FOCUS: Learning & Leading
Nursing Review August/September 2014/$10.95
New Zealand’s independent nursing Series
A DAY IN THE LIFE OF A cosmetic nurse
Practice, people & policy
Boundary keeping Another opinion taster plate
Q&A
Margareth Broodkoorn
EVIDENCEBASED PRACTICE Home safe and sound
Learning & Leading Failing students clinically
Tall young poppies
Nurse endoscopist training on way
Where are the PHC nursing leaders?
www.nursingreview.co.nz
PREVENAR 13 is Now thE fully fuNdEd PNEumococcAl VAcciNE foR childREN.¹ ®
PREVENAR 13 has replaced PCV10* on the National Immunisation Schedule.1 So now you can give children the broadest coverage of any pneumococcal conjugate vaccine.2-4
®
*PCV10 = Pneumococcal polysaccharide conjugate vaccine, 10 valent adsorbed.
References: 1. PHARMAC Notification Document, http://pharmac.health.nz/news/notification-2013-12-17-national-immunisation-schedule-changes/. 2. PREVENAR® Approved Data Sheet, 1 November 2010. 3. PREVENAR 13® Approved Data Sheet, 10 March 2014. 4. Synflorix Approved Data Sheet, 29 July 2013. Before prescribing, please review Data Sheet available from Medsafe (www.medsafe.govt.nz) or Pfizer New Zealand Ltd (www.pfizer.co.nz) or call 0800 736 363. ®
PREVENAR 13 (30.8 µg of pneumococcal purified capsular polysaccharides) suspension for I.M. injection Indications: Active immunisation for the prevention of disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F in infants and children from 6 weeks up to 5 years of age and in adults aged 50 years and older. Contraindications: Hypersensitivity to any component of the vaccine, including diphtheria toxoid. Allergic or anaphylactic reaction following prior administration of 7vPCV. Precautions: Do not administer intravenously, intravascularly, intradermally or subcutaneously. Avoid injecting into or near nerves or blood vessels. Do not inject into gluteal area. Postpone administration in acute, moderate or severe febrile illness. Only protects against Streptococcus pneumoniae serotypes included in the vaccine and may not protect all individuals from pneumococcal disease. Consider the risks of I.M injection in infants or children with thrombocytopenia or any coagulation disorder. Appropriate treatment and supervision must be readily available in case of a rare anaphylactic event. Prophylactic antipyretic medication is recommended for children receiving concomitant whole-cell pertussis vaccines, and for children with seizure disorders or history of febrile seizures. Consider the potential risk of apnoea when administering to very premature infants. Adverse Effects: Very common/common: Injection site reactions; fever, chills; decreased appetite; vomiting; diarrhoea; rash. Drowsiness; restless sleep; irritability in children. Fatigue; headache; new or aggravated joint or muscle pain in adults. Uncommon/Rare: Hypersensitivity reaction; anaphylactic/anaphylactoid reaction; angioedema; erythema multiforme. Seizures, hypotonic-hyporesponsive episode in children. Others, see full Data Sheet. Dose: 0.5 mL I.M. Infants 6 weeks to 6 months of age: 3 doses at least one month apart. A single booster should be given in the second year, at least 2 months after the primary series. Previously unvaccinated children: Varies with age at first dose, see full Data Sheet. Children aged 12 months to 5 years who have completed primary infant immunisation with Prevenar (7vPCV) may receive 1 dose, at least 8 weeks after the final dose of 7vPCV. Adults >50 years: 1 dose. If sequential administration of Prevenar 13 and 23vPPV is considered, Prevenar 13 should be given first. Medicines Classification: Prescription Medicine. V10812. ® Registered Trademark Pfizer New Zealand Ltd, PO Box 3998, Auckland, New Zealand 1140. DA 3414SW. BCG2-H PRE0248. P8839 06/2014
Inside: Focus: Learning & Leading
Letter from the Editor New graduate employment: trapped in a cycle? One of my first reporting tasks for Nursing Review was photographing striking Christchurch nurses in early 2002 – I recall my toddler son waving at them from his buggy. Looking back at those early editions, the news pages were full of nurses frustrated by understaffing, unfilled vacancies, and lack of nurse leadership, while the back pages were full of job ads – lots of them – not specific jobs but generic ads for ‘staff nurses’, ‘registered nurses’, or ‘nursing positions’. The country’s hospitals were desperate for nurses. The theme continued for much of the next decade, while the tide of interest in nursing started to turn with the ‘fair pay’ deal of 2005. This was when the inaugural, government-subsidised nurse entry to practice (NETP) programmes were rolled out in mid2006 and there were more hospitals wanting new graduates than new graduates keen to work for them. This situation remained right through until the end of 2008, when the global financial crisis (GFC) brought the ‘perfect storm’. The recession saw turnover and vacancies fall as more nurses stuck to their jobs or returned to the workforce; nursing school enrolments surged, with many seeing nursing as a secure career, and district health board recruitment budgets got tighter and tighter. The first hint that those bumper cohorts of nursesin-the-making would face the toughest job market since the early 1990s was when Nursing Review reported in July 2010 that once sought-after mid-year graduates were now graduating without a job to go to. The trend – an international one, as New Zealand is far from alone – continued to worsen. Even though nurse leaders scrambled to find new NETP places, the graduating cohorts grew faster. The result has been too many frustrated new graduates having been told that a nursing shortage loomed but are now getting the message ‘yes, we will need you in the future – just not right now’. So now an NZNO-led petition of 8,000 signatures has been presented to the Health Minister Tony Ryall, calling for 100 per cent of new graduate nurses to be found NETP places. The risk of losing too many disillusioned new graduates now is that, when the inevitable nurse shortage hits, they will be long gone. And the cycle will begin once again. Fiona Cassie editor@nursingreview.co.nz
www.nursingreview.co.nz Twitter@NursingReviewNZ
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: Margareth Broodkoorn – Northland DHB’s director of nursing and midwifery and the lead DHB DoN for Ngā Manukura o Āpōpō – is our Q & A profile on p.2 this edition. PHOTO CREDIT: Glenn McLelland, www.aerialvision.co.nz Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
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RESEARCH: failing flailing students with SALLY DOBBS
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Wanted: more PHC nursing leaders with a capital ‘L’
9 Directors of nursing: Caught between a rock and a hard place? 10
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Flying high – a leadership programme for tall poppy recent grads
PROFESSIONAL DEVELOPMENT: nurses share their career paths
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The tale of an evolving new role – nurse endoscopist
RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe
Practice, People & Policy 18
Maintaining boundaries advice with nurse-turned-lawyer ROBIN KAY
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Online Opinion ‘tasters’ menu:
MARK JONES, weary of election billboards, asks for more policy analysis
ANDY McLACHLAN enthuses about technology as cool as Star Trek
DARYLE DEERING’s report card on Mental Health still shows room for improvement
Regulars 2
Q & A Profile: lead DoNM for Ngā Manukura o Āpōpō MARGARETH BROODKOORN
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A day in the life of… cosmetic nurse ANGELA FRAZER
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Evidence-based Practice: Preventing re-admissions
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College of Nurses column: JUDY YARWOOD’s election challenge
Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ Editor Fiona Cassie Advertising Belle Hanrahan editor-IN-CHIEF Shane Cummings production Aaron Morey Dan Phillips David Malone Publisher & general manager Bronwen Wilkins Photos Thinkstock
Nursing Review
Vol 14 Issue 4 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
Margareth Broodkoorn
JOB TITLE | Director of Nursing and Midwifery (DoNM), Northland District Health Board & DHB sponsor of Ngā Manukura o Āpōpō, the national Māori nursing and midwifery workforce development programme.
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Where and when did you train? Graduated in 1989 from one of the last hospital-based training programmes at Greenlane School of Nursing.
What do you love least? There are not enough hours in the day or days in the week to do what needs to be done. I think Cliff Curtis articulated it well when he sang John Rowles’ “If I only had time …”.
Other qualifications/professional roles? Realising the need for a higher qualification, I completed a Bachelor’s degree at Unitec (1996), then a MHSc Nursing 1st class Hons at the University of Auckland (2006). My thesis title was “He Puawaitanga no nga Ao e rua; The Best of Both Worlds”. It explored the relationship between kaupapa Māori and participatory action research methodologies in supporting Māori community development.
If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? 1. More Māori student nurses 2. More Māori new graduate nurses 3. And more Māori nurse leaders
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What are the characteristics of a good leader? Are they intrinsic or can they be learnt? A colleague of mine recently shared her adaptation of The Seven Habits of Highly Effective People (Stephen Covey’s work), which I think are so applicable to the characteristics of a good leader. A leader needs to be kind, be clear in one’s intentions and direction, be loyal and true, keep promises, say sorry with sincerity and say thank you. While these characteristics can be learnt, these abilities are intrinsic and come naturally to a great leader.
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Why did you decide to become a nurse? It sounds a little predictable, but my mother was a nurse. Growing up with a mother who was a nurse and a father who was in the military, I had a couple of career options. However, Dad definitely did not want me to go into the army. I literally grew up at the old Kingseat Hospital, where my mum worked as an enrolled nurse. I was exposed to a lot of positive role models who were strong Māori mental health nurses who kept me on track. While I chose not to work in the specialty of mental health nursing, the guidance of my ‘aunties’ provided me with a solid foundation on which to build a nursing career.
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What was your nursing career up to your current job? While I have travelled overseas, my nursing career has all developed in Aotearoa. My clinical practice has included haematology, general surgery, and gynecology and obstetrics theatre nursing. I have enjoyed education roles at MIT and UoA specialising in kawa whakaruruhau/cultural safety and Te Tiriti o Waitangi training. I then progressed into management and leadership roles as the assistant DoN: Māori with Auckland DHB, managed a Māori health provider service, and then returned home to Hokianga as a community development manager before starting the director role in 2010.
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So what is your current job all about? I have the best job ever as the director of nursing and midwifery for Te Tai Tokerau, Northland. While employed by the DHB, the DoNM role has a district-wide responsibility for leading safe and effective nursing and midwifery practice, ensuring we provide the best care for our Northland community.
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I am a member of the executive team that includes the DHB CEO, our partner PHO CEOs (Manaia and Te Tai Tokerau PHOs), the chief medical officer and GM colleagues. Other potae (hats) that I wear as an executive member include sponsorship for advanced care planning, workforce development and smoking cessation. As the sole DHB DoNM who identifies as Māori, I sponsor Ngā Manukura o Āpōpō, the national Māori nursing and midwifery workforce development programme. NMoA has gone from strength-tostrength building on the programme that was initially situated within ADHB. The programme has graduated over 160 leadership candidates, developed an ePortfolio for nurses and midwives, piloted the Poutama programme (a workplace competency assessment framework) and published a midwifery mapping project and tertiary education scorecards.
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What do you love most about your current nursing leadership role? Being a nurse in Northland. The DoNM role epitomises all that I love – leading nursing practice, influencing change in health care, and the opportunity to do what I love in the place where I was born. Obviously, I can’t do this alone, and I am surrounded by amazing nurse leaders employed in various settings across the DHB and primary health organisations.
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What do you do to try and keep fit, healthy, happy and balanced? Can’t say I do this very well at all, although my Staffordshire bull terrier helps by taking me for regular walks on the beach. My 16 and 18-year-old teenagers keep me grounded – watching my son playing rugby every weekend and keeping up with my daughter’s shopping sprees. Lately, I have found the benefits of Thai massage very therapeutic.
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What is number one on your ‘bucket list’ of things to do? Visit Amsterdam (where my father was born) and my Dutch whanaunga in Holland, along the way take a walk along Broodkoorne St in Belgium.
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If I wasn’t a nurse I’d be a… Singer – who am I kidding? In my dreams I can hit those high notes, reality is far from it. It is amazing how good a loud radio can make you sound.
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What is your favourite meal? I am from the Hokianga so it is only natural that I love kaimoana – crayfish, paua and cream, kina, oysters, mussels … which is why I like going home especially when the boys have been out diving! Tino reka (delicious).
A day in the life of a ... cosmetic nurse
NAME | Angela Frazer JOB TITLE | Plastic Surgical Nurse Consultant/ Clinic Co-coordinator LOCATION | Prescription Skin Care, The NZ Institute of Plastic and Cosmetic Surgery, Remuera Auckland.
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AM WAKE UP TO ALARM My alarm is usually set for 6.40 am. However, this morning David is flying to Queenstown. I had planned to get up too, and go for a walk …
6.40
AM actually get up On rising, I shower, do my skin care regime, make my lunch, breakfast on egg, toast, and coffee while watching the TV breakfast news. Then it’s make-up on and out the door for the short drive to work.
