FOCUS: Healthy Year Ahead
Nursing Review FEBRUARY/MARCH 2014/$10.95
NEW ZEALAND’S INDEPENDENT NURSING SERIES
Q&A
with Denise Kivell
LIFE’S MORE THAN WORK…
SURFIE NURSE LEADER DRAWING FROM LIFE EXERCISING THAT MUSCLE
SAYING ‘NO’ IN THE NICEST WAY
PRACTICE, PEOPLE & POLICY
Unspecial care for special Olympians Welcoming difference
A DAY IN THE LIFE OF A PRISON NURSE
EVIDENCE-BASED PRACTICE: Exercise reduces fall injuries?
HEALTHY YEAR AHEAD OBESITY: NURSES NOT IMMUNE
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LETTER FROM THE EDITOR You can’t tell at a glance whether somebody walks to work every day, swims three times a week, or is a keen tramper – nor whether they live on coffee and adrenalin or three healthy balanced meals a day. But at first glance we’ll, often subconsciously, make a judgment on whether somebody is ‘skinny’, ‘fat’, or some nebulous ‘in-between’ using our own scale of whether someone has an ‘unhealthy’ (or unfashionable) physique. We know that most of us will never be skinny – nature makes us in all shapes, sizes, and metabolisms. But for millennia, nature also never gave us access to a superfluity of high-energy food or freedom from hard physical labour. So modern life has given us the potential to be obese like never before. Should we be worried? Yes and no. American law professor Paul Campos argues in his book The Obesity Myth (2004) that the research shows that a person’s cardiovascular and metabolic fitness are more significant measures of a person’s health than their BMI. The latest longitudinal Whitehall research findings, following a cohort of 6705 London civil servants, also raises big question marks over the accepted relationship between recent weight gain and type 2 diabetes. The vast majority of the 645 developing type 2 diabetes were not obese and had been “stably overweight” for a decade or more before diagnosis and showed only minor insulin-resistance. From my own technically overweight perspective, I’ve no desire to live my life hungry or spend every spare minute at the gym. But having lost too many friends to cancers they couldn’t prevent, I think it is only fair to their memory that I do my best to eat well and exercise regularly so I can live as long, and as healthily, as my lifestyle, genes and luck allow. And isn’t positively supporting ourselves and others to live as healthily, and happily as possible what it’s all about? Now where are my running shoes… Fiona Cassie editor@nursingreview.co.nz
Inside: FOCUS: Healthy Year Ahead 4 Obesity: Nurses far from immune 9 ROBYN WALSHE on saying ‘no’ assertively
not aggressively
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Outside work passion 1: DEBORAH ROWE shares the joy of catching a wave
11 Outside work passion 2: Artist ANNEMARIE McCAMBRIDGE on drawing from life
12 LYNDA LOVATT: Tips for exercising that often forgotten muscle
RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe
PRACTICE, PEOPLE & POLICY: 18 19
JUDY SECCOMBE on being more welcoming to new colleagues
from other cultures
Special Olympics CEO KATHY GIBSON on unspecial health care
REGULARS 2 3 14 16 17
Q & A Profile: New Nurse Executives of New Zealand (NENZ) chair DENISE KIVELL A day in the life of … prison nurse DENIS ALLEN Evidence-based practice: ANDREW JULL on reducing fall injuries Webscope: KATHY HOLLOWAY on RSS, the simple way to keep up-to-date College of Nurses column: NICOLA RUSSELL challenges all nurses to step up to
make a difference
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For the record: News round-up
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Exclusive online content Nursing Review is a genuine multimedia publication. Our recently revamped website has content not found in the print edition, including exclusive online articles, live Twitter updates, social sharing, and the downloadable RRR professional development archive. Visit: www.nursingreview.co.nz COVER PIC: Lynda Lovatt – nurse-turned-personal trainer shares tips on keeping your pelvic floor strong. Read more on p.12 PHOTO CREDIT: Glenn McLelland, www.aerialvision.co.nz
EDITOR Fiona Cassie @NursingReviewNZ ADVERTISING Belle Hanrahan EDITOR-IN-CHIEF Shane Cummings PRODUCTION Barbara la Grange Aaron Morey PUBLISHER & GENERAL MANAGER Bronwen Wilkins PHOTOS Thinkstock
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NursingReview
Vol 14 Issue 1 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 © 2013/2014. 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
Denise Kivell
JOB TITLE: Director of Nursing, Counties Manukau District Health Board and Chair of NENZ (Nurse Executives of New Zealand)
Q A Q A
All nurses receiving coaching and mentoring as part of their leadership development. And the spread of dedicated education units (DEUs) focused on providing a learning environment for the wider health team, with a strong focus on the nursing workforce pipeline.
Where and when did you train? Palmerston North Hospital class, Jan 1975-78.
Other qualifications/professional roles? Registered Sick Children’s Nurse at Great Ormond Street (GOS) 1986, MHSc University of Auckland 2004. These two qualifications shaped my career. Recently became the chair of Nurse Executives of New Zealand (NENZ)
Q A
What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt? Characteristics for me include values such as integrity, being authentic, caring about people. I rate developing and guiding others to maximise their leadership potential is an asset along with developing your own self-awareness. The emotional intelligence factor is also a key characteristic. In regards to whether it is intrinsic or learnt I say being able to learn is the deciding factor
Q A
When and/or why did you decide to become a nurse? I always wanted to be a nurse. I remember in my early school days rescuing and saving the “baddies’’ and the “goodies”. My mum was a nurse and I heard many stories of being a ward sister in charge of a children’s ward at Stratford during the polio epidemic.
Q A
Q A
What was your nursing career up to your current job? I set off travelling two years after graduation and worked as an agency nurse in London to supplement my travel bug. I returned to New Zealand and worked at the then-Hastings Memorial Hospital before heading off again and stopping off in London for two years to work and study at Great Ormond Street, which made me see what was possible in paediatric nursing. After a year back at Hastings, where I helped two children and their amazing families undertake the inaugural home TPN (total parenteral nutrition) management, I shifted up to Auckland to work in the Princess Mary paediatric intensive observation unit. A post for a new charge nurse manager role, overseeing the development of New Zealand’s first 24-hour paediatric observation unit and medical ward at Middlemore, was my next significant step. Five years later, I was involved in setting up the paediatric home care service, which is now in its 15th year. The road to a nurse practitioner closed at this stage as I chose to go on to clinical nurse director roles in paediatric, primary health and intermediary care before stepping up for the DHB director of nursing role in 2007. Recently, my role has been redefined with a focus on our hospital services.
Q A
So what is your current job all about? I am accountable for standards of nursing care and the strategic development of nursing. Six years ago, we had a 15 per cent vacancy rate. We also had too many complaints of poor care. Addressing such issues requires a team effort with clear vision and commitment
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to quality improvement. I serve three masters: firstly patients, whānau, and our community; followed by nursing; and thirdly my boss, our CEO. Currently, I am leading one of our six organisational strategies – developing patient and whānau-centred care; which is so the right thing to do and makes the difference for patient, whānau, and staff experiences at all levels.
Q A
What do you love most about being a director of nursing? The opportunity to be a significant influence for nursing at the top table. Every day is different with such variety and diversity. To be able to work and network with inspiring people. I love seeing the result of investments in staff development.
Q A
What do you love least about being a DoN in 2014? The increasing bureaucracy, the challenging workload demands on frontline staff, and seeing and hearing about the impact of causing harm to our patients.
Q
If there was a fairy godmother of nursing what three wishes would you ask to be granted for the New Zealand nursing workforce? Recognition of the value and increase of advanced practice roles across the health system.
A
What do you do to try and keep fit, healthy, happy and balanced? I’ve just returned from doing the threeday Tora coastal walk with friends, where we dined well, had a few bottles of great local wine, and mixed in laughter and fun as we experienced the stunning rural Wairarapa countryside. Having regular breaks, where there is a challenge or some uniqueness, energises me – this can include shopping in Wellington or doing the Rail Trail. My ‘balance’ acknowledges long hours – usually due to too much talking and not enough action – along with energising time off. Once away, the phone is off as I trust my team to effectively handle a range of issues.
Q A
While waiting in the supermarket checkout queue which magazine are you most likely to pick up to browse and why? Dreams are free – so I pick up a variety of mags that are timely – including travel mags with inspiring places to take you away. I also often check in what the ‘women’s mags’ are saying about the latest miracle cure … just in case it is evidenced-based.
Q A
What are three of your favourite movies of all time? Ghost with Demi Moore and Patrick Swayze; I love James Bond movies and yes, Star Wars: Return of the Jedi.
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What is your favourite meal? I love the association of food with their country of origin: so I would start with Champagne in Reims; then an entrée of Peking duck in Beijing; my main would be New Zealand roast lamb with all the trimmings (including a Central Otago pinot noir); my dessert would be crème brulee in a Paris street café; followed by port from Portugal and Belgian chocolate truffles.
A day in the life of a ... prison nurse
NAME | Denis Allen JOB TITLE | Registered nurse LOCATION | Hawkes Bay Regional Prison, Hastings
6:00
AM WAKE Usually I wake before the alarm. Today I am working a 7.30 shift. After breakfast, I sort the dog out, feed and liberate the chooks and make a cup of coffee for my wife (who has the task of waking our teenage son up). A quick look out the window and decide to take motorbike and not the car to work today.
once said “always ignore everything before the but”) she has a patient waiting for his lunch-time controlled drug. Lunch over!
3:30
7:15
AM ARRIVE AT WORK I arrive at the prison guard house, proper name ACF (Access Control Facility). Stow my gear and go through the scanner; no metal objects on me, no prohibited items. Head to key room to receive the keys I need today. I also pick up a radio – all-in-all, over a kilo in extra weight to carry around. I have been nursing for almost 40 years now after going through hospital (both psychiatric and general) based training. I’ve also done military nursing and occupational health nursing. I started working at HB prison in 1995, left for three years to work in occupational health, and then returned in 2007. Some of my clients (and staff) accuse me of being a reoffender. I find prison nursing to be one of the most challenging and rewarding areas I’ve worked in. We are responsible for assessing and managing many acute and chronic health conditions, both physical and mental. I guess I am wellsuited to this rather unique environment; it feels comfortable, both professionally and physically.
