Nursing Review 2013 International Nurses Day

FOCUS: International Nurses Day

Nursing Review VOL 13 ISSUE 4 2013/$10.95

New Zealand’s independent nursing Series

EVIDENCE-BASED PRACTICE:

Coffee’s post-surgery perk

A DAY IN THE LIFE OF

a Starship RN first surgical assistant

PRIMARY HEALTH NURSING

Acute care walk-in clinics

Practice, people & policy Nightingale a smartphone fan?

Too few Maori nurses

International Nurses Day Celebrating

Kiwi nursing ‘heroes’

Prescribing Pragmatic & passionate NP RN prescribing on way www.nursingreview.co.nz

Q&A with Gary Lees

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Inside:

Letter from the Editor Closing the gaps Closing the gaps is a recurring theme for International Nurses Day being celebrated on May 12.

For our IND edition we look close to home at some initiatives by New Zealand nursing to increase access and improve health outcomes for Kiwi patients – particularly the long awaited prescribing ‘revolution’. (p 4) Statistics New Zealand in April announced that the gap in Māori and non-Māori life expectancy had narrowed slightly from nine years in the mid-1990s to 7.3 years. That means Māori men’s life expectancy is still only 72.8 years compared to non-Māori men’s 80 years.

In this edition Far North whānau ora NP Adrianne Murray shares her down-to-earth, community-driven approach that is beginning to bring Māori men back into the health care fold. (p 9) Doctoral candidate Reena Kainamu also puts the argument for why more focus is needed to recruit and retain Maori nursing students to meet Māori health needs. (p 25) Another existing and growing gap is between patient demand for primary health care (PHC) and what stretched general practice can deliver.

We look at MidCentral’s nurse-led acute care walkin clinics as one response to meeting the demand for same day care for minor illnesses and ailments. (p 12) PHC nurse Nicola Russell also argues that it is time for the 2001 PHC Strategy to live up to its promise – to deliver a more flexible, accessible, populationfocused model of care – after years of largely “business as usual” in general practice. (p 23) Lastly and far from least, this edition is celebrating just some of the nursing heroes whose everyday extraordinary efforts continue to make a difference in today’s lean and demanding health system. (p 17-20)

www.nursingreview.co.nz Twitter@NursingReviewNZ

Focus: International Nurses Day 4

9 Pragamatic & passionate Far North NP ADRIANNE MURRAY

12 GP busy? See the nurse instead: nurse-led walk-in acute care clinics

15 Specialist RN prescribers-in-waiting 17 Celebrating just some of our unsung, innovative and dedicated Kiwi nursing ‘heroes’

RRR professional development activity (subscribers edition only) See subscription info at www.nursingreview.co.nz

People, Practice, & Policy 24 Nursing informatics: MICHELLE HONEY on technology enhancing the art of nursing

25 REENA KAINAMU calls for action on low Māori nursing student numbers 26 Best practice: SHELLEY McMAHON on Northland’s nurse-led preoperative assessment clinic

Regulars 2 Q&A profile: GARY LEES, chair of Nurse Executives New Zealand (NENZ) A day in the life of… Starship RN first surgical assistant SUE GLOVER 3 21 Evidence-based practice: ANDREW JULL looks at coffee’s post-surgery perks 22 Webscope: KATHY HOLLOWAY on attending conferences the ‘virtual’ way College of Nurses column: NICOLA RUSSELL is tired of ‘business as usual’ 23

in general practice

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COVER PIC: Adrianne Murray, the Far North whānau ora NP making a difference after becoming the country’s second ever nurse prescriber in 2005.

Read more on p 9.

PHOTO CREDIT: Glenn McLelland, www.supersharpshooter.co.nz

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Closing the gaps: prescribing revolution on its way?

Nursing Review

Vol. 13 Issue 4

APN Educational Media Level 1, Saatchi & Saatchi Building 101-103 Courtenay Place Wellington 6011 New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 Fax: 04 471 1080 © 2013. 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 International Nurses Day 2013

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Q&A

with Gary Lees

Job Title | Director of nursing and midwifery, Lakes District Health Board and chair of Nurse Executives of New Zealand (NENZ)

We profile a leading nurse, covering their background – training and work history – and also provide their personal insights into having a rewarding career.

Q

Q A

Would you recommend your child/ nephew/neighbour/grandchild to go into nursing?

Yes, but I would make it clear to them that nursing is a hard job that needs people committed to doing the job well and if they are willing to give it the effort it requires it will be a very rewarding career.

Where and when did you train?

I trained in the United Kingdom at the Bedfordshire school of nursing. I was in the last group to go through under the old hospital-based training and graduated in 1984

A

Q A

Other qualifications/professional roles?

Before nursing I gained a BSc (Hons) in psychology. Probably where my interest in mental health care started. Since becoming a nurse I have gained an MA in social policy and social administration and a postgraduate diploma in leadership across multi-agency settings. I am a fellow of the Institute of Leadership and Management (UK) and an associate fellow of the ACHSM (Australasian College of Health Management). I am currently the chair of Nurse Executives of New Zealand (NENZ).

Q A

When and why did you decide to become a nurse?

During my childhood I always wanted to be a marine biologist. Then somebody lent me a book on psychology and I was instantly hooked on the way human brains work. That led to my psychology degree and my interest in mental health. I originally thought nurse training would be helpful in getting me a place on a clinical psychology course (very hard to get into at the time without some practice experience of some kind), but once I started I absolutely loved the work. Although, like everyone, I have the odd bad day at work I still, 28 years later, can’t think of a better job than being a nurse.

Q A

What was your nursing career up to your current job?

I came to New Zealand in 2006 to the DoNM role at Lakes DHB. Prior to that all my practice had been in the UK within mental health services. Including unit manager of first an acute day hospital and then a psychiatric intensive care unit. Then as a service manager of secure services and a community mental health team leader.

Immediately before moving to New Zealand I worked as assistant director of nursing (learning and development) where I was responsible for developing and implementing a major culture change programme for the NHS trust I worked for.

Q A

Share a moment when you felt particularly proud to be a nurse?

Nowadays I feel proud of being a nurse as I walk around the hospital and see the way busy nurses, calmly and compassionately deal with the care of their patients.

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Nursing Review series International Nurses Day 2013

Q A Personally when I was working with patients it would be getting a letter or card from someone who appreciated my efforts to help and support them.

Q A

So what is your current job all about?

My current job involves providing nursing advice to the executive team at Lakes as well as sharing in the team’s decision making. I also manage nursing professional development programmes and the nurse educators at the DHB report to me. The role also includes primary and community nursing so I have regular contact with nurse leaders outside of the hospital. I am involved in promoting nursing development at regional and national level so work closely with DoN colleagues on such issues.

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

Back in the UK my hobbies were karate and historical re-enactment (dressing up as a Viking and beating each other with blunt swords/axes). Since moving to New Zealand – with less opportunity to put on my chain mail shirt – I have switched to kayaking and occasional dog walking. I also read a lot and have to admit that I do enjoy playing games such as Baldur’s Gate or Dragon Age on the computer at home.

Q A

What is your favourite way to spend a Sunday?

Generally spend the morning in church, my children are both involved in the youth band and I trained as a sound tech, so whether it is helping them or one of the other bands I am often operating the sound desk. After the service we generally head off to on of Rotorua’s many cafes for lunch. Then usually home and, if it is a nice day, we might get the kayaks out or, if we can’t avoid it any longer, get out and do some gardening.

Q A

Q

Q A

A Q A

Q A

Q A Q A

What do you love about your current job?

I like to think that I am a strategic thinker so the part I like best is looking at the big picture, planning for change and development and looking at how systems and services are put together to best meet the needs of patients.

What are the bits you love least?

The parts I find least rewarding are the detailed, small-scale things like signing requisitions or processing leave forms. Of course they are important too and have an impact on individual staff if not done properly, but if I could find a way to get someone else to do that stuff I would.

Have you ever wanted to give up nursing and why?

Occasionally if am having a bad day…but when I stop and reflect, there is still no better job. The difference nurses make to the lives of people all over the world every day of the year is just incredible. What a great thing to be part of that.

While waiting in the supermarket checkout queue which magazine are you most likely to pick up to browse?

Often a computer magazine or New Scientist.

What is number one on your ‘bucket list’ of things to do?

Always wanted to go diving on the Great Barrier Reef. Living in New Zealand makes that much more possible than it was back in the UK. If I wasn’t a nurse I’d be a…?

Probably would like to go back to my first plan and be a marine biologist.

What is your favourite meal?

Beef lasagna. I lived in Italy for five years as a child so have always had a liking for Italian food.

A day in the life... of a PUBLIC HOSPITAL CNS/RN FIRST SURGICAL ASSISTANT

NAME | Sue Glover JOB TITLE | Clinical Nurse Specialist / Registered Nurse First Surgical Assistant, Paediatric and Congenital Cardiac Services LOCATION | Starship Children’s and Auckland City Hospitals, Auckland District Health Board

05.00

AM WAKE Alarm usually set for 5.15am but the cat jumps on my chest at 5am so that’s my day started!

Up at 5.15am, cat fed and happy, partner still snoring! Ready and out the door at 5.45am.

Arrange admission of baby for observation and spend time reassuring parents. Then it is off to follow-up other phone messages and I carry out several more wound and drain reviews then liaise with the coordinator over the weekend patient plans as I am on call.

06.15

5.00

AM ARRIVE AT WORK Traffic and parking are not an issue at this time and I like to get in early and spend the journey planning my day in my head!

I have been nursing for 32 years, the last 13 years within the Greenlane cardiac theatre team and for the past three I’ve been a clinical nurse specialist / registered nurse first surgical assistant (CNS/RNFSA) for the paediatric and congenital cardiac services. My position was the first official RNFSA appointment for the Auckland District Health Board and coincided with the first intake of the RNFSA course now being offered by the University of Auckland.

RNFSA is a very adaptable role and in my case covers the complete perioperative journey as I see my patients preoperatively, assist the surgeon during surgery and am also involved with their postoperative care through to discharge and clinic follow-ups. Many of our children have staged surgeries throughout their childhood and it is a great privilege to be involved with them and their families.

Before heading to my office I review and chat with our adult patient in cardiovascular intensive care (CVICU) who had a pulmonary valve replacement and pacemaker/AICD implant yesterday.

Then to my desk to complete my preop preparation for today’s case, a two-day old 2.8kg baby with Hypoplastic Left Heart Syndrome having a Stage I Norwood procedure. I add the final touches to the preop summary sheet I have devised for theatre staff, check latest blood results, weight etc and ensure the blood bank has issued bypass bloods.

07.00

AM MEET THE FAMILY Head to paediatric ICU (PICU) to check the baby has been stable overnight and everything is ready to go for surgery. This is also the time to introduce myself to the parents. I explain my role in today’s surgery, what the day will involve for them and their baby plus answer any further questions they have.

The preop visit is a very important link that I’ve worked hard to establish. Being involved from pre-op to discharge and follow-up provides parents with a constant person they are comfortable with, especially at the very daunting time of handing over their precious child to a team of “strangers” in the operating

PM WEEKEND SURGERY ALERT Consultant calls me to do a ward round with the on call consultant for the weekend.

It’s at this point I hear we will be operating tomorrow morning on a three-week-old, 2.1kg premature neonate for a hypoplastic arch repair.

room. It’s also an important link between the operating room (OR) and ward teams.

07.30

AM BABY TO THEATRE Time to take baby through to theatre. I give the parents further reassurance before heading into OR to begin prep for surgery. Normally, if not in theatre, I do morning ward rounds and reviews with the consultant. As the surgical fellow is actually listed to be first assistant today I hand over to him when he arrives and head to PICU to catch up with my consultant.

Then another quick change of plans when she requests that I be first assistant today! So I hightail it up to CVICU to confirm that patient’s plan, make a quick stop at the paediatric ward to explain I’m now in theatre for the day and am back to OR in time to scrub and complete the prepping and draping of patient before the consultant arrives to start surgery.

2.30

PM SURGERY COMPLETE After seven hours in the OR and a very successful surgery, baby is transferred back to PICU with chest left open and a duoderm patch secured to the wound to allow the heart to recover and swelling to subside before the sternum is wired shut and the chest closed (about one to two days post-surgery).

3.00

PM ANOTHER BABY TO REVIEW After handing over to PICU staff and completing the paper work I head with the cardiology registrar to review a baby who was discharged four days prior but has been extremely unsettled. Clinically there are no indications for his extreme distress and the wound shows no signs of active infection so I remove the drain sutures and redress the wounds. The child settles within five minutes of having dressings done and some panadol - parents think I am a miracle worker!

6.00

PM MORE PREP So begins again my usual preop preparation – liaise with theatre team, surgeon, anaesthesia and perfusion to confirm case.

Discover there are no bypass bloods issued so resolve this with blood bank. Liaise with NICU to confirm theatre start time and fasting times and check notes to ensure all relevant documentation is present. I will introduce myself to the parents tomorrow as it has been a rather mammoth day for them and they need to spend precious time with their baby tonight.

7.00

PM OUT THE DOOR…NEARLY Head back to finalise a few things at the desk for tomorrow’s case, check on my patients in the adult and paediatric wards and the PICU before heading out the door

8.00

PM HEAD HOME Finally on the way home, definitely takeaway dinner tonight! Hmmm now I think about it, whatever happened to breakfast and lunch today?? And looks like my partner and the cat will be looking after themselves this weekend too…

9.00

PM HOME Feed cat, eat dinner, sit on the couch to rest for five minutes…Wake up a lot more than five minutes later - thank goodness for MySky and I can watch that program again some other time!!

10.30

PM TO SLEEP Time for bed and another day closes on my busy but very rewarding working life.

Put aside the guilt about no exercise again today…and takeaways…tomorrow is another day!

Nursing Review series International Nurses Day 2013

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FOCUS n International Nurses Day

International Nurses Day FOCUS: To mark upcoming International Nurses Day, we are focusing on nursing moves to help “close the gaps” in access to health care – particularly prescribers, both pioneering and potential. We are also celebrating nursing heroes from the top to tail of New Zealand.

Intro ???????

Ready to take

the medicine

Some call it the biggest revolution for New Zealand nursing since training left hospitals. A decade since the first Kiwi nurse practitioner was authorised to prescribe, the Nursing Council is proposing the long-awaited widening of prescribing to registered nurses. Prescribing is the buzz. Along with cries of “at last” and “fantastic”, there is a desire to get it right from the outset if the country wants more RNs to leave the protection of standing orders and become prescribers in their own right. FIONA CASSIE reports.

A

ny mum can dish out paracetamol to a child grizzly and miserable with a runny nose and mild fever caused by a simple head cold.

But a registered nurse cannot. Because that’s prescribing.

The frustration has long been there that experienced nurses cannot use their clinical judgment to provide simple pain or fever relief without a doctor countersigning their decision.

Paracetamol is just one of many medications and supplements you can buy off your supermarket shelf that RNs cannot provide without standing orders or knocking on the doctor’s door.

Nurse practitioners were the first to step over the prescribing threshold in 2003, and after many

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Nursing Review series International Nurses Day 2013

legal hiccups and detours (see timeline p.8), there are now about 100 prescribing NPs. Those same legal hiccups also stalled the momentum to extend prescribing to RNs until in 2011 came the successful demonstration of prescribing by diabetes nurse specialists that’s now being rolled out to more nurses across the country.

The demonstration went ahead as part of a new zeitgeist – sanctioned and backed by Health Minister Tony Ryall and Health Workforce New Zealand – for all health practitioners from pharmacists to dietitians to work at the top of their scope. The aim is to provide better access for patients to timely and affordable health care – particularly the growing number with chronic conditions.

Now the Nursing Council, at the invitation of Tony Ryall, has put out a comprehensive consultation document as the first step to formally seeking Government approval for two levels of RN prescribing.

