Nursing Review February 2015 by NZME. Educational Media

FOCUS: Healthy Year Ahead

Nursing Review February/march 2015/$10.95

New Zealand’s independent nursing Series

EVIDENCE-BASED PRACTICE:

Pelvic floor exercises: what's best?

A DAY IN THE LIFE OF

A nurse turned clown doctor

Q&A

Lorraine Hetaraka-Stevens

Practice, people & policy

Nursing can take you anywhere 9 out of 10 good enough?

Healthy Year Ahead

• Shiftwork: Minimising the risks & selling the benefits • Welbeing lessons from post-quake Canterbury • Sexual wellbeing: keeping it ‘normal’ • Skin care tips for the busy nurse

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Letter from the Editor One small silver lining…

Had a good boogie lately? When did you last get caught up in the moment? Tried something a little different lately? When did you last really catch up? These questions have been popping up on ‘feel good’ posters all over Christchurch for the past year or so. They make you smile, make you think and sometimes even make you act. As there is perhaps one tiny silver lining of people’s lives being severely shaken by the Canterbury quakes. We can of course never erase, trivialise or forget those who have suffered greatly by losing family, friends, workmates, homes and businesses. But all 350,000 or so of us now share something in common. We discovered simultaneously how just a few short seconds can change our lives and our city. And then over the weeks, months and years that followed we also learnt that thousands of quakes, EQC reports, insurance claims and road cones can test even the most resilient of souls. So many Cantabrians are now aware for the first time that not only does their physical health need looking after but also their mental health. Canterbury’s All Right? mental health campaign (see p.14) was set up to help Cantabrians help each other through the tough times with tolerance, humour, exercise, compassion and giving. The campaign centred on the Five Ways to Wellbeing to prompt people to do the things that help boost and maintain their wellbeing; and it lead to those whimsical posters. Not all love them – Cantabrians are as divergent in views as any community – but they have struck a chord with many, like me, who realised that sometimes they were so busy getting on with life that they forgot to prioritise the ‘good stuff’ like fun, family and friends. And the silver lining? Well maybe, just maybe, the rest of the country doesn’t need to go through a disaster to realise just how important it is to look after their mental health and wellbeing. So when was your last moment of wonder? When did you last really catch up with your best mates? Fiona Cassie editor@nursingreview.co.nz

Inside: Focus: Healthy Year Ahead 4

Unnatural, unhealthy but essential: managing SHIFTWORK

SEXUALITY: Therapist MARY HODSON on keeping it ‘normal’

Wellbeing lessons from post-quake Canterbury four years on

It might not heal all ills but is laughter the best medicine?

Tips for fabulous skin from cosmetic nurse LARA MOLLOY

RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe Practice, People & Policy 22

23 24

KIM CARTER asks whether patients deserve more than nine out of 10 A decade on: MECA pay talks underway again Nursing can still take you anywhere says, MARK JONES

Regulars 2

Q & A Profile: ProCare’s first nursing director LORRAINE HETARAKA-STEVENS

Twitter@NursingReviewNZ

A day in the life of… nurse turned clown doctor ZACK McCRACKEN

Wider distribution for Nursing Review

20 Evidence-based Practice: CYNTHIA WENSLEY looks at pelvic floor exercises and asks whether more than a pamphlet is needed?

www.nursingreview.co.nz

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

Multimedia platform for nursing Nursing Review is a genuine multimedia publication. With five print editions and our recently revamped website which contains 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: Lorraine Hetaraka-Stevens, the first nursing director for the country’s largest PHO, ProCare. Find out more on p.2. 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).

College of Nurses: KATHY HOLLOWAY on e = enhanced and not just electronic health

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 production Aaron Morey David Malone Advertising & marketing manager Belle Hanrahan Publisher & general manager Bronwen Wilkins images Thinkstock

Nursing Review

Vol 15 Issue 1 2015

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Errors and omissions: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.

Nursing Review series 2015

Q&A

Lorraine Hetaraka-Stevens

JOB TITLE | Nursing Director ProCare IWI | Ngati Kahu, Te Arawa me Ngati Ranginui HAPU | Te Whanau Moana, Rorohuri, Ngati Pikiao, Tapuika me te Pirirakau

Q A

Where and when did you train? I was comprehensively trained at Waiariki Institute of Technology in Rotorua 1994–1996.

Q A

Other qualifications/professional roles? I went on to complete a postgraduate certificate in Māori health followed by a postgraduate diploma in leadership and long-term conditions. I am currently enrolled in the master’s programme at The University of Auckland. I sit on a range of DHB advisory groups and am also on Ngā Manukura o Āpōpō (the national Māori nursing and midwifery workforce development group), the Northern Cancer Network and the Maternal Foetal Medicine advisory group.

Q A

When and/or why did you decide to become a nurse? My daughters were my inspiration and motivation, and I choose nursing as a career because I wanted to make a difference to my whānau and the communities I serve. I have two younger sisters who are currently undergraduate nursing students and I enjoy supporting them on their pathway. Both in my personal and professional life I am dedicated to encouraging rangatahi into nursing and health-related careers and then supporting them to develop into our future leaders.

Q A

What was your nursing career up to your current job? My first position was at Tauranga Hospital’s Te Puna Hauora (kaupapa Māori service) and I was a member of the service’s first new graduate programme cohort. I was placed in maternity services and rotated between postnatal, delivery suite and the special care baby unit. At the time I thought of training as a midwife but ended up accepting a position in the paediatric ward. I spent a couple of years working in paediatrics then moved to Auckland to further my career; I worked for several years at Starship Children’s Hospital in general medicine. My next move was to HealthWest PHO where I went on to specialise in paediatric respiratory medicine with a primary focus on bronchiectasis. This sparked my interest in population health, primary prevention and health policy. I accepted a position at Tamaki PHO as nurse leader, a role I thoroughly enjoyed. Wanting to further develop my leadership abilities, I successfully applied for the role of associate director of nursing at Auckland

Nursing Review series 2015

DHB, where I spent four years until my recent appointment as nursing director for ProCare.

Q A

So what is your current job all about? I’m fairly new to the role, having only been appointed three weeks ago, so I’m still finding my feet. My role is to be accountable for standards of nursing care and the strategic development of primary care nursing. I am part of ProCare’s clinical directorate and I’m responsible for several portfolios across the network, some of which include allied health, child and maternal health, professional development and education, new graduate programmes and workforce development.

Q A

What do you love most about your current nursing leadership role? Working with inspirational people; the ability to influence change; the variety and diversity of the role; the challenges that come with that and the opportunity to contribute to making a difference.

Q A

What do you love least? Workload demands placed on the workforce that are challenging, particularly on frontline staff; inequities that persistently exist across the health care system; fragmentation across the health system and bureaucracy.

If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? Other than wishing for more wishes, I would wish for the following: »» Guaranteed employment for all New Zealand-trained new graduates, with a priority on recruitment in primary care. »» Increase Māori nurse numbers across the healthcare system and develop them into designated leadership positions. »» Remove ALL barriers to enable primary care nurses to work at the top of their scope.

Q A

What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt? We all have the ability to be leaders – health systems will not naturally gravitate towards equity. There is a multitude of books and articles on the subject and there is no ‘one size fits all’ approach to leadership. Key characteristics of great leaders that resonate with me have personal attributes such as self-awareness and reflection, integrity, the ability to be adaptable and to drive for improvement. Leaders that I admire also possess the ability to steer change through people, collaborate and empower others, and achieve effective and strategic influence. These attributes are built on a strong foundation of values, dedication, commitment and a higher purpose.

Q A

What do you do to try and keep fit, healthy, happy and balanced? I run two to three times a week and have started taking boxing classes at City Boxing, which I’m really enjoying. My family would say that cleaning is my hobby – I do enjoy keeping my home life organised.

Q A Q A

What helps keep you sane, busy or on task outside of work? My whānau and friends – they keep me grounded and connected.

What is your favourite way to spend a Sunday? Spending time with my grandson. He is just the centre of my universe. I love him to pieces.

Q A

What is number one on your ‘bucket list’ of things to do? My dad was in the army and spent time in Vietnam – I would love to do an Intrepid tour with him through Vietnam and Malaysia, where he was also stationed.

A day in the life of a ... clown doctor

NAME | Zack McCracken (aka Dr Cracker) JOB TITLE | Artistic director of the Clown Doctors New Zealand Charitable Trust and former RN LOCATION | Starship Children’s Hospital, Auckland.

6.00

AM WAKE I’m not really a morning person so I like to have a relaxed coffee and then, if it’s warm, a quick swim before I start my day.

9.30

AM HOMEWORK As Clown Doctors’ artistic director I have extra duties like setting the roster, planning training schedules and arranging coaching for our clowns. I also keep in touch with our Wellington and Christchurch teams.

11.00

AM FERRY TO AUCKLAND One of the best parts of living on Waiheke Island is my commute into town. I love the scenery and I’d much rather spend half an hour here than on the motorway.

12.00

PM LUNCH I grab a quick bite before putting on my ID and talking to the charge nurses of the wards I’m visiting today. It’s essential to get a general sense of the ward, as well as specific patients. The charge nurse informs me if there’s a birthday, if someone has a condition we need to be aware of, or if there is something more serious, like a death, which means the nurses are feeling particularly stressed. All these situations must be handled with appropriate sensitivity and respect.

12.30

PM PREPARATION I meet my colleague Ruth (Dr Pick-me-up) in the volunteers’ room, get into my Dr Cracker costume and run some quick warm-ups. Clown doctors always visit wards in pairs; it’s better for creativity and it doesn’t obligate anyone to interact with us.

1.00

PM FUN STARTS It’s a sunny day so we walk outside to Ward 26B. On our way we pass the hospital shuttle bus so I climb aboard to do one of my favourite things, giving an aeroplanestyle cabin safety announcement. “In an emergency your oxygen masks should fall from here… Please fasten your seat belts and shortly we will be serving drinks.” In between giggles, someone tries pointing out we are on a bus. I introduce one of the hospital security guards as the flight captain, at which he jumps into character and pretends to fly the ‘plane’, much to the delight of everyone. At Ward 26B we visit a 14-year-old boy who we’ve been told us hasn’t smiled all week. No pressure! Teenagers can be difficult to

Pictured: Ruth Dudding (Left) and Zack-McCracken (Right) connect with and his mum is quite anxious. DVDs surround him so we try re-enacting some scenes from the movies. No luck. Finally, after singing a bad rendition of Johnny Cash’s Ring of Fire, he cracks up laughing and his mother starts crying with relief. It’s wonderful when you have a positive impact like that because sometimes you’re not sure if you can achieve it. I started training as a nurse in the 1980s when I was 17 years old at what was then Greenlane Hospital. kidnapped her husband. “You can keep him,” Becoming a nurse was an incredible training she jokes back. He joins us and we have a few for life and I don’t regret it. more laughs but before we leave they both I think an important commonality give us teary-eyed hugs. They thank us for between nursing and being a clown doctor breaking the monotony and stress of waiting. is confidentiality. When you’re dealing with Busy nurses don’t always have time to take sensitive personal information it’s essential care of worried parents. They have more for the patients and reassuring for the responsibility and reporting than I ever had. medical staff. It’s also important to maintain one’s professionalism. I’ve seen some terrible pM things in hospitals: terminal patients and Finish victims of accidents or abuse. You can’t help We take off our costumes and collect feedback them if you get caught up in the pain or grief. from hospital staff, taking note of how It’s a hard balance because to do your job many people we’ve seen, as evaluation and well you have to connect with people and be accountability is important to clown doctors. authentic, but also not be paralysed by their A nurse says when she first encountered situation. clown doctors she questioned our place in a I also like to think nursing and clown medical environment. “Now I love you guys. doctoring share a non-judgemental and You have a neutrality and capacity to play inclusive view of their patients. Ultimately with kids that I can’t provide. I wouldn’t do we are both concerned with the kids’ without you now.” wellbeing, but the nurses’ focus is more on Wherever possible we love to improve their physical health while ours is on their clown doctor/hospital staff collaboration. psychological needs, particularly their desire We rely on nurses for information and for play. more nurses are now coming to us for help distracting or engaging a patient during a PM procedure. BREAK Stepping ‘out-of-clown’ by taking our red pM noses off, we head to the Ronald McDonald FERRY HOME House Family Room for a cuppa and a Sailing past Rangitoto and looking out over biscuit. It’s a chance to reflect on what we’ve the water helps me unwind. Even successful days like today are emotionally draining and done well and what we could improve. my partner knows I’ll have no energy to cook, PM so dinner is always on the table. BACK ON THE WARD I spend a little time in my vegetable garden We encounter a man by the vending PM machines anxiously waiting for his daughter Bed to come out of surgery. He asks if we can visit his wife. We find her and announce we’ve After a soak in the spa pool, I’m in bed early.