7:25
AM ARRIVE AT HEALTH CLINIC Pass through eight different remotely controlled doors to get to the clinic. It’s very quiet, the earlier shift are out in the satellite units (where the majority of the over 600 prisoners are housed). I’m on the 0730 shift so mostly in the main part of the jail, which has approximately 180 high security prisoners. Nurse clinic appointments for the day include the usual list of blood tests, new arrival health assessments, and requested appointments. Today is Friday, so also dentist day. Greet the health prison offer and discuss general flow of patients for the day. The next hour is taken up with preparing the morning medications and issuing medications to prisoners who “walk over” from satellite units.
8:40
AM MEDICATION ROUND Off on my medication round for patients in the main jail. There are six units to cover and many gates and doors to open and close.
9:30
AM BACK IN CLINIC I’m back with a few health issues from staff and patients, to follow up. The dentist is
in full swing. The health officer tells me she has “one for me”, a blood sample to gain. I know this patient. He has regular (28 day) blood tests as he is currently taking the antipsychotic Clozapine. He doesn’t particularly like having blood tests and venous access is not easy. He is very suspicious but has enough insight to know how important the blood tests are. We talk as we walk to the exam room, keeping the conversation light.
12:00
PM CATCH UP & LUNCH? Morning duties are completed. The midday shift nurse is already here and – depending on new arrivals from court, transfer, or police – we should be able to see the remaining patients on the nurse’s clinic list this afternoon. Time to grab some lunch and catch up with other health centre staff.
12:15
PM LUNCH INTERRUPTED Well that didn’t last long: the health officer tells me there’s a phone call for me. It’s the DHB with instructions for a patient.
12:20
PM SECOND ATTEMPT FOR LUNCH BREAK Back to the staff room; nobody there, “Nigel no mates!”
12:30
PM GIVE UP ON LUNCH… Health officer interrupts again, says she is sorry; not sure about that, but (a wise man
PM SHIFT OVER Afternoon duties over. The dentist has completed his list of eleven patients, the nurses’ clinic list is mostly completed. Most patients have been seen, some unavailable; at court, transferred, or with lawyers and all have been recalled and rebooked. I have also carried out a physical and mental health triage screen of two new arrivals at the receiving office. One is a patient we know well, returning only a short time since he was released. He assures me he is neither “at risk” of self-harm nor is he contemplating suicide. He says he saw his GP while he was “out” regarding his antidepressant medication but is more intent on obtaining NRT (Nicotine replacement therapy) patches. After a brief discussion, he decides he really isn’t a current smoker and is trying to obtain NRT for ‘currency’. Notice he has ‘pocketed’ my pen following signing a form. He says, “I thought I had it then,” and laughs. Not a bad day at work, very typical for working the 7.30 shift; no “break, break, break” (emergency) calls, a mixture of planned and unplanned activities, and I get away from work on time.
4:00
PM HOME Great ride home on the bike – a beautiful Hawkes’ Bay day. My son is home already. I hassle him off the Xbox to do his chores (dog and chooks) and homework. I get in the washing, sort, and start preparing dinner. My wife will be home soon, so its nice to sit down for a chat with her before dinner. My son does his chores but is now on YouTube and requires more hassling to start his homework.
7:00
PM
Watch the delayed news and get motivated to turn on the computer to look at the work coming up for the postgraduate paper I am working on at EIT. All I do is answer some forum questions and leave the quiz questions until tomorrow.
9:00
PM
Hassle teenager to get off the Xbox, tell him it’s time for bed.
10:30
PM
Off to bed, should have gone earlier but watched something on TV, can’t remember what it is! Hassle teen to put his book down and turn off light; remind him I love him (he mumbles “Love you, too”).
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FOCUS n Healthy Year Ahead
Healthy Year Ahead We turn the lens and look at nurses’ own health and wellbeing. This edition we raise the complex issue of nursing and obesity; look at nurses’ passions outside of the workplace; being assertive not aggressive; and not forgetting your pelvic floor!
Nurses and obesity:
Do as I say, not as I do? Promoting healthy lifestyles is bread and butter for today’s nurses, but recent research indicates Kiwi nurses are more likely to be obese then their patients. FIONA CASSIE discovers more about nursing, obesity, and weight management.
H
ow good are nurses at walking the talk of healthy living? Nurses know more than most the importance of being active and eating well. They also are aware of the increased health risks of being obese. Yet obesity levels are still growing rapidly in New Zealand, and it appears that nurses are far from immune. New Zealand obesity levels were just 10 per cent in 1977, 19 per cent in 1997, and have now reached 31 per cent according to the latest 201213 New Zealand Health Survey. One of the first studies to look at the weight of Kiwi nurses – the Nurse eCohort study – found that 28.2 per cent of the 780 New Zealand nurses taking part were obese. Which was 1.7 per cent higher than obesity levels in the general population at the time (2006–2008). The gap was similar or higher for nurse participants from Australia and the United Kingdom. In all, nearly 62 per cent of the 5000 nurses involved in the three nation eCohort study were overweight or obese – slightly more so than Jane and Joe Average in their home countries.*
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Fiona Bogossian, who led the eCohort obesity analysis, found the high percentage of nurses outside the healthy weight range “surprising” given that health professions should have a “more acute understanding” of both the health consequences of obesity and of strategies “to avoid or overcome” obesity. She goes on to say in her 2012 article* that the findings “suggest that nurses and midwives are less able to manage their weight than their age and genderrelated cohorts”. Massey University professor Jenny Carryer says she has often wondered whether nurses are more overweight than the average population and Bogossian seems to have confirmed this. But Carryer, who has a long-standing research and personal interest in the topics of body size and health, says she still can’t see any likely hypothesis for why this would be so. “For me, it compounds my growing certainty of two things – that we still really poorly understand the notion of obesity, and that just like clothes, I don’t think there’s a one size fits all cause.”
Big bones, muscle and diabetes
The standard and simplest international definition of obesity is a body mass index (BMI) of over 30 (see Apples, pears, and BMI sidebar). One doubts that double Olympic gold medalist Valerie Adams, who reportedly has a BMI of 31.6, is being advised by her health professionals to be more active or eat a better diet. The champion shot-putter would not be alone in being healthy and fighting fit while technically obese. But crude as BMI may be, a high, long-term BMI is also statistically associated with being as twice as likely to get type 2 diabetes or high blood pressure and being more likely to have heart disease, a stroke, osteoarthritis, and several common cancers, including some breast cancers. It is the growth in type 2 diabetes that is particularly worrying, with a University of Otago analysis of 3300 blood tests from the 2008-09 NZ Adult Nutrition Survey showing that 7 per cent had type 2 diabetes and 20 per cent had pre-diabetes – so more than one in four Kiwi adults either had or were at very high risk of diabetes.
FOCUS n Healthy Year Ahead
“One doubts that double Olympic gold medalist Valerie Adams, who reportedly has a BMI of 31.6, is being advised by her health professionals to be more active or eat a better diet.” And it appears that it is not genes, big bones, or muscles that are making more and more New Zealanders obese. The Ministry of Health on its obesity web page says while “some people are more genetically susceptible to weight gain than others, the rapid increase ??????? in the prevalence of obesity in recent Intro years has occurred too quickly to be explained by genetic changes”. “Most experts believe it is due to living in an increasingly ‘obesogenic’ environment – one that promotes over-consumption of food and drinks and limits opportunities for physical activity,” says the ministry. Carryer would argue that expert research also indicates that weight gain is not as simple as eating too much and exercising too little and the obesity phenomenon is “very, very complex and multifactorial”. “Nurses being overweight really affirms that complexity for me because many, many nurses are extremely physically active – not all, but many – and extremely health conscious. It is a conundrum.” The eCohort study found nurses who were parttime or casual were less likely to be overweight or obese compared to their full-time colleagues, no matter what their age. Another related eCohort study, by Isabella Zhao, suggests that staying or changing to shift work can increase a nurse’s BMI. Bogossian says the associations between work conditions and weight gain is still not fully understood. Though some have proposed that job stress may “promote unhealthy behaviours and/or modify endocrine function”, another hypothesis is that long working hours, shift work, and overtime can lead to fatigue and so hamper preventative and healthy behaviours. Carryer agrees that many nurses are stressed and there are research studies now pointing to the role of stress hormone cortisol in obesity. “But again, you can’t apply that to everybody, and we shouldn’t be looking for a single cause – everything including stress, food availability, women’s role in feeding others, juggling multiple roles, lack of sleep … all of those things obviously play a part.” Bogossian’s analysis also found that nurses were more likely to be overweight as they got older and – with 90 per cent of the study being women – particularly when they were post-menopausal.
Middle-aged women already very aware of weight
Nurses, of course, are not alone in putting on weight in middle age and a recent study has found that weight management is very much on the minds of middle-aged Kiwi women – excessively, in some cases. The University of Otago study of 1600 women aged 40 to 50 found more than 80 per cent were either trying to lose weight (39 per cent) or prevent weight gain (42 per cent). This included 23 per cent with BMIs of less than 25. Associate professor and nutritionist Caroline Horwath says the most common methods of weight control were cutting down meal sizes or reducing fat and sugar intake, which is in line with healthy recommendations. About half said they were exercising predominantly to lose weight or control their shape. “Women in New Zealand are really conscious of attempting to put into practice strategies to lose weight or prevent weight gain,” says Horwath. “In spite of all of that, when you look at what’s happening with the prevalence of obesity, it’s high and it’s still rising.” She says overseas longitudinal studies also indicate women can gain 0.6 to 0.7 of a kilo per year through the decades of midlife. For women who are already overweight or obese the weight gains can be even more substantial putting them at increased risk of metabolic syndrome. During the menopause transition, there is evidence of increased body fat levels and a deteriorating lipid profile with women’s risk of cardiovascular disease also increasing markedly post-menopause. “Clearly, what comes up is that we need more effective solutions to help people deal with extra weight, but we also need to focus more on how to help people prevent weight gain. Menopausal transition time is a particularly important time as it’s an at-risk time for weight gain.” The cohort was first surveyed in 2009, again in 2012, and a further follow-up is due in May this year when the team will be looking to see any emerging trends in which factors or measures impact on weight change. One area they will be looking at closely is motivation to live a healthy lifestyle to prevent weight gain, with the hypothesis being that the quality of motivation is the key rather than the quantity. >>
Apples, pears, and BMI: what is a healthy weight?
