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FOCUS  n  Infection Control / Wound Care / Child & Youth Health

Nursing Review october/november 2016/$10.95

New Zealand’s independent nursing Series

INFECTION CONTROL/ WOUND CARE Battling antibiotic resistant bugs Diabetic foot ulcers

Q&A Vicky Noble with


a Kiwi nurse in Belgium

CHILD & YOUTH HEALTH Kiwi kids growing up or out? Activities to ease anxious kids New child & youth vaccine schedule

free 60-minute

Professional Development learning activity

Unlike some other private surgical providers, Southern Cross Hospitals’ primary focus is to deliver the highest quality care at the lowest price we can. We concentrate all our resources and energy on our patients’ wellbeing, helping people in the communities we serve to get back on their feet again. That’s not going to change for many years to come. You see, we’re different. We’re a not-for-profit private hospital network. We invest any surplus into advancing our facilities, developing a high quality workforce and in the safety of those we provide care for. We don’t have to think about generating shareholder wealth, or making short term profits. We leave that to others.


Simple childhood diseases not so simple The other day I came across a photo of my then four-yearold son soaking in a bath trying to ease the itching from his chicken pox. He came through fine but the photo brought back other memories. The day before the pox emerged, my son seemed his usual bouncy self and we had invited a mate back to play after kindy. That mate’s brother was going through treatment for a childhood leukemia. The next morning when I saw the pox I didn’t recall that at first but when I did my heart sank. I rang the mate’s mum to pass on the unwelcome news and was sweetly reassured that the mate and his brother had had chicken pox so not to worry. Though I’m sure she did. Soon after I heard that the mate’s brother had shingles. The story, eventually, ends very, very sadly. I don’t know if or whether it is technically feasible that my son’s virus had a part in his mate’s brother’s losing battle against cancer, but what it did bring tragically home to me is that simple childhood diseases are never simple for some people in the community. So the announcement that from 1 July next year that the Government will be funding the varicella (chicken pox) vaccine for all babies at 15 months is one I warmly welcome and endorse.

REMINDER: Free 60-minute PD learning activity All print copies of Nursing Review now include Nursing Review’s regular RRR professional development article. Read the article, reflect on it and apply it to the reality of your nursing practice and you will have earned 60 minutes towards the Nursing Council requirement for 60 hours’ professional development over three years. Check out our latest RRR PD article in the middle of this copy. Fiona Cassie

Wider distribution for Nursing Review Free copies of Nursing Review are now sent directly to every ward at every major hospital. If this is your first time reading Nursing Review, contact editor Fiona Cassie and tell her what you think (especially if you have news or ideas to share!). These free copies will have all the features and opinion Nursing Review is known for, but only subscribers will receive print and online access to the RRR professional development activity. To get your personal copy (including RRR), go to: COVER PIC: More and more strains of bacteria are becoming resistant to antibiotics and other antimicrobial medicines. Read on p.4 what nurses can do to help combat this international public health threat. PHOTO CREDIT: iStock Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).

Inside: FOCUS: Child Health/ Infection Control/ Wound Care 4 ANTIMICROBIAL RESISTANCE: Nurses’ vested and vital role, including tales of the H-Bug and pre-antibiotic days 8 Deep breaths: project to ease childhood anxiety 10 Kiwi kids: growing up or growing out? 12 Childhood obesity: empathy not judgement

Professional Development 15 Prevention of catheter-associated urinary tract infections Reading, Reflection, and application in Reality To subscribe go to

19 20 21 24

Cancer-protecting vaccine: don’t forget the boys Chicken pox joins evolving immunisation schedule WOUND CARE: preventing & detecting diabetic foot ulcers Something in the water: lessons from HAVELOCK NORTH

Practice, People & Policy 27 29

CULTURAL SAFETY: facing stereotypes & prejudices Policy: culture-changing huddle in ED

Regulars 2 Q&A Profile: Corrections’ health leader VICKY NOBLE 3 A day in the life of… a Kiwi nurse in Belgium 30 Evidence-based Practice: CYNTHIA WENSLEY on ‘chilling out’ cannula pain 32 College of Nurses: JENNY CARRYER on snapshot postgrad survey

Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ Editor Fiona Cassie 03 981 9474 Advertising & marketing manager Belle Hanrahan 04 915 9783 commercial manager Fiona Reid production Aaron Morey Subscriptions Gunvor Carlson 04 915 9780 images iStock

Nursing Review

Vol 16 Issue 5

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

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


Vicky Noble

JOB TITLE | Principal Health Advisor, Department of Corrections

There is a bigger issue here too. Nursing has always managed to combine warmth and integrity with specialist knowledge and skills. As budgets grow tight – and the world of health care becomes increasingly complex and demanding – it is hard for nurses to sustain their long-established ways of working. I’m not sure I know what the answer to this is, but I think it is something that I am increasingly aware of and concerned about.


What do you think are the most important personal characteristics required to be a nurse? Patience, sensitivity, warmth and resilience – and a sense of humour! If there was a fairy godmother of nursing what three wishes would you ask to be granted for the New Zealand nursing workforce? More money, more numbers and more authority.


Where and when did you train? I trained at Greenlane Hospital in Auckland in one of the last hospitalbased training programmes in the 1970s. By the way, I really loved the fact that this involved me learning on the job in a practical sort of way. Over the years I have come to recognise the value of having such a solid foundation to my work.


Other qualifications/professional roles? I took time out in the 1980s to get a BA (Hons) degree in three-dimensional design specialising in glass. Later I did my New York State nursing exams when I thought we would be living in New York for an extended period (as it turned out we only stayed a short time). I did my Master of Nursing through Victoria University of Wellington, completing it in 2004. As far as professional roles are concerned, I have done a lot of different things. These have included helping to set up an international health centre in Beijing, running a regional health training and quality programme in Jakarta, and being a clinical nurse consultant at Hutt Valley DHB. Most recently I was the Director of Nursing Primary Health Care and Integrated Care at Capital & Coast DHB.


When and/or why did you decide to become a nurse? I decided to become a nurse when I was 14 years old. I went with my mum to see a friend of hers who was in need and

we found her dead, alone in her flat. At that point I decided I wanted to contribute in a practical way to give people care, warmth and support so that if they suffered from ill health they would not be neglected and left on their own.


So what is your current job all about? I am the Principal Health Advisor in the national office of the Department of Corrections in Wellington. On a day-to-day basis I advise on policy and best practice in relation to healthcare delivery to prisoners at 16 sites. Overall the main purpose of my job is to improve and strengthen clinical practice in the prison system. I have been in the job eight months so far and have visited most of the sites. I am still learning about my job but I am enormously struck by the extraordinary talent and commitment of so many of the people I work alongside. It is a demanding environment to work in and there is still so much to be done.

What do you do to try and keep fit, healthy, happy and balanced? I walk to and from work, do yoga and try to sleep well. Also a glass or two of good red wine and tasty food with friends and family is something I always look forward to.


Which book is gathering dust on your bedside table waiting for you to get round to reading it? Emma Sky’s The Unravelling – about a woman’s extraordinary achievements in the horror of Iraq. She started as a British council worker and then ended up as the senior advisor to one of the most powerful US military generals because her combination of skills in Arabic and hard common sense was a rare, if not unique, asset.


What have you been reading instead? I have just finished David Galler’s Things That Matter. Beautifully and sensitively written, especially the last chapter, which focuses on his “best patient ever” – his beloved mother, Zaza.





As a leader in primary health care what do you believe are the strengths of nursing practice in the 21st century, and where is there room for improvement? Over the years, nursing has held onto the central importance of practical experience combined with knowledge and skills. The 21st century is giving us the opportunity to work in a wide range of extended and expanded roles. In response we need to focus on increasing the breadth and depth of our knowledge.

2    Nursing Review series 2016  |

If I wasn’t a nurse I’d be a…? Jeweller or a glassmaker (I was that once) – or doing something working creatively with my hands. What is your favourite meal? Slow-cooked lamb, Moroccan style.

A day in the life of ...

a Kiwi nurse in Belgium

NAME | Rachael Maunsell JOB TITLE | Ward nurse in the VIP ward of a private hospital LOCATION | Brussels, Belgium


AM WAKE My alarm clock goes off at 5.15am but I need to hit the snooze button at least two or three times before I can make it out of bed. I shower, get dressed and always need to eat breakfast otherwise I feel out of sorts. Breakfast is porridge with a cup of tea and then I’m out of the door by 6.15am. It is summer in Brussels and light when I leave, so I’ve started biking to work. I find it good exercise and it only takes me 25 minutes. On arriving I change in our rather cramped locker rooms and head upstairs to the ward.

telephone when it rang, answer a nurse call bell, or speak to the doctors and take medical orders. There was a lot of learning in those first three months. I was so exhausted, I was in bed every night by 9pm. However, Belgians are open people and generally incredibly understanding of my grammatical mistakes and terrible phonetics (Kiwi accent). Some patients and doctors like to practice or speak English, but usually 90 per cent of my day is in French.


PM LUNCH Lunch is usually a quick 15–20 minutes to eat something before we start the report for the afternoon staff at 1.30pm.


AM START My working day starts with the handover from the night nurse. Today we are a team of two nurses, one nurse aide and an agency nurse to help us with the increasing number of patients. I work in the VIP ward of a private hospital. The VIP ward has 17 rooms which are designed more like a hotel room for patients willing to pay more for the comfort. Each room has a small kitchenette with tea and coffee facilities, a bathroom with Bvlgari soap products and nice towels, etc. The sheets for the beds are made from silk cotton and patients are able to order room service from the restaurant. The standard of care and the preference for medical treatment is no different to any other patient in the hospital. The majority of patients are Belgians, but we have had a real variety including some French musicians and European politicians. Most of our patients are coming in for surgery, but we take a wide range of medical patients as well.



AM MORNING ROUTINE After report it is assisting patients to have a wash – whether in their bed or helping them to the bathroom, making sure they have adequate pain relief, and following up on treatments following the doctors’ round. Being the VIP ward you have to be adaptable, although it is not always possible. Some patients like to sleep late, some like to have their breakfast first and it can be challenging and demanding. It is a very individual style of care. Most patients always ask how a New Zealand nurse ended up working in a hospital in Brussels. I moved to Brussels four years ago because my partner is Belgian. I was lucky to get this job and also lucky that it was relatively easy getting Belgian nursing registration. It helped that I had a living/working visa (based on being in a relationship with a Belgian) and that I had had nursing registration and experience in the UK, an EU state (for now). I had to get all my documents officially translated but there

were no examinations or even a language proficiency test – after three months I received my Belgian registration. While waiting for registration I went to French school each morning. (I was not able to speak any of Belgium’s three official languages – French being the most prominent in Brussels). After three months of classes, I didn’t think it would be possible to work in nursing with such a basic level of French but my partner encouraged me. We found this hospital, which wanted an Englishspeaking nurse for their new VIP service, though French was still essential. I started work on a three-month trial period with both the hospital and I knowing my French needed to improve dramatically if I was to continue. My French was incredibly basic and working in a noisy and busy environment made it difficult to understand and be understood. I was terrified to answer the

PM MEDICATIONS After the report it’s time to give the 2pm medications, follow up on any care or treatment, maybe take an admission and finish off any last minute arrangements. The names and preferences of drugs are different from New Zealand and the manner of nursing is subtly different, for example IV antibiotics, controlled drugs can be checked and given by one nurse. I had been nursing for 12 years before nursing in Belgium and could not have survived those first months without this knowledge and technical experience behind me. The Belgian health system is complicated but it offers a wide variety of technical health care options with direct access to consultants and minimal wait times. There is a payment for each medical visit and procedure. Every Belgian is required to belong to a mutuelle health insurance scheme and the majority of the medical cost is reimbursed by the mutuelle. The final price the patient pays depends on whether the patient chooses a private or public system. This amount can also be covered by health insurance.


PM LEAVE WORK FOR YOGA After leaving work today I bike into the centre of town where I have my twiceweekly yoga course. I find it a good exercise and it helps to relieve the stress of the working day.


PM HOME After yoga it’s a quick stop to the supermarket to find something for dinner and I am home by 7pm. My partner and I sit at the table eating dinner and chatting and then it is a collapse on the couch for some internet, reading or television.


PM TIME TO SLEEP  |  Nursing Review series 2016    3

FOCUS  n  Infection Control / Wound Care

Antibiotoc resistance:

how can nurses help?

Seventy-five years after the ‘wonder drug’ penicillin saved its first patients, we could be heading toward a post-antibiotic era in which common infections once again kill. Nurses have both a vested interest and a vital role in preventing this. FIONA CASSIE reports.


n January 1941 Mrs Elva Akers, a “pleasant” 50-year-old woman with terminal breast cancer, readily agreed to try a new medicine that could benefit others, though not herself. The medicine was penicillin1. A few weeks later, a 43-year-old policeman who was “desperately and pathetically ill” received the first therapeutic treatment of the drug. A sore on his lips had led to both staphylococcal and streptococcal septicaemia. He had multiple abscesses on his face and had lost one eye; the infection had also made its way into the bones of his right arm, there were abscesses in his lung and he was in great pain. After the first day of treatment he felt “a little better”; by the fifth day he was “vastly better” with no fever, the abscesses healing and he was eating well2. The golden age of antibiotics and modern medicine had begun. Advance 75 years and the world’s health leaders are warning us that that golden age is at dire risk of being very short-lived. Already 700,000 people a year die of antimicrobial resistant (AMR) infections (see definition) and this is estimated to rise to 10 million people a year by 2050. The British Government’s O’Neill Report earlier this year predicted not only this chilling human toll but also that by 2050 rapidly escalating AMR could have a gobsmacking potential US$100 trillion impact on the world’s economy. It’s not like we weren’t warned. The very same year that penicillin made the policeman “vastly better” the first bacteria resistant to penicillin were identified. And as early as 1945 Sir Alexander Fleming, who first isolated the antibiotic substance from mould back in 1928, was speaking out about the consequences of “thoughtless” use of the resulting new wonder drug. But despite the warnings the decades that followed have seen “systematic misuse and overuse of these drugs in human medicine and food production”, says the World Health Organization (WHO). In response to this threat to modern medicine WHO last year launched a global action plan on AMR, stating: “Without harmonised and immediate action on a global scale, the world is heading towards a post-antibiotic era in which common infections could once again kill.” Healthcare workers, says WHO, have “a vital role in preserving the power of antimicrobial medicines”. So what should and can nurses do?

What can nurses do?

Nurse leaders say that, whatever the causes of AMR, nurses definitely need to be part of the solution. If they are not, and the spread of AMR continues as projected, nurses will no longer be able to nurse the way they do today, says Dr Frances Hughes, the New Zealander leading the International Council of Nurses – a federation of 130 national nurses associations representing 16 million nurses worldwide. In March the Geneva-based chief executive put out a media release stressing the key role of nurses worldwide in reducing the impact and limiting the spread of this major threat to public health, after discussing the health workforce implications of AMR with other international professional organisations. “We’ve legitimately got a role in this,” says Hughes. “As when antibiotics aren’t available for infections we will be the caregivers.” Entering a post-antibiotic era would force nursing practice to adapt to nursing infections and fevers that most nurses have never faced, says Hughes, and, maybe

“We are the major players in infection control.” in the future, to do so in the community as hospitals try to protect themselves from antibiotic-resistant superbugs. Dr Jane O’Malley, Chief Nursing Officer at the Ministry of Health, agrees nurses have a “huge” role to play in the campaign against AMR – both at the strategic level and at the practical frontline level because of how many patients they are in touch with over the course of a year. Nurse practitioners have been prescribing in New Zealand since 2003 and new regulations passed this year will see many more specially trained and authorised registered nurses able to collaboratively and carefully, prescribe antibiotics. But whether nurses are prescribers or – more commonly – administrators and advisors about medicines, O’Malley says one of nursing’s biggest roles is educating and advocating for better public understanding and awareness of when antibiotics are needed and when they are not. Hughes agrees that nursing has a major role in health education and improving health literacy and says ICN is actively pushing for investment in

4    Nursing Review series 2016  |

educating nurses so that nurses can in turn put in place AMR strategies with consumers and patients around the world. “Nurses are prescribers and we are administrators of medication,” says Hughes. “We can and do inform on medication side effects. We are the ones that can educate patients about medication regularly because we are with the patients regularly. We can educate them about the difference between viral and bacterial infections. And about how else they can look after themselves and treat common ailments (without antibiotics). “We are the ones that can vaccinate and immunise people so they don’t get common diseases that they shouldn’t get – like flus – that can lead to secondary infections. And we are the major players in infection control.” What about now? What impact is AMR already making on how healthcare is delivered in New Zealand? And how close has poor antibiotic practice brought us to the worse case scenario?

