FOCUS: Healthy Year Ahead
Nursing Review February/march 2016/$10.95
New Zealand’s independent nursing Series
LOOKING AFTER YOURSELF
EVIDENCE-BASED PRACTICE Does mindfulness matter?
• Collegiality: fun in the ward • The other ‘feminine’ cancers • Are you ‘match fit’ & self-caring?
A DAY IN THE LIFE OF
Q&A
an ED nurse
with
Frances Hughes
CARING FOR OTHERS
• Preventing Māori & Pacific nurse burnout • When nurses grieve • Homesick overseas nurse educators • Who is more empathetic, RNs or Drs?
Practice, people & policy OPINION: prescribing to ‘hidden hearts’ PRACTICE: Macular degeneration
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Inside: LETTER FROM THE EDITOR
Caring for yourself and others One of the articles in this edition quotes that oft-shared airline safety advice to “put on your own oxygen mask first before assisting others”. This is the fifth year that Nursing Review has begun the year by focusing on nurses walking the talk of healthy living by remembering to look after themselves first. This is sometimes easier said than done. And it doesn’t always come naturally to a profession that tends to attract more than its fair share of the world’s ‘givers’ rather than ‘takers’. But giving is also one of the Five Ways to Wellbeing (see more at http://bit.ly/1zJTTTn). So giving in itself can be a positive and rewarding thing to do for yourself, as long as you don’t forget to also find time to care for yourself. In this edition one of the themes that has emerged is nurses caring not just for themselves but for each other as a profession. Three nurse researchers have looked at aspects of this theme: one focusing on the importance of collegiality and fun in nursing; another on caring for colleagues at risk of misconduct; and the third on how good nursing is at caring for the carers when nurses themselves are the bereaved. We also look at ways that pressured Māori and Pacific nurses can prevent the risk of burnout as a minority workforce serving high priority populations. We all agree that caring for colleagues can be a good thing for nursing as a whole, as well as the patients being cared for. Just remember – as another researcher quoted in this edition said – “giving can be good – it is the over-giving that can be the issue”. Fiona Cassie, Editor www.nursingreview.co.nz
PS: download our digital-only edition from late last year If you missed our special digital end-of-year edition, including a report card on 2015 from nursing leaders and coverage of the National Nursing Informatics and Australasian Nurse Educator conferences, then you can download a PDF version at http://bit.ly/1T0LVOF
Wider distribution for Nursing Review Free copies of Nursing Review are now sent directly to every ward at every major hospital. If this is your first time reading Nursing Review, contact editor Fiona Cassie and tell her what you think (especially if you have news or ideas to share!). These free copies will have all the features and opinion Nursing Review is known for, but only subscribers will receive print and online access to the RRR professional development activity. To get your personal copy (including RRR), go to: www.nursingreview.co.nz/subscribe
Multimedia platform for nursing Nursing Review is a genuine multimedia publication, with five print editions and our recently revamped website, which contains content not found in the print edition, including exclusive online articles, live Twitter updates, social sharing, and the downloadable RRR professional development archive. Visit: www.nursingreview.co.nz COVER PIC: Dr Frances Hughes, the former Chief Nurse of New Zealand who in February will become the first southern hemisphere nurse to lead the Geneva-based International Council of Nurses. See Q&A profile on p.2 PHOTO CREDIT: Michael Farr, Mifarr Productions, Wellington Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
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FOCUS: Healthy Year Ahead
Fun in the ward: JOCE STEWART shares yarns from the good old days Māori and Pacific nurses: balancing high expectations and low numbers Nurse-turned life coach JAN AITKEN on self-care for nurses FIONA ROWAN asks how well we care for grieving nurses Personal trainer LYNDA LOVATT on being ‘match fit’ for nursing Gynaecological cancers: silent no longer PATRICIA McCLUNIE-TRUST on caring for colleagues on the edge
Homesickness and culture shock: REEN SKARIA on the overseas nurse educator’s experience
25
Empathy: PETER GALLAGHER compares the empathy levels of nursing and medical students
RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe
Practice, People & Policy 26 27 28
29
PRACTICE: VICKY MIYEONG YOU on innovative nurse treatment of macular degeneration OPINION: MICHAEL GERAGHTY on the ED silly season DES GORMAN and RUTH ANDERSON’s update on Health Workforce New Zealand and nursing
OPINION: ROSEMARY MINTO on uncovering your patient’s ‘hidden heart’
30
MARK JONES and JILL WILKINSON on nurse prescribing and the Queen
Regulars 2 3 31 32
Q&A Profile: FRANCES HUGHES, the new CEO of the International Council of Nurses A day in the life of… ED nurse ERIN DOOLEY Evidence-based Practice: CYNTHIA WENSLEY on mindfulness College of Nurses: JENNY CARRYER calls for “courageous disruption”
Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ
Editor Fiona Cassie 03 981 9474 editor@nursingreview.co.nz Advertising & marketing manager Belle Hanrahan 04 915 9783 belle@nzme-ed.co.nz Publisher & general manager Bronwen Wilkins production Aaron Morey Subscriptions Gunvor Carlson 04 915 9780 gunvor.carlson@nzme-ed.co.nz images istock
Nursing Review
Vol 16 Issue 1 2016
NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6141, New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 © 2016. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014
Errors and omissions: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.
www.nursingreview.co.nz | Nursing Review series 2016 1
Q&A
Dr Frances Hughes
JOB TITLE | Chief Executive of the International Council of Nurses (ICN), Geneva
Q A
people who are shaping our environment in a positive manner. I also love being humbled by stories of families and consumers, who remind me of what we are all here for.
Where and when did you train? I completed two hospital-based training programmes. The first was training as an RGON at Hutt Hospital (won the Florence Nightingale Award on graduating in 1979, a lovely medal I still wear as a necklace) and the second was a two-year psychiatric nursing programme at Porirua Hospital (1981–1983).
Q A
What do you love least about being a leader in 2016? The demand is great; we expect more and more of our nurse leaders, and at times it is completely unrealistic. We want them to be the best clinician, the best researcher, the best academic and the best strategist.
Q A
Other qualifications/professional roles? BA, MA and Doctor of Nursing. I was the first nurse to be awarded a Harkness Fellowship in health policy, The University of Auckland’s first professor of nursing, a JP, chair of Careerforce ITO, Colonel Commandant of the Royal New Zealand Nursing Corps, first New Zealand president and councillor for former Australian & New Zealand College of Mental Health Nursing, and the founder and chair of Kapiti Community Enterprise Trust (a charity for those with complex mental illness and developmental disabilities). I was a Fulbright senior scholar in 2013 and I am a credentialed MH nurse.
Q A
Why did you decide to become a nurse? I remember being in the sixth form and my best friend Marie was going nursing. I needed somewhere to live post-school, as my family moved away, so I decided to follow suit. In those days, going to university straight from school was not that common and I really wanted to be with my friends. If anything, I wanted to go into the police force but I was too young.
Q A
What was your nursing career up to your current job? I began teaching CPR for the National Heart Foundation. Since completing my psychiatric nurse training, I have always been active in mental health nursing, initially as a clinician and then in other roles, including as an educator at Whitireia Community Polytechnic, where I developed the forensic mental health nursing programme while nursing part-time. I’ve also been a regional nurse educator, worked for Family Planning and held the director of mental health nursing role at Porirua Hospital. I became a senior advisor and then chief advisor nursing for the Ministry of Health (1996–2004); then became professor of nursing at The University of Auckland, facilitator of the Pacific Island Mental Health Network for WHO, and a senior consultant then acting deputy director of mental health for the Ministry of Health. From 2012
Q
If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the world’s nursing workforce? I would wish for more courage, confidence and ability to influence. I would wish for all nurses to have mentorship and professional support in their careers.
A Frances Hughes (until taking up the ICN post in February), I was Queensland’s chief nursing and midwifery officer. I was also the owner, with my husband Kevin, of an NGO residential mental health and disability provider in Kapiti for 12 years (where I worked part-time as an RN). I worked with an amazing group of clients, mainly males with complex mental and developmental disabilities.
Q A
So what is your new job all about? As chief executive of the International Council of Nurses (ICN), I work for the board and for the members of ICN – the 130 countries covered by national nursing associations (NNAs). My job is to maintain the organisation, deliver on the strategic directions, and make sure we have strong, robust systems and processes to take ICN into the future. It is also to expand our members and partners, and to understand the expectations and issues of our members. I will be representing nursing to ensure we have a voice where it matters at global decision-making tables.
Q A
What do you love most about being a nurse leader? I love the complexity of problem solving and developing strategies and approaches. I love being surrounded by
2 Nursing Review series 2016 | www.nursingreview.co.nz
Q A
What do you think are the most important personal characteristics required to be a nurse? Courage, confidence, integrity and a sense of justice. Then I think I would add positivity and being a strategist.
Q A
What do you do to try and keep fit, healthy, happy and balanced? I drink and love green tea, I meditate, I go to the gym as much as I can, and I love and appreciate my family and friends and tell them so frequently. Keeping in contact and taking wise counsel from my friends and treasured colleagues is important when you are often leading from the front in regards to nursing work. As a mental health nurse, I have always had, and continue to have, professional supervision.
Q
While you are waiting in the supermarket check-out queue, which magazine are you most likely to pick up and browse, and why? Real estate guides – I love looking at property and houses.
A Q A Q A
What is number one on your ‘bucket list’ of things to do?
Learn another language. What is your favourite meal?
Anything with potatoes and spinach.
A day in the life of...
an ED nurse
NAME | Erin Dooley JOB TITLE | Registered Nurse LOCATION | Christchurch Hospital Emergency Department
6.35
AM ALARM GOES OFF Press snooze. I have been nursing for eight years, the past five years in ED. Today I am on a 10.30am–9pm shift, so have the luxury of extra time and keep hitting the snooze button. Listen to the 7am radio news – somebody died in a car accident in Christchurch overnight, and I lie in bed wondering if they made it to ED… then I head out for a walk, music blasting.
8.10
AM HOUSEWORK, PACK BAG and HEAD FOR COFFEE Home to water the garden, housework, shower, pack a bag (with smoothie, lunch, dinner and my week’s supply of socks) and head out the door with enough time to meet a friend for coffee before work.
10.24
AM ARRIVE AT WORK Arrive just in time to change into scrubs and run into handover with my arms overflowing with shoes, socks, stethoscope, tourniquet, trauma scissors, ID and pens. Handover includes a brief overview of the department’s current state – busy, not busy, traumas and critical patients – plus a whole-hospital overview as this impacts on patient flow.
10.45
AM TIME TO HIT THE FLOOR I work in 10 different ED roles/areas and these change daily. Today I am working in ‘the front’ which from 10.30am steps up to four nurses: a triage nurse, a FAST (Focused Assessment and Supportive Treatment) nurse, an ambulatory nurse, and a team leader. I start my shift as the FAST nurse giving initial assessments to the ambulatory patients the ‘walking wounded’ and acute orthopedic injuries. Today we start on a good foot; it was very busy overnight but by 10.30am the department is in a settled state. I call in patients from the waiting room to take a history, assess the complaint, and initiate appropriate treatment. This may include analgesia, tetanus boosters, bloods, wound wash-outs, X-rays or nurse referral to ‘bone shop’. All this can be done by ED nursing staff if patients meet the ED’s Nurse-Initiated Treatment criteria. (The ED doctors are happy to be called in if you want a review.) Today has been a nice morning. Between 10.45am–1.30pm I’ve seen 12 patients, aged from 12 days to 88 years with limb to eye injuries, plus lacerations, sore throats and various aches and pains.
1.30
pM LUNCH The team leader relieves me for lunch and I nip away to the tea room, which is always a hive of activity.
2.00
pM BACK TO IT… PACE STEPS UP By now a steady flow of GP referrals and work-related injuries is starting to arrive. I have seen nine patients since returning from lunch, things are busier but I have had some time-consuming tasks, the FAST nurse is not always fast! I spend a long time trying to remove an 80-year-old lady’s wedding ring that hasn’t been off her finger in 60 years! She has a nasty wrist injury and we need the ring off before the hand swells any more. I try every trick I know, lubricant, oxygen mask elastic, cotton, but this ring is not budging; we have to resort to using the ring-cutter which I absolutely hate, not only is it heart-breaking cutting a wedding ring, but it’s slow and painful on an already broken limb.
4.30
pM CHANGE TO TRIAGE ROLE The influx of patients now comes thick and fast. Triage is like a constant multitasking battle; patients keep walking through the door needing triage at the same time as mental health liaison want to discuss a patient, registrars ring about incoming patients, the children’s ward rings about an admission, a triage 5 patient keeps asking when they’ll see the doctor and all the while the patient the police brought in is yelling and screaming and making a scene… but first you need to get the guy clutching his chest a bed in Resus (Resuscitation area).
but I see that you’re quiet so thought I might as well”. You want to scream, “It’s not quiet, there are no beds anywhere, patients in the corridor and clearly you don’t really need to be here!” Instead I take a deep breath, put on a smile and say, “How can I help you today?”
8.45
pM NIGHT SHIFT ARRIVES, HALLELUJAH! I give a handover of the waiting room patients, brief and to the point; for example, “lady in second row, blue top, finger injury, seen by FAST nurse, for ambulatory”. I also handover the expected ‘incomings’.
8.55
pM DEPART Walking into the changing rooms I hear a trauma call come… part of me wants to stay and see what’s coming but as soon as I’ve taken off one shoe I remember the bliss of going home, quickly get changed and head away.
9.20
pM home I walk in the door and park myself on the couch and submerge myself in Facebook or something else completely mind-numbing, I’m over talking and listening to people. My partner pours me a wine and after about 20 minutes I look up from my phone and ask how his day was – I’m now ready to enter the world again.
12.00
am TO BED Crawling into bed, I tell myself I meant to have an early night. I’ll try again tomorrow night...
N.B. Full version is available online at www.nursingreview.co.nz
6.00
pM TEA TIME Every time I look up, another two people have walked in and joined the queue in front of me. My tea room escape is timed perfectly.
6.30
pM BACK TO IT While at triage you constantly scan the waiting room and the ever-growing line to ensure no one is deteriorating before your eyes. If I get a break in traffic I will quickly pull a patient in for a FAST assessment or try and update the computer patient system.
8.30
pM CALM TAKES OVER Calmness finally sweeps over the waiting room. So of course a patient comes up to the desk and says, “I wasn’t going to come in
Erin Dooley
www.nursingreview.co.nz | Nursing Review series 2016 3
FOCUS n Healthy Year Ahead
Fun in the ward:
stories of the good old, bad old days
Cartoons courtesy of Joce Stewart's Dad
Joce Stewart
G
Nurse researcher JOCE STEWART believes some fun and camaraderie in the ward can only be healthy for both nurses and patients. Nursing Review shares tales of laughter, mischief and collegiality amongst nurses in the 1970s and 1980s from Stewart’s thesis oral history research.
et a bunch of nurses of a certain vintage together and the yarns start to flow. Tales of sneaking into the nurses’ hostel after curfew, practical jokes on the way to the morgue and recollections of that terrifying sister in Ward X. What these nurses usually have in common is a shared experience of the ‘good old, bad old’ days of hospital training, when both working and living together forged communal bonds that were often lifelong. Nurse educator Joce Stewart trained at the then Wellington Polytechnic, but that earlier generation still dominated the workforce when she started nursing in 1986 and she recalls camaraderie and fun on the ward being commonplace. So when it came to looking for a thesis topic, she chose to look back at ‘the way we were’ and explore the collegiality of nursing back in the 1970s and ‘80s. “What were the fun things that rolled us out of bed in the mornings; what were the things that made us laugh and made us smile in an often harsh environment that was fraught with hierarchy, difficult, challenging situations and often responsibility beyond experience.” Stewart started with the assumption that collegiality was built by sharing experiences and having fun, and then gathered tales of fun, fear, warmth and silliness from still-practising nurses now in their 50s and 60s. She says she wanted to explore the historical context of the camaraderie this generation had shared – back in the days when patient churn and high acuity were not the issues they are today – and a number of themes emerged. Her research did not leave her nostalgic for the rigid hierarchy and apprentice-style training of the past but did leave her with a feeling that she had
missed something in not being hospital-trained herself and a sense that nursing had lost the ‘fun’ element of earlier days. “I really wanted to explore what it was [that created that fun] and my research reiterated to me that it was the training in the hospital and living in the nurses’ home that did it, as it bound those nurses together,” she says. Her research also raises questions about what collegiality means for the new generation of nurses and how nurses can still foster a sense of fun in today’s busy wards. But she adds that her research project was also a great excuse to pull together some wonderful nursing yarns from the 1970s and ‘80s. This article shares some of those stories and the themes that emerged.
