Te Puawai April 2013

TE PUAWAI

April 2013 1

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TE PUAWAI

CONTENTS age •

Editorial - Prof Jenny Carryer

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Inspiring all New Zealanders to lead healthier lives - an introduction to the work of the Health Promotion Agency

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• HDC Annual Report

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• Ethics Committees

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• National Health Professional Prescribing Summit Conference Report

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• Hospice New Zealand Conference Report

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• Australasian Cardiovascular Nursing College (ACNC) Conference 2013 Report

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• Conferences and Events

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Editorial glected by a Trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care.

The evidence gathered by the Inquiry shows clearly that for many patients the most basic elements of care were neglected. Calls for help to use the bathroom were ignored and patients were left lying in soiled sheeting and sitting on commodes for hours, often feeling ashamed and afraid. Patients were left unwashed, at times for up to a month. Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding. Staff failed to make basic observations and pain relief was provided late or in some cases not at all. Patients were too often discharged before it was appropriate, only to have to be re-admitted shortly afterwards. The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections.

Professor Jenny Carryer RN, PhD, FCNA(NZ), MNZM Executive Director

In this editorial I want to explore some events in Britain as they have unfolded over recent months. They relate to an inquiry into poor care of patients at Staffordshire Trust Hospital in the UK. I shall quote verbatim from the report release, from media commentary on the UK response to the report findings and consider an article

by Professor Phillip Derbyshire critiquing the educational response to this and other similar publicity.

Release of the report ( http://www.midstaffsinquiry.com/pressrelease.html )

Speaking at the publication of his final report, Robert Francis QC said: “I heard so many stories of shocking care.

These patients were not simply numbers they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives.�

The Inquiry Chairman, Robert Francis QC. concluded that patients were routinely ne4

TE PUAWAI evidence shows that the Board’s focus on financial savings was a factor leading it to reconfigure its wards in an essentially experimental and untested scheme, whilst continuing to ignore the concerns of staff.

The Inquiry found that a chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care. Morale at the Trust was low, and while many staff did their best in difficult circumstances, others showed a disturbing lack of compassion towards their patients. Staff who spoke out felt ignored and there is strong evidence that many were deterred from doing so through fear and bullying.

Announcing the Inquiry findings, Mr Francis told staff and patients: “A number of staff and managers at the hospital, rather than reflecting on their role and responsibility, have attempted to minimise the significance of the Healthcare Commission’s findings. The evidence gathered by this Inquiry means there can no longer be any excuses for denying the scale of failure. If anything, it is greater than has been revealed to date. The deficiencies at the Trust were systemic, deeprooted and too fundamental to brush off as isolated incidents.”

Robert Francis QC added: “It is now clear that some staff did express concern about the standard of care being provided to patients. The tragedy was that they were ignored and worse still others were discouraged from speaking out.”

The Inquiry concluded that a number of the deficiencies at the Trust had existed for a long time. Whilst the executive and non-executive Board members recognised the problems, the action taken by the board was inadequate and lacked an appropriate sense of urgency.

Reading the full report is indeed deeply sobering, if not horrifying. Sadly in reading it one is reminded of stories that have surfaced in New Zealand from time to time. I think of particular letters to Kaitaiki; Nursing New Zealand written by registered nurses who have been present alongside hospitalised elderly parents and who have been devastated by the care administered.

There is recognition in NZ amongst the nursing community that the provision of high quality nursing care can not be guaranteed at all times in all settings and there is awareness that this causes considerable distress to many nurses themselves.

The Trust’s board was found to be disconnected from what was actually happening in the hospital and chose to rely on apparently favourable performance reports by outside bodies such as the Healthcare Commission, rather than effective internal assessment and feedback from staff and patients. The Trust failed to listen to patients’ concerns, the Board did not review the substance of complaints and incident reports were not given the necessary attention.Problems at the Trust were exacerbated at the end of 2006/07 when it was required to make a £10 million saving. The Board decided this saving could only be achieved through cutting staffing levels, which were already insufficient. The

The dilemma that underlies these many reports (anecdotal or otherwise) is whether to look within nursing itself for the cause or instead to consider that short stay, high acuity, patient churn, constant restructur5

or health support workers, who are paid much less than nurses and do not have their status.

ing, inadequate staffing and a constant focus on the bottom line have created an environment that precludes good quality care . My personal observation would be that when an either or response is possible, the answer lies in both possibilities.

Ministers see the move as essential to ensuring the nursing profession rediscovers the values of compassionate care which critics claim has been lost amid pressure to meet NHS targets, rising numbers of patients and some nurses displaying appalling behaviour towards some patients.

Critics also fear that too many nurses have become too detached from the fundamentals of patient care and avoid too much routine contact with patients, such as help with feeding and moving around for those who need it.

In the UK it appears that a strong response has been generated which looks firmly to nurses having become “too posh to wash” and having lost basic compassion during the process of academic preparation. This is an age-old response now and one that has rippled around in one guise or another for many years.

Recently the Guardian newspaper in the UK reported on impending planned changes as follows

“Frontline, hands-on caring experience and values need to be equal with academic training. These measures are about recruiting all staff with the right values and giving them the training they need to do their job properly, so that patients are treated with compassion,” Hunt said.

Nurses will have to spend up to a year helping patients eat, wash and get dressed – work usually done by healthcare assistants – under government plans to shake up NHS care in response to the Mid Staffordshire hospital scandal that left between 400 and 1,200 to die as a result of poor care.

Any would-be nurse who refuses to undertake such hands-on work will be denied NHS funding for their degree, which is worth about £40,000 over three years and relied upon by almost all the 20,000 new student nurses a year. In effect they will be debarred from training.

Jeremy Hunt, the health secretary, is expected to announce the move on Tuesday when he sets out the government’s response to Robert Francis QC’s report into the scandal.

At the moment the basic tasks of caring for patients, which also include helping them get out of bed and going to the toilet, are mainly done by healthcare assistants

In a speech last November he castigated some NHS staff for their involvement in cases of patient care which he said had included “contempt” and “a kind of normalisation of cruelty”.

Hunt’s initiative follows an almost identical suggestion made by Francis. Recommendation 187 in his report said: “There should be a national entry level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision of a registered nurse. Such experience should include direct care of patients, ideally including the elderly, and involve hands-on physical care.”

