Page 1

FOCUS: Infection Control/Wound Care

Nursing Review VOL 12 ISSUE 12 2012


WOUND CARE Easing pressure injuries

No time to heal








with Jenny Carryer

A DAY IN THE LIFE OF a MH nurse on the bumpy roads of Christchurch

Relieving pressure on heels





29% of IPD cases in NZ children <2 years are caused by the strain 19A.4


Offer your patients the choice. References: 1. Prevenar 13® Approved Data Sheet, 9 March 2011. 2. Prevenar Approved Data Sheet, 1 November 2010. 3. Synflorix Approved Data Sheet, 21 September 2011. 4. Heffernan H, et al. IPD Q4 2011 ESR Report. Before prescribing, please review Data Sheet available from Medsafe ( or Pfizer New Zealand Ltd ( or call 0800 736 363. Prevenar 13® (pneumococcal polysaccharide conjugate vaccine, 13-valent adsorbed) suspension for I.M. injection minimum data sheet. Indications: Active immunisation against disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F (including sepsis, meningitis, pneumonia, bacteraemia and acute otitis media) in infants and children from 6 weeks up to 5 years of age. Dose: 0.5 mL I.M. Do not administer to the gluteal region or intravascularly (see also Precautions). Infants: 6 weeks of age: 3 doses at least one month apart. A single booster should be given in after 12 months of age, at least 2 months after the primary series. Previously unvaccinated infants 7 to 11 months of age: 2 doses approx. 1 month apart, followed by a third dose after 12 months of age, at least 2 months after the second dose. Previously unvaccinated children 12 to 23 months of age: 2 doses at least 2 months apart. Previously unvaccinated children 24 months of age or older should receive a single dose. Contraindications: Hypersensitivity to any component of the vaccine, including diphtheria toxoid. Allergic reaction or anaphylactic reaction following prior administration of Prevenar. Precautions: Do not administer intravenously, intravascularly, intradermally or subcutaneously. Avoid injecting into or near nerves or blood vessels. Do not inject into gluteal area. Postpone administration in subjects suffering from acute moderate or severe febrile illness. Prevenar 13 will not protect against Streptococcus pneumoniae serotypes other than those included in the vaccine nor other micro-organisms that cause invasive disease, pneumonia, or otitis media. Prevenar 13 may not protect all individuals receiving the vaccine from pneumococcal disease. Infants or children with thrombocytopenia or any coagulation disorder. Appropriate treatment must be available in case of a rare anaphylactic event following administration. Safety and immunogenicity data in children with sickle cell disease and other high-risk groups for invasive pneumococcal disease are not yet available for Prevenar 13. Prophylactic antipyretic medication recommended for children receiving Prevenar 13 simultaneously with whole-cell pertussis vaccines, or children with seizure disorders or prior history of febrile seizures. Antipyretic treatment should be initiated whenever warranted as per local treatment guidelines. The potential risk of apnoea should be considered when administering the primary immunisation series to very premature infants. Adverse Effects: Very common: Injection site erythema, induration/swelling, pain/tenderness, fever, decreased appetite, drowsiness, restless sleep, irritability. Common: Vomiting, diarrhoea, rash. Uncommon: Urticaria or urticaria–like rash, seizures, crying. Rare: Hypersensitivity reaction including face oedema, dyspnoea, bronchospasm.V10111. Contains: 30.8 micrograms of pneumococcal purified capsular polysaccharides and 32 micrograms of CRM197 protein. The decision to administer Prevenar 13 should be based on its efficacy in preventing IPD. Risks are associated with all vaccines, including Prevenar 13. The frequency of pneumococcal serotypes can vary between countries and could influence vaccine effectiveness in any given country. Otitis media and pneumonia can be caused by various organisms and protection against otitis media and pneumonia is expected to be lower than for invasive disease. Prevenar 13 is a fully funded prescription medicine for children meeting the high-risk criteria or pre- and postsplenectomy criteria (Immunisation Handbook 2011). For children not meeting these criteria, Prevenar 13 is an unfunded prescription medicine – a prescription charge may apply. Pfizer New Zealand Ltd, PO Box 3998, Auckland, New Zealand 1140. DA1212SW. BCG2-H PRE0123. P5786.

FOCUS: Infection Control/Wound Care

Nursing Review VOl 12 issue 12 2012

New ZealaNd’s iNdepeNdeNt NursiNg series

WOUND CARE Easing pressure injuries

No time to heal






hand hygiene’s missed moments


with Jenny Carryer


a mh nurse on the bumpy roads of christchurch


Relieving pressure on heels

FOCUS: Infection Control/Wound Care 4 Rheumatic Fever: the sore throat that can break hearts


SoRE thRoatS mattER

8 SANDRA BALL: an Opotiki nurse with a mission 10 Hand hygiene: how well do we scrub up? 1 3 JAN RICE on old-fashioned wound cleaning and

ch oa pr Ok ap O h l es eW fr N

new wound science

LETTER FROM THE EDITOR It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm Florence Nightingale 1859 In our Infection Control and Wound Care edition, we have two articles focusing on just that: nursing efforts to ensure patients come to no harm from preventable pressure injuries and the national hand hygiene campaign underway to reduce hospital-acquired infections. Meanwhile, earlier this year, a major University of Otago study found that hospital admissions through infectious diseases had jumped dramatically in New Zealand over the past two decades – against the trend of most developed countries. The study, published in Lancet, noted clear ethnic and social inequalities in infectious disease risk and called for stronger prevention efforts, including addressing disparities in income levels, housing, and access to health services. This edition we talk to some of the campaigners against one of those diseases – rheumatic fever – including Helen Herbert, who has since won the Public Health Association’s (PHA) prestigious Tu Rangatira mo to Ora award for leadership in hauora (Māori health) development.

The health ‘literate’ patient: more than just reading skills So what is health literacy again? This edition’s RRR professional development activity looks at the evolving concept of health literacy – the skills and support patients need to be empowered to safely navigate the complexities of the modern health system. Shelley Jones looks at theories about what health literacy is, why it matters, and how the nursing role can promote health literacy.

14 WAYNE NAYLOR and the wounds that time won’t heal

19 Pressure Injuries: a preventable sore on the health system

RRR professional development activity 15

Health Literacy: Patient-centred communication is still the answer

People, Practice, & Policy 25 Nurse researcher MARTIN WOODS on the pressures leading to high moral distress amongst Kiwi nurses 26 American NP SHARON MYOJI SCHNARE on the brave new world for nursing

28 JILL CLENDON on what’s lacking in our primary health care model

Regulars 2 Q & A profile: JENNY CARRYER 3 A day in the life of… Community Mental Health Nurse Case Manager JENNI MANUEL 22 Evidence-based practice: ANDREW JULL looks at heel offloading device research 23  Webscope: KATHY HOLLOWAY on leaving ‘cookie’ crumb trails 24  College of Nurses column: TAIMA CAMPBELL speaks ‘plainly’ about tobacco industry

packaging of the truth


For the Record: News round-up

ADVERTISING Belle Hanrahan PRODUCTION MANAGER Barbara la Grange LAYOUT Aaron Morey EDITOR-IN-CHIEF Shane Cummings PUBLISHER & GENERAL MANAGER Bronwen Wilkins COVER PIC: Jenni Manuel on p.3 shares a day in her life travelling the bumpy roads of Christchurch as a community mental health nurse case manager for the Canterbury District Health Board.


Vol. 12 Issue 12

EDITOR Fiona Cassie

PHOTOS Thinkstock

APN Educational Media Level 1, Saatchi & Saatchi Building 101-103 Courtenay Place Wellington 6011 New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 Fax: 04 471 1080 © 2012. 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 Infection Control/Wound Care 2012



with Jenny Carryer

JOB TITLE | Professor, also Executive Director of the College of Nurses Aotearoa (NZ)

We profile a leading nurse, covering their background – training and work history – and also provide their personal insights into having a rewarding career.


made by some nurses, that academics are out of touch. To be honest, through constant exposure to registered nurse students from a wide range of settings, we know a great deal about what happens and how it is ‘out there’.

Where and when did you train? At Palmerston North Hospital in those quaint times of white uniforms, separate dress uniforms, red capes, strange and pointless caps, and standing up for student nurses who had been there six months longer! Registered in 1972.


Would you recommend your child/ nephew/neighbour/grandchild to go into nursing? This is a really hard question, and despite my passion for nursing, I would struggle to make a whole-hearted recommendation. In 2012, nursing is still not taken seriously, still not accorded full respect, still treated as an adjunct to medicine, and often patronised by people who should know better. This is not conducive to nurse’s personal wellbeing, and it is an additional burden to carry when working so very hard.



Other qualifications/professional roles? Directly after registering, I did a postgraduate cardiovascular course at Greenlane Hospital, then one in oncology and a two-year diploma in counselling. Started a BA in the mid-eighties, planning to do just a BA, but I became completely engrossed, finishing a PhD in 1994.


When and/or why did you decide to become a nurse? To be honest, I think I did it without even thinking. In 1969, career options for women were extremely limited … my mother was a nurse, and I blindly followed. No regrets, however.


hat was your nursing career up to your current job? I spent many years in clinical practice, especially years in ICU and five years as charge nurse of an oncology ward. I then enjoyed clinical teaching for some years before becoming an academic. I took up the role of Professor of Nursing in a joint Chair between Massey University and MidCentral District Health Board in 1999 and then full Professor at Massey only since 2009. The joint chair and the role of executive director of the College of Nurses means that, as an academic, I have continued to have a very close engagement with a wide range of nursing and health sector activities.


hare a moment when you felt particularly proud to be a nurse? There are many, but last year, I sat through the night with a friend as a surgical team at Capital & Coast DHB struggled to save her husband’s life following an unexpected, catastrophic, late post-surgical bleed. Next day, an ICU nurse spoke to my friend in a way that so deeply recognised her fear and her exhaustion,


Q A and yet enabled her to feel it was safe for her to take a break and rest. On a lighter note, I have never forgotten learning years ago that an elderly man had only been able to remain in his own remote home because a district nurse had dug a new long drop for him every so often. This is nursing, really, spanning such a complex array of environments and being tuned to people’s needs – whoever they are and wherever they are.


So what is your current job all about? Being a nurse academic carries a responsibility to be a critic and conscience in society, and I take that role seriously. We are the only nurses with the real freedom to comment honestly. I do research, and I teach and write.


What do you love about your current job? I gain the most joy from seeing nurses achieve beyond their wildest dreams.

What are the bits you love least? Having to sit down so much, especially as growing evidence shows how bad for us it is to sit for long periods. And sometimes, I do become annoyed with the assumption, still

Nursing Review series Infection Control/Wound Care 2012

What do you do to try and keep fit, healthy, happy, and balanced? Because my job is so sedentary, I am pretty fanatical about exercise. I adore Zumba and have overcome having no coordination (I think) to become confident enough to stand in the front row, although never in front of the mirror! I do resistance training at a gym, a number of long distance walks/tramps, and garden regularly. My Kindle goes everywhere with me, and I belong to two book groups. Friends are really important.


What have you been reading lately? I read to relax and mostly devour wellwritten novels, but I did just read The End of Illness by David B. Agus. Highly recommended.


What is number one on your ‘bucket list’ of things to do? I would like to say jumping off the Sky Tower, but my natural terror of heights may always get in the way. I adore travel and value any opportunity to do that. I think an African safari is high on the list, as is seeing more of Japan.


If I wasn’t a nurse I’d be a... in criminal cases.

A day in the life...

of a community mental health nurse case manager NAME | Jenni Manuel JOB TITLE | Nurse Case Manager, Early Intervention in Psychosis Service, Canterbury District Health Board LOCATION | Totara House, Christchurch


AM WAKE The first alarm goes off, and after pushing snooze multiple times, I finally rise and push my husband out of bed. I get up and head straight to the gym, where I put my headphones on to avoid talking to anyone; I am not a morning person. Back home, I get ready for the day and grab some toast and tea for the car ride to work. Unfortunately, Totara House was badly damaged in the February earthquake, so we have been relocated twice. Currently, we are in a small cottage at the front of the Hillmorton Hospital site – across town from where we live in one of the badly affected streets in the east. Our house is significantly damaged (we are waiting on land tests to find out whether it needs to be rebuilt), but luckily, it is liveable, albeit draughty in the winter. So I bump to work down the broken roads of the east side and through the road works to the less affected part of town.


AM START WORK I’ve woken up properly now. I see that one of my clients has presented to Psychiatric Emergency Services over the weekend. He was returned home with the request for me to follow-up today. I will need to fit that into my diary. Time to make a quick cup of tea before settling into the morning MDT (multidisciplinary team) meeting. I bring my client up in the “hotspots” slot and discuss his presentation to emergency services. I have been working in mental health since I graduated over seven years ago and love the autonomy I have in my practice. I entered the workforce through the DHB’s new graduate programme, which included a postgraduate certificate in health sciences. I have continued studying and recently completed my master’s thesis (with gratefully received funding from Te Pou). Initially, I worked in inpatient wards but have been in my current community role for about four years. We work with people between the ages of 18 and 30 who have experienced a first episode of psychosis and follow them up for two years following the initial referral. This is an important time and requires intensive input to ensure better outcomes for the future. As a case manager, you are the first point of contact for a client and their family as you coordinate a person’s treatment. The role is broad and includes one-on-one intervention and education about their diagnosis to mental state assessment and community

liaison. We have low caseload numbers, around fifteen, which means we can build sturdy relationships with people and really get to know them and their families. It is very rewarding seeing people gain an understanding of what has happened for them and realise they can recover and move on with their lives.


AM CLIENT CALL Following the meeting, I make a call to the client and arrange for a visit after lunch. I also get an opportunity to speak with his mother to find out how she thinks he’s been. Sounds like he’s been really struggling.


AM ON THE ROAD I am on the road to visit my first client of the day and travel through more road works and over badly damaged roads. Luckily, a lot of our clients live with family, but helping find housing for others has become a major difficulty. I greet my client’s mother at the door and ask her how she feels things are going and how she is managing. I suggest to the client that we go out walking, which is a good opportunity for him to get some exercise. He walks very slowly and is

It is very rewarding seeing people gain an understanding of what has happened for them and realise they can recover and move on with their lives.

difficult to engage in conversation because of a depressed mood. We talk about some basic activity planning for the week and go over what he has been working on in his psychology appointments. I get a laugh out of him as he relaxes.


PM CALLS AND GRABBED LUNCH Back in the office again, and I return the calls that I have missed whilst out of the office. In the lounge, a group of clients are gathering for a mountain biking group, so I sit and chat with them for a short while and eat my lunch (I am secretly pleased it is not my turn to take the group out today).


PM BACK ON THE ROAD I’m in the car again. I meet with a client who is near the end of her time with our service. She is on her lunch break at work and has been doing well for a while now. We sit down by the river and chat about how far she has come and about the planned discharge back to the care of her GP.


PM CHANGE OF PLANS Back at base, I realise I am running out of time, so have to postpone an appointment. I travel nearby to see the client of concern from the morning. I realise quickly that he has deteriorated because he appears distracted and is not as welcoming in manner. I call back to base and arrange for the psychiatrist to see him. We talk with him and his family and decide that he needs some time in respite for closer monitoring. I make arrangements for the respite and for additional support from the community intensive care team who will visit daily. This process and the relevant paperwork takes a while, and by the time, I have dropped him off and settled him in, it is close to five. I sit down to do some quick notes and leave work around half-past five.


PM HOME Finally home. I light the fire, take the dog for a walk, and then prepare dinner. My husband arrives home from rugby training and we flop down in front of the TV for a couple of hours.


PM LIGHTS OUT Time for sleep before it all starts again.

Nursing Review series Infection Control/Wound Care 2012


Infection Control/Wound Care

Infection Control/Wound Care Keeping infection at bay and tending wounds – some of the basic tenets of nursing. This edition, we feature articles on campaigns against bacterial infection and avoidable wounds, plus nurses treating wounds with science and sensitivity.

Rheumatic Fever:

What is it and what does it do?

»» Rheumatic fever is triggered by a ‘strep’ throat – otherwise known as a Strep A or group A streptococcus (GAS) infection – with 10–20 per cent of sore throats caused by GAS. »» GAS is very infectious and can be transferred through droplets from coughs and sneezes (or indirectly through droplets contaminating food). »» Most ‘strep’ throat infections get better without developing into rheumatic fever, but for a small number of people, it triggers a strong immune system reaction leading to inflammation of the heart, joints, brain, and skin. »» Rheumatic fever is nearly always preventable with early detection and treatment of strep throat with a ten-day course of antibiotics. »» About 70 per cent of children who get rheumatic fever will have some heart damage, and if the inflammation scars the heart valves, the person can develop rheumatic heart disease and may require heart valve replacement surgery. »» After having rheumatic fever, children must have painful monthly intramuscular penicillin shots until they are 21 to prevent further bouts of rheumatic fever (or longer, if they develop rheumatic heart disease).

the basics

Girl having throat swabbed as part of Northland DHB’s rheumatic fever prevention programme

The sore throat that can break hearts Just a sore throat … too many families now know some sore throats last a lifetime. FIONA CASSIE talks with some of the passionate pioneers of school throat-swabbing campaigns as the national Rheumatic Fever Prevention programme rolls out.


elen Herbert can still remember sending her son off to school that day with just a sore throat. By the time he got off the school bus that afternoon, she knew something else was definitely wrong. She was right. He had rheumatic fever, leaving a mother feeling livid and let down by a health sector that hadn’t warned her how devastating “just a sore throat” can be. She has been a passionate rheumatic fever campaigner ever since – first in her home community of Whangaroa, then wider Northland and beyond, and this year, she became the national co-coordinator for the Ministry of Health’s Rheumatic Fever Prevention Programme.

It all began with rheumatic fever levels peaking at internationally high levels at the turn of the millennium in the small Far North community of Whangaroa. Helen Herbert’s son was eight when he got rheumatic fever. He is now 21 and the family has this year just celebrated him being given the all clear to no longer have the painful monthly antibiotic injections required to keep further rheumatic fever, and the risk of major heart damage, at bay. “It is very traumatic for the kids when they first start – and for their families,” says Herbert. “My son packed his bags heaps of time to run up the hill. He told me he was running away from home and he’d come back later on.” Herbert says it was devastating in those early days realising just how many of the community’s children were getting rheumatic fever and all for the lack of treating a sore throat.