Rigid hierarchy
Society was changing rapidly in the 1970s, but the traditional rigid hierarchy of matrons and sisters still held sway over most of our public hospitals. Stewart says a common theme emerging from the stories was the collegial bonds student nurses formed by being at the very bottom of that nursing hierarchy.
4 Nursing Review series 2016 | www.nursingreview.co.nz
Do you remember when you were the most junior nurse? You stood up for everyone that walked through the door. (Nurse 3) Soon as you heard the door open, you stood up. (Nurse 4) Yes, I remember they would have two junior nurses on and a registered nurse, and at morning tea time, she would be in there suppin’ [tea] and having all this food with the doctors while we worked our butts off. (Nurse 6) Junior nurses were in charge of ensuring the ward was clean and shipshape, including meeting some pedantic requirements like ensuring bed wheels all pointed the same direction and pillows faced away from the door. “One of the things that enabled nurses to meet these standards and remain cheerful was the ability to later mock some of these processes,” says Stewart. Some of the traditions, however, brought back warm memories. Remember on Christmas Eve we used to go round singing Christmas carols in our white uniforms and red capes? That was beautiful. I really enjoyed doing that. (Nurse 2) Continued on page 6 >>
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Recommended dosing: One dose of Prevenar 13 followed no less than 8 weeks later by 23PPV. Note some conditions may recommend more than one dose of Prevenar 13 be given.2
References: 1. PHARMAC Hospital Medicines List. http://www.pharmac.govt.nz/HMLOnline.php?osq=Pneumococcal. Accessed 7 August 2015. 2. Immunisation Handbook 2014. http://www.health.govt.nz/publication/immunisation-handbook-2014 accessed 31 August 2015. Prevenar 13 has risks and benefits. Prevenar 13® (Pneumococcal polysaccharide conjugate vaccine, 13-valent adsorbed) suspension for I.M. injection. Contains 30.8 μg of pneumococcal purified capsular polysaccharides conjugated to non-toxic diphtheria CRM197 protein. Indications: Active immunisation for the prevention of disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F in adults and children from 6 weeks of age. Contraindications: Hypersensitivity to any component of the vaccine, or to diphtheria toxoid. Allergic or anaphylactic reaction following prior administration of 7vPCV. Precautions: Do not administer intravenously, intravascularly, intradermally or subcutaneously. Avoid injecting into, or near nerves or blood vessels. Do not inject into gluteal area. Postpone administration in acute, moderate or severe febrile illness. Only protects against Streptococcus pneumoniae serotypes included in the vaccine and may not protect all individuals from pneumococcal disease. Consider the risks of intramuscular (IM) injection in infants or children with thrombocytopenia or any coagulation disorder. Appropriate treatment and supervision must be readily available in case of a rare anaphylactic event. Prophylactic antipyretic medication is recommended for children receiving concomitant whole-cell pertussis vaccines and for children with seizure disorders or history of febrile seizures. Consider the potential risk of apnoea when administering to very premature infants. Adverse Effects - Very common/common: Children 6 weeks to 5 years: Injection site reactions (redness, pain, swelling), fever, diarrhoea, vomiting, decreased appetite, drowsiness/increased sleep; restless sleep/decreased sleep, rash, irritability. Children and adolescents 5 to 17 years: Irritability, injection site reactions (redness, pain, swelling), somnolence, poor quality sleep, injection site tenderness (including impaired movement), fever, decreased appetite, vomiting, diarrhoea, headaches, rash. Adults: Diarrhoea, vomiting, chills, fatigue, injection site reactions (redness, pain, swelling), limitation of arm movement, fever, new or aggravated joint or muscle pain, decreased appetite, headaches, rash. Adverse Effects - Serious: Hypersensitivity reaction; anaphylactic/anaphylactoid reaction including shock; angioedema; erythema multiforme. Seizures, hypotonic-hyporesponsive episode in children. Others, see full Data Sheet. Dose: 0.5 mL I.M. Infants 6 weeks to 6 months of age: 3 doses at least one month apart. A single booster should be given in the second year, at least 2 months after the primary series. Previously unvaccinated children: Varies with age at first dose, see full Data Sheet. Children aged 12 months to 17 years who have completed primary infant immunisation with 7vPCV and children 6 to 17 years who have received one or more doses of 7vPCV may receive 1 dose, at least 8 weeks after the final dose of 7vPCV. Adults: 1 dose. If sequential administration of Prevenar 13 and 23vPPV is considered, Prevenar 13 should be given first. High Risk Individuals: Up to 4 doses, depending on condition. The dosing schedule should be guided by official recommendations. Medicines Classification: Prescription Medicine. Prevenar 13 is a fully funded prescription medicine for children up to 59 months inclusive as part of the National Immunisation Schedule and for older children and adults with certain immunosuppressive conditions (see PHARMAC criteria - Online Pharmaceutical Schedule). For individuals not meeting these criteria, Prevenar 13 is an unfunded prescription medicine – a prescription charge may apply. Before prescribing, please review Data Sheet available from MEDSAFE (www.medsafe.govt.nz) or Pfizer New Zealand Limited, Auckland (www.pfizer.co.nz) or call 0800 736 363. ® Registered Trademark V10715. In pneumococcal-vaccine naïve adults aged 18-49 years, percentages of solicited local and systemic reactions were generally higher compared with older subjects (aged 50-59 and 60-64 years). Limited safety and immunogenicity data on PREVENAR 13 are available for patients with sickle cell disease, or HIV infection, and are not available for other immunocompromised patient groups. Efficacy/ effectiveness has not been established. Immunocompromised individuals or individuals with impaired immune responsiveness due to the use of immunosuppressive therapy may have a reduced antibody response to PREVENAR 13. Vaccination should be considered on an individual basis. Pfizer New Zealand Limited, Level 1, Suite 1.4, Building B, 8 Nugent Street, Grafton, Auckland 1023. ® Registered Trademark. DA1536YL. BCG2-H PRE0328, resize of PRE0306. PP-PNA-NZL-0002. 08/2015.
FOCUS n Healthy Year Ahead
<< Continued from page 4
Laughter is the best medicine
Stewart is quick to add that, of course, nursing was still a serious business, with patients in hospital because they were ill or dying. “Despite the gravity of the situation, nurses found ways to lighten their daily working life.” Humour was an important element of this, says Stewart, not only for the nurses but often for the patients too. Every single person had their bowels sorted out and a bath because there were no showers, we only had one bath. The patients would be sitting there on the toilet, with only a curtain around – no privacy – only a curtain between each patient, and we would be singing that Boney M. song ‘… show me a motion, tra la la la la…’ (Nurse 3) I must have been bored one night on night shift, in between wet rounds, and we actually made a life-sized model of this person, stuffed her with stockings and things, put a shawl on her, put her in a geriatric chair, borrowed someone’s thick framed glasses. It was quite good, life-sized and lifelike and everything. She ended up outside the emergency department where all the drunks who came in would talk to her. We would [also] put her in a ward and then ring the ward and say, ‘Excuse me, but we are missing a patient, she is in a red geriatric chair, have you seen her? No? I am sure she is outside your ward’. She ended up all around the hospital. We called her ‘Malena Stools’. (Nurse 3) It appears nurses with time on their hands were prone to a little mischief. There are also tales of ‘apple-pieing’ beds, putting K-Y Jelly on the ward phones and laxatives in the staffroom coffee, sewing up pyjama pant legs, and patient urinals fizzing after being dusted with baking soda. But sometimes the practical jokes bit back: Years ago the orderlies used to get an extra $10 for every body they took over to the mortuary. We put this nurse on a mortuary trolley once and told the orderly the patient had died in the dayroom. We gave her [the nurse] strict instructions to sit up slowly when going up the ramp (I was walking beside the trolley trying desperately not to laugh) but instead of sitting up while going up the ramp, she sat up while going down the ramp. The orderly let go of the trolley and the thing went straight across the road and hit the gutter – she fell off and broke her ankle. (Nurse 4)
Cartoons courtesy of Joce Stewart's Dad
“Despite the gravity of the situation, nurses found ways to lighten their daily working life.”
The nurses’ home
One of the greatest bonding experiences for generations of nurses was not only training together and laughing together but also living
together in the once iconic nurses’ homes and hostels up and down the country. The friendships forged were often instant and lifelong. I am still friends with the girls I met on my very first day. (Nurse 3) We cared for each other … we constantly cared about what was happening in each other’s lives. (Nurse 2) For this generation before tertiary training, there was no returning each night to a student flat (or in the case of many mature students, to their kids and spouses) and the domestic duties of grocery shopping, cooking and cleaning – let alone getting the kids ready for school or heading to your parttime job to pay for your study. Instead, with long hours on the ward – and in the early days only one day off a week – the basic domestic duties were taken care of by the nurses’ home, giving time for junior nurses to ‘debrief’ after the nursing day. We used to sit in the lounge after a pm shift and make toasted cheese sandwiches and sit up ‘til the small hours of the morning talking about what had happened in that shift and the fun times we had. (Nurse 10) In the nurses’ home we had baths where the walls did not go all the way to the roof,
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so I remember we used to do a lot of chatting in the bathroom while soaking in the bath – do all that debriefing from a bad day. (Nurse 8) Nurses’ homes also allowed junior nurses to make the most of their limited day or days off. And make the most of it many did – despite the 11pm curfew. Stewart says it appears from the anecdotes that the socialising – and the sometimes ‘rulebending’ associated with socialising – helped to build strong rapport between nurses and allowed them to get rid of work tensions. When you think about what kind of work we do, and what we deal with… you have got to be able to let your hair down. (Nurse 5) We would come in [after curfew], having danced all night. The doors were locked so we would climb in the window, or we had a secret knock for the orderly who would let us in the fire escape. We would sneak upstairs trying desperately not to disturb the sister on duty, all go to the toilet at the same time and, on three, flush at the same time. (Nurse 1)
Collegiality today
Nurse training and nursing in the 21st century has quite clearly changed. Patients are much sicker and spend much less time in the wards than they did in the ‘70s and ‘80s, when there was more time for nurses to build a rapport with them over days, and even weeks. In addition, there isn’t the same collegiality forged by living and training together, not to mention less spare time and energy to think up practical jokes. But Stewart believes collegiality, camaraderie and a sense of fun are just as important as ever for nursing. “I think it’s hugely important. We spend eight hours of our day working in an environment and we have to enjoy ourselves. That’s what I strongly believe,” she says. “We have to get on [with each other] to be productive and have good outcomes for our patients. “If we didn’t have that collegiality… if we couldn’t have fun together, then actually we would walk around in bad moods and our patients would suffer,” believes Stewart. “So it was, and is, very important to create [collegiality and camaraderie] in that environment. And how is that created in today’s nursing workforce? Well, that’s a research topic for somebody else – to find out what stories nurses in this generation will share when in the future they gather together to remember ‘back then’.
Author: Joce Stewart is a nurse educator at EIT’s School of Nursing.
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Nursing Review looks at the extra expectations that are often placed on Māori and Pacific nurses and shares some advice for nurses and workplaces on how to avoid the risk of burnout.
Eseta Finau
Jackie McHaffie
Kerri Nuku
Lisa Stewart
Māori and Pacific nurses:
is burnout inevitable? W e just need somebody to lead the powhiri... The Church is looking for someone just like you to... An elderly Samoan man has just turned up, can you translate... Auntie is sick, can you just pop round after work... We are looking for a Māori nurse for this working party, you’d be great... Sorry to wake you up, but Mrs Toleafoa from down the street has had a turn… Few nurses see their profession as just a job. But the expectations placed on Māori and Pacific nurses by themselves, their employers and their communities can make an already demanding profession even more challenging. This is particularly true now, when health strategies stress the need for more Māori and Pacific nurses to help counter poor Māori and Pacific health statistics, while the percentage of Māori and Pacific nurses still lags far behind the actual populations (see statistics sidebar). So there are too few nurses and too much need. How does this impact on Māori and Pacific nurses? And how do they cope? For her PhD thesis, organisational psychologist Dr Lisa Stewart looked at whether the occupational stress experienced by Māori health workers was different from their mainstream counterparts. She says two themes emerged, one being the cultural expectation from Māori communities – shared by Pacific communities – that Māori nurses and other health workers give back to the community in some kind of service. The second was institutional racism – often caused by misunderstandings and a lack of cultural competence – which added to Māori health workers’ stress loads.
Community expectations
Māori and Pacific are not the only cultural groups where community and family expectations outside of work are important, says Stewart. But that cultural expectation is very real. She recalls as a young university student in the 1980s being told by Māori student association leaders that, on graduating, Māori students like herself should help their whānau, hapū and iwi in some way, be it serving on the marae committee or helping out at kohanga reo. Kerri Nuku, kaiwhakahaere of Te Rūnanga o Aotearoa NZNO, agrees and says being a nurse within a whānau group can lead to additional expectations. “You will be the contact person for aunty down the road who is not really sure whether she should rock on down to the doctor’s or just put a bandage on it,” says Nuku. “We hear stories of nurses, particularly who work in rural communities with high population Māori, that in the supermarket people come up to you when you are trying to do your shopping at the weekend and ask you for your advice because you are whānau, because you are Māori and because you are approachable. “Then if you’ve got somebody sick within the whānau, you go to work, do your work and then come home and take over your shift caring for the sick whānau member. You build your own roster around them so that caring doesn’t stop when you leave the hospital grounds or workplace.” This sense of duty begins as nursing students, believes Jackie McHaffie, who is in charge of the Tihei Mauri Ora stream of Wintec’s bachelor of nursing programme and has been involved with the programme for around 15 of its 25 years. “There’s a cultural component that is always going to be there and will add to your duties above and beyond being a registered nurse.
“Why are Māori patients the sole domain of Māori nurses and why are Tongan patients the sole domain of Tongan nurses? Aren’t all patients the domain of all nurses?” Loma-Linda Tasi
Sione Vaka
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They try and give as much as they can back and in doing so they often burn out.” Dr Sione Vaka, Tonga’s first male nurse, who is now a lecturer for Massey University’s School of Nursing, says likewise there is an expectation from the Pacific community for nurses to deliver as much support as they can. For him this means that in addition to his day job he is on the executive of the Tongan Health Society; he’s also vice-president of the Pacific Island Mental Health Professional organisation, chair of his church’s health committee, a member of both the Tongan Nurses Association of New Zealand and the Aotearoa Tongan Health Workers Association, informal mentor to Pacific postgraduate students from a variety of institutions, feedback provider on Pacific mental health research – and he also holds various other community service positions. And this is all after cutting back his out-ofwork commitments to fit his targeted areas of expertise.
Workplace expectations and institutional racism Then there are the workplace expectations that can be placed on a scarce and already stretched thin Māori and Pacific nurse workforce. Stewart says one of the stress issues unique to Māori that emerged as a theme during her research (which assessed the work stress levels of 130 Māori health workers, including nurses) was institutional racism; for example, workplaces playing lip service to the Treaty of Waitangi and related policies aimed at improving health outcomes for Māori. And Stewart says when organisations do recognise bicultural responsibilities – like holding a powhiri to welcome new graduate nurses – non-Māori managers can see this as a Māori-
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only role, adding an extra layer to Māori nurses’ workloads. She says it doesn’t have to be that way. A positive example was an organisation she worked at where it was clearly expected that a Māori staff member would lead the karanga but all ethnicities and nationalities were invited to be part of the waiata group that performed support songs and helped set up the powhiri, including food if that was involved. McHaffie adds that Māori nurses who work for organisations where they may be one of the few or only Māori can find themselves approached for advice on all things Māori, as well as being expected to say the karakia or sing a waiata. But there are also high cultural expectations placed on Māori who are working for Māori providers, which can extend the working day and week for Māori if they need to attend hui or practice for iwi cultural events. Then on top can come expectations for postgraduate study. McHaffie says that over the years she has seen some graduates burn out after struggling to cope with the pressure to be not only a good nurse but also a good Māori nurse. Nuku says she’s also heard of hospitals placing Māori new graduates in particular units or wards well known to be “not conducive to Māori … oh I will just put it out there… they are areas known to be racist” in the hope of trying to change the behaviour of the staff. “So these are conscious decisions that are being made that put our nurses in unsafe places because nobody has dealt with the issue of racism.” Nuku and her NZNO colleague Eseta Finau, who heads the Pacific Nursing Section (PNS), also both receive reports of interview processes and panels that are seen as discriminatory and demoralising for Māori and Pacific nurses.
Finau says an ongoing issue for many Pacifictrained registered nurses is being used as “cheap labour” by rest homes while struggling to afford time off to attend the English language training they need to become registered in New Zealand. Another workplace expectation often adding to the stress loads of already stretched nurses is the belief that Māori and Pacific nurses should be allocated the Māori and Pacific patients, without the workload impact being considered. “Why are Māori patients the sole domain of Māori nurses and why are Tongan patients the sole domain of Tongan nurses? Aren’t all patients the domain of all nurses?” asks Stewart. Vaka echoes this, saying sometimes non-Pacific nurses are keen to transfer the care of a Pacific patient to a Pacific nurse, saying they would do a better job. He believes it is important to encourage other nurses to be comfortable and confident in working with Pacific people, rather than trying to refer all patients to a potentially already overloaded Pacific nurse or Pacific health service.
