Issue 4 August/September 2017
Free 60-minute PD learning activity Healthy sleep
Leadership & Management Practice nurse to director of nursing Direction and delegation confusion
New Zealand’s independent nursing Series
Students Stress, understaffing and student optimism
Innovation & Technology Surviving a DHB IT meltdown App of the Month: asthma aid
Postgrad funding shake-up www.nursingreview.co.nz
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Squeezing in study It has been a tough winter around the country with hospitals full to overflowing and demands on nursing high. But you can be sure that somehow 2,000-plus nurses will still have managed to squeeze in postgraduate study, despite the pressures of winter illnesses, covering for sick workmates, looking after their families young or old, and trying to fit in looking after themselves. As a journalist covering nursing for more than a decade, the number of nurses who sacrifice ‘me time’ for study time has always made me feel somewhat inadequate. One of our ‘day in a life’ nurses a few years ago wrote about waking before 5am, grabbing her thermal socks, wrapping a blanket around her legs and fitting in a couple of hours study for her master’s degree before waking her sons and getting them off to school and herself off to work. She acknowledged she was a lark but I’m sure that there are owls out there doing the equivalent at the other end of the working day. Such commitment has been rewarded, with Nursing Council annual practising certificate data indicating that 3,000-plus nurses now have clinical master’s degrees in nursing and thousands more have master’s degrees in more than 25 other areas, from public policy to tropical health and bioethics to health management. And that’s not forgetting the many more who have postgraduate certificates and diplomas and the growing number with doctorates. For the past decade the funding model for postgraduate nursing study – and the dollars in the funding pool – have remained virtually unchanged. The pool has seen many, but far from all, nurses have their study funded. This spring the sector is awaiting news of a proposed postgraduate funding shake-up for health. The nursing sector, for one, hopes that the hard yards put in by nurses pursuing postgraduate qualifications will be recognised, with nursing not getting a penny less than it should and perhaps even a few pennies more as the country’s largest health professional workforce (see p. 4 for more). Fiona Cassie, Editor firstname.lastname@example.org www.nursingreview.co.nz NB: This edition’s 60-minute PD learning activity (p. 15) looks at sleep – its association with illness and healing and how to advise and support patients to improve their sleep. COVER IMAGE: This edition we look at the reforms
underway for the funding of postgraduate nursing education (see p. 4). Photo courtesy of iStock. Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by the New Zealand Audit Bureau of Circulation (ABC).
Round-up: News briefs + Bulletin board
FOCUS 4 8 12
Postgrad funding shake-up: what is a fair slice of the cake? Putting postgrad study into action: day-of-surgery mobilisation Pay equity: a history of caring before money-making
PROFESSIONAL DEVELOPMENT 14 15 20
Evidence-based practice: best answer for relieving eczema flare-ups? FREE 60-MINUTE PD learning activity: why does sleep matter? Direction and delegation: developing the skills needed and how it can go wrong
INNOVATION & TECHNOLOGY 22 22 23
Webscope: Kathy Holloway’s website recommendations Health Navigator’s App of the Month: Asthma management aid Surviving and leading the way through a DHB IT meltdown
LEADERSHIP & MANAGEMENT 26 28
How to help nurses struggling with direction and delegation Chris Kerr: from practice nurse to DHB director of nursing
STUDENTS 29 30
NSU chair Phoebe Webster on student optimism and stress Student survey findings on self-care
OPINION 31 32
OPINION: China starts shift from hospital-centred care College of Nurses: Jenny Carryer calls for more NPs, not more GPs
Fiona Cassie 03 981 9474 email@example.com
Yvonne Gray 04 915 9783 firstname.lastname@example.org
NursingReview Vol 17 Issue 4
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nursingreview.co.nz Issue 4 1
News briefs Read the full versions of these online articles at www.nursingreview.co.nz/news. Safe staffing top of DHB MECA agenda Addressing concerns about chronic understaffing and implementing safe staffing tools remained on top of the agenda for nurses’ union NZNO as collective bargaining negotiations with the 20 district health boards entered the second month. NZNO industrial advisor Lesley Harry said members wanted urgent action to relieve chronic understaffing and facilitated forums were held on 18 July and 15 August with DHB, NZNO and Ministry of Health representatives to focus on safe staffing and implementing the Care Capacity Demand Management (CCDM) tools. During the 2015 negotiations the DHBs reaffirmed their commitment to implementing CCDM, including making a ‘timely response’ when CCDM analysis showed more nursing positions were needed to meet patient acuity and demand trends. But by midway through this year only 14 DHBs had begun implementing CCDM and few had completed implementation.
Nursing administration error found to breach Code A heart patient died in hospital after a graduate nurse increased the dosage of a beta-blocker, thinking the prescribing doctor had made an error with the decimal point. The report into the 2013 incident by the Health and Disability Commissioner (HDC) found that in this and other actions the nurse breached the Code of Health and Disability Services Consumers’ Rights. Independent nursing advisor Dawn Carey informed the HDC that the nurse’s 2 Issue 4
error was not the first time a nursing administration error with metoprolol 11.875mg had led to “significant outcomes” for patients. She said a Health Quality & Safety Commission Safety Signal for that dosage of metoprolol had been issued in 2012 after two such incidents.
Mental health nursing vacancies high and morale low Morale among mental health nurses was at the lowest ebb since he began working in the sector more than 25 years ago, said mental health nurses organiser Ashok Shankar. The Public Service Association’s organiser was responding to media reports on high numbers of job vacancies in acute mental health wards and crisis assessment teams, which he believed were actually worse than reported, with some DHBs forced to fill nursing positions with other workers in the interim. Mental health nursing leaders told Nursing Review that high vacancies were not new but nurses were feeling pressured and sometimes overwhelmed by the significant increase in demand and the complexity of acute mental health patients who often also face housing, addiction and other issues that affect their wellbeing. Health Minister Jonathan Coleman said in May that over the past decade the number of people accessing secondary mental health and addiction services has increased from around 96,000 to almost 168,000 – a 75 per cent increase.
Migrant nurse caregiver qualification controversy Migrant caregivers with nursing degrees being told they are ineligible for the top of the new caregiver pay scale without more study was described as “an insult”, by Filipino Nurses Association of New Zealand president Monina Hernandez. NZQA said that care workers with overseas nursing degrees were assessed as meeting the health and wellbeing qualification requirement at Level 4. But Careerforce said workers also needed to demonstrate they were culturally competent in New Zealand’s unique multicultural setting before being assessed as having met the Level 4 qualification requirements to receive the top caregiver pay rate under the historic $2 billion pay equity settlement. Under its statutory role, Careerforce had assessed care workers holding overseas nursing degrees as being at Level 3 for pay equity purposes.
Palliative care nurses back inquiry stand Palliative Care Nurses New Zealand and Hospice New Zealand has welcomed the country’s biggest inquiry into assisted dying recommending no legislative changes to introduce euthanasia. In early August the Health Select Committee released its report, following the two-year inquiry into assisted dying. It opted not to make any formal recommendations and instead provided a summary of the arguments for and against, as presented by more than 21,000 submitters. Jane Rollings, chair of Palliative Care Nurses New Zealand (PCNNZ), said it acknowledges that everyone is entitled to their opinions but PCNNZ believes that nurses and doctors should not be involved in euthanasia.
Southern DHB leadership restructuring
Primary health leader new chair of Nurse Executives Karyn Sangster, the chief nurse advisor for primary and integrated care at Counties Manukau District Health Board, stepped in as the new chair of Nurse Executives of New Zealand, replacing outgoing chair and fellow Counties Manukau nurse leader, director of nursing Denise Kivell.
Otago Polytechnic nursing lecturers Dr Liz Ditzell and Mereana Rapata-Hanning were both awarded $20,000 Sustained Excellence Awards at the annual Tertiary Teaching Excellence Awards ceremony in Parliament in August.
Longstanding executive director of nursing Leanne Samuel resigned from Southern District Health Board following a major restructuring of nursing leadership positions at the financially troubled DHB that disestablished 11 nursing leadership positions, including Samuel’s, and created seven new ones. The board has appointed Jane Wilson as its new chief nursing and midwifery officer. Wilson has been based at the DHB’s Commissioner’s Office since late 2015 but prior to that had been a nursing director for the DHB since 2010.
Public health nursing launches new framework
Rural nurses elected to working party
A long-awaited knowledge and skills framework has been launched, recognising the public health nurse’s broad and varied role – from treating a child’s sore throat to responding to public health emergencies. The Te Rākau o te Uru Kahikatea Public Health Nursing Knowledge and Skills Framework 2017 can be downloaded at www.pha.org.nz.
Eight nurses from the Far North to Stewart Island, including four nurse practitioners, have been elected to the Rural Nurses NZ working party. The elected nurses were Kate Stark, Rachel Pretorius, Cathy Beazley, Debi Lawry, Rhonda Johnson, Rhoena Davis, Emma Dillon and Virginia Maskill.
Two nurses receive top tertiary teaching honours
Video promotes PHC for Māori new graduates A video encouraging new Māori new graduate nurses to consider entering primary health care straight from nursing school, and particularly to join Māori health providers, has been launched by the National Hauora Coalition primary health organisation and Māori nursing and midwifery workforce development group Ngā Manukura o Āpōpō. It can be viewed at www.ngamanukara.nz.
HQSC Open for Leadership awards Recent nurse winners of the Health Quality & Safety Commission’s Open for Leadership awards include mental health nurse Rachel Malone from Tairāwhiti District Health Board, for being a gentle champion of improvement projects; charge nurse manager Olivia Pearson from South Canterbury District Health Board for making swift positive changes on her new ward; and district nurse Jessie Gibbens from the West Coast District Health Board for advocating to ensure rural patients receive the same quality care as city patients.
PHO comings and goings Erin Meads, previously the regional clinical director of health for Corrections’ northern region, was appointed earlier this year as nursing director for the country’s largest primary health organisation, Auckland’s ProCare. Chris Kerr left her position as chief operating officer at Wellington’s Compass PHO at the end of July to become Hutt Valley District Health Board’s new director of nursing. nursingreview.co.nz Issue 4 3
Postgraduate funding shake-up: what is a fair slice of the cake?
A major shake-up of postgraduate funding is on its way and nurses are keen to ensure they don’t get a penny less than they should. They’re also arguing that, as the largest health profession, they should, in fact, get a few pennies more. Nursing Review reports.
very year around the country there is a scramble to decide which nurses get their postgraduate study funded and which do not. Rationing limited funds results in about 50–80 nurses – and many hundreds more around the country – being turned down each semester at Counties Manukau District Health Board, where Dianne Barnhill is the coordinator of postgraduate nursing education. Barnhill, national spokesperson for the country’s postgraduate coordinators, says the annual rationing includes deciding which priority level is given to prescribing, nurse practitioner or other advanced practice training within each DHB. The problem is that for each nurse who is funded to complete a prescribing or clinical practicum, two other nurses miss out on funding for a conventional postgraduate paper. The number of nurses being turned down, or being too discouraged to apply, is believed to be the reason behind a snapshot survey undertaken by the National Nursing Organisations last year,
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which found that around 30 per cent of postgraduate nursing students are self-funding their studies. With the launching of the new postgraduate diploma for nurse prescribers, the nurse practitioner role leaping in numbers and gaining increasing traction, and other advanced practice initiatives, the pressure on the limited postgraduate nursing funding pool is not expected to let up anytime soon. Meanwhile a funding shake-up is on its way. Nurse leaders are adamant that nursing funding should not be reduced and are ready to argue that it should increase so that nursing can better meet the country’s healthcare needs.
Change is on its way As Nursing Review went to print, it was anticipated that postgraduate funding would be ‘business as usual’ for 2018. The postgraduate nursing funding pool, which in almost a decade has increased only slightly from $12.5 million to $12.9 million*, and the funding system itself are not expected to change, yet.
But any day now a decision is expected on the likelihood of a new funding model for the 2019 academic year for not only nursing postgraduate training but also for post-entry and postgraduate training for all the health professions and workers funded out of the $185 million Health Workforce New Zealand (HWNZ) pool. The decision will follow a HWNZ consultation document Investing in New Zealand’s Future Health Workforce released earlier this year that argued that change is needed as the current funding approach is based largely on “historic and current hospital-based services” and needs to be more responsive to “unmet need, emerging technologies, and changing models of care”. More than 90 submissions were received on HWNZ’s proposal to start an annual process of “disinvesting” funding from some training areas in order to free up a rolling proportion of HWNZ funding to go into a new contestable “investment” funding pool that will be allocated using transparent,
Focus Postgraduate prioritisation criteria aimed at better meeting future health needs. Not surprisingly, analysis of the 90-plus submissions from across the health professions and sectors found “strong views” that the current funding pool was inadequate and highlighted “considerable concern” about the impact of “disinvesting” in some training areas, plus limited support for a contestable funding process. “We don’t want to lose a single dollar of it [nurse postgraduate funding],” says Sue Hayward, head of the national Nursing Education Advisory Team (NEAT). Hayward, the chief nursing and midwifery officer for Waikato DHB, says nursing fought hard to access the funding in the first place and it is worried that – unless “miraculously” there was new funding – the rolling shift to contestable funding could risk some of that hard-won funding being lost. At present, medical (including GP) training takes the lion’s share (just under $117 million or 63 per cent) of the HWNZ funding, with nursing following next with
$22.1 million (12 per cent, which includes the $12.9 million postgraduate funding pool, roughly $850,000 for the pilot NP training scheme and up to 1,300 places for new graduates in the Nurse Entry To Practice programmes). The next biggest share is to mental health and addictions ($21.8 million or 12 per cent, which includes post-entry clinical training of psychiatrists and psychologists and some funding for mental health nursing, allied health and other mental health workers), followed by voluntary bonding ($8.2 million or four per cent) and smaller pots for midwifery (three per cent), allied health, disability support, and Māori and Pacific support (which all get about two per cent each). Nursing submissions to HWNZ, including Barnhill’s on behalf of postgraduate nursing coordinators, the New Zealand Nurses Organisation, College of Nurses and Nurse Education in the Tertiary Sector (NETS) are open to change but share common concerns that the proposed model still seems to be medically focused and that nursing, despite being the largest health profession, risks being invisible and sidelined.