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TE PUAWAI poor practice or the perceived decline in standards of care.” (Willis, 2012, p. 6) and it seems that nursing education is off the hook. We are not so sure nor so reassured. Nursing education needs to do its own critical thinking that we so value in our students. Similar red flag concerns about nursing education are invariably raised by nurses, whether they be in Australasia, North America or Europe. These should not be new to anyone in nursing education, so what do we intend to do about them?

He recommended: “Satisfactory completion of this direct care experience should be a pre-condition to continuation in nurse training. Supervised work of this type as a healthcare support worker should be allowed to count as an equivalent.”

The change will be piloted before being made routine in England, Department of Health (DoH) sources said. Ministers will consider making other health professionals, notably health professionals such as physiotherapists, but not doctors, do the same as student nurses, depending on what those trials show.

The Guardian (Tuesday 26 March 2013)

Let’s take primarily the abandonment of ‘basic nursing care’ to a growing army of unqualified and largely unregulated care assistants.

I have to say that I find this proposed response quite extraordinary and probably completely useless in addressing the problem. For me it seems like a superficial response, which in no way attempts to understand the fundamental nature of problems recognised. It harks firmly back to the age old arguments about the irrelevance of academic preparation to high quality nursing care. My argument would be that whilst we should never need in 2013 to justify that relevance we should not be above rigorously considering the role of education in equipping registered nurses to deliver what is needed to ensure appropriate care is delivered.

A hospital CEO in Australia has recently suggested that training nurses to undertake e.g., colonoscopies, endoscopies, cystoscopies and X-rays “was an innovative way of stretching them to their full potential while sparing them more basic tasks (our emphasis) such as washing and feeding patients — jobs he said less skilled and lower paid nursing assistants could do” (Medew, 2013). What role has nurse education played in devaluing and marginalising such care? What have we done or failed to do in our curricula, in our teaching or in our relationships with ‘service partners’ that contributed to the situation where such essential nursing care is being seen, even by default, as being the realm of the HCA (health care assistant)?

Professor Phillip Derbyshire, an Australian nurse academic has written extensively and provocatively on the topic. A very recent paper with Lisa Mckenna in Nursing Education Today notes that

I find this argument perhaps unhelpful.

Whether we like it or not, the environment in which nurses deliver care in acute settings has changed irrevocably and is unlikely to ever revert to former more gentle days. Increasing demand, workforce crises

“The commission did not find any major shortcomings in nursing education that could be held directly responsible for 7

who were in my ward. My job as charge nurse was to see that every member of the ward’s staff, permanent or visiting, delivered the highest standard of care to each and every patient. That involved teaching, guiding, directing, supervising, and co-ordinating. It meant having an intimate knowledge of every patient in the ward and their immediate and future needs. It involved calling people to account (nursing, medicine and allied health) when something was missing or neglected. It involved planning and evaluating care and I had a strong sense of authority and responsibility directed towards the welfare, comfort and safety of patients even though I almost never delivered the care myself.

and fiscal challenges mean that delivering services is now fraught with problems.

I agree with Derbyshire that we have been rather defensive about our education. The need to defend tertiary education against the ancient apprentice model has perhaps created a knee-jerk defensiveness, which we need to move beyond. We are now preparing registered nurses for an environment that has undergone enormous change. Have we really sat down as a profession and talked that through? When NZNO hosted the undergraduate nursing education forum a few years ago my memory of the discussion was of a level of defensiveness and no real critical thought about what might need to change.

My suggestion in this editorial is that the role of the RN may need to move closer to the older role of charge nurse. People take up nursing through a desire to care and we know that moral distress, burn out and sometimes horrible behaviours ensue through frustration and despair when personally caring for people properly is impossible. I think the time is long overdue for a critical examination of how we prepare nurses to function effectively in the contemporary health service setting. Let’s do it before we are faced with the kind of reports now dominating the UK environment.

For me it comes down to the difference between caring for and caring about. My challenge is that we are still preparing students to care for people and patients in a hands-on fashion yet the environment has indeed long passed the performance of many tasks to health care assistants of one sort or another. Many other ward-based changes have increased the demands on RNs and reduced the available time to be at the bedside by a substantial amount. I see many RNs as being confused about their relationship with HCAs and their relationship with patients. Lack of consistency in how different environments are staffed, further adds to the confusion.

It is always dangerous to “hark back to the old days” but I sometimes think about the five years I spent as charge nurse of a very busy oncology ward. During that five years I very rarely delivered any hands on care (cared for) but my days were consumed with a passion to care about the patients 8

TE PUAWAI

Inspiring all New Zealanders to lead healthier lives

- an introduction to the work of the Health Promotion Agency Our work spans a range of major public health topics including immunisation, nutrition, cardiovascular disease, rheumatic fever, mental health, minimising gambling harm, tobacco control and sun safety.

Our work around alcohol seeks to reduce alcohol-related harm in New Zealand and includes a special responsibility to give evidence-based advice to the government, industry and others in this area.

Inspiring all New Zealanders to lead healthier lives - an introduction to the work of the Health Promotion Agency The Health Promotion Agency (HPA) was established in July last year under legislation to lead and support public health initiatives. Its aim is to inspire all New Zealanders to lead healthier lives.

We work with partners including medical professionals, researchers and academics, community groups, public health advocates, government agencies, industry groups, the media and many others who are aligned with our goals.

All the functions and responsibilities formerly undertaken by the Alcohol Advisory Council (ALAC) and the Health Sponsorship Council (HSC) were transferred to the HPA on its establishment.

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Healthier lives cont...

Promoting health and wellbeing is the public facing part of our work – communicating health messages to priority audiences.

Many of you will be familiar with some of the campaigns that we are involved with such as the ‘Ease up on the drink’ campaign to reduce binge drinking, the John Kirwan national depression initiative, and Smokefreerockquest, which has played an important part in reducing the number of young people that take up smoking.

The HPA is a Crown agent with its own board made up of seven people appointed by the Minister of Health. Dr Lee Mathias is chairman of the HPA Board. A nurse, Dr Mathias has an extensive background in health service management and governance and was the chairman of the Health Promotion Agency Establishment Board.

Other Board members are Rea Wikaira, Dame Susan Devoy, Katherine Rich, Professor Grant Schofield, Barbara Docherty (also a nurse) and Jamie Simpson.

Equally important is ensuring the environments in which we live, work and play support and promote health and wellbeing.

We work to ensure we get the best laws by making submissions to select committees, we work with communities to help them fund local solutions to local problems, and we fund research to inform both our work and the work of others.

Our alcohol and gambling harm minimisation work is funded by levies collected

by NZ Customs. All other HPA work is funded directly by the government from Vote Health.