Not a burden
Community, and employer, expectations may be high of Māori and Pacific nurses but often so are the nurses’ expectations of themselves in doing their best to improve the health outcomes of their people. Stewart says Māori and Pacific nurses don’t usually see this work as a burden but more a natural extension of being part of a community. “I find when I’m giving back to a really good cause – and I’m helping the whānau in some way – as much as that’s work, it also feels really, really good and has a way of energising you too.” So giving can be good – it’s over-giving that can be the issue.
Pacific nursing students: walking the talk
oma-Linda Tasi got tired of teaching nursing students about Pacific people’s negative health statistics. The nursing lecturer, co-ordinator for year two of Whitireia Community Polytechnic’s Bachelor of Nursing (Pacific), decided she had to start somewhere to make a difference and a good place to begin was with herself and her students. Her philosophy is to try and build a healthy lifestyle into everyday living to stop the real risk nurses face of being so busy looking after others that they forget to look after themselves. So her personal journey has included giving up her car so she walks to work most days, her teenage kids are more active and the temptation is removed to drive to get takeaways after a busy day. Her teaching journey includes supporting her very committed students to build an understanding of other’s health needs by turning it around and looking at their own health needs first. “The statistics tell us that Pacific people are highly represented in rates of obesity and chronic disease and you can bet that that statistic is represented in the classroom too.” The pressures of study can also impact negatively on health with students working long hours and filling up on cheap hot chips from the student café.
Empowering students
Tasi says she tries to takes an empowering holistic approach so sets aside time in the study week for students to gather in small groups to set a simple 8 Nursing Review series 2016 | www.nursingreview.co.nz
personal health goal for the year; examine the evidence behind it, identify the challenges (including being time and money poor students) and support each other through the year to meet that goal; be it quitting smoking or eating more healthily. She backs this in the classroom by teaching the science behind healthy lifestyle changes that can reduce the risk of chronic diseases like diabetes and heart disease. For example when she does a session on acids, alkalis and blood pH she makes students record all they ate in the previous three days. They arrive in the classroom to find acidic written up on one side of the white board and alkali on the other and she gets them to write-down each serving of vegetables, chips, fruit, pie, alcohol, soft drink or cereal they ate or drank on a Post-it note and stick them on the appropriate side of the board. She says there is a lot of laughter during the exercise but quickly the acidic side of the board fills up giving students a graphic depiction and reality check that their diet is not okay. “Over the term students report back that they’ve changed a lot in their family’s diet and also saved money in some cases.” Tasi’s aim is to empower Pacific people to reverse unhealthy lifestyle patterns, caused by shifting to New Zealand, as part of a nursing curriculum that emphasises Pacific nurses understanding who they are, where they came from and equipping them with the knowledge to rebuild a healthy lifestyle one step at time; starting with their own family, their friends and, in time, the community they care for as nurses.
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Finau says family upbringing is also a major influence, with multitasking just something you do when you’re from the Pacific. “Because at home you grow up with so many kids around, there are family things and church things … and you just learn to juggle and cope with things. Giving back to the community is just another thing you take on and being a nurse you manage your time.” Stewart’s research found that occupational stress was not lower in kaupapa Māori health providers than in mainstream providers – on the contrary, role overload and organisational constraints were all higher. But the coping strategies were better, which matched earlier research findings (see retention sidebar) that the top factors encouraging Māori health workers to stay with a health provider included being able to make a difference to Māori health and to their iwi or hapū, and that Māori practice models and approaches were valued. Nuku agrees, saying Te Rūnanga o Aotearoa used to see nurses shifting from Māori provider groups to DHBs because of the money, but, despite pay parity being an ongoing issue (see sidebar), she says the reverse is also happening. “What we are feeling is that there is a trend that they are going back because they can’t cope with the amount of racism that is happening in workplaces.” There is also a frustration that poor Māori health statistics are used as “a patu [weapon] against ourselves”; innovative strategies that do work don’t get sustainable funding; and the Māori nursing workforce is still static, despite strategies aimed at boosting recruitment and retention. “I don’t think we have looked enough at how we support Māori and Pacific nurses in the workplace,” she says.
Te Whare Tapa Whā image published courtesy of Ministry of Health
Cultural competence of all staff important One step in the right direction, believe many, is placing value on cultural, as well as clinical, competence in the workplace. “If all of our nurses were culturally competent to deal with all of the cultural groups that they see in their practice, then the burden of being responsible for Māori patients becomes everybody’s responsibility – not just Māori nurses’ – and Tongan patients are not only the responsibility of Tongan nurses,” says Stewart.
Advice on stress management »» Learn to recognise and notice your own symptoms of stress »» Find out what resources are available either within or outside your organisation to prevent, reduce or manage that stress. Try: »» workplace exercise or mindfulness classes »» EAP (employee assistance programmes) that may offer counselling »» Look to culturally relevant models of health as a framework for managing your stress: i.e. Professor Mason Durie’s Māori health assessment framework, known as Te Whare Tapa Whā (1982) and the Pacific health and wellbeing model Fonofale (2009), developed by Fuimaono Karl Pulotu-Endemann. Both of these models have four elements in common: »» Physical health: could be pilates, netball, jogging, touch rugby, dancing, healthy eating, etc. »» Mental health: mindfulness or meditation or time out to simply read or go for a quiet walk. »» Spiritual health: could be church or prayer or taking part in cultural activities such as kapahaka and cultural festivals. »» Social health: connecting with your whānau/family and with other communities you are part of (be it your church or your touch rugby team) to help nurture and re-energise you. »» Remember that giving is good, but over-giving is not good and can impact on your own health, which is not good for the community you serve. »» Be aware of your limitations. »» Set priorities for what goals you value most and be strategic in how you allocate your time and expertise to best support those goals. »» Learn when and how to say ‘no’ in a way you are comfortable with. »» See related articles in this edition on general stress management, being work-fit and looking after yourself.
Vaka says he is aware, through non-Pacific nursing friends, that some have a fear they will do something wrong when caring for Pacific patients, so they look to transfer them when possible. He agrees a better approach is for all nurses to upskill themselves culturally, seek advice and “have a crack” themselves in looking after Pacific people. “If we are able to learn more about one another and how to work with different cultures – it is such a diverse community that we are living in at the moment – it would be improving our overall health care as well,” he says. Stewart also believes the handover of patients to Māori or Pacific nurses is not intentionally malicious but more a lack of understanding and a lack of confidence in being able to work effectively with those client groups. “The reality is that as a Māori when I go into a health service would I prefer to work with a Māori member of staff? Sometimes I would, but I know the reality is that I won’t. But what I do expect as a Māori health user is that when I use the health services I get treated with dignity and respect in the same way that every other cultural group would expect to be.” Nuku says there are expectations that registered nurses be culturally competent and clinically competent “but time and time again clinical competency outweighs the need for nurses to be seen to be culturally appropriate.” She says, as an example, that nurses must undergo ongoing professional development to be deemed clinically competent, whereas it is accepted that nurses will be still culturally competent after attending, though not necessarily participating in, a Treaty of Waitangi workshop five years previously. “It’s almost like a default that we sanction ignorance around working in Aotearoa and the unique relationship we have as tangata whenua.”
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Mentoring and supervision
Having strong support mechanisms for Māori and Pacific nurses in hospitals and other organisations is also seen as key to recruiting and retaining nurses. Nuku says strong mentoring programmes are needed not only for new graduates but also for Māori nurses throughout the continuum of nursing until retirement. McHaffie also recommends that her graduates find a cultural advisor or mentor from whom they can obtain advice or talk to about situations that may arise. Nurses can also seek support from the Māori health units that are often within larger DHBs. What is needed and wanted by many Māori nurses, believes Stewart, is cultural supervision, just as clinical supervision is offered to nurses in the mental health sector, to support best practice. Networking with other Māori health professionals also emerged as an important coping strategy for stress, says Stewart, but this was often seen by non-Māori managers as a social activity, rather than a chance to share ideas, download and support each other. “There seems to be a lack of understanding about what organisational conditions need to exist in order for Māori nurses and other health professionals to be most effective at their job.” Likewise, Pacific Nursing head Eseta Finau says one of the most important roles of the country’s various Pacific nurses associations – such as the umbrella NZNO Pacific Nursing Section, the Samoan Nurses Association, the Tongan Nurses Association (which she also leads), and other Pacific nursing groups – is the support and mentoring they provide for members. But when she invites nurses to join the NZNO Pacific Nursing Section and help to train a new generation of leaders, she says employers often won’t allow them to attend in work time. “Yet this is all towards the wellbeing and the future of our Pacific people in the communities that we live in.” With many Pacific nurses being the breadwinners for their family, it is a big
Stats
ask to take a day off to attend a meeting, but committed nurses will use precious annual leave to attend, which Finau says is “just not fair”. She says one way to deal with stress and burnout is by supporting people to be trained to fill leadership positions such as in the PNS to share the load.
Barriers to retention of Māori in the health and disability sector* In mainstream roles, expected to be expert in and deal with Māori matters Māori cultural competencies are not valued Dual responsibilities to employer and Māori communities Lack of or low levels of Māori cultural competence of colleagues Limited or no access to Māori cultural competency training Limited or no access to Māori cultural support/supervision Racism and/or discrimination in the workplace Isolation from other Māori colleagues
65% 64% 58% 58% 51% 48% 39% 33%
Retention enhancers for Māori in the health and disability sector Making a difference to Māori health Making a difference for my iwi/hapū Being a role model for Māori Ability to network with other Māori in the profession Strengthening Māori presence in the health sector Being able to work with Māori people Māori practice models and approaches valued Opportunities to work in Māori settings
92% 89% 80% 83% 92% 89% 81% 80%
Source: Participants’ ratings of importance of barriers as either ‘quite a lot’ or ‘major importance’ in research carried out for RATIMA et al. (2007), Rauringa Raupa, Ministry of Health. (Republished in Lisa Stewart’s ‘Māori Occupational Stress’ thesis.)
As at 31 March last year, 3,510 practising nurses – comprising 15 nurse practitioners, 3,245 registered nurses and 250 enrolled nurses – identified as Māori. This represents seven per cent of the total nursing workforce. In the 2013 census, Māori comprised 15.6 per cent of the total New Zealand population and were younger overall than the non-Māori population (a third were aged under 15).
PACIFIC
HEALTH STATISTICS
There are more than 40 different Pacific ethnic groups in New Zealand, each with its own culture, language and history.
An important skill for preventing burnout is the art of when to say ‘no’. Culturally, this is not always simple for Māori and Pacific nurses. Stewart says it is actually harder for Māori and Pacific nurses to say ‘no’ to their cultural communities then it is to say ‘no’ to people at work.
Barriers and enhancers sidebar table
As at 31 March last year, 1,733 practising nurses – comprising three nurse practitioners, 1,628 registered nurses and 102 enrolled nurses – identified with at least one Pacific ethnic group. This represents three per cent of the total nursing workforce. In the 2013 census, people identifying as Pacific comprised 7.4 per cent of the total New Zealand population and were also younger, on average, than the total population, with more than a third of Pacific people aged under 15 (compared with z20 per cent of the total population). Twenty-five per cent of Pacific nurses (425) were trained overseas – the majority in a Pacific nation.
Māori
Learning when to say ‘no’
Ministry of Health statistics show that Māori have higher rates than non-Māori for many health conditions and chronic diseases, including
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cancer, diabetes, cardiovascular disease, chronic pain, arthritis and asthma. About two out of five (40 per cent) Māori are obese, compared with around a third (33 per cent) of the total population. Ministry of Health statistics show Pacific people have a higher burden of chronic disease, such as diabetes, ischaemic heart disease and stroke. Two out of three Pacific adults are obese, compared with a third of the total population and the diagnosis rate for diabetes is approximately three times the rate for the total population. Socioeconomic determinants of health (such as unemployment, income, education and housing), plus lifestyle behaviours and cultural, historical and other factors all impact on the health risks and unmet health needs of Māori and Pacific people.
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Enough is enough:
Pay equity wanted for Māori and iwi health provider nurses Finau acknowledges saying ‘no’ can be an issue for Pacific nurses. “Some of us are just too polite and say ‘yeah’, ‘yeah’, ‘yeah’ and don’t say ‘no’ to anything. And commit and commit and you can tell they are over their limits. It’s a cultural thing – just trying to be nice and serve others rather than thinking about what you can do and what you can cope with.” The result is that nurses can learn to cope and over-cope, but Finau says she can say ‘no’. “I know when to say ‘no’ and tell them when this is enough and when things are rubbish.” Vaka says he used to overcommit to a lot of community projects and, combined with his PhD study, this left too little space for family time. “No wonder my wife would call my PhD the ‘other woman’,” laughs Vaka. He realised he had to be very selective in what extra commitments he said ‘yes’ to and now, unless he believes his expertise in health and research is going to be well-used, he will recommend another person. But it is still not easy. “At the moment I am still struggling to say ‘no’ to people. But I think I know now how to say ‘no’ nicely,” laughs Vaka. “And I think for us Pacific people we need to know when to say ‘no’, as we need to reassess when we have enough on our plate already if we want to deliver a good quality service [to our work and our community]. Don’t be scared of saying ‘no’.” Stewart agrees that it helps if nurses prioritise which goals are most important to them and decide how to make the best use of their time and expertise to meet those goals. This includes being aware of their own capabilities and when they are at risk of burnout “rather than just blindly saying ‘yes’ to everything.”
Conclusion
With its small numbers of nurses and high population needs, the Māori and Pacific health workforce is unfortunately at real and ongoing risk of burnout. Helping the existing workforce look after itself seems essential if that workforce is to have the rapid growth required to meet government targets and community needs. One part of the equation is for funders and employers to keep working at better supporting and fostering this scant workforce. Another may be for communities to be realistic in the expectations they place on their nursing members. The last is for nurses themselves to do their best to look after themselves (see sidebar for some ideas). “Nurses are no strangers to reflective practice – it is just a matter of reflecting on themselves rather than their work,” says Stewart. “The reality is that if we aren’t looking after ourselves, how can we do our best to look after our communities? The best way we can serve our communities is to make sure we are well ourselves.”
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ack in 1908, one of the country’s first Māori registered nurses and midwives, Akenehi Hei*, struggled to get the government to pay for her work. (See her story below.) More than a century later, nurses working for Māori and iwi health providers are still struggling with pay equity issues, says Kerri Nuku, kaiwhakahaere of Te Rūnanga o Aotearoa NZNO. Nuku says the pay gap between iwi nurses and their district health board counterparts has now got to the point that she knows of iwi nurses taking on extra jobs or contracts to make up for the low wages and to ensure a reasonable standard of living for their families. The journey for pay equity for these nurses began back in 2006. It followed the ‘pay jolt’ ratified in 2005 for district health board nurses, which initially saw the pay gap widen between all nonDHB nurses and their DHB colleagues. A further pay gap subsequently emerged between nurses employed by Māori-led healthcare organisations and their counterparts employed by primary health organisation (PHO) funded general practices. At the crux of the issue is a government funding model for Māori and iwi health providers that differs from that of a typical neighbourhood general practice. An 11,000-plus petition was presented to Parliament back in July 2008, pointing out the inequity and calling for the Government to work with NZNO and Māori and iwi PHC employers so that pay equity could be funded and delivered to their nurses and other health professionals. In 2009, in response to the petition and other evidence presented, the Health Select Committee recommended to Parliament that a working group look further into the petition issues – including recruitment and retention issues for the providers that deliver targeted services to Māori communities – and report back in six months. But Nuku says the Committee’s recommendation was vetoed by the Government and the working group never formed. She says there is also increasing frustration that health workforce projects keep setting Māori health workforce targets to meet health needs but as yet New Zealand still doesn’t have a single data repository showing what the current Māori workforce looks like, let alone addressing pay equity issues impacting on retention and recruitment of that workforce. Nuku says after a decade of unsuccessfully petitioning, lobbying and negotiating for more data and improved funding so Māori and iwi health providers can close the ever-widening pay gap, the rūnanga have said “enough is enough”. “How do we shine the spotlight on this discriminatory practice that has been going on for way too long?” There are documents such as 2012’s Thriving as Māori 2030, which says health services need to “at least triple” the Māori workforce by 2030 to reflect the communities they serve, and the tripartite Nursing Workforce Programme, which late last year set 2028 as the date that the percentage of Māori nurses needs to match the percentage of Māori in the population. But Nuku says that initiatives to date have done little to grow the Māori proportion of the nursing workforce, which has been basically static since the 1990s. “So we have been feeling quite aggrieved for a wee while,” she says. But after years of being wary of speaking out, she says rūnanga members are readying themselves for a ‘big year’ in 2016 and to start challenging the status quo. She says they are now viewing pay parity for Māori and iwi providers, and the lack of information on Māori health workforce data, as human rights issues. To this end, NZNO has written to the Universal Periodic Review (the United Nation’s Human Rights Council process that reviews the human rights situations of all 193 UN member states) to express its concerns about the issues and has also raised its concerns with New Zealand’s Equal Employment Opportunities (EEO) Commissioner, Dr Jackie Blue.