So you know you aren’t a fashionable weight – very few are – but when does your weight tip over to being unhealthy? The most common measure is BMI, which as the Ministry of Health website acknowledges, only provides a crude measure of body fatness in individuals and doesn’t distinguish between muscle and fat or where the fat is located. But it is still the simplest indicator that your weight may be putting your future health at risk – particularly if you have other risk factors like your family history, high blood pressure, high blood glucose, poor nutrition, and/or an inactive lifestyle. The Ministry of Health’s 2011 weight management guidelines recommend health professionals engage further with adults if they either have a BMI of 30 plus or a BMI over 25 if they have known risk factors or ‘central fatness’. Research indicates that fat around the tummy (apples) is more predictive of potential health risks than fat on the hips and thighs (pears). Diabetes New Zealand says women should aim to have a waist circumference of less than 90cm and men less than 100cm. The World Health Organisation says there is a “substantially increased risk” of metabolic complications if your waist is over 88 cm for a woman or 102 cm for a man. Heart Foundation Body Mass Index calculator: www.heartfoundation.org.nz/ healthy-living/losing-weight/bmi-calculator
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FOCUS n Healthy Year Ahead
<< So people saying they were eating healthily because they enjoyed it were more likely to have a healthy BMI than those people who said they ate healthily because they were being ‘nagged to’, says Horwath. The ‘non-dieting’ approach to weight management has been a research topic of interest to Horwath for some years. With many overweight women knowing as much as, if not more than, the dietitians about the calories, GI, and ‘points’ of every crumb they eat – it is clear that the restricted diet approach does not work for everyone. She says that clinical trials of weight loss programmes usually show the maximum weight loss in first six months then it’s very common to return to the initial weight in following five years. Many of the overweight women she had worked with in her research were spurred into their first restricted diet as very young women after comments about their weight but look back now and see they were very healthy young women. But once started down the restricted diet road the research shows dieting can make you more preoccupied and out of control with food. You diet and lose weight, which makes you feel good, but then the weight goes back on plus a bit more, so you diet and lose weight again, but once again, put back on the weight plus yet a little bit more. “This ongoing yo-yo pattern of gaining more and more weight over the years continues until finally they really are substantially overweight,” says Horwath.??????? Intro
“The University of Otago study of 1600 women aged 40 to 50 found more than 80 per cent were either trying to lose weight (39%) or prevent weight gain (42%).” “Women tell themselves that they have failed on all these diets. They don’t tell themselves that these diets have failed them.” It can be a discouraging and damaging cycle. Horwath says it’s all very well to encourage people to get active and eat healthily to protect themselves from weight gain. But the bigger issue is how can people be motivated and empowered to adopt, sustain, and enjoy these behaviours for not weeks or months, but their lives. “Obviously, we’ve got this food environment, which is making unhealthy choices very, very easy and cheap,” says Horwath.
Appetite for 10 steps to a healthy weight 6. Include plenty of vegetables in your meals and snacks 7. Get into the fruit habit 8. Be smart with snacks 9. Choose drinks wisely 10. Ditch the takeaways. Be healthy in a hurry
Go to the Appetite for Life website for more information: (www.appetiteforlife.org.nz/10-steps-to-a-healthier-weight)
SOME USEFUL WEBSITES TO CHECK OUT: FAB approach to weight management New Zealand resources, tools and services available for health professionals on the FAB (Food, Activity, and Behaviour Support) approach to weight management are shared on this HIIRC (Health Improvement and Innovation Resource Centre) website. http://weightmanagement.hiirc.org.nz Heart Foundation’s Healthy Living site with tips on exercise, healthy eating (including new Healthy Heart visual food guide) and managing stress etc www.heartfoundation.org.nz/healthy-living Appetite for Life is a Canterbury DHB nutritionist’s initiative. A six-week healthy lifestyle programme with emphasis on health gain not weight loss delivered by nurses and GPs. Site includes range of recipes from breakfast to dessert and ‘10 Steps to a Healthy Weight’: www.appetiteforlife.org.nz Ministry of Health: Food and physical activity Links to information on Green Prescriptions, good nutrition, obesity (definition and statistics), physical activity, and guidance for workplaces: www.health.govt.nz/your-health/healthy-living/food-and-physical-activity
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Nurses walking the talk?
That web resource could fill an unmet need and be a helpful tool for both nurses and their clients. Which begs the question of how easy is it for an obese nurse to counsel an obese client about weight management. Bogossian says a systematic review suggests that normal-weight nurses are more likely than their overweight colleagues to use preventative strategies and provide general advice to obese or overweight patients. But they were also more likely to have negative attitudes towards their obese patients. Continued on page 8 >>
Useful free apps
Life:
1. Fill up on breakfast 2. Follow a regular meal pattern and prepare healthy meals 3. Make healthier food swaps 4. Caution with your portions 5. Be mindful when you eat, and plan ahead
“Part of the problem is rooted in the environment that makes it easy for people to be sedentary and easy to eat high energy foods in excess.” She says any answer to the growing obesity rate needs to address environmental issues but also to provide people with the motivation and skills to make more right choices when faced by the inevitable unhealthy options of modern life. To that end, her team is looking to develop a web-based weight management intervention using their research findings in areas such as learning to eat in response to hunger and satiation signals (intuitive eating); mindfulness and motivation skills; and recognising and dealing with the triggers that can set off overeating or unhealthy eating. The hope is to run a feasibility study on the website later in the year and in time have a resource open to women across the country.
Healthy Heart app Heart Foundation as an online ‘app’ which guides you through a weekly menu planner – complete with recipes – that meets its new Healthy Heart guidelines and even creates you a shopping list. See link below: www.heartfoundation.org.nz/healthy-living/ healthy-eating/healthy-heart-visual-food-guide FoodSwitch app This smartphone or tablet app allows you to scan barcodes in the supermarket aisle to get traffic light-style colour coded ratings for total fat, saturated fat, sugar and salt for more than 8000 food products. It also suggests similar foods that are healthier choices. Developed by University of Auckland’s National Institute for Health Innovation (NIHI), Australia’s George Institute for Global Health and Bupa NZ. Available to download for free from iTunes or Google Play. http://www.foodswitch.co.nz
FOCUS n Healthy Year Ahead
Nurses and obesity:
Helen’s story
Intro ???????
Before
After
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During her nursing career, her weight continued to grow, and while she doesn’t believe nursing as such impacted on her weight, she is conscious of the research about shiftwork and scoffing your food too fast in a snatched meal break. Depression has also been an issue. “I struggled the whole time doing Weight Watchers, Jenny Craig, starving myself, micro diets … the whole lot … losing lots of weight then putting on twice as much again. Doing lots of exercise, joining gyms. So it’s been a constant until four years ago.” That is when she decided to follow her partner (who has lost more than 65 kilos) in having a radical Fobi Pouch gastric bypass, which reduced her stomach to the size of a man’s thumb. It involved major abdominal surgery, costing about $35,000 and requiring considerable time off work, so it was not a step taken without a lot of thought by the couple. One motivating factor was their daughter and not wanting her to be judged “because she had two fat mothers” and because, eventually, the weight would have started to have a physical impact on their health and ability to be active older parents. Bloomer reiterates her solution is not for everybody and people need to have a BMI of over 35 and go through counseling before being accepted for the radical private surgery which leaves you only able to eat the equivalent of three cups of food a day – one cup at a time. With research indicating that bariatric surgery is the only answer for some morbidly obese people, she thinks the government should seriously consider increasing funding for public surgery as the costs could soon be recouped by savings from reduced diabetic kidney failure, amputations, heart attacks, and strokes.* She hasn’t looked back since her own surgery and says while her weight was never obviously an issue with her patients, and her relationship with her nursing mates is unchanged, it has made her “more visible” to some others at the hospital.
hen orthopaedic nurse Helen Bloomer talks to her overweight patients about weight loss, she can see them thinking “what would that skinny runt know”. If it’s the right time and the right patient, she tells them she knows quite a bit and will share her story of going from size 24 plus jeans to size ten. At the same time, she is also very conscious that her choice of radical private bariatric surgery four years ago is not financially or personally the answer for everybody. But after years of dieting, exercising, and counseling to try and address her yo-yoing weight – which saw her peak at 113 kg and a BMI of 36 – she doesn’t regret her choice one iota. She says she may have been fat but she was always fit, and apart from having high blood pressure when pregnant with her now 12-year-old daughter, her blood sugar levels were good, her cholesterol levels in an acceptable range, and she felt healthy and physically well able to do her job right up to her surgery. “It was more emotional and psychological discomfort than physical,” says Bloomer of her motivations for the surgery. “…the impact of society and people’s beliefs. Though in hindsight, probably physical as well. “Talking to patients at work about being overweight was a bit hypocritical.” Weight has been a life-long issue, though initially, it was more of an issue for Bloomer’s mother than for her energetic, active, and plump daughter. Her loving but critical mum’s comments about her body shape and eating habits started when she was just five or six. “I can remember her dragging me along to Weight Watchers if not at intermediate then definitely at high school.”
“Like the surgeons I’ve worked with for 15 years who didn’t talk to me before and suddenly they know my name and are happy to have a conversation with me,” says Bloomer. “For orthopaedic surgeons – who are weight obsessed at the best of times – I’ve become human. It’s awful but it’s seriously true.” Having been on both sides of the fence, she is angry that stereotypes still abound about “fat” people. “I say as long as you are fit, healthy, and happy, nobody should comment or have an opinion, really.” When it comes to whether obese nurses should be ethically expected to “walk the talk”, she says that is a hard one. She agrees with smoking research having repeatedly proven that smoking is bad for the smoker’s health; that health professionals should walk the talk and encourage others to give up. “So if I follow that logic through, then if excess weight is having a negative physical impact on our health, then we should try to live a healthier lifestyle.” As an orthopaedic nurse, she is also well aware that six times your weight is borne by your hip joint every time you take a step. “Every kilo you are overweight is increasing the stress on the hip joint by six kilos … and so if you are ten kilos over, it is like carrying an extra person on your hip joint,” says Bloomer. “I understand in a way why orthopaedic surgeons do get grumpy. “In a way we are role models, but it’s not easy. If you smoke, it isn’t easy to give up, and if you are overweight, it isn’t easy to lose weight.” *BARIATRIC SURGERY: The number of publicly-funded bariatric surgeries has risen from 131 in 2008 to 421 in 2013 partly due to four years of extra targeted funding. People need to have a BMI of 40 or over to be considered for public bariatric surgery. Nursing Review series 2014
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<< Continued from page 6 A recently published Australian qualitative study talked to 21 patients who had received healthy eating and exercise advice from their GP, which indicated they felt more confident receiving advice from a doctor who was not overweight themselves. Carryer says she was quite surprised by the Australian findings as she expected fat people might feel more rapport with a fat GP or nurse. “But the public assumption remains that thin people have earned their thinness through hard work, diligence, and abstention and that fat people are fat because they lie about stuffing their faces,” says Carryer. “Generally, that’s the belief everybody has at some level. It very much clouds our ability to work constructively with people. “If we say the only thing you can do for a fat person is to encourage them to lose weight, then that is why we’ve continued to lose the battle.” She says such research findings affirm what she has long argued that health professionals need to “stop focusing on body weight, visual size, and BMIs and think very constructively on how every individual can be supported to be as healthy as they possibly can be.” Carryer says the overweight nurse, rather than feeling hypocritical in giving advice, should be able to share with their overweight and obese patients that although overweight, they exercise four to five days a week and are really fussy about eating healthily. “They could add that, for them, it hasn’t made them lose weight but it could for the patient. It had certainly made them healthier, and the patient, too, will be healthier if their diet is good and they exercise regularly.” That’s what walking the talk is all about – promoting healthy living.
