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FOCUS: Summer Edition

Nursing Review VOL 13 ISSUE 2 2012/2013

NEW ZEALAND’S INDEPENDENT NURSING SERIES

Q&A

PRACTICE, PEOPLE & POLICY

DISASTER MAGNET?

with Associate Health Minister Jo Goodhew

PRIMARY HEALTH

NURSE’S TIPS ON BUYING A GENERAL PRACTICE

PROFESSIONAL DEVELOPMENT SPEAKING UP AND OUT A DAY IN THE LIFE OF a Christchurch Plunket nurse

REPORT CARD NURSES ASSESS 2012

RESEARCH

ED’s reluctant ‘frequent fliers’ Phone contact keeps frail elderly home?

GEN Y NURSES Old-fashioned values & modern loyalties www.nursingreview.co.nz

! R RRUTR.E.

T S OMO S A MISFOR L E N’CTRIBE H T DSOUBS


ONLY PREVENAR 13 PROVIDES COVERAGE AGAINST THESE 3 STRAINS. 1-3

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

®

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


LETTER FROM THE EDITOR Communication – one of the 6Cs Speaking up and speaking out for the sake of your patients and yourself are concepts tackled in this edition. In our RRR professional development article Shelley Jones explores talking about practice as a way of keeping yourself, your colleagues and your patients safe. Jo Ann Walton in her column, Compassion, criticism and complaints, calls for a conversation about compassionate care in the wake of stories of patient neglect both here and abroad. It is the UK’s beleaguered NHS that has been the focus of too many of those stories leading to the upcoming Francis Report (due January). At the same time, the Royal College of Nursing has been accused of scaremongering with its November estimates that more than 55,000 NHS jobs have been axed or will be across the UK, with nursing posts making up a third of those. Meanwhile, in early December, England’s two top nursing leaders released Compassion in Practice their vision for nursing, midwifery, and care staff in England’s public health system. The pair acknowledges “there are big challenges” but “we must never underestimate our significance”. “As health and social care changes, what does not alter is the fundamental human need to be looked after with care, dignity, respect and compassion.” Their vision is built on the 6Cs: care, compassion, competence, communication, courage and commitment. (Read more at: http://bit.ly/ YBeUPo ) Also in this edition, College of Nurses executive director Jenny Carryer looks back on 2012 as well as paying tribute to outgoing colleague, NZNO chief executive Geoff Annals on his leadership role in helping nursing groups here reach another “C” – cohesion. And Frances Hughes reports on disasters with a capital D after fate landed the disaster management scholar in the path of Hurricane Sandy.

Inside: FOCUS: Summer Edition

4 2012: Nurses assess the year that was 6 ISABEL JAMIESON on what makes Gen Y nurses tick 8 KIM CARTER on buying a general practice 10 Child Protection: Training to step up to the challenge 18 Aged Care: Stopping the dominos ‘toppling’ 19 KATHY NELSON on ED’s reluctant ‘frequent fliers’

RRR professional development activity 13 Talking about practice: A way to keep yourself, your colleagues and your patients safe

People, Practice, & Policy 23 JO ANN WALTON on conversing on compassion

24 SANDY RICHARDSON on nursing quake research

25 FRANCES HUGHES unplanned disaster ‘action research’

Regulars 2 Q&A profile: JO GOODHEW, Associate Health Minister 3  A day in the life of… Plunket nurse MARIA BROWNE 21  Webscope: KATHY HOLLOWAY on being informed and informing 22 Evidence-based practice: ANDREW JULL reviews replacing IV lines 26  College of Nurses column: JENNY CARRYER on battles and bouquets in 2012 27 For the record: News round-up

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 ADVERTISING Belle Hanrahan For avid readers of our RRR professional development articles (see centrefold), this issue is the last time you’ll see RRR unless you subscribe to Nursing Review. RRR is worth 45 minutes of professional development for RNs each issue, so don’t delay in subscribing – otherwise, you’ll miss a golden opportunity for PD next year. Visit www.nursingreview.co.nz and click on the ‘Subscribe’ link.

www.nursingreview.co.nz Twitter@NursingReviewNZ COVER PIC: Researcher Isabel Jamieson explores Gen Y nurses views on the profession on p.6.

PRODUCTION MANAGER Barbara la Grange LAYOUT Jay Tweedie EDITOR-IN-CHIEF Shane Cummings PUBLISHER & GENERAL MANAGER Bronwen Wilkins PHOTOS Thinkstock

NursingReview

Vol. 13 Issue 2

APN Educational Media Level 1, Saatchi & Saatchi Building 101-103 Courtenay Place Wellington 6011 New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 Fax: 04 471 1080 © 2012. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014

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

Nursing Review series Summer Edition 2012/2013

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Q&A

with Jo Goodhew

JOB TITLE | Minister for the Community and Voluntary Sector, Senior Citizens, Women’s Affairs and Associate Minister of Health

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

Q A Q A Q A

about people. Nurses need excellent communication skills, as do politicians.

Where and when did you train? I qualified RGON at Timaru Hospital in 1982.

Q

Do you still consider yourself a nurse? And if so, how does this influence your work as a politician? I think my nursing career was such a significant part of my life, therefore, I will always think a bit like a nurse. Caring about the plight of constituents and looking for ways to make the lives of individuals or many better, is a similar task for nurses and politicians. The difference is the “public” nature of the politician’s life and work.

Other qualifications/professional nursing roles and honours? BN from Otago Polytechnic 1995 (distance learning).

A

When and/or why did you decide to become a nurse? My mother was a karitane nurse and great-aunt and cousin registered nurses, but it was actually a last-minute decision when I decided not to go to university. It was a decision I never regretted for one minute.

Q

What do you think are the characteristics of a good leader? And are they intrinsic or can they be learned? Good leaders need great communication skills, determination, vision and courage. Some of these characteristics are intrinsic but can be further developed; some are learned.

A

Q A

What was your nursing career before entering politics? After finishing my training, I worked in a geriatric ward in Timaru hospital and then moved to Dunedin where I worked in neurosurgery/neurology until travelling overseas. While in the UK, I did agency nursing in private homes and some private hospitals in London. On my return, I went back to the same neuro ward in Dunedin followed by acute orthopaedics. I then shifted to Napier Hospital and worked in the general surgery and gynaecology wards. After getting married I returned south working at surgical wards in Timaru Hospital before leaving to spend 11 years practice nursing. I left nursing in 1998 and was working in crime prevention prior to campaigning for election in 2005.

Q A

Share a moment when you felt particularly proud to be a nurse. I was privileged to have many moments when I felt proud to be a nurse. The first time I delivered a baby, albeit I was very carefully assisted and supervised. The privilege of nursing patients through their final days. The time when I played my role in nursing sick young children back to health. The times when I worked in the special care unit in neurosurgery in Dunedin, challenging, but rewarding work.

Q A

Briefly outline your current role and responsibilities., The first three ministries are probably self-explanatory. As Associate Minister

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Nursing Review series Summer Edition 2012/2013

Q

What advice would you give to a nurse wanting to follow in your footsteps and enter politics? No reason why not, but you will need patience, determination and loads of energy (and a thick skin!).

A I think my nursing career was such a significant part of my life therefore, I will always think a bit like a nurse. of Health I have delegated authority for: public health, aged care, certification of healthcare services (Health Cert), and oversight of Health and Disability (Safety) Act; Health Quality and Safety Commission; Health Promotion Agency; rural health; and assistance with primary healthcare policy and implementation.

Q

Was nursing a good grounding for your subsequent political career? If so, what nursing skills and experience were the most useful? Trying to understand the issue an individual or group is dealing with requires the ability to listen and care

A

Q A

What do you do to try and keep fit, healthy, happy and balanced? I try to exercise at least five times per week and try to eat a healthy diet (and fail sometimes!). I put time aside in my diary for family and friends as those relationships are very important to me.

Q A

What is your favourite way to spend a Sunday? Sunny day, long walk, brunch with family and/or friends, time reading for pleasure, or a movie.

Q A Q A

What are three of your favourite movies of all time? Shrek, Out of Africa and Gloomy Sunday. What is number one on your ‘bucket list’ of things to do? See the Lipizzaner horses at the Spanish riding school in Vienna.


A day in the life...

OF A PLUNKET NURSE

NAME | Maria Browne JOB TITLE | Plunket Nurse LOCATION | East Christchurch

06:50

AM WAKE I wake ten minutes before my alarm goes off and think through my own and the family’s day in my head. I rise at 7am and knock on the three teenagers’ doors. At least two of them will need another reminder it’s morning in another ten minutes. I grab a quick coffee and toast as I read The Press headlines. We live in Avonside, a badly damaged part of Christchurch, which has implications for the teenagers regarding schools and transport.

08:15

AM START WORK I arrive at work, greet my colleagues and quickly check the messages. I then gather my files for the day, check in with the health worker and check whether there are any new baby referrals. I’ve been working for Plunket for seven years completing my postgraduate certificate in primary healthcare nursing in 2006 and a health sciences postgraduate diploma this year. During that time, I have worked as a Plunket nurse and also spent several years in a clinical advisor role. I thoroughly enjoy my job and my recent decision to return to frontline care delivery has been primarily led by a desire to support families in the community post-quake plus a drive to begin my journey towards nurse practitioner. On a daily basis, my colleagues and I drive around badly broken streets, negotiate road works and detours, and see houses we have visited demolished. However, at the same time, new lives are starting in the area and families are moving in with their young families as Christchurch rebuilds. The sense of community is strong, and as a Plunket nurse, I feel privileged to be part of this community.

ON ROAD Each day is very busy. I mostly visit my clients at home and view being welcomed into families’ homes as a privilege as well as an opportunity to individually plan the level of service and support the family requires. This morning, I undertake four home visits. The first client I call in to see I met three weeks ago when I enrolled the family with Plunket. This baby is now seven weeks old but was born early at thirty-two weeks and spent several weeks in the neonatal unit. I check in with the mum as to how a referral I made for her has gone, and I watch a feed after weighing the baby. The baby’s latch and milk transfer seem much improved and his growth is well within the expected range. I affirm this fantastic progress and congratulate the

mum for her determination to establish and maintain breastfeeding. The next family I visit is a second visit with a young teenage Afghani mum and her eight-week-old baby. This mum is gaining confidence as her mother, who she lives with, has returned to Afghanistan for three weeks. But she is very relieved to see me, as she is desperate to bath her wee one and doesn’t feel confident enough to do it by herself. I offer for Maree the Plunket kaiawhina to call in the next day to guide her through bathing her son. I also discuss a referral for a BCG vaccine with her and she is positive and receptive to my visit, asking lots of questions. At the next visit – to the home of a threemonth-old and a two-year-old – I am greeted by a tearful, overwhelmed mother. When I undertake the postnatal depression screening, it is clear that the combination of sleep deprivation, a recent breast infection and a two-year-old using new found tantrum skills have taken their toll. We talk, focusing particularly on the supports she has and her experience with postnatal depression with her first baby. She expresses her fear that this depression may be setting in again. As a result, I refer her to her GP for further assessment and to our Plunket postnatal adjustment team for further support. The final visit for the morning is a WellChild check with a four-month-old who is thriving.

I assess his growth and development, affirm the family’s parenting, discuss appropriate timing for the introduction of solids, link them with a new playgroup being set up in the area, support ongoing breastfeeding and provide anticipatory guidance regarding safety.

12:30

PM LUNCH I return to clinic for a much-anticipated cup of coffee and lunch, touch base with colleagues, complete my morning’s documentation, and head out on the road again.

1:00

PM ON ROAD AGAIN My next visit is a new baby case; the family live on a street which is having major repairs. My visit necessitates a five hundred or so metre walk with the scale bag on my back. These initial visits involve gaining a full history of the family health determinants, initiating a therapeutic relationship, assessing the family’s needs, and planning care. I spend a little longer at this household today as this client’s sister is visiting with her two children, who are also clients, so I provide WellChild assessments for them, too. After this visit, I meet with my clinical leader to review complex high-need cases and collaboratively review my plan of care including preparing a CYF (Child, Youth and Family) request for information.

4:00

PM BACK TO OFFICE I make it back to the clinic by four and complete my paperwork and any necessary referrals, before checking tomorrow’s schedule and initiating a few text reminders. Just as I leave work, I get a text from my son; “just want it noted the mess in the kitchen has nothing to do with me!” – the joys of teenagers.

5:15

PM LEAVE WORK After preparing dinner with my partner and checking in with the kids’ days over dinner, I manage a quick walk around our river loop. Then I spend a little while on the computer sorting PTA emails and also critiquing an article I am preparing for Plunket’s Care Delivery News publication outlining a systematic literature review on screening for family violence. I then blob briefly in front of TV and touch base with my partner as the kids have headed to bed.

11:00

PM TIME TO SLEEP

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FOCUS n Summer Edition

Summer Edition FOCUS: Nursing Review kicks off its summer edition with nurses looking back on the year that was. Then we round off the year with a good summer read on the generation gap to ED ‘frequent fliers’ and child protection training to buying your own general practice.

2012:

It’s been a year when the new graduate job market remained tough, funding squeezes started to take a toll, and a new generation of enrolled nurses graduated. A year where registered nurse prescribing inched closer, the milestone of more than 100 nurse practitioners was met, non-nursing roles like physician assistants and practice assistants were pushed, and there was continuing high interest in nursing school enrolments. A year when new innovative nursing

roles and practice developed but also when barriers – real and artificial – still frustrated nurse-led services. It has been a year when Indian nurses went on a hunger strike over registration, some aged care nurses took industrial action, and district health board (DHB) nurses voted for a 4.5 per cent pay increase spread over three years, while still seeking safe staffing. In the wider health arena, more government health targets were met, DHB budgets

constrained, pushes for alcohol and tobacco control had mixed success, residential aged care kept making headlines for the wrong reasons, a new mental health blueprint was released, Whānau Ora models evolved, the White Paper for Vulnerable Children was released and much, much more. Nursing Review asked a number of nurses to give us their report card on how nursing and health scored in 2012.

TAIMA CAMPBELL Consultant & senior teaching fellow University of Auckland (former director of nursing at Auckland District Health Board), Auckland

‘nibbling’ at the problem. The ‘agenda’ isn’t that well hidden – just get on with it.  Reducing inequalities in health care for Māori and Pacific. Again another area where the rhetoric doesn’t match the reality. Actions speak louder.  Goals for 2013: Improvements in health care will come from Māori leadership and involvement in the way our system is designed, on the ways services are best delivered and by practitioners who are better able to engage with the people who need our care. So Māori clinical leadership and workforce development are still high on my list.  Health public policy has a role to play in improving health care. Changes to alcohol law reforms were a bit of a failure, tighter tobacco legislation is going to help with quitting and prevent people starting, and there is more work to do to ensure practitioners are not hamstrung by legislation making it harder to do their job. So getting nurses fired up about policy is on my list for next year.

morbidities (and/or their behaviours), and we need their help and expertise for crisis management and prevention.

Nursing and health in 2012 made great strides forward in: Contributing to patient safety initiatives and improved hospital patient experiences. Participating in new and innovative models of care such as the registered nurse first surgical assistant and diabetes nurse prescribing. Taking the lead on providing better care for the elderly, particularly in residential care. Being entrepreneurs and starting their own primary health care businesses rather than being the employed practice nurse. Passed but could do better: Speaking up for the most vulnerable people in our population, particularly our children. Nurses gave feedback on the Government’s policy on vulnerable children, but there needs to be more action and advocacy if there is to be any change. Supporting Hone Harawira’s bill for lunch in schools and better housing would be a good place to start.  Areas showing initial promise but failing to deliver in 2012: Primary health care. The Government and various ministers have talked about how nurses can contribute to better primary healthcare but – as a nurse and consumer – I just don’t see it (with the exception of communities where disruption has resulted in innovation). Good on the nurses who have used their own initiative and become partners in their own general practice and community. We need more pioneers like this.  Failed abjectly: To reduce the district health board bureaucracy. It’s simple – we don’t need three DHBs in Auckland. The process of ‘regionalisation’ is a long, protracted way of 4

Nurses review the year that was …

Nursing Review series Summer Edition 2012/2013

VAL WHATLEY Clinical manager Parkwood Rest Home and Hospital, Christchurch

Areas showing initial promise but failing to deliver in 2012: Highlighting areas for improvement within aged care. Failed abjectly: Promoting any positive aspect of aged care nursing as relevant, vibrant, hardworking workforce under very trying difficult circumstances. Continued denigration of aged care nurses and trial by press. Goals for 2013: Recognition of role of aged care registered nurse as career pathway instead of denigration. Promotion and recognition of partnership between acute sector/primary health and aged care – not ‘us’ and ‘them’ – so we can get the best possible outcomes for residents/patients. The acute sector areas cannot handle our residents and their multiple co-

ROSEMARY MINTO Nurse practitioner Chair of the College of Primary Health Care Nurses NZNO, Tauranga

Nursing and health in 2012 made great strides forward in: Providing excellent quality nursing services to New Zealand population. Improving the performance management target results (most of this work is completed and often managed by nurses being willing and able to provide innovative models of care, for example, Horowhenua Clinic in MidCentral DHB, Waves in New Plymouth, Evolve in Wellington, and Victory Community Health Centre in Nelson). Areas showing initial promise but failing to deliver in 2012: Nurse practitioner numbers are growing but visibility is not – the Medicines Bill has failed to help NPs deliver better sooner more convenient care. Failed abjectly: To advocate for nursing to be included in all levels of governance and funding and planning management teams consistently across DHBs and PHOs. To gain any additional funding for NPs or indeed recognition from/by Health Workforce New Zealand. HWNZ fund the clinical master’s degree programmes and then ignore the need for an internship programme to imbed clinical practice and support into workplaces. Also engaging consumers in the debate around using nursing to solve health service delivery issues. Goals for 2013: To have all legislative barriers for NPs removed or solved. To have nurses involved at every level of service planning for innovation and delivery moving forward on the Government’s drive for integrated health services.


