FOCUS: Learning & Leading
Nursing Review AUGUST/SEPTEMBER 2015/$10.95
New Zealand’s independent nursing Series
Practice, people & policy
Nursing the rainbow NP training scheme
A DAY IN THE LIFE OF a MERCY SHIP NURSE
Q&A
with Michael McIlhone
Learning & Leading Career path tales Comparing graduate incomes
Battling bottle stores Peer group supervision
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LETTER FROM THE EDITOR CNS numbers surge, NP growth slower If I’ve learned anything from reporting on nursing over the years, it’s that many nurses are multitaskers extraordinaire. They juggle demanding workloads: raising kids and completing postgraduate study; and emerge with new skills to enhance their nursing practice and the letters PGDip, MN or even PhD after their names. Our health system is all the better for these nurses managing to apparently jam 25 hours into a 24-hour day (see cover pic caption below for a shining example). Health Minister Jonathan Coleman recently released statistics showing that the number of clinical nurse specialists in the 20 district health boards has risen from 744 in 2007 to 1449 in 2015. A few weeks earlier he announced government funding for a dedicated NP training programme in 2016 (see p.29) to support an extra 20 nurse practitioner candidates and help boost the about 145 NPs actively practising in 2015 (compared with 39 NPs in 2007). All of this begs the question: why has the number of clinical nurse specialists (CNS) jumped by 700 between 2007 and 2015 but NP numbers have only increased by around 100? It’s not as if there’s a lack of nurses tackling the postgraduate study required. Figures supplied to Professor Jenny Carryer, a member of the government’s nursing workforce governance group, indicate that there are now close to 1000 nurses with clinical master’s degrees, which is the prerequisite qualification for becoming an NP. Of course, not all clinical master’s graduates were on the NP career path but, anecdotally, quite a number were. So what has been the sticking point? Some DHBs preferring CNS over NPs? Seeking NP registration too tough a hurdle? Or are some just biding their time? Carryer thinks a number have just “drifted away” from the notion of becoming an NP after becoming discouraged. “And yet many of them are absolutely expert, senior clinicians who we could do well to use.” She says she has been approached by a number of master’s graduates, whose prescribing practicum is now out of date, inquiring about the new NP training programme as a chance to reboot their NP dreams. It will be interesting to see whether a clearer pathway for NPs will see more of those 1449 CNS transitioning to become NPs in years to come. Fiona Cassie editor@nursingreview.co.nz
www.nursingreview.co.nz
Inside: FOCUS: Learning & Leading 4
LEADERSHIP: practice nurse KAREN CARPENTER on battling a bottle store
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CAREER PATHS: five nurses share their personal career journeys to date
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Sharing the load: HELEN SHAW-BROWN on peer group supervision
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LIBRARIES: what modern medical libraries offer nurses
17
Where are our nursing leaders? JO ANN WALTON says right beside you
18
RESEARCH: graduate incomes – does nursing stack up?
19
Postgraduate funding steady for 2016
20
Update on PHYSICIAN ASSISTANTS following positive pilot
22
NETP: the new graduate programme is turning 10
25
JED MONTAYRE on the place of critical thinking in NURSE EDUCATION
RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe
Practice, People & Policy 28
OPINION: KIM CARTER on nursing patients across the sexuality spectrum
29
Launch of new NURSE PRACTITIONER training programme
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OPINION: Responses to last edition’s FAD DIETS article
Regulars 2
Q&A Profile: Pegasus Health director of nursing MICHAEL McILHONE
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A day in the life of… Africa Mercy nurse SUE CLYNES
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College of Nurses: NGAIRA HARKER on fostering the Māori nurse educator workforce
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Evidence-based Practice: CYNTHIA WENSLEY on ZINC and COLDS
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Wider distribution for Nursing Review
Free copies of Nursing Review are now sent directly to every ward at every major hospital. If this is your first time reading Nursing Review, contact editor Fiona Cassie and tell her what you think (especially if you have news or ideas to share!). These free copies will have all the features and opinion Nursing Review is known for, but only subscribers will receive print and online access to the RRR professional development activity. To get your personal copy (including RRR), go to: www.nursingreview.co.nz/subscribe
Multimedia platform for nursing
Nursing Review is a genuine multimedia publication, with five print editions and our recently revamped website, which contains 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: To’a Fereti is a CMDHB clinical nursing director in charge of 600 nurses, is studying simultaneously for two PGDips (before beginning her second master’s degree) and is a single parent of four children aged 8 to 17. She also recently became the second ever Pasifika nurse on the Nursing Council. Read about her ‘accidental’ career path on p.6. PHOTO CREDIT: Dionne Ward for Nursing Council of New Zealand. 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).
Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ Editor Fiona Cassie production Aaron Morey Advertising & marketing manager Belle Hanrahan Publisher & general manager Bronwen Wilkins images Thinkstock
Nursing Review
Vol 15 Issue 4 2015
NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6141, New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 © 2015. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014
Errors and omissions: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.
Nursing Review series 2015
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Q&A
Michael McIlhone
JOB TITLE | Director of Nursing, Pegasus Health LOCATION | Christchurch
Q A Q A
Look after our new grads, make them welcome, learn from them but more importantly mentor and coach them, then stand back and watch our health service truly blossom.
Where and when did you train? Christchurch Hospital School of Nursing and was registered in December 1981.
Q A
What other qualifications do you hold? Postgrad Diploma in Health Sciences, Nursing Council Competence Review Group member for past five years, recently appointed to Health Practitioner Disciplinary Tribunal, Canterbury DHB clinical board member and member of the Canterbury Clinical Network’s Alliance Leadership team.
What do you think are the most important personal characteristics required to be a nurse? A sense of humour, don’t take yourself too seriously and strong sense of social values The ability to respect and appreciate the positives in each of us but at the same time recognise that we’ve all got a few rough edges that we may not be able to smooth out, so learn to live with them.
Q A
When and/or why did you decide to become a nurse? I was involved with the St John Ambulance Brigade from the age of six until my mid-teens. As a 17-year-old I was at Lancaster Park as a “zambuck” for the Lions playing the All Blacks. My mother was an enrolled nurse so was always supportive, but a key influence was essentially getting the OK from my secondary school careers advisor back in 1975 that nursing was a “good option” for a man. Actually all my secondary school teachers were very supportive… maybe so I’d continue to be the school’s unofficial first aid expert.
Q A
What was your nursing career up to your current job? I started in the emergency department, became a public health nurse and then in 1988 moved into neonatal intensive care. This lead to a 20-year career in neonates, which took me to Saudi Arabia (where I married my wife Elaine), Oxford (England), Auckland, back to Saudi Arabia, London, and then back to Christchurch, with a variety of positions. In 2008 I became the nursing director for Women and Children’s Health in Christchurch, including an 18-month secondment to Planning and Funding. I was appointed as director of nursing (DoN) for Pegasus Health in November 2014.
Q A
So what is your current job all about? The DoN is responsible for professional and clinical nursing leadership, providing a strategic vision and direction for nursing in primary healthcare teams, particularly in general practice. Also leadership and oversight of Pegasus Health’s nursing staff, who provide a number of services to support general practice, including education, professional development programmes, and postgraduate support and advice. Canterbury has a truly integrated health service that is developing all the time so collaboration and consultation at a senior nursing level across the region is vital and a priority. As one of the largest primary health organisations (PHO), it is important that this collaboration extends around
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Q A New Zealand via various forums. I am a member of the Pegasus Health Senior Leadership team so can influence not only nursing practice but also business practice within the organisation. Another aspect of the role is to ensure nursing is not working in isolation and is part of the multi-disciplinary team in primary health care.
What do you do to try and keep fit, healthy, happy and balanced? This changes with age but currently squash (I have an ongoing, 37-year grudge match with my brother). Listening to music, music and more music. I’ve been a vegetarian since I was 21 and I love to get out for a tramp and enjoy the outdoors. I should swim and cycle more – that’s the plan for the next few months. Running is good for clearing the mind and I am a Crusader/Canterbury/All Black fan for life! A group of us ‘male’ nurses that trained together meet once in a while for a real ale or two: puts our careers and lives in perspective and is good for the soul!
Q A
Q A
Michael McIlhone
What do you love most about being a director of nursing? This is the culmination of 36 years’ nursing experience! The people I have met and worked with over the years, the people who have coached and mentored me, and the people who have educated me still remain firmly in my mind and memory, so my love of this position is due to that team that got me here. I work with a brilliant and visionary team who always keep the health consumer as their priority and I get to be a leader – life is good!
Q A
What do you love least about being a DoN in 2015? The life of a DoN is full of challenges, as it should be, so nothing really springs to mind. Take the good with the bad – if 75 per cent is good then the other 25 per cent is just to be worked on.
Q
If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? Unilateral courage of conviction for all nurses to stand up and articulate their qualities and not get stuck on the minutia. Equality and equity should be everyone’s focus, so equity and equality when it comes to the allocation of Health Work Force New Zealand funding would be a great start!
A
What piece of advice would you give new nursing graduates? Long hours at work are sometimes necessary, but don’t make a habit of it, look for the balance and don’t make either your life or your job more important than the other. Laugh lots!
Q A
What keeps you sane, busy or on task outside of work? Our native garden and the native birds it attracts. Had our first tui last summer; bellbirds and fantails are regular visitors. My wife’s vegetarian cooking – to die for! Exercise, music and good coffee is a must.
Q A Q A
Which book is gathering dust on your bedside table? There isn’t one. If I can’t get into a book, I stop reading it and find another.
What are you reading at present? I’m currently reading Ralph Peer and the making of popular roots music, by Barry Mazor.
Q A
What are three of your favourite movies of all time? The Fifth Element (Luc Besson), High Fidelity, and Romeo and Juliet (the Baz Luhrmann version).
A day in the life of ...
a Mercy Ship nurse
NAME | Sue Clynes JOB TITLE | OR Nurse/Maxillofacial team leader LOCATION | On board Africa Mercy
5.45
AM WAKE My alarm chirps and I quickly turn it off before it disturbs my husband John. I like to spend some time in prayer before I start my day. I then shower, get dressed, and head up to breakfast with John and friends in the dining room. I live on board the Africa Mercy, which is a hospital ship giving free operations to the poorest of the poor. At the time of writing this we are working in Madagascar. There are approximately 450 people from all around the world living on board so mealtimes are interesting and fun. After breakfast I head back to my cabin, take my antimalarial tablet, clean my teeth, put my hat on and leave for work, which takes me about 30 seconds as I just have to walk down one staircase.
7.45
AM START WORK I like to get to work before everyone else so I can call into the ward and introduce myself to the patients and get the theatre set up in plenty of time. I turn the bed warmer on, and check the theatre lights and the suction unit. By then other nurses start to arrive so I can start to delegate tasks. Most staff are experienced theatre nurses but the majority only come for two to four weeks so have to be guided and supervised. It’s quite exhausting constantly teaching. The surgeon I work with, Dr Gary Parker, is the kindest person I have ever met. He has been on the ship for 28 years and brought up his family onboard. I have been the maxillofacial team leader for 18 months and at the end of July will have been on the ship for two years. I trained at Middlemore Hospital 40 years ago, leaving in 1981 to bring up my children before returning full-time as a theatre nurse and was a Tauranga Hospital theatre nurse for 10 years before joining the ship.
8.00
AM TEAM BRIEFING Staff gather for the team briefing on the three cases on today’s theatre list. The first patient is a 61-year-old man who had an anterior mandibulectomy three months ago to remove an ameloblastoma (a benign tumour originating from the enamel on teeth). He is coming today to have an iliac crest bone graft (ICBG) to cover and protect the titanium plate we used to reconstruct the mandible. This surgery takes about three hours.
In the afternoon I have a chance to check and restock plating sets with screws and drills. I have a long tea break during the parotidectomy to make up for my short lunch. I also start thinking about a recent shipment of boxes of sutures that need to be stored somewhere tomorrow.
5.15
PM OUTREACH BEGINS I often get back to our cabin before John so I check my emails and bank account. We usually meet in the dining room. Tonight is Tuesday night so it’s ‘Africa night’. Chicken with Sake Sake – yum!
6.00 Sue Clynes The second case is a 23-year-old with a parotid tumour for parotidectomy and the third case is an incisional biopsy of a maxillary tumour. This patient is also 23 and has quite a large tumour that she says first appeared 10 months ago. We are all hoping that it was longer than just 10 months because otherwise her prognosis is not very good… Today we have two maxillofacial medical students from Antananarivo (Madagascar’s capital city where the country’s only maxfax surgeon works) scrubbing in to work and learn alongside Gary Parker. Also in theatre is Canadian nurse Mandy (new to maxfax), a Korean nurse Molly who has been in OR for two days, and Esther from Australia who has been in our OR for four weeks so is my right-hand girl. Today we have an extra nurse so when Esther asks to scrub up for the ICBG I’m free to catch up on some admin. We should all get breaks today!
12.10
PM SCRUB UP I have to snatch a quick 10-minute lunch as the first case is coming to a close and I need to scrub up and relieve Esther who needs to have a proper lunch break. I’ll catch up later.
1.00
PM THEATRE BREAK/BACK TO TRAINING AND ADMIN Theatre doesn’t usually stop at lunchtime but the anaesthetic nurse needs her break as well. During this time I coach Mandy and Molly about scrubbing for the parotidectomy and third case.
PM LAUNDRY SLOT You get an hour slot to use the washing machine and then another hour to use the dryer. You have to be on time or you will miss your slot!
7.00
PM FELLOWSHIP GROUP On Tuesday nights I drop into Fellowship Group. I am getting to meet interesting people from all parts of the ship I may not normally meet hidden away in the OR. The rest of the time I am surfing the net or reading. We have a great library on board so it’s easy to slip up and grab a new book. In Madagascar some lovely person has paid for us to have fast internet so we are able to watch videos and Skype our families, a real treat. Other evenings I go for a walk on the dock with a friend for half an hour to get some fresh air. Otherwise, sometimes I get to the end of the week and realise I haven’t actually been outside.
10.00
PM SLEEP TIME Should be sleep time but I can’t stop thinking about storing those sutures. So John and I have a talk about them as he is the Engineering Stores manager and is very experienced in managing supplies. I then ask God for wisdom tomorrow and manage to drift off to sleep. All Africa Mercy crew are volunteers, having either self-funded or, if staying longer, raised sponsorship from family, friends, colleagues, churches or community groups to cover the costs of living and working on the ship. www.mercyships.org.nz. For a longer version of this article, go online to www.nursingreview.co.nz
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FOCUS n Learning & Leading
Nurse leadership:
having the bottle to make a difference Outrage at yet another bottle store opening in her down, but far from out, community stung Christchurch practice nurse KAREN CARPENTER into action. FIONA CASSIE talks to the Aranui nurse about her successful campaign, her resulting community leadership award and her realisation that nurses can make a difference.
I
t was leading up to Christmas when Karen Carpenter spotted the latest addition to the neighbourhood. She was ducking through the car park of a closed-down supermarket on her way to work when “I just happened to turn my head and look over – and I was just outraged”. The cause of her outrage was the Thirsty Liquor bottle store, a liquor outlet that had popped up between the then pharmacy, and a takeaway store in December 2013. It was just opposite an existing pub, a few hundred metres from Eastcare Health where she worked and only a short stroll from the Aranui primary and secondary schools. “I felt really angry,” recalls Carpenter. “This is the last thing we need in this area. We are trying to rebuild … I thought, how dare they?” The Aranui born-and-bred nurse went fuming on her way to work and, after discussing this unwanted new neighbour, decided to do something about it. So while most people were winding down for the Christmas break, Carpenter ‘wound up’ and within a couple of days had launched a petition. She dropped off paper copies to the local pharmacy, the Aranui Community Trust (whose mission since 2001 has been to nurture the wider Aranui community) and at the practice. She also launched a petition online at www.change.org against the liquor outlet, which she discovered had, through a combination of circumstances, been able to open up without consultation with a 90-day licence (issued under the Sale and Supply of Alcohol Act 2012) but would have to go through a public hearing process if the licence was to be permanent.
Community takes up nurse’s fight
Aranui is browner, younger and poorer than much of the rest of generally whiter, older and reasonably affluent Christchurch. It is also in the heart of east Christchurch that was hit hard by the earthquakes and five years on is
still surrounded by dust and roadworks. But that doesn’t mean the community is without heart. Carpenter returned to work in the New Year to find that she was far from alone in her outrage over the pop-up liquor store. The petitions had taken off – particularly the online one, which had attracted around 100 or so comments from many like-minded people. She found many people agreed that Aranui didn’t need four bottle stores within a kilometre of each other. And with the help of local Christchurch East MP Poto Williams she gained an understanding of the liquor licensing process. She also took her campaign to all agencies and forums she could think of, including the Pacific Reference Group of Pegasus Health, of which she is the Pacific nurse representative (Carpenter is part-Fijian). By the time a community meeting was held at the school in late January, she had more than 1,000 signatures. At the well-attended meeting it was revealed that amongst the unhappy opponents of the bottle store was an alternative school for teenagers that had unknowingly signed up for a lease in the same building just a month before Thirsty Liquor had opened. Momentum kept building against the store, helped by social media with some of Carpenter’s old Aranui Facebook mates across the country and the Tasman also taking up the cause. The initial battle was won when the 90-day licence ran out in March 2014 and the outlet closed. An application was lodged by the owner for a new licence, requiring a liquor licensing authority hearing, but nothing was heard for months and months and it wasn’t until 2015 that a hearing date was set for late April and the community once again garnered their forces ready to give evidence. But just weeks before the hearing date the owner withdrew the application and Carpenter and her fellow bottle store opponents could finally celebrate a moral victory. “I was on top of the world,” recalls Carpenter. “Very empowered by what we could do as a community. But humbled at the same time.”
TIPS FOR TAKING ACTION »» »» »» »»
Karen Carpenter in front of the bottle store she helped close.
