Issue 3 August/September 2018
NEW ZEALAND’S INDEPENDENT NURSING SERIES
Women’s health Women’s biggest killer – heart disease
Men’s health ‘Waterworks’ issues Addiction and mental health Free 60-minute PD learning activity Getting back to ‘basic’ nursing care
Child health Free plasters helping to heal Seasonal coughs and wheezes WWW.NURSINGREVIEW.CO.NZ
A letter to all healthcare professionals. The Ministry of Health declared a national outbreak of whooping cough (pertussis) in December 2017, which is ongoing.1,2 NZ’s last pertussis epidemic in 2014 was responsible for three deaths.3 Infants continue to be the most vulnerable to pertussis, especially in their first year. Between January and June this year 48 infants aged <1 were hospitalised due to pertussis.2 While pertussis is highly infectious — several times more than influenza — it’s also one of the most vaccine-preventable diseases.3,4 The Ministry of Health recommends and funds pertussis booster immunisation for pregnant women between 28 and 38 weeks of each pregnancy.3 They also recommend, but don’t fund, booster immunisation for the following groups (every 10 years for adults):3 • Lead maternity carers and healthcare personnel (such as GPs and practice nurses) working in clinical settings where they are exposed to infants. • Household contacts of newborns. • Early childhood workers. Over time pertussis immunity wanes. In a recent NZ survey 73% of adults were not aware they needed a ‘whooping cough’ booster vaccination.*5 Have you had your booster? Please ask patients and colleagues if their pertussis vaccinations are up-to-date.
*Adults who had been previously vaccinated 1.Ministry of Health. National outbreak of whooping cough declared Media Release. December 2017. Available at: https://www.health.govt.nz/news-media/mediareleases/national-outbreak-whooping-cough-declared. 2.Institute of Environmental Science and Research Limited. Pertussis report. June 2018. Available at:https:// surv.esr.cri.nz/PDF_surveillance/PertussisRpt/2018/PertussisReport10July2018.pdf ESR; Pertussis notifications and hospitalisations, 1998-2005. 3.Ministry of Health. Immunisation Handbook 2017. Wellington:Ministry of Health;2017 Immunisation Handbook. 4.Cowling BJ, Lau MS, Ho LM, et al. 2010. The effective reproduction number of pandemic influenza: prospective estimation. Epidemiology 21(6): 842–6. 5.Perceptive Research. Report on the Public understanding of whooping cough Survey. October 2017. WISEBoostr002068 Marketed by GlaxoSmithKline NZ Ltd, Auckland Adverse events involving GlaxoSmithKline products should be reported to GSK Medical Information on 0800 808 500. TAPS – DA 1857CO/18AU/BOO/0032/18 GSK00709
LETTER FROM THE EDITOR
Back in late 2001 I strapped my baby son into his stroller and headed for my first-ever news assignment for Nursing Review – photographing striking nurses outside Christchurch Hospital. It was a jolly outing for my son, waving at the nice nurses who waved their placards back. New to the world of nursing, I learnt more over the months and years to come about the previous decade of eroded nurse leadership, pay and morale that had led to those ‘nice nurses’ walking off the job. The Fair Pay campaign was launched in 2003 by NZNO, seeking a major pay jolt to bring nurses back in line with teachers and police and also, initially, mandated nurse-to-patient ratios to stop overloaded and distressed nurses leaving the profession. The pay jolt was won in late 2004, but the trade-off was putting aside ratios for a Safe Staffing Healthy Workplace (SSHW) Inquiry, which evolved into the SSHW Unit and the eventual creation of the safe staffing Care Capacity Demand Management (CCDM) system. Roll on a decade and the goodwill of the pay jolt had well and truly worn off and the snail-like place in implementing promised safe staffing was jarring more and more with stretched and stressed nurses. The nursing workforce kept growing and innovating, but at the same time the patients they cared for got older and sicker, the bed ‘churn’ ever faster, and the DHB budgets ever tighter. Looking back, it is obvious that after a decade of simmering frustration, nurses were ready to say ‘enough is enough’. But when I first started reporting on these latest DHB NZNO negotiations in the winter of 2017 – and planning my winter holiday for 2018 – I didn’t envisage my week’s leave would clash with the first national nursing strike in just short of 30 years. The roller-coaster year of negotiations is now over and was a tough one for all involved – the nurses, their leaders, their union and their employers. A decent deal was made, but the end was a ‘whimper’ not a ‘wow’ for the thousands of nurses who united via social media, marches and the strike picket line to bring home their concerns about their workloads, pay and the impact on the public health system. All sides are now on notice that action is needed quickly to turn the deal’s safe staffing and pay equity promises into concrete steps that make real differences for nurses both at bedsides and in their bank accounts. Otherwise the ‘nice nurses’ could be marching again quite soon – and some may march off and not return. Fiona Cassie, Editor firstname.lastname@example.org www.nursingreview.co.nz
Round-up: News + bulletin board
4 6 8 10 12 14 16
Women’s biggest killer – heart disease Views on vulvas: a look at cosmetic genital surgery Men’s ‘waterworks’: benign prostatic hyperplasia Self-medicating depression – not just a male issue Children’s coughs and wheezes Free plasters = fewer skin infections Child health briefs
FREE 60-MINUTE professional development activity Fundamental nursing care: getting back to ‘basics’ Critically appraised topic: is e-learning the best way to teach nurses?
Innovation & Technology
Enrolled nurses: think ‘can’ not ‘can’t’ Bullying notification not breach, court finds
Leadership & Management
27 27 28
App of the month: period-tracking apps Webscope: long-term conditions research and targets Plunket going digital creates rich child health data
Students & New Graduates
Tips for finding work
College of Nurses: Rebecca Sinclair – climate change and nursing
Fiona Cassie 03 981 9474 email@example.com
Rob Tuitama 04 915 9783 firstname.lastname@example.org
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Vol 18 Issue 3
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nursingreview.co.nz Issue 3 1
Round-up News Briefs
News briefs Read the full versions of these online articles at www.nursingreview.co.nz/subject/news. Deal settled but “much more work to do”
New graduate jobs on accord agenda
After a year of negotiations, simmering frustrations and a national strike, the majority of NZNO nurses this month accepted the DHBs’ fifth offer – but most see it as just a first step. Urgent work will be needed to convince weary and wary nurses – both those whose voted for and against the offer – that the deal will deliver on the safe staffing and pay equity concerns that saw thousands of nurses uniting on social media, marches and strike picket lines this year. NZNO has also acknowledged that there was “much more work to do” to secure decent pay and improved working conditions for non-DHB nurses, including those employed by Māori and iwi providers and those in primary health care and residential aged care.
The new safe staffing accord designed to keep DHBs on track with safe staffing is also exploring options for employing all new graduate nurses. The accord, brokered by Health Minister David Clark between the NZNO, the 20 DHBs and the Ministry of Health, was signed on July 30, just before voting got underway on the accepted NZNODHB deal. NZNO professional development services manager Hilary Graham-Smith said the accord signalling a readiness to consider full graduate employment was ‘absolutely huge’ as it was not satisfactory to have 400 or so new graduates sitting in a talent pool when the sector was so understaffed. The accord includes a requirement for DHBs to regularly report progress to the Director-General of Health on meeting the deal’s deadline of fully implementing the safe staffing CCDM (care capacity demand management) system by June 30 2021, including taking on the extra staff required. When the DHBs and NZNO began negotiations last year, only 14 of the 20
DHB-NZNO 2018 MECA: ▶▶ New agreement expires July 31 2020. ▶▶ Commitment to implement pay equity negotiation outcomes from December 31 2019. ▶▶ Safe staffing initiatives include immediate $38 million for equivalent of 500 nursing staff across 20 DHBs, $10 million for extra DHB nursing staffing to help fully implement safe staffing CCDM (care capacity demand management) system by deadline of June 30 2021, plus extra $750k for Safe Staffing Unit. ▶▶ Pro-rata $2,000 lump sum payment (in lieu of back pay), increase on-call rates to $8 an hour and increase to EN PDRP. ▶▶ All members get 3 per cent pay increase June 2018 + 3 per cent August 2018 + 3 per cent August 2019. ▶▶ 1 per cent added to senior nurse/midwife pay scale in June 2018. ▶▶ New steps on registered nurses/ midwives basic pay scale. Equivalent of 12.5 per cent pay increase (over three years) for those on step 6 in August 2019 and 15.9 per cent on step 7 in May 2020. ▶▶ Adds 3 per cent to top of community nurse/midwife pay scale May 2019 (12.6 per cent for nurses on top scale). ▶▶ Extra salary step for enrolled nurses May 2019 (12.5 per cent for ENs on new step) ▶▶ Extra 3 per cent increases on all grade steps for senior nurses (13.6 per cent for senior nurses on top grade step). ▶▶ Extra salary step for HCAs May 2019 (12.5 per cent for those on new step). 2 Issue 3
DHBs were signed up to implementing the CCDM tools built on the validated acuity software TrendCare. Four of the remaining six – Lakes, Canterbury, Waikato and Counties-Manukau – did not have TrendCare. An update in August from the joint DHBNZNO Safe Staffing Healthy Workplace (SSHW) Units show that all DHBs were now starting down the CCDM path, with all but one of the DHBs – Waikato – looking to use TrendCare. The accord’s three main commitments are: ▶▶ Explore options for providing employment and training for all nursing and midwifery graduates – taking into account the current model for doctors. (Report to Health Minister by end of November 2018.) ▶▶ Develop any extra accountability mechanisms necessary to ensure DHBs implement the additional staffing identified by CCDM within the agreed timeframe. (Report by end of February 2019.) ▶▶ Develop strategy for retaining existing nursing and midwifery workforce and re-employing those who have left the workforce. (Report by end of May 2019.)
DHB-NZNO MECA timeline June 2017: The 20 DHBs and NZNO start negotiations October 2017: First DHB deal offered day before Labour coalition government is formed December 2017: First offer rejected by 56.6 per cent to 43.4 per cent. Mediation in new year. March 2018: Month starts with ‘Nurse Florence’ founding ‘New Zealand, please hear our voice’ Facebook page. Ends with second offer being rejected 73 per cent to 27 per cent. April-May 2018: Nurses rally and march. Budget is delivered and Independent Panel makes recommendations. Nurses vote to strike on July 5 and 12. DHBs release third offer (increased funding to $520m over three-year deal) via media. June 2018: Third offer rejected by 69.4 per cent to 30.6 per cent. Urgent facilitation leads to fourth offer and July 5 strike is called off. July 2018 (first national strike in nearly 30 years): Fourth offer rejected by 50.6 per cent to 49.4 per cent and a 24-hour national strike by NZNO-DHB nurses goes ahead from 7am on July 12. Fifth offer struck in late July and goes to vote the day after minister-brokered safe staffing accord is signed. August 7 2018: NZNO announces deal is ratified by significant majority and two days later releases voting details showing it was accepted by 64.1 per cent to 35.9 per cent.
Round-up Bulletin Board
Bulletin board MH college launches new branches for specialties Addiction nurses and disability nurses were recently welcomed into Te Ao Māramatanga – New Zealand College of Mental Health Nurses with the launch of two new national branches. College president Suzette Poole and kaiwhakahaere Chrissy Kake said it had welcomed the opportunity to support addiction and disability nurses to have a voice. Addiction nurse practitioner Louise Leonard, the chair of the new National Addiction Nurses Branch, said addiction touched all areas of health and addiction nurses believed that addiction was, in fact, every nurse’s business. Henrietta Trip, chair of the new National Disability Nurses Branch, said the branch was an important development as many nurses continue to work alongside and for people with a wide range of intellectual, physical and other disabilities in a range of community, education and healthcare settings.
Nurses welcome wide health system review A complete review of the health system announced by the Health Minister in late May was welcomed by nurse leaders. Memo Musa, chief executive of the New Zealand Nurses Organisation, said the review was timely and welcome because “clearly” health system underfunding was putting pressure on health services and failing to meet the needs of many people. Professor Jenny Carryer, executive director of the College of Nurses, was delighted by the announcement and said that the inclusion of the primary care funding review in a wider system review was commendable and sensible.
Last barrier removed to NPs completing paperwork on patient deaths The barrier that stopped nurse practitioners being able to issue death certificates but not sign cremation certificates has been removed. New legislation that came into effect on 31 January had removed many legal barriers to their practice, but the Cremation Regulations had remain unchanged. Now NPs are able to complete all the paperwork for patients’ families at a patient’s death.
GP survey indicates regular practice nurse turnover Almost half of general practices had a practice nurse vacancy in the previous 12 months, compared with 39 per cent facing a GP vacancy, a 2017 GP survey found. These are some of the findings released last month in the second report from the Royal New Zealand College of General Practice (RNZCGP) annual survey of members, which had more than 2,500 responses. The results indicated that more general practices currently had a GP vacancy (26 per cent) than a practice nurse vacancy (17 per cent). But when asked about total vacancies over the previous 12 months, slightly more practices had experienced a nursing vacancy (68 per cent) than a GP vacancy (65 per cent).
Three nurses honoured in 2018 Minister of Health Volunteer Awards Kim Gosman was honoured in June as Minister of Health Volunteer of the Year, alongside Pacific nurse Sonya Apa Temata, who won the Pacific Health Volunteer Individual Award for her work both here and across the Pacific, and wound care nurse consultant Pam Mitchell, a longstanding member of the New Zealand Wound Care Society, who was a runner-up in the Long Service Awards. Gosman, now in her 80s, is the foundation member of Te Kaunihera Neehi Māori o Aotearoa (The National Council of Māori Nurses) and inaugural vice-president of the College of Nurses Aotearoa. She continues her volunteer work, including posts on a number of iwi/ Māori councils and as a board member of the Rural General Practice Network.
Canterbury nurse’s brave rescue recognised by Royal Humane Society Rushing to rescue an injured driver from a burning car saw Grant Wooding, a community mental health nurse, recently presented with the Royal Humane Society of New Zealand Silver Medal for bravery. Wooding said he was shocked and humbled to receive the award from the GovernorGeneral for a dramatic incident two years ago in which he saved a stranger’s life by pulling him from a burning vehicle. The man’s shoes had caught fire and Wooding used his bare hands to stamp out the flames. The Royal Humane Society says although Wooding is trained as a nurse and paramedic, the circumstances put him at a high risk of injury or death. The driver of the vehicle would almost certainly have died had Wooding not responded in the timely and brave way that he did, it said.