The near universal buzz from nursing is positive, with the proposal being called “a giant stride forward” to “pragmatic” by nursing leaders and practitioners keen to see nursing take what is seen by many as an inevitable and logical step. The only “buts” come when it gets down to the detail: Is two levels of RN prescribing a good thing? How qualified should RN prescribers be? Who is going to fund that training and mentoring? What should RNs be able to prescribe? Will RN prescribers feel safe?

Double trouble or the right thing?

At present only 0.25 per cent of New Zealand’s practicing nurses are authorised to prescribe compared to 7.5 per cent in the United Kingdom, where research has found nurses safe and conservative prescribers.

Community nurse prescriber and specialist nurse prescriber are the two RN prescribing options being proposed by Nursing Council to join the existing NP role (see prescribing model summary box).

That would see New Zealand end up with three prescribing levels – similar to the UK, where limited community RN prescribing began in the 1990s and where there are now more than 50,000 RN prescribers (see overseas box).

Continued on page 6 >>

FOCUS n International Nurses Day

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FOCUS n International Nurses Day

Hilary Graham Smith Rosemary Minto

The model being given a big positive tick by many in nursing is specialist nurse prescribing.

With the diabetes nurse specialist (DNS) prescribing pilot a success – and already many clinical nurse specialists and rural nurse specialist having a postgraduate diploma or masters degree under their belt – the specialist nurse prescriber model is seen as a comfortable fit.

It is the pioneer territory of community nurse prescribing where the feedback is mixed and includes a series of “buts”. Some think the Nursing Council has got it basically right first time, others that it is a good idea “but” the framework needs clarifying and tightening to ensure nurses feel adequately prepared and safe, and Rosemary Minto for one believes it shouldn’t be there at all.

“If we’re going to close the gap with the high needs people – which ultimately should be our aim – and provide health care to them, I don’t think having a community nurse prescriber with limited prescribing skills is going to help that,” says Minto. “All we are doing is plugging a current gap rather than looking to the future and being more effective about the use of our nurses and doctors.”

Helen Snell believes it is probably the title “community” that makes the lower level

Jill Wilkinson

Yes! But…

Pam Doole

<< continued from page 4 There is a mixed reaction to whether New Zealand should have a two-tier prescribing model for RNs – the limited community nurse prescriber model, for minor illnesses and ailments, and a higher level specialist nurse prescriber, like the diabetes nurse specialists.

The College of Nurses spokeswoman on prescribing, Dr Jill Wilkinson, says the two-level proposal is a pragmatic solution to getting nurse prescribing quickly where it is needed most.

Rosemary Minto, the chair of NZNO’s College of Primary Health Care Nurses, says her personal opinion is that it’s safest and simplest to just introduce specialist nurse prescribers. A prescribing NP herself, she believes primary health care is too complex to easily draw a line cutting off what is minor and what is not.

Hilary Graham-Smith, associate professional services manager for the New Zealand Nurses Organisation, thinks the community nurse prescribing role is a good idea but the model proposed is “perhaps a step too far just at this point in time” and more work needs to be done shaping it into a workable model.

Dr Helen Snell, the diabetes NP who has led the diabetes nurse specialist prescribing demonstration, backs the two tier model, believing it delineates well between lower level prescribing for the “everyday, straightforward and minor”, and prescribing at a specialist condition-focused level.

Pam Doole, the Nursing Council’s strategic policy director, says at the beginning the Council was Intro ??????? considering only one level of RN prescribing, with the likely qualification set at postgraduate diploma level or similar.

But when it looked at the qualifications held by primary health care nurses – the area it believes RN prescribing could make the most difference to patients – it found the number of primary health care nurses with a postgraduate diploma or papers was low.

“We were also hearing a lot of feedback about the frustration nurses were feeling about not being able to prescribe some quite simple, sometimes over-thecounter (OTC) medicines,” says Doole. “Like school nurses who couldn’t prescribe paracetamol.”

“So the idea of having another level that could have a much shorter qualification but enable nurses to prescribe for normally healthy people for minor ailments and things that would promote health like contraceptives and vaccines etc. seemed like it could be a good idea.”

prescribing tier appear problematic, and the focus should be on the targeted level of prescribing practice rather than the setting.

Jill Wilkinson, the Massey University lecturer who was one of the authors of the DNS prescribing evaluation report, says the lower level community prescribing option is a pragmatic solution to getting nurse prescribing

PROPOSED AND EXISTING NURSE PRESCRIBING MODELS

Community nurse prescriber

Able to diagnose and treat minor ailments and infections (e.g. common skin infections, sore throats and hay fever) in normally healthy people and promote health and prevent disease by prescribing contraceptives, vaccines and other medicines.

Minimum of three years experience and a community prescribing course (of up to six theory days and three days supervised practice with authorised prescriber mentor e.g. GP or NP).

Must have support of employer and identified mentor to undertake course and employer organisation has to support nurse prescribing through policy, audit, peer review and access to ongoing education.

Specialist nurse prescriber

Able to diagnose and treat common conditions in their specialty area (e.g. asthma, diabetes or hypertension) within a collaborative interdisciplinary team. Must seek doctor assistance when making complex clinical decisions.

Aimed at nurses with advanced skills and knowledge working in specialty services (like diabetes nurse specialists) or in general practice (including rural nurse specialists).

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Nursing Review series International Nurses Day 2013

Requires minimum of three years experience and postgraduate diploma in prescribing (including pathophysiology, pharmacology and 150 hours supervised prescribing experience with medical mentor).

RN must have employer backing to prescribe in their role once qualified. Also need support of identified medical mentor and to work in an organisation that supports nurse prescribing through policy, audit, peer review and access to continuing education.

Nurse practitioner

Able to independently diagnose, treat and prescribe for a range of acute and chronic conditions in their area of practice. Consults and refers to a doctor as required.

Minimum of four years of practice in specialty area and a master’s degree (that could include the postgraduate diploma in prescribing) plus advanced practice and education to be an authorised prescriber.

Currently NPs are designated prescribers but after Medicines Amendment bill is passed (had had second reading at time of going to press) they will become authorised prescribers). The two other nurse prescribing roles are proposed to be designated prescriber roles.

OTHER COMMENTs New Zealand Medical Association opposition “The NZMA opposes the proposals by the Nursing Council to extend designated independent prescribing rights to community and specialist nurses. This stems primarily from our concerns that prescribing is inextricably linked to diagnosis.

Medicines are a critical component in effective, quality and safe healthcare delivery. Prescribing of medicines, however, cannot be considered in isolation from diagnosis, which requires knowledge and skills built on years of study of anatomy, pathology and physiology, followed by years of training in clinical methods.

The NZMA would however support delegated prescribing rights* for nurses as this model would mitigate the risks involved in non medical prescribing and would best facilitate the collaborative team based care that is the shared objective of our respective professions.”

Statement by Dr Paul Ockelford, NZMA Chair *Delegated prescribing is to be introduced under the Medicines Amendment Bill, which has passed its second reading. A delegated prescribing order is issued by an authorised prescriber Intro ??????? like a GP or (soon) NP. Health Workforce New Zealand Brenda Wraight, director of Health Workforce New Zealand, says the agency is in continuing dialogue with the Nursing Council and is supportive “in principle” of prescribing by suitably qualified registered nurses in order to “provide patients with better access to healthcare and enable full use of registered nurses’ professional knowledge and skills”.

When asked about funding the training of future RN prescribers Wraight says nurse practitioner training funding includes prescribing practicums and “we would expect any authorised or designated nurse prescriber to undertake full training and assessment”. “However, it is too early to speculate on the funding of training for additional groups.”

She says HWNZ will continue to prioritise its training funding according to those areas that are critical to delivering better health care services. The proposal for a dedicated nurse practitioner ‘registrar’ or ‘candidate’ programme has also been received by HWNZ but it is “awaiting further advice” from the Council following the current consultation process.

Health Minister Tony Ryall “We support more health practitioners working to the full extent of their scopes of practice – and taking on new roles where it is appropriate. It’s good for patients, especially those with high needs. And nurses and other health professionals also benefit from further opportunities for developing their careers. For example, diabetes nurse specialists can now be designated prescribers – and they are operating very successfully for patients.”

more quickly into the area that increased access to medicine was needed most – primary health care.

“Because nurses who work in PHC have traditionally had pretty poor access to postgraduate education, there aren’t that many nurses who would be eligible to prescribe in the specialist category.”

With many of the drugs listed already used under standing orders, she believes the community nurse prescriber option, with its nationally consistent training qualification, could be “in many respects safer” than what currently occurs under standing orders with ad hoc training standards.

Graham-Smith says while she is hearing feedback that the community prescriber role has the potential to improve health care access, she is also hearing quite a few “buts” around assumptions in the model.

“I think there’s some assumptions that we have a skilled nursing workforce who are already doing this under standing orders – and to some extent, that’s true – but I don’t think every nurse working in the community has the skill set to function in that way.

“I think the other assumption is that nurses won’t prescribe if they don’t feel comfortable about it, and I think that’s true as well, as they are well aware of the risk, but is there going to be some pressure to step up?” asks Graham-Smith. “We’ve certainly seen that occurring in cases where practices already have extensive standing orders and nurses feel intimidated by those and also feel some pressure to use them when it’s actually outside their comfort zone.”

153 medicines from antibiotics to zinc

Some of the “buts” also centre around the proposed community nursing formulary – which at 153 prescription medicines and 110 non-prescription medicines looks intimidatingly large.

“There are drugs on there that I don’t pretend to want to prescribe as an NP,” says Minto.

Doole says the extensive list has been drawn up with the UK evidence in mind that “nurses will prescribe medicines they know, for patients they know, for conditions they know”. “So we don’t expect there to be many nurses who will prescribe everything on the list.”

The council also did not want to go down the failed pathway that nursing had been down before, of having individual lists for individual specialty areas. Instead the community prescribing list aimed to cover all medicines that all potential community

prescribers – from family planning to public health nurses and practice to prison nurses – might need to prescribe for minor illnesses and ailments.

And yes, the assumption is that nurses will only prescribe what they are qualified and competent to prescribe.

“I think it makes more sense for us to have a broad list and for us to educate nurses to understand their own level of competence when using those lists,” says Doole, but the list would be refined and shaped by consultation feedback.

As would the proposed community nurse prescribing qualification. A number of nurses, including GrahamSmith, expressed concern that a six day theory course and three days supervised prescribing was not enough to support nurses in taking the ‘leap of faith’ into prescribing. Minto says nothing less than a postgraduate diploma would do and GrahamSmith believes something more like a postgraduate certificate was needed to ensure nurses were adequately prepared.

Doole said it would definitely listen to feedback, particularly from the PHC sector, as it wanted a qualification and formulary list that was “first and foremost safe but also practical and enabling”.

Mentoring and employer support essential

The Nursing Council also wants wouldbe fledgling nurse prescribers to have the backing of their employer and a prescribing mentor before signing up to a training course.

This new criteria is partly in response to UK research showing that if newly authorised nurse prescribers have little or no employer support, their prescribing competence and confidence drops away. The criteria also aims to avoid a repeat of the situation back here in New Zealand where so many nurses with clinical master’s qualifications have not made the transition to being registered nurse practitioners or finding an NP job.

“I guess what we’re trying to do is set it up for Continued on page 8 >>

Nicola Corna

FOCUS n International Nurses Day

Specialist prescribing a “fantastic fit”

Opening up the option of specialist prescribing is a ‘fantastic’ fit for respiratory nurse specialist Nicola Corna.

A major motivation for her starting off down the nurse practitioner pathway was the belief that prescribing could add to her practice and becoming an NP was the only path.

But now with her master’s degree under her belt, she has put NP and prescribing practicum plans on hold as she believes being a clinical nurse specialist with prescribing rights could be a really good fit for her employer’s and patients’ needs as well as for herself and her family.

“Right now I think it is exciting to be a CNS because there are opportunities to extend your practice and provide better for the patients you care for. I think it’s fantastic.”

She says the service she works for, at Counties Manukau District Health Board, already has a respiratory nurse practitioner “doing some amazing work” and in the future she may sit down and reevaluate whether she too wants to start down the NP pathway once again.

“But it’s a pretty good fit for where I want to be at the moment.”

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“I think we also need to dispel the myth that prescribing is the key difference between the RN and the NP scope – people put too much emphasis on the NP prescribing role – an NP is much more than that.” << continued from page 7 success by putting those criteria in. So individual nurses have that support around them before they start and there is already an identified role for them as a prescriber,” says Doole. “It will grow naturally as people see the success of it.”

With the high numbers of nurses already having completed prescribing practicums, there may be several hundred nurses ready in the wings to apply for specialised prescribing status, if they can get employer backing.

Which brings us back to a “but”, with Graham-Smith pointing out that another assumption is that there are sufficient resources in the community to provide mentoring and support for nurse prescribers, but she’s not sure that’s the case.

She is not alone in that concern. Wilkinson, who co-ordinates prescribing practicums for Massey University, says she has students struggling to get funding for practicums, with some even resorting to paying their clinical supervisor out of their own pockets. With the Health Workforce New Zealand (HWNZ) postgraduate funding pool for nurses already stretched, she says a separate funding pot will be needed if would-be nurse prescribers Intro ??????? weren’t going to have “refight all the battles” that NPs have had to fight over the years.

Minto says extra HWNZ funding and support would be needed as it was already a struggle for GPs to find the time to supervise nurse practitioner candidates without adding the volume of nurses who might want to go down this new track.

“To be honest HWNZ has not done much for NPs in that area it will be interesting to see what they provide for nurse prescribers.”

Of course another unknown is how many employers and GPs at this point are keen to support having nurse prescribers on the team and whether the new roles will face less or similar barriers to nurse practitioners. Snell – who did much of the behind the scene’s work to make DNS prescribing a reality – says she may be “naively optimistic” but having encountered little resistance from any quarter, she believes rolling out wider nurse prescribing will be relatively straightforward.

Graham-Smith adds that for the benefit of any doctors anxious about liability, the nursing profession has to “simply keep reinforcing the message that nurses are accountable for their own practice”.

Doole says along with working with HWNZ and the Chief Nurse’s Office, the council has met regularly with the Medical Council, College of Physicians and College of General Practitioners during the drawing up of the consultation paper and says responses have been “reasonably positive to date” from the medical fraternity with the fine detail once again being the area where differences of view emerge. (see Other Comment sidebar for NZMA opposition) Meanwhile the jury is still out on whether opening up the option of specialist nurse prescribing will become a natural stepping stone on the way to independent NP status or a stepping-off point for nurses content to practice and prescribe at that level (and who may be dissuaded from going further by the demanding NP registration standards and/or an employer unwilling to offer them an NP position).

Snell, for one, believes many specialist nurse prescribers will go on to seek NP status as they (and employers) will become frustrated at not being able to deliver the full range of care of an independent NP. “I think we also need to dispel the myth that prescribing is the key difference between the RN and the NP scope – people put too much emphasis on the NP prescribing role – an NP is much more than that.”

Prescribing by RNs may, in time, be the ‘new normal’. Submissions on the Nursing Council’s consultation document closed on April 19.

Doole says after analysing the submissions and refining the models, it hopes by the end of year to put an application to the Health Workforce New Zealand board who will in turn advise the Minister of Health whether RN prescribing regulations are good to go.

And the judicious and timely ‘prescribing’ of paracetamol by suitably skilled and qualified nurses no longer requires a paperwork trail and trial.

Nurse prescribing overseas Nurse prescribing first began in the UNITED KINGDOM in the 1990s for community nurses with a limited formulary, independent nurse prescribing with an extended formulary followed in 2002, and supplementary prescribing in 2003. Since 2006 independent nurse prescribers (have to be suitably qualified and have employer support) are able to prescribe any medicine from the British National Formulary but recent research indicates they are “cautious” prescribers who self-restrict their prescribing. There are now more than 30,000 community prescribers (4.5% of all registered nurses) and in addition about 20,000 independent and supplementary prescribers (3%).