A driven community

Helen Herbert


Sue Dow

The Whangaroa Rheumatic Fever Prevention Programme was launched on Waitangi Day 2002 in response to that deep community concern with the support of an equally concerned Northland continued on page 6 >>

Nursing Review series Infection Control/Wound Care 2012

How severe is the problem?

»» New Zealand’s rheumatic fever rates are now 14 times higher than any other OECD country. »» One third of New Zealand children have a 1 in 250 chance of a preventable damaged heart by the end of school. »» The rates of rheumatic fever for Māori and Pasifika children aged between 5 and 14 are between 20 and 40 times higher than other Kiwi children of the same age. »» The rates in high risk areas are thought to be a combination of crowded living conditions, difficulties accessing health care, and lack of awareness that ‘sore throats matter’. »» Heart Foundation guidelines recommends throat swabbing any Maori or Pacific patient aged between 3 and 45 who presents with a sore throat and prescribing them antibiotics straight away if they meet strep throat criteria. »» A research project in Northland in 2010 scanned the hearts of 636 Kaitaia children and found seven with previously undetected rheumatic heart disease and 13 with inconclusive or borderline rheumatic heart disease. »» There are around 140 deaths per year from rheumatic heart disease.


For formula-fed infants Rapid weight gain during infancy may be associated with risk of later obesity.1–4 Enhanced S-26 GOLD® NEWBORN now has a lower total protein concentration,*5 for a rate of weight gain closer to breastfed infants at 4 months,5 and a lower overall energy intake due to changes in the feeding guide.6

Aiming for outcomes closer to breastfed infants, both now and in the future.

* Compared to previous S-26 GOLD


NEWBORN formulation.

IMPORTANT STATEMENT: Breast milk is best for babies and provides ideal nutrition. Good maternal nutrition is important for preparation and maintenance of breastfeeding. Introducing partial bottle-feeding could negatively affect breastfeeding and reversing a decision not to breastfeed is difficult. Professional advice should be followed on infant feeding. Infant formula should be prepared and used as directed. Unnecessary or improper use of infant formula may present a health hazard. Social and financial implications should be considered when selecting a method of infant feeding. Do you or your clients have a question?

The Pfizer Nutrition Careline is a free call service offered to parents and healthcare professionals. Staff include qualified healthcare professionals, who can provide advice and support on a range of topics. NEW ZEALAND: 0800 443 229 REFERENCES: 1. Baird J, et al. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ 2005;doi:10.1136/bmj.38586.411273.EO. 2. Monteiro POA, Victoria CG. International Association for the Study of Obesity. Rapid growth in infancy and childhood and obesity in later life – a systematic review. Obesity Reviews 2005;6:143–154. 3. Ong KK, Loos RJF. Rapid infancy weight gain and subsequent obesity: systematic reviews and hopeful suggestions. Acta Paediatricia 2006;95:904–908. 4. Stettler N, Lotova V. Early growth patterns and long term obesity risk. Current Opin Clin Nutri Met Care 2010;13:294–299. 5. Trabulsi J, et al. Effect of an α-Iactalbumin-enriched infant formula with lower protein on growth. European J Clin Nutr 2011;65(2):167–74. 6. Data on file, Pfizer Nutrition.

S-26 GOLD® NEWBORN is a Pfizer infant formula. Professional advice should be followed. Pfizer Nutrition, division of Pfizer New Zealand Ltd. PN-20120433-23/05/2012. WYE1025/NR. For healthcare professional use only.

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FOCUS n Infection Control/Wound Care

<< continued from page 4 District Health Board public health team. Herbert, who had taught music and been a teacher aide in schools, was on board from the start as one of the two kaimahi employed by Te Runanga O Whangaroa to promote and carry out the throat swabbing and rheumatic fever awareness programme three days a week at the six local schools. Sue Dow, a communicable disease nurse educator at the DHB’s public health unit, also involved from the early days, says at the time there were mixed views on throat swabbing interventions. But when the options for action were outlined to the community, they chose the community-driven intervention and then got strongly behind it. And the campaign worked. The last rheumatic fever case was notified eight days after the intervention started and then no more cases for ten years (a case may just recently have been notified but the source is still to be confirmed). Putting up your hand in class to get your sore throat swabbed is now normal routine, and if kids get sick in the holidays, families head up to the local hospital instead. Whangaroa knows that sore throats are serious. Dow puts the remarkable success of the Whangaroa intervention down in no small part to Helen Herbert herself. “She’s very passionate about her job and her community, and that’s what actually made it work up there in a big way.” Herbert says as a non-health

professional, having good clinical expertise behind her is essential, and from the start, she’s worked with Sue Dow, Northland Medical Officers of Health Jonathan Jarman and Clair Mills and leading rheumatic fever researcher Professor Diana Lennon. Her own expertise quickly grew beyond swabbing throats – though she has done countless thousands – to engaging everybody from teenagers to GPs in getting the message home that sore throats matter. For example, Whangaroa quickly got buy-in from primary school families – 100 per cent consent from the area’s five primary schools – but it struggled to get local high school students onboard with only a 28 per cent consent rate. It was too uncool for teenagers to seek whānau consent for throat swabbing at school. “Then we asked ourselves what are the most important things to teenage kids. Well, themselves, their music, and their tummies,” recalls Herbert. So they started again with a promotion campaign – including an assembly visit by a rheumatic heart disease patient to show their big scar from heart surgery – and a very appealing prize draw for kids who got their consent forms back the next Friday. Within a week, they had 80 per cent of the kids signed up.

“Public health nurses only had printed off fact sheets, which weren’t lively or enthralling to read,” recalls Dow. As educator, she got the job to help develop attractive flip-charts and the Sore throats can break a heart pamphlets that set out simply and attractively the take home messages of the Northland-wide awareness campaign. Public health nurses’ major rheumatic fever focus remains on looking after children and young people once diagnosed – about 130 in Northland – but Dow says they also have big roles in throat swabbing schools, including supporting the swabbers, taking child referrals, and helping track down families to ensure children with positive swabs get their antibiotics. And always, grabbing the chance to educate people that sore throats matter. “Anywhere we can get a plug in really.” In 2007, Herbert was Intro ??????? seconded to Kaikohe for six months to train kaimahi and support getting their school throat swabbing campaign underway, and then in 2008, she got the regional project co-coordinator position at Ngati Hine Health Trust and started taking calls from other regions keen to find out more about the Whangaroa model. Ngati Hine won the national coordination service contract for the $24 million Rheumatic Fever Prevention programme, and Herbert’s role is to keep all seven regions with high risk communities connected and working towards a consistent form of messaging, reporting, and training.


Resources and resourcefulness

A decade ago, there were also few rheumatic fever resources available to promote awareness.

Heart valve tragedy

The tragedy for cardiac nurse practitioner Andy McLachlan is that 50 per cent of his Middlemore Hospital valve clinic patients are there thanks to a childhood sore throat. Their untreated strep throat led to rheumatic fever and then on to heart valve failure, major surgery, and often a metal valve replacement, requiring them to be on warfarin for the rest of their lives. “You can imagine at 16 – your mates about to start their life, their career, join the army, whatever – and you are suddenly told you’ve got to have a major operation, a big scar down your chest, and you need to take these pills and have blood tests for the rest of your life.” “It can be a very challenging time. We have a lot of people who basically give up and can’t cope.” The consequence of that can be a big stroke in their 20s and they become even more disabled, or die. He adds that some people do very, very well, but others do very poorly. “I must admit it’s a very somber clinic ... it’s the valve clinic that makes me lie awake at night thinking about things.”


South Auckland randomised trial of school-based throat swabbing led by Professor Diana Lennon.


Whangaroa school throat swabbing project begins and other community projects follow in Kaikohe (2008), Opotiki (2009) and other high prevalence areas.


Heart Foundation rheumatic fever guidelines developed advocating throat swabbing and antibiotic prescribing for high risk patients with sore throats.


Ministry of Health advised to continue support for Healthy Housing programmes as “vital” and to put sore throat clinics in all high risk schools in New Zealand.


Government announces $12 million over four years for Rheumatic Fever Prevention Programme, including new school-based throat swabbing


Nursing Review series Infection Control/Wound Care 2012

programmes in high-risk areas (concerns raised in Counties Manukau DHB at low share of funding for their high level of disease).


»» Government announces doubling of rheumatic fever prevention campaign funding to $24 million, including community awareness raising, health professional training, and programme evaluation. »» Professor Diana Lennon advocates continuation of Healthy Housing programme funding as vital (not funded under RF Prevention Programme). »» Six new throat-swabbing initiatives funded by RF Prevention Programme involving 5000 children and 38 schools now underway in Porirua, Whangarei, Flaxmere, Kaitaia, South Auckland, and the Tuhoe area using local iwi and community health providers. »» More than 4700 swabs taken in past six months – on average about 10 per cent tested positive and were treated with ten-day course of antibiotics. »» Three more programmes involving 20 more schools due to start in October.

FOCUS n Infection Control/Wound Care

Head Intro ???????

Success, targets and setbacks?

The Government recently set a target of reducing the incidence of rheumatic fever cases by two-thirds by 2017. It will be hoping to replicate Whangaroa’s success. Whangaroa was so successful that Herbert says midway through last decade, the community even managed to go a whole year without any strep throat being detected. “I was saying to my colleague, ‘I can’t believe it – we’ve got no strep – we’ve done ourselves out of a job’.” But Strep A returned and positive swab numbers rose to levels as bad or worse as when the campaign started. While rheumatic fever has been kept at bay by Whangaroa’s swabbing campaign, Herbert is concerned that other socio-economic determinants like overcrowding, poor housing, and poverty means we may be seeing a trending upwards of Strep A and rheumatic fever nationally. Likewise, Dow says she would like to say that the numbers of children registering with rheumatic fever were falling in Northland. “We’d like to say yes, but no… we’ve not seen a huge change at this moment.” She says the Whangaroa project has worked “remarkably well” but Kaikohe had not been as successful to date and the Whangarei and Kaitaia programmes – only initiated this year – were still in their infancy. “If we can eradicate it, we certainly will, but it’s a long hard road and linked quite closely to environment and overcrowding and poor, damp, and uninsulated housing.” Maxine Shortland, Herbert’s manager at Ngati Hine, sees the whānau ora approach as a way of helping families work through issues contributing to strep throat risk, including referring families on to services that can assist and alleviate issues like housing. Dow says public health nurses also have strong links with WINZ and health housing and insulation programmes to get their families put on the list for help. “And hopefully, eventually get insulation and warmth.” Meanwhile, Herbert says one thing that they have learnt is that school communities without swabbing programmes don’t know that sore throats really do matter. “I’m definitely an advocate for these throat-swabbing projects as a means of getting the message through.”

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Sandra Ball

Third world stats shock nurse into action


ielding a big needle once a month doesn’t make Sandra Ball many friends with her young rheumatic fever patients. The district nurse grits her teeth as she injects the painful but necessary thick antibiotic paste deep into the child’s thigh or buttock. “It drives me nuts because it’s a really nasty procedure,” she says. “Usually, the kids leave limping, and you know you’re not their best friend as it hurts, but it keeps them well.” For most of her 20 years as a district nurse in Opotiki, she accepted as “pretty much normal” delivering monthly penicillin injections to stop these kids facing further bouts of rheumatic fever and risking major heart damage. But then she got a bee in her bonnet about so many kids getting rheumatic fever in the first place. She became one of the driving forces behind Opotiki in 2009 becoming a pilot school in the throat swabbing programme for the Eastern Bay of Plenty Primary Health Alliance. Other programmes have followed in Kawerau, Murupara, and most recently, a Tuhoe project. Ball now splits her time between district nursing for the Bay of Plenty District Health Board and being clinical lead for the Eastern Bay of Plenty throat swabbing programmes.

Third world stats

Ball, a mother of five, says it was her postgraduate studies that opened her eyes to the scale of the rheumatic fever problem in her community. A diploma paper asked her to look in-depth at a prophylactic treatment she carried out in her practice and she chose to look at the much-hated bicillin treatment. “It was then that I realised our (rheumatic fever) figures here were shocking, huge … third world stats!” Around the same time, a 2008 research project by public health physician Dr Belinda Loring, for Bay of Plenty’s Toi Te Ora Public Health Service, revealed that the true number of cases of rheumatic fever was double the official numbers registered and 90 per cent of the cases were Māori. It was found that a child in Murupara had a one in 39 chance of developing rheumatic fever during their childhood and a child in Opotiki one in 70. These compared with a one in 10,000 chance for the average Pākehā kid around the country. The statistics hit home hard and the district health board’s Toi Te Ora-Public Health Service started a series of major initiatives to increase community awareness that ‘sore throats matter’, including a web page, major newspaper and radio ad campaigns, resource material, and educating local GPs and practice nurses about the Heart Foundation rheumatic fever guidelines. Coordinating rheumatic fever initiatives alone is now half of Toi Te Ora communicable disease nurse Lindsay Lowe’s job. Ball still had a bee in her bonnet, and with the motivation of ‘fabulous paediatrician’ John Malcolm and the word from Belinda Loring that funding could be available, she started lobbying her local primary health organisation (PHO) to back a school throat swabbing project modelled on Whangaroa’s intervention. 8

A cry for help

She made the very most of the Opotiki district nursing office being just down the corridor from the office of the PHO manager. “So every time we did a bicillin and the child cried, you’d whip round the corner and say ‘Did you hear that child cry? That’s preventable. It shouldn’t be happening.’ and kind of planted the seed with them.” Not surprisingly, the PHO came in behind her, and in mid-2009, successfully sought DHB funding for Opotiki to be a school throat swabbing pilot project for the Eastern Bay of Plenty area using a local iwi provider. With “immense” support from the DHB’s public health service, including publicity advice and ensuring proper research evaluation was imbedded in the project, the Opotiki pilot programme got underway in term three of 2009, with Ball as part-time clinical lead. There are now four programmes underway covering more than 4000 pupils in 26 low decile schools. In term two, nearly 3500 swabs were taken, with 12 per cent coming back positive, prompting antibioticIntro prescriptions ???????to keep rheumatic fever at bay. Ball says an important part of the programme was engaging the GP practices they rely on for prescribing, at a nominal fee, the essential antibiotics. And to prescribe the ‘best practice’ once a day amoxicillin for ten days rather than expecting stressed mums and kids to remember to take antibiotics three times a day. As clinical lead, Ball trains and supports the nine community health workers – mostly local young mums but also one “amazing” 73-yearold Nan – who do the day-by-day school visits offering, twice-a-week, every kid in every class the chance to put their hand up and say they have a sore throat that needs swabbing.


Tutohia Huriwaka of Opotiki was six years old when he had his first attack of rheumatic fever, and in 2009, he had to have surgery at Starship to repair his damaged heart valve. He is the shy cover boy of the Opotiki rheumatic fever pamphlets and reckons his photo should be updated as he looks ‘cooler’ now.

The big picture

Awareness promotion by the community workers, including using popular resources like the Heart Foundation Bro’ Town comic series, have helped bring the sore throats matter message home. Another promotion was the use of localised pamphlets for Opotiki, Kawerau, and Murupara, produced by Lindsay Lowe and the Toi Te Ora Public Health Service team, each featuring a home town kid on the cover who’d had rheumatic fever – two of them resulting in heart valve surgery. Ball says it means a lot to local kids that the pamphlets feature someone they know. “The kids are absolutely fantastic … they are really, really good, and they’ve got the message that sore throats matter.” To date, rheumatic fever has not been entirely eliminated in the throat-swabbing communities, but research evaluator, Russell Ingram- Seal, assures Ball the numbers are trending downwards. “I kind of get reminded not to get disheartened because of the big picture stuff – the fact that the kids do have the message really strongly now and the families too really have it on board. In the big picture, what we are doing is working.”

Nursing Review series Infection Control/Wound Care 2012

Michael Savage, the Kawerau pamphlet cover girl, was eleven when she got rheumatic fever, and ended up spending three weeks in hospital. Now a teenager, she recovered well – playing volleyball in the summer and soccer in winter – but she still needs the monthly antibiotic injections.

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South Auckland

Re-educating nurses and GPs

ITS NOT JUST parents and kids that need to know “sore throats matter” but also the doctors and nurses the families front up to. “So when you get an awesome mum taking their child into the doctors with a sore throat, they don’t get someone pecking at their throat and saying ‘oh no, that’s not red enough, it can’t be a strep IT WAS IN SOUTH AUCKLAND that found again for sore throat clinics in throat’,” says a frustrated Sandra Ball. “I think, crikey dick, if you knew school-based sore throat clinics were South Auckland. how hard we had to work to get them through that door, you’d praise first trialled in New Zealand. “As a public health nurse, you them and educate them.” More than a decade later, the feel a sense of despair when you Ball says it’s not a blame game as for much of her 20 years of region, with the highest rheumatic see young people whose potential mothering and nursing, she too was trained, and trained others, to fever burden in the country and is blighted by an easily prevented think sore throats were probably viral, needing rest not antibiotics. She about 500 young people on the disease.” believes that message has come at a cost, with rheumatic fever in her register, is being funded to roll out Farrell teamed up with Lennon community hitting kids with great mums and great families. clinics again. Following a pilot last again last year for a research “They are really diligent families at looking after their children, and year, the South Auckland clinic project piloting a public health they wouldn’t want to think it was about poverty and they do live in model includes a public health nurse nurse-led, school-based primary good houses. There’s more to it… Registered Nurses per 400 children to address wider health care programme at “When you are a mum on a budget and you cart your kids in with health issues. Wiri Central Primary School that, a sore throat Mental and that’s the message your health professional gives Health & Forensic The initial 1998-2001 along with daily health worker throat you, then the next time yourDunedin kid gets a sore throat, you are going to & Invercargill randomised-controlled trial of sore swabbing, included nurses assessing do exactly what your health professional tells you – which is rest and throat clinics was lead by Professor skin infections and working with the maybe paracetamol and fluids. Full and part-time Diana Lennon of the University of wider family. “It works for most of our population, but we just missed that in some Auckland and involved about 24,000 We know, together we can make This has led to a different model of our communities, overcrowding and higher strep levels means it’s a children attending 53 historically a difference. We’re big enough to heck of a lot safer to take sore throats more cautiously.” of sore throat clinic being offered in high risk schools for rheumatic fever. be supportive of our superb team, Which means reaching for a throat swab and prescribing antibiotics South Auckland. Pupils at the 26 control schools enough to allow them to straight-off for those at high risksmall of having strep throat. The National Hauora Coalition received usual GP care and pupils make a very personal difference to Helen Herbert (pg4) agrees it is important but sometimes challenging, won the Ministry of Health contract at the 27 sore throat clinic schools their patients.prescribing re-educating GPs in high risk areas to change longstanding to fund throat swabbing three days received school-based education Intro ??????? habits and approaches to sore throats. a week in 18 schools in Counties The career you have chosen and throat-swabbing by community “I do understand that for years isthey’ve been told ‘don’t Manukau DHB, with the first clinic challenging, at the sameprescribe’,” health workers, with public health says Herbert. Kialaunched Tiaki in late July at Rongomai time it has unique rewards only nurse follow-up for positive swabs. Communicable disease nursethose educator Dow health acknowledges there School. withinSue mental can The major research project, was some nervousness that theappreciate. Northland Explore campaign lead to overCounties Manukau has stepped in thewould options funded by the Health Research prescribing or unnecessary prescribing of Contact antibiotics. with us. Lucy Butler to fund further child health services, Council, Heart Foundation, and “But we’ve stuck rigidly to Heart Foundation guidelines. If Māori and so the sore throat swabbing can be Ministry of Health, led to a 28 per Pacific aged between 3 and 45 present sore we treat that 03 470 with 9571aor Janthroat, Strachan offered five days a week and for one cent reduction in rheumatic fever. (seriously). Because we don’t know that if we don’t, it won’t jan.strachan@southerndhb.govt.nzbe the next public health nurse per 400 children Lizzie Farrell, clinical nurse case of rheumatic fever.” 03 214 5770. to offer wider child health services to manager for Kidz First public health Dow has also been working to bring home the same message to pupils and their siblings. nurse team at Counties Manukau Northland nurses across the spectrum from paediatric wards to general Farrell says the model is not District Health Board, was part of practice. totally school-based, with the school the project and experienced the “It hasn’t been fast, it’s been slowish, but I think we are making to be the hub for working with the frustration of it taking another inroads now into nursing awareness that sore throats matter and to get decade of lobbying, and the efforts school’s wider community, including them treated as quickly as possible.” of the Māori Party, for funding to be issues like healthy housing.

