Nursing Review June 2014

FOCUS: Long-Term Conditions/Aged Care

Nursing Review June/July 2014/$10.95

New Zealand’s independent nursing Series

Aged Care

De facto ‘hospices’?

Foot pampering a winner

A DAY IN THE LIFE OF

a job hunting new graduate RN

EVIDENCEBASED PRACTICE Quitting before surgery CASE STUDY: Diabetes care closer to home PRACTICE, PEOPLE & POLICY

Competent or confident?

Opinion taster plate

Q&A

Sharon Hansen

Long-Term Conditions

Mental health: the forgotten LTC A killer cough? www.nursingreview.co.nz

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Inside:

Letter from the Editor Nursing: duty to advocate for others but don’t forget yourself The word ‘advocate’ is sprinkled across both New Zealand nursing’s Code of Conduct and Code of Ethics.

“Advocate for, and assist, health consumers to access the appropriate level of health care,” says Standard 3.7 of the Nursing Council Code of Conduct and “nurses should be willing to advocate for appropriate health care for the communities within which they practise” says NZNO’s Code of Ethics.

I realised that this issue is stuffed with calls for nursing to advocate and ensure best care for those who are vulnerable or lack a voice.

First, we have a call to improve the physical health of those with chronic mental illness who die too early, too often – with medication side-effects, stigma, and socioeconomic deprivation all playing a part.

Next, we look to lung cancer and how the combination of late diagnosis and the “shame” of being a smokingrelated disease means lobbyists for our biggest cancer killer are fewer and less visible than their “pink ribbon” counterparts.

Then lastly there is the need to advocate for the vulnerable elderly who are increasingly dying in an under-resourced residential aged care sector stretched thin attempting to give both quality care for the living and quality palliative care for the dying.

But any call for nurses to be willing and ready to advocate for others’ health has to be balanced with the need for nurses to advocate to protect their own professional wellbeing – so they have the capacity to be health advocates for society’s most vulnerable.

Research reported on p.15 unsurprisingly found high burnout in aged care nurses and health care assistants but also found the more burnt out they were, the less ready they were to engage in palliative care training.

A recent New Zealand Medical Journal article found 93 per cent of hospital workers had experienced verbal anger from a patient in the last year, 65 per cent physical aggression, and 38 per cent had been physically assaulted. It prompts emergency department nurse practitioner Michael Geraghty (p.19) to ask what employers and professional organisations will do to protect their staff? Because nurses need protection and advocacy, too.

Fiona Cassie editor@nursingreview.co.nz

www.nursingreview.co.nz Twitter@NursingReviewNZ

Exclusive online content Nursing Review is a genuine multimedia publication. Our recently revamped website has content not found in the print edition, including exclusive online articles, live Twitter updates, social sharing, and the downloadable RRR professional development archive.

Visit: www.nursingreview.co.nz COVER PIC: Karori Medical Centre diabetes champions Jacqui Levine (left) and Heather Wilson. Read about their work on p.8.

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Focus: Long-Term Conditions & Aged Care

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MENTAL HEALTH: caring for both body and mind PHC: framing the future for practice nurses CASE STUDY: diabetes care closer to home Coughing up about New Zealand’s biggest cancer killer AGED CARE: ‘de facto hospices’?

Faith and foot pampering with NOREEN WRIGHT

RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe Practice, People & Policy 18 19

RACHAEL VERNON’s research: RN’s confident and competent?

ROSEMARY MINTO calls for meaningful PHC measures

MICHAEL GERAGHTY on ED insults and assaults

ANDY McLACHLAN on choosing nursing over the dole or army

Online Opinion ‘tasters’ menu:

Regulars 2

Q&A Profile: rural nursing leader and NP SHARON HANSEN

3 A day in the life of… job-hunting new graduate MEGAN LYELL

16 Evidence-based Practice: surgery and quitting smoking 17

College of Nurses column: TAIMA CAMPBELL introduces some HR advice

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For the Record: news round-up

Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart.

Find us on Twitter@NursingReviewNZ Editor Fiona Cassie Advertising Belle Hanrahan editor-IN-CHIEF Shane Cummings production Aaron Morey Dan Phillips Publisher & general manager Bronwen Wilkins Photos Thinkstock

Nursing Review

Vol 14 Issue 3 2014

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ISSN: 1173-8014

Errors and omissions: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.

Nursing Review series 2014

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Q&A

Sharon Hansen

JOB TITLE | Nurse practitioner (primary health care rural) and deputy chair of the Rural General Practice Network

Q A

it should be “easier” but it should fit what the sector requires NPs once they are registered.

Adequate funding; primary care is still the poor cousin. Negotiating support and remuneration for time-off to maintain competency is a big issue.

Stronger linkages between the sector (that’s us), the nursing schools and their funding bodies, Health Workforce New Zealand, and the Nursing Council. I think together we can solve the myriad of issues that need to be looked at.

Where and when did you train?

I began my nursing career in a psychopaedic institution at Templeton and then went on to do a diploma in general obstetrics at Christchurch Hospital. As soon as I was able, I undertook a bachelor’s degree in nursing from Otago Polytechnic, followed by a clinical master’s degree, which I completed in 2005.

Q A

Q

Q A

A

Other qualifications/professional roles I registered in the scope of nurse practitioner (primary health care rural) in 2007.

What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt?

I never saw myself as a leader, and I’m sure neither did my early nursing tutors.

You can learn to be brave, and to understand your own point of view and how it links with that of others. It is an important thing as a leader to see yourself as being part of a bigger whole.

Why did you decide to become a nurse?

I had no burning desire to nurse as a youngster and really came to it through applying for psychopaedic nursing. What attracted me to psychopaedic nursing was that no one else was doing it. At the time, I had no idea what it was or the path it would take me.

Q A

Q A

What was your nursing career up to your current job?

I worked in a variety of roles within secondary services in Christchurch and then Timaru. I went from working night shift in the intensive care unit to a public health nursing position covering Timaru to Aoraki/ Mt Cook. It was the beginning of my passion for rural primary health care. I worked there for five years leaving to have some time out to raise my family.

I then worked as a part-time practice nurse while completing first my bachelor’s and then my master’s degree. What got me was the amount of unmet need in primary care. It seemed obvious that nursing was hugely valuable but nurses needed to be able to follow through care and not have to refer on for scripts or ACC. I was also an on-call health practitioner on weekends in Twizel for three years.

Q A

So what is your current job all about?

It was difficult to move from being a RN to NP within the same practice for a variety of reasons. So when I was invited to join a sole GP, in a practice providing care for approximately 2500 patients in a neighbouring town, I took up the position.

My role has developed in response to the need of the community, which is a small, semi-rural and decile 5 town. About 10 per cent plus of the population are Māori (which is higher than normal in the South Island) and we have a growing population of immigrant workers on the local dairy farms.

I also have a small role in the Timaru sexual health clinic, which is run with another NP and myself.

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In my non-clinical role, I am deputy chair of the rural general practice network and am the clinical board member for Arowhenua Whānau services.

Q A

What do you love most about your current nursing role?

I really enjoy the relationships that I have developed with the families and individuals I care for, plus the autonomy I have in providing care. I work in a collaborate relationship with my GP colleague, however there is no hierarchy or micromanagement in providing care. I feel I have the best of both worlds; I have the benefit of accessible medical advice if I need it, and an experienced colleague with whom I can debrief.

Q A

What do you love least?

I dislike the length of my lists and the pressure to see more people at the end of a busy session. I don’t always feel that there is an understanding of the complexity of what we do.

Q

If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce?

Revisit the nurse practitioner training and registration process. I don’t think

A

What do you do to try and keep fit, healthy, happy and balanced?

I get up at 5.30am and go to the gym along with a van full of my gym buddies and my poor suffering husband. It is a lot of fun and therapeutic for us all. I also love to hike and bush walk. You must have balance and if you don’t, it’s of your own doing. I am learning to play the viola and have recently joined a community orchestra (now that’s right back at Benner’s ‘novice’ level).

Q A

What have you been reading?

My light-hearted reading lately has been The Daughters of Mars by Thomas Keneally and Donna Douglas’s Nightingale novels, which remind me of my nursing roots.

What are three of your favourite movies of all time?

I’m into escapism so it’s Star Trek; I also enjoyed The Others and The Quartet.

Q A

What is number one on your ‘bucket list’ of things to do?

I would like to study again, so that’s definitely on the list, as is travel with my sisters, and hopefully one day I’ll be a grandmother.

Q A

What is your favourite meal?

Oysters and seafood. Not really into ritzy food, it has to be home cooked and nutritious without being covered in fatty sauces.

A day in the life of a ... job-hunting new graduate nurse

NAME | Megan Lyell JOB TITLE | Part-time emergency response attendant and full-time job hunter.

LOCATION | North Shore

6:15

AM The alarm sounds.

I leap out of bed and go for a walk … NOT! Reality is that I snooze for another 15 minutes then drag myself from my happy place to make a cuppa. I knock on teenage daughter Bridget’s door to wake her and then life is all go …

8:00

AM SCHOOL DROP OFF I drop Bridget to school on the way to work, and try and engage in a positive conversation … but she is a teen and not a morning person. She says she loves me as I drop her off and I then start praying I’ll get to work on time – an annual goal of mine, but it’s actually working this year–maybe due to the recent mental health training* that has helped me live more in the present.

8:27

AM ARRIVE AT WORK Arrive at work with three minutes to spare, a miracle. Oldest daughter Anna (a farmer) has texted to say have a nice day, and hubby Ted has rung to say he will make dinner tonight. On arrival, the clinical nurse manager asks me to have the 2nd year nursing student work with me. The student and I sit down to discuss and plan how to meet her goals for the week.

I am booked to see patients for 20-minute appointments throughout the day, with a two-hour gap to cover lunch breaks. My first patient is a no-show, so I tell the student my career started with enrolled nurse training at age 18, followed by my RN training three years later. I initially worked in hospital surgical and medical nursing, then eight years as a family planning nurse and for the last 10 years I’ve worked as a primary health nurse with my current general practice. I tell her working as a practice nurse – with a special interest in women’s health and mental health – were the last areas I wanted to work in as a young nurse. Yet now I have an absolute passion for all these areas and firmly believe that this is where I am meant to be.

9:00

AM FIRST PATIENT I see my first patient for the day.

It is a young girl referred by one of the GPs for support with her self-esteem issues. I introduce myself and ask permission for the student to be present. I use open questions to ascertain what is concerning her. I listen to her concerns and together we come up with a plan to help her cope with her feelings of insecurity with her peers over the next two weeks. When she leaves, she is smiling and says she feels stronger, which makes me again realise why I love this job. I then see a toddler for immunisations, followed by a man for a punch biopsy.

10:15 10:30

AM QUICK COFFEE BREAK

AM ANXIOUS PATIENT I see another lady, referred to me three months ago because of her long history of anxiety and depression. Initially, her assessment results for anxiety and depression were high but, after walking alongside her in her journey and meeting regularly, her score today is within the low range. This lady is an inspiration to me as she was the first person I began seeing for mental health issues after I became MH credentialed. The MH training has meant I’ve been able to effectively assist her in her journey, which is great. Initially, we needed to meet weekly for 40 minutes and now it is 20 minutes every two to three weeks.

My next patient is a young man needing wound management, and during screening I find he’s a smoker who’d like help to stop.

I give him some information and will talk again at his follow-up appointment. I see another man for his quarterly 40-minute Care Plus appointment to manage his chronic disease, which takes me to midday.

NOON

PHONE CALL TIME I am at last able to clear my messages and return the seven calls to people wanting test results and advice about a sick child. I also ring the lady who missed this morning’s appointment. She’s been having some family difficulties and is grateful I’ve rung. I support her over the phone and we arrange to meet on Friday.

1:30 2:00

PM LUNCH

PM BACK TO WORK My last three patients of the day are a lady for an IV infusion, which takes 30 minutes, a little girl for immunisations and another man for his IV infusion. I check my taskmaster and inbox for things I need to follow up on; I manage to clear three tasks and check that there is nothing else urgent. The student and I go over the day and discuss tomorrow. She says that she’s enjoyed her day and feels she’s seen a different side to practice nursing that she likes.

I clear my phone messages once again and return calls to patients. It sounds like the afternoon is not as busy … but time just goes and before I know it, it is 5:30 and time to leave.

