FOCUS: Wound Care | Infection Control | Child & Youth Health
Nursing Review October/November 2014/$10.95
New Zealand’s independent nursing Series
WOUND CARE
EVIDENCE-BASED PRACTICE:
• Ouch! Crushed fingers • Burns: spills, flares & flames
Vitamins & tubefeeding
A DAY IN THE LIFE OF
Practice, people & policy
a school nurse
Survey: what do you do? Opinions: Deep-fried pizza to Whānau Ora
INFECTION CONTROL • Nursing Ebola in Sierra Leone • Ebola: What PPE needed?
Q&A
ANNE BREBNER
CHILD & YOUTH HEALTH
• One stop shop funding • Playing for the kids’ team www.nursingreview.co.nz
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Letter from the Editor Making a difference As Nursing Review goes to press, the day when the West African Ebola outbreak is contained and controlled still looks some distance away. Kiwi Red Cross nurses Donna Collins and Sharon Mackie returned in October from their stint of Ebola nursing in Sierra Leone – safe, sane, and good mates. But as Donna describes in an article this edition, “it was one hell of a mission to cut your teeth on”. Still, she would “absolutely” return to support local healthcare workers turning up day after day against all odds to fight a virus that has taken their neighbours and workmates. This edition was to feature a light-hearted ‘Day in the Life’ of an outback nurse on race day. Kiwi Andrew Cameron is nursing director in Birdsville, which hosts an infamous outback race meeting each year. But instead of recovering from having the settlement’s population swell from 172 to 7000 racegoers, Cameron took up a Red Cross invitation to head to Sierra Leone. Joining him will be Wellington ED nurse Liz McDonald who, like Donna and Sharon, is on her first Red Cross mission. Cameron has already been awarded Red Cross’s highest nursing award, the Nightingale Medal, for his work in war-torn Sudan to Afghanistan and Iraq to Yemen. But this time, he won’t be dodging bullets but a virus. As this time, the aftermath of war is not mine amputees or the bomb-injured but a rundown health infrastructure being hit by a devastating and “disgusting” viral haemorrhagic disease with no vaccine or proven cure in sight. While the first world debates how we could or should help this third world tragedy, we can only be deeply grateful for volunteer nurses like Donna, Sharon, Andrew, Liz, and the many others. Fiona Cassie editor@nursingreview.co.nz
www.nursingreview.co.nz
Inside: Focus: Wound Care | Infection Control | Child & Youth Health
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Ebola: “One hell of a mission to cut your teeth on”
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Ebola: how prepared is New Zealand?
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Youth services making a difference on a shoestring
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Helping children survive and thrive
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Ouch! Crushed fingers and purply-black nails
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Burns, spills, flares, and flames
RRR professional development activity (SUBSCRIBERS’ EDITION ONLY) To subscribe go to www.nursingreview.co.nz/subscribe
Practice, People & Policy 18
Nursing mourns loss of first Māori NP
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Global approach to advanced practice nursing
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Online opinions: lifestyle advice, whānau ora, drinking culture
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Nurses wanted: what do you do to earn your pay?
Twitter@NursingReviewNZ
Regulars
Wider distribution for Nursing Review
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Q & A Profile: mental health nurse president ANNE BREBNER
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A day in the life of … school nurse HEATHER LAXON
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College of Nurses column: MARGARETH BROODKORN on hand washing
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Evidence-based Practice: vitamins and tube feeding
Some nurses have told us they are not receiving copies of Nursing Review, so we’ve done something about it. From this issue onwards, free copies of Nursing Review will be sent directly to every ward at every major hospital. If this is your first time reading Nursing Review, contact editor Fiona Cassie and tell her what you think (especially if you have news or ideas to share!). These free copies will have all the features and opinion Nursing Review is known for, but only subscribers will receive print and online access to the RRR professional development activity. To get your personal copy (including RRR), go to www.nursingreview.co.nz/subscribe
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: Rebecca Zonneveld is a youth health nurse practitioner at Evolve, central Wellington’s Youth One Stop Shop (YOSS). Read more about YOSS in our feature on p.8. PHOTO CREDIT: Glenn McLelland, www.aerialvision.co.nz Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
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 5 2014
APN Educational Media Level 1, Saatchi & Saatchi Building 101-103 Courtenay Place Wellington 6011 New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 Fax: 04 471 1080 © 2014. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014
Errors and omissions: Whilst the publishers have attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publishers for any errors or omissions.
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Q&A
Anne Brebner
JOB TITLE | President, Te Ao Māramatanga, New Zealand College of Mental Health Nurses Inc.
Q A
all areas, and more Māori nurses would improve engagement andsupport for those needing support and their whānau. 3. That remuneration be fairer and more equitable with our medical colleagues.
Where and when did you train? I trained at Kingseat Hospital, South Auckland as a very naïve and uncertain 17-year-old. I immediately loved the big spacious grounds and the opportunity to play sports every day as part of the physical health programme. We played mixed staff and service user teams and had a lot of laughs. I completed my hospital-based training in 1983, and like many others, I went on to do undergraduate and postgraduate education.
Q
What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt? I believe good leadership is both. An ability to put yourself in someone else’s shoes, and to try to see the story from their side, helps enormously when in leadership roles. A strong sense of humour, highly developed professional integrity, and having great colleagues all make great people successful leaders.
A
Q A
Other qualifications/ professional roles? Following on from postgraduate education, I moved into nurse specialist roles in child and adolescent mental health. I moved into primary mental health and leadership roles. I was an active participant in the ANZCMHN (as our college was known then) and remained an active board member until taking on the role of president this year.
Q A
When and/or why did you decide to become a nurse? I have a photo of me playing dress ups in a white dress, a cardboard nurses’ cap and ‘dolls’ who were in beds like patients; I must have been eight or nine at the time. Despite this, it wasn’t a lifelong dream– more of a practical way to earn money and receive a qualification – but I soon realised this kind of nursing suited me perfectly.
Q A
What was your nursing career up to your current job? My nursing has all been in mental health, and mostly in child and youth or leadership roles. All in the Auckland metro area, apart from my current employment in a national role. I started my career ladder with nurse specialist roles and then became charge nurse at the Starship child and family unit. I then became first the primary mental health
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Q A coordinator and then my current national position of Nurse Lead for Te Pou o Te Whakaaro Nui (the national mental health workforce development agency). Being recently elected president for Te Ao Māramatanga (New Zealand College of Mental Health Nurses) has been a real privilege and challenge.
Q A
So what is your current job all about? The president role is voluntary; it involves leading and supporting a highly influential board to govern the New Zealand College of Mental Health Nurses, which has a strapline of ‘Partnership, Voice, and Excellence in Mental Health Nursing‘.
Q
What do you love most about your current nursing leadership role? Hearing about innovation in practice and seeing
A
examples of contemporary care that exemplifies professional care. I enjoy being privy to hearing about so many stories of nurses demonstrating excellence in their practice.
Q A
What do you love least? The reverse of the above – becoming involved if there are practice-based challenges for individuals and how that impacts on the profession.
Q
If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? 1. All nurses could be employed in the areas that they would like. 2. That we could recruit and retain more Māori nurses, especially in mental health and addiction. Māori tangata whaiora (clients) are over-represented in
A
What do you do to try and keep fit, healthy, happy and balanced? Besides my family, who keep me grounded and real, I have an adorable border collie called Coco who is so grateful for a walk that it keeps me outdoors and active. I love the fresh air and the sound of native birds; our small lifestyle property keeps this accessible for me.
Q A
What is your favourite way to spend a Sunday? Brunch at home, with the Sunday paper, followed by a beach walk including Coco.
Q
While waiting in the supermarket checkout queue, which magazine are you most likely to pick up to browse and why? The Listener: great selection of reading and crossword.
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Q A
What are three of your favourite movies of all time? Juno, The Lion King and Out of Africa.
A day in the life of a ... School Nurse
NAME | Heather Laxon JOB TITLE | School Nurse (funded by Ministry of Health) LOCATION | Mangere College
6.30
AM WAKE Woken by the alarm, I head straight to the shower to wake up properly while my husband empties the dishwasher. I wake the three kids at 7am (usually involves more than one attempt) then have a quick breakfast. I make sure the kids have everything they need for school, then I head out the door at 7.30am, leaving my husband to deal with the chaos of getting the kids out the door.
7.45
AM start work I have been a school nurse for six years; I enjoy working in an autonomous role and am energised by the young people I work with. The role is a great fit for the skills I gained from my emergency department and public health background. I work as part of a multi-disciplinary team made up of a social worker, counsellor, two nurses, and a receptionist in the Student Services Centre (SSC). It is quiet at this time of day, so I restock the clinic.
8.00
AM BREAKFAST CLUB Today the student health council runs a club providing free breakfasts for students. I have a quick chat with the two students on duty and make sure that they have everything they need.
8.30
AM STAFF BRIEFING The SSC team head to the staffroom for morning briefing. It is a good chance to catch up about students that staff have concerns about and hear what is happening around school. Back to SSC, and we decide that today my nurse colleague Fiona is going to do the comprehensive HEEADSS (home, education, eating, activities, drugs & alcohol, suicide & depression, sexuality, and safety) assessments that we carry out for all Year 9 students. I’m running the walk-in clinic.
1.30
9.00
2.20
AM STUDENT WALK-IN CLINIC Over the next few hours, I see 14 students who self-present. There are the usual headaches and stomach aches. Often, students present with one thing, but there are other issues that also need attention. It is nearly the end of the rugby season, so a few rugby players present with injuries – some I refer on to the onsite physio who comes in weekly.
11.30
AM TEA & TEAM CONSULT Time for a quick cup of tea, then I catch up with the rest of the team. I meet with the social worker and counsellor to consult about a student we have all been involved with. She has arrived at school today refusing to go home this evening. The young person has previously been under CYF (Child, Youth and Family) care, and she now discloses abuse at the place she is currently staying. We talk with her about a course of action and agree for our social worker to go ahead with another notification.
12.00
AM CLINIC: CUTTING The next student I see requests a bandage for her arm. I ask her what is wrong, and after a slight hesitation, she rolls up her sleeve. She has about 30 superficial cut marks up her arm; I ask her if she has been cutting, at which she starts crying. As I tend to her cuts we talk. It is the first time she has cut herself; there have been problems at home and also with friends and it has all got too much. I have a quick word with the counsellor, who sees the girl. After talking with the counsellor, the girl emerges smiling. I am often astounded by the resiliency of young people in the face of huge adversity.
PM Emergency call Emergency call-out to rugby field Five minutes before lunch, I get a call-out, so I grab my emergency bag and phone and head to the rugby field. A student has taken a knee to the back of his neck during a rugby game and is complaining of a lot of pain. The PE teacher has not moved him, and he is lying on his back where he fell. I carry out an assessment; he is very tender over his cervical spine but has no neurological symptoms. I make a 111 call for an ambulance as he is going to need further assessment*. PM Ambulance departs I grab a quick bite of lunch. I catch up with our whānau support worker, who runs the afternoon sore throat clinic as part of the rheumatic heart disease prevention programme. There is one student with a positive GAS throat swab. I call the student in to explain the result and then try – successfully – to phone the parent. I give the parent information about the need for treatment, check allergy status and medical history, and then obtain verbal consent to give the student antibiotics (under standing orders). I then go over instructions with the student and give her the antibiotics to take home.