Article reference:
FIONA BOGOSSIAN Intro ??????? et al (2012) A cross-sectional analysis of patterns of
obesity in a cohort of working nurses and midwives in Australia, New Zealand, and the United Kingdom. International Journal of Nursing Studies 49 (2012) 727–738
Suggested further reading Eating: Getting it right … most of the time Eating healthily ain’t rocket science. And it isn’t about fad diets either. But it does take organisation. Nurse-turned-life coach Jan Aitken shares tips for becoming a healthier eater. www.nursingreview.co.nz/issue/february-2013/eating-getting-itright-most-of-the-time
Sugar, snacking and shiftwork A pilot study into erratic eating in shiftworking nurses and doctors raises questions about the health risks of shiftwork. www.nursingreview.co.nz/issue/march-2012/sugar-snacking-andshiftwork
Stress-proofing yourself Annette Milligan, a nurse entrepreneur who has run stress management courses and seminars for 24 years, shares some of her top stressproofing tips. www.nursingreview.co.nz/issue/march-2012/stress-proofing-yourself
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Watching and weighing So should employers be walking the talk by supporting their nurses to maintain a healthy weight by supporting healthy lifestyle choices? A number of district health boards support staff to exercise through hosting a range of inhouse exercise programmes or supporting staff in one-off events like fun runs or workplace challenges. Currently, five district health boards run Weight Watchers at Work programmes. The research evidence is there for commercial diet programmes like Weight Watchers being effective in helping overweight and obese people lose weight in the short-term but the evidence about maintaining that weight loss long-term – i.e. five years or more-is mixed. MidCentral District Health Board was an early poster child for Weight Watchers in the workplace, taking out the New Zealand workplace of the year in the 2009 Australasian Weight Watchers award, with 250 staff shedding a total of 1692 kg in a year. But it no longer hosts Weight Watchers on site. Occupational Health Nurse Noeline King says hosting Weight Watchers was viewed as a healthy initiative allowing a wide range of staff, including nurses, to share in a collegial staff welfare programme. There were also seen to be potential benefits to the board for staff to be a healthy weight. She says it also had its costs in organising meetings and setting up direct debits from staff pay. “It wasn’t sustainable over time – neither the weight loss or time investment.” But King says the DHB does offer a number of health staff initiatives including access to bicycles for work-related commuting and its Next Steppers programme. Waikato District Health Board started offering Weight Watchers on site in 2011 and for the first year it was free with the DHB and Ministry of Health footing the bill for about 350 staff to attend a Weight Watchers cycle of meetings. Weight Watchers leader Jennie Poole says at the peak it was hosting 10 meetings a week on site. Waikato followed MidCentral in winning New Zealand Workplace of the Year in 2012, with staff losing 4200 kilos. Media attention on DHB staff getting free access to Weight Watchers meetings attracted strong online public comment, with those arguing the money would be better spent on patients or that it was staff’s own responsibility to be healthy, outnumbering those in support. Jan Adams, a registered nurse and Waikato DHB’s chief operating officer, says it initially funded Weight Watchers as it wanted staff to have access to a weight management programme and support them on their goal of losing weight and being healthy. It stopped funding them because it was mindful of budget constraints but kept hosting meetings as it still wanted staff to have easy access at work. “We know from our results that staff found that to be really beneficial.” Poole says the number of meetings has now dropped back to five a week and it has 63 ‘lifetime’ members on its books from meeting their weight loss goal.
FOCUS n Healthy Year Ahead
Assertiveness: A much maligned term So you want to say no, or want someone else to say yes, and you feel you have right on your side. You don’t want to be a doormat but neither do you want to be seen as bossy or demanding. Communications specialist ROBYN WALSHE shares some tips on how to assertively – not aggressively – put your case. Robyn Walshe
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ssertiveness is a very misunderstood word – and it has bad press. When someone is described as being “assertive”, there’s often a suggestion that it is a euphemism for bossy, demanding, or even bitchy. I believe the word needs some clarifying. Assertiveness is more than an attitude – it’s a head space, and it starts with mutual respect. When you regard the other party involved as also having rights, unmet needs, and wanting opportunities to voice those – you are coming Intro ??????? together as equals (i.e. a win-win situation). And it matters not whether you are the supervisor, nurse, colleague, parent, patient, or volunteer. By contrast, being passive (lose-win) is when you readily give up your own rights, unmet needs, and voice. Aggressiveness (win-lose) is when you demand those rights. The hardest space is dealing with others who respond passively or aggressively. So while you may have the intention is to work it out together – assertively – the other party prefers to cave in, or bully their way through. Your approach and response is what matters. So how do you manage this space? Know what you want and why you want it Principled-based stands are far more effective than those that are ego-based. If the reason you’re
holding your ground is because you need to win, look good, or hit back at the other party, then think about that and ask yourself “Why?”. What exactly are you afraid of that means you prefer to play this game? (Deep questions that need to be addressed before you can make an authentic stand.) Focus first on listening If you can understand the real need the other party has, you know what you’re dealing with. (And yes, it may be that their needs are egobased. Fine. At least you know what’s really going on.) You’ll establish a level of respect from the other by working to first understand.
The case for assertiveness Here are some fresh ways of looking at the value of being assertive: »» »» »» »» »» »» »»
If we don’t tell others how their behaviour affects us, we’re denying them the opportunity to change. We have a right to express ourselves as long as we don’t violate the rights of others. When we are assertive, we teach people how we would like them to behave towards us. By standing up for our rights, we respect ourselves and get others’ respect. Not letting others know how we feel is a form of controlling them. Sacrificing our rights can result in training others to mistreat us. When we do what is right for us, we feel better about ourselves and have more authentic and satisfying relationships with others. »» Everyone has the right to courtesy and respect.
Assertive people:
»» »» »» »» »» »» »» »» »»
Are effective listeners Give and get respect Receive compliments Give compliments Are fair and ask for fairness Are able to refuse a request Can change the topic of conversation Report good news about themselves Ask for help when they need it
»» »» »» »» »» »» »» »»
Aim for win-win situations State their needs, wants and preferences Don’t allow themselves to be interrupted without good reason Can tell someone they don’t want advice Are able to tell others when something really bothers them Can openly discuss another’s criticism of themselves Can express a different opinion Leave space for compromise when their needs and rights conflict with another person’s.
Ask clarifying questions There’s always something that needs checking: for example, the resources available, the background context, the deadline, and who else needs to know or be involved. Outline your position State what areas you have in common and what the points of difference might be.
“BUT”…avoid this dangerous three-letter word It always infers a defensive position and builds barriers, not bridges. Pause. Begin your response with something like this: “I think I understand where you’re coming from. This is how I’m seeing it.” ”SORRY”…another word to watch It infers a level of responsibility for what’s not working or for the emotion that’s surfacing. Try this instead: “I’m disappointed that you feel that way.” Or “I’m disappointed that today’s schedule won’t make that possible.” Or “I need to say no. I know you’ll be disappointed in that response.” Offer solutions “What else might we try here?” “Is there someone else we could ask?” “I can help you with that tomorrow. Today is difficult.” Note the use of ‘we’. It evokes a level of cooperation and support for solving the issue at hand. Eye contact, lower voice tones and volume These all reinforce a genuine interest in connecting positively. (Start by breathing well and they’ll happen naturally).
About the author: Robyn Walshe BA PGDip DipTch MBA leads Davidson Kemp Consultancy, which focuses on building competence and capability in organisations and their people including the health sector. Nursing Review series 2014
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There’s more to life than work … Nursing Review talks to two nurses about their out-of-work passions.
Making waves Surfing a wave at Piha and chairing Nursing Council meetings in Wellington are probably two of the more diametrically opposed activities you could find. FIONA CASSIE talks to DR DEBORAH ROWE about sharks, dolphins, and the joy of surfing with the whānau.