More detail is needed on how a contestable investment funding pool and national prioritisation framework would work in reality to create a health workforce better fit to meet future health needs. Some nursing groups also expressed fears of the contestable investment fund being captured by political or interest groups, applications being expensive and time-consuming to pursue, and also concerns about how return on investment is fairly measured in postgraduate education.
A fairer share What does nursing want from postentry training reforms? A fairer share of the cake is a common call, and for the health sector to take stock of what is the best health workforce mix to meet the country’s future health needs. This includes, some argue, taking a close look at whether investing proportionately more in medical training delivers the best value for the limited health training dollar. Kathy Holloway, previous chair of NETS and current co-chair of the College of Nurses, believes the country needs a Continued on next page >>
nursingreview.co.nz Issue 4 5
<< Continued from previous page national health workforce strategy first, before deciding on a new funding model. “One of the things we haven’t had in New Zealand is an ability to step back as an overall health system – rather than discipline by discipline – and look at what people who use the health system need and what workforce mix we need to deliver that. “Taking a whole-of-workforce approach gives us a better opportunity to get a sound and sustainable workforce policy rather than using an historical basis, which is what we have done.” Professor Jenny Carryer argues in the college’s submission that the current spend on medical training is not producing a fit-for-purpose, futureoriented workforce, particularly with the exponential growth of technologies and the increasing demands for “preventative, pro-active community-based care”. In this issue of Nursing Review (see College of Nurses page), she also asks whether producing more GPs will actually solve the problems in meeting primary health care demands. She urges careful consideration of a proposal to train more NPs (at a cost of approximately $100,000 each) rather than more GPs (at a cost of about $600,000 each). Health Workforce New Zealand is currently evaluating a pilot of the dedicated Nurse Practitioner Training programme – currently in its second year of supporting 20 NP candidates a year – to see whether it will be continued and/or rolled out to more providers in 2018. Nurse Practitioners New Zealand (NPNZ), in its submission to HWNZ, says a successful aspect of the training programme is that NP candidates have to have employer backing to be included. But getting employer or funding backing to become an NP, or another advanced practice role, can often be down to chance, says NPNZ. The chances are higher, it says, for those in a DHB with a supportive director of nursing, chief executive or nongovernmental organisation, but the odds are stacked against those based in a DHB “where nursing innovation is actively blocked or ignored due to personal philosophical stances, membership of a specific profession or personality clashes”. It asks what HWNZ intends to do to ensure that such a “postcode lottery” does not continue with future initiatives and training proposals. Such an initiative is an approval of RN prescribing, backed by the Government as 6 Issue 4
a way of delivering faster, more convenient care, but no new funding has been allocated for the prescribing practicum required for the prescribing qualifications, which requires roughly double the funding of a standard postgraduate paper. Barnhill says DHB coordinators can sometimes stretch the funding by finding an inhouse prescribing mentor volunteer, but this is less likely in the primary care and aged care setting where the business model usually means that all mentors’ time – GPs, NPs or other mentors – needs to be funded. Just how initiatives such as nurse endoscopists and nurse colposcopists are funded into the future is also unknown. Nonetheless, nurses’ appetites for postgraduate study, despite or perhaps because of the pressures to keep delivering quality patient care in a stretched healthcare system, is not in doubt. Thousands of nurses now have postgraduate qualifications and thousands more each year begin further study. Hayward says that directors of nursing are clear that the investment to date in postgraduate nursing training is having a positive impact on patient care and outcomes. For her master’s degree, Barnhill surveyed nurses, nurse managers and nurse educators working in acute medical and surgical wards to ascertain the effects of postgraduate study. All respondents perceived that clinical practice improves as a result, but Barnhill says it is very difficult to prove that impact on patients statistically. This issue was one of the reasons that NETS chose not to support the new HWNZ investment funding proposal, as it was unclear how return on investment from health professional education could be proven. All in all, the new postgraduate funding model proposed has raised more questions than answers for most of those in the nursing sector who are ready for change but want more detail before deciding whether proposed changes will help or hinder the nursing profession’s flexibility and readiness to meet future healthcare needs.
HWNZ listening to nursing concerns There is a “clear need” for further engagement with the nursing profession, says new HWNZ group manager Claire Austin. She says dialogue is continuing with nursing leaders and representative bodies and there are opportunities for more
dialogue with all parts of the sector on implementing any changes. “We know we need a model that is flexible and efficient and that meets the needs of all professional groups and all services,” says Austin. “HWNZ is mindful of the difference in training models and the fact that many nurses self-fund postgraduate training.” She says it is aiming to ensure that any changes “support innovation and new models of care and encourage individual nurses to pursue additional qualifications”. One of the strong themes in submissions, she says, is a desire to work with HWNZ on developing a national health workforce strategy. Developing that strategy in partnership with the sector will provide further opportunities to shape how post-entry training is funded. A decision on changes in the wake of the HWNZ consultation document is expected soon. Watch this space to see what this means for postgraduate nursing training and whether fewer or more nurses will be out of pocket in the future.
HWNZ-funded postgraduate nurse study statistics ▶▶ 2014: 2,282 nurses funded (1,524 training units**) ▶▶ 2015: 2,354 nurses funded (1,544 training units) ▶▶ 2016: 2,464 nurses funded (1,590 training units) funded in semester one ▶▶ 2017: Total nurses and training units funded have yet to be confirmed* * As Nursing Review went to press, Health Workforce New Zealand provided figures stating that $13.2 million was allocated to the postgraduate nursing training pool for 2016-17, of which $12.9 million has been spent. ** A training unit is the equivalent of a two-paper PGCert or one year of a PGDip or master’s degree programme. The cost of a unit varies from $7,374 per annum for two standard papers to more than $28,000 for two mentored practicums (i.e. the prescribing practicum required to become an RN prescriber or NP, and the clinical skills practicum required to become an NP).
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Putting postgrad study into action Early pain but quicker gain: mobilising hip and knee patients How soon should hip and knee replacement patients be up and mobile? Recent master’s graduate Diane Alder reports on putting study into action after a literature review led her to introduce mobilisation on day of surgery as her master’s research project.
great deal of research in recent years has focused on the benefits of mobilising all patients as soon as possible after surgery. Mobilising after hip or knee replacement surgery (lower limb arthroplasty or LLA), however, has traditionally been delayed. But advancements in surgical and anaesthetic technique mean it is now not only safe to mobilise these patients earlier, but there is also evidence that there are many benefits in doing so.
Background Arthrosis – the degeneration of a joint most commonly caused by osteoarthritis – is the leading reason for having joint replacement surgery or arthroplasty. Arthrosis is debilitating, often causing pain and disability and substantially reducing the quality of life of those affected. The first attempts at joint replacement surgery happened more than 100 years ago, but only became effective in the 1960s. Hip and knee replacements (LLA) have become more common in the last two decades and, with our ageing population, demand will continue to grow (it is estimated that arthrosis affects 75 per cent of people over 65).
To meet this growing demand, researchers are looking at ways to reduce costs. Traditionally, LLA patients spent extended periods of time recovering in hospital. While length of stay has reduced for all types of surgery in the past 10 years, there is still a huge variability in length of stay globally after LLA, with ranges of 1–21 days. A number of enhanced recovery programmes (ERPs) – also known as enhanced recovery after surgery (ERAS) or ‘fast track’ protocols – have gained popularity in Europe and the US, with beneficial results for both LLA patients and providers. Many ERPs are expensive to implement, however, with entire units set up with increased staffing and equipment. But while researching the barriers and opportunities for LLA patients in my own hospital (as part of a nursing research methods paper), I found one key component of many ERPs that I felt could be hugely beneficial as a stand-alone change: mobilising LLA patients on the day of surgery, not the day after. This became the focus of my master’s degree research. (Mobilising the day after surgery, i.e. day one, was standard when I began the study. See the sidebar on p. 10 for a summary of literature review findings on the benefits of early mobilisation of LLA patients.)
Summary of results Audit 1 DOS mobilisers
Audit 2 – one year later D1 mobilisers
1. Length of stay
3.53 days (range 2–5 days)
4.05 days (range 2–6 days)
3.43 (range 2–6 days)
3.63 (range 3–4 days)
2. Pain score day of surgery (DOS) and day of discharge/10
DOS / Discharge 4.71 2.29
DOS / Discharge 4.23 2.61
DOS / Discharge 4.06 1.88
DOS / Discharge 4.25 1.88
3. Mean patient-controlled analgesia (PCA) use
4. Mean oral opiate use (post-PCA) (mg)
5. Mean codeine use (postoral opiate) (mg) 86.32 8 Issue 4
Focus Postgraduate Safety criteria checklist for early mobilisation 1. Patient is haemodynamically stable ▶▶ Blood pressure is stable, with systolic ≥ 100 ▶▶ Heart rate is stable ≤ 100bpm ▶▶ Bleeding is minimal-moderate, if drain used then ≤ 50ml/hour ▶▶ Patient is not light-headed or short of breath at rest 2. Patient is neurovascularly stable
Introducing day-of-surgery mobilisation Like many idealistic students, I wanted to carry out a randomised controlled trial to compare outcomes between day-of-surgery
and day-one mobilisers. However, my literature review revealed so many benefits in mobilising early that I decided it would be unethical to make some patients stay in bed and not have the opportunity to benefit. Continued on next page >>
▶▶ Patient can actively plantar and dorsi flex ankles of both feet ▶▶ Patient can actively contract both quadriceps (doesn’t necessarily have to lift leg actively) ▶▶ Sensation can be reduced in operated leg, but not absent 3. Patient consent ▶▶ Patient is alert and oriented and able to consent to mobilising ▶▶ Pain is controlled to level considered acceptable to patient at rest
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nursingreview.co.nz Issue 4 9
<< Continued from previous page So, with the support of our surgeons and management at my 38-bed private surgical hospital in New Plymouth, I introduced an early mobilisation initiative for LLA patients as a quality improvement project. The initiative included developing a checklist so nurses could be confident that their patients were safe to mobilise (see the safety checklist box on p. 9). Three months later, after receiving ethics consent, I audited the discharged patient files for my master’s thesis and compared the outcomes of early mobilised LLA patients with the outcomes of patients mobilised on day one. Exactly a year after the first audit, I conducted a follow-up audit. This was partly because uptake of the idea at the beginning was relatively slow, but gained support over the year as nurses and surgeons saw the benefits to patients. I also wanted to ensure that the gains were sustained (see table p. 8 and sidebar at right for audit results).
Conclusion Many nurses were initially sceptical about mobilising LLA patients on the same day as their surgery. But the initiative soon gathered momentum when nurses saw for themselves their patients gaining independence earlier, with less pain and fewer adverse effects post-surgery. This change of heart was reflected in the audit results with only 56 per cent of LLA patients being mobilised successfully on the day of surgery in the first audit, compared with 84.6 per cent a year later. While pain scores on the day of surgery were slightly higher on the day of surgery for early mobilisers, by the day of discharge their scores were lower, and less pain relief was used by early mobilisers during their stay, indicating lower pain levels. The length of stay decreased after the initiative and continued to decrease in the follow-up. Early mobilisation after LLA has now become the norm at our hospital as we continue to see improved outcomes for these patients.
Author: Diane Alder Is a registered nurse at New Plymouth’s Southern Cross Hospital and completed a Master of Health Sciences last year. REFERENCES are available with the online version of this article at www.nursingreview.co.nz.
Early mobilisation New Zealand clinical audits Audit 1: December 2015, following the introduction of an early mobilisation initiative for LLA patients in September 2015. Subjects: n=52 (pre-initiative) + n=52 (post-initiative) = 104 patients, split into two groups; those who mobilised day of surgery (DOS) n=38; and those who mobilised day one (D1) n=66. Age range of patients was 51–92 years. Audit 2: Follow-up audit. December 2016, one year later. Subjects: n= 52, divided into DOS mobilisers n=44 and D1 mobilisers n=8.
The benefits of early mobilisation of LLA patients 1. Less risk of venousthromboembolism (VTE) Patients mobilised the day of surgery are 30 times less likely to suffer from VTE complications. 2. Less pain A number of studies show early mobilisers state lower pain scores overall. And the benefit isn’t just shortterm; a German study found their early mobilisation group stopped taking analgesia altogether by day 41, while the traditional day-one mobilisers continued to take analgesia for a further 30 days. 3. Less opiate pain relief required Lower pain scores means less pain relief. One study showed a 60 per cent reduction in opiate use in the early mobilising group. Less opiate medication means a reduction in side effects, such as nausea and vomiting, so a reduced need for anti-emetics. 4. Less syncope Often cited as a reason not to mobilise on the day of surgery, the risk of syncope is actually less likely to occur. Judicial intravenous fluid replacement and good pre-mobilising assessment is, of course, important.
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5. Fewer blood transfusions Fear of increased blood loss is also cited as a reason not to mobilise but early mobilisers actually have less need for blood transfusions – 9.8 per cent compared with 23 per cent. 6. Less joint stiffness Joint stiffness can be associated with chronic pain following LLA. A Danish researcher found that early and intensive mobilisation helped to avoid the development of specific knee arthroplasty complications such as prolonged stiffness and delays in recovery of strength. 7. Less mortality Several large studies show that mortality reduces with ERPs that include early mobilisation. 8. Less time in hospital Fifteen recent studies showed a reduced length of stay with ERPs; five of the studies isolated early mobilisation and studied its effect on length of stay. Results varied but 100 per cent had reduced length of stay for early mobilisers. 9. Increased quality of life/ satisfaction Most patients would prefer to be home, back to work or back to the golf course as soon as possible. A Danish study showed early mobilisers had increased quality of life/satisfaction.
10. Fewer infections Many studies show shorter lengths of stay mean fewer infections. If a patient is able to mobilise to the toilet within hours of having LLA surgery, there is no need for an indwelling urinary catheter, removing the risk of catheterinduced UTIs. The less time a patient is in bed, the less chance of orthostatic pneumonia. And less time in hospital means a reduced likelihood of a hospital-acquired infection. 11. Fewer readmissions Early opponents to fast-track protocols argued that, if discharged too early, patients would just return as readmissions. In fact, patients who mobilise earlier are far less likely to be readmitted. 12. Economic benefits There are huge savings to be made with reduced length of stay. Several studies have researched the economic benefits, citing savings of US$454,000 per annum in just one hospital in the US, €3.5 million in total per annum in Denmark, and £141 million in total per annum in the UK.