FOCUS n Summer Edition

To have consumers engaged in the discussion around what they want to see in their local health service including the nursing contribution.

DR JILL CLENDON NZNO nursing policy advisor/researcher Nelson

Nursing and health in 2012 made great strides forward in: Developing systems to measure new graduate jobs and availability of jobs (although this identified a range of issues, at least there is now a system in place). Nurses in schools – increased funding to see nurses in all decile 1 to 3 secondary schools. Cancer nurses – increased funding to roll out a case management approach to cancer care. Health Research Council funding for a Māori nurse smoking project. Recognition by the Human Rights Commission that pay and conditions for those working in the aged care sector are discriminatory. Passed but could do better: Nurse-led clinics – mixed success with the closure of Waves, but the proven impact of Horowhenua nurses providing safe and effective care to local people due to a lack of??????? GPs. Intro Areas showing initial promise but failing to deliver in 2012: The White Paper for Vulnerable Children – initial promise but failed to recognise the work of nurses with vulnerable children or provide specific direction for nurses’ roles working with children in the future. Failed abjectly: Few jobs for NPs. Health Workforce New Zealand and physician’s assistants – why is HWNZ prioritising this workforce at the cost of NPs? HWNZ generally – mandated to do workforce planning but absolutely no evidence of this. Goals for 2013: Get the changes to the Medicines Act implemented. Keep pushing HWNZ to recognise the essential work that must be done regarding nursing workforce projections and get them to do it. Keep pushing for improved accessibility to funding for nurse-led clinics. Make more visible the value of nursing to improved health outcomes (evidence for investment in nursing campaign). Get nurses engaged in the district health board elections – make safe staffing an election issue.  

ROSE STEWART National Nursing Advisor Family Planning, Wellington

Nursing and health in 2012 made great strides forward in: Nurse prescribing – the Nursing Council have taken on board the directive from Ministry of Health to set up prescribing for RNs. There are many nurses routinely supplying medication under standing orders that means access for patients is much better. They already need to make the clinical decision and so are well prepared in many cases. Nurses with appropriate training can take on the responsibility for prescribing

Passed but could do better: Nursing organisations are working very well together after years of silo activity. Areas showing initial promise but failing to deliver in 2012: Because there are approximately 45,000 nurses, it is critical that nursing continues to develop mechanisms to coherently contribute to health policy and strategy at a national level. Failed abjectly: Getting authorised prescribing for nurse practitioners – a no brainer – taking too long. Goals for 2013: RN prescribing and authorised prescribing for NPs.

JUDY YARWOOD Research leader, CPIT nursing school Co-chair of College of Nurses Aotearoa, Christchurch

Nursing and health in 2012 made great strides forward in: Authorised prescribing for nurse practitioners (well nearly). Passed but could do better: Understanding significance of NPs role in PHC, particularly in rural and remote locations. Areas showing initial promise but failing to deliver in 2012: Primary health care’ in nursing missed the boat as the ‘primary care’ reign continued unabated with its focus of treatment of disease. Meanwhile, social determinants of health such as education, employment, housing and poverty mostly remained in the too-hard basket. Failed abjectly: Addressing inequalities, rheumatic fever and diabetes. Goals for 2013: Make PHC a priority, that is, make it accessible, affordable, and acceptable for all.

SHELLEY FROST Pegasus Health director of nursing General Practice New Zealand deputy chair, Christchurch

Nursing and health in 2012 made great strides forward in: With my Pegasus Health director of nursing hat on, I am delighted to report that nurses are now full members of Pegasus, strengthening their voice and influence within the primary care network and the Canterbury health system as a whole. Nationally, I believe nurses have continued to make a significant contribution to leadership in primary care. There is increasing acknowledgment of the value nurses add within the primary care team and this is well evidenced in groups such as the General Practice Leaders Forum and national network organisations. Passed but could do better: The opportunities inherent in the “better sooner more convenient” context are yet to be fully realised. There are pockets of significant success with boundaries between disciplines and agencies becoming blurred, changes

from traditional practice, and a new ethos of collaborative partnerships breaking across old barriers. Consequently, the nursing role is becoming more dynamic and more complex. Learnings from such developments need to be shared and further built upon.  Areas showing initial promise but failing to deliver in 2012: Certainly in primary care we have not maximised the potential of either the enrolled nurse or NP workforce. It has been disappointing to see the introduction of new roles when we are not utilising our existing workforce to full potential. Failed abjectly: Giving up is the only sure way to fail, and I don’t believe nurses will ever give up! Goals for 2013: Strengthen the professional development and support of nurses to maximise their contribution to the delivery of quality patient care in the community, alongside other members of the primary care team. Build leadership capacity and capability within the primary care nursing workforce. Maximise opportunities for nursing contribution and influence at a national level.

ANNETTE MILLIGAN Director of workplace health and safety provider Nelson

Nursing and health in 2012 made great strides forward in: Seemed like a steady year – and in my area, hard to see where gains were made … steady year … Areas showing initial promise but failing to deliver in 2012: White Paper – while nurses have led many initiatives in protecting children, we have been left out again in the White Paper. Nurses barely get a mention, and overseas models in which nurses make a significant contribution seem to have been passed over. Goals for 2013: Keep nurses right at the forefront of health – nursing has yet to reach anything like its potential in the contribution to health and well-being. We need to work together to keep nursing in the minds of policy and decision makers.

GRACE WONG Smokefree Nurses Aotearoa/ New Zealand director Auckland

Nursing and health in 2012 made great strides forward in: Smoking cessation training to achieve a smokefree New Zealand by 2025. About a quarter of all New Zealand nurses (n=12,758) have completed the free Ministry of Health online ABC education. This is a fantastic tribute to the readiness of nurses to enhance their practice. Goals for 2013: More nurses ABC trained. All nurses who have trained delivering brief smoking cessation interventions to patients who smoke. Together nurses can tip the balance for a smokefree New Zealand. Nursing Review series Summer Edition 2012/2013

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FOCUS n Summer Edition

GEN Y NURSES:

HAPPY TO BE NURSES … but for how long? Most young nurses are passionate about their career choice – ­­ for now, at least. As many feel little long-term loyalty to a profession that leaves them feeling tired, stressed, and underappreciated, FIONA CASSIE talks to researcher Dr Isabel Jamieson about the workforce implications of her survey of more than 350 Generation Y nurses.

L

ounging on the beach with your iPhone, thinking up creative solutions for the world’s problems, is the stereotype of the ideal Generation Y job. Gen Y nurses can’t do that, and neither do they want to, found nurse researcher Isabel Jamieson. Instead, young Kiwi nurses want to be at the bedside making a difference by providing handson nursing care. They share the traditional values of altruism that’s motivated generations of nurses – just, it appears, not the old-fashioned notion of vocation. Intro ??????? Although passionate about their career choice now, like many of their Gen Y peers, life-long loyalty to a profession is another matter. Jamieson says this, and other findings about what motivates and concerns this newest generation of nurses, has major workforce implications if the profession, employers, and policy makers don’t work together to create a workplace and work conditions that keeps Gen Y nurses nursing. With an average age of 25, and four years experience, or fewer under their belt, her respondents were young nurses happy to be nurses but not happy about excess stress levels, workplace bullying, salaries, the impact of shift work, and baby boomer nurses telling them they are not well prepared. And to cap it all off, nursing only ticks off some of the boxes of what Gen Y want from a long-term career. Jamieson, a senior lecturer at Christchurch Polytechnic Institute of Technology, set out in her PhD research to find out the views of New Zealand Gen Y nurses towards nursing, work and career. Her online survey was sent out in late 2009 to nearly 540 New Zealand registered nurses born between 1980–1988 and drew 358 responses – a twothirds response rate and a sample equivalent to nearly ten per cent of the total cohort of Gen Y nurses.

Why nursing?

So what motivated these children of Baby Boomers – a techno-savvy generation negatively stereotyped by some as too casual and praiseseeking – to go into nursing? Jamieson found the old-fashioned ideals of being able to help others, work closely with people, and contribute to society were major motivators for Gen Y nurses, along with nursing being seen as “interesting”, “challenging”, and “exciting” work. 6

Nursing Review series Summer Edition 2012/2013

Rated as less important but still important factors were the more extrinsic rewards of starting salary, flexibility of hours, chances for promotion, autonomy, job security, and being able to combine nursing work with family commitments. Family, friends, career advisors, or teachers had little part to play in their decision to go into nursing. Once out in the workplace, the vast majority did not regret their career choice and many spoke of their passion for nursing. “This cohort was overwhelmingly proud to be nurses, which is great to know they are really happy that they have chosen nursing,” says Jamieson. “Nursing would appear to be attracting young people who are entering nursing for all the right reasons … they are altruistic in nature, which is also supposed to be a characteristic of Gen Y.” When asked about their five-year career plan, the majority were keen to remain at the bedside gaining clinical experience, with a number looking at postgraduate study and looking for promotion, including working their way through the professional development recognition programme (PDRP) process. Surprisingly to Jamieson, only about 40 per cent of these young nurses were looking to work overseas, and even then, they weren’t racing to start their OE in a big hurry and most planned to return after one or two years away. “I was wondering whether programmes like NETP (nursing entry to practice) was retaining them in New Zealand in those early years and also whether constraints like work visas and increasing barriers to working in Britain is encouraging them to stay.” It is what happens after that five-year plan is fulfilled that Jamieson believes the profession and workplaces should be worried about. This is a cohort of proud nurses who view themselves as career-motivated but are less clear whether nursing will be their long-term career. Forty-four per cent feel no pressures to keep them in nursing, only half think it would be too costly to change profession, only 22 per cent are in nursing because of a sense of loyalty to the profession, and only 20 per cent believe that people educated in a profession should commit to that profession for a “reasonable time”.

What ends the honeymoon with nursing? “What happens with this cohort is that they are wildly enthusiastic when they first start,” says Jamieson.

GENERATION GAP Veterans born 1925–1945 Baby Boomers born 1946–1965 Generation X born 1966–1979 Generation Y born 1980–1994 Generation Z born 1995+ NB: generation definitions used in Jamieson’s PhD thesis

Suggested characteristics of Gen Y »» »» »» »» »» »» »» »»

Work-life balance matters Favour flexibility in the workplace Workplace culture important Value mentorship Want regular feedback from managers Like change and variety Computer-savvy and fast learners Children of the Baby Boomers

“But within one year, the honeymoon is well and truly over and they are considering other options …” So what dampens the enthusiasm? Jamieson found stress and tiredness was taking its toll on a generation who values work-life balance highly. “They wanted rosters and a workload that didn’t mean they had to spend their days off sleeping to recover,” says Jamieson. She says the young nurses showed a very fair and mature attitude in recognising they needed to leave space in their days off to ensure they were fit and ready for work. But in return, they also wanted to be allowed time to enjoy friends and family and squeeze in study. They also felt their workplace wasn’t meeting that side of the bargain by providing a work life allowing them time and energy to do both. Jamieson says Gen Y nurses are unwilling to quietly accept a workload they see as unreasonable and unsafe. “They say we need to bargain around this – if you want me to be the best nurse I can be, then I need a workload that doesn’t stress me to the max,” says Jamieson. “Because they want to be very good nurses, they want to put into practice everything they have learnt.” The realities of shiftwork are more of a challenge than expected and enough to turn some off the profession.


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“I guess that suggests that more needs to be done in undergraduate programmes to better prepare those student nurses for the realities of shiftwork.” Another solution, once they are in the workplace, is for young nurses to be given strategies on how to cope with shiftwork and ensure they understand their part in the ‘big picture’ of how their unit and hospital is run. Young nurses are also seeing high levels of bullying amongst their nursing colleagues, with 37 per cent report having seen evidence of bullying on their ward. “It’s a lot and it’s not good enough,” says Jamieson. “I don’t think it’s unique to nursing, but it needs to be addressed as the downstream effect is catastrophic.” Generation gap tensions are also evident. As despite it now being nearly 40 years since nurse training first started moving away from hospitals and into the tertiary sector, there is still some tension between the hospital-trained baby boomers and tertiary-trained nurses. Jamieson says one Gen Y respondent potentially summed up the tension well by saying, “there seems to be an inherent thinking

that we’re incompetent as new graduates, yet we’ve been spending three years demonstrating that we’re competent.” It is also clear that the disrespect often goes both ways. “Possibly, it’s a reflection of their age and stage. However, there seems to be an overwhelming feeling in young nurses that nurses in management (like clinical nurse managers) are seen to be there because they failed at the bedside.” Most of the free comments were disparaging about senior management, and only about a third felt that management in general respected and appreciated nurses. Jamieson sees some irony in these tensions, as it is the Baby Boomers who raised Gen Y, and now they are employing and working with them. She says the literature talks of Gen Y being raised by attentive ‘helicopter’ parents who continuously gave praise and told them they’ve done well, and of a generation of children used to being given certificates for attendance and told participation, not scores on the sports field, is what matters. The literature also says that Baby Boomers and Gen Y are the closest generations ever, and generally, Gen Y and their Boomer parents get on very well. “So you would hope by default they would also get on with the older nurses really well, but they don’t. There is quite a tension.”

Would mentoring extend the honeymoon?

Intro ???????

So what else can nursing and employers do to capitalise on that initial enthusiasm and counter the negative start many young nurses are reporting? During her survey, Jamieson found an unhealthy ‘disconnect’ between what Gen Y nurses expect in a career and what they believe nursing delivers. Her respondents strongly endorsed the nine career factors identified as being important to Gen Y workers, but nursing was seen to be failing to deliver these on a number of fronts. While the vast majority saw their nursing career providing the factors of challenging work, access to ongoing education, and team work, there was a much more mixed response to whether nursing provided the creativity, regular feedback, and mentoring that they also valued highly. Jamieson found it surprising that nursing was seen not to be creative, but says the key factor for Gen Y is wanting feedback and mentorship. While two-thirds of respondents were satisfied with the way they were supervised, there were relatively low levels of satisfaction with the NETP (nursing entry to practice) programmes (54 per cent satisfied or fairly satisfied) set up to support new graduates in their first year of practice. Jamieson says NETP result should be taken with a high degree of caution, as it was just one question and few free comments were made about NETP, but respondents were clear on the desire for more feedback. “They want feedback and they want regular feedback and are quite clear that they are not getting this.” The introduction of some form of mentorship or clinical supervision (which is already part and parcel of mental health nurse practice) may be an answer to meeting this currently unmet Gen Y need. “You don’t want to throw all the support into year one and then they are dropped in it … ongoing support is important.”

Some NZ Gen Y Nurse survey findings

»» 81 per cent were proud to be nurses. »» 73 per cent are enthusiastic about being a nurse. »» 73 per cent were satisfied with the care they are able to provide. »» 58 per cent were satisfied with their salary. »» 54 per cent were satisfied with NETP (new graduate programme). »» 47 per cent find nursing work stressful. »» 39 per cent find nursing work repetitive. »» 37 per cent note that bullying of co-workers occurs.

