FOCUS: International Nurses Day
Nursing Review April/May 2015/$10.95
New Zealand’s independent nursing Series
EVIDENCEBASED PRACTICE: Preventing delirium
Practice, people & policy Jonathan Coleman on nursing Nursing opinions on NPs to PHC
Q&A
with Jocelyn Peach
A DAY IN THE LIFE OF a nurse in Antarctica
International Nurses Day Celebrating:
The ANZAC spirit:
• Today’s nursing ‘heroes’ • Safe staffing & other Kiwi nursing innovations
• Nurses fight to serve in WWI • The Marquette tragedy www.nursingreview.co.nz
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Letter from the Editor
Sister Anzac singing among the wreckage On a sunny Saturday earlier this year I was sipping coffee in a Lyttelton park when I glanced up at the names on the nearby war memorial. Leading the list of Herberts, Arthurs and Georges was a woman’s name: Nona Mildred Hildyard (Nursing Sister). I couldn’t recall ever seeing a woman’s name on a war memorial before and snapped a photo, intending to find out more. When I did, I realised that Nona was one of 10 New Zealand nurses tragically lost when a torpedo sank the troop ship Marquette a century ago this year. She and two other Christchurch nursing victims are commemorated in the historic, quake-damaged Nurses Memorial Chapel. I’ve now seen a photo of the 27-year-old nurse and a portrait (painted posthumously and funded by the people of Lyttelton) that both show an intelligent young woman with a quizzical look. I’ve also read how Nona was injured during the bungled lowering of a lifeboat as the disaster unfolded off the coast of Greece. But despite her injury, surviving nursing sisters recall her singing “wonderfully merry and bright” to keep up the spirits of the nurses, medics and troops who for nearly eight hours clung to wreckage or struggled to keep overloaded and damaged lifeboats from continually upturning. Hours in the water eventually took its toll and Nona reportedly died of exhaustion and heart failure before the rescue boats arrived. Her body was never recovered. Twenty-six of the 36 nurses survived and most went on to serve as nurses for the remainder of the war – some on hospital ships passing over the very same waters that had become their colleagues’ gravesite. This International Nurses Day edition of Nursing Review commemorates the nurses who clamoured for the right to be there to care when New Zealand troops fell in foreign fields all those years ago. Fiona Cassie editor@nursingreview.co.nz
www.nursingreview.co.nz
Inside:
Focus: International Nurses Day
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EVERYDAY NURSING HEROES: stories of innovative and compassionate nurses from across the country
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IND theme: courtesy, communication and compassion as part of good clinical care
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“In coats of grey and scarlet”: 100 years since the first New Zealand army nurses sailed to war
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The MARQUETTE sinking: survival and stoicism in our army nursing history’s greatest tragedy
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Is safe staffing a step closer? A major evaluation report is out on the CARE CAPACITY DEMAND MANAGEMENT programme
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TALES OF INNOVATION: Patient Experience Week, online procedures manual and online oral history archive
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SPECIAL ONE-OFF RRR OFFER TO NON-SUBCRIBERS RR professional development activity: R Hospital visitors –a help or hindrance to healing?
To subscribe go to www.nursingreview.co.nz/subscribe
Practice, People & Policy 30
HEALTH MINISTER JONATHAN COLEMAN on PHC funding, NPs vs PAs and the role of nursing
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Online Opinions ‘tasters menu’: • KIM CARTER on the Rapid Response Rural Grapevine • ROSEMARY MINTO on shoving PHC in the right direction • ANDY McLACHLAN asks for a fresh look at the NP role
Regulars
Twitter@NursingReviewNZ
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Q&A Profile: Veteran director of nursing DR JOCELYN PEACH
Special trial offer:
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A day in the life of… Antarctic flight nurse CARYN BRAUN
RRR professional development activity
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College of Nurses: LIZ MANNING shares a ‘dummies’ guide to nurse portfolios
This edition we are giving all readers special one-off access to our usually subscriber-only RRR professional development article and activity. The RRR article looks at the sometimes vexing question of how hospital visitors fit into a philosophy of patientcentred care. Are they seen as valuable contributors to a patient’s recovery, or as tolerated ‘obstacles’ getting in the way of busy nurses doing their job? Go to the special four-page pullout RRR to find out more. Reading the article and completing the related professional development activity is equivalent to 60 minutes’ professional development. And if you like what you see, become a subscriber to our print edition to get regular access to future RRR articles and also online access to our back catalogue of nearly 20 RRR professional development activities on a range of topics – from health literacy to delirium and self-advocacy to atrial fibrillation. Topics of universal interest and usefulness to nurses across the health spectrum reach a worldwide online readership (one RRR article on change management for nurses has received 10,000 hits in the past six months alone). To subscribe, go to: www.nursingreview.co.nz/subscribe
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Evidence-based Practice: CYNTHIA WENSLEY looks at interventions to reduce the risk of delirium
COVER PIC: Caryn Braun spent the Antarctic summer as a flight nurse at McMurdo Station. Find out more about the life of a nurse in Antarctica on p3.
Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ Editor Fiona Cassie production Aaron Morey David Malone Advertising & marketing manager Belle Hanrahan Publisher & general manager Bronwen Wilkins images Thinkstock
Nursing Review
Vol 15 Issue 2 2015
NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6141, New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 © 2015. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014
PHOTO CREDIT: Peter Rejcek, National Science Foundation Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
Errors and omissions: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.
Nursing Review series 2015
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Q&A
Dr JOCELYN PEACH
JOB TITLE | Director of Nursing and Midwifery, Emergency Systems Planner LOCATION | Waitemata District Health Board, Auckland
Q A
Where and when did you train? I trained at Middlemore Hospital as part of the Auckland Hospital Board School of Nursing graduating in 1978 as a registered general and obstetric nurse [RGON]. I loved every minute as it was a fulfillment of a dream. I had wanted to be a nurse since I was three years old.
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What other qualifications do you hold? Advanced Diploma of Nursing (1982), BA (1990), Masters in Business Studies (Hons) (1994), Doctorate in Nursing (2002), New Zealand Order of Merit (1999) for services to nursing.
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What positions have you held in your nursing career so far? After my post-registration year, I worked in Australia in a multi-trauma unit before returning to Auckland to specialise in Greenlane Hospital’s cardiothoracic unit. I went on to become a charge nurse manager in the cardiothoracic surgical ward and then a clinical nurse specialist. In the late 1980s, I became nurse advisor in the Auckland Hospital Board’s Chief Nurses Department, then in the early 1990s I was appointed as chief nurse to the Auckland Area Health Board and director of nursing at Auckland Hospital. In the mid-1990s I was appointed director of nursing and midwifery for the Auckland Crown Health Enterprise until 1999, when I applied for my current position at Waitemata District Health Board.
Q A
When and why did you decide to become a nurse? My father was a doctor and my mother a home economics teacher working in Africa in a mission hospital and later in a general practice setting. From three years old I helped my parents making swabs for the steriliser and later helped out in the general practice. I was determined to be a nurse from three and have never changed my mind.
Q A
What do you love about nursing? I have remained clinically engaged over the past 40 years of nursing, despite not being as confident clinically now as I used to be (due to being more involved in the leadership role). I love encouraging patients with meals, providing patient comfort care, helping patients in the emergency department and admissions unit. I enjoy assessing portfolios and encouraging nurses professionally.
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Q A
What comprises your current role? My role is that of professional leader, working with the DHB executive leadership team to plan strategically to meet our community’s health needs, and leading with the nurse and midwife leaders to develop the profession’s capability to respond to the health needs at the district, regional and national level. My role is diverse – I believe that anything that affects the patients or nurses and midwives is my business – so I am busy and involved in all aspects of planning service delivery and monitoring outcomes.
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What are the best parts of being a director of nursing and midwifery? Enjoy the variety of the role – being able to work at all layers from boardroom to bedside. I really enjoy working with primary care, with community-based health checks meeting people looking for reassurance about their health needs, as well as supporting nurses and midwives working in inpatient settings and communitybased care. I enjoy engaging with nurses in mental health and forensic mental health settings, public health nurses, district nurses, specialist advanced practice nurses, nurses working with children with disabilities, midwives – the list goes on. In my role I am excited by the diversity of practice and the wonderful clinical staff who work to provide the best care possible. I also enjoy being part of emergency systems planning.
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And the parts that aren’t so good in 2015? I have always disliked politics and making non-clinical decisions under pressure. The requirements of the role in 2015 haven’t changed from those of previous years.
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If there was a fairy godmother of nursing, which three wishes would you ask to be granted for the New Zealand nursing workforce? I want nursing to be present in the future as a strong and viable profession, confident of its place and contribution. The value of nursing is in its comprehensiveness, its practicality and its integration of caring and technical competence. I want nursing to continue to develop a strong self-image; to confidently express the value and purpose of nursing and be connected with the expectations of our community. I want every New Zealander and every community to have access to the power of
A
nursing expertise, whatever future scenario emerges. Nursing practised confidently and well is essential to the health and wellbeing of every community.
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What do you think are the most important personal characteristics needed to be a good nurse? Intelligence. Excellent communicator. Resilience. Positive, proactive attitude. Confidence. Empathy. Commitment. Teamwork.
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What do you do to try and keep fit, healthy, happy and balanced? I have to admit to not having a good work/life balance. I work every day and work long hours. I do limited exercise (though I do walk), and I love gardening, listening to music, reading and catching up with family and friends.
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What books are always on your bedside table? I love reading mystery detective novels and historical thrillers. My brothers share my books.
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What inspires your work ethic? I work from a number of philosophical frameworks. I aim to work in partnership, to emphasise that everyone matters, encourage participation and protect through compassion the needs of patients and the profession. I am inspired by this whakataukī: Tawhiti rawa i to tātou haerenga atu te kore haere tonu, maha rawa o tātou mahi te kore mahi tonu. We have come too far to not go further, we have done too much to not do more. I want to be remembered as having done my best.
A day in the life of a ... nurse in Antarctica
NAME | Caryn Braun JOB TITLE | Flight nurse, United States Antarctic Programme LOCATION | McMurdo Station, Antarctica.
7.30
AM WAKE UP I wake up with a call from my family; being gone from the US for almost five months makes these calls that much more important. There is 24-hour daylight here during the summer so there is no dawn to wake up to (I haven’t seen a sunset here for four months!). I get up and take a shower; the United States Antarctic Programme (USAP) encourages showers only four times a week to conserve water. But today is a shower day. I only wash my hair every other shower day though, because the environment is so dry that everything dries out, including hair and skin.
8.30
AM WALK TO WORK I’m dressed in civilian clothes, jeans and a sweater or long-sleeved shirt (occasionally a scrub top) because it is sometimes cold in the clinic and always cold outside. It is roughly a five-minute walk from my dorm to the McMurdo hospital/clinic. Even though it is the middle of summer here it is-17C° with the wind chill factor; the winds are at 50 kmh and snow is blowing around. So, as is the case every day here, I have my big red jacket on. ‘Big Red’, a large, down-filled jacket, is part of the extreme weather gear (EWG) handed out to everyone before they take the five-hour flight from Christchurch to McMurdo Station. I was hired by the current medical contract holder, the University of Texas Medical Branch (UTMB), to work for the USAP summer season as a flight nurse transporting patients with injuries or other needs off the ice and back to Christchurch. I have been a trauma, ED or ICU nurse for my entire career, since graduating from a nursing school in Maine. For the last 15 years I›ve been a flight nurse, working on a helicopter and on a jet. Coming to work in Antarctica was an adventure I could not pass up.
8.50
AM START CLINIC Clinic hours change to meet the needs of the community, which includes New Zealand’s nearby Scott Base (about 80 people), McMurdo Station staff (about 1,000 people) and the crew of visiting ships. Right now our clinic hours are from 6.30am to 6.30pm and I work the later part of the shift. Although I’m hired as a flight nurse, I work every day at the clinic that I am not doing a medivac (medical
evacuation). As I walk in, the phone is ringing, there are three patients who need to be seen, and the physician assistant (PA) and doctor (MD) are both busy seeing patients. For the next few hours, I am busy answering the phone and drawing blood for labs. I’m also caring for anyone who comes into the clinic – starting IVs as needed, getting vital signs, and giving meds as ordered. It’s a small team and we do most of our own labs (some go to Christchurch) and X-rays. To date, I’ve done four medivacs to Christchurch (an Air Force flight nurse and medic based here handle the lower acuity level transports).
11.45
AM LUNCH BREAK I usually have lunch with the other medical crew, including the Air Force team. We eat in the galley, which is like a huge cafeteria. Considering the number of people they have to feed, the food is usually very good. After lunch I try to go for a short walk. Looking for penguins, whales and seals is always a part of life down here. And I have seen many, many seals, one penguin jumping in and out of the ice, but no whales yet…
to be flown to Christchurch. This can take anywhere from a few hours after the patient comes through the door to several days, depending on the weather and plane availability. I may go into the hospital thinking I will be there all day, only to find I will be flying out that afternoon, so I have a bag packed at all times, ready to overnight in Christchurch – along with having all my patient-care bags and equipment ready to go.
9.00
PM BED I am in bed reading or watching TV, although there are only a few channels available on TV. After using the communal bathroom and saying goodnight to my room mate, I go to sleep – to begin everything over again in the morning. *With summer over, Caryn Braun is now back stateside. To be considered for an Antarctic flight nurse position for the summer season, you need to be licensed to nurse in the USA and have five years’ nursing experience.
12.30
PM BACK TO THE CLINIC I continue treating patients as they arrive. I also perform physical assessments on those who are coming back for the next season; there is a rigorous health exam that everyone must pass to be able to work on the Antarctica continent. The only day off is Sunday. I usually go to church and meet friends at the galley’s regular Sunday brunch (everyone’s favourite meal!). If the weather is good, we hike – the other weekend we hiked to one of the glaciers and then went cross-country skiing for the afternoon.
6.00
PM NEARLY DONE FOR THE DAY At the close of the day all the patient records need to be scanned for sending to our medical director, and then filed. If there is a patient sick enough to be admitted to our six-bed inpatient clinic, then we will all split the night duties to cover the care of the patient. Life can change rapidly here: a patient who needs further care, such as surgical intervention, a CAT scan or MRI, will need
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FOCUS n International Nurses Day
International
Nurses Day To celebrate International Nurses Day this year, Nursing Review once again invited district health boards and organisations across the country to contribute stories on their nursing ‘heroes’. Yet again we were sent amazing stories about some of the unsung, innovative, compassionate, high-achieving and dedicated nurses who make up the New Zealand nursing workforce. Read on…
Celebrating International
Nurses Day ‘heroes’ NAME: Debs Higgins DHB: Hawke’s Bay JOB: Family Violence Intervention Programme coordinator, The Hastings Health Centre Blanket screening for family violence in primary health is the dream of family violence intervention champion Debs Higgins. Debs Higgins is clearly embarrassed by the title “nursing hero”. When asked how she qualifies for such an honour, she immediately offers a self-deprecating response, which in turn draws an interjection from a nearby colleague: “Yes, she is [a hero]. She is”. A nurse with 26 years’ experience, Higgins spent the first 21 years at the Tairawhiti District Health Board and the past five years with The Hastings Health Centre (HHC). The farmer (managing a property with her husband) and mother of three children aged 10 to17 recently added a Master of Nursing degree from EIT in Taradale to her list of accomplishments. Her thesis, predictably enough, was on family violence intervention. It drew on five years of statistics and data from the Hastings Health Centre’s screening programme. Higgins took over as the Family Violence Intervention Programme coordinator at the centre in 2011, with routine screening of women and children having started at HHC three years earlier. The programme was initially developed with support from the Hawke’s Bay District Health Board (HBDHB) and the Hawke’s Bay Medical Research Foundation, and HHC was the first primary care provider in New Zealand to establish such a programme. “Screening is across the board here. It’s entrenched in daily activity – a cultural norm,” she says. 4
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“We have more than 40 nurses, 25 doctors and most of our receptionists involved in it, all ably supported by our champions team of 10 family violence intervention champions (nine nurses and a doctor), a clinical support nurse and myself. “It would be my dream that every doctor and nurse is routinely screening at every opportunity, because the opportunities are great. Eighty per cent of women see their GP once a year. And it’s known that the victims of domestic violence see their GP seven times more often than non-victims. Higgens says that a blanket screening approach is what is needed in primary care but it’s not happening yet. “While our programme has been adapted to suit primary care from the VIP programme used in hospitals, in reality we have more potential to come across the victims of violence in primary care than the hospital system does.” Once the ‘red flag’ is raised, it is time to refer victims on to relevant agencies and experts.
“We’ve had 13 perpetrators ask for help for their family violence problem since screening started at The Hastings Health Centre,” says Higgens. “Our programme covers the spectrum – elder abuse and neglect, child abuse and neglect, partner screening, victims of sexual assault. It was initially an in-house programme but now, in collaboration with Health Hawke’s Bay (PHO) and with support from HBDHB, we train other doctors and nurses.” Higgens says it’s important to recognise that family violence is not defined by religion, socioeconomic factors or ethnicity. “I live rurally, and there are a lot of stressed rural men. So things can go wrong in that community, which is often viewed by those outside it as wealthy. There is no one stereotype. Some are just more adept at hiding it.” Dr Faye Clark of Doctors for Sexual Abuse Care recently described The Hastings Health Centre as a “centre of excellence” for family violence intervention in primary care.
