FOCUS: eHealth / On the ward
Nursing Review DECEMBER 2013/JANUARY 2014/$10.95
NEW ZEALAND’S INDEPENDENT NURSING SERIES
Q&A
with Hemaima Hughes
eHealth
PRIVACY & HEALTH WITH A LITTLE “E” Goodbye unreadable drug charts
EVIDENCE-BASED PRACTICE:
Battle of the bugs…
PRACTICE, PEOPLE & POLICY
Bad news & whistleblowing
EPORTFOLIOS: EASY & FREE
A DAY IN THE LIFE OF A RESIDENTIAL AGED CARE NURSE
On the ward MEET ‘MS MEDIAN’ NURSES Why doesn’t it get easier?
www.nursingreview.co.nz
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LETTER FROM THE EDITOR The end of the year has swung around very fast. Our last edition for 2013 looks at how nursing is keeping pace with the push towards sharing electronic health information while still retaining patient privacy. We also look at one of the three DHBs that have been trialling ePrescribing so nurses can someday farewell unreadable drug charts and share an invitation for nurses to trade in their old paper portfolios for an electronic one as “easy as Facebook”. It has been another busy year on the wards for many New Zealand nurses, and we have several opinion pieces sharing thoughts on care rationing, whistleblowing, and learning from mistakes. We also have a researcher’s findings on why he thinks nursing doesn’t get any easier. We also profile two “On the ward” nurses whose careers began back in the early 90s when nursing jobs were even scarcer than today. As we went to press, we were still waiting to hear how many of the 1330 applicants were successful in gaining much ‘sought’ after new graduate positions and how many were not … I wish them all the best in their job hunting efforts and hope ongoing employer efforts will see as many as possible of this next generation of nurses nursing very soon … On behalf of the Nursing Review team, I wish you all a very Merry Christmas and a safe and sunny New Year.
Inside: FOCUS: eHealth / On the ward 4 eHealth: Privacy & health with a little “e” 8 JODIE HEALEY farewells unreadable drug charts
9 ePortfolios: as easy as Facebook and free 10 On the ward: Meet some ‘Ms Median’ nurses
13 Research: BERT TEEKMAN on why nursing isn’t any easier
RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe
PRACTICE, PEOPLE & POLICY: 19 20
JO ANN WALTON on bad news and whistleblowing ANECITA LIM on being vigilant with medication for the elderly
Fiona Cassie editor@nursingreview.co.nz
REGULARS 2 3 16 17 18 21
Q & A Profile: National Council of Maori Nurses president HEMAIMA HUGHES A day in the life of…residential aged care nurse JESSE GAMUTAN Evidence-based practice: ANDREW JULL on good bugs vs bad bugs Webscope: KATHY HOLLOWAY learning online from others mistakes College of Nurses column: JUDY YARWOOD from starched caps to care rationing For the record: News round-up
Connect with Nursing Review on Twitter www.nursingreview.co.nz
Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ
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Exclusive online content Nursing Review is a genuine multimedia publication. Our recently revamped website has content not found in the print edition, including exclusive online articles, live Twitter updates, social sharing, and the downloadable RRR professional development archive. Visit: www.nursingreview.co.nz COVER PIC: Jesse Gamutan, registered nurse at Summerset Falls retirement and residential aged care complex. Read about her day on p.3. PHOTO CREDIT: Glenn McLelland, www.aerialvision.co.nz
EDITOR Fiona Cassie @NursingReviewNZ ADVERTISING Belle Hanrahan EDITOR-IN-CHIEF Shane Cummings PRODUCTION Barbara la Grange Dan Phillips PUBLISHER & GENERAL MANAGER Bronwen Wilkins PHOTOS Thinkstock
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December 2013/January 2014
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A day in the life of a ... residential aged care nurse NAME | Jesse Lee D Gamutan JOB TITLE | Registered nurse LOCATION | Summerset at the Falls (Retirement Village and Hospital), Warkworth
5:00
AM: WAKE I am rostered to start at 6.45am. First things first, I iron my uniform and my boys’ (Raymond is 7 and Joel is 5) school shorts, make their lunches and get their bags ready. They are up at 5:45am and have breakfast with their Dad. I don’t leave the house until 6.45.
and followed my sister, who was already nursing in New Zealand. After getting my registration in 2002, I first worked at a rest home/hospital in Manukau, which was hard, at first, as it was definitely a different setting then the hospital I was used to. But aged care slowly grew on me. I have developed skills I did not think I would. And there is nothing more to ask for when you see a frail patient smile at you and say ‘thank you’, even if it’s a struggle for them to utter those words. Since 2002, I have nursed everywhere in Auckland and ended up living in Warkworth. When I heard that Summerset in Warkworth were hiring RNs, I applied and was one of the pioneering staff when it opened in March 2013.
6.47
AM ARRIVE AT WORK The night shift RN tells me she can never get over my being late when I only live two minutes drive away. We proceed with the handover, where I find out I’m one caregiver short. I check the roster and am happy to see I have reliable workers on with me. Then someone activates an emergency call bell in a care room. We all rush to check and find the patient on the floor under her bed. She had a fall while trying to get out of bed for breakfast. She is such a tiny, fragile-looking lady that I thought she may be hurt badly. I do my usual investigation and find she has landed on the floor very slowly. Upon assessment, she appears fine, no complaints of pain or discomfort, and when we assist her up, her mobility is satisfactory. I place her on the recliner chair, reassure her, and elevate her legs. It is then back to the handover. One caregiver is upset and tells me her dog had to be put down last night. I know that feeling and give her a big hug ... She cries a bit more and then is back to her usual cheerful self and tells me she’s ready for handover. That makes me happy!
7:30
AM: NEXT… I check the RN diary for appointments or special reminders – nothing much for today except for the GP’s regular Monday rounds that afternoon. I check the wound chart and make a list of all the dressings that require changing etc. I then get the drug trolley out of the drug room and call one of the caregivers to check the DD (dangerous drugs) with me. We do our rounds, and when we get to the last patient, charted with M-Eslon (morphine), we are surprised to see her so alert and happy. She started on M-Eslon on the Friday and says she hasn’t felt this good for quite some time – she is pain-free and had a good, undisturbed sleep. That’s really good! Why aged care? Random people, family, and friends always ask me that – even during job interviews. So I ask them back ‘why not aged care?’ My patients used to be like all of us, they are like any of us.
LUNCH TIME: What lunch time? By the time I finish showing some people around, and doing ‘obs’, and dressings in between, it was time for me to give out lunch meds. Most of my patients were happily seated in the dining area waiting for their meals and meds.
2:00
PM The GP shows up without notice. I was expecting him to arrive fashionably late … say 3ish? I have to rush since I hadn’t prepared the trolley and the list! We get there in the end, but the round is a bit of a rush – always is on Mondays.
... there is nothing more to ask for when you see a frail patient smile at you and say ‘thank you’, even if it’s a struggle for them to utter those words.
3.00
They have lived their lives and we can learn a lot from them. I finished my Bachelor of Science in Nursing in Cebu, Philippines in 1997. Nursing was more my mum’s choice than mine; it was either nursing or I didn’t go to university at all … I am very thankful to my mum. She’s a retired RN and she has good connections, as I landed a job at the Professional Regulation Commission (a Phillipines government agency). My boss was the chief nurse of the hospital where my mum worked as an orthopaedic nurse for over 30 years. When most of my friends from uni left for the States or the Middle East, I decided it was time to work abroad, too,
3:45
PM When we finish the round, I have to organise the pharmacy orders, referrals, etc. I hand it all over to the afternoon RN and do my documentation and then a proper handover. I find out only one afternoon caregiver has showed up. The morning caregivers feel sorry for us and so offer to stay on until we find someone to take over. PM KNOCK OFF I manage to knock off and pick my kids up from after-school care. At home, I make the kids some snacks and check out what I can cook for dinner. Help the kids with their reading and maths and watch TV until their dad arrives. I am so exhausted after dinner …
8.00
PM NAP Fall asleep in the lounge after my shower.
10.00
PM Wake up and head to our
bedroom.
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Q&A
Hemaima Hughes
POSITION: President of National Council of Māori Nurses (NCMN)/Te Kaunihera Neehi Māori o Aotearoa JOB TITLE: Nurse consultant/managing director: Maima Oranga Services Ltd, part-time duty nurse manager at Nelson Hospital, whānau health nurse. IWI: Whakatohea, Ngāpuhi HAPŪ: Ngāti Irapuaea and Ngai Tamahaua
Q A Q A
Q A
What do you love least? Hearing about vicious attacks on people unable to defend themselves, such as the recent sexual assault and brutal rape of an 87-year-old woman. I do not like injustice, inequality, unfairness, mistreatment, and violence.
Where and when did you train? Whakatane Hospital School of Nursing 1969-1972.
Other qualifications/professional roles? PG Papers BSS (Massey University), Cert. in Adult Teaching, BN (Nelson Polytechnic), MA(Applied) in Nursing with Merit (Victoria University of Wellington). Apart from my current NCMN president’s role, I have been an NZNO Te Runanga representative, a BHSc (Māori) Nursing curriculum writer, and a programme leader for the BN (Māori) at Whitireia from 2009–10. I am currently a Nursing Council competence review panelist plus holding a number of other committee and advisory posts.
Q A
When did you decide to become a nurse? At the age of 11, while a patient in Opotiki hospital, I was most impressed by the nursing care and decided I wanted to be a nurse. Being the eldest of six children, I also loved helping our mum caring for the whānau. And on the corner of our street was the Ark Haven rest home, where I loved visiting my nanny as well as helping feed the residents. During my secondary schooling, I made it known I wanted to go nursing but was told I couldn’t as I didn’t have the right subjects. When I finished college, I was sent to Māori and Island Affairs in Rotorua to work as court clerk. But one night, I had a very vivid dream of being called to be a nurse … and so began my journey.
Q A
What was your nursing career up to your current job? I have a background of 44 years in clinical nursing, Māori health leadership and management, nursing and cultural safety education, policy, provision of clinical and cultural supervision, curriculum and programme development, nursing research, and service delivery. My new graduate RN experience began as a volunteer from 1973 to 1975 at Atoifi Hospital, Malaita, on the edge of the jungle in the Solomon Islands. Loved the work and loved the people. I returned to Whakatane Hospital and was a charge nurse when I left for the birth of my first child in 1977. I later worked as a casual district nurse and did some practice nursing before returning to Whakatane Hospital. In 1986, we moved to Nelson with our five children, and I nursed at Nelson Hospital before being first seconded into nurse education and then in 1996-2003
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Q
becoming a clinical nurse educator/cultural safety coordinator on the BN programme at Nelson Marlborough Institute of Technology (NMIT). From 2003 to 2004, I was a parttime nurse manager of Ngāti Koata Health & Social Services and also a part-time teaching associate for Victoria University’s graduate nursing school.
Q A
What is your current job all about? My new appointment as president of Te Kaunihera o Ngā Neehi Māori o Aotearoa (NCMN) and being a recent recipient of an award for service to nursing and midwifery, are both honours. I continue to work as a nurse consultant managing Maima Oranga Services Ltd providing clinical and cultural supervision, advice, mentoring, research services, and facilitating cultural awareness workshops. I work part time as a whānau health nurse at Te Amo Health, a mobile nursing service for Motueka whānau, and as a part-time duty nurse manager at Nelson Hospital.
Q A
What do you love most about your current nursing leadership role? Being given the opportunity to lead Te Kaunihera (NCMN) forward into the future, “Waerea te ara ki te ora tātou ngā iwi – clearing the way toward total health and wellbeing for all our people.” I know that there will be challenges ahead. What excites me is that my 44 years nursing has given me broad experience of many leadership styles – some enhancing and some detrimental. That experience makes me strive to be an accomplished and caring leader.
