build a business case to the DHB board to get the capital necessary for not only the software but also the tablets, smartphones and/or laptops so nurses can record patient observations at the bedside that can be viewed in real time by the patient's doctor and others in their health team, from anywhere across the hospital. All going well, a DHB ward will be piloting the new Patientrack system in the second half of 2015. Waitemata DHB is also understood to be interested in following suit. Wood says the software platform not only records and tracks the essential vital signs like blood pressure, pulse, temperature and respiration etc. but also can replicate anything currently recorded by a paper chart. So it can include risk assessments for falls, pressure injuries, and infections, as well as calculate an early warning score to help early detection of a deteriorating patient. Once the data is recorded on Patientrack, it is visible to all team members from whatever electronic device they chose to access it – not just the desktop computers at the nurses' station. Wood says the software platform is also compatible with eHealth developments like electronic prescribing, which is currently being rolled out at Canterbury DHB, or acuity systems like TrendCare, currently used by other DHBs. Throwing away the paper chart and pen at the end of the bed is still some time away but the first steps are on the way, with Patientrack systems already in place in a number of English NHS hospitals, where the system was adopted first before the creator's home country Australia. It is now being used in Canberra Hospital.
FOCUS n eHealth
Update on sharing
electronic health records The vision for the end of 2014 was for all New Zealanders to have electronic access to their core personal health information*. The reality is that it is still some time away. NURSING REVIEW gives you an update on where sharing electronic health records between patients, practices, pharmacies, hospitals, and other health professionals is up to. Sharing patient records across health sectors Health One (formerly known as eSCRV or electronic Shared Care Record View) This is the recently renamed Canterbury and West Coast shared care record platform for health professionals to securely view relevant patient information shared by public hospitals, community pharmacies, and general practices. Trying to Intro ???????post-earthquakes prompted access information its development. Information available includes prescribed medications, medical diagnoses, test results, and allergies. First piloted in 2012, it has 118 general practices and 106 pharmacies contributing data, as well as hospital-held data, and it can be accessed by approximately 5000 doctors, nurses, and pharmacists working in primary, secondary, and community settings. (Uses Orion Health platform). Shared Care Record (SCR) This provider portal for practices in Wellington, Porirua, and the Kapiti Coast enables emergency departments and after-hours practices to view a summary of patients’ recent general practice records. Launched in April 2014 and led by Compass Health, it is also being implemented in MidCentral DHB region and is already live in Wairarapa. It now covers most Wellington and Wairarapa practices and patients. (Uses ManageMyHealth system.) Care Insight An information sharing portal being used to view patient information from GP practices by afterhours providers and emergency departments in Northland, Hawke's Bay, Tairawhiti, and NelsonMarlborough DHB regions. (Developed by DrInfo and Healthlink).
PATIENT PORTALS The vision of the National Health IT Board's IT Plan was for all Kiwis to have an electronic portal to their personal health information by the end of this year. But it is up to general practices to invest in one of the software systems available and to decide what information or services are accessible. Dr Sadhana Maraj, the board's eHealth clinical lead, acknowledges implementing portals has been "challenging" for general practices because it involves changing the way they work with patients and is costly.
She said in recognition of those barriers, the previous Minister of Health in June agreed to fund up to $3 million to support the uptake of patient portals. She said this funding and the board's promotion strategy – including eHealth ambassadors and the recently released patient portal implementation guide – should help to increase the uptake. The IT Board says more than 37,000 patients from 96 general practices have registered for a patient portal but the number that have an active portal and the services they can access is not known. Website-based portals allow patients to view health information made available by their GP and (commonly used by those overseas) to make appointments, request repeat prescriptions, send messages, and read lab results. Portals operate in a similar way to online personal banking. ManageMyHealth This is being used largely in Central region, particularly in Compass practices in Wellington and Wairarapa, as well as by Midland Health Network. In July, it had been implemented in 71 practices out of 230 contracted practices. (Linked to practice management software MedTech). Health365 The IT Board's July update says this patient portal had been implemented in nine practices with 37 GPs involved. (Linked to practice management software My Practice). Accession Patient Mid this year, this portal system was to be trialled by the first of 17 Rotorua practices with access to Accession Patient. (Linked to Intrahealth practice management software).
Electronic shared care plans An electronic Shared Care Plan allows a patient and their health professionals to not only securely access and send key health information but also collaboratively work together by electronic messaging to develop and monitor a patientcentred, coordinated care plan. The New Zealand focus has been on creating shared care plans for patients with long-term conditions and can include a patient’s daily or regularly reporting weight, blood sugar, etc. via their patient portal.
Shared Care Long Term Conditions Programme Auckland's healthAlliance has been leading a shared care planning project for the three DHBs in Auckland since 2010 with the support of the National Health IT Board. The largest component at present is Counties Manukau DHB's At Risk Individual (ARI) programme, which involves a care coordinator and a shared care plan and has 925 patients enrolled. The shared care platform has in all 99 practices involved, 13,531 patients enrolled (130 can access their shared care plan through a patient portal), and 1221 health professionals. (Uses NZ company HSA Global's Connected Care Management Solution software platform or CCMS). Collaborative Care Canterbury also has been offering electronic shared care planning since 2010. To date, ten pilot practices have created 480 long-term plans for patients with complex problems. In addition, 898 acute plans have been created across general practices and secondary care. The DHB says nearly all doctors and nurses in the region can read, write, or update acute plans, regardless of where they work. About 100 advanced care plans have been created and the CREST service (a short-term homebased rehabilitation programme) has created more than 3600 care plans readable by health professionals across the DHB. (Also uses HSA Global's CCMS).
Other electronic health record projects Plunket's ePHR Work began in 2010 on developing the Well Child providers' new electronic Plunket health record (ePHR) as part of its PlunketPlus information technology upgrade. It was first trialled in September 2013 and a pilot is to be underway in the New Year using tablets and the mobile ePHR app to record Well Child information by 28 nurses, two clinical leaders and a manager in Northland. Following the pilot, it is to be rolled out across the country. In 2010, Plunket said the long-term vision was for “clients to be able to access their child’s ePHR record through a secure patient portal and record their child's development milestones in an electronic version of the Plunket Book”. National Health IT Plan.
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FOCUS n eHealth
Northerner projects
streamlining patient experience At the top end of the country, Northland DHB nurses have also been busy with IT projects. Whangarei husband and wife nurse team JODIE and PETER WOOD report on how an orthopaedics ward developed a customised electronic whiteboard giving patient details at a glance and freeing up more nurse time for patient care. They also show how using a smartphone cut out the 'middlemen' and got ED patients into a ward bed quicker.
