Nursing Review June 2015

FOCUS: Long-Term Conditions/Aged Care

Nursing Review June/July 2015/$10.95

New Zealand’s independent nursing Series

A DAY IN THE LIFE OF an iwi provider recent graduate nurse

EVIDENCEBASED PRACTICE: Quitting & e-cigarettes

Q&A

with Stephen Neville

Practice, people & policy

• Life, death & nursing • Pelvic exams & cultural safety

Long-Term Conditions/Aged Care E-cigarettes: lifesavers or smokescreen?

Fad diets: pros & cons of paleo to fasting

Ragged race for interRAI Training recharges aged care RN’s career www.nursingreview.co.nz

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Letter from the Editor Smoke gets in your eyes

In this issue, my decision to write about electronic cigarettes came from the most personal of motives: someone I care for very much is a smoker. It’s likely that every non-smoker has one, two, or even several smokers they care about as the last census showed that, despite all the anti-smoking media and support to quit, there are still 463,000 adult smokers in New Zealand.

I’ve been nagging my particular smoker to quit on and off since I was a kid. Like most smokers, this individual is far from stupid – stubborn and sometimes stressed maybe – but not stupid. And he is severely addicted to nicotine.

It took me a decade or so to realise that nagging wouldn’t help but that didn’t stop me hoping he would find the space, time and motivation to quit.

Nearly four decades later, my smoker had the kind of wake-up call that his tobacco packs had warned him about daily. His partner, also a smoker, had a quarter of her lung removed. She’s stopped smoking and, thank God, is doing well. My smoker didn’t stop smoking. I wanted to scream.

But he is not uncaring, unintelligent or unlovable; he is severely addicted.

Then he found his answer. A quick online purchase and a parcel arrives regularly from China. When he needs his nicotine fix he heads outside with his electronic cigarette and ‘vapes’. He has reduced the nicotine concentration levels he inhales but is not ready to give away his e-cigarette yet. In 18 months he has had just one tobacco cigarette. I am so relieved for him and for his partner.

My smoker is not so sure. He is very aware of how deeply he inhales to get his nicotine fix. He wants to know whether he has exchanged one problem for another. He’d also like to be able to pick up his nicotine replacement therapy of choice from behind the counter in his local pharmacy and not in a plain paper parcel from China.

I went to try and find some answers to his questions and found that few answers yet exist and the involvement of ‘Big Tobacco’ in the e-cigarette market raises yet more questions.

Most agreed, though, that vaping, when compared with tobacco smoking, is the lesser of two evils.

And for me – I’m happier now that my smoker is a vaper. But that doesn’t mean I’d be happy for my teenage son to be one too.

Fiona Cassie editor@nursingreview.co.nz

www.nursingreview.co.nz Twitter@NursingReviewNZ

Wider distribution for Nursing Review Some nurses have told us they are not receiving copies of Nursing Review, so we’ve done something about it. Free copies of Nursing Review are now sent directly to every ward at every major hospital.

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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: Find out on p.3 about a day in the life of Courtney Fermanis, a recent graduate working as an outreach immunisation nurse for a Porirua-based iwi provider.

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Inside: FOCUS: Long-term Conditions/Aged Care 4

RESPIRATORY: Clearing the air about electronic cigarettes

9

Heart Foundation and Diabetes New Zealand dietitians check out FAD DIET trends

13

JEFF GARRETT on misdiagnosing and misprescribing asthma and COPD

17

SUE KING on CHRONIC PAIN: the other long-term condition

20

The race to be ready for interRAI in the residential aged care sector

22

GABRIELLE STENT on why she thinks interRAI is worth the race

23 Updates on the Ageing Well National Science Challenge and Canterbury’s Gerontology Acceleration Programme (GAP) 24

Profiling a success story from new training scheme for aged care RNs

RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe

Practice, People & Policy 27

ANDY McLACHLAN on nursing, death and the cycle of life

29

RESEARCH: Pelvic exams, comfort and cultural safety

30

ROSEMARY MINTO on the prostate cancer testing pathway

Regulars 2

Q & A Profile: new nursing school leader STEPHEN NEVILLE

3

A day in the life of… iwi provider nurse COURTNEY FERMANIS

31

Evidence-based Practice: CYNTHIA WENSLEY reviews e-cigarettes

32

College of Nurses: MARK JONES on why he's glad the college 'has his back'

Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart.

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Nursing Review

Vol 15 Issue 3 2015

NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6141, New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 © 2015. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher.

ISSN: 1173-8014

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

Nursing Review series 2015

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Q&A

Stephen Neville

JOB TITLE | Associate Professor and Head of Department (Nursing) LOCATION | AUT, Auckland

A

Q A

The 21st century is a really exciting time to be a nurse. Nurses have a variety of career opportunities available to them and there is a greater focus on research within nursing education. We have a much larger number of doctorally prepared and highly educated academics and clinicians who support the delivery of nursing curricula.

However, nursing education needs to work closely with practice to ensure new graduate nurses are prepared, encouraged and supported to work in primary healthcare, mental health and age related residential care. Recent New Zealand research has shown that new graduates are still encouraged to work in a hospital setting first.

Where and when did you train?

I initially trained at Templeton Hospital as a psychopaedic nurse in the late 1970s, then completed my general and obstetric training at The Princess Margaret Hospital in Christchurch.

Q A

What other qualifications do you hold?

BA, MA (First Class Honours) and PhD – all from Massey University. I’m a Fellow of the College of Nurses Aotearoa (NZ), president of the New Zealand Association of Gerontology, a visiting Fellow at the Faculty of Health, the University of Technology Sydney and an honorary senior Fellow at the University of Queensland’s School of Nursing and Midwifery.

Q A

What do you do to try and keep fit, healthy, happy and balanced?

Monday to Friday I start my day with the gym. I have always been an early riser so I’m up at 5.30am and at the gym by 6am. I do weights, attend group fitness classes and run. On the weekends I walk or go for a bike ride.

Q A

When and/or why did you decide to become a nurse?

I had no burning desire to be a nurse and no family members were nurses.

Originally I wanted to be a primary school teacher but I saw a newspaper ad recruiting for psychopaedic nurses, thought it looked interesting and applied. To my surprise, I was accepted and without any idea about what nursing entailed, let alone what being a psychopaedic nurse was, I started training.

By the time I graduated I knew that nursing was the career for me and so soon after I did my general and obstetric training.

Q A

What was your nursing career up to your current job?

My clinical experience as a registered nurse includes acute surgical, operating room, mental health, intellectual disability and gerontology. In 1987 I started working in nursing education first at Christchurch Polytechnic Institute of Technology then Otago Polytechnic. At this time I worked between clinical practice and education and continued to do this until 2002 when I started work at Massey University as the Director for Postgraduate Nursing Programmes and the Associate Head of School. I have very recently taken up my current role.

Q A

What is one thing you like about your job and what comprises your role?

One of the things I really like about working at AUT is the interdisciplinary focus. Students and staff have the opportunity to work and study alongside people from midwifery, paramedicine, physiotherapy, occupational therapy, podiatry and oral health as students are prepared for the multidisciplinary focus of contemporary healthcare. My role as

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head of department means I have overall responsibility for the undergraduate and postgraduate nursing programmes at AUT. I set the strategic direction for nursing and overseeing the day-to-day running of the department.

Q

If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce?

A

My three wishes would be: »» Firstly, to remove the structural and attitudinal barriers to nurse practitioners being able to function in their roles. »» Secondly, I’d wish for funding equity so there is a level playing field for postregistration education opportunities for all nurses. »» And thirdly, that nurse prescribing will be fully implemented and supported in New Zealand.

Q A

What do you think are the most important personal characteristics required to be a nurse?

Intelligence, being a critical thinker, acceptance of and compassion towards all people, good communication skills and being able to adapt to a rapidly and ever changing healthcare environment.

Q

As a leader in nurse education, what do you believe are the strengths of nurse training in the 21st century? And in what areas do you think there is room for improvement?

Q A

What or who helps keep you sane, busy or on task outside work?

I live with my partner Paul and my mother-in-law Maureen. Both of these people, along with my own parents and friends, are really important in helping me maintain some degree of work/life balance.

I am also a very keen gardener and we open our garden to the public from time to time, most recently to raise funds for hospice. We live in central Auckland so make the most of what inner city living offers. Mind you, I don’t drink so am always the designated driver!

Q A

What is your favourite way to spend a Sunday?

Sunday starts by taking the dog for a walk, getting the newspaper and then sitting down to breakfast and coffee. I usually do a bit of gardening and we might catch up with friends for lunch somewhere like Blue Breeze Inn on Ponsonby Road or the Elbow Room.

Q A

If I wasn’t a nurse I’d be a…?

Nurse!! I have always nursed, although when I was younger I worked part-time as a fitness instructor and briefly considered giving up nursing. However, that was only fleeting. I can honestly say that if I had my life over again I would still choose nursing. It has been the best career for me and one that I thoroughly enjoy.

A day in the life of ...

an iwi provider recent graduate nurse

NAME | Courtney Fermanis JOB TITLE | Outreach Immunisation Nurse LOCATION | Ora Toa Health Unit, Porirua

5.30

AM WAKE Waking up is probably the most difficult part of my day, especially when it’s dark and the weather’s miserable. However, the thought of missing crossfit motivates me to roll out of bed and chuck on gym clothes. Crossfit has got to be the most intense workout I have ever done, but the satisfaction of completing something impossible always puts me in good spirits and in perfect stead to tackle the day ahead. After a quick dash home, I rampage around the house hoping to find something decent to wear and then I’m out the door by 8.25am.

8.30

AM START WORK WITH MEETINGS I’m finally at work and, if I managed to find clothes, I’ve made it on time. I love coming into work, seeing my work colleagues and hearing about their weekend adventures.

Monday mornings are the best because we have a staff meeting and, as I’m last to report on my upcoming week, I’ve got enough time to eat breakfast. By the time the second meeting for the morning is underway, I’m really awake. We discuss up and coming groups, transports, health promotion and events etc.

10.45

AM QUICK CUPPA When the meeting is over, we all get together to have a quick cuppa and a catch-up over the five-minute quiz in the paper.

11.00

AM DAILY ROUTINE Now it’s time to get my daily routine underway: clearing emails, referrals and messages; checking the temperature of our vaccine fridge; making bookings and, as its Monday, the emergency bags are also checked, re-stocked and signed off.

This routine is now automatic as I’ve been working as an outreach immunisation nurse for one year and seven months.

This has been my first job as a registered nurse and I feel lucky to be able to work for my iwi (Ngāti Toa Rangatira) and for my whānau here at Ora Toa. My student days at Whitireia feel like a lifetime ago; I guess that’s what happens when you are so comfortable in a workplace.

12.00

PM LUNCH Yas! My favourite part of the day. I never bring my lunch as I’m always in a rush so I’m off to the Plaza to get sushi.

12.30

PM OUTREACH BEGINS The afternoon is normally fun because my friend (who happens to be my support worker) and I head out into the community to vaccinate some babies. Today we are off to see a seven-month-old boy who is overdue for his five-month immunisations. This particular visit is exciting as – after a month of multiple phone calls and home visits – it is ‘mission accomplished’ as we have finally found him.

When I first started this job I found it really fun looking for children; the never-ending phone calls and turning up to empty houses made me feel like a detective and I enjoyed the challenge of finding other avenues to locate them. Now it’s a bit more frustrating, especially when you turn up and no one is home.

This particular visit, mum and baby are home and, after immunisation education and consent, we can finally vaccinate this child and bring him up to date with the national schedule. The style of vaccinating always depends on the mother’s preferences; this may mean vaccinating while the mum’s feeding or holding baby, but other times

the mothers may not want to be part of the process at all. It’s good to have a support worker with me as she can hold the baby, support the mother or, the best part, distract the child (particularly the older children) so that vaccinating can be as stress-free as possible. It also makes vaccinating more efficient.

After vaccination, we wait 20 minutes to ensure that baby doesn’t have a serious reaction. It also gives us time to talk with mum to create a good rapport and to offer any support, advice or assistance that the family may need or want. Once we are happy with the child’s injection sites (and the mother knows who to contact if she is worried) we head back to the office to send all the information to their medical centre.

Then it’s back on the road – making sure our chilly bin is still at optimal temperature – to see our next client. This time, even though we called to remind them, no one is home and we leave a message in their letterbox for them to ring us. We won’t give up and will keep following them up until they are vaccinated. We use the freed-up time to stop off at a few more houses to try and locate other children before heading back to the office. By this time it’s 4pm and it gives me enough time to catch up on my workload, read and send emails and to also prep for the next day.

5.00

PM LEAVE WORK I’m out of here to pick up my sister from the train station. We normally head to the supermarket and usually end up walking up and down the aisles until we find something we both feel like eating. We head home to eat our dinner watching the news and relax for the next hour. My sister is off to the gym and so I get up and go for a run with my dog, Honey. I love running at night because the air cools me down, which makes me run longer, and I’m able to keep up with my dog.

Also, I love running past the harbour with all the streetlights illuminating the night sky. It makes the night feel so magical. After my run, I jump in the shower, chuck on my pjs and snuggle into bed to catch up on TV programmes I missed from last week.

11.00

PM TIME TO SLEEP

Nursing Review series 2015

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FOCUS n Long-Term Conditions

E-cigarettes: lifesavers or smokescreen?

When it comes to smoking cessation tools, it seems there are mixed signals around e-cigarettes.

Some argue they could be lifesavers for tobacco smokers struggling to quit; others argue they are a smokescreen for a new generation of problems. This can make it difficult for nurses quizzed by smokers about their views on e-cigarettes.

So what knowledge should nurses have on the subject? Nursing Review attempts to clear the air.

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“Hi all, what does everyone think of the electronic smokes? And does using one of these count as having given up smoking? ” . . . I know a lot of people are using them but wonder if they are still socially unacceptable as it still looks like you are puffing away on a smoke? Lots of questions. Hope someone can enlighten us. . . lol Excerpt from a Quit Blog conversation on Quitline’s website

S

elling nicotine for e-cigarettes is illegal in New Zealand. Any callers to Quitline who ask are told the Ministry of Health advises there’s not enough evidence to recommend e-cigarettes as an aid to quit smoking.

But just google ‘e-cigarettes’ and at least 20 New Zealand websites pop up selling various e-cigarette or vaping devices and vaping e-liquids in flavours from tobacco to caramel. (For the uninitiated, vaping is inhaling and exhaling the vapour produced by an electronic cigarette or similar device.)

And with just a few more clicks, people can go offshore to China or the USA and legally import nicotine liquid or cartridges for personal use in their e-cigarette or electronic nicotine delivery system (ENDS).

Quitline clients are definitely ‘very aware’ of e-cigarettes, Quitline’s director of strategy and communication Bruce Bassett told a national symposium on e-cigarettes in March.

Last year’s satisfaction survey of 611 Quitline clients found 15 per cent had used e-cigarettes but Bassett says a smaller, more recent survey of 34 clients found 75 per cent had used them – though mostly without nicotine.

Bassett says a further survey of 16 Quitline advisors found most had several callers a day mentioning e-cigarettes and those enquiries were increasing.

Most of the callers were keen to know whether e-cigarettes or ENDS were safe, where to get them and whether they would work. Bassett asked the advisors whether they thought they could offer a better service if they could talk freely about e-cigarettes and 10 said ‘yes’, five said ‘possibly’ and just one said ‘no’.

If a smoker heads to Britain’s National Health Service website to ask whether or not e-cigarettes are safe, they are also told nobody can say for sure without more research. But the website also adds: “However, compared with regular cigarettes, they are certainly the lesser of two evils”.

A quick tour of the internet also shows local smokers that ENDS are freely available and widely advertised in the USA, UK and Europe, with an estimated 2.1 million users in the UK and about 20 million in the USA. Though with ads promoting flavours from bubble gum to cola and, in American ads in particular, showing sleek young things in bikini thongs and glamorous women blowing ‘smoke’ clouds, Kiwi smokers may well wonder who the target market for e-cigarettes actually is.

Helping or hindering tobacco control?

While it is not surprising that many New Zealander smokers are curious about giving e-cigarettes a go, what advice should a Kiwi nurse give a smoking client who’s switched to e-cigarettes and wants to know whether they are safe? Or to a heavy smoker

FOCUS n Long-Term Conditions

E-cigarettes: the basics Refillable tank-style electronic cigarette

struggling to quit who wonders whether ENDS could be the answer for them?

The quick, unhelpful answer is that there’s no easy answer, partly because the arrival of e-cigarettes has generally divided the tobacco control community, both here and overseas, into two loose camps.

In the ‘precautionary’ camp are those – including our Ministry of Health, the Cancer Society and the World Health Organisation (WHO) – who argue that longitudinal, robust research is not there to prove that ENDs are either safe or effective as a quit smoking aid and quitters should stick to proven nicotine replacement treatments (NRT) like patches, lozenges and gum. There is also concern that e-cigarettes may see smokers continue to smoke tobacco and that aggressive marketing at youth could see ‘vaping’ become the gateway for a new generation of nicotine addicts and potential tobacco smokers.

In the ‘lesser of two evils’ or ‘harm reduction’ camp are those who argue that other NRT treatments don’t offer the same ‘handmouth’ experience that makes ENDS appeal to many smokers. And while we wait for longitudinal and definitive research on whether the constantly evolving ENDS technology is safe and effective, around 5,000 Kiwis a year are dying from smoking-related diseases.

