Issue 4 October/November 2018
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Contents
Inside:
ED’s letter A fair go needed Back in 1908 one of the country’s first Māori registered nurses and midwives, Akenehi Hei, struggled for a year to get the Government to fund its own plan to employ Māori district nurses to work with Māori. Now, 110 years on, nurses working for Government-funded Māori and iwi health providers get paid – but have been struggling for over a decade for extra funding to close the near 25 per cent pay gap with their district health board nursing colleagues. And that gap is now growing wider after a DHB pay settlement that fell short of many stressed DHB nurses’ expectations but is looked at admiringly by many nurses working for Māori and iwi health providers or for residential aged care facilities. Māori nurses have said ‘enough is enough’ and taken their longstanding pay and related grievances to the Waitangi Tribunal (see News Briefs p.2). The aged care sector is also sounding alarm bells that the pay gap is quickening the exodus of nurses to the DHB sector and an already fragile workforce is fast heading to crisis mode (also see p.2). It is acknowledged that some of the highestneeds patients in the New Zealand health system are Māori and the elderly. So why the pay gap when nobody can argue that the nursing is no less clinically challenging or the workload less than their DHB nursing counterparts? Particularly as the three sectors are largely funded from the same pot – the Government. The ‘pay gap’ employers will tell you they are keen to pay their nurses more – but the different funding formulas for their sectors makes this financially unfeasible without an injection of extra government funds. It seems simply fair that nurses should be valued equally wherever they work and whoever they care for. And it also just seems fiscally sensible to have a well-paid, clinically skilled and stable nursing workforce supporting some of the country’s highest need patients so they stay well in the community and don’t require expensive secondary care. Fiona Cassie, Editor editor@nursingreview.co.nz www.nursingreview.co.nz
News 2
Round-up: News briefs + Bulletin board
Focus 4 6 8 10 12
Scabs, scars and better wound healing Pressing forward with stopping pressure injuries Wound swabbing: doing it right and for the right reasons Cutting edge: trimming back surgical site infections Vaccination safety: reducing the risk of mistakes
Professional Development
15 20 22
FREE 60-MINUTE professional development activity ‘Safe care for multicultural patients in acute care’ Critically appraised topic: the nose knows – nasal rinsing for hay fever Scoping the future: the role of the nurse endoscopist
Innovation & Technology
24 24
App of the month: cardiac arrest bystander apps Webscope: preventing infection and disease
Leadership & Management
26
Want to be your own boss? Advice for nurses considering self-employment
Students & New Graduates
28 29
The struggle of being a nursing student and a parent Third-year students confident but not cocky, finds study
Opinion 30 31
Jenny Song: a nurse’s story of family caregiving College of Nurses: Jenny Carryer – Why do nurses feel undervalued?
Conferences 32
Upcoming conferences
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Fiona Cassie 03 981 9474 editor@nursingreview.co.nz
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Round-up News Briefs
News briefs Māori nurses’ decade-plus pay parity claim goes to Waitangi Tribunal A more than decade-long campaign to close the 25 per cent pay gap faced by nurses working for underfunded Māori and iwi health providers is in front of the Waitangi Tribunal. Māori nurses are to share their frustrations and argue that the Crown’s failure to address the pay disparity – despite repeated submissions on inequitable funding – is evidence of institutional racism in the health sector. The nurses will be speaking up in support of the Wai 2713 claim, made by NZNO kaiwhakahaere Kerri Nuku and Hineraumoa Te Apatu on behalf of Te Rūnanga o Aotearoa of Tōpūtanga Tapuhi Kaitiaki o Aotearoa (NZNO) at the historic Waitangi Tribunal hearing at Tūrangawaewae Marae that started in mid-October. Nuku has twice taken the case for Māori nurses to the United Nations after saying “enough is enough” following the failure of the long-running Te Rau Kōkiri campaign for pay equity for Māori and iwi provider nurses, which has been ongoing since the DHB ‘pay jolt’ of 2005 created a pay gap that continues to grow. Their claim says the pay disparities, which will increase with the recent DHB nurses’ pay settlement, are a by-product of how the Crown funds the Māori and iwi providers differently from general practices belonging to large primary health organisations. In addition, they say funding contracts awarded to Māori providers do not allow for pay equity or recognition of the dual competencies of many Māori nurses.
Feared loss of nurses to DHBs turning into reality, says aged care sector Urgent government action is needed as the feared exit of aged care nurses to better paid DHB jobs following the recent pay and safe staffing settlement becomes a reality, says the Aged Care 2 Issue 4
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Read the full versions of these online articles at www.nursingreview.co.nz/subject/news. Association. One facility manager, who has worked nights to cover roster gaps, fears the pay gap could “bleed aged care dry”. “Every day members are ringing and emailing me saying they’ve lost another nurse to a DHB because of the pay gap, and the vast majority are not able to pay their nurses more than they are funded for,” said New Zealand Aged Care Association Chief Executive Simon Wallace. He questioned why the Government was ready to recruit up to 900 more teachers for schools but wasn’t responding in the same way to the desperate nursing shortages in residential aged care. David Wait, NZNO’s industrial advisor for aged care, said the Association’s proposed solution of bringing in hundreds of registered nurses from overseas would do nothing to stop the exodus to DHBs “and would be like turning on the tap without putting the plug in the basin”. Wallace said easing immigration rules were a partial, short-term solution allowing facilities to recruit nurses overseas to fill the current gaps while the sector dealt with the pay issue.
PSA mental health pay offer – short staffing still an issue The PSA acknowledges that short staffing will remain an issue as its mental health nurse members started voting on a DHB offer that mirrors the NZNO with a new top base salary step for inpatient nurses of $77,386 – as well as a new top base pay rate of $83,712 for community nurses. But PSA national secretary Erin Polaczuk said the PSA was hopeful that the recommendations of the Mental Health Inquiry – due to be delivered to the Government at the end of November – would tackle these issues head-on and provide workable solutions that could be implemented almost immediately. As Nursing Review went to press, voting was closing on the DHBs’ offer to PSA nurses that mirrored the precedentsetting settlement between the 20 DHBs
and the NZNO made in early August after difficult and drawn-out negotiations. The offer to the about 3,500 mental health and public health nurses and mental health support worker members of the PSA includes an agreement to work with the DHBs and other union partners on a pay equity process for all members covered by the PSA nurse multi-employer collective agreement (MECA), with an implementation timeframe yet to be decided.
Extra pay for RN prescribers sought in Primary Health Care MECA Two years after registered nurse prescribing regulations came into force, there are now more than 200 and extra pay recognition is being sought for the extended role. Bargaining began in September and continued late October between the NZNO and representatives of the about 530 general practices and medical centres covered by the NZNO Primary Health Care (PHC) MECA. Chris Wilson, the NZNO industrial advisor for primary health, said a major focus of the talks was pay parity with the recently settled DHB MECA, but it was also seeking coverage and appropriate pay scales for registered nurse prescribers and nurse practitioners. A major focus of the talks would be the now six per cent pay gap between PHC and DHB nurses following the recent DHB NZNO pay settlement and the need to retain pay parity by also adding additional pay steps to the current fivestep pay scale to keep it in line with the DHB nurses’ new basic pay scale. The top of the current PHC pay scale is $32.44 an hour ($66,851 a year) and the new MECA would have to introduce a new step 7 of $37.10 an hour by May 2020 to retain parity with the new top step of the DHB basic pay scale (about $77,000 a year).
Round-up Bulletin Board
Bulletin board Enrolled nurse, Pacific nurse leaders and NP honoured in awards
Tributes to retiring outstanding Nursing Council leader
Two Pacific nurse leaders were amongst the four nurses honoured with awards at the annual NZNO Awards in September for making a difference at the national level to nursing. Siniva Leru-Cruikshank was honoured for her leadership work over her 40 years of nursing and community work both in New Zealand and Samoa, including being a founding member of NZNO’s Pacific Nurses section. Vaifagaloa Naseri was nominated for her award for her extensive and generous contributions to Pacific nursing and Pacific communities. Leonie Metcalfe has been an enrolled nurse at Waikato Hospital for 35 years and was nominated for being a great advocate for enrolled nursing at every opportunity, including being chair of NZNO’s Enrolled Nurse section. Sheryl Haywood, who became a nurse practitioner in 2016 after nursing for 25 years, was nominated for the significant contribution she was making to improving the lives of the older people she works with in Ashburton.
Nursing Council chair Catherine Byrne yesterday announced that Nursing Council chief executive Carolyn Reed would retire at the end of the year after a decade in the role as the Council’s registrar and chief executive. Byrne joined other nursing leaders in paying tribute to her work, saying she had been an outstanding, capable and visionary leader for the organisation and thanking her for her years of service. Reed first stepped into the role as acting chief executive in late 2008 and was appointed to the role in 2009. During her time, she oversaw some major changes for New Zealand nursing, including changes to the registered nurse, nurse practitioner and enrolled nurse scopes of practice and the introduction of registered nurse prescribing.
Nurse care equal or even better than GP care for some conditions, finds review For chronic conditions, nurses probably achieve equal or better health outcomes for patients than doctors, a major international research review has concluded. An updated Cochrane Review, Nurses as substitutes for doctors in primary care, was published last month and analysed 17 randomised trials comparing first contact and ongoing care provided by primary care nurses and doctors (GPs) with similar patients with similar health needs. The authors said the review was prompted by moves in many countries to use nurses more to help address the growing health needs due to chronic disease and an ageing population, and also doctor and other health worker shortages. The review concluded that for some ongoing and urgent physical complaints, and for chronic conditions, nurses, such as nurse practitioners, practice nurses and registered nurses, probably provide equal or possibly even better quality of care compared with primary care doctors.
Expanding NP training programme now on hold Plans to expand the successful Nurse Practitioner Training Programme (NPTP) to more would-be NPs are on hold until 2020. Health Workforce New Zealand had said it would put NPTP out to competitive tender in late August for 2019 after a successful evaluation project of the pilot and feedback that the programme should be expanded, but had now decided to rollover the current funding contract for 20 NPTP places for 2019.
Kiwi future nurse leaders head to Geneva
Equally impressive entries share Young Nurse of the Year award for 2018
A Kiwi nursing lecturer and a community child health nurse consultant were amongst 26 nurses worldwide selected to attend a global nursing leadership programme in Geneva in September. Dr Jed Montayre, a nursing lecturer at AUT, and Sarah Williams, a community child health nurse consultant at Auckland District Health Board, are delighted and honoured to have been selected for the International Council of Nurses’ Global Nursing Leadership Institute 2018 programme.
A Pacific nurse with a passion for child health and a te reofluent Kawerau practice nurse are the joint winners of this year’s Young Nurse of the Year Award. Middlemore Hospital paediatric medical ward nurse Annie Stevenson and Kawerau Medical Centre new graduate practice nurse Aroha Ruha-Hiraka were announced joint winners of the New Zealand Nurses Organisation award in September at the annual NZNO Young Nurse of the Year awards dinner. It is only the second time in the award’s five-year history that it has been given to two participants, because the judging panel found both nominees equally impressive.
Mental health leader takes out top Māori nursing award Māori mental health leader Moe Milne was awarded NZNO’s biennial Akenehi Hei Award at August’s Indigenous Nurses Aotearoa Conference 2018 for making a significant contribution to Māori health. The award was presented by Kerri Nuku, the kaiwhakahaere of the New Zealand Nurses Organisation, and adds to the New Zealand Order of Merit that Milne, a Māori mental health leader and consultant of Ngāti Hine and Ngāpuhi descent, received in the Queen’s Birthday Honours last year for services to Māori and health.
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Focus Wound Care
Scabs, scars and better wound healing Nursing Review talks to wound care nurse specialist SHARON CASSIDY about the best ways to reduce scarring.
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carring is a natural part of healing. But how large and longlasting that scar is depends on the wound healing quickly and well. Scabs, itches, infections and other issues that can delay healing can increase the risk of permanent scarring. For Christchurch clinical nurse specialist Sharon Cassidy, reducing scarring is all about starting with good wound care. Her wound care career began with burns and plastic surgery nursing and expanded to caring for all children’s wounds and in particular caring for the fragile skin of ‘butterfly’ children with the rare skin-blistering condition Epidermolysis bullosa. For this specialist nurse in burn care for all ages and wound care for children and young people, a key foundation for good wound care and scar-reduced healing is keeping wounds clean, moist and covered to aid pain-free healing.