4.00

2.00

5.00

2.15

9.30

Nursing Review series 2015

FOCUS n Healthy Year Ahead

Healthy Year Ahead FOCUS: Once again we turn the lens and look at nurses’ own health and wellbeing. This edition we look at unnatural but essential shiftwork, wellbeing lessons from post-quake Canterbury and share some tips on sexual wellbeing and skin care.

Coping with shiftwork: is there a perfect roster? Shiftwork isn’t natural, and long-term it isn’t healthy – but it is essential for modern health care. So the challenge is to minimise the risks and maximise any lifestyle benefits. FIONA CASSIE talks to a sleep physiologist and nurse leaders to find out how to do just that.

any would suggest that the perfect roster starts at 9am and finishes at 5pm. However, our hospitals and health care system must operate 24 hours a day, so that just isn’t realistic. Add to the conundrum the biological fact that humans are hardwired to sleep at night and the result, says sleep physiologist Dr Karyn O’Keeffe, is that there is no single, simple answer to shiftwork problems. O’Keeffe, a researcher at Massey University’s Sleep/Wake Research Centre who spent five years as a shiftworker herself monitoring people’s sleep patterns, says this doesn’t mean that the negative aspects of shiftwork and the risk of fatigue can’t be managed better. “Shiftwork is definitely a significant challenge, both for your body and for your mind, but there are sensible ways of managing it – for example, flexibility – that can make your life a lot easier.” Greater flexibility in shiftwork is high on the agenda of the Sustainable Nurse Workforce Project Group led by South Canterbury District Health Board director of nursing Jane Brosnahan. Brosnahan says the focus of the South Island project was initially on supporting its ageing nurses to stay in the workforce, but then broadened to look at strategies to sustain the entire nursing workforce.

Nursing Review series 2015

FOCUS n Healthy Year Ahead

Karyn O'Keeffe

“When we looked at shift patterns, we realised that what is good for older nurses is good for younger nurses as well. So we started to look across the whole of the system.”

Some of the science of sleep

A key to improving and building any shiftwork system is understanding more about the science of sleep and fatigue. And the most influential component of this is our biological or body clock. O’Keeffe says Jane Brosnahan the clock is a tiny group of cells that coordinates all the circadian (i.e. 24-hour) processes and cycles in our body using environmental cues, including natural light, as a guide (see side bar for details). Intro ??????? more Alertness is one of those cycles. Throughout the 24-hour day our Jill Clendon alert and sleepy periods vary. We are at our most sleepy from midnight to 6am, with a peak of sleepiness between 3 and 5am and then a second but lesser dip in alertness in the afternoon between 3 and 5pm. “So those particular times of the day are when we are most likely to be at risk for errors due to sleepiness or fatigue,” says O’Keeffe. We similarly have two peaks of alertness spread through the day – one mid-morning and another lesser peak mid-evening. When it comes to shiftwork, the problem is we are trying to sleep and work at times that are not aligned with those natural patterns. This makes it a challenge when we are trying to function optimally at times when our body is naturally sleepy – and to get good quality sleep when our body is naturally programmed to be alert. It is only since the advent of modern industrialised society that we have started to regularly fight our circadian clock by trying to convince our bodies that day is night and night is day. Technical definitions differ, but O’Keeffe says in the simplest terms shiftwork is any work pattern that shifts your usual sleep pattern – even if that is only by an hour or two. Knowledge of our biological clock has increased significantly in the past decade and there is now no doubt that the body can’t fully adapt to shiftwork, she says. Research indicates that even when we work permanent nights, our body clock shifts only slightly (by about three hours) and never reverses completely to turn us from a diurnal to nocturnal animal. And it is not only daylight that signals the time of day to our body clock – it is also when we eat our meals, when we talk to other people and when

we’re physically active. “So when we’re receiving this information that ‘it’s daytime, daytime, daytime’ our body finds it virtually impossible to shift to a different time zone,” says O’Keeffe.

Understanding our circadian rhythms

Our increased knowledge about our biological clock doesn’t mean we can influence it, but we can use the knowledge to improve a difficult situation. “We use the things that are working for us,” says O’Keeffe. “And we try and manage the things that aren’t.” We are most sleepy when our core body temperature minimum is at its lowest. Research shows that when we work consistent nights this temperature ‘low’ can shift from the usual time of around 5am to 8am. This means if you head straight home at the end of your night shift you can fall asleep relatively quickly. “So it’s a good idea to try and get into bed as soon as you can when you are working night shifts rather than stay up and go to bed later.” Research has also shown that we have a built-in alarm clock that tells us to wake up about six hours after the body reaches its minimum core body temperature. O’Keeffe says this works well when we are sleeping at night-time, as the alarm ‘wakes’ us around 10 or 11am, but when we try to sleep during the day it occurs at about 2pm in the afternoon. “That means sleep can be quite short and gets truncated to about six hours. Which is why quite often you will hear night shiftworkers say they wake up in the early afternoon period and can’t get back to sleep – it’s our natural drive to wake up at that time.” Or course, one of the hardest things to balance is what is best for your sleep patterns – that is, coming home from night shift and getting to bed as quickly as you can – and the reality of returning home to children needing lunches made and a dog demanding a walk. The reality may be that be that you don’t get to bed until the children have gone to school, and you will need a

catch-up nap later in the day to get your seven to eight hours’ sleep before starting the next night shift (see sleeping tips sidebar).

Assessing and managing fatigue risk

An employer has a responsibility to roster staff as safely as possible. But O’Keeffe says individual nurses also have a role in gauging whether their sleepiness or fatigue is likely to impact on their ability to do their job properly. “As a shiftworker, it is really important that we take responsibility for managing our own level of impairment.” O’Keeffe says there are three questions that shiftworkers can ask themselves to help judge the risk of being impaired by fatigue. The first is ‘how much sleep have I had in the last couple of days?’ “We know that when we haven’t had much sleep, the homeostatic process (the level of sleepiness) increases rapidly – particularly when we stay awake for more than16 hours at a time.” Staying awake for 17 hours, for example – that is, going to bed one hour later than your normal bedtime – means people start to function similarly to someone at the legal alcohol limit, O’Keeffe says. Anything over a 16-hour gap between bedtimes puts nurses at risk of making poor decisions and having reduced ability to make big-picture judgement calls and communicate effectively. Continued on the next page >>

What’s natural about sleeping? Two natural body mechanisms influence sleep: Sleep/wake homeostasis lets our bodies know after we’ve been awake for a long time that the need for restorative sleep is accumulating and creates a drive that balances sleep and wakefulness. It is particularly strong after 16 hours of being awake. Biological clock regulates our circadian (24 hour) rhythms, including the timing of periods of sleepiness and wakefulness throughout the day. This is a group of cells found in the hypothalamus, near the convergence of the optic nerves. This clock responds to light and dark signals from the eye. Morning light signals that it is time to be awake, to produce hormones such as cortisol, and to delay the release of hormones such as melatonin. When the eyes signal to the clock that it is dark, melatonin (associated with sleep) is produced, so melatonin levels rise in the evening and stay elevated throughout the night, promoting sleep. The clock also guides other circadian rhythms, including our core body temperature, the release of hormones and other important bodily functions. Regular bedtimes and waking times help keep the homeostasis sleep drive and the biological clock working smoothly. Shiftwork puts the biological clock and subsequently our circadian rhythms out of kilter.

Nursing Review series 2015

FOCUS n Healthy Year Ahead

<< Continued from the previous page

”Shiftwork is definitely a significant challenge, both for your body and for your mind, but there are sensible ways of managing it that can make your life a lot easier.” The second question to ask is ‘what time of day is it?’ Nurses working during the low circadian point of 3 to 5am are at the greatest risk of fatigue. Thirdly, nurses should ask themselves ‘how well have I been sleeping recently?’ If they haven’t been sleeping well, they are more likely to be impaired. If people do consider themselves at risk, that doesn’t mean they shouldn’t be working at all, says O’Keeffe. This should be applied only in cases of extreme fatigue. Rather, processes and strategies to manage standard fatigue should be in place, including improving communication processes with your colleagues when feeling fatigued and having someone working alongside you.

Ageing nurses and shiftwork

Dealing with fatigue and shiftwork becomes harder as nurses age. Despite that, a major survey in 2012 of older Intro ??????? nurses found that almost half of the 3,273 respondents were still working shifts. This surprised Dr Jill Clendon, a researcher for the New Zealand Nurses Organisation (NZNO) and principal researcher for The Late Career Nurse project survey of NZNO members. Clendon says older nurses did show a general tolerance of shifts as they were accustomed to them as part of their working lives. As one respondent reported: ”My family have left home but still my shifts dominate planning events long term to be together. The great side is I’ve never known any other social behaviour and have developed a life that allows me to involve myself in activities, to be flexible and plan long term – society is changing to meet the needs of shiftworkers, which I believe is very important.”

Nursing Review series 2015

But others also reported needing greater recovery time as they aged – particularly rotating shift rosters that included nights – and increasing concerns about their poor sleep and health. As another respondent commented: I have had many years of poor sleep patterns. Have developed hypertension and high cholesterol. Have no regular exercise and do not join exercise classes because of shiftwork.” Clendon says the older nurses’ coping mechanism for increasing difficulties with rotating shiftwork was to move to casual or agency work so they could control the shifts they worked. This was usually because they weren’t offered other shift options such as ‘no nights’ or shorter shifts. “So these nurses were lost as permanent employees on the ward, resulting in loss of experience, institutional knowledge, etc… “Is that (lack of roster flexibility) worth the risk of losing these skilled nurses? Just because someone is no longer able to cope with night shifts? Particularly when we’re moving into a nursing shortage.” Clendon believes that shiftwork can be managed better and employers need to be flexible and open to different rostering options to stop nurses – both older and younger – pulling out of shiftwork because of fatigue or incompatibility with their home life.

Young nurses and the push for social rostering

It is not only older nurses who like the idea of great flexibility in rostering and shiftwork. Those in the generation behind them have strong ideas about what work/life balance means. This was endorsed by a survey of 350 Generation Y nurses (i.e. born since 1995) carried out by Christchurch nurse researcher Dr Isabel Jamieson, that found that young nurses want flexible workplaces. She also found that they start off wildly enthusiastic about their nursing careers but within a year the honeymoon is over – and part of that is a rapid disillusionment with shiftwork. “They wanted rosters and a workload that didn’t mean they had to spend their days off sleeping to recover,” Jamieson told Nursing Review in a 2012 article. She added that the young nurses had a “very fair and mature” attitude to allocating time in their days off to recover but felt that too little space was left to also enjoy friends and family or squeeze in study. “If you want me to be the best nurse I can be, then I need a workload that doesn’t stress me to the max,” is a common attitude, says Jamieson. The Sustainable Nurse Workforce Project Group is conscious of the need to support young nurses to keep nursing, says Jane Brosnahan. An initial approach has been to draw up a position statement (endorsed by the national directors of nursing group NENZ), that recognises the

future state of nursing will require both “radical redesign” of some nursing processes and “subtle changes” to others, including “greater flexibility of work schedules and environments to meet the needs of nurses across the continuum”. Part of this project is considering a marketing campaign to promote what can be a positive spinoff of shiftwork – more ‘me time’ during the day. “Shiftwork does give you time to yourself when everybody else is at work (or school),” she says. Each South Island DHB is also being encouraged to gather information about flexible childcare options available in their respective areas, outside of the traditional 9am to 5pm childcare centres that don’t work well for shiftworkers. At the same time, the project is now at the initial stage of reviewing the research and best practices in order to establish a safe and healthy rostering process that balances staff desires, parttimers and full-timers and the needs of younger and older nurses, which will be shared across all South Island DHBs.