8.05
AM ARRIVE AT WORK My official start time is 8.30. However, I often have a patient booked for then, so I always like to arrive early to be prepared. I have been working as a cosmetic nurse and skin care specialist for nearly 18 years. My prior nursing includes working two years at the dermatology unit of London’s St Thomas’ Hospital and seven years at Middlemore Hospital’s acute plastic surgery and burns unit, where I completed a postgraduate diploma in plastic and reconstructive surgery. In 1997, I was invited to join this private practice to supervise medical skin care programmes and train as a collagen injector. Around 1999, I also became one of the first practitioners to administer botox in New Zealand. What I love about my job is that I get to combine all my nursing experience and knowledge with the artistic/creative skills required. It is a very positive role, and I love the feedback from patients and knowing that I am making such a difference in their self-esteem and confidence, particularly when it comes to improving skin concerns such as acne and rosacea. Today, my first patient isn’t until 8.45, so I take my iPad upstairs and spend 15 minutes with plastic surgeon Stephen Gilbert (our medical director) reviewing ‘before and after’ photos of one of my patients (who has had dermal fillers with me) and is now considering surgical options.
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AM: FIRST PATIENT OF DAY My first patient has been coming to me for botox and dermal fillers for 14 years, but today she is having a consultation about a non-surgical, permanent fat reduction treatment (involves freezing fat cells). My next patient is for a dermal filler topup’ treatment. I review her previous ‘before and after’ photos, which show a significant improvement. She is very pleased with the result but would like to further soften the lines around her mouth.
10.20
AM CHECK MY DAD As I finished ten minutes early with my last patient, I pop upstairs (where the plastic surgeons consult) to see my dad, who is having a follow-up visit after having a skin cancer removed from his leg with a flap repair. With my background, I have been given the job of changing Dad’s dressings between appointments!
10.30
AM regulars return Back downstairs to see my next patient, who is booked for botox. I have not seen her for over two years, and she explains this is due to finances. I update her medical form, and we discuss her priorities and budget. In the past, she treated her frown and the lines around her eyes, but today we treat only her frown. I notice she is very tanned, and discuss the importance of daily use of a zinc-based sunscreen and give her some samples. My next lady has been coming to me for 15 years and is now in her late sixties. We discuss her concerns, I make treatment recommendations, and together, we decide on a treatment plan for the year ahead. She tells me that this year she is going to focus on looking after herself.
3.00
PM quick break A quick bathroom stop, and I write up my previous patient’s clinical notes.
12.10
3.15
12.30
4.00
pm LUNCH She was a long-term patient and one that likes to chat … as do I … so I’m now running ten minutes late and eat my salad for lunch (a little too fast!). PM BACK TO WORK My afternoon starts with two more botox patients. I finish ten minutes ahead of schedule, giving me time to prepare a botox and dermal filler product order. Then another quick filler treatment followup and photos.
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PM new patient I welcome a new patient. It is a very ‘full’ consult, as she wants to find out about options for skincare and pigmentation, botox, fillers, and laser treatments. The 45 minutes fly by. I don’t have time to write up her clinical notes as my next patient is waiting!
2.30
PM crow’s feet Another follow-up and further botox treatment, as my patient would now like to treat her crow’s feet as well as her frown. She is a flight attendant, so she shares travel tips for San Francisco, where I’m attending a conference next month.
PM patient confidentiality Another filler patient. She doesn’t tell anyone she has been having treatments with me for the past 10 years but says people always comment how great her skin looks.
PM TEARS My next patient walks in and bursts into tears due to “everything going wrong” with her day. I offer to reschedule but she is definite she wants a treatment, so after 15 minutes of chat and ten minutes of actual treatments, she leaves with a smile on her face! My last patient for the day gets stuck in good old Auckland traffic and is 20 minutes late. I’m meant to finish at 5pm. However, after she leaves at 5.10pm, I finally get to turn on my laptop and catch up on emails.
6:00
PM HOME I watch a bit of the news, phone my mum, and before I know it, it is 7.15 and David arrives home. I make dinner and remember that yesterday I had promised to answer some questions on the latest trends with fillers for a beauty editor, which I do before heading upstairs for a shower.
10.10
PM SLEEP
Nursing Review series 2014
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FOCUS n Learning & Leading
Learning & Leading FOCUS: In this edition we once again look to nurses as learners, educators and leaders. Read on about failing students and high-flying graduates, the steps towards the new nurse endoscopist role, nurses sharing their career paths, nursing leaders with too little power, and health sectors with too few nurse leaders.
Nurses too nice or too wary to fail nursing students? Sally Dobbs
Some nursing students shouldn’t ever become nurses. But failing them is easier said then done – a process not helped by the looming possibility of facing not only unhappy students but also their parents and lawyers. FIONA CASSIE talks to Sally Dobbs about her doctoral research into nurses failing nurses-to-be.
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ally Dobbs spent most of her nursing career in the British military. In combat, you don’t get second chances, says Dobbs. She was very much accustomed to the culture that if you fail to make the grade, you’re out – be you a soldier who can’t fire a gun correctly or a nurse whose practice is unsafe. So she was somewhat surprised just days after entering ‘civvy street’ down under to hear a clinical nurse educator ask the question: “What do we do if we have a failing student?”. “I thought that was absolutely clear – fail them,” recalls Dobbs, who at the time was coming to grips with a new country and a new job as programme leader for third year nursing students at the Southern Institute of Technology (she is now head of the nursing school). But as the discussion ensued, she realised failing a failing student was not as simple as it sounds, and her other dilemma – finding a doctoral research proposal in a hurry – was resolved. Soon after, she had her own first-hand experience of failing a Kiwi student: a third year student who had provided “really, really unsafe care” during her clinical practice placement. “Boy, did we have problems actually failing her.” With lawyers called in to challenge the decision, Dobbs went through the student’s second year assessment notes and found the student had attempted to take a blood pressure with the cuff on one arm and the stethoscope on the other. “She couldn’t understand why she couldn’t hear a blood pressure.” After a second go at the clinical placement, and excuses being made for her, she was allowed to enter the third year, where things got steadily worse.
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A literature review early in Dobbs’ research revealed to her that nursing was not unique in struggling to fail students on their practical skills, with teacher, medical, occupational therapy, and social worker educators also finding the process challenging. Her next step was to interview 14 clinical nurse educators, employed by polytechnic nursing schools across the country to assess students during clinical placements*, about their experiences of assessing ‘failing’ students (*ethical approval precluded Sally conducting interviews within her own institution). The educators had a range of experience and qualifications, with five having a Master’s degree and a teaching qualification, but the majority were still studying towards a teacher qualification. Eight of the educators had failed students – with the least experienced less likely to fail someone – and five of the 14 had regretted not failing a student. Dobbs found the clinical nurse educators straddled, somewhat uncomfortably at times, two worlds: the nursing world, with its caring ethos and professional responsibility for patient safety, and the education world, with its different responsibilities, including to the student.
Would I want them nursing my loved ones?
The common ‘litmus test’ used by educators when making the call to pass or fail was “would I want this person looking after me or my family member”, says Dobbs. But some educators still opted out of failing students, with some confessing “I just hope someone else catches them later”.
FOCUS n Learning & Leading Dobbs’ thesis – due to be submitted for her Doctor of Education degree later this year – is exploring why nurses failing would-be nurses appears to be so hard. Assessing clinical practice at first-year level is often a simple tick box list to check off when students wash their hands, introduce themselves etc., but it becomes more complex and nuanced as students enter second and third year and begin being assessed against the Nursing Council’s competency domains. Assessing clinical practice is also not as black and white as marking a written exam. Dobbs says a number of the educators reported being “thrown into the world of education” with minimal training on assessment, particularly with the novices finding failing hard. One “very nurturing” educator, who was also very new to the role, reported she would do anything she could to help a student pass. Themes raised during the educator interviews included confusion over the point where an educator stops teaching and starts assessing a student’s clinical skills; assessing a student on a practicum in an area, like Plunket or district nursing, where a student is more often observing than delivering care; or if the placement was only for a week or too short get a clear picture of the students ability in that practice area. “The duration and location of placements was really important.” Educators always seek additional feedback from the students’ nurse preceptors, but even that has its limitations, as some preceptors aren’t well-prepared, preceptors may have different expectations and criteria from educators over what is a work-ready nursing student, and a student may have many different preceptors throughout their clinical placement. Dobbs says educators also reported dilemmas of having students who showed great aptitude for surgical nursing but showed no empathy in mental health settings, or vice versa. “But they have to pass absolutely everything,” says Dobbs, as the New Zealand degree is a comprehensive degree and registration allows them to work in all fields. This meant talk of passing students, as while “they’d be no good in surgical, they’d be all right in aged care”, which was of concern. Intro Some ??????? educators, when wobbling on the fence over a student’s clinical performance, let the student’s academic record sway their decision. “They are really good in the classroom – they are getting A’s in sociology and sciences so they will be fine – they will be a good nurse,” was the rationale they gave for passing a marginal student. Dobbs says educators also showed they were influenced by the ‘halo effect’, where people find it much harder to fail a student they like. Other themes that emerged included educators wanting to be popular and liked by students rather than having a reputation for failing, plus the need for educators to be ‘strong’ and have enough courage in their convictions to follow through and fail an unsafe student. A number reported opting out of taking responsibility for failing a student and handed on their assessment to the next in line, saying, “it’s not my job to fail” and it was “management’s problem”. Those who did fail students often felt “gutted” and all felt unsupported.
Education Commission. Dobbs says at least two polytechnic chief executives had made it clear to staff that nursing schools were not to consider themselves ‘gatekeepers’ to the nursing profession. That tension between the two worlds is heightened when a student appeals. Students bringing in lawyers to fight an appeal case is far from unknown, and Dobbs says nurse educators are all very aware that their decision may be scrutinised in an appeal process. “They find it very stressful.” She says educators feel their professional integrity is being challenged, and some also shared “harrowing stories” of being physically threatened by students and facing angry parents. “A lot of people are taking massive proactive measures to make sure they have their own files on students,” says Dobbs. A key reason was to have evidence if a decision was appealed, and if the need arose, to take to the Nursing Council. A number of educators spoke of having their decisions overturned by somebody further up the chain or during the appeal process. “It’s farcical to fail because so many decisions are overturned,” is how one educator put it to Dobbs. Some also reported that Nursing Council standards were “being overridden” by their polytechnic’s appeals process.
Failing someone can be less fraught
Failing someone is never easy for either the assessor or the student, but Dobbs believes that doesn’t mean the clinical assessment process cannot be improved. She points to the UK model, which has adopted ‘essential skills clusters’ that set out clear national criteria for clinical skills – from compassion to fluid monitoring and communication to taking blood pressures – that must be achieved by certain ‘progression points’ along a nursing training programme. Along with considering national clinical assessment criteria, Dobbs would like to see more support and accountability for clinical nurse educators, including a nationally recognised training programme in clinical assessment. She would also like to see more student accountability, with the possible adoption of student ‘indexing’ or ‘registration’ like that carried out by the Australian Nursing and Midwifery Board. Failing a nursing student may never be clear-cut in the military sense, but maybe it can be less fraught and more transparent for all involved.
Appeals, lawyers, and professional integrity
The ‘failing’ stakes go up if a struggling student is allowed to move from year two to year three; added to the educator’s ‘pass/fail’ dilemma is the time and money a student has invested in getting a nursing degree. The stakes get even higher if a student has already failed that clinical practicum once before, as Nursing Council policy is for no student to have more than two opportunities to pass a clinical experience placement. Straddling the two worlds of nursing and education also raised questions over who the educators were foremost responsible to when considering failing a student: the nursing profession, with its responsibility to protect patient safety? Or their polytechnic employer? In the current education environment, polytechnics are under pressure to balance maintaining academic standards and their obligations to their funders – the fee-paying students and the Tertiary Nursing Review series 2014
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FOCUS n Learning & Leading
More PHC nursing leaders needed with a capital ‘L’ Intro ??????? Public Hospitals had matrons, but publicly funded, privately owned general practices have no such nurse leadership tradition. In 2014, more than a decade on from the Primary Health Care (PHC) Strategy launch, nursing leadership in the sector remains ad hoc. FIONA CASSIE finds out more and why there are calls for PHC nursing to have a consistent leadership structure across the country – and soon.