Educating patients that scabs are not needed Nurses have long known that scabs hinder rather than help healing. Cassidy says the rule of thumb is that a wound taking longer than three weeks to heal will scar. Moist wound healing without scabbing can help the wound heal smoothly within the optimal time. Modern moist wound healing practice began with George Winter’s research in the early 1960s with pigs, which showed, contrary to common belief, that letting wounds dry out and scab actually delayed healing, while wounds kept moist and covered healed much faster. Moist wound care helps the smooth transition through the four wound healing phases: ▶▶ Haemostasis, when the wound clots (immediate). ▶▶ Inflammation wound repair stage (0–3 days). ▶▶ Proliferation, when the new tissue is rebuilt through granulation and epithelialisation (3–24 days). ▶▶ Maturation (up to two years). 4 Issue 4
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If the wound is allowed to dehydrate, the cocktail of blood cells, antibodies and exudate that collects at the wound site during the inflammatory repair and the proliferation phase dries and forms a scab. This scab crust on the wound was once the best natural protection the body could provide, but, like the poultices of yesteryear, modern wound science has proven that keeping the wound moist is much better. Many Joe and Jane Public still believe that a scab is an essential step of healing. “The myth is still out there that you put the wound out in the sun – or let the air get to it – so it dries, scabs and it is healed,” says Cassidy. Nurses need to educate their patients that a dehydrated wound and scab formation actually delays healing and increases the risk of scarring, because a scab or crust on a wound interferes with the proliferation healing phase. Proliferation starts with the granulation stage where the extracellular matrix (including collagen and elastin) starts to rebuild tissue in the wound bed, and is followed by epithelialisation, where epithelial cells grow across the wound surface to form the new top skin layer. For this to happen efficiently, a moist wound bed is needed to promote the growth of the matrix and new skin cells and help their movement across the wound surface. This also promotes the formation of even skin and reduces scarring. But if there is a crust or scab on the wound, this creates a barrier to smooth healing. “It is like those cells have got to dig under hills to find the moisture they need to form the new wound surface,” says Cassidy. When the cells burrow deeper to find moist tissue, this can result in a deeper scar. Epithelialisation occurs about three times faster in a warm, moist environment (note: a crust on a wound sometimes also includes, or is made up of, eschar, which is dead tissue and is usually dark or black in appearance).
The aim of good wound care practice is to prevent a wound ‘crusting’, but if a patient turns up with a scab (or eschar) already formed, it is usually best for it to be removed through a gentle debridement technique, such as a hydrating gel, that softens and dissolves the crust so it can be removed without causing trauma to the wound. If the scab cannot be easily removed, Cassidy recommends applying something like olive oil to penetrate through the crust and ensure the wound bed underneath is kept moist.
Getting the basics right Reducing scarring also begins with getting other fundamentals of wound care management right, says Cassidy. This begins with the first essential of cleansing the wound thoroughly to reduce the risk of infection. Infection control also includes good hand hygiene by the nurse and good education on hand hygiene and simple infection control tips for the patient at home. The nurse will then assess the wound’s tissue viability, wound edges and wound surround, with the aim of creating as clean and flat a wound bed as possible to aid even healing across the wound surface. If there is a blister over a joint, this should be drained to allow movement. The selection of dressings to keep the wound protected and moist – but not too moist – is the next important step. Depending on the nature of the wound and the amount of exudate, the general rule of thumb is that, after the early inflammation stage, ‘less is best’ when it comes to dressing changes to reduce the risk of damaging the healing wound surface. Cassidy says offering showerproof dressings to patients – particularly the elderly and the young – is also a good investment so they don’t have to worry about wrapping their wound in plastic to try and prevent it getting wet. A wet dressing allows bacteria to travel into
Focus Wound Care
Healing continues once the wound heals over
“The myth is still out there that you put the wound out in the sun – or let the air get to it – so it dries, scabs and it is healed.” the wound bed, increasing the risk of infection and delaying healing. When dressing a wound, nurses should also be careful not to damage the patient’s skin, and should take particular care around joints and the webbing between fingers and toes so that movement is not restricted.. Good nutrition is essential because, as Cassidy says, “wounds heal from the inside out” and a diet with high protein food, vitamin C and zinc will promote faster healing. Smoking, diabetes and other conditions affecting blood flow to the wound can delay healing, so it is good to talk to patients about the impacts these can have.
There are many external factors affecting whether a wound causes a permanent scar. These include the depth and size of the wound, the location (joints such as knees and elbows are prone to scarring), the cause of the injury or wound, and the age and health of the person. They also include the person’s ethnicity, as darker skins, which have higher melanin levels, are more at risk of keloid scarring. In addition, the melanin levels in the new skin may differ from the high levels in the surrounding skin, resulting in more variations in skin colour and tone.
Many wound scars will fade and disappear soon after the proliferation phase. The healed skin might have reddened, but Cassidy points out this doesn’t mean it is scarred, though the redness can take time to dissipate. Some scars will take longer to become less noticeable and, of course, it is difficult to prevent some scars being lifelong, such as like surgery scars, major burns and wounds over joints. Maturation (or the scar healing/ remodelling phase) takes six months to a year and can continue for up to two years, so skin treatment should continue. Cassidy says this includes advising patients to avoid exposing the fresh scar to the sun by wearing sunscreen or covering up the wound. The sun can stimulate pigmentation changes in the healing tissue and make the scar darker. Keeping the moisture levels of the skin high also remains important and Cassidy recommends moisturising the healed wound area daily with a non-perfumed moisturiser. She says case studies and trials have indicated that products containing keratin protein can aid healing and strengthen the skin. Gentle massage of the healed wound for about 10 minutes once or twice a day can also help to break up and prevent scar tissue during the maturation phase. Once the scar is mature, the wound area is thought to be about 20 per cent weaker than it was prior to the injury. If scarring is a major issue, a patient can be referred to a scar management team at their local DHB or a private specialist. An option may include covering the scar with silicon – in the form of sheets, gels or sprays – for a period of months to help healing. Made-to-measure pressure garments may also reduce the likelihood of a wound scarring. People can explore options such as dermabrasion, laser resurfacing or plastic surgery. The nurse’s role in reducing scarring starts right at the beginning by providing a good wound care plan and patient support so that the healing cascade flows smoothly without infection, dehydration or fresh damage delaying the wound healing process. While scarring may be a natural part of healing, it is something that both nurses and patients alike want to see as little as possible. nursingreview.co.nz Issue 4 5
Focus Wound Care
Stop Pressure Injury strategy presses forward Nursing Review catches up on new pressure injury initiatives, including national reporting and link nurses, in the lead-up to this year’s Stop Pressure Injury Day on November 15.
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rthopaedic nurse Julie Isitt aims to treat her patients like they were relatives – and she’d hate to have any of her family members suffer a pressure injury. Each year around 55,000 people get pressure injuries (PIs), once known as bedsores or pressure ulcers, ranging from an early-stage reddened patch over a pressure point, like a heel, to gaping wounds to the bone from which people can die. Isitt and Nurse Maude district nurse Jade Lippiatt (pictured above), are two of the more than 50 nurses across the Canterbury and West Coast DHB regions who have successfully applied to become pressure injury prevention link nurses. The new link nurse role is supported by a $6 million, three-year ACC campaign to reduce preventable PIs that kickstarted with Canterbury DHB last year and will see other regional initiatives rolled out nationwide. It is part of the momentum that has built after years of lobbying by wound care nurses and the New Zealand Wound Care Society for PIs to be taken seriously at a national level. PIs are regarded as a quality marker of care because the risk rises when care rationing due to understaffing or lack of awareness results in patients not being
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moved in bed or having their skin assessed regularly enough. This month the first quarterly reports on pressure injuries are being lodged with the Health Quality & Safety Commission by DHBs as a new joint strategy by the Commission, Ministry of Health and ACC steps up a notch. The strategy follows a major 2015 report commissioned by KPMG on reducing PI harm, which estimated that about 3,000 of, the 55,000 people will have a PI wound so severe that muscles, bones or tendons may be exposed, requiring surgery to treat and repair the skin and tissue damage. The DHB quality and safety marker reports will help to build the first solid, nationally consistent statistics on the scale of the problem and help to monitor the impacts of prevention strategies.
Link nurses Julie Isitt has worked in orthopaedics for 16 years and says it is changes in the patients she cares for in the past five years that has increased her awareness of the risk of PIs. An increasing number of older people are coming into hospital with complex co-morbidities like diabetes or dementia and less mobility, which has made her conscious of the need to turn and move patients at risk of PIs.
Jade Lippiatt first started working in older people’s health after graduating four years ago. After seeing the impact of PIs, she was motivated to become a link nurse to help stop these preventable injuries. The aim of the Canterbury/West Coast initiative is to have 72 pressure injury prevention link nurses – one in every ward and aged residential care facility, plus one to two from each of the district nursing providers. Susan Wood, a nurse and the Director of Quality and Patient Safety, Canterbury and West Coast DHBs, says the link nurse role is based on a UK concept to develop the skills of a network of nurses in a specialty area, in this case pressure injuries. And in turn, the link nurses can act as change agents in their own workplaces with an expectation they will drive PI quality improvement programmes in their workplaces. The voluntary link nurses are expected to be at a proficient PDRP level and to have already completed an online PI prevention course. In return, they are funded to complete a three-day PI prevention and management paper at Ara Institute of Canterbury and meet once a month to network and support each other in their PI prevention work.
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Focus Wound Care
Wound swabs:
CONSIDER WOUND SWABBING WHEN:
• there are clear clinical markers of infection like redness, heat, swelling or pain and the wound is malodorous and with an increase in exudate • cellulitis is present • antibiotic treatment is failing • the wound is deteriorating, increasing in size or failing to heal • the patient has high risk factors for MRSA. There is a lower threshold for swabbing wounds if the patient is very young, elderly, has a lowered immunity, diabetes or another chronic condition affecting circulation.
HOW TO SWAB A WOUND:
• Clean the wound and periwound thoroughly with water and gauze. • Swab the wound in a circular/ spiral pattern moving from the wound periphery to the centre of the wound area (covering the entire wound area). • Apply slight pressure while swabbing so fluid/bacteria is pushed up from below the wound surface. • Label the swab sample and add relevant information to the lab request form, including type and history of wound, if the patient has a chronic condition and what systemic antibiotics or topical antimicrobials were being used.
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doing it right for the right reasons Swabbing a wound is best done right or not at all. Nursing Review shares tips from wound care nurse specialist LIZ MILNER on how best to swab a suspected infected wound.
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on’t take wound swabs just for the heck of it. That’s wound care nurse specialist Liz Milner’s first rule of thumb on her ‘hobbyhorse’ of wound swabbing. And if a swab is called for, do it properly, otherwise the results may be of little use. Milner says people often appear to take wound swabs for the sake of it. If they don’t do it right – or for the right reason – the laboratory results are likely to come back showing a predictable ‘mixed skin flora’ result. “But if there’s no clinical markers of infection then we’re not going to treat,” says Milner, “because a lot of the wounds, particularly of long duration, are going to have colonised bacteria, which we wouldn’t treat anyway.” (The common skin flora or bacteria colonising a wound are mostly harmless and won’t result in infection.) But swabbing for the right reasons with the right technique can isolate the bacteria causing the infection and ensure that the patient is on the right antibiotic to treat it. A wound swab can be helpful or necessary when the nurse observes the
likely signs of an underlying infection impeding the healing process, such as redness, heat and swelling, an increase in pain, a malodorous wound and an increase in exudate. Milner reminds nurses that patients with diabetes may not present with the classic infection symptoms so the threshold for swabbing should be lower. “Some people with diabetes have a decreased arterial flow – so you may see a pale wound with minimal exudate, no change in pain levels (due to a sensory neuropathy) and no redness, heat or swelling. So just be mindful that the diabetic group is quite unique.”
Swabbing technique has zigged and zagged Milner says that over the years wound swab advice has changed. “Back in the day, we’d take a lab swab and the more pus we could get on it the better – it was quite exciting. We’d stick it in the tube and send it off to the lab.” Then there was a shift to the ‘Z’ technique, in which swabs are passed over the wound surface – avoiding the wound margins – in a zigzag fashion. More recently, the new ‘Levine’ technique was found to generate more
Focus Wound Care
useful bacterial results from the lab than the zigzag. The Levine technique involves applying slight pressure with the swab to take a sample from about one square centimetre of tissue at the centre of the lesion or in an area of the wound that appears infected. But that was then, says Milner. Now, the evidence-based method seen as even better at detecting the most types of bacteria present across the whole wound surface is the ‘Essen Rotary’ method. The Essen Rotary method involves taking the sample by moving the swab from the periphery toward the centre of the wound (covering the entire wound area) using a spiralling motion while applying slight pressure.