What are the risks of shiftwork to patient safety?

Another element of safe rostering is reducing the risk of errors and injuries due to nurse fatigue. The New Zealand Blood Donor study, involving more than 15,000 workers, found that people working rotating shifts (excluding night shifts) were 75 per cent more likely to report a workplace injury than people working conventional daytime hours and nearly 90 per cent more likely if they worked rotating shifts, including night shifts. The risk of injury was also higher for those working permanent nights (38 per cent), though less than for those working rotation shifts) International studies looking at nurses and shiftwork have found that nurses working rotating shifts are twice as likely to report a clinical error of some kind and three times more likely to have a car accident. Clendon believes the research indicating fewer risks from fixed night shifts than rotating rosters means it could be time to bring the option of permanent night shift back to the table for more discussion and debate. She points out that older nurses on permanent night shifts appeared to find nights “less challenging” than those on rotating shifts. And some ‘owls’ or younger nurses may be more willing to work nights if they had the option of a fixed roster. “I think a possible solution is to give nurses over 50 the option of not working night shifts – younger nurses may have to pick up the slack, but when they hit 50 they would also have the option,” she suggests. “Although it’s probably not a very popular option with young nurses, those with families may not have an issue and this is where fixed night shifts may work better.” Brosnahan says the sustainability project was also aware of research raising questions over rotating versus fixed rosters. There was particular interest in one piece of research indicating that rotating shifts over longer periods of time might be a healthier option. Staff might spend a month on day shift, a month on evenings and a month on nights, giving their bodies more time to adjust to each timeframe. The research also indicates that the risk of increased injuries and errors appear similar for

FOCUS n Healthy Year Ahead

nurses who work for more than eight hours at a time. O’Keeffe says that while there are few goodquality, nurse-specific studies, general research indicates that the risk of errors tends to increase with the number of hours worked. As a result, controversy exists over whether 12-hour shifts are the safest option for health care environments. Shift length, she says, is just one of many factors they consider when assessing whether or not a roster is safe. “So even if a nurse is working 12-hour shifts – and might not be getting as much sleep as someone working 10 hours – they might still be in a supportive work environment where fatigue is managed well.” Clendon says that NZNO is in the process of completing a systematic review of 12-hour shifts and error rates among nurses working in acute care environments, and the initial results are very interesting.

What about the risks of shiftwork to nurses’ health?

Nobody is arguing that trying to work at night and sleep during the day is natural – or healthier than working conventional hours. Increased understanding of how our body clock and circadian rhythms are involved in our daily??????? metabolism has seen an upsurge of Intro research interest in the impact of disrupting those rhythms through shiftwork. The findings linked to working shifts can make grim reading. “We do see that people who are shiftworkers have higher BMIs, higher reporting of gastrointestinal problems, and higher incidences of type 2 diabetes,” says O’Keeffe. Large cohort studies have also found increased incidences of

heart disease, diabetes and cancer amongst shiftworkers, compared with other workers. “So there are some fairly nasty health problems that can come with shiftwork,” she says. This all sounds very discouraging for a long-term shiftworker or a nurse about to commence shiftwork. O’Keeffe points out that the research studies can’t pinpoint the cause of the poorer health statistics as every shiftworker is an individual and there are many factors that come into play, including the type of shift, the length of time a person has worked shifts, their lifestyle and their sleep patterns. Most of the health risks are also shared by people who aren’t getting enough sleep, so a good start to reducing long-term risks is trying for seven to eight hours’ quality sleep every 24 hours.

Proposed nurse survey hopes to guide safe rostering

If the perfect roster is working permanent day shift, any other roster is always going to be a compromise of juggling giving nursing staff the shifts they request, meeting patient clinical needs, and reducing the risk of errors or injuries due to fatigued staff. O’Keeffe says the Massey Sleep/Wake Research Centre has used extensive surveys with RMOs (resident medical officers aka junior doctors) to gather data on characteristic work patterns and build matrices for assessing whether a roster is at a low, medium or high risk for fatigue. “We want to do the same thing for nurses.”

The centre has an application in to the Health Research Council for funding to carry out an extensive and complex survey of nurses to ask them about the shifts they work and when; about their work, sleep and alertness patterns, whether they have reported clinical errors, and when they are most likely to occur. “We’ve got our fingers tightly crossed and if we are successful we would aim to start the research later this year. We would use the survey data to build new fatigue management tools which would be relevant to nurses. The centre would also aim to develop a code of best practice for nurse rostering. She says many people still hold on to a belief that somewhere out there is the perfect roster with a formula for the right set of shifts, of the right length, in the right order and with the right breaks in between. “That’s just not going to be the case.” The elusive perfect roster will still remain just that – elusive.

Shiftwork tips Tips for staying awake during night shift

»» Avoid using devices with bright screens in the two hours before bed (i.e. smartphones, laptops, computers and iPads). »» Keep your bedroom only for sleeping and sex (no work, no TV or electronic devices). »» Turn your phone off so you aren’t disturbed by texts, Facebook notifications, etc. »» Cigarettes can stop you getting to sleep and wake you during the night. »» While caffeine might not always stop you falling asleep, it reduces the amount of deep sleep you get so you can wake up feeling unrefreshed. »» Similarly, alcohol may see you fall asleep quickly but will impact on the quality of your sleep.

Facilitating sleep (post-shift)

»» Establish regular bedtime routine for whichever shift you are on. »» Eat regular, light, healthy meals. This might require planning to ensure your only food options at 3am in the morning aren’t carb-rich or junk food. »» Get regular exercise. »» You need seven to eight hours’ sleep over 24 hours (five hours is not enough). »» When at home, listen to your body and if you feel sleepy, sleep. »» Naps always boost your functioning, even if you don’t feel great straight afterwards. Try to keep them short and sweet (20–40 minutes) to avoid sleep inertia (the groggy feeling you can experience after waking from a nap.) »» If napping for longer than 40 minutes, consider having two periods of sleep over the 24 hours, with one being a nap of about two to three hours.

»» Stay active. »» Keep a bright light on (to suppress melatonin). »» Schedule energetic activities earlier in the night, if possible (difficult for nursing). »» Consider having a 10–15 minute nap during your coffee break to keep you alert during the night. »» Use caffeine carefully – while it can be a good alertness booster, it takes five to eight hours to leave the body so can impact on your sleep post-shift. »» Get home safely – wind down the window and turn on the radio to stay alert. If you feel sleepy, stop as soon as possible and take a quick nap. »» Reduce caffeine/alcohol intake and avoid before bedtime. »» Wear sunglasses when driving home in the morning after night shift. »» Try to get to bed as soon as possible after a night shift as your core body temperature will be near its lowest and you will be at your sleepiest. »» Keep your bedroom dark (curtains or blinds – preferably blackout – are crucial). »» Use an eye mask if daylight can still enter your room. »» Communicate well with your family/flatmates to try and keep noise levels down when you are trying to sleep. »» Keep your bedroom cool for sleeping, with suitably comfortable bedding. »» Avoid ‘blue’ electronic light in room during sleep (i.e. clocks, stereo lights, iPads) as that disturbs your body clock.

General tips for shiftworking

Nursing Review series 2015

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Sexuality:

keeping it ‘normal’ Sexuality is central to being human but is not always a topic we are ready to discuss indepth over a cup of coffee or raise with our patients. Nursing Review Intro ??????? asked Mary Hodson, a therapist specialising in emotional and sexual intimacy, to share some thoughts on maintaining your sexual wellbeing.

oogle “what is a normal sex life?” and you get 126 million results in 30 seconds – article after article asking and answering “what is a healthy sexy life?” or “how much sex is normal?” Also ‘listicles’ like “11 wacky signs your sex life is totally normal” and “Four myths about healthy sex”. Probably the most obvious thing all these Google hits tell us is that it is fairly normal to wonder what’s “normal”.

But what a normal sex life actually is is very hard to define, says Mary Hodson, as there aren’t any norms when it comes to sexuality. And how people express or experience their sexuality is as diverse as any other human characteristic (see sidebar for definitions and research) but by the virtue of being human we are all sexual beings. Hodson’s work focuses on helping couple and individuals work through issues – either emotional

Some sexuality research findings

Sexual dysfunction findings from major cross-nation study

Full research references can be found at the www.kinseyinstitute.org/resources/FAQ.html

*Nicolosi, Laumann et al Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology 2004 Nov 64(5):991-7. Research sponsored by the manufacturer of Viagra.

»» The highest proportion of married men (according to a 2010 US study) have sex 2-3 times a week in their early 20s (45%) and this drops to weekly or a few times per month by their late 20s (47.7%) »» A similar trend is reported by married women with 35% reporting having sex 2-3 times per week in their early 20s and the trend shifting to sex weekly or a few times per month in their late 20s to 60, and after 60 the majority were having sex monthly or less. »» Many women express that their most satisfying sexual experiences entail being connected to someone, rather than solely basing satisfaction on orgasm. »» Men are more likely to orgasm when sex includes vaginal intercourse; women are more likely to orgasm when they engage in a variety of sex acts and when oral sex or vaginal intercourse is included. »» Among ages 18-59, older age for men is associated with lower likelihood of his own orgasm; for women it is associated with a higher likelihood of her own orgasm. »» 10% of men and 18% of women reported a preference for oral sex to achieve orgasm. »» 5% of men and 11% of women have never masturbated (1993 study). »» A study of married couples found age and marital satisfaction to be the two variables most associated with amount of sex. As couples age, they engage in sex less frequently, with half of couples age 65-75 still engaging in sex, but less than a quarter of couples over 75 still sexually active. Across all ages couples who reported higher levels of marital satisfaction also reported higher frequencies of sex. »» A 1993 study found 14% of men and 11% of women had some sexual experience with sadomasochism.

or sexual or both – affecting their intimate relationships. She says probably the most common reasons that people seek help in the age group the majority of nurses fall into – 35 years to 55 years – is low libido and most often female low libido. Also cases of one partner feeling pressured to have sex and, of course, unresolved relationship issues including sexual issues.

Nursing Review series 2015

The Pfizer Global Study of Sexual Attitudes and Behaviour* was a major survey of 13,882 women and 13,618 men aged 40 to 80 years in 29 countries across most world regions. It found that: »» More than 80% of the men and 65% of the women had sexual intercourse during the past year. »» The vast majority of people did not report any sexual dysfunction but the prevalence increased with age and overall 28% of men and 39% of women said they were affected by some sexual dysfunction. »» The most common sexual dysfunctions for men were early ejaculation (14%) and erectile difficulties (10%). »» For women the most common dysfunctions reported were lack of sexual interest (21%), inability to reach orgasm (16%) and lubrication difficulties (16%).

FOCUS n Healthy Year Ahead

“Don’t have sex, man. It leads to kissing and pretty soon you have to start talking to them.” Steve Martin “If I am feeling hurt, resentful,

The common myth about female libido

While it is more often low female libido than low male libido that prompts couples to seek her help, Hodson says it is a myth that women are less interested in having sex then men. “Recent research indicates that variation in sexual desire is much more related to relationship issues than gender traits. Women are more likely to leave an issue unresolved to keep the peace than men, and unresolved issues are usually love and passion killers.”

unappreciated, taken for granted, neglected or in any way unfairly treated for a sustained period, it is going to affect my feelings for, and my willingness to engage sexually with, my partner.” Women’s lives are also so often jam-packed that Hodson believes the major issue for many woman is managing that ‘busyness’ – and the distraction of electronic devices – in order to have time to devote to the emotional and sexual sides of their relationships. “With mothers having children later and staying in employment while they do so, life is really frantically busy and there isn’t much time or energy left over for our partners.”

How do you keep your sexual side alive in a busy life?