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here are a lot of leading nurses in primary health care, but not so many leaders with a capital ‘L’ … or the word ‘nurse’ in their job title. Instead, there are clinical directors, quality managers, programme facilitators, practice liaison leaders, clinical service managers, integration facilitators, and a host of other combinations and permutations of health monikers. Some of these titles have professional responsibility for nursing in their job descriptions, others do not. The PHC philosophy is to provide collaborative and interdisciplinary care that puts the patient at the centre. But many in nursing argue that this doesn’t mean that nurses – typically the under-represented half of the health professional workforce in general practice – shouldn’t have a professional and clinical leader with a capital ‘L’ batting on behalf of them and their patients. For this reason, earlier this year, the College of Primary Health Care Nurses went to the National Health Board and requested the board work with nursing bodies to speed up the development of a nursing leadership structure for primary health care. Rosemary Minto, former president of the College of Primary Health Care Nurses and a primary health nurse practitioner, says the college has been arguing for a long time that there is no consistent leadership structure for nursing in the primary health care sector. She says district health board DoNs (directors of nursing) already have very wide briefs and can only do so much.
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“A lot of the primary health organisations (PHOs) don’t have the capacity or capability to maintain a formalised PHC leadership structure. Minto thinks the time is not only ripe but also overdue to have a nurse leadership structure with expectations for alliancing between DHBs and PHOs and integrated health services. “If you don’t have strong (nurse) leaders leading that change nationally, regionally, and at a local level, then the change isn’t going to happen as fast as it needs to,” believes Minto. She says despite all the best efforts of nurses on the ground, they can only get so far in building a leadership structure without help from the key organisations involved.
Pioneering leadership role
Back in 1997, when Shelley Frost took up her role as nursing facilitator for Canterbury’s Pegasus Health, she had few role models to turn to. “When I began, I can’t remember any equivalent roles nationally. It was a blank sheet of paper, really,” says Frost of her pioneering role at Pegasus (which was initially an independent practitioner association but is now also Canterbury’s largest PHO). Her role kept stepping up the ranks until in 2002 she became director of nursing – a role she only recently resigned from. Frost continued to be a ‘poster girl’ for practice nurses, rising through the ranks by becoming first the deputy chair of General Practice New Zealand, which represents 14 general practice networks across the country, with about 2,000 GPs and 2,000 nurses – then its first executive director of nursing, and finally, she added the role of chair in 2012.
“There’s always been (PHC) nurses who have assumed leadership roles,” says Frost. “Though perhaps [leadership] with a small ‘l’.” “It took some time for the IPAs (former independent practitioner associations) to move from being quite medically dominated organisations to taking that team approach,” she adds, along with her thanks to former Pegasus leader and GP Paul McCormack, whom she says “very much modelled” the doctor/nurse team approach in Pegasus. Frost acknowledges that not all IPAs-turnedPHOs have followed. “We still have a significant amount of variation in the PHOs in terms of how nursing is acknowledged and developed … not necessarily all have nurses at governance level or at the executive management team level. “But those nurse (leaders) that are there in primary care are quite visible, they are strong leaders, they are bringing about significant change, and they are well thought of in the primary care world.” Frustration surfaced last year, which led to a letter to the Ministry of Health from the College of PHC Nurses NZNO and the College of Nurses Aotearoa about the lack of nurses around the table during the negotiations of the new PHO agreement. Some nurse leaders have argued that one barrier to more nurses on executive teams and governance boards in the primary health care sector is the funding model and the predominantly GP or private ownership of general practices. Frost says it probably comes as no surprise that she has never subscribed to the view that the
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Rosemary Minto
Shelley Frost
ownership model is holding back nurse leadership development or nursing innovation. She also refutes that nurses weren’t involved in last year’s negotiations, pointing out that there were nurses involved in supporting and advising the provider representatives put forward by the General Practice Leaders Forum, which includes the PHC nurses college, GPNZ and the rural nurse and GP organisation Rural General Practice Network. “GPNZ is one of the negotiating bodies of the contract, and as you know, their chair is a nurse. “I absolutely believe there should be dedicated nursing leadership positions and an infrastructure that sits beneath that role,” says Frost. She believes nurses need to be proactive to achieve this. “Nurses need to not sit back and (wait to) be invited to the table,” says Frost. “They need to be articulating what contribution they can bring and not be afraid to do that. Intro ??????? “Where there are nurses able and willing to step up and make a meaningful contribution, I think by and large they are welcomed into the fold.” Frost says that each of the 14 PHO or network members of GPNZ is encouraged to bring their nursing leaders to the GPNZ Council meeting. Currently, up to half-a-dozen nursing leaders attend.
Where are the missing leaders?
When Rachael Calverley in 2011 went in search of the nurse leaders of nine primary health collectives for her Master’s research, she found it no easy task.
Rachael Calverley
Karyn Sangster
The Waitemata director of nursing wanted to see what influence nursing leadership had on primary health innovations underway under the nine Better, Sooner, More Convenient (BSMC) business cases. In some cases, it was simple – there were known and titled nurse leaders. But other leading nurses in BSMC were nurse leaders only of the inverted commas variety and not by job title or description; these she had to track down through the PHO CEO and other mechanisms. “One of them couldn’t do the interview because her position was subsequently disestablished, which I felt was quite telling in itself,” says Calverley. The ad hoc nature of the nurse leadership roles left her convinced that work needs to be done on developing PHC nursing leadership, particularly in the current alliancing climate. “If we are going to have a number of services devolved or integrated into primary healthcare or the community, we need to have nurse leaders helping to steer that direction.” Her research showed that nursing leaders needed to be resilient and ready to fight to be visible, and unfortunately, they still faced “tall poppy syndrome” from some nursing colleagues. She identified that challenges and issues facing the leaders included variable investment in nursing leadership infrastructure, interdisciplinary relationship issues, limited training for nurse leaders, and that most were working in a generic management model rather than a professional practice model.
What models are out there? DHB and PHO PHC DIRECTORS OF NURSING (DoNs)
Three district health boards have PHC nursing leaders on the DHB’s executive team. Capital and Coast DHB has Vicky Noble (director of nursing, PHC & integrated care), MidCentral DHB has Chiquita Hansen (director of nursing PHC and executive director of the region’s Central PHO – see more below), and more recently Counties Manukau DHB has appointed Karyn Sangster (nurse leader PHC). Waitemata and Auckland DHBs have a shared primary healthcare nursing director, Jean McQueen, who isn’t on the DHBs’ executive teams. Some DHBs such as Waitemata and Southern, have one main PHO each with a PHO nurse leader reporting directly to the PHO chief executive. Waitemata has Rachael Calverley (director of nursing) and Southern has Wendy Findlay (nursing director).
Other partnership models
MidCentral Chiquita Hansen has the novel dual role of being the DHB’s director of nursing PHC and the Central PHO’s executive director. The DHB won Ministry of Health PHC nursing innovation funding in 2003 to build primary healthcare nursing capacity and leadership, and Hansen was appointed PHC DoN in September 2003. A PHO and DHB proposal also was selected in 2008 as one of the nine Better, Sooner, More Convenient business cases, and the board and PHO are now closely intermeshed. Northland has a partnership model between Northland DHB and the region’s main PHOs. It has two associate directors of nursing, primary healthcare – Mary Carthew at Manaia Health PHO and Hemaima Reihana-Tait at Te Tai Tokerau PHO. Canterbury was an earlier adopter of the whole-of-system approach to health, so the DHB’s executive director of nursing Mary Gordon heads the region’s nursing structure, underneath which are hospital directors of nursing and longstanding primary care directors of nursing out in the community, such as like Shelley Frost (and her successor) at Pegasus Health PHO and Sheree East at Nurse Maude. All the nursing directors meet once a month.
Chiquita Hansen
“There’s no point in having a director of nursing if it’s a tokenistic DoN and they aren’t able to influence funding and planning. “Having nurses sitting at the strategic table being able to influence service planning is really critical if we are going to get it right for our patients over the next five to ten years,” she says.
Filling the leadership gaps in some big PHOs
Nursing leadership models in primary health care have progressed and improved in recent years but continue to be fluid. An example of this is trying to find a nurse spokesperson for two of the country’s largest PHOs – Waikato-based Midlands Health Network (Pinnacle) and Auckland’s ProCare. Midlands’ former director of nursing Lindsey Webber has moved on and Midlands CEO John Macaskill-Smith responded to Nursing Review queries, saying the PHO had taken the opportunity to review how best to support nursing development across the network’s 400 nurses. He said the ongoing review had highlighted a “range of key areas” requiring different approaches – including professional development, clinical management, and development of new models of care – and it was unlikely it would follow the “more traditional route of appointing a DoN” and instead appoint a number of nurse leaders to lead the key areas. In the meantime, he said the PHO had three experienced nurses step up to form a nursing leadership team. Seeking out a nurse spokesperson for ProCare, with its 500 GPs and 600 nurses, was also not easy, with its website listings for executive and senior management team members not including a named nurse leader. A spokesperson said that ProCare’s COO Denis Baty and newly appointed medical director Allan Moffitt (both away at time of going to press) were – as part of moves to continue strengthening its clinical leadership – to make new nursing appointments; these were to include a new strategic nursing role, which would be a senior management role, on the clinical directorate working alongside Dr Moffitt. The news of ProCare’s impending new nursing appointments is welcomed as fantastic news by Karyn Sangster, a long-term nurse leader in primary healthcare who was last year appointed to become Counties-Manukau DHB’s first PHC nurse director. Sangster is not a DoN by title but is in role, as she sits on the DHB’s executive team, which she says is “vitally important” to translate the strategic direction for PHC nursing to and fro between the DHB and community. She has a broad brief including hospice and district nurses, along with the five PHOs – ProCare amongst them –working in the DHB’s region. “There’s no one (nursing leadership) model across all the PHOs, so it’s about trying to find where you need to go to influence nursing activity and nursing roles.” Nursing Review series 2014
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FOCUS n Learning & Leading Sangster agrees there definitely needs to be nurse leadership in PHOs to not only influence the clinical direction of nursing services but also to take professional responsibility to ensure nurses have the right resources, skills, capacity, and knowledge to deliver those services to patients. She believes it is also important for PHO nursing leaders to form a broader network with the community nursing (and other health professionals, such as, increasingly pharmacists) that also support patients in their community, so they can provide connected care and not duplicate each other’s work. In Counties-Manukau, PHC nurses across the region, from PHOs to youth health centres, have been meeting for over a decade.
She also acknowledges that not all PHOs are at the same point, and for PHOs still trying to develop nursing capacity and capability, “good strong nursing leadership is vital”, including nurses at the PHO board table. Hansen says they have hosted visits over the past half-a-dozen years from many DHBs and PHOs keen to find out more about the model and there’s no lack of willingness to replicate it elsewhere. “People leave with a lot of passion and commitment to go back to their own places … but they don’t have access to the resources to make it happen.”
A leading leadership model
Some DHBs, such as MidCentral, CountiesManukau, and Canterbury, have had a decade or more of building a primary healthcare culture where nurse leadership is increasingly the natural and accepted norm – but other regions are further back in the evolutionary chain. So how do you ensure that a new generation of leaders is ready and able to fill the current gaps in the ad hoc and uneven PHC nursing structure across the country? “GPNZ can and does play a role in supporting and developing nurses to be able to step up into those more governance and leadership and influencing roles,” says Frost. The organisation recently had more than 90 current or aspiring nursing leaders attend a leadership development day, and she works with a small executive team of six general practice network nursing leaders – not all directors of nursing but all with influencing roles. Frost emphasises again her belief that nurses have to be proactive and prepared to advocate what nursing has to offer and not just wait for opportunities to be offered to them. “Absolutely. I just didn’t sit back and wait to get invited to a number of tables,” she laughs. Calverley agrees that nurses need to stand up and be accountable and says her research made it clear that nurses needed to be more politicised if they want to leverage a key place for nursing at the leadership table. “It would be great to see more education and training into strategising, how to negotiate, and how to be confident in strategic forums and the political arena.” Having stepped into a CEO role, Hansen believes it is vital for nurse leaders to understand how the health system works, including how capitation and health target funding flow. “If you’ve got your eye on the ball (on how
Another region with a strong history of promoting nurse networking is MidCentral DHB, where nursing leadership is well embedded into primary healthcare. So much so that the DHB’s longstanding PHC nursing leader Chiquita Hansen has for just over a year now held the dual roles of PHC DoN and executive director (basically CEO) of the region’s Central PHO. Hansen says her DoN role was created in 2003, as the region recognised that if nursing wanted to respond to opportunities under the recently released Primary Health Care Strategy then it needed the infrastructure to grow and develop PHC nursing capacity. She says where MidCentral was fortunate and different from other regions was that it won funding Intro ??????? from both the Ministry (see What models are out there, page 7) and the DHB that allowed her to employ a “fantastic team” of nurses to support her in the work. “We have now morphed into something called Health Care and Development and we have 19 FTE (full-time employees) jointly funded and working across the PHO and DHB in service developmenttype work (like developing knowledge and skills frameworks) and they happen to all be nurses at the moment … oh no, there is one doctor.” She also laughs and adds that having trained management well over the past decade, she is also fortunate to work in a “nurse-centric” PHO. It is also a PHO that – with a DHB DoN as its CEO equivalent and many nurses in leading roles – doesn’t feel the need to have its own director of nursing and its senior clinical advisor is a pharmacist. “I go to many, many meetings now, and I don’t have to utter the word ‘nurse’ as I’ve got GPs saying nursing is the answer, which four or five years ago, we didn’t hear quite so often.”