Doing it correctly The first step before taking a wound swab is to cleanse the periwound and wound thoroughly so the swab sample can gather the bacteria in the wound bed and not the harmless skin flora or contamination
from the previous primary dressing. For example, taking a swab on a wound that has an iodine base dressing will not provide an accurate result. Milner advises not to clean the wound with an antiseptic, such as povidone-iodine, and instead use water or normal saline. If the wound bed is dry, pre-moisten the cotton-tipped swab to increase the chance of recovering organisms from the wound bed. Then combine the Essen Rotary swab technique with a gentle pressure that squeezes up bacteria from the deeper underlying structures. Recent research has shown that this method is a quick and easy-to-use modification of conventional swabbing methods, such as the Levine technique and the Z technique. It involves only slightly more effort and offers significantly higher sensitivity in detecting superficial bacterial colonisation in chronic wounds like venous leg ulcers.
Once the swab is placed into the culturette tube and labelled, the next important step is to ensure the laboratory request form includes relevant information. “It’s really important that you fill out on the lab form what antibiotics the person is on, whether you are using an antimicrobial dressing, and whether it’s iodine, silver, honey, etc,” says Milner. She says the more information a nurse can give the lab the better – including the nature of the wound, whether it is acute or chronic and any chronic conditions or illnesses the patient has that may affect the healing process. Providing the laboratory with accurate information will ensure a much better result, she says. Rather than receiving a result of ‘mixed skin flora’ after having ‘swabbed for swab’s sake’ the swab sample may aid the patient’s healing by ensuring they are on the right antibiotic for the right bacteria.
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Focus Infection Control
Cutting trimming back surgical site infections edge:
Nursing Review explores a campaign that has more than halved Southern Cross’s surgical site infection rate, despite an increase in obesity and diabetes.
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n infection in a post-surgery wound can range from irritating to devastating for a patient and can be costly for health services. The aim of reducing the harm of surgical site infections (SSIs) – and the estimated millions of wasted health dollars through readmissions – led to a targeted SSI monitoring and improvement programme, focusing first on hip and knee replacement surgery, being launched in 2012 in public hospitals across the country. Because SSIs are the cause of nearly all the healthcare-associated infections (HAIs) in private elective surgical hospitals, the 10 Southern Cross hospitals began much earlier monitoring and reporting results on not one but 10 surgical procedure groupings. An increased focus on the problem saw the Southern Cross SSI rate start to fall and an active quality improvement programme started in 2010 saw the rate fell even further. Recently published research in the New Zealand Medical Journal (NZMJ)1 shows that the Southern Cross campaign made a significant impact, with the number of patients experiencing an SSI within a month of their surgeries reducing from 3.5 per cent in 2004 down to 1.2 per cent in 2015. Nurses, particularly the network’s infection prevention and control nurses, played a major role in introducing the interventions, monitoring changes in practice and collecting data on the nearly 43,000 patients whose surgeries were part of the study. Rosaleen Robertson, Southern Cross Chief of Clinical Governance and a registered nurse, says it was a real team effort and not without its challenges – including getting everybody on board. “It is quite resource-intensive, but when you see the results it makes it all very rewarding.” The two main evidence-based interventions of the programme introduced in 2010 were delivering presurgery prophylactic antibiotics more often at the right time and at the right dose, as well as encouraging a shift on the operating table to using alcohol-based surgical site skin preparation. 10 Issue 4
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Also impacting on SSI rates was ongoing work on hand hygiene compliance, nurseled pre-admission screening and education, raised awareness of the increased SSI risk for patients who are obese or have diabetes, plus good blood glucose and patient temperature control pre- and post-surgery.
Pre-admission challenges A particular challenge for private surgical hospital nurses is the tight time frame they have to educate patients about the risks of infection, says Robertson. Most patients come into hospital almost immediately before their operations. This makes the assessment by preadmission nurses of the comprehensive patient health questionnaire even more important. The questionnaire is part of a patient’s pre-admission pack and is required to be sent in at least a week before their surgery so any patients with higher needs or greater risks of SSIs can be contacted as early as possible and, if needed, brought in for pre-admission consultations. Southern Cross engaged with patients using a co-design method to improve how it communicated one piece of pre-admission advice: the request for patients not to remove hair from surgery sites. “It’s really important that the patient avoids any method of removing hair themselves from their operation site before coming into surgery,” says Robertson. “Any breach of the skin caused by shaving – and they may only be micro-breaches of the skin – can provide an opportunity for pathogenic organisms to grow.” She says the few patients that do so are generally trying to be helpful, but any hair removal should be left up to health professionals because of the heightened SSI risk if patients do it themselves. Although little can be done about some of the SSI risk factors in the usually short lead-up to elective surgery, patients can be educated about hair removal, hand hygiene, pre-op showering and hair washing, and advised that having their diabetes under good control and stopping smoking will help their surgical wounds heal faster.
Obesity, smoking and diabetes The patients at greater risk of a surgical site infection include those who are obese, smoke, have higher surgical risk scores or have diabetes. And while the Southern Cross statistics indicate the number of surgical patients who smoked decreased between 2004 and 2015, the numbers who were obese, had high surgical risk scores or had diabetes all increased. The proportion of surgeries on people with a body mass index (BMI) over 30 grew from 29 per cent to 36 per cent of all surgeries. The Southern Cross research confirmed the findings of Health Quality & Safety Commission’s public hospital SSI reduction programme, with both finding that obesity is a key SSI risk factor. Dr Arthur Morris, a clinical microbiologist and lead author of the NZMJ’s Southern Cross article, says while the average SSI rate for orthopaedic surgery is about 1 per cent, if a patient is morbidly obese (a BMI of 40 or more), the infection risk may be four or five times higher. Morris is an infection control advisor to Southern Cross Hospitals and also clinical lead for the Commission’s public hospital SSI improvement programme. He says for smokers, people with diabetes and the obese the common risk is poor vascular supply affecting their bodies’ abilities to fight any bacterial contamination of wounds. For the morbidly obese, in addition to the problems caused by restricted blood supply to the wound are issues like less mobility and how well the wound edges can adhere to each other. With an obese person, it can be harder to get the skin edges on either side of the wound to be evenly matched, says Victoria Aliprantis, a registered nurse, who is Southern Cross’s Chief of Risk and Quality. She says that uneven wound edges can create gaps where the skin is not touching, which increases the chance that bacteria can enter the wound and cause infection. Aliprantis says nurses need to be mindful of the risks and build it into their monitoring and care of wounds post-op. She says that if a wound is not closing particularly well then this should be
Focus Infection Control
escalated to the surgeon, but nurses can also use steri strips and other wound care dressings to pull the wound together and improve how the wound edges meet.
Antibiotics use: right time and right amount For nurses to be as influential as they want to be in reducing SSIs, they need the time to be able perform their roles well, says Robertson. This includes their important role in supporting the ‘sign-in’ and ‘time-out’ safety checklist procedure in the operating room that includes prompts over the timing of when prophylactic antibiotics are given. Antibiotics timing is one of the key interventions in the SSI reduction strategy, with the aim of intravenous antibiotic cefazolin being given at the optimal time more often, to ensure enough antibiotic is in the tissue close to the surgery incision site before ‘knife to skin’, says Robertson. The optimal window of time is from one hour before surgery or, ideally, at least five minutes before ‘knife to skin’. The study found that on-time antibiotic delivery improved from 72 per cent of the time in 2004 to 95 per cent by 2015 and the better timing had helped to reduce the SSI rate. Morris says in the last 10 minutes before ‘knife to skin’ there are many things going on and sometimes ensuring the patient is properly anaesthetised and is breathing properly overrides the timing of the antibiotic. Their new guidelines are now recommending that the antibiotic is given at least 10 minutes before ‘knife to skin’ to avoid it being missed before the focus shifts to critical procedures like intubation. The right dose of antibiotic was another focus, says Morris, with a recommendation to use 2g or more of cefazolin for every patient to prevent the risk of the increasing number of obese patients receiving a dose that is too low.
Nurses ‘nudge’ shift to alcoholbased skin cleansing In another of the major interventions – increasing the use of alcohol-based skin preparation – nurses are in key position to influence a surgeon’s choice. The Southern Cross research confirmed that using an alcohol-based skin preparation can help reduce the SSI rate by almost 50 per cent and is ideal for most operations. But some surgery areas and some surgeons have protocols that still favour using aqueous-based skin preparations. Morris says some people are “a bit nervous” about using alcohol
“It is quite resource-intensive, but when you see the results it makes it all very rewarding.”
Grassy Zhao, an infection control nurse at Southern Cross Hamilton, has been part of the SSI campaign. (Photo: Carey Campbell)
preparations as they are worried about a fire risk or a harm. “Though if it is properly applied and left to dry, there is no risk or danger, but people have their preferences,” he says. Aliprantis says there is a lot of ritual in theatre and it can be a challenge to ‘nudge’ people who have developed a preference for one method to change to another. Robertson and Aliprantis say nurses are encouraged to be proactive in starting conversations and presenting the evidence to doctors to encourage them to consider change or to discuss it peer-topeer with Dr Morris. The research shows the use of alcoholbased skin preparation increased over the study period from 63 to 84 per cent, but a 2016 audit showed that there is still room for improvement as in 60 per cent of the time an aqueous skin preparation was used, an alcohol product should have been used instead.
Another area where it believes there is an opportunity to further reduce the SSI rate is targeting the most common bacteria causing SSIs – Staphylococcus aureus. A recent literature search for the Health Quality & Safety Commission (HQSC) showed using a proven ‘anti-staph bundle’, involving antiseptic nasal swabbing and antiseptic skin solutions to decolonise S. aureus from the skin and nose could reduce orthopaedic SSIs by about half. “We are piloting [the bundle] in one of our hospitals that was part of the HQSC bundle collaborative,” says Muriel McIntyre, a registered nurse who is a Southern Cross Clinical Safety Quality Risk Coordinator. “This is another initiative that is very much a collaborative process with nursing and doctors following through from pre-admission to admission services,” she says. 1. The full NZMJ research article can be read at https://bit.ly/2zKzlQP.
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Focus Infection Control
Vaccination safety:
reducing the risk of mistakes
Vaccination is a routine job for many nurses, but some recent cases have highlighted the ever-present potential for busy nurses to make mistakes. Nursing Review shares some tips on safe vaccination practice.
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arlier this year a Kiwi nurse was censured by the Health & Disability Commission for giving a 12-yearold girl the wrong vaccine after assuming she had come for her 11-year-old ‘booster’ vaccination. This followed the censuring last year of another nurse who, in a rush, mixed up one of the vaccines for a 15-monthold after she couldn’t find the yellow card (the Ministry of Health’s National Immunisation Schedule reference card) that spells out which vaccines to deliver at each age milestone. Neither child was harmed, but sadly, in Samoa, two nurses are awaiting trial after the tragic deaths of two infants following MMR vaccinations. The cause of the deaths is still unknown, but Samoa’s use of multi-dose vials of the MMR vaccine raises questions over dilution errors1. New Zealand uses the single-dose MMR vaccine with the diluent provided in a prefilled syringe in the same package. This minimises the risk of dilution errors, but other minor errors remain a risk – the same as in any medication administration environment. This is particularly the case for busy practice nurses juggling elderly patient phone calls, GP requests to squeeze in patients’ blood tests or wound dressings, plus waiting rooms of stressed mums with restless toddlers and crying babies. New Zealand’s immunisation standards for vaccinators are provided in the appendix of the Immunisation Handbook 2017 to guide nurses and other vaccinators on competent deliveries of safe and effective immunisation services so a patient doesn’t receive the wrong vaccine at the wrong age or by the wrong route or 12 Issue 4
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at the wrong interval. The handbook also provides, in another appendix, specific instructions for the preparation (including the reconstitution) and the administration of vaccines. Nursing Review talked to Immunisation Advisory Centre (IMAC) education coordinator Trish Wells-Morris and checked out Health Quality & Safety Commission advice for tips on safe vaccination and infection control for busy nurses. Wells-Morris says New Zealand has access to very good quality vaccines that are supplied ready for use and delivered via pre-filled syringes. “So the opportunity for contamination or to make a mistake is minimised.” When a very occasional vaccination error occurs, she says New Zealand’s open and voluntary approach to incident reporting means nurses will often ring IMAC’s 0800 IMMUNE number to discuss concerns and whether any further action is needed. “Organisations have quality systems to follow up and investigate any incidents and it’s a non-punitive system that works best.” These errors usually don’t cause harm; for example, a lack of documentation resulting in a child inadvertently receiving the same vaccine twice. “So the nurse is concerned about any harm to the baby... that the baby has had an extra vaccine and will they suffer… fortunately, babies are very resilient.” But it's a given that no nurse wants to cause anxiety or the risk of harm to a patient through avoidable human error. >>
TIPS FOR AVOIDING VACCINE ERRORS
• Store vaccines appropriately in a pharmaceutical refrigerator to reduce risk of child/adult vaccine formulations or vaccines with similar names being confused. • Always confirm which vaccine the adult or child has presented for. • Check their vaccination status via health records and, if a child, via the National Immunisation Register to avoid double-up errors and ensure correct interval between vaccine doses. • When administering two component vaccines like DTaP-IPV-HepB/HiB (Infanrix hexa), document both vials’ details before vaccinating to reduce risk of missing HiB. • Get a colleague to check you have the correct vaccines for the correct child using the Ministry of Health’s immunisation schedule yellow card guide. • Involve the parent or patient in verifying you are administering the right vaccine, as well as getting informed consent. • If more than one child from the same family is being seen, only bring one child’s vaccines into the room at a time. • Check the child’s identity by using both name and birth date prior to administering each vaccine. • Promptly document the details of vaccines given in the health record and, if a child, in the National Immunisation Register so the vaccination status is updated for future vaccinators.