New nursing director for NZ’s biggest PHO Gabrielle Lord has been appointed as nursing director of the country’s largest primary health organisation ProCare – the third for the PHO following the appointment in 2015 of Lorraine HetarakaStevens as its first-ever nursing director (the second was Erin Meads). Anna Wright has also been appointed as associate nursing director. nursingreview.co.nz Issue 3 3
Focus Women’s Health
Women’s biggest killer – heart disease
The biggest cause of premature death in Kiwi women is heart disease. Concern that too few women know it is heart disease that’s most likely to cut their lives short led Australian nurse Dr Lynda Worrall-Carter to found Her Heart. Nursing Review finds out more.
ynda Worrall-Carter now looks back and wonders why she nursed so few women in coronary care. The chilling conclusion the former Professor of Cardiac Nursing comes to is that probably most died before they ever got to a coronary care unit. Think heart disease and you visualise a middle-aged man clutching his chest after exertion or a stressful board meeting. Heart disease however is far from being a ‘man’s disease’. It’s the biggest single killer of Kiwi women – and when combined with strokes is the cause of more women’s deaths than all the cancers combined. And not just in old age – heart disease is the biggest cause of premature death too – pushing breast cancer into third after strokes. For Māori women, heart disease is the second biggest cause of premature death; the first is lung cancer.) Back in 2014 Worrall-Carter was a professor of cardiac nursing who had helped to establish the Cardiovascular Research Centre at Melbourne’s St Vincent Hospital, plus a nursing group that grew into the Australasian Cardiovascular Nursing College. She could not be accused of not playing a role in heart health, but frightening US statistics at the World Congress of Cardiology that year – that heart disease and stroke was killing approximately one women every 80 seconds in the US, and that 80 per cent of heart disease and stroke events may be preventable – made her think she wasn’t doing enough. “I thought, ‘I can’t sit back and do nothing’. When women don’t know…” recalled Worrall-Carter, a keynote speaker at the recent annual New Zealand conference of the Cardiac Society of Australia and New Zealand. “They think they are going to die of breast cancer.” So the nurse, who on a personal level has a family history of heart disease (mother, father and aunts) resigned from her professorship to found women’s heart health charity Her Heart. She says people thought she was mad – she had just 4 Issue 3
received a hard-won $7.9 million research grant – but she just didn’t think research alone was making the impact needed. “Women kept saying to me, ‘We have no idea that this is an issue’,” Worrall-Carter told the Christchurch conference. One of the reasons she believes women think breast cancer kills more women than heart disease is that everywhere you turn you see pink – pink ribbons on products, pink logos on t-shirts and other pink links and endorsements to various breast cancer charities. “They do such a fabulous job”. Other women’s cancers and health issues have their charities too, but the biggest premature killer of women – heart disease – is in a charity vacuum for women, which she filled with www.herheart.org, a place for women to access clinical information, education and advice on heart health that now has followers from 128 countries. “I want every women to know that the biggest killer is heart disease,” said Worrall-Carter, who is also in high level advocacy with the Australian Federal Government to bring home the cost in dollars and lives of heart disease in women. In the US a big ‘Go Red for Women’ campaign was launched in 2003 by the American Heart Association, a few years
after a survey found that only 30 per cent of women identified heart disease as the leading killer of women. By 2012 this awareness had increased to 56 per cent, but Go Red continues to advocate and push for greater health equity, arguing that women are still underrepresented in heart research and are still not receiving optimal treatment, with women more likely to die within five years of a heart attack than men. One reason for heart disease being considered a man’s disease and men being more readily diagnosed and treated, is that historically that’s who heart research focused on – men – partly because it affected men years earlier than women and also the fear of involving childbearing-age women in research. In the US the average age for a first heart attack continues to be younger for men (65 years) than women (72 years), with oestrogen thought to provide some protection for women until menopause, when heart disease risks such as blood pressure and ‘bad’ cholesterol go up. But Worrall-Carter told the Christchurch conference that one of the frightening statistics out of the US is that the biggest increase in heart disease is in women aged 25–40 years old, so it is no longer relevant to perpetuate the idea that heart disease is solely an older woman’s problem.
KIWI WOMEN’S HEART STATISTICS
WHEN SHOULD WOMEN GET A HEART CHECK?
▶▶ Heart disease is the single biggest killer of women of all ages in New Zealand ▶▶ Heart disease is the leading cause of premature death for women in New Zealand ▶▶ Nearly 60 women die from heart disease in New Zealand every week, more than 3,000 women a year ▶▶ At least two women die from a heart attack every day.
▶▶ Women without known risk factors: from 55 years of age ▶▶ Women with significant known heart disease risk factors: from 45 years of age ▶▶ Māori, Pacific or South Asian women: from 40 years of age ▶▶ Women with type 2 diabetes: as part of the annual diabetic review ▶▶ Women with severe mental illness: from 25 years of age.
Why don’t more women know?
Source: Heart Foundation and Ministry of Health
Source: Heart Foundation of New Zealand
Focus Women’s Health
An international study in 2008 compared how primary care doctors in the US, UK and Germany’s behaviour and diagnosis differed when presented with the same heart disease symptoms by patients of different gender and the findings suggested that women may be less likely to receive an accurate diagnosis and appropriate treatment than men. In the US women under 55 hospitalised by a heart attack are twice as likely to die than men of the same age. A 2015 US qualitative study indicated that women heart attack victims did not accurately assess their cardiovascular risk, reported poor preventative health behaviour and delayed seeking care for symptoms – suggesting that better heart knowledge and preventative care might help improve outcomes for women, along with better diagnosis and acute care. A major review published late last year of 180,000-plus Swedish cardiac patients found that women were three times more likely to die following a serious heart attack than men. The women were older, more likely to have diabetes or high blood pressure, and more likely to ignore their symptoms, but that did not fully account for the difference in death rates. The review found that women were less likely to receive the same diagnostic tests (making them 50 per cent more likely to be initially misdiagnosed), less likely to
It is no longer relevant to perpetuate the idea that heart disease is solely an older woman’s problem. receive stents or bypasses, and less likely to be prescribed statins or aspirin. When women did receive all the recommended treatments, however, the gap in mortality rates reduced significantly.
Heart attacks: don’t want to make a fuss… Women being more likely to dismiss or ignore their symptoms is an issue of concern.
HEART RISK FACTORS IN WOMEN ▶▶ Smoking (higher risk for women than men as nicotine metabolises faster) ▶▶ Being overweight or obese ▶▶ High blood pressure ▶▶ Diabetes (linked to greater risk of heart disease for women than men) ▶▶ Family history of heart problems (stronger predictor in women than men) ▶▶ Kidney disease ▶▶ Physical inactivity (being inactive could double your risk of heart disease) ▶▶ Excessive alcohol intake (can lead to weight gain, weakened heart muscle and irregular heartbeat) ▶▶ Depression/anxiety/stress (evidence now indicating that depression can be as big a risk factor as smoking. Stressed people can be at risk of unhealthy lifestyle behaviours) ▶▶ Slight increased risk if on contraceptive pill, increased if woman smokes or is older ▶▶ Metabolic changes in post-menopausal women can lead to increased blood pressure, ‘bad’ cholesterol, and greater body fat around the abdomen ▶▶ Having gestational diabetes or pre-eclampisa during pregnancy ▶▶ Some studies indicate suffering hormonal dysfunctions, such as polycystic ovary syndrome, increases heart disease risk in later life.
HOW TO IMPROVE HEART HEALTH IN WOMEN (AND MEN) ▶▶ Quit smoking ▶▶ Manage blood pressure ▶▶ Eat a heart-healthy diet ▶▶ Be physically active ▶▶ Control blood sugar ▶▶ Reduce stress
▶▶ Prioritise wellbeing and ‘recharging’ your body and mind ▶▶ Get regular heart check-ups ▶▶ Undergo a rehabilitation programme after a heart attack, heart surgery or procedure.
Source: Heart Foundation of New Zealand and www.herheart.org
Worrall-Carter says a focus of Her Heart is for women to put themselves first. Anecdotally, women urge their husbands to head to ED if chest pain strikes, but research indicates they are just not as good at following their own advice. No two heart attacks are alike for either sex. The difficulty for women is that heart attack symptoms can be more subtle, less likely to involve chest pain (see symptoms box) and not always easy to diagnose without a blood test and full assessment. The Heart Foundation says two-thirds of deaths from heart attacks in women occur among those who have no history of chest pain, and unfortunately women tend to wait longer than men to call for an ambulance. Her Heart emphasises the importance of women putting themselves first as it fears that feelings of embarrassment and not wanting to be a burden on others are major reasons why women tend to delay seeking treatment. Her Heart also wants to ensure that women’s heart health is on the radar for all women and the health professionals who care for them. The aim is that more women are diagnosed, treated and make the lifestyle changes that help prevent them from adding to the already frightening statistics of women who die too early because of heart disease.
SYMPTOMS OF HEART ATTACKS IN WOMEN ▶▶ Unusual pain in your neck, chest, shoulder, jaw, abdomen and/or through to your back ▶▶ Feeling short of breath, sweaty ▶▶ Racing of your heart or feeling of ‘fluttering’ ▶▶ Light-headedness, nausea and vomiting ▶▶ Women are more likely to experience non-chest pain symptoms (only 40% have crushing chest pain) ▶▶ In women the pain is more likely than in men to spread as far as the shoulders, neck, abdomen and even the back ▶▶ In women the pain may feel more like indigestion and not be consistent ▶▶ In women the symptoms may not be pain but unexplained anxiety, nausea, dizziness, palpitations and cold sweat ▶▶ Overwhelming weakness or fatigue is sometimes a symptom ▶▶ Women tend to wait longer to call an ambulance for their symptoms ▶▶ Women more likely to have heart attack mis-diagnosed than men.
Source: Heart Foundation of New Zealand and www.herheart.org nursingreview.co.nz Issue 3 5
Focus Women’s Health
Views on vulvas: a look at cosmetic genital surgery in New Zealand Female cosmetic genital surgery has been a growing field since the mid-to-late nineties. We speak with Dr Hera Cook about this emerging practice, particularly in relation to the history of women’s attitudes towards their genitals. SOUMYA BHAMIDIPATI reports.
ew Zealanders are said to be enthusiastic adopters of new technology and processes related to grooming and there appears to be no exception when it comes to female cosmetic genital surgery. Female cosmetic genital surgery is an overarching term that can relate to a number of different procedures performed on the female genitalia. The practice is thought to be on the rise in New Zealand based on statistics collected in overseas cultures similar to ours; however, substantial local research is yet to be conducted. University of Otago department of public health senior lecturer Dr Hera Cook says research conducted in America indicates people who were early adopters of other grooming practices, such as pubic hair removal, are more likely to have cosmetic genital surgery. “What we’re finding is that the number of cosmetic surgeries that white women are getting is disproportionate to the percentage of white women in the population as a whole.” According to DermNet NZ, the incidence of vulvoplasty (augmentation or, more frequently, reduction of the external female genitalia) has increased dramatically over the last two decades in high-income Western 6 Issue 3
countries. Statistics released by the Australian Government in 2014 reported a 105 per cent increase in Medicare claims for vulvoplasty and labiaplasty (reduction of the labia) from 2008 to 2013. Female cosmetic genital surgery is not illegal in New Zealand, although another branch of surgical genital alteration, female genital mutilation, or FGM, is. FGM became a crime in 1996, around the same time that women began opting to have cosmetic genital surgeries, and is illegal regardless of the patient’s age and whether she elects to have the procedure herself. There are several lines between the two subsections of genital alteration, Cook says; the clearest of which is that female genital mutilation is often performed on children, while cosmetic surgery is usually performed on adults. “The other thing about FGM is it encompasses a very wide spectrum of operations. Sometimes it’s really quite small alterations and sometimes it’s alterations that make it difficult for the women to menstruate, or not possible for her to have a child without having the scarring that resulted from the FGM cut open. When we look at labiaplasties, we’re looking at something that would be at the very mild end of female genital circumcision,” she says. “The problem with FGM is obviously we want to respect other cultures and in our own culture the difficulty is we want to respect women’s choices. “What we want is a society in which women feel comfortable and can enjoy their sexuality and their bodies and in both cases you’ve got incorrect information given to women about their bodies.” Cook believes the rise in prevalence of female cosmetic genital surgery represents
a rising number of women who see their genitals as an object for other people to look at, rather than a part of their body through which they experience sexual responses. “We know that this relates to other kinds of body disorders, from anorexia to all the kinds of issues around body dysmorphic disorder,” she says. “Concern and anxiety about appearance affects cognitive function, it affects women’s academic achievement; it affects women’s confidence, and confidence affects a whole lot of aspects of life.” Cook would like to see a reduction in the numbers of female cosmetic genital surgeries performed, but says this would require a significant shift in society’s views on female sexuality. While she believes we need to challenge the practice, she does not see any practical need to make these operations illegal. However, Cook says it is important not to reject the women who have elected to undertake these operations. “Women are not saying they’re having cosmetic surgery because they want their bodies to look like Kim Kardashian or they want their bodies to be perfect. They’re saying actually that they have parts of their bodies that they’re uncomfortable about, that they think there’s something wrong with them and they’re just trying to get their bodies back to a point where they see them as normal.” Dr Hera Cook is a historian of sexuality and sexual practices and is a senior lecturer at the University of Otago, Wellington.
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Focus Men’s Health
Waterworks, weeing and the
Peter J Gilling.