FOCUS n International Nurses Day
NAME: Jan Millar DHB: Canterbury JOB: Nurse practitioner (paediatric Intro ??????? oncology) Jan Millar helps families keep their heads above water while they are being swept along by the turbulent current that is child cancer. Jan Millar is a hero to many of her young patients as well as their families, says Canterbury DHB. Millar herself prefers to be seen as a consistent and steady support for families of children with cancer, helping them to navigate
along a sometimes very frightening path. Millar trained as a specialist children’s nurse at Great Ormond Street in the UK. She joined Christchurch Hospital’s paediatric department in 1997 and took on the role of clinical charge nurse in 2001 to establish the Children’s Haematology and Oncology Centre (CHOC). In 2011 Millar started the journey to become a nurse practitioner, which she completed in 2013. “It’s a very rewarding role… it’s the ultimate really. I get to be involved all the way along and see the patient’s care right through – from the time they are first admitted to the time they leave – and for some patients it can be up to three years later
after all their treatment, various surgeries, to then going into remission,” Millar says. “Seeing different faces all the time can be really daunting for a young child, not to mention parents and caregivers. I can be with them during those times, and also can talk them through it beforehand.” Millar has extended her practice to the complete management of oncological emergencies. “I can complete the whole process from initial assessment to prescription of antibiotics and fluids. It makes the process simple, quick and very reliable.” Millar always sees the positives when working with children with cancer and their families. “It’s a very complex, challenging area for young doctors and nurses who are new to it. I can bring them up to speed and remind them of the positives – when I started in this field in 1981 the survival of children with leukaemia was less than 50 per cent; now, for some types, it is well over 90 per cent.” Amanda Lyver, CHOC clinical director, says Millar has played a key role in the Paediatric Oncology Department since its beginnings at Christchurch Hospital. “Jan has been a ward nurse, charge nurse manager and is now a nurse practitioner. One of Jan’s great skills is her ability to explain things to parents in a manner that makes what their child is experiencing seem less scary and more manageable – she empowers parents when they are feeling vulnerable.”
NAME: Jane Dutton DHB: Whanganui DHB JOB: Nurse practitioner (primary health care) ’Tough customers’ are now turning up for appointments more and more often since Jane Dutton joined Whanganui’s Castlecliff Health nearly six months ago. Jane Dutton is under no illusion about how tough life is for many of her patients living in Whanganui’s beachside suburb Castlecliff. It’s an area of high deprivation, with all the challenges that go with that. But right now, Dutton says she wouldn’t want to be working anywhere else. Dutton is one of the country’s 50 qualified nurse practitioners in primary health, a qualified midwife and a prescriber, and currently is the only nurse practitioner in the Whanganui region. In the five months since she joined forces with practice owner Dr Praveen Thadigiri, Dutton knows the two of them have made a difference. The pair has earned the trust of patients, including some of their ‘toughest customers’ who in the past refused to attend doctor’s appointments and are now coming to the health centre on a regular basis. In addition, Castlecliff Health has now achieved a 100 per cent immunisation rate for children less than eight months old. Dutton says a key focus for her is encouraging patients to take the lead in doing all they can to improve their health. This includes giving up smoking, drinking in moderation, eating well, exercising, taking their medications and caring for their teeth. Former colleague, WDHB nurse manager surgical services, Declan Rogers says Dutton is the perfect person to guide and persuade people to live healthily. “She’s very approachable, gentle, reliable and thoroughly committed to her work and those she serves,” Rogers says.
“We’re very fortunate to have her working in primary health. I’m not surprised she’s having such a positive impact on her patients.” Meanwhile, Dutton is feeling very positive about the direction in which the nursing profession is moving. “We’re seeing excellent new nurses coming through, we have legislative changes happening to widen nurses’ scope of practice and the Nursing Council is improving the nurse practitioner application process,” she says. “I’m very pleased to be actively supporting several nurses working in Whanganui’s primary health sector who are following the nurse practitioner pathway. It bodes well for the future that we have nurses wanting to take up this opportunity.” Nursing Review series 2015
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FOCUS n International Nurses Day NAME: Melody Mitchell DHB: Waikato JOB: Waikato Hospital nurse manager of surgery
NAME: Dr Patsy-Jane Tarrant DHB: Southern JOB: Clinical nurse specialist, Forensic Services – Mental Health
Intro ??????? Dunedin’s criminal courts are home turf for Patsy-Jane Tarrant, who recently gained a doctorate in her specialty field of forensic mental health. Southern DHB says Tarrant’s contribution as a clinical nurse specialist in forensic mental health services is significant – not only through her clinical practice but also through the new knowledge she has brought to the area and the support she gives her colleagues to practice in contemporary and evidence-based ways. The role of the mental health nurse in New Zealand’s criminal courts is the novel topic explored in Patsy-Jane Tarrant’s doctoral thesis. Tarrant graduated in December last year after completing a doctoral research project that for the first time looked at nursing practice in New Zealand’s criminal courts. The court liaison nurse (CLN) is the sole health practitioner in the court setting and Tarrant says this means it is under a high level of public and media scrutiny. Her research looked at what it was like to nurse in a practice setting where two conflicting cultures – justice and health – met, and whether this generated tensions for the nurses involved. Her thesis findings provide a baseline for the court nursing role and ongoing development for nursing practice in this area. Tarrant – who achieved her doctorate while simultaneously working as a clinical nurse and forensic service leader and raising a family – also represents the Southern DHB on a national committee for women in secure care. This committee promotes standards of care for women within forensic mental health settings. She is also currently organising a Court Liaison Nurse Symposium to be held in Dunedin in May. It is the first time in more than10 years that there has been a specific forum for CLNs across New Zealand. Tarrant says the symposium will be an opportunity for both professional development and networking. There are also plans to work on developing a guideline for CLN practice that may possibly be adopted nationally.
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Melody Mitchell says being a Māori nurse in management (she is in charge of 270 surgical nursing staff) gives her a unique opportunity to articulate her community’s needs. Māori managers with a direct connection to the community can see the impact of inequity, says Mitchell, because it affects them and their families. “There are characteristics around populations that are seen as minorities that could be changed or better understood if they had more Māori representing these communities at a management level.” Mitchell manages one of the largest clusters of nurses at Waikato Hospital as the nurse manager of surgery and says the role can certainly be challenging. “Being a manager can sometimes be a double-edged sword. First and foremost I am a nurse but I am now also a manager and sometimes I have to make decisions that are not very popular.” This year she will begin postgraduate studies, and she has chosen to do her master’s degree in nursing, rather than health management or business. Becoming a career nurse was not originally part of Mitchell’s life plan. She was accepted into physiotherapy but she decided it wasn’t what she wanted and her mum then convinced her to go into nursing. “She told me it would give me career options, a job, but also I could go travelling,” she says. On graduating from the then-Taranaki Polytechnic,she worked at Middlemore Hospital, then at Waikato Hospital, returning to Middlemore as an associate charge nurse, and then going back home to Taranaki as a charge nurse. “I got so much exposure to procedures at a big hospital like Middlemore and then to those at a smaller hospital like Taranaki. I was really able to develop my management skills and
“I got asked a few weeks ago why I am doing nursing again and not business or management – it is really simple, I am just so proud to be a nurse.”
as a result got involved with nurse specialties at a national level.” Mitchell questions what job other than nursing could have given her “such exposure to human life and all its challenges”. “I got asked a few weeks ago why I am doing nursing again and not business or management – it is really simple, I am just so proud to be a nurse.”
NAME: Tracey McNeur DHB: MidCentral JOB: Clinical nurse specialist, long-term conditions (and authorised diabetes prescriber) A pre-diabetes education programme that is successfully helping to prevent diabetes in the community is one of the initiatives leading to Tracey McNeur’s hero nomination. MidCentral describes Tracey McNeur as an inspiring primary health care nurse who selflessly goes ‘above and beyond’ to ‘be the change she wants to see’. McNeur is employed by Kauri HealthCare, an integrated family health centre in Palmerston North, as a clinical nurse specialist in long-term conditions and is a strong component of the saying, ‘teamwork makes the dream work’. She is an authorised diabetes prescriber and is currently completing her master’s degree.
Kauri HealthCare GP and partner Dr Esther Willis says the pre-diabetes education programme she initiated illustrates McNeur’s commitment to quality improvement.
FOCUS n International Nurses Day NAME: Bev Gray DHB: Lakes JOB: Public health nurse (retiring)
NAME: Debbie Hailstone DHB: Counties Manukau JOB: Quality improvement facilitator, Emergency Care Hand hygiene compliance has almost quadrupled in Middlemore’s emergency care department since Debbie Hailstone provided evidence to staff of the bugs lurking on their phones and keyboards. It’s not easy to make hand hygiene appealing, but Debbie Hailstone has succeeded in turning the Emergency Care department’s hand hygiene compliance rates from a low 20 per cent to a very respectable 79 per cent. Hand hygiene compliance in the department is made more complex because of the wide range of staff who come and go, including doctors, nurses, allied health, non-clinical staff, paramedics, students and visitors. Annie Fogarty, acute care clinical nurse director, says Hailstone brings passion, enthusiasm and energy into the role. “Her creative and innovative ideas help to reinforce the message that everyone has a part to play in keeping patients safe while [they are] under our care.This includes keeping your hands Intro clean so ??????? you’re not spreading germs.” Fogarty says you will often see Hailstone out on the floor swabbing people’s hands and a range of surfaces, such as phones and computer keyboards, to show them that dirty hands can grow bugs. These bugs are then grown in Petri dishes, which are on display where staff can see them. This had a huge impact, resulting in a positive shift in attitude and behaviour, says Fogarty.
“What Debbie has helped to create is a culture shift – one where people are actively taking responsibility for ensuring their hand hygiene rates remain at a high level,” she says. As for Hailstone, it would be fair to say that she loves her job. “Nothing gives me more satisfaction than making a difference – it’s what motivates me to come to work each day,” she says.
“Nothing gives me more satisfaction than making a difference – it’s what motivates me to come to work each day.” “This is now an integral part of care within Kauri HealthCare. To date, none of the people who have gone through the prediabetes education programme have progressed to developing diabetes. All care is centred around patient needs and goals – I have no doubt this is a major contributing factor to the favourable health outcomes she achieves.” McNeur has been involved with a number of practice and district-wide quality improvement initiatives since 2008. At a district level, she is chair of the Long-Term Conditions District Group, chair of the Pre-Diabetes Working Party, a member of the Diabetes Partnership Group, and a member of the Map of Medicine Diabetes Collaborative Clinical Pathways.
At a practice level,she is involved with IFHC Practice Development Plans, Pre-Diabetes Programming, Diabetes Annual Review, and Diabetes Standing Orders. Chiquita Hansen, MidCentral’s primary health care director of nursing and also the Central PHO’s chief executive, says McNeur has well-recognised leadership skills in chronic care management. “Tracey is passionate about primary health care teams developing a proactive response to working with informed activated long-term conditions clients. She is cognisant of the value of teamwork and the benefits of offering individual and group consults to people with long-term conditions. “Tracey has a high level of professional competence, excellent quality improvement knowledge, a real commitment to improving the patient experience, awareness of ethical and social issues inherent in health care and dedication to achieving improved health outcomes.”
Bev Gray is retiring after 50 years of nursing and says, given the chance, she would choose nursing all over again. “I have loved my years of nursing. The bond I have had with the other nurses is just wonderful, it’s been fantastic,” says the Lakes DHB public health nurse. Gray trained at Rotorua Hospital, beginning in 1965. She says those early years of nursing were wonderful years – “great days” where there was a lot of fun. In those days the matron had strict control over the young nurses and standards of dress were high. She remembers having to change from her white uniform and cap in the hospital to a blue one to go back to the nurses’ home for a meal, all in half an hour. Gray worked in the medical ward and ICU and around1969 was asked to go to Waikato Hospital to learn about the running of a coronary care unit. She worked at Waikato for three months before returning to set up the coronary care unit at Rotorua Hospital, with the support of three local physicians. Gray had to learn and teach others about different heart rhythms, running the machines and new medications – it was new for the doctors too. “It was a huge project, scary at first, but I got more comfortable with it and the doctors were really supportive.” She worked in ICU/CCU for many years, with a few years off to have her three children and working part-time when her husband was home with the children. When it was time for a change, she moved to public heath 15 years ago. “I love it. Working with people and trying to see the whole story [because] there’s always more to the picture. It’s very challenging work and can be very rewarding. “It’s a very different working environment from the hospital ward, working alone in the community as a visitor in people’s homes.” Gray says once people realise she can work alongside families and help, they are more welcoming and she has built some really good relationships with families and schools. She would definitely choose nursing as a career, given her time again, but acknowledges there are so many more career options for women today. Gray was told she would know when it was the right time to retire and she agrees – she has heaps of other things to do and is looking forward to making a start.
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NAME: Brittany Jenkins DHB: West Coast JOB: Resuscitation Service leader
NAME: Uputaua Suniula DHB: Capital & Coast JOB: Community health and rheumatic fever prevention nurse, Porirua The mother of two children by the age of 17, Uputaua Suniula is now a nurse who is helping to turn around the health of teenagers and children in Porirua. Uputaua Suniula was recently recognised with the Margaret Faulkner graduate award for her compassionate care that is making a difference in Porirua – a difference she describes as “empowering”. “The positive impact I can make within the community has been mindblowing, especially working as the first point of contact for people in need,” she says. Suniula has worked on the front line of healthcare at both Waitangirua and Intro Porirua’s??????? Community Health Service. “My focus is to work with Porirua’s young population to help develop prevention strategies that can stop acute presentations of preventable things like asthma and skin infections, reduce the strain on hospital services, as well as lower our overall healthcare costs. “One of the problems we face is that teenagers and children don’t come in to see a doctor till they’re really sick,” she says. “What could’ve been addressed in the clinic instead becomes complex, at which point they become an inpatient in the hospital.” One campaign Suniula works closely on is the rheumatic fever prevention programme in Porirua, where finding and treating strep throat can prevent the risk of a lifetime of heart issues. “It’s all about treating the patient early, before they develop a serious problem.” Suniula is now working towards a postgraduate certificate of nursing, with the aim of gaining a master’s qualification specialising in primary health care.
NAME: Sue Patience DHB: Auckland JOB: Home Haemodialysis Unit staff nurse The hero nomination of home dialysis nurse Sue Patience is the result of her dedicated support of patients caught by last year’s Auckland power outage and her earlier work for evacuated Christchurch earthquake dialysis patients. All Sue Patience ever wanted to be was a nurse. She bought nursing books at school, cared for animals knocked over on the road, and had a potentially hazardous encounter with a candle as she pretended to be Florence Nightingale. Patience started her nursing career in 1976 and has spent the past 15 years working in renal services, most recently at the Home 8
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Haemodialysis Unit at Greenlane Clinical Centre, where she trains and supports patients to use dialysis equipment safely at home. In October 2014, widespread power outages hit Auckland. “I was on call that day and I’m sure I did what any other of my
Brittany Jenkins is a West Coast hero for developing a resuscitation service for health practitioners stretching from Karamea to Haast. Nurse specialist Brittany Jenkins expanded an existing resuscitation education programme into a DHB-wide Resuscitation Service to meet the isolated West Coast’s unique needs. Jenkins began her nursing career at the West Coast DHB in 2007 after graduating from Massey University’s Bachelor of Nursing programme. Originally from Montana, she describes herself as a “home-grown but American-accented” nurse and says she was drawn to the Coast by its small-town lifestyle and generalist career opportunities. She eventually settled into working between critical care and general medicine and in 2009 was nominated to train as a New Zealand Resuscitation Council CORE instructor. She taught CORE for three years before successfully applying for the Resuscitation Service leader role at the end of 2013. “I love the challenge and variety of the role. I enjoy teaching and the content – you can make it fun, but the role also involves everything from data collection and basic research to policy writing and working on local and national initiatives. “The role is also fairly unusual because it covers secondary and primary care, and is part of a trans-alpine collaboration with tertiary provider Canterbury DHB.” She says the wide scope spans the care continuum from pre-hospital to specialist services, and has seen her facilitate partnerships with a range of professional groups, including rural nurse specialists and generalists from Karamea to Haast, Canterbury-based specialists from anaesthetics and paediatrics, and practitioners within the South Island Regional Training Hub (SIRTH).
colleagues would have done in that situation,” she says. Knowing the disruption the power outage would mean to patients using home dialysis, Patience made every effort to find any available space to support dialysis patients who had lost power at home, as well as continuing the training and support for patients already in the unit “Of course, we didn’t know how long the power would be out for, so I made the space available for those who needed it urgently, and it really gave them peace of mind.” Patience had previous experience to call upon, having helped patients evacuated from Christchurch during the earthquakes. “I advocated hard to maintain after-hours dialysis and support for these patients. It was a traumatising time and lots of patients needed urgent help dialysing.
“I still see some of the patients, who pop in if they’re passing through Auckland. The renal population is very embracing, they’re a very strong group and I have much admiration for them.” Patience was also awarded Auckland DHB’s Local Hero award last October after being nominated by a patient. “There are so many wonderful things that I can describe about Sue,” said the patient. “She is so amazing, so caring, loving and giving of herself. She is very accurate and there are no shortcuts when doing her job. “When I first started at the Home Haemodialysis Unit, Sue taught me the machine, helped me with the troubleshooting and I nearly always got her on the 24hr helpline we have. I love her; she has made my life worth living.”