6:15

PM HOME – TEA WAITING I get home and Ted has made yummy bolognaise for tea. Bridget is doing homework (Facebook) and Anna is home

for tea. Ted and I go and feed the ducks and chickens and have a catch up on our day. I am thankful for my little piece of paradise that I live in and am grateful for the job I am able to do as a nurse. I play a couple of games on the computer and watch some mindless programme on TV. I find I need to do this to unwind, as I feel mentally drained when I get home; and it is nice not having to think for a little while.

10:30

PM BED I read a bit then drift off …

STOP PRESS CONGRATULATIONS As we went to press Megan Lyell - after seven hard months of job-hunting - had just won a position as a new graduate practice nurse.

Nursing Review series 2014

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FOCUS Nurses Day FOCUSnnInternational Long-Term Conditions

Long-Term Conditions FOCUS: Chronic mental illness is an oft-forgotten long-term condition with physical health implications.

We look at nursing efforts to stem those and other chronic conditions from diabetes to respiratory.

Dying unequally: striving for mental health patients to be equally well Long-term mental health clients die prematurely at up to three times the rate of the rest of the New Zealand population. FIONA CASSIE finds out how nurses have been responding to long-standing calls to improve the physical health of people with long-term mental illness.

“I

t’s not my job.” “That’s not in my scope.”

Mental health and physical health have long been the scope of all comprehensively trained nurses, but over time, nurses tend to “stick to their knitting”.

So a community mental health nurse’s stethoscope and blood pressure cuff may be gathering dust in the glove box, a practice nurse may be uncomfortable in offering smoking cessation support to a person with schizophrenia, or an emergency nurse may risk dismissing a physical health symptom as a mental health symptom.

A study led by Ruth Cunningham of the University of Otago* and published recently in the New Zealand Medical Journal highlighted has been long known – long-term mental health service clients have poorer physical health and die prematurely.

But Cunningham’s study quantified for the first time how big the problem is in New Zealand, with the death rate of people with psychotic disorder diagnoses, such as schizophrenia, before the age of 65 being three times

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Nursing Review series 2014

that of the total population – most of those being from natural deaths, particularly cardiovascular disease and cancer.

Her study joins the growing call to make improving the physical health of people with mental illness everybody’s “knitting”.

Heather Casey, director of nursing for Southern District Health Board, points out that the New Zealand Health Strategy back in 2000 highlighted the need to “improve the health status of people with severe mental illness”, and in 2004, the Mental Health Commission published Our Physical Health… Who Cares to try and provoke debate and action on that very issue.

Marion Blake, chief executive of the Platform network of non-government providers of mental health and addiction service, acknowledges the issue is not new with the evidence long available.

The momentum for the trust built a few years ago as providers around the Platform board table started increasingly reporting “we’re seeing so many of our clients dying”, recalls Blake.

FOCUS n Long-Term Conditions

Yes, it is in your scope A leader in getting the blood pressure cuff out of the glovebox and into the mental health nurses’ usual ‘toolkit’ has been Southern District Health Board.

Heather Casey, the DHB’s director of mental health nursing, says back in 2006 it became clear to her that not all her staff saw the physical health of their clients as their shared responsibility.

“Some nurses used to say ‘this isn’t in my scope’.”

Casey says mental health nurses have a very broad scope of practice, including physical health, which is also the point of difference between nurses and some of the other disciplines working in mental health.

“Mental health nurses need to have adequate skills and knowledge to respond to the physical health needs of the people we work with.”

Rather than wagging fingers or telling nurses what to do, she put in place a three-year plan aimed at raising awareness of the poor physical health of mental health consumers and supporting acute and community mental health nurses to develop their physical health knowledge and skills.

“A lot of times, [knowledge and skills] have Intro ??????? been lost over the years – so we weren’t blaming nurses for not having those skills.”

Something had to be done.

“People are dying; people we have worked with for years are dying a lot earlier with respiratory illnesses, cancers, cardiac problems…

“It’s not necessarily that [mental health] nurses need to do the full assessment, but they need to know the risks and what to monitor or refer on to their GP,” says Casey.

They also need to be aware that a mental health nurse may be the only person working with a client and can be the best person to provide oversight of their physical health needs.

This includes supporting and encouraging someone – who otherwise might fall through the cracks – to have a cervical smear, see their general practice about weight gain, or to ask for a prostate check.

The first year of the plan included monthly forums on topics ranging from vital signs to routine cancer screening, diabetes to wound care, and interpreting lab tests to health promotion. The second year, the DHB brought in documentation and guidelines for consistent metabolic monitoring of consumers on antipsychotic medication. Nurses were encouraged to educate consumers on healthy lifestyle choices, and pamphlets on medication, weight gain, and lifestyle choices were produced. The third year brought more physical health workshops with a focus on

The issue of poor physical health was seen to be a whole-of-system issue, and in 2013, Platform joined forces with mental health and addiction workforce development agency Te Pou to gather New Zealand-based evidence about the issue and practical solutions.

The result has been the Equally Well evidence review which, in addition to Cunningham’s research, has confirmed that Kiwis with an ongoing mental illness or addiction not only have significantly higher physical health problems related to metabolic syndrome (the taking of anti-psychotic medications can lead to an average weight gain of 12 kgs in the first two years) but also viral and oral health diseases, respiratory diseases, cancers, diabetes, and cardiovascular diseases.

The research also found that, like elsewhere in the world, there is not one single factor leading to the poorer physical health of mental health clients but many.

The picture is not a rosy one. Often mental health clients have fallen out of the routine population health screening (or have been put into the ‘too hard basket’); until recently smoking and second-hand smoke was a commonplace and accepted lifestyle risk (mental health clients’ smoking rate is three times the average Kiwi rate); and added to the mix is medication side-effects, poverty, discrimination, and stigma, along with system and workforce issues. The result is a perfect storm for poor health outcomes.

Anne Brebner, nursing clinical advisor for Te Pou (and the newly elected president of the College of Mental Health Nurses), says, apart from drawing attention to the issue through Equally Well, the area Te Pou can help most in is supporting the training of the workforce.

The nursing area she sees needing the most support is not practice or other primary health nurses – though work is being done to upskill them in mental health – but the dedicated mental health and addiction nursing workforce itself.

“Historically, mental health and addiction nurses have just done the one thing really well,” says Brebner.

Despite the vast majority having been comprehensively trained, the pressures of high caseloads meant many retreated to their ‘core business’ of mental health and physical health monitoring often fell by the wayside.

But Brebner says there is now recognition that mental health nurses needed to ‘widen the lens’ and pay greater attention to clients’ physical health needs, with physical health workstreams at recent mental health nursing conferences showing nurses are keen to improve their skills in this area.

‘hands-on’ learning.

Casey says a focus of late has been on staff being able to get their hands on the right equipment for physical health.

“Often in mental health, the physical health monitoring equipment has been appalling over the years. So making sure people had good functional equipment was really important.”

While there was usually a blood pressure cuff and stethoscope in the glove box of nurses’ cars, they weren’t always functional, says Casey.

“We’re following up an overarching policy document that pulls all of that together and lays out what the [physical health] expectations of the service are.”

This includes an expectation that all mental health nurses will go through the physical health workshops, which are held monthly.

Having taken an approach of focusing on, first, awareness then developing mental health nurses’ competence and confidence in physical health, Casey says they have had very little resistance.

Cl inical Nurse Specialist or Registered Nurse - Palliative Care

Medical Directorate, Southland Hospital • Permanent, full-time position

This is an exciting opportunity for a Registered Nurse who wants the opportunity to develop specialist palliative care nursing knowledge and clinical skills . You will be supported through development into an adva nced nursing practice role, that at minimum would be at Clini cal Nurse Specialist level. A development programme will be put in place for the successful candidate, which will involve some travel to Dunedin.

Ideally but not essential, you will hold a level 3 professional portfolio and a post-graduate certi ficate should include advanced health assessment and pharmacolog y.

Please apply online at www.sou therndhb.govt.nz/careers/ or for further information about this position you are welcome to contact me - Jan Strachan, Rec ruitment Advisor – Nursing and Midwifery, jan.strac han@southerndhb.govt.nz or phone 03 214 5770.

Closing date: Open

www.southerndhb.govt.nz/ca reers/ Nursing Review series 2014

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FOCUS n Long-Term Conditions

“It doesn’t take much to reignite or reinspire comprehensive nurses with the knowledge base they already hold,” says Brebner.

Daryle Deering, outgoing president of the College of Mental Health Nurses, says another issue in the past has been confusion about whose role the monitoring of physical health is: primary care or mental health services?

The College has recently stepped in to offer a credentialing programme in mental health for primary health care nurses which has highlighted that, while this generation of nurses may have been comprehensively trained, if they end up working primarily in physical health or mental health, their skills can lapse in either health dimension.

Deering says there has been a “huge push” to integrate or fuse the two back together and the College’s revised standards for practice for mental health nursing explicitly states that mental heath nurses are expected to address clients’ physical health needs either directly or by referring, consulting, and co-coordinating their care. Likewise, a primary health care nurse needs to be proactive to follow-up missed appointments by mental health clients and have close relationships with their community’s mental health nurses.

With the call from the government for greater integration between health services, Deering says the time is ripe for things to change. “You could argue that it’s a national disgrace.”

She also argues that people with mental illness are not alone, with many of the same factors leading to people intellectual disabilities having compromised health.

A common concern raised with Nursing Review was that somewhere along the way the mind and body or physical and mental health had been divided and siloed at the expense of the holistic care of patients. New Zealand’s comprehensive and broad scope of nursing was narrower as a result.

Blake believes everybody working with mental health clients–from Intro ??????? community support workers, mental health nurses and psychiatrists through to GPs, practice nurses, and hospital health professionals–have to develop their responses to addressing and improving the physical health of long-term mental health patients.

“It’s almost like connecting the head back to the body,” says Blake. “Some of the practices we have are putting people at higher risk.”

More could be done to help mitigate, rather than accept, the weight gain side effect of some medications, with early onset diagnosis meaning some young people can start such drugs at 17 or 18. If uncontrolled, the weight gain can impact on their mental health and head them down the path to metabolic syndrome and Type 2 diabetes.

“We have all stepped back and said ‘this is not my job, I can’t deal with this’ ... but we need to step up,” says Blake.

She was particularly taken by the higher cancer death rate of people with mental illness.

“There’s no reason why that population group should have a higher rate than anyone else in the population. What is that about? Is it we’re not screening people and not doing any intervention that we would do for the rest of the population? I don’t know whats the answer is but [Cunningham’s findings] really do raise questions.”

Equally Well hopes to highlight the questions and provoke a concerted effort to come up with some solutions to the factors behind the poor physical health of our chronically mentally ill.

The next step is formulating a consensus statement backed by key stakeholders, acknowledging poor physical health is a key problem for the mentally ill and a problem that can’t be ignored.

The goal is that fewer people will say “that’s not my job” and more will ensure it is part of their ‘knitting’ in the future.

Up the hill, down the hill, and meeting in the middle Nurse educators from up the hill at Auckland City Hospital’s main hospital are working down the hill beside their acute mental health nursing colleagues in an initiative to boost physical health skills.

Nurse educators Tessa Grant and Alicia Sutton say the learning is definitely a twoway street, with them also taking their new mental health skills and awareness back up to the main Auckland City Hospital.

Sutton was the first to work at Te Whetu Tawera, the 58-bed acute mental health unit down the hill from Auckland City Hospital, when she was seconded four years ago from vascular services to be a medical-clinical coach for nurses with tuned mental health skills but often under-utilised physical health skills.

Conscious of the need to improve mental health service users’ physical health, the aim was to boost the confidence and knowledge of mental health nurses in assessing and responding to general health issues – including metabolic syndrome – while mental health clients were in acute care.

“Initially, I felt like a fish out of water,” recalls Sutton.

While a number of nurses were keen from the start to brush up and build their physical health skills, some others surprised her by saying “it’s not my job”.

“They said physical health concerns belong in the main hospital.”

Sutton says a key to changing the culture was rolling up her sleeves and working alongside staff to “teach rather than do”. That included getting back to the basics of refreshing people on taking blood pressures, how to assess patients who became physically unwell, and initial responses to medical emergencies. It meant ensuring that the nurses not only had the skills to do a regular set of ‘obs’ but also the confidence to act on the results.

