Nursing Review October 2015 by NZME. Educational Media

FOCUS: Child Health / Infection Control / Wound Care

Nursing Review October/November 2015/$10.95

New Zealand’s independent nursing Series

Practice, people & policy

Tributes for Putiputi O'Brien Teaching Millennials

A DAY IN THE LIFE OF a cardiac care NP

CHILD HEALTH

• Healthy housing nursing • Coffee, books & child health

INFECTION CONTROL • To glove or not to glove? • Flu shots & masks

EVIDENCE-BASED PRACTICE

Legs up, heart down

WOUND CARE

• A sharp look at debridement • Reducing pressure injuries

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LETTER FROM THE EDITOR

Warm and well It was winter 2009. My husband and son set off to work and school in fine fettle and returned with identical hacking coughs and raging temperatures. Working from home often has its advantages but it was a mixed blessing finding myself juggling a deadline and caring for two likely swine flu cases. With my son too young and too unwell to stop spluttering and spraying virus all over me, I was desperately trying to recall any infection control tips I’d picked up as a nursing journalist over the years. Somehow I stayed well – I will never know whether my vigilant hand washing and covering of my face worked or whether somewhere along the line I’d acquired some immunity to H1N1. But it was around then that I decided getting my annual flu shot might be a good idea – an imperfect protection against the ever-changing flu virus but something I could do to reduce the risk to me and, more particularly, some friends with vulnerable health. I’ve been thinking a lot about the flu this edition, but what will probably stay with me longest is gratitude (and possibly a little guilt) that, if and when either I or my family are ever unwell again, we aren’t living in a house so cold, damp and mouldy that it is likely to make us even sicker. Read on p.4 about nurses who work with families who aren’t so lucky.

Inside: FOCUS: Child Health / Infection control / Wound care 4

CHILD HEALTH: healthy housing nurses TINEKE SNOW & SHIRLEY PIERCE

Housing stories from the South Auckland frontline

RESEARCH: cold rooms have high health costs

IMMUNISATION: don’t forget the dads

The asthma inhaler that moos

One-stop-shop for books and child health?

INFECTION CONTROL: to glove or not to glove?

Flu shot for nurses: masking the issue?

WOUND CARE: EMIL SCHMIDT on debridement

Pressure injuries: Northern Region making a difference

RRR professional development activity (SUBSCRIBERS’ EDITION ONLY)

Fiona Cassie editor@nursingreview.co.nz

To subscribe go to www.nursingreview.co.nz/subscribe

www.nursingreview.co.nz Twitter@NursingReviewNZ

Last print edition for 2015: sign up for digital-only end-of-year edition This is Nursing Review’s last print edition for 2015, but we will be producing a special digital end-of-year edition, including coverage of the upcoming National Nursing Informatics and Australasian Nurse Educators conferences. If you’d like a PDF of this edition emailed to you then go to our website www.nursingreview.co.nz, scroll to the bottom and click on the ‘subscribe’ link to sign up to our free online news alert service. The first print edition for 2016 should be wending its way to your mailbox, ward or practice in February.

Wider distribution for Nursing Review Free copies of Nursing Review are now 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

Multimedia platform for nursing Nursing Review is a genuine multimedia publication, with five print editions and our recently revamped website, which contains 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: Wellington-based ‘healthy housing’ nurses Tineke Snow (left) and Shirley Pierce. See story on p.4. PHOTO CREDIT: Amanda Garnet, photographer www.facebook.com/Amanda-Garnet

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).

Practice, People & Policy 29

Tributes to nursing treasure PUTIPUTI O’BRIEN

OPINION: Nursing down under from an Irish nurse’s perspective

GWEN ERLAM on teaching Millennials

Update on RN prescribing

Regulars 2

Q&A Profile: new NZNO president GRANT BROOKES

A day in the life of… cardiac care NP ANNETTE RIEF

Evidence-based Practice: CYNTHIA WENSLEY on steadying fast-beating hearts

College of Nurses: TAIMA CAMPBELL on health inequities for Māori

Connect with Nursing Review on Twitter Follow Nursing Review for breaking news, latest innovations, and professional issues close to your heart. Find us on Twitter@NursingReviewNZ Editor Fiona Cassie production Aaron Morey Advertising & marketing manager Belle Hanrahan Publisher & general manager Bronwen Wilkins images istock

Nursing Review

Vol 15 Issue 5 2015

NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6141, New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600 © 2015. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014

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

Nursing Review series 2015

Q&A

Grant Brookes

JOB TITLE | President, New Zealand Nurses Organisation

Q A

Where and when did you train? I was one of the young BN pioneers, going forth blinking into the bright new day for nursing education. In 1992, I joined the first intake of the undergraduate degree programme at Otago Polytech. After a gap year and some part-time study, I graduated from there in 1996.

Q A

Other qualifications/professional roles? Prior to my current position, my most recent professional role was on the National Committee of the NZNO Mental Health Nurses Section, where I served as co-editor of our Head2Head journal.

voice for those who are under-represented, to focus public debate on the social determinants of health and to help people take action themselves for change.

Q A

What are you looking forward to most about your new nursing leadership role? I am looking forward to continuing to connect with NZNO members. I’m committed to bringing their voices, their issues and successes to the board table, so that our organisation is guided by the membership. I am also excited about strengthening the bicultural relationship within our organisation, in order to support stronger action for Māori health.

Q A

Why did you decide to become a nurse? I worked in hospitality after leaving school and found I enjoyed serving people. I also relished an intellectual challenge and completed a physics degree and a diploma in liberal arts at the University of Otago. The Bachelor of Nursing programme seemed to bring these two things together. But above all, after graduating with my BSc (Hons), I sought a meaningful job I could put my heart and soul into. Friends and family, more conditioned by gender stereotypes, asked why I didn’t do medicine. But while volunteering in 1991 at the Otago Community Hospice I found the rewarding career I was looking for – nursing.

In recent years you have stood for Capital & Coast DHB, Hutt City Council and now have been elected NZNO president. What has drawn you to seek public office? Working in mental health, as I have done, you see social exclusion up close. The reality of the social determinants of health is unavoidable. And as an NZNO leader, I have seen how the voices of nurses can be marginalised and ignored. In 1987, the World Health Organisation published Leadership for Health for All: The Challenge to Nursing. The strategy document said: “Because politics is the vehicle of policy making and social change, some nurse leaders will have to combine the gentle art of nursing with the rougher one of political activity”. I have stood for public office to respond to that challenge. I have strived to provide a

Nursing Review series 2015

Q A

What do you do to try and keep fit, healthy, happy and balanced? I have recently become a runner. This year I entered the 10km race at the Wellington Marathon, as part of the Capital & Coast DHB team. I was chuffed to finish 77th out of 1,105. Our team came third overall and raised $4,000 for the Heart Foundation.

Q A

What was your nursing career up to your latest position? Providing direct care for mental health service users has been my passion. So I’ve spent my career at the coalface, in the community and in inpatient units in Auckland, London, Wellington and Melbourne.

of philosophy, whose career has included Harvard and Princeton. He said: “If your success is defined as being well adjusted to injustice and well adapted to indifference, then we don’t want successful leaders. We want great leaders – who love the people enough and who respect the people enough to be unbought, unbound, unafraid and unintimidated to tell the truth”. These are characteristics that can be acquired, through practice, by some.

Grant Brookes

Q A

What are you looking forward to least? See next column, for what I’m reading instead of the interesting books gathering dust at my bedside.

Which book is gathering dust on your bedside table waiting for you to get round to reading it? There are two books gathering dust there – Maire Leadbeater’s Peace, Power & Politics: How New Zealand Became Nuclear Free and The Chimes by Wellington author Anna Smaill. I confess that when it comes to novels I’m one of those time-poor individuals who lets the Man Booker judges do the searching. The best book I’ve read this year, however, is Naomi Klein’s This Changes Everything: Capitalism vs the Climate, which is now a feature documentary. It was timely, as delegates at our AGM last month voted that NZNO should support fossil fuel divestment.

Q A

What have you been reading instead? In week two of my new role, sadly, my reading seems to be governance manuals, terms of reference, financial statements and previous minutes.

If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? I would ask for safe staffing, so that nurses can deliver the care we dearly want to provide, and not go home utterly exhausted or in tears. I’d also ask for pay equity – an end to the discrimination based on gender, ethnicity or sector – and for a supported entry to practice (NETP or NESP) place for every new nurse.

Q A

What do you think are the characteristics of a good leader? And are they intrinsic or can they be learnt? My favourite quote about leadership comes from Dr Cornel West, a professor

While waiting in the supermarket checkout queue, which magazine are you most likely to pick up to browse and why? I sometimes despair at the New Zealand media landscape. The only magazine I’m likely to browse at the checkout – for intelligent commentary, fashion and more – is Rolling Stone.

Q A

What are three of your favourite movies of all time? Selecting three all-time favourites would be too hard. But my top three from the last year are Selma, Testament of Youth and The Dark Horse. Thanks for asking!

A day in the life of ...

a cardiac care nurse practitioner (with prescribing rights)

NAME | Annette Rief JOB TITLE | Nurse Practitioner for Adult Congenital Heart Disease LOCATION | Auckland City Hospital

6.00

AM WAKE I get up, shower, and cycle to the Birkenhead ferry terminal to cross the harbour on the Tiger Cat ferry. Highlight of the trip: a pod of Orcas hunting for stingrays in the harbour. People pay a fortune to see this and I get it on the way to work. Magical! However, the ferry has to slow down so as not to frighten the whales and I am running a little late. I quickly cycle up the hill to the hospital.

8.10

AM ARRIVE AT WORK I check emails, texts, planned appointments and get ready for my nurse-led clinic, underway at 8.30. Each year more than 100 children born with heart conditions transition to the adult services for their ongoing care. So demand for the adult congenital heart disease service has grown substantially over the last decade. Being a nurse practitioner with prescribing rights allows me to work almost independently and help meet that demand. Five patients are booked today. My phone rings just as I am taking the first patient into the clinic room. It’s a GP requiring urgent advice on a patient and together we make a plan of action. The phone keeps ringing, but all other calls are not urgent and I can call back later. The first patient is new and frightened; something serious may be going on and he lists a number of potentially serious symptoms. I ask a number of additional questions because chest pain, breathlessness, dizziness and faints can occur for many reasons. Understandably, most people with heart conditions worry a great deal about symptoms like those because they can be a sign of things getting worse. I encourage my patients to get in touch if they have health worries and usually arrange urgent reviews. This patient’s ECG looks normal and I don’t think the symptoms are typical of heartrelated problems, but I check the heart echo scan first and, after reviewing it with one of the consultants, I propose a management plan. The consultant and I share the plan with the patient, including a few additional baseline tests required over the next few weeks. The patient leaves, relieved, and will return in three months to discuss the test results. The next patient is well known to me and requires up titration of a medication. The clinic nurse checks show adequate blood pressure, heart rate and oxygenation and the patient has remained well. So I prescribe an

increased dose and give him a follow-up plan, including instructions to call me if he notices any new symptoms. The second patient is also long-standing and is coming for a heart failure check. She is well, her weight is stable and so no changes are required. The fourth booking is for a lost to followup patient who does not arrive but I talk to them on the phone, explain the importance of regular check-ups and negotiate a new appointment time. The final patient is 35 weeks’ pregnant and this is her last check before delivery. The heart of her unborn baby has been checked and it is normal (patients with congenital heart conditions have a higher chance of having a ‘heart’ baby and get an extra check). The ECG and heart ultrasound today show her own heart function has remained stable so the consultant confirms that a normal vaginal delivery is likely possible. This is great news and we are very happy for her.

health problems warranting further investigations, so I arrange these and bring forward their regular appointments. Our wait list for heart echo tests is several months long, but for now I am still able to get short notice clinic appointments. I get another call and decide this caller requires urgent admission to hospital. I fortunately work closely with our cardiology ward 31 and patients with obvious heart problems can be admitted straight away (space permitting), rather then wait for hours in the emergency department. The admission keeps me busy for the most of the afternoon and in between I check on the other two cardiac catheter cases in recovery. Both are well – phew! At 5pm I round with the consultant and our registrar to check the three cardiac catheter patients. We make a discharge plan for the next day. I notify the registrar about the new inpatient, as we share our workload when possible.

