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FOCUS  n  Learning & Leading

Nursing Review August/September 2016/$10.95

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kerri nuku A DAY IN THE LIFE OF A nursing student

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Bullying & the caring profession Super city collaboration

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Inside: FOCUS: Learning & Leading 4 8

LEADERSHIP: bullying and the caring profession CAREER PATHS: six nurses share their career journeys

Professional Development 15 ‘Legal highs’ and mental health: raising nurse awareness Reading, Reflection, and application in Reality To subscribe go to



Closing the generation gap

’ve been privileged in this edition to be able to speak with nurses at opposite ends of their nursing careers. Yosh (Yosua) Hadipurnomo is a Christchurch lad who likes to tramp with his mates, has an infectious smile, and is on this issue’s cover. The final year nursing student so loved his clinical placement in a remote West Coast settlement that he is seriously contemplating rural nursing further down the track. Yosh is one of those nursing students who makes you feel pretty good about the future of the profession. I also spoke with Judy Kilpatrick – one of two retiring nurse educators featured in this edition – who is looking back on nearly 50 years in nursing and 35 years in nursing education. Like Yosh, she both trained in Christchurch and had a father who was surprised at his child’s career choice. Also like Yosh, she has an ever-present laugh. Judy – whose career includes chairing the Nursing Council through the ‘amazing’ times leading up to the creation of the nurse practitioner role – has never shrunk from robust discussion and encourages the next generation of nurses to ‘front-up’ more to the people with influence and tell them why nursing matters. But, she adds, never forget to laugh at yourself and “don’t sweat it too much” – which sounds like good advice for young nurses starting out in their careers. I wish Yosh and Judy all the best for all the new adventures that 2017 will bring – and lots of laughter.

REMINDER: free 60-minute PD learning activity Since our last edition, all print copies of Nursing Review now include Nursing Review’s regular RRR professional development article. Reading the article, reflecting on it and applying it to the reality of your nursing practice means you will have earned 60 minutes towards the Nursing Council’s requirement of 60 hours’ professional development over three years. Check out our latest RRR PD article in the middle of this copy. Fiona Cassie

COVER PIC: Yosua Hadipurnomo is a third year student at Ara Institute of Canterbury (formerly known as CPIT). See page 3 for a day in his life on a student clinical placement. PHOTO CREDIT: Xander Dixon, 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).

20 JUDY KILPATRICK reflects on 35 years in NURSE EDUCATION 22 Postgraduate study funding: are we better off? 23 SUSAN JACOBS: three decades of nurse education change 24 A project in MENTAL HEALTH for PRIMARY HEALTH nurses in the super city 26 Professional boundaries: how close is too close? 28 SAFE STAFFING: what makes a shift safe or unsafe?

Practice, People & Policy 29 30

CULTURAL SAFETY: ways of being with ourselves and others Māori nurse pay parity issue goes to the UN

Regulars 2 Q&A Profile: NZNO kaiwhakahaere KERRI NUKU 3 A day in the life of… nursing student YOSUA HADIPURNOMO 31 Evidence-based Practice: CYNTHIA WENSLEY on heart failure medicine 32 College of Nurses: KATHY HOLLOWAY on ‘wicked’ problems

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Editor Fiona Cassie 03 981 9474 Advertising & marketing manager Belle Hanrahan 04 915 9783 commercial manager Fiona Reid production Aaron Morey Subscriptions Gunvor Carlson 04 915 9780 images iStock

Nursing Review

Vol 16 Issue 4

NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6011, New Zealand PO Box 200, Wellington 6140 © 2016. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014

Errors and omissions: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.  |  Nursing Review series 2016    1


Kerri Nuku

IWI | Ngāti Kahungunu/Ngāi Tai JOB TITLE | Kaiwhakahaere New Zealand Nurses Organisation/Tōpūtanga Tapuhi Kaitiaki o Aotearoa



What do you love least about being a nursing leader? The challenges that some of our nurses face are difficult and the demand often outweighs what can reasonably be done. The frustration and slowness of bureaucracy is the most impossible issue to deal with. If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? »» Having recently taken the issue of pay parity to the United Nations Permanent Forum on Indigenous Issues, I would wish for pay parity across all the health sector. »» That indigenous workforce issues are always on the national and international nursing agenda. »» To have the courage and resilience to collectively advocate for effective and quality health services.

Where and when did you train? I originally trained as an enrolled nurse at the Hastings Memorial Hospital and graduated as a registered nurse from the Hawke’s Bay Polytechnic in 1991. I later graduated in 1996 from Massey University with a diploma in midwifery.


Other qualifications/professional roles? I have continued professional studies at Victoria University and more recently at the University of Canberra. I have always had an interest in auditing and risk management, am a member of the Institute of Directors and am a trustee on a number of groups, including the Hawke’s Bay District Health Board Māori Advisory Committee.


When and/or why did you decide to become a nurse? Ever since I was a young girl I remember a black and white photo of my mother in a starched white uniform with the starched white cap and red cape. I guess I was attracted to the photo without really understanding what a nurse did. I also wanted to be an agricultural advisor but fortunately I made the right choice.


What was your nursing career up to your current position? After graduating I worked as an RN in maternity services in Hawke’s Bay and eventually, after becoming a midwife, I became the antenatal/outpatients clinic team leader for several years. I was also project manager for a number of projects, including developing a Māori responsiveness framework, developing community midwifery services, and a diabetes antenatal screening trial. Between 2003 and 2009 I changed direction and became a clinical nurse specialist for sexual health services for Hawke’s Bay District Health Board. At the same time I studied at Victoria University and completed my auditing training that allowed me to audit other services across New Zealand for the Telarc auditing organisation. I then made the most of my extensive background within the DHB sector and went to work for an independent international research organisation. As the organisation’s New Zealand director I was responsible for staff working across Aotearoa. In 2011 a colleague and I developed an independent nursing service where I provided oversight until becoming the kaiwhakahaere for NZNO/Tōpūtanga Tapuhi Kaitiaki o Aotearoa.


What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt? Matua Amster Reedy always acknowledged that the three attributes of a great leader are that they are unobtrusive, add value, and inspired. Te Poari and I believe this to be true and it is evident in many of our great nursing pioneers.

Kerri Nuku


So what is your current job all about? Tōpūtanga Tapuhi Kaitiaki o Aotearoa/ NZNO is a member organisation committed to working within a bicultural relationship so the kaiwhakahaere and president (Grant Brookes) are cogovernance leaders, which means we co-chair the NZNO Board of Directors and monitor the performance and progress of the organisation in achieving its strategic aims. As the kaiwhakahaere my role is also to be the voice for Māori members and to advance their issues and support the Māori governance roopu (Te Poari) and the wider Māori membership (Te Runanga).


What do you love most about being a nursing leader? I really appreciate my job and the opportunities I have had while being in this position. I love challenges and developing strategies to address complex situations. Being a nurse leader representing members keeps you humble and focused on achieving and making the most of opportunities to advance nurses across all the sectors.

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What do you do to try and keep fit, healthy, happy and balanced? Anyone that knows me will say that I am not the most physical person and would do almost anything to avoid exercise. However, when I was young I was a member of the amateur athletics and Harriers group so I like to think I did what I needed to do when I was young and now I can take things easy. It is my whānau that keep me healthy in spirit and mind, and my husband and I enjoy following their interests. I am also handy with a pair of knitting needles.


Helping keep me sane, busy or on task outside of work are... With our six children there is always something happening every day after school and every Saturday there is sports. This is a great distraction and always keeps me grounded as a parent.


What is your favourite way to spend a Sunday? Spending the day with the whānau and if it is raining watching UKTV and Emmerdale Farm.


What is your favourite meal? Thai green curry (mild).

A day in the life of ...

a third-year student nurse

NAME | Yosua Hadipurnomo JOB TITLE | Third-year student nurse, Ara Institute of Canterbury (formerly CPIT) LOCATION | Clinical placement on the West Coast


AM WAKE My phone alarm sings Redbone’s Come and Get Your Love and I peek around my curtains to check the weather for the morning – the amount of condensation on the window tells me how cold it is outside – but it seems clear at 7am. I climb into the clothes I prepared the night before and meander into the kitchen to have some breakfast then glance at the clock – it’s already 7.15! Suddenly I feel wide awake as I rush to clear my dishes, brush my teeth, gather my nearly completed learning activities and try to tame my hair. Darn, where’s my bread? Still in the freezer! I rummage around for a packet of two-minute noodles and a muesli bar for lunch – success!


AM OUT THE DOOR I grab my backpack, defrost my car … Is my clinical lecturer going to call today? I can’t remember …


AM START WORK: Pink Floyd, veins and vaccinations Arrive at work, my preceptor is already there reading through her emails and preparing today’s schedule. I wondered if today we will discuss the pathways of resuscitation or the intricacies of Pink Floyd’s Dark Side of the Moon – either way I will be happy because she is an expert on both topics and I know I will learn something. I check the temperature of the immunisation fridge, boil the jug, and ask, “Cup of coffee?” The community trickles in steadily for their regular blood tests, annual flu vaccinations and with their sore backs or their children with high temperatures. It’s a flurry of activity as I meet the locals and care for them under the watchful eye of my preceptor. I become flustered trying to find and anchor a particularly wiggly vein of an elderly gentleman so she takes over and shows me a tip for tricky veins. Throughout the day we talk about each patient and reflect on each encounter. It is an exceptionally supportive and encouraging environment to work in.


PM lunch Lunch is a welcome opportunity to escape filling out ACC forms and documentation on the computer screen. We tuck our trousers into our socks to prevent the sandflies from biting our ankles as we eat lunch on the beach behind the clinic. “Two-minute noodles again, Yosh?” asks my preceptor. I smile sheepishly, “Yup.” PM ON THE ROAD We pack the mobile clinic defibrillator and suction machine into the back of the car. Just as we are about to lock the clinic up to visit the township’s district nursing patients, the phone starts ringing. It’s my clinical lecturer. She checks how I’m coping away from Christchurch, has a short chat about some of my cases and patients, and gives great feedback about my leuprorelin acetate pharmacology project. She tells me when my next batch of work is due and reminds me that she’s available


by email or cellphone if I need to ask any questions or reflect on anything. What a cool lecturer, I think to myself. The waiting car is already pumping cool air and a track from Boney M’s Greatest Hits. This is my favourite part of the day, visiting district nursing patients in their own homes and communities. I love the ongoing therapeutic relationship between nurses and patients and caring for them in their own environments – whether they are palliative or post-operative patients – in contrast to the in/out nature of my previous hospital placements. An extra bonus of visiting district nursing patients is getting the chance to pet their dogs.


PM LEAVE WORK There are no callouts today. When we return to the clinic we sit down and write our documentation. We go through my notes for the day one more time and spend some time discussing, over a cup of tea and homemade caramel slice, the ethical issues around a palliative care patient’s tricky home situation.


PM BACK HOME… to the motel I arrive back at the motel with the pager in my pocket. I do some paperwork, call my family and email my lecturer with some changes I made to my project. Feeling tired of sitting down, I put on my running shoes and jog along the river. I feel quite hungry by 7.30pm as the caramel slice starts to fade away. “Oh no, did I take the chicken out of freezer? Argh, two-minute noodles again…”


Yosua Hadipurnomo

PM TIME TO SLEEP Showered and clean, I jump into bed. The room is warm and I finish uploading a photo of the West Coast sunset onto Instagram. I set my phone on the bedside and close my eyes, but then I hear a distant beeping noise. The pager is ringing! I throw the duvet off and snatch it off the floor, awaiting the words CODE RED. Thankfully, it says TEST PAGE ONLY. Relieved, I set it down and lie back in bed. Night night.  |  Nursing Review series 2016    3

FOCUS  n  Learning & Leading

Bullying and the ‘caring profession’ Bullying is prevalent in New Zealand workplaces and the ‘caring profession’ is far from an exception. Nursing Review reports on some challenging research on nurse bullying, some nurse leader thoughts on bullying and a nurse manager’s project to encourage nurses to be kinder to each other.

Time for a change Expecting bullied nurses to toughen up is not the answer, says workplace bullying researcher KATE BLACKWOOD.


eave” is currently the best advice Kate Blackwood can give to a victim of chronic, long-term bullying. But she believes the potential is there to change workplace culture to both reduce the risk of workplace bullying and resolve bullying earlier before changing jobs becomes the best, or only, option. The Massey University management lecturer interviewed 34 bullied hospital nurses for her PhD thesis and was shocked by the impact bullying can have. The majority of nurses had reported the bullying but she spoke to only one nurse whose complaint had been successfully resolved. Less than a handful had managed to stop or control the bullying by directly addressing the bully themselves while the remaining interviewees were either still being bullied or had resorted to changing jobs (see full research findings in the online version of the article at “The unfortunate reality is that at the moment targets (bullying victims) leaving is the best chance of getting away from workplace bullying,” says Blackwood.

Bullying an organisational problem

Blackwood’s research followed on from a 2009 workplace bullying study which found high levels of workplace stress (75%) and workplace bullying (18%) in the New Zealand health and education sectors. A number of health sector respondents in that research noted that bullying was a “big problem” within nursing – specifically ‘manager-to-nurse’ and ‘consultant/doctor-to-nurse’ but also ‘peer-topeer’ bullying.

The focus of workplace bullying research has moved on from looking at the personality traits to seeing bullying as a product of the work environment and placing the onus on organisations – like health sector employers – to do something about it. “Bullying wouldn’t be as rife in health care as it is right now if there wasn’t a culture of tolerance for bullying,” says Blackwood. “If there wasn’t a culture of nurses being expected to harden up and cope with these behaviours.” She says while resilience is important it is not the answer to workplace bullying and there needed to be a culture change from the top to create a workplace environment where responding to bullying is taken seriously. “As when bullying is still tolerated and normalised, managers aren’t following it up because they don’t have to.”

Leadership training for managers essential

The culture change needs to include training and support for direct line managers, like charge nurse managers, who are often the first port-of-call for nurses reporting bullying, says Blackwood. Particularly as one of her key research findings is that bullied nurses’ reports of bullying are often snubbed or trivialised so they are put off reporting again. Blackwood says poor leadership skills is one of the workplace factors that heightens the risk of bullying and is not helped by nursing’s tradition of often promoting managers based on clinical rather than leadership abilities.

4    Nursing Review series 2016  |

This can leave managers not only struggling to respond appropriately to bullying reports but also with handling performance management issues which – if done badly – can be perceived as bullying by the nurses involved. So this is why leadership training in areas like identifying bullying and conflict management skills are very important, believes Blackwood, so fewer managers’ default action is little or ‘no action’. A lot of the behaviours that can constitute bullying can be subtle and appear almost petty or trivial – like being ignored or having your work criticised – but when they are targeted and happen over and over again they can become really harmful, says Blackwood. On the other hand, a one-off incident, like a colleague losing their temper, is not bullying and neither is undergoing performance management. There also can be a fine balance between identifying bullying too early and creating a greater issue than actually exists, and identifying it too late when the bullying has escalated and low level interventions like mediation are less likely to be effective. Focus groups that Blackwood held with managers, and others at the receiving end of bullying complaints, expressed how very difficult they find dealing with bullying cases – often taking the strain home with them at night. They spoke of sometimes being hamstrung from intervening by

Bullying Resources New Zealand Nurses Organisation workplace bullying information and guidance: WorkSafe New Zealand bullying prevention tools: Lifeline Aotearoa 24-hour telephone counselling 0800 543 354

FOCUS  n  Learning & Leading the bullied nurse not wanting the ‘bully’ to know about the complaint for fear of repercussions; and also the difficulties of dealing with a generation more accustomed to praise than criticism, which could make it very difficult to performance manage some staff. Blackwood says different strategies were also needed for dealing with, for example, the ‘known bully’ who gets away with it as they are thought irreplaceable; than were needed for the ‘teacherstudent’ bullying of a new graduate nurse too scared and inexperienced to realise they are being targeted. Bullying reporting channels also needed to be clear, well known and reflect the complexities of bullying. So expecting nurses to report bullying via a DHB’s incident reporting system was “extremely problematic”. It could also be a “huge problem” if the only informal reporting channel is a nurse’s direct line manager, when it is the manager they are alleging is the bully.

Funding constraints one bullying barrier

Blackwood is keen to emphasise her research is “not about hauling DHBs across the coals”. She says the dilemma is not a lack of DHB awareness of bullying as an issue but having the tools and knowledge to change the workplace culture and reduce the risk of bullying and bullying going unchecked. At the same time funding constraints help not hinder the risk of workplace bullying – because as one nursing leader put it, a funding ‘sneeze’ at the top can impact like ‘pneumonia’ on front line staff. And Blackwood says stress is definitely one channel through which bullying develops and some of that stress also definitely comes through

underfunding and the pressure that can place on frontline nurses. “One of my key strategies (for addressing workplace bullying) is the need to work on organisational culture change but that can take a huge amount of time and resources – both of which DHBs have very little of.” But Blackwood doesn’t believe this means change can’t happen –she has heard examples

of simply the change of DHB leadership making a difference to a hospital’s readiness to intervene on bullying. She is also keen to contribute herself by investigating tools that could make a difference including seeking research funding to implement and evaluate a bullying intervention. Because leaving their job should be the last resort, not the only option, open to a bully’s victim. Continued on next page >>

WORKPLACE BULLYING DEFINITIONS: Numerous negative behaviours towards a single target over a period of time that makes the target feel powerless and causes personal harm. Definition used in Kate Blackwood research Workplace bullying is repeated and unreasonable behaviour directed towards a worker or a group of workers that creates a risk to health and safety. Unreasonable behaviour includes victimising, humiliating, intimidating or threatening a person.