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Know your community well. Contact existing interested community groups. Contact your local member/s of parliament for advice. Promote your cause by a community petition – both paper and online (Karen Carpenter used www.change.org). »» Use social media like Facebook to promote your petition. »» Be in touch with relevant agencies – if fighting against a liquor outlet, contact the regulatory authority and any agency working in the area of alcohol and drug addiction. »» Get the support of local churches, Pacific and Māori health providers.
FOCUS n Learning & Leading
“… it just makes me think I’ve got the confidence to actually do things, and anything is achievable.” Returning as nurse to her childhood community
The victory was all the more special as while Carpenter was no stranger to Aranui, in Christmas 2013 she was still relatively fresh to nursing. She had worked part-time as a personal carer while her children were little, then, after finding herself a single parent, she decided “to get out and do something” so she could give more of herself than her current role allowed. (She hesitantly told a friend in 2005 that she wanted to be a nurse, at which her friend confessed that she really wanted to be a mechanic. Both succeeded in following their dreams.) Carpenter said she knew early on in her nursing training she wanted to work in the community. However, on graduating in 2009 she accepted a job at Burwood Hospital until she heard through the grapevine of a job going in Aranui and she successfully applied to join Eastcare Health. Initially two GPs, two nurses and herself, the staff is now four nurses and four GPs. As a novice nurse she says she was really well supported by her nursing colleagues, GPs and Pegasus Health to develop her nursing skills in her childhood community. “It means a lot to me, this community… I think growing up here as a kid and seeing what it used to be and what we’ve lost, including through the earthquakes…” She looks back to the days when it was a lively, thriving community where kids played cricket on the streets. “There were kids everywhere – the park was full of kids playing after school until it got dark and time to head home. Parents always knew were their kids were – now I drive past that park every day and nobody is there. That’s quite symbolic to me of where Aranui was and where it is now.”
Stepping up as a community advocate
Carpenter’s focus has been on helping rebuild the Aranui community and – as a nurse in Aranui, as the facilitator of the Aranui Nurse Network, and as a child who grew up in a family affected by alcohol – she just wasn’t ready to let a new liquor outlet undermine the hard work underway. “As a nurse I’m an advocate for families and knowing from my own family, where alcohol was a big factor, that children and families needs aren’t always met in that situation. “So my challenge was from the heart, as an advocate for my patients and for the love of this community and the people who live in it.” She sees community advocacy as very much part of the nursing role and hopes her story will empower other nurses to follow their heart. “If we want to changes things for our patients, change things for nursing then we need to share
our stories of empowerment and let other nurses know that you can make a difference,” says Carpenter. “And not be afraid or fearful to take that step.” Though she admits doubts did run through her head at the time. “I can remember thinking ‘oh my gosh, what am I doing?’, but at the end of the day it was a cause I couldn’t let lie. I felt so passionate about it.”
Empowering nurses to act
Carpenter has already been contacted by a person working in another high needs community wanting advice on how to stop a planned bottle shop (see her tips in sidebar). She believes a key to a successful campaign is knowing your community. “That was one thing I was told when I came into nursing here by a colleague… being a practice nurse is knowing your community. She believes the time spent getting to know what supports are out there for her patients and linking in with other nurses and people in the community has paid off. And general practice is more than what happens within the four walls of the medical centre. “Just sitting in here – we’ve got our own little world in general practice but it’s what is going on outside general practice…” And to Carpenter the potential consequences of increased access to alcohol in the community was something she couldn’t ignore. “The children that might miss out on groceries in the cupboard, the family violence from alcohol… and (if closing the outlet) made a difference to even one family... “Because it’s such a big problem – there are things that go on behind closed doors that you don’t see… but you see the consequences in low decile communities like this – food banks, the drug and alcohol problems. Another bottle store would just add extra pressure on the community, health care, police, the court system. “I remember saying to somebody (about the impact of alcohol), ‘who doesn’t know somebody whose father or brother might be in prison [as a result of drinking] or somebody who has been pulled up for drunk driving? Everybody is affected by it.”
Taking that step out of her comfort zone to be an advocate for a community and cause she was passionate about has had unexpected payback for Carpenter. Christchurch media picked up on her successful campaign and she was awarded a Public Health Association scholarship to attend and present her story to the Population Health Congress in 2014. The first scholarship led to another: a University of Otago scholarship to attend a Pacific Health summer school. She then went on to attend a College of Nurses two-day primary health care leadership workshop. “It’s been this constant journey,” says Carpenter, who is still a little taken aback by where her ‘outrage’ has led her. It was the leadership workshop that cemented for Carpenter that what she had done in fighting Thirsty Liquor was actually leadership. “I was sitting there with these like-minded nurses who were thinking the same way as me and wanting to go forward and make a difference.” Back in December 2013 she was just driven but now she is growing more comfortable thinking of herself as a leader. “It makes me stand a bit taller,” she laughs. “Not being proud or anything, but it just makes me think I’ve got the confidence to actually do things, and anything is achievable.” So to any other nurses wanting to step up and make a difference she says “go for it”. “The support comes as you go through your journey and you never know where it will take you.”
Leadership award In July, Karen Carpenter won the Community Leadership award at the Pegasus Health Quality Recognition awards ceremony for her work fighting the opening of the Thirsty Liquor outlet in Aranui. The award citation said her “ongoing personal and professional contributions to the community greatly impacted on ensuring this liquor outlet did not open”. Michael McIlhone, Pegasus Health director of nursing, said Carpenter’s work had galvanised her community and despite some setbacks she wouldn’t give up. “As a human being and as a role model as a practice nurse for her community, she’s quite exceptional.”
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Career paths:
nurses share their journeys
Some career paths are direct and straight while others meander, reach forks or take u-turns. Nursing Review once again asked some senior nurses from across the country to tell us about the path they followed to where they are today. Migration, mentors, tight job markets, restarted nursing careers and chance all helped influence the paths of the nurses who share their career paths to their current job and nursing passion. The nurses also share tips on career planning and the skills, qualities, and qualifications helpful in their current roles.
Career path: clinical nurse director To’a Fereti shares her ‘accidental’ career path to be clinical nurse director in charge of 600 nurses – the first Pacific nurse to hold the post. Name: Safaato’a (To’a) Fereti (born in Samoa, raised and educated in Dunedin) Job title: Clinical Nurse Director, Medicine & Clinical Support Services, Counties Manukau District Health Board Nursing qualifications:
»» RN 1989 (Christchurch Polytechnic) »» Postgraduate Certificate in Specialty Care (Pacific Health) 2012 (Whitireia Community Polytechnic/Aniva Pacific Nursing Leadership Programme) »» Master of Nursing (MNurs) 2013 (University of Auckland) »» Postgraduate Diploma in Specialty Care (Pacific Health) in progress (Whitireia/Aniva) »» Postgraduate Diploma in Business (Healthcare Management) in progress »» Master of Nursing (Pacific Health) beginning in 2016 (Whitereia/Aniva)
Postgraduate study and Aniva Pacific nursing leadership programmes
I started postgraduate study in 2006 as it was expected of me on taking up a senior nursing role at Counties Manukau DHB. In 2012 I also did my Postgraduate Certificate in Specialty Care Pacific Health as part of the Aniva Pacific Nursing Leadership Programme. This programme – funded from next year to master’s level – is special and unique as the focus is specifically on the issues of Pacific peoples’ health and wellbeing and the challenges and opportunities these provide for Pacific nurses. It is delivered by some of the most pre-eminent Pacific health professionals, including Fuimaono Karl PulotuEndemann and Dr Margaret Southwick, with the support of Aniva director Dr Debbie Ryan. They have become my mentors. Next year I am planning to continue my postgraduate business diploma, as well as start my second master’s through the Aniva Fellowship programme. (I’m looking at whether I can cross-credit some of this towards a Doctorate in Health Sciences). Yes, everyone has called me crazy! 6
Nursing Review series 2015
Briefly describe your initial five years as an RN
My first job as a new graduate in 1990 was in Coronation Hospital, Christchurch, which was a long-term geriatric hospital. I believe this instilled in me the foundations and essence of nursing. It closed down in December 1991 and I was redeployed to Princess Margaret Safaato’a (To’a) Fereti Hospital AT & R ward until I moved to Auckland in 1993, motivated by wanting to work more with our Pacific people. I got a job pretty much straightaway in Middlemore Hospital’s Ward 8, which was the renal/medicine ward. Back then, there was only a handful of Pacific nurses. It is good to see this number has grown; however, there is still work to be done to increase the Pacific health workforce to reflect our population demographic. In 1995, renal was given its own dedicated ward (ward 15) where I became the ward-based acute haemodialysis nurse and basically remained in the ward until 2001.
Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career? My path to date has been ‘accidental’ – a phrase coined by Matafanua Hilda Faasalele. It was being at the right place, at the right time; however, it was
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also about having great friends behind me who recognised my potential and my strengths (even when I didn’t) and who pushed and supported me to go for the senior nurse roles – thank you. In 2001 I felt I needed a new challenge. I applied for senior nurse roles within the renal service but was unsuccessful as I lacked the required qualifications. But as they say, where one door closes another one opens. The ‘new door’ was at Auckland DHB where one of my best friends encouraged me to apply for the renal transplant coordinator role. It was the best thing that happened to me – a new DHB brought new knowledge, skills and networks. It was probably the turning point of my nursing career. I knew then that my pathway was more leadership/managerial rather than clinical. I returned to Middlemore Hospital as renal services nurse educator at the end of 2006 to be closer to home for my children. I was in this role for 10 months and then became charge nurse manager of the Acute Dialysis Unit, taking up my current role in April 2012.
What led you into your original specialty?
It is ironic that my specialty background has been renal for more than 20 years – this was my worst subject at nursing school. But on seeking a job at Middemore (as I was told it served the most Pacific people) I was given the choice of a job in AT & R or renal and chose renal as I’d come from AT & R in Christchurch. I soon learnt that Pacific people had a high incidence of diabetes and hypertension leading to renal failure. I loved working with and caring for our renal patients who became like my second family as the hospital was like their second home. I learnt a lot about the different cultures, values and beliefs. From this my understanding of my own cultural values has grown and how these values are translated into and through my nursing practice.
What qualifications, skills or stepping-stone jobs do you think were particularly helpful and/or necessary in reaching your current role?
To best answer this question, I need to quote the ‘3 C’s’ from Dr Margaret Southwick: »» Courage: the courage to take the first step into the unknown; stepping out of your comfort zone and getting uncomfortable »» Credentials: you need to have qualifications behind you to get into the more senior nurse roles. »» Credibility: standing up and doing what is right, even when everyone thinks you shouldn’t. It’s also about relationships – maintaining and sustaining good relationships with everyone. In June I accepted a Ministerial appointment to the Nursing Council of New Zealand, for a three-year term. I am proud to say I am the first CMDHB nurse appointed to the Nursing Council and only the second Pacific person (the first was Dr Margaret Southwick, who was chairperson from 2009– 2013). I was an independent consultant to the Ministry of Health, Samoa, in 2014 and undertook a review of the National Kidney Foundation of Samoa. I also undertook a review of the Lakes Satellite Dialysis Unit, Rotorua, in 2010. I have a passion for Pacific health and to increase the Pacific health workforce, in particular nurses. Definitely my journey through the Aniva Pacific Nursing Leadership programme with the guidance of my mentors has enhanced my leadership skills within my current role. And I remember the journey of how I got to where I am now, and those who helped and supported me along the way. Now it’s time for me to give back and help others pave their way.
What personal characteristics do you believe are particularly important for nurses working in your role?
Definitely the first three would be Dr Southwick’s ‘3 C’s’: courage, credentials, and credibility. Leadership is a key skill in this role, balanced by selfconfidence and humility (and a great sense of humour). Excellent communication and interpersonal skills are a must as you are providing professional leadership and governance over the practice of nurses. Also you need to have a strategic lens, to provide coaching, mentoring, and positive role modelling, and have emotional intelligence, critical thinking, and energy. For myself, being a Pacific nurse leader in a mainstream role and having a two-world view lens, it is also important to me that I remain authentic and infuse my own Samoan cultural values of faaaloalo (respect), alofa (love), tautua (service) and humility into my role and into my nursing practice.
Also being caring, kind and compassionate towards all people – that’s what I believe nursing to be and why I chose this profession.
Describe your current role and responsibilities
My current role is clinical nurse director of Medicine & Clinical Support Services and I have been in this role for over three years. I am proud to say that I am the first Pasifika nurse to get this role in Counties Manukau Health. I am part of my director of nursing’s (Denise Kivell) leadership team. She is an awesome and fabulous boss and I am proud to be under her leadership. I have over 600 nurses within my division for whom I: »» provide professional governance and leadership for at a strategic level »» ensure all nurses perform and conduct themselves in accordance with the DHB vision and values, and Nursing Council requirements »» ensure strategic and operational plans are successfully implemented with a strong professional nursing and clinical focus »» ensure patient and family safety and quality agendas within the service are championed as part of Counties Manukau’s quality focus »» provide clinical advice, coaching and mentorship for all nursing staff within the division to manage complex and difficult professional/clinical situations »» contribute to the strategic planning process for the workforce, ensuring that nursing professional issues and impacts are considered. My career to date has not been achieved on my own. I am here because of all the support and love from my four children, my family, friends, my director of nursing and my mentors. So it is only fitting that they are also recognised for their contribution to who I am, what I am doing and where I am today. As a Pacific nurse leader in a mainstream role my vision for the future is for the Pacific health workforce to make positive changes in the health status of Pacific people in New Zealand.
EXPAND YOUR KNOWLEDGE Start a postgraduate qualification in nursing in 2016. Study and work alongside national and international expert practitioners and scholars in clinical practice, leadership, education and research.
ENQUIRE NOW Graduate School of Nursing, Midwifery and Health Phone 0800 108 005 Website victoria.ac.nz/nmh
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Career path: mental health nurse educator A tight job market on graduation saw MEL GREEN enter mental health, then a supportive new graduate programme after realising how nursing can make a difference to people’s mental illness experience. Leadership opportunities saw her make it a career. Name: Mel Green Job title: Nurse Educator for Mental Health,
Addiction and Intellectual Disability Directorate (MHAID), Southern DHB, Dunedin
Nursing qualifications:
»» Bachelor of Nursing 1996 (Otago Polytechnic) »» Master of Nursing 2006
Briefly describe your initial five years as an RN
I began my career working in the sub-acute unit in Mental Health, Addiction and Intellectual Disability (MHAID) Services in 1997. Within the first four months of practice I was fortunate to have the opportunity to enrol in a new graduate programme for mental health and addiction nurses which had just been established in Dunedin. This enabled me to gain specialist knowledge and skills and provided me with a solid foundation for working in the mental health and addiction setting. After completing the new graduate programme, I transferred to a surgical ward for a year until a clinical and leadership position became available in the clinical rehabilitation unit in 1999. While on maternity leave in 2003, I worked for Otago Polytechnic with undergraduate students on clinical placements in mental health and addiction and I then went on to work for the Psychiatric Consultation Liaison Service at Dunedin Hospital.
Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career?
I was involved in St John cadets for 10 years during my schooling, which prompted my interest in nursing career. My initial plan when I graduated as a nurse was to work in a medical or surgical ward but because there were no jobs available at the time I applied for a position in mental health and addiction services. After 18 months in the mental health service, I still had a strong desire to work in a medical or surgical specialty, which I did and thoroughly enjoyed. I was then drawn back to mental health by an opportunity in a clinical rehabilitation unit. It was during these early years that it became evident to me how much nursing can make a real difference to people’s experience of mental illness/distress. I have found the mental health environment to be supportive, innovative and I was impressed by the multidisciplinary approach to patient care. Throughout my career I have been very fortunate to have been guided in my various roles by some excellent clinicians/colleagues and a very wise mentor who has a vision and passion for nurses and who never loses sight of the importance of endeavouring to ensure that the services we provide meet the needs of patients and families.
What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role?
Mel Green
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There are many experiences throughout my career which have been helpful for my current role, including management experience, working with students and working clinically. Postgraduate education was particularly valuable in encouraging me to read widely and challenged me to use the knowledge gained to think critically. These skills are a significant part of my current role. For many years now I have been a member of Te Ao Māramatanga, New Zealand College of Mental Health Nurses. For the past five years I have held the positions of college vice president and treasurer and I was convener for the College Conference held in Dunedin in 2011. The roles with Te Ao Māramatanga have enabled me to connect nationally with many mental health and addiction nurse leaders who provide a voice for the profession of mental health and addiction nursing in New Zealand. On occasions I also have the privilege of providing mental health representation for the Nursing Council of New Zealand when it is auditing nursing school programmes. These opportunities enable me to have a broader perspective about issues related to nursing, more specifically mental health and addiction nursing, and keep me feeling
enthusiastic and interested in working in this field. They also help create an awareness about the wider socio-political context of health and mental health nationally and internationally which informs the educator role.
What personal characteristics do you believe are particularly important for nurses working in your role?
Ability to relate well to others, curiosity, the ability to critically reflect on practice, energy, enthusiasm and self-motivation, desire to improve the quality of care provided to service users. The ability to think broadly about workforce development needs of the service whilst also paying attention to the detail that is required to organise and facilitate education and complete the project work that is part of the role.
What career advice would you give to nurses seeking a similar role to yours?
»» Find a good mentor(s) »» Be open to challenges and opportunities (step out of your comfort zone) »» Always critique what you are doing and why you are doing it (with a focus on improving quality of care for service users and families) »» Read widely and be well informed »» Be open to critique and don’t be defensive »» Seek out a broad range of opportunities and experiences (which will help inform the educator role) »» Don’t get caught up in what ‘we must do’ and what ‘we can’t do’ but what ‘we can do’ to improve the care we provide to service users.
Describe your current role and responsibilities
The MHAID directorate nurse educator role has a focus on workforce development across the directorate, including NGOs (non-governmental organisation providers) and PHOs (primary health organisations). The focus is on providing opportunities for staff to further develop their knowledge and skills to enhance the quality of care that service users receive. Working with colleagues, I help develop and implement an annual education programme, which includes between 80–100 training days each year for more than 700 staff across Otago and Southland. As well as providing education, nurse educators are involved in service development, incident investigations, supporting clinicians with postgraduate study as well as a variety of mental health and addiction projects, all of which aim to ensure as educators we are well informed.