Career commitment of Gen Y nurses

»» 64 per cent would continue to nurse even if they didn’t need the income. »» Only 3 per cent regretted becoming a nurse. »» 61 per cent consider themselves to be career motivated. BUT »» 47 per cent do not feel obliged to stay nursing. »» 48 per cent would not feel guilty if they left the profession. »» 40 per cent were considering working overseas but planned to return.

When it came to pay, they clearly wanted more. Particularly with the potential for young nurses reaching within five years the top of both the pay scale and PDRP, raising the question whether either or both should be extended. “They can plateau very quickly in their career.” Pay was important, but it wasn’t the deal breaker that the work-life balance was, and Jamieson says it is imperative that managers address Gen Y concerns about working conditions if they want to keep them in the profession

Market nursing to nurses

Nursing also has to do better at marketing the plethora of career opportunities and the flexibility of the profession to its newest recruits, believes Jamieson. In recent years, nursing has had no difficulty in attracting young people to study as nurses, but once they are at the bedside, Jamieson says more should be done to sell the profession to its newest generation. Steps that could be taken include the relative ease that nurses can move from one area of practice to another and the fluidity that allows nurses to move up and down the nursing hierarchy to meet their lifestyle needs. Nursing should also tap into young nurses’ initial enthusiasm by offering and supporting formal career planning right from year one. By mapping out a clinical career path for new graduates early in their career, the notion of nursing as a “career for life” can be promoted. The older generation of nurses also need to promote the career to those they want to step into their shoes. “But if they are feeling a bit burned out, frustrated, and overworked, they are not going to be sending good messages.” With budgetary constraints, staffing numbers challenged, and high acuity patients, it is a challenge to the whole health system to ensure nursing can be viewed as an attractive career to this next generation, says Jamieson. While Gen Y nurses are passionate now, how many of them that will still be around to mentor their children’s generation into the profession is the big unknown. Nursing Review series Summer Edition 2012/2013

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To boldly go …

Some thoughts on buying a general practice KIM CARTER two years ago boldly went where few nurses have gone before. She shares tips and encouragement for nurses considering following in her pioneer footsteps and buying a general practice.* Kim Carter (right) and Dr Kirsty Russell outside Temuka’s Wood St Surgery which they jointly own.

TIPS FOR OTHERS SEEKING TO GO BOLDLY…

The experience of the past two years has led me to some conclusions and advice that may be useful: Deal with your own internal resistance and reluctance Nurses are hugely resourceful, smart, and essential to the health service. We undervalue ourselves and often expect negative reactions. Nurses are uniquely placed to capitalise on our knowledge of the health system and the communities we serve to identify and fill gaps and meet needs. It is our greatest strength.

Intro ???????

I

t was my partner who suggested I buy a practice. Probably because she was tired of hearing about the frustrations of my professional life. Frustration at the lack of influence over my practice and that funding streams and employers had more determination over my clinical work than I did. Sitting on the deck looking at rural New Zealand, we agreed to mortgage the property and change my professional fortune. A series of events led me to rural general practice. Working with a GP colleague, Kirsty Russell, was exceptional. She had a real commitment to collaboration, interdisciplinary respect, and high standards of care. It was a satisfying experience. Also, a local GP was trying to retire. Kirsty, who had previously locumed in a sole practice, had been reluctant to “go it alone” and was keen to explore a new model of business. The light bulb went off and we decided “to boldly go” forward. Like Star Trek, it did feel like exploring new frontiers. Kirsty and I spent time developing our ideas and forming our business partnership. We had goals for the working environment we wanted to create for staff and ourselves, and the type, range, and quality of the services we wanted to provide.

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We decided on a model that split the governance and clinical roles. Kirsty and I are equal business directors and make decisions by consensus. Both of us sign off on financial transactions and business decisions to ensure transparency and safeguard our respective interests. We are both employed by the business clinically and our remuneration for our clinical work is separate from any dividends or director’s payments we receive. We have worked hard to minimise barriers to interdisciplinary practice and team work, through a strong values-based approach. We also realise the importance of work-life balance. We employ a practice adminstrator, receptionist, clinical assistant, two other registered nurses, locum GPs, and have two permanent GPs joining us next year. We have now been operating for two years. In this time, we have formed a property company, purchased and renovated a sprawling villa, plus built on a new extension from which we work. The general practice business leases the building from the property company, which provides us with security for the practice location. If the practice business should cease, or we exit the current arrangement, we still have an asset in the building that can continue to provide a return in the future.

Establishing a business is not that difficult There are many places to look to for support and advice. Health businesses are catered for by specialised teams within all the major banking institutions. Accountants and solicitors have often developed expertise, especially in communities with other general practices for whom they may be working. The Inland Revenue Department runs free courses and workshops for people entering business or keen to understand more, and education providers offer business management and accounting papers. There are opportunities everywhere Some GPs may not want to carry the burden of sole ownership, and other models have emerged that provide opportunities for nurses to invest. Community trusts, pharmacists, independent midwives, physiotherapists, and others want to be more involved and are interested in forming business partnerships with other health professionals. Be brave, ask questions, throw in a bluff or two and push to make a pathway through If you are working in general practice, start by asking your employers or business owners if they are interested in your investment, and if not, why not. Be prepared to tell anyone who will listen what you can offer and don’t downplay your earning potential. GPs and nurses bring in revenue in different ways. Sell the idea of your contribution as a strength to the business. Capitation alone does not provide financial viability for a general practice. Only 40–50 per cent of a practice’s income comes from capitation. The remaining income comes from (often) nurse-led or provided services like ACC, primary health organisation (PHO), and district health board (DHB) clinical programmes (Care Plus etc.) and fee-for-service payments made by


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patients to the practice. This is why development of non-capitation services is vital to the financial success of any general practice. Focus on fee-forservice ideas and opportunities. Get to know the various general practicerelated contract documents Plus the service schedules for both DHB andPHO contracts and those with other agencies i.e. ACC. Consider the implications and requirements, what needs to be in place to meet those provisions, and how you might go about organising these. (See box for the fact and fiction about capitation funding contracts.) Line up your finance in advance As well as major banks, there are specialist organisations that loan to general practice owners, like the Medical Assurance Society. You should be able to secure a loan to purchase the business or finance your buying into a partnership without too much difficulty. General practices are considered ‘safe’ businesses to lend to, especially if you have equity in a home/ property to use as security. If you want to buy into an existing practice, review and seek advice about the partnership agreement. Consider the buy-in and buy/sell-out implications. If you are establishing a new practice or taking over an existing practice, factor in cash flow, payroll ??????? and capital expenditure and allow Intro for at least six months operating costs being available – remember capitation is paid monthly but only after the quarterly enrolment register is submitted. Payment doesn’t always start immediately depending on where in the payment cycle you are and can lag months behind. Spend time on preparing Be clear about your ideas, goals, model, and finances. Benchmark your salary, as you will want to be remunerated at a higher level because of the additional amount of your time that will be required, and the additional expertise you will bring to the role of owner and clinician. Don’t underestimate the time commitment. The demands of clinical practice, business and staff management are quite formidable. To be a good employer you often need to be first at work and last home, and ensure staff are supported and provided with an environment to thrive in. Be good to yourself You aren’t always going to get things right or know all the answers. Don’t let yourself get knocked around when you get knocked back – there is a difference. Not everyone will share your vision and some will be outrightly opposed. Pick your battles – I let some go and am careful about which ones I choose to fight. I have no regrets. I have been able to test myself and try ideas in both clinical practice and as an employer. I have control over my work and can implement new services or improve what we already do. I can support nursing colleagues to flourish and follow their passions and interests. I have less fear of failure, less difficulty articulating my point of view, and I am definitely thicker skinned. My patients are enthusiastic and supportive. Anyone who has been well nursed knows the value of good care. It makes sense to patients

CAPITATION FUNDING:

KNOW WHAT IS FACT VS FICTION FACT: There is no barrier to anyone holding a provider or ‘capitation’ contract. The contract actually states that a “practitioner, general practitioner, or medical practitioner” can be contracted by a PHO, and goes further to define GPs and RNs, as ‘practitioners’ eligible to be contracted with if they hold appropriate registration and a current APC. Some PHOs and DHBs may have placed various restrictions around who they will allow to hold a contract. However, the contract holder can make their own arrangements about how the specifications |are met and there is leeway for how this can be done. This means a non-GP can hold a contract, and “buy-in” or partner with a GP for the medical and other services that are required by patients, and to meet the contract specifications. If a DHB or PHO are unreasonable in their approach to contracting with a non-GP, this should be challenged, especially if the assumption is that a nurse cannot do this. When we wrote to request a contract it arrived for signing with both our names on the cover. I hadn’t expected it wouldn’t but find out what your DHB/PHO’s position is and work through the issues if they are unreasonably restrictive. FACT: While capitation funding is paid to subsidise the cost of general practitioner consultations, it is not paid for each consultation with a GP. Rather it is paid as a lump sum every month based on the number of enrolled patients at the practice. For example, our patients are enrolled with the practice, not to a specific provider. This means that our model of care, i.e. the capacity and capability of the team to manage the workload and provide services, determines how many enrolled patients we can accommodate. Effectively, nurses through their work and contribution do enable a practice to enrol more patients. Therefore, you can say nurses currently ‘attract’ capitation to a practice. FACT: The capitation contract is not just about capitation. It also covers services like clinical programmes, services to improve access and health promotion. The bulk of a practice’s income is not via capitation, so this allows for great scope in non-capitated services to generate income. These are not just reliant on GP providers and allow opportunities for non-GP practitioners to provide and invoice for services.

Useful Links and Contacts »» »» »» »» »»

Inland Revenue Department PHO Provider Agreement, Version 18 (soon to be replaced with Version 19) Westpac Bank – Business Division (Health) ANZ Bank - Business Division Medical Assurance Society, Business Advisory Services - Shaun Phelan, National Manager 0800 800 MAS »» Ministry of Health, Primary Care section, www.health.govt.nz »» Kings Fund (www.kingsfund.org.uk) and Health Improvement & Innovation Resource Centre (www.hiirc.org.nz) for general information, current clinical evidence, ideas and updates that are useful when planning projects/new services »» General Practice New Zealand – www.gpnz.org.nz that I can influence and define the context of our work together. Looking back, the Primary Health Care Strategy never mentioned nurses changing service provision by seeking contracts themselves. Nurses were never encouraged to purchase or start up a health business. It is still not part of the discussion for nursing graduates or colleagues thinking about their career pathway. Nursing role models in business are not well known. Those who have followed this path have usually gone about it quietly. We now see nurse specialist and nurse practitioner role models for advanced practice and those looking to take this path have a clear map for how this can be achieved. However, I think we need now to also focus and support those who don’t wish to be

clinical specialists or NPs, but wish to push the boundaries and advance practice in other ways. We need to develop the next generation of nurse leaders. We need to build financial and political understanding in all our young colleagues. Exposing them to the wide range of opportunities for their careers and capitalising on the experience we are building up within the profession in business ownership, management, and development. For those who have a spark of interest, I encourage you to boldly go on your own journey, and I look forward to the day when it is commonplace to see nurses involved in primary care in this way. *This article was supplied by the College of Nurses Nursing Review series Summer Edition 2012/2013

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BEING SAFE NOT SORRY:

Intro ???????

training to protect vulnerable children The White Paper for Vulnerable Children was a major new policy plank for 2012 and training all ‘front line professionals’ in detecting child abuse and neglect is one of its key aims. FIONA CASSIE finds out more about why child protection training is important for nurses.

“W Anthea Simcock

Becky Conway

Merryl Ryan

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hat if I’m wrong?” “What if I make things worse?” “What if the family turns on me?” It is uncertainty and fear that can hold back a nurse from voicing concern that a child is being abused or neglected. “But what if you’re right?” is the question that Anthea Simcock, chief executive of Child Matters, asks back. The headlines, photos, and names of abuse victims in the country’s roll of shame are there to haunt us all. Training and education is a key to reducing child abuse, believes Simcock, the founding CEO of the child abuse prevention advocacy and training organisation. So people working with children, like nurses, have the skills to know what to look for, the knowledge to know what to do, and the confidence to take the appropriate action. It is a view shared by the recent White Paper for Vulnerable Children, which has opted for mandatory training rather than mandatory reporting. Many nurses have already received training in child protection, but by the end of 2015, all front line professionals working with children are to be trained in detecting child abuse. Legislation will also require all organisations working with children to have child abuse policies and reporting systems in place (see White Paper sidebar).

Nursing Review series Summer Edition 2012/2013

Ducking for cover

Education or mandatory training is no “quick fix” for child abuse, says paediatric nursing group, Nurses for Children and Young People of Aotearoa (NCYPA). But Becky Conway, chair of the NCYPA section of NZNO, says her members believe that if nurses have the appropriate training and skills to identify and intervene, the incidence of abuse and neglect can be significantly reduced. Because talking to parents in a suspected abuse case is “extremely uncomfortable” and if a nurse lacks the skills, the temptation is there to “duck for cover” and even avoid reporting the abuse. As one member recalls: “When it came to reporting this case, everyone ducked for cover, didn’t want to do the paperwork, didn’t want to make the decisions, so I got to tell mum that we had concerns and that it was necessary for me to notify CYF. Reassuringly, she just said ‘Okay, I have nothing to hide’, a big relief for me.” Conway says, as a group, NCYPA is undecided on the merits of (legislated) mandatory reporting but believe it would have been unlikely to make a significant difference without supporting education and policy. (She says that to the group’s knowledge all DHBs, and many

community health organisations, have already adopted policies of compulsory reporting for their workplaces.) For herself, a nurse educator working in paediatrics for almost two decades, she says child protection training gave her a heightened sensitivity and awareness of why child protection screening is needed. “If you don’t think you might see it, you probably won’t.” So while nurses don’t expect to come across abuse every day, it does become part of their daily consciousness – particularly when taking a child’s history on admission to hospital for any form of accidental injury. “I guess that’s a good example of how every professional working with children is always second guessing whether a child has suffered something that is nonaccidental,” says Conway. Training to detect abuse is the first step, but having a clear child protection policy and reporting process is also incredibly important, in Conway’s book, to encourage nurses to feel confident to take the second step and act on suspected abuse. “What is the next step is what everybody needs to know and wants to know – ‘now I have this information what am I going to do with it?”


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REFERRALS TO CHILD, YOUTH & FAMILY 2011-2012 Total FAR* Care & Protection Notifications (CPN) Education (1) 9,447 7,232 Health (2) 10,767 7,234 GP 552 348 Plunket 935 552 Family 10,282 6,398w Anonymous 5,990 3,932 Police (3) 62,678 9,626 In all there were 152,800 referrals made from 40 different professional groupings, agencies and concerned parties involving 95,532 children and in 61,074 of those cases ‘further action was required’ (FAR*) (1)school & early childhood (2) hospital staff, public health nurse etc (3) CPN & family violence referrals

Changing attitudes

Responding to child abuse does not always “come naturally” says Simcock, but doing nothing is not an option. In her presentation on child protection to the College of Primary Health Care Nurses NZNO conference in August, she included the chilling statistics that in New Zealand 57 children ??????? a day are proven to be abused, and on average, a Intro child is abused to death every five weeks. Training can help to overcome the inclination to assume all parents love their child, make excuses based on culture, optimistically look for positive explanations, or deny there is a problem because your own life is already stressful enough. Training can also avert the opposite problem of automatic ‘cover your butt’ reporting that overloads Child, Youth and Family social workers. “I think the Government got it right here – that if we just brought in mandatory reporting, then people report anything to just make sure that they are covered. And that’s not meeting what we’re trying to do. “It means that all sorts of cuts and bruises and Mongolian spots and impetigo will get reported because people don’t know whether it’s a school sore or a cigarette burn. And the very dangerous abuse we are missing now still gets missed.” Continued on page 12 >>

”57 children a day are proven to be abused, and on average, a child is abused to death every five weeks.”

WHITE PAPER FOR VULNERABLE CHILDREN White Paper’s Children’s Action Plan Timeline for professionals working with children By April 2013 »» Agree which professions form the ‘core’ children’s workforce and ‘wider’ children’s workforce in order to prioritise and target workforce actions. By end of 2013 »» Develop cross-sector common minimum standards, core competencies, and training requirements for children’s workforce. »» Introduce legislation requiring all agencies working with children to have policies and reporting systems in place to recognise and report child abuse and neglect. »» Release “Working with Children Code of Practice” for professionals working with children. By end of 2015 »» Front line people who work with children to be trained to recognise the signs of child abuse. »» Agree minimum standards and competencies in national guidelines for inclusion in organisations’ employment, contracting and audit obligations.