Nursing Review talks to people from both camps – and those trying to find a middle-ground – about the pros and cons of e-cigarettes.

Early advocate remains strong

Murray Laugesen is a public health physician with a passion to make New Zealand smokefree, who has definitely pitched his tent in the ‘lesser of two evils’ camp.

The chair of charitable trust End Smoking NZ wants people to quit smoking and cigarettes sales banned, but in the meantime he wants to reduce the deadly harm caused by smoking tobacco.

He has long been known for sticking his neck out in seeking safer alternatives to smoking tobacco for the addicted – including snuff and chewing tobacco – to stop the high death rate from lung cancer and other smoking-related diseases. “But I came to the reluctant conclusion that (recalcitrant) smokers were not interested in anything except smoking.”

So when the pioneering Chinese manufacturer of e-cigarettes approached him in 2007 wanting to know whether their product was safe, he was definitely interested. He saw it potentially meeting the need of many smokers struggling, or unwilling, to quit.

“I found that as far as I could tell the Ruyan [e-cigarette product] was safe in all respects so I gave them my report and that was it.”

He says he hasn’t been involved with Ruyan for a number of years but has retained an active interest in the ongoing evolution of e-cigarettes, particularly the latest versions that use a refillable tank. These, he says, are the most efficient yet in delivering nicotine to nicotine-addicted smokers and he is keen to see a randomised control trial on the efficacy of the tank devices as a quitting aid.

Laugesen’s own small study into the toxins produced by e-cigarettes was published this year in the New Zealand Medical Journal (see sidebar ‘E-cigarettes: recent findings’) and he says there is nothing much in the way of toxicants found in e-cigarettes that aren’t also found in nicotine patches or gum.

He also says New Zealand could wait to find out whether there are long-term risks from vaping nicotine, but with people dying every year from smoking combustible cigarettes he thinks that’s a costly option in both money and human suffering.

For Laugesen, it is quite simple – tobacco smoke kills people and e-cigarettes don’t.

So what does he think nurses should be advising persistent smokers?

“If a smoker can’t quit with nicotine patch or gum, they should definitely consider e-cigarettes, particularly the tank-style, as a possibility and nurses should encourage people to go ahead and give it a try.

“But it would be a lot easier for everybody if the Ministry of Health would move and make e-cigarettes available for sale in New Zealand,” says Laugesen. “There’s no reason why cigarettes, that kill 5,000 New Zealanders a year, should be permitted while e-cigarettes are only available by ordering from overseas.”

E

lectronic cigarettes are a relatively new phenomenon, with Chinese inventor Hon Lik – who lost his father to lung cancer – patenting his nicotine-vapourising e-cigarette in 2003. The first versions went on the market in China in 2004 and the pioneering Chinese manufacturer Ruyan began exporting a few years later.

The market for e-cigarettes, also known as electronic nicotine delivery systems or ENDS, has since taken off with multiple manufacturers in China and around the world and the devices have evolved into a variety of forms including ’cigalikes’ (that look most similar to cigarettes with the nicotine contained in a mouthpiece cartridge), the mid-size disposable or pen style e-cigarettes and the most recent generation which have refillable tanks (clearomizers). The tank variety of ENDS are said to be the most effective yet in delivering nicotine at levels closest to smoking tobacco cigarettes.

All ENDS are battery-powered and contain an electronic vaporisation system that heats e-liquids containing nicotine to release nicotine vapour that the user inhales. The e-liquid can contain levels of nicotine of varying concentrations (usually between 6–24mg of nicotine) and flavourings, which is atomised in a propylene glycol solution.

It is usually agreed that the vapour inhaled from e-cigarettes is less harmful than inhaling tobacco smoke but the long-term health impacts of vaping are not known.

There has also been consumer safety concerns raised about some cases of battery explosions and the need for childproof containers for nicotine liquids.

In recent years, tobacco companies have moved into the e-cigarette market, with several multinational tobacco companies now marketing e-cigarettes and one tobacco company’s e-cigarette brand now being the most popular in the US. The US market for e-cigarettes is expected to top $3 billion this year.

New Zealand legal status and official advice

The Ministry of Health’s position is that there is not enough evidence to be able to recommend e-cigarettes as an aid to quit smoking. “The Ministry will be assessing new evidence as it arises, but in the meantime smokers should continue to use approved smoking cessation aids, such as patches, lozenges and gum, to help them quit smoking,” is the current advice.

No e-cigarette or ENDS has been approved as a quit smoking aid by Medsafe. The sale of e-cigarettes and e-liquids by New Zealand retailers as recreational gadgets is allowed as long as they are not promoted as a quit smoking aid or contain nicotine. The selling of nicotine cartridges or liquids for e-cigarettes is illegal in New Zealand but it is not illegal for Kiwis to purchase nicotine for e-cigarettes from offshore online retailers and import it for their own use.

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E-cigarettes: recent findings Toxicity (2015)

Electronic cigarettes for smoking cessation and reduction (Cochrane Review 2014)

Murray Laugesen’s research into the concentration of nicotine and toxins in vapour from 14 electronic cigarette brands available in New Zealand concluded that e-cigarettes yielded a level of toxic aldehydes 200 times lower per puff than a Marlboro cigarette. He also found that the latergeneration (2013 onwards) brands of e-cigarettes yield more nicotine than earlier brands but far lower toxin levels than both cigarettes and earlier brands of e-cigarettes, indicating “potential as safer substitutes for tobacco”.

The review looked at 13 trials published up until July 2014 and found low grade evidence from two random control trials (including a New Zealand trial led by Chris Bullen, also one of the co-authors of the Cochrane Review) that e-cigarettes can help smokers to stop smoking long-term compared with placebo e-cigarettes. (See CAT analysis of review in evidence-based practice article on page 31.)

Full review available at www.cochrane.org.

New Zealand Medical Journal, March 27 2015, Vol 28 No 1411.

‘Real-world’ effectiveness of e-cigarettes

E-cigarettes: A scientific review (2014) A meta-analysis of research on e-cigarettes, including studies available at the time into smokers quitting while using e-cigarettes. Led by Professor Stanton Glantz (Centre for Tobacco Control Research and Education, University of California, San Francisco), the analysis found that smokers (including those not trying to quit) who use e-cigarettes are 30 per cent less likely to quit smoking than smokers who don’t use e-cigarettes. The study also found that dual use of both e-cigarettes and tobacco cigarettes was of concern.

This study led by Jamie Brown with Professor Robert West (director of Tobacco Studies at the Cancer Research UK Health Behaviour Unit, University College London) surveyed 5,863 adult smokers who had attempted to quit at least once in the previous 12 months. Of those who hadn’t sought professional support, the eight per cent (464) who had tried to quit using an e-cigarette only were more likely to report continued quitting of smoking than the 32 per cent who used licensed NRT bought over the counter and the 60 per cent who had attempted without any aid or professional support.

Circulation 2014; 129: 1972-1986. Available at www.circ.ahajournals.org/content/129/19/1972.long.

Addiction Vol 109, Issue 9, September 2014. Available online at http://onlinelibrary.wiley.com/doi/10.1111/add.12623/abstract

Time to take a deep breath

Few products are as dangerous as smoking tobacco, agrees Professor Janet Hoek, who falls into the precautionary camp.

“There is general agreement that using ENDS is not as harmful as smoking,” says Hoek, a University of Otago academic with a research interest in the marketing of e-cigarettes, particularly to children and young people. But she adds that agreeing ENDS are less harmful than tobacco is not the same as saying that ENDS are harmless.

Until there is long term data on the many types of ENDS available and the many types of inhaling (now including competitive ‘cloud chasing’) it will not be known whether ENDS and vaping are safe.

Hoek also points out that the question remains: do e-cigarettes help people quit? While there are anecdotal testimonials from former smokers that ENDS helped them quit, Hoek points to the metaanalysis by Professor Stanford Glantz (see sidebar ‘E-cigarettes: recent findings’) that indicates smokers using ENDS are less likely to quit smoking and that smokers continuing both vaping and smoking (dual use) is common. Once again, she says, there is a shortage of good data and more studies are needed.

So what does she think nurses should tell smokers about ENDS as a quitting aid? The short answer is that ENDS have helped some smokers

Murray Laugesen

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quit, answers Hoek, but, she adds, the big picture analysis suggests that ENDS users are less rather than more likely to quit smoking.

Paul Badoc, the national manager of the Ministry of Health’s Tobacco Control Programme, agrees, saying that the behavioural research suggests many smokers use tobacco and e-cigarettes depending on what is socially acceptable at any given time and location. He points to the 2014 Cochrane review (see sidebar and page 37) showing that the evidence for e-cigarettes as a quit smoking aid is low and more studies are required. The WHO review of the 2014 Framework Convention on Tobacco Control conference also recommended a precautionary approach to e-cigarettes and advised people to use approved NRT products instead.

Homegrown research findings

New Zealand is one of the few countries to have carried out a random control trial comparing nicotine e-cigarettes, nicotine patches and placebo e-cigarettes as aids to quitting smoking.

The Health Research Council project was led by Professor Chris Bullen, a public health physician who is director of The University of Auckland’s National Institute for Health Innovation and codirector of the government-funded Tobacco Control Research Tūranga. Published in late 2013, the trial, involving 657 Kiwi smokers, found that e-cigarettes,

Janet Hoek

Chris Bullen

with or without nicotine, were ‘modestly effective’ in helping smokers quit; it was one of two studies found in a Cochrane Review (also involving Bullen) to show some low level evidence that e-cigarettes may be effective as a quitting aid.

So what would Bullen say to a long-standing smoker who asks him whether e-cigarettes are better for their lungs than smoking tobacco?

“Those who vape for a few months as a means to quit tobacco smoking will almost certainly experience significant and rapid health benefits,” says Bullen. “But if a vaper also continues to smoke they won’t experience the same benefits, as even a single cigarette carries health risks.”

And, of course, the long-term health risks of vaping regularly are not known yet but, knowing what he does of the chemicals in e-cigarette vapour, he believes it is “very unlikely” there are major risks and they are unlikely to be “anywhere near as harmful or great as smoking”.

How effective does he believe e-cigarettes are for helping people quit? If e-cigarettes with nicotine are used daily, they are at least as effective a quitting aid as nicotine patches, says Bullen of the research to date.

“Ideally though, people should try the optimal ways of using existing evidence-based approaches first: patches plus a faster acting product (such as gum), plus counselling or other behavioural support (such as a text message quit support programme or a theory-based app such as SF28); or varenicline [trade name Champix] alone or in combination with NRT.” If these methods are unsuccessful, despite the quitter’s best efforts, then e-cigarettes are an option to be considered, he believes.

Bullen emphasises that e-cigarettes are no ‘magic bullet’ and should always be viewed as just one strategy in the total tobacco control package that includes price, plain packaging, sales restrictions etc. But meanwhile, he says some regulation of e-cigarettes is essential – at a minimum to ensure product quality, childproof lids on nicotine bottles and to restrict marketing and sales to minors.

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Marketing, big tobacco and e-cigarettes

The Ministry of Health is in an ‘ongoing’ process of considering regulatory options for e-cigarettes and associated products in New Zealand.

It is the current unregulated market and future marketing of e-cigarettes that worries many as much, or more, than their safety and efficacy. They look across to the USA where the unregulated e-cigarette market is expected to top $3 billion this year and the biggest selling brand is marketed by a multinational tobacco company.

It leaves many with a foot in both camps, including the New Zealand Nurses Organisation, which regards promoting e-cigarettes as a “harm reduction tool for recalcitrant smokers” as a valid use if properly supervised.

But, and it is a big BUT, NZNO also has major concerns about the safety and marketing of e-cigarettes, particularly now that the major multinational tobacco companies have entered the e-cigarette market.

NZNO researcher Dr Leonie Walker acknowledges e-cigarettes are a polarising issue.

“If the machines and flavours weren’t geared far more to getting new smokers than helping quitters, and if recent research hadn’t confirmed youth experimentation, we’d be less concerned,” says Walker (see sidebar ‘More New Zealand teenagers vaping’).

NZNO recently briefed the Associate Health Minister on its fears that public health gains will be undermined if tobacco companies succeed in gaining access to the New Zealand market for their new e-cigarette products, particularly with overseas experience showing aggressive marketing, recruitment of young people and the promotion of dual tobacco and e-cigarette use.

In addition, if vaping becomes visible and acceptable in public places, some fear it could undermine the smokefree message and quitters may be tempted to reach for a fag if they see others blowing vapour ‘smoke ring’ clouds.

Meanwhile NZNO says New Zealand’s current position – where nicotine for e-cigarettes must be bought online and there are no controls in place – is ‘untenable’.

The organisation’s preference is for e-cigarettes to be regulated as medicines and their sale and promotion handled like any other nicotine replacement therapy, including being accompanied by quit education and support.

Failing that, Walker says, it hopes at the very least that e-cigarette and refills are subjected to the same point of sale display and advertising restrictions as tobacco cigarettes.

But she adds that the sophisticated marketing used overseas to drive the potentially multi-billion dollar e-cigarette industry must still ring warning bells and New Zealand needs to heed that warning and go cautiously.

One smokefree nurse’s perspective

E-cigarettes are already steadily seeping into New Zealand’s ‘smoking’ culture. This is opening up new etiquette and ethical dilemmas as our smokefree legislation bans smoking, but not vaping, in public places.

were burning. There is also still a lack of research into whether exhaled vapour may be harmful to others.

Stevens, who manages Auckland District Health Board’s smokefree service, says that is one of the reasons why the board’s own smokefree policy treats e-cigarettes just like an ordinary cigarette and asks people to go outside.

While e-cigarette users are only a minority of its patients, visitors or staff, she says vaping is becoming increasingly common. Not as common as tobacco smoking though, with the 2013 census

“If the machines and flavours weren’t geared far more to getting new smokers than helping quitters, and if recent research hadn’t confirmed youth experimentation, we’d be less concerned.”

“Go to any restaurant here in Auckland and you are bound to find someone using an e-cigarette in the evening somewhere,” says Karen Stevens, a Smokefree Nurses Aotearoa member. The respiratory clinical nurse specialist points out it’s a tough call for the waitress to decide ‘is this a real cigarette or not?’; particularly as the end of the early generation ‘cigalike’ e-cigarettes used to glow red, as if they

showing 463,000 adults (15.2 per cent of our adult population) still smoke.

From a personal perspective and as a respiratory nurse specialist, Stevens wants those smoking statistics to fall and sits firmly in the ‘harm reduction’ camp.

“The crucial thing is we don’t want people to deliberately inhale smoke from combustion into their lungs on a daily basis,” says Stevens.

More New Zealand teenagers vaping The latest survey of year 10 students (14 to 15-year-olds) found that the number of teenagers trying out electronic cigarettes has nearly tripled in two years.

The Health Promotion Agency first asked about electronic cigarette use in its 2012 Youth Insights survey and found that seven per cent had tried them, but when they surveyed the 2014 year 10 cohort they found the rate who had “ever tried electronic cigarettes” had rapidly increased to 20 per cent. The most common reason cited for trying e-cigarettes was curiosity (65 per cent), followed by somebody recommending them (24 per cent) and that they were considered ‘safer than cigarettes’ (20 per cent). Trying e-cigarettes was most common amongst current, infrequent and ex-smokers. (Students were not asked whether they had tried nicotine or non-nicotine e-cigarettes).

The same 2014 survey found that six per cent of year 10 students were regular tobacco smokers and that 11.4 per cent had smoked tobacco in the previous month.

The yearly ASH Year 10 Snapshot Survey in 2014 also found that the number of students regularly smoking (at least once a month) was six per cent, but the number of year 10 students smoking daily had fallen below three per cent for the first time since the survey began in 2000. In addition, the number who had never smoked was the highest ever at 77 per cent.

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Leonie Walker

“So whenever we talk to any group of people about helping them stop smoking, we need to very clearly delineate that we want them to be smokefree, not necessarily nicotine free.

“I’ve got staff members – some of them nurses – and they’ve stopped smoking but are still on nicotine lozenges or gum four or five years down the track. They are not smoking but they find if they don’t get the regular nicotine they get cravings and find it hard to concentrate.”

So what about nicotine via an e-cigarette? How would she respond to a smoker who has struggled to quit with approved NRT who asks about using ENDS? For a start, she points to a recent UK study (see sidebar ‘E-cigarettes: recent findings’) where 20 per cent of surveyed smokers who attempted to quit on their own using just e-cigarettes reported successfully quitting, which was double the rate of those using solely over-the-counter NRT. “I would say [to any smoker who asks] that the risks of ill-health from e-cigarettes are far less than from smoking tobacco, so in terms of harm reduction the e-cigarette may be a good option for them.”

Should nurses be telling patients this? Yes, says Stevens, as she believes information about any quitting aid that prevents smoke inhalation, and doesn’t have significant poisonous affects itself, should be provided.

“A current smoker who wants to stop smoking and to reduce the risk to their health and wellbeing would jump at a chance to do it with a device where you still have the ‘hand-to-mouth’ going on and you still have all the habits associated [with smoking] but you have very much reduced harm.”