Smartphone speeds up ED to ward bed transition By Peter Wood*
T
he government's shorter ED stays target had already prompted Northland District Health Board to streamline its bed request process once, but still patient waiting times could be excessive. Our initial streamlined process involved a bed request form (capturing appropriate clinical information) being emailed from the emergency department (via an iPad) to our duty manager, who would phone the appropriate ward and agree a patient admission time. The bed request form was later faxed to the admitting ward. The process usually involved a high number of phone conversations between the emergency department coordinator, duty manager, and ward coordinator before agreement was reached to admit a patient. The time to physically Intro ??????? move the patient to a resourced inpatient bed was excessive, and at times, contributed to the number of patients who waited longer than six hours within the ED. So at our daily meetings to discuss breaches of the six-hour ED waiting time, one of the issues identified as an area of high need to reduce breaches was the bed request process. The diagram below shows the initial streamlined system used to request an inpatient bed.
Faxes 'filed' in bin
When the bed request process was developed, we actually believed that we were using technology to the best advantage, but after our review showed the number of contacts required and the potential delay points, it was obvious we had potential for further streamlining. We also realised that smartphone technology could receive an emailed bed request form and that the phone could be carried in the ward coordinator's uniform pocket. When we explored the faxed bed request form, we found that staff did not always use the document and the ward clerk filed them in a 'filing system': the bin. The faxed form had been originally set up so that the ward coordinators could use these details to assess suitability of the bed request. However, the fax machine was stored in a back office and busy out-of-hours' ward nurses did not have the time to search out the document. Furthermore, an actual document was given during the formal handover between ED and the ward, negating the need for another document. 10
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Smart phone handy in pocket
Each ward coordinator now has a smartphone device in their pocket. The ED coordinators email a bed request form to the ward coordinator, which is automatically forwarded on to the duty nurse manager for their information. This eliminates a number of telephone calls. The ward coordinator phones the ED within 15 minutes of receiving the email and confirms a bed; the ED coordinator sends the patient to the ward within 15 minutes. Ward nurses can now remain at a ward patientâ&#x20AC;&#x2122;s bedside and the bed request document is actually used to inform the ward staff prior to the patient arriving on the ward. This has enhanced patient safety by reducing the number of people involved in the bed request process and also shifted the attention back to the patient. The diagram shows the new bed request process. Training in the use of smartphones varied depending on need and we found
Diagram of initial streamlined process and other additional information available in full online version of article at www.nursingreview.co.nz
the 'non-technical' nurse coordinators embraced the new process as they could see the benefits to patient care. A future strategy will be to generate an electronic bed request process and improve our ED efficiency.
Evaluation
Our initial data has shown a sustained reduction in the time it takes to move a patient from initial bed request to the inpatient ward. Furthermore, the nurse managers have created their own audit form to record occasions when they haven't been able to achieve the 30-minute target time. There still remain a number of challenges as the volume of ED bed requests outstrip our available capacity, but we know that when a bed is available, it will be in use within 30 minutes of a request.
FOCUS n eHealth
Electronic whiteboard frees up nursing time By Jodie and Peter Wood*
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oo often, the modern administrative demands of healthcare result in less time actually spent at the patient’s bedside. The orthopaedic nursing team at Northland District Health Board's Whangarei hospital wanted to change this by demonstrating how using an electronic whiteboard could save nursing time spent on administration and showing their passion for patientcentred care.
Risks with handwritten whiteboards
A 2011 initiative had seen Whangarei Hospital medical wards get electronic patient information boards (displaying data from the TrendCare patient acuity system), but the orthopaedic ward still had a handwritten whiteboard for sharing patient information. Updating the handwritten board was time-consuming for nurses, and there was always the risk of transcription errors. The whiteboard ink would also often fade during the day, so there was the additional risk of information being accidentally wiped off. The opportunity to replace it with an electronic board came with Northland DHB implementing the Care Capacity Demand Management (CCDM) programme. CCDM – developed nationally by the joint DHB and NZNO Safe Staffing and Healthy Workplaces Unit using TrendCare data – includes a whole of hospital electronic display system known as the 'Hospital at a Glance' (HaaG) screen, which is viewable in every hospital ward and unit. So after successfully implementing CCDM, the orthopaedic ward's next key quality project was developing an electronic whiteboard. Intro ???????
Developing icons and visual triggers
The ward's whiteboard development process was very methodical and included a multi-modal education process to help staff with the principles of the TrendCare data feed, which flowed on to enhancing the information board developed. The team developed symbols to represent different patient pathways and the multidisciplinary team and the ward floor staff's clinical input helped in areas like the discharge planning process. A number of icons were also created as 'triggers' supporting Ministry of Health initiatives for elective and acute orthopaedics as well as National Quality and Safety Commission initiatives, such as reducing patient falls. The DHB's management information systems (MIS) staff developed the actual electronic display boards that draw on information from TrendCare and the DHB's Patient Management Information System. Nursing staff can now get a picture of the patient’s status at a glance by viewing the clinical information displayed on the electronic whiteboard. The new whiteboard still displays basic demographic data such as surname, age, sex, and domicile, as it was initially developed to replicate information recorded by the multidisciplinary team on the manual board. Information displayed on the whiteboard now includes the responsible shift nurse, consultant, pressure injury risk, specialised diet requirements, specific clinical pathways, and tissue return (full list and details available in online
version of the article www.nursingreview.co.nz). The data entry field within TrendCare allows free text so the board can also display planned interventions/investigations such as ultrasounds and x-rays and when they are booked for. Ward quality initiatives like the 'green bag' medication safety initiative and the use of specific mattresses for pressure injury risk also have special icons. Later enhancements include icons for ACC claim patients, patients from aged residential care facilities, patients waiting for transfer to rehabilitation and whether the patient has a baby boarder or adult caregiver.
Evaluation
The content displayed on the orthopaedic electronic whiteboard has probably now reached capacity as the ward nurses want patient information to remain clearly visible so they can still review a patient's details at a glance. Nurses used to spent up to 30-60 minutes each 24 hours updating the detail on the old physical whiteboard. They also used to separately update their patient information on the electronic TrendCare acuity system, as there was no interface between the two systems. Now the electronic whiteboard updates itself by taking the data feed from TrendCare, so inputting the TrendCare data becomes more meaningful and is done on a more regular basis. A staff survey is planned at the 6-month and 12-month period to determine whether the electronic whiteboard remains effective and that the display captures the required information.
*Jodie Wood RN MSc (N) is clinical nurse manager of Whangarei Hospital's orthopaedic ward. Peter Wood RN, BSc (Hons), PGDipHSc is the hospital's emergency and medical services manager.
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FOCUS n On the ward
On the ward Nursing Review wraps up the year with some recent research into what’s happening ‘on the ward’ in terms of missed care, the charge nurse role and how patient acuity data can help relieve chaos on the ward...