If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? »» The need for nurses to work together, value, support, and care for one another across the nursing spectrum. Let’s practise what we preach and strive to reduce horizontal violence and workplace bullying. »» Recruit, retain, and support an increase of Māori nurses in Aotearoa/New Zealand to deliver health care services, improve health outcomes and address the needs of Whānau Ora. »» More positions available for new graduate registered nurses through a supportive and cost effective process (instead of the current competitive application process for NETP places) We risk them leaving New Zealand or leaving nursing if they can’t find jobs and we know full well there is a nursing shortage on the horizon.
Q A
What do you think are the characteristics of a good leader? Faith, belief, passion, integrity, respect and confidence in one’s self. A leader needs be open and honest to instill honesty in others, to be respectful and sensitive, a good listener, empathetic, sympathetic, ethical, fair, trustworthy, caring, able to delegate, be a good communicator, have a sense of humour, be committed to the kaupapa (cause), be creative, have a positive attitude, be intuitive, and be able to inspire others.
Q
Are they intrinsic or can they be learnt? Leadership characteristics are intrinsic but can be learnt providing the potential leader is open to learning and being taught.
Q A Q A
What is number one on your ‘bucket list’ of things to do? Travel to Israel 2014. If I wasn’t a nurse I’d be a…
A social worker, a chaplain.
To read Hemaima Hughes’ mihi, check out her full Q & A profile in our online December edition at www.nursingreview.co.nz
FOCUS n eHealth / On the ward
eHealth This issue we look at health with a small “e”...and report on some of the advances, advantages, and risks of sharing health information electronically.
Privacy in the digital age By the end of 2014, the aim is for every New Zealander to be able to electronically access their core personal health information. This prompts new challenges and new privacy issues. FIONA CASSIE talks to nursing leaders about increasing moves to shared electronic health information, about protecting privacy and why it is important for nurses – even the IT shy – to be involved every step of the way.
I
t’s an age like no other for sharing intimate aspects of your life. Five hundred ‘friends’ can read how hungover a guy is after a night on the town. A mother can tweet pictures of her child’s chickenpox to the masses. But if your district nurse wants to see your latest test results, the ED nurse your current medications, or your pharmacist double-check your GP’s prescription, the information can often be a frustrating series of phone calls and faxes away. Consumers used to getting information at just a click of the mouse or slide of the finger are perplexed that basic information isn’t already being electronically shared between general practice,
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hospitals, and other health providers. In an age of Facebook, Twitter, and Instagram, there are still electronic and privacy barriers standing in the way of sharing basic health information electronically. The slow and steady arrival of shared electronic health information is changing this in pockets all over the country as pilots in eReferrals to ePrescribing and other broader initiatives, like Canterbury’s electronic shared care record view (eSCRV) and electronic shared care plan pilots in Auckland and Christchurch, are tested and rolled out. Walking the tightrope between providing ease of access to shared clinical information and protecting the privacy of health consumers is the difficult balancing job the health sector is currently working through.
High profile cases have shown that maintaining privacy is a real issue, with some nurses and doctors not immune from exploiting electronic access to take a nosey at records they have no reason to see. In the past health professionals might have got away with a gossipy huddle around an x-ray or taking a peek at a file in the cabinet. And it may be that those involved in the recent cases (see online only sidebar at www.nursingreview.co.nz) were unaware that nowadays such privacy breaches leave digital footprints that lead investigators right to them. Sue Wood for one is a nurse leader who believes ignorance or uncomfortableness with IT is no excuse for the nursing profession not to take a lead role
FOCUS n eHealth / On the ward
Sue Wood
in eHealth developments like shared electronic health records. The former director of nursing at MidCentral District Health Board is a bit of a nursing IT pioneer having brought the acuity software TrendCare to New Zealand. She is also the nursing representative on the IT Health Board which has set the eHealth vision of all New Zealanders and their health providers having electronic access to a core set of personal health information by 2014. Wood, now quality and patient safety director at Canterbury DHB, says patient portals, to electronic health information and incident management systems, are the way of the future. “And from the Minister (Health Minister Tony Ryall) it is an area that needs more emphasis.” Portals are also an area that still needs some work if the eVision goal is to be met by the end of 2014. Wood is clear what should be core and common across any electronic shared health record or care plan development. “As a nurse on the board I’ve been arguing for two years that assessment data needs to be core and that assessment isn’t biomedical examination (though I value that and it is a component of assessment),” says Wood. “We are looking for the psychosocial history, the context and how people Intro ??????? learn … we are looking at those sorts of things to be included in (nursing) assessment.” Wood says nurses’ psychosocial care of patients is core ‘bread and butter’ to nursing but it is totally invisible to others who do perceive nursing as an holistic profession. “We are perceived as biomedical.” So nurses needed to be in at the beginning of system development and clearly articulate what they need so the IT teams can deliver software and eHealth tools that recognise what nurses “bring to the party” of patient care, like holistic assessment, supporting self-management and the “invisible” coaching of families. Wood says nurses also need to leap forward and envisage future models of care – and the electronic systems needed to support them – as systems take time to be developed and are usually difficult to change. So nurses need to think where care will be in a decade, ensure to use a common universal language (like Snomed clinical terms) and avoid just turning existing paperwork into an electronic form.
IT security: most definitely a nursing role
Nurses also need to play an active part in IT security and privacy, says Brenda Hynes (left), project leader for PlunketPlus – the well child provider’s new electronic health record as well as the “Plunket book” of the future. “But often when I talk to people about information security they say ‘that’s not nursing, we don’t need to worry about that,” says the nurse who is also Plunket’s general manager of service delivery. Hynes challenges this, pointing out decisions about security directly impact on what happens in the field when a nurse picks up their tablet and tries to login to PlunketPlus. “If you lock everything down …and you have to
go through streams of passwords … that affects the performance that the nurse can do,” says Hynes. That’s why she believes nurses should be in on security decisions and examine the risks against the advantages of different levels of electronic security. “An example of this is for us being able to access a whole spreadsheet of all client contacts and be able to email that. We could have locked that completely down and then our business analysts wouldn’t have been able to do their work or we could have opened it right up so nurses could access such spreadsheets.” The decision was made that only business analysts could view such data to reduce the risk of a nurse accidentally emailing out all their contacts, a la ACC or EQC.
“The eHealth vision is for a person’s foundation health information to be collected once, kept current, stored securely, and accessed as needed by health professionals and individuals. Foundation health information includes an individual’s NHI number, along with their demographic details, allergies and alerts. It will also include information about their relationship with key caregivers and community-based clinicians. The foundation health information will support the underlying mechanism, allowing links to other health information stored for this person.” From National Health IT Plan Update 2013/14
Hynes points out you can’t eliminate or control every risk – some you have to accept so nurses can do their work; with trust and staff education also key to preventing privacy breaches. And ensuring notes are kept secure and private is a long given for nursing, says Hynes, with Plunket nurses locking them up every night in a filing cabinet and hospital nurses challenging any stranger hovering beside the notes trolley. The ‘key’ to the ‘filing cabinet’ is now an electronic password – which has to be a complex one, requiring a mix of nine letters, symbols and numerals that has to be changed every 90 days. Hynes shares an anecdote on why it’s probably best to have complex passwords based on her experience of asking a gathering of Plunket area managers last year how many of them used ‘Plunket’ backwards as their password. “All these hands shot up … and I said ‘oh dear you’ve just told me your password!’” It was no small feat to introduce complex passwords for Plunket’s 1500 staff and 5000
volunteers. They were given three months notice of the changeover to the tighter password system. A series of meetings outlined why the new password system was needed and giving hints on how to make a memorable but secure password, like using a code built on the lyrics of your favourite song. “So when you come in in the morning you do see people at their computers tapping away and nodding their head as if they are singing a song.” Hynes adds with pride only one person, of the 6500 or so involved, failed to register a new password prior to the changeover date. Work began on PlunketPlus back in 2010 and it went live for the first time in September this year with ten nurses in Auckland, with 4000 clients between them, testing it in the field using electronic tablets. Hynes admits it hasn’t been a fast process but prompting Plunket to take their time was the number of privacy breaches hitting the headlines last year. “That’s when we said hold on a minute we need to just review all our information security.” As a trusted organisation seeing more than 90 per cent of all new babies they wanted to ensure their system was secure – including paying for penetrating (PEN) testing to see whether people could hack into the tablets nurses use or Plunket’s server. It has also developed a new incident management system that covers security breaches as well as privacy breaches. So if somebody loses their smartphone – it’s an information security breach and needs to be reported straight away. It is Plunket policy that no client information is held on phones but the IT department would still promptly “kill” the phone to ensure numbers cannot be accessed. Plunket’s policy is that client information is not emailed through non-encrypted platforms like Microsoft Outlook. Instead it uses several encrypted systems if it needs to report client information, for example SEEmail (Secure Electronic Environment Mail) to send encrypted sensitive information to Child, Youth and Family. Information held on PlunketPlus tablets is also encrypted and while nurses are encouraged to take their tablets home, so they become familiar with them as an IT tool, there is a hands-off policy from any family members keen to play games on them or take ‘selfies’. In the future clients will also be able to access their child’s PlunketPlus record through a secure patient portal, similar to internet banking. But as that is the final stage of PlunketPlus work is yet to begin, says Hynes. But the vision is that parents will be able to read their child’s record, except for child safety information, and will also be able to contribute to the record, just like an electronic Plunket book, and record their child’s development milestones from rolling to first steps. Meanwhile evaluation is ongoing during the live testing in readiness to refine and make PlunketPlus work as well as possible for nurses and their clients. Once that stage is completed Hynes expects it will take between 12 and 18 months to roll out across the country With that roll out and the future patient portal will come the need to decide when and if information is withheld from clients. Hynes says the health privacy code means nurses already need to be clear with clients about the information they are gathering and why, and now will need add how it is being recorded and who will be able to see it. >> Nursing Review series 2013/2014
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Intro ??????? IT road map not roadblock for privacy
included health providers not having confidence the system would work properly and health professionals concerned there wasn’t adequate privacy protection. Evans says people often expect the Privacy Commissioner’s office to be anti-IT but that is not at all the case. “Sometimes IT can actually significantly improve your privacy situation and it can be a road map rather than a roadblock.” Retaining patient privacy is also more challenging today as the increasing complexity of health care means the average number of people involved in a person’s health care is estimated to have risen hugely from 2.5 people to 15.
<< Getting the fundamentals right from the start when it comes to privacy and electronic health records is probably not a bad idea. Katrine Evans (left), the assistant Privacy Commissioner, points to the UK’s scrapped £12.7 billion health IT project as a cautionary tale of getting the fundamentals of sharing electronic health information all wrong. Reasons for pulling the plug on the NHS project in 2011, after investing nearly a decade’s work,
New terminology with electronic shared records Break glass
The term draws its name from the action of breaking the glass to pull a fire alarm in an emergency. It enables somebody – like a nurse – in a health emergency to override electronic security and access health records they don’t have permission to access. Is set up so system administrator is alerted to “broken glass” and checks out whether it was a legitimate reason.
Digital footprint
A digital footprint (or possibly fingerprint when it comes to electronic files) is the data trail left in a digital environment. Meaning IT staff can detect who has accessed and searched a patient’s electronic record.
Proximity audit
System administrators can also audit access to a clinic record to see whether it was accessed by a health professional directly and currently involved in the patient’s care.