“In order to keep the sexual side alive we have to focus on it a little,” believes Hodson. “And I don’t mean become obsessed to the point of being driven by a desire for sexual fulfilment.” Hodson says the key ingredients in establishing and maintaining a longlasting, stable relationship is to nurture the love and the sexual desire that the couple both have. “If you don’t have it, then work very hard to grow it and do everything you can to take care of your partner’s emotional wellbeing.” She advises couples to be totally honest and clear with their partner Continued on the next page >>

Lubricants and the older woman For the older woman engaging sexually a good quality lubricant is vital in every single sexual engagement, says Mary Hodson. She advises women to buy a good quality lube made to European or North American health standards. “Then you will??????? know that it has no glycerine, menthol, alum, parabens and DEA; all of these have been shown to cause Intro significant health issues. In New Zealand lubes are not classed as a food or a medicine so there is very little control of what manufacturers put in them.”

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<< Continued from the previous page

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about how they can show love, nurture their sexual desire and take care of their emotional wellbeing. And also to: Speak respectfully to each other at all times; even when feeling angry. Be kind to each other at all times. Consider your partner’s needs and what is good for the relationship before making any decision and then make the decision together based on what is good for the relationship. Communicate carefully and thoroughly and make time on a daily or almost daily basis to talk about things that will encourage emotional closeness. Say clearly but gently what they think, feel and want to happen while not ignoring the other’s rights in the situation. Always be prepared to negotiate and compromise – a compromise can always be found even if it is only, “Well we cannot agree, so you make this decision and I’ll make the next curly one that comes up”. Treat your partner as an equal at all times.

Her experience is that it mostly attitudes, reactions Intro ??????? and responses (or lack of responses) that cause

the intimacy problems between couples, whereas couples who are emotionally and sexually in sync will cope better when faced with a major physical or psychological problem. “I am frequently amazed at the awful experiences, enormous stress and major problems that couples in loving, caring, cooperative and respectful relationships manage to get through, triumph over and come out the other end relatively unscathed.” “So, for example, a person who is recovering from a prostatectomy and having major sexual difficulties will generally cope better with the sense of loss and feelings of inadequacy when they are able to trust that their partner is there for them, will not judge them adversely and will continue to love and respect them. “On the other hand, I am sometimes sad and frustrated when couples aren’t coping with difficulties because one or both of them have stopped cooperating with the other or stopped caring and being kind, loving and respectful.”

Sexuality and the single woman

Hodson says she also worries a lot about single woman making the same mistakes with sex that older woman now regret. She advises people not to rush into any relationships – especially not a sexual relationship. “Take time to find out if the person can be trusted with your emotional wellbeing before you commit.” Which means looking back over your relationship history and working out at what point in a relationship you usually feel committed and holding back from taking that ‘commitment’ step until sure the person is right for them. “For many, many women, the point of commitment is when they engage sexually so, if that is your ‘point of commitment’, don’t go there until your prospective partner has proved to be trustworthy,” says Hodson. “Don’t accept second best; commit to someone that you really feel the 10

Nursing Review series 2015

“I haven’t trusted polls since I read that 62% of women had affairs during their lunch hour. I’ve never met a woman in my life who would give up lunch for sex.” Erma Bombeck

More about sexuality A definition of sexuality

Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical and religious and spiritual factors.

A definition of sexual health

Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. *Working definitions developed after World Health Organisation technical consultation on sexual health with the World Association for Sexual Health (updated 2010).

Further reading and information: HealthySex.com: a website led by American author and sex therapist Wendy Maltz. A website dedicated to promoting “love-based, healthy sexuality”. Maltz has also written widely on sexuality, including books on exploring women’s sexual fantasies, recovering from sexual abuse and help with pornography-related problems. www.healthysex.com A Woman’s Touch: a sexuality resource centre run by two women – a doctor and a sex educator/ counsellor. https://sexualityresources.com World Association for Sexual Health: www.worldsexology.org Includes professional ethics for those working in the area of sexuality World Health Organisation: sexual and reproductive health www.who.int/entity/ reproductivehealth/topics/sexual_health/en/index.html Work underway developing sexuality counselling guidelines for health care workers The Kinsey Institute: Indiana University’s Kinsey Institute focuses on advancing sexual health and knowledge and has been researching sexual behaviour for more than 60 years. www.kinseyinstitute.org Foundation Course for Health Professionals: For nurses interested in further education in the area of sexuality the University of Auckland’s Social and Community Health division is planning to reactivate and offer a two-day foundation course in sexuality and intimacy this year. For more information email p.huggard@auckland.ac.nz.

love for and feel the love from and also feel the sexual desire for and from.” “A relationship needs all of these components – a feeling of love that goes both ways, a feeling of sexual desire that goes both ways and it also needs a mutual will to work at making the relationship work including a mutual will to take care of each other’s emotional wellbeing.”

**Mary Hodson is a therapist specialising in emotional and sexual intimacy work for Sex Therapy New Zealand – a nationwide counselling service for help with intimacy and sexuality concerns.

FOCUS n Healthy Year Ahead Restricted access to Christchurch Hospital.

Toni Gutschlag

Heather Grey

Mental health matters:

Intro ???????

boosting nurses’ wellbeing

he ‘heroics’ are all behind us, the ‘honeymoon’ is well and truly over and it feels like we’ve been stuck in the ‘disillusionment’ phase for quite long enough, thank you. Four years on from the most devastating quake, and nearly four and a half years after the first and largest quake, Christchurch is very much ready to climb out of the ‘disillusionment’ doldrums into the fourth and final ‘reconstruction’ phase of the psychosocial recovery model for a disaster. With new and glistening buildings popping up in the city – and the cranes on the skyline now there to construct rather than destruct buildings – there is a feeling that the city’s ravaged inner city is on the up. Christchurch isn’t quite there yet though and its citizens largely feel the same. Many are still on an emotional rollercoaster – buoyant and optimistic

Four years on, Christchurch’s nurses are still driving on bumpy roads to workplaces that are often temporary or under repair before returning to a home that may still be cracked or leaking. And with a $650 million rebuild, redevelopment and reshuffle of hospital services underway over the next four years and increasing demand for mental health services, it seems there is little relief in sight. FIONA CASSIE looks at efforts to boost and maintain the wellbeing of Christchurch nurses and considers the take-home lessons for nurses under stress anywhere in the country.

at the peaks and frustrated to downright cantankerous in the troughs. And many are tired, increasingly tired, according to the 2014 survey carried out for the Canterbury District Health Board’s All Right? campaign in which 65 per cent of respondents reported feeling tired, compared with 55 per cent in 2012. That figure doesn’t surprise Heather Gray, director of nursing for Christchurch Hospital. “Last year just seemed to be a long, hard year for many of us… many people have said it was the hardest year for some reason.” She agrees that maybe it was because by 2014 people thought things would be getting easier. “We should be over this by now,” is a common comment, says Gray. Continued on the next page >>

Compassion fatigue: “I’m over it!” Plenty of people both outside and inside Christchurch would like to ‘move on’ about now. Surveys have found that 64 per cent of Cantabrians feel guilty that they got off lightly compared with others during and following the quakes. Now with their houses repaired and their lives relatively back on track they can feel ready to start ‘moving on’. But around a third of their fellow Cantabrians are still stuck, still struggling and still waiting for insurance and EQC wrangles to be resolved. (And that’s not forgetting those

who lost loved ones or suffered traumatic injuries.) All Right? campaign manager Sue Turner (see All Right? story on page 14) says experts predicted that it is at about this time when part of a community is ready to move on and part of it is still struggling. The issue of ‘compassion fatigue’ first emerged in the most recent ‘taking the pulse’ research carried out late last year. Turner says those ready to move on can feel conflicted when having conversations with people still caught in the

waiting stage. They can feel stressed as they feel they’ve got to ‘fix’ the other person’s problem or they feel guilty for thinking “actually I don’t want to hear this anymore – I’m so over it”. She says the message All Right? wants to get out to people, which also holds for people outside Canterbury, is that you don’t have to fix the problem, you just need to listen. “You just have to be there and hear what people are saying; listening is such a gift in itself.”

Nursing Review series 2015

FOCUS n Healthy Year Ahead

<< Continued from the previous page And while many more people now have new or repaired homes, others are only now requesting quake leave in 2015, having finally got the green light for their repairs. Others are still waiting – sometimes caught up in complicated wrangles over initiating first-time repairs or rejecting substandard repairs and sometimes still camping in garages or campervans.

”Looking after yourself is something that doesn’t come easy for nurses. I think they look after other people first before looking after themselves.”

Stats show 2014 a tough year

The DHB’s mental health services had a particularly hard time last year, with extra demand across the spectrum forcing the board into a one million dollar deficit, as cited by the DHB’s finance general manager in The Press late last year. General manager mental health services Toni Gutschlag says that in the past three years demand for community mental health services has increased by 30 per cent, acute emergency mental health services by 37 per cent, and rural mental health services by 65 per cent.

Getting the SWAG When the DHB’s first staff wellbeing survey in 2012 showed wellbeing floundering, chief executive David Meates created the Staff Wellbeing Action Group, known as SWAG. survey showed that, like the rest of Intro ??????? the“The Canterbury population, we as staff were facing challenges impacting on our wellbeing,” recalls Andy Hearn, the DHB’s staff wellbeing coordinator. Hearn, a physiotherapist by training, says the SWAG group initially deliberately went for the “low-hanging fruit” – getting people active – and quickly set up low-cost zumba, pilates and yoga classes across Christchurch Hospital and the DHB’s other four main city sites. Other interventions have followed to help staff meet the five ways to wellbeing and support people in dealing with the ongoing quake aftermath. These interventions include: »» Finance and retirement planning workshops for staff needing to revisit their retirement plans as a result of losing their home in the red zone etc. »» Contracted earthquake support coordinators to help case manage staff’s EQC and insurance issues, plus onsite, 30-minute, free appointments with Residential Advisory Service lawyers. »» Running 26 two-hour wellbeing workshops in 2014 (attended by up to 25 DHB line managers) focusing on self-care, personal wellbeing and resilience-building skills. »» Mindfulness sessions once or twice a week at each of the five main DHB sites, plus onsite Weight Watchers meetings and upcoming sleep hygiene workshops. »» Continued offsite counselling and onsite staff support through its employee assistance programme (EAP) services. »» Taking part in the Global Corporate Challenge in 2013, which got 580 people ‘stepping out’; signing up in 2014 to the Tracksuit-Inc programme, which offers a range of health-based wellness challenges during the year. These interventions and activities helped the DHB win the best new programme at the 2013 New Zealand Wellbeing Awards organised by the Health and Productivity Institute of New Zealand. The follow-up staff survey in 2014 indicates that, with many staff still struggling, Hearn and the SWAG team can’t step back any time soon. Two years on, Hearn still sees his primary role as helping staff to be as resilient as they can be as they cope with the huge and ongoing repair and rebuild of the DHB’s facilities. A recent key focus is finding ways to help people get moving, with Hearn being concerned that the percentage of staff achieving the Ministry of Health’s minimum recommended level of physical activity has dropped from 22 per cent in 2012 to 18 per cent in 2014.

Nursing Review series 2015

There has been an upsurge in children and teenagers presenting for specialist help for depression and anxiety (up by 56 per cent – 28 per cent in rural Canterbury) and admissions to the DHB’s 15-bed specialist child and youth inpatient unit at Princess Margaret Hospital has risen by 91 per cent. Gutschlag is also chair of the DHB’s Staff Wellbeing Action Group (SWAG) that was created after its own staff wellbeing was found to be floundering in the DHB’s first staff wellbeing survey in 2012 (see SWAG story on this page). The follow-up 2014 survey found that around a third of staff still had earthquake claims that were only partially resolved and a quarter of homeowners still had unresolved issues. On top of that, 13 per cent of staff reported being directly impacted by the three record floods that hit the city in quick succession in March and April last year. It is probably not surprising then that the DHB survey found that the emotional wellbeing of 35 per cent of its male staff and 37 per cent of female staff respondents rated ‘poor’, according to the World Health Organisation wellbeing index. This was a slightly better result for men than that of the 2012 survey but slightly worse for women. Once again lack of sleep and feeling fatigued was a very common theme. That feeling of post-quake fatigue is also likely to be shared by many of the nursing community working around roadworks, building repairs and rebuilds across general practices, rest homes, community nursing services like Nurse Maude and Health Care New Zealand, private surgical hospitals, community mental health providers and Plunket.