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hide from mental health Registered Nurses - Mental Health & Forensic Dunedin & Invercargill, Full and part-time We know, together we can make a difference. We’re big enough to be supportive of our superb team, small enough to allow them to make a very personal difference to their patients. The career you have chosen is challenging, at the same time it has unique rewards only those within mental health can appreciate. Explore the options with us. Contact Lucy Butler 03 470 9571 or Jan Strachan 03 214 5770.

Nursing Review series Infection Control/Wound Care 2012

NZ Nursing Review


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“There is a misconception amongst some in the medical profession that the call for hand hygiene is nurse-led hype and isn’t based in hard science.”

Head ‘Dishing the dirt’ on hand hygiene Intro ??????? Keeping your hands clean? Maybe not. National statistics show Kiwi nurses are missing one in three occasions they should be reaching for the hand gel. FIONA CASSIE looks at the Hand Hygiene New Zealand programme.

O Christine Sieczkowski

Joshua Freeman

Louise Dawson


n the one hand, it’s simple stuff: keep your hands clean … because on the other hand it could be bacteria that will blight your patient’s recovery at great cost to them and your hospital’s budget. But the reality is that hand hygiene in our hospitals doesn’t scrub up that well, and keeping your hands clean is easier said than done. The Hand Hygiene New Zealand (HHNZ) campaign seeks to educate health care workers about not only when, but also why, to use hand hygiene. The Health Quality & Safety Commission-funded campaign includes a national auditing programme to see how many hand hygiene opportunities are taken, or missed, and what impact this has on common health-care associated infections. Finding out just how often they’ve skipped cleaning their hands comes as a shock to many nurses, says infection control nurse Christine Sieczkowski. She is Infection Prevention & Control Coordinator for Auckland District Health Board – the DHB contracted to deliver the national hand hygiene programme since its first beginnings back in 2008. Sieczkowski says hand hygiene has always been core business for infection control nurses, but up until now, programmes were ad hoc up and down the country and often took a back seat as already stretched teams coped with infection outbreaks and other competing clinical issues.

Nursing Review series Infection Control/Wound Care 2012

And hand hygiene is a topic many people dismiss as old hat. “Yeah, hand hygiene ... what else can you tell us about hand hygiene? How hard can it be?” is not an uncommon response, says Sieczkowski.

Shock at initial results

When a baseline audit revealed Auckland DHB health care workers were cleaning their hands only about a third of the time they should be, it came as a shock to many. But not to Sieczkowski and her auditor team, who knew from the international literature that initial compliance rates were likely to be low. The baseline audit was just that – finding out the level of hand hygiene compliance, prior to educating staff why and when they should be carrying out the World Health Organisation’s Five Moment for Hand Hygiene (see box). That audit was also prior to ensuring alcohol-based hand gel dispensers were attached to each and every patient bed –

so health care workers don’t have to waste time hunting for the closest gel dispenser. Sieczkowski says with 56 wards to equip, this was no simple task, with the first lengthy obstacle being tendering for a quadrupling of hand gel dispensers and gel. The second was keeping gel bottles firmly attached to the patient’s bed, so they didn’t mysteriously disappear when orderlies wheeled a patient to surgery or radiology. “We kept joking that there must be a black hole somewhere swallowing up all these missing bottles.” The effort to educate and make easier compliance to the ‘five moments’ has made its mark. An evaluation three years down the track of Auckland’s pilot HHNZ programme (as published in a recent New Zealand Medical Journal article) showed hand hygiene compliance had risen to 60 per cent, and at the same time, the reduction in Staphylococcus aureus bloodstream infections was statistically significant.

The Five Moments for Hand Hygiene 1. Before patient contact. 2. Before a procedure. 3. After a procedure or body fluid exposure. 4. After patient contact. 5. After contact with patient surroundings.

World Health Organisation 2002.

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How well are we doing?

A flash mob “throw their hands up in the air” to Taio Cruz’s tune Dynamite to mark World Hand Hygiene Day this year at Auckland DHB (viewable on You Tube).

The HHNZ programme has since been rolling out around the country, with the 20 boards now at various level of implementation – some still struggling to get gel at every bed and others with more established programmes and experienced auditing teams. Seventeen out of 20 DHBs took part in the last quarterly hand hygiene audit, with national compliance results averaging 62.3 per cent (compared to 75.7 per cent in Australia, which has a more longstanding campaign and is the origin of our auditing system). Joshua Freeman, an Auckland DHB microbiologist and clinical lead for HHNZ, says there is a growing body of evidence that actually following the WHO ‘five moments’ makes a real difference to patient outcomes. “But it requires a culture change, as people not only need to know what to do, but they also need to know why it’s important and believe in it.” So how dirty are our hands? Getting that culture change takes different strokes for different folks. Sieczkowski says nurses – ever practical – want visual, physical proof of exactly how dirty their hands are.

“So we plate up the agar plates, get them to put their fingers on their plates and see what grows in the lab.” This is pretty effective in convincing them their hands aren’t squeaky clean. Also effective is getting nurses to use a ‘glow’ hand cream, wash their hands like normal, and then put their hands into an ultra violet light box. Any cream left on will let off a tell-tale glow, revealing weaknesses in their hand hygiene technique. It literally highlights the areas most likely to get neglected like around the thumbs, wrists, under fingernails, and between fingers. Sieczkowski says it also brings home the message about why jewellery wearing is discouraged. Doctors are more sceptical. They want research-based evidence on why they need to clean their hands so frequently. They also regularly score well below nurses in their hand hygiene compliance (see sidebar). Freeman says there is a misconception amongst some in the medical profession that the call for hand hygiene is nurse-led hype and isn’t based in hard science.

»» Nationwide nurses are cleaning their hands 65 per cent of the times required (i.e. missing 35 per cent of the potential 13,000 plus hand hygiene moments observed by auditors). »» This compares to 57 per cent compliance by medical practitioners, 64 per cent by health care assistants, and 72 per cent by phlebotomists. »» Health care workers FAIL to perform hand hygiene TWICE AS OFTEN when WEARING GLOVES as when not wearing gloves (38.3 per cent compared to 18.4 per cent). »» Health care workers are most likely to carry out hand hygiene AFTER touching a patient (71 per cent) than BEFORE touching a patient (56 per cent). »» Nearly double the number of district health boards (up from 9 to 17 DHBs) submitted audit data in the latest quarter than the previous quarter. »» DHBs are all at different stages of implementing the national hand hygiene programme and compliance rates range from 38.4 per cent to 73.7 per cent. »» National collecting of health care associated Staph. aureus bloodstream infection rates is also now underway. Source: National Hand Hygiene Compliance Audit June 2012. “A lot of my work is to try and explain that there’s a very compelling scientific rationale to performing hand hygiene,” says Freeman. It’s also very important to get senior medical staff on board to champion hand hygiene. “Positive role models can have a hugely positive, but negative role modelling, and a publicly dismissive kind of statement, can also have a very negative effect on the hand hygiene practices of more junior colleagues looking up to their seniors.” Flash mobs and league tables The trick is not just to improve hand hygiene compliance but also to keep improving and not slip back into complacency. This is where Louise Dawson comes in, a registered nurse turned baby product entrepreneur, who in January brought her marketing expertise to a new role as Auckland DHB’s first dedicated hand hygiene coordinator.

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Nursing Review series Infection Control/Wound Care 2012


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FOCUS n Infection Control/Wound Care Banner unfurled at hand hygiene flash mob

wards she has worked with to date having a 25 per cent increase in compliance in the latest audit. This, in turn, brings up the whole board’s compliance rates. With the board having gone through a particularly tough May and June – leading to nurses managing a lot more patients and a lot more being asked of them – she is also aware hand hygiene can sometimes slip because of barriers like multiple pressures on nursing time.

Stretched resources and auditing demands

Dawson is ready to use emotive appeal, league tables, inter-ward rivalry, peer pressure, and afternoon tea bribes – as well as science and statistics – to improve hand hygiene compliance. This year, she even injected some fun into International Hand Hygiene Day by launching a flash mob on an unsuspecting lunchtime crowd at Auckland Hospital. About 50 volunteers had several lessons with a local dance studio before “throwing their hands up in the air” to 2010 smash hit Dynamite. “It created quite a buzz around the hospital,” says Dawson. A major focus of her job is motivating the ten high risk wards for infections, which are audited quarterly for the HHNZ national compliance audit, to improve their compliance rates, including training one or two hand hygiene observers (or champions) per ward. Dawson’s resource toolbox includes a video (of an ex-patient sharing their real life story of having a hospital-acquired bloodstream infection) that pulls an emotional punch and cold hard statistics on what such infections cost the hospital. Another powerful motivator is competitive rivalry, and she used the last quarterly audit results to rank and compare the combined scores of nurses, doctors, and other health care workers across the ten wards. “That’s a first for ADHB. We’ve never really done league tables,” says Dawson “But it’s been a real driver for change.” The ward doctors at the bottom of the league table were very sceptical of the auditing process, opening up an opportunity for further education. “But those doctors, nurses, and health care workers at wards that got the best results weren’t sceptical at all.” Her overall approach is working, with the six

Another passionate believer in the HHNZ project is Jo Stodart, charge nurse manager for infection prevention control at the Southern District Health Board. Like Sieczkowski, she has been trained to platinum auditor level by Hand Hygiene Australia – just one of six in New Zealand – to ensure that all auditors trained across the country use the same consistent standards. And like Dawson, she knows each organisation can come across barriers or challenges – temporary or more complex – to improving and maintaining their hand hygiene compliance, including competing priorities for quality initiatives. She says for her small infection control team, the hand hygiene culture change campaign has to be part of business as usual, including labour intensive audits each quarter of the national reporting wards. Auditors have to pop in and out of wards at different times of the day, keeping a watchful eye out for each hand hygiene “opportunity” (missed or taken) to get their quota of moments. In the last national audit, 21,660 moments Intro ???????were observed across the 17 boards. “They say it takes a minute a moment,” says Stodart. She thinks this is probably a conservative estimate and those 20,000 plus moments represents many, many hours of auditors’ – mainly infection control nurses’ – time. It is also represents a lot of hand cleansing by busy health care workers – a level logistically impossible before the advent of convenient and effective alcohol-based hand gel. Dawson says a rough rule of thumb is roughly 70 per cent hand cleaning with alcohol rub to 30 per cent oldfashioned soap and water. Sieczkowski says having moisturiser in the hand gels also means they are well tolerated. “I could count the people on one hand who have gone to occupational health with problems.” Stodart is not so sure and believes it may be an under-reported issue. The passionate hand hygiene advocates are all united in backing a culture change, which is simple in concept if more complex in reality, that can make such a difference to patient safety. “We’re always keeping in sight the patient in bed who hopefully won’t get a hospital-acquired infection,” says Stodart. “It needs to be just as automatic as putting your seat belt on.”

Quality and Safety Marker Launch


Keeping infection rates down in hospitals is one of the new Quality and Safety Markers soon to be officially launched by the Government. The markers have been developed by the Health Quality & Safety Commission and will focus on reducing harm in four critical areas: »» Health care associated infections (also known as hospital acquired infections). »» In-patient falls. »» Surgery. »» Medication errors. Details of the markers will be reported publicly and regularly. HHNZ clinical lead Joshua Freeman says the new markers will help focus attention on the importance of hand hygiene.


Nursing Review series Infection Control/Wound Care 2012


The rise and rise of antibiotic resistant super bugs is a major driver behind hand hygiene campaigns internationally. Evidence that a successful hand hygiene “culture-change” campaign in Victoria significantly reduced blood stream infections from methicillin-resistant Staphylococcus aureus (MRSA) was behind the launch of the national Hand Hygiene Australia campaign that the New Zealand campaign is built on. Another motivator is the crude dollar cost to the health care system of preventable health care associated infections (HCAIs) from all bugs, including everyday Staphylococcus aureus. Joshua Freeman says decade old data conservatively estimates the cost of HCAIs in order of $140 million. Then there is the personal cost to the patients’ themselves. “If you want to look at it purely in financial terms, the arguments there, but if you want to look at in humanitarian terms, I think it’s the right thing to do ethically. We are under obligation to do this for our patients,” says Freeman. “There’s still a mentality out there that HCAIs are the inevitable consequences of modern health care and they can’t be prevented as ‘oh well, the person was very old’ or ‘the person was very sick’ or ‘they had to have a line in’ and their infection was unavoidable.” However, evidence shows that simple interventions like hand hygiene can put a huge dent in infection rates. Both the Australian and New Zealand campaigns are built on Five Moments for Hand Hygiene. These aim to not only prevent bacteria spreading from one patient to another but also to stop transmitting a patient’s own bacteria from one site to another like, for example, from a contaminated catheter to an infectionvulnerable site like an IV cannula. This has led to the ‘moments’, stressing the need for hand hygiene before and after procedures, including contact with any indwelling device. The fifth ‘moment’ highlights the fact that a patient’s immediate surroundings become contaminated with the patient’s bacteria, so if their chart is picked up, their locker shifted, or their bed remade, nurses are being exposed to bacteria and need to clean their hands. The risk of contamination is always heightened by the chance the bacteria is antibiotic resistant. Freeman says some of these bugs are becoming virtually untreatable, and there is little commercial incentive for drug companies to develop new antibiotics to counter them if a resistant variant quickly emerges. “It makes sense that we change our focus from treatment to prevention (of infections) and we increase our efforts and raise the bar to prevent them as the stakes have become higher,” says Freeman.

FOCUS n Infection Control/Wound Care

Something old

and something new FIONA CASSIE talks to Victoria’s doyenne of wound care, Jan Rice*, about new wound science, old-fashioned wound cleaning, and eating to heal.


ound care is not rocket science, but it definitely is science. The army of cell platoons mobilised in response to a wound – and the elaborate web of signals they send each other to guide the healing process – is complex to say the least. Jan Rice is a wound care nurse specialist and more than comfortable with discussing the usual suspects of macrophages, fibroblasts, and platelets but also anti-inflammatory cytokines, matrix metalloproteinases, and the some of the mindboggling 300 growth factor substances now discovered that trigger and direct cellular function. After decades of specialising in the field, and being brought in as consultant to the most challenging of chronic wounds, Rice knows how important it is to learn the science behind healing. “We have to know what is normal to be able to recognise what is abnormal.” So to know the cellular process in the phases of healing – from blood clotting and inflammation through to granulation and final epithelialisation – is to have insight when the right cells or ingredients are missing in action or the cellular signals have gone haywire and the wound has failed to move on to the next healing phase. She does not expect fellow nurses to be leading the science – the scientists are still struggling to work out when and how to use growth factor substances to aid healing – but does advocate knowing the science that can help guide clinical practice. That science includes research showing that patients taking anticoagulants are more at risk of haematoma, or that macrophages (the very important “boss” scavenger and cleaning cell) are less efficient in diabetics, or that if inflammation goes beyond 72 hours, then something is likely to have gone wrong at the start of the healing process. When informed observation doesn’t give you the answer, a blood test often can.

“I say blood is the essence of life, and if a wound isn’t healing, do a blood test and then go back and take a look at the bigger picture of the person.” As the health professional’s role is to help restore the person both physically and mentally to be in the best shape to heal (her keynote address on Wound management – do we have the answers??????? yet? can be found under wound Intro education at her website Rice says correct wound bed preparation (including a thorough cleansing of the wound) is also important in giving a wound the best chance to heal. She says though it still remains controversial, the pendulum has swung back against the gentle cleansing by swabbing taught in the 1990s. “We need to get a bit rougher,” says Rice. “When we first learnt about moist wound healing, we were taught to be gentle with the wound, and we’re told ‘it’s trying to heal and you are traumatising it’. “But we need now for people to go back and give [the wound] a good clean and that might require a bit more pressure and a bit better technique.” Of course, if it is going to be painful, give your patient something first. The research shows it is not necessary to clean a wound with saline – if the water is safe to drink, it is safe to clean a wound. The water should also be warm as it is less painful and cold saline or water can shut down healing cells when they are most needed. She says they now recommend that the majority of wounds be cleaned in the shower or in a bucket of warm water.


Jan Rice

*Melbourne-based Jan Rice was a keynote speaker at the recent NZNO College of Primary Health Care Nurses conference in Hamilton. The registered nurse is a recognised Australasian leader in the field of wound care. She is co-coordinator of wound care management education at Melbourne’s La Trobe University, runs a weekly wound clinic in general practice, and is a private wound care consultant to aged care, general practice and surgeons. She is also a Colonel in the Australian Defence Force reserve and a volunteer with international plastic surgery aid group Interplast.

