FOCUS: International Nurses Day
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A DAY IN THE LIFE OF
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Practice, people & policy
Clowning on the ward Measuring mental health success Difficult conversations
Right nurse, right time, right place? Is CCDM getting it right yet?
Q&A
Robyn Hewlett
International Nurses Day Tales of nursing heroes Models of care: are you a team player? Beginners guide to HCAs
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Letter from the Editor Are nurses ready to farewell basic care tasks? It is essential that nurses and world leaders focus on the global nursing workforce as a key priority for achieving better health for all. So states the International Council of Nurses (ICN) in its latest manifesto for International Nurses Day, which this year focuses on nurses being both a “force for change” and a “vital resource” for health care. It is a wide-ranging document looking at projected nursing shortages, migration and the downstream effect of the global financial crisis leading to governments and employers squeezing savings out of the workforce that make up the bulk of their health wages bill – i.e. nursing. Nursing Review this edition looks at one other issue raised by ICN – that of role substitution or task shifting to make vital health professional resources stretch further. In New Zealand, there have been some lively debates – sometimes a tug-of-war – between the medical and nursing professions about nurses wanting to work at the top of their scope and the resistance of some doctors at nursing moving “into their patch”. But there has been less debate about the other end of the nursing scope and the resistance of some in the nursing profession to give up basic care tasks to health care assistants (HCAs). One nurse I spoke to recently pointed out the irony of nurses protesting at doctors’ reticence at letting go of roles traditionally done by doctors but at the same time “kicking and screaming” if health care assistants start taking over some of the traditional care tasks of nursing. That reluctance is, of course, not helped by the United Kingdom’s Mid Staffordshire Inquiry showing the tragic consequences for patient safety, and dignity, if you go too far down the HCA path unheeded. So maybe it is time for New Zealand to have that debate? And to look at setting national parameters for the training, qualifications and accountability of HCAs and their delegating registered nurses, now so we can make the most of a limited and vital nursing resource; and ensure patient safety is foremost in our minds rather than balancing the books. Fiona Cassie editor@nursingreview.co.nz
Inside: Focus: International Nurses Day 4
Models of Care: Are you a team player?
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HCAs: unregulated dogsbodies or essential team members?
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A beginner’s guide to health care assistants
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Right nurse, right place, right time… a CCDM update
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Tales of 11 nursing heroes from a DHB near you
RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe
Practice, People & Policy 21
CAMERON TAYLOR on clowning around on the ward
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MARK SMITH on ‘judging’ mental health nursing outcomes
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Initiating end-of-life care conversations
Regulars 2
Q & A Profile: ROBYN HEWLETT, chair of the NZNO Enrolled Nurse Section
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A day in the life of… mental health-credentialed primary health nurse ROBYNANN DYSON
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College of Nurses column: JENNY CARRYER on new barrier for NPs?
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Webscope: KATHY HOLLOWAY on the Web’s 25th anniversary
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For the record: News round-up
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Exclusive online content Nursing Review is a genuine multimedia publication. Our recently revamped website has content not found in the print edition, including exclusive online articles, live Twitter updates, social sharing, and the downloadable RRR professional development archive. Visit: www.nursingreview.co.nz COVER PIC: One of our nursing heroes, Dr Alison Pirret, nurse practitioner (adult intensive and high dependency care) at Middlemore Hospital (Counties Manuka DHB). PHOTO CREDIT: Counties Manukau DHB
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Nursing Review
Vol 14 Issue 2 2014
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 © 2014. 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 2014
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Q&A
Robyn Hewlett
JOB TITLE | Chairperson Enrolled Nurse Section NZNO
Q A Q A
Q
Where and when did you train? I trained at Dunedin Hospital School of Nursing 1991–1992.
If there was a fairy godmother of nursing what three wishes would you ask to be granted for the New Zealand nursing workforce? 1) A workforce plan for the New Zealand nursing work force. 2) A fully funded, 6 month, new graduate enrolled nurse programme in the District Health Boards. 3) Safe, regulated nursing staff levels in all health care facilities in New Zealand.
A
Other qualifications/professional roles? Chairperson of the Enrolled Nurse Section NZNO; member of working group SDHB orientation programme for enrolled nurses; previous NZNO Board of Directors member; member of Ministry of Health Chief Nurse’s advisory group on an enrolled nurse fact sheet “Enrolled Nurses: Have you thought of employing an enrolled nurse” April 2013; DHB & NZNO National Delegates Committee since 2012; member of Ministry of Health Enrolled Nurse Stakeholder Group 2002; member of the Ministry of Health group developing competencies for the second level nurse 2000.
Q A
When and/or why did you decide to become a nurse? I came to nursing later in life as I was made redundant from Telecom, as a supervisor, in the 1980s. I applied for a psychiatric assistant position at Cherry Farm hospital. While I was working at Cherry Farm Hospital, the Otago Hospital Board at the time advertised for applicants for the hospital-based enrolled nurse training programme. I applied and was very fortunate to be accepted. On finishing, there were no positions at Dunedin or Wakari Hospitals, so I returned to Cherry Farm Hospital, working as a casual enrolled nurse and was offered a temporary sixmonth position at Wakari Hospital within the intellectually disabled service. This eventually became a permanent position.
Q A
What was your nursing career up to your current job? I worked at Cherry Farm Hospital in 1992 post graduation as a casual enrolled nurse until they commenced transferring clients to Wakari Hospital due to Cherry Farm closing. Then I worked on a six-month contract initially at Wakari and eventually gained a permanent position in Intellectual Disability Services for three years. Then I worked in Assessment, Treatment & Rehabilitation of the Elderly from 1995–2005 until restructuring in 2004. I transferred 2005 to the Dunedin Hospital Nursing Resource Unit, where I currently work (as well as on a surgical ward).
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Q
What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt? Being organised and committed to the role is very essential, as are communication skills and have a good knowledge of the enrolled nurse role and legislation relating to all aspects of nursing and health care.
A
Q A
So what is your current job all about? I work as an enrolled nurse on the Nursing Resource Unit, doing rostered duties where we cover sickness at Dunedin Hospital. I also work in a busy surgical ward. Enrolled nurses at Dunedin Hospital work under the direction and delegation of registered nurses.
Q A
What do you love most about your current nursing leadership role? During my time as chairperson of the enrolled nurse section, five years, second time round, I am really proud that the lobbying and perseverance over the years by the enrolled nurse section, enrolled nurses, and NZNO has ensured that the enrolled nurse title, role, and scope of practice has not only been retained, but broadened for the current enrolled nurse workforce to bring it in line with the 18-month Level 5 enrolled nurse diploma. For the current enrolled nurse workforce, they have re-gained what they lost in their scope of practice years ago, but in some workplaces, they are still not able to work to the top of their scope.
Q A
What do you love least? That a lot of our new graduate registered and enrolled nurses have no positions once they graduate.
Q A
What do you do to try and keep fit, healthy, happy and balanced? At the moment, I would like to be lying on a beach, doing nothing but soaking up the sun. I always have good intentions to keep fit and do walking, or aqua jogging, but … I enjoy movies, live theatre, shows, and concerts. Best live show: The Lion King.
Q
Which book is gathering dust on your bedside table waiting for you to get round to reading it? The Luminaries
A Q A
What have you been reading instead? The One Plus One by Jo Jo Moyes. I really enjoyed two of her previous books, Me Before You and The Girl You Left Behind.
Q A
What is number one on your ‘bucket list’ of things to do? To do my OE to Europe and UK at some stage, as I never went when I was younger.
Q A Q A
If I wasn’t a nurse I’d be... rich and retired!!!
What is your favourite meal? Buying fresh vegetables and fish at the Otago Farmers Market and any meal that someone else has cooked. I’m not fussy.
A day in the life of a ... mental health-credentialed primary health care nurse
NAME | Robynann Dyson JOB TITLE | Primary Health Care Nurse (MH credentialed*, PG Cert). LOCATION | Bush Road Medical Centre, Whangarei.
6:15
AM The alarm sounds. I leap out of bed and go for a walk … NOT! Reality is that I snooze for another 15 minutes then drag myself from my happy place to make a cuppa. I knock on teenage daughter Bridget’s door to wake her and then life is all go …
8:00
AM SCHOOL DROP OFF I drop Bridget to school on the way to work, and try and engage in a positive conversation … but she is a teen and not a morning person. She says she loves me as I drop her off and I then start praying I’ll get to work on time – an annual goal of mine, but it’s actually working this year maybe due to the recent mental health training* which has helped me live more in the present.
8:27
AM ARRIVE AT WORK Arrive at work with three minutes to spare, a miracle. Oldest daughter Anna (a farmer) has texted to say have a nice day, and hubby Ted has rung to say he will make dinner tonight. On arrival, the clinical nurse manager asks me to have the 2nd year nursing student work with me. The student and I sit down to discuss and plan how to meet her goals for the week. I am booked to see patients for 20-minute appointments throughout the day with a two-hour gap to cover lunch breaks. My first patient is a no-show, so tell the student my career started with enrolled nurse training at age 18 followed by my RN training three years later. I initially worked in hospital surgical and medical nursing, then eight years as a family planning nurse and for the last 10 years I’ve worked as a primary health nurse with my current general practice. I told her working as a practice nurse – with a special interest in women’s health and mental health – were the last areas I wanted to work in as a young nurse. Yet now I have an absolute passion for all these areas and firmly believe that this is where I am meant to be.
9:00
AM FIRST PATIENT I see my first patient for the day. It is a young girl referred by one of the GPs for support with her self-esteem issues. I introduce myself and ask permission for the student to be present. I use open questions to ascertain what is concerning her. I listen to her concerns and together we come up with a plan to help her cope with her feelings of insecurity with her peers over the next two weeks. When she leaves, she is smiling and says she feels stronger, which makes me again realise why I love this job. I then see a toddler for immunisations, followed by a man for a punch biopsy.
10:15
AM QUICK COFFEE BREAK
10:30
AM ANXIOUS PATIENT I see another lady, referred to me three months ago because of her long history of anxiety and depression. Initially, her assessment results for anxiety and depression were high but, after walking alongside her in her journey and meeting regularly, her score today is within the low range. This lady is an inspiration to me as she was the first person I began seeing for mental health issues after I became MH credentialed. The MH training has meant I’ve been able to effectively assist her in her journey, which is great. Initially, we needed to meet weekly for 40 minutes and now it is 20 minutes every two-to-three weeks. My next patient is a young man needing wound management, and during screening I find he’s a smoker who’d like help to stop. I give him some information and will talk again at his follow-up appointment. I see another man for his quarterly 40-minute Care Plus appointment to manage his chronic disease, which takes me to midday.
NOON
PHONE CALL TIME I am at last able to clear my messages and return the seven calls to people wanting test results and advice about a sick child. I also ring the lady who missed this morning’s appointment. She’s been having some family difficulties and is grateful I’ve rung. I support her over the phone and we arrange to meet on Friday.
1:30 2:00
PM LUNCH
PM BACK TO WORK My last three patients of the day are a lady for an IV infusion, which takes
30 minutes, a little girl for immunisations and another man for his IV infusion. I check my taskmaster and inbox for things I need to follow up on, I manage to clear three tasks and check that there is nothing else urgent. The student and I go over the day and discuss tomorrow. She says that she’s enjoyed her day and feels she’s seen a different side to practice nursing that she likes. I clear my phone messages once again and return calls to patients. It sounds like the afternoon is not as busy … but time just goes and before I know it is 5:30 and time to leave.
6:15
PM HOME – TEA WAITING I get home and Ted has made yummy bolognaise for tea. Bridget is doing homework (Facebook) and Anna is home for tea. Ted and I go and feed the ducks and chickens and have a catch up on our day. I am thankful for my little piece of paradise that I live in and am grateful for the job I am able to do as a nurse. I play a couple of games on the computer and watch some mindless programme on TV. I find I need to do this to unwind, as I feel mentally drained when I get home; and it is nice not having to think for a little while.