“It’s all there, and it comes back really quickly for a lot of them,” says Grant of the largely comprehensively trained mental health nursing team.

Grant says by the time she stepped in to take over the role two years later – now called an adult medicine nurse educator – it was like a well-oiled machine. Most nurses had taken on board what they had been taught and a policy of routine observations had been implemented, but the new challenge was maintaining and embedding those tasks and knowledge into the mental health nurses’ already busy working day.

“One of the hurdles has been implementing care plans such as fall care plans and pressure injury care plans. This is all additional paperwork.”

The pair says key gains from the educator role included the acute mental health nursing team having the skills and knowledge to pick up patient deterioration a lot earlier and intervening to treat it on the ward or transferring them to the main hospital when needed. Grant says acute mental health admissions can quite often be due to an underlying physical illness, leading to a deterioration in their mental wellness. The increased monitoring and assessment skills has helped the team know which illness should be the initial focus. “[The role] has also improved the communication between ‘up the hill’ and the mental health unit,” says Sutton.

The acute mental health unit and community nurses have the opportunity to go to the main hospital for adult health study days, where they can learn about diabetes to cardiovascular disease alongside nurses with a medical and surgical background.

While continuing her educator role at Te Whetu Tawera, Grant is also working with the small nursing staff at the district health board’s rehabilitation residential unit. She says she is very keen to work as holistically as possible with their clients. The next step is to start working with the community teams, in ‘bite-size’ groups, to help them focus on reducing the risk and impact of diabetes and cardiovascular disease amongst mental health service clients.

Meanwhile, the pair say they continue to be a link between services and when they return to the main hospital they bring with them an increased respect and understanding of mental health nursing skills and how hard both services work.

Premature death in Kiwi mental health service users »» Looked at the 266,093 people who between the ages of 18–64 had contact with mental health services between 2002 and 2010. »» Excluded people with dementia, intellectual disability, or who had first contacted services three months prior to their death. »» It found that both men and women using mental health services had twice the risk of the total population of dying before age 65 6

Nursing Review series 2014

with an increased risk of death from cancer and cardiovascular disease. »» The premature death rate was even higher for those with a psychotic disorder (three times the total population) with the risk of metabolic syndrome from antipsychotic medication a likely cause, along with socioeconomic deprivation and discrimination.

»» The majority of the deaths were due to natural causes (71% for women and 58% for men) with suicide accounting for 15% of premature deaths in women and 22% in men.

Premature mortality in adults using New Zealand psychiatric services, by Ruth Cunningham, Debbie Peterson et al; published in New Zealand Medical Journal 23 May 2014.

FOCUS n Long-Term Conditions

Practice nurses liked but could be much more …

A recently released survey of 1500 Kiwi patients found them to be largely satisfied with the nurse at their practice. Co-researcher Deborah Davies talks to FIONA CASSIE about the research and how it links to a new knowledge and skills framework that could see both patient satisfaction and expectations of their nurse rise.

K

iwi patients are pretty happy with the nurse they see in general practice, according to a major patient satisfaction survey.

Deborah Davies, a co-author of the article on the Australian-led research project* and lead clinical nurse specialist for primary health care at MidCentral District Health Board, is keen to extend both patient satisfaction and expectations of the role that practice nurses can play in their health care – particularly long-term conditions.

The vast majority of the 1505 patients surveyed in the research had booked an appointment with their nurse and 60 per cent of them saw a nurse only during that visit.

The most likely to be highly satisfied with their nurse’s care (that is, scoring higher than the Intro ??????? median score of 90) were regular nurse clients or people in paid employment. The least likely to be highly satisfied were those patients aged over 60 and those of European descent.

As a practice nurse herself for 15 years, up until 2005, it doesn’t surprise Davies that the over-60s were the least satisfied with seeing a practice nurse, as she says they are the generation most used to a traditional and hierarchical GP role.

“We were marginally disappointed (though) that there is still some confusion out there around the role of practice nurses, but you have to acknowledge there is variability (in practice nurse roles) across the country.”

The confusion emerged in the related qualitative research (published in 2013) involving in-depth telephone interviews with 18 of the survey respondents. A couple were unclear who was or wasn’t a practice nurse in their practice and what they did. Others were unclear about the potential scope of practice: “… I don’t think it’s ever been made clear all the things that you could use the nurse for. So my usual port of call is the GP.” This was also enforced by the satisfaction survey, which indicated that most patients were seeing their nurse for a procedural task like vaccination (39 per cent of them), though 246 had come in for a “general check-up”.

“It was definitely not top of scope,” says Davies, adding that the nature of patient appointments reflected the variability of practice nurse services offered across the country.

“Which is why we’re driven to our next step” says Davies, who chairs the College of Primary Health Care Nurses NZNO’s standing committee on professional practice.

The next step is increasing the profile of primary health care nurses in general practice and cementing in place the knowledge and skills framework for primary health care nurses that can showcase what they potentially can offer. The first framework phase, focusing on district nursing, is close to sign-off, and the next phase – aimed at

nurses in general practice – is gaining momentum.

Davies says the College is working on a business case to develop the evidence-based framework so it provides a career pathway for nurses in general practice that is linked to postgraduate education and the likely requirements for community and specialist nurse prescribing.

Discussions are underway with key stakeholders and the College hopes to successfully apply for funding from Health Workforce New Zealand for the project and to get endorsement from the National Nursing Consortium that primary health care nursing is a specialty area of practice.

Davies says with MidCentral’s track record behind it – MidCentral nurses led the development of the national diabetes nurse and the respiratory nurse knowledge and skills frameworks – the College was working in partnership with MidCentral’s Health Care Development team to develop the framework.

“We kind of have it all sitting there. We just want to pull it together into a cohesive framework, so as a nurse I can go in and say, ‘okay, that’s what I need to know for my area of practice, and this is how I can work at the top of my scope, and this is how I can demonstrate my knowledge and skills’,” says Davies.

She says the aim is to have all nurses in general practice “tipping their toes” into further study with proficient nurses working at postgraduate certificate level and experts at postgraduate diploma and master’s degree level. The focus was also not on tasks and technical skills but on being able to offer well-rounded nursing services.

The new levels of nurse prescribing being developed by the Nursing Council – with priority being given first to “specialist” prescribing followed by lower level “community” prescribing – will require postgraduate study with “specialist” prescribers likely to require a postgraduate diploma level qualification.

“We’re thinking how can we prepare the (nurses in general practice) workforce to be flexible over the next two to five years so when these opportunities come, (nurses) can keep removing the barriers to people getting effective care at the right time. It’s quite exciting.

“We’ve got huge untapped potential of nurses in the community.”

This aligns well with the ‘better, sooner, and more convenient’ push to have more healthcare in the community, with increased roles for general practices and initiatives like integrated family health centres.

“It’s really important that nursing gets its act together and knows exactly where [practice nurses] fit – it is particularly critical in long-term conditions.”

Deborah Davies

Key findings »» 2011 survey of 1505 patients across 20 general practices found high levels of satisfaction with the 89 practice nurses they saw (PN). »» People aged over 60 and of European descent were “significantly less satisfied”. »» People who had seen a PN more than 4x previously were more satisfied than those who had seen a PN less often. »» Vaccination (39%) was the most common procedure in most recent visit followed by taking blood pressure (16%), wound care/ dressing (8%), and other procedures (8%). »» While vaccination was the most common reason for the nurse consult (669 respondents), 246 people saw their nurse for a general check-up, 266 for an ongoing problem, and 219 for a follow-up visit. *Source: Elizabeth Halcomb, Deborah Davies and Yenna Salamonson Consumer satisfaction with practice nurses – a cross sectional survey in New Zealand general practice Australian Journal of Primary Health, 2014.

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FOCUS n Long-Term Conditions

Jacqui Levine and Heather Wilson.

Close to home: better nurse-led diabetes care on your back doorstep

Intro ???????

A few years ago, starting insulin treatment was intimidatingly new, not only for patients but also many of their nurses and GPs. FIONA CASSIE looks at the Nursing Practice Partnership – a Diabetes Care Improvement Package underway in Wellington for nurses to share their diabetes expertise with practice nurses across the region.

F

or some patients starting insulin is associated with scary tales from their families’ past – like an uncle who lost a leg or a granny who just got sicker and sicker.

With such family anecdotes foremost in their minds, it is maybe not surprising that some patients never find the time or courage to take up a referral to a specialist diabetes clinic at hospital.

The push in recent years is to remove some of the fear and barriers by offering greater diabetes support, including insulin start-up, in the familiar surroundings of their local general practice – and increasingly by their practice nurse.

Lorna Bingham, diabetes nurse specialist at Capital & Coast District Health Board, has long been a strong believer – along with endocrinologist Jeremy Krebbs – in taking secondary services into the community and upskilling staff along the way.

This recently has stepped up a notch with the Nursing Practice Partnership – a Diabetes Care Improvement Package (see overleaf – which is turning an ad hoc approach into a formal and structured programme by the DHB and local primary health organisations to mentor and upskill practice nurses in diabetes.

The package aims by the start of next year to partner diabetes nurse specialists (or nurses with a special interest and skills in diabetes) with nominated ‘diabetes champion’ nurses in all of the about 60 practices across the DHB. There will be up to 10 ‘partner nurses’ – some directly working for the DHB or a PHO and others employed in

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individual practices – working with a handful or so of practices each.

This builds on outreach work and diabetes services already developed by the DHB’s specialist service and Compass PHO’s diabetes nurse specialists with nurses and GPs at the like of Newtown Medical Centre, the Newtown and Porirua Union Health Services and other practices.

The partnership model is being rolled out this year, firstly to around 15 practices chosen because of their high numbers of patients with diabetes, or at risk of diabetes including those having high Mäori and Pacific populations.

The model of the Nurse Practice Partnership has been trilled with Karori Medical Centre, which Bingham and Krebbs first visited in 2011.

Bingham says up until then the secondary service had little direct contact with the very large practice – about 14,000 patients – which serves a largely middle-class community but also has pockets of poverty. (The ethnic breakdown of the centre’s patients is about 68 per cent European, 11 per cent Asian, 5 per cent Mäori and 5 per cent Pacific.)

Since then Bingham has been a regular visitor, offering specialist clinics at the centre with initially the centre’s first diabetes ‘champion’ Jacqui Levine, and later its additional champion Heather Wilson, sitting in to build their skills by watching and working alongside Bingham.

Levine and Wilson have both been in practice nursing for about five years and say prior to

Liz Dutton

Lorna Bingham

the partnership with Bingham, nurses at Karori Medical Centre had been offering diabetes annual reviews to the about 450 patients in the practice with diabetes. But they had not been offering other nurse-led diabetes care, as Care Plus services for people with chronic conditions tended to be doctormanaged.

The pair are now offering regular nurse-led diabetes clinics, including insulin start-ups, in league with Bingham and the patient’s GP; with Wilson needing to come on board because of demand for the nurse services. The pair built their competence and confidence by working with their mentor Bingham – who initially visited weekly to fortnightly and now is more often monthly or six weekly but is always only a phonecall or an email away. But they also built their knowledge through working their way through the free online diabetes learning modules developed for primary health

FOCUS n Long-Term Conditions

care nurses (more information at http://pro.healthmentoronline.com), which is being promoted strongly to all practice nurses in the DHB. In May 2012, the Karori Medical Centre also started a pilot of working with 55 patients with elevated HbA1c results (over 75 mmols) to look at the impact of the Nursing Practice Partnership programme offering increased diabetes management support from within the practice.

Nearly 80 per cent of the patients, including some who had insulin starts at the practice, dropped their HBA1C glucose to more manageable levels.

Robyn Taylor, the centre’s nurse manager, said the pilot also looked at other factors affecting their result, such as medication compliance, socio-economic factors and mental health issues. “It also showed the flow-in and out of the practice (of patients with elevated HbA1C) with diabetes patients leaving the practice, patients coming into the practice, and people being newly diagnosed with diabetes.”

For Bingham, the partnership is about building practice nurses’ competence and confidence in caring for people with diabetes so they are able to “opportunistically do more” or feel comfortable about contacting their ‘partner’ to seek advice.

The diabetes care improvement package is also upskilling GPs in practices, with specialists like Jeremy Krebbs and two other endocrinologists holding peer and case reviews with practice teams, including holding virtual clinics which nurse champions and GPs sit in on.

Intro ???????