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Career path:
aged residential care (clinical services manager) Migrating to New Zealand saw JINSU SHINOY fall into a job in residential aged care and never look back.
What career advice would you give to nurses seeking a similar role to yours?
Name: Jinsu Shinoy Job title: Clinical Services Manager, Ellerslie
»» Make a short-term and long-term goal for your career with some flexibility as this will help to put things into perspective (and help to develop and extend yourself to move out of your comfort zone) »» Actively take opportunities to keep up to date with best practice »» Develop the needed skills by experience and education »» Work in different roles to understand, learn and grow as a nurse »» Acknowledge the importance of communication and building relationships »» Dedication, hard work and honesty.
Gardens Home and Hospital, Auckland
Nursing qualifications:
»» Bachelor of Science (Nursing) 2008 (SNDT University, Mumbai, India) »» Preceptorship of Nurses in Practice 2013 (Wintec) »» Postgraduate Diploma in Leadership and Management in progress (AUT)
Briefly describe your initial five years as an RN I worked in a variety of settings during my training. After graduating I worked in the intensive care unit as a registered nurse for three years in Lilavati Hospital, Mumbai, before moving to New Zealand in 2011.
Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career?
I always wanted to work in a very challenging area, gain experience, improve my knowledge and complete higher studies overseas. My first three years of nursing were very interesting and the knowledge gained was worthwhile. So yes, my initial years as a nurse did influence my career in many ways. When I moved to New Zealand my initial goal was to understand the New Zealand health setting, gain my New Zealand registration and start working as a nurse.
What led you into your current field or specialty?
To be honest, the current field I am working in is by chance. My first choice was always intensive care. But as I had moved to a new country, and needed experience in the healthcare system, I accepted a job in aged residential care (ARC). As I started working in ARC I found my job very challenging, fulfilling and rewarding so I continued to invest more of my time in training to enhance my career in ARC.
What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role?
I am very thankful to my previous employer and manager who provided opportunities to enhance my ARC knowledge by sending me to training courses, conferences, workshops etc. I am passionate about gaining knowledge so have also attended a lot of courses in my own time. A stepping stone for my career was my previous employer, and the senior management team,
Describe your current role and responsibilities
Jinsu Shinoy
trusting me and offering me a position as a clinical manager. I accepted as I always had a passion to be a leader and this gave me a chance to work towards my passion. After accepting the role, I saw the need to support my role with postgraduate education. I am grateful for all the support I received from my previous employer and Waikato DHB, who encouraged and helped me to walk the education road once again. I personally think education and experience are both equally important to fulfil the needs of my current role. I am really fortunate to come into a new company and receive management backing to complete my postgraduate study. I would also like to acknowledge my family, my loving husband, and my friends, who supported me in every possible way and provided guidance in time of need. Above all, I thank God Almighty, who opened up the way and showered his blessings on me in this beautiful country, New Zealand.
What personal characteristics do you believe are particularly important for nurses working in your role?
I think as nurses we should have empathy, compassion and a caring attitude towards our residents/patients. Other attitudes and attributes I feel are important are commitment to excellence in the care of the elderly population, a good sense of humour, common sense, honesty, integrity, our own values, a desire to find solutions and a ‘can do’ attitude. It is vital as a clinical lead to have a conscientious and industrious work ethic. Keeping an open mind to change and learning as practice changes is essential. Communication and listening skills, plus patience, are indispensible attributes to have.
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»» »» »» »» »» »» »» »» »»
My role’s main aim is providing a high level of clinical leadership and support to clinical and care staff. The key objectives of my role are to: provide leadership, supervision and direction to staff with active and applied knowledge and practice (as per the Health Practitioners Competence Assurance Act) assist and support the facility manager in effective facility management by having extensive knowledge of relevant legislation and codes of practice (including Health & Disability Commissioner standards and code of rights, ARRC contracts etc.) actively participate in the facility’s quality and risk management programme by seeking continuous improvement of all services monitor the provision of care to residents to ensure the highest standards are achieved and maintained coordinate the provision and the use of clinical supplies within the facility ensuring resources are allocated and utilised cost-effectively provide the oversight of resident clinical records and recordings to ensure they meet organisational and legislative requirements participate in the implementation of an effective education programme be actively involved in all aspects of human resource management demonstrate commitment to the provision of a safe environment for residents and staff assume the responsibilities of the facility manager in their absence undertake additional responsibilities as required (infection control officer, restraint coordinator, health and safety officer etc.)
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Career path: nursing school lecturer and researcher The eye is small and should be ‘pretty easy to learn’ thought ELISSA McDONALD but, an ophthalmology PhD later, the now nursing school lecturer knows how wrong she was. Name: Dr Elissa McDonald Job title: Lecturer, Massey University’s School of Nursing (Albany) Nursing & other qualifications:
»» »» »» »» »»
Diploma in Nursing (Comprehensive) 1994 (AUT) New Zealand Diploma in Business 2004 (Universal College of Learning) Diploma in Management 2004 (New Zealand Institute of Management) Master of Nursing (First Class Honours) 2010 (Massey University) Doctor of Philosophy (Ophthalmology) 2015 (doctoral scholar, The University of Auckland)
Briefly describe your initial five years as an RN
I initially worked for two years in a regional hospital in the paediatric/ maternity wards and also as a practice nurse in a busy community clinic. I stopped working for five years while my children were pre-schoolers and then studied towards a business qualification while nursing part-time at weekends at an accident and medical clinic.
Did you have a career plan (vague or definite) on becoming an RN? And how did those first five years influence your subsequent career?
I decided to study nursing as a teenager due to a desire to make difference in the world. I was keen to work for the Royal Flying Doctor’s Service in Australia or for the Red Cross, but, at only 17, I didn’t fully appreciate the experience required for these roles. However, working as a practice nurse strengthened my interest in primary health care.
What lead you into your current field or specialty?
When I returned to full-time nursing after gaining the business qualifications, I applied for and was offered two positions at an outpatients clinic: one medical and one ophthalmological. I didn’t know much about the eye, but thought the eye is small and should be easy to learn quickly... how wrong was I! It took at least six months just to learn how to use the equipment and what ‘normal’ looked like. There was so much to learn. I had the invaluable support of the local ophthalmologist, who taught me beside the slit lamp for the five years I worked there, plus an experienced enrolled nurse, who initially showed me the ‘ropes’. In order to fast track my career, I began my Master of Nursing (MN) at Massey University and focused as many of my assignments as possible around ophthalmic conditions/diseases/treatments. My master’s research project consisted of conducting a systematic review of anti-viral medications for herpes zoster (shingles, which can also affect the eye) which was published in a prestigious British antiviral journal. As a result, I was approached by the World Health Organisation (WHO) to assist them on development of guidelines for treatment of herpes zoster. By the time I completed my MN I had a good working knowledge of common ophthalmic conditions, and an introductory level of knowledge in research, but I was ‘hungry’ for more…
What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role?
My academic supervisor at Massey advised me to study towards a PhD in Ophthalmology at The University of Auckland and arranged an initial interview with ophthalmology department head Professor Charles McGhee. Not only did Professor McGhee agree to accept me within his department, he also supervised my doctoral research. I moved back home to Auckland with my family. 10
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Dr Elissa McDonald
“Having academic supervisors and a supportive family who identified my potential and encouraged me to aim high was probably the most significant factor in my achievements to date.” The change in culture from nursing to medicine was significant, with a focus on quantitative research (which I thoroughly enjoy). I have never been strong at maths, but upskilled myself to be able to conduct my own statistical analysis for my thesis, which investigated the best treatment options for microbial keratitis (infection of the cornea). I have had the opportunity to present my research at international and national ophthalmology conferences and have published my research in acclaimed international journals. Having academic supervisors and a supportive family who identified my potential and encouraged me to aim high was probably the most significant factor in my achievements to date.
What personal characteristics do you believe are particularly important for nurses working in your role?
The first is tenacity, not to give up when something appears too difficult. Being able to set goals and be driven to achieve them despite obstacles. Prioritising and managing workload is essential, as it is easy for work/ research to be consuming. I always have Friday evenings and Saturdays free of work. In fact, I don’t even turn my computer on. It is vital to have a healthy work/life balance and ensure there is dedicated time for family.
What career advice would you give to nurses seeking a similar role to yours?
For nurses who wish to advance their careers, I recommend finding an area you are interested in and specialising (although I have found every area becomes interesting when you start learning more about it). Postgraduate education is important for knowledge acquisition and development of critical thinking and can help advance you in your specialty. Make the most of your learning opportunities and remember the things in life worth having don’t come easily.
Describe your current role and responsibilities
I am currently a lecturer at Massey University, School of Nursing. I supervise postgraduate students completing their prescribing practicum and am involved with teaching student and postgraduate nurses about research. I also provide seminars in pharmacology (for registered nurses) at the Pharmac Seminar Series held in Wellington, and provide peer review for various medical journals. I am also mum to four lovely teenagers aged 13–19 years and one naughty kitty.
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Career path: clinical nurse specialist on
NP pathway (private surgical hospital)
Nursing mentors have been instrumental in helping clinical nurse specialist JESSICA ONGLEY along her career path towards her ultimate goal of becoming a nurse practitioner. Name: Jessica Ongley Job title: Clinical Nurse Specialist, Southern Cross Hospital Wellington Nursing qualifications:
»» Bachelor of Nursing 2000 (Otago Polytechnic) »» Master of Nursing (Clinical) 2012 (Victoria University) »» Preceptorship of nurses in practice course & PDRP assessor course (Southern Cross)
Briefly describe your initial five years as an RN
I started my career as a new graduate in a medical ward in 2001, and after a few months moved into a surgical ward in a larger public hospital, where I stayed for two years. I then moved to Australia where I spent five months working in a very small regional hospital, followed by a two-year stint in a large general surgical and urology ward based in Perth.
Did you have a career plan on becoming an RN? And how did those first five years influence your subsequent career?
I’d never considered nursing before I went to university but I was passionate about helping people. I chose nursing after a year of not enjoying university and some very sound advice from family and friends. I applied and started studying in 1998. In my first new grad position I didn’t feel very supported so I left within the first few months feeling a bit disillusioned. Shortly after, I got a job in a large public hospital in the surgical ward, which was absolutely the best thing for my career. I was welcomed into an environment with supportive staff, including senior nurses, and had a charge nurse who always put her staff and patients first. I started to see the kind of nurse I wanted to become. Later, while working in Perth, I met my first nursing mentor. She demonstrated care, compassion, and empathy while maintaining her expert knowledge and evidence based practice – everything that I want to be. It was at that point I started to see nursing as a profession – not just something that I did for a job.
What led you into your current field or specialty?
My second nursing mentor led me to my current field. She was one of my lecturers when I was doing postgraduate study. I was inspired by the amazing examples she gave from her own practice and because she was genuinely interested in me and my professional potential. She encouraged me to complete my master’s and work towards becoming a nurse practitioner (NP) in an adult surgical setting. I came to work at Southern Cross as I saw the move as an opportunity to further my career. The nursing leadership and management team within this network are extremely supportive of my determination to achieve NP status.
What qualifications, skills or stepping stone jobs do you think were particularly helpful and/or necessary in reaching your current role?
As part of my recent role working clinically in the ICU, I was also part of the clinical research team. During this time I gained an even greater passion for evidenced-based-practice, it helped consolidate my skills in writing, accurate data collection, and knowledge of research principles. This has been very beneficial in policy and guideline writing, which is a part of this role.
What personal characteristics do you believe are particularly important for nurses working in your role?
»» Having a strong work ethic: There is always something to do if you are open and look for it. »» Being approachable and open to change: There are days when I may be required to work clinically at the last minute in any part of the hospital so being flexible is essential. »» Enjoying working with people: This role is about working with people and providing clinical care for patients, or educational care to staff so they are able to safely and effectively care for patients. »» Passion and patience: It’s essential to be passionate as an educator to foster the next generation of nurses, and have patience so they do not get discouraged.
What career advice would you give to nurses seeking a similar role to yours?
Always look for opportunities at work, volunteer for projects, learn about research, and learn how to write policies and guidelines. Work in a few places Jessica Ongley before you specialise, get a good grounding first. Postgraduate study is essential. Always remember that at the centre of your practice are patients and families that need your care and support; whether you are the CNS, educator, nurse manager or bedside nurse, it must ultimately benefit the people we care for.
Describe your current role and responsibilities
»» Work clinically on ward, intensive care unit, day-stay and post-anaesthesia care unit (PACU) providing advanced nursing care and assessment, if needed »» Assess patients daily and write plans of care »» Work with nursing staff to help care for complex patients »» Write guidelines and policies, care pathways, patient information leaflets »» Arrange staff education, run clinical study days »» Assess and support staff to complete PDRP portfolios »» Chase bloods and X-rays and discuss results with specialists »» Mentor and precept new graduate nurses »» Complete performance reviews »» Work on national projects »» Help with day-to-day running of the ward as required
Lecturer / Senior Lecturer / Professional Teaching Fellow Applications are invited for a Lecturer / Senior Lecturer / Professional Teaching Fellow position in the area of Adult Nursing within the University of Auckland’s School of Nursing. Medical surgical experience is advantageous. Level of appointment will reflect successful candidate’s experience. The Faculty of Medical and Health Sciences have established graduate and undergraduate programmes in Nursing. This allows nursing to develop as a University discipline and educates nurses alongside doctors and other health professionals within an environment of scholarship and research. Applications will be considered from candidates qualified at postgraduate level with a strong clinical focus in nursing. Successful candidates will be expected to establish close links with clinical areas. Teaching will occur in the undergraduate/ postgraduate area in a variety of clinical settings. Candidates must hold a nursing qualification and be registrable as a nurse in New Zealand together with a recognised qualification at postgraduate level. Candidates with experience in teaching and supervising nursing students would be preferred. Applications close Wednesday 23rd September 2015. For further information go to www.auckland.ac.nz/ opportunities The University has an equity policy and welcomes applications from all qualified persons. The University is committed to meeting its obligations under the Treaty of Waitangi and achieving equity outcomes for staff and students.
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Nurse peer group supervision:
sharing the load
Helen Shaw-Brown
HELEN SHAW-BROWN discusses how peer group supervision can offer support, shared learning and professional development for nurses in management and leadership roles.
A
re you constantly being challenged by the demands of your professional role as a nurse leader? Do you work in a specialist field, an isolated rural setting or a management position? Among your many other requirements, are you accountable for maintaining standards, improving client care and meeting organisational goals and targets1,2? Some research suggests working at this level may be a precursor to increased stress, burnout and job dissatisfaction3 . Now imagine that amidst your busy calendar of monthly meetings another type of meeting exists, with people who have identical or similar roles and often share the same or comparable issues with you. This meeting is purely for the purpose of mutual support. This support consists of shared learning, problem-solving, and reflecting on practice issues and the achievement of individual successes. The people at this meeting are your peers, with whom you may choose to set up a peer supervision group.
What is peer group supervision?
Els van Ooijen’s 2013 book Clinical Supervision Made Easy describes peer group supervision as a group where “there is no permanent supervisor; group members may either share overall responsibility or take turns at being facilitator”4. An ideal group has three to six members5 . With no defined leader, all group members are trained as both supervisor and supervisee prior to forming a peer supervision group6 . The facilitator for each session ensures that each supervisee has an equal amount of time to reflect on the practice issue they have chosen to take to supervision7. All members are presumed to have sufficient skill and resources within themselves as a group to make meaning of their experiences. This supported process enables group members to discover different ways of working7,8 .
What are the benefits?
Current research on peer group supervision is limited. A recent New Zealand article, written by Dianne Harker and her three fellow supervision group members, highlights the benefits of peer group supervision. Reduced stress, improved management of work-related situations and development of knowledge are all identified as outcomes. Improvements in skills and competence, plus the opportunity to discuss career choices and progression, are also identified outcomes of their 12
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well-structured, educational and positive peer group supervision sessions7. A 2009 article by Lakeman and Glasgow looked at an action research project evaluating the development and implementation of peer group supervision for 10 psychiatric nurses in Trinidad. Outcomes for the participants included feelings of greater satisfaction with their work, shared learning, increased positivity and collegial support8 . A further benefit noted in both articles was the cost and time effectiveness of group supervision, compared with individual supervision. The success of these two groups may be attributed to the commitment of the group members. Their tenacity in sticking to the boundaries set when the groups were first developed, together with following a structured process, paid dividends7,8 .
“Reduced stress, improved management of work-related situations and development of knowledge are all identified as outcomes.” What are the challenges?
People’s perceptions of the term ‘supervision’ are often a challenge when first introducing any form of professional or clinical supervision. For some the term conjures up feelings or memories of oversight and control. Instead professional or clinical supervision is a supportive and educative process that helps nurses to improve practice9. Other difficulties can be a fear of intimidation, breeches of confidentiality and general anxiety around the safety of the process1,3 . If a group does not follow a structured process, there can be a strong tendency for the group to break into a negative, grumbling mindset rather than trying to create a positive, supported learning environment7,8 .
The reduced amount of time given to individual issues can be a source of dissatisfaction for some. Also, the supervisee may not be skilled in the process, unsure of what to bring to supervision and what feedback they want from the group. This can affect the functioning and dynamics of the group9. Bond and Holland, in their 2010 guide to clinical supervision, advise that sharing practice issues in a group situation is fraught with uncertainty, as the risk of disclosure is thought to be higher than one-on-one supervision9. Lakeman and Glasgow also point out that a supportive group may be reluctant to challenge colleagues (which limits the critical analysis of practice) as they want to protect the group’s cohesiveness8 . Recommendations from the Trinidad pilot project included utilising a trained supervisor during the development of the group to help with the management of group dynamics and build facilitation skills. Another factor impacting on groups is inconsistent attendance. Fluctuating group numbers often arise because of the difficult task of organising and coordinating time away from people’s busy work environments1,9. However, if a robust implementation process is followed, with ongoing evaluation, these difficulties can be averted7.
