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FOCUS: International Nurses Day / Innovation

Nursing Review APRIL/MAY 2016/$10.95

New Zealand’s independent nursing Series

INNOVATION

Nurse research on aspirin to apps

Leaders keeping it real on ward walks

EVIDENCE-BASED PRACTICE Exercise impact on heart patients

A DAY IN THE LIFE OF a district nurse

Q&A

Carey Campbell

Practice, people & policy PEOPLE: New graduate tears & rewards PRACTICE: Reflecting on cultural safety

CELEBRATING NURSING Nationwide tales of nursing ‘heroes’ Research: a force for change

www.nursingreview.co.nz


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LETTER FROM THE EDITOR Nightingale and Seacole: Celebrating all nursing heroes I have to confess until relatively recently my knowledge of Florence Nightingale was limited to the stereotypical ‘Lady of the Lamp’ watching selflessly over the wounded soldiers of the Crimean War. When I researched her in 2010, the centenary of her death, I finally discovered what a feisty, intellectual and complex woman she actually was. And the reason her legacy has endured was due mostly to the hard lessons she learnt in Crimea, leading to the founding of the world’s first professional school of nursing at London’s St Thomas’ Hospital and her use of statistics to argue for health reforms. But for most of my life I was totally ignorant even of the existence of the other nursing heroine of the Crimean War, Jamaican Mary Seacole, who a quick Google search reveals that, like Nightingale, was feted by the British public, military and royalty of the time for her nursing work in Crimea. Seacole, the daughter of a Scottish officer and a Creole healer and hotelier, had experience nursing cholera in Panama and yellow fever in Jamaica before heading to Britain in 1854 with the aim of nursing at Crimea. After her attempts to join the second Crimean nursing contingent were rebuffed, she raised funds privately to head to Crimea, where she set up the ‘British Hotel’ and provided soldiers with food and nursing care, including at the front line. Twice after the war the British public raised funds to thank Seacole for her Crimean role and she published a popular autobiography in 1857. After her death in 1881, Seacole was largely forgotten, but a resurgence of interest in her story in recent decades lead to her being voted in 2004 into first place in the100 Great Black Britons online poll. A statue of Seacole is due to be unveiled this British summer in the grounds of St Thomas’ Hospital. The upsurge in interest in this once-forgotten, black nursing heroine has seen some fall into pro-Seacole or pro-Nightingale camps, attacking the veracity and virtue of the two nurses’ stories and characters. I’m sure neither woman is without flaws, but that shouldn’t mean we need to knock one hero off her pedestal to install another. We have room for many more heroes and in this International Nurses Day issue we celebrate all nursing ‘heroes’ – from the unsung and everyday to the pioneers and the exceptional. Fiona Cassie www.nursingreview.co.nz

Wider distribution for Nursing Review Free copies of Nursing Review are now sent directly to every ward at every major hospital. If this is your first time reading Nursing Review, contact editor Fiona Cassie and tell her what you think (especially if you have news or ideas to share!). These free copies will have all the features and opinion Nursing Review is known for, but only subscribers will receive print and online access to the RRR professional development activity. To get your personal copy (including RRR), go to: www.nursingreview.co.nz/subscribe

Multimedia platform for nursing Nursing Review is a genuine multimedia publication, with five print editions and our recently revamped website, which contains content not found in the print edition, including exclusive online articles, live Twitter updates, social sharing, and the downloadable RRR professional development archive. Visit: www.nursingreview.co.nz COVER PIC: A district nurse. Find out about a day her in her life on page 3 of this issue. PHOTO CREDIT: Glenn McLelland www.aerialvision.co.nz Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).

Inside:

FOCUS: INTERNATIONAL NURSES DAY / INNOVATION

4

NURSING ‘HEROES’: tales of nurses unsung and acclaimed making a difference across the country

14 18

INNOVATION: Becoming a researcher and a force for change

19 20 22 23 24 27

JANE KOZIOL-McLAIN research on delivering apt advice via an app for young people RESEARCH: mindful self-management for long-term conditions ANDREW JULL’S nurse-led drug trial of treatment for VLU Disaster research: do nurses practice what they preach? Disaster research: finding the time to care INNOVATION: keeping it real by walking the wards International Nurses Day: building resilient health systems

RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe

Practice, People & Policy 28

CULTURAL SAFETY: developing self-awareness through reflective practice

29 30

SUZANNE JOYNT on missing ‘conversations that count’

ROSALIE DAVIS: new graduate stress, tears and rewards

Regulars 2

Q&A Profile: Southern Cross and private hospital sector nursing leader CAREY CAMPBELL

3 31 32

A day in the life of… a district nurse Evidence-based Practice: CYNTHIA WENSLEY on cardiac rehabilitation exercise College of Nurses: LORRAINE HETARAKA-STEVENS on upping recruiting of PHC nurses, particularly Māori

Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ Editor Fiona Cassie 03 981 9474 editor@nursingreview.co.nz Advertising & marketing manager Belle Hanrahan 04 915 9783 belle@nzme-ed.co.nz Publisher & general manager Bronwen Wilkins production Aaron Morey Subscriptions Gunvor Carlson 04 915 9780 gunvor.carlson@nzme-ed.co.nz images iStock

Nursing Review

Vol 16 Issue 2 2016

NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6011, New Zealand PO Box 200, Wellington 6011 Tel: 04 915 9780 © 2016. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014

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

www.nursingreview.co.nz  |  Nursing Review series 2016    1


Q&A

Carey Campbell

JOB TITLE | Chief Nurse Advisor, Southern Cross Hospitals (National)

Q A

systems that enable all nurses to work to the full breadth of their scope of practice (and let’s put the hoops back in the PE shed?) All nurses work within a team culture where ‘speaking up’ appropriately is supported and loudly applauded.

Where and when did you train? I graduated from Waikato Technical Institute (now Wintec) at the end of 1986 with a Diploma in Nursing.

Q A

Q

Other qualifications/professional roles? Since then I’ve obtained my Bachelor of Nursing (Massey), Postgraduate Diploma in Health Leadership and Management, and Master in Health Practice (both from AUT). I am the chair of the directors of nursing group for NZPSHA (the New Zealand Private Surgical Hospitals Association), and I am a member of the Clinical and Technical Advisory Group for Health Informatics NZ (HINZ), a member of NENZ (Nurse Executives of New Zealand) and co-lead director of nursing for PDRP (professional development recognition programmes). Plus I chair nurse practitioner assessment panels for the Nursing Council of New Zealand.

Q A

Why did you decide to become a nurse? In a sense it just happened. I was attracted to healthcare and interested in the health professions and I guess nursing was the first door I opened and walked through.

Q A

What was your nursing career up to your current job? Much of my career has been spent at Waikato District Health Board, in a number of different nursing roles. These include staff nurse, clinical resource nurse/ educator (orthopaedics), charge nurse (gynaecology), professional nurse advisor, acting director of nursing and clinical nurse director. It was a tough decision to leave the DHB in 2008 and take up my current role at Southern Cross Hospitals – although I’ve never looked back!

Q A

So what is your current job all about? My role is to deliver professional leadership and strategic direction for our nursing workforce (about 800 nurses across 10 hospitals), with a strong focus on patient safety and workforce planning and development. I report to the chief executive and my senior management team position means nursing interests figure in executive decision-making.

What are the key differences in leading nursing in the private sector versus the public sector? No need to plan the Christmas roster (we close down for the holiday)! Seriously though, there are more similarities than differences. Nurses in both sectors strive to provide safe, quality, person-centred care. The context and environment may be different, but our patients’ needs for compassionate care are the same.

A

Carey Campbell

Q A

What do you love most about being a nursing leader? I can influence positive change, and work with amazing inter-disciplinary teams and nurses who really make a difference in patients’ lives. I enjoy being part of the development of nursing, and of individual nurses, and my professional conversations with NP applicants (during assessment panels). Learning about their practice and the amazing roles they hold is inspiring and makes me proud to be a nurse.

Q A

What do you do to try and keep fit, healthy, happy and balanced? I can’t claim to nail all four every time (though I am generally happy most of the time!). Having a national role with 10 hospitals from Auckland to Invercargill, I travel a lot. So in the weekends I love being at home with family and friends. Home may, in fact, be a football sideline, a movie theatre, a BBQ, or a beach (for a spot of fishing or diving). I love reading and cooking – but don’t get much time for those!

Q A Q

What is your favourite way to spend a Sunday? Purposeful inertia!

While waiting in the supermarket checkout queue which magazine are you most likely to pick up to browse and why? Gossip? Cooking? Sport? Fashion? Politics/news? None, I’m either too busy peoplewatching, chatting to other customers or zipping through the self-service checkout. But if I had to choose one, it would be a food magazine… looking at all the lovely recipes I never get the time to try.

Q A

A

Q

Q A

What do you love least about being a nursing leader in 2016? The best interest of the patient is never served by creating additional hoops for nurses to jump through, just to prove themselves. It can be tiring and frustrating working through this, but then it’s a cause worth fighting for. If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? Funded NEtP positions for all new graduate RNs, please. Can we please have environments and

A

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What are three of your favourite movies of all time? Finding Nemo (is that compatible with fishing?) Divergent (dystopian society and social experiments intrigue me) The Sound of Music (I’m not too keen on hill walking but love a good singalong!)


A day in the life of ...

a district nurse

JOB TITLE | District Nurse LOCATION | DHB

7.00

AM WAKE

I usually wake around now to the sound of my alarm clock and leave the house by 7.30 or 7.45am. I am lucky enough to live a fiveminute walk from work so I never have to worry about finding a park or getting stuck in traffic!

We work together with our wider community care team partners - like health care assistants, social workers, physiotherapists and occupational therapists – to deliver holistic care. My role also includes working with the hospice to deliver care to palliative patients in the community. It can be sad sometimes to see people pass away, especially when they are

8.00

AM START WORK

Work officially starts at 8am although I usually get there a few minutes early to check my emails and look through my list for the day. This morning was a bit busier than usual as it was my first day back after a break away and there were some referrals and notes to follow up on.

8.15

PM LUNCH

We have lunch once we have seen all our patients for the day. That is generally around 1pm though sometimes it can be as late as 2 or even 3pm. Some days it is so busy I just eat a sandwich on the go between seeing patients but today I had a little more time so I popped home for my 30-minute break, another perk of living so close to work! Sometimes if it is a beautiful sunny day I park the car overlooking the sea and eat my lunch while enjoying a million-dollar view.

2.00

PM BACK TO OFFICE

By 2pm most nurses are back at the office. We finish writing notes and organise our list of patients for the following day. We are mostly working by ourselves when out on the road so when back in the office we often discuss patients with our colleagues and bounce ideas off each other. Some afternoons we have an education session with the other district nurses and other days we have meetings and updates. Of all the nursing jobs I have had since graduating from Otago Polytechnic in 2009, I find this the most interesting and challenging. I went from being a medical ward nurse to district nursing and was hooked from my first shift. I enjoy the autonomy that we have, the rapport we can establish with our patients and also learning more about wound care as it is something I have always been interested in.

AM QUICK STAFF MEETING

We have a quick meeting with our charge nurse to make sure that everyone’s workload is manageable. We reshuffle the lists if needed as some days one area might be particularly busy. We also run a wound clinic from our base from 8.30–4pm for patients that can travel, so one nurse in the team will spend the day seeing those patients. After the meeting I organise myself for the day and ring patients to let them know what time I will be visiting. Then I load up the car with all the equipment needed, including a wound care bag and the wound camera.

9.00

AM ON THE ROAD

I head out to see my first patient for the day. I cover a seaside area. I enjoy working here as there are some amazing sea views as I drive from patient to patient. Each day as a district nurse is different, which is one of things I love the most about it. For example, today I did a lower limb assessment on a lady at a rest home, saw a couple of patients with chronic leg ulcers and visited another lady to administer the anticoagulant Clexane. I also saw an elderly bedbound man who is cared for at home by his wife. I was with them for over an hour as he has extensive pressure injuries. Many of the patients I see have been under our service since I began district nursing almost two years ago, so we end up developing quite close relationships. It can be challenging to see patients on a long-term basis so we tend to share them with other district nurses so we don’t get too burnt out.

1.00

4.30

PM LEAVE WORK

young, but it is a privilege to be a part of their care at the end of their lives. I have been involved in some interesting situations since starting district nursing. Shortly after I started this job a patient collapsed as he was coming out of the shower. I had to perform CPR on him for what seemed like an eternity until the emergency service arrived. He passed away a few hours later in ED and it took me a while to process things. On the wards I would have pressed the emergency bell but when it is just us we have to think fast and try to stay calm. I’ve also had lots of fun with patients. One elderly man used to call me Florence (for Florence Nightingale) and give me a chocolate as a “reward” every time I visited him. He had a great sense of humour and used to have me laughing at his jokes.

I am usually exhausted after finishing work but try to fit some exercise in before heading home and today I did make a gym class.

EVENING As work can be stressful at times I usually wind down in the evenings by reading, watching a movie or going for a walk. Once a week a group of us from work go to a quiz night, which is a bit of fun. Tonight I went out to dinner with my boyfriend then watched some episodes of my favourite TV series.

11.00

PM SLEEP

By 11pm I am in bed and asleep.

www.nursingreview.co.nz  |  Nursing Review series 2016    3


FOCUS  n  International Nurses Day

International Nurses Day

‘Heroes’

More than 52,000 nurses are practising across New Zealand and every nurse has a story. To mark International Nurses Day on 12 May, Nursing Review invited district health boards across the country to contribute stories on some of their nursing ‘heroes’ to celebrate the diversity and talent of just some of those nurses. In return, we have received tales of nurses, both unsung and high fliers, making a dedicated difference to the communities they serve. Read on and enjoy.

Jenny Percival DHB: Wairarapa

Nurse educator, acute services and Red Cross nurse

“I feel the pull to make a difference where it’s needed most.”

Wairarapa’s nursing hero painted a mural to brighten the children’s ED cubicle in her home hospital before flying out to nurse for the Red Cross in South Sudan. Jenny Percival wears a number of hats. She is a nurse educator in acute services at Wairarapa Hospital, a humanitarian aid worker and a talented artist. Currently she is wearing her Red Cross nurse hat and is nursing in the war-torn zone of South Sudan, which she left for soon after her local mission of brightening up the emergency department kid’s cubicle with the pictured owl mural. Jenny took up her nurse educator role at Wairarapa Hospital about a year ago, following 15 years as a staff nurse in the emergency department. She works with the nursing team in acute services to support, train and update staff on the latest developments and research in clinical practice and procedures. She assists new staff and graduates to develop skills and confidence and supports more experienced nurses to access opportunities to extend their knowledge. “It gives me great satisfaction to be able to support nurses to grow and develop,” says Jenny.

Jenny is also driven by a passion for humanitarian work. After training with the New Zealand Red Cross and their Red Cross partners in Switzerland, she worked on the front line in a treatment centre in Sierra Leone at the height of the Ebola epidemic. She says, “I feel the pull to make a difference where it’s needed most. If I can save one person from a life-threatening condition and that person survives, it creates a ripple effect.” She is currently on a six-month mission with the New Zealand Red Cross (seconded to the International Committee of the Red Cross); part of a small surgical team at Juba military hospital, in South Sudan – the world’s newest country where civil war has been waging for more than 10 years. “There are three expat nurses and we look after two surgical wards and a small ICU with limited resources, including water.” The biggest barrier though is communication. Jenny’s nurse educator skills are being put to good

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use as part of her job involves helping to train local nurses and nursing students who speak mainly Arabic, so teaching vital signs is a new challenge. There are plenty of other challenges too. “I have never seen so many limb amputations and it breaks my heart to see this, especially the young women and children with gunshot wounds,” Jenny writes from the war-torn zone. No stranger to a challenge, Jenny will no doubt rise to meet it, much like the way she took on her own mission to brighten the children’s cubicle with a mural of colourful owls – just before she left for South Sudan. Jenny’s prime motivation was to make children and their families more comfortable in times of pain and stress. “Having something attractive with lots of points of interest provides a welcome distraction where parents can talk to their children about what the owls are doing,” she says. Caring and humble, Jenny says she is “just an ordinary person doing something that feels like the right thing to do”.


FOCUS  n  International Nurses Day

“It’s like one big family. You get to know your residents and understand their needs more than you would working in an acute hospital setting.”