10:30
PM BED I read a bit then drift off …
*Robynann Dyson is one of eight nurses working in Manaia PHO general practices to recently complete a mental health credentialing programme run by the College of Mental Health Nurses.
Nursing Review series 2014
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FOCUS n International Nurses Day
International Nurses Day This year’s International Nurses Day theme is Nurses: A force for change – A vital resource for health To mark this theme, we look at what impact models of care in hospital wards, the unregulated workforce, and safe staffing initiatives may make on making the most of New Zealand’s nursing resources. We also celebrate some of our nursing heroes …
Caring about or caring for patients? Is a nurse showering a patient or brushing their hair an indulgence we can longer expect in today’s hectic wards? Is team nursing and delegation of more and more personal care to health care assistants the logical and inevitable next step? FIONA CASSIE finds out more about models of care in today’s acute hospitals.
O
nce upon a time, ‘Sister’ ruled the ward. It was a strict hierarchy from senior staff nurse down to nervous first-year student
nurse. Everybody knew their place, everybody knew their tasks, and patients knew the ward routines very well by the time they were discharged a leisurely fortnight later. Roll on a few decades and task-based nursing is replaced by the philosophically-driven primary nursing model of care. The aim is to develop a therapeutic relationship, by having the same nurse assessing, planning, and carrying out a patient’s personal and clinical cares from admission to discharge. For many, it remains the ideal. For others, primary nursing is an anachronism from some
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idyllic but short-lived time of fully registered nurse-staffed wards. Emerging alongside and gathering pace has been the more pragmatic team nursing model. Rather than a patient having a single nurse responsible for all care, their nurse is part of a nursing team and patient cares can be delegated to other team members, including health care assistants (HCAs). Detractors of this skill mix model point to the UK’s National Health Service, whose longstanding use of HCAs for many tasks is associated with the negligent care and lack of accountability that led to the Mid-Staffordshire Inquiry and Francis Report. At present, there is no one nursing model to ‘rule them all’ holding sway over New Zealand public hospitals. Models of care not only vary from
hospital to hospital, but ward to ward, and are often a hybrid mix with the words collaborative, partnership, and patient-centred also widely used. Amongst it all, nurses still strive for a therapeutic relationship with their patient. But headlines from up and down the country in recent times about care rationing, understaffing, and stressed-out nurses shows that the ideal of nurses having time to shower all their patients or brush their hair is definitely under threat at best, or at worst, lost long ago. With patients sicker, ward beds rarely empty, and constant patient churn, Dr Jill Clendon believes that trying to deliver a primary nursing model is “probably wishful thinking”. Clendon, a New Zealand Nurses Organisation researcher, has been working on a major research
FOCUS n International Nurses Day
project looking at the big picture future of nursing models of care. “In a rapidly evolving health environment facing significant challenges associated with an ageing population, ageing health workforce, and increasing patient acuity, there is widespread agreement that current models of health care provision will struggle to meet future health needs,” is how she opens her research report. Currently, she has a draft policy framework out for stakeholder consultation that looks at the fundamental principles she believes any nursing model of care should be measured against, whether it be district nursing or a paediatric ward (see panel below). But pragmatism also has to play its part in today’s resource-stretched public hospitals. Clendon believes the primary nursing model, still beloved and practised by many as best as they can, is “realistically no longer such a viable option”. Professor Jenny Carryer agrees. “We’re still maintaining an illusion that it’s possible with the short length of stay and the bed churn and the staffing levels for RNs to be all things to all people,” says Carryer, the executive director of the College of Nurses Aotearoa. She says the ideal of nursing doing all cares was possible back in the days of an average patient stay of a fortnight. People also forget that when primary nursing first came into vogue, wards were still heavily populated with student nurses, who filled many of the roles of today’s HCAs. By the time the 70s rolled into the 80s, wards were Intro ??????? no longer awash with student nurses as hospitalbased training schools closed their doors, and says Carryer, for a comparatively short time in the 80s, wards were solely staffed by registered nurses and enrolled nurses. “Then we hit the 90s, where there was this huge drive towards so-called economic reform, although I would never grace it with that word,” recalls Carryer. “My own research has shown that the level of RN staffing began dropping in 1989 and reached its lowest point in 2000.” As the nursing numbers dropped during the 1990s, the move to substitution with the precursors
of HCAs began and the concept of ‘skill mix’ introduced. Her research showed that during the same time scale, of 1989 to 2000, the average patient stay dropped from 14 days to 4.5 days and nurse sensitive patient outcomes, like infections and pneumonia, escalated. Nursing hours per patient days did not return to 1989 levels until 2006–2007, but patient stays haven’t got any longer or patient acuity any less. So has primary care nursing had its day? “It was a brilliant concept. Most nurses would love to give 100 per cent care to a reasonable amount of patients,” says Carryer. “But nurses’ current level of expressed distress, the level of nurse sensitive negative outcomes – which my research picked up – would tell us that that model is not successful.”
What’s happening on today’s ward floor? Heather Gray, director of nursing for Christchurch Hospital, says it is probably the nurses of her generation, working in and around hospitals for 30 years or so, who remember with most fondness primary nursing’s heyday. “But we also need to live in today and keep moving forward.” Christchurch currently has a high registered nurse workforce, with RNs doing most of the care with some assistance from hospital aides. Gray says while she tends to think as a primary nurse, she also thinks as a leader and personally believes Continued on page 6 >>
Definition/background What exactly is a nursing model of care again? There appears to be no easy answer to that question. On the big picture level, models of care are a philosophical and theoretical approach to delivering nursing care that is effective and appropriate for people’s needs. With nursing care delivered from remote rural communities to big city hospitals and everywhere in between there is no one, simple, single model to cover all people’s needs. Examples of models of care in nursing include nurse-led clinics, case management, whānau ora, the ‘recovery model’ in mental health, and ‘person-centred care’ in dementia facilities.
Primary nursing Comprehensive, individualised care provided by the same nurse throughout the period of patient care. Team nursing A team leader and team members providing various aspects of nursing care to a group of patients. Along with registered nurses the team’s skill mix can include enrolled nurses and health care assistants (HCAs).
Research seeking an answer for New Zealand
There can and should be some common underpinning principles to all nursing models of care, believes NZNO researcher Jill Clendon. She has just completed a major research project for Primary nursing vs team nursing the New Zealand Nurses Organisation looking There are also models of care in the narrower at Kiwi nurses’ perceptions of models of care. sense that this article is concentrating on, that This has led on to a draft policy framework for is how nurses deliver care at the ward level in our hospitals, which are largely variations on two models of care currently out for consultation with stakeholders that proposes a set of core principles broad themes:
for models drawn from both Clendon’s literature review and qualitative research with Kiwi nurses.
NZNO says models of care principles should include:
»» »» »» »» »» »»
person-centred culturally safe enable Māori-centred approaches ensure accessible, quality, evidence-based health care enable interdisciplinary practice make clear health professionals’ roles and responsibilities »» facilitate nurse leadership »» ensure staff have appropriate training and skills »» develop effective communication strategies »» focus on primary health care (in broadest sense of general health and wellbeing) »» maintain ‘healthy awareness’ of risks associated with business models. For more information on the research underpinning the draft policy go to www.nzno.org.nz/resources/nzno_publications Nursing Review series 2014
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»» Ward 16 is a 16-bed general surgical ward focused on upper gastrointestinal and hepatobiliary (liver/pancreas, etc) surgery. »» SARA (surgical assessment and review area) is a 12-bed unit at front of ward to assess acute patients. »» Charge nurse manager (CNM): Diane Haugh (Brown) plus RN co-coordinator without patient load in SARA to manage patient flow. »» Eight RNs per morning and afternoon shift plus two hospital aides (one in Ward 16 and one in SARA). »» Average ratio of one RN per four patients depending on acuity (each RN has a ‘buddy’ on a shift). »» Ward 16 has two six-bed rooms and four single side rooms. »» Team handover in separate room each shift followed by allocation of patients and one-on-one handover of patients by their Intro ??????? primary RN. »» CNM each morning leads 15-minute board round with allied health – social worker, physiotherapist, occupational therapist, dietitian, and sometimes a geriatrician – to discuss patient progress and discharge plans. »» Plus similar support by CNS, nurse educators and other nursing services similar to those available to Ward 27 (see page 7). << Continued from page 5 Canterbury District Health Board will have an HCA workforce in the future and is likely to increasingly move to a more ‘skill mix, team nursing’ mode. It is already underway in some wards (see case study sidebars) and student nurses are increasingly being exposed to collaborative, teambased styles of working through dedicated education units. “The tribe raises the new nurse … it’s been a huge plus for us.” She says the challenge for nursing directors like herself is not to take a “one size fits all” approach when it comes to models of care. In today’s culture of aiming for continual improvement of the patient journey, she believes any model of care shouldn’t stand still. “You may have a minute in time when you say ‘that is a model of care’, then there is another change.” Rather than interceding and imposing a model from the top, she believes the most important is setting the underlying principles – and that any model should include being patient-centred and offering efficient, effective pathways of care that matter for the patient. “Also partnership – nursing is a partnership with a patient, so if you are a ward nurse that hasn’t seen a patient for some time, you are not really nursing.” Post-quakes, the hospital has fast-tracked integrated models of care, like CREST and Acute 6
Nursing Review series 2014
Nurses want to shower their patient Asking a hospital aide to shower a surgical patient with wound dressings, drains, drips and feeding tubes is no easy step for nurse or aide. Which is one reason charge nurse manager Diane Haugh says the primary nursing model is still favoured in Ward 16 that cares for some very high acuity patients. “I guess for the surgical nurse there’s a lot of tasks – drains, drips, wounds and nutrition sometimes going in peripherally and sometimes through Peg tube,” says Haugh. “So to say to a HCA ‘please can you shower that patient’ … their likely response is like ‘oooh … where do I start’,” says Haugh. “If you got somebody up and they stood on the drain, it’s actually very detrimental to that patient. So in a surgical setting, I think it’s probably more difficult than in the medical.” Apart from the technical challenges of showering a surgical patient, Haugh’s nurses tell her they still prefer to shower their own patients so they can do a skin and functional assessment. “It’s a time to chat with the patient and talk about all those things that are so important, like what’s your home situation and do you have support.” Haugh hasn’t known anything else than the primary model apart from two years in the United Kingdom where the model was “very much” that the HCA did care tasks for you to the
Diane Haugh
Christchurch Hospital Ward 16 (+ SARA unit): Primary nursing model of care
Demand, which sees more of the city’s “less sick” patients being treated in the community or discharged early, leading to a concentration of more of the – very sick – in its hospital wards. This has seen models of care evolve in response to the new environment of short stay and patient churn requiring a high RN workforce to assess and plan early discharges. Currently, Canterbury hospital aides are not required to have any set qualification, and it is only just piloting a Level Three Careerforce-based national certificate to some of its aides in Burwood Hospital. With one of the country’s biggest ever public hospital works projects underway in Christchurch – a $650 million project for new hospital wings at Burwood and Christchurch campuses, along with post-quake redevelopments – new models of care are under development for the new look hospitals with Gray personally keen for these to be principlesbased.
