FOCUS: Long-Term Conditions & Aged Care
Nursing Review VOL 13 ISSUE 5 2013/$10.95
NEW ZEALAND’S INDEPENDENT NURSING SERIES
PRACTICE, PEOPLE & POLICY
WEBSCOPE
EVIDENCE-BASED PRACTICE:
Q&A
All a Twitter
Football fanatic CEO Working too long a day?
Keeping kids safer
Deborah Rowe
A DAY IN THE LIFE OF
a Community Hepatitis Nurse
Long-Term Conditions Nursing + Care Plus = ? Truckie stop CVD checks
AGED CARE Accelerating career pathway
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LETTER FROM THE EDITOR Winter ‘flu season looms Winter always puts health services under greater stress. The seasonal ailments and bugs that bring more patients through the door can also lead to fewer nurses on the floor. Last year, 46 per cent of district health board nurses got vaccinated against the ‘flu. This edition’s subscriber-only professional development article explores the debate around the value, ethics, and efficacy of health professionals getting the annual ‘flu vaccination. Because of the timeliness of the topic Nursing Review will be putting the article up (the learning activity remains subscriber only) online at www.nursingreview.co.nz on a one-off basis. Feedback is welcomed. Our focus section this edition looks at nursing efforts to stem the tide of long-term conditions plus initiatives to recruit, retain, and fast-track the next generation of aged care nurses. We also profile two new national nursing leaders – read on and find out who relaxes by catching a wave and who by playing the ‘beautiful game’. CLARIFICATION: Ready to take the Medicine (April edition) A registered nurse CAN provide advice about overthe-counter (OTC) medicines like paracetamol without a standing order from a doctor. However, the nurse must be knowledgeable and accountable for their advice, including making and documenting a comprehensive nursing assessment. Some of the latest advice for nurses on recommending OTC medicines can be read online at Nursing Review: Advising on OTC medicines at bit.ly/16eL96L RNs still can’t prescribe OTC medicines but Nursing Council chief executive Carolyn Reed says its proposal to bring in RN prescribing has received “huge interest” with about 200 largely supportive submissions. Analysis of the submissions and recommendations based on the feedback is due to go to the Council’s August meeting.
FOCUS: Long-Term Conditions &Aged Care 5 Care Plus: Adding value for long-term conditions patients?
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Getting the heart tick for CVD risk assessment
1 4
Checking up on diabetes ‘improving’ packages
16 RESEARCH: Getting back to basics with diabetes patients
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Supporting aged care nursing’s new blood
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Accelerating the aged care nursing career pathway
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Rest home in the home
RRR professional development activity (subscribers edition only) See subscription info at www.nursingreview.co.nz
People, Practice, & Policy 26
MEMO MUSA: new NZNO CEO and football fanatic
27 Profile: grandma, gardener and global Red Cross nurse JANET ASKEW 28 Policy: SANDY BLAKE on national falls campaign & new risk tool
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JO ANN WALTON on keeping the public’s trust in the caring profession
30 MICHAEL McILHONE on how long is too long a nursing day?
Regulars
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Q & A Profile: DEBORAH ROWE, chair of the Nursing Council of New Zealand
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A day in the life of… Community Hepatitis Nurse KERRY KENNEDY
23 Evidence-based practice: ANDREW JULL & SARAH MENZIES on a nurse-led intervention keeping kiwi kids safer 24
Webscope: KATHY HOLLOWAY is all a Twitter
25 College of Nurses column: NGAIRA HARKER on supporting Pacific nursing students 31
For the Record: News round-up
Connect with Nursing Review on Twitter www.nursingreview.co.nz
Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ
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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: Deborah Rowe, Auckland nurse consultant, neonatal senior staff nurse, surfer and chair of the Nursing Council of New Zealand is our Q & A profile subject this edition. Check out p2. PHOTO CREDIT: Glenn McLelland, www.supersharpshooter.co.nz Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
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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Vol. 13 Issue 5
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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 Long-Term Conditions & Aged Care 2013
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Q&A Dr Deborah Rowe
JOB TITLE | Senior staff nurse neonatal intensive care and nurse consultant for Auckland District Health board and lecturer at the University of Auckland’s School of Nursing. Also chair of the Nursing Council of New Zealand.
Q A Q A
Where did you train?
Auckland University of Technology
Q A
When and/or why did you decide to become a nurse? When I was a kid, I remember visiting someone in Princess Mary Hospital and was really inspired by the nurses and thought I’d really like to do a job like that.
Q A
What was your nursing career up to your current job? Since starting my career, I’ve been a staff nurse, charge nurse, clinical lecturer, research fellow, and an academic researcher. Since graduation, I have worked at Auckland City hospital, apart from a couple of periods nursing in Brazil in the rubbish dumps, and in Cambodia delivering nursing care to villages along the Mekong River.
Q A
So what is your current job all about? My current role requires me to have both a clinical and academic remit. My clinical role as a nurse consultant for Auckland City Hospital involves developing and implementing best practice systems and policies as well as a range of research projects. My role as a lecturer at the School of Nursing at The University of Auckland entails teaching and supervising students within a variety of undergraduate and postgraduate courses.
Q A
What do you love most about your current nursing leadership role? Working with amazing and stimulating people in various situations with the aim of making a real and meaningful difference.
2
Q A Q
What do you love least? With all my ideas, if only there was time …
If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? The first wish is to ensure that there is equal access to healthcare and that New Zealand continues to have quality healthcare services that are responsive to the health needs of its citizens. The second wish would be to have nurse prescribing in New Zealand. Research shows that nurses being able to prescribe provides significant benefits to vulnerable people that are in need of or unable to access healthcare. The third wish is for the development of a strategic roadmap that requires district health boards to coordinate a more efficient and effective care delivery system across disciplines within the acute/primary/ secondary care settings.
A
Q
What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt? I think a good leader guides a team, not rules a team. A good leader charts a course, gives direction, and instils confidence and enthusiasm. They also demonstrate credibility and integrity on a consistent basis.
A
Nursing Review series Long-Term Conditions & Aged Care 2013
Some people seem to have innate leadership characteristics but there is no concrete evidence that shows leaders are born that way; I think anyone can become a leader.
Q A
What do you do to try and keep fit, healthy, happy and balanced? I try to maintain balance within my life. I like any outdoor activities but my favourites are surfing, hockey and soccer.
Q A
Helping keep me sane, busy, or on task outside of work are? I have 12 iramutu (nephews and nieces) who keep me busy when I’m not working and also a great whaea (mum) who keeps me on track.
Q A Q A Q A
What is your favourite way to spend a Sunday? Take Daisy my dog for a walk and then head for the coffee shop! What is number one on your ‘bucket list’ of things to do? Go surfing in Ireland. What is your favourite meal? You can’t beat a hot Indian vindaloo curry!
Photo - Glenn Mcllenand
Other qualifications/professional roles? I have recently graduated with a PhD in Nursing. Since gaining registration, I have completed a Master of Health Science, a Master of Management, a Postgraduate Diploma in Health Management, and a Bachelor of Health Science. I’m currently chair of the Nursing Council of New Zealand. I also chair the National Screening Unit’s Māori Advisory Committee and am deputy chair of the Ethics Committee for Assisted Reproduction.
A day in the life... of a Community Hepatitis Nurse
NAME | Kerry Kennedy JOB TITLE | Community Hepatitis Nurse for The Hepatitis Foundation of New Zealand LOCATION | Based from home; covering South Auckland from Meremere to Mangere.
5.30
AM: WAKE My dog wakes me every morning at 5.30am. He sits by my bed grunting until I get up. If I send him back to his bed, I may get another ten minutes, but it’s not worth the effort. I feed the pets and make lunches for everyone. I know they could do it themselves; I also know they won’t. It’s a mum thing. The dog and I stretch our legs on a half hour walk. It’s getting dark and cold in the mornings but it is good planning time for the day ahead. AM: COMPUTER AND PHONE TIME When I’m not on the road, I work from home. I start the day at my computer, inputting notes for yesterday’s patients. It is vital patients with chronic hepatitis B get a blood test every six months to identify early characteristics of liver cancer and cirrhosis. It’s my job to do the blood tests for those who are late in getting their tests done. I also trace contacts of patients to check their hepatitis status and provide education for new patients and their families. My appointments for the day are already made as every Sunday evening I spend three hours scheduling the week ahead. While I’m on the phone to a general practice, the dog has brought his lead and all his toys to me. I can take a hint … and a break! Later, I have a coffee and load the car for a busy day ahead.
8.00
11.30
AM: ON THE ROAD My first appointment today is with a translator to provide education for a newly referred patient. He is an older Chinese man with limited English. His wife and eldest son are present. As well as education, we confirm there is no history of liver cancer in the family (if this was the case, he may need regular liver ultrasound scans). It’s important the rest of his family is tested. His wife is unsure if this has happened, so I ring the GP to enquire. I do a blood test for the wife and son. There are three others in the family who I will test on Thursday evening. PM: BACK ON THE ROAD My next appointment is not till one o’clock, so I visit a patient I have not been able to contact. The house appears empty. The neighbours are outside and have seen me arrive. They tell me the family moved to Perth three weeks ago. I ring the practice. They confirm this and inform me the patient has taken their notes. I’m relieved as this increases the chance they will get good follow-up care.
12.30
1.00
PM: A NO SHOW and COLD CALLLING My one o’clock appointment is not at home, and I get no response to cell phone calls or texts. I will call him again tonight. This gives me more time for cold calling. No one is home at the next house. In a sealed envelope I leave my card asking them to text or ring me. If no response, I will ring the general practice tomorrow to check contact details and when the patient was last seen. I can also check HealthLink and the phone book. My role: part nurse, part detective. I now visit a patient I saw six months ago. We discuss alcohol and THC use, as these are toxic to the liver. After discussing her previous results and taking her blood, I remind her that her next blood test is in November and the hours of the nearest lab. She walks me to the car. Her parting words are: “see you in six months”. Just down the road, I call in on an elderly visually-impaired man who lives in a tiny one bedroom flat. He seems distressed and asks me to read an official looking letter that has arrived for him. I tell him not to be concerned – it’s from Sky TV offering a deal. We laugh. No TV here! I take his bloods but
It is vital patients with chronic hepatitis B get a blood test every six months to identify early characteristics of liver cancer and cirrhosis.
I’m concerned about him, so I ring the practice to arrange a community outreach nurse to visit him. Then I visit a local general practice to give brochures to their hepatitis nurse. I could have posted them but this gives me a chance to update her and to use the toilets! The following three patients are all at home, so I get in as much patient education as I can while doing their blood tests, again emphasising the importance of regular blood tests. However, I do understand many can’t get their blood taken at the labs because of long working hours, limited transport, or because it is low on the list of priorities in a busy and sometimes chaotic life. I’m visiting my 4.30pm patient at the request of Middlemore Hospital gastroenterology department as he has missed his last two appointments. When I rang him on Sunday night, he told me he had moved to a new address in Mangere. He hadn’t received his appointment letters. I do his blood tests and find out he has run out of his hepatitis B antiviral medication, as he was too busy with the move to get a new script. I remind him how important his medications are and he says he will see his GP tomorrow. As I leave, I advise the gastro department of his new contact details and request a new appointment for him. to 6.30PM: LAST PATIENTS This is always a busy time as all my working patients are home and wish to see me. Blood tests and education completed, I finish my day by dropping off my blood samples at Middlemore hospital. PM: HOME Pets fed. Tea is cooked. I’d like to say we sit around the table sharing amusing anecdotes about our day but My Kitchen Rules is a family obsession. We all watch together. During an ad break, I call the patient who wasn’t at home and set up a new appointment for Saturday morning.
5.15
7.30
10.00
PM: SLEEP As I prepare for bed, I think about the things I am grateful for. Not far down the list is my job. It allows me autonomy in my practice and the privilege of seeing my patients in their homes and workplaces.
Nursing Review series Long-Term Conditions & Aged Care 2013
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ONLY PREVENAR 13 PROVIDES COVERAGE AGAINST THESE 3 STRAINS. 1-3
29% of IPD cases in NZ children <2 years are caused by the strain 19A.4
®
Offer your patients the choice. References: 1. Prevenar 13® Approved Data Sheet, 9 March 2011. 2. Prevenar Approved Data Sheet, 1 November 2010. 3. Synflorix Approved Data Sheet, 21 September 2011. 4. Heffernan H, et al. IPD Q4 2011 ESR Report. Before prescribing, please review Data Sheet available from Medsafe (www.medsafe.govt.nz) or Pfizer New Zealand Ltd (www.pfizer.co.nz) or call 0800 736 363. Prevenar 13® (pneumococcal polysaccharide conjugate vaccine, 13-valent adsorbed) suspension for I.M. injection minimum data sheet. Indications: Active immunisation against disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F (including sepsis, meningitis, pneumonia, bacteraemia and acute otitis media) in infants and children from 6 weeks up to 5 years of age. Dose: 0.5 mL I.M. Do not administer to the gluteal region or intravascularly (see also Precautions). Infants: 6 weeks of age: 3 doses at least one month apart. A single booster should be given in after 12 months of age, at least 2 months after the primary series. Previously unvaccinated infants 7 to 11 months of age: 2 doses approx. 1 month apart, followed by a third dose after 12 months of age, at least 2 months after the second dose. Previously unvaccinated children 12 to 23 months of age: 2 doses at least 2 months apart. Previously unvaccinated children 24 months of age or older should receive a single dose. Contraindications: Hypersensitivity to any component of the vaccine, including diphtheria toxoid. Allergic reaction or anaphylactic reaction following prior administration of Prevenar. Precautions: Do not administer intravenously, intravascularly, intradermally or subcutaneously. Avoid injecting into or near nerves or blood vessels. Do not inject into gluteal area. Postpone administration in subjects suffering from acute moderate or severe febrile illness. Prevenar 13 will not protect against Streptococcus pneumoniae serotypes other than those included in the vaccine nor other micro-organisms that cause invasive disease, pneumonia, or otitis media. Prevenar 13 may not protect all individuals receiving the vaccine from pneumococcal disease. Infants or children with thrombocytopenia or any coagulation disorder. Appropriate treatment must be available in case of a rare anaphylactic event following administration. Safety and immunogenicity data in children with sickle cell disease and other high-risk groups for invasive pneumococcal disease are not yet available for Prevenar 13. Prophylactic antipyretic medication recommended for children receiving Prevenar 13 simultaneously with whole-cell pertussis vaccines, or children with seizure disorders or prior history of febrile seizures. Antipyretic treatment should be initiated whenever warranted as per local treatment guidelines. The potential risk of apnoea should be considered when administering the primary immunisation series to very premature infants. Adverse Effects: Very common: Injection site erythema, induration/swelling, pain/tenderness, fever, decreased appetite, drowsiness, restless sleep, irritability. Common: Vomiting, diarrhoea, rash. Uncommon: Urticaria or urticaria–like rash, seizures, crying. Rare: Hypersensitivity reaction including face oedema, dyspnoea, bronchospasm.V10111. Contains: 30.8 micrograms of pneumococcal purified capsular polysaccharides and 32 micrograms of CRM197 protein. The decision to administer Prevenar 13 should be based on its efficacy in preventing IPD. Risks are associated with all vaccines, including Prevenar 13. The frequency of pneumococcal serotypes can vary between countries and could influence vaccine effectiveness in any given country. Otitis media and pneumonia can be caused by various organisms and protection against otitis media and pneumonia is expected to be lower than for invasive disease. Prevenar 13 is a fully funded prescription medicine for children meeting the high-risk criteria or pre- and postsplenectomy criteria (Immunisation Handbook 2011). For children not meeting these criteria, Prevenar 13 is an unfunded prescription medicine – a prescription charge may apply. Pfizer New Zealand Ltd, PO Box 3998, Auckland, New Zealand 1140. DA1212SW. BCG2-H PRE0123. P5786.
FOCUS n Long-Term Conditions & Aged Care
Long-Term Conditions FOCUS: We look at nursing efforts to stem the tide of long-term conditions from truck-stop heart checks through to enhancing self-management of diabetes to hypertension.
The Care Plus equation:
DOES IT ADD UP TO MUCH?
Care Plus entered nursing’s vocabulary a decade ago. Has it helped nursing tackle the burden of chronic conditions and better support for people to manage their health? Or has it added up to not much? FIONA CASSIE does the sums… Care Plus: Facts at a Glance
»» Care Plus is a primary health care funding stream targeted at supporting high needs patients –particularly those with chronic long-term conditions (LTC). »» A nurse or GP can assess whether a patient is eligible and offer the extra clinical support either individually or as a team. »» Care Plus is worth an extra $244 (GST exclusive) a year for every patient a primary health organisation signs up. »» There are currently about 190,000 people on Care Plus and the government is expecting to spend $50 million on Care Plus this year. »» To be eligible for Care Plus, an LTC patient must have at least two or more long-term conditions – like diabetes, hypertension, or respiratory disease. »» Care Plus services on offer differ from PHO to PHO and from practice to practice. »» Funding criteria means most Care Plus patients receive four reduced cost (or free) visits to their local nurse or GP at three-monthly intervals. »» The first Care Plus visit is usually a lengthy comprehensive assessment leading to the development of an individual care plan with health and lifestyle goals. »» The Ministry of Health says the aim of Care Plus is “to improve chronic care management, reduce inequalities, improve primary health care teamwork, and reduce the cost of services for high-need primary health users”. »» A funding lid for Care Plus was set at five per cent of the population but that funding threshold has never been reached across all PHOs. »» The Budget allocated an extra $3.2 million a year to Care Plus for the next four years to top-up the Care Plus funding pool to the five per cent level. »» Care Plus funding is to be bulk-funded as part of the flexible funding pool model (used in the Better Soon More Convenient business cases) being rolled out this year to PHOs after they negotiate alliance relationships with their district health boards.