So our aim is New Zealanders lead healthier lives. What does this mean? How do we work to allow New Zealanders to do that?

If New Zealanders are to be able to lead healthier lives, individuals and families need to be aware, motivated and able to improve and protect their own and their family’s health and wellbeing - that’s where the HPA comes in.

In practical terms we provide advice, resources and tools to a wide range of individuals and groups. For example, last year we developed a campaign in partnership with the Heart Foundation to help PHOs and DHBs reach the health target of more heart and diabetes checks and we work with the Ministry of Health’s immunisation team on promotional activities and advertising campaigns.

Our work draws on social marketing approaches to achieve behaviour change.

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TE PUAWAI Part of this work is supporting Immunisation Week and the HPA and the Ministry have developed a new resource about pneumococcal disease to provide parents information about the disease and the importance of immunisation as preventative measure.

Following Immunisation Week this resource will be available on the Health Education Resource website (www.healthed.govt.nz).

The HPA has also been asked by the Ministry to apply our marketing communications expertise to this year’s influenza vaccination campaign and the rheumatic fever programme among high risk groups.

The National Influenza Specialist Group (NISG), is contracted the Ministry to run the annual influenza programme (including promotion and communications) on its behalf. The HPA is supporting this work by complementing the current promotional and advertising activity in a bid to increase coverage from 1 million to 1.2 million doses this year.

how alcohol is managed in their area. Recently we produced an Intoxication Assessment Tool for use by enforcement agencies and licensed premises to help them better identify and manage intoxicated patrons.

This year as part of our sun safety work, we are working with local authorities and others to help them undertake shade audits in the outdoor spaces they’re responsible for. This is part of our sun safety work.

The additional material that has been developed for HPA has the same look and feel as NISG’s material and the HPA has established an excellent partnership with NISG to ensure messages are compatible and consistent. The HPA’s support has also included extra advertising to extend the reach of messages.

And finally, communities and organisations can use our brands and material (such as the Smokefree 2025 brand) at a local level to add value to their work.

We are working in partnership with Police, Justice, ACC and Local Government NZ on the implementation of the Sale and Supply of Alcohol Act (2012), particularly to ensure that local communities have their say on

Article supplied by the Health Promotion Agency, New Zealand.

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HDC Annual Report Reprinted with permission from the Auckland Women’s Health Council Newsletter

In December 2012 Health & Disability Commissioner Anthony Hill released his annual report covering the period from 1 July 2011 to 30 June 2012. year, with 98% of the enquiries closed within two days and 99% within five days.”

New format The latest annual report is in a completely new format to previous reports. The reports from the Director of Advocacy, the Deputy Commiss-ioner, Disability and the Director of Proceedings have been dispensed with, along with photos of any of the HDC staff – with the exception of the Commissioner. The Commissioner’s “foreword” is followed by a section on the role of the Commissioner. Section 3 which focuses on the HDC’s key activities includes nine case studies.

1,380 complaints closed

Complaints resolution

Of the 1,380 complaints resolved during the 2011/12 year, 140 complaints were referred to advocacy, (compared to 208 for the previous year), 142 were referred to other agencies such as the Privacy Commissioner, ACC, the Ministry of Health, DHBs, or Human Rights Commission, (compared to 154 for the previous year), and 79 were withdrawn or resolved by the parties or by the Commissioner (compared to 66 for the previous year.

During the 2011/12 the HDC received 1,564 complaints (compared to 1,405 the previous year) and responded to around 5,000 enquiries.

Some complaints were resolved by referral to providers (203 compared to 255 for the previous year) and two were resolved by mediation.

Advocacy

Section 38(1)

The advocacy service which consists of 48 advocates (41 FTEs) is located in 25 community-based offices around the country. Over half the core advocates are Maori.

Six advocates are specialist advocates with three working with the deaf community and three working with refugee/migrant communities.

Closing or resolving complaints by the use of Section 38(1) occurs when, in the Commissioner’s “discretion,” no further action is considered “necessary or appropriate,” eg, because there is no apparent breach of the Code, or because matters are already being addressed through other appropriate processes or agencies. Over half of all complaints (690 of 1,380) complaints were closed this way in the 2011/12 year compared to 557 the previous year.

The report states that “the advocacy service managed 10,816 enquiries for the 12

TE PUAWAI Investigations and Inquiries

Proceedings

Of the 1,380 complaints only 44 were closed after a formal investigation was undertaken. The 44 investigations resulted in 29 reports which found there had been a breach of the Code of Consumers’ Rights.

There were eight referrals to the Director of Proceedings.

Another consequence of so few investigations and breach findings, is a drop in referrals to the Director of Proceedings of providers found in breach of the Code.

There were only eight referrals of providers to the Director. There was one substantive hearing before the HRRT, three cases were dealt without the need for a formal hearing and one case concerning an obstetrician was concluded by negotiated agreement without the HRRT being asked to make orders.

The low numbers of investigations and breach findings are extremely concerning and raise questions about the functioning and resourcing of the HDC office, as well as how complaints about health providers are being dealt with. The current approach under-mines the accountability regime envisaged by the HDC Act, since consumers lose the benefits of formal investigation findings, and are denied access to the Human Rights Review Tribunal (HRRT) if there are so few breach findings. Even if the Commis-sioner essentially upholds the complaint but takes “no further action,” the consumer cannot take a case to the Tribunal without a formal investigation and breach finding.

According to the Medical Council Annual Report 2012, there was only one charge brought by the Director of Proceedings prosecutions before the Health Practitioners Disciplinary Tribunal (HPDT) – compared with six charges resulting from prosecutions by Professional Conduct Committees set up by a registration authority. The original Cartwright model of prosecutions independent of the health professions has been turned on its head.

Backlog

It is also noteworthy that, half way through his five-year term as Commissioner, Anthony Hill has not undertaken any “own initiative” inquiries, such as Robyn Stent’s Canterbury Health inquiry and Ron Paterson’s North Shore hospital inquiry. The ability to initiate a major inquiry is a significant power that can be used to investigate serious systems issues in the health and disability sector, eg medical devices such as metal on metal hip replace-ments, the gynaecological mesh, and breast implants that have caused great harm to patients.

