Nursing Review Issue 5 2017 by NZME. Educational Media

Issue 5 October/November 2017

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New Zealand’s independent nursing Series

Focus Child health, wound care & infection control Innovation & Technology Collaborative clinician platform Free 60-minute PD learning activity Code of Conduct refresher

Putting oy back into the workplace

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Contents

Inside:

ED’s letter Spring inspiration

NEWS

This spring I was lucky enough to go to two conferences that gave me the spark I needed after a long, wet winter. I listened to nurses speaking with infectious enthusiasm about innovations they led or shaped that are making a difference to their practice and patients. Some of their stories are shared in this edition and others are to come. I also listened to nurses challenging the status quo and questioning accepted truisms, such as how come training for the ‘caring profession’ by the ‘caring profession’ sees nursing students’ empathy levels decline and not increase? Is yet another tick-box care plan a useful addition to your nursing toolbox or a direct insult to your professional judgment as a nurse? And is nursing in danger of becoming extinct and being replaced by generic health workers who will do the work that was once the domain of nurses? It’s all stimulating stuff to wake me out of my winter lethargy and provide topics for many articles to come. One of the nicest compliments I’ve ever received as editor of Nursing Review – shared over the teacups at another conference – was when a reader described opening up her copy of Nursing Review as like going to a good conference. So I’m hoping that in this edition everyone finds at least one article to give them an added spring to their step, as these two conferences have for me.

NB: Our 60-minute professional development article and learning activity (p.15) in this edition is a must-read – it’s a refresher on the 2012 Code of Conduct and supporting documents, with which every New Zealand nurse is expected to be familiar. Fiona Cassie, Editor editor@nursingreview.co.nz www.nursingreview.co.nz

Round-up: News briefs + Bulletin board

FOCUS 4 5 8 9 10

CHILD HEALTH: ‘magic wand’ numbs pain Supporting complex needs children as a volunteer WOUND CARE: dying wish prompts innovation Reducing pressure injuries and reducing costs INFECTION CONTROL: hospital gastro outbreaks

PROFESSIONAL DEVELOPMENT 14 15 20

Evidence-based practice: being a dab hand at hand hygiene FREE 60-MINUTE professional development activity Code of Conduct refresher Empathy: what it is and isn’t, and why it matters

INNOVATION & TECHNOLOGY 23 23 24

Webscope: Infection control and child health websites App of the Month: Babble (for parents of neonatal babies) Accessing patient notes: new ‘cockpit’ app

LEADERSHIP & MANAGEMENT 26 27

World experts on the wicked problem of falls Bringing joy back into the workplace

STUDENTS 29 30

Clinical placement advice: good shoes and home baking Interprofessional: how well do graduates work together?

OPINION 31

Health inequity: a tale of two neighbourhoods

CONFERENCES 32

Upcoming conferences

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Fiona Cassie 03 981 9474 editor@nursingreview.co.nz

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NursingReview Vol 17 Issue 5

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Round-up

News briefs

Read the full versions of these online articles at www.nursingreview.co.nz/subject/news. Safe staffing ratios make nurses “happy again”, says visiting US union leader Nurses across the US are still fighting to join California in having mandated safe staffing ratios, says Jean Ross, the visiting co-president of National Nurses United (NNU), America’s largest nursing union. NNU was formed in 2009 by bringing together the California Nurses Association and two other unions. NNU also helped to initiate Global Nurses United, a global network of nursing unions that the NZNO recently joined, and Ross was in New Zealand recently to speak at the NZNO annual conference. Ross says California is still the only state in the US to have a safe patient ratio law where it has had set RN-to-patient ratios since 2004, including 1:2 in intensive care units, 1:5 in medical/surgical wards, 1:4 in emergency departments and 1:6 in mental health. These are the maximum number of patients a nurse can be assigned and the Californian law also requires additional RNs to be assigned based on patient acuity. Ross says there are currently two bills in front of the Senate and Congress calling for federal RN-to-patient ratios across the whole of the US and at a state-by-state level nurses are also campaigning for legislated safe staffing ratios. “They [ratios] have been very successful in California,” she says. “Hospitals continue to fight them tooth and nail but they have worked very well. Nurses are happy again; they can do what they like at the bedside.” She says nurses used to worry about taking a break as it would foist all their patients onto a colleague’s patient load but now wards had circulating nurses so ratios stayed in place even when nurses were on a break.

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RN prescribing reaches first anniversary Exactly a year on from registered nurse prescribing becoming a legal reality, there are now more than 80 RN prescribers. The regulation introducing RN prescribing in primary health and specialty teams came into force on 20 September last year, with the aim of improving access to medicines for vulnerable populations. The 29 new RN prescribers authorised to prescribe from a schedule of common medicines for common and long-term conditions join 53 diabetes nurse specialists authorised to prescribe in diabetes health, making 82 RN prescribers in total. Pam Doole, the Nursing Council’s Strategic Policy Manager, shared the updated statistics on the new second level prescribing at the Clinical Nurse Specialist Society NZ conference in Christchurch in September. There are now also 254 nurse practitioner prescribers (the top level and only autonomous nurse prescribers), and a group of nurses are currently trialling a third and more limited level of RN prescribing in community health. The first NP prescriber was authorised in 2003 and a pilot followed in 2011 of RN-designated prescribing in diabetes (applications under the diabetes regulations close in November).

New grad jobs up once again but more than 270 new nurses still job-hunting Job numbers were up but so were applicants, leading to just under half of new graduate nurses being successful in the latest job round. Statistics released by the Ministry of Health showed that 347 of the initial 701 new graduate applicants were matched with jobs in the July round of ACE nurse graduate job clearinghouse. This is equivalent to 49.5 per cent – slightly down on the 53 per cent success rate last

year when 332 of 648 applicants were successful. Nearly 390 positions had been available in the mid-year job round across 12 of the 20 DHBs and six positions in two Southern Cross hospitals, which was up on the 350 jobs on offer at the same time last year. By the end of August a further 48 candidates from the remaining talent pool had been matched with jobs, bringing the number of successful mid-year candidates up to 395 (56.3 per cent) and leaving about 262 applicants still in the job-hunting pool.

Research: missed nursing cares due to low staffing increases patient mortality Missed cares are the missing link in understanding why hospitals with lower registered nurse (RN) staff levels have a higher risk of death, says a study published in late August in the International Journal of Nursing Studies. The findings are drawn from the RN4CAST study that connected nursing levels, 400,000 patients’ outcomes and survey data from 25,000 nurses working across 300 hospitals in nine European countries. The latest research was led by Dr Jane Ball of the University of Southampton and fellow authors included study co-director Professor Linda Aiken of the University of Pennsylvania. Ball says for years it has been known there is a relationship between nurse staffing levels and hospital variation in mortality rates, but there has been no good explanation as to how or why. However, links have now been found between lower RN staffing levels, missed patient cares and increased risks of patient death. Each 10 per cent increase in cares left undone is associated with a 16 per cent increase in the likelihood of a patient dying.

Round-up

Bulletin board New president for College of MH Nurses Suzette Poole is the new president of the New Zealand College of Mental Health Nurses (Te Ao Maramatanga). Poole, who is a clinical lead at Te Pou, was announced as the new president at the college’s conference in October. She initially trained at Tokanui Hospital and went on to specialise in forensic mental health and to take on a range of clinical and leadership roles, including being a clinical nurse director and nurse advisor to the Nursing Council. Poole recently completed her Master of Nursing, is a fellow of the college, and is co-editor of Te Pou’s nursing newsletter Handover.

Cook Islands nurse appointed WHO chief nurse Cook Islands nurse leader Elizabeth Iro was recently announced as the World Health Organization’s new chief nurse. Iro, who has been a nurse and midwife in New Zealand, is currently the Cook Islands Secretary of Health and is the former Cook Islands Chief Nursing Officer and a former president of the Cook Islands Nurses Association. Her appointment was announced in October in Brisbane by Dr Tedros Adhanom Ghebreyesus, the director-general of WHO, who earlier this year pledged he would reinstate a nursing role in his WHO headquarters team in Geneva after a sevenyear gap. Until recently also based in Geneva was former New Zealand chief Dr Frances Hughes, who was chief executive of the International Council of Nurses from early 2016 until August 2017. Iro has more than 30 years’ experience in public health in the Cook Islands and New Zealand working initially as a staff nurse, midwife and charge midwife. In 2012 the nurse leader, who has a master’s degree in business administration and a master’s degree in health science, became the first nurse to head the Cook Islands Ministry of Health when she became Secretary of Health.

Rural MH nurse wins scholarship A mental health nurse leader working across the Far North took out this year’s $3,000 Rural Women New Zealand (RWNZ) scholarship. Roberta Kaio, who is of Ngāti Kahu ki Whangaroa and Ngāpuhi Nui Tonu descent, says she will use the scholarship to complete her Master of Nursing. She currently works as the primary mental health coordinator for Kaitaia-based Te Hiku Hauora’s mobile nursing team, which serves the Far North.

NP, 29, awarded Young Nurse of the Year 2017 Jess Tiplady, a young nurse practitioner who is helping to reduce distress and hospital visits for children with asthma and eczema in South Auckland took out this year’s Young Nurse of the Year award. The 29-year-old, who became a primary health NP in April, was awarded NZNO Young Nurse of the Year 2017 at the organisation’s annual conference. The NP is one of only four NPs under 35 and Tiplady, whose mother is Ngāi Te Rangi, is currently the youngest Māori nurse to have achieved NP status in New Zealand. To become an NP by age 29, Tiplady has studied every year but one since first enrolling in nursing school.

Nurse innovators among $20,000 Clinicians’ Challenge finalists Supporting youth in crisis and helping immigrant children catch up with immunisations are two digital innovations co-led by nurses to make this year’s Clinicians’ Challenge finals. The two projects are among the four finalists from 41 entries received this year for the $20,000 annual digital health challenge, with the winners decided at the 2017 HiNZ conference in Rotorua in early November.

Māori nurse leader takes out NZNO’s top award Kerri Nuku, the nursing leader who has twice taken Māori health and Māori nurse pay parity to the United Nations, has been honoured with the NZNO’s highest award. The kaiwhakahaere and co-leader of NZNO was awarded the biennial NZNO Award of Honour during the organisation’s annual conference. Nuku’s award was presented for her work making a positive impact on nursing, including her work on an international level for indigenous nurses and her submissions to parliament on a number of issues, including smokefree policies.

Aged care nurse receives palliative nursing scholarship Aged residential care nurse Kat Groenewald is the winner of this year’s Donny palliative nursing scholarship. The two-year palliative care nurse specialist training programme scholarship is offered by the Donny Trust in partnership this year with Wellington’s Mary Potter Hospice and Capital & Coast District Health Board’s hospital palliative care service. It covers her salary for two years, mentoring and funding her postgraduate diploma in palliative care. nursingreview.co.nz Issue 5 3

Focus Child health

‘Magic wand’ numbs kids’ pain

No pain and more gain is how RACHEL WILSON describes trialling a painnumbing device with Christchurch’s child cancer patients. NURSING REVIEW reports on the difference the ‘magic wand’ is making for children facing endless needles.

hildren going through cancer treatment can start to feel like human pincushions. Injections, intravenous (IV) lines, blood tests and implanted ports can lead, not surprisingly, to children being anxious and fearful about needles. Child health nurses muster all their skills to reduce the risk of distress – using the right words, play and distraction techniques, the support of the children’s caregivers and appropriate pain relief. The ‘go-to-treatment’ for topical pain relief, says Rachel Wilson, a clinical nurse specialist at Christchurch Hospital’s Children’s Haematology and Oncology Centre (CHOC), has been topical anaesthetic creams, but they come with their own side effects and complications. And, as she told the recent Clinical Nurse Specialist Society conference, for some children the most distressing part of a procedure can be removing the dressing holding the anaesthetic cream in place. Or if a child is needing urgent intravenous fluids or medication, there may not be enough time for the anaesthetic cream to do its job, resulting in a painful experience for the child. The research literature shows that children who are exposed to poorly managed and painful healthcare procedures are more likely to demonstrate increased pain perception, pain behaviours and medical fear later in life, says Wilson. That is why her eye was drawn to an item in the Children’s Healthcare Australasia (CHA) newsletter about a simple pain-numbing device being used at the Royal Children’s Hospital in Melbourne for more than 5,000 intravenous (IV) cannulations, with overwhelmingly positive feedback from patients. Called CoolSense, the small handheld device was first developed for dulling the pain of Botox injections and the like in the cosmetic sector. The device has a temperature-controlled head that cools and numbs the injection site. “It takes only 10 seconds to work before the injection can be given,” says Wilson. “It is simple, it is allergyfree and it is immediate – a no-brainer.” And, unlike using an ice pack on a wriggling child, the device’s small round head enabled a precise and controlled numbing of the injection site area. Wilson says that, also surprisingly, despite the sudden chill, using the device didn’t cause vasoconstriction of a child’s vein so veins still ‘popped up’ and were accessible. So with the support of CHOC charge nurse manager Chrissy Bond, it was decided to trial CoolSense on CHOC patients in May 2016, using the numbing applicator not only for IV cannulation but also venepuncture, accessing ports and giving subcutaneous and intramuscular injections. The CHOC nurses were trained in using CoolSense and, depending on the age of the child, prepared the children for the sudden cold of the device by talking about it being like a frosty Canterbury morning or giving younger children a lick of an iceblock. “Very quickly the CoolSense became known as the magic wand,” says Wilson. “One of our patients – she loved it – said the only thing that was wrong with it [the ‘magic wand’] was that it wasn’t pink and it didn’t have ‘bling’.” The trial was not without its hiccups: a week in there were reports of skin tissue injuries so the team stopped using the devices

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to investigate. They discovered there was an undetected fault with one device, which meant the cold metal applicator head (or pin) had shifted and was no longer touching the alcohol gel pad. “It is the alcohol that protects the skin from the very cold [applicator] head that you are pushing against the skin [for 10 seconds],” says Wilson. “So we were, in fact, causing [ice] burns to these children.” This led to refining the procedures and updating the education package to ensure that nurses checked there was no gap between the metal head and the gel pad, recorded which device they used, used a watch to time the 10-second application, and the devices were not stored in a freezer colder than -10oC. The team then reintroduced CoolSense and, the second time around, the ‘magic wand’ was rated a winner in a survey of CHOC parents (31 respondents or 80 per cent of CHOC children in trial). More than 83 per cent of respondents believed that CoolSense was more effective than the creams; more than 90 per cent agreed that using the numbing devices saved time; about 85 per cent believed it worked well in numbing their child’s skin before needle insertion; and 87 per cent would recommend the device to other parents.