A common health problem for men as they age is an enlarged prostate, bringing worrisome to debilitating ‘waterworks’ symptoms for some men. FIONA CASSIE finds out more from benign prostatic hyperplasia expert Professor Peter Gilling.
young man starts his adult life with a prostate gland about the size of a walnut. Around middle age it is common for the prostate to start gradually growing; in time it can reach the size of an orange or even a large grapefruit. For the vast majority of men, the cause of this growth will be benign prostatic hyperplasia (BPH), so-called as the tissue growing in the gland is not cancerous. The location of the prostate though – lying just below the bladder and surrounding the urethra tube that delivers urine and semen down the penis – means a prostate the size of an orange can cause worrisome waterworks problems. But not all men are bothered by their ageing and growing prostate, says Tauranga urologist Professor Peter Gilling. Even though more than 80 per cent of men in their 80s will have an enlarged prostate (BPH), the prevalence of lower urinary tract symptoms (LUTS) or ‘waterworks’ issues in men in that age group is only about 30 per cent. Over half of men aged over 50 will have BPH, but much fewer are worried by urinary problems. Some men who come to see Gilling aren’t bothered by their waterworks symptoms per se but are worried that getting up several times a night to pee, or a slowed urine flow, might reflect something more sinister. “Once we can reassure them [that their prostate is enlarged due to benign tissue growth, not a malignant prostate cancer] they say, ‘I’m quite happy Doc, see you later’ and don’t take things any further,” says Gilling. For others though, the pressure of the enlarged prostate – a gland that exists to secrete the milky fluid part of semen – can cause distressing and bothersome symptoms. In 2014 Gilling was named one of the world’s top experts in BPH research and treatment. He is based in Tauranga, where he heads the University of Auckland’s Bay of Plenty clinical campus and the district health board’s clinical trials unit. In the 1990s, with partner Mark Fraundorfer, he 8 Issue 3
developed a laser treatment for removing prostate tissue known as HoLEP (holmium laser enucleation of the prostate), which is now practised throughout the world. Many men will manage their BPH symptoms with lifestyle changes and medication, but about 25 per cent of men will go on to have surgery to reduce an enlarged prostate obstructing urinary flow.
Struggling to pee – irritation and obstruction symptoms How bothersome and troublesome the symptoms are, rather than the size of the prostate, is the main driver of what treatment is offered for BPH, says Gilling. Most men with BPH will first present to their general practice with lower urinary tract symptoms (LUTS), with the most common being slow urine flow, but others include needing to pee more often, a sense of urgency and not being able to ‘hold on’, dribbling urine and nocturia (frequent nighttime peeing). An initial assessment by a general practitioner or nurse practitioner is likely to include: checking a patient’s medical history and current medication for possible causes; assessing the severity of physical and other symptoms by using the International Prostate Symptom Score (IPSS) and a quality of life (QOL) questionnaire; checking for infection or blood in urine; carrying out a physical examination, including digital rectal examination to check for abnormalities; and discussing prostate specific antigen (PSA) testing for signs of prostate cancer based on their age and family history. Gilling says the digital rectal exam (DRE) can only detect quite extensive disease and the “finger does not cut it” in accurately determining the prostate size but is still a useful test for detecting aspects of bowel function, the lower rectum and discovering some bowel cancers. For most men, the cause of the LUTS will be found to be BPH, but Gilling says
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in some cases further tests will find that the men have normal size prostates and excellent urine flow and their symptoms could be due to other reasons, including an overactive bladder (OAB), which is also a common cause of LUTS for women. For men whose LUTS are caused by an enlarged prostate, the nature of their symptoms – whether they mainly have ‘irritative’ symptoms like frequency and urgency to pee or ‘obstructive’ symptoms like restricted flow and difficulties peeing – will influence what treatment options they are offered and when.
Lifestyle and medical management of BPH The first response for bothersome but not severe LUTS due to an enlarged prostate (BPH) are usually lifestyle modifications. These may include reviewing fluid intake, including types of fluids consumed that may potentially irritate the bladder (like caffeine and alcohol), and limiting fluids after the man’s evening meal. Men are encouraged to empty their bladders completely – particularly at night – with peeing twice and/ or sitting to pee being options to consider. Men could also be asked to do a bladder or voiding diary to record how often and when they are peeing. This could be supported with pelvic floor exercises and bladder retraining to help with frequency and urgency issues. Since the 1990s a range of drug options have been available for medical management of the symptoms of an enlarged prostate. Gilling says the most common drug group used are alpha blockers, such as terazosin and doxazosin, which act on the sensitivity of the prostate and bladder. Although they have little impact on flow improvement, many men experience a significant reduction in symptoms. Another drug group acts primarily on the bladder and can reduce the urge incontinence symptoms; another group of drugs, including finasteride, can improve symptoms by shrinking the prostate a little but can take three to six months to kick in; and a fourth group of drugs known to relieve the BPH symptoms are PDE5 inhibitors, such as Cialis and Viagra, which can be options for men who also have erectile dysfunction issues. There is definitely a link between LUTS and erectile dysfunction, says Gilling, but it is not as simple as cause and effect. “There’s no question that your sex life improves when you’ve got your waterworks symptoms sorted out, which is really common sense,” says Gilling, “particularly if men have previously been up and down to the toilet all night and irritated by their urinary tract.
“Some men describe a definite improvement in getting an erection after you treat their LUTS with surgery or drugs.” But there is also a strong relationship between cardiovascular disease (CVD) and metabolic syndrome with erectile dysfunction, says Gilling, so, for example, men who start statins can find that not only do their CVD symptoms improve but also their waterworks are better and their erectile function improves.
Specialist assessment and surgical options Lifestyle modifications and drugs will be enough to manage and control the lower urinary tract symptoms of BPH for many men, but for others it will not and these men – along with those whose initial presenting symptoms were already severe – will be referred for specialist assessments.
“TURP is a very safe procedure and for most men – if the prostate is not too large – it can just change people’s lives.”
In the lead-up to or during their specialist assessment, if they haven’t already had them, men will have a blood test to check for kidney function, urine flow rate test, a urinary ultrasound (to check out the kidneys, the bladder full and empty and the size of the prostate), a further physical examination and routinely a PSA test. Gilling says if the IPSS result is severe or moderately severe and there are no signs of cancer then it is nearly inevitable that an ultrasound will find that the prostate is two or three times the normal size and the flow rate is very slow. Men with BPH that is affecting their kidney function, or have ongoing bleeding when they pee, or recurring, regular urinary tract infections, or bladder stones are high-priority candidates for surgery. But not everybody with LUTS symptoms is a good candidate for surgery, says Gilling. “You’ve got to make sure you are operating on people for the right reasons.” Men with physical blockages and obstruction symptoms that are severely
impacting on their quality of life are likely to get symptoms relief from reducing their prostates. But men whose main issue is a bladder problem may get little relief.
Surgery can change lives Surgery ‘down there’ is not something men enter into lightly, but technology has come a long, long way since the first serious attempts in the late 19th century to use surgery to resolve this male malady. During the last century, surgeons developed and refined the still most commonly used surgical treatment for BPH around the world, which is the TURP (transurethral resection of the prostate). A TURP involves inserting a thin tube-like telescope through the tip of the penis and up the urethra into the prostate gland. The surgeon then inserts a heated wire cautery loop up the tube to cut away excess tissue and seal the blood vessels at the same time. Gilling says some poorly undertaken studies in the past saw TURP unfairly given a reputation for causing erectile problems in about 10 per cent of men. But when follow-up research was done to assess similarly aged men’s erectile function before and after TURP or hernia repair surgery, he says it was actually found that erectile score tests improved for most men after TURP. “TURP is a very safe procedure and for most men – if the prostate is not too large – it can just change people’s lives,” says Gilling. Bleeding can remain an issue with TURP for some men (2–3 per cent) and a TURP is not suitable for men with an enlarged prostate of over 80g. This led to the development of a range of laser treatments, including HoLEP. “When you get above 100g [of prostate tissue], which is basically five times the normal size, then TURP becomes a bit unsafe and the laser procedures become a lot safer.” Gilling says one impact of introducing drug treatments is that patients’ symptoms are being better managed for longer, so when they do present for surgery their prostates can be much larger than in the past. “In the old days – in the 70s or 80s – if you did a TURP, the average amount of tissue they removed was around 15g.” He said the average now was two or three times that amount. There are a raft of new surgical treatments for BPH – some with more longterm effectiveness than others – and what is available in the public health system depends on the local expertise. “The laser procedures are enhancements, but TURP is still the workhorse.” nursingreview.co.nz Issue 3 9
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Self-medicating’ depression with drugs or drink – not just a male issue Increasing numbers of people are turning to alcohol or drugs to ‘self-medicate’ or cope with anxiety and depression. RACHEL HELYER DONALDSON talks to an addiction nurse practitioner and psychiatrist about the issue.
hink about those who self-medicate with alcohol and drugs for depression/anxiety and plenty of celebrity examples spring readily, and tragically, to mind: singers and musicians like George Michael, Amy Winehouse, Prince and Michael Jackson, actor Heath Ledger and comedian Robin Williams are just some of the high-profile, talented people who have lost their battles with addiction and/or mental illness. They are mostly men, and there is often a crossover (sometimes referred to as dual diagnosis, or co-existing problems [CEP]) between mental health and addictions. These stars either self-medicated with alcohol or drugs to cope with depression/ anxiety or, conversely, their addiction/ drug experiences triggered off depression, anxiety and even psychosis. But away from the headlines, there are plenty of ordinary, non-famous people also doing this to cope with everyday life.
Male/female numbers evening up With New Zealand’s sky-high suicide rate dominated by men (three-quarters of the 606 suicides last year were male), it seems plausible to conclude that they are also more likely to selfmedicate than women to cope with depression/anxiety. Waikato addiction nurse practitioner Louise Leonard says that, 15 years ago, this was perhaps true but, these days, women have caught up with men.
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The number of bed admissions to the medical detox centre where she works is roughly equal, she says. “We used to say men were more vulnerable and that men were often self-medicating… but I think women have caught up. Families are under pressure, and it’s impacting equally.” Professor Doug Sellman, a clinical psychiatrist who is director of Otago University’s National Addiction Centre, says self-medicating with alcohol and other drugs can seem to offer those with experience of depression and/or anxiety an easy, albeit temporary, fix. “If you’re low and getting up to normal, that’s self-medication and if you’re normal and going up to high that’s more social, recreational use.” Nowadays health professionals recognise it is common for patients to have both mental health and addiction problems, says Leonard, who prefers the term ‘co-existing problems’. True ‘dual diagnosis’ would involve a full-blown diagnosis, so meeting criteria according to a diagnostic manual for mental health and drug and alcohol addiction, she says. “These days we know that most people who present have mental health and addiction problems, so they may not be at a level that they necessarily will have a diagnosis but it’s causing problems in both domains.” Sellman says a “well-thought-
out clinical interview” should be able to identify what the primary problem is. There are a number of key steps to go through and he advocates a trial period of abstinence in the first instance. “Three-quarters of [the depression/ anxiety] will go away [during the abstinence], but a quarter of it doesn’t”. “Those are people who do have a more underlying depression/anxiety problem being primarily caused by some other factor.” Looking at family history can provide clues to whether there is a stronger family history of depression/anxiety or one of alcoholism. It is an “inexact science”, he admits, and the best and most proactive option is a period of abstinence. In 2007 the Te Pou report on dual diagnosis concluded that mental health and alcohol and drug services in New Zealand did not reflect an integrated approach to services for people with experience of both mental illness and alcohol and drug addiction. More than a decade later, a frequent criticism of the health system is that people with both issues are falling through the gap.
National inquiry underway A national mental health and addiction inquiry is currently underway to investigate this, with a six-person panel of experts making 25 visits to towns and cities across the country. Its findings won’t be heard until after it wraps up in October. However, inquiry chair, Professor Ron Paterson, was recently reported as saying that one of the common themes of the meetings so far was that mental health and addiction services are often fragmented. Doug Sellman and Louise Leonard feel things are improving for people with CEP. Sellman first identified people ‘falling through the gap’ more than three decades ago when he started
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studying this area. Since then things have improved, he says. “I think there is greater awareness amongst mental health clinicians, of these secondary conditions, that alcohol and other drugs can produce psychiatric symptoms that look exactly like the primary diagnosis like major depression or a manic episode or a psychotic condition. “There is [also] greater awareness now amongst clinicians in the addiction sector of the reality of primary disorders, that you can have these two co-existing, but there will be these 25 per cent of people who, even with abstinence, will continue to have these symptoms and they’re going to need other forms of treatment. “There’s greater acceptance and awareness of that. So I think it’s slowly improving, over time.” Services “are stretched”, admits Leonard, particularly as people are presenting with “more and more complex issues”. “I always say to clients, to patients, that it’s a matter of hanging in there. If you’re determined, you will be seen, you
will be properly assessed, you will have a treatment plan developed, but these things don’t necessarily happen overnight.” But she agrees that there’s more understanding among health professionals about both issues.
“These days GPs are being better trained in this area and know when to refer.” “These days we have the view that any door is the right door, that’s easier said than done but whether you’re presenting to a mental health service or a drug and alcohol service you should still eventually end up in the right place. “Services have got better and clinicians have become more skilled at recognising
both, but we’re certainly not in a perfect world.” Crucially people presenting with these issues need the help of an advocate. “Families can’t do it for you [but] whether it’s their family, or a friend or whoever, they need someone to be supporting them as they present for treatment and not going away, being determined. I think it’s that persistence that helps.” Both Leonard and Sellman say that, for anyone seeking help with CEP, the best place to start is with their GP. “In the majority of cases, it’s good advice,” says Sellman. “These days GPs are being better trained in this area and know when to refer, and can do that initial sorting things out – ‘what’s the likelihood of this being a primary mental health problem or a primary alcohol or drug addiction’.” It’s crucial to encourage people to get past any shame or embarrassment they might feel about their addictions or mental health issues, adds Leonard. “Often that’s why people don’t present for help, people just battle on and try and cope.”
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Focus Child Health
Children’s seasonal coughs and wheezes
Nursing Review shares a rundown on seasonal coughs and wheezes in children.
t’s the time of year when many children seen by nurses will be coughing, spluttering and wheezing. Coughs are common for children, particularly preschoolers, and the vast majority are caused by colds and other viral upper respiratory tract infections (URTI) and will improve with rest and time. Child Health nurse practitioner Debbie Rickard says while once viral coughs and colds used to be very seasonal in recent years, it has become more common for them to pop up at any time, including summer. When children do present with a runny nose or other symptoms indicating their cough is likely acute and viral, parents should be reassured that a cough is a normal reflex. They should be given a plan for looking after the child, including the likely trajectory of the cough (many children can cough for up to three weeks or more) and clear advice on when to seek medical attention if the symptoms worsen or the child is not improving (particularly an infant not feeding or sleeping and is lethargic) or the cough continues for longer than four weeks.