Two or more long-term conditions + four low-cost or free visits to your nurse or GP + three monthly gaps between visits + one wellness care plan = ??
Does Care Plus add up to better care for patients? It seems few get the same answer when they do the sums. First piloted a decade ago, Care Plus is a primary health care funding stream targeted largely at supporting patients with multiple chronic conditions. It opened the door to nurse-led care of long-term conditions (LTC) and patient-centred care plans – and in some places, it led to innovative models of care. But in other areas, little changed for patients, leading to criticism of ‘tick box’ health care and concerns that the quality of care funded via Care Plus was a lottery or “health by post code”. Many patients just stuffed their care plans into a drawer and regarded Care Plus as just offering cheaper visits to their GP or nurse. Nobody disagrees that Care Plus has offered nurses a greater role to play in chronic care management, but many believe it could and should have offered much more. On the horizon is bulk-funding of Care Plus, offering great flexibility and electronic shared care plans and allowing greater integration of services provided to LTC patients. But first, many would argue long-term conditions care needs to go back to the basics and get them right this time. “Care Plus was simply seen as a bundle of money that could be used predominantly by nurses to improve chronic care management, says Dr Eileen McKinlay (pictured left). “It gave nurses extra time to work with long-term condition patients but not the necessary skills, resources, and theoretical framework to do the work well,” says the nurse who lectures in long-term conditions (LTC) for the University of Otago. This is echoed by Massey University nursing professor Jenny Carryer: “At most, Care Plus gives some nurses more time to see some patients, and even that was not consistent across the country.” Continued on page 6 >> Nursing Review series Long-Term Conditions & Aged Care 2013
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FOCUS n Long-Term Conditions & Aged Care
<< continued from page 5 Both agree that innovative models have appeared in pockets around the country but in spite of, rather than because of Care Plus, as it is simply a funding stream and not a model of LTC care management.
Puzzled piloters evolve own model
“People think Care Plus is a programme for people with long-term conditions but it’s just a bunch of money,” says Alyson Clare (left). The lack of a programme soon became clear to Clare and Dr Shane Cross, (left below) a senior practice nurse and GP at Kaikohe’s Broadway Health Centre, when the practice put its hand up to pilot Care Plus back in 2003. By then the practice had already been offering nurse-led diabetes clinics since the early 1990s, and Kathy Menary, now a nurse practitioner, had also pioneered offering nurse-led insulin starts as about ten per cent of its adult clients have diabetes. The practice, serving a mostly Māori community, was keen to offer more structured care to its patients with other long-term conditions and to involve nurses more. “We certainly found when we first started it (Care Plus) that there was very little help from the Intro ??????? Ministry or anyone about how we should go about setting it in place in the practice,” says Clare. “I think that was really one of the flaws of Care Plus, really,” says Cross. “It didn’t really define in any way the expectations about the roles or how it was to be delivered or what was the patient’s involvement. It was very generalist.” It did call for Care Plus to provide a patientcentred plan and goals, but with long-term conditions management still in its infancy in New Zealand, there was a lack of education of health professionals about how to go about it, says Cross. “Now lots of models of Care Plus have developed from the extremely basic – essentially just collecting the extra money and not doing a lot for it – through to things that are a lot more complex.” Broadway’s own model evolved over time. At the beginning, LTC patients were leaving their first lengthy nurse consultation with a glossy folder containing a one sheet summary of their medication and one sheet setting out their health goals.
Wagner’s Chronic Care Model (CCM)
The Chronic Care Model (CCM) was developed by Edward Wagner in response to the increasing burden of chronic disease and the disparate approaches to managing and caring those with chronic illness. The model sets out six essential elements for an effective chronic or long-term conditions care model: »» Good health care organisation (or health system culture changes) »» Community engagement in resources and policies »» Self-management support »» Delivery system design (or redesign) »» Decision support »» Clinical information systems.
6
But Clare says this paper care plan was soon outdated as electronic record keeping became the norm and patients kept forgetting or losing their take home file. In early 2010, Cross started rolling out the practice’s own LTC model, known as the Star programme, with every eligible Star client allocated a doctor and one nurse to work with them and daily chronic care clinics offered by one of the six Star nurses. Cross also developed a electronic care plan tool for Star, based within MedTech, that pulls together the doctor’s clinical management plan and the nurse’s assessment with its wider social and cultural focus to draw up an individual wellness plan and goals for the patient.
Patient perceptions
So what ‘added value’ does Care Plus provide patients? Not that much, is the short answer, according to research into patient perceptions of their LTC care. Julia Ebbett’s (left) qualitative research found patients basically just saw Care Plus as providing cheaper visits to their general practice. As a nurse and Care Plus project manager for a group of Hawke’s Bay practices, she had noticed nurses’ competency in delivering Care Plus was variable, with goal setting a particular issue. “At times it seemed patients were given a telling off or goals that seemed challenging to keep.” Her Master’s research project – into patient’s perception of nursing’s contribution to Care Plus – soon found that patients had little understanding of what Care Plus was, let alone felt able to discuss the nurse’s role. Though with more probing, it appeared that patients did feel “guided” through their LTC management by their nurse. They also saw it as significant that their nurses were accessible to provide knowledgeable follow-up care but wanted their nurses to offer more support for pain, mental health, and sleep issues. A major longitudinal study, led by Jenny Carryer, (left) into general practice care for people with chronic illness also found patients reporting mixed experiences post-Care Plus, though they were satisfied with being able to receive “prompt attention from a known and trusted source”. The two-prong study surveyed hundreds of patients between 2005–2010 in the MidCentral District Health Board region and the data showed patients found appointments “brief and often left much unsaid”, that many still chose not to seek help because of cost or “not wanting to be a nuisance”, and nearly 60 per cent revealed “significant pain levels”. Across both survey periods, patients expressed a desire for “connection, co-ordination, information, health education, interpretation, and assistance with planning”. Nurses and GPs in Carryer’s second survey showed subtle changes, such as increased use of nurses, more emphasis on team work and complementary roles, and more structured care for people with LTC. But the health practitioners still rated themselves more highly than their patients did in providing
Nursing Review series Long-Term Conditions & Aged Care 2013
self-management support. Though nurses were perceived to provide more self-care support than GPs, Carryer believes more fundamental change is needed if patients are to get the support they deserve (see MidCentral story on page ). She was not surprised that a similar survey, carried out more recently and at the other end of the country by Robin Gauld (left), professor of health policy at the University of Otago, came to similar findings. Gauld says the research team surveyed a cross-section of 500 Southern PHO patients and their GPs and nurses about the care coordination provided under Care Plus. “What we found was that the results left a lot to be desired,” says Gauld of the yet-to-be published research. “The GPs and nurses tended to have a more sanguine or positive view of things (the care provided) than the patients.”
Cut down the barriers and ‘set nurses free’ Gauld says also emerging from his research is that the current primary care and Care Plus funding system is “not ideal” for delivering long-term condition services. “Providers receiving the funding don’t necessarily shift the way they provide care … for the most part, they still seem to be focused on the 15 minute appointment …” says Gauld. “If you maintain a fee for service type model – which is centred around getting patients through the door – it is not necessarily going to provide the optimal treatment and ongoing coordination and care of people with LTC.” This is not news to Carryer, whose personal mantra for many years has been that fundamental reform is needed of the primary health sector – particularly the removal of funding, structural and employment barriers. She says nursing has been sending that clear and consistent message to district health boards, primary health organisations (PHOs), and the Ministry of Health for more than a decade, particularly in the 2003 Investing in Health report by the Expert Advisory Group on Primary Health Nursing and the follow-up 2007 report by the College of Nurses and New Zealand Nurses Organisation. “Set the nurses free to do what they do well … nurses are educated in how to work with people with LTC, and if they are free to do that, then we’ll start to see care being transformed,” says Carryer. The newly negotiated PHO agreement has not resulted in radical reform of primary health funding as the biggest proportion of government funding to the sector –capitation funding – is left unchanged.
FOCUS n Long-Term Conditions & Aged Care
But it will lead to the expectation that all PHOs will form an alliancing agreement from July 1 with their DHB as a prerequisite to bulk funding of their Care Plus funding into a flexible funding pool. Alliancing agreements were used by the Better Sooner More Convenient (BSMC) business cases (see Masterton and MidCentral sidebars) and Cathy O’Malley (left), the Ministry of Health’s deputy directorgeneral for sector capability and innovation, says the agreements will see PHOs and DHBs working much more collaboratively together in planning and delivering services, including to people with long-term conditions. “We want to get away from siloed funding streams and attaching specific money to specific professional groups… we’re trying to break all that down,” says O’Malley. Instead the Ministry wants DHBs and PHOs to discuss how to use the total resources – including DHB funding – and the total workforce skills in the best possible way.
Is there an easy answer?
So what is the best possible way of delivering quality LTC services to people in the community? There is no simple answer but many people point to Ed Wagner’s Chronic Care Model as a good foundation and checklist for what a good model of care should include (see sidebar). The extensive Intro ??????? recommendations of the 2007 National Health Committee report on meeting the needs of people with chronic conditions are seen as another good starting point. What is commonly agreed is that whatever does make up good chronic conditions care, the current Care Plus tick list requirements of four quarterly visits and a wellness care plan far from guarantees that LTC patients will receive the support they need to better self-manage their health.
A key to slowing down the growing financial burden of chronic disease is to engage and support patients so they can be active partners in managing their own health. That takes more than just turning up to three-monthly appointments and taking home a script and a paper plan. Dr Janine Bycroft (left), the founder and clinical director of the Health Navigator self-management website, does some training around the country in self-management and chronic health conditions. “I still find quite a few areas where clinicians are not that comfortable around patient-centred goal setting, They are still prone to advising or directing patients as to what their goals should be for their hypertension or diabetes rather than spending a little bit of time finding out what the patient sees as important and what they’d really like to work on. “If the patient doesn’t chose (the goals), their chances of following through is really low.” Bycroft is also the primary health care clinical champion on the National Shared Care Plan programme (see sidebar on page 8), which is piloting a collaborative electronic shared care plan accessible by not only a patient’s health professionals, both primary and secondary, but the patient themselves. When asked for her three wishes for better national LTC care, her number one is a single electronic shared care record, with a care plan component. This is followed by adequate funding to provide case management for the top five to ten per cent of the most complex and high need LTC patients and care co-ordination for the next 20-30 per cent. Her third wish to would be to obtain clear measurements of what differences an LTC programme is making to a patient’s quality of life.
The fact that Care Plus only measures outputs like patients through the door and not quality of outcomes is one of its weaknesses, says Rosemary Minto (left), an NP and chair of the College of Primary Health Care Nurses. She joins Jenny Carryer in pointing to the nursing sector’s 2007 review as a model for improving Care Plus and LTC care, whose recommendations have largely been ignored by funders and planners. “The most crucial is national consistency around nursing leadership positions in primary health care.” Some opportunity for changing the model may be provided by the new flexible funding pool, but again, like Carryer, she thinks bigger barriers remain. “The current private business model in general practice is still a substantial barrier to any big changes that would positively affect health service delivery for patients – particularly high needs patients.” Others also talk about Care Plus criteria curbing the ability to provide care when and where needed; the need for greater integration and collaboration between professions and sectors; the need for more education on offering patient-centred care; and the need to improve patient consent processes so patients actually know what they are signing up to. Meanwhile, pockets of excellence do pop up around the country as individual PHOs, practices, or nurses whittle their way around the limitations of Care Plus to develop their own LTC services with their own assessment and care plan software and their own care co-ordination or case management models. But ad hoc pockets of excellence does not equate to a successful formula for LTC care. It is clear that many nurses and their health professional colleagues want Care Plus and any successor to add up to much more for many more people with long-term conditions. >> more overleaf
Helen Kjestrup (standing) and Anna Reed
Care Plus done, dusted and ‘replaced’ in Masterton Too narrow and too prescriptive is Helen Kjestrup’s verdict on Care Plus. So the clinical services manager for Masterton Medical Centre grabbed the chance offered by bulk-funding to say goodbye to the more onerous restrictions of Care Plus. In its place has come the nurse-led guided model of care (GMC) for people with long-term conditions, which can be pitched at the level of need right up to dedicated case management for people with high and complex needs. Kjestrup, a nurse for 30 years and a nurse leader at Masterton Medical since 2007, says the model was already evolving when Tihei Wairarapa’s successful Better Sooner More Convenient (BSMC) business case in 2010 opened up the opportunity for change. Wairarapa had been early adopters of Care Plus, with six per cent of the population signed up to the funding stream, and Masterton Medical, the region’s largest practice by far, had nurses operating dedicated clinics for patients with
diabetes, respiratory disease, or cardiovascular disease every working day, plus a marae-based Māori health clinic and nurses who went into people’s homes. However, frustrating barriers arose for Kjestrup such as the funding compliance red tape, a case where a newly diagnosed diabetic was seen twice in short succession (rather than the Care Plus requisite of three months apart), and the inability to offer intensive support to patients when it could make the most difference. It was the bulk-funding of Masterton’s Care Plus funding that gave the centre the freedom to decide when Care Plus eligible patients receive the care they are funded for – with the first visit and followup phone call free and a part charge of $15 for the next three visits – plus the flexibility to offer more or less visits depending on need and uptake. Kjestrup says when the centre first started Care Plus, the focus was on the highest need LTC patients with multiple and complex conditions. This small group of patients made up the ‘top of the triangle’ and soaked up the most resources. She says its focus has now “dragged into the middle of the triangle” to offer more support to the next tier of newly diagnosed, at risk patients before they become high needs. “You get better bang for your buck.” Thirteen of Masterton Medical’s nurses are
now delivering its guided model of care (GMC) to patients (with two or more long-term conditions) in collaboration with the patient’s GP and the rest of the specialist nursing team. The nurses all work part-time for the GMC programme and together make up the equivalent of 3.1 full time equivalent (FTE) GMC positions. “They are practice nurses as well … so they are specialised in areas but also work across the floor as well, which really spreads the knowledge beautifully,” says Kjestrup. One of the GMC nurses, newly approved NP Anna Reed, specialises in working in the community to coordinate the care and create wrap-around services for the high needs over-65s patients with LTC who may be recently out of hospital or referred to her as needing acute intensive support. Once the patient is stable and settled, she will hand them over to the two other nurses working with this group of older patients at the “top of the triangle”. A key to the Masterton model is also good communication and information sharing between all health providers so its nurses attend multidisciplinary team (MDT) meetings at the hospital to feedback information to the practice team. Kjestrup says its GMC model is a community response to meet its community needs, influenced by a number of chronic conditions philosophies and models, and is a “pretty simple recipe really”.
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FOCUS n Long-Term Conditions & Aged Care
Electronic collaboration for better LTC patient care »» An electronic Shared Care Plan means a patient and their health professionals can securely access key health record information and care plan details from any setting be it home, hospital, or general practice. »» The programme also promotes a collaborative approach between all health care providers to develop a comprehensive and coordinated care plan for their patients and to message each other. »» The plan is patient-centred and is built around mutuallyagreed goals, actions, and timeframes for addressing problems. »» Three Share Care Plan pilots began in 2011 in Auckland across the three district health boards with each DHB focusing on a different??????? area: Auckland on Intro heart failure, Waitemata on respiratory disease, and Counties-Manukau on gout and metabolic syndrome. »» In Christchurch, there is the Collaborative Care programme, which uses the same New Zealand developed software system as Auckland and has focused on COPD and heart failure, frequent visitors to ED, and high needs patients in the community. »» Currently about 530 (CHECK) patients are signed up to the Auckland pilots and more than 200 health professionals are registered as users. »» There are about 36 (CHECK) patients using their patient ‘portal’ to access their diagnoses, medication, recent medications, care plan, and to view which health professionals have viewed their record and care plan. There is also the option of patients messaging their health professional and updating their own measurements like blood pressure, weight, and blood sugar. »» By the end of next year, the Ministry of Health’s National Health IT Board hopes to start rolling out the Auckland shared care plan model nationwide for patients with long-term conditions. 8
Health assessment tool used in EnhancedCare+
Pioneering MidCentral makes “u-turn” and launches EnhancedCare+ ONE OF THE COUNTRY’S long-term conditions care pioneers has been bubbling with innovation but lagging behind in patients signed up to its basic care package. “We’ve been doing a lot of work around LTC for a long, long time,” says Melanie Taylor (left), the project lead for chronic care management for the Central PHO and MidCentral District Health Board. “So it’s kind of an irony that our (Care Plus) package of care wasn’t picked up and wasn’t working.” “We had a very low number enrolled. We only had 19 practices out of our 42 practices providing Care Plus and only nine of those were seeing anywhere the number of clients they should have been seeing ... so we really weren’t performing.” The region has been a pioneer in primary health care nursing leadership, the integration of primary and secondary services in long-term conditions (including specialist outreach clinics), and training and supporting a PHO community nursing team proficient in either diabetes, respiratory, or heart conditions. It is also one of the Government’s nine successful Better Sooner More Convenient (BSMC) business cases and was busy working on a web of innovations to improve primary health care delivery. So Taylor says when the PHO realised much of its region wasn’t offering a basic Care Plus package of care it stopped, took stock, and set out – using Ed Wagner’s Chronic Care Model as its guide – to repackage, enhance, and relaunch its own programme known as EnhancedCare+. The repackaging included “a u-turn” to change the focus of the PHO’s community nursing team – a 23 FTE strong team working with practices across the PHO – from focusing on a single condition like diabetes to becoming more generic LTC nurses. The aim is that a client with diabetes, hypertension, and a respiratory disease is no longer being passed from nurse to nurse like a parcel to ensure they get the care they needed. Instead, the nurses have become community clinical nurses long-term conditions (CCN LTC) and are now expected to be not only proficient in offering care for one chronic condition but also competent in the other conditions so they can offer a whole package of care for clients with multiple chronic conditions. The new EnhancedCare+, offered with the support of the CCN team, was launched in July 2011, and at present,
Nursing Review series Long-Term Conditions & Aged Care 2013
half of the practices have taken it up. Each package of *EnhancedCare+ includes an initial comprehensive health assessment (CHA), a client care plan and up to four more consultations to work with the client on meeting their care plan goals. Entry criteria are similar to Care Plus and are targeted at people with chronic conditions or high needs (aged over 65 if Pākehā and over 45 if Māori or Pacific) but with the flexibility of including some people who are younger or only have one chronic condition if it is felt they could benefit. In larger practices, the package is delivered on a 50/50 basis, with half of the clients having the package delivered by a community clinical nurse (CCN) – usually the most complex or challenging patients – and the other half by a practice nurse, with both working in collaboration with the client’s GP and the rest of the team. The initial assessment can last up to 90 minutes and takes a holistic approach that covers a client’s social and cultural background, as well as their physical and mental health. Taylor says while the assessment itself is seen as valuable, the “clunky” and “unstable” CHA electronic tool has received nothing but negative feedback, leading to another “u-turn” in 2012 and the decision to invest in developing a more userfriendly web-based tool to be rolled out in the near future. She says the initial tool’s reputation has seen some practices put off or delay offering EnhancedCare+ but the CCN team still works alongside these practices to support clients with chronic conditions. Therefore, the PHO is yet to be running the new EnhancedCare+ at full max and the package is still evolving and developing as the project team analyses and responds to feedback. Taylor says the results are promising, with the first formal survey of EnhancedCare+ patients – carried out late last year with 68 responses – showing “considerable progress” in how patients rated their care over earlier surveys carried out by Jenny Carryer’s research team (see main story) using the same Patient Assessment of Chronic Illness Care (PACIC) questionnaire. “There are some considerable measure points where we’ve made considerable progress.” The PHO plans to do the patient survey and the related health practitioner survey annually. This year, it will also be part of a major joint Victoria University and University of Otago research project evaluating the MidCentral and Wairarapa BSMC business cases. (more information on evaluations of the BSMC business case and EnhancedCare+ can be found at www.centralpho.org.nz)
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FOCUS n Long-Term Conditions & Aged Care
WHO SHOULD HAVE A CVD RISK ASSESSMENT?