The choice of dressing is also important. By looking at the tissue, a decision can be made on what the tissue needs. For example, if there is necrotic tissue that needs debriding, a dressing can be used that aids the debriding process. The range of dressings available can be mindboggling and expensive but Rice points out you don’t need to have them all – just the ones that work best for you in your setting. “You only need to have about seven dressings.” “The big thing is that nurses need to understand how the dressing works – its functionality – more than knowing just the name.” She also reminds that it’s not the dressing that heals the wound but the body. “If you have the most expensive, best dressing on the market and a malnourished body, the wound is not going to heal.” Rice says there is lots of evidence now on the role of nutrition in healing. “They say that a minor trauma (small wound) increases our basal metabolic rate (BMR) by ten per cent and severe burns increase your BMR by 100 per cent.” “For a nasty wound to your leg, you may need 40 per cent more nutrition because you are going to need all that energy to heal.” Therefore, that means more vitamin C, more protein, more zinc, and all the other components of good nutrition. Rice says the best analogy is that while a patient may appear to just be lying in bed, their body is doing the equivalent of a marathon in working to heal their wound.

General principles of wound management »» Define aetiology: have a name for the wound type, hopefully with some evidence to back its pathology. »» Control, when possible, known factors influencing healing. »» Select appropriate wound care product, device, or treatment regime based on site, size, volume of exudate, tissue type, and aim. »» Plan for maintenance of healing or current state and make no worse.

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FOCUS n Infection Control/Wound Care

The wounds that time won’t heal FIONA CASSIE talks to New Zealand Wound Care Society president Wayne Naylor about his wound care career, fungating wounds, and a palliative approach to wound care.


ome wounds empty rooms. The smell is so pungent that it has nurses gagging. Malodorous, fungating malignant wounds are challenging for seasoned health professionals, so one can only imagine how distressing it is for the cancer patient living and dying with the wound. Wayne Naylor’s nursing career has brought home to him that, just sometimes, wound care is not foremost about healing. Sometimes, there is no healing potential or simply no time to heal. Instead, it is about doing your best to ameliorate distressing symptoms, to reduce suffering, and to address a patient’s holistic needs by taking a palliative approach to wound care. The cancer wound care expert trained at Otago Polytechnic in the early 1990s when new interactive wound dressings first caught his interest. After a short stint in mental health, he built on that initial interest by working at Middlemore’s reconstructive plastic surgery and burns unit. On Naylor’s OE, he fell into an agency job at London’s Royal Marsden Hospital, at the time, the largest comprehensive cancer centre in Europe. He ended up spending five years there, inevitably becoming interested in cancer too, and he merged his two interests in the late 1990s by becoming Marsden’s first wound management research nurse at the same time as completing an honours degree in cancer nursing. Two kids later, he and his family returned to New Zealand in 2002 for him to take up a cancer clinical nurse specialist position in Wellington. His career since has continued to have a cancer or palliative focus, from his recent palliative care analyst role with the Cancer Control Council, to his new position as director of nursing for Hospice Waikato (he is also currently working on his PhD, looking at symptom prevalence and clusters in palliative care patients). But Naylor’s parallel passion for wound care has also continued. So much so that he’d been in Wellington less than a week back in 2002 before he found himself nominated as local coordinator for the Wound Care Society. He has now been


the society’s national president for nearly four years, and he has seen membership more than double in the past decade to just short of 500. The society, like the specialty itself, is dominated by nurses. Naylor says he likes the independent nature of working in an area where generally worldwide nurses hold the expertise. Wound care is also an area open to innovation, and as a creative person outside of work – his hobbies include bone-carving, drawing and jewellery – he likes putting his

reaction – often mistakenly called a radiation burn – which is caused by the skin absorbing too much radiation, resulting in an affect similar to “very, very bad sunburn” where the skin peels off, leading to the risk of infection. The third can follow if a bone marrow transplant triggers a ‘graft versus host’ reaction (the donor graft attacks the host body as a foreign object) affecting the skin, causing large blisters and skin loss. “I have seen people lose skin off

Head Intro ???????

A fungating, malignant wound

creative and problem-solving skills to work to find solutions for patients. Combining cancer nursing and wound care, as his London role did, was innovative on its own, with only one other nurse in the UK at the time, and very few globally, specialising in wound care management in cancer or palliative care patients. The type of wounds particular to cancer patients receive little research and the small volumes mean they attract little interest from the wound dressing companies, so a cancer wound specialist can’t readily find research literature on the topic or pull a dressing off the shelf to meet their patient’s needs. Naylor says there are three types of wounds that usually aren’t seen outside of cancer patients. The first are malignant, fungating wounds, where the cancer is actually growing out of the wound or causing ulceration. “So you have not only a wound but also an active cancerous tumour.” The second is radiotherapy skin

Nursing Review series Infection Control/Wound Care 2012

their entire bodies.” All three wounds are terribly debilitating, but the malignant fungating wounds usually occur in the last six to 12 months of the person’s life, so their wound care also becomes part of their palliative care. Naylor says some of the more distressing symptoms of a fungating wound can be exudate oozing from the wound, and sometimes, a pungent malodour arising from the wound. Bacteria in the wound can release foul-smelling cadaverine and putrescine chemicals that – like they sound – smell similar to rotting flesh, and gagging is a common reflex. He can recall nurses removing everybody from outpatients after the smell from a person’s fungating wound had permeated the whole department. “You had nurses setting up essential oil burners to try to get rid of the smell.” To have health professionals’ struggling to stay in the same room with you because of the smell is

distressing for a patient. Naylor says he has never become accustomed to the smell, but he focuses on the person beneath the wound and reminds himself that if it’s bad for him, it’s hundred times worse for them. Not surprisingly, people living with this wound can feel socially isolated and become depressed, angry and withdrawn. “You need to look at the whole care of the patient from a holistic point of view.” This includes carrying out a full patient assessment and history to find out what has led up to the fungating tumour and then explaining to the patient what is causing the smell and what can be done to treat it. Treatment includes debriding necrotic tissue, using topical or systemic antibiotics, and using antimicrobial or odour absorbing dressings on the wound like activated charcoal, silver, occlusive dressings, or honey. Naylor’s recent work in palliative wound care has seen his wound care focus swing to taking a palliative wound care approach to not only people dying with wounds but also people living with wounds that are not expected to improve or heal. “The vast majority of wounds can be healed, but I think there’s always going to be a group, for various reasons, where healing is not going to be achievable,” he says. He says this is no excuse for poor wound care. A full patient assessment and history may highlight a number of patient and wound factors – such as how long the wound has been there, co-morbidities, age, and the patient’s ability to tolerate or follow-through the treatment regime – that may mean healing this person’s wound is not a realistic goal. “Instead, you may need to get on with helping that person live their life as best they can while managing the wound as well,” says Naylor. “You may be able to set other goals like removing the odour, stopping exudate leaking, making it pain free, and ensuring they are not socially isolated. Achieving these goals may be possible and realistic, so both the patient and health professional can see you are making some positive steps.”



Reading, Reflection, and application in Reality By Shelley Jones

Health Literacy

Patient-centred communication is still the answer Health literacy has been described as an evolving concept. Its origins are in health promotion, where it was seen as personal skill development through education – in other words, a process of empowerment. More recently, health literacy has been viewed through the lens of patient safety – as a protective process. Either way, if lack of health literacy is a problem, whose problem is it? It’s ironic that health literacy is the new thing needed to ‘navigate the health system’ at a time when health administrators are realising that overly complex systems need to be simplified and made safer. In this learning activity, we’ll look at core ideas in health literacy, and how it can be understood as an interactive and responsive process between consumers and providers of healthcare services. LEARNING OBJECTIVES

WHAT IS HEALTH LITERACY? A theoretical perspective One literature review and concept analysis found five attributes for defining personal health literacy1: Reading as a skill set: including recognising words and their meanings, analysing context to understand new terms, and using text structures, such as headings and indexes, to find information in written materials. Numeracy or quantitative literacy: the ability to read and understand numbers appearing in print and do calculations. Comprehension or understanding: the process of making sense of new information in context and relating it to prior knowledge or experience. Being informed and capable of using that information in health decisions about lifestyle, using services and choosing amongst self-care or treatment options. Functioning successfully in a healthcare consumer role – i.e. navigating the healthcare system by applying new information and problemsolving skills as circumstances change.

The consumer perspective Speaking from a range of health service experiences, patients in a comprehensive qualitative study identified these key abilities: ►►knowing when and where to seek health information ►►being able to describe one’s health issues and understand health professionals’ responses ►►being assertive in clarifying information to understand it ►►literacy skills ►►retaining and processing information ►►applying information2.

Reading and reflecting on this article will enable you to: »» Describe components of health literacy. »» Outline reasons why health literacy is important. »» Identify ways your role can promote health literacy. »» Explain why health literacy has come to be seen as a process of interaction.

An evolving concept and context Some writers frame health literacy as a set of skills for use within healthcare settings, others as a capacity to make decisions and choices about health and wellbeing in a broader societal context 3 . The notion that citizens have responsibilities (to manage their health and choose a healthy lifestyle) that balance their rights (to healthcare and as consumers of healthcare services) means that health literacy clocks in with self-management as an idea whose time has come 3,4 . Broadly speaking, ideas about health literacy lie on a continuum: from a close alignment with the basic functional literacy skills required to follow treatment plans and use health services properly, to a wider conception of literacy as a process of personal and community self-determination and transformation, which includes addressing questions of access and equity, and socioeconomic determinants of health 5 . Definitions of health literacy seem to vary according to their historical context (i.e. contemporary thinking, policy developments, and characteristics of health service provision) and whether the perspective is health or healthcare at an individual, system, or population level.

An integrated definition A recent integrative review of seventeen definitions and twelve models arrived at this comprehensive and ‘all inclusive’ definition:

Health literacy is linked to literacy and entails people’s knowledge, motivation, and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention, and health promotion to maintain or improve quality of life during the life course 6 .

This definition can be fitted to individuals by replacing the public health perspective with a personal health perspective: ‘…and take decisions in everyday life concerning being ill, being at risk, and staying healthy’6 .

WHY HEALTH LITERACY MATTERS #1 Patient outcomes In relation to health outcomes for individuals, lack of health literacy is seen as a risk factor and having it seen as a personal asset at three critical points – accessing health care, interacting with health professionals, and self-care 5 . Compound difficulty at these three points, and it becomes obvious why adequate health literacy is thought to be especially important in conditions that require significant and complex self-care7. A recent systematic review for the United States-based Agency for Healthcare Research and Quality (AHRQ), commonly cited, reports good quality evidence for associations between lower health literacy and use of healthcare services: increased hospitalisation, greater use of emergency care, lower use of mammography, and lower use of influenza vaccination; health outcomes: poorer overall health status and higher risk of mortality for older people, poorer ability to interpret labels and health messages, and to demonstrate taking medications appropriately8 . The idea that assessing health literacy – ‘the newest vital sign’ – would help clinicians better meet patients’ learning and communication needs has been supported with the development of validated tools acceptable to patients and quick to use 9,10 . But there are several arguments against assessing patients’ literacy:

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Health Literacy Patient-centred communication is still the answer »» approaches recommended for those with

limited literacy (such as easy-to-read materials) should be considered ‘universal precautions’; »» all patients have the right to jargon-free explanations and to have clinicians confirm their comprehension – clear communication is not a scarce resource for targeting those most in need; »» screening has the potential for harm – those with limited literacy can feel ashamed about their lack of reading and writing skills and may be adept at concealment – in such situations, assessment may be stigmatising and alienating; »» clinicians are reluctant to conduct assessments that could embarrass patients with limited literacy11,12,13 .

#2 Demands of modern healthcare Our health care system places significant reading and comprehension demands on individuals 14 . The good news is that the great majority of [the] population is deficient only in literacy skills – not in intelligence. They can learn from nearly any health instruction that is designed and presented in ways suitable for them 15 .

Parallel to the realisation that a significant proportion of adults may have limited reading and numeracy skills is the realisation that healthcare information is often not well-designed and exceeds the abilities of people with average or good literacy, and that common tasks for patients (adjusting medications and understanding clinical results or nutrition information) require reasonable numeracy skills12,14,15 . Moreover, advances in clinical science and evidencebased medicine require advanced numeracy skills for clinicians and patients alike in understanding probability in disease risk and treatment benefit 16,17. Considerable research effort has been given to determining which methods and approaches reduce cognitive burden and are effective in meeting patients’ information and decision-making needs. There are many evidence-based resources designed to help clinicians: »» ensure that health materials use plain language, and conform to information design principles such as ordering, chunking, readability, and testing with end-users16 »» present numerical information and concepts in visual formats that facilitate understanding, such as decision-aids with graphic representations of incidence and probability17,18 »» remember that ‘telling is not teaching’ and ‘what is clear to you, is clear to you’ and to use effective teaching methods (such as limiting information-giving to just a couple of important points, using interactive communication strategies or

BACK TO THE FUTURE The Ottawa Charter of 1986 outlined a bold vision in five health promotion actions. The fourth action was to support ‘personal and social development through providing information, education for health, and enhancing life skills … [thus increasing] … the options available to people to exercise more control over their own health … and to make choices conducive to health’. The fifth action asked health care systems to reorient themselves in several ways: one was to move beyond providing clinical and curative services, to an expanded mandate of culturally sensitive and respectful health promotion; another was to change the attitude and organisation of health services to refocus ‘on the total needs of the individual as a whole person’27. the ‘teach-back’ method, checking for comprehension, and reinforcing over time) 9,12,19,20 .

#3 Patient safety The safety of patients cannot be assured without mitigating the negative effects of low health literacy and ineffective communications on patient care 12 .

Improving health literacy contributes to patient safety, in that better knowledge and understanding helps people ask the questions that need to be asked about their care, makes them aware of (and helps them avoid) risks associated with treatment and helps them join up fragmented services13 . Facilitating and supporting patient involvement in safety practices acknowledges what they already know: that health systems and clinicians can fail in their duty of care. Approaches that involve patients in ‘checking with’ rather than ‘checkingon’ build the care partnership, and rather than undermining clinicians, support the mindfulness that keeps practice safe12 . Adverse drug events resulting from patient misunderstanding are common and often serious, but unnecessarily difficult or poorly expressed instructions can be the direct cause21 . More generally, communication breakdowns between providers and patients are common root causes of preventable adverse events. The obligation to provide a culturally safe environment and information that patients can understand lies with health services and clinicians12 .

An interaction between service users and providers The 21st century has seen the construction of a new understanding – health literacy as an interaction between the demands of healthcare systems and the skills of individuals 22 , representing a significant shift from a deficit model in which it is the patient with, or as, the problem 5 . This shift acknowledges that we have to ask whether low literacy is the cause of poor outcomes or whether it is a marker for other problems that are the actual sources of poor health (e.g. low socioeconomic status, poor sense of self-efficacy, distrust of healthcare providers, or poor access to care)19 . The AHRQ review offered some answers:

»» a number of the studies concluded that knowledge, patient self-efficacy, and stigma act as mediators or intermediaries in the casual pathway between low health literacy and health outcomes, and thus may account for the negative impact of low health literacy »» further, evidence for social support and healthcare system characteristics as potential mediators and moderators between health literacy and health outcomes was identified8 . If health literacy can be thought of as ‘the currency needed to negotiate the system’23 – those needing the most from healthcare services may be quite challenged in their journey 7. The metaphor suggests that giving attention to how the system works pays off but begs the question of whether services are designed for service users. In the new thinking, healthcare organisations are encouraged to begin ‘their long journey to becoming health literate’ and to take immediate actions to bridge gaps where service users stumble or turn away24 . A significant and potentially transformative shift for health service provision lies in another new approach – experience-based design – which involves health service providers “thinking with” the people who use services, rather than “thinking for” them 25,26 .

Patient-centred communication Nurses have a professional and ethical obligation to communicate in a clear, purposeful way that addresses the unique information needs of each patient. Because knowledge is power and comprehension is empowering, the goal of all patient interactions should be to empower the patient to obtain, understand, and act on information that is needed for optimal health 20 .2011:331

Thinking about health literacy as something created through interaction connects with the idea of literacy as a social practice – it involves recognised ways of doing things, through which we come to understanding and make sense of experience30 . Having adequate knowledge and understanding is necessary, but not sufficient, in a conception of literacy in which people act on what they know and understand to improve or manage their situation. Self-efficacy, or a sense of confidence about one’s ability, and motivation are needed for action.

ABOUT LITERACY: CAUTIONS AND CRITIQUES New Zealand’s results in international literacy surveys are often cited as concerning. According to the 2006 Adult Literacy and Life Skills Survey (ALL): ►►56.2 per cent of adult New Zealanders have poor health literacy skills (i.e. below the minimum required to meet the demands of everyday life and work) ►►although Māori and non-Māori with a tertiary education are more likely to have good health literacy skills than those with lower levels of


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education, in general, Māori have poorer health literacy statistics than non-Māori28 . Designed for international comparisons and using only written materials, the ALL has been criticised for measuring a ‘test literacy’ unrelated to real life and cultural context 29. However, speaking and listening skills are critical for ‘being on the same page’ in conversations between clinicians and patients – verbal exchange and response to non-verbal cues means

that an ‘interactive literacy’5 can be created in the encounter. Further, as literacy is particular to a context 29, a person otherwise considered highly literate may be functionally illiterate when encountering new and complicated vocabulary and concepts in an unfamiliar setting1 , more so if their ability to pay attention and understand is compromised, for example, by anxiety or pain.

A PROFESSIONAL DEVELOPMENT ACTIVITY PROUDLY BROUGHT TO YOU BY What then does health literacy mean in the encounter with ‘the person before you’4 , at that moment in the patient or client role? It is our responsibility, as nurses, to create a trusting and respectful interaction that helps patients and families/whānau be open to learning: to listen responsively, to hear their understandings, to make it easy for them to ask questions, to communicate clearly in ways that are culturally safe, to acknowledge their work in self-management and engaging with health services, to affirm and expand their knowledge and capability, and to bring what we can to the interaction to make the situation or learning task less demanding. In short, to communicate in a way that tells the patient, “It’s all about you”.

An environmental scan of health literacy initiatives in New Zealand, undertaken in 2011, is on the Health Quality and Safety Commission website publication/42/ The website has resources relevant to the New Zealand context. It is supported by Workbase, a not-for-profit organisation committed to improving the literacy, language and numeracy skills of New Zealanders. Workbase and Health Navigator, hosts of the conference Health Literacy: From Discussion to Action held May 2012 in Auckland, have presentations available at Visit Write Limited at for details of a workshop on writing health information clearly, or to download a free ebook Unravelling Medical Jargon.