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Relevant legislation, codes and standards: »» »» »» »»
Privacy Act (1993) The Health Information Privacy Code (1994) Health Information Security Framework (2012) Nursing Council of New Zealand’s Code of Conduct (2012)
Further reading and information:
National Health IT Plan Update 2013/14 www.ithealthboard.health.nz/national-healthit-plan Health privacy tool kit http://privacy.org.nz/how-to-comply/healthprivacy-toolkit/ Voluntary privacy breach guidelines: http://privacy.org.nz/news-and-publications/ guidance-notes/privacy-breach-guidelines-2/ See also in online version of article two recent US research studies into patients’ response to gaining online access to their electronic health records www.nursingreview.co.nz
“Managing the complexity of care is something that information sharing can help you to do but in the health relationship trust is absolutely central. This is not about the IT, this is about the people.” Evans says also the fundamental privacy rules and rights of patients don’t change whether the information is being recorded with pen and paper or electronically. “That’s the beauty of a principles-based system – it doesn’t matter what technology you use.” She says her colleagues across the Tasman in Privacy Victoria summarised the health privacy relationship as: “the right information to the right people, for the right reason, in the right way and at the right time”. So privacy was not about blocking information but facilitating the right use of that information. The key for health practitioners like nurses was to be transparent and communicate clearly to consumers why they are collecting the information, how it will be used and that it won’t be disclosed other than for reasons they have been informed about. Accuracy was always important but what was different under shared electronic health records was if there was an error there was a need to have a system in place to ensure that any correction gets to all those who may have shared the record. The increasingly mobile health workforce going out into the community with tablets, smartphones and mobiles also creates the potential for privacy breaches. Evans says encryption is an increasingly available and easy way to ensure the loss of a work laptop is inconvenient but will not result in a breach of patient privacy. But with health staff also bringing their own electronic devices to work employers had to have clear policies about ensuring sensitive information was not being carried on emails or texts on staff smartphones.
FOCUS n eHealth / On the ward
Evans adds that it is also important that any electronic security systems or policies are workable. “It needs to be a system that people can use and will use.” Make it too tough to do their jobs and you will force “workarounds” which can create security nightmares. “People will take the path of least resistance, particularly very, very busy people like health professionals, so make it easy for people to do it right and it will also help to protect patient privacy.” Again trust is key to the health practitioner/ patient relationship and surveys in New Zealand continue to show, deservedly says Evans, very high levels of trust in our health system and health professionals. “But all you need is a couple of big incidents and that trust can be damaged and it takes a very long time to rebuild it.”
Quake drives shared electronic health record
Christchurch is home to the country’s most extensive electronic shared care record known as eSCRV. It was lessons learnt from the quakes that drove the development of eSCRV which district nurses for one are describing as “revolutionising” their work. In post-quake Christchurch with hospital services stretched, some general practices and pharmacies closed (or their computer systems down), sharing Intro ??????? health information was more important than ever but there was no simple mechanism to do so. Sheree East (left), director of nursing for Christchurch community health service Nurse Maude, says post-quake there were not only particular concerns about the vulnerable elderly falling through the gaps but also valuable resources being wasted by double and even triple-up visits by services working in an information vacuum. So that was a driver for Canterbury District Health Board to start work in 2011 on a shared health record with general practices, Nurse Maude and community pharmacies that evolved into eSCRV (electronic shared care record view – see box). East says creating a privacy framework was the first task in creating eSCRV including developing a matrix of which health professionals could access which parts of the shared records and when and why. Nurse Maude at present only contributes its care coordination data and not its nursing data but in return for being a contributing partner its nurses can access eSCRV. The first handful of Nurse Maude nurses started accessing the pilot shared record from late 2011 with all its district nurses coming on stream at the start of 2013 when the record went live. “Nurses are telling me it has revolutionised their practice,” says East. “One told me it has added an hour a day back into her life. Which is huge when you look at productivity.” That hour was largely saved by not having to chase up referrals to and from other providers for her clients. East says consumers are often surprised to find their health professionals don’t already share health records and don’t realise that it just isn’t that easy to share information for privacy as well as IT reasons. “But they expect us to have a
seamless service and to protect their physical health safety by having the relevant information.” Instead most health professionals are still reliant on phone calls, faxes, and letters for sharing patient information. “When you are chasing pieces of paper around the system it makes you look really inefficient.” This is all changing with eSCRV. District nurses are telling East they can be more clinically accurate when they can have a patient’s recent clinical record up on a screen in front of them while taking a patient history. Likewise it saves on the patient’s time not having to repeat their entire health story and saves nurses time on the phone checking up on missing patient information or forgotten details. Test results now can also be quickly viewed and acted on. Also nurses can be proactive and stop unnecessary repeat testing or prompt testing if they see that health screening tests have been missed or lapsed. East says one nurse pointed out that she believes an electronic system is more secure as she doesn’t have to rely on referrals by fax that could be lost or seen by people who shouldn’t. Or having to phone somebody to get information, with the risk they could misinterpret what they are reading, whereas now she can read it for herself. Nurse Maude district nurses are also part of the Canterbury pilot of working at a higher level of multidisciplinary collaboration with long-term condition consumers to develop electronic shared care plans. East says the new ease of access to patient information also comes with responsibilities with a lot of time being into training into privacy plus how and when nurses can access eSCRV. Nurse Maude nurses ask permission of each patient to access their eSCRV and usually do so when the patient is present. Nursing notes are yet to be shared electronically but when they do if a nurse reviews and changes their notes the original notes are only “greyed out” so while not readable they are not lost from the system Each nurse also has to sign an access deed that outlines their obligations to only access a patient’s
shared care record to support direct patient care, to maintain confidentiality and not share their access code or password with anyone. The need to do this was highlighted by an investigation finding seven breaches of cricketer Jesse Ryder’s files while in Christchurch Hospital with two staff identified as having accessed the record via another staff member’s log-on (see online only sidebar story). The one positive of electronic records is, unlike the paper files of yesteryear, a snooper can now be traced. “We are always going to have to rely on ethical practice of health practitioners and people working in the health sector that they have that respect for people’s information but we will also now have the digital footprint as well,” says East. “At the end of the day we have to ensure we have informed everybody of their responsibility and they are committed to acting ethically and managing privacy as they should.” Because while the world may be sharing like never before the patient’s right to privacy remains sacrosanct and unchanged.
Quake drives shared electronic health record Out of the Canterbury quakes has arisen the country’s first shared electronic health record that can be viewed by community nurses, GPs, practice nurses, pharmacists and hospital doctors and nurses. Recent and relevant information from a patient’s general practice, community care, pharmacy and hospital files, including diagnosis, prescribed medications and test results, is now shared through a common portal - the eSCRV (electronic shared care record review) that is accessible by the health professionals caring for them. More than 400,000 people enrolled with a primary health organisation in the Canterbury DHB area now have their essential health information available and accessible through eSCRV on a need to know basis by their health professionals. So a practice nurse can see current diagnosis, medications, a discharge report and upcoming appointments but not anaesthetic assessment. Before going live the DHB promoted the opportunity for people to “opt” out of being part of Shared Care View and to date 207 people
have opted not to have any of their information shared. People can also opt to screen off aspects of their health history from being available on Shared Care View for example their sexual health history. More than 115 of the region’s 134 general practices are now contributing and accessing data via Shared Care View along with 106 of the 109 community pharmacies. Nearly 500 practice nurses, 102 Nurse Maude community nurses and Canterbury DHB nurses can also access relevant patient information via the portal. Audit processes are built into the system to signal if somebody has been accessing records of a non-patient and patients can ask who has viewed their record. If a health professional is found to inappropriately access information action could include being reported to the privacy commissioner or their professional registration authority. Canterbury DHB says the next priority for the scheme is to refine it for possible roll out to more South Island DHBs and then to look at patient access to eSCRV.
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FOCUS n eHealth / On the ward
Hello brave new world: farewell to unreadable medication charts Self-declared ‘BC’ (before computers) nurse Jodie Healey, once daunted by IT, is now the e-Medication clinical liaison nurse for Southern District Health Board. FIONA CASSIE talks to her about bringing her fellow ‘BC’ nurses over to the advantages of electronic medication management at the bedside.
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ou think the drug chart shows pain medication was last administered at 3pm or is that 5pm? But the dosage is undecipherable anyway … Safely administering medications in your average hospital ward can be a daily tussle to decipher doctor, pharmacist, or nursing handwriting – let alone the time spent trying to track down the drug chart. Electronic medication management eliminates problems with scribbled notes and lousy handwriting with a drug chart (MedChart) that Intro ??????? is viewable from any hospital computer and can be pulled up on a laptop trolley at the patient’s bedside. Jodie Healey is a convert but says as a ‘BC’ nurse, she was initially daunted by MedChart during its 2010 pilot in Dunedin Hospital. She was also worried that the methodical electronic tool may stymie a nurse’s practice but is now convinced it enhances practice. “MedChart is a system that replaces our paper chart but it doesn’t replace our clinical judgement.” Healey points out that nursing education doesn’t include deciphering handwriting. “This is a skill that is picked up on the job. As I have often said to prescribers through my nursing career – if I can’t read it … I can’t give it!” says Healey. “I’ve also found myself saying to the prescriber ‘if you make it legible, I’ll make it happen’.” With MedChart, prescribers can be paged and update a prescription from any computer in the hospital using their unique ID and password. When it comes time to administering medication the nurse picks up a ward laptop and takes it everywhere a paper chart would be taken – i.e. from the medication room where the medications are prepared and on to the bedside. There are up to five per ward for drug administration, so no queue in morning, and there are separate trolleys for prescribers. Healey says this is another plus for MedChart because, as a former resource nurse deployed to different wards most shifts, she quickly found that no ward had the same place to store medication charts and it took time to track them down. “On some wards, there could be two designated places – and then there were the random ‘drop-off’ zones like the bench, another patient’s clipboard, near the computer, the handover room or tearoom …” The nurse logs on to the laptop using their ID and electronic ‘signature’ password and 8
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accesses the patient’s chart, which opens on an administration medication chart that also provides information on any allergy the patient has, clinical decision support and any alert – like whether the patient is known to hide their medications. It also clearly shows when the patient’s next medication is due or has an ‘alarm clock’ symbol if it is overdue by more than an hour and a clinical decision needs to be made. In each MedChart ward, there is a ward overview screen up at all times, viewable by nurses (and not the public) that summarises which patients are due for medication and any that are overdue. Any attempt to catch up by administering medications to more than one patient at time is quickly frowned upon with Healey saying she tells any nurse attempting to do so that they were “in a very dark space in the nursing spectrum”. Once medications have been successfully administered, the details and any notes entered on screen the nurse logs out leaving an updated chart that is easily readable to the nurse on the following shift. Healey says MedChart replaces the ward’s Notes on Injectable Drugs (NOIDs), which is a much-loved manual but usually battered, stained, and sometimes missing the vital page. Nurses can now access NOIDs on the laptop in the midst of preparing patient medications. The nurse can still, if the order allows, use their clinical judgement on which medication route is the most appropriate for the patient. The MedChart alert system can also be used to inform a patient’s discharge notes. “If you receive a patient from ED at 9.30 at night with a Pak’n’Save bag filled with 15 medications – not all of them belonging to them – you can then put an alert on their chart to say ‘recommend this patient uses blister packs on discharge’,” says Healey.
Which is another advantage as while nurses have been known to complain over their medical colleague’s handwriting, Healey points out nurses should also spare a thought for prescribers trying to determine when a drug was last given from an administration chart filled in by nurses on the run. MedChart is slowly being rolled out to adult wards across the Southern DHB with one hour formal training on using the scheme – including emphasising how vital it is to protect your password – and then intense 24 hour phone support for first two weeks once a ward goes live. Healey says like any change it initially creates disruptions for nurses. While being able to ‘find’ charts easily does save time, some users feel MedChart takes longer to use the computer than in does a pen. “Speed does not always equate to safety and this is a patient safety system.”
MedChart summary »» Each nurse has unique ID number to access MedChart »» Also have individual password that acts as electronic ‘signature’ »» Does not replace nurse’s clinical judgment »» Laptop also used to update patient acuity for TrendCare »» But nursing notes and observations still recorded on paper charts.