3.20
PM SCHOOL BELL It has been a busy but not untypical day – I love that each day is unpredictable and never boring. Fiona pops in to say goodbye, and I catch up on some notes and check that the list is ready for tomorrow’s visiting GP clinic.
4.00
PM LEAVE WORK I arrive home just in time to pick up the kids and head to their tennis coaching. While waiting for them, I go for a much-needed walk up Mt Eden and clear my head. Back home, I make dinner and find out what has happened in the kids’ day. My husband walks in at 6.30pm just in time for dinner. Then it’s time to clear up, fold washing, make lunches, and tonight, I manage a bit of time to relax reading a book.
10.30
PM TIME TO SLEEP
* The boy was discharged later that day after having an X-ray of his cervical-spine, which showed no bone injury.
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FOCUS n Infection Control
Infection Control The devastating Ebola outbreak in West Africa is infection prevention and control (IPC) nursing at its life and death extreme. We report on Donna Collins’s experience in Sierra Leone and on how nurses back here should brush up on their IPC and PPE for whatever may walk through the door. Donna with the red ‘vomit’ buckets for Ebola patients containing basic hygiene packs and sarong and ID bracelet.
Nurses and patients at the triage tent outside Kenema Hospital.
“One hell of a mission to cut your teeth on.”
Returning Red Cross nurse Donna Collins says the true heroes of fighting Ebola are the national nurses who have lost colleagues, faced eviction by landlords, and have been ostracised by their villages, yet they keep turning up for work each day. Back safely from Sierra Leone, Donna talks to FIONA CASSSIE about the testing, sometimes fearful, but ultimately very satisfying mission to help the Ebolastricken nation. 4
Nursing Review series 2014
“I
nitially, I was scared witless,” says Red Cross nurse Donna Collins when asked about caring for her first Ebola patient in Sierra Leone. “I looked at this gentleman, and I thought ‘oh my God, you have the ability to kill me if either of us do the wrong thing or if I didn’t have this PPE (personal protection equipment) on’. “It was one of those life moments when you stop and think ‘far out – this is serious’ and then I thought ‘put your big girl pants on, girl, and get on with it’. So that’s what I did. “… that poor man was dying of Ebola, so he had more problems than I did.” It wasn’t the only time that Donna told herself to “put her big girl pants on” or drew on her sense of compassion, strong practical streak, and Kiwi down-to-earthness to get her through her first-ever Red Cross assignment. “It was one hell of a mission to cut your teeth on,” she acknowledges. Rather than being intimidated, the Whangarei nurse and her fellow first-timer, Wellington nurse Sharon Mackie, requested for their initial three-week assignment in Sierra Leone to be extended. The pair ended up staying for nearly four and a half weeks, as they weren’t prepared to leave before the Ebola treatment centre (built from scratch by their international Red Cross team) was open and caring for its first Ebola patients.
After overcoming her initial fear, Donna says she thrived. Luckily her family (she has four children aged 16 to 22) are accustomed to mum and dad’s work (her husband is also a nurse) taking them to exotic places. For example, the family lived in an aboriginal community in outback Australia for five years. “So they take most things in their stride.” “My youngest one said, ‘I don’t want you to die, Mum’, and I said, ‘don’t worry, babe, that’s not on my agenda, either’. “My foster daughter said to me, ‘I don’t want anything to happen to you as you are the best mother I’ve ever had’. That really struck me in the heart.” The 17-year-old focused on the positives and was ‘stoked’ she could use mum’s car while she was in Africa. Donna and Sharon returned home safely to family and friends in New Zealand at the start of October – after a three-week quarantine period in Morocco – and a week later, they were back in their day jobs. One of Donna’s three ‘day jobs’ is as a midwife at Whangarei Hospital’s maternity unit, and she found it very tough going from bringing new lives into the world to facing constant death in an Ebola unit. This was compounded by the fact that pregnant woman are very vulnerable to Ebola and no pregnant woman, or her baby, has been known to survive the virus.
“Which is just devastating. I found that very difficult as a midwife.”
Claustrophobic PPE in cloying heat
The pair initially arrived in Freetown, Sierra Leone’s capital, in mid-August, and after initial orientation and training, they headed west to the 60bed Medicine Sans Frontières (MSF) hospital in Kailahun, near the border with neighbouring Guinea, for three days of hands-on, literally life-saving training in how to don and doff the personal protection equipment (PPE) required to safely care for Ebola patients. (See online-only story, Ebola nursing: how to safely get out of PPE at www.nursingreview.co.nz.) After donning for the first time the multiple layers of PPE – including double gloves, ‘duck bill’ mask, all-in-one suit, hood, and apron all tied tightly around the head and neck area, with ski goggles on top – Donna says she initially felt claustrophobic but got over it quickly as she had a job to do Worse was the heat. Temperatures were constantly in the 30s and humidity was high. She says her colleague Sharon Mackie’s description of wearing PPE in Sierra Leone as like wearing a personal sauna “was a great analogy”. Her first patient contact was having to certify a nine-year-old boy’s death. He’d died in the night. “Then I was taken by an obstetrician (who heard I was a Continued on page 6 >>
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FOCUS n Infection Control Donna Collins in her full “claustophobic, personal sauna” PPE gear in Sierra Leone.
<< Continued from page 4 midwife) to see a 22-weeks-pregnant woman who didn’t look well … she was vomiting blood. Four hours later, she was dead. “Ebola is a disgusting death – it’s a haemorrhagic disease, so there is a lot of body fluids. “…people are vomiting, they have got raging diarrhoea, they are bleeding, pregnant women are miscarrying – any body fluid you can think of, it’s there, it’s happening.” She says nurses don’t end a session covered in blood. If she did get blood on her apron, she would wash it off straightaway under one of the chlorine taps in the unit. Because of the heat, the nurses and hygienists can only spend up to one hour at a time working in full PPE, “so you get down to it and do your work; you are giving medications, checking ID bands, washing the patients, or changing them”. She always worked with a buddy nurse for support and safety. “A high percentage of Ebola patients experience confusion. One of our first patients in the treatment centre was throwing rocks, so we were Intro ??????? dodging rocks as well.” Donna says the time it took to don the PPE and to methodically take it off under careful supervision (ensuring skin did not come in contact with PPE contaminated by the deadly virus) meant most people could only squeeze three one-hour nursing sessions into a shift.
Triage tents and the ‘happy shower’
The base for their Red Cross team’s assignment was Kenema, the third biggest city in Sierra Leone, with an estimated population of around 190,000. There, they supported the government hospital that had early on been overwhelmed by Ebola, with the loss of nearly 30 staff to the viral haemorrhagic disease. The team was made up of 28 Red Cross personnel from across the globe, including Spanish architects, engineers, and builders, to doctors and nurses from Finland to Colombia. The team’s mission was to set up a two-stage triage tent outside the city hospital, and at the same time, build, equip, and staff from scratch the Red Cross’s first ever Ebola treatment centre – a 60-bed unit being built on a cleared piece of jungle about 18km outside the city. Back in the city, the triage tent was used to screen for Ebola in the up to 100 patients arriving each day at the hospital grounds, and so leaving hospital staff to concentrate on providing essential non-Ebola health services, which had largely gone “by the by” for the sizable city during the peak of the outbreak. 6
Nursing Review series 2014
Staff in the triage tent wore scrubs, gloves, and gumboots and were separated from their patients by a 1.5m fenced-off gap (see photo) over which the hospital nurses would hand the patient a digital thermometer. After recording the temperature, the nurse would verbally assess for Ebola, and if they had no fever (defined as 38 degrees or above) and no symptoms, they were allowed to continue on into their hospital for their outpatient or maternity appointment. But if they had a fever or other symptoms, they went on to triage 2, where an epidemiologist would take a more stringent history and they would have a blood test, which could confirm within about six hours whether they had Ebola or not. While the patients waited for results, they were further triaged into either ‘suspect’ or ‘probable’, depending on the severity of their symptoms. If a blood test was positive, they were moved into ‘confirmed’ – which Donna is quick to point out did not mean an inevitable death sentence, as at least 30 per cent of people survived. “People who had gone into ‘confirmed’ sick walked out alive after a week or two. We still don’t know why some people survive and some people don’t. We just know that people with a low viral level initially … if we fed them up well, gave them antibiotics, and wormed them, they survived and walked out happy people.” “We used to have a shower at the end that was called the happy shower, which was for people who were leaving from ‘confirmed’. Their clothes would be burnt and we would hand them a new pack of clothes, their money (disinfected in chlorine), and they would leave, but usually with a social worker to escort them back to their village and reintroduce them after the stigma of having Ebola.”
Humble and dedicated
Donna says they worked 12–14 hour days as they not only did a morning or afternoon shift at the hospital triage tents, but they were also ‘jacks-of-all-trades’ on setting up the new treatment centre, with jobs from interviewing new graduate nurses eager for work, to taking the ‘wheel barrows’ of cash needed in inflationhit Sierra Leone to buy centre supplies. They also had to train the new staff in PPE and infection control and be team leaders as the novice staff worked in the newly opened treatment centre. “It was a big responsibility, but I loved it. I thrived on it.” Donna also developed huge affection and respect for the Sierra
Leone nurses and hygienists she worked with. “These are the true heroes of this whole Ebola response,” she adds. “People keep saying ‘oh you are amazing going’ but it just embarrasses me as the true heroes were the national staff because they are ostracised within their own community for working with Ebola patients. “Some of the nurses were evicted by their landlords, who said they didn’t want Ebola in their house. They also had to deal with a lot of myths and ignorance about Ebola. “Most, if they had not lost family members, they had lost extended family members or neighbours and workmates … they had initially been losing huge numbers of nurses. “They were brave, brave nurses that kept coming to work every day. “The most humbling thing for me was that they often thanked us for coming to help. My team of workers – that I’m just absolutely in love with – often said to me ‘thank you, thank you for coming and leaving your family to help our family’. At the end of the day, that’s all you need.”
Mates in the worst circumstances
Donna saw death and dying in Sierra Leone on a scale she had never seen before. “It’s a terrible way to die – it’s actually the fastest death I have ever seen.” The medical team meetings each night were a chance to debrief with people who could understand. “You would never do it at the whole team meeting because the builders would have looked horrified if we said what we’d seen.” The medical team of nurses and doctors were “astounding”, and Donna had the added good fortune to have the “fabulous Sharon Mackie” to “sound off at”. “We’ll be lifelong mates.” Would she go back to West Africa to help the fight against Ebola? “Absolutely, I would!” is the instant reply. An abridged version of this article went online at www.nursingreview.co.nz on October 10. Also online is full description of the “life and death” method of getting safely out of Ebola PPE (Donna, right, pictured in last stages).
FOCUS n Infection Control
Ebola: how prepared is New Zealand? As Nursing Review went to press, three nurses in Western hospitals had acquired Ebola after caring for patients originally infected in West Africa. Though the chance of an Ebola victim arriving in New Zealand still remains very slim, both the Ministry of Health and the Infection Control Nurses’ College believe the devastating West African epidemic is a good wake-up call to be ready for what could walk through the door someday.