Gene Ruiz DHB: Canterbury

Clinical services manager and clinical advisor – Bishop Selwyn – Ultimate Care Group Empowering her nursing team to make a difference in Canterbury’s older persons health and aged residential care sectors led to Gene Ruiz’s nomination. When Gene Ruiz arrived in New Zealand in 2006, she thought working in aged residential care (ARC) would be just a stepping-stone to acute care nursing. But a decade on she’s leading a team of eight registered nurses and empowering them to be the best after discovering not only an enthusiasm for older people’s health but ensuring professional development opportunities for her staff and quality improvements leading to better outcomes for her residents. She was also shoulder-tapped in 2013 to be part of Canterbury DHB’s first gerontology acceleration programme intake – involving postgraduate study and ‘job-swapping’ between services – that aimed to fast-track potential nurse leaders in older people’s health. Gene says she loves ARC because you develop a sense of family and friendship with residents, their families and staff. “It’s like one big family. You get to know your residents and understand their needs more than you would working in an acute hospital setting. I really like that consistency and continuity of care we can provide. “With our facility manager, Diane Topschij, and our nursing team… we seek to deliver the right care, at the right time, in the right place. In line with this, we empower our nurses and caregivers through continuing professional development, to enable them to deliver the right intervention at the right time in the right place.” Gene says she’s noticed a shift in the type of admissions since the earthquakes. “Thanks to more community services that are allowing older people to live longer in their own homes, we have noticed that when they do get to ARC, their dependency and acuity is much greater. “Having a skilled workforce able to respond quickly and provide a much higher level of care and treatment is critical to this.” Gene sees ARC’s place in the health system as one where increased acute and specialist care can be provided, without the need to admit patients to hospital. “Our biggest achievement at the end of 2015 was the reduction in the numbers of acute hospital admissions, which was more than halved from 31 in 2014 to 12 last year. “It’s a better outcome for everyone. It’s better for the resident, for their family and for the health system as a whole, but it relies on a skilled workforce. “We encourage and provide our RNs the tools to further their knowledge and skills. We empower them to be involved in quality activities, like auditing, surveillance and trend analysis of the quality indicators, and letting the RNs take a champion area, such as falls prevention, to focus on.” Gene says empowering staff now frees up her some of her time to help other clinical service managers across the Ultimate Care Group, in her role as clinical advisor, to implement similar changes in their facilities. “I feel so proud to see our RNs so enthused and passionate in their work. We take pride in the service we provide and are happy to be able to make our mark in the lives of those we care for.”

Natalie Scott DHB: Capital & Coast

Clinical nurse specialist, wound care Natalie is nominated for being “a hard-working, modest and truly professional nurse” whose wound care skills and leadership are making a difference to both the patients she cares for and the nursing colleagues she supports in building their own clinical skills. Patients previously nursed in hospital beds are now regularly supported at home due to the expert assistance Natalie Scott provides both the patient and her nursing colleagues. Natalie is a clinical nurse specialist for wound care with Capital & Coast’s district nursing service and supports the development and improvement of wound care practice for her 60 district nursing colleagues, many aged residential care nurses and other nurses in the community sector who have patients with complex wounds. The board says her warm and approachable manner enables others to gain expertise in complex wound management and she aims to empower nurses with evidence-based literature, guidelines and processes to support best practice including ‘one-on-one’ case collaborations, face-to-face teaching sessions and electronic learning tools. Measuring wound care outcomes has been an ongoing mantra for Natalie. To assist her and her colleagues in this she introduced to the service the New Zealand-developed 3D wound-measuring laser tool and documentation system, known as the Silhouette, to promote the routine collection of wound data during the treatment and healing process. As a result, nurses can now quantify their patients’ wound healing speeds and Natalie reports that their results compare very favourably with national and international outcomes. Through her personal enthusiasm and collaboration she also in 2011 initiated a leg ulcer clinic in a high health need area, in partnership with a local Māori PHO. This targeted clinic continues to provide specialist wound care integrated with GPs, podiatrists, practice nurses and other health professionals. The aim of the clinic is to support the development of the primary health care team and grow the connection between specialist nursing services and general practice. Also by bringing expert care closer to a hard-to-reach population, the clinic helps avoid referrals to vascular specialists and unnecessary hospitalisations plus enabling faster healing rates of long term chronic wounds. Natalie also works hard helping to develop local, national and international wound care practice standards and maintaining her own professional development.

Measuring wound care outcomes has been an ongoing mantra for Natalie.

www.nursingreview.co.nz  |  Nursing Review series 2016    5


FOCUS  n  International Nurses Day

“Trying to influence the distribution of resources and improve healthrelated policy is a key objective of public health nursing.”

Liz Read DHB: Hawke’s Bay

Nurse manager for public health nurses

Liz Read is nominated for her work as a stalwart champion of public health from her career outset – while at the same time wearing a number of leadership hats. Some nurses want the buzz of ED, others the precision of theatre or the hustle and bustle of wards but from the outset Liz Read has always wanted to nurse in the community. Even when she started her nursing career, more than 30 years ago in Napier Hospital’s paediatric ward, she already had her heart set on working beyond the hospital walls. “I saw it as a stepping stone to public health which has always been my passion,” says the nurse who for the past four years has been the district health board’s nurse manager for public health nurses and also wears several other community health leadership hats. “Our team is involved with traditional nursing but from a public health perspective – child health such as skin infections, immunisation, managing communicable diseases like TB, measles, mumps,

meningitis and hepatitis, and adolescent health,” she says. “We’re focused on health promotion, prevention and early intervention, and work predominantly in communities disadvantaged by lack of income, poor housing and unemployment,” says Liz. “Trying to influence the distribution of resources and improve health-related policy is a key objective of public health nursing, whether this be canteen or nutrition policy in schools, smokefree areas, child safety legislation, or supporting teachers in their delivery of the health curriculum.” Liz also manages the sexual health service and is proud of the closer relationship forged between primary and secondary care over the last four years that has led to an improved service and increased access to free services. The establishment of a dedicated sexual assault service has also made a big difference, she says. After four years in her public health leadership role Liz says she now has the confidence to put a public health perspective firmly on the agenda at management meetings, which are often focused on hospital services.

“As resources get tighter and demand on services greater, I’ve become more passionate about making sure we’re efficiently delivering services where the highest need is, while never losing our public health focus.” Recently seconded to the role of acting manager at Napier Health, she says the extra workload is made easier by her great multi-disciplinary team of 45. The married mother of three children – two boys and a girl aged between 14 and 20 – is also coordinator of the child and youth mortality review group for Hawke’s Bay. “It’s a no-blame review process to improve systems and prevent further deaths – things like our suicide prevention strategy, and safe sleeping action plan have come out of it,” she says. HBDHB chief nursing officer Chris McKenna says, “Liz is a proactive, pro-nursing leader. She leads many projects and initiatives, but is always looking at ways in which nursing practice can be advanced to deliver better care to the community.”

Diane Williams DHB: Nelson-Marlborough Nurse practitioner (primary health care)

Photo credit to Marlborough Express

“It’s cradle to grave and dealing with everything that walks in the door.”

After an eclectic nursing career, Diane Williams became an NP as she wanted to help offer the best access to healthcare. Nearly a decade later, she remains committed to doing just that. Diane Williams reckons she’s been around nursing long enough to reinvent herself a few times. She’s worked in ED, theatre, ski patrol, schools and in industrial, rural and occupational nursing roles. Originally trained in Sydney, as her nursing experience grew Diane developed a focus on remote rural and community nursing. She moved to New Zealand over 25 years ago and has developed a wealth of experience looking after health needs in rural communities. While she was living in Te Araroa, on the East Cape, Diane started her clinical master’s in nursing and was later interviewed by the Nursing Council to gain accreditation as a nurse practitioner. “Te Araroa means ‘long pathway’ in Māori and that was quite appropriate at the time,” says Diane. “However, I wanted to have the best

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capability and offer the best access to healthcare so it started me on a journey.” Diane looks back now at the study and time involved and wonders how she managed it. “I must have been mad – I had a young family, I was doing a variety of positions and doing call-outs at night.” Despite this, Diane remains committed to the primary care nursing speciality. “It’s cradle to grave and dealing with everything that walks in the door,” she says. “You are in a very privileged position – being involved in people’s lives and helping to make positive outcomes.” Diane believes primary health professionals have many opportunities to change not just one person’s life but whole families and communities. She says the nurse practitioner role is successful in many locations and is becoming well accepted. “For instance, on the West Coast the nurse practitioner role is part of a general practice team and is well accepted by patients.” Late last year Diane became the first NP to work at the Marlborough After-Hours GP service. She’s been registered as an NP for over nine years and is one of only two working in Marlborough.


FOCUS  n  International Nurses Day

“It’s important to recognise everyone and support them to rise to challenges.”

Lorraine Thompson-Aramoana DHB: Auckland

Charge nurse, older people’s health Lorraine Thompson-Aramoana started her nursing training to fill in time until she was old enough to apply for the police force. But she became hooked and nearly 40 years later is nominated as a hero for her passion and leadership in older people’s health. The police force was Lorraine Thompson-Aramoana’s first career choice but nursing was her destiny. She had already been accepted into police training when fate intervened and the police force entry age was raised. Her friend encouraged her to ‘give nursing a go’ instead. “My intentions were to reapply for the police when I was old enough, but after my first two years of nursing, I thought it would be ridiculous, given what I’d enjoyed so far,” recalls Lorraine. Lorraine describes herself as a home-grown nurse, beginning her training at Auckland City Hospital in 1977, and registering in 1980. She became a charge nurse within seven years in general medicine before moving into orthopaedics and working with the frail and elderly. “I was able to share and develop my skills from general medicine to support the older population, who were becoming quite unwell with delirium and falling. It was a natural progression to work in older people’s health where I was involved in various projects.’ One of these more recent projects was the ‘falls concept ward’ at Auckland City Hospital, which aimed to reduce falls causing harm for the vulnerable, older population.

“It was really positive to work with other nursing, medical, quality and safety staff, and important that everyone on our ward had a shared understanding of what we wanted to achieve.” Initiatives introduced included coloured mobility wristbands, a confusion screening tool and improved toilet signage as well as increased awareness amongst staff of bed positions, patient toileting needs, pain and medication levels and post-fall review processes. The successful project is now in place on other wards. Lorraine’s holistic approach to nursing leadership is also admired. “It’s important to recognise everyone and support them to rise to challenges. I try to make sure staff have a shared understanding of the wider context and why we do what we do. Reminding them of even the small things, remembering people’s names, saying hello with a smile and reminding patients of who we are.” Outside of work she is a former netball player and now referee and has never stopped learning. In 2007, not long after receiving the Trophy of Tradition for nursing professionalism, she completed her master’s in health sciences with a dissertation focused on cultural competence and its impact on the quality of care. “There are so many in nursing who deserve to be a nursing hero. I don’t see myself as being any more special than anyone else who puts the effort in, in what they believe and enjoy. I’m fortunate in that I’m here because I choose to be here, I’m supported to be here and I’m here to stay.” Next year, Lorraine celebrates 40 years of nursing and 30 years as a charge nurse. www.nursingreview.co.nz  |  Nursing Review series 2016    7


FOCUS  n  International Nurses Day

Amanda Van Elswijk DHB: Whanganui

Clinical nurse manager AT&R and acute stroke unit Rising to the challenge of a project to develop Whanganui’s stroke service – a specialty area new to her – won Amanda Van Elswijk the Whanganui nursing hero nomination. Amanda Van Elswijk’s career took a sharp turn in 2012. Following many years working as a paediatric, neonatal and public health nurse, she was asked to lead the Whanganui DHB’s stroke service development project. It was a challenge she rose to and, four years on, Amanda is making her mark on stroke services and has fully embraced her new specialty. In 2014, she was instrumental in establishing Whanganui Hospital’s acute stroke unit in the assessment, treatment & rehabilitation (AT&R) ward. So rather than the traditional path of acute stroke patients being treated in medical wards and then being transferred to ATR, they are now admitted straightaway to a unit within ATR. Amanda says the new approach is proving successful, with a stroke patient’s rehabilitation beginning as soon as they are admitted to the acute stroke unit. Amanda and her team were determined to provide an acute stroke unit where people of all ethnicities feel comfortable, so they are guided by Mason Durie’s Te Whare Tapa Wha* model of care, which describes concepts of health and wellbeing from a Māori perspective. Amanda stresses to her staff how important it is to understand and empathise with stroke patients and their families. “When a person has a stroke their lives can change irrevocably,” Amanda says. “They might be with us for three to four months and almost overnight, they (and their family) might have to come to terms with knowing they may never work again, that their house will need to be modified and they may struggle to speak. “They have so much to take in and there are times when stroke patients’ behaviour can be challenging. So to address this, I and my team have done a lot of training to learn about grief, loss and change; how a patient is feeling and how to adapt their care plan around that,” says Amanda. “From the moment a patient enters our acute stroke unit, their rehabilitation begins and that can be very challenging for some people. Our job is to help them achieve the best recovery possible and I’m confident that we are doing this. The results we’re getting point to that.” Besides her work in the hospital, Amanda sits on local, regional and national working groups for stroke and has been instrumental in developing services for primary, and well as secondary care, of stroke patients. She’s currently completing her clinical master’s degree, with her research component focused on caring for stroke patients. Amanda also heads up the Map of Medicine for stroke, which sees her working closely with the Whanganui Regional Health Network, GPs, and St John Ambulance, among others.

*Te Whare Tapa Whā compares health to the four walls of a house where all four walls (the psychological, physical, spiritual and family/whānau dimensions of health) are necessary to ensure strength and symmetry.

“Our job is to help [stroke patients] achieve the best recovery possible and I’m confident that we are doing this.”

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She has created a very robust network of people who are passionate about improving healthcare outcomes in Apia’s ICU.

Jenny Stewart DHB: Counties Manukau

Associate charge nurse manager, critical care complex Counties Manukau’s nursing hero is nominated for her work in making her mark not only in Middlemore’s critical care services but across the Pacific in Samoa. Jenny Stewart has worn several hats in the past decade but they all have a common theme of striving to develop and improve critical care nursing. In April 2014 the DHB’s critical care complex (covering Middlemore’s intensive care and high dependency units) was asked to go and review the critical care services for the intensive care unit at Tupua Tamasese Meaole Hospital in Samoa’s capital Apia. This led to 12 months’ work with the Apia ICU supported by funding from the Regional Pacific Health Development. Jenny led this programme of work with the board saying she demonstrated excellent leadership with her organising, networking and team-building skills, along with her

excellent powers of persuasion. The result was she has created what has been described as a very robust network of people, both at Counties and in Apia, who are passionate about improving healthcare outcomes in Apia’s ICU, through developing staff skills, by offering training and education, but also through ensuring the provision of ICU equipment is reviewed to enable staff to better assist in providing high quality care. The DHB says her leadership both in New Zealand and Samoa has been a real credit not only to her but also to the critical care complex. It hopes to continue building on Jenny’s foundational work in the years to come to assist in the development of intensive care nursing in Samoa. Counties Manukau Health has been working with countries in the wider Pacific region since 2002 when it signed its first memorandum of understanding with the Cook Islands. The Ministry of Foreign Affairs and Trade (MFAT) funds the DHB to provide services to a number of Pacific countries which now also include Samoa, Niue, Fiji and Kiribati.


FOCUS  n  International Nurses Day

Val Scott DHB: Bay of Plenty Enrolled nurse, acute surgical ward (retired)

Retiring enrolled nurse Val Scott is nominated for her quirky sense of humour, patientcentred care and the invaluable work she puts in on DHB committees and working groups as an NZNO representative.

Tauranga Hospital’s Ward 3c says it will miss Val Scott’s dedication to quality patient-centred care and her quirky sense of humour. Val recently retired from Bay of Plenty District Health Board – after 27 years’ service as an enrolled nurse and many years working as a New Zealand Nurses Organisation representative and delegate – to return to her hometown of Gisborne. During her years at the board she was also known for her dedication to communication and collaboration developments. Val was an inaugural member of the NZNO team who were trained in using the coaching model to work in partnership with DHB management. She worked as part of the joint action group (DHB/NZNO partnership) that aimed to improve the journey for both nurses and patients, and was also an active member of the NZNO enrolled nurses section, northern region PDRP Council, discretionary sick leave panel, and the falls prevention group. The board says Val was also

Val’s caring and professional expertise helped many people through their nights in hospital that could otherwise have been very quiet, lonely and scary. an invaluable support for nurses as an NZNO delegate, guiding them through sometimes sensitive issues. But most of all the board thanked her for the excellent care she gave to thousands of patients throughout her working career, saying Val’s caring and professional expertise helped many people through their nights in hospital that could otherwise have been very quiet, lonely and scary.

Amanda (Mandy) Shanley DHB: Waikato

Clinical nurse specialist, mental health and addictions Free head and shoulder massages, fruit packs and quit smoking support have been offered at health promotion days organised by Amanda Shanley with the aim of improving the physical health of Waikato mental health service clients.

