Issue 1 February/March 2018
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Free 60-minute PD learning activity Identifying and managing workplace bullying Leadership & Management Jane O’Malley moving on
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Contents
ED’s letter
Inside:
The “triple impact” of nursing on global health and wealth
Our international nursing theme edition will arrive in your letterbox or on your tearoom table soon after the launch of the global nursing initiative Nursing Now. While this Nursing Review focuses on Kiwi nurses using their profession as a ticket to see the world and/or make a difference, Nursing Now looks at how strengthening nursing globally can make its mark on the world’s health and wealth. The campaign grew out of a report by the UK’s All-Party Parliamentary Group on Global Health, led by former chief executive of the National Health Service (NHS) Lord Nigel Crisp, and is being run in collaboration with the World Health Organization (WHO) and the International Council of Nurses (ICN). The UK ‘Triple Impact’ report argues that achieving the ambitious United Nations target of providing universal health coverage for the world’s people cannot possibly be achieved without strengthening nursing globally – not only by increasing the number of nurses (currently the US has around 30 times more nurses per 1,000 people than Mozambique and Ethiopia), but also, and crucially, by ensuring that nurses’ contributions are acknowledged and they can work to their full potential. The report goes on to argue that boosting nursing globally will have a triple impact as it can improve people’s health and can also have major effects on gender equality and countries’ economies. By developing and investing in nurses – the vast majority of whom are women – new community leaders who can act as role models and mentors to other women and girls are created; women gain economic independence and empowerment; and local economies are strengthened. Nursing Now has gained the support not only of WHO’s new chief nurse, Cook Islands nursing leader Elizabeth Iro, but also of HRH The Duchess of Cambridge; both will be at the London launch on 27 February. By putting nursing at the forefront of politicians’ and policy-makers’ minds and enabling the richest countries to work with some of the poorest to support investment in nursing training, the aim is that nurses will be able fulfil their potential of making a difference to the world’s health. NB: Our 60-minute professional development article and learning activity this edition looks at the troubled issue of bullying within nursing – check out Do nurses ‘eat their own’? Identifying and managing workplace bullying on page 18. Fiona Cassie, Editor editor@nursingreview.co.nz www.nursingreview.co.nz Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
News
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Round-up: News briefs + Bulletin board + Nurses on the move
Focus: International Nursing
4 6 8 10 12 14 15
Short, sharp but satisfying volunteering Training new nurses in post-war Bougainville Overseas volunteering options for Kiwi nurses The big (nursing) OE Crossing the Tasman for good The non-nursing nurse’s OE Nurturing a culturally diverse nursing team
Professional Development
18 24
FREE 60-MINUTE professional development activity Do nurses ‘eat their own’? Identifying and managing workplace bullying Evidence-based practice: trial of cultural intervention for self-harm
Innovation & Technology
26 27
‘Prescribing’ apps to patients Webscope: global health campaigns
Leadership & Management
28
JANE O’MALLEY on morale, management and moving on
Students 30
Using interpreters: the right to understand and be understood
Opinion 32
College of Nurses: MARK JONES on globalised nursing and poaching
Conferences 33
Upcoming conferences
EDITOR
Fiona Cassie 03 981 9474 editor@nursingreview.co.nz
ADVERTISING
Yvonne Gray 04 915 9783 yvonne.gray@nzme-ed.co.nz
COMMERCIAL MANAGER Fiona Reid
PRODUCTION
NursingReview
Vol 18 Issue 1
NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6011, New Zealand PO Box 200, Wellington 6140
Aaron Morey
SUBSCRIPTIONS
Fiona Reid 04 915 9795 fiona.reid@nzme-ed.co.nz
IMAGES
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© 2018. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014
ERRORS AND OMISSIONS: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.
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Round-up News Briefs
News briefs
Read the full versions of these online articles at www.nursingreview.co.nz/subject/news. DHB nurses waiting for new employer offer
As Nursing Review went to press, 27,000 nurses, midwives and healthcare assistant members of nurses’ union NZNO were awaiting news of a new pay offer from the 20 district health boards. The New Zealand Nurses Organisation (NZNO) and the negotiating team for the 20 DHBs entered mediation on 31 January after NZNO’s DHB nurses, midwives and healthcare assistants voted to reject the initial pay offer made in November. The NZNO negotiating team said in an update in early February that it presented the findings of its online member survey at the mediation, including that members wanted an increased pay offer, safe staffing, a shorter term for the agreement (the original offer was for a 33-month term), and a firmer timeframe for pay equity. The original pay offer – a two per cent increase, backdated to 6 November, for the majority of nurses and midwives covered by the MECA and further two per cent pay rise in August 2018 and August 2019 – was widely viewed by nurses as too little, too late. Members were also divided on how quickly the initial offer’s agreement to start negotiating a pay equity settlement would deliver results for nurses. The NZNO negotiators said the DHBs were now going to look at their ability to reconstruct an offer that addresses NZNO concerns. The DHBs were due to report back to NZNO by 26 February and members were to be updated on the outcome prior to a series of member meetings on 6-23 March. Prior to mediation, the union indicated that it would not rule out using the March meetings to vote on industrial action if a deal couldn’t be reached that it believed members would be ready to accept.
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More than 80 per cent of new grads still nursing five years on New graduate nurses are much more likely to be nursing five years after graduating if they start their careers in a new grad programme, just-released analysis confirms. This backs ongoing calls by the national nursing organisations for 100 per cent placement of new graduates in new graduate programmes – a goal they had set to be met this year. The Ministry of Health analysis found that 86 per cent (806) of the 2012 nurse graduates who gained a place in a government-subsidised NETP (Nurse Entry to Practice) programmes were still in nursing five years on. The proportion was even higher for mental health nurses, with 88 per cent of the 123 new grads signed up to a specialist mental health NESP (New Entry to Specialist Practice) Programme) still having valid annual practising certificates (APC) five years later. In comparison, just 73 per cent (330) of the 455 new graduates who failed to gain a place in a NETP or NESP programme still had an APC in 2017. Overall, 1,244 (82 per cent) of the 1,514 nurse graduates who were registered in 2012 were still in nursing five years later (see table below). Chief Nursing Officer Jane O’Malley said the higher proportion of new graduates still nursing if they had started their careers in a funded new-graduate programme was “telling” and showed the importance of the programmes for nursing retention. In 2013 the National Nursing Organisations – including the New Zealand Nurses Organisation and College of Nurses Aotearoa – called for full utilisation of all NETP funding to support the goal of 100 per cent employment of new graduates by 2018. Government funding is potentially available to subsidise 1,300 NETP and about 125 NESP places but lack of vacancies and tight budgets – particularly at district health boards – means only the NESP funding is fully utilised.
New roles for NPs and RNs come into effect Nurse practitioner leaders saw amended laws that came into effect in January – removing barriers to NP practice – as part of building momentum for the now-fastgrowing role. From 31 January, for the first time, nurse practitioners can issue death certificates for patients in their care. Suitably qualified nurses can also write sick leave certificates. There was one blot on the long-awaited legal changes, though, when NPs realised that cremation regulations had not been updated so GPs’ signatures were still needed for the approximately 80 per cent of deaths that are followed by cremation. Ministry of Health Chief Nursing Officer Jane O’Malley said the Ministry was aware of the oversight and was “working as quickly as possible to remedy this”. Dr Michal Boyd, an NP and former chair of Nurse Practitioners New Zealand (NPNZ), said it took 10 years to register 100 NPs and five years to register 200, but only a further two years for the registrations to climb to more than 300. “This growth shows that the value of nurse practitioner practice is being recognised nationally more than ever,” he said. More than a decade in the making, the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill amended eight Acts to replace references to ‘doctors’ or ‘medical practitioners’ where nurse practitioners (NPs), and other health practitioners like pharmacists, registered nurses and physiotherapists are now qualified to carry out those roles.
Round-up Bulletin Board
Bulletin board Inequities in kids’ asthma control helps prompt new guidelines Unhealthy homes and income inequity are some of the ‘big picture’ factors that are included in new asthma guidelines for health professionals caring for Kiwi children and adolescents. The new Asthma and Respiratory Foundation NZ child and adolescent asthma guidelines are designed to help nurses, doctors and other health professionals who are delivering asthma care in the community and in emergency departments to provide simple, practical and evidence-based guidance for the diagnosis and treatment of asthma in children and adolescents up to 15 years of age. Download at www.nzasthmaguidelines.co.nz.
Inspirational ‘who’s who’ list of Māori health leaders Māori have identified a ‘who’s who’ of Māori health leaders, including nurses Denise Wilson, Mere Belzer and Moe Milne, to help motivate the next generation of leaders. The new website – 100 Māori Leaders – was launched by Te Rau Matatini late last year as a contribution to building the capacity of the Māori health workforce. Maria Baker, chief executive of Te Rau Matatini (the National Centre for Māori Health, Māori Workforce Development and Excellence), said Māori are under-represented amongst most professional groups who contribute to the health of New Zealanders. The site currently includes seven nurses and two former nurses. Visit www.100maorileaders.com.
Nursing tool proposal wins Clinicians Challenge An IT proposal to help lessen the workload of practice nurses having to calculate ‘catch-up’ immunisations for migrant and refugee children was a Clinician’s Challenge winner in 2017. The online immunisation catch-up calculator for immigrant or refugee children took out the $8,000 Clinician’s Challenge New Idea award presented in November. The project was co-lead by nurse Jillian Boniface, the Southern District Health Board’s Programme Leader for Vaccine Preventable Disease, and DHB Public Health Analyst Dr Leanne Liggett. Boniface, formerly a practice nurse, said she and Liggett worked together as a team to turn a nursing issue and a good idea into a proposal for a nursing tool.
Shingles vaccine free for older Kiwis from 1 April A vaccine to prevent the often painful and debilitating shingles vaccine will be offered free for over-65s to 80-yearolds next year at the same time as their annual ’flu jab. PHARMAC announced late last year that it would fully fund the shingles vaccine Zostavax for 65-year-olds from 1 April and also fund a catchup programme for people aged 66-80 years until March 2020. Around one in three New Zealanders will have at least one attack of shingles in their lifetime.
Hauora Māori Scholarships for undergraduate and graduate student nurses open Applicants are being sought for the up to 155 Hauora Māori scholarships available to support and encourage Māori nursing students in their careers. Applications for the scholarships that are open to Māori students in nine health disciplines, as well as health-related postgraduate qualifications and several excellence awards, close on 28 March. More details are available on the Ministry of Health website: www.health.govt.nz.
A quick guide to who’s who in health in the new Government David Clark, Minister of Health, is responsible for the overall functioning and operation of the health system, community health, health workforce, aged care, and mental health services. Clark is also Associate Minister of Finance and is 10th in Prime Minister Jacinda Ardern’s cabinet line-up. Jenny Salesa, Associate Minister of Health, is responsible for policy and service delivery relating to Maori and Pacific health; the Health Promotion Agency; tobacco; problem gambling; and healthy school environments. Salesa is inside Cabinet as she is also Minister for Building and Construction, Minister for Ethnic Communities, Associate Minister for Education and Associate Minister of Housing and Urban Development – with responsibility for
public and emergency housing, Pacific people’s housing and housing for groups with particular needs like disabilities or mental health issues. She is 15th in the Cabinet line-up. Julie Anne Genter, Associate Minister of Health, is responsible for policy and service delivery (with the exception of abortion and wage settlements, which is retained by the Minister of Health) relating to climate change and health; population health (built environments); women’s health (including breast and cervical screening); sexual health and disability support services (Ministry of Health-funded for under-65-year-olds). Genter is a Green Party MP and also holds an outside Cabinet portfolio as Minister for Women and Associate Minister of Transport.
The Health Select Committee members are: Louisa Wall (Labour, Manurewa), chair, social policy advisor; Dr Shane Reti (National, Whangarei), deputy chair, GP; Dr Jonathan Coleman (National, Northcote), National’s health spokesperson, GP; Dr Liz Craig (Labour, List), first-time MP, public health physician; Matt Doocey (National, Waimakariri) National’s mental health spokesperson; Anahila Kanongata’a-Suisuiki (Labour, List MP), first-time MP, social worker; Nicky Wagner (National, List MP), National’s disability spokesperson, businesswoman; and Angie WarrenClark (Labour, List MP), first-time MP, barrister, and Women’s Refuge manager.
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Focus International Nursing Lucas Fraser (far left) with NZMAT co-workers on Cyclone Winston-hit Koro Island.
NZMAT: Short, sharp but satisfying volunteering Lucas Fraser says volunteering for New Zealand’s Medical Assistance Team gives you the chance to help out when disaster strikes with minimal disruption to your ‘day job’.
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n the almost five years since Fraser first joined New Zealand’s Medical Assistance Team (NZMAT), he has worked in Solomon’s capital Honiara after severe flash flooding and been helicoptered onto Fiji’s Koro island, which was battered by the worst of Cyclone Winston. He has also attended training in Darwin and Indonesia. After those short, sharp missions of one to two weeks, he returns to his ‘day job’ as a duty nurse manager at Waikato Hospital. Fraser had recently returned from working in Saudi Arabia when he signed up in 2013 to join NZMAT’s first cohort. NZMAT is a team of volunteers recruited and trained by the Ministry of Health to be ready for rapid deployment of up to two weeks in response to government requests for health support in the event of major disasters or emergencies in our corner of the Pacific.