She agrees more research and regulation is needed, but also believes e-cigarettes can be considered another option in the NRT arsenal

Karen Stevens

Grace Wong

helping people to stop inhaling toxic smoke that is proven to kill. And for those who argue against e-cigarettes because some vapers also smoke as well, she points out that dual usage is not new, with some smokers continuing to smoke while using evidence-based NRT like gums and lozenges, and even prescription drugs such as Champix.

“The ideal is not to use nicotine at all, but then how many people are addicted to caffeine, and now sugar, which is also getting a bad press?”

Her overall advice on e-cigarettes is to proceed with caution and remain focused on the main objective. “Basically, every breath should be a breath of fresh air – it should not have smoke in it – that’s the bottom line for whatever we talk about.”

Smokefree Nurses Aotearoa: a foot in both camps

Dr Grace Wong, the director of Smokefree Nurses Aotearoa, says currently the advocacy group – dedicated to supporting nurses help people quit smoking – doesn’t have a formal position on e-cigarettes.

Smokefree Nurses’ brief website advice on e-cigarettes recommends, like the Ministry of Health, that regulated NRT should be nurses’ firstline smoking cessation aid.

But the website also neatly sums up the current ‘foot in both camps’ dilemma by adding: “There is not enough evidence to recommend e-cigarettes to patients OR discourage the use of them as a substitute for smoking”.

Are they less harmful than tobacco? “Well, almost certainly they are,” replies Wong, “but they are not less harmful than not vaping or smoking.”

(An interesting aside is that Wong says nurses and GPs were recently informed that ex-smokers who use e-cigarettes now officially count as non-smokers for health statistic purposes.)

Like NZNO, Wong is keen to reduce harm to current smokers and also to curtail the risk of a new generation of smokers being created. “A lot of the concern is about young people trying e-cigarettes – not as a substitute for tobacco or smoking – but to see what they are like,” says Wong.

She points to the latest Health Promotion Agency survey showing a rapid rise in New Zealand teenagers trying out e-cigarettes in the past two years (see sidebar ‘More New Zealand teenagers vaping’). The worry, unproven to date, is whether the next step is smoking, particularly when looking at the United States where tobacco companies’ current marketing of e-cigarettes is very reminiscent of the halcyon days of tobacco cigarette marketing.

Regulation is the logical next step for New Zealand, believes Wong, with e-cigarettes already here and nicotine liquids only a few clicks on the internet away. “I think the stable door is open and the horse has bolted – it’s gone and we can’t turn back time,” she says. “But we can regulate it and put some reins on the horse.”

Smokefree by 2025?

Everybody agrees more research is needed and most agree more regulation is required for the controversial product that is now a multi-billion dollar industry.

“They (e-cigarettes) are here to stay and we have to decide what to do with them,” sums up Bullen. “Can they be seen as an opportunity or relegated to a threat?”

He believes it is possible for New Zealand to regulate a quality-assured e-cigarette for smokers wishing to try them “without increasing the likelihood of reversing our successes with (reducing) youth-smoking and gradually declining smoking rates”.

The Health Research Council recently granted $1.2 million to The University of Auckland for a further randomised trial of e-cigarettes (with and without nicotine) for smoking cessation – this time combined with nicotine patches.

Whether such research and regulation can come together in time for e-cigarettes to be proven a friend (or foe) of the Government’s Smokefree New Zealand 2025 goal is as yet unknown.

But here’s hoping the air is clearer for all of us very soon.

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Fad diets:

what do dietitians say about the latest crop?

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ny diet that bans fruit has to raise eyebrows. The same goes for a diet that advocates lashings of cream and butter with every meal.

The demonising of one food group as the source of all dietary evil, or the fixation on another as a saviour, is often the key selling point for the latest fashionable weight loss diet.

With increasing numbers of New Zealanders being overweight or obese – and corresponding numbers of people being diagnosed with type 2 diabetes and heart disease – the ‘appetite’ for trying new dietary regimes is also growing.

While nurses and dietitians may advise clients to make gradual changes towards more sustainable and healthier eating patterns, many people with long-term conditions want to speed up the changes and are drawn to the latest reduction/detox diet making headlines.

So how should nurses advise their type 2 diabetes and heart patients on the pros and cons of some of the latest fashionable diets?

Nursing Review talks to Diabetes New Zealand dietitian Margaret Thorsen and Heart Foundation nutrition spokesperson Dave Monro about four of the current dietary trends: the Paleo diet, the 5:2 intermittent fasting diet, the ‘no sugar’ regime and the low-carb, high-fat (LCHF) approach.

The dietitians give thumbs-up to some of the positive takehome messages common to the latest fashions, highlight some of the pitfalls or dangers, and also share some advice on guiding long-term condition and other patients towards sustainable healthy eating habits.

If a new dietary regime helps somebody to kick start a new, healthier eating pattern, that is a positive. It just needs to be sustainable.

Diet needs to be realistic

Heart Foundation dietitian Dave Monro and Thorsen agree that for healthy eating changes to be sustainable they also need to be realistic. If a diet takes a ‘thou shalt never have’ approach to a particular food, or food group, then those items can become much more desirable. Then if that forbidden food is eaten the person can feel they have ‘failed’ the diet and may return to old eating habits.

Thorsen says one positive aspect across many of the new eating fashions is their emphasis on moving away from processed, pre-packaged foods to cooking from scratch using fresh whole foods so people know what they are eating. But they both say the reality is that not everybody’s supermarket budget stretches to cover the high-quality ingredients often promoted in such diets. Today’s busy families are also often time poor so struggle to regularly cook from scratch and often fall back on processed foods to get dinner on the table quickly.

Fat is a fad topic

Fat intake has been one of the hot media topics of recent years, with many arguing that the pendulum has swung too far in damning dietary fat. But Thorsen and Monro agree that doesn’t mean the pendulum has swung back so far that a high saturated fat intake is now okay – science still shows saturated fats have a negative impact on heart health.

Monro says the healthy heart message focuses less on a low fat diet and more on reducing one’s saturated fat intake. “So it is fine to have a slightly higher fat diet but keep the saturated fat content in the diet low.”

He says there has been a range of factors causing heart disease rates to plummet over the past 50 years and key amongst them has been reducing saturated fat intake.

Thorsen agrees, saying that some heart-friendly fats are okay. “Olive oil, avocado and nuts, including some peanut butter on your toast, can be part of a healthy diet,” she says. (See also some general healthy eating tips at end of article.)

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iabetes New Zealand advocates that the best weight management strategy for most people is a moderate, balanced diet coupled with regular physical activity.

Margaret Thorsen, a Diabetes New Zealand dietitian, acknowledges the moderate approach is sometimes a ‘hard sell’. But repeatedly eating too many calories, regardless of their source, can lead to weight gain and put people on the path to type 2 diabetes. Healthy eating patterns lead to more stable blood sugars, so those with prediabetes are less likely to progress to full diabetes and when diabetes already exists, it can be better managed.

If a new dietary regime helps somebody to kick start a new healthier eating pattern, that is a positive, adds Thorsen. It just needs to be sustainable change. If people repeatedly start and stop reduction diets – as they struggle to comply with a dietary regime’s rules – they risk yo-yoing weight loss and gain which can have a detrimental effect on their metabolism.

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The 5:2 diet (intermittent fasting)

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his diet involves eating normally five days a week (2,000 calories or 8,400 kilojoules a day for women) and then cutting one’s calorie intake down to a quarter of that for two days of the week (for example Monday and Thursday). This means eating 500 calories (2,100 kilojoules) a day for women and 600 calories (2,500 kilojoules) for men.

The argument for intermittent fasting is that occasionally eating less is an easier dietary regime to comply with than cutting calories every day. If people eat sensibly, it advocates (that is, don’t binge or overeat on the other five days), they will lose weight. Research is also ongoing into whether intermittent fasting may have other health benefits.

Allowed: all foods in a normal balanced diet with a calorie intake of around 2,000 calories a day for woman and 2,400 for men.

Not allowed: more than 500 or 600 calories during the two fasting days.

This diet regime clearly states that intermittent fasting is not suitable for children (under 18 years), type 1 diabetics or type 2 diabetics on medication (other than Metformin), pregnant woman and people recovering from surgery.

PLUSES: »» Maintaining a healthy diet on the nonfasting days is encouraged, so this diet may help to break unhealthy dietary habits »» Unlike other, more rigid, dietary regimes, no specific food groups are banned »» As participants can eat a normal, healthy diet most of the time, it may be easier to comply with.

MINUSES: »» Unsuitable for type 1 diabetics or type 2 diabetics on medication (other than Metformin) because of the risk of hypoglycaemia on fasting days »» Not everyone will be nutritionally competent enough to cut their dietary intake down to 500 calories on fasting days »» The energy levels of some people – particularly those who have physically

demanding jobs, or are active – could be compromised and they could feel extremely tired on fasting days »» Diabetics would need to monitor their blood sugar levels on fasting days »» Yo-yo eating habits that may not be healthy or sustainable could be encouraged.

OTHER: The Centre for Endocrine, Diabetes and Obesity Research (CEDOR) at Wellington Hospital is currently researching the effect of intermittent fasting (the 5:2 diet) on blood sugar levels and diabetes management, including changes in medication requirements, hormone levels and weight, and how well the diet is tolerated.

The argument for intermittent fasting is that occasionally eating less is an easier dietary regime to comply with than cutting calories every day.

Low-carb, high-fat (LCHF) diet

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n an LCHF diet participants slash their carbohydrate intake and eat a diet high in saturated fats. At the most extreme end is the ketogenic diet (developed to prevent epileptic fits), which has a strict 4:1 ratio of fats to proteins and carbohydrates and leads to falling blood sugars and the rise of ketones as the body switches from breaking down glucose for energy to breaking down fat. This can cause ketosis, which can result in nausea, headaches, fatigue and bad breath.

Allowed: meat, fish, eggs, cured meats like salami and bacon, vegetables growing above ground (i.e. not potato or kumara) and natural fats (including butter, cream, full-fat cheeses, full-fat plain yoghurt and other full-fat dairy products, the fat on red meat and the skin on chicken).

Berries in moderation.

Not allowed: sugar and starchy foods (like bread, pasta, rice, beans and potatoes, including chips), low-fat products, sweetened dairy products like fruit yoghurt or ice cream, vegetable oils, trans fats and margarine. In many versions of this regime you are encouraged to reduce or cut out your fruit intake.

PLUSES: »» Foods with a high protein or fat content can increase feelings of satiation or fullness »» Refined carbohydrates (like those in sugary drinks, white bread and cakes) are not necessary for a healthy diet.

MINUSES: »» Not suitable for type 1 diabetics or type 2 diabetics on medication (other than Metformin) because of the risk of hypoglycaemia or ketoacidosis »» Some people only hear part of the message and see it as a licence to eat high levels of saturated fats, such as butter and fatty meats, without changing other aspects of their diet »» A high saturated fat intake results in a higher cardiovascular risk; the reduction in saturated fat intake in the past 50 years has been an important factor in reducing heart disease rates

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»» A blanket restriction on all carbohydrates is too restrictive and unnecessary »» Some highly nutritious foods that contain carbohydrates – like whole grains, legumes and vegetables – have been shown to protect against heart disease »» The restrictive nature of this diet means it may be unsustainable in the long term »» Some versions suggest taking a multivitamin supplement, suggesting the restricted diet was not providing all the necessary vitamins and minerals.

Some people only hear part of the message and see it as a licence to eat high levels of saturated fats.

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The Paleo diet

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he Paleo approach is to eat modern foods while trying to mimic the food groups eaten by our hunter-gatherer ancestors before they began growing crops and farming animals. Interpretations of this diet can vary, with some people adopting the ‘85:15 rule’ whereby they are allowed to consume three non-Paleo meals per week, including a glass of wine.

Whether Palaeolithic times were a golden era for human nutrition is open to debate, though if our ancestors did manage to have meat at the fireside every night, they probably had to expend more energy to catch it than just driving to the supermarket.

Allowed: grass-produced meats, fish, seafood, fresh fruit and vegetables (excluding starchy vegetables like potato), eggs, nuts and seeds and ‘healthy’ oils including olive, avocado and coconut.

Not allowed: cereal grains (so no wholegrain bread, porridge or rice), dairy products, legumes (i.e. beans, lentils, chickpeas and including peanuts), refined sugar, potatoes, processed foods, salt and refined vegetable oils.

PLUSES: »» Encourages people to move away from processed foods and refined starches »» Promotes cooking of whole foods from scratch »» Could help to retrain the palate away from sweetness and salt

… if our ancestors did manage to have meat at the fireside every night, they probably had to expend more energy to catch it than just driving to the supermarket.

MINUSES: »» Not suitable for type 1 or type 2 diabetics because of the risk of hypoglycaemia through low carbohydrate intake »» Excludes foods that modern science has shown help to protect against heart disease i.e. legumes and unrefined whole grains »» Eliminates other food, such as low-fat dairy and starchy vegetables, which also contain valuable nutrients »» When early man had to hunt for meat it featured less often in their diet – the Paleo diet should not be seen as a licence to overdose on meat or animal fat »» Can be costly in time and money to shift away from all processed foods, to purchase some of the foods promoted in this diet and to cook food from scratch.

‘No sugar’ diet

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ome recent diets concentrate on severely reducing or eliminating added sugar to ‘detox’ and lose weight. Advocates point out that the advent of low-fat foods saw food manufacturers use more sugar and sweeteners (like corn syrup) to compensate for the reduction in flavour and make their products more palatable.

Increased sugar consumption is now regarded by many as one of the major causes of the world’s rising obesity levels. A can of fizzy drink, for example, can contain 9 –10 teaspoons of sugar.

The response has ranged from people aiming to reduce sugar intakes to WHO recommended levels (around 12 teaspoons a day from all added sugar sources or ideally half that level) to people trying to eliminate all sugars from their diet, including not only fruit juice but also fruit itself.

Allowed: vegetables, fruit, nuts, meat, eggs, natural yoghurt, cream and cheese (milk sugar i.e. lactose is okay), bread with no added sugar.

The emphasis is on natural, unprocessed foods. Some ‘no sugar’ plans still allow dry wine, beers and spirits but not liqueurs, dessert wines or mixers like tonic.

Not allowed: sweetened milks, fruit juices, honey, cured meat products, maple or corn syrup, table sugar (beet or cane), confectionary, muesli bars, any baked goods or breakfast cereals with added sugar.

People are encouraged to read food labels carefully for ‘hidden sugars’. Some also advocate not eating fruit.

»» Avoiding unnecessary added sugar in the diet is already recommended for diabetics and pre-diabetics »» Taste buds could be retrained to prefer less sweetness in food.

MINUSES: »» Not suitable for someone managing their diabetes with insulin or any medication that could lead to hypoglycaemia as they need a source of immediate, fast-acting sugars (like glucose tablets) in case of a potential ‘hypo’ incident »» Trying to avoid all added sugars may be unsustainable; probably better to first focus on reducing sugar intake in drinks or other commonly consumed foods and allow taste buds to adjust »» Can be costly in time and money to shift away from processed foods and to cook and bake food from scratch »» Reducing one’s added sugar intake is positive but becoming obsessed about a single nutrient can be problematic »» Some people take it to extremes and don’t just avoid added sugar but stop eating fruit (contains natural fructose) and drinking milk (because it contains lactose), when both foods have positive nutritional benefits »» People may become preoccupied with removing sugar from their diet and ‘loosen the reins’ in other dietary areas.

The emphasis is on natural, unprocessed foods.

PLUSES: »» Encourages people to move away from processed and sweetened foods »» Promotes cooking of whole foods from scratch to reduce chance of getting hidden sugars in processed food

OTHER: Diabetes New Zealand says a small amount of sugar in the diet is allowed for people with diabetes but should be consumed in appropriate amounts AND times to avoid spikes in blood sugar levels.

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Healthier eating tips for you and your patients Check your drinks: aim to drink predominantly water, milk and sugar-free coffee or tea and steer away from sugary drinks.

Look at your meal pattern: are you having three regular meals spread throughout the day? If you are eating a snack between meals, is it a healthy snack? Are you ‘grazing’ in the evening and eating more than you think?

Serving sizes: is your plate following the Diabetes New Zealand healthy plate model of ½ vegetables, ¼ protein and ¼ carbohydrates?

As writer and researcher Michael Pollan sums it up: “Eat food. Not too much. Mostly plants.” Or just eat real food.

Fine tuning: once you’ve addressed the above three areas then you can start fine-tuning the meals you eat to better manage your weight or blood sugar levels.

Be realistic: dietary changes have to be sustainable and fit in with people’s budgets, lifestyles and available time. For example, it may be difficult to eliminate all processed foods but try and make good choices whenever possible.

Coconut oil is not healthier than unsaturated oils: check out the Heart Foundation’s findings on this other fad at www.heartfoundation.org.nz/uploads/Evidence_paper_coconut_ August_2014.pdf.

SOME HELPFUL LINKS Diabetes New Zealand website information including recipes, healthy food tips, information on the glycaemic index, shopping and reading food labels. www.diabetes.org.nz/food_and_nutrition

STAY WELL FOR†

SPIRIVA ®

(tiotropium 18 mcg)

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Don’t get fixated on nutrients: people don’t eat nutrients, they eat food, and people should focus on trying their best to eat healthy food.

Consider referring people to a dietitian: if a patient wants specialist help to change and improve their diet, refer or suggest a dietitian.

Get the basics right: eat MORE vegetables and whole foods and eat LESS processed food, refined starches and added sugars.