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aves can look deceptively modest when you are sitting on the beach sunbathing. But the reality offshore is those “not so big waves” can be “quite daunting”, says surfer and Nursing Council chair Deb Rowe. “I remember my friend and I were out there sitting on our boards at Karekare having a yarn and looking at the shore.” They were chatting so much that it wasn’t until they Intro ??????? glanced behind them they saw a five-foot wave about to break on them. “We got absolutely pummeled,” laughs Rowe. That brought home to her the lesson ‘keep your eyes out to sea’. It is one of the many lessons the Auckland nurse consultant and lecturer has learnt in the decade or so since she took to the waves. Rowe has always been sporty and loved the sea, but it was her siblings’ enthusiasm for surfing (to the point of buying a surf shop as a family business) and Rowe’s decision to buy a bach in Piha that saw her start board surfing in her early 30s. Piha is the home of modern surfing in New Zealand after two young American lifeguards spent a summer on the beach in the late 1950s with their long-style Malibu boards. West Auckland beaches like Piha and Karekare are not the easiest places to learn, and you have to be quick and nimble to get yourself up on a modern short board when catching a wave, says Rowe. If you miss the ‘top of the fall’, you can end up dumped on the sand and churned around in the waves like laundry in a washing machine. But Rowe persevered and is now severely hooked. “When you actually master getting a wave and surfing down the wave… it’s such an exhilarating feeling that you’ve actually got up and mastered something. “Just being out on the water and being able to relax and sit on your board and talk to your friends … it’s relaxing and is a good time to gather your thoughts.” Now the second generation of surfers is joining her on the waves, with her brother’s and sisters’ children just as keen as their parents. “It’s especially fun going out with all my little nephews and nieces.” The youngest is a five-year-old nephew whose mum is an avid surfer and who can already get up on a wave. She goes to the gym most days after work (which includes working shifts in neonatal intensive care) but says surfing reminds you “you’ve got a few muscles you forgot about”. Her most challenging time on a surfboard was when she “popped” out her shoulder before getting dragged out in a rip. “That was the trickiest thing trying to get back in with a dislocated shoulder.” She put her hand up to signal distress but says lifeguards tend to leave surfies to themselves as they’ve got boards and didn’t realise she was injured. “So unfortunately they didn’t come and rescue me …” says Rowe. “My lovely brother-in-law was sitting in the car wondering why I was taking so long!” “I managed to get in… but it took a long time… because the tide was going out at the same time, which wasn’t helpful for me,” she says with typical understatement. “I wondered whether I was going to end up in Australia, but thankfully, I didn’t.” 10
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“I wondered whether I was going to end up in Australia, but thankfully, I didn’t.” Then there was the time at White Bay, around the corner from Piha, while surfing with friends when she had an unwanted mate of the shark variety come next to her board. “It was a fairly big one…” She tries to avoid her finned friends and was happy to see shark nets around the surfing beaches in Queensland and has fond memories of how consistently and easily the waves ‘peel’ in Noosa, meaning surfers are “pretty much guaranteed” to catch a wave. Rowe believes it is important for nurses – who sometimes can get so tied up in their work – to have an outside interest or passion that can be a “destressor” or allows them to take time out for themselves and their own thoughts and which will help them stay fit. Surfing had to take a back seat for a while recently for Deb while she completed her PhD, but with that behind her, she is enjoying more time on the board with family and friends, which has reminded her that just being at the beach brings the potential for those magic moments. “Just last weekend, I’d gone to the beach to take a look and there was a whole pod of dolphins surfing down the waves. It was quite spectacular.”
FOCUS n Healthy Year Ahead
A life in art
Intro ???????
Theatre Nurse ANNEMARIE McCAMBRIDGE’s passion for art.
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ometimes while scrubbed up and waiting, theatre nurse Annemarie McCambridge spies a scene she’d love to draw. Occasionally, she fits in a quick sketch, but more often than not, the patient or surgeon arrives and the working day is under way. But that is okay for the Waitemata District Health Board nurse and keen artist because painting and drawing is the passion she has outside of work. While her first ‘perioperative’ painting exhibitions in 2008 captured theatre scenes – and also the eye of Shortland Street art directors who used her paintings in a set – her latest passion is for life-drawing. The Dutch-born and trained perioperative nurse has always loved art but it was put low on her priorities after marrying her Scottish husband, first juggling work and then being a mother of three children. The family lived first in Switzerland for 11 years and then for shorter periods in the USA, Scotland and England before coming to New Zealand in the year 2000. It was working as a Dutch interpreter at Waikato DHB that lured McCambridge back into theatre nursing in 2004 but a severe illness at the end of 2006 saw her taking time out to rehabilitate. “My husband was very supportive. He said, “Why don’t you take a year off and do something you really enjoy?” says McCambridge. So she enrolled at an art centre to learn the basics. “And I’ve never looked back.” Dealing with the human anatomy on a regular basis at work has carried over into her art with a growing enthusiasm for life model drawing in charcoal or pencil. “Drawing from life models is just absolutely wonderful.” McCambridge also finds art classes and working at the art centre to be important “me time” where she can relax and concentrate on her painting or drawing without being distracted by the washing machine or door bell. The results give her pleasure – most of the time. “It’s the creating of this piece of work on canvas; it gives you an immense feeling of satisfaction when it goes well,” says McCambridge. She adds with a laugh, “when it doesn’t go well, it’s really frustrating, but when it goes well it’s really, really good.”
Best Care for Everyone
FOCUS n Healthy Year Ahead
Don’t be ‘weak’ and ‘leak’ Forget about crunchies and taut abs – exercising your pelvic floor and transversus abdominis have rewards all of their own. FIONA CASSIE talks to nurse-turned-personal trainer Lynda Lovatta about exercise to protect and strengthen your pelvic floor for new mums, the middle-aged, and vigorous athletes.
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e’ve all seen them in the gossip mags: those before and after shots of Hollywood yummy mummies who seem to bounce back into glamorous shape post-baby in a matter of weeks. Those flat abs on display as they stroll the beach in a bikini with a baby on their hip. Nurse-turned-personal trainer Lynda Lovatt believes it is likely that a fairly extreme diet and exercise regime was required to be paparazzi photo-ready so quickly. “It can look good on the outside but what’s happening on the inside of the body could be another story,” says Lovatt. “The pelvic floor could still be weak and the core muscles might not be strong.” Flat taut abs may look good in the glossy mags but doing crunchies and other exercises that focus on the rectus abdominis or ‘six-pack’ muscle put pressure on the pelvic floor and can actually weaken it. “The six-pack … you don’t even want to go there. Intro ??????? Everybody wants to talk about it but it’s not a good muscle to concentrate on,” says Lovatt.
Concentrate on the core
While it is the most talked about of the abdominal muscles, the six-pack or rectus abdominis is less used in daily living than the deep muscles of the abdominal “core”, says Lovatt. One particularly hard-working muscle is the transversus abdominis (TVA), the deep core muscle that wraps like a corset around your back and pelvis. It works together with the pelvic floor (that group of muscles stretching like a diamond across the floor of the pelvis supporting the bladder, bowel and reproductive organs), the multifidus (the thin muscle running the length of the spine), and the diaphragm to help stabilise and support the lower back and pelvis. “You need to get that core strong before you work on anything else.”
weights; activities like running, jumping, and skipping; or sports with stop-start running and rapid direction changes like tennis, netball, basketball, and touch rugby. Or avoid them and seek other forms of exercise that your pelvic floor can cope with. The Pelvic Floor First campaign, begun by the Continence Foundation of Australia and adopted by the New Zealand Continence Association, aims to educate fitness professionals and the public about pelvic floor safe exercises and has just recently launched a smartphone and tablet app as a handy reference tool for what is safe and unsafe (see more info in sidebar).
Gravity, age, and dysfunction New mums need to be particularly careful when exercising abdominal muscles as the effects of the hormone relaxin that loosens your ligaments during pregnancy – particularly around the pelvis – can last for up to six to nine months after giving birth. So while new mums wanting to return to exercise quickly often seek out high impact activity – as they only have short bursts of free time to exercise – it can put them at risk of injury. “We need to get the word out that that while new mums can exercise they need to start up slowly again.” Physiotherapists, continence nurses, and midwives in recent years have also been highlighting the fact that high impact exercise – for particularly mums new and old and menopausal women – can puts them at risk of pelvic floor problems that can lead to a range of bladder or bowel control symptoms. If you already have a weakness in your pelvic floor, you should consider working on strengthening that group of muscles before undertaking resistance exercises like sit-ups or lifting heavy
But it isn’t just women who are at risk of pelvic floor problems. The pelvic floor is also battling with gravity as it does its job holding up the pelvic organs over the years. “As you get older, naturally everything starts to go south,” laughs Lovatt. “So that’s why it’s really important to keep the pelvic floor exercised and strong.” While people with back problems, multiple births, birth trauma, or women and men who have had gynaecological or prostate surgery are more likely to have pelvic floor issues, incontinence is not an uncommon problem and may affect up to 1.1 million New Zealanders. Common it may be, but it still isn’t normal for a healthy adult to pee when they cough or sneeze. Just because you’ve had a baby or are middle-aged doesn’t mean you have to accept a lifetime of continence pads. The TV ads of smiling mums on trampolines may give the impression wearing an absorbent pad is the answer to any embarrassing or uncomfortable leakage, but physios and personal trainers are keen to get the word out that any form of unwanted peeing or leakage is not okay, it is a dysfunction.
Helping your pelvic floor and preventing leakage More about the pelvic floor »» The pelvic floor is like a mini-trampoline of muscles that stretches from the pubic bone at the top, to the sitting bones at the edges and the tailbone (coccyx) at the end. »» The muscle group bears the load of carrying the pelvic organs: the bladder, the bowel and (in women) the uterus. »» These muscles are also important for sexual function and sensation. »» Weakened or loose pelvic floor muscles can lead to difficulty controlling the release of urine, faeces, or wind – i.e. incontinence. »» Pregnancy, childbirth, and hormone changes at menopause make women particularly prone to weakening of the pelvic floor muscles.
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»» Age and gravity also impacts on both men’s and women’s pelvic floors over time along with obesity, heavy lifting, or high impact exercise like running and tennis. »» Correctly isolating and exercising the pelvic floor can strengthen the muscle again and be effective in recovering or building pelvic floor function.
Am I doing it right? »» Quite possibly not – research shows that up to 50 per cent of women trying to learn pelvic floor exercises from a pamphlet got the technique wrong. »» The toughest thing is to ensure you are isolating and exercising the right muscles. »» For both women and men trying to stop or
slow the flow of urine in mid flow is one way of checking you are squeezing the correct muscles (but it should not be done repetitively as an exercise). »» Another method is to imagine stopping the flow of urine and holding in wind at the same time. »» If you are doing it right nothing above the belly button should tighten or tense. If you are tensing or pushing out your ‘six pack’ tummy muscle you aren’t doing it correctly and you could be bearing pressure down on your pelvic floor.
Images courtesy of the Continence Foundation of Australia
FOCUS n Healthy Year Ahead
“If you are passing water during coughing, sneezing, or laughing, that’s not normal. It’s also not normal if you are having to go to the toilet more often than not and if you are worrying about where all the toilets are when you away from home in case you’ve got to go to the toilet suddenly or urgently.” What you should do is go off and seek help and advice – either directly to a private women’s health physiotherapist (who are specialists in assessing and teaching pelvic floor function) or talk to your GP, NP, or nurse and seek a referral to a district health board-funded women’s health physio or continence nurse specialist. Intro ???????
Getting it right: old and new ways
There is a good chance people think they have been doing their pelvic floor exercises with no results, but often, they just haven’t been doing them right. “The pelvic floor can be tricky to isolate. A lot of women think they are pulling up the pelvic floor and lifting it, but in fact, they are squeezing their glutes or they are contracting their abdominal muscles, or clenching their fists, or doing a facial grimace,” says Lovatt. “It’s a muscle you need to isolate properly for the exercise to be effective. So good exercise instruction is helpful, along with being relaxed and having good posture. You’ve just got to switch off other muscles that may be trying to help you to lift it, but once you’ve got it, you’ve got it.” Common practice used to be that women were trained to exercise the pelvic floor while peeing by trying to slow or stop the midstream urine flow.