Ever more expensive and inconvenient treatments

One common infection experienced by most women and also, less commonly, men are urinary tract infections (UTIs). Mark Thomas, an infectious disease physician at Auckland City Hospital, says once such infections – usually caused by E. coli (Escherichia coli) from the intestine making its way into the bladder – could all be treated with an oral antibiotic. But the associate professor in the University of Auckland’s molecular medicine and pathology department says now about 5–6 per cent of E. coli found in women’s urine are “resistant to pretty much every oral antibiotic”. So intravenous antibiotics and time in hospital are needed to knock back the resistant E. coli causing cystitis (bladder) or the less common pyelonephritis (kidney) infections.

Definition of antimicrobial resistance (AMR) The major focus of antimicrobial resistance (AMR) strategies is the growing number of bacteria resistant to antibiotics. But AMR is also about viral and fungal diseases – and common parasites like scabies and head lice – becoming resistant to antiviral, antifungal and antiparasitic medicines.

FOCUS  n  Infection Control / Wound Care

“The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism.” Sir Alexander Fleming, shortly after receiving the Nobel Prize in 1945 for his 1928 discovery of penicillin.

to antibiotic treatment and others do not. For instance, the group A Streptococcus bacteria that causes strep throat and can lead on to rheumatic fever has never become resistant to penicillin, despite decades of penicillin use. But increasing resistance to antibiotics by other bacterial infections and diseases means ever more expensive and inconvenient treatments. He says a great example is gonorrhoea – once simply treated by an oral antibiotic, increased AMR means it now requires an intramuscular antibiotic plus an oral antibiotic. Another is New Zealand’s internationally very high use of topical antibiotics – like fusidic acid (Foban) or mupirocin (Bactroban) – for impetigo (school sores) and other skin infections – has seen us end up with a high proportion of S. aureus (Staphylococcus aureus) infections that are resistant to antibiotic ointments.

Overseas – luckily very rarely here – there has developed not only a MDR-TB (multi-drug-resistant tuberculosis that is resistant to two drugs) but also XDR-TB (extensively drug-resistant TB). Then there is the new generation of superbugs – those resistant bacteria strains that develop faster than new classes of antibiotics can be developed to fight them. Thomas says at present New Zealand only sees the occasional patient turn up – often having been in a hospital overseas – who has an infection that is essentially impossible to treat, and sometimes these patients die. “They are usually patients who have got horrible health problems – they’ve had a transplant or repeated surgery or have had something that has led to them having lots of courses of antibiotics.” Those superbug patients are still very rare in New Zealand – Thomas estimates the number lost to a completely untreatable infection is around one

Antibiotic histories Fighting pus in pre-antibiotic days

and the sterilising of anything and everything possible, including instruments and dressings. But as you couldn’t “boil a nurse or surgeon” antisepsis or antiseptics had their place.

Fighting sepsis was a major preoccupation of nursing in the pre-antibiotic days, says nursing historian Dr Pamela Woods. Unfortunately, she says, antimicrobial resistance might see that return and her collection of antique nursing texts on preantibiotic surgical nursing and aseptic wound dressing might need to be dusted off and put into use once again. The EIT associate professor spoke recently at a major research symposium in London looking at the past and future of hospital infection control, presenting a paper called Pus and pedagogy: sepsis, surgical nurses and suppurating blame 1900–1935. Wood says hospital gangrene and other horrific post-surgery infections were the norm in the early days of surgery and surgical success depended on the prevention of sepsis. The first significant technological inroad into fighting sepsis began with Joseph Lister in the 1860s championing ‘antisepsis’ by using carbolic acid as an antiseptic to kill off the newly discovered, airborne, disease-causing microbes. The discovery that most microbial infections were transferred by contact not by air saw the advent in the 1880s and 1890s of ‘asepsis’

“Now we are at this time we can’t rely on antibiotics – we simply can’t – we need to think back to those pre-antibiotic days and see what were they doing that was so successful – including scrupulous aseptic practice.”

either valued by surgeons as guarding patients from “microbial attack” or blamed if wounds became infected. “Septic wounds meant septic relationships.” Wood says there was also a strict nursing hierarchy in who could do what, with the junior trainee nurses taught medical asepsis or medical cleanliness that focused on keeping the environment and patient’s body clean. It was only the senior nurses who were taught surgical asepsis, including responsibility for sterilising theatre instruments, cleaning the surgical site preoperatively and doing the aseptic dressings after surgery. “They understood the need for really careful aseptic technique, including lengthy hand washing before doing a dressing, and if there was an infected wound on the ward they would save that to last to reduce the risk of cross-infection. “And if there were more septic wounds then senior nurses would share the job. One would do the all the clean, uninfected wounds – she was called the ‘clean nurse’ – and the other who did the infected wounds was the ‘dirty nurse’. “Now we are at this time where we can’t rely on antibiotics – we simply can’t – we need to think back to those pre-antibiotic days and see what were they doing that was so successful – including scrupulous aseptic practice.”

“And we expect the proportion won’t be just 5–6 per cent – in two or three years it will be 7 or 8 or 10 per cent and that proportion will steadily rise so that common infection will more commonly require people to be in hospital having intravenous treatment.” The source of the problem is well known. The world’s wide use of antibiotics knocks back the normal, dominant strains of a bacteria causing infection, creating environments where the resistant, minority strains of a bacteria can multiply and spread in a way not possible in pre-antibiotic days. WHO says these drugresistant bacteria – created by antibiotic overuse in medicine and, food production – can then circulate in human and animal populations and through food, water and the environment, helped along by trade, travel and migration. Thomas says what does remain mysterious is that some bacteria very quickly become resistant

The combination in the early 20th century of asepsis and antisepsis – including stringent hand washing and surgical gloves – made a “huge difference” to hospital practice, says Wood, and for the first time surgeons could expect that surgical patients would heal and recover. The professional responsibility for following the strict aseptic, sterile procedures for pre and post-operative wound care was given to the surgical nurse. Wood, after studying nursing journals, textbooks, exams and memoirs of the time, says it becomes clear that nurses in pre-antibiotic times were  |  Nursing Review series 2016    5

FOCUS  n  Infection Control / Wound Care

AMR and stewardship: What can nurses do? Help reduce the demand for antibiotics/antimicrobials by:

»» improving public awareness and understanding of antimicrobial resistance (AMR) and its impact »» educating patients and consumers about the difference between viral and bacterial infections and why antibiotics aren’t the answer for colds, flus etc »» carrying out careful assessment and following best practice guidelines in prescribing antibiotics and other antimicrobial medicines »» educating people how to look after themselves and others when they have common ailments, rather than seeking antibiotics »» promoting health literacy amongst consumers »» role modelling by not requesting antibiotics for treatment of viral or fungal infections for themselves or their families.

Help reduce the need for antimicrobials by:

»» promoting and practising good hand hygiene to prevent infection transmission »» promoting good general and personal hygiene in the home using ordinary soap and water (antibacterial soaps and wipes are unnecessary) »» practising good infection prevention and control measures in hospitals and other settings including good environmental hygiene, contact precautions, patient placement and screening etc »» encouraging and supporting the uptake of immunisation against diseases or two a year – a lot fewer than overseas countries that use a lot more antibiotics than we do. So on the world scale New Zealand’s AMR situation could be worse. But Thomas says we could also be much, much better with still far greater antibiotic consumption in New Zealand than in careful, prudent countries we should be modeling ourselves on, such as the Netherlands and Sweden. Thomas, who is a member of a Ministry of Health and Ministry of Primary Industries working group helping to develop New Zealand’s own AMR Action Plan, believes that New Zealand’s farming use of antibiotics is not the biggest

Antibiotic histories H-bug takes human toll in the ‘50s Penicillin first became available, initially in limited supplies, in New Zealand public hospitals in 1944. Just a few years later Dr Doris Gordon, the Director of Maternal Welfare from 1946 to 1948, observed worrying signs that increasing reliance on antibiotics was already leading to a slipping in maternity care standards developed to reduce the risk of infection. Dr Deborah Jowitt, who did her master’s thesis on the H-bug epidemic in New Zealand, says that Gordon visited one North Shore maternity home during her post-war baby boom directorship to find 18 mothers jammed into a premises licensed for 12 and their 18 babies squeezed into a nursery so tiny that cot touched cot. The matron explained her simple method of housing extra babies – “just put two babies head to toe in one cot”. “Today’s doctors blandly tell me,” Doris Gordon later wrote, “that penicillin will take care of cross infections! My prophecy is that penicillin may not always take care. It’s not a panacea for carelessness and someday these Staphylococci will stage a comeback…” In the mid-1950s to early 1960s her prophecy was proven right with an epidemic of penicillinresistant staphylococcal infections occurring

like the flu that have a risk of secondary bacterial infections »» following best practice in the insertion and management of invasive devices (like urinary catheters, intravenous lines, PEGs etc) to reduce the risk of infection »» advocating and supporting public health strategies – like smoking cessation, healthy eating and regular exercise – so people ‘live well’ and don’t suffer health complications that compromise their immunity »» managing and tracking infectious outbreaks and improving infection surveillance.

Help enhance the effectiveness of appropriately prescribed antibiotics by:

»» following best practice medicines management (including obtaining samples/swabs etc to confirm source of infection) »» dispensing antibiotics at the right time, the right route and under the optimal circumstances (i.e. with or without food or other medications) »» educating patients and their carers on how to take antibiotics in the home setting, including not sharing with other people and taking a full course of appropriately prescribed antibiotics (only stopping the course after a consultation with the prescriber).

Support global AMR strategies and objectives by lobbying:

»» governments to develop and strengthen national antimicrobial resistance surveillance systems »» for increased investment in new medicines, diagnostic tools, vaccines and other interventions »» for investment in educating nurses in how best to carry out their AMR roles.

issue. Neither is it hospitals. Instead it is in the community, with 95 per cent of human antibiotics used outside of hospitals. Therefore, a major focus, he believes, for health professionals should be educating the public about AMR and doing their best to reduce both unnecessary antibiotic use and unnecessary infections.

Changing the habits of a lifetime

The public definitely has a role to play in AMR, says chief nursing advisor Dr Jane O’Malley, by not expecting an antibiotic every time they rock up to their GP or NP with a cough, cold or flu. in New Zealand hospitals and communities. Called the ‘H’, or Hospital, bug, these infections occurred frequently among mothers and babies in maternity units. In her master’s thesis Jowitt, a nurse and infection prevention and control specialist, described the impact of these infections on her own family at that time.

Educating the public why antibiotics aren’t the answer when they have a viral or minor infection is a key role for nurses – the health professional who often spends the most time with patients, says O’Malley. (See sidebar for more suggestions.) Thomas agrees. “The most common infections that people go to their general practice about are respiratory tract infections (RTIs): colds, coughs, sore ears and sore throats,” says Thomas. “And for most people those infections are relatively trivial.” (The exception to this is Māori or Pacific children and young people with sore throats because of the rheumatic fever risk.) “If we were to stop taking antibiotics for those RTIs – and there are endless guidelines around the world saying that’s what we should do – then we could dramatically reduce the antibiotics we are using and make a big difference to the selective pressure for antibiotic-resistant germs. Waverley Newson, a Lakes District Health Board’s infection control nurse specialist, agrees, saying the fact that antibiotic prescribing data shows a seasonal upswing is concerning. “It makes you think that antibiotics are being prescribed for viral illnesses over winter – antibiotics can be appropriate to use for a secondary bacterial

Resources and useful links Ministry of Health

AMR advice, updates on AMR action plan development, and guidelines on controlling multi-drug-resistant organisms “As children in Kaitaia we all suffered from recurrent boils and our baby brother became very ill after being admitted to hospital with our mother as a boarder baby,” wrote Jowitt. “She took him to Auckland several times before he was diagnosed with a penicillin-resistant infection. The medical superintendent at Kaitaia Hospital was able to dispense erythromycin, a new antibiotic developed in the early 1950s and he recovered. “Our baby cousin was not so lucky – she died of staphylococcal pneumonia the following year.”

6    Nursing Review series 2016  |

World Health Organization (WHO)

UK’s O’Neill Report

Site for the UK Government’s Review on Antimicrobial Resistance and the resulting report by economist Jim O’Neill released earlier this year.

FOCUS  n  Infection Control / Wound Care

infection – but the quantities make you suspicious that isn’t the only reason they are being prescribed.” Newson sits alongside Thomas on the national AMR Action Plan group, representing the Infection Prevention and Control Nurses College, NZNO, and is one of three nurses on the working group. O’Malley says the Action Plan group started meeting this year in response to WHO’s strong call for all member countries to have a national AMR strategic plan in place by May 2017. “And the Ministry of Health is working with the Ministry of Primary Industries on a One Health approach, as obviously the use of antibiotics for agriculture, horticulture and aquaculture does happen in New Zealand,” says O’Malley. It is hoped a draft strategic plan will be available to the Ministers before the end of year ready for consultation in the New Year. “So we are moving in the right direction,” says O’Malley, who once again stresses the importance of nursing’s role in both the strategic and frontline response to fighting AMR. And 75 years after Mrs Elva Akers agreed to be the first human tested with penicillin, in the hope that it “could be of value to many1”, it also seems respectful to honour this “pleasant” woman’s legacy to modern medicine by ensuring the wonder drug’s influence is not cut any shorter by thoughtless use. 1. Charles Fletcher. First clinical use of penicillin, BMJ, 289, 1984 2. Fletcher reports that the research team’s quantities of penicillin were so limited that supplies were exhausted on the fifth day and sadly the policeman deteriorated and died.

Antibiotic histories Hips, knees, and MDROs In modern hospitals reducing antimicrobial resistance (AMR) is a major focus for infection prevention and control (IPC) nurses. This is reflected by three nurses with IPC backgrounds being part of New Zealand’s AMR Action Plan group. One of those is Lakes District Health Board’s infection control nurse specialist Waverley Newson – the representative of the Infection Prevention and Control Nurses College, NZNO, on the group.

Newson says the IPC sector has long been aware of AMR and in particular trying very hard to prevent the transmission of MDRO (multi-

drug-resistant organisms) in hospital and other settings. This is a dual role of trying to prevent the transmission of MDRO from patients known to be colonised and also trying to prevent the risk of MDROs developing through reducing unnecessary or inappropriate antibiotic use. She says IPC nurses’ ability to directly influence inappropriate prescribing has been more limited but one recent success has been influencing the prescribing of prophylactic antibiotics during hip and knee surgery. The surgical site infection (SSI) improvement project, led by the Health Quality and Safety Commission, included very clear advice on reducing AMR by focusing on the timing, dose and length of prophylactic antibiotic therapy following hip and knee surgery. Newson says in the past quite frequently prophylactic antibiotics were given for much longer than the best practice advice of 24 hours post-operatively. The research indicated extending antibiotics use beyond 24 hours provided no benefits and instead increased the risks of side effects and the potential for antibiotic resistance. “I believe infection control nurses have been very influential in providing education and feeding back audit results to the orthopaedic teams, and we’re now seeing a very good compliance with that measure,” says Newson. She says a further spin-off appears to be better prophylactic use of antibiotics in other surgical specialties.  |  Nursing Review series 2016    7

FOCUS  n  Child & Youth Health

Helping kids

take a deep breath

Canterbury schools. The rural hinterlands had not only been shaken like their urban counterparts but also had quake-traumatised families move into their school communities. More recently North Canterbury has been suffering a long, morale-draining drought.