Don’t get fixated on whether foods contain carbohydrates: it is the type of food that matters more than the carbohydrates it contains i.e. whole grains get a tick and refined white flour gets a cross.

Don’t expect to be perfect all the time: people shouldn’t be too fixated on eating healthily 100 per cent of the time – aim for perhaps 70 per cent some of the time and 80 per cent the rest of the time.

Heart Foundation’s Healthy Living website has pages on healthy eating and managing a healthy weight. The healthy eating page has links to the ‘Healthy Heart’ visual food guide, the Heart Foundation’s ‘Tick’ programme, and recipes.

Healthy Habit Exchange is a new Facebook app to encourage people to switch to a healthy habit i.e. switching from starting work on an empty stomach to having a good breakfast or swapping blue-top milk for green. www.heartfoundation.org.nz/healthy-

www.heartfoundation.org.nz/healthy-living

living/healthy-eating/healthy-habit-exchange

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Asthma or COPD: stop and rethink?

That patient with the persistent cough or wheeze may be mislabelled asthmatic. And that COPD patient prescribed a steroid inhaler may only be increasing their risk of pneumonia. Nursing Review talks to respiratory physician associate professor Jeff Garrett about misdiagnoses and misclassifications that can result in misprescribing for some airway disorders. We also highlight the simple blood test biomarker that could help more respiratory patients start off with the right label and, most importantly, the right treatment.

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s that an asthmatic wheeze or a smoker’s cough? Is it a ‘weak lung’ from a childhood disease or ‘twitchy’ lungs due to asthma?

Respiratory physician Jeff Garrett believes fixating on fitting respiratory patients into neat diagnostic boxes for asthma, chronic obstructive pulmonary disease (COPD) or bronchiectasis may not be as helpful as targeting the right treatment.

Taking a patient’s history can reveal whether the patient wheezes, coughs up phlegm, has ever smoked or gets breathless upon exercise.

Testing lung function with a peak flow meter can tell you more – and a spirometry test even more again. Garrett believes that spirometry should be routinely available, but only half of those in general practice in New Zealand have access to it.

Bringing all the information together can give you a likely diagnosis and an indication of where the patient sits on the spectrum.

“But you can still end up with substantial overlap,” says Garrett, who is also clinical director of medicine at Middlemore Hospital and an asthma researcher. An example can be someone in their 60s who has experienced a lifetime of asthma and, over time, has developed fixed airways obstruction (i.e. COPD) due to ‘remodelling’of their airways.

“So which box do you put them in now – the COPD box or the asthma box?” he says.

Furthermore, about 20 per cent of people with smoking-related COPD will end up with bronchiectasis because of recurrent infections, and as many as 10–15 per cent of more severe asthmatics will develop bronchiectasis due to remodelling of their airways, resulting first in COPD, then in recurrent infections and bronchiectasis.

“So the diagnostic labels are pretty crude ways of classifying patients, though they still have their uses,” says Garrett.

Steroids fighting or feeding inflammation?

The answer, Garret believes, is to spend less time trying to fit an asthma or COPD label onto patients and more time regarding people as having an inflammatory airways disorder.

“You need to think about such patients as having an airways disorder that is associated with inflammation – reddening and swelling.”

He believes the best way to identify what is causing the inflammation – and therefore which treatment is best – is to use a biomarker.

Canadian researchers in the 1990s developed a test that revealed the different types of inflammatory cells in patients’ airways. They developed an induced sputum test, where patients are given a very salty solution (hypertonic saline) by nebuliser that causes them to cough up sputum, which is tested to evaluate whether eosinophils, neutrophils or both cells are present. (Eosinophil levels rise in response to allergens and neutrophils in response to bacterial or viral infection or as a result of exposure to an irritant.)

Subsequent researchers, including Garrett, have found that when the sputum of asthmatics, or suspected asthmatics, is tested, around 40 per cent are found to contain eosinophils, 20 per cent neutrophils, 5–10 percent have both and about 30 per cent have few, if any, inflammatory cells (because they either have well-controlled asthma or don’t have asthma at all).

Further research has confirmed that the most helpful treatment for a respiratory patient with elevated eosinophil levels is inhaled steroids at a

”I go on my ward rounds stopping steroids left, right and centre for COPD patients with low eosinophil counts and have never seen anyone deteriorate as a consequence.”

dose required to return eosinophils back into the normal range.

“Eosinophils dislike steroids and if used correctly and if targeted to the right part of the airway will usually lead to satisfactory control,” says Garrett.

However, if neutrophils are present instead (neutrophils are associated with COPD but also found in the airways of some people labelled as asthmatic) then Garrett says inhaled or oral steroids will make absolutely no difference. “If anything, they may make the situation somewhat worse.”

Garrett says the best treatment for the neutrophils group is to identify what is irritating the airways or to treat the bug or the condition that is causing the neutrophilic inflammation.

“These people tend to require antibiotics,” says Garrett. “If you continue to give inhaled or oral steroids to these people [with neutrophilic inflammation], you actually reduce the effectiveness of the antibiotic.

“Because the bugs that are down there love steroids, they will proliferate, so the worst thing you can do is to give steroids to somebody with neutrophilic inflammation.”

This group includes the 20 per cent of people labelled with asthma who don’t have eosinophilic inflammation and most COPD patients.

Too many misprescribed steroids

Research has found that the vast majority of COPD patients don’t have eosinophil cells in their airways.

In fact, it is estimated that only about 10–15 per cent of people labelled as COPD have lung inflammation due to eosinophils.

But Garrett says that current audits suggest that as many as 70 per cent of COPD labelled patients in New Zealand are currently being prescribed inhaled steroids. “For two-thirds of those people, they are not getting any benefit from steroids and potentially the steroids are doing harm.

“The harm is that recent research has shown you can increase their risk of episodes of pneumonia, particularly if you give them high doses of steroids – for example, 500mcg Flixotide a day or doses of Pulmicort greater than 800mcg a day.”

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COPD has been diagnosed in at least 200,000 New Zealanders (though it is thought there are another 300,000 who are undiagnosed). That is potentially a lot of money being invested in prescribing steroid inhalers that may be causing more harm than good. Garrett has estimated that up to $14 million a year is wasted on prescribing inhaled or oral steroids to patients who gain no benefit from them. This includes the 20 per cent or so of people labelled as having asthma, but who actually have small airways damage or bronchiectasis.

Simple blood test may be helpful

The gold standard for detecting whether there is airways inflammation, and whether steroids are the answer, remains the induced sputum test.

But Garrett says the test is largely limited to research laboratories (it is available privately in Auckland) and has not become standard clinical practice worldwide as it is time-consuming and reasonably costly. Consequently, researchers have sought an easier but less accurate test. A lot of time

and effort was spent developing an expired nitric oxide test (simple breath test), which is reasonably good at identifying patients with eosinophilic inflammation, but not those with neutrophilic inflammation. The expired nitric oxide test is also artificially influenced by other factors, including smoking, and whether patients are on inhaled steroids at the time.

Research undertaken at Middlemore Hospital (and since validated by four other groups internationally) has revealed that the best surrogate for the induced sputum test – for predicting eosinophils in the airways – is a straightforward blood test using a white blood cell count differential.

Garrett’s team found that an eosinophil count of greater than 0.35 indicates an 80 per cent likelihood that eosinophils are present in the airways. So if a patient presents with bronchitis and blood test results show an eosinophil count of, say, 0.45, then a GP or NP could reasonably confidently prescribe inhaled or oral steroids.

Conversely, a Belgian group has found that if the eosinophil count is less than 0.25 there is a

Definitions Eosinophils

Eosinophils are the inflammatory white cells that rise in response to allergens or after certain viral infections. They are found in higher levels in sputum or blood when airways inflammation is due to an allergic response or after some viral infections.

BIOMARKER: A blood test that shows eosinophil levels greater than 0.35 indicates an 80 per cent chance that airways inflammation is eosinophilic and steroids are the treatment of choice.

Neutrophils

Neutrophils are the most common inflammatory white blood cell and their main role is in fighting against bacterial or fungal infection, so neutrophil levels are elevated when inflamed lungs are fighting a bacterial infection. (Irritants and pollutants like tobacco smoke can also trigger neutrophilic inflammation, however, and are more strongly associated with COPD or with patients who have damaged their small airways.

BIOMARKER: If a blood test shows an eosinophil count of less than 0.25 then there is a 76 per cent likelihood that neutrophils are causing the inflammation, therefore inhaled or oral steroids should be avoided. The best treatment is to remove the cause of the irritation (i.e.stop smoking) and/or use antibiotics to combat the bacteria the neutrophils are fighting.

COPD

Chronic obstructive pulmonary disease* (COPD) is a term used to describe lung damage that makes breathing difficult, with tobacco smoking being the main cause in 70–80 per cent of cases. The two main types are emphysema and chronic bronchitis. COPD is the fourth most common cause of death in New Zealand after cancer, heart disease and stroke. It accounts for about 200,000 GP visits a year and more than 453,000 prescribed medications.

Asthma

In New Zealand about one in four children and one in nine adults who have a cough or wheeze are diagnosed as having asthma*. (Garrett believes that childhood asthma is overdiagnosed and may be around half that rate). Asthma happens when airways become oversensitive and react to certain triggers by tightening up (bronchospasm), swelling (inflammation) and producing more mucus.

About 70–80 per cent of asthma in New Zealand is associated with allergies.

Bronchiectasis

Bronchiectasis* is a condition caused by damaged airways, usually occurring in childhood and often leading to colonisation by pathogenic bacteria causing low grade inflammation, mucous production and repeated infections.

*Source: Health Navigator NZ www.healthnavigator.org.nz

About 70–80 per cent of asthma in New Zealand is associated with allergies.

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76 per cent likelihood that neutrophils are present instead. In this situation steroids are unlikely to help and other treatment options like antibiotics and bronchodilators (non-steroidal inhalers that open the airways) should be considered.

Garrett says the simple blood test should be used by GPs and NPs whenever a respiratory patient presents with an attack of bronchitis.

An English group used a simple cut off of 0.3 eosinophil levels to decide whether to use oral steroids for exacerbations of bronchitis in patients with COPD. They found if a patient with an eosinophil level of less than 0.3 was given Prednisone then the outcome was inferior to when antibiotics alone were used.

So rather than the knee-jerk reaction of sending a patient away with antibiotics and a course of the oral steroid Prednisone – that may hinder rather than help recovery – the health practitioner can use a straightforward blood count to target which patients will or won’t benefit from the addition of steroids.

Garrett says he sees plenty of patients admitted to Middlemore with bronchitis attacks who have been misprescribed oral steroids when they have low serum eosinophil counts.

“I go on my ward rounds stopping steroids left, right and centre for COPD patients with low eosinophil counts and have never seen anyone deteriorate as a consequence.”

Better diagnosis and management is key

The blood test can also be used by GPs and NPs when a patient first presents with asthma-like symptoms to better determine whether they have asthma or not.

“If you just take a patient history, measure their lung function and consider the blood test biomarker you will get it [asthma diagnosis]more right, more often,” says Garrett.

“Certainly if you are experienced at using blood tests then you get it right in between 80–90 per cent of cases when tested against the gold standard of an induced sputum test. We tested our respiratory physicians’ and nurse specialists’ ability to predict the inflammatory cell present and they were similar in their accuracy. It was mainly the mixed inflammatory subtypes, not surprisingly, where clinicians have the greatest difficulty.

“At the moment a lot of doctors are doing it by the flip of a coin – with about 50–60 per cent accuracy in predicting which inflammatory cell is present in the airways.”

Garrett adds that while on the one hand New Zealand is overprescribing unnecessary steroids for COPD patients, on the other hand it is underutilising inhaled steroids for some asthma patients. “We are not maximising their effect to control the inflammation.”

He says it doesn’t make sense to keep giving people bronchodilators (short-acting or longacting symptom relievers) if you haven’t first done your best to control the inflammation. And, in the case of asthma patients, that means controlling the eosinophil inflammation by using inhaled steroids at the appropriate dose and frequency.

As it is Garrett says many people regard their steroid inhaler as a ‘preventer’ rather than ‘controller’ and if their asthma worsens, and they get an asthma attack, they reach for their ‘reliever’ inhaler thinking the ‘preventer’ has failed. Whereas, he argues, if their blood eosinophil count has increased above 0.35 they should be escalating their inhaled steroid dose.

FOCUS n Long-Term Conditions

He recommends that patients with suboptimal control of asthma (i.e. those who despite using 500mcg of Flixotide or 800mcg of Pulmicort remain symptomatic and with impaired lung function) should have a blood count. If the eosinophil count is high (i.e. greater than 0.35 x 109/L) then they should either double their inhaled steroid dose or switch to the most efficacious inhaler QVAR MDI. (Garrett says QVAR deposits 60 per cent of medication to the airways and to all the airways, as opposed to the other inhalers, which deposit only 15–20 per cent to the airways and only to the first few generations.

Steroid inhaler adherence remains a major issue for asthma patients with Garrett’s research indicating that 80 per cent of people hospitalised with asthma attacks are poorly compliant and that around 50 per cent of asthmatics within the outpatient clinic are poorly compliant.

He says nursing has a key role in helping people improve adherence through the use of education and, potentially, through the support of devices such as Nexus6’s Smartinhaler (a wi-fi-based system developed in Auckland that has been shown to improve adherence by 50 per cent).

A further 25 per cent of people have poor inflammation control as a result of poor inhaler technique, which he says can be remedied by instruction from a nurse, use of a spacing device or transfer to QVAR, which overcomes a lot of the effects of a poor technique.

Diagnosing a respiratory condition – even with the help of blood test biomarkers – is still not an exact science.

But Garrett says adding the biomarker to the lung function data and the information gathered from a full patient history data helps in more accurately

placing the patient on the diagnostic continuum.

This allows more accurate assessment of what is causing inflammation in the airways and better targeting of treatment.

“If we use the tools available to us better and target treatment more effectively we would have 90 per cent of asthmatic patients optimally controlled (as opposed to the 50 per cent estimated from telephone surveys) and at a lower cost,” believes Garrett. “And we would have a greater proportion of COPD patients on appropriate long-

acting bronchodilators and far fewer on inhaled steroids.”

That may mean no steroids for some, more steroids for others and better-targeted treatment for all. And maybe more people able to breathe a big sigh of relief.

Key points when assessing and managing patients with airway disorders »» What is the underlying diagnosis in this patient – COPD or asthma? (History/spirometry.) »» What is the key cause of their airways inflammation? (Blood count or FeNO or induced sputum if available.) »» If asthmatic, what impact does their asthma have on the patient? What are their current symptoms? What is their control level? (The Asthma Control Test www.asthmacontrol.co.nz is a validated and effective tool for assessing asthma control.) »» Are they on the right medication? (I.e. will steroids help or hinder them?) »» If on inhaled steroids, are they on the right medication, the right dose and the correct frequency? »» Are they using the right inhaler technique? »» Do they have the right inhaler for their needs? »» Are they compliant with the use of their inhalers? (Checking can be done electronically using TestSafe to see how many inhaled steroids have been dispensed in previous year.) »» Are they suitable candidates for a pulmonary rehabilitation programme (offered by a multidisciplinary team including dieticians, physiotherapists, nurses and psychologists)?

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Nursing Review series 2015

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PNEUMOCOCCAL

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FOCUS n Aged Care

Chronic pain:

the other long-term condition Nursing Review talks to pain management NP Sue King about not only the pain associated with the more common long-term conditions but also about chronic pain as a long-term condition in its own right – and how nurses can best help their patients manage it.

L

iving with chronic pain – stabbing, throbbing, darting, sharply stinging or dully thudding – is a fact of life for many people. While most people experience severe, acute pain some time in their lives – be it toothache, childbirth, a broken limb or when recovering from surgery – for some, pain becomes an unwelcome, long-term companion.

Helping people deal with chronic pain is part of the brief of Waikato pain management nurse practitioner Sue King. Chronic pain is defined as pain that continues to persist beyond the expected time of healing or beyond a three to six month period.

King sees her potential clientele increasing because as the population grows older, more people survive cancer and the burden of long-term conditions like diabetes and heart disease keeps growing, so does the number of people potentially living with chronic pain.

At the other end of the age spectrum, King says chronic pain is also an issue for children and adolescents, with a wide range of causes from scoliosis of the spine to abdominal pain following multiple surgeries for a congenital condition.

Nurses can play a part by recognising that all pain is real, regarding the whole person not just the pain, and helping people identifyand manage acute pain before it becomes a chronic pain issue.

Pain underrated

The numbers living with chronic pain may be growing but King says resources to support them are not keeping up and politically, pain doesn’t garner the same attention as cancer or heart disease. And there are even fewer resources for paediatric pain management than there are for adults.

New Zealand is not alone in this, with the International Association for the Study of Pain saying that there is inadequate access to pain management worldwide. It goes on to say that there is also a failure internationally to recognise chronic pain as a chronic or long-term condition in its own right, requiring management support just like diabetes or heart disease.

The pain may begin as a consequence of classic long-term conditions like diabetes, chronic obstructive pulmonary disease (COPD) and heart disease, or following an injury or surgery. But the research is now showing that if the body faces a persistent barrage of pain signals, then the oversensitised nervous system can also be affected long-term, so pain can switch from being an acute to a chronic issue needing its own long-term management.