That is now seen as an unsafe way to exercise because you should be relaxed when peeing to reduce the risk of bladder retention and UTIs. To get the pelvic floor back into shape, it’s recommended people should be doing exercises three times a day at first to strengthen the muscle. Lovatt says the exercises need to done in two speed modes – slow and fast – to match the two types of muscle fibre found in the pelvic floor. The ‘slow twitch muscle fibres’ are the ones you rely on to support your pelvic floor in the normal activities throughout the day from carrying groceries to hanging out washing. The ‘fast twitch muscle fibres’ are the ones that stop you from leaking when coughing, sneezing or laughing. Initially – particularly just after having a baby or having not exercised your pelvic floor for a very long time – it may feel like nothing is actually happening when you do your exercises, says Lovatt. “But it will come back. So it’s good to persevere – even if you can’t feel a lift happening straight away – as initially the nerves and muscles are still trying to connect.” Then, just find a time to do it in your daily routine that works for you, preferably in a relaxed time when you can ensure good posture, which is key. “The good thing is that it doesn’t take long. Once you’ve started exercising the pelvic floor you can regain pelvic floor strength quite quickly.” You will be grateful for the rewards next time you sneeze or cough – or when you want to get back into running or netball and know you can rely on your pelvic floor not to let you down.
Found them– what do I do now? »» Try and do your pelvic floor exercise when you are relaxed and don’t forget to breathe »» When starting out try them first lying down and then move on to sitting and standing. »» Repeat these exercises for five or six times in a session. Do quick contractions and then long contractions. »» Make sure you co-ordinate the breath with the longer contractions. »» Aim for a 25–30 per cent lift to avoid engaging other muscles other than the pelvic floor. »» Aim for three sessions a day when you are starting out to strengthen your pelvic floor.
Q. A bit of leakage is normal isn’t it? A. No!
Leaking urine when you cough, sneeze or laugh is not normal just because you’ve had a kid. Nor when jogging, jumping on the trampoline with your kids or doing a workout. If you have been trying to exercise your pelvic floor without any improvement, see your GP or NP and ask for referral to a continence nurse specialist/advisor or women’s health physiotherapist. Women’s health and general physiotherapists are also increasingly using real-time ultrasound so you can see on a screen for yourself how well you are activating your pelvic floor and other core muscles.
For more information check out these useful websites:
New Zealand Continence Association www.continence.org.nz (Has links to continence nurse specialists/advisors and women’s health physios in your area) Home website for Pelvic Floor First campaign www.pelvicfloorfirst.org.au Continence Foundation of Australia www.continence.org.au
Safe exercise app launched
A free app, based on the Pelvic Floor First website featuring video workouts and pelvic floor safe exercises was launched late last year by the Continence Foundation of Australia. It is suitable for smart phones and tablets and is available from iTunes and Google Play (select ‘iPhone only’ if downloading app to an iPad). *Lynda Lovatt trained as a nurse at Waiariki Polytechnic graduating in 1991 and worked mostly at plastic surgery and burns plus paediatrics and has worked in Waikato, London, Starship and Middlemore. After having her children (now 10 and 12) she moved into exercise and is a registered personal trainer in Wellington whose company Puff Fitness specialises in fitness during pregnancy, postnatal fitness and promoting fitness for mothers.
Find a visualisation analogy or technique that works for you:
Elevator: Imagining your pelvic floor is an elevator in the ground floor of a six-storey building. First ‘close the doors’ then lift your pelvic floor slowly up to the ‘top floor’ and then slowly lower it again and ‘open the doors’ and relax. Silk handkerchief: Imagine you are sitting on a silk handkerchief and are using your pelvic floor muscles from the back passage through to the vaginal area and urethra to gather up the handkerchief and draw it inside your pelvis, then exhale and slowly release. Drop of water: Visualise a drop of water falling into a bucket and imagine reversing the action to draw the drop back up and out of the bucket.
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EVIDENCE-BASED PRACTICE
The rise (of exercise) and fall (of injuries) Do community exercise programmes for the elderly reduce injuries as well as falls? CLINICAL BOTTOM LINE: Organised exercise prevents injury from falling by older adults living in the community. The rate of all injury falls may be reduced by about 40 per cent and fracture falls by up to 60 per cent. Hospitals should consider investing in organised exercise for older people as a means of harm reduction and demand management. CLINICAL SCENARIO: Patient falls in hospital are currently a national focus, but amount to a small part of the burden of injury from falls. Residential care has also been focusing on client falls in your region, but attention has not been given to the opportunity to prevent admission of independent-living older people for fall-related injuries. You know exercise prevents falls in older people living in the community, but you also want to know what effect it has on injury levels, which may be more persuasive for your district health board. QUESTION: Among community-dwelling older people, do exercise programmes reduce injuries from falls? SEARCH STRATEGY: PubMed – clinical queries (therapy, broad): falls prevention AND exercise AND community. CITATION: El-Khoury F, Cassou B, Charles MA, DargentMolina P. The effect of fall prevention exercise programmes on fall-induced injury in communitydwelling older adults: a systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f6234. STUDY SUMMARY: A systematic review of randomised controlled trials where exercise for falls prevention was compared to either ‘no intervention’ or a ‘placebo control’, such as social visits. Inclusion criteria were: Type of study was randomised controlled trials published in English or French that provided data on injurious falls, serious falls, fall-related injuries or fall-induced fractures;
Patients were people aged 60 years or older, living in the community, but excluding participants that had specific neurodegenerative disease or other condition not corrected by exercise; Intervention was exercise for falls prevention, but excluding trials that had exercise as part of a multifactorial intervention; Outcomes were rate ratio of injurious falls (falls and falls injuries were classified from trial reports based on the ProFANE definitions). VALIDITY: The search strategy was specified and the electronic databases searched included the Cochrane Library, PubMed, Embase and CINAHL to July 2013. Trials were restricted to those published in English or French. Two reviewers screened study titles, abstracts and full texts of papers for inclusion and independently-assessed full texts to determine eligibility for inclusion, with additional information sought from authors where necessary. The two reviewers independently assessed the risks of bias and extracted the data. Risk of bias assessment followed that specified by the Cochrane Collaboration and included random sequence generation (selection bias) randomisation, allocation concealment (selection bias), blinding (detection bias), and incomplete outcome data (attrition bias). Publication bias was assessed using funnel plots. Overall – this was a high quality review, perhaps only marred by the language restriction. RESULTS: Seventeen trials involving 4305 participants, with a mean overall age of 76.7 years. Seven trials selected participants on the basis of being high risk (history of falls, age over 80, or functional limitations). Fourteen trials delivered the intervention in a group setting, and six of these supplemented group sessions with home-based exercise. Study size varied with sample sizes of 53 to 486. Most trials focused on balance, gait and strength training with two being Tai Chai only. Twelve trials were judged as at low risk of bias on random sequence generation, eight on allocation concealment, nine on blinding of falls and injurious falls assessment, eleven on incomplete
Results with 95% confidence intervals Rate Ratio (95%CI) All injurious falls Falls resulting in medical care Falls resulting in serious injury Falls resulting in fracture
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0.63 (0.51 – 0.77) 0.70 (0.53 – 0.92) 0.57 (0.36 – 0.90) 0.39 (0.22 – 0.66)
Heterogeneity (I2 statistic) 50% 20% 46% 0%
Number of trials 10 8 7 6
outcome data, and six on ascertaining serious harm injuries. The six trials confirmed serious injuries using medical records. Intervention duration ranged from 5.5 weeks to one year and from six to 30 months. Four trials had a ‘no intervention’ control. Ten trials provided data that could be included in a meta-analysis. The funnel plot constructed from the ten trials included in the meta-analysis was symmetrical, suggesting publication bias was probably not present. Only minor adverse effects were reported in two trials and were restricted to musculoskeletal discomfort after exercise. Six trials stated there were no adverse effects, while others did not report on ill effects. See table below. COMMENTS: »» This review strengthens the case for investment in exercise programmes for community-dwelling older adults. The programmes not only prevent falls but prevent harm from falling. »» Sensitivity analyses removing lower quality trials had little effect on rate ratios. Reviewer: Dr Andrew Jull, RN PhD, Associate Professor, University of Auckland & Nurse Advisor – Quality & Safety, Auckland District Health Board.
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WEBSCOPE
CHECK THESE OUT
RSS = Really Swift & Simple A
KATHY HOLLOWAY shows you how to keep updated on fresh material on your favourite websites through RSS and how to catch a podcast.
s a web-savvy health professional, you can set forth on a new adventure by becoming a connected online information user. While push marketing (e.g. online ads and pop-up or pop-under links) can litter the screen when you go surfing the internet you can also take control and create pull channels to deliver you information you actually want. At a recent professional meeting, I was asked by some internet-savvy nurses how to best use technology to get “just in time” and “just in case” information from pre-selected sources. There are many other technologies out there to enhance your experience like RSS, Atom feed, and podcasting. Read on to develop your understanding of these and further impress your friends and family with your own technological savvy!
RSS or Atom Feeds RSS stands for Real Simple Syndication or Rich Site Summary and was the first product to offer the convenience of collected updates from webpages on demand. Atom feeds were developed in 2005 and provide an alternative but similar service. You will have seen the symbols for these on many websites, particularly journal and blogging sites. Look for the orange square with white radio waves (the industry standard for RSS or Atom) – you click there to subscribe to that site. The idea is that this syndication tool goes in search of new content relevant to that site constantly and then has it available for you at your convenience. An RSS document, which is called a ‘feed,’ ‘web feed,’ or ‘channel,’ contains either a summary of content from an associated web site or the full text. RSS makes it ‘real simple’ for you to keep up with your favorite web sites (or blogs) in an automated manner that’s easier than checking them manually – check out more info at http://en.wikipedia.org/wiki/Rss But, you might say, I get everything emailed to me already – why use a feed? According to Wikipedia, there are a number of advantages to feeds compared with using an email-based content service:
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»» No need to disclose your email address when subscribing to a feed, so you are not increasing exposure to threats associated with email: spam, viruses, phishing, and identity theft. »» If you want to stop, no need to send an unsubscribe request to stop receiving news. Simply remove the feed from the aggregator. »» The feed items are automatically sorted in that each feed URL has its own sets of entries (unlike an email box where messages must be sorted by user-defined rules and pattern matching).