»» Māori, Pacific, or Indian ethnicity (males aged 35-74 and females aged 45-74) »» All other ethnicities (males aged 45-74 and females aged 55-74)
After lagging at the bottom, Western Bay of Plenty PHO is now perched at the top of the ‘more heart checks’ performance table. FIONA CASSIE talks to RN and general practice coordinator Donna McArley on getting the heart tick and moving on to managing those highlighted as being at risk. She also talks to outreach clinical nurse leader Sue Matthews about doing heart checks at truck stops to freezing works.
Getting the
HEART TICK Intro ???????
F
ighting heart disease is more than just ticking off boxes on a checklist. But if you aren’t ticking the boxes in the first place, it’s much harder to highlight those needing help to manage their heart disease risk. Three years ago Western Bay of Plenty Primary Health Organisation (PHO) found itself lagging at the bottom of the league table with only 30 per cent of its eligible patients receiving a cardiovascular disease (CVD) risk assessment. With 44,000 patients eligible for checks – nearly a third of its enrolled population of 145,000 people – the PHO set up a clinical committee to turn this lacklustre performance around. Donna McArley (left), the PHO’s general practice coordinator, says the low reporting levels were the result of both electronic barriers and the need for a PHO-wide focus. The electronic challenge for the large PHO – it has 27 practices with about 160 GPs and 150 nurses – was it had four different practice management systems and no electronic tool to calculate and record CVD risk. So the PHO had the ‘best practice’ decision support tool installed across three of the four systems and then rolled out to the fourth so it wasn’t reliant on manually extracting data. McArley says once the PHO had a better data picture of how practices were performing, she highlighted the ten worst performers and went out and met with all of the practices’ staff – not just the GPs and nurses but also the administration staff, “as it needs a team effort to meet health targets.” She says each practice had a CVD target champion put up their hand – in some practices, it was a GP, and in others, it may have been a nurse already offering nurse-led clinics – and they were
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the drivers for change. And change the practices did, with the PHO becoming the highest performing PHO at the end of 2012 with a 75.6 per cent CVD risk assessment rate. “All the practices have demonstrated quite a significant improvement since we addressed the issue. It has lifted us up from our abysmal record of being right at the bottom of the league table to the top.” Offering CVD risk assessment training to nurses across the PHO and the resulting increase in nurses carrying out opportunistic CVD risk assessment contributed greatly to that improvement. McArley says nurses and GPs being ready to grab the moment is really the only way to carry out CVD risk assessments as there is no subsidy available and people aren’t likely to pay-up to see their doctor or nurse unless they are unwell or need a prescription renewed. The difficulty is capturing those at risk groups – often male and working – which is why the PHO also funds Kaitiaki Nursing Services and its mobile nursing team who stake CVD and diabetes risk assessment into people’s workplaces (on page 11).
What next after ticking the boxes?
“Just doing CVD risk assessments alone is meaningless,” says McArley. “But we have to get everybody assessed and recorded so we can identify whose actually at clinical risk.” She says the PHO is very conscious that just topping the check league table is not enough and the PHO’s practices must also be prepared to be measured on how well they are managing the CVD high risk patients the checks reveal. It is also well aware that cost was another obstacle for at-risk patients. So the PHO has recently approved allocating some discretionary funding so general practices can regularly see their high risk patients and help them manage their CVD risk.
Nursing Review series Long-Term Conditions & Aged Care 2013
With limited funds available, it was decided to target only those who were 55 years or younger and had a CVD risk of greater than 15 per cent – a cohort of about 3000 patients. She says setting this age target means it can offer a meaningful programme of about four patient visits a year and also capture the younger Māori demographic, which statistics show are some of the most at risk. “If we can get those (high risk) patients in their 40s and get them managed well, hopefully we can improve their outcomes.” In return, the practices will need to provide regular blood pressure and lipid levels data – as well as information on what new medications the patient has been prescribed – so the PHO can measure how well they are managing. She says it will be left up to practices to decide what combination of GP and nurse care is offered to the CVD patients but with prescribing and monitoring new medications a major part of CVD management she envisages it is likely patients will be offered combined care with nurses particularly focusing on helping patients manage lifestyle risk factors. Patients can also be referred to a PHOfunded Sports Bay of Plenty programme that is a combined self-management and green prescription programme covering nutrition and exercise for people with a CVD risk of more than 14 per cent. The CVD risk assessments include the diabetes check component, which is leading to practices picking up patients with impaired glucose tolerance (IGT) or pre-diabetes, and these people can also be referred to the green prescription programme. Because McArley says the PHO is not content with just having jumped the league table ranks in assessing and finding the patients at high CVD and diabetes risk, it is now also aiming to be “ahead of the game” in helping those people keep well. And it’s pretty keen to top that league table, too.
FOCUS n Long-Term Conditions & Aged Care
HEALTH ON THE HOOF:
Truckie stops to freezing works T
ruckies are being waved down and pulled off the road in the Bay of Plenty for the good of their health. Once a year, freezing workers end their shift on the chain to find a tent full of nurses offering fruit kebabs and keen to take their blood pressure. And kiwifruit packhouse workers are grateful after being shocked into action by an opportunistic on-the-job health check. Kaitiaki Nursing Service’s readiness to take free health assessment to the people is another reason why Western Bay of Plenty is topping the country’s league table for heart and diabetes checks. Sue Matthews (left) is the clinical nurse leader for the service, which employs 28 nurses to carry out a range of contracts providing outreach health services, including whānau cancer, whānau nursing and community access nursing services. A major source of funding is the Western Bay of Plenty PHO, which Intro ??????? uses its SIA (services to improve access) funding to contract Kaitiaki to improve access to health care in vulnerable communities and to people who aren’t engaged with conventional health services. This means for the past three years the nurse service has not only been carrying out opportunistic health assessment checks in client’s homes or at its nurse-led clinics in high need communities and local marae (working in close liaison with the local Māori health provider), they have also been setting up one-off annual tent clinics in workplaces, which in some cases is literally the side of the road. “The best way to actually access men – particularly Māori – in that 35-60 age group is to go to the workplaces, especially where there are low income earners.” Or in the case of the freezing works, a rollercoaster seasonal income. One freezing worker told Matthews that he hadn’t seen a doctor for five years as “when he had the money, he didn’t have the time, and when he had the time, he didn’t have the money”. Truckies can be another workforce hard to pin down and engage with health services. A higher than average truck crash rate in the Bay of Plenty prompted police to approach Kaitiaki to work with them and the ACC injury prevention unit to offer the first roadside health ‘pit stop’ back in April 2011.
High-vis vests and tents
The police set up the truck stop on a busy s tate highway in the Bay of Plenty and pulled over 75 trucks and offered their bemused drivers a free health assessment by one of Matthews’ waiting team of eight nurses clad in their high-vis vests. Only three men turned the opportunity citing delivery deadlines, but the rest, says Matthews, were happy and relieved to have a ‘health warrant of fitness’ that checked out their blood pressure, cholesterol, and blood glucose levels and offered them a chance to discuss any health
concerns and get health promotion advice on anything from prostate health to quitting smoking. “I work 16 hour days and there is no way I can get to the GP for a warrant of fitness. It is really important for me to be healthy as I put the food on my family’s table,” said one grateful driver. Some truckies told the nurses they hadn’t seen their GP for anything from four to 18 years. Matthews says the nursing team she pulls together for the truck stops and other one-off clinics have all completed an advanced assessment and reasoning paper (plus other postgraduate papers) and work hard to make each nursing assessment ‘patient centric’. For some truckies, the roadside health assessment just provides them with a snapshot of their health and for others it is “a wake-up call,” says Matthews. Many are given referrals for a followup visit to their GP usually because of elevated blood pressure, cholesterol, or blood glucose, but also on a few occasions for depression or drinking problems. The nursing service also, with the permission of the client, informs the general practice they’ve carried out the assessment and sends them the results. “Truckies seem really honest – they will talk about their drug taking, their alcohol consumption, or their smoking,” says Matthews. The roadside warrant of fitness gives the nurses a 30-minute window to give the drivers some health promotion and a “traffic light” assessment of whether their health was green (good to go), orange (need to make some lifestyle changes), or red (need to take immediate action).
Leave with goodies bag and GP referral
It appears that when truckies get back on the road, after their complimentary coffee and picking up their free water, fruit, sandwich and ‘goodies’ bag (complete with freebie chamois, pen and pamphlets), they don’t forget their traffic light rating. Now on to their fifth truck stop, Kaitiaki nurses are getting drivers reporting back that since the last truck stop, they’ve been to see their GP and are now on medication. Matthews had one GP reporting he had four truckies turn up one morning all waving a Kaitiaki referral note and talking about ‘truck stop’, leaving him intrigued and wanted to know more. Similarly, setting up one day health assessment clinics each year at some of the Bay of Plenty’s very large kiwifruit packing houses and cool stores has reaped health rewards, including one middleaged woman who had thought she was hyperfit but found she had dangerously high blood pressure and cholesterol. The woman credits her now good health on that timely health check, especially as both parents were dead by 65 and
she had had close whānau die of strokes. She told the Te Puke Times: “At family tangi, I usually stand up and plead with all present to have a health check. It could save their life like I’m sure it saved mine.” A forklift driver sent for follow-up tests was also shocked to discover he had type-2 diabetes. Since 2011, Kaitiaki has also been setting up an annual health extravaganza tent at the AFFCO freezing works offering health assessments to workers as their shift on the chain finished. Waiariki Institute of Technology nursing students helped initiate the first extravaganza and were on hand to manage booths providing health promotion material and to hand out fruit kebabs and non-alcoholic drinks to the tired freezing workers at the end of a hard working day. At AFFCO’s invitation, the nursing service now has regular clinics at the works at least once a month to provide health assessment, follow-up monitoring, and cervical smears. Matthews is passionate about equal access to health care and believes primary health nursing can do even more, with her current dream for the region to have a director of nursing for community and primary health to provide visionary strategic leadership. “I haven’t gone hoarse yet,” says Matthews, whose services to health were recently recognised by becoming a Member of the New Zealand Order of Merit (MNZM) in the Queen’s Birthday honours list (see June 4 News Feed at www.nursingreview.co.nz).
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Nutrition Update Overfed and undernourished: New Zealand toddlers are missing out on vital nutrients for growth and development. With nutritional gaps commonplace despite an abundance of food, how can healthcare professionals and parents work together on bridging the gap to make every mouthful count? About 1 in 3 New Zealand children are overweight or obese, increasing their likelihood of premature death and disability in adulthood.1 Obesity also puts toddlers at risk of conditions such as diabetes and cardiovascular diseases at a younger age during adulthood.2 Yet despite this overabundance of energy/calories, many toddlers are deficient in vital nutrients such as iron and vitamin D.3 This occurs because there is a gap between what children are eating in reality and what is recommended.
Recommended intakes may be difficult to achieve in day-to-day life, resulting in inadequate levels of micronutrients, despite excessive energy intake in the form of calories. This so-called Toddler Paradox poses a challenge for healthcare practitioners and parents. Why does it occur? First, the stomachs of toddlers are 3 times smaller than those , of adults,4,5 which means they are easily ‘filled up . They need to be fed little and often with nutrient-dense foods to meet their high nutritional requirements. However, today’s busy lifestyle means that our food culture has changed significantly over the years, affecting how and what New Zealanders eat.6 With more eating on the go, increased reliance on convenience and fast foods, fewer home-cooked meals and time-poor parents, it’s little wonder that toddlers are at risk of gaining empty calories at the expense of rich nutrition. Toddlers also tend to develop a fear of new foods in their second year, causing them to refuse certain foods. In addition, a toddler’s appetite may be affected by factors such as illness or even the weather.
Why does toddler nutrition count? In the first 3 years of life, infants and toddlers grow faster than at any other stage of life,7 doubling their size and adding 5 times their weight. As well as the demands from increased physical growth, toddlers are at a highly demanding stage of development with a toddler’s brain reaching 80% of its adult size by the age of 2,8 an increase in nearly 1 gram of brain every day.9 During this rapid period of growth and development toddlers have higher requirements for many nutrients compared to adults. Toddlers need up to 7 times more nutrients than an adult per kg of body weight,3 but have a stomach 3 times smaller.4,5
Comparison of the nutritional requirements between 1–3 year old toddlers and male adults (based on 70 kg adult and 12 kg toddler)3 9 Toddler needs vs adult male – x-fold increase
The Toddler Paradox
8 7
7x
6 5
6x
4 3 2
3.5x
3x
2.3x
1 0 Calcium (mg)
Iron (mg) Vitamin D ( g) Iodine ( g) Selenium ( g)
3 simple ways to help bridge the nutritional gap There are several practical tips health professionals can offer parents to help improve their toddler’s nutrition and make every mouthful count.
1. Encourage healthy eating habits Mealtimes can be challenging for parents. Offer them some practical advice to make every toddler’s mouthful count. Advise parents to: • involve their toddler with healthy food e.g choosing and placing fresh fruit and vegetables in the shopping basket • encourage their child to try new foods and repeatedly offer a toddler a food that has been refused – it can take up to 15 exposures before they will accept a new food10 • ensure the parents and family enjoy a wide range of healthy, nutritious foods so they can set an example – toddlers learn through imitation even if this means • have family meals at times that suit the child, the family eating a little earlier than usual.11
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why toddler nutrition counts 2. Aim to include foods from the four main food groups every day To get the right balance of nutrients, a toddler’s diet should contain foods from the four major food groups every day. These include 1. vegetables and fruit, 2. breads and cereals, 3. milk and milk products and 4. lean meats, chicken, seafood, eggs, legumes, nuts and seeds. For more information see the Ministry of Health New Zealand Dietary Guidelines: Eating for Healthy Children from 2 to 12 years.11
3. Try toddler milk drinks As part of a healthy balanced diet, toddler milk drinks can help a toddler meet their high nutritional requirements in a way that is familiar. Toddler milk drinks are based on cows’ milk that is enriched with nutrients, like iron and vitamin D, critical for a toddler’s growth and development.