1.00

5.30

pM LUNCH No time to eat just yet, as I check on the first of three cardiac catheter patients in the recovery room. I met them the previous day and am responsible for checking there are no unexpected complications following the procedure. I am lucky, the first patient is well, and so I head off to grab a bite to eat.

2.00

pM AFTERNOON ROUTINE I dictate letters from this morning’s clinic, a note to the GP of the patient who didn’t come, and book the additional tests for the new patient. I then call back the patients from earlier this morning. Both have developed

pM LEAVE WORK I change back into my cycle gear and leave work exhausted. Luckily it’s not raining and I draw in the blue sky (my office doesn’t have daylight). The way to the ferry is mostly downhill and I get to see the sun set on the way home. I usually cook to relax when I get home but today I am too tired. So tonight it’s a takeaway – pulled pork burrito – which I eat with my partner on the couch, feet up, watching a movie. Getting off the comfortable couch is hard, but I manage eventually.

10.30

pM TIME TO SLEEP

Annette Rief

Nursing Review series 2015

FOCUS n Child Health

Poor child health and housing:

what’s being done? Thousands of children turn up each year in hospitals with respiratory and skin conditions. Many of them return to damp, cold or overcrowded houses that further aggravate or caused the conditions in the first place. FIONA CASSIE talks to two nurses whose focus is working with families to prevent the adverse effects of sub-standard housing on child health.

echnically, not all of healthy housing nurses Tineke Snow and Shirley Pierce’s families have homes to be healthy in. Instead, they alternate week about sleeping on the floors or couches of the already crowded homes of families and friends. Other families live with mushrooms growing in the corners or spend the winter sleeping huddled in the lounge as it is the only heated room. Snow and Pierce are two of the very few public health nurses in New Zealand whose practice focuses solely on housing and health. Pierce began working in the role in 2013 under the previous Healthy Housing scheme and Snow joined her in 2014 when Wellington’s Housing Assessment and Advice Service was launched. The pair between them have assessed homes, and advised and advocated for hundreds of families referred to them by health professionals because of concerns that their housing situation is adversely impacting on their health. They check leaks, inspect mould, count heads and beds, ensure the toilet works, help fit curtains, promote smoking cessation, write letters to landlords, liaise with client’s health professionals, ring Housing New Zealand, and advise tenants of their rights and responsibilities. The pair are passionate about their work and the difference a registered nurse can make after a thorough health and safety check of the house and assessment of the family’s health and housing needs. A research project is also underway to measure the difference their service actually makes (see related article). The original Healthy Housing scheme operated between 2001 and 2013 and was a collaboration between Housing New Zealand and some district health boards in Auckland and Wellington. Funding for that scheme ended in 2013 and the rheumatic fever-targeted (called Well Homes in Wellington) scheme was launched in 2014 to work on healthy housing issues facing families with children hospitalised with rheumatic fever, respiratory conditions and some other conditions, whether they live in state or private rentals or their own home (see details in sidebar p.7). Wellington’s Regional Public Health decided in 2014 to continue to offer in addition a Housing Assessment and Advice Service with wider referral criteria than the quite tightly targeted Well Homes scheme; and Hutt Valley District Health Board employs the two nurses to deliver the service across the region.

Nursing Review series 2015

saturated and mushrooms were growing in the corner so the mother and child were forced to retreat into a lean-to area. “And coming into winter we knew there was nothing we could do to make that area warmer or drier.” An urgent appeal for a dry home for the mother and high-risk child was successful but connection with the family continues still as Snow works through the Tenancy Tribunal process as an advocate for the family and to ensure the property is not rented out as a ‘home’ again. Another of Pierce’s clients was an Tineke Snow (L) and Shirley Pierce (R). 18-year-old rheumatic fever patient referred by the nurse giving him his monthly prophylactic bicillin injection. That means Snow and Pierce can also work Pierce arrived to find he was living with his partner with the families of children with skin infections, and their 14-month-old baby and during the visit it older teenagers and adults. The most common became clear the partner was pregnant with their referrals are those for eczema, asthma and other second child but hadn’t received any maternity respiratory conditions. care. The young family were shifting from house to house, co-sleeping on a single mattress and Homeless and garage dwelling clients with his health history, and the baby to come, The pair’s clients may rent rooms in a boarding Pierce was able to work with Ministry for Social house, live in their own rundown homes or rent a Development (MSD) and Housing New Zealand to social or private rental house. Others technically get them an urgent home. don’t have a home at all. “We think of homelessness as being rough Pierce says for example one of her clients – a sleepers or just people living on the street but we woman with a young baby admitted twice to have couch-surfers and people who live in cars hospital in three months for respiratory conditions too,” says Pierce. ”And that’s where some of our – was living between two families’ properties. One prioritisation comes in. A family needing another was a three-bedroom home with seven people bedroom will have less priority than a family living already living in it and the other property – Pierce in a car.” stops to count off the inhabitants in her head – stretched to house 11 when the mother and baby were staying. “They are effectively homeless so it is about supporting them into an urgent social housing property.” Snow had a teenage mum living in a rented converted garage with a seven-month-old baby. Bad leaks meant the carpet was constantly

Definition of overcrowding Structural crowding: when more than two people share a bedroom e.g. nine people living in a three-bedroom house. Functional crowding: when there are enough bedrooms but everyone sleeps together; for example, in the lounge, because it is too expensive to heat the whole house or because the bedroom/s are damp and cold.

Overcrowding and sharing beds

The waiting lists for social housing are very large and the wait can be very long. When situations are really dire, the pair say MSD and Housing New Zealand are very good at helping them get people into housing quickly. “But for the majority it is getting people on the waiting list,” says Pierce. “So we do a lot of managing expectations and talking to families about what is realistic and what is not.” That refers not only to being rehoused but also to what is fair to expect from Housing New Zealand and other social housing providers and what is feasible to expect from private landlords. Requests for curtains or an improved heating source, when backed by a family’s medical history, are often responded to by Housing New Zealand but responses from private landlords to health-based housing requests can vary widely. Continued on page 6 >>

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FOCUS n Wound Care & Infection Control/Child Health

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Nursing Review series 2015

FOCUS n Child Health

“It is very common for landlords to say – I don’t have the money to do that. Or we don’t hear anything back from them,” says Snow. Private tenants are also wary any improvements may see the rent go up. For instance, the pair refers eligible clients to Warm Up New Zealand (see sidebar p.7) for free insulation whenever they can. “Our installers are quite good at reminding landlords that it is a free service and they shouldn’t expect to put up rent because of it,” says Pierce. “But it sometimes does happen,” says Snow. The pair are keen advocates for their clients but pick their battles. “We’re limited in what we can do because of the law around private rental property,” says Pierce. “So we’re not always as successful as we’d like to be.” The pair would like to see higher expectations of rental properties – including tenants’ rights to simple things like curtain rails. A good heat source, or even a heat source in some cases, would be great too. “At the moment all you need [legally for heating] in a rental property is to supply a plug.” But they believe the introduction of any minimum standards (or warrant of fitness) needs to be a practical and workable solution for both tenants and landlords.

But if not, they share practical tips to reduce health risks, such as children sleeping ‘top and tail’ in a bed or other ways to ensure children’s heads are at least a metre apart as they sleep. And if children are sleeping on a mattress on the floor, they advise to try and air it every day. They say up to half of the families they see could benefit from having a larger house (see definitions of overcrowding on p.4).

Vinegar, ventilation and curtain banks

parenting support and community support, such as food banks. They also contact the family’s GP and practice nurse to share what support they have been able to give and let the original referring agency know the family has been visited. The pair say this is not only to keep people “in the loop” but also as part of a community education process so general practices and other health providers are aware of what services are available for their patients, such as referrals for free insulation, curtain banks or free fire service checks of homes. Snow and Pierce says that combined expertise means they can take the time-consuming housing advocacy role off the shoulders of any other health professionals working with the family.

Being a nurse adds clout

Unlike any other agency walking through the family’s front door, the pair hold an effective combination of both housing and health professional expertise. As part of their initial one-hour assessment, they touch on wider family needs and work with agencies to links families with budgeting and

They know how to write to landlords, how the Tenancy Tribunal process works, and who to contact at MSD or Housing New Zealand. Being registered nurses also adds an extra dimension to the healthy housing service they can provide their clients. At one level it means they access their clients’ hospital notes and, with permission, draw on relevant health information when advocating for their housing needs. But they can also can draw on their clinical experience when working with clients in a familycentred way. Pierce has a background in mental health and practice nursing while Snow has worked in neonatal care, district and older person nursing. The pair go into homes with the focus of making houses warmer, safer and drier but their nursing background and experience means they also have the skills to advise on smoking cessation, and talk about the correct use of asthma inhalers and managing a child’s eczema symptoms. “I think being nurses means we are lucky because people trust the profession and we’re also one group that aren’t afraid to talk to people honestly.” “We try and be respectful but sometimes we are talking about things that people don’t want to hear – like about the cleanliness of their home, the need for engagement with parenting services or we are screening for domestic violence. “People disclose a lot more to us than you would probably expect them to disclose to other people,” says Pierce. The pair often have an ongoing relationship with a client for many months where they try to make the most impact they can on health-related housing issues. But even if they can’t resolve all housing issues for a complex family, they at least have been able to visit their home, make an assessment and their notes are now another piece of the puzzle that provides a more comprehensive picture to the general practices and other agencies working to improve a family’s health and wellbeing.

”We think of homelessness as being rough sleepers or just people living on the street but we have couch-surfers and people who live in cars too.”