What form a practice’s enhanced diabetes care takes is up to each practice so they have “ownership” but each has to have a diabetes plan. Bingham says for practices just starting on their “diabetes journey” the plan might initially just involve regularly reviewing target figures, whereas for practices further along on the journey, such as Karori, it might include a target number of insulin starts.

Bingham says because starting insulin is now commonplace for people with type 2 diabetes, it increasingly needs to be done in primary care where that is practicable.

However, a practice needs to have high numbers of potential insulin clients, as from her experience teaching insulin start-up is most successful when a practice and its new diabetes nurse champion can do six starts in a row – roughly one a week over six weeks. “Traction” was needed early on to embed the skills and build confidence.

Bingham says five years ago the vast majority of insulin start-ups were done in the DHB’s secondary specialist clinics.

Likewise, Liz Dutton, one of the two diabetes nurse specialists employed by Compass Health (to which 54 of the DHB’s about 60 practices belong) to, says when she stepped into the role eight years ago none of the Compass practice nurses were starting insulin.

Now, about 16 of its practices are trained to start insulin, bringing the number of practices across the DHB offering insulin start-up to about 20.

“It’s been a long haul,” says Dutton.

She says upskilling practices seemed the best solution, as she couldn’t cover all of the referrals from the 32 medical centres in her patch on her own.

GPs can also be “intimidated” at starting insulin with patients, says Dutton, so were quite happy to refer firstly to the nurse specialists and latterly to have their practice nurse upskilled so they can do start-ups. So standing orders are now available that Compass practice nurses trained in insulin start-up can use to titrate insulin dosages for their patients.

Devine and Wilson at Karori don’t have standing orders and are happy at present to work in a

collaborative team approach with the patients’ GPs. The two diabetes champions, out of a workforce of eight nurses, now offer nearly all the diabetes annual reviews and pick up the patients who need more intensive involvement – about 150 or so – and enrol them in Care Plus and draw up a care plan in league with their GP. Now, alongside their everyday practice nurse work, such as immunisations, acute care of walk-in patients and taking cervical smears, they run a diabetes clinic once a week for the reviews and Care Plus patients, and work closely one-on-one for the first few weeks of a patient starting insulin.

This includes meeting up with them prior to starting insulin to ensure they are “mentally prepared”, says Wilson, and finding out what expectations or experiences they’ve been exposed to.

“Because insulin and injections have changed over time and people often have horror stories about relatives with legs getting chopped off or getting sicker on insulin, they have a negative view of it.”

Bingham says a strength of having clinical nurse specialists working alongside champions like Devine and Wilson is they can share the skills and techniques they have built over the years to “tease out” the stories and fears that people have about diabetes – particularly starting insulin.

“For example, there was a gentleman who was very reluctant to start insulin and people often assume it is fear of needles, but when we talked to him we found he’d been a health professional in

a previous life and the only people with diabetes he’d ever seen were people having severe hypoglycaemic attacks. So being able to tease that out, we were able to tell him he’d seen a very skewed part of the population and most people handle their diabetes very well and don’t need an ambulance.”

Bingham is excited that one long-term impact of the partnership programme some years down the track may be a decrease in demand for renal dialysis.

She says prior to the programme there has been a risk of people falling through the cracks when referred to secondary services as some of the most high-risk patients never show up.

By supporting practices to support in-house more complex patients with poorly controlled diabetes, rather than referring them to unfamiliar and distant clinics they may never attend, she hopes fewer will be lost and more will improve their diabetes self-management (which includes being supported to make appropriate lifestyle changes, take their medication regularly and start insulin when appropriate).

“In Karori, the work they did with people with HbA1c over 75 – which is really the hardest group to work with. We have made quite big inroads in improving those results.”

If that’s colled out wider so that all diabetes patients can get enhanced care close to home they maybe, just maybe, the escalating demand for dialysis may be slowed and even reversed.

Diabetes Care Improvement Packages Funding for Get Checked free annual diabetes review stopped on June 30 2012, after being offered for 10 years, because the scheme was not getting the desired results.

The $8 million funding (upped to $11 million a year in 2013 budget) is instead redistributed to district health boards to develop primarycare focused Diabetes Care Improvement Packages.

Diabetes annual reviews are no longer a formal target or nationally funded but are still encouraged as good practice and required by some DHBs and PHOs. The national health target of more heart and diabetes checks is aiming for 90 per cent of the eligible population to have had their cardiovascular (including diabetes) risk assessed in the last five years with the national average now sitting at 73 per cent.

MidCentral’s specialist diabetes nurses in practice project Neighbouring MidCentral DHB and Central PHO also now has diabetes nurse specialists working alongside nurses and GPs in general practice.

Debbie Davies, lead clinical nurse specialist in primary health care in the DHB’s Health Care Development team, says it is employing diabetes nurse practitioner Pauline Giles and diabetes nurse specialist Lois Nokolajenko to offer specialist care in general practices at the same time as building capability in the general practice team.

The pair are working as part of the region’s Diabetes Care Improvement Package, as well as the Better Soon More Convenient business case, and are targeting 12 general practices –particularly the large integrated family health centres in outlying areas such as Horowhenua and Fielding.

Instead of providing an outreach service, the specialist nurses are working alongside the

general practice teams, carrying a case load as well as providing collaborative consultations with the GP, practice nurse and the EnhancedCare+ community clinical nurse* to help build confidence, competence and an integrated multidisciplinary approach.

Davies says the Specialist Diabetes Nursing in General Practice project has been underway since the New Year and anecdotal feedback suggests one area it is impacting on is that people are turning up to specialist appointments when they are offered in a familiar setting with staff they already know.

But a full research study is also linked to the project to measure the impact on both clients’ and health professionals’ knowledge. *The region has 23 community clinical nurses who are long-term condition nurses proficient in one long-term condition and competent in the others.

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FOCUS n Long-Term Conditions

Not just a

smoker’s cough Not ignoring “just a smoker’s cough” and other symptoms could see more of the 2000 Kiwis diagnosed with lung cancer each year living longer and better quality lives. FIONA CASSIE talks to lung cancer and respiratory nurse specialists about how nurses can play a part.

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reast cancer has many pink-festooned fundraisers and prostate cancer has Movember but New Zealand’s biggest cancer killer gets little fanfare.

The smoking stigma and too few survivors means lung cancer awareness falls short, to the point where most people surveyed recently* thought breast and prostate cancer were our biggest killers.

In fact, lung cancer accounts for 1650 deaths a year (19.2 per cent of cancer deaths) and the five-year survival rate is just 10 per cent, compared with 86 per cent for breast cancer and 91 per cent for prostate cancer.

While the statistics provide a chilling incentive to quit smoking, the news is not all bad for lung cancer patients. Early diagnosis and treatment of non-invasive cancer increases the five-year survival rate dramatically*, and at the least, earlier diagnosis and targeted therapy can improve the quality and length of life.

Intro ???????

Catherine Smith, a lung cancer nurse specialist at Canterbury District Health Board, was one of the nurses attending the launch in May of the Cancer Society’s 2014 Lung Cancer Health Report**.

The push was to raise lung cancer awareness so people seek help earlier and highlighted a survey of 1500 Kiwis that found little knowledge of common lung cancer symptoms. The expectation was also there for health professionals to educate themselves and be more proactive in promoting lung cancer awareness and investigating symptoms including chronic persistent coughs.

For the past five years, Smith has seen the downside of late diagnosis – she works with patients from their GP referral with suspected lung cancer through to death – a journey that can sadly sometimes be as short as a month, though more commonly around a year for people diagnosed with advanced cancer.

The short survival rate has a Catch 22 effect. “One of the problems with lung cancer is because survival after (delayed) diagnosis is generally short, we don’t actually have a lot of people who survive long enough to be spokespeople.”

More spokespeople to raise awareness might lead to more early diagnoses, an improved survival rate of potential spokespeople and less fatalism that a lung cancer diagnosis is a death sentence.

The focus is mainly on prevention – getting people to give up or never start smoking – but 2000 people a year are still diagnosed with lung cancer and that figure is unlikely to change for some time yet.

Screening for lung cancer is also not simple, with research showing that regular chest X-rays or sputum analyses of current or ex-smokers do not reduce mortality from lung cancer; while CT-scan screening of smokers does reduce mortality by 20 per cent, it also has a 25 per cent false positive rate that increases the risk of complications from invasive diagnostic techniques.

Smith says the stigma and shame of having a smoking-related illness also impacts on awareness. “I come across a lot of people who say ‘I’ve got no-one to blame but myself’.”

“Absolutely” patients often blame themselves, agree Hutt Valley respiratory nurse practitioner Betty Poot, MidCentral NP Victoria Perry, and MidCentral lung care coordinator nurse specialist Linley Gulasekharam. The stigma and guilt means fewer people are ready to speak-up and lobby for lung cancer.

“That is why their ribbon is a clear ribbon, because it’s the unseen and unknown cancer … compared with the pink ribbon for breast cancer,” says Gulasekharam.

The Cancer Society survey also found that nearly two-thirds of respondents believed people were less likely to be sympathetic to someone with lung cancer than any other cancer.

This may be why Dr Wendy Stevens’ research* for the Northern Cancer Network found that one barrier to earlier diagnosis was GPs and patients having “nihilistic” or “fatalistic” attitudes to lung cancer. Another barrier the 10

Nursing Review series 2014

research found was GPs identifying when to investigate suspected lung cancer – with the strongest trigger being patients coughing up blood, but only 15 per cent of patients present to their GP with that symptom and most (49 per cent) presented with a cough.

Smith’s unscientific survey of Christchurch Hospital nurses prior to talking to Nursing Review showed all could identify a cough as a lung cancer symptom but then had to stop and think a bit harder. She says only a few could name additional symptoms that weren’t associated with advanced cancer, like lack of energy and weight loss.

“My personal view is that nurses, generally speaking, have slightly more awareness than the general public but very few could list all the common symptoms like cough, hoarseness of voice, shortness of breath, pain, and coughing up blood.”

“Some of the nurses said ‘but some of these patients have a smoker’s cough so how do you differentiate a smoker’s cough from a lung cancer cough?’”

The short answer is there is no easy answer. Finding the cause of any persistent or protracted cough can involve a lengthy assessment and history gathering and may require an X-ray to eliminate causes like lung cancer.

Betty Poot, an NP who also chairs the Respiratory Nurses Section of NZNO, runs the country’s only nurse-led cough clinic.

“There is no way you can tell the difference between a cough that is straightforward and a cough that is more serious,” says Poot.

She says a cough is one of the most common reasons people present to their GP, but diagnosing the cause of a less common persistent and protracted cough can be challenging, with for example a post-viral cough persisting for up to three months.

“So my thoughts are that you can’t say to a smoker that it is a ‘smoker’s cough’ because you don’t actually know that. But that doesn’t mean you ignore it.”

Perry say smokers often accept a cough as their lot and dismiss it to their GP or nurse as “just my usual cough”.

Gulasekharam adds that the health professional some lung cancer patients see most, pre-diagnosis, is their pharmacist, while stocking up on cough medicine and throat lozenges. “They need to be encouraged to get their GP’s advice and not keep just throwing money at symptom management.”

She also points out that not everybody with lung cancer has a cough either.

They can have any other of the symptoms, ranging from a hoarse throat to pain in the chest, or they can be asymptomatic and the cancer is found during a scan for another condition.

Poot and Perry emphasise that any chronic, persistent (lasting longer than eight weeks) or protracted cough should be investigated.

Perry adds smokers or health professionals also shouldn’t assume that a person’s cough is caused solely by their smoking.

“I see it time and time again when you undertake an assessment and go through all the triggers and background, there are often other causes or reasons as well, like reflux or chronic sinusitis (that can be treated).”

So smokers shouldn’t put off getting their chronic cough assessed out of fear of cancer or believe it is a symptom they have to tolerate.

Patients are referred to MidCentral’s respiratory NP clinic predominantly for a cough after suspicious flags for lung cancer– like an abnormal chest X-ray or weight loss – have already been ruled out but, with a large proportion having smoking-related respiratory disease like COPD, Perry says lung cancer is always “on their radar”.

If a patient with respiratory disease is cleared once of lung cancer, they should be investigated again if they develop a new, chronic cough or their

FOCUS n Long-Term Conditions

existing cough changes – for example, becoming more frequent, more painful, or sounding different.