Even though the HDC is undertaking fewer investigations and prosecut-ions, the backlog of open files is growing. At 30 June 2010, shortly before Anthony Hill took office, there were 323 open files; by 30 June 2012, that had ballooned to 557 open files, an increase of 72% over two years. The age of open files is also increasing. In 2010 there were no files open over two years; the 2012 Annual Report does not specify the number, but notes that 30 files were over 2 years old at the time of closure. It seems that the lengthy delays in the complaint 13

system, reported by Helen Cull QC in her 2001 inquiry, have returned – bad news for complainants and providers.

Lamb and Tania Thomas since Anthony Hill became Commissioner, the state of the HDC is of serious concern to consumers. What has happened to our public watchdog?

Combined with reports of a very high turnover amongst the Complaints Resolution staff at the HDC, and the early departure of experienced Deputy Commissioners Rae

The HDC report is on the HDC’s website: www.hdc.org.nz

Ethics Committees Reprinted with permission from the Auckland Women’s Health Council Newsletter

It is almost 25 years since the release of the Cartwright Inquiry report which resulted in major changes to the health system, the development of a code of consumers’ rights, the establishment of the National Cervical Screening Programme and major reforms to the process of ethical approval for research. New ethics committees were established, and a national standard and guidelines for ethics committees were developed which made the protection of the patient the main purpose of the new system of ethical review.

Now there are four

During the past two decades many changes have been made to the operational standards for ethics committees as well as to the structure and number of committees. Alongside these changes, the focus began to shift away from the patient, who is now referred to as the research participant. The changes that were implemented last year completed the process of ensuring that the focus is now firmly on the research study or clinical trial and was designed to make life easier for the researchers.

In June 2012 the Ministry of Health’s seven ethics committees were disestablished and on 1 July four new streamlined, clinical trials focused and thoroughly disempowered ethics committees began work under new Standard Operating Procedures (SOPs). (1) The new SOPs drastically reduced the scope of the ethics committee review process and contain a list of studies that no longer require review and approval by these new ethics committees. The studies that require a review by the whole ethics committee are now restricted to those that involve human 14

TE PUAWAI rently meets in a small conference room at the Novotel Hotel in Greenlane Road.

It is not an easy thing to do as members of the public do not have ready access to an agenda or a summary of information on proposals that are due to be discussed.

It is often difficult trying to work out what is going on.

participants, the use, storage or collection of human tissue, and the use or disclosure of health information.

Studies that do not require ethics committee review include studies on low risk devices, minimal-risk observational studies, audits and related activities, and student led research.

Applications online

Going “in committee”

Research proposal applications must now be completed online, and during the first few months under the new regime the numbers of research proposals being submitted fell dramatically as researchers struggled with the new online system.

Nine months later, flaws with the online application process are still being reported during the ethics committee meetings.

One disturbing development is the fact that most meetings of the Northern A ethics committee now include a research proposal that is discussed “in committee” with members of the public having to wait outside the meeting room while the committee discusses the research proposal behind closed doors.

Official Information Act request

The new system of ethical review is now working to two different clocks. There is a 35-day review clock for the full review pathway, and a 15-day clock for the expedited review pathway. An expedited review does not involve a physical meeting, and is a review involving a subcommittee of the ethics committee.

The AWHC was so concerned about this development that in December last year we wrote an Official Inform-ation Act request asking for the documents on the research proposals that had been dealt with “in committee” by all four of the new ethics committees. The box of documents that subsequently arrived contained most of the documents relating to 14 research proposals, but unfortunately they did not include the key documents – the actual research application and the research protocol.

As already noted, the new committees have now been meeting for nine months.

Some of the members of the new committees are new but many have been on the Ministry of Health ethics committees for several years.

Merck Sharp and Dohme was the sponsor of eight of the 14 research proposals that were considered behind closed doors.

Boehringer Ingelheim, Bayer, JanssenCilag, and Amgen were each the spon-

Since July last year two members of the Auckland Women’s Health Council have attended most of the meetings of the Northern A ethics committee which cur15

sors of a study. Living Cell Technologies NZ Ltd was the sponsor of another, and there was no sponsor for the study on S gene mutations and hepatitis B. The population-level Child Maltreatment Research based on Linked Administ-rative Data study was referred to the Ministry of Social Development.

far the system has strayed from the path of safeguarding patients – these days some patients find they have to opt out of research trials they have automatically been enrolled in.

References http://ethics.health.govt.nz/operatingprocedures

The AWHC is working on a letter to the Ombudsman about the missing documents.

http://www.womenshealthcouncil.org.nz/Features/ Ethics.html Report of the Cervical Cancer Inquiry 1988. Page 148.

Lack of independence As reported in a previous issue of the AWHC newsletter, ethics committees were never going to be appropriately managed and safe from being amended to suit professional and commercial interests by being placed within the Ministry of Health.

(2) The Minister of Health and the Ministry of Health decide who gets appointed to ethics committees which makes the ethical review process even more unsafe.

Consumer groups have argued for more than a decade that responsibility for ethics committees should be placed within the office of the Health & Disability Commissioner.

The New Zealand Society of Travel Medicine Conference.

3-4th August 2013 Te Papa, Wellington.

Out of Africa The New Zealand Society of Travel Medicine will hold its annual conference at Te Papa Wellington 3-4th August 2013. The theme of the conference is ‘Out of Africa’. The key note speakers are Dr David Hill (USA) and Professor Dennis Shanks (Australian Malarial Institute).

Topics will include Vaccination for Travel, Vaccination for Life, Travellers’ Diarrhoea – Can anything be done?

Yellow Fever, Safety and Travel Health, Travel Health from a Guides Perspective, Volunteerism, Malarial Chemoprophylaxis, Refugee and Migrant Health, the Returning Traveller and breakout sessions. A Yellow Fever workshop will be held on Sunday after lunch.

Lack of accountability In her 1988 Report of the Cervical Cancer Inquiry Judge Silvia Cartwright referred to the duty of an ethics committee “to safeguard patients and healthy volunteers,” and to the “duty to see that unethical practices did not occur” and right of the public “to be satisfied that they did not.” (3)

Please register online at: https://nzstm-conference-2013.lilregie.com/step1 or contact Tanya for more details: nzstm@bgamarketing.co.nz Check the website: www.nztravelmedicine.co.nz to join the society and view the draft programme

The story that follows reveals just how 16

TE PUAWAI

Conference report - Jill Wilkinson

National Health Professional Prescribing Summit Melbourne October 2012 deal with, but also different rules for access to publicly funded medicines (the pharmaceutical benefits scheme or PBS). Nurse practitioners were authorised to prescribe in 2010, but as most NPs work in specialty areas in hospitals with few in primary care, it’s hard to understand the value NP prescribing adds when there’s a doctor to be found at every turn of the hospital corridors (or so we’re told in New Zealand). NPs can prescribe during an inpatient episode of care, or more often during a stay in the ED, but are then unable to complete a discharge prescription.