Pioneering nurse Akenehi Hei
In 1901 Akenehi Hei began a basic nursing skills programme intended to make her an “efficient preacher of the gospel of health” when she returned to her village as a “good, useful wife and mother”. In 1905 the scheme was extended to offer full nurse training and the still-unmarried Hei qualified as a registered nurse in mid-1908. She quickly completed her midwifery training in the same year in readiness to be part of a 1907 Public Health Department scheme to employ Māori district nurses (working in public hospitals was not envisaged or encouraged for the first Māori nurses.) But by 1908 there were still no government funds allocated to pay for Māori district nurses and it wasn’t until June 1909 that she was offered a two-month post nursing in a Northland typhoid epidemic. After that it took several more months until she was finally offered another post in New Plymouth. Tragically, she succumbed to typhoid herself in late 1910 after returning to Gisborne to nurse family members ill with typhoid. Her biography in Te Ara – The Encyclopedia of New Zealand states she not only had to deal with institutional racism – her postings were seen as a test case “to see how these Māori nurses act” – but also with little support from a department which was concerned with minimising costs and was not fully committed to Māori health work. www.nursingreview.co.nz | Nursing Review series 2016 11
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Self-care for nurses:
are you looking after yourself? Jan Aitken
Nurse turned life coach JAN AITKEN reflects on how well nurses look after themselves and offers some advice on self-care for nurses.
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s nurses our job is to work with people. We do this in a huge variety of settings, working alongside many other health professionals and colleagues, delivering our professional services to a huge variety of patients/clients. Our work can be incredibly rewarding, exciting, sad, frightening, joyous and plain hard – and that could be just in a single shift! Nursing is a very privileged occupation. We get to spend time with people when they are often at their most vulnerable and scared. We see and hear things that the rest of the community don’t see and hear. We learn about people’s lives from the inside out. Sometimes our work can be emotionally confronting. Shift work can be disruptive to our lives, our families’ lives and our sleep patterns. Sometimes the work is easy and other times it’s physically demanding – we’re on our feet constantly, we’re moving patients and equipment and there always seems to be more work than there is time. As well as being rewarding, nursing can be incredibly draining. As nurses we are very good at looking after others and taking care of their needs, but how good are we at looking after ourselves given the complex and sometimes stressful nature of our jobs?
Don’t run on an empty tank
We’re still early on in a new year so it’s a good time to think about what we do for ourselves to recharge our batteries. Just as you can’t run a car on an empty gas tank I don’t think we can nurse and be our best if our energy tanks are constantly being drained. As I look around me, I see many colleagues who are better at giving their time, energy and care to others than they are to themselves. So let’s make 2016 a year when we regularly do things to refuel our own energy reserves.
What can we do to care for ourselves better?
Practice self-care: Do something that you enjoy and take some time for you. This is not selfish. Ditch the guilt. Don’t try to be super-human: Remember unattainable perfection is just that: unattainable. You don’t have to be super-human, you don’t have to be perfect and it’s okay and normal to feel, frustrated, upset and tired sometimes. Self-compassion: Have some self-compassion. Use the skills that you have for being
“To recharge, keep it simple, do it often and enjoy it.” compassionate towards others on yourself. The empathy, concern and willingness to help you show your patients can be used for you to be kinder and more gentle toward yourself. Try to recharge batteries: Look for small gaps of time to recharge the batteries and keep the recharging simple. Life is busy and there are many competing demands on your time and energy. Make the most of your discretionary time. Get some fresh air: Research has shown that getting out and about in the fresh air can be incredibly good for body and soul. For many of us, our work day can be entirely inside with no natural lighting. So get outside for five, 10 or 15 minutes, it really doesn’t matter! This can be as simple as a walk in the park, pottering about your garden, walk along the beach, take the dog for a run, park further away from work or the shops and walk a little further, try out some of the tracks and parks around you, visit the local botanical garden. Be a bit mindful: Try being a bit more mindful throughout your day. Again, keep it simple! Several times during the day take a moment to concentrate on breathing deeply and slowly, in through your nose and out through your mouth. Pay deliberate attention to what you’re doing at any given time. You might be prepping a dressing, sitting down to write notes or walking to the café for lunch. You might be on a crowded bus, or maybe you’re preparing the veggies for dinner. What can you feel, what can you hear, what’s happening around you, how are you feeling, what’s your body doing? When your mind wanders off, and it will, gently bring your focus back to the breathing and paying attention to what you’re doing. Don’t be hard on yourself for
12 Nursing Review series 2016 | www.nursingreview.co.nz
losing focus, just let it go. These moments of minimindfulness need only be five or six deep breaths at a time but they are wonderful for helping you become more aware, calmer, and allowing you to catch your breath. Don’t forget your hobbies and passions: Do you have a hobby? Is there something you’re passionate about that fills your soul when you do it? Is there something that helps you to unwind and re-energise? Make a conscious effort (set a goal) to incorporate it into your schedule regularly. Confucius said: “We all have two lives, the second begins when we realise we only have one”. Make 2016 the year that you really begin to look after the one precious life you have. Caring for ourselves doesn’t just benefit us, it benefits all those we come into contact with. To recharge, keep it simple, do it often and enjoy it. AUTHOR: Jan Aitken BN, PGCert Adv Nursing (Surgical Assisting), Adv Life Coaching, is a life coach for Fit for Life Coaching: www.fitforlifecoaches.co.nz
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When nurses grieve: caring better for the carers
FIONA ROWAN asks how well the caring profession cares for its own when nurses lose loved ones and shares findings from her survey of 70 bereaved nurses that indicate New Zealand could do better.
W
e are all familiar with the mantra ‘should an oxygen mask appear in front of you, secure your own mask before helping others’, and also being told to ‘take note of our nearest exit’. In other words, ensure your own safety first so you can then care for others, and also have an escape plan in case things don’t go well. These are recommendations that few airline travellers would argue with. But to what extent are these strategies relevant when a nurse has experienced a personal bereavement through the death of a family member, friend or colleague? My recent research indicates that while some bereaved nurses adopt the airlines’ ‘care for yourself first so you can care for others’ approach, others do not, or are unable to do so.
Bereaved nurses feel ‘unsafe’
For my Master of Nursing research thesis I asked nurses in three district health boards about their experiences of returning to work following a personal bereavement, including whether or not they felt safe to work on resuming their nursing duties. Alarmingly, 28 per cent of the 70 nurses who responded indicated that they felt unsafe while working, with over one third testifying that their critical analysis skills were adversely affected. Bereaved nurses returning to work described enduring physical and psychological symptoms of grief including ongoing fatigue (64 per cent), tearfulness (57 per cent), insomnia (48 per cent), inability to stop thinking of their loved one (60 per cent), difficulty concentrating (42 per cent), being easily distracted (42 per cent), poor memory (28 per cent), and difficulty making decisions (22 per cent). Nurse managers and charge nurses were also asked to comment about the strategies they use to assess a bereaved nurse’s safety to work. Eighteen per cent of the 31 nurse leader respondents indicated they initiate an informal conversation with the nurse or request that the nurse self-assesses their own safety to work. The remaining nurse leaders (82 per cent) did not assess bereaved nurses’ safety to work in any way. The validity of relying solely on a bereaved nurse’s self-assessment of their safety to work must be questioned. Nearly half of the 72 per cent of nurse respondents who described themselves as safe to work went on to express 14 Nursing Review series 2016 | www.nursingreview.co.nz
Fiona Rowan
an array of grief symptoms upon resuming their nursing duties. Although the impact of these symptoms was not explored, the study data suggests that bereaved nurses may not be in the right place to critically analyse and make decisions about their own safety to work, as it is these very skills that are adversely affected by bereavement. This limited consideration of nurses’ safety to work following a personal bereavement is of concern, particularly given that American nursing academics Marguerite Purnell and Lucy Mead suggest that bereaved nurses should be considered as a unique cohort of the bereaved, separate from the general population. Anyone experiencing personal bereavement will require support to adjust to the changed reality of living without their loved one. However, Purnell and Mead contend that, unlike the general public, nurses need to do so while remaining empathetic to and understanding of their patient’s concerns – patients who themselves may be experiencing illness, pain, grief or impending death. Purnell and Mead have termed this intermingling of nurses’ personal grief with the professional response to their patient’s grief, as “layered suffering”.
Presenteeism risk
That bereaved New Zealand nurses report nursing while experiencing this disruption to their physical health and cognitive proficiency confirms that some bereaved nurses practice what is known as presenteeism; that is, working when unwell. A presenteeism study by American nurse researcher Susan Letvak and her colleagues published in 2012 found that nurses who worked while unwell escalated patient risk, resulting in an increase in medication errors and patient falls, and a decrease in the quality of care. When this practice of presenteeism in bereaved nurses is combined with shift work-related fatigue and the increasing acuity of today’s healthcare environment, there is the potential for creating a ‘perfect storm’ for these grieving nurses and their patients. The nurses’ motivations for practicing presenteeism were not explored in detail in this research. However, respondents indicated that limited access to both paid and unpaid leave, limited nurse manager understanding of the
FOCUS n Healthy Year Ahead
“ … bereaved nurses may not be in the right place to critically analyse and make decisions about their own safety to work.”
impact of bereavement on core nursing values, and the socialisation of nurses to the caring role (whereby their own needs are subsumed by the dominant team culture) were all contributing factors.
Bereavement leave recommendations
A number of recommendations and suggestions have arisen from this research around bereavement leave, including: »» improving flexibility and extension of leave options to help reduce the practice of presenteeism in bereaved nurses »» recognising that legislated bereavement leave requirements are frequently insufficient to meet the needs of grieving nurses »» advocating regular nurse manager contact with the bereaved nurse, focusing on acknowledging the nurse’s loss and helping them to identify the impact of the bereavement and any specific needs »» assessing a bereaved nurse’s safety to return to nursing duties. This may involve identifying existing or developing novel grief assessment tools.
Return-to-work strategies
The research also recommends the adoption of some practical strategies for when bereaved nurses return to work. Adopting such strategies may mitigate the adverse layering effects of bereaved nurses caring for patients who themselves may be grieving and the risks associated with presenteeism in bereaved nurses. Some return-to-work strategies suggested include: »» a phased return to work »» allowing for flexible work hours and/or workload »» allocating an empathetic caseload (ie, avoiding the care of palliative clients or those with particular conditions) »» adopting a routine supported practice model for bereaved RNs returning to work; for example, the grieving nurse working alongside a mutually agreed experienced colleague. (Both caseloads could be managed as one so decision-making is shared, medications co-checked, and support provided in a personalised and timely manner.) Further consideration needs to be given to identifying the impact that personal bereavement may have upon nurses’ core values and upon their ability to retrieve tacit and formal knowledge. Ultimately, we need to consider the implications for our patients if bereaved nurses fail to attend to their own needs first, or are unable to identify when using an ‘exit strategy’ is the safest course of action for all. Author: Fiona Rowan, RN, MN, Nurse Educator, MidCentral Health. Her MN thesis for the Eastern Institute of Technology was inspired by her personal experience following the tragic death of her brother as a result of the 22 February 2011 Christchurch earthquake. Rowan’s thesis ‘When nurses grieve: how well are we caring for the carers?’ can be downloaded at www.digitalnz.org/records/36302521
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www.nursingreview.co.nz | Nursing Review series 2016 15
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Are you
‘matchforfit’ nursing?
Lynda Lovatt
N
ursing is very physical – it is like a sport in a way. You can be lifting patients, bending and twisting, squatting, sitting, walking and standing throughout a long shift – particularly on day shift. This can be for days on end and with little recovery in between. We need to be match fit to cope with the demands of nursing on our body. Here are some things you can do to look after yourself and feel great on a shift.
Improve your cardiovascular fitness
Quite simply, being fitter will help you get through your shift: »» Do an activity that you enjoy that gets your heart rate up. »» Aim to increase the intensity or duration a little EACH TIME you do this exercise. A good example is walking – you can add in stairs, do the walk faster or go for longer; doing this will get you fitter. »» Take your radial pulse in the morning, make a comparison in a month after training in this way and see if it has taken your pulse rate down – a measure of improved fitness. Well done. Let’s do this!
LYNDA LOVATT – a nurse turned personal trainer – shares tips on being ‘match fit’ for the physical demands of nursing.
Gain core synergy
»» When you inhale the breath should be coming from the base of your lungs, and not so much from your chest. As you breathe out long and slowly, you should feel a connection with your pelvic floor and deep abdominal muscles. »» To engage your core, instead of drawing in your abdomen, think about lifting your pelvic floor (men have one too). »» Before you go to lift something, think about engaging your pelvic floor a little before you do the task. As you go to lift the object, engage your pelvic floor more strongly and exhale all at the same time. »» Lifting like this will help to protect your pelvic floor. It will also connect with the rest of your core muscles. »» Follow carefully the safe lifting guidelines in your workplace to further protect your back. Or check out ACC’s Moving and Handling People: The New Zealand Guidelines (2012): http://bit.ly/23C4gGT For more information about pelvic floor, read my Nursing Review article from 2014 on the topic: http://bit.ly/1nxselv
Eat well and stay hydrated
»» Please make sure you have breakfast – this is a no-brainer. You are about to do an endurance event, an eight-hour shift of walking, bending, lifting and standing. You need to eat, and eat well, before you start the shift and frequently during it. »» If you are starving after your shift, it is most probably because you have not eaten sufficiently during your shift. »» Eat some protein and carbohydrate with every meal. Add in some veges or fruit. »» Plan what you are going to eat for when you are working. »» Make sure you drink water. As you are nurses, check your urine color and if this is clear, you are well hydrated. If it is yellow, top yourself up with more water. You guys know this stuff.
Rest and recover
»» Be in tune with your body after a shift. How are you feeling? It is good to bear in mind that exercise is a stress on the body; it can make you feel amazing or it can leave you feeling depleted. »» On your days off, or after a shift, run a little experiment on yourself. Go for one of your fitness-boosting walks and note when you come home how you feel. If you are feeling energised and happy, that exercise has been good for you. If you are feeling shattered, that exercise was too much for you. It would be better to reformat the way you did that exercise next time or relax instead. »» Schedule time for you. Have a massage or a pamper session booked. Organise a relaxing holiday. Always enjoy some chill time every day to unwind and recuperate. 16 Nursing Review series 2016 | www.nursingreview.co.nz
»» Try to eat well most of the time and drink lots of water on your shift (see previous section). If you are tired after your shift, stop and ask yourself why and what you can do to feel better. You are important and you do a wonderful job every day. Please take some time this year to work on your cardiovascular fitness, core synergy and eating well. You will really notice a difference in your energy levels and look and feel so much better at work. I wish you all a wonderful year ahead. I hope you can take some of this advice away to help you be match fit in 2016. Author: Lynda Lovatt is a personal trainer and the owner/operator of Puff Fitness. She specialises in women’s health and fitness and covers pregnancy, postnatal and menopausal exercise. She has a special interest in pelvic floor issues and core restore.
FOCUS n Healthy Year Ahead
Gynaecological cancers:
Silent no longer More than 1,000 New Zealand women are diagnosed with gynaecological cancers every year and around 400 die of them – the majority from ovarian cancer. Nursing Review seeks to raise awareness of this female-only group of cancers, including why labelling ovarian cancer the ‘silent killer’ is not helpful, what obesity has to do with endometrial cancer, and how a vaccine can save lives. FIONA CASSIE reports.