Lobbying landlords for repairs, supporting tenancy disputes and waiting for clients to inch their way up social housing waiting lists all takes time. So a major focus of the pair’s work is helping families with cheap and faster solutions to make the most of the housing they already have, including, of course, seeking free home insulation. “We are looking for the cheapest alternatives as we’re not funded to provide a lot of interventions,” says Pierce. For instance, mould is a major issue that many families have to battle in New Zealand’s very cold and damp housing stock. Mould caused by leaks is not a tenant’s fault and Pierce and Snow will approach landlords about repairs. But the pair educate tenants that lifestyles can also contribute to the risk of mould and simple housekeeping tips can make a difference, such as opening the curtains every morning, wiping condensation off walls and windows, and opening all windows for at least a few minutes every day for cross-ventilation. The aim is to reduce moisture inside the house as a drier house helps lower both heating bills and the risk of mould. They also advocate drying washing outside or in a garage or carport (see these and other tips in sidebar). For mould, they give out simple and cheap mould cleaning packs made up of a spray bottle, white vinegar, a cloth and instructions. “We found that mould is very common and if you leave them a kit using white vinegar it is not only cheap to replace but it is right there and ready to use,” says Snow. Pierce adds white vinegar is not only cheap and effective it is also less toxic for people with respiratory and skin conditions than alternative mould spray options. Overcrowding is common in many households they see, so children sharing beds is quite frequent. In most cases it is not for cultural but financial reasons because the family lacks sleeping spaces and beds. The pair have access to some limited funding and resources so when possible they supply extra beds and bedding for children. 6

Nursing Review series 2015

What nurses can do to help TIPS FOR WARMER AND DRIER HOMES »» »» »» »» »» »» »» »» »» »» »» »»

Open curtains every morning (and close them at night) Wipe condensation off windows and walls Open windows for at least a few minutes every day to cross-ventilate house Try to have a bed or mattress for every child If mattress on floor, ensure mattress is aired every day – preferably outside in sun If children have to share bed, ‘top and tail’, or otherwise try to keep children’s heads more than a metre away from each other to reduce infection risk Dry washing outside or in garage/carport to reduce moisture in house Wipe away mould using either white vinegar or bleach Refer eligible people to Warm Up New Zealand for free home insulation Use curtain banks to source curtains to help keep house warm Prioritise the heating of the bedrooms of the most vulnerable family members over winter to reduce impact of asthma and respiratory infections Check house for obvious health hazards like adequate cooking space, functional toilet and shower.

Main source: The resource Key tips for a warmer, drier home and related videos can be downloaded and viewed at the Ministry of Health’s rheumatic fever learning resources page for health professionals: www.health.govt.nz

FOCUS n Child Health

Housing stories from the frontline in South Auckland Kidz First public health nurses see the reality of how Auckland’s housing crisis impacts on often struggling families. Seven nurses and their clinical nurse manager Lizzie Farrell share stories of some of the families they work and walk alongside.

Kidz First Public Health Nurse team from Otara: (from left) Samantha Anderson (PHN), Dolly Chetty (PHN), Lizzie Farrell (Clinical Nurse Manager), Pam Williams (PHN, sitting), Joanne Rosier (PHN), Pele Latu (PHN), Liz Tiamulu (PHN), Lemau Tesese (PHN)

isiting overcrowded, damp and cold houses to follow up children with health problems is the daily reality for Kidz First public health nurses. The Counties Manukau District Health Board nurses refer eligible families to the healthy housing schemes AWHI and Warm Homes Counties Manukau (see below) and work collaboratively with other agencies to try and make a difference.

Healthy housing schemes Healthy Home/Well Home initiatives

Funding targeting rheumatic fever was announced in the 2013 budget initially for the Healthy Home initiative in Auckland. Budget 2014 saw further funding spread to the Well Home initiative in the Wellington region, as well as initiatives in Northland, Waikato, Lakes, Bay of Plenty, Tairawhiti, and Hawke’s Bay. Referrals can be made by sore-throat clinics, hospitals and bicillin injection services, and criteria include the number of positive strep throat swabs or reason for hospitalisation and the age and number of children in the household. AWHI (the Auckland-wide Healthy Homes Initiative) is the coordinator for nine providers offering Healthy Home services in Auckland. Chae Simpson, the AWHI manager, says in the 12 months to June 2015 it received about 1,160 eligible referrals, of which 950 came from Counties Manukau DHB. Community health workers are sent out to visit eligible families to carry out a standardised assessment and develop an action plan to resolve issues that can include applying to Housing New Zealand for a new or larger home if overcrowding is established. Simpson says the situation is challenging as Auckland is in the midst of a housing crisis but AWHI providers had been able to successfully rehouse or house close to 65 AWHI families in social housing in Auckland.

Lemau Tesese recently followed up a 6-yearold girl with bronchiectasis to find her living in a damp, mouldy, uncarpeted, meagrely furnished, three-bedroom home with six siblings and a single mum with many social issues. She advocated for the mum, got the school involved and collaborative inter-agency work saw the family able to move into a well-insulated, carpeted, five-bedroom Housing New Zealand home. “It is a new beginning for

Warm Up New Zealand The Warm Up New Zealand scheme provides free ceiling and underfloor insulation for low-income households occupied by people with health needs related to cold, damp housing. Homeowners or tenants may be eligible if they have a Community Services Card and the house is occupied by someone under 17 years or over 65 years.

Warm Up Counties Manukau Warm Up Counties Manukau also provides free home insulation for eligible families but accesses additional funding to offer a comprehensive health and social assessment by registered nurses of Warm Up families, after the insulation is installed, to ensure they are accessing appropriate health and social services.

Wellington’s Regional Public Healthy Housing Assessment and Advice Service This is a nurse-led service offering free home visits and housing, health and social needs assessments to low-income families identified as having a housing-related health condition in households outside the rheumatic fever, age and conditionlimited Well Homes/Healthy Homes services. The service is funded by the Service Integration and Development Unit (SIDU), which was formed from a merger of the Planning and Funding teams in the Wairarapa, Hutt Valley and Capital and Coast DHBs.

Nursing Review series 2015

FOCUS n Child Health

Mould in homes can have serious health effects on children.

them and they are much happier and we’ve seen a huge improvement in the child’s health, as well as the mum.” A child with numerous positive strep throat swabs drew Liz Tiamulu to a family of three children where the mum herself had had rheumatic fever. A pattern emerged that when the boy was living with parents he had numerous throat infections but when he went to stay with his grandfather he did not. A visit to the family home found that it was cold, windows closed and the parents smoking inside so Tiamulu gave them some health education about ventilation, smoking outside and encouraged them to quit. A recommendation to AWHI saw the family put on the waiting list and in 18 months they were moved to a warmer home and the boy hadn’t come back positive since. Dolly Chetty tells of an 11-year-old intermediate school pupil with frequent bleeding noses, hay fever and repeated positive strep throat infections whose single mum had taken him to the GP but failed to get a resolution. Chetty referred the family back to the GP, leading to an ENT referral and surgery in Starship. She also referred the family, which had three children, to AWHI and the family were rehoused and overall are much healthier and happier. Health promotion about how families can help make their houses warmer and drier is also stressed by Pam Williams who visited a family on a beautiful warm spring day during the recent school holidays to find the three children playing inside the cold house with all the windows closed. “And the mum wearing a puffer jacket as it was actually warmer outside than it was inside the home.” She shared some of the Key tips for a warmer, drier home (see tips on p.6) from the recently released Living Well toolkit, including getting the kids outside, opening windows and wiping down the mould in the hallway. Williams sees sharing such knowledge as having always been a huge part of the public health nurse role. Joanne Rosier agrees and shares a story about arranging a visit to a home where a family had multiple strep throats to see whether there was anything they could do about improving the housing situation. She found mouldy carpet in the bathroom that had resulted from the kids flooding the bath. “And although the mum knew it didn’t 8

Nursing Review series 2015

smell nice she had no idea about the health effects that mould could have on her children.” So Rosier has been working with the mum and Housing New Zealand to get the carpet replaced. She said the mum’s lack of knowledge about the health consequences of mould was not uncommon. Housing situations in Auckland are also hindered by high prices with families forced to pay up to $500 plus a week. Samantha Anderson says this is hard on client families who are often “part of the working poor” but do the best they can with what they’ve got. The low incomes prompt overcrowding as families take in other relatives to try and spread the cost. Pele Latu backs this saying the average weekly rent for a three-bedroom house is $450–$480 a

week and this can lead to three families sharing a three bedroom house so they can share the rent. “I’ve got a family at my school with a child who was diagnosed with rheumatic fever.” When their housing was assessed they found the landlord had thrown up light partitions in a cold, damp basement so it could be rented as a “threebedroom” dwelling. Migrant families trying to gain New Zealand residency can face even more difficulties with Lemau Tesese reporting she found a mum, dad and seven children living in one bedroom at a boarding house after one of the children was admitted to Kidz First with respiratory problems several times. But because they aren’t residents they aren’t eligible for AWHI or Warm Up so finding help for them is especially challenging. Finding suitable warm, dry and affordable housing in Auckland for all families in need is far from easy and families can sit on waiting lists for a very long time. Kidz First public health nurse clinical nurse manager Lizzie Farrell says a strength of public health nursing is that they can develop relationships with families and support them until rehousing does happen. “And we can make it happen sometimes.” Particularly if health and social agencies pull together and collaborate. But it is a “miracle” if rehoused children can keep attending the same school. Farrell also manages the Warm Up Counties Manukau scheme which, unlike most schemes around the country, includes a health assessment by a community nurse after the insulation is installed – bringing some Auckland houses’ temperatures up from just nine degrees to something more healthy and liveable. Farrell thinks a major issue that does need addressing is improving the standard of private rental housing and she for one would love to see some form of rental warrant of fitness.

Compulsory insulation and ‘WOF’ for housing

ealthy housing advocates would like to see some form of warrant of fitness (WOF) introduced to ensure minimum health and safety standards for New Zealand’s rental housing. The government is yet to be convinced but this winter announced it has reformed the Residential Tenancies Act so that from July next year all social housing must have retrofitted ceiling and underfloor insulation and from 2019 all other rental housing will require insulation. Smoke alarms will also be required in all tenanted properties from July 2016. Housing Minister Nick Smith said at the time the changes would make houses warmer, drier and safer and were a more pragmatic and efficient way of improving housing standards than a housing warrant of fitness. “Such a scheme [WOF] would cost $100 million a year and $225 per house for inspections alone, and these costs would be passed on to tenants in rent.” In June the Health Research Council awarded a $5 million Health Research Council grant to the University of Otago’s He Kainga Oranga/housing and health research team to further its ongoing research, including trialling a rental warrant of fitness prescribing minimum standards for existing properties. Lead researcher Professor Philippa Howden-Chapman said rental housing was on average of lower quality than social housing or owner-occupier housing and just under half of children in households below the poverty line lived in private rental dwellings. The study aims to establish the effect of implementing a rental WOF on tenant health, particularly children’s health, and to determine the effect of a rental WOF on housing supply and affordability. (Earlier research by the team on the health impacts of insulation prompted the government’s Warm Up New Zealand scheme that lead to retrofitting insulation in state housing stock and subsidising or funding nearly 280,000 more homes being insulated.) An initial draft rental WOF – developed by the He Kainga Oranga team with the New Zealand Green Building Council and in collaboration with ACC and five of the country’s largest local bodies – has been pretested and is being refined. This WOF has 31 health and safety criteria including: ceiling and underfloor insulation; no cracks or holes in roof or cladding; opening bedroom and living area windows (with latch); curtains in the lounge and bedrooms; fixed, effective and safe heating in the living areas; an operational toilet; and a functional bath or shower.