Over-the-counter medicines Parents worried and sleep-deprived by their child’s cough should also be advised that over-the-counter cough medicines can cause serious side effects in young children and should not be given to children under six. Seasonal viruses can trigger asthma, but Rickard says it is common for a young child to respond to a winter virus with an asthma-like cough or wheeze that responds to inhalers; however, they may outgrow this and not have asthma. When a child presents with a distressing cough where the cause is less clear, or becomes recurrent, a more extensive history should be taken, including whether its onset was sudden (possibly the child inhaled a foreign body) and the nature of the child’s cough (wet/dry/how long going 12 Issue 3
on/do they cough at night/triggers). Checking immunisation status and environmental factors (like damp living conditions and cigarette smoke exposure) is also helpful in the initial assessment of a child with an acute cough. Rickard says parents think if they smoke outside the house it will have less effect on their children, but it still has an effect if the smoker is in regular close contact or is the main carer who cuddles the child. A clinical assessment will usually include checking the child’s respiratory and heart rate, temperature, ear/nose/throat exam, a chest examination and checking the child’s demeanour, such as if child is comfortable, happy, distressed or lethargic.
Red flags Red flags to watch out for include signs of respiratory distress like nasal flaring, a tracheal ‘tug’ at the front of the neck and obstructed breathing causing harsh stridor noises. Age is also an important consideration with, for example, croup’s barking cough (a cough like a seal caused by a virus triggering inflammation and narrowing of the larynx and windpipe) being rare in children over six. For example, an eightyear-old who arrived at Rickard’s clinic had an initial ED diagnosis of croup but was later found to have whooping cough. Also in very young children wet cough symptoms may be different as they don’t cough regularly or frequently. So rather than coughing up mucous, they swallow it and eventually throw up, therefore it can
be useful to check whether the child has vomited and reassure parents this is normal for infants. Bronchiolitis is a very common viral chest infection in babies, affecting one in three before the age of 12 months, and is the most common cause of wheezing in children under a year. It is usually mild, but if a baby is under three months old or has a severe case they may need to be admitted to hospital.
Antibiotics If a child has a consistent, wet/moist, productive cough for more than four weeks then they need to be reviewed as they may have a bacterial infection that needs antibiotics. Rickard says sometimes it may be that the child has recovered from one virus just to catch another straight afterwards, with children in childcare or preschools on average having 15 illnesses a year. If symptoms and a chest examination indicates an infection needing antibiotics, it is important to explain to the family why taking the full course of antibiotics is essential – particularly if the child has had frequent respiratory infections. New Zealand, unlike most other developed countries, still has problems with bronchiectasis – especially in Māori and Pacific children living in areas of socioeconomic deprivation. Leaving a wet, persistent cough untreated increases the risk of bronchiectasis, leading to scarring and permanent damage to the lungs.
COUGHS IN CHILDREN RESOURCES: ▶▶ Asthma and Respiratory Foundation NZ child and adolescent asthma guidelines: a quick reference guide (2017): www.asthmafoundation.org.nz/resources/child-and-adolescent-asthma-guidelines ▶▶ Cough in Children, Health Navigator: www.healthnavigator.org.nz/health-a-z/c/cough-in-children ▶▶ Cough in Children, BPAC 2010: https://bpac.org.nz/BPJ/2010/July/cough.aspx ▶▶ Nurses can also access their regional ‘HealthPathways’ via their local DHB or PHO
Failure to deliver medication to the target site can lead to inadequate asthma control in children Only extrafine QVAR reaches the very smallest of airways 2
QVAR patients have consistently better outcomes compared to fluticasone patients
fluticasone-salmeterol (standard pMDI)
QVAR beclomethasone dipropionate
16% lung deposition
58% lung deposition
References: 1. Gelfand EW & Kraft M. The importance and features of the distal airways in children and adults. J Allergy Clin Immunol. 2009; 124(6 Suppl): S84-7. 2. Leach CL, et al. Characterization of respiratory deposition of fl uticasone-salmeterol hydrofl uoroalkane-134a and hydrofl uoroalkane-134a beclomethasone in asthmatic patients. Ann Allergy Asthma Immunol. 2012;108(3):195-200. 3. Price D, et al. Prescribing practices and asthma control with hydrofl uoroalkane-beclomethasone and fl uticasone: A real-world observational study. J Allergy Clin Immunol. 2010;126(3):511-8. Qvar Inhaler and Qvar Autohaler are Prescription Medicines containing 50 mcg and 100 mcg of beclomethasone dipropionate per inhalation. Please refer to the data sheet available at www.medsafe.govt.nz before prescribing. Indications: Prophylactic anti-infl ammatory treatment of reversible obstructive airways disease including asthma. Contraindications: Hypersensitivity to beclomethasone dipropionate or any other ingredient in Qvar. Not for use in children under 5 years. Precautions: Not for relief of acute attack, pregnancy and lactation. Adverse Eff ects: Candidiasis of mouth and throat, hoarseness, throat irritation. Qvar Inhalers contain Ethanol and the CFCfree propellant Norfl urane (HFA134a). Interactions: No clinically signifi cant drug interactions have been associated with therapeutic doses of BDP. Dose: The recommended total daily dose of Qvar is lower than that for current CFC-BDP products and should be adjusted to the individual patient. Starting and Maintenance Dose: Adults: For mild to moderate asthma: 50 mcg to 200 mcg twice daily. For more severe asthma: doses up to 400 mcg twice daily. Maximum recommended daily dose: 800 mcg. Children: 5 years and over 50 mcg twice daily. In more severe cases this may be increased up to 100 mcg twice daily. Maximum recommended daily dose is 200 mcg. To minimise the systemic eff ects of orally inhaled steroids, the dose should be titrated down to the lowest that provides eff ective asthma control. Qvar is a fully funded Prescription Medicine. Distributed in New Zealand by Radiant Health Ltd, c/- Supply Chain Solutions, 74 Westney Road, Airport Oaks, Auckland. Bausch & Lomb (NZ) Ltd, PO Box 4199, c/o Bell Gully AUCKLAND 1140. For all product enquiries: New Zealand Toll Free: 0508 375 394. TAPS PP1979.
Focus Child Health
Free plasters = fewer skin infections Too many children turning up in hospital with serious skin infections prompted a public health response in Bay of Plenty to make a difference. FIONA CASSIE reports.
t was the grins of kids who were once covered in school sores that showed district nurse Sandra Innes-Smith the team was on the right track. Giving out plasters, soap and antiseptic cream, along with friendly, repeated advice, is part of a nurse-led project in schools in the Eastern Bay of Plenty town of Kawerau that’s making a major difference to skin infections in children. The Kiri Ora Healthy Skin project is one of the initiatives prompted by the region’s public health service, Toi Te Ora, after concern at the start of the decade at the high number of children being admitted to Bay of Plenty DHB hospitals with preventable skin infections – from infected scabies to eczema and nappy rash to cellulitis. The DHB’s serious skin infection rates peaked at more than 80 per 10,000 children in 2009–10, far above the national average and costing the DHB more than $1 million a year, not to mention the trauma for the children and families involved. The rate was much higher for the region’s Māori children – 140 per 10,000 children – again much higher than the national average for Māori, raising issues over equity, poverty and access to health care, in particular some of the region’s rural towns and communities. Having arrived from Scotland only a few years previously, where rheumatic fever was virtually unknown and skin infections like impetigo (school sores) rare, the region’s statistics in both were 14 Issue 3
worrying for Dr Jim Miller, a Toi Te Ora medical officer of health. In 2011 Toi Te Ora communicable disease nurse Lindsay Lowe and colleagues carried out a skin infection health needs assessment, which confirmed that serious skin admissions were on the rise in the region. James Scarfe, a Toi Te Ora public health analyst, says research in neighbouring Gisborne also indicated that the hospitalisation statistics were the tip of the iceberg, with for every child hospitalised around 14 cases of skin infections being seen by general practices. The public health team set in place a range of strategies to meet its goal of reducing the human and financial cost of child serious skin admissions by twothirds in five years. It is not there yet, but the latest Bay of Plenty statistics available (from 2015–16) show the rate dropping from the peak of 80 in 2009–10 to 54 per 10,000 children – the lowest this century. In addition, the rate for Eastern Bay Māori, the region’s highest, dropped from more than 160 to 100 over the same time period. Part of that success story is the Kiri Ora project launched and led by Sandra Innes-Smith.
Plasters a ‘luxury’ When talking to mums about their children’s impetigo, it became increasingly clear to district nurse Innes-Smith that for many homes a box of plasters is a luxury. “I know these are really good mums but their budgets are just zero,” she says. She
would be sharing clean-skin messages with these mums and realise that buying even basic products like plasters was beyond their budgets. So when Toi Te Ora set a goal of reducing skin infections she was adamant that equally important as educating parents and kids was providing basic skin care resources to families in need, so they could put the education into action. Toi Te Ora were in agreement and the DHB’s planning and funding manager came on board to fund healthy skin packs – built on a Wellington Regional Public Health initiative. Inside the pack is soap, plasters, chlorhexidine wipes, toothbrushes, nail clippers, nit combs and family-friendly health information. The region’s skin packs have played a key role in the Kiri Ora project since Innes-Smith first carried out her pilot skin clinic in Kawerau schools back in 2014, with the support of Lizzie Farrell, the public health nurse leader for the Wiri School skin clinic programme that inspired the Mana Kidz programme in South Auckland schools. The pilot built on the Eastern Bay of Plenty Primary Health Alliance’s Rheumatic Fever Prevention project, which Innes-Smith is clinical lead for, with the twice a week nurse-led skin clinics at each school coinciding with the throat swabbing team visits. A successful pilot evaluation led to a nurse being funded to continue the project which has since expanded from the original primary schools in the Kawerau area to include
Focus Child Health schools in Edgecumbe and Whakatane, bringing the number of schools to 10 and the children under the programme to about 2,000. Some of the first children Innes-Smith saw at the pilot school clinics had got used to managing their scrapes, grazes and bites without plasters. She says it was matter of some friendly retraining that if they got a scab or sore they needed to clean it and cover it with a fresh plaster every day rather than just pulling their jersey down to hide it. They were then sent home with plasters and maybe cleansing wipes and antiseptic cream too – while the full skin packs are only given out once or twice a year, the project makes sure that no child leaves a clinic with simply advice, but also with the products they may not have at home to help them heal without infection. If a sore requires antibiotics, the clinic nurse refers and works with local general practices to ensure the child gets a prescription and follows up with the family.
Clean, cut, cover and check The Toi Te Ora clean skin key message consistently delivered to all children and families across the DHB is “clean, cut, cover and check” – or clean hands and nails regularly, keep nails cut to avoid scratching, wash and cover any sores and cuts with plasters, and check sores and seek help if they don’t get better, increase in size or have pus or red streaks coming from them. Friendly and fun repetition of the message is essential, says Innes-Smith,
“What they learn is that we really like seeing them, we’re really friendly and we will give them positive reinforcement when they do ‘get’ it.” as once is never enough for children. So nurses will praise and endorse the child who returns to the school clinic with a clean wound covered with a fresh dressing, but they will also give a warm welcome to the child who returns with an open wound that’s still struggling and happily talk them through the message once more. “What they learn is that we really like seeing them, we’re really friendly and we will give them positive reinforcement when they do ‘get’ it.” Sometimes the project’s clinic nurse has had to battle for a month or two to heal kids who arrived with as many as 10 infected school sores and new ones still popping up. Until comes the day the kid knows to return with just a single wound – a fairly minor school sore – at just the right time to be treated before it cascades and the nightmare starts all over again. “With lots of positive reinforcement the kids really, really do learn how to nip things in the bud,” says Innes-Smith. “I can hardly express how amazing it is when kids come back proud as Punch of how they’ve managed their own scrape, scratch or sore,” says Innes-Smith. “They know they’ve done the right thing and they are just grinning from ear to ear. That’s
when you know you’ve really cracked it.” She stresses again that she believes education is not enough on its own for financially struggling families. “It was disempowering them not to provide product (like plasters, wipes and creams), she says. “If you just provided words all you were going to do was make them feel guilty.” And kids respect their product – telling her it has a special place in their drawer or the fridge. The potential link between skin infections and acute rheumatic fever is also another motivation for InnesSmith for bringing home the clean skin message. “Even if there’s not a direct pathway between skin infection and acute rheumatic fever, at least if you are not carrying strep bacteria on your skin it’s got to be a win,” she believes. Innes-Smith would also dearly love to be able to expand the skin clinics to kohanga reo and to more schools – particularly in the Opotiki area – but skin packs are distributed to children via other schools and early childhood centres in the throat-swabbing programme and the team works closely with the public health nurse team. She says on average the area is giving out nearly 40 skin packs of various types a day.
considered normal it was getting to the point of being too accepted. Toi Te Ora adapted Wellington public health resources to promote and share the healthy skin messages with parents, whānau and early childhood centre staff along with the skin packs. The second strategy was focused on health professionals – and Toi Te Ora held a series of workshops to highlight not only the local health burden of serious skin infections but also increase the skills and responsiveness of nurses and GPs when they saw children with skin infections. The third strategy was to improve the effectiveness of primary and community health services in preventing and managing skin infections including promoting the use of community pharmacies, developing closer collaborations between providers, continuing to provide skin packs to high incident communities and focusing interventions on those highlighted at most risk from their analysis, which were babies and Māori children aged up to four years in particular.
(The high baby statistics were thought to be partly due to the lower threshold for admitting babies to hospital with infections that included infected eczema, insect bites and nappy rash.) Reducing serious child skin infections is to date the most successful of the three child infection reduction goals set by Toi Te Ora in 2012 along with rheumatic fever and respiratory infections. All three are often linked through the underlying factors of poverty and deprivation with families living in overcrowded conditions in often damp and cold houses more at risk. With progress in reducing respiratory and rheumatic fever more mixed Miller says Toi Te Ora is also trying to support housing initiatives that can help reduce some of those risks. Meanwhile, with kids in Kawerau treasuring their plaster packs, and families and health professionals getting the clean skin message, it looks like reducing skin infections is on track for a start.