Nursing research finds presenteeism steps up risk of missed care "One nurse … six bells ... maths doesn't work" – New Zealand's first missed care research finds, not surprisingly, that missing patient care is a reality in Kiwi nursing, although relatively rare. FIONA CASSIE talks to research leader Dr Clare Harvey about the trends found, including the high level of 'working-when-sick' reported and its link to increased missed care.
N
urses turning up for work despite being sick or injured are more likely to miss or delay patient care, finds recent research. The missed care survey found nearly 70 per cent of nurses surveyed reported recently working while sick, injured, stressed, or fatigued, which the research found was linked to increased likelihood of missed patient care. Lead researcher Dr Clare Harvey says the working-when-sick phenomenon (presenteeism) findings prompt questions about why nurses feel such a sense of duty to work when apparently unfit. It also asks, "Why do nurses and nurse managers allow this to happen when patient care is clearly compromised?" With about 200 respondents – and just over half of those in hospital settings – Harvey acknowledges that the small sample size is a major limitation of New Zealand's first missed care study. However, she believes the findings provide a "very insightful overview" of the issues around managing care in an "environment of cost constraint". Harvey was first involved in the South Australian missed care research survey and is a member of an international research consortium working on the topic. After she moved to Hawke's Bay's EIT nursing school, she and a team of EIT researchers replicated the South Australian study. The research uses the MISSCARE survey tool developed by the field's leading US nurse researcher, Professor Beatrice Kalisch, and has also been used in the US, Turkey, and Lebanon. Study participants were invited via an email sent out to a random sample of 2345 New Zealand Nurses Organisation registered nurse members; 845 respondents opened the email and 199 (8.5 per cent of the total sample or 23.6 per cent of those who opened the email) went on to complete the survey. One finding where New Zealand differed from the other countries surveyed to date was that rather than missed care being more common after-hours – when there are fewer nurses, doctors,
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admin, and other support staff on duty – the levels of missed care were similar across all shifts. The nurses were asked to rate on a scale of one to five (one = never, 2 = rarely and then up to 5 = always) how often they missed 25 different types of nursing care, from toileting to emotional support (see sample of results in sidebar). The average score across all shifts varied from 1.9 to 2.05, so hovering around the ‘rarely’ level and the most likely care to be missed was ambulation of patients on night shift, which had an average score of 3 (= sometimes). Of concern when the findings were broken down further was that glucose monitoring was reported as being missed ‘rarely, occasionally, or frequently’ by nearly 50 per cent of the respondents to whom it was applicable. "While the overall mean score for this element of missed care was low (1.6) … the immediate implications of this care being missed at all are possibly both deleterious and far-reaching." One of the most significant findings of the New Zealand survey, and the one which Harvey and her research team are to follow up in more depth, was the high levels of presenteeism reported by respondents. Nearly 90 per cent of respondents reported working more than their scheduled hours. 70 per cent reported working while "sick, injured, stressed, or fatigued", with nearly 20 per cent reporting working unwell for more than six shifts in the previous three months and the remainder between one and six shifts. Harvey says the two main reasons given for working when apparently unfit were feeling obligated to work or because the unit was shortstaffed – which included concerns about skill mix and staff experience. She says missed care coupled with tired staff – who may be working when sick or injured – has implications for patient outcomes, the quality of care, and nurses' own professional practice. "The risk of creating the potential for adverse clinical events remains unacceptably high when nursing care is missed."
NZ MISSED CARE SURVEY Five cares MOST likely to be missed or delayed
»» »» »» »» »»
Ambulating patients Attending ward rounds etc. Mouth care Fluids monitoring Patient washes.
Five cares LEAST likely to be missed or delayed
»» »» »» »» »»
Documentation Focused re-assessments Patient assessments Glucose monitoring Feeding.
Some key findings
»» The nurses least likely to report missing patient care worked in the private sector, primary care settings, were full-time and worked 'office hours'. »» The nurses most likely to report missing patient care were working in public hospitals or aged care settings, were part-time and worked shifts. »» The higher the number of presenteeism or working-when-sick shifts worked, the more likely the nurse was to report missed care. »» The older the nurse, the less likely they were to report missing patient cares.
Definitions
Missed care is “any aspect of required patient care that is omitted (either in part or in whole) or delayed” (As defined in the MISSCARE survey tool). Care rationing is defined as any time that a patient does not receive an aspect of care that professional consensus judged to be in their interests. Care may be delayed, performed to a sub-optimal level, omitted or inappropriately delegated (as defined by Safe Staffing Healthy Workplaces Unit). Source: Aberrant Work Environments – Rationed Care As System Failure Or Missed Care As Skills Failure? Clare Harvey, Clare Buckley et al., Eastern Institute of Technology, presented at the 2nd Worldwide Nursing Conference in Singapore, June 2014.
FOCUS n On the ward
Wearing two hats at one time:
nurse managers on the ward FIONA CASSIE reports on KERRI-ANN HUGHES’ initial research findings into the support and barriers that help and hinder nurse managers in their work.
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earing two hats can contribute to nurse burnout Intro ??????? for nurse managers on the ward trying to balance their operational an professional roles. Researcher Kerri-Ann Hughes – a nurse and teaching and research fellow in Massey University’s School of Management – followed up her PhD research on ‘making sense’ of the modern director of nursing (DoN) role by surveying nurse managers further down the health system hierarchy about their roles. Her survey of 78 members of the NZNO nurse managers section – which includes charge nurse managers and duty managers – found that they were far more operationally focused than their DoN colleagues and were largely focused on their particular sphere of influence, be it operating theatres or a medical ward. But what the managers surveyed did share with their other nurse manager colleagues were the same barriers (see box) hindering them from meeting their dual professional and operational role of influencing nursing quality. "All the obvious things were barriers, in adequate resourcing and being time-poor etc. and these all lead to nurse burnout … to someone feeling overwhelmed." Just over 40 per cent of the nurse managers surveyed had to report operationally to a different person when wearing their operational hat or their professional hat, with just on half reporting to the same person for both 'hats'. Seventy-two per cent of nurse managers' immediate bosses were registered nurses (RNs), with 30 per cent of them required to maintain a current annual practising certificate (APC), nearly a quarter not requiring an APC, and the remainder unknown. Hughes said this was important as the international research, particularly the Magnet Hospital findings, indicated where nurses reported to nurses both professionally and operationally, there was a "shared culture of professional practice
and nurse leadership" that provided for more effective and safe patient outcomes. The nurse managers surveyed had between three to 125 staff directly reporting to them, with the mean being 31 staff – most of whom were nurses. When asked how much they were able to influence the quality of nursing practice in their area, 46 per cent said "significantly", nearly 18 per cent said a "reasonable" amount, and a quarter said their influence was variable. Major blocks hindering managers were seen to be a lack of senior management support, poor consultation on change, management not listening, and a "perceived lack of interest by managers of what was happening at the coalface”. Hughes said nurse managers also commented about the "constant push of new initiatives" from above, with little time given to bed them down. Being time-poor was the second most common barrier, with managers reporting that it was stressful and unsatisfactory not having the time to do the job properly – particularly because of being overloaded with paperwork, constant interruptions, and increased ward volume. She said added to the reports of overloaded workloads, more than 50 per cent of managers’ responses noted inadequate resourcing, ranging from not enough staff, not replacing staff, and having the wrong skill mix. "The combination of these, with the emotion and passion nurse managers put into their role, can sometimes lead to nurse burnout." Hughes reported her research preliminary findings to the NZNO nurse managers conference in November and is to hold a second survey to capture responses from more South Island nurse managers. She is also following up her initial research with a literature review to find the best nursing strategies to break down the barriers managers experienced in trying to influence nursing quality in their workplace.