Definition used by WorkSafe New Zealand  |  Nursing Review series 2016    5

FOCUS  n  Learning & Leading

Be nicer to each other

A lack of kindness and courtesy is as much or more of an issue than bullying, believes Sue Hayward.

The director of nursing at Waikato District Health board said her fellow nursing director colleagues are aware of concerns about bullying and she personally investigates any that come to her attention. “Many things are not at all bullying – just someone who has had a bad day and has interpreted somebody’s action in a different way,” says Hayward. “But I think, with the increasing pressures placed on individual nurses and nurses as a whole, we have stopped being quite as kind to each other as we should be.” She adds that in society as a whole she sees a real lack of courtesy.

“Standards of good behaviour just don’t seem to exist or don’t seem to be embedded in society to the degree that they once were.” Hayward says nurse managers wanting to create a caring environment for their nursing staff need to “role model, role model, role model”. “Role model, listen to staff, acknowledge their concerns, never minimise them or never marginalise an individual because of what they are saying – that’s my mantra.”

That was then and this is now Bullying is cruel and destructive, wastes energy, causes nurses to leave the workforce and creates untold misery, says Jenny Carryer. The Massey University professor and executive director of the believes nursing should be very concerned about it. But whether bullying as it is defined today has always been a factor in nursing she finds hard to say. Back in the early 1970s, when she trained, nursing was so hierarchical and militaristic that she doubts many recognised they were being bullied although they almost certainly were. The difference was that it was not individualised bullying and “there was a sense we were all in it together”. “We used to do ridiculous things like a first-year student had to stand

up when a second-year student came into the room. “And you had to turn sideways when the matron was walking down the corridor – the most extraordinary, antiquated, bizarre behaviours that we took as normal.” That type of behaviour was in its dying days in the early 70s but student nurses still had to accept they were at the bottom of the pecking order and senior people would be “very, very hard on them” or they left. And leave they often did. “The attrition rate was huge.” It was also one of the reasons that training was shifted from the hospital model to polytechnics. >>

Try a little kindness Nursing Review talks to nurse manager MIKAELA SHANNON about a project to encourage and role model caring and kindness between nurses.

Mikaela Shannon


inter can be a challenging time to be nice on the ward. Demand for beds can go up and staff numbers go down as winter illnesses hit. It is the second winter for Mikaela Shannon as nurse manager of inpatient services at Kenepuru Hospital, which is 18 months into a ‘Care with Dignity’ project that morphed from focusing on staff being kind to patients to nurses being kinder to each other. Shannon says this winter, when wards are short-staffed and flag they need help, it may well be a team manager who arrives to work on the floor beside them. “All my managers are in uniform now. They used to be in their own clothes. At the end of the day we are all nurses and we are slowly getting that culture that we are all there to help. And I too can make a bed and take a patient to a toilet.” Shannon believes “absolutely” that if you want culture change you need to “get on the floor and role model it”. And when she arrived nearly two years ago to take up the post of managing around 100 nurses and healthcare assistants in Kenepuru’s five inpatient wards, a culture change was being called for by Capital & Coast District Health Board’s head office. There was concern about some ‘unpleasant’ online patient feedback and a series of complaints to the Health and Disability Commissioner, says Shannon. Working with the director of nursing’s office, it was decided to adapt the United Kingdom’s ‘Dignity in Care’ approach and the Royal College of Nursing’s related ‘Dignity: At the heart of everything we do’ campaign to form the basis of Kenepuru’s Care with Dignity programme, which was held last year and underwent an independent evaluation by Whitireia New Zealand. Shannon says the campaign started simply with wearing name badges and taking a “Hello my name is” approach to communicating with patients. It then moved on to an education workshop looking at dignity, patients’ rights and ideas for improving patient care, which were supported by appointing

“Most people don’t come to work to be unprofessional – they come because they want to do a good job, but they get stressed and snap or say the wrong thing.” 6    Nursing Review series 2016  |

‘dignity advocates’ in each ward to highlight and champion putting the improvements into action. The project focused on treating patients with dignity and respect but it got some staff questioning how respectful staff were of each other. And amongst the Whitireia evaluation report recommendations – including management providing the resources, time and environment to put the Care with Dignity philosophy into action – was a call for all healthcare workers themselves to “model a culture of care with dignity”. “Over 18 months we probably had four or five events where people had not been very nice to each other … really harsh, ‘eat your own’ type stuff,” says Shannon. Some events involved new graduate registered nurses or new enrolled nurse staff being snapped at when asking a question or for help, leaving them in tears. The dignity training meant staff were ready to speak up about unkind behaviour, including one healthcare assistant reporting, “Yes, I’m under direction and delegation, but I don’t need to be shouted or screamed at.” “People can have a bad day,” says Shannon. “But they still need to communicate respectfully to each other.” Some staff also expressed concern about patients having to hear the “silly banter” of staff being disrespectful to each, including the incoming shift’s nurses sniping about what the previous shift had left undone. The result is that this year there is a follow-up pilot Care with Dignity project for fostering respect and dignity between nursing staff that got underway in April to build on the groundwork of last year’s patient-focused programme. It’s early days yet but Shannon says things are changing and nearly 60 per cent of staff are on board, with feedback indicating that the dignity advocates, focus groups and ward teams are working on developing a ‘culture for caring’ and a zero tolerance for bullying-type behaviour (see sidebar). All her senior team staff are trained and supported in conflict management, including giving staff feedback and assessing ward culture. Work has also been done with staff whose actions prompted the call for more kindness, including using a ‘coach and buddy’ system, role reversal discussions and peer mediation, plus making sure that staff have the appropriate professional language and strategies to use when things go wrong. They are also encouraged to come to meetings with not only problems but also possible solutions.

FOCUS  n  Learning & Leading

No magic answer Bullying is a reality in all workplaces, says Anne Brinkman.

Add to the mix hospital nurses working under the everyday challenge of rostered and rotating shifts and the pressure of constant change and it is no surprise that there is bullying in nursing, believes the professional nursing advisor for the New Zealand Nurses Organisation. Brinkman says there is no magic answer to the systemic and human factors that lead to some

Carryer says individualised bullying between nursing colleagues today is “absolutely an oppressed group behaviour” with the sociological literature describing it as horizontal violence. “So where nurses feel hugely valued – and hold appropriate power and control over their own destiny – I suspect that bullying decreases markedly.”

people bullying and being bullied. But probably not helping was the constant push for change, calls to do more with less, stress caused by rostered and rotating shifts, and a lack of mental health skills and political awareness in many nurses. “We might clinically be able to help someone with blood pressure but we don’t necessarily get it right when it comes to helping ourselves be more resilient and less bullied as a profession in an increasingly stressful environment.” Brinkman says though there is no single answer to solving bullying, nurses should remember standard 1.1 of the Nursing Council Code of Conduct – which says treat people with kindness and consideration.

Kate Blackwood

Shannon says she once had new grads and ENs coming to her in tears but now she believes that the former ‘I’m not helping you’ or ‘we’re not working as a team’ vibe is very much gone.

Work pressure and rostering stress

Shannon acknowledges that the stresses and strains of the modern health system also take their toll on a nurse’s capacity to be caring. “Most people don’t come to work to be unprofessional – they come because they want to do a good job but they get stressed and snap or say the wrong thing.” She believes what is helping is having the dignity advocacy groups where people can talk about some of the pressures and issues that make them act unprofessionally. “It is not perfect yet by a long shot – don’t get me wrong.” But she feels Kenepuru is now on the right track. Part of the move to “being nicer to each other” is Kenepuru’s new approach to rostered and rotating shifts. Shannon says the roster may have been a source of tension before but there is now a push towards a ‘self-rostering’ model with the aim of allocating shifts fairly and “looking after each other like a team”. “It is no longer ‘my way or no way’. [For example] we had an awful lot of nurses who had had their families and worked mornings but their families had now left home and they were still working mornings – that kind of thing.” Roster discussions start at ward meetings and while some people request shifts online there is still a paper roster in the staffroom where people can negotiate and swap shifts before the roster is finalised and published.

Care with Dignity ENCOURAGE

»» »» »» »» »»

Initiating and participating in workplace celebrations. Complimenting colleagues. Respecting each other’s ideas. Thinking before responding. Supporting colleagues who are struggling with personal or workplace issues.


»» Disrespecting feedback. »» Being emotionally reactive. »» Not sharing information or resources. »» Isolating peers. »» Changing information (written or verbal) without delegation. »» Poor attitudes. »» Screaming or shouting. »» Unrealistic expectations of each other. Behaviour and values guidelines developed by Kenepuru nurses to foster respect and dignity between nursing staff.

Sue Hayward

Also a “skilled, experienced and balanced charge nurse manager (CNM) who can lead, manage and inspire is worth their weight in gold” believes Brinkman. Though she echoes Karen Blackwood in saying too many CNMs are promoted because of their clinical expertise, and historically and nationally there was “very inadequate orientation” for CNMs who need leadership education and support to do their job well and create a caring environment for their staff. But meanwhile nurses can be aware of their own strengths and weaknesses, work on having a balanced life and strive to be kind, considerate and supportive of each other.

Jenny Carryer

Anne Brinkman


Shannon says it can be hard work role-modelling a culture change and she needs to be mindful that she may not always get it right. But while it may take longer to get some staff on board with the new philosophy than others, she says a Dignity Week in March was a turning point for her as positive things happened on wards not just because she or her senior managers were around or had initiated them. “We now have a platform where dignity is business as usual,” says Shannon. And, “touch wood”, after 22 months in the job, staff turnover is very low and she has not had to deal with any serious patient complaints. “Which, for me, says volumes.”

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FOCUS  n  Learning & Leading

Career Paths

Some nurses know their career direction from the get-go; others have their early careers shaped by friends, the job market or chance. Nursing Review has once again asked some mid-career to senior nurses from across the country to share their career paths. This year’s nurses have worked from Gibraltar to the Kimberley. Some have spent their whole nursing careers in the regions in which they trained and others have spent a decade or more nursing outside New Zealand. Read on as six nurses share their stories and useful tips for those interested in following a similar path. Anne Hodren

cardiothoracic surgery and radiology before moving to Christchurch to work in the neonatal unit and then a general medical ward. Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career? On graduating I had no particular career plan as I was bonded, which meant on gaining a hospital placement I was routinely rotated between areas. Focusing on a particular practice area as a result was not possible but I had the opportunity to have a wide variety of experiences. Each experience provided me with growing skills in nursing care and communication, working as a team member and developing an interest in quality and innovation.

Career path: Plunket educator Seeing vulnerable children and stressed families on the paediatric ward gave ANNE HODREN the drive to nurse in the community to improve child health through prevention and early detection. NAME: Anne Hodren JOB TITLE: Plunket Society national educator

Nursing qualifications:

»» Diploma in Nursing 1984 (Wellington Polytechnic) »» Plunket Certificate 1989 (Plunket) »» BA Social Sciences (nursing) 1999 (Massey University) »» Postgraduate Certificate in Professional Nursing Practice 2003 (Otago Polytechnic) »» Master of Nursing 2005 (Massey University) »» Further postgraduate papers 2013 (University of Auckland) Briefly describe your initial five years as an RN. In my early nursing career I worked in several roles at Hutt and Wellington Hospitals including medical, general surgical, paediatrics,

What led you into your current field or specialty? One of my rotation placements was paediatrics; at the time it seemed like a daunting area of practice for a new graduate but it started my passion for working with children and their whānau. The vulnerability of children and disparity in health outcomes was apparent with many children with preventable infectious diseases and injuries admitted to the ward. In the paediatric ward and NNU I saw the considerable stress that hospitalisation places on whānau. This gave me the drive and passion to want to work in the community to improve child health through prevention and early detection. On returning to Wellington from Christchurch an opportunity to undertake the Plunket training became available, leading to an amazing career change. I was provided with opportunities to work with whānau to share in their challenges and delights and to work in nursing leadership and education. What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role? Undertaking professional development and postgraduate study has been vital to my practice, leading to my current role as a Plunket educator. My BA and MN degrees are the foundation that further professional development has built on. I have developed a passion for learning about health disparity and its impact on communities

8    Nursing Review series 2016  |

and vulnerable children. More recently I have become increasingly interested in education on nurse client partnership, parenting and infant mental health. Last year I was awarded the Margaret May Blackwell Travel Fellowship to explore how child vulnerability could be reduced by strengthening caregiver infant relationships. The opportunity to travel to meet international experts in the field of infant mental health, community child health, training and research was invaluable to my role and the potential to lead change in practice and service delivery. What personal characteristics do you believe are particularly important for nurses working in your role? In my role as an educator I see the important personal characteristics as being empathy for nurses in their complex role, to be open-minded, reflective and innovative. As a Well Child nurse, I believe there is a need to be passionate to work within communities, to be hopeful that adverse child experiences will be reduced, to have a belief in the capacity of parents and the role of the Well Child nurse to support the reduction of disparity. What career advice would you give to nurses seeking a similar role to yours? I would suggest that nurses wanting to have a role in community practice and education talk to colleagues and nursing educationalists about their passion and career pathway. This includes how to gain clinical experience and which education pathway to take. This is not only nursing postgraduate education but also opportunities to attend conferences, short courses and seminars. Reflecting on current practice and evidence will help identify gaps and potential for innovation and change. Talking to clients and community groups about their current and future needs will help to keep relevant and client focused. Nurses also need to surround themselves with passionate people and mentors. Describe your current role and responsibilities? Currently I am a national educator working for Plunket. This role includes supporting Well Child/ Tamariki Ora nurses undertaking the Postgraduate Certificate in Primary Health Care Speciality Nursing (Well Child/Tamariki Ora) and supporting ongoing professional development within Plunket.

FOCUS  n  Learning & Leading

Leaha North

your way. Keep up to date with the professional development recognition programme (PDRP) within your organisation. Move jobs, move cities, move countries – do not stay in the same role for long periods (you can always go back). Have a good work and home life balance. When my daughter was six months old I got a job in the children’s ward in Gibraltar and we moved from London to Spain, getting submerged into a European culture where the traditional family values resonated with home. It became clear after two years that we needed to come home where I knew as a nurse I had so much to offer and I wanted to be close to my whānau and to be back in the New Zealand health system. On my return I was successful in getting a job as an RN in the Ambulatory Team at Wellington Hospital and then as a nurse educator just over a year later. I am on the senior level of the PDRP.

Career path: Clinical nurse coordinator LEAHA NORTH knew when she was a girl playing hospital with her dolls that she wanted to work with children. After returning from a lengthy OE mostly spent paediatric nursing, she is also keen to work on reducing Māori health inequalities. NAME: Leaha North (Ngāti Raukawa descent) JOB TITLE: Clinical nurse coordinator, Capital and Coast District Health Board

Nursing and other qualifications:

»» Diploma of Nursing 1994 (Whitireia Community Polytechnic) »» Bachelor of Nursing 1996 (Whitireia Community Polytechnic) »» Certificate in Te Ara Reo Māori Level 2, 2012 (Te Wānanga o Aotearoa) »» Te Tohu Whakawaiora, Certificate in Healthcare Capability 2015 (a regional DHB initiative) »» Ngā Manukura o Āpōpō Clinical Leaders Programme (for Māori nurses and midwives held at Tapu Te Ranga Marae, Wellington).