“I have always been passionate about holistic health care.”

A holistic health initiative by clinical nurse specialist Amanda Shanley is making a difference for mental health service users in Hamilton. Amanda was appointed to the role of clinical nurse specialist mental health in March 2015, from a background of working with service users diagnosed with eating disorders. “I have always been passionate about holistic health care and after researching global initiatives I started raising awareness across mental health teams about the alarmingly reduced life expectancy of people with a serious mental illness. “The ultimate aim is to increase the life expectancy and quality of life of the service users that we work with,” she says. Using the umbrella of Equally Well (a Te Pou initiative) and with “amazing support” from the community clinicians, Amanda and her colleagues held two nurse-led health promotion days at the Hamilton community mental health service base last year. The first event saw over 50 service users and their whānau take up the opportunity to discuss their concerns on smoking and trialling a nicotine replacement therapy (NRT). Free packs of fruit, other healthy snacks and signed quit cards (to access free NRT) were given out to all who attended.

One of the positive spin-offs of this initiative was much stronger mental health clinician engagement in seeking advice and NRT support for their clients who smoke. Next, Amanda linked with secondary, primary and NGO services and Sport Waikato to turn on a ‘Treat yourself for Christmas, look after your health’ event. With live music, balloons, free fruit and gift baskets, free head and shoulder massages, and health promotion stalls, the outside event got an extremely positive response. “It was a relaxed setting where service users, whānau and clinicians could share simple strategies for improving physical, mental, emotional and spiritual health – holistic health.” This success means the holistic health initiative will continue into the future, with strong support from those involved and the mental health service’s senior leadership team. Carole Kennedy, nurse director of Waikato DHB mental health & addictions says, “The initiative illustrates Amanda’s commitment and dedication to mental health and addiction service users and to making a positive difference to their lives”. www.nursingreview.co.nz  |  Nursing Review series 2016    9


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“The opportunities are unlimited really – it’s a great career destination for men, particularly as a nurse.”

Kim Tito (left) with wife Jenny and Kim’s retirement gift. Photo credit: Paula Martin

Kim Tito DHB: Northland

General manager, Māori health and mental health and addiction services (retired) The call of the waves nearly saw Kim Tito give away nursing training for an extended surfing OE. But he returned to start a four-decade health career – including the championing of Māori health – and recently resigned as Northland DHB’s general manager of Māori health and mental health & addiction services.

Champion for Māori health Kim Tito ended his time with Northland DHB in February with a moving whakawatea (farewell), 44 years after he originally joined the organisation from school. He began as a pay clerk and left as Northland DHB’s general manager of Māori health and mental health and addiction services, with his resignation reflecting a consciousness of his health and an appetite for new challenges. “It’s my decision to finish at this juncture and time for me to explore a different awa [river] on a different waka.” Kim says his family has “a torrid history” of men dying at relatively young ages. “My dad and all his brothers died before they reached 60, so making it to that age has been a goal for me.” Now 61, he says, “Stopping this job and doing something different should give me the opportunity to do the things I really want to do. Jenny [his wife] and I are setting ourselves up for the next couple of decades.” However, he expects to maintain some involvement with the health sector and the national, regional and local networks he has built up. Kim was the first man to gain his registered nursing qualification in Whangarei in 1976. However, after applying and being accepted for nursing, he instead left New Zealand on a surfing OE with a mate, starting in Queensland. “I met this hippy guy under a palm tree who was sleeping rough and he convinced me that I should go back to New Zealand and get started on my training, so I gave up following the waves.” Although his decision to train as a nurse raised eyebrows at the time, Kim believes the health sector is a fantastic

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environment for people to work in if they are motivated by helping others. “The opportunities are unlimited really – it’s a great career destination for men, particularly as a nurse.” Reflecting on developments since his own training, Kim says the education of nurses has changed quite dramatically and the process of nursing has also changed. “I can remember the first intravenous drips coming in and having to learn how to operate them. Nowadays there is all sorts of technology that nurses have to learn about and operate successfully.” “But the relationship that nurses need to foster when they meet people for the first time, and build some sort of trust and rapport with the individual and family or whānau, is still the same. “Having personally been a patient a number of times in bed, it’s very easy to identify those people who have a very genuine desire to listen and develop a helpful relationship between patients and nurses.” As chief nurse in Whanganui, he once gave an address about the importance of the ‘hyphen’ in the patient-nurse relationship. “What it is about the hyphen that makes people trust and understand and develop that relationship?” he says. “It either happens or it doesn’t. About three-quarters of Kim’s career has been spent in Northland, interspersed with roles in Taranaki and Whanganui. Highlights include the establishment of Te Poutokomanawa (Northland DHB’s Māori health services directorate) and the Kaunihera and Kaumatua council of elders to provide cultural advice to the organisation. Another has been supporting and seeing the development of a strong network of Māori health providers throughout Northland.


FOCUS  n  International Nurses Day

Georgina McPherson DHB: Waitemata

Nurse practitioner, women’s health, colposcopy unit, Waitakere Hospital A decade on from becoming New Zealand’s first Pacific NP, Georgina McPherson hasn’t stopped striving for new ways to improve the access of all women, and particularly Pacific and Māori women, to health services. In 2006 Georgina McPherson became New Zealand’s first Pacific nurse to become a nurse practitioner. A decade later, the women’s health NP’s passion for providing quality care to all women has only grown, with a special interest in improving access and equity for Pacific and Māori women. Georgina has 20 years’ experience in women’s health and her clinical leadership role in Waitemata DHB’s colposcopy service includes implementing quality improvement initiatives aimed at driving gains in care and service use. Her keen interest in improving access to services for Māori and Pacific women has seen Georgina running ‘well women’ clinics in primary care to raise awareness of services within the community. Georgina hopes to expand the NP role within the DHB’s gynaecology service and has recently commenced study under the Doctor of Health Science programme. She is involved in various projects and professional bodies, including being a member of the Nursing Council’s nurse practitioner assessment panels, a member of the National Cervical Screening Project development group and a member of the DHB’s Pacific nursing leadership and Pacific health advisory groups. Dr Jocelyn Peach, Waitemata DHB’s director of nursing and midwifery, described Georgina as “a tremendous role model who is committed to ensuring healthcare is more accessible to all women”. “We are fortunate to have a person of Georgina’s calibre. She is a calm, considered person who exudes professionalism. She ensures that all who encounter her feel they are listened to, understood and have her total focus. She is enthusiastic and skilled, brings people together around the patient and their needs. She has wonderful empathy. “She lives the Waitemata DHB values of ‘Everyone matters; Compassion; Connected; Better, Best, Brilliant’. She has made a considerable difference to the health and access for our community. We value her and consider her our Health Hero.”

“... a tremendous role model who is committed to ensuring healthcare is more accessible to all women.”

Cecelia van HasselO’Brien DHB: South Canterbury

Practice nurse and businesswoman

A South Canterbury unsung hero is nurse Cecelia van Hassel-O’Brien, a mother of four and daughter of an ageing mother, who is proudest of being able to juggle all her roles with the demanding profession of nursing. Cecelia van Hassel-O’Brien says she is grateful for the opportunities and transferable skills provided by nursing during her more than 30-year career. She trained in Christchurch and has nursed in hospitals (public and private), primary and community, and private enterprise in the community. “I’m like an appliance,” she says. “You can plug me in anywhere and I should be able to work.” Cecelia now splits her time between being a practice nurse and running a new ear health business. “In primary care you have continuity and you get to know them and sort of get to go through their lives with them and it’s lovely to have those relationships with people. You are dealing with people and families and life and the whole person really which is what I love about primary care.” When asked what her proudest achievement is, she says it is simply being able to juggle all the responsibilities in front of her, such as working in a challenging profession, continuing with ongoing nursing studies and parenting alone. “It hasn’t been easy and it is hard work. As a mother – and all the other nurses will know this too – you are looking after your family, and I’m looking after an aging mother who is now in a rest home, and I’m on my own… You have to somehow find a balance. Because you have to be well and you have to be in the right place to help others, so you have to look after yourself.” Cecelia has found that balance in movement; in particular, yoga. “Yoga keeps you strong mentally and physically – it’s a part of me and I have been doing it for a long time and I just love it and it keeps me healthy.” Cecelia sees the true value of nursing to be in the skills nurses have with their patients. “There is a place for really good skills and being close to your patients and what you are doing. That is what’s real and perhaps the amount of letters you have behind your name is not so important. I think nurses have to keep sight of that really. There seems to be increasing pressure from places for nurses to be nurse practitioners. To be a really good nurse, you need to be able to think holistically, but at the same time you need to stay close to your work and your patients and their families.

“There is a place for really good skills and being close to your patients and what you are doing.”

www.nursingreview.co.nz  |  Nursing Review series 2016    11


FOCUS  n  International Nurses Day

Dianna Last DHB: Lakes

Clinical nurse specialist, mental health, Whare Whakaue Inpatient Unit, Rotorua A third generation mental health nurse who loves her work – and also loves taking to the slopes on her mountain bike or snowboard to keep work/life balance – is Lake’s nominated nursing hero. Mental health nursing is in the blood for Rotorua clinical nurse specialist Dianna Last. Her grandparents worked as psychiatric nurses, at the former psychiatric institution Seaview Hospital in Hokitika and her mother worked as an enrolled nurse. She’s been working for Lakes DHB’s mental health and addiction services for eight years, after six years overseas.  She chose Rotorua because it was a central location for her sporting passions of mountain biking and snowboarding and started part-time at iCAMHS, the infant, child and adolescent mental health service, and part-time on the inpatient unit at Lakes DHB, before moving to full-time on the inpatient ward and into the role of clinical nurse specialist.

Dianna says she enjoys the range of skills needed to work in an acute unit, including therapeutic engagement, de-escalation, assessing mental state, treatment and medication and working with families. “Building rapport with patients is core to all interventions. Managing self-stigma, for patients, is as difficult as the stigma more broadly associated with mental illness.” A recent practice research project led by Dianna and her senior nurse colleagues was the development of a specific inpatient model of care that drives the therapeutic alliance. She also helps mentor the three new graduate nurses in the inpatient unit, co-facilitates a weekly STEPPS group therapy session at Te Ngako, the DHB’s adult community mental health service in Rotorua, and fills in as acting clinical nurse manager for the inpatient unit when required. Dianna has completed two papers towards her master’s in nursing, and aims to become a nurse practitioner in the mental health area. Work/life balance is important to Dianna,

“Building rapport with patients is core to all interventions.” and her outdoor sports help her achieve this. In the workplace, Dianna says that emotional competence is key for nurses working in the acute area of mental health, as it helps minimise the impact of workplace stressors on personal lifestyle. “You have to be able to separate work and your response to things that happen in the workplace.” The leadership role requires a strong focus on maximising patient autonomy while managing the multiple risks associated with acute psychological disturbance. The negative in her role is the constant pressure on the 14 beds in the unit, and the challenges of having to triage patients out prior to them being optimally ready to leave the ward.

Julie Coverson DHB: Southern DHB Psychiatric liaison nurse A mental health nurse with an empathetic air for all has been nominated as Southern DHB’s unsung nursing hero.

“She is an extraordinary teacher and an empathetic ear to all.”

Julie Coverson is a very modest person and needed some assistance to recognise her hero qualities. A nurse for 25 years, Julie started her nursing career in the United Kingdom, where she specialised in mental health nursing. She has spent the past 15 years working in Dunedin in various mental health roles and now works as a psychiatric liaison nurse as part of a small team working with a consultant psychiatrist and a registrar. Her broad role encompasses taking care of the mental health needs of patients within general hospital settings as well as the support and education of nursing staff.

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Heather Casey, the Southern DHB’s nursing director for the Mental Health Addictions and Intellectual Disability Directorate, says that Julie does a wonderful job as the psychiatric liaison nurse. “She has a wonderful ability to work alongside all disciplines in a way that supports and builds their knowledge and confidence when working with people who have mental health needs. Additionally, she is an extraordinary teacher and an empathetic ear to all.” Julie has a particular interest in maternal and infant mental health and after completing several papers in this area has just commenced a postgraduate diploma in infant mental health through an Australian university. She says she always knew she wanted to do a job that involved looking after people. She loves her role and feels humbled by what human beings can tolerate. She says her job keeps her mindful and appreciative of what she has.


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“Chris has long championed ongoing education, best practice and placing the patient at the centre of care.”

Chris Black DHB: West Coast

Clinical nurse educator (retired), orthopaedic ward, Grey Base Hospital One of the proudest memories of West Coast nursing hero, the recently retired clinical nurse educator Chris Black, is helping to train patients to give their own IV antibiotics so they could return home to their often isolated communities. When Chris Black and her husband shifted to the Coast, it was just to be a couple of years, but this year she retired after nearly 30 years’ nursing at Grey Base Hospital. Chris had trained as a theatre nurse but first got casual work on the wards until she was employed permanently on Barclay (surgical) ward in 1985, and moved back into theatre at the end of 1986. But after a couple of years, she says, she was missing the patient interaction so moved back to work in Barclay and Couston (orthopaedic) wards. Chris took a year’s maternity leave when her daughter was born in 1990 and then worked casually to ‘keep her hand in’ before resuming her full-time nursing career in 1994 when her husband Murray

became redundant and stepped into the role of house husband. During the 1990s, Chris and 12 others on Barclay ward started studying for the newly offered, long-distance Nelson Polytechnic bachelor of nursing degree for hospital-trained nurses. All the Barclay nurses graduated, along with 18 others from around the DHB. In 2001 Chris was appointed associate clinical nurse leader of Barclay ward and since 2005 has been a clinical nurse educator. Chris says she has many fond memories and experiences. One initiative she has always been proud of was being involved with training patients to give their own IV antibiotics so that they could be discharged and take charge of their own lives in the community. Karyn Bousfield, West Coast DHB’s director of nursing and midwifery, says during Chris’ career at the DHB she has been an inspiration to others. “Chris has long championed ongoing education, best practice and placing the patient at the centre of care. Her level of skill and knowledge is renowned and the nursing teams will miss her reassuring presence about the place; she is one of our heroes”

Chris (61) chose to retire a little earlier due to her husband’s health. Murray has cancer, and the two want time to spend doing things together. Chris says she will miss the camaraderie of the working environment. “It’s the first hospital I’ve ever worked in where everybody is on first-name terms. In small hospitals you mean something to people – I’ve really noticed the amazing love and care since Murray has been sick.” She says what makes a great nurse is their attention to detail, to the small things. “I’ve really noticed while Murray has been a patient that there are some nurses who will check if he has a drink, will always wash their hands.” And things have moved a long way from the first training Chris received, where you had to do what you were told. Now it is very much the nurse’s role to question, and to take responsibility when they make mistakes. “You want to be able to use that so everyone else can learn. If people are being put at risk by someone else’s practice, then you can’t stand back and ignore it.”

www.nursingreview.co.nz  |  Nursing Review series 2016    13


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Nurse researchers:

creating a force for change This year’s theme for International Nurses Day is ‘Nurses: A force for change’. Florence Nightingale was just such a force, using statistics and data to challenge practice and develop health policy. We talk to some nurse researchers about the motivation and goals of nurse research, background some researchers’ career paths and share some advice for those who may wish to follow and some examples of diverse nurse research currently underway.

C

uriosity is a word that keeps popping up when you talk to researchers. Why do we do it x way? What would happen if we did y way instead? How about if we did both x and y ways? With the pool of nurses who have pursued or are pursuing postgraduate study ever growing, more and more nurses are carrying out research in diverse topics using a broad spectrum of research methodologies for their master’s and PhD degrees. Some of these nurses won’t want to stop there and will go on to pursue research as a career, which prompts further questions like: Why do research? How do you get to do research? And what types of research are a ‘force for change’?

Why do it?