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Focus Infection Control Don’t shortcut pre-vaccination checks Following a clear pre-vaccination check list, including gaining informed consent, helps to ensure the right vaccines are given to the right child or adult. But a rushed nurse – working with a mother distracted by tired and fractious children – can miss a check and risk an error happening. “Take a few breaths, slow down, and follow the process,” recommends WellsMorris. “The potential for error increases if corners are cut.” This is particularly the case when everybody is busy, children are crying and a hard-working practice nurse is under pressure. The pre-vaccination check includes not only screening to check there is no reason why the vaccine/s shouldn’t be given that day but also which vaccine the child or adult is due to have and what their current vaccination status is. In the case of a child, Wells-Morris says that may involve checking firstly their Well Child record; secondly the practice’s electronic patient management system record; and thirdly, the National Immunisation Register. Checking is particularly important if the family are new or infrequent visitors to the practice and they may have had an opportunistic vaccination at another practice by an outreach nurse or during a hospital visit. With no national register for adults, nurses must rely on patient recall. When the vaccines are taken out of the vaccine fridge, the vaccine expiry date is checked and the nurse visually checks the vials for any contaminants; for example, if anything has broken off the rubber seal that could be drawn up into the syringe. Wells-Morris says ideally at this point the vaccinator would check the selected vaccines with another vaccinator using the yellow card to ensure that they are the correct vaccines for the child in question. In the two recent Health & Disability Commission complaints mentioned in
the opening paragraphs, the vaccinating nurses’ errors were not picked up. In one case, they had mislaid the card and failed to correctly inform the checking nurse of the child’s age. In the other case, the checking nurse was told the 12-year-old girl was having her 11-year-old Boostrix vaccine rather than the requested Gardasil. The HDC’s expert nurse advisor in the Gardasil case suggested that the vaccine check should have been done in the same room as the patient and, if working alone, a nurse could use the caregiver or patient to confirm the vaccine. Wells-Morris agrees that, in the right circumstances, nurses may wish to ask a parent or caregiver to check the vaccines against the Ministry’s yellow card. Gaining informed consent from the caregiver or adult to each vaccine administered is also another safeguard. Once the right vaccine is consented and confirmed, the nurse draws up and mixes the vaccine and administers it as directed on the vaccine’s data sheet. They then document the vaccine details, including on the National Immunisation Register and Well Child book if vaccinating a child, to complete the records.
The WHO-approved MMR vaccine used in Samoa is delivered in multidose vials containing five doses, and vaccines from the same batch have been used safely around the world. (The only multidose vial vaccine used in New Zealand is the BCG vaccine, which is only administered by specially trained vaccinators.) Samoa’s Commission of Inquiry into the deaths of two infants who died after being administered the MMR vaccine in July was adjourned in September until after the court case of the two nurses charged with manslaughter is heard early next year. The cause of the deaths is still unknown, but there have been calls in Samoa for ongoing nurse training, with indications that human error may have been involved in the dilution of the multidose vaccine. 1
COMMON VACCINE ERRORS AND CAUSES
• Wrong vaccine: often because they have similar names or cover the same diseases i.e. Infanrix. • Wrong interval between doses: the immunisation history is not up to date. • Wrong age: usually involves vaccines with age restrictions or different vaccines targeted at different age groups. • Wrong injection site or route: an intramuscular vaccine given in site without enough muscle, or MMR given intramuscularly rather than subcutaneously. • Wrong patient: multiple siblings turning up at the same time to a busy clinic for vaccinations. • Incorrectly prepared vaccines: multiple component vaccines where an extra component, e.g. Hib, is not added or only the diluent is administered. • Expired vaccine used: nurse forgot to check or the expiry date is unreadable. • Cold chain failures: failure to keep vaccines at 2–8 degrees C at all times. Source: Health Quality & Safety Commission, Medication Safety Watch, October 2015
“Take a few breaths, slow down, and follow the process. The potential for error increases if corners are cut.” RESOURCES:
• Immunisation Advisory Centre’s vaccine administration overview: www.immune.org.nz/healthprofessionals/vaccine-administrationoverview • Ministry of Health Immunisation Handbook 2017: includes the Immunisation Standards for Vaccinators: www.health.govt.nz/publication/ immunisation-handbook-2017 • Vaccination video guides: IMAC has vaccination guide videos available on its community pharmacist advice page: www.immune.org.nz/pharmacists • Cold chain guidelines: www.health.govt.nz/publication/ national-standards-vaccine-storageand-transportation-immunisationproviders-2017
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Professional Development Learning Activity
Safe care for multicultural patients in acute care
By Krinessa Valenzuela and Monina Hernandez
Patients from minority ethnic groups experience challenges in the healthcare system resulting from cultural and language factors. This article looks at some of the challenges that multicultural patients can experience as in-patients and suggests some strategies to help minimise those challenges. INTRODUCTION
LOCAL CASE STUDIES
New Zealand is an ethnically diverse society and is set to become more so, with record levels of net migration in the past five years. In Census 2013, the major ethnic groups in New Zealand were European (74 per cent); Māori (14.9 per cent); Asian (11.8 per cent); Pacific (7.4 per cent); and Middle Eastern/Latin American/ African (1.2 per cent)1. Multicultural populations require a healthcare system that provides culturally safe care. Culture and language barriers have a big impact on health outcomes for patients from culturally and linguistically diverse (CALD) backgrounds. Understanding the patient’s experiences, identifying their challenges and implementing strategies to help solve these challenges ensures that patients receive culturally safe nursing care, disparity is reduced and good health outcomes are achieved.
This article draws on the authors’ own case study research, which is aimed at helping nurses understand the in-patient experiences of patients belonging to CALD groups in New Zealand and identifying strategies to support patients and their families during their hospital stay. The case studies involved patients from CALD backgrounds who received care at the coronary care unit of a district health board hospital between April and May 2018. Three themes emerged from interviewing the coronary care patients using Purnell’s Model of Cultural Competence (see Figure 1). These are: the importance of family; views about illness and its impact on their lives; and barriers in accessing healthcare services.
family support in the care of a sick family member.
“Children and grandchildren look after the loved ones.” Mr VM, 67, ventricular fibrillation arrest, Tongan.
“To look after the elder, it is important.” Son of Mrs VN, 80, end-stage IHD, Indian. Looking after family members was central to the patients interviewed, who were from Tongan, Samoan, Indian and Serbian backgrounds.
The importance of family Patients from collective cultures value family involvement and engagement in their care. The first theme that emerged from the interviews was the importance of
“It is better for us to look after the sick at home so they don’t feel lonely in the hospital.” Mr VM, 67, VF arrest, Tongan.
Learning outcomes Reading and reflecting on this article will help nurses to: ▶▶ increase awareness of the challenges multicultural patients experience as in-patients ▶▶ identify the barriers that affect the health outcomes of multicultural patients ▶▶ identify strategies or interventions to remove the barriers.
The learning activity is relevant to Nursing Council competencies 1.5, 2.1, 2.2, 2.3, 2.6 and 3.2. nursingreview.co.nz Issue 4 15
Professional Development Learning Activity “Always stay with the sick. We look after the sick.” Son of Mrs VN, 80, end-stage IHD, Indian. Extended family also play an important role in looking after sick family members.
“It [extended family] is important. Grandkids look after their grandparents.” Mr O, 60, NSTEMI, Samoan. Family support is important in providing patients from CALD groups with physical and emotional support while in hospital2.
Views about the illness and its impact on their lives Cultures have different ways of understanding illness and may attribute different causes to the origin of their symptoms. How illness is explained is strongly influenced by families’ cultural and religious backgrounds. Patients’ views about disease causation and how it impacts on their lives vary. One patient attributed his illness to a higher power.
for advertising healthcare services to the Samoan community.
“Some people do not know how to access health care. Public should be aware what services are available. Broadcast services.” Mr O, 60, NSTEMI, Samoan. Another patient identified language as a barrier and also the concerns that patients may have about their privacy and confidentiality when interpreters are used.
“The difficulty is the language barrier. The problem with the translator is that she will not say the same thing to the translator that she will say to me.” Son of Mrs VN, 80, end-stage IHD, Indian.
Mr S, 60, STEMI – PCI to LAD, Serbian.
Patient insights in the interviews about barriers to accessing healthcare services highlight a number of areas for improvement. The first is the need for translated information in relevant languages delivered through ethnic media, such as radio stations and newspapers. Targeted and tailored health education needs to be available to ethnic communities. The second is patient’s concerns about their maintaining privacy and confidentiality when professional interpreters are used. Confidentiality becomes an issue, particularly in smaller communities. Patients may be reluctant to use an interpreter because they know the interpreter or have fears that their medical information will be made public. At the beginning of a consultation, it is important to reassure the patient and their family that the health practitioner and the interpreter will respect the patient’s rights to confidentiality.
Some of the patients displayed feelings of contentment even when they were sick.
HEALTHCARE CHALLENGES AMONG CALD GROUPS
“It [illness] is a way God teaches you sometimes in life; a wake-up [call] from God” Mr VM, 67, VF arrest, Tongan. Whereas another attributed it to lifestyle.
“The first reason is smoke. Then after 15 years, illness comes. Second is food; I eat anything.” Mr S, 60, STEMI – PCI to LAD, Serbian.
“Keep rules, restrict – no fats, stop smoking, exercise.”
“I’m better, I’m happy. Everything is in my hands now.” Mr S, 60, STEMI – PCI to LAD, Serbian.
BARRIERS TO ACCESSING HEALTHCARE SERVICES Patients’ views and explanations of their illnesses affect the way they respond to and manage them. In addition to the wider systemic barriers, language and cultural issues are the two most widely experienced barriers to service utilisation3, 4. Patients identified several barriers in accessing healthcare services. Migrants from CALD backgrounds may be unfamiliar with New Zealand health services and how to access them. One patient saw the need 16 Issue 4
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Patients from CALD groups may face psychological stress, treatment barriers, language barriers, challenges with informed consent, and the risk of adverse events when there are communication difficulties.
Psychological stress The stresses that CALD patients experience are not just physical in nature but also psychological5. For any patient, illness can be a major stressor, but for patients from CALD backgrounds, the stress may be exacerbated by communication difficulties. In particular, patients with limited or no English language experience anxiety and powerlessness because of their inability to communicate with health practitioners2.
Even with the use of interpreters, the patient may feel stressed as they may not feel fully understood. Moreover, the problem with communication causes stress not only to patients but also to healthcare providers6. For this reason, knowing how to work with interpreters – including how to pre-brief and debrief when using an interpreter for a consultation – is an important skill for health practitioners to gain.
Treatment barriers Besides the psychological stress that the patients may experience while in the hospital, they may also encounter treatment challenges. A CALD patient is more likely to refuse treatment7. Treatment refusal may be due to the patient’s inability to understand their illness and the treatment offered2, 8. Treatment refusal can lead to non-adherence with prescribed treatment plans, longer hospital stays and increased risks of readmission compared with English-speaking patients9. Communication problems also lead to treatment delays10. Patients who have limited or no English language require an interpreter before they can make decisions regarding treatment. This may delay treatment, including procedures where the patient is required to follow instructions, such as X-rays and surgical procedures. Successful treatment requires good communication between the health practitioner, the patient and their family5, 11.
Language barrier Good cross-cultural communication is important for health practitioners and patients to understand each other. Health practitioners need to assess, for example, whether patients are using traditional remedies or herbal medicines. Patients need to understand their illness and the treatment being offered. In acute care settings, health practitioners must utilise professional interpreters, where needed, to help them communicate effectively. However, some studies prove that errors in transmitting information still occur even with the utilisation of professional interpreters12. This often occurs when the health practitioner is not trained in how to work with an interpreter and is not in control of the interpreting session. Underutilisation of interpreters has also been reported in the literature13. It is sometimes easier to not utilise interpreters for patients who can speak basic English. However, this may lead to major impacts on the patient’s health outcome14. Sometimes bilingual staff are accessed as interpreters; however, because of the lack of professional training, errors such as omissions, addition, substitution and condensation of information occur8.