Recommended reading and resources Articles SPEROS Carolyn I (2011). Promoting health literacy: A nursing imperative. Nursing Clinics of North America 46(2011):321-333. Health literacy for nurses, a project undertaken jointly by the New Zealand Nurses’ Organisation and the College of Nurses Aotearoa New Zealand, comprises a Position Statement at nz/LinkClick.aspx?fileticket=GPbcXpviZxM%3D, and A call to action at aspx?fileticket=fB1oBdHhRWA%3D Web resources Medline has a collection of health literacy information resources here health_literacy.html

A scan of the 1996 classic (but now out of print) book by Doak, Doak and Root, Teaching Patients with Low Literacy Skills is downloadable from www.hsph.harvard. edu/healthliteracy/resources/doak-book/index.html Particularly useful for nurses giving information are Chapter 5 on the comprehension process and Chapter 9 on teaching. Roett and Wessel’s guide, Help your patient “get” what you just said is available from wp-content/uploads/2012/04/healthliteracyarticle.pdf An excellent resource on organisational responsibilities for health literacy is Brach et al’s 2012 discussion paper Ten Attributes of Health Literate Health Care Organizations, available here Perspectives/2012/HealthLitAttributes.aspx


? QUESTIONS THIS ARTICLE MIGHT PROMPT YOU TO ASK YOURSELF »» How easy is it for people using our service to find their way through the system? »» What do we take for granted that may need to be explained to service users? »» What do we know about the level of knowledge and understanding of the patients using our service? How did we reach those conclusions? »» What other or better ways could you assess comprehension than asking ‘do you understand?’.

About the author: Shelley Jones RN BA MPhil has been working in nursing professional development for 30 years.

Acknowledgements: Thank you to peer reviewers Rosie Knight and Faith Roberts for their helpful critique (declaration of interest – Rosie Knight is a plain English specialist at Write Limited).

BIBLIOGRAPHY A full bibliography is available at REFERENCES 1 SPEROS C I (2005) Health literacy: concept analysis. Journal of Advanced Nursing 50(6):633-40. 2 JORDAN JE et al (2010) Conceptualising health literacy from the patient perspective. Patient Education and Counseling 79(1):36-42. 3 PEERSON A & SAUNDERS M (2009) Health literacy revisited: what do we mean and why does it matter? Health Promotion International 24(3):285-296. 4 JONES S (2012) Shared decision-making: Where self-management and clinical expertise meet? Nursing Review 12(11):15-18. 5 NUTBEAM D (2008) The evolving concept of health literacy. Social Science and Medicine 67: 2072–2078. 6 SORENSEN K et al (2012) Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health (12)80:1-13. 7 MARTIN LT et al (2011) Patient activation and advocacy: Which literacy skills matter most? Journal of Health Communication 30(16S3):177–190. 8 BERKMAN ND et al (2011). Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. Agency for Healthcare

Research and Quality: Rockville, MD. 9 ROETT MA & WESSEL L (2012) Help your patient “get” what you just said: A health literacy guide. The Journal of Family Practice 61(4):190-196. 10 SHAH L C et al (2010) Health literacy instrument in family medicine: The “Newest Vital Sign” ease of use and correlates. The Journal of the American Board of Family Medicine 23(2):195-203. 11 PAASCHE-ORLOW MK & WOLF MS (2008) Evidence does not support clinical screening of literacy Journal of General Internal Medicine 23(1):100-102. 12 JOINT COMMISSION (2007)“What Did the Doctor Say?” Improving Health Literacy to Protect Patient Safety Retrieved from What_Did_the_Doctor_Say/ 13 VOLANDES AE & PAASCHE-ORLOW MK (2007) Health literacy, health inequality and a just healthcare system. The American Journal of Bioethics 7(11):5-10. 14 ANDRUS MR & ROTH MT (2002) Health literacy: A review. Pharmacotheropy 22:282-302. 15 DOAK CC et al (1996) Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia: J B Lippincott Company. 16 SHERIDAN SL et al (2011) Interventions for individuals with low health literacy: A systematic

review, Journal of Health Communication: International Perspectives 16(S3):30-54. 17 ANKER JS & KAUFMAN D (2007) Rethinking health numeracy: A multidisciplinary literature review Journal of the American Medical Informatics Association 14(6):713–721. 18 STACEY SD et al (2011) Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2011, 10(CD001431). 19 DeWALT DA et al (2004) Literacy and health outcomes: A systematic review of the literature. Journal of General Internal Medicine 19(12):1228–1239. 20 SPEROS C I (2011) Promoting health literacy: A nursing imperative. Nursing Clinics of North America 46(2011):321-333. 21 WOLF MS et al (2007) To err is human: Patient misinterpretations of prescription drug label instructions. Patient Education and Counseling 67(3):293-300. 22 RUDD R et al (2007) Health literacy: an updated review of the medical and public health literature. In: COMINGS J, GARNER B, SMITH C (eds). Review of Adult Learning and Literacy, Volume 7 (pp 175–204) Lawrence Erlbaum Associates: Mahwah NJ. 23 KNIGHT R (2006) Literacy is a Health Issue. Pharmacy Guild of New Zealand: Wellington.

24 BRACH C et al (2012) Ten Attributes of Health Literate Health Care Organizations (Discussion Paper). Institute of Medicine. Retrieved from Attributes.pdf 25 SANGIORGI D (2011). Transformative services and transformation design. International Journal of Design 5(2):29-40. 26 FREIRE P (2007) Pedagogy of the Oppressed. Continuum: New York. 27 WORLD HEALTH ORGANISATION (1986) The Ottawa Charter for Health Promotion. Retrieved from previous/ottawa/en/index1.html 28 MINISTRY OF HEALTH (2010) Korero Marama: Health Literacy and Māori Results from the 2006 Adult Literacy and Life Skills Survey. Ministry of Health: Wellington. 29 HAMILTON M & BARTON D (2000). The international adult literacy survey: What does it really measure? International Review of Education 46(5):377-389. 30 LANKSHEAR C & KNOBEL M (2007) Sampling “the New” in new literacies (Chapter 1). In KNOBEL M & LANKSHEAR C (eds) A New Literacies Sampler (pp 1-24). Peter Lang: New York.




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Health Literacy


Patient-centred communication is still the answer


NAME: ____________________________________


NURSING COUNCIL ID:_______________________


Undertaking this learning activity is equivalent to 45 minutes of professional development. It contributes to maintaining competence by helping you reflect on why and how your communication in educating and informing patients and their families/whānau is critical to their understanding of their health

issues, self-management, and treatments and is also critical in supporting their safety within and access to health services. See the Nursing Council defined competencies related to patient education, safety, and health outcomes for RNs, ENs, and NPs at http://www.nursingcouncil.,55,0,0,html/Competencies

The questions in this section are designed to help you read the article attentively.


Health literacy is a concept that is relevant at the level of the… Tick one  system  population  individual


According to the 2006 Adult Literacy and Life Skills Survey the proportion of adults in New Zealand with poor health literacy skills is… Tick one  52.6%  62.5%  56.2%


Which of these is not given in the article as a reason that clinicians are reluctant to assess patient’s health literacy levels? Tick one  concern about potential embarrassment  literacy assessments are very time-consuming


Which of these catchy phrases used in relation to health literacy was not cited in this article? Tick one  telling is not teaching  an epidemic of incomprehensibility  what is clear to you is clear to you


Because communication breakdowns between health service consumers and health service providers can cause preventable adverse events, a theme in this article is that the onus for improving communication is on … Tick one  health service consumers  health service providers

This section helps you reflect on your learning from reading and relate it to your experience. How can my role support health literacy - from either the patient, professional or organisational perspective?

What are your ‘take home’ insights or learning? List 3 points from the article 1 2



 all of these





The notes you make in this section show how you intend to apply your learning in practice Please select from ‘Questions this article might prompt…’ the one most relevant to your role and responsibilities. Outline your answer, note which resource (see previous page) will be helpful to you, and list actions you plan to take in some brief notes below:

Verification by a colleague of your completion of this activity:





COLLEAGUE NAME: _______________________


NURSING COUNCIL ID:____________________

WORK ADDRESS:____________________________ CONTACT #:______________________

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DATE: ___________________________

FOCUS n Infection Control/Wound Care


AN UGLY SORE ON THE HEALTH SYSTEM They rarely grab the headlines but thousands of New Zealanders each year get preventable pressure injuries – and some die. FIONA CASSIE looks at new guidelines, the new name, and new efforts to heal this health system scar.



ed sores, pressure sores, decubitus ulcers, pressure ulcers, and now pressure injuries. By any name they are ugly – what can start with a simple reddened patch can develop into a gaping wound raw to the bone. The latest name – pressure injury – has been chosen because the vast majority of pressure injuries (PIs) are preventable and avoidable. Thousands of New Zealanders have experienced a pressure injury of Intro some ??????? degree in recent years on their hips, heels, backs, or elbows. At least eight have died as a result. Good nursing care is one key to preventing them. But to date, New Zealand has no national statistics on pressure injuries, haphazard reporting of the harm caused by them, and no common standards for Wayne Naylor Pam Mitchell Emil Schmidt measuring PIs and what strategies reduce them. While falls in hospital dominate the yearly serious and sentinel adverse events, Likewise, Schmidt sees a risk that the guideline could gather dust on the pressure injuries rarely get a mention. shelf without the right impetus. His personal belief is that implementation Moves are afoot to change this. For a start, the Pan Pacific Clinical Practice needs to be driven by the Ministry of Health and the guideline should Guideline for the Prevention and Management of Pressure Injury was launched be adopted as a national tool leading to a pressure injury prevention across the Tasman in March. It brings the best evidence together into the first programme at each DHB and also in residential aged care. nationally consistent guideline to assessing risk, and preventing and managing “Pressure injuries must be part of the key performance indicators (KPIs) pressure injuries. for every DHB, using an international validated survey around the country.” But first, pressure injuries need to come out from ‘under the sheets’ and catch Wound Care Society president Wayne Naylor agrees that collecting the attention of the powers that be. national data is vital for monitoring the impact of the guideline on pressure So nurse advocates are calling for debilitating pressure injuries to be reported injury rates. as serious events, more nurses to lodge ACC claims for pressure injuries, and the adoption of a national quality indicator to measure pressure injuries. No national picture At present, nobody really knows how good or bad our health system is at Preventing devastating wounds preventing and managing pressure injuries. Emil Schmidt is clear – he hates pressure injuries. The Dunedin Hospital wound Some of the worst cases of pressure injury surface as complaints to care nurse specialist is often called in once the “horse has bolted” to deal with a the Health and Disability Commissioner, and increasingly, claims are nasty and complex wound that can take up to two years to heal, if at all. being made to ACC for treatment injury costs as a result of developing a He and Pam Mitchell are two passionate nurse advocates for reducing the social, debilitating pressure ulcer. personal, and health costs of pressure injuries. They represented the New Zealand Wound Care Society on the Pan Pacific guideline development steering committee DEFINITION OF A PRESSURE INJURY and are now part of a review team developing international PI guidelines. A localised injury to the skin and/or underlying tissue usually over a The impact of pressure injuries was brought home to Mitchell, a former plastic bony prominence, as a result of pressure, shear, and/or friction, or a surgery nurse, while working with patients undergoing wound reconstructions combination of these factors. following massive pressure injuries. “For patients who develop a pressure injury, their life changes immensely; the NPUAP/EPUAP/Pan Pacific Pressure Injury Classification deterioration in their quality of life is huge,” says the Christchurch Hospital wound System consultant. Stage I Non-blanchable erythema (redness) of an area usually over a Often, Mitchell and Schmidt’s pressure injury patients are old, malnourished, bony prominence like a heel and have complex co-morbidities. Schmidt says PIs are devastating events for all Stage II Partial thickness skin loss involved and prevention is the key. “One PI is too many”. Stage III Full thickness skin loss “There’s huge money we could save if we prevent them, along with better quality Stage IV Full thickness tissue loss (exposing bone, tendon or muscle) of life (for patients at risk),” adds Mitchell. Unstageable pressure injury Both see implementing the national Pan Pacific pressure injury guideline Depth or stage of the PI can’t be determined because the wound is nationally as a step in the right direction (see sidebar). But to do this, Mitchell covered by slough or dead tissue points out, needs national resourcing and backing to ensure nurses and clinicians Suspected deep tissue injury on the floor have the knowledge, equipment, and management support to make Skin unbroken and depth of damage unknown it happen. Nursing Review series Infection Control/Wound Care 2012


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But unlike most other OECD nations, New Zealand does not collect national annual data on PIs. Many district health boards carry out PI prevalence surveys on an ad hoc basis, usually with the support of the specialist mattress industry, but only some do them annually, definitions of PIs differ, and the results are usually carefully guarded. Back in 2009, Jan Weststrate, another pressure injury nursing advocate, held a pilot survey of care indicators (including pressure injuries, falls, and incontinence) involving five hospitals and 15 rest homes across three DHBs. The pilot found pressure ulcer prevalence rates of 11.4 per cent and 5.6 per cent, respectively. His approaches Unstageable pressure injury (due to to the Ministry of Health and Health Quality & Safety Commission slough) on sacrum (HQSC) to pick up the University of Maastricht-developed survey nationally to date have been unsuccessful. However, Weststrate has been part of a nurse expert team working with the Office of the Chief Nurse, under the leadership of senior nurse advisor Paul Watson, to develop quality indicators to measure and monitor the harm from both pressure injuries and falls. Watson says the data that is available indicates pressure injuries are quite a big problem in New Zealand. Looking at a breakdown of the National Minimum Data Set (NMDS) for the six months to the end of July 2011, they found 2739 hospital events where pressure injuries were recorded. This was twice the Stage II pressure injury on toe due number of falls recorded in the same period. to too tight TED (thrombo-embolus That figure is likely to be an underestimate, as while the NMDS deterrent) stockings post-surgery should, in theory, capture all pressure injuries, the coding of patient clinical data is known to have its limitations. At best, it can only be as good as the initial patient notes which, international research shows, are often poor at documenting PIs. Another source of data is ACC claims for treatment injuries due to pressure injuries. These have been steadily growing from 35 in 20052006 (the year ACC switched focus from “medical misadventure” toIntro ??????? “treatment” injuries) to 143 in 2010-11. Rachel Taylor, a registered nurse and ACC clinical analyst, says the increase in PI claims lodged is probably one of the strongest they have seen in the area of treatment injuries. A pressure injury on the hip Exactly why is unknown, but Taylor believes the trend is likely because of passionate senior nurses being proactive in lodging claims so their clients can get the help they need, especially equipment like special mattresses.


Upping the ante

Taylor says a flow-on effect from the rise in PI claims is that ACC, which has a duty to report public risk, is reporting on pressure injuries to the Ministry of Health, which in turn, gives feedback to DHBs. “It has become something the chief medical officers noticed … they seem to be starting to talk to nurses about what do they need to prevent these (PIs) happening.” However, it appears most DHBs pressure injury rates still remain hidden under the sheets, with only a handful (including one death) last year reported to the HQSC as a serious or sentinel event. Paul Watson says this is where we differ from the US where the National Quality Forum regards stage three and four PIs as events of “serious” harm, and in the United Kingdom, PIs of that level are regarded as serious incidents requiring investigation. “They are not captured in serious and sentinel events in New Zealand. For whatever reason, hospitals are not coding pressure injuries, particularly stage III or IV, as serious (events).” Unlike falls, which have gained ‘burning platform’ status by dominating serious and sentinel event reporting, PIs often go under the radar. The chief nurse’s office’s development, in league with stakeholders like the directors of nursing and DHB quality managers, of a national quality Rachel Taylor indicator aims to get PIs back on the radar screen. Watson says a regular prevalence survey – giving a snapshot of the number and severity of PIs at any one time – is seen as the best way to improve the pressure injury data collected and raise awareness at the coalface. A final report, The Development of Quality Indicators on Measuring Harm from Falls and Pressure Injuries, is now due to go to the Health Jan Weststrate Minister, and a decision will follow. 20

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Unstageable pressure injury on heel

Stick or carrot?

Pressure injury statistics

»» 2739 pressure injury events were recorded for hospital patients discharged in the six months to the end of July 2011.* »» This was twice the number of falls recorded in the same period. »» Nearly 630 claims for treatment injuries due to decubitus ulcers (pressure injuries) were accepted by ACC between July 1 2005 and 31 December 2011 (just under 75 % of the PI claims lodged).** »» Eight of these claims related to a fatal outcome. »» 143 claims for pressure injuries were accepted by ACC in 2010-11 (compared with 35 in 2005-2006). »» Only 5 serious and sentinel events related to pressure injuries (including one death) were reported by DHBs in 2010-11.*** »» In comparison, in that same year, 714 treatment injury claims for falls were accepted by ACC and 195 falls reported by DHBs as serious and sentinel events to the HQSC. »» 88% of the pressure injury ACC clients in past six years were aged over 65. »» 91% of the claims related to events in DHB facilities. »» A pilot national survey of care indicators of 570 hospital patients in 2009 found a 12% prevalence of pressure injuries compared to 10% in the Netherlands survey and just under 5% in Austria.**** Sources: * National Minimum Data Set and Chief Nurses office. ** ACC treatment injury statistics. *** Serious and Sentinel Events reported by DHBs to Health Quality & Safety Commission in 2010-11. **** NZ Pilot National Survey of Care Indicators 2009 (University of Maastricht).

Meanwhile, pressure injuries were put into the ‘too hard basket’ when HQSC recently put out a consultation document on its 17 proposed quality indicators for the health system. Falls made the 17 but pressure injuries missed the cut this time round, being described as an “important area” but requiring “significant further work” to develop an indicator and collect data. Chief Nurse Jane O’Malley still hopes her office’s work will lead to PIs becoming a quality indicator but says, more importantly, it has lead to a common language to describe PIs and measure the success of strategies to prevent them. Watson emphasises the work’s aim is to improve PI reporting and monitor quality improvement, not to benchmark DHB against DHB or create league tables. Naylor believes the only way to ensure good national data is collected on pressure injuries is to make it mandatory. “We need to have some bite behind it, so people actually report on it.” He says a likely next step for the society is writing to the HQSC requesting DHBs be required to report all stage II pressure injuries and above as serious events. Schmidt backs this, saying this will help understand the size of the problem. Weststrate believes another way for pressure injuries to garner the level of attention given to falls is for nurses to fill in an ACC claim every time they see a patient with a stage II pressure injury or more. This would also help bring home the dollar cost to the country of pressure injuries. The dollars spent are just part of the total cost of pressure injuries – an unsightly sore on the health system now coming out from under the sheets.