Nurses not named but included …

Nurses may fail to gain a mention in the White Paper but are to be included in training development plans. Social Development Minister Paula Bennett says the Government will work with professional groups for teachers, doctors, and nurses to develop core competencies and minimum standards for child protection skills. Asked about the likely nature of training, Bennett points to the ‘Working Together’ child protection workshops that the Government has been funding free around the country since 2010 for local teachers, health professionals, and social service providers. The multidisciplinary workshops are a partnership between Child, Youth and Family (CYF) and training organisation Child Matters. “By the end of June 2013, we will have reached around 4,500 professionals,” says Bennett. She says consultation work on the competencies and developing the Working with Children Code of Practice resource will “help to identify those front line professionals who have not yet received abuse detection training and ensure they attend similar workshops from 2015”.

Ministry of Health’s Violence Intervention Programme (VIP) for DHBs

The Ministry of Health began a family violence health project back in 2001 and in 2007 launched the renamed Violence Intervention Programme (VIP) in district health boards (DHBs) covering both partner abuse and child abuse and neglect programmes. An audit in 2011–2012 of the 20 DHBs found all had VIP systems in place to respond to child abuse and neglect, and a roll-out of staff training and VIP services was occurring across designated services (emergency, maternity, child health, sexual health, mental health, and addiction). However, the proportion of personnel in a service, including nurses, who had completed VIP training was unknown. Fifteen of the boards had been approved to deliver the Ministry-approved standardised national VIP training package (which covers both domestic and child abuse). Two DHBs had established National Child Protection Alert Systems (NCPAS) and five DHBs were working to join NCPAS.

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Nursing Review series Summer Edition 2012/2013

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Plunket more than weighing babies

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<< Continued from page 11 Simcock says training should lead to better quality reporting and flow-on to a better quality response from social services because they are not so overstretched. As a child protection advocacy group – and specialist in child protection training across the spectrum of emotional, physical and sexual abuse – Child Matters is keen to have input into the nature of that training including their recommendation it should be multidisciplinary. “Ideally, if you can train front line professionals across sectors together, that breaks down barriers and they get to understand each other’s role in child protection.” Training also needs to be in-depth enough to change people’s attitudes and behaviours and give them the skills to intervene earlier, respond appropriately, and report if necessary. The basic requirement, she believes, was for the equivalent of a day’s training (around 6–7 hours) and it needed to include role play so nurses can practise how to talk to children and parents in suspected cases, know how not to put words in a child’s mouth, and know not to make promises they can’t keep.

Training experiences uneven and competency complex

Nurses currently working in ‘front line’ roles report mixed experiences in child abuse training from the very good to the very brief. Conway says the national violence intervention programme (VIP) training on offer to district health boards (see Ministry of Health sidebar) currently 12

Nursing Review series Summer Edition 2012/2013

consists of two four-hour sessions covering child abuse and partner abuse. But, she says, her members report that some DHBs run very helpful two-day training workshops in family violence and child abuse, including input from Women’s Refuge and Police. “However, in other DHBs, nurses have found training in child protection to be too brief or too inaccessible even though they are in ‘the front line’,” says Conway. Some nurses also reported frustration at not being able to attend regular paediatrician meetings about abuse cases or being excluded from case meetings because they are not part of dedicated child protection teams. The White Paper’s proposal to set core competencies and training requirements for the children’s workforce (see sidebar) may also not be straightforward for nursing. “The challenge of assessing competence is very subjective and even experienced and skilled nurses may be afraid to approach the topic of abuse and neglect with families and therefore assessment and intervention does not occur,” reports Conway from member feedback. “Logistically, assessing competence of all child health workers in child protection skills would be difficult.” She says training needs to be accessible and transparent, and the challenge for nurses was to develop a competency framework covering key “knowledge bundles” including identifying, responding, assessing, supporting, and referring; along with understanding the prevalence of abuse, socio-political influences, and the life-long impact on health.

Unfortunately, screening for family violence is a growth area for Plunket nurses going into families’ homes every day. The child health organisation’s 600-plus clinical staff made more than 930 child protection referrals to CYF in the past year. Providing nurses with the ongoing training and tools to support Plunket nurses in their child protection role is a long-established part of Plunket training, says Merryl Ryan, Plunket’s national education manager. That role comes as a shock to some. “A lot of people think that Well Child (nursing) is ‘nice’ – it’s weighing babies – and they don’t possibly come with the understanding, initially, that it’s looking at the family in the community and that’s the growth area – particularly when it comes to screening for family violence.” A huge emphasis is made on communication, with the Plunket nurse right from the outset making it clear to a family that their role includes screening for family violence. “So we take them (nurses) through how to set up the screening, the leading-in statements, and the framing of questions.” When new Plunket nurses start their postgraduate training (the postgraduate Certificate in Well Child Primary Health Care Nursing offered in partnership with Whitereia Community Polytechnic), they write a 3000 word assignment looking at disparity within their own community, population health, and what services, like Women’s Refuge, are there to support the community. Later on during live-in block courses, there is more intensive training on family violence and child protection. This is followed-up by at least 90 minutes annual ongoing training (out of the 20 professional development hours offered each year by Plunket) to update on policy or law changes, revise skills, and discuss cases. Ryan says that while there is room for online learning further down the track, she believes it is essential for initial child protection training to be face-to-face so people can use role-play and scenarios to practise skills like leading-in statements and framing questions. So, for example, a nurse realises that asking a parent the generic question “do you feel safe?” may get the non-useful brush-off answer “Yes, I’ve got a dog”. Plunket nurses are encouraged to work in partnership with families when initiating CYF referrals, but also to work with their clinical lead in implementing Plunket’s policy, so if they don’t feel safe they are not going through the reporting process alone. “I don’t think you ever get used to it,” says Ryan. “They are never easy conversations to have. But to support the ‘ease’ if not the ‘easiness’, it’s important to have that ongoing relationship with families and also the ongoing training every year.”

Ready to step up to responsibility

Under the White Paper, training requirements will differ for the “core” children’s workforce like Plunket and those nurses in less frequent contact with children, but compulsory training is on its way. “The responsibility for taking action does lie with us when children and their families come into our spheres of influence,” says Conway. “And so we need the training and the ongoing support to enable us to carry out this mandate.” The White Paper, with its emphasis on collective responsibility for helping and protecting the country’s vulnerable children, may result in more nurses stepping up to the challenge.


FOCUS n Summer Edition A professionAl development Activity proudly brought to you by

NursingReview

Reading, Reflection, and application in Reality By Shelley Jones

Talking about safe practice LEARNING OBJECTIVES reading and reflecting on this article will enable you to: »» discuss shifts in thinking about clinical error and adverse events prompted by the patient safety movement. »» identify two types of process failures and the reasons why we generally fail to learn from each type. »» reflect on your own role and actions in building a safety culture within your work team.

A way to look after yourself, your colleagues, and your patients We like the good news – that nurses are consistently ranked by the public as one of the most trusted professions. But we are not so keen to embrace the bad news – that health care services harm patients at a surprising and unacceptable rate. We cannot assert that nursing is an integral and critical part of health care and have little to say about our share of responsibility for that harm, especially when we also claim that it’s the closeness and continuity of the nurse-patient relationship that makes it distinctive. Ironically, the good news may be based on an inaccurate image of nursing, yet the bad news is based on hard evidence of reported incidents. In this learning activity, we’ll look at how every day talk contributes – and could contribute more – to safety for patients.  Helping not harming Medicine used to be simple and ineffective and relatively safe, but now it is complex, effective, and potentially dangerous2. Health care presents a challenging paradox by pairing the mandate to ‘do no harm’ with mounting evidence that much harm is done in the course of delivering care 3.

WHAT IS PATIENT SAFETY? the term patient safety can refer to: » a way of doing things – an approach or philosophy with its own explanatory framework, ethical principles, and methods » a discipline with a body of expertise, concerned with applying safety science methods to achieve a trustworthy health care system » an attribute or property of a health care system that minimises the incidence or impact of adverse events and maximises recovery from them1. patient safety as a discipline uses methods from cognitive psychology, human factors engineering, and organisational management. it applies principles of systems design and safety culture as found in high-reliability, high-risk organisations – such as in the aviation industry. but the discipline also accommodates the individualised and personal nature of health care that, for instance, requires confidentiality and privacy for patients1.

Patient safety and health literacy are relatively recent developments that shape – or should shape – everything we do in our increasingly complex, specialized, and fragmented health care services. We’ve discovered that the incidence (probably under-reported) of patients being harmed in the course of treatment is unacceptably high1,4,5. And in realising that health literacy helps patients self-manage and navigate the health system, we have recognised that information, treatment, and services could be better designed to reduce complexity and risk and thus increase safety6 . Involving patients in safety practices, for instance, in a ‘checking with’ approach, brings health literacy and patient safety together by accepting that patients know that errors can occur, legitimising their right to ask questions, and reinforcing their right to receive safe care7. In the traditional view, which assumed that competent, committed clinicians do not make mistakes, those involved in adverse events were deemed to be incompetent and careless. According to a principle of individual accountability, clinicians admitting to an adverse event were subjected to ‘blaming and shaming’ intended to motivate them to be more careful1,3. An unintended but predictable consequence was reluctance to report errors for investigation. The resulting silence affords no learning, and the opportunity is lost for the organisation to discover and correct causes beyond individual practice8,9.

Challenging the silence Patient safety thinking challenges this silence in three ways that support clinicians. Firstly, it reconciles the precept ‘first, do no harm’ with the insight that ‘to err is human’3. Without abandoning clinicians’ obligations to give safe and effective care, it recognises that the demands of normal clinical work (managing complexity and uncertainty in diagnosis and treatment for medically fragile patients under time pressure) can obscure the safest course of action 3. Put another way, ‘Errors are to be expected, even in the best organisations’8 . Secondly, viewing adverse events through a systems design and human factors ‘lens’ reveals that strategic decisions may create weaknesses in safety defences (e.g. unworkable procedures) or translate into error-provoking conditions (e.g. understaffing, time pressure, inadequate equipment and supplies, lack of training). These latent or ‘blunt end’ conditions can set up the circumstances in which the clinician at the ‘sharp end’ of care delivery actively makes a mistake (e.g. by taking their focus off patient care)1,8 . Conversely, systems can be designed to make it more likely that the right thing will happen and more difficult for the wrong thing to happen. In other words, ‘We cannot change the human condition, but we can change the conditions under which humans work’8 . Thirdly, threats to patient safety require a response from everyone involved in health care, but especially clinicians. Accountability for safe and competent care is integral to any professional role and code of conduct10. Patient safety requires that we realise our collective accountability for learning from not only near misses and errors but also look at what we need to do differently if the quality of care has been compromised1. The Health and Disability Commissioner’s complaints process and

Nursing Review series RRR pullout

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Talking about safe practice

A way to look after yourself, your colleagues, and your patients decisions acknowledge that one of the motivations for patients and families bringing complaints about care is to ensure ‘it doesn’t happen again’11. As nurses, we need to shoulder our share of the responsibility for preventing adverse events and addressing poor care by learning what we need to do so that ‘it doesn’t happen again’23.

DEFINITIONS: ERRORS AND ADVERSE EVENTS Errors are failures of planned action. There are two types: » when the action is correct but does not proceed as intended – error of execution » when the intended action is not correct – error of planning Adverse events are injuries caused by treatment interventions; they are not the result of the patient’s health condition. A large proportion of adverse events are the result of errors, and are therefore considered preventable adverse events4.

Learning from process failures Organisations in which reliability is a more pressing issue than efficiency often have unique problems in learning and understanding, which, if unresolved, affect their performance adversely 12 . When small failures are neither identified widely, nor discussed and analysed, it is very difficult for larger failures to be prevented 13 .

The small mistakes and problems that occur in care delivery processes are not seen as material for systematic shared learning in the same way that adverse events are. Yet these frequent, apparently inconsequential failures can be compounded by one failure too many, and the accident no one knew was waiting to happen finds its mark. If we are serious about safety, we have to pay attention to ‘…these small failures or vulnerabilities are [which are often] present in the organisation long before an incident is triggered’14 . In other words, a shift from reactive to proactive risk management8 .

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Nursing Review series RRR pullout

Edmondson, in her findings from an ethnographic study of teams in hospital wards, differentiates errors and problems as two types of process failure. »» Errors were defined as unnecessary or incorrectly executed actions that, with the right information, could have been avoided. But interpersonal relationships or the professional dynamic at the frontline often inhibits nurses speaking up to ask questions, express concerns, or directly challenge a colleague. Because drawing someone’s attention to their error – even though it is unintentional and the person is not aware of it – is potentially threatening for both people, saying nothing may be easier. If it is difficult to talk about errors, then there is no shared learning. »» Problems were defined as disruptions to a worker’s ability to complete a task because either an element needed for its completion was not available or some other thing interrupted or interfered with task completion. Problems mostly originated somewhere other than where they showed up, meaning they qualified as system issues. Problems made up the majority of the process failures observed (86 per cent), and managing them took on average 15 per cent of the nurses’ time. Nurses’ dominant responses to these obstacles were quick fixes and workarounds – rather than looking for root causes and applying systematic problem solving – not at all surprising given their incidence at one per nurse per hour. In contrast to errors, nurses were very aware of problems – they were obvious, frustrating, and disruptive to the smooth organisation of work. Even though one person’s quick fix may create a problem in another department, these recurring disruptions were not discussed as failures with implications for patient safety13. The researchers found that nurses generally just quietly got on with it: they seamlessly corrected for someone else’s error (without bringing it to their attention), and faced with obstacles to patient care, made adjustments and improvised without asking their colleagues for help or bothering their managers. Describing the nurses doing this as ‘adaptive conformers’, Edmondson acknowledges that this behaviour is valued but argues that the opportunity to address unrecognised threats to patient safety is lost. To make the most of the safety lessons in these undramatic process failures, Edmondson says we need ‘observant questioners’ who manage the error or problem and also escalate it to their managers13. Then, rather than finding this annoying, managers need to welcome and act on staff questions and complaints as part of being serious about patient safety9,13.

Making it safe to say what needs to be said …a new role for health care leaders and managers is envisioned. It is one that places high value on understanding system complexity and does not take comfort in organizational silence 9. …there are at least two ways in which leaders enable safer practices on the front line: first, by directing attention to safety, and second, by creating contexts where practitioners feel safe to speak up and act in ways that improve safety 9.

Adverse events in health care often have communication issues at the heart 15 .

Safety tools are designed to address the honest mistakes that humans will inevitably make, but even well-designed systems need supportive dialogue between the staff using them. A safety tool may highlight a problem, but if the interpersonal climate makes it unsafe to speak up or get others to pay attention, it undercuts good design and compromises patient safety, according to two linked studies with the hard hitting titles: ‘Silence Kills’ and ‘Why safety tools and checklists aren’t enough to save lives’16,17. Findings were that health workers had often seen their colleagues make mistakes, flout rules, or demonstrate incompetence that threatened patient safety (and staff morale), but most didn’t speak up. However, about ten per cent did, and the critical difference between them and the silent 90 per cent was their confidence in being able to say the thing that needed to be said16,17. There were common patterns in these crucial conversations – the nurses who talked with their colleagues: »» explained their positive intent to help the colleague and the patient »» assumed a good response would be forthcoming »» did their homework on the problem – used facts and data as much as possible »» avoided creating defensiveness in the colleague by making it safe for them »» avoided negative stories and accusations, and »» defused or deflected anger and emotion. The researchers concluded: “If every caregiver has these skills, it will go a long way toward resolving the problem of organisational silence”17. It could be argued that all nurses already possess a set of highly refined and sensitive interpersonal communication skills – those we bring to our encounters with patients are nearly sufficient to equip us for this task18,19. A key theme in the patient safety literature is the critical importance of developing a safety culture in which everyone is clear that safety is central to ‘how we do things around here’, and which attends to building highquality relationships within the team so that it is safe to take the interpersonal risk involved in raising a question or concern about practice. Making it safe to speak up can be as simple as a team leader or manager asking “Was everything as safe as it could have been for our patients this week?” and being prepared to fight whatever battles are needed to overcome the routine organisational failures that otherwise take focus and time away from patient care13.