Respecting lives. Restoring independence. At RDNS NZ, (Royal District Nursing Service) quality care is not just about what we do in a client’s home. It’s the values our support is based on, and the services we have in place to ensure our clients can live the life they choose.

Our services include: Personal care – Assistance with showering, dressing, and meal preparation. Domestic help – Including housework, laundry and shopping. Restorative activities – From exercise programmes to socialisation activities, allowing people to lead more fulfilling lives. Respite in the home – Enabling full time carers to have a break. Nursing – Generalised and specialised home nursing including wound care, medicine management, stomal care and more.

0800 RDNS NZ (0800 736 769) www.rdns.org.nz

Nursing Review series 2015

FOCUS n Child Health

Housing research: cold rooms have high health costs Housing researcher NEVIL PIERSE talks to Nursing Review about getting the hard statistics and evidence to back healthy housing initiatives.

iwi kids’ health is suffering as too much of our rental housing is “too damned cold, old and mouldy”, as housing researcher Dr Nevil Pierse bluntly sums up the situation. The statistician is part of the University of Otago’s He Kainga Oranga/housing and health research team that this year received a $5 million Health Research Council grant to further its ongoing research into improving New Zealand’s housing stock for the “sake of our children’s health” see more in ‘Warrant of Fitness’ sidebar p.8). One of the six new studies funded involves Pierse following the work of Wellington housing nurses Shirley Pierce and Tineke Snow to see what impact their intervention service, which draws on the team’s research, makes to housing-related health conditions in children. Pierse says in recent years around 4,400 Wellington children were hospitalised because of conditions potentially attributable to housing – or just over a quarter of the children hospitalised. He says Pierce and Snow’s nursing service is innovative as, rather than children who are hospitalised for housing-related conditions just being sent back to the same environments, the pair assess the homes and try to resolve issues so the children don’t end up in hospital again.

Warmer in the freezer

The story of one asthmatic boy in Bluff involved in another of Pierse’s research projects, provides a stark example of how housing impacts on health. “He was sleeping in a room that we measured as being down to minus 4 degrees Celsius at its coldest. This boy would have been warmer in his freezer than in his bedroom.” Not surprisingly, this boy had four hospitalisations for asthma in the winter. The following winter, after his house was insulated and adequately heated, he had no hospitalisations. That study, led by Pierse, involved looking at the temperature of children’s bedrooms and the impact on their lung function. It found that when a child’s bedroom temperature dropped to less than 12 degrees Celsius for even around an hour, the resulting decrease in lung function was still detectable two weeks later. Pierse says room temperatures that low are not uncommon in Wellington or Christchurch if a bedroom isn’t heated during winter. “It would be cheaper for the Government to ensure that low-income families can heat their children’s bedrooms rather than paying for the health consequences afterwards because the health consequences last for a lifetime – and they are rapid and substantial.” 10

Nursing Review series 2015

Nevil Pierse

”It would be cheaper for the Government to ensure that low-income families can heat their children’s bedrooms rather than paying for the health consequences afterwards.” New Zealand has amongst the highest rates of asthma in the world and Pierse says that can probably be linked in part to our damp, cold and mouldy housing. He says every asthma hospitalisation is estimated to cost a district health board about $2,500 and a further financial burden of at least $350 to the family through lost work time and extra costs. “And these are the poorest families paying for this – they really can’t afford these costs.”

Studying nursing intervention

One answer is targeted interventions like those provided by Snow and Pierce’s healthy housing nursing service. The health outcomes of the pair’s client cohort are being followed by Pierse for

five years and will be compared with a control group of “equally sick” children hospitalised for potentially housing-related conditions, including skin conditions. He hypothesises though that the nursing intervention will impact most on respiratory conditions as skin conditions are more related to overcrowding, which is more difficult to resolve than making houses warmer and drier. Having nurses lead a housing intervention makes sense to Pierse. “Nurses are very practically minded people and there are a lot of practical answers to these [housing] problems. “And I think people do respond very well to well-trained nurses.” Nurses can explain the health consequences to families on taking practical steps, from wiping down condensation to giving up smoking, and can also explain the health consequences to landlords and other agencies when they write letters in support of tenants or make referrals on housing-related issues. Pierse says it would also be helpful for nurses and others working in the public health field if there was more regulatory clout to enforce basic housing standards.

More regulatory clout

In the United Kingdom it has been calculated that having minimum building standards saves them more than £7 billion in health costs, says Pierse. New Zealand taxpayers are paying for the increased health costs resulting from poor housing and the Government is also spending $1.3 billion on accommodation supplements a year, including low-income families living in cold, damp and mouldy rental stock. For Pierse the statistician it makes economic sense for the government to enforce minimum standards for rental housing it subsidises or a rental Warrant of Fitness (see sidebar p.8). He says while there is some nervousness about heating and safety requirements, in general most landlords want good habitable housing of a good standard. “Nobody wants to be a slum landlord.” Also, having set minimum standards for rental housing would empower nurses and other public health professionals to ensure a house is brought up to standard, particularly if a tenant had been hospitalised for housing-related reasons. The World Health Organisation recommends children’s bedrooms never go below 20 degrees and even with insulation and heating we struggle to get many Kiwi houses above 16 degrees, says Pierse. At present the whole burden of that old and cold housing is falling on the health system argues Pierse. “It is the health system that is fixing up the kids and sending them back out (to the same houses that often caused the problem).”

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FOCUS n Child Health

Childhood immunisation: don’t forget the dads Nursing Review talks to paediatrician Cameron Grant about some of the take-home messages around childhood immunisation in the longitudinal Growing Up in New Zealand study.

xpectant mums are often the focus for immunisation education but recent research shows that dads are just as important. The Growing Up in New Zealand study found that children of fathers (or partners) who receive discouraging information about immunisation during their partner’s pregnancy are 50 per cent more likely to have delayed immunisations. Cameron Grant, a Starship Hospital paediatrician and associate director of the major longitudinal study, says the messages given to partners are a really important issue. “I worry that partners are a wee bit excluded from some of the conversations that happen during pregnancy.” The study interviewed 6,172 of the pregnant women enrolled in the study, along with 4,158 partners (mainly the biological fathers of the babies) about their immunisation intentions prior to the birth and where they had received their information on immunisation from. It found that expectant parents who received information discouraging them from immunising their child were twice as likely not to get their baby vaccinated on time as those who didn’t. (Timely vaccination was defined as babies receiving their six-week, three-month and five-month vaccinations within 30 days of the due date). The impact was greater if mothers were discouraged, with 60 per cent of their babies receiving timely vaccinations compared with 73 per cent of babies of mothers who didn’t receive discouraging information. But ‘discouraged’ partners also had an impact on timely vaccination, with 64 per cent of their babies not being vaccinated on time, compared with the 74 per cent of babies whose fathers had not been given discouraging information. In all, 14 per cent of mothers and 13 per cent of fathers reported being aware of discouraging information, compared with 39 per cent of mothers and 30 per cent of fathers who reported receiving encouraging information. The ‘encouraged’ mothers were most likely to get their information from a midwife (62 per cent) and the fathers also, but to a lesser extent (44 per cent), followed by the would-be parents’ GP. Fathers were more likely than mothers to be informed – for or against – by what they hear,

Nursing Review series 2015

read or see from family, friends, antenatal classes, television and the internet. Cameron Grant believes the findings show that it is important to give fathers an opportunity to express their concerns and give them the chance to be informed by people who are knowledgeable. “This is an area where nurses could make a significant contribution.”

”This is an area where nurses could make a significant contribution.”

Are healthcare professionals positive or negative role models?

Some of the study’s findings of concern included finding out that more than half of the pregnant women interviewed had received no information – good or bad – about immunising their baby. Healthcare professionals were the most common source ofencouraging information but – for a minority of parents – some healthcare professionals were the source of a negative message. Midwives were described as the source of discouraging information by 11 per cent of pregnant women and 8 per cent of their partners, and GPs were cited by 3 per cent of parents. “Healthcare providers are a source of a negative message for about one in six of the parents who said they got a negative message,” said Grant. “I think healthcare professionals need to behave as healthcare professionals and, even if they have got personal opinions on these things, it is inappropriate for them to express them in a professional context.” The study shows that while discouraging information had a negative impact on the timeliness of vaccination, receiving encouraging

information had no positive effect at all on babies receiving that important first vaccination on time. Cameron Grant “The whole reason vaccinations start so early is you don’t get much immunity from your mum against whooping cough,” says Grant.”So you are very, very vulnerable early on and the babies that we see who die from whooping cough are in the first couple of months of life. “Breastfeeding certainly helps against some infections but some of these vaccine-preventable ones it doesn’t. “So I think we need to be doing better at selling the positive immunisation message. And that is somewhere that nurses can make a positive contribution.” Just remember to include the dads too.

Basic facts:

Growing up in New Zealand »» 6,822 pregnant women and 4,401 of their partners living in the Auckland, Counties-Manukau and Waikato district health board areas were recruited into the longitudinal Growing Up in New Zealand study. »» The study cohort is made up of around 7,000 of the resulting babies born between Anzac Day 2009 and 25 March 2010. »» Of the children, 24 per cent identify as Māori, 21 per cent as Pacific Island, 16 per cent as Asian and 66 per cent as European (or other). »» The study is following the growth and development of the children until they are at least 21 years old. »» The government-funded research contract is led by The University of Auckland.

More information on the study’s initial findings can be found at www.growingup.co.nz

FOCUS n Child Health

Childhood asthma:

the inhaler that moos and miaows Research on a ‘smart inhaler’ that moos, miaows or rings out pop tunes and makes kids with asthma use their preventer more often won young hospital pharmacist Amy Chan the recent Medicines New Zealand 2015 Value of Medicines award.

o parent wants their child to end up in ED with an asthma attack. But for some children and their often busy parents it can be a struggle to remember to regularly puff the asthma preventer medication (orange inhaler) that can keep their asthma under better control. Doctoral student and hospital pharmacist Amy Chan led a project to trial the impact of a ringtone smart inhaler on the asthma control of 110 high risk children, aged six to 15, who had already presented at emergency departments with an asthma attack. She found that the real-time reminder dramatically improved the children’s medication adherence, which markedly reduced their asthma symptoms. The findings of The University of Auckland study (funded by Cure Kids and the Health Research Council) were published in The Lancet early this year and in September won Chan the Medicines New Zealand 2015 Value of Medicines Award for the work. Chan, who is just finalising her doctoral thesis, hopes that her findings will result in Pharmac looking seriously at funding the Nexus6 smart inhaler reminder device for those children presenting at hospitals with asthma, as they generally have low levels of medication adherence. She is also keen to see whether the device could help children, adolescents and adults with other chronic diseases where taking regular medication is an issue. “We know from the World Health Organisation that only 50 per cent of people take medications as prescribed, so clearly that is a place where we can intervene (and make a difference). “I think technology has a major role to play and I’d like to see technology used in chronic conditions to support people’s health.”