Focus Child health

Less pain and fewer dollars Wilson says another plus for the numbing applicator was the potential for cost savings. “Even though as nurses we like to pretend we don’t want to know about it [money], it is actually very important as we all work with a budget that is limited.” She says the topical anaesthetic creams they traditionally used took an hour for optimal effect and cost between $6.75 and $9 per 5g tube, leading to an annual bill for Canterbury DHB’s child health services in excess of $60,000. In comparison, a CoolSense applicator costs about $160 and each device comes with an alcohol cartridge lasting 350 applications. Wilson says the cost of the device and replacement cartridges average out at 22 cents per use – so potentially there could be a saving of $8,780 per 1,000 uses. CoolSense training is now a routine part of orientation for new nursing and medical staff in child health, says Wilson. The numbing device was also being used beyond child health services in other hospital areas where children are treated, including intensive care, radiology, emergency and operating theatres. The innovation was the runner-up in the improved quality and safety experience category of Canterbury DHB’s Innovation Awards last year and Wilson and the Child Health team have also presented their findings across the Tasman, as well as at the recent Australasian Nurse Educators Conference. “We are providing the evidence and getting it out there for people to show how this very little piece of technology can change outcomes for children,” says Wilson. She says pushing for innovations and implementing something new did take some courage and tenacity. “You have to have passion for it – people ask me do I actually have shares in CoolSense because I keep going on and on … and I still am,” laughs Wilson. “But it just goes to show that small innovations can grow into evidence-based best practice, delivering improved health experience outcomes for our patients.” And maybe fewer children will now have memories of their time in hospital as human pincushions.

The initial research into using CoolSense at Melbourne’s Royal Children’s Hospital was recently published in the journal Anaesthesia and Intensive Care by paediatric anaesthetist Philip Ragg. The prospective observational audit of 100 children and adolescents (aged 6-18 years) looked at the patient and carer satisfaction rates with using the device and how effective it was in reducing the pain of intravenous cannulation. The study found that 94 per cent of patients rated the pain during cannulation as less than or equal to three on a numerical pain rating scale of zero to 10. Patient and carer satisfaction with the device and cannulation success rates were also high; 66 per cent of patients and 82 per cent of carers ‘really liked’ the device and 28 per cent of patients and 12 per cent of carers ‘liked’ it. Ninety-five percent of patients were cannulated on the first attempt. The article concluded that the device appeared to be a useful tool that provided effective analgesia for intravenous cannulation in children with minimal complications. Source: Ragg P et al. (2017) A clinical audit to assess the efficacy of the Coolsense® Pain Numbing Applicator for intravenous cannulation in children. Anaesthesia and Intensive Care45(2)

Creating a village

Caring for a child with complex needs is a 27/7 job for families. Nurse CHRIS MOIR is a respite volunteer for one such family.

vividly recall spending a day at Cherry Farm’s ‘Babies’ villa as a student nurse. It was the 1980s and I was doing a clinical placement at the former psychiatric and intellectual disability hospital north of Dunedin as part of my Comprehensive Diploma. I remember the day so clearly as it was incredibly sad. The people we were caring for, some were adults, were changed and fed and put on mattresses on the floor with no stimulation and little interpersonal interaction. I was reminded of this experience recently when I watched an online video where the mothers of two young men – who in the past may have been in a setting like the ‘Babies’ villa – talk about their sons being the first generation growing up outside institutionalised care (www.complexcaregroup.org. nz/connect/our-stories). The two mothers interviewed share very moving accounts of their lives caring for their children. While it seems, from my brief experience of institutionalised care, to be much better for the child/ young person to be in a home environment, I can also appreciate the stress on the parents and family is extreme. No parent of children without such complex needs can watch these interviews and not be humbled at the commitment of these parents and the consuming nature of the care they must provide.

Chris Moir.

Research highlights families’ need for respite The support offered to Canterbury families with children and young people with high level, complex, healthrelated needs was the subject of a 2015 study led by Nurse Maude. The goal of the mixed methods research study was to consider what services would meet these needs. The feedback from focus groups make this study’s report as moving to read as watching the videos from the Complex Care Group. Sleep deprivation, strained relationships within the family, a complex and poorly understood funding environment, and a lack of attention available for other children’s needs are just a few of the issues raised. It appears no system is without its Continued on next page >> nursingreview.co.nz Issue 5 5

Focus Child health

Seeing first-hand the psychological, physical, and emotional toll on the primary carers of children with complex needs has been a revelation for me.

issues. I’m sure that going back to the big institutional model is a move few families would consider, but the lack of respite care makes life hard for these families. The needs of the families in Canterbury echoed the needs of families in research studies from similar countries. One aspect highlighted is that families require flexible services as their needs can change rapidly. Another is that families prefer in-home respite care, but this is seldom available due to the difficulty in finding suitable carers, other than willing family members. While some families have support from grandparents, there are limitations in the services that ageing parents can provide. Parents reported their informal support services were highly variable and significantly strained. The study recommended that a Respite Care Connections Service be established, with the key aims of: ▶▶ expanding respite care to take a whānau/family rather than child or young person-centred view through predominantly home-based individualised respite care options ▶▶ formalising and further developing current informal networks through collaboration, connections and communication, maintaining a ‘Connections’ database. The tangible result was that in 2016 the Complex Children’s Respite Care Connections Service (CCRCCxS) was established and Nurse Maude appointed a co-ordinator to achieve those aims.

The privilege of volunteering I spotted the service’s ad in a local paper seeking volunteers ready to work alongside parents of children with complex health needs. 6 Issue 5

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Two to four hours a week was the time commitment suggested, and the range of activities described as “doing anything from babysitting the child with complex needs to taking other children to sporting commitments”. As a newcomer to Christchurch at the time, I thought I had some time to offer. They weren’t looking for nurses, so I wasn’t thinking that I would be doing anything clinical. I was interviewed, police-checked, had a day of orientation with the five other volunteers in the first intake and was then introduced to the family I support. I visit the family most weeks and it has become a highlight of my week. Just as nursing is a privilege, it is likewise a privilege to be able to go into a family’s home, even if you are there to help in the most basic of ways. Seeing first-hand the psychological, physical, and emotional toll on the primary carers of children with complex needs has also been a revelation for me. The mother of my family has a calendar constantly full of appointments she must get her child to or visitors coming to their home. The moving story she tells of the journey to diagnosis of her child’s complex condition is difficult to hear as a health professional as she was not always listened to. The services they receive now seem to be very responsive to their needs. Her child is regularly admitted to hospital with the flow-on effects for the other children and family members this involves. As a nurse, working in the education setting, I did not appreciate all that goes on for families in this position. I also realise I cannot fully relay its reality to my students. Some of the most moving moments have been small. Last week the child nodded at me when I asked her if she was okay and

I realised she does understand me. When the cutest little wheelchair arrived, the mother told me she had shed a tear, as it is one thing to know your child can’t walk and another thing to have it put in front of you so graphically. While I don’t have to flush the child’s MIC-KEY button after a tube feed, I do if we are out walking so she can get out of the wheelchair to play. This isn’t an activity specific to nurses, but I am sure I feel more comfortable doing it because of my nursing experience. For this family, the time I spend with the child allows the mother to do everyday jobs like grocery shopping. The idea of doing anything that might seem relaxing to me doesn’t even register with her as the care of her family is all-consuming. It is relaxing for her to be able to do the groceries alone. The first group of volunteers has been followed by more and, in a report done this year, 10 families are receiving volunteer support. Nursing is a great background for work with families of children with complex care, but it’s not essential. I have found flexibility, being open to other families functioning differently from your own, and a bag of paper, pens and bubble mix are all essential. A new co-ordinator has recently come on board and she is keen to hear from anyone in the area who thinks they have time to offer. If you would like more information, please contact Fleur.Hope@nursemaude.org.nz as more volunteers are needed. Author: Dr Chris Moir is a lecturer and clinical co-ordinator for the University of Otago’s Centre for Postgraduate Nursing Studies.

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Focus Wound care

Dying wish prompts innovation A woman’s wish to spend her dying days at home saw Christchurch’s Nurse Maude nurses go into overdrive. FIONA CASSIE reports on the speedy wound care initiative.

Rose McConchie.

Elizabeth Croton.

Mary Fairhall.

ulie* wanted to be at home in her own bed with her family and friends around her. But the daily dressing of her terminal malignant wound was just too painful without the relief of Entonox gas, traditionally only available in secondary care. As Julie lay in Christchurch Hospital wishing to be at home – and to be as normal as possible for as long as possible – a team of Nurse Maude nurses rallied to make her goal achievable. The team presented to the recent Clinical Nurse Specialist Society conference on how meeting Julie’s wish motivated them to – within a week – fast-track the policies, training and equipment that were required to enable Nurse Maude district nurses for the first time to deliver home-based Entonox (a mix of nitrous oxide and oxygen) pain relief. The results were that not only did Julie get to return home to be with her husband Ken*, but also the innovation she motivated has seen home-based Entonox used again for another wound care patient facing severe acute pain when her wounds were cleaned and dressed. Unlike other forms of pre-and post-dressing pain relief, Entonox works quickly, gives the wound care patients control over their own pain and is short-acting, so doesn’t leave them drowsy for the remainder of the day.

Julie’s story Julie was a 63-year-old woman with a strong belief system, a very supportive husband and a close circle of family and church friends, says palliative care nurse specialist Mary Fairhall. She was first diagnosed and treated for metastatic rectal adenocarcinoma in 2013 but the cancer returned in 2015 and treatment was unfortunately unsuccessful. When Fairhall met Julie in late 2016 the palliative patient had an extensive fungating 8 Issue 5

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tumour on her back producing a lot of exudate, and the daily dressings of the large, open, tunnelling wound were causing severe pain and nausea. The team tried to address the pain by using oxycodone before and after dressings but Julie still rated her pain five-out-of-five at dressing change time. This led to Julie being hospitalised, where she was reviewed for analgesia and cares. The “transformative” change was using Entonox gas for dressing changes, as it dramatically reduced Julie’s pain during wound dressings from a five-out-of-five to a one-outof-five, or even a zero. But Julie had a real desire to be at home and to live a life as normal as possible. The barrier was that Nurse Maude – or any other district or palliative care nursing service that they knew of – had never delivered Entonox at home. The high oxygen content of the 50/50 nitrous oxide/oxygen gas means transporting and storing the Entonox gas cylinders is not without risk. District nurses were also not trained in delivering Entonox, and would be doing so in a person’s home without the back-up support available to hospital nurses if there was respiratory failure – so training and processes were required to be in place to keep both nurse and patient safe.

Speedy response Nurse Maude decided to see meeting Julie’s goal of being home “as an opportunity rather than a challenge”, says Rose McConchie, Nurse Maude’s community clinical nurse educator. “Our main constraint was time,” says McConchie. Julie started to deteriorate in hospital and the team knew they needed to do a lot in a hurry. This included training, creating safety policies and protocols; and working out how to supply and fund Entonox in the home.

“Certainly the pressure was on,” says McConchie. But, she says, they had a great collaborative team in the oncology ward team, the palliative care team, the wider Nurse Maude team (including the Community Nursing Service Manager and the Clinical Nurse Manager), the gas provider BOC, and Julie’s family. McConchie had to create Entonox usage guidelines for the patient, a gas monitoring and re-ordering system, and a consent form for storing Entonox gas in a private home. The consent form set out a safety checklist, which included that the storage space should be well ventilated and there should be no open fires, no smoking, and no mobile phone use near the cylinder and its combustible contents. The district nursing team in Julie’s area needed to be trained to be competent to deliver Entonox for Julie and to respond in a respiratory emergency. The aim was to assign two nurses for each wound dressing – one to do the wound care and the other to deliver the Entonox. The nurse administering the gas has a pulse oximeter to check the patient’s oxygen saturation, and monitors their pulse, blood pressure and sedation level to ensure the patient is not over-sedated. Oxygen, a mask, and emergency equipment are also on hand in case there is respiratory failure and an airway needs to be inserted. The Entonox training was done speedily by McConchie completing the DHB’s online Entonox training package and being signed off by Canterbury DHB nurse educators as competent, before going on to sign off the district nurses one by one as they each completed the online competency training.