Ai Ling Tan
Y
ou can rarely get through the supermarket aisles or glance through a glossy magazine without coming across a Pink Ribbon promotion or something to do with breast cancer. But when it comes to the other ‘feminine’ cancers – those that begin in women’s wombs, ovaries, cervixes or vulvas – we see or hear much less. This may partly be because breast cancer is much more common – roughly 3,000 diagnoses in New Zealand each year, compared with around 1,000 for the five main gynaecological cancers combined, and it may also be because breasts are more socially acceptable to discuss than ‘down there’. A survey last year by British gynaecological cancer research fund The Eve Appeal found that 39 per cent of women believe there is a greater stigma around gynaecological cancers than other types of cancer. The lower profile of gynaecological cancers may also, sadly, be because there are fewer survivors to advocate for greater awareness. The most deadly of the gynaecological cancers – ovarian cancer – has a five-year survival rate of 40–50 per cent, compared with closer to 90 per cent for breast cancer. The New Zealand Gynaecological Cancer Foundation was founded in 2006 with one of its
major aims being to help raise awareness of the signs and symptoms of gynaecological cancer so that more women’s cancers are detected earlier and more lives are saved. The longest-serving member of the Foundation’s board of trustees is Dr Ai Ling Tan, one of the country’s handful of certified specialist gynaecology oncologists. Gynaecological oncologists first complete training as obstetrics and gynaecology specialists and then do an additional three years of sub-specialty training focusing mainly on the specialist surgery required but also covering all aspects of the diagnosis and care of women with gynaecological cancers. A major part of Auckland-based Tan’s work – and her counterparts in Auckland, Christchurch and Wellington and their multidisciplinary teams, including gynaecological cancer nurse specialists – is working with the, on average, about 300 new cases a year of ovarian cancer and 500 or so uterine (mostly endometrial) cancers. New Zealand currently has seven or eight gynaecological oncologists, five of whom have RANZCOG certification, and it is estimated that we need at least 11. There is also a shortage of gynaecological cancer nurse specialists, who have a core role in the patient’s journey.
www.nursingreview.co.nz | Nursing Review series 2016 17
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The not so ‘silent’ disease
When people do talk about ovarian cancer, it is often referred to as the ‘silent killer’. It was historically given this lethal label as the symptoms were not thought to emerge until the chance of cure was poor. It is true that in the majority of ovarian cancer cases there is no disease-specific early warning sign, like a breast lump or abnormal bleeding, and no screening programme like there is for breast and cervical cancer. So by the time most women are diagnosed with ovarian cancer it is often a stage III cancer and has spread throughout the abdominal cavity. But in recent decades – as treatment improved and evidence grew of consistent, though nonspecific, symptoms that could lead to earlier diagnosis – there has been a backlash against the ‘silent killer’ metaphor. In 2007 the American Cancer Society, the Gynecologic Cancer Foundation, and the Society of Gynecologic Oncologists announced for the first time a national consensus around the early signs of ovarian cancer and a similar consensus was released in the UK in 2008. At the same time, the American Cancer Society disassociated itself with the term ‘silent killer’ for ovarian cancer, saying it was “a catchy phrase” but it was wrong. Ai Ling Tan agrees, saying people call it the silent disease “but in actual fact it is not that silent”. She says the research from Australia and the US shows many women who present with ovarian cancer have had symptoms for more than six months. Their symptoms include feeling consistently bloated, having difficulty eating/feeling easily full and persistent pelvic and abdominal pain (see also sidebar). The symptoms may be non-specific, but if they are new, persistent and worsening, women should talk to their GP or NP. “Most women when I sit and talk to them will say that they had A, B, C or D symptom but thought it was due to menopause or something else.”
Tan believes greater awareness of ovarian the tumour tissue as possible from within the cancer symptoms could see more women abdominal cavity. The surgery is usually followed diagnosed earlier, along with women being by a course of chemotherapy. persistent in seeking answers if the symptoms Tan says the “major, major surgery” required continue or worsen. “If the GP doesn’t can take between four and seven hours and the investigate then ask again or get a second research data indicates that women with ovarian opinion.” cancer operated on by gynaecological oncologists About one in 10 ovarian cancers are genetic have increased survival rates. She says this is cancers. Tan says while genetic cancers make because of the specialist surgery required, the up a small proportion of ovarian cancers, it is a gynaecological oncologists’ understanding of the proportion in which women can be proactive. A total disease, and the fact that they work as part mutation, particularly in the BRCA1 gene, but of a multidisciplinary team, including medical also in the BRCA2 gene, is associated with an oncologists, pathologists, radiologists and increased risk of ovarian and breast cancers. specialist nurses. The most wellChristchurch known example gynaecological is Angelina oncologist Jolie, whose B is for Bloating (it is persistent and doesn’t come and go) Dr Bryony mother and Simcock was E is for Eating (difficulty eating and feeling full more quickly) grandmother quoted last year A is for Abdominal (and pelvic pain you feel most days) both died of in The Specialist, T is for Talking (tell your GP) ovarian cancer the Association of and her aunt Salaried Medical of breast cancer. After testing positive for the Specialists’ magazine, saying “gynaecological BRCA1 gene, Jolie first underwent a prophylactic oncology in New Zealand provides a world class mastectomy and then the removal of her ovaries service in less than world class conditions”. and fallopian tubes. The five-year survival rate for all ovarian In New Zealand it is advised that if there are cancers has been improving, with Tan saying the two or more cases of breast or ovarian cancer survival rate for early stage ovarian cancers is in a woman’s close family then women should about 80–90 per cent and for stage III, which is seek advice from their doctor (see sidebar p.22 what about 75 per cent of women present with, for link to Gift of Knowledge website for more the survival rate is about 40-50 per cent. information).
BEAT ovarian cancer
Ovarian cancer treatment
The most common ovarian cancer is epithelial cancer, which Tan says can have two disease pathways. Some women present early (stage I or II) with a lump, but the majority present later (stage III) with widespread disease within the abdomen. The later presentation cancers require surgery to not only remove the ovaries and uterus but also ‘debulking’ surgery to remove as much of
Don’t ignore abnormal bleeding
The most common gynaecological cancer is endometrial cancer – that is, cancer of the lining of the womb. Unlike ovarian cancer, more women are diagnosed in early stage endometrial cancer because they present with abnormal bleeding. Also unlike ovarian cancer, where the vast majority of cases occur in women aged 45 or older, currently around half of the endometrial cancer diagnoses are in women under 65.
Symptoms of gynaecological cancers NOTE:
Having the symptoms below doesn’t mean you have or will get cancer – but it is important to consult your GP or NP. »» Bleeding following menopause is NOT normal »» Bleeding after sexual intercourse is NOT normal »» If, after visiting your GP or NP, the symptoms continue or worsen, it is important to return and inform them of this.
Ovarian cancer
If you have the symptoms below and these symptoms persist on most days for two weeks or more, see your GP or NP. Most frequent symptoms: »» Persistent pelvic and abdominal pain »» Increased abdominal size/persistent bloating – not bloating that comes and goes »» Difficulty eating and feeling full quickly. Sometimes you may experience these symptoms on their own or at the same time:
»» »» »» »»
Change in bowel habits Extreme tiredness Urinary symptoms Back pain.
N.B. See information sidebar p.22 for downloadable ovarian cancer symptom diary. There is a genetic link to some ovarian cancers so if there are two or more cases of ovarian or breast cancer in your close family, seek advice from your doctor. For more information, visit the Gift of Knowledge website (see information sidebar p.22).
Uterine cancer (including endometrial cancer)
If you have any one of these symptoms, please see your GP or NP. »» Abnormal bleeding »» Bleeding after the menopause »» Bleeding between periods
18 Nursing Review series 2016 | www.nursingreview.co.nz
»» Heavier periods than normal. »» Abnormal discharge »» More than normal or strong smelling.
Cervical cancer
If you have any one of these symptoms, please see your GP or NP. »» As with uterine cancer (see above) »» Painful sex »» Bleeding after sex.
Vaginal and vulval cancer
If you have any one of these symptoms, please see your GP or NP. »» Vulval itching, soreness »» Obvious change in colour of the vulval skin »» A noticeable lump. Source: Symptoms reproduced with thanks from the New Zealand Gynaecological Cancer Foundation’s website: http://bit.ly/1Slll4p
FOCUS n Healthy Year Ahead
The earlier diagnosis also means higher survival rates, with New Zealand’s latest cancer survival statistics showing a five-year survival rate of 78.5 per cent for uterine cancers in general. (Endometrial cancer makes up the majority of uterine or womb cancers, with the other forms of uterine cancer being more rare). But Tan says greater awareness is still needed amongst women in general about what is abnormal bleeding (see symptoms sidebar). “My big message is to tell women that if you have any bleeding after menopause – that is not normal.” “One of my major hobby horses is women who are post-menopausal who think bleeding after menopause is normal,” says Tan. She says unfortunately there are a lot of women out there who think that it is. “My big message is to tell women that if you have any bleeding after menopause – that is not normal.” Tan says nurses can play a huge part in promoting awareness of gynaecological symptoms, like abnormal bleeding, when they work with female patients – particularly in general practices but also other settings. “I always tell the practice nurses I talk to that they have a fantastic opportunity for education, promoting awareness and responding to concerns that could turn out to save someone’s
Obesity a risk factor
life,” says Tan. “Because a woman might not be telling the GP that she is having post-menopausal bleeding as she thinks it’s embarrassing – particularly an older woman. They usually have a much better rapport with nurses as they feel more comfortable with them.”
Obesity is a known risk factor for endometrial cancer, which Tan says is an important link as New Zealand is starting to see more cases. The Cancer Research UK website, in a posting from late last year, says studies show an increased risk of breast and womb cancer in women who are overweight or obese after menopause. It quotes Professor Martin Wiseman of the World Cancer Research Fund saying that he is in no doubt that oestrogen made by fat cells is a leading culprit in post-menopausal breast and womb cancer as too much oestrogen can encourage breast and womb cells to “keep dividing when they shouldn’t be”. Tan agrees there is good biochemical data about the impact of obesity on hormones like oestrogen, which impact on the lining of the womb. She says studies have also shown that unless overweight women who have been treated and cured for endometrial cancer lose weight and maintain a healthy lifestyle, they risk dying within five to 10 years of a cardiovascular event. “In America, they tell every woman who has had endometrial cancer, and who is also overweight, that they need to lose weight,” says Tan, who believes it is important that women are informed of the relationship between obesity and endometrial cancer.
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www.nursingreview.co.nz | Nursing Review series 2016 19
FOCUS n Healthy Year Ahead
The cancer that screening and vaccine can prevent
T
he number of women who die from cervical cancer in New Zealand has dropped dramatically by 60 per cent since 1990. The human papillomavirus (HPV) vaccine, available free to all young women under 20, may in the future see even fewer women lost to this most preventable and most high profile of the gynaecological cancers. The high profile in New Zealand grew out the 1987 Metro article ‘An unfortunate experiment at National Women’s Hospital’ by Sandra Coney and Phillida Bunkle, involving under-treatment of women with severe pre-cancerous (CIN3) changes of the cervix. The article prompted the 1987–88 Cartwright Inquiry, named after the presiding judge, Judge Dame Silvia Cartwright, and in turn the setting up in 1990 of the National Cervical Screening Programme, in which more than 95 per cent of eligible women are now enrolled. It is now well known that having a regular smear test reduces a woman’s risk of developing cervical cancer by 90 per cent. Jill Lamb has worked in women’s health for more than three decades and in colposcopy for two, so has seen the full impact of the Cartwright Inquiry. In 2009 she became New Zealand’s first registered nurse colposcopist, joining already authorised women’s health nurse practitioner Georgina McPherson in being the first non-doctors to use colposcopy to diagnose whether women with moderate to high-grade abnormal cervical smears have pre-cancers, cancers or non-cancers.
Jill Lamb
Changes over the decades in which Lamb has worked in the field have meant a refining of the screening programme as more research evidence becomes available about HPV infections, abnormal smear tests and cervical cancer. “We used to do a lot more treatments for lowgrade abnormalities but we now realise that they usually clear by themselves and the women are monitored instead.” With thousands of women each year getting low-grade abnormal smears (CIN1), this has prevented many going through the anxiety of unnecessary colposcopies.
HPV and cervical cancer »» It is estimated that at some point in their lives about 80 per cent of sexually active women will become infected by one of the about 40 types of human papillomavirus (HPV) that affect the genital area. »» Most HPV infections have no symptoms and clear on their own, but if infection by one of the 15–20 ‘high-risk’ HPV types is persistent, this can lead to abnormal pre-cancerous cells developing. »» If the abnormal cells are not detected, via a regular smear test every three years, and treated, they may progress to invasive cervical cancer. »» Having regular smear tests can reduce a woman’s risk of developing cervical cancer by 90 per cent. »» An HPV vaccine that is now available for free for young women aged 12–20 targets several high-risk HPV types known to cause around 70 per cent of cervical cancer. »» In 2012 there were 166 new cases of cervical cancer diagnosed and 56 women died of cervical cancer. »» HPV can also cause cancer of the vulva, vagina, penis, anus, some head and neck cancers, and genital warts. »» Genital warts are caused by ‘low-risk’ HPV types and are not associated with cervical cancer. Sources: National Cervical Screening Programme http://bit.ly/1SScOFH Immunise Australia Program http://bit.ly/1TvuCWx
20 Nursing Review series 2016 | www.nursingreview.co.nz
HPV awareness and vaccine
Lamb thinks some generational differences have also emerged since New Zealand introduced a national, free, HPV immunisation programme in 2008 for young women under 20, aimed at reducing HPV infection and cervical cancer. The Gardasil vaccine targets four high-risk HPV types that are responsible for 70 per cent of cervical cancer and 90 per cent of genital warts. “Young woman are very comfortable – if they’ve had the vaccine – with realising that HPV can cause cervical cancer and they are trying to
“ ...nurses can play a huge part in promoting awareness of gynaecological symptoms, like abnormal bleeding, when they work with female patients – particularly in general practices but also other settings.”
FOCUS n Healthy Year Ahead
prevent it by being vaccinated against the most common virus types causing the cancer,” says Lamb, “while many women now in their 40s, 50s and 60s didn’t even realise that an abnormal smear test was caused by a virus.” An important part of her job is raising awareness of the HPV vaccine in every patient she meets, telling them that a free vaccine is available for their daughters, sisters, nieces and grand-daughters and that across the Tasman it is also now offered free to boys. “A lot of people who have had colposcopy are very keen to get their children vaccinated… a lot of them don’t want their daughters going through unnecessary vaginal examinations and treatments if they can avoid it.” Lamb also spends much of her time putting people’s fears to rest by telling them that testing positive for a high-grade HPV virus is more normal than not; and in most cases it clears naturally. She says many women who present for colposcopy with medium to high-grade abnormal smears are already very anxious. “They arrive thinking they have cervical cancer because of the word ‘abnormal’ and then you mention they have a virus… “So I try and normalise them and tell them that having HPV is a very normal part of being a human being. We share the planet with viruses, parasites and bacteria and it’s what we do. What we don’t want people to get is cervical cancer.” While most people with high-grade HPV will clear the virus naturally within 6–24 months, around 11 per cent of people will have high-risk virus throughout their lives – this doesn’t mean they will get cancer but they will need to be carefully monitored and referred to colposcopy. Of those women who do go on to develop high-grade (CIN3) pre-cancerous abnormal cells, about a third (33 per cent) would also go on to develop cervical cancer if the abnormalities were not removed. “We can remove the abnormality but we cannot remove the virus,” says Lamb. This is one of the reasons why Lamb is also a strong smokefree advocate, as smokers, and the immunocompromised, can struggle to clear the HPV virus from their systems. HPV awareness is growing with the advent of the vaccine and will need to grow even more, as the National Cervical Screening Programme has been consulting on moving from the current cytology screening for abnormal cells to HPV screening for high-risk HPV types, which is thought to be a more reliable screening tool. Women would notice little change to the actual cervical screening, with the major difference being at the laboratory end and the likelihood of screening dropping from three-yearly to five-yearly for those with normal test results. The hope is that immunisation, combined with regular screening, will see cervical cancer numbers continuing to fall. At present Lamb says she sees between 40–50 women a week in her colposcopy clinics and probably only sees, on average, one woman every two months with actual cervical cancer. May that number keep on falling.
“My big message is to tell women that if you have any bleeding after menopause – that is not normal.”