”I think technology has a major role to play and I’d like to see technology used in chronic conditions to support people’s health.” She says apps are one part of that. “People would often say to me, ‘Oh can’t you just use a smartphone with a reminder’ but it’s not the same,” says Chan. “As I’m sure you know, if you have a reminder on your device often it will ring and you will just turn off the reminder as it’s very easy to get reminder fatigue.”

Real-time rings prevent reminder fatigue

That is the difference with the ringtone smart inhaler; it only rings when you have actually missed a dose so Chan says you don’t have a chance to get attuned and ‘zone out’, which is the risk with a reminder set for the same time each day whether you have or haven’t take your medication. Parents chose the times that children took their dose and the children could choose their rotating favourites from the 14 ringtones available – top choices included animal noises, The Simpsons theme tune and the Madagascar movie theme song ‘I like to move it’. The audio-visual device also has a screen that displays when a child last took their medication and the sensor is set so it only records when the child has taken a “proper puff”.

“This is quite helpful for parents as well, as the child may say ‘yeah, yeah I’ve taken my medicine’ but the parent can press the button on the side, check the screen and say ‘no you haven’t’.”

Exciting research results

Amy Chan

The study focused on high risk children and Chan says the research literature shows that generally children who present at ED for asthma attacks have lower rates of medication adherence than the average children’s rate, which is already low at around 40–50 per cent. That was why the researchers were excited to find that the medication adherence of the 110 children randomly allocated ringtone inhalers was 84 per cent, compared with 30 per cent for the 110 children allocated to the control group, whose inhalers had the audio-visual elements turned off. The researchers also used a smart device to monitor the impact the increased medication adherence had on the children’s use of their ‘blue’ reliever inhaler. They found the control kids had to resort to their blue inhaler 17.4 per cent of the days in the six-month trial, which was nearly double the days (9.5 per cent) that the intervention group did. In the first two months nearly a quarter of the control group had asthma attacks, compared with just six per cent of the intervention group. The intervention group families also reported less coughing, less wheezing, less night-time waking and being better able to participate in daily activities like sport and bouncing on trampolines without parents being frightened that it would trigger an asthma attack.

12 months

Part time

Home based

Fee free Nursing Review series 2015

FOCUS n Child Health

One-stop-shop for books, coffee… and child health Rotorua is well on the way to having a New Zealand-first – if not a world-first – combination of a child health hub and a public library. FIONA CASSIE talks to Gary Lees, the director of nursing for Lakes District Health Board to find out more.

laygrounds and literacy don’t usually go together but for Gary Lees they’ve both been uppermost in his mind lately. The director of nursing at Lakes District Health Board is busy helping refine the design brief for the country’s first combined library and child health hub. A need to rehouse some of Lakes DHB’s child health services kickstarted the DHB to consider not only combining those services into a single building but also to think bigger and take most paediatric outpatient services away from the hospital to a new shared space. This idea of a hub, focused on children’s health needs, was being raised around the same time as the Rotorua City Council was contemplating a major refurbishment and earthquake strengthening of its existing central city library building. UNICEF’S Child Friendly Cities initiative provided the impetus for the council and the library to collaborate in a proposal to create a combined library and child health hub in the refurbished library building.The council announced in September that work on the new partnership hub could be underway by July next year, with the grand opening pencilled in for November 2017.

Economic sense

Lees says the proposal made economic sense and child health services were also keen to relocate to a family-friendly central site away from the hospital. The new child health hub will be home to the DHB’s paediatric outpatients’ service, child development team, child and adolescent mental health team, public health service (including the vision and hearing testing service), the dental health service management team, and management staff of the multi-government agency Children’s Team. The aim is to promote a more child-centred, collaborative approach to child health services by having many of the services under the same roof. 14

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Early concept drawing for the magazine/waiting area of the Child Health service at Rotorua’s proposed library and child health hub.

Lees says some of this work is already underway in Rotorua (with the Children’s Teams and the Social Sector trials) but it is hoped that the health hub will help interagency collaboration and lead to a culture change and improvement in child health outcomes across Rotorua.

Multiple benefits

Another aspect of the hub project that has major appeal to Lees and the DHB is being in partnership with the library. “We can see some amazing connections between health and literacy information,” says Lee. “We have already been talking about how we might be able to refer parents of children with newly diagnosed conditions [to librarians] for reliable sources of information about that illness/ condition, rather than people doing Google searches and who knows what they might find. “The library also runs a toy library, so the DHB is in consultation about the library including toys that might be therapeutic for children with some conditions.” The plan is for the hub to have a common front entry, with access to the child health centre to the left and library facilities to the right. There will also be a single reception area for all child health services so library visitors won’t know whether a family is coming for a hearing check or a mental health consultation.” So we hope it might break down some of the possible stigma.” The hub is focused on DHB-delivered child health services but is incorporating extra consultation rooms so invitations can be extended to other providers, such as Plunket, if they want to deliver some of their services from the hub.

Gary Lees

What the hub will not be providing is acute primary care presentations, as that is delivered by general practice and some outpatient services, like orthopaedic, that need imaging equipment. “But we do want the centre to be the place people come if they have questions about health so we can then either refer them directly to the right service (maybe even booking an appointment) or signpost where they need to go,” says Lees. A library is also a wonderful place for children and parents to wait by browsing a magazine, checking a computer, having a coffee or flipping through picture books. Lees says the DHB is in discussion with librarians over how to make that happen. One possibility is having the magazine section sited in the health hub’s waiting area and another is to have café style ‘buzzers’ or a text system to call families back to the hub for their appointment. “That means they can roam freely round the library space or get a coffee from the café and get called back when it’s just time to go rather than having to sit staring at a wall.” There will also be a separate entrance to the child health centre for families who may want privacy when they arrive or leave an appointment As part of the redesign, the council is also looking at public transport and cycleway access to the hub and developing a new playground outside the hub that appeals to a wide range of children, including those with disabilities.

”We can see some amazing connections between health and literacy information.”

FOCUS n Infection Control

Hand hygiene:

to glove or not to glove?

To glove or not to glove? Is it ‘nobler’ and safer for nurses to increasingly wear gloves when caring for patients? Fiona Cassie finds out the answer from British infection control researcher Dr Jennie Wilson.

loves were once a rare sight on a hospital ward. Now gloves are constantly being donned, doffed and discarded during a nurse’s working day. But does regularly pulling on gloves reduce the risk of infection? Do patients feel more comfortable or ‘untouchable’ if a nurse dons gloves as they approach them? And just who is protecting who when some common nursing procedures are increasingly done with a layer of latex between the nurses’ hands and the patient? These are questions that infection control nurse specialist Dr Jennie Wilson has been researching in recent years. Wilson, now an associate professor and researcher in healthcare epidemiology at the University of West London, recently spoke to the Infection Prevention and Control Nurses College NZNO conference in Napier on her findings in a presentation called ‘To glove or not to glove?’. Wilson, who has worked in the field of infection prevention and control for more than 30 years, says concern about the overuse of clinical gloves began to appear in the research literature about a decade ago. It wasn’t until the HIV epidemic in the late 1980s that healthcare workers were encouraged to use disposable gloves during direct contact with patients’ blood and body fluids, because bloodborne viruses were seen to pose a risk to staff. Wilson says this didn’t instantly trigger widespread use of gloves and in the mid-1990s there was still a concern that nurses weren’t using gloves as often as they should. But gradually the glove habit became increasingly embedded until, during the 2000s, a new concern started to surface; healthcare workers being too ready to pull on gloves and not quite so quick to pull them off or change them.

Glove cross-contamination risk

The Five Moments for Hand Hygiene guidelines were introduced by the World Health Organisation in 2009 to focus healthcare workers’ attention on good hand hygiene as a simple but effective means of infection prevention and control.

Appropriate times to use non-sterile gloves are:

»» direct contact with blood »» direct contact with body fluids (secretions, excretions and items visibly soiled by body fluids) »» procedures that involve a risk with direct contact with blood or body fluid »» all contact with mucous membranes or non-intact skin »» IV insertion and removal »» drawing blood »» pelvic and vaginal examinations »» contact with infectious material

Some inappropriate times to use non-sterile gloves are:

»» taking blood pressure, temperature and pulse »» bathing and dressing the patient »» mobilising patient »» feeding patient »» performing SC (subcutaneous) and IM (intramuscular) injections

If gloves are worn they must be:

»» changed between patients »» changed between procedures »» removed and hands must be decontaminated afterwards

The aim is to promote the routine use of hand hygiene at each ‘moment’ to reduce the risk of cross-contamination of infection-causing bacteria or viruses from one patient (or patient environment) to another. Wilson says if you assume cross-contamination can occur whether you touch the patient or patient environment with bare hands or gloves then not to change gloves (or use adequate hand hygiene after removing gloves) at the ‘Five moments’ would also risk cross-contamination (see box). She was part of a research team that set out to observe when healthcare workers (HCW) at a UK hospital used gloves, why they were using them, and whether how they were using them posed a risk of cross-contamination. They published findings in 2013 that showed nearly 40 per cent of the time that gloves were used in patient care there was a risk of cross-contamination (see box 2 for examples), including gloves used for toileting a patient not being removed before touching other surfaces or patients. The majority of the healthcare episodes using gloves involved nurses, and nurses were slightly more likely to cause cross-contamination risks than other HCW, such as doctors or healthcare assistants. Wilson says the risk of cross-contamination from gloves had already been demonstrated by a French research team, Girou et al, recovering pathogens from 86 per cent of gloves used by HCW, even after the use of an alcohol hand rub. In 2007 another research team, led by Gonzalo Bearman, found a significant increase in healthcareassociated infections when gloves were used for all patient contact, compared with just using gloves for standard precautions (i.e. involving blood and body fluids). And a University of Otago research Continued on next page >> Nursing Review series 2015

FOCUS n Infection Control

team reported in 2013 that it was likely poor HCW hand hygiene that led to faecal and other bacteria being found on unused gloves in glove boxes on a busy hospital ward.

Gloves not always needed

So is it a case that – rather than protecting patients from infection – wearing gloves is potentially putting patients at greater risk? The short answer is, quite possibly. Wilson’s initial research found that not only were glove wearers failing to meet the ‘Five moments of hand hygiene’ around 40 per cent of the time, but they were also using gloves unnecessarily. In fact, 42 per cent of the time, HCW were observed using gloves when they didn’t need to, including using gloves for low-risk procedures. “The overall message from that was that gloves are being put on too early and taken off too late,” says Wilson. Gloves were being put on “way before” people had direct contact with the patient and then weren’t taken off immediately after doing the procedure. Or the gloves weren’t being changed, and hand hygiene used, between carrying out a ‘dirty’ and ‘clean’ procedure, for example between cleaning up a patient’s incontinence and then handling their IV device or catheter. The research team has since extended its observations to cover two more hospitals and found exactly the same pattern repeated. This swing in the practices of healthcare workers – who just two decades before had to be persuaded to use gloves to protect themselves but were now quick to pull on gloves even when not needed – prompted the first study to interview 25 staff at the initial hospital about what influenced their wearing of gloves.