How is effective peer group supervision implemented?
An excellent starting point is to recognise that peer group supervision can offer many benefits to nurses in leadership and management roles. The greater challenge is to implement peer group supervision that is effective and sustainable. Outlined below are some selections from the literature, and the New Zealand Institute of Rural Health Policy and Guidelines, regarding peer group supervision and the implementation process: »» Promotion of professional and clinical supervision for role development: Education through workshops, discussion groups and/or articles is essential in creating an understanding of professional and clinical supervision7,8 . »» Support at all levels: According to English researchers Davis and Burke, support on all levels is essential for allocation of resources to peer supervision1 . Time, funding for training and staff coverage are all required to enable peer group supervision to be integrated into everyday practice.
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cohesiveness, trust and safety within the group. Access to appropriate technology, such as Skype, is helpful for nurses working in isolation. Freedom from interruptions enables the session to be productive for all8,9. »» Session structure: According to the Harker article and Lakeman and Glasgow, effective peer group supervision works best with a formalised structure7,8 . The local nursing group used seven tools designed by the New Zealand Coaching and Mentoring Centre. In both cases, the facilitator was responsible for guiding the process, thereby assisting supervisees to meet their initial supervision goal. »» Training in peer group supervision: Harker’s peer group and Lakeman and Glasgow used a single one-day workshop to establish their groups7,8 . There may be a need for additional training depending on the experience of group members. The presence of a trained supervisor was advantageous in the initial stages of the group development 7. In Lakeman and Glasgow’s second pilot project, on evaluation, it was recommended that the group started with a trained supervisor8 . »» Guidelines and working agreement: A working agreement to guide the process and function of the group is essential for effective and sustainable peer group supervision. Detailed information can be found in the
New Zealand Institute of Rural Health Policy and Guidelines on Peer Group Supervision5 . In addition, van Ooijen’s book provides quality information on setting up peer group supervision4. »» Regular dedicated time and a safe environment: To gain benefits from peer group supervision, a strong commitment to attend sessions on a regular basis and in a dedicated space is paramount. Regular time to reflect on issues and experiences creates
Give it a go
Peer group supervision presents a unique opportunity for managers and nurses in leadership roles for personal and professional development through shared learning and peer support. Harker and colleagues in their 2015 article say: “Our experience has been that effective peer supervision groups provide a rich learning environment and increase professional effectiveness. We would urge other nurses to start peer supervision groups.”7.
About the author: Helen Shaw-Brown RGON, MHSc (Nursing) is a CPIT nursing lecturer, professional supervisor, an associate and peer group trainer for the NZ Coaching and Mentoring Centre, and a peer group participant. * The full reference list for the article is available with the online version of this article at www.nursingreview.co.nz.
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Libraries:
informing nurses anytime, anywhere What do today’s modern libraries offer nurses who walk through their doors or, more frequently, login online? FIONA CASSIE talks to district health board librarians VIV KERR and PETER MURGATROYD.
W
hen the world’s latest health findings are just a few clicks away, do we still need medical libraries and librarians? “I think they are probably more important than ever,” argues Peter Murgatroyd, library manager for Counties Manukau District Health Board (DHB), “because the evidence and knowledge to inform your work is greater than ever, through online technology and online resources, and what most people find is they are overwhelmed by potential information sources.” Murgatroyd says a key role of his team of six librarians is to identify the high-value, highly relevant evidence-based resources (usually subscriber-only) that can best inform practice. “Dr Google has a role to play – particularly for consumers – but for a nurse, doctor or allied health professional, they need to rely on evidence they know is validated and is not going to cause harm.” Viv Kerr, library manager for Hawke’s Bay District Health Board, agrees, saying libraries and librarians’ comprehensive knowledge of the majority of electronic resources makes them a one-
stop shop for nurses. “This is more efficient for them as they have a centralised point of contact.” Sue Hayward, director of nursing for Waikato District Health Board, sees DHB libraries as a great asset to nursing, with Waikato’s own library services closely involved with the project to provide an online nursing procedure resource that is now delivered to 10 DHBs across the country. “The support we get from our librarians is phenomenal. And I think in every DHB where nursing leadership links with the libraries and the librarians we become much richer for it.” In 2015 the stereotype of medical libraries as institutions with dusty text books and shelf after shelf of hard-bound journals is long gone, with more and more DHB libraries now supplying material via subscriber databases, e-journals and e-books. A trek across the hospital to access that e-material is also no longer necessary, with intranet access available at ward desktop computers or, as more and more hospitals get wifi, via cell phones, tablets or laptops. Even when hospital staff head home, many can still login to their DHB library’s electronic resources.
Ask a librarian – they know where to look
A
fter 11 years as a DHB librarian, Kerr is well aware that health professionals are generally busy so says she is always keen to streamline access to library resources. “You might have a nurse get lucky and snatch a five-minute break to take a look at something,” says Kerr. “But realistically, hospital libraries have had to get smart and make available resources via the intranet.” In the case of Hawke’s Bay, the pressure to invest more in electronic resources than in print was also Viv Kerr prompted by DHB staff stretching from Wairoa to the north to Waipukurau in the south (and until recently the Chatham Islands). Kerr says a nurse on the ward can now access the library’s complete electronic resources – from catalogue to electronic databases – from their desktop computer. “If they want to get a book out (electronic or print), they don’t actually have to come to the library – we will send it to them. So everything they require is at their fingertips really,” she says. “And if they can’t find an article or we don’t hold it, we will interloan it for them – we make it as easy as we can. It’s about supplying the information, not hanging onto it. “DHB libraries have a good wealth of knowledge and staff are always happy to support any type of inquiry or study.” Kerr says nurses commonly ask her for help with literature searches, 14
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particularly to find evidence for policy development, updating procedures or DHB innovation projects, as well as postgraduate study. She says nurses also seek out articles to read for professional development or as part of a journal club. Kerr is also education and development manager and says the combined library and education centre offers a multitude of different services for nurses and other staff, including links to online training modules, helping people use Microsoft Word, or learning about endnotes and referencing. “We are talking about busy people so they do often need a lot of support and help to get to where they need to be.” Murgatroyd also says his librarian team has specialist expertise with databases so can offer DHB staff a literature search service for the latest evidence to support clinical research, new initiatives and DHB projects etc. and can also offer all health professional staff a one-on-one tutorial on what resources are available and how to best use them. He adds that Counties-Manukau, where he has been library manager since late 2013, has also moved away from the traditional hospital library model that was largely focused on just servicing doctors’ and nurses’ patient care roles. He says with his DHB being one of the largest – with more than 5,000 staff and an annual budget of around $1.5 billion – the focus of the library is on the business of health as a whole and not just to inform patient diagnosis and treatment.
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“DHB libraries have a good wealth of knowledge and staff are always happy to support any type of inquiry or study.”
“We need to inform not just clinicians but managers, project leaders and staff involved in improvement initiatives,” he says. “So we need to understand the health system well enough to identify potential sources of data, reports and literature for staff but also keep an eye on social media and blogs to understand the current thinking around particular fields of practice. We curate both types of resources.” By curation, he means identifying and pulling together relevant information from a range of different sources into an “easily accessible package that provides good coverage of a subject area”. For instance, Counties Manukau has a very large Pacific population so many staff have a special interest in Pacific health and are looking at how they can address the very challenging needs of the Pacific community. Murgatroyd says the information is often out there but it’s scattered and people often don’t know how to start, so the library has pulled together a cluster of links to some of the best resources in a variety of areas, including Pacific health, Māori health and, recently added, Asian health. These clearinghouse sites are sited on Healthpoint so are freely available to all interested people.
Some still unaware of what libraries offer online
Murgatroyd says some nurses are avid users of these curated resources on Healthpoint and other resources the library offers electronically. “But there are many nurses who don’t make use of the library and who aren’t aware of the shift in resources, including nurses who may have been working for a long time and remember the library primarily as a physical place you went to find a physical journal or book. “So some maybe aren’t aware that so much more (library resources) are now accessible from their ward desktop computer or their laptop … and increasingly in the future through apps and mobile access.” He says he still comes across nurses, doctors and allied health professionals who have no idea what is available from the library service until they are actually sat down and shown. Kerr says with many nurses having been away from study for a number of years before they take up postgraduate study, she offers support and advice in study areas like referencing, footnotes and assignment management. When it comes to postgraduate study, Murgatroyd says he is keen for the library to support postgraduate students to be self-reliant and build their capability to use the libraries of the university or polytechnic where they are enrolled. “That’s a shift we’ve made here and I’m not sure what other DHBs do, but we feel that it’s far more sensible to encourage our staff to be aware of the resources that are available through their tertiary provider and for us to complement that and not duplicate it.” Many of the health libraries are also linked together via Te Puna (the National Library) Health Library Group, which shares resources via interloan, and there is also a health special interest group in the national librarian organisation LIANZA.
Still a physical space for study and reflection
While more and more resource material is whizzing around electronically, ‘virtual library’ style, the ’real‘ library space continues to appeal to many. Both Counties Manukau and Hawke’s Bay DHB libraries are connected to their DHB’s learning centres. In Counties-Manukau’s case, the library is adjacent to the Ko Awatea innovation and learning centre and in Hawke’s Bay the library and the education centre share a single physical space, with the purpose-built centre opening in 2005. Kerr says nurses at Hawke’s Bay mostly use the library electronically for research but some will retreat to the physical space when they need to study or work on a project or assignment – including after hours. (When Kerr first joined the DHB in 2004 only DHB doctors were allowed after-hours access to the library but she soon saw this changed.)
Now nurses often set themselves up in a corner for a few days, with the library pretty flexible about allowing them to leave their study material huddled in one spot. “We know that people like to build themselves a nest for a few days,” laughs Kerr. She says some nurses are regular library visitors; many would never or rarely ever use the library, and some arrive in a hurry two days – or even on the day – before an assignment is due. But in Hawke’s Bay’s case most DHB nurses have been through the door because they enter the space on their way to training or lectures in the learning centre lecture theatre or meeting rooms. “So they might inquire about their training course then wander off around the library browsing, sit down to read a newspaper or book, or jump on a library computer to look up their training history record.” Murgatroyd says likewise some nurses are very heavy users and appreciative of the service offered, including providing a resource space they can come to after-hours or at weekends to work on their projects or professional development. Continued on next page >>
DEPARTMENT OF PRIMARY HEALTH CARE & GENERAL PRACTICE - UNIVERSITY OF OTAGO, WELLINGTON
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Contact Information:
Postgraduate Coordinator Tel 64 4 918 5626 Email primarycare.distance@otago.ac.nz otago.ac.nz/studyprimaryhealthcare *Deadline for enrolment late January
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DHB libraries: Peter Murgatroyd
sharing with the community
M
edical libraries are also increasingly opening their doors and sharing their online resources with non-DHB health professionals. Some charge, and others like Hawke’s Bay and Waikato make much of their material and services (depending on subscription licenses) free to nurses in the community health sector from aged care to hospices. Murgatroyd says when he joined Counties Manukau DHB he was asked to take a new strategic approach to the library’s work. “My team’s role is to take a bigger view and not let our vision stop at the doors of the hospital but think of our wider partnership with PHOs and primary care,” says Murgatroyd. “Also to look at how we can improve access to resources and information for our community.” He says his challenge has been to extend access to its resources within its existing budget. Ideally he would have liked to provide access to all the many nurses working in schools across South Auckland and nurses in other community roles. But he began by negotiating with publishers for increased electronic access to its major databases and journals for health professionals working for local primary health organisations (PHOs) – some companies have given extended access initially for free and others are charging a 10 per cent premium. The new service went live in September 2014 with the key flagship offer to nurses being access to the full text nursing and allied health literature database CINAHL. Murgatroyd says take-up from the PHOs is a “slow burn”, with each PHO asked to nominate a key contact who can arrange usernames and passwords for electronic access for interested nurses, doctors and other health professionals. Meanwhile its physical library is open to any health professionals – from hospices to rest homes and schools to general practice – to access during office working hours. “We have a ‘walk-in, sit-down and make yourself at home and we will help you find what you need to find’ policy,” says Murgatroyd. He says the library’s philosophy is to have as equitable access to library resources as possible for clinicians, whether they are serving patients in a small rural practice or at Middlemore Hospital. Kerr says the DHB library service has been open to non-DHB health professionals for at least eight years as part of the DHB’s ‘transform and sustain’ focus on the Hawke’s Bay health system as a whole. This means the library also incorporates health professionals from the wider community in any consultation or planning. She says the reality is that not many non-DHB staff physically visit the library but they do access the resources available electronically (some are not available to non-DHB staff due to on-site only licences) and if they are visiting the hospital for Grand Rounds or training they will come and visit afterwards.
“... ask a librarian because nine times out of 10 they will be able to point you in the right direction.”
Check it out for yourself
Take a visit to your local DHB library in person to check out what is on offer, is Kerr’s final advice to nurses. 16
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“There is just a raft of resources that will help them … even if they’re not sure what they want. Just go in and talk to somebody. They don’t need to be fully knowledgeable about libraries because librarians are always happy to help and to show you what you need to know and help you get what you need to get. “Definitely feel free to come and visit – I would encourage it actually.” Kerr says she speaks each year on orientation day for new nurses and one of the first things she always says is “don’t leave it to the last minute – come and see us first because we can inevitably help you. It gets more difficult the longer you leave it. “It doesn’t matter what it is, I would suggest you ask a librarian because nine times out of 10 they will be able to point you in the right direction,” laughs Kerr. “You would be surprised the knowledge that librarians have of any organisation.”
What libraries can offer »» Help with literature searches or literature search services »» Tutoring on how to search electronic databases »» Interloan services to access articles or books held by other library services »» Often online 24-hour access to electronic information »» Help with using APA (American Psychological Association) referencing style »» Some offer advice on proofreading, endnotes and assignment management »» Books and journals to browse »» A quiet place for research, study, reflection or to catch up on the newspaper »» Often local historical health and hospital material in archives. NB: Most DHB and/or medical libraries are open to visits from non-DHB local health professionals but access to library services, particularly electronic, for non-DHB staff varies from region to region. Some are free, some charge a membership fee and some restrict access to some electronic resources because of subscription licence conditions.
Information clearinghouses
The library service for Counties Manukau DHB has developed a range of clearinghouses of selected databases, journals and other useful research, information and resources on a range of topics including: »» Pacific health »» Māori health »» Patient and whānau-centred care »» Asian health. The clearinghouses can be found at: www.healthpoint.co.nz/public/other/ counties-manukau-health-library-database
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Where are our nursing leaders?
Closer than you think OPINION: JO ANN WALTON says it is time to stop hoping some ‘mythical matrons’ – a la Florence – will emerge to lead the nursing profession to new heights. Instead, she argues, it is time to recognise the everyday leaders working amongst us.
I
have just spent two weeks in a classroom with some wonderful nurses, midwives and others talking about health care, research and a range of other topics. The opportunity to explore experiences and ideas is one of the things I most love about my job as an academic. Mostly I am excited about what I hear, especially the creative solutions generated in the room. On the other hand, sometimes I leave the classroom troubled. One of these troubles resurfaced for me last week. We were discussing health care leadership. Somehow the familiar refrain “where are our nursing leaders?” was raised yet again. I think I have heard this question, or variations of it, repeated numerous times in every one of my 30plus years as a nurse. It keeps being raised in the media too. In fact, on my desk last week was a short article from the Nursing Times in the UK (17 September 2014) in which one of the peers (the only member of the House of Lords with a nursing background) was commenting on the problem of leadership at all levels in nursing in her country. But leadership doesn’t depend on position or level. It is about action and vision. That troublesome question – “where are our nursing leaders?” – has been playing on my mind for days, like an annoying tune (an earworm, I’ve heard it called) that won’t leave you alone.
A leader by any other name
So there I was in the classroom, and we were talking about the challenges and rewards of working in health care. We heard about the challenges of keeping the team together, of managing in the face of budgetary constraints and policy limitations, and of working to lift spirits, meet individual needs, and help solve personal crises. We learned about ways to help resolve team conflicts, to manage across disciplinary boundaries, and to design and launch new projects that enable safer, better and more efficient care for patients, families and communities. We talked about creative problem-solving, ways to help our managers manage better, and the importance of really listening when
someone needs to be heard. People described the challenges they face and how, at times, they struggle to achieve the work-life balance they need while counselling others on just this topic. We discussed the challenges of dealing with ‘difficult’ colleagues, of guiding others gently, of deciding when to pull rank, how to develop others, when to blow the whistle and when to whisper rather than shout. We examined the difficult task of leading through influence when you don’t have authority, and how to harness our personal power. We considered the importance of maintaining our own values, of working from our individual strengths and ways to clarify what exactly these are for each of us. And still the question arose: “where are our nursing leaders?” As I see it, the question is all wrong. It is as if we are expressing a nostalgic longing for a past that never really existed, in which a strong and charismatic figure (a mythical matron: maybe Florence herself) would take charge and lead us into a rosy future. Somehow, perhaps, a return to ‘how it used to be’ would shelter us from uncertainty and all our troubles would be over. In this wistful dream the hierarchical pecking order, subordination of juniors, sluice room horrors, sputum mugs, and misaligned bed wheels that made up the ‘good old days’ are all forgotten. We also forget that we have won other victories over time. And with time what we now know about good and effective leadership has changed.