Risk reduction Some steps to reduce the risk of the following: Cervical cancer »» Practice safe sex (ie, use condoms to reduce exposure to HPV virus that can cause cervical cancer). »» Encourage uptake of free HPV vaccination for young women up to 20 years old and consider vaccination of young men also. (Vaccination can also help protect against vaginal and vulval cancer.) »» Have a three-yearly cervical smear test from the age of 20 to help prevent cervical cancer. (Note: a smear test will NOT detect or protect against other gynaecological cancers). All gynaecological cancers »» Be smokefree. »» Keep a healthy weight: being overweight can increase risk of some gynaecological cancers, particularly endometrial. Source: adapted from the New Zealand Gynaecological Cancer website http://bit.ly/1SSjgfY
Gynaecological cancer statistics »» »» »» »» »»
1,063 women were diagnosed with gynaecological cancers in New Zealand in 2012. The most common diagnosis was uterine (513), ovarian (266) and cervical (166) cancers. 394 women died of gynaecological cancers in New Zealand in 2012. 175 died of ovarian cancer, 121 of uterine cancer and 56 of cervical cancer. Ovarian is the fourth biggest killer of New Zealand women, with one woman dying every 48 hours from ovarian cancer (on average about 310 cases year and 200 deaths). »» In comparison, in 2012 there were 3,025 women diagnosed with breast cancer and 617 deaths due to breast cancer. »» In 2011 New Zealand’s five-year relative survival rates were: breast cancer (87%), cervical cancer (72%), ovarian cancer (39%) and uterine cancer (78.5%). »» Gynaecological cancers make up approximately 10 per cent of all cancer cases and cancer deaths in New Zealand. Sources: Ministry of Health (2015) Cancer: New Registrations and Deaths for 2012 Ministry of Health (2015) Cancer Patient Survival (1994 to 2011) New Zealand Gynaecological Cancer Foundation www.nursingreview.co.nz | Nursing Review series 2016 21
FOCUS n Healthy Year Ahead
We need to
talk more about vulvas
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“very, very distressing” cancer that nobody talks about. This is how Christchurch gynaecological oncologist Bryony Simcock opened her address on vulval cancer to last year’s NZNO Women’s Health section conference. Vulval (or vulvar) cancer is amongst the rarest of the gynaecological cancers and can occur on any part of women’s external genitalia but most commonly on the labia. Almost half of the women surveyed last year by British gynaecological cancer research fund The Eve Appeal said they’d like to be able to talk more openly about gynaecological health, and 34 per cent said they would feel more comfortable talking about gynaecological health if the sexual stigma was reduced.
Silent suffering
Simcock sees the results of women being too shy or embarrassed to raise the topic of their vulval health. In her presentation last year, she shared the sad tale of an “absolutely delightful” woman in her 70s who presented to hospital as being generally unwell and “off her legs”. The woman’s husband told hospital staff that he knew something was wrong as she was increasingly housebound and he kept asking her to go to her GP, which she had done several times with minor complaints in the previous few years. In the first 48 hours after admission the medical team found nothing wrong with her but that she was uncomfortable and had noticed a “funny smell”. On the third day after admission a CT scan was done and they discovered 9cm nodes in her groin. The woman was sent to Simcock, who examined her and discovered a “huge tumour” replacing the entire perineum, a tumour so large that the poor lady couldn’t sit properly – the cause of her discomfort. “She had been in hospital for more than 48 hours and nobody had looked below her belly button,” recalls Simcock. She says the woman was aware that she hadn’t told anybody what was the cause of her discomfort but Simcock also noted that nobody had asked her.
Bryony Simcock
Simcock shared another story of a young woman who had been referred to colposcopy for low-grade cervical smears, but it was several years later that she mentioned that she had also had a vulval itch for four years. On referral to Simcock, the 28-year-old woman was found to have high-grade pre-cancerous cells of the vulva – caused, as in cervical cancer, by high-risk HPV infections – that are known as VIN3 (vulval intraepithelial neoplasia) and these cells had to be cut away. “We’d been seeing her but we hadn’t looked properly.” Another young woman in her 20s, a smoker who took occasional drugs, presented after having had a vulval itch for two years and was also found to have VIN3 due to HPV infection, which had to be removed by surgery. Simcock says vulval cancer is a rare cancer, with probably only about 10–15 cases a year in Christchurch, and the vast majority of all vulval cancers (95 per cent) are squamous cell cancers with the remainder being melanomas. Vulval cancer is a cancer that is most common in older women but it can also be seen in young women. There are two pathways for vulval cancer. One is infection by HPV or wart viruses that many women are exposed to, but some get high-risk HPV infections that lead to pre-cancerous VIN, a condition that is more common in smokers and the immune suppressed. The other is through a chronic and benign skin condition known as lichen sclerosus, which can cause an itch that Simcock says prompts many women to wash more frequently, thinking they must be dirty, which can make them even itchier. The cause is unknown, but it is associated with autoimmune diseases and about 1 in 20 women with the condition will develop a cancer.
Listen, look, educate, encourage
Simcock says the take-home messages about vulval cancer for nurses working with women is to listen, look, educate and encourage vaccination against HPV, which can reduce the risk of vulval, as well as cervical, cancer.
Vulval and vaginal cancer
»» In 2012 there were 67 new registrations of vulval cancer and 14 of cancer of the vagina in New Zealand. »» Fourteen women died of vulval cancer in 2012 and eight of vaginal cancer. »» Like cervical cancer, a risk factor for vulval and vaginal cancer is HPV infection leading to precancerous changes known as VIN (vulval intraepithelial neoplasia). »» A chronic benign and progressive skin condition called lichen sclerosus can also predispose women to cancer of the vulva. 22 Nursing Review series 2016 | www.nursingreview.co.nz
FURTHER INFORMATION All gynaecological cancers New Zealand Gynaecological Cancer Foundation Aims to inform and educate community about gynaecological cancers with the aim of increasing survival rates. Has information on symptoms, statistics and personal stories and resources for health professionals. www.nzgcf.org.nz
Ovarian Gift of Knowledge Registered charity focused on raising awareness and reducing incidence in New Zealand of genetic breast and ovarian cancer. www.giftofknowledge.co.nz Ovarian Cancer Australia’s Symptom Diary Downloadable tool that women can use to track and record four common ovarian cancer symptoms (pelvic abdominal pain, increased abdomen size/bloating, urinary frequency/ urgency and feeling full after eating a small amount) over four weeks. http://bit.ly/1KQrjCd
Uterine cancer (including endometrial) Cancer Research UK Blog published in November 2015 on links between obesity and some cancers, including the ‘oestrogen connection’ between obesity and increased risk of womb (endometrial) and breast cancers. http://bit.ly/1TvzJ98
Cervical National Cervical Screening Programme http://bit.ly/1SScOFH HPV immunisation programme Information on New Zealand’s Human Papillomavirus (HPV) immunisation programme for girls and young women up to 20 years old. http://bit.ly/1TvC83F The New Zealand HPV Project Information on genital HPV, its management and HPV vaccination, including of boys and young men. www.hpv.org.nz Immunisation Advisory Centre For response to last year’s 3D programme on HPV vaccine Gardasil. www.immune.org.nz/3d-story-gardasil
FOCUS n Healthy Year Ahead
Caring for colleagues:
noticing factors leading to disciplinary action
PATRICIA McCLUNIE-TRUST looks at caring for nursing colleagues who are close to the edge and shares insights gathered from her research into Health Practitioners’ Disciplinary Tribunal misconduct cases.
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very year we see a number of our nursing colleagues disciplined for inappropriate responses to clients, professional boundary violations, or breaches of client confidentiality. I have often wondered what circumstances led to nurses contravening nursing’s values and beliefs about how our profession ought to conduct themselves with clients, families and colleagues. These values and beliefs, about what constitutes professionalism and professional conduct, are integral to the socialisation of students in preregistration programmes and the Nursing Council of New Zealand professional development requirements for registered nurses. A belief that we need to understand more about what lies behind these disciplinary cases inspired me to research case reports published on the Health Practitioners’ Disciplinary Tribunal website between 2012 and 2014. Each of the 14 disciplinary cases I reviewed represents a professional life lost to nursing or, at the very least, a nursing career that has been profoundly disrupted. In these cases, some nurses were deregistered for breaches of conduct that clearly compromise public safety and the reputation of nursing in New Zealand. Their professional lives were lost to nursing for good reasons. However, other nurses found guilty of professional misconduct were not deregistered, and after appropriate sanctions and a period of supervision, were permitted to return to practice. The effects of being disciplined are profound. The case reports suggest nurses were either dismissed from employment or resigned. Finding further employment in such circumstances is challenging and it is likely that some of these nurses do not return to the workforce. The question in my mind is whether nurses could do more to help colleagues moderate or modify their behaviour in noticing conduct that leads to disciplinary action.
Factors leading to misconduct
In the cases I reviewed, there was a ‘perfect storm’ of elements that coalesced in situations where nurses made inappropriate decisions about how to respond to a client, family or colleague. These elements included professional, personal and organisational factors, that were present in the circumstances surrounding an inappropriate response or series of actions that constituted professional misconduct. I am not suggesting that these factors in any way mitigate the actions of these nurses. However, a deeper understanding
of the context in which misconduct events occur may help nurses to understand more about how to recognise and call a colleague’s attention to professionally unsafe practice. Some professional factors apparent in the descriptions of nurses’ behaviour included a borderline level of competence or lack of knowledge about some aspects of practice, or a lack of ability to capably respond to an unusual or demanding situation. Failure to check out what a colleague might do in a similar situation is an important aspect of teamwork and communication that was missing in these cases. Personal factors were apparent in descriptions of stress and anxiety experienced in relation to major life events such as relationship loss or breakdown, the death or critical illness of a child, partner or other family member, financial stress and other life challenges. Being stressed, impulsive, defensive, or ‘set in their ways’ seemed to isolate nurses from their colleagues, particularly when they decided on a course of action knowing it was wrong or thinking they knew best. An inability to reflect on or modify their behaviour, and a lack of personal control was evident in descriptions of the nurses’ actions in the case reports. Organisational, or workplace factors also impacted on nurses’ ability to make appropriate decisions. High patient acuity and particularly complex and challenging clients created demanding situations where the nurse either loss control or responded inappropriately. Unresolved or ongoing dissention within collegial relationships and team conflict provided further stress within the work environment. There was also reference in some cases to a ward unit or culture that tolerated unprofessional behaviour in the spirit of ‘everyone is doing it’. While each of the nurses in these cases acted on their own account, and ought to have known their actions breached established norms of the profession, nurse colleagues might have had some influence in helping them to notice the ‘perfect storm’ gathering.
impact personal events might have on our professional work. I remember the support I received from colleagues when my husband was dying 18 years ago. This was a time when much of my energy and thinking was focused on managing all of the emotional and practical issues around a profoundly life-changing event. While my mistakes involved such things as booking cars or classrooms for the wrong day, it could also have impacted on client care in my clinical teaching. Eventually someone was brave enough to tell me about these mistakes and I understood it was time to take some leave to focus on my own life events. This experience taught me that supporting others helps them to become stronger and more resilient practitioners having resolved personal challenges. Encourage members of your team to talk about professional issues in your daily practice and be self-responsible in reflecting on feedback from colleagues. Professional issues are often concerned with doing the right thing at the right time in the right context. Colleagues help us to ‘benchmark’ what another thoughtful, careful nurse might do in similar circumstances. I regularly seek peer supervision on challenging aspects of my current practice, because it enables me to be challenged and reflect more deeply on whether I am doing the right thing. Compassionate care of colleagues also involves noticing the impact of organisational factors such as high workloads and rapidly changing care contexts, including new technologies. Developing our own individual and team support systems is essential to manage the demands of work load and ongoing change that are the hallmark of contemporary workplaces. Being professional requires us to be responsible in both setting limits and engaging with our colleagues and the organisational systems we work within.
What can colleagues do to help?
Be mindful of other nurses’ needs for compassionate and respectful support. Notice those moments when you see other nurses enduring personal challenges such as a relationship breakdown or other personal loss. While people manage such things in their own unique way, sometimes we are not aware of the
Author: Dr Patricia McClunie-Trust PhD RN is the principal academic staff member at Wintec’s Centre for Health and Social Practice.
Patricia McClunie-Trust
www.nursingreview.co.nz | Nursing Review series 2016 23
FOCUS n Healthy Year Ahead
Nurse education: adapting to
education Kiwi-style
Challenges faced by India-trained nurse educator Reen Skaria prompted her to ask fellow overseas-trained nurse educators about their experiences of teaching in New Zealand. She shared her sometimes surprising research findings at last year’s Australasian Nurse Educators Conference (ANEC). Nursing Review reports.
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tepping in front of their first classes of Kiwi nursing students can be an overwhelming experience for overseas-trained educators, a researcher has found. Dealing with big classes, students laughing at their accents, and having to learn on their feet about cultural safety were just some of the challenges shared with Reen Skaria during her doctoral research into the experiences of overseas-trained nurse educators. Skaria, a nurse educator at the Southern Institute of Technology’s nursing school, gained her master’s degree in nursing in India and told ANEC the challenges she faced as an overseastrained nurse educator prompted her to interview 17 colleagues about their experiences teaching in nursing schools up and down the country. The overseas-trained educators she interviewed came from the United Kingdom to Asia and the Pacific to the USA but Skaria says common themes emerged that could help to influence policies and practices to support overseas nurse educators in their roles, particularly as the push to train more nurses means New Zealand needs to recruit overseastrained educators to bolster the local nurse education workforce. Skaria says most of the educators had worked as nurses in New Zealand prior to starting teaching but that still hadn’t prepared them for working as a nurse educator in New Zealand. Challenges they described included differences in classroom ‘codes of conduct’, competency-based assessment, high numbers of mature students, cultural safety, long hours and being ‘thrown in the deep end’ with little orientation. Sometimes these challenges were combined with homesickness and the result was many found their new teaching jobs initially very stressful. “My job in UK was highly stressful but I rarely went home and cried and took a glass of wine. I did that a lot here though,” one participant told Skaria. Another talked of spending the first month sitting in the garden after work with their head in their hands, crying. Skaria said some nurse educators spoke of being unused to the big classes that can
Cultural uncertainty
Reen Skaria
“My job in UK was highly stressful but I rarely went home and cried and took a glass of wine. I did that a lot here though.”
happen in New Zealand. “I was scared to stand in front of 90 students and teach,” said one participant. “I was not expecting that. My first lecture was on a Tuesday in May. It was a cold day but when I came out from the first session I was sweating.” Speaking in front of a class with a strong non-Kiwi accent was another worry for many participants. “In the beginning it was awful and very difficult. I think people can immediately pick up my accent,” said one. Another said students sometimes laughed at them and one, even more worryingly, told Skaria that their most difficult experience was being accepted by the other lecturers.
24 Nursing Review series 2016 | www.nursingreview.co.nz
Teaching in a new culture was generally an issue, with Skaria reporting many overseas educators were “terribly worried” that they might offend their colleagues or students. She said most participants were familiar with working and living in multicultural societies but were new to biculturalism. “Most OE educators embraced biculturalism and they thought it was something to be celebrated and really unique to New Zealand.” But working in a bicultural education system was a learning experience; some said it was one of the hardest changes they had had to come to terms with including some expressing initial shock at having karakia and pōwhiri at their nursing schools. Skaria said discussions about cultural safety also prompted some “beautiful stories” about educators’ own cultural safety learning journeys. One spoke of learning that the head was tapu by the shocked response by a colleague to her suggestion of putting an IV line into a vein on the head of a very sick baby. Another spoke of a classroom of students gasping simultaneously when the educator touched the greenstone around a student’s neck while teaching about the anatomy of the neck.
Advice for new overseas-trained educators
Participants said it could take up to three years to culturally adapt to New Zealand but Skaria said most had, and were happy to now call New Zealand home. When asked for advice they would share with other overseas-trained nurse educators coming to New Zealand, they said not to be shy and to be proactive in accepting people’s dinner invitations or offers of friendship because, if they hesitate, the offers might not be repeated. She also said to research the job first, be ready to be adaptable, try not to make comparisons, and to avoid saying “back home we used to do this”. “As, remember,” she says, “you aren’t back home, you are in New Zealand now.” Skaria is working on finishing her doctoral thesis and hopes the results will lead to a greater understanding of the feelings and experiences of overseas nurse educators and perhaps help to inform policies and practices to improve those experiences.
FOCUS n Healthy Year Ahead
Empathy: does nursing Are nursing students more empathetic than their medical colleagues? Former nurse and medical education advisor Dr Peter Gallagher* and colleagues set out to test this hypothesis. Nursing Review reports that the findings may surprise.