How to build leaders?
the system works), there is nothing to stop you maximising what a nurse can do in a general practice environment.” Sangster believes a weakness in nursing education both before and after graduation is a lack of knowledge about the business side of health – particularly for PHC nurse leaders. “As nurses doing training, the cost of the care we deliver isn’t often discussed.” She believes being able to draw up the business case for a new service or find a revenue stream to meet an untapped clinical need are all very useful skills for PHC leaders in the making.
From ad hoc to accepted
Firstly, however, nurse leadership roles to need to be filled. A decade on from the roll-out of the PHC strategy, dedicated PHO and DHB PHC nurse leadership roles on the executive team or around the board table is in some cases still the exception rather than the norm. With 20 DHBs and 32 PHOs of varying sizes, structures, and geographical structures, it is admittedly not easy to have a one-size-fits-all approach to PHC nursing leadership (let alone adding in all the other community nursing services, from Plunket to prison nurses). But most agree that the PHC sector could do a lot better for half of its workforce, and Minto and Calverley argue that they also need to do it much quicker – particularly if the country is to maximise the benefit from the push for alliancing and integrated health care. Hansen believes the answer lies in being smart as a small country and, where possible, investing resources in PHC nurse leadership role that can work across the DHB and PHO. “Absolutely ideally, it would make very good sense to have a nurse leader within each PHO who works in collaboration with their nurse leaders within the district health board.” Calverley believes that having some level of PHC nursing leadership role in both PHOs and DHBs is important. “The remit of the DHB director of nursing is huge, so having somebody who can also liaise as PHC director with PHO nurse leaders is critical.” Minto believes the best approach is to start with the DHBs. “A commonsense approach would be to have a PHC DoN or associate DoN in each DHB and build it from the ground upwards,” says Minto. The college is still waiting for a response from the National Health Board to its call, but in the meantime, nurses will continue advocating for more nurse leaders with a capital ‘L’.
Canterbury PHC nursing stalwart moves on Seventeen years after stepping into her pioneering role as a Canterbury primary healthcare nursing leader, Shelley Frost has stepped down to concentrate on national roles. Her path to becoming Pegasus Health’s first director of nursing began 33 years ago, when, as a young nurse freshly back from her OE, she took on a relieving practice nurse role on her return to Christchurch. She resigned from Pegasus in July to concentrate on her General Practice New Zealand roles (see main story) and a new part-time role as quality clinical advisor for the College of GPs. Last year, she also became deputy chair of the board of the Health Quality and Safety Commission – a role she says is a significant challenge but one she is “absolutely loving”.
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Frost says among the her proudest nursing achievements during her time at Pegasus include:extending Pegasus’s small group education programme to nurses in 1998; the establishment of Pegasus’s influential nursing advisory group; being the first nurse director on the Pegasus board and being involved in the signing-off of a nursing development strategy in 2001; and most recently, setting up a nurse membership company within Pegasus, of which 120 of the 350 nurses are shareholders. As Nursing Review went to press, Pegasus was advertising for a new director of nursing, calling for an “aspiring and visible leader” whose main focus was the “provision of professional and clinical nursing leadership” but with a “crucial” component of working closely with other clinical leaders to design and implement innovative models of care.
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Directors of nursing:
Caught between a rock and a hard place?
Are today’s directors of nursing “disempowered” and “disconnected”? Kerri-Ann Hughes’ PhD research attempts to “make sense” of where (and if) nursing power sits in New Zealand’s public hospital system. Kerri-Ann Hughes
O
nce upon a time, there was one nurse to rule them all and she was called ‘matron’. Matron (or principal nurse as the role came to be known) was part of the traditional triumvirate of hospital management Intro ??????? power – the hospital administrator, the medical officer, and the matron. While ‘matron’s’ actual power in that triumvirate may have been more mythical than reality, the health reforms of the late 1980s and 1990s saw the triumvirate thrown out to be replaced by a chief executive (CEO) and a generic management structure built around services delivered and not the health professionals who delivered them. So out also went the operational line of reporting from the nurse at the bedside up the nursing chain of command to the principal nurse. Sitting at the top of the traditional hierarchy, the matron or principal nurse had been not only nursing’s professional leader but also often held the purse strings and decision-making powers for the nursing workforce. Researcher Kerri-Ann Hughes says the shift to directors of nursing (DoN) under the new “managerialism” climate “disempowered” nursing. Nursing still had professional reporting up and down to a top nurse, but the operational reporting – and with it, usually the budget and decisionmaking powers – now went via service managers up the line to the chief executive. The hospitals’ nursing leader appeared to have been largely sidelined to a professional and clinical advisory role. Hughes, a nurse and teaching and research fellow in Massey University’s School of Management, decided to focus her PhD research on “making sense” of the modern director of nursing role and how it fitted into the decisionmaking process of public hospitals from a management and nursing perspective. “The loss of senior nurse leadership was one of the major casualties of the reforms and this loss of leadership becomes one of the factors that influences the visibility and authority of nursing leadership during the period of this research (2006 to 2012),” says Hughes in her thesis. Hughes first wrote a paper exercise comparing 13 of the DHBs’ overall organisational structure
charts with their nursing structure charts and found in nearly all cases the structures bore little relationship to each other. The charts left the impression that nursing was “siloed” within the organisation and the DoN’s status in the leadership structure was “ambiguous”. She then went on to survey DHB DoNs and CEOs (see sidebar for more details) to get their own perceptions of the DoN’s organisational role and responsibilities. This didn’t make things that much clearer. Hughes says while the perception given by the DoNs was that they had a voice at the executive decision-making level, the comments by the CEO indicated that the ‘voice’ of the DoN was regarded predominantly as an ‘advisory voice’. Too often, she got the impression that many “DoNs struggled to be heard” and “they weren’t visible in the board room”. About half of the DoNs had faced having their roles restructured in the previous five years; one had faced “disappointing” talk of disestablishing the DoN role and another said they had been demoralised by being left “hanging” for months. Hughes also found that while most DoNs had strategic oversight of the hospital’s spending on nursing – very few had operational budgets per se, and in most cases, it was only a nursing department budget covering professional development and a small unit of staff, such as educators and associate directors of nursing. Instead, it is the service managers who have the operational budgets that feed down to the charge nurse managers and the RNs. Hughes says this leaves DoNs with a “huge disconnect” between their professional oversight role of operational
DHB DoN and CEO research findings 2006–2012
»» 17 out of 20 DHB DoNs took part in survey »» Average age was 45.5 years »» Average time nursing 16+ years (6 years as DoN) »» 13 DoNs had a Master’s degree or PhD »» Of the then 19 DHB CEOs surveyed, there were 10 responses (2 from COOs) »» 3 CEOs came from a nursing background and 1 from a medical background.
budgets and their power to influence what is happening at the coalface. One DoN reported frustration at dealing with service managers with no clinical background who did not consult them over decisions “potentially affecting clinical outcomes” or “being overruled due to fiscal concerns”. The CEOs spoke positively about the working relationship with their DoN, but again, they most commonly described the role as a professional and clinical advisory role. Despite this, a number of CEOs also expressed an expectation that DoNs be accountable for nursing resources and one CEO said a “greater balance between clinical and financial accountability was needed”. The contradiction was not lost on Hughes. The managerial model that had “disempowered” and “disconnected” nursing – by taking away responsibility at the operational reporting level and budgetary control – still wanted accountability. She says having both professional and operating reporting lines going through to a nursing leader and full financial accountability is the definition of a professional practice model of nurse leadership outlined by the research-backed Magnet hospital process. The Magnet process has identified nursing leadership has the ability to impact on patient outcomes. It is also interesting that the DoNs in her research talked of their first priorities for nursing being “safe professional practice”, “safe staffing”, and “patient safety”. “The focus on safety implies that practice and staffing are unsafe, and given the regulation and educational standards nursing has as a profession, the perceptions of ‘being in an unsafe situation’ is a damning indictment of how the organisation is operating,” writes Hughes in her conclusion. Talking to Nursing Review two years on from her initial research, Kerri-Ann believes there are signs that things may be changing and improving on the nurse leadership front. “With the focus on more frontline staff and the bringing back of clinical governance … you are starting to get more influence for nursing coming through with the new clinical structures being put back in place. [There is also] the emphasis on quality.” “As a researcher, I believe there needs to be support to (the) nursing voice, not only clinically but also strategically, due to the complex environment in which nursing is operating.” “It’s about getting them heard in the boardroom and making their voice count,” says Hughes. “Probably some of them would say ‘that’s happening for me’.” Kerri-Ann would like to see that become the accepted norm for nursing leadership in the future and not the exception. Nursing Review series 2014
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Fast-track leadership path
for new nurses
Catch them young. Waikato DHB last year launched a leadership programme for high-flying nurses who stood out in their new graduate year. Some are now moving on to do their PhDs and other DHBs are adopting the model. FIONA CASSIE finds out more about the unabashedly “elitist” programme.
F Sue Hayward Intro ???????
Lesley Macdonald
resh-faced new nurses are usually pretty far down the pecking order of hospital hierarchy. However, at Waikato Hospital, some nurses just a year or so on from graduation are having monthly chats with the senior executive team and discussing their honours research projects with the director of nursing. The shoulder-tapped nurses – all young and only one male to date – are taking part in Waikato District Health Board’s new leadership programme, run in league with The University of Auckland and targeted at new nurses with leadership potential. With their research projects now handed in, three of the initial cohort are now wanting to move through to their doctoral studies next year. Sue Hayward, director of nursing and midwifery at Waikato DHB, said in an interview last year with Nursing Review that the aim of the scheme was to identify nurses who were “obviously flying high” as they came into their second year of practice. The now 13 nurses (there have been three intakes – one each semester) all stood out during their new graduate year academic studies and had demonstrated they were already applying critical thinking to their clinical practice. Lesley Macdonald, who coordinates the programme and the DHB’s new graduate programmes, says it is deliberately seeking out those who are academically and clinically able. “It is elitist in the true sense of the word and it is intended to be,” says Macdonald, who believes the profession could do better at nurturing nurses who show ability. “It’s not for everybody. It’s for those who are already looking at practice differently and critically,” says Macdonald. “We need to capture that and give them the chance to think creatively and innovatively and foster that skill development.” Hayward said at the time that the programme was partly prompted by not always getting a large number of wellqualified and capable nurses applying for positions like charge nurse, nurse educator or clinical nurse specialist. “We’re not the first ones to have done it – it’s been done in the past,” said Hayward. “We’re just wanting to try a slightly different way.” The new programme did not exclude other nurses from following leadership paths and other programmes on offer at the DHB. The leadership scheme’s nurses all enroll in The University of Auckland’s Bachelor of Nursing (Honours) programme, with the research methodology paper taught on the hospital site.
Coffee with the CEO
Matthew Parsons
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That research project was driven by service requirements, with ideas coming from their immediate managers, service managers, or Hayward herself. Because an important component of the leadership programme is seen to be getting a good grounding in the nuts and bolts of how hospitals and DHBs are run. So the young
leaders-to-be also meet monthly with different members of the DHB’s senior executive team, including the CEO. The programme is unapologetically focused on ensuring that the would-be leaders are exposed to the machinations of how the health system works, rather than simply advanced clinical roles. Hayward and Macdonald believe that what is lacking in many nurses’ career paths is not clinical role models but how clinical practice on the floor fits in with the ‘bigger picture’ of health system operations. “We are exposing them a little bit more to the political world in which we as nurses work,” said Hayward last year. Macdonald also believed that because nurses are rarely exposed to the operational context of health they are “uncomfortable” when later they move into senior roles and need to think both clinically and operationally. “This is about teaching them early on how to do that,” says Macdonald. This is useful if they go on to be a nurse practitioner or a charge nurse manager.