Graduate School of Nursing, Midwifery and Health Te Kura Tapuhi Hauora
EXPAND YOUR KNOWLEDGE Our Nursing Science programme is designed for qualified and experienced registered nurses seeking to develop their theoretical knowledge and practical skills, both in general areas of clinical practice and in areas of specialist expertise. This programme of study includes pathophysiology, advanced assessment, diagnostics and therapeutics and pharmacology courses. You can complete registered nurse prescribing and nurse practitioner pathways that have been approved by the Nursing Council of New Zealand (NCNZ).
Nurse prescribing pathway To meet the health and wellbeing needs of people with long-term and common conditions, new professional practice initiatives that support registered nurse prescribing have been introduced by the NCNZ. The initiatives provide a distinctive pathway and structure within the Postgraduate Diploma in Nursing Science (PGDipNS) that supports registered nurses who wish to undertake prescribing roles within their practice in primary care and specialty teams. Entry requirements: ■ A Bachelor’s degree in Nursing (or equivalent) ■ Be a registered nurse with a current NCNZ practising certificate. This qualification within the PGDipNS covers the courses below. HLTH 502 Applied Pathophysiology (30 points) HLTH 514 Advanced Assessment and Clinical Reasoning (30 points) HLTH 518 Clinical Pharmacology (30 points) HLTH 529* Special Topic: Prescribing Practicum (30 points) * Contact the programme director for specific NCNZ and academic requirements for entry into HLTH 529 Special Topic: Prescribing Practicum
JANE CLARKE Graduate, Master of Nursing Science —Registered Nurse Prescriber A large proportion of Jane’s role as an associate clinical nurse manager involves running nurse-led cardiology clinics in which patients with an established diagnosis are assessed for ongoing symptoms and their medication is adjusted accordingly. Jane enrolled in the HLTH 529 Prescribing Practicum course and, with the support of a clinical mentor, she successfully completed all the components of the course and the Nursing Council of New Zealand granted her designated prescribing authority. She can now prescribe specific medications, making it easier for patients to get the treatment and health care they need. “Being able to prescribe allows me to work at the top of my scope of practice, and improves the efficiency of our service whilst I continue to be fully supported by my entire team,” she says. “As I travelled through my academic journey it became clear that I wanted to achieve a qualification that would benefit my overall practice and improve the service that I deliver to my patients.”
POSTGRADUATE CERTIFICATE IN NURSING SCIENCE 60 points
POSTGRADUATE DIPLOMA IN NURSING SCIENCE 120 points
MASTER OF NURSING SCIENCE 240 points
■ 30-point elective course from HLTH 501–518 and HLTH 521–550
■ HLTH 502 Applied Pathophysiology* (30 points)
■ 120-point Postgraduate Diploma in Nursing Science
■ 30-point elective course from HLTH 501–518 and HLTH 521–550
■ HLTH 514 Advanced Assessment and Clinical Reasoning* (30 points) ■ 30-point elective course from HLTH 501–518 and HLTH 521–550 ■ 30-point elective course from HLTH 501–518 and HLTH 521–550 * Course can be completed during the PGCertNS and/or the PGDipNS.
COURSEWORK PATHWAY ■ 30-point elective course from HLTH 501–518 and HLTH 521–550 ■ 30-point elective course from HLTH 501–518 and HLTH 521–550 ■ HLTH 519 Research Review (30 points) ■ HLTH 520 Practice Project (30 points)
■ HLTH 521 Research Methods (30 points) With a B grade minimum ■ 90-point HLTH 594 Thesis For more information, go to
www.victoria.ac.nz/health/postgraduate or email email@example.com
Focus Pay equity
Pay equity: “money-making” matters too
History shows that nursing as a profession has been nothing but patient when it comes to getting paid its due. With a pay equity claim now lodged for DHB nurses, Nursing Review takes a look at the pay timeline for the still-female-dominated (91 per cent) ‘caring profession’. “A nurse must be a woman, working not in the first place for the sake of moneymaking, but for the good of her fellow creatures to alleviate suffering when she can and help towards health those who need her care.” This 1909 statement from Hester Maclean, our country’s first chief nurse, could probably take pride of place as Exhibit A when arguing the case that a nurse’s monetary worth has historically been undervalued because of the association with ‘womanly’ qualities. Such evidence might be needed after the NZNO lodged a pay equity claim in June for nurses working in DHBs as part of its bargaining talks. Pay equity claims are said to have merit if the work is performed predominantly by women; there are ‘reasonable grounds’ to believe the work has been historically undervalued because it uses skills or qualities ‘generally associated with women’; and the work continues to be subject to gender-based undervaluation. Nobody is expecting such a claim to be settled quickly, particularly as the shockwaves from the historic pay equity settlement for caregivers are still being worked through, particularly by nurses in the residential aged care sector who have lost pay relativity with their unregulated co-workers (see story last edition). But NZNO sees the pay equity claim as the first page in the final chapter of closing the gender pay cap for its DHB nurses (and other members) and, eventually, nurses beyond the public health sector. The union argues that, unlike the 2005 Fair Pay settlement, this time around the Kristine Bartlett vs TerraNova pay equity settlement is creating not only 12 Issue 4
a legal precedent but also a legislative framework to pursue and settle pay equity claims (although unions are not happy with the current wording of the draft bill introducing that framework). It is also acknowledged that the pay equity process will take time, with NZNO industrial services manager Cee Payne writing in Kai Tiaki recently that eliminating the gender pay gap would “most likely take the next decade to be fully realised”.
“Not for the sake of moneymaking” Our formidable first matron-in-chief and chief nurse Hester Maclean’s belief that nurses should put caring before commerce set the culture for much of the first half of the 20th century. Nursing shortages in World War II saw a revised salary scale negotiated and a salaries advisory committee for public hospitals set up in 1947, but as the country
Some current DHB MECA pay rates RN (new graduate to Step 5)
$49,449–$66,755 (base salary)
Senior RN (8-grade merit scale)
Clinical psychologist (new grad to Step 9)
Clinical psychologist (merit scale 1–9)
Radiation therapist (Step 1–15)
House surgeon (year 1)
$55,944–$102,564 (40–65+ hrs/week)
Registrar (year 1)
$71,097–$117,314 (40–65+ hrs/week
$152,000–$216,500 (base salary)
Some current non-DHB MECA pay rates Primary care RN (new grad to Step 5)
Residential aged care RN (new grad to Step 5) $49,920–$62,400 (approx. range) Top of payscale caregiver
$48,880 (after pay equity)
General practitioner trainee* (year 1)
$74,880 (base salary)
General practitioner* (year 7+)
$90,372 (base salary)
Sources: DHB MECAs were downloaded from centraltas.co.nz; nursing MECA from nzno.org.nz; and GP MECA from nzrda.org.nz. *NB: Statistics supplied to Careers New Zealand in 2017 from the New Zealand Medical Association indicate that trainee GPs earn between $80,000 and $130,000 per year and GPs between $95,000 and $250,000 a year.
Focus Pay equity settled back into peacetime nurses lost industrial traction, with little salary movement for nearly two decades. Nursing was once again seen as a feminine vocation not to be marred by talk of money. In 1957 the New Zealand Nurses Association (the forerunner of today’s NZNO) even withdrew from the Council for Equal Pay and Opportunity for fear that the professional organisation might become “too political”. But times were changing and in 1962 international advice was sought by the association on better methods for negotiating pay and conditions, leading in 1965 to the introduction of overtime and weekend penal rates – the first real pay rise since 1950 – and the replacement of the salaries advisory committee with an arbitration mechanism in 1969. The 1970s saw public hospital nursing unionised, but it wasn’t until 1985 with the ‘Nurses are worth more’ campaign that nurses really tried to use industrial clout and public opinion to seek fairer pay, including marching on parliament for the first time. In an even bigger first, in 1989 nurses took strike action for the first time, followed soon after by a decade of health restructuring and industrial reform that saw nursing go into survival mode for much of the 1990s.
Pay jolt and pay gaps between sectors With the new millennium and the return of national bargaining, nurses were again ready to look at the issue of pay equity. On Suffrage Day 2003, NZNO launched its ‘Fair pay – because we’re worth it’ campaign to gain pay parity for DHB
Hester Maclean might not approve, but it is probably about time that the value of a nurse “working for the good of her (his) fellow creatures” was calculated once and for all “for the sake of money-making”. nurses with teachers and police. After a hard-won campaign to get such a deal funded, a settlement was reached, leading to ratification in early 2005 of a national DHB multi-employer collective agreement (MECA) that introduced an up to 20 per cent pay jolt for nurses. That pay jolt created a gap between DHB nurses and many of their non-DHB nursing colleagues. A decade later, that pay gap is nearly closed for nurses covered by MECAs in sectors such as primary health, family planning and prisons. But the pay gap still remains for nurses with less industrial clout, including nurses in residential aged care, whose take-home pay is on average 23 per cent lower than their colleagues in public hospitals. And some nurses working for Māori and iwi providers are earning up to 20 per cent less than colleagues working for similar primary healthcare services. Those pay gaps are thrown into even starker relief by the realisation that the caregiver pay equity settlement could see the pay gap between nurses in those sectors and their unregulated colleague shrink or even disappear. NZNO believes that the best step toward pay equity for all nurses is to begin by negotiating in the DHB sector, where it has the greatest numbers and influence. The State Services Commission and Combined Trade Unions (CTU) had also agreed that
unions in the public sector could lodge pay equity claims through collective bargaining using the principles agreed by the tripartite Joint Working Group on Pay Equity late last year. This led to NZNO lodging its claim when talks began in June, rather than waiting for the progress of the draft Employment (Pay Equity and Equal Pay) Bill, which NZNO and other unions oppose in its current form, saying it takes a backward step by placing new and “unreasonably onerous” requirements on women taking claims. Meanwhile, once NZNO and the DHBs agree on terms of reference for pay equity talks, the task of assessing, with a genderneutral eye, the value of nursing work in terms of skill, knowledge, responsibility, effort and working conditions will begin. Then comes selecting historically maledominated occupations of equal value as comparators to back the claim that nurses are underpaid because of historic and ongoing gender inequity. Hester Maclean might not approve, but it is probably about time that the value of a nurse “working for the good of her [his] fellow creatures” was calculated once and for all. Hester Maclean.
Lessons learnt from midwives’ pay equity case? Community midwives lodged an historic pay equity claim under the Bill of Rights Act in 2015 and found that proving gender inequity was far from simple. The College of Midwives’ claim for its self-employed lead maternity carers (LMC) led to mediation in 2016 with funder the Ministry of Health. In May this year it withdrew its court action after winning an interim pay increase and a legally binding agreement from the ministry that midwives would work with officials to design a new funding model for midwiferyled care that resolved the college’s longstanding concerns about pay equity and working conditions. But in a report to members, the college said that after putting thousands of hours and dollars into researching and providing more than 3,000 documents for the case, it had proven easier to prove that midwifery pay was inequitable than it was to legally prove that inequity was due to gender. LMC midwives had fought a case for equal pay for work of equal value in 1993 through the Maternity Benefits Tribunal and won, but there had been only two small increases since 2007, raising questions as to whether midwifery funding provided a sustainable income for the 24-hour, on-call service. The midwifery case was unique because, as self-employed health professionals, community midwives were not covered by the Employment or Pay Equity Acts. But they too went through the process of looking at the historic discrimination of a female-dominated ‘caring profession’ and
seeking out comparators in historically male-dominated professions. So are there lessons to share? Alison Eddy, a midwifery advisor for the College of Midwives, says proving that a profession’s pay is inequitable because of gender is potentially difficult. She says it is easier to measure the clinical and technical skills and the professional accountability required of nurses and midwives than the so-called ‘soft skills’ that are also key to both femaledominated professions. The skills such as building relationships, working alongside people, and empowerment are all areas that can potentially be undervalued. Commodifying those skills in order to match and compare pay with a comparator occupation in a field that has been historically maledominated can also be challenging. Eddy says that after going through a lengthy process of using equitable job evaluation tools, the midwifery case had opted for pharmacists and GPs as two potential comparators and decided that midwifery fitted somewhere above the role of pharmacist and slightly below the role of GP. Under the agreement with the ministry was the commissioning of an independent evaluation of the midwifery role and the provision of comparators and a market value for the role, using a gender-neutral lens, in readiness for a new funding model being in place by July 2018. However, Eddy says that there are real concerns that the numbers now leaving the midwifery workforce due to feeling undervalued could impact on the sustainability of the service. nursingreview.co.nz Issue 4 13
Professional Development Evidence-based practice
Relieving eczema flare-ups: are antibiotics the answer? What is the best treatment for a distressed child presenting with crusty, weeping eczema? CLINICAL BOTTOM LINE Children in the community with signs of mildly infected eczema respond well to topical emollient and corticosteroids. Adding oral or topical antibiotics appears to have little clinical benefit.
CLINICAL SCENARIO As a nurse, you notice some children’s symptoms improve with just the usual topical emollients and corticosteroids. You decide to review the evidence on the effectiveness of antibiotics for treating mildly infected eczema.
QUESTION In children with signs of infected eczema, do antibiotics, in addition to topical emollient and corticosteroids, improve symptoms?