New therapies for quake-anxious kids

Simple activities developed to help teachers calm anxious kids in postquake Canterbury are soon to be shared more widely to help nurses, parents and teachers boost child wellbeing around the country. Nursing Review talks to mental health nurse MICHELLE COLE to find out more.


hen kids bounce, bound or slope back into a classroom after playtime it takes time to settle them down ready to learn. Add to the mix children who have experienced their home and classroom being literally shaken on thousands of occasions – including some who may have lost their home, school and even loved ones – then settling them down can be even more challenging – particularly when their teachers and parents have been through the very same stresses. It was dealing with such scenarios that spurred a project in Canterbury aiming to provide simple, evidence-based interventions that can be used by all adults to support children both “in and out of difficult times”. The project being developed by Canterbury’s school-based mental health team – with the support of Canterbury wellbeing agency ‘All Right?’ – started with a working title of ‘Tiny Interventions’ but the final name is yet to be decided. The school-based mental health team was set up in 2013 to provide outreach services to post-quake Canterbury with mental health nurses making up four of the seven-strong team serving schools from Ashburton to Kaikoura. The Canterbury District Health Board-based team is one of the Government’s youth mental health initiatives and the model may in time be rolled out to other regions. At present the team is working with more than 90 of Canterbury’s 200 or so primary and secondary schools. Michelle Cole, a mental health nurse with a strong background in youth mental health, joined the team in late 2013 to start reaching out to rural

8    Nursing Review series 2016  |

The seed for the project came about when a school approached the team in 2014 wanting support for about 17 children it had identified as having anxiety issues in its year 3–4 cohort. The children were seven to eight years old at the time so had been aged around four and five when the quakes hit in 2010–11. Cole says while there is no simple formula for forecasting which ages or developmental stages were most affected by the quakes there were “definitely some groups of kids that have more vulnerabilities”. And the cohort of children that were preschoolers or early primary school age around the time of the quakes are one of the cohorts that the team often gets requests from schools to work with. Though she adds there are pockets of kids and youth across all ages whose developmental trajectory has been thrown off track by the quakes. “I will still go and consult on a kid who may have an issue with attendance or something like that and when you start to talk to them you sometimes find they are still cosleeping in their parents’ bed … and earthquakes are still something they think about quite frequently.” When Cole and the team went to work with the rural school with its cohort of 17 anxious children she says it wanted to see what therapeutic tools or skills it had to share with the staff that could make a difference. When the team suggested introducing ‘tummy’ (diaphragmatic) breathing in class circle time as a self-calming technique for children it found that while some of the teachers had heard of the technique none of them had actually done it. Teaching the teachers how to share tummy breathing with their class seeded the idea with the team to look further for simple, do-able interventions that could help teachers help their students and along the way also help themselves. “As our poor teachers had been through so much as well,” says Cole. “So doing something that is good for their own wellbeing is good for the kids’ wellbeing as well.” “The idea then grew its own legs and took off,” laughs Cole. The project now has around 30 activities or interventions aimed at primary school age children. Early on the team approached Sue Turner, the campaign manager at All Right?, as it had loved the Tiny Adventures resource it had developed for families (see more next page) and wanted to develop something similar for schools. With the support of Christchurch Earthquake Appeal Trust (CEAT) funding the project was widened to create a resource not only useful for teachers but also parents, nurses and other adults supporting children’s wellbeing. A steering group was established to drive the project made up of representatives from the DHB’s school-based mental health team, health promoters from the DHB’s Community and Public Health division, Pegasus Health and the All Right? team. The project is being led by the school-based mental health team, in collaboration with the steering group. Cole says as part of designing and developing the resource it has been offering professional development to other professionals working with children in schools including public health nurses. The ‘pick ‘n’ mix’ simple activities or interventions the team are sharing with teachers and nurses aim to proactively lay the seeds of wellbeing as children grow up and into adolescence.

FOCUS  n  Child & Youth Health

School-based Mental Health Team

School-based outreach service to support schools in addressing emerging child and youth mental health issues in Canterbury in the postearthquake recovery stage

All Right? Canterbury

This organisation has supported a range of projects to support Cantabrians’ mental health and wellbeing, including the upcoming schoolbased mental health project. Other projects include: »» Tiny Adventures An app designed to suggest quick, fun and affordable activities with children »» Activities for the whānau A set of activity cards designed to help connect with whānau and culture, including Matariki calendars, encouraging kōrero with elders, playing traditional knucklebones and going fishing.

“I suppose from a nurse’s point of view – as a nurse who has worked offering brief interventions to adolescents – it is like my ‘dream wish list’ of what you wish that that 14-year-old in front of you could have been exposed to when they were at primary school,” says Cole. So while the project was prompted by children suffering quake anxiety it has resonance beyond Canterbury and could be helpful for all children, as anecdotally Cole hears that some of the behaviours being reported by Canterbury schools – including increasing numbers of new entrants not seeming ready for school, with behaviours ranging from struggling to sit still at mat time to hurting other children – are not just a Canterbury experience. “At first we thought it might be related to the earthquakes and upsets to the children’s developmental trajectories but we are being told that they are also being seen at a national level.” The quakes may also only be a component in Canterbury schools’ reports of increased anxious behaviour being shown by children around ages 10 and 11 and reports of self-harming behaviour starting to emerge at primary and intermediate school level. Cole says the aim of the project is to help children notice their emotions, balance their energy and become aware of their senses and are clustered into five themes including ‘Managing self’, ‘Showing kindness’ and ‘Creating a calm space’. The project’s activities or interventions are still being refined but are built on exercises the team already use with schools including a popular breathing workshop developed by Cole’s colleague Carmen Murphy which she has offered in many classrooms in many schools around Canterbury. “It’s incredible – and we are all using it as well.” “It’s amazing when you go back and ask the small children ‘how are you going with your tummy breathing?’ and they tell you they are using it to help them get to sleep at night or when they’ve had an argument with their big brother … they are adopting it and soaking it up in a way that is quite surprising to us. “And the teachers are reporting that it is very beneficial and they are using it [tummy breathing] at times like when kids come back in from lunchtime or other busy times to help settle the children.” Tummy breathing and other resources being shared by the project will follow a similar format. So each intervention or activity has the same subheadings: i.e. ‘The skills’ (under which they list the skills enhanced by the intervention), ‘Why we love it’ (which introduces some of the science behind the intervention) and finally ‘What to do’ (how to carry out the intervention).

One activity can involve colouring-in mandalas (usually circular symmetrical patterns) which is a ‘flow activity’ that allows kids to relax into and stop a busy mind by engaging in a calming activity. Another is called ‘Energy rollercoaster’ and aims to help kids identify their energy levels at that moment on a scale from 1–5 and then flow on to use other ‘Managing self’ interventions to either help them burn-off some energy (like star jumps) or help boost their energy levels if feeling lethargic. Cole says an advantage of the project is that it is offering simple and inexpensive activities and interventions that work and don’t soak up schools’ limited budgets and times for professional development. “We find schools pretty thirsty for easy, doable, achievable things.” The mental health nurse is also keen for the team to be able to share these simple mental health interventions with nurses in other practice areas who work with children. And so maybe more kids will be able to take some deep tummy breaths next time they feel angry or want to relax.

Tummy breathing: an intervention example Tummy breathing (also known as diaphragmatic or deep breathing) focuses on expanding the abdomen rather than chest, to help boost oxygen intake. Mindful breathing is a quick, easy way to trigger the body’s natural relaxation response. It draws our attention to the present, and can even help us to turn anxiety and anger into feelings of relaxation and focus. We suggest giving students regular opportunities to practice this skill, and encouraging them to tune in to their breathing whenever they feel upset or angry, or want to unwind and relax.

Project intervention themes for fostering child wellbeing »» »» »» »» »»

Creating a calm space. Managing self. Taking notice. Feeling good. Showing kindness.  |  Nursing Review series 2016    9

FOCUS  n  Child & Youth Health

Kiwi kids: growing up or growing out? A new national health target is underway on screening and referring obese fouryear-olds. FIONA CASSIE finds out more and whether this is enough to help curtail the 10 per cent of Kiwi kids who are now clinically obese – fat to the point that their health is likely to be at risk.


t is a given that kids come in all shapes and sizes. Some grow up to be Olympic medal winners like Valerie Adams, Eliza McCartney, Tom Walsh, Lydia Ko and Lisa Carrington. The vast majority of them just grow up. But worryingly, more and more Kiwi kids are growing up obese – not just carrying a bit of extra weight, but fat to the point where they are at risk of developing type 2 diabetes as children, and are struggling to sleep.

Worrying statistics

The numbers are getting frightening, says Professor Barry Taylor, head of paediatrics at the University of Otago’s Dunedin School of Medicine and founder of Dunedin’s Childhood Obesity Clinic. Around 10 per cent of New Zealand children are now obese – topping the 98th percentile in BMI (body mass index) growth charts and about 5 per cent of those have extreme obesity (a BMI of 35 or higher), with extreme obesity a particular concern among Pacific people and Māori.

The reasons are complex and multiple but easy access to cheap, energy-dense, nutrientpoor foods at the same time as increasing screen time is definitely taking a toll on our children’s waistlines. And an obese child is very likely to be an obese adult. Obesity can now also start very early. Taylor says about 70 per cent of children aged between six months and two years are gaining weight too fast. But the whole nation has been getting heavier in the past three decades, so we are starting to see overweight children as the new normal. Results from the 2013–14 New Zealand Health Survey highlighted this, with nearly 90 per cent of parents of obese two- to four-year-olds saying their child was a normal weight and more than half the parents of obese five- to nine-year-olds. It is the consequences of this normalising child obesity that worries Taylor. A study of New Zealand obese children, just published in September, for the first time showed how prevalent the risk factors for developing

10    Nursing Review series 2016  |

serious weight-related illness were amongst Kiwi obese children. And how young these risk factors were emerging. The study looked at 200 Taranaki obese children and teenagers involved in a 12-month multidisciplinary, weight management intervention in Taranaki called Whānau Pakari. Dr Yvonne Anderson, the study’s co-author and a paediatrician, says children as young as five were found to have risk factors for type 2 diabetes and signs suggestive of obstructive sleep apnoea. Tests found that overall 40 per cent of the children involved had high risk signs for type 2 diabetes, 75 per cent had signs of inflammation (increasing long-term heart disease risk) and 50 per cent snored four or more nights a week. Anderson said the children in the study were not just “carrying a bit of extra weight” – they had health indicators that could be life-limiting if not addressed.

Heads in the sand?

Knowing that obesity in childhood could be lifelimiting is one thing. Knowing and feeling confident

FOCUS  n  Child & Youth Health

… it is time for a culture change to shift the focus from children failing to thrive to children growing too fast.

that you can help make a difference is another. When Dee Repko set out to survey fellow paediatric nurses for her master’s thesis, she found she was not alone in providing limited obesity interventions to overweight or obese children they worked with. The Hawke’s Bay nurse’s survey two years ago was prompted by her own experience of seeing a lot of large children in her hospital work but few conversations being started with families about the long-term health implications of their children’s weight or referrals made. “Basically nothing was being done … it was put into the too-hard basket.” Her survey found the majority of paediatric nurse respondents were aware of programmes like Active Families in their own region but few referred families largely due to their workload, lack of time and the perception that families were not open to referrals. But the vast majority were keen in receiving education on obesity interventions. As a paediatric nurse, Repko says she is expected to screen all families on immunisations to being smokefree and questions why such a major public health issue as child obesity isn’t added as a fifth screening requirement. She, for one, sees a vital need for national guidelines in BMI measurements and training in effective obesity interventions that paediatric nurses like herself and other nurses can use in their daily practice and not just during the B4 School Check.

Screening for children’s BMI

From 1 July this year screening and referring obese four-year-olds at the B4 School Check is a national health target as part of the Government’s Childhood Obesity Plan. But should we be routinely screening earlier and more often than just at four years old? Since the first Plunket book, measuring, charting and monitoring children’s growth has been part and parcel of nursing in New Zealand. Barry Taylor thinks it is time for a culture change to shift the focus from children failing to thrive to children growing too fast. Taylor, chair of the combined South Island district health boards’ childhood obesity plan strategy, says ideally that we should not only screen for obesity at age four but much earlier and at least once again at age 11. “It would be really good to know whether children are growing excessively at age two,” he says. If height and weight measurements and BMI calculations were routine and regular through a child’s life, nurses and others could pick up if the trajectory of growth started to accelerate too fast and then show parents objectively what was happening on their child’s BMI chart. Taylor is pushing for the Ministry of Health to adopt a standardised online child BMI

Obesity Plan target seeks to raise referrals from 28% to 95%

calculator that leads through to the Be Smarter resources (see corresponding article) if a child’s BMI is too high. Natalie Parkes, psychologist for Waikato’s Bodywise child weight management intervention, agrees “absolutely” that in an ideal world the more routinely and regularly all children’s growth was measured and charted the more natural it would be. Likewise Barbara Docherty, who specialises in offering behavioural training to health professionals, says why not continue measuring growth milestones beyond baby and toddlerhood. But only if regular BMI screening was universal and not just targeting certain people or groups. “Once we are targeting people they know they are being judged … we don’t want overweight kids to be targeted at school, and at their general practice and for them to keep feeling targeted over and over again.” Because, as physical education researcher Professor Lisette Burrows points out, it is not automatic that all overweight children will go on to be obese and have weight-related diseases; they may instead feel stigmatised and end up with poor body images and relationships with food. “And some [fat acceptance advocates] would say the way they are regarded and treated by society is much more damaging to their mental health and wellbeing than any damage done by physical disease.”

resources Ministry of Health: Childhood Obesity Plan

Agencies for Nutrition Action (ANA)

Research and resources on improving nutrition and physical activity in Aotearoa

Weight: A parent’s guide

Paediatric Society of New Zealand and Starship Foundation joint website

BMI for children

UK’s NHS BMI healthy weight online calculator Healthyweightcalculator.aspx NZ’s Weight-Height to BMI conversion chart pages/weight-height-bmi-conversion-chart.pdf

Some Māori and Pacifika weight management research projects

»» weight-management-programme-focusespacific-churches

Since 1 July this year the new childhood obesity target ‘Raising healthy kids’ is one of the Government’s six national health targets. The target, one of the initiatives in the Government’s Childhood Obesity Plan, is to have 95 per cent of obese children identified in the B4 School Check programme offered a referral to a health professional for clinical assessment and family-based nutrition, activity and lifestyle interventions by December 2017. A child is defined as clinically obese if their BMI is above the 98th percentile (using the NZWHO Growth Charts – see resources sidebar). In the 2015–16 year B4 School Checks were delivered to 57,985 four-year-olds, of which about 9 per cent were identified as clinically obese. About 28 per cent of these children and their families were recorded as being referred on for further assessment and an intervention programme.

Don’t blame the kids:

tax fizzy drinks and stop the ads Many argue that the biggest driver of childhood obesity is the modern world we live in. Kiwi kids, unlike their grandparents, are growing up surrounded by heavily promoted, easily available, cheap food and drinks that are high energy and nutrient poor. And the addictive lure of screen options sees kids spending more sedentary hours. Making the healthy choice the easy choice is a growing call from the World Health Organization (WHO) to the New Zealand Medical Association. The ideal, says Professor Barry Taylor, is to have an environment where resisting temptation is just not so hard. Frustrated anti-obesity campaigner Dr Robyn Toomath, in her 2016 book Fat Science, argues overweight people are entitled to an environment that makes it easier, not harder, to remain healthy and slim, and government policy is key. “Eating healthy food and getting enough exercise should be the default, not something we have to battle for.” Recommendations from WHO’s 2015 Ending Childhood Obesity report – backed by most New Zealand obesity advocates – include the following: »» Implementing an effective tax on sugarsweetened drinks. »» Restrictions on the marketing of junk food to children and adolescents. »» Eliminating the provision or sale of unhealthy food and drinks in schools. STOP PRESS: Recommendations released on October 20 for changes to current voluntary Children’s Code for Advertising Food including increasing age coverage to young people under 18 years and for “occasional” (junk) food and drink ads “not to be screened, broadcast, published or displayed in any media or setting where more than 25% of the expected audience are children”.  |  Nursing Review series 2016    11

FOCUS  n  Child & Youth Health

Childhood obesity:

empathy, not judgement

Nursing Review reports that nurses need to put away their own prejudices or guilt about weight and start conversations that will help families find a healthy way forward


sk Kiwi kids what makes a healthy diet and 80 per cent will tell you eating fruit and vegetables. Eighty-five per cent of them will also tell you their most common drink is tap water. And they are very aware you need to be physically active every day to be healthy – and the vast majority are. It is not a lack of information that is making some Kiwi kids fat. Experts will you tell you it is a complex mix of genetic, psychological, lifestyle and social deprivation factors, combined with today’s obesogenic environment promoting the double whammy of easy access to high energy foods and sedentary behaviour. In fact, Professor Lisette Burrows says her research shows the “sheer relentlessness” of prohealth/anti-obesity information in schools means kids know the healthy living message “inside out and back to front” from a very young age. But information, says the University of Otago academic, who helps train the country’s physical education and health teachers, doesn’t necessarily change a person’s behaviour. Neither does fear, with her studies showing some very young children obsessing that having fat on their bodies means they will never get a job or get married. Burrows believes a more holistic, less ‘weight management’ view of health needs to be taught, with some of the best examples of improving health in the sense of wellbeing being done by Māori providers for Māori communities.

She encourages her students to nurture kids having a regular relationship with food – which should be a pleasurable and sociable activity – and to move for fun and not as a chore. “So both of these things (eating and exercise) are just not anchored to getting thin.” “As there ain’t no quick solution [to obesity], intentionally, or unintentionally, making kids feel bad about their bodies or that they are not doing the right thing is not necessarily helpful.” For the kids whose rapid weight gain is putting their health at risk, paediatrician Barry Taylor, a fellow Otago professor and obesity researcher who founded Dunedin’s Childhood Obesity Clinic, says interventions should focus on the parents and not the child. “To focus on the children labels them and the evidence is that it is actually the family interventions, and working with the families to change that family’s lifestyle, that will be more effective than just saying to the child, you’ve got to stop eating rubbish.” That is one reason why Taylor, who is leading the combined South Island district health boards’ childhood obesity strategy, has opted for the Triple P Healthy Lifestyle parenting programme (see interventions sidebar page 14) as its main referral intervention for the family of a very obese child. He adds that working with families needs to be done gently, without criticism, and with empathy and respect as many families are in difficult

12    Nursing Review series 2016  |

situations surrounded by many influences pushing them towards the wrong sort of food and away from exercise. Not all will be ready or willing to make lifestyle changes when first approached. In fact, it is anticipated that only about half of children and their families identified as obese under the new national health target (see page 11) are likely to take up the offer of a referral to an obesity intervention programme.