Disgust, fear and protection

The research team found that one primary motivation for wearing gloves was an emotional response. “There was a fear and anxiety about touching things that are perceived to be unclean or dirty. And a sense of disgust – that some things were too ‘yucky’,” says Wilson. Another major theme was that glove wearing was now part of the organisation’s culture, with gloves widely available on the ward and a perception that HCW wear gloves because it was ‘safer’. “The overarching message that staff picked up is that they are not only protecting themselves but also protecting their patients by wearing gloves,” says Wilson. “They don’t seem to recognise that gloves don’t act as a sterile covering for the hands or that gloves aren’t immune from bacteria… gloves will pick up bacteria in exactly the same way that hands do.” The healthcare workers interviewed were not without empathy and some expressed strong concerns that their glove-wearing might make patients feel uncomfortable or ‘dirty’. But others also had the perception that patients preferred them to wear gloves as it appeared cleaner and more clinical. The follow-up research (yet to be published) includes interviews with patients about their views on glove use. Wilson says early indications are that the public’s perception about when gloves 16

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should be worn are quite a close match to infection control guidelines, like, for instance, expecting gloves to be worn when taking blood or clearing up after incontinence. “You could maybe argue that the public have a clearer understanding of when gloves should be worn than perhaps the staff who are delivering the care.” Both patients and staff talked about gloves providing a form of ‘protection’ when receiving and giving intimate cares, however. “It’s not seen to be quite as intimate if you touch somebody wearing gloves than if you touch somebody with a bare hand,” says Wilson. “When patients are having their private parts washed then perhaps they like the ‘psychological barrier’ of having a gloved rather than a bare hand. “So there may be situations when it makes the patient feel more comfortable for staff to wear gloves but they aren’t necessarily infection control reasons.” Wilson stresses it is really important to be clear why gloves are necessary. “Because if you are not clear when gloves are required (for infection control reasons) then you start to get into the situation that they are used as a personal preference and the reason may be obscure.” For example, she says there is no infection control reason why nurses or other healthcare workers should wear gloves to feed a patient. “It’s quite demeaning to the patient … feeding is the kind of task that needs to be done with compassion and wearing gloves conveys the wrong message when we are helping someone with a basic human need.” Likewise, when showering and dressing a person, unless there is incontinence, there is no reason to wear gloves, says Wilson. “It indicates some unrealistic need to protect yourself and conveys to the patient a sense that they are dirty or unclean in some way.”

Wilson reiterates that nurses and healthcare workers should think twice before using gloves as her research, and others, indicate the more often HCW wear gloves the more likely they are to risk cross-contamination. “Because they put them on too soon and take them off too late.” The unnecessary use of gloves not only increases the risk of healthcare acquired infections, which is costly in itself to patients and hospitals, but also the risk of costly wastage of the healthcare dollar. “We are saying that at least half the glove use, in the UK settings we observed, was unnecessary so that means half the budget we are spending on gloves in these hospitals is being wasted.” Most of those wasted gloves are also going into a clinical waste stream so there is a further cost to dispose of them. So ‘to glove or not to glove?’ is a question that Wilson believes nurses should always ask themselves before they reach their – of course, freshly clean – hands into the closest gloves box. Jennie Wilson

Glove overuse costly and risky

But, most simply, reducing unnecessary glove use just makes good infection control sense.

High inappropriate glove use in New Zealand

nappropriate use of non-sterile gloves continues to be a “barrier to excellent hand hygiene practice”, says the latest Hand Hygiene New Zealand report. The national campaign regularly audits the hand hygiene practices by staff at the country’s 20 district health boards, including when gloves are put on, taken off and during patient care. In its latest audit it found when gloves were put on that 22.6 per cent of hand hygiene opportunities were missed, compared with just under 10 per cent when gloves are taken off. It also found that once healthcare workers donned gloves they failed to complete hand hygiene at the appropriate five moments nearly 21 per cent of the time. This is an improvement on the statistics 12 months before when hand cleaning moments were missed 33.3 per cent of the time when gloves were put on. But Hand Hygiene New Zealand remains concerned and says glove use continues to be an ongoing issue. “A sustained focus on how to maintain good hand hygiene when using non-sterile gloves is needed to improve this aspect of patient care,” it says in its quarterly report to 30 June 2015. The World Health Organisation’s ‘Five moments for hand hygiene’ requires hand hygiene to be performed at each required ‘moment’ irrespective of whether or not gloves are used. A hand hygiene survey in 2014 of 344 healthcare workers from 17 DHBs showed that 93 per cent of respondents did not think that glove use was a substitute for good hand hygiene. But when asked in what instances did they need to clean their hands when wearing gloves, only 40 per cent ticked all three correct options.

FOCUS n Infection Control

Flu shot:

masking the issue? Three Waikato DHB frontline staff were suspended this winter for refusing to wear a mask after declining the flu vaccine. FIONA CASSIE looks at the sometimes fraught issue of infection control campaigns that aim to reduce the risk of influenza by increasing the vaccination levels of nurses and other healthcare workers.

K Lance Jennings

Leonie Walker

Michael Gardam

nown as “the flu”, influenza is a nasty, infectious disease caused by a virus that can hit both the vulnerable and the healthy hard. It sometimes kills too. There is little argument about this. The seasonal influenza vaccine is safe and is science’s imperfect but best method to date for protecting people from the fast evolving virus. The above statement would also prompt little argument from the New Zealand Nurses Organisation; virologist Dr Lance Jennings; Canadian infection control physician Dr Michael Gardam; or district health board employers. Nor is there dissent from these parties over wanting as many healthcare workers as possible to receive a free seasonal flu vaccination in order to reduce the risk of getting or giving the flu to their vulnerable patients. However, when it comes to the methods employers use to increase the uptake of flu vaccinations in nurses and healthcare workers, dissent abounds. This winter was the first in which a DHB actively enforced a Canadian-style ‘vaccinate or mask’ (VOM) policy for the flu season, with non-vaccinated staff required to wear a mask when in clinical areas. The result was a steep upsurge in vaccinated nurses at Waikato DHB, from 52 per cent last year to 81 per cent in 2015. Across the island, at Tairawhiti DHB in Gisborne, there was no VOM policy but the vaccinated nurse rate topped 83 per cent – a record for the board, which two years ago also had nurse vaccination rates languishing around the 50 per cent rate. Both boards worked hard to make vaccination readily available to their staff members. One board also enforced mask wearing, suspended three staff members and made headlines that garnered both popular support and a union backlash.

Getting the message across Sue Hayward

Dr Leonie Walker is pro-vaccination. In fact, the New Zealand Nurses Organisation researcher, whose ‘distant’ PhD was

in immunology, went out of her way this flu season to get a quadrivalent (four strain) vaccine rather than the more readily available trivalent flu shot. NZNO is also very much pro-vaccination, she says. While it recognises that the seasonal flu vaccination is “at best” about 60 per cent effective on average each year, this still remains the best protection on offer for nurses and their patients. But NZNO does object to what it sees as vaccination by compulsion, be it mandatory vaccination or compulsion ‘masked’ in the form of VOM policies. “I think the mask wearing is a complete red herring,” says Walker. “It’s being used as pure leverage to bully people into getting vaccinated and that doesn’t strike me as a sensible approach.” Earlier this year the National Bipartite Action Group (NBAG) released guidelines for DHB vaccination policies that endorsed vaccination as the best protection available against influenza. The joint guidelines were negotiated by unions and DHBs in the wake of conflict over another board’s policy, and set a new target of more than 85 per cent of staff receiving a flu shot each year. The parties also agreed that “a positive health message is more effective than negative, consequential or threatening messaging or activity” when promoting vaccination. The NZNO’s Infection Prevention and Control Nurses College has not taken a stand on VOM policies Continued on next page >>

Waikato DHB’s Vaccinate or Mask (VOM) Policy Healthcare workers who are unable to establish that they have received the current seasonal influenza vaccination will be required to wear appropriate personal protective equipment (PPE) such as surgical or procedural face masks during the declared influenza season while undertaking clinical duties or being present in a clinical area.

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and chair Robyn Boyne says its members have a range of differing opinions. But the pro-vaccination body does support the NBAG emphasis on promoting a positive health message. Sue Hayward, director of nursing at Waikato, is also provaccination and she believes her DHB’s policy is in line with the spirit of NBAG. In written responses to Nursing Review questions, she says the right of the patient to be protected from vaccine-preventable communicable diseases is an “absolute” that healthcare providers should accept and meet. For her, the onus “falls on us as nurses to employ all known procedures and processes, based on evidence and research, to uphold that standard”. Hayward supports a VOM policy as she believes unvaccinated staff wearing a mask in a patient area provides the next-best protection to their patients; and it is in line with NBAG as it couldn’t be “compellingly argued that (our) policy implicitly required or coerced individuals to get vaccinated”. Hayward also believes positive health messages and education alone are not enough as overseas research and New Zealand experience had established “it is difficult to achieve and consistently maintain high levels of vaccination amongst healthcare workers without either compulsion or policies such as ‘vaccinate or mask’”. Statistics from the United States Government’s Centers for Disease Control and Prevention (CDC) indicate that even at US hospitals where flu vaccination is mandatory, the vaccination rate is about 85 per cent at the start of the flu season and around 96.5 per cent by the end. New Zealand’s NBAG guidelines set a target of annually vaccinating more than 85 per cent of not only all DHB staff but also DHB contractors and regular visitors. Tairawhiti this year became the first DHB to exceed the target by vaccinating 86 per cent of its staff. Large DHBs like Canterbury and Auckland also reached 75 per cent staff vaccination last year without resorting to a VOM policy. There were other DHBs though, large and small, across the country which last year struggled to get half of their staff vaccinated and three DHBs where

there were far more nurses unvaccinated than vaccinated. This year NBAG unions and employers agreed to agree that the seasonal flu vaccine provides the best protection currently available against potentially deadly influenza. So what is the best way to reach the mutually agreed target of 85 per cent of DHB staff vaccinated nationwide?

“We need multiple strategies to lessen the risk of transmission of virus to those at greatest risk in a healthcare setting.”