Look for leaders all around you
Much (if not almost all) of the current writing about leadership suggests that good leadership requires highly developed communication skills, good insight, the ability to empower and develop others, to listen carefully and well, to build teams, to work from a strong values base and to articulate a clear vision that others want to work towards. That and more. Leadership isn’t easy. I have my own answer to the question “where are our nursing leaders?” They are all around us. I have just been talking with classrooms full of leaders. I sit with them in committees and meet with them in the wards and in clinics and the community. Highly motivated, generous, wellqualified women and men whose passion is to see
Jo Ann Walton
“It is as if we are expressing a nostalgic longing for a past that never really existed…“ that our health care system does what it promises in delivering competent, safe and compassionate care. People who are ready to push themselves to achieve yet another step in their career; who accept and even look for challenge; who are willing to stand up and to step forward are there in all sorts of guises: young and not so young, new graduates and old hands, born here or born elsewhere. When their lives are already full of responsibility they enlist for more. They are the nurses we all aspire to be. Some are strong and commanding, others are quiet and thoughtful. Next time you hear the question “where are our nursing leaders?”, don’t hesitate. It is a question that deserves a confident and genuine answer. Start naming some of the very many you already know. I know I will. *About the author: Jo Ann Walton is Professor of Nursing at Victoria University’s Graduate School of Nursing and an elected member of the Nursing Council of New Zealand.
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Graduate incomes:
How does a young nurse’s income stack up How nursing against those of his or her peers who become stacks up… teachers or lawyers? Do we lose more young nurses overseas than other professions? and falls down Why does the average income of nurse graduates plateau and fall after five years? FIONA CASSIE reports on two Ministry of Education studies about young graduates’ incomes and destinations.
S
chool leavers these days can go online and check out how their likely income as a nursing graduate compares with those for more than 50 other types of graduate degrees. The information shared on the Careers New Zealand website is based on Ministry of Education research that uses tax data to track the income and destination of our young graduates (see more about studies below). The focus is on young New Zealand graduates, with the aim of helping guide young people, their families and their career advisors to make career choices.
Good news – at first
So what does the potential young nurse find out about nursing’s prospects? And how does graduating with a nursing degree stack up against other degrees? The good news is that, at least initially, the incomes for young nurse graduates stack up pretty well compared with the average young graduate. Study lead author Zaneta Park says in general the median earnings for nursing degree graduates are good, particularly in the first five years poststudy. She says median earnings start off higher for nursing graduates than for many of the other bachelor graduates, including those who study computer science, accountancy, law, languages and biological sciences. Even five years after graduation, nurses’ earnings are still relatively high – though by this stage law and accountancy graduates are similar and computer science graduates are now higher.
Six years post-study – not so good
But Park says nurses’ incomes then show an unusual trend by dipping in both the sixth and seventh year after study, with the average income seven years post-study actually being lower than it was four years after graduation. The only other graduate group dozens of degrees examined. 18
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experiencing a similar trend are the human welfare studies and services graduates, whose income peaks at six years post-study, then falls. Graduate in both degrees are overwhelmingly female: 95 per cent of young nurse graduates and 88 per cent of human welfare studies and services graduates. “Our assumption was that this [dip] may indeed be because graduates who complete a bachelor’s qualification in nursing tend to be female and so six to seven years after graduation tend to be more likely to reduce their hours of work for family care reasons (or otherwise make changes that reduce their earnings; for example, perhaps they are less likely to work overtime, or to be on call),” says Park. But looking at other careers where a high proportion of graduates are female; for example, teacher education (91 per cent) and radiography (89 per cent), there is no similar fall-off in earnings. “We are not sure why this is the case,” says Park. Another trend in which nursing stands out from the crowd is the high proportion (69 per cent) of young nurses pursuing further study in their first year after graduation, which is due to the many district health boards that include postgraduate certificates or papers as part of their NETP (nursing entry to practice) programmes.
High number pursuing further study
Because the Ministry of Education assigns each graduate to a single destination category each year (and carrying out any study means graduates are assigned to the ‘further study’ category rather than the ‘employment’ category), this results in
a degree of confusion for students and parents when comparing job prospects immediately after graduation. (N.B. In table 1 the figures for ‘in work’ and ‘further study’ have been combined to reflect this anomaly.) Young nurses carrying out further study are rewarded with the median and top incomes for nurses with a postgraduate certificate or diploma being substantially higher (see table) than for nurses with only a bachelor’s degree. But while the incomes of the top 25 per cent of earners kept steadily growing, the median income for postgraduate qualified young nurses also dipped in the sixth and seventh year.
Young nurses heading offshore
Traditionally leaving New Zealand for an OE (overseas experience) has been a common rite of passage for many young New Zealanders and nurses have been no exception. But if anyone in the nursing sector was concerned that young nurses made up a disproportionate part of the ‘brain drain’ of young people heading offshore, this is not borne out by this study. It shows that eight per cent of 2008–2009 young nursing graduates (a pool of 1,300) headed overseas straight after graduation, which is lower than the 10 per cent average for all 28,800 young people who graduated at the same time. The number of young nurses heading overseas continues to grow until it peaks at 29 per cent five years after graduation. It then falls back to 25 per cent overseas by seven years post-study, which
Study details The studies are based on the anonymised tax and tertiary education data of cohorts of young people who graduated between one and seven years before. The cut-off for this study was the tax year to the end of March 2012, so the cohort of nurses who were seven years post-study was based on nurses who had graduated in either 2003 or 2004. The nurses who were two years post-study had graduated in 2008 or 2009. The focus of the studies is on young people, with the cut-off age being 24 years or under for nurses on finishing their degree and 26 years or under on completing a postgraduate certificate. Both the ‘What young graduates earn when they leave’ study (published online May 2014) and the ‘What young graduates do when they leave’ study (published online June 2014) can be found at www.educationcounts.govt.nz. Zaneta Park, of the Ministry of Education’s Tertiary Sector Performance Analysis group, was lead author for both studies.
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is considerably lower than the 31 per cent of all graduates from the same time period who are out of the country. When it comes to health professionals, the number of nurses overseas seven years post-study is on a par with medical graduates (26 per cent) and substantially less than pharmacy graduates (39 per cent), radiography graduates (35 per cent) or dentistry graduates, with the statistics showing half of young dentists are overseas six years after graduating.
“… median earnings start off higher for nursing graduates than for many of the other bachelor graduates…” Law (35 per cent), accountancy (37 per cent) and computer science (37 per cent) graduates are also far more likely to be overseas seven years after graduation. Amongst the graduates least likely to be overseas are teacher education graduates, with 17 per cent overseas seven years post-study.
Whether the school leaver contemplating nursing will be influenced by these statistics and findings is not known but current statistics show that nursing is holding its own in the graduate income stakes, well for at least the first five years.
Comparison between nursing and other degree graduates Nursing
Teaching
Law
Medical
Median income 2yrs after graduating
$51,000
$47,000
$47,000
$90,000
In work and/or further study 2 yrs after graduating
81%
90%
84%
83%
Overseas 5 yrs after graduating
29%
17%
27%
22%
Overseas 7 yrs after graduating
25%
17%
27%
26%
‘Other’ 7 yrs after graduating (i.e. not in paid work, or overseas, on benefit, or on ACC or paid parental leave)
7%
7%
7%
4%
Median income 7 yrs after graduating (undergrad degree only) (hons/postgrad cert or dip)
$54,000 $61,000
$56,000 $62,000
$67,000 $81,000
$114,000 -
Top earners 7 yrs after graduating (undergrad degree only) (hons/postgrad cert or dip)
$67,000 $78,000
$67,000 $68,000
$84,000 $108,000
$134,000 -
Postgraduate funding steady for 2016
I
t is now around eight years since funding for postgraduate nursing study was decentralised to district health boards. The funding has been basically static for a number of years but the number of training units it supports has still managed to grow slightly as more nurses across the regions come on board (see table). Health Workforce New Zealand (HWNZ) group manager Ruth Anderson says $12.7 million of the $13 million allocated for postgraduate study was utilised last year. She says the funding pool is the same for 2015 and at this stage it looks like it will remain the same for 2016. (HWNZ has said a pilot to boost the numbers of nurse practitioners in 2016 – see ‘Nurses unconvinced by positive PA evaluation’ on page 20 – will not be funded from the postgraduate nurse funding pool.)
Increased study uptake by ARC nurses
Sue Hayward, head of the national Nursing Education Advisory Team (NEAT), says one trend in recent years for the funding pool has been the increased study uptake by nurses in aged residential care who are feeling more supported by their employers and are becoming “positively engaged” in postgraduate study. “In residential aged care we are breaking down the concerns of facility owners about getting funding to release their nurses for study – they are
finally getting to understand all that, which is really great for that workforce,” says Hayward, who is also director of nursing for Waikato DHB. Hayward says directors of nursing in the DHBs around the country are driving the uptake of HWNZ postgraduate funding in areas they know the workforce is most vulnerable and needs extra educational opportunities to support the patient demand.
DHB spending prioritisation challenge
Hayward says the next challenge is to allow each DHB to prioritise how they spend their allocated postgraduate study funding. This will become
particularly important as the country heads down the path of nurse prescribing and expanded scope roles like nurse endoscopy and nurses as first surgical assistants. She says it is likely there will be a little concentrated “hump” of spending once the prescribing postgraduate diploma is confirmed and nurses seek support and funding to pursue becoming prescribers in their specialty. “I think what we want to relook at is how we support financially the expanded scopes – particularly ongoing implementing of roles like nurse endoscopist – because of the amount of time they need to be backfilled.”
HWNZ-funded postgraduate nurse study statistics
2011 1,429 (training units*) 2012 1,442 2013 1,480 2014 1,524 ($12.7 million of the $13 million allocated to postgraduate nurse study was utilised) 2015 793 (to date i.e. semester one) *A training unit is the equivalent of a two-paper PGCert or one year of a PGDip or master’s degree programme (with or without clinical mentoring).
Te Pou skills matter (targeted mental health nurse postgraduate funding) 2013 2014 2015
40 funded places on Clinical Leadership in Nursing Practice (CLNP) programmes 47 trainee places on CLNP programmes 39 trainee places on CLNP programmes (reduced to increase NESP – New Entry to Specialist Practice – places in 2015).
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A positive evaluation of a Health Workforce New Zealand-funded physician assistant (PA) pilot in primary health has been released. HWNZ has no plans to take further steps to initiate a PA training programme but more US-trained PAs are being sought by practices and an application for regulation of the role is in the pipeline. FIONA CASSIE reports.
Nurses unconvinced by positive PA evaluation
A
just-released evaluation of the $1.2 million pilot of physician assistants working in general practices is generally positive about the new health role. But nurse leaders remain sceptical of the usefulness of importing an unregulated workforce needing doctor supervision when New Zealand is yet to make the most of the nurse practitioner (NP) model. The evaluation report was on Phase II of the physician assistant (PA) demonstrations commissioned by Health Workforce New Zealand (HWNZ), which involved seven US-trained PAs being brought in to work in four general practice or rural settings across the country. (See more about PA role and pilot on the next page.) The report was commissioned to consider the potential contribution of the PA role to the existing health workforce and found that the vast majority of demonstration site staff believed PAs made a valuable contribution and patients were satisfied with the care they received from the PAs. The report concluded that all demonstration site employers were ”very keen” to maintain the PA role beyond the end of the demonstration pilot and
NZPAS says supervision doesn’t limit PA usefulness George Froehle, a spokesperson for the New Zealand Physician Associate Society (NZPAS), says it was misleading [for NZNO and the College of Nurses] to say the need for supervision limited PAs’ usefulness in primary care. “While PAs do operate under supervision, that supervision is not overly burdensome to the supervising physician and it does not in any way limit our scope of practice,” says Froehle. He says supervision involves ensuring the supervising physician and the PA develops a scope of practice plan that reflects the PA’s specific skills sets; the physician being available to answer questions either in person or over the phone, and retrospectively reviewing the PA’s caseload every few months. “The trial specifically showed that PAs were incredibly useful in primary care, delivering high levels of care to over 30,000 patients without a single incident of harm,” says Froehle. Froehle is working with NZMA on the submission for PAs to be regulated under the HPCA Act (see main story).
Tui Medical keen for more PAs
Froehle was one of three pilot PAs who worked alongside a nurse practitioner and four more nurses on the NP pathway at three Hamilton drop-in clinics. Rebekah Elphick, quality manager for Hamilton’s Tui Medical Centres (formerly part of Radius Medical) as well as a clinical master’s qualified nurse on the NP pathway, says Tui is keen to employ more PAs to work in its clinics. “We have found that the PAs and nurses training to be NPs have worked incredibly well together, particularly in the acute medical and accident scope of our services and in our larger free clinic with the high-needs population,” says Elphick. She says of the three pilot PAs starting out in Tui’s clinics, two were still working with Tui in August and the third had returned to the United States at the end of her two–year visa for personal reasons. Elphick says Tui has advertised for more PAs from the USA and was near to offering jobs so it could add more PAs to its team. She says one of the two original PAs would be staying on with Tui, as she had no visa issues due to being married to a New Zealander. Froehle is returning to the USA at the end of his two-year visa but says he plans to continue as president of NZPAS to support the role in New Zealand and may return once regulation is established.
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it did not receive any evidence to suggest that this should not happen. Hilary Graham-Smith, associate professional service manager for the New Zealand Nurses Organisation, says NZNO remains unconvinced the PA role is required in New Zealand. “NPs do not need supervision and PAs do – limiting, we believe, their scope and usefulness across the sectors where they would be most useful e.g. primary care.” Professor Jenny Carryer, executive director of the College of Nurses, says the evaluation shows that no harm has been done by the PA demonstration but she too has no idea why New Zealand would want to start afresh with PAs when NPs can already do all the work of PAs and more, including prescribing, without supervision.
No PA training plans
Ruth Anderson, group manager of HWNZ, says there are no plans to offer further HWNZ funding to establish, or support training infrastructure for, the physician assistant role in New Zealand. “The Ministry will evaluate any applications for regulation of the role according to the criteria and processes employed for all applications,” says Anderson. She adds that employers are currently able to recruit PAs as long as the PAs do not undertake work regulated under the Health Practitioners Competence Assurance Act or other legislation. Graham-Smith says NZNO is pleased that there will be no further investment in PA training by HWNZ. “In our view, the pilot was unnecessary and was conducted in a vacuum without any policy work to support the introduction of the role.” Carryer, who was a member of the demonstration advisory group, says she believes the evaluation was properly conducted and efficient but she regrets that a million-plus dollars was spent on an experiment for a “workforce that we do not need if we got our act together with the existing workforce”. “More investment in NP positions and more investment in postgraduate education for primary health care nurses would have been a better use for that money.” Carryer adds that she cannot see why New Zealand should need to go to all the ‘”extra trouble’” of regulating the PA role when “we have yet to fully utilise the NP model fully”.
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The New Zealand Medical Association (NZMA) and the New Zealand Physician Associate Society (NZPAS) have confirmed that they are working together on a submission to HWNZ asking for the PA role to be regulated under the Health Practitioners Competence Assurance (HPCA) Act. It is understood the submission is currently in draft form and once lodged HWNZ would make a recommendation to the Minister of Health. An NZMA spokesperson said the Medical Council of New Zealand has agreed to provide regulations if the Minister backs regulation of the PA role. Meanwhile Health Minister Jonathan Coleman recently announced HWNZ is to allocate $846,000 to pilot a one-year dedicated training programme for 20 would-be nurse practitioners in 2016, which has been warmly welcomed by nurse leaders.
PAs welcomed by practices
During the Phase II PA demonstration, three PAs were based at three drop-in clinics run by Hamilton’s Radius Medical group (now called Tui Medical). Two went to a Tokoroa practice, one
”NPs do not need supervision and PAs do – limiting, we believe, their scope and usefulness across the sectors where they would be most useful e.g. primary care.” to Waikato-based iwi provider Raukura Hauora o Tainui, and one was based at Gore Hospital’s emergency department. (The Phase I trial of the PA role involved two PAs working at Middlemore Hospital in Counties Manukau District Health Board in 2012.) The evaluation report found the physician assistants undertook more than 30,000 patient consultations during the evaluation period and surveys indicated that doctors, nurses and other staff believed the PAs made a “valuable contribution” to their clinical settings, including improving patient throughput and reducing the workload of existing staff. Patients surveyed were equally satisfied with the care they received from PAs and the existing health workforce.
Pas: the current position »» PAs undergo generalist training based on medical training. »» PAs can be delegated to carry out patient assessment and prescribing under physician supervision. (During the New Zealand trial, PAs were unable to sign prescriptions or file ACC claims etc). »» In the United States training is a two-year postgraduate qualification, with about half coming from a nursing background and the remainder from other health professions, such as paramedics and physiotherapy. »» A US Department of Health report says that there were approximately 106,000 nurse practitioners and 70,000 physician assistants practising in the US in 2010 (55,000 of the NPs and 30,000 of the PAs were practising in primary care). »» Other countries that have adopted the PA role in some form include Canada, the United Kingdom and the Netherlands. »» Australia has trialled PAs and the Australian Society of Physician Assistants reports on its website that Australia is reviewing its legislation and government position.
Hwnz role in demonstration sites »» HWNZ developed a governance document making it clear that the medico-legal responsibility for unregulated PAs’ work lies with the supervising doctor. The supervising doctor also sets the scope and responsibilities of the PA and must be available for consultation by the PA at all times. »» HWNZ facilitated the appointment of PAs, including taking part in interviews and offering funding support for travel, visa and relocation costs. »» HWNZ also funded professional development for the PAs and general project coordination.
The survey says most nursing respondents indicated there was no negative impact on nursing and that the two roles complemented each other. “In a few cases, some nurses indicated that they had stopped doing some tasks they had Jenny Carryer previously undertaken, such as suturing, and a nurse at one of the sites indicated a concern that the autonomy of nurses at the site had been reduced,” says the report. The report also noted that some interviewees expressed concerns that the growth of the PA role would come at the expense of developing the NP role. Senior managers of the three host employers emphasised the cost–effectiveness of the PA role. The evaluation report noted it was commissioned only to look at the “potential contribution of the PA role” and not to look at PA regulation, establishing training programmes or long-term integration of the role. But it says that if the PA role is to develop into a “homegrown” role then several issues need to be considered. These include regulation and medico legal issues (including prescribing and supervision boundaries), the cultural fit of UStrained PAs, implications for developing existing professions, and whether in some settings the reduced costs of PAs, compared with doctors, may be a “powerful driver” to develop the PA role further. *The usual title given to the profession is physician assistant and this is the established title in the United States. But since the demonstration got underway, HWNZ has been using the alternative title of physician associate.