2015: the best year yet? Working amongst traffic cones and orange vests

After a bright, hot summer many Cantabrians have returned from holidays optimistic that 2015 could just be the year that the city turns the corner. “It is only lately that I’ve started meeting people who are more hopeful that we are going forward,” says Heather Gray. “We’re building a few buildings rather than ripping them down… it’s quite nice to see that.” “I think though there are still some challenges ahead – particularly on this campus,” says Gray of the central city Christchurch Hospital. “We’ve got a building construction site out back and road construction out front and we have business as usual – sort of – in the middle,” she laughs. “All our access-way roads have been moved. Our two-way streets have become one-way, our one-way street has become two ways and one street is cut off entirely. So all of the flow past the hospital is different.” The construction site out the back is a new acute services hospital building – already in the pipeline, pre-quake – which got under way in late 2014. Out front the City Council is carrying out a major transformation of the roading network. Sandwiched between the road cones to the north and the jackhammers to the south are the ongoing repairs to the existing acute services building, with virtually every room having experienced quake damage. To the east, work is under way on the new green belt along the Avon River – a long-term plus for hospital staff but currently yet another disruption. All this construction also means that from late October last year all car parking around Christchurch Hospital – except for limited mobility parking sites – has ceased. Staff parking is not directly affected but hospital visitors are now encouraged to park on the site of a demolished brewery (earmarked for a new sports facility) and take a free shuttle to the hospital. It’s no wonder that patients and visitors can present as more than a little harried when roads, car parks, entrances and facilities may have been closed, shifted or changed between visits. “We have certainly found that over the last four years people are less tolerant,” says Gray. “There’s a shorter gap between coping and not coping than perhaps there was before the earthquake. “I think we’re developing a phobia for orange cones in Canterbury. People almost run them down on purpose, it seems,” she adds, with a laugh. Across town in the north-east of the city at the Burwood Hospital campus, major new facilities are being built to house the team at the CDHB Older Person’s Health Specialist Service. The big shift, scheduled for 2016, will take them from their current home at The Princess Margaret Hospital, which is in the opposite, south-west corner of the city. The completion date of the project, originally set for 2018, is now looking more like 2019.

FOCUS n Healthy Year Ahead

High demand for MH services yet to peak?

In the midst of these rebuilds and reshuffles the mental health service is becoming seriously stretched, with increased demand driven by those with mental health issues triggered by the quakes’ aftermath. Toni Gutschlag is not sure whether this increase in demand, particularly the “extremely concerning” rise in child and youth presentations, has yet to reach its peak. She says previous international disaster research has indicated that mental health needs increase a couple of years after the main event. “We were lucky we had a reduction in demand for the first 12 months – things dropped off as people were preoccupied with other things.” As a result, the DHB was able to action some plans already in the pipeline before the quake and make some quick changes in readiness for the expected increase in demand “which for us has been in the last 18 months.” Gutschlag believes one of the reasons for the increased demand is Cantabrians’ greater awareness, post-quake, of mental health and wellbeing and how to get access to professional help. “I think some of the stigma has reduced so it’s okay now to get help, because mental distress has been experienced by so many more people.” But it was also worrying that the upsurge in post-quake demand meant parts of the community were under such pressure that it was impacting on their mental health. The demand has come at the same time as mental health staff turnover and sick leave has increased, however, as mental health staff are all part of that same pressured community. Recruitment has also been “really challenging”, Gutschlag says, particularly with Christchurch’s limited and increasingly expensive housing stock. One successful response has been to invest heavily in the DHB’s nursing and allied health new graduate programmes to help meet the ongoing high Intro demand ??????? for mental health services. Continued on the next page >>

Department of Nursing noticeboard devoted to helping you find your way to and through hospital building zone.

Touch of humour and Where’s Wally to help you navigate through Christchurch Hospital building zone.

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<< Continued from the previous page “It (the upsurge) was predicted and what we are experiencing is consistent but we don’t know when it’s going to end…”

Maintaining and building nursing resilience

‘Challenging’ may be somewhat understating the trials that many Christchurch nurses will be facing in their professional lives for possibly another four years, on top of an already tough four years. So how do you keep nurses ‘keeping-on’ in the ongoing aftermath of a major disaster that at times has tested the resilience of even the most buoyant? “I don’t think there is one formula for that,” says Gray. She believes the accumulation of some really simple intangibles can help make a difference. Things like ensuring people take their holidays, sensitive rostering and making sure they are aware that their work is appreciated. “Because it is easy to forget to appreciate the quiet ones,” says Gray. Also giving people a vision of where the service is headed, as vision and teamwork is a priority. Then there are the more tangible things like the programmes offered by SWAG and the All Right? campaign (see related story) posters plastered on the walls of hospital corridors and wards. “Just asking people ‘are you okay?’ is also really important,” adds Gray. Nurses are learning to pace themselves too, if the trend noted by postgraduate nursing education coordinator Jenny Gardner is anything to go by.

Intro ???????

She says funding applications last year exceeded supply, leaving a waiting list of nurses who were eager to begin studying and were not letting the quakes hold back their careers. But this year there has also been a noticeable trend of nurses with approved funding for two papers deciding over the summer to settle for one paper or take a break before launching into their dissertation year. “I think the drive and the want and the intention is definitely there – that hasn’t waned at all – but it’s just been tempered with reality really,” says Gardner. The most common reason for postponing study is house repairs, with nurses reporting that they’ve just been notified by their insurers that they need to shift out next month so repairs can begin. “It’s hard to study when you’re living out of boxes.”

Seeing the silver lining

Taking a breather is a sensible approach but it can be challenging when you are part of the mental health service, which is facing increased demand, increased staff turnover and recruitment challenges. “At the end of the day it is tough going,” acknowledges Gutschlag, when asked how mental health services staff deal with the pressure. Though, she adds, there was also a positive side to being so in demand, particularly in the early days post-disaster. Gutschlag says staff told her that in their personal lives they had felt a lack of control over what was happening to their homes, their children’s schools and their local community. “But they could come to work and get on with their jobs and be involved in change and making things better,” recalls Gutschlag.

Wellbeing messages relevant to all FIONA CASSIE talks to SUE TURNER, manager of Canterbury’s All Right? wellbeing initiative, about one small silver lining of the quakes – people’s awareness of their own mental health – and how All Right? is helping people restore and maintain their personal wellbeing.

series of devastating earthquakes is a pretty violent way of shaking a community into realising that mental health matters. But it does bring home to people the importance of their mental wellbeing when their usual resilience ‘buffer’ is worn thin by ongoing aftershocks, insurance wrangles and coping with the ‘new normal’. Sue Turner says the quakes have provided public health and mental health sectors with a ‘silver lining’ opportunity to focus on mental wellbeing. “People have suddenly recognised that they have mental health as well as physical health,” says Turner. “It takes something like a crisis for people to recognise that and feel okay about it.” Turner is manager of the All Right? wellbeing initiative that is led by the Canterbury District Health board and the Mental Health Foundation and funded by the Ministry of Health. All Right? was launched in Canterbury in February 2013 with a series of posters and advertisements popping up all over the city telling people: “It’s All Right?…” to feel frustrated, to feel lucky, to feel overwhelmed, to feel proud of how they’ve coped or to feel blue; in fact, acknowledging all the wide-ranging emotions that Cantabrians felt and can continue to feel on the post-quake emotional rollercoaster. That initial campaign has been followed up by a range of other initiatives built on the Five Ways to Wellbeing (see next page) and guided by both international research and regular ‘taking the pulse’ research on how Cantabrians are

Nursing Review series 2015

feeling about their city and their lives (see more at www.allright.co.nz). A key to the campaign has been the eye-catching, quirky and feel-good posters, postcards and advertisements created by hometown advertising agency, Make. Turner says although the destigmatisation of mental health had already begun with the work of the Mental Health Foundation and people such as Sir John Kirwan talking about depression, the quakes had sped up the process. “Because in New Zealand (in the past) it’s been a bit of a ‘no-no’ topic to talk about your mental health because you don’t want people to think you’re ‘mental’,” says Turner. “Now we’ve got lots of people in the same boat all talking about it.” The quakes accentuated the need of the population of an entire metropolitan city and the

surrounding region to stop and ask whether they and others were All Right? and the realisation that if they weren’t All Right? they were far from alone. For some that meant seeking clinical help, for many others it meant trying to take a little more care of themselves and each other. Turner says a main take-home message of All Right? is to recognise the things you can’t control in your life and the things you can. “And what you can control on a day-by-day basis are the little things that support your wellbeing.” “We are often very focused on our physical health – making sure that we get exercise, nutrition and all that kind of stuff,” adds Turner. “This (the All Right? initiative) is just a reminder that we need to do the same thing for our heads.” Recovery from both the infrastructural and psychosocial impacts of disasters on the scale of the Canterbury quakes, however, takes time. “I remember we laughed at the beginning when people said this recovery could take 10 to 15 years. We said ‘What? You must be joking, that’s a ridiculous amount of time!’ but now we all believe it,” says Turner. The one silver lining may be that people will continue to take their own mental wellbeing seriously beyond the recovery time. Turner says other organisations are also keen to use the All Right? resources for campaigns in their communities to help people cope with the normal ups and downs of life. So Christchurch may just be able to give something back, which is pretty ‘all right’.

FOCUS n Healthy Year Ahead

Givers need to take time for themselves

‘Giving’ is one of the five ways to mental health wellbeing, and the strong ‘giving’ trait is also fundamentally why most health professionals are there in the first place. But givers and carers also need to care for themselves. “We can be very good at providing care for others and not prioritising ourselves, and that is a challenge not only for the mental health workforce but the whole (health and social service) workforce,” says Gutschlag. CDHB chief executive David Meates is keen for his staff to get the takehome message of doing something for themselves. In his September CEO update he signed off by saying: “Remember that to care for others you need to look after No. 1 first”. Gray says ‘looking after yourself’ can sound a little glib but the worth of it was brought home to her personally last year. Bogged down with a range of work projects, she had hardly seen the sun for five months and not surprisingly found her mood was flat. “In a way I think you have almost got to fail at that (looking after yourself) before you realise you’ve got to do better. Looking after yourself is something that doesn’t come easy for nurses. I think they look after other people first before looking after themselves. “But it’s like the airline safety messages, isn’t it? ‘Put on your own oxygen mask first before assisting others’.”

The Five Ways to Wellbeing The All Right? Campaign uses bright and funky posters and images to prompt Intro ??????? to take a little extra care of themselves and others. Cantabrians Based on the premise that it is vital to feel good and function well the campaign uses the framework of the Five Ways to Wellbeing* to prompt people to do things that will help boost and maintain their wellbeing. TAKE NOTICE When was your last moment of wonder? Encouraging people to be mindful, savour the moment, reflect on what gives joy or remark on the unusual.

KEEP LEARNING Tried something a little different lately? Encouraging people to try something new, rediscover an old interest or take on a new challenge.

CONNECT When did you last share kai with the whānau? When was your last ‘mate date’? Encouraging connections with family, friends, colleagues and neighbours.

GIVE When did you last show a little love? Encouraging people to give, from simply thanking people and smiling to doing something nice for someone or volunteering.

BE ACTIVE Had a good boogie lately? Encouraging people to be active – be it walking, dancing, running, kicking a ball or digging the garden.

*The Five Ways to Wellbeing were first developed by the New Economics Foundation, a UK think tank, using evidence gathered in the UK Government’s 2008 Foresight Project on Mental Capital and Wellbeing.

Nursing Review series 2015

FOCUS n Healthy Year Ahead

Laughter is the best medicine?