TOI TE ORA STRATEGIES Catching and treating more skin infections in the community – like the Kiri Ora project does – before they became so serious children needed hospitalisation was a major aim of Toi Te Ora’s serious skin infection prevention and education strategies. Jim Miller said Toi Te Ora’s statistics focused on serious infections that ended up in hospital as those were the infections the DHB could count but they also gave an indication for child skin infections across the wider community. “You are never going to get rid of all serious skin infections – but a lot we were seeing were quite clearly preventable by good hygiene and skin care and should be easily managed in the community.” Lindsay Lowe said one of their three key strategies was on increasing awareness and understanding in the community about skin infection prevention and management. “Some people didn’t even recognise it as a problem,” says Lowe. Children were turning up at schools with infected sores and while it fell short of being
nursingreview.co.nz Issue 3 15
Focus Child Health
Child health briefs Kids’ wellbeing toolkit given thumbs-up A free wellbeing kit that school-based mental health nurses helped develop for kids in post-quake Canterbury has been expanded after a positive evaluation. Activities such as teaching children tummy breathing to calm them down and how to play ‘compliments tag’ were launched on the Sparklers toolkit website last year and received 10,000 hits in the first few months. Twenty new Sparklers activities have been added, bringing the total to 50, including 10 activities specific to Year 7 and 8 children that focus on topics such as working together, building friendships and understanding and regulating big emotions. The seed for the project germinated back in 2014 when the school-based mental health team – set up by Canterbury DHB after the quakes – was approached by a school concerned about anxiety issues 16 Issue 3
in a group of Year 3-4 children. A youth mental health nurse on the team, Michelle Cole, said they suggested teaching tummy breathing and the process of teaching teachers how to share tummy breathing with their class prompted the idea of more simple, ‘doable’ mental health interventions that could help teachers help students and also help nurses who work with children. The Sparklers online kit was developed by All Right?, a joint initiative between Canterbury DHB and the Mental Health Foundation of New Zealand, and a positive evaluation involving five schools has just been completed and released. It found that one school had introduced Sparklers’ activities across all classrooms as a way of helping students struggling with the transition into classroom activities after playtime and lunch breaks. “We did tummy breathing – after breaks we would lie down and we would tummy
breathe for 10 or two minutes. It felt nice and it calmed us,” said one child interviewed during the evaluation. The Sparklers activities can be viewed at www.sparklers.org.nz.
Link between time in green space and child health being researched Researchers are investigating whether time spent by children and pregnant women in our lush outdoors could prevent adverse health conditions in New Zealand children. The Massey University public health study is using Stats NZ data to follow a cohort of babies born in 1998 from the prenatal stage until they are 16 to 18 years old. Researchers look at where the babies or children live and satellite data is used to map the area and measure how much greenery or biodiversity is in the area. The study breaks down the findings into time windows – prenatal, postnatal, early
Focus Child Health
life and later in childhood – and determines which age bracket children get the most benefit from time spent in nature. The hypothesis for the study came about from existing literature suggesting proximity to green spaces had health benefits. “There’s one study, for instance, which is quite fascinating and started all this; it shows that people recovering from surgery who look out over green space recover more quickly than patients who don’t have those views,” said Massey University Professor Jeroen Douwes, the Director of the Centre for Public Health Research.
School children surrounded by unhealthy eating habits School children are being bombarded by messages about unhealthy eating, a new study has revealed. A three-year study by University of Auckland researchers has, for the first time, mapped the nation’s food environments and policies.The study analysed food composition, labelling,
marketing and prices, as well as food in schools and retail outlets. It found only 40 per cent of schools had a food policy, but even those that did were “weak and not comprehensive”. Over 90 per cent of schools used unhealthy food for fundraising and 42 per cent sold sugary drinks, the study found. The survey found that within 500 metres of the school gate there were an average of 2.4 takeaway or convenience stores, and nine advertisements for unhealthy foods. Research leader Professor Boyd Swinburn said people chose their diets from the food environments around them and when it was dominated by unhealthy foods and drinks it was no surprise that overall diets were unhealthy and obesity rates so high. Lower socio-economic neighbourhoods had about three times as many takeaway and fast food outlets, more advertisements for unhealthy foods around schools, and more shelf space devoted to unhealthy foods in supermarkets.
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nursingreview.co.nz Issue 3 17
Professional Development Learning Activity A VIDEO TO START YOU THINKING Before you start reading this article we recommend you watch the short video (link below) and reflect on how nurses in all settings may learn from this woman’s experience: bit.ly/2Mh1IwY
FREE 60-MINUTE professional development activity
Fundamental nursing care:
getting back to ‘basics’ Fundamental cares provide the foundation for all nursing care. So, what are fundamental, ‘basic’ or essential cares, and what enables or stops nurses providing this care? Nursing is under increased scrutiny to deliver care that follows the principles of patient-centredness, with the aim of improving patients’ experiences and outcomes. In patient-centred care, whānau or family and the patient are partners in care delivery. Care labelled as ‘fundamental’ is now identified as essential to reduce harm, optimise recovery, for positive patient experiences1 and to be congruent with the delivery of patient-centred care. However, there is increasing concern in the international literature that these cares are often omitted1. The reasons for these omissions are complex but the most common are nursing shortages, organisational cultures, and a mechanistic and task-focused care approach2. The World Health Organisation global strategy for health care is ‘people-centred’ not ‘disease-centred’3, and fundamental cares provide the foundation for all
nursing care. So, what are fundamental cares, and what enables or stops nurses providing this care?
The ‘basics’ are not basic Some call fundamental cares ‘basic nursing care’, but this implies care that requires less skill. This argument then supports the delegation of ‘tasks’ to unregulated workers, like the emergency department volunteer providing food and drink to patients: This is ‘basic care’ if the patient is otherwise fit and well, but for the frail elderly patient who hasn’t had anything to eat or drink in 24 hours, food and fluids are no longer ‘basic’. Its provision, in a safe, appropriate, and monitored manner is essential. ‘Essential care’ is another label, which does acknowledge the pivotal place of this care. The degree of complexity in health care today, with an aging population, increasing numbers of patients with multi-morbidities, and more use of technology and pharmacology, results in the need for high-quality fundamental care across the healthcare continuum1 to address these complex needs. However, the lack of an agreed definition on what constitutes fundamental care, and the nature of patient and family or person-centred care, has created a challenge in the reprioritisation4 of care needs. Many policies, standards and
By Claire Minton and Lesley Batten interventions are designed to improve all nursing care, based on the recognition that there are widespread failures in the delivery of fundamental cares – across the globe. Providing fundamental cares as part of patient-centred care requires sensitivity to patients’ (and families’) unique physical, psychosocial, cultural and emotional needs, and therefore nurses require the knowledge, skills and models of nursing care that are congruent with these approaches. Healthcare organisations also need to support nurses working in ways that recognise this approach to care. As nursing knowledge has advanced, nursing theories have developed and emphasised a more holistic perspective, where the person has primacy in all aspects of care. This can be seen in theories such as Jean Watson’s theory of human caring, which focuses on the art and science of human caring, and offers a way of conceptualising and maximising human-to-human interaction in nursing practice. Furthermore, Katherine Kolcaba in 2003, returned to the nursing theory origins of Florence Nightingale, with her ‘Comfort Theory’ recognising that increasing technological advances can be detrimental to a patient’s comfort2. The Fundamentals of Care Framework (the framework) was developed to capture the complexity of everyday practice by describing the practical aspects of caring and nursing6.
Learning outcomes Reading and reflecting on this article will enable you to: ▶▶ define the Fundamentals of Care Framework and its importance to clinical practice ▶▶ describe the importance of the nurse-patient
▶▶ explore how the framework can inform your practice ▶▶ consider healthcare system barriers and facilitators to the provision of fundamental cares.
relationship within the framework
This learning activity is relevant to the Nursing Council registered nurse competencies: 1.1,1.5, 2.4, 2.6, 2.8, 2.9, 3.1, 3.2, 3.3, 4.3. 18 Issue 3
Professional Development Learning Activity Fundamentals of Care Framework
These considerations should occur Reflection concurrently in any care encounter. The ▶▶ Reflect on your prior understanding of The Fundamentals of Care Framework framework focuses on the practical acts of fundamental care. Does it differ from articulates the key principles of care using helping patients manage their fundamental the Fundamentals of Care Framework? the clinical and research expertise of care needs, such as personal hygiene, ▶▶ How does your organisation support you members of the International Learning sleep, rest, feeling safe, being respected providing fundamental cares? Collaborative (ILC), an organisation and having a choice – which are essential dedicated to transforming the delivery of and redefining the Fundamentals The patient-centred approach for toReclaiming meet patients’ unique caring and safety of Care: fundamental care internationally through response to meeting patients’ basic human needs improved outcomes research and education. The framework Nursing’s needs. This requires nursing behaviours has three dimensions: to encapsulate factors establishing and It is no surprise that patient-centred care 1. Establishing a relationship with the maintaining positive nurse-patient focuses on the needs and priorities of the patient. patient, and their whānau or family, to relationships, such as recognising patients 2. Assessing. achieve positive outcomes and experiences. as experts in their own experiences, finding 3. Delivering physical, psychosocial When nurses establish positive out what is important to the patient, and and relational care within the wider relationships with patients, it helps them showing insights into patients’ experiences. contexts of health care5. deliver care that is patient-centred, because The final dimension of the framework it can support patients to make informed refers to the context of care. This All three dimensions are necessary to decisions, promotes their dignity and 4 dimension recognises a healthcare deliver quality fundamental care . Within advocates their needs. The nurse-patient organisation has its own culture that can the framework, the relationship between relationship is also central to the delivery either hinder or enable care delivery; the nurse and patient (and whānau or of fundamental care as the nurse must however, it also recognises the need for family) is central and therefore must be connect meaningfully with patients to policiesabove, and resources that support the establishedwith firstthe (seedefining figure 1). parameters outlined Consistent the Fundamentals of Care understand their care needs through 8 delivery of fundamental . Framework rests relationships upon the ability of the nurse to connect with thecare patient and through Nurse-patient compassion and respect6. that connection be able to meet or help the patient themselves meet their fundamental Patients participate in care as they are The nurse-patient relationship is integral care needs. The framework does not focus on clinical diagnosis, treatments or able within the framework. Closely aligned to meet the needs and health outcomes ESTABLISHING A POSITIVE NURSEtherapeutic outcomes. on enabling the patient and the nurse to confidently with this is the nurse-patient relationship. of the patient, to ensureIts no focus harm, is and PATIENT RELATIONSHIP REQUIRES: and competently assess, plan, implement and evaluate care around the fundamental This relationship and ‘knowing the that they are supported throughout their care needs. Whilst clinicaland condition performance fundamentals of patient’ enables nurses to detect signs Developing trust withofpatients patient journey. A positive trusting will affect▶▶the ▶▶ Focusing on patients and giving them care, we arguerelationship that the contribution of nursing to the patient’s journey is facilitating the of deterioration, recognise changes in nurse-patient is essential for undivided patients’ physiological and psychological effective execution of such care basic needs in a way that is attention competent, respectful, personal the delivery of fundamental within ▶▶ Anticipating the patient’s needs parameters, and then initiate appropriate and Thisfactors is therequired bedrockforof effective nursing care and is achieved through theempathetic. framework7. The ▶ ▶ Knowing enough about them to act interventions8. Not knowing the patient, establishment of the nurse-patient thethe conscious alignment of three core elements: establishing the relationship with the appropriately relationship listed in box on right. patient; beingare able to integrate the patient’s care needs; and ensuring that the wideron the contrary, creates potential negative ▶▶ Evaluating the quality of the Once the nurse has established a trusting health system or context is committed and responsive to these core tasks. Figure 1 consequences for patients, including late relationship. or delayed detection of deterioration, and relationship the withframework. the patient (and whānau), summarises depersonalised care because patients can they focus on how they can address the be objectified9. person’s fundamental care needs, which Figure 1 The Fundamentals of Care Framework: Relational, Integrative and Contextual Dimensions Missed fundamental cares are also include psychosocial, physical and associated with numerous other harms like relational needs. pressure injuries, increased infection rates and emotional distress from loss of dignity, autonomy, and lack of compassionate care10. 5 Figure 1 .
3. The emerging Fundamentals of Care Conceptual Framework
Barriers and enablers to delivering fundamental cares
The ILC group list many barriers and enablers to the delivery of fundamental cares. The core barrier is that care identified as fundamental is invisible across the healthcare system, including in education, practice, research and policy. Consider how you document, for example, developing a relationship with the patient and their whānau or family. How do you know what is important to them, to their wellbeing and to help them with their recovery goals? Is this sort of information valued and visible in your clinical setting? Other barriers include medical dominance and the healthcare system structures. nursingreview.co.nz Issue 3 19
Professional Development Learning Activity Medical dominance Dominance of the medical model creates a potent barrier to the provision of fundamental cares in many practice settings. Consider how often you see the following in your practice setting: ▶▶ The biomedical model prioritises interventions for diagnosis and cure first. ▶▶ The biomedical model devalues fundamental care as less important to illness and recovery. ▶▶ Physical problems, needs and care (e.g. nutrition, mobility, hygiene) are prioritised over social, psychological, relational, cultural and spiritual determinants of health. ▶▶ Relationships formed with compassion and empathy are thought to add little to cure. ▶▶ Physical tasks are assigned to different allied healthcare professionals, and to non-regulated workers, without a comprehensive care planning approach. When using the Fundamentals of Care Framework the nurse acknowledges the causes and consequences of illness at multiple levels, including recognising the biological, psychological, cultural and social aspects of illness. The framework, when applied holistically, changes the focus of nurses’ work, which is underpinning other important diagnosis and disease focused work. Healthcare system The healthcare system provides both barriers and enablers to the provision of fundamental cares: ▶▶ Nursing work can be conceptualised as technical and physical work, at the expense of relational components. ▶▶ In an attempt to reduce paperwork, assessment forms and care plans with tick boxes can result in reduced consideration of the person’s needs as a whole and how these interventions come together to create an integrated care plan. ▶▶ The metric approach to patient outcomes relates to risk, and not positive patient experiences – both are needed. ▶▶ Only physical fundamental cares are visible – the psychological and relational aspects are often poorly documented, therefore invisible and unmeasurable. ▶▶ Task-based capacity demand systems can result in nurses becoming disengaged from patients and devaluing fundamental cares, used for falls and pressure injury planning. ▶▶ Caring is not always rewarded or recognised, resulting in some nurses devaluing it or becoming morally distressed when they cannot deliver care they identify as essential. ▶▶ Care ‘rationing’ and time pressures mean nurses prioritise tasks, with some fundamental cares left undone. 20 Issue 3
Nursing devaluing fundamental cares There are also components within the structure of nursing that create barriers: ▶▶ Highly specialised and technical care is seen as more prestigious. ▶▶ Nursing care planning tools that are task focused and may not consider patients’ psychological needs. ▶▶ The division in labour, with experienced nurses carrying out technical tasks such as administration of complex medication, and fundamental skills are delegated to unregulated healthcare assistants.