Innovation brings ease The result was that within one week Julie was able to return home. The thankful patient told the team that their efforts meant she was “much more at ease, much more relaxed and her pain was much better”.

Focus Wound care

In addition, “her family and friends could visit any time and the pressure was taken off her supportive husband”. District nurse Elizabeth Croton says she had cared for Julie and Ken in their home so was quick to say yes to Entonox training. “I knew them both well enough to know that they would both want to be home for these final weeks,” said Croton. “The Entonox training was going to enable this to happen and give me the confidence and skills to provide that care at Julie’s home.” Julie’s goals wanted to live as normal a life as possible with family and friends in a home that was ‘non-medical’, apart from a treatment room where the dressing changings were carried out. “Her husband was thrilled to have her at home,” said Croton. Fairhall said the team continued to adhere to Julie’s wishes. In mid-July Julie and her husband requested a hospice admission and she died peacefully five days later. The Nurse Maude team was very proud that with the support of many they were able to rapidly respond to Julie’s wishes. The creative ‘under the pump’ response has also resulted in a robust process for

prescribing and delivering Entonox inhome on future occasions. Nurse Maude District Nursing has already had another referral, by a nurse practitioner, for delivering Entonox to a woman who had surgery on abscesses under each arm that required cleaning by irrigation and then packing of the healing wound – a process the woman found very painful. McConchie said the short-acting nature of Entonox made it perfect for painful procedures such as this as it was quickly out of the system, unlike traditional pain relief like morphine. Using Entonox meant

this client could get up straightaway, have breakfast, get on her bike and carry on doing what she needed to do for the rest of the day. The legacy of Julie’s wish is expected to be more wound care clients whose pain needs are not being well met by traditional means being considered for home Entonox treatment. More patients will also be able to choose to receive care in their own homes – reducing both costs to the taxpayer and stress to palliative patients who, like Julie, just want to go home to their own beds. *Julie and Ken are pseudonyms

Nurse-led pressure injury intervention saves millions

housands of New Zealanders each year develop preventable pressure injuries at a great personal cost to themselves and their families. Heather Lewis, a clinical nurse specialist for soft tissue infections and cellulitis, was the organisation lead of a PI working group to reduce the number of hospitalacquired pressure injuries (PIs) at Counties Manukau Health’s five hospitals. In September Lewis was the lead author of an article in the New Zealand Medical Journal indicating the intervention had saved the DHB millions between 20112015. The intervention included identifying nurse wound care champions in each ward or unit, an extensive education package (including a PI website and e-learning packages) and standardisation of risk assessments across the DHB. It also set the expectation that full PI risk assessments be

carried out within six hours of admission, and appropriate bundles of care (including pressure-relieving rental equipment)

“We are confident that our study does at least indicate that savings can be made by the implementation of interventions such as ours to manage pressure injuries in hospitals.” provided based on the patient’s assessment score and clinical judgement. Lewis and her colleagues estimated the mean cost of treating PIs in a hospital

or long-term care setting – using the inflation-adjusted findings of a 2004 UK study – resulting in treatment costs of $2,400 for a stage one PI up to $23,750 for a stage four PI. These costs included nurse time, dressings, antibiotics, diagnostic tests, support surfaces and extra inpatient days. The audit findings were used to estimate of PIs at the DHB’s hospitals (for 2011 to 2015). The results showed an estimated cost of treating PIs for the DHB in 2015 was $14.18 million – $12 million less than the $26.47 million estimated cost for 2011. Lewis and the team said they accepted the estimated savings were very approximate. “However, we are confident that our study does at least indicate that savings can be made by the implementation of interventions such as ours to manage pressure injuries in hospitals.” nursingreview.co.nz Issue 5 9

Focus Infection control

Not one bug lessons learnt from recent but two: gastro outbreaks A patient vomits. The next day, 11 patients are vomiting. FIONA CASSIE talks to infection prevention and control nurse specialists at three hospitals about lessons learned from recent norovirus and other gastroenteritis bug outbreaks.

t was a tough winter around the country for many hospitals this year. A bad flu season, tight budgets and bulging wards. So with the flu season all but over and spring blossoming around the country, many nurses were looking forward to the workload pressure easing. Then in came a report of vomiting and diarrhoea. It is every infection prevention and control (IPC) nurse specialist’s bogeyman. Has there been a breach of infection control practice – possibly due to staff being stressed and tired after a long winter? Will the case be a one-off? Or are the infection control practices of the hospital or residential aged care facility about to be tested by an explosive norovirus outbreak?

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On 14 September Whangarei Hospital had one vomiting patient. By the next morning it had 10 more and promptly closed its surgical ward. A few days later, further down the island, Whakatane Hospital closed the door on its Acute Care Unit because of a diarrhoea outbreak hitting patients and staff. Then just a few days after that, Whakatane’s big sister hospital, Tauranga, had infection control staff running between the fourth and second floor battling to contain three small outbreaks in three different wards. No gastro outbreak was the same. Vomiting was widespread and violent in Whangarei’s Ward One outbreak, while down the island in Whakatane diarrhoea dominated and Tauranga faced a mixture of both. A norovirus outbreak isn’t easy to deal with “whichever end it comes from”, as one nurse put it, but with violent vomiting comes the added risk of the airborne spread of a virus so virulent that ingestion of just one viral particle can cause infection. All three hospitals quickly contained and controlled the outbreaks using their established outbreak plans (see case studies for details). Other hospitals around the country empathised and hoped

they wouldn’t need to put their own plans to the test this spring. Nursing Review spoke to the infection prevention and control nurse specialists involved in the latest outbreaks about their experiences, and asked what advice they had to share with their colleagues around the country.

“Extremely virulent” Whangarei’s orthopaedic ward was full and the hospital busy when a single vomiting case overnight turned into a major suspected norovirus outbreak. The rapid acceleration of cases meant airborne spread was possibly involved, as the first affected room – located in the middle of the ward – was open to the ward corridor. Mo White, IPC clinical nurse specialist for Northland DHB, says it turned to the DHB’s microbiologist to help interpret the literature indicating norovirus particles are only airborne for ‘a short time’ following vomiting. “Now you can’t measure ‘a short time’,” says White, “but the literature goes on to say that these viral particles, which are extremely virulent, will land on surfaces, curtains and just everywhere, so people can be infected via [the airborne virus settling on] the surfaces they touch.”

Focus Infection control The decision was made by the Outbreak Management team to close the ward; elective surgery was put on hold; and the number of cleaners was doubled and their hours were extended to keep the infection at bay through thorough environmental cleaning and careful infection control practices. White says the team had little option but to close the ward with isolation rooms already full, which is an increasing trend with the number of patients coming into hospitals with multi-drug-resistant organisms (MDRO). A security staff member distributed information pamphlets, sanitising gel and personal protective equipment (PPE) outside the ward’s closed doors; extra linen and PPE were ordered to get the ward through the weekend; and the team met regularly, with updates being sent out to staff and local media.

ADVICE TO SHARE

Hand hygiene, hand hygiene, hand hygiene! ▶▶ During gastro outbreaks, wash your hands with soap and water, not just sanitising gel, as there is mixed evidence about the effectiveness of alcohol hand disinfectant against norovirus. ▶▶ Use an N95 mask if the patient is vomiting and do NOT touch the mask. Instead, remove gloves, wash your hands and remove the mask by grasping tapes or elastic and drawing it away from your face. Wash your hands again after disposing of the mask. ▶▶ Isolate a suspected gastroenteritis patient quickly to contain the risk of infection. ▶▶ Send specimens from symptomatic patients as soon as possible for testing. ▶▶ Do NOT assume that all symptomatic patients are infected by the same organism, or that a gastro outbreak is norovirus. ▶▶ Keep your ear to the ground about gastroenteritis in the community so that staff can be forewarned to be extra vigilant for cases of vomiting and diarrhoea. ▶▶ Emphasise the need for good environmental hygiene using bleach, as gastroenteritis bugs – both norovirus and C. difficile – can survive on contaminated surfaces for a long time. ▶▶ Maintain frequent communication with the outbreak team about the number of cases; an outbreak log sheet can be useful to document and trace the outbreak pattern.

CASE STUDY: Whangarei Hospital ▶▶ First suspected case was reported in a four-bed room of the 32-bed orthopaedic ward on the afternoon of Thursday 14 September, with vomiting the major symptom. ▶▶ The affected room and some other similar four-bed rooms open directly onto the ward corridor (i.e. no doors). ▶▶ The vomiting and diarrhoea were unexpected gastroenteritis symptoms so the affected patient was isolated, airborne precautions put in place and other room occupants closely monitored for symptoms. ▶▶ The clinical head of service and duty manager was informed. ▶▶ By the following morning (Friday 15 September), the ward had 11 patients meeting the case definition for norovirus – most vomiting – and two more patients became symptomatic later in the outbreak. ▶▶ The ward was full, including isolation rooms, and the hospital very busy so was unable to isolate all affected patients and contacts from the other patients in the ward. ▶▶ The Outbreak Management team met at 10am on Friday 15 September and the decision was made to close the ward and inform the media. ▶▶ Seven staff from the outbreak ward were off-duty with varying symptoms during the outbreak (not all with norovirus). ▶▶ Seven of the 13 symptomatic patients had samples tested for norovirus and two were positive for norovirus. ▶▶ The outbreak was contained and officially over within 10 days.

“These viral particles, which are extremely virulent, will land on surfaces, curtains and just everywhere, so people can be infected via the surfaces they touch.”

Norovirus is a highly contagious virus that can cause the sudden onset of gastroenteritis with acute nausea (81 per cent), vomiting (54 per cent), abdominal cramps (72 per cent) and diarrhoea (85 per cent). The virus is shed in faeces and can spread very easily from faeces to mouth through contaminated hands, food, water and items in the environment. There is also some documented evidence of airborne spread through aerosolised vomit. The virus is very hardy and can survive for a long time on handrails, taps and door knobs. The incubation of norovirus can be between 10 and 50 hours and there can be asymptomatic infections.

Clostridium difficile (C. difficile) is a bacterium spore shed in faeces that is the most common cause of diarrhoea in hospitalised patients. Spores can live for long periods on surfaces and faeces-contaminated surfaces such as toilets and commodes can be a ‘reservoir’ for C. difficile. Up to 20 per cent of hospitalised patients are estimated to be colonised with C. difficile, but only a minority experience symptomatic disease. Source: Guidelines for the Management of Norovirus Outbreaks in Hospitals and Elderly Care Institutions (2009). Ministry of Health. Measures for the Prevention and Control of Clostridium difficile Infection (2013). Ministry of Health.

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Focus Infection control White says the DHB’s microbiologist was proud that staff managed to contain the outbreak to one ward, but it had been very demanding on staff caring for 13 symptomatic patients who were in traction or recovering from hip or knee surgery. “To have to access the toilet in a hurry is a real challenge.” A debrief is scheduled for October, and White says some of the outbreak challenges the IPC team want to discuss include how to manage isolation in a shared room that can’t be isolated from the rest of the ward, and how to ensure an affected outbreak ward has enough appropriately qualified staff.

Not one bug, but two Two separate bugs were circulating at the time of the gastro outbreaks at Tauranga and Whakatane Hospitals – and sometimes both bugs were present not only in the same ward but also in the same patient. “It always pays to think that not just one organism is necessarily causing the symptoms,” says Bay of Plenty DHB IPC nurse specialist Adrienne Stewart. “There may be at least a couple of things circulating at the same time.” She says this means it needs to be stressed to staff that they need a new set of PPE (i.e. disposable gloves and gown) for each patient they are looking after. “So [this means] not going from one symptomatic patient to another in a fourbed room with the same set of gloves and gown on, which we sometimes see.” Whakatane Hospital IPC nurse specialist Sarah Winship adds, in retrospect, that the DHB’s press release should have talked about a gastro outbreak closing Whakatane’s unit, rather than a suspected norovirus outbreak, as in the end only two of the five symptomatic patients actually had norovirus. Test results from the 20 symptomatic cases in Whakatane and Tauranga found seven in Tauranga had norovirus alone

and one had C. difficile; and two of five patients in Whakatane had norovirus, with one of those having both norovirus and C. difficile. The cause of seven of the cases is unknown, as stool specimens were either not collected for testing or tests came back negative for both organisms. “One of the unfortunate things is that sometimes staff are a bit tardy in getting specimens sent off,” says Adrienne Stewart. She says it is important for staff to be prompt in not only reporting patients with gastroenteritis symptoms but also in sending specimens for testing. “Another thing I found difficult at times was that although we’ve placed symptomatic patients into isolation promptly, very often I would go past and find both doors to the isolation unit wide open.” This meant that any well-placed card on the outside of the doors – setting out and stipulating isolation procedures – was unable to be seen by anybody walking in and out of the room. “I’d ask for the doors to be closed so the door card could be seen but five minutes later the doors would be open again.” Stewart says the outbreaks are “hugely disruptive” for staff, particularly at the beginning when moving orthopaedic patients and beds into an isolation area, and then cleaning and disinfecting behind them, so one part of the ward can continue to function normally. “But in my experience here, it is far better you do that,” she says, “than have symptomatic patients spread throughout a surgical ward and have to have the whole ward closed down (and surgery cancelled).” The disruption of a spring gastro outbreak in the wake of a tough winter and ‘flu season is what every hospital and facility plans and hopes to avoid. But with an estimated 50,000-plus norovirus cases alone occurring in New Zealand each year, it is inevitable that outbreak plans will be

tested someday. The hope is that the plan will do its job – as in these occasions – and the outbreak is contained and lessons learnt for the (unfortunately) inevitable next time it is tested. Meanwhile, as Mo White says, remember: hand hygiene, hand hygiene, hand hygiene.