T
he first Ebola victim walking into a US hospital recently brought one step closer to home the possibility it might happen here. Thomas Duncan, a recent arrival from Robyn Boyne Liberia, was initially sent away from a Dallas hospital by a physician with just antibiotics for a fever, despite a triage nurse recording he had recently been in Africa. Infection control nurse leader Robyn Boyne says that situation just Intro ??????? “beggars belief”. Boyne, the chair of the Infection Prevention and Control Nurses College, NZNO, hopes ew Zealand never has to prove that its triage system is better. Duncan has since died and two nurses caring for him at Texas Health Presbyterian Hospital (see web link in sidebar) have contracted Ebola, as well as a Spanish nurse caring for an Ebola victim who had been airlifted to Madrid. America's largest nursing union, National Nurses United, has reported anonymous Texas Health Presbyterian RNs’ concerns that their hospital was not prepared for Ebola, with staff not trained in or aware of protocols and what PPE should be worn. Dallas has shown a health system’s IPC protocols are only as good as the training and equipment provided and a hospital's management and staff's readiness and ability to carry them out. The Ministry of Health’s director of public health Dr Darren Hunt says district health boards and public health managers have been receiving regular updates on the viral haemorrhagic fever outbreak and requested to ensure that their response plans are up to date, including ill traveller protocols and border emergency response plans. A suspected or confirmed case would be transferred to a tertiary hospital, with the four preferred
facilities being Auckland, Middlemore, Wellington, or Christchurch, and the patient to be placed in an airborne infection isolation (negative pressure room). The Ministry says hospitals and nurses are experienced at dealing with a variety of infectious diseases transmitted through direct and indirect contact with blood, secretions, organs, and body fluids, and Ebola is less easily transmitted than many other viruses. But the seriousness of the illness and the high mortality rate of Ebola has prompted the Ministry to provide, and continually update, information and guidance to health professionals – including extra personal protection equipment (PPE) requirements – and to establish a technical advisory group to provide advice as needed on managing a suspected Ebola case.
Supervised donning and doffing of PPE
The 16 October update of the Ministry's Ebola advice to health professionals –in the wake of the Spanish and Texas cases – stresses that the donning and removing of PPE should be supervised by a staff member “competent in PPE management to reduce the risk of accidental skin exposure or self-contamination”. It also stresses that staff should be regularly trained in procedures around how put on and take off PPE, along with clear instructions on how PPE should be used and disposed of. Hunt says practice and being comfortable with PPE cannot be overemphasised. A retrospective Canadian study of how health care workers became infected in the 2003 SARS outbreak in Toronto – after special infection control procedures were introduced –highlights the importance of training to ensure protocols are followed (see http://bit.ly/1qEAzPf). That study, as in the Texas case, indicates that extra vigilance is needed in high-risk, aerosol-generating procedures like suctioning airway secretions or intubation. The Ministry advice emphasises that the basic key to minimising any healthcare infections
remains, as always, good hand hygiene and strictly carrying out the 5 moments of hand hygiene. Boyne said IPC clinical nurse specialists like herself were using Ebola as a “wake-up call” for nurses and other health professionals to take getting accurate travel histories seriously, to brush up on their standard and droplet transmission precautions, and PPE use and to emphasise once again the importance of hand hygiene. “Because if it’s not Ebola it could be something else – like the Middle Eastern Respiratory Syndrome (MERS) virus – and that’s the message we are trying to get out – that all staff should be prepared at all times for anything unexpected that could come through the door.” The ministry is advising people to wear semiimpervious splash-resistant disposable isolation gowns or all-in-one disposable coveralls when caring for a suspected or confirmed case of Ebola. Boyne says some DHBs don’t have all-in-one suits and they are not routinely used. The suits are more complicated to remove than the gowns that most staff are used to so they would next extra training to do this safely. “So you’ve got to look at your risk: it might be better to use something that staff are familiar with, and are going to use correctly, until they can be safely trained in the use of the all-in-one suits.” She says the Texas cases show that, while health care workers try to do the right thing, it can take just a small lapse in procedure to contract this disease, particularly when removing PPE. *We need to always be aware of where our potentially contaminated hands are, and never to touch our bare skin, especially on the face, whilst removing PPE.”
NZ-recommended PPE gear for suspected or confirmed Ebola victim
More useful websites
Gloves: Double gloving if risk of heavy contamination. Disposable gowns: fluid-resistant long-sleeve isolation gown or an all-in-one coverall. Disposable white plastic apron: If risk of significant exposure to blood or bodily fluids. Face, mouth and eye protection: Wear a surgical mask plus full facial shield and goggles to protect the eyes. Respirator mask: If involved in aerosol generating or splash procedures, wear a N95 or P2 respirator mask and do ‘fit checking’ of mask. Shoe and hair covers: Wear disposable shoe and hair covers. More info at: Ministry of Health: www.health.govt.nz/ebola or http://bit.ly/11xvRND
Infection Prevention and Control Nurses College, NZNO: www.infectioncontrol.co.nz World Health Organisation (WHO): hwww.who.int/csr/don/en Centres for Disease Control & Prevention (CDC): www.cdc.gov/vhf/ebola/ The Texas Health Presbyterian Hospital, Dallas: www.texashealth.org/ebola-virus US nursing union National Nurses United: www.nationalnursesunited.org
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FOCUS n Child & Youth Health
Child & Youth Health Nursing Review goes one-stop shopping for youth health services and also takes a look at nursing’s role with the Children’s Team initiative for supporting vulnerable children.
Vibe Youth Workers and young people from the Hutt Valley celebrating the Vibe ‘peer soup’ – peer support training.
Intro ???????
Youth services
making a difference on a shoestring Young people walking through the door of Youth One Stop Shops around the country are offered a holistic, wraparound service that many nurses aspire to. FIONA CASSIE learns that it comes at the cost of a continuous funding struggle to keep the – often nurse-led – youth health services running.
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here is a nice circular ending to young mum Ella's* story. As an 18-year-old, she had her positive pregnancy test with a nurse at Kapiti Youth Support (KYS), and after counselling, decided to continue her pregnancy. Ella was then supported by KYS antenatally, brought her baby to its massage classes, connected with KYS's young parent group and its vegie garden project, and went on to offer childcare for other groups that gather at the Youth One Stop Shop (YOSS). Now a mother of a happy toddler, the young woman – with a complex family history of her own – came back to KYS the other day seeking advice and help on how to apply for nursing school. Not a bad outcome for a teenager who may have ended up as the wrong kind of statistic. “That's just through us having continual contact,” says nurse and KYS general manager Raechel Osborne. “With the YOSS model, people can dip in and dip out as they need to. It's having that consistent relationship, which is important in young people's lives. She knew the door was always open.”
Cap in hand
Consistency and continuity of care is the aim of YOSS, but many of the centres live year-on-year, 8
Nursing Review series 2014
cap in hand, unsure which of the multiple contracts and grants they juggle to survive will be renewed, capped, or stopped. YOSS run on the tightest of budgets and appears sometimes to only keep the juggling balls in the air through the sheer enthusiasm and sincere belief in the cause by the dedicated nurses, GPs, youth workers, peer support staff, social workers, counsellors, and clinical psychologists providing the services. Sometimes dedication is not enough. Waves in Taranaki had to close the doors on their health service in 2012 when district health board (DHB) funding was pulled and Christchurch's 198 Youth Health Centre had to temporarily close its doors in 2010, also through lack of DHB funding, but resurfaced in 2012 in post-quake Christchurch as 298 Youth Health Centre. Invercargill's Number 10 also faced a funding crisis in 2010, which was not long after it first opened its door. The problem is not new. A major 2009 evaluation of the then-12 identified YOSS around the country found that “in general, funding for YOSS is tenuous”. The report, carried out by consultants Communio for the Ministry of Health, went on to say the lack of a national funding model led to “inequalities in youth access to services” across the country, the current funding
FOCUS n Child & Youth Health
Maria Kekus
Sue Bagshaw
models were “complex and fragmented”, and short-term funding cycles led to “reduced certainty, sustainability, and a lack of ability to proactively plan services”. The issue of YOSS sustainability was raised again as part of the Prime Minister's Youth Mental Health Project, and as a result, the Ministry of Social Development (MSD), working with the YOSS network, carried out a review of the ongoing financial needs of YOSS and looked at how to improve their sustainability. An interim response in 2013 was a one-off $50,000 grant to each YOSS by the Ministry of Youth Development to support youth mental health services and help the more vulnerable YOSS. This year's Budget saw nearly $1.2 million (stepping up to $2.35 million a year in 2015–16) allocated through Vote Health to the ten YOSS that meet the MSD criteria of a YOSS (see below) and distributed Intro ??????? according to the size and scale of each of the centres’ services. Trissel Eriksen, who coordinates the national Network of Youth One Stop Shops (NYOSS), worked closely with MSD on the YOSS funding review, with the aim of centres not having to make media headlines and be on the brink of closing before they garner public and funding attention. Eriksen, a social worker who has been a pillar of Palmerston North's YOSS centre (simply called YOSS) for 18 years and is also its director, says the 10 YOSS centres are all extremely grateful for the extra MSD funding for social service support to young people. However, ongoing sustainability issues remain an issue, as there was far from funding equity for YOSS across the country. “We're all funded as individual centres, and at the moment, half of us look really healthy and the other half look a little bit unwell.” No stranger to unhealthy funding levels is Dr Sue Bagshaw, founder of Christchurch's 198 (now 298) Youth Health Centre, who is now into her third decade of battling for YOSS funding. “You just can't get used to it. It's about getting the system to work for you rather than against you. That's the skill … and it takes a lot of work for sure.” The funding security of YOSS currently depends largely on the support – or lack of it – by the local district health board (DHB) and primary health organisations (PHOs). The 2009 evaluation found that all of the then YOSS were either charitable trusts, incorporated societies, or both. All received some funds from their local DHB and 10 of the 12 from a PHO. All in all, health funding made up 70 per cent of their collective $6.8 million funding in the 2008–2009 year (annual YOSS budgets ranged from $200,000 to $1.35 million). YOSS’s wraparound service means many YOSS have a range of social service, training, and MSD contracts, including some having contracts with Work and Income to work with NEAT (not in education and training) young people.
Gill Alcorn
Rebecca Zonneveld
But health remains the major funding component for most, and while all DHBs are entrusted to provide youth health in their regions, it is up to each board to decide what youth health services they will fund. The largest of the YOSS – Hutt Valley’s Vibe with 32 full-time equivalent (FTE) staff and 6,000 young people on its books – has had a very supportive DHB with a past Hutt Valley DHB chair also a past chair of the Vibe’s trust. With strong DHB backing, the YOSS delivers youth health and social services in its two bases and across 10 other sites, including five secondary schools, marae, and a teen parent unit. Likewise, Palmerston North's YOSS, which employs 16 FTE staff across two sites, has close links with MidCentral DHB and the Central PHO. This includes a special contract with the DHB to transfer the triage 4 and 5 level young people from the local emergency department to the YOSS. Eriksen describes the Palmerston North centre as one of the lucky healthy ones with a supportive DHB and PHO leading to healthy funding levels.
Why should we have YOSS?
Other centres struggle and some – like Waves – fail. Is that such a terrible thing? Many communities with YOSS also now have school nurse services or polytechnic and university health centres for those in tertiary education; low-cost medical centres for the unemployed and low-waged; and family planning centres for contraception and sexual health. Do we also need YOSS on top? Rebecca Zonneveld, a youth nurse practitioner, left low-cost Newtown Union Health Centre a decade ago to become the first nurse for Evolve, the YOSS serving Central Wellington. She says there is no such thing as an average YOSS client and the one-stop shops fill a much-needed niche for a wide range of young people – not just those who prefer the convenience, atmosphere, and anonymity of a free central city health centre for youth but also those who would otherwise not see anybody at all.