Postgraduate study journey

I had returned home to New Zealand in 2010 after 13 years living and working in London and Europe and struggled through my first paper towards my Master of Nursing. I chose to put this on hold and reconnect with my whānau, culture and community, including several courses. I am now ready to complete my master’s but am going to start a Master of Professional Practice in 2017 through Whitireia Community Polytechnic. Briefly describe your initial five years as an RN. From the start of my career, working with children and whānau was my passion. I worked in an aged care facility as a student nurse and as an RN for three months before securing a job based in Porirua as a public health nurse in schools. After 15 months I moved to work at Starship Children’s Hospital. This was a requirement to become a registered sick children’s nurse (RSCN) in London and I was ready to travel the world. I arrived in London in 1997 and did agency nursing while on a two-year working holiday visa. I returned home to New Zealand in 2000 but I longed to return to London and was sponsored by Chelsea and Westminster Hospital to return to work in general paediatrics. Two years later I obtained my first senior nurse role as paediatric pre-anaesthetic nurse specialist. Did you have a career plan on becoming an RN? And how did those first five years influence your subsequent career? My career plan was to work with children and whānau, travel the world and have a good time. The first five years reinforced my passion,

energy and motivation to work with children. The challenge I faced was there were so many specialities and hospitals for children in London, I wanted to do everything! I worked in the public and private sector in all paediatric specialities as an agency nurse. Any permanent jobs were always in generalist areas such as medical, surgical and emergency departments as I did not want to limit my job options when I came home. My strengths as a nurse were a strong work ethic and connecting easily with the people I worked with, possibly due to the culturally diverse and transient life we often shared. What led you into your current field or speciality? I knew from a young age I wanted to work with children; as a child I would line all my dolls up in the hallway and play hospitals for hours. I left school to do a nanny course at Whitireia but the course facilitator sat me down one day and told me I’d be a great nurse, so with her support I secured a place in the 1991 intake. The nursing team that mentored me as a newly graduated public health nurse and the community of Porirua I served helped to give me a solid foundation and the motivation to provide evidence-based, highstandard nursing care right from the start. I continue to strive to reduce inequalities in accessing healthcare services for Māori and advocating for increased Māori workforce development, believing it is not about Māori fitting in with current policies and processes but what we can do to change these policies and processes to meet the needs of Māori. Having completed the Māori nurse leadership programme, I am now part of a wider leadership network and believe that together we can make a difference to addressing inequalities and disparities. What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current goals? I believe that ongoing professional development is essential and you should embrace every course, conference and networking opportunity that comes

What personal characteristics do you believe are particularly important for nurses working in your role? »» Good clear communication skills. »» Get to know all kinds of people – whether they are directly related to your role or not. »» Demonstrate advanced clinical competence and coordination of complex patient care. »» Be confident, always be thinking forward, but stay focused. »» Be kind to yourself and your colleagues. »» Be yourself. What career advice would you give to nurses seeking a similar role to yours? »» Continue to develop professionally, whether it is undergraduate or postgraduate study. »» Look for quality initiatives within your workplace and act on improving patient care. »» Gather evidence and information, look at showcasing your work, presenting at conferences or making a poster/resource for your clinical area. »» Believe in yourself and seek opportunities out of your specialist area. »» Get involved in local and national working groups. »» Seek out nurturing people, work together as a team. »» Share with your colleagues and whānau about why you went into nursing. »» And reflect on your career – it reignites the passion when you have had a hard day. Describe your current role and responsibilities. The role I am currently in is coordinating people, systems and resources for elective surgical services to ensure appropriate and safe care is delivered efficiently and effectively. The specialities covered are general surgery, standby patients, urology and child health. I work Monday to Friday full-time and my hours are flexible to accommodate the service needs, plus I am close to my daughter’s school and our home, which are both just up the road. Responsibilities include working in partnership with clinical staff and management to ensure patients are well prepared for elective surgery interventions in a safe, timely and efficient manner. The role requires a sound knowledge of standards, processes and policies and advanced clinical practice and expertise, including outsourcing patients to external hospitals and working within a multidisciplinary team.  |  Nursing Review series 2016    9

FOCUS  n  Learning & Leading

The chance to experience the adrenaline and environment of a normal day of an emergency nurse during my new graduate year sparked my interest in emergency nursing into a passion and gave me the drive to follow my dream. Career path: Charge nurse manager Graduating in a tight job market saw JO PRIOR cross the Tasman for her first job. That job sparked an interest in emergency nursing into a passion that has seen her working within or near an ED for most of her career. NAME: Jo Prior JOB TITLE: Charge nurse manager, Assessment and Diagnostic Unit, North Shore Hospital, Waitemata DHB

Nursing qualifications:

»» Diploma of Nursing 1991 (Auckland Institute of Technology – now AUT) »» Health Assessment papers 2001 (Christchurch Polytechnic Institute of Technology – now Ara Institute of Canterbury) »» Master of Health Science still in progress (Auckland University of Technology) Briefly describe your initial five years as an RN. New graduate nurse positions in New Zealand were limited when I gained my nursing registration in 1991. Due to this I applied across the Tasman and gained a new graduate post at the Princess Alexandra Hospital in South Brisbane. New graduates at Princess Alexander rotated between three types of specialties to gain experience, including four months on a general medical ward and four months on a general surgical ward. This opportunity allowed me to gain valuable experience, skills and knowledge. For the last four months I chose to move to the emergency department (ED) and that was the commencement of my 20-year journey in ED throughout Australia and New Zealand. After completing my new graduate year I was fortunate enough to be offered a permanent position and spent a further four years consolidating my knowledge and skills in trauma with emergency nursing. After spending five years at the Princess Alexandra I wanted to develop my skills and moved to Darwin, Northern Territory, to work at the Royal Darwin Hospital in the ED for a further five years. Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career? My initial career plan was focused on getting a job after I qualified. The lucky opportunity to move to Australia and gain the post at Princess Alexandra

Jo Prior

gave me the opportunity to experience different nursing specialties. I always had an underlying dream to do emergency nursing. The chance to experience the adrenaline and environment of a normal day of an emergency nurse during my new graduate year sparked my interest in emergency nursing into a passion and gave me the drive to follow my dream. What led you into your current field or specialty? After a further five years in Royal Darwin Hospital I moved back to New Zealand to be closer to family and worked at the ED at the North Shore Hospital for 10 years. During this time I was lucky enough to progress through the senior ranks and worked as a clinical charge nurse for five of those years. This experience gave me my first taste of leadership and management and started my current journey of management and has led me to where I am today. I progressed to team leader at a large rural GP service north of Auckland and then as clinical learning leader at AUT for the undergraduate nursing degree before settling in my current role. Throughout my career three mentors assisted with my career path and without their inspiration, direction and guidance I would not be where I am today. What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role? My personal stepping stones for progression were the ability to lead a team in the emergency department. This progressed with relevant courses, e.g. preceptorship, leadership and

10    Nursing Review series 2016  |

management courses, and the ability to develop leadership experience by hands-on experience, mentoring, clinical supervision and reflection. What personal characteristics do you believe are particularly important for nurses working in your role? The ability to lead a team must coincide with individual ownership and partnership for all team members. Communication, meeting team expectations and being a visible leader who both listens to staff and is approachable is imperative. Keeping staff fully informed and included with the change process allows a joint ownership and partnership for moving forward to achieve best optimum results. What career advice would you give to nurses seeking a similar role to yours? Set your goals, get a mentor and start to be the leader you want to be. Describe your current role and responsibilities. My current role is charge nurse manager in the Assessment and Diagnostic Unit at North Shore Hospital. This unit is a 50-bed unit, which works alongside the emergency department and is an acute, fast-paced environment with a high turnover of patients. My responsibilities include managing: »» the quality of nursing care to meet patient needs »» the culture to deliver excellent customer service for positive team relationships »» the environment, equipment and systems that delivery cost effective service of the highest standard »» professional development, applying learning to enhance clinical leadership and patient outcomes. Continued on page 12 >>

This article is sponsored by Southern Institute of Technology

Postgraduate study

exceeding expectations Postgraduate study couldn’t have been further from Annie Smith’s mind. She had two small children and simply didn’t have the time. Colleague and friend Shelley McDonald was keen to complete the Postgraduate Diploma in Health Science offered at the Southern Institute of Technology (SIT) and Annie reluctantly agreed to join her. “It was Shelley who was looking for someone to do it with and convinced me it would be okay,” says Annie. “I have been nursing for 20 years with Medical/ Surgical experience and for over half of those years I have been in Paediatrics. “I had never intended to do any postgrad study.”

Initially Annie says the programme was ‘mind blowing’ and not in a good way, but with the support of study buddy Shelley she soon saw the benefits. “Each paper exceeded my expectations,” she says. “The support you receive from the lecturers was fantastic. “They were always willing to assist in any way they could.” Annie says it took her two papers to realise that the programme offered her a fantastic opportunity to both learn and succeed. “Not only have I had personal growth, postgraduate study has also given me opportunities for job development. “I have become the Clinical Nurse Specialist in Respiratory for Paediatrics, which wouldn’t have been possible without postgrad study. Annie has now gone from never even thinking of completing further study to this year completing her Masters. Colleague Shelley on the other hand was looking for a new challenge after working in Paediatrics for six years. “I found a position that I wanted to apply

for, unfortunately I couldn’t as one of the requirements was post grad study,” she says. It was then that Shelley realised, in order to progress to a more senior and specialist role, postgraduate study would be necessary. And so her journey towards the Postgraduate Diploma in Health Science with SIT began. “I never dreamt I would have graduated with a Diploma,” Shelley says. “I was only going to do one paper. She says the knowledge gained was practical and could be related into everyday practice which made it enjoyable. “It adds another dimension to your practice and enhances your critical thinking. Since starting postgraduate study Shelley has taken up a position within the acute assessment unit and is now a nurse educator. She says she enjoys both positions and they are definitely challenging. Shelley has continued to study and will soon be graduating with her Masters. “For anyone thinking about continuing study, I would strongly encourage you to do so,” she says. “You never know the opportunities it can open up.”

Postgraduate Diploma/ Certificate in Health Science SIT’s Postgraduate Diploma/Certificate in Health Science is Nursing Council approved and can lead onto further study offered by other tertiary providers at masters level. These programmes are eligible for the Zero Fees Scheme and can therefore significantly lower the cost of the programme in comparison to other institutes. Semester One: HS801 Advanced Clinical Assessment and Diagnostic Reasoning HS802 Advanced Pathophysiology HS816 Advancing Practice in Primary Care Semester Two: HS801 Advanced Clinical Assessment and Diagnostic Reasoning HS809 Applied Pharmacology HS810 Advanced Practice to Support Older Persons’ Wellbeing HS812 Advancing Specialist Practice HS815 Advanced Clinical Emergency Care

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FOCUS  n  Learning & Leading

My very early days in caring began at the age of three. Mum tells me I was always worrying when someone hurt themselves and I was forever playing the family nurse.

Career path: Senior nursing lecturer The chance to teach nursing students to become culturally competent healthcare professionals inspired DONNA FOXALL to swap working in primary healthcare for a career in nurse education. Name: Donna Foxall (Tainui/Taranaki) Job title: Senior nursing lecturer/kaitiaki o nga tauira Māori tauira at Eastern Institute of Technology (EIT)/Te Aho a Māui

Nursing and other qualifications:

»» Enrolled Nurse 1991 (Hawke’s Bay Hospital) »» Diploma of Nursing 1995 (Hawke’s Bay Polytechnic – now EIT) »» Bachelor of Nursing 2000 (Hawke’s Bay Polytechnic – now EIT) »» Diploma of Adult Education 2009 (EIT) »» Master of Nursing 2015 (EIT)

Other roles:

I am an executive member and the co-chair of Nursing Education in Tertiary Sector (NETS), the national chair of Wharangi Ruamano (Māori Nurse Educators), a member of Ngā Manukura o Āpōpō Leadership Group, and kaitiaki for Māori nursing student support. Briefly describe your initial five years as an RN. My journey into nursing began at Hawke’s Bay Hospital in the 1990s, where I trained as an enrolled nurse before doing my RN training at Hawke’s Bay Polytechnic (now EIT) in the mid1990s. I worked in mental health and considered forensic mental health nursing, but instead moved into primary health care, where I worked as an extension of general practice into the community as a vaccinator and specialist respiratory nurse for the local independent practitioners association before pursuing my career in education. Did you have a career plan (vague or definite) on becoming an RN? My very early days in caring began at the age of three. Mum tells me I was always worrying when someone hurt themselves and I was forever playing the family nurse. My career in health began as an enrolled nursing student at the age of 24. I was the young mum of an eight-year-old child at the time and balancing my whānau and cultural responsibilities, plus my studies and shift work, was challenging.

Donna Foxall

With great support from my teachers I was able to complete assessments and clinical practice with confidence and graduate. This experience helped to make me the teacher and beacon of change that I am today. What led you into your current field or speciality? Working in the community highlighted to me the multiple healthcare inequalities of the time. So when the opportunity to become a teacher arose I was inspired to teach nursing students to become culturally competent healthcare professionals. Being able to integrate Māori world views and kawa whakaruruhau (cultural safety) into nursing education and into clinical nursing practice continues to be one of my objectives. I am passionate about sharing and promoting te ao Māori (Māori world views) in order to help create a better awareness and acceptance of other cultures in our diverse society. My inspiration came from leaders such as the late Akenehi Hei, whaea Putiputi O’Brien and Irihapeti Ramsden. Moe mai e kuia ma moe mai moe mai ra. Rest in peace. What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role? Life skills and feedback from families during my primary healthcare nursing days influenced me when I moved into tertiary education. On entering the tertiary sector I also had to complete my Diploma in Adult Education and Master of Nursing as professional development. What personal characteristics do you believe are particularly important for nurses working in your role? Teachers have to exhibit a range of skills. Working in a team environment and demonstrating

12    Nursing Review series 2016  |

responsiveness to student needs; role modelling integrity, innovation, ambition, reliability, initiative, a positive attitude, assertiveness, leadership, enthusiasm, and a good dose of humour are vital in this role. These are all characteristics of a good nurse. A passion to share knowledge and facilitate learning is fundamental. Effective communication skills with a diverse range of people is essential, as well as a sound understanding of nursing education in the tertiary sector. Strong administration, organisation and IT skills are equally important. What career advice would you give to nurses seeking a similar role to yours? »» Have a passion to improve the health and wellbeing of Māori – it’s crucial. »» Understand disparities for Māori. »» Support your role by understanding te ao Māori (Māori world views) and tikanga (knowledge of Māori practices and protocols). »» Create opportunities to meet the head of school and Wharangi Ruamano member at your local nursing school for teaching opportunities in tertiary teaching. »» Complement this opportunity by utilising your clinical expertise and knowledge as a guest speaker to undergraduate or postgraduate students. Describe your current role and responsibilities. The roles and responsibilities as kaitiaki (Māori nursing student support person) and senior nursing lecturer also include providing pastoral, cultural, academic and clinical support. Being responsive to student needs is a priority in my role, alongside supporting my work colleagues within the School of Nursing.

FOCUS  n  Learning & Leading

Being humble is also important. I care for people who have faced adversity and survived.

including collecting data in Perth for the state’s trauma registry. As a result of my role I now belong to several trauma professional groups, including the Major Trauma National Clinical Network, the National Trauma Nurse Network and the Australasian Trauma Network. What personal characteristics do you believe are particularly important for nurses working in your role? You need to be able to work autonomously and utilise your time well. Since I started my CNS role has expanded exponentially and so it is critical to have good time management skills. Being humble is also important. I care for people who have faced adversity and survived. They are often left with the impacts of their traumatic event (be they physical or emotional scars) and recognising this, and what they have gone through, is incredibly important. Humility is also important when communicating with my peers as this isn’t a job I can do alone. Good patient advocacy is an important skill, not just for the patient currently in my care, but for future patients, which means having difficult conversations with peers in order to make changes and keep up with international guidelines.

Katrina O’Leary

Career path: Clinical nurse specialist (trauma) “Get a master’s degree” is the single most important piece of career advice, believes clinical nurse specialist KATRINA O’LEARY, who discovered her love of study on arriving in New Zealand and is now contemplating her PhD. NAME: Katrina O’Leary JOB TITLE: Clinical nurse specialist, Trauma Service, Bay of Plenty District Health Board

Nursing qualifications:

»» Diploma of Health Science (Nursing) 1990 (La Trobe University, Northern Campus, Bendigo, Australia) »» Bachelor of Nursing 1996 (Edith Cowan University, Perth, Australia) »» Postgraduate Diploma in Nursing 2011 (Wintec) Master of Nursing (Distinction) 2014 (Wintec Briefly describe your initial five years as an RN. Initially I worked in a regional hospital in Victoria, Australia, on medical/surgical/paediatric/ emergency department (ED) wards, which was a fantastic experience. In 1993 I headed off to the Kimberley region of Western Australia to do remote area nursing for six months. On my return I did a critical care nursing course, worked in ED for a year, then left for Perth to pursue a career in intensive care for the next 10 years.

Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career? I always wanted to be a nurse, but I don’t really know why. If I had my time again, I’d consider being the costume designer for a major ballet company. That’s not to say I wouldn’t still choose to be a nurse, but reflects the opportunities now available for women. My first five years’ nursing didn’t really shape my career. I went to the Kimberley because a friend told me it was paradise (I shouldn’t have listened!) and I only did the critical care course because all my closest friends were applying. When I moved to New Zealand I was introduced to the postgrad study culture here, which was a surprise, but one I welcomed and relished. I’m planning on starting a PhD in the near future. Although most colleagues think this is a form of madness and torture, I see it as career planning. How long can I work full-time in nursing and still be effective? I don’t know. Therefore my PhD will fulfil my research passion, and reduce my hours – or at least allow me to put in the hours I want to put in – not what a contract tells me I have to. What led you into your current field or specialty? After moving to New Zealand I found I’d had enough of intensive care and was excited at the thought of returning to ED. While working in ED I was interested in the trauma patients and decided to research a few trauma-related topics through my postgraduate diploma. Then a position opened up for a clinical nurse specialist (CNS) in the Trauma Service. What qualifications, skills or stepping-stone jobs do you think were particularly helpful and/ or necessary in reaching your current role? There is no specific qualification for becoming a CNS for trauma. The critical factor in my gaining this position was my experience in critical care areas,

What career advice would you give to nurses seeking a similar role to yours? I believe the single most important advice is to undertake a Master of Nursing. This enables you to reflect on who you are as a nurse and what you need to change in order to improve. I had been nursing for many years when I started my master’s and I didn’t realise the personal growth it would bring. An interest in research is also essential. I collect data on 1,500 patients per year and can use the information gained from this data to contribute towards some exceptional research papers in injury prevention. Communication is absolutely critical to the success of my role and is essential for patient care delivery. Describe your current responsibilities. My CNS role is multi-faceted. One of the key areas is case management of the severely injured. My case management involves, but is not limited to, a needs assessment, a review of radiological studies (to pick up on injuries missed because of distracting injuries), liaison with the patient and their family, ensuring appropriate referrals are made and early discharge planning. Data collection is a large component and is undertaken on most trauma patients admitted to hospital. This data contributes to research, including my own, published in national and international journals. I contribute to community-based injury prevention initiatives through outreach programme presentations and I develop traumaspecific protocols and policies for the DHB to ensure care is based on current evidence-based practices. I participate in local and regional trauma initiatives and in national trauma strategies as I am currently part of a national trauma committee. Another part of my role is education, mostly at a patient’s bedside or through informal dialogue with my colleagues, but several times a year I present at local study days, regional meetings and at conferences across Australasia.  |  Nursing Review series 2016    13

FOCUS  n  Learning & Leading

Professional development (te ao marama), we all have a responsibility to continue learning as nursing practice continually changes. Marianne Te Tau

»» Self-determination (tino rangatiratanga), to work in a patient/whānau-centered, respectful and appropriate manner with all patients coming into this (foreign) environment. This concept also extends to tino rangatiratanga as a nurse and to value others in the multidisciplinary team. What led you into your current field or specialty? I saw an opportunity to improve the patient’s elective surgery experience. I wanted to provide an opportunity to optimise patient health and ensure patients felt informed prior to elective surgery. What skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role? »» Knowledge and understanding of pre and post-op care of the surgical patient, including discharge planning. Preoperative assessment is a valuable time to walk through the elective surgical experience, while ensuring patients feel informed and supported during a potentially vulnerable time. »» The follow-up coordinator role was an autonomous position that required a critical lens to review patient progress and promote optimal post-op recovery. It was also the avenue to oversee complex, long wait cases that needed intensive management. What personal characteristics do you believe are particularly important for nurses working in your role? A positive attitude, great communication skills, flexibility, patience, being proactive, organised and always looking to improve.