Common deficiencies in New Zealand toddlers Iron
Vitamin D
Nearly 8 in 10 (78%) of New Zealand toddlers aged 1–2 years aren’t meeting their recommended dietary intake (RDI) needs,12 and recent research has shown that 14% of under-2s are actually deficient in this vital nutrient.12,13 Yet the body’s demand for iron to support brain development continues well into the toddler years – in fact, a toddler’s need for iron is 7 times higher per kg bodyweight than that of an adult.3 In addition, iron plays an important role in the formation of haemoglobin and the transportation of oxygen around the body.3 Iron deficiency can adversely affect cognitive and behavioural development.12 Risk factors • Low vitamin C intake (which helps iron absorption) • Low intake of iron-rich foods (e.g. meat) • Drinking too much cows’ milk (more than 500mL per day).14
1 in 10 New Zealand toddlers aged up to 2 years are not getting enough vitamin D,15 which can lead to inadequate bone mineralisation.16 Given that vitamin D and calcium work together to enable healthy building of bones, and toddlers need large amounts of calcium to support their rapid bone growth, a lack of vitamin D may result in rickets, which could lead to osteoporosis in the long-term.16 In Auckland, around 6 out of every 10,000 children under the age of 3 years were hospitalised with vitamin D-deficient rickets.15 Risk factors • Lack of sunlight exposure16
•
A recent New Zealand study showed that children were placed most at dietary risk because there is no current New Zealand policy to ensure both routine vitamin D supplementation during early childhood and adequate vitamin D status.15
FOR HEALTHCARE PROFESSIONALS ONLY
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References: 1. Ministry of Health. NZ Food NZ Children: Key results of the 2002 National Children’s Nutrition Survey. Wellington: Ministry of Health, 2003. 2. NZ Nutrition Foundation. Maintaining a healthy bodyweight. Children [Online]. Available at: www.nutritionfoundation.org.nz/nutrition-facts/maintaining-a-healthy-bodyweight/children. 3. Department of Health and Ageing, National Health and Medical Research Council, Ministry of Health. Nutrient Reference Values for Australia and New Zealand Including Recommended Dietary Intakes. Canberra: Commonwealth of Australia, 2006. 4. MacGregor J. Introduction to the anatomy and physiology of children. 1st ed. London: Routledge, 2000. 5. Snell R. Clinical anatomy for medical students. 4th ed. London: Little Brown, 1992. 6. Patrick H et al. J Am Coll Nutr 2005;24(5):83–92. 7. WHO Multicentre Growth Reference Study Group. Acta Paediatr Suppl 2006; 450:76–85. 8. Muscari ME. Pediatric Nursing. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2005. 9. Dekaban AS et al. Neurology 1978;4:345–356. 10. Ministry of Health New Zealand. Eating for healthy babies and toddlers [Online]. 2012. Available at: www.healthed.govt.nz/system/files/ resource-files/HE1521_3.pdf. 11. Ministry of Health New Zealand. Eating for healthy children from 2 to 12 years [Online]. 2012. Available at: https://www. healthed.govt.nz/system/files/resource-files/HE1302_0.pdf. 12. Wall CR et al. Public Health Nutrition 2008;12(9):1413–1421. 13. Grant CC et al. J Paediatr Child Health 2007b;43:532–538. 14. Ministry of Health. Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2): A background paper– Partially Revised December. Wellington: Ministry of Health, 2012. 15. Grant CC et al. Public Health Nutrition 2009;12(10):1893–1901.16. Scientific Advisory For more information please visit www.nutricia4professionals.com Committee on Nutrition. Update on Vitamin D. Position Statement by the Scientific Nutricia New Zealand Limited, 37 Banks Road, Mt Wellington, Auckland, New Zealand. NBM1571-22/5/13-NZ. 11020-A2/DPS. Advisory Committee on Nutrition. London: TSO, 2007. RESEAR
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Nursing Review checks out the momentum on the new Diabetes Care Improvement Packages and finds report cards ranging from ‘excellent’ to ‘could do better’.
Diabetes: patchy but progressing The basic facts »» Funding for Get Checked free annual diabetes review stopped on June 30 2012 after being offered for 10 years because scheme not getting desired results. »» The $8 million funding is instead redistributed to district health boards to develop primary-care focused Diabetes Care Improvement Packages (DCIPs). »» The funding cannot be used for diabetes annual reviews (DARs) but Government still requires DHBs to report on DARs, as they are a??????? “measure of how well primary care is Intro delivering diabetes services”. »» Packages are built on core diabetes services already underway, differ from DHB to DHB, and can involve nurse-led services such as diabetes nurse clinics, patient education groups, community outreach, and may include ‘upskilling of staff’. »» Nursing Reviewsurvey of DHBs Diabetes Care Improvement Package (DCIP) plans a month out from 1 July 2012 finds wide disparity in depth and detail of plans, with most yet to inform general practices of how the new package will work. »» A year on, Ministry of Health reports there has been “variation in progress” but recent DHB reports for the third quarter show “significant progress” and some “excellent results”. »» Late last year, a free online learning web site was launched offering seven self-directed learning modules in diabetes care for primary health care nurses. The programme provided by NZ Society for the Study of Diabetes (NZSSD) with the support of diabetes nurse specialist section of NZNO can be found at: www.healthmentoronline.com »» The May Budget announced additional funding for DCIPs bringing overall funding up to about $11 million a year. »» The Budget also announced an extra $15.9 million (over four years) to increase the number of heart and diabetes checks nationwide. »» Plus an extra $7.2 million (over four years) to double the number of nurse and GP ‘green prescription’ programmes that encourage healthy lifestyles for people found to be at increased risk of diabetes or heart disease.
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ifty people a day are diagnosed with diabetes in New Zealand. More than 200,000 Kiwis have already been diagnosed and the Ministry of Health believes there are probably another 100,000 people out there with diabetes yet to be diagnosed. From July 1 last year, the targeted funding for diabetes in primary health care was redirected from the Get Checked free annual diabetes check to region-by-region driven Diabetes Care Improvement Packages (DCIPs). Local plans means no national consistency with some regions targeting their high needs Māori and Pacific population, many offering increased retinal screening and most promoting greater access to nurse-led care and support of people with diabetes. The jury is still out on how successful the redirected funding will be in helping improve diabetes management and stem the down-thetrack complications of the diabetes epidemic. Some are cautiously optimistic, others are wary, and most agree it is early days. Chris Baty (left), chair of consumer group Diabetes New Zealand, last year called for primary health post-Get Checked to stop ticking boxes in clinics and take services out to the people with diabetes who need them most. She says outreach and fresh initiatives are underway in some areas under the new Diabetes Care Improvement Packages (DCIPS) with a few district health boards (DHBs) and primary health organisations (PHOs) being “really notable leaders” but in other places change has been “regrettably slow”. Rosemary Minto, a primary health nurse practitioner (NP) and chair of NZNO’s College of Primary Health Care Nurses, says from her personal experience the implementation of the package has been “patchy”. “Many GPs have found the lack of directives from DHBs/PHOs problematic as they don’t have the time or the capacity to set up their own processes within their general practice, unless there are nurses who are able to drive this and provide the services, including insulin initiation.” Lorna Bingham (left), a diabetes clinical specialist for Capital & Coast DHB and NP candidate, believes the shift to packages has provided increased flexibility and opportunities to build on what was developed through Get Checked.
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“But we need to ensure we don’t lose too much momentum or traction until the new plans and packages are in place and implemented.” Rachael Calverley (left), director of nursing for the Waitemata Primary Health Organisation (PHO), says it can take several years for change to get embedded in primary health care. She says one positive has included a focus on nurse education – including the new online learning modules in diabetes care for primary health care nurses – and her own PHO has been able to review and revamp its three face-to-face diabetes courses for nurses. She sees a downside of the change as the “very real danger” that some people with type-2 diabetes will let their diabetes slide because they don’t qualify for targeted funding support under her region’s new package . An example could be an Indian patient in their 30s or 40s who feels okay and has no complications or co-morbidities with their diabetes (so isn’t eligible for Care Plus funding) and puts off paying to see their GP or nurse until issues arise. “We’ve really got to watch those ones as we know diabetes can escalate quite rapidly and these people have significant risk of complications,” says Calverley who is also a member of the primary health care nurses college board. “That’s a potential risk that we have to be aware of as health service providers and planners.”
No single approach
But every DHB and PHO is slightly different in how they target their DCIP funding and in their willingness to be flexible in using other funding sources as a “back stop” so nurses can offer sufficient support to people with uncomplicated diabetes so they stay that way. Baty says while some areas packages have identified podiatry services as a real area of need and others retinal screening, more often than not, the packages were about nurse-led initiatives. “That’s one of the things we are really excited about within the diabetes sector – it’s a very collegial sector from a professional point of view and we’ve had things like diabetes nurse prescribing which is hugely exciting.” However, it will take time to get a critical mass of nurse prescribers qualified, particularly in primary care. Baty encourages people to check out their local DHB website and become familiar with their region’s package. Diabetes New Zealand is also
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WHAT CAN MAKE UP A DIABETES CARE IMPROVEMENT PACKAGE?
Nursing Review asked the Ministry of Health for some examples of what a good diabetes care package can look like. Karen Evison, the Ministry’s national programmes manager for CVD, diabetes, and long-term conditions, responded saying different regions have taken different focuses but some broad themes are: working with the Ministry on how to foster local consumer feedback. “When you have 20 individual plans you (groups like Diabetes New Zealand) cannot give a national response apart from saying (packages) can be variable.” Changes can take time to filter through to the consumer level. Donna McArley, RN and general practice coordinator for the Western Bay of Plenty PHO, says her PHO continues to fund one annual free diabetes assessment at its 27 practices. The PHO also has??????? targeted funding to help manage patients Intro with an HbA1c over 75, with many of the practices running diabetes nurse-led clinics and special subsidies for the eight practices whose nurses are offering insulin starts for patients. Alyson Clare, a senior practice nurse at Kaikohe’s Broadway Health Centre, which has about 600 patients with diabetes and has been offering nurse-led insulin starts for more than a decade, says it is business as usual for its diabetes care. The centre still offers diabetes annual reviews, provides nurse-led diabetes care, and sends Clare to attend regular meetings with the Whangareibased diabetes specialist nurses, who are available for phone advice when needed. Bingham says Capital & Coast wants to support practice development in diabetes, and one initiative she has been involved in for several years is an outreach programme where she and a DHB consultant go out to general practices to hold case conferences and promote new research, guidelines, and educational opportunities. During the usually hour-plus length conference, the pair discusses with the practice team the care of about six to eight complex patients. She says the conferences build professional relationships, making it easier for nurses and GPs to contact the DHB diabetes clinic to ask for advice and improving the specialist service’s awareness and understanding of some of the difficulties encountered by primary care colleagues. “It allows for clarification around accountability of who is actually looking after which patient, especially for those who fail to turn up for appointments and may fall between the cracks.”
Trend for less amputations
Karen Evison, the Ministry of Health’s national programme manager for diabetes, says while there has been “variation in progress” between DHBs in implementing packages, the DHB reports for the third
quarter had shown “significant progress and some excellent results”. She says it had reviewed a range of DCIP plans from across the DHBs and was pleased with the approach and confident in the quality of services they were delivering. “Data from the Virtual Diabetes Register (VDR) from December 2012 shows a reduction in the number of people having to undergo amputations as a result of their diabetes,” says Evison. “This indicates that people with diabetes are receiving more effective care under the DCIP approach and gaining better control over their condition.” Minto says she is not convinced that diabetes outcome measures will show much improvement from the packages because the nature of diabetes was always to get worse rather than better. “We are not measuring patients’ perceptions of quality of service or improved self-management skills, which should be the focus.” She has also personally found that the people eligible for targeted funding in her region are the “hard to reach” population (often people who are seasonal workers or whose working hours make mainstream general practice services hours unsuitable) or those who are “difficult to assist because they have other priorities other than their diabetes and therefore will not take advantage of the funding, no matter what the incentives”. The recent Budget (see basic facts sidebar) has seen more funding invested in both the packages and extra heart and diabetes checks and green prescriptions for those found at risk of developing diabetes. Baty says the extra Budget funding, while never enough “is a step and you have to start a journey somewhere”. “We’re obviously pleased that diabetes had been highlighted … if we don’t start something at the stage when intervention can really make a return on investment, then we haven’t got a hope.” Calverley agrees that intervening at the pre-diabetes stage is an issue that needs to be addressed to “whittle” away at the diabetes “iceberg” that is about to emerge. Meanwhile, she says it is early days for the packages with the change from Get Checked still to imbed down and further change coming thick and fast. “If we consider the changes that are happening around (health services) integration, PHO agreement changes and also the potential changes and developments around nurse prescribing, plus pharmacist and dietician prescribing, we could see a whole new picture developing in a year’s time.” It may well be a case of watch this space.
Improving access
For some, access to services is a key issue and some district health boards have introduced a number of initiatives addressing this “very effectively” such as: mobile outreach clinics and screening services, co-located services, transport vouchers, and additional prescription subsidies. Northland, Waikato, Counties Manukau DHBs are good examples of these initiatives.
Education and self-management
In other regions, education/self-management are key issues and DHBs and primary health organisations (PHOs) have responded with initiatives like community education evenings, nurse-led clinics and group workshops, and innovative tools such as ‘conversation maps’ that walk people visually through the journey of diabetes care and management. West Coast and Northland DHBs are two examples of these approaches.
Other common approaches
Some common initiatives being included in packages across all DHBs include: green prescriptions, workplace screening programmes, self-management programmes, increased access to retinal screening, and greater access to nurses to deliver care and provide community education to people with diabetes and their supporters.
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A Christchurch randomisedcontrol trial found people struggling with managing their diabetes made significant improvements after a one-day education session. FIONA CASSIE talks to Lisa Whitehead about the research team’s findings and their ‘hunch’ that combining cognitive behaviour therapy with education could be even more effective.
DIABETES: Revisiting ‘back-to-basics’ education helps poor self-management
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evisiting ‘back to basics’ diabetes education for people with long-standing, poorly managed diabetes is welcomed and makes a difference, Christchurch research has found. In fact, research leader Dr Lisa Whitehead says a number??????? of participants told researchers that it Intro was the first time they received any basic education about diabetes. The two-year study on enhancing the selfmanagement of diabetes was led by the University of Otago’s Centre for Postgraduate Nursing Studies and focused on people who struggle to maintain glycaemic control (HbA1c ≥ 7%). The 118 people recruited into the study were randomised into three groups: one group of 34 people were offered a day of education on diabetes; another group of 39 people a day that combined education with acceptance and commitment therapy (ACT – a form of cognitive behavioural therapy); and the final control group of 45 people received usual care. The data collected included questionnaires on health and wellbeing, illness perception, and self-management, as well as HbA1c at baseline and at three and six months.
Hunch’ that therapy could make longer term impact
The study found that the education intervention had a statistically significant impact (p-value .019) on the participants’ blood glucose levels compared to the control. The combined education and therapy intervention had a lesser impact (p-value .062) but Whitehead and her team have a ‘hunch’ that this intervention may have greater impact in the long-term and still want to explore that intervention further. “We know that education can be effective. We know that after education, people will change their diet, improve their blood glucose monitoring, and have an increased knowledge around being ‘hypo’ or hyper’ glycaemic.” “But the hunch is that it will wear off and the changes are unlikely to last.” The team believes that given the combined education/therapy intervention did have an impact, and they want to explore further whether delivering that intervention in a different way could see it making a greater and longer lasting impact than education alone. 16
The ACT intervention included some mindfulness training and exploring of people’s attitudes and beliefs around diet and medication and any difficult thoughts and feelings about having diabetes. The idea was that addressing some of those attitudes could help the participants improve their emotional well-being and lead to better diabetes selfmanagement and ultimately improved glycaemic control. Keeping glucose control within the recommended range (3.5-6.5 per cent) is known to significantly delay the onset and progression of diabetes-related complications
Return to basics
The education intervention offered the basics on diabetes and its management and the nurses employed to deliver the education intervention were initially worried that the package was “too basic”, says Whitehead. But the qualitative feedback from the participants was that the package’s content and level was pitched just right and was “exactly what they wanted”. “They wanted to go back to basics and lots of people told us they had never had them (the basics) before.” “It shows that you really need to go back, repeat, and follow-up to check the client’s knowledge of diabetes,” says Whitehead. “And even if these people have been given the basics at some point, they told us they really appreciated the refresher session.” Both the education group and the education/ therapy group reported back positively on their particular interventions.
Quakes and out-of-date blood tests
The researchers began recruiting participants in early 2010 and found it challenging to get participants even before the quakes hit the city, with only 300 responses to the more than 1500 letters sent out. The team was seeking people who had less than optimal glycaemic control – and not just people who had a one-off incident but people who had been over the threshold for some time with at least two over the optimum level HbA1c test results. Whitehead says setting blood sugar level criteria for participants uncovered an unexpected
Nursing Review series Long-Term Conditions & Aged Care 2013
hiccup, as a number of practices were unable to supply a recent HbA1c level for their patients. “We were surprised to find that,” says Whitehead. “We had to request quite a few practices to do an up-to-date test.” She says the researchers also found it really difficult to recruit a representative number of Māori and Pacific participants for the study, despite trying a number of different tacks, including approaching churches. As a result, the team was looking more closely at making the information provided to participants more appealing and how to better approach and engage potential participants. The quakes also impacted on recruitment in the latter end of the research, with people unwilling to add one more thing to their already busy lives. And running the intervention sessions at its central city multi-story building also caused difficulties for some people. But of the recruits who were signed up to the project when the quakes hit, very few people dropped out. Inevitably, when participants were interviewed for the qualitative part of the study, they talked about the quakes and their impact on their diet, exercise, and stress levels, and these findings were being analysed by a Masters student as a related but separate piece of research. Whitehead says while the quakes were not an ideal time to run a randomised controlled trial, the researchers were pleased with the final outcome. “We’re really pleased that given everything that went on we found a significant result for education and moving towards a significant result for the combined education and ACT intervention”. The University of Otago is now looking to publish its findings and considering follow-up research to further explore ACT’s long-term effectiveness on improving self management for people with poor diabetes control. *Dr Lisa Whitehead, director of the University of Otago’s Centre for Postgraduate Nursing Studies, was lead investigator of the study which was one of the research projects funded under the $2.7m STAR (Strategy to Advance Research) Fund designed to build research capability in nursing and allied health disciplines.
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Aged Care FOCUS: We look at new efforts to recruit, retain and fast-track the next generation of aged care nurses. Plus an initiative to offer ‘rest home’ care at home.
Intro ???????
Supporting new blood FOR AGED CARE Aged care has one of the fastest ageing workforces. Getting new blood into the workforce is an obvious need and a pilot underway of providing extra support for new graduates entering residential aged care is one step being taken. FIONA CASSIE finds out more.