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MOVES AFOOT IN AUSTRALIA FAILURE TO MEET pressure injury standards may hit Australian hospitals in the pocket from next year. Preventing and managing pressure injuries is one of the ten National Safety and Quality Health Service Standards (NSQHS) recently developed by the Australian Commission on Safety and Quality in Health Care. From January next year, all Australia’s states and territories have agreed that hospitals and day procedure services will be accredited to the new NSQHS standards. So from then on, if a health service is assessed as not meeting the standards, the state health department will be informed and may take action and/or provide support to health services to address these issues. Jan Rice, Australian wound management guru, says many see Australia heading in the direction of the USA and withholding funding from a facility not meeting pressure injury prevention standards. In the States, insurance companies refuse to pay for extra days if a patient’s hospital stay has to be extended because of a hospital-acquired pressure injury. “It is seen as negligence,” says Rice. She says in Australia, all states have data available on pressure injury prevalence and incidence, and it was the initial high prevalence levels (24 per cent) that frightened her home state of Victoria into funding education and equipment to bring the levels down.

Head Intro ???????

Sensitivity over nurse sensitive indicators PRESSURE INJURIES are one barometer for the quality of nursing care. The level of pressure injuries are one of the so-called nurse sensitive indicators used in assessing whether a facility meet Magnet Hospital status. Or as Chief Nurse Jane O’Malley puts it, in the absence of decent nursing staffing and good systems, pressure injury levels go up, and under good staffing and leadership, they go down. While there is a direct link between good nursing, bad nursing, and pressure injury levels, there is also sensitivity to labeling pressure injury levels as a nurse sensitive indicator when other factors also come into play. Nurse and ACC analyst Rachel Taylor says a fairly consistent theme in ACC claims for pressure injuries is a gap in patient care. So patient notes show no risk assessment, or an inappropriate assessment was done on the patient’s admission, or the assessment is done correctly but the needed special mattress never arrives, and five days later, a pressure ulcer is reported on the left heel. “And you think, so what was happening in between times? “It’s about consistently, across the board, doing the risk assessment, doing it correctly, putting a plan in place, following through on the plan, and if you can’t follow it through, putting another plan in place,” says Taylor. “It’s that mindful, thoughtful nursing that says, ‘okay, I can’t get the mattress, but what can we do instead until we can get the mattress’ – those are where the gaps are coming.” But nurses point out the gaps are not just by nurses. “Pressure injuries are a painful, debilitating, and serious outcome of a failure of routine medical and nursing care,” says wound care nurse specialist Emil Schmidt. Likewise, as wound nurse consultant Pam Mitchell puts it, “It is seen as a nurse sensitive indicator – it is actually an interdisciplinary indicator, not just a nurse one, but it lands at the nurses’ door”.

PAN PACIFIC GUIDELINE: WORKING OFF THE SAME PAGE A simple flow chart – capturing in a single page the best evidence and advice for preventing and managing pressure injuries - is now available at the click of a button. Comprehensive risk assessment, nutritional advice, which mattress and when, patient education, regular repositioning and pain advice, and how to classify PIs are all summed up in a nutshell. The flow chart is part of the new 120-page Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury released in March and downloadable from the New Zealand Wound Care Society website: nz It is the first PI guideline jointly developed by Australia, New Zealand, Singapore, and Hong Kong clinical – mainly nursing – experts. The next aim is to get the voluntary guideline adopted nationally, so for the first time, as Pam Mitchell puts it, “everybody is working off the same page”. For a start, a survey of more than 600 clinicians in the four countries involved unanimously supported adopting the name pressure injury over the previously favoured pressure ulcer. The word ulcer implied broken skin, but in some pressure injuries, like stage one PIs and suspected deep tissue PIs, the skin remains intact. “There was some confusion because people had this intact skin but they were calling it an ulcer,” says Mitchell. But there was also a push to label them ‘injuries’ in recognition that the international literature indicates 95 per cent of PIs are preventable and avoidable. At present, there is ad hoc use by district health boards and rest homes of different guidelines. Some use the European (EPUAP) or North American (NPUAP) guideline and others the predecessors of the Pan Pacific guideline, the AWMA guideline. The Pan Pacific guideline is built on the best of all of them, including the 2011 Trans Tasman Dietetic Wound Care Group guideline, and adopts the NPUAP/EPUAP pressure injury classification system. The Australian Wound Management Association (AWMA), the instigator of the voluntary guideline, has a health research grant to develop an implementation plan for Australia. Across the Tasman here, the wound care society has less resources, but Wayne Naylor, society president, wants to see it implemented here too – and is starting with its nearly 500 members. It has also sent the guideline to the Office of the Chief Nurse, the district health boards, and residential aged care as part of an initial awareness raising.

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three participants (2.5 per cent) were lost to follow-up in each group. The intention-to-treat analysis included all participants. The nature of the trial meant it could not be blinded. The groups received equal treatment and the baseline groups were comparable, although there were differences in time to surgery (that favoured the intervention group) and time in surgery (that favoured the control group). Not clear if these differences were adjusted for in the Cox regression. Overall validity – reasonably high quality study, although with an absence of blinding.


Showing a clean pair of heels… Can elevating the heels help prevent pressure injuries? CLINICAL BOTTOM LINE: A heel offloading device may reduce pressure injuries in patients already treated with pressure redistribution surfaces. Cost-effectiveness of the device has not been established.

CLINICAL SCENARIO: An improvement specialist on a pressure injury prevention project asks about the effectiveness of practises and devices for preventing pressure injuries on heels, as they are the second leading site of injury in a hospital–wide audit. Existing pressure injury prevention guidelines and a Cochrane review provide limited guidance or do not address the issue. A PubMed clinical query search reveals one randomised controlled trial of a heel offloading device.

QUESTION: Among patients in acute hospital, does a heel offloading device reduce the incidence of pressure injury compared to standard practice?

SEARCH STRATEGY: PubMed – Clinical queries (therapy/broad search): pressure injury AND heels.

CITATION: Donnelly J, Winder J, Kernohan WG, Stevenson M. AN RCT to determine the effect of a heel elevation device in pressure ulcer prevention post-hip fracture. J Wound Care 2011;20(7):309-18.

All patients were nursed on pressure-redistributing surfaces, including high specification foam mattress, AlphaExcel or AutoExcel overlay, and Nimbus 3 alternating pressure mattresses. Choice of surface was clinically determined, recorded, and entered as covariate in regression analyses. Heel-offloading device (HOLD) (n=119): Heelift suspension boot applied to both lower limbs of the patient. Device wraps around the foot and lifts heels off surfaces by redistributing pressure over the lower leg. Standard care (n=120): Usual care not described although patients nursed on pressure-redistributing surfaces. Outcomes: Primary – presence of any pressure injury grade 1 or greater at any site at point of censor (death, discharge, or transfer). Pressure points inspected daily.

STUDY VALIDITY: A randomised trial using a computer-generated sequence method. The allocation of the randomisation was concealed as managed by a senior nurse separate from the study. There was not complete follow-up as


»» Pragmatic trial with few exclusion criteria. Although study population was limited to people with hip fractures, there is no reason to suppose a device might be less effective in other at-risk patient groups, although differences in age distribution need to be considered. »» Trial stopped early when interim analysis at half the proposed recruitment (480) by an independent statistician found a highly significant difference between the groups that exceeded the stopping rule of p<0.01. »» No indication as to whether or how the device’s manufacturer was involved in the study or what the sources of funding might have been. »» Cost-effectiveness has not been established.

Reviewer: Dr Andrew Jull, RN PhD, Nurse Advisor – Quality, Auckland District Health Board & Associate Professor (School of Nursing).



Pressure injury

A two-arm parallel group, randomised controlled trial conducted in a Belfast tertiary hospital. Inclusion criteria were age 65 years or more and suffered a hip fracture within the previous 48 hours. Exclusion criteria were patients not consenting, existing heel pressure damage, and history of previous pressure ulceration.

Adverse event


In all, 705 patients were screened and 239 randomised. Main reasons for exclusion were age, non-consenting, or time since injury. Mean age of the study population was 81 years and 55 per cent were female. Thirty nine patients developed 48 pressure injuries. Frequency of any pressure injury was lower in HOLD group (table). The main finding was robust to sensitivity analyses that excluded grade 1 pressure injuries or where all patients lost to follow-up were considered to have developed a pressure injury. There were 17 heel injuries in the control group compared to none in the treatment group. Frequency of adverse events was similar in both groups, with one adverse event possibly related to the HOLD device (bruising).

Standard care


AD (95%CI)

HR (95%CI)

26.1% (31/119)

6.7% (8/120)

19.4% (10.3 to 28.4%)

0.21 5 (0.08 to 0.54) (4 to 10)

16.7% (20/119)

19.3% (20/120)

2.7% (-7.1 to 12.4%)

HR = hazard ratio; NNT = number needed to treat; NS = not significant

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NNT (95%CI)



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Leaving cookie crumbs in cyberspace

Are you an unknowing Hansel or Gretel, leaving a trail of ‘breadcrumbs’ behind you as you wend your way through the internet? KATHY HOLLOWAY explains cookies.


ow do you track where you have been as you click from one fabulously interesting site to the next on the net? You are probably aware of the useful history facility provided for your use by two common browsers - Firefox and Explorer. You can check here where you (or others) have been surfing. However, as you gaily embark upon your surfing odyssey, spare a thought for the ‘breadcrumb’ trail you may be leaving behind – that trail may not only track where you have been but also predict where you are most likely to go. I refer to ‘cookie’ technology. What is a cookie? The following outline of the function of cookies was obtained from a very useful site: A cookie is a small piece of information about you (actually, about your computer – the IP or internet protocol address). A cookie is a small file that a web server automatically sends to your computer when you browse certain web sites. Cookies are stored as text files on your hard drive, so servers can access them when you return to web sites you’ve visited before. To check out your cookie files in Internet Explorer, go to the Tools button on your browser and select Internet Options and Settings on the Temporary Internet files section. Clicking on View files will let you know what is stored there for access by sites when you visit – you will note that cookies are designed to expire within varying times – however, the latest technology allows cookies to be stored until 2037. Prepare to be amazed at the number of files that you store unknowingly! For other browsers, use the help function to find the cookie files. But wait! Cookies are not all bad – they contain information that identifies each user, for example: login or username, passwords, shopping cart information, preferences, and so on. When a user revisits a web site, his or her computer automatically ‘serves up’ the cookie, which establishes the user’s identity,

thus eliminating the need for you to re-enter the information. Basically, the server needs to know this information in order for the web site to work correctly, and the information is nothing more than a string of letters and numbers. However, within the internet industry, advertisers are able to track your browsing and buying habits using cookies, unless your privacy settings exclude this. In this realm, cookie technology enables advertisers to target ad banners based on what you’ve said your interests are – ever notice how targeted the Google ads become? Cookies allow sites to tailor their appearance to suit a user’s established preferences. It’s a double-edged sword for many people because on the one hand, it’s efficient and pertinent in that you only see ads about what you’re interested in. On the other hand, it involves actually ‘tracking’ and ‘following’ where you go and what you click on – a disturbing thought for some. Further information as to how to restrict cookie collection is best obtained at sites like The bottom line is that you, as the user, should find the web portals and online services that suit your needs and only sign up with a select few. In New Zealand, privacy concerns for local e-commerce are governed by legislation that does not apply to international companies. A recent forum in Wellington – Think Big? Privacy in the Age of Big Data – warned of our generally relaxed approach to the privacy of our own information. Make a habit of checking out privacy policies on the sites that you visit and check your own browser’s privacy settings. Further information can be accessed here Remember that with awareness comes choice – you can take control of your trail in cyberspace. Increasingly, the internet is being used by consumers to rate their experiences of services received from trades professionals, retailers, and the hospitality sector. This is now possible for consumers of the health care sector, and internationally, patients are using the internet to research their local hospitals, doctors, and residential care facilities. In Ireland (USA and Canada also) there is a Rate My Hospital ( website, where patients can rate all parts of their hospital experience. In contrast, there is no patient involvement as yet in this Australian site, launched this year, but it marks an interesting government initiative to inform the community about their hospitals. The website provides information about hospital services, patient admissions, waiting times for elective surgery and emergency department care, measures of safety and quality (hand hygiene and staph. aureus rates), cancer services, and hospital accreditation. The website also provides comparisons to national public hospital performance statistics on waiting times for elective surgery and emergency department care. [Accessed 19 August 2012 and last updated 2012].

BMC Nursing – free access journal BioMed Central is an independent publishing house committed to providing immediate open access to peerreviewed research, a growing area for professional and clinical journals. BMC Nursing is an open access journal publishing original peer-reviewed research articles in all aspects of nursing research, training, education, and practise that has been published since 2002. The journal is included in PubMed and all major bibliographic databases. The editorial board is comprised of esteemed nurse scholars from Australia, USA, Canada and the UK – this is a useful avenue for publication. [Accessed 19 August 2012 and last updated 2012]. Dr Kathy Holloway is dean of the Faculty of Health at Whitireia Community Polytechnic.

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Smoking – a choice or a tobacco industry-designed addiction?

TAIMA CAMPBELL ‘plain packages’ the need to tell the truth about the tobacco industry.


rive past any hospital and you will see smokers – staff and patients – outside in the cold having a cigarette. This is a sight that generates strong opinions amongst the public and health professionals alike. It is easy to ‘blame’ the smoker – many do. Most argue that smokers have a Taima Campbell choice and so should ‘take responsibility’ for their actions. Smokers blame the ‘public health police’ who are impacting on their freedom to inhale a product sold over the counter in the local dairy. The first cigarette might have been a choice – if you were immune to the displays of tobacco products for sale behind shop counters or seeing your parents and peers smoke. In New Zealand, research shows the average age people start smoking is just fourteen-and-a-half. Once people started smoking, the physiology of addiction did the rest. Cigarettes are highly effective nicotine delivery devices. They have been designed by the tobacco industry to deliver the dose of nicotine that smokers need every few hours to relieve the imminent symptoms of withdrawal. This is the cycle that smokers live – not by choice, ask any who have tried to quit. If there is blame to be laid, let’s take a look at the tobacco industry. Professor Ruth Malone is a nurse and researcher from the Center for Tobacco Control Research and Education at the University of California, San Francisco, who recently visited New Zealand. She has been examining the tobacco industry and its efforts to undermine public health policies and maximise profit for years. Her research has involved searching through the Legacy Tobacco Documents, a digital library containing more than 13 million documents created by major tobacco companies related to their advertising, manufacturing, marketing, sales, and scientific research activities. There in black and white is the tobacco industry’s overt and covert intent to market cigarettes to our children, to women, to minority groups, to us – including the infamous comments of an R. J. Reynolds Tobacco executive recalled by former Winston cigarettes ad model David Goerlitz: “We don’t smoke the shit, we just sell it. We reserve the right to smoke for the young, the poor, the black, and the stupid”. These millions of documents have now been used as part of a campaign to denormalise the tobacco industry in California, where there is now a smoking prevalence rate of 11.9%. Malone says the tobacco industry has been fudging the truth and manipulating science for years. This was well


traversed at the Māori Affairs Select Committee Inquiry into the tobacco industry in 2010. Members of the Committee had the opportunity to ask British American Tobacco executives’ questions about their marketing strategies and product safety. By his own admission, a tobacco manager admitted nicotine is addictive and no cigarette is safe. On her visit, Malone applauded New Zealand’s tobacco control efforts. She acknowledged that New Zealand will shortly be banning tobacco product displays in shops and removing the last bastion of tobacco branding by considering plain packing. What’s missing, she said, is sharing the truth about the tobacco industry with the New Zealand public. Where is the truth about the deliberate tactics employed by the tobacco industry to increase global tobacco consumption? Where are the facts about the industry including additives and flavourings like menthol to make them easier to smoke, or the truth about the environmental devastation of tobacco farming in third world countries? This is what we need to know. Where is the truth about the efforts tobacco companies have gone to in order to secure trade agreements that will enable them to maximise their profits? Are our politicians immune to the generous overtures of the tobacco industry over cocktails and canapés in return for protection of free trade? Earlier this year, Mike Moore – the former prime minister and director general of the World Trade Organisation (WTO) and current New Zealand ambassador to the US – co-hosted the Governors and Ambassadors World Trade Reception, whose sponsors included tobacco company Phillip Morris International, in Washington DC. As a party to the Framework Convention on Tobacco Control (FCTC), the New Zealand Government is obliged to protect public health policies from the interests of the tobacco industry. Moore’s co-hosting of the event sponsored by the tobacco industry is in conflict with the FCTC. In response to critic’s concerns, Trade Minister Tim Groser backed Moore’s hosting role and gave assurance that TPP (Trans-Pacific Partnership) free trade agreement negotiators were well aware of the ‘tobacco issues’ raised. I hope that they remember this when plain packaging of cigarettes is introduced here and Phillip Morris decides to take New Zealand to court claiming a breach of free trade – like the makers of Marlboro cigarettes are still trying to do to the Australian government under another trade agreement (a separate court case to the constitutional challenge lodged by several tobacco companies against plain packaging that was rejected in August by the Australian High Court). New Zealand has the goal of being a smokefree nation by 2025. This means phasing out tobacco sales to achieve

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a near zero prevalence rate in this country. To achieve this, Ruth Malone’s advice is to ‘pull back the curtain’ on the tobacco industry. We need to expose how multi-national tobacco companies are making obscene profits marketing and pushing a highly addictive product that will kill thousands of New Zealanders this year. We need to get outraged about how the tobacco industry has ‘played’ us. Smokers were never in control. The tobacco industry has socialised and manipulated us from childhood into an industry-designed addiction. This is not a normal industry. Let’s not pretend it is. The College of Nurses Aotearoa recently made an oral submission to the Finance and Expenditure Committee on the Customs and Excise (Tobacco Products—Budget Measures) Amendment Bill. The submission supported an excise tax increase of 40 per cent in 2013 followed by three successive 20 per cent increases between 2014 and2016, and removing the duty-free tobacco allowance. We encourage nurses to make a submission by October 5 on the government’s proposal to introduce plain packaging of tobacco products here (go to plain packaging proposal at Let’s remove the last place the tobacco industry can market this addiction.