Career path: Clinical nurse specialist (APAC) MARIANNE TE TAU’s career to date is being guided by the philosophy of reflective practice, pursuing professional development and being patient/whānau-centred. NAME: Marianne Te Tau (no Tainui me Te Arawa au) JOB TITLE: Clinical nurse specialist, Anaesthetic Preoperative Assessment Clinic (APAC), Dunedin Public Hospital, Southern DHB

Nursing and other qualifications/awards:

»» Bachelor of Nursing 2004 (Otago Polytechnic) »» Bachelor of Nursing (first class honours) (while completing new graduate programme at Dunedin Hospital) »» Toi Paematua Raranga (Diploma in Traditional Māori Weaving) 2009 (Te Wānanga o Aotearoa) »» Aoraki Bound 2012 (Kai Tahu and Outward Bound course) »» Level 4 Professional Development and Recognition (PDRP) portfolio 2013 (Southern DHB) »» Master of Nursing (with Merit) 2014 (Massey University, Albany)

»» Ngā Manukura o Āpōpō Leadership Course 2015 (marae-based course for Māori nurses and midwives at Tuahiwi Marae, Christchurch) »» Southern DHB Nursing Excellence Award 2016 (plus recipient of Dunedin North Rotary scholarship for professional development) Briefly describe your initial five years as an RN. I started nursing in Older Person’s Health (medical/ rehabilitation/psychiatric). I believe Older Person’s Health is a great platform to embed the fundamental skills taught in the nursing degree. I stayed on for six months after completing the new graduate programme for this reason, before transferring to general surgery. I worked in a number of areas within general surgery, including the surgical ward, surgical pre-admission, day of surgery admission, and as the follow-up coordinator. Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career? Not really, a wise nurse once said we do not know the jobs we will be doing in the future as they are yet to be created. When I graduated with my BN degree, my philosophy of nursing practice had three parts under the kaupapa of cultural safety (kawa whakaruruhau). These aspirations still resonate with me today: »» Reflective practice (i ngā wā ō mua), we take our experiences with us into the future, so we must take time to reflect. »» Professional development (te ao marama), we all have a responsibility to continue learning as nursing practice continually changes.

14    Nursing Review series 2016  |

What career advice would you give to nurses seeking a similar role to yours? »» Know yourself and work to your strengths. »» Have good support and mentors. »» Be self-caring and have a good work/personal life balance. Describe your current role and responsibilities. I take care of the operational aspects of APAC at Dunedin Hospital, including: »» running APAC at Dunedin Hospital, including day-to-day rostering and organising leave cover »» being a resource person by providing leadership, mentoring, training and support to staff in APAC »» working alongside a team of registered nurses, a healthcare assistant, and the consultants and registrars rostered to clinic, with accountability to the APAC manager »» providing presentations about APAC »» problem-solving any operational issues and ensuring APAC processes are robust »» working closely and collaboratively with the consultant clinical leads to manage quality issues »» working closely with the surgical specialties »» maintaining the APAC electronic database and initiating quality improvements »» ensuring collaboration between Dunedin and Southland sites via the Anaesthetic Preoperative Assessment Governance Group. »» I am a member of the Perioperative Nurses College and the Gerontology Section of NZNO.

NursingReview Professional Development ReaDing, Reflection, anD aPPlication in Reality

By David & Bernadette Solomon

Reading this article and undertaking the learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council competencies 1.4, 1.5, 2.1, 2.8, 3.1, 3.2 & 3.3.

learning outcomes

Reading and reflecting on this article will enable you to:

‘Legal highs’ and mental health:

raising nurse awareness The use of novel psychoactive substances (NPS) or ‘legal highs’ is an emerging issue worldwide. There is rising concern around the risks of NPS and the detrimental effects on individuals’ mental health. How can you as a nurse identify and manage risks around NPS in your everyday nursing practice? Introduction Novel psychoactive substances (NPS) or the so-called ‘legal highs’ are emerging rapidly worldwide, as are concerns about NPS abuse. NPS have been a growing trend over the past decade for a number of reasons, including difficulties detecting them in routine urine drug screens, legal loopholes, easy access through the internet and low cost1. Labelling these drugs as ‘herbal highs’ or ‘legal highs’ is misleading as there is nothing natural about these synthetic and untested drugs and also currently none of them are legal in New Zealand2. But there has been an explosion in numbers of NPS worldwide with the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) reporting this year that it is now monitoring 560 NPS and 98 new substances that were reported for the first in 2015 and 101 in 20143. There are several typical categories of NPS drugs including synthetic cathinones (e.g. mephedrone and MDPV), plant-based NPS (e.g. khat and salvia divinorum), synthetic cannabinoids (e.g ‘Spice’, ‘Kronic’ and ‘K2’), and ‘party’ drugs like benzylpiperazine (BZP). Synthetic drugs can be taken through insufflation (snorting), oral ingestion and rectal insertion, as well as being taken intravenously, intramuscularly and subcutaneously. These drugs are considered to have an effect on mental health wellbeing. Identified mental

health symptoms that can result from NPS use are low mood, confusion, and anxiety1. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)4 identified synthetic cannabinoids as prominent in affecting mood and perception and that intoxications can cause agitation, tachycardia, and arterial hypertension. The centre says that synthetic cannabinoids are 100 times more powerful than traditional strains of cannabis4. The EMCDDA also identified synthetic cathinones as hallucinogenic stimulants with cardiovascular and psychiatric side effects. The number of deaths involving NPS increased by 15 per cent in 2013 in the United Kingdom, with 60 deaths, up from 52 deaths in 20125. New Zealand attempted temporary bans on different NPS before passing the Psychoactive Substances Act in 2013, which puts the responsibility on NPS producers or importers to prove they are low risk6. At present no NPS products are legally available for sale in New Zealand2, but the the ingredients for making illicit drugs are still available for purchase on untraceable internet sites so access to NPS continues. Detection of NPS use can be difficult as adult users – who usually present with agitation, cardiovascular and psychiatric symptoms – can often pass urine drug screening due to the lack of detectable metabolites. To further complicate matters, the molecular makeup

» increase your knowledge of novel psychoactive substances (NPS) and how they affect mental health » identify potential physical health and mental health risks resulting from NPS use for clients in your area of nursing » increase your understanding of co-existing substance use and mental health problems and some approaches to managing clients that misuse substances like NPS.

of NPS drugs can be changed slightly to make detection through urine drug screening tests even more difficult7. It has been suggested that health professionals, for example, in emergency departments, primary health and mental health services, need to be made aware of the growing levels of NPS misuse so that it can be identified and treated accordingly7.

Examples of NPS and the risks they could pose to the people you nurse It is useful for nurses to have an understanding of the potential risks of NPS. Nurses also need to maintain a therapeutic relationship that is respectful of the individual’s choices, experiences and expertise11,12. This section looks at some of the NPS currently available.

Synthetic cathinones

Mephedrone is one of a group of synthetic cathinone drugs that are chemically similar to amphetamines. Another is methylenedioxypyrovalerone (MDPV). Synthetic cathinones can result in the stimulation of psychosis, neurological and other health complications. Mental health professional intervention is needed for people with mental health problems as a result of mephedrone misuse. Synthetic cathinones have been found to have similar effects to psychostimulatory drugs of misuse including cocaine, amphetamine and MDMA (ecstasy). Psychiatric symptoms as a result of mephedrone/cathinone misuse include aggression, agitation, anhedonia, anxiety, confusion, delusions, depression, dysphoria, irritability, loosening of association, mental fatigue, panic attacks, paranoia, perceptual distortion, psychosis, self-mutilation, suicidal

Professional Development thoughts/suicide and visual and auditory hallucinations. Addictive symptoms identified include tolerance, craving and withdrawal syndrome13.

’N-Bomb’ or NBOMe

The psychedelic drug commonly known as ‘N-Bomb’ (25I-NBOMe, 2C-I-NBOMe) is a powerful hallucinogen that has been prevalent in New Zealand since 201214. N-Bomb’s high potency increases risks of toxicity in small doses. Common routes of administration include sublingual, buccal, and nasal/ intranasal15. The hallucinogenic effects of N-Bombs mimic LSD and can last between six and 10 hours and include feelings of euphoria, mental and physical stimulation, a pleasant or positive change in consciousness and unusual body sensations. Risks include tachycardia, hypertension, pyrexia, agitation, hallucinations, seizures and death. There have been media reports in New Zealand of renal and cardiovascular complications following use and overseas there have been a number of N-Bomb-related deaths14.

Spice and other synthetic cannabinoids

The misuse of ‘Spice’ or synthetic cannabinoids is increasing among teenagers and adults. Spice has over 220 compounds in various different combinations or brands16. There is also a risk of Spice causing psychopathological disturbances, namely psychosis, causing what is known as “Spiceophrenia”. Spice can affect a person’s physical state and can trigger vomiting, seizures, tachycardia, mydriasis, hypertension, confusion and restlessness. Mental health symptoms include delusions, paranoia, disorganised thought and visual and auditory hallucinations. Fluctuating mood, anxiety, perception, thinking, memory, and attention is common. Agitation, panic, dysphoria, psychosis and bizarre behaviour are also common17.

Why may people who experience MH issues use NPS? There are various reasons for the prevalence of people with mental health problems abusing illicit substances like NPS. This includes the cheap availability of NPS, accessibility and peer pressure1. Also, according to Ponizovsky et al18, people with co-existing problems are more at risk of non-adherence to prescribed medication and therefore more prone to relapse, rehospitalisation, and illicit drug and alcohol use. One recent research study talks about mental health service users using illicit drugs to control their distressing symptoms, or to “relax” and to get “high”19. The findings of this empirical study suggest that substance use was related to controlling emotional states, anxiety, and depression. Alcohol was seen as less harmful than cannabis and other psychoactive compounds in the perception of the mentally ill substance user. Counteracting psychiatric medication side effects was also identified as a reason, alongside controlling psychotic states, i.e. managing auditory hallucinations by

smoking more cannabis. So nurses should be aware that some clients may ‘manage’ mental health symptoms with illicit drugs and alcohol. Mental health professionals use a range of patient-centred and focused risk assessments that have been formulated specifically for people with co-existing problems9,20. One harm reduction approach to tackling NPS or other substance misuse, that can be done in non-specialist addiction settings like primary health, is using a brief assessment tool to assess whether alcohol or drug problems are at the ‘social or harmless use’ end of the continuum or the ‘moderate to severe’. This helps identify the level of intervention needed with mild problems usually just needing a brief intervention to reduce use to safe levels,

while ‘moderate to severe’ problems require a comprehensive assessment and management plan9.

Co-existing problem approaches The New Zealand guidelines for the assessment and management of co-existing problems9 take a client-centred approach. The guidelines set out seven key principles, including screening all clients presenting in mental health and addiction services for CEP and, if positive, undertaking a comprehensive assessment that gives equal weight to both mental health and substance use problems. Also emphasised is safety, stabilisation, engaging with clients by developing a ‘trusting, empathetic and non-judgemental therapeutic

tiPS foR awaReneSS anD Detection of nPS uSe nPS drug

effects of drug

Stimulant ‘legal highs’

» Raised energy levels & euphoria

These act in similar ways to cocaine, ecstasy or amphetamines.

» Rapid thoughts

Examples include: khat, benzylpiperazine, Benzo Fury, party powder, mephedrone, TNT, legal ecstasy and legal speed.

» Confusion & anxiety

» Paranoia » Psychosis » Effect on the heart as well as the immune and nervous systems. The potential cause of tachycardia, bradycardia, high blood pressure, respiratory rate and pulse.

Sedative or downer ‘legal highs’

» Similarities to cannabis

These work and act in a similar way to benzodiazepines.

» Euphoria

They include: Spice, Kronic (and other synthetic cannabinoids), GHB, V8 (ex-Fast Lane – legal coke), Mello Man (opium effect), Space Trips (LSD substitute), Hi-Octane (energy pills), TNT (speed), Big Daddy (ecstasy) and Sex Intense pills (sex party pills).

» Reduced disinhibition

» Sedation » Confusion, panic and dissociative effects. Can cause unconsciousness, coma and death, particularly when mixed with alcohol and/or other downer drugs. » Anxiety is common in people misusing downers, and severe withdrawal syndrome may develop in regular or heavy drug users.

Psychedelic or hallucinogenic ‘legal highs’

» Feelings of euphoria, warmth and dissociation

These have effects similar to those of magic mushrooms and LSD.

» Hallucinations, some leading to ‘bad trips’

Examples include: ketamine, N-bomb, 3-MeO-PCP, Space Trips, Bubble Bud, Druids Fantasy, Space Cadets and Salvia divinorum.

» Dissociative effects are common and users sometimes have an ‘out of body’ experience.

» Confusion, anxiety and panic. Altered perceptions

Table reference: (Solomon et al 2014)1

co-exiSting PRoBlemS Mental health problems are widely associated with substance misuse, including the use of legal highs. There are a range of terms used to describe this combination of problems, including dual diagnosis, but the term ‘co-existing substance use and mental health problems’, or co-existing problems (CEP) for short, is used in New Zealand with ‘co-existing’ chosen as it implies interaction more than ‘co-occurring’8. CEP are highly prevalent in therapeutic settings in New Zealand with an estimated third to half of all tangata whaiora (service clients) in mental health settings likely to have current CEP and up to three-quarters of clients seeing addiction services9. People with severe CEP experience higher rates of institutionalisation, more failed treatment attempts, poverty, homelessness and risk of suicide8. It is estimated that 40 per cent of people with psychosis also have substance misuse problems. People with co-existing substance use and mental health disorders have higher rates of unmet needs and a higher rate of relapse and hospitalisation than those who primarily have psychosis10. It has been identified that some people with psychosis commonly misuse non-prescribed medication to deal with persisting psychiatric symptoms, which ultimately exacerbate psychiatric symptoms10.

‘legal highs’ and mental health: raising nurse awareness relationship’, taking cultural needs and general wellbeing into consideration; and that CEP management should include strategies to enhance motivation, deliver interventions appropriate to the nature and severity of the problems, and provide integrated care9. Barriers to CEP treatment can be prevalent across health settings due to miscommunication, lack of awareness and inappropriate referrals between mental health, substance misuse and community services8. There is a need for co-ordination between services, effective policies, protocols and effective clinical leadership. A clear referral pathway to addiction and mental health services is also needed8.