In the beginning, when the creator was giving out stuff, New Zealand slept in. Late to the table (and in addition to pineapple lumps), we got just one national law-setting institution and not the eight Australia got.

Sweet-as dude! 1 Well, at least sweeter in New Zealand than it is in Australia. I know this because I recently attended the National Health Professional Prescribing Summit held in Melbourne. I learned that if you regard the states and territories as different Australian countries, the complexities surrounding nurse and other ‘non-medical’ prescribing in Australia begin to make some sense. Of course New Zealand law can be subverted at a range of different levels too, but in Australia, federal law can be re-interpreted by each of the state and territory authorities, and then by local organisation policy, protocol and employers. For example, in Victoria alone there are 8 specialty-based formularies (approved list of medicines) for the 8 different categories of nurse practitioner (NP), whereas New South Wales approves individual NP formularies. Furthermore, none of these formularies are consistent with the Nursing and Midwifery Council formularies.

Of course New Zealand is way ahead on this. We have regulations that provide for registered nurses (RNs) to prescribe medicines although only in diabetes health as yet, and soon also pharmacists. In Australia, the debate about prescribing concerns nurse practitioners, pharmacists, optometrists, podiatrists and midwives, and RN prescribing is not at all up for discussion.

Bear in mind also that the few midwives who have applied for prescribing authority are still waiting, and have been since 2010. The international literature refers to prescribing by health professionals other than doctors as ‘non-medical’ prescribing.

It’s a term I’m not at all comfortable with but am at a loss to come up with a satisfactory alternative that collectively names the groups of health professionals who are not doctors.

Not only are there different formularies to 1

http://www.youtube.com/ watch?v=hpj2oVJhYjM

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National Health Prescribing Summit cont...

Nevertheless, the responsibility and the training required are not the same. Lisa Nissen from the University of Queensland discussed the different prescribing models and associated responsibilities. She presented a model that positions the different models using two intersecting axes (see figure 1). The horizontal axis represents a continuum of narrow to broad formulary (left to right); the vertical axis represents a second continuum of ‘no protocol’ to ‘protocol driven’ (top to bottom). Independent prescribing is located in the top right quadrant as minimally protocol driven and draws on a broad formulary (in this context, formulary refers to available medicines).

Collaborative or dependent prescribing arrangements are in the bottom right quadrant and are more protocol driven but use a broad formulary, and standing orders are in the bottom left quadrant as highly protocol driven and use a narrow formulary.

At the conference Professor Mary Chiarella from the University of Sydney outlined the rather convoluted accountabilities in traditional prescribing arrangements whereby doctors assess, diagnose and prescribe, pharmacists supply, and nurses administer the medicines, evaluate the effectiveness and report back to the doctor on outcomes.

When nurses prescribe autonomously (and in Australia that means NPs) the process and reporting accountabilities are linear, and the entire process is managed by the same practitioner. Counter to arguments put forth by the Australian Medical Association, a linear model offers an inherently lower risk to patient safety, yet in Australia, NPs are required to have a collaborative arrangement with a doctor in order to prescribe. Professor Chiarella compared collaborative arrangements for prescribing to being a bit like a marriage in which NPs are asked to love, honour and obey, and doctors are asked to enjoy it!

If we were to add to the model ‘more responsibility and training’ and ‘less responsibility and training’ to the vertical axis (top to bottom), it becomes clear that while the process, skills and knowledge needed to use standing orders may be the same or similar to independent prescribing , the responsibility and breadth of training are not. And therein lies the difference.

Conference presenters tended to include protocol or standing orders in their discussion of different prescribing models. We are careful not to do this in New Zealand and make a clear distinction between the supply and administration afforded under a standing order and the provision of a written prescription – which we call prescribing.

Yet if prescribing is generally understood to mean that a health practitioner follows a process of clinical assessment that leads to a diagnosis and decision to provide a medicine to a patient, then all that differentiates this process from prescribing by protocol is a piece of paper (i.e. the prescription).

The formulary and the availability of an appropriate protocol may be limited, but the process used to make a decision are the same.

Again, this model is useful to position individual practitioners on the ‘narrow to broad’ formulary axis. We could add to this axis ‘specialist’ and ‘generalist’ (left to right).

Collectively NPs could be positioned in the top right quadrant as generalists. But an individual NP can be a specialist with a very high level of skill, knowledge and experience in a more defined area (e.g. pain, or long term conditions). They will 18

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ing competency framework for all health professionals in Australia. The framework describes the knowledge, skills and behaviours expected of practitioners as they ‘prescribe medicines judiciously, appropriately, safely and effectively’. 2 The framework is a means to support non-medical prescribing as part of the drive to increase productivity and heighten quality of care. The United Kingdom also has a single competency framework for all prescribers, and in my view, New Zealand could do with one too.

Such frameworks may eventually lead to the pre-fixation of ‘non-medical’ to ‘prescriber’ becoming redundant.

consequently make use of a more limited formulary and be positioned in the top left quadrant. The same principle would apply to GPs (on the right) and medical specialists (on the left). Other health professionals, as well as consumers, often have difficulty understanding the different areas of specialty for NPs, but seem to readily understand the model as it applies to medicine.

In addition to those speakers already mentioned, there were presentations on a variety of topics about the Australian regulatory environment, education requirements, and case studies that illustrated the day to day reality of NP, midwifery, pharmacist and optometrists practice. Of considerable significance was the recent launch of a nationally consistent prescrib-

2 NPS. (2012). Better Choices, better health.

Competencies required to prescribe medicines: Putting quality use of medicines into practice. Sydney: National prescribing Service Ltd. Retrieved from http://www.nps. org.au/health-professionals/professional-development/ prescribing-competencies-framework 19

National Health Prescribing Summit cont... cated process to the way standing orders are issued. Prescribing in this way raises the same concerns about responsibility and training that standing orders raise.

Consequently, nursing professional groups and the Nursing Council are clear that the designated class is more appropriate for nurse prescribing. Delegated prescribing will have its own regulations and the Nursing Council would be required to set the necessary education and competencies if it were to pursue this option. Other groups of health professionals appear to be interested and have supported the introduction of the delegated category.