Nurses’ attitudes can create barriers

Some of the barriers stopping families making lifestyle changes are actually the attitudes and actions of health professionals themselves, says nurse blogger Barbara Docherty. Docherty has spent nearly 20 years researching lifestyle behaviour change and how health professionals can best provide brief lifestyle interventions. She says patients tell her they put up barriers after feeling judged and preached at by nurses and other health professionals. “Time and time again you can see what got in the way and prompted parent to say, ‘I don’t have a fat child – my child is normal’,” says Docherty, who now specialises in offering behavioural health training to health professionals. “It was always judgement … and always the presumption that it [obesity] was the parents’ fault. And those parents will immediately find a way to get out of having a conversation with us.” Continued on page 14 >>


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FOCUS  n  Child & Youth Health << Continued from page 12 If the nurse raising the issue of the child’s weight is overweight themselves, parents may also grab the chance to point this out and use that as a barrier for continuing the conversation. Docherty says research shows that patients know within the first two seconds whether they want to be with a nurse or not. So, if nurses want to successfully sow the seed for a lifestyle behaviour change, they firstly need to put aside any personal prejudices or hang-ups about weight because patients quickly pick up on them through body language and tone of voice. Secondly, they have to avoid making judgements. “We presume that telling people that their lifestyle is shortening their life is going to knee-jerk them into making change,” say Docherty, “but sustainable change is very rarely triggered by fear.” Finally, she says nurses have to resist giving advice and instruction (unless requested). Instead, she says nurses need to learn to turn the conversation around and use a few non-threatening questions to find out more about a child’s story and whether a family is ready, willing and able to start making long-term change. And if they are, then ask questions like, “What is getting in the way of you doing something?” to help them identify barriers, and how to overcome them, so the change is driven by the family and not the nurse. Docherty suggests nurses also start the conversation with the child. “I’ve asked a fiveyear-old, ‘How does this feel to you?’ And, I can remember this very clearly, she said to me, ‘Well, all my friends say I’m fat’.” The child went on to say, “Mum says I’m not fat, but Dad says I’m fat’ and to reveal that being bullied at school was one of the main reasons she was overeating. Docherty’s interaction with a Coke-loving family during her stint as a “supermarket nurse” this year provides another example of how asking the right questions at the right time may trigger positive lifestyle change. (This year Docherty has been joining community health advocate Dr Tom Mulholland in setting up Dr Tom’s retro ambulance outside supermarkets and other sites up and down the country to offer free and instant health tests to people, without a GP, under a Healthy Families contract with the Ministry of Health.) One visitor to the ambulance for blood sugar and other tests was a mother worried that her family had a big wheelie bin full of Coke cans by the end of the week. “I said, ‘So what is one thing you think you could do differently this week?’, to which she replied, ‘We could aim to not have it full’.” In a follow-up call, the mother told Docherty the family had come on side and – thanks to a suggestion of serving fizzed-up soda-stream water as a healthy ‘bubbles’ alternative – the following week the bin was only filled to the halfway mark.

Be Smarter – another way to start the conversation

Psychologist Natalie Parkes agrees that starting the conversation is rarely easy as childhood obesity is a very difficult topic to bring up. Parkes, a member of the multidisciplinary team delivering Waikato DHB and Sport Waikato’s Bodywise family-focused child obesity intervention, says a direct and objective way is to take a child’s measurements and show parents where their child sits on the height, weight and, finally, BMI chart (see other story page 10). Another way is to wait until a parent brings up any concerns, or makes any comments, that allow you to bring the child’s weight or lifestyle changes into the conversation.

A third is to use the Be Smarter tool that the Bodywise team (the other members are a dietitian, doctor and Active Families coordinator) developed for nurses and other health professionals so there’s no need to mention weight at all. The tool is designed to initiate a conversation between the nurse and the family around some ‘basics’ to help kids be as healthy as they can be. The nine basics – all carefully selected risk factors for childhood obesity – are built around the acronym BE SMARTER and range from B for Breakfast every day to R for Reduce screen time <2 hours. Families are asked to tick whether the child always, mostly, sometimes or not yet meets each healthy basic goal. “The great thing about it is that every parent that you talk to will be doing one or more of those,” says Parkes. “So it can be quite a positive tool.” The tool is not an obesity intervention, although it has relevance to all families and kids. Its primary purpose is to engage families in discussing the basics, sharing hints on how to achieve them, and offering the chance for a child and their family to select a goal or goals that along the way may also

help weight management. Parkes says having a Be Smarter conversation can also be a good opening if a family wants to raise a concern about their child’s weight, which may lead to a referral to a dietitian or an intervention programme such as Green Prescription’s Active Families. She says the Be Smarter tool is already being widely used by nurses doing the B4 School Check. Be Smarter is also to be used extensively as part of Barry Taylor’s South Island DHBs’ child obesity strategy, with Taylor saying he was keen to have consistency across the health sector so parents have the same key messages reinforced from whomever they see. “We are not trying to make a population of skinny kids,” says Parkes. “We’re trying to make a population of healthy kids so they don’t have limitations as they grow into adolescence and adulthood. “And if that family leaves you – wherever you are as a health professional – with enough support to make one change for their child’s health, then we are winning, a little bit,” says Parkes.

Be Smarter – Be Bodywise


Multidisciplinary weight management intervention for children aged 5–12 years. Also the home of the Be Smarter programme. Be Smarter packs – training DVD, manual, poster and 150 goal sheets – can be ordered for $50 a pack. »»

Whānau Pakari (Taranaki)

Multidisciplinary intervention programme focused on families of 5–16-year-olds »» aspx?page_main_id=64

Project Energize (Waikato)

School-based nutrition and physical activity programme running in Waikato primary and intermediate schools since 2005. Key findings from a 2011 evaluation included obesity rates

14    Nursing Review series 2016  |

3 per cent lower than national average. »» »»

Triple P Healthy Lifestyle Group (starting in South Island) One of the Triple P parenting programmes developed by the University of Queensland. »» »» Triple_P_Practitioner_Info_Sheet_Group_ Lifestyle.pdf

Green prescriptions (GRx): Active Families (Nationwide) Free family-based activity and healthy eating programmes. »» food-and-physical-activity/green-prescriptions/ active-families

Healthy Families

The Government’s flagship initiative in the Childhood Obesity Plan to use community leadership to drive innovation – now operating in 10 locations. »»

NursingReview Professional Development ReaDing, Reflection, anD aPPlication in Reality

By Monina gesmundo, anna King and lisa Stewart

Reading this article and undertaking the learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council competencies 1.1, 1.4, 2.1, 2.8, 2.9, 4.1, 4.2 and 4.3.

learning outcomes

Reading and reflecting on this article will enable nurses to:

» define catheter-associated urinary tract infection (CAUTI) » describe the pathogenesis of CAUTI » identify risk-factors associated with CAUTI » identify CAUTI prevention strategies that nurses can implement to promote patient safety.

CAUTI pathogenesis

Prevention of catheter-associated urinary tract infections Eight out of 10 healthcare-associated urinary tract infections are attributed to poorly managed indwelling urinary catheters. The longer the catheter remains in situ, the higher the risk for catheterassociated urinary tract infection (CAUTI). This article by Monina gesmundo, anna King and lisa Stewart presents strategies that nurses can use to prevent CAUTI and promote patient safety. Introduction Catheter-associated urinary tract infection (CAUTI) is the most common healthcareassociated infection (HAI) worldwide1. Urinary tract infections (UTI) comprise 40 per cent of HAIs and 80 per cent of these UTIs are attributed to indwelling catheters2. Catheterassociated urinary tract infection complications include genito-urinary tract infections and life-threatening bloodstream infections that develop secondary to a UTI4. The primary risk factor for CAUTI is the prolonged use of urinary catheters5. With the catheter in place, the daily risk for bacterial

growth in the urine or bacteriuria is about 3 to 7 per cent6,7. Ten per cent of patients with bacteriuria will develop CAUTI, while three per cent will go on to develop bloodstream infections. Bloodstream infections result in discomfort, prolonged hospital stays, increased costs and, sometimes, deaths3,4,8. CAUTI events are costly for both the patient and the entire healthcare system7,9. The clinical consequences and economic burden of CAUTI makes CAUTI prevention fundamental to patient safety.

Indwelling urinary catheters are used therapeutically to drain urine from the bladder; however, when used inappropriately, catheters can pose both mechanical and physiological risks to patients1. Catheters cause mechanical erosion of the bladder mucosa and ischemic damage when swelling occurs due to blockage. Catheters also provide a route for microbial entry from the colonised perineum to the sterile bladder through a catheter’s internal and external surfaces1. Microorganisms that colonise the perineum and intestinal tract cause about two-thirds of CAUTI, while a third are caused by urine collection systems contaminated by healthcare workers’ hands11. Urinary catheters interrupt the normal bladder defence mechanism1,11. When bacteria are present in the urinary system, the bacteria bind to the sterile mucosa, which starts an inflammatory response characterised by the inflow of neutrophils and shedding of epithelial cells12. When the catheter is in place, the bacteria bind to catheter surfaces and form a biofilm, which bypasses the normal bladder defence mechanism11. Biofilm Biofilm formation is central in the development of CAUTI12. Biofilms are slimy structures made up of communities of microorganisms. Biofilm forms when a conditioning film of host components attaches itself to the inner and outer surface of a urinary catheter after insertion. Biofilm traps free-swimming microorganisms that then multiply, attract more microorganisms, and further secrete extracellular matrix that makes the biofilm grow in size. Biofilm microorganisms function as a

Professional Development community and communicate closely with one another1,13. Some microorganisms also detach from the biofilm and seed the urine1. Biofilms help microorganisms survive through: resistance to being swept away by shear forces; resistance to being engulfed by other cells, and resistance to antimicrobial agents1,13. Studies have shown that antimicrobial agents penetrate biofilms; however, the slow growth of microorganisms in a biofilm confers antimicrobial resistance11. The affinity of microorganisms with each other in a biofilm also permits the exchange of antimicrobial resistance genes, thereby increasing the risk for other CAUTI complications12.

Risk factors for CAUTI Prolonged catheterisation is the major risk factor for CAUTI3,5. Other risk factors include: nonadherence to aseptic technique during catheter insertion11; poor hand hygiene compliance8; catheter insertion after the sixth day of hospitalisation; poor hand hygiene; catheter insertion outside the operating room9, and a break in the closed drainage system8,14.

STRATegIeS To pRevenT CAUTI Multiple strategies have been shown to prevent CAUTI. Prevention strategies were published by the US CDC in 1981 and subsequently updated in 20098 and 20143. These strategies and recommendations were summarised by the USA-based Institute for Healthcare Improvement (IHI)7 into four components of urinary catheter care. Australia and New Zealand’s 2013 catheterisation guidelines break down the principles for reducing CAUTI into similar sections or components, but with the addition of a section on selecting the appropriate catheter type and drainage system18. The following discussion expands on those components of care to include other evidence-based recommendations.

Component one: Reduce inappropriate use of urinary catheters Urinary catheter presence in the bladder is the primary risk for CAUTI; thus, reducing inappropriate use is the best way to prevent it11,15. Catheters should only be inserted when clinically indicated. Some indications for using short-term catheterisation are: » acute and chronic urinary retention » urinary obstruction » close monitoring of fluid intake and output of critically ill patients » risk of worsening sacral decubitus ulcer due to urinary incontinence or end-of life care5,8,16,17 » selected surgical procedures that last more than three hours » management of acute urologic conditions when straight catheterisation is not possible8,16,17 » patients undergoing urologic surgery or surgery on other genitourinary tract structures » patients anticipated to receive large-volume infusions or diuretics during surgery, and the

caUti Definition The definition of CAUTI varies worldwide, as does the criteria for identifying CAUTI. One of the more commonly used definitions in acute care settings is that of the National Healthcare Safety Network (NHSN) of the United States Government’s Centers for Disease Control and Prevention (CDC). The NHSN define CAUTI as a urinary tract infection in a person with an indwelling urinary catheter for more than two days and at least one of the following criteria: » With catheter still in place, the person develops at least one of the following – fever (> 38C), suprapubic tenderness, costovertebral angle pain, and a positive urine culture of > 105 colony-forming units (CFU)/ml with no more than two species of microorganisms. » With catheter removed the day prior to, or on the day, the person manifests at least one of the following – fever (> 38C), urgency, frequency, dysuria, suprapubic tenderness, costovertebral angle pain, and a positive urine culture of > 105 CFU/ml with no more than two species of microorganisms10. need for intraoperative monitoring of urinary output. » urinary catheterisation may also be indicated for patients requiring prolonged immobilisation8.

Inappropriate indications for using indwelling catheters include: » as a substitute for nursing care of incontinent patients » as a means of obtaining urine for culture when the patient can voluntarily void8 » for prolonged postoperative duration without appropriate indications8. Nurses are also encouraged to: use a bladder scanner in assessing urine volume to reduce unnecessary catheter insertions, and consider other bladder management methods such as intermittent catheterisation3,8.

Component Two: perform proper techniques for indwelling catheter insertion Indwelling catheter insertion is an invasive procedure that requires care and proper technique to avoid pain, trauma and infection. For more guidance you can view the bestpractice urinary catheterisation guidelines [see recommended resources] developed by the Australia and New Zealand Urological Nurses Society (ANZUNS)18.

Selection of catheter » Select appropriate length and type of catheter for patient. » Use smallest gauge catheter possible, while ensuring good drainage to minimise bladder neck and urethral trauma3,8.

Hand hygiene Hand hygiene before and after catheter insertion prevents the introduction of microorganisms into the catheter, thereby minimising CAUTI risk3,8. Aseptic technique and the use of sterile equipment Aseptic technique minimises the risk of microbial entry into the sterile urinary system. Aseptic technique during catheter insertion, the use of sterile equipment, and even the setting of catheter insertion all play a significant role in reducing the incidence of bacteriuria19. The use of sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion is recommended8. Secure indwelling catheters after insertion to prevent movement and urethral traction Indwelling catheters should be kept secure to minimise movement that may cause urethral trauma or erosion of the bladder mucosa7,8,20. Trauma to the bladder mucosa releases organic molecules, which, when combined with glycoprotein from the urine, facilitate bacterial colonisation, thereby increasing CAUTI risk12.

Component Three: Implement proper urinary catheter maintenance procedures Proper maintenance of urinary catheters focuses on maintaining a closed system and maintaining an unobstructed urine flow8. Ongoing good hand and general hygiene is also very important3,8.

Maintain a closed drainage system Urinary drainage systems should remain closed because disconnections at the catheter-

Prevention of catheter-associated urinary tract infections collecting tube junctions have been shown to significantly increase bacteriuria risk due to bacterial spread along the internal surface of the catheter. The relative risk of acquiring CAUTI the day after catheter disconnection has been shown to double21. If there are breaks in aseptic technique, disconnection or leakage, nurses should replace the catheter and collection bag using aseptic technique and sterile equipment8. Microbial spread along the internal catheter surface can also happen if urine in the collection bag is contaminated through improper emptying. In this way microorganisms can gain access to the drainage system and ascend to the bladder, particularly if standard precautions are not observed22. When draining the bag, nurses are also encouraged to avoid splashing urine, to use a separate clean collecting container for each patient, and to prevent contact of the drainage spigot with the non-sterile collecting container3,8,20. The CDC further recommends that the collection of urine samples should be performed aseptically through the needleless sampling port or the drainage bag using a sterile syringe/cannula after the port is cleansed with a disinfectant8.