New hospital, new model
New hospitals are often a wellspring for new models of care – as the physical restrictions of ward layouts, room configurations, and shortages of staff space can often restrict or stymie change in ageing hospital buildings. When staff moved into Auckland City Hospital back in 2003, the Auckland DHB took the opportunity to introduce a team model of care and put its hospital aides through an NZQA level four
point of sometimes doing vital signs and blood pressure. “I found it quite scary, but I wasn’t brought up that way,” recalls Haugh. “I just found it very hard to rely on an HCA who doesn’t necessarily have the training. I just had to continually chase the carer to give me that information and they weren’t that forthcoming.” She agrees the crux of moving to a skill mix, team nursing model is having the right education and the right support. Nicky Graham, surgical nursing director, says it has adopted team nursing in some areas in surgical and is likely to look to it more in the future. “I think the challenge, is as we are moving more and more patients into community sooner and sooner, the complexity of patients we have here is quite high … even something that seems relatively simple like a shower does actually become quite a complex task.”
certificate programme to create a new health care assistant role. Jane Lees, until recently the acting director of adult health, cardiac, and cancer care, says it is fair to say that its unregulated workforce went from being supplementary to nurses on the ward to a complementary part of the new team nursing model. She says arriving at the then-Auckland Hospital 18 years ago, the nursing model she first encountered could be better described as room-based nursing rather than primary nursing, as a nurse could be allocated a different six-bedded room day-by-day. Now a typical 24-bed ward has two teams – with usually three RNs and an HCA per team, but depending on the nursing skill mix, a team could also be two RNs, an EN, and HCA, or three RNs and an EN. Each team has an RN leader and each nurse is usually allocated the care of four patients in a four-bedded room, but there is a team bedside handover and the team supports each other and the team’s patients. “That is the fundamental difference; it is a collaborative, integrated model,” says Lees, “whereas before there was just you in a six-bedded room, and if you were drowning, who would know?” Like Auckland before them, Capital and Coast, under former director of nursing Cheyne Chalmers, introduced a team nursing model when it moved into the new Wellington Hospital in 2009 and also looked at its regulated to unregulated skill mix. Current director of nursing and midwifery Andrea McCance, working in Melbourne at the time,
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Christchurch Team model shaken, showered, shifted & survived There are probably fewer shift its mode of working to include taking GP admissions Hospital Ward 27: »» General medical ward. »» Charge nurse manager Donna Galloway. »» 30-bed ward with five beds to a room and some single side rooms. »» Two teams (‘wine’ and ‘cheese’). »» Each team = 3 nurses and 1 hospital aide (one RN is designated team leader). »» Plus senior RN co-coordinator working across the ward floor. »» Ward chose approximate patient load of five patients per RN (i.e. one nurse to a room) rather than four patients so it could have RN coordinator. »» Bedside handover between morning and afternoon shift with all team (including HCA) present. »» Other nursing support includes CNS and nurse educator working across medical wards plus across hospital specialist nursing services and other services including ‘transfer of care’ nurse and resource nurse and services bridging the gap between hospital, community, and Intro ??????? home-based care like Acute Demand and Crest.
can recall people looking back across the Tasman and asking “what’s going on across the ditch, the Kiwis appear to be ahead of the game”. Like Auckland, Capital and Coast had a big push to upskill and train an HCA workforce to work under the new model but opted for a Level Three National Certificate in Community Support Services as its benchmark training level. “So here we are five or six years later and the model of care has evolved into a more hybrid model,” says McCance. “It is no longer a purist model, with a dilution of the HCA workforce due to a more acute and complex patient population, which has required an increase in the registered nurse workforce.” “But having said that, we never stay
more challenging tests of teamwork than a 6.3 magnitude earthquake turning your ward into an indoor waterfall, followed by having to evacuate patients on mattresses down a sodden stairwell in ongoing aftershocks. Donna Galloway took up the post of charge nurse manager of the then-Ward 30 in the fourth floor of Christchurch Hospital’s Riverside building in 2010. The team model – initially called the practice partnership model – was introduced across the medical cluster of wards soon after and was just bedding in prior to Feb 22 turning the ward literally into a disaster zone. For Galloway, it was not so much the initial post-quake days that was a test of her nurses and the new model, but the years to follow. “I think people forget what some of these nurses have been through.” The ward staff were initially dispersed for three months across the hospital before setting up a new temporary, medical ward across town in Princess Margaret Hospital in mid-2011, and then finally returning to their old building Riverside – third floor this time – in September last year. It was the shift to Princess Margaret where the new team model with its enhanced communication – both verbal and visual – truly came into its own, says Galloway. “It was a saviour.” Along with the physical shift the ward staff had to
Donna Galloway
Team nursing model of care
straight from the community. “So the fact that we had good communication skills and good team work set us up in good stead for that, I believe,” says Galloway. The model also drew on releasing time to care initiatives like the patient status white board and wearing medication jackets during drug rounds to stop nurses being interrupted by doctors or others while holding a kidney dish of morphine. It also has meant a structured role for hospital aides in the team who – though not at present expected to have any set qualifications – can be allocated to tasks like showering patients at the discretion of the team leader. Galloway is aware that some nurses are reluctant and concerned about giving up showering to unregulated staff, fearing that HCAs or aides might not pick up skin or other issues. “That’s funny because I find hospital aides pick up more things than some of the nurses sometimes,” says Galloway. “Because the nurses are so busy that if a hospital aide is taking a patient to the shower, or washing them, they report directly back to the RN. And they say ‘I washed Mr So-and-So and his sacrum is very red’. They are very, very good at reporting things – trust me – they certainly don’t let things slip by. “The hospital aides really like it (team nursing) as they are part of a team, they are communicated with, they feel supported … and as long as everybody is communicating, everybody seems to be happy.”
still or static, so we are reviewing our models now, particularly as we – along with our DHB partners – consider integration of clinical services across our health care system,” adds Vicky Noble, the DHB’s primary health care director of nursing.
Debate needed about the future
Clendon believes it is now time for nursing to do some serious thinking and start a debate about what is the optimal model for making the most of nurses’ knowledge and skills. “What is going to be the best in terms of patient outcomes given our limited resourcing and our increasing patient acuity? What is the best way to use the education, knowledge and skills of RNs in the workplace?” Continued on page 8 >>
Vicky Noble (left) and Andrea McCance (right)
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FOCUS n International Nurses Day << Continued from page 7 “Is it to do showers and feed patients?” Clendon says yes, in some circumstances, but with DHBs expecting wards to tighten their belts, something has “got to give” and maybe registered nurses letting go of more tasks at the bottom of their scope is the right way to go. “Nurses are still slow to give up the things that they traditionally hold precious,” says Clendon. Even though it may free up more time for nurses to just sit down and listen and reassure a patient, which, Clendon says, can be the essence of nursing. Likewise, Carryer says some nurses might argue they need to shower patients to assess their skin but “trust me – they are not achieving that now, anyway”. If an HCA is delegated to check a patient’s skin integrity during showering they are “not stupid” and will report back if somebody has a red patch or skin break. “And hopefully because the RN isn’t flat out trying to shower three other people in the next room she might actually come and look at the pressure sore and instigate the right treatment for it,” says Carryer. Intro ??????? Fears that having HCAs and ENs doing more traditional RN tasks will fragment care and put patient safety at risk are also not shared by Lees following a decade of the team model in place in Auckland. “Having HCAs and ENs on the ward is about better care, and the skill mix contributes and complement each other,” says Lees. “Probably the most important skill the RN needs to have is delegation – and understanding who to delegate
what to. For example, knowing why an EN or HCA can’t provide feedback on somebody’s skin condition.” While Clendon believes primary nursing is no longer a viable option she is also not totally convinced that team nursing is the inevitable model of care for acute hospital wards. She also calls for caution before New Zealand goes too far down the route of building up its unregulated HCA workforce – with UK’s Mid Staffordshire NHS Trust being a cautionary tale of how bad things can go – and particularly when New Zealand is investing in a new generation of enrolled nurses, which are an accountable and regulated nursing workforce with known education levels. (See article on HCA training, page 10.) Carryer acknowledges that delegating cares to a regulated EN is more straightforward than to an HCA but believes nationally standardised training and employment practices for HCAs is also an answer. With research consistently showing that RNs on the ward on both sides of the Tasman are spending about three hours of an eight-hour shift at the patient bedside, she also believes something has “got to give”. “Are we foolish to believe RNs can continue to ‘care for’ patients in that space of time?” Instead she advocates nurses should move from ‘caring for’ to ‘caring about’ their patients including using a “very rigorous assessment, delegation and supervision model” to ensure they follow-up and check the outcomes of delegated tasks. “If you use a ‘caring about’ model than you are saying that the RN still has the absolute accountability of the experience and safety of that patient.” Gray considers Carryer’s proposal
an interesting one. “It’s about being the leader of clinical care rather than providing it. Or maybe mixing the two because I think both are important as caring ‘about’ is okay but I think as an RN you can’t entirely move away from caring ‘for’. There has to be a blended model for me.” Nobody wants to return to the
days of whatever Sister says rules. Or economic imperatives and businessspeak dictating what nurses can or cannot do for their patients. Maybe it is time for a fresh debate as a profession about what is the best use of a nurse’s skill, knowledge, and caring hands?
Capital and Coast DHB: Short Stay Unit Traditional models of care also don’t fit non-traditional forms of acute care services. Like the growth in acute observation units like Capital and Coast DHB’s Short Stay Unit. It is an observation unit for cardiology and ED patients opened midway through last decade. Mikaela Shannon has been charge nurse manager of the unit for the past two years and says 95 per cent of its patients are discharged within 24 hours, the vast majority home, and the average length of stay is 11 hours. The unit’s usual staffing is three RNs on duty in the morning with an HCA and the same for the afternoon shift. So the ratio of patients per nurse is about five or six with the unit’s average turnover of 18–20 patients a day. But one recent Friday they had 30 patients in 24 hours. So the nurses need to be very skilled in assessment, treatment and discharge planning along with
strong links with community care. The cardiac role is a new one for the short stay unit that followed the opening of the SAPU (surgical assessment and planning unit) easing some of Shannon’s unit’s workflow so it could step in to help the cardiology flow by assessing low acuity chest pain. So the unit has 12 cardiac monitors and the team has spent a lot of time over the last 18 months upskilling in cardiac care as well as being trained to work with at risk mental health patients. Shannon says a lot of making the unit’s new focus work is team work and found the Releasing Time to Care process gave the nursing team the tools and skills to make the changes needed. So the daily flow of nursing tasks are nurse-led to make it work for patients and staff. “It’s worked. We don’t have many complaints and we have lots of compliments.”
Mikaela Shannon
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Intro ???????
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The health care assistant debate Unregulated dogsbodies or essential members of the clinical team – either way, health care assistants are increasingly having a stronger presence in our hospital wards. FIONA CASSIE provides a beginner’s guide to HCAs and shares some nurse leaders’ thoughts – positive and negative – on the role and some recent HCA training innovations.