Flooding in the Solomons Fraser’s first call-up came in 2014 when the first NZMAT team was deployed in response to flash flooding caused by Cyclone Ita in the Solomon Islands’ capital Honiara, which killed 22 people and washed away the homes of 12,000 of the city’s poorest residents, affecting more than 50,000 people. Displaced people 4 Issue 1
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living in cramped camps contributed to a dengue fever outbreak and contaminated water supplies meant gastroenteritis and infections were major issues. An advance team was sent to assess how NZMAT could best help out and four days after the initial phone call alert Fraser and his teammates were on a commercial flight to Honiara with a few hundred kilograms of excess luggage, including requested antibiotics and other necessary supplies. The New Zealand team of doctors and nurses – in partnership with some doctors from Australia’s established MAT (known as AUSMAT) – were to be based in the emergency department of Honiara’s main hospital to help local staff with the extra influx of flood-affected people. The exhausted local doctors and nurses were happy to see the team, after dealing with the flooding aftermath for over a week with very little respite to be able to help out their own affected loved ones. “They were working on empty,” recalls Fraser. It was to be a fortnight of hot, humid, hard and sometimes heartbreaking work, but Fraser says it was probably still the most rewarding time of his nursing career to date. “You had to use all the skills you had to try and make the best decisions.”
Much of Fraser’s time was split between triaging the waiting crowds on the tropical hospital’s deck in 35-degree heat or working with the patients in the crowded waiting room. Fraser says there were consistently 50–60 people waiting outside ED at any one time to be seen. Only the very, very unwell got to the front of the queue – the rest were triaged and moved into a small three-by10-metre waiting room that was crammed with people who were waiting up to two days to see a doctor because the on-duty doctors were so busy. Up to 15 severely ill babies and children were arriving each day, dehydrated – some to the point of unconsciousness – as a result of dengue fever or gastroenteritis, and in need of urgent resuscitation and intravenous fluids. “There were children dying on a reasonably regular basis because of how severe the gastro outbreak was,” says Fraser. People were also coming in with infected cuts from treading on corrugated iron submerged in the dirty flood water, and the normal ED workload of people with heart attacks to sepsis. If a patient needed admitting to the ward, they would be walked or carried to the ward where a nurse would make space – even if it meant topping and tailing two
Focus International Nursing
patients to a bed – and then carry on with their work. Fraser says it wasn’t uncommon in the resuscitation room to have two children being resuscitated on the same bed and the parents wouldn’t bat an eye. “It’s just what you do.” It was challenging but also “very, very rewarding” work. “There are very few occasions in medicine and nursing where you have to fully rely on what you know – often you can refer to someone, request a test or specialist opinion – but there you had to dig deep into your memory banks and do as good as you could.”
The aftermath of Cyclone Winston in Fiji When Cyclone Winston hit Fiji in February 2016 – the most severe tropical cyclone ever recorded in the Southern Hemisphere – there was little doubt that NZMAT would be deployed and Fraser was ready for the call. More than 40 people had been killed in the Category Five cyclone, which cut a swathe through Fiji, destroying an estimated 32,000 houses, 88 health facilities and affecting 350,000 people in the cyclone’s path. Several teams of NZMAT volunteers were flown to the area in an air force cargo plane and after a briefing the five members of the mobile team to which Fraser was assigned were helicoptered onto Koro Island, which had borne the brunt of the cyclone. Koro had been hit by 200–300-kilometres-an-hour winds and tsunami-like storm surges, which had combined to destroy nearly 1,000 homes and most of the medical centres and schools, stripped the coconut palms back to sticks, and in some areas washed away not only the crops but the topsoil in which they had grown. By the time the Kiwis arrived, nearly a week after the cyclone, most of the severely wounded had been evacuated and a number of the about 4,000 island residents had crossed to the main island to escape the devastation that had destroyed their homes and livelihoods. The helicopter left and the team – three nurses, a doctor, a logistician (firefighter when at home) and their Fiji Health Ministry support person – looked around them at the
stripped and uprooted trees, and the foundations of where a village had stood. They headed up the hill to a less-devastated village at the top and set up their tent beside the hill village’s health clinic, which was standing roofless, but Australian armed forces had managed to pull a tarp over for protection. The Kiwis spent the first couple of days with local staff helping to treat the villagers who turned up to the clinic with cuts from cyclone debris, infections or needing medication to replace that which had been lost along with their homes. If there was any downtime they tried to help restore order in the clinic and sort through the rain-damaged and windtossed medications and supplies to see what could be salvaged, plus unpack and store the medications that had been air-dropped in. Once on top of the clinic’s work, they headed out in convoy with an Australian defence force team that was clearing the roads to more isolated villages. When the convoy arrived in a village, the team’s Fijian Health Ministry support person liaised with the chief to use any building still standing to offer a four-hour clinic to the injured and ill before moving on to the next village and setting up another short-lived clinic. “The injuries we were seeing at that point were old injuries but we were still seeing significant lacerations that needed IV antibiotics and a few fractures that needed to go back to the main island to be set.” With the cyclone still so recent, most islanders were still in shock at their losses, but on the last day of the team’s week on the island they watched about 40 villagers go down the hill to take a symbolic first step to rebuilding their destroyed coastal village by moving a log across a stream to create a footbridge.
“There is very little sacrifice – you are still getting paid; it’s only a few weeks and it’s exciting – you don’t get to do that every day.”
Thankfully, New Zealand’s corner of the Pacific has not had a major disaster of the scale of 2016’s Cyclone Winston, 2015’s Cyclone Pam, or 2014’s Cyclone Ita in recent times. “But if something big happens,” says Fraser, “it [NZMAT] gives you the opportunity to help, which is often what you want when you are home looking at the pictures on the TV and thinking ‘I feel like I should be helping’ – then that’s an avenue to do it. “And there is very little sacrifice – you are still getting paid; it’s only a few weeks and it’s exciting – you don’t get to do that every day. And for me it gives me the extra element of nursing – I think without it I wouldn’t still be nursing, but knowing I can help communities really in need when they need it the most – it keeps me in the job.”
Back to the day jobs Once the volunteer missions are over, Fraser and the team then fly back to their day jobs and wait for the phone to ring again. For Fraser, part of the appeal of NZMAT volunteer work is that it is a form of volunteering that fits into the real world with minimum disruption to family and work life – as long as employers and workmates are supportive.
The devastation caused by 2016’s Cyclone Winston to Fiji’s Koro Island.
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Kiwis helping to re-establish war-ravaged nursing school Bougainville is training nurses once again, with the support of VSA and Kiwi nurses.
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or nearly 30 years Bougainville had no nursing school. The local Arawa School of Nursing was destroyed in 1988 at the outset of the Bougainville Crisis and never reopened after the civil war between Papua New Guinea and the secessionist forces of the Bougainville Revolutionary Army ended 10 years later in 1998. By 2016 not only was there a serious shortage of nurses to serve the around 250,000 residents of the Autonomous Region of Bougainville (ARoB), but the existing registered nurse workforce was close to, or even past, retiring age. Two local health professionals, nurse Celyn Tusalah and medical officer Dr Joe Vilosi, were determined to remedy this. So in early 2016, despite having no government funding, 40 nursing students began their studies in a single classroom on the ground floor of a small house. Soon afterwards the call went out from Bougainville’s health secretary and Tusalah, now the principal of the reopened Arawa School of Nursing, to New Zealand’s Volunteer Service Abroad (VSA) for volunteer support for the pioneering school. VSA, which has deployed more than 20 health sector volunteers to Bougainville since 1998, agreed to the request and in January 2017 Kiwi nurses Drs Marian Bland and Mary Ann Hardcastle arrived in Arawa for one-year assignments as a nursing school management advisor and a health services and nursing management advisor, respectively. VSA is currently recruiting for a new nursing school management advisor (along with other healthrelated Bougainville positions) and VSA Bougainville programme manager Paul Bedggood says the myriad challenges faced by the new nursing school, and the region, mean that the school will probably need periodic external support for at least five years. Now back home, Bland says her year in Bougainville was one of the hardest and most rewarding things she has ever done. “This was an amazing opportunity to share my skills and be part of educating a whole new generation of much-needed nurses,” she says. Her year at the school began by being asked to help develop a new nursing curriculum for the school and watching a 6 Issue 1
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classroom being assembled on the front lawn as the school swelled to nearly 100 students with the arrival of a new intake of first-year nursing students and the first intake of a two-year community worker programme. Below, Bland shares some of the challenges, rewards and tips from her time in Bougainville. The challenges: ▶▶ The big differences between New Zealand and Bougainville in access to healthcare and average life expectancy, and in infant and maternal mortality. ▶▶ The ongoing impacts of the Bougainville Crisis. ▶▶ The effects of the heat and humidity and the erratic power/internet/phone access. ▶▶ Adjusting to teaching students from a range of educational backgrounds (the 10-year crisis disrupted education opportunities for many). ▶▶ Remembering to speak slowly and clearly – the programme is taught in English, which is not the students’ first language. ▶▶ Having to prioritise how I could help the school, as I would only be there for a year. The rewards: ▶▶ Being incredibly fortunate that the school principal Celyn Tusalah was so keen to learn and make the best use of my skills and experience. ▶▶ Being able to support her set-up of systems like student handbooks, a clinical skills competency book, and weekly teaching timetables.
▶▶ Working with the teaching staff to help them plan units, design assessments and gain confidence. ▶▶ Getting to know the staff and being part of their lives. ▶▶ Working with the students and sharing my enthusiasm about nursing with them. ▶▶ Being able to immerse myself in the colourful and diverse culture of Bougainville – a region that has been through some hard times. ▶▶ Working alongside locals striving so hard to improve the lives of the people – it was a privilege. Tips for nurses volunteering in similar settings: ▶▶ Don’t expect too much of yourself at the start – getting used to the climate takes a while, and so does building a relationship with your partner organisation. ▶▶ Write down at the end of each week what you’ve done or been involved in – this can be helpful to look back on when you are discouraged by things not going to plan. ▶▶ Try to stay fit. I found early morning walks a great time for clearing the head. ▶▶ Make use of the support available to you from your agency – talking things over can provide a fresh perspective. ▶▶ Leave all your assumptions back in New Zealand – be open to new ideas, new ways of seeing the world, and new possibilities and experiences.
Arawa School of Nursing students in front of the school building and open-sided temporary second classroom.
“This was an amazing opportunity to share my skills and be part of educating a whole new generation of much-needed nurses.”
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So you want to volunteer overseas? Nursing Review outlines some of the overseas volunteering options available to Kiwi nurses.
Médecins Sans Frontières (MSF or ‘Doctors Without Borders’) MSF has about 30,000 field staff providing medical assistance to populations in danger around the world. New Zealand field workers are recruited through MSF Australia’s Sydney office, which sends and supports about 200 Australians and New Zealanders field workers a year. Registered nurses applying to join MSF need at least three years’ post-registration experience in areas ranging from emergency to public health and must be available for a minimum of nine months in potentially unstable locations. A typical field placement lasts from six to 12 months. MSF covers travel arrangements and costs, accommodation, daily living costs, a monthly salary and additional benefits. www.msf.org.nz/join-our-team/work-overseas
Mercy Ships Mercy Ships is a Christian charity that anchors its volunteer-run hospital ships in the harbours of some of the world’s poorest countries and offers free, life-changing operations, post-surgery rehabilitation, and help to build local healthcare workers’ skills. The current hospital ship Africa Mercy has five state-of-the-art operating theatres and five wards and plans to launch a second ship, the Atlantic Mercy, this year. Mercy Ships 8 Issue 1
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New Zealand recruits and supports about 40 Kiwis volunteer to serve on board the Mercy Ship each year. All volunteers on Mercy Ships pay their own way and are required to provide or raise their own funds to cover crew fees, insurance, transportation to and from the ship and personal expenses. Nurse volunteers need a minimum of two years’ experience and commit for two weeks to a maximum of three years. www.mercyships.org.nz
New Zealand Defence Force Reserves (Territorials) Nurses can apply to serve as part-time nursing officers in the Army Reserve (also known as the Territorial Force). Reserve nursing officers are required to have a current registered nurse APC, pass a medical assessment and an Officer Selection Board and undergo specialist training. Various military or health-related training opportunities are available throughout the year. There is the potential for paid travel overseas, either for training purposes or humanitarian assistance, as well as for longer deployments supplementing the regular defence forces. Reserve officers are paid a daily rate based on their seniority. www.defencecareers.mil.nz/army/jobs/armyreserve/reserve-officer
Focus International Nursing
New Zealand Medical Assistance Team (NZMAT) NZMAT is a Ministry of Health-organised and trained volunteer group deployed by the Government in response to requests in major emergency situations – predominantly in the South Pacific. Nurses make up about 80 of the 180 trained NZMAT staff. About half of the nurses on the volunteer database currently are emergency nurses; the rest are primary health nurses, mental health nurses and other specialties. Nurses need employer approval to be deployed within as little as 24 hours and for up to 14 days for an international deployment. Travel costs and living expenses are covered by NZMAT and team members are paid at their usual pay rates while on deployment. www.health.govt.nz/our-work/ emergency-management/new-zealandmedical-assistance-team
New Zealand Red Cross The New Zealand Red Cross recruits, trains and sends nurses and other aid workers to support International Red Cross field operations around the world. Kiwi Red Cross international aid workers are supported by Ministry of Foreign Affairs and Trade aid funding and by donors. Nurse applicants need a minimum of three or four years’ post-registration experience, plus previous humanitarian and/or crosscultural experience. New Zealand Red Cross has a pool of more than 130 trained technical aid workers, including nurses, available for deployment. Standard missions range from six to 12 months, with shorter missions of two to eight weeks offered during emergency responses. Aid workers are employed on fixed-term contracts that cover salary, travel costs, all pre-deployment and postdeployment support, medical clearance and insurance. www.redcross.org.nz/get-involved/aidworker-programme
Volunteer Service Abroad (VSA) VSA focuses on meeting requests for expert volunteers from eight countries (mainly in Melanesia and Polynesia). In recent years VSA has sent nursing advisors/educators to Bougainville, Papua New Guinea and Kiribati and currently has nurses serving overseas as diabetes nurse advisors and mental health programme advisors. VSA workers are supported by Ministry of Foreign Affairs and Trade aid funding and by donors. Most assignments are for one to two years but it sometimes has short-term assignments. Volunteers receive a living allowance, and accommodation, insurance, and medical costs are provided. Travel arrangements are organised and funded by VSA, along with other costs. For assignments of six months upwards, a partner may apply to accompany the volunteer and if accepted their expenses are also covered by VSA. www.vsa.org.nz
Looking for a nursing adventure? Volunteer Service Abroad is looking for nurses to work alongside local organisations in the Pacific and beyond. Find your overseas adventure: www.vsa.org.nz/nursing
nursingreview.co.nz Issue 1 9
Focus International Nursing
The big (nursing)
OE
Being a registered nurse can be a ticket to see the world. Some return with new skills and new views. Some never return. Nursing Review takes a look at the big (nursing) OE.