“Anybody, particularly a current smoker or an ex-smoker, who has a cough that doesn’t go away should be reviewed,” reiterates Smith, who deals daily with the reality of lung cancer.

She emphasises the “anybody” as 10 per cent of lung cancer victims have never smoked.

Health professionals must promote awareness and investigation of suspected lung cancer but many also have to change their own fatalistic attitude and misconception that lung cancer is an automatic death sentence.

“I was talking to an orthopaedic surgeon the other day (about her role) and he said ‘but they all die’,” says Gulasekharam.

“My anaesthetic colleagues said ‘they all die’.” But times have changed and targeted therapies are making their mark.

“With lung cancer, you can now extend life considerably with appropriate and targeted gene therapies,” says Perry.

Not only should nurses encourage all smokers to quit, but they should also don their ‘clear ribbons’ and be an advocate for making patients more aware that a persistent hacking cough or husky voice should not be ignored until it is too late.

COMMON SYMPTOMS of LUNG CANCER

»» A chronic persistent cough (more than eight weeks) that does not go away. »» Hoarseness or loss of voice. »» Repeated bouts of pneumonia or bronchitis. »» Shortness of breath or increased breathlessness. »» Noisy breathing.

Intro ??????? »» Pain in the chest, upper back or rib. »» Coughing up blood (haemoptysis). »» Low energy levels. »» Neck and arm swelling and swollen veins. »» Don’t dismiss symptoms of non-smoker.

BARRIERS* TO EARLIER DIAGNOSIS INCLUDE: »» Difficulty identifying which patients to investigate and refer. »» GPs have high threshold for chest X-rays. »» GPs, most common trigger for suspecting lung cancer was coughing blood but only 15 per cent of lung cancer patients had that symptom. »» Most common presenting symptom was cough (49 per cent) but did not trigger GP suspicion as lung cancer patients often have existing respiratory disease like COPD. »» Sixteen per cent of Pacific and 8 per cent of Māori patients are ‘do not attends’ when referred and more likely to decline further investigation. »» Barriers to patient attendance include fatalistic attitudes and fear, lack of knowledge of symptoms, lack of culturally appropriate support, and transport and financial barriers. »» Many GPs and patients had nihilistic attitudes to lung cancer, being unaware that outcomes could be good if diagnosis was made early. *Source: ‘Identifications of barriers to the early diagnosis of lung cancer and description of best practice solutions’, Northern Cancer Network (2012) principal investigator Dr Wendy Stevens et al. www.northerncancernetwork.org.nz/Research/tabid/110/language/enNZ/Default.aspx

FURTHER READING »» National Standards of Service Provision for Lung Cancer Patients in New Zealand (2011) »» www.health.govt.nz/publication/standards-service-provision-lung-cancerpatients-nz »» CICADA: Cough in Children and Adults: Diagnosis and assessment.

Australian cough guidelines summary statement (2010) »» www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adultsdiagnosis-and-assessment-australian-cough »» Lung Cancer Health Report (2014) Cancer Society of New Zealand »» www.cancernz.org.nz

General alarm symptoms for chronic cough include:

»» Coughing up blood (haemoptysis). »» Smoker with > 20 pack-year smoking history. »» Smoker over 45 years of age with a new cough, altered cough, or cough with voice disturbance. »» Hoarseness. »» Recurrent pneumonia. »» Abnormal clinical respiratory examination. »» Abnormal chest X-ray.

FACTS you might not know about LUNG CANCER Lung cancer is the most common cancer death in New Zealand (1650 per year) but only a third of Kiwi men and 20 per cent of Kiwi women are aware of this, with many believing the more high profile breast, prostate and melanoma cancers are our biggest killers**.

Late diagnosis is believed to be behind New Zealand’s poor five-year survival rate from lung cancer – 10 per cent for total population and 7 per cent for Māori – compared with survival rates of 12–16 per cent in Australia and USA. Five-year survival rates increase to 26.1 per cent if diagnosed at stage III disease and 53.5 per cent if diagnosed at stage 1 or II disease and as high as 73 per cent with successful surgery of non-invasive cancer.

Mäori patients are 2.5 times more likely to have locally advanced disease when present and longer timelines from diagnosis to treatment.

Pacific people most likely to have metastatic disease.

Of 1507 New Zealanders surveyed for the 2014 Lung Cancer Health Report only 29 per cent could identify a persistent cough as a potential symptom of lung cancer.

In the same survey, almost two-thirds of respondents believed people are less sympathetic to someone who has lung cancer, as opposed to other forms of cancer.

About 10 per cent of people who get lung cancer are non-smokers.

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FOCUS n Aged Care

Aged Care FOCUS: Caring is our theme – how best to support the caring of the dying in our residential aged care sector and a nurse honoured for caring for the feet of the elderly.

Intro ???????

Are aged care facilities becoming de facto hospices?

New Zealanders are more likely to die in residential aged care than most countries around the world. Some say our rest homes and hospitals could be called “de facto hospices” but without the resourcing or recognition to offer palliative care at the same level. FIONA CASSIE finds out more.

S

arah hasn’t forgotten that night in a hurry.

She was one of two health care assistants (HCAs) on duty that night in the rest home – with one wing each to cover. Suddenly within the space of two hours, three of the residents died unexpectedly.

“We were just running around – it was crazy.”

“I remember one had a frightened face that scared us … must have had a big heart attack.”

It wasn’t the dignified passing away that anybody involved wanted: the dying residents, their stressedout, stretched carers, or the loved ones getting the unexpected phone call in the night.

Increasingly, more and more New Zealanders are dying in residential aged care. In fact, a research project looking at 16 million deaths across 45 million

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countries, of which Professor Merryn Gott of the University of Auckland’s school of nursing was a part of, found New Zealand had the highest proportion of older people dying in residential aged care. The average was 18 per cent and New Zealand is around 31 per cent.

With the median age in residential aged care now over 85, and residents increasingly frail and with complex co-morbidities, people aren’t residents for long.

As another recent study co-authored by Gott founded the number of residents dying within six months of admission to residential aged care in New Zealand was high – 20 per cent – and was even higher (36 per cent) for those admitted straight from

acute hospital. This led the researchers to dub the residential aged care sector the ‘de facto hospice’ for New Zealand’s elderly.

“I just don’t think that we acknowledge that ‘palliative care’ is a big part of the work done in aged residential care,” says Gott.

By the time most people enter residential aged care, many have a ‘life-limiting illness’ and so fall under the broad definition of palliative care New Zealand has adopted (see box on page 14).

That trend is also reflected in statistics, quoted by the New Zealand Aged Care Association in 2013, that the average length of stay of the 40,000 elderly in the sector in 2012 was around one year at rest home level and six months at hospital level care.

“As a society, we don’t just perceive residential aged care as fulfilling that (palliative care) role in the same way that we do a hospice and we certainly don’t resource it to the same extent,” says Gott.

This reality prompted the ‘de facto hospice’ researchers, led by geriatric medicine professor Martin Connolly, to call in their recent article in the Australasian Journal of Ageing for training and resources to reflect residential age care’s unofficial Intro palliative??????? care role.

‘De facto’ wrong label

The need to improve palliative care for the aged has also been recognised by Hospice New Zealand in recent years with the development of a specific training programme for the residential aged care sector. Though Anne Morgan, practice advisor for the hospice movement’s national body, is less supportive of calls to label residential aged care facilities as ‘de facto hospices’.

“I don’t like them being called de facto hospices for the very reason that a hospice provides multidisciplinary, holistic care, and it looks after body, mind, and spirit,” says Morgan.

“Most residential aged care facilities … they don’t have the resources for it for a start, and they don’t have the specialist knowledge to provide (hospice level) specialist palliative care.”

She says that doesn’t mean facilities aren’t offering palliative care. “They are doing it – and many of them are doing a very good job.”

But there are a number of impediments, including the need for education, which prompted the development of the Fundamentals of Palliative Care training package.

The nine-module package is delivered for free by hospice educators or similar specialists. It is designed for everybody working in residential aged care, from the HCAs, RNs, and attending GPs to the receptionist, gardener, and cleaning staff because “everybody involved with the care of the elderly is part of their palliative care”.

She says it is also known that the people patients will most often speak to are the cleaners, to whom they will tell their deepest fears while the cleaner tidies their room.

Morgan says the package has had a “huge uptake” since it was first rolled out in 2012 with thousands of modules taught across the country. The only module that is compulsory is the introductory ‘Essence of palliative care’ module, with the other modules – including pain and symptom management, ethical

issues, palliative care for people with dementia, and staff caring for their own wellbeing – being optional.

The aim is to educate people working in aged care to provide generalist or primary palliative care.

Morgan says most people don’t need specialist palliative care, and if they do, aged care facilities can call on the support of specialist palliative care teams across the country. She says what people in residential aged care all need is good primary palliative care.

Demand and burnout

There is no doubt of the burgeoning need for quality palliative care in the aged care sector.

The Palliative Care Council’s 2011 report looked at potential demand for palliative care by examining death records and estimating the number of deaths that may have benefited from palliative care. Its mid-range estimate, including deaths from cancer, circulatory, and respiratory diseases, was more than half of all annual adult deaths, or up to 19,000 deaths a year by 2026. The council also looked at where people with these mid-range palliative care needs have been dying. Twenty-five per cent of those deaths were happening in residential aged care, 47 per cent in hospitals and 17 per cent in people’s homes.

That same report says, “therefore residential care facilities will require adequate resources and appropriately trained staff, as well as access to specialist support, to deliver high-quality palliative care”.

With the aged care workforce already under pressure, another research project Gott was party to indicates that the extra resources might need to come before training makes a difference.

The project, led by Rosemary Frey, surveyed more than 400 clinical residential aged care staff – the majority HCAs – and found high levels of burnout and stress. The higher the burnout, the research found, the less likely staff were to report being ready to engage in palliative care education.

“We tend to think the solution is very straightforward – that we will just educate people and that will automatically lift the quality of palliative care – but we haven’t really thought about these other factors that restrain staff, particularly HCAs, in their work,” says Gott.

“Education isn’t the full answer. It absolutely isn’t,” agrees Morgan. “It is just one of the parts of the answer.”

“It is a very stressed workforce,” adds Gott. “They (HCAs) are receiving minimum wage, are often also facing challenges as immigrants to the country, and

they are just not very highly regarded. There are news stories all the time about how aged residential care is failing people and quality of care is bad, and that must have an impact on staff morale.”

Whereas, says Gott, hospice workers – doing, in many cases, a very similar job to people in the aged care sector but with more support including clinical supervision – are seen as very special people to do the work they do.

“I think residential aged care provides some amazing care against the odds with the staff numbers that they have,” says Morgan.

“We have to recognise that many of the staff working in the facilities are paid very poorly and sadly many of the facilities are run on a business model, not a care model … you just need to look at the turnover of staff.”

In the business of dying

There is not much disagreement from the aged care sector with the notion that residential aged care could be viewed as a ‘de facto’ hospice.

“There’s no doubt that we’re in the business of looking after people as they die – more and more so,” says Gina Langlands, the quality and risk director for healthcare provider BUPA. This is echoed by aged care nurse managers like Jeannie Sale, a Christchurch clinical manager with more than 25 years experience in the sector and Jean Colbeck and Chris Beckett, the facility manager and clinical manager, respectively, at BUPA’s Beachhaven Hospital.

They all report excellent support from teams at their local hospices – Nurse Maude and North Shore – for both education and advice for their 24-hour RN-staffed hospitals. “We can access the hospice at any time day or night. We just ring them for advice if we have a person we are a bit concerned about,” says Beckett.

They are also increasingly seeing end-of-life care as a major part of their facilities’ role. Not only in caring for elderly hospital residents but also, Sales says, it has become more and more common in the past decade for the aged care sector to find themselves caring for people under 60 with life-limiting illnesses, like people with end-stage COPD. “The palliative care journey should really begin when they are admitted.”

She says the reality is that not all facilities have the resources to hold conversations with patients and their families on admission about end-of-life care, particularly younger patients, which can result in interventions that aren’t appropriate or necessary.

Nursing Review series 2014

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FOCUS n Long-Term Conditions

Advanced Care Planning is seen to be an initiative that could see aged care nurses able to raise and discuss what people wish and help work through endof-life care expectations that can differ between a 55 or 65-year-old and those of a 95-year-old.