CASE STUDY: Whakatane Hospital ▶▶ On Saturday 16 September, a patient at Whakatane Hospital’s Acute Care Unit came down with gastroenteritis symptoms – no vomiting but abdominal pain and diarrhoea. ▶▶ By the end of the weekend, five patients were ill and four staff (two more staff were sick by Tuesday). ▶▶ The Acute Care Unit is made up of 16 individual bays that are open (no doors) to the corridor of the horseshoeshaped unit. ▶▶ Because of the location of the affected patients – in one end of the horseshoe (used primarily for acute admissions requiring ventilation/high dependency care) – and the number of staff off sick, the decision was made on Monday 18 September to close the unit to new patients and restrict access by visitors and staff. ▶▶ The unit was split into an affected half and non-affected half and staff were allocated to work on either side of the demarcation zone (there were empty bed spaces between the two areas as the unit was not full). ▶▶ Test results from the five patients showed that one had norovirus, one had both norovirus and C. difficile, one had just C. difficile and the other two were tested for norovirus and C. difficile but came back negative for both.

CASE STUDY: Tauranga Hospital ▶▶ On Thursday 21 September, alerted to four gastroenteritis cases in the 40-bed orthopaedic ward – the largest ward in the hospital located on the fourth floor. In all there were to be five orthopaedic ward cases. ▶▶ Two days later (23 September), and two floors below, the first of four more symptomatic cases appeared in one of the three medical wards that occupy the second floor. ▶▶ Then on 24 September another 22-bed medical ward on the second floor had four symptomatic patients. ▶▶ These patients were moved into isolation in a section of the ward that, where it was possible, was divided by double doors so the rest of the ward could continue to function as close to ‘business as usual’. The contact patients were also shifted into a separate area of the isolation section so they could be kept under surveillance. ▶▶ Of those involved in the initial orthopaedic ward outbreak, one patient was found to have norovirus, one had Clostridium difficile (C. difficile), and three others did not have specimens sent for testing. ▶▶ Test results from the 23 September medical ward outbreak found all four symptomatic patients had norovirus and one also had C. difficile. ▶▶ Of the patients in the second medical ward outbreak on 24 September, two were found to have norovirus and two had no specimens taken. ▶▶ The confirmed norovirus patient in the orthopaedic ward had been seen by health professionals working on both floors. Anecdotally, several staff were off work with gastroenteritis-like symptoms during these outbreaks as well. 12 Issue 5

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CERTIFIED NATURAL

@ComvitaNZ comvita_newzealand

Professional Development Infection control

How to be a dab hand at hand hygiene How do you improve hand hygiene compliance? CLINICAL BOTTOM LINE Strategies to improve hand hygiene compliance are effective and justified but it is unclear which strategy or combinations of strategies are the most effective.

CLINICAL SCENARIO You know hand hygiene is the simplest and most effective way to prevent the spread of healthcare-associated infections. So compliance with hand hygiene is therefore a key patient safety issue. You are charged with improving hand hygiene compliance in your area but what is the best way to do this?

QUESTION Which (if any) intervention strategies improve healthcare staff compliance with hand hygiene?

SEARCH STRATEGY PubMed Clinical Queries (Therapy/Narrow): hand hygiene compliance

CITATION Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2017; 9:Cd005186. doi: 10.1002/14651858. CD005186.pub4

STUDY SUMMARY A systematic review to assess the short and long-term success of strategies to improve hand hygiene compliance, and to determine whether an increase in hand hygiene compliance can reduce rates of healthcare-associated infections (HCAI). Inclusion criteria were: Type of study: randomised trials, non-randomised trials, controlled beforeafter studies, and interrupted time series analyses (ITS). Excluded were studies involving surgical hand disinfection and surgical scrubbing. Participants: nurses, doctors and other healthcare workers. Intervention: any intervention intended to improve compliance with hand hygiene using soap and water or alcohol-based products, or both. Outcomes: Primary outcome: Hand hygiene compliance. Secondary outcomes: Reduction in HCAI or colonisation rates by clinically significant nosocomial pathogens e.g. MRSA.

STUDY VALIDITY Search strategy: Electronic databases searched were MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) to Oct 2016. The search for unpublished studies was comprehensive. No language restrictions were applied. Review process: Three authors screened the search results for potentially relevant studies; four authors independently selected the studies; two extracted data using a standardised form; and two authors conducted risk of bias assessment. All work was checked by others. Discrepancy resolved by discussion. Quality assessment: Yes, via Cochrane Effective Practice and Organisation of Care ‘Risk of bias’ criteria (adjusted for different study designs). Overall validity: A good-quality review involving a large number of studies of varying quality and study design.

STUDY RESULTS The search yielded 4,219 abstracts (excluding duplicates), from which full text of 534 studies were assessed for eligibility and a further 511 excluded. Included in the review were 26 studies (three studies located from an earlier review). Of these studies, 23 were conducted in acute care settings. Fourteen were randomised trials, two were non-randomised trials and 10 were ITS studies. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO). Strategies consisted of the following: increasing the availability of alcoholbased hand rub (ABHR), education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Twelve studies evaluated the effectiveness of single interventions as follows: performance feedback (six studies), education (two studies), cues such as signs or scent (three studies), and placement of ABHR (one study). Eight studies reported

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COMMENTS ▶▶ Increases in hand hygiene compliance were small (less than 20 per cent) but larger than seen in control groups. ▶▶ Certainty of evidence was generally low for all outcomes, there is an urgent need for methodologically robust evidence. ▶▶ There is no ‘silver bullet’ for improving hand hygiene compliance. As with any effort to change behaviour, adapting strategies to local context and understanding of barriers is recommended, as is auditing improvement efforts and revising accordingly. ▶▶ The Health Quality & Safety Commission New Zealand provides excellent resources for improving hand hygiene compliance at www.hqsc.govt.nz. Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD candidate, Deakin University, Melbourne. cwensley@deakin.edu.au.

Summary of results Types of intervention#

Hand hygiene compliance

Number Certainty of of studies evidence

Multimodal; some but not all strategies recommended by WHO

Slightly improved

Low

Multimodal; all strategies recommended by WHO plus additional strategies (WHO enhanced)

Slightly improved

Low

Multimodal; all strategies recommended by WHO

Uncertain impact

Very Low

Single component strategies: performance feedback (six studies); education (two studies); cues (three studies); and placement of ABHR (one study)

May improve

Low to moderate

# Compared with different or no interventions: WHO. 14 Issue 5

either infection or colonisation rates. Substantial heterogeneity between studies meant that it was not sensible to pool data using meta-analysis. Compared with no or different interventions, multimodal interventions that included some but not all strategies recommended by WHO may slightly improve hand hygiene compliance. Multimodal interventions that contain all strategies recommended by WHO plus additional strategies (WHO enhanced) may also slightly improve hand hygiene compliance. It was uncertain if multimodal interventions that included all WHObased strategies improved hand hygiene compliance. Single component interventions may also improve hand hygiene compliance, as follows: performance feedback (may improve), education (may improve), cues such as signs or scent (may slightly improve), and placement of ABHR close to the point of use (probably slightly improves). Hand hygiene compliance strategies may reduce infection or colonisation rate but certainty of evidence was low.

Professional Development Learning activity

Code of Conduct refresher The Code of Conduct guides nurses – and the people they care for – on the behaviour expected from the nursing profession. This article provides a refresher on the 2012 Code and its supporting documents, which every New Zealand nurse is expected to be familiar with. By Liz Manning Introduction Three documents from the Nursing Council of New Zealand (NCNZ) provide a comprehensive guide to nursing professional conduct and behaviour in New Zealand. The documents span all scopes of practice3,4,5, settings and specialties. Every nurse should be very familiar with these documents and copies of them should be easily accessible in all work settings.

This article provides an overview of each document with useful tips and examples to prompt reflection. It does not cover everything OR replace the need to read the documents. The Code of Conduct² is the primary document, with the two additional documents Guidelines: Professional Boundaries⁷ and Guidelines: Social Media and Electronic Communication⁸, providing extra information and guidance.

Useful tip Refer to these THREE documents if you are dealing with practice issues; they may help you to identify or approach a situation. They can even provide helpful wording for framing feedback. The three documents, plus many more standards and guidelines are freely available to download from www.nursingcouncil.org.nz.

Learning outcomes Reading and reflecting on this article will enable you to: ▶▶ increase familiarity with the Code of Conduct standards for professional nursing conduct and behaviour

▶▶ raise awareness of the appropriate approach for health professionals towards professional boundaries, social media and electronic communications

▶▶ practise applying the principles and standards of the Code

▶▶ locate and review guidelines that underpin nursing practice.

Nursing Council registered nursing competencies covered: 1.1, 1.4, 2.9, 4.3 nursingreview.co.nz Issue 5 15

Professional Development Learning activity

The Code of Conduct “The Code is a set of standards defined by NCNZ describing the behaviour and conduct that nurses are expected to uphold. The Code provides guidance on appropriate behaviour for all nurses and can be used by health consumers, nurses, employers, NCNZ and other bodies to evaluate the behaviour of nurses²”. The Code promotes four core values; respect, trust, partnership and integrity. These values are referred to throughout the eight principles and the 81 standards.

Code of Conduct Example 1:

“I’m worn out working two jobs; if it’s quiet I sleep through the night shift – I tell the HCA to wake me if anything major happens.”

Specific problems

▶▶ Too tired to work and provide safe care. ▶▶ Not readily available for patients or colleagues. ▶▶ Not following Guideline: Direction and Delegation to an HCA6. ▶▶ The HCA may perceive this as coercion/bullying¹,¹0. ▶▶ Creating an environment of risk.

Standards to consider

4.2 Be readily accessible to health consumers and colleagues when you are on duty. 6.4 Your behaviour towards colleagues should always be respectful and not include dismissiveness, indifference, bullying, verbal abuse, harassment or discrimination.

Code principles Respect the dignity and individuality of health consumers (10 standards). Respect the cultural needs and values of health consumers (10 standards). Work in partnership with health consumers to promote and protect their wellbeing (8 standards). Maintain health consumer trust by providing safe and competent care (12 standards). Respect health consumers’ privacy and confidentiality (8 standards). Work respectfully with colleagues to best meet with health consumers’ needs (10 standards). Act with integrity to justify health consumers’ trust (14 standards). Maintain public trust and confidence in the nursing profession (9 standards). The Code also contains guidance on: professional misconduct, escalating concerns, fitness to practise and public confidence.

6.8 When you delegate nursing activities to enrolled nurses or others, ensure they have the appropriate knowledge and skills, and know when to report findings and ask for assistance. 7.3 Act promptly if a health consumer’s safety is compromised.

Other standards that may also apply here include 4.10 and 6.1. Code of Conduct Example 2:

“I help my neighbour out by checking her husband’s clinical notes for his results as he never gets around to telling her; she says he doesn’t mind her knowing. He isn’t my patient but I can easily access his information.”

Specific problems

▶▶ The husband’s privacy is being breached9. ▶▶ No consent was sought from the husband (he may have chosen not to inform his wife). ▶▶ Not the nurse’s patient.

Standards to consider

5.1 Protect the privacy of health consumers’ personal information.

5.6 Health records are stored securely and only accessed or removed for the purpose of providing care. 5.7 Health consumers’ personal or health information is accessed and disclosed only as necessary for providing care.

Guidelines: Professional boundaries Nurses must remember that within any professional relationship there is a significant power dynamic in play. This dynamic – and the boundaries of professional practice – can be tested as nurses seek to support and empathise with patients and patients’ families. Patients and their families will often feel vulnerable and seek to increase a relationship with a nurse, feeling they can trust the nurse to have their best interests at heart. The professional boundaries document highlights the need for nurses to be responsible for maintaining a professional boundary in all aspects of the nursepatient relationship, and gives examples that can occur across nursing. The balance required is illustrated using the ‘Continuum of Professional Behaviour’ diagram (see Figure 1). The guidelines also contain clear and effective ‘questions for reflection’ on professional boundaries (page 8):

5.2 Treat as confidential information gained in the course of the nursehealth consumer relationship and use it for professional purposes only.

Other standards that may also apply here include 5.5. Professional boundaries Example 1:

“I house-sit for the family of a long-term patient. I had told them I don’t like my current flat and want to get away. They trust me and even pay me $50 a week for expenses.”

Specific problems

▶▶ Personal gain/financial benefit. ▶▶ Over-involvement/boundary violation. ▶▶ Discussion of personal circumstances with patient/family. ▶▶ Over-involvement could affect professional judgement. ▶▶ Providing a service other than nursing to patient/family. ▶▶ Responsible for patient/family possessions and property.