Maintain an unobstructed urine flow Unobstructed urine flow can be achieved through the following measures: keeping the catheter and collection bag free from coils or kinks and off the floor at all times, and emptying the collection bag regularly3,8,20,23. A study conducted among intensive care patients showed that drainage tubing kinking or coiling was significantly associated with fever and bacteria in the urine23. The presence of kinks and coils is thought to compromise bladder emptying and possibly increase bladder hydrostatic pressure, thereby causing transient bacteriuria, thus the fevers. The recommendation that the collection tubing and bag should always remain below the patient’s bladder to allow proper urine drainage is supported by a large prospective study in the US showing that improper positioning of the collection tubing and bag is associated with a

ReFeRenCeS 1. SIDDIQ D & DAROUICHE R (2012). New strategies to prevent catheter-urinary tract infections. Nature Reviews Urology, 9, 305-314. 2. WEBER D, SICKBERT-BENNETT E, GOULD C ET AL. (2011). Incidence of catheterassociated and non-catheter-associated urinary tract infections in a healthcare system. Infection Control & Hospital Epidemiology, 32(8), 822-823. 3. LO E, NICOLLE L, COFFIN S ET AL. (2014). Strategies to prevent catheterassociated urinary tract infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(5), 464-479. doi:10.1086/675718 4. CENTERS FOR DISEASE CONTROL (2013). April 2013 CDC/NHSN protocol corrections,clarification, and additions. Retrieved from 5. MOHAJER M & DAROUICHE R (2013). Prevention and treatment of urinary catheter-associated infections. Current Infectious Disease Reports, 15(2), 116-123. 6. REBMANN T & GREENE L (2010). Preventing catheter-associated urinary tract infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, elimination guide. American Journal of Infection Control, 38(8), 644-646. 7. INSTITUTE FOR HEALTHCARE IMPROVEMENT (2011). How to guide: Prevent catheter-associated urinary tract infection. Retrieved from Pages/Tools/HowtoGuidePreventCatheter AssociatedUrinaryTractInfection.aspx. 8. GOULD C., UMSCHEID C, AGARWAL R, ET AL. (2009). Guideline for prevention of catheter-associated urinary tract infections . Retrieved from

significantly increased risk in CAUTI because of the backflow of potentially contaminated urine from the drainage bag24. The authors of a European microbiology study explain that when the drainage bag is placed above the level of the bladder, microorganisms from the urine bag can gain access to the drainage system along the internal catheter surface and ascend to the bladder22.

Component Four: Review catheter necessity daily and remove promptly The length of time a urinary catheter is in place is the strongest predictor of CAUTI development8. Recommendations indicate that indwelling urinary catheters should be removed as soon as possible post-operatively, preferably within 24 hours unless there are indications for continued use8. It has been found that patients develop bacteriuria at a rate of three to seven per cent per day7. This risk increases to 25 per cent when the catheter remains in place for one week and increases to nearly 100 per cent when the catheter remains in place for up to a month7. Effective catheter care involves collaborative effort8; however, nurses remain largely

responsible for indwelling catheter care. Daily assessment of catheter need and the possibility of removal is recommended3, with electronic alerts or other daily reminder systems important in acute care. Nurses are also advised to use standard precautions during catheter removal to prevent cross-transmission of microorganisms, thereby preventing CAUTI8.

Conclusion In summary, the components of care to prevent CAUTI include: reduction of inappropriate use of urinary catheters; performance of proper indwelling catheter insertion techniques; selection of correct catheter and drainage system; implementation of proper catheter maintenance procedures, and removal of catheters in a timely manner. These catheter management components are all inter-related and can help to prevent this most common of the healthcare-associated infections – CAUTI. In addition, education on CAUTI prevention should not only focus on one aspect of care, but should also be spread across all components of care.

Recommended resources: Detailed best-practice urinary catheterisation guidelines from the australia and new Zealand Urological nurses Society (ANZUNS) can be downloaded from their website at Evidence-based guidance on the prevention of healthcare-associated infections in primary and community care can be found at the national institute for Health and care excellence (NICE) website at The CDC website also offers resources for both patients and healthcare workers. The cDc guideline for caUti prevention is downloadable from their website at

About the authors: Monina Gesmundo RN, BSN, PGCertTT, PGDipHSc, MNur (Hons) until recently worked as a clinical nurse specialist for infection prevention and control at Counties Manukau Health. She is currently a lecturer at the School of Nursing, Massey University. Dr Anna King is a lecturer at the School of Nursing, the University of Auckland. Lisa Stewart, RN, BA, PGDipHSc, MNur (Hons) is a professional teaching fellow and PhD candidate at the School of Nursing, the University of Auckland.

This article was peer reviewed by: Ruth Barratt RN BSc MAdvPrac (Hons), a clinical nurse specialist infection prevention and control for the Canterbury District Health Board. 9. BURTON D, EDWARDS J, SRINIVASAN A ET AL. (2011). Trends in catheterassociated urinary tract infections in adult intensive care units – United States, 1990–2007. Infection Control and Hospital Epidemiology, 32(8), 748-756 10. CENTERS FOR DISEASE CONTROL (2015). Urinary tract infection (catheterassociated urinary tract infection and non-catheter-associated urinary tract infection and other urinary system infection events. Retrieved from 11. CHENOWETH C & SAINT S (2013). Preventing catheter-associated urinary tract infections in the intensive care unit. Critical Care Clinics, 29(1), 19-32 doi:10.1016/j. ccc.2012.10.005 12. TRAUTNER B & DAROUICHE R (2004). Role of biofilm in catheter-associated urinary tract infection. American Journal of Infection Control, 32, 177-183. 13. NIKOLAEV Y, & PLAKUNOV A (2007). Biofilm -“City of microbes” or an analogue of multicellular organisms? Microbiology, 76(2), 125-138. 14. KING C, GARCIA ALVAREZ L, HOLMES A ET AL. (2012). Risk factors for healthcareassociated urinary tract infection and their applications in surveillance using hospital administrative data: a systematic review. Journal of Hospital Infection, 82, 219-226. 15. BERNARD M, HUNTER K & MOORE K (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urologic Nursing, 32(1), 29-37. 16. TITSWORTH W, HESTER J, CORREIA T ET AL. (2012). Reduction of catheterassociated urinary tract infections among patients in a neurological intensive care unit: A single institution’s success. Journal of Neurosurgery, 116(4), 911-920. 17. MURPHY C, FADER M & PRIETO J (2013). Interventions to minimise the initial use of indwelling urinary catheters in acute care: a systematic review. International Journal of Nursing Studies, 1-10.

18. AUSTRALIA AND NEW ZEALAND UROLOGICAL NURSES SOCIETY CATHETERISATION GUIDELINE WORKING PARTY (2013). Catheterisation Clinical Guidelines. ANZUNS, Victoria. Catheterisation-Clinical-Guidelines.pdf 19. BARBADORO P, LABRICCIOSA F, RECANATINI C, ET AL. (2015). Catheterassociated urinary tract infection: Role of the setting of catheter insertion. American Journal of Infection Control, 43(7), 707-710. 20. HOOTON T, BRADLEY S, CARDENAS D ET AL. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases, 50(5),625-663. doi:10.1086/650482 21. PLATT R, MURDOCK B, FRANK POLK B, & ROSNER B (1983). Reduction of mortality associated with nosocomial urinary tract infection. The Lancet, 321(8330), 893-897. doi:10.1016/S0140-6736(83)91327-2 22. WENZLER-RÖTTELE, DETTENKOFER, SCHMIDT-EISENLOHR ET AL. (2006). Comparison in a laboratory model between the performance of a urinary closed system bag with double non-return valve and that of a single valve system. Infection, 34(4), 214-218. 23. KUBILAY Z, LAYON A, KUBILAY Z ET AL. (2013). What we don’t know may hurt us: Urinary drainage system tubing coils and CAUTIs – A prospective quality study. American Journal of Infection Control, 41(12),1278-1280. doi:10.1016/j.ajic.2013.06.009 24. MAKI D, & TAMBYAH P (2001). Engineering out the risk for infection with urinary catheters. Emerging Infectious Diseases, 7(2), 342.

Professional NursingReview Development

ReaDing, Reflection, anD aPPlication in Reality

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Reading the article and completion of this Prevention of Catheter-associated Urinary Tract Infections learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council competencies 1.1, 1.4, 2.1, 2.8, 2.9, 4.1, 4.2 and 4.3. Please discuss all your answers with your peer/s. a

learning outcomes

Reading and reflecting on this article will enable nurses to:

» define catheter-associated urinary tract infection (CAUTI) » describe the pathogenesis of CAUTI » identify risk-factors associated with CAUTI » identify CAUTI prevention strategies that nurses can implement to promote patient safety.

Read the specific evidence-based recommendations under each component of urinary catheter care

1 Which among the recommendations is a new learning for you? Discuss why.

2 Are the recommendations consistent with your own practice? If not, how do you intend to implement the recommendations in your patient care?



1 Reflecting on your own indwelling catheter care practice, which among the recommendations need to be done more frequently?

2 In what ways can your indwelling catheter care practice be improved further?


applying in reality

1 Review the clinical policies and guidelines in your workplace. Are they consistent with the evidence-based recommendations presented in the literature?

2 Is there any recommendation that is not feasible to implement in your area of practice? If yes, how would you intervene to improve this situation?

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



Nursing council ID

Work address

Contact #

FOCUS  n  Child & Youth Care / Infection Control

Pox, warts and cancer-protecting vaccines Two major immunisation announcements were made this winter affecting children and young people in 2017.

Don’t forget the boys From January 2017 both boys and girls will be offered free vaccine protection against human papillomavirus (HPV), which causes genital warts, cervical and some other cancers.


early a decade after New Zealand began offering the cancer-preventing HPV vaccine to girls for free, we are to follow Australia in offering it free to boys too. Not only is the vaccine going to be available to both sexes that can be affected by HPV-associated cancers but also the age of eligibility has been extended to 26 and a new vaccine covering more cancer-causing strains is to be used. The majority of sexually active people will be infected in their lifetime by one of the many types of HPV that affect the genital area and most will clear the virus without any complications. But about 25 per cent of infected people will develop genital warts and some infected people will go on to develop HPV-associated cancer. The most prevalent of these is cervical cancer (which killed 56 New Zealand women in 2012) but HPV can also cause rarer cancers like anal, penile, vulval, vaginal and some forms of throat cancers. It is the growth in oral and throat cancers – especially in men – that has partly been behind a growing push worldwide for the vaccine to be offered to boys as well as girls. Also the ‘herd immunity’ effect of protecting people from the sexually transmitted virus and associated cancers would be improved if both sexes, not just females, were vaccinated. This is particularly so in New Zealand as the uptake of the HPV vaccine since its introduction in 2008 has hovered below the national target of 60 per cent of 12-year-old girls being immunised. The relatively low uptake has not been helped by some active social media campaigns questioning the safety of the vaccine. These campaigns continue despite the Ministry of Health reporting large clinical trials involving 20,000 people from 30 countries – including New Zealand – have shown the vaccine to have a good safety profile; and reactions reported from HPV immunisations being similar to other immunisations with the most common being injection site pain, redness and swelling. Throat cancer patient Dr Grant Munro, a scientific expert on viruses, spoke to the New Zealand Herald earlier this year about his

decision to pay for his teenage son to be vaccinated against the sexually-transmitted HPV virus. The patient-representative of New Zealand’s HPV Project, whose own cancer has been linked to HPV, said he considered the Government’s policy of only making the vaccine free for girls as a form of discrimination against males. The United Kingdom’s NHS Choices website says major risk factors for oral cancer are alcohol and smoking but 25 per cent of mouth and 35 per cent of throat cancers are HPV-related and it is likely that oral sex is the primary cause of HPV infection in the mouth. Child and youth health NP Paula Renouf says she wholeheartedly supports HPV vaccination of boys and men and the new vaccine will protect both men and women from almost all the strains of HPV that cause genital cancer as well as oral/throat cancers.   Youth Health NP Rebecca Zonneveld said the Evolve Wellington Youth Service has seen a significant drop in genital lesions caused by HPV infection since the vaccination programme began and anticipates a drop in HPV-associated cancers will follow.

RESOURCES The New Zealand HPV Project

»» Information on HPV in general including impact on boys and men:

HPV immunisation programme

»» Information on New Zealand’s current HPV immunisation programme:

Immunisation Advisory Centre

»» One-hour module on HPV vaccination for nurses and other health professionals: hpv-vaccination-module

“We have been there when young people who demonstrate a devastating HPV infection realise that it could have been prevented,” says Zonneveld. “Even those who marry having never been with anyone but their new spouse can be infected and face the same consequences. Why allow this to happen when infection is so preventable?”

KEY FACTS for HPV VACCINE CHANGE (from 1 January 2017) »» Boys and young men are now also eligible for the free human papillomavirus (HPV) vaccine. »» Age eligibility is extended from present under-20 years to all people up to the age of 26 years. »» Current HPV Gardasil vaccine (that targets four high-risk HPV serotypes) will be replaced with the Gardasil-9 vaccine that targets nine serotypes. »» HPV causes genital warts and can cause a number of cancers with the most prevalent being cervical cancer but also rarer cancers like anal, penile, vulval, vaginal and some forms of throat cancers. »» The 2008–2016 vaccine targets two HPV serotypes (16,18) that cause 70 per cent of cervical cancers and other HPV-related cancers plus targeting the two HPV serotypes (6,11) that cause about 90 per cent of genital warts »» The 2017 Gardasil-9 vaccine covers five additional serotypes that cause a further 20 per cent of cervical and HPV-related cancers. »» A two-dose schedule will be funded for children 14 and under through the schools programme (starting year 8 in 2017 and moving to starting year 7 in 2018). »» A three-dose schedule will be funded for people aged 15–26 through primary health providers. Sources: Pharmac consultation and decision + The New Zealand HPV Project  |  Nursing Review series 2016    19

FOCUS  n  Child & Youth Care / Infection Control

Pox, warts and cancer-protecting vaccines Two major immunisation announcements were made this winter affecting children and young people in 2017.

Chickenpox joins Kiwi child immunisation schedule Chickenpox, the last of the common vaccinepreventable childhood diseases, is to be added to the free childhood immunisation schedule from 1 July next year. NURSING REVIEW finds out more. Varicella (chickenpox) vaccine (from 1 July 2017)


common public perception is that chickenpox is a mild disease – getting the pox may be itchy and unsightly but is a childhood rite of passage. Vaccine funder Pharmac agrees that chickenpox may not be a serious disease for most children. But in deciding to follow Australia and the United States in adding varicella (chickenpox) vaccine to the childhood immunisation schedule, Pharmac also points out that for some children it is a very serious disease, with more than 220 children under five years old admitted to hospital every year as a result. The USA’s CDC (Centers for Disease Control and Prevention) says chicken pox vaccination also protects others in the community including those with weakened immune symptoms or pregnant women. Pharmac decided to go with a single dose varicella vaccine over using the combined MMRV (measles-mumps-rubella-varicella) vaccine, which was associated with increased incident rates of febrile seizures in children aged 12 to 23 months. This means that children will now receive four injections at their 15-months scheduled appointment but Pharmac was advised by its expert immunisation sub-committee that this was preferable to splitting the 15-months schedule into two visits at 12 and 15 months. “The current evidence indicates that if the vaccinator is confident in the delivery of multiple injections then the parent or caregiver will be accepting of the number of vaccines,” Pharmac says in announcing its final decision. Another issue raised during the Pharmac consultation and discussion was whether vaccinating against the varicella-zoster virus that causes chickenpox increases the risk of people getting shingles – the disease caused by reactivating the latent virus. But Pharmac says there is no evidence of a change in the incidence of shingles in the United States (which has had a varicella vaccination programme since 1995) or in Australia, which has funded a varicella immunisation programme since 2005. Further information and details on introducing the varicella vaccine to the immunisation schedule is expected in the New Year.

»» From July 1 a single dose will be funded for all children at 15 months (i.e. for children born since April 2016) »» Decision made to go with single vaccine as evidence indicates fewer side effects than when offering MMRV (measles-mumpsrubella-varicella) vaccine option. »» This means four injections will be scheduled for 15-months appointment. »» A single dose will be offered at age 11 in general practice to children who haven’t had chicken pox or a previous varicella vaccine.

OTHER CHANGES Vaccine brand changes

»» Change of Rotavirus vaccine brand and the three-dose regimen will be replaced with a two-dose regimen. »» Also changes of brands for MMR (measlesmumps-rubella) and Haemophilus influenzae type B (Hib) vaccines.