Ask researcher Jane Koziol-McLain why she pursued a research career and she says she’s always had a questioning mind, from her early days nursing at an emergency department in Chicago. She was curious when each time a new registrar was rotated to her ED they brought with them their own variation on ED practice. “I wondered, why is it there are these different ways of doing things? Don’t we know which way is better?” says Koziol-McLain, whose questioning mind eventually led her to Auckland and her current position as professor of nursing at AUT. Likewise, Dr Kathy Nelson, acting head of Victoria University’s Graduate School of Nursing, says she had a questioning mind and recalls wanting to know why mental health clients appeared to have insight into their illness the second time they were admitted but not at their first. That was back in the late 1970s when nurse researchers were few and far between and she was unable to find a supervisor for her curiositydriven research. But curious she remained and she sought jobs that brought her research experience until she made it up the research ladder to become a researcher herself. Dr Andrew Jull of The University of Auckland remembers emerging from his first foray into university studies without a degree, but with a strong desire to do research and to be of service. He eventually combined the two with nursing; first

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as an early ‘adopter’ of the Cochrane approach of using evidence to ensure best practice and then by becoming a researcher himself to help fill the gaps in evidence about what is best practice and what makes a difference to patients. Honouring the special insight that nursing provides into illness and health is another driver for nurse researchers, believes Massey University’s professor of nursing Jenny Carryer. “If think about a lot of the PhDs that have been done – there’s a desire to actually [honour and reflect] an alternative or more people-centred way of how people experience health and illness. And how they experience health service delivery.” Koziol-McLain would agree, saying nurses have so much to offer research based on the knowledge they gain from working alongside clients. “It really is quite a privilege to be with people and support them in gaining health during those difficult times... Along with that privilege really does come a responsibility to do the best that we can.” In the case of Koziol-McLain – whose major research focus for more than two decades has been family violence – this sense of responsibility saw her volunteering at women’s refuges so she could gain a wider perspective on domestic violence than the limited view she got as an ED nurse.

How do you do it? Getting the skills and finding the time

The question to follow ‘why’ nurses pursue research is ‘how do they do it?’ Perseverance and tenacity seem to be important qualities, as even now – when there are dedicated postgraduate paths for nurses and funding for course costs is more widely available – it is no easy task to pursue a research career. “When I think back to my own time doing a PhD – actually working full-time with small children – it was a mad time of life. You’d never do it twice,” says Carryer. Many nurses still come to postgraduate study later in life so nursing PhD students can often be juggling children, mortgages and demanding senior nursing roles. And the very few full-time PhD scholarships available to clinical nurses are highly contestable and may not be viable if the nurse is


FOCUS  n  Innovation

the family’s principal breadwinner. So part-time study is often the only option – stretching a PhD from the usual three years into six. “But it is interesting how many nurses actually soldier through that process,” says Carryer. Gaining the research skills that studying for a master’s and a PhD will provide is an essential step for nurses who want to pursue a full-time research career and ultimately lead their own research teams. Established researchers say that potentially all nurses can play a role in research projects making a difference to clients, be it simply helping recruit participants or right through to being lead investigators for million-dollar-plus research projects. Nurses also work in research teams as clinical research nurses carrying out a variety of clinical and research roles and others work as research managers coordinating and managing research trials. “Nurses have incredible skills and knowledge and the respect of clients and an understanding of clients and communities,” says Koziol-McLain. “So nurses, I think, are very well positioned to make an important contribution to research.” Nurses interested in becoming more actively involved in research can just start small by volunteering for improvement projects or putting their hands up to assist in local research (see ‘Tips’ sidebar). Finding a mentor at work or in the local nursing school can also help nurses get a foot in the door by joining a research project and building skills, experience and gradually building that all-important research track record. Koziol-McLain says being a principal investigator for a small nurse-led research project as an ED nurse, prior to even starting her master’s degree, was an important stepping stone to her next job and more research opportunities. “When I was interviewed for the job they were impressed that we had started the study, conducted it safely, finished it and reported on it.” Gaining a PhD is also not always essential – as associate professor of nursing Andrew Jull points out – to winning major research grants if you build the right research team around you and gain a reputation in your research niche. After completing his master’s degree – a systematic review of evidence on an aspect of venous leg ulcer (VLU) care – he identified a gap in nursing research as “very few folk” doing quantitative research had a nursing background and he was keen to fund and run his own quantitative research. Jull says there was a perception that it was necessary to have a PhD first, but he wasn’t convinced as he knew that very few of his medical colleagues had PhDs and they still won funding. “So I thought, ‘Why can’t I do that?’

“Don’t be put off as you learn a lot from applying, even if it’s a rejection, as you learn how to shape-up applications and become more successful. And you do have to keep applying for money in different sources.”

Kathy Nelson

Beverly Burrell

Andrew Jull

“And it seemed to me that the key to getting funding was having the right kind of team – so if you had skills gaps then

you had the team around you to support those skills gaps.” This philosophy helped him eventually win a Health Research Council grant for a multi-centre research trial that also helped build a network of nurse research collaborators around the country with whom he continues to work nearly 15 years later. “It is the people working at the study centres who really make me look good. They do all the hard work when it comes to turning trials into reality.” This research also ultimately led to his PhD.

How do you fund it? Getting the funding to answer your research question

Getting the funding to release your time and meet the costs of a research project is rarely simple. For nurses who join academia, the Performance-Based Research Fund (PBRF), which divvies up a substantial pool of government funding to universities and participating polytechnics based on the research performance of individual academic staff, has led to increased pressures and rewards for doing research, says Carryer. (Nursing, which is still regarded as an emerging research field, compared with established academic disciplines like medicine, has not fared well in the initial PBRF rounds, coming in at 41 out of 42 disciplines in 2012, but it was noted that nursing scholars had improved their average score “markedly” since the first bruising results in 2003.) Carryer says while it is hard enough for nursing academics with high teaching loads to find the time and money to do research, it is “very, very difficult” for nurses to do so in clinical practice. “So the bulk of the research being done by nurses in practice is being done by people engaged in a master’s or doctoral programme.” That hasn’t prevented nurses from completing prizewinning PhD research ‘on the job’, including Waikato neonatal nurse practitioner Dr Debbie Harris’s “Sugar Babies Study” and Auckland intensive care nurse and senior research fellow Dr Rachael Parke, who last year was the first nurse to receive The University of Auckland’s Vice Chancellor’s Award for best doctoral thesis of 2015 for her work investigating the effect of nasal high flow oxygen in patients following cardiac surgery. And some district health

boards have created nurse-focused research positions – like that of Dr Sandy Richardson, who is based at Christchurch Hospital as the country’s only emergency nurse researcher, as well as being a senior lecturer for the University of Otago’s Centre for Postgraduate Nursing. Dr Beverley Burrell, a senior lecturer and researcher at Otago’s Centre for Postgraduate Nursing, believes that the more young or early career nurses who obtain PhDs, the more likely nursing as a profession and discipline will succeed in building long-term research collaborations and teams and in winning those elusive major research grants. Nurses are not alone in their frustration around winning funding grants to support research. With limited funding Continued on next page >>

Jenny Carryer

Jane Koziol-McLain

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FOCUS  n  Innovation

Continued from previous page >>

pools available for health research – for example, of the 321 research funding applications to the Health Research Council last year just 33 were successful – rejection is more common than not. It is also a case of nothing ventured, nothing gained, and Kathy Nelson for one believes nurses don’t apply often enough for funding to explore nursing research questions. She says most people applying to the HRC have to apply a couple of times and sometimes three to win funding for a project. Jull well knows this and says funding his current aspirin trial (see related article) was a matter of perseverance. The team first applied for an HRC grant back in 2010 and got to the second round before being declined; the second application didn’t even make it to the second round. The third time they just applied for pilot funding and were still declined and then finally on the fourth attempt – after a related small trial had been published – they gained enough traction to be awarded a grant. Burrell says it never hurts to apply for research grants. “Don’t be put off as you learn a lot from applying, even if it’s a rejection, as you learn how to shape-up applications and become more successful. And you do have to keep applying for money in different sources.” Knowing the research priorities of funders is also important and Burrell says new researchers applying for major research grants need to be mindful of what funders are seeking.

What research should you choose?

So what type of research can create a ‘force for change’? What sort of research are funders looking for? And how much should nurse research be influenced by such funding drivers? Answering these questions could probably generate several research projects alone as research philosophy is a field in its own right. But the pragmatic answer to the middle question is that on the whole funders, like the HRC, generally favour research that can be translated into evidence-based practice. “Funders definitely favour studies that can show effectiveness and research that just doesn’t sit on a shelf but is rolled out and utilised,” says Burrell.

TIPS FOR BEGINNING A RESEARCH CAREER »» Be curious, have a questioning mind and a healthy dose of scepticism. »» Start small – read research, become involved in quality and improvement projects and initiatives in your practice environment. »» Volunteer to be a research assistant for a local research project or approach your local nursing school, saying you are keen on gaining some research skills. »» Seek advice and support about postgraduate training pathways from the postgraduate programme director or coordinators at your DHB or nursing school. »» Find a research mentor in your practice setting or nursing school. »» Seek out a job – be it in an academic or practice environment – that supports and fosters a research culture. »» Build comprehensive research skills by coming through a master’s/PhD programme or an honours/PhD programme. »» Search vigilantly for research scholarships and study grants available; for example, the Nursing Education Research Foundation and other NZNO administered grants, the Health Research Council, the universities, Health Workforce New Zealand and any funds in your specialty area. »» Apply for research grants. Don’t be afraid to apply – start small, learn from rejections and incrementally build a research record and reputation by beginning, completing and reporting on your research results. »» Report on your research results to your participants and community and try to publish your findings to help the researchers who follow in your footsteps. »» Find people who have skills that complement your own skill strengths and deficits; research is not a solo endeavour, it is a partnership and collaboration. These tips are drawn from the advice shared by the researchers interviewed for this article. considered relatively radical,” recalls Carryer. “That is no longer the case at all. And major funding bodies now consider qualitative research quite realistically.” She acknowledges, though, it is still a challenge to get research funding for the “highly experiential, lived-experience type” of qualitative research, which she says many nurses still tend to gravitate towards. “Because at the end of the day that’s what fascinates nurses – it’s what informs what we do.” Which brings us back to the opening question – what type of research can create a ‘force for change’? Burrell thinks a primary driver of nurse research should be what is good for patients. “I think we’ve had an introspective view in the past of looking at the profession a lot. I don’t think you can neglect that, but really our business is about better patient

“Nurses have incredible skills and knowledge and the respect of clients and an understanding of clients and communities. So nurses, I think, are very well positioned to make an important contribution to research.” So funders largely, but not exclusively, favour quantitative over qualitative research. As in the international hierarchy of evidence-based practice, it is the randomised controlled trial (RCT) that sits at the top. Which, as Jull noted earlier, is an area that nursing research was traditionally not strong in; but with the nursing sector fostering of collaborative research teams – sometimes interdisciplinary and increasingly international – this is changing and nurse-led RCT trials are becoming more common (see examples next page). On the other hand, the research form that nursing has been strong in for longer, qualitative research has gained more legitimacy over time. “When I did my PhD in 1997 qualitative work was

outcomes and improving healthcare delivery for the population – that is our main purpose, isn’t it?” Koziol-McLain says another driver is nursing’s sense of justice and concern about health inequalities that makes nursing research often focus on improving systems to promote wellbeing and health. Carryer agrees there’s a critical need to do research that may influence policy, though she adds that policy is too often “insufficiently and infrequently” informed by research. Her own experience of policymakers’ readiness to be informed by a major quantitative research project she led (published in 2011 with the late Professor Donna Diers of Yale University) was mixed. The research team looked at the impact

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of registered nurse staff levels on nurse-sensitive patient outcomes following the 1990s health reforms and, after analysing 12 million discharges from New Zealand hospitals, showed that there is a clear relationship between declining RN staff levels and rising nurse-sensitive negative indicators. “I didn’t have a sense really that that work was taken particularly seriously,” says Carryer. “Even though it was based on huge numbers and had quite significant findings.” What the nurse researchers all agree on is that there is no ‘one-size-fits-all’ research approach that can answer the many research questions that could make a difference to the health outcomes and experiences of the populations that nurses serve. Koziol-McLain believes the research method should be driven by the practice issue or health challenge the researcher wants to tackle and then by establishing the best way to address those issues in a way that will be heard by the target audience and help create change. “It is also important to have the ears of the policy-makers and sometimes that’s the nurses you work with, sometimes the interdisciplinary team and sometimes the Government.” She says that means sometimes the best method is a randomised controlled trial and other times it may be qualitative research that tells stories – as stories can be very powerful in engaging people. Burrell agrees that RCTs have their place but there are other important research questions that need qualitative work; for example, interviews that ‘drill down’ and elicit people’s pattern of thinking that influences and motivates their health behaviour. Others add that sometimes a mix of quantitative and qualitative research is the answer and that there should always be room for pure, serendipitous research and for research that gives voice to philosophical and ethical debates. “We can’t neglect any of them,” says Burrell. Because questioning minds are a force for change in whichever direction their curiosity may take them.


THIS ARTICLE IS SPONSORED

Patient Portals

proving a winner all round More and more general practices are introducing patient portals. The health equivalent to online banking, portals enable patients to book appointments, order repeat prescriptions and view lab test results online. In some cases, they can also view their patient notes.

done this. Patients enjoy it, and not having to go through a third person makes their communication with the GP much smoother.”

Portals have had the additional spin-off of reducing admin workloads.

“We spend far less time on the phone, less time playing phone tag – which has freed us up to spend more time with patients. And the more people using the portal, the greater the admin time savings,” say McNeill.

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ationally, around 30 per cent of general practices offer patient portals. It’s not hard to find passionate advocates among those who have taken the plunge.

Adelle Curham is a practice nurse at MEDPLUS on Auckland’s North Shore. About 55 per cent of the practice’s patients have registered to use their portal.

Curham says while the practice was initially unsure what impact the portal would have, ‘if it was taken away now the phones would go crazy, we would have to add a nurse’. She says not having to ring patients with their results or deal with repeat prescriptions greatly reduces nurses’ workloads.

“We spend far

“And it’s great for patients because they can see their own information and results and direct questions and requests for repeat prescriptions straight to the GP. Patients can look at information whenever it suits them – they can book an appointment in the middle of the night or less time on the from the other side of the world.”

phone, less time playing phone tag – which has freed us up to spend more time with patients.”

Curham says nurses need to spend time up front with patients, getting them used to the portal.

“We have learned that it’s really important for people to use the portal straightaway, otherwise they forget how and you have to show them again. Now, if someone registers we say, ‘When you get home, go on it straightaway and have a play’.” Maureen McNeill is nursing team leader at Wanaka Medical Centre. She says the portal has reduced workload for nursing staff – although that wasn’t the reason for its introduction. “For us, the portal was about promoting a partnership between doctors, nurses and patients, and it has certainly

She says while some of the practice’s GPs were initially quite worried they would be overwhelmed with emails, this hasn’t been the case. “They were quite surprised when this didn’t happen!”

Trish Beresford is nurse team leader for two practices in Whangarei. The smaller of the two, Widdowson Sprague in Kamo, introduced the portal in August 2015. It already has 925 people registered on the portal, and 755 are actively using it. Beresford says the introduction of the portal was seamless. “We had a small amount of training from the vendor, but really, for staff, it was about getting on and using it. Once we all got our access numbers and authorisations, we were away. “And there was really fast uptake from patients. There are six of us at the practice – GPs, nurses, receptionist – and we were all enrolling patients. Our receptionist would ask everyone who came in if they had access to a computer, explain the benefits of the portal and then register them.”

Like Maureen McNeill, she says that while the portal saves admin time – “it’s much quicker than when people ring up on the phone” – its biggest benefit is allowing patients to be partners in their own health care. “We can work much more collaboratively with patients. They have access to their results and records and a say in their own health. It hands control back to them.”

ProCare’s portals development manager Cornelius Dirven has been tasked with promoting the benefits of portals. He echoes the practices’ views about the increasing popularity of portals, and their impact on workload. “In the past 13 months the number of ProCare practices with a patient portal has grown from 12 to over 70. These practices have a combined enrolled population of about 450,000 patients. “We now have practices with over 1,000 online appointments a month, which is a very significant time saving for the front desk.”


FOCUS  n  Innovation

Safe relationships:

an app for young people Jane Koziol-McLain

PROFESSOR JANE KOZIOL-McLAIN, a longstanding researcher into family violence, is leading a research team currently working with young people to develop a ‘health relationships’ smartphone app to be piloted in schools next year.

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urning to an app, not an adult, for relationship advice sounds very 2016, with today’s teenagers rarely separated from their phones. But Jane Koziol-McLain, the lead investigator of the research team developing a health relationships app, says the app is not designed to replace teenagers seeking advice from friends, family or the school nurse or guidance counsellor but to guide the young person to decide if, when and how to seek help. The four-year, AUT-led project – funded by a research grant from the Ministry of Business, Innovation and Employment – is drawing on indepth interviews with Northland youth about relationships by researchers Moana Eruera and Terry Dobbs in which young people stressed they “don’t want lectures and don’t want pamphlets”. Koziol-McLain says the young people also made clear that while they want to go to whānau over boyfriend or girlfriend troubles, they fear that if they do that adults may dismiss or minimise the relationship. So with young people using technology more and more to get help and health information, an app to guide young people through relationship concerns – and to also help adults and friends understand and better support them – seemed like a good idea.

iSAFE

The app project is also drawing on a major randomised control trial – again lead by KoziolMcLain – of an online decision-making tool called iSafe, which aims to help women identify their priorities, weigh the dangers of leaving or staying in an abusive relationship, and provide a tailored action plan if they decide to seek help. Similarly to the Northland teenagers, research indicates that abused women sometimes have negative experiences when they first try to ask for help or tell their story – as people often minimise their experience unknowingly, says Koziol-McLain.