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In the short time she has been in the role, Jenkins has multiplied the number of advanced and basic resuscitation training sessions offered on the West Coast. She has also established and chaired a multidisciplinary Resuscitation Committee, is supporting a growing team of instructors developing the DHB’s first CPR policy and associated procedures, and is conducting the first DHB-wide audit of emergency equipment and checking practices. Another initiative she is involved in is creating a system for reviewing clinical emergencies, and she is also working to tailor any initiatives to evolving models of care. Last year, Jenkins successfully completed her Master of Nursing with distinction, during which she explored the experiences of internationally qualified nurses who had transitioned into New Zealand and were working as registered nurses in aged care. While studying, Jenkins spent some time working in the Office of the Chief Nurse on workforce issues associated with international nurses.
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NAME: Anne Sisam DHB: Waitemata JOB: Public health nurse Anne Sisam is a public health nurse hero working with vulnerable families in a caravan park in West Auckland to empower them to keep healthy. After registering as a nurse 40 years ago, Anne Sisam has spent half of those years working in the West Auckland community, taking a particular interest in the needs of vulnerable children experiencing disparities in care. Her current role involves working with people living in a caravan park in very challenging circumstances and who often present with illnesses typical of lower socio-economic communities. “Within this role, my focus is on prevention and intervention. What I see as being most important is empowering and enabling people to take control of their own health,” she says. “That’s what I love about this job, as opposed to working in hospitals when people have already got conditions. “It’s been such a good opportunity to change health outcomes for the better.” Sisam has invested time getting to know the caravan park community so she is able to make a difference to the families living in a transient environment where poverty and ill health require careful assessment, negotiation and partnership. “A lot of it is about building relationships and really looking after those relationships with that community. “These people have limited resources and limited knowledge so it’s about supporting them with any health issues they may have, but also working with them to help them gain knowledge about their health and find realistic solutions.” Jocelyn Peach, Waitemata DHB director of nursing says Sisam also demonstrates cultural awareness. “She uses the Māori health model Te Whare Tapa Whā, working in partnership, encouraging participation of the community and different
agencies as well as protecting the most vulnerable and their culture. “We consider Anne a hero, meeting the needs of a vulnerable group in a challenging environment,” says Peach. “The people we’re working with are an amazing bunch of resilient people and I do believe we’re making progress,” adds Sisam. “When people open their doors to you and they respect what you’re trying to do for them, you form really good relationships that help them see the whole healthcare system in a better light.”
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The College of Nurses extends greetings and congratulations to nurses and nurse practitioners on International Nurses Day. We salute the endurance, persistence and commitment of nurses who continue to practice and care for patients in often difficult or challenging circumstances. Let us make International Nurses Day an opportunity to reinvigorate our efforts towards safe staffing , towards appropriate leadership structures and the release of the full potential of nurses and nurse practitioners in primary health care and community settings. E ngā mana, e ngā reo e ngā karangarangatanga maha, tēnā koutou, tēnā koutou ka huri noa i te motu tēnā koutou katoa. I runga i te mana o ngā tupuna kua huri ki tua, ka mihi au. E rere kau ana taku mihi ki a mātou te hunga ora, ko mātou te hunga ki te whakapakiri, ki te poipoia te ora o tēnā o tēnā o rātou. Kati ake ra tēnā koutou tēnā koutou e ngā rangatira mā tēnā tātou katoa.
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Nurses asked to
maximise the health dollar NAME: ROSE STEWART EMPLOYER: Family Planning JOB: National nurse advisor More clients than ever before can consult with a nurse by phone following a new initiative that Rose Stewart helped develop. Rose Stewart’s position description “Responsible for nursing staff clinical practice and professional development” sums up her role in just a few words, but it doesn’t describe her passion for making Family Planning clinic services as easy as possible Intro ??????? for clients to access. For some clients, this now means they don’t need to come into a clinic at all. Stewart, alongside National Medical Director Dr Christine Roke, has driven the clinical aspects of a new phone consultation service, which allows an increasing number of clients to “be seen” by phone. Phone consultation services require a balance between ease of access and appropriate clinical management. “Phone consultation development was underpinned by our strategic focus to make it as easy as possible for young people, particularly rangatahi Māori, to use our services,” says Stewart. Consulting by phone was originally only offered to clients wanting the emergency contraceptive pill or a contraceptive pill repeat. This service has now expanded by stages to include contraceptive pill repeats, emergency contraception, condoms, consultations prior to contraceptive implants or IUDs, and discussions of contraceptive options. And there is more to come. These services are free for New Zealand residents 21 years or under and are paid for by debit or credit card for those aged 22 years or over. Stewart is very focused on improving women’s choice and autonomy in sexual and reproductive health. “Women have a lot to manage in their lives in terms of their fertility and they need all the help we can give them,” she says. “For women who live remotely; women who cannot afford childcare or transport; women who cannot get time away from work to attend appointments – being able to have a phone consultation might make all the difference in the world. “It could be the difference between rapid repeat pregnancies or a pregnancy gap chosen by the woman; heavy periods better managed that allow her to have fewer sick days away from work – there are all sorts of scenarios where providing that help can make a real difference in women’s lives.” 10
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This International Nurses Day, nurses are being asked not to leave health system finances just to the bean-counters in the back room. Instead, the International Council of Nurses (ICN) says nurses should be actively engaged in thinking about how each dollar can be best spent to improve health care. Nursing Review reports. The global financial crisis (GFC) that began in 2008 had a “devastating impact on the nursing workforce and access to care”, says the International Council of Nurses. The council says the crisis acted as a brake on recruitment and staffing levels, despite a global shortage of nurses and a growing demand for health care. “In many countries around the world, governments have cut back on expenditure on healthcare and, in particular, on nursing.”
What is the role of nurses in health system finances?
“Nurses have an important contribution to make in health services planning and decisionmaking, and in development of appropriate and effective health policy,” reports ICN in a 2008 position statement on the issue. “They can and should contribute to public policy related to preparation of health workers, care delivery systems, health care financing, ethics in health care and determinants of health.” Nurses also have a role in improving health systems on the floor level and wider, so that health services are more effective and efficient, with fewer errors and less wasting of resources. »» The World Health Organisation estimates that over half of all medicines are prescribed, dispensed or sold inappropriately. »» The problem of medical errors is huge, with a 2003 study finding a quarter of adults with health problems in Australia, Canada, New Zealand, and the USA reported experiencing a medication error or medical error in the previous two years. »» Nurse-sensitive care indicators, like healthcare acquired infections (HCAIs) and pressure injuries, are not only negative for the individuals involved but also expensive for health systems, with HCAIs estimated to cost the United States US$6.5 billion in 2004
and pressure injuries more than US$10 billion a year. Nurses’ roles can include: »» improving prescribing guidance »» developing evidence-based best practice guidelines »» adhering to and championing infection control procedures »» undertaking more clinical audits.
Nurses can have a major impact
ICN president Judith Shamian and chief executive David Benton, in the foreword to the International Nurses Day kit, point out that the cost of health care is rising worldwide, placing a heavy financial burden on health systems and populations globally. “Nurses, as the single largest profession in the health workforce, are well positioned to drive efficiency and effectiveness improvements while providing quality care and attaining optimal patient and population outcomes,” they say. “The decisions that every nurse makes multiple times a day in everyday practice can make a vital difference in the efficiency and effectiveness of the entire system. The nursing role in cost-effective care is described as follows: »» Primary health care nurses who have a unique opportunity to put people at the centre of care, making services more effective, efficient and equitable. »» Evaluations show advanced nursing practice roles (like nurse practitioners) can improve access to services and reduce waiting times. »» Nurse prescribing has the potential to save costs for the patient and the health system by freeing up a doctor’s time for more complex patient issues. »» Nurses must use supplies and equipment effectively and be aware of how much supplies cost and how waste occurs. »» Nurses have a role in reducing polypharmacy and promoting rational use of medicines.
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In coats of grey and scarlet: New Zealand nurses at war
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One hundred years ago the first ever contingent of the New Zealand Army Nursing Service sailed out of Wellington clutching bouquets and waving multicoloured streamers. FIONA CASSIE tells the tale of how nursing fought hard for the right to accompany their boys to war and, like them, serve while battling heat stroke and dysentery in the East and trench foot on the Western Front. Image above: The first contingent of the New Zealand Army Nursing Service on board the Rotorua heading to World War I in 1915. (Photo courtesy of Alexander Turnbull Library: image PAColl-0321-001)
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e’ve all heard the stories. Farm boys riding into town and carpenters dropping their tools to rush to enlist on hearing New Zealand declare war on 5 August 1914. Less is heard about the nurses who clamoured to serve their country. More than 400 volunteered within two months of the outbreak of war, but troopship after troopship left to defend the ‘home country’ without a nurse on board. This was much to the frustration of the country’s feisty nursing leader Hester Maclean – the founding editor of Kai Tiaki Nursing New Zealand and the driving force behind the New Zealand Trained Nurses Association – who in 1911 had been given the titular title, Matron-in-Chief, of an army nursing reserve yet to exist. Her urgent efforts – and those of her predecessor Janet Gillies – to create an army nursing reserve in the lead-up to the ‘Great War’, and in its early days, were continually hindered by a Government reluctant to take the proposal seriously. Apart from the seven nurses the Government sent to Samoa (not as military nurses but to replace German nursing staff in the hospital in Apia), it was initially the Boer War all over again, with only those New Zealand nurses who could make their own way to Britain able to do what many more nurses were longing to do – care for their brave lads fighting on foreign fields. Requests to go officially continued to be stonewalled, with Minister of Defence James Allen telling a delegation from the Trained Nurses Association that it would be difficult to have female nurses on crowded troop ships and “until the Mother Country asks us to provide nurses, it would be a presumption to send them”. Maclean was well aware of hundreds of New Zealand nurses keen to “share to some extent in the dangers and hardships of the troops” so kept pressing the Government until finally, in January 1915, it was agreed to create a military nursing service and send 50 nurses to England. The matron-in-chief sprang into action, selecting the 50 from hospitals and district nursing services across the country and nominated herself to accompany the contingent to London in April and hand them over to the British War Office before sailing back to New Zealand. A last minute distraction was a 25 March invitation from the Australian Nursing Review series 2015
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Nurses of the New Zealand Stationary Hospital, France, give a garden party in the hospital grounds in 1917 (probably Hazebrouck). (Photo courtesy of Alexander Turnbull Library: image 012798-G)
Government for a dozen nurses to be ready to cross the Tasman on 31 March to join an Australian nursing contingent destined for Egypt. Despite the short notice, the nurses eagerly accepted. Amongst the 12 was Aucklander Hilda Steele, one of the nurses whose stories were told in the recent television mini-series ANZAC Girls
and the play Sister ANZAC (see sidebar). Finally, on 8 April, the first 50 official New Zealand Army Nursing Service (NZANS) nurses to leave for overseas service set sail from Wellington on the Rotorua, making what their proud matron described as a “picturesque group” in “their coats of grey and scarlet”.
A century of service The centenary of New Zealand’s official military nursing service is to be marked with a special gathering in July. Lieutenant Colonel Lee Turner, director of nursing services for the New Zealand Defence Force, is the modern day equivalent of Hester Maclean – the first matron-in-chief who led the infant New Zealand Army Nursing Service, which since the 1950s has been known as the Royal New Zealand Nursing Corps (RNZNC). The peacetime corps has about 30 nurses in the regular forces and 12 in the reserve, but the Army, Navy and Air Force also employ another 40 or so non-uniform or civilian nurses to provide primary health care to staff on their bases. Turner says RNZNC had hoped to be able to have the corps’ Colonel-in-Chief Princess Anne attend a centenary event but unfortunately she was not available.
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It is now planning to mark the occasion by holding a special event during its annual two-day gathering or hui in July and inviting nursing veterans to attend and present on their experiences of the corps. Sherayl McNabb, who is currently writing an updated history of the corps to mark the centenary, will also present to the gathering. There will also be a commemorative service and wreath laying at the National War Memorial’s Hall of Memories, attended by His Excellency the Governor-General Sir Jerry Mateparae. This will be followed by a special afternoon tea with veterans at Government House. A formal dinner is also planned. The corps will also be closely involved with the Christchurch events being organised for late October to commemorate the 100th anniversary of the sinking of the Marquette.
These first nurses were feted on both sides of the Tasman with farewell ceremonies and gifts, including silk umbrellas from David Jones in Sydney for the Australian ‘dozen’ and deckchairs and electric torches for the nurses from Dunedin.
Gallipoli, dysentery and heat stroke
As the nurses steamed towards England and Egypt, the ill-fated Dardanelles campaign began at dawn on 25 April 1915 on the tiny stretch of Turkish coastline now known as Anzac Cove. Upon their arrival in London, the first 50 nurses were given orders to travel on to Egypt to nurse those arriving from Gallipoli with “terrible wounds and the most distressing diseases”. The unstoppable Maclean accompanied them and stayed on in Egypt to await the second NZANS nursing contingent, and then the third aboard the specially equipped hospital ship Maheno. Maclean had reluctantly left by the time New Zealand’s second hospital ship, the Marama, arrived in early 1916. In all, New Zealand army nursing historian Sherayl McNabb estimates at least 610 nurses served with the NZANS during World War I, with about a further hundred New Zealand nurses serving with British or Red Cross nursing units. The early contingents of nurses were posted to a variety of military hospitals in and around Cairo and the port towns of Alexandria, Suez and Port Said. One of those Cairo hospitals, caring
FOCUS n International Nurses Day Top image: Four nursing sisters look out of the windows of their sleeping quarters at the New Zealand Stationary Hospital, Wisques, France. (Photo courtesy of Alexander Turnbull Library: image 013482-G) Bottom image: Nurse and patients in the New Zealand Stationary Hospital, Wisques. (Photo courtesy of Alexander Turnbull Library: image 013470-G) Inset image: A New Zealand nurse and orderly outside the diphtheria ward of the New Zealand Stationary Hospital, France. (Photo courtesy of Alexander Turnbull Library: image 013466-G)
Intro ??????? for New Zealanders evacuated from Gallipoli, quickly grew from 300 to 1,000 beds. Maclean says the hospital was frequently short-staffed, the heat was “very trying” and working in tents and pavilions pitched on the sand tested the New Zealand nurses’ endurance to the limit. Most nurses did find time though for a trip to the pyramids and a photo on a camel. The first New Zealand nurses to come within sight of Anzac Cove were the nurses aboard the
Maheno, which arrived in late August as a new attack was launched on the peninsula. For two days the ship’s two operating theatres never stopped as boatload after boatload of wounded soldiers were brought on board so the deck was always overloaded with mattresses and men. One nurse on board, Lottie Le Gallais, wrote of the “terrible, terrible wounds”. “The bullets aren’t so bad but the shrapnel from exploding shells is ghastly. It cuts great
New Zealand’s only nurse anaesthetists At least seven New Zealand nurses underwent three months’ training as nurse anaesthetists and went even closer to the Western Front than their colleagues to work and live under canvas at casualty-clearing stations. They worked 16-hour shifts, with enemy planes flying overhead every night and antiaircraft guns disturbing what little sleep they could get. These nurse anaesthetists performed 400–500 anaesthetic procedures (using ether or nitrous oxide/oxygen, but not chloroform) under the most challenging of situations and were involved in the pioneering use of blood and saline transfusions to resuscitate the wounded. When they returned, post-war, Maclean lobbied for the expertise of these women not to be wasted and suggested they could be usefully employed in small rural hospitals. All boards were canvassed in 1919, with seven hospital boards keen to employ them; eight were at least sympathetic and only two expressed outright disapproval. But while several veteran nurse anaesthetists applied for positions, none was employed and the Director-General of Health officially quashed the issue with a letter in 1924 prohibiting non-medical practitioners from administering anaesthetics (see Rawstron reference at the end of the article). gashes, ripping muscles and bones to shreds,” she wrote. The Maheno made six trips from Anzac Cove to military hospitals on the Greek Island of Lemnos with 400 to 500 wounded at a time. In October it finally left the Gallipoli peninsula but, like its larger sister ship, the Marama, its service continued transporting invalided soldiers back to New Zealand. In 1916 both were part of the White Fleet that continually shuttled back and forth across the English Channel ferrying the wounded and the shell-shocked soldiers from the trenches of the Somme back to hospitals in England. On one occasion the Marama, fitted with 600 beds “bore no less than 1636 patients from Le Havre”. The sisters and orderlies were engaged all day and night dressing wounds with even the walking wounded often severely injured. New Zealand nurses served on hospital and transport ships across all theatres of war – fighting back seasickness and nausea at treating patients with dysentery, lice, fleas and festering wounds. One nurse talked about the “appalling heat” of the Persian gulf, which saw them end the day soaked with sweat and their long white dresses “wet to the knees” from using ice baths to try and revive patients, engineers and crew suffering fatal heat stroke – an affliction that took 21 patients in four days.