Since 2008 IRELAND has had nurse prescribing with similar entry requirements to the UK and has 545 registered prescribers. Ireland requires the nurse prescriber to have a collaborative practice agreement with a medical practitioner, which stipulates the medicines the nurse may prescribe and in what setting.

In AUSTRALIA there are 788 prescribing NPs and 804 RNs in rural and isolated practice authorised to supply medicines. Health Workforce Australia is in the process of developing a consistent prescribing pathway for all health professionals Prescribing in the UNITED STATES is largely restricted to NPs, nurse anaethetists, nurse midwives and clinical nurse specialists with the level of prescribing differing state to state.

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Nurse prescribing Timeline 1998 n Ministerial Taskforce on Nursing launched

by Health Minister Bill English who backs nurse prescribing.

1999 n Amendments to Medicines Act 1981 allows nurse prescribing.

2001 n NP scope of practice launched and first NP authorised. n Medicines (Designated Prescriber: Nurses Practising in Aged Care and Child Family Health) Regulations gazetted.

2003 n Paula Renouf approved as first prescribing NP (child health).

2004 n Attempt to “streamline” NP prescribing regulations hits legal brick wall.

2005 n New NP prescribing regulations go out to consultation twice after medical opposition to proposed process before Medicines (Designated Prescriber: Nurse Practitioners) Regulations 2005 gazetted in December n Adrianne Murray becomes second NP prescriber.

2006 n Therapeutic Products and Medicines Bill introduced that proposes new prescribing regulations for NPs and nurses.

2007 n Therapeutic Products and Medicines Bill shelved because of controversy over trans-Tasman therapeutic products authority.

2010 n Health Minister Tony Ryall signals Medicine Amendment bill on way including prescribing reforms for nursing.

2011 n Medicines Amendment Bill enters parliament proposing authorised prescribing status for NPs. Also proposes third prescribing category of delegated prescribing.

2012 n Health Select Committee reports back on submissions to Medicines Amendment Bill.

2013 n Nursing Council releases RN prescribing consultation document. n Medicines Amendment Bill has second reading.

See extra online-only story Pioneer prescriber looks back on New Zealand’s first NP prescriber Paula Renouf at www.nursingreview.co.nz

FOCUS n International Nurses Day

Fishing, truck-driving and prescribing Adie-style Far North nurse practitioner Adrianne Murray is the pragmatic but passionate face of nurse prescribing.

FIONA CASSIE talks to the country’s second ever-prescribing NP about doing the groundwork to be a prescriber. but she has got Maori men willing to talk about their health problems.

“A patient’s wife, actually said, ‘my husband would never go on medication for his health problems, so when I heard he’d started treatment for it, and then had been to see you three times for follow-ups, I thought I’d better come see who this nurse was, (she) must be pretty good’...”

Wake up and smell the roses

PHOTO: Glenn McLelland, www.supersharpshooter.co.nz

For Murray it is payoff for a decade of hard work – first doing the groundwork of networking and building the trust of the GPs, pharmacists and other health professionals she works in everyday collaboration with, then raising awareness of the NP role in the community and lastly letting her work ethic and work speak for itself. “And I believe it has now.”

Focused and pragmatic she had negotiated an NP job and funding for herself long before gaining registration as an NP. And she advises others they need to put in the hard yards in groundwork if they want to step up to working at an advanced level. “You really have to network and collaborate and do that hard”. And to those who think it should be more straightforward…

“Wake up and smell the roses – this is the world in which you are going to work in, this is the world that you have chosen to step up to the plate to,” says Murray. She says it’s not only tough for nurses but also new GPs –all new prescribers have to network and build professional trust.

As a pioneer prescriber she says what she did find surprising in the early days was having to convince some of her own nursing peers about the benefits of nurse prescribing – an issue that has gone away with time.

Prescribing barriers do remain for NPs but Murray says it’s a “huge improvement” on when she first started and there is a willingness from Pharmac to work on overcoming issues like electronic access to special authority medications. And the hopefully imminent passing of the long awaited Medicines Amendment Continued on page 10 >>

Adrianne Murray

S

o how does Adie Murray know nurse prescribing can make a difference?

Maybe when blokes whose medical notes have gathered dust for up to two decades started fronting up to her outreach clinic at an isolated Far North bay.

And then their truck-driving mate - who has turned a blind eye to his diabetes diagnosis for years - turns up soon after.

Then another mate follows and tentatively agrees to start medication for his long untreated hypertension and maybe his diabetes the month after.

“You bring in their notes and find for ten or up to twenty years they have had untreated hypertension or untreated diabetes and you are starting work with these guys from scratch,” says Murray – a whanau ora NP for Kaitaia-based Maori Health provider Te Hauora O Te Hiku O Te Ika ???????

Intro For whatever reason, Murray says these hardto-reach patients – mostly Maori men aged 30 to 60 – have let sometimes multiple co-morbidities go untreated or undiagnosed for years. But since 2002, first as an outreach clinical nurse specialist and from 2005 as a prescribing NP, she has become a familiar and trusted face in her ‘clinic on wheels’ and these men have been slowly but steadily seeking help.

“I think that was one of the initial pushes of wanting NPs - particularly in primary health care - was that we were nurses who were communitydriven; who had intentions of staying in our communities so we were going to become regular providers and a face that was going to be there all the time.”

Murray says it may also help that her van clinic isn’t a conventional general practice setting and the guys get to deal with “a very down-to-earth, straight-talking whanau ora NP who loves fishing”,

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<< continued from page 9 Bill will open more doors when NPs become authorised prescribers.

“She has been a long haul and I will be celebrating when that comes through for sure!” says Murray. Frustrated at the beginning by the delays she says when you compare New Zealand to the USA - where several decades on there are still states where NPs are unable to prescribe – “we’ve really come a long way”.

A down-to-earth straight talking NP

With eight years of prescribing behind her she has also come a long way in developing her prescribing culture for the three communities she serves each week. In two of those communities she works in collaboration with a local general practice and GP and the third is the isolated Far North Bay where she runs the weekly outreach clinic from her van and has her own enrolled population.

She cares for infants to the elderly and all in between. And she says she cannot stress the importance enough of NPs like herself being able to provide on the spot prescriptive care to rural families – particularly those without a car or a registered car –when getting to their closest

one of a medication and thought ‘bugger that I’m not going to have that again it nearly killed me’.

So for some, Murray believes, the safer option is to start slowly with just one condition at first, talking through very carefully about the medication and dosage level and always encouraging phone feedback so she can monitor those early days of treatment very closely.

“It’s so important to do the follow-up stuff - you have one bad reaction and you can lose them (again).”

“So I say ‘phone me there’s the number and in the first week I want to hear how it’s going … and if I don’t hear from you after ten days I’m going to ring you anyway. So I say ‘don’t waste my time …call me…otherwise I’m going to track you down anyway’ – and we have a laugh.”

Once having successfully kickstarted treatment of one condition and got the patient ‘on the page’ she and the patient can look to move on to treating the second or third condition also.

She will always advise the patient which she believes is their highest health priority but is ready to listen if they choose to start with their diabetes rather than their high blood pressure.

“As starting at some point is better than starting at no point.”

the best for her patients. “I have regular case reviews you have to – where I work it is not uncommon to have patients with five or more conditions and on 10-17 medicines. So case reviews are quite frequent during the week. I have a set time for case reviews but it’s not just done in that time as we found it’s not enough.”

But she says her GP colleagues are fine with that – and at the end of the day the patients are also registered under a GP in the practice – which is not an issue for Murray who is happy to work as part of a team.

“Personally I love it and am grateful for it because when you start managing these really complex clients you have to have a good support network – you just have to. You can’t work in isolation or alone. You can still make those independent decisions as the nurse practitioner – that’s not a problem but you also have to have a collaborative supportive network around you of your medical colleagues. I don’t see how a NP working out in the community cannot have that relationship...to not develop those networks is actually isolating your patients. You can have your enrolled population as I do but you still have to have your medical colleagues and your networks.”

“It’s a huge weighty decision (becoming a prescriber) and it should be treated in that light.” general ??????? practice is often not practicable or even Intro

possible.

Murray also loves the clinical and personal challenge of bringing Maori men back into the health care fold after a decade or more of untreated chronic conditions.

Once back through the door she doesn’t aim to shock them but she is very straight about the risk they face if they walk out the door and don’t return.

She takes the time to sit down and explain their condition and discuss their test results. Then she tells them the rest is up to them.

“I say ‘if you have a heart attack it’s not going to personally affect me, if you have a stroke it’s not going to personally affect me. It’s all about you’.” And she brings home Adie-style some of the down-to-earth implications of not treating their conditions… including who would look after them or their kids if incapacitated by a stroke.

“I say to the guys that I’d like to be walking around, showering myself and wiping my own bum…that’s how I like to see my life.”

Telling men their CVD risk is in the danger zone of 20 per cent plus or their blood sugar readings are high doesn’t sink in for most men as they can’t feel anything and it isn’t immediately impacting on their day-to-day life, says Murray. But bringing it back to the personal level sometimes does. Including pointing out to patients who drive big trucks for a living that if they have out-of-control blood sugars then their license and job could be on the line.

Getting patients back on the page

Having got them open to considering treatment Murray says she weighs up very carefully the best prescribing path for patients ‘coming in from the cold’.

They generally now face two or three chronic conditions – some known and some unknown – and many aren’t ready to face being sent home with multiple medicines. Particularly as some have had an adverse reaction in the past on day 10

Prescribers have to be able to sleep well at night

Case reviews and collaboration

She says such prescribing decisions have been questioned during case reviews with her medical colleagues who say “but Adie we need to tackle this and this”.

“Which is good, but I document really well why I haven’t. ‘I gave them the choice and they didn’t want to’. I explain that the patient said it was more important that we tackle this condition first.”

And such prescribing decisions are never taken lightly. For Murray prescribing is “huge” and she relishes the challenge of using her knowledge and skills to get the best prescribing outcomes she can for her patients.

“I’m always thinking do they live alone, do they have a support, do they operate a digger, are they a truck driver? You have to make it individual …

“I think that’s the challenge of the work because we are all different as people – we all have different wants and different needs and medicine should cater to suit us.”

With a frail and elderly mum she always relates her prescribing back to personal experiences. “And if you want your loved one to have the best experience of any medicine that they have, then why wouldn’t you do that with your own patients?”

She not only loves the human side of prescribing but also the science. “I’ve always loved medicine…I never want to leave it. I love the complexity of it.”

She also respects the need to work collaboratively with her GP colleagues to get

Nursing Review series International Nurses Day 2013

Council proposals for community and specialist prescribing are given the thumbs up by Murray – particularly the plans to formalise training and competencies that can be ad hoc and inconsistent under standing orders.

“I think this is great for the public I really do,” says Murray. “And I salute those nurses who decide to go ahead with it.”

She believes committed specialist and community nurses will jump at the chance to prescribe but the competencies required could also make others look twice.

And that is how it should be believes Murray as moving from standing orders to prescribing “changes the ball game completely” as it shifts the accountability from the doctors shoulders to the nurses.

“It’s a huge weighty decision (becoming a prescriber) and it should be treated in that light. As I tell people you have to be able to sleep well at night when you make a decision – and if you can’t then I say definitely consult and refer on.

“That’s why knowing your boundaries and knowing your limitations is so important.

For those contemplating dipping their toes into prescribing Murray advises first seeking advice from a nurse who currently has prescribing authority. “We can provide a lot of insights into the reality of prescribing.”

And for those, like herself, working in rural settings and small town communities – be clear about setting your professional and personal boundaries.

“My home is my castle – it is my place of freedom. End of story. It is the only time out I have so I protect it ferociously.”

She’s on to her fourth unlisted home phone number “but I haven’t had to change that for at least …three years now!”

You can be passionate about your job – but it also pays to be pragmatic.

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Before prescribing, please review Data Sheet available from Medsafe (www.medsafe.govt.nz) or Pfizer New Zealand Ltd (www.pfizer.co.nz) or call 0800 736 363.

Prevenar 13® (pneumococcal polysaccharide conjugate vaccine, 13-valent adsorbed) suspension for I.M. injection minimum data sheet. Indications: Active immunisation against disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F (including sepsis, meningitis, pneumonia, bacteraemia and acute otitis media) in infants and children from 6 weeks up to 5 years of age. Dose: 0.5 mL I.M. Do not administer to the gluteal region or intravascularly (see also Precautions). Infants: 6 weeks of age: 3 doses at least one month apart. A single booster should be given in after 12 months of age, at least 2 months after the primary series. Previously unvaccinated infants 7 to 11 months of age: 2 doses approx. 1 month apart, followed by a third dose after 12 months of age, at least 2 months after the second dose. Previously unvaccinated children 12 to 23 months of age: 2 doses at least 2 months apart. Previously unvaccinated children 24 months of age or older should receive a single dose. Contraindications: Hypersensitivity to any component of the vaccine, including diphtheria toxoid. Allergic reaction or anaphylactic reaction following prior administration of Prevenar. Precautions: Do not administer intravenously, intravascularly, intradermally or subcutaneously.

Avoid injecting into or near nerves or blood vessels. Do not inject into gluteal area. Postpone administration in subjects suffering from acute moderate or severe febrile illness. Prevenar 13 will not protect against Streptococcus pneumoniae serotypes other than those included in the vaccine nor other micro-organisms that cause invasive disease, pneumonia, or otitis media. Prevenar 13 may not protect all individuals receiving the vaccine from pneumococcal disease. Infants or children with thrombocytopenia or any coagulation disorder. Appropriate treatment must be available in case of a rare anaphylactic event following administration. Safety and immunogenicity data in children with sickle cell disease and other high-risk groups for invasive pneumococcal disease are not yet available for Prevenar 13. Prophylactic antipyretic medication recommended for children receiving Prevenar 13 simultaneously with whole-cell pertussis vaccines, or children with seizure disorders or prior history of febrile seizures. Antipyretic treatment should be initiated whenever warranted as per local treatment guidelines. The potential risk of apnoea should be considered when administering the primary immunisation series to very premature infants. Adverse Effects: Very common: Injection site erythema, induration/swelling, pain/tenderness, fever, decreased appetite, drowsiness, restless sleep, irritability. Common: Vomiting, diarrhoea, rash. Uncommon: Urticaria or urticaria–like rash, seizures, crying. Rare: Hypersensitivity reaction including face oedema, dyspnoea, bronchospasm.V10111. Contains: 30.8 micrograms of pneumococcal purified capsular polysaccharides and 32 micrograms of CRM197 protein.

The decision to administer Prevenar 13 should be based on its efficacy in preventing IPD. Risks are associated with all vaccines, including Prevenar 13.

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Prevenar 13 is a fully funded prescription medicine for children meeting the high-risk criteria or pre- and postsplenectomy criteria (Immunisation Handbook 2011). For children not meeting these criteria, Prevenar 13 is an unfunded prescription medicine – a prescription charge may apply.

Pfizer New Zealand Ltd, PO Box 3998, Auckland, New Zealand 1140. DA1212SW. BCG2-H PRE0123. P5786.

FOCUS n International Nurses Day

No doctors appointments ‘til Friday. Why not see the nurse instead? The Nursing Council is proposing introducing community nurse prescribing for minor ailments and illnesses. MidCentral is one region already upskilling practice nurses to assess and treat patients who front up to acute care walk-in clinics with conditions fitting just that bill …but without prescribing. FIONA CASSIE finds out more.

Runny noses, cut fingers & UTIs

The team looked at the top presentations for same day acute care and decided that registered nurses could handle many of them with the right training and support. So they developed a core set of knowledge and skills to upskill practice nurses on ‘top-to-toe’ triage assessment for children and adults and then acute care nurse management of the most common presentations.

Once nurses are trained the aim is for all practice teams to work with Debbie and her MidCentral team towards offering nurse-led acute care walk-in clinics with nurses assessing and deciding which patients are within their scope to treat and which need to see the GP. First off the block was Tararua Health that was already offering acute care walk-in clinics in Dannevirke for a number of years, thanks to GP Tom Gibson, to counter frustrated patients and stressed-out doctors unable to meet demand.