Nurse managers’ top five barriers to influencing nursing care »» »» »» »» »»
Lack of senior management understanding Being time-poor Overloaded workloads Inadequate resourcing Nurse burnout.
Nurse managers’ top five supports for influencing nursing quality »» Own individual energy and passion »» Good clinical skills and knowledge »» Support from senior management team, colleagues and nursing team »» Good leadership from all levels of management »» Good management systems in place. Duty nurse managers made up eight per cent of those surveyed and while they had no direct reports they could have from 10 to 1000 people reporting to them on a shift-by-shift basis. The majority of staff reporting to nurse managers were RNs, enrolled nurses (ENs), and healthcare assistants (HCAs), but 32 per cent also had ward clerks and administrators reporting to them and a range of other staff. Nursing Review series 2014/2015
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FOCUS n On the ward
Turning ward chaos into order:
data is the key
If your ward is chaos, the best argument for more staffing is hard data, says Cherrie Lowe, the Australian nurse founder and CEO of patient acuity software system TrendCare. FIONA CASSIE reports on Lowe's presentation to the recent NZNO nurse managers conference, including a major benchmarking study analysing 9.9 million nursing shifts.
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t the stroke of midnight, all is quiet in
the ward. Only three out of six beds are Intro ??????? occupied.
A service manager might be wondering why the ward's charge nurse manager keeps complaining about understaffing. But roll back the clock and you will see some of those 'empty' beds had up to three patients through them during the day as patients were discharged, transferred, admitted, or died. So while the midnight census shows just three patients, five other patients had been nursed on the ward that day, making an average bed utilisation of 6.67 patients for those six beds. Cherrie Lowe, founder of TrendCare and a doctoral candidate, says using the wrong data can underestimate nursing work and a midnight census "doesn't recognise at all the nursing workload".
Higher workloads
Nurses are experiencing higher workloads than ever before due to four main reasons, says Lowe. These are increased patient throughput, decreasing length of stay, increasing patient acuity, and an inadequate supply of skilled nurses. It is not a new trend but has accelerated in the past decade, with her data indicating the average length of stay in a standard surgical ward dropped from nine days to four days between 2002 and 2013. She points out this hasn't lessened the nursing workload – just squeezed the clinical and administration time required into a shorter timeframe. The patient acuity is constantly high, whereas in the old regime, says Lowe, by the end of their stay, patients were self-mobilising and "helping with the flowers". The result is that acuity calculations show that the average nursing hours per patient day (HPPD) required for a surgical ward has gone up from 4.1 HPPD in 2002 to 4.7 HPPD in 2013. Lowe acknowledges there is "chaos" in some wards due to increasing demands on nursing staff, and it is very stressful for ward leaders having to "put out bushfires" every day. 14
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To convert chaos into order, she believes the best thing a nurse ward leader can do is take time out and gather data to put a case for a solution. She says the problem is nursing not being correctly staffed, though the answer may not always be to employ more nurses. First, ward leaders need to convince service managers – particularly those who aren't nurses themselves – that there is a problem with the ward's staff resources, and for that, Lowe says, hard data is needed (such as HPPD, patient turnover and length of stay) to make the nursing workload visible. "If you don't have data, emotions don't cut it." In addition, emotive arguments can see nursing leadership losing control of this nursing issue to non-nursing leaders. Lowe says one of her "greatest heartbreaks" on first coming to New Zealand was discovering the loss of nursing leadership and finding herself talking to nursing service managers who weren't nurses and didn't understand nursing. "You might just think that I'm here trying to sell my show," acknowledges Lowe. "But if you don't measure acuity, then you have nothing to work with." She points to Australia's adoption of nurse-topatient ratios, which she claims has proven to be a "blunt instrument" by not allowing for the wide variation in patient acuity that can be faced on a ward. She argues that collecting accurate acuity data and accurately representing nursing costs is one of the best strategies for ensuring adequate funding of nursing services. Models of care need to be looked at because nursing not being correctly staffed doesn't always mean nursing is understaffed, as sometimes what is needed is a skill mix change and re-engineering the roster to ensure the right staff at the right time are doing the right work. At the conference, she presented a table with a guideline of recommended skill mix between registered nurse (RN), enrolled nurse (EN), and healthcare assistant (HCA) per shift. This ranged from 100 per cent RN patient care for intensive
Staying within your safe staffing 'buffer' in CCDM
»» CCDM's Mix and match system uses patient acuity data to determine nursing hours required including a "realistic allowance for non-clinically available time".* »» The total predicted nursing hours required for a specific shift includes a 12.5 per cent buffer above the calculated nursing hours required. »» About four per cent of this buffer is to allow for tea breaks (up to 40 minutes per FTE). »» The remaining 8.5 per cent is an allowance or 'buffer' for unpredicted extra work required during the shift. »» If the gap between the hours required and the hours available is over the 8.5 per cent mark, then there is no buffer. At this point, nurses' breaks start being shortened or dropped, contributing to nurse fatigue and an increasing risk of clinical errors. »» If the variance between hours required and hours available is more than 12.5 per cent, then the shift "flips into a critical zone". »» The ideal is for the hours required to match the hours available or not to go over the 8.5 per cent variance threshold. * From 'Acuity in Action' presentation to Nurse Managers Conference in Christchurch 6 November by Rebecca Oakes of the joint NZNO/DHB initiative, the Safe Staffing Health Workplace (SSHW) Unit. The unit's care capacity demand management (CCDM) system uses nurseentered TrendCare patient acuity data to determine nursing and HCA hours required.
FOCUS n On the ward
“You might just think that I'm here
trying to sell my show. But if you don't measure acuity, then you have nothing to work with.