Where progress is being made in New Zealand is via the Medicines Amendment Bill 2011 which has now passed its second reading. Recommendations from the Select Committee are that NPs become authorised prescribers (under the 2005 regulations NPs are designated prescribers). This means they will be able to prescribe in their area of practice from the full schedule and not from the current limited schedule of 1379 medicines. The designated class will remain available for RNs to be authorised as prescribers in much the same way as the current group of diabetes nurse specialists (DNS). The Nursing Council is currently consulting on proposals for two levels of nurse prescriber within this class.3 One would be for overthe-counter and other relatively simple medicines and available to most RNs who meet specific competency requirements.

The other would be for advanced practice nurses such as clinical nurse specialists who will be able to prescribe from a gazetted formulary according to their area of practice. The move from a schedule of medicines listed in the regulations to notification by publication in the Gazette will mean the list can more easily be updated as new medicines become available.

Submissions on the consultation document close on 19 April.

My final point in this report is that there are significant responsibilities that accompany any form of prescribing and for risk to be properly managed an autonomous and educated workforce is required. Professor Mark Jones from Curtin University observed in his closing remarks at the conference that there are an inevitable series of steps that lead to non-medical prescribing, although none seem to be the same in each country. They must be travelled nonetheless, and despite a few lumpy bits, New Zealand seems to be well ahead of Australia.

Well done New Zealand!

The Medicines Amendment Bill also introduces a new category of prescriber - the delegated prescriber. These prescribers would be able to generate a prescription via a ‘delegated order’ issued by an authorised prescriber in a similar, but more compli-

Acknowledgements: My thanks to the College of Nurses Aotearoa for meeting the flight costs to Melbourne, and to Professor Mark Jones for a complementary pass to the summit.

Dr Jill Wilkinson Senior Lecturer, School of Nursing Massey University, Wellington

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Nursing Council of New Zealand. (2013). Nurses consulting on prescribing rights. Retrieved from http://www. nursingcouncil.org.nz/index.cfm/1,284,html/Media-Release28-February-2013-Nurses-consulting-on-prescribing-rights

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Trailblazer Award Recipient 2012- Carla Arkless NP

Hospice New Zealand Conference Report

Kirsty Russell GP and Kim Carter RN in front of the Wood St Surgery.

Carla Arkless presents her poster - Impact of Palliative Care Nurse Practitioner Role in the Residential Aged Care Setting.

I was awarded $700 towards the cost of attending the Hospice New Zealand conference in Auckland on 14-16 November 2012, where I presented a poster. The title of the poster was: “Impact of a Palliative Care Nurse Practitioner Role in the Residential Aged Care Setting”

The other ‘role’ I had at the conference was to chair the Palliative Care Nurses New Zealand (PCNNZ) AGM, where I stood down from the committee after 4 years, and announced the new committee. This was with mixed emotions – PCNNZ has been a large part of my life for the last few years and in some ways I was looking forward to the reduced work load and less email traffic! And in other ways I was sad to be leaving such a great committee, working with people so committed to palliative care nursing.

The poster was very well received, with many delegates interested in the role and the impact in Residential Aged Care. Almost all of the 50 printouts of the poster were taken.

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Hospice NZ conference report cont...

Impact of a Palliative Care Nurse Practitioner Role in the Residential Aged Care Setting Carla Arkless, Julia Russell Presbyterian Support Southland

Background Presbyterian Support Southland (PSS) is the southern most region of the Presbyterian Support National Federation. It lies within the Southern District Health Board (DHB) and Southern Primary Health Organisation (PHO) boundary covering Otago and Southland. PSS has four Residential Aged Care Facilities with a total of 289 in-patient beds, providing all levels of care.The NP role was developed in response to a recognition that there were significant gaps in the provision of care, particularly as increasing numbers of residents are admitted for palliative care and/or have very complex/rapidly changing needs, and that advanced nursing roles are a proven, effective way of addressing this.

In Invercargill there is no consistent 24hr GP availability, and GP intervention is not always adequate in itself. Such gaps particularly affect residents who are approaching the end of their life, and for whom active treatment/hospital transfer is inappropriate or not wanted.

The hospice provides support for residents enrolled in their service, however the expectation is that the GP or Urgent Doctor will be contacted for intervention; such intervention is not always timely or adequate, and highlights the need for additional measures.

Review of NP role Sep 2011-Sep 2012

Highlighting the effectiveness of the NP role

› Quantitative data regarding NP clinical activity including: • Number of clinical contacts • Number of hospital transfers and unscheduled GP visits directly avoided • Number of directly measurable improved outcomes from specific intervention ›Survey of staff and GPs ›File reviews ›Anecdotal evidence

Mr Y is a gentleman with advanced dementia. He developed aggressive behaviour and was violent towards staff on a number of occasions. Staff assessed that pain was likely a trigger for the aggression; a decision was made with family not to pursue investigations and he was started on analgesia. One lunchtime mid-week, Mr Y was violent towards a staff member, causing significant anxiety and fear amongst the staff, and concern for the safety of staff and other residents. Staff felt he was in pain but he refused to take analgesia, and staff felt unable to get near him. There was no GP available to him at that time. The NP visited, assessed that Mr Y was likely in significant pain and gave a morphine injection with very good effect; after 15 minutes there was no sign of aggression and he was cooperative. A very clear plan was made with the nursing staff to manage Mr Y’s unstable pain and associated aggression. He was reviewed by the NP several times over the next 3 days and analgesia was titrated up until stable control was achieved. The GP finally returned urgent messages 24 hours after the initial event and agreed with the plan. At family’s request, his GP was changed and the new GP visited – the NP and GP together with family and staff, re-visited decisions previously made, and made an on-going plan for monitoring and managing this distressing situation.

Although many staff were ready to walk away from the job due to Mr Y’s violent behaviour, they became more confident to care for him and felt well supported. The GP and NP have continued to share his care as his general condition declines, managing fluctuations in pain levels promptly and effectively. Without the NP, the only medical intervention available to Mr Y at the time of crisis was hospital – this would have been a very distressing and inappropriate environment for him. Although this has been a complex and challenging situation, ongoing, appropriate comfort-orientated care in a familiar environment has been achievable, thus maintaining optimal quality of life for Mr Y, and minimising distress for his family.