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n unregulated, low-cost workforce potentially putting patient safety at risk? Or an essential and inevitable addition to the health workforce that frees up valuable nurse time? Whichever way you view them, health care assistants (HCAs) – in their many forms and titles – are a growing sector of the health workforce and are likely to keep doing so as nursing Intro ??????? shortages loom ominously in the future. While there was much debate amongst the nursing profession over rebuilding an enrolled nurse workforce, there has been much less debate about setting standards and training for the growing role that health care assistants play in acute patient care. In the last four or so years, more than 500 enrolled nurse graduates have emerged from the 18-month, Level 5 diploma but many have struggled to find nursing work – particularly in the public hospital sector. Meanwhile, the 20 district health boards in the past six years have taken on an additional 920 HCAs and hospital aides across a wide variety of DHB settings, with training levels of most of those HCAs a great unknown. New Zealand Nurses Organisation researcher Dr Jill Clendon says she worries about the lack of accountability for an unregulated HCA workforce. The greatly varying training and qualification standards for HCAs makes it “really, really difficult for a nurse to trust an HCA unless they know them really, really well.” “I’m not saying we shouldn’t go down that route in terms of HCAs and practice assistants, but I think we need to be very cautious,” says Clendon, who has been working on a major project looking at future models of nursing care. “I say that because if you look at the UK experience, they disestablished their ENS and totally went to an HCA model, and now they are talking about regulating HCAs because the risks to patients were so great.” Professor Jenny Carryer, executive director of the College of Nurses, acknowledges nurses don’t always know what to expect of an HCA on their ward. “In the rush and craziness of the average ward, you don’t tend to have time to sit down and say have you done six-week training, three-month training, or no training at all,” says Carryer. “Or have you been there 10 years or 10 minutes.” 10
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“My argument has always been that we should have nationally agreed employment standards for HCAs and nationally standardised training and not to employ HCAs until they’ve been trained. Then you deal with the confusion and any uncertainty (over what tasks you can or cannot delegate to them).” Carryer is not only in favour of HCAs being able to ease the workload of nurses on the ward but also of practice nurses. “Any RN in general practice who feels threatened by the employment of a practice assistant is probably not being fully utilised as a registered nurse,” believes Carryer. Clendon questions setting up a new practice assistant training programme (some of it at Level Five) when graduating enrolled nurses can’t get jobs. “Why is it that we’re not using a resource we already have? The great thing about ENs is that we know what skills and knowledge they hold and
therefore we know what tasks and responsibilities they can take.” Carryer has never been in favour of an enrolled nurse workforce and believes any advantage of being able to delegate tasks to a regulated enrolled nurse rather than an unregulated HCA is countered by the potential for employers to blur boundaries between the registered and enrolled nurse scopes. Meanwhile, Robyn Hewlett, chair of NZNO’s enrolled nurse section, is frustrated to see new graduate ENs unemployed while unregulated HCAs are employed to do tasks that some DHBs won’t even allow qualified enrolled nurses to do. “My firm belief is that nursing is being devalued if HCAs are increasingly employed to replace the regulated nursing workforce,” says Hewlett. She also believes a better answer to projected nursing shortages is for every EN and RN nursing graduate to have a nursing job rather HCAs taking on duties that used to be the domain of the regulated nursing workforce. “New Zealand could end up like the UK, where HCAs are doing the patient care and also taking on other tasks such as cannulation, bloods, etc. and the RNs are doing the paperwork,” says Hewlett. “Eventually, the powers that be are going to say ‘well, we don’t need regulated nurses as HCAs are doing the work of the nurse’.” She believes a team nursing model of RNs and ENs is not being explored enough or enough research being undertaken into what ENs can contribute to patient care and outcomes. The Nursing Council is “very mindful” of the whole area of unregulated health workers, says chief executive Carolyn Reed. “Council has on numerous occasions touched on it but quickly realised it’s not within their brief under the current legislation.” She personally believes, like Carryer, that there needs to some form of standardisation of training and skills for HCA. She also believes that regulation is not required but would like to see considered a code of conduct for HCAs and a system for managing those who breach that code. Maybe it is time for the benefit of all parties – the HCA, nurse, and their patients – that clear, national parameters about training, qualifications and accountability of HCAs (and delegating RNs) are given serious consideration to show patient safety is always foremost in everybody’s mind?
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Beginners’ guide to HCAs
Learn from UK’s mistakes?
So what is a health care assistant?
That varies hospital to hospital. But the New Zealand Nurses Organisation and DHB collective agreement (MECA) defines an HCA or hospital aide as meaning: “An employee who is an auxiliary to the nursing team and is able to perform tasks in their position description relating to patient care and who works under the direction of a registered nurse or midwife.” That same agreement also recognises at least 18 different titles for the HCA/hospital aide role, including caregiver and the intriguingly named milk room aides.
What can they earn?
Under the MECA, a new HCA can earn $35,520 (compared to $42,776 for a new graduate enrolled nurse and $47,528 for a new graduate registered nurse). The pay scale ends at step four ($40,994), but an HCA who achieves merit criteria can earn an extra $1000–2000 per year.
What training do they receive or require?
This also varies from hospital to hospital. Some DHBs, like Auckland, require HCAs to have a Level 4 certificate offered through an external training provider (to compare, the 18-month enrolled nurse diploma is a Level 5 qualification and the RN degree is Level 7). Others, like Waikato DHB, offer a work-based, Level 3 national certificate with the Careerforce industry training organisation. Yet other DHBs have no required level of training for HCAs, though assistants may have attended a range of in-house training courses ranging from hand hygiene to falls prevention.
Intro ???????
New national qualification for hospital HCAs on the way?
A New Zealand Certificate in Health and Wellbeing (acute health care support) targeted for public hospital HCAs is under development with the aim of the Level 3 national certificate being available in early 2015. The industry training organisation Careerforce led a targeted review into the heath, disability, social services, and whānau ora sectors’ training and qualification on behalf of the New Zealand Qualifications Authority and reported back late last year, leading to the various strands of the new qualification now being developed. “The roll-out of this suite of qualifications will effectively result in national standards for the sector, and graduate profiles for each qualification,” says NZQA deputy chief executive quality assurance, Jane von Dadelszen. She says, in particular, this review identified a need for expected competencies among HCAs and support workers who work in public hospitals, aged residential care facilities, and home and community settings.
What is happening in the general practice sector? The new role of primary care practice assistants (PCPA) was piloted in Auckland and Northland in 2012-2013. The Health Workforce New Zealand (HWNZ) funded pilot saw 19 students from 13 general practices undergo training involving one Level 4 and three Level 5 papers (at Unitec and AUT) plus practice-based learning. An evaluation project of the new role – in some cases PCPAs take patients blood pressure and sterilise equipment – found RNs initially reluctant to delegate tasks but became more positive and reported that it freed up time for patient education and more nurseled clinics. Graeme Benny, HWNZ director, said an immediate national rollout of the PCPA role and qualification was delayed because of the NZQA qualification review (see above), so HWNZ was working in the interim on a change management strategy for ensuring uptake and acceptance of the role.
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n the wake of the Francis Inquiry into Mid-Staffordshire NHS Trust, and reports of failings in other hospitals and care homes, the UK Government asked Times journalist Camilla Cavendish to review what can be done to “ensure that unregistered staff in the NHS and social care treat all patients and clients with care and compassion”. The resulting Cavendish Review was published last year and found HCAs »» Made up around a third of the caring workforce in NHS hospitals »» Spent more time than nurses at the bedside »» Have no compulsory or consistent training »» A profusion of job titles. “Some HCAs are now doing jobs that used to be the preserve of nurses, even doctors,” writes Cavendish. “The review met a group of health care assistants from a busy A&E who are inserting IV drips, taking blood, and plastering. Yet they are paid at three levels below a newly qualified nurse.” The review recommendations included: »» Directors of nursing take full responsibility for recruiting, training, and managing HCAs. »» Develop a ‘certificate of fundamental care’ linked to nursing degree. »» Make caring experience a prerequisite to starting a nursing degree. »» HCAs and nursing students complete the certificate together. »» HCAs able to use the title ‘nursing assistant’ on completion of certificate. »» Development of bridging programmes and career framework for HCAs. »» Provide employers advice on managing dismissal of unsatisfactory staff. »» Skills for Health body to refine its proposed code of conduct for staff.
How many HCAs do New Zealand hospitals have? A breakdown of the DHBs’ quarterly workforce “snapshots” shows that: »» There were 3156 HCAs and 25,078 RNs employed (heads) across the 20 DHBs at the end of 2013. »» The HCA/hospital aide full time equivalent (FTE) workforce grew 30% in the six years to December 2013. »» Over the same time period the nursing workforce grew 17.6 per cent. »» The total DHB workforce grew by nearly 12 per cent. »» The HCAs to nurse FTE ratio has risen from 1 HCA per 9.7 nurses in 2007 to 1 HCA per 8 nurses in 2013. »» The average age of an HCA in 2013 was 49.8 years compared with 45 years for your average DHB nurse. »» HCAs mean length of service was 8.3 years compared to 9.1 for nurses. »» HCAs are more ethnically diverse, including 11.6% Māori (4.5% RNs), 18% Asian (15.5% RNs), and 11.7% Pacific (2.3% RNs). »» The HCA workforce is 80 per cent female. *Data supplied by Health Workforce Information arm of DHB Shared Services using the NZNO/DHB MECA definition of what job titles are considered HCA or hospital aide equivalent roles
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Colleen Mellsop (front row, left) with HCA graduating class and fellow nurse educators Lyn Macleod (front row, right) and Jane Widdowson (middle row, second from right)
Waikato DHB offers condensed HCA training course in-house
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raining health care assistants is a “win-win” both for the unregulated workforce and for patients, says the nurse leader of Waikato District Health Board’s training programme. Being able to offer a qualification in-house for free to HCAs – and completing it in around less than half the time of the usual training programme – has attracted interest from many DHBs and other providers across the country, says Colleen Mellsop, the nursing coordinator for the DHB’s HCA training. Waikato first offered Careerforce’s Level 3 National Certificate in Health, Disability, and Aged Support as a pilot in 2011 and afterwards decided it could simplify and speed up the process to take less than the standard 10–12 month timeframe. It had the resource material rewritten so it was both simplified and appropriate for HCAs working in the acute care sector. Then after another pilot, offering the programme over just a six-month time frame, Waikato’s Nursing and Midwifery Professional Development Unit worked closely with Careerforce to rewrite and condense the assessment material. “In a nutshell, what we’ve done is made the qualification, we feel, more user friendly and relevant for our HCAs in this DHB,” says Mellsop. To date, 82 HCAs and therapy assistants have completed the revised six month Careerforce certificate, and 108 HCAs are in line to also do the qualification, which is promoted as ‘desirable’ but not compulsory, this year. The programme is delivered over two formal study days and a half day for a practical assessment on moving and handling but the rest of the study is done in the HCA’s own time at home. Registered nurses are also involved in the verification process on the ward and while some RNs were reluctant at the additional workload, Mellsop said most had embraced the training programme. “They see the enormous benefit for themselves because the HCA workforce is doing most of the basic personal cares on the patients. So it really frees up the RN to focus on the other things they need to do.” The board has a designated list of tasks that HCAs can or cannot do, and part of the training days stresses the importance of keeping themselves and their patients safe and how to say no to tasks they aren’t qualified to do. “We talk about direction and delegation in reverse so they understand the concept and how it applies from their perspective.” Mellsop says her involvement in the programme, which is delivered by herself and nurse educators Lyn Macleod and Jane Widdowson, who were extensively involved with its development, has been one of the most satisfying roles of her long nursing career. “I really think they are a workforce that’s been neglected from a learning perspective. Sometimes they feel the RNs don’t treat them particularly well … and they get to do all the dirty jobs … So it had been “really nice” to see HCAs achieve a qualification that makes them feel valued and validated and that they’ve “really got a strong place in the health care team”.
Best Care for Everyone
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Right nurse, right place, and right time? Five years down the track, implementing Safe Staffing Healthy Workplace Unit’s safe staffing tools in public hospitals is still a steady work in progress. FIONA CASSIE talks to unit director LISA SKEET about early pockets of success, TrendCare naysayers, and the need for DHBs to turn hard data into more nurses on the floor.
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cepticism was rife last year when nurses were surveyed about whether TrendCare was improving their nursing workload. A quarter of the nearly 1500 respondents to the New Zealand Nurses??????? Organisation employment survey were aware of having TrendCare Intro or Care Capacity Demand Management (CCDM) at their hospital but reported being uninformed or unimpressed or their workload virtually unchanged as a result. It appears that confusion and cynicism is still rife five years down the track since the Safe Staffing Healthy Workplaces Unit started developing the CCDM system. Lisa Skeet, the SSHW unit director, is not that surprised at the NZNO survey results, saying it is still early days for CCDM at the 11 boards it is currently underway in (Auckland DHB will be the 12th and gets underway this year). CCDM is a sophisticated system developed with the aim of bypassing crude nurse to patient ratios (like those adopted in Victoria or California) and instead using robust patient acuity data to decide base staffing so a ward has the right staff at the right time to safely meet patient demand. “There have been pockets of success with CCDM. However, it’s still not implemented on the scale where the full benefits of the programme will be seen with DHBs,” says Skeet. She is calling for patience with only one board – Bay of Plenty – close to full implementation, and it has had a 3–4 year start on many of the other boards. Nurse perceptions have also not been helped in cases when staff levels stay the same despite CCDM data indicating a ward’s base staffing needs to increase to reflect patient demand. Calculating what a ward or unit’s base staffing should be is done using the CCDM’s “mix and match staffing methodology” that draws on data from TrendCare – an Australian, nurse-developed software package that Skeet says is the only tool available that provides validated patient acuity data. The fact that the NZNO survey described TrendCare as an example of “a CCDM” system rather than as a software tool required to gather data to implement “the CCDM” system just further brings home the confusion out there. TrendCare is a dirty word amongst some nurses, but Skeet points out that TrendCare had been around in district health boards for some time before the SSHW unit started developing CCDM. “TrendCare makes nursing work visible and the data created shows what is actually happening on the ward,” says Skeet. “At the end of the day, it is just data and it’s the way that data is used for decision-making in the organisation which actually makes the difference.” That is one area of mixed success because for CCDM to work, DHBs need to use the data created by the mix and match staffing methodology to inform their annual staff budgeting process. “That’s still not embedded as business as usual within a number of DHBs we are working with.”