FOCUS n eHealth / On the ward
An electronic portfolio record for nurses developed by Ngā Manukura o Āpōpō* (NMoĀ) – the Māori nursing workforce development programme – is now open and available to all nurses for free.
ePortfolio…
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reaking down the barriers for Māori nurses – especially those nurses working in the non-district health board sector – to accessing nursing portfolio systems was the initial aim of the Ngā Manukura o Āpōpō project team. “NMoĀ noticed that there were access gaps into programmes, evidence of professional isolation, paucity of nursing leadership within some organisations, and lack of support from some employers in allocating time for nurses to complete their portfolio,” says Liz Manning, a nursing workforce consultant who was the ePortfolio project manager for NMoĀ. The resulting ePortfolio was piloted from July to December 2012 and drew 44 nurses, including two nurse practitioners, more than double the initial target of 20 Māori nurses. Intro ??????? The success of ePortfolio was confirmed recently by taking out the Gold Award for Best Social Learning Platform at the 2013 Learn X Impact Awards. It now it is being made available to all New Zealand nurses for free. Manning says the vision was to explore options for streamlining, standardising, and improving access to portfolios in which nurses record their evidence of competence to meet Nursing Council requirements. The solution they chose was an easy-to-use online option that could be accessed on work or home computers, personal smartphones, iPads, and other tablets. DHBs and many other large health organisations use PDRPs (professional development and recognition programmes) but some nurses either choose or are unable to access them so NMoĀ concentrated on portfolios, says Manning. After reviewing the options available the project team turned to Mahara. Mahara is a collaborative venture between three universities and the Open Polytechnic that was funded in 2006 by the Tertiary Education commission to develop the learner-centred Mahara ePortfolio System. It is open-source software that is now used by institutes and organisations around the world. The MyPortfolio mode is used by more than 1200 New Zealand schools and has 46,000 active users. Mahara linked NMoĀ with Kineo Pacific who used the Mahara ePortfolio system to develop a nursing portfolio platform that wasn’t only user friendly for nurses but was also compatible with supporting the employers’, assessors’ and regulators’ roles in assessing ongoing competency. Manning says she and NMoĀ project lead Sonia Rapana facilitated a collaborative approach so the project could translate a platform initially designed for education to meet a health regulation role, including developing competency templates and other key documents
that users need to upload for evidential requirements. “The project team has been the key to success, with lead nurses from across the sector taking a role including Nurses Executives NZ, Nursing Council NZ, National PDRP coordinators and NZNO,” says Manning. The resulting ePortfolio is linked with Totara e-learning and is Moodle compatible. Users are able to upload and share their nursing evidence and developments online in a space that is controlled by NMoĀ as the hosting organisation. Rapana says the “dashboard” or front page of ePortfolio includes a checklist of portfolio items that you need to meet Nursing Council requirements and training videos. Nurses create their own profile and can conveniently copy one of the seven templates set up to cover the different competence requirements for different practice areas (i.e. clinical RN, policy RN, EN or NP). The ePortfolio platform can be used to find ‘friends’ also registered on the system and who is online at the same time. While it as “easy as Facebook” nurses are reminded that it isn’t Facebook and any content needs to be kept professional and meet Code of Conduct guidelines. *Ngā Manukura is a Ministry of Healthfunded Māori nursing and midwifery workforce development programme with three key work streams: clinical leadership, professional development (where the ePortfolio sits), and recruitment and profile-raising. Article material contributed by Liz Manning, consultant for Ngā Manukura o Āpōpō (NMoĀ), and Sonia Rapana, NMoĀ ePorfolio Project Lead (until recently assoc. director of PHC nursing for Lakes DHB).
Q&A about ePortfolio Q What is an ePortfolio? A ePortfolio is a tailored, online electronic platform for bringing together, holding and presenting evidence of your nursing competence. The same evidence nurses currently put into their paper portfolio. Q Who can use ePortfolio? A Nurses registered in New Zealand What does it cost? A Kore, nothing … Q Can I use this if Nursing Council of New Zealand audits me? A Yes, you just need to make sure that only the items Nursing Council have asked for are ‘shared’. Q How do I register? A Through the NMoĀ website www.ngamanukura.co.nz. Add your details and a password then you can start building your portfolio. Q What can I add? A You can type in case studies etc directly into ePortfolio templates. And you can scan (or take a picture) of any certificates and load the image straight into your portfolio. The option is also there to add audio, video and podcasts. Developers say it is as easy to use as Facebook. Q Who will have access to my ePortfolio? A Only you, until you ‘share’ any of your work with someone i.e. peer reviewer or assessor to verify your evidence.
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FOCUS n eHealth / On the ward
On the ward Nursing Review wraps up the year by profiling two nurses’ stories about what drew and keeps them nursing on the ward, and reports on a PhD researcher’s findings on why he thinks nursing on the wards never gets any easier.
Ms Median profiles
A few years ago, the Nursing Council drew up a profile of the “median” New Zealand nurse based on their workforce statistics. She was a ‘she’ (the vast majority of New Zealand nurses are), aged in her mid-40s, probably Pākehā and worked 0.8 in a ‘med/surg’ role for one of the three Auckland district health boards. FIONA CASSIE went searching for Ms Median and found Intro ??????? Adrienne Batterton from Counties Manukau District Health Board and Melissa Lee from Waitemata DHB. At 42, both are a little young for the profile. Their stories are individual but commonalities emerged from the two interviews. Both have 20 years in health behind them, both are mums of similar aged children, both have just started (or about to start) postgraduate study, and both say patient acuity and ward nursing is tougher than ever before but – while patient expectations are also higher – the patient experience and safety have improved for the better.
Taking the next step after 20 years Two decades on, nursing is the same but harder, says North Shore Hospital nurse Melissa Lee.
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ursing in North Shore Hospital for the past 20 years – 17 in the same acute orthopaedic ward – Melissa Lee has seen many nurses come … and many go. Still nursing at the hospital where she and her classmates did their clinical training, she can’t think of any of her year that are still on deck. At least four are now in medical sales. But Lee says she still enjoys nursing and the teamwork on the ward and works four shifts a week to fit around her primary school-age family. Though she also finds nursing more demanding clinically than ever before, with higher acuity patients and greater patient-centred care, and more demanding professionally, with the need to keep up her portfolio and be involved in auditing and research. The demand is to the point that next year she hopes to do some postgraduate study to build her research and writing skills – her first formal study since graduating from the then-AIT nursing school back in 1993 – and confesses to being more than a little nervous about stepping back into academia. Lee worked in retail and banking before beginning her nursing training in July 1990. “I’d left school early, and I wanted to do something more meaningful.”
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When she graduated in 1993, nursing jobs were scarce, and with graduates facing the catch-22 of needing experience to get a job, Lee jumped into the deep end and became a bureau nurse at Auckland Hospital. From Auckland, she went to the North Shore bureau, and finally, about a year after graduating, she gained her first full-time position at North Shore’s Ward 6. She recalls that first job as physical hard work – the average nursing ratio was six patients to one nurse and health care assistants were still to come. “I do remember having a pair of gumboots with my name on the side. It was a hard slog that I can vividly recall, particularly as it was a medical ward and I would be doing showering and basic cares till about 1 o’clock.” It was also a chance for Melissa, then in her mid-20s, to consolidate her nursing practice before moving across to ward 7, where she remains 17 years later. Lee says she imagined herself back then taking up her studies again and in time moving up the nursing ranks. But after having the first of her children at 30, she found it busy enough being both a mum and a nurse
FOCUS n eHealth / On the ward
in a demanding ward environment, and she has stayed in her comfort zone on the ward floor. “It is a very taxing job; you get here and hit the ground running from the morning until 3.30pm, and then you have to get home and do your other job,” says Lee. It is also not an easy climate to change jobs with so many new graduates and others keen to find posts. Now 42, she works four rotating shifts a week on the ward and juggles that with family. She looks fondly at the new graduates, “full of energy enthusiasm and charging around … I remember being like that, but 20 years down the track, it is quite tiring.” The full-on demand of an acute ward catering for patients such as road crash or fall victims sees very few senior nurses left on the team, says Lee. Most have moved into clinic work, education, or left the hospital altogether “because they get burnt out.” “The pressure is on now; patients have a lot higher acuity and are a lot more dependent.” The nursing itself is more patient-focused, more multi-disciplinary, and more technical, with the use of vacuum dressings and senior nurses now assessing and treating wounds. The patient load is unchanged, though, with Lee having five patients the day she talks to Nursing Review and six the day before. There are now two health care assistants on the ward, which helps a lot, Intro ??????? but the nurse is still responsible for their patients. She says new graduates can sometimes be overwhelmed after their evidence-based training to “find the reality is that it is still a very heavy, physical job” alongside the need to provide clinical reasoning to back your practice. Having just updated her nursing portfolio, she says the professional expectations of nursing today can be a bit overwhelming for “oldies” like herself, even though she’s only 42. Today’s ward 7 has a lot of new graduates and a lot of overseas-trained nurses. “I can be on a shift with me and seven Indian nurses from Kerala – and they are wonderful nurses. There are also lots of nurses from the Philippines and China. All wonderful nurses, but it takes them some time to get up to speed with the culture.” “But it’s a very demanding job – and after 20 years, I still get the same pay as someone who has been nursing five years.” “Nursing is probably the same but harder – there are more expectations on a nurse now,” says Lee. “There are a lot more people at the top monitoring you – putting in new policies and procedures and not really seeing the time that you have to do all these things.” Workload management tools like TrendCare also mean that if there is ever some spare capacity on the ward, then a staff member may be pulled out to help some other ward. So what has improved over the two decades? “I think the way we involve patients and their families in their care and care planning is better. Also, patients know their rights. So for the patient, the experience is better now.” If she had her time over, would she make the choice to go nursing again? “I’ve got an 11-year-old daughter, and I’m not encouraging her to go nursing … which is a bit sad.” But she adds that the graduates who join her team are still loving nursing and are really welleducated and keen on the profession. “So there are still a lot of pluses.”
Counties Manukau DHB nurse Adrienne Batterton struggled to get her first bedside nursing job in the early 90s, exchanged clinical work for health management ‘Civvy Street’ in the new millennium, and then two years ago, returned to the bedside as a clinical nurse.
Drawn back to the bedside
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hen Adrienne Batterton sat state finals in 1991, the job market for new grad nurses could only be called dire. Just a handful of her classmates had jobs to go to, and she wasn’t one of them. It was the year of the “mother of all budgets”, fiscal frugality was the climate of the day, and graduates struggled to get a shoe in the door of the big hospitals. Batterton had first started studying business but kept getting “extremely distracted” by the nursing texts in the library. “It was the science of nursing that first fascinated me.” So she switched to nursing training at the thenCarrington Technical Institute (now Unitec) in time to graduate into one of the toughest nursing job markets for many a decade. It sounds like déjà vu for the early 2010s. “Even back then, we talked about there being a seven year cycle in nursing. There’s either no nurses and lots of jobs or there’s no jobs and heaps of nurses. It was never very stable.” “But we all felt that if we hung in there and did some fill-in jobs that the DHBs – or CHES (Crown Health Enterprises) as they were called back then – would eventually give us a job.” Meanwhile, the later fashion of graduates crossing the Tasman to seek work was yet to emerge. Instead, the trend in the early 1990s was to look to the USA with the help of the Nurses Society. The starting salary of the equivalent of nearly NZ$100,000 compared to around $24,000 back home was also a drawcard. So Batterton and four nursing mates, having had no luck in New Zealand, made a flying visit New York in 1992 to sit the American licensure exam NCLEX before flying home to cross their fingers and wait up to eight weeks for the results.