Pneumococcal vaccine

»» The 13-valent pneumococcal vaccine (PCV13) will be replaced by the 10-valent vaccine (PCV10) that covers most serotypes in New Zealand. »» Pharmac acknowledges there may be a “small loss” in health benefit but the savings gained would allow widened access to varicella and HPV vaccines, which would provide “significant” health benefits. »» PCV13 would still be available for people considered at risk. Source: Pharmac consultation and decision

RESOURCES Immunisation Advisory Centre Information on chickenpox (varicella) and vaccine: Resource for health professionals on mitigating vaccination pain and distress:

20    Nursing Review series 2016  |


1941 Diphtheria is offered routinely to children aged under seven by the School Medical Service and the Plunket Society (first offered to selected schools and orphanages in the 1920s). 1948 BCG (Tuberculosis) immunisation is introduced initially for nurses then later for all adolescents. Universal screening and vaccination of 13-year-olds stops in the South Island in 1963, is phased out in the North Island in the 1980s, and ceases in 1990. 1956 Polio vaccine became available. First offered only to 8- and 9-year-olds then widened. Delivered by Department of Health up to 1967. 1960 Routine childhood immunisation begins with Diphtheria, tetanus and whole cell pertussis (DTwP) being delivered by general practices. 1969 Measles introduced to national immunisation schedule for children aged 10 months to 5 years who had not had measles. 1970 Rubella introduced for children aged four and school-based programme for children aged 5–9 years. 1988 Hepatitis B added to schedule 1990 Mumps immunisation added to schedule with introduction of MMR (measlesmumps-rubella) vaccine at 12–15 months. 1994 Haemophilus influenzae type b (Hib) added. 2004 Meningococcal B (MeNZB) used as epidemic control vaccine between 2004 to 2008. 2008 Human papillomavirus (HPV) vaccination offered to girls at age 12. Pneumococcal vaccines added to schedule. 2014 Rotavirus vaccine introduced to schedule. 2017 Chickenpox (varicella) added to schedule (from July) and HPV vaccination for boys. *Source: Immunisation Handbook 2014 (2nd edition April 2016)

FOCUS  n  Wound Care

Diabetic foot ulcers:

the importance of early detection Checking the feet of diabetes patients may be some of the most effective wound care a nurse can provide. FIONA CASSIE finds out more about how to prevent and detect the early signs of foot ulcers that can see people losing toes, feet and even legs.


alking barefoot on hot sand. Throwing on your gumboots to do a spot of gardening or fishing. Getting a blister from a new pair of shoes. These are all common enough experiences for your average Kiwi. But for people with diabetes these experiences may mean they are just a few numb and unfeeling steps away from a diabetic foot ulcer. And for some those steps could be taking them down the path to losing toes, a foot or even a lower leg. The International Diabetes Federation reports that every 20 seconds somebody with diabetes has a limb amputated. Statistics from New Zealand’s Artificial Limb Service show that people with diabetes have gone from making up 24 per cent of new amputees each year to 38 per cent of new amputees (174 people) in less than a decade. And that doesn’t include toes. Sadly, it is estimated that 85 per cent of all amputations caused by diabetes are preventable if foot complications like diabetic foot ulcers are detected and treated early. It is also estimated that 15 per cent of the more than 257,000 people in New Zealand with diabetes will have a foot ulcer in their lifetime – that percentage is stable but the number of people getting diabetes is not, so the number needing specialist foot and wound care keeps growing.

Foot screening: “notoriously poorly done”

Michele Garrett is a diabetes specialist podiatrist at Waitemata District Health Board providing such specialist foot care. She says an unfortunate reality of today’s “flat out and full on” general practice is that annual diabetes foot checks are “notoriously poorly done”. “Some anecdotal data tells that only about 40 per cent are done and some other audits show that between 30–60 per cent of people with diabetes get an annual foot screen when it is meant to be everybody.” Garrett says there are multiple factors influencing the poor statistics including patients not liking showing their feet, the doctor or nurse doing the screening not liking feet and sometimes feeling pushed for time to get the person to take their shoes and socks off. “It is amazing how many foot screens get done with footwear still on.” She says health professionals can’t just ask people with diabetes about their feet – they have actually got to see the feet. “You must remember that neuropathy or numbness is a major contributing factor to foot problems,” says Garrett. “People will say that their feet are okay but very few foot ulcers are identified by the patient – quite often they are only identified at opportunistic screenings because numbness meant the person was unaware.” Garrett was part of the New Zealand Society for the Study of Diabetes podiatry team that developed the 2014 diabetes foot screening and risk stratification tool. The tool is built on the Scottish guideline, but with the addition of Māori ethnicity as a risk factor to reflect the much higher risk of amputation experienced by Māori with diabetes (see link in resources next page).

The latest international guidelines recommend on top of the annual diabetes foot screen that all people with high risk feet or neuropathy should have their feet checked each time they see a health professional. This is because people with numb feet may not have pain “as their friend or indicator” that something is wrong. Also obesity, age, vision impairment and other factors sees some people struggle to adequately care for or check their feet.

Bare feet and jandals – the Kiwi attitude to feet

Kiwis also typically think their feet are ‘tough’. Garrett recently undertook some qualitative research looking at how growing up ‘Kiwi’ influenced the attitudes of people with diabetes towards their feet. “All of them went barefoot as children and didn’t wear special footwear for sport and grew up with a real ‘she’ll be right’ attitude to their feet,” says Garrett. The most people did was “dab a bit of Dettol” on a cut or a blister, but once people have diabetes such cursory first aid is not enough as a simple cut can quickly become a major issue for people with a moderate to high risk of diabetes foot ulcers. Garrett says people with diabetes need to be told not only how to take good care of their feet but also why and the what if consequences of activities like walking barefoot on a black sand beach on a hot summer day with numb feet through neuropathy.

“People will say that their feet are okay but very few foot ulcers are identified by the patient.”

Diabetes foot screening

»» Use Ipswich touch test and/or a monofilament to test whether person has sensation in feet. »» Check for significant callous build-up, redness or blisters. »» Check for signs of structural foot deformity (possible precursors of Charcot Foot). »» Check foot pulses. »» Ask whether they have painful neuropathy symptoms, alongside other screening checklist questions. »» Note any previous ulcerations and/or amputations. »» People found to be at moderate to high risk of diabetes foot disease should be referred to a podiatrist. »» If person has active ulceration, unexplained hot, red, swollen feet (with or without pain) or severe or spreading infection, refer urgently to MDT or hospital foot clinic.  |  Nursing Review series 2016    21

FOCUS  n  Wound Care

Regular foot screening is key

The annual diabetes foot screen provides an opportunity for just such patient education as well as detecting any new risk factors or spotting active or potential ulcers. Garrett says a good foot screen can be a simple process needing only your eyes and fingers and taking just a few minutes. With their fingers nurses can check the pulses in the feet for signs of vascular problem. Also, if a nurse doesn’t have a 10g monofilament on hand for the neurological test, they can just use their fingers instead to carry out the Ipswich touch test to assess for loss of sensitivity to the toes (see link in resources sidebar). After asking the set questions on the NZSSD foot screening checklist, the screening process is finished with a visual inspection of the feet for callouses, redness, blisters, cuts or ulcers. Depending on the screening results, the response can range from patient education and self-management for the low risk foot through to referral to a podiatrist for the moderate to highrisk foot. For people with active foot disease most regions have some form of specialist diabetes foot clinic that people can be urgently referred to, with clinics often working in conjunction with a district nursing service, says Garrett. She says it is imperative with foot ulcers to offload the pressure on the foot by putting people in special surgical shoes, moon boots or casts. “It is the constant pressure (on the foot) combined with the diabetes that inhibits ulcers healing.” Rapid referral to a specialist service with the right offloading strategies in place can see ulcers heal relatively quickly and stop them progressing to complex chronic wounds that are much more time-consuming to heal. It also reduces the risk of amputations. Foot screening is not only important in primary health settings but also if a person with diabetes or neuropathy is admitted to hospital, because of the increased risk of pressure injuries on their heels and the bottom of their feet, says Garrett. Also people with neuropathy may be allowed to wander around the ward in bare feet and socks when they should be wearing special footwear. Urgent hospital admission is needed for people found to have severe or spreading infection or critical ischaemia. Garrett hopes that regular screening, education and rapid referral can help more Kiwis with diabetes work through their ‘she’ll be right’ attitude to their numb feet and see fewer face chronic ulcers or risk amputations.




People at risk of foot ulcers

»» People with type 1 or 2 diabetes (particularly if poorly controlled). »» Anyone who has had peripheral vascular disease. »» People with neuropathy (often causing loss of sensation in the feet). »» People with previous ulcers or amputations or Charcot Foot are seen as particularly high risk.

How to reduce risk of diabetic foot ulcers

»» Keep diabetes well controlled. »» Good diabetes foot care education from time of diabetes diagnosis. »» Annual diabetes foot screening of low-risk patients by suitably trained nurse or health professional. »» More frequent screening of moderate to high-risk feet during patient’s three-monthly visits (particularly if they have a loss of sensation) plus an annual assessment by a podiatrist and a mutually agreed treatment plan. »» Check footwear is fitting well, with no pressure points, and has cushioned soles.

»» Diabetes New Zealand Diabetes & Your Feet nz/about_diabetes/ complications_of_ diabetes/feet »» The New Zealand Wound Care Society Diabetic Foot Assessment Forms about-us/lower-limbulcers/diabetic-footassessment-forms »» New Zealand Society for the Study of Diabetes (NZSSD) Diabetes foot screening and risk stratification tool healthprofs/14%20 07%20Primary%20 diabetes%20foot%20 screening%20and%20 referral%20pathways. pdf »» Podiatry New Zealand Advice on when to see a podiatrist Diabetes »» Ipswich Touch Test A ‘touch the toes’ sensation test touch-the-toes-test

DIABETIC FOOT CASE STUDIES Stories from the front line of diabetes foot care


ebecca Aburn regularly sees the results of when things go wrong with caring for the diabetic foot. The former district nurse – now an infection control clinical nurse specialist with a special interest in microbiology and wound care – coordinates a multidisciplinary team diabetic foot clinic that cares for foot ulcers and works with highrisk patients to prevent further ulcers. The Southern District Health Board clinic has a diabetes nurse specialist, herself, a vascular surgeon, orthopaedic surgeon, a podiatrist and the orthotics team offering a holistic approach to patient-centred care, including optimising diabetes control, effective wound care and infection control, pressure-relieving techniques and ensuring adequate blood flow to the limb. Aburn believes that if people, when first diagnosed with diabetes, could see the potential impacts on their feet of diabetes complications like

neuropathy and peripheral vascular disease, then health professionals may see a lot fewer diabetic foot or lower leg ulcers. She is a strong supporter of nurses providing quality foot care education right from the outset of diabetes diagnosis and regular foot screening thereafter – annual screening for the low risk and more frequently for those with poorly controlled diabetes, loss of sensation and other risk factors. She also believes a key message for nurses wanting to help prevent diabetes foot disease is to try and help address the underlying causes of why the person has difficulty controlling their diabetes or is at risk of foot disease. And if the nurse is not a specialist in treating diabetic wounds – or people at risk of them – to promptly refer them to a service or clinic where they can get the specialist care required. “You can’t muck around with diabetic feet by waiting around to see whether a wound is infected

22    Nursing Review series 2016  |

or giving oral antibiotics in the hope it goes away.” Aburn shares some case studies illustrating how quickly a simple rubbing injury or blister may lead to an ulcer requiring months to heal or the loss of toes or even a foot. The case studies also show that every wound, like every Kiwi, has a story and Aburn believes it helps to know the ‘story’ or underlying causes if you are going to help somebody successfully heal or avoid another wound in the future.

CASE STUDY: The fashion shoe-lover

A 40-year-old woman newly diagnosed with type 1 diabetes wanted to keep wearing fashion shoes as she had a corporate-type job. Her first blister saw her heel go black; a pharmacist gave her an antimicrobial cream but the infection escalated until she needed a skin graft and was hospitalised for a long time.

FOCUS  n  Wound Care

The woman had been fit, healthy and had her diabetes well under control until the ulcers developed. Following her first bad experience she inserted some gel pads into a pair of old fashioned boots in the belief she was doing the right thing. But the pad altered the position of her foot so she ended up with six blisters on her other foot – three of which turned into ulcers. Because of her job she was very reluctant to wear a moon boot, an off-loading shoe, or go into a total contact cast, so the diabetes foot clinic team had to find a more attractive footwear solution that worked for her. It took three months to heal the ulcers. After a tough learning curve the woman has not re-presented at the clinic with any more ulcers.

with her to boost her nutrition with supplements and help her sign up to a quit smoking programme with the support of her GP and practice nurse. A recent clinic appointment showed her wound had taken a turn for the worse and the team discovered she’d had a bad week where she stopped taking her supplements and begun to smoke heavily again. They sat down and talked with her again about the benefits of eating better and smoking less.

CASE STUDY: The recently widowed

A woman turned up at the diabetes foot clinic with multiple small wounds on her feet. The team discovered she hadn’t been managing herself or her diabetes well since losing her husband. She had lost her appetite, smoked, had peripheral vascular disease and hadn’t been looking after her skin so had callouses and cracks on her feet. The cracks had broken open and bacterial infection had set in. Recognising the multiple factors behind the wounds, the clinic worked

They also showed her on the electronically graphed treatment record how her bad week had impacted on the healing of her wound. Seeing the reality on the graph meant the woman agreed to try to cutting back on the cigarettes and eating better to get healing back on track.

CASE STUDY: The whitebaiter

A trim man in his 60s with well-controlled type 2 diabetes had gone whitebaiting at the weekend in his gumboots and got a very small blister on the right side of his foot. He went to his GP on the Monday and Rebecca Aburn, a district nurse at the time, was assigned to change his dressing on the Wednesday. “I took the dressing down and there was a very small wound area – probably less than 5mm but the surrounding area was grey and boggy.” She knew his history included vascular surgery about seven years previously so sent him straight into the diabetic foot clinic. On arrival he was quickly admitted to hospital as his underlying vascular disease had deteriorated, which meant the tiny innocuous gumboot blister had an impact far beyond its actual size. They had to debride his foot back to the bone and he eventually lost two toes. The healing time was more than six months.

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FOCUS  n  Infection Control

Something in the water Hawke’s Bay nurses were recently tested when Havelock North was hit by what’s believed to be the country’s worst ever waterborne disease outbreak – more than 5,000 people brought down with gastric illness. FIONA CASSIE shares the stories of some of the nurses involved and some of the lessons they learned.


he gastro outbreak that slugged Havelock North so hard was slow to sneak up on the community at first. The first residents began being hit by vomiting and diarrhoea around Monday 8 August – just small numbers at first but gradually increasing. Carolyn Dale, the nurse team leader at Te Mata Peak Practice, recalls as the week went on that the practice, Havelock North’s largest, was starting to think, “Gosh, there’s a nasty tummy bug going round”.

THURSDAY 11 AUGUST: Drink lots of fluids…

It was a text message that Thursday – her day off – that was the first hint to Jo Miller that something might be awry. Miller is the infection prevention and control officer at Mary Doyle Lifecare, a very large retirement village and care centre complex in Havelock North that is home to about 410 residents. The nurse was told that three residents at one of Mary Doyle’s five care centres (Miller manages one of them) had come down with vomiting and diarrhoea overnight. Miller came into work worried she may be facing a norovirus outbreak and was on the phone notifying the Public Health Unit in Napier when more reports of ill residents arrived, consolidating her fears. Then yet more reports arrived – this time from a dementia unit in a separate building. “I thought, ‘Oh my God, it’s everywhere’,” recalls Miller. In outbreak mode, the complex ‘locked down’ the affected units, restricted visiting and sent specimens for lab testing to confirm whether or not it was norovirus. Meanwhile, they gave the usual advice for treating vomiting and diarrhoea – to drink lots of fluids…

FRIDAY 12 AUGUST: An increase in ‘d’s and v’s’ overnight

The Friday began for infection control nurse Margaret Drury with an email from the Hawke’s Bay Hospital’s duty manager giving a heads-up of a slight increase in ‘d’s and v’s’ overnight. Drury, the Hawke’s Bay District Health Board’s infection prevention and control advisor, already knew that Mary Doyle and one other aged care facility in Havelock North had reported a suspected norovirus outbreak. She scanned and duly noted the email. By the time Jo Miller arrived back at work Friday morning, there was a handful of reports of residents in Mary Doyle’s 135 independent villas becoming ill. Then one of the specimen results came back positive, not for norovirus but for campylobacter. Miller scratched her head trying to find a foodborne link between cases as she reported the results to public health and continued on with her infection control protocols. Meanwhile, over in Napier, Liz Read, nurse manager for public health and Susan Stewart, public health nursing team leader, started to get reports rolling into the public health nursing team of large numbers of children becoming unwell at Havelock North schools and early childhood centres. “They had big numbers – 30, 40 to 50 children who had become unwell during the morning,” recalls Read. The first wind that Drury got that they were dealing with much more than an ‘increase in d’s and v’s’ was the public health team calling a teleconference early that afternoon followed by a larger meeting early that evening with DHB and Hastings District Council leaders and staff. (It was later released that Hastings District Council received “suspicious” water results about 10.30am on Friday with confirmation on Saturday that two of Havelock North’s water bore supplies were contaminated – likely by animal faeces.) 24    Nursing Review series 2016  |

By the end of the day the water was chlorinated and a media release was out that night urging all Havelock North residents to boil their water because of a still to be confirmed, water-linked vomiting and diarrhoea outbreak. It was a ‘boil your water’ post shared on Miller’s Facebook page around 8pm that night that solved the puzzle of her outbreak. She immediately rang all the care centres telling them not to drink any water straight from the taps or water purifiers. Likewise, Carolyn Dale was alerted via Facebook that night that it was possibly bugs in the water causing the “nasty tummy bug”. Dale says she carried on with scheduled plans to head away for the weekend early the next morning as “nobody really realised the enormity of what was about to pan out”.