The morning clinics – with a GP and nurse assigned to work with walk-in patients – had been underway for about three years when Kathleen Brown started working for Tararua as an acute 12

care clinical nurse specialist in late 2010. A clinic in Pahiatua had also been underway for some time.

But up until recently the triage process was ad hoc, if at all, with most of the practice nurses stepping into the acute care role with little preparation apart from some practical on-the-job skills teaching by GPs. “There was no formalised training that gave nurses the knowledge and skills they could stand on as a foundation and be confident and competent in assessing acute patients when they walk in,” says Brown.

Now, thanks to the MidCentral acute care nurse training programme, Brown says the nurses are skilled to not only assess whoever walks in the door but also to treat those that fall within their scope, and the initial vision of a nurse-led acute care clinic is being fulfilled.

She says the numbers of people seen in the walk-in clinic has just increased and increased until they now average 40-45 patients a morning and sometimes up to 50 - and this is on top of the patients with booked appointments to see their GP or nurse.

Debbie Davies

he phone line’s running busy at the local medical centre. Doctor’s appointments are as scarce as hen’s teeth.

Some patients needing to see somebody that day don’t even bother to phone any more and head straight to their local drop-in afterhours centre whether it is afterhours or not.

It is meeting the demand for same day primary health care that is the prime motivation for MidCentral’s acute care nursing programme for practice nurses, says Debbie Davies, lead clinical nurse specialist in primary health care for MidCentral District Health Board.

MidCentral was one of nine business cases given funding blessing in late 2009 to transform primary health care services to meet the government’s Better Sooner More Convenient (BSMC) vision.

Intro ???????

The business case is a collaboration between the region’s district health board and primary health organisations, and one of the four target areas is improving acute demand management.

Davies says a casual survey of patients fronting up to a local 12-hour accident and medical centre in office hours had brought home the need to better manage the demand for same day acute care.

“Seventy per cent had not even bothered trying their local GP team as they knew the response would be most likely that they couldn’t get in.”

Stakeholder workshops looked at what practices were already doing to manage same day demand and showed widely varying practices including some centres literally turning people away at the front desk and sending them home to phone the triage nurse.

Kathleen Brown

T

Avoiding waiting room woes

nurse will either refer the patient on to the clinic’s assigned GP (or Brown who is a nurse practitioner intern) or continue to assess and treat the patient themselves.

‘Bread & butter’ work of an RN

Brown, who hopes to become the first NP specialising in acute care in primary health settings, helped oversee the training. She is adamant that the walk-in clinic work does not require clinical nurse specialist or NP-level training and just requires an experienced RN to work at the

Davies says the biggest area that nurses lack confidence in is assessing sick children. “Sick children are very scary”.

As many as 20 people can turn up at 9am for the walk-in clinic with conditions ranging from a runny nose to appendicitis or a cut little finger to a heart attack.

The clinic’s triage nurse has to keep a safe waiting room by scanning the waiting patients for anyone looking short of breath, sweaty and pale (or has presented to reception with chest pain or some other high end acute presentation) but usually people are seen on a ‘first come first seen’ basis. And after the triage assessment the clinic

Nursing Review series International Nurses Day 2013

Acute care training programme for PHC nurses

Presented in six teaching modules of two hours each involving a mix of theory and hands-on practice including examining cranial nerves to auscultating a chest. Each session was held about four-six weeks apart to allow time for on-job peer assessment of the nurses putting the previous session’s knowledge and skills into action The sessions are: »» Acute care assessment framework, triage and resuscitation (adult) »» Acute care assessment framework, triage and resuscitation (infant/child) »» Acute cardiovascular and respiratory care »» Acute head, neck and neurological care »» Acute abdominal and genitourinary care »» Acute musculoskeletal and skin care

top of their scope.

This is echoed by Davies who says it is a bonus not a requirement that MidCentral has NPs and NP interns working in a number of the six primary health sites involved in the project. “But we didn’t want the RNs to perceive this as only the business of advanced pathways. The majority of this is the bread and butter work of a level two competent RN.” Davies says it is fair to say that the rollout of the project had not been without its pitfalls – much of it to do with the ‘busy-ness’ of general practice but also resistance from some to changing the model of care.

“For some of them it’s quite a mindshift – actually having to push themselves outside of their comfort zone of what they are currently doing.”

The acute care training programme (see box) has been trimmed down from an initial eight sessions to six sessions of two hours each presented in the workplace at a time to suit the practice – for some that is within work hours and others evenings.

Davies says the biggest area that nurses lack confidence in is assessing sick children. “Sick children are very scary”. But the training is pitched at the level of minor illnesses, minor injury and minor exacerbations of chronic conditions, with nurses referring on any patient beyond their scope and competency level.

Trust also has to be built between GPs and nurses - so GPs don’t feel the need to redo nurse

FOCUS n International Nurses Day

assessments and nurses aren’t reluctant to do Intro ???????

them. “Because what you found was that most of these practice nurses weren’t doing the initial assessment on children because they knew darned well the GP would do it again and for the child that’s not pleasant.”

Some nurses are also initially uncomfortable with having to have their existing or newly gained knowledge and skills validated, and there have been some challenges with getting a peer assessor or GP to carry out the on-the-job assessment.

(Davies says offering the acute training package has also seen an interesting trend of other training needs emerge – such as for IV (intravenous) cannulation, plastering and suturing – as general practices seek to take on work once the realm of ED.) Over 120 Registered Nurses across the MidCentral DHB are now involved in the acute care training programme but the most advanced, and first to finish, has been Tararua. Davies says a key to this has been the buy-in of the local clinical excellence group which supported and mandated Kathleen Brown and the programme’s nurse educator to work alongside the nurses to assess and sign off their skills or build their competence in a particular skill they identified as needing help in.

The other sites are at different stages along the project’s phase one training pathway and phase two stage of analysing their current acute care processes and further refining them to make the most of nurses working at the top of their scope and improving same day acute care demand.

Triage and standing orders

The MidCentral project team has also been working with Tararua to develop a triage template tool to provide consistent documentation and decision-making on whether a patient sees a nurse or a GP. Plus a tool kit to guide an organisation on developing standing orders to help deliver the new model of care for their general practices.

Brown says in Tararua they have revised and released a number of new standing orders so

nurses working in the acute care roles can initiate and give medications like paracetamol, ventolin and oxygen.

Next off the block – once approved by the Tararua clinical excellence group - is to be a standing order setting out criteria for uncomplicated urinary tract infections (UTIs) and, if a patient fits the criteria, nurses will be able to supply them with a pharmacy prepackaged medication for single use only.

Brown believes one of the strengths of the acute care training programme has been unifying standards across the practice so all are “singing from the same song sheet”.

Surveys on nurses skills before and after the training also show an upswing in confidence in nurses of their acute care knowledge and skills which is having spin-offs not only for the walk-in clinics but also telephone triaging and general assessment skills.

For the public there is the spin-off of knowing they are able to get their acute care needs met on the day in their own general practice. Novel roles like Brown’s proposed acute care in primary health NP role will make this even more likely.

Not total answer says GP and NP intern

David Hill, a GP at Tararua for the past year who also works in ED, for one believes the clinic’s popularity with patients does not mean it is a success in addressing ongoing patient demand.

“All I think you are doing by bringing in nurses (to acute care walk-in clinics) is increasing patient demand … if you lessen waiting times you increase demand”.

He sees while the clinics and acute nursing role have value he believes what is really needed is a reform of the current flawed general practice model to look at better collaborative models of funding and delivering planned and unplanned care.

Tararua is a progressive practice Hill agrees but he personally sees the busy walk-in clinic as not addressing the fundamental issue of patient

demand. And having up to 50 patients turning up in a morning meant patients didn’t get a good deal and neither did the nurses and doctors.

Brown agrees that the general practice model as it stands is probably not working with the increasing demand for the acute clinic almost unmanageable. People who can’t get a GP appointment just present to the clinic and wait until their needs are met. For example she had a week recently where two of the GPs rostered to the acute clinic were sick and she as the NP intern was “it”. “Forty-three people presented for that day – a lot were minor illnesses but in amongst them were a few rather sick people and three were referred to ED.” She also says there needs to be a change in how health professionals work so care is better planned to minimise acute care needs and the demand for acute clinics.

But Brown sees beauty of her role – and also of the walk-in clinic – is that patients who might otherwise have had to head to an after-hours clinic or ED can be see in their own practice so herself and others can ensure continuity of care and monitoring of their acute condition (including exacerbations of any long term conditions). Plus keeping emergency departments free for those most in need.

An aspirational target of the MidCentral business case is to reduce ED admissions by 30 per cent. “Which is actually a very big ask,” says Davies.

“But we’ve actually just reached that target with 0-4 year olds and started to make some traction in the up to 18 year olds.”

Collaborative teamwork in the community and more nurses working at the top of the scope appears to be making some mark but not without some impact on the demand for general practice too. With more acute care walk-in clinics to follow it could be a matter of watching this space to see whether that target is just aspirational or achievable.

Continued on page 14 >>

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Community nurse prescribing a good fit?

Yes but ….

Community RN prescribing is a logical next step for models like the Tararua acute care walk-in clinic, agrees Kathleen Brown.

“RNs running nurse-led clinics in a number of areas around NZ are already practicing independently and competently diagnosing and treating uncomplicated minor ailments and infections using standing orders in alignment with the legislation and guidelines.”

Being able to prescribe for those minor ailments and injuries would make better use of those nurses skills, be more efficient for patients and could enhance the effectiveness of both GPs and NPs working in the primary health care setting.

But, adds Brown, more clarity is needed about what the Nursing Council means by community RN prescribing as the model as currently proposed raises some concerns for the NP intern. Particularly around the suggested qualification timeframe (up to six theory days and three days supervised practice), which she thinks, looks totally inadequate to ensure competent and confident community RN prescribers.

“The knowledge community RNs would need to prescribe requires training in Intro ??????? pharmacology, pharmacotherapeutics, clinical assessment diagnostic reasoning, writing prescriptions, teaching and more”.

Brown also has concerns about the drug list as currently proposed (see additional comment and Nursing Council response in main prescribing story).

Tararua GP David Hill reiterates that while he thinks community nurse prescribing could be helpful - and nurses working in collaborative teams with GPs would lessen the risk – he says it is the flawed general practice model as a whole that needs to be addressed first if future patient demand is to be catered for.

“I don’t see nurse prescribing lessening the load of the GP unless we change the structure of the way we work.”

Brown still believes RN extended prescribing will be a key part of stepping up to meet future health care needs. But she also agrees with Hill that the current model is not sustainable and is not delivering on reducing health disparities.

“Health professionals don’t work together, we exist in silos, care is disjointed, duplicated at times, not co-coordinated, we have to start working together collaboratively, integrating the resources/ capacity we have.”

She also believes that collaborative practice across all disciplines and greater integration of primary and secondary services is needed if primary health care is expected to meet more and more health needs of the communities. “If this is achieved we will start to make a difference using all resources available in the community not in competition with each other but working together.” Integrated Family Health Centres could make a key difference and the RN role must expand to meet the challenges ahead.

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International Nurses Day:

Reaching the Millennium Health Goals

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ursing’s role in helping achieve the United Nation’s Millennium Development goals is the theme for this year’s International Nurses Day. International Nurses Day is celebrated on May 12 each year – the anniversary of Florence Nightingale’s birth – and each year the International Council of Nurses chooses an annual theme.

This year the theme slogan is Closing the Gap: the Millennium Development Goals 8,7,6,5,4,3,2,1 to highlight the countdown to 2015 when the eight goals to reduce poverty and its impacts were meant to be achieved.

The Millennium Development Goals (MDGs) aim was to create a framework to galvanise development efforts, set priorities and focus attention, action and resources on meeting the targets set for each of the eight goals.

Key successes to date reported to the UN include reductions in levels of extreme poverty, halving the proportion of people without access to drinking water, and increasing the numbers of girls enrolled in primary schools but much work is still needed to be done.

“As the largest health care profession in the world, there is no doubt that nurses are key to the achievement of the Millennium Development Goals,” says ICN president Rosemary Bryant and chief executive David Benton.

“Nurses are often the only health professionals accessible to many people in their lifetime,” says the pair. “So nurses are particularly well placed and often the most innovative in reaching underserved and disadvantaged populations.”

In particular nurses have a role in achieving the

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three health related goals: goal 4 to reduce child mortality, goal 5 to improve maternal health and goal 6 to combat HIV/AIDS, malaria and other diseases.

ICN reports that while there has been significant success in reducing global deaths of children under five, the majority of the 7.6 million child deaths that occur every year could be prevented using effective, affordable interventions. Also while there has been an almost halving in the number of women who die during pregnancy and childbirth there were still significant regional variations, with 56 per cent of maternal deaths occurring in sub-Saharan Africa.

The final health goal also shows significant regional variation with some successes but no room for complacency because of increased reports of resistance to anti-malarial treatments and multi-drug resistant tuberculosis.

ICN as an organisation has established five wellness centres for health care workers in subSaharan Africa and its MDR-TB project has educated and supported tens of thousands of nurses and health workers on helping combat the threat of multidrugresistant tuberculosis.

It said another example of nurses working to meet the goals is the Southern African Network of Nurses and Midwives that works across national boundaries to maximise its resources and impact on health challenges like HIV/Aids.

“The countdown is on. The clock is ticking and we are running out of time. Each and every one of you can make a difference,” says Bryant and Benton. And they quote the words of UN Secretary General Ban Ki-Moon, ‘There is no global project more worthwhile. … Let us keep the promise’.

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Diabetes nursing managed to ‘jump the gun’ to RN prescribing with a successful demonstration site. Next off the starting blocks is expected to be respiratory nursing. FIONA CASSIE looks at some specialist areas and their likely prescribing ambitions.

Taking a special approach Taking a deep breath

Asthma and chronic respiratory disease are amongst the most common treatment areas for nurse prescribers in the United Kingdom.

Respiratory nurse specialists were already discussing following their diabetes colleagues down a similar path to prescribing when news of the Nursing Council proposals started to filter through.

Last year, prescribing was top of the agenda of a respiratory nurse gathering at the Thoracic Society of Australia and New Zealand (TSANZ) annual meeting, where they were addressed by Helen Snell, the NP behind the diabetes nurse prescribing project.

What the respiratory nurses hold in common with their diabetes colleagues is a knowledge and skills framework (KSF) and they were looking at using their KSF to accredit the first respiratory prescribers when the Nursing Council consultation document proposed a different pathway.

Nicola Corna, chair of the respiratory section of the New Zealand Nurses Organisation, says it is now a matter of wait and see but the buzz from the TSANZ meeting and section feedback is that fellow respiratory nurse specialists are Intro ??????? keen to have the chance to prescribe for their patients.

This is particularly relevant as at the moment, if respiratory nurse specialists give written directions around a patient’s medications while following their management care plan, they are technically seen as prescribing.

“If, for example, I have a patient who is asthmatic and I say to them that ‘okay when your peak flow gets to this point you need to use this medication in this way’, and if I write that down, and it’s not countersigned by a doctor, I’m seen as prescribing.”

“That’s a real barrier, a huge barrier to helping our patients,” says Corna, as it is nurses who see patients the most and are usually the ones who write the action plan.

But Corna for one also believes the Nursing Council will have to proceed with caution to get the training, formulary, and prescribing supervision right so it is consistent for all specialist nurse prescribers whether they are working in big metropolitan hospitals or small centres with just one nurse in the specialist field.

“So we have nurses who are safe prescribers, providing the best of care, and who are supported in their role and are not left feeling uncertain, insecure or unsafe in their practice.”

Diabetes a sweet success story

“I’m on a lot of medication and if people can get help other than from their GP, that will be great.”

That’s what Northland diabetes patient Geoff Sadler’s told Northland District Health Board on hearing that four Northland diabetes nurse specialists (DNS) are on the path to becoming designated prescribers.