L
iving in a packed Kiwi flat in London and fitting nursing work between backpacking trips with mates was a rite of passage for many New Zealand nurses. Nici Gardner was one of them in the late 1980s, along with about 10 of her Christchurch Hospital nursing school classmates. Most had done a year or two staff nursing postregistration and she conservatively estimates that about a third of her graduating class of 80 ended up in the UK at some stage. Roll on 30 years and 25-year-old Christine Stanley (see story page 14) thinks she is one of the very few of her University of Auckland classmates to have left New Zealand three years after graduating. Student loan debt and more mature cohorts of graduates are probably influencing the timing and numbers doing the great Kiwi nursing OE. At the same time a much more time-consuming and expensive registration process has virtually killed the UK as a base for a nursing working holiday. (It now costs £1,415 for non-EU nurses to register in the UK – including clinical competence tests.) But Kiwis still have itchy feet and last year 1,800 applied to the Nursing Council of New Zealand for proof of registration so they could nurse overseas – the vast majority (1,555) applying to nurse in Australia.
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How many of last year’s 1,555 applicants were planning to permanently cross the Tasman and how many were popping across for some Oz-based OE – including short-term, lucrative, rural and remote contracts – is unknown. What is known from Nursing Council annual practising certificate (APC) stats is that in 2016 there were 1,347 overseas-based nurses with valid New Zealand APCs, which indicates that many were at least keeping the option open of returning to nurse in New Zealand at some stage. (Some, of course, will also be doing humanitarian aid or volunteer work overseas – see other articles in this edition.)
Anecdotal evidence is that young nurses are still heading to the UK, but opting to work, like Stanley, as live-in carers. Nursing Council statistics for nurses seeking verification indicate that while the majority are seeking to register in Australia (1,555), some are aiming to nurse in the UK/ Ireland (99), others in North America (100 seeking verification in USA or Canada where, like the UK, overseas nurses must first pass an exam or competency test process) or the Middle East (31). The Trans-Tasman Mutual Recognition scheme for nursing registration means crossing the ditch to work as a nurse is by far the simplest option.
Kiwi nurses seeking to nurse overseas 2005
2017
United Kingdom
448
86
Australia
447
1555
USA
114
76
Canada
59
24
Eire
35
13
United Arab Emirates
--
31
Source: Nursing Council verification statistics
Focus International Nursing
The availability of well-paid, threemonth contracts to work in the Outback or other remote locations is also a drawcard. One Australian agency’s website features profiles of two Kiwi nurses taking up short-term rural and remote contracts that highlight another trend – the midlife nursing OE. One profile is of an Australian-based young Kiwi doing the traditional OE of nursing for 6–8 months and then travelling – last year it was to SouthEast Asia and the year before to Paris. The other profile is of a Queenstownbased nurse with grown-up children (one based in Australia) who has been crossing the Tasman regularly for around a decade, initially taking short-term contracts to explore Australia but now returning to her favourite remote outposts. Contracts with hospitals in Saudi Arabia or the less restrictive neighbouring United Arab Emirates states like Dubai or Abu Dhabi is another option chosen by some Kiwis for their working holidays. While choosing to nurse in restrictive Saudi is not for everyone, the opportunity
to work for a tax-free salary, with free rent and frequent leave does appeal to some. Nurses seeking jobs in countries with more complex registration requirements most commonly use agencies to help them. The NZNO recommends nurses ask around for word of mouth references or personal experiences as the best way to check out an agency. It also advises nurses to have all overseas contracts checked out by a lawyer
and to be suspicious of any agency that doesn’t allow them to do so. The other advice, of course, is to enjoy – being a registered nurse has long been seen as a ticket to travel and the Kiwi nurses who return from their OEs bring back with them rich experiences of different cultures and health systems. The nub, as always, is how many choose to return.
Why not give nursing in Australia a go? The process is easier than you think. We will help you every step of the way. • Advise on all things Australia • AHPRA advise We have Nursing jobs available for you now. • Casual shifts • Permanent employment positions • Work in the best health care facilities in Australia Contact ANA today. w australiannursingagency.com e recruitment@australiannursingagency.com t +613 9481 7222
nursingreview.co.nz Issue 1 11
Focus International Nursing
Profile:
Crossing the Tasman for good Kiwi-trained nurse Ruci Saqayalo crossed the Tasman last July. She says the nursing workload and stress are the same but the pay isn’t and she’s not planning to come back.
R
uci Saqayalo is one of the Kiwi nurses who cross the Tasman each year and decide not to come back. Better pay, a better climate and not being offered a permanent position in her former home town of Wellington all contributed to her and her family moving to Adelaide last year. Several colleagues from her BN (Pacific) graduating class of 2014 at Whitireia had crossed the Tasman before her and another followed soon after. Whether her colleagues plan to cross back is unknown, but Saqayalo, her husband and 14-year-old son are happy with their decision and are planning to stay. After finishing her degree in 2014 Saqayalo, 43, accepted an NETP (nursing entry to practice) place at Wellington Hospital based at the emergency department’s short stay unit. After her new graduate year she was unsuccessful in getting a permanent job at the short stay unit and instead was taken on as a permanent member of the hospital’s nursing bureau. Saqayalo, who is originally from Fiji and moved to Wellington in 2010, made further attempts to get a permanent ward position unsuccessfully. “I’d been for a few interviews for permanent positions and didn’t get them. And I thought, ‘you know what, it’s just best to go overseas and get some experience in Australia and probably move on’.” She says being taken on by the bureau worked well for her. “We were sent to any ward in the hospital and I got the experience of working across all the specialties.” During a recruiting drive by the Australian agency that now employs her, 12 Issue 1
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she discovered her varied experience was one of the things that agencies looked for. Saqayalo had never been to Australia until she made the move last July, so she wasn’t sure where to go and how better off financially they would actually be. “We thought it might just be hearsay but we also thought we should come over and find out for ourselves and it’s really true.” Working as an agency nurse, her pay is much better and she has found the cost of living in Adelaide “quite cheap”. Since arriving in July, she has been sent on shifts at the 800-bed Royal Adelaide Hospital and the 300-bed Queen Elizabeth Hospital, along with several private hospitals.
“Nursing can take us anywhere; the flexibility – it is just great.” She says the workload is very similar to what she experienced as a bureau nurse at Wellington Hospital and the work environment is no less stressful. But the pay is good and she is getting constant work. Just recently she was sent to work in Royal Adelaide’s intensive care department, and found herself enjoying an experience that she had never had in Wellington. (She has heard since that the Royal Adelaide wasn’t taking on permanent staff, which may have been why it was employing expensive external agency staff.)
Ruci Saqayalo.
NZ Pacific nurses heading to Austrailia Saqayalo is conscious that she and her Pacific classmates are moving to Australia at the same time that New Zealand’s health leaders are talking about wanting to build the Pacific nursing workforce to better meet local health needs. “We tend to talk about that with my colleagues – and it is a shame,” says Saqayalo. She says she would have stayed if she’d obtained a job with much better pay. “But I’m getting double what I used to get back in Wellington, to tell the truth.” A colleague who has just followed – also Fijian – has left behind in New Zealand her grown-up children to come over with her husband to take up a lucrative ‘rural and remote’ contract in Queensland. Other classmates who crossed the Tasman before her were from other Pacific backgrounds, including Samoa and the Cook Islands. Saqayalo says it was not only the pay that attracted her Pacific colleagues across the Tasman: being on a one-year NETP programme contract meant they didn’t get the security of a permanent position on completing their new graduate year. So is she ever planning to come back? “No, I’m not coming back, sorry,” she laughs. “But I will probably come back to visit.” At the moment she is still enjoying agency work – both the pay and working in a variety of hospitals and specialities. Where her career goes from here, she is not sure. “Nursing can take us anywhere; the flexibility – it is just great.”
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Focus International Nursing
Profile:
The nonnursing nurse’s OE
Young Kiwi Christine Stanley has opted to put nursing aside for a year and be a carer in the UK.
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I
n April last year 25-year-old Kiwi nurse Christine Stanley headed off on her OE. After six weeks travelling through the US and Canada she arrived in the UK keen to get a job, save some money and travel through Europe. This is a familiar path that thousands of Kiwi nurses have followed before her. In the ’50s they went by ship and in the ’70s many travelled overland via the hippy trail but the most common OE destination was the ‘mother country’, England, where New Zealand nurses could typically easily get nursing jobs, earn some money, travel and gain some experience in some of London’s top teaching hospitals at the same time. But since 2005 registering as a nurse in the UK as a non-EU trained nurse has become increasingly more complex and expensive, resulting in Stanley being part of a new generation of Kiwi nurses on their UK OE who opt to put nursing aside for a while to work as live-in carers. Stanley graduated in late 2014 from the University of Auckland nursing school and went to work in the surgical ward of a private hospital. With two years’ experience under her belt she decided to follow her sister and some non-nursing mates and head off. Initially she planned to just be away for six months so didn’t think the complex and costly UK RN registration process was worth pursuing, and having heard about
nursingreview.co.nz
“ ... it is really worth it for the experience of giving one-on-one care to a person. You can really make a positive difference to their life.”
live-in care work she decided it sounded a much simpler option. She has now stretched her OE plans to closer to 15 months – long enough away to see a good chunk of the world but not too long from nursing to put her annual practising certificate in jeopardy. Stanley is in the UK on a Youth Mobility Scheme (YMS) visa that allows 18–30-year-olds from New Zealand (and seven other eligible countries) to work in the UK for up to two years. She is based in Oxford, working for agency Oxford Aunts as a levelfour carer working with complex clients needing advanced-level carers. Her first client was for just a month and she has been with her second, who requires a hoist to get in and out of bed, since August. “The downside of live-in care obviously is that you do sacrifice a bit of your social life but it is really worth it for the experience of giving one-on-one care to a person. You can really make a positive difference to their life.” The sacrifice is rewarded by free board and food, a combination that has allowed her to save funds to travel around Europe and Asia with mates, plus have the security of slipping back into the same job on her return to UK as a reliever steps in to look after her long-term client while she takes leave. In September she went to France, Italy and Germany for about a month; in November she spent two weeks in Europe; and she has
recently returned from India and Sri Lanka and another trip to France. Stanley says her actual hourly pay rate is similar to what she received as an RN for less stressful work, but she works more hours. Typically her contract is for 8–10 hours’ work a day – spread across the day for when her client needs her – but she has a three-hour break outside the house once a day, and once a week a reliever provides an eighthour break, during which she can visit friends in London or head elsewhere on a day trip. Stanley is planning to return in home in July. She says she is not tempted to stay on and seek registration, even though there appear to be nursing jobs available from what she saw online. “The trouble is that the pay of nursing jobs is not very good in the UK – I think it’s almost worse than New Zealand from my limited research. Also if you are going to live in London to nurse, the cost of living is insane.” For now she is planning to return to work in a surgical or medical setting to broaden her nursing skills. Stanley says her time as a live-in carer has made her passionate about aged care and sparked her interest in working in this area in the future – but first she has one big trip to do before she finishes her OE and heads back downunder to resume her nursing career.
Focus Cultural Diversity
Healthy culture: nurturing a culturally diverse nursing team
Nursing is a global profession, with New Zealand’s nurses trained in 89 countries. How well are we doing at nurturing culturally diverse nursing teams?