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NETP:
a decade of growth Ten years after The 2014 NETP graduates at Tairawhiti DHB introduction, nursing entry to practice (NETP) programmes are now seen as the established norm but demand for places outstrips jobs available. FIONA CASSIE reflects on a decade of NETP and talks to nurses about the very first NETP intakes.
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There have been alarming instances of new graduates being employed on a casual basis as part of an emergency ‘pool’...” So stated the 1998 Ministerial Taskforce on Nursing. The Taskforce report also noted many acute hospitals expected nursing graduates to “immediately take up a high workload and a high level of responsibility with little structured help or support”. It’s been 10 years since the government gave the green light to funding new graduate programmes, bringing in the first nationally consistent clinical training support for novice nurses. At the time, support for new graduates in their first year of practice varied considerably across the country with some fortunate new graduates securing a place in formal new graduate programmes and others, like the less fortunate casual pool nurses, being expected to be workready in any setting. The gold standard then was the already long-established new graduate programme for mental health nurses (now known as the NESP or new entry to specialist practice programme). The Taskforce recommended NESP be the template for a national framework of funded new graduate programmes to support this “vital time in the development of a truly professional and effective nurse”. After a pilot in 2002 and a positive evaluation report in 2004, the government in July 2005 finally announced funding for a national framework of nursing entry to practice programmes (NETP). So in mid-2006 the first three district health boards to gain Nursing Council accreditation for their NETP programmes were given a subsidy of $6,000 per graduate to deliver the course – roughly 50 per cent of the estimated cost. The rest of the DHBs came on board in 2007 and in 2009 the first NETP places were offered in primary health and residential aged care.
Fluctuating supply and demand for NETP places
For many of the early years of NETP there were more funded places available than were ever filled, with a number of DHBs struggling to attract new graduates in a buoyant job market. 22
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But this reversed when the global financial crisis saw nursing turnover stagnate and DHB budgets tighten, at the same time as record numbers were graduating from the country’s nursing schools in readiness to replace the country’s ageing nursing workforce. It was a perfect storm that saw NETP numbers fall and plateau in 2010 and 2011 (see table) and then start to steadily climb, but not fast enough to match the growing graduate cohorts. Faced with keen new graduates struggling to find work – and the added fear they could be lost to the profession, which would ultimately need them to replace retiring baby boomers – the New Zealand Nurses
Organisation (NZNO) last year launched a petition calling for the government to fund an NETP place for every graduate. The petition reached 8,000 signatures and the then health minister, Tony Ryall, responded by announcing 1,300 NETP places would be funded in 2015. Unfortunately, with nearly 1,800 new graduates registered last year, this falls far short of NZNO’s expectations. Also, whether the sector will be able to step up and employ 300 more nurses than last year (see table) to fill those extra NETP places is yet to be seen. Improved data is now available on graduate trends through the central clearinghouse for NETP
Southern Cross joins NETP Southern Cross this year became the first private surgical hospital group to get NETP government subsidies for its new graduates Carey Campbell, chief nurse advisor for Southern Cross Hospitals, said Southern Cross first started working towards gaining NETP funding in 2010 but at the time Health Workforce New Zealand (HWNZ) specifications didn’t allow government funding for new graduates employed by private surgical hospitals. But she says by 2013/14 the country’s private surgical hospitals were employing about 50 new graduates (25 of those by Southern Cross). “This was a significant contribution to the nursing workforce – the number being larger than many DHBs.” Campbell said sharing this information with HWNZ and the Ministry of Health’s Office of the Chief Nurse at the same time as there was ministerial pressure over employing new graduates “certainly helped our cause”. HWNZ spokesman Ruth Anderson said it considered Southern Cross’s application last year as part of its commitment to increase the number of new graduates employed in quality entry to practice programmes. It also followed the government’s July 2015 announcement to fund up to 200 additional new graduate places in 2015. “HWNZ has a role to ensure the sustainability of all parts of New Zealand’s health workforce,” said Anderson. “To fulfill this role, funding support for training in both the public and private sectors must be considered.” As a result, HWNZ agreed in October 2014 to fund Southern Cross for up to 25 new NETP new graduates in 2015 ($7,200 per graduate) dependent upon Southern Cross’s NETP programme getting Nursing Council approval. Campbell said Southern Cross gained Nursing Council approval in April and currently has 20 new graduate RNs employed across the country, with 17 funded through NETP. Two further NETP places will be available in the September intake, making a total of 19 NETP this year. For the first time, Southern Cross will also be added as an employer option for new graduates applying through the Advanced Choice of Employment (ACE) recruitment clearinghouse for the 2016 NETP intake. The number of NETP places Southern Cross will be funded for in 2016 is still under discussion and HWNZ says it also needs to consider existing training funding commitments to district health boards.
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“…there are still issues around the fact that we are not funded for every single graduate and so a number of graduates miss out on the NETP programme, therefore can fall between the cracks.” and NESP applications known as ACE, which was first used for the February 2013 NETP intake. The February 2015 ACE round saw an increase in new graduates in NETP jobs and also saw places in the mental health NESP programmes swell from 152 last year to 175 this year. And for the first time NETP funding has been allocated to new graduates employed at private surgical hospital provider Southern Cross (see sidebar).
NETP: a year for clinical consolidation and/or postgraduate study?
“I don’t think anybody would argue that the NETP programme has been a tremendous asset to establishing people’s first year of practice in a safer way then we used to do,” says Professor Jenny Carryer, executive director of the College of Nurses. “But there are still issues around the fact that we are not funded for every single graduate and so a number of graduates miss out on the
NETP programme, therefore can fall between the cracks,” says Carryer. While only a handful of DHBs at the outset included postgraduate papers as part of their NETP programme, this has expanded over the years until only a handful now do not. Some DHBs have taken this a step further and are offering top graduates an honours programme in their second year, with the option of progressing into studying for a health sciences doctorate. Carryer, for one, sits in the camp that believes NETP should be a year focused on the consolidation of clinical skills. “It is a year they [new graduates] are under enormous pressure to think on their feet, time manage and take responsibility for decision-making – all of those first-year learning challenges. And personally I don’t think we should distract them with a postgraduate paper that year.” Also, graduates in their first year of practice usually haven’t yet decided on their likely career path or specialty.
NETP places filled 2006
174
2011
835
2007
710
2012
911
2008
813
2013
933
2009
886
2014
1,000
2010
840
2015
777
Sitting in the other camp is associate professor Judy Kilpatrick, head of The University of Auckland nursing school, which offers postgraduate papers in partnership with many DHBs’ NETP programmes. “What we actually found was that graduates were doing some quite high-level things in that first year and postgraduate study was a perfect way to give credit and shape up their thinking.” She said the paper involved a high level of clinical assessment but formal study did not commence until the second semester of the NETP year to give graduates a chance to adjust to working life. “I think that postgrad study firstly helps retain the graduates; secondly, they are able to get new knowledge – at a sharper and higher level than Continued on next page >>
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Nursing Review series 2015
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NETP pioneer inspired to nurture today’s new nurses
undergraduate – that they can apply in the clinical area; and lastly, by the end of the first year they are already cementing themselves in the pathway of where they want to go.” She says rather than being burnt out, the graduates all complete and many will go on to pursue further postgraduate study (though quite a few take a break after completing their postgraduate certificate and look around before resuming study at the next level). Sue Hayward, director of nursing for Waikato DHB, which offers the honours programme to leading second-year nurses and now has two recent graduates on the doctoral path, also believes postgraduate study in the NETP year consolidates what graduates have learnt in their undergraduate degree. She says the Midlands region of DHBs have negotiated for graduates then to have a longer gap, if they wish, before they do the second paper of their postgrad cert but most have completed their certificate within three years. “It’s not arduous – though it’s not easy,” says Hayward. And retention, even taking into account the current economic environment, was very good, with 96 per cent of NETP graduates staying on and going into permanent positions. Dr Kathy Holloway, national chair of nurse educator group NETS, was part of a team that evaluated the first three years of NETP and found the supported first year of practice programmes was enhancing trainees’ confidence and competence. She says DHBs had always done some form of new graduate programme but they were very variable across the country and there needed to be some consistency and structure, which national funding enabled it to have. And expanding the scheme into primary health care, aged care facilities, some non-governmental organisations and some private surgical hospitals meant it could support graduates entering the wider nursing workforce. “But we still have the goal of 100 per cent employment of nurse graduates into an NETP position if they seek one.”
NETP specifications »» A maximum of two clinical placements/ rotations within the maximum 12-month programme. »» Clinical preceptor support throughout the duration of the programme (sharing clinical caseload for six weeks in total). »» The equivalent of 12 group learning/study days (including any postgraduate papers). »» A sub-contract between the parent DHB and any other employer, i.e. general practice or residential aged care facility. »» Health Workforce New Zealand funds $7,200 per graduate towards six-week clinical caseload sharing by preceptor, 12 days release time for study days and 16 hours training for preceptors. »» Aged residential care providers meeting certain training criteria can receive an additional $12,800 to cover extra preceptorship and supernumerary release time.
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Sharon Fisher was not new to her first ward but still recalls those first few weeks as a ‘real’ nurse as “absolutely terrifying”. The mature student and mother of two had had a student placement at the Waitakere Hospital medical ward that became her nursing home as a new graduate nurse in Waitemata DHB’s first official NETP cohort (also one of the country’s first) back in 2006. The ward was familiar and friendly but being a new nurse was still testing to the nerves. Sharon Fisher “I can recall around week four doing a blood pressure on a patient and it was something ridiculous like 80/60 when I knew that 120/80 was normal,” recalls Fisher with a laugh. “I wasn’t panicked as such but I was certainly perturbed and can just remember the clinical coach being on the floor at that stage and calming me down by making me aware that you look at the patient as a whole, rather than as a set of numbers. So when I took that into account I realised she was a tiny little dot of an old lady… and I recall feeling really, really supported by my ward staff and the NETP people.” Fisher had applied to both Auckland and Waitemata DHBs and been accepted by both but chose Waitakere as she had enjoyed her placement and lived ‘out west’. But another factor was Waitemata’s NETP at that stage did not include a postgraduate paper and after three years of study with two preschoolers, she didn’t want to do any more study for a while. “I really felt that a year of just learning to be a nurse – without the pressure of more study [was what she wanted].” (Though she has since done the assessment paper now offered in the NETP year and thinks it may not have been as hideous as she had feared as a new graduate.)
Emerging confidence
Looking back, Fisher can recall near the end of her NETP year an incident when she had the confidence to test her nursing wings. “I had a patient who was dying in a little windowless treatment room and I had the opportunity to move her into a single room with a view over our little pond – so I did. “Our charge nurse questioned me, as the patient died within hours, about the cost of the moving, extra cleaning etc – and I can recall feeling very much that I was able to justify why I’d done it. I really felt that for the family to have their family member die in a room with a nice view and some sunshine rather than a poky internal room was an important part of that patient’s death. I thought it was the ethical, right thing to do … and I certainly wouldn’t have done that at the beginning of my new grad year.” Fisher went on to become a district nurse, still based at Waitakere Hospital. She completed her postgraduate diploma and has started her Master of Health Science research thesis looking at new graduates’ interest in placements with older adults. She herself also became a preceptor and recently successfully applied for a clinical coach position within the NETP programme, which she sees as playing a vital role in nursing. “I think if we can get in and shape our new grads at the beginning and give them an experience like I had – I’m still nursing 10 years down the track and I’m still at Waitakere.” She says being able to spend time with fellow new graduates in the same position as herself made a “huge impact” as that year can be “overwhelming” and she definitely sees herself long-term working as a nurse educator to help nurture new nurses.
Supportive new grad year sealed love for ED nursing Lola Brownlee’s new grad year in ED was so positive she is still there a decade later. Another of Waitemata DHB’s first cohort of NETP graduates, she started in North Shore Hospital’s emergency department (ED) in 2006. She has now completed her clinical master’s in emergency medicine and is one of the ED’s team of clinical charge nurses. The former bookkeeper and mother-turned-nurse recalls being excited just Lola Brownlee being on the floor doing what she had chosen to be her new career – nursing, though it was also quite daunting coming from nursing school straight to ED as you initially thought you didn’t know anything. “But you quickly learn, with support, to trust what you’ve learnt and to trust the people around you … and with NETP you’ve got somebody you can trust to ask the silly questions to make sure everything is okay.” She says her pioneering ED NETP programme may not have included postgraduate papers but did include intense learning of the ED training manuals for each area and training in areas like cardiac assessment skills and resuscitation. “I think to do postgrad study in the first year in ED would have been too much because we had so much learning to do on the floor that year but they’ve revamped our ED programme and now they start postgrad study in the second semester. I think some new grads find it difficult to try and learn what they need for working on the ED floor, as well as postgrad study.” Brownlee thinks ED is possibly slightly different from nursing in other acute areas. Just consolidating newly learnt skills in the first year could be a good thing, she says, then starting postgrad study in the second year when nurses better “know what they don’t know”. “I think the support I got from the coaches in the new grad programme was really amazing. So I never felt scared – though there were times I felt challenged… like the first time you see a death.” Brownlee says in time, and with support, you can tell from the data and your observations that the patient in front of you is not just sick but really sick and you realise you are really nursing. “It boosts your confidence that you’ve developed that critical thinking where you can tie things together and when you go to the doctor there is a reaction and they start trusting you as a nurse – it’s quite exciting.”
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Critical thinking in nursing education:
addressing the theory-practice gap
Jed Montayre
T
he ability to critically process information to make sound nursing decisions is an important skill that nurses acquire through years of experience. The framework for nursing education means nursing training is not typically delivered like other professional degrees and includes an enormous practical component during which a student hones their knowledge and skills. Every nursing school aims to provide the best quality learning experience to their students. Nursing education also has a significant role in preparing students for the challenges beyond the four walls of the lecture theatre or simulation lab and out into the real world of nursing. So activities encouraging critical thinking skills are integrated into the nursing curriculum.
Critiquing in theory and practice
The term ‘to critique’ is a popular and commonly used instruction in education. It comes from an ancient Greek word, which means ‘faculty of judgment or ability to discern’. In nursing practice, to critically assess, observe and examine patients are all equally important to providing safe nursing care. However, in nursing education, the task of critiquing an article (or writing a critical analysis of something) is not always a concept well understood by students. During their nursing training, students are assessed on how they are progressing in acquiring critical thinking skills and the ways to capture this progress is multifactorial. However, some research suggests there are students who can effectively critique theoretical knowledge but may not use those same critical thinking skills in their actual nursing practice. Whether this research is correct or not, the concept of thinking critically and applying critical thinking has a huge bearing on nursing education. Most believe that a nursing curriculum that emphasises critical analysis in its learning activities should produce better students with advanced levels of knowledge and skill. This might be true but it is questionable how much critical thinking is really imparted to nursing students during their years of study. Additionally, how well do schools track students’ progression towards being critical thinkers? Over the years, the models and frameworks for nursing education have changed. The drive for evidence-based nursing practice requires
OPINION: Nursing lecturer Jed Montayre* argues nursing education could do better in teaching that critical thinking skills aren’t just needed for written assignments but also to provide safe and effective nursing care. complementary evidence-based teaching and learning. Being well informed about research is one way of facilitating the critical thinking approach to delivering a nursing education programme. However, academics must be ready to counter the challenges when students are not receptive to, or resist, this way of promoting learning. Assignments that require students to critique a research article or to integrate readings from their research findings into an essay are a good way of developing students’ critical thinking skills. Students also need to know that these skills they build academically can be applied practically. Consequently, nursing lecturers need to stress that critical thinking is not just for academic essays but also transcends to practical nursing work. This message can then be reinforced during practical sessions in simulation labs and clinical skills sessions.
written assessments and practical nursing work needs to be done in a way that harnesses our natural ability to learn to think critically. This could be done by giving students activities that stimulate their critical learning skills through emphasis on problem-solving, real life scenarios. By critically analysing events in everyday life, humans can develop their critical thinking skills. Students encounter real patient situations in the clinical environment and they look after real patients during their clinical placement, but most of them have difficulty articulating why things were done the way they were. It is this awareness of the rationale for doing things in nursing that gets missed, probably because there is a gap in emphasising the transition of theory into practice; or it could be that not all students appreciate the value of theoretical knowledge as applied to practice.
“Nursing lecturers need to stress that critical thinking is not just for academic essays but also transcends to practical nursing work.” Just another essay?
While most nursing schools do stress critical thinking skills, what seems lacking is an emphasis on effectively linking critical thinking skills in theory and in practice; that is, the ability to critique theoretically and apply learned critical thinking skills to practice. One issue hindering this process is the students’ focus on examinations or assessments, instead of the learning that comes with the course. Also crucial to the process is the value students place on their written assignments and what they have learned from them. Students’ realisation of ‘where to from here’ rarely occurs if they view assignments as mere events or requirements they must undertake to pass or gain a merit mark. Recent UK research suggests that students don’t even really care if they receive written feedback on their assignment or not (unless they fail and then they want to know why). These are not solely student-driven issues as academics also contribute to this process. I believe that strengthening the link between
Anecdotal reports suggest students also have differing views on the usefulness of written assignments, with some saying they do not stir their interest or relate to the real nature of the profession; instead they regard these types of assessment as mere paperwork to be passed. Whether this is true or not, it makes perfect sense to try and better match up students’ learning perceptions and the kind of assessments crafted and integrated into the nursing programme. Most importantly, we need to prepare them to link the learned theory to practical skills. This is most effective if critical thinking skills are cultivated in both theory and practice and an emphasis is placed on the ability to critically synthesise theoretical knowledge as applied or observed in practice. This is the key to critical thinking in real life nursing scenarios, which informs sound and safe nursing care. *Dr Jed Montayre RN DPS (Doctor of Professional Studies) DipT is a nursing lecturer at AUT’s school of nursing.
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College of nurses
Māori nurse educators: sustaining a Māori worldview NGAIRA HARKER says a plan to foster and grow the Māori nurse educator workforce is critical to meeting future health workforce needs.