Centers for Disease Control (CDC) podcasts www2c.cdc.gov/podcasts/index.asp This site, within the US Centers for Disease Control and Prevention, hosts a large number of podcasts on topics as diverse as pandemics, bioterrorism and concussion. The site provides help for those new to podcasting in terms of downloading. Additionally there are clear guidelines for those of you who are inspired to develop your own podcasts. Just like using any other communication channel, the decision to use podcasting technology must be based on formative research including target audience selection, goal setting, marketing plan and messaging strategy development. There are also RSS feeds that you can subscribe to from the site to keep you up-to-date in chronic disease management and flu updates to name but a few topics. [Site accessed 15 February and last updated 5 February 2014.]
To access your feeds simply go to the section of your web browser that collects them and scroll down – in Internet Explorer, this is under Favorites; for Firefox, you simply need to download a free plug-in and go.
Podcasting While it sounds like something out of science fiction, podcasting is simply a form of web broadcasting (the casting part) of audio files, which may then be downloaded into either a computer or an iPod/MP3 player (the pod part). You can use iTunes, Zune, or other free software to download (remembering the limitations of dial-up versus broadband as discussed in columns previously). Also check out www.cmecorner.com/podcast/whatis.htm You could even make your own podcasts for others to download. Podcasting has been described as the same as audioblogging (blogs with sound) with the added benefit of RSS. Podcasts are encoded with basic data so that when downloaded, the listener gets more information about the content. If burned to CDs, they can be transported and played in the car – this technology is becoming more popular in continuing education. A quick search found 2,310 nurse podcast sites ranging from ‘A & P’ lectures to personal stories. Continuing education is available at sites like http://ebn.bmj.com/site/podcasts Scroll down for podcasts, like Self-harm within inpatient psychiatric services, with many available free of charge. Remember with awareness comes choice and happy podcasting!!
Medscape Nursing RSS Feed www.medscape.com/public/rss The Medscape Nursing site is often mentioned in this column and subscribing to the RSS feed allows you to easily keep up to date with the content being published here. Registration is free and content is evaluated, created, and presented under the guidance of a WebMD Health Professional Network programme director and a nursing professional advisory board. The website generally contains the following sections, with feature articles and multimedia selected specifically for nursing: »» Nurses News: the top news stories of the day (updated daily from Reuters etc.) »» Journal Articles: Updated weekly »» Resource Centers: sections on specific conditions or topics of interest »» Nurses Perspectives: Stories and commentary relevant to nursing »» Conference Center : reports and highlights from key nursing meetings »» Blogs: a forum for discussions with your peers. Also available here are over 50 podcasts on various topics – check it out today. [Site accessed 15 February and last updated 7 February 2014.]
COLLEGE OF NURSES
Nicola Russell
Birds of a feather should flock together NICOLA RUSSELL challenges each of the country’s 47,000 or so registered nurses to this year step up and take action – small or large – in a collective effort to make a difference for the patients they care for.
T
he summer sojourn is likely to be a distant memory for many of us. Blissful lazy days replaced with the daily grind of trying to skilfully manage the work/life balance…or at least giving the appearance of doing so. It is tempting to insert an inspirational, if not slightly pipe dream-like, list of must do’s to aspire to, but resolutions for major lifestyle changes often get relegated to a list of ‘casual self-promises that one is under no legal obligation to fulfil’. Instead, I look to broader ambitions for the nursing collective in the coming year – and trust that each and every one of us is fully aware of the need to altruistically care for ourselves as a pre-requisite to being able to provide quality nursing care to others. It has been highlighted, ad nauseam, that nursing has the collective potential to effect great change – if only we could ditch our ill-founded reliance on being ‘too nice to create trouble’. Yes, we are a caring profession, but caring is more than just quiet diligence. When we work within a society that clearly requires a greater need for equality and equity for all health care consumers, then our silence and inaction equates to acceptance of the status quo. But taking action can feel all too consuming, daunting even, when you think that you are alone. “What can I possibly do or say to effect real change?” you may ask. Fortunately, through the sheer will and determination of some amazing pioneers and leaders in our nursing community, there is a strong foundation of support for us all. We all need to make a concerted effort to recognise, utilise and capitalise on the wealth of knowledge that our leaders hold, and most importantly, we need to act and think like a 47,000 member plus strong team! We need to share the load, contribute to discussions that affect our patients and our working lives, and answer the calls for our knowledge when asked – and be brave enough to offer our input even if we have not been asked.
WHAT WE CAN LEARN FROM GEESE
In the next year, if each of us picks just one issue, makes one contribution to a call for submissions, completes one survey, answers one call for nursing research volunteers, or challenges something they see or hear in their practice on just one day – that is a minimum of 47,000 acts of resistance and advocacy for our health care consumers! Imagine what we can achieve! Many of you may be familiar with Dr Robert McNeish’s “Lessons from geese” (see sidebar). The lessons speak to the responsibilities of being an effective team member and the power of a collective effort towards a common goal. So I challenge each and every one of us to evaluate what we can do this year to support the team. Whilst our key focus is the health and wellbeing of patients and communities we should also be mindful of our own health. Accepting frustration, turning frustration in on ourselves and each other, feeling we have not been able to deliver good care: these are all recipes for dissatisfaction and distress and are inherently unhealthy. Myself? Well, I plan to take up Zumba, begin my PhD, do more things that scare me (feel the fear and do it anyway!) and actively seek opportunities to learn new skills of leadership. What about you?
About the author: Nicola Russell RN, BN, MPhil (Nursing) and member of the College of Nurses board.
FACT 1: As each goose flaps its wings, it creates an up-lift for the birds that follow. By flying in a ‘V’ formation, the whole flock adds 71 per cent greater flying range than if each bird flew alone. LESSON 1: People who share a common direction and sense of community can get where they are going quicker and easier because they are travelling on the thrust of one another. FACT 2: When a goose falls out of formation, it suddenly feels the drag and resistance of flying alone. It quickly moves back into formation to take advantage of the lifting power of the bird immediately in front of it. LESSON 2: If we have as much sense as a goose, we stay in formation with those headed where we want to go. We are willing to accept their help and give our help to others. FACT 3: When the lead goose tires, it rotates back into the formation and another goose flies to the point position. LESSON 3: It pays to take turns doing the hard tasks and sharing leadership. As with geese, people are interdependent on each others’ skills, capabilities and unique arrangements of gifts, talent or resources. FACT 4: The geese flying in formation honk to encourage those up front to keep up their speed. LESSON 4: We need to make sure our honking is encouraging. In groups where there is encouragement, the production is much greater. The power of encouragement (to stand by one’s heart or core values and encourage the heart and core of others) is the quality of honking we seek. FACT 5: When a goose gets sick, wounded, or shot down, two geese drop out of formation and follow it down to help and protect it. They stay with it until it dies or is able to fly again. Then they launch out with another formation or catch up with the flock. LESSON 5: If we have as much sense as geese, we will stand by each other in difficult times as well as when we are strong. Attributed to Dr Robert McNeish (1972)
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Nursing Review series 2014
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Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy NZ’S SPECIAL ATHLETES
GETTING ‘UNSPECIAL’ HEALTH CARE Screening of the country’s Special Olympics athletes shows high levels of undiagnosed health issues. Special Olympics CEO KATHY GIBSON challenges the policy makers and the health sector to provide free health screening for people with intellectual disabilities.
DEMOGRAPHICALLY, David appears to be similar to many other New Zealanders. He’s aged in his 50s, lives independently, works part-time, receives a benefit, and plays sport. What the picture doesn’t show is that David has an intellectual disability and suffers from a multitude of health issues that have only recently been uncovered. It was through his involvement with sports organisation Special Olympics New Zealand that David managed to get the care he needed. Cases like David’s are seen regularly within athletes who train with Special Olympics New Zealand. We work with people with a range of intellectual disabilities, from those with a high level of needs and dependence to those who are at a near-elite level in their chosen sport and train with mainstream teams. All have unique health requirements over and above many other New Zealanders. Yet many of them, in our experience, fail to get the care they require. Often it is due to communication barriers with some unable to say that they are suffering from pain or feeling different from usual. We know from international research that people with an intellectual disability have poorer health than the general population. It has widely been assumed that these studies would be reflective of the health status and needs of New Zealanders with an intellectual disability. We can attest to this anecdotally through our work in the sector. Special Olympics New Zealand’s report Athlete Health Overview (released November 2013) goes some way toward addressing New Zealand’s gaps in knowledge. The report focuses on data gathered from our Healthy Athletes® screening at Special Olympics New Zealand’s National Summer Games in 2005 and 2009. Researchers from the Donald Beasley Institute, which specialises in disability research and education, analysed the data from ‘Opening Eyes’, ‘Healthy Hearing’, ‘Special Smiles’, and ‘Fit Feet’ screens and provided comparisons to 18
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Healthy Athletes® screening results from the Special Olympics World Winter Games held in Ireland in 2003. The researchers have done a stellar job in putting together this report, which provides New Zealand’s first insight into the state of health of our population with intellectual disabilities. During the screening, 9 out of 10 athletes failed one of the Opening Eyes screening tests; serious, undetected, and untreated ear conditions were discovered; two in three athletes presented with poor oral health (including four in five athletes over the age of 50 having missing teeth); and one out of five athletes was wearing a shoe that was more than two sizes too big or too small for their feet. Alarmingly, the research uncovered regional discrepancies in which athletes from some areas presented with far more health issues than others, indicating they are not getting an appropriate level of care from their district health boards or primary health organisations.
Special Olympics’ Healthy Athletes® screening is the only regular health screening conducted in New Zealand that reaches people with intellectual disabilities. But even our programme has its limitations. At present, the Healthy Athletes® screening only captures athletes who are capable of competing at our National Summer Games. By and large, international research has found that Special Olympics athletes tend to be younger, more able, healthier, and better supported than other individuals with an intellectual disability, and this is particularly the case with athletes who attend the National Summer Games in New Zealand. For this reason, the state of health of New Zealand’s intellectually disabled population may well be worse than the findings in this report. We have more than 6000 athletes who train with Special Olympics New Zealand across our 44 clubs, yet only around 1000 compete at our National Summer Games and receive health screening. It is estimated 1 per cent of New Zealand’s population has an intellectual disability. On this basis, there could be upwards of 39,000 New Zealanders who have undiagnosed health issues due to a lack of health screening. We have incorporated the findings of the Athlete Health Overview report into the upcoming screening programme at our National Summer Games 2013 in Dunedin (held in late November/early December). The results from these games will give us an even clearer picture of the state of health of New Zealanders with intellectual disabilities. In time, we hope to extend our Healthy Athletes® screening programme beyond the Games. In the meantime, we hope that policy makers and district health boards across New Zealand will read our report and take up the mantle of providing free health screening for people with intellectual disabilities. The challenge has been laid.