T
he simple act of nurses greeting each other at the start of a shift can be the source of cultural confusion. “My staff still call me ‘ma’am’ – why don’t they just call me by my first name?” “My charge nurse manager jokes she’ll fire me if I don’t call her by her first name, but I’m just being respectful.” As New Zealand’s nursing workforce becomes increasingly multicultural, so does the potential for cultural misunderstandings at the nurses’ station, the bedside and the tearoom. Kiwi-born nurses can feel uncomfortable when new migrant nurses chat in the corridor in a language other than English. And new migrant nurses can struggle to understand Kiwi-born nurses’ informality, jokes and jargon. Both can struggle to understand each other’s accents. Integration is definitely a two-way street. New migrant nurses need help and time to adjust to Kiwi nursing culture and Kiwitrained nurses need help to understand and respect the cultural differences that their new workmates bring to the ward or rest home. But integrating nurses from diverse cultures into a cohesive and collegial nursing team can be a challenge. Nearly a decade ago Sue Lim, national director of eCALD, and her team developed courses, and eventually a free online toolkit, to help do just that. The courses were developed initially to meet the needs of the migrant nursing workforce but the Toolkit for Health Workforce Working in a Culturally Diverse Workplace is also aimed firmly at helping Kiwi nurses and nurse managers (and others in the health workforce) to better understand, appreciate and work with their culturally
diverse workmates and build a collegial team culture (see more about eCALD in the sidebar). “It’s important for all staff because everyone – regardless of whether you are migrant or New Zealand-born – needs to understand the cultural context that they are working in and needs cultural competencies,” says Lim. Her colleague Dr Annette Mortensen, who is a nurse and eCALD’s research and development project manager, also points out it is not just migrant nurses from Asia and other CALD (culturally and linguistically diverse) countries who can face issues in adjusting to nursing in New Zealand, but also migrant nurses coming from the UK, North America and Europe.
NZ reliant on migrant nurses New Zealand has long had a reliance on overseas-trained nurses, with more than a quarter of New Zealand’s nursing workforce being trained overseas. But the makeup of that migrant workforce has increasingly changed over the past decade, with the numbers of migrant nurses from the traditional sources of the UK and Ireland falling away and the number of migrant nurses from Asia, particularly the Philippines and India, steadily growing. Those two countries alone were the source of 1,047 of the 1,433 overseas-trained nurses registered in New Zealand last year. As New Zealand becomes more culturally diverse – Asian people made up nearly 12 per cent of the population in 2014 and nearly one in four Aucklanders – so does the Kiwi-trained nursing workforce. Just under 20 per cent of newly registered New Zealand qualified nurses in 2012–13 identified as being from an Asian
ethnic group, compared with 11 per cent identifying as Māori and six per cent as Pacific. This increase in cultural diversity in the nursing workplace is not all smooth sailing. A major survey in 2012 of new members of the New Zealand Nurses Organisation (NZNO) – both New Zealand qualified nurses (NZQNs) and internationally qualified nurses (IQNs) – found evidence of cracks in the multicultural nursing workforce. Researchers Drs Leonie Walker and Jill Clendon reported some NZQNs commenting on “too many IQNs”, expressing stereotypes about particular cultures and making negative comments about some IQNs’ training, cultural awareness or English skills. Both NZQNs and IQNS reported witnessing racism towards Asian and Indian nurses – particularly from patients – including very high numbers reporting patients refusing to be cared for by a “foreign nurse”. IQNs themselves reported feeling discrimination, frustration and disappointment at their career opportunities in New Zealand. Mortensen says the NZNO research illustrates what can go wrong in a multicultural workforce when integration is not successful. She also recognises that for some long-standing Kiwi-born nurses the changing makeup of the workforce also comes with a feeling of loss of community and collegiality. “I’m in a workforce that isn’t like me and it’s not like it used to be”, is how some Kiwi nurses are feeling, believes Mortensen. “There’s a confusion and sadness about not knowing how to change with the times.” Continued on next page >> nursingreview.co.nz Issue 1 15
Focus Cultural Diversity Leadership needed to nurture multicultural teams Bringing together new migrant nurses and Kiwi-born nurses into a multicultural team that works well together takes good leadership skills. Lim offers a face-to-face programme for frontline managers, like clinical nurse managers, on managing “It’s important for all culturally staff because everyone diverse teams, – regardless of whether which is now embedded into you are migrant or the management training New Zealand-born – programmes needs to understand offered at all the cultural context three DHBs in the Auckland that they are working region. (Also in and needs cultural available are courses targeted competencies.” at helping migrant nurses adjust to the Kiwi workplace and a workshop designed for culturally diverse healthcare teams.) Lim says managers have to understand that for migrant nurses the process of adjusting and adapting to the New Zealand workplace can be difficult. “A lot of migrant nurses can feel full of anxiety, discomfort and resentment at being asked to integrate because it is a difficult process.” Mortensen adds that NZ-born managers, coming from the host culture, have to be conscious that the power balance is in their favour, so need to be ready to go the ‘extra mile’ to be welcoming and friendly. What eCALD advises clinical nurse managers to do is to help new migrant nurses adjust with small changes, take time to engender trust and be transparent about their expectations. This includes being Annette Mortensen. aware that many migrant nurses are coming from different and often more hierarchical workplace cultures where speaking up at a meeting without being asked – or calling your manager by their first name – would be considered rude and disrespectful. Lim says as a new migrant from Malaysia 30 years ago it took her three months to feel comfortable calling her manager by her first name. Sue Lim. Managers need to give new migrant staff time and, if possible, 16 Issue 1
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mentor them or give them a buddy to guide them as they adapt. Managers also need to be ready to be a role model, to risk making mistakes and learning from them, and to accommodate difference. (Mortensen says she knows of one rest home manager who modified the uniform for her Muslim staff so it met both health and safety standards and was culturally appropriate.) Lim stresses that team ground rules need to be set by managers, including zero tolerance for discrimination and stereotyping and setting clear, fair house rules on what can be a common cause of tension – new migrant staff talking together in their native language. She says this risks offending some patients and some staff, because they worry that the person talking in the native language may be talking about them. She says when managing a team of Korean and Chinese staff she allowed staff to chat in their own language in the lunchroom but they needed to make a friendly acknowledgement of anybody else who entered the room.
Developing cultural awareness and competency Once again, multiculturalism is a two-way street. For all nurses to be culturally safe practitioners, they need insight into their own culture and acknowledge how that influences their interactions with other nurses in the team – as well as patients – from cultures or ethnicities other than their own. Along with being aware of New Zealand’s bicultural heritage stemming from the Treaty of Waitangi, nurses also need to accept the reality that nursing, like New Zealand, is becoming increasingly culturally and ethnically diverse. A major section of the eCALD toolkit is aimed at all staff in a multicultural team and places a strong emphasis on building cultural competence, being self-reflective about any prejudices they might hold and how to work through any crosscultural issues they encounter. This includes thinking about what culture is, the dangers of stereotyping people, and of being ethnocentric and viewing one’s own culture as the only right way to do things and viewing all others as inferior. It also includes
increasing understanding of how different cultural values can impact on communication – such as different attitudes about making eye contact, saying ‘no’, speaking up and interpreting body language and facial expressions. The toolkit also emphasises that it is a myth that food, music, dance or other visible aspects of culture are the best way to better understand cultural diversity: “It is the invisible and unstated differences that present the most challenges and violations of trust and respect. These [differences] are held largely in the values, and in the expectations, goals and styles of communications. In fact, many cultures have values and styles that are almost opposite to each other. If we assess meaning based on patterns in our own culture, we are likely to misinterpret, misunderstand and be confused.” Lim and Mortensen also stress that while offering cultural competency education is important, it isn’t enough without an organisationwide cultural diversity and inclusion policy in place. Countries with similar and even less migration and cultural diversity than New Zealand already have such policies in place in their health organisations. Such a policy here could help to reduce the risk of those cultural misinterpretations and confusions that can get in the way of good teamwork and good patient care.
ABOUT CALD AND ECALD CALD refers to culturally and linguistically diverse groups who are migrants and refugees from Asian, Middle Eastern, Latin American and African backgrounds. Since 2010 eCALD has been providing a variety of free, accredited e-learning courses for health professionals working with culturally and linguistically diverse (CALD) groups in New Zealand – including their fellow health professionals. The Ministry of Health-funded eCALD service is based at Waitemata District Health Board’s Institute for Innovation and Improvement. Around 24,000 learners have completed a CALD course since 2010, with more than a third of those being registered and enrolled nurses. More information on free e-learning CALD courses and resources at: www.ecald.com.
Culturally competent care is essential for improving health equity and the delivery of quality, safe, culturally acceptable care for CALD groups. CALD refers to culturally and linguistically diverse groups who are migrants and refugees from Asian, Middle Eastern, Latin American and African (MELAA) backgrounds.
We have a range of courses and resources for the New Zealand nursing workforce for enhancing CALD Cultural Competence.
Research commentary
Courses for Working with CALD Patients
eCALD® news & updates
• Culture and Cultural Competency • Working with Migrant Patients
List of migrant & refugee services
CALD related publications
List of translated resources
Screening tools in multiple languages
• Working with Refugee Patients • Working with Interpreters Go to www.eCALD.com to view other ‘Courses for Working with CALD Patients’. NB: Courses are accredited for CNE points and are available in both online and face-to-face formats. Courses for Working in a Culturally Diverse Workplace • Working in Culturally Diverse Teams
eCALD® courses
Cross-cultural resources
For information on courses and resources, eligibility and enrolment, and how to access:
www.eCALD.com
Check the list of face-to-face courses online via the CALENDAR. Existing users: please go to LOGIN page to access your accounts. New users: please go to LOGIN page to register for a new account.
• Intercultural Competence for the Migrant Workforce • Managing Cultural Diverse Teams
Professional Development Learning Activity
Do nurses ‘eat their own’? Identifying and managing workplace bullying By Kate Blackwood
Workplace bullying is a pervasive problem for nursing in New Zealand, resulting in harmful consequences for individuals exposed to bullying and their organisations. This article explores the problem of bullying, strategies for its prevention and management, and the obstacles to resolving bullying complaints. Introduction Workplace bullying is a known problem in the nursing profession internationally. If findings from research conducted in the New Zealand healthcare sector1 are applied to the nursing workforce, it is estimated that approximately 10,000 of New Zealand’s nurses have experienced workplace bullying in the past six months (about one in five), and that over 40,000 (87 per cent) have been exposed to occasional negative behaviours. The detrimental consequences of workplace bullying extend well beyond those directly exposed. Bullying targets, witnesses, and individuals accused of bullying may experience harmful consequences, such as stress, depression, difficulty sleeping, low self-esteem, posttraumatic stress disorder, and suicidal
ideation. Workplace bullying lowers morale, job satisfaction, commitment and productivity, and increases the likelihood of staff absenteeism and turnover. In the nursing profession in particular, workplace bullying has detrimental impacts on workforce productivity and negatively impacts the quality and safety of health services provided to the public. Bullying in nursing is enabled or encouraged by a range of work environment conditions, such as physical and emotional stress, high workloads, limited resources and community expectations. A politicised climate is also said to exist in nursing, leading to a lack of collegiality and a climate of nurses “eating their own”2. Bullying is often passed down from experienced nurses, with nurses
commonly reporting being exposed to bullying during their training and induction years3. Such exposure to bullying throughout socialisation processes normalises bullying behaviours from the point of entry into the profession, encouraging and embedding a perpetual culture of bullying4. Research in New Zealand shows that newly registered nurses are subjected to bullying behaviours, such as having learning opportunities blocked, being undervalued, suffering emotional neglect, being distressed about conflict, and being given too much responsibility without appropriate support5. However, it is not only junior nurses who are at risk of bullying: bullying can occur anywhere in an organisation.
Learning outcomes Reading and reflecting on this article will enable you to: ▶▶ increase your understanding and awareness of workplace bullying
▶▶ describe ways that you can contribute to the prevention and management of bullying in your organisation.
▶▶ reflect on how individuals experience bullying and how your organisation manages bullying
This learning activity is relevant to the Nursing Council of New Zealand competencies 3.3, 4.1, 4.2. 18 Issue 1
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Professional Development Learning Activity Identifying bullying Although a range of definitions exists, it is generally agreed that bullying consists of systematic and persistent behaviours directed towards an individual over a period of time. The definition used by WorkSafe in their good practice guidelines Preventing and Responding to Bullying at Work6 is: “Bullying at work is repeated and unreasonable behaviour directed towards a worker or a group of workers that can lead to physical or psychological harm” (p. 14). There is a range of behaviours that constitute bullying. These are generally categorised as being work-related, person-related, or physically intimidating behaviours and are outlined in Table 1.
targeted that an experience would constitute bullying. Hence, the nature of workplace bullying is such that targets of bullying are often unable to identify an experience immediately. However, as bullying behaviours continue over time, a cycle of demoralisation develops where the individual begins to doubt themselves and their confidence is undermined. In the initial stages of a bullying experience, they will often struggle to make sense of whether they are being targeted or whether they are misinterpreting the behaviours. A common response by nurses when reflecting on the initial stages of their bullying experience is: “I thought it was all my fault”. At this stage of an experience, the targeted nurse will often seek to
Table 1: Bullying behaviours Work-related
▶▶ Someone withholding information that affects your performance. ▶▶ Being ordered to do work below your level of competence. ▶▶ Having your opinions ignored. ▶▶ Being given tasks with unreasonable deadlines. ▶▶ Excessive monitoring of your work. ▶▶ Pressure not to claim something to which by right you are entitled. ▶▶ Being exposed to an unmanageable workload.