Summary of outcomes Hospital transfers and unscheduled GP visits were avoided on a number of occasions Numerous specific measurable improved outcomes for residents, e.g. timely, effective control of pain; and on family, such as reduction in significant distress Staff and most GPs identified that the role has had a positive impact on residents Staff identified improved, more timely medication management, support and guidelines for staff in managing symptoms, improved choices and planning at the end of life for residents Staff feel the role has had a positive impact on their roles, identifying provision of tools and support for staff, the specialist knowledge, professional example, and availability as being significant One mention from a staff member and from a GP that there was, at times, confusion over who was managing the care – the NP or the GP

Conclusions Positive impact on residents, families and staff Timely palliative care provision across all settings has improved

Advance Care Planning (ACP) Part of the NP role has involved the implementation of ACP across the organisation in line with the Ministry of Health guidelines and the work of the ACP Cooperative. Of course ACP is not just about palliative care; however it does influence the delivery of and experience of end of life care. Following a comprehensive implementation and ongoing training process, a review of the first six months of ACP implementation was carried out, revealing very positive outcomes for residents, families and staff. Many GPs have also expressed positive comments, and feedback from families of deceased residents has also been extremely positive.

More residents able to remain in the facility and receive their preferred approach to care.

Particularly positive impact in the 40-bed dementia unit.

Additional benefits have been seen from the implementation of ACP specifically Staff job satisfaction improved, which will affect staff recruitment and retention Missed opportunities and capacity for further improving outcomes and understanding of the role identified The role is not funded; however there is evidence of cost savings to both PSS and to the DHB

For more information on the NP role or on Advance Care Planning in Residential Aged Care, contact CARLA ARKLESS at Carla.Arkless@pss.org.nz

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TE PUAWAI ful meetings, and the role of informal music (ukuleles) in the hospice setting – which could be easily translated into other care settings.

The conference was hugely beneficial to me, and there was a great deal of reference to Aged Care and non-malignant disease, which is very relevant to my current practice. Highlights included:

I wish to thank the College of Nurses committee for the award allowing me to attend this conference, which I thoroughly enjoyed and which has been of huge benefit.

• Networking opportunities. At this conference I have established and reaffirmed a number of important connections, particularly with regard to the development of advanced nursing roles around the country, and also with regard to Advance Care Planning. It was also very worthwhile meeting up with colleagues already known to me. As there is a degree of isolation associated with my role these connections are so important in sustaining and developing my role and everyday practice.

Thank you.

Carla Arkless Palliative Care Nurse Practitioner Presbyterian Support Southland

Moving House or Changing Job

• Many sessions focussed on the role of the community in end of life care, and the notion that dying should perhaps be less in the domain of health care providers, and more in the domain of the community. This resonates with me, in an era where death and dying is becoming more and more medicalised – it was refreshing to see this is not being taken for granted, or seen as necessarily inevitable, in New Zealand.

Remember to update your details with the College office ASAP.

• Michal Boyd did a presentation, with a focus on residential care – challenging delegates to consider how palliative care and aged care services might truly work together. This, of course, is very relevant to my area of work.

admin@nurse.org.nz

(06) 358 6000

• There were also a number of concurrent sessions which interested me, including the use of genograms, success23

Trailblazer Award Recipient 2012- Jo-Ann Downie

Australasian Cardiovascular Nursing College (ACNC) Conference 2013 Review

University and am completing the prescribing practicum. I am also the Nurse Coordinator for Cardiac Angiography at TDHB, and do angiography pre-assessment clinics once a week which works well with my Nurse Practitioner intern role.

I really wanted to attend this conference as it is the first time it has been held in New Zealand, and as a nurse working within cardiology there are very few conferences which are purely nurse orientated and focussed. I find these to be the most informative of meetings, and provide some of the best networking opportunities around. The only other conference I have attended with a nurse’s session is the Cardiac Society of Australia and New Zealand (CSANZ); this has the cardiovascular nurses working group satellite meeting attached to it.

First I would like to thank the College of Nurses - Aotearoa for the very kind Trailblazer award that allowed me to attend the awesome and inspiring conference - Australasian Cardiovascular Nursing College (ACNC) conference 2013 held in the SKYCITY Convention Centre 23rd and 24th February.

At the conference I presented two posters, along with a 3 minute verbal presentation of each. This was my first time presenting at a large conference, and as a result I have no nails left! Having said that I found it a very positive experience.

The posters I presented were on my role as a Nurse Practitioner Intern and what I do within cardiology; it was an overview of the clinics I run and the different areas of care I carry out with my patients. The clinics are for Exercise Tolerance Testing, post coronary angiography follow-up and cardiac clinics for those patients who have had intervention, or are

My name is Jo-Ann Downie and I am a Cardiac Nurse Practitioner Intern at Taranaki District Health Board (TDHB). I have been in this position for the past year, with the agreement that I will have my portfolio for Nurse Practitioner with prescribing rights completed within two years. I will then be fortunate enough to have a job secured as a Nurse Practitioner. I completed my Masters of Nursing with first class honours at Auckland 24

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Barriers to communication, philosophical differences ( medical model versus nursing model creates a difference of dynamics ) and strategies to ensure effective communication were discussed during this talk. The following day Kathleen spoke about reducing the delay to treatment in AMI. What came out is that the patients recognition and identification of symptoms delays time to calling for help and timely reperfusion. There are many issues surrounding this and to date with all of the interventions tried have made no difference. She noted that every 30 minutes delay increases the 1 year mortality rate by 7%!. The future is unclear but will most likely be addressed by technology such as phone app ECGs for example.

long-term cardiac patients. It also included other aspects of the role such as colleague education, writing, reviewing and updating policies and procedures, ongoing education, exploring role exapnsion and support from the Cardiologists.

The second poster I presented was titled: Are Māori accessing enough cardiac diagnostic tests within Taranaki District Health Board. I am interested in this because within Taranaki Māori have almost twice the rate of cardiac related mortality than non- Māori. This was to look for inequalities within the service; are they being referred at an earlier age? are they attending the diagnostic tests? and so on. The outcome was that there was a variability in access when grouped into age groups, and the DNA rate was strikingly high, however access to coronary angiography was very good in contrast. In order to help decrease this inequality reducing the DNA rates is a suggestion, along with more referrals being made to access tests.

We then had three very interesting talks on interesting imaging, informed consent ( I didn’t realise that the consent form used in hospital is not a legal document?), and resilience in nursing. I think we all took away something from Iris Fontanilla’s (Registered Psychologist) talk on resilience, and recognising symptoms of burnout. Her practical strategies included celebrating success, laughter, keeping track of feedback and very importantly – boundaries, when to stop and ensuring you separate yourself from work (identity check).