King says persistent pain signals can reprogramme the nervous system so the pain switches from being localised (a classic example being migraine pain) to spreading to other areas of the body. Another example is acute post-surgery pain which, if not controlled appropriately and adequately, will see some people go on to develop chronic post-surgery pain. And the pain initially caused by arthritic inflammation or injury to a joint may sometimes continue as chronic pain, even after the affected knee or hip is replaced.

“So pain is potentially a disease in its own right but it is mostly recognised as an outcome of another condition,” she says.

Seeking explanations for pain

King says some people with chronic pain can find themselves stuck on a conveyor belt of specialist

appointments, seeking relief from their debilitating pain.

“They are looking for someone to find an explanation, a cause (of their pain) and a fix for that cause. And often they spend many months, years even, visiting specialists, having repeated investigations and sometimes multiple surgeries.”

The end result may still be that their pain is labelled ‘medically unexplained’ and it is suggested they see a psychiatrist.

“Well, you can imagine how that makes you feel,” says King. She believes the label ‘medically unexplained pain’ says more about the failure of the biomedical approach then the reality of the person’s pain.

“It’s important to emphasise that all pain is real.

That’s also why it is important from the outset to work with the person in pain as a whole person and to regard their pain as more than a physical symptom.”

Chronic pain services, such as the service she works for at Waikato District Health Board, are often the end of the line for those who have found no relief from specialists.

Having invested so much in trying to find a cause and solution, King says people are often hugely resistant to being moved away from a “fixing and curing” approach to their pain towards Nursing Review series 2015

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an approach of understanding and self-managing their pain so they can take back some control over their lives.

The multidisciplinary team offers a range of support and tools to help people self-manage chronic pain, including pacing their day so pain doesn’t overwhelm them, learning relaxation skills and slowly reintroducing stretching and exercise into their lives.

“People fight pain. Nobody wants to live with pain – who would! It is potentially quite destructive but people can have meaningful lives and they can get back to work – they might not be able to do the same things they did before they had pain but they can get a life back, which is the important thing,” she says.

“But it takes work and commitment and that’s why it’s important to get people engaged early with chronic pain services – if they have a service in their region –rather than late.”

King emphasises that medication is only a small part of the therapeutic approach to chronic pain, which focuses on reactivation/functional goals and helping people understand the role of thoughts, behaviours and actions in managing pain effectively. “Medicines merely offer a window of opportunity to achieve the functional gains important in self-management.”

Most commonly, diabetic neuropathy affects the feet and, depending on the type of nerve fibre affected, can lead to weakness or loss of feeling. If diabetes also results in damage to the blood vessels to the feet then people can also face painful legs when walking, pain in their legs and feet at night, and increased risk of pain from foot or leg ulcers that fail to heal. Heart disease can also increase the risk of leg ulcers and pain through circulation and fluid retention problems.

King says neuropathy can be awful as it can be unpredictable, shock-like pain, and one of the hardest to treat effectively. Medications used for neuropathic pain differ from those used for inflammatory pain and can include drug groups like anti-convulsants and tricyclic anti-depressants.

She says people with chronic neuropathic pain generally sleep poorly as the pain wakes them up so the tricyclic anti-depressants are used to try and improve the quality of sleeping and also to modulate the experience of the pain.

The anti-convulsants are prescribed to try to settle and calm the nerves down to stop the ‘erratic firing’ that causes the distressing, spontaneous neuropathic pain.

Another group of long-term patients at risk of pain are people with chronic respiratory issues who can face painful breathing and coughing.

Long-term steroid use also increases the risk of brittle bones and painful cracked ribs from the constant coughing and spinal fractures.

“Nurses need to be aware of all these potential outcomes of a patient’s chronic condition that can lead to a new acute condition – pain – that needs attention in its own right,” says King.

Dealing with the acute pain as it arises may also prevent the chance of the pain lingering and persisting until it becomes chronic pain.

Pain is the 5th vital sign

Some years ago, American pain specialists were keen to heighten the profile of pain during patient assessment.

Pain – is it all in the head?

“… it is important from the outset to work with the person in pain as a whole person and to regard their pain as more than a physical symptom.”

Pain from long-term conditions

It is estimated that chronic pain affects one in five people at some time in their life. Ministry of Health surveys indicate that one in four adults have persistent back or neck pain and about one in six have arthritis. That is about one million New Zealanders living with persistent pain.

Complications of poorly managed long-term conditions like diabetes and cardiovascular disease can also lead to chronic pain through ulcers, stroke and diabetic neuropathy.

People who have had diabetes, or poorly controlled blood glucose levels, for a long time are at highest risk of diabetic neuropathy – a form of nerve damage that can cause prickling, tingling, burning, aching or sharp jabs of needle-like pain.

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“So in order to encourage nurses to include pain as part of their initial assessment,” says King, “they coined the idea of pain as the 5th vital sign.”

She says that while it gained little attention in New Zealand she agrees pain should always be part and parcel of nurse assessment, be it a district nurse dressing a venous leg ulcer or a practice nurse doing a regular blood test for a patient with diabetes.

“Nurses are very good at asking people how they are ‘doing’ in the widest sense of the term and through the answers they get they can drill down and seek further clarity. ‘How are you doing Mr Smith? How are you sleeping? What activities are you up to these days?’ These are all good questions to help ascertain whether pain is interfering in a person’s daily life.”

King says nurses can play a key role in monitoring their regular long-term condition patients to see whether pain is beginning to impact on their quality of life. “Particularly as patients often like talking to nurses rather than their doctor as nurses can be seen as more sympathetic or having more time.”

Of course, a key nursing role remains health education, whether it’s supporting patients to quit smoking or encouraging other lifestyle changes that could help them manage their condition and reduce the risk and impact of pain. Finding out about a patient’s use of analgesics (are they taking something around the clock, or reluctant to take even the occasional paracetamol?) and educating them about appropriate pain management is also important.

And once again, considering the whole person is important, emphasises King. Health professionals need to look at whether ongoing pain is leading to stress in patients’ lives and whether stress in turn is reducing their ability to manage an exacerbation or flare-up of pain.

“People with chronic pain have reduced capacity or reserve to manage stress because their body is already under stress from the pain.”

DEFINITIONS Pain

A physical and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Chronic or persistent pain

Pain that persists beyond the expected time of healing or beyond a three to six-month period.

King says a key part of chronic pain management is managing the head and often retraining the brain. That’s not the same as saying chronic pain is only in the head, but the head is often a major factor in the pain continuing.

“The brain releases chemicals in response to pain because that is its job – it prepares the body for ‘fight or flight’ when a potentially harmful signal of pain comes in.” Unfortunately that protective and helpful mechanism can go awry.

“In people with chronic pain, that mechanism can become unhelpful and pathological because the brain becomes overly alert and people can become hyper-vigilant to signals from their body.”

The resulting chemicals rushing around the body can make them anxious and stressed; their heart rate goes up and they worry about aggravating the pain so get fear-based avoidance behaviour, says King.

“So that’s why it’s important to help people with how they think about pain.”

She says nursing can play a role in helping people examine their thoughts, feelings and behaviours around pain. But nurses also need to be wary of stepping beyond their expertise and be ready to refer to a psychologist or mental health services as some chronic pain sufferers can sink to a very low ebb and there is a risk of self-harm.

Other harmful behaviour to watch out for is misuse

FOCUS n Aged Care

USEFUL RESOURCES

of prescribed opioid drugs or using alcohol to excess.

King says opioids are best kept for acute pain or cancer pain and should have a limited role in chronic, non-malignant pain. “But unfortunately they are widely prescribed because GPs get desperate as they have tried everything else and it seems to be the natural progression to put people on strong, morphine-like drugs.”

Before they know it, the drug levels are going up with very little benefit or improvement in functionality, which King says is the main function of pain medication – to allow people to function well enough to do the activities they need or want to do. Also with increased doses comes increased risk of falls, inadvertent overdoses, and misuse. So King says the trend is to avoid using opioids for chronic, non-cancer pain unless there is shown to be a clear benefit and the dose can be kept low.

Medication though is always only one part of the answer to managing chronic pain. Getting your head around the role of the head is a major step forward but King says some people will always struggle with understanding the role of the brain in their pain. “You think it’s all in my head,” is a common response.

“And the answer is yes and no, as it is actually in your head – that’s the brain’s job,” says King.

This doesn’t mean the pain isn’t real, but once people accept the brain’s role in the maintenance of chronic pain they can access strategies to help them regain a life and learn how to live with this long-term condition.

»» Peter’s Pain Toolkit: a 24-page booklet developed for both patients and health care professionals on self-management of persistent or chronic pain. The toolkit and related website are the brainchild of UK-based Peter Moore, who lives with chronic pain, working collaboratively with two GPs (one a pain rehabilitation specialist). www.paintoolkit.org or go directly to download the New Zealand version of Pete’s Pain Toolkit www.paintoolkit.org/downloads/Pain_Toolkit_New_ Zealand_%281%29.pdf »» Pain Management Knowledge and Skills Framework for Registered Nurses (2013): developed to identify and outline the fundamental knowledge and skills that nurses need to care for people with pain from the competent level (for nurses working in any setting) up to the expert nurse working with people with complex pain and health needs. The framework can be downloaded at www.health.govt.nz/our-work/nursing/nurses-new-zealand/knowledge-and-skillsframeworks-nurses »» Helpful YouTube videos on chronic pain: check out the animated ‘Brainman’ videos developed by a New South Wales health authority’s integrated pain service. »» Understanding pain: what to do about it in less than five minutes? www.youtube.com/watch?v=4b8oB757DKc »» Understanding Pain: Brainman chooses www.youtube.com/watch?v=jIwn9rC3rOI »» Understanding Pain: Brainman stops his opioids www.youtube.com/watch?v=MI1myFQPdCE »» Understanding pain and what’s to be done about it in less than 10 minutes: (New Zealand version for children and adolescents). www.youtube.com/watch?v=eJ8THITj_2Y#t=67 »» Pain Management in Nursing Practice by Shelagh Wright (2014): King strongly recommends this new book for hospital and other nursing libraries. »» New Zealand Pain Society: the society is the national organisation that brings together scientists, health professionals and others with an interest in pain research and management and includes a nurses’ interest group (NIG). www.nzps.org.nz »» International Association for the Study of Pain: The website has a range of resources, including a link to the Declaration of Montreal that says pain management is inadequate in most of the world and access to pain management should be a fundamental human right. www.iasp-pain.orgwww.iasp-pain.org

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InterRAI:

the tight and tiring race to meet mandatory deadline From 1 July – after a somewhat G hurried and harried introduction – interRAI will be the mandatory clinical assessment tool for nurses to use in residential aged care facilities nationwide.

FIONA CASSIE catches up with some nursing leaders as facilities head down the home straight in a race to meet the deadline to train nurses in an already time and resourcestretched sector.

etting enough nurses to be proficient with the new electronic interRAI tool by the Government’s 1 July deadline has been a tight race. Some facilities have crossed the finish line early; others will make it after hard slog, and some are in panic mode, with nurse turnover undermining their best efforts to be prepared.

Training courses are being run right up to and beyond 1 July to ensure nurses are competent in the clinical assessment tool – a 53-hour process that is costly both in time and resources. Concerns about lack of government support for its own project prompted a backlash from the aged care sector during contract talks last year, leading to a post-budget, pre-election funding boost for ongoing interRAI support, which starts from 1 July this year. (See timeline sidebar for details of interRAI funding.)

The Ministry of Health reports that 2,302 registered nurses had reached interRAI competency as at 21 May and it expected to exceed the project target of 2,370 and have 2,500 RNs trained by July.

It appears the problem a number of facilities face is not getting nurses interRAI trained – but retaining them, says aged care nurse practitioner Dr Michal Boyd.

Boyd was the lead researcher for an initial demonstration trial of interRAI in residential aged care in Waitemata and Bay of Plenty DHBs back in 2008. She has always believed the standardised interRAI assessment tool could bring rewards, as long as effort was put in to making the electronic tool user-friendly for time-pressured nurses.

“They have succeeded in training staff in residential aged care for interRAI, that is true,” says Boyd. “And they have succeeded in people doing interRAI in residential aged care, but at different levels depending on the facility and how up to speed they are.”

She says a major dilemma for facilities with interRAI is the huge turnover of nursing staff. “I was talking to one facility manager who said she

has trained five nurses in interRAI and only one of them still remains at the facility.” Boyd says high turnover is now an ongoing issue as residential aged care is a relatively low-paid sector and if nurses get an opportunity for higher pay or better shifts they will take it.

Staff turnover of interRAI-trained nurses has hit Metlifecare’s eight facilities hard, says Amanda Iavarone, an experienced aged care nurse who is Metlifecare’s clinical quality and risk manager.

Asked whether she thinks all their facilities are ready for the 1 July deadline, she replies: “Not at all, in fact there is a lot of panic.”

She says all of its facilities have lost interRAItrained staff and had to start over and train more, with the result being in early June they had 14 of the 35 interRAI-competent RNs that they required.

Iavarone said Metlifecare was one of the first providers to get on board with interRAI and the initial response had been positive. “This has changed now…”

Hilda Johnson-Bogaerts, an experienced aged care sector who is general manager of residential and community care for the Selwyn Foundation’s 10 facilities, said it also had had to train”a few more nurses than initially envisaged” because of staff turnover.

However, it had also been able to recruit some trained interRAI nurses and had been able to meet the ratio of interRAI-competent RNs set by the DHB. “Which I’m confident will be sufficient.”

She says it had initially thought that all its primary nurses with a care-planning caseload needed to be interRAI proficient, but after gaining more experience with interRAI, that was no longer the goal.

“We may have interRAI-trained nurses preparing the assessments for the primary nurses, who can then use the information to further work on their residents’ care plans.”

Sylvia Meijer, an older adult nurse practitioner, says most of the facilities she works with in Horowhenua have the majority of RNs trained and

TIMELINE for interRAI »» 2008: Pilots using interRAI assessment tool in residential aged care facilities are held in Canterbury, Waitemata and Bay of Plenty DHBs. »» 2011: The Government allocates more than $10 million over four years towards nurse training, a software licence and funding for at least one laptop or computer to implement interRAI in facilities. Forty facilities are selected as ‘early adopters’ in the planned four-year national rollout across the about 700 facilities nationwide. »» 2012: From June all DHBs are using a community version of interRAI for assessing older people living in their homes who may need home-based support services or a place in residential aged care.

In October the Government announces that from July 2015 using the interRAI Long Term Care Facilities (LTCF) assessment to inform care planning will be mandatory in all aged residential care facilities in New Zealand.

The NZ Aged Care Association criticises the Government for implementing interRAI too quickly, investing too little money in training and making it mandatory.

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In late 2012 the Ministry of Health sets up a project training team to fasttrack the training of one RN per 15 facility beds (training process takes 53 hours per nurse). »» 2013: In April the Government announces an extra $1.5 million towards the cost of interRAI implementation. DHBs report facilities making slow progress hampered by IT infrastructure issues and the cost and time required for nurse training. »» 2014: In June the Government announces a post-budget grant of $4.5 million a year for four years from 1 July 2015 to provide “ongoing support and training for nurses and rest homes”. The announcement follows concerns about interRAI raised by the aged care sector during a pre-election contract dispute.

The Ministry reports by November 2014 that 1,706 nurses in 580 facilities have been trained to competency level in interRAI; this had risen to 2,302 RNs by 21 May 2015 and it was predicted that by July this year 2,500 nurses would be competent with interRAI (the initial target was 2,370).

FOCUS n Aged Care

Amanda Iavarone

appear to have systems in place to ensure they meet the deadline.

Audit and hardware

Early in the interRAI journey much of the frustrations were IT-based in a largely low-tech health sector – and the length of time interRAI assessments take.

Johnson-Bogaerts says all Selwyn facilities now have Wi-Fi internet access and at least one COW (computer on wheels) but government funding had not been enough to cover the hardware or the backfill cost to cover training and ongoing increased demand on staff time.

Iavarone says Metlifecare facilities are using desktop PCs to carry out interRAI and thinks the government investment in hardware was “enough”. But she says a lot of the RNs “aren’t very computer savvy”, seeing hands-on care as their priority, and find interRAI assessments take a very long time.

Meijer says there was initial reluctance by some nurses because of the IT requirements of interRAI and she still hears occasional comments by nurses about the time interRAI assessments take. Nurses also talk about finding it hard to concentrate on completing assessments, she says, because facility computers are often in a busy office, leading to many interruptions.

Boyd says another conundrum for facilities has been that auditors have not recognised interRAI data for certification and spot audit purposes; so facilities already using interRAI have had to double-up and continue with traditional assessment reporting as well as interRAI. (N.B. after 1 July 2015 auditors will officially begin considering how facilities are using interRAI assessments to inform care planning).

Meijer agrees, saying most facilities she deals with still have separate care plans and IT

Hilda Johnson-Bogaerts

Michal Boyd

Sylvia Meijer

In theory, interRAI is excellent, and of course in time when everyone is trained and faster at doing the assessments then things will run more smoothly.”

compatibility with organisational policy sees some facilities continue to simultaneously operate an electronic and paper system.

Next step: using interRAI for care planning

Boyd says the next step, now that interRAI training has been established, is to really focus on using interRAI assessment findings to inform care planning.

Boyd says the next step, now that interRAI training has been established, is to really focus on using interRAI assessment findings to inform care planning.