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t just 22 years of age and fresh from nursing school, Whitney McIntyre says working in residential aged care is not without it challenges. “The challenge for me is probably – especially for someone of my age – is being the senior person for a shift where you have to delegate and direct staff who have been here a lot longer … and also maybe a few years older,” says McIntyre. But the rewards are also there for the new graduate from Nelson, who started job hunting in July last year in the lead-up to her graduation and was eventually successful in February when offered a job in Timaru as one of 16 graduates taking part in the Aged Residential Care Nursing Entry to Practice (ARC NETP) pilot. Continued on page 18 >>
Aged Residential Care Nursing Entry to Practice (ARC NETP) pilot »» Provides 16 extra NETP places in residential care. »» There are four places in the Auckland region, three in Wellington region, two each in Waikato, Nelson-Marlborough, South Canterbury, and Southern District Health board regions, and one in the Hawke’s Bay. »» Each ‘enhanced’ ARC NETP trainee contract is worth $20,000 – the lead DHB gets the standard NETP funding and the extra funding goes to the ARC facility, which receives $12,800 per trainee. »» The extra funding allows for an extended minimum six week orientation period during which trainees are rostered on with an RN who takes overall responsibility for their shared case load. »» The trainee nurse is not allowed to be the only RN in a facility for the first six months of the programme. A clinical preceptor is to be available to the trainee throughout the programme, including weekends and late shifts. »» Trainees to access the existing DHB NETP education programmes and receive 12 backfilled days off to attend NETP support days. »» Only ARC facilities that have more than 50 beds and are certified for hospital-level care are eligible for the scheme. Nursing Review series Long-Term Conditions & Aged Care 2013
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<< continued from page 17 Jane O’Malley, (left) the Ministry of Health’s Chief Nurse, says the idea for the pilot, which offers increased funding and support for new graduates in aged care beyond the normal NETP scheme, arose from a workshop with aged care nurse leaders. The main focus of the $320,000 ARC NETP demonstration project, being overseen by Health Workforce New Zealand, is ensuring extra supernumerary support to the novice nurses during the orientation period. O’Malley says unlike a new graduate starting work in a hospital ward, with up to six other nurses working with them, a new grad in residential aged care nurse can find themselves working in relative isolation. The pilot aims to bolster the support offered to new nurses entering the sector to not only attract more but also retain more in one of the fastest ageing workforces. Nursing Council statistics for Intro ??????? 2011 show that while 41 per cent of the active nursing workforce is
aged over 50, it is 56 per cent in the continuing/aged care sector. While about 12 per cent of all active nurses are aged over 60, it is nearly double that figure (22 per cent) in the aged care sector – so the need is definitely there.
Small DHB signs up two trainees
Whitney McIntyre is one of two graduates signed up in South Canterbury to the ARC NETP pilot. Paula Finnigan, the NETP coordinator for South Canterbury District Health Board, says the small board has good established relationships with its aged care providers and was already in its fourth year of offering new graduate placements in residential aged care when the additional pilot places became available. Taking up one of those places was Whitney’s employer, Strathallan Lifecare Village – a large Timaru retirement village with a 29-bed rest home, 20 bed dementia unit, and 27-bed hospital – which has been offering NETP places since 2010. Up to this year, it had only taken
Strictly limited spaces!
The Selwyn Foundation Gerontology Nursing Conference
Wednesday, 14 August 2013, 7.30 am - 4.30 pm Waipuna Conference Centre, Mt Wellington, Auckland
• Full-day professional development conference • Latest leadership on clinical and dementia care issues • Person-centred, holistic teaching of individualised aged care • Expert nurses teaching advanced nursing practice • Special ‘early bird’ registration price available To see our full programme or book visit www.selwyncare.org.nz
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Nursing Review series Long-Term Conditions & Aged Care 2013
New graduate Whitney McIntyre (right)and Strathallan Lifecare Village general manager Debbie McMaster. on new graduates in its hospital wing and already had a NETP nurse in the hospital for 2013 when an extra ARC NETP place became available. Debbie McMaster, registered nurse and Strathallan’s general manager, says the extra funding for supernumerary support enabled them for the first time to bring a NETP nurse into the rest home environment. “Our management team consists of registered nurses but to have a RN on the floor in the rest home for that many hours a week, we wouldn’t be able to do that. So to have a programme where we can have her being mentored by a care manager is a big advantage, really.” McIntyre is also getting exposure to Strathallan’s dementia unit and the plan is to rotate her into the hospital wing later in the year. The NETP new graduates have never been rostered on to night shifts at Strathallan, and following their orientation period with their preceptor, they begin on morning shifts, so there is a care manager RN also on deck and they are not left on their own. McIntyre was not new to the aged care sector, having worked part-time as a health care assistant in residential aged care while she studied. She says she has always really enjoyed working with the elderly but hadn’t sought a new graduate job in the sector until the opportunity was opened up with the ARC NETP pilot. “It’s been really hard for nursing students to get jobs, but ARC NETP has opened up a lot more opportunities for students for jobs which is really good.”
Out-of-towners drawn to jobs
Finnigan says South Canterbury is in the novel situation this year that it started out with more NETP placements in the community than in the secondary sector, with initially five in aged care (one North Island graduate has since withdrawn for personal reasons), one in the local hospice, and one in general practice. With no nursing school in Timaru (though it does have an affiliated cohort with Otago Polytechnic) the majority of its NETP graduates are always from out-of-town, and nearly all of its aged care graduate placements, apart from Nelsonian Whitney, were from the North Island. Finnigan says from her perspective her role remains the same and she is there to support all of her 12 NETP graduates and provide the same support to all four aged care graduates, whether on the pilot or not. She says most of the aged care graduates are young and vulnerable, having left their support networks behind to shift to Timaru, and she sees her role as not only looking at how they are integrating into their work environment but also the wider community as well. The graduates working in aged care attend the same NETP study days and are encouraged to keep in touch outside of work and study time. Having two graduates employed at Strathallan also means they can be a great support to each other. “It can be quite lonely and isolated working in an environment where the age of the people working is probably above
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Long-term career choice?
McIntyre says shifting to a new town where she had no family or friends was initially difficult, but she says her workplace has been very supportive, she has now joined a hockey team, and has regular catch-ups with other new graduate nurses in Timaru – including her fellow NETP graduate at Strathallan. Being familiar with aged care meant she came into the job knowing??????? what would be expected of Intro her, and ten weeks into the job, her biggest challenge was directing and delegating experienced care staff quite a bit older than herself. But she says everyone is really supportive, including the health care assistants and the rewards include being respected as a nurse and having the chance to experience the challenge of being the senior person on staff. It is early days yet but does she see herself staying in aged care? “It’s definitely something I will be looking at but I’m also looking at doing a lot of things throughout my career.” McMaster sees the ARC NETP pilot as a good chance to have young nurses exposed to aged care. The ideal, of course, would be for them to stay in the sector. She says while Strathallan’s first NETP graduate is still with them, their second left at the end of the programme to work in the public hospital, and the third returned to Christchurch to work in a private hospital. “So the success rate is one in three staying in aged care, but you can’t not have a NETP nurse for that reason, either,” says McMaster. “You have to offer new graduates a chance to develop their practice, and hopefully, it will help them throughout their practice to have had that exposure to residential aged care and the issues facing the elderly and their families – whether they stay in aged care or come back to aged care – at least they know what aged care is about.”
NEW GRADUATES, DESPITE entering a tight job market for first jobs, are still on the whole reluctant to seek out work in the residential aged care sector. Only four per cent of the 1232 new graduates applying for jobs late last year via the new Nursing ACE (Advance Choice of Employment) clearing house put down aged residential care as one of their choices, and only a tiny seven of those 49 new nurses put it down as their first choice. It appears to be residential care rather than working with older people that’s putting off new graduates, as triple that number (152) chose the older person’s health setting of ‘assessment, treatment & rehabilitation’ as a preferred job option. Likewise, when it came to registering interest in the Voluntary Bonding scheme’s aged care option (which included DHB older person’s health services) around 20 per cent of new graduates were ready to sign up. So what are the barriers to new graduates wanting to work in residential aged care?
NZNO: safe staffing and support are key
David Wait, aged care industrial advisor for the New Zealand Nurses Organisation, says NZNO is concerned that the low numbers of new grads nominating aged care will not replace the number of nurses retiring. “The gap will only grow with expected demand for more aged care over the next few years.” He says when you look at new graduate wages (see table below), most of the large aged care employer pay rates are higher or fairly close to the DHB rates (but when other conditions like penal rates and shift leave are taken into account, the pay advantage is reduced or lost). If pay at the new graduate level is not the barrier, what is? Wait thinks the root cause is inadequate government funding for the sector that places financial pressure on providers that impacts on not just penal rates and the like but also professional development opportunities and staffing levels. ”Staffing levels often place nurses in situations where they have to ration care and subsequently place themselves and their practicing certificates at risk.” The situation is generally better and safer for those working for ‘not for profit’ providers, says Wait. Another factor impacting on the appeal of aged care for new graduates is they can find themselves in situations where they are the only RN on duty and are responsible for the work of the unregulated care staff. He says NZNO wants to see appropriate government funding for the sector that would allow the
Chief Nurse Jane O’Malley
the average age – which is probably pretty high, anyway.” She tries to see graduates once every two weeks and encourages phone, text, and email contact between visits if they have any concerns. “They are very good at doing that.” Calls come about collegial relationships, direction, and delegation issues, which Finnigan says is a common issue for new graduates, and sometimes personal issues that are impacting on their work.
HOW TO BUILD LAGGING NEW GRAD INTEREST IN AGED RESIDENTIAL CARE
recommendations from the Human Rights Commission report Caring Counts to be implemented. Wait adds, “from a professional development perspective, if aged care employers want to attract new graduates they need to provide opportunities for them to grow and develop. These opportunities are generally lacking at the moment.”
Chief Nurse: support the keen and willingChief Nurse Jane O’Malley acknowledges the sector is not without difficulties and that few new graduates seek to work in the sector. She says that makes it important to concentrate on giving good support to the graduates who do show a preference for working in the sector, in the hope they may wish to pursue a long-term career in aged care. That support should include having access to a good new graduate programme, being exposed to a model of care that encourages best practice, receiving good support for their career progression, and access to postgraduate education funding so they can further their skills and knowledge. “So I think my strategy is more focusing on not what we don’t have or can’t do but actually on what we can do with the willing,” says O’Malley. “Then you create pockets of excellence that people want to come and work in. I think that’s another way of going.” She points to regions like Canterbury, Waitemata, and Horowhenua, which are working on local solutions that are leading to really good outcomes for staff and patients. O’Malley says the same workshop that lead to the ARC NETP pilot also discussed ways of highlighting good models of care leading to improving patient outcomes and staff retention and satisfaction. The resulting short videos, showcasing innovative and integrated care models involving residential aged care and DHB services, are due out later this year. “We’re hoping that we will also be able to use these videos in undergraduate education to give students insight into the potential for a career in aged care,” says O’Malley.
RN base salaries*
New Grad
Step 5**
NZNO/District Health Board MECA
$47,528
$63,336
NZNO/Primary Health Care MECA
$45,760
$61,152
Best religious/welfare group ARC
$52,382
$64,480
Radius
$48,942
$52,873#
*NB Based on figures supplied by NZNO and a conventional 40-hour week without penal rates. **NZNO says DHB new graduates automatically progress a pay step each year to step five but in aged care nurses can get ‘stuck’ at step one or two of the pay scale. #Radius pay scale only has three steps. Nursing Review series Long-Term Conditions & Aged Care 2013
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‘Job swap’ to fast track aged care nursing career With a workforce crisis looming in aged care nursing, Christchurch is headhunting and helping the new generation of aged care nurses to fast track their careers. Fiona Cassie finds out more about the Gerontology Acceleration Programme (GAP).
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here was a buzz around the tea cups at a recent gathering in Christchurch. It’s not that often that you get a group of aged care nursing leaders and gerontology clinical nurse specialists and nurse practitioners in a room with a bunch of nurses shouldertapped to hopefully follow in their footsteps. The occasion was the introductory afternoon tea for the nurses, preceptors, mentors and Intro ??????? managers signed up to Canterbury District Health Board’s new GAP (gerontology acceleration programme) scheme. The looming workforce crisis in aged care nursing has prompted Canterbury to create the ‘fast track’ programme to start building future nurse leaders for the sector. Six nurses – two from Christchurch residential aged care facilities and four from Canterbury District Health Board older people’s health related wards – have been selected for the inaugural programme, which got underway in late May. The one year programme includes postgraduate study and “job-swapping” between workplaces, so the rest home nurses experience working in DHB services and the DHB nurses experience nursing in residential aged care. Kate Gibb, the DHB’s older people’s health nursing director, says the idea for the scheme grew out of a committee formed in mid-2011 to look at post-quake issues for older people’s health, particularly workforce issues. Even before the quakes, there was a real sense of a looming workforce crisis, with half the nurses working in residential aged care in Canterbury over the age of 50 and 20 per cent over 60.
First for New Zealand
The result has been the Gerontology Acceleration Programme (GAP), which supports the development – both professional and academic – of motivated registered nurses already working in older people’s health who have the potential to be future clinical leaders, specialists or managers. Gibb says the GAP scheme is not only a first for Canterbury but also a first across New Zealand for gerontology nursing. Jenny Gardner, the DHB’s coordinator of postgraduate nursing education, says a similar nursing ‘exchange’ programme has been carried out in-house, but this is the first time the job 20
Christchurch aged care nurses on the inaugural GAP course (from left): Ruth Cahutay (BUPA), Gene Ruiz (Ultimate Care Group), Vivienne Erickson (CDHB), Grace Amoafo (CDHB), Kathryn Stewart (CDHB) and Wedzerai Matsheza (CDHB). swaps have been between DHB and non-DHB workplaces. Each of the six nurses will have two 12-week clinical rotations where they will step in and fill the shoes of their fellow GAP nurse while staying on the payroll and pay conditions of their home employer. During each rotation, they will have an orientation period where they will be supernumerary and be assigned a preceptor at that workplace. The GAP nurses have also all been allocated a mentor for the programme, a gerontology clinical nurse specialist or NP, to assist them in setting goals and helping them advance their gerontology nursing practice. Gardner says the programme is also working very closely with the University of Otago’s Centre for Postgraduate Nursing Studies. Each of the GAP nurses will be expected to complete Otago’s postgraduate gerontology paper in the first half of the programme and then (during the third and final 12 week rotation when they are back with their home employer) the advanced health assessment paper. Two of the nurses have already done some of the papers and will do related postgraduate papers.
Whole big world of gerontology
One of the GAP nurses, Ruth Cahutay, is a Philippines-trained nurse who has been working as an RN on nightshift at BUPA’s Parklands aged care facility since 2009 after completing her competency assessment programme at CPIT. Having already completed her postgraduate health assessment paper last year Cahutay believes the GAP scheme will be a good experience and a good chance to get out and meet other people working in the same field.
Nursing Review series Long-Term Conditions & Aged Care 2013
“There’s a whole big world out there of gerontology, and I don’t think there’s a lot of nurses who are going down that path.” Fellow Philippines-trained nurse Gene Cruz has been working at Bishop Selwyn Lifecare for six years and was persuaded to put her hand up for the programme by her manager. “When I first came to New Zealand, I thought it (residential aged care nursing) would be just a stepping stone, but I loved it from the start.” She has been doing a graduate certificate in gerontology at CPIT and is looking forward to her rotations, particularly to the dementia and delirium ward (K1), as Bishop Selwyn doesn’t have a dementia unit. Grace Amoafo is still new to nursing and older person’s health, having just completed her new graduate programme in February. The Christchurch Polytechnic of Technology graduate says her original intention was to go into a medical ward but her second new graduate placement was in Princess Margaret Hospital’s K1 ward for dementia and delirium and she found she liked the work and found the staff very supportive. Her first GAP rotation will be into residential aged care, which she knows little about but is aware that you can be the only registered nurse on a shift with health care assistants doing most of the hands-on caring. “So it’s an area where you can feel very isolated,” says Amoafo. “It’s only when I get there that I will really know what the RN’s role is, and I’m really looking to learning what really goes on.” She is also looking forward to the postgraduate study, particularly building her skills with the health assessment course.
FOCUS n Long-Term Conditions & Aged Care
Rest home in the home
Canterbury quakes saw Christchurch lose more than 650 residential care beds. One response was TotalCare – a collaborative approach led by community-based Nurse Maude to offer residential care in the home. Nursing Review reports on Sheree East’s recent presentation on the scheme to the Home Health Association conference.
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Sheree East
ebruary 22 2011 saw some rest homes turn into sand pits and others left cracked, broken, and unlivable. In all, eight rest homes were forced to close by the February and early September earthquake, leading to more than 650 residential care beds being lost from the city. The hospital also lost beds, creating pressure on where and how to care for the city’s vulnerable elderly. Sheree East, director of nursing for Nurse Maude, says one response by the region was the development of TotalCare – a ‘stay at home’ alternative to clients who would otherwise require admission to residential care. Nurse Maude is also involved in the CREST (Community Rehabilitation & Enablement Support Team) scheme, which is another Canterbury older person’s health response to the quake but focusing specifically on offering elderly patients intensive interdisciplinary support Intro ??????? in the home on being discharged from hospital and also to prevent avoidable hospital admissions. TotalCare was modelled on Waikato’s Community First programme and funded Nurse Maude, which has been providing community health care to Christchurch for 115 years, to deliver suitable clients a high and complex care service in their home. East reports that the results for the nearly 70 clients to date who have been part of TotalCare have been positive, with the number of emergency department presentations by clients halved since before TotalCare and reduced hospital admission stays. East says there were overall high levels of satisfaction reported by patients and their ‘significant others’, though patients were more satisfied than their ‘significant others’, who expressed a desire to be more involved and engaged in the delivery of the care. But generally, she says, “families love it and clients want it”. It has led to “excellent outcomes of care” and allowed couples to stay together in their own home. It has also been positive for the workforce involved, with the registered nurses gaining increased case management experience and familiarity with the Omaha System for documentation and a new IT system. In addition, the enrolled nurses involved were new graduates who were mentored, gained orientation to residential care, and got to put new competencies to use. East says the scheme extends the role of community-based services but it also requires “full engagement and agreement across service providers”. Patients were referred by a clinical assessor or social worker from Canterbury District Health Board’s Older Persons Health Service and an interRAI patient assessment sent to the TotalCare team. The team’s registered nurse co-coordinator attends a client assessment with the clinical assessor and there are family conferences and
discussion with the patient’s general practice to establish relationships before the client is transferred to TotalCare. Nurse Maude has two TotalCare teams – each led by an RN coordinator and each providing care for up to 35 TotalCare clients. Each team also has an enrolled nurse and there were about 22 full time equivalent (FTE) support workers across the two teams. Occupational therapy and physiotherapy support were also available, plus on-call nursing support, monitoring, and interface with the local St Johns Ambulance service and support of the other Nurse Maude community health services. Sixty-one per cent of TotalCare clients were aged 85 years or older, half lived alone, and the majority owned their own home. They had a range of health and care needs with more than half (55 per cent) at high risk of
developing pressure sores, the vast majority were at risk of falling, more than half (56 per cent) had a cognitive disability, and three-quarters had continence issues, and about a quarter were classified as being independent on admission to the scheme. The vast majority needed help with their personal care (90 per cent) and more than two-third with their medication regime (as the majority had eight or more medications prescribed), their health care supervision, continence, and nutrition. In all, the nearly 70 patients received nearly 4000 registered nurse interventions (categorised under the Omaha System) with the most common being to address physical symptoms or for wound care. Other interventions included medication administration or co-ordination, general nursing care, communication, and bladder care.