Skeet says the most visible CCDM project to date is the variance response management (VRM) system – with its ‘capacity at a glance’ screens showing how busy the hospital is in real time and the ‘traffic light’ system which sees support swing into action when a ward hits ‘orange’ or worst-case scenario ‘red’. Skeet says the VRM system is supposed to be there as the fallback ‘plan B’ for a district health board. Plan A is for DHBs to use the CCDM’s mix and match tools successfully so that base staffing is at the right level for patient demand the vast majority of the time and variance response or escalation is rarely needed. A full, independent evaluation is already underway of CCDM with a final report due at the end of the year – shortly before the DHB/NZNO MECA expires in February and negotiations begin for a new agreement and also prior to the current funding contract for SSHW ending in June 2015. Watch this space.
SSHW history at a glance »» 2007 Safe Staffing Healthy Workplace Unit set up as joint New Zealand Nurses Organisation/district health board initiative to implement 2006 SSHW inquiry recommendations. »» 2009 Bay of Plenty, West Coast and Counties Manukau DHBs demonstration sites for SSHW Unit’s Care Capacity Demand Management (CCDM) tools. »» 2014 15 out of 20 boards have TrendCare – the patient acuity tool that CCDM is built on – 12 are currently actively implementing CCDM at varying stages and four more are interested. »» 2014 Those DHBs that don’t have TrendCare are Capital & Coast (under discussion), Counties-Manukau, Waikato, Lakes and Canterbury. CCDM three core components 1. Mix and Match Staffing (i.e. using ward patient acuity data to match FTE base staffing with patient demand patterns) 2. Variance Response Management (i.e. capacity at a glance screen (CAG), ‘traffic light’ system to alert when ward is in need and systems of how to respond) 3. Core data set
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CCDM research: right staffing = happier staff
“Here, have our Smart Fives card”
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taff were happier and care rationing less likely to occur when staffing levels met CCDM criteria during a nursing shift, a research report released last year found. The SSHW unit study looking at nurse and patient perceptions of care after shifts which were either understaffed or staffed according to the ward’s CCDM ‘mix and match’ staffing methodology. Six wards at two district health boards took part in the study and data was collected from 734 shifts over six weeks – of which only 24 per cent met the full criteria of a “designmet” or appropriately staffed shift. On the 75 per cent of shifts that failed to meet the good staffing criteria, nurses were nearly twice as likely to report care rationing, like not answering patient bells within five minutes or mobilising patients. They were also less likely to be happy (45 per cent) after the shift than if the shift was staffed appropriately Intro ???????(58 per cent). But patients reported little to no difference in perception of their care. The study also found that all six wards “consistently fell short” in responding quickly to sudden surges in patient demand. The
study reports that these findings, and the SSHW unit’s experience of working with DHBs “suggests that DHBs cannot expect to have a lean staffing base and a lean buffer, and expect to maintain safe production in the face of predictable and significant variance between demand and capacity”. The study also says “further investigation will be required to determine if the recommended staffing design is ‘good enough’ as opposed to simply ‘better than’ shifts that do not meet the design level.” A shift was regarded as “design met” when: »» Actual nursing hours available were within 10 per cent of nursing hours required by patients »» 80 per cent or more of skill-mix staff were RNs (during day shift) »» At least 75 per cent of staff were from the home ward.
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he traffic light system can see gifted nurses arriving to help out a ward in strife for an hour or two to find ward nurses too rushed off their feet to brief them. So the Smart Fives cards – setting out jobs that can be delegated and quickly done by a borrowed nurse (or health care assistant), initially developed by Bay of Plenty DHB and adopted by CCDM – are there to allow the briefing to be streamlined and snappy. One side of the card welcomes the helping nurse, names their ‘buddy’ ward nurse, and below has a check list of the top five or five-minute activities ticked to show what would be most helpful to the ward at that time. The other side of the card has a map of the ward, so visiting staff can find what they need, and the key codes used. Visiting nurses might be asked to do the obs in one room, or if the nurse is familiar with that service or patient type, may be asked to help their buddy with medication rounds. Skeet says the aim of the cards is to help change the culture of nurses feeling uncomfortable about helping out in a strange ward and how they are accepted when they get there.
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International Nurses Day ‘Heroes’ Once again, to celebrate International Nurses Day, Nursing Review invited district health boards across the country to contribute stories on nursing ‘heroes’ in their region. We received stories on some of the unsung, innovative, compassionate, high-achieving and dedicated nurses that make up the New Zealand nursing workforce.
Intro ???????
an identified ICU outreach need and works in Middlemore’s critical care complex as an outreach NP and in support of the Patient At Risk team. Fogarty says Pirret’s role is pivotal in supporting nursing and medical staff to identify and successfully manage patients at risk, within the ward setting. “Alison would maintain this is nothing special, it’s what she does every day; we would argue that it takes a special type of hero to do this.”
has been to reduce harm from falls by minimising the risk of falls by patients by meeting the patient’s fundamental care needs. The mantra of the ward is now A for aid mobility; B for bell, pain, position; C for clutter; D for drink; E for elimination (toileting), and signs reminding staff and patients are found throughout the ward. “The systems introduced include mobilisation recommendations, rounding checks, signs in every patient’s room, all actions recorded in the Care Plan, and audited twice a month, with an intentional rounding audit once a month,”says Watene. Additional prompts Watene has introduced include rounding checks on computer screensavers and coloured 3D rounding checks ticker-taping across computer screens.
NAME: Dr Alison Pirret DHB: Counties Manukau JOB: Nurse practitioner (adult intensive and high dependency care), Middlemore Hospital Dr Alison Pirret is a nurse practitioner whose vision has taken critical care nursing beyond the walls of the traditional ICU and into the ward setting. Last year, the adult intensive and high dependency care NP successfully completed her PhD comparing the diagnostic reasoning of NPs and medical registrars. She is the author of a 390-page acute care nursing textbook that is into its second edition. “Alison is the epitome of what it means to be a hero role model,” says Counties Manukau acute care clinical nurse director, Annie Fogarty. “Like how the media portrayed (super) heroes, on the surface, Alison appears incredibly normal and unassuming. However, this highly intelligent, passionate, professional, and empathic educator, team player, and visionary leader in her field doesn’t suddenly need to change her personality, shape, or form to bring her skills to the fore in a time of crisis.” Pirret developed her NP role to meet
NAME: Anamaria Watene DHB: Bay of Plenty JOB: Clinical nurse manager, Kaupapa Ward, Tauranga Hospital Anamaria Watene has turned her Kaupapa ward from one that has faced complaints to one that regularly receives compliments. An intentional rounding pilot was introduced into the ward at Tauranga Hospital in 2011, leading to a dramatic rise in the frequency of times patients are checked every hour. The raw data collected in 2011 showed the lowest daily hourly rounding was 46 per cent, which increased to 100 per cent in 2012, and has remained at this high level through 2013 and the first two months of 2014. Watene, charge nurse manager of the ward, attributes the dramatic improvement to her staff buying into intentional rounding and all disciplines working as a team. Her major goal with intentional rounding
NAME: Anna Reed DHB: Wairarapa JOB: Nurse practitioner, Masterton Medical Anna Reed is a nurse practitioner creating wrap-around care for the high needs elderly in the community with often complex health needs. She works for Masterton Medical Centre, New Zealand’s largest general practice, with 23,000 patients. About half of her patients are in the community and the other half in residential aged care facilities. Nursing Review series 2014
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After completing her clinical Masters in 2009, Anna was Wairarapa DHB’s clinical nurse specialist in aged care before moving to general practice to train as an NP. “Once I worked with older people, I never wanted to do anything else,” she says. “Most have had such a remarkable journey and have so many stories to tell. Many are lonely, anxious, and some are angry. Their families may have gone away, their friends are dying, and some struggle to care for themselves in their own homes.” Their health issues can be complex and many of her referrals are for people in the early stages of memory impairment or dementia. “Ensuring support packages are in place such as access to day activities, respite and carer-relief is essential to protecting the valued carer role.” Anna’s role includes assessment, diagnosis, and treatment, including prescribing, of acute and chronic illness in consultation with GPs, DHB physicians, and other members of the multidisciplinary team involved in coordinating care of older people. She also does the threemonthly reviews of rest home patients, looking at their mobility, medication, and wellbeing, and talking to family members.
nurses, which may include the development of a nurse endoscopist role in New Zealand. She will also be supporting the national implementation of the NZGRS (a patient-centred quality improvement tool) and other NEQIP activities. In addition to these roles, Anne has been treasurer on the New Zealand Nurses’ Organisation Gastroenterology Nurses Section and is also a member of the National Bowel Cancer Working Group. Recently she was awarded a travelling scholarship and visited England to view hospitals that have implemented the Global Rating Scale and viewed workforce development initiatives and efforts to improve the patient journey. Gastroenterology charge nurse Lynley Morton says that Cleland’s work is helping put gastroenterology in the spotlight. “Not only is her experience helping us develop our service here at MidCentral Health, but it’s helping nurses and patients around the country.”
“She really listens to them, understands what they want for their life, and then she works closely with them and their families to help them achieve their goals. “Brenda is well-known and loved by our patients who comment they feel better when she walks in the room.”
Intro ??????? NAME: Delia Williams DHB: Whanganui JOB: Clinical nurse specialist diabetes
NAME: Brenda Baird DHB: Auckland JOB: Staff nurse, respiratory ward, Auckland City Hospital
NAME: Anne Cleland DHB: MidCentral JOB: Gastroenterology lead clinical nurse specialist Anne Cleland is in the forefront of helping build a endoscopy nursing skills framework, which may lead to the development of the nurse endoscopist role in New Zealand. Cleland, who has a Master’s degree in nursing, has a background of 25 years of endoscopy nursing, mostly at MidCentral Health, but including some years in America. She has recently been appointed to a part-time position with the National Endoscopy Quality Improvement Programme (NEQIP) as a nursing workforce development lead. In this role, her focus will initially be on the continued development of an Endoscopy Knowledge, Skills and Competency Framework for endoscopy 16
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Brenda Baird is a staff nurse who made up to two litres of Milo a shift for a vulnerable long-term patient and is seen as a nursing hero for consistently going the extra mile. Each month, one member of the Auckland DHB team is selected as a local hero with nominations coming in from patients, their families, and from staff alike. Earlier this year, Brenda Baird, a staff nurse of 30 years at Auckland City Hospital, was nominated by her charge nurse, Sarah Wilson. Wilson says Baird consistently goes the extra mile for patients. “The effects of her care and attention were recently demonstrated when she was looking after a very vulnerable, long-term patient. Every shift, Brenda would make this patient up to two litres of hot Milo, one cup at a time. She led the team to manage his pressure sores, improving his health and enhancing his experience of being in hospital. This patient now smiles and communicates – he is a completely different man.” Wilson says Baird works tirelessly for patients to ensure that they get the best out of life.
Becoming Whanganui’s first diabetes nurse specialist prescriber has enabled Delia Williams to make a big difference to her patients. Williams, who has been in nursing since 1984 and a diabetes nurse for 13 years, is one of only 27 nurses in the country employed in the prescribing diabetes role. “Being a designated diabetes prescriber is a small but very exciting aspect of my role because it gives me the opportunity to advance my clinical practice while offering an efficient and comprehensive service for those with diabetes,” Delia says. “Prescribing can make a significant difference for the patient by simplifying the processes involved for them and by influencing their continuity of care. “Unfortunately, the number of patients with diabetes has almost doubled in the last 10 years, so it’s important we extend the scope and skills of our healthcare team to help us manage the increase. Williams see patients on the hospital ward, outpatients, and also hold clinics in rural health centres. She also provides education and support to nurses working at the hospital and in general practices. Williams supports a collaborative approach by the DHB’s diabetes service to strengthening the partnership between primary and secondary care with the aim of maximising available resources for the management of diabetes. Her vision is to bring about change by empowering nurses through their knowledge and skills, working alongside them to build confidence and foster a seamless service for people with diabetes.