Iavarone says currently nursing staff often view interRAI as too time-consuming and tedious and don’t always see the big picture of what interRAI can offer.

“In theory, interRAI is excellent, and of course in time when everyone is trained and faster at doing the assessments then things will run more smoothly,” says Iavarone. “In reality, there are many RNs who are struggling with this, those older RNs who aren’t tech savvy, or those with English as a second language – often both. So far there isn’t a great benefit for our residents that we have found.”

Meijer says interRAI is helpful in her NP role as it provides more detailed information on residents that is used as a basis to discuss care

with the client and/or staff. She has noticed some variability in interRAI skills among nursing staff, with some RNs more “confident and competent” to do assessments and others needing additional teaching. “Assessments in general should be person-focused, but as a starting point, interRAI is helpful to have a level of consistency and rigour throughout the country,” she says, about the nowmandatory tool.

Johnson-Bogaerts says Selwyn nurses also initially felt that the increased time spent on interRAI assessment was taking them away from actual ‘hands-on’ caring for residents.

“Now that they have more experience in using the tool, there is greater understanding of how the evidence-based interRAI assessments contribute to improved care planning and, ultimately, to improved care,” says Johnson-Bogaerts.

“InterRAI enables nurses to quickly focus on health issues and plan care interventions to improve or prevent the issue from getting worse.”

Nonetheless, she expects there to be increased pressure on nurses’ time for a period post-1 July as they work to ensure all existing long-term residents have an interRAI assessment.

With the finishing line in sight, it may still be some time before the country’s residential aged care facilities can catch their collective breath and decide whether they’ve won the race.

What is interRAI? The interRAI assessment tools were developed by a network of researchers from over 30 countries making up the interRAI collaborative.

The aim of the tools’ standardised questionnaires and algorithms are to promote evidence-based clinical practice and policy to improve health care for the elderly, frail or disabled. The tools use a common language to assess the health and needs of people in community care or residential care including their medical, rehabilitation and support needs.

The electronic tool, which can be used on a tablet or laptop, uses standardised data collection so statistical trends can be gathered on a facility-by-facility, regional or national level.

New Zealand is the first country in the world to have a national implementation of the tool. *interRAI stands for international Resident Assessment Instrument.

interRAI Long Term Care Facilities (LTCF) requirements from 1 July

»» Aged care residential care facilities must use the interRAI LTCF assessment to inform their care planning. »» The first interRAI LTCF assessment of a resident should be completed by an interRAI competent RN within 21 days of admission. (N.B. the interRAI home care assessment tool is used by the DHB to assess the older person’s eligibility for residential aged care and results made available to the facility). »» The interRAI LTCF tool is then to be used for all residents’ ongoing six-monthly reassessments. It is a full clinical assessment tool that covers areas including pain, falls or pressure injury risk, behaviour, body mass index, communication and cognitive performance. »» The assessment triggers clinical assessment protocols (CAPs) that identify possible solutions, risks and potential for improvement that can be used to inform RN care planning. »» If there is a significant change in a resident’s health status, interRAI tools are used to reassess whether the resident is eligible for a hospital-level bed and/or extra funding. »» Auditors undertaking certification or surveillance (spot) audits will be looking at how facilities use interRAI assessments to inform their care planning.

Nursing Review series 2015

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InterRAI:

convert says it’s worth the effort

Gabrielle Stent

While interRAI is still the new, and sometimes unpopular, kid on the block in residential aged care, it is already well established in the DHBs’ Health of Older People community sector. FIONA CASSIE talks to a Nelson gerontology nurse and interRAI lead practitioner GABRIELLE STENT about why she thinks interRAI is worth getting to know.

G

abrielle Stent is not without empathy for her colleagues in residential aged care still coming to grips with the interRAI tool.

But her advice – seven years on since she was trained to use interRAI for Nelson-Marlborough District Health Board’s needs assessment and service coordination (NASC) service – is to persevere, as it’s worth the effort.

“I’ve nursed in rest homes, I’ve worked in doctors’ surgeries, I’ve worked in wards and I’ve worked in NASC,” says Stent. “And from all those points of view, I can see how this tool works. And I think it’s the best tool we’ve had to assess need, as what you have is a tool that strips away personal opinion or personal preference.

“You are getting down to the grass roots functionality of somebody that is indisputable. And the information is transportable to wherever it needs to be to meet the needs of that person.”

Stent first started assessing older people in the community for the DHB’s NASC in 2007. She was trained in 2008 in interRAI leading up to the community version of interRAI becoming, in mid2012, the national assessment system for whether older people living at home are in need of homebased support or a place in residential aged care.

She was already a convert when, in 2013, she became the DHB’s lead interRAI practitioner. Stent is also the DHB’s systems clinician who prepares the DHB’s quarterly interRAI reports for the South Island’s Health of Older People’s Service Level Alliance (HOPSLA).

experience to recognise and make the call when a person is about to ‘tip over’ and require residential care.

Consistent assessment

Benefits in NASC

The homecare interRAI tool ensures consistent assessment across the whole country, not just the South Island, though there is currently no consistent threshold for what interRAI tool score leads to older people obtaining support – be it with housework or entry to a rest home.

Stent says it is difficult to talk about interRAI’s relation to people’s eligibility for support as interRAI is an “all-encompassing tool” looking at all the areas in which a person functions, including such things as their social need for companionship.

“It (interRAI) will trigger and point out to you – in league with your clinical knowledge – that there are aspects here that could improve a person’s quality of life – and they aren’t solely around the provision of housework and showering.”

Also, she adds, nurses around the country still draw on their clinical knowledge base and 22

Nursing Review series 2015

“…it’s the best tool we’ve had to assess need, as what you have is a tool that strips away personal opinion or personal preference.”

One of the huge benefits of introducing interRAI is the ‘readability’ of the standardised, electronic assessment tool between health professionals, not just nurses, says Stent.

For instance, it came into its own during the time Stent spent as a NASC assessor in the acute wards of Nelson Hospital. If an occupational therapist or physiotherapist quizzed her during a discharge meeting about how well an elderly patient had been functioning at home and what home support they were getting “we could go straight onto interRAI”.

“We could look at their last assessment, look at their care plan and we would know whether they had home allied health visits; we would know what their informal supports were; we would know how they were managing their ADL (activities of daily living) before they came in for this latest health

event; we could see who their help agency was, and how much support they were getting a week.”

With all that information just a few keystrokes away, the multidisciplinary team had a good base from which to draw up a successful discharge plan.

“That connectivity we never used to have [preinterRAI].”

Stent has also set up read-only access for emergency department (ED) staff so they can check out the interRAI files of elderly people when they come in – including residents of aged care facilities already using interRAI as their assessment tool.

“In the past, if a person came from a residential facility into ED for some reason the RN on duty at the rest home would have to hurriedly write up a transfer form and photocopy off drug charts and try to get all this information together before the ambulance arrived.”

(See extended version of article at www.nursingreview.co.nz)

FOCUS n Aged Care

Research focus on Ageing Well Nursing-led research projects are being recommended for a share of the $14.6 million Ageing Well research challenge launched earlier this year.

A

geing Well is one of the 11 National Science Challenges announced by the Government last year that aim to draw scientists and researchers together from across different institutions and disciplines to work collaboratively to meet goals.

In the case of Ageing Well, the mission is to add ‘life to years’ for all older New Zealanders and the research strands include enabling independence, ensuring a meaningful life, recognising older people’s contributions, reducing disability and developing ‘age-friendly’ environments.

Dr Michal Boyd, a gerontology nurse practitioner and researcher at The University of Auckland, is the leader of one of the 10 research projects that have been recommended for a share of the $8.5 million funding allocated for ‘core’ projects for the challenge. Leading another of the recommended projects is Professor Merryn Gott, also from The University of Auckland School of Nursing.

Boyd is excited by the potential of the Ageing Well challenge to make an impact on those caring for older people and says there is an emphasis on a consumer-focused research addressing issues that New Zealanders face as they age. “There is

also a focus on research that can be translated into practice really quickly, which I think is good thing.”

“From my point of view as a clinician, I think the direction they are going in will see benefits sooner to older people on the ground,” says Boyd.

She says one very positive experience from her involvement in the challenge to date has been the chance to meet and network with scientists doing a wide range of research into ageing, from those working with rats in laboratories to those doing population-based studies in health care systems.

Ageing Well National Science Challenge VISION: To add life to years for all older New Zealanders by ‘harnessing science’ to sustain health and wellbeing into the later years of life.

FUNDING: An initial budget of $14.6 million to support research up until June 2019 and then a second allocation, expected to be at a similar level, for the following five years.

THEMES: »» Maintaining brain health »» Dealing with physical frailty »» Enhancing the role of older people in society.

Find out more at www.otago.ac.nz/ageing-well/index.html.

‘Job swap’ scheme filling GAP in aged care training Two years on, Canterbury’s Gerontology Acceleration Programme (GAP) is seen as having a positive impact directly and indirectly on the aged care nursing workforces involved.

GAP, launched in mid-2013, aims to fasttrack the careers of mid-career nurses working in residential aged care and district health board nurses working in older adult health. Six nurses were involved in the first cohort and nine in the second cohort of the programme that involves postgraduate study, mentoring and ‘job swapping’ so the nurses spend two 12-week rotations working in a sector of aged care that is new to them.

A generally positive executive summary of the project’s evaluation report has been released, and the full report, along with recommendations for improvements and refinements, is due to be released shortly.

Kate Gibb, the nursing director of older people’s health for Canterbury District Health Board, says the DHB is really pleased with how the scheme is progressing. She says the two nurses from the residential aged care sector in the first cohort had both

The other recommended core projects in the challenge are led by researchers from a range of disciplines, including neuroscientists, psychologists, geriatricians, general practitioners and sociologists.

Boyd’s research proposal is looking into whether individualised interventions can improve end-of-life care for people with neurodegenerative diseases like Alzheimer’s and Parkinson’s. Gott’s proposal is looking at social isolation and loneliness amongst older people across cultures and the implications for ageing-in-place and service delivery.

since taken on more senior roles with their employers, with one now a unit manager and the other having a national clinical role for their organisation. Also, a DHB nurse had taken on a new DHB quality role involving the residential aged care sector.

Gibb says some had been worried that the scheme would see residential aged care nurses leaving the sector for DHB jobs, but this concern had not eventuated. She admitted, however, that job offers had been made to the facility nurses by charge nurses during their DHB rotations but the nurses had stuck with their facility employers.

A new cohort was due to start in June this year but the decision was made to put the scheme on hold for a year because of a busy year ahead for the DHB, including moving the Older Persons’ Health Service from its current home at Princess Margaret Hospital to the Burwood Hospital campus.

Tool kit for nursing job swapping schemes Lessons learnt from an acceleration training programme involving mid-career nurses rotating between employers are being shared in a new tool kit.

Nursing leaders at Canterbury District Health Board initially developed the resources for its gerontology acceleration programme, which is designed to fast-track the careers of potential aged care clinical leaders, nurse specialists or managers.

Nursing leaders decided that the resources developed could be useful and relevant to any nursing specialty wanting to offer a career acceleration programme exposing midcareer nurses to a wide range of professional development opportunities.

The Canterbury scheme involved ‘job swaps’ between nurses employed by residential aged care facilities and nurses working for the DHB and the tool kit has advice on how to manage the human resources and legal aspects of rotating nurses between employers.

GAP involved two 12-week rotations to different work settings, mentoring, relevant postgraduate study and completing a professional development recognition programme (PDRP) at proficient level within the 12-month programme.

The 55-page tool kit has guidelines on how to set up similar programmes and includes copies of a business case, advice on timing of rotations, copies of invitation and confirmation letters and a programme handbook.

More information and a copy of the Nursing Workforce Acceleration Programme Tool Kit can be found at www.sialliance.health.nz.

Nursing Review series 2015

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“Just a rest home nurse”: LARK Helping make aged care nurses more visible and valued

P

rofessional isolation was highlighted as an issue for the aged residential care sector in Waikato back in 2011.

The same piece of research also highlighted the age-old issue of recruitment and Lindsay Duncan retention in the sector, plus the difficulties faced by new graduates starting their nursing career in ARC. Waikato District Health Board felt a responsibility to do something in response, says Lindsay Duncan, who is the practice development nurse coordinator at the DHB’s Nursing and Midwifery Professional Development Unit, which, up until that point, had had little contact with the ARC sector.

Working with Kate Yeo, the DHB’s then still new clinical nurse director for rural, community and older persons (and with the support of the DHB’s clinical nurse specialist in the field, Julie Daltrey), the pair went out to the sector to find out more. The result is a suite of three DHB programmes developed and offered for free to the aged care sector, with 124 nurses from the Bombay Hills to the King Country having now gone through the programmes.

Gerontology turns to foundation skills

The first in the suite of programmes was a clinically focused gerontology workshop series designed for RNs working with older persons in the community and residential aged care, which began in 2013.

Those workshops highlighted the high turnover of ARC staff and the need for a foundation skills training for nurses new to aged care (including migrant nurses and new graduates ineligible or not on a new graduate programme) and the resulting foundation skills programme (five days spread over four months) got underway in 2014.

Leadership programme cross-pollinates

The workshop experience also highlighted the need for a leadership programme to extend and develop the nurses who had actually shown a commitment to the ARC sector, which led to the LARK leadership development programme.

Nurses from 44 of the 55 aged care facilities in the region have since taken part in one of the three programmes.

Up until recently, all the programmes have been held in Hamilton, which Yeo says has started some useful ‘cross-pollination’ as it has not only allowed ARC nurses to network and better understand the work of DHB nurses but has also altered the attitude and understanding of DHB nurses about the knowledge and skills of the ARC nurses.

A change assignment is a major part of the LARK programme that Duncan says was built using a Practice Development approach. She says part of this evidence-based approach is to help people look at themselves and identify their 24

Nursing Review series 2015

…the programmes also aim to impress upon them that their work with the very frail and elderly – who often have complex comorbidities – is a skilled and demanding speciality.

own values and ways of working, so by better understanding the person they are they can also better understand the values and needs of the person they are caring for.

Duncan says after hearing ARC nurses dismiss themselves as “just a rest home nurse” the programmes also aim to impress upon them that their work with the very frail and elderly – who often have complex comorbidities – is a skilled and demanding speciality.

Significant DHB support available

Introducing nurses to the material available through the DHB’s library, which, along with the region’s online nursing procedure service, is accessible from both home and work, supports the ongoing development of the skills part of each of the programmes. Yeo says one spin-off of the free professional development programmes is that that the number of ARC nurses seeking postgraduate study funding through the DHB has jumped from less than a handful 18 months ago to nearly 25 in the latest round.

During the LARK programme the nurses are also exposed to a variety of speakers, including DHB and ARC sector managers; introduced to leadership theory and given the skills to undergo their own change project. They start the project on day one of the programme and present about four months later on day four with their facility manager sitting in for the 15-minute presentation.

To date, 36 nurses have completed LARK and their change projects have covered topics as diverse as infection control, hydration, nutrition, falls reduction, minimising restraint, staff orientation and incident reporting.

Duncan and Yeo say the philosophical basis of the programme – borrowed from the National Gerontology Section’s vision – is the need to have a valued and visible group of nurses working in ARC. The hope is to support the workforce to have a strong identity and not dismiss themselves as they had been previously.

The aim is also, of course, to help stabilise the workforce in a sector with a reputation for lower wages and high turnover. Research into the impact of the programme is being planned but the pair says anecdotally it appears that most programme graduates are staying in the sector, with only a handful coming to the DHB so far.

leadership and catheters

recharge career

After two decades in aged care without any study, Sabya Mohan is now enrolled for not one but two diplomas and is on the clinical nurse specialist pathway.

She tells FIONA CASSIE how Waikato’s LARK leadership programme, and her change project on catheterisation,

reinvigorated her career.

I

t was the drawcard of permanent daytime shifts that drew Sabya Mohan to her first nursing job in residential aged care.

Fijian-born and trained, Mohan has nursed in New Zealand for 26 years of her 30-year career.

Sabya Mohan She had a variety of nursing jobs and was working shifts at Waikato Hospital when, about 20 years ago, she and her husband bought a small business and she sought a daytime job so she could manage the business in the afternoons.

The family business has since gone but she developed expertise, familiarity and a passion for the aged care sector. “So I started in aged care, kept going and never looked back.” For the past eight years, she has been at Selwyn Wilson Carlile Village’s rest home and hospital as a clinical coordinator and nurse.

Overcoming initial doubts

When her manager nominated her for the LARK leadership development programme, offered by

FOCUS n Aged Care

”It made me proud, it made my patients more settled and happy, my family were happy and the staff benefited. So you experience this achievement not only for yourself but for others too.”

Waikato District Health Board, it was the first extended training she had done in decades. At first she had doubts whether a leadership course was for her.

“In the beginning, when I first went to LARK it didn’t make sense to me. But I started realising we are leaders in our field.” She also found she was comfortable being in a course surrounded by fellow aged care nurses who shared her expertise, knowledge and experiences. “So when we discussed things we were on the same planet.”

A major component of the LARK programme is completing and reporting on a change project, which at first had Mohan panicking on what she should do. Then it dawned on her that she was already working on a change project – she just hadn’t given it that label as the project was just what she needed to do to better meet the clinical needs of some of her patients.