SEARCH STRATEGY PubMed Clinical Queries (therapy, narrow): eczema AND antibiotics
CITATION Francis NA et al. (2017). Oral and Topical Antibiotics for Clinically Infected Eczema in Children: A Pragmatic Randomized Controlled Trial in Ambulatory Care. Ann Fam Med, 15(2), 124-130. doi: 10.1370/ afm.2038
STUDY SUMMARY The CREAM (Children with Eczema Antibiotic Management) study was a threearm, double-dummy, blinded, randomised controlled UK trial involving children with atopic eczema presenting with clinically suspected infected eczema. Included were children (mean age was 3.1 years) with signs of infected eczema that could include: failing to respond to standard treatment with emollients and/or mild-to-moderate topical corticosteroids; a flare in the severity or extent of the eczema; weeping or crusting. Excluded were those who had recently used potent topical corticosteroids or antibiotics, had features of severe infection, or significant comorbidities. Of 171 children assessed, 113 were randomised to one of three study arms. Standard care: Topical corticosteroid: hydrocortisone one per cent for the face and clobetasone butyrate 0.05 per cent (or equivalent) for other parts of the body, and an emollient of parents’ choice (nonantimicrobial). Follow-up at two weeks, 14 Issue 4
four weeks by research nurse and at three months via clinical record review. Intervention 1: (n=36) Oral antibiotic and topical placebo (oral antibiotic group): flucloxacillin (floxacillin) suspension (250mg/5mL), or erythromycin suspension (250mg/5mL) for those with penicillin allergy, for seven days using age-adjusted doses. Intervention 2: (n =37) Topical antibiotic and oral placebo (topical antibiotic group): two per cent fusidic acid cream, applied three times a day for seven days. Control: (n= 40) Oral and topical placebos (control group): Placebos were matched by taste and appearance. Primary outcomes: Eczema severity (skin redness, cracking, soreness, itch, sleep disturbance, oozing or weeping, bleeding, and fever) at two weeks measured by the patient-oriented eczema measure (POEM). Secondary outcomes: Eczema Area and Severity Index (EASI), Infants Dermatitis Quality of Life instrument or Children’s Dermatology Life Quality Index (depending on age of child); Dermatitis Family Impact (DFI)18 instrument, and the Atopic Dermatitis Quality of Life instrument; adverse events.
STUDY VALIDITY Randomisation – yes; allocation concealment – yes (information from protocol); complete follow-up – small loss to follow-up for primary outcome; intention-to-treat analysis – all participants with baseline and two-week POEM scores were included; blinding – yes, children, parents, outcome assessors; equal treatment between groups – appears so; groups similar at baseline – yes, including POEM scores, infection features, and skin swab S. Aureus results. Overall, a high-quality study.
Results At baseline, 104 children (93 per cent) had one or more of the following: weeping, crusting, pustules, or painful skin. Also 70 per cent had S. aureus isolated from a skin swab and 27 per cent of those were resistant to fusidic acid. At two weeks, POEM scores had reduced (improved) in all three groups, with no significant differences in the POEM scores of the two intervention groups compared with control (see table). No significant differences in POEM scores were found at four weeks and three months either, or in secondary outcomes or adverse events. No serious adverse events were reported.
Comments ▶▶ Children recovered quickly, regardless of treatment group. ▶▶ Topical corticosteroids use was measured and similar in each group. Adherence to oral and topical antibiotic (or matched placebos) was 61.3 per cent and 81.8 per cent respectively. Adjusting for adherence differences did not change the results. ▶▶ Although recruitment targets were not met, the lower boundaries of the confidence intervals (-1.4 and -1.6) are less than an effect from treatment considered to be important to patients (published minimal clinically important difference for POEM is three), suggesting that a larger study would not change these results. ▶▶ Results do not apply to children with severe infection. Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD Candidate, Deakin University, Melbourne. firstname.lastname@example.org
Results with 95 per cent confidence intervals (CI) Outcome
POEM at baseline
Baseline, mean (SD)
Intervention effect (95 per cent confidence intervals)
Control versus oral antibiotic
Control versus topical antibiotic
POEM at two weeks 6.2 (6.0)
1.5 (-1.4, 4.4)
1.5 (-1.6, 4.5)
POEM scores range from 0 to 72, with higher scores representing more severe eczema
Professional Development Learning activity
‘Appeared to sleep well’: How much sleep has your patient had and why does it matter? By Lesley Batten and Claire Minton
Good-quality sleep aids healing and recuperation; however, it is well known that institutional environments often do not support adequate sleep and as a result patients experience poorer health outcomes. Nurses are in a unique position to promote multi-pronged approaches, based on research, to enhance the environment so that patients can gain the most benefit from sleep. Introduction Of one thing you may be certain, that anything which wakes a patient suddenly out of his sleep will invariably put him into a state of greater excitement, do him more serious, aye, and lasting mischief, than any continuous noise, however loud. (Florence Nightingale1, 1860, p. 44)
Sleep is defined as the “temporary state of relative unconsciousness from which an individual can be roused either by internal or external stimuli”2 (p. 105). Since Florence Nightingale’s time1, nurses have recognised the importance of sleep to patients’ recuperation and wellbeing as well as nurses’ capacity to support patients’ sleep. Patients experiencing sleep deprivation or fragmented sleep develop complex physiological reactions that, with their other health conditions, result in poorer health outcomes, including increased hospital stays and delirium. However, nurses often rely on their own observations to assess sleep quality – an inherently unreliable process. In this article we provide an overview of current understanding of the impact of sleep and sleep deprivation on recuperation for adults in
institutional settings and argue for a whole-ofsystem approach to ensure that environments where patients sleep best meet their needs. While we particularly mention sleep in institutional settings such as hospitals, the information is relevant for nurses working with patients in all areas and for nurses themselves, especially those who undertake shift work. We do not address the many sleep disorders in this article.
Sleep Mrs Brown, aged 72, admitted today with a #NOF following a fall at home. While awaiting surgery, she is in traction in a six-bedded bay, with a PCA for analgesia. She usually cares for her husband who has mild dementia, and states that she sleeps lightly at home.
Learning outcomes Reading and reflecting on this article will enable you to: ▶▶ gain an understanding of the current knowledge of the physiology of sleep and its association with illness and healing ▶▶ consider steps to enhance patient sleep, including identifying poor sleep quality and advising patients on steps they can take to improve their sleep, and considering the institutional environment for sleep, therefore potentially improving health outcomes.
Reading this article and completing this ‘Appeared to sleep well’: How much sleep has your patient had and why does it matter? selfassessment learning activity is equivalent to 60 minutes of professional development.
NCNZ competencies addressed: Registered Nurse competencies: 1.4, 1.5, 2.1-2.4, 2.6, 2.8-2.9, 3.2, 4.1-4.3 nursingreview.co.nz Issue 4 15
Professional Development Learning activity box 1: When Mrs Brown reports feeling exhausted the next day, what factors would you consider? What, if anything, could you change? Sleep is a complex phenomenon and is vital for many bodily functions. Two processes are involved in sleep regulation: a homeostatic component of sleep pressure after periods of wakefulness, and circadian influences via the circadian body clock. The circadian body clock regulates all circadian rhythms including the sleep-wake cycle – periods of sleep and wakefulness over a period of approximately 24 hours2,3. Sleep patterns differ throughout life stages and change with ageing processes. Normal sleep involves a sequence of complex physiological states controlled by the central nervous system (CNS) and associated with changes in many body systems. Sleep is a cyclical process with distinct physiological responses over the course of the sleep cycle. There are two sleep states: ▶▶ Non-rapid eye movement (NREM) sleep (approximately 75% of sleep time). ▶▶ Rapid eye movement (REM) sleep (approximately 25 per cent of sleep time). NREM sleep includes three stages N1–3, progressing from light to increasingly deeper sleep, when it becomes increasingly more difficult to rouse a person3,4. REM sleep occurs at the end of these stages, and usually gets longer throughout the total sleep period. Each full sleep cycle ranges from approximately 70 to 120 minutes, with an average of 90 minutes, and most adults have about five cycles over an eight-hour sleep with some brief awakenings between cycles. While asleep, the body undergoes processes of physiological and psychological conservation and restoration. During NREM sleep stages, parasympathetic activity increases, sympathetic tone decreases and the release of human growth hormone aids epithelial and cell repair, while skeletal muscles relax, allowing the conservation of chemical energy for cellular processes. The basal metabolic rate falls, heart rate, breathing rate, muscle tone, core temperature and blood pressure all decrease. REM sleep is important for cognitive restoration and is associated with changes in cerebral blood flow, increased cortical activity, increased oxygen consumption and cortisol release 16 Issue 4
What affects a patient’s sleep?
The individual, their health condition and responses ▶▶ Their normal sleep pattern. ▶▶ Current condition. ▶▶ Co-morbidities. ▶▶ Pain and discomfort. ▶▶ Anxiety. ▶▶ Pre-existing sleep disorders, such as apnoea. ▶▶ Age. ▶▶ Cultural needs, including whether sleeping in an environment with strangers or with people of other genders is appropriate. Therapies ▶▶ Medications (e.g. steroids, diuretics). ▶▶ Indwelling devices (e.g. catheters, IV devices). ▶▶ Equipment (alarms, mechanical noises). ▶▶ Care interventions. Environment ▶▶ Temperature, such as air-conditioned rooms. ▶▶ Noise. ▶▶ Disturbances. ▶▶ New environments, including hospital beds. ▶▶ Light. ▶▶ Presence of others in single or multi-bed rooms. with alterations in heart rate, temperature, blood pressure and breathing rate. Most muscles become atonic during REM sleep. Increased cerebral blood flow is thought to aid memory storage, learning and concentration2. All sleep stages are important to health; however, when unwell and in an unusual environment such as a hospital ward, individuals’ sleep patterns change in multiple ways, including with reduced sleep depth, increased sleep fragmentation, including more arousals, awakenings and limited REM sleep. A list of the factors that may disrupt a patient’s sleep cycle is included in Box 1.
“Nurses’ perceptions are highly unreliable, with nurses overestimating the perceived sleep quality. It also results in the ‘appeared to sleep well’ record commonly seen in clinical notes.”
Inadequate sleep – its effects Sleep deprivation, either acute or chronic, causes a stress response that disrupts the key hormone release cycles normally linked to circadian rhythms, including the early evening melatonin release, the latenight release of growth hormone and the peak of cortisol release soon before waking naturally2 (see Table 1). These effects of sleep deprivation and the stress response combine to contribute to poor health outcomes. Those outcomes include increased length of hospital stay, increased morbidity including nosocomial infections, and hospital-acquired injuries such as pressure injuries, poor wound healing, and mortality2,5,7. Specifically for hospitalised elders, these outcomes increase the risk of needing residential care post-discharge9.
Modifying the sleep environment As shown in Box 1, many factors impact on sleep, and some are potentially modifiable by either the individual or the institution. Research findings about sleep quality are consistent, with around 30 per cent of hospital patients reporting unsatisfactory sleep12. Firstly, patients’ sleep is often disrupted. In one study9, patients woke about 13 times per night. Secondly, sleep
Professional Development Learning activity
duration is short – about 3.75 hours per night in one study9. Thirdly, disruptions often mean that patients are woken midsleep cycle (of about 90 minutes). There is the potential for patients to then experience disorientation (sleep inertia), depending on the stage of sleep from which they were awoken, the amount of sleep that they have had and the time of day they are woken13. Patients attempt to catch up on sleep during the day but this is largely unsuccessful6. However, research findings about other factors are more nuanced and contextual, such as the impacts of light and type of noise on sleep, the differences between sleeping in a single or multi-bed room, and even how much the hospital bed affects sleep9,14. There is, however, much interest in how the environment can be modified and a number of approaches are being tested internationally. While many single approaches, such as ‘quiet times’ are tried, the most successful approaches are those that are whole-of-system, including consideration and management of all the work and of all the staff who affect what happens at night time in a ward or
unit14. Successful approaches include a combination of the following activities: 99Agreed ‘quiet times’ when disturbances are limited and routine care activities are put on hold if possible. Those times are usually between 10pm and 6am. 99Lights automatically dimmed corresponding with quiet times. 99Shifting of the times for ‘routine’ cares and vital signs recording throughout the 24-hour period to limit disruptions at night. 99Reducing the prescription of medications given during quiet times, or shifting the times for administration (e.g. intravenous antibiotics). 99Limiting the administration of medications known to inhibit or impact on sleep to earlier in the day. 99Monitoring noise in corridors, with warning lights when a threshold is breached. 99Assessment and care planning so that patients who want to settle first at night are settled first. 99A night-time routine, including quiet music, lights gradually dimming.
99Care with the use of sedatives. 99Grouping of cares overnight 9,10,14.
Personalising sleep interventions Individualised approaches to promoting sleep have also been researched. Interestingly, while individual patients may respond positively to these approaches, the evidence is quite weak and more research is needed11. The current evidence is strongest for massage, acupuncture, music, and natural sounds 5,11 , and weak for ‘sleep hygiene’ (good sleep habits) and relaxation approaches11. However, there is also the opportunity for hospitalised patients to receive information at this time to aid their sleep at home.
Assessing sleep Considering how important sleep is to healing and recuperation, attention to assessment of a patient’s sleep pattern is important. While sleep measurement is complex and reliant on tools such as EEG, sleep assessment includes understanding the person’s baseline sleep pattern and how the patient perceives their own
Some effects of sleep deprivation on body systems2,5-11 Selected body systems Signs/symptoms/conditions associated with stress responses Cardiovascular
▶▶ Arrhythmias ▶▶ Hypertension
▶▶ Impaired glucose tolerance and reduced insulin sensitivity ▶▶ Type II Diabetes ▶▶ Obesity ▶▶ Catabolic state ▶▶ Muscle loss
▶▶ Delayed wound healing ▶▶ Increased susceptibility to infections, including colds and influenza ▶▶ Decreased respiratory muscle endurance and response to hypercapnia
▶▶ Insomnia ▶▶ Sleepiness ▶▶ Fatigue ▶▶ Poor memory and concentration ▶▶ Acute delirium ▶▶ Confusion and disorientation ▶▶ Increased sensitivity ▶▶ Pain ▶▶ Noise ▶▶ Hyperalgesia ▶▶ Dysregulation of emotional responses ▶▶ Irritability ▶▶ Mood swings ▶▶ Short temper ▶▶ Visual disturbances and hallucinations
▶▶ Reduced postural control ▶▶ Falls nursingreview.co.nz Issue 4 17
Professional Development Learning activity sleep quality, questions about which are included in every nursing assessment. Standardised sleep assessment tools that are often only used in research could be used in everyday clinical practice12. These tools could replace nurses’ perceptions that are the most common assessment method. Nurses’ perceptions are highly unreliable, with nurses overestimating the perceived sleep quality8,12,15. It also results in the ‘appeared to sleep well’ record commonly seen in clinical notes. One easy-to-use tool that, to date, has been mainly used in critical care units, the Richards-Campbell Sleep Questionnaire, includes five separate line measures of: ▶▶ Sleep depth (light-deep) ▶▶ Sleep latency (delay in falling asleep – fell asleep almost immediately) ▶▶ Awakenings (awake all night – awake very little)
▶▶ Returning to sleep (when woken or waking, couldn’t get back to sleep – got back to sleep immediately) ▶▶ Sleep quality (a bad night’s sleep – a good night’s sleep). When used in research, another question is added related to the noise level in the environment15. Importantly, this tool requires patient self-report and is therefore a more valid measure of sleep.