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NAME: Helen Lloyd DHB: Canterbury JOB: Community clinical nurse specialist (older people’s health)
Intro ???????
Helen Lloyd is passionate about helping older people stay well in their own homes and has been key to a number of post-quake Canterbury initiatives aiming to do just that. “I have a huge passion for older people in terms of helping them to live the way they want to live.” Lloyd is a key member of the Community Older Persons Health Team and has been instrumental in a number of innovations in the Canterbury Health System for older people in the community including a lead role in launching the Community Rehabilitation Enablement and Support Team (CREST). “If it was not for the amazing team of people I work with, then this job would be impossible. We have the best clinical leaders and multidisciplinary teams I
NAME: Fiona Unaç DHB: Hawke’s Bay JOB: Acute care nurse practitioner (radiology and vascular services) Fiona Unaç is the only nurse practitioner in Australasia working in the acute care specialties of radiology and vascular services. Hawke’s Bay DHB chief nursing officer Chris McKenna says Fiona is a real nursing hero because she is “innovative, positive, and goes the extra mile to improve patient outcomes”. “Fiona carries out technical skills traditionally performed by doctors, such as ultrasound guided paracentesis and thoracentesis, and she has a core responsibility of delivering advance nursing care across radiology and vascular services from first specialist assessment to post procedural follow-up. “She is the only nurse practitioner in Australasia working across these specialties and has a special interest in peripheral vascular disease (PVD) management, particularly as people with PVD are a high risk but neglected disease population.” McKenna credits Unaç with working to make sure this group of patients is better integrated into the system and not forgotten. Unaç’s nursing achievements have also been recognised by her peers firstly as a recipient of the DHB’s Innovation in Nursing Award in 2010, and then as a recipient of a New Zealand Nurses Organisation Award for Services to Nursing and Midwifery in 2013. She is the current chair of the Perioperative Nurses College (NZNO) and is a technical expert in medical imaging nursing for International Accreditation New Zealand. Nursing Review series 2014
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have worked with anywhere in the world; that includes the 20 years I spent in England,” Lloyd says. Kate Gibb, the DHB’s nursing director for older people’s health, says Lloyd continues to work closely with CREST along with filling gaps across a multitude of other roles including managing clinical teams and supporting gerontology nursing colleagues in Canterbury and the West Coast. “Helen manages to fit an enormous amount into her working week … amidst all of this she still manages to support and regularly visit her own clients.” Post-quake, Lloyd was part of the team supporting vulnerable aged residential care facilities, providing practical support to facilities, which had lost vital services and infrastructure such as power and water. She was also part of the team that led to the development of a Motor Neurone Disease facilitator role within the Canterbury Initiative. Helen is an assessor and advocate for the Professional Development Recognition Programme (PDRP) and has also led the introduction of nursing students and Nurse Entry To Practice (NETP) into the community team, which is now a Dedicated Education Unit (DEU). She also established a team to develop Older Person’s Health Specialist Service education days, which are attended widely by nurses??????? across the DHB, community, and Intro residential care sectors.
mental health consumers is both critical to develop, as well as a challenge, but that is what I enjoy about mental health nursing,” says Fleming. “Developing rapport and trust with a person to allow you to provide care is the most important part of my job.” Last year, while working full-time during her Nursing Entry to Practice (NETP) new graduate programme, she completed a Postgraduate Certificate in Nursing (Mental Health) through Whitirea Community Polytechnic. She says she really enjoyed study at this level and will continue to study to keep her practice current and to create a body of knowledge that reinforces “why we do what we do”. She is nominated by NMDHB as a young nursing hero who has embraced both the academic and therapeutic aspects of nursing.
NAME: Sara Best DHB: Capital & Coast JOB: District nurse (wound care management)
NAME: Nikita Fleming DHB: Nelson-Marlborough JOB: Mental health nurse (second year) Nikita Fleming’s career has moved from beauty therapy to building therapeutic relationships with her mental health clients. The 24-year-old came to nursing via a roundabout route, as after leaving school at 16, she worked in her father’s factory and completed a beauty therapy diploma before deciding she wanted a career with more substance. As a nursing student, Fleming did a placement at Nelson Hospital’s mental health acute unit and was hooked. “Building a therapeutic relationship with 18
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District nurse Sara Best’s enthusiasm and humour has helped introduce 60 of her colleagues to using a high tech, handheld laser camera to measure and monitor wounds. Best has been named Capital & Coast’s nursing hero for her pivotal role in training the DHB’s district nursing workface in the use of the innovative wound care technology across the board’s Kāpiti, Kenepuru, and Wellington bases. The Silhouette system comprises a 3D laser camera that captures dimensions of length, area, depth, height, and volume of a patient’s wound at home or in a clinic. That information is then logged on a secure database, from which reports can be generated to assist district nurses in the management of surgical wounds, pressure sores, and leg ulcers. “It’s motivating for staff and patients – the graphs that we can produce make it clear for people to understand if their wound is progressing or not, and provides objective, robust data when we’re liaising with clinicians.” Now just one paper shy of her Master’s in Nursing, Best has educated district nurses of all ages, backgrounds, and computer skill levels with humour and enthusiasm, on top of her regular role providing lower limb Doppler assessment
and complex wound care management. She’s been a district nurse for around 15 years and has tried other roles but always gone back to district nursing, specialising in her passion of wound care management. “Now we can track an ulcer. If it’s not improving, we can assess the aetiology of an ulcer and intervene proactively with best practice treatment to ensure a faster healing rate.” Her colleagues praise Best’s compassionate and inspiring manner and speak highly of the way she challenges their thinking to encourage evidencebased best practice.
NAME: Kirstin Unahi DHB: Southern JOB: Oncology nurse educator and nurse-led oncology assessment clinic. Kirstin Unahi is helping cancer patients by identifying early potential side effects of their chemotherapy and offering timely intervention. Southern DHB says Unahi is a dedicated oncology nurse educator for the Southern Blood and Cancer Service in Dunedin. She is also on the nurse practitioner pathway and is working on expanding her clinical skills and knowledge by running nurse-led oncology clinics for the board’s oncology assessment unit. This unit provides a proactive service to patients having chemotherapy treatment by phoning patients post-treatment with the aim of promptly identifying potential side effects and providing early intervention. Patients can also come into the unit for a nursing assessment, after which nurses liaise with the medical teams in developing treatment plans. The DHB says the unit’s service is reducing the number of patients requiring admission to the oncology in-patient ward, enabling patients to stay in their own homes. Unahi’s motivation and positivity is admired by her colleagues and nursing leaders and is seen as a role model to younger members of the nursing team of what can be achieved through hard work and a ‘can do’ attitude.
college of nurses Jenny Carryer
New anti-competitive barrier being created for NPs? PROFESSOR JENNY CARRYER is alarmed that after 10 years of battling barriers hindering nurse practitioners, a new contract currently being negotiated for primary health providers could create yet another barrier.
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he College of Nurses is distressed to learn that it is proposed that a new definition of a general practice team will become embedded in agreements between PHOs and contracted providers. That definition will assert that a full team contains both nurses and medical practitioners and exceptions will need to be negotiated individually with the relevant district health board. Those of us who have spent more than 10 years now battling the tedious barriers to NP practice see this as a potential additional barrier, as once again we waste precious energy arguing for an exception to a rule and eventually arguing for removal of ‘the rule’. This is so contrary to notions of flexibility, responsiveness, and sheer pragmatism. It also ignores considerable long-standing evidence that nurse practitioners are able to deliver safe and effective care in a highly cost effective manner. This situation may have arisen on the basis of the proposed payment of GMS (general medical schedule) payments to all members of the primary health care team as opposed to just GPs. The situation involves apparent attempts to redefine the definition of primary care team as a component of this work. The proposal to pay GMS to NPs, nurses, and pharmacists was approved by Health Minister Tony Ryall and announced on his behalf last year by Dr Jane O’Malley at the College of Primary Health Care NZNO nurses conference in Wellington. Following the announcement workshops were held to address implementation issues (Background: GMS is an additional payment directed to general practice as reimbursement from the Ministry of Health. It covers a small but important component of the 60 per cent government funding that sustains general practice services). College members Kim Carter and Sharon Hansen reported that the GMS implementation meetings went smoothly, with the group working together to resolve technical and other issues related to the proposed change.
It was agreed that those claiming GMS would be general practice-based and that technical changes were required in the ministry processes to facilitate a wider range of claimants. While there were understandable concerns about the potential for cost blowouts, it seemed that issues were resolved satisfactorily. Early on, the college expressed concern that the ability to claim GMS should not be linked to the presence, or otherwise, of a GP in the claiming organisation. We did this because of our concern for the viability of rural services and services delivering care to homeless and
Those of us who have spent more than 10 years now battling the tedious barriers to NP practice see this as a potential additional barrier, as once again we waste precious energy arguing for an exception to a rule and eventually arguing for removal of ‘the rule’. vulnerable clients, which are increasingly nurse-led. The actual and predicted scarcity of GPs leads us to believe that sustainability of services will require NPs and nurses to have greater independence. Philosophically nursing has no argument with the advantages and value of a collaborative and multidisciplinary primary health care team. Pragmatically however, we know that it is not always possible and may quickly become less so. Based on the college’s vision of 100 per cent access and zero disparities we believe that all agreements, contracts, and policy decisions must be future proofed towards the greatest degree of
flexibility and responsiveness to community and patient need. It is perhaps ironic that this should be happening under the auspices of a Nationalled Government, which by its very nature, promotes competition in support of market forces. A recent US policy paper debating this very topic warns legislators to be cautious about proposals that limit the scope of practice of advanced practice nurses. Limiting the range of services nurses can provide and the extent to which they can practice independently, is likely to have a number of anti-competitive effects. The paper goes on to say that: Competition in health care markets benefits consumers by helping to control costs and prices, improve quality of care, promote innovative products, services, and service delivery models, and expand access to health care services and goods. While state legislators and policymakers addressing health care issues are rightly concerned with patient health and safety, an important goal of competition law and policy is to foster quality competition, which also furthers health and safety objectives. Likewise, to ignore competitive concerns in health policy can impede quality competition, raise prices, or diminish access to health care – all of which carry their own health and safety risks. The new team definition has murky origins, no obvious evidence base and would seem highly counter to all asserted goals about maintaining services in the face of escalating need. So why is it needed? Whose interests are to be served by embedding such a definition? Reference: Federal Trade Commission. (2014, March). Policy perspectives: Competition and the regulation of advanced practice nurses. Retrieved from www.ftc.gov/reports/policy-perspectivescompetition-regulation-advanced-practicenurses Professor Jenny Carryer is Professor of Nursing at Massey University and executive director of the College of Nurses.
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Webscope
CHECK THESE OUT
25 years on the web unites …and divides us
KATHY HOLLOWAY celebrates the World Wide Web’s quarter century but adds a cautionary note about the digital divide that still sees many miss out on access to the web that most of us now take for granted.