▶▶ Student nurses may be paired with healthcare assistants to learn fundamental nursing cares early in their undergraduate degrees. ▶▶ There is a lack of research evidence about the importance of fundamental care and a lack of clear definitions about what constitutes fundamental care. We all need to challenge these barriers through valuing and developing evidencebased practice on how to deliver effective fundamental cares and changing organisational cultures for improved patient outcomes1. Consider Suzie scenario below.
Suzie, a 30-year-old woman is admitted to hospital with acute abdominal pain due to gallstones. It is her first hospital admission, she is alone, and is terrified of needles and the sight of blood. The ED nurse assigned to her care talks to her the whole time, explaining what she is doing as she takes her observations. The nurse notes Suzie’s fear of needles so arranges for a support person to distract Suzie with conversation while she prepares to cannulate and give her analgesia. As she goes about her work to manage Suzie’s pain, she explains everything she is doing.
Quickly the nurse established a positive nurse-patient relationship through trust, focusing on Suzie’s needs and explaining what she is doing, anticipating her need for support during cannulation and has made an effort to know her needs. By doing this, she meets Suzie’s fundamental needs of comfort, information, empathy, respect, compassion and safety.
Two hours later, while her nurse is at a dinner break, another nurse starts an infusion. She informs Suzie she is “just hanging a bag of fluids ordered by the doctor” and leaves. Suzie feels anxious about the infusion and her now-dependent situation. She wonders why the nurse couldn’t have had a few moments of conversation.
The nurse fails to establish any relationship with Suzie, who now feels anxious and ignored. This nurse met Suzie’s physical need for hydration, but her relational or psychosocial needs are unmet.
▶▶ Which of the barriers and enablers previously mentioned were at play in this scenario?
Professional Development Learning Activity Research on patients’ experiences of fundamental cares The Fundamentals of Care Framework is being used as a template to explore patients’ experiences of care within various clinical settings and with different health conditions11-14. Patient populations include those after a stroke, admitted to intensive care, cancer patients, and patients with acute abdominal pain that resulted in hospitalisation. Narratives from these patients demonstrate how the three dimensions of physical, psychosocial and relational care are entwined within their experiences. Findings included that: ▶▶ As patients strived to regain control of their life, the relationship with a nurse was essential. ▶▶ Their engagement with the nurse affected how fundamental cares were experienced. ▶▶ When patients felt a rapport with the nurse, and the nurse understood their individual needs, their fundamental care needs were met and this provided motivation in the recovery process11-12,14. After a stroke patients identified the impact of their illness, particularly their loss of mobility, and how this affected managing fundamental cares. However, relationships developed with nurses were important in maintaining their dignity, privacy and self-esteem. Loss of independence and the emotional trauma of having to rely on others was hard to bear. Kitson et al14 (p. 398) noted:
“The loss of personal standards of hygiene, feeling unclean, smelling, having unkempt hair or not wearing their own clothes had been a humiliating experience for some people.” Importantly, physical and psychosocial effects were linked, as the experiences of the physical problems had a profound effect on the patient’s psychosocial and emotional wellbeing. Therefore, for patients to experience dignified and integrated care all aspects of the Fundamentals of Care Framework need to be present throughout the caring process14. Interestingly some cancer patients, in contrast to patients poststroke, described dignified care, when one nurse performed a simple act of washing attentively:
“…and she was really the only one that I felt at the time showed me really great kindness. She actually washed my legs and feet, which was wonderful, and just that very simple human touch and that very simple kindness of doing that made me feel so much better”13 (p.2327).
What enabled this nurse to overcome the barriers to demonstrate this caring? Caring nurse-patient relationships for those undergoing surgery provided patients with feelings of safety:
“When nurses are calm and talk clearly, it makes me feel safe. When they show me that they care about me. It is the caring that is important. It is so important to feel that you are seen.”11 (p. 2316)
Conclusion There is now renewed attention on how nurses can provide care that best meets patients’ and families’ needs in an integrated way. Dividing care into levels of basic and essential can have unintended consequences that do negatively affect patient experiences and outcomes. The Fundamentals of Care Framework provides nurses and nursing with a way to refocus on what elements of nursing care must be provided with the system level changes needed, together with the work that is related to diagnosis and treatment. It is only when these components come together that patient and whānau and family-centred care will eventuate.
RECOMMENDED RESOURCES ▶▶ The International Learning Collaborative: http://intlearningcollab.org ▶▶ Point of Care Foundation: Their programmes help create open and compassionate organisational cultures and provide tools and support to bring about radical change within your workplace. www.pointofcarefoundation.org.uk ▶▶ Why might good people deliver bad care? Yvonne Sawbridge argues that the caring professionals undertake hard, emotional labour which needs the same recognition by management that physical labour is given. www.youtube.com/watch?v=VC4FajTFpRU
REFERENCES 1. FEO R, & KITSON A. (2016). Promoting patientcentred fundamental care in acute healthcare systems. International Journal of Nursing Studies 57, 1-11. doi: 10.1016/j.ijnurstu.2016.01.006. 2. KITSON A, ATHLIN A, & CONROY T (2014). Anything but basic: Nursing’s challenge in meeting patients’ fundamental care needs. Journal of Nursing Scholarship 46(5) 331-339. 3. World Health Organization. (2015). WHO global strategy on people-centred and integrated health services: interim report. Accessed 24 June 2018 from www.who.int/servicedeliverysafety/areas/ people-centred-care/global-strategy/en 4. FEO R, ET AL (2017). Towards a standardised definition for fundamental care: a modified Delphi study. Journal of Clinical Nursing 27 22852299. Doi:10.1111/jocn.14247 5. KITSON A, CONROY T, KULUSKI K, LOCOCK L, & LYONS R (2013). Reclaiming and redefining the Fundamentals of Care: Nursing's responses to meeting patients' basic human needs. Retrieved 24 June 2018 from https://digital.library.adelaide. edu.au/dspace/bitstream/2440/75843/1/hdl_75843. pdf 6. DELAUNE S, LADNER P, McTIER L, TOLLEFSON J, & Lawerence J. (2016). Australian and New Zealand Fundamentals of Nursing. Cengage Learning: Melbourne. 7. FEO R, RASMUSSEN P, WIECHULA R (2017). Developing effective and caring nurse-patient relationships. Nursing Standard 31 (28) 54-63. 8. JEFFS L, SARAGOSA M, MERKLEY J, & MAIONE M (2016). Engaging patients in meeting their fundamental needs: Key to safe and quality care. Nursing Leadership 29(1) 59-66. 9. WHITTEMORE R (2000). Consequences of not "Knowing the Patient". Clinical Nurse Specialist 14(2) 75-81. 10. JACKSON D, & KOZLOWSKA O (2018). Fundamental care – the quest for evidence. Journal of Clinical Nursing 27 11-12. Doi. org/10.1111/jocn.14382 11. JANGLAND E, TEODORSSON T, MOLANDER K, & MUNTLIN ATHLIN Å (2018). Inadequate environment, resources and values lead to missed nursing care: A focused ethnographic study on the surgical ward using the Fundamentals of Care framework. Journal of Clinical Nursing 27 2311-2321. Doi:10.1111/jocn.14095 12. MINTON C, BATTEN L, & HUNTINGTON A (2018). The impact of a prolonged stay in the ICU on patients' fundamental care needs. Journal of Clinical Nursing 27(11-12) 2300-2310. doi: 10.1111/ jocn.14184. 13. MUNTLIN ATHLIN Å, BROWALL M, WENGSTRÖM Y, CONROY T, & KITSON A L (2018). Descriptions of fundamental care needs in cancer care – an exploratory study. Journal of Clinical Nursing 27:2322-2332. Doi: 10.111/ jocn.14251 14. KITSON A, DOW C, CALABRESE J D, LOCOC L, & ATHLIN Å M (2013). Stroke survivors’ experiences of the fundamentals of care: A qualitative analysis. International Journal of Nursing Studies 50(3),392-403.
ABOUT THE AUTHORS Claire Minton RN PhD is a nursing lecturer at Massey University, Palmerston North Lesley Batten RN PhD is a senior researcher at Massey University, Palmerston North This article was peer reviewed by: Sue Wood RN MNS is the Quality & Patient Safety Director for Canterbury District Health Board and former director of nursing for MidCentral District Health Board. Sally Houliston RN MN is a Nurse Consultant (workforce development) at Hawke’s Bay District Health Board. nursingreview.co.nz Issue 3 21
Professional Development Learning Activity
Reading and reflecting on this article will enable you to: ▶▶ Define the Fundamentals of Care Framework and its importance to clinical practice ▶▶ Describe the importance of the nursepatient relationship within the Framework ▶▶ Explore how the Framework can inform your practice ▶▶ Consider health care system barriers and facilitators to the provision of fundamental cares.
Reading the article Fundamental nursing care: getting back to ‘basics’ and undertaking this learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council registered nurse competencies: 1.1,1.5, 2.4, 2.6, 2.8, 2.9, 3.1, 3.2, 3.3, 4.3. A
Watch the TEDx talk (10 minutes) by jason leitch on “what matters to me” – a new vital sign: bit.ly/2KDpjTW
Reflect on how in your practice you find out what is important to your patients as part of your development of therapeutic relationships with them and their whānau or family
Reflect on how your practice setting hinders or enables your ability to deliver fundamentals of care – what can you change?
Find polices within your organisation that support the application of the Fundamentals of Care Framework in practice
Identify the ways in which you could reprioritise the Fundamentals of Care Framework into your practice
Describe ways to overcome system-level influences that hinder the implementation of the Fundamentals of Care Framework.
Verification by a colleague of your completion of this activity Colleague name
Nursing council ID
22 Issue 3
Professional Development Research Review
Is e-learning the best way to teach nurses? Which method of teaching nurses has the best impact on patient outcomes – traditional or e-learning? Clinical bottom line Low-quality evidence suggests that e-learning is no more effective than traditional teaching methods for improving patient outcomes, health professionals’ behaviours, skills or knowledge. Other factors than presuming e-learning is superior should guide decisions on which approach to use.
Clinical scenario As a nurse educator, you are aware that e-learning – online educational programmes – offer flexibility and increased access to learning. e-Learning is
also generally thought to be more effective than traditional learning methods for changing nursing behaviour, skill and knowledge – but is this true?
Question In comparison to traditional learning methods how effective are e-learning programmes for changing nurses’ practice impacting on patient outcomes?
SEARCH STRATEGY PubMed-Clinical Queries (Therapy/ Narrow): e-learning AND nurses.
nursingreview.co.nz Issue 3 23
Professional Development Research Review Citation Vaona A, Banzi R, Kwag KH, Rigon G, Cereda D, Pecoraro V, et al. e-Learning for health professionals. **itals** Cochrane Database of Systematic Reviews **2018, Issue 1. Art. No.: CD011736. DOI: 10.1002/14651858.CD011736.pub2. 22(14):188.
STUDY SUMMARY A systematic review to assess the effects of e-learning programmes versus traditional learning in licensed health professionals for improving patient outcomes or health professionals’ behaviours, skills and knowledge. Inclusion criteria were: Type of study: Randomised trials and cluster-randomised trials. Excluded were non-randomised trials; programmes focusing on non-clinical topics. Study participants were licensed health professionals (doctors, nurses and allied health). Intervention: Any education intervention on a clinical topic delivered primarily by internet, extranet or intranet. No restrictions on programme length. Comparison: Educational interventions on the same topic without access to e-learning (e.g. print books, face-to-face courses, guidelines dissemination). Outcomes: Primary Outcome: Objective measures of patient clinical outcomes or health professionals’ behaviour affecting outcomes (such as tests ordered). Secondary Outcomes: Objective measures of health professional skills (such as demonstrating a procedure or technique) or knowledge (such as factual or conceptual understanding).
Study Validity Search Strategy: Comprehensive search strategy involving multiple electronic databases, trial registries and review of referenced lists of included trials and e-learning reviews.
Review process: Two authors independently screened the search results for potentially relevant studies, selected the studies, extracted data using a standardised form and conducted risk of bias assessment. Disagreements resolved by consensus. Quality assessment: Yes, using the standard Cochrane Effective Practice and Organisation of Care Group (EPOC) risk of bias criteria. Overall validity: A good quality review involving studies of high or unclear risk of bias.
Study Results Screening 3,465 titles/abstracts and 137 full text articles identified 16 eligible randomised trials. Trials involved 5,679 licensed health professionals; 4,759 mixed health professionals (four trials), 587 nurses (seven trials), 300 doctors (four trials) and 33 childcare health consultants (one trial). Trials were conducted in 10 different countries: eight trials in hospital settings, seven in community/primary healthcare settings and one trial involved health professionals from both hospital and community. e-Learning was not found to be better or worse than traditional learning for the primary outcome of patient outcomes, or health professional behaviours related to appropriate screening or treatment of dyslipidaemia (see table). There were also no significant differences between teaching methods for outcomes related to improving health professionals’ skills (2,912 health professionals; six studies), or knowledge (3,236 participants; 11 studies). Follow-up varied between studies and ranged from 0 weeks (immediately after training) to 12 months. ▶▶ Only one randomised trial measured impact on patient outcomes. Pooling of data (meta-analysis) from studies included in other outcome measurement was not always possible.
▶▶ Certainty of the evidence for all outcomes was low. However, these results suggest that e-learning is no ‘magic wand’ and supports approaches to learning that include e-learning, traditional, or a blended approach. ▶▶ Common sense indicates advantages of e-learning may include increased accessibility, convenience and costs but these outcomes were not measured. ▶▶ It would be interesting to know the comparative effectiveness of both methods for overcoming barriers to changing behaviour relating to lack of confidence, social influences or where teamwork is an essential skill. However, subgroup analysis exploring effectiveness of both approaches by educational content and aim was not possible.