You must be joking…

Nursing Review YOU KNOW YOU’RE A NURSE WHEN… takes a quick look »» You don’t get excited about blood loss … unless it’s your own. »» You find yourself checking out other customers’ veins while queueing at the supermarket. at the science of laughter »» You believe that unspeakable evils will befall anyone who utters the phrase: “Wow, it’s really quiet, before getting down to the isn’t it?” serious stuff of sharing some »» You’ve ever had a patient look you straight in the eye and say: “I have no idea how that got stuck in there.” nursing humour. »» Your idea of fine dining is sitting down to eat.

umour might not heal all ills, but a good laugh definitely does you more good than harm. Psychology and neuroscience professor Robert Provine took a look at the science of laughter in his 2000 book Laughter: A Scientific Investigation. Interviewed for an article on WebMD in 2008 (see below) he said the definitive research into the potential health benefits of laughter had yet to be done. Provine says while there is research showing laughter’s positive impacts, it is unclear whether having a good scream might not have the same physiological impact as a good laugh. Or that laughter’s ability to dull pain might be more to do with being distracted than having your funny bone tickled. Intro What ??????? is agreed is that laughter: »» Stretches and stimulates muscles across your whole body, so can help relieve tension and increase endorphin release by the brain »» Stimulates your stress response by making your pulse and blood pressure go up and then down, leaving you potentially more relaxed »» Makes you breathe faster, so increases your oxygen intake throughout your body »» May keep blood flowing normally (research has indicated blood vessels of people watching drama can tense, restricting blood flow when compared with people watching comedy) »» Is associated with easing pain and causing body to produce its natural painkillers »» May help release neuropeptides that help fight stress and boost immunity »» Can help lessen mild depression and anxiety. So while the jury may be out on whether laughter is the best medicine, there is definitely a strong case for prescribing yourself a giggle, chortle or full belly laugh to be taken as needed.

»» You believe the inventor of call bells has earned a special place in Hell. »» You’ve ever heard a patient with a nose ring, a brow ring, and 12 earrings say: “I’m afraid of shots.” »» You can keep a straight face when a patient responds: “Just two beers.” »» You believe chocolate is a food group. »» If someone coughs and brings up sputum in front of you, you have the desire to know what colour. »» You’ve seen more penises than any prostitute. »» Your talk of wounds and drainage in a restaurant makes the people at the next table run for the door. »» You’ve ever restrained someone … and it wasn’t a sexual experience. »» You can almost SEE the germs on the doorknobs and telephone. »» After spending the night with surgeons, they still won’t respect you in the morning. »» Your idea of a meal break is finishing your coffee before it gets cold. »» You are counting your husband’s pulse while he sleeps and worrying because he is wheezing on exhalation. »» You believe experience is something you don’t get until just after you need it. »» You look at even your own bowel movement to make sure it’s okay. »» You consider a tongue depressor an eating utensil. »» Family and friends call you to describe their injuries over the phone. »» You call some of your co-workers ‘flowers in the field of medicine’ because they’re bloomin’ idiots. »» You want to throttle anyone who states: “Night shift must be so boring, all the patients do is sleep.” »» You ever wished that they would make corrugated catheters to use on really annoying patients. Drawn from: 250 funny reasons you know you’re a nurse at www.nursebuff.com MORE ON HUMOUR AND HEALTH: WebMD: Why, for some, laughter is the best medicine by R Morgan Griffin, reviewed by

Michael W Smith MD. www.webmd.com/balance/features/give-your-body-boost-with-laughter MAYO CLINIC:

www.mayoclinic.org/healthy-living/stress-management/in-depth/stress-relief/art-20044456?pg=1 CLOWN DOCTORS NZ: www.clowndoctors.org.nz/Clown-Doctors-New-Zealand-humour-and-health.html

Nursing news, views, trends and analysis If you want to know what your colleagues are thinking or doing, subscribe to Nursing Review. Multimedia format includes: »» Five print editions per year »» In depth website, newsfeed and professional development tools

Nursing Review series 2015

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FOCUS n Healthy Year Ahead

Intro ???????

Skin care for the busy nurse Looking after our skin often comes a distant second to extramural study, full-time work and looking after family in the busy world of today’s nurses. Cosmetic nurse LARA MOLLOY shares some practical and quick skin care tips for nurses on the go.

“K

eep it simple” is the mantra for cosmetic nurse Lara Molloy. Many women have bathroom cabinets and drawers cluttered with cleansers, toners, hydrating face masks, exfoliating scrubs, pore minimisers, eye gels and other creams and lotions offering to lift, firm, hydrate, renew, boost and otherwise make our skin radiantly youthful. Molloy is well aware that many of these lotions and potions just sit on the shelf gathering dust. So what she advises clients at her appearance medicine clinic – many of them nurses aged from their mid-20s to close to retirement – is to get back to the basics. While her clinic offers Botox to laser treatment, she says the secret is getting the ‘canvas’ right; that is, looking after the biggest organ of your body – your skin. “To me, the canvas is far more important than the odd line here or there,” says Molloy. “I really work hard on getting great skin.”

Good skin care at your supermarket

Good basic skin care doesn’t have to break the bank. For nurses who don’t have the inclination or the money for high-end skin care products, Molloy advocates investing in a good moisturiser and UV protectant and not wasting money on cleansers and toners. “You can get dragged into a myriad of products that you don’t need,” she says. “All the cleansers that have special ingredients in them – they are just put on and washed

off immediately so you really don’t need to get anything too flashy.” She says Cetaphil is a good basic range – they have a cleanser for both dry and oily skins – and it is available on the supermarket shelf. “It is one I would recommend for people who are budgetconscious – and nurses usually are.” Likewise you don’t need a toner. Molloy says pick up a pack of microfibre cloths from your supermarket aisle instead – the everyday ones for dusting and cleaning, not the shiny ones for glass polishing as they are too smooth. “The normal microfibre cloth feels really soft but they are actually quite rough and abrasive. So at night after cleansing your skin just give your skin a gentle buff with a microfibre cloth and warm water. Then just rinse out the cloth so it dries and is and ready for the next night. “That’s instead of using toners as the cloth gets all the residual make-up off and helps lift off the dead skin cells as well, without any chemicals. I’ve put most of my clients onto microfibre cloths now – they are brilliant. “It’s like a mini micro-dermabrasion every night – but don’t be too rough.” In your 20s your night-time regime can then just end with the applying of a simple moisturiser suitable for your skin type. Molloy says if you have oily skin or combination skin you should avoid cream-style moisturisers containing oily substances (like cocoa butter/ coconut oil) and instead opt for lotion-style products with humectant (moisture absorbing or attracting) agents like glycerine and hyaluronic acid.

Everyday UV protection is a must

Sun damage leads to premature ageing of the skin for many Kiwis. Many of us, with the wisdom of hindsight, look back to the sun-filled days of our smooth-skinned 20s and wish we had slipped on a hat and slapped on some sunblock far, far more often. Molloy agrees that prevention is better than cure so she recommends that Kiwis take sun protection one step further if we don’t only want to reduce the risk of skin cancers but also our chances of premature wrinkles and sun spots. “Absolutely every morning – summer and winter – you should use a SPF30+ (sun protection factor) moisturiser under your make-up.”

Yes, even indoors

Even if you are likely to be indoors at work all day, Molloy points out that fluorescent lights also emit UV (ultraviolet) rays that, with long-term exposure, can impact on the skin. A 2012 study found that energy efficient CFL (curlicue compact fluorescent lamps) bulbs emit even more UV rays than traditional fluorescent tubes and may damage healthy skin cells and exacerbate existing skin conditions. Nursing Review series 2015

FOCUS n Healthy Year Ahead

Finding the right SPF moisturiser that suits you and your pocket is a matter of trialling some of the many products on the market, says Molloy, but it is the area that people should avoid going ‘budget’ if they can. People with oily skins can struggle to find a combined SPF moisturiser that works for them without having skin breakouts. Also people with dry skin whose skin feels tight after applying an SPF moisturiser will need to shop around. So some people can opt to use a standalone SPF30+ sunscreen and then a moisturiser on top. “For people on a really tight budget with dry skin, probably popping on an SPF30+ block and olive oil is absolutely fine,” says Molloy. “Anything that traps or prevents moisture loss for a dry skin is fantastic, as long as they are not prone to pimples.”

Skin care as we age

A daily skin regime for the nurse in their 20s can be quick, simple and relatively cheap. But even the skin of those who have been religious in protecting themselves from sun damage will naturally start to change as people get further into their 30s, 40s and beyond. And for those of us who had a peeling nose every summer as a child this process is even faster. So Molloy suggests stepping up your skin care regime as you move into your 30s and 40s if you care about keeping your skin looking as good as possible. And that usually means adding at least Intro one more??????? product or step to your nightly regime after the usual cleansing, buffing and moisturising. How far you go is a matter of personal choice, budget and the amount of time you are ready to invest in your beauty regime. “You should see my bathroom,” she laughs. What that product or treatment is also depends largely on your skin type and history.

Active ingredients the key

Molloy suggest that once you get into your 30s and if you’ve had a history of sun damage as a child you should look to add an antioxidant product. “A decent vitamin C (ascorbic acid) product or serum is essential and it helps repairs the cell membranes. It is protective as well as repairing and that would be a basic one to start using.” Vitamin C treatments are also ideal for people who have pale, thin skin with red vessels (broken capillaries) just starting to show through around the nose or cheeks and who are prone to flushing. “Well vitamin C is really good for everyone,” says Molloy. “It really does slow down the ageing process.” She says this is the point when you do start to need

Nursing Review series 2015

to spend more money as off-the-shelf products at your pharmacy or department store don’t have active ingredients in the form and percentage levels required to be absorbed into the skin and make a difference. Instead you need to start stepping into the realm of ‘cosmeceuticals’ – a term coined by the beauty and dermatology sector to describe cosmetics containing high levels of an active pharmaceutical ingredient, such as vitamin C or the vitamin A derivative, retinol. She says while the big name cosmetic companies may make claims about antioxidants in their beauty products, they are not present in high percentages. “And while they can use lovely emollients and the products feel good on your face, they are not going to protect your skin and make a long-term difference.” While high-strength cosmeceuticals can cost a little more, she says, you can be very frugal with them and just use a drop of serum for each cheek; the difference is obvious after three months. Vitamin C is the most plentiful antioxidant in human skin. It helps protect the skin from oxidative stress and is essential for the making of collagen. A quick Google search of research studies finds numerous citations for topical vitamin C and vitamin A derivatives improving the appearance of sun-aged skin. For women who seek help in their 40s and beyond – who so often have accumulated more sun damage – she may possibly suggest alternating nights with a vitamin A product as well. “But with nurses you just don’t want to overwhelm them with too many products. So if anything I would stick to a cleanser, a sunblock and a moisturiser and then I would add in a ‘C’ and possibly alternate with an ‘A’ and that’s as fancy as we get.” (Vitamin C and A treatments should not be used together as they can interfere and nearly negate each other.)

Retinol

recovering from bad name Retinoids – the vitamin A derivative used in skin treatment – had their fair share of negative press back when Retin-A (retinoic acid) first came on to the market in the 1990s as the miracle anti-ageing cream. Molloy says the early cosmeceutical came under attack because of uninformed people getting hold of prescription strength Retin-A and going “gung-ho” with it. “Retinol is fantastic for every skin type,” says Molloy. “But you’ve just got to be really careful because if you use too much of it before your skin’s receptors are ready to take it on you will get redness, irritation and be sensitive to the sun.” Dermatologists still believed in retinoids and after the backlash of the 1990s went on to develop new products – often using the milder form, retinol. Retinoids still have to be used with caution. “But Retinol is amazing if you use it twice a week and slowly build up.” Too much too soon and you will get flakiness of the skin and you will need to back off. Because of the need to ensure people use this very effective cosmeceutical wisely and well, it is now marketed in a variety of strengths. So Molloy says a first-time user will be given the weakest strength in case they are tempted to use “buckets of it” in the belief that “the more the better”. After three months they will then be trusted to step up to the next strength and can step up again in a further three months.