T
he future direction of nursing workforce development is a key area of discussion for College of Nurses Aotearoa (NZ) Inc board members. As one of three Māori board members, my worldview always navigates me towards the current state of Māori nursing workforce development. Are we on track to support growth and sustainability for Māori? Current evidence suggests there are major issues impacting Māori nursing workforce growth that need to be addressed 1 . The number of Māori nurses in the workforce has remained static for over a decade. Māori represent 7.5 per cent of the total nursing workforce 2 . In contrast to this, the Māori population is projected to grow at a faster rate than the total population. It is expected that Māori will make up 16.6 per cent of the New Zealand population by 2021, thus Māori health consumers will make up a larger portion of the population in the future. A growing number of DHBs now recognise the benefits of having a workforce that mirrors the local community and they are actively working to make this happen 3 . Ensuring there is a workforce plan that addresses growth and supports the increased visibility of Māori nurses is critical to help meet future health workforce needs.
The right undergraduate environment A key area that will impact on the future growth of the Māori health workforce is the undergraduate nursing environment. If we are to see growth over the next 30 years in the Māori nursing workforce, we must promote retention and success at the nursing school level by ensuring this environment is supportive and relevant. To this end, it is critical that Māori nurses and educators are visible throughout4 . I have the privilege of teaching and facilitating learning within Te Ōhanga Mataora Paetahi/Bachelor of Health Science Māori Nursing. This is a unique kaupapa Māori nursing programme based in Whakatane and delivered at Te Whāre Wānanga O Awanuiārangi. This development was in response to the ongoing need to develop the capacity of the Māori health
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workforce, and to address the recruitment and retention issues of Māori in nursing. The programme values te reo me ōna tikanga (the Māori language and its customs) and incorporates Māori teaching and learning methods. Because Māori learners are more likely to engage and become connected with a programme when they consider it to be culturally relevant to them 5 , providing nursing programmes that are kaupapa-based may help to retain Māori nursing students and increase their chances of success. Māori success requires educators who can facilitate these experiences, validate the students’ worldview, and prepare them to work effectively within Māori communities 6 . This requires a sustainable pool of Māori nurses, within both education and clinical settings, so Māori students can see nurses like themselves who work and care for whānau, hapu and iwi and deliver healthcare within this kaupapa. Given the limited pool of Māori nurses nationally, it is a very real possibility that a nursing student during their three-year nursing programme may have very limited to no exposure to Māori nurses. Māori students will be shaped by their experiences within both classroom and clinical environments. Without Māori nurses delivering nursing education, the reflection, understanding and validation of health experiences from within a Māori worldview will be compromised7.
Creating a Māori workforce strategy Currently there is no specific workforce plan for growing or mentoring Māori nurses within education. It is essential to create pathways where Māori nurses are supported in developing these skills. A first step for developing an education pathway is identifying the number of Māori nurses currently working within undergraduate education. Groups such as Whārangi Ruamano could provide insight into the national picture for Māori nurse educators and the factors that support Māori success within the educational environment. Other Māori workforce groups and organisations should also be supported to lead a collective evaluation of the work already done to grow the workforce. This combined work
is essential in creating a Māori workforce strategy. We pride ourselves as global leaders Ngaira Harker in cultural safety and indigenous ways of knowing. Nationally and internationally, nurse educators celebrate this point of difference. However, with a limited supply of Māori nurses nationally, and no pathways identified to encourage Māori nurses to enter into undergraduate education, our input in supporting nursing development is being increasingly diminished. Ensuring students have the opportunity to engage and grow knowledge from within a Māori worldview is essential in the delivery of undergraduate education in our country. As a member of the College of Nurses, my ability to discuss these issues is empowering. The input and discussion from our group will potentially contribute to the establishment of a future workforce plan that can meet this and other Māori workforce issues. Author: Ngaira Harker, RN MN, board member of the College of Nurses Aotearoa (NZ) Inc. 1. Nursing Council of New Zealand. The New Zealand Nursing Workforce: The future Nursing Workforce Supply projections 2010–2035. Wellington Nursing Council of New Zealand 2013. 2. He Pa Harakeke Māori Health Workforce Profile by MOH in 2007. 3. Central Regions DHB Māori Health Workforce Development Plan 2012. 4. Ministry of Education. Ka Hikitia – Managing for Success: The Māori Education Strategy 2008–2012. Wellington: Ministry of Education, 2012. 5. Wilson D, McKinney C, Rapata-Hanning M. Retention of indigenous nursing students in New Zealand: a cross-sectional survey. Contemporary nurse. 2011;38(1-2):59-75. 6. Greenwood J, Te Aika L. Hei Tauira: Teaching and Learning Success for Māori in Tertiary Settings. Ako Aotearoa, 2008. 7. Future Workforce DHBNZ. Report on Support for Māori and Pacific Nursing and Midwifery Undergraduate Students. Wellington, New Zealand: District Health Boards. New Zealand, 2009.
Evidence-based practice
‘sink’
Does zinc help cold symptoms? It’s cold season; your nose is running and your throat is sore. CYNTHIA WENSLEY looks at the evidence for zinc as a cold remedy. CLINICAL BOTTOM LINE: In otherwise healthy adults, high dose zinc acetate lozenges taken within 24 hours of the onset of a cold may shorten the duration of a cold and its various symptoms (such as nasal discharge, nasal congestion and muscle ache) by 33–54 per cent. The amount of zinc (around 80 mg/day of zinc ion) is far higher than the recommended daily dietary intake but appears to be well tolerated when taken for a period of two weeks or less.
CLINICAL SCENARIO: You have the usual miserable symptoms of the common cold. Keen to get over it quickly, you wonder how effective over-the-counter remedies are for reducing the duration of cold symptoms. Your work colleague swears by zinc and so you decide to examine the evidence for its effectiveness.
QUESTION: In normally healthy adults, how effective is zinc for reducing the duration of common cold symptoms?
SEARCH STRATEGY: PubMed-Clinical queries (Therapy/Narrow): zinc AND common cold
CITATION: Hemila, H., & Chalker, E. (2015). The effectiveness of high dose zinc acetate lozenges on various common cold symptoms: a meta-analysis. BMC Fam Pract, 16, 24. doi: 10.1186/s12875-015-0237-6
STUDY SUMMARY: A systematic review assessing whether high dose zinc acetate lozenges have different effects on the duration of common cold symptoms. Inclusion criteria were: »» Type of study: placebo controlled trials involving people with the common cold who were otherwise untreated »» Types of intervention: zinc acetate lozenges in which the dose was >75 mg/day of zinc ion compared with placebo »» Outcomes: total duration of the cold, and duration of respiratory and systemic symptoms. Adverse events were also recorded. Symptom duration was to be converted from days to a percentage scale to enable meaningful comparison between different patient groups and different outcome definitions.
STUDY VALIDITY: A simple but appropriate search strategy was used to search the PubMed database (in Jan 2015) to locate published trials additional to those included in the 2013 Cochrane Review on this topic. No language or date restrictions applied. No process for locating unpublished studies was described but authors are
experts in this field and knowledge of all relevant studies is presumed. The review process involved both study authors checking the accuracy of data extraction, data entry and data calculations. The included studies were assessed for risk of bias by considering randomisation method, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, loss to follow-up and selective outcome reporting. Publication bias was not discussed. Overall this was a high-quality review involving three small but high-quality studies.
STUDY RESULTS: From 28 trials identified, three randomised, placebocontrolled, double-blind studies involving 199 participants were identified as being eligible for inclusion. Participants were students or staff from two universities in the United States. A cold was defined as presence of ≥2 of the typical respiratory (nasal discharge, nasal congestion, cough, hoarseness, scratchy throat, sore throat, sneezing) or systemic (muscle aches, fever, headache) symptoms. All three studies compared zinc acetate lozenges with placebo lozenges. The daily dose of zinc varied between 80–92 mg/day and was taken in divided doses throughout the day. In the majority of participants, the intervention began within 24 hours of onset of symptoms. Compared with placebo, zinc lozenges significantly reduced the duration of colds by 42 per cent, the duration of nasal discharge by 34 per cent, nasal congestion by 37 per cent, scratchy throat by 33 per cent, hoarseness by 43 per cent and cough by 46 per cent (Table). The reduction in duration of sneezing and sore throats seen in the zinc group was not significant. In comparison with the placebo, zinc lozenges halved the duration
of muscle ache (Table) but made no difference to the duration of headache or fever. Heterogeneity between the included studies was generally low. There was no substantial difference in adverse events between zinc and placebo groups and low drop-out numbers suggest the intervention was well tolerated.
COMMENTS: »» When converted back to days, these results mean that the duration of common cold symptoms may be reduced by 1–2 days (possibly more), which seems worthwhile. »» The recommended daily dose of zinc is 11 mg/day for men and 8 mg/day for women. »» Based on adverse events data from the included studies (and other studies involving high dose zinc for extended periods) the review authors concluded that high dose zinc taken for the duration of the cold (under two weeks) was unlikely to cause serious, irreversible adverse events. »» The included studies excluded people with comorbidities and children, therefore safety and efficacy of high dose zinc in these populations cannot be presumed. »» Zinc acetate lozenges are not readily available in New Zealand; pharmacists can advise regarding substituting lozenges for other forms of zinc supplementation. Reviewer:
Cynthia Wensley RN, Honorary Professional Teaching Fellow, The University of Auckland, and PhD candidate, Deakin University, Melbourne cwensley@deakin.edu.au
Summary of Results Outcome
Number of studies (n)
Mean difference (95% CI)
Inconsistency between studies
Duration of the total cold
3
42% (35% to 48%)
I2 = 40%
Duration of nasal discharge
3
34% (17% to 51%)
I2 = 0%
Duration of nasal congestion
3
37% (15% to 58%)
I2 = 0%
Duration of scratchy throat
3
33% (8% to 59%)
I2 = 38%
Duration of hoarseness
3
43% (3% to 83%)
I2 = 41%
Duration of cough
3
46% (28% to 64%)
I2 = 64%
Duration of muscle ache
3
54% (18% to 89%)
I2 = 0%
Interpretation: for each comparison, the duration of symptoms in the placebo group was given the value of 100% Nursing Review series 2015
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Practice, People & Policy OPINION
Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy
C ming Kim Carter
KIM CARTER on why nurses may need to step out of their comfort zones to ensure good care for all clients across the spectrum of sexuality and gender identity.
W
e make huge assumptions all the time about our clients. We generalise and label people for lots of reasons – from their ability to pay, their likely priorities, and how good their parenting skills are to how well they take care of themselves. We also usually assume everyone is heterosexual and is the gender they appear to be. I am no expert in the field of sexuality and gender issues (other than my own!); however, I think rethinking such assumptions is becoming increasingly important as the visibility, voice and needs of lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) people grows. LGBTQI people are generally an under-screened and under-served community due in part to the constant need to ‘come out’ to every health provider they are in contact with. Some LGBTQI people find this coming out process so difficult that many will simply not present for care, or if they do, present late, and may withhold valuable information that might be relevant to their care. It also means that the special and significant people in the lives of LGBTQI people are often not involved in their care, which further isolates and separates LGBTQI people from the very support so needed by all of us at times of crisis and recovery.
Challenging assumptions I think what lies underneath the problems experienced by LGBTQI people is the lack of comfort clinicians have about sexuality and gender issues generally. To illustrate this point, ask yourself when you last raised the issue of sexuality with a client? Do you assume people are heterosexual or do you routinely ask how people identify their orientation? Do you assume because someone appears to be male or female that this is how they identify themselves? Are you mindful there is a difference between sexual identity and gender identity and the implications for this in clinical practice? When did you last discuss what effects chemotherapy or menopause might have on libido? Have you discussed ways that people might cope with ostomy bags, urinary catheters or disabilities so they can continue healthy and fulfilling sexual lives? In your last ‘safe sex‘ discussion with a client, did you tailor your information because you already knew that person’s sexual orientation or did you assume they were heterosexual? Do you routinely ask clients about any issues with incontinence? What do you advise parents who tell you their son wears nail polish and skirts or likes pink shoes? Have you considered that transgender men might still need to be offered breast and cervical screening and transgender women prostate screening? Do these questions make you squirm? You may ask why considering these issues matters but I believe we improve care for all people when we make sexuality part of our everyday work. If we acknowledge that sexuality and gender expression is a fundamental part of human experience, identity and wellbeing, then we should incorporate and normalise sexuality as a regular part of our care interactions. This in turn provides environments and opportunities for LGBTQI people to be honest and open with us as clinicians; however, it also requires that we are educated and informed about sexuality and gender issues, and prepared to provide holistic, unbiased and relevant care to everyone. In addition, it requires a truly open and non-judgemental approach, which in my view and experience is significantly lacking. 28
Nursing Review series 2015
ut of your comfort zone
Changing language A small first step is to change our language. A lesbian client recently asked me to explain her hospital discharge letter, which advised that she should refrain from intercourse for six weeks after her surgery. She was confused about the word ‘intercourse’ as it related to her life. She was even more bemused because the surgeon was aware she was lesbian, and had met her partner, so she didn’t understand why he couldn’t be specific and relevant in the post-op instructions. Not only were these form letter instructions confusing, and therefore meaningless, but they also conveyed a lack of respect and care for her individual situation. This example demonstrates how language can be enabling and supportive but equally it can be a barrier and cause confusion. Language can facilitate trust and openness or close down communication. Language can be helpful or unhelpful, convey respect or discrimination and be insidious or explicit. Language is the wide open door through which we engage or the door we close tightly against anyone too challenging and different from ourselves. I think we need to start talking about sexuality and gender openly and often. Not just to make life easier for LGBTQI people, but to make it easier for all people, because many of our clients experience challenges related to sexuality and gender within their lives and relationships. Most never raise this with us or seek advice and we miss the opportunity to provide help because we also don’t open a door to a conversation or provide an environment which makes it okay to raise these issues. Our own level of discomfort and lack of knowledge is a big challenge to overcome but what a difference we can make in helping people with both the significant and the small things. Whatever your own personal sexual and gender identity, and whatever your own perspectives, we have a duty of care and ethical professional responsibility to provide for everyone in a holistic and appropriate way and this includes sexuality and gender. Therefore, I encourage you to consider how approachable and welcoming your service, building and team are for people in all their wonderful diversity. This could be as simple as considering the appropriate use of pronouns (i.e. he or she), asking people how they want to be referred to, or making it a policy to ask and record sexual orientation and gender identity when any client enrols with your service. I also encourage you to reflect on your own clinical practice and consider where you might be able to change your language to be a little more inclusive, a little more accepting of difference and a little less afraid to start difficult conversations. It is bad enough that LGBTQI people are marginalised in our society – let’s not keep them invisible within the health system as well. Author: Kim Carter is an RN, general practice owner and College of Primary Health Care Nurses (NZNO) representative on the General Practice Leaders Forum.
Practice, People & Policy workforce
NP training programme
gets green light
The nursing sector has long wanted a more streamlined and supported path for nurses seeking to be nurse practitioners Nursing Review reports on a pilot that hopes to do just that.
T
he long-awaited go-ahead has been given to piloting a dedicated training programme for 20 would-be nurse practitioners in 2016. Health Minister Jonathan Coleman announced the go-ahead in late July for the $846,000 demonstration that will be funded by Health Workforce New Zealand (HWNZ) and provided by The University of Auckland and Massey University nursing schools. Associate professor Judy Kilpatrick, head of The University of Auckland nursing school, says the school was delighted to hear about the green light. “We see this as an extremely positive move to ensure a steady stream of well-qualified NPs into the health workforce.” Professor Jenny Carryer of the Massey University school of nursing says Massey is also “absolutely delighted”. “We will be working now with the numerous individuals and potential employers who have expressed interest,” she said. The first NP was registered in 2001 but growth in NPs and NP jobs were slow with it taking a decade for the 100th NP to be registered, prompting an initial proposal in 2010 by the then Nurse Practitioner Advisory Commmittee of New Zealand (NPACNZ) for a dedicated NP training programme. In December 2013 the latest proposal was first put forward to HWNZ and 18 months later has won ministerial support. Kilpatrick says the aim of the NP programme is to streamline the NP pathway with a one-year focused programme of study and supervised clinical practice.
Closing “wasteful gap” Kilpatrick and Michal Boyd, a practicing NP and senior lecturer, argued in their initial application for HWNZ funding that a dedicated training programme was needed because of the current “wasteful gap” between the number of nurses completing their clinical master’s training and the number progressing to obtaining NP jobs. Two of the reasons suggested for this gap were the need to streamline the NP training pathway, including protected supervised clinical training hours, and ensuring there is a job for prospective NPs at the end of the pathway. This proposal requires NP trainees to already have the backing of an employer ready to offer them employment as an NP on registration. Kilpatrick says depending on interest from candidates and employers the school may look to broker arrangements between keen employers and appropriate NP candidates. Carryer says she has also had approaches from some potential NPs who have completed a master’s degree but are still very interested in aspects of the programme. NP Dr Helen Snell, who was behind the initial NPAC-NZ application, says she is sure the members of the former committee will be as delighted as she is to finally see an NP training programme up and running. “We congratulate the two universities and the nursing leadership groups for collaboratively pursuing and achieving the
establishment of a structured programme to support our future nurse practitioner workforce.” She says the universities’ programme addressed most of the concerns that NPAC-NZ had at the time and that were proposed in NPAC-NZ’s draft specifications. But she says one area that did not appear to be specifically covered by the university programme is clinical leadership. Snell says while NPs are primarily clinicians they also have a responsibility as advanced practice clinicians for clinical leadership, practice development and measurement of outcomes. Priority for places in next year’s training programmes being offered by Massey and Auckland will be given to applicants in primary health care, aged care and mental health. If successful, it is expected the programme will be opened up to other nursing schools currently offering clinical master’s degrees to would-be NPs. A spokesperson for Coleman’s office said the $846,000 funding was not new money but would be “reprioritised” from HWNZ’s overall appropriation of $174 million and would be on top of the existing $13 million allocated annually to postgraduate nursing study (including trainee NPs, who are not part of the demonstration). “Nurse practitioners are a valuable resource. They are highly educated and experienced, and are a key part of our health workforce,” Coleman said at the time of the announcement.