COMMENTS: ▶▶ Only one randomised trial measured impact on patient outcomes. Pooling of data (meta-analysis) from studies included in other outcome measurement was not always possible. ▶▶ Certainty of the evidence for all outcomes was low. However, these results suggest that e-learning is no ‘magic wand’ and supports approaches to learning that include e-learning, traditional, or a blended approach. ▶▶ Common sense indicates advantages of e-learning may include increased accessibility, convenience and costs but these outcomes were not measured. ▶▶ It would be interesting to know the comparative effectiveness of both methods for overcoming barriers to changing behaviour relating to lack of confidence, social influences or where teamwork is an essential skill. However, subgroup analysis exploring effectiveness of both approaches by educational content and aim was not possible. Reviewer: Cynthia Wensley RN, PhD. Lecturer, School of Nursing, University of Auckland email@example.com
TABLE: SUMMARY OF RESULTS Outcomes
Difference in improvement (95% CI)
Odds ratio (95 % CI)
Patient outcome – proportion of patients with low-density lipoprotein cholesterol of less than 100 mg/dL
4.0% (-0.3 to 7.9)
Patient outcome – proportion of patients with glycated haemoglobin level of less than 8%
4.6% (-1.5 to 9.8)
Behaviour – screening for dyslipidaemia
0.90 (0.77 to 1.06)
Behaviour – treatment for dyslipidaemia
1.15 (0.89 to 1.48)
CI – Confidence Interval; n – number of participants; * – patients involved in analysis 24 Issue 3
Leadership & Management Enrolled Nurses
Enrolled nurses: think ‘can’ not ‘can’t Most of the world experiences some confusion over what ENs can or cannot do. Nurse managers can make the difference, reports Nursing Review.
hat enrolled nurses can or cannot do should be guided by the scope of practice, not manager preference, cost or risk aversion, says a Canadian nurse leader. Dianne Martin, chief executive officer of the Registered Practical Nurses Association of Ontario, has been studying the enrolled nurse (EN)/practical nurse (PN) and equivalent roles in six countries around the world and shared her findings to date at this year’s Enrolled Nurse Section conference. One of her key findings was that while the registered nurse (RN) scope was diverse around the world the EN/PN scope was “wildly” diverse internationally, including qualifications ranging from six months to three years. Most of the controversial negative research about second level nursing scopes had historically come from the United States, where the PN scope was actually very similar to the healthcare assistant role, and where RN training programmes can range from two years to four years. Martin, who holds registration as both an RPN and RN in her home province of Ontario, says one of the common themes around the world was that there was universal and longstanding confusion over the second level scope. But this confusion was less in countries where there were strong accredited training programmes and where the nursing scopes were educated early on about each other’s roles. “Two countries did it best – New Zealand and Australia – which are head and shoulders above the rest of world in knowledge and understanding of each other’s role/scope,” says Martin. “You see
yourselves as one profession. I wish I could say that was true globally.” Enrolled nurses at the conference were proud of the praise but also agreed with Enrolled Nurse Section Chair Leonie Metcalfe that work still needed to be done to change some of the attitudes and myths in Kiwi nursing leadership about what role ENs can play in nursing models of care. “It is easy to say enrolled nurses can’t and it is harder for them to say enrolled nurses can,” says Metcalfe.
Reasons in common Martin says after looking at EN/PN roles in three states in the USA, New Zealand, Australia, Finland, Belgium and England she found the common reasons for boosting or re-introducing the role were shortages of RNs, increasing costs and the increasing needs of the ageing population. Her study led to a number of recommendations including that organisations should use the EN scope of practice to guide decision-making on the role and not rigid inhouse policies, manager’s preferences or cost. “Cost is going to be a driver in health care for everything but do not let cost change your scope of practice,” advises Martin. Nor should ENs be used to address an RN shortage unless it was appropriate for an EN to take on the role, she says. Decisions should also be based on risk management not risk aversion, and not on the belief that having an RN at every bedside “will somehow create this great care”. The conference was told that there had only been 1,052 new EN graduates in New Zealand since re-training enrolled
nurses began early in the millennium – not enough to replace ENs retiring in the ageing workforce. The current 18 month diploma was not launched until 2011 by which time EN numbers had fallen to around 3,000 and have continued to fall and by 2017 were down to 2,648.
Backlash a challenge Martin says in Ontario the RPN workforce was actually increasing, was a very young workforce – and was facing a backlash from the ageing and not growing RN workforce who saw RPNs as taking their jobs. “And the biggest problem we have in Ontario is that we have a RN group who are not only not working to full scope of practice, in my opinion, they don’t know what their full scope of practice is. So they end up bunching up in the middle with the RPNs.” She says Ontario RNs with a four-year degree should be developing care plans for the sickest, most unpredictable patients to develop a safety net for that patient – “You are not going to just take the vitals, write them down and hope the doctor will see them and react to them… you are going to make high level, difficult, complex decisions every day” – while the RPN/EN is going to be working with patients with more predictable outcomes and who are moving along an expected path of care. “And they are going to do it equally well but just with a different group of patients.” Martin says her research is continuing this year where she plans to work with some of England’s first nursing associate graduates (their EN equivalent) and to work alongside PNs in Finland where they greatly outnumber their RN equivalents. nursingreview.co.nz Issue 3 25
Leadership & Management Misconduct
Bullying notification not breach, court finds A DHB’s decision to report a nurse who had bullied fellow nurses to the Nursing Council has been upheld by the Employment Court.
everal nurses made complaints of bullying against a registered nurse employed by the Southern District Health Board. They alleged the nurse was bullying, undermining the practice, confidence and decision-making of colleagues and disparaging others. An independent investigator concluded the complaints were substantiated and that the DHB’s Code of Conduct and the Nursing Council’s Code of Conduct had been breached. The nurse rejected the report’s conclusions and any suggestion that her behaviour fell short of what was expected. The DHB informed her that its preliminary decision was to accept the report’s findings. Prior to formally deciding whether misconduct had occurred (and any disciplinary action), the parties entered into a settlement agreement signed by a mediator. The settlement agreement included the following: ▶▶ The terms of settlement were confidential to the parties “so far as the law allows”. ▶▶ Both parties would not make disparaging comments about each other to third parties. ▶▶ The nurse agreed to resign. ▶▶ The settlement agreement was a “full and final settlement of all matters between the employee and the employer arising out of their employment relationship”. There was no reference in the agreement to the nurse’s reasons for resigning or about the board’s reporting obligations under the Health Practitioners Competency Assurance (HPCA) Act 2003. Several months later, the DHB’s Executive Director of Nursing and Midwifery notified the Nursing Council under section 34(3) of the HPCA Act. The brief notification stated that the nurse had resigned prior to the investigation concluding, and that the seriousness of the allegations meant she had been on paid leave during the investigation. The 26 Issue 3
DHB attached copies of the complaints, its letter to the nurse about the complaints, and the investigation terms of reference. The nurse claimed that the DHB’s notification breached the settlement agreement and the HPCA Act did not justify its behaviour. The DHB did not accept this, given its legal obligations under the Act and the legal protection from civil liability in section 34(4) of the Act.
Mandatory reporting obligations come first Nurse employers are required under the Act to notify the Nursing Council whenever a nurse resigns or is dismissed from employment “for reasons relating to competence”. The Employment Court confirmed that this compulsory reporting obligation could not be circumvented by a settlement agreement. It also held that the Act’s threshold for notification is low and only requires that competence was raised or played some part in the decision to end the nurse’s employment. The DHB was not required to establish a competence issue or issue a final decision prior to notifying the Nursing Council. The Court also analysed the meaning of competence, including whether bullying fell within the Nursing Council’s domain. The Council’s competencies extend beyond patient care and clinical competence and apply to ethical matters, such as the way nurses deal with one another. These include effective communication, collaboration and participation with colleagues. The Code of Conduct also requires nurses to work and communicate clearly, effectively and respectfully with other nurses. In the Court’s view, the alleged bullying behaviour (if substantiated) could be a breach of these expectations. Once the DHB also formally decided there had been a breach, notification to the Nursing Council was compulsory and inevitable.
No confidentiality breach The settlement agreement required confidentiality “so far as the law allows”. The DHB acted in reliance on its statutory obligations and only disclosed information necessary to meet that obligation. The notification contained simple statements of fact and did not include the settlement agreement or any terms of settlement. As such, there was no breach of confidentiality, nor was there any disparagement. The Court was very clear that neither the DHB or nurse could contract out of their legal obligations and that the settlement agreement did not prevent notification to the Nursing Council. It is not clear whether the DHB informed the nurse it was considering notifying the Nursing Council, and the Court did not comment on whether there was any requirement to inform her. Arguably the DHB’s obligation of good faith could have required disclosure, although that could have been a barrier to reaching a settlement. The obligation to disclose depends on the circumstances, including the employer’s own assessment of whether the behaviour meets the reporting threshold. The dismissal or resignation of a professionally registered employee endangers not only their employment but also their prospects of working again in their chosen field. Employers should therefore take additional care in reaching adverse findings that may result in a professional body investigation. Earlier cases suggest that an employer should consider advising an employee early on in the process if there is the potential for wider professional consequences. This is an abridged version of an article by Hamish Kynaston (Partner) and Jennifer Howes (Senior Solicitor) of commercial and public law firm Buddle Findlay. The full article is available at https://bit.ly/2OrEYIT.
Innovation & Technology
Health Navigator App of the Month
hese two apps help women who want to track, predict and monitor their menstrual cycles (periods) for a variety of reasons, including wanting or not wanting to get pregnant. Both apps provide useful health information and allow women to record menstrual cycle symptoms and note when they have had sex. Both apps also help women to predict their fertility windows and ovulation cycles by using basal temperature and changes in vaginal discharge.
Period Tracker Flo APP OVERVIEW ▶▶ Clinical score ▶▶ Availability
WEBSCOPE Non-communicable disease: campaign for action – meeting the NCD targets www.who.int/beat-ncds/en
his WHO website provides a host of resources about the global situation and strategies to achieve the nine-global voluntary NCD targets with the overall objective to reduce premature deaths from cancers, heart and lung diseases and diabetes by 25 per cent by 2025. An additional resource about the impact of nursing on NCD management can be found here: www.who.int/hrh/resources/ observer12/en. [Site accessed 29 April and last updated February 2018].
New Zealand research reviews – diabetes and obesity Free for Apple & Android
Full review www.healthnavigator.org.nz/app-library/p/period-tracker-flo-app PROS include: ▶▶ Menstrual and pregnancy tracking modes. ▶▶ Reminders for contraceptive pills, injections etc. ▶▶ An alert if period is late. CONS include: ▶▶ No emergency contraception alert for those who’ve indicated they don’t want to get pregnant and who record having unprotected sex during fertile window. ▶▶ Slightly ‘buggy’ and sometimes crashes.
This focused review features key medical articles from global diabetes and obesity journals, with specific New Zealand expert commentary. Broadly, topics include insulin and metformin use, type 2 diabetes, gestational diabetes, type 1 diabetes, bariatric surgery, diabetic retinopathy, thiazolidinediones and sulphonylureas. [Site accessed 29 April and last updated 2018]. Dr Kathy Holloway is the director of the Graduate School of Nursing, Midwifery and Health at Victoria University.
Period Tracker Clue APP OVERVIEW ▶▶ Clinical score ▶▶ Availability
Mental Health Nurses Dunedin Free for Apple & Android (with option of paid upgrade)
Full review www.healthnavigator.org.nz/app-library/p/period-tracker-clue-app PROS include: ▶▶ Can connect to partner’s phone. ▶▶ Creates reports for sharing. CONS include: ▶▶ No pregnancy tracking mode. ▶▶ No pill reminder.
The NZ App Project: Health Navigator, a non-profit trust, is using technical and clinical reviewers to help develop a New Zealand-based library of useful and relevant health apps. Health professionals who would like to be part of the project can email firstname.lastname@example.org.
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nursingreview.co.nz Issue 3 27
Innovation & Technology
Plunket going digital creates ‘rich’ child health data
Plunket nurses shifting from paper to digital records is providing huge potential to make real changes for child health, as REBEKAH FRASER explains
n 2015, Plunket embarked upon a bold digitisation programme that saw nurses swapping pen and paper for a tablet and a cloud-based app. Today, all of the organisation’s 800 nurses work entirely on the digital platform, known as the Electronic Plunket Health Record (ePHR). With key data from older paper records now added into the system, it now holds 250,000 client records and is proving to be a valuable tool. Chief executive Amanda Malu says that the data has huge potential to make real change. “It’s a significant and powerful dataset we now have. We do need to be careful because we are guardians of this data, but it is a very rich data set and we want to ensure the best possible use for Kiwi families.” At present Plunket is able to share high-level anonymised data, says Malu. “We can see pockets of concern where, for example, immunisation rates might be low. We can then team up with other health organisations and make that a priority for that area.” Information collected and analysed through the system has led to a new breastfeeding strategy within Plunket. “We’ve now got that solid data that at around the six-week-old mark, breastfeeding rates decline.” That insight led to Plunketline nurses training to be lactation consultants, who can now video-conference mums needing more support with breastfeeding. Over time, the ePHR data will begin to show the correlation between the support and interventions provided by nurses and the longer term health of the child, says Malu. “And suddenly we’re having the
28 Issue 3
important conversations – talking about health outcomes, not outputs.”
Access to information On a day-to-day basis, the real benefit of the digital system is timely access to information. “We are more joined up as an organisation than we have ever been.” Malu gives the example of an Auckland mother with a premature baby who went to Wellington to be cared for by family. While in Wellington, she attended Plunket appointments. On her return home, her Aucklandbased Plunket nurse was able to see everything that had been done with mother and baby in Wellington. “Not rocket science I know, but this meant we saved so much time. Under our old system, we may have missed the opportunity to meet with the mum when she was in Wellington, potentially losing her altogether, or missing important development issues that could have been picked up in an early visit.” Trying to ensure all the relevant information was recorded between the two nurses would have seen staff faxing and emailing information to one another. “Not the greatest use of specialist nursing time.” Malu says that for hard-to-reach families, a nurse will often arrive for an appointment to find other family members staying there too. “This digital system allows nurses to pull up information for those children then and there and keep them connected.” Auckland-based community Karitane nurse Sharleen Rapoto has worked for Plunket for 13 years. She says on the very first day of using the digital system, she noticed the benefits. “I was no longer having to take bundles
of notes with me. Carrying those around threw up lots of issues around privacy risks, but ePHR eliminated that.” Rapoto says instant access to resources via the app is also a bonus. “I don’t have to carry around bundles of pamphlets now. I can instantly pull up a resource on safe sleeping or dental hygiene, or whatever the family needs, right then and there.” She is looking forward to updates to make the programme even more accessible and intuitive. “I really love it. It has so much potential for not only our staff, but for our families and the health of our tamariki.” Malu says Plunket is keen to share its system and data with other health organisations. “The worst thing we could do was keep it to ourselves. It’s a fantastic way to create change in the healthcare system.” Plunket is currently talking to the College of Midwives on how to link its system with ePHR, and aims to pilot and assess a referral system that will cut down duplication. “Our families have told us they want a seamless transition from midwife through to Plunket. This proposal will make the all-important first visit more about getting to know one another, and talking about the baby, and less about gathering data.” There are also plans for parents to be able to add to their child’s record. “After all, the data belongs to the family.”