Psychosocial interventions helpful for clients who use NPS Psychosocial interventions can be beneficial in the treatment of substance use problems including NPS. The traditional approach for treating drug problems includes medication approaches and psychosocial (psychology-based) interventions. Psychosocial interventions include treatments such as cognitive behavioural therapy (CBT)

RecommenDeD fuRtheR ReSouRceS new Zealand Drug foundation: Aimed at preventing and reducing harm from drug use and includes information on NPS used in New Zealand Psychoactive Substances Regulatory authority: Information on New Zealand’s ‘legal highs’ regulation system nePtune (Novel Psychoactive Treatment UK Network): guidance on managing harm from NPS toxinz: National poisons information database nice (National Institute for Health and Care Excellence): UK site with pathway for psychosis with coexisting substance misuse fRanK: UK site offering ‘friendly, confidential drugs advice’


1. Solomon D, Grewal P, Taylor C, Solomon B (2014). Managing misuse of novel psychoactive substances. Nursing Times 110(22): 12-15. 2. Psychoactive Substances Regulatory Authority (2016) http://psychoactives. (accessed June 20 2016). 3. European Monitoring Centre for Drugs and Drug Addiction (2016) European Drug Report 2016: Trends and Developments. 4. European Monitoring Centre for Drugs and Drug Addiction (2013). European Drug Report 2013: Trends and Developments. 5. Office for National Statistics (2013) Deaths related to drug poisoning in England and Wales: 2013. 6. NZ Drug Foundation (2014) (accessed June 20 2016). 7. Bajaj J, Mullen D, Wylie S (2010) Dependence and psychosis with 4-methylmethcathinone (mephedrone) use. BMJ Case Reports 2010. 8. Ministry of Health (2010). Service delivery for people with co-existing mental health and addiction problems. Ministry of Health, Wellington. 9. Todd F (2010) Te Ariari o te Oranga: The assessment and management of people with co-existing mental health and substance use problems. Ministry of Health, Wellington. 10. Copello A, Walsh K et al (2013). A consultation-liaison service on integrated treatment: A program description Journal of Dual Diagnosis 9(2): 149-157.

that aims to modify cognitive processes and behaviour21 and can be used as an approach to enhance subjective wellbeing8. Motivational interviewing (MI) is a common psychosocial intervention aimed at enhancing motivation and readiness for treatment. Miller and Rollnick define motivational interviewing as a non-judgmental, non-confrontational and nonadversarial approach that enhances a person’s awareness of the problems caused and the consequences experienced as a result of their behaviour e.g. alcohol dependence22. Motivation – including strategies to enhance motivation like CEP-adapted motivational interviewing (MI) – is one of the seven key principles of CEP treatment in New Zealand9. New developments in MI include an increased emphasis on the client’s hopes and values and structured first interviews aimed at enhancing engagement in treatment9. Contingency management is another psychosocial technique that provides a system of incentives or reinforcement to encourage abstinence. Dutra et al23 suggest drug abstinence increased by using strategies such as food vouchers, money or other incentives for positive behaviour. Other emerging psychosocial approaches that the 2010 New Zealand guidelines say show promise include kaupapa Māori approaches, mindfulness, and acceptance and commitment therapy9.

Conclusion Mental health problems as a result of adults misusing novel psychoactive substances (NPS) are emerging around the world and in New Zealand. Despite law changes, NPS – and the ingredients to make illicit drugs – are available to purchase on hidden internet sites

that are untraceable to law enforcement worldwide. There is a push in New Zealand to address co-existing problems (CEP) of mental health and substance use with strategies and guidelines8,9 and an updated blueprint for mental health24. CEP is highly prevalent in New Zealand and NPS is a newly contributing factor. Therefore it is important that nurses have a knowledge and understanding of substance use and CEP issues in general, including the common effects and risks of NPS use. Collaboration and partnerships between mental health, addiction, primary care and other areas of nursing are essential to providing a safe and harm reduction approach to substance misuse. Monitoring, early detection, engagement with clients and using suitable interventions are very important in minimising harm from NPS and other substance use. These approaches are inherent to the addiction nursing framework 25, the mental health nursing standards of practice and the New Zealand College of Mental Health Nurses credentialing programme for primary care nurses26. At present the research on managing NPS misuse is limited and there is a need to identify interventions that health professionals agree can work in managing co-existing problems resulting from NPS misuse. Services also need to respond early to communication problems and interface issues between services that can create barriers for CEP clients receiving access to mental health and drug treatments. Poor mental health is disempowering for substance users and health professionals need to acknowledge personal experiences, empower recovery and improve the quality of life for people with mental health issues11,12.

About the authors:

David Solomon MSc, PG Cert HE, BSc (Hons), Fellow of Higher Education. Independent Prescriber; RMN. Senior Lecturer, Nurse, Faculty of Health, Social Care and Education, Essex, Anglia Ruskin University. Bernadette Solomon DHSc candidate, MSc (Applied Criminology), PG Cert HE, RMN. Professional Teaching Fellow, Faculty of Medical and Health Sciences: Mental Health and Addictions, the University of Auckland, New Zealand.

This article was peer reviewed by:

Daryle Deering RN PhD is a senior lecturer at the National Addiction Centre, the University of Otago. Louise Leonard RN NP BA (Psych) MNurs is a nurse practitioner working in alcohol and other drug addictions for Waikato District Health Board’s mental health and addiction services.

11. Barker P (2001). The Tidal Model: developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing 8: 233-240. 12. Barker P, Buchanan P (2011). Myth of mental health nursing and the challenge of recovery. International Journal of Mental Health Nursing 20: 337-344. 13. Advisory Council on the Misuse of Drugs (2010). ACMD report on the consideration of the cathinones. London. Available at 14. NZ Drug Foundation (2014). NBOMe (accessed June 22 2016) 15. Rose S, Poklis J, Poklis A (2013). A case of 25I-NBOMe (25-I) intoxication: a new potent 5-HT2A agonist designer drug. Clinical Toxicology 51: 174-177. 16. Schifano F, Corazza O, Deluca P, Davey P, Davey Z (2009). Psychoactive drug or mystical incense? Overview of the online available information on Spice products. Journal of Culture and Mental Health 2(2): 137-144. 17. Mustata C, Torrens M, Pardo R, Perez C et al (2009). The Psychonaut Web Mapping Group. Spice drugs: Cannabinoids as new designer drugs [Spanish]. Adicciones 21(3): 181-186. 18. Ponizovsky A et al (2015). Trends in dual diagnosis of severe mental illness and substance use disorders, 1996-2010, Israel. Drug and Alcohol Dependence 148.

19. Petterson H, Ruud H et al (2013). Empirical study: Walking the fine line: Self-reported reasons for substance use in persons with severe mental illness. Int J Qualitative Stud Health Well-being 8: 21968. 20. Matua Raki (2012). Co-existing problems (CEP) service checklist 21. Conrod P, Stewart S (2005). A critical look at dual-focused cognitive-behavioral treatments for comorbid substance use and psychiatric disorders: Strengths, limitations, and future directions. Journal of Cognitive Psychotherapy 19(3): 261-284. 22. Miller W, Rollnick S (2002). Motivational interviewing: Preparing people for change. Guilford Press, New York. 23. Dutra L et al (2008). A meta-analytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry 165(2): 179-187. 24. Mental Health Commission (2012). Improving mental health and wellbeing for all New Zealanders: A companion document to Blueprint II. Accessed at: 25. Drug and Alcohol Nurses of Australasia (2012). Addiction specialty nursing competency framework for New Zealand, Matua Raki, Wellington. 26. New Zealand College of Mental Health Nurses (2012). Standards of Practice for Mental Health Nursing in New Zealand Aotearoa 3rd Edition. Te Ao Māramatanga New Zealand College of Mental Health Nurses, Auckland.

Professional NursingReview Development

ReaDing, Reflection, anD aPPlication in Reality

Brought to you by

Reading the article and undertaking this ‘Legal highs’ and mental health learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council of New Zealand competencies 1.4, 1.5, 2.2, 2.5, 2.7, 2.8, 2.9, 3.1, 3.2, 3.3, 4.1, and 4.3. Discuss all your answers with a peer/s a

learning outcomes

Reading and reflecting on this article will enable you to:

» increase your knowledge of novel psychoactive substances (NPS) and how they affect mental health » identify potential physical health and mental health risks resulting from NPS use for clients in your area of nursing » increase your understanding of co-existing substance use and mental health problems and some approaches to managing clients that misuse substances like NPS.

Reading: identifying the risk factors associated with nPS

1 What are the potential physical health risks to your clients from using NPS?

2 What common mental health risks are associated with NPS misuse?


Reflecting: Critical reflection

1 What are your beliefs about co-existing problem (CEP) service users who misuse NPS (legal highs)?

2 How might your beliefs and values shape or influence how you care for those clients in your clinical area?


Reality: applying in reality

1 How could your practice area encourage awareness regarding the symptoms and effects of NPS misuse?

2 What other strategies could be useful to promote education in your practice area around NPS misuse?

Verification by a colleague of your completion of this activity Colleague name



Nursing council ID

Work address

Contact #




Not only do patient portals free up nurses’ time – they are also proving a big hit with patients. Wellington’s John Eade goes to the Karori Medical Centre and uses the portal for booking appointments and ordering repeat prescriptions, but finds it particularly useful for monitoring his blood glucose levels. “It’s a very tricky balancing act, monitoring blood sugar. “Every Tuesday I use the portal to send my previous week’s results to my GP. I can do that at a time that suits me – I’m not usually in bed before midnight so it might be 11pm when I send them in. “My GP can look at the results at a time that suits him and comment or ask questions about those results – usually along the lines of what did I eat on that particular day!” He says it works the other way too – when his GP receives John’s HbA1c results from the lab, he can copy them on to John, with his comments. Eighty-seven year-old Peter, from Christchurch, is such a supporter of patient portals he switched GPs in an attempt to access one. Peter had read about patient portals, given them some thought, and gone to the patient portals website to find out more. “At my age, it would be so much easier if I could get information through the portal. I wouldn’t have to travel to the doctor as much, and I could make appointments and renew prescriptions through it.” Peter’s wife died of cancer four years ago and he wishes they’d had access to a portal then. “We would have had more information and could have been more active in the management of her illness.” “Doing the best thing for my health is very important to me. I may be 87, but my oldest brother is 96! I’ve been in my house for 36 years and I want to stay here. Things like patient portals make that easier because you can do more without leaving home.” As more general practices offer a patient portal and patients hear from others how convenient they are, there is a growing expectation from patients that their GP will have a portal. Find out more by going to

Patient portals began to be introduced from early 2014, and uptake was initially slow but steady. In 2015, there was a noticeable increase in practices offering a portal and patients registered to use one. These increases have continued and there is a feeling we may be close to a ‘tipping point’. As at July 2016 around 36 percent of general practices offered a patient portal and about 173,000 patients were registered to use one. Practice nurses have been instrumental in this increase, both in terms of driving the introduction of portals in practices and encouraging patients to sign up.

Go to to find out which practices offer a patient portal.

Tips to increase patient portal registration • • • •

Set targets. For example, 20 percent of patients register each month. Promote it everywhere – your website, newsletter, TVs, posters, handouts. Make sure doctors and practice staff are your most enthusiastic portal proponents. When a patient needs to have bloods done, asks about repeat prescriptions, or books an appointment – sign them up to the portal so they can action these online. • Automatically register every new enrolment on the portal. • Have an iPad at reception and register patients there and then. • After a patient registers for the portal, encourage them to go home and use it straight away so they don’t forget how.

FOCUS  n  Learning & Leading

Starched cuffs to university caps:

one nursing leader’s journey

After nearly 50 years in nursing and 35 years in nursing education JUDY KILPATRICK is set to retire at the end of the year. The selfdeclared “happy chappie” talks to FIONA CASSIE about a lucky career spanning starched cuffs, life-threatening illness and major milestones for the nursing profession.


he young Judy Kilpatrick fancied herself as a lawyer … or maybe a history teacher. She was definitely university bound, she believed, but the December after leaving school she spontaneously popped into Christchurch Hospital and walked out having signed up to the January nursing intake. She’s still not totally sure what prompted her. Possibly the practical nature of the course or having some doubts about teaching, which the associate professor and head of the University of Auckland’s school of nursing now finds a little ironic, given her final career. But the result was in January 1968 she pinned on her “little starched cap” and put on her “little starched apron” and “little starched cuffs” over her blue longsleeved uniform, and began her training in the very proper Christchurch School of Nursing. “We looked ever so smart and crisp.” These were the days when you might be learning the theory of ENT (ear, nose and throat) while working in orthopaedics – “so nothing made a lot of sense really” – and when appendix patients stayed in so long they ended up being put on ward tea trolley duty. “You were paid a pittance, but you were kept warm, fed and watered by the nurses’ home; there was always companionship around and some of those friends are lifelong.” While she “really, really enjoyed” her apprenticeship-style training, she says in retrospect “it wasn’t right really”. “People were just thrown in and if you survived that was good … but there was a number in the class who did not.” For her final year of training Kilpatrick transferred to Auckland Hospital and soon realised she had changed not only islands but also hospital cultures. “Oh I arrived and they were wearing these white, flimsy little dresses – I thought they were the scruffiest things I’d ever seen,” she recalls with her ever-present laugh. She graduated in 1970 and her first staff nurse job was at Greenlane Hospital A&E (accident and emergency department), an “amazing place” with a great staff culture.

20    Nursing Review series 2016  |

During downtime on quiet shifts – Kilpatrick says you could have downtime back in 1970, unlike today’s “poor sods” – they used to get up to “some crazy, silly kids stuff”, like making balls out of plaster, grabbing some crutches and having an improvised hockey game out the back. Nursing in A&E was her favourite hands-on clinical job as she never knew what would happen next and “people constantly amazed me what they did to themselves”.

Teaching, study and career about-turns

But then that ‘thing’ she had about teaching nudged again. First she was called back to the central nursing school at Auckland Hospital to teach and then in 1977 headed south to Wellington to study at the New Zealand School of Advanced Nursing Studies (SANS). While she found the diploma of nursing curriculum a little “same old, same old” she says she learnt a lot about nursing as a profession during her study leave year that gave her time to reflect on what she wanted to do – which was to put teaching aside once again and go back to clinical nursing. (And despite ultimately opting to teach, Kilpatrick says having ongoing relationships with clinical nursing has always remained critical to her.) So she returned to Greenlane where she became a charge nurse under the “wonderful matron at the time – Margaret Taylor” who was “quite a stern woman” but ready to embrace new ideas like those Kilpatrick brought back from SANS. Kilpatrick went up the ranks and in her late 20s became the senior supervisor (like assistant matron) of Greenlane and was on the path to becoming a matron herself when around 1980 the latent teacher within was given another nudge. The nudge took the form of meeting Yvonne Shadbolt – who sadly died this year – the founder in 1975 of Auckland’s first polytechnic-based nursing diploma at the then Auckland Technical Institute (now Auckland University of Technology or AUT). Tertiary-led nurse training instead of the apprenticeship-style model appealed to Kilpatrick the

FOCUS  n  Learning & Leading

teacher and Kilpatrick the nurse. “So in 1981 I decided not to be a matron and went and joined Yvonne at ATI’s new North Shore campus.” Yvonne Shadbolt was to be Judy’s second great mentor – a sharp, ‘new world’ thinker who was at the cutting edge of nurse education. Kilpatrick set herself the ambitious task of progressively teaching each year of the three-year curriculum. It was an eye opener for the A&E nurseturned-lecturer who thought she knew all about shock, for example, until she had to teach it. And on some occasions her learning was just a few steps ahead of her students. The always would-be teacher says she loved her new job but remained anxious not to lose her own clinical skills. Living on a small farm near Paremoremo Prison she used to do some casual shifts at the maximum security facility. “Interestingly, prisoners who are bad, mad, a mixture of both, or just sad kids, really just want the same nursing as everybody else. I got on with them quite well.” Meanwhile her teaching career progressed and she became first associate head of school under her next nursing mentor, the very clever Margaret Horsburgh, then in 1991 became head of school herself.

Nursing Council, NPs and a professional shift

In 1996 Kilpatrick became chair of the Nursing Council of New Zealand at a time when nursing education was going through another surge of change. The council was reviewing post-registration education, which had yet to catch up with the shift to nursing being a degree-entry profession and the push for more advanced practice roles like nurse practitioners. “Nursing had so many certificates – you could do a course in anything and get a certificate that went in your bottom drawer.” Kilpatrick says that certificate might reflect you were an expert in your field but it had no academic clout or cred. She says the shift in the 1990s to first the undergraduate degree and then a clinical postgraduate framework offering postgraduate diplomas and master’s degrees, while frightening for some, was “amazing” as nursing finally let go of the apprenticeship model and truly became a profession. Being Nursing Council chair throughout the heady years and political shenanigans in Wellington leading up to the approval of the first nurse practitioner in late 2001 is one of the things she is most proud of in her career. Back up in Auckland, with her nursing education hat on, Kilpatrick was increasingly convinced that advanced nursing practice should be taught alongside medicine. “We needed to teach nurses right alongside ‘the docs’ so we could lift the expectations of nursing and have the doctors see what those expectations were.” These thoughts culminated in the late 1990s when Kilpatrick and Mia Carroll (nursing leader of what was shortly to become Auckland District Health Board) approached then University of Auckland medical faculty dean Professor Peter Gluckman about having a school of nursing alongside the medical school.

“No-one would get my job now with my credentials – no-one. But I did and I’m not apologetic about that. My job was to open the school of nursing and make it successful, which I did.” Kilpatrick says Gluckman saw the merits of their arguments and in 1999 she and Dr Margaret Horsburgh left AIT (which became a university itself the following year) to become founding directors of the University of Auckland’s school of nursing, which enrolled its first undergraduate and master’s students in the year 2000. More than 15 years on, Kilpatrick is looking to hand over the reins of a school with a capped undergraduate intake of 100 students a year, more than 20 students a year doing PhDs, and an academic staff building a very respectable research record. To top her final year in nurse education the first global ranking of university nursing schools saw Auckland ranked 32nd in the world – the highest global ranking of any school in the university’s medical and health sciences faculty and the sixth highest ranked department in the university overall. This more than meets Kilpatrick’s dream as school co-founder to see the school respected and endorses her belief that “nurses are clever and smart as well as still good at what they do best – nursing”. Establishing nursing in a medical-centric faculty has on occasion required some ‘robust discussions’, from which Kilpatrick has never shrunk. She thinks nursing should do more of that – “fronting up to talk to the people with influence and influencing them about why you matter”.