“
2012–2013 nursing hours per patient day (HPPD) benchmarking findings* Surgical patients Medical patients Orthopaedic Mental Health (acute adult) Intensive Care
majority range between 3.02 to 6.12 HPPD majority range between 3.4 to 5.94 HPPD majority range between 3.46 to 5.81 HPPD majority range between 2.1 to 6.9 HPPD majority range between 11.42 to 17.75 HPPD
*Using anonymised TrendCare patient acuity data entered by nurses in hospitals in Australia, New Zealand and Singapore. TrendCare is used by 16 of the 20 district health boards and is the basis of the CCDM system (see other sidebar).
A LIFE LESS ORDINARY
care units down to RN (15 per cent)/EN (30 per cent)/HCA (55 per cent) in the night shift at residential aged care hospitals. Other suggested skill mixes include 60/20/20 for general medical wards during the day shift, stepping up to 75/25/0 in the night shift. And 70/20/10 for a general surgery ward day shift, moving to 75/25/0 overnight. Lowe's presentation concluded with analysis from the latest TrendCare acuity data benchmarking that showed the range and mean of nursing HPPD measured for 106 patient types cared for across nearly 50 hospitals in Australia, Singapore, and New Zealand during 2012–2013*. Drawn from 3.3 million patient days and 9.9 million nursing shifts, the nursing acuity measures are shown for day oncology to high dependency mental health adolescent patients and a huge range in between. "These results clearly show increasing patient acuity and support the urgent need for nursing services globally to collect, analyse, and use nursing data proactively if a strong viable nursing service is to be maintained with adequate funding," says Lowe. As nursing is the largest labour force, nursing services are often targeted when cost savings are required. Without data backing the hours and skill mix required to deliver quality clinical services, Lowe believes that nursing hours may be reduced inappropriately – increasing nursing workloads to an unsafe level – or conversely, resulting in overstaffing of some areas and wasting nursing hours needed in another area. "As the patient’s level of dependence on nursing hours increases and the patient throughput increases, the nursing workload continues to grow. If this growth is not accurately monitored and resourced, patient safety will be adversely affected and nurses’ job satisfaction will decrease, contributing to high staff turnover."
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Intro ???????
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Evidence-based practice
Smart steps
– no selfie required Is a smartphone app more successful in increasing physical activity than setting goals? Step up and check out this edition's critically appraised topic (CAT). CLINICAL BOTTOM LINE: Users of a smartphone pedometer app achieved a modest, but significant, increase in daily walking distance, compared with those only given basic exercise advice and goal setting.
CLINICAL SCENARIO: During a routine GP visit, you confess your rather sedentary lifestyle to the practice nurse. Never one to miss a teachable moment, she pulls out her smartphone and demonstrates her ‘walking app’. With expectations of a readily available ‘gym buddy’, you decide to review the evidence around smartphone technology and exercise promotion.
CLINICAL QUESTION: In generally healthy adults, does a smartphone app increase physical activity, compared with basic physical activity goals and exercise advice only?
SEARCH STRATEGY: Best Evidence for Nursing+ http://plus.mcmaster.ca/NP/ Quick search: smartphone application AND physical activity
CITATION: Glynn, L. G., Hayes, P. S., Casey, M., Glynn, F., AlvarezIglesias, A., Newell, J., Murphy, A. W. (2014). Effectiveness of a smartphone application to promote physical activity in primary care: the SMART MOVE randomised controlled trial. Br J Gen Pract, 64(624), e384-391. doi: 10.3399/ bjgp14X680461.
STUDY SUMMARY: The Smart Move study is a two-arm, open-label, randomised controlled trial conducted in a single, rural primary care setting in Ireland in 2012. It evaluates the effectiveness of a smartphone app – Accupedo-Pro Pedometer –as an intervention for promoting physical activity. Participants were recruited from an economically diverse, predominantly white population via referral from primary healthcare professionals or self-referral in response to community advertisements. Eligible participants were active android smartphone users over 16 years of age. Exclusion criteria were acute psychiatric illness, pregnancy, inability to undertake moderate exercise (for any reason, including being overweight). Of the 139 screened for eligibility, 49 were excluded (mainly because of phone device); 90 were randomised. At study commencement, the app was downloaded onto each participant’s phone to enable step count measurement. At the end of week 1, all participants were given physical activity goals and information on the benefits of exercise. Study duration was eight weeks. 16
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Intervention: (n=45) At the end of week 1, participants were able to access the smartphone app features. These included live feedback of daily step count, a graphic display of step count history, goalsetting functions, and goal achievement feedback. These features were explained and interaction with the app was encouraged. A physical activity goal of 10,000 steps per day was set. Control: (n= 45) At the end of week 1, participants were given a physical activity goal of walking for 30 minutes per day (equivalent to 10,000 steps) in addition to their normal activity. The app features were not activated. Outcomes: Primary outcome measure was the difference in daily step count between week 1 (baseline measurement), and follow-up (weeks 2-8). Participants’ daily step count data was automatically recorded and stored in the app prior to downloading via the ‘share data’ function. Secondary outcome measures were blood pressure, heart rate, weight, body mass index (BMI), mental health, and quality of life at eight weeks.
VALIDITY: Random allocation to study groups occurred via the Research Randomizer computer software programme. A centrally located, independent investigator ensured allocation concealment. Participants and investigators were blinded until end of study week 1 for screening, baseline assessment of physical activity and phone calibration. There was complete follow-up of 86 per cent of study participants (82 per cent in smartphone group and 89 per cent in control). Most loss of follow-up data was phone-related and reported to have occurred during baseline week 1 (pre-intervention). Analyses used on-treatment data. Loss of data after week 2 appears to have been managed via appropriate statistical methods. Baseline group differences (gender and quality of life) were adjusted for, as per the published protocol. Groups were treated equally. Overall study quality was good.
RESULTS: The mean age of participants was 44 years, mean BMI was 28.2, and mean step count at baseline was 4771 (3.6kms), although some participants were quite sedentary. All had prior experience with smartphone apps. A significant and sustained improvement in physical activity between week 1 and week 8 was seen in the intervention group, compared with control (Table) and this effect remained after adjustment for possible explanatory variables (including age, BMI, socioeconomic status, mental health, and quality of life). These results provide evidence of an increased level of physical activity by, on average, 0.8 km or around half a mile (1029 steps) per day in the app user group compared with the control group (Table). There was no significant difference in any secondary outcomes measures.