Taima Campbell is co-chair of the College of Nurses Aotearoa. References are available by emailing

Articles, profiles and opinion pieces from across the nursing spectrum



Research indicating nearly half of nurses have considered quitting their job because of moral distress hit a chord recently. FIONA CASSIE talks to researcher Martin Wood about moral distress and why we can’t keep ignoring its toll.


ver felt morally torn at being unable to deliver quality care through understaffing? Or felt ethically compromised at providing high tech interventions that just prolong the dying process? Martin Woods. If so, you are not alone, according to preliminary findings from the first major survey of New Zealand nurses about moral distress. The Massey University research team, lead by nurse researcher Dr Martin Woods, found 48 per cent of the 400 plus respondents had at some stage considered quitting their job because of moral distress. Moral distress was also behind16 per cent actively considering quitting right now, in particular, younger nurses. Moral distress in nursing is the phenomenon first described in the 1980s by American nurse researcher Andrew Jameton as nurses knowing the ethical or right action to take but feeling powerless or constrained from taking it. The New Zealand research found that institutional constraints like management cost-cutting pressures, unsafe staffing levels, or incompetent workmates (see box) causing nurses to compromise their care were the most common cause of moral distress. These were followed closely by ethical dilemmas at carrying out unnecessary or unwanted treatments and interventions, often related to end-of-life care. Woods’ research made the headlines in mid-August with the New Zealand Nurses

Organisation (who helped fund the research), College of Nurses Aotearoa, and emails from individual nurses confirming that his research reflected a current and very real problem for nurses. “We can’t go on ignoring this issue for too long,” says Woods. As part of the research project, he aims to develop guidelines and advice for reducing moral distress issues, including the need for sufficient staffing numbers and the right skill mix to cover each shift. “Some nurses have found some of these issues quite disturbing, and if nothing is resolved, their feeling of ill ease will linger,” says Woods. “If the feeling continues for a long period, it’s understandable that some nurses will decide to try another branch of nursing or move out of nursing.” More than 400 nurses took part in the research, about a 33 per cent response rate to the survey that was sent out last year to a random sample of NZNO nurse members working in the public health system. The vast majority were hospital-based, with the most common areas of practice being critical care (22.3 per cent), surgical (18.2 per cent) and medical (17.5 per cent). Nearly half of respondents had nursed for more than 25 years, and more than 60 per cent were 45 years or older. Only nine per cent were under 35 years old, but it was these younger nurses who had the highest moral distress score and were most likely (19 per cent) to be currently considering leaving their job due to moral distress. The area of practice experiencing the most moral distress was medical nurses. Woods says many nurses attribute their moral distress to circumstances that are

largely outside their control, like staffing numbers, skill mix, and difficulties convincing managers that there are workplace issues to be resolved. “All these things I think come through quite strongly in the report,” says Wood. The situations causing the highest intensity of moral distress were working with levels of nurses they considered unsafe (86 per cent), working with incompetent nurses (85 per cent), and witnessing diminished patient care due to poor team communication (82 per cent). “These are things that are going to need to be paid attention to – it’s not just a nursing issue, it’s an issue across the health services really that affects nurses.” “Nurses are under huge pressure, and this doesn’t help them address some of the difficult ethical issues that face them.” He says these ethical issues are more acute than 30-40 years ago, and many of the issues currently causing consternation for nurses involve end-oflife and palliative care.

Woods says a trend he found concerning was that youngest group of nurses (aged between 25-34) reported significantly higher levels of moral distress (a score of 63.4) than their older colleagues, whose moral distress scores averaged between 38 and 47. He says the younger generation of nurses will have studied ethics as part of their training and there would be some irony if the increased moral distress of younger nurses was due to their training making them more acutely conscious of ethical issues. Also, it was open to debate whether the older nurses experienced less moral distress as they were more accustomed to being ethically compromised or whether having had less ethical training meant they were less acutely aware of ethical issues. Woods said the next steps for the research team along with working on the guidelines was analysing the themes raised in the optional additional written comments made by 350 of the respondents – some up to a page long. “That material is really absorbing and tells a lot more than the survey itself.”

Top five major sources of moral distress »» Moral concerns over delivering less than optimal care due to management pressures to reduce costs (39 per cent). »» Watching patient suffer due to lack of provider continuity (38 per cent). »» Working with nurses or other health care worker who are less competent than the patient’s care required (36.4 per cent). »» Carrying out physician orders for what the nurse considers as unnecessary tests and treatments (33.5 per cent). »» Initiating extensive life-saving actions when the nurse thought they would only unnecessarily prolong the dying process (31.6%).

Nursing Review series Infection Control/Wound Care 2012


People, practice & policy PRIMARY HEALTH

No greater calling Sharon Myoji Schnare, a United States-based family and women’s health nurse practitioner addressed the recent primary health care nurses' conference* about the brave new world opening up to nursing, including nursing entrepreneurs, while reminding nurses not to forget the profession’s compassionate roots. “Do I believe in education – you bet I do. But we really need to appreciate all nurses, whatever their qualifications … my best nursing and midwifery teachers did not have master’s degrees.”



ew technology, expensive drugs, and ethical dilemmas will all help shape the future of nursing, believes Sharon Myoji Schnare. But nurses are also at a critical point of deciding how nursing as a profession will shape the future of health care. Directing health policy, managing nurse-led specialist units in diabetes to rehabilitation, and doing the hard science, as well as using other’s research to advance nursing practice were some of the roles she saw growing for nurses in the future. Schnare opened her keynote speech on the Future of Nursing by saying one of her objectives was to remind nurses of how important their role is, and the profound impact they have on patients’ lives. “I believe there is no greater calling.” She also called on nurses to return to their roots and remember why they became nurses and what gives them the greatest satisfaction in their work. Schnare has been a nurse practitioner for more than 25 of her 33 years in nursing –specialising in family health and women’s health. She’s run a private NP practice serving uninsured families, as well as for state health providers, is a clinical educator for the University of Washington’s nursing school, the director of a women’s health NP training programme, and sits on the editorial boards of a number of journals on reproductive health and contraception. Her contributions to advancement of nursing practice have been recognised by the American Academy of Nurse Practitioners and the National Family Planning and Reproductive Health Association. She sees the future increasingly including more ethical dilemmas about who will receive and who will pay for increasingly more technical care and new, often expensive, medications. That pressure was increasingly making its mark on the uninsured patient group she cares for. “I’ve never seen so many sick people in my whole career.”

Nursing Review series Infection Control/Wound Care 2012

This includes a 27-year-old woman with kidney failure who was peeing blood and only able to get one day dialysis a week. The young woman was living in a car with her partner and a trip to ER can see her leaving with a $10,000 bill. “Where will we stand with this ethical dilemma?” Schnare says nursing is at a critical point of deciding how the profession can create its own future. “We want nurses to stand up and tell policy makers about what they do.” She says she is well aware that nurses are very busy, but they have the ability to be voices for their patients. “Nurses must lead governmental task forces that will be pivotal to assessing, improving, managing, and funding health care for all citizens.” Nursing also had to be prepared for what the future would ask of the profession – which includes nursing education needing to provide continual clinical education to keep up with the rapid pace of change – and for nurses to be flexible and ingenious. “Nurses are really good at plugging holes or stretching things,” says Schnare. Nurses will also have to be good at analysing data both everyday data emerging from pathology and radiology and also searching out and carrying out statistical analysis to decide whether research data is valid and useful to their practice. Nursing research is also no longer limited to theories with nurses doing research in the “hard sciences” like, for example, in her own field, the impact of vaginal flora bacterial colonisation. Technology will keep advancing, including nanotechnology, robot technology, and three-D printers that can create devices designed to individual specifications in minutes. “We need to embrace technology without forgetting the power of our presence with our patients,” says Schnare. But increasingly expensive technology and new medications will create ethical dilemmas and the potential for this “brave new world” of nursing to see widening division between patients who can and cannot afford health care. Nurses will also face ethical challenges around cost containment in the health sector. “Where will we have to cut services and at what cost to our patients and to ourselves. “It’s a brave new world in nursing, but that’s

okay because nurses are brave,” says Schnare. “If we weren’t brave at the start, we have trained to be courageous. We’re ready to roll up our sleeves and take on these dilemmas.” She says barriers in the way of nursing’s future potential could include “educational hierarchies” that need to be reminded that clinical experience matters as well as educational “status”. “Do I believe in education – you bet I do. But we really need to appreciate all nurses, whatever their qualifications … my best nursing and midwifery teachers did not have master’s degrees.” Education also has to conform to working nurses needs by being flexible in their delivery and affordable. Plus, education needs to forward-thinking to anticipate future niches for nursing, including technologylinked opportunities, nurse inventers, and independent nurse practitioners. Nurse entrepreneurs are another trend for the future. Schnare sees nurses managing centres for health excellence and designing and owning specialised facilities like hospice care. Or like a friend of hers, offering a specialist niche continence care service to provide bladder training for elderly women so they can stay independent in their own homes. Schnare also envisages the trend continuing for nurses to choose and pursue specialties and subspecialty services, including specialist technical skills. “The times of generalist nurses may fade as acute specialisation becomes necessary.” She says examples of technical specialties include colposcopy, which she has been doing for decades, and some NPs in the States are doing vasectomies. “Let’s push the box a little. We can expand our scope if we want it.” This brave new world must also include improved salaries for nurses, especially those with specialised skills. “Do not be hooked by the idea that being a technician makes us whole,” concludes Schnare. “Never negate the power of compassion and loving kindness in care for our patients … for we are lost as a profession without it.” *Sharon Myoji Schnare was a keynote speaker at Shaping the Flow, the Inaugural Conference of the NZ College of Primary Health Care Nurses NZNO held in Hamilton, August 2012

People, practice & policy PRIMARY HEALTH

Shape-up call for primary health care New Zealand Nurses Organisation policy advisor Jill Clendon took a look at the New Zealand general practice model of primary health care and found it lacking at the recent primary health care nurses conference.* She also spoke of nurses’ ethical obligation to be advocates on the socioeconomic issues impacting on their patients’ health.


elivering primary health care through general practices is not working for those who need it most – the country’s poorest, says Jill Clendon. She told the conference that the business model and funding of general practice needs to be addressed as one way of addressing disparities in health between the rich and poor, white and brown in New Zealand. Also needing addressing were the social determinants of health – like employment, housing and education – that she says research has shown to be more influential on population health outcomes than medical care. Clendon began her presentation by clarifying what she saw as the fundamental differences between the terms primary health care and primary care. She says primary health care is a broad philosophy of care intended to redress inequities in health (with a key principle being social justice). Primary care, on the other hand, she says, is just one part of primary health care and generally revolves around the type of individualised care provided in general practices. “In this presentation, I would like to look at ways that nurses can include a primary health care perspective in their primary care practice.” She told the conference that in terms of equity New Zealand ranked poorly in a number of measures when compared to other OECD developed countries, particularly in child poverty and child mortality. Also, it was known that Māori live at least 8 years less than non-Māori in this country, and life expectancy for Pacific males was 6.7 years less than total males and Pacific females 6.1 years less than all females. Latest research has also shown clear ethnic and social inequalities in infectious diseases in New Zealand. “The gap in health between white New Zealand and brown New Zealand has actually widened, as has the gap in health between those considered well off and those who live in poorer socio-economic conditions. Quite simply put, this is unfair, and it is wrong.” She says the 2001 Primary Health Care strategy was intended to address many of these disparities, but after more than a decade, New Zealand health care statistics in terms of equity were no better, and in some instances worse, than in 2001. “How can this be in a country that once prided itself on its egalitarian ethos and which now has one of the biggest rich/poor gaps in the OECD?” asks Clendon. “One of the reasons is because our PHC system is delivered primarily through general practice, and quite simply, this isn’t working for those who need it most.” She says costs remains a major barrier to accessing

GP services, and while there were some moves in the right direction – like free care for under-sixes and the very low cost access scheme – these were just “tinkering around the edges”. The strategy had in some cases freed up funding for different services delivered in different ways, including a number of nurse-led initiatives, but it had also created another layer of health bureaucracy, and the businessdriven model for general practice meant people missed out on care. She says the primary health organisation (PHO) structure in theory was “excellent” but she was not convinced that PHOs truly understand what primary health care is with only a few PHOs – including Māori providers who ‘get it’. The challenge also remains in getting funding for primary health care nursing, so the profession could help meet the goals of the PHC strategy Clendon also got spontaneous applause and calls of “hear hear” when she commented on the PHO and government emphasis on measuring outcomes like immunisations and cardiovascular checks. “Do such indicators truly measure health outcomes? I think not …” Ethical obligation to act Clendon says the business model in general practice needs to be addressed, but this would only resolve part of the health disparity problem. The other reasons for health disparities – the social determinants of health – also needed to be addressed to ensure an equitable PHC system develops. She says researchers have shown that 14 determinants of health, including employment, income, education, and race have been shown to have larger effects on health than the effects associated with physical exercise, diet, or alcohol and tobacco consumption. “While the role of nurses in addressing issues such as smoking, diet, and exercise is clear, what is less clear is how nurses can address these social determinants of health – aspects that have an even greater impact on health. How can we address levels of education or housing issues?” She says if improvements in these areas have a far greater effect on health outcomes than anything we do on the shop floor, then nurses must do something about them. “We have an ethical and moral obligation to.” Clendon says, firstly, nurses can assess for the social determinants of health by asking appropriate questions during patient assessments to ensure, for example, a person has a warm house, food in the cupboard,

Clendon also got spontaneous applause and calls of “hear hear” when she commented on the PHO and government emphasis on measuring outcomes like immunisations and cardiovascular checks. “Do such indicators truly measure health outcomes? I think not...”

or transport to their appointment, so issues can be identified and appropriate support or referrals made. Having a resource list in your practice of the agencies that may be able to help and support your clients can be useful in helping you make quick links and referrals. Secondly, nurses can play a key role in advocating for health equity in their own practice, local nursing school, interaction with student nurses, and supporting your professional group in their lobbying and advocacy roles. Also, nurses can look at how to change the current primary care business model and advocating for a shift to better models. “Some models of primary care do work better than others, and we should be advocating for a shift to better models. Primary care should be centred on patient need, not provider income for a start.” She says some such models exist – like union health centres, some community health centres, and Māori and iwi providers – but funding remains an ongoing battle. * Jill Clendon was a keynote speaker at Shaping the Flow, the Inaugural Conference of the NZ College of Primary Health Care Nurses NZNO held in Hamilton, August 2012

Nursing Review series Infection Control/Wound Care 2012


A round-up of national and international nursing news



NURSING SCHOOLS AND the Nursing Council continue to agree to disagree over the reasons behind a review of two bridging degree programmes for overseas nurses but all say they are now ready to move on. In early September, the New Zealand Qualifications Authority (NZQA) released its findings into reviews of the one-year registered nurse to bachelor of nursing (RN-BN pathway) programmes offered by Waiariki Institute of Technology and the Universal College of Learning (UCOL). The reviews followed publicity around Indian-trained nurses being declined for registration by the Nursing Council, including graduates and current students of the two programmes. The nursing schools and students have argued that the Council had changed the goalposts in how they assessed the three-year Indian nursing diploma since November (see findings box), but the Nursing Council disagrees, saying its overall method of assessing education standards has not changed. The NZQA review teams released two 21-page reports that closely examined the approval processes for the two individual pathway programmes and their overseas student admission processes. The findings (see box) do not find issue with the teaching quality or find that students were misinformed but do call on both institutions to introduce more “robust” and “consistent” processes for assessing overseas nursing qualifications and recognition of prior learning. In late July, the institutions and Nursing Council announced they had agreed on additional free and short clinical assessment programmes so graduates of the RN-BN pathway could meet council registration standards. Paul McElroy, UCOL’s chief executive, said while UCOL could take issue with the review, it was “focused on moving forward”. “We do acknowledge that some internal processes can be improved, and UCOL has already started doing this. We have learnt from the review and will implement NZQA’s recommendations.” Keith Ikin, Waiariki’s chief executive, said he believed the final NZQA report was as “balanced as we’re going to get”. “We’re actually relieved that we’ve


now got a report out. It’s been a long process and a fair amount of uncertainty for our students.” Ikin said the report was “now quite historic”, the pathway no longer existed, and a lot of NZQA’s requirements had been or were being addressed by Waiariki.

Lessons learned McElroy said it had initiated an audit into its enrolment processes, was investigating using the benchmarking tools suggested by NZQA to help verify overseas qualifications, and was now using online verifications of English language test (IELTS) results. Ikin said it had carried out an internal audit of all systems and processes for international student recruitment and enrolment and was making a number of changes, including ensuring its overseas agents adhere to best practice, introducing extra verification of IELTS results, and a system for double-checking international students’ qualifications. He added that he asked a gathering of about 200 overseas-trained nurses enrolled at Waiariki whether “any agent of our institution has given you any commitment or promise of registration, and not one responded ‘yes’”. Carolyn Reed, chief executive of the Nursing Council, said the council welcomed the release of the review and hopes it will “represent closure of the matter”. “The reviews are clear in their findings,” she said. McElroy said the review was driven by a “nursing registration issue graduates were experiencing with Nursing Council” and he was pleased with the solution negotiated with Nursing Council for its students.

Nursing Review series Infection Control/Wound Care 2012

NZQA report findings on UCOL & Waiariki RN-BN pathways »» Overseas registered nurses (RNs) who completed the one-year RN-BN pathway programmes were awarded a Bachelor of Nursing (BN), but unlike the three year BN degree, the pathway did not lead to Nursing Council registration. »» Degree regulations were consistently applied and met NZQA’s approval criteria. »» Information provided to student by UCOL and Waiariki to students made it clear that completing the one-year RN-BN bridging programmes did NOT meet Nursing Council requirements for registration. »» But in practice, many overseas RNs enrolled in the pathway programmes believed it gave them the best opportunity to get accepted by Nursing Council onto a competency assessment programme (CAP), which is the last hurdle for New Zealand registration. »» In November 2011 NZQA, at the Nursing Council’s request, assessed one Indian nursing school’s three year diploma, and advised it was equivalent to level five on the New Zealand Qualification framework (degrees are level 7). »» Both Waiariki and UCOL told NQZA that prior to November 2011, students completing their RN-BN pathway were being accepted by Nursing Council onto CAP programmes without “apparent issue”. »» Both institutions believe the Nursing Council has changed its approach to assessing education standards for registration, but the Council disagrees, saying standards have not changed. »» Both RN-BN pathway programmes have been withdrawn. »» Both institutions have worked with the Nursing Council to develop free and brief additional training courses so RN-BN students and graduates meet Nursing Council standards (see NewsFeed July 26 at »» The review team’s findings do not call into question the quality of the teaching in either RN-BN pathway or the support institutions have given to international students. »» NZQA found both institutions processes for recognising overseas-trained RNs previous education and clinical experience were “not comprehensive enough, nor were they based on good practice”. »» Both institutions are required to introduce more “robust” and “consistent” processes for assessing overseas nursing qualifications and prior learning and clinical experience. »» In addition, NZQA recommended that “given Waiariki’s focus on international provision … it is timely for Waiariki (to) undertake a broader review of its approach to international export education”.