Professional Development Learning Activity Patients who require interpreters have problems with taking in and remembering information15. It is therefore important to ensure that patients get adequate support from the healthcare team to ensure that correct and adequate information is provided for successful care and discharge.
Challenges with informed consent Communication is also important when patients provide informed consent. Since informed consent is legal in nature10, patients should understand what they are consenting to. The transfer of information should be clear and accurate. When medical information regarding a necessary procedure is given to a patient, it is critical for informed consent that they understand and agree to what the health practitioner is communicating to them. It is difficult enough at times to obtain informed consent from an English-speaking patient, but it is much more so from those who speak no or limited English. In such cases, interpreters play an essential role. Regardless of the language spoken, informed consent is a patient’s right and healthcare providers need to ensure that this process is managed competently and professionally.
Adverse events CALD patients are at risk of adverse events when there is a language barrier between themselves and the health professional. Diagnostic and medication errors are examples of adverse events9, 16, 17. NonEnglish-speaking patients may struggle to understand medical terms in English18, which may directly affect the quality of services they receive and their timely access to services18, 19. These patients are disadvantaged in accessing health services equitably with other groups due to the cultural and linguistic barriers discussed8. Healthcare practitioners can improve the quality of care that CALD groups receive by gaining the knowledge, attitudes and skills needed to become culturally competent.
and understanding of the client’s culture; accepting and respecting cultural differences; adapting care to be congruent with the client’s culture (Purnell, 1998)20. Providing culturally competent care is a way to reduce barriers to accessing healthcare services for CALD patients18. Practitioners’ abilities to engage patients and their families and to assess and understand their explanatory models of health and illness will contribute to good health outcomes for the patients6, 16, 21.
Developing cultural competence Campinha-Bacote and Munoz (2001)22 proposed a five-component model for developing cultural competence, which is outlined as follows: ▶▶ Cultural awareness involves selfexamination of in-depth exploration of one’s cultural and professional background. This component begins with insight into one’s cultural healthcare beliefs and values. A cultural awareness assessment tool can be used to assess a person’s level of cultural awareness.
▶▶ Cultural knowledge involves seeking and obtaining an information base on different cultural and ethnic groups. This component is expanded by accessing information offered through sources such as journal articles, seminars, textbooks, internet resources, workshop presentations and university courses. ▶▶ Cultural skill involves the nurse’s ability to collect relevant cultural data regarding the patient’s presenting problem and accurately perform a culturally specific assessment. The Giger and Davidhizar model23 offers a framework for assessing cultural differences in patients. ▶▶ Cultural encounter is defined as the process that encourages nurses to directly engage in cross-cultural interactions with patients from culturally diverse backgrounds. Nurses increase cultural competence by directly interacting with patients from different cultural backgrounds. This is an ongoing process; developing cultural competence is a journey.
Figure 1: Purnell Model for Cultural Competence Global Society Community Family Person
STRATEGIES TO HELP REDUCE THE HEALTHCARE CHALLENGES There are ways to help reduce the challenges faced by minority ethnic groups in health care. These include promoting and practising cultural competence and safety among healthcare providers, using professional interpreters, and encouraging family support.
Providing culturally competent care Cultural competence can be defined as developing an awareness of one’s own existence, sensations, thoughts and environment without letting it have an undue influence on those from other backgrounds; demonstrating knowledge
Source: Purnell L (2005), The Purnell Model for Cultural Competence, Journal of Multicultural Nursing & Health, 11(2): 7–15. bit.ly/2CefvAQ
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Professional Development Learning Activity ▶▶ Cultural desire refers to the motivation to become culturally aware and to seek cultural encounters. This component involves the willingness to be open to others, to accept and respect cultural differences, and to be willing to learn from others. The disparities that arise due to cultural factors make cultural competence a priority in health care24. But there is no simple formula for solving cultural issues and establishing plans in delivering culturally competent nursing care. When challenging cultural issues arise, nurses might like to discuss and consult with senior colleagues and management to ensure that such issues can be resolved in the best interest of the patient.
Using trained interpreters Using trained interpreters, rather than family members or bilingual staff, is important10 as it ensures that correct information is being relayed to patients, reduces the risk of errors and leads to improved health outcomes16. The importance of using trained health professionals to ensure good cross-cultural communication and safe, effective care for non-English-speaking patients is also highlighted in this article.
Extended family provides support
“To look after the elder, it is important.” Son of Mrs VN, 80, end-stage IHD, Indian. It is important to recognise the role of extended family in the care and support of the sick in collective cultures18. Knowing how to engage with family members, to work with the decision-makers and to communicate respectfully is an essential part of building trust and rapport. The family will expect to be engaged and consulted and will play a significant role in decision-making for those who are sick2. Family members may advocate for the sick member, facilitate communication among healthcare providers, as well as provide basic care2. They may also communicate the sick member’s fears, needs and feelings to the health practitioner2. Encouraging family support in the care of patients from CALD groups is recommended. Patients’ and families’ cultural and religious beliefs and practices should also be included in treatment regimes where practicable and safe16.
ABOUT THE AUTHORS: Krinessa Valenzuela, RN, BSciNsg, PGDip gained her nursing degree at the University of the Philippines and currently works in the coronary care unit of Hutt Hospital HVDHB while studying for her Master of Nursing. Monina Hernandez, RN, BSN, MNur (Hons) is a lecturer at the School of Nursing, Massey University. This article was peer reviewed by: Annette Mortensen, RN, PGDipEd, MPhil (Nursing), PhD, project manager research and development for eCALD services at Waitemata DHB. Jenny Song, RN, BN (Wintec), PGDip (Nursing), Bachelor of Medicine (Xuzhou), a senior academic staff member at Wintec’s Centre for Health and Social Practice.
REFERENCES 1. STAT NZ (2013). 2013 Census quick stats about culture and identity. Retrieved July 2018 http://archive.stats.govt. nz/Census/2013-census/profile-and-summary-reports/ quickstats-culture-identity/ethnic-groupsNZ.aspx. 2. GARRETT P, DICKSON H & WHELAN A (2008), What do non-English-speaking patients value in acute care? Cultural competency from the patient's perspective: A qualitative study. Ethnicity & Health, 13(5): 479–96. 3. MEHTA S (2012). Health needs assessment of Asian people living in the Auckland region. Auckland: Northern DHB Support Agency. Retrieved from www.countiesmanukau.health.nz/assets/About-CMH/ Performance-and-planning/health-status/2012-healthneeds-of-asian-people.pdf. 4. STATISTICS NEW ZEALAND AND MINISTRY OF PACIFIC ISLAND AFFAIRS (2011). Health and Pacific peoples in New Zealand. Wellington: Statistics New Zealand and Ministry of Pacific Island Affairs. Retrieved from: http://archive. stats.govt.nz/browse_for_stats/people_and_communities/ pacific_peoples/pacific-progress-health.aspx. 5. LEE T, SULLIVAN G & LANSBURY G (2006). Physiotherapists' communication strategies with clients from culturally diverse backgrounds. Advances in Physiotherapy 8(4) 168–174. 6. COLEMAN J & ANGOSTA A (2016). The lived experiences of acute-care bedside registered nurses caring for patients and their families with limited English proficiency: A silent shift. Journal of Clinical Nursing 26 678–689.
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7. NELSON A (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Journal of the National Medical Association 94(8) 666-668. 8. HEANEY C & MOREHAM S (2002). Use of interpreter services in a metropolitan healthcare system. Australian health review: A publication of the Australian hospital association 25(3) 38–45. 9. WU M & RAWAL S (2017). 'It's the difference between life and death': The views of professional medical interpreters on their role in the delivery of safe care to patients with limited English proficiency. Plos One (10) doi:10.1371/journal.pone.0185659. 10. GARLOCK A (2016). Professional interpretation services in health care. Radiologic Technology 88(2) 201–204. 11. VAN ROSSE F, DE BRUIJNE M, SUURMOND J, ESSINK-BOT M et al (2016). Language barriers and patient safety risks in hospital care: A mixed methods study. International Journal of Nursing Studies 54 45–53. 12. FLORES G (2005). The Impact of medical interpreter services on the quality of health care: A systematic review. Medical Care Research and Review 62(3) 255–299. 13. SEERS K, COOK L, ABEL G, SCHLUTER P et al (2013). Is it time to talk? Interpreter services use in general practice within Canterbury. Journal of Primary Health Care 5(2) 129. 14. ISAAC K (2001). What about linguistic diversity? A different look at multicultural health care. Communication Disorders Quarterly 22(2) 110–113. 15. LIPSON-SMITH R, HYATT A, MURRAY A, BUTOW P et al (2018). Measuring recall of medical information in nonEnglish-speaking people with cancer: A methodology. Health Expectations 21(1) 288–299.
CONCLUSION Providing culturally competent and safe care to all patients is an essential nursing responsibility. Due to the growing number of patients from CALD groups – and the challenges and barriers they experience in the healthcare setting – it is important for nurses to practice cultural competence, to use professional interpreters, and to encourage family support. It is essential for nurses to reflect on the experiences of their cross-cultural interactions with patients and their families’ experiences, as well as the cultural knowledge and skills needed to ensure that quality care can be provided for CALD patients at all times.
RECOMMENDED RESOURCES: ▶▶ eCALD: the Ministry of Healthfunded eCALD service provides free, accredited e-learning courses for health professionals working with culturally and linguistically diverse (CALD) groups in New Zealand, including working with interpreters: www.ecald.com/courses/ cald-cultural-competency-courses-forworking-with-patients. ▶▶ Cultural awareness assessment tool: a simple, 17-question tool for gauging a nurse’s cultural awareness from Catalano’s Nursing Now: Today’s Issues, Tomorrow’s Trends. Available online at bit.ly/2oUDQC1. ▶▶ Cultural assessment model: key components of the Giger and Davidhizar cultural assessment model23 for assessing cultural differences in patients can be viewed at bit.ly/2O3rzGn. ▶▶ Working with interpreters for primary care practitioners: an e-learning module developed by the University of Otago: www.otago.ac.nz/wellington/ e-learning/arch/story_html5. 16. DAVIES S, DODD K & HILL K (2017). Does cultural and linguistic diversity affect health-related outcomes for people with stroke at discharge from hospital? Disability & Rehabilitation 39(9) 736–745. 17. SCHYVE P (2007). Language differences as a barrier to quality and safety in health care: The joint commission perspective. Journal of General Internal Medicine 22(2) 360–361. 18. TRUONG M, GIBBS L, PARADIES Y & PRIEST N (2017). ‘Just treat everybody with respect’: Health service providers' perspectives on the role of cultural competence in community health service provision. ABNF Journal 28(2) 34–43. 19. THOMPSON D (2002). Cultural aspects of adjustment to coronary heart disease in Chinese-Australians: A review of the literature. Journal of Advanced Nursing 39(4) 391–399. 20. PURNELL L (2013). Transcultural Health Care: A Culturally Competent Approach. Philadelphia: F.A. Davis Company 21. BRACH C & FRASER I (2000). Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review 57(14) 181–217. 22. CAMPINHA-BACOTE J & MUNOZ C (2001). A guiding framework for delivering culturally competent services in case management. The Case Manager 12(2), 48–52. 23. GIGER J & DAVIDHIZAR R (2002). The Giger and Davidhizar transcultural assessment model. Journal of Transcultural Nursing 13(2) 185–188. 24. CAMPINHA-BACOTE J (2002). The Process of Cultural Competence in the Delivery of Healthcare Services: A Model of Care. Journal of Transcultural Nursing 13(3) 181–184.
Professional Development Learning Activity
Professional Development
Learning Activity
Reading and reflecting on this article will enable you to: ▶▶ Increase awareness of the challenges multicultural patients experience as inpatients. ▶▶ Identify the barriers that affect the health outcomes of multicultural patients. ▶▶ Identify strategies or interventions to remove the barriers.
Reading the article Safe care for multicultural patients in acute care 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: 1.5, 2.1, 2.2, 2.3, 2.6 and 3.2. A
Reading
1
View the Purnell Model of Cultural Competence by Larry Purnell (Figure 1 on p.17). Source: Journal of Multicultural Nursing & Health 11(2) 7–15. Full article can be viewed at: bit.ly/2CefvAQ (accessed Sept 2018).
2
Read again the short summary of Campinha-Bacote & Munoz’s five-component model for developing cultural competence (see main article).
B
Reflection
Using the above models reflect on a patient case where you worked with a patient from a culturally and linguistically diverse background: 1
What challenges did you encounter? What were your feelings?
2
How did you manage these challenges?
3
How might your own cultural background have influenced your response?
4
If these challenges arose again how could you do better?