“Having a web-based programme means women can be safe from judgement and shame,” says Koziol-McLain. The iSafe trial, funded by a more than $1 million grant from the Health Research Council, saw 412 women recruited online – largely through advertising on Trade Me – and randomised to either an interactive decision science tool or the control, which was a safety planning website. Koziol-McLain says analysis is now underway of the outcome measures (self-reported at three, six and 12 months after signing up to the trial), but anecdotal feedback has been encouraging, with women emailing researchers to tell them how helpful the intervention had been. She says thinking about prevention of violence to women made the team think about the importance of the experiences of young people and adolescents at the time of their first relationships; and that led to the current app project for young people that will build on the iSafe findings and some overseas projects. Koziol-McLain says high profile cases of what can go wrong for young people – like the Roast Busters and incidents of cyber-bullying – means the team will be working very carefully to ensure

Researcher bio:

Jane Koziol-McLain

From her early nursing career days in the emergency department of Chicago’s Mount Sinai Hospital, Jane Koziol-McLain had a questioning mind. That niggling curiosity was the first step to a research career that eventually saw her receive a US National Institute of Health postdoctoral fellowship at Baltimore’s John Hopkins University at the turn of the millennium and brought her to Auckland University of Technology in 2001. She says she started small back in Chicago by getting involved in quality improvement, being active in the local nursing organisation, and being a keen reader of research “even if I didn’t understand all the nuances of research design at the time”. Then in the late 1980s she offered to be a research assistant before being a principal investigator in a nurse-led study of women who presented

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abuse measures used in the app capture some of the challenges faced by today’s adolescents. Focus groups will soon be underway in secondary schools to start co-creating the healthy relationships app with young people to ensure it provides the information they want in the way they would like it delivered. The next step will be to pilot the app in eight secondary schools next year as part of a wider initiative to support healthy relationships for young people, “As an app by itself isn’t going to change things,” says Koziol-McLain. Some schools are already using healthy relationship programmes like ‘Mates and Dates’ and ‘Loves-Me-Not’. The aim of the app is to provide both education on what is a healthy relationship and a pathway for young people to assess and act if their relationship is abusive and unhealthy. It is important that the team also works with guidance counsellors, school nurses and others to ensure that clear pathways for seeking help are available and these support people have the skills to provide assistance without being judgemental or dismissive. And, of course, that young people have the confidence to put down their phones and ask for help when a relationship goes wrong.

to ED with a miscarriage. She later gained her master’s degree and then her PhD through the University of Colorado, Denver.

Life-changer

One of Koziol-McLain’s ongoing research focuses – violence against women and children – grew out of her ED experience. The Colorado research team she was part of in the early 1990s was one of the first to ask women presenting at ED about partner violence. “It was just a life-changer for me,” recalls Koziol-McLain. Her ongoing research work in the area has seen her win a research excellence award from the Nurses Network on Violence Against Women International in 2003 and do work in Kiribati, the Solomon Islands and Malaysia. Her work in New Zealand has contributed to the Ministry of Health’s Violence Intervention Programme (VIP) for district health boards. She is now a Professor of Nursing at AUT and co-director of AUT’s Centre for Interdisciplinary Trauma Research.


FOCUS  n  International Nurses Day

Mindful management trial for Beverly Burrell

older people with LTCs

As our population ages, more and more people are living into old age with multiple long-term conditions. A University of Otago nurse-led randomised controlled trial is looking at whether training in both healthy living and mindfulness can make a difference to these people’s lives.

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antabrians into their early nineties are being introduced to the principle of mindfulness as part of a healthy living education pilot. Dr Beverley Burrell, from Otago’s Centre for Postgraduate Nursing Studies in Christchurch is principal investigator for the randomised controlled trial (RCT) of the education intervention for over-65-year-olds in Canterbury living independently with more than one long-term condition (LTC). She says it decided to look at older people both because of the ageing population and also the shift in recent years to policy encouraging and supporting older people to stay in their own homes and be as independent as possible for as long possible. “And then we looked at people with more than one LTC because of the complexity in managing themselves at home and keeping themselves well.” Research had shown that self-management programmes have had some success but some of the existing ones were quite long – often eight weeks – and it decided to look at a shorter intervention for an older population where attending something regularly could be burdensome. With some evidence also available on the effectiveness of mindfulness training, they decided on a two-hour small group intervention delivered once a week for four weeks that combined standard selfmanagement education with mindfulness education. The study, funded by a two-year grant from the Canterbury Medical Research Foundation, is now at the midway point, with the last intervention programme being delivered this winter. Burrell says it has had a good response from the participants, who are aged from 65 right through to their late 80s, including one 92-year-old.

The RCT is using a wait-list control system. Once 20 people are signed up to the trial, 10 are randomised to receive the intervention straightaway and 10are wait-listed to receive it at a later time. Burrell says this means equity for participants as everybody gets the intervention. All participants are surveyed on entering the trial on their health-related quality of life (HRQL) and other factors like medication adherence, nutrition, sleep and self-management. Then they are surveyed six weeks after the intervention – when the findings from the ‘exit point’ of the intervention group can be compared with the ‘entry point’ of the control group – and finally three months post-intervention. Burrell says each intervention session is divided in half, with the first hour being self-management education, delivered by nurses and nurse practitioners, that includes areas like medication management, healthy living, information on local services, and symptom management of generic symptoms like pain, breathlessness and fatigue. The second hour is a mindfulness session, led by a clinical psychologist, which takes a cognitive behaviour therapy (CBT) approach and includes areas like goal setting, values clarification, ‘acceptance’ concepts related to their conditions and skills on how to cope and reduce worrying about their conditions. Meditation is not a major part of the programme, but there is a short exercise with a recording that can be taken home. The researchers hope that the combined intervention will be effective in helping people to gain the confidence and ability to cope better with their LTC and improve their HRQL.

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FOCUS  n  International Nurses Day

Participants wanted:

VLU trials underway Andrew Jull

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Venous leg ulcers (VLU) are an ‘orphan disease’ in which nurse researcher Dr Andrew Jull has a longstanding interest. He talks to Nursing Review about his team’s latest VLU research project – Asprin4VLU – his first, and one of New Zealand’s first ever nurse-led, randomised, controlled trials of a drug treatment.

enous leg ulcers are unsightly, unhealing painful sores that can rule people’s lives. “VLU has big impacts but it’s the kind of disease that can be hidden under people’s trousers,” says nurse researcher Dr Andrew Jull. “And folk live with these things for a very long time believing there is no treatment that will help them. Yet we’ve known what works since the 17th century – and that is tight compression – all we are doing now is trying to find out what else we can do.” Finding ‘what else we can do’ has been a research focus for Jull for coming up two decades (see bio box) but his seventh research project in the area is the first time he has been a lead investigator for a drug trial. In 2014, on the research team’s fourth attempt, they won a Health Research Council (HRC) grant to see whether taking low-dose aspirin could accelerate healing of VLU when taken alongside standard compression bandaging therapy (at present 30–60 per cent of participants in compression trials remain unhealed after 12 weeks of treatment). Early in Jull’s research career he found evidence that another adjuvant treatment – pentoxifylline (Trental) – was beneficial, but using it was complex. Two small trials suggested that the much simpler to use, over-the-counter drug aspirin may also be effective, but more research was needed. Jull and The University of Auckland research team, working with the five wound care nurse experts who are the trial site investigators and the trial’s research nurses, have designed a pragmatic, randomised, controlled trial (RCT) to do just that.

Balancing who to exclude and who to include

It is believed that aspirin may aid VLU healing because firstly VLUs result from chronic venous insufficiency (CVI), which is associated with platelet aggregation, and aspirin is known to inhibit platelet aggregation. Secondly, aspirin may also have an effect on the underlying inflammatory pathway associated with ulcers. A major part of the trial design was debating the daily dosage of aspirin. Geriatricians advised the team that it wouldn’t be appropriate to give a 300mg dose (two standard aspirin pills) to the

“I would love to have more people knock on our door to help us answer these questions for other patients.” elderly. So to replicate the previous trials – which used a high daily dose of aspirin – the trial risked excluding the very old, who make up about a third of people with VLUs. “Because venous leg ulcers typically happen in older people, you don’t want to exclude the very old from the treatment you are offering,” says Jull. But on the other hand, the platelet inhibition

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effect of aspirin is known to be variable when using low-dose aspirin (75–100mg a day is the dosage prescribed for prevention of heart disease). It was decided to compromise by using a 150mg dose – on the high end of the low-dose range, but low enough that geriatricians were happy for the elderly to take it daily.

Manufacturing own drugs

But deciding on that dose posed another challenge to the research team. No New Zealand manufacturer was registered to make 150mg aspirin tablets so they had to seek a clinical trial exemption under the Medicines Act to manufacture and distribute an unregistered medicine. The team contracted a New Zealand company to make the aspirin capsules one day and the placebo the next. The trial statistician generated a randomisation sequence that was given to the manufacturers so that each bottle of aspirin, or placebo, was allocated a unique trial treatment number, which meant all the investigators, research nurses, district nurses and other clinical providers were ‘blind’ to what treatment participants received. There is no ‘emergency unblinding’ service so if there is a medical event clinicians are advised to assume the venous leg ulcer sufferer is taking aspirin. So ‘blind’ is the study that the data analysis will also be conducted blind and the unique treatment code only broken once the trial steering committee has decided on interpreting the blinded results.


FOCUS  n  International Nurses Day

Researcher bio:

Andrew Jull

Trial so far

The trial kicked off in March 2015 in district nursing services in five centres around the country: Auckland, South Auckland, Waikato, Christchurch and Dunedin. Each centre has a senior site investigator – a senior nurse who is a wound care specialist – and a part-time research nurse seconded from the district nursing team. Wound care clients who meet the inclusion criteria are given normal compression therapy along with a 24-week course of trial treatment and told to take a capsule a day until their VLU heals. The study’s main aim is to evaluate whether aspirin makes a difference to healing time, but it will also look at health-related quality of life and adherence to the treatment capsule routine. The trial is aiming to sign up at least 260 people over the two-year trial period. By the end of the first year, the trial had signed 140 people; that, says Jull, is a good response, but of course the team wants more. “I would dearly love that we could have more people in our trials – that folk turned up at the district nursing services where we are conducting the studies and knocked on the door and said, ‘Hey check out my wound – is it a leg ulcer and can I help by participating in your trial?’ I would love to have more people knock on our door to help us answer these questions for other patients.”

Research was on Andrew Jull’s horizon before nursing. He started an undergraduate degree – ‘playing around’ in an eclectic mix of subjects, including psychology, philosophy, economics and English, while also ‘majoring’ in the many movements that made up campus life in the early 1980s. He didn’t emerge with a degree, but did emerge knowing he wanted to do research. By now in his mid-20s, he decided to apply for nursing – he’s still not totally sure why, but thinks maybe a mix of his strong feeling for the underdog and a tendency to not “swim in the same stream as other folk” meant starting nursing training as a man in 1986 felt the non-traditional and right thing to do. “Those things all sort of coalesced into wanting to be of service – and ultimately that’s what I’ve always wanted, is to be of service – it’s just a question of how to be of service.” He started practising in 1989 in orthopaedics and by the late 1990s was a clinical nurse consultant (including wound care) and an ‘early adopter’ of the Cochrane Collaboration movement, which led him to be involved in developing the first New Zealand VLU guidelines. This work revealed the gap in evidence about the effectiveness of pentoxifylline (Trental) in assisting VLU healing, which he sought to fill through a systematic

review of existing trials for his master’s thesis at Victoria University. The review became a paper in The Lancet and set him off on his now well-trodden research path in VLU. He was successful in 2001 in applying to the Health Research Council (HRC) for a Foxley Fellowship, allowing him to take a year’s research sabbatical in 2002. During that year he carried out the quality of life data analysis for the already completed Auckland Leg Ulcer Study. He also did an investigation into adherence to the national leg ulcer guidelines that sparked a number of ideas for further research, including the effectiveness of honey in healing VLU, which won funding in the 2002 HRC round. This turned into the HALT (Honey as Adjuvant Leg ulcer Therapy) trial, which to his knowledge is still the world’s biggest trial of using honey in wound care, and ultimately his PhD. The Foxley Fellowship and HALT trial saw him working with The University of Auckland’s Clinical Trials Research Unit –now known as the National Institute for Health Innovation (NIHI), where he has been involved in a variety of VLU trials, and also in other areas including the development of clinical weight management guidelines. Since 2009 he has held a joint position as associate professor with the School of Nursing and nurse advisor, quality & safety for the Auckland District Health Board, as well as continuing to do research with NIHI.

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FOCUS  n  International Nurses Day

Post-disaster self-care:

do nurses practice what they preach? How nurses responded to the challenges of post-quake Christchurch was the focus of a research project by the Joint Centre for Disaster Research. Nursing Review reports on centre researcher ZOE MOUNSEY’s presentation to the recent People in Disasters conference, where she shared insights on nurses’ coping mechanisms. Zoe Mounsey

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urses were more interested in looking after their patients than in looking after themselves in post-quake Christchurch, a research project has found. Researcher Zoe Mounsey says this was a common finding when the Joint Centre for Disaster Research analysed its indepth interviews of 11 nurses working in acute hospitals, community care and aged residential care during and after the Christchurch earthquakes. She says the nurses were very ready to talk about the psychological support and self-care advice they gave to patients and clients. “But one of the things we found, compared with the GPs we interviewed, was that while nurses knew the science of self-care, they didn’t do it,” says Mounsey. “They didn’t practice what they preached.”

“One of the things we found, compared with the GPs we interviewed, was that while nurses knew the science of selfcare, they didn’t do it.” Some nurses joked that their idea of self-care “was a bottle of wine and a bar of chocolate”. “But they also said, ‘I know I should be exercising, I know I should be [taking] time out and I knew I should be doing these other things’ but they very much had this [sense that their] duty of care was to look after people, and they, themselves, were secondary. And that came across very clearly.” Mounsey addressed the People in Disasters conference, held in Christchurch recently to mark the fifth anniversary of the 22 February 2011 quake, on some of the nurse findings from the joint Massey University and GNS Science research centre project, which also included post-quake interviews with GPs and mental health professionals.

Much of the post-disaster research of health professionals looks at the ‘blue light’ response in the immediate aftermath of a disaster and doesn’t look at the longer-term impact, says Mounsey. The centres’ research interviews were held around three years after the quake series began and found that the nurses were still facing ongoing effects of the quakes on their workplace, workloads and personal lives; with many reporting increased workloads and more stressed clients and then returning home after frustrating commutes to face housing and insurance issues.

Reluctance to accept help

Despite the interviews being held several years down the track, Mounsey says some of the nurses said it was the first time they had really sat down and talked to somebody about what had happened on 22 February and in the years since. “What we found was that the interview itself was a therapeutic process in its own right,” says Mounsey. She sees this as a clear lesson on how organisations can support staff by giving them an opportunity to debrief or reflect on their experiences. Nurses who worked for the District Health Boards could name a number of post-quake support services available to them including onsite counsellors and EQC advice but those who worked for smaller organisations, like in the residential aged care sector, reported struggling to get the out-of-town head office to understand the difficulties they were working under or the emotional impact on staff. “There was a sense of inequality and inequity about the kind of support services people got depending on their organisation.” But even when support services were available, Mounsey says researchers found that with both the nurses and other health professional interviews there was “a real reluctance to seek out and accept help”. “There was a real sense, particularly from the nurses, that they are the ones who look after people so they shouldn’t need looking after themselves.” The nurses had reported using distraction techniques, such as focusing on others and keeping busy, to avoid dealing with their own emotions.

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Others talked about not wanting to ask for help as it felt like admitting a weakness. But two nurses explicitly acknowledged they had been or were at risk of burnout and others talked about compassion fatigue, lack of energy, and increased illness. Mounsey says this may mean organisations need to be proactive in offering help and support to nurses rather than waiting for nurses to come to them. In the early days most nurses reported that the key source of support was peer support; being able to talk to colleagues not only about the impact of the quakes on their workplace and workload but also what was happening at home. Participants said the best way their organisation supported them was allowing space for this to happen, whether it be morning teas or barbecues where people could get together informally and talk about their experiences. Though one participant said eventually they had to “step away” from emotionally supporting other nursing colleagues as they hadn’t “too much more to give”. Another finding Mounsey says they found very interesting was that half of the cohort had changed roles or reduced their working hours. Some were due to changes to services but a “significant proportion” reported the change was due to emotional stress and reducing their hours or changing to a role they saw as less intense.