SATURDAY 13 AUGUST: Cases begin pouring in

At 9am Te Mata Peak Practice opened it doors with its usual single doctor and a receptionist for business as usual. But as the phone started incessantly ringing, they called in an extra doctor, nurse and reception staff to try and cope with the gastric onslaught. It was to be nearly a week before any semblance of ‘business as usual’ was to return. Dale says the called-in doctor was put to work phoning back patients and triaging those who needed to be seen in person and those who could be given advice and assurance over the phone.

“The first four people through the door are really sick and need IV fluids – we need to do something.” Margaret Drury’s day started early by meeting the emergency response advisor (also a nurse) to put together an email to send out to Havelock North’s five aged care facilities. She then got on the phone to the managers or acting managers of all the facilities (two of which manage somehow to escape the outbreak). Miller, concerned about Mary Doyle’s independent villa residents missing out on the boil water alert came in to work to make up a flyer and started door knocking. Residents of about 16 villas were ill and a third were unaware of the boiling water alert. (By the time the outbreak was over, 128 of Mary Doyle residents became ill, two seriously, and sadly one, with underlying health issues, died that first weekend. In addition, 25 of its 250 staff became ill.) After the 10am public health team meeting in Napier, Drury headed over to Hastings-based Hawke’s Bay Hospital “to do what an IPC (infection prevention and control) nurse should do” and talk to hospital staff, including its ED acute assessment unit, and ensure that personal protection equipment (PPE) was being worn. Drury says a fortunate circumstance was that, despite being mid-winter, the hospital was not at full occupancy so was better able to cope with the increasing numbers presenting over the weekend and beyond. Confident the hospital was managing the IPC requirements, Drury says she spent much of that first weekend liaising with aged care facilities and working with DHB logistics team to ensure extra PPE, hand sanitiser and IV supplies got out to those who needed them. She didn’t know it then but she was about to work 12 long days in a row.

FOCUS  n  Infection Control

…as the week went on the general practice, Havelock North's largest, was starting to think, "Gosh, there's a nasty tummy bug going round”.

The scale of the outbreak quickly saw the DHB sending district nurses out to check independent residents in the town’s retirement villages and offer advice and support to the ill over the weekend. The district nurses provided subcutaneous fluids for dehydrated residents. Miller says the district nurses were “fantastic” and were a constant presence in Mary Doyle’s villas for the next week and a half, for which she was more than grateful as she was continuously getting called out as residents fell ill.

SUNDAY 14 August: Dehydration cases escalate

At 8am neighbouring Hastings Health Centre opened its Accident & Medical Centre. By 8.20am a call went out to Marie Beattie, the centre’s clinical services manager. “They rang saying, ‘The first four people through the door are really sick and need IV fluids – we need to do something’ and I said, ‘Well, I’m on my way’,” recalls Beattie. Beattie, with 14 years’ public health nursing behind her, says the centre implemented its pandemic plan and opened up one of its GP suites as a minihospital ward for patients needing IV fluids. She spent the rest of Sunday offering phone triage – largely assuring people with gastro symptoms they were doing the right thing. The key messages that the centre’s clinical director told her to share was that if anyone had blood in their stools or experienced increasing lethargy (a sign of worsening dehydration) then he wanted to see them. Meanwhile as the posts built up on school social media sites it became ever clearer that more and more children were becoming unwell. Liz Read says she and other public health unit staff were called in for an urgent meeting with the Ministry of Education on the Sunday with the focus on how schools would operate under the boiled water order and would ensure that unwell children stayed at home. Water tankers were arranged for all the schools and additional hand washing instructions put in place ready for the next day. Back at Mary Doyle, Jo Miller was in her fourth day in outbreak mode and says staff kept on keeping on as more and more residents became ill. “The staff worked over and above … they were just amazing. It was hard work as they were cleaning up residents in hospital wings who couldn’t toilet themselves.”

MONDAY 15 AUGUST: Schools open half empty

When nurses arrived to start the day at Te Mata Peak Practice on Monday morning, there were already 50 answerphone messages stacked up for them to answer.

Carolyn Dale says she assigned two nurses permanently to dealing with the outbreak – one taking incoming calls and others making callbacks. The doctors were also doing phone consultations and the practice cancelled all non-urgent appointments. “We freed up all our available resources to deal with the phone consultations [most consultations were over the phone] and the acutely ill patients who came in.” The ones they did get to come in were mostly older patients, people living alone or those just not managing to keep any fluids down. “So we did a lot of IV fluids here … we’ve always done IV fluids but certainly never to the extent where you are wondering where you will hang up the next IV bag,” says Dale. The two public health nurses who usually worked with the Havelock North schools were on deck that Monday morning, working behind the scenes as schools opened their doors. But soon the town’s eight schools – including three boarding schools – were reporting half the school or more were unwell or absent – teachers included. And the about 23 early childhood centres were hit very hard too. Back at the Public Health Unit the notifications of campylobacter started to flood in, so six to eight of the 16-strong public health nursing team were redeployed from their normal school work to concentrate on the outbreak – largely following up campylobacter notifications of people living or working outside Havelock North. The local primary health organisation (PHO) also stepped up early that week to support primary health care in Havelock North by setting two PHO nurses the task of ringing every enrolled patient in Havelock North 80 years and older living independently – which is a very large population in the popular retirement centre. The pair went on to ring all insulin-dependent diabetics and all patients on warfarin, advising them to get their blood tested. The mobilising of district nurses from Manawatū helped to free-up local district nurses to go into the homes of people triaged as needing assistance with rehydration and other cares. Miller began the huge task of case logging all the cases in the complex (a job that didn’t end until 29 August) with the support of the DHB’s gerontology nurse specialist Lorraine Price. Mary Doyle staff and residents also had to face media hanging over their fence line with cameras after news got out that a resident had died. Overall, the numbers hospitalised during the outbreak peaked on the Monday at 19, including several needing intensive care. Drury says the less serious cases  |  Nursing Review series 2016    25

FOCUS  n  Infection Control

CAMPYLOBACTERIOSIS Campylobacteriosis is New Zealand’s most frequently notified foodborne disease and causes gastro illness of variable severity: »» Incubation period: usually 2–5 days but can range from 1–10 days. »» Most often transmitted by eating contaminated food. »» In New Zealand, consumption of faecally contaminated water is another common transmission route. »» Person-to-person transmission is uncommon but possible with poor hand hygiene causing contamination of food that is ingested. »» Fluid replacement is the main treatment.

that met the campylobacter case definition were ‘cohorted’, when necessary, into three- or four-bedded rooms. Meanwhile, by the end of the day schools, under public health and education ministry advice, made the decision to close because of the large number of staff and children affected and – although it was a waterborne illness – to limit the possibility of secondary infection, says Liz Read. So all schools and most early childhood centres closed on the Tuesday and Wednesday – extended to Thursday for the primary schools – but with the secondary schools reopening as they were more confident that the older students would meet the extra hand hygiene vigilance needed. “The impact on the community was massive – economically and emotionally, I think,” says Read.


In retrospect, the worst of the outbreak was over on Monday 15 August, but the long incubation period, recurrences and those hit by severe dehydration meant it took many days before health providers could step back from crisis mode. Even then the alert was out for the complications that can arise after campylobacter infection, such as Reactive Arthritis and the much rarer GuillainBarré Syndrome (as at early October one person had been hospitalised due to Guillain-Barré Syndrome linked to the Havelock North outbreak). On 26 August – two weeks after the water was chlorinated and a week before the boil water notice was lifted on 3 September – the DHB also announced that an elderly patient hospitalised during the campylobacter outbreak had died of an unrelated medical condition, bringing deaths linked to the outbreak to two. Apart from personal losses great and small, the DHB alone estimates the outbreak cost it $380,000, about half due to staff sick leave. This includes $24,000 spent on ongoing household telephone surveys that indicated that nearly 5,200 people – more than a third of Havelock North’s 14,000 population – has been struck by gastro illness due to the waterborne outbreak. Apart from social media alerts, the telephone was the technology that nurses spoke of most often, with telephone triage being seen as invaluable in the outbreak.

MESSAGES AND LESSONS TO SHARE »» Ensure a good consistent communication plan is in place and the right information gets to the right people in a timely manner. »» Hand and general hygiene messages should be sent out early and reinforced throughout. »» Telephone triage in primary health care is very important to both advise and assure those who do not need to be seen in general practice and screen for those that

do need to be seen or supported by outreach services. »» District nursing services, including back-up from other regions, are vital in providing outreach services, particularly to the elderly living independently. »» The value of surge capacity in the public health service across all district health boards being available to support other DHBs in need. »» Ongoing education on outbreak management in residential aged care facilities and having good infection control practices and policies in place is important.

26    Nursing Review series 2016  |

Dale says that prior to the outbreak the practice had only just started implementing a phone callback system but the crisis required “a lot of thinking on their feet” and it was decided to use it in earnest to deal with the hundreds of phone calls flooding in. “The phone call demand was huge but it was also our lifesaver,” says Dale. “We couldn’t have managed it otherwise.” Beattie agrees that telephone triage was one of the key ways her centre managed the crisis by stemming the flow of people who didn’t need to be seen but did want advice and reassurance. The Hastings centre had 64 people present with gastro symptoms on Monday 15 August and 66 telephone consultations; this dropped to 50 presentations and 42 telephone consultations by the Tuesday and by the Wednesday the numbers finally started to wane. Read and Stewart say that apart from tracing notifications another major role for public health nurses was supporting reopened schools and early childhood centres to reinforce hand hygiene education. This involved also grabbing the moment to once again highlight to schools how good it would be if someday they could find money in their budget to bring hot water to all school toilet blocks. The vital importance of critical incident management (CIM) training exercises was also brought home to the pair. “When you have CIM training it can sometimes be hard to see the relevance,” says Read. “However, when there is an massive outbreak the value of preparing for a CIM is obvious.” The outbreak also highlighted the big-picture lesson of the importance of public health fundamentals such as clean water and clean air, says Read. The nurses report that staff illness was an issue for all health providers – including staff who needed to look after sick children or elderly parents or children off school – but relieving staff and staff coming in on their days off stepped up and filled the gaps. Gratitude for the support given by the DHB, local pharmacies, suppliers, neighbouring city nurses and the community was warmly expressed by the Havelock North nurses for everything from the district nurse support, the quick supplies of extra PPE, to IV lines, to the gifts of hydrolytes and hand sanitiser, as well as morale boosting cakes and gift baskets. Plus there was pride and gratitude for how their staff worked as teams to get through the challenging times. There was also acknowledgement of the ‘lucky break’: a mild winter had meant that flu and winter ailments hadn’t reached their peak when the outbreak hit. “If it had happened at the same time last year, it would have been a different story,” says Beattie. “So someone was looking out for us.” »» Adopt standard precautions and wear personal protection equipment when working with patients with vomiting and diarrhoea, including a mask if they have explosive vomiting. »» Check what medications patients or residents are on, or conditions they have, such as diabetes, that could be affected by ongoing diarrhoea and vomiting. »» Advise people on regular diuretics or laxatives to stop taking them while ill because they could further dehydrate them. »» Ensure campylobacter-affected patients or residents on warfarin

have their blood tested to monitor their INR (international normalised ratio) levels. »» The waterborne outbreak highlighted that most schools don’t supply warm water to children for hand washing. »» The importance of the relationship of public health nurses with their schools and health promotion in schools about hand hygiene and preventing communicable diseases. »» The relevance of critical incident management (CIM) training exercises is made clear when put into practice in a real crisis.

Practice, People & Policy Practice

Articles, profiles and opinion pieces from across the nursing spectrum

Practice, People & Policy

Cultural safety: becoming a reflexive practitioner Stereotypes, often perpetuated by media headlines and unconscious prejudices, can all affect how nurses relate to patients. In KATRINA FYERS and SALLIE GREENWOOD’s third and final article they look at how nurses can think in reflexive ways to be more culturally safe practitioners. An anxious mother arrives in the emergency department with a child with an unexplained injury. A nurse assesses the injury but subconsciously also ‘assesses’ the mother’s socioeconomic status and ethnicity and makes an unwitting assumption about whether the injury is accidental or not. How could the nurse respond to be a more culturally safe and reflexive practitioner? In our first two articles we talked about reflection, self-awareness and being relational as important aspects of cultural safety. These same concepts and practices are also critical to becoming a reflexive practitioner which is the focus of our third article. There are many and varied definitions, and uses, of the term reflexivity and in this article we hope to clarify the term’s meaning and use in cultural safety education and practice.

Sallie Greenwood and Katrina Fyers

As part of teaching cultural safety and anti-racism approaches we ask our students to reflect on how, for example, a female patient’s perspective and world view may differ from that of a male patient. Or how a client’s viewpoints may differ if they have a disability or a long-term condition. We also ask them to imagine how they as nurses in the future will consider and respond to those differing world views. Through developing their knowing of themselves as future nurses they also consider how they, perhaps unwittingly and naively, play a role in social processes (historical, economic and political) that allow the continuation of inequities and the marginalisation of some people. Reflexivity, in this context, is being aware of oneself and the person/people that we are working with as we communicate with them, noticing the effects of who we are, our ways of communication and then being responsive to what we notice. To do this it helps to have some knowledge and understanding of cultural norms, particularly our own and also those of the people we work with. However, often we do not have that cultural knowledge, or our knowledge is only partial, therefore we also need to be able to manage and work from a place of ‘not knowing’. In our research with students they noticed how valuable this approach could be:

In a way I feel relieved as I now realise that I don’t have to know every culture’s specific values and belief systems. If I develop my knowledge and skills on how to form relationships with patients, allowing for self-determination, I feel that not only will I practise cultural [sic] safe nursing but it may also enhance the health care and outcome of the patients. (Janet)

Reflexivity encompasses paying attention to the emotional and relational aspects of what is happening as well as understanding the broader societal influences both past and present. In particular being reflexive (see figure next page) asks us to question how power affects relationships, and also how what we perceive as ‘common sense’ affects relationships. Or as one student noted:

Just because someone in authority said something is true does not mean that it is true. One has to do his or her own research as well in order to validate the information given. (Adi) We can do this by thinking during our day-today interactions about whose world views and standards of living are the most privileged – or given the most legitimacy and credibility – and how this impacts on behaviours.

Mother and child scenario Let us return to the scenario we opened this article with. A mother brings her child into the emergency department with an unexplained injury. What assumptions does the nurse make? What assumptions do the rest of the team make? And how does the mother anticipate she will be perceived – with empathy or suspicion? Some of this will depend on the mother’s ethnicity and socio-economic position because the impression gained from media headlines can be that family violence occurs predominantly within one social sphere. While this is not the case it enters the subconscious unbidden. This is more likely to happen if people are uncritical about how people and situations are talked about.  |  Nursing Review series 2016    27

Practice, People & Policy FLAG Practice

How should a nurse respond reflexively to this mother and her child? To begin with the nurse can reflect on and recognise their own ‘ready-to-hand’, automatic thoughts; while at the same time making a conscious decision to keep an open mind because children hurt themselves all the time. Nurses also need to recognise the mother’s fears and concern for her child and respond relationally, to put her at ease as much as is possible. What we are talking about are “skills of listening and noticing, and on ways of allowing oneself to be affected by the other [person/people] whilst also maintaining a reflective distance.” Part of the work we need to do as practitioners is to develop as many standpoints or views of a situation as we possibly can so that we do not settle for the most obvious conclusion. So practitioners should keep alive several possibilities for what happened to the child until more information is available. For example, the child may have been in the care of someone else and so the mother does not know what happened, the mother’s attention was on another child or some other task when the accident happened, the child is an energetic child that pushes its physical abilities beyond its capacity, the child did normal child things and hurt itself, another child was too rough in play... there are many possibilities. At the same time we experience concern for the mother and the situation that she finds herself in, feeling judged, feeling afraid, feeling concerned, feeling disempowered in an alien environment… By being relationally engaged with the mother and her child we can avoid the risk of perpetuating stigma and marginalisation because we recognise this mother as an individual and not a stereotype. At the same time we are aware of being in a position of power due to the authority given to us by the institution (hospital) that we work for, by our discipline (nursing) and authority we carry by reflecting the dominant cultural values and beliefs.

I now have a greater understanding of this term [cultural safety]. I like the fact that it places accountability on the nurse, making the nurse aware that difference exists and that there is also a power imbalance. (Liz) I also feel that understanding my own culture and identity has helped me to have an open mind towards other cultures and this has helped me to understand the prejudiced views I have about other cultures. (Sophie) One way of consciously thinking about this may be through using what some British nursing academics have called ‘inequalities imagination’. Using our imagination we can visualise creative responses to complex situations such as our example above. Sometimes this may mean

understanding our limitations and noticing that others are able to work more relationally than we can at present. This approach may also allow nurses to imagine a broader range of responses than those they might otherwise have in the moment.