COMMENTS: »» Short follow-up and small numbers limited the detection of changes in secondary outcomes. However, if sustained, even the modest increase in physical activity seen in app users is likely to promote clinically meaningful health benefits. »» A concurrent qualitative evaluation of participants’ experiences suggests that, despite technological challenges, app users viewed this intervention as a positive motivator for physical activity. »» Low cost app, easy to download, available in New Zealand. No conflict of interest with app developer reported. »» Not known whether similar or free smartphone pedometer apps would have the same motivational benefits Reviewer:
Cynthia Wensley RN MHSc is a PhD candidate at Deakin University. She also works at the School of Nursing, University of Auckland as an Honorary Professional Teaching Fellow.
Table: Results with 95% Confidence Intervals (CI) Outcome
Intervention Mean Difference (SD)
Control Mean Difference (SD)
Difference in Mean Improvement (95% CI)
P value
Improvement in mean daily step count from week 1 to week 8
1631 (3842)
-386* (3281)
2017 (265 to 3768)
0.025
Improvement in mean daily step count from week 1 to week 8 (adjusted)
-
-
1029 (214 to 1843)**
0.009
SD – Standard Deviation; *step count decreased over time; **step to km conversion 0.8 km (0.17km to 1.4km) CI – Confidence Intervals;
college of nurses
Secondary school nurses
treated as second-class citizens?
Jenny Carryer
The role of the school nurse in our secondary schools needs urgent attention, argues College of Nurses executive director Professor JENNY CARRYER. With no formal requirement to have nurses in all schools, many secondary school nurses face professional isolation, low pay, and unpaid holidays. School nurses are a critical frontline resource for primary and integrated care for young people. To have skilled health professionals on site where children and young people can opportunistically – or through necessity – access treatment, advice, care, and support is a valuable resource not to be squandered. The opportunity for timely advice, guidance, and early response for young people is unlimited. The mental and sexual health needs of young people are especially important. School nurses have a vital role in supporting the health of today’s youth, with secondary schools now having rolls of up to several thousand young people. Youth health specialist Simon Denny’s research team surveyed 8500 secondary school students in 2012 and then surveyed the 125 secondary schools they attended to see what levels of school health services were provided. The team found better student health outcomes, including fewer pregnancies and better mental health, when higher level school health services (largely delivered by registered nurses) were available. Despite school nurses being an obvious youth health resource, it seems that the New Zealand health sector is yet to take the role seriously across all schools in all regions. Currently, there is no formal requirement to have a registered nurse in all schools or colleges. In 2009, following a period of raised awareness of the school nurse role, the Ministry of Health started funding school nursing services in lower socioeconomic communities, starting with decile 1–2 secondary schools and then rolling it out to include all decile 3 secondary schools. These school nurses are linked to a professional leadership structure and are more likely to be appropriately remunerated. Many school nurses are, however, funded through Ministry of Education (Vote Education)
funding delivered via the school’s annual operational grant. So in effect, these nurses are employed directly by the school as school ‘support workers’ with a pay scale and conditions commensurate with support worker status. For the majority of Vote Education nurses, their salary is not at a registered nurse level. Neither do these registered nurses (RNs) have access to nurse leaders or to anyone who supports their professional development. Nor is there someone to ensure appropriately qualified RN applicants are employed under appropriate RN employment conditions. School nurses are often abysmally paid and they go unpaid in school holidays. Despite holding an equivalent qualification to most of the school teachers they work alongside, the nurses are treated entirely differently. A teacher working in a hospital would not expect to receive a teacher aide pay rate, so it is interesting that the education system considers it is acceptable to pay some RNs in schools a support worker’s pay. Nurses in schools funded through Vote Education mostly do their professional development in their own time and self-fund this activity. Because they are disconnected from professional leadership structures there are many anomalies. In some instances, the school ‘nurse’ is a first aider with no formal qualifications. Over the years, nursing has made various attempts to put this issue on the policy table but has been spectacularly unsuccessful in garnering any sustained attention to the problem. The consequences of this failure are multiple but they are of most importance to the young people whose health may be jeopardised. If the school nursing workforce is not always appropriately deployed, then the service they deliver may, as a result, be less cohesive and less effective. This means that a valuable and vital potential source of important primary health care is wasted. There is no evidence that
young people in higher decile schools have less need for health care and no rationale for neglecting the school nursing service as a national strategy for delivering preventative health care at a critical point in life. If school pupils are exposed to an underresourced and undervalued school nursing workforce, this may reduce their likelihood of selecting nursing as a career. As other school staff see that school nursing is just a support worker position, they are unlikely to recommend nursing to appropriate students as a career opportunity. Given the predicted nursing shortage beginning to bite in 2017, this is problematic. The school nursing service is unlikely to be sustained on this basis. While at present a large number of dedicated and largely mature woman continue to serve school populations, regardless of such unfair conditions, this will not last. It is highly unlikely that new graduates will seek out such anomalous employment. Finally, and perhaps most importantly, the current drive in health service delivery is towards integration and seamlessness of services. Where school nurses continue to work in isolation from the health sector, they are not only professionally isolated but opportunities for an integrated primary healthcare service are lost. District health boards need to address their population health objective and ensure that school nurses are deployed as a key component of the regions’ primary health care service as a matter of course. Young people deserve no less. *References available on request or online www.nursingreview.co.nz
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Practice, People & Policy Feature
Articles, profiles and opinion pieces from across the nursing spectrum.
Practice, People & Policy Remembering the beginning for
Te Kaunihera o Ngā Neehi Māori o Aotearoa It is 30 years since a group of Auckland Māori nurses hosted the first national hui for Māori nurses and the Te Kaunihera o Ngā Neehi Māori o Aotearoa (National Council of Māori Nurses) was incorporated. FIONA CASSIE talks to a founding member of Te Kaunihera, Linda Thompson*, about some of her personal memories of those early days.
L
inda Thompson stood out in her graduating class in the 70s. For three years, she had been the only Māori student in the Auckland School of Nursing: "I was the one little brown girl in the mix". She rarely saw another Māori nurse on the hospital wards: "I did come across one or two". The country girl from Raetihi did meet a handful more when she went on to work as a public health nurse in South Auckland and found a tight supportive network of Māori nurses in the field, but still, she could count them on the fingers of one hand. So it resonated with her and her colleagues when in 1983 three Māori leaders issued a challenge in The New Zealand Herald to the then-Auckland Hospital Board about its obvious lack of Māori nurses to care for Māori patients. "We read it – and thought 'oh gosh'," says Thompson. "It prompted a conversation about who are we and where are we and it was decided that those of us who we do know should meet". So the four public health nurses rang around the other Māori nurses they knew, and 11 nurses from across the city met in a Ponsonby meeting room. "By the time the first four of us got the 11 of us together, we knew where virtually everybody else was". Many of those other Māori nurses were working in the former psychiatric hospitals of Carrington and Kingseat. All were invited to join an inaugural hui of the Auckland Māori Nurses group at Te Tira Hou Marae in Panmure in 1983.