Life-threatening illness and luck

Kilpatrick has been skilful enough at articulating her vision for nursing education to have become the head of a globally ranked university school of nursing without having a PhD or master’s degree. “I was one of the lucky ones, love,” says Kilpatrick when asked how she managed it, then goes on to reveal a little more. “I was on the cusp, I had my undergrad degree (a BA in education from the University of Auckland) and I was starting my master’s when I had a brain haemorrhage.” She adds it was a subarachnoid haemorrhage and was a “bit of a life-threatening occasion”. It was early 1997, she was 49, head of AIT nursing school and the chair of the Nursing Council at the time. “It was thought I wasn’t going to make it and the whole family was around the bed…”

Judy Kilpatrick

The treatment and care she got from Auckland Hospital’s critical care department was “outstanding”. “The way those people fought for me … you are going to make me cry shortly … I guess that makes you think you’ve got to give something back.” In 1998 she was “stunned” to be awarded the Companion to the New Zealand Order of Merit (CNZM) for her services to nursing education and says, “That little trinket gives you the confidence to go on really.” It helped her to pursue her dream of a nursing school alongside the medical school. “No-one would get my job now with my credentials – no-one. But I did and I’m not apologetic about that. My job was to open the school of nursing and make it successful, which I did.”


“I think I’m one of those little unique apples,” sums up Kilpatrick, reflecting on what she has achieved in a world in which by most accounts she shouldn’t have succeeded. She adds it may have also helped being smart, being ready to take risks and being around at the right time with the right people to support her. Not to mention she may “also have a bit of a reputation for being a bit of a hard nose”. “I’m not going to apologise for that because we need more nurse leaders to stand up and work with the system but never accept the system. Be solution driven, treat people with respect and work at it to change their minds – even if it sometimes takes 15 years, like the efforts to gain backing for a dedicated NP training programme.” And at the end of the day, she says, never forget to laugh. “I never forget to laugh at myself first. Don’t sweat it too much … and have a gin,” she says, with a grin in her voice. Retirement will see her having more “me time” on her “gorgeous” lifestyle property and for her lovely partner, son and first grandchild. “I’m a pretty happy chappie overall.” So, any regrets about wandering into Christchurch Hospital all those years ago and coming out having signed up for nursing? “Best bloody thing I ever did.” N.B. This is an abridged version of the full article, which can be read in the online edition at  |  Nursing Review series 2016    21

FOCUS  n  Learning & Leading

Postgraduate study funding:

are we better off? Nursing demand for a share of the $13 million postgraduate study funding pool for nurses appears undiminished. National statistics on what qualifications and specialties that the money is spent on are not readily available, but from next year a new contract framework will be asking how the funding leads to Kiwis being better off. Nursing Review reports.


t’s nearly a decade since government funding for ongoing training for nurses was bundled together and refocused on nurses gaining postgraduate qualifications. It’s now coming up eight years since the last national statistics were published on what qualifications and in what specialties nurses were studying – and passing – using grants from the initially $12.5 million (now $12.9 million) postgraduate funding pool. It is also not clear how many of the 2,000-plus nurses whose study is subsidised each year work in the district health board, primary health care or residential aged care sectors. This information is gathered by the 20 district health boards that distribute the nursing funding on behalf of Health Workforce New Zealand (HWNZ), say Sue Hayward, head of the national Nursing Education Advisory Team (NEAT) and Kathy Holloway, chair of Nursing Education in the Tertiary Sector (NETS). But the pair say that while much of that national data was reported by the former Clinical Training Agency, this hasn’t been the case under HWNZ. HWNZ is currently working on providing more detailed statistics in response to a Nursing Review request but meanwhile, in line with government policy, HWNZ is moving to a new framework for evaluating the impact of spending on postgraduate training. Holloway, the new head of nursing at Victoria University, says perhaps the new results-based accountability (RBA) framework will include some of that statistical data. The Ministry of Health on its website describes RBA as “a simple, practical way” of using publicly available data and provider data to track the impact of a programme (or in this case, funding nurse postgraduate study) on the wellbeing of a population. Hayward, director of nursing for Waikato DHB, says nursing will be the first cab off the rank to have its funding evaluated using RBA and a working group of skilled nurses from across the country has been set up in partnership with HWNZ to assess what measures should be adopted. “It is something we have all put our hats on and thought, ‘What should we measure to show that having postgraduate education funded by

HWNZ has made a difference to the retention of nurses, the skill and knowledge base of nurses, the experience of patients and maybe even the outcomes of patient care?’,” says Hayward. Paul Watson, acting strategy and relationships manager for HWNZ, says the measures decided on will focus on answering the questions ‘How much did we do?’ and ‘How well did we do it?’, and ‘Is anyone better off?’ HWNZ plans to introduce the RBA reporting framework for the 2017 postgraduate funding contract. Watson says RBA is unlikely to affect the total funding for postgraduate nursing education but “may help direct the funding” to education in areas achieving the desired outcomes.

Nursing spends all of its thin slice of the pie

Despite national data not being released on how or where postgraduate funding is spent, nursing leaders report that they have been told they aren’t spending all of their allocated pot. “Professor Des Gorman [the HWNZ executive chair] keeps announcing that the postgraduate nursing fund has been underspent,” says College of Nurses executive director Professor Jenny Carryer. She says that bothers her seriously as she couldn’t find evidence either way and she consistently meets nurses in her postgraduate classes who are self-funding. Kathy Holloway says her impression is there’s no underspend, but “without the actual hard data it’s hard to either agree or disagree”. Likewise, Sue Hayward says she finds it “interesting” that she’s been told that nursing is not spending all its money if HWNZ is not able to share how the funding is actually spent. Hilary Graham-Smith, associate professional services manager for the New Zealand Nurses Organisation, says any underspend may also be being used as a “flawed argument” against nursing consistently calling for a fairer slice of the postgraduate funding pie. Hayward says DHBs experience strong demand for nurse postgraduate funding and underspend can only occur if HWNZ isn’t flexible in allowing funding ring-fenced for a nursing workforce with low demand to areas with over-demand. She says NEAT has been talking to HWNZ about the need for flexibility with funding to meet demand for

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expanded role training like the new postgraduate diploma for registered nurse prescribing available next year. Nursing Review asked HWNZ for clarification about underspending and was told that there was a “small underspend” of postgraduate nursing funding in 2014–15 but HWNZ encouraged DHBs to work regionally to ensure funding was fully utilised and this had resulted in no underspend of the $12.9 million allocated in the 2015–16 year. Funding for the 2016–17 year is yet to be announced but is anticipated to be similar to this year’s $12.9 million. HWNZ also confirmed that there will be additional funding once again next year for nurse practitioner training following this year’s $846,000 allocated for 20 places in the country’s first dedicated NP training scheme. See more in the online story at: news-feed/2016/np-training-scheme-gets-fundingfor-another-year. HWNZ postgraduate funding is available to registered nurses working for a governmentfunded health service such as a district health board, rest home or primary health care provider. To find out more about funding priorities and eligibility, nurses can contact their local DHB’s postgraduate nursing education coordinator. HWNZ-funded postgraduate nurse study statistics 2011 1,429 training units* 2012 1,442 2013 1,480 2014 2,282 nurses funded (1,524 training units) 2015 2,354 nurses funded (1,544 training units) *A training unit is the equivalent of a two-paper PGCert or one year of a PGDip or master’s degree programme (with or without clinical mentoring). The cost of a unit can vary from $7,374 per annum to more than $28,000 per annum.

FOCUS  n  Learning & Leading

Nursing education:

freeing up nursing to make a difference Nursing Review looks back with recently retired SUSAN JACOBS on three decades of nurse education change.

Susan Jacobs


merican politics of the 1980s saw Susan Jacobs looking for a “saner” place to raise her family. She and her husband Cap started thinking down-under and took their blended family to New Zealand for a holiday when, serendipitously, the then Hawke’s Bay Community College was seeking an associate head of the nursing school. The result was in 1986 Susan began a threedecade career in Hawke’s Bay nursing education that saw her become Dr Jacobs and head of school and ended with her retirement in May as EIT’s executive dean of education, humanities and health science. Jacobs, a nurse who had practised for 11 years in the US before teaching nursing at Oregon’s Portland Community College, says on first arriving

she found New Zealand nursing practice “still incredibly hierarchical, very military in its structure and behaviour”. “But it is so much more innovative now and, while there are still constraints on some nurses being able to practice to their full capacity, I think nurses have been freed up to make a much greater contribution to health than certainly they did in the 1980s.”

Career highlights

Looking back on her nursing education career, she says there were several things that stood out for her as hugely exciting and great privileges. One was being nominated to the Nursing Council for just over a year to fill a short-term vacancy in 1999–2000. “But that was an incredibly exciting time because Nursing Council was grappling with the scope of practice for nurse practitioner and the educational criteria for master’s programmes leading to nurse practitioner. I remember that time with great humility but also a mix of pride.” The second honour was in 2006 to be part of the Nurse Practitioner Employment and Development Working Party, which was given

a small budget to see how the sector could create more awareness and opportunities for NP development, which led on to the DHBNZ NP Facilitation Project. The third special memory was in 2003 when NETS (Nursing Education in the Tertiary Sector) celebrated the 30th anniversary of the first pilot polytechnic nursing programme at the Grand Hall at Parliament. Jacobs, pursuing a PhD at the time of looking at the journey to the NP role, was thrilled to give a keynote address. That same year EIT’s Master of Nursing – offering an NP pathway – was launched just seven years after its bachelor programme. Jacobs says in the past decade it has been delightful to see increasing numbers of nurses becoming hooked on postgraduate study and growing their practice. “I think that has just been an enormous change as the pathways for nursing education up until the 1990s … they were a torture.” And as Jacobs retires, she says the next great contribution to improving timely and affordable access to health care is underway with the move to registered nurse prescribing for people with longterm and common conditions.  |  Nursing Review series 2016    23

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Super city collaboration for better

mental health “O

Rudy Bakker

Rachel Calverly

A tsunami of mental health challenges on the horizon is helping to bring PHC nursing leaders across the Auckland isthmus together. FIONA CASSIE finds out more about the resulting collaborative project to upskill primary health nurses in mental health and addiction.

Lois Boyd

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h God, I’d better ask them … but what if I do and get an answer I can’t deal with? What do I say then?” Such thoughts used to tumble through the head of primary health nurse Jacqui McMahon when mental health or addiction issues were flagged by patients. But now, she says, she feels quite comfortable to just come out and ask the questions, knowing that whatever the answer may be she can provide something to support them. It may be a brief intervention, pointing patients in the right direction for some self-learning resources or liaising and referring them on to the appropriate community or secondary services. McMahon is one of the 24 nurses who last year completed the inaugural mental health and addictions credentialing programme for primary health care nurses that is being offered to nurses across metropolitan Auckland. In a near unprecedented collaboration, the nursing leaders from the super city’s three district health boards (DHBs) and seven primary health organisations (PHOs) developed and delivered the education programme to prepare nurses for credentialing in mental health from the New Zealand College of Mental Health Nurses/Te Ao Māramatanga. An independent evaluation found the pilot programme a success, with pre and post-programme surveys showing a surge in nurse confidence reflected in a 90 per cent jump in screenings, brief interventions and referrals by the nurses. More funding for the collaborative training model has been approved by the three DHBs for a further year, so two more cohorts can be trained with the first of those due to start in the spring.

Nurse leaders keen to collaborate

The project began with two of the city’s largest PHOs – ProCare (with around 600 nurses) and Waitemata (around 210 nurses) – coming together to discuss using some DHB funding earmarked for nurse workforce development for mental health and addictions in primary health care (PHC); probably building on a successful programme already offered by Northland’s Manaia PHO.

Rachael Calverley, director of nursing and workforce development for Waitemata PHO, says it didn’t seem sensible to duplicate education programmes across Auckland so a large meeting was held to bring together the three DHBs: Auckland, Waitemata and Counties-Manukau; and the remaining five PHOs: Alliance Health Plus, National Hauora Coalition, Auckland PHO, East Health Trust and East Tamaki Healthcare. “That meeting discussed that practically and logistically a collaborative approach would be the most sensible way to do this,” says Calverley. And by aiming to have a cohort of 10 nurses from each of the three DHB regions, the programme should see a spread of nurses from across the seven PHOs serving the city. Soon after, Calverley was asked to chair the collaborative project’s steering group made up of nurse leaders, senior mental health nurses and planners and funders drawn from across the DHBs and PHOs. Fortnightly meetings followed, as Calverley believed the group needed to “drive hard and fast” to show getting an Auckland-wide programme off the ground was possible. “Above anything else we needed to demonstrate for the benefit of nursing – and obviously for patients by improving patient outcomes – that we could commit to this and work with a really collaborative approach.” With a highly competitive primary health care sector in Auckland, and the complex logistics of bringing together people from across the super city, this was no easy ask, but Calverley says the nurses involved were keen to put all politics aside and demonstrate a great collaborative nursing leadership model. “Which I think we did,” she says, adding that all seven PH0s now have dedicated nursing leaders, unlike when she took up her role three years ago and PHO nursing leaders were few and far between. Pivotal to making it work was also a project manager employed by ProCare, who “did a lot of the grunt work” and a colleague from Waitemata PHO’s Comprehensive Care Limited supported Calverley two days a week, but she emphasises that everybody contributed “a little bit of the pie”.

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The Auckland programme, built on the initial MH credentialing programme delivered by Manaia PHO, comprised six study days delivered over six months and interspersed with five group supervision sessions and ongoing reflective practice. The seven PHO nursing leaders were charged with promoting the programme – which was free to participants but did not pay for nursing cover during study days – to their nurses. It was also promoted to school and public health nurses. The result was that, within about half a year of the collaborative project being agreed to, 27 nurses attended the six-month programme’s first study day in June 2015 at the Waitakere Hospital conference centre. Twenty-four of them completed the programme and have since gone on to seek credentialing from the college.

MH tsunami on the horizon

The Metro Auckland programme was a direct response to the Government’s call for moving health services closer to home through better integrated care, including primary care taking a greater role in mental health. “I really think there is a huge tsunami of mental health and addiction challenges on the horizon for us,” says Calverley. “And all the literature supports that.” She says physical wellbeing and health tends to be core business for nurses in general practice, and mental health and addictions are not always well understood or well attended to in primary health. But mental health issues are becoming increasingly prevalent and a “huge amount” of the work nurses do in areas like long-term conditions management involved dealing with related anxiety and depression. “For example, we know that approximately one in three people with diabetes and one in four with heart disease also suffer from depression.” The programme’s aim was to give nurses increased skills, knowledge and confidence so they could also regard mental health as part of their core business. Evaluation of the programme indicates it is making a difference, with nurses reporting picking up issues earlier and helping to prevent them developing into bigger problems and draining health resources, says Calverley. “And a number of the nurses have become the ‘go to’ person in the practice because of their extra knowledge and skill.”

Professional supervision and reflection

Gaining knowledge and skills is one thing, but building confidence is another and a key component of building confidence was the credentialing programme’s group supervision sessions, believes Calverley. Coordinating the supervisors of the geographically based groups – all experienced MH nurses – was Rudy Bakker, a mental health nurse working for East Health PHO as its mental health and addictions coordinator Bakker says that professional supervision was quite poorly understood to start with because, although firmly embedded in MH nursing, it was quite a foreign concept to most PHC nurses, with some assuming it was about supervising a particular procedure rather than reflecting on and developing their own practices. The peer group supervision was slotted in between the study days with occasional one-on-one supervision if particular issues came up.

“Above anything else we needed to demonstrate for the benefit of nursing – and obviously for patients by improving patient outcomes – that we could commit to this and work with a really collaborative approach.”

Bakker says the sessions were multi-faceted and included reflecting on how the theory they were learning on study days related to their day-to-day practice, discussing the management of particular patients or patient groups and the nurse’s own personal development. An hour and a half was allocated for each supervision session, mostly held in the evenings after work, but often they ran on for two hours to give each nurse a share of the time. Calverley says while there were some challenges initially with using a group model overall using the less expensive option of group rather than one-on-one supervision had been “reasonably effective”. “It gave them the chance to talk through some challenging situations and get that ongoing coaching and mentorship.” Lois Boyd, the College of Mental Health Nurses’ board member with responsibility for credentialing, says feedback she has received is that exposure to supervision has been one of the standout parts of the credentialing programme, with some of the Manaia PHO nurses continuing to organise their own peer supervision. Jacqui McMahon, an integrated care coordinator for East Health PHO working with patients in their homes, says she found the supervision a good opportunity to talk with others, brainstorm ideas for how to do things better next time and share the good outcomes as well. Bakker sees the credentialing programme as filling a much-needed gap as mental health and addictions issues have always been ‘bubbling’ in practices, but offering early interventions was outside the comfort zone of some clinicians. The programme not only builds confidence, he says, but he is also aware of some nurses in his supervision group now being inspired to pursue postgraduate study in mental health. He also believes that it would be good if one day supervision was the norm for practice nurses as well as mental health nurses like himself.