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wenty-five years ago, the World Wide Web did not exist. While the internet – the ability to link together networks of computers – was developed back in the 1960s, the World Wide Web that allows us to easily search and surf those networks was just an idea back in 1989. In March, the man behind the idea, British computer scientist, Sir Tim Berners-Lee, was celebrated as the creator of the World Wide Web, which was initially as an attempt to improve communication between the thousands of scientists involved with the European Organisation for Nuclear Research. As you surf blithely from site to site, consider this interesting research on more than 2000 Kiwi internet users gathered by AUT researchers in 2013 as part of the World Internet Project survey that found that 92 per cent of Kiwis use the internet, while 5 per cent never have, and 3 per cent are ex-users. Of those that do use the internet, 14 per cent used the internet only occasionally, 40 per cent were first generation users using mostly a computer, and finally 38 per cent were the highly connected next generation using multiple mobile devices. The internet is seen as the highest-rated source for information for all age groups, but highest by those under 30 (94 per cent). Viewing online news, seeking travel and health information, along with social networking are key areas of activity. Interestingly, New Zealand is ranked number five in the world by the Web Index, a unique annual ranking of countries on the progress and social utility of the Web: see thewebindex.org/data/index What does this mean for health care and for nursing? In my view, what is most significant is equity of access which remains uneven for the poor, the elderly and for Māori and Pacific people. The digital divide exists globally with as many as three
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out of five people estimated to not have access to the internet. The 2013 New Zealand Census data suggests that the percentage of households here with access to the internet has increased from 58 per cent to 73 per cent since the 2006 Census, leaving us with just a little over one in five households without access. This has implications for access to the vast array of health information available now on the web, both nationally and globally. We know from previous research that the most important variables identified as influencing household connectivity levels were household income, the level of educational qualification and household composition. These are also key determinants of health, so the populations that are less likely to have internet access are also the groups highlighted as being more likely to experience poor health status. As discussed in many previous columns, the health professional’s role is often to interpret the volumes of material that health consumers can download off the over one and a half billion web sites available to search. Alternatively, the nurse can be the knowledge broker for the communities they work with. This can be accessing highquality information in an appropriate language – for example, visit www.healthed.govt.nz for free resources in Māori and a variety of Pacific languages. Many support organisations also have web presences that provide quality resources for people living with a variety of health concerns – check out www.diabetes.org.nz/resources. Remember that with awareness comes choice, thus your role for those without access is in the provision of the awareness of potential choices to your community – keeping up to date with best practice is a professional imperative. Dr Kathy Holloway is dean of the Faculty of Health at Whitireia Community Polytechnic.
Best practice sources Clinical Practice Guidelines Portal www.clinicalguidelines.gov.au This Australian site is an initiative of the National Institute of Clinical Studies (NICS), part of the Australian Government’s National Health and Medical Research Council. The portal provides access to clinical practice guidelines produced for Australian practice that have been assessed against criteria modified from the United States National Guidelines Clearinghouse, and adapted to the Australian context. Over 2000 documents have been assessed and added. The portal fits with the aim of NICS to help bridge the gap between what is known (the research findings) and what is done (day-to-day clinical practice). While it is important to remember that guidelines, developed for one country do not necessarily translate to another, there is often merit in considering the work others have done. We do not want to be reinventing the wheel but may need to be prepared to 'retread' one! Let’s continue to maximise our resources by utilising and adapting the work of our colleagues in the virtual community of practice that the internet supports. [Site accessed 6 April 2014 and last updated 24 March 2014].
The Henderson Repository, Sigma Theta Tau International www.nursinglibrary.org/vhl Speaking as we are this edition about the professional imperative to keep updated … This repository (previously known as the Virginia Henderson Library) from Sigma Theta Tau International has the stated aim of providing nurses, in all roles around the globe, free online access to reliable nursing information related to all aspects of nursing research that can be easily utilised and shared. The ultimate goal is to make the repository one of the most comprehensive resources for digital nursing information, from dissertations to slide presentations and committee reports to preprint journal articles.The repository also houses more than 38,000 study and conference abstracts. Primary investigators can be contacted for more information. So you now can both seek knowledge and contribute your own knowledge through this website – check out other links to the STTI’s work and watch out for an opportunity to join STTI (NZ) later this year. [Site accessed 6 April 2014 and last updated 24 March 2014].
Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy
Clowning around on the ward
CAMERON TAYLOR of Clown Doctors shares why a smile is good medicine on the ward. A concerned mother and daughter crane their necks up at a small TV in the corner of their hospital room. Not entertained by the funny cartoon, both mum and her five-year-old seem anxious. Suddenly, a head pokes around the door. “Look Doctor Bob, it’s our friend Anna*.” A second head looks in at the puzzled pair sitting on the hospital bed. You could forgive their quizzical expressions as the duo in the doorway are wearing white lab coats but have bright red noses. Dr Bob Brrooom! and Dr Bluebottle, are clown doctors. Clown Doctors New Zealand is a charity active in Christchurch, Wellington, and Auckland. The aim is to spread joy and laughter to children in need, and it clearly works in this case. Within minutes of Dr Bluebottle playing ‘The Wheels on the Bus’ on her ukulele, Anna is laughing and singing along while her mother smiles and visibly relaxes. The Clown Doctors New Zealand Charitable Trust was co-founded in 2009 by chief executive and creative director Thomas Petschner, a health scientist with a particular interest in humour in medicine, and programme director Rita Noetzel. Nurses who’ve interacted with clown doctors will know they are not medical doctors or anything like circus clowns with their large wigs, outlandish costumes, and garish make-up. The only reference to Drs Bob and Bluebottle being clowns are their red noses. Under his lab coat, Dr Bob has a green Hawaiian shirt, brown shorts, and knee-high purple socks, while Dr Bluebottle wears a flowery dress with a blue hem and matching hat. They look a little strange compared to the regular staff, but there’s nothing over-the-top that might frighten anyone. Clown doctors are also not just for patients as hospital staff can have fun with them, too. It’s something Lisa Wingfield, aka Clown Dr Bluebottle, enjoys. “We were with one of the nurses when she was doing some blood pressure tests with a child, and the kid was laughing away. She said ‘Oh this is marvellous, their blood pressure has gone right down.’ So there’s an absolute direct response,” says Wingfield. “If they had a little stress-reducing thing on the wall, that would be even better because we would see that dropping too.” Clown doctors have also been incorporated into patient rehabilitation therapy. “There was a child who broke both legs in a car accident, so he had to learn to walk again. But because of the pain he didn’t want to,” says
Petschner. “He wasn’t responding to therapy, and the physiotherapists and nurses were desperate because they wanted the kid to walk. “So two clown doctors started a race with him through a corridor. The kid was in the middle and the clowns started moon-walking. They were going backwards for every half-step the child took. He was so motivated, he actually walked the whole length of the 30-metre corridor.” Clown doctors are increasingly becoming a normal part of hospital routine. “We can use them as a distraction for people who are going to have a painful or a scary procedure,” says Noetzel. “We’ve seen it time-and-time again. The hospital staff knows the clown doctors will be on the ward and they wait until the clown doctors are there so there’ll be a distraction. It won’t be as traumatic for the child, it won’t be as traumatic for the family; everyone will just be happier.” A child health psychologist at Christchurch Hospital, Tony White, agrees. “While they are being silly, they are always highly respectful of patients and staff. They religiously keep detailed records of all interactions with patients and they are very responsive to feedback from medical staff. They also give the medical professionals a ‘permit’ to laugh again in those humourless hospital environments, so we would always like to keep them clowning around,” says White. Lynda Driscoll, the ward clerk for Christchurch Hospital’s Children’s Acute Assessment Unit, believes clown doctors connecting with staff is almost as important as their connections with patients. “It is always a pleasure to see the clown doctors. They bring a sense of fun that gives a lift to the
whole atmosphere on the ward. I think they make a very valuable contribution to the well-being of children in hospital.” April 7 was New Zealand Smile Day, the annual awareness day for Clown Doctors – an opportunity for us each year to share joy and laughter with children who don’t usually receive a visit from us. A great way for nurses around the country to join in the celebrations next year is to incorporate a little humour into their daily routine. The first step, Petschner says, is not taking yourself too seriously and finding the humour in everyday situations. “Place a (clean) pencil horizontally between your teeth. This puts the mouth in the smile position,” he says. “Then with the pencil there, first try to tell yourself in the mirror, and afterwards your colleagues, about last night’s dinner or what you did in the weekend. You will feel better right away because your mouth is smiling, which has the same biological effect as a genuine smile.” “It may sound unrealistic but even just thinking about laughing, even when you don’t feel like it, can have a positive effect on your mood,” says Petschner. “Try to consciously laugh for one minute. It may seem a little strange but you will soon start to laugh naturally. While laughing you are stimulating the nerves in your face, the brain registers ‘something is funny’ and everything else follows.” It’s easy to share a smile and incorporate humour everyday, especially on Smile Day. *Name changed. For more about New Zealand Smile Day and Clown Doctors, visit www.clowndoctors.org.nz Nursing Review series 2014
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Practice, People & Policy Mental health
‘Judging’
mental health nursing MARK SMITH of Te Pou puts the case for using ‘outcomes’ to judge ‘success’ in mental health nursing.
Mark Smith
‘Passing judgement’, being ‘judgemental’, ‘judging the worth of something’ are terms that elicit fear, consternation, and anxiety. “How dare they judge me?” is how the thinking goes. And “who do they think they are to pass judgement?” inevitably follows. Yet judge we do, whether we like it or not. We can’t stop ourselves. In terms of mental health services, I often wonder what criteria we use to pass judgement? There are lots of ways we could pass judgement: counting the number of staff employed by mental health services (an example of an input-based judgement) or counting the number of people seen (an example of an output-based judgement). But how do we judge what makes for a good mental health service? Until recently in New Zealand, inputs or outputs have generally been the favoured approach. However, outcomes may well be a better and fairer way of judging services. That is we may have inputs (money, resources, and staff) that generate lots of outputs (people seen, number of contacts, bed nights etc.) but to what effect? Outcomes can help answer this question. New Zealand has decided to develop an outcomesfocused mental health and addiction service. This approach to workforce development shows how outcomes and other indicators can be collected and used at both the individual and aggregated level. New Zealand has mandated using the HoNOS family of measures (see box). At the individual level outcomes can assist service users to set goals for their own recovery which can help them to recover more quickly. Clinicians are often buried under a considerable burden of information. Not all of it is equally important. A clinician who is more efficient and focused through their emphasis upon outcomes will have more time to devote to their core role.
A personal note Outcome measurement has played an important role in my own career. As an applicant for nurse practitioner registration in 2002, the Nursing Council – not unreasonably – wanted to know what evidence there was I was making a difference in my proposed new role. That role involved working as a nurse practitioner with young people at risk of self harm or suicide after being discharged from an inpatient unit. I found myself turning to HoNOS and HoNOSCA as a way of indicating the difference I was making. Though this didn’t always show positive change, it indicated that changes were happening in people’s outcomes. While not all these changes could be attributed to the work I was doing, it did provide an indicator of my 22
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contribution. This certainly helped with my Nursing Council application, and subsequent to getting my NP registration, it helped establish my role with collegues. While in my own clinical role I have found it useful to collect and use outcome measurement scores, I realise that there remains some scepticism in the sector about their usefulness. It is for this reason that I want to indicate what some of the clinical uses can be.
Overcoming outcome sceptics While outcome scores will be sent onto the Ministry of Health to become part of the national collection, many clinicians don’t get any aggregated reports back and wonder about their utility. However, in practice clinicians can use outcome measurement for a number of purposes at the individual level: »» Feeding back outcome scores to service users can help establish the therapeutic alliance and the rapport of the relationship. »» Developing plans based on the outcome scores can be a useful way of ensuring outcome scores, plans and clinical notes are all synchronised. »» Outcome scores can be a useful way of allocating referrals since they provide a way of determining the severity of presentations rather than simply relying on numbers. »» They can be a helpful way of determining when to discharge people, giving permission to discharge if someone repeatedly scores 0s and 1s. There are numerous aggregated uses for outcome measurement for reporting at team, DHB, and national level that can help with benchmarking services and identifying trends and patterns over time.
Stop Press: new measure for addiction services The ministry has signalled its intention to mandate the ADOM (alcohol and drug outcome measure) from
July 2015 for addiction services. This will mean that the HoNOS family of measures for mental health services and the ADOM for addiction services will be two mandated outcome measures. As the only currently mandated, routinely collected outcome measures in mental health services, the HoNOS family of measures provides one way of judging services. While we would never advocate using these measures to pass judgement in isolation, when combined with other indicators, they do provide a useful way of judging performance. Author: Mark Smith RN NP PhD is clinical lead for mental health and addiction workforce agency Te Pou.