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have a monopoly?
ursing is considered a caring after they had completed their transition profession, if not the caring to practice clinical placement), alongside profession. several cohorts of fifth-year medical students Empathy is one of the caring (only some of whom had received empathy characteristics that many nurses hold dearly training). and the Nursing Council lists demonstrating When the results were compared, it was empathy as one of the indicators of nursing found that the cohorts’ mean empathy competency. scores were all very similar and there was no “There is an accepted view – and it statistical significance between the nursing may be axiomatic – that nursing is the student cohort and the medical student pre-eminent caring profession,” nurse and cohorts. (The vast majority of the nursing educator Dr Peter Gallagher told the recent students were female and around 60 per The Nursing Council of New Zealand’s Australasian Nurse Educators Conference. cent of the medical students were female Competencies for Registered Nurses “I’m not saying it is or it isn’t, but it is a view also.) Competency 3.1: Establishes, maintains and concludes that is widely shared.” “I was surprised, as I was hoping that therapeutic interpersonal relationships with health Many examples of uncaring nursing that nursing students would portray a higher consumers. were highlighted by the Mid Staffordshire level of self-reported empathy,” Gallagher Indicator: Demonstrates respect, empathy and interest NHS Foundation Trust Public Inquiry in 2013 told the conference. in the health consumer. caused great shock in Britain and led to “But there was no evidence from our headlines such as ‘Nursing is no longer the results that these student nurses were by caring profession’ in The Telegraph. nature more or less empathetic than their medical measuring all medical students’ self-reported There is also a significant body of nursing theory student counterparts, or that nursing training by empathy levels using the Jefferson Scale of examining the nature and role of empathy and its nature produces a more empathetic health Empathy (JSE) tool, which was initially developed caring in nursing and nursing education. Amongst professional than medical training.” by an American medical school to measure the most prominent of these is nursing theorist Gallagher says the numbers involved in the empathy in physicians but was later adapted for Jean Watson, who said “caring is the essence of study were small and the study’s findings had other health professionals and health professional nursing and the most central and unifying focus for its limitations but they did “chip away” some of students. nursing practice”. the myths around nursing being the most caring Gallagher told the conference that he and his Gallagher says while empathy is regarded as profession. colleagues decided to use the empathy tool to test a characteristic of all health professionals there out the aphorism that nursing students are more remained a view, within nursing at least, that empathetic than their medical school counterparts. nursing is the most empathetic of the health *This article is based The JSE tool involves 20 questions, with students professions. on Peter Gallagher’s asked to rank how strongly they agree or disagree Such views prompted one nursing colleague to presentation to the with the 20 statements (slightly altered depending tell him he was “crossing to the dark side” when ANEC conference on whether the students are medical or nursing he took a position at the University of Otago in November on the students) with the highest potential score being Wellington School of Medicine. research carried 140. Statement examples include: “Attentiveness But once at the medical school, Gallagher told out by himself, Faye to patients’ emotions is not important in history the conference, he was surprised at the amount Davenport (UCOL), taking” and “I believe that empathy is an of caring – both explicit and implicit – within the Mark Huthwaite, Helen important therapeutic factor in nursing care”. medical curriculum. “I started to think maybe we Moriarty and Bee Lim The students tested were part of a nursing [nursing] didn’t have complete ownership over that (all of the University of school cohort of third-year nursing students (soon Peter Gallagher [characteristic].” Otago, Wellington). He said it was also unclear whether people applying to become health professionals were inherently empathetic to start with or whether it was something they ‘caught’ by seeing it modelled in clinical practicums or something that should be The caring professions: professions such as nursing and social work that are involved with explicitly ‘taught’ during their studies. looking after people who are ill or who need help in coping with their lives (Collins Dictionary) Some fifth-year Otago medical students receive Empathy: intellectual and emotional awareness and understanding of another person’s thoughts, up to five hours of empathy training, involving feelings, and behaviour, even those that are distressing and disturbing. Empathy emphasises actors and role play, where they are assessed and understanding; sympathy emphasises sharing of another person’s feelings and experiences. given feedback on their portrayal of empathy. But other cohorts have no explicit training in empathy. (Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition) Since about 2009, the medical school has been
”I was surprised, as I was hoping that nursing students would portray a higher level of self-reported empathy.”
DEFINITIONS
www.nursingreview.co.nz | Nursing Review series 2016 25
Practice, People & Policy PRACTICE
Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy Nurses step up to meet demand for Zealand’s ageing population is experiencing an upsurge in specialist eye New common age-related eye diseases. Clinical nurse specialist MIYEONG YOU reports on an innovation at Greenlane Eye treatment VICKY Centre that has seen nurses trained to deliver collaborative specialist treatment for one of these diseases – wet macular degeneration.
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ge-related macular degeneration (AMD) is the leading cause of blindness in people aged over 50. In 2009 people with AMD made up nearly half (48 per cent) of the registrations with New Zealand’s Blind Vicky MiYeong You Foundation for that age group, much higher than the registrations for other age-related causes of blindness, such as glaucoma (16 per cent) and cataracts (11 per cent). New Zealand’s rapidly ageing population means all age-related diseases – including those of the eye – are an increasing burden on the health sector. Statistics New Zealand data shows that in the early 1970s the elderly comprised 8.5 per cent of our population. Today they comprise 12.3 per cent; the increase in the number of elderly has outpaced the growth in the general population. To reduce the impact of age-related diseases on the health sector, nurses in a range of specialties have been trained in tasks traditionally done by doctors. In this review, I discuss my own experience of working in collaboration with ophthalmologists to deliver specialist treatment for wet AMD (see box for more about AMD).
Treatment of AMD Historically, the abnormal retinal blood vessels of wet AMD used to be treated with laser. Although this arrested the development of wet AMD, only a small number of patients benefited as laser treatment scars the retina and damages vision. Laser treatment has been replaced over the past decade by the use of anti-vascular endothelial growth factors (anti-VEGF). These medicines are injected straight into the eye in a technique known as intravitreal therapy (IVT). Avastin, being the cheapest of the anti-VEGF agents ($30 per treatment) is used as first line therapy in New Zealand. The other two anti-VEGFs are Lucentis, and Eylea ($1,500–$2,000 per treatment), which are reserved as second line therapy for patients who fail to respond to Avastin. While there is no cure for wet AMD, regular treatment with an anti-VEGF is effective, if the treatment is applied in a timely manner.
The growth in demand for IVT At Greenlane Eye Clinic, the number of IVT injections given has almost doubled, from 2,500 in 2012 to more than 4,500 in 2015. The increase in demand for this treatment includes not only the ongoing demand generated by patients with wet AMD but also the expansion of the use of the antiVEGF agents into the expanded treatment of both diabetic macular oedema and retinal vein occlusion.
Macular Graph 1 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0
2012
26 Nursing Review series 2016 | www.nursingreview.co.nz
2014
2015 (estimated)
Total number of IVT injections per year. Courtesy of Samalia et al., 2015 (see below)
Senior hospital management recognised that there were insufficient medical staff to cope with the surge in demand so it was decided to recruit and upskill senior ophthalmic nurses to administer IVT.
Nurses trained to monitor and treat AMD In 2013 myself and two other nurse specialists, already skilled in sub-Tenon local anaesthetic administration, were trained to administer IVT. After the training was completed, our practice was audited and we were credentialed to undertake IVT clinics in collaboration with ophthalmologists. Today, nurses carry out more than 85 per cent of IVT, whereas back in 2013 IVT was only performed by doctors.
What is age-related macular degeneration (AMD)? The macula is the central part of the retina that provides us with fine vision. In the early stages of the disease, vision is often blurred and distorted but in the late phases of the disease blindness may eventually develop. Afflicted patients have difficulty with the normal activities of daily life, such as reading, writing, cooking and driving. The condition may necessitate early retirement, which in turn increases the risk of financial hardship. AMD also increases the risk of falls and injury and there is a recognised link between AMD and depression. A New Zealand Medical Journal article by Waikato ophthalmologist David Worsley last year estimated that 10.3 per cent (184,400) of people between the ages of 45 and 85 years were affected by AMD in 2014. The article predicted that by 2024 this will increase to 12.9 per cent (208,200) (5), meaning that, in less than 10 years’ time, AMD is expected to affect one in seven people aged over 50 and one in four aged over 80. There are two types of AMD, dry and wet. The dry form results from atrophy of the retinal pigment epithelium, leading to loss of photoreceptors. There is no treatment for dry AMD. Wet AMD results in vision loss due to abnormal blood vessel growth. The proliferation of these abnormal blood vessels in the retina is stimulated by vascular endothelial growth factor (VEGF). The new vessels are fragile and leak blood, leading to irreversible photoreceptor damage and rapid vision loss.
2013
(Total number of IVT injections per year. Courtesy of Samalia et al., 2015)
Macular Graph 2 100 90 80 70 60 Doctor Nurse
% 50 40 30 20 10 0
2013
2014
2015
(Comparison of injections administered by nurses Comparison of injections administered by nurses and and doctors over a 3 month period, to March, March, doctors over a three-month period, January January to on 3 consecutive years. Courtesy of Samalia et al., 2015) on three consecutive years. Courtesy of Samalia et al., 2015 (see reference on next page)
Practice, People & Policy PRACTICE
… in less than 10 years’ time, AMD is expected to affect one in seven people aged over 50 and one in four aged over 80. In addition to providing the injection treatments, nurses also educate patients on modifiable AMD risk factors. These risk factors include smoking, prolonged exposure to strong sunlight, and poor diet. Patients are advised that a diet rich in carotenoids (fruit and vegetables), omega-3 fatty acids and fish products can slow the development of wet AMD.
One-stop AMD service Recently patient care at Greenlane Eye Clinic has been streamlined with a ‘one-stop’ service. Previously patients diagnosed with wet AMD were treated at an IVT clinic two to three weeks after their initial assessment. Now patient assessment and treatment are completed on the same day. An ophthalmologist monitors and assesses the patient and those needing treatment are immediately seen by the nurse for IVT.
The future A United Kingdom study in 2007 found that the cumulative health care cost of patients with AMD in both eyes was seven times those of healthy individuals. In New Zealand it is estimated that the number of people with AMD will increase to 13 per cent by 2026, so it is important to educate the public about AMD and what they can do to lower the risks. The current model of a hospital-based AMD service is not sustainable, given these anticipated demands. As a result, I believe there is a need to explore alternative models of care; these may include collaboration with community optometrists, further expansion of the nursing role and local satellite ophthalmology clinics. The Greenlane experience has proven that offering collaborative ‘one-stop’ clinics – where AMD patients are assessed by ophthalmologists then treated with IVT by nurse injectors – is a safe and effective model for providing care to our patients with wet AMD.
Written by: Vicky MiYeong You, RN, MNurs, clinical nurse specialist, Greenlane Clinical Centre, Auckland District Health Board. Co-authors: Reena Patel, RN, MHSc, School of Nursing, University of Auckland; Sue Raynel, MA, BHSc, OND, RGON, Research & Development Manager, New Zealand National Eye Centre, University of Auckland; David Squirrell, BMed Sci (Hons), MBChB (Hons), FRCOpth, FRANZCO, consultant ophthalmologist for Auckland District Health Board. Acknowledgments: Samalia P, Garland D, Zhen W, You V, & Squirrell D (2015). Nurse specialists for the administration of anti-vascular endothelial growth factor intravitreal injections. Unpublished manuscript.
OPINION
ED silly season over for another year
Michael Geraghty
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As the country heads back to work and school, memories of the festive season may already be starting to fade. For some, however, memories of a holiday trip to ED may not be forgotten so easily. Emergency nurse practitioner MICHAEL GERAGHTY shares an emergency nursing perspective of the summer silly season.
rom an Auckland perspective, one of the best things about summer is that for the fortnightlong Christmas/New Year break there are no traffic jams – anywhere! Auckland seems to empty out for that period and, ipso facto, we (the emergency department) should be nice and quiet; sadly, this is not the case. I drew the short straw and worked through most of the stats, which was good for the wallet, but less so for the soul. This time of year is traditionally known as the ‘season to be merry’ and, typically, some people take that statement literally and over-imbibe. From an ED perspective, the ‘silly season’ can at times equally be called ‘the season to beat up the wife or child’, ‘the season of near drownings’ or ‘the season of eating undercooked food off the BBQ’. At Auckland City Hospital we had record numbers over the Christmas/New Year fortnight and, while there are always some tragic or traumatic presentations, there were also a huge number of non-emergent cases filling the waiting room to capacity most days. Here are my top 10 examples of silly season visitors guaranteed to raise the eyebrows of the triage nurse:
1. “Hello, my uncle is upstairs on ward 33 so I thought I would pop in about this lump I’ve had for about 10 years now… you’re not busy, are you?” 2. “Can I make an appointment and come back later?” 3. “My GP is closed and I just need: »» a repeat prescription for my codeine and tramadol OR »» a quick blood test OR »» my blood pressure checked.” 4. “I’m visiting here from [insert any city] and I just thought I’d pop in for a check-up.” 5. “I have had one bout of diarrhoea one hour ago and I feel fine now, is it serious?” 6. “What do you mean, there is no free wi-fi?” 7. “I was bitten by a monkey in Thailand and was told to come here for my final rabies injection today, oh and my flight to Australia leaves in three hours.” (Usually happens on a public holiday.) 8. “I have come back because I am still in pain… no, I haven’t filled the prescription given to me.” 9. “I was Skypeing my sister in Australia, she has measles and I think I may have caught it.” (Yes, this did happen!)
10. “I can’t sleep but no, it has nothing to do with my amphetamine binge three days ago.” This was my 30th southern hemisphere silly season and little surprises me now! I left the UK in 1986 for a ‘short holiday downunder’ but have now lived and worked longer in New Zealand than I did in England and figure I can now call myself a Kiwi. Like most people, I look forward to the New Zealand summer: the sun, surf, downtime from work and the chance to catch up with friends and family and all that entails. Hopefully, though, not an unnecessary trip to ED.
www.nursingreview.co.nz | Nursing Review series 2016 27
Practice, People & Policy policy
HWNZ:
Nurses still play pivotal role in healthcare
Nursing Review asked Health Workforce New Zealand for an opinion piece on HWNZ’s recent and future plans and on nursing’s role in that work and vision. Chair DES GORMAN and acting director RUTH ANDERSON responded.
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rimary and community healthcare services are a priority and so too is more integrated and better connected people-centred service delivery. Nurses have a pivotal role to play in both. The knowledge, skill and commitment of the nursing workforce is a major feature of our health and disability system, and one that we see reflected in healthcare service delivery throughout the country. Nurses continue to be integral to the sustainability of our health and disability services. As our largest regulated health profession, the nursing workforce is a necessary, dynamic and indispensable part of our healthcare system. Health Workforce New Zealand (HWNZ), along with the wider Ministry of Health, is committed to maximising the potential for nurses to contribute to improving health outcomes for the New Zealand population. This includes ensuring as many new nurse graduates as possible are employed; supporting enhanced skill development through funding of postgraduate education; developing new roles to support future models of care; addressing regulatory barriers to nursing advancement; and advancing nurse leadership. Some highlights achieved in the past year include the: »» progression of Designated Nurse Prescribing to allow prescribing rights for registered nurses who deliver healthcare to patients with long-term and chronic conditions »» development of the Nurse Performing Endoscopies postgraduate training programme, which is due to commence in Semester One of 2016 »» introduction of a revised Nurse Practitioner training programme to be undertaken by 20 nurses in 2016 »» progression of the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill, which will allow health practitioners, including nurse practitioners, to undertake activities previously restricted to medical practitioners. These initiatives represent a substantial and ongoing commitment to enhancing the contribution that nurses make to the care and wellbeing of all New Zealanders. The programme of work will continue to grow the nursing workforce and support nurses to work to the full extent of their scopes of practice. While New Zealand’s health and disability system works well, we need to continue to adapt the way we do things to better ensure that our health and disability system has the flexibility and resilience it needs in the future. Primary and community healthcare services are a priority and so too is more integrated and better connected people-centred service delivery. Nurses have a pivotal role to play in both.
Des Gorman
Ruth Anderson
... successful implementation of the Health Strategy will be very dependent upon the knowledge, skills and leadership that nurses are able to bring in the future. Draft Health Strategy not without challenges The draft Health Strategy, released in late 2015, will guide the future delivery of healthcare services. The Health Strategy has the wellness of all New Zealanders as its key driver and places emphasis upon people empowerment, delivery of services closer to home, the importance of value and high performance, the essential nature of one
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healthcare team, and the importance of a smart healthcare system. Given the wide and varied contribution to healthcare currently made by nurses, successful implementation of the Health Strategy will be very dependent upon the knowledge, skills and leadership that nurses are able to bring in the future. Achieving the vision of the Health Strategy will not be without its challenges. New Zealand’s population is ageing; chronic and long-term conditions are more prevalent, and health inequalities, particularly among Māori and Pasifika communities, persist. For this reason, HWNZ, the Office of the Chief Nurse and the wider Ministry of Health are working in partnership with the National Nursing Organisations Group to maximise the potential of nurses to initiate, and participate in, introduction of new models of care; contribute to integrated multidisciplinary teams, and demonstrate clinical leadership in multiple healthcare settings. Nurse practitioners, clinical nurse specialists, and the potential introduction of registered nurse prescribers will all be important in furthering the role of nurses and most importantly, increasing patients’ access to healthcare services.
Nursing should play a lead role The future envisaged in the Health Strategy will require strong and effective system leadership going forward. The Nursing Taskforce, a tripartite sponsorship comprising HWNZ, the Office of the Chief Nurse, and the National Nursing Organisations Group, continues to provide guidance and strategic leadership for the advancement of the nursing workforce. In this, we are grateful to the Taskforce chair, Professor Jenny Carryer, and members of the Taskforce Group. However, the momentum achieved thus far will need to continue into the future and will require the support of all nurses as well as that of the wider health sector if the vision of a highly performing, future-focused and sustainable profession are to be realised. More than ever before, nurses can, and should, play a lead role in shaping the future of healthcare service delivery. To do so, nurses need to be actively engaged in change; foster and support knowledge and skill development that enables nurses to increase patients’ access to high quality healthcare, and demonstrate and promote strong clinical leadership within multidisciplinary team environments. Nurses have a critical part to play in ensuring the future viability and sustainability of New Zealand’s healthcare system and HWNZ remains committed to supporting nurses in this.