CASE STUDY:

TAIRAWHITI DHB One of the most isolated of the country’s 20 DHBs, the East Coast’s Tairawhiti DHB, tops the league table for influenza vaccination uptake by its staff.

ith no pressure or incentive beyond a lollipop – and the biggest change being ease of access in a focused week-long campaign – the DHB jumped its staff vaccination rate from just above 50 per cent in 2012 to 75 per cent in 2013 and 86 per cent of its 739 staff in this flu season just gone. (This doesn’t include staff that were vaccinated via their local general practice). Occupational health nurse Cathy Brown is modest about Tairawhiti’s jump to the top of the league table. She stepped into her roll in 2012 and quickly realised in the first flu season that the established policy of expecting staff to come to occupational health just didn’t work. So the next year she took the vaccines to them and launched the board’s first Flu Week publicising when she and her colleague would be available at each department across 18

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the board’s two sites in Gisborne. The uptake soared, with some hesitant vaccinatees encouraged by seeing their colleagues rolling up their sleeves, and catch-up clinics near the staff cafeteria capturing those who may otherwise have missed out. Brown believes the DHB offering the option of the microneedle Intanza vaccine one year helped some needle-phobic staff to overcome their fears of an annual flu shot. The education campaign included sharing staff’s own flu stories in the DHB’s newsletter The Nerve, which this year featured the story of the new communication manager who had declined the flu vaccine the previous year. “She was like ‘no, no, no I don’t want to have that’. I explained the benefits to her and left it like that,” recalls Brown. “And then she got quite sick with the flu. So she was in

Thumbs down by expert

Dr Michael Gardam would ask another question – is the science there to justify requiring unvaccinated staff to wear masks? The Canadian infection control physician has raised eyebrows and some ire amongst his peers by taking an open stand against ‘mask’ policies. Gardam is a strong proponent of vaccination in general and gets his flu shot every Canadian fall but believes the science falls short of justifying a ‘vaccinate or mask’ approach for those who decline the flu shot – even if they decline for reasons that have little or nothing to do with good science. Requiring reluctant staff to wear masks all flu season, he argues, just gives ammunition to an already virulent anti-vaccination movement in return for “negligible impact” on patient safety. He believes health providers should encourage healthcare workers to take up the influenza vaccination but save their battles for vaccine campaigns with more impact and scientific clout than those used to justify VOM policies in his native Canada. Gardam, the director of infection prevention and control at Toronto’s University Health Network and an associate professor of medicine at the University of Toronto, presented on the science backing his stand on VOM policies at the recent Infection Prevention and Control Nurses College NZNO conference in Napier. Canada is where British Columbia’s Fraser Health Authority implemented a VOM policy in 2012–2013 that prompted an unsuccessful legal challenge from local unions. Gardam was subpoenaed to give evidence in a legal challenge by the Ontario Nurses Association against a VOM policy implemented over the last

Tairawhiti DHB occupational health nurse Cathy Brown gives anaesthetist David Freschini his annual flu shot (photo courtesy of Gisborne Herald).

front of the queue this year and put her story in the newsletter, which I think encouraged a few people.” Also this season there had been extra input from unions encouraging members to get vaccinated. “I think that’s quite a helpful support.” Brown thinks the late arrival of the vaccine this season also focused interest as the weather became chillier and people started to think that winter and flu were just around the corner. She also sent a second vaccination team to work during

Flu Week, which meant “it was very difficult to avoid us”. A little healthy rivalry between doctors and nurses to see who was beating who in the vaccination uptake stakes – updated regularly on a prominent chart – played a part too. (Nurses edged ahead with 83 per cent uptake, compared with the doctors at 82 per cent). Does Brown think she can top 86 per cent? “It’s always possible,” she says.

FOCUS n Infection Control

CASE STUDY: two northern hemisphere winters at a Toronto hospital. That lengthy arbitration case did not set out to “challenge the desirability of influenza vaccination for healthcare workers (HCWs)” but to weigh up the scientific evidence behind the hospital’s VOM policy and had expert witnesses from both sides of the VOM divide interpreting the research literature on the disease burden posed and faced by healthcare workers, on asymptomatic transmission of viruses, and whether HCWs wearing masks would reduce the nosocomial transmission of influenza. In a recently released decision the arbitrator decided that the hospital’s VOM policy was unreasonable, was introduced to drive up vaccination rates, and breached the employment agreement right for nurses to refuse any required vaccination. “If the mask evidence were as supportive as claimed, it would suggest that vaccinated HCWs should also wear masks, given the limited efficacy of the vaccine even in relatively ‘good’ years,” the arbitrator added near the end of the 136-page ruling. (The arbitration ruling can be found at www.ona.org/news_ details/ONA_wins_landmark_ influenza_20150910.html.)

Save your battles

“The flu shot is a one-trick pony,” argues Gardam, who advocates not putting all your infection control eggs in one basket. Evidence indicates the seasonal flu vaccine is on average about 60 per cent effective each year but Gardam points out that influenza causes only a minority of influenza-like illnesses that hit communities and hospitalises patients every winter. He also argues nosocomial influenza infections are rare, the studies looking at the impact of vaccinating HCW are flawed, and a particularly fast mutating virus meant the vaccine was completely ineffective against the dominant H3N2 season strain last Canadian winter, but still only unvaccinated staff were required to wear masks. The impact of the flu vaccine, he argues, is therefore modest – still enough for him to warrant having it every year but too modest, he believes, for policy makers to justify emotive rhetoric and estranging the minority of anti-vaccination staff by enforcing mask policies. He sees the ethics of the influenza vaccine issue as more grey than black and white and, in influenza’s case, would put equal or greater ethical policy emphasis on having good hand hygiene, avoiding work when nurses Continued on next page >>

Auckland individualised approach Individual emails to non-vaccinated staff has helped Auckland DHB for the first time see 80 per cent of its nurses vaccinated – nearly double the rate of three years before. Adoption of the board’s Staff Seasonal Influenza Vaccination Guideline last year has helped increase the overall uptake of its nearly 10,000 staff from 63 per cent in 2013 to 76 per cent this year. Christine Sieczkowski, the nurse manager of Auckland DHB’s infection prevention Christine Sieczkowski and control service, says it first set the goal of 80 per cent in 2014 along with its new guideline. That guideline has four phases: »» Phase One: Offer vaccination through several fixed venues for at least two weeks (along with in-team vaccinators vaccinating colleagues). End of April to early May. »» Phase Two: Letter is sent out to all non-vaccinated staff encouraging them to be vaccinated. The fixed venue continues for an additional week, along with the in-team vaccinators, plus introduced mobile vaccinators who staff can ring and request to come to their area. Mid-May. »» Phase Three: Email is sent out to all non-DHB vaccinated clinical staff, including an “opt-out survey”. Survey asks staff whether they have received vaccination at their general practice, and if they have opted not to have the vaccine they are asked why. In-team and mobile vaccinators continue. Third week of June. »» Phase Four: Fliers are sent out to all non-vaccinated staff reminding them that the vaccine is still available. Third week of July. Sieczkowski says 2014 was the first time the DHB undertook such a structured campaign and a key element was having senior clinical leaders out amongst staff spreading the same consistent message of ‘protect, don’t infect’. While the campaign identified and targeted non-vaccinated clinical staff with letters and emails, it stopped several steps short of requiring them to wear masks. “The message went out that, obviously, we would strongly encourage the wearing of masks in non-vaccinated clinical staff but it was left more as a matter of professional judgement,” says Sieczkowski. “Really relying on staff conscience to do the right thing, particularly when caring for vulnerable patients like the young in Starship; the frail elderly; pregnant women; or the immune compromised.” The result was that some non-vaccinated staff did wear masks “but it definitely wasn’t a ‘you must’ it was a ‘you should’,” says Sieczkowski. “As a nurse, I do think we have a professional obligation to keep both patients and ourselves safe at work, like keeping ourselves well, wearing the right protective clothing at the right time, and hand hygiene etc. Vaccinations are just part of that picture.” She is comfortable that the new structured approach is a happy middle ground and it received very little negative feedback from people sent the phase three survey. People said they had chosen not to have the vaccine for a variety of different reasons and 313 staff members said they had received the vaccine at their GPs (they were included in the final staff total). “We were just trying to get a handle on why people weren’t taking up the offer of a free flu vaccination,” says Sieczkowski. “And get any clues about how we could improve the campaign next time.”

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FOCUS n Infection Control

clearly have influenza-like illness symptoms, and wearing a mask if they must attend or visit work when ill. Gardam still encourages nurses to have the annual flu shot but thinks it is more ethically imperative, for instance, to make the MMR vaccine mandatory for healthcare workers. “Because the evidence is so overwhelming that the MMR vaccine works … I fully support that in the same way I support mandatory Hepatitis B vaccination for healthcare workers so they are not exposed to Hep B in the workplace. I have no problems with pushing these as the vaccines are so good, the diseases are so bad and it’s so obvious (these) work.” He says the same cannot be said for the effectiveness of the seasonal flu vaccine and believes employers should save the rhetoric and hardline strategies for vaccines that are proven to make a marked difference.

Still the best shot we’ve got

Canterbury clinical virologist Dr Lance Jennings would like to see 100 per cent of healthcare workers vaccinated against the flu. He believes the discussion simply needs to come back to first principles, including that healthcare workers should ”do no harm”. “Yes I agree that there are a lot of gaps in our knowledge about influenza,” says the spokesman for the National Influenza Specialist Group. “This is why I keep coming back to a common sense approach: that influenza is a serious illness and we know people die of it. And we know that vaccination is our best strategy for controlling the more severe consequences of influenza infection… “Ideally everyone who gets admitted to hospital should have a seasonal influenza vaccine but of course they don’t. So the only way we can contribute

CASE STUDY: Waikato Staff influenza vaccination rates jumped 28 per cent in a single year at Waikato DHB after adopting a ‘vaccinate or mask’ policy. The policy also led to three staff members being suspended, one of Lesley Harry whom lost their job. Waikato’s chief executive Nigel Murray brought the VOM policy with him from his old employer, British Columbia’s Fraser Health Authority where the policy successfully withstood a union legal challenge. (see policy statement p.17) The New Zealand Nurses Organisation, which says it is pro-vaccination but anticompulsion, challenged the Waikato policy’s consultation process leading to mediation and an agreement for a joint working party, including other DHB unions, to fully consult on and review the policy before the next flu season. Sue Hayward, Waikato’s director of nursing and midwifery, said in a written response to Nursing Review that, overall, staff “recognised the intent of the policy to provide a safer clinical environment”, with 81 per cent making the choice to be vaccinated through the DHB programme (a further 2 per cent were vaccinated elsewhere). This was a marked increase from 53 per cent last year and nurse