TOTALCARE FEEDBACK FROM FAMILY AND PATIENTS “This service has been great for my aunt as prior to this she ended up in hospital every 3–4 months, but since she has been under the TotalCare service, she hasn’t had any admissions in over a year! She really wants to be in her own home, so it is perfect.” “Marvelous service – grateful. Absolutely fabulous for my age group. I’m hard to please. Like place nice – so this service achieves that. Like independence – don’t like to be ‘taken over’.” “No suggestions for improvement, very satisfied, helping me to stay at home and don’t want to go into a rest home.”
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Tacera
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Email us at info@austco.co.nz Call us on 0800 287 826 TACERA is an advanced IP based nurse call solution for healthcare facilities that has plug-and-play functionality. This minimizes the cost of installation and commissioning, as well as making ongoing maintenance more cost effective. Selecting a Nursecall system is a daunting task, with so many technologies involved how do you choose the right product and the right supplier? Over the past twenty five years, 6,000 healthcare facilities have chosen Austco as their trusted supplier.
Graphical user interface
Our range of Nursecall Systems provide;
TACERA comes with a comprehensive touch screen application that offers centralised activity reporting and system management facilities. The touch screen interface allows users to easily navigate through the software to build reports.
• National support and servicing network • Audio, Non Audio and IP Based Nurse Call Systems • Comprehensive reporting for risk and cost reduction
Infection control
• Compliant with AS2999 and AS3811 • Anti-Bacterial Silicone Rubber for infection control • Wireless Telephony Integration • Touch Screen Workflow Terminals
Text and Audio messages When your patient presses the call button on their handset, the information is instantly displayed at the Nurse’s Station as well as on Annunciators throughout the ward. The call may also be displayed on pagers and wireless telephones, instantly alerting staff that a call has been activated. TACERA’s VoIP interface provides crystal clear voice communications between nursing staff and patients, without the need for third party middleware. Alerts generated from Patient Monitors, Ventilators, IV Pumps and Stat Lab results may be integrated into TACERA allowing “one click” staff allocation.
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All ErgoPLUS handsets and SteriButton Callpoints are manufactured from silicone rubber with an anti-bacterial additive for improved infection control. To avoid nuisance alarms during cleaning, callpoints incorporate a cleaning mode. The cleaning time and date is logged on the central server, providing an audit trail for infection control compliance.
About Austco Austco is a wholly owned subsidiary of Azure Healthcare, an international provider of healthcare communication and clinical workflow management solutions. The company is headquartered in Australia, has subsidiaries in six countries and supports more than 6,000 healthcare facilities through our global reseller network. Azure Healthcare (ASX:AZV) is listed on the Australian Stock Exchange.
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EVIDENCE-BASED PRACTICE
Keeping kids safer
What nursing-led intervention has been proven to help protect vulnerable Kiwi children? CLINICAL BOTTOM LINE: Home visitation programmes are associated with about one third reduction in unintentional injury, halving of harsh physical punishment rates, and with improvements in parenting competence and child behaviour.
CLINICAL SCENARIO: As a community nurse, you are aware that child abuse is a prominent issue in society. With New Zealand having one of the highest rates of child abuse in the developed world, you know that interventions need to be implemented in order to address this problem. You look to the literature for how your role as a nurse can help play a part in reducing child abuse.
QUESTION: In New Zealand families, do home visitation programmes help reduce child abuse in comparison to families receiving no home visit?
SEARCH STRATEGY: PubMed Clinical Queries – (therapy, broad): Child abuse
CITATION: Boden J, Fergusson D, Horwood J. Nine-Year Followup of a Home Visitation Program: A Randomized Trial. Pediatrics 2013;131(2):297-303. doi: 10.1542/ peds.2012-1612
STUDY SUMMARY: Two-arm, parallel group, randomised control trial with families recruited from Christchurch over a 19-month period beginning in January 2000. Families were screened by Plunket nurses using a screening tool that covered parent age, social support, whether pregnancy was planned, parental substance use, financial situation, and history of family violence. Exposure to two or more risk factors led to referral. Plunket nurses were also asked to refer any family where they had serious concerns about the family’s capacity to care for the child. 4523 families were screened; 3935 families were not eligible, and 145 declined to participate. 443 families were randomised. Scheduled intensive home visits occurred for the Early Start families, and for both groups, assessments were made at baseline, six months, annually from one year to six years, and at nine years. Data was gathered through structured client interviews, medical records and school teacher questionnaires. Families in the control group were offered $50 for each data collection visit. Intervention (n=220): Of the 220 families randomised, 14 families declined support after the first month. Trained support workers (qualified nurses) provided intensive home visits throughout the study. Each support worker had a caseload of 10-20 families. The intervention was based on the social learning model and involved [1] assessments of family needs, issues, strengths and resources [2] developing a positive partnership between family and support worker [3] collaborative problem solving [4] provision of support, mentoring, and advice to mobilise strengths, and [5]
involvement with family throughout pre-school years. Control (n=223): Of the 223 families allocated to the control group, two families declined participation after the first month. These families were not provided with intensive home visits. Outcomes: A broad range of outcome measures were included in the trial – e.g. reduction in child abuse, improvements in child health, parental physical and mental health, family relationships, and material wellbeing. Measures reported in this nine-year followup included hospital attendance for unintentional injury, harsh punishment/parental use of physical punishment, parenting competence, child behaviour, maternal depression, parental substance use, family violence, life stress, and economic circumstances.
STUDY VALIDITY: Randomisation occurred at point of referral to the trial, with families being randomised based on a computergenerated series of random numbers. Allocation concealment was not reported. There was complete follow up of 86 per cent of the study participants at nine years (78 per cent in Early Start and 89 per cent in control). Intention to treat – the primary analysis used data from “completers” only. Two sensitivity tests were done to test effect of missing data – data was first imputed assuming Early Start had no effect on baseline variables and then the data was imputed assuming Early Start had same effect on missing families as on those followed up at nine years. These analyses showed the effects varied little from the “completers” analysis. Blinding was not possible in this study, and apart from the intervention, no differences
in treatment were likely. The control and intervention groups were similar at baseline.
RESULTS: Mean maternal age was 24.5 years at baseline, in 81 per cent the pregnancy was unplanned, about two-thirds were single parent families or lacked educational qualifications, and about one third had been assaulted by their current partner at baseline. There were reduced rates of child abuse in those families enrolled in the Early Start programme, parentally reported harsh punishment, and physical punishment scores. Average parenting scores were higher in the Early Start programme. There were no statistically significant differences in depression symptoms, cigarette smoking, alcohol problems, illicit drug use, intimate partner violence, welfare dependence, or level of debt.
Comments: Positive effects on child health, including unintentional injury, were reported earlier (Fergusson DM et al. Pediatrics 2005;116:e803). This longer term report confirms earlier findings. Important to note that child-related benefits are apparent, although programme failed to produce change in parental and family circumstances. Cost effectiveness of the Early Start programme has not been reported. Reviewers: Sarah Menzies, 3rd year student nurse, and Andrew Jull, Associate Professor, School of Nursing, University of Auckland
Table: Outcomes to the 9 year follow up Outcome
Early Start (n=177)
Control (n=199)
RR (95%CI)*
Attending hospital for unintentional injury
50 (28.3%)
84 (42.1%)
0.67 (0.52-0.85)
Parent-reported harsh punishment
17 (9.8%)
40 (20.1%)
0.48 (0.32-0.72)
Physical punishment score ‡
1.29
1.44
P<0.05
Parenting competence score ‡
10.13
9.88
P<0.01
Parent reported behaviour score ‡
9.91
10.08
P<0.05
P value
* RR (95%CI) = Relative Risk (95% Confidence Interval); ‡ mean scores averaged over 3, 5 and 9 year time points.
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WEBSCOPE
KATHY HOLLOWAY suggests celebrating Matariki – the Māori New Year – with a resolution to explore the Twittersphere.
Tweeting start to the ‘new’ New Year
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n June as we celebrate Matariki, take a moment to review your previous New Year resolutions (if you had not made any, this is your chance!). According to the Māori Language Commission, Matariki – the Māori New Year, this year marked on June 10 – signals a time of growth and change. It’s a time to prepare, and a time of action. Make 2013 the year you decide to explore Twitter as a social media tool to link with the wider nursing and health community. You are probably already using social networking (an estimated 48 per cent of adults use Facebook for example) in your private life but what about professionally? Nurses can use Twitter to connect globally and even locally with nursing colleagues through a kind of micro-blogging process aka ‘tweeting’. Of course just like with Facebook and other social media, when entering the Twittersphere, nurses should follow the professional guidelines for social media (see NETS and NZNO guidelines here http://nurseducation.org.nz/ content/download/448/1782/file/Social Media and the Nursing Profession FINAL.pdf and Nursing Council guidelines here http://nursingcouncil.org. nz/Media/Files/Guidelines-Social-Media). Twitter is an online social networking service that enables its users to send and read text-based messages of up to 140 characters, known as ‘tweets’. It is important to remember that Twitter is a highly public domain where everybody can see your posts. Twitter was created in 2006 by American software developer Jack Dorsey, and in 2013 has over 500 million registered users (http:// expandedramblings.com/index.php/march-2013by-the-numbers-a-few-amazing-Twitter-stats/) generating over 340 million tweets daily. Twitter is available in more than 20 languages and can be viewed online or via apps on smart phones. The name has evolved from the original Twttr (after Flickr and Tumblr, other social networking sites) to the current Twitter and to tweets after the developers found synergy in their meaning as ‘short bursts of inconsequential information’. The top five tweeters in the world have over 30 million followers (Justin Bieber is currently at No. 1). 24
The use of Twitter in healthcare is growing, with the National Health Service in the UK using Twitter as a forum for patient information and gathering feedback on its services. In the USA, a recent Computerworld article revealed that around 30 per cent of health consumers now use social media sites such as Facebook and Twitter to seek medical information and track and share symptoms. Patients are also using the sites to vent about health professionals, treatments, medical devices, and health providers. The CDC uses Twitter as a mechanism for raising health literacy with over 160,000 followers. An example of the global potential is nursing Twitter chats, real time discussions that take place on Twitter at a given time using hashtag # to link conversations together. Keen to start? Follow the simple steps as below: 1. Log on to www.twitter.com and follow the instructions to sign up. 2. Add some information about yourself (remember to be aware of the privacy of your information). 3. Every Twitter user has an @ symbol in front of their username – mine is @KathyHollow – not an exact match but you may not get one (remember those other millions of users). 4. Search for people or organisations that you want to follow by using the search box. Check out these ones for a start: @WeNurChat, @NursingReviewNZ, and @BBCHealth 5. Or you can search for a topic of interest by using the hashtag symbol # in front of the topic – e.g. #healthcare You are now ready to become an independent tweeter – check out this site for further information http://www.hashtags.org/platforms/ Twitter/basic-Twitter-terms-you-must-know/. Remember, with awareness comes choice and tweet away! Ed. Connect with Nursing Review (@NursingReviewNZ) as your gateway to the world of Twitter. We’d love to share your tweets. Dr Kathy Holloway is dean of the Faculty of Health at Whitireia Community Polytechnic.
Nursing Review series Long-Term Conditions & Aged Care 2013
CHECK THESE OUT
Online Issues in Nursing Journal – Social Media and Communication Technology: New “Friends” in Healthcare http://www.nursingworld.org/ MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/JournalTopics/ Social-Media-and-Communication-Technology This American peer-reviewed publication provides a forum for discussion of the issues inherent in current topics of interest to nurses and other health care professionals. The intent of this journal is to present different views on issues that affect nursing research, education, and practice, thus enabling readers to understand the full complexity of a topic. When each new topic is posted, the previous topic becomes available to all viewers. This topic is from September 2012 and very relevant to this month’s column, with six articles on the emerging presence of social media in healthcare. Of particular interest is an article about Health Tweets: An Exploration of Health Promotion on Twitter. Follow the journal on Twitter at @ANAOJIN [Site accessed 25 May and last updated May 2013].
Pediatric Nursing Journal http://www.pediatricnursing.net/ The website for the well-known journal, Pediatric Nursing, which has a stated focus on the needs of professional nurses in pediatric practice, research, administration, and education. It provides information related to health care for normal, sick, or disabled children and their families; pediatric clients in the hospital, clinic or office, school, community, or home. A variety of full text articles are freely available that highlight current topics and issues in pediatric practice and health policy, serving a wide range of pediatric professionals – from those who practice nursing in acute care or specialty units to those who promote health in non-hospital environments. You can access professional practice resources and continuing education from the site without registration or you can subscribe and get full access to the journal which is published six times per year. Follow this journal on Twitter @PedNursing (Site accessed 25 May and last updated March 2013).
COLLEGE OF NURSES
Engagement and success for Pasifika nursing students NGAIRA HARKER reflects on the importance of supporting Pasifika nursing students.
C
reating opportunities within mainstream nursing programme for Pasifika students to have relevant cultural health experiences can create challenges for nursing education. The limited pool of Pacific Island nurse educators and the small number of Pacific Island students within nursing degree programmes is potentially a factor in the lack of Pasifika views and models of health care within some programmes. Added to this issue are the limited practice opportunities for Pasifika students to gain relevant cultural clinical experiences. The future health workforce will require knowledge of Pasifika health issues. It is estimated that by 2050, half of the population in Aotearoa will identify as Pasifika. Having Pasifika nurse educators as role models for our students has been an important factor in creating opportunities, and the growth of Pasifika knowledge within Waiariki School of Nursing and Health Studies and inspiring this group of students to think and aspire to leadership positions as a future goal. We are fortunate to have two Pasifika nurse educators both at master’s level who are committed to creating gains for our students. This commitment enabled a group of Pasifika students, together with three staff, to attend the 2012 South Pacific Nursing Forum held in Melbourne. A year of preparation and fundraising, led by nursing lecturer Ana Waqairawaqa, was key in ensuring this trip was well planned and students could benefit from the experience. The New Zealand Fijian Nursing Association also provided financial support for the group to attend. The forum exposed students to a diverse group of nurses from throughout the South Pacific region. It broadened their knowledge of current health issues impacting on all Pacific nations and supported the development of networks with other South Pacific nursing academics, researchers and clinicians. Being surrounded by Pasifika nursing colleagues sharing their experiences and knowledge of health issues and nursing practice was a vital immersion experience for the students that was inspiring and provided valuable motivation to support their continued pathway. A forum report by Adi Losalini Cegumalua, a first year nursing student of Fijian descent, shows the value of this experience: I’ve been excited about this trip from the beginning of this year when we were told that we could attend. A presentation that captured my attention was from Dr Amelia Tuipulotu, University of Sydney, with her presentation on ‘Tatau pē Equality and Talanoa Tongan Oral Culture’. Her philosophy interwove nursing and the concept of cultural ornaments within a nursing context. She gave the example of the traditional Tongan woven mat with the four strands demonstrating it as a framework in which to frame culturally appropriate nursing standards. She explored nursing standards from within a Tongan and Western world-view to support improved approaches to care supporting the needs of the Tongan community. She showed passion and patriotism with her speech that captured everyone’s attention. Overall, for me, the trip was hugely beneficial. It enabled me to see what was happening in the Pacific nursing world, to gain an understanding of what nurses from the Pacific encounter during their daily work, the different challenges they face, and the challenges each Pacific Island country faces to improve nursing qualifications and nursing standards within the South Pacific.
Students and staff at the South Pacific Nursing Forum (from left): Ruci Cabemaiwai, Adi Losalini Cegumalua, Stephanie Zoing, Alena Kaitani, Sereana Smith, Ana Waqairawaqa (BN Lecturer), Aneta Nawainilaga(CNM), Denise Riini (Academic Advisor)
Other students provided insight into how attending the forum impacted on their view of Pacific health. These insights included: »» Cultural influences and low economic status that hinder nurses from becoming nursing leaders in the South Pacific. »» As a nursing student, it was so good to learn how nurses in leadership roles can make a difference in their workplace if they are provided with the proper training and ongoing support. »» The Commonwealth Nurses Federation and their purpose – which is to contribute to the improved health of citizens of the Commonwealth by fostering access to nursing education, influencing health policy, developing nursing networks, and strengthening nursing leadership. They play a critical role in improving nursing standards of practice by providing commonwealth countries with this assistance. »» It was informative to know the progress of each Pacific nation focusing on the issues of diabetes, cancer, mental health and nutrition, which is steadily improving but still much work (to be done) and health promotion (needed to) impact on these areas. The collective efforts of the group also resulted in some amazing traditional outfits made and worn at the forum by both students and staff. Students and staff decided on two outfits to represent the Bay of Plenty region and also their traditional links; one was blue and yellow (the colours of the Steamers rugby team) and the other green, red, yellow, and black (representing Waikato chiefs and Waiariki colours). The next South Pacific Nursing forum will be held in Tonga and Ana and the team have already started planning to support the next cohort of Pacific students to attend this important occasion. Author: Ngaira Harker, director of the School of Nursing and Health Studies, Waiariki Institute of Technology and board member of the College of Nurses Aotearoa.