Topical research topics
The honours dissertation topics are all topical and relevant as they have arisen from needs or ideas from the managers and then been approved by the team. One of the first cohort of students worked with a general manager looking at a follow-up phone intervention with young women who present with alcohol-related admissions to the emergency department. Another looked at patient safety in the theatre environment, another the patient experience for an acute surgical patient, and the fourth looked at nursing roles in ED. Professor Matthew Parsons of The University of Auckland says Counties Manukau DHB has now taken up the nurse leadership model, with three students in the first semester, and another DHB also close to adopting it. Parsons and MacDonald says the model has also now been given national endorsement by Health Workforce New Zealand, with nurses on the scheme meeting and presenting their work recently to HWNZ executive chair Des Gorman and director Graeme Benny. In another first, three of the initial four are to move on to take up full-time doctoral internships next year in a partnership between the DHB, HWNZ, and The University of Auckland funded by the HWNZ Advanced Training Fellowship scheme and The University of Auckland scholarships. “Again, they won’t be given choice in the matter (their PhD topics). They will be given their topics by the DHB (at general manager level or above) so they become change agents for priority areas of work,” says Parsons. Macdonald says the scheme overturns the assumption that junior nurses are not ready to take on such challenges. These fledgling nurses are being encouraged to fly high.
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Career paths: Four nurses’ journeys
Nursing Review once again asked some nurses from across the country in senior roles to tell us what path they followed to where they are today. They each have a good story to tell, from schoolgirl volunteering to careers being diverted by motherhood, and of job options closed in their chosen area but opening in another, plus the importance of role models and mentors. They share tips on career planning and the skills, qualities, and qualifications helpful in their roles.
Intro ???????
Role modelling by nurse leaders and pushes by a mentor helped mental health nurse educator KATHY MOORE’s career fall into place.
NAME: Kathy Moore JOB TITLE: Nurse Educator Mental Health, Ko Awatea, Counties Manukau District Health Board NURSING QUALIFICATIONS: Psychiatric Nurse 1974 (Sunnyside Psychiatric Hospital*) General and Obstetric Nurse 1979 (Middlemore Hospital) Postgraduate Diploma in Mental Health Nursing 1998 Postgraduate papers in clinical education and supervision *I was recruited at 17 by Margaret Bazley, the then Sunnyside principal nurse at Sunnyside Hospital, whose later roles have included New Zealand Chief Nurse and Social Welfare Director-General.
Briefly describe your initial years as an RN?
I gained a variety of experience in acute inpatient, forensics, older persons, and intellectual disability before I moved to the former Kingseat Hospital to work with those with an intellectual disability. After training as a general and obstetric nurse, I recognised that this was essential to provide holistic nursing practice. An opportunity came up to be part of the new mental health community services. This was an exciting initiative working with clients across the whole continuum. Doctor cover was minimal, so nurses completed initial assessments, ran groups, day patient programmes, and other psychological interventions with colleagues such as psychologists. This was also the beginning of seeing clients in crisis and completing assessments in general wards and ED. Commitment to a mortgage and family sent me back to inpatient services to take up a charge nurse position.
Did you have a career plan (vague or definite) on becoming an RN? How did those early years influence your subsequent career?
I just wanted to be a really good nurse. I had observed things in my first five years that that did not provide dignified care and I wanted to influence change, and develop patient-centred services. I did not have a specific plan. I just fell into things. I became a charge nurse and worked for the next four years in inpatient services. The charge nurse role in the 80s was a very autonomous role that allowed me to truly influence nurses’ clinical practice, models of care, and client pathways.
What led you into your current field or specialty?
While working as a CN, I was encouraged by a nurse colleague (Tim Wallace, who later became my mentor) to apply for the in-service educator role – an amazing opportunity and challenge that involved me in new initiatives like development of an advocacy service and establishing homes in the community.
What qualifications, skills, or stepping stone jobs were particularly helpful and/or necessary in reaching your current role?
Work experience: »» a wide range of clinical areas developing a generic skill set in both inpatient and community settings »» being a charge nurse »» working as an inservice educator across settings and disciplines »» working as ECT clinical nurse specialist. Influence: »» Margaret Bazley – she was a major change agent and told us as new student nurses that we were to be change agents. Learning that: »» I felt uncomfortable during the management of change process that I had little influence over. This influences me today to recognise the stress of change, even if the change is exciting, and to ensure the process is very transparent »» clinical work and education was where my passion was.
What personal characteristics are particularly important for nurses working in your role?
»» To be tenacious in ensuring principles and values are upheld. »» Deciding the type of nurse you want to be i.e. drawing a line in the sand about your principles and practice for the rest of your career. »» Being prepared to change and learn as practice changes. »» To actually want to be a nurse and make a difference in people’s lives. »» To keep nursing strong by nurturing and developing new nurses to do our job.
What career advice would you give to nurses seeking a similar role to yours? Seek to develop a wide range of clinical skills through experiences and actively take opportunities for new learning. Seek out mentors who are prepared to challenge you to look at your practice. Make a plan for your professional development that extends you and moves you out of your comfort zone. Never underrate the importance of relationships and communication.
Describe your current role and responsibilities?
I am nurse educator mental health, which is really a misnomer as my work is far wider than this. I have clear responsibility for support and leadership to nursing but also have a multidisciplinary function, especially around education. The whole team works as part of a professional development unit for the DHB. I contribute to the Safe Practice and Effective Communication education (SPEC) provided for mental health services and security at the DHB and wider afield, including recently delivering SPEC training in Samoa. My role has enabled me to work with, grow and develop nurses across our service and this has probably been one of the most rewarding aspects of my nursing career. Nursing Review series 2014
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Rest home nurse manager SUE MILTON sewed the seed for her passion for gerontology during volunteer work as a schoolgirl.
NAME: Sue Milton TITLE: Nurse Manager, Gulf Views Rest Home, Auckland NURSING QUALIFICATIONS: RN 1973 Greenlane Hospital postgraduate qualification in gerontology 1984 AUT health management course
I worked at Greenlane in a ward dedicated to infectious wounds e.g. postoperative complications and perianal abscesses. There was a mix of medical and surgical cases.
learnt a lot in those first five years of registration, especially about accountability as sometimes you would be the only RN on a shift, with the balance of the staff being student nurses. Being the only RN meant you had to think on your feet and be confident in the decisions you made. As we rotated around the hospital during our training, everyone knew each other and the areas of the hospital, and we tended to work in collaboration. I can’t say I became more aware of my strengths or weaknesses. We just got on with things.
How did those first five years influence your subsequent career?
What led you into your current field or specialty?
Briefly describe your initial five years as an RN?
Intro ???????
I had always wanted to go nursing from a very young age and never wavered from that ambition. I
I volunteered at the old Cornwall Hospital (via the Red Cross) on Saturdays making beds and also
worked in a rest home during my school holidays until I started nursing. I had amazing experiences and developed a greater understanding about acceptance and tolerance from this age group. I was also enthralled listening to the stories of their lives. I suspect this was where I developed my passion for this specialty. I gained a gerontology qualification through AUT and also a health management course. I am currently the chair of the Auckland region of NZNO’s Gerontology Section and previously served on the section’s national executive. Part of my role is to assist with the planning of study days and conferences. Recently, I was awarded the Counties Manukau District Health Board 2014 Health of Older People Residential Care Award for recognition for my commitment to the care of the elderly.
What personal characteristics are particularly important for nurses working in your role?
An inherent passion to working with older adults, good listening skills, and a supportive attitude when dealing with both residents and staff. Working
in the private sector, there needs to be an ability to accept people as equals and acknowledge every skill level.
Any helpful advice for nurses wanting to follow a career in older people’s health – particularly in becoming a nurse manager?
Work your way up the ranks. Consider time in related disciplines such as orthopaedic, medical, and surgical areas. Gerontology is a specialised field now due to the complex needs of the residents. You need to build and lead a strong team to achieve exemplary outcomes for the older adult.
Describe your current role and responsibilities? Being a rest home nurse manager is an extremely diverse role with both clinical and business aspects. I am responsible for the overall management of the facility including clinical leadership, budgets, human resources, risk management and certification. In fact, I am the glue that bind these all together.
PHO clinical manager BARBARA VARDEY says until recently she has been an “accidental tourist” along her career path… Briefly describe your initial five years as an RN?
My first role as a registered nurse was in the orthopaedic ward of the newly built and innovative Kenepuru Hospital. I left after eight months and went to work in the surgical ward of an Australian teaching hospital, which still had student nurses and the model of nursing was still task orientated. I returned to New Zealand after 12 months as my first child was due. I had children over the next few years and worked casually at Kenepuru Hospital and also at a local GP practice.
NAME: Barbara Vardey TITLE: Clinical Services Manager, Compass Health, Wellington NURSING QUALIFICATIONS: RN 1980 (Wellington Hospital) PG Cert in Primary Care 2006 PG Cert in Pacific Health 2012 (through Aniva Pacific Nurse Leaders programme) 12
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Did you have a career plan (vague or definite) on becoming an RN? How did those first five years influence your subsequent career?
In both my Cook Islands family and my English/Kiwi family, there have been doctors, nurses, and traditional healers. I always wanted to be a nurse as it was a role I identified with. The positions I held in the first
five years affirmed my belief that nursing was where I could influence and support people to get well and keep well. I enjoyed the contact and relationships you can develop with likeminded colleagues and also with patients and families.
What led you into your current field or specialty?
I have been an accidental tourist in my career to date and have only recently recognised this. There was no active planning to get to my current role. I got my first role in primary care with a GP in Cannons Creek through word of mouth. I recognised the potential that nurses had in primary care to influence people’s wellbeing. I did casual nursing until I got a permanent role in Porirua’s Waitangirua Health Centre. This role worked well with my growing family, and it was close to home. I worked with amazing nurses and doctors; their experience, practice and skills helped build my knowledge. While working there,
I got an opportunity to work in youth health in secondary school clinics and develop a new outreach nursing service working with GP clinics. These new roles built my confidence and increased my awareness of the barriers to healthcare and also the disparity experienced by some members of our community.
What qualifications, skills, or stepping stone jobs were particularly helpful and/or necessary in reaching your current role? I am curious by nature and have been surrounded by some incredible nurses, doctors, managers, and others in all the roles I have worked in. I have observed them and taken from them skills, knowledge, and the courage I needed to grow my ability to be a more effective nurse and manager. Although I did not go down the academic pathway, I have been supported to do courses I felt would assist me support staff and benefit my performance as a nurse and
FOCUS n Learning & Leading
Surgical nursing director NICKY GRAHAM’s initial career path diverted from paediatric to adult surgery and she hasn’t looked back. Did you have a career plan on becoming an RN? How did those first years influence your subsequent career?
NAME: Nicky Graham JOB TITLE: Surgical Nursing Director, Christchurch Hospital NURSING QUALIFICATIONS: BN 1998 Christchurch Polytechnic Institute of Technology Postgraduate Cert in Health Sciences (Nursing Leadership & Management) 2006 Xcelr8 Management Development Programme 2007 NZIM Four Quadrant Leadership 2010
Briefly describe your initial five years as an RN? On graduating I worked in
paediatrics, both at Brackenridge Intro ???????
and in a paediatric surgical ward. I moved to Blenheim and rotated between ATR (assessment, treatment, and rehabilitation), paediatric, gynaecology, and general surgery wards. I returned to Christchurch to a general surgical and vascular ward. leader. I have had leadership roles outside of my ‘job’ that also helped me form a leadership style which works for me.
What personal characteristics are particularly important for nurses working in your role?
I believe you need to have credible leadership skills that are evident in your relationships and performance of the role. You need to be knowledgeable and competent in the area in which you work. Being personable, approachable and direct when required helps teams understand how to work with you. Do not shy away from the difficult discussions but be fair. Your team needs to feel you believe in them and are prepared to support them fully.
What career advice would you give to nurses seeking a similar role to yours? Work in as many roles as possible and learn as much as you can about nursing and how you can influence change. Spend time understanding the communities you work in. Participate in courses or do
My initial plan was to work in a surgical paediatric area. However, on returning to Christchurch, there were no vacant positions, and I followed an adult surgical path, which I really enjoyed. The first five years cemented my passion for nursing and gave me good exposure to different facets of nursing and the health system.