A key aspect of developing an ‘inequalities imagination’ involves putting into practice a questioning approach to the subject of inequalities and disadvantage. It also involves thinking of the different constellations of disadvantage that may come into play for each individual client. When thinking about the way that society works we might also consider how common ways of talking about health and people’s circumstances reinforce stereotypes and continue to marginalise people. Significantly, being reflexive asks nurses to think about health equity or consider the unfair distribution of resources that support good health. This is particularly relevant in Aotearoa New Zealand where the effects of colonisation and the dominance of neoliberal socio-economic ideologies still contribute to health inequities.

I can see other people’s perspectives and understand why they may feel differently about it, for example I can see how a Pākehā person may have the attitude that we as a society need to move on. But, I can also see how unjust this would be to the indigenous population of Aotearoa if we all just ‘forgot’ the past and moved on. (Kath) This approach also recognises the complexity of health – and the importance of targeted interventions that reflect this complexity – so it is bigger than simply illness prevention.

28    Nursing Review series 2016  |

I may not be able to stop worldwide racism or discrimination but I can do everything in my power within my ‘own world’ to stop it. As a mother it is my job to educate my children (New Zealand’s next generation) in nondiscriminatory behaviour, and the best way I can achieve this is by being a role model, and this is something I can also implement in my nursing practice. (Liz)

Conclusion The intention of our research was to gauge an understanding of the effects of particular learning and teaching strategies on students’ ways of knowing and whether these strategies were assisting the development of greater complexity in thinking. We have shown that thinking did become more complex and students demonstrated an increasing willingness to be open to alternative perspectives. For students to process challenging material they needed to feel safe in tutorial groups and facilitating this sense of safety was a critical aspect of the teaching. Particularly important was being aware of the processes and reflection needed to develop greater complexity in thinking, and the significant effect this can have on relational and reflexive ways of being to develop culturally safe practice.

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

Practice, People & Policy FLAG policy

Nurse manager PETER WOOD believes that a new move to start the day with an ED huddle – instead of a negative meeting focusing on breaches of the ‘shorter stay’ ED target* – has been a positive culture change for Whangarei Hospital.

What used to happen A daily emergency department (ED) meeting was held every weekday morning at 8.30am to look at any breaches of the Government’s ‘shorter stay’ ED target. The ‘shorter stay’ breach meeting had been in place for five years in response, in part, to the challenges of achieving the Ministry of Health shorter stays in emergency department target*. The meeting was attended by the ED manager, coordinator, clinician, service manager and hospital duty nurse manager of the day. It was a retrospective review of the previous 24-hour patient ‘breaches’ to investigate the causes of delay and to seek performance improvement.

The pros and the growing cons The ED breach meetings were an integral part of the hospital-wide acute care reform programme and had been successful in identifying root cause problems. However, over time, the focus of the ED breach meetings drifted towards a negative reflective lens in the face of the organisation failing to consistently achieve the ED shorter stay target. The meetings were held in the main ED area to raise visibility, focus on the shorter stay target and to allow attendees a ‘feel’ of the department. But it became challenging to consistently engage meeting members and poor attendance demonstrated ineffectiveness. Developing and installing hospital at a glance (HaaG) screens had improved organisational visibility hospital-wide and there was growing confidence that the screens reflected the real time ‘match’ between the clinical time needed to deliver patient care and the actual clinical hours and resources available. (Though often during busy periods the ED HaaG screen did not reflect a nearcapacity ED as the staff busy with patients had less time to update the HaaG screen.) But the HaaG screen and ED electronic ‘whiteboard’ screen were not discussed at the daily breach meetings because of the meetings’ retrospective focus.

‘Light bulb’ moment ED nursing staff indicated they saw little point to the breach meeting because things didn’t change. The meeting generated a lot of actions arising from historical, firmly embedded processes that failed to evolve with the organisation’s growing needs. In retrospect these actions could never be achieved without the ongoing quality improvement framework to provide structure and process.

ED: starting the day with a culture-

changing huddle As the group pondered the meetings’ effectiveness it became apparent that people wanted a more proactive approach to improving patient flow. This coincided with the development of a revitalised programme to improve the acute medical patient flow and reviewing the breach meeting process became part of that. Then a light bulb moment occurred and it was decided to suspend the daily ED breach meeting and implement a daily ED huddle the following week. A simple email notification (available in the online version of this article) was sent on the Friday to acknowledge and thank the staff for their breach meeting contributions before starting the huddles on the Monday. The positive aspects of the breach meetings were maintained, with the breach reports remaining in their current format and distributed via email. This ensures service issues associated with patient breaches can be actioned by the appropriate manager and breach themes actioned via the service improvement work streams.

Putting into action: plan, do, study, act A PDSA (plan, do, study, act) cycle of improvement was created to test and evolve the new ED huddle which got underway in early May this year. Meeting notes were initially taken but later discontinued to keep the focus on current patient flow issues and not revert to using a retrospective lens. A simple automated data feed – from the standalone ED whiteboard to the ED HaaG screen – was used to reflect ED activity and allow an appropriate organisational response. A snapshot of the HaaG and ED whiteboard were recorded and used to demonstrate flow improvement as it took place; focusing on the successful flow of patients instead of the proportion of patient breaches. The ED reports were included in the notes so that a full situation of events was available in one place. The overall feedback demonstrated the usefulness of the ED huddle and staff felt a sense

of purpose in helping enable patient flow. The meeting no longer had a negative focus but helped to coordinate the day ahead as it integrated well within the hospital-wide care capacity demand management (CCDM) strategy. The ED huddle could occasionally lack structure and it was agreed to follow a template of discussion and action so that there was a consistent approach irrespective of attendees.

What happens now? There is consistent attendance at the 7.45am ED huddle. The winter pressure and patient volumes were challenging but the proactive approach to patient flow continues. The ED whiteboard and HaaG are no longer casually viewed during the meeting but are essential components to the group discussions.

What will happen next? The ED huddle continues to evolve; further iterations include the attendance of the night medical registrar and attendance of the oncoming ED senior medical officer (SMO). The ED huddle has not been developed in isolation but with other pieces of service improvement. The emphasis upon this initiative was the profound effect it had upon the group, and others, as it shifted our retrospective lens into a positive proactive approach to improving the flow of patients and ultimately the quality of care we deliver to our patients.

Reflective comment The process or system that we create can influence the culture and lens in which the world is viewed.

AUTHOR: Peter Wood, RGN, MHSc, PG Dip, BA (Hons) Health Management is service manager of Emergency, Medical and Renal Services for Northland DHB. *The Ministry of Health’s shorter stays in emergency department (ED) target calls for 95 per cent of patients to be admitted, discharged or transferred from an ED within six hours. NB: A copy of the ED huddle email can be viewed in the online version of the article at  |  Nursing Review series 2016    29

Evidence-based practice

‘Chilling out’ the pain This edition’s Clinically Appraised Topic (CAT) asks whether a cold spray helps to ‘chill out’ the pain of inserting IV cannula. CLINICAL BOTTOM LINE: Vapocoolant (cold) spray applied to the skin immediately before intravenous (IV) cannulation may produce a small, but significant, reduction in pain experienced during the procedure. Spraying made no difference to first attempt success rates of IV cannulation and was also not associated with serious adverse effects when compared with placebo or no treatment, but it can cause mild discomfort when first applied.

CLINICAL SCENARIO: Intravenous (IV) cannulation for blood tests or treatment can be painful. Current pain relief options are not ideal. Topical anaesthetic creams take a long time to work, while injected local anaesthetic can sting and requires another needle. You have heard about using vapocoolant spray (cold spray) to produce rapidonset anaesthesia on the skin around the cannulation site but wonder if it really helps reduce the pain of IV cannulation and if it is safe. You decide to review the evidence.

QUESTION: Does vapocoolant spray safely reduce the pain of intravenous cannulation as compared with no treatment or placebo?

SEARCH STRATEGY: PubMed Clinical Queries (Therapy/Broad): vapocoolants

CITATION: Griffith RJ, Jordan V, Herd D, Reed PW, Dalziel SR. Vapocoolants (cold spray) for pain treatment during intravenous cannulation. Cochrane Database of Systematic Reviews 2016, Issue 4. Art.No.: CD009484. DOI: 10.1002/14651858.CD009484.pub2.

STUDY SUMMARY: A Cochrane systematic review assessing the efficacy of vapocoolants for pain treatment during intravenous cannulation. Inclusion criteria were: Type of study: Randomised controlled trials comparing a vapocoolant with placebo or no treatment for analgesia associated with IV cannulation in adults or children. Quasi-randomised controlled studies were excluded.

Intervention: Any vapocoolant used for intravenous cannulation. Comparison: Placebo or no treatment. Outcomes: »» Primary outcome: Pain during IV cannulation. »» Secondary outcomes: Pain immediately after IV cannulation; pain at time of application of vapocoolant; first attempt success rate of IV cannulation; adverse events, and participant (or caregiver) satisfaction.

STUDY VALIDITY: Search strategy: Eligible studies were sought via a comprehensive search strategy involving six electronic databases (CENTRAL , MEDLINE, EMBASE, LILACS, CINAHL, ISI Web of Science up to May 2015), relevant databases for ongoing trials, reference list review of all retrieved articles and hand searching abstracts of the American Society of Anesthesiologists. No date or language restrictions applied. Review process: At least two reviewers independently examined titles/abstracts and then full text of potentially relevant studies for eligibility. Three authors independently extracted data using a standardised data extraction form, and assessed the quality of included studies. Differences in opinion were resolved by consensus. Quality assessment: Included studies were assessed for risk of bias using the following criteria: random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessor, incomplete outcome data and selective reporting. Overall validity: A high-quality review involving randomised controlled trials of low to high risk of bias.

STUDY RESULTS: The search identified 1,884 studies after removal of duplicates. After screening titles/abstracts, 17 full text articles were assessed for eligibility, from which seven articles were excluded. The remaining nine RCTs (10 articles) were included in the review; eight RCTs (848 participants) had data suitable for quantitative meta-analysis of the primary outcome. Six studies took place in emergency departments, the other three studies involved patients undergoing planned elective

Table: Summary of results

procedures. Participants were adults (six studies), or children (three studies). Placebo spray was used as a comparison in five studies. Vapocoolant spray resulted in a statistically significant reduction in pain score during IV cannulation compared with control, measured using a visual pain score range of 0 to 100mm (0 = no pain and 100mm = worst possible pain). On average, pain scores were reduced by 12.5mm (see table). Application of vapocoolant (pre-cannulation) was associated with a small increase in pain/discomfort compared with control (see table). There was no significant difference between groups for pain one minute after cannulation (one study), first attempt success rate of cannulation (six studies), adverse events (five studies), or participant/caregiver satisfaction, although patient preference/satisfaction was poorly measured in the included studies.

COMMENTS: »» Excluding studies of unclear or of high risk of bias did not change the results for the primary outcome. Heterogeneity was not explained by study quality, participant age (adults vs children), type of vapocoolant, or study setting and most likely ref lects the varying results in the small number of trials. »» The reduction in pain seen with use of vapocoolant was small but probably clinically significant, at least for some people. As with most treatments, vapocoolants will work better for some than others. Adverse events from vapocoolant were minor and included a cold sensation, transient reactions of erythema at the site of spray and one report of a burning sensation. »» This review did not compare vapocoolants with other pain relief options, but advantages of vapocoolant spray are its rapid onset, ease of application and no extra needles. »» These results suggest that vapocoolant spray may be a useful option to offer patients, especially those not happy with a ‘grin and bear it’ approach to managing procedural pain.

Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD Candidate, Deakin University, Melbourne

No. of studies (number of participants)

Mean difference (95% CI)

Statistical heterogeneity I2

Quality of the evidence*

Pain during cannulation, VAS 100

8 (848)

-12.5 (-18.7 to -6.4)



Pain at application VAS 100

4 (461)

6.3 (2.2 to 10.3)




VAS 100 – 100 mm Visual Analog Scale; *Grade Working Group criteria – Moderate quality means that further research is likely to impact reviewers’ confidence in the estimate of effect and may change the estimate. 30    Nursing Review series 2016  |

Nursing Review 2017 issues & dates New Zealand’s independent nursing Series

issue 1  |  February/March Healthy Year Ahead

issue 2  |  April/May International Nurses Day/Innovation

issue 3  |  June/July Long-Term Conditions/Aged Care

issue 4  |  August–October Learning & Leading

issue 5  |  November/December Child Health/Infection Control/Wound Care

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College of nurses

Self-funding: snapshot survey shows room for improvement PROFESSOR JENNY CARRYER reports on a snapshot survey of how many postgraduate nursing students currently self-fund their studies. Background Health Workforce New Zealand (HWNZ) is currently consulting on how postgraduate medical training is funded in New Zealand. There is a strong consensus that change is needed so HWNZ funding can be more responsive to future health needs. Of the about $200 million per annum HWNZ funding, about $170 million goes to district health boards (DHBs) for mainly hospital registrar doctor costs (determined by their professional colleges) and to the Royal New Zealand College for General Practitioners (RNZCGP) for GP registrar costs. Approximately $30 million goes to ‘other workforces’, of which nursing is one. Models to change future funding allocations have been put forward by sector stakeholders. Nursing is keen to align postgraduate funding with nursing’s capacity to contribute effectively to the New Zealand Health Strategy’s requirements. The National Nursing Organisations’ leaders group recently surveyed postgraduate nursing students on how many were funded from HWNZ’s dedicated nursing postgraduate funding pool (about $13 million a year) and how many self-funded. The survey’s aim was to quantify whether the current HWNZ funding pool was adequate.

The survey The link to the online survey was sent to all schools of nursing to send on to their postgraduate students; 513 responses were received.

Findings The majority of survey respondents worked in DHB acute and community services (combined 60 per cent), followed by primary health care (17.61 per cent), residential care (6 per cent), private hospitals (just under 4 per cent) and Māori health providers (2 per cent). The DHB ‘other’ category was 6.25 per cent. Overall 82 per cent of respondents reported that they had applied for HWNZ funding and 18 per cent had not. Of those who had applied, 88 per cent were successful. This indicates that 30 per cent of postgraduate students are

self-funding their study (i.e. the 18 per cent who didn’t apply but were studying, plus the 12 per cent declined but still studying). Selffunding options reported by respondents most typically involved personal funds, employer contributions and student loans. The number of HWNZ funded respondents was probably skewed upwards as some respondents were enrolled in papers associated with the NETP (nurse entry to practice) programme or the pilot nurse practitioner training programmes, both funded from separate HWNZ funding pools than the dedicated nursing postgraduate pool.More than 90 respondents who did not apply for funding explained why, with the reasons falling into three main categories (in order of prevalence): »» Being unaware that funding was actually available until seeing this survey. »» Being actively discouraged from applying or feeling discouraged as they thought it was pointless. »» Considering the application process was too hard or they were not linked to a PDRP (professional development recognition programme) as required in some settings. Partial funding was also significant. This included a number of respondents (in the funded category) who said they were doing two papers but were only funded for one. Additionally, a number of students commented that they were investing considerable amounts in travel and accommodation because of their distance from the education provider. One respondent said she worked in aged care earning $21.50 per hour, did not know of her eligibility for funding and was self-funding to improve her practice. Another commented that they were not aware they could [apply for funding] and believed hospital nurses took priority. Another believed her DHB did not hold such funding.

Discussion This simple snapshot provides useful evidence about the processes, amount and distribution of HWNZ funding for nursing postgraduate education. Thirty per cent of students are self-funding. Students who are paying

32    Nursing Review series 2016  |

for their second papers or contributing to necessary travel or accommodation, where it is not included, further increase this personal contribution to study costs. The survey does not reveal the complexities around how funding pool decisions are made at the local level. The results suggest that there are students not employed by DHBs who are unaware that they too are eligible for HWNZ funding. The HWNZ training specification is clear that nurses working for governmentfunded health services – like residential aged care and primary health care – are eligible for postgraduate funding. We know that currently there is limited HWNZ investment in developing future nursing faculty staff. University nursing schools require doctoral education and all nursing schools require clinical and nonclinical educational development for staff. Currently HWNZ does not fund nursing doctoral students who are either self or scholarship funded. We also hear anecdotally from students that significant preference is given to clinical papers, which leaves a gap in both leadership and faculty development. The HWNZ training specifications do not make any such limitations or directives; however, interpretation and priorities vary nationally. Nursing innovation and increased contribution is ideally underpinned by appropriate postgraduate education. Postgraduate education increases not just competence but also confidence and personal efficacy. Clearly there is room for a much greater national investment. The ongoing review of HWNZ funding will need to critically examine the degree to which current investment in nursing postgraduate education aligns with the goals of the refreshed Health Strategy. Investment could capitalise more powerfully on the major achievements nursing has made in becoming a flexible, responsive, highly generalist workforce closely aligned with those very goals. AUTHOR: Professor Jenny Carryer is the executive director of the College of Nurses.

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Seriously tired? NTA1731

Shift workers are 6 times more likely to die in crashes caused by tiredness. If you finish your shift and you feel more tired than usual, have a 15 minute nap before you drive home. It could save your life.

Nursing Review October 2016