“There’s definitely a group of young people who come here who wouldn’t access their family doctors.” Given this reluctance, their depression, addictions, or STIs would go untreated. YOSS are good at building relationships with some of those more vulnerable, harder-to-reach, low health literacy, young people, Zonneveld says. Confidentiality is also a major drawcard for many attending YOSS who worry about going to the family doctor and seeing someone they know and having to explain why they are there. Young people being too embarrassed to attend Family Planning was one of the motivations for Dr Sue Bagshaw setting up Christchurch's original YOSS, 198 Youth Health. She had been offering a youth clinic at Family Planning in the early 1990s “but the kids still didn't come and when we asked them why, they said it was too embarrassing”. She formed a trust in 1991, opened the doors in 1995 with two years funding that she eked out to three, and has been a YOSS advocate ever since. Another pioneer, Raechel Osborne, who has been involved in KYS as a trustee since its founding in 1997, came to YOSS – like many nurses in youth health – from a public health nursing background. She says while YOSS all evolved differently, at their heart, all centres have people passionate about working with and helping youth. Young people are the reason YOSS exist, and they are trustees and drivers of YOSS’s interdisciplinary services. “YOSS is an amazing model because it holds the young person central to what it does.” Having a one-stop-shop for health to employment issues means a young person doesn't have to retell their story again and again, they are not siloed, and they are not referred out of a YOSS into secondary services without someone tracking their progress. “It’s about making sure that our service fits around the young people rather than the young person having to fit into our service.” It appears YOSS are good at what they do. KYS's own expertise in offering innovative youth health services was recognised in the 2013 Capital & Coast District Health Board Quality Improvement and Innovation Awards, with KYS taking out both the Team of the Year award and the Supreme Award across the DHB. Other YOSS websites also list awards that their services, nurses, doctors, and other workers have won. Maria Kekus, the past – and founding – chair of the Society of Youth Health Professionals Aotearoa
OTHER MODELS OF YOUTH HEALTH SERVICES SCHOOL-BASED HEALTH SERVICES (SBHS)
The Ministry of Health has been funding nurses to offer School-Based Health Services in decile 1 and 2 secondary schools since 2009. This was extended under the Prime Minister's Youth Mental Health Project to all decile 3 secondary schools, which meant by July this year, a further 44 schools and 19,000 students were to be covered by the service, bringing it to a total of around 55,000 students. Many secondary schools also directly employ their own nurses, some YOSS are funded to provide school nursing services, and DHBs also offer public health nursing services into schools
WEST AUCKLAND'S YOUTH HEATH HUB
A hub for youth health services based in Henderson that is collectively run by HealthWest, Odyssey House, Te Puna Hauora, West FONO Health Trust, Youthline, and Waitemata DHB Child and Family Services. The hub is home to a specialist youth health clinic, the Your Choice mental health service, the Teen Dads programme, school-based health services and school-based clinics
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FOCUS n Child & Youth Health New Zealand (SYPHANZ), says when it comes to youth health services, it is not a case of “either/ or” but of young people having the right to access healthcare and ensuring there are not unmet needs. Kekus, also a youth health nurse practitioner, until recently worked for HealthWest in West Auckland and was clinical lead for the Youth Health Hub, which opened last year in Henderson in league with Health West, Waitemata DHB, and a consortium of other services, including Youthline. Like the name suggests, it is not a YOSS but a hub for specialist and collaborative youth health services, including mental health and addictions. Although it doesn't offer walk-in services, it never turns away a young person in need. She says YOSS is a great model but points out that with Waitemata DHB having 34,000 young people under 25, it would need five YOSS to serve West Auckland communities, let alone the North Shore and beyond. What she sees as most important is that New Zealand ensures young people's right to access healthcare and that cost is not a barrier to getting the healthcare they need, whether it is provided at secondary school, a YOSS, specialist DHB services, or general practice. Bagshaw agrees that when it comes to youth health, it is not an “either/or” situation with, in particular, nurse clinics in schools being “absolutely vital”. “The problem is that they don't cater for the young people who drop out early or the people who have left school. The most under-served people Intro ???????I believe, are the 18–22-yearin our community, olds because they don't have regular employment. They are casual labour, on cheap wages, or they are students and they can't afford a GP.” Gill Alcorn, a nurse practitioner who has been working at Hutt Valley's Vibe for the past 11 years, stresses that YOSS are there to complement rather than compete with general practice. One caters for patients across the lifespan, while the other's specialty is young people from age 10 to 24.
Do they make a difference?
At present, YOSS are rich in anecdotal reports of making a difference and also efficient in reporting Kapiti Youth Service (KYS) general manager Raechel Osborne (far right) with the KYS team after winning the Supreme Award at Capital and Coast DHB's 2013 Quality Improvement and Innovation Awards.
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outputs to meet the requirements of their multiple contracts. But a lack of robust data from YOSS on actual health outcomes was one of the findings from the 2009 YOSS evaluation report. The report also note, however, that, though that, despite the lack of evidence, YOSS managers strongly believed that their services improved the health and wellbeing of their clients, and 89 per cent of stakeholders and 94 per cent of clients surveyed agreed with them. Osborne and the improvement-focused KYS decided to work in partnership with company Evaluation Works to develop an outcomes model and measure for YOSS. “Anecdotally, feedback indicated that we were making a significant difference for the young people that use our service, but we needed a measure and reporting system that fully captured our integrated, interdisciplinary, and positive youth development approach to working with young people, and which was both robust and outcomes-based.” Thanks to Health Research Council funding, KYS has been able to undertake an impact evaluation study (reporting findings shortly) and to further develop the outcomes measurement tool. Plus some additional MSD funding is being used to use the tool to develop a comprehensive monitoring and reporting framework. “It is about measuring the difference we make to young people. It wasn't funder-driven, but it is a tool we can use to show funders what change we make.” KYS was also deeply involved in trialling the self-help e-therapy tool SPARX and is part of both the international Pathways to Resilience research study and the longitudinal Youth Transitions Research study.
Smell of an oily rag
Talking to YOSS stalwarts, a common characteristic is positivity, which is probably an essential survival technique in a health service where funding certainty is never a given. Osborne strongly believes that YOSS, like KYS and others, are delivering high quality and best
practice youth health services not only of national but international standing. But when pushed, she acknowledges it is challenging doing so knowing that the majority of KYS's nearly-a-dozen funding contracts expire in June next year. Bagshaw says the Christchurch centre has to apply to two philanthropic trusts a month just to maintain their base income. “It's very timeconsuming.” YOSS around the country invest a large amount of time not only in building and maintaining relationships with funders but also in meeting the individual reporting requirements of their onaverage 10-plus funding contracts. Eriksen says for the young person walking through the door, it looks simple, but behind the scenes, it is a complicated scrabble of allocating subsidies and costs to different funding pots and spitting out outcomes reports at the other end that makes sense to the funder and satisfies their contract. She adds that funders never want to fund “boring” back-office stuff like overheads. “When the money comes in, absolutely everybody sticks it on the front line because that's what delivers outcomes.” However, this is no good for long-term sustainability or capacity building. Eriksen says after the Ministries of Health and Social Development scrutinised the finances of the YOSS, the feedback was something like “we know that you told us that you run on the smell of an oily rag … but you really do run on the smell of an oily rag”. “I think we ran some figures and found that we run at about half the cost of a general practice,” adds Eriksen. They strive to keep nurses salaries aligned with nurses in the public sector but can struggle. “Nobody does it for the money … and sometimes that's a good thing.”
Don't fit neatly into one box
Amongst the funding struggles YOSS face is having a client base whose needs straddle across primary health, mental health, and youth health, not to
FOCUS n Child & Youth Health mention social services and education and training needs. “We don't fit neatly into any one box,” says Osborne. One box YOSS struggle to fit into, but have been encouraged to do so in recent years, is joining a PHO. The PHO funding model is built on population-based funding for each patient/client you enrol. While many YOSS are now members of a local PHO, Eriksen points out that with PHO membership comes the tricky issue of how many young people need or want to enroll with a YOSS as their main health provider. “Generally, enrolment doesn't work for young people, and it doesn't work for the business model of a YOSS,” says Eriksen. She said Palmerston North trialled enrolments “but it doesn't really work” so it has stuck to being bulk-funded by its local PHO and agreeing not to “double dip” by claiming back the GMS (General Medical Subsidy) for clients enrolled in a general practice or provider elsewhere. “If you have a generous bulk fund, you are not pushed to look for all the types of claiming that you can do,” acknowledges Eriksen. “But if your bulk funding is bare bones, then you absolutely go for everything you can.” This includes not only GMS, but also ACC, maternity co-payments, sexual health co-payments, and others. Osborne agrees that joining their local PHO has been “quite challenging”, not least because of Intro ??????? confidentiality issues if a young person goes back to visit their usual general practice with a parent who is unaware they are using YOSS services. She says KYS has about 700 young people enrolled with them as their main health provider but the majority of their 5,000 registered clients choose to remain enrolled with their existing provider – which is likely in most cases to be their family's general practice. Likewise, PHO member Evolve has about 5,000 clients on its books, but only 800 clients of those are directly enrolled with them. Nurses and NPs are now able to claim the General Medical Subsidy (GMS) for seeing clients
enrolled elsewhere, and Osborne says it will start claiming shortly. Zonneveld says Evolve has already starting to claim GMS clawbacks for eligible PHO clients, which is having a positive impact on their income. Vibe, one of the oldest and most sustainably funded of the YOSS, is also one of the exceptions in not having joined a PHO, thanks to a successful funding relationships, says Alcorn. “There has been that willingness to fund and support us separately, so we haven't been made to go down the PHO track.” Part of their income comes from claiming ACC and GMS subsidies, but Alcorn says it is minimal compared with the bulk funding that they receive.
Any easy answer?
Is there a simple solution to creating a sustainable YOSS model? Alcorn thinks the model developed by Vibe with Hutt Valley DHB is one that could work across the country. But Vibe still doesn't escape from the same issue facing most YOSS – multiple short-term contracts – particularly since the three neighbouring DHBs started cooperating and Vibe's health contracts have gone from three-yearly to yearly. A common wish expressed by a number of people Nursing Review spoke to is that funding should follow young people wherever they seek health services. “There's always been that debate for a long time since I've been involved with youth space … that the money should follow the young person,” says Kekus. “The problem is that we see general practice as the primary care home, but there are different models of primary healthcare that YOSS, and some of the iwi providers, have demonstrated.” Kekus adds that rather than dividing
WHAT IS A YOSS? Ministry of Social Development definition:
A Youth One Stop Shop is a service that: »» provides a primary health care service, plus other services »» actively models youth development principles »» is open sufficient hours (for the health service, at least 20 hours a week) »» takes a holistic approach to clients, supporting them and extending the opportunities available to them.