Conference speakers were amazing. Professor Kathleen Dracup (RN, FNP, DNSc, FAAN) presented both days. On day one she spoke about interprofessional relationships in cardiac care. What I gained most from this talk is that poor communication between health professionals remains the number one cause of poor outcomes for patients, sentinel events, medication errors, wrong surgery performed, ...the list goes on. Other problems that contribute to this are human factors and poor leadership. The airline industry worked this out 30 odd years ago, they now they lead the way in communication and teamwork.

They used to have hierarchical problems within this industry which is not present now, the health care system however is a different kettle of fish, although we are now starting to

After lunch (which was lovely) concurrent sessions were run. I attended the Heart Failure sessions which were very interesting.

These were presented by health professionals working in the field and it was good to hear from our colleagues working in Northland, NZ, and Australia. Workshops were then held on how to understand research, ECGs, and cardiovascular physical exam.

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ACNC Conference Review cont... self management and promoting patient centered care; this is essential as almost everyone is able to monitor and manage some aspect of their health more successfully. Of interest; 80% of all medical symptoms are self diagnosed and treated!. Also she noted the need to be specific in what you tell your patients, choose what is the most the important aspect as patients will only remember 20% of what you talk about.

That evening we had drinks and a fantastic meal in the Observatory Restaurant in the Sky Tower. It was a beautiful evening and showcased Auckland for our Australian delegates. As Ross Proctor (President ACNC) said “ it is very important we have fun with our colleagues”, and we did!.

Sunday brought just as many fantastic talks.

Professor Jenny Carryer spoke on “Working to the top of your licence” Yet another catch phrase or an important challenge? I took a good deal away from this talk as Jenny spoke a lot about Nurse Practitioners and models of care, mostly we need to remain nursing focussed and continue to push for a transformative paradigm of care. She noted that clinical input contributes 20% to health outcomes and social determinants and other factors contribute the reamining 80%.

Nurses therefore have the most opportunity for developing sustainable health services in New Zealand.

This was a good introduction to the next talk from Pat Flanagan from the NZ Heart Foundation on risk management in primary care.

She spoke on the new booklet from the Heart Foundation called Taking control: My plan for heart health. This booklet is extremely user friendly and covers many different aspects of heart health.

Wendy Bryson (Cardiac Nurse Practitioner) then finished the sessions with an update on the Cardiac Society of Australia and New Zealand (CSANZ).

I would encourage anyone to attend one of the ACNC conferences, and to present an abstract or poster to a non-threatening audience. It was so applicable as it was nursing focussed and it covered many different aspects of nursing. I will definitely try and get to these again in the future.

Dr Nicolette Sheridan spoke about Health Equity in the New Zealand health care system: a national survey. Unfortunately there are no easy quick fix answers, but as a health care system we need to continue to try and reduce the inequalities we currently have.

This is also very apparent in Australia, I sat in on the Tackling the CHD diaspora: working with different ethnicities workshop. We sat in groups to try and come up with ideas to improve this. I got the distinct impression that some of our suggestions around what we do in New Zealand, for example Marae based intervention and education would be taken back to Australia for further discussion.

Again thank-you CNA( Aotearoa) NZ for this wonderful opportunity.

Jo-Ann Downie Cardiac Nurse Practitioner Intern.

Dr Janine Bycroft (G.P, Flinders Trainer and Self-Management Clinical Advisor for several DHBs and PHOs) presented on supporting 26

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ACNC Conference Review cont...

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College of Nurses Membership fees for 2013 The 2013 fees have been rolled out and all members paying by automatic payments will by now have received notification to change their automatic payments.

Subscription Fees

Annual

Monthly

Indemnity Insurance Covered #

Member

$460.00

$38.50

Yes

Fellow

$520.00

$43.50

Yes

Discounted Member* • Working under 20 hrs p/w • RN in full time study • International

$340.00

$28.50

Yes

Retired Member **

$260.00

$22.00

No

* Reduced Income – employed at or under 20 hrs per week, annual employer verifica tion required for discount to qualify. * RN in full time study – Non working Registered Nurses returning to study, verification required from tertiary provider. ** Retired Members - Non working members of retirement age. # Indemnity Insurance cover is assured in New Zealand providing members hold a current APC and/or the appropriate qualification or training for related work at the time of any claim.

Dual Professional Membership Discount- You may choose to opt out of College Insurance cover if you hold another professional membership covering your Indemnity Insurance. A $50 discount applies to our regular Membership or Fellowship fees – please contact the office if this applies to you.

Disclaimer - The College of Nurses Aotearoa (NZ) provides Te Puawai as a forum for its members to express professional viewpoints, offer ideas and stimulate new ways of looking at professional practice and issues. However, the viewpoints offered are those of the contributors and the College of Nurses does not take responsibility for the viewpoints and ideas offered. Readers are encouraged to be both critical and discerning with regard to what is presented.

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Conferences & Events Workshops for 2013 Professional Boundaries Workshop

with Dr Patricia

McClunie-Trust

This workshop is designed to help nurses to define and explore professional relationships within the clinical, cultural and social communities in which they work and live. Being involved in caring and advocating for other people can involve complex and challenging personal and professional situations. This workshop will assist participants to define and manage their professional boundaries in a practical and effective ways.

College members $175, Non College members $195. Earlybird discount of $20.

Professional Boundaries Workshops for early 2013 Wellington 18 April 2013 FULL (Wait list Full) Nelson 19 April 2013 Spaces available - get in quick Rotorua 30 May 2013 FULL (Wait list only) Napier 28 June 2013 Limited spaces available at Earlybird rates New Plymouth 6 Sept 2013 Spaces available at Earlybird rates Other locations will be announced later in the year.

Information & Registration online www.nurse.org.nz under ‘workshops’ tab.

Nurse Practitioner Development Day to be announced.

If we have enough interest, this workshop is likely to be in Wellington in mid October. Please email admin@nurse.org.nz if you would like to attend.

Professional Portfolio Workshops with Dr Stephen Neville

Scheduled throughout the year, these workshops are open to all registered nurses (not in a PDRP programme) and make the task of preparing and maintaining your Professional Portfolio easier than you think.

Check the website under workshops for details www.nurse.org.nz

www.nurse.org.nz To aid us in scheduling workshops around the country, please send expressions of interest to admin@nurse.org.nz with the workshop name & your location in the subject line, we will let you know as soon as we have a scheuled workshop close to you.

If you know of an event that you would like to see in this section of our next issue, please send details to admin@nurse.org.nz

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