Adult acne and dermatitis

While most of Molloy’s clients come to see her with age-related concerns from frown lines to pigmentation changes, there are also other skin conditions that clients want remedied. People with oily skin are less likely to get the premature fine wrinkles worrying other woman, and their skin needs less moisturising, but they can have other issues like adult acne. The onset of adult acne – usually hormonally triggered – is not an uncommon problem, says Molloy, but it can be devastating for women who’ve had great skin all their lives to suddenly get pimples in their 30s, 40s or 50s. Acne usually occurs along the chin and jawline and sometimes down the neck but can also affect all areas of the face. Molloy says her skin clinic’s resident doctor will carry out tests on the women’s hormone levels and may put some women on the oral contraceptive pill to help stabilise their levels and also consider prescribing a low-dose antibiotic. But the first preference is for the clinic’s nurses to work

with the woman on developing a skin treatment regime that heals the acne without resorting to medication. Another condition is rosacea, which is redness across the cheeks and nose that can be treated with a topical antibiotic and light-based therapy. Molloy says it is also surprising how many people walk around unknowingly with low-level dermatitis. “I will go to do a facial treatment for someone and I will feel this very little insidious bumpy rash – just little tiny, tiny bumps everywhere. They’ve actually got reactionary dermatitis to some skin product they’ve used for years and they don’t even know.” She says they will tell her “oh that’s just how my skin is” at which she tells them “no, it isn’t” and that they need to change their skin care products. As a transition, she usually advises them to use the most basic and pure of products –a tub of fatty cream – as an interim moisturiser until their skin stabilises and they can reintroduce something a little more high-tech. Her nurses will suggest a similar regime for anybody with general dermatitis or eczema. “They withdraw all the patient’s usual skin products and give them Cetaphil to cleanse with and fatty cream as a moisturiser. They will then slowly re-introduce products one-by-one to make sure they are not reacting to anything in the new regime.”

FOCUS n Healthy Year Ahead

”You can get dragged into a myriad of products that you don’t need.”

Basic skin care tips MORNING REGIME

1. Cleanse your skin morning and night. 2. Dry skin: use a milky cleanser. 3. Oily skin: use a gentle foaming cleanser. 4. Don’t spend a fortune on a cleansing lotion – Cetaphil is a good option. 5. Every day use an SPF30+ moisturiser to prevent not only sun damage but also environmental damage from fluorescent lighting. 6. If you are on a really tight budget and have dry skin, you can get away with putting on an SPF30+ sunblock and using olive oil as a moisturiser.

NIGHT TIME REGIME

1. Remove makeup and cleanse with your usual cleansing lotion. 2. You don’t need to use a toner, instead gently buff your face with an everyday microfibre cloth and warm water. The cloth is mildly abrasive and will remove any residual make-up and dead skin cells. 3. Apply moisturiser suitable for your skin type. 4. When you get into your 30s, consider adding a vitamin C serum to Intro ??????? your nightly regime to protect and repair sun damage. 5. In your 40s, consider also adding an additional vitamin A/retinol treatment but remember to follow instructions closely to avoid adverse skin reactions.

HAND CARE

1. Try to avoid using alcohol-based hand sanitiser as it dries out your skin. If possible use soap and water instead. 2. If you can’t avoid using alcohol hand sanitiser during the day in your work, take extra care of your hands at night. Apply a creamy hand cream treatment and leave it overnight to act as a moisturising mask for your hands. Some effective options include Lucas’ Papaw Ointment or Elizabeth Arden Eight Hour Cream hand treatment.

HINTS FOR LOOKING YOUR BEST WHEN TIRED

1. Drink lots of water during the day to keep yourself hydrated. 2. Consider popping some antioxidants such as vitamin C, and vitamin B for stress. 3. Eat lots of fresh fruit and vegetables. 4. Consider using a skin illuminating base or primer under your make-up to help your foundation sit nicely and make your skin look brighter and fresher.

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Nursing Review series 2015

Evidence-based practice

Keeping leakage at bay Is one-off advice on pelvic floor exercises enough to keep urinary incontinence at bay? This edition’s critically appraised topic (CAT) looks at whether pelvic floor muscle training makes a difference. CLINICAL BOTTOM LINE: Pelvic floor muscle training (both during pregnancy and after delivery) can prevent and treat urinary incontinence in pregnant or postpartum women. To be most effective, a supervised 8-week training programme is recommended so that women are supported to do the exercises correctly and often.

CLINICAL SCENARIO: It is very common for women to experience urinary incontinence as a complication of pregnancy and childbirth. In your antenatal classes you advise women to do pelvic floor muscle exercises but wonder if a structured programme is needed. You decide to review the evidence for the effectiveness of pelvic floor muscle training (PFMT) for preventing and treating urinary incontinence in this group of women.

CLINICAL QUESTION: What effect does pelvic floor muscle training during pregnancy and after childbirth have on the prevention and treatment of urinary incontinence?

SEARCH STRATEGY: PubMed Clinical Queries (therapy, narrow): “pelvic floor muscle training” AND pregnancy

CITATION: Morkved, S., & Bo, K. (2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Br J Sports Med, 48(4), 299-310. doi: 10.1136/bjsports-2012-091758

STUDY SUMMARY: A systematic review testing the effect of PFMT for preventing or treating urinary incontinence (UI) in pregnant or postpartum women. Inclusion criteria for studies assessed in the review are: »» Type of study: Randomised controlled trials (RCTs) and quasi-experimental studies involving primiparous/multiparous pregnant or postpartum women »» Intervention: A structured programme of pelvic floor muscle training »» Control: Usual care (such as advice only about pelvic floor exercises) or no PFMT »» Outcomes: Urinary incontinence (outcome measures not specified).

by the World Confederation of Physical Therapy (1993–2011), International Continence Society and International Urogynecology Association (1990–2011) were manually searched. Language of publication was restricted to English or Scandinavian. Both review authors independently reviewed, grouped, assessed study quality, and qualitatively synthesised the trials but inclusion criteria, and processes for study selection, data extraction were not described. Disagreement between authors was solved by consensus. A 10pt PEDro rating scale was used to assess the quality of included studies. The publication bias was not formally assessed. There was a lack of detail for some review methods but overall a high-quality review of mixed-quality studies.

STUDY RESULTS: After the removal of duplicates, 117 references were initially reviewed, from which 22 studies were selected as meeting the review criteria. Within these 22 studies there was considerable variation in the PFMT programme (intervention) offered and also considerable variation in the study population and the outcome measures used. Interventions were structured PFMT programmes with or without biofeedback, vaginal cones or electrical stimulation. All involved at least one supervised training session. Control groups received either usual care consisting of self-motivated PFMT supported only by one-off instruction or advice, no advice, or were instructed not to exercise pelvic floor muscles. Because of the high heterogeneity of the studies the numerical study results were not combined using metaanalysis. A detailed qualitative synthesis of study results was provided for four pre-specified review questions (table). Interpretation of the results involved careful

Nursing Review series 2015

COMMENTS: »» This review adds to the evidence of the effectiveness of PFMT in women with UI. »» In particular, a strong dose-response relationship was observed. »» The PFMT intervention in studies reporting significant improvements in UI involved supervised training sessions, optimal dosage (8-12 maximum contractions, 3-4 times a week) and programme duration of at least eight weeks. »» Studies showing little or no effect of PFMT programmes involved inadequate training dosages, minimal supervision of training and had had large dropout rates in the intervention group. »» Long-terms effects and optimum maintenance dose of PFMT remains difficult to establish. Reviewer:

Cynthia Wensley RN MHSc is a PhD candidate at Deakin University. She also works at the School of Nursing, The University of Auckland as an honorary professional teaching fellow.

Summary of Results Intervention

Participants

Number/type of study involved

Effect of PFMT during pregnancy to prevent UI

Women with and without UI

10 short term RCTs and 2 long term f/up studies

PFMT during pregnancy to treat UI

Women with UI

3 (2 RCTs)

2 trials reported a significant reduction in UI, both in late pregnancy and at 6-8 weeks postpartum, with PFMT compared with control.

Women with and without UI

5 short term studies (3 RCTs) and 2 long-term f/u studies

3 studies reported statistically relevant reductions in symptoms or frequency of UI with PFMT compared with control. Improvement was maintained at 1 year f/u in 1 study.

PFMT after delivery to prevent UI

STUDY VALIDITY: Electronic databases searched were PubMed (12 June 2012), the Cochrane Central Register of Controlled Trials (12 June 2012), EMBASE (1980 to 2012, week 24) and Physiotherapy Evidence Database (12 June 2012). In addition, reference lists of included studies and meeting abstract books published

analysis of study quality, study size, PFMT programme content and adherence. Based on this analysis, the review’s overall conclusion was that high adherence to a supervised programme of intensive pelvic floor muscle strength training during pregnancy and after delivery can prevent and treat UI. No adverse events were reported.

PFMT after delivery to treat UI

Women with UI

PFMT – Pelvic floor muscle training UI – urinary incontinence

Results 7/10 RCTs reported statistically significant reductions in symptoms, episodes of UI, or a lower percentage of women with UI in late pregnancy or during 3 months after delivery with PFMT compared with control.

4 RCTs reported statistically significant reductions in symptoms or frequency of 4 RCTs and 2 long UI after PFMT compared with control. term f/u studies. Improvement was maintained at 7 year f/u in 1 small study.

RCT – Randomised control trial f/u – follow-up

College of nurses

Balancing the ‘e’ and ‘health’ in e-health KATHY HOLLOWAY looks at e-health from a nursing perspective and the need to remember that the ‘e’ should stand not just for ‘electronic’ health but for ‘enhanced’ health.

utting an ‘e’ for electronic at the front of a word is now a ubiquitous indication that technology is involved. So we have e-learning, e-commerce, e-sports, e-government and, of course, e-health. The development and integration of technologies (wanted or not) in many aspects of modern life is as much the reality for health services as it is in other industries. Interestingly, when the Canadian Nurses Association developed an e-nursing strategy in 2006 – centred around integrating information and communication technologies (ICT) into nursing – it believed the need to add the ‘e’ would be redundant within a few years. However, nearly a decade later, New Zealand has a national ‘eHealth vision’ and various related ICT strategies (as outlined in the previous issue of Nursing Review). The ‘e’ is very much still here! As a critically reflective health professional, I wonder if it is worth considering that simply placing an ‘e’ in front of health should not change the core functions and philosophy of health practices. For example, e-learning is still required to be pedagogically sound and e-business has financial standards to meet. This is a fundamental premise to consider when integrating technology into nursing practice – the intent is to enhance health services, not to provide less with more.

So what is e-health exactly? The term e-health is broadly understood as being an umbrella term covering two facets: health informatics and telehealth. Health informatics relates to the collection, analysis and movement of health information and data to support health care. Telehealth involves the delivery of health information or health care either directly, for example videoconferencing, or indirectly, such as via a website (definitions drawn from the Standards Australia e-health site www.e-health.standards.org.au).

The vision of the National IT Health Board (as covered in the last edition of Nursing Review) was to have all New Zealanders and their treatment providers able to electronically access their personal health information, regardless of setting, by 2014. This is part of a growing expectation for real-time access to a patient’s clinical information and care journey, with nursing work very much tied up with both those areas. For the College of Nurses Aotearoa, a key strategic direction is the aligning of nursing workforce development with community need. The Institute of Medicine’s 2012 report Best Care at Lower Cost clearly links improved health outcomes for our communities with nurses effectively applying emerging technologies to both improve healthcare efficiency and communication. Communication and collaboration using technological tools is seen as key to sustainable and safe healthcare systems. Health informatics is key to the development of various electronic patient portal systems being used to share health information across disciplines and with consumers. The health information being shared ranges, at the simplest end, from basic contact details right up to developing shared care plans (you can see more at http://ithealthboard.health.nz/about-us/ ehealth-vision). In order for information sharing to work well and transparently, it is essential for clinicians and employers to have carried out the appropriate technical and organisational groundwork. This means clinicians and consumers must have computer literacy, information literacy and, naturally, health literacy. A critical element is gaining the trust of health consumers, who are often concerned about data security and privacy. As clinicians, we must understand and be mindful of the security processes that protect and support healthcare delivery technologies.

The second e-health facet, telehealth, is about using technology to improve chronic care and to enable people to be supported at home. In New Zealand this can involve telemedicine (providing clinical health care at a distance), telemonitoring (remotely collecting and sending patient data for management) and mobile health (known as m-health). The latter is a rapidly growing area that uses mobile communication technology – usually smartphones and tablets – for the delivery of health information, health services and healthy lifestyle support programmes. Examples of New Zealand m-health programmes include the text-messaging STOMP (stop smoking over mobile phone) smoking cessation support programme offered by Quitline; and Listen Please, a clinical translation smartphone app helping patients and families to communicate with clinicians in an emergency or intensive care situation.