Catheterisation project an urgent need

The project was prompted by a letter from Waikato DHB’s gerontology nurse specialist Julie Daltrey noting that some of the facility’s patients had been making frequent night trips to Waikato Hospital’s emergency department.

Mohan instantly knew what the issue was.

At that stage the facility had several patients with complex comorbidities and longstanding indwelling catheters that were prone to blocking or being pulled out – and this mostly occurred at night. The night duty nurse then sent them by ambulance into ED for the blockage to be cleared or the catheter to be reinserted. It seemed the right thing to do at the time.

“But this was causing a lot of trauma and distress for the frail residents. They were sitting in the cold in ED for two, three and sometimes up to five hours before it was fixed and they were sent back.” The men’s relatives were also being woken up in the middle of the night to sit and wait with them in ED. One family she approached about the issue were tearful as they talked about the long wait in the wee hours.

Mohan spoke to Daltrey and, after examining the ED reports with her, realised that if the facility’s nursing staff were competent in managing catheterisation, including reinsertion, then the patients and their families could be spared this distress.

Comorbidities cause added difficulties

Technically, it was a simple procedure that could be managed at the rest home but what made it more difficult were the complex comorbidities of the patients involved, including the fact that the most common cause of trips to ED was the catheter being blocked due to bleeding caused by trauma from the patients pulling on the tubing.

“So we had to involve a lot of people, including the families, the gerontology clinical nurse specialist, the wound care nurse practitioner, the

incontinence nurse, the urology nurse, the GP and the facility manager.”

A first step was having the patients reassessed by the urology nurse to see whether they needed the catheter to pass urine, and it was confirmed that they did.

Mohan had earlier identified that the patients’ visits to ED were happening every 8 to 14 days and so the next step was reviewing with the incontinence nurse the possible reasons for the pattern. They concluded the patients only pulled on the catheter when the tube began to irritate them.

Successful two-pronged approach

The answer was two-pronged: firstly to try a different catheter product and secondly – though the norm for changing indwelling catheters was three-monthly – they decided to change the tube fortnightly to reduce the risk of irritation and the risk of more trauma from the catheter being pulled by the distressed patient.

The next step was to ask the DHB incontinence nurse to train the facility’s nursing staff so they were competent and confident in changing and managing catheters for these complex patients.

They opted for a ‘train the trainer’ approach, with Mohan to be the trainer. So Mohan was trained during a fortnightly catheter changing by the incontinence nurse, then for the next two changes Mohan did it herself under her trainer’s supervision. She then developed a three-month training plan for the other five nurses (using the same observation/supervision training model) beginning with the most vulnerable staff – the nurse on the night shift – when historically the catheter-pulling had been most likely to happen.

Training on managing the catheter bag was also given to all nurses and caregivers to ensure it was strapped correctly to reduce the risk of trauma.

Patient trauma slashed

Most importantly, the project worked. The catheter patients’ visits to the emergency department came to a halt. The patient trauma was reduced dramatically, the families were no longer being disturbed in the night, the ED was pleased and the facility’s nurses were competent and confident in a new skill, with the night nurse in particular feeling more secure. It also saved the facility the $400 ambulance cost of transporting a patient to and from ED. Another bonus was the patient’s infection rate went down, with infection being another cause of the catheter being blocked.

Significant personal achievement

For Mohan, the success of the project and the LARK course opened up to her another dimension to nursing older people and what leadership can achieve.

“It made me proud, it made my patients more settled and happy, my family were happy and the staff benefited. So you experience this achievement not only for yourself but for others too.”

From being uncertain whether LARK was for her, she is now regularly invited by LARK training leader Lindsay Duncan to be a mentor for new LARK leadership trainees and share her experience. Mohan says aged care is clinically demanding and can suffer from lack of support but her project, and the support of CNS Julie Daltrey, had shown her that if she asked for help from the DHB and other colleagues then the help was there.

LARK, and its focus on career planning, has also spurred her to start studying. Last year she did two papers to complete a postgraduate certificate and this year she has enrolled in a further two papers towards her diploma in elderly care. She has now firmly taken her first steps along the pathway to a master’s degree and becoming a clinical nurse specialist in her own right.

Not content with just that, she also earned a scholarship and enrolled herself into a diploma in adult teaching to help her in her role of educating facility staff. It is a lot of study, but Mohan appears far from daunted, is relishing the challenges and is grateful to Lindsay and the LARK team for inspiring her to pursue new goals.

She laughs when asked whether she had done much studying leading up to LARK: “In 20 years of aged care I’d done no study!” But she is definitely making up for it now and gerontology nursing is the winner.

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FOCUS n Aged Care

In brief: aged care news Budget boost for palliative care welcomed A funding boost for palliative care is warmly welcomed to help attract young nurses onto the palliative care nurse specialist pathway, says the Palliative Care Nurses New Zealand (PCNNZ) chair Jude Pickthorne.

The May Budget provided a $76.1 million package for palliative care over the next four years, including employing up to 60 new palliative nurse specialists, educators and others in hospice roles around the country.

Pickthorne says the funding is a positive step forward, though finding or training that number of additional specialist palliative care nurses will not be an easy task.

But, she adds, with an ageing palliative care nursing population the new funding is an opportunity to attract young and new nurses into the palliative care nursing pathway, including to nurse practitioner status.

Jane Hollings, the PCNNZ vice-chair who works with Christchurch’s Nurse Maude hospice, says the hospice sector is delighted with the news and is now looking forward to details from the Ministry of Health about how the funding is to be allocated.

Pickthorne adds that, while the focus of the funding is on palliative care nursing within primary, hospice and aged care, there are also hospital palliative care teams providing expertise within the acute care setting.

Nurses appointed as first SI dementia education coordinators

The South Island has appointed its first dementia education coordinators with the aim of earlier dementia diagnosis and better quality of life for dementia patients.

The new part-time roles are in response to many people with dementia receiving a diagnosis late in their illness, says Jenny Keightley, chair of the South Island Health of Older People Service Level Alliance (HOPSLA).

Keightley says helping GPs make an early diagnosis of dementia, and providing links to

support services, can make a real difference to patients and their families.

“The new positions are an exciting development as they will specifically focus on primary care settings, looking at the education resources and the implementation of a dementia education programme across the South Island, so that we can help promote better, earlier diagnosis of dementia and continuity of care.”

One of the new appointees is Carole Kerr, a Nelson-based registered psychiatric nurse with extensive experience working in mental health services for older people and people with disabilities.

Sharing the role will be Rebecca Winsor, currently working as a clinical nurse specialist for older persons’ health and a new graduate programme coordinator for Canterbury District Health Board at The Princess Margaret Hospital, Canterbury.

HCAs develop ‘observation’ training guide

A patient-centred guide to the observation of dementia and delirium patients while in hospital

has been developed by a team of Whanganui health care assistants.

Colleen Hill, clinical nurse manager of Whanganui Hospital’s medical ward, says the eight HCAs have been champions for change in the way that confused patients with delirium and/ or dementia are cared for while in hospital.

“We know that cognitively impaired patients can feel overwhelmed and disoriented when admitted to hospital, which, besides being distressing for the patients, can lead to challenging behaviours for our HCAs to work with.

“Patients with delirium or dementia are at risk of falling, getting pressure ulcers, and generally having poorer outcomes. Such events often result in patients losing their independence and ability to return home when the acute episode of care is completed and this can be devastating for them and their families.

“The HCAs have led the work to modify the care delivery for people with cognitive impairment and as a result of their ideas and suggestions we now have training and a workbook to guide them and to help orientate new HCAs.”

Aged care news, views, trends and analysis If you want to know what your colleagues are thinking or doing in the aged care and retirement sector, subscribe to INsite.

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Practice, People & Policy OPINION

Articles, profiles and opinion pieces from across the nursing spectrum

Practice, People & Policy Nursing, death and the cycle of life Cardiology NP ANDY McLACHLAN shares his career-changing first experience of death and contemplates nursing, humanity and the ‘great circle of life-death’.

R

ecently amongst the usual inane Facebook feeds – you know the type, pictures of unsuspecting animals dressed as showgirls and unsolicited YouTube clips of drunk, Albanian farmers dancing to Nirvana – came a statement that made me pause over my coffee:

”Nurses work within the great circle of lifedeath. This reality recognises that we all share this common task of facing our humanity at a deep level, both personally and professionally.”

A colleague had posted this quote by nurse theorist Jean Watson, who wrote these words in 2008.

This quote made me stop because I had been thinking about my own experiences recently following some clinical interactions and I was facing my own humanity (gulp) – not an easy thing to do.

Of course, it’s not just nurses who are faced with the reality of life and death on a regular basis. A friend of mine works for the ambulance service and routinely recounts tales of children killed in car smashes, suicides, gang fights and just plain old nasty accidents, usually involving high speed saws.

I could never be a paramedic because the blood and horror would never leave my dreams. It’s the reason I chose not to go down the emergency department route, which a lot of male nurses do.

I’m just a bit soft, I think.

Some nurses are good at dealing with people with gnarled or missing body parts, or with holes where holes shouldn’t be. I’m not. I like a gory, zombie movie as much as the next man as I know it’s just Hollywood – it’s the real stuff that freaks me out. I can cope with busy wards and vomit and poo and I enjoyed my time in the cardiac ICU, which was pretty adrenaline-soaked at times but also very clean and somewhat sterile.

and take a pulse. I was then pointed in the right direction and was off for what turned out to be essentially three years of this sort of task-driven malarkey.

I enjoyed it; most patients were very happy to see someone and most were bored rigid and liked to talk. So an obs (observation) round could take a first year student anything from a whole day to sometimes two to three days, with occasional stops for a canteen sausage roll and lukewarm coffee.

Patients quickly introduced me to the ‘gallows humour’ of the heart ward, having bets on who would be next to pop off, telling funny stories about their own near-death experiences and generally trying to keep their spirits up.

Most had suffered major heart attacks and had been treated with clot-busting medicine, which was slowly becoming more sophisticated. However, quite a few had suffered very severe left ventricular

Having the ‘right stuff’ From the outset as a student nurse I knew I was on a bumpy course to discover if I had the ‘right stuff’. I quickly realised I didn’t – I was never going to be the guy with my hand inside someone’s chest cavity hand-pumping their heart. I’ve always been more a hand holder.

My first ward was cardiology in the early 1980s.

I was on the psychiatric nurse pathway and so, naturally, my first placement was acute medical.

The wards were in a ‘Nightingale’ set-up, with rows of beds, all neatly made; patients so tightly tucked in that they had to use the call bell (with their teeth) to be released enough to pee in the papier mache urinals. Everyone, I soon learned, was on bed or chair rest. It seems crazy now, and even then we all thought it was stupid, but hey, this was our early lesson in “don’t question the process”…

On my first day, I was shown to do a BP with an old metal, very creaky, sphygmomanometer

Andy McLachlan

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People, practice & policy opinion

scarring, which meant the development of heart failure symptoms and dangerous arrhythmias was still pretty common. But in my first couple of days I had no clue about this sort of detail and thought this nursing lark was really a blast.

Confronting death head-on On one of those early days, I was walking down the corridor when I saw a commotion at the end of the ward. The curtains were being hastily drawn around a patient who had recently been transferred from the CCU (coronary care unit) after suffering a major heart attack a week before. That morning, he had been sitting beside his bed in a La-Z-Boy chair (usually code for getting better), telling me about his family. He had two young kids and worked as a mechanic at the local busyard. He was 35 years old.

What I experienced next is seared into my memory and shaped my future career. My fellow student and best friend came flying out from behind the curtains carrying a La-Z-Boy chair.

“Dude,” I laughed,“it’s got wheels, what are you doing?”

But the look on his face conveyed a terrifying, instantly received message. His face was pale, sweaty, his eyes wild; panic and fear radiated off him in a wave … something terrible was happening. “Cardiac arrest!” he croaked as he ran off carrying a very heavy chair like it was a box filled with chiffon party dresses.

A staff nurse pushed me inside the curtains and for the first time in my life I came face-to-face with someone in the process of dying – the guy I had spoken to only minutes before. CCU nurses had somehow appeared and were in the full throes of a resuscitation; the monitor was making an eerie, high-pitched squeal and spitting out reams of paper with an ominous, squiggly line.

Suddenly, in strode the senior registrar, who calmly flicked a switch and the defibrillator began to hum; he looked at me, nodded and handed me the metal paddles. “He is just a student,” the charge nurse said. I nearly hugged him – not the done thing in 1980, or even now, for that matter – as he took the paddles from my shaking hands and delivered the first of many shocks. I remember being shown how to prepare adrenaline syringes,

all the while flicking glances at the young man lying peacefully on the bed, oblivious to all the hullabaloo going on around him.

As quickly as it had begun, it was over. “He’s gone,” someone said and all activity ceased. The registrar stalked off with the notes, the CCU nurses left and then it was just me, the charge nurse (CN) and the man – now ‘the body’ – who I had been speaking to just a short lifetime ago. The CN, not unkindly, suggested that I stop standing about and get the last offices’ kit. “It’s time to dress your first body.” I guess you should never miss an opportunity to teach.

As I stepped out, I noted blankly that visiting time had started. Then I saw a young woman walking towards me with wide eyes, her hand covering her mouth. I knew straight away who she had come to visit and Imade a strangled kind of groan, a pitiful cry for help, and the charge nurse popped his head out to see if I had fainted.

Thankfully, he took over and we all went into a quiet area.

I remember keeping my mouth firmly shut as events were recounted and the woman with a quiet dignity, politely kept her grief in check as the business of death was discussed, homogenised and, eventually, the responsibility for this young man’s next journey was passed from the ward to his young widow.

When the CN stepped out to find the doctor to repeat the process, I found myself making ridiculous small talk with this lady who had just lost her husband and her children’s father; she couldn’t have been any older than 30. I remember thinking later how kind she was to me as I prattled on while she dealt with her own grief.

Reviewing attitudes to death and dying Sadly, like all nurses, this wasn’t my last experience with death, but I quickly realised that there are nurses who are very comfortable dealing with the Grim Reaper and then there are nurses, like me, who aren’t. At times of impending doom, I somehow always managed to exit stage left and usually my colleagues would sweep past me to comfort and offer the required sympathy, tea and kind, thoughtful words.

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Growing up, I think I was sheltered from death. My parents’ generation had encountered all manner of loss during the war and it had affected our family so much that when people died, they were just never mentioned again. It’s happened, have a wee cry, move on… one way of coping. I never really learned to see death as a natural consequence of living, as it was just never discussed.

Now that I no longer work in the acute arena, I’ve been reviewing my attitude to death. It’s often easier to promote unhelpful medications or interventions that don’t add value to a person’s life and simply prolong life with little quality.

Last week I ran a clinic seeing people for review after heart valve surgery. I like this clinic as most patients are keen to hear about what they can do to stay well and mostly they feel better than they did before the operation.

One elderly woman came slowly into the clinic room; she was frail but feeling okay and was accompanied by her elderly husband and her daughter. However, on my assessment I identified that her tissue valve replacement, now 16 years old, was failing. The valve was leaking and a quick scan identified the problem was severe.

We organised a meeting with the cardiologist to discuss what to do now. There were surgical options but surgery came with many risks and few guarantees.

The daughter wanted to discuss the surgery but the woman looked at her husband and asked a very important question: what would happen if she didn’t have the surgery?

The cardiologist and I outlined the likely course of events and what support and management we could provide and offered them time to think about things, but the couple was determined.

She didn’t want more surgery; she accepted that she may die and, when that time came, she wanted to do it at home with her family. When the family left the clinic, she grasped my hand, looked into my eyes and said, with a smile, “make sure you write down my wishes”.

I made sure I did.

Practice, People & Policy RESEARCH

Gynaecological exams:

enhancing cultural safety and comfort Pelvic examinations involve much more than good speculum technique.

Researcher Dr Catherine Cook addressed the recent NZNO Women’s Health Section conference about what Māori women reported made a gynaecology exam into a positive experience they were willing to repeat. FIONA CASSIE reports.

A

welcoming smile, a caring question about family and taking time to build a rapport – these all have little to do with speculum technique but were as important or more important to the women interviewed by Dr Catherine Cook about what made a gynaecological examination go well.

The Massey University School of Nursing researcher spoke to the recent NZNO Women’s Health Section about her recently published research looking at optimising cultural safety and comfort during gynaecological examinations.

She interviewed 10 women who identified as Māori as part of a larger study involving 16 female patients and 16 clinicians (including 10 doctors). The 10 women were aged 18–54 and between them had undergone160 speculum examinations.

Cook said the study built on her earlier doctoral research, which found that compliance is influenced strongly by the clinician’s actions and words. These include the clinician’s attention (or inattention) to power relations, rapportbuilding, attentiveness to the patient’s comfort (or discomfort), their technical skill and their gender.

Cultural competency requires nurses to reflect on the significance of their own cultural identity and its impact upon their nursing practice, says Cook. This includes nurses having an understanding of historical and social influence on health and not just a narrow awareness of rituals and practices. It also requires a mindfulness of the power relations between clinician and patient and the ability to adapt care to meet diverse needs.

It’s the little things that count Sometimes it is just getting the simple but very important things right – like the mihi or welcome that women receive when arriving at a clinic for a pelvic examination. Or as one interviewee told Cook:

How do clinics offer me a service that fits with me being Māori?