Person-related
▶▶ Being humiliated or ridiculed in connection with your work. ▶▶ Having key areas of responsibility removed or replaced with more trivial or unpleasant tasks. ▶▶ Gossip and rumours being spread about you. ▶▶ Being ignored or excluded. ▶▶ Having insulting or offensive remarks made about your personality, attitudes or private life. ▶▶ Hints or signals from others that you should quit your job. ▶▶ Repeated reminders of your errors or mistakes. ▶▶ Being ignored or facing a hostile reaction when you approach. ▶▶ Persistent criticism of your errors or mistakes. ▶▶ Practical jokes being carried out by people you don’t get along with. ▶▶ Having allegations made against you. ▶▶ Being the subject of excessive teasing and sarcasm. ▶▶ Being shouted at or being the target of spontaneous anger.
Physically intimidating
▶▶ Intimidating behaviours, such as finger-pointing, invasion of personal space, shoving, blocking your way. ▶▶ Threats of violence or physical abuse or actual abuse.
Source: Negative Acts Questionnaire – Revised7 Because of the covert nature of many of the behaviours that can constitute bullying, bullying is often difficult to identify at first. Also, the definition of bullying is such that it is not until the behaviours have been going on for some time (official measurements of bullying prevalence use a six-month duration7) and an individual has been frequently and persistently
re-establish a sense of safety and security, rebuild comfort, and validate their value in their work team. While a number of studies point to a struggle by those who are bullied to identify that what they are experiencing is workplace bullying, in some cases, the perpetrators may also struggle to identify cases of workplace bullying. Cultural norms can cause individuals to
behave in such a way that they believe their behaviour appropriate in their work context, and bullying perpetrators may claim to have little insight into the impact their behaviour is having on the other person.
Coping with bullying There are a number of strategies that an individual experiencing bullying can use to try to deal with the situation. These strategies can include: ▶▶ seeking help ▶▶ responding assertively ▶▶ avoiding the bullying (for example, by taking leave, seeking a job transfer or asking to be rostered to a different shift) ▶▶ ignoring the behaviours and trying not to let it affect them. Research indicates that junior or low-status employees are more likely to respond by trying to please the perpetrator and not giving them an opportunity to bully than they are to respond assertively8. It is recommended that targets of bullying should be more assertive in dealing with perpetrators to avoid being perceived as easy targets of mistreatment. Several cases of effective coping by responding assertively to the bully have been reported by New Zealand nurses9, as in the following quote: “I decided I wasn’t going to let her bully me. Every single time I spoke back to her nicely, no matter how bad she was, no matter what she said. And from my point of view, it worked. I was amazed. Her attitude towards me started to change.” It should be noted, however, that targets of bullying who have success using this approach generally also have validation from their managers that they are not in the wrong and are well supported by colleagues. For many targets of bullying, responding assertively is often easier said than done, particularly when the bully is at a senior level in the organisation or when the experience has escalated and the target has become demoralised and lost confidence. Indeed, targets of bullying are often forced into positions where they have little power to deal effectively with their own experiences of workplace bullying and, unless the organisation steps in, an unfortunate and all too common outcome is that once the targeted individual’s personal coping resources are depleted they will leave the organisation. Hence, early identification and reporting is essential for resolving cases of workplace bullying. nursingreview.co.nz Issue 1 19
Professional Development Learning Activity
Reporting bullying Most anti-bullying policies will outline the channels for reporting within the organisation. Generally, nurses who believe they are being subjected to workplace bullying are encouraged to report to their direct line manager in the first instance, if they feel safe to do so. Other reporting channels include other managers, a harassment contact person (if the organisation has them), a union representative, or a human resources manager (HR). Some organisations also encourage reporting by way of lodging an incident report; however, experiences of bullying do not often involve a single major incident and instead the harm experienced is a result of a build-up of subtle behaviours over time. In such cases, incident reporting may not be appropriate. However, despite being aware of policies and reporting channels, research shows that many targets of bullying do not formally report their experiences10. Under-reporting may be due to: ▶▶ unclear or unsafe reporting channels ▶▶ a perceived lack of support from the organisation ▶▶ fear that a complaint will be perceived as unsubstantiated ▶▶ fear of retaliation from the bully. When a target has previously seen other complainants being blamed or seen as troublemakers and having their problems deflected with little or no support, they too become reluctant to complain. In organisations where there is a culture of bullying and it is perceived to be tolerated, encouraging reporting is particularly problematic.
Managing bullying If a target of bullying makes a formal complaint to HR, they will respond by conducting an investigation into the complaint, interviewing both parties and witnesses, and provide recommendations based on the outcome. However, targets of bullying often find this process overwhelming and emotionally draining. By the time a bullying experience has escalated to a point that a target believes a formal complaint is warranted, the targeted individual will often feel highly demoralised, having experienced numerous unsuccessful attempts to resolve the situation. Due to the historical nature of many of the behaviours (with some experiences having continued for years prior to a formal complaint being made), and the contextual nature of the harm experienced (i.e. the build-up of behaviours, rather than a major incident), targets often have 20 Issue 1
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little evidence to support a bullying complaint. In addition, perceptions of right and wrong are usually strongly embedded by this stage and neither party is able to compromise on their views. As such, the outcome of workplace bullying investigations is rarely accepted by both parties and for these reasons a number of early, low-level interventions are strongly recommended.
Coaching The preliminary findings of current research into the competencies required for managing bullying show excellent practice by some New Zealand nurse managers, including providing perpetrators with insights into their behaviours and coaching them in effective communication with colleagues. Coaching the targets in effective responses to bullying can also increase their resilience; however, managers should be aware that relying solely on target-focused responses is rarely sufficient to resolve a case of workplace bullying and is unlikely to be suitable in escalated cases or when there is a power imbalance between the target and the alleged perpetrator.
Mediation Mediation is also a commonly used strategy for resolving cases of workplace bullying and can be conducted formally by an external mediator or by a manager or organisational representative. The efficacy of mediation for resolving cases of bullying is debatable; however, it is generally agreed that in escalated, highly destructive cases of bullying or where the alleged perpetrator is a manager, mediation is less appropriate due to the power imbalance that exists between the two parties. Although mediation is not recommended in such cases, if such a case does go to mediation, encouraging the target to bring a support person or advocate is advised.
Importance of managers’ skills and awareness Although there is evidence of good practice by managers and organisational representatives in responding to workplace bullying, ineffective intervention in workplace bullying is common. If the bullying intervention is not effective, the target is often left with little choice but to leave the organisation. Research indicates that unsuccessful resolution is often due to: ▶▶ lack of managerial confidence and skill in dealing with complaints ▶▶ lack of time ▶▶ managers believing that conflict between staff is not their responsibility.
In cases where the alleged perpetrator is a manager, managers have been found to be able to justify their behaviours as performance management, and HR may often side with management. That said, however, staff may also use the term ‘bully’ in an allegation of managerial bullying as a response to legitimate performance management that they deem is unfair. It is well-documented that effectively resolving escalated cases of bullying is near impossible, and therefore it is strongly recommended that early identification of potential cases of bullying and early reporting and intervention is encouraged.
Organisational culture Although line managers hold the role with most influence on the immediate work environment – and are often heavily relied upon to address behavioural issues within their team – the support of the organisation is also required to address an underlying culture of workplace bullying. While it is commonly recommended that an anti-bullying policy is developed and implemented by organisations, research indicates that a policy alone is unlikely to have a significant impact on the prevalence of workplace bullying and multi-level interventions are required. Organisations should work to minimise work-related causes of bullying, such as role conflict and ambiguity, poor leadership, and institutionalised processes and practices that encourage bullying. A strong zero tolerance for bullying should be communicated and enforced by senior leadership and commitment to this policy demonstrated through frequent communication and resourcing of interventions. Organisation-wide culture change programmes aimed at fostering dignity and respect in the workplace are also encouraged11. Bullying intervention recommendations include: ▶▶ training staff and managers to identify and report bullying ▶▶ training managers to deal with bullying ▶▶ building leadership competencies ▶▶ ensuring senior management and organisation commitment to addressing bullying ▶▶ programmes/initiatives aimed at culture change ▶▶ minimising risk factors in the work environment that contribute to the proliferation of bullying. Risk factors for workplace bullying include: ▶▶ unclear organisational change processes ▶▶ role ambiguity and role conflict ▶▶ destructive or laissez-faire leadership
Professional Development Learning Activity
▶▶ hierarchical structures and reward systems that encourage sabotage ▶▶ highly stressful work environments and high workloads ▶▶ socialisation/induction traditions ▶▶ cultures of tolerance and acceptance of bullying.
or avoiding, whereby they allow the perpetrator to continue bullying, or simply walk away from the situation. Witnesses to bullying often fail to speak up at the time of an incident, often choosing to support the target behind closed doors instead, for fear of retaliation from the bully.
Are you a bystander?
Conclusion
Witnesses to bullying have been acknowledged as playing an influential role in shaping the bullying experience and its resolution. Witnesses can influence a bullying experience in a number of ways12. Those who associate themselves with a nurse clique may be more inclined to assume an instigating, manipulating, collaborating or facilitating role, whereby they encourage the bully or create situations for the perpetrator to go after the target, often for their own personal benefit. Alternatively, a witness may take an intervening, defusing, empathising, or defending role, whereby they actively support the target. Unfortunately the most common role assumed by witnesses is one of abdicating
Although the prevalence, causes and consequences of workplace bullying are reasonably well documented, the search continues for effective strategies for prevention and intervention. Therefore the problem continues to persist and cases of bullying are rarely resolved effectively. However, early identification and lowlevel interventions prior to escalation are vital if cases are to be resolved. All staff within an organisation should be encouraged to familiarise themselves with the behaviours that can constitute bullying, report behaviours early, and stand up for colleagues experiencing bullying. Organisational support and a zero-tolerance culture of bullying are also required to put a stop to this pervasive problem.
ABOUT THE AUTHOR Kate Blackwood PhD is a lecturer and a member of the Healthy Work Group at Massey University, Palmerston North. Her recent research projects include exploring target experiences of workplace bullying complaint resolution, the efficacy of mediation in bullying cases and management competencies for fostering healthy work. If you are interested in reading further on the research that informed this article, email k.blackwood@massey.ac.nz. This article was peer reviewed by: Stacey Wilson RN PhD is a senior lecturer at Massey University’s School of Nursing. Her research expertise includes mental health, crisis interventions and emotional competence. Mikaela Shannon RN BN MN is a nurse manager at Capital & Coast District Health Board. She has a special interest in fostering respect, kindness and dignity between nursing staff and initiated and leads a Care with Dignity project at Kenepuru Hospital.
REFERENCES 1. BENTLEY T et al (2009). Understanding stress
and bullying in New Zealand workplaces. Final
5. MCKENNA B, SMITH N, POOLE S, COVERDALE
RECOMMENDED RESOURCES ▶▶ WorkSafe’s Good Practice Guidelines Preventing and Responding to Bullying at Work contains a range of useful tips for targets and organisations in preventing and responding to workplace bullying. https://worksafe.govt.nz/thetoolshed/tools/bullying-preventiontoolbox ▶▶ WorkSafe’s Quick Guide Bullying at Work: Advice for Workers provides useful tips for targets and alleged perpetrators of bullying. https://worksafe.govt.nz/thetoolshed/tools/bullying-preventiontoolbox ▶▶ The NZNO website contains a range of information on workplace bullying and what you can do about it. www.nzno.org.nz/bullyfree ▶▶Australian conflict coach Judith Herrmann in her 2012 article compares conflict coaching and mediation and discusses the most suitable service in a given conflict situation. https://researchonline.jcu.edu. au/26122/1/A_comparison_of_ conflict_coaching_and_mediation_-_ article_from_ADRJ.pdf ▶▶Bullying targets needing wellbeing support: can approach their employer’s EAP (Employee Assistance Programme) if they have one, talk to their health professional or access free support services like Need to talk? (Free call or text 1737 any time for support from a trained counsellor), Lifeline 0800 543 354 or Samaritans 0800 726 666.
9. BLACKWOOD K (2015). Workplace bullying in
J (2003). Horizontal violence: Experiences of
the New Zealand nursing profession: the case
registered nurses in their first year of practice.
for a tailored approach to intervention., Massey
Journal of Advanced Nursing, 42(1) 90-96. 6. WORKSAFE (2017), The WorkSafe Quick Guide for
University, Auckland. 10. VESSEY J, DEMARCO R, GAFFNEY D, BUDIN W
report to Occupational Health and Safety Steering
Bullying at Work: Advice for Workers,
Committee, Auckland.