After a slow start the interest in credentialing has started to pick up pace, with now 61 primary health nurses across the country credentialed in mental health by the college, says Lois Boyd. Most of those have come through the three Manaia PHO cohorts and now the Metro Auckland programme, but a handful of individual nurses have successfully sought credentialing. Programmes are also underway or being considered in the Western Bay of Plenty and Hawke’s Bay. Boyd says credentialing assessment is carried out by board volunteers and it is currently investigating funding options for supporting the positive increase in demand for credentialing. Meanwhile the 80-page evaluation report on the Metro Auckland credentialing programme has been distributed widely to nursing groups and the Ministry of Health by Calverley. “It is a model that could be picked up and utilised and I hope it is,” she says. Maybe now more primary health nurses will be comfortable to ask the questions and offer the early intervention that can make a difference to their patients.


METRO AUCKLAND MH and ADDICTIONS PROGRAMME for PHC NURSES »» The Metro Auckland mental health and addictions credentialing programme for primary health nurses was developed and delivered collaboratively by the three district health boards and seven primary health organisations in metropolitan Auckland. »» The programme had six study days and five small group supervision sessions over a six-month period during which nurses were expected to prepare four written reflections towards their credentialing portfolio. »» Twenty-four nurses completed the programme, with the majority working for general practices, but also including a school nurse, a nurse practitioner, a public health nurse and a nurse for a tertiary institution. »» The number of assessments/screenings, brief interventions and referrals done by the nurses increased 90 per cent after the training programme. »» The percentage of nurses rating their intervention performance as “good” increased from 32 per cent to 90 per cent after the programme. »» All but three nurses were paid while attending study days; just over half had no-one employed to cover them during study days.

MH and ADDICTIONS CREDENTIALING »» Credentialing is open to any registered nurse working in primary health who has the “knowledge, skills enhancement and experience to apply mental health addiction assessment, referral and interventions in a primary care setting”. »» The first primary health nurse was credentialed for their mental health and addiction skills by the New Zealand College of Mental Health Nurses/Te Ao Māramatanga in 2012. »» The first PHO to offer a credentialing education programme was Northland’s Manaia Health in 2013.

More information about the credentialing criteria and application process are available from the college’s website nz/Credentialing.  |  Nursing Review series 2016    25

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Professional boundaries:

Patricia Mcclunie-Trust

how close is too close?

When is a nurse at risk of jeopardising being a ‘good nurse’ in their eagerness to be a ‘good neighbour’ or ‘good teammate’? PATRICIA McCLUNIE-TRUST uses a case study to work through some of the professional boundary issues that nurses can face.


vital element of being a competent nurse is the ability to successfully establish, maintain and conclude therapeutic relationships. Nursing inherently involves some of the most intimate health care that people experience, during times when they are at their most vulnerable. Working in partnership with health consumers requires knowledge, skill and good judgement, especially in challenging situations where nurses find themselves in close or ongoing relationships with clients. In New Zealand, because of our relatively small population, or perhaps because of the number of rural practice settings, sometimes nurses already know people with whom they come into contact professionally. The way that nurses understand and deal with their responses to clients – and recognise the effects of complex, challenging, or culturally different relationships – is the key to successfully managing these relationships. Nurses learn about boundaries, and the professional values that underpin managing therapeutic relationships, during their preregistration training. However, values and expectations around what being professional means change over time and in response to societal needs. The Nursing Council’s Code of conduct for nurses (2012) emphasises the need to justify the trust that health consumers place in nurses as knowledgeable, capable and independent-thinking practitioners who act with integrity. Guidelines: Professional boundaries, also released by the Nursing Council in 2012, provides advice about how to work through the complex and challenging issues that are part of nurses’ everyday practice1. Having the opportunity for ongoing professional education on boundaries, particularly being able to talk through ideas about what professionalism actually looks like in practice, is essential for nurses working in complex and rapidly changing work environments. It is also important for nurses from differing cultural and practice backgrounds to share their values about professional relationships in practice. The following discussion presents some ideas about how to frame our thinking and reasoning about professional boundaries.

CASE STUDY: Kate’s story

Kate is a practice nurse and a keen netball player in her rural town’s local team. Some people in the rural community she practices in have to travel a considerable distance

to get to town. Since graduating as a registered nurse three years ago, Kate is often approached by other netball team members for advice about health conditions. After the game on Saturdays she occasionally invites teammates and their children back to the practice where she works, as it is closed on weekends. In these informal free clinics, Kate does basic health screening, checks children’s ears and gives dietary and contraceptive advice.

Boundaries as lines or limits

Would another careful, thoughtful nurse think Kate’s actions were reasonable? Thinking about boundaries as lines that set limits on professional activities nurses undertake with health consumers is helpful in defining how nurses ought to act. A 2001 article by a staff member of America’s equivalent of the Nursing Council suggests that blurring lines between formal and informal roles in professional relationships can cause role ambiguity, threatening the safety of both the health consumer and the nurse. Understanding lines as limits defines behaviour that is clearly ‘out of bounds’, or a boundary transgression. While well intentioned, Kate’s actions commit two key transgressions: »» Firstly, Kate has no authority or professional mandate to undertake this ‘informal’ practice. Given that some of the women she sees are not enrolled at the health centre, she is not able to document care, or appropriately follow up or refer clients to other practitioners. She is practising outside the usual professional context without formal contractual systems and support, including the collaborative team relationships that are the hallmark of good practice. »» Secondly, using the health centre premises and equipment after hours without the knowledge or consent of the practice manager involves a degree of deception, which is both an employment and professional issue.

Boundaries and therapeutic benefit

Is there any therapeutic benefit in Kate’s actions? Thinking about boundaries as therapeutic outcomes or fitting within the ‘zone of helpfulness’ is another way of evaluating whether the nurse’s actions fit within the professional mandate for practice and the continuum of behaviour expected from health professionals. Given that Kate has no clear professional mandate for practice, these women may not fully understand the limits of her practice in consenting to a therapeutic relationship for themselves or their children.

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As a graduate with three years’ clinical experience, Kate may not have the necessary knowledge, skill or resources to adequately assess health consumers’ need for care. Since she is not documenting or communicating her findings to other health professionals, Kate may be adversely affecting therapeutic outcomes for these women by coming between them and their usual health providers. In most circumstances it is appropriate for nurses to intervene in an emergency situation where they can clearly make a difference to therapeutic outcomes. However, when members of a community seek advice from nurses outside of formal practice contexts, the best approach may be to encourage the person to see their usual health practitioner. That does not mean to say that nurses cannot discuss health concerns with people in an informal context, but it does require careful thought about the best therapeutic benefit in responding to them.

The very qualities that make us good nurses can sometimes contain the seeds of our undoing. Professional boundaries in practice

Professional boundaries define the scope of therapeutic relationships. Boundaries are limits or borders to relationships that are both enabling and constraining, providing a clear focus for the therapeutic aim and purpose of healthcare encounters. Defining the limits protects both the nurse and health consumers, ensuring that whatever activities are undertaken within the therapeutic relationships benefit health consumers. Professional boundaries also refer to the differences between scopes of practice, with the authority and professional mandate to undertake some therapeutic actions limited to specific scope of practices.

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Boundaries and negotiated identities

The key question Kate needs to ask herself is, ‘Who am I in this encounter – nurse or teammate – and what is my purpose?’ Living and working in rural or other small communities where people have multiple relationships with one another presents particular challenges for health professionals. Thinking about boundaries as ongoing negotiations in relationships is another approach. Canadian sociologist Muriel Mellow describes this negotiation as ‘doing a dance’ by shifting or shuffling to the fore or background an individual’s personal and professional identities. This negotiation of identities and their inherent roles and responsibilities depends on the context of the relationship, and the shifts between personal and professional roles need to be discussed with health consumers “in an open and transparent way”. Consumers should also be given the choice of another health professional where possible. Kate’s actions led to ambiguity about her role and the transgression of professional boundaries as she did not define the purpose of her role, i.e. nurse or teammate, in her differing relationships with members of her community. She elicited privileged information from teammates and undertook physical assessments without a clear, professional mandate.

A nurse’s responsibility for confidentiality and the need to balance professional power with the health consumer’s vulnerability also become confused when a nurse’s professional identity is brought to the fore within an informal or personal relationship.

Discussion: the risk of stepping over the line in the desire to help others

Kate’s concern with the wellbeing of people and her desire to contribute voluntary services to her community show how ‘informal’ practice may put both health consumers and nurses at risk. Professional boundaries define who we are, how far we can go, and what we should do within therapeutic relationships. In professional relationships, limits are primarily concerned with managing the power of the nurse, and the client’s vulnerability, needs and interests. Boundaries help to guide nurses if they are moving closer to risky territory, but the dilemma is sometimes in knowing how close is too close, and how far is too far. Weighing up the therapeutic benefit of closeness and distance is a matter of judgement based on the context of client care, the expectations of the profession, and the recognition of what another thoughtful, careful nurse might do in a similar situation.

Crossing a boundary can be understood as going beyond the usual limits required for helpful therapeutic relationships. Nurses possess a particular kind of social generosity that sometimes finds expression beyond our work roles, but the very qualities that make us good nurses can sometimes contain the seeds of our undoing. Having said that, there are times when a carefully considered boundary crossing, such as an appropriate disclosure of a personal experience, may have therapeutic benefits. The difference between a boundary crossing and a boundary transgression is the degree of harm done to the client, family or whānau; for instance, where a nurse meets personal needs in ways that exploit the vulnerability of others. A central element of boundary transgressions is the degree of complexity that develops in the relationship, and also the nurse losing sight of the therapeutic aim and professional purpose of their interactions with the client. Author: Dr Patricia McClunie-Trust PhD RN is the principal academic staff member at Wintec’s Centre for Health and Social Practice. N.B. References for this article can be viewed in the online version at

Take your health career to the next level Advance your nursing knowledge and practice with postgraduate education. EIT offers the following programmes: ■ Postgraduate Certificate in Health Science ■ Postgraduate Diploma in Health Science ■ Master of Health Science ■ Master of Nursing with an accredited Nurse Practitioner pathway Develop skills of research, critical analysis, constructive synthesis and advanced practice within your discipline area, and advance your appreciation and capabilities for collaboration. Study full or part-time in our flexible blended/online programmes.


0800 22 55 348 |  |  Nursing Review series 2016    27

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Safe staffing: what forces make a shift safe or unsafe? Rhonda McKelvie


Nurses driving home from work probably know whether a shift felt ‘safe’ or ‘unsafe’. PhD researcher RHONDA McKELVIE wants to talk to nurses about the forces influencing safe, or unsafe, staffing.

magine a nurse, we’ll call her Sandra, leaving an afternoon shift at 11.20pm. She’s late leaving her shift. She’s had one break of 12 minutes in in her ‘eight-hour’ shift. Her dinner is still in the staff fridge. She might get time to eat it tomorrow night…. Sandra knows her colleagues had similar length breaks and, when they did cross paths that evening, all agreed that there was way more work to be done than they could possibly achieve. Each nurse was looking after five to seven patients. At 5.17pm there was a drug error; at 7.10pm one of the patients fell in the bathroom sustaining significant bruising but no fractures or skin tears. During this particular shift only three of the 32 patients received all of the care requirements mapped out in their clinical care pathways and progress notes.. All of the nurses worked 45 to 75 minutes after their shift ended, a similar shift pattern for the previous few weeks. Sandra gets home just after midnight. After a hot drink and some TV – to try and quieten her frantic mind – she falls into bed at 12.45am. She wakes at 1.45am panicking about whether she had charted the volume of the wound drain she’d emptied on her way out the door; she calls the ward to check, and of course she had. She then lies awake for several hours processing her distress at not being able to provide all the care her patients required. She’d had to do a number of patient care activities for junior colleagues without PCA (patient controlled analgesia) or epidural skills. There just hadn’t been enough time for to get everything done, and some needed equipment and meds weren’t available or were hard to find. As a result, Sandra feels, patients were put at risk through lack of resources, fatigue-related errors and insufficient staff for surveillance of all patients at risk of falling. Reflecting on the shift, Sandra believes it was unsafe for both patients and staff – and tomorrow night’s shift could well be exactly the same.

What factors and forces shape safe staffing?

Scenarios like the one above are the motivation behind my doctoral research into the factors affecting safe staffing. Despite abundant research evidence from highly credible researchers, such as US researcher Linda Aiken’s work on nurse staffing, burnout and patient mortality, and widespread and comprehensive evidence-based strategies, safe staffing for nurses remains an unresolved conundrum in New Zealand and abroad. This is because nursing safe staffing is not, and cannot be, a magic fixed number. Patients’ care requirements are dynamic, they fluctuate and surge, and, though predicting these requirements is increasingly sophisticated, meeting them safely every hour of every day in every unit is a challenge that few, if any, healthcare providers achieve and sustain long term. And where the requirements are not met safely every hour of every day, patients are at risk of harm. Harm to patients, as a result of unsafe staffing, is an untenable outcome of care for nurses. New Zealand’s evidence-based safe staffing strategies for nursing combine the best of overseas evidence and experience with homegrown initiatives and on-the-ground testing, including the acuity-based Care Capacity Demand Management (CCDM) system developed by the joint union and district health board Safe Staffing Healthy Workplaces Unit. There have been some significant gains from these strategies, but to date it appears their scale and penetration into DHBs falls short of what was hoped for. This seems to be the result of the complexity of the healthcare environment, including competing priorities and tensions between a safe and socially-just standard of care, constrained funding and the ever-present drive for productivity and efficiency.

Can you help?

My doctoral research project aims to uncover some of the factors and forces that result in shifts like the Sandra scenario above, while

28    Nursing Review series 2016  |

acknowledging that these same factors and forces are also present when shifts are safely staffed and the nursing team leaves feeling satisfied with the care provided. Some of the project findings are likely to reflect the complexity and tensions of the healthcare environment, but where do these complexities and tensions originate? And how do they have such a powerful effect on how a shift actually plays out? This study aims to begin with a small group of nurses describing their everyday experience of ‘safe staffing’ and ‘unsafe staffing’ shifts in public hospitals and will then investigate, on their behalf, how their shifts are organised to occur as they do. This research will not evaluate individuals or organisations or speculate on whether organising factors and forces are right or wrong – it is concerned with what these factors and forces are and how they affect everyday work. It is not concerned with who or why. I want to interview DHB registered nurses working in direct patient care in clinical areas such as surgery, paediatrics, medicine, maternity, mental health, acute planning and emergency and outpatient departments. I would also like to interview a small number of clinical nurse managers and duty nurse managers. Your contributions will be anonymous and confidential. Nurses’ contributions will be anonymous and confidential. Your experiences and perceptions will form the basis for the study, which will go on to examine the wider safe staffing context, including legislation, policy formation and implementation and local documents and practices. If you are interested in being interviewed and describing your on-the-ground, everyday experience of safe staffing, please contact me at AUTHOR: Rhonda McKelvie is a registered nurse and PhD scholarship student. She currently works (very much part-time) as a programme consultant for the Safe Staffing Healthy Workplaces Unit. N.B. References for this article are available in the online edition at


Articles, profiles and opinion pieces from across the nursing spectrum

Practice, People & Policy

Sallie Greenwood & Katrina Fryers

Cultural safety and relational practice:

ways of being with ourselves and others


ursing has always been more than providing competent clinical care. Nursing is also very much about relating to the people being cared for with respect, trust and compassion and in ways that are culturally safe. The art of authentically being with people is part of relational practice, a concept that has been widely discussed and considered in depth by nurse scholars, educationalists and writers interested in leadership. But what it actually means to be ‘relational’ in nursing is a question that is often still asked. So this article begins by sharing our understanding of what it means to be relational as a nurse and as a nurse educator. As with reflective practice, being relational requires a conscious awareness of both one’s own experience in the moment and the experiences of those with whom we work, be they students, patients or clients. Relational practice is a way of being that includes collaboration, trust, compassion and empowerment. True compassion is based on empathy, respect and recognition of the unique individual and a willingness to engage in a relationship with them that acknowledges the limitations, strengths and emotions of all parties. It requires that practitioners engage in a ‘real’ dialogue with patients based on honesty and courage. Imagine what it feels like to receive a diagnosis of a chronic illness: heart failure, for example. You may have had some symptoms, followed by a few tests and then are told that, although the symptoms can be managed, you cannot be cured. This is devastating. You are no longer the person you were before the diagnosis; you are now someone who has a life-limiting and possibly lifechanging illness. As the nurse who is with the patient when they are given the diagnosis, how are you going to be? What will guide your decisions about how to be with this person who is struggling to find meaning? Hopefully you will consider the context within which this catastrophe is happening; an alien context full

How nurses relate to patients is integral to nursing. In their first article, KATRINA FYERS and SALLIE GREENWOOD looked at developing reflective skills to support self-knowledge and culturally safe practice. They now consider how selfknowledge enhances the concept of relational practice and draw examples from their research. of machines, medical jargon and uniforms. Perhaps there is no privacy, perhaps there is no close friend or family there. Will you take the time in a busy environment just to be still with this person; to be whatever it is they need? Perhaps they need to be alone. Understanding the patient in their context, what they need and how you can best respond to that need are part of relational practice and also important aspects of cultural safety. The decisions that nurses make in every patient encounter make an immense difference to the patient’s experience. It is clear therefore that relational practice is an ethical issue. Joan Lischenko has argued this in her research around nurses’ efforts to search for a bridge with patients that they did not like. Therefore a relational ethic builds upon a justice and care ethic to include ‘‘a concept of personhood that values autonomy through connection, a recognition that sensitivity to ethical questions is as important as the ability to secure answers, and an awareness that our practice environments shape our moral responses’’.