Nurses like Beckett and Sales believe elderly hospital patients with life-limiting co-morbidities want to be comfortable, pain free, and in familiar surroundings at end-of-life, rather than face a stressful end-of-life intervention or deathbed trip to a public hospital.

“At the end of the day, as nurses, we appreciate the trust that people put in us for caring for their dying elderly and people who come to us palliatively,” says Sales. “It is not appropriate for people in aged care hospitals to be sent off to public hospital to die. We do need to have that good plan.”

“Moving towards allowing a natural death is very difficult for some people,” says Colbeck.

Many families can call for antibiotics to fight chest infections in a frail relative rather than to relieve symptoms and to continue feeding with nasogastric tubes when the patient is frail and unconscious.

The trio also hold in common the belief that aged care facilities without nursing expertise should not take on palliative care patients or continue to care for elderly end-of-life patients with complex co-morbidities needing pain pumps and other specialist support.

“I feel very strongly that rest homes shouldn’t be having patients with those needs (i.e. pain pumps) unless there is 24-hour registered nurse coverage,” says Sales.

Beckett??????? and Colbeck agree. “Our RNs are skilled at Intro putting up pain pumps and they can do that night or day anytime.”

The difficulty emerges at rest home-only level care when a night duty HCA has to get the on-call RN out of bed to set up a pain pump for a patient in need.

Not all facilities have their own GP on-call 24 hours a day to prescribe pain relief.

“I also really feel we should have mandatory staffing levels in aged care facilities. Here, and most places I’ve worked, we have one staff member for five hospital care patients,” says Sales.

“But a lot of places it is a much higher workload – up to six or seven hospital care residents – and if you’ve got one dying patient in that mix, you can’t give them the proper care.

“If we had mandatory staffing then it (aged care) would always be a safe place for people to be cared for at end-of-life.”

Morgan was due to speak to an all-parliamentary meeting in late May representing aged care palliative care to outline some of the challenges faced by the sector, including staffing levels.

“We are going to be in dire straits if we don’t look at the care of our older persons.”

She agrees that if you want to deliver best practice at end-of-life care with only one care staff member for seven people then “something has to give”.

“If you give your time to the dying, what happens to the living?”

To Morgan, best practice palliative care is about affirming life until we die, which means putting quality of life into each of those days. This means not only good symptom management, including pain management, but also seizing the moment and skipping a shower to take a patient out for one last visit to the garden on a sunny day.

Nobody seems to be arguing for funding of hospicelevel specialist palliative care for residential aged care – and hospices point out that they are heavily reliant on fundraising and donations to top up state funding to be able deliver to the specialist care that they do to their communities.

There is an argument that if New Zealanders want their mothers, uncles, granddads, and great-aunts living in rest homes to get consistent, quality primary palliative care, more than education is needed.

Of course, death will never always come neatly at a convenient time, with family gathered at the bedside, a favourite nurse or caregiver hovering nearby, and a pain pump easing any suffering.

But with more resources, more staff, and more dedicated training, residential aged care may be more often able to give the dignified and comfortable death we all want, without stress and without compromising the care of the living.

Nurses active ‘proxy’ role in palliative care prescribing A New Zealand and Australian research team’s work looks to confirm that community nurses play an active role in palliative care prescribing, though not prescribers themselves.

Dr Kay de Vries and other members of the research team made a conference presentation earlier this year on some initial findings from their survey of nurses working in community palliative care on both sides of the Tasman.

The initial analysis indicates that, while only a handful had prescribing qualifications, most had 25-plus years nursing experience. And the vast majority of the palliative and district nurses discuss prescribing frequently with their palliative care patients, particularly when the patient is deteriorating, and more than 85% recommend prescriptions – typically pain relief – to the prescribing physician.

The New Zealand definition of palliative care is: Care for people of all ages with a life-limiting illness which aims to: 1. Optimise an individual’s quality of life until death by addressing the person’s physical, psychosocial, spiritual and cultural needs.

2. Support the individual’s family, whanau, and other caregivers where needed, through the illness and after death.

Generalist palliative care is palliative care provided for those affected by life-limiting illness as an integral part of standard clinical practice by any healthcare professional who is not part of a specialist palliative care team.

Specialist palliative care is palliative care provided by those who have undergone specific training and/or accreditation in palliative care/medicine, working in the context of an expert interdisciplinary team of palliative care health professionals.

Current inequalities include access for Māori, Pacific peoples, isolated communities, children, the very old, those with non-malignant disease, as well as those with special needs: asylum seekers/ refugees, people in prison, and those with mental illness.

From: NZ Palliative Care: A Working definition 2007

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Dementia and palliative care One of the chronic conditions associated with old age is dementia. It is recognised now that dying with dementia, like dying of other chronic illnesses, can be equally as bad as cancer, says Anne Morgan.

“Dementia is one of our biggest issues with the ageing population … it’s going to be just enormous, really, and without good quality palliative, their deaths can be quite traumatic,” says the hospice New Zealand practice advisor.

Dr Kay de Vries, head of Victoria University’s postgraduate school of nursing, research focus has been palliative care, particularly dementia, with her doctoral research in the UK indicating increasing numbers of people with dementia being referred to hospices in the past decade, from virtually none in the past.

“It’s been recognised in the literature for a long time now that this group does definitely need palliative care input … they have very similar physical symptoms and difficulties to people who are dying from anything else, like cancer,” says de Vries.

“Sometimes those symptoms go on for much longer as well … so having people with expertise in palliative care being involved with their care at end of life is pretty essential I think.”

She has written a chapter on end-of-life care for The ABC of Dementia, a book published this year in the UK, in which points out that in many cases professionals and families do not view dementia as a terminal illness and have little knowledge or understanding of the possible causes of death.

“However, people with dementia who are dying have significant health care needs and there are particular challenges and ethical dilemmas that both families and caregivers encounter.”

It is encouraged that initiation of discussions about death and dying should take place at an early stage when the person with dementia can participate meaningfully.

As aged care facilities are where the majority of people with advanced dementia live and die, de Vries believe such facilities need a combination of people with palliative care skills and specialist dementia care skills.

Anne Morgan, herself an experienced oncology and palliative care nurse, made the decision to take her own mother with advanced dementia out of residential aged care because her mother was declining. She was not eating, her only communication was distressed sounds, and they thought she was dying.

“But in actual fact when I tended to her needs, she came to and started eating and engaging with the family again.”

She ended up living for not just a few weeks but 20 more months, and the family had some special time together, but also some major struggles to get support services into the family home.

Despite those struggles, Morgan didn’t consider putting her mother back into care as she wasn’t seeing recognition of the need for palliative care for people with dementia. Neither did her GP regard advanced dementia as a reason for referral for specialist palliative care for her mother in her last dying weeks.

“There’s still an ignorance or lack of recognition of dementia as a life-limiting disease.”

FOCUS n Long-Term Conditions

Faith, duty, and foot pampering wins nurse QSM One of faith community nurse Noreen Wright’s flock jokingly calls her the “toe pruner”.

T

he 74-year-old registered nurse was recently awarded a Queen’s Service Medal for services to senior citizens, including launching highly popular foot clinics for the elderly that have been running for 14 years in her hometown of Christchurch and further afield.

The six-weekly pampering – involving a footbath, trimming of toenails, and finishing off with a relaxing foot massage – now attracts 135 people over two days to the Avonhead Baptist Church clinic.

But when the clinic – open to all people in the community who struggle because of age or injury to reach their own toes – first opened its doors, Noreen recalls they had only one patron for the first few months.

Her team of fellow former and current nurses started to question whether the idea would work.

“And I said, have a little faith … I think we need to pray harder.”

Faith, more community notices, and word of mouth saw the idea take off to the point now that 15 clinics have been set up around Canterbury built on the Avonhead model and with training support from Noreen’s team. There are also now clinics in the deep??????? south and the North Island.

Intro It is all part of the caring ethos that means retirement as nurse manager of the Archer Memorial Baptist rest home and retirement village has meant little rest for Noreen, who just stepped up her role as faith community nurse in Avonhead.

She first trained and qualified as a registered nurse at Christchurch Hospital in1958-1961 and worked in medical wards before marrying Colin and raising their four children.

Her daughter’s upcoming wedding and a friend who was matron at George Manning House prompted her return to nursing in the 1980s, caring for people in the centre’s cottages.

It was a district nursing-type role that Noreen loved, including the chance to give that little bit of extra care – like a lady who loved to sew but her sight meant she struggled to thread a needle. “Each week I’d make sure she had four needles threaded in her pin cushion.”

When the job came up as nurse manager for Archer Home, Noreen was encouraged to apply, which after some trepidation, she did and went on to hold the post she loved from 1990 until her retirement in 2004. “You were there to support and guide and teach (the staff) and make it home for the older folk.”

Attending a conference in Canberra on Spirituality and Pastoral Care of the Elderly that had a workshop on faith community nursing resonated with Noreen, and she brought together a group of former RNs at Avonhead Baptist Church, out of which the foot clinics grew.

Her faith community nurse work was on top of her role at Archer Home and she jokes that “there’s no ‘nine-to-five’ about me at all” and thanks her husband Colin and family for allowing her the freedom to do the work she loves The Avonhead group started with offering blood pressures on the first Sunday of the month and Noreen developed information packs for young mothers in the congregation.

They then started the foot clinics in 2000. So why feet?

Noreen Wright

“If you have got sore feet it shows on your face… and it’s only doing what they could do if they could still reach their toes.”

The clinics are now finely tuned; there is somebody to greet clients and book appointments, two at work keeping the footbaths cleaned and full, three to four toenail cutters (all registered nurses) and three to four providing the foot massages.

Then there is a cup of tea and a bite to eat in a neighbouring room, which Noreen sees as an important part of the service, with the friendships forged at the clinic one of its joys for her.

She has also drawn on the services of infection control nurse specialist Alison Carter to advise on hygiene, to ensure no fungal or bacterial infections are spread, and has a podiatrist to refer on people whose feet need more attention.

Noreen no longer does the massages herself as she has needed knee surgery (and her enthusiasm for ongoing learning meant she watched, live, on a monitor her own knee being operated on).

“It was just wonderful to see all those wonderful little tools he had. This made me appreciate the expertise of the surgeon.”

But she does still do the toe clipping and sees it as an opportunity to really listen to people.

“It just gives them a comfortable space to talk … because some people clam up and they don’t share

things that are deep within – if you really listen, you can hear what they are saying behind the words and I think that’s one of the most important things along with respecting what they say – no matter how small or how trivial it might sound.”

As a faith community nurse she is ready to advocate for people who may be reluctant otherwise to speak up.

“I don’t hesitate to ring on behalf of somebody… sometimes they struggle and they don’t want to bother anybody.”

So she is ready to call in family or ring their doctor or nurse or home help agency to get the help they need.

She also checks on people in their home after surgery or hospital visits and would love to be a “matchmaker” to bring together more of the lonely people that she visits.

While she appreciates her QSM she is keen not to rest on her laurels and is considering taking a greater role in advocating on elder abuse issues.

She also has ideas in the back of her mind about writing down her thoughts on people dying well.

With another knee operation to come, her main upcoming project is ensuring that the clinics that she helped instigate are in good health and good heart so they can continue evolving and giving comfort to older people.

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Evidence-based practice

Cut it out sooner than later Heading into surgery, does it make much difference if you delay quitting smoking just another week…

CLINICAL BOTTOMLINE: Quitting more than four weeks before surgery more than halves the risk of complications. Quitting less than four weeks before surgery does not reduce complications.

CLINICAL SCENARIO: You need to determine what advice is given to patients about quitting smoking before surgery – a key question is when to set the quit date before surgery.

QUESTION: Among adults having surgery, does pre-operative smoking cessation reduce the risk of complications compared with not quitting?

SEARCH STRATEGY: PubMed clinical queries (broad): smoking cessation AND post-operative.

CITATION: Mills E, Eyawo O, Lockhart I, et al. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis, Am J Med 2011;124:144-54.

STUDY SUMMARY: Systematic review of trials and observational studies testing the effect of smoking cessation on post-operative complications. Inclusion criteria were: • type of study was randomised controlled trials and observational studies; patients were not clearly specified, but could be assumed to be patients undergoing any type of surgery; • intervention was not clearly defined but could be assumed to be smoking cessation; • outcomes end included total complications (primary outcome) and any wound healing, pulmonary or respiratory complications, all-cause mortality, and all cause length of hospital stay (secondary outcomes).