For the record “UCOL does accept that the Nursing Council needs to be aware of the complexities of internationally qualified nurses seeking registration in New Zealand and that processes will need to change from time to time,” said McElroy. Ikin said a lesson to be learnt from the events affecting the Indian-trained nurses was the need for all parties to do a better job at communicating changes affecting internationally-qualified students. “That is critical for the sake of our students and critical for the sake of our export education market. “I think its something that all of us need to take on board: institutions, the Council, and NZQA.”

Council overseas registration review findings soon Reed said Council was already in the process of consulting on the overseas registration standards, prior to the NZQA review, and had been reviewing all its internal processes. “One of the learnings from this has been the need to have our communications (letter and emails) with internationallyqualified nurses reviewed to ensure they are clear, concise, and easily understood by a recipient who has English as a second language,” Reed said. She said its consultation document, which includes proposing a third and tougher registration pathway for overseasregistered nurses trained in countries like India and the Philippines, had drawn “considerable interest”. It had been circulated to 183 key stakeholders and it had received 67 written submissions, including one submission from a health consumer group, one from a member of the public, and 29 submissions from individual nurses. The submissions have been analysed and will be considered by the Council at its September 20 meeting.

UCOL TO LAUNCH NEW DIPLOMA FOR OVERSEASTRAINED NURSES UCOL plans to fill the gap from dropping its RN-BN pathway by launching a new graduate diploma that provides a registration pathway for overseas-trained, degree-qualified nurses. McElroy said it was consulting with the Nursing Council about the proposed diploma, which

was at the stage of being reviewed by stakeholders. The main difference between the RNBN pathway and the 12-month graduate diploma programme is the inclusion of 12 weeks clinical experience. “Our requirements and relationship with international agents remain the same. They must present suitable candidates with all the necessary documentation for consideration to UCOL.” If the diploma gains approval, it would be available in 2013.

AUCKLAND BOARDS SLOWER OFF MARK WITH SAFE STAFFING TOOLS BETTER PATIENT WORKLOAD prediction and improved rostering of staff to match can help meet the challenging demands of the modern health care system, says Jane O’Malley, Ministry of Health Chief Nurse. O’Malley said she could not comment on board funding, but anywhere in the health system, there were times when the amount of work to be done outstripped the staff available to do it. She said one response was the Safe Staffing Health Workplace (SSHW) unit’s development of electronic care capacity demand management (CCDM) tools, which (along with releasing time to care projects) “can at least ameliorate what is undoubtedly an incredible amount of work to be done”. “Adopting an approach where you can more rationally predict the amount of work to be done and the type of person to do it – whether it be a health care assistant, EN, or RN – and roster that ahead of time, you are more likely to have a more manageable workload most of the time,” said O’Malley. To introduce the CCDM tools, DHBs must have TrendCare (which currently about 12 DHBs have invested in) or a similar electronic patient acuity/ workload management system that can help objectively measure nursing workload. Waitemata now has TrendCare in place in an initial 20 wards, including two mental health units, and working with the SSHW unit on the first stages of rolling out the CCDM tools. Peach said she anticipated the CCDM


programme would help the DHB understand its demand and capacity issues, but it was not a quick fix and would take at least 12 months to roll out across three areas. Last month, the DHB launched the CCDM questionnaire to get feedback from all staff (not just nurses) on how they perceive their workload. Dotchin said she hoped within a couple of months to put a business case to the DHB board for purchasing TrendCare – the move follows a presentation by the SSHW unit in early July about its work and the CCDM tools. The presentation arose from a bipartite union DHB advisory group meeting and Dotchin had made a commitment for NZNO delegates to be involved in preparing the business case, including proposing which areas TrendCare and the CCDM tools should be piloted in first. “Patient safety, quality of care, and staff welfare are of utmost importance to me, and I believe working collaboratively with the union will assist us in meeting those goals,” Dotchin said. Kivell said Counties Manukau was in the early scoping stages of considering a business case for purchasing a validated electronic acuity tool like TrendCare. She said it did have capacity planning tools to look at daily workload resources and incoming patient demand and an escalation plan when extra staffing is required. “I don’t doubt it would be useful to have a validated acuity tool as well,” Kivell said.

LOSING 200 PROSPECTIVE overseas nurse students next year will cost Waiariki’s nursing school close to $2 million in lost income. Keith Ikin, Waiariki CEO, said discontinuing the RN-BN pathway programme would result in a “significant loss of income” and the school had to review its budget for next year on the basis of losing 200 prospective international student enrolments. Waiariki has been a large player in the international nursing student market, with 407 students graduating from its RN-BN programme since 2007 and also high oversea enrolments in its infection control programmes. The NZQA review findings recommended that Waiariki undertake a broader review of its approach to export education, given its focus on international provision. Ikin, when asked whether Waiariki had become too reliant on export education, said it was a government directive to the

tertiary sector to double export education. He said the positive impact for Waiariki of attracting international enrolments in the past three to four years had been creating surpluses for the institution, which it had not been able to generate for “probably the last 20 years”. That had meant Waiariki was able to start building a new $10 million purposebuilt nursing school in 2013 and able to double the student support network across the institution for all students, said Ikin. “That’s the catch-22, really. I know there’s a criticism out there that institutions like ours are enrolling international students purely to make money. “I just disagree with that. If it was purely about money, we wouldn’t be getting the completion rates of our students, and we wouldn’t be getting the feedback from employees about the quality of our graduates that we’re getting.”

Nursing Review series Infection Control/Wound Care 2012


For the record

Spoonful of medicine for prescribing bill by FIONA CASSIE

NURSING OPPOSITION TO the proposed delegated prescriber role has been tempered by amendments proposed by the Health Select Committee to the Medicines Amendment Bill. Nursing organisations made strong submissions to the committee that they saw no need for creating a third prescribing category and registered nurse prescribing would be better served under the existing designated prescriber role. The new category will still go ahead, but the committee recommends delegated prescribing be implemented through regulations to control the new role. Applications for delegated prescribing rights would also now require the support of the relevant responsible authority, like the Nursing Council. Marilyn Head, policy analyst for the New Zealand Nurses Organisation, says even though the role remains, the amendments show that the nursing profession has been listened to. Jenny Carryer, executive director of the College of Nurses, agreed, saying the amendments meant the profession’s regulatory body could avoid delegated prescribing if they chose to. The bill, yet to have a date set for its return to Parliament for its second reading, also brings in the long-awaited and applauded move to give nurse practitioners the same authorised prescribing status as medical practitioners, midwives, and dentists. The Health Select Committee reported back last month on the bill after considering 43 submissions and hearing additional submissions in person from 19 of them. The committee has recommended the bill be passed with minor amendments. These include scrapping proposed provisions for temporary prescribing rights – a move called for by the nursing sector – as they were seen as superfluous as designated and delegated prescribing regulations could already specify a time limit. A further amendment aims to ensure more “flexible” and “efficient” ways of updating the lists of medicines that designated prescribers can prescribe by allowing updates to be done by the Director-General of Health by notice in the Gazette. The nursing sector had called in its submission 30

Nursing Review series Infection Control/Wound Care2012

for the current nursing ‘cumbersome’ process to be revised to prevent medicine lists from quickly becoming outdated. Carryer said moving to a gazetted list would shorten the process of adding new drugs as they became available. The committee has also recommended that introducing delegated prescribing rights for a group of health professionals “would require the support of the relevant responsible authority” and would be done under regulation. The proposed delegated prescribing category enables limited prescribing for registered health professionals under the sanction of an authorised prescriber. The nursing sector had called for the delegated prescribing category to be scrapped as unnecessary, as mechanisms already existed for broadening and regulating registered nurse prescribing, but Head said the amendments had allayed NZNO concerns. She said even though the committee had recommended going ahead with the delegated prescriber role, they had made very clear, support was required from the responsible authority. “And the Nursing Council has already indicated that they won’t be pursuing delegated prescribing,” said Head. Carryer said the amendments did allow the Nursing Council to “not necessarily buy-in to delegated prescribing for RNs” and it could pursue the designated prescribing category. Head believed the designated prescribing category – already used to allow the diabetes nurse specialist prescribing demonstration sites – was the right mechanism to pursue new prescribing roles for registered nurses and the amended bill “absolutely” allowed for this to continue. She said other health professional groups might pursue delegated prescribing. The committee said the intention of delegated prescribing was to give patients “more convenient, efficient access to medicines by broadening the range of practitioners who may prescribe, while ensuring patients’ safety”. Associate health minister Peter Dunne’s office has said the Government’s intention is for the bill to be passed by the end of the year.

For the record

Safe staffing tools may help unsafe workload survey concerns by FIONA CASSIE

New Code of Conduct

All nurses over the next three years will be expected to undergo professional development on the r ecently released new Code of Conduct for Nurses. The Nursing Council has produced the new code, and the related new professional boundaries guidelines, to replace the outdated code that was first developed in the mid-1990s. The 48-page code is now built around eight principles rather than the original four, and the eighth, about reflecting the cultural needs and values of health consumers, was added following the consultation process. The 33-page professional boundaries guidelines now includes guidance on social media, and following feedback from submissions, more detailed advice on the boundaries around sexual relationships and working with health consumers nurses have existing relationships with. The code is framed around the four core values of respect, trust, partnership, and integrity, with the key message of both documents that nurses must make the care of patients their first concern, and to do this, they must maintain professional boundaries. Interactive presentations are to be held around the country to support nurses meeting professional development requirements around the new code. The use of online learning is also being explored. Details are expected to be released shortly. Nursing Review will take an in-depth look at the new Code in our next edition.

Review of HPCA Act

How can our health professional regulatory framework be more responsive and flexible is one of the questions being asked in a major review of the Health Practitioners Competence Assurance Act. The Ministry of Health has released a 50-page consultation document examining the HPCA Act, which has been the backbone of health professional regulation since its passing in 2003. Currently, the regulatory authorities of 13 health professions are covered by the act, including the Nursing Council, and the review asks whether this number should be reduced, as it has in the UK, where nine bodies regulate 25 health professions. The review also asks questions around whether the Act be used to promote a more flexible workforce, promote effective ways of the different health disciplines working in teams, and become more responsive to keep pace with integrated and innovative models of care. Further areas examined are whether the Act is keeping the public safe from harm and whether it is keeping the public informed on health regulatory matters that concern them. Developing a robust data collection system to inform workforce planning is also being considered as part of the review and whether regulatory authorities should have a role in pastoral care of health professionals. The consultation document can be downloaded from publications section of the Ministry of Health website:

SAFE STAFFING TOOLS could help ameliorate unsafe workload concerns raised recently in the second union survey of Auckland health workers to link unsafe staffing with underfunding. The Public Service Association released a survey last month of 627 members (171 of those nurses) across the three district health boards in Auckland, with the majority of nurses and other staff ranking the workload manageability at very high or unsafe levels, causing them to feel exhausted and stressed. That survey follows a New Zealand Nurses Organisation member survey at Auckland District Health Board, released in early June, which showed the DHB was short of 120 nurses and linked this to cost cutting pressure to stop a $4 million budget blowout. Richard Wagstaff, national secretary of the PSA, says DHBs are working under tight financial constraints as they try to deliver services on “significantly reduced” budgets. Many DHBs were responding by holding open staff vacancies for extended periods of time, which was taking its toll on staff and services, Wagstaff said. “The government is forcing DHBs into a very difficult position, and decisions are being made that compromise frontline services. The result is that cuts are being made by stealth.” The survey asked members to rank from one to 10 how manageable they felt their workload was, from acceptable (1) to unsafe (10), and whether they left work to head home feeling ‘up-to-date’ (1) or ‘exhausted/stress’ (10). In both questions, the vast majority of nurses scored between 5-10, including high numbers scoring 7-10 for the workload question (PSA membership includes nurses working in mental health and public health). Ngaire Buchanan, joint interim chief executive of Auckland DHB, said the DHB understood staff were concerned, but while it did hold recruitment for a time in March, as part of successful efforts to come in under budget on June 30, it was not accurate to say it held open vacancies for an extended period of time. She said it actually had more, not less, nurses employed in hospitals, but “it may not feel like it” for nurses dealing with the pressure of complex cases and very ill people.

Buchanan said the DHB had recruited 892 extra staff across all professional groups since March, and Margaret Dotchin, Auckland DHB director of nursing, added that it actually had 14 less vacancies in mental health nursing than it did at the same time last year. Dotchin also said a business case for purchasing acuity tool TrendCare, a necessary first step towards introducing safe staffing tools at ADHB, was close to being signed off in a collaborative initiative with NZNO. First off the block with investing in TrendCare and starting to roll out safe staffing tools is Waitemata DHB. Its director of nursing, Jocelyn Peach, said the programme would help the DHB understand its demand and capacity issues. She said that Waitemata, which had 87 nurses respond to the PSA survey, was not underfunded, but like all DHBs, was living within its means, so questioned overtime and additional shifts. Beth Bundy, Waitemata’s human resources manager, said while it was always of concern if some people felt stressed and overworked, an independent organisational wide survey last year found 79 per cent of the 2500 respondents liked their job and would recommend the board as a place to work. Denise Kivell, director of nursing at Counties Manukau DHB, noted that the number of nurses responding to the survey at CMDHB was low (25), but it was still important to keep an eye on all workload surveys, particularly involving frontline staff. Counties Manukau would also be holding its own two-yearly organisational survey in October. “I’m aware that this winter has been extremely demanding with increased patient complexity and numbers requiring hospitalisation,” said Kivell. “So I’m not surprised that there are staff members who feel exhausted and who have worked extremely hard.” She said Counties was proactively recruiting to maintain full staffing levels and had recently taken on permanent contract 37 of the 42 nurses who had just completed their new graduate programme.

Nursing Review series Infection Control/Wound Care 2012


For the record PHC College awards The achievements of primary health nurses were celebrated with a series of awards at the inaugural conference of the New Zealand College of Primary Health Care Nurses NZN0 held last month in Hamilton. Taking out the clinical excellence award was Clare Heng, a clinical nurse leader at Blenheim’s Wairau Community Clinic. Denise White (Clinical Nurse Specialist Community for MidCentral District Health Board) and Emma Hickson (charge nurse manager for Capital & Coast DHB) were presented awards for services to district nursing. White also won an innovation award. Wellington public health nurse Chris Campbell took out the award for innovation in public health. Strategic leadership awards were presented to Nelson independent nurse consultant Brenda Bruning and Palmerston North PHC nurse contractor Jane Ayling. More than 350 nurses attended the conference, with Rosemary Minto continuing as chair and Debbie Davies as vice-chair.

Correction In Nursing Review’s last edition by error a photo of Diana Hart (incorrectly captioned Marina Lambert) was published with the article Building your diabetes and respiratory nursing skills (p.14) instead of a photo of the article’s co-author Marina Lambert. We apologise for the error.

Appointments and movements Kerry-Ann Adlam, the longstanding director of nursing for Taranaki District Health Board, has left to take up a new position at HealthShare,

the shared services agency for the five midland region DHBs. She is project manager for two HealthShare clinical groups. Gail Geange is currently acting director of nursing at Taranaki DHB. Sonia Gamblen, has been recently appointed director of nursing for Tairawhiti District Health Board after being acting director since March last year. She was previously associate director of nursing and has been at Tairawhiti since 2006, when she arrived from the United Kingdom to become the nurse entry to practice coordinator. Margaret Dotchin, was confirmed as executive director of nursing by Auckland DHB midyear after stepping into the interim role in February following the resignation of Taima Campbell. She was previously director of nursing for adult services and has held both general management and nursing leadership roles for adult nursing and has been general manager of National Women’s Hospital. Kate Rawlings, a former nurse educator, has been appointed head of the South Island Regional Training Hub. The hub is one of four established nationally by Health Workforce New Zealand with the goal of providing more effective postgraduate education and training for health professionals. Rawlings has a Bachelor of Education (nursing) and a Master’s of Health Administration and is the former manager of the University of Canterbury’s College of Arts. Former nurse-turned-health manager, Ron Dunham, is the new chief executive of Lakes District Health Board. Dunham replaces fellow nurse-turned-CEO Cathy Cooney, who stepped down in June after 11 years in the job.

Meningitis website launch The vital message of ‘don’t swap spit’ and information about the symptoms of meningitis are available on a new dedicated website launched in August. The website was launched just weeks prior to the sudden death of 12-year-old Wellington school girl Amanda CrookBarker from meningococcal disease. Paul Gilberd, spokesman for the The Meningitis Foundation Aotearoa New Zealand, which created the website, said meningitis is difficult to diagnose as it presents with flu-like symptoms but can often strike and progress quickly. He said the website can educate New Zealanders about meningitis, the preventative role of vaccinations, and to know what symptoms to look for. He said people also needed to be reminded of the vital message ‘don’t swap spit’. “In practical terms, this means don’t share drink bottles, cigarettes, spoons, or straws. The foundation website can be found at


Dementia campaign and website launched Sooner and smoother diagnoses of dementia are behind a campaign to prompt people to talk to their doctor or practice nurse about early signs of Alzheimer’s disease. The campaign called “The sooner we know, the sooner we can help” also includes a dedicated website aimed at informing health professionals about dementia so they can support patients and families. Matthew Croucher, a psychiatrist specialising in old age, said a timely diagnosis allows the transition into dementia to be smoother and allows issues to be managed before they become crises. An estimated 48,000 New Zealanders have dementia, and it is set to increase to 88,000 by 2030 and 147,000 by 2050. Croucher says general practices can help a person with dementia symptoms through education, practical support, relieving symptoms, monitoring risk (for such things as falls and wandering) and helping plan ahead. The website includes a directory of support services and specialists, links to evidence-based information, and resources that patients can be referred to.

Nursing Review series Infection Control/Wound Care 2012

Nursing Review series Infection Control/Wound Care 2012


Nursing Review 2012 Infection Control/Woundcare  

Nursing, New Zealand

Nursing Review 2012 Infection Control/Woundcare  

Nursing, New Zealand