Practice, People & Policy opinion
Uncovering the
‘hidden heart’ of your patient
ROSEMARY MINTO believes the key to making a difference to patients is finding the selfbelief system driving their health behaviours. Read on to find out how out the primary healthcare nurse practitioner has chosen new year’s resolutions to help her to do just that.
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ew Year always spawns new resolutions, old regrets and dire predictions about the future of the human race. The media seems to target those of us who are too fat, too lazy, too dedicated to smoking or drinking (or any other vices) and too environmentally challenged. This makes me wonder how we humans have managed to survive at all for so many centuries. My conclusion is that core to all our life choices – be it who we connect with (or who we don’t), who we partner with, what we eat and how we live – are the relationships that sustain us (or not). I believe that our relationships with the other people in our lives, created by choice or circumstances (including being born into our families), ultimately influence who we are and who we become. I look at some of the people I am privileged to care for and I see not only a mother struggling with five kids, battling alcohol addiction and poverty, but also the small child within who was abandoned by her own mother, left adrift from her whānau with no sense of self-worth and no positive role model. And that obese man with no job, because his leg ulcers won’t heal, is still an 18-year-old boy with an abusive father who tells him he is a worthless waste of space, which has moulded the core of his self-belief system into a destructive pattern of self-harm. Death by overeating is the external mechanism of choice. The tricky component to changing behaviour is embedded in that complex system that houses our self-beliefs. Evidence has shown that if this belief system (our understanding of our world as it relates to our identity) is threatened, we are much less likely to want to make changes. So to lead a horse to water, or to facilitate a person to make better lifestyle choices, requires not only knowledge, but also uncovering that ‘hidden heart’ or the self-belief system that drives a person’s behaviours.
Once that hidden heart is revealed, we can use our unique relationships and connectedness with the wider health system to facilitate change for that person. Only by understanding – and then in a therapeutic way persistently challenging the values that underpin people’s choices and attitudes – will we address health issues like obesity and family violence that are so damaging to our wellbeing. I believe the training you have had or how theoretically well you have achieved as a health
The more I see of the social ills – poverty and family violence, the diseases of our modern society – the more I feel that my role should be more than
The tricky component to changing behaviour is embedded in that complex system that houses our self-beliefs. professional matters little if you are unable to connect, to communicate, to care, and to uncover the hidden heart of the person you seek to help. Listening, giving your time, and being willing to wait until the time is right for change, are all skills every health professional needs to have in abundance to win this war on illness.
a ‘technician of health’, who monitors and treats blood pressure and the like, and should place more emphasis on being a ‘caring connector’ who assists people to move positively to wherever they need to be to help them get well and stay well. So this year my resolutions are to listen better, hear more and care constructively.
www.nursingreview.co.nz | Nursing Review series 2016 29
Practice, People & Policy OPINION
Nurse prescribing and the Queen As registered nurse prescribing inches closer, MARK JONES and JILL WILKINSON argue that prescribing innovations could be better and faster in the future if the Queen wasn’t involved. They are calling for the proposed new Medicines Act to see a handover in power for deciding nursing’s prescriptive authority from the Queen (ie, the Crown) to the Nursing Council.
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s far as extending prescriptive authority to nurses is concerned, we have around 40 years’ experience between us in influencing national health policies around the world. Although we are both Kiwis now (Jill always and Mark recently so), in both our respective home countries the answer to “who decides about nurse prescribing?” is “the Queen”. This may seem a little odd for a country seriously considering eradication of all reference to ‘the motherland’ from its flag, but yes, the agent of Her Majesty (the Governor-General), and the Ministers of the Crown determined back in 1998 that nurses could prescribe here in New Zealand. As for the United Kingdom, the original legislation in 1992 allowing nurses to prescribe was “enacted by the Queen’s most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Temporal, and Commons”. Of course, everyone knows the Queen doesn’t really sit down and spend a great deal of time thinking about who prescribes (although she may a little); rather she has been advised that the legislation she, or her representatives, sign-off on is a good thing for the people. The ability of nurses to prescribe here in New Zealand is founded in the Medicines Act 1981. Even though nurses (as nurse practitioners) had been prescribing in the US for more than 20 years, nobody seriously thought they would here. So now New Zealand has a raft of regulatory amendments stuck over that original Act to permit such outrageous ideas. Essentially this is a ‘sticking plaster’ approach and it means the original medicines legislation is simply out of touch. New Zealand is now at the point where there are more plasters than original text and some are starting to peel, revealing a bit of a mess underneath. Fortunately, New Zealand’s legislators have acknowledged the Medicines Act 1981 is out of date. We have been working on a consultation submission from the College of Nurses, putting our case forward as to how prescriptive authority for nurses should be determined once the current Medicines Act (and associated plasters or regulatory amendments) has been repealed and replaced by a new one. Our submission didn’t say so much about the Queen.
”Clunky, out-of-date” legislation Right now, New Zealand’s medicines legislation tries to encompass a range of things not considered when it was drafted 35 years ago. Consider also, when innovations to improve patient care – such as the right of nurses to prescribe – were being mooted some people didn’t really like that idea and lobbied long and hard against regulatory change. Sometimes these people also told government officials, ministers (maybe even the Queen) and the nation in general that, at best, nurse prescribers could harm people and fragment care, and at worst there would be deaths. This happened in the United Kingdom and other countries too. Perhaps not surprising then that New Zealand’s medicines legislation wrestles with protecting the public from errant prescribers, while facilitating prescribing by new groups such as nurses. It ties everybody up in knots and tries to determine what safe practice should look like. There should be warning bells ringing about now for everyone who understands our professional regulatory system. Is it not our Nursing Council that determines safe practice, not some clunky, out-of-date medicines legislation? Well, this is exactly the point. Sure enough, the Health Practitioners Competence Assurance (HPCA) Act we all know and love has the official approval of the Queen via the GovernorGeneral too, but it recognises the best place for professional regulation is with the professional regulator. With this in mind, we have proposed something that might be a radical shift for some people, including nurses. Rather than have an Act that permits people to prescribe also telling us how, where and what they should prescribe, why not just have our new medicines legislation facilitate prescribing by nurses and leave the nitty gritty to the Nursing Council? In this model, the Ministry of Health and whoever is in government doesn’t have to try and understand and legislate for an expanding area of nursing practice; rather the Council is charged to do this. The replacement Medicines Act should simply reiterate the legality of nurses as prescribers.
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What this means is that our primary medicines legislation should allow registered nurses to legally prescribe medicines Mark Jones and therapeutic products that are deemed safe for use in New Zealand, full stop. The Nursing Council will then use its current processes to determine the nature of education and expression of competency required for nurses to prescribe Jill Wilkinson within their various scopes of practice. In this model we’d no longer see categories such as ‘authorised’, ‘designated’ or ‘delegated’ prescriber complicating things; rather, which nurse prescribes what and how becomes the responsibility of the Council. Of course, the Council may wish to describe prescribing practice as a tiered activity of sorts underpinned by a range of educational options associated with practice scopes; but this time around it will be nursing deciding who, what, where and when, not some dislocated, patched-up legislation. The Queen might not get to know much about this, but if she did she would see it makes sense!
Authors: Dr Mark Jones is a former Chief Nurse of New Zealand, a director of the College of Nurses Aotearoa and now the associate head of school for Massey University’s School of Nursing. Dr Jill Wilkinson is a senior lecturer at Massey University’s School of Nursing and a College of Nurses Aotearoa spokesperson on prescribing.
Evidence-based practicE
Does minding the moment matter? Is mindfulness clinically effective? Check out this edition’s Critically Appraised Topic (CAT)
CLINICAL BOTTOM LINE: When compared with an active control, mindfulness meditation programmes can help reduce negative dimensions of psychological stress such as anxiety, depression, stress/distress, in some clinical populations, but their effectiveness is uncertain for improving positive dimensions of mental health and stress-related behaviour.
CLINICAL SCENARIO: Mindfulness meditation has become fashionable for treating stress, stress-related health problems, and promoting wellbeing. You decide to review the evidence for the effectiveness of this therapy. In order to appraise the most robust evidence you are careful to choose evidence that has controlled for the placebo effect in its study design.
QUESTION: Is mindfulness an effective therapy for treating psychological stress, stress-related problems and promoting wellbeing?
SEARCH STRATEGY: PubMed-Clinical queries (Therapy/Narrow): mindfulness AND psychological stress, wellbeing
CITATION: Goyal, M., Singh, S., Sibinga, E.M., et al., Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine, 2014. 174(3): pp. 357-368
STUDY SUMMARY: A systematic review assessing the efficacy and safety of meditation programmes on stress-related outcomes in a diverse adult clinical population. Inclusion criteria were: »» Type of study: Randomised controlled trials (RCTs) with an active control conducted in a general or clinical setting. Studies were to include adults with a clinical (medical or psychiatric) diagnosis, defined as any condition (eg, high blood pressure, anxiety) including a stressor. »» Types of interventions: Structured meditation programmes (any systematic or protocol meditation programme that follows predetermined curricula) consisting of at least four hours of training with instructions to practice outside the training session, including mindfulness-based programmes, mantra-based programmes, and other meditation programmes. »» Comparison: Active control, defined as a programme that is matched in time and attention to the intervention group for the purpose of matching participants’ expectations of benefit. »» Outcomes: Stress-related outcomes that included anxiety, depression, stress, distress, wellbeing, positive mood, quality of life, attention, healthrelated behaviours affected by stress, pain and weight. Adverse events.
STUDY VALIDITY: Search Strategy: A comprehensive search strategy was used to search electronic databases – MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL,
AMED, and the Cochrane Library – through to June 2013. Reference lists of relevant reviews and included studies were also reviewed. No publication date or language restriction applied. Review process: Initial screening of titles and abstract, and then full text of those meeting initial selection criteria, were independently reviewed by two trained investigators. Data extracted included intervention fidelity (dose, training, receipt of intervention and participant adherence). Study quality was assessed independently and in duplicate. Differences in opinion were resolved through consensus. Quality assessment: Reputable methods were used to assess the risk of bias within the included studies. The strength of evidence for each outcome was graded after considering the following four domains: risk of bias, directness, consistency, precision. The assessment of publication bias and its impact on results provided. Overall validity: A high-quality review involving a large number of RCTs of varying risk of bias.
STUDY RESULTS: A total of 18,753 citations were screened, of which 1,651 full-text articles were assessed for eligibility. From these, 47 RCTs met inclusion criteria and were included in this review. Most trials were short-term but duration ranged from three weeks to five years. Fifteen trials studied psychiatric populations, including those with anxiety, depression, stress, chronic worry, and insomnia. Five trials studied smokers and alcoholics, five studied populations with chronic pain, and 16 studied populations with
diverse medical problems, including those with heart disease, lung disease, breast cancer, diabetes mellitus, hypertension, and human immunodeficiency virus infection. There was moderate evidence that in comparison with non-specific active control (ie, not a known therapy), mindfulness meditation programmes resulted in small improvements in both anxiety and depression at eight weeks and at three to six months, and pain severity (see table) and low evidence that mindfulness meditation improved stress/distress and mental healthrelated quality of life. There was low evidence of no effect, or insufficient evidence of any effect, of meditation on positive mood, attention, sleep, substance abuse and weight. In comparison with specific active controls (comparing effectiveness against known therapies such as drugs, exercise, and other behavioural therapies), there was no evidence that meditation programmes were better for any outcomes. No harmful effects from meditation were reported.
COMMENTS: In comparison with other reviews, restricting inclusion criteria to RCTs with an active control provides greater confidence in these results. Mindfulness meditation programmes are a useful option for addressing psychological stress but the optimum dose, duration and instructor experience for effective mindfulness training stress reduction programmes is unclear. The programmes involved in this review typically provided around 20 to 27.5 hours of training over eight weeks. This level of support may not be readily available to many clinical populations. High-quality research with a longer follow-up time is needed to confidently establish the effect of mindfulness meditation on positive dimensions of mental health and stress-related behaviour. Reviewer:
Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD Candidate, Deakin University, Melbourne cwensley@deakin.edu.au
Table: Summary of Results Outcome Anxiety at 8 weeks
No. of studies involved in meta-analysis
Effect size* (95% CI)
Grade of evidence**
7
0.38 (0.12 - 0.64)
Moderate
Anxiety at 3–6 months
4
0.22 (0.02 - 0.43)
Moderate
Depression at 8 weeks
8
0.30 (0.00 - 0.59)
Moderate
Depression at 3–6 months
5
0.23 (0.05 - 042)
Moderate
Pain
4
0.33 (0.03 - 0.62)
Moderate
* Cohen’s d statistic – publication provides guidance for determining clinical significance **Graded as high, moderate, low or insufficient (unclear) Moderate indicates moderate confidence that evidence reflects the true effect and further research may change the results. Low indicates low confidence that evidence reflects the true effect and further research is likely to change the results. www.nursingreview.co.nz | Nursing Review series 2016 31
College of nurses
Draft Health Strategy:
good intent but short on action Jenny Carryer
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PROFESSOR JENNY CARRYER calls for courageous disruption to ensure the new Health Strategy leads to changes in the health system with a positive impact on population health.
ast year an energetic and commendable level of consultation was put into reviewing and refreshing the country’s now aged Health Strategy document. There was also consultation on funding structures in the health system and into capacity and capability issues. A new draft Health Strategy document has been produced and a roadmap of actions designed. Principally the strategy aims to enable New Zealanders to “live well, stay well and get well”. Key among the many goals is a move towards increased personcentredness as a guiding focus for the way forward. We should ask ourselves why very similar and equally admirable goals adopted in 2001 (at the launch of the Primary Health Strategy) have not been successful. The document seems short of actual population health goals and there is almost no evidence of planned actions to address the major preventable causes of poor health and premature death. Overall, there is an excessive focus on the “treatment of illness system” as a supposed means of keeping people well. The red flag signifying this concern is exemplified at the very start of the document when the number of GP visits per person is listed as evidence of success. I suggest we need to move to a state where we measure success quite differently. The document contains eight principles for the New Zealand health system and they are certainly the appropriate goals to guide the strategy’s implementation. However, caution is indicated. Historically, funding models have a privileged downstream and reactive focus to illness care. Even if that was not the intent of the original funding models, the control and distribution of
funding has tended to sustain a reactive model of care. The result is that it has been difficult to move beyond the ‘tyranny of the acute’ and to achieve reduction in overall longterm demand. In order to redesign funding models that support new ways of operating, many in nursing would argue that there needs to be a significant change in how the Ministry of Health and district health boards consult on and consider policy advice. It is vital that vested business interests do not continue to hold sway in consultation processes and that there is greater meaningful consultation with those, such as nurses, whose primary focus is on embedding community wellness rather than treating illness in a downstream manner. It is also entirely pointless to speak of person-centred care unless the public genuinely has a great deal more engagement in the planning and design of services. The strategy is remarkably silent on workforce, beyond noting that “it is important that we have a workforce whose size and skills match New Zealand’s needs”. There are also comments about the need to ensure that every health professional is able to be utilised to the greatest extent of their potential. Workforce and workforce flexibility will undoubtedly be critical to the success of the Strategy refresh and to health service sustainability. It will be vital to pay more than lip service to this particular goal. Every health professional should be able to use their expensively gained skill set, knowledge base and training to the fullest advantage. But perhaps this will require some courageous decisions and a move to considering the workforce as a whole, rather than in discrete silos.
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The findings of the recent physician assistant trial would suggest strongly that GPs in particular are being resourced to do a great deal of work that the evaluation clearly showed could be done by others. The even greater actual and potential contribution of nurse practitioners remains largely untapped. We should be considering how much general practitioners could alleviate the shortages of specialist positions in areas such as dermatology and many others. In a similar vein, I have long argued that there is a problem with GP employment of practice nurses, if such employment constrains nurses’ autonomous design and deployment of nursing services in the most patient-centred manner. Teamwork in general practice is of vital importance and it is generally agreed that a team functions best when all individual members have clear autonomy over the development and direction of their practice. Yet again, this requires courage, focus and disruption. Words are easily said but the Ministry of Health should critically examine, as one example, the extensive delay that has prohibited nurse practitioners from carrying out the very processes for which they are legally authorised. There are also examples of the creation of recent barriers through failure to consider and consult outside the traditional power structures. Unless we learn from such processes, we will continue to see slow or no progress towards the necessary changes which will underpin the strategy’s vision. The Health Strategy document is of vital importance for ensuring sustainable health services in a demanding future. Here’s hoping that this time we have courage to be sufficiently disruptive in order to make the vision real and the goals achievable.
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