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If a study reported a distinct type (or types) of complications, but not total complications, the distinct types were not combined for the systematic review.

847 titles were screened, 75 were retrieved for further review trials, and 30 studies included. Six studies were randomised controlled trials, which are the focus of this critical appraisal tool (CAT) article.

VALIDITY: The search strategy was specified and involved electronic searches of databases including Medline, EMBASE, Cochrane CENTRAL, AMED, CINAHL, TOXNET, and the Web of Science. No language, sex, or age restrictions applied. Also searched were bibliographies of previous reviews and health technology assessments as well as databases of full text journals – e.g.

Science Direct and Ingenta . The researchers used modified Cochrane risk of bias tool and included assessment of randomisation sequence generation, allocation concealment, blinding, intention-to-treat, descriptions of loss to follow up, and sources of funding. Data entered by the two researchers into electronic form and where data differed, differences were resolved by discussion and third party arbitration. Publication bias was not examined. Reasonably high quality review of moderate quality studies.

RESULTS: Six trials involving 552 participants were included covering patients that received hernia repairs, Outcome

laporoscopic cholecystectomies, joint replacements, colorectal, urologic, ORL, or gynaecological surgery.

Most trials involved the evaluation of a smoking cessation intervention several weeks prior to surgery.

One trial compared buproprion with placebo and one trial compared nicotine patch applied on day of surgery.

Four trials reported sequence generation and allocation concealment; five trials were blinded; all trials used intention-to-treat analysis and one trial had greater than 20 per cent loss to follow up. All trials were funded publicly with pharmac providing the drugs. Smoking cessation almost halved total complication rates (table), shorter term cessation (< 4 weeks) and less intensive interventions are less effective than longer term cessation (> 4 weeks) and more intensive intervention.

Table. Results with 95% confidence intervals (95%CI).

COMMENTS: Results contrast with observational evidence that suggests a lesser effect on total complications.

Only observational studies provided evidence for effect of smoking cessation on pulmonary complications, wound complications, length of stay and mortality.

Reviewer: Dr Andrew Jull, Associate Professor, School of Nursing, University of Auckland, Nurse Advisor, Quality and Safety, Auckland District Health Board.

N

RR (95%CI)

Total complications

552

0.59 (0.41 to 0.85)

Short term cessation

Not presented

0.92 (0.53 to 1.60)

Longer term cessation

Not presented

0.45 (0.30 to 0.68)

Less intensive

Not presented

0.78 (0.34 to 1.80)

More intensive

Not presented

0.55 (0.31 to 0.98)

Heterogeneity I2 = 14% I2 = 0% I2 = 0% I2 = 0% I2 = 61%

Taima Campbell

Managing our greatest resource - people

college of nurses

TAIMA CAMPBELL introduces some human resources advice for nurses – both employers and employees – on some approaches to resolving employment dilemmas.

From time to time, the College of Nurses office fields questions from members about employment and human resource management issues. Questions come from nurses who are the employer, as well as nurses who find themselves in situations where they lack access to good advice or are seeking a second opinion. The College network includes members with expertise in these areas, but even we need to call on the experts. We have invited human resources company EQ Consultants to share some of their problem-solving approaches and experience.

When good relations go bad As a human resources company, EQ supports employers working through employment issues. We often have both employees and employers getting into difficulty, usually when a good relationship goes bad.

Just to be clear, we are not employment lawyers, so the legal disputes we leave to our litigious colleagues; instead we work within organisations like an external HR department.

The reference points we use for the dayto-day questions that come up (for both employers and employees) are the law, employment agreements, and policies and procedures. Otherwise, we work through a process of defining the issues and potential solutions for the parties concerned.

To give you some examples, the two (fictitious) scenarios below are typical of the issues that we deal with.

Scenario 1: John and Jean John is the new CEO of an NGO and contacted us because there were a large number of issues he was uncovering within his organisation. One issue concerned Jean, who had been in her nursing role for 20 years and was not coping with the recent introduction of a new computer system.

Having been in nursing for a long time, Jean

was not open to being challenged on her practice or behaviours. She was being rude to younger staff and not following instructions from anyone.

When working with someone like John, we explore the current situation with them and identify key questions that need to be addressed. The common questions we ask are: »» Where does he want to start? (what are the key problems he wants to address?) »» What process is best to follow? (i.e. is this a performance or disciplinary issue?) »» Is it worth trying to address the problem or has it gone too far? »» Will it create low morale with the rest of the team if he challenges the behaviour? »» What has been tried so far?

Firstly, there is a need to understand Jean’s history within the organisation. Part of this is unbundling each issue and identifying the reasons why Jean is behaving in this way and what the reward is for her doing so.

From this comes a plan, which we will either support John in implementing himself or take the lead. Depending on the answers, a possible outcome could be performance management and extra training for Jean on the new computer system. John and Jean may have purely got off on the wrong foot.

Scenario 2: Sue’s sick child dilemma Sue was new to the organisation and has just discovered that her youngest child has an illness that will require her to take time off work. As yet the diagnosis has not been confirmed, and she is worried. It is beginning to affect her work as she is often late and needing to take time off to attend specialist appointments.

The questions for Sue are: »» I’m new in a role, will I be supported? »» How much sick leave do I have?

»» My child needs me, and I need to put them first, but will my employer be understanding?

Our role in this situation is to work with both the employer and the employee in finding a ‘win-win’ solution. This may be to give Sue unpaid ‘time-out’ until a diagnosis is confirmed. Once this is established, both parties can develop a plan. This may involve a re-negotiation of the terms and conditions of employment, which would be reviewed at an agreed time. The employer then has flexibility and money to cover the role.

Each situation that we are involved in has a number of possible outcomes. Good ‘win-win’ solutions are generated when both employees and employers address issues early and openly. Apart from the formal employment agreements, organisational policies and procedures, answers usually lie in the culture of the organisation and the way people treat each other. Central to the message is developing high-performing cultures that deliver to the organisation’s goals and the individual’s desire for job satisfaction.

If you have a question or would like to know more about best practice on a human resource management issue, please email the College of Nurses office – admin@nurse.org.nz – and we will respond to the most common issues in future articles and posts. Please don’t send confidential information.

If you have a major issue or concern about your employment or a human resource management issue, please seek appropriate advice.

Taima Campbell is co-chair of the College of Nurses Aotearoa, former director of nursing for Auckland District Health Board, and a health consultant

Nursing Review series 2014

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Practice, People & Policy Mental health

Articles, profiles and opinion pieces from across the nursing spectrum

Practice, People & Policy

Competent or just confident?

For a decade now, New Zealand nurses have had to declare each year that they continue to be competent to practise safely. DR RACHAEL VERNON, a leading researcher into New Zealand and other nations’ continuing competence frameworks, says such frameworks can predict and imply a nurse is safe to practise, but never guarantee.

How safe is the health professional caring for you or your loved ones is an issue that has gained increasing public attention over recent years.

Assuring the public that robust processes exist to ensure and monitor the continuing competence and safety of nurses to practise has become a priority for nursing regulatory authorities (see sidebar).

In general, nurses understand that they must meet a minimum standard of competence for initial registration, but the concept of ensuring continuing competence throughout their professional career is not so well understood. Maintaining ongoing competence as a nurse is influenced by a number of factors, including individual behavioural traits (such as insight, judgement and decision making) and environmental factors (such as the context of practice, health policy and systems, access to resources, and patient acuity).

Current literature suggests that despite models being developed to “ensure” continuing competence, behavioural traits and environmental factors have the potential to significantly influence a nurse’s continuing competence and safety to practise at any given time or situation.

Translating knowledge into safe nursing practice requires the nurse to be able to make clinical judgements, based on sound knowledge and skills. A lack of self-awareness or personal insight has been identified as a key contributor to unsafe practice. Nurses who lack personal insight are less likely to reflect on or assess their own practice. They are also less likely to seek continuing professional development opportunities or recognise when their practice or environment is unsafe.

However, in the absence of a quantifiable and defensible mechanism for assessing continuing competence, many countries have implemented continuing competence models using a range of competence indicators.

I was lead researcher of an evaluation of the Nursing Council of New Zealand’s Continuing Competence Framework, completed in 2010, that concluded the framework is a well-accepted and recognised regulatory tool for assessing and monitoring the continuing competence of nurses and their safety to practise.

This New Zealand research was the first internationally published study to evaluate a continuing competence framework in practice. The interest in the findings from nursing regulatory jurisdictions internationally led to the development 18

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of a separate piece of research, completed in 2012, that determined the international consensus view of regulatory experts from six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America), with regard to what constitutes continuing competence and also the foundations for the development of a best practice international consensus model for the assessment of continuing competence.* It is argued that it is the professional responsibility of all practising nurses to maintain their competence to practise. It also argued that well-developed and comprehensive continuing competence frameworks provide assurance to the regulator and the public that the nurse is indeed continuing to be competent to practise. But no independent indicator of competence has been identified that can ensure the continuing competence of a nurse.

However, there are many common philosophies and processes related to measuring, assessing and monitoring continuing competence. In addition, there is a presumption that the measurement and/ or assessment of the competence and continuing competence of nurses, assures and ensures their safety to practise.

Overall, the findings from the 2010 and 2012 studies have identified that the indicators of continuing competence (self-assessment, recent practice hours, and continuing professional development/education) are all considered to be appropriate indicators of competence, and when used together can predict continuing competence and therefore may imply safety to practise.

However, they cannot guarantee that a nurse is safe to practise on any given day. In addition, the stipulation of a minimum number of practice, and continuing professional development/education hours, when used independently, are pragmatic or arbitrary requirements and not considered to be a valid measure of competence, continuing competence, or safety to practise.

But on the other hand evidence of recent practice and active engagement in professional development/ education opportunities arguably provides a more robust indication that the nurse’s knowledge and skills are continuing to be current, and that the nurse might be aware of what they do not know or what skills and knowledge they lack.

Therefore the assessment of competence can only be used as the yardstick that will predict continuing competence and imply safety to practise.

In conclusion, the assessment of a nurse’s competence at any time during their career is a predictor that demonstrates their continuing competence, or not and therefore implies their safety to practise, or not. However, it cannot ensure the safety of the individual nurse to practise at any given time.

Author: Dr Rachael Vernon, head of EIT’s School of Nursing, was the first New Zealand nurse in 33 years to be awarded the Fulbright Senior Scholar Award for Research. Her research looked at the relationships between legislation, policy, public safety, and continuing competence requirements for nurses, nationally and internationally. *Details of the publications can be viewed in the online version at www.nursingreview.co.nz

Legislation to protect public safety, not nurses’ interests The nursing profession in New Zealand has been regulated for more than 100 years but the arrival of the Health Practitioners Competence Assurance (HPCA) Act 2003 introduced a significant change to the regulation of all health practitioners, including nurses.

Nurses and other health professions often misunderstand that the purpose of this legislation is protective. Therefore, the institutions, roles, and committees created by the legislation all exist to protect the public from the risk of harm, rather than to protect the interests of the professions they regulate.

A regulatory authority’s functions and powers are defined in the legislation and establish a type of regulatory regime known as a ‘protective jurisdiction’. This form of professional regulation provides: • A barrier to entry to the professions by untrained persons • A mechanism for standards of education and practice to be established and enforced including continuing competence; and • An avenue for consumers to have complaints against practitioners addressed.

The Nursing Council of New Zealand is the regulatory authority that administers the HPCA Act for nurses, and among other responsibilities, it establishes and maintains education and practice standards, including continuing competence.

Practice, People & Policy opinion

More features and opinion online The recently revamped Nursing Review website is bursting at the seams with webexclusive content, so if you’re reading the print edition, you’re only getting half the story.

Go to www.nursingreview.co.nz for the latest news and opinion.

Here is a selection of excerpts from the most recent articles published online:

Charlie’s story: measuring what makes a difference Free prescriptions and more time … primary health nurse practitioner ROSEMARY MINTO argues for what could most help patients like Charlie*.

I saw Charlie last week: a fifty-two-year-old Māori man with diabetes, stage two renal failure, and obesity.

Before meeting Charlie, I presumed he was there to get his prescriptions, which he hadn’t had for five months. However, that wasn’t at the top of his priority list. Charlie’s blood sugars are poorly controlled and have been for months, and his renal function is declining, neither of which Charlie can “feel”, so it doesn’t impact on his daily functioning. Higher on

Do we care about carers?