To the Western Front
The closest that nurses got to the firing lines was when they left the Middle East and Mediterranean to serve on the Western Front. “They learned to sleep to the sound of the guns and the bombs falling nearby, not knowing when their shelter might be hit. A few could not endure the nerve-wracking strain, but, nonetheless, service in France was eagerly sought after,” recalled Maclean in a history published in 1923. The No. 1 New Zealand Stationary Hospital Nursing Review series 2015
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An advanced dressing station at the Western Front. (Photo courtesy of Alexander Turnbull Library: image 012928-G) Image top right: The nurses and medical officers at the New Zealand Stationary Hospital, Wisques, France. (Photo courtesy of Alexander Turnbull Library: image 013483-G) Image bottom right: Inside the sisters’ lounge at the New Zealand Stationary Hospital, Wisques, France. (Photo courtesy of Alexander Turnbull Library: image 013483-G)
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at Hazebrouck had to be hastily evacuated in 1917 when shelling became too close – explosion after explosion forced the shipping out of nearly 700 patients in only three hours. The hospital was relocated to Wisques, which was beautiful in summer (see photos) but by winter was found to be damp and swampy. And, like the lads in those nearby trenches, the nursing sisters at the No. 1 New Zealand Stationary Hospital suffered severely from trench feet that winter – a condition similar to frostbite resulting from being continually exposed to damp, cold and unsanitary conditions. Maclean says the nurses could barely carry on with their work but after treatment made their way around the hospital in large felt slippers covering bed socks and bandages. “Many times the sister attending a man with trench feet who was admitted as a patient, could, if she had chosen, show a condition worse than her patient,” recalled Maclean. “They were not there as patients, however, and they bore the excruciating pain without complaint.” It was to Wisques that the casualties of the Battle of Passchendaele (which took the lives of 846 New Zealand troops in just four hours on 12 October 1917) were brought, with the soldiers’ uniforms so caked in mud that nurses reported struggling to get to the wounds. With a policy of New Zealand hospitals for New Zealand soldiers, there were also New Zealand General Hospitals (NZGH) set up in England with nurses serving at NZGH 1 in Walton-on-Thames, NZGH 2 in Brockenhurst, NZGH 3 in Codford and later a convalescent hospital. Between them they cared for tens of thousands of New Zealand soldiers who were left amputees, disfigured, lame, or suffering from severe pneumonia or shell shock by the war. The end of 1918 finally brought peace and with it the Spanish Influenza pandemic and it was not until April 1919 – four years after departing – that the first large contingent of NZANS nurses returned home. After the welcome home morning tea at parliament, Hester Maclean once again began lobbying to ensure that nurses who served their country were given not only the same opportunities for post-war assistance as the soldiers they nursed, but also the respect that their officer status demanded. She was not always successful, but the nurses did get a 28-day pass on the railways, plus those unfit for service were given a pension and one veteran nurse successfully took over a rehab farm abandoned by its soldier owner. The NZANS was now official and embedded so 20 years later when war broke out again it was only hours, not months, before the first reserve nurses were called-up for overseas duty. 14
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Romance amongst the poppies With the centenary of World War I, writers and producers looking for a fresh perspective on the Great War have turned to the nurses who looked after the soldiers shattered by Gallipoli and the Western Front. British television drama The Crimson Field, set in a British army hospital in France, opened the BBC’s World War I coverage in 2014 but only ran for one season. Down under, we had ANZAC Girls – an Australian TV mini-series inspired by Peter Rees’ book The Other Anzacs: Nurses at War 1914-1918. The book, now re-issued as Anzac Girls, follows the stories of Australian and New Zealand nurses serving in Egypt and France, based on the real stories of five nurses (four Australian and one New Zealand nurse, Hilda Steele). The play Sister Anzac by Geoff Allen (again featuring Hilda Steele) also debuted in Auckland last year, telling the stories of nurses serving on the New Zealand hospital ship Maheno, which was stationed off Anzac Cove to treat and ferry the injured, the sick and the dying from the battle zone. Head of New Zealand’s defence force nursing services Lieutenant Colonel Lee Turner felt Sister Anzac was the pick of the three, with the storytelling being “appropriate, relevant and quite moving at times – it was done really, really well”. Of the other two, he noted there was some “artistic licence”, with quite a lot of focus on romance, which he was sure would have been a “tiny little element” in the nurses’ lives compared with the main event – dealing with the trauma of war. (Only about 14 of the New Zealand nurses are known to have married while serving overseas.) SOURCES: »» New Zealand Army Nurses by Hester Maclean, Chapter V of The War Effort of New Zealand by Lt H T B Drew. Whitcombe & Tombs (1923) »» While you’re away: New Zealand nurses at war 1899–1948 by Anna Rogers. Auckland University Press (2003) »» New Zealand Military Nursing: A History of the Royal New Zealand Nursing Corps Boer War to Present Day by Sherayl Kendall and David Corbett. Kendall & Corbett (1990) »» A unique nursing group: New Zealand army nurse anaesthetists of WWI by R E Rawstron. Rawstron Publishing Company (2005) »» Anzac Girls: An Extraordinary Story of World War I Nurses by Peter Rees. (NB First published as The Other Anzacs in 2008) Allen & Unwin (2014)
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Reading, Reflection, and application in Reality Reading this article and undertaking the learning activity is equivalent to 60 minutes of professional development By Lesley Batten and Marian Bland
Hospital visitors: visiting in our hospital or are we visiting in their lives?
There is increasing evidence of the potential contribution that visitors can make to patient wellbeing and recovery. Although some district health boards in New Zealand have recently relaxed visiting hours, others have not. This article explores perspectives on hospital visiting and including visitors as valued members of the health care team.
Introduction
As I was pushing my niece in a wheelchair to see her new premature baby the day after her emergency caesarean section, the unit receptionist asked who I was. Her response to that information was to tell me I could visit this time (as I was pushing the wheelchair), but in future would have to wait for visiting hours. She then recited the visiting rules. What a welcome, and not what my niece needed at that time 1.
Visiting hours in New Zealand’s public hospitals have been a moveable feast over recent decades. While the rules around visiting may be becoming more accommodating, restrictions remain in many parts of the country with a significant variation in official visiting hours between DHBs. Although restrictions in hospital visiting may follow historical precedents2, it is often difficult to identify the rationale behind current restrictions. The most common explanation found on DHB websites was the need to allow patients to rest. Other reasons included: »» Increased staff workload, which is then disrupted by visitors »» Lack of space »» Patients requiring treatments »» Privacy issues associated with medical rounds »» Visitors being inconsiderate to other patients »» Concerns about theft and vandalism, especially after hours »» Cross-infection.
LEARNING OBJECTIVES Reading and reflecting on this article will enable you to:
»» Consider the impact of institutional visiting hours on patients, their family or whānau »» Reflect on your personal and professional response to visitors in your work area »» Compare staff responses to visiting in your own work area »» Formulate strategies that will allow you to effectively manage and maintain the safety of patients and staff, while still maintaining a partnership approach that values the input of families and whānau.
These reasons link to broader concerns about maintaining a safe environment for staff, patients and other visitors. In 2010, Waikato Hospital was reported as being about to trial new restricted visiting hours in response to what they referred to as “chaotic, overcrowded wards” in the hope of “regaining control” over patients’ recoveries3. In late 2014, an unnamed staff member at Whanganui Hospital claimed in the media that nurses feared for their safety at the hospital because of a lack of control over what were described as “volatile” visitors4. While these concerns are real for the staff concerned, are restrictions on visiting always the answer or are they sometimes the problem?
Applying the rules Even within the one hospital there can be considerable variation in visiting hours between wards and units, as well as differences between institutions in the same DHB. Regardless of what the official visiting hours may be, inconsistencies in adherence to those hours are common and problematic for everyone. At a ward/unit level, some staff may be prepared to put patients’ needs ahead of the policy, as the following anecdote demonstrates:
I was the identified support person for a close friend recovering from extensive abdominal surgery. My friend was deeply shocked by her diagnosis, as well as recovering from the surgery. She wanted somebody with her constantly to support her for the first few days post-op. The ward was closed to visitors for several hours each afternoon. Some nurses were quite comfortable with me reading quietly in her room, as long as I didn’t disturb her rest or that of any other patient. Other staff were sticklers for pushing everyone out the door and locking it fast1. Working out whether staff are ‘sticklers’ or not puts additional stress on patients and families who have to decipher the rules5.
Having to plead for access out of hours can be demeaning for visitors, and patients may be left distressed:
I was scared that I was going to die because of my previous reaction to Fentanyl. My husband knew, my mother knew, but they weren’t there. That terrifying situation happened because the hospital’s rules wouldn’t allow my family to stay with me 6. Not only was this patient distressed, but it is likely that her family were also discomforted – wanting to be there, knowing they should be there and not being allowed. This raises the issue of whether ‘visitor’ is even the correct term for family members, whānau or significant others?
Visitor status
I’d been staying with Mum in hospital, showering her, taking her to the toilet, doing whatever she needed. The nurses watched her drip. We have a pākehā friend who is like family to us. Mum calls her ‘her other daughter’. I’d been there for three nights, and was exhausted, so my ‘sister’ took over being with Mum for the night shift. I told the nurse I was going home, and that my sister would be with her. I rang later to check how Mum was, and the nurse said, “Oh, you are supposed to be up here with your mother”. I asked if anyone was with Mum, and she replied, “There’s a blonde person sitting out there with her”. That doesn’t sound very nice, does it7?
Family presence and participation Restrictive visiting policies are often based on long-held beliefs that the presence and participation of families interferes with care, exhausts the patient, is a burden to families, or spreads infection. These are myths and misperceptions. There is no current evidence to support those beliefs5.
Hospital visitors: In this situation, staff were comfortable with family members being present 24 hours a day, and undertaking much of their mother’s personal care. Unfortunately, assumptions were made based on cultural stereotypes about who could be a whānau member, and without understanding that a kaupapa whānau includes others not related by kinship. Contemporary families are complex and diverse and it is always dangerous to make assumptions as to who is the most significant patient supporter, or to attempt to determine ethnic identity on the basis of physical characteristics. One useful approach is to adopt personcentred visiting, where the patient and their family decide who are the significant people to be present when someone is in hospital. Use of a ‘nominated contact person’ or ‘identified support person’ goes some way in enabling patients and family to identify significant supporters, but the missing component is free access to provide the necessary support.
Working in partnership?
As Taima Campbell, the then Director of Nursing and Midwifery for the Auckland DHB, noted in 2012: “On the one hand we talk about patient-centred care; for a lot of patients, part of their healing is having their family. On the other hand, we kick [families] out.8” Restricting visiting not only limits family access to the patient, it also reduces
visiting in our hospital or are we visiting in their lives?
the important opportunities for staff and families to interact. Restricting opportunities for families to communicate with staff conflicts with nurses’ professional and legal responsibilities to work in partnership with the patient and their family (refer to related competencies and standards sidebar). The New Zealand Health Quality and Safety Commission9 recently published the results of its survey of 6,000 people who were inpatients in DHB hospitals in November 2014. Only 55 per cent of respondents reported that the hospital staff included their family or whānau or someone close to them in discussions about their care. The people who are essential to the ongoing support, comfort, and wellbeing of the patient must be identified and included. As argued by Clisset et al10 in a study of the experiences of family carers of older people with mental health problems who were admitted to general hospital wards: “Health care professionals need to be more consistent in working in partnership with family carers, recognising them as a source of expertise in the specific needs of a person …” This theme of the need for nurses and families to work in partnership recurs in the literature supporting open visiting policies11.
Cultural considerations
The need for families to be present when a family member is sick is an almost universal cultural value5. The configuration of our public hospitals poses some challenges in relation to person-centred visiting. Our older hospitals have a predominance of shared rooms, where four-bedded cubicles are common,
The presence and participation of families/other partners in care »» Families and other partners in care welcome 24 hours (as determined by patient preference) »» Patients asked to define family/partners in care, and with the guidance of staff determine what their role will be »» Negotiation about the number of people who can be at the bedside at any one time »» Expectations for when children visit »» Identification of a family spokesperson »» Directly and promptly addressing disruptive behaviour »» Visitors free from infection »» During disease outbreaks, staff work to facilitate selected family members still being present. Extract from guidelines developed by the Institute for Patients and Family-Centred Care19.
patient privacy is at a premium, and small, uninviting patient lounges provide limited opportunities for visiting family groups. These environmental factors create problems for nurses, and also for families:
My uncle was in hospital, and all the whānau came in to see him because that’s what he wanted and expected. He had many visitors, and there wasn’t enough space in his room so others were waiting quietly in the lounge. Just feeling those vibes from staff like ‘you shouldn’t be here, there are too many of you in there’. I was feeling a bit stressed out ‘cause they were all looking at us, but uncle didn’t want us to go. They had their rules, even down to the numbers of visitors he was allowed, but those rules were a problem for uncle, and therefore for us 7. In this example, space for a large whānau caused challenges, however so did the style of communication between nurses and the whānau. The whānau were the ones caught between the rules, the patient’s need for family support, and the whānau obligations to care. The importance of the whānau to patient recovery is well recognised12. While some new hospitals now include visitor lounges/rooms to accommodate larger family groups, these are not available in all hospitals, however they should be prioritised.
Open all hours?
Research has identified the impact on patient outcomes when family members are present, including benefits such as a reduction in patient falls6. In one of the few randomised trials comparing restricted with unrestricted visiting in an intensive care unit13, researchers identified positive outcomes for patients when visiting was unrestricted including reduced anxiety scores, lower levels of stress hormones, reduced cardiovascular complications, and no increase in sepsis. The National Health Service Scotland has produced a short film celebrating the many positive effects resulting from their implementation of person-centred visiting14. This includes family support when staff are busy, staff gaining an increased understanding of the patient’s background, and improved safety and effectiveness of care. They note that when visitors are not constrained to specific short periods of visiting, they are much more likely to leave when the patient is tired, knowing they can come back again later. In many overseas countries, families are expected to be present 24 hours a day to provide all of the personal cares that a patient requires. In New Zealand’s professionalised health care system, the roles of families in providing care have changed, but staff then frequently report they are unable to provide such care because they are too busy15. There are opportunities for enhancing nursing roles when families who are able are supported to take responsibility for activities such as
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ensuring the patient is assisted at meal times. However, ongoing communication between the staff, patients and family members about caregiving roles is crucial for safe care16. In organisations where open visiting is supported, additional responsibilities have been identified for nurses, including transitioning from patientcentred to family-centred care and caring for family members16. With person-centred visiting, there are few, if any, restrictions on the hours during which visitors may be present. However there are guidelines to maintain a safe environment and a core component is the need for communication between all parties. Ensuring the safety of visitors during emergency situations must also be considered. The evidence from institutions that have moved to this system is that it has been positive for patients, families and staff14,17,18,19 although a formal change management process is essential for success. Clear guidelines are necessary to
About the authors: Lesley Batten RN PhD Works for Research Centre for Māori Health & Development, Massey University, Palmerston North. Marian Bland RN PhD Quality coordinator, Ranfurly Residential Care Centre, Feilding & health care auditor.
This article was peer reviewed by: Denise Wilson RN BA MA (hons) PhD Professor of Māori Health Research & director of Taupua Waiora Centre for Māori Health Research, Auckland University of Technology. Sue Wood RN MNS Quality & patient safety director, Canterbury District Health Board.
REFERENCES 1. Personal anecdotes freely shared with the authors about visiting in New Zealand hospitals when people heard they were developing this article. 2. ISMAIL S & MULLEY, G (2007). Visiting times. British Medical Journal 335 1316. 3. TWENTYMAN, M (2010). ‘Chaotic’ hospital targets visiting times. Waikato Times 28 August, A9. 4. Nurses fear for safety. Hawke’s Bay Today, 13 December 2014, A017.
ensure patient, visitor and staff safety. These may include: »» Patients and families nominating who is to have unlimited access »» Guidance about supporting patient recovery through rest periods »» Acceptance by families that staff may require them to leave temporarily when treatments are being undertaken »» Emergency management plans also include strategies to support family/visitors present at the time of an emergency »» Appropriate security arrangements, especially after hours, when there are fewer staff present »» Adequate space for visitors to avoid disturbing other patients »» Consistent communication with patients and families via information from staff, appropriate signage, and information booklets.
Conclusion
Restricting visiting hours limits the opportunity for working in partnership with patients and their family or whānau. Reconsideration of what constitutes visiting, and who visitors are, is long overdue. One perspective worthy of further consideration is the notion that it is hospital staff who are visitors in the patients’ lives, rather than their families being visitors in the life of the hospital6. Changes in attitudes, policy and practice, and most importantly, communication, are required to ensure that the visiting experience is a positive one for the patient, their family/whānau and all members of the health care team.
NursingReview
Related competencies and standards NCNZ Competencies for Registered Nurses (2007)20 Competency 1.2 Demonstrates the ability to
apply the principles of the Treaty of Waitangi Te Tiriti o Waitangi to nursing practice. Competency 1.4 Promotes an environment that enables health consumer safety, independence, quality of life, and health. Competency 1.5 Practises nursing in a manner that the health consumer determines as being culturally safe. Competency 3.2 Practises nursing in a negotiated partnership with the health consumer where and when possible. Competency 4.2 Recognises and values the roles and skills of all members of the health care team in the delivery of care.