Nurses do need support

She concluded that a “clear and clean” message from the research was that nurses did need support post-disaster to help manage their work and personal lives. This could include recognising workload issues and whether organisations post-disaster were “trying to do too much with too little”. Mounsey says there was also no ‘one-size-fitsall’ answer but support needed to be not only in the first months after a disaster but extend for several years and to recognise the “barriers that healthcare professionals” have in accepting and getting support. “Also perhaps being more proactive about how they model self-care behaviour and showing everybody that it is all right to take time off and all right to have a life outside work.”


FOCUS  n  International Nurses Day

Postdisaster: finding the time to care

Research into insights gained by a ‘rapid scan’ survey of Nurse Maude’s district nurses 18 months after the February 2011 Canterbury earthquake was also shared at the People in Disasters Conference.

D Sheree East

Chris Hendry

istrict nurses and care workers negotiating potholes and roadworks were a lifeline for many isolated and elderly people in post-quake Christchurch. In 2013 Christchurch’s Nurse Maude district nursing service staff were still reporting the quakes’ ongoing health and social impacts on their clients and delivering services remained a continuing challenge. Director of nursing Sheree East and Chris Hendry, New Zealand Institute of Community Health Care, wanted to understand how their clients were faring 18 months down the track from the most devastating of the quakes on 22 February 2011. The pair told the People in Disasters Conference, held in Christchurch in late February to mark the quake’s fifth anniversary, that they faced a dilemma of how best to do that quickly in post-quake Christchurch with vulnerable clients, staff stressed with their own quake issues, and limited time and resources. Hendry says they opted to send a ‘rapid scan’, short, six-question survey relating to the clients they care for in the community to all community health nurses and support workers with their paysheets. Just over a third responded, with 172 surveys returned from 34 nurses and 138 support workers and healthcare assistants. The majority had worked for Nurse Maude for more than five years and 60 per cent of them provided services in the hardest hit areas. Two-thirds of the staff believed their clients’ health and/or other needs had worsened since the quakes. Nurses reported that the issues that were of most concern to clients were the loss of family and friends, increased severity of chronic illnesses, and nutritional and dietary needs. When it came to psychosocial issues, the nurses talked of social isolation, loss of confidence and many clients having anxiety and depression issues. Hendry told the conference that nurses were concerned that the clients left behind in the hardest hit areas, who had

Christchurch earthquake damage

lost services and supermarkets, were the least mobile and elderly; they were becoming increasingly isolated and unable to get about as they couldn’t navigate the cracked footpaths and roadworks by foot or mobility scooter. In the free comments section of the survey, nurses and care workers talked about needing more time to care for clients in these challenging environments. For a start, finding clients could be difficult, not only because of damaged and blocked roads, but also because some moved house without warning. Also the staff wanted and needed more time to reassure and support clients, including listening to their stories and helping calm them down, because clients were more cautious and slower to move in the post-quake environment. The service responded to the survey findings by giving feedback to the staff, and providing nurses and staff with more tools, resources and information to help them refer clients or families to other appropriate support services. East says this was particularly important to the nurses as they felt they could do something practical to make a difference to their clients. Nurse Maude also offered a series of resilience workshops for staff as it recognised that some of the client issues reported in the survey reflected the staff’s own issues. East says the survey also helped bring home to management that staff needed to have their daily caseload reduced to allow them more time with clients. East told the conference the service tried to do its best at the time but “while you think you are doing enough but you can never do enough”. She says in hindsight Nurse Maude would have established earlier ways of seeking regular feedback on concerns and actions taken; it would have provided early training for staff on how to manage depression and anxiety and it would have given staff more information earlier on how to access support agencies and better coordinate care for their clients. “We needed to share the load more.” www.nursingreview.co.nz  |  Nursing Review series 2016    23


FOCUS  n  Innovation

Patient safety:

keeping it real by walking the wards

Charge nurse manager Jabu Mlangeni (left) with Counties Manukau director of nursing Denise Kivell (centre) and Jacqui Wynne-Jones (clinical nurse director for surgical and ambulatory care services) during a Patient Safety Leadership Walk Round of the renal ward.

Ensuring health leaders are in touch with what’s happening at the bedside is a major motivation of Counties Manukau’s Patient Safety Leadership Walk Rounds. Counties Manukau nursing and improvement leaders Jacqui Wynne-Jones, Lynne Maher and Bev McClelland contributed to this article, outlining the background, format and results of leaders ‘walking the wards’.

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he publishing of the Francis Report in 2013 on the tragedy at Mid-Staffordshire NHS Foundation Trust rang alarm bells in healthcare around the world. The report showed that a hospital could appear to meet performance targets while concealing appalling standards of care. One of the problems identified by the Francis Report was that senior management at MidStaffordshire was not listening to patients and their families, or to staff. Despite continual signs of dissatisfaction in staff and patient surveys, no action was taken. Leaders were distanced from what was happening on the front lines and did not fully understand the reality of care being provided to patients. Leaders at Counties Manukau District Health Board (CMDHB is also known as Counties Manukau Health or CM Health) were left wondering if a similar tragedy could happen in their organisation. CM Health routinely gathered quantitative data under its Patient Safety Framework – including the incidence of falls and pressure injuries and hand hygiene compliance rates – but the Francis Report proved that this sort of data didn’t tell the whole story. CM Health decided it needed to gather different information about safety in its wards and units, and this information needed to be from the points of view of staff, patients and patients’ families. In early 2014, a collaborative team led by clinical nurse director Jacqui Wynne-Jones created the Patient Safety Leadership Walk Rounds. In the fortnightly Rounds, a team of six staff, including at least one member of the executive leadership team, visits a Middlemore Hospital ward or unit.

24    Nursing Review series 2016  |  www.nursingreview.co.nz

(There are plans to expand the Rounds into CM Health satellite clinics.) The Rounds team uses three qualitative tools to assess how safe the ward is and capture the experience of staff and patients on that ward (see ‘Qualitative Safety’ box).

“We feel very responsible when we interview patients. We have to be careful that we don’t just open up an emotional wound and then walk off and leave them.” Tools to help assess patient safety

The first of the tools used during the fortnightly Rounds is ‘First 15 Steps’, adapted from a National Health Services (NHS) toolkit called ‘The 15 Steps Challenge’ that assesses how safe a ward is based on first impressions of the ward environment. The development of the NHS toolkit was sparked by a comment from the mother of a young patient in an NHS hospital: “I can tell what kind of care my daughter is going to get within 15 steps of walking onto a ward.” The other two tools are a patient experience questionnaire and a staff experience questionnaire that each comprise 10 questions. The patient


FOCUS  n  Innovation

experience questionnaire also contains a scale to measure how patients feel about ward processes, routines and interactions with staff. Wynne-Jones brought together a range of leaders and advisors to co-design the questionnaires. Further staff and patient input was also sought.

Keeping leaders in touch with the front line

The Francis Report warns of the dangers of healthcare strategic and operational leaders becoming distanced from the reality of everyday care. Patient Safety Leadership Walk Rounds are regarded as a mechanism for CM Health leaders and other staff to see first-hand the care provided on the wards, and to hear the voices of staff and patients. Wynne-Jones’s team contacts charge nurses the week prior to the visit to inform them about its purpose and background. The visiting team of six is made up of a consumer, clinical leaders, heads of departments, clinical directors, senior medical officers and members of the executive leadership team. During the Rounds two of the leaders assess the ward using the First 15 Steps, while two interview patients and two interview staff. Leaders typically interview about three people each per visit. The team tries to speak to a cross-section of medical, nursing and allied staff and does not collect personally identifiable information during interviews. The Rounds were developed using PDSA (plan, do, study, act) cycles, with the aim of being perceived positively rather than as a specific mechanism for ‘checking up’ on staff.

Celebrating what’s great and improving what isn’t

At the end of each walk round, leaders produce a summary identifying what they saw or heard that was great about the ward, and what could be improved. The summary, along with a copy of the completed tools and notes, is supplied to the ward charge nurse, head of department, service manager and clinical nurse director within 24 hours. Also supplied is a facility for wards to track improvement actions and to request support. Wynne-Jones’s team also keeps in touch with wards. Sometimes intervention to resolve problems is more direct. “We feel very responsible when we interview patients. We have to be careful that we don’t just open up an emotional wound and then walk off and leave them. So if there is a specific complaint, we discuss this with the charge nurse or help the person to access the complaints process if they prefer this option,” says Wynne-Jones. The Rounds also often help staff to identify and address isolated problems. For example, one Rounds visit provided traction for a charge nurse to obtain some long-needed documentation privacy cupboards that the ward’s budget could not cover. With assistance from the director of nursing, Denise Kivell, surplus cupboards were located elsewhere in the hospital and moved to the ward that needed them. However, responses are often broader. Clutter was noted as a problem in a number of ward environments during Rounds. As a consequence, Kivell made a formal request for refresher training in 5S Workplace Organisation methodology for these wards to improve their environment. Interestingly, clutter was less of a problem in wards with strong leadership.

Rounds: NZNO feedback It is still early days but staff are happy the Rounds give them the chance to talk directly with senior management, says Deb Chappell, one of the New Zealand Nurses Organisation organisers working with CMDHB staff. “At the moment it is working well. Our staff are liking it because they [senior management] are actually talking and engaging with staff on the floor – they are not just coming through and talking to the charge nurses and the patients,” says Chappell. “In the past, senior management would come into the ward but they would normally go straight to the charge nurse and that’s where the conversations would begin and end.” Chappell says with Rounds still only a new initiative staff are a little wary over how long it will be maintained, but hope it continues as a way for staff to engage with DHB management, particularly as Middlemore is a very busy hospital and members were feeling the increased strain.

The qualitative safety assessment tools The First 15 Steps

»» »» »» »» »» »» »» »» »» »»

Using my senses – what can I hear, smell, see, feel, touch? How does this ward make me feel? What is the atmosphere like? Is it calm? Chaotic? What interactions are there between staff/patients/visitors? Is there visible information that is useful and reassuring? What is it? What have I noticed that builds my confidence and trust? Is essential information about each patient clearly visible? What makes me less confident? Do storage rooms look well organised and clean? Are areas well maintained?

Things to look out for:

»» »» »» »» »» »» »»

Welcoming reception area Clear signage Acknowledgement on arrival – eye contact, smiles Information available, clear and visible Contact information for relatives and visiting times Information about who the staff team are Is there evidence that the ward is disabled accessible?

The Experience of Staff 1.

How did you feel about coming to work today? How do you feel now you’re here? 2. What would you like to see changed that would support you more? 3. What stops you providing the safest care? 4. Is this ward safe 24/7? Does this ever change and if so can you tell us more about when and why? 5. What patient safety initiatives are happening on your ward? 6. What do you consider are the biggest risks to patients and their safety on this ward? 7. How would you feel about your grandmother or close relative being cared for in this area? 8. How useful do you find the Patient Safety Measure boards? 9. Tell me about the last incident report you submitted? 10. Are there any further comments you’d like to make about anything we haven’t touched on?

The Experience of Patients 1. 2.

When staff are with you, how does this make you feel? How are you kept informed about your treatment? Do you know your plan of care? 3. Do you know your nurse for today? 4. How safe do you think this ward is? What would make you think this ward is unsafe? 5. When you have your visitors, family and caregivers come to see you what things about the ward and your care have they commented on? 6. What stands out on this ward? Is there anything that makes it special? 7. How do the days compare to the evenings and nights? 8. Is the care we provide responsive to your cultural needs? 9. Do you feel safe when mobilising? When going to the bathroom? 10. Do you see staff sanitising their hands before and after being with you? *Scale not included. www.nursingreview.co.nz  |  Nursing Review series 2016    25


FOCUS  n  Innovation

Lynne Maher

Jacqui Wynne-Jones

Strong leadership, good communication and systemic issues

The Rounds repeatedly reinforce the importance of leadership development on wards. “We are seeing best practices where there is strong leadership,” says Wynne-Jones. This has led to the creation of a new programme for charge nurse managers on clinical quality leadership that is informed by learning from the Rounds. Patient Safety Leadership Walk Rounds act as a vehicle for spreading good practice and new ideas, particularly around communication, with the need to improve communication being one of the strongest themes to have emerged. There is also helpful evidence about the effectiveness of communication tools, such as hourly vigilance rounds, huddles and bedside handovers involving the patient in the plan of care. This feedback was given to a rehabilitation ward that had changed its model of care to accept post-op orthopaedic patients earlier due to the ERAS (Enhanced Recovery After Surgery) Programme. This patient population is at high risk of falls. Following recommendations by the Rounds team, the ward’s charge nurse manager developed a team nursing model that included a walk-round handover and huddles to improve safety. Some issues identified, such as after-hours staff shortages, are systemic. Kivell informs the CM Health board of systemic issues emerging in the feedback across wards. In this way, qualitative input from patients and staff complements other evidence used to guide the development of CM Health policies and processes. For example, feedback from the Rounds is helping to inform the development of a workload planning and acuity tool for CM Health (see box 1 for more information). The approach with staff is one of ‘appreciative inquiry’ – Rounds aim to learn, support and encourage, not to find fault (see box 2 for staff feedback). “All the charge nurses have fed back afterwards that staff appreciated us listening to them,” says Wynne-Jones. “And the patients love it, because they love someone to talk to them about these important aspects of care. People are asking us when we’re coming to their ward!” The Rounds link with other initiatives at CM Health designed to improve the design and delivery of services. Most importantly, the Rounds complement the Patient Safety Framework, providing qualitative feedback from staff and patients on the wards. “If there is a mismatch between what the data tells us around safety and what the narrative from patients and staff tells us, then that is an alert to us,” says Bev McClelland, organisational development consultant. The aim is to ensure no tragedy like Mid-Staffordshire happens at CM Health.

Authors:

»» Jacqui Wynne-Jones is clinical nurse director, surgical and ambulatory care services, at Counties Manukau Health (CMH). »» Dr Lynne Maher is director for innovation at CMH’s health education and improvement hub, Ko Awatea. »» Bev McClelland is an organisational development consultant at Ko Awatea. REFERENCES »» Francis R. (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry: Report of the Mid Staffordshire Foundation Trust Public Inquiry. Available at: »» http://webarchive.nationalarchives.gov.uk/20150407084003/ »» www.midstaffspublicinquiry.com/report »» NHS Institute for Innovation and Improvement. The 15 Steps Challenge. 2006–2013. 26    Nursing Review series 2016  |  www.nursingreview.co.nz

Beverley McClelland

Workload planning: CMDHB and Care Capacity Demand Management Update Counties Manukau was one of three demonstration sites in 2009 for the joint union/district health board Safe Staffing Healthy Workplace (SSHW) Unit, but is yet to come on board with the safe staffing tools the unit has evolved. The set of tools – known collectively as the Care Capacity Demand Management (CCDM) system – require a ‘validated patient acuity tool’ and were built using the patient acuity software TrendCare, which the majority of DHBs now have, but Counties Manukau and three other DHBs do not. During last year’s New Zealand Nurses Organisation/DHBs MECA talks the NZNO sought and gained a commitment from DHBs to implementing CCDM, including a “timely response” to when the safe staffing tools data show the need to adjust staffing levels. Denise Kivell, director of nursing at CMDHB, says the DHB is planning to introduce the CCDM tools by seeking validation of its existing McKesson rostering system. She says it keeps SSHW unit director Lisa Skeet up-to-date with the DHB’s plans – including Skeet sitting in ex-officio to governance meetings – and is working with Waikato DHB, which has the same system. Kivell says the board’s first step will be rolling out the CCDM workload tool with its McKesson Rostering system and the next step will be gaining validation for the rostering system and this would lead onto the rolling out of other CCDM tools like the staffing base design and the responding to variance tools. Asked by Nursing Review what current safe staffing measures the board has, Kivell says it has had a capacity planning tool, CAPPLAN, for many years and its data is currently around 95–97 per cent accurate. She says this data is used in combination with daily charge nurse manager meetings and a 15-minute midday ‘huddle’ of all services that provides a bed management and staffing update. Also Middlemore Central (the hospital’s integrated centre) provides bed and staffing management oversight and the hospital’s web-based ‘dashboard’ is updated every 15 minutes. She says the Rounds feedback provides the ‘reality factor’ of what is occurring on the ward from the patient and staff perspective.