What is HoNOS? HoNOS stands for Health of the Nation Outcome Scale. It collects information about a person’s mental health and social functionioning across 12 areas – eg. behaviour, delusions/hallucinations, and social problems and gives them a score of 0-4 (a score of 0 indicates no problem and 4 indicating a severe problem). The measurement scale was developed for people with severe mental illnesss by UK’s Royal College of Psychiatrists in the mid1990s at the request of the UK Department of Health. In New Zealand, HoNOS is used as the standard measure of mental health outcomes across mental health services. HoNOS scores are usually initially collected at admission to an acute mental health service, reviewed after three months and then periodically until discharge. Outcomes are calculated by the change in the HoNOS scores
Practice, People & Policy Professional Development
Postcards at the edge Initiating difficult conversations with the elderly or very ill about their end-of-life care is very much the ‘bread and butter’ of patient-centred nursing care. April 16 has been designated Conversations that Count Day as a national awareness day for advance care planning (ACP). Find out more ePostcards and eLearning in this sensitive but sensible area. Most of us want to die peacefully in our sleep at an advanced age. Many of us may end up dying attached to tubes in a hospital. Advanced Care Planning, promoted in New Zealand since 2010 by the National Advance Care Planning Cooperative, aims to prepare patients and families to make informed choices and plans about their future health care – especially end-of-life care. To help families and patients take the first steps to discuss what matters most to Aunt Joan or Poppa in the last months of life, the cooperative this year promoted Conversations that Count on April 16. Along with events and talks by nurses, GPs, and others involved in ACP, people were encouraged to send postcards – both electronic and real – to start a conversation with their family and friends on the topic, be it at round a family meal; a walk on the beach, a game of golf or fishing off the jetty (the
postcards posters and helpful advice on promoting conversations can be found at www.conversationsthatcount.org.nz) The cooperative, which now has 800 members nationwide, also offers training of GPs, nurses and other health professionals in ACP. The South Island Alliance of district health boards is promoting ACP throughout the south through its Health of Older People Service Level Alliance (HOPSLA). Late last year, nurse Jane Goodwin was appointed to the newly established role of ACP facilitator for Canterbury, but she has had a longstanding passion for the concept since researching her Master’s thesis in 2006. She has also been involved in the delivery of the ACP Cooperative’s training since 2013, which has taken her across New Zealand teaching the Level 2 ACP programme to health care professionals.
ACP training helps sharpen skills Goodwin says any health professional can have an ACP conversation and many have been doing so successfully for years. While there are no required competencies, the ACP cooperative does want nurses and other health care workers to ensure they are comfortable with the process – and aware
of the challenges discussing ACP may pose – before initiating such conversations with patients and their families. The cooperative has developed two levels of training to help nurses do just that – the first level is offered online via four interactive eLearning modules, which guide professionals through understanding the full ACP process, including the legal basis, how to explain the benefits of ACP, and when to refer a patient on to someone with level two skills. About 340 health care workers have completed the level one training programme since it went online in August last year. The second level course is delivered via a two-and-a-half-day, face-to-face course and trains people to be ACP practitioners who can initiate, facilitate, and participate in ACP conversations including assisting patients in the documentation of their ACP decisions. The 56th level two course got underway in April, bringing the number of level two trained staff up to about 550 plus. Goodwin says the ACP fits very well within the nursing scope of practice, as it is a process of conversations between patients, their families and their health professionals. “This is very much the bread and butter of nursing – patient-centred care.” She says the process is also not so much about completing a document – though some patients may wish to do so with a written advanced care plan – but about exploring what is important to the patient. “It may be that a nurse plants the ‘ACP seed’ with a patient when they are on the ward asking questions like ‘what is important to you about how we care for you’ or ‘have you talked to your family about what worries you about your condition?’ etc.” says Goodwin. “These conversations can then be continued by their general practice or their specialist or their community team on discharge.” She says in Canterbury a number of specialist nurses, working in areas like heart failure or motor neuron disease, have picked up and run with ACP and are completing the whole process with patients from inception to completion. “They have a strong relationship with their patients and are able to identify what the likely issues are for the patients as the diseases progress. “We are finding other nurses in general practice and the aged residential care sector are very happy to help facilitate the first parts of the ACP process – like exploring a patient’s beliefs and values – but will refer them to their GP to complete the advanced directive portion of the document.”
To find out more about Advanced Care Planning go to: www.conversationsthatcount.org.nz www.advancecareplanning.org.nz
Nursing Review series 2014
23
A round-up of national and international nursing news
For the record
Anger at new ‘barrier’ to NP practice Nursing leaders are angry and frustrated at moves to exclude nurse practitioner-led services from being eligible for general practice-only funding. The outcry is in response to current contract negotiations proposing that a general practice team has to have both GPs and nurses. The Government announced late last year that NPs and nurses could now join GPs in claiming GMS (general medical schedule) payments but the proposal on the table of primary health organisation (PHO) agreement negotiations would mean that only NPs and nurses working with a GP would be eligible for the funding. “The general practice team definition recognises that the full range of first contact services in general practice are best delivered by a team of health professionals that includes doctors and nurses,” said the Ministry of Health in a statement. Memo Musa, the chief executive of the New Zealand Nurses Organisation, and Professor Jenny Carryer, executive director of the College of Nurses, disagree, seeing it as another barrier to NPs helping meet patient needs. They both argue that a general practice team can be made up of either a general practitioner and/or a nurse practitioner
along with registered nurses and other health professionals. “Those of us who have spent more than 10 years now battling the tedious barriers to NP practice and to nurses practising at the ‘top of their licence’ see this as a potential additional barrier,” said Carryer. She also could not understand putting a “stranglehold” on the definition of general practice at a time when there was growing concern that it was getting “harder and harder” to find GPs to serve rural and vulnerable populations. “This is so contrary to notions of flexibility, responsiveness, and sheer pragmatism. It also ignores considerable long-standing evidence that nurse practitioners are able to deliver safe and effective care in a highly cost effective manner. “One asks whose interests are being served? It sure ain’t the patients.” Musa said the proposed definition had the potential “to close the door” on nurse practitioners contributing to innovation in general practice that could lead to improved access and outcomes in primary care. He added not allowing NPs to be eligible for the full range of funding opportunities in general practice was “a significant missed opportunity to provide effective care in areas that are already experiencing GP shortages”.
20 per cent of bumper new nurse cohort still job-hunting The number of new graduate nurse jobs has stayed static at around 900 for the third year running, despite the number of nursing graduates growing 25 per cent in the same time period. The annual graduate destination survey shows that while a bumper crop of 1323 registered nurses graduated in November 2013, the number of jobs has not grown to match, resulting in more new graduates than ever still jobhunting. Graduate employment reached a heady 85 per cent for the 1050 nurses graduating in November 2011 before dropping to 75 per cent for November 2012’s 1209 graduates and has now slumped to 69 per cent for the November 2013 graduates. For the second year running, the survey, coordinated by nurse educator organisation NETS, asked graduates without jobs whether they were actively looking for work. The survey found that 909 (69 per cent) were employed as registered nurses, 268 (20 per cent) were actively
seeking work, 51 (4 per cent) were not actively seeking work, and 95 (7 per cent) didn’t respond to the survey. The number employed in district health board medical or surgical wards dropped by 50, while the number employed in primary health care (including practice nursing) grew from 67 to 101 and the number finding jobs in ‘continuing care elderly’ grew from 81 to 115. The number nursing overseas fell from 38 a year ago to 24 this year, with the highest numbers working overseas being Otago Polytechnic graduates, with seven graduates nursing overseas. The job-hunting success rates for nursing schools ranged from 60 to 89 per cent, and despite well-publicised restrictions last year on new graduate jobs in Dunedin Hospital, 76 per cent of Otago Polytechnic graduates are in nursing jobs. In addition, despite calls to increase the Pacific nursing workforce, 44 per cent of Whitireia’s Bachelor of Nursing (Pacific) graduates were still job-hunting in March.
By FIONA CASSIE
“Excluding NPs from definitions of the general practice team may exacerbate inequalities in health.” Cathy O’Malley, a Ministry of Health deputy director general, and Jane O’Malley, Ministry of Health chief nurse, said in a joint statement that the extension to allow nurses and NPs to claim GMS had been “carefully organised” as an enabler for “team-based integrated care” and to ensure there was “not a fragmentation of service”. “This extension is not intended to apply to health clinics outside of general practice. It is however enabling of nurses, including nurse practitioners within general practice.” “The ministry will continue to work with the sector to ensure health practitioners working in other important models of care and settings, also have business models available to support those roles, including nurse practitioners who work outside general practice.” Carryer said she did not want NP-led services to be an exemption to the general practice model or “an inferior desperation move”. “Nor do I want to see the sector expending the time and energy we’ve spent fighting all the other ridiculous barriers. “It’s about wasting people’s energy which should be directed at caring for people, not by jumping through hoops and endless bureaucratic garbage to do the glaringly obvious.”
Recent nursing director appointments Three new nursing directorate positions were recently created at Auckland District Health Board. Brenda Clune has been appointed nurse director of adult medicine and cancer and blood directorates after previously holding the position of service manager for the neurology, urology, neurosurgery HSG (health service group). The new position of nurse director community and long-term conditions is being filled by Jane Lees, previous acting nursing director of adult, cancer, and cardiac directorates, who has a particular interest in the care of the elderly. The third new appointment is Anna MacGregor, who is nurse director for the cardiac, surgical, and perioperative services directorates after being nurse manager of the cardiovascular intensive care unit. Michele Coghlan took up her new role as director of nursing at MidCentral Health DHB in February. She was previously based at West Coast District Health Board, where she held numerous roles, including acting director of nursing, acting general manager of hospital services, and most recently, nurse manager at Grey Hospital. Plus check out these news articles online: Substantial jump in nurses getting flu jab to 55%: bit.ly/1ncCixv Changes afoot for nurse-led telehealth service: bit.ly/1j2FXr5
Meningococcal C can take it all away Meningococcal disease can kill in less than 24 hours. Children and young adults in New Zealand are well known high risk groups for meningococcal disease. Healthcare professionals have 25 times increased risk of invasive meningococcal disease compared to the general population1.
Protect with Meningitec Suspension for I.M. Injection Meningococcal Serogroup C Conjugate Suspension for I.M. Injection Vaccine Meningococcal Serogroup C Conjugate Vaccine
References: 1. Gilmore et al., Risk of secondary meningococcal disease in health-care workers. THE LANCET Vol 356 pg. 1644-1655. November 11, 2000. MENINGITEC (Meningococcal Serogroup C Conjugate Vaccine) contains 10µg of Neisseria meningitides serogroup C conjugated to 15µg diphtheria toxoid. Meningitec is given to protect children from 6 weeks of age, adolescents and adults against meningococcal disease caused by Neisseria meningitidis (c). Meningitec will not prevent meningitis caused by other groups of Neisseria meningitides or meningitis caused by other organisms. Meningitec has benefits and risks Do not have this vaccine if you are allergic to any of the ingredients in the vaccine including diphtheria toxoid or if you have had a previous allergic reaction to Meningitec. Delay vaccination if you have severe acute fever. Precaution if you have a reduced immune response, are pregnant or breast feeding or are elderly. Tell your healthcare professional if you are taking or have recently taken any other medicines. Side effects at injection site – pain, redness, swelling, tenderness. Systemic side effects – tiredness, irritability, decreased appetite, vomiting, diarrhoea, drowsiness. Talk to your healthcare professional to see if MENINGITEC is right for you. If you have side effects, see your healthcare professional. Meningitec is an unfunded Prescription Medicine – a charge will apply. For more information call 0800 Te Arai (832 724) or visit www.medsafe.govt.nz. Te Arai BioFarma, Auckland. TAPS CH3935
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