(2009). Bullying of staff registered nurses in the
www.worksafe.govt.nz/worksafe/toolshed.
workplace: A preliminary study for developing
7. EINARSEN S, HOEL H, NOTELAERS G (2009).
personal and organizational strategies for the
2. HUNTINGTON A et al (2011). Is anybody listening? A qualitative study of nurses’ reflections on
Measuring exposure to bullying and harassment at
practice. Journal of Clinical Nursing, 20(9-10)
work: Validity, factor structure and psychometric
1413-1422.
environments. Journal of Professional Nursing,
properties of the Negative Acts Questionnaire-
25(5) 299-306.
3. BIRKS M et al (2017). Uncovering degrees of workplace bullying: A comparison of baccalaureate
Revised. Work and Stress, 23(1) 24-44. 8. AQUINO K (2000). Structural and individual
nursing students’ experiences during clinical
determinants of workplace targetization:
placement in Australia and the UK. Nurse
The effects of hierarchical status and conflict
Education in Practice, 25(1) 14-21.
management style. Journal of Management, 26(2)
4. BIRKS M et al (in press). A ‘rite of passage?’: Bullying experience of nursing students in Australia. Collegian.
171-193.
transformation of hostile to healthy workplace
11. BAILLIE L, GALLAGHER A (2010). Evaluation of the Royal College of Nursing’s ‘Dignity: at the heart of everything we do’ campaign: exploring challenges and enablers. Journal of Research in Nursing, 15(1) 15-28. 12. PAULL M, OMARI M, STANDEN P (2012). When is a bystander not a bystander? A typology of the roles of bystanders in workplace bullying. Asia Pacific
Journal of Human Resources, 50(3) 351-366.
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Professional Development Learning Activity
Professional Development
Learning outcomes ▶▶ increase your understanding and awareness of workplace bullying ▶▶ reflect on how individuals experience bullying and how your organisation manages bullying
Learning Activity
▶▶ describe ways that you can contribute to the prevention and management of bullying in your organisation.
Reading the article Do nurses eat their own? Identifying and managing workplace bullying and undertaking this learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council of New Zealand competencies: 3.3, 4.1, 4.2. A
Reading
1
Watch the TEDx Talk (15 minutes) on Caroline Dean’s experience of workplace bullying and her recommendations for how organisations can best address bullying in the workplace. www.youtube.com/watch?v=nG1oCU0ijP0
B
Reflection
1
Reflect on bullying that you have experienced or witnessed in your workplace and how you responded to the situation. If you haven’t experienced or witnessed bullying, reflect on Caroline’s experience (see above) and think about how an experience such as this could play out in your workplace.
2
Reflect on your own behaviour in the workplace and how your behaviour could be interpreted by your colleagues.
C
Reality
1
Find information about what strategies your organisation has in place for preventing and managing bullying. Do they have an anti-bullying policy, harassment contact people, training for staff?
2
Identify the ways in which you could contribute to preventing and managing bullying in your workplace.
3
Talk with a colleague or student about the issue of bullying and highlight the need to take action to counter this long-term workplace culture.
Verification by a colleague of your completion of this activity Colleague name
Designation
Date
Nursing council ID
Work address
Contact #
Body.
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Professional Development Learning Activity
Cultural intervention for self-harm trialled What impact did a ground-breaking, randomised trial of a cultural intervention for self-harm have for its Māori participants? CLINICAL BOTTOM LINE
CITATION
A culturally informed, multimodal intervention holds promise for improving health outcomes in Māori presenting to emergency departments with intentional self-harm.
Hatcher S, Coupe N, Wikiriwhi K, Durie SM, Pillai A. Te Ira Tangata: a Zelen randomised controlled trial of a culturally informed treatment compared with treatment as usual in Māori who present to hospital after self-harm. Soc Psychiatry Psychiatr Epidemiol. 2016;51(6):885-94. doi: 10.1007/s00127-0161194-7
CLINICAL SCENARIO As a nurse working in mental health, you are aware of the disproportionately high rates of intentional self-harm in Māori, compared with non-Māori. You wonder whether an intervention tailored to the cultural needs of Māori may be more effective than usual care and decide to review the evidence.
QUESTION Does a culturally informed treatment programme improve outcomes for Māori presenting to hospital after self-harm, compared with usual care?
SEARCH STRATEGY PubMed Clinical Queries (therapy, broad): self-harm AND Māori. 24 Issue 1
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STUDY SUMMARY The study was a double consent, Zelen design, randomised controlled trial (RCT) conducted in seven hospitals across three district health boards. Included were Māori who had presented at the hospitals’ emergency departments following an episode of intentional self-harm. Self-harm was defined as intentional self-poisoning or self-injury, irrespective of motivation. Self-injury was defined as any injury that had been intentionally self-inflicted. Excluded were those aged under 17, still at school, or unable to give informed consent. Of 497 assessed as eligible,
365 were randomised (pre-consent) and 198 did not subsequently consent to either intervention or control, leaving 167 consenting to participate in the study. All participants received standard care. Length of treatment and follow-up was 12 months. Intervention 1: (n=182 allocated, n = 95 consented) A package of interventions delivered by Māori to Māori with an emphasis on cultural identity. Interventions included monthly postcard contact, problem-solving therapy (maximum six sessions), patient support (up to two weeks), a focused risk management strategy, improved access to primary care, and cultural assessment in addition to standard care. Cultural assessments aimed to increase engagement of patients in Māori cultural services and paid attention to sense of belonging and feelings around ethnicity.
Professional Development Learning Activity Table: Results with 95% confidence intervals (CI) Outcome
Consented to intervention (n = 95)
Consented to control (n = 72)
Group difference (95% confidence interval)
NNT*
Beck Hopelessness Scale# at baseline, mean (SD)
11.8 (6.3)
8.5 (5.5)
-
-
Beck Hopelessness Scale, change baseline to three months
-4.5 (5.6)
-1.3 (7.1)
-1.7 (-3.4 to -0.01)
-
Beck Hopelessness Scale, change baseline to one year
-6.6 (6.0)
-2.8 (5)
-1.6 (-3.4 to 0.3)
-
Presentation to hospital for non-self-harm at 12 months
42 (44.2%)
44 (61.1%)
16.9% (32% to 1.8%)
6 (3 to 54)
# Beck Hopelessness Scale – range of 0 to 20 with higher scores indicating increased hopelessness * Number needed to treat
Control: (n= 183 allocated, n = 72 consented) Standard care, which included referrals to multi-disciplinary mental health teams or referral back to the general practitioner. Primary outcomes: Self-rated change in scores on the Beck Hopelessness Scale after one year. Secondary outcomes: Patient-reported outcomes of hopelessness, anxiety, depression, quality of life, sense of belonging and cultural impact profile – measured at baseline, three months and one year. Repeat self-harm and health service use (telephone questionnaire, health records) measured at three months and one year.
STUDY VALIDITY Randomisation – yes, stratified minimisation randomisation helped ensure balance in key prognostic factors; allocation concealment – unlikely because of Zelen design; complete follow-up – yes, for repeat hospital presentation data (n= 365); continuous outcomes data – available for 69 per cent and 66 per cent of those consenting to treatment and control, respectively; intention-to-treat (ITT) analysis – yes, for hospital repeat visits, otherwise per-protocol analysis; blinding – outcome assessors only; equal treatment between groups – appears so; groups similar at baseline – increased hopelessness in the intervention group, adjusted analysis. Overall impression: variable risk of bias present across outcomes of interest.
STUDY RESULTS Of those consenting to participate, 65.3 per cent (n = 109) were female and 59.9 per cent (n = 100) had a history of self-harm. There was a statistically significant greater change (decrease) in hopelessness scores at three months, but not at one year for those consenting to intervention, compared with those consenting to standard care (see table). There were no other significant differences between groups for any other continuous outcome measures at either three or 12 months. However, those receiving the intervention were significantly less likely to present to hospital for non-self-harm reasons in the year following the first presentation (see table). The intervention group was also significantly less likely to re-present with self-harm at three months {10.4 per cent (19/182) vs 18 per cent (33/183), p = 0.04} but not at 12 months, compared with the control group (ITT analysis). There were no deaths in the intervention group and one suicide in the control.
COMMENTS ▶▶ This study is significant in that few RCTs have explicitly evaluated the effect of a culturally informed intervention and, to my knowledge, this is the only RCT of this type conducted in New Zealand.
▶▶ Qualitative interviews – and the proportion consenting to intervention – indicated the culturally informed approach was acceptable to many Māori. There is work to be done in isolating the effective components of such a programme. ▶▶ These results contribute to research knowledge highlighting the importance of finding ways to promote and maintain meaningful patient engagement with health service providers in order to enhance health-seeking behaviour, improve patient experience and, ultimately, health outcomes. Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD Candidate, Deakin University, Melbourne cwensley@deakin.edu.au
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nursingreview.co.nz Issue 1 25
Innovation & Technology
‘Prescribing’ apps: helping patients to select a health app
Nursing Review talks to Sandra Ponen, a clinical pharmacist and medical writer who has been working on the App Library project for Health Navigator, about how health professionals can guide patients on whether an app will help them or not.
A
ccess to health support is only a swipe or a tap away on a smartphone or tablet. Hundreds of thousands of health apps are now available, designed to help people track their health info, count carbohydrates, exercise more or drink less and provide information on their health conditions. The quality of apps can vary greatly, not only in design but also in the quality of advice – making some apps potentially dangerous. Attempting to review the apps available is nearly impossible, but in 2016 the nonprofit, consumer-focused Health Navigator website (www.healthnavigator.org.nz) launched a New Zealand-based online app library – with Ministry of Health support – to make it easier and safer for Kiwis to identify useful and relevant apps for the New Zealand setting. It was never expected to be an easy task and to date about 80 reviews of free health apps – from alcohol tracking to stroke risk prediction and medication adherence to anxiety management – are now available. Many more app categories have yet to be reviewed and included in the library.
Keeping the patient’s own needs in mind What should a nurse or health professional look for if they are considering ‘prescribing’ an app or helping a patient decide on a useful app for their condition? Ponen points to Australian research, which indicates there are three main 26 Issue 1
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things to keep in mind when considering a health app: Is it credible and safe? Is it user-friendly? Is it appealing and engaging? She believes health professionals, as experts in their field, definitely have a role in helping determine whether an app is credible and safe for patients or clients to use. Research showing that the app works (i.e. changes lifestyle behaviours) would be a ‘nice to have’ in the credibility stakes, but Ponen says such trials are rare and difficult to carry out. It is more realistic to check if an app comes from a legitimate source and was developed using evidencebased methods or with health professional expertise (see app review checklist below). If an app appears credible, health professionals can then go on to discuss with the patient whether it is easy to use and meets their needs. Also under consideration is whether the app is appealing and engaging enough for the patient to use regularly. Ponen says health professionals also need to take into consideration the app’s target audience, as an app viewed as easy by a teenager may seem fiddly and confusing to a smartphone novice. And what is appealing and engaging to one person could appear childish and patronising to another. Nurses and other health professionals need to keep in mind that the usability ‘tick lists’ of patients and health consumers might not match their own, says Ponen. For example, an app created
by a university may have more clout with health professionals, but a quit-smoking game app developed by an ex-smoker might mean more to a patient struggling to quit. Ponen points out that an app also should not be just a digital textbook or pamphlet – it can have features like video, pleasing graphics, interactive tools and charts and connect the user to social media and links to more learning resources. The potential is there for prescribing credible, user-friendly and engaging apps that can make a difference to patients’ health and wellbeing. You can access the Health Navigator list of peer-reviewed apps at www. healthnavigator.org.nz/app-library. If you want to review an app yourself, below is a quick checklist to consider before supporting a patient in their choice of app. (A more comprehensive checklist can be viewed online at www.nursingreview.co.nz.)
DO YOU WANT TO HELP? You can help Health Navigator build its online app library by emailing sandra@healthnavigator.org.nz with: ▶▶apps that you are currently recommending to patients and the reasons why ▶▶an offer to become a peer reviewer of future health apps.
Innovation & Technology CHECKLIST IS IT CREDIBLE AND SAFE? ☐☐ Does the app come from a legitimate source? I.e. is it sponsored or developed by a reputable organisation/university/health provider ready to put its reputation on the line? Does it have a website with contact details? ☐☐ Is it suitable or relevant for New Zealanders? I.e. if it is an overseas app, are its recommendations in keeping with New Zealand practice; does it include options for metric measurements and does it mention medications that are available in New Zealand? ☐☐ Does the app make suggestions about changing medication or treatment plans without consultation with the person’s health professional? ☐☐ Does the app have clear privacy guidelines on how data shared via the app will be stored and used? Does the app ask for permission to access unrelated information that may be used for advertising or other commercial purposes?
IS IT USER-FRIENDLY? ☐☐ Is the layout simple, clear and well designed? Or cluttered and confusing? Is it easy and intuitive to learn how to use? Does it have long lags or technical bugs? ☐☐ Is the app’s language and information suitable for the target group your patient belongs to? If local, does it include Māori and other language options? ☐☐ How much data space will the app take up on a smartphone or tablet and/or how much mobile data will it require to run? Does it require the internet to use its core features? Does it have ongoing costs or charges? ☐☐ What are the reviews and ratings of the app on sites that you trust? (Keeping in mind a company in the US has been prosecuted for being paid to post fake comments on an app it was promoting.)