Conclusion The impacts of restful sleep cannot be overestimated and nurses are in a unique position to both monitor and promote sleep in institutional settings and to also support individuals at home. Patients who experience sleep deprivation exhibit poorer health outcomes, some of which are preventable, and identifying poor sleep and its causes are important steps
in improving sleep health. There is much potential in a multi-pronged approach to modifying the sleep environment, combined with better use of assessment tools.
About the authors: ▶▶ Lesley Batten RN PhD is a senior researcher at Massey University, Palmerston North. ▶▶ Claire Minton RN MN is a lecturer and PhD candidate at Massey University, Palmerston North.
This article was peer reviewed by: Sally Powell RN MHSc (Clinical), a clinical nurse specialist in sleep health at Canterbury District Health Board’s Sleep Unit. Karyn O’Keeffe PhD, a research fellow and sleep physiologist at the Sleep/Wake Research Centre, Massey University. Recommended resources ▶▶ The Memorial Sloan Kettering Cancer Centre website provides self-help information for patients about how to improve their sleep during their hospital stay: www.mskcc.org/cancer-care/ patient-education/improving-your-sleepduring-your-hospital-stay. ▶▶ The Australasian Sleep Association has resources for health professionals on sleep disorders: www.sleep.org.au/ professional-resources/health-professionalsinformation. ▶▶ The Sleep Health Foundation Australia has resources for patients and health professionals on sleep health and sleep disorders and their management: www.sleephealthfoundation.org.au.
References 1. NIGHTINGALE F (1860). Notes on nursing.
7. RADTKE K, OBERMANN K, & TEYMER L
12. HOEY L, FULBROOK P, & DOUGLAS J (2014).
(2014). Nursing knowledge of physiological and
Sleep assessment of hospitalised patients:
psychological outcomes related to patient sleep
A literature review. International Journal of
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nursing/nursing.html 2. CRAFT J, GORDON C, HUETHER S, MCCANCE K,
8. RITMALA-CASTREN M, LAKANMAA R, VIRTANEN I, & LEINO-KILPI H (2014). Evaluating adult
13. TROTTI LM (2016). Waking up is the hardest thing I do all day: Sleep inertia and sleep drunkenness.
BRASHERS V, & ROTE N (2015). Understanding
patients’ sleep: An integrative literature review
Sleep Medicine Reviews http://dx.doi.org/10.1016/j.
pathophysiology. Mosby: Sydney.
in critical care. Scandinavian Journal of Caring
3. SCHWARTZ JRL, & ROTH T (2008). Neurophysiology of sleep and wakefulness: Basic science and clinical implications. Neuropharmacology 6, 367-378. 4. SILBER, MH (2012). Staging sleep. Sleep Medicine
Clinics 7 (3) 487-496. 5. SU C-P, LAI H-L, CHANG E-T, YIIN L-M, PERNG S-J,
Sciences 28, 435-448. doi: 10.1111/scs.12072 9. MISSILDINE K, BERGSTROM N, MEININGER J, RICHARDS K, & FOREMAN M (2010). Sleep in hospitalised elders: A pilot study. Geriatric Nursing 31(4) 263-271. 10. BARTICK M, THAI X, SCHMIDT T, ALTAYE A,
14. FILLARY J, CHAPLIN H, JONES G, THOMPSON A, HOLME A, & WILSON P (2015). Noise at night in hospital general wards: A mapping of the literature.
British Journal of Nursing 24(10) 536-540. 15. KAMDAR B, SHAH P, KING L, KHO M, ZHOU X, COLANTUONI E, COLLOP N, & NEEDHAM
CHEN P-W (2012) A randomized controlled trial of
& SOLET J (2010). Decrease in as-needed sedative
D (2012). Patient-nurse interrater reliability
the effects of listening to non-commercial music
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questionnaire. American Journal of Critical Care
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11. HELLSTRÖM A, FAGERSTRÖM C, & WILLMAN A
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Medicine 31(1) 14-23. Doi 10.1177/0885066614538749
2648.2012.06130.x 6. PULAK L, & JENSEN L (2016) Sleep in the intensive
18 Issue 4
Professional Development Learning activity
Professional Development Learning Activity
Learning outcomes ▶▶ gain an understanding of the current knowledge of the physiology of sleep and its association with illness and healing ▶▶ consider steps to enhance patient sleep, including identifying poor sleep quality and advising patients on steps they can take to improve their sleep, and considering the institutional environment for sleep, therefore potentially improving health outcomes.
Reading the article ‘Appeared to sleep well’: How much sleep has your patient had and why does it matter? and undertaking this learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council of New Zealand16 competencies 1.4, 1.5, 2.1-2.4, 2.6, 2.8-2.9, 3.2, 4.1-4.3. Please discuss all your answers with your peer/s. A
Watch the short YouTube clip by Claudia Aguire, ‘What would happen if you didn’t sleep’ at www.youtube.com/watch?v=dqONk48l5vY.
Review the Australasian Sleep Association website for information for health professionals on sleep disorders, including those related to shiftwork. Visit www.sleep.org.au/professional-resources/health-professionals-information.
Reflect on how you ask patients about their sleep.
How is that information shared at nursing hand-over?
Review the ward/unit/hospital guidelines on promoting a healthy sleep environment. a. What information does your organisation and staff provide to patients to help them self-manage their sleep while they are in hospital? b. Could this information be improved and how? c. Do you know what services and referral pathways might be available for people in your region with a potential sleep disorder?
Identify a resident/client/patient in your service who you think might not sleep well. Obtain the required permissions to review the individual’s nursing assessment and care plan. a. What strategies are documented to aid this person’s sleep?
Talk to one or two patients about their sleep quality, depth, latency, awakenings, and returning to sleep. a. What was most disruptive and what did or would assist them to sleep better? b. What is currently recorded in the patient’s care plan? Update this if necessary.
Verification by a colleague of your completion of this activity Colleague name
Nursing council ID
Contact # nursingreview.co.nz Issue 4 19
Professional Development Delegation skills
Direction and delegation:
when it goes wrong
Bad direction and delegation can impact on both patient safety and nursing careers. As part of Nursing Review’s focus on the topic, Margaret Hughes shares how to develop the skills involved and cites an example of when the delegation of a nursing activity went wrong.
any nurses are confused about direction and delegation roles. Registered nurses worry they’ll get into trouble if the person they delegate a nursing activity to ‘mucks up’. Enrolled nurses (or health care assistants) worry what will happen if they turn down a task they think is outside their skill set. Looking at the Nursing Council’s Guidelines: responsibilities for direction and delegation of care to enrolled nurses is a useful starting point for discussing what is actually required for good direction and delegation. And who is responsible for what. The 2011 guidelines are by necessity broad-brush as they cover both registered and enrolled nurses’ responsibilities across the diversity of nursing workplaces. (Similar guidelines were also released in 2011 for delegating to unregulated health care assistants (HCAs). The guidelines provide definitions (see box) of direction, delegation and accountability, and list a number of responsibilities required of both registered and enrolled nurses (RNs and ENs), and employers during delegation. Accountability is clearly defined in the guidelines as “being answerable for your decisions and actions”. In the guidelines, 20 Issue 4
and also in the enrolled nurse scope of practice, it states that the enrolled nurse is “accountable for their own nursing practice”. (Likewise the Nursing Council’s HCA delegations make clear the HCA is accountable for their own actions.) But despite no guideline or nursing document in New Zealand stating that an RN is responsible for a delegated EN’s nursing practice, many RNs continue to believe that they are. At the same time, the enrolled nurses’ scope states that the RN maintains responsibility for the overall “plan of care”. But there is a lack of recognition that RNs are responsible for the way that direction and delegation is initiated and managed (as direction or delegation may be part of the overall “plan of care”). This can create confusion for nurses who are told in their respective scopes of practice that they are required to direct or delegate, or be directed or delegated to, but are unsure how exactly to carry out this role. This is especially true for new, inexperienced RNs who are required to delegate to highly experienced ENs, casual and agency RNs unfamiliar with the specialised ward they have been sent to, and new inexperienced ENs emerging
on to the employment scene in greater numbers expecting to be directed, or delegated to. Some of the direction and delegation assessments required of the RN include the need to “assess the health status of the health consumer, the complexity of the nursing intervention required, the context of care, and the level of knowledge, skill and experience of the enrolled nurse” (Nursing Council of New Zealand, 2011, p. 8). However, the EN’s role during these assessments is not covered in the guidelines. The story in the following sidebar is a true account of an experienced EN who is sent to an unfamiliar ward due to overstaffing in her own workplace. The story illustrates what can happen when the art of delegation goes wrong because the skills and attributes required for ‘good’ delegation are not known (or used). So instead, delegation just becomes an allocation of tasks.
The art of assessment The advanced communication and, more importantly, listening skills required by registered nurses to assess the knowledge and skills of an enrolled nurse (or HCA) they are delegating to are part of the art
Professional Development Delegation skills
of ‘good’ delegation, along with the ability of the enrolled nurse (or HCA) to selfassess their own competence to take on a delegated activity or task. Deanna’s story (see sidebar) shows that an essential element for ‘good’ delegation practice is registered nurses understanding that enrolled nurses are responsible for self-assessing their own knowledge and skills and for saying ‘no’ if they are unsure of the delegated task or do not feel comfortable or safe to carry it out. A poor understanding of the rights and responsibilities of delegation can lead to confusion and poor outcomes for the nurses involved. However, how an RN should carry out this professional competency – in particular the swift assessments required before delegating and directing a nursing task – are not included in any guidelines on direction or delegation in New Zealand. Nor are the advanced self-assessment skills required of the ENs. When registered nurses do not understand these roles and do not make the required assessments before delegating, there can be negative consequences for the patient, such as the EN carrying out unfamiliar and therefore unsafe tasks. There is also an ambiguity related to lines of accountability in the guidelines, and there is no advice or discussion about the RN’s role in leading the direction or delegation interaction. The impact of a lack of leadership, and confusion about the direction and delegation role, are magnified when there is poor communication. Poor communication and confusion about roles and responsibilities can lead to a reluctance to be directed or delegated to, or to direct or delegate. A lack of direction
or delegation interactions means that both registered and enrolled nurses could be working outside their scopes of practice.
Summary The art of direction and delegation is a delicate balancing act between ensuring a thorough set of assessments are carried out, leadership of the delegation interaction is provided, and that there is good communication. These skills and abilities are required in busy nursing workplaces where there are many decisions needed. The consequences of getting it wrong can impact negatively on the patient on the receiving end of the direction or delegation decision – and on a nurse’s registration. To master the art of direction and delegation, nurses need time to carry out assessments, to learn about direction and delegation, and time for their leaders to support their access to direction and delegation information and advice. AUTHOR: Margaret Hughes explored registered and enrolled nurses’ direction and delegation communication practices in New Zealand for her PhD thesis (see p. 26). She is a senior lecturer at Ara Institute of Canterbury’s school of nursing.
Direction or delegation? Direction is the active process of guiding, monitoring and evaluating the nursing activities performed by another. Direction can be provided directly or indirectly. Delegation is the transfer of responsibility for the performance of an activity from oneperson to another, with the former retaining accountability for the outcome.
Recommendations ▶▶ Separate guidelines for registered and enrolled nurses that clearly explain who is accountable and for what (including the registered nurses’ role in leading the delegation interaction). ▶▶ Guidelines make clear that an enrolled nurse has the right and the professional responsibility to self-assess and decline to do a delegated task. ▶▶ Guidelines include advice on inclusive and respectful communication strategies required by registered and enrolled nurses during the direction and delegation relationship. ▶▶ Workplace-specific information about direction and delegation roles and responsibilities would be a useful addition to the nursing tool box (see related story in Leadership & Management on p. 26).
Deanna’s story – a true account Deanna* had been transferred to an unfamiliar ward because the ward was short of staff. Being shifted between wards had happened many times in her 40-year nursing career, but this shift turned about to be slightly different. The lack of welcoming to the ward and the lack of consultation about the tasks Deanna was ‘instructed’ to do were the start of an unpleasant and anxious time for her. On arrival the RNs told her they had really wanted an “IVed” registered nurse, “not an enrolled nurse!” They then assigned her a set of tasks to carry out saying that “at least you can be another pair of hands”. Deanna explained that she did not feel confident doing the tasks they were asking of her as she had not worked in this specialty nursing workplace before. The delegating RN became angry and accused her of “being difficult”. That evening the RNs got together to write a formal complaint about her poor performance. The charge nurse of the ward in question – new to her position and unfamiliar with delegation – had not supported Deanna’s right to self-assess and to decline to do the delegated tasks. The complaint from the RNs about her was upheld and there were further meetings and repercussions that“really knocked her confidence”.