Being Māori "left at the door" Thompson says the main topic of those early meetings was sharing their stories and experience of training and nursing as Māori. "We were meeting as Māori nurses and we began to talk about that Māori part of us that was left out of our training as nurses … it was a lot like having a little personality split.” "So in the storytelling, we realised that other part of us should never, ever have been left at the door." But not everybody agreed – some of the older generation of Māori nurses, who had worked hard to succeed, were assimilated in the Pākehā-dominated nursing world and could not understand why Māori nurses would need or want to meet. Thompson recalls meeting one genteel retired principal nurse in her home to invite her to join and finding her strongly adverse to Māori nurses meeting and "singling themselves out to be different". 18
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Another of the old school was Matire (Tum) de Ridder, who had been principal public health nurse in Gisborne for many years. She, too, was not impressed when she heard of this upstart group of Māori nurses in Auckland and was a loud opposing voice from the East Coast. "She came up to the first national hui that we called and she came deliberately to tell us off," recalls Thompson. "To tell us virtually 'get back to your jobs and get on with it. We all know who we are and we've got work to do'. "But by the time we all left that hui, she was totally bowled over, and the following year, she became the first elected president," laughs Thompson. That first national hui was held in February 1984 at the Te Puea Memorial Marae in Mangere with Te Arikinui Dame Te Ātairangikaahu (the then-Māori queen) in attendance, along with the then - Department of Health director of nursing Dame Margaret Bazley – who heard on the grapevine of the hui and asked for an invite – and health minister Aussie Malcolm. At that hui, it was decided that the Māori nurses group would be called the National Council of Māori Nurses, Te Kaunihera o Ngā Neehi Māori o Aotearoa, and the council's kaupapa was Waerea te ara ki te ora – Clearing the way towards total health and wellbeing.
Articulate women and raising cultural awareness Thompson says helping win over Tum de Ridder at that first hui was the movement's first and very charismatic chair Pia Makiha. Makiha had also been a public health nurse, which Thompson believes is not totally coincidence. Nursing in the community meant Māori nurses could be independent, have an opinion, and it provided them with a broad education and experience, as public health nurses needed to work with a range of agencies to support families. Thompson said working in public health was probably the most rewarding time of her nursing practice. Her job was to work where the greatest need was. "We had teenagers having babies under bridges, and we had little children under houses sniffing glue out of milk bottles." But not all days were like that; it was also health promotion, screening and working with school children – "a lovely variety in your day's work really". "So it's a totally empowering type of nursing, and I suppose that gave us a bit of gumption to speak up … So we had a team of articulate women … but the cultural part was still simmering away in the background." Pia Makiha, freshly retired, decided it was time to bring the cultural side to the forefront, which Thompson says was "fairly ground-breaking and pretty dramatic". "I was very excited by all this awareness raising that we were doing amongst Māori nurses," says Thompson. "Pia started talking about all the cultural things that were pretty dormant in our practice – like what we do with the whenua (the afterbirth) at birth. We had all these pictures in our heads of what we did. Of course, we put them down the sluice, everybody else did, and that was the practice." Pia started inviting kaumätua she knew to come to hui and listen to the Māori nurses' stories and Thompson says these elders quickly perceived that the nurses had put up a division between their nursing world and their Māori world. One elder told the gathering that he was "absolutely spellbound" when they talked about their clinical nursing knowledge but when they started talking about things cultural "they ought to sit down and shut up" because culture was the area they knew nothing about and the elders were there to teach them and
Practice, People & Policy feature
Te Kaunihera today – and the return of the nursing degree
O
ne of the motivations for founding Te Kaunihera three decades ago was to see more Māori enter and graduate from nursing
schools. Early efforts to break down barriers included pre-nursing programmes that offered a Māori health perspective to encourage young Māori into nursing. A long-held vision was to develop a kaupapa Māori training programme for nurses, which culminated in the three-year degree Te Ōhanga Mataora Paetahi, Bachelor of Health Sciences Māori (Nursing) being offered in 2009 by Te Whare Wānanga o Awanuiārangi. Current Kaunihera president, Nelson nurse consultant Hemaima Hughes, joined Te Kaunihera over a decade ago when efforts stepped up to develop a kaupapa Māori nursing degree curriculum. "I was one of the original writers of the curriculum with Denise Wilson and my engagement with the council was really to do with the development and progression of the programme and building the Māori nursing workforce. The initial intention was for the degree to be offered at the wānanga's home base of Whakatane. but the Tertiary Education Commission directed the wānanga to offer the degree from Auckland. This ended up being problematic for the degree and the wānanga, with the first cohort being the only cohort. After the six remaining students successfully sat state finals in November 2011, the degree was shelved. But three years on, the degree is being relaunched and a slightly modified programme has won full Nursing Council and New Zealand Qualifications Authority (NZQA) approval and is ready to get underway in February 2015 on the wānanga's Whakatane campus, with former Waiariki Nursing School head Ngaira Harker as its leader.
Harker says interest is strong in enrolling in the first Whakatane intake, with 27 students also soon to complete an 18-week bridging to nursing programme. The wānanga was interviewing applicants for the degree's February intake with the aim of having 30 students successfully complete the first year. Hughes said membership of the council was growing, with five branches established or re-established since she became president last year, including an Otautahi (Christchurch) branch. With currently 200–300 members – many of them senior Māori nursing leaders – the council continues to grow with the support of Ministry grants – "it is really re-building itself". While it is a niche group, Hughes says it is a mandated group as the original founders moved around the country sharing its kaupapa. While the New Zealand Nursing Organisation's Te Rūnanga (representing Māori nurses, nursing students, midwives, healthcare assistants, and allied health staff members of NZNO) may now be larger, Hughes says the longer established Te Kaunihera is still recognised as the indigenous Māori nursing group and sits at the table at the National Nursing Organisations' group as the mandated Māori nursing group. Hughes adds while members of Te Kaunihera, including herself, are also members of NZNO, the objectives of the groups are quite different. She is optimistic about the future of the council and is actively working to recruit more younger nurses. She was heartened by the number of young Māori nurses who attended the council's very well-attended AGM in Te Teko – which is also the homeground of Te Kaunihera's 92-year-old Patron Aunty putiputi O'Brien. With the Te Kaunihera-backed degree about to get underway again in Whakatane, she is looking forward to even more young nurses joining them in the future.