Standards to consider

7.5 Act in ways that cannot be interpreted as, or do not result in, you gaining personal benefit from your nursing position. 7.6 Accepting gifts, favours or hospitality may compromise the professional relationship with a health consumer. Gifts of more than a token value could be interpreted as the nurse gaining personal benefit from his/her position, the nurse taking advantage of a vulnerable health consumer, an attempt to gain preferential treatment, or an indicator of a personal or emotional relationship. 7.13 Maintain a professional boundary between yourself and the health consumer and their partner and family, and other people nominated by the health consumer to be involved in their care. 8.8 Ensure you only claim benefits or remuneration for the time you were employed or provided nursing services.

Other standards that may also apply include 7.8, 7.10, 7.11 and 7.12. 16 Issue 5

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Professional Development Learning activity

Questions for reflection:

A continuum of professional behaviour

Figure 1. A continuum of professional behaviour. Nursing Council of New Zealand (2012) p.4

Social media Example 1:

“If I post a photo or story about work on social media, I always keep the privacy setting to just my friends and I never use patient names.”

Specific problems

▶▶ Social media privacy settings do not prevent copying/sharing. ▶▶ Patients or staff could be identified whether their names are used or not. ▶▶ Patient and colleague privacy breach9.

Standards to consider

5.2 Treat as confidential information gained in the course of the nurse-health consumer relationship and use it for professional purposes only. 5.8 Maintain health consumers’ confidentiality and privacy by not discussing health consumers, or practice issues in public places including social media. Even when no names are used, a health consumer could be identified. 6.4 Your behaviour towards colleagues should always be respectful and not include dismissiveness, indifference, bullying, verbal abuse, harassment or discrimination. Do not discuss colleagues in public places or on social media. This caution applies to social networking sites e.g. Facebook, blogs, emails, Twitter and other electronic communication mediums. 8.1 Maintain a high standard of professional and personal behaviour. The same standards of conduct are expected when you use social media and electronic forms of communication.

▶▶ Is the nurse doing something the health consumer needs to learn to do themselves? ▶▶ Whose needs are being met – the health consumer’s or the nurse’s? ▶▶ Will performing this activity cause confusion regarding the nurse’s role? ▶▶ Is the behaviour such that the nurses will feel comfortable with their colleagues knowing they had engaged in this activity or behaved in this way with a health consumer? Key areas for nurses to be aware of are covered, including: caring for close friends or family; sexual relationships with patients or former patients or patients’ partners/family members; gifts, bequests, loans; financial transactions; power of attorney; and concluding professional relationships. Boundary transgressions have resulted in some serious breaches and consequences. If you become aware of a colleague’s boundary transgression, the document provides advice on how to proceed.

Guidelines: Social media and electronic communication Electronic communication is part of everyday life for most people, including nurses. Health professionals have a responsibility to take a more considered approach to what they communicate and to understand the consequences of what is sent in an email, text or posted online. The social media guideline highlights specific areas related to breaching confidentiality and privacy, either intentionally or unintentionally, working respectfully with colleagues and employers, using professional language Remember Employers, employees, staff, colleagues, patients and their family members may well check your online presence. Privacy settings do not prevent the sharing of information. Anything you send to another person can be copied and shared with others. nursingreview.co.nz Issue 5 17

Professional Development Learning activity

at all times, working with integrity and maintaining public trust and confidence in the nursing profession.

How do I use the documents if I’m concerned about a colleague? Practice issues will often spread across a number of principles and standards. Check through the Code of Conduct and also refer, as required, to the two guideline documents. ▶▶ If you see a professional practice situation that concerns you to the degree that you think you need to refer your concerns, write it down.

▶▶ Refer to the Code and/or the social media and/or professional boundary documents. ▶▶ Review each principle and each standard to see where the issues you have identified fit. ▶▶ Note down the relevant standard(s). ▶▶ Follow your organisation’s professional practice reporting process. Note: Check with your employer and employer policies in the first instance. If you then consider notifying the NCNZ, ensure that what you have identified is a professional practice issue and not an employment issue.

Social media Example 2:

“I needed to place Mum in a rest home. I looked for the nurse manager of the nearest one online and his social media account was full of photos of his partying and bad language.”

Specific problems

Patients/family members and others (e.g. employers) can and will check up on their current or potential care providers or employees online. The Code of Conduct clearly states: “Nurses are expected to uphold exemplary standards of conduct while undertaking their professional role. Because nurses must have the trust of the public to undertake their professional role, they must also have a high standard of behaviour in their personal lives²”.

Standard to consider

8.1 Maintain a high standard of professional and personal behaviour. The same standards of conduct are expected when you use social media and electronic forms of communication.

Quick Code challenge See if you can identify which principles and standards could be relevant to these three scenarios. Challenge 1

One of the clinic patients is Māori and she often requests that whānau come into the clinic room with her. It’s absolutely not appropriate in my view and makes me feel I’m being watched, so I’ve started saying no.

Challenge 2

One of my colleagues shouts at residents who are hard of hearing. She really talks down to them and doesn’t bother explaining when she is doing something as she says it just takes ages. They don’t get a choice.

Challenge 3

One nurse I work with was quite rough and demeaning to a patient in the emergency room and didn’t explain any of the care given. The patient was under police escort. I’ve seen this nurse behave this way many times with patients who are prisoners with guards or under police escort.

References 1. COLLEGE OF NURSES (NZ) Inc (2017). Professional

4. NURSING COUNCIL OF NEW ZEALAND (2017).

Competencies for Enrolled Nurses. Wellington:

5. NURSING COUNCIL OF NEW ZEALAND (2007).

6. NURSING COUNCIL OF NEW ZEALAND (2011).

www.legislation.govt.nz/act/public/1993/0028/latest/ DLM296639.html 10. WORKSAFE NEW ZEALAND (2017). Bullying

Guideline: delegation of care by a registered nurse

Prevention Toolbox. Retrieved from www.worksafe.govt.nz/worksafe/toolshed/bullying-

7. NURSING COUNCIL OF NEW ZEALAND (2012).

Guidelines: Professional Boundaries. Wellington:

nursingreview.co.nz

9. PRIVACY ACT (1993). Retrieved from

to a health care assistant. Wellington: Author.

Author.

18 Issue 5

8. NURSING COUNCIL OF NEW ZEALAND (2012). Guidelines: Social Media and Electronic

Author.

About the author Liz Manning RN, BN, MPhil (Nursing), FCNA (NZ) is the director of Kynance Consulting and provides project management services, professional nursing supervision, coaching, mentorship and portfolio development support. This article was peer reviewed by Cheryl Atherfold RN MHSc (Nurs) FCNA (NZ), who is an associate director of nursing practice and education at the Waikato District Health Board. Erin Meads RN, BN, PGDipAdvNsg is the director of nursing for the Aucklandbased primary health organisation ProCare.

Communication. Wellington: Author.

www.nurse.org.nz/powerpoint-presentations.html

Code of Conduct. Wellington: Author.

Recommended resources ▶▶Health and Disability Commissioner (2009). Code of health and disability services. Consumers’ rights. Retrieved from www.hdc.org.nz/the-act--code/thecode-of-rights. ▶▶The NCNZ’s Code of Conduct and guidelines are freely available to download at www.nursingcouncil.org. nz/Nurses/Code-of-Conduct. ▶▶The College of Nurses (NZ) website for Professional Support Guides on bullying and practice issues at www.nurse.org.nz/powerpointpresentations.html. ▶▶Worksafe NZ: Bullying Prevention Toolbox at www.worksafe.govt. nz/worksafe/toolshed/bullyingprevention-toolbox.

practice. Wellington: Author. Competencies for Registered Nurses. Wellington:

3. NURSING COUNCIL OF NEW ZEALAND (2012).

These three documents, which are freely available on the NCNZ website, provide comprehensive guidance for professional nursing practice. Used alongside the relevant nursing competencies, they provide nurses, employers and the public with a clear framework for all aspects of professional nursing behaviour and conduct.

Competencies for the nurse practitioner scope of

Support Guides. Retrieved from 2. NURSING COUNCIL OF NEW ZEALAND (2012).

In conclusion

prevention-toolbox.

Professional Development Learning activity

Professional Development

Learning Activity

Learning outcomes ▶▶ increase familiarity with the Code of Conduct standards for professional nursing conduct and behaviour ▶▶ practise applying the principles and standards of the Code ▶▶ raise awareness of the appropriate approach for health professionals towards professional boundaries, social media and electronic communications ▶▶ locate and review guidelines that underpin nursing practice.

Reading the article ‘Code of Conduct refresher’ and undertaking this learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to NCNZ competencies 1.1, 1.4, 2.9, and 4.3. Please discuss all your answers with your peer/s. A

Reading

Read these three NCNZ guidelines: Code of Conduct, Professional Boundaries, Social Media and Electronic Communications.

Reflection

Reflect on a practice situation where you or a colleague have been unsure about the boundaries around patient care. Identify which of the principles and standards from the Code or professional boundaries guidelines are relevant. What would you do differently next time? Consider the four ‘questions for reflection’.

AND/OR 2

Think about a practice-related situation where you have been unsure if you or a colleague acted appropriately. Identify which of the principles and standards from the Code of Conduct are relevant. What would you do differently next time?

Reality

Note down all the ways in which you use social media and electronic communication, including text, instant messages and email. Search for information about and images of yourself online. Review the relevant guidelines and principles. Do you need to make any changes?

Consider a time where you think you or someone you work with has been (or is being) coerced or bullied. Identify which of the principles and standards from the Code of Conduct are relevant. Consider what you might do differently next time.

Verification by a colleague of your completion of this activity Colleague name

Designation

Date

Nursing council ID

Work address

Contact # nursingreview.co.nz Issue 5 19

Professional Development Practice

All nurses are empathetic … aren’t they? Although empathy is in decline, it matters profoundly in nursing and can be taught, believes Australian nursing professor Tracy LevettJones. NURSING REVIEW reports.

here’s a big difference between empathy and sympathy, but often we get them confused, says Tracy Levett-Jones. “While empathy and sympathy are both reactions to the plight of another person, sympathy is just a feeling of pity for their misfortune. Empathy is like walking a mile in someone else’s shoes; sympathy is just being sorry that their feet hurt.” Levett-Jones, Professor of Nursing Education at the University of Technology, Sydney (UTS), addressed the recent Australasian Nurse Educators Conference on why empathy still matters to nurses and the patients they care for, and how her research shows that empathy should – and can – be taught.

The three levels of empathy Levett-Jones explains that there are three levels of empathy and some levels come more easily than others. The first level is affective empathy, which is the easiest form of empathy as nearly everybody, except narcissists, is hardwired to feel empathy for misfortunes they can relate to – particularly if the person suffering that misfortune is similar in sex, age, nationality or ethnicity to themselves. 20 Issue 5

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The next level is cognitive empathy, which requires more than the empathetic imagination necessary for affective empathy, as it requires empathetic intelligence to attempt to see the world through another person’s eyes. Levett-Jones says cognitive empathy also requires a nonjudgmental stance, which is a challenge to everybody, but particularly for nurses. “I’m a proud nurse, but I’ve also sat in many handovers when nurses have made judgmental statements like: ‘[That’s just] drug-seeking behaviour’ and ‘They are just a whinger’. “If we could look into each other’s eyes and understand the unique challenges that each of us faces, we would treat each other with much more empathy, patience, tolerance and care,” says Levett-Jones. The third and highest level of empathy is behavioural empathy, which steps empathy up a further notch and requires effort, intelligence and deliberate practice to develop and communicate empathetic concern for another and a readiness to put that empathy into action. Levett-Jones says many regard behavioural empathy as being synonymous with compassion.

Empathy in decline Interest in empathy has never been higher, with double the number of books written on the subject in the past five years than in the previous years, says Levett-Jones. Likewise, the number of web searches on the topic have tripled. But while interest is high, research indicates that empathy itself is going

through new lows, with Levett-Jones quoting one large retrospective study of American college students showing that empathy has declined by more than 40 per cent over the past 30 years, with the steepest decline being this century. Screens and social media are thought to be one possible cause of the decline, with young people spending increasing amounts of time reading and sending emoticons and emojis, rather than reading real faces. Nursing and medicine is not immune to this decline, with a body of evidence showing that fresh-faced nursing and medical students’ empathy levels decline by up to 50 per cent from when they start their degrees to when they finish them. LevettJones says some of the reasons are believed to be prioritising technical and procedural skills over values like empathy, limited attention to teaching and assessing empathy skills, and students being desensitised and suffering compassion fatigue from being exposed to human suffering without appropriate preparation or support. “We kind of got the hunch that if we threw nursing students into Continued on page 22 >> Empathy: a definition* The ability to step into the shoes of another person, aiming to understand their feelings and perspectives, and to use that understanding to guide our actions.

(*The preferred definition used by Professor Tracy Levett-Jones.)

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Professional Development Practice

situations that obviously were intended to generate an empathic response, it would happen,” says Levett-Jones. “It actually doesn’t, as what happens is that students are in survival mode and they can shut off.”