C
Reality
When next caring for a patient with a culturally and linguistically diverse background: 1
Using the key components of the Giger and Davidhizar23 cultural assessment model (view at bit.ly/2O3rzGn), do a brief assessment of this patient’s cultural needs.
2
Identify three challenges to providing care to this individual and describe how you responded.
3
What steps could you take to further develop your cultural competence in working with patients from culturally and linguistically diverse backgrounds?
Verification by a colleague of your completion of this activity Colleague name
Designation
Date
Nursing council ID
Work address
Contact # nursingreview.co.nz Issue 4 19
Professional Development Research Review
The nose knows:
nasal rinsing for hay fever Spring pollen is once again tickling people’s noses. Does nasal irrigation help? CLINICAL BOTTOM LINE Nasal saline irrigation may help relieve symptoms of allergic rhinitis (hay fever) in both adults and children when compared with no saline irrigation and is unlikely to be associated with adverse effects. It is unclear which is the best type of saline irrigation to use.
CLINICAL SCENARIO Nasal irrigation – rinsing inside the nose – with saline water is commonly recommended for reducing symptoms of allergic rhinitis and can be used alone or as an adjunct to other therapies. As a ‘natural’ remedy it may be considered free of side effects. But is this procedure really a safe and effective way of relieving the symptoms of this troubling and common condition?
QUESTION Does saline nasal irrigation reduce symptoms of allergic rhinitis in comparison with no saline irrigation?
SEARCH STRATEGY PubMed – Clinical Queries (Therapy/ Broad): saline AND allergic rhinitis
CITATION Head, K., Snidvongs, K., Glew, S., Scadding, G., Schilder, A. G., Philpott, C., & Hopkins, C. (2018). Saline irrigation for allergic rhinitis. Cochrane Database Syst Rev, 6, Cd012597. doi:10.1002/14651858. CD012597.pub2
STUDY SUMMARY A systematic review to evaluate the effects of nasal saline irrigation in people with allergic rhinitis. Inclusion criteria were:
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Type of study: Randomised controlled trials (RCTs), cluster-randomised trials and quasi-randomised trials, and crossover trials. Participants: Adults and children with clinical symptoms characteristic of allergic rhinitis. Main exclusions were people with non-allergic or chronic rhinosinusitis; acute sinusitis; cystic fibrosis; immunotherapy within the prior year; aspirin-exacerbated respiratory disease. Intervention: Saline, as an active treatment, delivered to the nose by any means (douche, irrigation, pulsed, spray or nebuliser) and with any volume, tonicity and alkalinity. Comparison: (1) No nasal saline irrigation or (2) other pharmacological treatments. Outcomes: Primary outcomes: Disease severity, significant local adverse effects: epistaxis. Secondary outcomes: Disease-specific health-related quality of life (HRQL), individual symptom scores, general HRQL, local irritation or discomfort, ear symptoms and nasal endoscopy scores.
STUDY VALIDITY Search strategy: Comprehensive search strategy to locate published and unpublished studies. No language or date restriction. Review process: Two authors independently screened the search results for eligible studies, selected the studies, extracted data using a standardised form, and conducted risk of bias assessment. Disagreements were resolved by consensus.
Assessment of risk of bias in included studies: Conducted using the Cochrane risk of bias tool. Overall validity: A good quality review involving small studies of varying risk of bias.
STUDY RESULTS Screening of 1,402 titles/abstracts and then 86 full text assessments identified 14 eligible RCTs. All studies reported outcomes under three months follow-up. Studies included children (seven studies, 499 participants) and adults (seven studies, 248 participants). Saline volumes ranged from ‘very low’ to ‘high’ volume and used either hypertonic or isotonic saline solution, where reported. Only the results of the saline compared with no saline (our clinical question) are discussed here. Studies used different scoring systems to report on patient-reported disease severity and so data was pooled using standardised mean difference (SMD). There was a statistically significant improvement in patient-reported disease severity in those who used saline irrigation compared with no saline at up to four weeks and between four weeks and three months (refer table). Whether saline irrigation improves disease-specific HRQL is uncertain because just one small study reported this outcome. Two studies (240 children) reported no adverse effects (epistaxis or local discomfort) in either group and only three reported no adverse effects in the saline group. No other prespecified outcomes were reported, other than those described here.
COMMENTS ▶▶ High heterogeneity between studies was appropriately investigated and partly driven by one small positive study. Evidence was low quality for all outcomes, which reflects uncertainty in the clinical bottom line. ▶▶ The standardised mean difference (SMD) at both four weeks and four weeks to three months were considered large effect sizes. The authors equated the SMD of -1.32 to a decrease of nearly two points on a ‘0 to 10’ point visual analogue scale (VAS) for nasal symptoms (lower = better). This seems clinically meaningful considering how miserable symptoms can make people feel. Improvement occurred in both adults and children. ▶▶ This review was not able to determine the best way of irrigating with saline, or the best strength of solution. ▶▶ Salty water is cheap and widely available and there are various options for getting it up your nose. Until we know more, it seems the best way is personal preference. Reviewer: Cynthia Wensley PhD, RN, Lecturer, School of Nursing, University of Auckland c.wensley@auckland.ac.nz.
Table: Summary of results Standardised mean difference (95% CI)
Studies (number of participants)
Heterogeneity# I2
Patient-reported disease severity at 4 weeks
-1.32 (-1.84 to -0.81)
6 (407)
75%
Patient-reported disease severity between 4 weeks and 3 months
-1.44 (-2.39 to -0.48)
5 (167)
86%
CI - Confidence Interval; # Random effects model
Professional Development Advanced Practice
Scoping the role of the the future: nurse endoscopist Colonoscopy workforce shortages are one of the constraints on rolling out the lifesaving National Bowel Screening Programme. Training nurse endoscopists can help. LESLEY DOUGHTY and JACKY WATKINS report on the challenges of and progress in implementing a new training programme for nurse endoscopists.
A
recent review of the National Bowel Screening Programme (NBSP) raised concerns about the capacity and fragility of the colonoscopy workforce. Professor Gregor Coster, the review chair, said the colonoscopy workforce capacity remains a significant risk and is constraining the current NBSP roll-out. In 2014 the National Nurse Endoscopy Advisory Group was established to develop and implement endoscopy nursing roles to help meet the expected workforce demands of the bowel screening programme. Implementing the training programme to meet the demands for this new workforce, while being able to meet the targets set for the National Bowel Screening Programme, has not been without its challenges. Some of those we have faced and conquered, while some are still being addressed. One of these challenges is that DHBs have to demonstrate a level of organisational readiness to be able to support nurses to complete the nurse endoscopy training and credentialing programme. The training programme needs not only nurses who have met
Criteria
the academic and clinical practice prerequisites but also the endorsement by DHBs of nurses performing endoscopies and a plan for the execution of the programme in accordance with the Nursing Council of New Zealand’s guidelines for the expanded practice for registered nurses.
The first priority for credentialed nurse endoscopists will be to provide routine endoscopies, which will free up experienced endoscopists to carry out bowel screening colonoscopies. The criteria for determining DHB readiness are discussed in the table below, where we look at the particular challenges we have faced, and are still currently facing, in the ongoing delivery of the endoscopy training programme.
Delivery of the inaugural nurse endoscopy training programme got underway at the University of Auckland in 2016 as part of the Health Workforce New Zealand initiative to introduce the role of the nurse endoscopist. The first cohort of four candidates has successfully completed the oneyear academic programme (plus over 200 scopes each) and all have been accredited in at least one of the three scope modalities: gastroscopy, flexible sigmoidoscopy and colonoscopy. It takes at least two years of supervised training for any endoscopist trainee to reach competence, with the timing varying on their access to training lists and individual ability. The challenges mentioned earlier meant there was no cohort in 2017, but a further four candidates started the academic programme this year and it is hoped to have four students in 2020. DHBs still have many questions about how to prepare for nurse endoscopists and part of our role has been to coach and support DHBs in introducing the new role. Geographically, the students are from Auckland, Waikato and Otago, with five
Challenges
Enablers
No clear vision for the role. Understanding the expanded scope of nursing practice (nurse endoscopist) and how that fits with medical practice.
Pressures to prepare for NBSP provide motivation to explore new ways to meet population needs. Many endoscopists have worked with nurse endoscopists in other countries.
Capacity to provide and support training of nurse endoscopy trainees.
Limited physical capacity. Availability of trainers. Competing pressures of service delivery and training capacity for medical, surgical and nurse trainees.
Dedicated funding from Health Workforce NZ helps to fund extra training lists. Trainers can be funded to provide dedicated extra training lists.
Organisational commitment to workforce reform.
Coordination between nursing, service and funding planning for the new role.
Strong support from NZ Directors of Nursing. Planning may start up to two years before training to meet prerequisites and plan funding for services.
Commitment to establish a nurse endoscopy service.
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Professional Development Advanced Practice free up experienced endoscopists to carry out bowel screening colonoscopies. The academic/clinical partnership was critical when it came to working with the national steering group and setting the expectation that nurses provide both clinics and endoscopy lists to ensure holistic practice and the development of assessment and diagnostic skills. The nurse endoscopy candidates are encouraged to spend time with areas aligned to the service to develop networks and gain a wider knowledge of pathology, radiology, surgery and multidisciplinary meetings. We have also worked with DHBs to develop standing orders as the sedation drugs commonly used during endoscopy are not currently on the list of drugs available to designated nurse prescribers. The support from anaesthetists in providing theoretical and simulation training has also been appreciated and is ongoing as we plan for changes at a national level to support this new role. We have worked closely with DHBs and interested nurses to ensure they are ready before starting their journey. It has been a pleasure and a privilege to work with a wide range of people to overcome barriers when implementing this new role and delivering services to patients in a new way. It is humbling to witness the personal and professional growth of students as they undertake the endoscopy training programme and lead the way for the future nursing workforce. About the authors: Lesley Doughty RN MEd (Hons) (PG Programme Director) and Jacky Watkins RN MN (Course Coordinator) are professional teaching fellows at the University of Auckland and are responsible for developing and implementing the nurse endoscopy training programme.
DHBs – Auckland, Counties Manukau, Waitemata, Waikato and Southland – currently engaged in the programme. There is growing interest from other DHBs, which is promising. Nurse endoscopists have the potential to work across the continuum of care and this is already becoming evident, with two of the candidates from the inaugural course completing their prescribing pathway; one following the RN designated prescriber pathway and the other on the nurse practitioner pathway.
Collaborative curriculum The University of Auckland developed the curriculum in collaboration with clinical experts to provide the theoretical and clinical skills component. The academic component of the programme includes two postgraduate courses at master’s level completed in one academic year. To join the programme, nurses must have a clinical postgraduate diploma and a minimum of five years’ clinical experience post-registration. Three of those years are required to be in gastroenterology/ endoscopy or a related specialty area such as colorectal surgery. The endoscopy training programme focuses on the ongoing development of clinical expertise, using a practice development approach emphasising person-centred, evidence-based practice and critical thinking skills to improve health outcomes. The clinical course coordinator of the endoscopy programme plays a crucial role, using knowledge of the sector to work with DHBs and clinicians to support trainees. Work-based training starts alongside the academic programme to allow the integration of increasing theoretical knowledge with practical skills. Training continues until competence is achieved against an independent set of criteria aligned to national standards set by the Endoscopy Guidance Group of New Zealand (EGGNZ) for performing bowel screening colonoscopies. These standards apply to all endoscopists, whether they are medical practitioners or nurses. The first priority for credentialed nurse endoscopists will be to provide routine endoscopies, which will
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nursingreview.co.nz Issue 4 23
Innovation & Technology
Health Navigator App of the Month
CARDIAC ARREST BYSTANDER APPS
Y
ou are biking home from a night shift and see a jogger collapse in front of you. Or you are eating out at a café and a patron outside a food truck down the street has a heart attack. The two apps reviewed this edition could help you save lives.
AED locations APP OVERVIEW ▶▶ Clinical score ▶▶ Availability
Yet to be reviewed Free for Apple & Android (with option of paid upgrade)
Full review www.healthnavigator.org.nz/app-library/a/aed-locations-app PROS include: ▶▶ Lists the location of 9,500 AEDs across the country. ▶▶ Additions and changes uploaded to app every 48 hours. ▶▶ Now indicates if an AED is available 24/7. ▶▶ An NZ-developed app that also has a website: www.aedlocations.co.nz. ▶▶ Supported by organisations including the Heart Foundation, the Cardiac Society, St John New Zealand and NZMA. CONS include: ▶▶ Does not guarantee that the AED is in full working order, that you have a right to use it, or that the location is geographically correct.