The avoidable and unpleasant situation was hard for her to come back from and made her question if she wanted to continue in nursing. Deanna knew and understood that she had a responsibility to say ‘no’ if she felt that the task being asked of her was outside her skill level, training and confidence, but the charge nurse and the registered nurses who had written the complaint, did not. It wasn’t until many weeks later that she realised how the lack of being welcomed on to the ward, and being referred to as “another pair of hands” had devalued and affected her. Deanna explained that she had worked with many RNs who had shared their knowledge with her and supported her to be a contributing member of the team. “We’re not just here for ourselves you know. We’re here to help others, so anything or anyone who helps me do this is respected by me.” She believed that ENs needed to be assertive and know how to politely and diplomatically say ‘no’ to a delegated task when required so that they did not take on tasks that were unsafe for the EN, and therefore the patient. However, there needed to be a respectful and inclusive communication approach from RNs too. *not her real name nursingreview.co.nz Issue 4 21
Innovation & Technology
Health Navigator App of the Month
My Asthma App (patient education and action plan app)
WEBSCOPE Keeping abreast of nursing issues and evidence-based practice around the world is the focus of this edition’s website recommendations from Kathy Holloway. Online Journal of Issues in Nursing http://nursingworld.org/ojin Keeping yourself informed of global nursing issues is made easier by accessing this American-based online journal published three times per year. The Online Journal of Issues in Nursing (OJIN) is a free, peerreviewed, international, full-text, online publication that addresses pertinent topics affecting nursing practice, research, education and the wider healthcare sector. Both Medline and CINAHL index the journal. The latest topicHealthcare Reform: Nurses Impact Policy (available from 30 September) will be of great interest to many nurses. Past topics include issues such as global health concerns, barriers to the RN scope and the patient experience. [Site accessed 6 August 2017 and last updated May 2017].
National Institute for Health and Care Excellence (NICE) www.nice.org.uk With the increasing amount of information available online, this UK site provides a portal to quality resources for evidence-based practice to improve health and social care. The National Institute for Health and Care Excellence (NICE) is an independent organisation responsible for providing national guidance on treatments and care for people using the National Health Service in England. Their guidance is intended for healthcare professionals, patients and their carers to help them make informed decisions about treatment and healthcare. NICE provides this guidance across three main areas: ▶▶ Producing evidence-based guidance and advice as interactive flow charts. ▶▶ Developing quality standards and performance metrics. ▶▶ Providing evidence services across the spectrum of health and social care. While it is important to remember that guidelines, procedures and appraisals developed within one context do not necessarily translate to Aotearoa, there is significant merit in considering the work that others have done. [Site accessed 5 August 2017 and last updated 4 August 2017]. Author: Dr Kathy Holloway is director of Victoria University’s Graduate School of Nursing, Midwifery and Health. 22 Issue 4
app Overview ▶▶ Clinical score Pending ▶▶ NZ relevance NZ developed app ▶▶ Technical score ▶▶ User score Pending ▶▶ Formal review (MARS) 4.2 out of 5 ▶▶ Availability Free for Apple & Android
he New Zealand-developed app provides asthma information, the ability to create a digital asthma action plan and a step-by-step guide to giving asthma first aid. The app was launched by the Asthma and Respiratory Foundation NZ and the asthma information on signs, triggers and treatments includes links to downloadable documents and pages on the foundation’s website. It also provides users with a digital template they can work through with their nurse or doctor to develop an asthma action plan that matches the medication and treatment required for different peak flow levels and symptoms ranging from ‘feeling good’ to ‘severe’ or ‘emergency’. The app also links to an external website where users can take an asthma control test. PROs include: Engaging and appealing design. Asthma action plan can be shared as an email attachment with family members and sport coaches, etc. CONs include: Only has generic, not real, images of commonly used inhalers. Doesn’t feature symptom tracking or reminder settings.
Full app review at www.healthnavigator.org.nz/ app-library/m/my-asthma-app/ For more information www.asthmafoundation.org. nz/your-health/living-with-asthma/asthma-app The NZ App Project: Health Navigator, a nonprofit 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 email@example.com.
Innovation & Technology
Surviving a DHB IT meltdown What do you do when your IT system crashes, leaving two hospitals and a community service without access to electronic health records, emails, the internet, voicemail… FIONA CASSIE talks to Lakes DHB director of nursing and midwifery Gary Lees about leading the way through a DHB IT crisis.
ary Lees arrived fresh and early to work on Monday 17 July after a week’s leave, only to be greeted in the corridor by the chief operating officer sharing that “there had been a bit of a disaster” and there was a briefing in his office at eight o’clock. The “bit of a disaster” was a fire in the wee hours of that morning in Lakes DHB’s main computer server room in the Rotorua Hospital site. The fire had started in the, somewhat ironically named, uninterruptable power supply (UPS) that had more than interrupted the DHB’s IT system – all electronic services served by that main computer server were out
of action, leaving the Rotorua and Taupo hospital sites and community service teams without access to electronic patient management systems, the internet, email or even voicemail. As a result, everybody was about to start the new week with blank screens. Lees says everyone in the DHB’s executive team is trained to operate within the CIMS (coordinated incident management system) structure but he has a special interest and had just recently completed a postgraduate diploma in emergency management at AUT. So when it was agreed that a formal emergency operation centre was needed, the DHB’s
director of nursing and midwifery volunteered to become incident controller, set up an emergency control centre and called the first of the three-hourly incident meetings for 9am. The situation was fairly grim. How long it would take to get ‘all systems a go’ again was a big unknown. Meanwhile two hospitals had to continue safely. “We couldn’t get anything to come up on any computer screen anywhere in the system,” says Lee. People could phone each other, but couldn’t leave voicemail messages, and there was no intranet or access to the electronic management systems that staff now took for granted. nursingreview.co.nz Issue 4 23
Innovation & Technology
In all, 54 software products used by DHB clinical and administration staff were unavailable, including electronic meal ordering. Lees says that on the good news front the laboratory was on a different computer system so blood reports were still available and also radiology could still do scans and imaging so those diagnostic tools weren’t affected. The problem was how to share results and information that people were now accustomed to receiving and storing electronically. The DHB’s business continuity plan meant it already had on-hand templates for paper versions of all the electronic forms commonly used by the DHB. The team quickly got a laptop and printer to work printing off templates; IT staff were sent running about the hospital to set up ward printers to be used as photocopiers, and the communications officer was set up to be able to write and print staff bulletin updates. Lees says by about 10am the hospital had switched into paper mode and was tracking admissions and discharges on paper, as well as taking meal orders. 24 Issue 4
To get paper from A to B and back again – and keep staff updated – the incident team ramped up the existing internal post system by bringing in more runners, including nurses in roles such as nurse educators, who could be pulled out of their normal duties to help out during the IT crisis. Fortunately the DHB’s patient records were not fully digitised, so it had paper files containing paper copies of most, if not all, the patient information and reports held electronically up to the time of the outage. Lees says it was also lucky that the medical records office was in the habit on Friday afternoons of printing off the electronic theatre and outpatients list for the first days of the following week, so the DHB had paper lists of who was due to present and made the clinical decision to postpone some surgery and appointments until the impact of the outage was clearer. The emergency department was a clinical priority so it was loaned the incident control team’s stand-alone wifi hotspot, which can connect up to six laptops or tablets, so that it could access national systems to check or create NHI (National Health Index) numbers.
Also supporting ED was the “absolutely brilliant” primary health organisation, Rotorua Area Primary Health Services, which turned up at ED with some of its own computer equipment, allowing ED staff to regain their usual access to GP patient records, but directly via the PHO’s network. The DHB’s pharmacy found its own quick fix by logging in to Taranaki DHB’s ePharmacy system using a mobile phone, the 4G network and a laptop, so it was quickly back dispensing medicines as normal. Lees says that staff in other areas popped home and got their laptops and printers. He expects a number also used personal mobile data and devices to access clinical apps or support systems – improvisation was the order of the day.
Getting back on track Day one had started with some clinical concern and uncertainty about attempting business as usual in the midst of an IT outage, says Lees. But by midday people were “much happier”. By the end of that first day the two hospitals were functioning, slowly and with some inconvenience – and with some inevitable concern about missing
Innovation & Technology
With the health system nationwide moving steadily towards full electronic health records, the Lakes outage has highlighted the vulnerability of a health service being reliant on a single-server site.
something stored electronically – but overall Lees said there was an “amazing response” by everyone. “We were so, so pleased with how the nurses, allied health, doctors, support staff and admin people all pulled together.” By Tuesday, surgery and outpatients were basically back to normal and the hospital’s free public wifi system, provided by an external company, was up and running. It wasn’t secure so it couldn’t be used for transferring patient data, but it did give staff with mobile devices and laptops free access to the internet, and the DHB’s external website could be used to share outage updates. While the emergency control centre worked on keeping the hospital up and running under a paper-only regime, the specialist IT team was swiftly seeking expert advice on how best to get the IT system’s backup running. The DHB had to track down and fly in forensic cleaning experts to clean up the smoke and soot in the server room and it had to find, hire and install a replacement UPS. This meant IT staff working round the clock, and neighbouring DHBs lent IT and emergency planning staff to share the load.
The first time the switch was flipped on the replacement UPS, the airconditioning failed and the DHB had to wait another 24 hours to get replacement parts to ensure that the room had the consistent temperature and humidity control required by the sensitive server equipment. The IT team also started working on setting up a backup secondary server to run a skeleton IT system and was on standby to redeploy 50 desktop computers or laptops – to replace computer monitors that couldn’t run without the main server – to every ward or outpatient clinic room to run the patient management system. Fortunately, when the switch was flipped again on the Wednesday night, the full system came back to life. With the health system nationwide moving steadily towards full electronic health records, the Lakes outage has highlighted the vulnerability of a health service being reliant on a single server site. Having a backup server offsite in theory sounds a good idea, but Lee says he was told that there was about $2 million of IT ‘kit’ in the server room so duplicating that wasn’t an option for small DHBs. And also it wasn’t the server itself that failed – all data was safely backed up and not at risk of being lost – it was the loss of a guaranteed uninterrupted power supply to the server that was the major issue. (Not taking the risk of plugging the server straight into mains power was brought home that week by a storm cutting power to Rotorua homes and creating a power spike big enough to have blown everything in the server room.) The July IT outage has prompted Lakes to speed up joining the regional data centre being developed in Hamilton for the Midland region DHBs. This is part of the national infrastructure platform that aims to increase the security and reliability of DHBs’ IT infrastructure and reduce the risk of critical outages.
“Business as usual” Everyone involved was relieved that the outage lasted just three inconvenient and challenging paper-shuffling days. Returning to “business as normal” turned out to be, however, not just a matter of successfully flipping the switch. Electronic patient management systems were up and running on the Thursday, but patients who had been admitted on paper couldn’t be discharged electronically until somebody manually uploaded the
information from the paper admission forms. This meant that paper discharges had to continue until the hospital caught up with inputting the backlog of paper forms. Hiccups emerged when staff inputting the forms discovered gaps in the information – that electronic templates would normally prompt nursing or clerical staff to complete – and these gaps were time-consuming to fill once the patient was long gone home. This has prompted another lesson learnt for Lees, who says if ever Lakes had to revert to paper forms again it would set up a small team to check over filled-in forms immediately and send them straight back if gaps were spotted. Lees and the incident control team finally handed over to a recovery manager at 2.30pm on the Thursday after an intense and challenging three and a half days. Time to take a deep breath… and catch up on all those emails that spilled into his mailbox after Lakes rejoined the digital world.
ADVICE and LESSONS LEARNED
▶▶ Have a business continuity plan – even if the reality is different, having worked through different ways of responding to emergencies is invaluable. ▶▶ Use a CIMS (Coordinated Incident Management System) approach right from the beginning of a major incident – don’t think you can manage it with your normal processes. ▶▶ Set up a system so you can save and still access electronic surgery and outpatient client lists if an outage occurs. ▶▶ Keep paper templates of electronic forms up to date and consider having a stockpile of pre-printed paper forms. ▶▶ Consider knowing how many standalone desktop computers and laptops you can deploy i.e. that aren’t reliant on the main server to operate. ▶▶ Have more than one stand-alone wifi hotspot device on-hand for emergencies. ▶▶ Move the UPS (uninterrupted power supply) outside of the server room to remove the risk of a fire in the UPS damaging the server. ▶▶ Big picture – pursue shifting to regional IT data and infrastructure models sooner rather than later to increase security and reduce the risk of critical local outages disrupting electronic services. nursingreview.co.nz Issue 4 25
Leadership & Management Delegation support
“Utter confusion” around direction and delegation
PhD researcher Margaret Hughes talks to Nursing Review about how leaders and managers can help nurses who are struggling with direction and delegation.
n busy wards every day, rapid decisions are being made to delegate patient care into another’s hands When PhD researcher Margaret Hughes interviewed registered nurses and enrolled nurses about direction and delegation roles, she found “utter confusion”. But that confusion only becomes visible, she says, if a delegation of patient care goes “horribly wrong”. Hughes’ qualitative research involved indepth interviews with 36 nurses – 17 registered nurses and 19 enrolled nurses – across a range of settings and from the inexperienced to the very experienced. She concluded that gaps in the Nursing Council’s direction and delegation guidelines need to be filled and aspects of the delegation process should be made more overt.
26 Issue 4
“The strength of the guidelines is that they are broad, but that is also their downside,” says Hughes. “And very few nurses actually read them as they don’t provide the practical help nurses are seeking.” She says all the nurses she spoke to wanted more training and support from their leaders on how to direct and delegate. Hughes says the current workforce includes a generation of registered nurses (RNs) who rarely worked with enrolled nurses (ENs). So the arrival on wards and other healthcare settings of a new cohort of ENs – plus health care assistants (HCAs) with variable skillsets and qualifications – exposes skill gaps in direction and delegation. As one RN she interviewed put it: “We are just supposed to know this stuff by osmosis.” Hughes says her findings highlight not only the confusion around the different roles in the direction and delegation relationship, but also the need to overtly state that ENs (and likewise HCAs) have the right and responsibility to self-assess and decline a delegated nursing task if they believe they can’t do it safely. The confusion could be reduced, believes Hughes, by leaders and managers providing workplace-relevant information and training on how to carry out ‘good’ direction and delegation. Some of her suggestions for useful additions to the
nursing tool box in this area include looking at communication strategies, how to quickly assess or self-assess an EN’s or HCA’s skills, and providing clear, workplace-relevant guidelines on who is responsible for what.