“I have always had a great relationship with the diabetes nurses at the centre. If I get into trouble, I know I can ring her and she gives me advice”, adds Geoff Sadler.

“The registered nurse prescribing is a very positive thing alongside Care Plus and the care from my practice team”.

A dozen diabetes nurse specialists were the pioneers of registered nurse prescribing in 2011.

After a positive evaluation report for Health

Keeping it in the family

For more than a decade, Family Planning nurses have been “supplying” the pill and treating uncomplicated infections for the vast majority of clients walking through the door.

This is all made possible through a clean and clear-cut training path for the association’s nurses and extensive use of standing orders that must be countersigned within four days.

The chance to step out from standing orders and have their skilled nursing workforce endorsed as prescribers would be welcomed, says Family Planning national nursing advisor Rose Stewart.

“Every day a doctor in every clinic spends time (countersigning standing orders) when they would otherwise be able to see clients…” says Stewart. “Many observe that it is unnecessary as the nurse’s clinical assessment and medication supply are done within clearly defined protocols and are appropriate.”

It also means nurses will carry full responsibility and doctors will not have to feel responsible for the nurses. Processes for getting medications to clients would also be less complex.

She agrees that possibly Family Planning has been ‘de facto’ pioneers of RN prescribing for many years, with nurses able to gain experience quite quickly because of the specialised area of practice. “It has enabled clients to access medication much more seamlessly as nurses do 75 per cent of all consultations and the volumes of medication supply are large.”

Stewart says Family Planning nurses have extensive training, including 60 hours one-on-one mentoring in the first weeks, seven days of courses over the first 12–18

Workforce New Zealand the nurses have kept on prescribing and 16 more nurses, including the four Northland nurses, have been selected to follow as the project is rolled out nationwide including, for the first time, three nurses working in primary health organisations.

Helen Snell, the driving force behind the demonstration project, says she may be “naively optimistic” but she believes the success to date of the project bodes well for widening collaborative RN prescribing. Including primary health care with the 30 GPs who replied to the project evaluation survey all being comfortable and satisfied with the prescribing decisions made for patients under their care.

The one potential barrier Snell sees to widening RN prescribing to more settings – particularly primary

months, and ongoing monitoring by chart audit and peer review.

She believes some of its nurses, who are doing or contemplating postgraduate study, may be eligible for endorsing as specialist prescribers but the majority of its nurses are likely to be endorsed as community prescribers.

“In a sense we would like them to be specialised nurse prescribers at community prescribing level.”

The organisation is also keen for its nurses to able to get community prescribing endorsement via a pathway specific to Family Planning and its context.

“Family planning nurses undergo a significant practicum during their training to level 2 and would need only a top up in terms of pharmacology and prescriber context. So the pathway to this lower level of prescribing should be as flexible as possible.”

Stewart says from its experience of preparing nurses to ‘supply’ medications the critical aspects are “in-practice mentoring and supervision, and the use of clear protocols nurses can refer to when providing medication”.

health care – is finding the mentors and funding to support prescriber training. Under the demonstration project, the DNS prescribing practicum was carried out inhouse by the specialist services with no fees or tertiary education provider involved.

“You could argue that by doing that there wasn’t consistency of approach but we had a detailed practicum assessment document setting out requirements for case studies etc.”

With training dollars likely to be limited she had concerns if the prescribing practicum required to become a specialist nurse prescribers followed the model currently required for nurse practitioners, as the cost “could be prohibitive”. With potentially hundreds rather than dozens of nurses seeking practicums in the future, Snell believes there could be models explored for doing them in-house without too much of a burden to the employer organisation.

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International Nurses Day

Heroes

To celebrate International Nurses Day this year Nursing Review invited district health boards across the country to contribute stories on nursing ‘heroes’ in their region. We got stories back on just some of the unsung, innovative, compassionate, high achievers and dedicated nurses that make up the New Zealand nursing workforce. Read on…

NAME: Ngaire Murray DHB: Auckland JOB: Clinical charge nurse, Starship

Intro ???????

Ngaire Murray uses distraction, fun and fairy dress-ups to help reduce the anxiety that some paediatric patients feel before visiting theatre.

The Clinical Charge Nurse has implemented nurse-led care in Starship’s Operating Rooms (OR) and added sparkle to journey of patients like Claudia (pictured with Ngaire).

Claudia was diagnosed with acute myeloid leukaemia at age three and developed Graft Versus Host Disease following a bone marrow transplant.

With large non-healing wounds on her scalp and thighs, Claudia needed numerous skin grafts and twice-weekly dressing changes under general anaesthetic. As Ngaire recalls, “Claudia was always upset coming into the theatre environment and would scream and hide under a blanket.”

Things came to a head when the surgical team declared that Claudia’s wounds could not be cured and that ongoing treatment would be palliative. Ngaire proposed that nurses, rather than registrars, be responsible for Claudia’s ongoing OR care.

Prue Hames, Starship’s OR Manager says nurse-led care is extremely rare in the OR environment. “Ngaire consulted widely across the multidisciplinary team, including paediatric anaesthetists, specialist surgeons, child psychologists and wound care experts in her decision making.”

Ngaire’s team put holistic patient-centred care into action and made it their mission to make Claudia’s treatment as painless as possible. They talked to her about her interests, involved her in treatment decisions and allowed her to sit with her cat in the ‘pet corner’ during pre-operative checks.

There was dancing, singing and dressing up – and the development of a family-like bond.

As a result, Claudia is no longer afraid of the OR and her health and quality of life have improved

There have also been other spin-offs associated with the project, Tony says, such as closer collaboration with other specialists, particularly renal and primary care.

Tony says he and his colleagues are now working along side their primary care colleagues so they can learn more about the patient and provide a better and more well-rounded service that meets more of the patients needs.

dramatically. Claudia’s mother has “no doubt that without the fantastic team looking after Claudia she would not be where she is today”.

“Ngaire goes the extra mile for our fragile patients like Claudia”, says Prue Hames. “She is definitely a nursing hero.”

NAME: Tony Loversuch DHB: Hawke’s Bay JOB: Diabetes clinical nurse specialist

Delivering a streamlined, seamless service to diabetes patients is now part and parcel of Hawke’s Bay clinical nurse specialist Tony Loversuch’s job.

He has prescribing rights after being one of the 12 nurses involved in the diabetes nurse specialist prescribing demonstration pilot, which he describes as a landmark for New Zealand nursing.

Tony says times had certainly changed since he began working in diabetes 13 years ago. Not only were his twin daughters born that same year, but he became adept at using a computer and can now prescribe insulin and oral agents, as well as medication to manage hypertension and dyslipidaemia.

“Patients can now be seen, assessed, and a care plan implemented in a seamless way,” he says.

“While lifestyle changes may be integral to diabetes management, pharmacology is often required. Nurse prescribing has increased the “team approach” to managing patients with diabetes in Hawke’s Bay.” When the pilot programme began there were strict supervision requirements, with each DHB involved providing a physician supervisor. These weekly team meetings were vital for learning and sharing knowledge, he says.

“Nurses were forced to upskill and take a holistic view to managing the complexities of diabetes and the metabolic syndrome. It has been great for patients and has meant time with a specialist can be better used.”

NAME: Jane Bocock DHB: Taranaki JOB: Neonatal Unit head nurse

Taranaki neonatal nurse leader Jane Bocock’s research work with teenage mothers recently gained her a research excellence award.

She took first place in the 2012 Wintec Postgraduate Research Excellence Awards that celebrate the contribution masters’ students make to the research environment across a range of disciplines at the Waikato Institute of Technology.

Jane’s research project the experiences of teenage mothers in the Neonatal Unit was undertaken as part of the Master of Nursing programme.

“The purpose of the study was to hear and value the stories as told by the teen mothers; inform and strengthen health care practice, and identify areas of change if necessary,” said Jane.

A key finding of Jane’s research was that teenage mothers, despite their developmental stage, had similar experiences to those of older mothers in the same situation.

Jane was nominated by her senior lecturer Sallie Greenwood who said Jane’s strong commitment to neonatal nursing was evident in her research topic.

“While Jane does all this she works full time at Taranaki DHB as head of the neonatal unit.” The nurse leader finished her master’s degree last year and has also over the last 11 years found time to spend two weeks a year volunteering in Vietnam.

Continued on page 18 >>

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NAME: Betty Gilsenan DHB: West Coast JOB: Immunisation outreach coordinator

Bouncing along rural tracks trying to find houses with only a number as a reference can be challenging but when it means a baby will be immunised, it is worthwhile.

West Coast District Health Board immunisation outreach coordinator Betty Gilsenan says she’s often come home with her petrol gauge on empty after taking a few wrong turns trying to find families in remote locations.

Betty, who started working on the West Coast in 1968, covers the area from Karamea to Haast.

“There are long distances between houses and with the remoteness, you can’t just pop in to a store to ask for directions or into a neighbour’s house to ask where someone is,” she says.

Parts of Betty’s geographic area are so remote she has to negotiate with families to meet them at a relative’s home or encourage them to attend an outpatient clinic. Immunisation is important everywhere, but the West Coast has had multiple outbreaks of pertussis (whooping cough) in the last 18 months so it has been particularly crucial.

Betty recalls how delighted a mother in a very Intro ??????? remote area was to have Betty turn up at her home recently to vaccinate her newborn baby.

“It was a gravel road with lots of pot holes and dips that were full of water and you can never be too sure how deep it is,” Betty says.

“Doing home visits means you can spend a little more time answering the parents’ questions in a relaxed setting without them feeling there is a waiting room full of people,” she says.

The West Coast DHB’s immunisation team’s hard work has resulted in a significant improvement in the immunisation rate of eightmonth-olds.

NAME: Jo Vigenser DHB: Whanganui JOB: Critical care and emergency department nurse coordinator

Jo Vigenser would be the first to say she doesn’t see herself as a nurse hero –but she is to the many who view her as an inspiration at Whanganui Hospital.

Employed as Whanganui District Health Board’s critical care unit and emergency department nurse coordinator, Jo has 20 years’ experience in critical care – six of them as critical care nurse educator.

When asked to described her qualities, WDHB director of nursing Sandy Blake said Jo’s always calm, very patient focused, a leader with the gift of seeing the big picture and someone who is always happy, where possible, to drop everything to support nurses on other wards if they’re dealing with a difficult situation..

“She sees what’s needed and has the confidence to quietly make it happen,” Sandy says. “She’s a team player through and through.”

When told this, Jo said she’d been lucky to 18

have wonderful mentors who’ve nudged her along during her 30-year career as a registered nurse. She does admit that one of her strengths is driving initiatives which she sees to the end.

One such example is seeing the opportunity for a nurse educator role in critical care and going for it.

Jo has assisted to develop and drive the acute coronary syndrome pathway for the DHB, which involved getting buy-in of staff across the board from medics to social workers. She led and provided the nursing perspective for the WDHB’s Central Line Associated Bacteraemia (CLAB) project, for which the team’s CLAB poster recently won a regional award, and she also sits on the Clinical Board.

NAME: Maria van den Heuvel DHB: Canterbury JOB: Clinical nurse specialist at Burwood Spinal Unit

Empowering people with spinal cord injuries is a key driver behind Christchurch clinical nurse specialist Maria van den Heuvel‘s volunteer work in Samoa.

Maria and Burwood Spinal Unit colleagues first travelled to Samoa in 2010 to support Ben Lei and his family who was an inpatient in Tupua Tamasese Meaole Hospital following a rugby injury that resulted in tetraplegia.

Since then, Maria has made four visits back to Samoa. Other spinal specialist health professionals - from consultants to physiotherapists - from the Altus Resource Trust also travel to Samoa each year to support individuals with spinal cord injury (SCI) and their families.

Maria says it’s been an amazing journey to help empower individuals with SCI, their families and the newly formed Samoan Spinal Network to work together for better outcomes.

When she first travelled to Samoa it was unknown how many people living in Samoa have spinal cord injuries.

“We now know of at least 35 individuals with SCI, thanks to the established Samoa Spinal Network (SSN) and the hard work of its president, Epenesa Pouesi Young. She said the ongoing involvement of the kiwi team and the sharing of best practice, on areas like pressure relief and bladder and bowel regimes, was reducing secondary complications common to SCI However more support is needed, she says as equipment and consumables needed by people with SCI were scarce.

The New Zealand team are heading back to Samoa to provide further education and support at a three day workshop and undertake fale [home] visits this June.

“If anyone has consumables (does not matter if expired) they would like to donate these would be greatly appreciated by the SSN. In particular; wound care products, bandages, and uridomes, indwelling catheters, catheter bags, gloves and lubricants,” Maria says.

Maria first qualified as an enrolled nurse in 1984, gained her nursing degree in 2003 and has most recently been doing research towards a master’s degree in rehabilitation.

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NAME: Margot Love DHB: Southern DHB JOB: Charge nurse manager, internal medicine ward

Margot Love’s “outstanding clinical leadership” in initiatives from e-prescribing to linen and laundry innovation has won her a hero nomination from the Southern DHB.

The charge nurse manager at Dunedin Hospital completed her postgraduate certificate in leadership and management from Otago University in 2011 Since then Margot has been clinical leader for a number of initiatives including leading the pilot ward for the e-prescribing nationally and rolling out a standardised patient transfer communication tool between rest homes and the main hospital.

Margot’s latest project is providing clinical input into the South Island Alliance project on linen and laundry in conjunction with Health Benefits Ltd (HBL). She uses her ward as a “linen laboratory” where she tries out new products or processes to improve hospital linen provision for patients ensuring the linen is fit for purpose, individualised for the patient as well as saving health dollars.

Margot has provided a testing site for initiatives such as blue polar fleece blankets, fitted sheets and a return to cloth flannels from disposables and is still on target to save over $10,000 dollars off her linen budget this financial year.

In her own time she has created a promotional video called “Love your Linen” which is being shown in DHBs around the country and is also now working with HBL to promote South Island Alliance concepts nationally.

NAME: Pauline Tout DHB: Nelson-Marlborough JOB: Diabetes clinical nurse specialist

Pauline Tout was a pioneering diabetes nurse specialist in Nelson and with her master’s degree under her belt is keen to also add prescribing to her practice soon.

It is over 40 years ago since Pauline started her nursing training at Nelson Hospital.

After gaining her overseas experience in London hospitals she returned to Nelson to nurse, raise two children, become a nursing school tutor and in 1993 returned to hands on nursing as a diabetes nurse educator. She progressed to becoming a clinical nurse specialist in diabetes in 1996 - the sole diabetes nurse for the Nelson area at the time.

Pauline has been a national executive member for the Diabetes Nurse Specialist Section (DNS) of NZNO (1997-2000) and a member and chairperson of the DNS Accreditation Board (20002003) for which she is still an assessor.

She says it has been interesting watching changes over the years in her diabetes CNS role which was initially across primary and secondary then the focus changed as resources became constrained. Now the push is once again to bridge the continuity of patient/client care across

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community, outpatients and inpatients and extending more support to primary care.

Pauline completed a clinical master’s in nursing degree in 2009 and is keen to pursue nurse prescribing. She facilitated a diabetes course in 2010 and 2011 for primary care nurses at Nelson Marlborough Institute of Technology and assists with the development in the diabetes specialist nursing team.

Pauline says that diabetes is a fascinating area to work in and although challenging is rewarding.

She believes the demand for diabetes care will be overwhelming in the future, and health services must prepare for the diabetes epidemic.

NAME: Sera Tapu-Ta’la DHB: Capital & Coast JOB: Diabetes nurse educator

Sera Tapu-Ta’ala was drawn back from nursing in Melbourne to pilot a diabetes nurse role for Pacific people.

She had graduated from Whitireia’s mainstream nursing programme in 2002 and worked in Melbourne for a year with neurosurgery and rehabilitation but she missed New Zealand. there was a need for this kind of “I knew Intro ??????? service so I worked extremely hard to prove it to the Ministry of Health, and to ensure patients were followed up intensively. I can’t take all of

the credit though – I was just one of many in a much bigger team.”