What led you into your current field or specialty?
After developing as a senior RN, I became more involved in informal and formal leadership roles. I became second in charge of the Gastroenterology Investigative Unit at Christchurch Hospital for four years before moving to Australia and a position as the clinical charge nurse of a day surgery and endoscopy unit. I returned to Christchurch and became the nurse manager of the perioperative service on an 18-month secondment. Following a restructure, I continued as the charge nurse manager in this area before being seconded for 12 months to the role of service manager for the General Surgery department. I then had the postgraduate study that will help you understand the difference in clinical leadership and management models. Attend clinical supervision or peer review to self-reflect and continue developing your own style of leadership. Take opportunities to grow yourself.
Describe your current role and responsibilities?
I work as a clinical services manager in a large PHO; the role has developed over the last few years. Initially my responsibilities were to manage the outreach nursing team, oversight of the school nursing service, and rheumatic fever service and workforce development for nurses as chair of the nurses committee. I have membership on many local, regional, and sub-regional committees, steering groups, and governance groups. My responsibilities changed in the last month, and I now have clinical leadership of the Pacific Navigation Services (a regional service with some of the team employed by another PHO), Rheumatic Fever Services (which are also regional) and workforce development. I am also ‘2IC’ to the clinical director.
exciting opportunity to apply for and gain the role of surgical nursing director.
What qualifications, skills, or stepping stone jobs were particularly helpful and/or necessary in reaching your current role?
I believe my surgical and perioperative background, nursing leadership, and management papers and previous leadership roles were extremely beneficial in providing the knowledge and skills required for this role. I have been actively engaged in strategic planning, change management, and numerous quality improvement, innovation, and organisational change initiatives during my career, which has assisted with the skill set required for the role.
What personal characteristics are particularly important for nurses working in your role?
A passion for nursing and a patientfocused and continuous improvement ethos are essential.
I believe it is important to have excellent communication skills and the ability to develop collaborative partnerships with nursing, medical, community, allied health and management.
What career advice would you give to nurses seeking a similar role to yours?
It is important to get involved in additional portfolios within the ward/ unit setting to grow your knowledge and skills. Make it known to your nursing leader you are interested in career advancement and senior roles within the organisation. It would be advisable to have a career plan in place but with some flexibility within this, as different opportunities may arise.
Describe your current role and responsibilities?
My current role is to lead the surgical nursing cluster to ensure CDHB vision and strategy is implemented and that daily operations are maximised whilst delivering quality nursing care. I work in a collaborative manner, embracing nursing innovation and identifying opportunities to improve the journey for the patient and health outcomes.
EXPAND YOUR KNOWLEDGE Start a postgraduate qualification in nursing, midwifery or health care in 2015. Study and work alongside national and international expert practitioners and scholars in clinical practice, leadership, education and research.
ENQUIRE NOW Graduate School of Nursing, Midwifery and Health Phone 0800 108 005 Website victoria.ac.nz/nmh
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FOCUS n Learning & Leading
Nurse endoscopists:
the evolution of a new nursing role
If New Zealand is to cut back the death rate from our second biggest cancer killer – bowel cancer – we need a bigger endoscopy workforce. After some years of investigation and Intro ??????? preparation, Health Minister Tony Ryall fast-tracked the pace recently by announcing training of New Zealand’s first nurse endoscopists is to get underway early next year. FIONA CASSIE talks to Jenni Masters and Ruth Anderson about the big steps required to shift from wanting a new nursing role to making it a viable reality.
I
t sounds a no-brainer. International evidence indicates that screening can reduce annual bowel cancer mortality by at least 14–16 per cent annually. The Waitemata screening pilot underway since 2011 has so far detected cancers in about 180 people before symptoms emerged. Along with finding the approximately $60 million a year it would cost to screen all 50–74-year-olds, and ensuring the laboratory capacity to test for blood in faecal samples, more endoscopists would be needed to provide the possibly 50–75 per cent increase in demand for colonoscopies to diagnose whether cancer is present. How can that increased demand be met? With nurse endoscopists already established in the UK, and training soon to be underway in Australia (see more online), training our own nurse endoscopists was soon bandied around as one possible answer. But it wasn’t an easy answer. It raised questions about how willing and able our already pressured endoscopy services were to train nurse endoscopists on top of training more traditional gastroenterologist and general surgeon endoscopists. A survey in 2011 of the 84 medical endoscopists then working in public hospitals found just 30 per cent of respondents had a positive attitude towards introducing nurse endoscopists. A survey at the same time of the about 190 nurses working in public endoscopy services found that only 35 per cent of respondents were willing to consider training as nurse endoscopists. New Zealand was also lacking a national quality and auditing programme for endoscopy and no competency framework for nurses working in the field (which didn’t help the proposal to recruit a
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UK-trained nurse endoscopist for a New Zealand pilot – the proposal eventually fizzled out).
Uneven quality and lack of national standards in endoscopy services
Things were not moving fast when Jenni Masters – now the National Endoscopy Service improvement lead – was appointed in 2010 with clinical director Dr David Theobald to the National Endoscopy Quality Improvement programme (NEQIP). The first focus of the programme was gauging the quality of endoscopy services already on offer as the Ministry of Health geared up to begin the Waitemata bowel screening pilot in 2011. Masters’ own nursing background included gastroenterology and being a charge nurse manager in gerontology and committee member of the NZNO Gastroenterology Nurses Section. She says NEQIP began by carrying out a national stocktake of public endoscopy services
How long to train an endoscopist?
The NHS said in 2013 that it takes a year to build the skills to independently carry out flexible sigmoidoscopy and two years to be able to competently perform colonoscopy. In 2011, the New Zealand Society of Gastroenterology said it took 12–18 months to become competent in routine gastroscopy, 18–24 months to be able to perform flexible sigmoidoscopy, three years to competently perform colonoscopy, and up to five years before being at a satisfactory level to carry out colonoscopy screening.
that found a wide variation in the way endoscopy services were being delivered across the country. Likewise, endoscopy nursing roles varied greatly, with some nurses assisting physician endoscopists with manipulating auxiliary equipment down the endoscope and others not (see sidebar and online only sidebar at www.nursingreview.co.nz). The lack of consistency was further highlighted when NEQIP trialled in four DHBs – now rolled out nationally – the United Kingdom-based quality assurance system known as the Global Rating Scale (GRS) that has a set of quality standards for endoscopy services to be working towards, including workforce standards. One need identified was for national consistency in assessment, education and training for endoscopy nurses and a project was set up, initially led by Megan Buckley of Tauranga Hospital, to develop a knowledge and skills competency framework for endoscopy nurses. A competency framework was seen to improve not only the quality of endoscopy nursing but also the quantity, by providing a career path towards senior nursing roles – such as clinical nurse specialists in areas from hepatology to irritable bowel syndrome, and in time, nurse endoscopist and nurse practitioner roles – that could attract more nurses into the field.
Pro or anti-nurse endoscopist?
Difficulties in recruiting and retaining endoscopy nurses, along with the need for more gastroenterologist endoscopists, was noted in the 2011 report to Health Workforce New Zealand (HWNZ) by the Gastroenterology Workforce Service Review.
FOCUS n Learning & Leading
“Having nurses sitting at the strategic table being able to influence service planning is really critical if we are going to get it right for our patients over the next five to ten years.” The review report noted not only the ageing endoscopy nurse workforce and the lack of appeal to younger nurses but also “major concerns with nurses currently performing extended roles with no recorded job description, no title, no competencies programme, and no reimbursement structure”. In addition, there was “high awareness” that some within the medical profession were anti-nurse endoscopist. With only an estimated 50 full-time equivalent gastroenterologists and general surgeons (a number work across both the public and private sectors) currently delivering endoscopy services in public hospitals, and with only a handful of gastroenterologists graduating each year, the report noted that there was only a limited pool of endoscopy training places available for gastroenterology registrars and general surgical registrars before adding trainee nurse endoscopists to the mix. “In addition, doctors need to agree to training and overseeing nurse endoscopists, which is a barrier currently,” said the 2011 review document. The workforce service review recommended that HWNZ work with the Nursing Council and Intro ??????? other relevant bodies to set in place the means for RNs to train to become “nurse endoscopists in supervised roles in larger centres”. In the wake of that recommendation, the New Zealand Society of Gastroenterology surveyed its membership and reported “more than half” supported the appointment of nurse endoscopists and “most” would be willing to train nurse endoscopists. In November 2012, the society came out with a revised position statement supporting the introduction of nurse endoscopists but said first an agreed practice framework had to be established and issues of safety and competencies had to be addressed.
Knowledge and skills framework for endoscopy nurses
By this time, work was well underway on the knowledge and skills framework, with good input from public and private sector endoscopy nurses keen to help. Masters said this led to the first iteration of the framework, with ongoing development work picked up by Christchurch endoscopy nurse leader Gendy Bradford, who was employed last year by NEQIP as nursing workforce development lead (she was joined this year by MidCentral DHB gastroenterology clinical nurse specialist Anne Cleland). To ensure the framework is practical and usable in the endoscopy workplace, it was decided some directly observed practical skills (DOPS) assessment tools for different types of endoscopies and preand post-procedural care were needed. Feedback on how effective the assessment tools will be was gathered at a meeting with gastroenterology charge nurse managers in August, along with further discussion on when and how to launch the knowledge and skills framework. The framework does create a path for endoscopy nurses from competent through proficient to expert but competencies and training standards for nurse endoscopists will not be just nurse-specific.
NEQUIP says its strategic goal is for New Zealand to train endoscopists and “not surgeons, physicians, or nurses who perform endoscopy”. “Everyone should be trained in exactly the same way because they are doing exactly the same procedure,” says Masters. So along with refining the endoscopy nursing framework, NEQIP has other work streams in enhancing endoscopy training overall and the setting up of a national governance body to oversee a new competence-based training and assessment platform for all endoscopists Masters says the interdisciplinary governance body – with representatives from the relevant medical and nursing professional groups – would be a first for New Zealand. The Nursing Council has now also approved processes for the credentialing of expanded practice in specialty nursing areas – though there were quibbles by some over whether endoscopy fitted the criteria and whether it was more a technical skill than expanded practice. But others argue that nurse endoscopy is much more complex than skilfully inserting an endoscope into somebody. Masters says nurse endoscopists need not only expert technical skills but also knowledge of histology and pathophysiology, along with highlevel clinical decision-making abilities to ensure patient safety and good care. The next step is deciding on an education and training programme.
Nurse endoscopist training underway soon?
Laying the groundwork to build the quality and quantity of public endoscopy services has been steady to date but the training of nurse endoscopists now appears to be on the fast track. The pace stepped up in March when Tony Ryall announced an April symposium looking at ways of boosting the colonoscopy workforce–and nurse endoscopists were definitely on the agenda. Ruth Anderson, HWNZ’s manager of Workforce Education Intelligence Planning, says out of the symposium came several “pieces of work” around the “role of nurses performing endoscopy” i.e. nurse endoscopists – including establishing an advisory group which Anne Cleland of NEQIP and gastroenterologists group, of which are amongst the members. Anderson says amongst advisory group purposes are finding the best ways of increasing the number of nurses able to do endoscopy and establishing education and training requirements. “The development of that role (nurse endoscopist) and performing gastrointestinal procedures will be considered in a wider context of developing advanced nursing roles so that it contributes to a career pathway for nurses,” says Anderson. But any training is also to come under the national governance body and training standards that are consistent and identical whether they are doctor or nurse endoscopist trainees. “From the viewpoint of the patient, they will be able to have the same level of confidence in the endoscopic procedure, regardless of who carries it out, but recognising that follow-up work from
Endoscopy Endoscopy is a medical procedure using an endoscope – a long, thin, flexible tube with a light and a video camera – to view internal organs. Endoscopy is also used for taking biopsy samples, removing polyps (polypectomies), and increasingly therapeutic interventions, such as stenting, by inserting auxiliary equipment down the endoscope. Colonoscopy is an endoscopic investigation of the lower gastrointestinal (lower GI) tract i.e. the large bowel (colon) via the anus. Gastroscopy investigates the upper gastrointestinal (upper GI) tract via the mouth to examine the oesophagus, stomach, and duodenum section of the small bowel. Sigmoidoscopy is an investigation of the rectum and the sigmoid (lower colon area) using a flexible sigmoidoscope. Commonly used to investigate rectal bleeding.
nurse endoscopy would then be undertaken by a gastroenterologist.” Anderson wanted to stress that the training of nurse endoscopists was to complement and not replace gastroenterologists and general surgeons carrying out endoscopy, with registrar training numbers in the two medical specialties also to be increased. Nursing Review spoke to Anderson in early July prior to the Minister’s July 29 announcement that the first nurse endoscopists were to start training next year. She said at the time that training processes were still under development and it was hoped to have an agreed training by the end of the year. The aim for the theory side was likely to develop a postgraduate diploma with an endoscopy focus that was “professionally recognised, credentialed, portable, reflected best practice and absolutely demonstrated inter-professional learning”. Asked when it was likely that a training programme was likely to be available to trainee nurse endoscopists, Anderson said at the time they were not certain and to get tertiary education providers on board could “take another year beyond next year” but the pace could depend on government decision-making. She indicated that initial nurse endoscopist trainees are likely to be senior nurses who have already undertaken significant postgraduate study relevant to endoscopy. Following the Minister’s announcement, his office was asked whether the qualification and training programme for nurses was now to be fasttracked and give the go-ahead prior to setting up the national governance body. His office declined to comment and referred all questions to HWNZ. Anderson said in a written response that “while final specifics such as available places are currently being developed, Health Workforce New Zealand expects to have nurses beginning postgraduate training to perform endoscopy from early 2015”. So it looks like a matter of “watch this space”, but nurse endoscopists are on the way. Nursing Review series 2014
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Evidence-based practice
Successful returns from hospital to home Can we do more to prevent readmissions after hospital discharge? CLINICAL BOTTOMLINE: Comprehensive and highly-supportive discharge interventions – aimed at enhancing patients’ capacity for self-care – are more effective at reducing early hospital admissions (<30days) than interventions without these features.