FOCUS  n  International Nurses Day

International Council of Nurses

NURSES: A force for change

IMPROVING HEALTH SYSTEMS’ RESILIENCE

12 MAY 2016 INTERNATIONAL NURSES DAY #IND2016

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he Ebola outbreak in West Africa in 2014 is a tragic illustration of what can go wrong when a health system is not strong enough to respond rapidly and effectively in an epidemic. The World Health Organization (WHO) reports that when the outbreak hit, the most affected countries had a fragile health system with insufficient numbers of healthcare workers, many of whom died. “In fact, a May 2015 preliminary report by WHO (2015c) on health workers infected with Ebola, stated that of the 815 healthcare workers who had been infected by the Ebola virus since the onset of the epidemic, more than 50 per cent were nurses and nurse aides,” reports the International Council of Nurses (ICN) in its International Nurses Day (IND) kit for 2016. It also adds the grim statistic that two-thirds of the health workers infected with Ebola died. In an article for the British Medical Journal last year, James Campbell, the executive director of the Global Health Workforce Alliance, and colleagues gave the following definition of resilience:

“The resilience of a health system is its capacity to respond, adapt, and strengthen when exposed to a shock, such as a disease outbreak, natural disaster, or conflict.” In the opening letter of the IND kit, the ICN president Judith Shamian and chief executive Frances Hughes acknowledge that nurses “may wonder” how they can help strengthen health systems around the world. “As members of the single largest group of health professionals, with a presence in all settings, nurses can make an enormous impact on the resilience of health systems,” they say. “Every decision that you make in your practice can make a significant difference in the efficiency and effectiveness of the entire system.” They go on to add that it is imperative that nurses identify opportunities in their organisations, and themselves, to strengthen and develop resilience. Shamian, in an article published last year, listed nine ways that nurses can make an essential

International Nurses Day:

resilience in the health system To be a force for change nurses need to be part of a resilient health system. The sub-theme for this year’s International Nurses Day (IND) on 12 May is ‘Improving health systems’ resilience’. Nursing Review looks at the IND kit* on the theme and the tragic consequences when systems fail. contribution to discussions on health systems and health workforce strengthening: »» Lead and support interprofessional education (IPE) and interprofessional collaborative practice (IPCP) »» Advocate for a paradigm and operational shift in health care that balances illness-focused care with population health »» Identify and champion global and national strategies to address health workforce maldistribution and migration »» Strengthen and diversify primary health care »» Ensure a strong nursing voice in all health and social system policy development and planning dialogues »» Consider the influence of regulation and legislation on the health system and health worker resource planning issues »» Design and improve information infrastructures and data collection to support health system redesign and planning »» Participate in research related to health worker resources and in health systems research and evaluation »» Consider the influence of complex, ubiquitous social and gender issues, such as the determinants of health, and inequality and inequity. The IND kit concludes by saying that providing quality health care services to all people in need is the ethical and professional responsibility of nurses. “As committed, innovative and solutionoriented professionals, nurses continue to provide care with resilience and versatility, even with little or no resources or organisational support,” it says. However, improving health systems’ resilience requires a collaborative effort for all involved in healthcare services and ICN calls for nurses to play an integral role in leading change. “With redesigned health systems and full participation of nurses in policy, we will be better equipped to provide quality care for all, even in times of difficulties.” *Source: IND 2016 kit, International Council of Nurses: www.icn.ch/images/stories/documents/ publications/ind/IND_kit_2016.pdf.

Resilience in action A nurse in El Salvador, distressed by how many patients she was seeing with Dengue fever in her remote and rural clinic, took action. Knowing she needed evidence to get the support of her local manager, she went to books and the internet and used her records to create a map of cases that identified the locations and magnitude of the problem and highlighted the worsening problem. She presented the information and suggested the clinic should develop targeted health information sessions for the most affected local groups. Progress in fighting Dengue fever was dramatic and the nurse became part of the local management team supporting the development of similar programmes. (Source: IND Kit 2016)

Fast facts: International Nurses Day The marking of Florence Nightingale’s birthday on 12 May as International Nurses Day (IND) was initiated in 1965 by the International Council of Nurses (ICN). Geneva-based ICN was founded in 1899 and is a federation of more than 130 national nurses associations, including the New Zealand Nurses Organisation, representing more than 16 million nurses. The ICN is now led by a New Zealander – former New Zealand and Queensland chief nurse Dr Frances Hughes – who took up the chief executive post in February.

www.nursingreview.co.nz  |  Nursing Review series 2016    27


Practice, People & Policy Practice

Articles, profiles and opinion pieces from across the nursing spectrum

Practice, People & Policy

Cultural safety:

developing self-awareness through reflective practice How culturally safe is your practice? In the first of a short series of articles on cultural safety, Katrina Fyers and Sallie Greenwood focus on the skills of developing reflective writing to foster self-awareness and support culturally safe practice.

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he aims of cultural safety education have remained unchanged since its inception nearly 25 years ago. The Nursing Council of New Zealand’s guidelines say the aims are to educate student nurses and midwives to “examine their own reality and the attitudes they bring” to practice relationships, to “demonstrate flexibility in their relationships” and to “evaluate the impact of historical and social processes” on populations. In their 2014 book How to nurse, Canadian nurse scholars Gwen Hartrick Doane and Colleen Varcoe observe that self-knowledge helps us to change the way we think about others, ourselves and society so that our practice can be responsive to the complexity of patient need. Over the last two years we have been researching student ways of knowing (epistemology) and our learning and teaching strategies when teaching cultural safety in a Bachelor of Nursing degree. In the module called ‘Social Context of Nursing in Aotearoa New Zealand’ we aim to help student nurses to widen their perspectives and think about how they develop and use knowledge. Following a pilot study in 2013 we undertook a second piece of research analysing student reflective journals. Our participants were first year, second semester nursing students who generously agreed

to share their online reflections at the end of the semester.

Mastering reflective practice takes time It is important to remember that mastering the skills of reflection (see table 2) takes time and will develop with perseverance. In the process of reflecting we can learn to see ourselves, our thinking and behaviours in new ways; we can learn to question our taken for granted understandings of ourselves and others and importantly the ways in which power affects our relationships. A significant finding from our research was the importance of using reflection as a way to support learning and develop selfawareness, an important aspect of cultural safety practice. For many of our students using reflection for the first time early in their degree was hard and frustrating. However, developing good reflective writing techniques and understanding the relevance helped them to make sense of the material they were presented with in class. We suggested a number of frameworks to help make the process clearer, as using defined frameworks helped students to stand back from their experiences and critically analyse them for new understandings or views.

Sallie Greenwood (left) & Katrina Fyers

There are multiple explanations of what reflective practice is and a number of models can be used. In our research we noticed that using Professor Graeme Gibbs’s Reflective Cycle (1988) framework, though sometimes helpful at the beginning, became limiting as the semester progressed as it forced students into simplistic evaluations rather than true analysis. Writing a description of an event or a response to something new or different is the beginning point of reflection and that needs to be followed by analysis of feelings. Getting a grasp of the feelings evoked in a situation is very important to the reflective process. The next stage is to think more deeply about the knowledge that has informed your point of view and how this might impact on what you do or think. All this helps to develop self-knowledge. See the boxed ‘Reflective practice scenario’, which outlines an imagined scenario and how a student might reflect on it using the ‘What’, ‘So What’, ‘Now What’ model outlined in table 2.

Reflection can deepen understanding The quotes below are from the student journals in our research that demonstrate how students have used the reflective process to deepen their understanding and shape their practice.

Table 1: Reflective skills to develop Intellectual effort

Self-awareness

Description

Openness to new ideas

Analysis of feelings

Taking time to reflect and reconsider

Examination of how a situation, experience or event has influenced you and how you have influenced that situation

Ability to bring together significant information and develop into a thorough readable summary or tell a short story

Imagining alternatives Allowing for not knowing and ambiguity Being courageous and truthful

Table 1: Adapted from Bulman (2013) 28    Nursing Review series 2016  |  www.nursingreview.co.nz

Critical analysis

Synthesis and evaluation

Incorporating new Determining the value knowledge into new ways of knowledge, thinking of knowing and acting and about previous knowledge, then evaluating the impact of analysing assumptions, those new ideas values and beliefs, imagining alternatives, finding different perspectives Creating a toolbox of ideas to respond to complexity Questioning the taken-forgranted Be willing to reflect again Challenging previous ways of thinking, reacting


Practice, People & Policy Practice I realised that I must step out of my own “zone” in order to view other important waves (perspectives) in situations that I may face as a future nurse. (Kim) I felt I was trying to place pieces of a zig saw [sic] puzzle together at the beginning of this semester. It took me days of deep thinking to be able to write my first reflection regarding my own culture. (Felicity) A sound knowledge of who I am, and my own culture helps me to relate to people with similar values and beliefs. Being aware of my own thoughts and feelings also helps me to know how I will react in certain situations, and gives me the ability to take a professional approach rather than a personal one. (Henri) Developing reflective practice is essential to many of the professions that aim to work with people effectively and has become a significant aspect of nursing practice. It can be framed as a way into considering accountability, verifying ability or noticing development or as a critical process that involves thoughtful analysis and increased awareness of self in relation to others and context. In this article we have focused on the process and skills of developing reflective writing to support practice. Our next article, based on our research, will develop the connection between self-awareness and practice.

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

Table 2: Framework to guide reflective practice What? This is the descriptive phase (all questions start with what)

»» »» »» »» »»

What happened? What did I do? What did others do? What did I feel? What was I trying to achieve?

So what? This is the theoretical/conceptual phase

»» So what is the importance of this? »» So what is the significance for me? »» So what more do I need to know about this? »» So what have I learnt about this?

Now what? At this phase we think about other ways of thinking or acting and choose the most appropriate

»» Now what should I do? »» Now what would be the best thing to do? »» Now what will I do? »» Now what might be the consequence of this action?

Table 2: Adapted from Jasper (2013) based on Borton (1970)

Reflective practice scenario The student has attended a lecture where racism was discussed followed by a tutorial where some strong feelings were expressed by some students. WHAT: The descriptive level includes the context, actions, expectations, feelings and thoughts evoked by the experience. We might see something like this: The lecturer talked about racism and I felt as though I was being blamed or accused of being racist. I was really angry with the lecturer and said so in the tutorial. Lots of people in the class agreed with me. SO WHAT: The next stage of reflection is the learning phase, a deeper level of reflection on what the responses mean. The student might ask themselves what was going through their mind and how did they understand their responses. They might ask themselves what other views they could bring to their understanding of the situation. We might see something like this: I wondered why I felt so angry. Maybe I didn’t need to take the information so personally. I read some of the articles provided about different levels of racism and realised it wasn’t necessarily aimed at me personally but at the structures. I began to think how it might feel to be discriminated against and wondered whether I had ever discriminated against someone without even realising it. NOW WHAT: The final stage involves reflecting on future actions and possible consequences. We might see something like this: Now I can see that if patients are discriminated against it can have profound effects on their health and wellbeing and stop me being able to nurse them effectively. I think I need to find out more about racism and notice my reactions to people who are different from me.

New graduate nursing:

People

stress, tears, laughter and rewards The first year of nursing can be a challenging initiation to the realities of the profession. Rosalie Davis* spoke at the graduation of her NETP (Nursing Entry To Practice) programme year on the ups and downs of that journey. Her honest and touching speech is shared here.

T

Rosalie Davis

his year has challenged me. As I look around the room – from the nurses I work with on the ward to the ones I’ve got to know in study days – I think those challenges resonate with you all. We’ve had to learn the routine of a nurse’s life, that is, that there is no routine. We’ve had to accept that stat holidays don’t exist – except for the bonuses on our pay cheques. We’ve learnt how important it is to make a plan at the start of the day, and the equal importance of adapting that plan to meet any one of hundreds of unexpected circumstances. We’ve learnt to step up and be accountable for everything we do and say because we can, and will, be questioned on the decisions we make;

because we are working with lives and what we do and say impacts on those lives. We’ve learnt to advocate. To go by our instincts, to trust ourselves and to ask for help and do whatever it takes to ensure the best outcomes for our patients and their families, whether it be in restoring health, or honouring a life by providing a dignified and comfortable death. We’ve learnt to cry (something I’m very practised at). To go to the treatment room, wipe away our tears, take a deep breath, and accept that some things can’t be fixed. We’ve learnt how to hold hands as people grieve, but to accept the grief as theirs and not our own, because when we do this we are much more Continued on next page >>

www.nursingreview.co.nz  |  Nursing Review series 2016    29


Practice, People & Policy

Practice, People & Policy

People

OPINION

Continued from previous page >> effective nurses. We’ve had days where we have wanted to run away, where we’ve questioned who we are, why we’re here and why we do what we do, when the same pay – or more – could get us a job much easier than the career that lies ahead of us. But we also have the kind of days like I’ve had today. When you have time to laugh and joke with your patients, to share time with your colleagues and enjoy the bliss of one of the very few (dare I say it) quiet days. We have days when you see a patient walking out the hospital doors, who just a week earlier you fought to hold a ventilator on for two hours, as the chance of them dying if you didn’t was just not worth gambling with. You see their daughter laughing with them as they leave and you think the fact you didn’t get a break that night doesn’t really matter in the scheme of things. And there are days you start your shift to find your patient is over being in hospital and today – after weeks of tests and treatments – is their breaking point. They start to get mad, they start to cry, and your shift plan crumbles as you sit down and patiently listen to find out their fears and what is wrong. You don’t promise to fix it, but you promise to try. A few hours later that patient thanks you for understanding and for helping, and apologises for taking it all out on you. You tell them that it doesn’t matter, because it doesn’t. What matters is that all you gave was your time and you made a difference in their day and that, to me, is worth something more than meeting some target in a corporate job. We see patients and families in some of their lowest moments and it is an honour to be trusted in these moments, with their questions, their fears, and to be accepted and respected for the knowledge we have. We’ve all grown this year, but we couldn’t have done it without the support of our friends and families, our colleagues and the NETP team. Thanks also to our friends and families. You’ve held us when we’ve cried – you’ve dealt with us when we’ve been tired, stressed, moody and exhausted. Thank you for understanding. I want to thank the staff who have supported us – for hiring us for starters, for seeing a future in us, and for nurturing and supporting us. For not judging us when we weren’t coping, for being there when we needed it, but still giving us space as well. Also for offering their advice and wisdom, for helping us grow into confident nurses who can and will make a difference in the lives of our patients. Thank you to the whole NETP team, who pop up on the ward when we least expect it but need it the most, especially during those first few weeks on our own. You helped us stay afloat. Finally, I want to thank my fellow new grads, because it meant so much being able to share how we were really doing. It made it OK to know we were all feeling just as lost as each other. We have all come a long way since our scary and exciting orientation days. We have grown confident in the areas we work in; we still have a lot to learn, we always will, but the future is ours. I’m excited to see where we all go, where we specialise and where our careers take us. Because nursing offers a future with hundreds of different paths, and this year, I believe, has helped to prepare us to walk down any of those paths that we choose, to push boundaries, to ask questions, to act in a way that will drive the future of nursing and patient care.

“What matters is that all you gave was your time and you made a difference in their day and that, to me, is worth something more than meeting some target in a corporate job.”

*About the author: Rosalie Davis is now a second-year nurse in the same ward at Waitemata DHB’s North Shore Hospital in which she spent her NETP year. 30    Nursing Review series 2016  |  www.nursingreview.co.nz

Missing out on the

‘conversations that count’

Suzanne Joynt

After nursing patients with chronic kidney disease for more than two decades, Suzanne Joynt has seen the comfort and support that advance care planning (ACP) about end-of-life care can provide for patients and their families. So when her stepfather was diagnosed with a terminal illness, she hoped other nurses would be aware of its benefits too.