Health and Disability Sector (Core) Standards 200821 Standard 1.12 Consumers are able to maintain links with their family/whānau and their community. Criteria 1.12.1 Consumers have access to visitors of their choice.
Guidance: Consumers have access to visitors of their choice (including children) when the safety of the consumer and others is not compromised. The safety of consumers in the presence of visitors needs to be assured. This may include, but is not limited to: a) Clinical stability of consumer b) Legal status of consumer c) Safety in relation to room size and/or other consumers in a shared room d) Appropriate behaviour of visitors – such as behaviours that impinge on the safety of the consumer, other consumers, and/or service providers.
Recommended resources
The American Joint Commission on Healthcare website has resources on effective communication and cultural competence related to family-centred care. www.jointcommission.org/Advancing_Effective_Communication Better Together: Partnering with Families is an initiative of the American Institute for Patient and Family-Centred Care. www.ipfcc.org/advance/topics/better-together-partnering.html White Coat, Black Arts is a Canadian radio programme discussing various aspects of visiting hours, the restrictions imposed when patients are in shared rooms, and the consequences for the family of a terminally ill patient. www.cbc.ca/radio/whitecoat/the-end-of-visiting-hours-1.2801166 Health Safety and Quality Commission New Zealand outlines a number of strategies for getting feedback from health consumers about services. www.hqsc.govt.nz/our-programmes/consumer-engagement/work-streams/ consumer-engagement/capturing-the-consumer-experience 8. CASSIE, F (2012). Patients as best teachers. Nursing Review 12(9), 26. 9. NEW ZEALAND HEALTH QUALITY & SAFETY COMMISSION (2015). Patient experience results. Retrieved February 2015 from www.hqsc.govt.nz/assets/ Health-Quality-Evaluation/NEMR/patient-experience-survey-results-Feb-2015. pdf 10. CLISSETT, P, POROCK, D, et al. (2013). Experiences of family carers of older people with mental health problems in the acute general hospital: a qualitative study. Journal of Advanced Nursing 69(12) 2707-2716. 11. TRUELAND, J (2014). A flexible approach in Scottish hospitals is making visitors feel welcome on the wards. Nursing Management 21(2) 8-9.
5. CIOFFI, J (2006). Culturally diverse family members and their hospitalised relatives in acute care wards: a qualitative study. Australian Journal of Advanced Nursing 24(1) 15-20.
12. WILSON, C, & BAKER, M (2012). Indigenous hospital experiences: A New Zealand case study. Qualitative Health Research 22(8) 1073-1082.
6. BETTER TOGETHER: PARTNERING WITH FAMILIES (undated). Facts and figures about family presence and participation. www.ipfcc.org/advance/topics/Better-Together-Facts-and-Figures.pdf
13. FUMAGALLI, S, BONCINELLI, L, et al. (2006). Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit. Circulation 113 946-952.
7. BATTEN L, HOLDAWAY M & THE LCP RESEARCH TEAM (2012). Data excerpts from the unpublished study. Culturally appropriate end-of-life care for Māori. Palmerston North: Research Centre for Māori Health and Development, Massey University.
14. NATIONAL HEALTH SERVICE SCOTLAND (2014). Person-centred visiting in NHS Scotland. FILM. Retrieved February 2015 from www.qihub.scot.nhs.uk/video-hub/-person-centred-visiting-in-nhsscotland. aspx
15. CARVILLE, O (2014). Overworked nurses ration patient care. The Press, 27 May, Retrieved February 2015 from www.stuff.co.nz/the-press/news/10079520/ Overworked-nurses-ration-patient-care 16. RICCIONI, L, AJMONE-CAT, C et al. (2014). New roles for healthcare workers in the open ICU. Trends in Anaesthesia and Critical Care 4 182-185. 17. SHULKIN D, O’KEEFE, T et al. (2013). Eliminating visiting hour restrictions in hospitals. Journal for Healthcare Quality 36(6) 54-57. 18. NUSS, T, KELLY, K et al (2014). The impact of opening visitation access on patient and family experience. The Journal of Nursing Administration 44(7/8) 403-410. 19. INSTITUTE FOR PATIENT AND FAMILY CENTRED CARE (2015). IPFCC challenges hospitals to eliminate restrictive visiting policies. Retrieved February 2015 from www. ipfcc.org/advance/topics/better-together.html 20. NURSING COUNCIL OF NEW ZEALAND (2007). Competencies for registered nurses. Retrieved February 2015 from www.nursingcouncil.org.nz/Publications/ Standards-and-guidelines-for-nurses 21. STANDARDS NEW ZEALAND (2008). Health and Disability Sector Standards (Core) Standards. Retrieved February 2015 from www.health.govt.nz/system/files/documents/pages/81340-2008-nzs-health-anddisability-services-general.pdf
Date:..................................................................................................... Name:.................................................................................................... Nursing Council ID: ........................................................................ Designation: ..................................................................................... Workplace: .......................................................................................
RRR LEARNING ACTIVITY:
A professional development activity proudly brought to you by Nursing Review
Reading the article and undertaking this hospital visiting learning activity is equivalent to 60 minutes of professional development. Discuss all your answers with a peer/s A: Reading (watching) 1
Watch the NHS Scotland video that outlines experiences with implementing person-centred visiting. www.qihub.scot.nhs.uk/video-hub/-person-centred-visiting-in-nhsscotland.aspx
2
Identify what you consider are the five most important benefits NHS Scotland reports from implementing this system.
B: Reflection 1
Reflect on five barriers that would need to be overcome in your work area if person-centred visiting were to be implemented. Develop five strategies to overcome the barriers
2
Open the ‘Changing the concept – from families as visitors to families as partners’ website. www.ipfcc.org/advance/topics/better-togetherpartnering.html
3
Read the pocket guide for staff, and the pocket guide for families. Reflect on how many of those guidelines are currently in place now in your workplace.
4
Reflect on the benefits and disadvantages of including families and significant others as members of the health care team in your clinical area.
C: Reality 1
1. Undertake some informal research (simple observations, informal conversations with staff, patients, families) in relation to the following: Are the current visiting policies for your ward/unit/facility consistently applied? Always Often Sometimes Never
2
If Always, why do you think this is the case?
3
If Often, Sometimes or Never, why do the inconsistencies occur?
4
How clearly is the visiting policy communicated to patients, visitors and new staff? Ask a few visitors and new staff what they know about the policy.
5
Discuss with two colleagues the strategies they use when visitors are disrupting other patients, or when constant visitors are overwhelming a patient. Reflect on whether you think those strategies were appropriate, and determine which strategies you will personally use in similar situations in the future.
Verification by a colleague of your completion of this activity:
(Signature)
Colleague Name:.............................................
Designation: ....................................................
date: ...................................................................
Nursing Council ID: .......................................
Work address: ................................................
contact #: ........................................................
Nursing Review series
FOCUS n International Nurses Day Marquette survivor Edith (Poppy) Popplewell at the Walton-on-Thames military hospital. (Photo courtesy of Sherayl McNabb.)
Tragedy on the
Marquette
Intro ???????
In October 1915 the theninfant New Zealand Army Nursing Service suffered its greatest ever disaster, then or since. A torpedo struck the transport ship SS Marquette, leading to the death of 10 nurses and to great feats of bravery and tenacity by the 26 surviving nurses. FIONA CASSIE draws on nursing histories to recreate the tragic tale.
“Perhaps it was the worst of nurses’ experiences, not only because of the terrible loss of life in proportion to numbers, but because of the long, drawn-out suffering of those many hours in the water – hours during which strong men succumbed or became raving mad.” (Chief nurse Hester Maclean writing in 1923 of the wreck of the Marquette)
I
t was a cool morning as the troop carrier Marquette steamed into the Gulf of Salonika on 23 October 2015. The ship had left Port Said, Egypt, a few days earlier with 600 British troops, more than 500 mules, tons of ammunition and the 130-plus members of the No. 1 New Zealand Stationary Hospital on board. The Marquette was expected to dock in its destination, the city of Salonika on Greece’s Aegean coast, by midday after a sunny and calm crossing of the Mediterranean that not even rumours of lifeboat drills, German U-boats, or the Balkan war zone awaiting them could mar. Around 9am that morning, nurses Mary Grigor and Jeannie Sinclair were walking briskly along the deck with hospital colleague Captain Isaacs. Most of the 36 nursing sisters were below deck – including Fanny Abbott with her stockings
off, having a morning wash in her slippers – when the trio saw a “green line” whizzing through the sea. They wondered aloud whether it was a torpedo just before it struck the Marquette’s starboard, close to the bow. The ship quickly dipped in the bow and started to list heavily to port. What happened in the next few minutes (some say it took just seven and others up to 15 minutes for the Marquette to sink) is not without controversy. Some contemporary media reports were later criticised by surviving nurses for exaggerating their bravery and condemned by some army officers for calling into question their gallantry (see controversy box ).
”Bungled” boat lowerings
By all accounts, at first the lifeboat drills held people in good stead, with the nurses donning their life belts
and dividing into two groups with 18 stoically waiting at the port lifeboat station and 18 at the starboard for the boats to be lowered. “Everyone was so calm and although men and girls alike were as white as sheets no-one cried or spoke even, except to give orders,” recalled survivor Edith (Poppy) Popplewell. But then things started to go terribly awry, as reported by Major Wylie of the New Zealand Medical Corp in his official statement. “Owing, however, to the unfortunate bungling of the lowering of these boats, a series of catastrophes occurred on each side of the vessel.” On the port side, one boatload of nurses was successfully lowered but “bungling” and the list of the ship saw the second boat swing and fall on the first, killing some of the nurses outright and severely injuring others.
Portrait funded by the people of Lyttelton of 28-year-old Marquette victim Nona Hildyard. (Image courtesy of Friends of the Chapel.)
Jeannie Sinclair was on the damaged first boat and was pulled onto the “hopelessly overloaded” second boat, but with the Marquette listing ominously she decided – though a poor swimmer – to risk returning to the water and swimming for shore. She asked a swimming crew member to tow her, which he did. “It was awful going past the ship and seeing a large, gaping hole and all the mules there, and wondering if the vessel would fall on top of us and I would be killed.” Nursing Review series 2015
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FOCUS n International Nurses Day
Fanny Abbott, in her slippers, was on the second boat that crashed onto the first and her response was to spring into the water. “I always thought I could not swim, but somehow or other I got away from the ship, although the suction of the ship was so great I thought the propeller would hit me.” On the starboard side, the first lifeboat tipped during launching, spilling many into the sea. Those who clung on had to eventually abandon the boat because of the huge hole in its side.
One of those was Mary Grigor, whose right arm had been crushed between the boat and ship and who then joined others ducking for their lives as the ship sank “with a fearful noise”. Just as the ship was on the brink of sinking, four nurses were still on the Marquette’s deck (see controversy box ). One of those four, Mabel Wright, watched Marion Brown and Isabel Clark walk a few feet down the gangway, take hold of each other’s hands and jump into the water. Neither survived. Wright
and Ina Coster had been helping two sick orderlies onto the gangway and missed their own chance of getting off the sinking Marquette. They were sucked down with the ship but surfaced and both were rescued – Wright was found later to have a fracture to the base of her skull.
Bravery and self-sacrifice
By all accounts the scene was one of hellish chaos over several hours as the exhausted, injured and chilled nurses – along with hundreds of British soldiers, crew, orderlies
and medics – swam and clung to makeshift rafts, boards, lifebuoys and the few waterlogged lifeboats that were already crammed and prone to ‘turning turtle’. There are tales of self-sacrifice by crew, soldiers, orderlies, officers and nurses alike to save nurses, who were hampered by their long skirts, alongside tough calls not to take any more survivors onto already overloaded rafts or boats. Nona Hildyard, one of those injured by the falling boat, sang “It’s a Long Way to Tipperary” and other
Nurses Memorial Chapel
to be saved post-quakes The Nurses Memorial Chapel, commemorating those lost on the Marquette, has been closed to Intro ??????? the public since the Canterbury earthquakes. But restoration plans are being drawn up and a fundraising campaign is to be launched later this year for the estimated $1 million needed to reopen this unique memorial to nurses and women lost in war. The 1915 Marquette tragedy hit South Island communities particularly hard – nine of the 10 nurses lost were from the south and three of those were from Christchurch. A collection began for a chapel at a memorial service for the victims at St Michael and All Angels church in November 1915, but the idea lay dormant until revived by matron Rose Muir in 1924. The arts and crafts-style brick chapel, largely financed by public donations but on the Christchurch Hospital site, was opened in 1927. The chapel is a memorial not only to the three Christchurch nurses lost on the Marquette but also to the two nurses who died while working during the 1918 influenza epidemic. The interdenominational chapel became an integral part of hospital life for trainee nurses, patients and relatives. It was the first hospital chapel in the country and is believed to be the only chapel in the world specially built to commemorate nurses lost in the ‘Great War’. It is the only chapel in New Zealand dedicated to remembering women who died in any war. Ray Wootton, a former nurse and Friends of the Chapel president, says nurses dominate the committee and chapel volunteers who formerly kept the chapel open to the public, regularly did the flowers and raised funds by using the chapel as a popular wedding venue. But all this came to a halt after the earthquake of 22 February 2011 and the chapel has only been entered since under engineering supervision to retrieve special chapel furniture, artefacts and records now in storage at the Air Force Museum at Wigram. David Morrell, the former Christchurch City Missioner, chairs the chapel trust and says the
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Nursing Review series 2015
Ray Wootton (left), president of the Friends of the Chapel committee, with fellow committee member Nanette Ainge outside the quakedamaged Christchurch Nurses Memorial Chapel.
chapel is undoubtedly of national significance to the nursing profession in the first instance but also to the Royal New Zealand Nursing Corp which, like the Marquette disaster, is also having its centenary this year. “I think it’s a very significant building and think it is very important to nursing that it’s restored, and restored to an excellent state. And the trust is certainly committed to that.” Wootton says the Friends of the Chapel committee meanwhile continues to sell cards of the chapel’s beautiful, nurse-inspired stained glass windows, and is very involved in organising special events to mark the centenary of the Marquette tragedy in late October. A special memorial church service is to be held at St Michael and All Angels – where the first memorial service was held one hundred years
ago – and a special Marquette exhibition sharing the stories of the nurses lost and the survivors is also to be mounted. “We are hoping to have descendants of the nurses who lost their lives and the survivors attend the service,” says Wootton. Meanwhile in May 2009 a Greek dive team located and identified the wreck of the Marquette. She rests in 87 metres of water off the Thermaikos Gulf (formerly known as the Gulf of Salonika). Friends of the Chapel committee member Nanette Ainge says several Christchurch nurses will join a commemorative cruise in September that will sail in the wake of the ANZAC nursing sisters of 1915–1916; they will lay a wreath on the chapel’s behalf above the wreck where the 10 nurses lost their lives.
FOCUS n International Nurses Day
popular songs of the day to keep spirits up until she suffered heart failure and died. Another nurse, Mary Gorman, whose legs had been crushed during the bungled lifeboat lowering, gave away her lifebelt, knowing she had no chance of survival. Mary Grigor says she swam “sick and sore”, nursing her crushed arm, until a crew member came alongside with a board, to which she clung for some time. She and her rescuer made their way to a submerged boat that continually ‘turned turtle’. “My rescuer died soon after this from cramp or exhaustion,” she wrote later. Mary Rae arrived soon after on the lifebuoy of “one of our New Zealand boys” and asked to come aboard the ‘turtle’. “She held out for a while, but soon after showed signs of exhaustion and died. I wondered if I should be the next,” recalled Grigor. “Men died on all sides. Some lost their reason and went away from us all.” Jeannie Sinclair thanked a London lad called Joseph for saving her life as the??????? pair floated clinging to a Intro makeshift raft of boards and buoys and he supported her to rest as she got tired. Poppy Popplewell described being sucked down as the boat sank as a “fearful experience”, feeling like she had touched the bottom of the sea. After surfacing, she joined her “little chum” Lorna Rattray, a British soldier and later Mary Walker in clinging to a life-saving board. Her friend tragically died sometime in the afternoon – Poppy wrote that the thought that they would be next was the only reason she let her go. The soldier also “went off” and the exhausted remaining pair climbed onto and lay astride the board. The rescue finally came around seven hours after the Marquette went down as finding the wreckage
Image of the troop ship Marquette with names of the New Zealand nurses and medics who lost their lives. (Courtesy of Alexander Turnbull Library: image 000610-G.)
was delayed by a false SOS signal that gave a wrong location. In all, 170 men and women were lost – including the 10 New Zealand nurses, and 22 New Zealand men, nearly all members of the New Zealand Medical Corp. As news of the tragedy spread, a common question being asked was why New Zealand hospital staff – including women – were being carried on a troop ship and not a hospital ship under the protection of Red Cross markings, particularly as a British hospital ship, with spare capacity, had sailed from Alexandria to Salonika just a few days before. While the New Zealand Government chose not to make a diplomatic issue of the disaster, the Governor, Sir Arthur Foljambe, did send a crisp letter to the British War Office requesting: “In view of the loss of Marquette, my Government would be glad if arrangements could be made whereby medical units, such as
stationary hospitals etc. should when possible be transferred by sea in a hospital ship”. Nearly all of the surviving 26 nurses went on to continue serving during the war – including, poignantly, on hospital ships passing over the very waters in which they had lost their companions.