Does empathy still matter? Does it matter whether nurses are empathetic? Most definitely yes, believes Levett-Jones, with empathy being a key component of all therapeutic relationships. Demonstrating empathy is also seen as a key competency indicator by the Nursing Council of New Zealand. Levett-Jones says there is compelling research that empathetic engagements with patients have a major impact – from decreasing levels of depression and distress, increasing adherence to treatment plans and improving physiological outcomes, from tissue healing to blood pressure. “What medication, technology or high-level medical intervention could influence all of those outcomes?” she says. Research also indicates that having empathy is a plus for health professionals as it enhances their clinical reasoning ability and is linked to job satisfaction, resilience and coping skills. Other research has indicated that nurses are at a higher risk of burnout, distress, depression and attrition if they don’t have the required level of empathy skills. “There has been a lot of hype about the fact that nurses get compassion fatigue if they are too empathetic – if they care too much – but actually the opposite is true,” says Levett-Jones. “Empathy is actually energising; it is fulfilling and it is satisfying. A lack of empathy is actually soul-destroying and saps our energy.” Sadly, she says, it has been demonstrated that the people who get the least empathy from healthcare professionals are those who need it most – that is, people from culturally and linguistically diverse (CALD) backgrounds, aboriginal people (in Australia), and people with physical or intellectual disabilities, mental illnesses or lifestyle-related diseases.

Yes, empathy can and should be taught Empathy, therefore, matters to both nurses and their patients, concludes Levett-Jones; it matters enough that nursing shouldn’t rely on the hope that the people drawn to the profession are intrinsically empathetic. She quotes from the UK’s 2013 Francis Report on patient neglect in MidStaffordshire hospital, which, amongst its findings, said: “In addition to safety, healthcare needs to have a culture of empathy. Such a priority cannot be assumed, it needs to be the subject of training.” 22 Issue 5

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Also guiding the nursing education professor’s philosophy is Aristotle’s quote that “educating the mind without educating the heart is no education at all”. “One of the statements that runs around my mind the whole time is that if we ‘capture their hearts, their minds will follow’,” says Levett-Jones. “So I never, ever, tell my students a whole series of facts about a disease. I always tell them about a person with that disease and their life story in a way that hooks the students’ imaginations and attention.” Amongst the methods of teaching empathy is using tools, such as film, art and literature, that give students insights into the perspectives of people they may not normally encounter or engage with in meaningful ways. Movies such as The Diving Bell and the Butterfly (about a man with locked-in syndrome) and Wit (a challenging film about a woman dying of ovarian cancer) are amongst the teaching tools in Levett-Jones’ toolbox.

“Empathy is actually energising; it is fulfilling and it is satisfying. A lack of empathy is actually souldestroying and saps our energy.” But she says a review of four recent randomised, controlled trials indicates that experiential simulations – where students are asked to ‘stand in the patient’s shoes’ – were the most beneficial for teaching empathy. LevettJones has developed several such simulations herself to put students in the shoes of some of those patients who need empathy the most, but receive the least – including CALD patients, who are twice as likely to experience serious adverse events in hospital as English-speaking people.

Teaching empathy by simulation scenarios Levett-Jones’ cultural empathy simulation puts nursing students in the scenario of being a backpacker who becomes a bedridden patient in the hospital ward of a developing country. Wearing a 3D virtual reality visor, they watch a 3D video unfold where everything is alien to them – the hospital environment, the language and the clinical practices show cultural behaviours and symbols unfamiliar to an Anglo-Celtic Australian.

The research tested the students using several standard empathy scale tests. A cultural competency scale test before and after the simulation found significantly higher scores after the simulation. Students also told researchers that they were amazed how quickly a 10-minute video had changed their views and how they now had an understanding of being an outsider. The second major simulation scenario came about after Levett-Jones become concerned about students’ attitudes to people with disabilities. A trigger for the scenario was the unempathetic treatment of a nursing colleague’s teenage daughter, who had been hospitalised for three months after a brain injury. The resulting disability simulation put second year students either into the role of a person with a brain injury (following a car accident) or of a rehabilitation nurse. The ‘patient’ wore a special hemiparesis suit that replicates the experience of aphasia, dysphagia, and being blind and weak on one side of their body. The ‘nurse’ comes and helps to dress the ‘patient’ then takes them for a walk, before leaving them to sit at an outside table in a busy public area for five minutes (while the ‘nurse’ watches from a distance). Levett-Jones says in nearly all cases people turned away from the ‘patient’ and didn’t offer to pick up a dropped walking stick or help them to stand. The findings from the research showed a significant increase in empathy pre and post-simulation for the ‘patient’ student, but somewhat surprisingly the increase in empathy pre and post-simulation was even higher for the students who played the ‘nurse’ role. It appeared that watching people being indifferent to their patient had really challenged them and the test for the teachers was to ensure the students received an empathetic and not a sympathetic or pitying response. But simulation has shown that it is possible to teach future, and current, nurses to feel increased empathy for people whose lives are beyond their own experiences. “We have such an opportunity with undergraduate students, new grads and with other nurses to really challenge their level of empathy,” says Levett-Jones. “To really do things that can increase empathy because – as I have shown you – empathy has a profound impact on patient outcomes.”

Innovation & Technology

Health Navigator App of the Month

New app for parents of neonatal babies

WEBSCOPE Infection control and child health sites

Kathy Holloway recommends handy websites for more information on two of this edition’s themes – infection control and child health. International Federation of Infection Control (IFIC) http://theific.org/ijic Our very own NZNO College for Infection Prevention and Control Nurses is affiliated with this UK-based international organisation. The IFIC’s stated mission is to facilitate international networking in order to improve the prevention and control of healthcare-associated infections worldwide. This site provides free full-text access to the International Journal of Infection Control. Additionally, there is full access to the 2016 edition of IFIC Basic Concepts of Infection Control, which provides a resource of research-based concepts to support the development of local policies and procedures in a number of languages. [Site accessed 2 October 2017 and date of last update is unknown].

Child Health Research Review www.researchreview.co.nz/nz/Clinical-Area/Paediatrics/Child-Health.aspx This New Zealand site provides digests of international research across a number of fields. With over 10,000 medical journals from over 50 areas reviewed, this site makes it easy to keep up to date with podcasts and research article reviews. All you need to do is register and select your area of interest for free email updates. This specific review page features key medical articles from global paediatric journals with commentary from a rotating team of Starship paediatric specialists. The Child Health Research Review covers topics such as paediatric endocrinology, nephrology, pharmacology, fractures, immunology, adolescent health, and paediatric neuropsychology. Research Review publications are free to receive for all NZ health professionals. [Site accessed 2 October 2017 and last updated 2017].

app Overview ▶▶ Clinical score ▶▶ NZ relevance ▶▶ Technical score ▶▶ User score Pending ▶▶ Formal review (MARS) 4.6 out of 5 ▶▶ Availability Free for Apple & Android Full review www.healthnavigator.org.nz/app-library/b/ babble-midcentral-dhb-app

he brainchild of a MidCentral DHB paediatrician, the app’s aim is to help parents or caregivers whose baby is admitted to a neonatal, NICU or special care unit. It contains brief information on routine checks and tests, feeding, equipment, common diseases, and medication. Also brief general information about having a pre-term baby. Parents can use the app to store photos and stories about their child that they can share with family and friends. PROs include: Great starting point for parents on information for caring about their babies in care; attractive app; can create own baby’s profile; users can connect to others through app community features. CONS include: Some of the medical terms are difficult to understand; only brief information on topics so parents still need to look further for more in-depth information on important topics. Full app review at www.healthnavigator.org.nz/app-library. The NZ App Project: Health Navigator, a nonprofit trust, is using technical and clinical reviewers to help develop a New Zealand-based library of useful and relevant health apps. Health professionals who would like to be part of the project can email sandra@healthnavigator.org.nz. nursingreview.co.nz Issue 5 23

Innovation & Technology

Clinicians clamour for

collaborative ‘clinical cockpit’ app A New Zealand-developed app is allowing simultaneous sharing of patient notes, tasks and secure instant messaging by care team members. Danielle Spencer and Christine Baxter share with NURSING REVIEW why the nurses at Christchurch Hospital’s general surgery wards are such ardent fans.

Christine Baxter (left) and Danielle Spencer.

24 Issue 5

he typical busy morning shift at hospitals around the country can be a mad scramble of clinicians trying to access patient notes. Once they get their hands on the patient’s file, they may struggle to read a colleague’s handwriting. Or when they finally manage to log in to a computer screen – and see something that raises a red flag – their attempts to double-check by pager can end up in a frustrating game of phone tag. And at the back of their minds, they keep wondering where those test results have got to. But what if all the clinicians caring for a patient could access their relevant notes and test results simultaneously – on an iPad or iPhone – whether at the bedside or attending a conference? And a nurse could instant message their patient’s doctor by a means as simple – but more secure – than texting? Clinical nurse specialist Danielle Spencer and senior nurse Christine Baxter enthusiastically presented at the recent Australasian Nurse Educators Conference on the trial this winter of a local clinician-developed app and platform – Cortex – that is making these ‘what ifs’ a working reality for the 180-plus clinicians working in Christchurch Hospital’s three general surgery wards. The digital platform allows clinical notes to be taken at the bedside, diagnostic tests ordered, test results notified and accessed, and observations viewed – along with creating a patient journey timeline of clinical tasks, bedside notes and test results from admission to discharge. Developed initially to support the role of the medical team, it soon became apparent that the app and platform would also benefit nurses and Allied Health by bringing the entire patient journey to all members of the team involved in their ‘circle of

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care’. (N.B. Nurses are yet to be able Members of the clinical team can to use Cortex to record their nursing also use Cortex to ‘tag’ another team notes, although there are plans to add member and request them to take nursing documentation templates.) on a clinical task. But Baxter says Spencer says staff like to think one of the business rules agreed on of Cortex as “kind of like a clinical at the start was: “I own the task until cockpit” or a common platform that the person I tag accepts it. If they allows clinicians to readily access don’t accept it, I still own it.” She the clinical information they need says everybody has been very good on a patient from the many digital with this rule and the clear lines clinical ‘silos’ that hold electronic of accountability are probably one information on a patient. of the reasons the trial has been so She says previously on a ward successful. round it was time-consuming and The trial of the app by the frustrating to access electronically three general surgery wards was stored blood results or also spurred on by observations as there Christchurch Hospital “It was that were different logins building a new Acute for each ‘silo’. But with Services Block, due to open simple that Cortex the clinician late next year, which is most nurses has a single login to designed to be ‘paper-lite’ the common platform and will not provide the walked out and from there, clinical file storage space after 20 depending on their that would have been health profession and required in the ‘paperminutes, seniority, a clinician past. The trial began saying ‘I’ve got heavy’ can readily access in late June this year in the relevant and this’ and ‘This partnership with Sense up-to-date clinical the company is easier than Medical, information they need that developed Cortex, Facebook or about the patient’s which was founded in journey and care. Christchurch and led by Trade Me’.” Clinicians who are local clinicians. part of the patient’s Baxter says nurses ‘circle of care’ can also quickly and on the general surgery wards were securely instant message the patient’s already using iPads at the bedside nurse, doctor, occupational therapist, for MedChart (electronic prescribing pharmacist or social worker. and medication administration “In the old-school ways, if I needed software) and Patientrack (software to contact the patient’s doctor I would for recording vital signs observations), have to look in the patient’s notes, so those were available then look on the board for their pager for the trial – although keeping number, page them and then sit by them charged for 24/7 use was a the phone waiting for somebody challenge. Junior doctors were to maybe reply,” says Spencer. Now provided with a device, with the she can send the patient’s doctor a option to BYOD (bring your own message straight from the iPad and device) also available. Funding was copy in other health team members found for one iPad per ward for non– so if the main doctor is busy a surgical medical staff and funding colleague might pick up the message was also found for iPads for Allied and come instead. Health staff.

Innovation & Technology

Training for busy nursing staff quickly evolved under Spencer, who soon realised that nurses preferred hands-on training by ‘having a play’ with the app on the iPad. “And it was that simple that most nurses walked out after 20 minutes, saying ‘I’ve got this’,” says Baxter. “They said ‘This is easier than Facebook or Trade Me’.” The trial saw the speedy uptake of Cortex by the general surgery wards’ 150 nursing staff, 60-plus doctors and 11 Allied Health staff. Baxter says within the first 35 days there were 91,000 views of patient records. Cortex users also managed to nearly ‘crash’ the local laboratory’s results portal Éclair, as the platform had made it so much easier for clinicians to view their patients’ lab results – just a simple click of a button – that there were an unexpected 13,000 views of results in just over a month. Baxter says she had a login to Éclair [the results portal] for 15 years but had rarely used it in the past. “Because to do that, I would have to go find a computer, kick someone else off; it would then take at least 88 seconds to log in and fire up my computer before logging in to Éclair and searching for the patient’s results. But with

Cortex I could do that at the bedside within 12 seconds.” By the end of the first month, 97 per cent of acute admission notes were being done on Cortex, 5,400 bedside notes had been recorded, 2,000 test orders made and 3,900 tasks assigned via Cortex. “That is 3,900 times a colleague was not interrupted midtask [to be paged or phoned] about a job,” says Baxter. “We think that’s huge. And so do our colleagues.” Spencer says the feedback from nurses has been overwhelmingly positive – not only that it was fun to use but also that it allowed them to stay at the bedside of a deteriorating patient while messaging a doctor and not rush away to find a phone. And if the whole team turned up at that bedside, everybody could be given an iPad and view the patient notes while a nurse could continue to take and record vital signs. The Cortex developers at Sense Medical were also able to respond with a digital solution to a serious adverse event that occurred during the trial – a failure in the paper-based system to ensure that a followup appointment for a patient was requested.