After taking some time out to start a family she returned to practice as a diabetes nurse educator. Sera grew up in Samoa and believes that her fluency in her native language makes all the difference to the work she does.

“It’s given me a really good grounding – there are casual and formal layers to the Samoan language, and being able to address elders in the correct way establishes that I’m here to help them understand their condition, not tell them what to do.” Sera has also taken her message to the airwaves via a weekly Pacific Radio health programme.

In 2011 she completed her Masters of Nursing (Clinical), which looked at the experience of Samoan people transferring to insulin therapy.

“My study reminded me to be mindful of the fact that we can sometimes rush people.

The health environments we work in can be constrained at times by demand, but the clinical and social health needs of our people are also complex.”

Sera also volunteered to assist with the clean-up following the 2009 earthquake and tsunami, an experience she describes as “heartbreaking”.

“One of the cases I was allocated was a complex wound management case on top of existing diabetes. There was very little I could do clinically with the limited resources, it was kind of like Florence Nightingale, but the Samoan nurses appreciated the knowledge we brought regarding wound care and diabetes management.”

“Doing home visits means you can spend a little more time answering the parents’ questions in a relaxed setting without them feeling there is a waiting room full of people.” - Betty Gilsenan

NAME: Helen Snell DHB: MidCentral JOB: diabetes nurse practitioner and nurse leader of MidCentral diabetes and endocrinology service

MidCentral DHB says its nursing ‘hero’ Dr Helen Snell is recognised as making an outstanding contribution to her specialty, her profession and to the health of New Zealanders.

Helen was the country’s first diabetes nurse practitioner in 2003 and most recently has been instrumental in implementing and leading the national diabetes nurse specialist prescribing demonstration project and now its managed rollout to more nurses across the country.

She is also actively involved in clinical practice and is the nurse leader of the MidCentral’s health diabetes and endocrinology service.

Helen has been described as a leader, mentor and expert clinician and embodying the attributes all nurses endeavour to hold. She was the lead author of the pioneering 2009 National Diabetes Nursing Knowledge and Skills Framework with the structure of her framework forming the basis of knowledge and skills frameworks of other national nursing groups in New Zealand.

Continued on page 20 >>

COUNTIES MANUKAU DISTRICT HEALTH BOARD

Thanks ALL Nurses and Midwives...

“Our Everyday Heroes”

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<< continued from page 19 In 2005 Helen was a visiting scholar at Yale University where she met and worked with other internationally recognised scholars on diabetesrelated research.

She has also served on a wide range of local, regional and national working groups and committees including leading the former Nurse Practitioner Advisory Committee of NZ and being a member of the New Zealand Society for the Study of Diabetes (NZSSD)executive committee.

In recognition of her work in 2011 Helen received the MidCentral DHB Directors of Nursing Pre-eminent Award for a “significant impact on the New Zealand health system”.

NAME: Arun Valiyaveetil-Raju DHB: Waitemata JOB: Medical ward RN at North Shore Hospital

Arun Valiyaveetil-Raju’s sensitive care of the family of a dying patient earned his nursing hero nomination from Waitemata DHB.

Arun is aware when nursing a terminally ill patient that he also has to take care of the family. As while caring for patients in their last days is part of what nurses do, most families do not experience death often.

Intro ???????

“Along with the patient, it’s the family that matters,” says the Ward 2 nurse. “For them this could be the first experience of seeing a person die.”

Arun recently nursed the father of a staff member, who was struck by his consideration for the family and how he explained what was happening.

“For renal patients, there are lots of things the family may have to witness when the body is trying to shut down,” says Arun. “The health professionals know what’s happening most of the time, but the family might not. In that situation, I really try to make sure I explain everything.

“It just takes me five or 10 seconds to explain to the family what I’m going to do.”

Although Arun was not nursing the patient when he died, he made a point of giving his condolences to the family – a gesture that touched them.

“I will always make sure I express my condolences,” he says.

It is important to acknowledge the family. And, he says, it’s also personally important – he was chatting and laughing with this man just a week earlier. “We are nurses, and we are also human.”

NAME: Judy McHardy DHB: Northland JOB: Until recently PHC nurse coordinator of the B4 School Check programme for Northland

Judy McHardy’s long commitment to improving child health was rewarded recently with a travelling fellowship to explore other countries models of care.

The Margaret May Blackwell bequest funds an annual fellowship to enable a nurse working in early childhood health to increase their knowledge by visiting and experiencing child health initiatives in other cultures.

Judy was the worthy recipient of the 2011/2012 fellowship (administered by the NZ Nursing Education & Research Foundation, and the NZ Nurses Organisation) which was seen as a just reward for a nursing career that focused primarily on the health and well-being of children. She used the fellowship to travel to Europe and North America in 2012 and explore overseas models of care for three months. The award also affirmed Judy’s leadership role.

Judy has worked as a Plunket and Public Health Nurse in the mid and Far North regions of Northland, and until recently was the coordinator for the B4 School Check programme (B4SC) in Northland. She set-up the B4SC programme (the universal health screening programme for four-year-olds) and has coordinated the successful multi-provider model for the past four and a half years.

Mary Carthew, associate director of nursing for Manaia Health PHO, says Judy is widely respected and admired for her nursing knowledge and skills, and her tenacity and determination to deliver a high quality service to the children of Northland.

NAME: Janine Colpman-King DHB: Lakes JOB: A nurse leader at Lake Taupo Hospice

Janine Colpman-King believes all nurses have a responsibility to mentor the next generation of nurses.

The Lake Taupo Hospice nurse was the winner of the 2012 Lakes DHB Nursing/ Midwifery Leadership Award.

“I believe that all nurses are leaders from new graduates to nurse leaders practising at a higher level.

Janine trained in Palmerston North Hospital and has been a nurse for 30 years working in a wide range of health care settings and in recent years has worked in specialist palliative care. She has a Masters in Nursing with a focus on palliative care, is a Liverpool Care of the Dying Pathway facilitator and a licensed Flinders self-management trainer and PDRP assessor.

She has developed a robust, evidence-based range of education services focusing on palliative care and plays an important part in educating health professionals working across primary, community and hospital services.

“People think working in the area of palliative care would pull you down, however during sad and challenging times we also do have a lot of fun. Walking along side patients and their families, supporting them to fulfil their bucket lists and live life every moment as opposed to waiting to die is a privilege.”

Janine’s nomination said she was a transformational leader who encourages staff development, influences changes, provides academic stimulation and contributes widely at local, regional and national levels.

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INSOMNIA LOSING SLEEP OVER IT?

PRACTICE, PEOPLE & POLICY HWNZ ON LOOMING NURSING CRISIS

A DAY IN THE LIFE OF a Whangarei flight nurse

eViDence-baseD Practice:

Coffee’s post-surgery perk

a Day in tHe life of

international nurses Day celebrating

Kiwi nursing ‘heroes’

BABY BOOMERS Older nurses keep on keeping on

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Practice, PeoPle & Policy NightiNgale a smartphoNe faN?

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Evidence-based practice

Wake up and smell the coffee Is ‘prescribing’ a post-surgery long black good for the bowels as well as morale?

CLINICAL BOTTOM LINE: The addition of regular espresso coffee the day after surgery – involving a fast-track colorectal surgical protocol – accelerated time to first bowel motion without undue effects for elective patients.

CLINICAL SCENARIO: Although British science writer Ben Goldacre notes coffee both increases and decreases the risk of cancer, as a committed coffee drinker you are ever alert to its possible benefits. A recent notification reveals the effects of coffee may extend into improving patient outcomes in surgical nursing. You investigate further.

QUESTION: Among adults having bowel surgery, does coffee hasten return to normal bowel function compared to usual care (hydration using water)?

SEARCH STRATEGY: No search strategy – paper notified through push mechanisms (Evidence Update)

CITATION: Muller SA, Rahbari NN, Schneider F, et al. Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy. BR J SURG 2012;99:1530-38.

STUDY SUMMARY: Open-label randomised controlled trial in three German teaching hospitals, conducted from May 2010. 103 patients were screened and 80 randomised.

Patients must have been aged at least 18 years and been scheduled for open or laparoscopic colon surgery for benign or malignant disease. Patients were excluded if a rectal resection, stoma or multivisceral resection was planned, had a known sensitivity to or distaste for coffee, or had impaired cognition. Fast-track surgery principles were applied to all patients (no mechanical bowel preparation; no oral antibiotic therapy; one preoperative enema for patients receiving left hemicolectomy or rectosigmoid resection; single dose of antibiotic prophylaxis at anaesthetic induction; and low molecular weight heparin and compression stockings).

Postoperative feeding was standardised – water was first offered six hours after the operation, liquid food on day 1 and solid food on day 2 post-op. Patients were instructed not to drink any tea or extra coffee, but could drink any amount of mineral water they wished.

Intervention: Three cups of coffee daily (100 ml LaVazzo Blue Espresso Dolce 100% Arabica, 8 gram per coffee capsule, given at 0800, 1200 and 1600) beginning on the morning after surgery. Patients were asked to drink all the liquid within ten minutes and no additives (milk, sugar) were allowed.

Control: Three cups of warm water daily (100 ml at 0800, 1200 and 1600) beginning on the morning after surgery.

Outcomes: Primary outcome was duration of postoperative ileus after surgery using time to first bowel movement as a surrogate for duration of ileus.

Secondary outcomes included time to tolerance of solid food, time to first flatus, need for laxatives, safety and length of stay.

STUDY VALIDITY: Randomisation was by 1:1 allocation without stratification by centre. The allocation concealment was through sequentially numbered, opaque, sealed envelopes stored in a central office with allocation made by contacting study manager. One patient (1%) in control arm was removed as did not have planned surgery. Analysis was by intention to treat. The trial was open-label with investigators, staff and participants aware of allocation. The groups were similar for important factors (diagnosis, types of procedure, co-morbidities, ASA grade, duration of operation and epidural anaesthesia) and there was no evidence that participants were not treated equally. Overall the methodological quality of the study was high.

RESULTS: Time to first bowel movement (BM) was significantly earlier for the coffee group (see table). Other outcomes were not significantly different. Using coffee did not increase nasogastric tube reinsertions, anastomotic leakage or need for laxatives and the rates for these safety variables were all lower in the coffee arm.

COMMENTS: The coffee was well-tolerated by patients – only ten per cent of patients did not want coffee the day after surgery.

Patients received prepared espresso. It is not known whether the treatment effect would remain if instant coffee was substituted.

The heterogeneity of the sampled patients reflects the reality of elective surgical practice.

An unexplored benefit of including espresso coffee in patient care may be a counterbalancing effect on staff morale.

Reviewer: Dr Andrew Jull, RN PhD, Associate Professor, University of Auckland & Nurse Advisor – Quality, Auckland District Health Board.

Table: Outcome data and 95% confidence intervals Outcome

Coffee

Control

Absolute difference (95%CI)

P value

Time to first BM

60.4 hours

74.0 hours

13.6 hours (4.0 to 23.2)

0.006

Time to solids

49.2 hours

55.8 hours

6.6 hours (-5.4 to 18.4)

0.276

Time to flatus

40.6 hours

46.4 hours

5.8 hours (-3.5 to 15.2)

0.214

Length of stay

10.8 days

11.3 days

0.5 days (-1.5 to 2.6)

0.497

Nursing Review series International Nurses Day 2013

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Webscope

CHECK THESE OUT

KATHY HOLLOWAY explains how to attend a conference without leaving the house

Webinar: I

attending conferences the virtual way

t is a well understood that continuing education and ongoing engagement with professional colleagues supports high quality, safe and effective clinical practice. Conferences are recognised as providing an excellent mechanism for achieving both of these goals. However time and expense may preclude your ability to participate in the myriad of relevant international and national conference opportunities available to registered nurses these days.

A quick peruse of the NZNO conference and event site reveals around 50 different workshops, conferences and professional development opportunities available nationally. Some of these may have a webinar option also referred to as an online conference, web meeting, net meeting or virtual meeting. A webinar is an online technology that provides a mechanism for nurses across the world to connect globally to benchmark and develop their practice. The phrase webinar is derived from the combining of web and seminar and is thought to have first been used in the 1990’s.

Webinar technology is a new tool emerging in the world of health and other disciplines, making it possible to connect people beyond conference calls and e-mails. During webinar sessions online participants have the opportunity to watch, listen, use email or text chat to ask questions and have a discussion with the presenter. Within the software there’s a presentation area for slides and document sharing.

With a good internet connection (i.e. broadband) and access to a telephone you have all you need to

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join a webinar or even organise your own webinar.

There are a number of free software applications that can be used to host webinars such as Google Hangouts or Web-Ex that you can register with.

For an example see Patricia Benner in a 2010 webinar on Educating Nurses and Physicians: Toward New Horizons hosted by the Carnegie Foundation at www.carnegiefoundation.org/ resources-webinar-nursing-and-medical-education.

Webinars are a real-time session that people can log in to and often includes time for questions or discussions either live via chat or by phone.

If you don’t manage to make the synchronous broadcast then the webinars can often be accessed later on host websites. Many international health organisations provide webinars for example the CDC, American Nurses Association and Institute of Medicine. In New Zealand recently to mark World Suicide Prevention Day 2012 an online, interactive webinar on the topic of strengthening protective factors and instilling hope was held – copies of these presentations are available www.spinz.org. nz/page/239-events-archive+webinar-for-worldsuicide-prevention-day-2012.

So let your mouse do your walking and check out your favourite conference sites for webinars or recorded presentations post-conference. Don’t let geography get in the way of broadening your professional horizons – with awareness comes choice.

Dr Kathy Holloway is dean of the Faculty of Health at Whitireia Community Polytechnic.

Nursing Review series International Nurses Day 2013

Inspire 2012: Reshaping Australia’s Health Workforce http://www.inspire2012.org.au/ This is an example of how you might use online technology to attend Health Workforce Australia’s inaugural conference, Inspire 2012: Reshaping Australia’s Health Workforce, held in November 2012. The conference brought together some of the world’s most respected leaders in workforce innovation and reform. Many of the key note presentations from this conference have been captured as streaming video sessions allowing you to experience some of the impact of attending this important Australian conference. [Site accessed 6 April 2013 and last update unknown].

Online Issues in Nursing Journal Social Media and Communication Technology: New “Friends” in Healthcare http://www.nursingworld.org/ MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/JournalTopics/ Social-Media-and-Communication-Technology An American peer-reviewed publication provides a forum for discussion of issues in current topics of interest to nurses and other health care professionals. The intent of the journal is to present different views on issues that affect nursing research, education, and practice, thus enabling readers to understand the full complexity of a topic. When each new topic is posted, the previous topic becomes available to all viewers. This topic is from September 2012 and has five articles that present existing research and expertise on the emerging presence of social media in healthcare giving nurses an insight into both risks and benefits of social media. Don’t forget to check out our own nursing council’s perspective at http://www.nursingcouncil.org.nz/download/309/ smedia.pdf [Site accessed 6 April 2013 and last updated February 2013].

college of nurses

Turning frustration into action Nicola Russell

NICOLA RUSSELL vents some frustration that in 2013 general practice is still largely “business as usual” despite the optimistic rhetoric of the 2001 Primary Health Care Strategy. She also calls for input into an upcoming College of Nurses workshop for nurses keen to explore developing primary health care nursing services.

I

have worked in primary health care for a decade – and depending which era you come from, that either makes me a novice or an expert!

I am a Generation X primary health care (PHC) nurse working in general practice, in small town New Zealand ... and these comments are my reflections on life as I know it. They are also a call for some input from other primary health care nurses as the College of Nurses, Aotearoa considers development of a workshop focused on the development of PHC nursing services.

In 2007 with a little (actually a lot) of trepidation I duly accepted the challenge of completing two new masters’ papers offered through Massey University – Primary Health Care and Management of Long Term Conditions.