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Articles, profiles and opinion pieces from across the nursing spectrum
Memo Musa
People, practice & policy Morale, leadership, AND FOOTBALL BOOTS FIONA CASSIE talks to new NZNO chief executive Memo Musa 20 days into the job about his new role, new constitutions, and nursing leadership … plus a little bit about football and gardening.
BOOTS, SHINGUARDS, SOCKS, and footballs ... the first impression you will get of the Musa household will make clear their love of “the beautiful game”. “We’re a family who are fanatics for football. My wife is a referee. I play. I referee. My daughter has refereed and she played for reps in Whanganui.” Not to forget the soccer star of the family, the 21-year-old UK-based James Musa, who has played for the Phoenix and New Zealand’s Under-23 Olympic team in London. He’s just finished a year with the under-21 squad of premiere league club Fulham and most recently played with the New Zealand A football team against Jordan. “Come to our household and the only thing you will see is socks, boots, and footballs. That’s how I relax,” says Musa. It is unlikely his son, or his 18 year-old daughter now studying at Victoria University, will follow in their father’s footsteps and become nurses, but they share the family passion for football. That passion saw Musa start his new job as head of the New Zealand Nurses Organisation with his arm in a sling after surgery to repair a football-related shoulder injury that has kept him off the pitch so far this season. This has allowed him to dedicate even more attention to his new role, which is demanding enough as it coincides with NZNO embedding a new constitution and a new joint leadership model and the upcoming election of a new governance board. Talking to Nursing Review just 20 days into the job, Musa was still in the midst of handover and meeting stakeholders (internally and externally) but was also gathering first impressions of the state of the sector and his likely priorities for the coming year. He left his first National Nursing Organisations’ meeting (the semi-regular gatherings of the head of the nine national nursing bodies) heartened that there were good cohesion amongst the national nursing leaders. “My impression was that nursing leadership was in a good place and there’s a common understanding of the value that nursing can bring to the health and disability system.” 26
PROFILE
Survey finds low morale and loss of nursing leadership While nationally leadership is cohesive, there are concerns emerging at the loss of leadership roles elsewhere in the health system. NZNO leader researcher Leonie Walker recently wrote in Kaitiaki about the results of its third biennial nurse employment survey (carried out in February this year), which indicated declining morale since the first survey in 2008. Of the survey’s nearly 1500 respondents (a 30 per cent response rate to the random sample survey), nearly a quarter reported they had experienced significant restructuring in their workplace, 27 per cent reported reductions in senior nursing leadership and changes to skill mix, and 43 per cent of those affected were questioning their nursing future. Musa says it is still early days in his role, but he believes NZNO will continue to advocate to district health boards (DHBs) and other providers that reducing nursing leadership roles – either through restructuring or changes in service model – is an unwise move. He says the Care Capacity Demand Management (CCDM) system, which NZNO wants rolled out to DHBs across the country, supports this by showing how nursing leaders and decision-makers in key places in an organisation contribute to a more efficient system, as well as helping deliver safe and good quality care. With DHBs still under tight fiscal constraint, he says NZNO advocates for nursing to be at the table right from the start in any discussions about changes in structure or services so they can provide a nursing voice and nursing evidence. “So nurses are actually heard and seen to contribute to whatever changes are taking place rather than just being at the receiving end,” says Musa. “From my perspective, there should be no excuse for not engaging and involving nurses in the work that’s been done by health providers as the mechanisms are there.”
Leadership pathway Musa’s own pathway to his current role included being Whanganui DHB CEO chief executive from 2001-2008 (see also April News Feed
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story at www.nursingreview.co.nz for more on his background career). His mother was also a nursing leader. She was the director of nursing of a hospital in Bulawayo, the second largest city in Zimbabwe. Musa left Zimbabwe as a teenager to study in England, but his parents and family remain living there. With Zimbabwe’s recent history, one has to ask what it is like to be outside looking in. “Zimbabwe is a good country. It’s gone through a lot of changes. I’ve remained in close contact with my family all the way throughout.” Today’s technology means he is contact with his family every other day. The last time he saw them in person was when he went to South Africa for the 2010 football World Cup. Meanwhile, NZNO not only has a new CEO but also a new constitution. Yet to meet with many stakeholders – both inside and outside the organisation – he is still formulating his own priorities as CEO for the coming year as he gains an understanding of the structure, systems, and culture of the organisation in the midst of major change. “The challenge for me is we already have a strategy that goes to 2015 and we have a new board starting (to be elected in September) with a new constitution.” He says one “crystal clear” priority for the coming year for him is ensuring the new constitution – which outlines the structures of NZNO and how it should work – is well understood by both members and staff. “If you can’t understand the constitution and what it means, then delivering against the strategy becomes a huge challenge.” The footballer in him is keen to be back on the pitch again as soon as he gets sign-off from his surgeon. In the interim, his other way of relaxing is gardening, and the other first impression you might have of the Musa household is its productive veggie garden. Having kept the family fed in carrots, potatoes, silver beet, broccoli, and cabbage over the summer and autumn, this is one health CEO walking the talk when it comes to being healthy and selfsufficient.
People, practice & policy PROFILE Gisborne nurse Janet Askew loves her garden, being a grandma, and working in some of the world’s worst trouble spots. A decade of working in war-torn Sudan to natural disaster-hit Indonesia recently won her Red Cross’s highest international nursing award – the Florence Nightingale Medal. She tells FIONA CASSIE why she loves her work.
A proud cross to bear
JANET ASKEW WANTED TO pinch herself with joy. The temperatures were soaring into the high 40s, the roads were broken, and the health centre was made of mud brick by refugees from a 20-year war. But she fell in love with both the work and the country when sent to southern Sudan for her first Red Cross mission in early 2003. It was Africa, it was intriguing, the Sudanese people were engaging and she was making a difference. “I felt that I had really found my niche in life,” recalls Askew, who agrees some sights were not happy. “We often like to focus on the danger and the negative, but in fact, people are often –particularly on that mission –very, very grateful that Red Cross was there and there were some very happy times. Without us there, many people would have died … many more people would have died, especially children.” At the tender age of three, after having her tonsils out in Wairoa Hospital, Askew decided that nursing was for her. A few years later, reading a book about nurses working in difficult circumstances “it may even have been about Florence Nightingale” sowed the seed of wanting to do similar work overseas. But it wasn’t until the early 2000s – divorced and with the youngest of her two children just finishing university – that she felt free and ready to send off a letter to Red Cross saying she wanted to be part of a humanitarian team. By then she had been nursing for more than 30 years in Gisborne, with a career including practice nursing, surgical night nursing when her children were little, district nursing for eight years, public health nursing, and working in health promotion until restructuring in the late 1990s saw her taking redundancy and becoming a tutor. First mission She was 49 when in early 2003 she arrived in Juba, the capital of Sudan, as a Red Cross delegate working with local health officials to help restore primary health care services in the broken city, which was flooded with refugees from the countryside escaping the long drawn-out conflict. “They came with very little but they’d build mud brick health centres, churches, and schools. Always with
Janet Askew last year with tutors at the newly renovated midwifery school in El Fasher in northern Darfur, Sudan. a view to go home someday if they could.” The Red Cross was one of the few agencies working in the region and was providing all medicines, consumables, and helping train staff and community health educators. “It was just fantastic work”. So much so that after returning at the end of that first year for her son’s wedding, she returned to Sudan in 2004 for another year-long mission. Askew was home again for Christmas 2004 when the Boxing Day tsunami wreaked its havoc. Unwell at the time, she couldn’t answer a call to join the immediate Red Cross emergency response team, but 18 weeks later, she took up a high-level health delegate role in Jakarta working to help coordinate the many Red Cross and Red Crescent national societies working on the rebuild and restoration. During her year there, the region also was hit by the Yogyakarta earthquake, which killed around 6000 people, injured tens of thousands, and left an estimated more than a million homeless. Also that year was the second Bali bombing … Bombs were also a theme of her mission in Iraq. “I was there when there were plenty of explosions going off,” says Askew, sounding remarkably unperturbed by the memory. With each bombing or explosion killing tens of people and injuring potentially hundreds, understandably hospitals struggled to cope and soon ran out
of IV fluids and other essentials. Her role was working with the Red Cross’s biggest medical warehouse on the logistics of helping restock hospitals with IV fluids, antibiotics, bandages, gauze, and other emergency and essential supplies.
Terrible consequences of female circumcision Her latest mission was back to Sudan – her fourth mission there – but this time to the north where the more traditional rural villages still practice full female circumcision (also known as FGM or female genital mutilation) with ‘terrible consequences’. Askew says many of them are very young and they start having babies young, go onto obstructed labour, and if they don’t die, they end up with a fistula. Her last mission involved flying woman from rural areas of South Darfur to North Darfur to see whether the fistula could be surgically repaired. “We had 18 young women that were just leaking, pouring out urine really, and only two of them were successfully repaired,” says Askew. “So it’s a terrible outcome for the young women because they are ruined for life.” “They call it the three sorrows of women: the circumcision, the wedding night, and the childbirth. Can you imagine that?” Askew says sadly it is the village grandmothers and the aunties who ensure FGM continues, believing the
tradition must continue so the women are clean.
Packing bags again after a year of being Grandma Despite a decade working in some of the world’s trouble spots, Askew describes herself as a basically a homely kind of person. She loves her family, her garden, and her home (which incidentally her 87-year-old mother lives in and looks after during her time away, including until just recently mowing the lawns). This time, she has spent a whole year back in New Zealand to be with her son and daughter-in-law leading up to the birth of her grandson, Felix, and she was working for the Cancer Society when the announcement was made of her Florence Nightingale Medal. With Felix and his parents happily settled, she is now packing her bags in readiness to flying out to Geneva in late June on the way to her seventh mission – this time to Lebanon working to help the region support the Syrian refugees who have flooded across the border. She is not looking forward to facing her old – enemies temperature and tiredness – leaving a southern hemisphere winter for 35 degrees plus in Beirut which plays havoc with her biorhythms as she adjusts to a new time zone and climate. But a decade on, she still loves the work too much to let such personal discomforts put her off. “It is just such fantastic work.”
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People, practice & policy PATIENT SAFETY
Sandy Blake
Push to reduce falls In the last two years, 170 patients fell while in public hospital care and broke their hips, and 22 of those people died earlier than expected. FIONA CASSIE talks to Sandy Blake about the new national drive to reduce falls and her pilot of a bedside electronic falls risk assessment tool using TrendCare.
PATIENT FALLS IN HOSPITAL can be devastating, expensive, and preventable. It is a given that district health boards want to reduce falls, which are the most commonly reported serious and sentinel event in our public hospitals. Sandy Blake, clinical lead to the Health Quality & Safety Commission’s Reducing Harm from Falls programme, says a survey of the 20 boards found not one region taking the same approach. “They are all different. There’s great variety. Everybody says they have an evidence-based policy and no two policies are the same,” says Blake. From now on, one common component of falls policy – carrying out falls risk assessments – will be used as a quality marker and the percentage of elderly hospital patients receiving falls risk assessments will be reported back on a six-monthly basis (see sidebar). Data will also be collected on how many at risk patients receive an individualised care plan and how the country is doing in reducing the harm and cost from falls. When seconded into the falls programme role a year ago Blake visited hospitals around New Zealand spending some time on the ward with nurses and found lots of good ideas about reducing falls but yet again no one risk assessment or care planning tool was quite the same. Some tools spat out the same falls risk rating and care plan whether the patient was at risk because of Parkinson’s disease or only having one leg. Some tools also resulted in lengthy ‘tick-box’ style care plans that were hard for the nurse to scan and find the individually pertinent advice, like ensuring a patient’s artificial leg was handy. One of Blake’s responses was to research and write a paper suggesting evidence-based guidelines for falls risk assessment and care planning (to be released shortly and discussed at a workshop in July) and also to use her findings to develop an electronic falls assessment and planning tool that is shortly to be piloted at several DHBs including her own. The falls programme is also supported by a cross-sector, multidisciplinary expert advisory group and other aspects of the programme include promoting DHBs sharing the learning from their analysis of falls reported to the commission as serious or sentinel events. “The prevention of falls is a tough nut to crack, and I’m not saying we’ve got all the answers,” says Blake. “But I certainly know from my experience that if we had a bit more standardisation, and we shared the things that really worked well with each other, we’d have more of a chance of keeping our patients safer.” Blake returned to New Zealand three years ago to become the director of nursing for Whanganui DHB after 22 years nursing in Queensland, with her last job being a state-wide nursing director role for patient safety. Using her patient safety background, she has analysed the current risk assessment tools in use, plus the latest international evidence, to draw up the core components of what she believes falls risk assessment and care planning should involve, including room to 28
allow a nurse’s own clinical judgment and for patient and family input. She says risk assessment is aided by having a tool that asks the right questions, so she has drawn up evidence-based guidelines of what an effective risk assessment tool should cover including a patient’s medications, history of falling, and mobility. The risk assessment also needs to lead to a individualised care plan to meet and highlight the patient’s own unique set of needs. Blake argues that the suite of good care that every patient should expect – whether at risk of falling or not – should not need to be separately listed in every care plan. “Things like having their call bell within reach, having their environment uncluttered, having their personal stuff within reach, knowing the way to the toilet, and having their bed at the right level for them,” says Blake. “Those are things that I would expect, and any director of nursing should expect, are the standards expected for all patients.” Soon 16 out of the 20 DHBs will be using the patient acuity software TrendCare and Blake saw the potential for including a standardised falls risk assessment process within TrendCare. The resulting electronic tool is to be piloted at Whanganui and MidCentral DHBs. Wearing her director of nursing hat, Blake believes strongly in having patient and family involvement in the assessment process and so is wary that the shift from a paper tool to an electronic tool may result in nurses doing the risk assessment at the nursing station computer rather than at the patient’s bedside. She is holding off starting the pilot at Whanganui until she has the wireless technology and laptops on trolleys that will allow bedside assessments. But she is hoping this winter will see the pilot begin and is also looking forward to workshopping and debating her paper’s proposed guidelines as another step in the patient safety and quality campaign to reduce the harm from falls.
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Open for better care: NATIONAL PATIENT SAFETY CAMPAIGN Open for better care is a national patient safety campaign co-coordinated by the Health Quality & Safety Commission and aligned with existing patient safety initiatives. It was officially launched on May 17 by associate health minister Jo Goodhew and focuses on reducing harm in the four areas of: falls, surgery, healthcare associated infections and medication The first area of focus is the prevention and reduction of harm from falls. Falls resources developed for the campaign can be found at: www.open.hqsc.govt.nz/falls/ publications-and-resources DHBs’ first baseline data of how well they are achieving the campaign’s quality and safety markers were due to be released in late June and from here on in will be reported six monthly. The quality marker for falls will be the percentage of patients 75 years or older given a falls risk assessment with the desired level being 90 per cent or more.
People, practice & policy OPINION
Jo Ann Walton
When the ‘caring’ profession
IS PERCEIVED NOT TO CARE JO ANN WALTON reflects on the state of nursing in the wake of the United Kingdom’s damning Francis Inquiry and the need to reiterate respect, kindness, and dignity as nursing core values.
SOME HEAVY THINGS HAVE been weighing on my mind in the last few months. Along with all nurses who know about it, I have been thinking about the disaster at MidStaffordshire in the United Kingdom, where a catastrophic failure of care led to the neglect, abuse, and death of patients, a major national inquiry, and a crisis of faith in the NHS health services – particularly in the ability of nurses to fulfil the role expected of them by the public at large. If you do not know about Mid-Staffs, I urge you to find out about it. Just type ‘Francis Inquiry’ into your search engine and you will find more than you could want to read. It is distressing and upsetting reading. But in spite of this, I think it is important that we face the unpleasantness. There are things we can learn and questions we need to ask ourselves about the state of nursing in our times. What kind of questions? Well, some nurses are asking “Could this happen here?” Others might ask “What makes us think it is not?” Are there ever lapses in our (individual or collective) professional behaviour? Have you witnessed behaviour, demeanour, attitudes, or acts of omission or commission that were not at the highest level of professional comportment? I think we all have. Which is not to say that everything is bad; not at all. The trouble is that it takes so little to destroy public trust and so much to gain it back. Whenever we face bad press, it is easy to become defensive. Of course none of us wants to see nursing represented in a bad light. Not one of us entered this profession intending to harm, to ignore, or to wound. Our fundamental desire is to help other people, to alleviate suffering, and to heal. And yet sometimes things go wrong – and when things go wrong, they can go very wrong. Devastating effect of ongoing small neglects Alongside the official report of the Francis Inquiry, I have been reading the account of a woman whose elderly mother received shockingly poor care at Mid-Staffordshire Hospital. Julie Bailey’s book From ward to Whitehall tells the story of her mother’s hospitalisation and eventual death, her family’s struggle to comprehend what was happening to them, and then, over a period of years, to reveal a culture of denial that pervaded the NHS.* Along with others, Julie Bailey helped to bring the whole situation to light, to precipitate the Francis Inquiry, and thereby to help us look again at what is happening in our health care systems. I think we have much to thank her for. Julie’s story is one of fear. I find it hard not to feel ashamed when I read of the appalling sequence of small offences against professional care that led, in the end, to the shocking neglect faced by patients and families in this system. The real horror to me is that so many of the incidents are in themselves small, but together, their effect is devastating.