GoodSAM (Good Smartphone Activated Medics) responder APP OVERVIEW ▶▶ Clinical score ▶▶ Availability
Free for Apple & Android
Full review www.healthnavigator.org.nz/app-library/g/goodsam-app PROS include: ▶▶ Developed in the UK but now integrated with St John New Zealand and Wellington Free Ambulance to alert nearby registered responders when a 111 call of a suspected heart attack is received. ▶▶ Supported by the New Zealand National Cardiac Network and the New Zealand Resuscitation Council. CONS include: ▶▶ In order to receive alerts, you need to have the app open. ▶▶ If you swipe up or log out, or reset your phone, the responder app switches off. CPR trained volunteers can download and sign up to be ‘Good Samaritan responders’ and receive ambulance alerts of suspected cardiac arrests nearby so they can assist before emergency services arrive. The app alerts registered responders within a kilometre of the person in need and also tells them if there is an AED (automatic external defibrillator) nearby. 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 sandra@healthnavigator.org.nz.
Webscope Preventing infection and disease by KATHY HOLLOWAY. Health Quality and Safety Commission (HQSC) Infection Prevention and Control
Centers for Disease Control and Prevention (CDC) Public Media Library
www.hqsc.govt.nz/our-programmes/infection-prevention-andcontrol
https://tools.cdc.gov/medialibrary/index.aspx#/results
The Health Quality & Safety Commission (HQSC) has a specific website with a focus on infection control and prevention. HQSC’s stated position is that infection prevention and control is everyone’s business and responsibility, whether you are a patient, family member or a healthcare professional. The two current HQSC projects are related to hand hygiene and surgical site infection improvement, with a focus on orthopaedic and cardiac surgery in public hospitals. Available on the site are hand hygiene resources, recent reports about New Zealand health services, and access to presentations from a recent HQSC workshop, Putting prevention first: Leadership and action on preventing healthcare associated infections. [Site accessed 7 October 2018 and last updated July 2018]. 24 Issue 4
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This site within the US Government’s Center for Disease Control and Prevention hosts a large volume of quality assured media on topics as diverse as pandemics, bioterrorism and concussion. The site also provides online help for those who wish to syndicate resources to their own social media sites. There is a range of resource types, including infographics, pdfs, podcasts and videos, to name a few. Main categories are Data & Statistics, Diseases & Conditions, Emergency Preparedness, Environmental Health, Global Health, Healthy Living, Injury, Violence & Safety, Travel Health and Workplace Safety & Health. You can also subscribe to one of 47 specific newsfeeds to keep you up to date in cancer care, food safety, seasonal flu and many other areas. [Site accessed 7 October 2018 and last updated October 2018]. Dr Kathy Holloway is the director of the Graduate School of Nursing, Midwifery and Health at Victoria University of Wellington.
Leadership & Management
Want to be your own boss?
Advice for nurses considering self-employment
Self-employed nurse consultant LIZ MANNING shares some advice and new resources for nurses considering the career option of self-employment.
N
ew Zealand registered nurses are fortunate to have a scope of practice that is broad and enabling. In fact the scope is often undervalued, misunderstood and probably underestimated in terms of the flexibility it offers the New Zealand nursing workforce. This is particularly so for those nurses who are working, or considering working, in non-traditional settings in non-traditional ways, for example selfemployed nurses. In many countries, nurses who become self-employed can struggle to retain their regulatory equivalent of an annual practising certificate, even if they are delivering clinical practice. Not so in New Zealand. Despite this, selfemployed nurses still make up only a tiny percentage of the total nursing workforce; however the number is slowly and steadily rising. Self-employment in nursing is still relatively unusual, but there are examples from New Zealand, particularly from the 1980s onwards, where entrepreneurial nurses saw an opportunity to deliver a clinically based service and took it, in areas like occupational health and nurseled primary care services. Today, nurses are self-employed not only in clinical practice, but also increasingly in non-clinical ‘consultant’ roles working locally, regionally, nationally or even internationally. These nurses are often in management, quality, policy or professional advice roles, where nursing knowledge and experience is vital, alongside project management and leadership skills. Resources for self-employment The steady growth in self-employed nurses has been recognised by the College of Nurses Aotearoa which has created a suite of web-based resources to support nurses considering self-employment as a future career option.
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Planning a new business can feel daunting, especially for registered nurses and nurse practitioners as – unlike midwifery, physiotherapy or general practice – the New Zealand nursing profession does not have a strong history of selfemployment. For nurses considering solo self-employment or becoming an employer – either as a clinical or non-clinical business – there are now links in the resource kit to support them at each stage, from set-up to self-care, as well as how to maintain an income and professional nursing registration. The resource has six sections containing helpful advice, direction, prompts and links.
Planning: first steps Nurses who successfully set up and run businesses usually have a niche, or a specific skill set on which they draw and which will attract clients. Nurses new to this environment need to be sure about their abilities and that they have the professional networks, skill set, infrastructure, capital and qualifications to be offering and charging for the service they plan to deliver. They also need to make decisions about how to position the business, to check the markets and to assess how to find work.
Set up: business structure, marketing and tools for business Businesses come in many shapes and sizes, but there are some fundamental similarities. These include needing a memorable name, registering the company, filing an annual return and deciding on business structure, website and email hosting, as well as managing contracts.
Finance: Invoicing and tax Finance, invoicing and tax considerations are often the steepest learning curve for people new to running a business. They are often experts in the actual work, but not many nurses have had previous experience in calculating GST, dealing with the IRD or sending monthly invoices.
Security: insurance, indemnity and privacy Security and business insurance is not something nurses need to consider as employees, however if they become employers or solo self-employed then these become vital. If delivering a clinical service, nurses need to be sure they are meeting the principles of the Nursing Council’s Code of Conduct and keeping records according to the Privacy Act. Those delivering a clinical service also need to consider public liability insurance. All nurses should have professional indemnity as this is financially vital if any complaints are made in relation to their practice. Self-employed nurses should also consider insurance for the business, in case they become unwell or unable to trade for any period of time.
Leadership & Management Nursing regulatory requirements Registered nurses who move into selfemployment in non-clinical roles will often ask if they need to maintain an annual practising certificate (APC) from the Nursing Council of New Zealand: ▶▶ Registered nurses undertaking any clinical practice, delivering clinical care must complete the clinical competencies. ▶▶ Registered nurses who practise in direct client care AND management or education or policy or research must meet both sets of competencies. ▶▶ If only in non-clinical practice then check for the correct registered nurse competencies – either management or education or policy or research. ▶▶ The correct competencies and assessment forms are on the Nursing Council website. Nurse Practitioners have one set of competencies¹⁵, also available on the Council’s website.
Self-care Research shows that people running their own businesses often forget to look after
themselves. Examples range from never taking holidays and working longer and longer hours to feeling huge responsibility for sustaining an income. Another vital component of nursing self-employment is keeping professionally connected. This can be through professional nursing organisations, such as the College of Nurses, or making time to attend conferences and nursing events. Isolation can be a big factor for the selfemployed; there is a need to connect with others in similar roles. How self-employed nurses achieve that connection can be varied, but it is important, especially if working from home, to remember to link back up to colleagues and support.
Conclusion Self-employment can certainly be rewarding, but it doesn’t suit everyone and for most who take that pathway, it means learning a whole new set of skills. So, before considering setting up any sort of business providing a nursing service – either clinical or non-clinical – it is important to do your homework and consider the niche into which you may fit.
Do you have the qualifications or experience? Do you have somewhere to work? Is there a market? What is your risk? Do you have the ability to manage a potentially precarious income and the day-to-day management of your own business, as well as offering a quality service? If you need more information, check out the self-employment resources on the College of Nurses website www.nurse. org.nz. The resource has links to the College’s professional supervisor’s page but for specific enquiries about setting up a business in nursing you can contact the College office on admin@nurse.org.nz. Author: Liz Manning RN, MPhil, FCNA(NZ), is director and owner of Kynance Consulting, where she works as a self-employed nurse consultant and is currently undertaking a PhD research study on self-employed, non-clinical registered nurses in New Zealand. NB: References are available in the online version of this article at www.nursingreview.co.nz
An NZME custom publication | 2018
HealthCentral FutureFocus: a new quarterly guide for health-conscious kiwis An NZME publication, HealthCentral FutureFocus will have a print run of 90,000 copies and will be inserted into the New Zealand Herald, Northern Advocate, Bay of Plenty Times, Daily Post, Hawkes Bay Today, Wanganui Chronicle as well as the NZ Herald, attracting a combined average issue readership of 525,000 Monday–Friday readers.
22 November
Managing Health y Dental health - navigating the costs and systems of looking after your teeth y Physiotherapists, chiropractors, osteopaths - what’s the difference and who should you see? y The Green Prescription - how does it work? y Depression - recognising the signs y Superfoods to the rescue - the foods that pack a healthy punch
Find out more rob.tuitama@nzme.co.nz
04 915 9783
@HealthCentralNZ healthcentral.nz
/healthcentralnz
Or contact your local NZME media specialist
nursingreview.co.nz Issue 4 27
Students & New Graduates
The struggle of being a nursing student and a parent
With a 2017 study of nursing students in Aotearoa showing that a third of them were juggling responsibilities for children or whānau and their studies, what are the obstacles and challenges facing these students? BAZ MACDONALD investigates.
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ursing is a demanding degree, with a huge range of clinical knowledge, theory and practice contained within the three-year bachelor’s degree. For a third of nursing students, on top of this intensive study, they also juggle caring for children or whānau. This is the case for second-year nursing student Rachelle, who is married with four children between two and nine years old, and third-year student Katie, who is a solo parent with three children between 11 and six. “[Juggling study and my family] is a constant struggle – constant. It is really, really tough,” says Katie. Both Rachelle and Katie have had to be flexible about how much time they can commit to their studies, with both moving between part-time and full-time study in order to balance their family commitments. For instance, Rachelle underwent her first semester of study while pregnant with her fourth child, and even sat her first exams at 37 weeks pregnant, and then took a year off before returning to study.
undertaking, not just with the fees involved, but also from the loss of an income and the added financial burdens it can bring, such as the need to pay for childcare services. Understandably then, finances were a significant consideration for Katie when going into study. “There was nothing to gain financially by becoming a student, in fact the opposite – it is a huge challenge,” Katie says. Both parents said that planning is a key part of how they juggle their studies with their family. Rachelle sits down with her husband on Sunday afternoons and plots out the schedule for the week for herself, her husband and the kids. Together they formulate a plan for how to coordinate all this activity. “We have an unwritten rule that one of us drops them off and one of us picks them up. For the kids, I think that is important,” Rachelle says. Katie says she creates excel spreadsheets breaking down the days for each child by who will be where and what person is caring for which child.
Finances and forward planning
Both Rachelle and Katie have family who live close by and offer them support. The extra pairs of hands makes juggling family and study much more manageable, they say. In fact, both thought that it wouldn’t be logistically possible to manage without the support of extended family and friends.
Studying has required both women to be aware of all aspects of their circumstances and assess how possible it is to undertake their training at every step. A big consideration is finances. Studying is a fiscally intensive 28 Issue 4
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Support networks and parent guilt
“I don’t think I’d be able to manage without them,” Rachelle says. “And I don’t think I’d be able to manage if my husband wasn’t as flexible in his job either.” “My mother is fantastic,” Katie says. “She comes to my house at ungodly hours when traditional childcare isn’t even open or available.” “I also have some mums from my kids’ schools who I rely on heavily as well. Without that network, it wouldn’t be possible.” This need for extra support is particularly necessary because of the wide range of hours involved in both class work and placements. Placements could involve a range of different shift work, but classes also range from 8am to 6pm on some days. “We had a class last semester which went until six at night,” Rachelle says. “Another mum’s kids were in childcare, but the childcare closed at six.” Situations like these often put nursing students into a position where they must choose between their education and their family. “That is where a lot of the guilt comes from,” Rachelle says. “You feel guilty if you are not there for your family, but you also feel guilty if you’re not putting the effort into your studies.” But, Rachelle says, this can also be a motivating factor – with every day making you aware of what you and your family are sacrificing for, and a desire to do well so that sacrifice is not for nothing.
Students & New Graduates
Both parents think entering the nursing profession will both make life easier and more difficult with juggling their families. Although nursing can be an incredibly demanding job, Rachelle says that depending on the position she gets it should offer life a little more stability and allow her to leave the job at work in a way it isn’t possible to do with study. “[It will make a difference] knowing that a shift is done, and not having to then go home and do a few more hours of study,” Rachelle says.
Clinical placements present one of the biggest challenges for parents studying nursing. There is far less understanding in placements around your personal circumstances, says Rachelle. At a training institution, lecturers and administrators become aware of the challenges you have outside of schoolwork and can be accommodating of that. However, placement workplaces are such a whirlwind that often there is no time or interest in this kind of accommodation.