Not just an allocation of tasks: good communication needed Respectful communication is essential for developing a good direction and delegation relationship, says Hughes. A harried nurse standing hands on hips in the corridor telling an EN or HCA to “go do this” or “go do that” is neither good communication nor a respectful relationship. Hughes’ research shows that for delegation to be successful it needs to be a relationship rather than just one person issuing a set of instructions to another. And communicating professionally and well is crucial, otherwise the relationship can break down and patient safety suffers as a result. Providing staff with training in respectful and inclusive communication styles and strategies is therefore important, says Hughes – including the basics such as what tone to use, and avoiding body language like hands on hips.
Leadership & Management Delegation support
“I know nurses are busy; you are tired and you are running, but if you don’t get the communication right you have a communication breakdown and that puts the patient at risk.”
Speedy assessments required In a busy ward the delegation of patient care can by necessity happen very quickly. A lot needs to happen in that short time including, according to the Nursing Council guidelines, the RN assessing “the health status of the health consumer, the complexity of the nursing intervention required, the context of care, and the level of knowledge, skill and experience of the enrolled nurse”. At the same time, though not stated, the EN (or HCA) needs to selfassess whether they currently have the skill and experience to do the task or tasks asked of them. Hughes says during her interviews it became clear that nurses want guidance from their leaders and inservice education on performing this quick but very important assessment role. If the RN and EN (or HCA) has a longstanding working relationship, this assessment may be relatively simple. But when staff are new, inexperienced or – as increasingly happens under the Care Capacity Demand Management system – have been sent to help out in an unfamiliar ward or service, they may have to start that relationship from scratch. Hughes says the first rule is to ask and not assume anything, which sounds obvious, but her research showed it wasn’t happening. “Just because the enrolled nurse looks older – don’t assume they are experienced, as they may have just graduated.” Likewise, because an EN or HCA is able to perform a task in a surgical setting, don’t assume they are skilled enough to do it in a spinal unit or mental health service. RNs also need to make sure they are asking in an environment where the EN or HCA doesn’t feel too intimidated to say, “I’m really sorry but I can’t do that”. “But I’ve come across examples of RNs putting their hands on their hips and asking (in a scathing tone) ‘so what can you do?’” says Hughes. “And if an EN or HCA doesn’t feel safe to say they aren’t skilled enough for a certain task then that impacts on patient safety.” Of course, says Hughes, an EN or HCA can’t just continue to say “I can’t do this” as it will eventually become an employment issue. But there is also an onus on the clinical nurse management team to provide training opportunities so an EN or HCA can upskill, as well as provide
clear role descriptions for staff, based on their scopes. In addition, employers are responsible for ensuring the right skill mix to provide safe patient care and for ensuring that RNs are supported and sufficiently competent to safely delegate care and that ENs and HCAs understand their delegated roles and responsibilities.
Dedicated training and planning tools could be useful Developing an e-learning tool dedicated to training nurses in the knowledge and skills needed for direction and delegation would be very useful, believes Hughes.
“I know nurses are busy; you are tired and you are running, but if you don’t get the communication right you have a communication breakdown and that puts the patient at risk.” Similar training programmes have already been developed in district health boards around the country to teach the handover or communication tool ISBAR (introduction/identify, situation, background, assessment, request/ recommendation – also known as SBARR or SBAR). She says such a tool needs to go beyond the current delegation guidelines and should cover areas like handy hints on collaborative communication, guidance on how to assess and self-assess skills, and making clear the responsibilities of each party to a delegation relationship. These include making clear that an RN is not responsible for the nursing practice of the enrolled nurse (or an HCA’s actions) but is responsible for the way that direction and delegation is initiated and the patient’s overall plan of care. Similarly, the EN or HCA is responsible for self-assessing and declining a task that they don’t have the skill or experience to undertake safely. Depending on the model of care, the development of suitable planning tools could also be useful. Hughes says she spoke with one RN who had experienced a planning tool used in an Australian hospital where the RN and EN worked through a patient’s care plan together to
decide who was best suited to perform each listed task, and then ticked them off as they were completed. Hughes acknowledges that having good direction and delegation all takes time and, while the Nursing Council recommends employers factor time into a nurse’s workload to safely delegate care, this doesn’t always happen. “The RN has got to slow down and take the time to quickly – in seconds – assess the EN (and find a replacement if the EN is not able to do it). And also take the time to make sure that the tone, and what, and how she is saying things is collaborative. Also time for the EN to self-assess, do the job, and report back to the RN. All of this takes time.” Hughes says you could argue that expecting nurses to find the time to do delegation properly is just “pie in the sky”. “But actually there were two patient deaths just in the course of this research and many, many examples of lack of patient dignity, like patients wetting beds as their bells weren’t answered,” says Hughes. “That is not acceptable and it goes totally against the Bill of Rights.” All nurses she spoke to want to do it better to ensure they keep their patients safe. “It’s the how to do it that they are asking for.”
Recommendations for nurse leaders to improve direction and delegation skills ▶▶ Enrolled nurses (and healthcare assistants) must be given time to quickly self-assess and decline a task they are not confident to do. ▶▶ Workplace leaders supply information and training to support ‘good’ direction and delegation interactions including on assessment roles, communication styles and who is responsible for what in the interaction. Recommendations for updating Nursing Council guidelines ▶▶ The guidelines should make clear that an EN has both the right and the professional responsibility to self-assess and decline a delegated task. ▶▶ That there should be separate guidelines for registered nurses and enrolled nurses that make clear who is accountable for what in the delegation relationship and include guidance on good communication strategies. nursingreview.co.nz Issue 4 27
Leadership & Management Profile
From practice nurse to DHB nursing director Nursing Review talks to nursing leader Chris Kerr about her career journey and her switch, after 25 years in primary health, to become Hutt Valley DHB’s new director of nursing.
S Chris Kerr.
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eeing first-hand the realities of nursing on the floor in a morning, afternoon and night shift is high on the todo list for new director of nursing Chris Kerr. After nearly 25 years working in primary health – a journey that has taken her from practice nurse to chief operating officer of one of the country’s four biggest primary health organisations – Kerr knows she has some catching up to do on secondary care nursing. She is also aware that a DHB appointing a director with such a strong primary health background may be “quite unique”, but suspects she was successful because as a leader she is “very pragmatic, systems-oriented and clinically sound”. With integrated services high on the health policy agenda, her background in primary health can be seen as a strength for a nursing leadership role covering nurses across the health sector – and not just in secondary care. And she says what she doesn’t know about hospital systems and hospital nursing she is ready to learn. Kerr’s career to date certainly shows a willingness to learn. In 2000 the practice nurse leader was tapped on the shoulder to join Hora Te Pai Health Services, a new iwi provider on the Kapiti Coast. She started out as the nurse and manager of two community workers, an admin person and a voluntary, part-time GP. By the time she left nearly a decade later, the staff numbers had swelled to 17. Her latest role has been chief operating officer for Compass
Health, the primary health organisation serving the greater Wellington and Wairarapa regions. Compass Health provides not only general practice services but also a range of wider, mostly nurseled, community health services, including school-based services, outreach nursing and mental health, which Kerr managed along with integrated care development. Kerr trained at Wellington Hospital between 1980 and 1983 and nursed in women’s health until 1989, rising to acting charge nurse before taking maternity leave. She returned to nurse part-time in residential aged care nursing
“My passion and my drive is really to make a difference to people, so when these opportunities come up, I don’t hold back.” and then in an older people’s health ward, before beginning practice nursing in 1993. Along the way she also gained her postgraduate diploma in primary health. By 2000, when she was asked to become Hora Te Pai’s first registered nurse and manager, she was already a practice nurse leader, having helped to set up a new practice and mentoring nurses new to primary health. So when in 2001 the Wellington Independent Practitioners Association (WIPA) came to talk to the iwi provider about the move to primary health organisations
(PHOs) and becoming part of the new Kapiti PHO, Kerr was ready to take a leadership role. She quickly became a member of the PHO’s establishing committee, then the board, and then became its chair from 2006 to 2009, only resigning to become clinical director at Compass, which ultimately absorbed Kapiti PHO in 2010. Kerr believes she gravitated quite naturally to leadership roles. “My passion and my drive is really to make a difference to people, so when these opportunities come up I haven’t held back,” she says. “But I will always see myself as a nurse first and foremost, no matter what I do.” She acknowledges the main learning curve in the new role she started on 31 July is gaining a better understanding of the nursing workforce she leads and how the hospital works. “Finding out things like are there enough nurses at the right level and the right skill mix and the right training to be able to do what is required? Do they need nurse prescribers? What is the place of nurse practitioners within wards?” She also plans to bring her primary health experience to the fore to improve the integration of care and how the DHB can empower nurses in the community to do more, including supporting primary health nurses to work at the top of their scope. It sounds a heady time, but it’s one that Kerr is enjoying. She says her family keeps her balanced – as does a love of trail running/hillwalking (she has set herself a target of completing 21 21-kilometre races). “It’s about just getting out in nature where you can offload, clear your mind and get rid of some of the clutter,” she laughs.
Stress, understaffing and student optimism Nursing Review talks to National Student Unit chair Phoebe Webster about the “happy accidents” that led her into the role and about understaffing, nursing shortages and student optimism.
tudent nurses constantly hear and experience the impacts of nurse understaffing, says National Student Unit chair Phoebe Webster. But that hasn’t put her off her career choice. The third-year nursing student at Massey University, Wellington, is the current chair representing the 2,860-plus nursing students belonging to the National Student Unit (NSU) of the New Zealand Nurses Organisation (NZNO). Phoebe says that student nurses not only hear about but experience the pressures created by understaffing. “We experience that as student nurses because you come into a placement and you don’t know who your preceptor for the day is – and nobody knows who your preceptor for the day is,” says Phoebe. “So you are chucked in with somebody and they are stressed because they’ve got a huge patient load and they’ve got this student they have to look after. And because they are stressed, patient care isn’t probably optimal either… “ Phoebe says she has also missed out on clinical placements because of staff sickness and shortages or been warned she would have to stay late on most days as the workload was too high to be completed within normal working hours. She is also aware that the same issues are likely to arise when entering the workforce as a new graduate, leading to the risk of burnout and nurses leaving the profession. This is one of the reasons that self-care was a topic in this year’s National Nursing Survey carried out by the unit (see page XX). It is also one of the reasons Phoebe became involved in NZNO as a student nurse as she wanted to be part of helping to shape the future direction of the profession she is joining. She is also worried about the predicted nursing shortage to come – an important issue for both students and new graduates. “But I think the mood is generally optimistic amongst my cohort as we are nearly done (graduated).” The immediate concern for most third-year students was whether they would get a job next year. “I don’t know if people are thinking much further away than that, as that’s the first hurdle.” She says that, apart from that hurdle in front of them, her classmates are “pretty bright-eyed and bushy-tailed” about their choice of profession.
Career choice and chair role through “happy accidents” Phoebe doesn’t regret the series of “happy accidents” that led her into nursing and her National Student Unit role. On leaving school, nursing wasn’t even on the horizon and she did a BA at Victoria University in philosophy and religious studies. But on graduation she wasn’t sure what to do next, until an aunt pointed out that her student jobs as a nanny or a caregiver had a consistent theme of being around people, and suggested she consider nursing. Phoebe filed the idea in the back of her mind and headed off to Europe but then, while living in a van in Germany, she decided to apply. She heard she was successful while in Italy, so returned home to start her nursing training at the age of 24. “I didn’t really know what I was signing
“I didn’t really know what I was signing myself up for. But when I got there it all clicked into place and I thought ‘I’m doing the right thing’.” myself up for. But when I got there it all clicked into place and I thought ‘I think I’m doing the right thing’.” The next happy accident was when a lecturer told Phoebe’s first-year class that she was off for two days to an NZNO gathering at Te Papa and Phoebe decided to check it out herself. The curious student discovered on arrival that you can’t just roll up to a national conference on the day. However, the woman on the conference desk to whom she chatted just happened to be the National Student Unit administrator, and she suggested that Phoebe contact the current Massey University student rep, who was looking for a successor. “She gave me the lowdown and it sounded awesome,” said Phoebe. So she put forward her name and in the following January completed her delegate training to become the Massey NSU rep.
Being an NSU rep Phoebe says the rep role ranges from supporting, recruiting and advocating for students at her own school to reporting and gathering ideas from fellow reps at schools around the country at national meetings. Student membership of NZNO varies from school to school and is influenced to some extent by whether schools, like her own Massey, offer private indemnity insurance. “A lot of the time, it [membership] isn’t on a student’s radar – they are just trying to get through their studies and pass their exams,” says Phoebe. “And that’s totally understandable. It’s not real for them yet, being part of an organisation that is helping to shape the workforce they are entering.” But this year the $40 student membership fee has been dropped for first-year students and Phoebe says that has led to a sizable jump in membership on her campus. Membership also becomes more relevant as students move through their degrees and start thinking about their working conditions, pay and the professional issues that will matter to them once they are registered. “Then they realise that NZNO is in their corner, fighting for their cause.” Phoebe’s involvement stepped up late last year when she became the national chair. Initially worried about the time commitment, she says that NSU members are all told to prioritise their studies and she thinks that as long as unit reps keep up their grades it is definitely a good thing to do and have on their CVs. The role has meant getting to network and meet with nurses from all over the country and is a rare opportunity as a student to see nursing in its widest context. At the local level, Phoebe has organised first aid training and visits to the firstand second-year classes to keep them updated about scholarships and grants and encourage them to sign up. Phoebe’s final clinical placement is in a community mental health team and she intends to apply for a mental health new graduate place through the NESP programme. She will step down from the role of chair at the NSU AGM in September and knuckle down to finishing her degree and job hunting. nursingreview.co.nz Issue 4 29
How good are nursing students at self-care? Preliminary findings of the National Nursing Student Survey show that managing fatigue, responding to emotional stress and finances are all issues for which students want more support.
ore than 920 students responded to the anonymous online survey held two-yearly by the National Student Unit of the New Zealand Nurses Organisation (NZNO). Phoebe Webster, the national chair of the student unit, said it was decided as part of the 2017 survey to look at student self-care as this was a “huge” issue for students and obviously nurses as well. “The idea is that you start as you go on. And the concern was that if students didn’t develop good selfcare habits during their nursing training this was unlikely to change when they became a new graduate and increased the potential they would burnout in the years to come,” said Webster, who presented on the preliminary findings to nursing schools recently. Sally Dobbs, chair of Nursing Education in the Tertiary Sector (NETS), said the survey presentation
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highlighted some of the concerns heads of school were also noticing around student health. “Certainly from our perspective and their perspective there’s a definite synergy there in terms of some the issues raised by the students.” Including financial and health issues. Webster said this year’s survey looked at how nursing schools were promoting and supporting students to be well in themselves so they could do their jobs when out there in the real world. It also looked at the self-care knowledge and behaviours of nursing students. The survey asked students for feedback on a number of areas including whether their schools provided health care and childcare facilities, did schools talk about managing fatigue and shift work, did schools provide cultural and religious support on campus, and did they promote wellness in general. Phoebe said for the most part schools were doing an ‘awesome’ job in supporting students. Preliminary findings were presented to a recent meeting of Nursing Education in the Tertiary Sector (NETS) and the full survey results are expected to be released shortly.