Love and NWH change fate
Batterton was the only one of the five to pass, but while she was waiting, fate intervened in the form of National Women’s Hospital and love. Firstly, National Women’s offered her two days work a week, which she jumped at as a foot in the door. Secondly, she met the man who is now her husband. Looking back two decades on, she doesn’t regret her decision to stay put in Auckland. She says she always believed nursing would open up opportunities for her, and she initially envisaged this would happen through travel. “But my nursing career has offered me a multitude of opportunities and they have all been in my own backyard – I didn’t have to go very far at all.” The first of those opportunities was stepping up slowly and surely into a full-time position at National Women’s Hospital. She says while she was a “little bit bullet-proof” in her early 20s, her major recollection of those initial years was the collegiality and the teamwork, plus a more hierarchical nursing structure and some of the last of the “old school scary” nurses. Batterton says her early ambition was to be a charge nurse and she was “very lucky to have an amazing charge nurse at the time who supported me in that, and it was very encouraging.” It was in the days of Jocelyn Peach being director of nursing at Auckland, and Batterton says she took all the opportunities for in-house management courses; external postgraduate study was not the push at the time. She moved into an after-hours clinical nurse advisor role and then moved into an operating theatre role to widen her experience. “I pretty quickly worked out that wasn’t for me … I absolutely despised theatre nursing, >>
“But my nursing career has offered me a multitude of opportunities and they have all been in my own backyard – I didn’t have to go very far at all.”
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<< but luckily for me, a charge nurse role in women’s health opened up at what is now Counties Manukau DHB. I’ve basically been at Counties ever since.” Batterton says she was lucky again with her next boss as when she and her husband tried to start a family it unfortunately did not go smoothly for them. They decided to adopt, and in the meantime, she found continuing clinical nursing in women’s health just became “too difficult”. “My boss wouldn’t just let me plod along and wait for that to happen – she said come and do this while you are waiting.” The “this” was becoming a project manager for South Auckland’s acute hub project – which at that point was the biggest emergency department in Australasia – “a really exciting but slightly daunting job”. “I can remember having some incredibly deep, dark doubts about my ability to do that job, but as it happened, I really loved it. It was one of the best jobs I’ve had.” During her next job as acute care services manager, the couple adopted their son (now 11). “One ??????? week I was on the job and next week I Intro wasn’t,” recalls Batterton with a laugh. After her parental leave, she decided she didn’t want to go back to full-time work. So she rang a nursing colleague working in procurement and for the next eight years worked 0.7 as a procurement specialist for the DHB-owned shared services organisation, healthAlliance. During that time, the family adopted their daughter (now 8) – again followed by another rapid exit from the workforce for parental leave – and returned to the procurement role.
Jump in patient acuity an “eye opener”
“In 2010, I started to get the feeling there was more to life than contracts and buying big bits of machinery, and what I was really interested in was going back to nursing.” Yet again, her timing was not favourable, with the nursing job market tight following the global financial crisis (GFC), but in 2011, she successfully spotted a job as a clinical specialty nurse in quality and risk for surgical and ambulatory care (SACS) back at Counties.
“The patients were so sick and the complexity of care they required was just much higher,” says Batterton of that eye-opening exposure to a modern medical ward. “Ten years earlier, I reckon they would have been HDU patients – the patients were having massive surgery and had so many co-morbidities and needed complex interventions. It was drastically different from a decade before … though you have to allow for different specialties – women’s health is women’s health and highend general surgery is always more higher acuity – but this was noticeable.” She persevered and now works as 0.3 in the quality and risk nursing role after taking on a 0.4 clinical nurse specialist role in the acute pain service in May. The traditional path for her new CNS role is through post-anaesthetic/recovery nursing, but because of her senior nursing experience, the pain service was open to giving her a go as she could learn the clinical content. “I work 27 hours a week for both of my roles and the study requirements were 20 hours a week above that for a 30 point paper … with two kids, it was full on … a real challenge, says Batterton. “I just have to keep in my mind that anything that hard has to be worthwhile. Things that come easily are generally not that worthwhile.” Though extra study is now an accepted part of today’s nursing culture, her previous role as
“I remember care rationing when I was a new grad as well … it’s not a new concept in nursing,” The only sticking point was that having not nursed for more than a decade, she had to do a return-to-work course to regain her annual practicing certificate The eight-week course, with about 20 local and overseas-trained nurses, was a “real eye opener” for Batterton, who couldn’t believe the patient acuity during her Middlemore clinical placement in a general medical ward. “In the first two days I thought ‘oh my god!’” recalls Batterton, but she kept reminding herself how many fantastic nursing jobs would re-open to her once she had her APC. 12
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a charge nurse manager in the late 90s had also been “full on”, but a major difference was postgraduate study was never discussed and in-house courses were the norm.
Patient safety better but nursing more demanding
She doesn’t regret her return to clinical nursing. “I love it. Counties has a really unique culture and if that culture works for you it’s fabulous … and it works for me. I really love it.” The make-up of the nursing workforce has changed over the decades but the nursing ethos
remains the same. “The team work never fails to astound me. Some things never change.” “The most overwhelming thing that I’ve noticed, in terms of improvement, is patient safety. We’ve got much more wrap-around intervention bundles now on how to guide care; on top of your nursing gut instinct, there are also things like early warning systems, care pathways, deteriorating patient algorithms, and on-call patient-at-risk (PAR) nursing teams. “We are also now a lot more patient-focused or patient-centric in what we do.” That doesn’t mean care rationing is happening on hospital wards. “I remember care rationing when I was a new grad as well … it’s not a new concept in nursing,” says Batterton. “To me, care rationing is just another term for prioritisation of tasks. On the days when you have five very sick, high acuity patients to look after, you prioritise to get the job done and keep the patient safe. That hasn’t changed at all.” Batterton says it would have been wonderful to think you could give everybody a wash in bed or full nursing care services ‘like the old days’ but is convinced that patients are safer today than they were in the good old days. She says some people see the use of algorithms and pathways as a “dumbing down” of nursing. “But I say working with a tick box doesn’t absolve you of any responsibility to think critically. It doesn’t absolve you from assessing the patient and taking accurate and timely interventions.” Batterton says another thing that’s changed is patient expectations. “I think they want case management rather than nursing care sometimes.” Nursing may be no easier than ever before but Batterton doesn’t believe it has lost its heart or ethos. “I think the art of nursing is really alive and kicking – I see it every day when I do my clinical work. There are the nuances; there are the grey areas and the critical thinking and decisionmaking. There’s absolutely a place for people with loads of experience to bring the art of nursing to the bedside. Patients know that, and see that, and they comment when it happens.”
FOCUS n eHealth / On the ward
Missing in action:
rationed time leads to rationed care Missed care, rushed care, and tick box care plans … Researcher BERT TEEKMAN set out to find out was happening to bedside nursing and decided your average ‘med/surg’ nurse was definitely more sinned against than sinning under today’s managerial-focused health system. FIONA CASSIE finds out more.
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ert Teekman was puzzled. Student nurses kept coming back to his class reporting they weren’t seeing the nursing assessments they were taught actually being done by busy nurses on the ward. Patient’s vital signs were being taken, of course, but beyond this, nursing assessment was usually limited to a quick “how are you this morning?” Missing in action at the bedside was the in-depth and holistic health assessments the students were being taught as best practice. After doing a one-year stint on the wards as a clinical lecturer, Teekman started to think maybe they weren’t exaggerating. He began his PhD research with the aim of observing and analysing the use of health assessment in bedside practice and its impact on nursing Intro ??????? interventions in medical and surgical wards. Fairly quickly, he observed that holistic health assessment was rarely happening, with nurses instead rushing from one task to another. Seeing a nurse sitting at the bedside chatting to a patient was hardly ever observed. The nurses kept telling him the main obstacle to doing more was lack of time. Due to circumstances, he had to pause his research for three years. On starting again, he re-interviewed some of the nurses and it was apparent staffing levels had improved, workloads were more manageable, and stress levels
reduced. But the nurses also said that despite this, their nursing practice had little changed. He was even more puzzled and wondered why. “It’s easy from the outside to blame the nurse, and to a certain degree, and I hate to admit this, that’s how I started out as well … why aren’t they doing this?” recalls Teekman. His research focus shifted to what was really happening on wards. Why did nursing rhetoric talk about being “patient-centred” but in reality nursing on the ward floor was “task oriented” and focused on getting the job done? Why – despite improved staffing levels and an influx of new graduates with new ways of thinking – were ward routines and nursing practice remaining largely the same, despite nurses he talked to expressing frustration and distress with that way of working? “They look inwards and feel that they are failing, that they are failing their patients by not giving them the care you are supposed to give … and they look at themselves and their own time management.” But Teekman believed something else was amiss. He spent 41 days observing the bedside practice of 12 staff nurses working in busy medical and surgical wards and interviewing them afterwards. He also did an extensive literature review and decided to additionally interview seven senior nurses including charge >>
What do nurses think about nursing today?
Some findings from NZNO Employment Survey 2013 »» 46.4 per cent felt there were enough nurses where they worked to meet patient needs (public hospital nurses were least likely to report enough nurses). »» Two-thirds reported that having “too few nurses to provide safe care” was the most common unsafe event. »» Patient load, throughput, and acuity were all cited as having risen. »» Nearly one in five nurses were currently job-hunting, with half of those looking to nurse overseas or leave nursing altogether. »» 24 per cent had been affected by significant restructuring in their main employment in the past two years, including loss of senior leadership positions and reduction in nursing skill mix. »» 44 per cent said the restructuring had damaged their feelings about their employer. »» 82 per cent were positive about nursing as a career, 81 per cent were positive about their job satisfaction, and nearly 93 per cent believed the quality of care provided at their workplace was good. »» Half felt their workload was too heavy, about 60 per cent did not believe they were well paid for the work they did, and about 45 per cent felt under too much pressure at work. *Our Nursing Workforce: “For Close Observation”, NZ Employment Survey 2013, authors Dr Leonie Walker and Dr Jill Clendon, NZNO. **The 3rd biennial web-based survey of NZNO members was sent out to a ten per cent random sample (4571) of the NZNO’s RN and EN membership in February 2013. There were 1448 responses, which was a 32 per cent response rate.
Fairly quickly, he observed that holistic health assessment was rarely happening, with nurses instead rushing from one task to another.
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FOCUS n eHealth / On the ward
<< nurses, clinical nurse educators, and clinical nurse specialists. He concluded the failure to do in-depth health assessment and the inertia to break away from set ward routine was the symptom of a “deeper malaise” in the high-churn, high-acuity medical and surgical wards of today. “In the reality, it’s not so much what nurses do or not do – instead, it is the context in which they work which makes it really, really hard for them to nurse the way they think is appropriate.” Teekman looked to the British sociologist Anthony Giddens’ structuration theory to get an understanding of why nurses struggle to change ward culture and routines. Giddens concept of ‘structure’ is based on the idea that rules and resources make up the framework of social systems that both enable and constrain social activities like work. “Giddens says social environments, like workplaces, are developed by us, maintained by us, but are also imprisoning us,” says Teekman. “You can see that so nicely with nursing and ward routines but also in other professions with strong routine cultures. Nurses are more or less forced to comply with those routines, and if you don’t, colleagues will tell you ‘that’s not the way we do things here’. “Which makes it really difficult for nurses to stand up??????? and say ‘well I’m sorry, I’m going to do Intro this differently’,” says Teekman. A number of nurses in his research endorsed this by telling him ‘this is just the way things are’ and they didn’t have the freedom to make changes.
Management style and TrendCare takes toll on autonomy The 1990s introduction of generic management principles to the New Zealand health sector took its toll on nursing autonomy, believes Teekman. Along with dismantling nurse leadership, the 90s brought a new focus on productivity and technical advances that saw patient length of stay shorten and shorten, which meant that patient acuity got higher and higher. He says managerial rationalism is reflected in the new vocabulary that has infiltrated nursing practice since the 90s; language like ‘patient management’, ‘patient outcomes’, ‘bed management’, ‘patient turn-around targets’, ‘hot bedding’, and ‘cost effectiveness’. Teekman says the advent of the acuity-based nursing workload measurement tool TrendCare* (see box) followed nurse staffing levels being heavily reduced in the 1990s and attempts were made to better understand how to calculate a safe staffing level. TrendCare requires the nurse to fill in an acuity computer checklist for each of their patients based on their level of dependence – for instance, whether they are incontinent or have an IV. The software tool then calculates a workload in hours and minutes for their patient caseload. Teekman says on the face of it TrendCare is an excellent system for putting some rationale behind staffing levels and staffing deployment, but he got a mixed response to TrendCare from nurses on the wards during his research. “I have yet to come across one nurse who tells me that it is an accurate tool and that it is a true reflection of a nurses’ workload. I have 14
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spoken to a large number of nurses, many more than directly involved in the research, and they all have the same message; it is not an accurate tool, yet their workload is based on it. “Once it is introduced and becomes part of the routine, that system starts to dictate how much time you can spend on each patient. It also means that if you spend ten minutes more on one patient, then those ten minutes have to be taken from somewhere else as otherwise you wouldn’t be able to fit your workload in.”