Talking amongst ourselves But it’s not just what leaders do. If all team members are open to the possibility that they may make a mistake (for any reason), then having one’s human error brought to awareness is true colleagueship. What is needed are trusting and respectful relationships amongst team members and time given to talking about safe practice, whether the informal learning and debriefing with each other in course of the day21, or in peer learning partnerships22 or purposeful discussion in team meetings. If trust and time are not there at first, finding even small amounts of each will help develop a commitment to a process of shared learning. Let’s not forget the part of safety we hold dear in the nursing role – that our patients and their families feel safe with us. We are committed to helping, not harming. Bringing


A professionAl development Activity proudly brought to you by a colleague to an awareness of how aspects of their approach with patients may be less than helpful, supports them in developing the insight that their practice could be safer and prompts their learning different approaches. Talking amongst ourselves – at all levels, as a personal and professional imperative – about safe nursing practice is what Philip Darbyshire means when he says, ‘We do, indeed, need to talk about nursing’23. When you think about how many lives we touch every day24 – in ways great and small - we should have no difficulty in saying something as simple as ‘Have you washed your hands?’ to a colleague.

?

QUESTIONS THIS ARTICLE MIGHT PROMPT YOU TO ASK YOURSELF »» how would i feel if a colleague said something that stopped me from making a mistake? »» What are the workarounds that we take for granted in our team? What would it take to address these ‘workarounds’ as potential sources of failure or learning? »» how would i react if a colleague said something that made me rethink how i was interacting with a patient or family?

Recommended reading and resources Articles FIRTH-COZENS J (2001) Cultures for improving patient safety through learning: the role of teamwork. Quality in Health Care10(suppl 2):ii26-ii31. HENRIKSEN K & DAYTON E (2006) Organizational silence and hidden threats to patient safety. Health services research 41(4p2):1539-1554.

Boladeras, Juliet Manning, Teresa Shapleski, Karen Shaw, Marian Partington and Maria Baynes. I would like to thank my colleagues at Bowen Hospital for an ongoing dialogue about whether and how peer feedback processes can foster mutually supportive professional development. Thank you to peer reviewers Roanne Crone, Sam Denny and Teresa Shapleski for their helpful critique; and to Teena Robinson for testing the questions.

Erratum In the RRR Change management: A classic theory revisited, Nursing Review 13(1), at page 15, under the heading Change competencies, the second dot point should read “The rate of quality improvement implementation in health care is less than 50% 14”.

REFERENCES 1 EMANUEL L, BERWICK D, CONWAY J, COMBES J, HATLIE M, LEAPE L ...WALTON M (2008) What Exactly is Patient Safety. A definition and conceptual framework. Agency for health care Quality and Research, Advances in Patient Safety: From Research to Implementation. Retrieved from www.ahrq.gov/downloads/pub/ advances2/vol1/Advances-Emanuel-Berwick_110.pdf 2 CHANTLER C (1999) The role and education of doctors in the delivery of health care. The Lancet 353 (9159):1178–81 3 VOGUS TJ, SUTCLIFFE KM & WEICK KE (2010) Doing no harm: Enabling, enacting, and elaborating a culture of safety in health care. The Academy of Management Perspectives 24(4):60-77. 4 KOHN LT, CORRIGAN JM & DONALDSON MS (1999). To err is human. Building a safer health system (Executive summary). Washington: National Academy Press. 5 HEALTH QUALITY AND SAFETY COMMISSION (2012) Making our Hospitals Safer: Serious and Sentinel Events reported by District Health Boards in 2011/12. Health Quality and Safety Commission: Wellington. 6 BRACH C, KELLER D, HERNANDEZ LM , BAUR C, PARKER R, DREYER B, …SCHILLINGER D (2012) Ten Attributes of Health Literate Health Care Organizations (Discussion Paper). Institute of Medicine. Retrieved from http://iom.edu/~/media/Files/ Perspectives-Files/2012/Discussion-Papers/BPH_Ten_HLit_ Attributes.pdf 7 JOINT COMMISSION (2007) “What Did the Doctor Say?” Improving Health Literacy to Protect Patient Safety. Retrieved from www.jointcommission.org/NR/rdonlyres/D5248B2E-E7E6-41218874-99C7B4888301/0/improving_health_literacy.pdf. 8 REASON J (2000) Human error: models and management. British Medical Journal 320(7237):768-77

NursingReview

9 HENRIKSEN K & DAYTON E (2006) Organizational silence and hidden threats to patient safety. Health services research 41(4p2):1539-1554. 10 NURSING COUNCIL OF NEW ZEALAND (2012) Code of Conduct for Nurses. Nursing Council Of New Zealand: Wellington. 11 HEALTH AND DISABILITY COMMISSIONER at www.hdc.org.nz/ for online complaint process and Commissioner’s decisions. 12 WEICK KE (1987) Organizational culture as a source of high reliability. California Management Review 29 (2):112-127. 13 EDMONDSON AC (2004) Learning from failure in health care: Frequent opportunities, pervasive barriers. Quality and Safety in Health Care 13:3-9. 14 LEAPE LL, WOODS DD, HATLIE MJ, KIZER KW, SCHROEDER SA & LUNDBERG GD (1998) Promoting patient safety by preventing medical error. Journal of the American Medical Association 280(16):1444-1447. 15 DuPREE E, ANDERSON R, McEVOY MD & BRODMAN M (2011) Professionalism: a necessary ingredient in a culture of safety. Joint Commission Journal on Quality and Patient Safety 37(10):447-455. 16 MAXFIELD D, GRENNY J, McMILLAN R, PATTERSON K & SWITZLER A (2005) Silence kills: The seven crucial conversations for health care. Retrieved from http://www.silenttreatmentstudy.com/ silencekills/ 17 MAXFIELD D, GRENNY J, LAVANDERO R & GROAH L (2011) The silent treatment: Why safety tools and checklists aren’t enough to save lives. Retrieved from http://www.silenttreatmentstudy.com/ index.html 18 I am grateful to my colleague Teresa Shapleski for her comment that the patterns in these conversations amounted to “good intent - a genuine caring approach for their colleague and positive patient outcomes. Core nursing attributes”. 19 KUPPERSCHMIDT B, KIENTZ E, WARD J, REINHOLZ B (2010) A healthy work environment: It begins with you. OJIN: The Online Journal of Issues in Nursing 15(1): Manuscript 3. 20 NEMBHARD IM & EDMONDSON AC (2006) Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior 27(7):941-966. 21 BAUER J & MULDER RH (2007) Modelling learning from errors in daily work. Learning in Health and Social Care 6(3):121-133. 22 MANTESSO J, PETRUCKA P & BASSENDOWSKI S (2008) Continuing professional competence: Peer feedback success from determination of nurse locus of control. The Journal of Continuing Education in Nursing 39(5):200-205. 23 DARBYSHIRE P (2011) We do, indeed, need to talk about nursing. Australian Nursing Review August 2011:14-15 24 The question of how many lives a nurse might touch in the course of a year occurred to me whilst attending a workshop run by the Health Quality and Safety Commission. Discussing the idea with the Commission’s General Manager Karen Orsborn in the break, she suggested the calculation apply to the course of a day.

Web resources The United States based Agency for health care Research and Quality covers more than 20 topics in a comprehensive set of ‘Patient Safety Primers’: http:// psnet.ahrq.gov/primerHome.aspx The principles of assertive communication are a good basis for raising an issue with a colleague or manager: http://www.mindtools.com/pages/article/Assertiveness. htm Kupperschmidt et al’s online article about skilled communication styles in relation to healthy work environments is useful in relation to making it safe to say what needs to be said: bit.ly/YXqvs6 The Johari window is a useful model for looking at self-awareness http://www.businessballs.com/johariwindowmodel.htm The text of Darbyshire’s 2011 article is at a link from his blog: bit.ly/S5MVV2 More on the topic of getting feedback from peers at my blog at www.learn-ability.co.nz

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

Acknowledgements: This discussion follows on from a presentation, Talking about what we are doing together: Why and how?, developed for the Australasian Nurse Educators Conference ‘Innovations in Nurse Education in Practice, Thinking Aloud, Thinking Ahead’, Wintec, Hamilton, 23 - 25 November 2011 with my PDRP colleagues Robyn

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A professionAl development Activity proudly brought to you by

talking about safe practice

downloAd the interActive pdf worksheet And Answers At: www.nursingreview.co.nz

a way to look after yourself, your colleagues, and your patients

Date:_________________

Name: ____________________________________

DesigNatioN:________________________________

NursiNg CouNCil iD:_______________________

WorkplaCe:_________________________________

undertaking this learning activity is equivalent to 45 minutes of professional development. it contributes to maintaining competence by helping you reflect on your responsibilities to provide safe care (including clinical and cultural safety) and manage threats to patient safety, and your involvement

Amongst other insights, the patient safety movement supports the idea that:  professional training means clinicians never make errors  poorly designed systems can cause clinicians to make errors.

Tick one

2

Tick one

4

Which of these is not given in the article as an explanation for silence around errors?  avoiding ‘blaming and shaming’ as punishment  no compelling reasons to change established practice  team members may feel it is not safe to speak up. Adverse events are defined in this article as:  injuries caused by treatment  idiosyncratic responses to treatment

Tick one

Reasons given in this article for analysing and addressing recurring but seemingly inconsequential disruptions in daily work include:  workarounds take time away from patient care  they can compound to cause a larger failure  they offer safety learning opportunities  all of these factors  none of these factors

Tick one

this section helps you reflect on your learning from reading and relate it to your experience. Think about a time when you were aware that patient safety was compromised. Which points in the article explain what helped you or others to speak up or take action? Which points in the article explain what inhibited speaking up or taking action?

What are your ‘take home’ learnings? List 3 points from the article

reflection

B

see the Nursing Council defined competencies related to ensuring that patients receive safe care for rNs, eNs, and Nps at www.nursingcouncil.org.nz/ index.cfm/1,55,0,0,html/Competencies

this learning activity also helps you explore the values underpinning professional conduct – especially integrity – as outlined in Nursing Council’s Code of Conduct for Nurses at www. nursingcouncil.org.nz/index.cfm/1,255,html/Codeof-Conduct-and-guidelines

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

1

3

in quality activities that address safety issues and improve care for patients and their families/whānau.

reading

A

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1 2 3

the notes you make in this section show how you intend to apply your learning in practice Please select from ‘Questions this article might prompt…’ the one of most relevance and interest to you. Outline your responses and then make brief notes on what would be most likely to help you and/or your team be open to reconsidering your practice. Note two or three specific attitudes or actions you can take to make it safe for yourself and others to speak up and raise issues in your work team.

Verification by a colleague of your completion of this activity:

16

reality

C

(Signature)

Colleague Name: _______________________

DesigNatioN:_____________________________

NursiNg CouNCil iD:____________________

Work aDDress:____________________________ CoNtaCt #:______________________

Nursing Review series RRR pullout

Date: ___________________________


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FOCUS n Summer Edition

Stopping the dominos toppling Timely phone calls after discharge can help the frail elderly stay well and stay home. FIONA CASSIE reports on Dr Claire Heppenstall’s PhD research into the frail elderly recently presented to the College of Nurses symposium.

F

or the frail elderly, it doesn’t take much to start the ‘dominos’ tumbling and a rapid decline in health and wellbeing, says aged care researcher Claire Heppenstall. Intro ???????She says health professionals often feel a sense of futility when faced with a frail patient but research shows that interventions can improve outcomes and keep the dominos standing. Heppenstall, a doctor specialising in aged care and research fellow in University of Otago, Christchurch’s older adult health department, received Health Research Council funding to study fragile elders. Her PhD research first looked at frailty in general and then focused on the frail elderly admitted to Canterbury District Health Board’s inpatient Older Person’s Health Service (OPHS) for rehabilitation after an acute hospital admission. Heppenstall says frailty as a concept has become increasingly defined in recent decades with physical symptoms like weight loss and decreases in muscle strength and activity along with psychosocial factors like health, attitude, social supports and financial resources. “Sometimes, a urinary tract infection (UTI) can just tip someone over to frailty.” Or there can be a domino effect of being less active (through choice, angina, or arthritis) leading them to getting less vitamin D from sunshine, weaker muscles that can increase the fear and risk of falling, and lead to even less activity. Multiple drugs and inappropriate prescribing also impact on the outcomes of the frail elderly. What has been proven to help includes comprehensive geriatric assessment, multidisciplinary team (MDT) rehabilitation, medication review, exercise, and nutrition.

What keeps the frail elderly independent? Heppenstall’s Maintaining Independence Study set out to find out what factors influenced outcomes of the frail elderly post-hospital discharge and how the OPHS could improve those outcomes. Phase two involved recruiting 159 older people as they were discharged from the service and 18

Nursing Review series Summer Edition 2012/2013

using their notes and face-to-face interviews to gather data on their level of frailty, co-morbidities, mental health, medication, cognition and social circumstances. The patients, average age 81 and more than half living alone, were phoned at three months and six months post-discharge to ask them whether they felt their health had improved, stayed the same, or worsened since they came home from hospital. Heppenstall says that people’s selfreported health was linked to their risk of moving into residential aged care, with 40 per cent of people reporting “deteriorating health” at three or six months being four times less likely to be still living at home 12 months after leaving hospital than those reporting improving health. Overall, 12 months after discharge from the DPHS 14 per cent of the cohort were dead and 67 per cent were still living in their own home (which compared favourably to an American study finding older people who failed to regain their previous functioning level after a hospital admission had a 41 per cent chance of death within a year). Threequarters had had a further hospital admission. Her study found that dementia was the biggest predictive factor for moving into residential care, with people with dementia 4.3 times less likely to be still living in their own home 12 months after discharge. The next biggest risk factor was further hospital readmissions (3.7 times the risk), followed by visual impairment (2.7 times the risk), and frailty and quality of life were lesser factors at 1.3 and 1.4 times the risk, respectively. She also found that men were four times more likely to have hospital readmissions than women. The qualitative phase of her study included a series of face-to-face interviews with 16 older people – half of whom remained at home (stayers) and half moved into rest homes (movers) – and their carers.

Tripping the dominoes

Risk factors raised by the ‘movers’ included further hospital admissions with one interviewee telling her “the doctor, the hospital, they put me in here. The virus. For instance … I caught the Norovirus.” Heppenstall says the domino effect of cascading illness and disability also was reported, with one family carer telling her that the first ‘domino’ to fall was a “leg ulcer that seemed to be persistent and not improving … morphine and immobility caused her to get constipated, she ended up with abdominal pain and was in so much pain that she pressed her alarm and went to hospital … then she got the diarrhoea bug …”.

The ‘stayers’ reported being busy and able to function independently enough to do housework and bake a cake, while the ‘movers’ reported struggling to walk more than 20 paces or being unable to do the supermarket shopping. Other factors for moving was not the need for a higher level of care but their usual carer becoming unwell, becoming worried about the level of stress placed on their caring spouse, or not wanting to be a burden on extended family. Heppenstall reports that attitude also played its part with a ‘stayer’ reporting “no use lying down … I’ve always worked hard” compared to a ‘mover’ reporting “nothing further could have been done; it was inevitable”. The final phase was to trial an intervention based on her finding that self-reported deterioration in health was a risk factor for moving into residential aged care. She hoped finding out about deterioration earlier rather than later would make a difference, so she trialled an intervention of regularly telephoning a group of 26 frail elderly, following their hospital discharge to ask them whether their health had improved, stabilised, or deteriorated. Heppenstall rang them fortnightly or monthly (depending on their level of need) and any who reported ‘deteriorating’ health triggered a comprehensive medical review and MDT intervention. Seven of the 26 did report deteriorations prompting interventions. Two of the patients were admitted to hospital before a review could be carried out and one of those died soon after. A third reporting weight loss and difficulty in swallowing and preparing meals had a medical review but support with meals failed to start so the person was admitted to residential care. The other four reported issues from weight loss to depression and after review were all able to stay home with a range of support from psychiatric services, dietitians, and the MDT service. Heppenstall says, overall, 21 of the 26 older people involved remained at home (three died, one went to residential care, and another to an independent unit) and most of them reported they found fortnightly telephone calls useful and that it helped their health. While there were some teething problems and some feasibility issues needing further assessment, she believes her telephone-based intervention proposal can improve outcomes for the frail elderly living at home.