Description of Youth One Stop Shop Model from 2009 Evaluation of YOSS Report:
Youth One Stop Shops provide specialised services to a client group with specific and special needs. This model for service delivery aims to provide a range of integrated community-based health and other services, using a holistic model of care that is responsive to the needs of young people and the communities served. The goal of this service model is to support young people to achieve and maintain wellness, increase resilience and promote positive decision-making. A model service reduces barriers such as cost, is youth-focused, strengths-based, and delivers care in a manner that gives rise to trust, safety, and confidentiality. Source: Communio Evaluation of YOSS Report 2009
and segregating off youth health, we need to “to start changing the mainstream system to help all our populations”. Alcorn and Zonneveld agree that having YOSS doesn't absolve general practice GPs and nurses from the requirement of being skilled in engaging and working with young people – including the need to assure young people about confidentiality. The pair of NPs believes for equity's sake there should be YOSS in sizeable communities. “In my perfect world, I'd like to see a YOSS in every city and big cities to have several,” says Zonneveld. The veteran youth health advocate Bagshaw sees the problem facing YOSS stemming from youth one stop shops being a ‘bottom-up’ community solution to meeting the needs of young people. Therefore, it clashes with a ‘top down’ government bureaucracy that doesn't know how to deal with them. Meanwhile, YOSS keep on keeping on doing what they do best: caring for and supporting young people. “We've had to survive, and it hasn't been easy for us,” sums up Osborne. “But it’s about how we face challenges. One door might shut, but it’s going to the next door… “That's incredibly exhausting, but the work we do is incredibly satisfying, and I know that it makes a difference to young people's lives. That is what drives us.” It’s an inspiring task – and one that would definitely be easier if the funding dollars flowed as simply and consistently as the number of young people who flow through the door.
What smokers really want Smokers want to be seen as real people, trying to beat their addiction.
Nurses have the ability and power to connect and guide smokers on their journey to wellness. Because defeating addiction is a very individual process, nurses can provide encouragement from start to finish. To understand what smokers go through, we have created this resource to empower nurses and help smokers on their journey to stay smokefree.
Typically, YOSS offer a mix of general health care, sexual health, mental health, counselling, alcohol, and other drug addiction services, health promotion, advocacy, social work, youth work, employment services, mentoring, and youth development programmes. See online at www.nursingreview.co.nz an historic timeline and list of YOSS
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FOCUS n Child & Youth Health
Helping children survive and thrive FIONA CASSIE talks to nursing leader and Children's Team member Sonia Rapana about her role in the Children's Team initiative to help children not only survive but also thrive. Rotorua Children’s Team members (l-r) Shelley McIntosh (Public Health RN), Penny Brooks (DHB/CYF liaison), Sonia Rapana (Tipu Ora) and Johan Morreau (paediatrician).
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he wraparound support that can be offered by Children's Teams and lead professionals epitomises what holistic nursing is all about, says Sonia Rapana. Rapana, a nurse and clinical manager for Tipu Ora (a Rotorua provider of primary health and social services), is a member of the country's first Children's Team, which was launched in Rotorua in July last year. Children's Teams aim to step in and offer intensive child-centred family support to vulnerable children so they don't progress down the path to needing Child, Youth and Family child protection or being abused, or worse, becoming a statistic. The team is made up of professionals from across health, education, social, and other sectors who have the skills, resources, and networks to help children and their families. The team also provides oversight and advice to the lead professionals (often social workers or nurses) who coordinate an individual child's care plan. Rapana says nurses often aim to work Intro ??????? holistically to try and help a client's housing or school issue but soon come across systemic or time barriers to finding out the information or seeking the support they need. “As a lead professional, you've got at your immediate disposal people in the Children's Team from those sectors that you can go to for that information.” In August –just over a year after being launched as the country's first demonstration site – he Rotorua Children's Team and its 10 lead professionals were supporting 57 children and their families/whānau. Rapana is one of seven members of the Rotorua Children's Team, which includes a senior social worker (working in liaison role between Child, Youth and Family and the Lakes District Health Board), a paediatrician, another registered nurse representing Whānau Ora, a third registered nurse with a mental health background, a police representative, and it is chaired by regional children's director Mahalia Paewai, who has a background in education and psychology. The team meets weekly to consider referrals for Children's Team interventions, with referrals
Staying at school, and at home: A young man who was going off the rails is now showing a significant improvement in behaviour after a Children's Team lead professional began working across agencies, with his family, his school, and youth development team. Since the team got involved, he has started going to school again, and staying there. He is making friends and wearing his uniform rather than a gang patch. The young man’s underlying learning impairment is being addressed and he is no longer regularly sleeping on the streets.
Source: Children's Action Plan Newsletter August 2014
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coming in from the organisations and agencies like the DHB, CYF, Family Start, Ministry of Education, and Police. If the referral meets the criteria, the child/children and their family are assigned a lead professional who works with them to draw up a shared care plan and to coordinate all the agencies and professionals needed to bring the plan to fruition – be it housing, health, school, or finding their whakapapa (lineage). “Making sure everybody is on the same waka,” Rapana says. Rapana says a family will not be accepted if the team considers the family situation is too complex and the risk too high that CYF intervention is needed instead. Tragic abuse victim Nia Glassie would have been unlikely to come under the team. The team may also decline a referral if it believes the needs of the family can be met by existing services and agencies. An example is Family Start, which works with children from 0–3 years old. “It was very obvious that some health and other professionals didn't really know that programmes like Family Start existed, so we were referring children to the Children's Team,” said Rapana. “It has highlighted that some services need to be more visible.” Tipu Ora has provided one lead professional (LP) to the team, a social worker working full-time as an LP, but other LPs, which include nurses, are working part-time for the team and part-time for their regular employer. Rapana says as a demonstration site the Children's Team process is still evolving, but she says the big point of difference from before and now is having all sectors sitting around the same table and feeding into a shared plan for a child in need. “It's how we should all be working.”
Children's Action Plan Timeline JULY 2011
Green Paper for Vulnerable Children released.
OCT 2012
Children's Action Plan released as part of White Paper for Vulnerable Children.
JULY 2013
Launch of first Children's Team in Rotorua (followed by Whangarei in October).
JULY 2014
Vulnerable Children Act 2014 came into law.
AUGUST 2014
National Children's directorate reports still investigating options for common core set of skills and competencies for all children's workers.
JUNE 2015
Eight more Children's Team to be established by now including Horowhenua, Marlborough, Hamilton, Clendon/Manurewa/Papakura, Gisborne, Whakatane, Whanganui and Christchurch.
END OF 2015
The minimum standards and core competencies to be in place for employing organisation's employment, contracting and audit obligations.
CHILDREN'S TEAMS: THE BASICS
»» Children's Teams are formed from local experts and professionals from education, health, police, welfare etc. and are chaired by regional director. »» Meet weekly to consider child referrals and whether to appoint a Lead Professional to work with child and family. »» Provide clinical oversight and support to the Lead Professionals. »» Review and advice on plans drawn up by Lead Professionals for the child family.
LEAD PROFESSIONALS: THE BASICS
»» Work directly with child and family. »» Pull together appropriate people from local agencies to form Children's Team and assess information known about child and family. »» Draw up a whole-of-child kete (full picture of child/family situation). »» Use kete to draw up a plan for the child which is peer reviewed by Children's Teams and supported by Children's Teams regional director. »» Find out more at: www.childrensactionplan.govt.nz.
FOCUS n Wound Care
Wound Care Nursing Review looks at some of the common wounds that nurses treat – jammed fingers, scalds and burns.
Ouch: crushed fingers and purply-black nails
Fingers may be small but wounds to them can be disproportionately painful and debilitating. FIONA CASSIE seeks first aid advice for nurses from emergency NP Margaret Colligan on crushed fingers and other common finger wounds.
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t happens all the time. A hammer heading for the nail hits the thumbnail instead. Or a lapse of attention sees fingers jammed in a door, drawer, or machinery. The wounds may be small but the pain of a throbbing swollen finger or fingers is not easily forgotten. “Mostly the (crushed finger) injuries that present at ED are people who may have been chatting to someone with their hand on the open car door and then they have inadvertently closed the door,” says Intro Auckland??????? Hospital ED nurse practitioner Margaret Colligan. She says the pain that brings people into ED is usually caused by bleeding under the nail (subungual haematoma) following a minor laceration. “The blood that forms under the nail has nowhere to go because it is such a small compressed area and that is why it throbs so much.” When a nurse in a general practice, rest home, or other community setting has a patient present with a throbbing finger and a subungual haematoma, they need to follow initial first aid steps (see sidebar). They then need to assess whether they can care for the wound or if the damage is such that the person needs to be sent to ED. Colligan says in the case of industrial accidents, the blow to the finger can have significant force behind it and often the worker may have also broken the bone underneath the nail and suffered significant damage to the nail. In cases where the patient has a very sore and swollen finger or fingers and there is a suspected fracture of the bone and/or the nail is badly crushed or cracked, the person needs to be referred to ED or an A&E clinic as the nail is likely to have to be removed and the nail bed repaired. An X-ray will also be required.
If the nail is intact and bone fracture unlikely, the nail can be assessed by the nurse for trephination (i.e. making a hole in the nail to release the blood and so reduce the pressure and pain). Colligan says one factor nurses have to take into account before trephination is how recent the injury is. After 12–24 hours, the blood under the nail is likely to be clotted and trephining will have less impact. If the haematoma covers 50 per cent or more of the nail, trephination is likely to be worthwhile in relieving pain. If the coverage is 25 per cent or less, a judgment call needs to be made on whether trephination will benefit the person. Before trephination the nail must be cleaned. The best way to actually carry out trephination is a matter of some discussion (see sidebar). Colligan says her preferred method is to use a sterile 18-gauge needle and gently rotate the needle (between finger and thumb) down through the nail until it pierces the nail and blood comes out. If there is a fracture underneath the nail, there is conflicting evidence about whether prophylactic antibiotics should be used after trephination because there is a portal through the nail for infection into the tissue. “I can’t find any good evidence to support that (prophylactic antibiotics), but anecdotally, that seems to be the practice,” says Colligan. “This is particularly the case if the injured person is, for example, a mechanic in a garage who is going to continually get the finger dirty. I would have a higher threshold for giving them antibiotics then somebody who works in an office environment.” Colligan says nails usually grow back within three to six months without any complications.
See also online sidebar for advice on splinters or thorn injuries at www.nursingreview.co.nz
FIRST AID RESPONSE TO CRUSHED FINGERS
»» Run injured fingers under cold water for 10–20 minutes or apply ice wrapped in facecloth or gauze. »» Offer simple pain relief. »» Check history of injury, including level of force. »» Assess whether nail is badly damaged or whether the level of pain, swelling, and inability to move finger indicates a possible broken bone. If so, refer to ED. »» If crush injury is elsewhere on the fingers and is accompanied with major swelling and loss of movement – even if the skin is not broken – a tendon may be lacerated and the injury should be reviewed in ED or A&E clinic. An ED referral should be made if there is a delayed presentation or a risk of infection. »» If nail intact and fracture unlikely, assess bleeding under nail and pain and decide whether trephination will be helpful. »» Clean nail area and use appropriate trephination technique (see trephination sidebar). »» Always consider giving a tetanus booster. »» Consider prophylactic antibiotics after trephination. »» Be cautious with patients who are immunosuppressed or slower healing. »» Elevate injury in sling for 12–24 hours to help reduce swelling and pain. »» Follow-up: if patient can’t move fingers or throbbing pain persists beyond 24 hours, then refer on.