Missing care
“Many patients now in a med/surg ward used to be in intensive care 25 years ago,” says Teekman. “They are now being looked after by nurses on the floor.” The high acuity, high patient turnover, and the administration demands of the modern med/surg ward mean nurses are “continuously struggling” to try and ensure that patients get the care that they require, says Teekman. “At the same time, they have to do that within the time calculated by TrendCare. What my research showed is that nurses start to manipulate what they do for patients and what they don’t do for patients. So they start to miss out some aspects of care …” Teekman says there is increasing discussion about ‘missed care’ in the nursing literature, but he argues that such cares have not been overlooked but deliberately left out as nurses ensure that they prioritise the ‘essential’ cares within the allowable time. Hence, it is more a case of care rationing, with nurses now adept at making calls about what is critical for patient survival, like medication and
IV care, and what is not, like mobilising a patient or taking them for a walk. Sometimes even hygiene care is reduced or dropped when nurses are pushed for time. Then there is the “one size fits all” approach to nursing or “a nurse is a nurse is a nurse”. Teekman says flexibility of bed use to increase hospital efficiency has resulted in increased case mix, a term used to indicate the placement of patients with different medical conditions into one ward. He believes the spread of patients over different wards means that nurses do not build up the same level of expertise as they could in the past. “Expertise is not something you can get from education alone, rather it is gained from education plus actual clinical practice and being confronted by similar cases time and time again,” he says. “Lack of frequent exposure makes it is more difficult for a nurse to quickly see whether a patient follows the expected trajectory towards recovery or whether there are early warning signs of complications.” Failing to pick up complications can lead to adverse events going to the coroner or health and disability commissioner’s office.
The interruptible health profession
It is colleagues not call bells that continuously interrupt nurses’ workflow, says Teekman, after closely observing general ward life for his research. Patients told him they “felt sorry” for busy nurses, so they held off using their call-button or waited until a nurse happened to come
FOCUS n eHealth / On the ward
into a room. But other members of the multi-disciplinary team (which has expanded significantly), nursing colleagues, and visitors felt less compunction at interrupting nurses, which along with phone calls and missing equipment and files, constantly broke up the workflow. He says because so many services have been outsourced in the drive for efficiency, nurses have become the default team member who spends hours searching for missing pharmaceuticals, unavailable dressings or equipment, insufficient linen, and many other essentials. Nurses were seen as an ‘interruptible workforce’ to the point that Teekman observed on more than one occasion a nurse setting out medication for a patient only to be disrupted by a doctor asking for, and then walking away with, the patient’s drug chart for a ward round. “What does this say about the value of nurses’ work?” “If a doctor can’t find a file or something they need for a patient, they go to a nurse,” says Teekman. Standing in a corridor one day, he watched a physio and a doctor bypass a group of talking doctors to find a nurse to answer their question. “I think nursing has always answered to the medical profession to a degree … but the health reforms??????? of the 1990s have placed another layer Intro on top of it, and that’s management. So nursing now in effect has a new master – the general manager – who says this is the way nurses have
to work. As a result of that, nurses have lost their autonomy. “Now in general wards nurses are ruled by the routines that have been placed upon them by generic management principles, and by ‘keeping to these rules’, the nurses themselves are continuously reinforcing work practices even if they are undesirable (Giddens’ structuration theory in action). “Nurses in the interviews would suddenly say: ‘Oh, yes, now I come to think of it, I can’t remember the last time I saw a nurse sitting at a patient’s bedside’. “Now, if you are a nurse, you know that is something nurses frequently used to do, particularly with a patient who was anxious or a patient who wanted to ask questions … now it’s more likely they would give the patient a pamphlet … and there’s an assumption that the patient will read it or that they can read it and understand it.”
Focus on patients lost
Teekman believes that while the rhetoric of modern health care is all “patient-centred” the managerial culture introduced from the 1990s onwards means the reality is “very, very different”. He says you could crudely sum it up that the ward nurses’ focus is now directed to looking after the organisation’s needs and routines rather than the patients. Including plugging the gaps left by other members of the multi-
disciplinary team – so senior nurses support junior doctors and nurses pick-up drugs that pharmacists can’t deliver. All of these activities impact on the actual time nurses need to do their own nursing role. “It’s worryingly different. It concerns me a great deal when I talk to a student who cries, ‘I wanted to do all these things for my patient, and I’m frustrated because I’ve not been able to give the care I wanted to give’. When you hear these things you really wonder what are we doing, and why is this continuing?” Teekman says he has come to the conclusion that autonomy is not something nurses will be given – it is something that nurses need to claim back. He stresses that his research and focus is on nurses caught in the routines of generalist med/surg wards. Clinical nurse specialists that came into the wards did have the autonomy and the time to focus on their patients. These nurses were able to carry out a complete assessment and used that information to write an individualised care plan. Teekman says ward nurses also have the knowledge and the skills to do that kind of work – what they don’t have is the time or the required level of autonomy. “As long as nurses don’t claim it, they will not have autonomy over the profession of nursing.” Bert Teekman RN PhD is the Programme Director for Massey University’s Bachelor of Nursing programme
Teekman says he has come to the conclusion that autonomy is not something nurses will be given – it is something that nurses need to claim back. TrendCare
The TrendCare patient acuity and workload management system was developed in Australia nearly two decades ago. It is being used as the main building block for the care capacity demand management (CCDM) system developed by the Safe Staffing Healthy Workplaces (SSHW) unit. The unit is a joint venture between the 20 district health boards and the New Zealand Nurses Organisation and grew out of a safe staffing inquiry report in 2006. CCDM was tested and evolved in three demonstration DHBs during 2010–11. It is now used in 13 DHBs and is soon to be rolled out to 16 DHBs. It uses TrendCare data to not only retrospectively measure and analyse workload – both core nursing and non-core administration – on a ward but in real time recognise when a ward is understaffed or predict ahead when more staff need to be added to a roster. The recent NZNO Employment Survey 2013 (see also other box) sought comments from respondents
in workplaces with CCDM/ TrendCare. About 25 per cent were aware of having a CCDM system and the survey authors say there was “evidence of a feeling of patchy implementation and variable benefit.” “Nearly half of those who knew about CCDM in their workplace felt uninformed about TrendCare and around a third used it.” About a third believed CCDM/ TrendCare had had no impact on their workload and only 3.5 per cent believed CCDM was improving their workload management. The authors added that additional comments were made about TrendCare, none of them were positive and the following comment was representative of comments. “….trend care (sic) is an absolute waste of time it does not work in real life …//… it is a joke the management is really fast to remove staff when they feel that we are overstaffed but never seem to replace staff when we need it.” TrendCare’s electronic tool calculates an estimate of the hours required for nursing care (based on patient acuity information and
average care times) and how many actual nursing hours are available that shift (after subtracting the non-core hours required for other activities like training and orientation). A nurse fills in the acuity profile for each patient under their care using one of the 110 different patient type profiles. TrendCare says it should take 10–15 seconds for a nurse to use their clinical judgement to fill in an acuity profile by selecting the appropriate variable for each acuity indicator – i.e. whether they can feed themselves or not, have continence issues, need extra emotional support, and their mobility level. The tool then calculates the nursing hours requirement for that patient based on data built on timing studies of patient care. Cherrie Lowe says the acuity system is “constantly reviewed and upgraded” through ongoing timing studies across a wide range of user sites. “They are reasonable averages considering an average skill mix of nursing,” says Lowe. She says TrendCare is based
on 20 years of research and development, the first decade in Australia but the last decade also in New Zealand and Asia. Lowe agrees that patient acuity is increasing due to an ageing population, increasing comorbidities, shorter length of stay, and increased surgery for high-risk patients, and this was reflected in TrendCare data. “Nurses as a profession need evidence of increasing workloads and this requires a scientific approach to measuring nursing workloads on a daily basis,” says Lowe. “Adequate funding for nursing services in New Zealand can only be achieved if nurses provide this evidence in an organised and uniform way.” She says like any tool, its benefits to nurses are determined by their skill and accuracy and recommends that “inter-rate reliability testing” of TrendCare users needs to be done annually to maintain skills and confidence in the system. “Nurses can become discontent with the system when they are not appropriately trained and/or competency based.” Nursing Review series 2013/2014
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EVIDENCE-BASED PRACTICE
The battle of the bugs Does taking good bugs (probiotics) keep bad bugs at bay in hospital? CLINICAL BOTTOM LINE: Taking high dose probiotics for 21 days does not prevent antibiotic-associated diarrhoea or Clostridium difficile diarrhoea in stable older adults receiving oral or intravenous antibiotics in hospital. CLINICAL SCENARIO: Efforts to reduce the incidence of hospital-acquired infections have concentrated on hand hygiene, as well as isolation procedures and antibiotic stewardship. Past reviews have also suggested lactobacillus (probiotic) preparations may prevent antibiotic-acquired diarrhoea, but the evidence is based on small trials. A large trial suggests otherwise and necessitates closer review. QUESTION: Among hospitalised older adults, do probiotics reduce the incidence of antibiotic-associated diarrhoea? SEARCH STRATEGY: PubMed – Clinical queries: Probiotics AND hospital AND adults AND diarrhoea. CITATION: Allen SJ, Wareham K, Wang D, Bradley C, Hutchings H, Dhar A, et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): a randomised, double-blind, placebocontrolled, multicentre trial. Lancet 2013;382:1249-57. STUDY SUMMARY: Two-arm, pragmatic, double-blinded, randomised controlled trial conducted in five hospitals in Wales and England from 2009. 17,420 patients were screened, 3202 were not eligible, 9068 declined to participate, and 2981 were randomised. Included participants were hospitalised adults aged 65 or older who were either about to start or had already had one or more oral or intravenous antibiotics in the previous seven
days. Exclusion criteria were existing diarrhoea, immunocompromised to the degree that isolation or barrier precautions required, high dependency or intensive care patient, had prosthetic heart valve, Clostridium difficile diarrhoea in preceding three months, inflammatory bowel disease that needed treatment in previous twelve months, suspected pancreatitis, known abnormality or disease of mesenteric vessels or coeliac axis, jejunal tube present, previous adverse reaction to probiotics, or unwilling to discontinue current use of probiotics. Intervention (n=1493): Capsule containing lyophilised powder containing 6 x 106 live bacteria from two strains of Lactobacillus acidophilus and two strains of bifidobacterium (B. bifidum and B. lactis) once daily for 21 days. Control (n=1488): Capsule containing maltodextrin powder once daily for 21 days. OUTCOMES: Primary outcome measures were occurrence of antibiotic-associated diarrhoea (AAD) or Clostridium difficile diarrhoea (CDD), with diarrhoea defined as three or more loose stools in a 24 hour period. Stool samples were collected during episodes of diarrhoea. Secondary outcomes included severity and duration of diarrhoea, abdominal symptoms, serious adverse events, duration of hospital stay, acceptability of the microbial preparation, and quality of life . VALIDITY: Randomisation – computer-generated randomisation using variable sized blocks, stratified by study centre; Allocation concealment – not described, but likely to have been addressed through blinding mechanism. Complete follow-up – almost complete follow-up with only 40 lost or excluded from analysis (1.3per cent);
Table. Nosocomial infections rates Outcome AAD CDD Serious adverse event
Probiotic (n=1470) 159 10.8% 12 (0.8%) 294 (20%)
OR = odds ratio; 95%CI = 95% confidence interval 16
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Placebo (n=1471) 153 10.4% 17 (1.2%) 284 (19.3%)
OR (95%CI) 1.04 (0.83 – 1.32) 0.70 (0.34 – 1.48) 1.04 (0.87 – 1.25)
Intention-to-treat analysis – modified intention-to-treat analysis with a small number (1.5 and 1.1per cent in each group) excluded from the analysis because the allocated intervention was not known (labelling error), the participant did not receive the intervention, or was lost to follow-up; Blinding – participants, study staff, and analysts were blinded to assignment; Equal treatment – appears equal on type, number and duration of antibiotic use; Baseline comparability – appears equal on demography, source of admission, smoking and alcohol use, previous admissions and comorbidity. Overall impression is that it was a high quality study. RESULTS: Mean age of participants was 77 years. About 49 per cent of participants were female, more than 90 per cent had been admitted from own home, and about one third had been in hospital within the previous eight weeks. About 4 per cent had taken probiotics or yoghurt within the previous two weeks prior to the trial. The incidence of AAD was 10.6 per cent and the incidence of CDD was 1.0 per cent. There was no difference between the groups (table). The median duration of hospitalisation was four days and no different between the groups. The incidence of serious adverse event (death, life-threatening event, prolonged hospitalisation, or other serious medical event) was 19.7 per cent, no different between groups and no serious adverse event was ascribed to the treatment. COMMENTS: Trial funded by NIHR Health Technology Assessment programme and registered on the ISRCTN WHOcompliant trials registry. Previous systematic reviews have suggested probiotics prevent AAD or CDD. Although this trial finds no effect for probiotics, when added to meta-analysis from those previous reviews, the meta-analysis still suggested probiotics reduce diarrhoea in older adults. Raises the question of what evidence to believe – a meta-analysis of small poor quality trials or a large trial? Reviewer: Dr Andrew Jull, RN PhD, Associate Professor, University of Auckland & Nurse Advisor – Quality & Safety, Auckland District Health Board.