FOCUS n Summer Edition

ED’s reluctant ‘frequent fliers’ once or twice to ED during the year but the statistical analysis showed about one per cent of presentations were by people coming six times or more. Phase two involved interviewing some of those people making six or more visits to their local emergency department (PMPs) to find out why. Nurses at the three EDs were asked to identify and contact PMPs who had presented for mental illness or chronic respiratory disease issues in the past three months. “We then contacted these people knowing not one thing about them other than their name,” says Nelson. Interviewers turned up having no idea whether the 34 interview subjects had last presented for mental health or chronic respiratory issues. They soon found that their interviewees were a chronically unwell group of people, with many having multiple chronic health conditions and a number who didn’t neatly fit into either category. “We ended up with a third group of patients … a group who mainly presented for chronic pain,” says Nelson. “This is because when they go into the emergency department they can be seen as anxious or they can be seen as having a drugrelated problem.” The group’s multiple chronic Getting the big picture The first phase of the study looked health conditions – one person had six – meant they crossed categories at the big picture by analysing with some people with chronic the 115,000 presentations in respiratory disease also having 2009 to three neighbouring emergency departments (ranging associated depression. “And those from a tertiary hospital to a small with mental health issues had abdominal pain issues and asthma provincial hospital) to calculate also.” what it takes to be defined as “We hadn’t expected that. And a ‘multiple presenter’ in we hadn’t expected the level of New Zealand. serious and chronic health (issues).” The vast majority of people (about 90 per cent) only presented Continued on page 20 >>

‘frequent flier’ is a loaded term and one that researcher Kathy Nelson is keen to avoid. It comes with connotations of people abusing the system and unnecessarily Intro ??????? filling up the waiting rooms of stretched emergency departments. But little is actually known about people who make multiple presentations (PMP) to emergency departments (EDs). In 2008, Dr Nelson and her team won a STAR* research grant to help fill the gap by finding out more about PMPs in New Zealand’s emergency departments. The senior lecturer from Victoria University’s graduate school of nursing focus was to look at the role of ED in chronic health care – particularly people with mental illness and chronic respiratory disease. “These were two kinds of chronic illnesses that if community-based services were working well and effectively, there should be a minimum number of exacerbations or deteriorations in health. That was our rationale to start with – if services were working well generally, then this group shouldn’t have to present quite so often to ED.”

So-called ‘frequent fliers’ to emergency departments are often very unwell with complex health needs and feel they have little other option, a nurse research team has found. FIONA CASSIE talks to leader researcher Dr Kathy Nelson about some of her initial findings.

Looking to study in 2013?

Primary Health Care Promoting Interdisciplinary Healthcare Practice Complete a Certificate or a Diploma Offering papers in: Supporting Healthier Lifestyles • Core Principles • Tackling Obesity • Challenging Conversations Long-term Conditions Management Mental Health and Illness in Primary Health Care

Interested? Tel: 04 918 5626 Email: primarycare.distance@otago.ac.nz Details of the programme available online: UOO2808

ED

www.otago.ac.nz/studyprimaryhealthcare

Nursing Review series Summer Edition 2012/2013

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FOCUS n Summer Edition

<< Continued from page 19 The group was aged from 17 to 77, two-thirds were female and the most common last ED presentation was for mental health (18 out of 34).

ED visit not an easy decision

Nelson says probably their most important finding was that going to ED was a considered decision, and it wasn’t an easy decision. “They always went knowing that they didn’t actually have lots of other options.” People also didn’t have “timely crises” of health that fitted in with general practice appointment books or the more costly after-hours services. If their health deteriorates rapidly – like acute respiratory failure or a suicide attempt – the decision was also often taken out of their hands by family or other people calling an ambulance. In situations where there was a gradual deterioration of health

people did try to manage it themselves first. “ED was a considered decision when their own resources had failed or their set plans had failed. The important message is that ED was never the first choice unless they were acutely unwell … people don’t want to go and spend three to six hours in the ED … You don’t go there unless you feel you need it.” All but one of the interviewees had a GP, and despite their chronic conditions, only eleven were aware of being signed up to their general practices’ CarePlus service for chronic conditions. Most were engaged with one or more specialist services (up to six) and many spoke of having been admitted to acute care at least once in the past year, sometimes more often. Nelson says one question that needs to be asked – when looking for interventions to help reduce the exacerbations and

deterioration leading to multiple ED presentations – is why so few of the interview subjects were either not on CarePlus or unaware they were on CarePlus. Questions also had to be asked about the lack of continuity and coordination in the care of this population group. Many were engaged with multiple health services and found themselves in the “messy situation” where they looked to ED as a place for decisions to be made about their health. “The decisions can’t be made in the ED about long-term strategies for this group – the decisions need to be made between primary health care and specialist teams.” “The bottom line is how can we manage (exacerbations and deteriorations in their conditions) in a community setting and minimise the seriousness of them, because it’s when they get serious they go to the ED department.” Better management options include looking at what happens

in primary care (like better use of CarePlus), supporting people in their health self-management, early identifying of multiple presenters, and integrated approaches to developing and supporting a person’s care plan. Because these people with complex health needs don’t want to end up once again in ED either. “ED doesn’t entice them back,” says Nelson.

*STAR research grants were part of the $2.7m STAR (Strategy to Advance Research) project funded in 2008 by the Tertiary Education Commission to build research capability in nursing and allied health disciplines. The research team was Kathy Nelson (VUW), Cheryle Moss (Monash University), Amohia Boulton (Whakauae Research for Maori Health and Development), Margaret Connor (VUW) and Cynthia Wensley (Deakin University). 

Intro ???????

Associate Professor School of Nursing Faculty of Medical and Health Sciences Vacancy Number: 15264 The University of Auckland invites applications for an accomplished researcher to help provide leadership to academic staff in the School of Nursing. The appointee will be expected to engage in relevant research and publication, supervision of research students, external competitive grants procurement and teaching in their disciplinary area. Successful research student supervision at PhD level, demonstrated leadership skills and evidence of highly effective interpersonal skills are required. Applications are invited from proven academics with a PhD and significant experience in health research and exceptional ability as an independent researcher. We invite applicants with a track record of high quality research aligned to our current research groupings which are: Mental Health, Cancer/ Palliative Care, Gerontology, Child and Family Health, and Primary Care. Applications close 31 January 2013. For further information go to www.auckland.ac.nz/opportunities The University has an equity policy and welcomes applications from all qualified persons. The University is committed to meeting its obligations under the Treaty of Waitangi and achieving equity outcomes for staff and students.

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Nursing Review series Summer Edition 2012/2013

AWARD FOR

TRACKING AMBULANCE PATIENTS

A Christchurch system tracking ambulance patients’ journeys from initial call to ED and beyond, including multiple callouts, recently won an Australasian ambulance award for excellence. Canterbury District Health Board, St John New Zealand, and IT company Lightfoot Solutions took out the top award for its “Joined Up Data” project trialled last year to link St John and Christchurch Hospital data. The joined-up data allowed them to compare the diagnosis made by St Johns to that made by the emergency department team, and to monitor the times from 111 call to triage for patients with life-threatening conditions like strokes. It also enabled them to take a closer look at patients brought by ambulance to ED four times or more in previous months (about 14 per cent of all ambulance attendances) and consider more appropriate care pathways. “We could see for example that most of the chronic obstructive pulmonary disease (COPD) patients we saw frequently didn’t have a GP and we could advise them to register with one. Their GP will then work with them to manage their condition through advice, appropriate medication and community-based support,” said St Johns operations director Michael Brook. The pilot is now to be extended to roll out across the rest of Canterbury DHB.


Webscope

CHECK THESE OUT

Finding the answers online Dr KATHY HOLLOWAY asks what the connection between evidence-based practice and health literacy is.

E

vidence-based nursing is the foundation of professional practice – as evident in the Nursing Council of New Zealand competencies for registered nurses. However, evidence-based nursing (EBN) is more than simply finding the latest evidence and acting on that. The Sigma Theta Tau International society defines EBN more broadly as “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served”. Some definitions also include the consideration of the fiscal impact or constraints in care delivery. This level of optimal care and integration assumes that nurses have access to a synthesis of the latest research, a consensus of expert opinion, and are thus able to exercise their judgment as they plan and provide care that takes into account the cultural and personal values and preferences of those receiving care. How are you placed in relation to your practice area? Can you access quickly the synthesised latest research, expert opinion from senior colleagues and integrate this with the values and preferences of your population? Provide safe, effective patient care by locating the best available evidence online. Website portals such as New Zealand Guidelines group (www. nzgg.org.nz) and Joanna Briggs Institute (http:// www.joannabriggs.edu.au) provide quality assured synthesised evidence of both research and expert opinion to begin the process. There are three recognised common barriers to implementation of EBN – lack of time, overwhelming amounts of information and lack of

knowledge. Implementation science is a growing field of study which considers methods to promote the integration of research findings and evidence into healthcare policy and practice. Check out the Fogarty Institute at National Institute of Health in the USA (www.fic.nih.gov/researchtopics/pages/ implementationscience.aspx). The values and preferences of individuals are additionally influenced by how confident people are with the information provided – i.e. their health literacy. Health literacy has been reported to be one of the strongest demographic factors associated with health outcomes, greater than age, ethnicity, and other socioeconomic factors. One of the key elements in this is communication between the clinician and patient. This ranges from what is being discussed at the point of care, how it is conveyed through to whether it’s understood – essential to cover the remaining elements of the EBN model. Ask Me 3 [featured site this month] is a patient education programme designed to promote communication between healthcare providers and patients in order to improve health outcomes. The programme encourages patients to understand the answers to three questions: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? Using this framework you can ensure that with awareness you, your patients and communities can make choices in relation to evidence-based nursing practice. Dr Kathy Holloway is dean of the Faculty of Health at Whitireia Community Polytechnic.

Ask Me 3 – National Patient Safety Foundation http://www.npsf.org/for-healthcareprofessionals/programs/ask-me-3 The Partnership for Clear Health Communication (PCHC), USA’s leading non-profit organisation dedicated to improving low health literacy, joined forces in 2007 with the National Patient Safety Foundation (NPSF) to form the Partnership for Clear Health Communication at the National Patient Safety Foundation and launched this website. The website aims to provide resources for patients, individual providers and organisations to support health literacy. These resources are free to download and whilst it is important to remember that guidelines, procedures and appraisals developed with one context in mind do not necessarily translate, there is merit in considering the work others have done. [Site accessed 19 November 2012 and last updated October 2012.]

Implementation Science online journal http://www.implementationscience.com This site hosts an open access, peer-reviewed online journal that aims to publish research relevant to the scientific study of methods to promote the uptake of research findings into routine health care in clinical, organisational or policy contexts. As well as hosting papers describing the effectiveness of implementation interventions, Implementation Science provides a unique home for articles describing intervention development, evaluations of the process by which effects are achieved, and the role of theory relevant to implementation research. Recent articles consider the value of clinical networks and implementation of nutrition guidelines in older person’s residential care. [Site accessed 19 November 2012 and last updated 2 November 2012.]

Nursing Review series Summer Edition 2012/2013

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EVIDENCE-BASED PRACTICE

Bed baths to beat bacteria

Does bathing patients with antiseptic cloths reduce bloodstream infections? CLINICAL BOTTOM LINE Daily bathing with a 2 per cent chlorhexidine-impregnated washcloth reduced hospital-acquired bloodstream infections rates by 28 per cent. CLINICAL SCENARIO: Ever on the alert for opportunities to reduce hospital-acquired infection rates in your hospital, you notice a new trial of chlorhexidine bathing for intensive care units. Although already participating in the national CLAB (central lineassociated bloodstream infection) initiatives, you wonder if there might now be sufficient evidence to implement routine chlorhexidine bathing. QUESTION: Among adult intensive patients, does bathing with chlorhexidine reduce hospital-acquired infections? SEARCH STRATEGY: No search strategy – paper notified through push mechanisms (Table of Contents alert) CITATION: Climo MW, Yokoe DS, Wareen DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection,New Eng J Med 2013;386:533-42. STUDY SUMMARY: Cluster randomised crossover trial conducted between August 2007 and February 2009 in eight intensive care units (ICUs) and one bone marrow transplant unit (BMT) in six hospitals in the United States. All patients admitted to the units were approached to participate and only eight declined; 7735 patients agreed to participate. The types of intensive care unit included medical intensive care (4), surgical intensive care (3), and cardiovascular intensive care (1). The clusters were randomised to bathe participants daily using a proprietary chlorhexidine-impregnated washcloth or a proprietary non-antiseptic washcloth, and then after six months, the units crossed over to using the alternate washcloth to that which they had used in the previous six months. Before the study started nursing staff trained in use of both washcloths. Intervention: Daily bathing with 2 per cent chlorhexidine gluconateimpregnated alcohol-free and rinse-free 14

washcloths used in accord with manufacturer’s directions. Control: Daily bathing with nonantiseptic rinse-free washcloths used in accord with manufacturer’s directions. Outcomes: Outcome measures included the overall multi-drug resistant organism (MDRO) acquisition, hospitalacquired blood-stream infections (HABSI), acquisition of MRSA (methicillinresistant staphylococcus aureus) and VRE (vancomycin-resistant enterococci) colonisation and infection, and adverse events. STUDY VALIDITY: Method of randomisation was not reported, although it was reported that the individual ICUs and BMT were the unit of randomisation. Not reported how allocation concealment was maintained to the point of randomisation. No loss to follow up and analysis was by intention to treat analysis with Poisson regression to adjust for confounders. Trial was open label with investigators, staff, and participants aware of allocation. Patient characteristics not presented, although age and sex included as characteristics in adjusted analyses. Number of admissions, total days of care, total central catheter days, mean length of stay, and MRSA and VRE prevalence similar on the two treatment periods. No evidence that participants were not treated equally. Overall the methodological quality of the study was reasonable. Results: There were significantly fewer infections during the chlorhexidine-bathed periods (see table), including less MDRO acquisition, less VRE acquisition, fewer HA-BSI infections, and fewer central catheter-associated bloodstream infections (CC-BSI), and fewer adverse skin reactions (2.0 per cent versus 3.4 per cent, absolute difference 1.4 per cent, 95 per cent confidence interval 0.7 to 2.1 per cent). There was no significant difference in rates of MRSA acquisition. Comments: Treatment with chlorhexidine was interrupted by a product recall and data on infections during this period were censored from the survival analysis. A sensitivity test was conducted to ensure this did not bias the findings –

Nursing Review series Healthy Year Ahead 2013

incidence of infection was still lower in the chlorhexidine group (4.78 versus 6.32 cases/1000 bed-days, p=0.02) with inclusion of data from the recall period. Originally, 12 units were recruited into the study, but one unit withdrew from the study and data from two other units were excluded because of low compliance with the protocol. Cost-effectiveness has not been reported (although may yet be undertaken); however, any costeffectiveness analysis would compare rates under the two conditions, which

Outcome

may not be applicable if the control bathing approach is not being used in local units. Local cost-benefit analyses may be needed. It is not apparent whether the participating units had already implemented the central line bundles and whether this study represents potential for added benefit. Reviewer: Dr Andrew Jull, RN PhD, Associate Professor, University of Auckland & Nurse Advisor – Quality, Auckland District Health Board.