TREPHINING TECHNIQUES: a matter of some debate The ACC’s 2008 Nursing Treatment Profiles came out against the technique of using straightened-out paper clips heated on a flame until hot enough to burn a hole through the nail and release the blood. It says while using a hot paper clip was a “simple, common, and straightforward” procedure, the practice remained “somewhat primitive” and has hazards related to it being performed incorrectly. ACC also advised strongly against using a sterile needle because “overexuberance” with a sharp needle point could cause trauma to the nail bed. It advises instead that using disposable electrocautery devices is considered “more current and humane”.
Subungual haematoma advice, updated in September 2014, on the American Medscape website still includes the careful use of a heated paper clip or an 18-gauge needle as options for trephination, along with a cautery tool. See video: http://emedicine.medscape.com/article/82926-overview#a15. Some other articles also refer to a trephination technique using an extrafine 29-gauge insulin syringe needle inserted under the nail via the quick (hyponychium).
Nursing Review series 2014
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FOCUS n Wound Care
Burn injuries:
spills, flares, flames, and the wounding results Every year, more than 20,000 claims are made to ACC for burn injuries. Burn clinical nurse specialists Deborah Murray and Jackie Beaumont see many of the worst of them. FIONA CASSIE gets advice from the pair about first aid and management of minor burns for nurses in the community and discovers there is no such thing as a ‘simple’ burn.
I
t makes you wince just to think of it. The toddler tugging a tablecloth and a scalding bowl of noodles spilling in their lap. Or the bloke in his back garden who decides to throw some accelerant onto a smouldering rubbish fire and gets hit with a flash burn. Deborah Murray and Jackie Beaumont are burn clinical nurse specialists at the National Burn Centre at Middlemore Hospital whose daily work is work to treat the aftermath of such accidents. Approximately half of their patients are children. The majority of those are heartbreakingly under Intro ??????? two years old. The pair says with children, scalding is the most common burn injury, including spilt hot drinks and baths. With adults, it is flames and explosions. While the National Burn Centre’s staff see much of the nation’s most horrific burn wounds, they also work with the more common, smaller burn wounds from their local region. These include the kind more likely to first present at their local general practice than an emergency department. “These smaller wounds are still complex in their own right,” says Murray. “There is still some uncertainty (amongst health professionals in the community) over how to manage them and at what point to ask for help or refer them to a burns unit.” The pair is keen to share some take home messages with nurses in the community from general practices to rest homes. Firstly and most importantly, to encourage prevention of burns; secondly, to share some first aid tips for burn injuries; and lastly, a call to assess the patient, not just the burn, and be conservative in referring on quite simple burns in patients with compromised healing ability.
Out of the frying pan …
Most of us have seen those Fire Service ads on the telly, but Beaumont says this doesn’t stop people leave their cooking unattended. Unfortunately, the pair sees the consequences. “They are cooking with oil in a pan and leave for just a few minutes. The oil starts to smoke and catches fire,” says Beaumont. “They come back and their first instinct is not to put out the fire but to lift the pan and take it outside. You can imagine getting hold of a flaming hot pan – the handle is hot and the flames can reach up to a metre. So they invariably drop that pan, which then spills hot oil over them, and if the flames catch hold of their clothes, too …” Beaumont says they would always encourage people to put the flames out, either with a fire blanket (if available) or a wet tea-towel. 14
Nursing Review series 2014
Then there is the backyard cook cleaning off their barbecue grill with methylated spirits. They open the lid to double check it’s working … and get hit with a flash burn. It is a case of accidents will happen, but some are more preventable than others. The risk of other accidents – particularly tragic ones involving inquisitive and active toddlers – can be reduced by advising people to turn down their hot water cylinder so the temperature is a maximum of 55 degrees C at the tap. Extra vigilance with hot drinks, boiling kettles, and pots and pans will also reduce burns (see links to SafeKids Aotearoa guide below).
Old wives tales still hold
When it comes to first aid in the home for burns, Murray and Beaumont are very aware that old wives tales are still resorted to rather than the simplest and best remedy – tepid running water. “We try to get the message out there (about running water), but there are lots of other things that people use,” says Beaumont. “Like they put toothpaste on burns because they think it's cooling.”
CHILDREN’S BURNS: the sad facts »» On average, six children each year die from burn injuries in New Zealand. »» Every day a child is burned severely enough to be admitted into hospital. »» Burns are a leading cause of injury for young children. »» Of the severe burns to one- and two-yearolds admitted to hospital, over half are caused by spilt hot drinks (tea and coffee) and other liquids. Source: SafeKids Aotearoa, Starship Children’s Health
Or they use ice to cool the burn. “Which is getting the theory right but the wrong product as ice can cause a burn itself as it is too cold. It can add to the injury rather than help it.” Then there are people who use butter and other products like flour or eggs. The pair says a great deal of research has been put into what is the optimal cooling method for a burn, and the general consensus internationally is 20 minutes of cool running water. If that ‘first’ first aid is done right, damage to the skin can be minimised. For some patients, that means they don’t actually need to have a skin graft to repair their burn. The temperature to aim for is basically what comes out of your cold-water tap. But with the very young or very old, there is a risk of the burn victim getting hypothermia, so Murray suggests keeping the rest of their body warm, or if it is a large burn area, the temperature of the shower can be turned up until it is lukewarm. The pair urges people not to be reluctant to call an ambulance – particularly if it is a child with a burn as 20 minutes under running water can be a very long time with a distressed child.
Three-hour window of opportunity
So what should a nurse do if a child is brought into their general practice or a medical clinic an hour or so after a minor burn incident with flour on the child’s wound? Murray says the great thing about the running water first aid process is that it is still useful up to three hours after a burn injury. “There is a three-hour window of opportunity to actually cool the burn. Obviously, the quicker this is done, the more effective it is. “But if a practice nurse is at work and a mum comes in with a child who has burnt their arm, and the mum has put butter on it, you can still start the cooling process.” First, though, get the butter off, because as an oily, greasy product, it actually retains the heat in the burn. Likewise, flour and eggs also retain heat, says Murray. “So give lots of pain relief and lots of assurance and wash any products off, then start the first aid cooling of 20 minutes under running water.” If the patient is finding the running water soothing or relieving – more often the case for adults than children – it is not unsafe to go over the 20 minutes. It is better to go too long than too short.
FOCUS n Wound Care
Brief First Aid for Burns*
Clothing over the burn needs to be removed, but this follows the running water and should also follow appropriate pain relief. The pair says a general practice usually quickly identifies if a fresh burn wound is beyond their capacity and refers the patient on to their local ED – particularly the very young and the very old. Murray and Beaumont also point nurses towards the National Burns Service website (see details in box), which outlines first aid and initial assessment of burns, plus guidance on referral pathways and burns wound management. For wounds that can be managed in the community the National Burns Service wound management guideline (see website link in box) recommends dressing the wound with an antimicrobial or specialist dressing for the first few days before changing to a moist wound healing product, if possible.
Assess patient’s ability to heal, not just size of burn
While some burns and patients are obvious candidates for an ambulance or immediate referral to ED, some other seemingly minor burns can end up being much more complex than they first appear. Beaumont and Murray are keen to stress that the complexity of managing a burn wound can be as much about the patient’s ability to heal as it is Intro about the??????? size and appearance of the burn. If a frail rest home resident tips a hot cup of tea all over themselves, the impact may be much more than for a healthy young adult. “You need to be mindful that burns (of the frail resident) have the potential to be quite deep – as children and elderly have thin, delicate, and very fragile skin. It doesn’t have to be really super-duper hot water to cause a deep burn. They can easily sustain a full thickness burn.” A nurse caring for an elderly burn victim needs to be extra vigilant with the cooling first aid and more ready to consider referral. People can also be vulnerable to delayed healing of what appear to be simple burns because of underlying health issues such as diabetes or cardiovascular disease, or if they are on medication that restricts the blood flow to their fingers or toes. “You need to look at your patient holistically rather than just focusing on the burn,” says Beaumont. “It is very easy to focus on the burn because it’s visual and right in front of your eyes, but you need to look at the patient as a whole and the factors that may affect their healing.” An example could be a diabetic putting a hot water bottle on their cold feet overnight and waking up in the morning with a nasty contact burn because their diabetes made them insensitive and vulnerable to being burnt from the still-intact hot water bottle. Wheat bags can be another culprit. Murray says people with chronic conditions can present at their general practice with such burns, which may appear as just a simple blister, but once burst, they are slow to heal. Sometimes the patient may have tried to manage the burn at home by applying an ointment and only present when the burn is infected. “These are significant burn injuries because although they are small, they are on a patient who is vulnerable, so those sorts of patients should really be referred on to a plastic surgical unit for assessment.” The pair says a rule of thumb for referral to a
burns or plastic surgery unit is basically how long a burn wound takes to heal, with the threshold for referral being when the wound is unable to heal within three weeks of the initial injury. If a practice or community nurse is monitoring a wound – preferably seen every two or three days – that is looking unlikely to heal within that timeframe, then the patient should be referred on for further assessment and follow-up. The pair says the aim is not only a good cosmetic outcome for the patient but also a good functional outcome. “We don’t want any unattractive scarring of a patient if we can avoid it,” says Murray. Delayed healing of burns – particularly over hands, elbows, shoulders, feet, and other joints – increases the risks of scars that cause contractures (skin that is hard, rigid, and tightened over the joint, thereby reducing its mobility). “So say you have a burn across the top of your foot and it takes weeks and weeks to heal. Basically, you can end up with your toes being pulled up, which makes it harder to walk or keep your balance,” says Beaumont. “We’d rather people referred earlier rather than later,” concludes the pair. It goes without saying, that burn prevention efforts see fewer burns ever happening in the first place.
»» Run tepid water over burn injury for 20 minutes (between 8–25 degrees C, aiming for 15 degrees C). »» Running water still effective in reducing tissue injury within the first three hours from burn occurring. »» Give adequate pain relief. »» Keep patient warm. »» Remove clothing and jewellery. »» Can loosely cover wound with cling film as temporary transport dressing for up to eight hours after burn (inside surface of film against wound). »» Elevate burned limbs to manage swelling. »» Consider tetanus booster.
*Source: Summary of First Aid Management of Wounds from National Burn Service Initial Assessment – Guideline (2013). See website link below.