CLINICAL SCENARIO: Ward staff strive hard to prepare patients well for discharge and many patients transition safely from hospital to home. However, some patients contact you after discharge for advice about their care, medications, and potentially serious symptoms. You feel sure this advice has prevented readmissions and question whether more discharge support (such as telephone follow-up or home visits) is required to help patients transition home safely.
QUESTION: Among adult patients discharged home from hospital, does a highly supportive discharge intervention reduce early readmissions compared with standard discharge planning?
SEARCH STRATEGY: PubMed Clinical Queries (therapy, broad): hospital readmission AND discharge interventions.
CITATION: Leppin, A. L., Gionfriddo, R.., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., . . . Montori, V. M. (2014). Preventing 30-Day Hospital Readmissions: A Systematic Review and Meta-analysis of Randomised Trials. JAMA Intern Med. doi: 10.1001/jamainternmed.2014.1608
STUDY SUMMARY: A systematic review testing the effects of discharge interventions to reduce early (<30 days) hospital readmissions. The cumulative complexity model (CuCoM) was used to help identify features within each intervention that might explain their effect on readmission rate. Inclusion criteria were: Type of study was randomised controlled trials involving adults admitted from the community to an inpatient ward for at least 24 hours with a medical or surgical cause. Obstetric or psychiatric admissions, and discharges to skilled nursing facilities, were excluded; Interventions focused on the hospital-to-home transition and were generalisable to contexts beyond a 16
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single patient diagnosis. Discharge activities occurring in the intervention but not the comparison group were coded by their unique activity (e.g. home visit, formal discharge planning, timely follow-up). Intervention features, such as the extent they affected patient workload or capacity to self-care, were also rated; Outcomes were unplanned or all-cause readmission with or without out-of-hospital deaths at 30 days from discharge. Pre-specified sub-group analyses included patient and intervention characteristics, and publication year.
VALIDITY: The Search Strategy involved searching electronic databases PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013). Unpublished studies located by hand-searching bibliographies of included studies and recent reviews. Experts in the field contacted. Language of publication restricted to English and Spanish. Studies were selected by independent screening of titles/abstracts, and then full texts. A piloted, standardised form was used for risk of bias assessment and data extraction. Conflicts resolved by consensus. Reviewers were blinded to trial results systematically coded and rated discharge interventions (framework, definitions supplied); reviewer agreement checked and study authors confirmed fidelity. The risk of bias assessment was based on the Cochrane Collaboration tool. Studies obtaining readmission data from internal health systems records only were considered to have a high risk of bias. The publication bias was assessed as small, the effect unknown. Overall this was a high quality review of mainly good quality studies.
RESULTS: From the 1135 titles screened, 256 full texts were reviewed, and 47 trials met the criteria to be included in this review. Interventions occurred in both inpatient and outpatient settings, and varied in complexity but commonly involved activities of case management,
patient education, home visits and self-management promotion. Meta-analysis of 42 trials found that highly supportive interventions reduced 30 day readmission rates by nearly 20 per cent (table) compared with baseline discharge activity: this was regardless of age (≥ 65 years or not), diagnosis (heart failure or not), and hospital ward (medical or not). More effective interventions were those rated to increase patients’ capacity for self-care, involved ≥ 5 unique activities, and involved ≥ 2 individuals in a structured and required role. Readmission rates were not associated with delivery setting (an inpatient and outpatient component, or not) or the effect on patients’ workload. Post hoc analysis showed increased effectiveness with interventions providing comprehensive support (table).
COMMENTS: The significance of this review lies in its use of the CuCoM model to explore and highlight the underlying features of what makes an effective discharge intervention. This patient-centred model predicts that readmissions may be avoided by interventions that balance the patients’ workload (related to accessing care and adhering to complex care plans) with their capacity to look after themselves at home (determined by the quality and availability of resources). The findings provide objective evidence of the benefits of a commonsense approach to effective discharge interventions – i.e. targeting identified barriers to self-care with comprehensive support. Understanding these barriers from the patient and caregivers’ perspective, especially for those most at risk (ethnic groups, complex conditions), is an essential step towards addressing this important healthcare issue. Reviewer:
Cynthia Wensley RN MHSc is a PhD candidate who also works at the School of Nursing, The University of Auckland as an Honorary professional teaching fellow.
Table. Results with 95% Confidence Intervals (CI) Outcome Readmission rates within 30 days Comprehensive support **
Number of studies
Relative risk (95% CI)
Inconsistency between studies
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0.82 (0.73 to 0.91)
I2 = 31%*
7
0.63 (0.43 to .91)
Not provided
*low to moderate ** variable developed from subgroup analyses findings and CuCoM prediction
Judy Yarwood
college of nurses
Election time challenge to RNs JUDY YARWOOD, co-chair of the College of Nurses, reflects on the negative impacts of inequality on people’s health and wellbeing and calls on RNs to challenge inequality as election day looms. None of you will need reminding that an election is nigh, a time when politicians step up their rhetoric, promising, if elected, much to many. It’s a good time for us to evaluate politicians’ performance over the last three years, especially in matters that affect us all, such as the economy and healthcare. I was reminded how these two fields are inextricably linked, when I listened to the 2014 Robb lectures recently held at Auckland University. The 2014 lecture series, “The human cost of inequality” (viewable at www.auckland. ac.nz/en/about/perspectives/publiclectures.html) was presented by two English epidemiologists, Professors Kate Pickett and Richard Wilkinson. The pair brought home the links between economics and health by showing how destructive inequality can be to health and the social fabric of a country. An example they shared was the outrageous changes in income distribution internationally over the last decade. Whereas a ratio of 1:10 or perhaps 1:20 between the lowest and highest paid employees in a company was acceptable, we now have large corporations with ratios as high as 1:400. How is it possible that one person’s worth is 400 per cent higher than others? The New Economics Foundation, described as UK’s ‘think tank’ to promote social, economic, and environmental justice, contends that many of the world’s economies are increasingly unsustainable, unfair, and unstable. The two speakers highlighted New Zealand’s levels of inequality, which are frequently found high on the list alongside the ‘top unequal’ countries, the USA and Singapore, debunking the claim that New Zealand society is relatively equal. Kate Pickett finished on behalf of both speakers by saying they hoped that within 20 years, or perhaps fewer, it would be as
embarrassing to be seen to be individualistic, greedy, and out for yourself as it was to be homophobic, racist or misogynistic – sentiments roundly applauded.
Time for RNs to take up the challenge As Nicola Russell pointed out in her challenge in the Feb/March edition of Nursing Review, 47,000 RNs, the largest group of healthcare professionals, are a force to be reckoned with. Increasing numbers of RNs working in primary healthcare see daily the impact on people’s and communities’ health and wellbeing of socioeconomic determinants like poor housing, income inequality, violence, neighbourhood contexts, and low levels of education. However, it’s one thing to identify the issues and another entirely to know how to make a difference. If, as Pickett and Wilkinson suggest in their acclaimed 2010 book The spirit level: Why equality is better for everyone, the institutions that employ many of us are a source of income inequality, what does that say about the focus of district health boards, primary health organisations, and health-related institutions? You cannot find a place where these ideas resonate more strongly than in the care of the elderly, where many aged care workers, often unskilled, are paid less than the minimum wage. What this suggests is that our society places little value on caring for older people, who increasingly are seen as burdensome rather than beneficial. Baby boomers, currently a prime target, are constantly referred to as creating huge problems for our finite health resources. We seem to be caught in a time warp where ageing is seen as a disease rather than as a natural process. Our humanity for the elderly is perhaps converse to the country’s increasing emphasis on the GDP.
Over the past 50 years, enormous social change has occurred, transforming our society. But changes such as women’s position, gay rights, and civil unions, to name a few, came about, as Kate Pickett noted, through people’s action driving political will rather than vice versa. As members of society, RNs have the capacity to lead such action by drawing attention to the impact of social determinants and income inequality on people’s health and wellbeing. Despite barriers, often economic and/or managerial, nursing leadership is alive and well, if unsung, in diverse urban, suburban, and rural PHC contexts. Visiting nursing students on clinical placement up and down the West Coast, I find expert, skilled, and enlightened RNs, often in sole charge of remote health clinics, working daily with the effects of poor housing, loneliness, violence, and unemployment. Without these RNs, many people would have little or no access to health care, a central tenet of primary health care. So as RNs and nursing leaders, we not only have a personal choice on September 20 this year. We also have a professional responsibility to consider how inequalities can be challenged and addressed, social determinants recognised and tackled. All of which won’t happen overnight, but with people power and political will, it can happen. Don’t let September 20 pass without doing your part. Judy Yarwood is co-chair of the College of Nurses and principal lecturer at Christchurch Polytechnic Institute of Technology nursing school.
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Practice, People & Policy Professional development
Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy
Maintaining appropriate boundaries with patients There’s a slippery slope between going the extra mile for a patient or their family and crossing the threshold into inappropriate behaviour. Nurse-turned-solicitor ROBIN KAY explores the boundaries of this tricky issue. It is widely accepted that the therapeutic relationship between nurse and patient is central to the quality of care. But it is also acknowledged there’s a risk that this relationship may become something more than is strictly required for the delivery of care. Sadly, the New Zealand Health Practitioners Disciplinary Tribunal website, www.hpdt.org.nz, contains a significant number of complaints against clinicians, including nurses, of inappropriate relationships with their current or former patients or health consumers.
Guidance on professional boundaries
7.14 Do not engage in sexual or intimate behaviour or relationships with patients in your care or with those close to them. In recognition of the importance of maintaining appropriate clinical boundaries, the Nursing Council issued further guidance in June 2012 with the release of its Guidelines: Professional Boundaries – a nurses’ guide to the importance of appropriate professional boundaries. That guide clearly notes that a sexual relationship with a current patient or one of their family members is inappropriate. However, the
Nursing guidelines around the world recognise the possibility that a nurse may fail to maintain professional boundaries. The Nursing Council of New Zealand issued a Code of Conduct for Nurses in June 2012. This code contains a set of standards describing the conduct and behavior that nurses are expected to uphold. Principle 7 of the code focuses on the need to act with integrity to justify patients’ trust, which includes the following: 7.13 Maintain a professional boundary between yourself and the patient and their partner and family, and other people nominated by the patient to be involved in their care.