IS IT APPEALING and ENGAGING? ☐☐ Is the app visually attractive and appealing? Is it fun or entertaining? Does it use game strategies or appealing animations to keep you engaged? ☐☐ Is the app interactive? Does it provide feedback and options like medication reminders, data syncing, user control, data visualisation and exportation? Or is it more of a glorified information pamphlet? ☐☐ How likely is it that the app may engage and motivate the user to change their health behaviour or attitudes or increase their knowledge or improve/maintain the management of their health condition?
Checklist source resources: Health Navigator ‘How to choose a health app’ www.healthnavigator.org.nz/app-library/h/howto-choose-a-health-app STOYANOV et al. (2015) Mobile App Rating Scale: A new tool for assessing the quality of Health Mobile Apps. JMIR Mhealth Uhealth 3 (1). Mobile App Rating Scale (MARS) App Review Guideline, Queensland University of Technology’s Institute of Health & Biomedical Innovation.
WEBSCOPE Global health campaigns
Kathy Holloway introduces two websites with a global focus on improving procedures and strengthening practice, including one hosting the Nursing Now campaign. All-Party Parliamentary Group (APPG) on Global Health – Nursing Now www.appg-globalhealth.org.uk/home/4556655530 This UK site, recognising that health is interdependent and interconnected on a global scale, hosts many evidence-based reviews on topical global health issues. The APPG group is supported by UK academic institutions, The Lancet and the Bill & Melinda Gates Foundation. This support allows the group to connect the interest, impact and knowledge of parliamentarians with the expertise and experience of the wider global health community. A recent report from Lord Nigel Crisp detailed the positive economic, gender equality and health outcomes of nursing. The report, titled ‘The Triple Impact’ sparked a worldwide campaign, endorsed by the International Council of Nurses congress in 2017. The Nursing Now campaign wants to make sure that all nurses and midwives, in every role and at every level, are skilled and supported to develop and strengthen nursing and midwifery practice, mobilise others and make change happen. There are links on this site to free educational resources for both nurses and midwives about practice improvement, as well as information about the Nursing Now campaign, which is being launched on 27 February 2018. You are welcome to register if you would like updates. [Site accessed 4 February 2018 and last updated December 2017].
Choosing Wisely New Zealand http://choosingwisely.org.nz Choosing Wisely New Zealand is a part of a global, health-professional-led and patient-focused initiative to promote quality care through better decisions. The intent is to promote a culture where low-value and inappropriate clinical interventions are avoided, and for patients and health professionals to have well-informed conversations around treatment options, leading to better decisions and outcomes. The Council of Medical Colleges (CMC) is facilitating this initiative in New Zealand, which is also endorsed by the Health Quality and Safety Commission. Specific health-professional or patient/consumer sections on the site provide recommendations about tests, treatments, and procedures that healthcare professionals, patients and consumers should question. On a similar Australian site, the Australian College of Nurses provides ‘Choosing Wisely’ resources on peripheral IV cannula replacement, blood glucose monitoring, urinary continence and the use of X-rays in foot and ankle trauma: www.choosingwisely.org.au/recommendations/acn. The Canadian Nursing Association also provides a list of recommendations at https://choosingwiselycanada.org/nursing. Overall, health consumers should be encouraged to ask their health practitioners four questions: ▶▶ Do I really need this test or procedure? ▶▶ What are the risks? ▶▶ Are there simpler, safer options ? ▶▶ What will happen if I don’t do anything ? [Site accessed 4 February 2018 and last updated January 2018]. nursingreview.co.nz Issue 1 27
Leadership & Management Profile
Good data in your head and patients at the heart of all you do
Recruitment, retention and removing barriers were ‘the three Rs’ that reigned over much of outgoing Chief Nursing Officer Dr Jane O’Malley’s time. FIONA CASSIE talks to her about morale, management and moving on.
J
ane O’Malley says she’s often been asked about the conflict of wearing her two hats – one as the country’s nurse leader and the other as chief nurse, answerable to the Government. Her answer was that it simply isn’t that difficult. If you have the hard data at your fingertips and keep patients and consumers at the heart of all you do, then it is very easy to give ‘free, frank and fearless’ advice to a health minister or her CEO, she says. As a chief nurse, O’Malley says she’s always been keen on using data to tell the story but that first required getting the data so she knew what story to tell. She says former Director General Kevin Wood used to tell her to stop focusing so much on the workforce because they now had Health Workforce New Zealand (HWNZ) to do that task. Her response was that she didn’t want people some time in the future facing a nursing shortfall to look back at her time and ask “so what was the chief nurse doing”. With concern rising about the ageing nursing workforce, getting a good grasp of where the nursing workforce was at was a high priority for O’Malley when she walked into the Office of the Chief Nursing Officer (OCNO) in late 2010.
Recruitment: ACE and the ‘ageing’ workforce At the start of the decade, nursing turnover had fallen – an international phenomenon as nurses stepped up hours, put off retiring or returned to the workforce as the global financial crisis hit their families’ livelihoods. At the same time, anecdotal reports of new graduates struggling to find work started to emerge. But when then Health Minister Tony Ryall asked O’Malley a question (which she says he did a lot) – whether new graduate nurses were getting jobs – she, shamefaced, had to answer that they just didn’t know. At that time the OCNO had to wait a whole year, until new graduates renewed their APCs with the Nursing Council, to 28 Issue 1
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“If we know we have a need for care, we must staff for it.”
get an accurate picture of employment rates or wait three months after graduation for partial information when the NETS (Nursing Education in the Tertiary Sector) graduate destination survey results arrived. Getting better new graduate job data quickly went to the top of the list for the new chief nurse, leading to nursing in 2012 adopting medicine’s ACE one-stop-shop clearing-house system for new graduate job placements. “Now we have a good five to six years of strong data about the new graduates applying through ACE, their specialty preferences and their regional preferences,” says O’Malley.
They also know that – despite people’s ongoing concerns that only 50–60 per cent of applicants get jobs in the ‘first flush’ – within five months 60–70 per cent will have nursing jobs and by the end of 12 months only around 3–5 per cent are still job-hunting. Thanks to work done by her then advisor Dr Paul Watson, the office also had data on the skill mix and turnover of the nursing workforce in DHBs and knew that the largely experienced DHB workforce had the capacity to replace experienced staff nurses with new graduates from the ACE talent pool. O’Malley says HWNZ analyst manager Emmanuel Jo recently presented her with a graph that shows the nursing workforce now has a “dip in the middle” between the new generation of young nurses and the ageing generation of nurses nearing the end stages of their career. “The concern when we first started this work was that the young weren’t coming in – but what we are seeing is a nice wave of our new graduates steadily coming in each year.” Based on that data trend, Jo was predicting a steady number of nurses across the age spectrum into the future. “So the ageing workforce people were worrying about is now going to be a ‘youthening of workforce’ over the years, if we continue to do what we are doing at the moment. So that’s really good.” ACE and Nursing Council statistics are also showing that 86–88 per cent of nurses gaining places in either of the new graduate programmes are still nursing five years on. It’s some encouraging news on which to end her term.
Retention: safe staffing and the slow adoption of CCDM But the news has not always been good about nursing over the past near-decade. Nurses are often reported feeling under the pump as patients get sicker, bed turnover faster and budgets tighter. So retention has been another one of the ‘three Rs’ that has preoccupied her time,
Leadership & Management Profile
with much of the focus being on ensuring good working conditions, in particular safe staffing. O’Malley’s own career has been closely aligned with safe staffing. She was president of the NZNO when the 2004 historic ‘pay jolt’ deal for DHB nurses set up the Safe Staffing Healthy Workplace (SSHW) Inquiry. She was also director of nursing for one of the early SSHW demonstration sites, the West Coast DHB, and a member of the SSHW Unit governance group, which oversaw the development of the acuity-based, safe staffing suite of tools known as CCDM (Care Capacity Demand Management). But she admits the pace of rolling out CCDM across DHBs has been so slow and so fragmented that it risked putting the whole programme under threat. “Nurses might be tempted to say CCDM doesn’t work. And chief executives might fail to realise the potential for CCDM to impact on patient and staff outcomes and actually improve hospital productivity if they don’t see the full scale roll-out.” So it was great news to her, and one of her career highlights, that late last year the DHB chief executives agreed that the national rollout of CCDM will be “over the line” across all 20 DHBs by July 2021. She emphasises that ‘over-the-line’ means not only introducing the tools, but DHBs also building into their budgets the funding to boost nursing numbers if CCDM analysis reveals that a ward or unit is understaffed to meet patient demand. O’Malley acknowledges that CCDM at the moment is very much focused on DHB inpatient settings “but it’s a good place to start”. The national rollout will also provide good national data and O’Malley reiterates that it is good data that should be driving decisions about workforce and skill mix. “If we know we have a need for care, we must staff for it,” she says. While supporting specialist and advanced nursing practice, O’Malley is also a champion of the generalist nurse working to the fullest extent of their scope. Generalism is a nursing attribute that comes to the fore in a CCDM environment, which encourages wards to plan and be ready to transfer or receive a nurse if a crisis arises. “The truth is that registered nurses (RNs) are generalists – they can move from one ward to another and not do the specialist part of nursing in that ward but the generalist part,” says O’Malley.
In addition, she says that more care could be provided by enrolled nurses (ENs) – a workforce she believes could easily be grown to support RNs – and some by healthcare assistants (HCAs). “We have to be ready to look at our own practices rather than always blame the funding, or the operations manager,” says O’Malley. “My challenge to registered nurses would also be to not assume that all that care needs to be RN care.”
Removal of barriers: prescribing and law changes The third ‘R’ – removing legal barriers to practice that were creating ‘road blocks’, particularly for nurse practitioners, but also RNs and other health practitioners with advanced skill sets – was another major ongoing task for O’Malley’s office. Pulling together an omnibus law to amend and remove ‘doctor’ and ‘medical practitioner’ from eight Acts where other suitably qualified practitioners could now safely carry out the roles was a complex and convoluted process. But O’Malley says the triumvirate of Alison Hussey (OCNO), Mary Louise Hannah (HWNZ), and legal advisor Jane Hubbard successfully shepherded the bill through and the amended Acts were finally enacted on 31 January this year. Under O’Malley’s watch the Nursing Council and Government also brought in two new levels of registered nurse prescribing, amended standing orders regulations and tweaked a number of other regulations to ease the way for nurse practitioners. Nursing leadership – particularly under the DHBs – is another area that has been in the spotlight during O’Malley’s watch. “I’ve heard people saying that nursing leadership is under pressure and restructuring is taking out nurse leaders,” she says. “I’ve actually looked at the last five DHB restructures and I can’t see evidence that nursing has been restructured out of the decision-making.” During her behind-the-scenes discussions with chief executives over restructuring, she says the CEOs “really listened” and while restructuring is stressful and some nursing leaders have gone, others have been appointed to take their places. She also can’t see evidence that nursing clinical advice is not being listened to – though she acknowledges “you will have pockets of it”.
Morale, frustrations and rewards What about the toughest and most difficultto-measure test of her tenure – how has nursing morale changed in the time she has been the country’s chief nurse? “I don’t think morale is any worse or better than it was seven years ago … I’m an optimist,” says O’Malley. “I always think it’s not bad but it could be better.” “I think if we utilise nurses well; if we make sure that we deliver them predictable workloads that allow them to do the work they need to do for patients; if we make sure that every nurse is accountable for their practice in an environment where they are free to make good decisions; and if we value people as people and give them time to grow, then we will always get better patient and nurse outcomes.” O’Malley leaves the Ministry – a place in which it has been a pleasure to work, she says, as there are so many intellectually smart people with a passion for health in one space – in March to become Plunket’s first chief nurse. Will she leave any frustrations and regrets behind her? “There’s always frustration and always more that you could do.” Only time will tell whether people will look back at her time and ask “what was the chief nurse doing?”. Jane O’Malley leaves knowing that she did a lot. nursingreview.co.nz Issue 1 29
Students Literature Review
Using interpreters:
the patient’s right to understand and be understood A situation where a nursing student found themselves as a reluctant, untrained interpreter for a patient raised questions for a group of five secondyear nursing students. The questions prompted a literature review on access to and the use of interpreters in health. In this article, the students share their findings.
I
nterpreters are an increasing need in New Zealand hospitals, particularly in Auckland, which has a multicultural and very diverse society. However, hospitals are predominantly English-speaking environments. Statistics from the New Zealand Census showed that English was not recorded as the first language for 87,534 Aucklanders. While this can create language barriers and impact on communication between staff and patients, accessing an interpreter for the patient can be difficult at times. This is due to confusion over whether an
interpreter is needed or not, uncertainty around whether a phone or an in-person interpreter is more appropriate, and a lack of knowledge about accessing an interpreter in the first place. These difficulties impact on the convenience of using an interpreter and can result in the medical team using someone present on the ward who speaks the language but is not trained as a medical translator. Second-year student nurses have witnessed this happening or have been asked themselves to interpret for both doctors and nurses. Use of untrained interpreters The first issue that will be discussed is the use of unqualified interpreters in a hospital setting. What the student nurse saw in the above scenario was that medical students, student nurses and health professionals are occasionally asked to interpret for patients. This puts the safety of both the patient and the medical staff at risk, along with breaching various patients’ rights. Convenience of accessing an interpreter The second issue that can arise from interpreter use in a hospital setting is whether accessing an interpreter is convenient for healthcare professionals. The student nurse involved in this scenario perceived a lack of interpreter availability on the part of the healthcare team. Accessing an interpreter also consumed a lot of time, therefore it was not convenient for them to use one.