I

’ve been involved with advance care planning for a number of years now and have seen first-hand the comfort and support it can bring to a patient and their family. And I wished the benefits of ACP had been more widely known during my recent personal experience with my step-dad. Last year, quite suddenly, my step-dad Barry was diagnosed with a terminal illness following a hospital admission. As a nurse with knowledge and skills on advance care planning, I spoke with Mum and Barry about ACP and gave them reading material to look at. Advance care planning makes sure patients, their whānau and healthcare professionals are all aware of plans for end-of-life care, and as a living document it can be changed by the patient at any time. In my experience, having the conversation not only helps the patient, but also the family and whānau by avoiding those difficult situations and decisions about their loved one’s wishes when unsure of what they would have liked. My mum, with the support of my family, tried to care for Barry at home but sadly, this was hard and he needed to be admitted when his symptoms became unmanageable. On this hospital admission, I mentioned to the staff about advance care planning, but was told that this was ‘premature’. This seemed odd since we’d had a conversation about palliative care. I was left feeling uncertain that anyone knew of the benefits of advance care planning. After his discharge, Barry lasted another five days at home with support from his brother, my sister and me. After a few falls and other deteriorations of his health, he was admitted for the very last time. It was now obvious he was dying but still no conversations were initiated by staff about advance care planning and what Mum and Barry wanted. The care provided in those last few days was fantastic though and for that we were all appreciative. Barry passed away peacefully three days after his admission. Unfortunately, Barry was not able to fully complete his advance care plan as his illness was quite aggressive and his death was a month after his diagnosis. I was, however, able to spend a great deal of time talking with him about what he wanted, including a very difficult conversation about his resuscitative status. As nurses, we need to think about the holistic care that is needed for patients with terminal illness, not just the physical care. It’s about having those ‘important conversations’, which research has shown is what our patients want. Yes, these conversations can be difficult, but there is training available and nurses should be encouraged and supported to do it. I have found that having conversations with patients is both rewarding and a privilege and, to me, is part of what nursing is about.

On 16 April, New Zealand holds Conversations that Count Day, a national day to raise awareness about advance care planning. Visit www.advancecareplanning.org.nz for more information. Author: Suzanne Joynt is a nurse unit manager in Auckland District Health Board’s renal and gastroenterology services and has cared for patients with chronic kidney disease for more than 20 years. After experiencing the positive benefits of supporting patients and their families to discuss and document endof-life care and decisions, she introduced advance care planning into her own and her team’s daily working practice.


Evidence-based practice practicE

Does stepping-up exercise

step down risk for heart patients?

This Critically Appraised Topic (CAT) looks at whether getting on a bike or lacing up walking shoes improves the life, and life span, of people with coronary heart disease. CLINICAL BOTTOM LINE: Exercise cardiac rehabilitation reduced the risk of cardiovascular mortality in lower risk individuals with coronary heart disease by around 25 per cent, hospital admissions by 18 per cent, and improved health-related quality of life when compared with no exercise controls. Exercise cardiac rehabilitation was found to be safe in the population studied but did not significantly reduce the risk of total mortality, myocardial infarction or revascularisation in comparison with no exercise controls.

CLINICAL SCENARIO: Exercise-based cardiac rehabilitation (CR) is recommended for reducing the risk of future cardiovascular events and promoting wellbeing. However, improvements in medical management, alongside possible overestimation of benefit and narrow inclusion criteria in earlier studies, have raised questions about the effectiveness of exercise-based CR and for whom. You decide to review the evidence.

QUESTION: In patients with coronary heart disease (CHD), is exercise-based CR more effective than standard care (without a structured exercise component) in reducing cardiovascular mortality and improving quality of life?

SEARCH STRATEGY: PubMed - Clinical queries (Therapy/Narrow): exercisebased cardiac rehabilitation AND mortality

CITATION: Anderson L., Oldridge N., Thompson D.R., et al, Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol, 2016. 67(1): p. 1-12 10.1016/j. jacc.2015.10.044

STUDY SUMMARY: A Cochrane Systematic Review assessing the efficacy of exercise-based cardiac rehabilitation for people with CHD. Inclusion criteria were: »» Type of study: Randomised controlled trials (RCTs) comparing exercise-based CR with a control and a follow-up period of at least six months. Studies were to include patients irrespective of sex or age who had a myocardial infarction [MI], had undergone revascularisation (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]), or who have angina pectoris or CHD defined by angiography. »» Types of Interventions: Exercise-based CR was defined as a supervised or unsupervised inpatient, outpatient, community-based, or home-based intervention that included some form of exercise training, either alone or in addition to psychosocial and/or educational interventions.

»» Comparison: Standard medical care and psychosocial and/or educational interventions, but not any structured exercise training. »» Outcomes: Total or cardiovascular (CV) mortality; fatal or nonfatal MI; revascularisations (CABG or PCI); hospitalisations; health-related quality of life (HRQL) or costs and cost-effectiveness.

STUDY VALIDITY: »» Search Strategy: Electronic databases searched up to July 2014 included CENTRAL, DARE, HTA, MEDLINE, EMBASE, and CINAHL Plus. Conference proceedings were sought via Web of Science Core Collection, bibliographies of systematic reviews and trial registers were hand-searched. No publication date or language restriction applied. »» Review process: Two reviewers independently assessed all identified titles for possible inclusion. Data was extracted by one reviewer using a standardised form and a second reviewer checked for accuracy. Study quality was assessed independently and in duplicate. Differences in opinion were resolved through consensus. »» Quality assessment: The Cochrane Collaboration tool and three additional criteria (equivalence at baseline, comparable care between study groups apart from the exercise component of CR, and intentionto-treat analysis) were used to assess risk of bias in included studies. The quality of evidence for each reported outcome was assessed using the GRADE framework. »» Overall validity: A high-quality review involving a large number of predominantly small RCTs of either low or unclear (because of unreported details) risk of bias.

STUDY RESULTS: A total of 11,028 titles were screened, of which 91 full-text articles were considered for inclusion. From these, 63 RCTs (14,486 participants) met inclusion criteria and were included in this review. Most studies were conducted in Europe (37 studies) or North America (12 studies); 29 studies were published after 2000.

Exercise-based CR was typically delivered in a supervised setting either with or without the expectation of home-based exercise. Fifteen studies involved exclusively home-based exercise; for example, an exercise prescription supported by text messaging and/or nurse contact. Exercise was aerobic (cycling, walking or circuit training) but there was considerable variability in exercise dose (duration, frequency, session length, and intensity). A statistically significant reduction in CV mortality and overall risk of hospital admission was seen with exercisebased CR when compared with a no exercise control (refer table). Outcomes were independent of whether patients had MI or not, type of CR (exercise-only or comprehensive), exercise dose, length of follow-up, setting (home-based or hospital), year of publication, risk of bias or sample size. There was no statistically significant difference between groups for risk of all-cause mortality, fatal and/ or non-fatal MI, CABG or PCI. Five of 20 trials (5,060 participants) reported significant improvements in ≥50 per cent of the subscales used to measure HRQL in those receiving exercise-based CR. Evidence of cost effectiveness of exercise-based CR over standard care was mixed.

COMMENTS: »» A diagnosis of CHD can be life-changing and calls for comprehensive supportive rehabilitation. »» This updated 2011 Cochrane Review provides evidence of the benefits of exercise CR – in addition to psychosocial and/or educational interventions – and in the context of contemporary medical CHD management. »» Participants had a median age of 56 years, were predominantly post-MI or revascularisation (CABG, PCI); just 15 per cent were women. »» Clinical judgement is required when applying these results to people with CHD who are underrepresented in the study populations involved in this review. Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, The University of Auckland, and PhD candidate, Deakin University, Melbourne. cwensley@deakin.edu.au.

Table: Summary of Results Outcome (median follow-up period 12 months)

No. of studies (number of participants)

Relative risk (95% CI)

Statistical heterogeneity I²

Quality of the evidence*

Cardiovascular mortality

27 (7,469)

0.74 (0.64–0.86)

0%

Moderate

Overall hospital admission

15 (3,030)

0.82 (0.70–0.96)

34.5%

Low

*Graded as high, moderate, low or very low; moderate and low quality evidence indicates that findings may change with future studies. www.nursingreview.co.nz  |  Nursing Review series 2016    31


College of nurses

Action needed to

recruit new blood Nursing director LORRAINE HETARAKA-STEVENS calls for innovative and courageous strategies to recruit more new graduate nurses, including under-represented Māori, into the ageing primary health nurse workforce.

I

t is well documented that New Zealand’s primary health care sector is under increasing pressure with an ageing GP/ practice nurse workforce and reduced access to services in some communities. BERL’s 2013 nursing workforce projection report for the Nursing Council of New Zealand predicted that more than 50 per cent of the present nursing workforce will retire by 2035. Increasing the supply of new graduate nurses into primary care is one way to build a sustainable workforce. However achieving this requires an understanding of the current structural and systemic influences impacting on new graduate recruitment in the primary care sector. Since around 2006 the Nursing Entry To Practice (NETP) programme has provided a government-subsidised, supportive framework for new graduates across the district health boards (DHBs). In 2008, the the NETP programme was expanded to include primary care which gave new graduate nurses the opportunity to work in primary health without previously working in a hospital or other setting. In 2012 the Nursing Advanced Choice of Employment (ACE) system was introduced enabling graduates to apply online for NETP places in multiple DHBs using one application. Graduates can also identify up to three preferred practice settings. Primary care is a popular choice and ranks as one of the top four preferred practice settings for new graduate nurses (after surgical, medical and mental health nursing). Another advantage of ACE is that nationwide recruitment data is now available but the NETP statistics show that, despite the interest shown by new graduate nurses, the number recruited into primary care has been disappointingly low. This, by and large, reflects the lack of resources in the primary care sector to

support the recruitment and retention of new graduates. The current support resources available are largely administered through the DHBs, are non-flexible and focus exclusively on new graduates on NETP. This limits the primary care sector’s ability to develop sustainable workforce planning including areas like the retention and development of clinical leaders, increasing undergraduate placements, and wider practice team development (like whānau ora workers/nurse practitioners/pharmacists/ health care assistants/general practitioners/ administrators). Recent initiatives to increase the uptake of new graduate nurses into primary care include the Ministry of Health’s new graduate nurse employment (scholarship) scheme in Very Low Cost Access (VLCA) practices serving high needs populations. The investment involved one-off extra funding of $2.4 million to employ and pay salaries for 48 new graduate nurses for 12 months in qualifying VLCA practices. The 2015 evaluation suggests that the scheme provided a valuable pathway for supporting new graduates into primary care. Further attention to this area would be valuable. There are other health workforce strategies – nationally, regionally and locally – with a focus on increasing new graduates in primary care and, more specifically, on increasing the uptake of Māori new graduates. These include DHBs’ District Annual Plans, the DHBs’ Māori Health plans, workforce reports and policy documents. But workforce data suggests that strategies designed to increase the number of Māori in the health and disability workforce have had little impact on Māori workforce participation rates. The National Nursing Organisations group (NNO), a group made up of New Zealand’s key nursing stakeholder organisations,

32    Nursing Review series 2016  |  www.nursingreview.co.nz

prepared a report in 2014 on nursing issues for Health Workforce New Zealand (HWNZ). That report identified a number of key recommendations including employment of more new graduates, improved employment of new graduates in the aged care and primary care sectors and improved employment of Māori and Pacific new graduates. Last year the HWNZ Nursing Governance Group set 2028 as the date for matching the Māori nursing workforce to the percentage of Māori in the population. To achieve this there needs to be short, medium and longterm strategies and goals, coupled with a whole-of-system approach and adequate, sustainable resourcing. Recent ACE figures indicated 821 new graduate nurses (57 per cent) were known to be employed by late January 2016 and 630 were still looking for work through the Nursing ACE system. Of those 630 jobhunting new graduates 84 were Māori (13 per cent). A key target should be 100 per cent recruitment of all Māori new graduate nurses as the data suggests that even if we did recruit all Māori new graduates we would still fall short of achieving equity. If we want to achieve results for increasing new graduate nurses in primary care, with a focus on 100 per cent recruitment of Māori new graduates, we need to be courageous, try innovative approaches and focus on results. Author: Lorraine Hetaraka-Stevens is a College of Nurses board member. She is the nursing director for Auckland’s ProCare primary health organisation and nursing director of the ProCare and Pegasus-owned teletriage organisation Homecare Medical. N.B. References for this article are available online: www.nursingreview.co.nz.


HELP PREVENT PNEUMOCOCCAL DISEASE IN YOUR HIGH-RISK ADULT PATIENTS 1

Recommended dosing: One dose of Prevenar 13 followed no less than 8 weeks later by 23PPV. Note some conditions may recommend more than one dose of Prevenar 13 be given.2

References: 1. PHARMAC Hospital Medicines List. http://www.pharmac.govt.nz/HMLOnline.php?osq=Pneumococcal. Accessed 7 August 2015. 2. Immunisation Handbook 2014. http://www.health.govt.nz/publication/immunisation-handbook-2014 accessed 31 August 2015. Prevenar 13 has risks and benefits. Prevenar 13® (Pneumococcal polysaccharide conjugate vaccine, 13-valent adsorbed) suspension for I.M. injection. Contains 30.8 μg of pneumococcal purified capsular polysaccharides conjugated to non-toxic diphtheria CRM197 protein. Indications: Active immunisation for the prevention of disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F in adults and children from 6 weeks of age. Contraindications: Hypersensitivity to any component of the vaccine, or to diphtheria toxoid. Allergic or anaphylactic reaction following prior administration of 7vPCV. 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 acute, moderate or severe febrile illness. Only protects against Streptococcus pneumoniae serotypes included in the vaccine and may not protect all individuals from pneumococcal disease. Consider the risks of intramuscular (IM) injection in infants or children with thrombocytopenia or any coagulation disorder. Appropriate treatment and supervision must be readily available in case of a rare anaphylactic event. Prophylactic antipyretic medication is recommended for children receiving concomitant whole-cell pertussis vaccines and for children with seizure disorders or history of febrile seizures. Consider the potential risk of apnoea when administering to very premature infants. Adverse Effects - Very common/common: Children 6 weeks to 5 years: Injection site reactions (redness, pain, swelling), fever, diarrhoea, vomiting, decreased appetite, drowsiness/increased sleep; restless sleep/decreased sleep, rash, irritability. Children and adolescents 5 to 17 years: Irritability, injection site reactions (redness, pain, swelling), somnolence, poor quality sleep, injection site tenderness (including impaired movement), fever, decreased appetite, vomiting, diarrhoea, headaches, rash. Adults: Diarrhoea, vomiting, chills, fatigue, injection site reactions (redness, pain, swelling), limitation of arm movement, fever, new or aggravated joint or muscle pain, decreased appetite, headaches, rash. Adverse Effects - Serious: Hypersensitivity reaction; anaphylactic/anaphylactoid reaction including shock; angioedema; erythema multiforme. Seizures, hypotonic-hyporesponsive episode in children. Others, see full Data Sheet. Dose: 0.5 mL I.M. Infants 6 weeks to 6 months of age: 3 doses at least one month apart. A single booster should be given in the second year, at least 2 months after the primary series. Previously unvaccinated children: Varies with age at first dose, see full Data Sheet. Children aged 12 months to 17 years who have completed primary infant immunisation with 7vPCV and children 6 to 17 years who have received one or more doses of 7vPCV may receive 1 dose, at least 8 weeks after the final dose of 7vPCV. Adults: 1 dose. If sequential administration of Prevenar 13 and 23vPPV is considered, Prevenar 13 should be given first. High Risk Individuals: Up to 4 doses, depending on condition. The dosing schedule should be guided by official recommendations. Medicines Classification: Prescription Medicine. Prevenar 13 is a fully funded prescription medicine for children up to 59 months inclusive as part of the National Immunisation Schedule and for older children and adults with certain immunosuppressive conditions (see PHARMAC criteria - Online Pharmaceutical Schedule). For individuals not meeting these criteria, Prevenar 13 is an unfunded prescription medicine – a prescription charge may apply. Before prescribing, please review Data Sheet available from MEDSAFE (www.medsafe.govt.nz) or Pfizer New Zealand Limited, Auckland (www.pfizer.co.nz) or call 0800 736 363. ® Registered Trademark V10715. In pneumococcal-vaccine naïve adults aged 18-49 years, percentages of solicited local and systemic reactions were generally higher compared with older subjects (aged 50-59 and 60-64 years). Limited safety and immunogenicity data on PREVENAR 13 are available for patients with sickle cell disease, or HIV infection, and are not available for other immunocompromised patient groups. Efficacy/ effectiveness has not been established. Immunocompromised individuals or individuals with impaired immune responsiveness due to the use of immunosuppressive therapy may have a reduced antibody response to PREVENAR 13. Vaccination should be considered on an individual basis. Pfizer New Zealand Limited, Level 1, Suite 1.4, Building B, 8 Nugent Street, Grafton, Auckland 1023. ® Registered Trademark. DA1536YL. BCG2-H PRE0328, resize of PRE0306. PP-PNA-NZL-0002. 08/2015.


eat most milk, yoghurt, cheese use some oils, nuts r ods o Cut baCk on junk o f & s y a w a foods, take

fa ts

fish, meat, chicken, legumes, eggs

wholegrain & high-fibre tr an s

starchy vegetables

lean & skinless

&

eat some bread, cereals, grains,

a variety of colours

ed

vegetables & fruit

t ra u at s r reduced fat to l a ,s r a ug s in h g i sh k n dri

simple steps to healthier

eating


Nursing Review April 2016