Number of infections (rate/1000 bed days)

RRR

P value

Chlorhexidine

Control

MDRO

127 (5.10)

165 (6.60)

23%

0.03

HA-BSI

119 (4.78)

165 (6.60)

28%

0.007

VRE

80 (3.21)

107 (4.28)

25%

0.05

CC-BSI

21 (1.55)

43 (3.30)

53%

0.004

RRR = relative risk reduction


Articles, profiles and opinion pieces from across the nursing spectrum

Professor Jo Ann Walton

People, practice & policy COMPASSION, CRITICISM, AND COMPLAINTS

OPINION

With the release of the new Nursing Council Code of Conduct, PROFESSOR JO ANN WALTON sees this as an opportunity to create a culture and conversation about compassionate care. TWO ISSUES ARE receiving a great deal of attention in the nursing press and online media at present. There is a resurgence in calls for compassionate care at the same time as we read about shortfalls in service provision. Among the latter have been some dreadful stories of patient neglect, both here and abroad. In the United Kingdom the Mid Staffordshire NHS Trust crisis brought these issues into public notice. Much of the discussion about problems there (including a much higher than expected death rate over a three-year period) is related to the forthcoming Francis Report, which will recommend changes to prevent such scandals from happening again. In the meantime, the Telegraph newspaper reported this week that 43 hospital patients starved to death last year and 111 died of thirst while being treated on hospital wards. At home in New Zealand, there have been yet more reports of grossly inadequate care in residential homes for the elderly. It all reminds me of the dreadful revelations of the ‘Unfortunate Experiment’, the scandal at New Zealand’s National Women’s Hospital. When the then Minister of Health, the Hon David Caygill, first heard of those events, he reportedly told a friend that the fact that people had spoken up about the situation and events at the hospital “was the second best thing that could have happened”. The first best thing, he said, “would have been that it never happened in the first place”. The Cartwright Enquiry that resulted from the expose by Sandra Coney and Phillida Bunkle in the June 1987 edition of Metro magazine had a huge impact on the broad health services environment in New Zealand. From it came the Health and Disciplinary Commissioner, with a clear complaints process for the New Zealand public, and a new process of ethical approval for all health-related research. Another aspect of Coney and Bunkle’s legacy is their example of what can be achieved by speaking up and speaking out. Which brings me to another point. In a recent article in the Dominion Post, British writer Bryony Gordon ponders why women let men do most of the talking in mixed company. She draws on research suggesting that this is so, and concludes that often women just give

up rather than appear to be outspoken, impolite, and ill-mannered. Sadly, her work resonates only too well to me, at least in social situations, or when nothing too important is at stake. But there are times when the stakes are too high for shyness, coyness, or fear of being seen as outspoken. When is that? When our moral compass calls. When something is clearly wrong. When someone will be seriously hurt, or worse, if we don’t speak up and speak out. Of course, as professionals we know this. Right? Or do we? How does it happen that the scandals I referred to earlier still go on? Are we prepared to speak when something needs to be said? The new Code of Conduct published by the Nursing Council of New Zealand is a wonderful tool for centering ourselves as professionals in the New Zealand healthcare context. Not only does it remind us of our professional values and mission, but it also addresses the professional respect we hold for our health team colleagues. In addition, there is clear guidance about escalating concerns when we have witnessed, observed or been made aware of “issues, wrongdoings, or risk that could endanger health consumers or others”. It is well within our power to maintain and build a culture of compassionate care. That, after all, is at the heart of our professional values, our history and our purpose. It is what makes a day at work a good one, even when things are sad, hard and exhausting. Knowing we have done our best is satisfying, gratifying and health giving. Sounds good, doesn’t it? And yes, there is a catch. No one said it would be easy. It also doesn’t happen overnight. One of the things most of us need to learn to do better is to speak up. In

the same way that the most effective praise is both positive and specific, so it is with criticism and complaint. The most effective critique is highly specific, not just because it pinpoints concern, but because it makes alternative action easier to identify. The five rights could be helpful here: the right concern, expressed to the right person, in the right dose (enough to be heard, not so much as to become the problem yourself), at the right time and by the right route (in person, in writing?). Writing about life in the abbey, Saint Benedict wrote about grumbling. Grumbling is complaining that is illfocused, ineffective, and often ongoing. If a leader sees or hears grumbling, its source should be found and fixed, as grumbling is a vital sign of the health of the organisation. Grumbling is infectious and contagious and has the effect of disrupting cohesion in the group. Here’s the challenge: no more grumbling. Read, digest, and live the Code of Conduct. And make active efforts whenever it is necessary to dispense criticism by the five rights. The people we serve are depending on us. * Jo Ann Walton is professor of nursing and head of Victoria University’s Graduate School of Nursing

Nursing Review series Summer Edition 2012/2013

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People, practice & policy NEWS

Lessons from the disaster zone –

twice over

Dr Frances Hughes doesn’t court disasters but they have a habit of finding her. The former chief nurse was in New Jersey on a Fulbright scholarship studying post-disaster lessons when Hurricane Sandy hit. FIONA CASSIE reports on her latest literal lesson. FRANCES HUGHES MAY have been tempting fate. On her last study trip to New York she was in Manhattan the day the twin towers fell. That disaster led to her return more than a decade later to study post-disaster lessons – just in time for the deadliest hurricane to hit the US east coast in more than 50 years. Hurricane Sandy destroyed thousands of homes, forced three Manhattan hospitals to evacuate, and killed 131 people in eight states – including 37 in battered New Jersey where Hughes was staying. It knocked out cell phone towers and cut off power to millions, leaving the elderly and ill trapped in high-rise apartments with lifts out of action. “There’s huge lessons in all this,” says Hughes. The predicted super storm hit hardest one of the world’s most sophisticated cities, New York. “But still, back-up hospital generators fail and you have nurses right in the thick of it – carrying babies and equipment down flights of stairs.” “They (the US) are prepared at one level, and on another level, they are as vulnerable as a developing country.” As a mental health nurse, Hughes always had an interest in psychosocial support in times of vulnerability but says being on the ground for 9/11 was instrumental in her taking a greater personal and professional interest into postdisaster response. She went on to be commissioned, with Australian colleague Margaret Grigg, by the World Health Organisation to write international guidelines for nurses on coping with post-disaster mental health issues. The pair also ran a series of workshops for New Zealand nurses after the Canterbury earthquakes. Late last year, just before taking up her current post as Queensland chief nurse, she won a senior Fulbright scholarship to study post-disaster lessons for health professionals in the United States. This saw her end up in New Jersey in time for Sandy’s arrival and gave her the opportunity to observe some lessons first-hand.

“One of the big lessons for me is you need to constantly do scenarios and role plays with staff – not just about clinical techniques about how you deal with casualties but things like evacuations and how you manage in situations without power and communication technology.” “It sounds basic but you’ve got to do the simulation,” emphasises Hughes. “As otherwise, staff are absolutely flawed when they don’t have that technology.” Gun-toting vigilantes Post-Sandy she found herself in her own “action research” project in a New Jersey community without power, long queues for petrol and milk, and the unsettling feeling that if you went door-to-door offering help, you might be confronted by a gun-toting vigilante worried about looters. Ironically, she started her autumn study tour in the northern parts of New York with the aim of avoiding snow and blizzards – there she had found good examples of pastoral care to critical nursing and medical staff in the event of snow cutting off communities. She had also been south to hurricane-prone Florida to visit the University of Miami, which specialises in disaster management – including training the military – from natural disasters to bio-terrorism and bombs. “It was stunning stuff … in retrospect, I thought these were the kind of systems that New Jersey needed.” These systems included the development and training of nurses in specialist and very efficient triaging of disaster casualties. Florida’s “reserve” health professionals, who are credentialed, trained and ready to be called on to work in the hospital system if a disaster strikes, also impressed Hughes. Like our army territorials, they get paid to train and paid if deployed, and there is a real time database, so at any one time, the health system knows how many reserves can be called into action (see sidebar about a new New Zealand initiative).

It was on her return to the New York region that she got caught up in Hurricane Sandy – the former Wellingtonian says the noise of these winds made her experiences of southerly storms fade into the background. Post-Sandy, she talked with a Kiwi friend working with the New York Community Nursing Service about the struggle to care for renal and palliative care patients stuck in high-rise apartment buildings without power, with often the only contact being the nurse ready to climb flight after flight of stairs by torchlight. The biggest lessons to be learned, she believes, are from the hospital evacuations, and she has established links with nurses from the affected hospitals to help inform her ongoing research (full hospital services are still not expected to be restored at Manhattan’s main public hospital Bellevue until February and only slightly before that for NYU Langone Medical Centre’s Tisch Hospital). Hughes says the evacuations – some in the middle of the hurricane – showed that one just can’t be prepared enough. “It’s not the place to learn by experience.” It brought home to her the need for New Zealand and cyclone-and flood-prone Queensland to ensure it has good basic training for nurses in disaster management and a good core of nurse leaders with postgraduate-level training in the roles needed, from coordination to counselling, when a disaster strikes. Meanwhile, her Fulbright scholarship will see her returning to the States in February, where she will attend the third ever national symposium on hospital disaster response – including evacuation – which was already scheduled before Sandy but has now “taken on a whole new flavour”. Her second trip has been scheduled in the American winter and includes trips to post-Hurricane Katrina New Orleans, Memphis, the tornado-prone Kansas, and finally, San Francisco. Here’s hoping that fate doesn’t provide any more opportunities for action research.

NZ seeks nurses for disaster volunteer database Nurses willing to volunteer in disasters both here and across the Pacific Islands are being invited to register for New Zealand’s new Medical Assistance Team (NZMAT). The NZMAT volunteer database is seeking to create a pool of appropriately skilled and experienced nurses, doctors, paramedics, allied health, and logisticians who can be deployed by the Ministry of Health if and when needed. The first official NZMAT training course is scheduled for April next year. Volunteers are being sought from across the health spectrum, including emergency medicine, surgery, paediatrics, primary care, public health, and mental health. The volunteer database follows more than 800 health sector staff volunteering to help out after the 2009 Samoan Tsunami, with all the applications having had to have been manually sifted to find the skill sets required. The Ministry says registration does not automatically mean selection for training or deployment, but pre-registered and appropriately trained staff are the most likely to be deployed to an emergency, either domestically or within the south-west Pacific. More information about volunteering for NZMAT is available at the emergency management page of the Ministry of Health website www.health.govt.nz You can register for the volunteer database at: https://volunteerhealth.org.nz

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Nursing Review series Summer Edition 2012/2013


People, practice & policy QUAKES

Nursing research and the Canterbury earthquake events Christchurch Hospital’s ED nurse researcher SANDY RICHARDSON reports back on nursing research arising from the aftermath of the Canterbury quakes. THE SERIES OF earthquakes and aftershocks since the initial 7.1 quake back in September 2010 has given rise to a number of research opportunities. As one of the many nurses working clinically during this time, and as the nurse researcher in Christchurch Hospital’s emergency department (ED), I believe this was a unique moment in time and one where nurses made a significant contribution to the health and wellbeing of the community. As a founding member of the RHISE group (Researching the Health Impact of Seismic Events) I became involved in a series of research projects. These have included the establishment of an injury database for the February 22 earthquake, a collaborative project developing a resource for future research activities. This database is a unique contribution to disaster knowledge, and one that was recognised and funded by the Health Research Council, the Canterbury District Health Board, the Emergency Care Foundation and the regional Emergency Care Coordination Team (ECCT). One result of this funding support was the appointment of a research nurse, Viki Robinson, to coordinate the database and establish the network of responders who provided data. A second project is one that I felt strongly about – having worked alongside so many nurses, medical, allied health staff, and volunteers on February 22 – I felt that it was important to ‘capture’ these experiences and recognise the significance of those contributions. As a result I established a project that involved interviewing staff and others who contributed to the ED response. This work was supported by the Foundation, and with over one hundred interviews completed, is now in the process of being written up. Tracking quake victims through ED Other nurses involved with the RHISE group have developed their own research projects and collaborations. One of these is ED nurse and PhD candidate Polly Grainger who has chosen to investigate the processes used to track patients as they arrived in ED and onwards to wards or home, as well as documentation in general during the hours after the earthquake. This tracking is looking at the unique identifiers used to identify patients,

their samples and their clinical imaging. She has been interviewing staff from a range of clinical and support fields while looking at processes used internationally in disasters. Literature at this point has been drawn from Australia after their fires and floods and the USA and Italy after their earthquakes. She hopes to develop a more robust system for use in disasters and major incidents in general. This study has the potential to be used by health organisations wherever there is the possibility for multiple casualty incidents. In my role as senior lecturer with the University of Otago’s Centre for Postgraduate Nursing Studies in Christchurch, I have developed a series of research projects looking at the impact of the quakes on healthcare learning and teaching processes. One has investigated the students’ ability to learn and continue with their formal studies. This has involved surveying undergraduate and postgraduate nurses enrolled in a course of study at the time of the major quakes, together with registered nurses who were studying as part of the nursing entry to practice (NETP) and new entry to specialist practice (NESP) programmes. Another study has focussed on the experiences of teaching, administration and support staff who worked with students during this time. These studies were funded by Ako Aotearoa Tertiary Teaching Excellence and through the University of Otago’s CALT funding respectively. The support for nurses involved in research relating to the earthquakes has been significant, with many other projects registered with RHISE or occurring independently. The support has been more than just financial, with strong interdisciplinary collaborations developing, and the recognition of the role of nurses not only as contributors to the healthcare response but also as researchers able to explore and share the significance of these events. Sharing hard-won experience While I have been privileged to be able to carry out both independent and collaborative research, nurses have also presented findings and recommendations from this experience, perhaps without fully recognising their role in the research process. Several ED senior nursing team

members have been invited to present on their experiences and share their recommendations. This seems to me to be an effective and practical reflection of the integration of theory and practice – these nurses are also researchers, learning from a clinical experience and then translating this learning into changes that can potentially impact on nursing practice throughout the country. The significance of the earthquake experiences lies not only in the moment of crisis, but also in terms of understanding its ongoing impact. We talk laughingly about the “new normal” and “quake brain”, but these are the realities for many living in Canterbury and for others who have been impacted in a secondary manner from the events. We no longer feel that instinctual assumption of safety in regard to our physical environment.

Even now, two years and over 10,800 aftershocks later, people are still struggling to make sense of their lives; we still jump at the sound of a truck going past. The hyper-vigilance has been linked to high adrenaline levels, but what health issues might be associated with this? How well are nurses dealing with the fallout now that we are supposed to have passed the worst? There are still many questions waiting to be addressed, and many opportunities to share the learning that results. Please contact Sandy Richardson at sandra.richardson@cdhb.govt.nz if you have any questions about the earthquake research or the RHISE group.

Professor Margaret Walshaw has researched doctoral engagement and is a published author in the field of doctoral study. www.engine.ac.nz

DOCTOR OF EDUCATION Massey University’s Doctor of Education programme will support your career development as an educational leader. This high-level qualification will expose you to the most upto-date research from New Zealand and and support you to carry out an in-depth exploration of a professional area of most interest to you.

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Massey University’s College of Education and Centre for Educational Development provide ongoing teacher and educator courses from inschool professional development, to Diplomas, Masters and Doctorates. Find out more at www.massey.ac.nz

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COLLEGE OF NURSES

JUDY YARWOOD

Pilgrim’s lessons for 21st century challenges College of Nurses co-chair JUDY YARWOOD shares some touchstones or life lessons for today discovered by a friend while following an ancient pilgrim’s trail.

W

ading through the reading pile gathered over the year is one of the joys of holidays. This year a friend’s reflections on a pilgrimage she’d recently completed caught my eye. Known as ‘The Camino’, this Christian pilgrimage, dating back to medieval times, has people from different points in Europe walking to the Spanish city of Santiago de Compestela. While the penitential aspect for pilgrims of yesteryear has faded, this more and more popular walk can provide spiritual solace in an increasingly spiritless world, along with physical and mental health benefits. Reflecting on this life-changing experience, my friend identified six touchstones – or lessons for life, if you like – for challenging times. All of which, are, I think, relevant for those working in the health sector, which if nothing else, is certainly facing challenging times! See what you think … Context is everything, so picture two sisters walking the Camino from a small village in the south of France. This involved walking over and around the Pyrenees and through four provinces, in both hot and cold weather, for 30km each day. The journey was mentally relaxing, spiritually uplifting, emotionally and physically challenging, and ultimately, a reminder of important ‘life lessons’. 

Lesson 1: Get over yourself When getting by in only two sets of clothing, sleeping in cramped accommodation with up to 120 strangers, and walking some days with inadequate food or water, the ability to ‘get over yourself’ and find humour in every situation was critical.  The key to ‘getting over yourself’ is self awareness. How we see and experience the world is only how we see and experience it, no one else. We all carry well-buried self-limiting beliefs, negative attitudes, and expectations about ourselves and others that unwittingly hold us back or tie us in knots. And when faced with challenges, when push really does come to shove, we will find we can actually do more than we may ever thought possible. ‘Getting over yourself’ requires making no assumptions

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Nursing Review series Healthy Year Ahead 2013

about anything and avoiding judgements, having no expectations (of anyone or anything), and adjusting quickly to change. If we’re really clever, deliberately setting our intentions for each day and deliberately choosing the attitude we want to take into each day lifts our game and energy levels immediately.

Lesson 2: Self care Despite adequate preparation and preventative measures, leg injuries and blisters struck a week into the walk but recovery was relatively quick. Numerous pilgrims who weren’t fit or adequately prepared had a miserable time and struggled from the outset. The key to self care is embracing the ‘if it’s to be, it’s up to me’ motto. Self care is our own responsibility and we can’t blame others for what we may or may not have done to date. Good ongoing self care strategies are essential to cope with everyday life and ordinary challenges, as well as extraordinarily difficult times. This necessitates healthy eating, regular exercise, reducing negative stress, having a range of strategies to manage multiple stressors, and having enjoyable, fun things in our life. Keeping one’s health and wellbeing is critical because if it’s lost other losses inevitably follow.