The Primary Health Care Strategy (2001) had offered so much to us in terms of future of nursing governance, not least of which the eventual release of funding streams for PHC-focussed postgraduate nursing education and the construction of nurse practitioner (NP) training programmes.

Nurses were touted as crucial to the implementation of a primary health system that was innovative, efficient, population-focused and accessible to all members of the community. There was a verbal commitment to increased possibilities for nurses to take on roles of clinical leadership and decision-making. Behaviours traditionally firmly ensconced in the medical domain, were finally going to be ours to take ownership of! The future was exciting, the possibilities endless.

I began to have conversations with colleagues that even included the (then) staggering option of nurses one day maybe buying their own practice – what if we actually employed GPs and made the rules? What if we could effortlessly design and deliver a mobile nursing service for hard-to-reach patients? Oh...yes, the future looked amazing. Nursing was going to transform the parameters of delivering primary care to the masses.

Fast forward to 2013, masters under the belt, but general practice continues largely as ‘business as usual’ and what have I learned?

Well, I have come to the realisation that, whilst I

know what needs to be done – it sure is difficult to cut through all the political jargon, rules, regulations and biases that permeate our health care system. Seems like every month a new ‘focus’, a new ‘target’, a new or often pervasive ‘barrier’ stands in the way of true patientcentred care. Yes, being a primary health care nurse is often fraught with constant change and sadly, what often feels like a juggling act of epic proportions.

We are in a unique position to clearly identify what impedes ‘better, sooner and more convenient’ patient care within the mainframe of traditional general practice models of care. Issues like access due to lack of transport, restricted opening hours, after-hours access, financial

NP training and registration, only to find themselves shut off from silos of available funding that would allow them to work to their full scope of practice, determining the nature, design and structure of the services they provide and thus transforming primary health care services.

Good things take time (and all that) and certainly there are some upcoming changes to legislation and policy that will solve some of the issues, but we certainly need to start thinking about ways we can take ownership of our role as leaders in the development of a consumer friendly and sustainable primary health care service. As a rather large group of health care

I am embarrassed when I have to explain to a frail, elderly patient that they have to make their way to the clinic for nursing care – because new rules mean that community nursing hours have become stricter to access. difficulties, poor health literacy...and the list goes on.

I don’t know about you, but it frustrates me when I see patients constrained to a system that doesn’t meet everyone’s needs. I lament the resources wasted and the inconvenience/suffering experienced by a patient when they are hospitalised for a condition that could have been effectively managed in the community – if only the service was more easily accessible for them.

I am embarrassed when I have to explain to a frail, elderly patient that they have to make their way to the clinic for nursing care – because new rules mean that community nursing hours have become stricter to access. I worry about the lack of access to screening opportunities for those working within high risk, low pay industries – particularly within a pressurised economic environment. I’m sure you can think of many, many other examples from your own practice experience.

I find it hard not to be cynical about what was – and continues to be - promised to us and through us to our patients . Being clinically autonomous and having access to funding is not a reality for most nurses working in primary health care, especially general practice.

This is especially so for many of those in our nursing community who have completed the arduous task of

providers, we have enough integrity and experience to drive the process. Maybe we just need some more intensive and focussed knowledge about how to get there?

The College of Nurses is in the process of organising a workshop for primary health care nurses and NP’s who want to explore their options for nurse-led or more patient-focused service delivery. Whilst there are a few trailblazers who have already successfully taken up this challenge, how many of us continue to dream of the possibilities but get stuck on the seemingly insurmountable task of actually realising these dreams.

So, have a think about what would be useful for you to know. What frustrates you? What issues need addressing to ensure certain patient groups in your practice can have greater access to primary health care services? What would you do differently if you could?

You can send your thoughts, stories or requests to me at tn.russell@hotmail.com About the author: Nicola Russell BN M.Phil (Nursing) works as a primary health care nurse in general practice, Invercargill. She is also a board member of the College of Nurses (Aotearoa).

Nursing Review series International Nurses Day 2013

23

Articles, profiles and opinion pieces from across the nursing spectrum

Michelle Honey

People, practice & policy Nightingale the first informatics nurse?

Technology will never replace the art of nursing … but it can make the job a darned sight easier. FIONA CASSIE talks to Michelle Honey, the chair of the Nursing Informatics group, about nurses using information technology to improve health care.

If Florence Nightingale were nursing today, she’d probably be walking the wards with a smartphone rather than a lamp.

Always seeking better patient data to guide her work, Nightingale is widely regarded as one of the first informatics nurses. One can imagine her delight at the deluge of data now available with a simple click or slide of the fingers and its potential to improve health care.

As just like thermometers were once a foot long and only wielded by physician experts, information technology is now smarter, smaller, swifter, and easier to use. But to ensure that information technology is nurse friendly and helps not hinders their practice, nurses need to get involved, says Michelle Honey.

Honey is an enthusiast for nurses using information technology to help nursing do what nursing does best.

She chairs the Nursing Informatics group, a group of 40–50 nurses working in roles ranging from education, management, clinical, and IT, all with a special interest in the specialty of nursing informatics.

Computers, the internet, and mobile phones are now commonplace tools, but Honey says she still sometimes hears nurses say “they didn’t come into nursing to ‘get into computers and stuff like that’, they came into nursing to care for people”.

“I say if you can replace me with a computer or a robot or anything like that then you should. Because if what I add as a nurse isn’t significant enough to make a difference then use a computer… for me, technology never replaces the human element of what I bring.”

So a fingertip pulse-oximeter may give you a pulse as well as oxygen saturation, but it doesn’t replace the handson nursing art of checking the quality of the pulse and the regularity of the rhythm.

What nursing informatics seeks to do is to ensure nursing input into new technology – like electronic patient records, online decision-making tools, databases, and mobile apps on everything from interpreting electrocardiogram (ECG) rhythms to drug calculations – so the resulting innovations reflect and enhance nursing practice, knowledge, and research, as well as integrate with the wider health system.

“Health informatics has the potential to reduce duplication, costs, and errors while improving communication between providers, integration of services, and patient safety,” says Honey.

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Nursing Review series International Nurses Day 2013

“My challenge to nurses is that we need to make sure that nurses’ voices are heard about what we need to ensure nurses can do their job properly.”

Another challenge is ensuring the contribution nurses make to the healthcare equation is captured in health sector data, so, for example, statistics on elective surgery reflect more than just how many hip replacements were done.

Honey says research has shown nurses have positive attitudes to computers and IT as long as they can be shown that the technology makes a difference in their work and to their patients. And with a generation of nurses used to internet banking, Facebook, and mobile apps, it is often now nurses’ personal use of technology that is driving their expectations of what should be available in the workplace.

District health board budgets and policies are not always keeping pace with those expectations, including some DHBs only allowing health professionals access to the DHB’s intranet and not the internet, or having far fewer computers on the ward than staff needing to use them. As an aside, things will have to start moving on that front as the country’s ambitious eHealth vision aims by 2014 to have all health providers having electronic access to a patient’s medical history, test results, and a single shared care plan, along with electronic decision support tools to support “optimal delivery of care and clinical risk assessment”.

Honey says you don’t need to be an IT expert to be into nursing informatics – just an interest in using technology to help healthcare. She started intensive care nursing in the 1970s when computers were not the norm at home or on the ward (though she recalls ICU nurses could for the first time do their own blood gas analysis without needing technicians).

She first got into computers in the mid-1980s when her husband bought an early PC but describes herself as “not particularly technologically able” and she’s no programmer.

“I’m a user who comes with a nursing focus and knows what we are trying to achieve.”

Honey, now a senior lecturer at the University of Auckland, did her master’s degree looking at practice nurses use and attitude towards computers, and a decade later, she completed a PhD on teaching and learning with technology.

Honey says nurses interested in entering the specialty of nursing informatics can join the HINZ group to

connect with other like-minded nurses, and there are postgraduate papers available in health informatics.

She suggests if you are a nurse on the ward, the first step may be as simple as putting up your hand if volunteers are required for an IT project team, so you can ensure nursing needs are met. “Because we’re the only ones who know what nurses need.”

Definition of nursing informatics The science and practice of nursing informatics integrates nursing with information and communication technologies to promote the health of people, families, and communities worldwide.

Nursing informatics in New Zealand Nursing informatics was established in New Zealand in the early 1990s by a small group of nurses lead by Jan Hausman, Marilyn Appleton, and Robyn Carr.

Carr went on to become the chair of international nursing informatics group IMIA-NI. Nursing informatics is now a special interest working group under the umbrella Health Informatics New Zealand (HINZ) organisation, with two of the past five HINZ chairs being nurses.

Michelle Honey is the current chair of the HINZ Nursing Informatics group.

For more information and how to join the group, go to the nursing informatics working group page at www.hinz.org. nz, where you can also find postgraduate study options and presentations from the recent HINZ conference. eHealth Vision for New Zealand “To achieve high quality health care and improve patient safety by 2014, New Zealanders will have a core set of personal health information available electronically to them and their treatment providers regardless of the setting as they access health services.” *IT Health Board

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People, practice & policy

OPINION

Reena Kainamu

Too few Māori nursing students: action needed Reena Kainamu, member of the Māori Caucus of Te Ao Māaramatanga New Zealand College of Mental Health Nurses (NZCMHN), shares the concerns about the under-representation of Māori students in nursing programmes and Māori nurses in the workforce.

Prior to formal nursing registration in New Zealand, Māori people were ‘caring clinically and culturally’ among their communities. Manākitanga, tiakitanga, and wairuatanga were traditional practices associated to Māori wellbeing underpinning healthcare and were valued and nurtured in whanau from a very young age*, continuing to the present day. Māori were providing ‘maternity and nursing care’ in colonial history during a climate of institutionalised racism, where barriers prevented access for Māori to hospitals, doctors, and healthcare*.

Since formal nursing registration in New Zealand, the nursing profession has been valued among indigenous Māori communities, commencing with the early registered nurses Mereana Tangata and Akenehi Hei*. Perhaps there were others like Tangata who chose to use Pākehā names in disguising their ethnicity to minimise the effects of racism in nursing education and training.

In negating an unhelpful and incorrect ‘myth’ that nursing is undervalued by Māori, the Caucus is unequivocal that nursing remains valued among Māori communities and the cultural concepts of manākitanga, tiakitanga and wairuatanga are a match for the core nursing tenet of ‘caring’.

National Māori mental health workforce development initiatives like Te Rau Puawai and Te Rau Matatini provided mentorship, financial grants, and a professional development programme for Māori mental health nurses at postgraduate levels. However, the numbers of Māori nurses exiting having completed nursing programmes is underwhelming, and the numbers entering into mental health is reflective of low numbers of Māori nursing graduates.

The 2011 research lead by Denise Wilson, Retention of Indigenous nursing students in New Zealand urges the development of strategies to address attrition and failure at undergraduate levels inclusive of culturally relevant content in nursing curricula and the creation of supportive and culturally safe learning environments grounded in the cultural and learning needs of indigenous nursing students.

Historically, the education environment was a place of power and dominance over indigenous knowledge in New Zealand*. Academic and educational institutions continue the practices of hegemony in suppressing the emergence of ‘many’ truths of minority peoples*. ‘Whiteness’ or Western ways of knowing are privileged over indigenous epistemology and the knowledge systems of minorities in tertiary education environments.

Anectodally, Māori nursing students and Māori nurse lecturers face ‘micro-aggressions’ daily in undergraduate nursing programmes. To complain is to risk further aggressions or made ‘invisible’ by dominant others.

Education should be liberating.

To this end, Māori Caucus supports: »» investigating the numbers of Māori nurses required to match the healthcare needs of the Māori population (ethnicity percentages) »» extrapolation of the numbers of Māori entering undergraduate nursing programmes »» extrapolation of attrition rates of Māori nursing students »» identifying the numbers of Māori exiting with completed nursing degrees.

As spoken about at the National Nursing Organisations meeting held December 2012, let us not look offshore to solve nursing workforce issues in New Zealand. Let us increase the numbers of nurse practitioners, inclusive of Māori nurse practitioners by “growing our own”.

About the author: Reena V. Kainamu (Ngā Puhi,Ngāti Kahu ki Whangaroa) RPN, MN, doctoral candidate *Reference list available online: www.nursingreview.co.nz

Shelley McMahon

Preop clinic making its mark Clinical nurse specialist Shelley McMahon reflects on the ongoing development of Northland’s Nurse-Led Preoperative Assessment Clinic.

In late 2006 Northland took its first fledgling steps towards a fully Nurse-Led Preoperative Assessment Clinic (NLPAC).

The result of this initiative was well documented in a report in 2008 by fellow clinical nurse specialist Zoe Pathan and anaesthetist Rod Harpin. This was a very exciting time for the Northland District Health Board (NDHB) clinic, but as we settled into our new roles we knew that we had to constantly revise and review the high standards originally set. Over the last five years, the earlier success of the clinic has been built upon to improve the service and ensure its sustainability.

Hatchett in 2003 defined nurse-led Clinics as “a clinic where the nurse has his or her own patient caseload… involves an increase in the autonomy of the nursing role…to refer onto more appropriate healthcare colleagues”.

Northland’s Nurse Led Preoperative Assessment Clinic began with just three nurses but the clinic’s staff has since doubled. Now there is a clinical nurse specialist and four specialty clinical nurses working in Whangarei and one specialty clinical nurse working in Kaitaia. All preoperative assessment clinic (PAC) nurses have successfully undertaken the DHB’s core clinical competencies and completed University of Auckland’s Advanced Assessment and Clinical Reasoning paper.

Postgraduate education over the last five years has seen all PAC nurses gain postgraduate qualifications ranging from a postgraduate certificate to a masters degree in nursing.

The Kaitaia clinic began in February 2008, with two nurses travelling once a month to Kaitaia for two days. This was to capture patients whose first specialist

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Nursing Review series International Nurses Day 2013

appointment (FSA) was undertaken in the Far North and to ensure equity of access to our service. In 2011 Kaitaia gained its own preoperative assessment clinic.

New patient-centred criteria Much of the clinic criteria were dictated by age. For example, all patients over 50-years-old had an ECG performed and required routine blood tests. This has recently been reviewed by the anaesthetic department and the PAC. To expect a patient to attend the PAC because of their age and not their co-morbidities is not patient-centred care. Patient safety is paramount. Asessments are underpinned by clinical competence and the ability to interpret health information and fitness for anaesthetic.

Age is not now a major factor in our decision to see a patient. Patients are assessed by phone when possible and brought into clinic if a physical assessment is required. Our decision-making skills are challenged on a regular basis, but with peer support and an open door policy with the anaesthetists, positive outcomes are achieved.

In 2010 referral to the clinic was adapted to allow us to take ownership of the whole PAC process. Prior to this each service’s booking clerk would book patients independently into the clinic. This was on a ‘first come first served’ basis and did not take into account the urgency of the surgery or staffing levels.

Upsurge in demand The increase in elective surgery completed in Northland is reflected across the rest of New Zealand. In the first nine months of 2007 2,174 patients were seen in PAC, of these 423 were seen by the anaesthetist. This

represents 19.4% of patients seen in clinic by the PAC nurse.

Approximately 1,550 patients were fast-tracked (assessed by post, phone etc.). Of the patients seen in clinic 65 were cancelled as “unfit” on the day of surgery. This represents 2.9% of all patients seen in PAC. By contrast, patients seen in PAC up until the end of September 2012, numbered 2,755. 705 of these patients required an anaesthetic assessment. This represents 25.5% of all patients seen in the PAC. Fast-tracked patients totalled 1,959. 80 patients, who were seen in PAC by the nurse and/ or the anaesthetist, were cancelled as “unfit” on the day of surgery. This represents 1.1% of all patients seen in clinic.

A really exciting piece of news is that the preoperative assessment clinic held its first combined cardiology/ anaesthetic clinic in December. This is a new innovation for PAC and is working really well. Previously patients were referred to the medical outpatient department to wait their turn for an appointment. They did not go onto the surgical booking list until all of their preoperative tests had been completed and their health optimised. This could mean a wait of up to six months for surgery on top of the optimisation period. By co-ordinating our service with cardiology to review preoperative patients, we hope to reduce the wait for surgical optimisation and promote a more patient centred service.