“You are trying to prove you have good work ethic – you don’t want to be the person making excuses because you have a sick kid,” Rachelle says. Both parents say their schools have been accommodating. Katie says it has been her experience that lecturers can be amenable to requests for class or tutorial slots, when they are available, making this scheduling of family and classes more feasible.
Third-year students confident but not cocky, finds study The initial findings of research into nursing students’ readiness to practice has proven interesting and in line with similar findings overseas.
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ore than 90 per cent of finalyear nursing students feel comfortable communicating with doctors, but only about 60 per cent feel comfortable knowing what to do in the care of a dying patient. These are some of the findings of research led by Ara Institute of Canterbury nursing academic Dr Isabel Jamieson into just how ready to practise final-year students considered themselves. The researchers surveyed five cohorts of third-year students on their final clinical placement and found that more than 95 per cent felt ready for the professional nursing role. Just under half (nearly 250) of eligible students took part in the anonymous survey, with the vast majority of students being female, under 30 years old and of New Zealand European ethnicity. Students showed high levels of confidence in communication, with 85 per cent feeling comfortable delegating tasks to others, while nearly all felt confident communicating with patients from diverse populations and coordinating care with other members of an interdisciplinary team.
When it came to clinical procedures, about half of the students felt uncomfortable with their skills in bladder catheter insertion, and about a quarter were uncomfortable with chest tube care. One of the professional responsibility areas in which the students showed reduced confidence was knowing what to do for a dying patient. Jamieson says this could be an area in which to consider a stronger teaching focus. “But having said that, you’d need a reasonable amount of experience to feel comfortable in that role,” she says. The young age of the cohort meant they may not yet have experienced a loved one dying, she added, let alone a patient. The vast majority of students felt that writing in reflective journals had helped to develop their clinical decision-making skills and high numbers also felt that simulation had helped to prepare them for clinical practice. When asked what could have been done to make them feel more prepared, students called for more clinical time (they were evenly divided on wanting longer placements or more diversity of placements) and more simulation time across all topics.
High numbers of students expressed confidence in being able to care for two patients at one time; this fell to the majority feeling confident in caring for three patients but then fell markedly to very few students feeling confident in caring for four or more patients. “I think that’s a completely understandable concern,” says Jamieson. “They are recognising that they don’t have the skills yet to manage large numbers.” She says the findings on patient numbers mirrored almost exactly a recent US study covering three different nursing programmes. How the students fare as new nurses in the reality of the workplace will become clearer through a longitudinal study of these graduates. Jamieson has begun analysing the research findings from tracking these new nurses across the beginning, middle and end of their first year of practice. “It will be interesting to see whether that degree of confidence in their readiness [to practice] pans out,” she says.
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Opinion Family Caregiving
A nurse’s story of family caregiving JENNY SONG could see the fear in her 90-year-old father’s eyes at finding himself a stroke patient in a hospital where he understood nobody.
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remember sitting in a hospital meeting room with a hospital consultant, a social worker, two occupational therapists and a hospital translator. The purpose of the meeting was to discuss my request to discharge my elderly father from hospital. “The reason why we have a translator here is because we need to make sure it is your father’s own decision rather than yours, although we know you are a nurse and can speak English,” they told me. “Your father needs two people’s assistance and a hoist to help with his mobility, and we don’t think you can look after your father by yourself.” I burst into tears upon hearing these comments from those health professionals.
I realised that he was terrified of the hospital environment; he felt like an abandoned and worthless child. My father had a stroke in December last year, which left him with right side hemiplegia. A week later, when I got home from overseas and visited him in hospital, I realised that he was terrified of the hospital environment; he felt like an abandoned and worthless child. As a 90-year-old man from an Asian country, he could not understand any English. Whenever hospital staff talked to him, his eyes would be wide open with fear. Dad had a mental breakdown and refused to eat anything while in hospital. Thankfully, the consultant, along with the social worker and occupational therapists, made the final decision that my father should be discharged home with a GP follow-up. I believe that the decision was made with full cultural considerations rather 30 Issue 4
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than from a purely medical point of view. I am very much appreciative of the open-mindedness of the hospital health professionals as they understood the cultural effects on health and health management. Although I was grateful that all the health professionals cared for my father to the best of their efforts, I also knew it was challenging for them when facing such language and cultural barriers. In Asian culture, it is a moral duty for family members to look after sick family members – filial piety is a tradition. For me, my parents brought me up, so it is my turn to look after them. Because of the cultural differences, the question is then raised: how can healthcare professionals relate to patients and their family members? Cultural safety is one of the aspects of nursing practice reflected in the Nursing Council’s competencies for nurses in all scopes of practice. Recognising the powerlessness of the patients and the cultural differences in health practice could help nurses create a friendly environment to patients and their family members. A positive health outcome can only be achieved through recognising and understanding, with an open mind, the powerlessness of patients, as well as a strong commitment to serving the best interests of the patient. My father lives at home with us now, making considerable progress both physically and mentally. My lovely daughter Cynthia helps me look after her grandfather in the weekend and during school holidays, and she has developed skills in looking after a stroke patient and using a hoist. All other family members also take care of my dad whenever they have time. I am grateful that a multidisciplinary approach was taken to care for my father, made possible by a group of healthcare professionals: the occupational therapist who had been visiting us since dad was discharged from hospital and who provided all the equipment dad might
need at home; the district nurse who came and performed all necessary nursing assessments; and the general practitioners who sent all the referrals. Without their efforts, we would not be able to look after Dad at home. Jenny Song is a registered nurse and senior academic member at Wintec’s Centre for Health and Social Practice. She wrote this article with her daughter Cynthia Lee.
Jenny Song, Cynthia Lee and grandfather.
Opinion College of Nurses
Why do nurses feel undervalued?
Let me count the ways…
In a year where nursing grievances made headlines, Professor JENNY CARRYER reflects on the long and ongoing struggle for nursing to be heard.
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he last few months have been marked by an unprecedented focus on nursing and nurses’ despair about the conditions under which they provide care to patients. It has caused me to reflect on a conversation I once had with the CEO of a DHB who asked, with genuine mystification, why it was that nurses constantly told him that they felt undervalued? In a nod to Elizabeth Barrett Browning – the poet who famously asked “How do I love thee? Let me count the ways” – I ask, “Why do nurses feel undervalued? Let me count the ways”.
Decades of struggling to be heard It has been a salutatory experience to be a nurse leader now for more than 25 years. My overriding sense is of a long struggle to be present at the table, to be heard at the table and to be taken seriously. As a nurse academic especially, I have been involved in numerous efforts to raise awareness of the enormous wealth of New Zealand and international evidence about the relationship between registered nurse staffing and patient safety. For years, nursing talked about needing to amass the evidence and it has now done so extensively all over the world. It is difficult to understand the complete lack of interest with which this evidence has been greeted in numerous settings here. I remember the long struggle – and eventual failure – to have taken seriously the Magnet evidence on the nurse job satisfaction and patient safety factors
that give a hospital ‘magnet’ status for attracting and retaining nurses. Numerous studies of the nursing workforce environment have also shown that nursing should have direct line accountability for nursing from the executive table to the bedside. But just this morning I read yet another DHB restructuring document that gives huge leadership to medicine and positions nursing as an adjunct. DHBs have simply ignored the evidence about nursing leadership, with very few directors of nursing (DoNs) holding the budget for nursing. Many are sidelined to advisory positions where they experience full accountability for nursing outcomes but have little control over the mechanisms influencing those outcomes.
Lack of respect and recognition As someone who teaches primary health care at master’s level, and through the College of Nurses, I have listened over and over to nurses from general practice and from older care settings who are treated appallingly in terms of recognition, respect, remuneration and collegiality. Yet at the same time, I have watched the contribution made by nurses in these settings escalating exponentially. Despite the relative narrowness of biomedicine and the comparative breadth of nursing, it is almost always still necessary to ask tiredly, “What about us?” when new decision-making, leadership or review groups are being established. It is irritating and
demeaning to consistently be reminding people that we are the largest health professional group with an enormous sphere of engagement and we are alongside consumers 24/7 in every possible setting and every possible experience. We know a great deal about what works and what doesn’t. Nursing has also had to constantly defend its need for leadership positions, for advanced practice positions and for investment in postgraduate education (which to this day remains absolutely minimal, despite considerable evidence linking nurses’ education level with increased patient safety). We also now know that nurses and nurse practitioners can provide the full service in primary health care and general practice for a fraction of the investment made in the current workforce.
Taking notice of nursing – at last – but yet… The recent industrial activity brought unusual media interest in nursing, with one journalist actually wondering aloud why she had been a health reporter for so long and never really taken any notice of nursing. Why indeed? I well remember fielding calls from journalists when nurse prescribing was approved and thinking journalists would be keen to know what this might mean for consumers and their access to services. Sadly, the only real question any journalist ever asked was, “What will medicine think about this?”. >>
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Opinion College of Nurses This year there is finally a tacit acknowledgement that nursing has been the ‘go-to’ area for cost savings, leaving a wide gulf between what is needed and what we actually have, in terms of staffing. There is a belated race on now to close that gap. The signing of the Safe Staffing Accord will hopefully bring major gains for nurses (and patients) in hospitals. Similar action is needed for other settings. But I am aware of an intriguing and
concerning development amongst health bureaucrats and generic managers. Just when there is some much-overdue attention being paid to the value of nursing, it has become improper or unwise to talk about nursing alone. Rather, we are exhorted to think and speak of the multidisciplinary team. I have no argument at all with the vital importance and value of multidisciplinary teams; nurses have always understood the value of the team. But I would hate to think that this is an
unconscious mechanism to distract us from some vitally needed, long overdue investment into nursing. Nursing remains the largest, most generic, flexible and fit-for-purpose health workforce in the system – a workforce whose potential has never been fully released because of a persistent reluctance to acknowledge the value of doing so. Professor Jenny Carryer is executive director of the College of Nurses Aotearoa and chair of the National Nursing Organisations (NNO) group.
Conferences
Upcoming conferences 2018 NZNO Pacific Nursing Section Symposium and AGM ▶▶ 9 November 2018 ▶▶ Auckland ▶▶ www.nzno.org.nz/groups/colleges_ sections/sections/pacific_nursing/ conferences_events NZNO Nurse Managers Conference ▶▶ 8–9 November 2018 ▶▶ Napier ▶▶ www.nzno.org.nz/groups/colleges_ sections/sections/nzno_nurse_ managers_new_zealand Nursing Research Section Inaugural Research Forum 2018 ▶▶ 13 November 2018 ▶▶ Dunedin ▶▶ www.nzno.org.nz/groups/colleges_ sections/sections/nursing_research_ section Gastro 2018 (NZ Society of Gastroenterology/NZNO Gastroenterology Nurses’ College Annual Scientific Meeting) ▶▶ 21–23 November 2018 ▶▶ Dunedin ▶▶ www.gastro2018.co.nz/gastro18 eHealth in Nursing @ HiNZ Conference ▶▶ 21 November 2018 ▶▶ Wellington ▶▶ www.hinz.org.nz
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College of Child and Youth Nurses NZNO Symposium ▶▶ 23 November 2018 ▶▶ Auckland ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/college_of_child_ youth_nurses NZ Respiratory Conference College ▶▶ 22–23 November 2018 ▶▶ Auckland ▶▶ www.nzrc2018.org
2019 Goodfellow Symposium 2019 ▶▶ 22–24 March 2019 ▶▶ Auckland ▶▶ www.goodfellowunit.org/symposium/ programme 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 ▶▶ www.coinn2019.com Aotearoa College of Diabetes Nurses Study Day/NZ Society for the Study of Diabetes (NZSSD) Annual Scientific Meeting ▶▶ 7–10 May 2019 ▶▶ Napier ▶▶ www.nzssd.org.nz/meetings NZ Wound Care Society 9th National Conference 2019 ▶▶ 23–25 May 2019 ▶▶ Dunedin ▶▶ www.nzwcs.org.nz/education/ conferences Infection Prevention and Control Nurses NZNO Conference 2019 ▶▶ 23–25 September 2019 ▶▶ Christchurch ▶▶ www.infectioncontrol.co.nz World Congress of Intensive Care ▶▶ Australian College of Critical Care Nurses & Australian New Zealand Intensive Care Society ▶▶ 14–18 October 2019 ▶▶ Melbourne ▶▶ www.worldcongressintensivecare2019.com
TO SUBMIT A NURSING CONFERENCE OR EVENT, EMAIL EDITOR@NURSINGREVIEW.CO.NZ
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
1
fluticasone-salmeterol (standard pMDI)
QVAR beclomethasone dipropionate
16% lung deposition
58% lung deposition
(extrafine pMDI)
3
2
2
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.