Special Olympics New Zealand’s Athlete Health Overview is available at www.specialolympics.org.nz
Practice, People & Policy RESEARCH
SUPPORT OR DISCRIMINATION: HOW WELCOMING ARE YOU TO NURSES ‘DIFFERENT’ FROM YOURSELF?
Judy Seccombe
JUDY SECCOMBE looks at nursing attitude to those who are ‘different’ and challenges kiwi nurses to be more welcoming to new colleagues from different ethnicities, cultures, or countries. MORE THAN A decade ago for my master’s degree, I studied the attitudes of nursing students towards people with disabilities. The literature review for this study showed very clearly that nurses’ interactions are affected when working with people who are ‘different’ in any way. The studies I looked at covered nurses’ attitudes to people with intellectual impairments, mental health issues, brain injuries, and physical impairments. I undertook this research because of my concern at hearing reports, and frequently observing, negative nursing approaches to caring for people who are different. Society’s perceptions about ‘different’ people were also often reflected in the attitudes of first year nursing students. Clinical placements for nursing students at the time included places like the former Kimberley Hospital, IHC (now IDEA) residences and workplaces, special needs classes in primary and secondary schools, and rehabilitation units in various settings. These experiences allowed students to learn how to interact and communicate with people of varying abilities; they learnt to value the person and to work alongside and within that person’s abilities. Most of all, they learnt not to judge, not to discriminate, and that all people respond positively to caring, patience, and kindness. Sadly, these valuable clinical placements are no longer accessible due to the lack of registered nurse (RN) supervision for student nurses. This means that today’s RNs often encounter people who are different for the first time in an acute healthcare environment. In many cases, these nurses find they are ill-prepared to understand, communicate and safely manage an acutely ill person with a significant existing impairment. I was thinking about this recently as I reflected on the transition of nurses of different ethnicities and cultures into our nursing workforce. Research shows that communities in many countries are becoming increasingly diverse in terms of their cultural and ethnic mix. This trend is reflected in the changing face of our nursing workforce which, according to the Nursing Council of New Zealand 2011 workforce statistics, is 68 per cent New Zealand European/Pākehā, 7 per cent Māori, and 4 per cent Pacific, with the remaining 21 per cent drawn from a wide range of ethnicities. New Zealand relies heavily on overseas nurses to replace and grow our nursing workforce. Women and men from a wide variety of countries and cultures are also evident in our student nurse
population and the internationally qualified RNs who seek New Zealand registration through competency assessment programmes (CAP). Every year in New Zealand, a proportion of nurses are audited by the Nursing Council to demonstrate that we can meet all the competency indicators including cultural safety, accountability, effective communication, and inter-professional collaboration. We are also bound by the Code of Conduct and Code of Ethics that guide us on upholding our professionalism in practice. So how is it that nurses from another culture continue to be treated differently when they enter our healthcare workplaces? I would suggest that this arises from the same intolerance shown to people different through disability. During my many years in clinical practice and as a nurse educator, I have listened to students and RNs, and observed for myself, the discrimination often evident from my nursing colleagues towards nurses of another ethnicity endeavouring to practise in the New Zealand healthcare system. This is not only culturally unsafe but is a total disregard of our professional and inter-professional responsibilities. Rather than facilitating a new nurse’s integration into the team, this negative behaviour creates fear, loss of confidence, mistakes, and increased difficulty communicating in English. This is well documented in the literature. Every nurse has a responsibility to support and encourage other nurses as they transition into working as an RN in New Zealand and becoming a colleague and team member. Some nurses take a little more time, direction, and effort than others but every individual deserves a chance to grow into their new role. We have excellent international RNs
who are valued members of their healthcare team but many can readily describe the struggle it was to reach that point. Established RNs also have a significant impact on the experiences of nursing students and new graduates transitioning into the workforce. That impact can range from being empowering and liberating to disempowering and disillusioning; and at times can result in an RN leaving the workforce. Each and every one of us can think back to our first days as an RN and how frightening that was. We can also name those colleagues who, through their patience and support, made a difference in our developing confidence as a nurse. The Nursing Council Code of Conduct has a new principle on working respectfully with colleagues which I believe also encompasses respecting their cultural needs. Think about this! Think about your attitude to people who are different and how your professionalism is demonstrated in your practice. Cultural safety in nursing practice encompasses our interactions with clients, colleagues and students; people who are the same and people who are different. We can learn so much from others – parents, children, older adults, people with impairments, and people from other cultures – and we will be personally and professionally richer from that experience. New Zealand needs a multicultural workforce to provide healthcare for our multicultural community and we all have a part to play in achieving this.
Judy Seccombe RN MN (Dist) is a programme leader at UCOL’s nursing school in Palmerston North.
Nursing Review series 2014
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A round-up of national and international nursing news
For the record 551 new grads still job hunting in late Feb The number of new graduate nurses placed in work through the “one-stop job shop” has risen to 777 by late February, according to the latest Ministry of Health statistics. This means that there were 551 or 41.4 per cent of new graduates still left in the talent pool seeking positions in government-subsidised NETP (nursing entry to practice) or NESP (mental health) new graduate programmes. A bumper 1,328 graduate applicants signed up to the ACE “one-stop job shop” late last year, including 247 July graduates applying for a second time after being unsuccessful in the mid-year round. But the job numbers did not match the high application numbers with only 605 nurses (45.5 per cent of applicants) getting positions in the first round in early December compared to 730 (59 per cent) at the same time the year before. The number finding work over the summer saw numbers rise to 705 by late January, and
by February 22, there were 777 (58.5 per cent) who had been placed in jobs as registered nurses. In late January, Ministry of Health chief nurse Jane O’Malley said the medium and long-term employment prospects for nurse graduates remained good. She said the 2013 statistics showed new graduates don’t always receive job offers “immediately”, but by four months after graduation, the annual NETS survey indicated about 75 per cent of November 2012 graduates had gained nursing jobs, with a number of those finding work in private hospitals and other jobs not included in the ACE process. She also said that Ministry of Health and Nursing Council modeling both showed that the number of nurses would need to increase to cope with the growing and ageing population. “We know that as the economy recovers, an increasing number of nurses are likely to reduce their hours of work or change careers creating more positions for new graduates.”
The three Auckland DHBs had by early February managed to take on the same or more new graduates (230) than the previous year employing about a third of the new graduates (more detail in “New grad nurse market tightest yet” at: www. nursingreview.co.nz/news-feed/february-2014). High interest in the government’s scholarships to employ new graduate nurses in Very Low Cost Access (VCLA) practices saw the number of places boosted to 48 in the New Year. A high proportion of the places (13) were taken up by South Auckland practices. Practices spread from the Far North to east Christchurch also participated (more detail in “South Auckland general practices take on novice nurses at”: www.nursingreview.co.nz/news-feed/ february-2014).
NEWS BRIEFS interRAI funding
Registration medal shortage
An additional $1.5 million is available to help train more registered nurses before interRAI is mandatory from July next year. Associate health minister Jo Goodhew said in February that all aged residential care (ARC) providers had signed up to training for the new national clinical assessment tool six months before deadline. She said about 720 registered nurses had been trained to use the tool and had completed over 10,000 assessments. The focus was now on training more nurses before the tool becomes mandatory for all primary assessments July 1 2015. “To ensure this goal is reached, this Government has made an additional $1.5 million available to support each facility to backfill their registered nurses during training,” said Goodhew.
High demand from new nursing graduates has seen a delay in delivery of registration medals, the Nursing Council said in February. More than 1,310 graduates successfully sat state finals in November last year. The Nursing Council said the medal contractor was experiencing delays in completing the medals due to the high numbers requested. It said the completed medals would be sent out to new graduates as soon as possible.
Greens up ‘nurses in schools’ policy $40 million of the Green’s proposed $100 million School Hub policy is earmarked for nursing services in primary schools. The Green Party first proposed in June last year the employment of 280 new nurses to work in decile 1–3 primary and intermediate school (at the rate of one nurse for every 400 students) as part of their ‘nurses in schools’ policy. The School Hub policy announced by co-leader Metiria Turei in late January has widened the policy proposal to include decile 4 schools, so 350 new school nurses would be required in schools (approximately one full-time nurse per typically large urban primary or intermediate school) at an estimated cost of $40 million.
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Mid-year graduating nurses still job-hunting at year’s end Nearly half of the about 500 new nurses graduating in July were still job-hunting in November, Ministry of Health statistics show. Only 212 (41 per cent) of the 515 midyear applicants for new graduate nursing programme places were successful in July. It appears not many more were successful in the following months as the Ministry of Health reports that 247 (47 per cent) of the July applicants applied again for jobs in the December round.
Appointments Former NZNO industrial advisor Glenda Alexander is standing as Labour candidate for the South Island electorate of Waitaki. Alexander was lead advocate for the historic ‘fair pay’ national collective agreement negotiated between the New Zealand Nurses Organisation and District Health Boards in 2004. She is taking three months leave from her current position at NZNO to campaign for the seat that straddles South Canterbury and North Otago.
Dr Anita Bamford-Wade has left Auckland University of Technology’s nursing school to take up a new post as inaugural professor of nursing and midwifery at the new Gold Coast University Hospital. Bamford-Wade was director of nursing at Capital and Coast District Health board for seven years before leaving in 2005 to become a senior lecturer and then joint head for some years of AUT. She describes her new position at the 750 bed public hospital as a “very exciting opportunity”. It is a joint appointment with Griffith University. Karyn Sangster has stepped into a new primary health care nurse executive role at Counties Manukau DHB. Sangster is now chief nurse advisor primary and integrated care, working in partnership with the DHB’s director of nursing Denise Kivell and clinical nurse director of aged care Kathy Peri. Sangster, who trained at Middlemore, was first a district nurse leader for Counties Manukau and then primary health before her latest role, which has her reporting directly to the chief executive and sitting on the executive leadership team. Vanessa Pullan has been appointed to the new role of clinical advisor for Alzheimer’s New Zealand. The former Hutt Valley DHB team leader for older person’s mental health services will be responsible for advising the organisation and its 21 members on best practice dementia care.
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