To summarise, over the last five years the service has grown in size and complexity. The PAC staff case-manage more and more complex patients. The work is exciting and attracts dynamic, motivated staff. Northland DHB are also justly proud that the Nurse Led Pre-operative Assessment Clinic was also chosen by the Ministry of Health to be a Demonstration Site for 2012.

A round-up of national and international nursing news

For the record New nurse leaders appointed Andrea McCance has been confirmed as director of nursing and midwifery for Capital & Coast District Health Board after acting in the role since former director Kerrie Hayes resigned late last year to take up a nurse leadership post in Canberra. Andrea McCance came to New Zealand in 2007 and was registration manager at the Nursing Council before becoming associate director of nursing for surgery, women’s and children’s health for Capital & Coast. Prior to coming to New Zealand she was director of nursing and midwifery at Eastern Health Melbourne. She holds post-registration qualifications in midwifery and cardiac care and a postgraduate diploma in organisational behaviour.

Dr Deborah Rowe stepped into the chair role of Nursing Council of New Zealand after former chair Margaret Southwick’s term ended. A nurse consultant and lecturer Rowe was appointed to the council in 2008 and has previously been deputy chair. She holds a joint appointment between Auckland District Health Board and the University of Auckland, recently completed her PhD, and also works as a neonatal intensive care nurse. Rowe (Ngāi Tahu) is also currently chair of the Māori Advisory Committee National Screening Unit, Deputy chair of the Ethics Committee for Assisted Reproduction, and is a committee member on other Ministry of Health Committees Check out online NewsFeed for…

New NZNO president Memo Musa: interview with the former Whanganui DHB CEO and British-trained, Zimbabwean-born new CEO of the New Zealand Nurses Organisation.

Latest on controversial RA ‘merger’ proposal: The business case – including retaining dedicated nursing staff was presented to the chair of Nursing Council and the 15 other regulatory authorities on April 15 and is to be voted on in May. Check out at www.nursingreview.co.nz or on Twitter: @NursingReviewNZ About 200 nurses affected by migration changes The dropping of 11 nursing categories from the long-term skill shortage list may affect about 200 nurses currently nursing here on work visas.

Immigration New Zealand said about 800 registered nurses were currently issued visas to work in New Zealand and about 200 of those were for nurses working in areas no longer on the LTSSL. Nursing categories dropped include mental health, surgical, child and family, community health, nurse researchers, nurse managers and nurse practitioners. The registered nurse categories remaining on the list are aged care, perioperative, medical, critical care, and emergency. Other health occupations still on the LTSSL are physiotherapists, GPs, and clinical psychologists.

The New Zealand Nurses Organisation has advised nurses, particularly with visas due to expire, to contact Immigration New Zealand to explore their options.

Immigration NZ said options open to affected RNs include applying for an essential skills work visa, skilled migrant category residence or “work to residence” (accredited employer) if they are working for an accredited employer.

The changes to the LTSSL were made earlier this year by Immigration New Zealand after “extensive consultation” with stakeholders, relevant government agencies and analysis of labour market trends. Employers can still recruit migrants in categories removed from the list if they demonstrate ‘genuine attempts’ to recruit suitable New Zealand citizens or residents.

New STI resource for health professionals New sexual health guidelines and resources have just been released to help nurses and GPs better manage sexually transmitted infections.

The 2013 sexual health management packs have been developed by the Sexually Transmitted Infections Education Foundation (STIEF) in collaboration with New Zealand Sexual Health Society (NZSHS) and 6000 are to be distributed to health professionals. The foundation says 80 per cent of people will contract genital HPV in their lifetime and 30 per cent will get herpes and New Zealand also has one of the highest rates of Chlamydia in the OECD. To find out more or order a pack you can email: info@stie.org.nz

At least 15% of graduates still job hunting by FIONA CASSIE

About 75 per cent of new graduates had nursing jobs by March down on last year’s 85 per cent employment rate, according to the latest graduate survey.

It showed that at least 185 new nurses were still looking for a nursing job four months after graduation.

But it also showed that the number of new graduates finding jobs on new graduate programmes has risen strongly, the number heading overseas has declined, and the total number in work – about 900 – is the same as last year.

The annual snapshot of November graduate’s job destinations, coordinated by nurse educator group NETS, was responded to by 94 per cent of last November’s graduate cohort of 1209.

That bumper cohort was 15 per cent more than the previous year’s 1050 graduates but job numbers available to them stayed steady at around 900.

Cathy Andrew, a NETS survey spokeswoman, said for the first time in the survey it asked graduates without jobs whether they were actively looking for work as it was thought this was important data to be “capturing”.

It found that 185 graduates (15 per cent) were still actively looking for work, 44 (3.6 per cent) were not looking and the job status of 78

graduates who didn’t respond to the survey (6.4 per cent) was unknown.

Chief Nurse Jane O’Malley was unavailable for comment at time of going to press but Andrew, also head of CPIT’s nursing school, believed the 75 per cent employment rate was a “great result” given the current economic conditions.

The survey found that the number employed in new graduate programmes had grown from 637 last year (72 per cent of those nursing) to 744 (83 per cent) this year. The number of graduates heading overseas to work had also fallen from 53 (5 per cent) last year to 38 (3 per cent) in 2013.

The numbers employed in district health board medical or surgical roles was up (probably reflecting the rise in new graduate places) and the numbers in primary health care, mental health and continuing care/ elderly were slightly down.

Outlook ‘good’

Meanwhile nursing is still rated as a good job prospect in the Department of Labour’s Occupational Outlooks for 2013.

The department rates 40 key occupations as “low, medium, or high” in the areas of student fees and potential income or “limited, fair, and good” in terms of job prospects.

Nursing job prospects are rated “good” compared to “medium” prospects for law and architecture graduates and “low” for journalists and firefighters.

Nursing student fees are ranked as high (an average of $16,000 to 18,000), which is the same ranking as given for doctors ($63,000) and dentists ($66,400).

When it comes to income, nurses are predicted to have “medium” income prospects, the same category given to architects, graphic designers, farm managers, police, and plumbers.

Nursing researchers score higher Investing in nursing research appears to have paid dividends with the country’s nursing scholars stepping up a notch in the latest research quality rankings.

The emerging research field still has a long way to go, though, with nursing still only ranked 41 out of 42 subjects assessed in the latest Performance-Based Research Fund (PBRF).

But the overall quality score (out of 10) has grown from the bruisingly low score of 2.57 in 2003 to 3.34 in the 2012 round released recently by the Tertiary Education Commission (TEC).

“It’s great to see that nursing has certainly improved,” said Associate Professor Lisa Whitehead, project director for the STAR project.

The $2.7 million STAR project was funded by TEC in 2007 to build and boost the research capability of nursing and allied health disciplines.

“It looks like its paid direct dividends in the quantity and quality of research that nurses have been undertaking,” said Whitehead.

The number of nursing scholars from the country’s nursing schools assessed as being research active or emerging has grown from just 21 in 2003 to 63 in the latest round. Also the number of scholars getting an “A” for world class research has gone from none in 2003 to one in 2006 and three in 2012. The number getting a “B” for good research has also more than doubled to 15.

The improvement was also noted in the PBRF report, which said the relatively low scores of areas like nursing (and the newly bottom ranked sport and exercise science) reflected their emerging nature but the number of nursing researchers demonstrating high levels of research quality had “increased markedly”.

Whitehead, who is director for the University of Otago’s Centre for Postgraduate Nursing Studies, said with the STAR funding now all allocated, the project had sent in its final report to TEC. “We were very happy with the outcomes and very impressed by the number and breadth of research we were able to fund.”

The STAR fund was used to fund 16 research projects in 2008/2009 and a number of PhD scholarships and post-doctoral fellowships with the last two fellowships just granted this year.

Nursing scholars on average scored 3.34 compared to the average for all 42 subjects of 4.66.

Allied health (grouped together under ‘other health’) had a score of 3.98 and ranked 40th.

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For the record Bibliography celebrates Cultural safety

‘coming of age’

A bibliography tracing cultural safety from the late 1980s to today has been released by the Nursing Council to celebrate a major milestone for cultural safety.

Carolyn Reed, Nursing Council chief executive, said 2012 marked 21 years since the Council resolved that cultural safety would become part of the New Zealand nursing education curriculum.

“After considering several pathways to mark this significant milestone, the Council decided that gifting back to nurses a bibliographic resource was the most appropriate,” said Reed in her foreword to the recently released 46-page bibliography.

Dr Elaine Papps, chair of the Council at the time, in her more extensive foreword says the decision to present the bibliography as a timeline provided a “unique overview of cultural safety”.

The first entry is in 1989 with an article by the late Dr Irihapeti Ramsden, the nurse and nurse educator who introduced the concept of cultural safety and who in 1990 published Kawa whakaruruhau: Cultural safety in nursing education in Aotearoa.

In 1992 the Council released its guidelines for cultural safety in nursing and midwifery education and practice. Media attention followed soon after gathering steam in 1993 with the story of Christchurch nursing student Anna Penn garnering cultural safety a lot of negative press and airwave time, and then again in 1995, leading to the Education and Science select committee starting its own inquiry (later suspended).

“Throughout this turbulent time the Nursing Council did not resile from its commitment to cultural safety,” said Papps in her foreword. The initial guidelines have been revised and the definition refined over time “but remains true to its original intent”. Cultural safety has been taken up by other health disciplines and researchers in other nations – particularly Canada and Australia. She noted that Canadian researchers in 2009 said that cultural safety would continue to hold value for nursing practice, research, and education when used to emphasise critical self-reflection, critique of structures, discourses, power relations and assumptions, and because of its attachment to a social justice agenda.

The bibliography can be downloaded at the publications page of the Nursing Council website: www.nursingcouncil.org.nz

Mixed response to UK call for student nurses to first work as HCAs A pilot of student nurses working first as health care assistants could be underway in the United Kingdom before the end of year despite major reservations from nursing leaders.

The policy initiative was announced in late March by the British government as one of its responses to the long awaited Francis Report into a National Health Service (NHS) trust.

The Francis Report was the culmination of a two year inquiry into lessons to be learned for patient care from the failings of the Mid Staffordshire NHS Trust late last decade.* The report recommended that student nurses spend at least three months working on direct patient care under nurse supervision as a pre-entry requirement to nursing school but the government stepped this up to students being required to spend up to a year working as health care assistants (HCAs) as a prerequisite for getting NHS funding for their degrees. “This will ensure the people who become nurses have the right values and understand their role,” said Health Secretary Jeremy Hunt.

The Royal College of Nursing said it had “urgent questions” about the proposal for student nurses to first spend a year working as an HCA with the UK having about 18,000 nursing students start training each year.

“Who will train, employ and monitor tens of thousands of these support workers? How can the Government deliver this radical change to nurse training on a cost-neutral basis? And how will we ensure that the supply of nurses does not become restricted?” said the College’s chief executive Peter Carter.

The Council of Deans of Health, representing British nursing schools, also expressed concern with chair Ieuan Ellis saying an influx of trainees could add more pressure onto existing staff.

“Prospective students spending up to a year working as a healthcare assistant will place an over-stretched health service and its staff under even greater pressure, putting more unqualified people on the wards.”

“If this is piloted and evaluated then we will engage with it, but we are clear that if this becomes a blanket provision it will risk patient safety rather than protect it.

This is the wrong answer to the wrong question.”

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HCA regulation Meanwhile a Francis Report recommendation that HCAs should be regulated by the Nursing and Midwifery Council was not taken up by the Government.

Instead it issued a code of conduct and minimum training standards for the unregulated workforce.

Royal College of Nursing CEO Peter Carter said compulsory registration was a “crucial” Francis report recommendation and was deeply concerned registration had been dismissed by the government.

He pointed to a survey recently carried out by the British Journal of Healthcare Assistants which found the vast majority of HCAs supported compulsory registration and said it was clear HCAs took delivering safe patient care “very seriously’. *Mid Staffordshire NHS Foundation Trust Public Inquiry chair Robert Francis said the trust’s ignoring of warning signs and putting “corporate self interest and cost control ahead of patients and their safety” lead to “appalling and unnecessary suffering of hundreds of people” including elderly and vulnerable patients left “unwashed, unfed and without fluids”. In his report, released in February, he said there had been a “lack of care, compassion, humanity and leadership” and made 290 recommendations designed to change the culture and ensure patients came first. The full report can be read at: www.midstaffspublicinquiry.com An analysis of the Francis report by NZNO and its implications for nursing in New Zealand can be read at: bit.ly/14u31gW

Nursing Review series International Nurses Day 2013

New leadership structure criticised and defended

by FIONA CASSIE The country’s once Magnet health service – Hutt Valley District Health Board – is being criticised for ‘eroding’ nursing power under its new merged leadership structure with neighbouring Wairarapa DHB. Former Wairarapa nurse leader Helen Pocknall has been appointed the new executive director of nursing and midwifery (EDONM) position in a professional oversight and advisory role­that is part of the new single executive team covering both DHBs. Only nurse educators will directly report to the new leadership post, with other nursing leadership roles reporting to their hospital manager in a move strongly opposed by New Zealand Nursing Organisation members at Hutt.

NZNO organiser Jo Coffey said it was “unacceptable to downgrade” the voice of the largest workforce and ignoring nursing submissions had left nurses and midwives “out in the cold”. She said being unable to report directly to the nurse leader sitting at the executive table “diminished” nurses’ power and ability to influence the delivery of quality healthcare.

Pocknall said she understood the disappointment the Hutt nurses were feeling over the new reporting structures and part of her new role was “ensuring the voice of nursing remains prominent”.

She said she saw her role initially as ensuring that the “significant achievements and gains” made over the last 12–18 months, by nurses working in partnership with other clinical and management colleagues, were not lost. As well as ensuring the nursing voice was prominent and “the importance of the nursing workforce to the delivery of health services” was not diminished in any way.

Graham Dyer, joint chief executive of the two boards, has acknowledged the concerns and said the new reporting lines were not to be seen as a “demotion” or indicating a “lack of value” for nursing’s contribution.

He said he wanted to ensure that the executive director could focus on the professional and strategic aspects of the role and the risk with an operational and professional EDONM position was that professional and strategic issues were “crowded out” by operational issues.

Coffey believed that the “eroding” of the nurse leadership structure “was only the start” of cost-saving measures as the DHB grappled with government demands to reduce the two DHBs deficit by $5.3M. Hutt Valley in 2007 became only the second hospital outside the United States to gain the “gold standard” nursing accreditation as a Magnet health service. The decision was made in 2010 to let the expensive accreditation drop but to continue to live up to the Magnet principles.

Hutt and Wairarapa DoNs ‘swap’ roles Michele Halford, the executive director of nursing at Hutt Valley DHB since late 2011, has been appointed to the new nursing director role in the Wairarapa.

Pocknall is chair of the DHB directors of nursing group, is a member of the Health Workforce New Zealand board and a member of the Ngā Manukura o Apopo steering group.

Two other nursing leadership positions – Wairarapa’s associate director of nursing and Hutt’s perioperative nurse manager role – have been disestablished.

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Demelza has two hospices, one in Sittingbourne, Kent, one in Eltham, South East London as well as a community nursing team based in East Sussex.

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Children’s Palliative Care Nurses (Kent) Band 6 £23,914 - £32,530 ($43,087 - $58,611) + Enhancements We are seeking motivated children’s nurses to provide quality care whilst enhancing their clinical and bereavement support skills. You will be able to access extensive CPD through our dedicated education department. Utilising your core observation and nursing skills, you will adjust care and medication regimes for ultimate symptom control. You will be able to hone mentoring and tutoring skills alongside nursing students and care assistants.

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www.facebook.com /demelzahospice

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Enhanced Disclosure checks by the DBS will be undertaken for successful applicants.

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Bring your wound care patients out of hiding

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