Useful websites
National Burns Service Website includes National Burn Service Initial Assessment – Guideline (2013) for health professionals: www.nationalburnservice.co.nz NZ Fire Service Useful tips on preventing fires within the home: www.fire.org.nz/Fire-Safety/Fire-Safety-Advice/Pages/ Inside-your-home.html Get Firewise NZ Fire Service safety education resources for children and young people: www.getfirewise.org.nz SafeKids Aotearoa The child injury prevention services of Starship Children’s Health. Good tips on preventing burn injuries, including the ‘Fancy a cuppa’ flier and setting your hot water temperature to 50–55 degrees C at the tap: www.safekids.org.nz. Nursing Review series 2014
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college of nurses
Margareth broodkorn
Out, damned spot! Out, I say! MARGARETH BROODKORN takes a look at the chequered history of hand washing and asks whether today's health professionals have progressed that much? The paranoid subconscious of the sleepwalking Lady Macbeth in Shakespeare’s Macbeth may have some relevance to the challenges of hand hygiene compliance with health professionals. Lady Macbeth’s hallucinations of blood on her hands and paranoid response could be a useful analogy for health professionals not washing their hands and the subsequent risk to the patients they care for. Attempts at minimising cross-infection though effective and appropriate hand hygiene practice has been a longstanding issue within the health sector, stemming back as far as the 1800s. Hungarian physician Dr Ignaz Semmelweis (1818–1865) – while later acknowledged as an early pioneer of antiseptic procedures – was sadly deemed a madman by his peers. Regarded as the ‘saviour of mothers’, Semmelweis suggested that the incidence of puerperal fever could be drastically reduced by the use of hand disinfection in the field of obstetrics. While working in a Vienna hospital, he noted that doctors’ wards had three times the mortality of the midwives’ wards and postulated the theory of washing with chlorinated lime solutions in 1847. Despite various publications showing his hand washing theory reduced mortality to below 1 per cent, his observations conflicted with the medical establishment of the day and were rejected by the medical community. One strident opponent to the idea that doctors could be transferring puerpereal fever between their patients was American obstetrics professor Charles Delucena Meigs, who reportedly said “doctors are gentlemen, and gentlemen’s hands are clean”. It wasn’t until Louis Pasteur’s germ theory of disease offered what was deemed a more scientific explanation to Semmelweis’s work that he was recognised. Unfortunately, and ironically, Semmelweis died at the age of 47 of septicaemia after being admitted to an asylum. In 1859, Florence Nightingale stated in her Notes on Nursing that “every nurse ought to be careful to wash her hands very frequently during the day”. Therefore, it is not a new concept that healthcare workers should be diligent with washing their hands.
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Fast forward to 2014 and we ask ourselves how far we have come in adopting a wellproven healthcare intervention? Given that hospital-acquired infections represent some of the most frequent adverse events in healthcare worldwide – and up to 10 per cent of patients admitted to modern hospitals acquire one or more hospital acquired infections – have we progressed that much? Hand Hygiene New Zealand (HHNZ) maintain that hand hygiene is one of the simplest yet most effective measures in the fight against such infections, making hand hygiene practice a key patient safety issue in New Zealand hospitals. Established in 2008, the Hand Hygiene New Zealand programme promotes the five internationally accepted moments of hand hygiene and aims to reduce
The 5 Moments for Hand Hygiene Moment 1: Before touching the patient or the patient’s surroundings (on entering the patient zone) Moment 2: Before performing an aseptic procedure Moment 3: After a body fluid exposure risk Moment 4: After touching the patient (if leaving the patient zone) Moment 5: After touching the patient’s surroundings only (if leaving the patient zone).
healthcare associated infections through adherence to The 5 Moments for Hand Hygiene for every patient every time. Of course, it goes without saying that health care workers should wash their hands after going to the toilet, after sneezing or coughing into hands, after handling contaminated material and removal of gloves, and before handling food. The objective of the HHNZ programme is to achieve 75 per cent compliance by June 2014 and 80 per cent in June 2015. Since the first performance data was submitted in October 2012 at 61.2 per cent, steady improvement in hand hygiene performance has been noted across the country. In March 2014, this had risen to 72.6 per cent. Data from the April to June 2014 Hand Hygiene performance report noted a 73 per cent achievement. The results from hand hygiene audits show that nurses and midwives have responded well to adopting the five moments and role modelling effective hand hygiene practices. Unfortunately, national and local surveys of our medical colleagues paint a different picture of poor hand hygiene practice. To ensure that effective and hand hygiene is part of everyday ‘business as usual’ practice, leadership is critical in turning this around, given that these surveys show that the hand hygiene practice of doctors is influenced more by their senior colleagues than patient influence. Hand hygiene initiatives such as local champions, hand hygiene campaigns and audits, and various health promotion activities are making a difference, but we need to maintain vigilance in ensuring that a patientcentred care approach in improving effective hand hygiene practice is held as a high priority. We cannot succumb to the so-called unfortunate Semmelweis reflex, where the common sense and clinically proven practice of effective hand hygiene is ridiculed and rejected as something that is not achievable or reasonable to expect of all health care workers. Margareth Broodkoorn is director of nursing and midwifery at Northland District Health Board and a director on the College of Nurses Aotearoa’s board.
Evidence-based practice
Do daily 'vitamins' make a difference to the tube-fed? CYNTHIA WENSLEY in this Clinically Appraised Topic (CAT) looks at whether or not enriching tube feeding with immune-boosting nutrients reduces infection. CLINICAL BOTTOMLINE: In critically ill, mechanically-ventilated adults in intensive care, adding nutrients thought to boost immunity (glutamine, omega-3 fatty acid, and antioxidants) to the patient’s high-protein enteral nutrition does not reduce infection risk or improve recovery. Instead, it is associated with a 57 per cent increased risk of dying within six months of follow-up when compared with standard high-protein nutrition. The lack of benefit – and potential for harm – in this group of patients means supplementing enteral nutrition with these nutrients is not supported.
CLINICAL SCENARIO: You are an intensive care nurse caring for a critically ill, ventilated patient starting enteral feeding. The family say their mum takes antioxidants daily for immunity support and worries that without these she has less chance of pulling through. You know that some units supplement enteral feeding with immunonutrition – nutrients to modulate the immune and inflammatory response to illness – in the critically ill and wonder what difference this makes.
CLINICAL QUESTION: In critically ill, ventilated patients, does the supplementation of enteral feeding with immunemodulating nutrients reduce infection risk compared with standard enteral feeding?
SEARCH STRATEGY: PubMed Clinical Queries (therapy, narrow): enteral nutrition AND Immunomodulation
than 72 hours, commencing within 48 hours of ICU admission. The main exclusion criteria was Sequential Organ Failure Assessment Score (SOFA) of >12. The number pre-screened or who declined consent (sought from patient or legal representative) was not stated; 301 patients were randomised. Participants were fed according to routine practice, although a study protocol provided recommendations for early enteral feeding, energy requirement, and complementary feeding. Patients received study treatment for a maximum of 28 days. The study duration was six months. Interventions: (n=152) High-protein enteral nutrition (IMHP) enriched with immune-modulating nutrients glutamine, omega-3 fatty acid, and antioxidants (experimental product, NV Nutricia, Zoetermeer). Full nutritional supplementation details provided in supplemental material. Comparison: (n= 149) High-protein enteral nutrition (HP) commercially available as Nutrison Advanced Protison (NV Nutricia, Zoetermeer). Outcomes: Primary outcome measure was the incidence of new infections from start of study product until either ICU discharge or a maximum of 28 ICU days. Secondary outcome measures included mortality (at ICU and hospital discharge, day-28 and six months), SOFA scores, mechanical-ventilation duration, ICU and hospital length of stay, sub-types of infections, and severe adverse events. Infections were classified using the Center for Disease Control and Prevention (CDC) definitions.
VALIDITY:
modulating nutrients, infections and antibiotic use. There was no evidence that groups not treated equally. Study quality was high.
RESULTS: The study population was a mix of mechanicallyventilated, intensive care patients (36 per cent medical, 52 per cent surgical, 12 per cent non-surgical trauma). Study product was administered for a median of 12 to 13 days (IMHP and HP groups respectively). Compliance to the study product was good. There was no significant difference in the incidence of new infections between the IMHP and HP group (see table); this lack of benefit was consistent across predefined subgroup analyses. There was no significant difference between groups for any secondary outcomes or adverse events except for a statistically significant increase in six-month mortality in the medical group receiving IMHP (54 per cent) compared with HP (35 per cent). Mortality at six months (adjusted for age and Acute Physiology and Chronic Health Evaluation ll score) was significantly increased in those receiving IMHP (see table).
COMMENTS: The results of this high-quality study add to the growing body of evidence for lack of benefit and possible harm of immunonutrition in the critically ill. The involvement of multiple, international centres, and a heterogeneous intensive care patient population increases applicability of the study results to other ICU settings. Given the biological rationale for immunonutrition, the reason for the lack of benefit seen with IMHP is unclear. The benefit of individual components of the IMHP study treatment, and immune modulation for specific subgroups of the critically ill population, require further examination with robust clinical trials.
Van Zanten, AR: Sztark: F, Kaisers UX et al. (2014). High-protein enteral nutrition enriched with immunemodulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomised clinical trial. Jama, 312(5), 514-524. doi: 10.1001/jama.2014.7698
Patients were randomised using computer generated randomisation lists. Allocation concealment method was not described, although blinding technique would restrict prediction of upcoming allocation. Participants, clinicians, and investigators were blinded via study products that were ready-to-use and identical in packaging, appearance, texture, and smell. Minimal loss to follow up. All analyses performed on an intention-to-treat basis. Study groups were similar at baseline for prognostic characteristics that included morbidity risk, baseline levels of immune-
STUDY SUMMARY:
Table: Results with 95% Confidence Intervals (CI)
CITATION:
The MetaPlus study is a randomised, multi-centre, international, parallel group, two-arm, double-blind trial conducted in 14 intensive care units (ICUs) in the Netherlands, France, Germany, and Belgium, commencing February 2010. Clinical records of patients in participating ICUs were pre-screened for eligible patients; inclusion criteria were mechanically-ventilated adults who were expected to require ventilation for more than 72 hours and enteral feeding for longer
Reviewer:
Cynthia Wensley RN MHSc is a PhD candidate who also works at the School of Nursing, University of Auckland as an honorary professional teaching fellow.
IMHP n=152
HP n=149
RR (95% CI)*
HR (95% CI) **
P Value
Incidence of new infections
80 (53%)
78 (52%)
1.01 (0.8 -1.25)
-
0.96
Six-month mortality
53 (35%)
42 (28%)
-
1.57 (1.03 - 2.39)
0.04
Outcome
IMHP – High-protein enteral nutrition enriched with immune modulating nutrients; HP – High protein enteral nutrition * RR (95% CI) – Relative Risk (95% Confidence Interval) ** HR (95% CI) – Hazard Ratio (95% Confidence Interval) Nursing Review series 2014
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Practice, People & Policy NURSE PRACTITIONER
Articles, profiles and opinion pieces from across the nursing spectrum.
Practice, People & Policy Nursing mourns loss of
first Māori NP The loss of Janet Maloney-Moni – the country's first Māori NP and author of a book on a kaupapa Māori nursing model of care – has saddened many in the nursing world. Nursing Review shares some words and tributes to mark the passing of a nurse whose legacy is being recognised by a new nursing scholarship.