Charlie’s mind is the fact that he can’t maintain an erection and as yet hadn’t figured out how to bring this up in a consultation – he is too ‘whakama’ (shy).

Charlie often can’t afford to get all his prescriptions at once, so he makes a random choice as to which ones he takes, and besides, he doesn’t feel too much different off them. He is employed in a low paying job working six days a week and can’t afford to take days off sick or to visit the doctor/ nurse because he has dependants at home relying on the wage. He and his family have already been evicted twice from homes for not meeting rent this year, and as he says, who can budget something with nothing?

...

Violence and the healthcare setting Michael Geraghty, nurse practitioner in the Adult Emergency Department at Auckland City Hospital, calls for a zero tolerance policy against violence and verbal threats in our hospitals.

One of the joys of having teenagers who have left the roost (or imminently about to) is reclaiming the radio station of my choice in the car. I’m showing my age here, but to me, the National Programme is mostly interesting, at times educational, and occasionally plays good music. All in all, it’s good listening fodder whilst driving, and thanks to Jim Mora, I was alerted to a recently published

article discussing a topic dear to all healthcare professionals.

Having worked in the emergency department at Auckland City Hospital for the past 15 plus years, it never ceases to amaze me how supposedly average members of the public seem to think that normal social values and rules of communication have no place the minute they walk into the hospital. Behaviours that would never be tolerated in a queue at the bank, supermarket etc. seem to be considered ‘okay’ in the ED setting – despite being given very good service (most of the time)

The frustration and isolation of suddenly becoming a 24/7 carer for her husband in an “ad hoc” and “failing” health system prompted long-standing Wellington local politician HELENE RITCHIE to tell her story and call for a Royal Commission inquiry into carer issues.

I believe there are lessons to learn from my experience of being a 24/7 carer of my husband Peter during his last four years.

Caring for Peter – who had early onset (diagnosed aged 55) Parkinson’s with Lewy Body dementia – led me to write and publish our story* about the impact of complex chronic and degenerative disease and the frustrations of dealing with a failing and ad hoc health system. This story was written with the need for change and significant improvement constantly in my mind.

You, as nurses, can and do make a significant contribution to ‘caring’, and in future, you are likely to do more so as a scarce commodity in this most rewarding and challenging area of work

…

...

Male nurses – as Tom Jones said...”it’s not unusual” The army, the dole or nursing? NP Andy McLachlan reflects on falling into the career that turned him from a boy into a man.

And the need to attract more men and more Māori and Pacific into nursing.

“What do you do?” “I’m a nurse!”

“What?” “You know, a nurse!” (Slightly more forced).

“You’re a NURSE, a MALE nurse?”

There it is.

I think most nurses who are men (and yes, therefore a male nurse) will have had this conversation th rough their careers. The conversation can then go a number of ways …

Either….

• Wow that’s cool! Yes it is.

• Are you gay? No but I am sometimes kinda fabulous in my own wee way.

• Do they call you Matron? Only my fabulous male colleagues.

• Why did you pick nursing? Indeed.

Nursing kind of picked me. I grew up in Thatchers Scotland in the 80s when traditional industries were being wiped out and job opportunities dwindled to job creation schemes, you know the type of inspiring role where you dig a hole and then, well … fill it back in again. Johnny Rotten was screaming “NO FUTURE” in my ears and alcohol was cheap and available to kill the despair (and your dreams). At 19 years old, my options were the army (not a good choice for a pacifist and Smiths fan) or the dole, until an old teacher suggested I think about being a nurse. A male nurse, what the heck would I have to do?

…

Read the full articles at www.nursingreview.co.nz Nursing Review series 2014

19

A round-up of national and international nursing news

For the record

India once again NZ’s biggest migrant nurse source Nurses from India are again New Zealand’s biggest source of overseas qualified nurses, with migrant nurses from the United Kingdom at an all-time low.

A decade ago, New Zealand registered around 800 nurses a year from the UK and around 150 each from India and the Philippines.

The number of nurses registering from the UK steadily declined over the decade, then slumped markedly in 2009 with the impact of the recession and tighter registration criteria.

Registrations from the UK have now dropped to a new low of just 128 nurses.

Registrations from the Philippines and India at the same time have been steadily growing, with India for the first time overtaking the UK as New Zealand’s largest source of migrant nurses in 2009 and then the Philippines for the following three years.

Provisional figures from the Nursing Council show in the year to March 31 2014 India was again our top source of nurses registered with 509 nurses, followed by Philippines with 339, the UK 128, and Australia 84. On average, New Zealand is now registering 1200–1300 overseas nurses a year after peaking at about 1700 overseas

Sharp drop in Kiwi nurses crossing Tasman The number of Kiwi nurses seeking to cross the Tasman has dropped sharply by about a third and is at the lowest level for about a decade.

Preliminary data from the Nursing Council indicates that just over 1000 nurses sought verification to work in Australia in the 12 months leading up to 31 March 2014 compared with nearly 1500 the year before.

The number of nurses seeking to work in other countries like the USA and UK has also fallen, with the result that only 1280 nurses in total sought verification, down nearly 1000 from the peak of nearly 2300 in 2011-2012.

“Which I guess is good news,” says Nursing Council chief executive Carolyn Reed.

She also points out that while people seek verification to work overseas, it doesn’t mean all will actually leave.

“It doesn’t necessarily mean that we lose them to practice in New Zealand, because we are aware of some nurses who hold dual registration and who do temporary contracts in Australia.”

The decline in verification mirrors the overall fall-off in New Zealanders crossing the Tasman, with the net loss to Australia down to just over 11,000 people – well down on the previous year’s 34,000 net migration loss. The monthly net loss of migrants across the Tasman in April 2014 was also the lowest since such data started being collected in 1996.

Record new graduates registered A record 1788 new graduate RNs were registered in the year to March 2014, initial Nursing Council data indicates.

When combined with the nearly 120 new enrolled nurses, this brought the new New Zealand-trained nurses on

the register up to 1907.

“It’s massive, really,” said Reed.

It was also ahead of the projected growth recommended in the Nursing Council’s BERL nursing supply report, which said to maintain the same nurse-to-New Zealander ratio in 2035 the number of graduate nurses would need to grow from about 1500 in 2010 to 2,200 a year by 2035. (To meet the high needs scenario, it was suggested the number of new graduates would have to rise to nearly 3000 by 2035).

But the desired surge in new graduates to meet projected future demand has also come at a time when the ongoing impact of the recession means low nurse turnover – including delayed retirements and few nurses heading overseas – and very tight district health board budgets, “We’re in an interesting situation where everyone is predicting shortages but there aren’t a lot of jobs around for nurses (at present),” says Reed. (See www.nursingreview.co.nz.

Newsfeed stories for latest graduate job hunting numbers, which indicated that about 230, or 17 per cent, of November graduates were still job hunting six months later) But Reed says, looking at the council figures, the number of new graduates nursing in New Zealand appeared to be possibly above Australia’s graduate employment levels.

Australian trade unions recently called for a tightening of temporary work visas for nurses, with nearly 3100 brought in annually to fill nursing positions, which they estimated was about the same number of graduates turned away by public and private hospital employers.

registrations a decade ago.

Reed says the Council doesn’t really know what is behind the decline in UK enrolment and is unsure whether there has been less active recruiting in the UK by district health boards than in the past.

“From my perspective, what I see is a really strong commitment to grow our own graduates or employ our own graduates at least unless it is an advanced position where you need some overseas expertise.”

Go to www.nursingreview.co.nz to read further stories about Indian nurses in New Zealand.

NNO vision for 100% new grad employment by 2018 Boosting new graduate employment, improving workforce data, and developing the nurse practitioner role are amongst recommendations made in a National Nursing Organisations, report to Health Workforce New Zealand.

The 25-page report summarises data and initiatives developed by the ten-member organisations in the past three years and follows a critical open letter to HWNZ penned by three of the organisations in late 2012.

HWNZ responded last year, saying nursing would be a major focus, and in its June 2014 stakeholder bulletin, this was updated to say it was working with the NNO and Office of the Chief Nurse on a nursing workforce programme, with the four workstreams to be up-and-running by the end of July.

The organisations’ paper, released in May, says “piecemeal initiatives” addressing parts of the health system had not been integrated and its recommendations require “urgent consideration”.

NNO says its vision is for 100 per cent new graduate nurse employment by 2018 “at the least” and recommended nursing schools and employers working together to employ more new graduate nurses. Of particular note was the need to improve employment of new graduates in aged care and primary health and offer specific funding and solutions to develop Māori and Pacific new graduate employment.

It also says a more streamlined approach to NP development and employment had been agreed by the NNO group and a proposal for a demonstration of an alternative NP pathway was presented to the HWNZ board in March 2014.

HWNZ said in its stakeholder bulletin that other initiatives to be part of the nursing workforce programme included role development for nurses undertaking endoscopy and further development of the nurse practitioner role.

The full paper can be seen at: http://bit.ly/SVrh6Z.

PREVENAR 13 is Now thE fully fuNdEd PNEumococcAl VAcciNE foR childREN.¹ ®

PREVENAR 13 has replaced PCV10* on the National Immunisation Schedule.1 So now you can give children the broadest coverage of any pneumococcal conjugate vaccine.2-4

®

*PCV10 = Pneumococcal polysaccharide conjugate vaccine, 10 valent adsorbed.

References: 1. PHARMAC Notification Document, http://pharmac.health.nz/news/notification-2013-12-17-national-immunisation-schedule-changes/. 2. PREVENAR® Approved Data Sheet, 1 November 2010. 3. PREVENAR 13® Approved Data Sheet, 10 March 2014. 4. Synflorix Approved Data Sheet, 29 July 2013.

Before prescribing, please review Data Sheet available from Medsafe (www.medsafe.govt.nz) or Pfizer New Zealand Ltd (www.pfizer.co.nz) or call 0800 736 363. ®

PREVENAR 13 (30.8 µg of pneumococcal purified capsular polysaccharides) suspension for I.M. injection Indications: Active immunisation for the prevention of disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F in infants and children from 6 weeks up to 5 years of age and in adults aged 50 years and older. Contraindications: Hypersensitivity to any component of the vaccine, including diphtheria toxoid.

Allergic or anaphylactic reaction following prior administration of 7vPCV. Precautions: Do not administer intravenously, intravascularly, intradermally or subcutaneously. Avoid injecting into or near nerves or blood vessels. Do not inject into gluteal area. Postpone administration in acute, moderate or severe febrile illness. Only protects against Streptococcus pneumoniae serotypes included in the vaccine and may not protect all individuals from pneumococcal disease. Consider the risks of I.M injection in infants or children with thrombocytopenia or any coagulation disorder. Appropriate treatment and supervision must be readily available in case of a rare anaphylactic event. Prophylactic antipyretic medication is recommended for children receiving concomitant whole-cell pertussis vaccines, and for children with seizure disorders or history of febrile seizures. Consider the potential risk of apnoea when administering to very premature infants. Adverse Effects: Very common/common: Injection site reactions; fever, chills; decreased appetite; vomiting; diarrhoea; rash. Drowsiness; restless sleep; irritability in children. Fatigue; headache; new or aggravated joint or muscle pain in adults. Uncommon/Rare: Hypersensitivity reaction; anaphylactic/anaphylactoid reaction; angioedema; erythema multiforme. Seizures, hypotonic-hyporesponsive episode in children. Others, see full Data Sheet. Dose: 0.5 mL I.M. Infants 6 weeks to 6 months of age: 3 doses at least one month apart.

A single booster should be given in the second year, at least 2 months after the primary series. Previously unvaccinated children: Varies with age at first dose, see full Data Sheet.

Children aged 12 months to 5 years who have completed primary infant immunisation with Prevenar (7vPCV) may receive 1 dose, at least 8 weeks after the final dose of 7vPCV. Adults >50 years: 1 dose. If sequential administration of Prevenar 13 and 23vPPV is considered, Prevenar 13 should be given first. Medicines Classification: Prescription Medicine. V10812. ® Registered Trademark Pfizer New Zealand Ltd, PO Box 3998, Auckland, New Zealand 1140. DA 3414SW. BCG2-H PRE0248. P8839 06/2014

Bring your wound care patients out of hiding

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A dressing specially designed to have a positive impact on patient wellbeing by helping those with chronic wounds regain their freedom.

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