Skills that contribute to a relational way of being Communication in nursing is often taught in a behavioural way, as a set of skills to be mastered; this can be useful for beginning practitioners. However, relational practice requires much more of us in terms of knowing how and when to use the skills. As Hartrick, Doane and Varcoe remind us, relational practice is at the heart of nursing practice, which is complex work carried out in rapidly changing situations with diverse individuals and groups of people. Because one size or one way of responding does not fit all, whether we decide to be with someone in silence or to provide them with reassuring knowledge will depend on the patient and the situation. Similarly in the learning environment, as educators, we have to judge whether to offer a gentle challenge to the views being expressed by a

student, or whether to hold the challenge because it would be too destabilising to that student or to others in the class at that particular moment. To support this stance, we endeavour to model relational practice in our interactions with students and believe that this supports the development of a safe space for students to explore difficult issues. It is often through reflection that we become aware of our previously unquestioned beliefs. This can in turn challenge our values and so be a very uncomfortable experience. This is when students need to feel supported and not judged.

One of the biggest things I have learned from this course and from reflecting is that these are huge, contentious topics and people often feel uncomfortable being confronted about them. Although they might make us feel awkward, angry or any other feeling, it’s okay to feel that way and important to recognise why you have those feelings and not just ignore them. (Kath) As a result of this course, my standpoint on a lot of things has changed. It has raised a lot of questions and has left me questioning what I thought I knew, and therefore I have felt very challenged at times. (Liz) In some senses human beings are always relational; that is, we understand ourselves in terms of our relationship to others, but in many western societies we have also come to understand ourselves largely as individuals and the focus is more on autonomy. So we may place less emphasis on our relationship with others or being ‘otherdirected’. Cultures that are more collective in their approach often place more emphasis on how others are feeling than on the self. Individualistic models of relating to others tend to minimise or disregard the power relations that are a part of all relationships, so acknowledging power as part of relational practice is a fundamental. Therefore our journey of becoming relational aims to make explicit some of the values and orientations that may have informed our sense of ourselves and others.

Nursing students’ journeys to relational practice As future nurses, we must remain aware of a power imbalance. It is the nurse’s role to ensure this power imbalance is transformed into a partnership and builds trusting relationships (Felicity) In addition to understanding what is happening in the relational moment, we need to understand the social context of how groups within society are positioned in relation to each other. By being conscious of how people view themselves and how others view them in relation to the world we can then see the complexity of the situation and respond more meaningfully. For example, someone receiving a diagnosis that is life-changing may now have a more passive relationship with  |  Nursing Review series 2016    29

Practice, People & Policy Practice health providers, be seen only as a ‘patient’ or a ‘diagnosis’ and be thought about differently in terms of their future contribution and value in society. In our research we noticed that students’ thinking over time moved towards a more relativistic stance (i.e. noticing other ways of knowing). Consequently they were more able to incorporate ideas about difference and recognise that understanding differences between people was as important as understanding similarities. This enabled them to adopt a more inquiring stance towards those they were working with.

I also feel that understanding my own culture and identity has helped me to have an open mind towards other cultures and this has helped me to understand the prejudiced views I have about other cultures. (Sophie) As expressed in the word clouds derived from students’ more relativistic comments, the language used became more other-focused as the students moved through the module and thinking positions. When stretching to relativism (Figure 1) students incorporated ideas about culture and difference. ‘Culture’, ‘different’ and ‘understand’ were the most dominant words, with ‘think’ and ‘feel’ and ‘values’ also included. Interestingly the word ‘patient’ was here replaced with ‘people’ a less objectifying term. At relativism (Figure 2) students wrote much more about how they think and feel, these words


Figure 1: Stretching to relativism

Figure 2: Relativism

now being the most dominant terms. ‘People’ had become ‘someone’. Without wanting to attribute too much significance to these findings, which could look different from another cohort, we did find the language shifts interesting as an indicator of where this group of students went to in their ways of knowing about the issues.


Developing relational practice is a way of being that enables nurses to work with uncertainty and complexity and is strongly linked to the principles of cultural safety. Through reflective practice, student nurses developed new ways of knowing that enabled them to be more conscious of practising in relational ways (see Figure 3) by recognising that people come into relationships from many different social contexts. The final article based on our research will consider what the concept of reflexivity can contribute to relational practice and cultural safety.

Figure 3: Ways of being in relationship

AUTHORS: Katrina Fyers MA, RGON is a senior academic staff member at the Centre for Health and Social Practice, Wintec. Sallie Greenwood PhD, MSocSci, RGN is a principal academic staff member at the Centre for Health and Social Practice, Wintec. N.B. References for this article are available in the online version, which can be found at

Māori nurse

pay parity battle continues In the latest battle in the pay parity war, the NZNO has presented a number of interventions to the United Nations Permanent Forum on Indigenous Issues on behalf of iwi provider nurses and health workers.


ealth and Māori Development ministers have declined to comment on NZNO kaiwhakahaere Kerri Nuku taking a call for pay equity for iwi provider nurses to the United Nations. But Te Ururoa Flavell, in his capacity as Māori Party co-leader and not the Minister of Māori Development, said that he “absolutely” supported pay parity for nurses working for Māori and iwi providers. Nuku, the Māori co-leader of the New Zealand Nurses Organisation, said it was currently waiting for the non-binding UN recommendations after presenting a case to the United Nations Permanent Forum on Indigenous Issues in New York in May. She says the presentation focused on building Māori workforce capability to better reflect the population it serves and the pay parity “plaguing our Māori and iwi health providers sector”. The call for pay parity for iwi provider nurses and health workers dates back to 2006 after the NZNO ‘pay jolt’ ratified in 2005 for district health board (DHB) nurses saw the pay gap widen

between initially all DHB and non-DHB nurses. A gap then also emerged between Māori-led healthcare organisations and their counterparts employed by PHO-funded general practices because of different funding mechanisms. An 11,000 strong petition was presented to Parliament in July 2008 backing the pay equity call and a subsequent 2009 Health Select Committee report called for a working group to look into the petition issues but the Government did not adopt the report. Flavell said in 2012 the Human Rights Commission found that Māori and iwi health workers earned up to 25 per cent less than their colleagues in hospital settings. He said there were a number of contributing reasons for this, including the funding model. “Our nurses do a wonderful job, whoever employs them, and I would like to see progress towards pay parity,” said Flavell. Asked whether he supported NZNO going to the UN forum, he said he supported using available avenues to get better outcomes for whānau Māori, and highlighting whānau concerns.

30    Nursing Review series 2016  |

“I also encourage the NZNO to continue its discussions with the Minister of Health and the Ministry of Health, as well as providers of health services to whānau. Much can be achieved through this engagement.” There was no comment from Health Minister Jonathan Coleman in response to Nursing Review queries about the ongoing pay parity issue and Nuku’s approach to the UN forum. Nuku said the NZNO presented a number of interventions to the forum to help address the issues, including the need for high-quality Māori workforce data collection to allow the sector to better understand the workforce capability nationally. It also asked for a commitment to indigenous health workforce equity, with currently seven percent of the nursing workforce identifying as Māori, compared with just under 15 per cent of the population – and the seven per cent figure had been static since the 1990s. It also sought better approaches to identifying workforce barriers and developing recruitment and retention initiatives. See earlier story at

Evidence-based practice

Heart failure: getting the dose right Can nurse-led titration of heart failure medicine make a difference? Check out this edition’s Clinically Appraised Topic (CAT). CLINICAL BOTTOM LINE: In adults with symptomatic heart failure, nurse-led titration of heart failure medications significantly increased the number of participants reaching optimal dose, reduced the time taken to reach optimal dose and improved patient morbidity and survival when compared with physician-led titration. Despite mixed quality evidence, these results suggest that nurse-led titration is an effective and safe strategy for ensuring high-risk patients get the optimal medication dose.

CLINICAL SCENARIO: You have a leadership role spanning primary and secondary care and are concerned about the number of people with chronic conditions not receiving optimal doses of beneficial medication. You wonder if nurse-led titration (NLT) may be a good strategy for addressing the complex barriers to patients getting the right dose of the right medications. You decide to review the evidence.

QUESTION: In people with chronic illness and in comparison with usual care, does nurse-led titration safely increase the number of patients receiving optimal doses of medications known to be an effective treatment for their condition?

SEARCH STRATEGY: PubMed - Clinical queries (Therapy/Narrow): nurse-led titration

CITATION: Driscoll A, Currey J, Tonkin A, Krum H. Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD009889. DOI: 10.1002/14651858.CD009889.pub2.

STUDY SUMMARY: A Cochrane systematic review assessing the safety and effectiveness of NLT of beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) for people with heart failure (HF). Inclusion criteria were:

Type of study: Randomised controlled trials comparing NLT with medication optimisation by another health professional involving adults with symptomatic HF and reduced ejection fraction. Uncontrolled and nonrandomised studies were excluded. Intervention: Nurse-led titration of beta-adrenergic blocking agents, ACEIs, and ARBs. Nurses were to have delegated responsibility for making protocol led changes in medication dose or were nurse practitioners titrating medications as part of their scope of practice. Comparison: Usual care: patients under the management of a physician responsible for titration of ACEIs, ARBs, and/or beta-adrenergic blocking agents or a heart failure nurse who did not alter medication.

Outcomes: Primary: all-cause hospital admissions; heart failure-related hospital admissions; all-cause mortality; all-cause, event-free survival. Secondary: time to maximum dose; adverse events associated with titration; proportion reaching target dose of medications; change in quality-of-life scores; cost-effectiveness.

STUDY VALIDITY: Search Strategy: Reviewers searched CENTRAL, MEDLINE, EMBASE, clinical trial registries, reference lists of eligible studies and heart failure guidelines and unpublished theses. No date or language restrictions applied. Review process: Two reviewers independently examined titles/abstracts and then full text to identify relevant studies, extracted data using a data extraction form, and assessed risk of bias in all studies. Discussion resolved any disagreement. Quality assessment: The Cochrane Collaboration tool was used to assess risk of bias in included studies. Assessment criteria were random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessment, incomplete outcome data and selective reporting. Overall validity: A high-quality review involving studies of mixed quality and generally small sample size.

STUDY RESULTS: The search identified 1,016 studies. Following title review, 100 abstracts and then 18 full text articles were closely examined for eligibility, after which a further 11 studies were excluded. Seven RCTs involving 1,684 participants were included in this review. NLT occurred via nurse visits to a residential care facility (one study), telephone follow-up (one study), nurse-led clinic in primary care (one study) and outpatient clinics of tertiary hospital (four studies). Studies involved titration of beta-adrenergic blockers (three studies), beta-adrenergic blockers and ACEIs

(two studies); just two studies involved titration of betaadrenergic blockers, ACEIs, and ARBs. Median follow-up was 12 months. Usual care consisted of primary care physician-led titration. Participants receiving NLT experienced a 20 per cent reduction in all-cause hospital admissions, 49 per cent reduction in heart-failure related hospital admissions, and a 34 per cent reduction in all-cause mortality (see table) compared with usual care. Participants in the NLT group were also twice as likely to reach target dose of medications (see table) and did so in a significantly shorter time (two studies, no meta-analysis). All results were statistically and clinically significant but quality of evidence was mixed.

COMMENTS: »» NLT involved heart failure nurse specialists, was protocol-led and occurred alongside varying levels of patient education and support. »» Low-quality evidence grading (substantial heterogeneity, small studies, risk of bias in included studies) for the outcome of proportion reaching target doses, therefore this result may change with future studies. »» Adverse events related to the study medications were poorly reported so comparing safety of nurse-led and physician-led titration is difficult. Available data suggests that optimising therapeutic medications through NLT is safe, provided specialist nurses monitor risks associated with each medication in keeping with evidence-based prescribing guidelines. »» People with symptomatic heart failure have high mortality and morbidity, therefore strategies for promoting optimal dosing of effective medications are crucial. Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, the University of Auckland and PhD Candidate, Deakin University, Melbourne

Table: Summary or results No. of Studies (Number of Participants)

Relative risk (95% CI)

Statistical Heterogeneity I2

Quality of the Evidence*

All-cause hospital admissions

4 (560)

0.80 (0.72 - 0.88)



Heart failure-related hospital admissions

4 (642)

0.51 (0.36 - 0.72)



All-cause mortality

6 (902)

0.66 (0.48 - 0.92)



Proportion reaching target dose of medications

5 (966)

1.99 (1.61 - 2.47)

72 %



* Grade Working Group criteria; High quality – further research is very unlikely to change reviewers confidence in the estimate of effect  |  Nursing Review series 2016    31

College of nurses

Leading as One Team to address ‘wicked’ problems KATHY HOLLOWAY looks at the importance of nurse leadership and teamwork when responding to the complex ‘wicked’ problems in the health system that have no easy answers.


eadership in nursing is not a new concept and we are fortunate in New Zealand to have many great nursing leaders both past and present. Many nursing researchers identify leadership as a key component for success in practice improvement activities. It is also clear that leadership is pivotal if we are to meet our ‘contract’ to deliver high-quality, evidence-based, relational nursing practice to the communities we serve. Our healthcare system needs nursing leaders who can solve problems and provide guidance as we constantly seek to improve care quality, health outcomes and the patient experience. Globally and

“Our healthcare system needs nursing leaders who can solve problems and provide guidance as we constantly seek to improve care quality, health outcomes and the patient experience.” nationally nurse leaders face chaotic environments and complex issues that have been characterised elsewhere as ‘wicked’ problems.

Wicked problems are not inherently bad, instead the phrase is used to describe those diverse and multi-layered situations that are not amenable to a simple resolution1. Wicked problems require an approach that encompasses moral courage, perseverance, transparency and a willingness to fail and try again2. Wicked problems also respond best to a systems and policy approach that involves the wider healthcare team.

The ‘One Team’ approach An overarching intent in the refreshed New Zealand Health Strategy is the focus on developing an integrated and cohesive system that puts people, families and whānau at the centre of care. This is conceptualised within the strategy as being linked to a ‘One Team’ approach. Inherent to the One Team approach is a need for strong leadership across the disciplines, including nursing. A One Team approach – where nurses are full partners with physicians and other disciplines in redesigning health care – is a key platform for change identified in the US-based Institute of Medicine’s The Future of Nursing: Leading Change, Advancing Health report3. This influential global report, published in 2011, remains the most downloaded publication from the IOM website (145,000-plus downloads) and is well worth a read.

32    Nursing Review series 2016  |

Within the One Team approach nurses must work to the full extent of their education and training (another Future of nursing message) to contribute to the end goal. Strong and effective relational nursing leadership has been linked to improved patient outcomes. Outcomes such as patient satisfaction, lower mortality, complications and adverse event occurrence are reported as being positively affected by the presence of effective nursing leadership4. The mechanism for this positive impact is suggested to come from nursing leaders developing positive practice environments that have greater staff engagement. As nurses in formal leadership roles, or as members of healthcare teams, nurses can demonstrate leadership through their contribution to these mechanisms. The College of Nurses, through its members, aims to provide health leadership and critical advocacy, and contribute to national health and socio-economic policy. Choosing to belong to and actively participate in the College is considered an act of professional leadership and a commitment to better health services.

N.B. References for this article are available in the online version at Author: Dr Kathy Holloway is the co-chair of the College of Nurses Aotearoa (NZ) Inc and also chair of NETS (Nursing Education in the Tertiary Sector Aotearoa NZ).

INVEST IN YOUR FUTURE You can do it with Massey University’s Master of Nursing degree. Study with us and you will be prepared for a range of clinical leadership roles – including Nurse Practitioner – in the changing and challenging world of New Zealand’s healthcare system. Nurses like you taking on postgraduate study are almost all in clinical practice. Life is busy! That’s why we support you so you can study part-time. Our programmes are approved by the Nursing Council of New Zealand. You can do a Postgraduate Diploma that leads to Registered Nurse Prescribing or go on to a Master of Nursing for Nurse Practitioner registration and other advanced practice roles. This study also supports you to meet ongoing professional development requirements. Study now with New Zealand’s top ranked university nursing programme for research. Massey is also in the top 100 nursing programmes in the world (2016 QS World University Rankings). Learn from the best. Join us today. Shape the future of healthcare.

CONTACT US 0800 MASSEY (0800 627 739)

Thursday 3 November 2016 | SKYCITY Auckland

PLUS three other conferences | 31 October to 3 November



The NZ Nursing Informatics Conference runs concurrently with the HiNZ Conference and two international telehealth events.

NZNIC keynote speakers are:

Hear about the latest developments in digital health from around the world.

• Deb Boyd, CEO, Auckland Eye

Delegates can attend any conference session across six streams over three days. 1, 2 or 3 day passes available. Discount available for members of Nurse Executives of NZ. Alternatively, you have the option to register just for the NZ Nursing Informatics Conference on Thursday 3 November for only $248.

• Margaret Hansen, Professor of Nursing, University of San Francisco • Dr Robyn Whittaker, Waitemata DHB • Chai Chuah, Director-General of Health Plus hear about 18 local digital health projects. Topics include telehealth, mobile devices, apps, virtual clinics, ePortfolios, big data, EHRs & more. Registration includes access to the webcast library so you can view sessions by mobile device during & immediately after the event.

EARLYBIRD REGISTRATION CLOSES 23 SEPTEMBER 2016 NZNIC registration for Thursday 3 November costs only $248 View the conference programme and registration options at

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