Within four days the platform producers had expanded the Cortex discharge checklist to ensure a follow-up appointment request was electronically sent and monitored. Other additional functions added to the platform after requests were notifications of when a doctor had seen a patient and updated their notes, plus a one-click button that gave nurses faster login – five seconds, compared with 72 seconds via the usual login route – to Patientrack for recording and updating patient observations. The trial officially ended on 13 September, but Spencer and Baxter say nobody wanted to go back to the pre-Cortex days. “We will walk before we lose our Cortex,” jokes Baxter. The platform continues to evolve in other ways, with doctors able to use ‘Siri’ to record their notes or tasks and plans to filter notes so you could just view doctor’s notes or delegated tasks or – in the future – nursing wound notes. As clinicians from areas of the hospital come across Cortex, they are also smitten with the ‘clinical cockpit’ and keen to be on board. “It has taken the hospital by storm,” says Spencer. “Everybody wants to be us.”

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Leadership & Management Patient safety

The wicked

problem of falls

Very common problems, like falls, can have complex causes and no simple solutions, nursing fall prevention experts tell NURSING REVIEW. And preventing falls needs the whole team on board – not just nurses.

Frances Healey.

Julie Windsor.

26 Issue 5

ursing interventions alone can’t prevent falls, say nursing fall prevention experts. Instead, a whole-team approach is needed to reduce the resultant broken hips, loss in confidence and extended hospital stays. Fall prevention specialists from the UK, Australia and New Zealand came together in September to discuss and share approaches to reducing harm from falls during the Health Quality & Safety Commission’s tri-nation forums in Auckland and Wellington. In recent decades, fall rates in hospitals and other inpatient settings have often been viewed as a nurse-sensitive indicator of the quality of patient care – or lack of quality when nursing is understaffed and under pressure. But Dr Frances Healey, a nurse and deputy director of Patient Safety for National Health Service (England), says framing falls as a nursing problem does patients no favours. “As actually we know that some of the key risk factors for people who fall in hospital are undetected medical causes, dementia that has not been confirmed, inappropriate medication prescribing, and poor fluid retention management.” So the solutions – or causes – may not be nursesensitive. “All of our work in England has been very much based on reframing falls prevention as a totally multi-disciplinary problem,” says Healey. “I’m speaking as a nurse and I’m not for one moment denying the criticality of nurses within the team.” She says they now regard falls as a symptom rather than just an accident. Tri-nations forum colleague Lorraine Lovitt, the lead for the New South Wales fall prevention programme, uses the analogy of seeing falls as the ‘canary in the mine’ that tells you something wider is amiss with the patient. Julie Windsor, the patient safety clinical lead for older people for NHS (England), says at least 400 risk factors have been identified for falls. “So you can’t just say they [the risk factors] are all in the nursing arena – because they never will be and they’re not,” says Windsor who – like Healey and Lovitt – is a nurse herself. “Instead it is identifying for each individual person what their risk factors are and then working out how these can be resolved or best managed.” Healey says that is not to say that nurse staffing levels are not a factor.

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“Of course we’d say it makes complete common sense that if a patient is going to call for help, needs help and you don’t have enough nurses to answer the call, of course that’s going to cause a problem.” But she says there are better tools for measuring whether staffing is adequate to meet patient acuity and demand than using falls as a nurse-sensitive indicator. She says the point of reporting incidents, like a fall or medication error or misdiagnosis, is to learn from them and, as deputy director of Patient Safety, she wants to encourage reporting of incidents so that learning can happen. “If you don’t report it – how can you learn from it? So to then use them [incident reports] to say you are not a good quality provider is detrimental and counterproductive to the whole purpose.” Healey says the NHS does publish incident rates per provider, but the regulators are most concerned when reported incidents are very low and classify them as “potential underreporting of safety incidents”. “It is not perfect, but is a far healthier way, perhaps, of encouraging it [reporting].” Likewise, she says labelling falls as primarily a nursing quality indicator “can’t help us with the message that we need the whole team to help our patients”. Lovitt says in New South Wales hospitals one interdisciplinary approach they are taking is ‘safety huddles’ where nurses can flag the risks that showed up in their patient screenings – like delirium or a memory issue – and take a team approach to managing them. Early last year the results were published in the British Medical Journal (Anna Barker et al.) of a randomised controlled trial in six Australian hospitals of a nurse-led ‘six-pack’ bundle of nursing interventions to reduce fall injuries. The 12-month trial found no difference in falls or injury rates between the intervention and the control group. In an online letter to the BMJ, Julie Windsor wrote that while the results might at first appear disappointing to the many frontline nurses and nurse leaders who had “wholeheartedly and valiantly” tried to make improvements, it was now time to move on. “[It is] time now to re-energise and look at innovative and novel quality improvement initiatives that include all professional groups,” she said. Because nursing can’t do it alone.

Leadership & Management Engagement

Bringing the oy back into work Joy, not burnout, should rule the day, argues the Massachusetts-based Institute for Healthcare Improvement. In a recent White Paper, it puts a case for health leaders addressing the barriers to joy in work. NURSING REVIEW finds out more.

obody denies that burnout and stress is high amongst many health professionals around the world. But that doesn’t mean joy in work is impossible, says the Massachusetts-based Institute for Healthcare Improvement (IHI). In fact, it argues, improving joy in work is “possible, important and effective” as joy impacts not only on staff satisfaction but also on patient experience, quality of care and an organisation’s performance. The institute sought to put its theory into action with a series of innovation projects in 2015-16 involving hospitals and health organisations in both the United States and the United Kingdom – including the American Association of Critical Care Nurses – and earlier this year published the resulting IHI Framework for Improving Joy in Work.

Dr Donald Berwick, IHI’s president emeritus, admits that joy in work sounds “flaky”. And, as he writes in a foreword to the 42-page framework document, the first feedback he received to suggesting joy in work should be a strategic goal for health organisations was “Get real!” He acknowledges getting through the day is probably a more common goal in “inevitably stressed” work environments where “truly good people try hard to cope with systems that don’t serve them well, facing demands they can, at best, barely meet”. But the research literature is there that joy is both possible and important for the healing professions.

Why focus on joy in work? Recent US studies found that 33 per cent of registered nurses seek another job within a year and 50 per cent of doctors report symptoms of burnout.

The institute decided that part of the solution was to focus on steps to restore joy to the healthcare workforce through a practical framework. It did a scan of the current published literature on engagement, satisfaction, and burnout; carried out interviews and site visits based on the literature scan; and worked with 11 health and healthcare systems in a twomonth prototype programme testing steps, refining the framework, and identifying ideas for improvement. The report – two of its six authors are nurses – says focusing on joy in the “physically, intellectually and emotionally demanding” health professions was important for three reasons. Firstly, it says joy is one of healthcare’s greatest assets and looking at assets – and not just the health system’s deficits and gaps – may help find a solution to burnout. Continued next page >>

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www.invisabeam.com nursingreview.co.nz Issue 5 27

Leadership & Management Engagement

“Healthcare is one of the few professions that regularly provides the opportunity for its workforce to profoundly improve lives,” says the report. “Caring and healing should be naturally joyful activities.” The second reason was that joy was more than the absence of burnout – it was also about having meaning and purpose. “By focusing on joy through this lens, healthcare leaders can reduce burnout while simultaneously building the resilience healthcare workers rely on each day.” Finally, having joy in work can be seen as a fundamental right. The report authors point to the work of W Edwards Deming, the ‘father of quality management’, who said, “Management’s overall aim should be to create a system in which everybody may take joy in [their] work.” The report says there is also a strong business case for improving joy, though it acknowledges there is not a single validated measure for joy in the workplace. But the business case for joy in work draws on outcomes including staff engagement, satisfaction, patient experience, burnout and turnover rates which in turn have been linked to greater professional productivity, lower turnover rates, improved patient experience, outcomes and safety resulting in lower costs. “Perhaps the best case for improving joy is that it incorporates the most essential aspects of positive daily work life,” says the report. “A focus on joy is a step toward creating safe, humane places for people to find meaning and purpose in their work.”

Taking action on joy Creating joy and engagement in the workplace is a key role of effective leaders, believes the Institute. But it says in developing the framework it became evident that leaders often find it challenging to see a way to move from the current state to joy in work. This led to the ‘Four Steps for Leaders’ (see box) to help guide them in: finding out what matters to their staff, identifying impediments to joy, taking a systems approach to addressing those barriers, and testing whether the approaches are working. An example from one of the framework prototype initiatives was a hospital inpatient unit deciding to focus on improving teamwork by testing introducing change-of-shift huddles to the unit’s various teams until the nurses involved established the best time, what to focus on and who would lead the huddle. By the end of four months, 90 per cent of teams on the unit were conducting daily huddles and engagement scores had risen by 30 per cent. 28 Issue 5

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Another example was staff at the University of Virginia School of Nursing who identified a strong desire not to feel the pressure to respond to work emails when on time off. A small group of staff tested a small change – stopping sending email to staff during their time off – and the positive benefits led to it being expanded to all employees. The paper says the ‘Four Steps for Leaders’ do not ignore the larger organisational issues, or “boulders” that exist, such as the impact of electronic health record functionality on clinicians’ daily work, or workload and staffing issues. “Rather, the steps empower local teams to identify and address impediments they can change, while larger systemwide issues that affect joy in work are also being prioritized and addressed by senior leaders. This process converts the conversation from ‘If only they would …’ to ‘What can we do today?’” The institute also created a framework that sets out the nine core components they believe contribute to a happy, healthy, productive workforce. With Maslow’s hierarchy of needs in mind, it identified that there were five fundamental human needs that must be met to improve joy in work. These are: physical and psychological safety; meaning and purpose; choice and autonomy; camaraderie and teamwork; and fairness and equity.

IHI Framework for Improving Joy in Work ▶▶Physical and psychological safety: Do people feel free from physical harm? Including work-related injuries, infections and violence? Do they feel secure and free to express relevant thoughts and feelings, ask questions, admit mistakes or speak up about unsafe conditions? ▶▶Meaning and purpose: Do people feel that the work they do makes a difference? ▶▶Choice and autonomy: Do people feel they have a choice and voice in the way things are done? ▶▶Camaraderie and teamwork: Do people feel like they are part of a team and have mutual support and companionship? ▶▶Recognition and rewards: Is there meaningful recognition of people’s contribution? Are team accomplishments celebrated?

“While all five of these human needs will not be resolved before addressing local impediments to joy in work, actions and a commitment to addressing all five will ensure lasting results,” says the report. The framework and steps aim to help health leaders start on the path to more joy in the workplace and less burnout – a path that the institute believes is worth following for both the benefit of staff and patients. “The gifts of hope, confidence, and safety that healthcare should offer patients and families can only come from a workforce that feels hopeful, confident, and safe,” says Berwick. “Joy in Work is an essential resource for the enterprise of healing.” He adds that leaders who use the framework “might well find that the joy it helps uncover is, in large part, your own”.

Four Steps for Leaders (towards fostering joy in the healthcare workforce) 1. Ask staff, ‘What matters to you?’ 2. Identify unique impediments to joy in work in the local context. 3. Commit to a systems approach to making joy in work a shared responsibility at all levels of the organisation. 4. Use improvement science to test approaches to improving joy in work in your organisation. ▶▶Wellness and resilience: Is the health and wellness of all employees valued including cultivating personal resilience, stress management, an appreciation of work/life balance and provision of mental health support? ▶▶Participative management: Do leaders involve and engage others before implementing change? Keep individuals informed of future changes that may impact on them? Do they consistently listen to everyone – not only when things are going well? ▶▶Daily improvement: Does the organisation use improvement science to identify, test, and implement improvements to the system or processes? ▶▶Real-time measurement: Do the measurement systems used enable regular feedback to facilitate ongoing improvement? Source:Perlo J et al (2017) IHI Framework for Improving Joy in Work. (IHI White Paper) Cambridge, Massachusetts: Institute for Healthcare Improvement. (Available online at ihi.org.)

Students Clinical placement tips

A good attitude, good shoes and home baking: a student’s tips on preparing for your first clinical placement

Mady Watt.

Third-year nursing student Mady Watt looks back and shares some advice she’d liked to have read before her first clinical placement, including some tips for getting along with preceptors.

Be prepared for your first patient death

Be ready for the long hours

ooking back three years ago to my very first clinical placement, I wish I had been given some advice on what to expect and some tips for getting along with my preceptor. It’s a challenging time for student nurses. Most of us have never been in a situation where we are the ones responsible for someone’s life. Well that’s how it seemed anyway. In this article, I share some advice I think could be useful before you start your clinical placement. Be prepared and have a solid support system in place

You are likely to encounter situations and cases you have never been exposed to before. Take a moment to process these experiences and, if needed, vent to your family and friends (while protecting patient confidentiality, of course).

Introduce yourself to the healthcare team and be a positive team member

Introducing yourself helps start a friendly and open relationship with your colleagues. Being a positive team member makes you stand out as someone who wants to be there – and you won’t be labeled as just ‘the student’.

Mistakes happen

We are only human! Try not to dwell on your mistake. Focus instead on what you could have done better and how you can learn from the situation. Don’t be afraid to talk through your mistakes with your preceptor; they are there to support and guide you on how to learn from your mistakes.

Watching families and friends in emotional pain while their loved ones die is hard to take. You may be present for the deaths of babies, children, adults and older people. I found the best way to support someone who is grieving is by providing privacy and comfort. This may involve being ‘all ears’ or simply providing cups of tea. It all makes a difference.