N
ursing has lost someone very special, says nurse practitioner Helen Topia on the passing of her colleague and friend Janet Maloney-Moni. Janet's sister Hemaima Hughes, president of Te Kaunihera o ngā Neehi Māori (the National Council of Māori Nurses) says she has lost a wonderful sister and nursing has lost a trailblazer. Her daughter Nadine Maloney, also a nurse, said her mother had been contacted during her illness by the Eastern Bay Primary Health Alliance to ask permission to offer postgraduate and student scholarships under her name. "She was very overwhelmed but thought it was great that her legacy could live on, particularly as she had a lot to do with clinical supervision and mentoring of nurses undergoing postgraduate study and who were on the nurse practitioner pathway," says Nadine. "It was their way of acknowledging the huge changes that she made towards nursing – particularly here in the Eastern Bay of Plenty." Helen in her tribute to Janet at the recent Nurse Practitioners New Zealand conference said she mourned the loss of "our shining star of Māori health". "Janet had been one of the drivers of kaupapa Māori health services and of the whānau ora model of care," said Helen. "For whānau ora to be realised in mainstream services and to contribute to making a difference, we need drivers like her. That is one of the greatest losses. We have lost someone special who would have been able to
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Nursing Review series 2014
further the whānau ora model and contribute to meeting the complex needs of Māori patients." Janet was born in 1952 in Opotiki of a Māori mother (Whakatohea; Ngati Ira) and a Scottish father. She told Nursing Review in 2006 that she grew up comfortable in both cultures as she had a Māori mother exhorting her to grow up Pākehā and a Scots father who encouraged her to be proud to be Māori. As a 17-year-old, she began her nursing career originally training as a community health nurse at Whakatane Hospital and then did a bridging programme to become a registered comprehensive nurse in 1991. In 2000, she was one of a group of Māori nurses who successfully studied for their postgraduate diploma in disease state management. She built on her work delivering home-based chronic disease management support and primary health care to clients and their whānau in the Waikato, and in 2003, she became the country's first nurse practitioner in primary healthcare Māori. Deborah Harris – the country's first nurse practitioner – mentored her, and she became one of the first ten nurse practitioners ever registered in New Zealand. Her master’s degree research through the University of Auckland looked at the synergy between clinical nursing expertise and an intimacy with things Māori in her own nursing practice and why it worked for her Māori clients. The resulting thesis into kaupapa Māori nursing practice (or a nursing model of care built on Māori principles) led in turn to her book Kia Manna: A Synergy of Wellbeing a framework of a Kaupapa Maori Model of care. Nadine says her mother's book continues to provide both educational institutions and clinical workplaces "a ‘place’ in which to locate cultural ways of practicing that empowers our indigenous people to follow treatment plans for chronic disease".
Helen says the book's "insightful and spiritually connected stories of her family and kinsmen reveals dimensions of world view Maori seldom discussed". "It is a tribute to her life and work." On becoming a nurse practitioner, Janet returned to Opotiki and founded Moni Nursing Services Ltd, and using her Kia Mana model of care, was funded by the Bay of Plenty District Health board to provide a rural health service to Māori in the wider Eastern Bay of Plenty, as well as some work with the Whakatohea Health Clinic. She became a prescribing NP in 2011, and Nadine says in 2012 her mum took a 'gap year' and went to nurse in an outback aboriginal community near Coober Pedy, Australia. On her return in 2013, she worked at the Whakatohea clinic, offering general primary healthcare. At the beginning of this year, she had wanted to start offering a specialist chronic management service again, but sadly, she became ill. Nadine says Janet passed away peacefully in August, after a short and sudden illness, surrounded by her whānau. She leaves behind her three children and five adored mokopuna. Applications for the Janet Maloney-Moni postgraduate and nurse/medical student scholarships are now open and more information can be found at: www.ebpha.org.nz
KUA HINGA TE TOTARA NEEHI MĀORI
Haere atu ra āku tuāhine ataahua Janet. Moe mai e hine i tou moengaroa i roto i te ringa ā tātou kaihanga. “Farewell beautiful sister. Sleep your long sleep in the arms of our creator. Your pain and suffering have ended and we are sad that we have lost such a wonderful sister, mum, nurse, trailblazer, and friend. Although you have left us, the light of your candle burns brightly and you will never be forgotten." Arohatinonui Hemaima me ngā hoa o Te Kaunihera o ngā Neehi Māori o Aotearoa.
Practice, People & Policy
Check out our online opinions
Global approach to advanced practice nursing Nursing Review catches up with DR KATHY HOLLOWAY on a recent global symposium to define advanced practice nursing (APN) roles to help nursing improve access to healthcare worldwide.
Lifestyle advice: Would you follow advice from ... you? ANDY McLACHLAN – Scotsman, cardiology NP, and past-consumer of deep-fried pizza and hamburgers the size of your head recently got lectured by an after-hours pharmacist while picking up his type 2 diabetes medication. As a reformed character with great blood sugar, cholesterol, a BMI of 24 (and only succumbing to the occasional pink iced bun) McLachlan suggests sensitivity is needed for when and how health professionals’ offer lifestyle advice to patients. I would love to be able to run, feel the wind in my (thinning) hair, and lope gracefully past the meandering masses. However, wishing is not enough, and despite trying it many times, I end up looking like a fish out of water, flapping about and gasping for breath. Bits of my body that were never meant to meet flop and slap together, reminding me of my constant struggle for a modest BMI …
Whānau Ora: who cares? Nurses should… Primary health nurse practitioner ROSEMARY MINTO argues why nurses and health planners and providers should sit up and take more notice of Whānau Ora – a homegrown model she believes could help overcome health inequities in New Zealand. “You can’t solve the problem with the same thinking that caused it” – Einstein. As the election loomed, I found myself pondering the various political parties’ election promises about health, and I wondered who would come up with the best solutions for our inequities, inequalities, and other social ills that currently prevail. Very recently, I was able to participate in Whānau Ora practitioner training. It made me reflect as to why New Zealand healthcare system planners, funders, and providers seem to be on the eternal search for the ultimate in “models of care” when we have such an all-encompassing solution already in the system ...
Don’t drink and fry… how about not drinking till drunk? Former barman and now ED nurse practitioner MICHAEL GERAGHTY wonders when Kiwis will grow out of defining a great night as waking up feeling sick with no memory of the previous night and no cash in their wallet. I think many people in New Zealand are now cognisant of the harmful effect of alcohol and the associated social and health costs. So I was intrigued by a recent advert and campaign – sponsored by the NZ Fire Service – to reduce the incidence of ‘drink and fry’ house fires. The ad features three barely coherent people being interviewed on the street and stuffing their faces with burgers or paninis and advocating the benefits of having a good feed before heading home, and therefore, not needing to have a fry up/burn down the house later that night …
Nursing is the world's largest health profession, but the expectations and limits of what healthcare nursing can provide varies widely around the globe. Dr Kathy Holloway, chair of nurse educator group NETS and dean of Whitireia New Zealand’s health faculty, was recently one of a select 14 nurse leaders from around the world invited to a symposium in Philadelphia to discuss the development and use of advanced practice registered nurses (APRN). Holloway (and Australian-based New Zealand nurses Frances Hughes and Anita Bamford) joined an additional 15 invitees from across the United States for the Robert Wood Johnson Foundation-funded symposium. Holloway said the assumption of the symposium was that advanced practice nurses had the potential to play a much bigger role in improving the health of people – particularly to underserved populations. "We all agreed that healthcare needs were outstripping the ability of our current models (of healthcare) to supply."
Full article available online at www.nursingreview.co.nz
A LIFE LESS ORDINARY
10 Clinical Nursing specialties now fully online Expand your knowledge and skills in clinical nursing in the context of clinical practice with ACU’s postgraduate programs in Clinical Nursing. The following specialties are available: • Acute Stroke Care • Interventional • Perioperative* • Aged Care* Cardiology • Perioperative Nurse • Anaesthetics • Medical* Surgical Assistant • Cardiothoracics • Neonatal Care • Plastics • Child and Adolescent • Neurosciences Reconstruction Health* • Oncology* • Rehabilitation • Cardiac Care* • Ophthalmology • Renal* • Emergency* • Orthopaedics • Surgical* • Intensive Care • Palliative Care* * From 2015 ACU is offering these 10 specialties fully online to students not employed in one of ACU’s partner health facilities.
www.acu.edu.au/clinical-nursing-specialties
Nursing Review series 2014
Australian Catholic University – CRICOS registered provider: 00004G
If you’re reading the print edition, you’re only getting half the story. The recently revamped Nursing Review website has web-exclusive content, and from now on, news stories will only be published online. Go to www.nursingreview.co.nz for the latest news and opinion. Here are excerpts from recent opinion articles published online:
OPINION
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People, practice & policy WORKFORCE RESEARCH
Nurses wanted:
what DO you do to earn your pay? Nurses nationwide are invited to take part in a major online survey hoping to pinpoint the real differences between a staff nurse and a specialist nurse’s daily work. The New Zealand Nursing Practice Survey was launched online in early October by Massey University researchers Professor Jenny Carryer and Dr Jill Wilkinson and is funded by the Chief Nurses Office of the Ministry of Health. Carryer says the research survey aims to address confusion in the nursing sector – both here and overseas – about the difference between the many different nursing roles and titles and what difference that experience, qualifications and job title actually make. A particular focus is what actually is an advanced practice nursing (APN) role and the level of nursing practice it involves. “We want to know if there is any consistency between how different jobs are titled, paid, employed, and understood (across the country),” said Carryer. New Zealand currently has a plethora of clinical nursing job titles, including clinical nurse specialist, clinical nurse consultant, clinical nurse educator,
specialty clinical nurse, clinical resource nurse, clinical nurse coordinator, and associate clinical nurse manager. The only protected title is nurse practitioner. “The New Zealand Nurses Organisation has done some very good work around trying to clarify titles, roles, and pay scales (of senior nursing roles),” said Carryer. “What we don’t actually know is the different nature of practice between all those roles and titles.” The research hopes to discover more by asking nurses a series of questions using a sophisticated research tool to get a better grasp of the differences in clinical and leadership responsibilities and in the clinical practice level between nursing roles across the whole spectrum of practice, from new graduates to nurse practitioners and nurse leaders. The survey is based on the Strong Model of Advanced Practice Role Delineation (APRD) tool first developed in the United States. The model has been further developed and tested by an
Australian nursing research team led by Glenn Gardner, which has just completed surveying 6,000 Australian nurses and is currently analysing the data. Carryer said the New Zealand survey and research has been given a unanimous thumbsup by the National Nursing Organisations group, which includes the New Zealand Nurses Organisation, the College of Nurses Aotearoa, the Nursing Council, the two nurse educator groups, the College of Mental Health Nurses, and the National Council of Māori nurses. The anonymous online survey is inviting any nurse currently practising in a clinical environment – i.e. a public hospital, general practice, private hospital, or rest home etc. – to take part. The survey asks nurses about their qualifications, position, role titles, and experience. This is followed by 41 questions that cover five domains of nursing practice, including direct care and professional leadership. The survey will close in December, and the first results will be released from mid-next year.
Help us to help understand advanced nursing practice in New Zealand New Zealand nursing is a complex tangle of roles, levels and titles and sorting through the meaning of these is difficult for the profession, health care consumers and service managers. The problem is not confined to New Zealand and researchers in Australia have developed a survey tool to measure and differentiate levels of nursing practice through questions
about the time nurses spend on particular activities.1 Jenny Carryer and Jill Wilkinson from Massey University are using this tool to survey nurses in New Zealand. There are over 45,000 registered nurses and nurse practitioners in New Zealand and there is the potential for a large sample to influence the study and make an important contribution to workforce development in New Zealand.
Many nurses have generously participated already, but if you haven’t yet and you are a Registered Nurse or Nurse Practitioner currently employed in a clinical service environment you are invited to participate in the research. All nurses in any type of hands-on, management, leadership, research, or education roles, including senior nursing leadership roles are needed.
More information about the study and access to the survey itself is at this link:
www.surveymonkey.com/s/Nursing_practice_survey
1 Gardner, G., Chang, A. M., Duffield, C., & Doubrovsky, A. (2013). Delineating the practice profile of advanced practice nursing: A cross-sectional survey using the modified
strong model of advanced practice. Journal of Advanced Nursing, 69(9), 1931-1942. doi: 10.1111/jan.12054
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Nursing Review series 2014
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
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