Well Child books to stay However, Malu is quick to point out that the “well-loved” Well Child books will still be printed. “I still have mine. We know how treasured they are. They won’t be going anywhere.”
Students New Graduates
tips for finding work
In 2014 Megan Lyell created a Facebook page to support unemployed new graduates like herself. Four years on, she shares with BAZ MACDONALD some pragmatic advice on getting your first job and where nursing has taken her.
ack in 2014 Megan Lyell went public with her struggles in finding a position as a graduate nurse. After seven months unemployed, “a hundred, if not more” applications submitted, and 17 job interviews, she finally got her first nursing job at a GP clinic in mid-2014. Now entering her fifth year of professional nursing, Megan reflects on some of the issues she identified – and still sees – for graduating nurses plus shares some advice for job-seeking new graduates.
Be pragmatic over first job choice Like many nursing students, Megan had her eyes set on a specific specialty and was working towards a career in paediatrics, so when in her final year she filled out her Nursing Entry to Practice (NETP) application on the ACE Nursing website, she highlighted paediatrics as her desired field. However, after seven months without work, on reapplying to ACE Nursing for the mid-year NETP intake, she changed her first choice to community nursing and gained a NETP place in a general practice. Since her NETP year she spent a year as
the school nurse for Rangitoto College, and is now in her third year as a public health nurse. For nurses approaching graduation, she says it can pay to be pragmatic about which practice area they apply for. For instance, it may be easier to get a job in less popular areas such as geriatric care or an AT&R (assessment, treatment and rehabilitation) ward. Even if you want to end up in an area, such as paediatrics, it is often more realistic to get some experience and work your way into your preferred area than it is to get a job there straight out of school, says Megan.
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Students New Graduates Her own journey also illustrates that a winding path can lead you to jobs that you hadn’t considered, but you may love. For instance, having initially set her heart on paediatrics, Megan says she now can’t imagine herself leaving community nursing, having seen the difference it makes. “Because I get to see families in the community for a huge range of reasons, I often will go in for one child, but the family has six kids. So, I can go in and support any number of children in a variety of ways. It really has satisfied my passion for paediatrics.”
Persevere and consider volunteering For graduate nurses looking for work, she says the best advice she can give is to persevere and keep applying, even when you don’t seem to be gaining any traction in finding a placement. Nurses looking for work should also consider volunteering, says Megan. Doing volunteer nurse work will strengthen your CV and hopefully help you to stand out from the pack of other applicants. While she was looking for work, she volunteered for Plunket, participated in dance classes for disabled children, and made treats for sick kids with Project Sugar. Megan has continued to volunteer as well, taking a month in 2016 to volunteer at an orphanage in India.
Be ready to say ‘no’ to unsafe positions While finding a job can be difficult, Megan says job-seeking nurses still need to be selective about the jobs offers they receive. Before gaining her NETP job at the GP clinic, she had been offered a non-NETP
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job as a nurse in a supported respite facility for disabled children. However, the role was a night-shift role in which Megan would be working alone. “I was a brand-new nurse, so I said ‘no’. It would have been incredibly unsafe,” says Megan. “It wasn’t right of them to offer it to me either. It would have put me in a situation where something could have happened to the children while I was on duty. “I was quite aware that it wasn’t the right thing to do.” It is situations like these that can make the first year in nursing practice incredibly difficult, she says. Not only is there the challenge of applying the skills you have learned in a real-world setting, but there is still so much to learn both clinically and about working in the health system. On top of this, Megan says there is potential for graduate nurses to get taken advantage of – with too much expected of them, and not enough time and resources put into making sure they are ready for that workload. She has talked to a nurse the same age as her, who during her NETP year often ended up being the most senior nurse on duty and had to take on senior responsibilities such as coordinating the shift. Megan too had a difficult first year of practice. “[The GP clinic] had never had a new grad before, and unfortunately, it was not managed very well, and I ended up being bullied quite badly,” says Megan. “The whole experience really wore me down. Even though it was only a year, a lot of that was an unpleasant experience.” But, although the first years were difficult, she says that she still learnt a lot from them and it put her on the right path.
Openly discuss challenges Straight out of training, Megan was very outspoken about the challenges faced by graduate nurses, and her first few years of practice further embedded her desire to see a greater discussion around these continuing issues. “I was so passionate about talking about New Zealand needing more NETP placements, because, even though graduate nurses have had three years of training and placements, you still have so much learning to do.” As well as speaking out herself, she encouraged other graduate nurses to also openly discuss the issues around finding safe and stable employment out of training. She created a Facebook page for nurses looking for work and encouraged those on the page to share their stories as much as possible. “Going from seven months without work into a workplace where I was treated unfairly confirmed to me that I needed to be speaking out – not just about the issues around finding a job but also the conditions that new grads are having to work in. “The NETP programme could be better than it is. There are still a lot of New Zealand trained nurses who can’t get a job in their own country. “If there was a NETP position for every trained nurse, that would be ideal. That way we can keep our nurses in the country and not have to make them think about moving to Australia and help the situation around unsafe staffing.”
Opinion College of Nurses
What’s climate change got to do with nursing? REBECCA SINCLAIR argues that climate change matters a lot to nursing and health.
ith all the talk about climate change in the media – what does this have to do with nursing? The Lancet medical journal and the World Health Organisation recognise that “Climate change is the greatest threat to global health in the 21st century”. It also offers nurses the greatest public health opportunity for a fairer distribution of health. Globally, 2016 and 2017 were the hottest years on record, with New Zealand having the hottest January ever in 2018. The Royal Society Te Aparangi in 2017 published an excellent summary of the Human Health Impacts of Climate Change for New Zealand, such as increased flooding, fires, damage to infrastructure and changing disease outbreak patterns. These can cause injury or worsening illness, food and water supply changes, disruption to livelihoods and communities, forced migration and conflict. We can expect weather extremes including heatwaves, more frequent severe storms, heavier rainfall and more droughts. The greatest impact will be on those already experiencing social and health disadvantages. If greenhouse gases continue rising, many parts of New Zealand by 2100 may experience more than 80 days a year with temperatures above 25°C, more than double what we have now, and contributing to more heat-related deaths. If the planet warms by 3–4°C half of the world’s coastal cities would be gone, displacing 100 million people.
The New Zealand Government target is to reduce carbon emissions to zero by 2050, with health currently responsible for around 3–8 per cent of total greenhouse gas emissions. So, what can we do? We can talk about climate change! I see a parallel with my work as a public health nurse around immunisation. We speak from an evidence-based perspective and work alongside patients to help them make informed choices around their health, and in this case, the health of the environment too. As nurses, we have a unique role as trusted health professionals working with individuals and their families and we are also able to call for policy change and advocate at both local and national levels. The actions we take now may not show up in the environment for another 20 years, but the benefits to our health start now! “Health gains are possible for heart disease, cancer, obesity, diabetes, respiratory disease, and mental health”, which would also have cost savings for the health system and help reduce greenhouse gas emissions argues Ora Taiao (The NZ Climate and Health Council www.orataiao. org.nz). Another consideration is Te Tiriti O Waitangi and how we work together to reduce the climate change impact on the hauora (health) of Māori. With a quick search online, we can educate ourselves around climate change’s health risks like the asthma deaths in Australia after a severe thunderstorm led to the release of dangerous pollen levels, or how the groups disproportionately affected by or vulnerable to climate
change are older people, children, marginalised communities and people with mental illnesses. As nurses we can promote physical activity, walking and cycling – this reduces transport emissions that contribute to air pollution, improves fitness and reduces the risk of heart disease, obesity and diabetes. Plus reducing the need for surgery and the highly potent anaesthetic gases that are released into the atmosphere. Reducing red meat intake and eating a more plant-based diet of fruit, vegetables and legumes also helps cut greenhouse gas emissions from animal agriculture and decreases the risk of bowel cancer and heart disease. We can lead the way in choosing these lifestyle options for ourselves, e.g. learning how to cook a vegan meal. Nurses can promote efforts to reduce the carbon footprint in the workplace by looking at the products we use. Community nurses can encourage home insulation as this reduces energy emissions, and people living in warm, dry homes have better health and fewer hospitalisations. There is also the ‘Greening Your Practice Toolkit’ (2010), which supports general practices to make environmentally responsible changes. It just takes one person to get started and get the team on board. Start with the changes that are the easy changes! Rebecca Sinclair, RN, PgDip SCPHN is a Public Health Nurse and member of the College of Nurses Aotearoa. References available by emailing: firstname.lastname@example.org
nursingreview.co.nz Issue 3 31
Upcoming conferences NZ Rheumatology Association/NZ Health Professionals in Rheumatology Annual Scientific Meeting 2018 ▶▶ 30 August–2 September ▶▶ Wellington ▶▶ www.eenz.com/nzra18 All Together Better Health International Conference (Collaborative Practice and Interprofessional Education) ▶▶ 3–6 September 2018 ▶▶ Auckland ▶▶ www.atbhix.co.nz New Zealand Association of Gerontology Conference ▶▶ 6–8 September 2018 ▶▶ Auckland ▶▶ www.gerontology.org.nz New Zealand Faith Community Nursing Association Conference ▶▶ 7–9 September 2018 ▶▶ Tauranga ▶▶ www.faithcommunitynursing.nz Mental Health & Addiction Nurse Educators Forum 2018 ▶▶ 13–14 September 2018 ▶▶ Auckland ▶▶ www.nzcmhn.org.nz/events/regionalevents New Zealand Nurses Organisation Conference and AGM ▶▶ 19–20 September 2018 ▶▶ Wellington ▶▶ www.nzno.org.nz 23rd Hospice NZ Palliative Care Conference ▶▶ 19–21 September 2018 ▶▶ Auckland ▶▶ www.hospice.org.nz/conference-2018 International Society of Nurses in Cancer Care Conference ▶▶ 23–26 September 2018 ▶▶ Auckland ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/cancer_nurses_college Neonatal Nurses College Aotearoa Symposium ▶▶ 28 September 2018 ▶▶ Hamilton ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/neonatal_nurses_ college/conferences_events Selwyn Foundation Gerontology Nursing Conference ▶▶ 1 October 2018 ▶▶ Auckland 32 Issue 3
▶▶ www.selwynfoundation.org.nz/learning/ learn/2018-gerontology-nursingconference Perioperative Nurses College NZNO Annual Conference ▶▶ 11–13 October 2018 ▶▶ Nelson ▶▶ www.confer.nz/periop2018 71st Annual General and Scientific Meeting of the New Zealand Society of Otolaryngology, Head and Neck Surgery ▶▶ 16–19 October 2018 ▶▶ Queenstown ▶▶ www.eiseverywhere.com/ ehome/243459/Welcome College of Emergency Nurses NZ Conference ▶▶ 26–27 October 2018 ▶▶ Napier ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/college_of_emergency_ nurses Infection Prevention and Control Nurses NZNO Conference ▶▶ 30 October–2 November 2018 ▶▶ Lower Hutt ▶▶ www.ipcconference.co.nz IUSTI Asia Pacific Sexual Health Congress (including NZ Sexual Health Society) ▶▶ 1–3 November 2018 ▶▶ Auckland ▶▶ http://iustiap18.com Children’s Continence Education Day ▶▶ 2 November 2018 ▶▶ Wellington ▶▶ www.continence.org.nz/c/Education-Events/79 New Zealand Melanoma Summit ▶▶ 2–3 November 2018 ▶▶ Auckland ▶▶ www.melnet.org.nz/2018-melanomasummit Selwyn Institute 2018 Ageing and Spirituality Conference ▶▶ 1 November 2018 ▶▶ Auckland ▶▶ www.selwynfoundation.org.nz/ learning/learn/2018-ageing-andspirituality-conference
College of Gerontology Nursing Conference ▶▶ 5–6 November 2018 ▶▶ Hamilton ▶▶ www.comingintoage2018.org.nz Gastro 2018 (NZ Society of Gastroenterology/NZNO Gastroenterology Nurses’ College Annual Scientific Meeting) ▶▶ 21–23 November 2018 ▶▶ Dunedin ▶▶ www.gastro2018.co.nz/gastro18 NZNO Nurse Managers Conference ▶▶ 8–9 November 2018 ▶▶ Napier ▶▶ www.nzno.org.nz/groups/colleges_ sections/sections/nzno_nurse_ managers_new_zealand Pacific Nursing Section Symposium and AGM ▶▶ 9 November 2018 ▶▶ Auckland eHealth in Nursing @ HiNZ Conference ▶▶ 21 November 2018 ▶▶ Wellington ▶▶ www.hinz.org.nz NZ Respiratory Conference ▶▶ 22–23 November 2018 ▶▶ Auckland ▶▶ www.nzrc2018.org
2019 2019 NZRGPN National Rural Health Conference ▶▶ 4–7 April 2019 ▶▶ Blenheim ▶▶ https://rgpn.org.nz/event/conference2019-abstract-call-open Nurse Practitioners New Zealand Conference ▶▶ 10–12 April 2019 ▶▶ Marlborough ▶▶ www.nurse.org.nz/npnz 10th Council of International Neonatal Nurses Conference ▶▶ 5–8 May 2019 ▶▶ Auckland ▶▶ http://www.coinn2019.com
TO SUBMIT A NURSING CONFERENCE OR EVENT, EMAIL EDITOR@NURSINGREVIEW.CO.NZ
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