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guide is less clear when advising nurses about relationships with former patients and their families, just stating that such a relationship “may be inappropriate”. The use of the word may indicate that there are some circumstances when such a relationship is deemed inappropriate and others when it is not. The guide does makes it clear that where the clinical relationship was a psychotherapeutic one (with the patient/consumer accessing mental health services or intellectual disability services) or the misuse of the information by the nurse could compromise the health of the former patient, a sexual or intimate relationship may never be appropriate. Despite the Nursing Council’s very best efforts to offer guidance on this tricky topic, the guide acknowledges that: “It is not possible to provide guidance for every situation and nurses must develop and use their own professional and ethical judgment and seek the advice of colleagues and/or their professional organisation when issues arise in relationships with patients.” The guide details a number of factors that impact on whether a relationship will be deemed to be inappropriate or not, and these are taken into consideration by the Health
Signs of over-involvement
How to avoid over-involvement
A nurse can be alert to the possibility that their professional boundaries, or those of a colleague, are being threatened by looking out for the following: • revealing information about their personal life that’s unnecessary in the context of care • the nurse attempts to see the patient, or the patient attempts to see the nurse, outside normal working hours • the nurse thinks about the patient when not at work • the nurse provides the patient with personal contact details • the nurse maintains contact with the patient after the clinical relationship has ended • the patient is only willing to speak with a particular nurse • the nurse changes their dress style for work when working with a particular patient • the nurse’s interactions with the patient appear flirtatious, or contain sexual references • the nurse fosters the patient’s reliance on them, rather than encouraging them to be more independent.
• Keep to relevant personal detail in history taking • Be aware of the messages, verbal and non-verbal, that the nurse sends to patients and that there is a risk that they may be misinterpreted • Refrain from undue familiarity • Offer the option of an appropriate chaperone during intimate examinations or treatment • Be cautious of the context and intent if accepting a gift from a person in your care • Never use sexually demeaning words or actions or dirty jokes • Maintain proper appointment systems • Be aware that people may be vulnerable at times of crisis in their personal life • Do not involve the people in your care or members of their immediate family, or any other person involved with their care, in your personal problems • Consult with colleagues about difficult situations.
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Practice, People & Policy Professional development
Practitioners Disciplinary Tribunal when it considers a complaint of this nature: • how long the clinical relationship lasted – for example a short-term intervention is very different from long-term care • the nature of that relationship and whether there was a power imbalance that the nurse may have used to commence an intimate or sexual relationship • the vulnerability of the patient at the time of the care relationship, and their current vulnerability • whether the nurse is exploiting information gained from the clinical relationship • whether the nurse may be caring for the patient or their family member in the future. An appearance before the tribunal, by its very nature, is not a pleasant experience and the best way to avoid this happening to you is to recognise the signs of becoming inappropriately involved with a patient or one of their family members (see overinvolvement sidebar).
the Nurse’s Code of Conduct states that a nurse has a duty to: “Intervene to stop unsafe, incompetent, unethical or unlawful practice. Discuss the issues with those involved. Report to an appropriate person at the earliest opportunity and take other actions necessary to safeguard patients.” You may consider speaking to your colleague about what you have witnessed. If you decide to take this approach, remember that what you say may come as a total surprise to your colleague, so give some thought to when, where and how you raise this with them. If you decide to speak to your colleague, you should explain: 1. what you saw or heard 2. what impact the act appeared to have on the patient or their family member (or on the nurse, if the nurse was the recipient of the words or acts) 3. the need to maintain appropriate boundaries as per the Code of Conduct. If you feel uncomfortable speaking to your colleague – or having spoken to your colleague, he or she fails to acknowledge the matter – you should speak to your supervisor. To ensure that you accurately recall the event you witnessed, and also to provide your supervisor with clear information, you should write down the details of the incident, including date, time, parties involved, and any other witnesses to the event. If you have approached the nurse, you should document the detail of this conversation. Taking this action protects the patient, the nurse and yourself.
Key points
What if a colleague is becoming overinvolved?
A relationship with a current patient or a member of their family is deemed to be inappropriate. A relationship with a former patient or member of their family may be inappropriate. While the Nursing Council guidelines and tribunal decisions do give an indication of the factors they consider, it is very difficult for a nurse to be certain that they can enter such a relationship without fear of a professional misconduct complaint being made against them. If the nurse gets this wrong, they run a very real risk that their registration could be cancelled or suspended. If you are unclear about professional boundaries, consider discussing it with a colleague knowledgeable in this area, or attending an appropriate course, such as the one offered by the College of Nurses. It’s better to do this type of course out of choice than it being a stipulation by the Health Practitioners Disciplinary Tribunal of you getting your registration back. You trained for years to get your nursing registration – don’t make an uninformed decision about relationship boundaries and thereby run the risk of having your professional bodies decide whether you can keep it. If it feels dodgy, it probably is!
Unfortunately, sometimes a nurse will not recognise that their relationship with a patient or a member of their family is becoming intimate. If you think that colleague is in danger of failing to keep appropriate professional boundaries, you have a duty to do something about it. If you witness such behaviour by a colleague, you cannot ignore it. Standard 6.9 of
The author: Robin Kay RMN, Dip. Health, LL.B (Hons) and LL.M (Health Law) was a mental health nurse for more than 20 years before becoming a Christchurch solicitor. He has a keen interest in the legal aspects of nursing practice, particularly professional conduct, and is an associate member of the College of Nurses Aotearoa. robin.kay@laneneave.co.nz
What should a nurse do if a person in their care or a family member is attracted to them? Sometimes a nurse will find that a person that they are caring for, or their family member, is attracted to them and displays sexualised behaviour, perhaps flirting in the first instance. When this occurs, the nurse should firstly advise a colleague and consider contacting their professional body to seek advice on the most appropriate step to take. The nurse may decide to speak with the patient or family member displaying the attraction, gently explaining what they have noticed and then outlining the professional boundaries that they as a nurse are required to maintain. This conversation is not an easy one for the nurse and the individual to have, and the individual should be reassured that the matter is being treated with the appropriate degree of confidentiality. However, despite the best efforts of the nurse, it may be that the result is that the clinical relationship cannot be re-established. In that case, the patient’s care should be transferred to another nurse.
Tribunal finds nurse’s relationship with stroke victim’s husband ‘wrongful’ Ms S suffered multiple strokes in November 2008 and was transferred into X Hospital in December 2008 where she was settled into the facility by Nurse E. Ms S was left with total right-sided hemiplegia, initially had no speech, is now mobile with an electric wheelchair but still requires assistance with all daily cares. Ms E’s role meant she was only occasionally involved in Ms S’s care but met Ms S’s husband Mr S and her family. In June 2009, around six months after Ms S was admitted to the hospital, Ms E and Mr S met at a social function and an intimate relationship began to develop. Nurse E was aware that her developing relationship with Mr S might place her in a ‘conflict of interest’ and in July informed her manager Ms R and told her she didn’t want to leave the hospital but understood if she had to. Ms R said they discussed the fact that Mr S was under a “great deal of stress”, the need to inform Ms S’s family, and was given the impression from Nurse E that the relationship was ethically okay under Nursing Council guidelines. It was agreed that Nurse E should not provide patient care or plan care for Ms S. The tribunal was told that news of the ongoing relationship split the hospital staff and by November 2009 rumours circulating in the local supermarket reached the DHB. This led to the redeployment of Nurse E in January 2010 and formal complaints being laid that she had breached the Nursing Council Code of Conduct. The Nursing Council professional conduct committee sent the complaint to be heard by the Health Practitioners Disciplinary Tribunal and recommended Nurse E be suspended for two years. The tribunal found that Nurse E had entered into and continued an inappropriate relationship with Mr S between June 2009 and January 2010, which was an act of professional misconduct as it amounted to “malpractice in the scope of her nursing practice” and further that the relationship had brought, or was likely to bring, discredit to the nursing profession. “It is wrongful conduct amounting to misconduct for a nurse to have a relationship of intimacy with the spouse or partner of a patient in circumstances such as this. It is for the nurse either to take the initiative to back away from the relationship or be prepared to compromise, if not completely abandon, his or her nursing career.” The tribunal censured Nurse E and suspended her for six months but that suspension order was suspended for 12 months to allow Nurse E to demonstrate she understood the ethical standards required of her and under the condition that she had professional supervision for 12 months. She was also ordered to pay $21,000 towards the cost of the hearings.
N.B. The full decision can be read at:
www.hpdt.org.nz/portals/0/ nur10159pdecisionsubsweb.pdf Nursing Review series 2014
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People, practice & policy 2014 opinion
Check out our online opinion If you’re reading the print edition, you’re only getting half the story. The recently revamped Nursing Review website has web-exclusive content, and from now on, news stories will only be online. Go to www.nursingreview.co.nz for the latest news and opinion. Here is a selection of excerpts from the most recent opinion articles published online.
Election 21014: Lots of billboads but where’s the policy analysis? Former Chief nurse DR MARK JONES is back in New Zealand and getting tired of being confronted with billboards of smiling politicians. The now-independent health consultant and theology student asks nurses to not to take politicians at face value and to research their policies on health and other issues impacting on their community before casting their vote. Circumnavigating Rodney district at the weekend with my dear Suzie (motorbike) and kind of enjoying a typical Auckland weather pattern (sunrain-easterly-sun-rain-westerly on a 20-minute cycle), my necessary attention to dodgy road surfaces was frequently distracted by the smiling visage of our Prime Minister. He seemed to appear around every bend, more so as we re-entered his home electorate of Helensville. On the final leg home though Kumeu, the image loomed larger than ever as we passed the National Party office – that sure is some grin!
Yes, it’s that time again where our ‘pollies’ truly believe plastering their faces on giant billboards all over the place will influence our vote. I can’t quite grasp the sincerity behind the PM’s beaming smile. Having spotted David Cunliffe’s offering as I descended into Henderson Valley yesterday, I would have to say that he also looked a little unnerving. Don’t get me wrong; it must be hard to strike a natural pose for a picture to be seen by millions.
Will health technology ever be as cool as Star Trek? NP ANDY McLACHLAN enthuses about his love of technology and science fiction (even the really bad stuff with rubber monsters, polystyrene boulders, and fake eyebrows) and how cool new tech might fit into the future of healthcare. He also wonders what people really want in their darkest hour – an attentive human being or their nurse’s face eerily lit up by their smartphone screen as they update their Facebook status.
With the explosion of new mobile, electronic, time-saving (and okay, just a few timewasting) gizmos over the last few years, I think it’s fair to say I am in my element. I am often to be found looking intently at the newest smart phone/tablets/watches in Harvey Norman, and if I didn’t have a mortgage the size of the Greek national debt, I would be an early adopter of almost all new electronic thingies. I am also a bit tight, so that doesn’t help either. The other day, we were in a meeting, and a colleague produced a standard (dumb?) cell phone and proceeded to text ... the response was amazing. People looked longingly at the antiquated phone and oohed and ahhhed.
Upskilling mental health nurses Addiction lecturer and mental health nurse Dr DARYLE DEERING says people affected by mental health and addiction issues need a response from compassionate and skilled nurses. There has been significant progress made in combatting the stigma associated with the experience of mental health and addiction issues. A number of prominent New Zealanders have made their experiences visible, and in doing so, they have also provided hope for others. Despite this progress, there are many New Zealanders who can attest to the personal impact of the pervasive stigma associated with mental health and addiction issues and less than helpful responses when they have ‘screwed up’ the courage to seek help for themselves or for whānau and family members.
Letter to the Editor We were delighted that in the June/July 2014 issue of Nursing Review our article “I didn’t want that”: Assessing individual cultural needs during end-of-life care was published. This article was another avenue to share some of our research findings with nursing audiences. On receiving our published copy, we noted that a photo of an unfurling fern frond had been added to the article. Our team’s response to this seemingly harmless photo was one of resounding dismay. This image was similar to the one that featured on the front cover of the information sheet for relatives on the New Zealand version of the Liverpool Care Pathway for the Dying Patient (LCP), when we commenced our research. It was an image about which we received much spontaneous feedback. Some of our research stakeholders (both Māori and non-Māori) identified it as a pleasant and appropriate image, emphasising its links with nature and a life process. Others (both Māori and non-Māori) had different perspectives. Stakeholders told us how culturally inappropriate the image was when associated with end-of-life care, and that some groups would not use the LCP document because of this image. 20
Nursing Review series 2014
As a result of these conflicting opinions and the negative implications for culturally appropriate care, early in our research we worked with the then National LCP Office (one of our research partners) to have the image removed. We also asked for advice to be attached to the LCP regarding the need to seek cultural advice from within each district health board about the use of images on the document. To have this image used in association with our article was distressing and it may offend some of our research stakeholders. However, it is a clear reflection of much of our research findings, how we all perceive things differently, and how what appear to be simple actions can have unintended and negative consequences. Images are powerful on so many levels and we certainly didn’t want that. Kind regards Lesley Batten, Marian Bland, Maureen Holdaway, and the LCP Research Team Ed. We apologise if the photo published in last edition’s RRR professional development article caused distress or offence. The photo has been changed in the online version of the article.
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