Nona Hildyard commemorated on Lyttelton War Memorial.
SOURCES: »» “New Zealand Army Nurses” by Hester Maclean, Chapter V of The War Effort of New Zealand by Lt H T B Drew. Whitcombe & Tombs (1923) »» While You’re Away: New Zealand Nurses at War 1899-1948 by Anna Rogers. Auckland University Press (2003) »» New Zealand Military Nursing: A history of the Royal New Zealand Nursing Corps Boer War to Present Day by Sherayl Kendall & David Corbett. Kendall & Corbett (1990) »» ANZAC Girls: The extraordinary story of our World War 1 nurses by Peter Rees. (NB First published as The Other Anzacs in 2008) Allen & Unwin (2014) More information on the chapel and about cards and donations can be found at Friends of Christchurch Nurses Memorial Chapel www.cnmc.org.nz
Nursing news at your fingertips! If you want to know what your colleagues are thinking and doing, join Nursing Review’s FREE email newsfeed. Nursing Review has New Zealand nursing covered: »» Latest news in print and online. »» Opinion from every corner of the sector. »» In-depth features on nursing trends, workforce issues, clinical matters, and more!
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Is safe staffing for nurses closer?
A major evaluation report says yes It is more than a decade since the nursing union NZNO put aside its claim for improved nurse-to-patient ratios and agreed to look for a less clumsy and more sophisticated method to meet nurses’ concerns that wards weren’t staffed safely. The result has been a suite of homegrown tools – known collectively as the Care Capacity Demand Management (CCDM) programme – that has just been given a firm thumbs-up by a major independent evaluation report. FIONA CASSIE looks at the report, which also includes a warning that nurses may Intro ??????? become sceptical if the CCDM programme is not appropriately resourced and backed. “It is important that nurses, midwives and DHB management realise that this is a long-term process.” These words in the foreword to the 2006 Safe Staffing/Healthy Workplaces Committee of Inquiry report by chair Diana Crossan Julie Robinson have proven somewhat prophetic. It is a decade on since the joint union and DHB inquiry committee went out to listen to the concerns of stressed nurses and anxious employers about ensuring safe staffing levels in the country’s public hospitals. As a result it Hillary Graham-Smith recommended setting up the Safe Staffing Healthy Workplaces (SSHW) Unit and, amongst a raft of other recommendations, for the unit to develop and roll out a toolkit of best practice safe staffing tools across the DHBs. In 2009 the unit began testing and evolving the toolkit, now known as the Care Capacity Chris Hendry Demand Management (CCDM) programme, with the core tools really only finalised in 2012/2013. And to date only one hospital – Tauranga in the Bay of Plenty, where 22
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many of the more high-profile tools were created and honed – is close to completing implementation of the programme across all its acute care wards. Another 10 DHBs have implementation up and running at various levels, and four more are at the very early stages. Others are not even off the block.
Worth the wait
It is probably not surprising then, that upping the implementation momentum is fairly high on nurses’ priorities in the latest NZNO and DHB contract negotiations. It is also fortunate that the final evaluation report on CCDM, released earlier this year, concludes the programme is worth the wait and recommends that all DHBs implement it (see sidebar for summary of evaluation findings and recommendations). “This programme provides a safe level playing field for frontline hospital staff in the drive to provide efficient and effective health services,” says the executive summary of the evaluation report by the New Zealand Institute of Community Health Care. CCDM aims to ensure a ward has the right staff at the right time to safely meet patient demand by analysing historic and robust patient acuity data gathered by TrendCare. Developed by an Australian nurse leader, TrendCare is patient acuity and workload management software that is an essential component of CCDM. The evaluation shows that once the ward workload and staffing analysis component of CCDM is done, evidence that the skill mix, rosters and model of care need to change to better meet patient demand consistently emerges. The suite of CCDM tools also includes systems for responding to unexpected demand – be it in orthopaedic ward or emergency department – with the busy ward in need made visible through
Capacity at a Glance (also known as Hospital at a Glance) screens spread across a hospital campus, often including the staff café.
Can’t just ‘pick and mix’
Twelve tools make up the CCDM programme and the evaluation report’s lead author, nurse and midwife Dr Chris Hendry is clear that all 12 are necessary to ensure safe staffing. She says as part of the evaluation, the team went through each tool and process to see whether the programme could be stripped back to a bare minimum of tools. “But to be honest every single bit is a very important part of the whole.” Julie Robinson, director of nursing at pioneering Bay of Plenty DHB, which developed the first Hospital/Capacity at a Glance screen, says there can be a tendency for some DHBs to just “take the toys” like the “nice screens”. “But you can’t just pick one bit and hope that it will be successful,” she says. Hilary Graham-Smith, NZNO’s associate professional services manager and representative on the SSHW Unit’s governance group, agrees that DHBs can’t just take a ‘pick and mix’ approach to the CCDM programme and endorses Hendry’s finding that the complete programme needs to be implemented in a systematic way. Robinson says she is a firm advocate for CCDM amongst her DHB colleagues but always reinforces that it’s not a quick fix. “It’s a whole of system change,” notes Robinson. And taking a whole of system approach to staffing, the model of care, patient flow and variance response management is “incredibly challenging”. She says these changes don’t happen overnight, emphasising that it not only takes time but also a good partnership with NZNO and a commitment to being open and transparent.
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”That’s what I think is the beauty of this programme – it allows decisionmaking and management between services, rather than being a centralised system.” Openness and transparency required
Transparency includes not being afraid to discern whether there is a mismatch between a ward’s workload and its current staffing. And not being afraid to share the result – whether it is ‘too few’, ‘too many’, the ‘wrong’ skill mix or ‘just right’ – with the staff involved. “Nurses know what is going on – there’s no point in hiding data,” says Robinson. “Because fundamentally they are the ones there every day; they know what it’s like and they know what’s going on.” Intro ??????? The evaluation report notes that boards risk nurses becoming sceptical if the whole CCDM programme is not maintained and monitored or there is an inadequate response to meeting patient demand. It also notes that some boards appear fearful or reluctant to carry out ward-by-ward
workload analysis in case ‘costly’ understaffing emerges. “I think some people are a bit concerned what it might show-up, but in actual fact you may find you are using that FTE (fulltime equivalent staffing) anyway,” predicts Robinson. Robinson, who is also the DHB directors of nursing representative on the SSHW Unit’s governance group, says Bay of Plenty DHB has now carried out the workload analysis and
FTE calculation in all bar one of Tauranga Hospital’s acute inpatient wards. The workload analysis showed that the base staff for the orthopaedic ward needed to be boosted – but its use of TrendCare acuity data meant it had already been plugging the workload gap with casual staff. So creating permanent nursing positions for the ward was virtually cost neutral over the year because the casual pool costs went down.
Findings of the CCDM Evaluation Report »» The CCDM programme provides a safe level playing field for front line hospital staff wanting to provide efficient and effective health services. »» The full CCDM programme is the first step in a nationally consistent, fair and valid process to review and realign the nursing and midwifery workforce in hospitals to more truly reflect patient acuity on the day. »» CCDM provides a nationally standardised and professionally agreed set of tools to monitor and respond safely and immediately to unexpected changes in variance between workforce availability and patient demand (acuity). »» While CCDM provides an ideal suite of tools and activities to meet the safe staffing outcomes called for by nurses a decade ago, the patchy implementation of the programme in DHBs to date has made the results difficult to quantify. »» The staffing diagnostic tools used to analyse workload and FTE staffing on a ward have the potential to identify under-resourcing of staff at ward level, which some DHBs feared would be costly and this has been put forward as a reason for the slower uptake of the base staffing calculation in particular.
»» The few budgetary findings to date indicate that CCDM is relatively cost neutral as the reduction in the use of casual staff, the increase in flexibility of existing staff, combined with roster re-engineering and changes in skill mix, balanced out any increases in nursing FTE required. »» As at September 2014, only 51 of the 85 potential wards had undergone a workload analysis and only 19 had implemented recommended changes. In almost every case evidence emerged that the skill mix, rosters and model of care needed to change to better meet patient demand. »» If the ward/hospital/DHB does not continue to maintain the CCDM programme, monitor its performance and respond appropriately to the patient care demand on the day and over time it runs the risk of being viewed by nurses with scepticism.
Summary of the CCDM Evaluation Report* main recommendations
»» All DHBs should implement the Care Capacity Demand Management (CCDM) programme. »» The focus should firstly be on completing the rollout for all nurses and midwives in hospital wards in the current participating DHBs.
»» DHB chief executives should make the SSHW Unit a permanent structure and ensure it was appropriately resourced to facilitate and assist the rollout of CCDM. »» The Ministry of Health and DHB chief executives should negotiate and manage a national licence with the current validated patient acuity tool provider i.e. TrendCare. »» The SSHW Unit should focus on refining and streamlining the CCDM tools to make the implementation process more effective, more efficient, and simpler to describe. »» DHBs and unions should provide change management training for staff prior to CCDM implementation, as in order to effectively implement CCDM, nurse managers require “a significant level of leadership and managements skills”. *The report, An evaluation of the implementation, outcomes and opportunities of the Care Capacity Demand Management (CCDM) programme, and its recommendations are yet to be fully discussed or endorsed by the SSHW Unit governance group or the other stakeholders, including DHB chief executives. An action plan is to be decided on shortly. The full report is available on the website of the Health Improvement and Innovation Resource Centre www.hiirc.org.nz
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Likewise, when the analysis found too many FTE in its AT&R (Assessment, Treatment and Rehabilitation) ward it shifted some of that nursing resource to the two surgical wards shown to be in need of more nursing power. Graham-Smith believes a vital ingredient for this re-engineering of rosters or base staffing is that it is based on patient acuity data from a validated acuity-measuring tool. “Nurses nurse patients, not beds – identifying your staffing resource based on just how many beds are full is not going to cut it.”
Momentum needed to keep nurse buy-in
But to get this accurate data on patient need, their nurses need to build time into every shift for entering patient data into the electronic TrendCare tool. TrendCare pre-dates CCDM and a 2013 NZNO survey showed that nurses were somewhat sceptical about whether TrendCare alone was making a positive impact on their workload. There has also been some confusion between the wider suite of CCDM tools (using TrendCare data) and TrendCare as a standalone tool. Graham-Smith says entering TrendCare data can appear to be adding another “onerous” task in an already “fraught environment” but it does not take a huge amount of time, and nurses will embrace it if they can see it making a difference. Intro ??????? “That’s the critical thing – nurses have to see the results. They have to see that doing this additional step actually works for them.” Hendry agrees: “If you start measuring things then people get excited but if nothing is happening to the measurements then people just lose interest and then the measurements aren’t as reliable.” Graham-Smith adds that nurses understand that DHBs are fiscally stretched. “But more often or not they bear the brunt of it and their patients suffer as well. And that’s not a tenable situation for nurses – they don’t like having their safety and their practice compromised like that.” So even if their ward’s workload and base staffing analysis doesn’t lead to immediate change, the nurses need to be able to see and discuss the results and to also know that a concrete plan of action is underway to remedy any shortfall. Hendry also points out that one very visible way of showing TrendCare measurements in action every day is by using the Capacity/Hospital at a Glance screens that show the ‘busy-ness’ of every ward and unit across a hospital. “And if you don’t have something like that simple screen up, then you wouldn’t have a nurse in the café glance up at the screen and see that ‘x’ ward is desperate and busy and her ward is not so busy. She then goes back to her charge nurse and says ‘I think we can give some nursing time to that ward’. “That’s what I think is the beauty of this programme – it allows decision-making and management between services, rather than being a centralised system,” says Hendry. Robinson says the screens and other variance response tools play a vital role in showing up unexpected bottlenecks in patient flow on any given day on a ward-by-ward basis. Early on, Bay of Plenty realised that if a medical ward, for example, was super busy first thing in the morning then ED was often quiet at that time and transferring some ED staff to the ward for just two hours could help clear the bottleneck and smooth the workload before ED demand built up. 24
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Safe Staffing timeline 2003–2004 NZNO Fair Pay campaign for DHB nurses raises idea of piloting nurse- to-patient ratios as answer to concerns about unsafe staffing. 2005 Nurse-to-patient ratios dropped when national DHB pay jolt settlement made. Safe Staffing Healthy Workplaces (SSHW) committee of inquiry begins instead under independent chair Diana Crossan. 2006 SSHW report released along with action plan. 2007 SSHW Unit created. 2009 Bay of Plenty, West Coast and Counties Manukau DHBs are demonstration sites for SSHW Unit’s still-evolving care capacity demand management (CCDM) tools. 2015 CCDM final evaluation report released (based on 11 DHBs). SSHW Unit now actively working with 14 DHBs in various stages of implementing CCDM, with the latest to join being Auckland and Hawke’s Bay and the 15th (Capital & Coast) due to start next year. NZNO seeking more action from DHBs in implementing CCDM as part of current pay negotiations
But Robinson says such staff shifts – and the handy “smart five” cards setting out jobs that can easily be delegated and quickly done by a ‘borrowed’ nurse – are probably used less now. “Because the more you get your base roster right, the less you should have to – in the main – move people.”
Hendry believes there needs to be strong support and change management capability amongst charge nurse managers and the evaluation report recommends that DHBs and unions step up and provide training to help them meet this challenge.
Change management
The evaluation report says the challenge is worth it, as the potential outcome of having the right person with the right patient at the right time is good for both patients and nurses “I know there are people around the country who think it’s just about the union wanting to grab more of the pie – but it’s nothing like that, not remotely,” says Graham-Smith. “Our agenda is exactly the same as the Safe Staffing HW Unit – and the people on the governance group – we want to see staff being able to work safely to deliver all of the care a patient needs on a given shift and not having to ration care, which is what occurs when you are not adequately resourced. “Definitely we would like to see improvement in the pace and scale, but at the same time we have to acknowledge it’s a massive change programme and it is quite complex. “And it is very much dependent on commitment at the top level of DHB leadership and for them to take the nurses along with them on that journey.”
Getting to a point in time where safe staffing mechanisms are embedded in the system and unsafe staffing is the exception and never the rule, is where everybody wants to be. But it is not always an easy task. The evaluation report acknowledges that the actual human and IT resources required to implement and establish CCDM were underestimated and this was exacerbated by the programme still evolving as it was being introduced. Hendry believes how the programme was presented – with gimmicky names that didn’t call a ‘spade a spade’ and the lack of a simple one-page summary for busy people at the ‘coalface’ – also didn’t help sell the programme. “I don’t think the potential had been fully understood.” So hospitals, wards or units that are ‘early adopters’ and good at rolling things out have progressed, while others have floundered. “It’s probably become a bit stuck in areas where they are more resistant to embracing a new way of doing things,” says Hendry. “Because basically CCDM questions the model of nursing care. There’s more of a move to a teambased nursing care provision.” Hendry says it also questions the skill-mix. “It actually asks if there should be more in the skill-mix. And if so, when, where and what sort of other skill do you need to add to the mix?” That might mean health care assistants, extra clerical staff cover, or changes to cleaning staff and orderly rosters. CCDM also questions roster lengths and staffing numbers and asks whether the right staff are in place at the right times; if there are enough staff, or too many. “These are big things for charge nurse managers to have to manage,” says Hendry.
Top-level commitment needed
A no-brainer?
“I can’t understand why you wouldn’t want to do it!” is the view of Julie Robinson, a convert to the difference that the Care Capacity Demand Management system can make. To her it is simple – it’s an evidence-based method, staff feel listened to and valued and, at the end of the day, patients get better care. Now it is just a matter of convincing all parties – from the Ministry, Minister and DHB executive to the nurse on the ward floor – that the evaluation report has it right, and after a decade of waiting it is time to step up the resources and commitment to ensuring safe staffing becomes an embedded reality.
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Gidday my name is…
Not forgetting the ‘niceties’ Patients shared stories across the Auckland isthmus last month during the inaugural region-wide Patient Experience Week. LYNNE MAHER tells FIONA CASSIE why nurses and other health professionals need timely reminders that patients seek courtesy, communication and compassion as part of good clinical care.
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t is sometimes the simplest things that get left out in the hustle and bustle of a health professional’s busy shift; things like not introducing themselves to the patient or not acknowledging their son, aunt or friend sitting at the bedside. “No health professional comes to work not meaning to do a good job,” says Dr Lynne Maher, nurse and director of innovation at Counties Manukau DHB’s Ko Awatea Centre. Intro ??????? “But sometimes our focus gets diverted with the busy-ness of the job.” And she says usually when that happens it is the ‘niceties’ that can fall by the wayside. It’s good communication – including introducing oneself – that Maher says patients and family members surveyed, both nationally and worldwide, consistently rank as the most important factor contributing to the quality of their patient experience – higher even than compassion and dignity. “I think communication has a particularly strong link (with all the other factors) including compassion and dignity,” says Maher. “Because if I’m a patient or family member and I feel that you are taking time to communicate well with me – so I understand what is happening and have time to ask questions and think about it – then I really feel I’m being treated like a whole person.”