If you’re anything like me, you may not be used to working eight-to 12-hour shifts for three to four days a week. Standing and walking for eight-plus hours, holding your bladder, moving and handling patients weighing more than 120kg; these are just a few of the physical battles you may deal with each day, so it is important to take care of yourself too. Many nurses develop back problems from lifting patients, so learn to use proper techniques and don’t be afraid to ask for a helping hand. A good pair of comfortable shoes is also essential!

Don’t be afraid to put your hand up and ask to do new things

We’re there to learn, right? So don’t shy away or expect the nurse to always come to you. Be assertive and step out of your shell. The best learning happens with practice, so give it a try while you have supervision.

Volunteer to make beds and hand out meals

I know these aren’t the best jobs and you’re probably thinking ‘I didn’t come to nursing school to make a bed’; however, you are part of a team. Helping out your team members and doing little jobs really makes the difference. It shows people you are a helping set of hands and are willing to do pretty much anything.

Learn what to do if there is an emergency

Have a notebook in your pocket to jot down key words

It’s easy to feel like you’re in the way of nurses and doctors when there’s an emergency. Ask your preceptor what your role should be if an emergency occurs. This may just be clearing and decluttering the surroundings or being a runner. But be ready to put yourself out there and ask if you can do the vital signs or assist in other ways.

I’ve found it helpful to have a notebook in my pocket to jot down medications, illnesses, procedures, and anything I need to learn at a later date. It’s hard to remember things when you have a busy schedule, so this helps get around that.

10.

Workplace bullying can happen

Students can sometimes be seen as a burden for nurses who don’t want a long, dragged-out shift. Continued on next page >> nursingreview.co.nz Issue 5 29

Students Interprofessional

My advice is to tell your preceptor upfront what you can currently do within your scope of practice, and what you would like to achieve from the shift. This will hopefully sway the preceptor to seeing you as an asset rather than a burden. Try not to get frustrated if you have a new preceptor daily and you are repeating the same small tasks each day. Your preceptor needs to see that you are competent doing these tasks in order to build trust. If bullying does occur, try to raise the topic with the preceptor in a nice manner. However, this is way easier said than done. Don’t suffer in silence. I’d recommend speaking to either the charge nurse or your nursing school clinical mentor if an issue arises. And don’t leave it until it’s too late to solve. Also, try not to lose focus on the real reason why you are there.

Top tips for getting along with your preceptor Discuss your weekly goals and objectives Letting your preceptor know your weekly goals is essential as it gives them direction on what they need to teach you. Tell them what you’re not so confident in doing and what you would like to learn, so they can make sure you get hands-on practice. Give them feedback on what you enjoyed learning and what you found helpful Preceptors like to hear feedback just as much as students do. Let them know if they are doing a good job and ask them for feedback too. For example: “Did I do this well?” or “What can I do better next time?” Answer call bells and phone calls Show initiative by answering not only your call bells but also other nurses’ call bells. And, if you are near the phone, answer phone calls too. There is nothing more frustrating to staff than seeing a student sitting next to a ringing phone and not answering it.

Answer the phone professionally by introducing yourself and naming the ward. Always take a message or pass the phone on. And always remember to report information back to your nurse. Ask questions and show you are interested in being there Instead of clock-watching, show that you’re willing and excited to be there learning. When drawing up medications or doing an assessment, ask reasonable questions that show you have insight and critical thinking skills. For example, ask why something is happening and what the outcome will be, as this shows forward thinking. Home baking Home baking works a treat! This may seem like a bribe but it really is a great way to show your appreciation for your preceptor’s support and time. Author: Mady Watt is currently a third-year nursing student at the University of Auckland’s School of Nursing.

Interprofessional study:

how well do health professional graduates work together? A longitudinal study is following a group of following a group of graduates from nursing and seven other health professions in their early career to partially check out interprofessional teamwork in action.

ow well health professionals adapt to the workforce and learn to work in teams is the subject of a longitudinal study now underway involving 600 graduates. The five-year Longitudinal Interprofessional (LIP) study, being run by the University of Otago in collaboration with Otago Polytechnic and the Eastern Institute of Technology, involves graduates from eight health professions (nursing, dentistry, dietetics, medicine, occupational therapy, oral health, pharmacy, and physiotherapy). Lead researcher and physiotherapist Dr Ben Darlow says there is a real lack of data about how new health professionals adapt to the workforce and learn to work in healthcare teams. The LIP study will explore attitudes and skills related to

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interprofessional practice, as well as early career trajectories and influences on these. The study involves whole year groups from each discipline and first surveyed the students before they started their final year of training (in 2015 or 2016) and continued with yearly surveys until their third year of professional practice (either 2018 or 2019). About 130 of the participants went through the Tairāwhiti Interprofessional Education (TIPE) Programme (based on the East Coast) and part of the research is comparing attitudes to collaborative team work between the TIPE graduates and the other graduates. Darlow said keeping track of the graduates as they start work and keeping them engaged with the study was a real challenge, but also an exciting opportunity. To date it has had on average

around an 80 per cent response rate to its annual survey of graduates. The next survey is due out in October, with the survey questions adaptable for graduates who may have changed clinical field, career or are taking a break. Nurses make up 13 per cent of study participants. The average nurse participant age at graduation was 23 years old and 99 per cent were female. Jennifer Roberts, head of EIT’s School of Nursing, said it was fortunate that TIPE allowed its nursing students the opportunities to learn alongside other health professional students, particularly as interprofessional health care and quality improvement is a key competence for registered nurses. More information is at the study website lipstudy.researchnz.com.

Opinion College of Nurses

Health inequity:

a tale of two neighbourhoods

SONIA HAWKINS explores health equity by looking at two neighbourhoods recently named the most deprived and the most advantaged in the country.

n some respects we are spoilt for choice in Rotorua. Our whenua (land) boasts an abundance of stunning natural thermal resources, and we consider our lakes and forests to be world-class. Our hapori (community) is also renowned for its thriving tourism industry that attracts global recognition. Our cultural capital is our hapū, iwi and marae, which have stood resolute against the test of population decline, political hegemony and oppressive legislation (since the signing of Te Tiriti o Waitangi in 1840). Recently our community of Fordlands hit the national headlines. To our communal shame, the Rotorua suburb ‘boasts’ significant deprivation, with the New Zealand Index of Multiple Deprivation (IMD)1 reporting that Fordlands is the most socio-economically deprived neighbourhood in Aotearoa/New Zealand. In contrast, and despite the 2011 Christchurch earthquake and its aftermath, the Christchurch suburb of Merivale was found by IMD to be the neighbourhood with the most advantages and least deprivation.

Inequity in action: Fordlands and Merivale What, if anything, do these findings have to do with health equity, one might ask? Everything, is the only plausible answer! Starting with Fordlands, the 2013 census data indicates a population of about 1,700. People in the community are mostly Māori. About 45 per cent have no qualifications; almost the same percentage have a level 1-6 qualification, and the predominant occupation is labourer. The average income is between $10,000 and $20,000 per annum; 60 per cent of families in Fordland are sole parents, and most live in rented dwellings. The neighbourhood has one block of corner shops, including a Four Square supermarket and a liquor store.

There are two general practices (seven doctors) near Fordlands – one is a 40-minute walk and the other is almost an hour’s walk. Neither practice is on the bus route. The children’s parks are minimal, and a far cry from other parks in the advantaged areas of Rotorua. A gang presence is not uncommon, making parents think twice about whether riding a bike in their neighbourhood is safe2. Merivale’s census data indicates that most of the advantaged suburb’s about 2,700 people are European; 23 per cent have a degree and they earn in excess of $70,000 per annum. A property search comes up with descriptions like ‘architecturally designed splendour, impeccable landscaping and an array of shopping facilities’. Another search reveals at least five general practices (25 doctors); most practices can be reached by foot in roughly five to 10 minutes, plus there is a private hospital to boot. Not only are the people of Merivale spoilt for GP choice, they also reside in a healthenhancing environment. Whitehead’s widely used definition of health inequity is “health inequalities that are avoidable, unnecessary and unfair are unjust”. Braveman broadens the definition to argue that health equity is the absence of disparities for socially disadvantaged populations that are persistently exposed to systemic discrimination within a society. A health equity lens would suggest that Fordlands residents’ disproportionately low share of resources is unfair, avoidable and unjust. In contrast, the already advantaged people of Merivale have greater access to government-funded primary health care and attractive local amenities. Being healthy, it seems, is a whole lot easier when you live in areas of affluence.

Strengths, lessons and solutions? You can argue that the system and structures are skewed favourably towards the people living in Merivale, not Fordlands. This bias is avoidable, and ‘disrupting’ the status quo is within the remit of policy decision-makers and nurse leadership. It is remiss to blame individuals; instead we must always apply a critical and health equity lens on the system and the, at times invisible, bias towards privilege. We could also learn from Rotorua’s main industry, tourism – an industry reliant on attracting people by providing services that meet tourists’ wants, needs, cultural worldview, preferences and desires. Understanding these factors is tourism’s core business and it unashamedly moulds itself to fit its target populations. To do otherwise would bankrupt an entire industry. Arguably, the health system – with DHB budget blowouts and burgeoning demand outstripping supply – is an industry near bankruptcy. Taking a lesson or two from tourism seems both logical and sensible. Another strength for Rotorua is its marae: focal points for whānau, hapū and iwi and places where Māori take reo, kawa and tikanga for granted. Whakapapa connects individuals, and from marae a sense of belonging is affirmed. Roles and responsibilities are also equally valued, which is critical to sustaining livelihoods. But how are these strengths reflected in the design of our systems? And, importantly, are we truly ready to design systems that move us closer to health equity by meeting the needs of people most in need? Author: Sonia Hawkins is a College of Nurses Aotearoa board member and Director Consultant for Te Pani Limited. References are available in the full-length online-only version of this article at www.nursingreview.co.nz.

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Conferences

Upcoming conferences Neonatal Nurses College of Aotearoa Conference 2017 ▶▶ 1–3 November 2017 ▶▶ Wellington ▶▶ http://nnca.org.nz NZNO Nurse Managers Section 2017 Conference ▶▶ 2–3 November 2017 ▶▶ Dunedin ▶▶ www.nzno.org.nz/groups/colleges_ sections/sections/nzno_nurse_ managers_new_zealand/conferences_ events Health Informatics New Zealand (HiNZ) and NZ Nursing Informatics Conference 2017 ▶▶ 1–3 November 2017 ▶▶ Rotorua ▶▶ www.hinz.org.nz/?page=2017HINZConf South Island Stroke Study Day ▶▶ 2 November 2017 ▶▶ Christchurch ▶▶ https://strokenetwork.org.nz/ Conferences+-+Study+Days Psychosocial Oncology New Zealand 2017 ▶▶ 2–4 November 2017 ▶▶ Christchurch ▶▶ www.ponz.org.nz Continence NZ Men’s Health Education Day ▶▶ 3 November 2017 ▶▶ Auckland ▶▶ www.continence.org.nz/pages/MensHealth-Education-Day/201

NZNO/College of Air and Surface Transport Nurses Aeromedical Symposium ▶▶ 13 November 2017 ▶▶ Christchurch ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/college_of_air_surface_ transport_nurses/conferences_events NZ Gastroenterology Annual Scientific Meeting 2017 ▶▶ NZ Society of Gastroenterology/NZNO Gastroenterology Nurses Section ▶▶ 22–24 November 2017 ▶▶ Auckland ▶▶ www.gastro2017.co.nz College of Child and Youth Health/AUT Child Health Research Centre symposium ▶▶ 24 November 2017 ▶▶ Auckland ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/college_of_child_ youth_nurses/conferences_events New Zealand Respiratory Conference 2017 ▶▶ 23–24 November 2017 ▶▶ Auckland ▶▶ www.nzrc2017.com Neuroscience Symposium: ‘Nursing through the journey’ ▶▶ 29 November–1 December 2017 ▶▶ Wellington ▶▶ https://strokenetwork.org.nz/ neuroscience+symposium

To submit a nursing conference or event, email: Editor@nursingreview.co.nz 32 Issue 5

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2018 Australasian Cardiovascular Nursing College Conference 2018 ▶▶ 9–10 March 2018 ▶▶ Sydney ▶▶ www.acnc.net.au Intravenous Nursing New Zealand Conference 2018 ▶▶ 16–17 March 2018 ▶▶ Rotorua ▶▶ www.ivnnz.co.nz Goodfellow Symposium 2018 ▶▶ 23–25 March 2018 ▶▶ Auckland ▶▶ www.goodfellowunit.org/symposium/ programme National Rural Health Conference ▶▶ 5–8 April 2018 ▶▶ Auckland ▶▶ www.rgpn.org.nz NZ Population Health Congress ▶▶ 18–20 April 2018 ▶▶ Auckland ▶▶ www.pophealthcongress.org.nz/nzphc18 NZ Resuscitation Council Conference 2018 ▶▶ 19–23 April 2018 ▶▶ Wellington ▶▶ www.confer.co.nz/nzresus2018 Australian Pain Society 38th and New Zealand Pain Society Conjoint Annual Scientific Meeting 2018 ▶▶ 8–11 April 2018 ▶▶ Sydney ▶▶ www.dcconferences.com.au/ apsnzps2018

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