WEBSCOPE
Global talk and local action KATHY HOLLOWAY challenges nursing in New Zealand to connect globally including seeking out and learning from the findings of UK’s Francis Report into caring failures at Mid-Staffordshire
T
he use of information and communication technology (ICT) and the internet are growing in all regions of the world. As of 30 July 2012, there were nearly 2.5 billion Internet users globally – which represents just over a third of the world’s population (Internet World Stats, 2012). Social media is now well established as an integral part of our information gathering and sharing strategies, as well as revolutionising the way we communicate. This applies to the area of healthcare as with all aspects of society. High levels of connectivity in healthcare have the potential for both benefit and harm. Often the focus is around the inappropriate use of social media and the lack of professionalism shown by some individuals resulting in harm. Recently, the Nursing Council of New Zealand released guidance for registered nurses on the use of social media www.nursingcouncil.org.nz/content/ download/549/2254/file/Guidelines%20 Social%20Media.pdf. There are great benefits for healthcare consumers also in terms of connectivity between expert patient groups, support for selfmanagement of health and transparency in patient experiences, which have been discussed in previous columns. Being connected as a registered nurse increases your chances of being aware of current professional debates and gaining learnings from across the globe. This is a professional imperative for reflective, evidence-based nursing practice. As one example, take the crisis in care provision that surfaced in the NHS Mid Staffordshire Trust ospital in the United Kingdom in 2010 – see www. theguardian.com/society/mid-staffordshirenhs-trust. The ensuing investigations, inquiries, and reports have been studied by health systems around the globe including our own Ministry of Health. The reports and resulting discussions and responses from the NHS are all available online. In October 2013, the New Zealand Health Quality and Safety Commission hosted a workshop on reflections from the Mid-Staffordshire Trust NHS Foundation Inquiry. The YouTube presentation at this workshop from Robert Francis QC is available on the website and provides a valuable lesson for all of us who work in healthcare.
Professor Don Berwick, an international expert in patient safety, was subsequently asked by the Prime Minister to carry out a review following the publication of the Francis Report into the breakdown of care at Mid-Staffordshire Hospitals. Professor Berwick’s report can be accessed online www.gov.uk/government/publications/ berwick-review-into-patient-safety. Four key guiding principles for change were detailed by Professor Berwick in a letter to NHS clinicians asking them to incorporate these into their daily work the following: »» Place the quality and safety of patient care above all other aims for the NHS. »» Engage, empower, and hear patients and carers throughout the entire system, and at all times. »» Foster wholeheartedly the growth and development of all staff, especially with regard to their ability and opportunity to improve the processes within which they work. »» Insist upon, and model in your own work, thorough and unequivocal transparency, in the service of accountability, trust, and the growth of knowledge. I would invite you to consider these four principles in your own practice environment and discuss with your colleagues the concept of a duty of candour*. More reports and reviews are being published as a wider review of the NHS is undertaken. The most recent on October 28 is a review of the NHS hospital complaints system www.gov.uk/government/publications/nhshospitals-complaints-system-review, which I am sure will also be reviewed by our Health Ministry. In last month’s Nursing Review, Dr Jo Walton reminded us that we can’t address what we don’t acknowledge. Being aware of and engaging in global conversations can support us to acknowledge issues and identify solutions in relation to our professional responsibility to deliver safe and effective health care to the communities we serve. With awareness comes choice. Kathy Holloway is dean of the Health Faculty at Whitireia Community Polytechnic * See Health Foundation ‘duty of candour’ blog at: www.health.org.uk/blog/ why-do-we-need-a-duty-of-candour
CHECK THESE OUT
Healthcare and Quality: Perspectives from Nursing – Online Issues in Nursing Journal www.nursingworld.org/MainMenuCategories/ ANAMarketplace/ANAPeriodicals/OJIN/ TableofContents/Vol-18-2013/No3-Sept-2013 This edition of the international peer-reviewed publication provides a forum for discussion of the issues for nurses in the healthcare and quality space. The intent of this journal is to present different views on issues that affect nursing research, education, and practice, thus enabling readers to understand the full complexity of a topic. This topic is from September 2013 and very relevant to this month’s column with six articles on various aspects of healthcare quality and patient safety. Of particular interest is an article about new graduate nurses and academic service partnerships (a matter close to my own heart). Follow the journal on Twitter at @ANAOJIN [Site accessed 9 November and last updated November 2013].
Open for Better Care campaign http://www.open.hqsc.govt.nz/ The New Zealand Health Quality & Safety Commission (HQSC) is undertaking a national patient safety campaign, Open for Better Care to reduce harm and improve quality and safety in health and disability care settings. The campaign website launched in September 2013 and focuses on four priority areas where evidence shows change can reduce patient harm. Those areas are: falls, healthcare associated infections (HAIs) – specifically, surgical site infections (SSIs) – perioperative harm, and medication safety. The website has many free resources and updates in relation to DHB engagement with the four key areas targeted. [Site accessed 9 November and last updated November 2013].
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COLLEGE OF NURSES
Judy Yarwood
Good gals doing what good women do… It is 50 years since College of Nurses co-chair and nursing lecturer JUDY YARWOOD donned a starched nursing cap for the first time. She reflects back on those five decades plus on caring and care ‘rationing’ for today’s nurse.
I
entered the nursing profession 50 years ago as a young idealist, never imagining I would still be at it five decades later, albeit in a difference guise. In the 1960s, nursing was seen as a very suitable profession for a young woman, not to mention great preparation for domesticity and motherhood! At the tender age of 17, accompanied by my mother, I entered the nurse’s home, not unlike entering a nunnery, I thought at the time. There waiting in my allotted bedroom were the three other young things I was to share the room with –and the uniforms that we were instructed to don. Struggling with starched collar and caps, not to mention cufflinks to hold everything together, we shyly dressed, watching each other take on the mantle of student nurse – much like convent novitiates. Those young women were to become my lifelong friends. Celebrating 50 years in a profession does lead you to reflection. Firstly, where on earth did those years go? And secondly, how has the profession changed over that time? On reflection, apart from much higher levels of acuity in hospitals now and only having one day off a week back then, nursing is much the same, as we deal mostly with people. Nursing in the 1960s mirrored the society of that time. It was hierarchical, steeped in biomedicine, patriarchal, and women knew their place. We were, by and large, very proud of our profession and were respected for what we did – good gals doing what good women do! So how much have things changed? Certainly, the second
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wave of feminism flew through, although how much this movement influenced nursing is debatable. Nursing education moved, slowly, away from the apprentice-style bedside training into educational institutions, a move some still question. Patientcentred care emerged, as did a push to professionalise nursing. Today registered nurses (RNs) are no longer just RNs, they are nurse specialists, consultants, practitioners; and district, practice, or public health nurses – enough roles and titles to confuse even those familiar with them. Patients (they were all called patients in the 60s), clients/residents/ people, however named, are often confused by who does what – the last thing we want for people navigating our complex health system. Gloria Smith, a much admired nurse scholar, in a recent guest editorial questioned nursing’s focus on professionalism at, what she saw, the detriment to our ability to care. I thought of Gloria recently when I read that some nurses felt they had to ‘ration’ their nursing care. How do you ration what is fundamental to nursing practice? However you may define it, ‘caring’ is what nurses do – we care about, and for, people in sickness and in health. Sounds like those marriage vows we used to take, but that is what we do. I’m not going to say we did it better back in the 1960s. But I will question why is it, when we have an amazing array of knowledge, skills and understanding at our fingertips, we have to ration what we do best, providing nursing care. If health care delivery – be it in hospital or the community – is so pressured and economically-
Judy Yarwood (right) on ‘study day’ with mates Joan McMaster (left) and Tricia Warhurst (centre) in Hagley Park near Christchurch Hospital
driven that nurses feel they need to ration their care, then what is the profession doing about it? It’s not possible to compare one era with another. Neoliberalism, well under way in the later decades of last century, galloped into the 21st century foisting rampant capitalism and consumerism on us as never before. And yet underneath all this upheaval, people are still people, we still want to love and be loved and feel as if we can make a difference. Which brings us back to nursing in the 21st century when it appears to be more challenging to be a successful nurse than back in the 60s … Looking ahead to the next 50 years, we’ve got a pretty good idea that long-term health conditions, such as diabetes, heart disease, and cancer, will be topping the list of health needs and that the impact of social determinants on health (described by WHO as the ‘conditions in which people are born, grow, live, work, and age …’)
will be more to the fore than the biomedical approach of the past. Over the last decade or so, two key strategies have positioned nursing well to play a strong role. The first, the Primary Health Care (PHC) Strategy identified RNs as key players in improving health care delivery and addressing health inequalities. The second saw nurse practitioners (NPs) emerge with much to offer, especially for those who find access to health care difficult. Nursing leadership was, and is, crucial to the success of both. Not hierachical leadership as we knew it in the 1960s, but leadership through collaboration, advocacy, and political involvement. To conclude, I sometimes wonder if we truly value what nursing has to offer. Perhaps a focus on valuing and respecting, rather than rationing what we do best would benefit everyone, especially those most in need of our nursing care.
Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy Jo Ann Walton
A LETTER FROM LONDON: WHO ARE HEALTH SERVICES SERVING? JO ANN WALTON writes from London about lessons to be learned from yet another NHS bad news story – this time one where ‘bullied’ health staff falsified cancer patient waiting lists to keep funding flowing.