Communication a focus
Ko Awatea, the South Auckland-based centre for health system innovation and improvement, hosted the first Patient Experience Week at Counties Manukau in 2013. This year the focus week was repeated and broadened, with all three DHBs in the region taking part. The Health Quality & Safety Commission’s national patient surveys, which commenced last year, indicate that the vast majority of patients are happy with their experience, including communication. The surveys, now carried out regularly, show DHBs scoring highly across all four indicators: communication, partnership, physical and emotional needs, and coordination. But Maher says that while communication is predominantly good, it’s when it’s not so good that patient experiences can go awry. “They don’t feel that they are cared about as much, they don’t feel they are respected, and they are nervous because they don’t know what is happening – and those are the typical feelings of patients and family members.
“What we’re trying to do with nurses and other staff is to help them to really focus on the person’s experience,” says Maher. It is a matter of reassuring clinicians, she says, that “it doesn’t take hours out of their day” to take the time to introduce themselves properly to patients and their family members. “And when taking a pulse or blood pressure, using that opportunity to talk about discharge and answer questions a patient might have, rather than whizzing in and whizzing out again.” Introducing oneself well is a popular issue at present, with the UK’s “Hello, my name is…” movement; Waitemata’s recent “3Ms” programme; and Counties Manukau’s use since 2012 of an “AIDET” approach(see sidebar).
We can’t choose what’s thrown at us but we can absolutely, with help, choose how we respond to that situation.” Walking in a patient’s shoes
But ensuring a good patient experience extends further than just introductions –and the Patient Experience Week events across the region showcased some of these other issues. All three DHBs invited patients to come in and share their stories, either in person over lunchtime or teatime sessions or through photos, videos and storyboards. Waitemata DHB organised a “Have your say” live video booth in the hospital’s foyer and Auckland DHB arranged “Share it” stations for people to share their experiences of DHB services in words or drawings. A session presented at Auckland DHB by Air New Zealand on enhancing the customer experience was video-linked with the two other DHBs, and a regional event, largely organised by
Waitemata DHB, saw young people converge on Counties Manukau DHB for a lively session on the youth mental health consumer experience, featuring the Phoenix Performing Arts group.
Hello, my name is… Terminally ill doctor Kate Granger began the “Hello, my name is ...” campaign in the United Kingdom. It was prompted by a hospital stay in 2013 when many staff looking after her didn’t introduce themselves before delivering care. So she and her husband began a campaignto encourage and remind healthcare staff about the importance of introductions. “It is about making a human connection, beginning a therapeutic relationship and building trust,” says Granger. “In my mind, it is the first rung on the ladder to providing compassionate care.” The campaign is now backed by around 90 National Health Service organisations and the Twitter hashtag #hellomynameis has been used more than 75 million times. Find out more at www.hellomynameis.org.uk or Twitter @GrangerKate
AIDET Another approach to improving clinician communication with patients and families is known by its abbreviation AIDET. The “A” is for acknowledging the people in the room (patient, family members or other visitors; the “I” for introducing themselves to the patient before they outline what they are planning to do. This outline should include how long the procedure should take or that the patient may need to wait for an appointment, test or results (i.e. “D” for duration) and then explain (the “E” of AIDET) what the procedure/ test etc would involve. The final “T” is for thank you.
3Ms “3Ms” is another campaign that aims to get clinicians communicating better with patients as they forge a therapeutic relationship. In the 3Ms case the “M” stands for “My name is…My role is…May I…” Nursing Review series 2015
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Waitemata DHB also held a hands-on “I’m not a tick box” interactive expo for health professionals and Counties-Manukau set up an “empathy zone” to give staff a taste of what it was like to walk in their patients’ shoes. “It was fantastic to show how difficult it was to get dressed or put jackets on when you’ve got both arms splinted [to simulate what it was like if you had damaged both arms or had arthritis in your wrists or elbows],” says Maher. Wearing special gloves that mimicked the loss of sensation in fingertips that is quite common in diabetics, staff then attempted to thread beads onto cotton. People were also able to experience walking up and down stairs using crutches.
Compassion and mindfulness under pressure
Maher says Waitemata also used the week to showcase some of the findings of 12 staff projects initiated last year on different facets of the patient experience, including seeking patient feedback on the advanced care planning process and working with transgender youth and their families. A further project looked at teaching compassion. Maher acknowledges once again that stretched staff on a busy day may be more focused on
waiting bells and pending tasks than on communication and compassion. She says one response at Counties-Manukau was investing in mindfulness training to help staff to look after themselves and be present in the moment. They could then think about ways to reduce time spent on unnecessary tasks and increase the time spent on things that were going to give them and their patients “higher reward and higher value”. According to Maher, staff constantly comment on the positive feedback they get when things go well. “Then we got the team who did that[mindfulness training],” she says, “to look at another training opportunity around compassion; to really help people ground themselves and understand what we’re here for is to be compassionate and compassion is a really important part of our role.” A pilot of the one-day training in compassion was held during Patient Experience Week and an initial review of the evaluations was very positive. Maher says more training sessions are likely to follow in the programme that aims to raise awareness of compassion, and understanding and
tolerance of people who may not reciprocate that compassion . “It is dead hard out there. We are asking people to do everything at once, so how do we help people to sort that out – and that is what we’re trying to do with these [mindfulness and compassion] training and projects. “We can’t choose what’s thrown at us but we can absolutely, with help, choose how we respond to that situation. I think it’s a really important part of a nursing role to be compassionate – not just for patients but for staff as well.”
Intro ???????
Nursing tales go live
with launch of new website Tales of the days of nursing hostel curfews, starched caps and when “doctors were God” can be heard online with the launch of New Zealand’s first nursing oral history archive.
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nippets of the stories of nearly 60 nurses who trained in the 1950s and 60s are available on a new website that is the culmination of a three-year oral history project by the Nursing Education and Research Foundation (NERF). Dr Jill Clendon, a New Zealand Nurses Organisation researcher, was an advisor to the oral history project and project facilitator for the new website www.nursinghistory. org.nz, which she hopes will become
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a “repository for all things nursing history in New Zealand”. “Our intention is that this is the ‘go to’ site for information about nursing history in New Zealand.” Clendon says that in the past oral history recordings were only archived in the Alexander Turnbull Library and not easily accessible to nursing students, researchers or nurses in general. The new website, designed using open-source software, aims to be an ‘online museum’ for NERF, containing not only interesting ‘click and hear’ snippets of oral histories but also historic photos, documents, mementos, reminiscences and research into New Zealand’s nursing history. In 2012 NERF contracted a University of Auckland project
team – made up of health historian Professor Linda Bryder, nursing academics Associate Professor Margaret Horsburgh and Dr Kate Prebble, and historian Dr Debbie Dunsford – to carry out oral history interviews with a wide range of nurses who trained in the 1950s and 1960s. The resulting almost-60 oral histories feature a wide variety of nurses, from well-known nursing leaders to ‘everyday’ nurses, and includes male, Māori and mental health nurses. While many are retired, a number are still practising today. “I’m pleased that people will be able to listen to fascinating snippets of history, and dip in and out of different nurses’ stories,” says Bryder. “The audio files are the
perfect length to listen to on the train or in the car.” Clendon says the full recordings are held by the Alexander Turnbull Library’s oral history archive, which is also the home of 300-plus other nursing oral histories (185 of them collected by NERF), which include those of nurses who registered before 1920, wartime nurses, nursing nuns and Plunket nurses. The Turnbull is in the process of digitalising its oral history archives, Clendon says, and snippets of these other nursing stories might also be loaded onto the site in the future. Nurses and researchers who think they have material that could be a good addition to the site can contact Jill Clendon (jillc@nzno.org.nz) to discuss further.
”… people will be able to listen to fascinating snippets of history … the audio files are the perfect length to listen to on the train or in the car.”
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Nursing procedures:
a one-stop online shop for half the country Keeping nursing procedures up to date can be a tedious and neverending task. For the past three years, however, the five Midland region DHBs have been using a ‘Kiwified’ online nursing procedure service that is shortly to go live across the South Island. FIONA CASSIE finds out more. It’s not unusual to see new graduate nurses on Waikato Hospital wards pulling out their iPhones to do a quick double-check on IV procedures. That is just one of about 1,200 DHB-endorsed nursing procedures they can tap into online via a service they’ve had access to since they were students at the region’s nursing schools. And if their nursing careers see them shift to a rest home in Waihi,??????? a hospital ward in Tauranga or a Waikato Intro hospice, they can still access the same procedural protocol and service. This is all thanks to a Midlands project led by Waikato DHB, with seed funding from the Ministry of Health, which evaluated and then selected a United States guide, Lippincott’s Nursing Procedures, to be delivered online to the region’s five district health boards. (The Midland region covers the Bay of Plenty, Lakes, Tairawhiti, Taranaki and Waikato DHBs). After reviewing and customising some of the procedures to reflect New Zealand practice, the guide went live online in May 2012 to nurses and midwives at the five DHBs and also to nurses in non-DHB services, from hospices to rest homes. Soon afterwards, the region’s nursing schools came on board. Three years later, an entire cohort of smartphone and tablet-savvy graduates who have been trained using the standardised online procedures platform are now out in the workforce.
One step closer to national standardisation
Cheryl Atherfold, clinical nurse director for professional development at Waikato DHB, says Midlands is now excited that the South Island DHBs, nursing schools, rest homes and community nursing services are also coming on board from 5 May this year with what is now called the Lippincott Procedures New Zealand instance. With 10 out of 20 DHB regions now involved, it is a step closer to the long-term vision of having a nationally agreed platform for nursing procedures. Angela Broring is the Waikato DHB librarian who was part of the initial project team (with project leader Michael Bland, the then-clinical director for Waikato DHB, and John Clayton of Wintec’s Emerging Technology Centre) and she manages the editing of the procedures and systems support. She is very supportive of the New Zealand instance going national and providing streamlined nursing procedures everywhere and for everyone.
That is no easy task, with the five Midland DHBs involved in the pilot each rolling out access to the procedures at their own pace over the past three years and one DHB still only selectively using some of the online procedures.
Significant advantages
But the advantages to having a common online platform for procedures are seen to be multifold both by Atherfold and by Kate Rawlings, a former nurse and programme director of the South Island Regional Training Hub, who facilitated the contract on behalf of the South Island directors of nursing. For one thing, standardisation means patients should be able to move between the community and hospital and receive the same evidence-based clinical procedure. Similarly, staff can transfer between services without having to familiarise themselves with a new procedures regime. Then there is the time saved by having an outside provider do the donkeywork of reviewing procedures. When changes are made, procedure folders across the hospital don’t need to be manually updated – it all just happens online and any procedure can be checked via a desktop computer or mobile app (initially only on Apple products but an app for Android products will be available from June). Rawlings says standardisation of evidence-based procedures across the South Island will increase patient confidence, ensure ‘optimum patient safety’ and save time spent duplicating the updating of procedures across the five DHBs. Atherfold says the main value for Midlands has been that all procedures are constantly under critical review. “And before this there were so many outdated procedures,” adds Broring.
Seismic perception change
The move to the new platform has required a “big shift” in thinking, says Atherfold – switching from a “this is the way we do it around here” mentality to ascertaining best practice for a particular clinical procedure. The provider, Lippincott, regularly reviews its 1,200 procedures against evidence-based research and sends out quarterly updates to the New Zealand instance, making recommendations for any changes. The local review team can then discuss the recommendations and decide whether to ‘switch on’ any changes or add additional notes
Kate Rawlings to the New Zealand procedure or put the recommendations aside as being only relevant to the American context. The DHBs’ directors of nursing make the final sign-off for any changes. Initially, 200 medicines management procedures (including intravenous therapy) of the total 1,200 clinical procedures Cheryl Atherfold provided by Lippincott were customised for the New Zealand environment by the Midlands medicines management team. Some of those 200 customised procedures were required because Lippincott did not initially provide metric measurements but now the procedures have Angela Broring been metricised and have reduced to just 30. “It is an evolving piece of work as we get better at it and trust the mechanisms,” says Atherfold. “So where it aligns [New Zealand and US protocols] we use the Lippincott procedure and if it doesn’t we use the New Zealand procedure,” says Atherfold. But all procedures are accessed through the same New Zealand instance platform. Broring says the other areas where the New Zealand instance continues to supply its own procedures are wound care and infection control, with about 34 New Zealand-developed wound care procedures and around 30 New Zealand infection control procedures up online. These procedures are developed and reviewed by New Zealand nurse experts in the field, which will shortly include those in the South Island. To date intravenous therapy procedures are the most commonly accessed on the platform; they are readily available via a glance at a smartphone at the bedside, a quick check at a nursing station or by printing a copy for handy reference.
Nursing Review series 2015
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College of nurses
Tips for a top nurse portfolio P ortfolios were first introduced to New Zealand nursing in 1988. In the almost three decades since then, the portfolio process has spread, evolved, been refined and now embraces new technologies. Despite this, the thought of starting a portfolio can still put some registered nurses into a tailspin. While portfolios are developed for many reasons, the three main reasons are to: »» Store career, education and practice information. »» Meet the requirements of a random recertification audit by the Nursing Council of New Zealand. »» Meet requirements for a professional development and recognition programme (PDRP). (If you can join one of the country’s 29 PDRP programmes it is advantageous as PDRP is a Nursing Council-approved process)
Options to present The first thing to decide is how you would like to present your portfolio: 1. Hard copy desk file: this is the traditional way and involves collecting and copying items to add into a file or organiser. 2. Electronic portfolios: either simple computer-based files or your organisation’s electronic nursing portfolio programme. 3. ePortfolio: A number of organisations have opted to link with the ePortfolio developed by Ngā Manukura o Āpōpō (www.ngamanukura.co.nz), including the College of Nurses Aotearoa. This is a simple way to store and present your information and the Nursing Council will accept random audits presented this way. Any of these methods can be used for a recertification audit, storing information or even a PDRP; they are simply ways of carrying your evidence (if you are linked to a PDRP, check with your coordinator). A portfolio is a way of presenting evidence of your practice to a standard agreed across New Zealand. Whether you work in a small, independent practice, an aged care facility or a DHB, or whether you are randomly audited or part of a PDRP programme, undertaking a portfolio is an opportunity to take stock, reflect and consider where you are in your career.
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LIZ MANNING shares some simple tips on how to keep your nursing portfolio manageable, succinct, and of a good quality.
HOW-TO GUIDE
Getting started »» Once you have decided (see above) how you are going to present your portfolio: Create or use an existing checklist of items required for your portfolio. »» If it’s a hard copy portfolio, find a folder with plastic sleeves and use sticky notes to label the evidence needed to fill each empty sleeve. »» Keep it simple, professional and tidy.
Collecting evidence »» If you’re unsure how to begin selfassessing against the up to 20 Nursing Council competencies required (depending on the nature of your practice i.e. clinical or education etc), begin with the ones you can fill now, rather than starting with Competency 1.1. »» You need one piece of evidence per competency, so look at the competency indicators to decide what piece of evidence you would insert under that competency. »» Only use things that describe your competency; e.g. if you attend an education session, include verification that you attended (a certificate) and a reflection on what you learned. (NB a flyer advertising the education session is not evidence of competence.) »» A nurse assessor has to assess your work within a given timeframe so only add items that are required, current and relevant. »» The assessor will be looking for objective examples of your practice. »» If someone writes you a reference letter, ask them to link it to the four domains of practice. »» Ask your peer reviewer to include examples of actions or activities from your practice. »» Use normal language. You don’t have to write an academic essay (though you do need to reference if you use someone else’s words or ideas). »» If you are isolated in your role (e.g. not many other nurses around), describe how you engage professionally i.e. where
do you meet other health professionals to share ideas, access education or review cases?
Common pitfalls »» Be aware of privacy issues: never use identifiers of any sort, such as patient names, NHI numbers, addresses or names of any other health professionals. »» Stick to the rule that you won’t use anything that can identify anyone unless you have their written consent. »» Items with privacy implications include emails (also not considered good quality or objective evidence) and thank-you cards (nice to receive but meant only for you). »» Meeting minutes don’t demonstrate competence. If you attend a professional group or meetings, get a verified note from the organiser. »» Watch your use of acronyms: assessors may not know the abbreviations commonly used in your setting.
Before you hand in your portfolio »» Develop a contents page so your assessor can easily find evidence. »» Make sure you have considered every page. »» Show your portfolio to a colleague who can proofread it and check it is complete. You can ‘share’ your ePortfolio with a colleague. NB The College of Nurses Aotearoa is offering portfolio workshops again in 2015; please contact the college for further information and dates www.nurse.org.nz
Author: Liz Manning RN, BN, MPhil is a consultant and College of Nurses board member.
Evidence-based practice
Teamwork to reduce risk of
delirium CLINICAL BOTTOM LINE: Non-pharmacological interventions – when the intervention is consistently implemented and has multiple components – reduce the incidence of delirium in elderly patients in acute hospitals by about 30 per cent. They may also substantially reduce the risk of accidental falls.
CLINICAL SCENARIO: Elderly patients are at risk of developing delirium, particularly after surgery or severe illness. This is distressing for the patient and their family, and increases the risk of poor outcomes. As a nurse leader you are also aware that caring for patients with delirium puts increased pressure on an already stretched nursing workforce. Non-pharmacological strategies are understood to prevent delirium but you are unsure of their effect and maybe you are doing enough already? To inform quality improvement you decide to search for evidence of their effectiveness.