bring the balance back, so they never forgot they weren't only nurses but Māori nurses as well. Thompson says in her early nursing days she had quite matter-of-factly put the afterbirth down the sluice. Other nurses at the hui shared stories of their cultural and spiritual disquiet at carrying out a practice that clashed with the Māori belief of the link between the land and placenta that bears the same name: whenua. Similar stories were shared at that first national hui with the chief nurse and health minister of the time listening and getting insight into Māori people's perception of the health system. At the same time, there was also a growing Māori voice in the then-Department of Health as improving Māori health became higher on the country's agenda. This groundswell was also behind the cultural safety (kawa whakaruruhau) movement in nursing. Thompson says the council initiated and its members worked closely with cultural safety theorist Irihapeti Ramsden in co-authoring the original cultural safety document in the 1980s, from which Ramsden further developed and championed the concept of cultural safety – particularly in education. Thompson is proud that nursing was the standout profession in first recognising and including cultural safety and identity in the curriculum but says it also became apparent that cultural safety had to be applied in practice in the nursing world, and one part of her own career was built around looking at quality cultural practice in health service delivery. The council membership has never been large but it has influence beyond its membership numbers after holding national consultation hui in 1985 with iwi, hapu, and Māori nurses up and down the country to gain a mandate from iwi to speak on their behalf about Māori health and nursing matters. The first Māori nursing student nurse hui at Ratana Pa in 1986 – an event Te Kaunihera has kept hosting ever since – was attended by about 2,500 people – students, nurses, and supporters. Thirty years on since Te Kaunihera's inaugural national hui, Thompson says its membership is increasing and its presence is “felt and sought after” at national and international nursing forums – and it all started with a handful of nurses rising to meet a challenge. * See online for a contributed article by Linda Thompson and Te Kaunihera with more on the founding of the council and a history of its early days and achievements: www.nursingreview.co.nz Nursing Review series 2014/2015
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People, practice & policy Opinions
Check out our online opinions If you’re reading the print edition, you’re only getting half the story. The Nursing Review website has web-exclusive content, and from now on, news stories will only be online. Go to www.nursingreview.co.nz for the latest news and opinion. Here are excerpts from recent opinion articles published online: To feed or not to feed? That is the question Palliative care nurse advisor ANNE MORGAN asks whether feeding the dying is the right thing to do or simply the easiest option when faced with families who see withdrawing nutrition as "cruel" or "starving the person to death". Why are so many people who are dying given subcutaneous fluids? Is it the right thing to do or is it simply the easiest option in order to avoid the sometimes challenging conversations with families and whānau? Without these conversations, how can patients, families, and whānau make informed choices about their end of life care? Love and concern have always been expressed through feeding, providing food, and celebrating by sharing meals. Since time immemorial, we show nurture and love to one another in this way. People therefore become anguished over decisions around withdrawing or withholding food or fluids. Artificial nutrition and hydration (ANH) is a medical treatment given to a person who is unable to eat or drink enough to sustain life or health. Such treatment does not offer the comforts that come from the taste of familiar food and fluids (which is so often the argument offered for providing these treatments at the end of life). People with advanced disease will, at some point, lose their appetite, stop eating and drinking, and therefore, lose weight. The body is no longer able to process food and fluid as a healthy person might. Force-feeding people does not help them live longer or feel better. Commonly, people with advanced disease do not complain of hunger or thirst but may say their mouth is dry. All dying people will have a dry mouth and giving subcutaneous fluids will not relieve that. However, good and frequent oral care will. Emotive arguments such as, “we can’t starve the person to death”, “they will be so thirsty and their mouth dry”, and “it is cruel to watch them suffer without food and fluid” are just emotive words without understanding the reality …
First do no harm … role-modelling of hand hygiene Hand hygiene nurse champion LOUISE DAWSON recently reminded a clinician to carry out hand hygiene before cannulating her. The clinician's response was a cursory hand rub and a comment that the evidence didn't stack up for hand hygiene in most cases anyway. Dawson wonders whether it will take more superbugs and increasing antibiotic resistance before some finally get the hand hygiene message. The practice of hand hygiene in healthcare is certainly not new. However, getting all healthcare workers to consistently carry out hand hygiene at patient 'point of care' remains an ongoing challenge.
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Nursing Review series 2014/2015
Slowly but surely, though, the patient safety message is getting through – particularly within the public hospital system, where constant vigilance and reporting of hand hygiene performance ensures a strong focus on hand hygiene. I believe two of the most positive actions to improve our public hospital hand hygiene over the last five years have been the nationwide district health boards' hand hygiene improvement programme (Hand Hygiene New Zealand, HHNZ) and the widespread use of alcohol-based hand rub (ABHR), particularly at the point of care. Despite these two actions, there are still highly-educated healthcare workers who do not believe that hand hygiene in all clinical care is a reasonable request. I am currently part of a community-based university research project and recently found myself, alongside many others, being cannulated for a series of blood tests. The doctor gathered the necessary equipment and reached for her gloves. I asked if she would please use the hand rub, located very closely, before she gloved and cannulated me. Her response was to perform the scantest of hand hygiene …
Health literacy and flicking that switch Primary health nurse practitioner ROSEMARY MINTO looks at the challenge of "flicking the switch" to good health habits and the need to realise the story behind each reluctant quitter or non-exerciser. She also discusses the need to be funded to give the time required to support people to make and maintain lifestyle change. Sometimes when I sit down with a patient at their home or in the clinic, I just know that whatever I say will not convince them to reconsider their lifestyle. However I describe how their lifestyle choices are affecting or threatening their health, they will refute my knowledge, with their own world-view acting as a barrier to understanding or acceptance. One of my biggest challenges, and one I continually face, is how to reach people with chronic conditions or at high risk of poor health. How to help them "flick the switch” from unhealthy lifestyle choices – be it smoking, daily fast food, no exercise, alcohol, drug taking, or any combination of those – and change their attitude to their health. I have had more than one patient tell me that one of the reasons they attend appointments so infrequently is because they are “sick of being told off”. I have recently had the privilege to present at the College of Emergency Nurses conference … during the conference Marama Tauranga, an emergency department (ED) clinical nurse leader introduced her research, which describes, amongst other things, the danger of assuming that a “single story” exists when people present to the ED. Marama discussed the multiplicity of stories that make up a person’s experience and the importance of recognising this when we care for them.
What smokers really want Smokers want to be seen as real people, trying to beat their addiction.
Nurses have the ability and power to connect and guide smokers on their journey to wellness. Because defeating addiction is a very individual process, nurses can provide encouragement from start to finish. To understand what smokers go through, we have created this resource to empower nurses and help smokers on their journey to stay smokefree.
Bring your wound care patients out of hiding
Designed for people. Designed for life. Results from research on why living with a chronic wound stops people living the life they want to lead inspired us to create ALLEVYN Life. A dressing specially designed to have a positive impact on patient wellbeing by helping those with chronic wounds regain their freedom.
â&#x201E;˘Trademark of Smith & Nephew ŠSmith & Nephew 2013 SN10587 (01/13)