Lesson 3: Let go The best laid plans can go to pieces. It happens. Despite intentions to walk every step of the 800km route, leg injuries necessitated bus travel for a few days.  The key to letting go requires us to stop railing against things we have no control over. It means identifying the things we can control and identifying the things that aren’t in our control – it pays to know the difference. It requires us to see the new situation simply as it is. There is no point analyzing it to death or going on about it; alternative plans are needed, as is getting into gear, quick smart.

Lesson 4: Be in the present moment Without the need to be ‘doing’ anything else than walking, the opportunity was to be truly human ‘beings’, fully engaged in the present moment – i.e. this minute, this hour, this morning.

The key to be in the present moment is to stop wasting energy and time looking back to how things were or looking too far forward on how things might be. It is easy to ruminate endlessly on grievances, missed opportunities, past successes, or disappointments. Too much focus in the past or on the imagined future means we miss now – the present. The challenge is to remember that this moment, this day, will never come again. The past is gone, the future isn’t known, and there is no guarantee we’ll have a tomorrow, so all there really is, is now. We need to focus on that.

Lesson 5: Ask for help The help of strangers was relied on for clarifying directions and finding transport, medical facilities, accommodation, banks, and shops.  The key to asking for help is to understand it isn’t a sign of weakness; instead, it is a sign of self awareness. It is about realising that sometimes time is of the essence and input sooner rather than later is the best option. 

Lesson 6: Receive gracefully On a number of occasions, villagers and fellow pilgrims offered food, drink, medicine, help with accommodation, and unsolicited much-needed directions in random acts of kindness. The key to receiving gracefully is to ‘get over ourselves’. People most used to giving freely to others may find it strange and uncomfortable being a recipient of other people’s generosity or kindness, yet receiving is the other side of the giving coin and needs embracing. A reminder, too, that gratitude needs to extend beyond an immediate need to all that is good and great in one’s life. A ‘gratitude list’, reviewed daily, is one way to do this. Entitlement attitudes and deficit thinking are best avoided. There is nothing new about these ‘life lessons’ – they are as old as time itself. Yet in the busy-ness of personal and working worlds, and in the context of extraordinarily difficult or challenging events, they can be forgotten. There is no time like the present then to start anew. The touchstone lessons were written by personal management coach Sue Dwan of Dwan and Associates © 2012.


A round-up of national and international nursing news

For the record DIABETES E-LEARNING SITE LAUNCHED FOR PHC NURSES A FREE ONLINE LEARNING PROGRAMME to help primary health care nurses meet the growing demands for diabetes care is being offered on a newly launched website. The e-learning resource has been developed by nurses for nurses by the New Zealand Society for the Study of Diabetes (NZSSD), with the support of the Diabetes Nurse Specialist Section (DNSS) of NZNO. Helen Snell, a diabetes nurse practitioner and a NZSSD spokesperson, said a catalyst for the online resource was the growing incidence of diabetes and the demands this was placing on primary health care nurses. “In particular, with the change from the Get Checked Programme to Diabetes Care Improvement Packages, a pressing need was identified for a contemporary and evidence-based online resource to be readily available. The content of the programme is based on the Whanganui PHO (primary health organisation) diabetes workbook and aims to help nurses feel confident and effective when caring for people with diabetes. It contains seven modules aligned with the Diabetes Nursing Knowledge and Skills Framework and is aimed at the ‘fundamental’ and ‘generalist’ levels on the framework. Snell said areas covered include different diabetes management strategies, self-care of diabetes, and also initiating insulin in general practice, which was being increasingly encouraged. “We hope that it (the e-learning programme) will whet nurses’ appetite to learn much more about diabetes and to go on to become diabetes nurses specialists and registered nurse prescribers.” The learning resource website can be accessed via NZSSD www.nzssd.org.nz or NZNO www.nzno.org.nz. The online learning resource is stage one of a wider diabetes knowledge and skills platform website being developed by NZSSD, with the long-term aim of the site to provide resources and networks for diabetes consumers, non-regulated diabetes workers, and health professionals working in the field. Meanwhile, a second cohort of 15 diabetes nurse specialists who wish to prescribe has been recruited and is working to complete a practicum so the nurses can meet Nursing Council prescribing standards. The nurses are spread across six sites, from Northland to Central Otago, and will bring the total number of diabetes nurse specialist prescribers to 26.

HWNZ ‘trivialising’ nursing concerns Health Workforce New Zealand’s initial response to the nursing sector’s lack of confidence call was trivialising serious concerns, says NZNO professional services manager Susanne Trim. Leaders of the New Zealand Nurses Organisation, College of Nurses Aotearoa, and College of Midwives in late November sent an open letter to HWNZ expressing “significant concern” at HWNZ’s performance and the need to restore sector confidence in its core workforce planning role (see Nursing Review online NewsFeed story November 30). In a statement, HWNZ director Brenda Wraight said she was disappointed to read of the concerns and recognised there were “significant changes under way in the sector which can cause unease”. “I think she’s trivialising the lack of planning that HWNZ has done around the nursing and midwifery workforce and trying to sideline us as uneasy and upset,” said Trim. “Actually, we’re a bit more than upset – we don’t take the move of writing an open letter lightly. We’ve got serious concerns and HWNZ needs to take these seriously.” Jenny Carryer, executive director of the College of Nurses, said Wraight’s response was “outrageous” and did not recognise the enormous efforts made by nursing to deliver on its full potential. Trim said the three nursing organisations believed there were serious concerns about the long-term impact of the ageing workforce and the over-reliance on overseas-trained nurses that needed to be addressed by HWNZ. “With 50 per cent of the nurses joining the register each year being overseas-trained, it’s quite high risk if things change internationally and that market dries up,” Trim said. Meanwhile, Health Minister Tony Ryall’s office responded to the letter’s comment about HWNZ chair Des Gorman having a “direct line” to Ryall by saying the Minister appointed the chair and so kept in regular touch with him. The Minister declined to comment further on concerns raised in the open letter and directed all inquiries to HWNZ. Nursing Review has requested an interview with HWNZ executive chair Professor Des Gorman to discuss the concerns raised and a range of nursing workforce issues.  

Poaching’ of ENs to Oz could grow New Zealand needs a better workforce plan for its enrolled nurses with Australia predicting a 30,000 shortfall in ENs by 2025, says EN leader Robyn Hewlett. Hewlett, chair of NZNO’s enrolled nurse section, has expressed frustration at the lack of workforce planning to back the ‘return’ of the enrolled nurse. A survey in October found only 56 per cent of the July graduating cohort of ENs were in nursing work, with the majority in residential aged care and very few employed by district health boards. At least six of the 130 graduating ENs had crossed the Tasman to find jobs. She said she was aware of ENs being ‘poached’ from New Zealand, including employers ringing up polytechnic nursing schools seeking new graduates. Hewlett hoped that the ENs would return to New Zealand with their knowledge and skills. But such poaching was only likely to grow with a Health Workforce Australia report predicting the supply of enrolled nurses to start falling from 2013, leading to a shortfall in 2025 of about 30,000 ENs to meet projected demand. The report said that to meet that projected demand Australia would need to start near doubling the number of students enrolled in enrolled nurse programmes, with the aim of having nearly 6000 graduates a year from 2016 onwards. Meanwhile, Hewlett has been part of a working party developing an EN fact sheet to help encourage the employment of ENs in acute care settings. The EN section has also drawn up its own workforce paper with 19 recommendations.

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For the record

PHC nurse gets MH stamp of approval THE FIRST PRIMARY HEALTH nurse to gain formal recognition for her mental health nursing skills has been credentialed and others are due to follow. Anne MacLean, who works in a primary mental health nurse role for East Tamaki Health Care, successfully sought her mental health credential under the framework developed by the New Zealand College of Mental Health Nurses. Jo Harry, college and credentialing manager, said the aim of credentialing was to help primary health care meet the mental health and addiction needs of their enrolled populations. “We know from the research that there is a relationship between mental disorder and chronic physical conditions, and at any one time, 20 per cent of the population suffer from mental health and addiction issues.” The framework, supported by Health

Workforce New Zealand, also aims to help PHC nurses work at the top of their scope by setting down the knowledge and skill standards required to “competently and confidently” provide a primary care response to people with mental health or addiction problems. Being credentialed means a nurse has specific skills in basic mental health and addiction assessment and intervention but not to the specialist level required for mental health nursing. Harry said Rotorua Area Primary Health Services and Northland’s Manaia Health and Te Tai Tokerau PHOs (primary health organisations) were also progressing with upskilling and credentialing nurses and were looking to their local district health boards for support with training and mentoring. Initially, under a planned HWNZ innovation project, the large Auckland PHO ProCare was to develop a mental health skills training programme for general registered nurses to

be rolled out across the country, but this had not eventuated. More information about the credentialing process can be found at the College’s website: www. nzcmhn.org.nz Meanwhile, credentialing is part of the College’s overarching Accreditation, Certification and Credentialing Framework and the College is in the early planning phase for introducing a certification process for mental health nurses.

Shared secretariat push still divides

THE PUSH TO MERGE the Nursing Council’s regulatory and support services with the 15 other regulatory authorities continues with a detailed business case being developed. The Nursing Council has expressed ongoing reservations about the Minister of Health’s merger proposal but is part of a steering group spending up to $250,000 commissioning a business case into a full shared secretariat. “The Nursing Council remains unconvinced that full amalgamation

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would result in greater efficiencies and/or lower costs for this regulatory authority,” said Nursing Council chair Margaret Southwick. The Council, the largest by far of the 16 regulatory authorities (RAs), believes that one of the Minister’s aims – a national health workforce database – is possible without merging the authorities’ regulatory services. Southwick said the Council was always open to working collaboratively with other RAs but was “cautious about

Nursing Review series Summer Edition 2012/2013

proceeding down any pathway that we believe might undermine the validity and credibility of nursing regulation within the New Zealand context”. The division between the authorities over the scale of the merger (the Medical Council and Dental Council are understood to be in favour of a full merger) led to the setting up of the steering group, with three representatives from each camp. The steering group, chaired by former Health & Disability Commissioner Professor Ron Paterson, has been asked to develop a detailed business case (DBC) for the proposal that the “RAs collaborate across all their functions (including regulatory, IT, finance, and support services) to ensure better regulation of the health professions in New Zealand”. Paterson said the steering group was “working very well together” and making “good progress”. The group is on target to sign the contract, worth up to $250,000, with the selected business case provider before Christmas. The resulting business case is due to be completed by midApril and presented to each of the 16 authorities for them to decide whether they support implementing the proposal. Southwick said the Nursing Council has been advised that the Minister has limited options

by FIONA CASSIE

under the Health Practitioner Competency Assurance (HPCA) Act to compel authorities to merge. “Without a change to the Act, it would have to be a voluntary move on the RAs part.” A review of the HPCA Act is underway by Health Workforce New Zealand, with further consultation on proposed changes to the Act scheduled to take place in March and April next year (see online NewsFeed story Nov 16 on NZNO concerns about Act review). The business case provider has been asked to report back on how the authorities currently function, develop a DBC on a single shared secretariat (including identifying associated costs and benefits and a supporting IT strategic plan), advise on shifting to shared premises, plan for all transition and implementation costs, and estimate the impact on annual practicing fees for health professionals.

Southwick said the Nursing Council has been advised that the Minister has limited options under the Health Practitioner Competency Assurance (HPCA) Act to compel authorities to merge.


For the record Nursing Council ‘effective’ but needs greater transparency

Tide change for Waves

by FIONA CASSIE

TARANAKI’S WAVES YOUTH HEALTH SERVICE is still seeking to re-open but its founding nurse practitioner Lou Roebuck is seeking a fresh start. The youth health service, which has struggled for sustainable funding since opening five years ago, closed its doors in October after being unable to gain ongoing funding for its ‘youth one stop shop’ (YOSS) model of care. Garth Clarricoats, the chair of Waves’ Taranaki Youth Health Trust, said it currently had a strategic plan out for consultation and was open to discussions with any potential providers of services committed to the trust’s wraparound holistic approach to youth health. A year earlier, tensions between Waves, Midlands Health Network PHO (primary health organisation), and Taranaki District Health Board over the Waves model of care, clinical practice, and funding led to a mutual agreement for Waves to exit its health services contract with Midlands. Waves continued to offer youth health services for a further year while working on gaining Te Wana quality accreditation as a first step in seeking a new health services contract. It gained accreditation in nine months but ran out of funding before securing a new PHO contract. Lou Roebuck says she remains committed to youth health but after putting “huge amounts of time and energy” into Waves – including two and a half years unpaid work and constant funding struggles – she now wanted to move on. She was continuing to work with Family Planning, was being an NP locum for other YOSS around the country, and next year, she was looking at the possibility of working alongside a GP practice and gaining capitation funding for her own youth clients. At the time of going to press, she was doing an NP locum at Rotorua YOSS, Rotovegas, and said working at a better resourced YOSS had brought home to her how underresourced Waves had been. “I’m definitely passionate about youth health, but I can’t see Waves actually gaining the funding that it requires to keep open – not in the foreseeable future anyway –even though the (trust) board are really keen to get going, they are a great bunch of people, and they’ve done excellent work.” She said she also felt “shamed and blamed very unfairly” by a local media report in November that Waves had ‘failed’ a DHB audit of Midlands health services contract back in September 2011. Midlands chief executive John Macaskill-Smith said in a statement that the DHB had initiated the audit following Midlands passing on a health professional’s concerns about some clinical practices at Waves. Roebuck said Waves was already seeking to exit the contract with Midland Health – because of it ‘not being in line’ with the YOSS model – when the short notice audit was called and carried out with a new staff member. Midlands said the audit found one high risk concern (unlocked medication storage cabinets), eight moderate risks, and three low risk concerns relating to the quality framework, clinical supervision activities, and documentation issues. Clarricoats said the health service had not ‘failed’ the audit, and if there had been clear systemic failures that placed people at risk, the service would have been shut down. He said the high risk that needed immediate addressing – the unlocked cabinets – involved prescription medication such as the emergency contraceptive pill, not controlled drugs, and the offices had always been locked when not being used by clinicians. Clarricoats said all of the risks had been addressed and the total Waves service had gone on to compete the two-year Te Wana accreditation programme in nine months and passed with merit. He said Waves had some rebuilding of relationships to do and was in contact with a large number of potential stakeholders in anticipation of changes to PHO membership rules next year that could benefit organisations like Waves.

The Nursing Council is an effective regulator with strong leadership and a commitment to improvement, an external review found. The review, carried out for the Council by the British Council for Healthcare Regulatory Excellence (CHRE) that reviews the UK’s nine health professional regulatory authorities, generally gave the Council a thumbs-up. But it also made a number of recommendations for suggested improvements, including changes in the process of selecting and appointing council members and greater transparency. “The NCNZ is doing a good job but it seems to be doing it mostly in private,” the review says. “One of its roles is to maintain public confidence in regulation. It cannot do this if the public does not know what it is doing.” It recommended that Council papers, agendas, and minutes should be published so the public and registrants can have confidence in the Council’s work, and that the Council’s role and decisions be better communicated to patients and the public. The review said the Council was protecting the public through its conduct, competence and health processes and overall reviewers found “sound decision making”. Nursing Council Chief Executive and Registrar Carolyn Reed said the review was both pleasing and useful. “The review of our functions was extremely thorough and provided us with a critical external perspective. It is always helpful to see one’s performance through the eyes of others and we particularly value the patient/public focus of the review.” The full review report and the Council’s action plan for responding to the recommendations can be found on the Council’s website: www.nursingcouncil.org.nz

Three-way contest now for NZNO presidency Successful appeals have resulted in the current and ex-presidents’ bids to lead the New Zealand Nurses Organisation being resurrected. Nursing Review reported online in September that current president Nano Tunnicliff and immediate pastpresident Marion Guy had their nominations declined for failing to meet all the new constitution’s criteria for the soon to be full-time paid position. NZNO has now reported that the two candidate’s appeals were successful and they have joined former NZNO board of directors’ member Lynn Latta in contesting for the presidency. Voting by members closes in mid-January and the new president is expected to be announced in early February.

Snippets »» Hawke’s Bay renal nurse practitioner Rachael Walker was joint runner-up in the recent Health Informatics’ Clinicians Challenge for her proposal on streamlining chronic kidney disease referrals. She wins up to $5000 towards professional development. The top prize went to Opotiki GP Jo Scott-Jones and Rural General Practice Network chair for his proposal on improving standing order processes. »» Capital & Coast District Health Board director of nursing for the past three years Kerrie Hayes is now director of nursing for Calvary Health Care in Canberra. Andrea McCance is currently acting director of nursing and midwifery.

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Nursing Review 2012