This edition’s critically appraised topic (CAT) looks at how best to reduce the risk of delirium in elderly patients without turning to drugs.
reviews, cognitive stimulation programmes, daily reorientation activities, educational interventions for staff and family members, family involvement in patient care, and physical or occupational therapy during hospital stay »» Comparison: Usual care defined as the standard care given to patients, including interventions specific to correction of underlying causes when already present »» Primary outcomes: Incident delirium at any point during hospitalisation »» Secondary outcomes: Delirium duration, length of hospitalisation, accidental falls, institutionalisation rates and in-hospital mortality.
STUDY VALIDITY:
Martinez, F, Tobar, C, & Hill, N (2015). Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and metaanalysis of the literature.Age Ageing, 44(2), 196-204. doi: 10.1093/ageing/afu173
Seven electronic databases were searched from inception to 31 December 2012 using a comprehensive iterative search strategy. No language restrictions applied. Unpublished studies were sought via grey literature repositories (OpenGrey, Clinicaltrials.gov) and by hand searching reference lists of delirium guidelines. Two authors independently conducted the searches, quality assessment and data extraction. Data extraction included methods for delirium diagnosis and used a standardised form. Disagreements were solved by consensus, or third party arbitration. The Cochrane Collaboration criteria was used to evaluate study quality and included assessment of appropriateness of randomisation, allocation concealment, blinding, loss to follow-up, and intention to treat analysis. Publication bias was formally assessed using funnel plots and Egger’s test. Overall it was a high-quality review of moderate to high-quality studies.
STUDY SUMMARY:
STUDY RESULTS:
QUESTION: In the hospitalised elderly, do non-pharmacological delirium prevention strategies prevent delirium when consistently implemented alongside standard care?
SEARCH STRATEGY: PubMed Clinical Queries (therapy, narrow): preventing delirium AND (nonpharmacological or non-pharmacological)
CITATION:
A systematic review assessing the effect of multicomponent non-pharmacological interventions in preventing incident delirium (developing during the hospital stay) in the elderly. Delirium was diagnosed using standardised National Institutes for Clinical Excellence (NICE) criteria. Inclusion criteria for the review were: »» Type of study: Randomised controlled trials involving elderly over 60 years »» Studies excluded: Trials evaluating management of prevalence (existing) delirium, assessing pharmacological interventions or aimed at alcohol withdrawal delirium were excluded »» Intervention: Multicomponent interventions were considered to be those with at least two components from the following domains: physical interventions including hydration (fluid therapy), electrolyte and nutrition, safe environment directives, drug
A total of 21,788 articles were screened, of which 602 were considered for the review. After abstract assessment, 28 full texts were assessed; seven studies involving 1,691 participants met the selection criteria and were included in the review. Studies involved elderly patients in an orthopaedic ward with hip fractures (three studies), in
acute medical wards (two studies), in a coronary care unit (one study) and in intensive care (one study). Studies were conducted in Australia, Sweden, United States, Spain, Chile and Italy and the majority were published from 2005 onwards. Various interventions targeting known risk factors were involved. Common components were physiotherapy (70 per cent of trials), daily reorientation (60 per cent), family involvement in care (60 per cent), and avoidance of sensory deprivation (60 per cent). Meta-analysis of seven studies found that multicomponent interventions significantly reduced incident delirium in hospitalised patients by nearly 30 per cent when compared with standard care (table). Two of these seven studies also measured accidental falls (these two studies were of moderate quality) and found that multicomponent interventions led to a 60 per cent reduction in accidental falls (table). Non-significant reductions in delirium duration, hospital stay and mortality were observed with delirium prevention interventions.
COMMENTS: »» The significant reduction in delirium rates identified in this review supports the results from other published reviews that had included nonrandomised (lower quality) trials. »» Delirium is a complex neuropsychiatric condition – prevention therefore requires complex interventions that target known risk factors. »» Multidisciplinary teamwork, staff training in delirium prevention, and family involvement were key features of successful interventions. Many intervention components related to the consistent provision of high-quality nursing care. »» Standardised protocols for reducing delirium incidence will require sound implementation strategies to ensure that practice change is adequately supported, resourced and sustained. Reviewer:
Cynthia Wensley RN MHSc is a PhD candidate at Deakin University. She also works at the School of Nursing, The University of Auckland as an honorary professional teaching fellow. cwensley@deakin.edu.au
Summary of Results Outcome
Number of studies (n)
Relative Risk (95% CI)
P Value
Inconsistency between studies
Incident delirium
7 (1619)
0.73 (0.63 to 0.85)
< 0.0001
I2 = 0%
Accidental falls
2 (486)
0.39 (0.21 to 0.72)
0.003
I2 = 0%
n = number of participants in meta-analysis Nursing Review series 2015
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Practice, People & Policy POLICY
Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy Turning around the ocean liner:
the shifting of resources to the primary health sector Nursing Review caught up with Minister of Health and former GP, Hon Dr JONATHAN COLEMAN, recently to talk about his plans to move more funding from the secondary to the primary health sector, and his views on the nursing and physician assistant roles.
J
onathan Coleman says he has made it very clear to district health boards that he wants to see more resources transferred to the primary health sector. “I have signalled that, if DHBs are not coming up with clear plans on how they are going to shift resources into primary care, I’m going to direct them,” the former GP told Nursing Review. Coleman returned to New Zealand after a lengthy OE at the end of 2001 – the year that the Primary Health Care Strategy was launched – with plans to transform the primary health sector. Many nurses viewed the 2001 strategy as opening up new opportunities for nursing to make a difference and a number have also expressed frustration that it has yet to live up to its promise. “I think Labour made very limited progress since the time of the launch of that strategy,” says Coleman. “But the strategy laid out the direction we need to go. I’m keen to see the pace pick up around that.”
Extensive health background Dr Coleman trained at The University of Auckland Medical School and gained a diploma in obstetrics before leaving on his OE to the UK where he underwent his GP training. After a short stint in the Flying Doctor Service in Australia, he returned to the UK to work in a general practice in Islington, a London suburb whose most famous resident at the time was then-Labour Party leader Tony Blair. “But I arrived a few months before the May 1997 general election [which Labour won] so he moved straight out [to 10 Downing St]. Coleman says while gentrification was well underway in the inner London suburb at the time, it was still a very mixed area socio-economically, with big council estates and quite significant deprivation. 30
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“So I’ve worked across the whole spectrum of general practice both in the UK and back here in New Zealand.” During his time in London he completed an MBA from the London Business School and on returning to New Zealand he worked as a consultant with PricewaterhouseCoopers on health sector issues four days a week and spent one day a week as a GP in Otara. In 2005 Coleman won the Northcote seat for National and entered Parliament as its health spokesman; in 2006 he admitted an error of judgement by smoking a cigar in British American Tobacco’s corporate box during an U2 concert and in 2008 he first entered Cabinet. Following former health minister Tony Ryall’s resignation, Coleman picked up the health portfolio in late 2014.
”Real shift” envisaged Talking to Nursing Review five months after taking
on the health minister’s role, Coleman says he is serious about seeing a “real shift” in resources as “we’ve got to have a truly integrated system”. “It’s much better for the patients. We’ve got to have a system that is based around the patients and that they are living longer, healthier lives closer to home. “But we’ve also got to see – in the interests of the long-term financial sustainability of the system – action taken earlier and for that reason services will be logically provided away from the hospital. “And I think if you look at the future of the healthcare system, where we want more services devolved out into primary care, nurses are an absolutely essential part of the team. We’ve got to use all the resources we’ve got right across the healthcare workforce and nurses have a big role to play. And I envisage an expanding role in the future.” He says he is currently considering a mechanism to ensure DHBs make clear plans to shift resources
and it may involve asking boards to demonstrate how a “certain proportion” of their revenue and resources is directed out into the community. Coleman says this won’t be simple. “As you can see, by the fact the PHC strategy was launched in 2001, this is pretty complex work and it’s like trying to turn around an ocean liner. But for the long-term sustainability of our system it has to happen.”
Funding for nurses too? Nursing Review asked the minister how the
resources shifted from the secondary to the primary sector were likely to be distributed, particularly as the nursing sector was a bit bemused by the Government’s initial announcement last year of free primary health care for under-13s only pertaining, in effect, to free GP visits. The minister says that is “a fair point”, as in actual fact the policy was for free primary care visits for under-13s and, of course, that includes nurse practitioner (NP) visits. (A few days earlier on 13 March, at the Rural General Practice Network’s annual conference in Rotorua – an audience of rural GPs, NPs and nurses – the minister’s speech had referred only to free GP visits.) Coleman told Nursing Review that NPs were a group that the Government was “really keen to see grow”. At the time of talking to Nursing Review, he was waiting on a report from Health Workforce New Zealand on trialling an NP training proposal put forward jointly by Massey University and The University of Auckland. When asked about whether new funding would be considered for the trial, he said that was still to be decided. “Obviously we can’t deliver it without funding. But right across health and government there’s always pressure on where funding will come from and what we put it into and where the trade-offs are made.”
Practice, People & Policy WORKFORCE
To the editor:
Hand hygiene and hand care Dear Editor
PA evaluation due soon Nursing Review also asked Coleman for his opinion on the
physician assistant (PA) role; with some in the nursing sector expressing disquiet that promotion and funding of the PA demonstrations was detracting from supporting the NP workforce to grow. Coleman says he is expecting the final evaluation of the PA demonstration on his desk in April and support of a PA training programme would depend largely on demand. “But I’m keen to use all the skills that we’ve got in the nursing workforce and to get them prescribing more and enable them to have more autonomy and take on more responsibility. “So we haven’t said definitely that the PA thing is going ahead. We’re still waiting on the evaluation. And I think we’ve got to see how that fits together with NPs.” Finally, Nursing Review asked the minister whether he had any mechanism for ensuring fairer pay for two groups of nurses serving high needs and vulnerable populations: residential aged care and iwi/Māori provider nurses. With time running short, he pointed to the current pay negotiations in the public sector and that a number of “legal issues” playing out at the moment may have relevance for “wider labour market issues”. He also says as yet no-one has raised the issue of mandatory nursing staff levels in rest homes with him “but I’m happy to hear about that”.
”We’ve got to use all the resources we’ve got right across the healthcare workforce and nurses have a big role to play. And I envisage an expanding role in the future.”
I am writing in relation to the Nursing Review edition dated Feb/Mar 2015. On page 19 you had an article on basic skin care tips. Under hand care, in the first bullet, there was an advice to try and avoid using alcohol hand gel as it dries out your skin. If possible use soap and water instead. The national hand hygiene programme (Hand Hygiene NZ) in New Zealand and all the district health board-based programmes promote the use of alcohol-based hand gel as it is actually more effective in killing microorganisms on the hands, as well as it is readily available at the point of care. It is impossible to provide a sink in each patient cubicle. Also, while I understand that alcohol can act as a solvent dissolving lipids in the skin, all alcohol-based products have emollients and moisturisers in them, so they actually end up harming the skin less than washing with soap and water. All this info can be referenced if need be. Another very important point is that preferring to use soap and water means that staff may not be able to clean their hands as per the best evidence-based practices; for example, immediately before a procedure. I would like to raise my concern around publishing this advice. It has its drawbacks on our efforts to improve hand hygiene practices. Nurses compose the main healthcare workforce that we work with. I am looking forward to receiving your feedback on this issue. Much appreciated.
Kind regards Eman Radwan MPH, MSc. Public Health, MBBCh Quality Lead – Infection Prevention & Control Waitemata DHB
Dear Editor
I concur with Eman’s comments. District health board healthcare workers are actively encouraged to use alcohol-based hand rub (ABHR) as their main hand sanitiser product due to its quickness and point of care availability. As you know from my previous contributions to Nursing Review, changing healthcare worker hand hygiene behaviour is challenging and unfortunately deriding ABHR as causing dry skin is not helpful and somewhat misinformed. We do advocate for soap and water when hands are visibly soiled or after dealing with certain microorganisms. However, ABHR purchased by healthcare facilities and used by healthcare workers usually contains moisturisers, emollients and are better for hands long term than most healthcare associated soap and water-based products. Your ‘tips’ do say that if ABHR is unavoidable to make sure that hands are well cared for; we would agree with this regardless of what hand sanitation is used. I am surprised that you offer several branded and named products to use – unless this is an advertorial as opposed to independent editorial/advice?
Kind regards Louise Dawson RN HHNZ Hand Hygiene Coordinator Auckland District Health Board
Editor’s response and correction
The hand care tips included in the Skin Care article were most definitely not intended to discourage nurses from following good hand hygiene practice. The tips were drawn up from the advice and opinion provided by the cosmetic nurse interviewed for the article. Since receiving the letters, I have looked at the recent research on the issue and understand that particular tip was no longer accurate or helpful for nurses using hand rubs containing moisturisers and emollients. As a result, that tip has been withdrawn from the online version of this article and this correction has been published for our print readers. Regarding the naming of several products, these were just examples given of common products that the reader might be familiar with. The article was definitely not advertorial and Nursing Review approached the cosmetic nurse in question for information on cosmetic skin care for our edition focusing on nurses’ own wellbeing. For more information on hand hygiene and hand care tips for nurses, go to www.hha.org.au/ About/ABHRS/abhr-limitations/hand-care-issues.aspx. See also www.handhygiene.org.nz to find out more about Hand Hygiene New Zealand (HHNZ).
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People, practice & policy POLICY
Check out our online opinions If you’re reading the print edition, you’re only getting half the story. The recently revamped Nursing Review website has web-exclusive content and news stories online. Go to www.nursingreview.co.nz. The following are excerpts from recent opinion articles published online.
”Curiouser and curiouser”: Is it time for a fresh look at the NP role? The perpetually curious ANDY McLACHLAN (an Auckland cardiology NP) wonders whether there are sharks in swimming pools and whether it may be time for a fresh look at the nurse practitioner role. Here are some excerpts from his latest online opinion. Children have an abundance of natural curiosity and my own kids seem to be going through this very important, but slightly annoying, phase in their lives. The older one asks about practical (well, sort of practical), issues like: “Dad, why is the sky blue?” “How do TVs work?” “What’s the point of Minecraft?” My middle child asks more ethereal questions: “Where does the tooth fairy live, Dad?” “Are there any sharks in the swimming pool?” And my personal favourite (as I wonder this sometimes too): “When will you die, Dad?”… Like my kids, as I learned and read more widely, my thinking changed. I began to develop a new passion for nursing and its role in delivering
effective, innovative and quality health care. I read all I could about the nurse’s role in supporting health and became convinced that the nurse practitioner scope was the ideal model. In my DHB another 17 nurses have completed their clinical master’s degree since I qualified as an NP more than five years ago; but none have been able to develop an NP role. Too many barriers remain, preventing skilled and passionate nurses becoming NPs, and it’s clear that DHB leadership has not embraced the potential advantages of an NP workforce An NP isn’t just an expensive nurse but a way to expand capacity to care for an increasingly complex population.
Nursing and the village grapevine:to share or not to share? Small-town nurse KIM CARTER is well aware of the Rapid Response Rural Grapevine (RRRG) and even more so after her recent wedding. She reflects on when to share and not to share with patients; and finding the balance between building a therapeutic relationship and maintaining Code of Conduct professional boundaries. Over the New Year I got married…finally! Having such a major, life-changing event has made me really think about how much personal detail we share (or others share on our behalf) with patients. Particularly because our wedding came fairly soon after I attended a Nursing Council Code of Conduct education session. I live and work in a small rural community and am well aware of the Rapid Response Rural Grapevine (RRRG). In this instance, the RRRG kicked into gear the moment we contacted the local bakery to place a catering order and patients were congratulating us before we had the dents on our fingers from the rings!
When personal information is out there, what should be my response when questioned by people who are both neighbours and patients? Within my work I have always been reticent to divulge much in the way of personal details. I, like we all do, carry the professional burden of holding to therapeutic and personal distance standards, but it is very challenging at times to remain removed from patients by withholding every scrap of personal information. People can find it both rude and disrespectful when you provide a vague answer or fail to respond in a manner that reflects back to them a level of genuine human-to-human interaction.
Primary healthcare: in need of a paradigm shift? NP Rosemary Minto looks back to successes of the past and looks forward to a time when the primary healthcare paradigm gets a bigger shove in the right direction. I have just finished reading Te Puea by Michael King. What a great book about an extraordinary Tainui leader. Naturally, I was interested in the references about healthcare during Princess Te Puea Herangi’s time. And, as is happening more often with me these days, I recognised familiar themes to today’s health issues and to today’s solutions, one of which our current government is now calling Whanau Ora. Working alongside health authorities in the 1940s, Te Puea set about bringing healthcare to her people, including starting up a marae clinic at Ngāruawāhia with a general practitioner in attendance. She also recognised the importance of addressing not only immediate health issues but the social determinants of health, like employment, and the benefits of reducing alcohol consumption.
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The result was that health standards of Māori in the region improved to match that of their Pākehā neighbours. So when I see commentary about New Zealand’s lack of progress in healthcare provision evolution, as seen in a recent New Zealand Doctor commentary, part of me heaves a weary sigh. I sigh on behalf of primary healthcare ‘evangelist’ providers everywhere for the years of toil they have put in to pursuing equity, equality and more effective services. And the result: the paradigm shifts with just an infinitesimal ‘lurch’. My other more tolerant and patient psyche acknowledges the improvements that the PHC sector, and nursing in particular, has seen over the last decade or so.
TAPsPP9243
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