The findings released to date show that the issues flagged by students as “significant” and needing more resources or information included: managing fatigue and shift work, financial difficulties, managing the emotional response to relatives in distress, and gender identity issues. NZNO researcher Dr Jinny Wills said the largest proportion of the 922 respondents (41 per cent) were aged 18–21 years and for many of them their nursing training was the first time they had faced grieving and distressed families so the survey highlighted that students wanted more support in that area. Also raised were concerns about financial issues and having support available to “nip in the bud” the risk of financial difficulties getting to the stage students couldn’t continue with their studies. Jinny Wills said nursing students faced the particular issue of long clinical placements making it difficult to undertake part-time work. Also around a third of student respondents had children or family responsibilities. Wills said the survey showed that students who had accessed student health services or resources available at their school had been very pleased with 85 per cent of respondents rating them highly.
Opinion Innovation in China
Primary nursing in China: from hospital ward to home
Shifting China away from a hospitalcentred healthcare system is a work in progress. One response has been nurses at Shenzhen People’s Hospital delivering patient care from the ward to home. Yueming Peng, a Shenzen neonatal nurse manager and Jenny Song, a Wintec nurse academic, reflect on the differing primary care models in China and New Zealand*.
istorically China’s model of healthcare – unlike New Zealand’s – has put hospitals at the centre of its delivery system. But major health reforms underway means that hospitals like Shenzen People’s Hospital (SPH) now need to develop a more decentralised health service. In the absence of community healthcare facilities, one model adopted by SPH – the largest public hospital in the southern Chinese city of 20 million people – has been for hospital nurses to provide a follow-up discharge health service. By the end of 2016, a total of 1,590 patients from the 2,400-bed hospital had received home visits from their primary care nurses after being discharged. Alternative models of delivering health care were among the topics discussed when last year some of SPH’s 1,174 registered nurses were hosted by Wintec during a series of one week visits to learn more about the New Zealand healthcare system. The thinking behind SPH’s model was that hospital nurses were more familiar with their patients’ health situation and therefore best positioned to provide both inpatient and outpatient care. In the neonatal unit, for example, neonatal nurses who had supported the parents and caregivers of premature babies
Yueming Peng (left) and Jenny Song.
(weighing less than 1,500 grammes) would provide an extension of their hospital role during home visits, taking follow-up blood samples when needed and arranging other postnatal support. However a critical shortage of nurses in China is now looming because of a relaxation of the one-child policy, forcing SPH to revise the model. The visiting SPH nurses learnt that in New Zealand, rather than providing home visits by primary nurses from a hospital, the inpatient team, prior to discharge, arrange outpatient follow-up with the appropriate professionals, such as a GP, district nurse or nurse specialist. Discharge summaries accompany patients and relevant information – such as medication, diagnostic tests and follow-up needs – are shared with these primary health professionals. In addition, the SPH nurses – during discussions about the differing healthcare systems and sociocultural contexts in which nurses in China and New Zealand practise – recognised that primary healthcare provision in New Zealand was not defined solely by the provision of medical care. And that while treating illnesses and monitoring a patient’s programme of recovery is important, comprehensive community health care focuses on education and empowerment so that people are aware of the influences affecting their health and accordingly have more personal choice. In other words, comprehensive community health care not only addresses medical concerns but also examines other issues that stem from a person’s broader social landscape. For the Chinese, it can be foreseen that the New Zealand model might better suit the needs of their nation in order to promote a balanced system of health promotion, disease prevention, rehabilitation and illness treatment. Separating inpatient care from follow-up outpatient care would doubtless also take the pressure off hospital nurses. Perhaps it is time for the development of off-site community healthcare hubs, where multidisciplinary teams of general practitioners, social workers, physiotherapists, occupational therapists and other healthcare professionals work together to address the social, political and environmental factors that impact on people’s health. *For references, see the online version at nursingreview.co.nz. nursingreview.co.nz Issue 4 31
Opinion College of Nurses
Train more NPs, not GPs,
says nurse leader
JENNY CARRYER argues that an answer to the ongoing concern about rural GP shortages is in “plain sight” – stop the calls to train more GPs and invest more in training NPs instead.
recent media report noted that graduate doctors’ interest in working in small towns and provincial cities continues to decline, adding to ongoing concern about the sustainability of rural health services. The New Zealand Doctor article went on to say that very few medical graduates want to live and work in towns with a population under 10,000, but rural health advocates point out these communities have increasing health needs as residents age. The statistics were drawn from the latest Medical Schools Outcomes Database (MSOD) report that shows only 1.6 per cent of New Zealand medical graduates in 2015 saw small towns as places they wanted to practise. New Zealand has a long history of trying to incentivise doctors to remain and practise in small towns and rural areas. Many continue to call for incentives (for doctors) despite the historical and demonstrable failure of the many forms of incentives tried. Alongside the increasing struggle to recruit GPs to many parts of the country is the huge amount spent on GP locums over the years. I personally have no idea exactly how big that spend is, but I can confidently suggest that over our history it has run into many millions of dollars. Currently there is a push to try and increase GP numbers by establishing a new medical school at the University of Waikato that will produce rurally oriented GPs. It seems to be based on a similar model at Flinders University in Adelaide, which has had success in providing GPs for rural areas.
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Provocative questions My questions in response are outspoken and provocative: ▶▶ Will producing more GPs actually solve the many problems that confront us in providing primary health care services, be they urban or rural? ▶▶ Will more GPs actually change the model of service which, I would candidly suggest, is broken? ▶▶ Is an extensive training in biomedicine the best fit with communities’ needs to live well, stay well, die well and to stay out of hospital regardless of income levels, ethnicity and residential location? These are challenging questions but they need answering if we are to really deliver on the goals of the New Zealand Health Strategy. We should be very concerned that more and more New Zealanders are experiencing diminished access to health services – or poor quality, poorly coordinated care – with different health outcomes for Māori and Pacific, poor or no rural access, rising mental health problems and many other concerns. We are in danger of becoming inured to such reports as they come so frequently. Whichever way we look, there is a system under severe and growing pressure. Those working in hospitals dealing with the consequences of poor primary health care are under even more pressure. At least half a million people can no longer afford general practice visits. Many such people, in desperation, are currently putting emergency departments under intolerable pressure. At the same time GPs are reporting that their practices are not viable with current funding levels. This situation should not be allowed to continue as it can only worsen under the pressures of an ageing population, increasing levels of
long-term conditions such as diabetes and kidney disease and the impending threat of antimicrobial resistance.
Stuck record I feel like a stuck record in noting that one answer is hiding in plain sight. In New Zealand it costs approximately $600,000 to produce a general practitioner (GP) and $100,000 to produce a nurse practitioner (NP) yet the scope of service is the same. Registered nurses are widely distributed around the country in rural, remote and urban areas. Evidence shows they are inclined to remain in the areas where they begin practice. Evidence now shows that approximately 4,000 nurses have a clinical master’s degree and many would not be far off seeking NP registration if encouraged with minimal further investment. There is a long overdue need to stop the repeated calls to educate more GPs and instead divert substantial investment towards developing some of the existing nursing workforce to nurse practitioner level. Doing so would provide a rapid, cost-effective, completely safe and highly accessible solution to the problem. There are already nearly 300 NPs in New Zealand, half of whom are providing primary health care services. I would urge more careful consideration of this health workforce solution which is right under our noses.
*National report on students graduating medical school in New Zealand in 2015 – NZ MSOD Steering Group www.otago.ac.nz/ medical-school/otago645047.pdf AUTHOR: Professor Jenny Carryer RN PhD FCNA(NZ) MNZM is executive director of the College of Nurses.
Upcoming Conferences New Zealand Sexual Health Society 39th Conference 2017 ▶▶ 7 September 2017 ▶▶ Christchurch ▶▶ www.nzshs.org/events/upcoming-events 10th New Zealand Immunisation Conference 2017 ▶▶ 7–9 September 2017 ▶▶ Wellington ▶▶ http://nzimmsconference.co.nz Clinical Nurse Specialist Conference 2017 ▶▶ 8–9 September ▶▶ Christchurch ▶▶ www.cnssnzconference.com New Zealand Faith Community Nursing Association Conference 2017 ▶▶ 8–9 September 2017 ▶▶ Auckland ▶▶ www.faithcommunitynursing.nz 28th Australasian Soc. of Clinical Immunology & Allergy Conference: Nurses Update ▶▶ 15 September 2017 ▶▶ Auckland ▶▶ http://ascia2017.com.au New Zealand Nurses Organisation Conference and AGM 2017 ▶▶ 19–21 September 2017 ▶▶ Wellington ▶▶ https://goo.gl/4Si6FL New Zealand Occupational Health Nurses’ Association Conference 2017 ▶▶ 21–22 September 2017 ▶▶ New Plymouth ▶▶ https://goo.gl/dBFZz8 18th Australasian Nurse Educators Conference 2017 ▶▶ 28–30 September 2017 ▶▶ Christchurch ▶▶ http://anec.ac.nz Palliative Care Nurses New Zealand Conference 2017 ▶▶ 9–10 October 2017 ▶▶ Wellington ▶▶ www.eenz.com/pcnnz17 5th International Conference of Te Ao Maramatanga/New Zealand College of Mental Health Nurses ▶▶ 10–11 October 2017 ▶▶ Hamilton ▶▶ https://goo.gl/CNFNZu
New Zealand Urological Nurses Society/ Urological Society of Australia and New Zealand (New Zealand section) Conference 2017 ▶▶ 11–13 October 2017 ▶▶ Tauranga ▶▶ https://goo.gl/E5FMra 26th Annual College of Emergency Nurses New Zealand Conference 2017 ▶▶ 13–14 October 2017 ▶▶ Queenstown ▶▶ www.cennz2017qtown.co.nz Infection Prevention and Control Nurses College NZNO Conference 2017 ▶▶ 15–18 October 2017 ▶▶ Auckland ▶▶ https://goo.gl/Z6vWWo 44th Annual Conference of the Perioperative Nurses College of NZNO ▶▶ 19–21 October 2017 ▶▶ Napier ▶▶ www.confer.co.nz/periop2017 The Australian and NZ Orthopaedic Nurses Association Conference 2017 ▶▶ 25–27 October 2017 ▶▶ Perth ▶▶ www.anzonaconference.net Neonatal Nurses College of Aotearoa Conference 2017 ▶▶ 1–3 November 2017 ▶▶ Wellington ▶▶ http://nnca.org.nz NZNO Nurse Managers Section 2017 Conference ▶▶ 2–3 November 2017 ▶▶ Dunedin ▶▶ https://goo.gl/oz6edg Health Informatics New Zealand (HiNZ) and NZ Nursing Informatics Conference 2017 ▶▶ 1–3 November 2017 ▶▶ Rotorua ▶▶ www.hinz.org.nz/?page=2017HINZConf
NZNO/College of Air and Surface Transport Nurses Aeromedical Symposium ▶▶ 13 November 2017 ▶▶ Christchurch ▶▶ https://goo.gl/EZKQpT NZ Gastroenterology Annual Scientific Meeting 2017 ▶▶ NZ Society of Gastroenterology/NZNO Gastroenterology Nurses Section ▶▶ 22–24 November 2017 ▶▶ Auckland ▶▶ www.gastro2017.co.nz College of Child and Youth Health/AUT Child Health Research Centre symposium ▶▶ 24 November 2017 ▶▶ Auckland ▶▶ https://goo.gl/UUejBo New Zealand Respiratory Conference 2017 ▶▶ 23–24 November 2017 ▶▶ Auckland ▶▶ www.nzrc2017.com Neuroscience Symposium: ‘Nursing through the journey’ ▶▶ 29 November–1 December 2017 ▶▶ Wellington ▶▶ https://goo.gl/SFSu73
2018 Intravenous Nursing New Zealand Conference 2018 ▶▶ 16–17 March 2018 ▶▶ Rotorua ▶▶ www.ivnnz.co.nz National Rural Health Conference ▶▶ April 5–8 2018 ▶▶ Auckland ▶▶ www.rgpn.org.nz NZ Population Health Congress ▶▶ 18–20 April 2018 ▶▶ Auckland ▶▶ www.pophealthcongress.org.nz/nzphc18
South Island Stroke Study Day ▶▶ 2 November 2017 ▶▶ Christchurch ▶▶ https://goo.gl/ne4u6j
NZ Resuscitation Council Conference 2018 ▶▶ 19–23 April 2018 ▶▶ Wellington ▶▶ www.confer.co.nz/nzresus2018
Psychosocial Oncology New Zealand 2017 ▶▶ 2–4 November 2017 ▶▶ Christchurch ▶▶ www.ponz.org.nz
Australian Pain Society 38th and New Zealand Pain Society Conjoint Annual Scientific Meeting 2018 ▶▶ 8–11 April 2018 ▶▶ Sydney ▶▶ https://goo.gl/Yr3B4J
Continence NZ Men’s Health Education Day ▶▶ 3 November 2017 ▶▶ Auckland ▶▶ https://goo.gl/bCTkLT
To submit a nursing conference or event, email: Editor@nursingreview.co.nz nursingreview.co.nz Issue 4 33
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Published on Aug 31, 2017