I AM WRITING THIS from a desk at City University in London. I am here to discover more about nursing and health matters in the United Kingdom and future learning and sharing opportunities. Something that is becoming all too familiar here is the constant media attention on problems in the National Health Service. It seems that the media tell a new and shocking story nearly every day. I have written before about the Francis Inquiry and related stories continue to appear. Happily, while here I have met many influential leaders making a difference in meaningful ways. So there are good stories to be told …
Yet another shocking NHS story… Perhaps I ought to apologise about writing about yet another of the bad NHS news stories. This is the story of Colchester Hospital, where the CQC (The Care Quality Commission, Britain’s health watchdog) has reported staff were “pressured and bullied” into falsifying cancer patient waiting time statistics in order to meet government targets. The CQC reported the Colchester Hospital University Foundation NHS Trust to police, with the media suggesting criminal charges may be pending against some managers involved. It is believed the falsification, involving up to 6,000 patients, may have led to several patient deaths. The story is shocking and worrying. How does it happen that a health service industry – whose purpose is the treatment of illness and injury – can inflict such harm? How could managers be so out of touch with their industry’s purpose that they force employees into such unethical and dishonest behaviour? What is happening in the lives of the “pressured and bullied” staff that enough of them are ready to comply? And how, after all the publicity surrounding the Mid Staffordshire inquiry, could managers ignore staff warnings of major problems within their own health service? From news reports, it appears that the situation was brought to senior managers’ attention by both nursing and administrative staff, along with professional groups’ representatives, but the warnings were ignored. It is understood a union group were the whistleblowers who informed the CQC. It is also alarming that several NHS quality reviewers failed to notice the tampering of dates in patient records >> Nursing Review series 2013/2014
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Practice, People & Policy RESEARCH >>
Better whistleblower protection needed here? The Colchester case also provides food for thought in New Zealand. I have written before about the need for nurses to have the courage to speak out. It is easy for frontline health workers (the majority nurses) to be blamed for problems in health care. But nurses are not responsible for all things that go wrong. Do we need better systems of whistleblower protection? Or are we already able to tell the truth about systemic problems to the right people at the right time? Do we have a suitable mechanism for identifying and investigating systemic problems? Does the New Zealand health system have adequate safeguards? Britain’s Care Quality Commission and their Chief Inspector of Hospitals are charged with reviewing the quality of health care across the UK. It was during a visit by the CQC that the problems at Colchester finally came to light. The Colchester Hospital case raises serious issues about the disconnect between financial incentives and the core business of a health service. When entire systems are dependent for their funding on meeting “quality measures” (that may not actually measure quality), we shouldn’t be surprised that perverse incentives kick in. At Colchester Hospital, records were presumably falsified so funding streams would continue. The money kept flowing, as it appeared Colchester was ‘delivering’ the desired outcomes. My hunch is that the money would have stopped if the truth had been told. This would not have helped patients on the waiting list, either. So this aspect of the health funding system was also flawed. How well are our quality measures reflecting health service functioning?
Who are health services serving? A third aspect to be explored is the cohesion of purpose (or lack of it in Colchester’s case) across the entire health services team. Successful businesses have a common vision and purpose from top to bottom of the business. From the board room to the front of house, everyone knows and agrees what they are there to do. Clearly something went wrong with the vision at Colchester. Is your workplace one where governance, management, and frontline operations (nurses and doctors to porters and cleaners) all know who and what they are there for? From the times of ancient Greece, we have known that patients require a team effort for them to get well. While sightseeing at the National Science Museum, I found a quote from Hippocrates in medical history exhibition. Actually, it is the first of his Aphorisms, which have informed medical practitioners and scholars for centuries. Here’s what he said: “Life is short, the craft long to learn, opportunity fleeting, experiment deceptive, and judgement difficult. Not only must the physician be ready to do his duty, but the patient, the attendants, and external circumstances must all conduce to a cure.” Is our health system conducive to curing patients? What do you think? I would love to hear from you. Jo Ann Walton is Professor of Nursing at Victoria University of Wellington and an elected member of the Nursing Council. 20
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VIGILANCE REQUIRED IN MEDICATIONS FOR THE OLDER ADULT Dr Anecita Gigi Lim backgrounds adverse drug events for the elderly and how to avoid them.
Adverse drug events are prevalent and can lead to serious or potentially fatal outcomes for older adults. This is a particular concern because we are seeing a rapid rise in the proportion of older people in our population. However, to date there is only limited research that addresses drugs and related adverse drug events specific to older people. Older adults are increasingly susceptible to adverse drug events. Generally, the older population will have a greater number of co-morbidities, with the implication that they will be polymedicated with many different kinds of drugs. There will also be age-related changes in the physiology of the body that will alter the pharmacodynamic and pharmacokinetic mechanisms through which a particular drug affects the body or conversely the way in which the body deals with the drug. It has been suggested that almost 50 per cent of adverse drug events in older adults are preventable, and so appropriate pharmacovigilance may well serve to avoid such unnecessary harm. Understanding the early signs of adverse effects would allow for earlier detection of an inappropriate medication and serious adverse drug events could be avoided as a result. Moreover, the initial dosing of medication and subsequent monitoring and evaluation of the given therapy is crucial to the safer management of the older patient and awareness of these various parameters is essential as an appropriate preventative measure. A student summership project was undertaken in 2010 by Tony Lee (3rd year medical student) to re-examine those medications that most commonly
Dr Anecita Gigi Lim
(and the resulting false statistical returns) until the whistleblowers’ information was taken seriously. Unsurprisingly, UK unions are now calling for better protective legislation for whistleblowers.
cause problems when prescribed to the elderly. Specific criteria were drawn up from the information gathered to inform current research on psychotropic drugs and their use in the older population. The purpose of the review was to enhance the understanding of drugs that are highly likely to cause adverse drug effects in the older adult population. The results of the literature review identified a group of medications that most commonly cause adverse effects in the older population. These are antidepressants, atypical antipsychotics, cholinesterase inhibitors, benzodiazepines, and statins. Each class of medication had a specific set of common adverse effects and more serious adverse drug effects such as falls, cerebrovascular adverse events and rhabdomyolysis were associated with some medications. The review found that there are a range of adverse effects that are associated with each class of drug. These adverse effects are more likely to occur in elderly patients. As older patients tend to have poor functioning liver and kidneys, they are highly susceptible to develop these adverse effects. Nurses must therefore ensure that they monitor the older adults for these adverse effects. Overall, for many of these drugs, dosing should be carefully initiated within the ranges recommended for older adults, and limited to the smallest effective dose particularly with benzodiazepines and statins. Also critical to safe care is appropriate prescribing of medications depending on patients’ renal and hepatic status and close monitoring of medication levels when renal and/or hepatic function is impaired. It is therefore important that nurses in particular are aware of these factors. References available on request. Author: Anecita Gigi Lim, RN PhD is a senior lecturer at the University of Auckland nursing school and coordinates three prescribing papers.
A round-up of national and international nursing news
For the record NPs delighted to gain same prescribing status as midwives and GPs by FIONA CASSIE THE NURSING SECTOR’S patience has finally been rewarded with the passing of a bill that grants nurse practitioners equal prescribing status to GPs, midwives, and dentists. Nurse practitioner leaders Dr Michal Boyd and Rosemary Minto say NPs are “delighted” and “relieved” that the Medicines Amendment Bill 2011 has finally been passed. Likewise, College of Nurses director and longstanding nurse prescribing advocate Dr Jenny Carryer said it was wonderful to have the bill passed “at last” to “free NPs to do what they are qualified to do”. Temuka NP, Sharon Hansen, who is also deputy chair of the Rural General Practice Network, has described the bill’s passing as a “good start” to overcoming legislative barriers hindering NPs working at the top of their scope. The long-awaited change from designated prescriber to authorised prescriber means NPs are no longer limited to prescribing from a gazetted list of medications but can prescribe all medicines relevant to their scope of practice. They can also now, like their GP colleagues, issue and supervise prescribing standing orders for registered nurse colleagues. “It is great news for NPs who are struggling to provide essential services to patients, for example, prescribing opioids, and who can only prescribe three days worth under the current legislation,” said Minto, the immediate pastpresident of the NZNO College of Primary Health Care Nurses. She said this has been an unnecessary barrier for patients and created more hardship by more prescription costs or the need to see more than one provider. The first NP was approved by the Nursing Council to prescribe a decade ago and the lobbying began soon after to remove some of the cumbersome barriers to NP prescribing, leading in 2007 to the first bill being tabled (the later shelved Therapeutic Products and Medicines Bill) that proposed authorised prescribing status. Carryer noted that the “world of health policy and legislation moves so slowly” but now the bill had been passed, it “paved the way for RN prescribers and much greater
consumer access to care”. Minto said it was also a boon for NPs who wished to mentor or be clinical supervisors for NP interns. “It will take some of the load off busy GPs and doctors who historically have been providing oversight for these NP students.” Hansen said it was heartening to see the support of the work NPs do as the restriction placed on NP prescribing had been an “ongoing source of frustration” and a significant barrier for patients requiring controlled medications. The Rural General Practice Network chair and GP Dr Jo Scott-Jones said the move was an appropriate acknowledgement of NP’s skill, training, and responsibilities. “Rural primary care services remain at significant strain due to the continued pressure of attracting health professionals into rural areas. The ability of NPs to prescribe more freely can only be good news for patients in the communities where they serve.” Boyd, a leading NP and former head of Nurse Practitioners New Zealand, said she was delighted to see the bill finally passed. A year ago, as then-NPNZ leader, she expressed frustration that the long awaited bill’s fine print said it would not come into effect until July 2014. A spokesman for the Associate Health Minister Peter Dunne said at the time “that no delays were anticipated” and the commencement date was expected to be “well before” July 2014. But in a statement to acknowledge the passing of the bill, the current Associate Health Minister, Todd McClay, said the default commencement date for the prescribing changes was still 1 July 2014 and the default commencement date for amending the medicines approval process was 2017. He said the bill was an “interim measure until such time as the Therapeutic Products and Medicines Bill is passed”. The bill also gives authorised prescriber status to optometrists so both NPs and optometrists are now aligned with medical practitioners, midwives and dentists and can “prescribe all medicines appropriate to their scope of practice”.
NEWS BRIEFS More PHC nurses credentialed in MH Eight primary health care nurses recently celebrated being credentialed for their mental health skills. The Manaia Health PHO in Northland was the first primary health organisation to take a group approach to the credentialing programme offered by the College of Mental Health Nurses with the support of Health Workforce New Zealand. Associate director of nursing, Mary Carthew, and primary mental health nurse, John Hartigan, were the advocates that led to a six-day MH training programme being developed and delivered over six months to the eight nurses. The nurses reported an enhanced level of confidence to screen, assess, provide brief intervention, and refer people experiencing mental health and addiction issues following the programme, which included group supervision.
Old healthy food pyramid dropped The old healthy food pyramid is being dropped by New Zealand Heart Foundation in favour of a new “healthy heart” guide. Delvina Gorton, the foundation’s nutrition advisor, said it had swapped the traditional food pyramid for its new ‘healthy heart’ tool that shows ‘at a glance’ the balance of foods to eat most of, eat some of, and cut back on. “Apart from the new shape, the biggest change is that vegetables and fruit are at the top and claim the biggest proportion of the heart to show we should ‘eat most’ of them.” The foundation’s website www.heartfoundation.org. nz/healthyheart has an online tool that helps you build a shopping list and experiment with recipes to put the Healthy Heart Visual Food Guide into play.
HPV website launched A new one-stop shop website for information on genital HPV, vaccines, and cervical and throat cancer has gone live. The site has been launched by the New Zealand HPV Project and says it provides up to date information on human papilloma virus (HPV) including “that most people will get HPV at some time in their lives but for most it will be transient and will go away without causing significant health problems”. The site also provides the latest emerging knowledge about the wider implications of HPV involvement in throat cancers, as well as the genital tract of both women and men. Check it out at: www.hpv.org.nz
Nursing Council rejects Government push for merger The Nursing Council has voted to reject a Governmentproposed merger after 98 per cent of submissions backed the council staying a standalone entity.
More than 1330 job-hunting new nurses have fingers crossed More than a third of the country’s new nurses are competing for just 53 positions currently on offer through the Auckland District Health Board.
Celebrating 40 years since nursing training first left hospitals Four decades on from nursing training first taking the leap from hospital to tertiary-based training is to be celebrated in Christchurch later this month.
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