Not every part of me is about being Māori but when I got there the receptionist was really busy but she looked up and she smiled… she had noticed me and I felt kind of really invited, I felt like I’d been welcomed. And then another woman who had brown skin who might not have been Māori, she turned around and she said, “Oh, kia ora, welcome,”... it felt like she was so happy to see me and from that moment my experience… became positive because suddenly yes, I was in the right place.”

Cook says whanaungatanga (a sense of belonging through relationships of shared experience) is also very important and women she spoke to who had longstanding, trusted relationships with their clinicians talked about feeling a sense of kinship with the clinic team. One interviewee put it this way:

I’ve been coming to this clinic for about 16 years... the staff are really friendly… and they can help with any needs of whatever’s happening ‘down there’….they’re soft people, because it’s all sensitive things that go on here... Mum having cancer – when I came in last week she [nurse] goes, “How is your Mum?” So like it’s not only what’s happening there [indicates pelvic area], she remembers so it’s like you’re valued, you’re not just another patient.”

Another skill emphasised was a clinician’s ability to listen, alongside their readiness to take the time to build a rapport and to explain and inform women about the examination and the timeframe for what could happen next. In addition, a willingness to take a collaborative approach to the examination, and any follow-up interventions, including a readiness to agree to go only as far as the patient was willling to go at that time, was also very important.

“For examinations to go well, women required clinicians to listen responsively, with a focus on the whole woman,” says Cook. “Listening was rendered extraordinary in that these experiences were uncommon and stood out to women.”

Dr Catherine Cook

”For examinations to go well, women required clinicians to listen responsively, with a focus on the whole woman.”

Much more than a privacy issue Clinicians also need to be aware that examinations and sexual health talk are tapu during consultations, says Cook. For women to feel safe when normal bodily boundaries were broken, like having a pelvic examination, they emphasised that it was about more than just privacy. One woman put it this way:

“In terms of my own sense of self and my body, I’m very comfortable with my body... It’s not a privacy issue around privacy of the genital area but is around as a Māori needing a connection with the practitioner, with the receptionist, with all the people involved before I’m allowing people in my space.”

Pain is never welcomed as part of a pelvic examination but Cook says it is the clinician’s attention or inattention to the woman that can be more memorable and upsetting than any pain. Such a memory was shared by one interviewee:

“The procedure itself wasn’t painful but at one stage, she said, ‘You’re making it hard for me because you’re all tight.’ I thought, ‘Are we surprised by that!’ It was something like, “Relax, relax!’ [screeching]. She was really pissy [angry] with me. I said, ‘How do I do that?’ I’m quite kinaesthetic. I need things like, ‘Flex your toes’.”

Cook ended her conference presentation with some take-home messages based on a short Māori proverb: aahakoa he iti he pounamu(although it is small, it is a treasure).

“Although a speculum examination may seem like a small procedure, it is a treasure of an opportunity to engage with women in supporting them to value their health, and to demonstrate health professionals’ valuing of women,” says Cook.

“Although one health professional may wonder about the difference they can make, the data showed that when these women experienced culturally safe clinical practice, there was a ripple effect – they returned with their daughters, their relatives, their friends, and stayed connected with particular services and practitioners for years.”

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People, practice & policy opinion

The prostate cancer testing dilemma

– help is finally on its way

Rosemary Minto

ROSEMARY MINTO calls for nurses to be informed and take a lead in educating men and their whānau about prostate cancer. The NP, who sadly lost her own father to the most commonly diagnosed cancer in men, is a member of the Prostate Cancer Working Group, which is soon to release a long-awaited best practice pathway for prostate cancer testing and management.

My dad died of metastatic prostate cancer, which shocked me for two reasons.

The first was that I didn’t know he had been diagnosed with prostate cancer in the first place. The second was because I was told by family that he’d made an informed choice, when first advised of his rising PSA (prostate-specific antigen) levels, to disregard conventional follow-up in favour of alternative treatment.

Was his choice informed? I will never know because I wasn’t involved in that initial decisionmaking and also 20 years ago there were no clear guidelines on testing, screening or ongoing management for prostate cancer. The sad thing is that today New Zealand men face similar choices and we still don’t have clear best practice guidelines for prostate cancer testing or for the management of metastatic disease. That is, until now … but more about that further on.

Prostate cancer second only to lung Prostate cancer was for many years the poor relation when compared with national awareness campaigns for breast and cervical cancers, which is not good considering it is the most commonly diagnosed cancer in men and the third most common cause of cancer deaths in New Zealand adult males. Recent research also shows it kills Māori men at a higher rate than European men, second only to lung cancer.

For years general practitioners have been calling for clear recommendations on whether or not to test or screen for prostate cancer and for these recommendations to be backed by resources they can discuss and share with patients and their families.

Prostate cancer screening is a topic guaranteed to get GPs arguing vociferously for and against, with both sides quoting evidence to back up their claims – which just goes to prove that you can twist data any way you want to prove a point!

Unfortunately for health professionals and patients, the evidence around the benefits or lack thereof of population-based screening remains murky and open to interpretation, with findings from two of the larger, more recent trials being somewhat contradictory. (Last year The University of Auckland also released their excellent Midlands prostate cancer study by Waikato-based Professor Ross Lawrenson and colleagues, which provides New Zealand-based research.)

“I would recommend that ALL nurses become well informed now on the available evidence, information and guidelines, rather than waiting for the new tools.”

New awareness programme In 2013, in response to the calls for greater clarity, the Ministry of Health set up the Prostate Cancer Awareness and Quality Improvement Programme (AQIP) action plan based on recommendations from a prostate cancer taskforce.* As part of the AQIP, the Ministry commissioned a National Prostate Cancer Working Group (of which I’m a member) to guide the implementation of the improvement programme. The group has developed Prostate Cancer Management and Referral Guidance to help primary care practitioners provide men and their whānau with consistent information on prostate cancer testing and treatment. The guide will likely be published in September this year.

Where are the nurses?

So where are nurses in this conversation? Within the prostate cancer working groups and subgroups are three nurse members, with other members including medical specialists, GPs, academics and lay people.

Until now, nurses have largely been absent from the debates around prostate cancer. I suspect that while this is mostly because they have not had an active role in diagnosis, it is also partially because of the lack of clarity around screening.

If you consider the extensive role that practice nurses have in cervical and breast cancer screening, then it makes sense for nurses to be better informed so they can take a lead in educating men and their whānau about prostate cancer.

With the newly developed guidelines being available shortly to providers, and the planned development of a software decision support tool for patient management systems in general practice, nurses will have access to tools to help men make informed choices, in particular about prostate cancer testing.

It is a pragmatic approach developed by New Zealand doctors, nurses and experts, based on consensus and the best evidence we currently have.

I would recommend that ALL nurses become well informed now on the available evidence, information and guidelines, rather than waiting for the new tools, so they are prepared and competent to answer men’s questions. This information is readily available on the Ministry of Health’s website (see below).

Don’t be a bystander in the healthcare decisions of your male patients and relatives – be informed and actively participate.

References: Lawrenson, R., Brown, C., Obertova, Z., Lao, C., and Conaglen, H. (2014). The final report: the Midlands prostate cancer study: understanding the pathways of care for men with localised prostate cancer.

Retrieved from fmhs.auckland.ac.nz/en/som/about/clinical-schools/waikato/research/cancer-research/ prostate-cancer-research/cancer/publications.html Ministry of Health (2013). Prostate Cancer Awareness and Quality Improvement Programme: Improving outcomes for men with prostate cancer. Wellington: Ministry of Health health.govt.nz/ publication/prostate-cancer-awareness-and-quality-improvement-programme-improving-outcomes-menprostate-cancer *The taskforce concluded that there was currently no good quality evidence that routine prostate specific antigen (PSA) testing can effectively reduce prostate cancer deaths. So population-based screening for prostate cancer is not recommended in New Zealand.

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Evidence-based practice

Early smoke signals mixed about

e-cigarettes CLINICAL BOTTOM LINE: The limited studies to date show e-cigarettes (delivering low nicotine levels) are no more effective than nicotine patches at helping smokers to quit but may help smokers unable to quit to reduce their cigarette consumption.

Also, short term e-cigarette use was not associated with serious adverse effects. More studies are needed about the safety and effectiveness of e-cigarettes as a smoking cessation aid and these studies are underway.

This edition’s critically appraised topic (CAT) looks at whether reaching for an e-cigarette has been proven to be more helpful to quitters than slapping on a STUDY VALIDITY: nicotine patch.

A comprehensive search strategy was used to search six

QUESTION:

electronic databases (Cochrane Tobacco Addiction Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, and CINAHL) from July 2004 to July 2014.

Unpublished studies were sought via reference lists of located studies, the metaRegister of controlled trials database, and through contact with authors of relevant publications.

Two authors independently pre-screened the titles, abstracts and full-text versions of potentially relevant papers, assessed the risk of bias in each study, and undertook data extraction and data entry. Any disagreement was solved with a third reviewer. The risk of bias in each included study was assessed using the Cochrane Collaboration criteria. Assessment of publication bias was not feasible because of the small number of studies involved.

Overall, a high-quality review involving two highquality RCTs and lower quality cohort studies

In comparison with nicotine patches, how effective and safe are e-cigarettes for helping tobacco smokers to quit?

STUDY RESULTS:

CLINICAL SCENARIO: As a nurse, you frequently ask patients about their tobacco use. Some people swear that electronic cigarettes (e-cigarettes) helped them quit, saying that nicotine patches didn’t help at all. E-cigarettes are increasingly used as a smoking cessation aid, despite some concern about their toxicity. You decide to review the evidence to find out how effective and safe e-cigarettes really are.

SEARCH STRATEGY: PubMed-Clinical queries (Therapy/Narrow): electronic cigarettes AND nicotine

CITATION: McRobbie, H., Bullen, C., Hartmann-Boyce, J., & Hajek, P. (2014). Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev, 12, Cd010216. doi: 10.1002/14651858.CD010216.pub2.

STUDY SUMMARY: A systematic review assessing whether e-cigarettes could help smokers to stop smoking or cut down on their smoking and whether e-cigarettes are safe to use.

Inclusion criteria were: »» Type of study: randomised controlled trials (RCTs) involving current smokers who were motivated or unmotivated to quit. Randomised cross-over trials and cohort follow-up studies examining at least one week of e-cigarette use were also included to help assess adverse events. »» Types of intervention: e-cigarettes compared with placebo (non-nicotine) e-cigarettes; e-cigarettes compared with alternative smoking cessation aids, including nicotine replacement therapy or no intervention; e-cigarettes added to standard smoking cessation treatment (behavioural or pharmacological or both) compared with standard treatment alone. »» Outcomes: primary outcome was smoking cessation. Secondary outcomes were a reduction in cigarette use, and adverse events (serious and nonserious) after one week of use or longer. Smoking cessation and reduction follow-up was at least six from the start of the intervention.

A total of 594 articles were screened, of which 68 full-text articles were assessed for eligibility. From these, 29 articles representing 13 completed studies (2 RCTs and 11 cohort) and nine ongoing studies were located as suitable for inclusion in this review.

The two RCTs involved middle-aged, highly dependent smokers; the larger RCT (n= 657) was conducted in New Zealand and involved smokers motivated to quit. Just one study (the New Zealand study) compared nicotine e-cigarettes with nicotine patches. There was no difference between these two quit methods in smoking cessation rates at six months but people using nicotine-delivering e-cigarettes were significantly more likely to reduce their usual cigarette consumption by at least 50 per cent (Table).

Pooled data from two RCTs identified that users of nicotine e-cigarettes, compared with placebo (no nicotine) e-cigarettes, were significantly more likely

to stop smoking for at least six months. In those not able to quit, use of nicotine e-cigarettes reduced cigarette consumption by at least 50 per cent compared with use of placebo e-cigarettes (Table). Short-term use (up to two years) of e-cigarettes was not associated with serious adverse events.

COMMENTS: »» Smoking abstinence was biochemically verified;smoking reduction was measured using self-report. »» The e-cigarette interventions in this review delivered a lower level of nicotine than either the patches or latest generation of e-cigarettes. Higher levels of nicotine may help people to quit tobacco smoking by providing better withdrawal relief. »» Because of their study design, cohort studies are at high risk of selection bias. As per protocol, authors focused on RCT data for analysing cessation and reduction outcomes. »» Although the RCTs were of high quality, there were just two available and the results lacked precision.

Because of this, the overall quality of the evidence is low. »» Anecdotally, e-cigarettes are a popular quitting aid amongst smokers. Debate continues about the wisdom of New Zealand’s ban on selling e-cigarettes that deliver nicotine, their effectiveness as a smoking cessation aid, whether fears that e-cigarettes renormalise smoking are justified, and the safety of long-term use.

Reviewers:

Uditi Pandya, 3rd year student nurse, School of Nursing, The University of Auckland and Cynthia Wensley RN, Honorary Professional Teaching Fellow, The University of Auckland and PhD candidate, Deakin University, Melbourne cwensley@deakin.edu.au.

Summary of Results Outcome

Number of studies (n)

Risk ratio (95% CI)

Inconsistency between studies

Smoking cessation at six months: nicotine e-cigarettes vs nicotine patches

1 (584)

0.73 (0.63 to 0.85)

-

Reduction in cigarette use*: nicotine e-cigarettes vs nicotine patches

1 (546)

0.39 (0.21 to 0.72)

-

Smoking cessation after at least six months: nicotine e-cigarettes vs placebo e-cigarettes

2 (662)

2.29 (1.05 to 4.96)

I2 = 0%

Reduction in cigarette use*: nicotine e-cigarettes vs placebo e-cigarettes

2 (612)

1.31 (1.02 to 1.68)

I2 = 0%

n = number of participants; *pre-defined as ≥ 50% reduction in baseline cigarette consumption, 6-12 month followup, theanalysis excluded quitters.

Nursing Review series 2015

31

College of nurses

Dr Mark Jones

What’s in it for you?

AA membership, car, motorcycle, house and contents insurance; these are a few of the regular ‘just in case’ deductions from my bank account. But they are exactly that, payments for when things go wrong and you need a bail out for unexpected costs and inconvenience.

At one level, membership of the College of Nurses is similar as it provides $1 million of indemnity insurance as part of the package.

Having this ‘cover’ is reassuring but just as my house burning down or car being wrecked doesn’t enter my consciousness on a regular basis, neither does being charged with malpractice. Indemnity insurance is a nice safety net at the back of my mind, but College membership is much more than that.

Wide-ranging resources As a member, I have a wide range of free resources available to support me as a nurse.

These range from briefing documents on a wide range of pertinent issues in nursing and health through to professional publications.

Nursing Review gives easy insight into contemporaneous nursing issues, and while accessible online a ‘real life’ hard

DR MARK JONES shares why he’s glad the College of Nurses ‘has his back’ and what membership means to him. copy also arrives in the mailbox of College members. Te Puawai updates members on the work of the College, summarising conference proceedings, working party reports, government publications and so on.

Whereas Nursing Praxis, one of New Zealand’s very, very few peer-reviewed journals for our profession, gives access to the latest healthcare research findings. As a College member, I also receive weekly email bulletins providing a roundup of national and international nursing and health news, plus links to recent international publications.

”For me, the College’s ability to act as an information broker is a key reason for joining.”

For me, the College’s ability to act as an information broker is a key reason for joining.

Like many of you, I don’t have the time to pull together information as the College does, let alone summarise and have it delivered directly to my mailbox.

Likewise, when it comes to making my views and opinions known, the College helps with that too. The Ministry of Health, the Nursing Council, and many other significant entities issue a seemingly continuous series of requests for input to consultation exercises and draft policy statements. I know that, as someone who cares about my profession and the health of our population, I really should have my say, but even if I did know of everything that is going on, I don’t always have the time to submit anything.

Again, the College is able to compile members’ submissions, even just quick comments and bullet points, and turn them into a professional, well-crafted response commanding attention and respect.

Comprehensive knowledge base The College is able to do all of this so well because its membership is full of nurses

32

Nursing Review series 2015

who really do know what they are talking about. With around 100 Fellows drawn from most areas of nursing, and specialist nurses in membership, the College is a focus of expertise available to me, and you.

It is possible to log onto a discussion board and interact with experts in your field, or go along to a workshop held nearby. I can’t overemphasise the true significance of this knowledge base. Many members have benefited from ongoing workshops on developing professional portfolios and the College now also offers access to an ‘ePortfolio’ facility.

Coming from the reasonably unique position of being a former New Zealand chief nurse, I can say the College of Nurses Aotearoa is a force to be reckoned with.

The College’s profile is way up there and its opinion – often succinctly voiced by executive director Professor Jenny Carryer or co-chairs Dr Kathy Holloway and Taima Campbell – is certainly well regarded by government and policy makers. No one in their right mind seeking to devise health strategy relying on nursing would do so without asking the College for input, which it ably provides, in collaboration with other national nursing organisations.

It’s obvious the College has much to offer and is an organisation be taken seriously. As a member of the College, you join and buy into the collected wisdom of leading nurses shaping the profession’s future and into an organisation that can both represent you in doing that and assist you in making a contribution. I am pleased the College has my back; I am impressed that an organisation, with the skill and ability it has, is representing my interests and those of our communities, and I am honoured to stand tall as part of my country’s professional organisation for nursing.

You can be a part of this too.

Author: Dr Mark Jones is a Fellow and board member of the College of Nurses Aotearoa (NZ).

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