Literature review The challenges and issues presented by ethnic and language diversity have been reviewed in the research literature. District health boards have policies in place to support large immigrant populations with limited English proficiency. New Zealand research has shown that health professionals who are aware of the DHBs’ policies show a greater use of trained interpreters. However, often these policies are disregarded by healthcare professionals, as observed on clinical placements. Disregard for policies leads to the use of untrained interpreters, possibly because accessing a professional interpreter is not convenient. There can be various underlying factors to a nurse or other health professionals’ decision to use an unqualified interpreter over a professional interpreter. Researchers have noted that there were three main factors: the availability of bilingual staff, perceptions of interpreting quality, and cost concern. New Zealand has a diverse population with many bilingual staff and students, and sometimes the availability of bilingual staff can be seen as an opportunity to use them for interpreting. This is supported by another research article that elaborates on how bilingual medical students have been asked to interpret for patients
Clinical scenario Mr J, a 75-year-old Indian man who did not speak adequate English, was admitted to hospital with chest pain. He had a medical history of Parkinson’s disease and type 2 diabetes. Mr J had a tremor in his hands, which is a prominent symptom of Parkinson’s. After taking his vital observations and blood sugar levels, the nurse attempted to book an interpreter but was unable to obtain one. The nurse then asked a student nurse, who spoke the same language as Mr J, to help interpret so the nurse could complete the assessment. Because Mr J wasn’t proficient in English, the nurse was entrusting the student nurse to interpret correctly. Although the student was not fully comfortable with interpreting, they felt obliged to do what the senior nurse asked them to do. This scenario raises some questions: ▶▶ Is asking an untrained interpreter acceptable in a clinical setting? ▶▶ What are the factors that contribute to accessing or not accessing an interpreter? This is an issue that can lead to nurses breaking the codes of ethics and creating miscommunication between patients and medical teams. 30 Issue 1
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Students Literature Review
in hospital. According to a 2008 New Zealand Medical Journal article, the services for interpreters are not developed enough to handle New Zealand’s diverse population. While there is also no accreditation system currently in place for interpreters, telephone interpreter company Language Line has seen an increase in business since its establishment in 2003. Low-cost telephone interpreters are now more readily available and are steadily reducing the barrier to interpreting services in general. Another factor potentially influencing interpreter use is knowing how to access interpreting services. Nurses in clinical settings play a main role in liaising with interpreters, but often lack the knowledge of how to go about it. According to other researchers, training on employing both professional and general interpreters increases the frequency with which interpreter services are used. The use of interpreters is important in supporting the patients’ cultural identity while bridging the language barrier between client and healthcare professional and allowing for effective communication. The lack of interpreter use, therefore, not only ignores clients’ consumer rights under the Code of Rights but also puts their health at risk.
Ethical questions over using students In clinical settings, using nursing students and other medical staff as interpreters leads to many ethical issues relating to consumers’ confidentiality and autonomy. The Code of Health and Disability Services Consumers’ Rights states that patients
have the right to be fully informed. Furthermore, the healthcare professional is required to make every effort to help the patient understand any information that is provided to them. The healthcare professional also needs to “where necessary and reasonably practicable” provide a competent interpreter for patients. This is in the spirit of the Health and Disability Commissioner Act and Code as patients are given the opportunity to comfortably ask questions to help enhance their understanding and to ensure treatments are explained to them in detail, including the advantages, costs, and alternatives. Given this information through the services of an interpreter, the patients can make their own decisions. Allowing patients to make their own decisions enhances patient autonomy. Autonomy is one of the key principles of the Code. An underlying value of autonomy is ensuring cultural safety which allows them to make the best choice.
Recommendations There are various ways in which healthcare professionals can decrease the use of untrained interpreters and use appropriate interpreters in hospitals instead. Such strategies include the use of flowcharts, like those in an interpreter clinical toolkit developed by University of Otago researchers**, which help guide clinical practice to improve communication with patients of limited English proficiency. The flowcharts could include scenarios and information boxes on when untrained interpreters, trained interpreters and telephone interpreters are appropriate to use, for example, and the benefits for each.
Such flowcharts should be easily accessible around the ward and staff nurses educated on how to use them. Having such resources would provide a guideline for nurses, but education should also be provided to improve clinical judgement when deciding what type of interpreter is needed in each situation. The literature also shows evidence that training should be given for all staff on the ward, including how to determine the need for an interpreter, the type of interpreter and how to access trained interpreters. Offering specific training increases the likelihood that health professionals access appropriate interpreters and improves health professionals’ knowledge of and attitudes towards cultural competence. Nurses should also be trained using interactive methods, such as role-playing, to practise communication skills based upon situations that may occur in clinical settings. Providing health professionals with visual guidelines, education and practices can enable them to recognise and acknowledge situations where trained interpreters are needed and have the confidence to respond appropriately.
Conclusion This article puts emphasis on the importance of interpreter use and explores the problems that arise from not using one. It also discusses the policies and codes in place to promote the use of interpreters in New Zealand. Several recommendations for improvement of health professionals’ understanding and use of interpreter service are also made, including providing health professionals with visual guidelines, providing appropriate education on how to use the guidelines, and improving clinical judgement skills through interactive methods like role-playing. *University of Auckland nursing students Melanie Lee, Jessica Skelly, Hanna Willis, Shanjiazi Kong and Amarjot Sandher wrote and contributed this article for an assignment as secondyear students in 2017. **Gray B, Hilder J & Stubbe M. (2012). How to use interpreters in general practice: the development of a New Zealand toolkit. Journal Of Primary Health Care, 4 (1), 52-61. Full references are available with the online version of this article at www.nursingreview.co.nz.
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Opinion College of Nurses
Globalised nursing and poaching:
G
lessons for all
lobalisation and internationalisation – two different words with similar meanings as far as world trade and economics are concerned – remain contentious issues for the nursing workforce. The more-developed countries have been accused of ‘poaching’ nurses from the less-developed, who aren’t able to match the salaries or working conditions to hang onto their nursing workforce. Such has been the concern about poaching that, following lobbying from our profession at the World Health Assembly back in 2004, a resolution was agreed (WHA 57.19) urging the World Health Organization (WHO) to develop an international recruitment code of practice to limit the practice. WHO eventually issued a code in 2010, but this is non-binding on member countries so international recruitment, and consequently nurse migration, still goes on. Clearly, rich, developed countries attracting nurses away from poorer ones is not a good thing. Chief nurses here in New Zealand are frequently reminded that a fifth of our nursing resource has been trained overseas. As one of both of those – an internationally qualified nurse (IQN) and a former chief nurse who is now proud to be a Kiwi – I would like to think we IQNs have something to offer. Without doubt, experienced nurses with a specialist background add to our ability to deliver quality care, and likewise New Zealand nurses heading to countries with more developed healthcare systems gain knowledge and skills that contribute to improving care standards when they return home. There lies the rub though: they need to come home.
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Dr Mark Jones discusses the implications for global health of wealthy countries ‘poaching’ nurses from poorer countries. Helping nurses stay home It should be possible for us to allow nurses from our neighbouring Pacific Island nations to come here, learn new skills, and return home to enhance the delivery of nursing care. Yet it is incredibly difficult to facilitate such programmes as requirements like English language competency get in the way. We need to be more creative here. The other concern is that internationally qualified nurses moving to developed countries for education might never leave. Working with the Western Australian Government, I headed an outreach programme to enhance the skills of Tanzanian nurses and midwives with the aim of reducing maternal and infant mortality.
In Africa and several Pacific Island nations, I have witnessed primary healthcare that knocks the socks off what we are able to achieve here.
Our programme did what we intended and hundreds of nurses and midwives improved their knowledge and skills through attending short courses delivered in-country by Australian nurse/midwifery educators. Yet we observed commensurate distress among those colleagues as, whilst they were pleased to acquire new skills, they were frustrated in putting their new-found knowledge to good use, due to inadequate resources at even the most basic level. What use was learning WHO’s Five Moments for Hand Hygiene when there was no soap or clean water? Or learning the best possible dressing techniques when bandages and
swabs were having to be re-used between patients? Not to mention the multiple recycling of ‘single use’ items that we casually tossed in the bin back home. Significant improvements in working conditions were required for expert nurses and midwives not to seek to move to a country where not only could they could earn more, but they could also practise as they really wanted to.
Global lobbying needed for better resources This is perhaps the ultimate challenge in the nurse migration debate. We can send nurses as volunteers offshore to share skills and knowledge, but infrastructure challenges work against the domestic workforce being able to raise care standards long-term, no matter how keenly they embrace the assistance. The global nursing community really needs to engage at a political level and lobby hard for resource reallocation into the healthcare system We also need to avoid falling into the trap that developed countries ‘do healthcare’ better than those that are less well resourced. In Africa and several Pacific Island nations, I have witnessed primary healthcare that knocks the socks off what we are able to achieve here. Certainly our drugs, diagnostic technology, and complex technical interventions are better, but our ability to work in a cohesive, multi-functioning team of professionals in true partnership with the community lags way behind. There is a transnational cost-benefit analysis just waiting to be done there and I would suggest we too have much to learn. Author: Dr Mark Jones is a board member of the College of Nurses Aotearoa and Head of School of Nursing, Massey University.
Conferences
Upcoming conferences Biennial Te Ao Māramatanga Wānanga 2018 ▶▶ 7-9 March 2018 ▶▶ Porirua ▶▶ www.nzcmhn.org.nz/Maori-Caucus Australasian Cardiovascular Nursing College Conference 2018 ▶▶ 9-10 March 2018 ▶▶ Sydney ▶▶ www.acnc.net.au Intravenous Nursing New Zealand Conference 2018 ▶▶ 16-17 March 2018 ▶▶ Rotorua ▶▶ www.ivnnz.co.nz National Gerontology Section NZNO Study Day ▶▶ 21 March 2018 ▶▶ Auckland ▶▶ https://goo.gl/AqXkpT Goodfellow Symposium 2018 ▶▶ 23-25 March 2018 ▶▶ Auckland ▶▶ https://goo.gl/QUm1Yc Perinatal Society of New Zealand Annual Scientific Congress 2018 ▶▶ 25-28 March 2018 ▶▶ Auckland ▶▶ https://goo.gl/TZpAxo Australia and New Zealand Intensive Care Society/NZ College of Critical Care Nurses Regional Annual Scientific Meeting ▶▶ 4-6 April 2018 ▶▶ Auckland ▶▶ www.eiseverywhere.com/ehome/260362
National Rural Health Conference ▶▶ April 5-8 2018 ▶▶ Auckland ▶▶ www.rgpn.org.nz Australian Pain Society and New Zealand Pain Society Conjoint Annual Scientific Meeting 2018 ▶▶ 8-11 April 2018 ▶▶ Sydney ▶▶ www.dcconferences.com.au/ apsnzps2018 College of Respiratory Nurses NZNO Symposium 2018 ▶▶ 13 April 2018 ▶▶ Wellington ▶▶ https://goo.gl/c2J328 NZ Population Health Congress ▶▶ 18-20 April 2018 (N.B. POSTPONED) ▶▶ Auckland ▶▶ www.pophealthcongress.org.nz/nzphc18 NZ Resuscitation Council Conference 2018 ▶▶ 19-23 April 2018 ▶▶ Wellington ▶▶ www.confer.co.nz/nzresus2018 Aotearoa College of Diabetes Nurses Study Day/NZ Society for the Study of Diabetes (NZSSD) Annual Scientific Meeting ▶▶ 1-4 May 2018 ▶▶ Hamilton ▶▶ www.ivvy.com.au/event/akB118 Enrolled Nurse Section NZNO Annual Conference 2018 ▶▶ 15-17 May 2018 ▶▶ Christchurch ▶▶ www.nzno.org.nz/groups/sections/ enrolled nurses
Women’s Health College NZNO Conference 2018 ▶▶ 17-19 May 2018 ▶▶ Blenheim ▶▶ https://goo.gl/x8J66M NZ Dermatology Nurses Society Conference 2018 ▶▶ 9-10 August 2018 ▶▶ Auckland ▶▶ www.nzdermatologynurses.nz Involve 2018 (Youth sector conference supported by Society of Youth Health Professionals Aotearoa NZ) ▶▶ 13-15 August 2018 ▶▶ Wellington ▶▶ www.arataiohi.org.nz/initiatives/ involve#reg NZ Rheumatology Association/NZ Health Professionals in Rheumatology Annual Scientific Meeting 2018 ▶▶ 30 August – 2 September 2018 ▶▶ Wellington ▶▶ www.eenz.com/nzra18 New Zealand Association of Gerontology Conference ▶▶ 6-8 September 2018 ▶▶ Auckland ▶▶ www.gerontology.org.nz International Society of Nurses in Cancer Care Conference 2018 ▶▶ 23-26 September 2018 ▶▶ Auckland ▶▶ https://goo.gl/nSpWVK Perioperative Nurses College NZNO Annual Conference 2018 ▶▶ 11-13 October 2018 ▶▶ Nelson ▶▶ www.confer.nz/periop2018
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Nothing is more important than health.