It is clear that the wards at Mid Staffordshire were understaffed. Nurses were too heavily burdened. Things were too busy. But as we all know, a shower missed on one shift might be compensated for. A shower missed for days on end leads to discomfort, skin breakdown, and infection. A bell not answered for a few minutes is distressing for a patient. A wet or soiled bed because no help is forthcoming is shameful, demoralising, and unacceptable. And so it goes on. In her book, Julie Bailey refers often to nurses avoiding eye contact, to her own fear of confronting poor care or even asking questions lest nurses’ responses be cruel, blaming, and vengeful. This is not what we chose for our professional image. And indeed, the publicity is hurting our own. A wonderful video clip tube shows Molly Case, a second year student nurse at Greenwich University reciting a poem relating her distress at the poor publicity nursing is receiving at present in the UK. It is well worth a watch: http://www.youtube.com/ watch?v=XOCda6OiYpg By now you may be saying, well, this is not about us here in NZ. And no, it isn’t, but could it be? What can we do to make sure that our proud reputation as New Zealand registered nurses continue to stand? How can we make sure that we continue to bring bright and brave young nurses like Molly into our ranks? And that the trust the public put in us is warranted and maintained?
count: that respect and dignity and kindness and gentleness are core values of our profession. To answer bells promptly, to come back when we say we will, to guide the lost visitor, to never say “that’s not my patient”. To practice remaining calm in the face of chaos, to look with careful regard at our patients and their family members, to speak with them honestly, to show them that we are effective and capable and that we take their concerns seriously. They need to know that we are on their side. Family members want to be included and to help but they will step aside, when we need them to, if they trust that their precious patient is safe in our hands. Is this all just a saccharine solution? I don’t think so. I am not suggesting for a moment that we don’t also need to work on remediating systemic dysfunction, uncovering workplace injustice, lobbying for institutional and national political change. Saving the planet and stopping war works for me, too (seriously). But these are different matters. If we are to continue the proud traditions of nursing and maintain public trust, we need also to demonstrate to the healthy, the ill, the vulnerable, the worried, the wounded, the dying, and their families that nurses are there to witness, to help, and to serve, not only in times of crisis but also in the little everyday things of life. That is what professionalism means.
Reclaiming kindness and dignity
*Julie Bailey, From ward to Whitehall: The disaster at Mid-Staffs published in 2012 by Cure the NHS. Jo Ann Walton is Professor of Nursing at Victoria University of Wellington and an elected member of the Nursing Council.
I want to revisit our ideas of professional behaviour. To reclaim the attitudes, motivations, and altruism that have been part of the nursing ethos for centuries. To remember that the little things
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People, practice & policy
MICHAEL McILHONE
OPINION
Nursing hours of practice:
HOW LONG IS TOO LONG? Christchurch nurse MICHAEL McILHONE reflects on just what is a typical nursing working day and asks when working long hours becomes counterproductive both personally and professionally.
LABOUR DAY COMMEMORATES the struggle for an eight-hour working day. New Zealand workers were among the first in the world to claim this right when in 1840 the carpenter Samuel Parnell won the right to work an eight-hour day in Wellington. Labour Day was first officially celebrated in New Zealand on 28 October 1890, when several thousand trade union members and supporters attended parades in the main centres. For many years, the eight-hour working day became entrenched in the New Zealand employment culture. There were always exceptions, particularly in the medical and nursing professions. It wasn’t uncommon for our medical colleagues to find themselves working up to 16-hour days and 80-hour weeks. Fortunately the length of shifts and the number of hours worked during a week have been reined in by active professional bodies. Nursing has faced its own challenges over the years and now it is not uncommon to find many nurses in acute care areas such as Emergency, ICU, Paediatrics, and Neonatal working 12-hour shifts as a matter of personal choice. There are two very opposed camps in the effectiveness and safety of working 12-hour shifts and examples of this are well documented in the international literature (most recently by an article by Stimpfel this year looking at the impact of shifts on paediatric outcomes). Over the past couple of years, Nursing Review has been publishing a series of “A day in the life...” articles that I have found to be very interesting and also, at times, providing relevant and useful insight into areas of nursing that I have little knowledge of. It appears to be an excellent avenue for nurses to extol their profession, and indeed, their expertise. Some of the profiles have got me thinking, and in line with my opening paragraphs, I hope to generate some discussion and opinions relating to the length of shifts and working hours that nurses currently undertake. I don’t want to get into the argument relating to 12-hour shifts as I do accept that this is an individual choice driven by both the culture and requirements of individual clinical areas (while at the same time recognising that legally, the eight-hour shift is the default if an individual doesn’t want to work 12 hours). But I have noticed a ‘creep’ by some nurses, particularly in advanced nursing roles, to work well over the 12-hour threshold. An example of this was demonstrated by a senior nurse who arrives at work at 6:15 am and leaves at 8:00pm. This equates to nearly a 14-hour shift. Of course there will always be emergencies 30
and situations that require us to go the ‘extra mile’ but neither of these reasons were apparent in this “Day in the life” profile. It appeared to be a routine day. My question is what sort of message do senior nurses who work these kind of hours give our colleagues and our employers? Is working extra long hours disguising the need that the organisation really requires more staff to cover the role? Is there a blurring of boundaries to the point that the nurses consider themselves so integral to the role that if they don’t stay longer and complete the task(s) then nobody else can or will? Is there an element of competitiveness? Or is a statement being made that “I can match any profession in the length of hours that they work”? Most importantly, how much does working extended hours impact on senior nurses’ work/life balance? As younger nurses graduate and enter the profession, they look at senior nurses both as role models and mentors. We highlight the need for professional boundaries and a good work/ life balance; we are also attempting to make advanced clinical nursing roles attractive and sustainable. I’m not sure that consistently working extended hours sends the right message. In the immediate aftermath of the February earthquake in Christchurch 2011, I was part of, and witnessed, hundreds of nurses across the Canterbury health sector consistently working extended hours to maintain a health system and achieve our number one goal of providing
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healthcare to our community. This in some cases went on for several weeks (aged care springs to mind), and I would expect no less either from myself or my colleagues. However, as soon as we were able to, it was important that the length of time that nurses spent at work was curtailed to pre-quake levels. It is all about sustainability and that elusive ‘work/life’ balance. Reed in the January edition of the American journal Nursing provides further discussion points and several steps to safety when considering healthy work hours. Although catering for the American nursing profession, many of the messages will resonate with a New Zealand audience. So what do you think is a healthy working day? And how long is too long and why? .
Author: Michael McIlhone, RN, PGDipHealSci, Canterbury District Health Board *Full references available on request
A round-up of national and international nursing news
For the record NEW PHO AGREEMENT SEEN AS LOST OPPORTUNITY BY FIONA CASSIE THE LACK OF NURSES around the table in negotiating the new PHO agreement – coming into force July 1 – doesn’t make sense, said Cathy O’Malley (left), the deputy director-general of health leading the negotiations. Frustration at having no nurses at the table when primary health organisations (PHOs), district health boards, and the Ministry of Health negotiated the new agreement prompted the NZNO College of Primary Health Care Nurses and College of Nurses Aotearoa to write to the Ministry about their concerns. O’Malley, the Ministry of Health deputy director general, for sector capability and implementation said the Ministry had involved nurses in the pre-negotiation discussions but it was not its role to dictate to PHOs who should be on their negotiating team. “It was interesting there were no nursing participants, and I think what that indicates really is the state of play of nursing leadership at the local level,” said O’Malley. She agreed it “didn’t make sense” not to have nurses involved in a service where nurses played a significant role. “I think that is something that needs to be discussed more locally. Nurses have a significant role to play… and where that’s not happening, you need to look at why that’s not happening.” Meanwhile, the Ministry had invited 15-20 nurses to be involved in a multidisciplinary meeting in June to discuss the development of the new primary health care performance framework. College of Nurses executive director Jenny Carryer (left) said to nursing organisations it was “very significant” that 13 years after the Primary Health Care strategy that PHOs still do not recognise the need to put nurses around the decision-making table and still had not created appropriate positions so there were nurse leaders who were obvious choices to be at negotiations at that level. Rachael Calverley (left), a primary health care nursing leader and board member of the College of Primary Health Care Nurses, said the college had been trying for many years to encourage nurse involvement in similar negotiations. “It’s an ongoing historical frustration that we tend to come into the discussion later on down the line, when nurses are quite capable of being able to articulate at high-level discussions.”
Jane O’Malley (left), Ministry of Health chief nurse, said her office obviously believed PHC nurses were critical to such discussions and one of its roles was suggesting appropriate nurses to be involved in Ministry policy development. “Not only is it obvious that nurses are the largest workforce but also they can provide a nursing lens on health services work and how they can be improved.” She said her office took all opportunities to encourage talks, like the alliance agreements with DHBs and the development of the new PHC performance framework, to include nurse leaders.
No radical change under new agreement to nurse ‘barriers’
The thrust of the new PHO agreement was to get PHOs and DHBs working much more strongly and collaboratively together in planning services and service design, said Cathy O’Malley. Asked whether the new contract would reduce barriers to or promote nurse-led services in primary health care, she said the Ministry wanted to get away from silo-ed funding streams or “attaching specific money to specific professional groups”. She also said the current barriers to the development of PHC nursing services fell into two camps – the real barriers and perceived barriers. The real barriers included a number of pieces of legislation and regulation that referred specifically to medical practitioners, which had implications for what nurses could be paid for, but a bill to amend that legislation was a step closer to being introduced to parliament. Another real barrier was nurses being unable to claim the general medical subsidy (GMS) for non-enrolled patients and this was also being looked but GMS funding was “miniscule” compared to first contact capitation funding which nurses could access. “The misconception is around what nurses can or can’t do with capitation funding,” said Cathy O’Malley. “There is absolutely no barrier to nurses enrolling patients or being paid capitation money.” “There is nothing in the contract that excludes nurses from participating,” she said. “I’m not at all saying that it’s an easy road for nurses out on the ground – all I’m saying is that it’s not the contract that is the problem.” Rosemary Minto (left), chair of the College of PHC nurses, said while the new flexible funding pool provided some opportunities for change the “current private business model in general practice is still a substantial barrier to any big changes that would positively affect health service delivery for patients”.
New PHO Agreement basic facts »» The biggest government funding source for general practice – the capitated ‘first level service’ funding streams– remain unchanged. »» After July 1, the four funding streams for Care Plus, Services to Improve Access, health promotion, and management services (making up about 11 per cent of PHO funding) can be bulk-funded as part of a flexible funding pool. »» PHOs have to negotiate alliance contracts with their local DHB in a similar model to those used under the Better Sooner More Convenient (BSMC) business cases. »» Once completed, PHOs and DHBs can negotiate new service models for areas like long-term conditions, which may include additional funding and resources from the DHB. »» The agreement will also include a new integrated performance and incentive framework currently under development with a multi-disciplinary reference group meeting to discuss the proposed framework in June.
NEWS BRIEFS New graduate job data online Nearly 90 per cent of successful new graduates got jobs in their first choice district health board, according to analysis of the new job hunting clearing house. A breakdown of the job hunting choices of the November 2012 graduates, which DHBs received the most applications, and graduates from which regions were the most successful has been released on the Ministry of Health website. The analysis showed that nearly half of graduates were only prepared to do job-hunting in boards in the region they trained in. Nursing school cohorts success in finding jobs ranged from 40 per cent for one school and 81 per cent for another, with the Ministry saying the results should not be read as a “league table” as much of the difference was due to the number of jobs available in the local DHB. The data also showed that most DHBs tended to employ local graduates who undertook their final clinical placement with that DHB, with the exception of Waitemata DHB (who only took 40 per cent local graduates) and small DHBs like West Coast and South Canterbury without local nursing schools. The DHBs taking on the most new graduates as a proportion of their existing nursing workforce were Tairawhiti and NelsonMarlborough, and the DHBs taking on the least were Auckland and Wairarapa. Read more at: bit. ly/12cwCnD Research highlights risk of sharing drinks Research by Victoria University has found that the bacteria causing meningitis can survive on drink bottles and glasses for up to a week. The research has shown that meningococcal bacteria can survive outside the body for periods ranging from four hours to seven days, and that environmental conditions are a key factor in survival rates for the bacteria. Using artificial saliva made and donated by the University of Otago’s School of Dentistry, survival rates were tested for a selection of strains on both plastic and glass, including the strain causing the 1990s and early 2000s epidemic. It was found that the bacteria of every strain that was tested could survive drying, in one case for up to 10 days. The bacteria lasted significantly longer on glass than on plastic.
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For the record NURSING FEEDBACK SOUGHT EARLY JULY ON CONTROVERSIAL MERGER PROPOSAL By FIONA CASSIE THE NURSING COUNCIL has “reservations” about a proposed merger proposal and is releasing a consultation document in early July seeking nursing and other stakeholder feedback. Carolyn Reed, Nursing Council CEO, said obviously the council had “some concerns” with the proposal and these would be highlighted in a consultation document currently being drawn up. The detailed business case to create a shared services organisation (SSO), including regulatory
functions, for the Nursing Council and the 15 other health professional regulatory authorities (RAs) was released in April and discussed at the Council’s June meeting. The business case follows Health Minister Tony Ryall backing a Health Workforce New Zealand proposal for the RAs to partially or fully merge, which has divided the RAs into two camps. Reed said the Council had received legal advice that it was required to carry out meaningful consultation on the proposal before making a decision. “It can’t be a Claytons consultation. It needs to be a real consultation where people are given all the information so able to give their feedback.” She said it had also received a risk assessment on the proposal and that would be included in the consultation document to be released shortly after the Council’s meeting on July 4. The Nursing Council and five other RAs last year commissioned KPMG consultants to draw up a model for a ‘shared business unit’ to deliver the nonregulatory functions of the six RAs. At least two of those RAs, the Psychologists Board and the Midwifery Council are also consulting on the SSO proposal. The Medical Council, which headed the other camp, declined to comment on whether it made a decision at its June meeting or whether it would be consulting on the proposal. The Psychologists Board has already released its consultation document in which it says its concerns about the SSO proposal included that it was not built on robust evidence, it might lead to processes taking longer, costs could increase, significant risks had not been addressed and the potential loss of relevant profession-specific knowledge.
Basic facts on merger proposal
»» One single registrar for all the health professions. »» Nursing Council of New Zealand and the 15 other regulatory authorities (RAs) to become shareholders in a limited liability company or SSO (shared services organisation). »» Nursing Council, representing the largest workforce, will have same votes as smallest RA. »» Nursing Council and other RAs would each be headed by a deputy registrar employed by SSO. »» The structure and role of the Nursing Council’s and the other RAs’ governing councils or boards remains unchanged. »» Regulatory and corporate staff working on nursing regulation and policy would be employed by SSO and not Nursing Council. »» $4.8 million transition costs would be funded from assets and reserves of the 16 RAs. »» A common IT platform to be adopted by July 2015 at cost of $2.3 million. »» Estimated savings of $3.5 million a year from 2017 onwards. »» RAs cannot be forced to become shareholders without amending the current legislation. »» If RAs accept the proposal the SSO could come into effect on January 1 2014.
LETTER TO EDITOR:
Green nail polish? Thank you for a most informative journal. I did find it strange, though, that following the excellent article Talking about Safe Practice (RRR professional development article in Vol 13 Issue 2 2012/2013) there was a picture on page 15 of what appears to be a nurse holding a clipboard and she is wearing bright forest green nail polish. I know in the past there has been some debate on the pros and cons of wearing nail polish in the workplace as it may be a source of infection if chipped, which may affect patient safety, but I am unsure of what DHB infection control policies state now … they may have changed. If not, the picture may be sending the wrong message. It is definitely mentioned as a consideration in the infection control policy we have in practice. So in the spirit of the final paragraph of the article “… when you think about how many lives we touch every day, in ways great and small – we should have no difficulty in saying something as simple as ‘Have you washed your hands?’ to a colleague”. I would add: “Have you checked your nail polish is not chipped?” Continue the great work! Penny Nel, Nurse Manager, Johnsonville Medical Centre Ed: Shelley Jones, the author of the article, was not involved in the selection of this image (and says she would never endorse green nail polish!). She notes that the 2009 WHO Guidelines on Hand Hygiene in Health Care state that nail polish is not permitted in ‘surgical hand preparation’ and cites evidence that chipped nail polish may support the growth of larger numbers of organisms on fingernails. Production: Well you do learn something new every day! Athough I must add that the pic was in an advertisement for RRR and not necessarily intended for the content of that particular RRR.
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Nursing Review series Long-Term Conditions & Aged Care 2013
NEWS BRIEFS Nursing ePortfolio to be rolled out The successful pilot of an ePortfolio for nurses will soon see it rolled out to a wider nursing audience. The pilot by Ngā Manukura o Āpōpō was initially aimed at Māori nurses who did not have access to an established professional development and recognition (PDRP) programme. It aimed to test the concept of an open source ePortfolio system. A wider public launch is planned for this winter and more information can be found at www.ngamanukura.co.nz Kiwi nurse in Oz honours list
New Zealand Red Cross nurse Andrew Cameron was honoured in the Australian Queen’s Birthday Honours list for services to nursing. The Australian-based nurse received the Medal of the Order of Australia (OAM) particularly for his work with the International Committee of the Red Cross. His missions have included working in Kenya, Sudan, Yemen, South Ossetia and most recently Afghanistan. In 2011, he received the Red Cross’s highest nursing award – the Florence Nightingale Medal. (Check out Nursing Review’s profile on Cameron online at: bit. ly/15ySgtB) New ICN president Canadian nursing leader Judith Shamian was elected the 27th president of the International Council of Nurses at the recent ICN congress in Melbourne. At the congress, the Chinese Nursing Association and the Palestinian Nursing Association were welcomed as new members.
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Nursing Review series Long-Term Conditions & Aged Care 2013
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