Jenny Carryer
Judy Kilpatrick
Helen Snell
NP training programme details Applicant nurses will need: »» to have already completed their postgraduate diploma (including prerequisite pharmacology papers) »» to be ready to enter the final year of study for their clinical master’s degree in nursing (including clinical practicums in advanced nursing practice and prescribing) »» written confirmation from an employer ready to support them during the training year and offer them an NP position once they are registered »» the support of a nurse practitioner or doctor ready to provide clinical supervision in their field of practice. Priority will be given to applicants in primary health care, aged care and mental health. The programme will involve: »» ten-months’ training, running February to November »» academic work to complete the Master of Nursing »» two days a week clinical practice (500 hours of practice) with committed employer to meet clinical practicum requirements in prescribing and diagnostic reasoning »» study days for diagnostic reasoning and prescribing practicum (140 hours) »» completion of portfolio by student, ready to submit to Nursing Council at end of programme »» standardised clinical examination at end of course to demonstrate advanced diagnostic and prescribing skills plus an oral exam (examining panel includes representatives from Nursing Council and external examiners).
Nursing Review series 2015
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Practice, People & Policy OPINION
Fad diets
article feedback
T
he last edition of Nursing Review contained an article called ‘Fad diets: what do dietitians say about the latest crop?’ that looked at some of the latest dietary trends; in particular, the Paleo diet, the 5:2 intermittent fasting diet, the no-sugar approach and the low-carb, high-fat (LCHF) approach. The article gave a brief summary of each diet’s key focus (a number of variations exist for three of the four diets) and asked a Diabetes NZ dietitian and Heart Foundation nutrition spokesperson for what they consider to be the pluses and minuses of these diets for people with long-term conditions.
The article gave a thumbs-up to the recent shift in dietary trends away from processed foods towards cooking whole food from scratch, expressed caution about a number of them for people with diabetes and had a general focus on eating a moderate, balanced diet. The article can be viewed at http://bit.ly/1DYABOf. Amongst the responses – positive, mixed and negative – was that of Professor Grant Schofield of AUT, co-author of What the Fat? Fat’s in, Sugar’s Out. Schofield is a professor of Public Health for AUT, director of AUT’s Human Potential Centre, the
country’s leading advocate for the LCHF approach, and has a background in psychology. Nursing Review offered Schofield and colleagues an opportunity to write an opinion piece in response to the ‘Fad diets’ article. Nursing Review also offered the opportunity to the Heart Foundation, Diabetes NZ and the convenor of Dietitians NZ’s Diabetes Special Interest Group to review and respond to Schofield et al. The resulting four pieces are published here.
OPINION ONE: Grant Schofield et al. The use of the word ‘fad’ to describe therapeutic diets, some with long histories of clinical usefulness, which enjoy popularity beyond the medical community, is lazy and misleading. This review, despite its commendable focus on real, unprocessed food, contained factual errors with regard to low-carbohydrate, high-fat diets, as well as Paleo and sugar-free diets. We have summarised only major errors* for comment. The most important correction* for the readership of Nursing Review, is that restricting dietary carbohydrate is an effective option for diabetics. Myth: Low-carbohydrate, high-fat diets, Paleo, or sugar-free diets can cause hypoglycaemia and ketoacidosis in diabetics Diabetes medication dosage usually needs to be adjusted downwards on low-carbohydrate diets. However, there are clear advantages to reducing medication when high doses are not needed and stopping it when no longer required. When blood glucose falls on a ketogenic diet, ketone bodies provide the brain with an alternative fuel source, decreasing the risk of symptomatic hypoglycaemic episodes. A typical result is a reduction of hypoglycaemic events by 80 per cent. Thus diets in which carbohydrate is sufficiently restricted allow better control of
blood glucose, often including sustained normal glucose and HbA1c readings in type 1 diabetes, and remission or reversal of diabetes altogether in type 2 diabetes. A 2015 review authored by 25 diabetes experts outlines 12 robust reasons why low-carbohydrate diets should be the first option for diabetes treatment1. Drugs that can be reduced or stopped include GSLT2 inhibitors, which have been shown to cause diabetic ketoacidosis in America2. Conversely low-carbohydrate diets have never been shown to cause ketoacidosis. The use of small amounts of glucose to correct hypoglycaemia caused by the unpredictability of insulin dosing still forms part of managing type 1 diabetes, even on a low-carbohydrate diet. This does not mean that there is a requirement for sugar in the diet. Myths: Low-carbohydrate, high-fat diets cut out fruit; Paleo diets eliminate starchy vegetables; not eating grains is a danger to health. Fruits are not removed on lowcarbohydrate diets, rather high-sugar fruits are limited; the degree of restriction depending on an individual’s level of insulin resistance. Paleo diets do not eliminate starchy vegetables, and may allow some dairy products or legumes. Grain avoidance is more than compensated for
REFERENCES 1.
2.
30
Feinman R, Pogozelski W, Astrup A et al. (2015). Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base. Nutrition 31:1-13 http://dx.doi.org/10.1016/j.nut.2014.06.011 FDA Drug Safety Communication: FDA warns that SGLT2 inhibitors for diabetes may result in a serious condition of too much acid in the blood. Retrieved 15 July 2015 from www.fda.gov/Drugs/DrugSafety/ucm446845.htm
3.
Nordmann A J, Nordmann A, Briel M et al. (2006). Effects of Low-Carbohydrate vs Low-Fat Diets on Weight Loss and Cardiovascular Risk Factors: A Meta-analysis of Randomised Controlled Trials. Archives of Internal Medicine.166(3):285-293. doi:10.1001/archinte.166.3.285.
4.
Jakobsen M, O’Reilly E, Heitmann B et al. (2009). Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. American Journal of Clinical Nutrition 89:1425-32. doi: 10.3945/ajcn.2008.27124.
Nursing Review series 2015
nutritionally by increased consumption of nuts, seeds, fish and vegetables. Myth: People will get half the message. Randomised controlled trials of various diet regimes show low-carbohydrate, high-fat eating is superior in short and medium-term weight loss in free living populations and has reasonable adherence, superior to the low-fat approach, showing that consumers can understand and implement this diet effectively when it is communicated clearly3. Myth: Saturated fat causes heart disease. Replacing saturated fat with carbohydrate does not reduce the risk of heart disease, and may increase it. Polyunsaturated fats found in fatty foods are associated with a lower risk of heart disease, whether they replace carbohydrate or saturated fats4. This evidence does not suggest that saturated fats are harmful in the context of diets in which fat replaces carbohydrate. Authors: Professor Grant Schofield, AUT; Dr Caryn Zinn, registered dietitian and senior lecturer AUT (co-author of What the Fat? Fat’s in, Sugar’s out); and George Henderson, AUT research officer.
Editor’s note: This opinion piece has been published as submitted. Publication means that Nursing Review is open to publishing counterviews on the issues raised and does not denote agreement that the original article contained errors. The original article did not say LCHF cut out fruit – it noted that some versions of the diet included people being encouraged to reduce or cut out their fruit intake. It also did not say that not eating grains was a ‘danger’ but rather said that whole grains have been shown to protect against heart disease. The founder of the Paleo diet concept, Loren Cordain, excludes potatoes, legumes and dairy products. The article noted that a number of variations of the Paleo diet exist, including some involving three non-Paleo meals a week.
Practice, People & Policy OPINION
OPINION two: Heart Foundation It is great to see the ‘Fad diets: what do dietitians say about the latest crop?’ article in Nursing Review has been widely distributed, stimulating much interest and debate. After all, it is encouraging to see that so many Kiwis are interested in what they should be eating. Given how divided the current nutrition landscape is, it is no surprise the article has been greeted with hostility by various commentators, even though it noted many positive elements about the diets being discussed. As we stated in the article, if elements of a new diet (e.g. no-sugar, low-carbohydrate/highfat (LCHF) or Paleo) help to kick-start, or move someone towards a healthier eating pattern then that is positive. However, we maintain that people do not need to resort to extremes to achieve a cardio-protective dietary pattern. We recommend an approach that works for the individual, is sustainable, and is based on foods shown by the best evidence to reduce the risk of heart disease. Dietary patterns that support heart health reflect a range of fat, carbohydrate and protein
intakes but share common features. These features include: fewer processed foods; plenty of vegetables and fruit; other plant foods such as legumes, intact whole grains, nuts, and healthy plant oils; and usually some fish, poultry, lean meats and reduced-fat dairy1. Comments relating to the specific points raised by Schofield et al. follow: Reducing saturated fat intakes will lower the risk of heart disease: Our comments in the previous article refer to reduction in saturated fat in general, and in fact highlight that a higher total fat intake is acceptable. Evidence shows a reduced risk of heart disease when saturated fat is replaced with polyunsaturated fat2,3. However, replacing saturated fat with slowly digested, high-fibre, less-refined carbohydrate foods will also provide a reduced risk4,5. The key is the type of carbohydrate. Replacing saturated fats with highly refined, sugary, carbohydrate-rich foods will offer little benefit. People will get half the message: Advocates of the LCHF approach have recently promoted cream, butter, and bacon (a heavily processed
meat) through major media stories. Sadly, the promotion of healthy cardio-protective fats from foods like nuts, seeds and plant oils, and the fat message in the context of healthy dietary pattern, has been missing from some of these stories. Confusingly, during a presentation at the 2014 Dietitians NZ National Meeting, those same LCHF advocates highlighted that cream, butter, and bacon were not key fats as part of the LCHF way of eating, whereas the previously mentioned cardio-protective fats were. Therefore, we believe the current LCHF messages being delivered to health professionals and the general population are incomplete, inconsistent and may lead to people making poor dietary choices. In summary, we continue to emphasise that the quality of carbohydrate and fat in the diet is key. People need to choose an eating pattern that works for them, and that is based on foods that the best available evidence shows reduces the risk of heart disease and diabetes. Author: Dave Monro is a dietitian and the nutrition spokesman for the Heart Foundation.
REFERENCES 1.
Heart Foundation. Dietary patterns and the heart position paper (2014). www.heartfoundation.org.nz/ uploads/Dietary_patterns_position_statement_2014.pdf. Accessed 24 July 2015.
4.
Pereira M, O’Reilly E, Augustsson K et al. (2004). Dietary fibre and risk of coronary heart disease: a pooled analysis of cohort studies. Arch Intern Med 2004; 164:370-76.
2.
Jakobsen M, O’Reilly E, Heitmann B et al. (2009). Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. American Journal of Clinical Nutrition 89:1425-32. doi: 10.3945/ajcn.2008.27124.
5.
Stratton I, Alder A, Neil H et al. and the UK Prospective Diabetes Study Group (2000). Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. British Medical Journal 321:405-12.
3.
Mozaffarian D, Micha R, Wallace S (2010). Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomised controlled trials. PLOS Medicine 7(3):e1000252.
OPINION three: Diabetes NZ Diabetes NZ offers support and information to help people take charge of their health and live well with their diabetes. We do not provide clinical advice – we complement the services of other healthcare providers. The dietary information we give is in keeping with national and international diabetes dietary guidelines. Lower carbohydrate diets: People with diabetes currently using insulin or sulphonylurea medication who choose to reduce the carbohydrate in their diets will need advice and guidance from diabetes specialists. This support will help them with carbohydrate counting and medication dose reduction/withdrawal while adapting from their previous eating pattern. Without adequate advice and guidance, the risk of hypoglycaemia is high.
Saturated fat: Diabetes NZ affirms its view that people with diabetes should not have a diet high in saturated fat. Saturated fat has been shown to have a negative impact on heart health and people with diabetes have a well-recognised increased risk of cardiovascular disease. A 2010 study by Otago University researchers found that patients with type 2 diabetes benefited from a reduction in saturated fat as part of a sensible moderate eating pattern1. These benefits included reductions in HbA1c, weight, and BMI, and some people reduced their diabetes medicine dose. No-sugar diets: While popular versions of these diets discourage the use of sucrose (table sugar), other sugars such as glucose and dextrose are commonly used in recipes. These sugars are unsuitable for people with diabetes.
Diabetes NZ’s overall message is for people with diabetes to reduce their intake of free sugar in all forms. Free sugar is defined by the World Health Organisation and the UN Food and Agriculture Organisation in multiple reports as “all monosaccharides and disaccharides added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and fruit juices”2,3. It is used to distinguish between the sugars that are naturally present in fully unrefined carbohydrates such as brown rice, whole wheat pasta, fruit, etc. and those sugars (or carbohydrates) that have been, to some extent, refined (normally by humans but sometimes by animals, such as the free sugars present in honey). Author: Submitted on behalf of Diabetes NZ.
REFERENCES 1.
Coppell K, Kataoka M, Williams S et al. (2010). Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment – Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomised controlled trial, British Medical Journal 341 doi: http://dx.doi.org/10.1136/bmj.c3337
2.
Joint WHO/FAO Expert Consultation (2003). WHO Technical Report Series 916 Diet, Nutrition, and the Prevention of Chronic Diseases. Geneva.
3.
Moynihan P and Petersen P (2004). Diet, nutrition and the prevention of dental diseases, Public Health Nutrition: 7(1A), 201-226.
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Practice, People & Policy OPINION
OPINION four: Shelley Mitchell, Diabetes Special Interest Group convenor for Dietitians NZ Nutritional science is constantly evolving and one of the key dietary trends that consistently proves its worth in terms of diabetes and cardiovascular outcomes is the Mediterranean style of eating1,2,3. This type of diet includes plenty of vegetables, fruits, legumes, wholegrain cereals, plus moderate amounts of heart healthy fats and lean protein. These principles have been widely incorporated into dietary recommendations for the prevention and management of type 2 diabetes around the world4,5. In New Zealand, we have our very own ‘Nine Steps for Heart Healthy Eating’ developed by the Heart Foundation6 and featured in the Ministry of Health Primary Care Handbook for cardiovascular disease screening and type 2 diabetes management7. I have used the ‘9 Steps’ with a number of people with type 2 diabetes who have gone on to achieve a healthy weight range (BMI 20-25 kg/m2) and a few have even come off their diabetes medications altogether. Others may have stayed on tablets or insulin but are feeling confident that they can stick with their new food plan because it includes a variety of affordable foods they can buy locally.
Naïve to think one diet fits all: It would be naïve to think that any one particular dietary pattern – be it the 5:2 diet, LCHF, or the Paleo approach – is an appropriate solution for the whole population. If only life were that simple! I agree that ‘free sugars’ should be limited8, but extreme restriction of wholegrains, legumes, starchy vegetables or fruit is unnecessary and disadvantageous given the role of dietary fibre in disease prevention4,5. I prefer to support people with diabetes to review whether they are eating the right amount of food for a healthy weight and focus on choosing heart healthy fats, good quality carbohydrates, and abundant non-starchy vegetables. If anything needs to be restricted it would be the heavily processed foods that add many calories but not much in the way of nutrition. Matching insulin to different diets challenging: Research is still emerging about the impact of high fat and/or high protein meals on postprandial insulin secretion and glycaemic control in adults and children with type 1 diabetes9,10,11. This presents a challenge for those of us in clinical practice in terms of how
we match the right amount and type of insulin to these meals, and challenges the assumption that following a low-carbohydrate diet means people with diabetes will require less insulin. Personalised advice important: In summary, most experts agree that there are multiple dietary patterns that are beneficial for cardiovascular health and it is important therefore that each person be given personalised advice based on their own needs and food preferences12,13. It is the position of the American Diabetes Association (ADA) that there is not a ‘one-size-fits-all’ eating pattern for individuals with diabetes14. Tempting as it might be to be swayed by the latest dietary trends, as clinicians we need to stay grounded in our person-centred practices and consider a number of factors that might impact on the efficacy of any particular dietary pattern as part of our clinical assessment. Author: Shelley Mitchell NZRD, MSc. is the diabetes specialist dietitian at MidCentral Health and convener for the DSIG of Dietitians NZ.
REFERENCES
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9.
De Logeril M, Salen P, Martin J et al. (1999). Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 99: 779-85.
Wolpert H, Atakov-Castillo A, Smith S, Steil G (2013). Dietary fat acutely increases glucose concentrations and insulin requirements in patients with type 1 diabetes: implications for carbohydrate-based bolus dose calculation and intensive diabetes management. Diabetes Care 36: 810-816.
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Esposito K, Maiorina M, Ceriello A, Giugliano D (2010). Prevention and control of type 2 diabetes by Mediterranean diet: a systematic review. Diabetes Research and Clinical Practice 89: 97-102.
Smart C, Lopez, P, Evans M et al. (2013). Both dietary protein and fat increase postprandial glucose excursions in children with type 1 diabetes, and the effect is additive. Diabetes Care 36: 3897-3902.
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Dyson P, Kelly T, Deakin T et al. (2011). Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabetic Medicine 28: 1282-8.
Bell K, Smart C, Steil G et al. (2015). Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous glucose monitoring era. Diabetes Care; 38: 1008-1015.
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Evert A, Boucher J, Cypress M et al. (2014). Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 37: S120-S143.
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Ministry of Health (2014). Quality Standards for Diabetes Care Toolkit Wellington www.health.govt.nz/publication/quality-standards-diabetes-care-toolkit-2014.
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The Heart Foundation www.heartfoundation.org.nz.
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New Zealand Guidelines Group (2012). New Zealand Primary Care Handbook 2012 (3rd Edition). Wellington: Ministry of Health.
Franz M, Boucher J, Evert A (2014). Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualisation. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 7: 65-72.
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World Health Organisation (2015). Guideline: Sugars intake for adults and children. Geneva.
American Diabetes Association (2015). Standards of medical care in diabetes 2015: summary of revisions. Diabetes Care 38: S1-S94.
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The PREDIMED Study http://predimed.onmedic.net/eng/Home/tabid/357/Default.aspx accessed 15 Aug 2015.
2.
Nursing Review series 2015
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