Integration the key Nurses need to be both abreast of the new health technologies and tools available and able to step back and critically assess how best to integrate these technologies into their practice. This allows the technology to be used as a tool to help nursing practice, rather than the technology itself taking centre stage. Ask yourself – what do I need to know about the technology involved in health data capture, storage and secure sharing? If you want to build your skills in this area there are health informatics competencies and standards that have been developed by nursing scholars (examples can be viewed at the nursing informatics page of the American Medical Informatics Association website). Let technology be transparent in your nursing practice by developing your awareness of, and confidence in, the delivery of health care with a little ‘e’. Author: Dr Kathy Holloway is the new co-chair of the College of Nurses, sharing the chair with Taima Campbell.

Nursing Review series 2015

Practice, People & Policy opinion

Articles, profiles and opinion pieces from across the nursing spectrum

Practice, People & Policy

Do patients deserve more than out of 10?

At first hearing, nine out of 10 nurses providing excellent care in a patient’s dying days sounds pretty good. But as KIM CARTER asks, if a bad experience in the tenth nurse’s care is the memory that lingers longest for the patient and the family, is it good enough?

palliative care patient with only days left to live told a colleague about her experience of being in hospital in the week before she died. The comment that struck me most was that in her opinion “nine out of 10 nurses were excellent”. Put another way, this really means that of the precious last 10 days of her life, nine days were made better by nurses, but one was not. Is this good enough? The idea of what is ‘good enough’ is convoluted

NursingReview Reviewseries series2015 2015 22 22 Nursing

and complicated by subjective opinions, values and perspectives. We might agree that 90 per cent on an exam is good enough. But would we think that 90 per cent of a car repair is adequate? What about 90 per cent of a bridge built? In the end, who decides what is good enough?

It may be that the nurse involved did very little wrong and it may be that their perspective would be quite different. Perhaps she/he wouldn’t be able to see what needed to be done better because they are genuinely unaware of this patient’s perspective. Perhaps that day, on that shift, the stressful, complex, acute, overworked and care-rationed environment all conspired to create the perfect storm. Perhaps that week 90 per cent was good enough. Perhaps that nurse just dropped the ball and let us all down. However, in the end it is almost irrelevant what, if anything, was said or done that caused this patient to feel the way she did about the care she received. As American author and poet Maya Angelou said: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” For this patient and her family, how they feel about their experience is more

important than whether they are right. They alone get to decide if the care was good enough. It pains me to think that one of their enduring memories of this patient’s last few days will always be linked to a bad experience – especially when it involves nursing. I don’t think we should accept 90 per cent. I don’t think it is good enough at all. I think if we can’t provide 100 per cent then we should do something about it. That’s what our colleagues in Southland did when they raised (and kept raising) their concerns about staffing levels. I also think that if we are aware that our colleagues have fallen short, we have a duty of care to act. I think we have to strive for 10 out of 10 because to accept 90 per cent is to allow our patients to experience less than our very best. And no patients – dying or otherwise – deserve that.

“… people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

Practice, People & Policy WORKFORCE

A decade on:

MECA pay talks underway again

On 28 February the fourth national MECA pay agreement between 20 district health boards and the New Zealand Nurses Organistion expired. FIONA CASSIE backgrounds the talks and some of the history leading up to the latest negotiations. It is a decade since the ground-breaking national MECA agreement was ratified by public hospital nurses, bringing about the first major pay jolt for nurses in a very long time. Ten years after safe staffing first raised its head as a major issue during the 2004 talks, it is still on the agenda as the DHBs and NZNO started formal talks in late January as the first step to renewing the MECA (multi-employer collective agreement) covering 25,773 DHB employees. The majority of the DHBs/NZNO MECA members are registered and enrolled nurses but the MECA also covers midwives, healthcare assistants and hospital aides. Lesley Harry, NZNO industrial advisor for the pay talks, said before going into the second round of bargaining in mid-February that it was aware that the parameters for public sector bargaining was 0.7 per cent. "That's been set by the State Services Commission," said Harry. "So we know we've got a long way before we resolve all our issues." In a recent update to NZNO members she said it had been made "very clear" at the highest level of government that members had told them a pay offer of less than one per cent "would not cut it". She also said that "not surprisingly" the DHBs had informed NZNO at the February talks that NZNO's expectations and the DHB's ability to pay were far apart. "In fact, the DHBs are unable to let us know anything about their financial situation until after the DHB chief executives meet in early March. "As you know, the bargaining environment is not made easy by Governmentâ&#x20AC;&#x2122;s constraints on funding and its obsession with reaching surplus." Harry said during the February talks it gave DHBs detailed information about the union's goal of a "decent pay rise for all" and how nurses' wages currently compared to similar occupations. The similar benchmarked occupational groups include police, teachers and medical radiation technologists. Harry has said NZNO was particularly interested in emulating the longer pay scales of these occupations than the current NZNO five-step basic pay scale. But Harry added that money was only one issue with other prominent issues being more action on safe staffing, access to professional development and ironing out the variations in content and access to professional development recognition programmes (PDRPs). By the end of last year, 12 of the 20 DHBs had started to implement the safe staffing Care Capacity Demand Management tools developed five years ago by the joint Safe Staffing Healthy Workplace Unit. A DHB spokesperson, Mick Prior of DHB Shared Services, said in early February that the DHBs were not yet ready to discuss their priorities for the negotiation process. The next negotiation dates are set down for March.

Timeline 1991

Employment Contracts Act (led to breakdown of national pay scale)

2001

First NZNO MECA (multi-employer collective agreements) negotiated for South Island DHB nurses and other regional MECA follow

2003-2004

Fair Pay campaign launched to create national MECA and get 'pay jolt' for nurses

June 2004

A 125,033 signature Fair Pay petition delivered to parliament 1st National NZNO/DHB MECA is ratified with 'pay jolt'

2005

2007

Safe Staffing Healthy Workplaces committee of inquiry begins Safe Staffing Healthy Workplace Unit established 2nd National NZNO/DHB MECA ratified

2010

3rd National NZN0/DHB MECA ratified (negotiated in tandem with PSA and Service & Food Workers Union)

2012

4th National NZNO/DHB MECA ratified (after joint union offer rejected)

2015

Talks underway for 5th MECA

Base pay comparisons 2001-2015 New Graduate

5th year

2001

$26,000 to $32,500

$34,600 to $41,500

2004

$33,000

$45,000

2006

$40,000

$54,000

2009

$44,562

$60,159

2011

$45,453

$61,362

2015*

$47,528

$64,163

*Last MECA pay increase came into effect on 1 March 2014

OTHER RECENT DHB PAY DEALS If recent DHB pay talks settled by other unions are setting a precedent NZNO nurses may be unlikely to receive a generous pay offer during these negotiations. The trend has also been for short 12 to 13 month time spans for the multi-employer collective agreements (MECAs). The junior doctor MECA was ratified on February 18 this year after drawn-out negotiations between the 20 District Health Boards and the New Zealand Resident Doctors' Association that followed the expiry of the last MECA in September 2013.

That DHBs/RDA MECA offer is for a 13-month contract backdated to January this year and includes a lump sum payment of $750-950 on ratification, a one per cent pay increase for registrars and house officers effective from 8 Dec 2014 and a 0.75 per cent pay increase on 30 November 2015 Last year nearly 12,000 Public Service Association members working at DHBs, including mental health and public health nurse PSA members, voted to reject a 0.7 per cent pay offer (or 1.5 per cent over an approximately two year contract) and go on strike.

The strike action was called off in August and nurses voted to accept a one year contract with a one-off lump sum payment of one per cent of their base salary and a 0.7 per cent pay rise on April 30 2015 on their eight step pay scale. The 12-month contract expires on April 30. The last DHBs/NZNO MECA was settled in March 2012 with nurses agreeing to a 4.5 per cent pay deal stretched over three years. The deal started with a two per cent pay increase backdated from March 1 2012, followed by a 1.5 per cent increase on March 1 2013 and a one per cent increase on March 1 2014.

Nursing Review series 2015

People, practice & policy opinion

Nursing can

take you anywhere Just back from a trip to the UK and more than a little disheartened at the current state of Britain’s NHS, former chief nurse Dr Mark Jones is reassured to find New Zealand’s younger generations are still inspired by traditional nursing values, and by the future opportunities and long-term rewards that nursing offers. I recently happened upon an intriguingly titled book in a quaint, second-hand bookstore: A complete system on nursing for male nurses. Millicent Ashdown was inspired to pen this tome in 1934 by Miss Collins, principal matron of the Queen Alexandra’s Imperial Military Nursing Service, as a fitting resource for the men in her charge. Essentially the book is a revamp of the previous Complete system of nursing but “with the exception that chapters dealing with nursing and diseases of women and children have been deleted”. (No lady and kiddie bits for 1930s blokes in nursing to worry about, then.) Anyhow, the book does give some of those great Nightingale-esque expected qualities of the nurse, reminding us “a real love of attending to the sick and helpless; a strong constitution, and an equitable temperament” are pretty much essential, and that “only those possessing these qualifications should attempt to train as nurses, as the life is a strenuous one”. Moreover, “to those who are not fitted for it, many of the duties are revolting and therefore difficult to accomplish satisfactorily”. I found the book during some chilling-out time in Devonport after returning from visiting the frozen United Kingdom where the National Health Service seems to be crumbling to its knees, at least in England and Wales. I should imagine those UK nurses lining up to meet ambulances ramped outside their EDs and trying to care for those bedded (if they are lucky) along hospital corridors

were stretching their love and temperaments to the limit. And no doubt they were finding the going pretty tough. My own career has had its rough spots but, by and large, it is great to be a nurse. We have tough times here in New Zealand too, but yet still we have plenty of recruits for our profession. Nursing has taken me around the world to work in very diverse settings, and now I still use skills and experience gained over 30 years or so in roles I have loved.

still demonstrate their determination to provide decent care every day, even in the most adverse circumstances. Kiwi nurses have recently been in Africa dealing with Ebola, and another spent her holidays on a mercy ship in the Indian Ocean. One of my favourite moments ever was facilitating the volunteering of an Australian NP on board a Sea Shepherd vessel taking on the Japanese whaling fleet. Yes, nursing can take you anywhere!

Caring goes a long way

Seeing beyond adversity

All this was still in the back of my mind when I chatted with a bright young checkout teller in Mitre 10 Albany the other day as I paid for my DIY supplies. It turned out she was on her summer break from AUT and she was shortly to commence the final year of her nursing degree. If her approach to caring matches her approach to customer service, she will go well. After the quizzical glance when I told her I was a nurse too, we had a good old chat about our profession. (It was quiet spell with nobody waiting!) I eulogised about the engrained Western Australian Government’s strapline of “nursing can take you anywhere” (I had previously worked for the Western Australia health department from 2010 to 2014), with some illustrations from my own CV. Mitre 10’s ‘nurse-to-be’ was already planning a future in developing countries and “paying something back” – which was pretty good to hear, especially coming from someone in their early 20s. So, I guess what Misses Ashdown and Collins had to say back in 1934 about what it takes to be a good nurse still holds today. Nurses worldwide

I am reassured, having met the AUT student, to know that in the face of the inevitable adversity our profession offers, and the strenuous life envisaged by Millicent Ashdown, young men and women can see through this to the potential rewards on offer as we reach out to people to help maximise their optimum health. Of course we still need policy makers to open up the full toolkit needed by 21st century nurses, knocking out the now-legendary barriers to practice for instance, but I am sure that from the hundreds of students returning from summer break we will see the dynamic leaders and practitioners of tomorrow emerge, along with those who decide that nursing in their local hospital or community is the best fit for their world – at least for now. Welcome back to uni or poly, my fellow nurses; go well in your studies, hang in there and enjoy the world that awaits you. Wherever you end up and whatever you finally do with your life, you can rest assured that nursing will provide a bedrock that won’t fail you. Enjoy!

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Nursing Review series 2015

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