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to their protection is by ensuring our staff have an influenza vaccine to lessen the possibility of transmission.” Jennings was an advisor to the NBAG vaccination guidelines working party that agreed to more than 85 per cent as an annual target but ideally he’d like to see 100 per cent of healthcare workers vaccinated, and not stop there. “I think nationally a universal vaccination strategy is what we need to aim for as we’re a small country and we may be able to modify the spread of influenza to the benefit of everyone, rather than our approaches at the present time where we are trying to protect those at greatest risk.” These include not only the elderly but the very young as he points to the fact that SHIVERS (Southern Hemisphere Influenza and Vaccine Effectiveness Research and Surveillance project) data shows that children under five years of age have the highest hospitalisation rate for influenza. Does that mean he’d like to see mandatory seasonal flu vaccination for HCWs? Well, yes and no. He is definitely not averse to the VOM approach of having the majority of HCWs receiving the vaccine and those HCWs at the ‘coalface’ not vaccinated, wearing masks. “So whether you call it a mandatory vaccination approach or whatever, it’s something that we should want to achieve with appropriate consultation – because that’s how we do things in New Zealand – and appropriate education.” He says the NBAG guidelines clearly suggest there needs to be a dialogue and consultation over vaccination. “And, as we’ve seen in Waikato, if you don’t have appropriate leadership, and all your staff on board and prepared to accept that they have to (otherwise) wear masks when in frontline situations, then you get a kick back.” This ‘kick back’ can lead to headlines and debate that can defeat the purpose, so Jennings has some empathy with Gardam on that point at least.

vaccination rates had also jumped from 52.2 per cent to 81 per cent. She also believes the VOM policy meets the spirit of the NBAG guidelines as “just fewer than one in five employees elected to wear masks rather than get vaccinated; as such we do not believe that it can be compellingly argued that policy implicitly required or coerced individuals to get vaccinated.” Also VOM was only one aspect of the DHB’s policy and she believes having 114 vaccinators based in wards and clinical areas plus weekly prizes were also key components of its success. Lesley Harry, industrial advisor for NZNO, says there are questions around whether all members felt they had a choice. “We’ve had feedback from people who really felt coerced to be vaccinated rather than exercise their free choice and that’s not okay. Coercion is not the solution.” She says NZNO supported three nurse members – two suspended and one threatened with suspension – when they refused to wear masks. (The terminated staff member is understood not to be a nurse or a union member.) NZNO also heard from the regularly vaccinated, who said the policy had impacted on morale. “So generally it was a pretty unhappy situation judging by the amount of calls and the communication that we had from our members at Waikato DHB.”

Hayward said the motivation for Waikato’s VOM policy was that unvaccinated staff were a higher risk to patients, colleagues and families and the DHB had an obligation to its patients. “The right of the patient to be protected from vaccine-prevented communicable diseases as well as preventable contamination is an absolute that a healthcare provider should accept and meet,» said Hayward. She added that overseas research and the practices in New Zealand had established “it is difficult to achieve and consistently maintain high levels of vaccination amongst healthcare workers without either compulsion or policies such as vaccinate or mask”. Managers and clinical leaders at Waikato had been responsible for requiring unvaccinated staff to wear masks in clinical areas and ensuring masks were available. Hayward says some have found the actual wearing of the mask uncomfortable; however, the majority of nurses had shown a high degree of professionalism and worn the mask as required. Harry says during the upcoming review NZNO will not be arguing the efficacy of influenza vaccination but will attempt to persuade the DHB “that there’s more ways than one to skin a cat” and to take a more positive campaign approach to meeting the 85 per cent target. “If the DHB thinks that this (VOM) is going to be the process each year then inevitably they are going to come across resistance and unhappiness about it.”

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But not with what he calls Gardam’s approach of ‘cherry-picking’ research that supports the Canadian physician’s anti-VOM stand. “Why go to great lengths to focus on things we have poor knowledge of and use it as a justification for not going down that track,” argues Jennings. He acknowledges there are gaps in the knowledge about influenza, including a lack of double blind, randomised controlled trials in areas like nosocomial and asymptomatic transmission of influenza, but he says there are good reasons for this. For a start, the numbers of influenza infections are small – so to carry out a randomised-controlled trial you would need to enrol a very large number of patients – and more importantly there are major ethical issues with trials involving a potentially fatal infectious disease like influenza. “That is why we rely on observational studies for most of the data.” The science does show patients are at risk of nosocomial infection once admitted to hospital – be it from HCWs, visitors or fellow patients – and some studies show that there is up to 50 per cent mortality following nosocomial influenza infection, says Jennings. And once again, he argues, you should bring it back to first principles – ethically HCW, like nurses, should do everything they can to protect their patients. The seasonal influenza vaccine is safe and can reduce the risk of influenza infection and mortality, so why not expect HCWs to get vaccinated each year? “We know that, even with vaccination, no one (infection control) initiative is perfect so we need multiple strategies to lessen the risk of transmission of virus to those at greatest risk in a healthcare setting,” says Jennings. “This includes good hand hygiene and a culture change, led from the top to encourage healthcare workers with flu-like respiratory symptoms to stay away from work.” So what does he think of Gardam’s argument that you should choose your battles and save your fights for more scientifically robust and proven vaccine programmes than seasonal influenza? “But it is something you can achieve, so why argue against it when it is achievable?” replies Jennings. “And mandatory vaccination has been shown to

be achievable in other settings… though we may have to use another word or another approach here.” He says the best approach is to ensure that your population is well educated so you can move towards a situation where you have nearly 100 per cent coverage. Meanwhile Michelle Kapinga, the chair of the National Influenza Specialist Group and manager of the National Influenza Programme, shared a presentation in late May entitled ‘Mandatory Healthcare Worker “Vaccination or Mask” Policy – the British Columbia Experience and Insights for New Zealand’ during a regular immunisation professional development day. The British Columbia evidence was drawn largely from a presentation given by the former chief medical officer of Fraser Health Authority, Paul Van Buynder, who is now a public health medical officer on the Gold Coast. He reported that though the first year of campaign “involved pain” it had strong media and public support; the cost of masks was small (changed when wet); the reduced absenteeism outweighed costs; and by the second flu season it was “routine and just happened”. Van Buynder was chief author (fellow ex-Fraser employee and now Waikato DHB chief executive Nigel Murray was also an author) of a journal article this year reporting that Fraser’s jump in staff flu vaccination rates to 77 per cent that first year (86 per cent of full-timers) had reduced sick leave over the flu season and saved the authority substantial money.

More winters of discontent?

To return now to where we began: the flu is nasty. It can hit hard and sometimes kill. The seasonal flu vaccine is still the best protection on offer to reduce the risk of nurses’ infecting vulnerable patients. Whether the next flu season is a more widespread winter of discontent may depend on how convinced DHBs are that getting closer to that 85 per cent threshold may be best met by goodwill and lollipops or the disincentive of wearing a mask.

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Nursing Review series 2015

FOCUS n Wound Care

Debridement: sloughing away to aid healing

Debridement can be simple and slow or quick and complex. FIONA CASSIE finds out from wound care nurse specialist Emil Schmidt some of the ‘whys’ ‘wheres’ and ‘hows’ of simple debridement – and when to call in the experts.

he aim of wound care is always to help, not hinder, the healing of a wound. There is a myriad of modern dressings available to aid wound healing but wound care nurse specialist Emil Schmidt says to make the most of these – often quite expensive – products you first need to ensure the wound bed is properly prepared. For this the wound needs to be not only cleaned but also often debrided. Schmidt has been working as the Southern District Health Board’s wound care specialist for more than a decade and in 2013 also became the president of the New Zealand Wound Care Society. Earlier this year he presented on aspects of debridement at the society’s biennial conference in Blenheim. Schmidt says sometimes people get confused over the differences between cleansing a wound and debriding a wound. To put it simply, cleansing usually involves washing a wound to remove loose dirt and foreign materials, while debridement is the removal of dead, adhered and contaminated tissue and needs to continue until a healthier wound bed has been created. “So debridement can also be referred to as a form of wound bed preparation.” Wound bed preparation is particularly important in chronic wounds like leg ulcers, where health professionals often need to intervene to facilitate or speed up the healing process. This article looks at how nurses can use debridement so modern wound dressings can be placed on a healthy wound bed and be their most effective. “If we don’t prepare the wound properly, modern wound dressings are a waste of time and money,” says Schmidt.

Deciding which form to use

Debridement itself can take many forms. Deciding when to debride a wound, and the most appropriate form, depends on many factors. There first needs to be a full assessment of the patient, including their level of pain, circulation and any comorbidities (such as diabetes).The diagnosis of different tissue types and bioburden (viable bacteria) covering the wound, combined with the state of the wound edge as well as the periwound skin, will assist in deciding which form of debridement will be the most appropriate. 22

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Schmidt says the rough rule of thumb is that all wounds with dead tissue (i.e.slough) need to be considered for debridement. What needs to be taken into account is the speed of healing. “If the wound, despite a moderate amount of slough, is healing then obviously there is no problem,” he says. “But if the wound is covered with tenacious slough, the wound edges are not progressing, the surrounding skin is macerated and the wound is static, then you need to act, because the slough is delaying wound healing, and is often harbouring harmful bacteria that is critically colonising the wound.” If wound healing has come to a halt then some form of debridement is indicated. The right diagnosis and identifying the tissue type is important to define the right time for debridement and to identify the most appropriate method. Another important factor is to define the exudate levels of the wound bed (ranging from dry to wet). Other parameters that need to be considered include pain, the patient’s environment, quality of life, patient’s choice, age and, in particular, the skill and resources of the health professional. If the assessment reveals that the wound may already be outside of the particular nurse’s skill set – for example, it is showing signs of local infection, is painful, odorous, has a lot of dead tissue or lot of tenacious slough– then it is important to seek support from a wound care specialist. The earlier the better, says Schmidt, who often gets photos of wounds emailed to him by colleagues from throughout Otago seeking advice on wounds they are treating. He says often a sound care plan can be established using email consultation, and he values and is very proud of the close working relationships he has developed over the years with many healthcare professionals in Otago.

Wound care plan important

Before starting any form of debridement, Schmidt emphasises the importance of debridement being seen as part of an integrated wound care plan. For example, he says it doesn’t make sense to just look at the sticky slough on a lower leg and apply a hydrogel to an ulcer without using appropriate compression support. The wound care plan needs to include the aims of the debridement, timeframe and a goal.

A diabetic foot ulcer before (top) and after (below) sharp debridement.

Those goals (i.e. reducing the amount of dead tissue) need to be reassessed at regular intervals. If the goals haven’t been achieved then an alternative plan should be considered. Again he says, bear in mind that assistance is only a phone call or an email away. The type of debridement will not only be influenced by the wound and patient assessment but also by the clinical setting, as the range of debridement products and tools available to a nurse in a general practice or a rest home may differ greatly from those available to a wound specialist in a tertiary hospital or outpatient clinic. The skills and experience of the nurse also need to be considered, along with any workplace regulations or guidelines they work under. Schmidt says forms of debridement can be loosely grouped into several categories.

Autolytic debridement

Autolytic debridement is the most common form used and basically involves encouraging or enhancing the body’s natural debridement process by keeping the wound moist. A wound can naturally rid itself of dead cells by producing slough, which is often quite wet, says Schmidt. The moist slough helps shift and shed the dead or non-viable tissue from the wound bed but when the slough dries and becomes sticky the natural debridement process can need a helping hand. Autolytic debridement involves adding a dressing with a high water content to the wound to moisten and loosen the thickened slough or necrotic tissue. Dressings commonly used for this purpose include hydrogel orhydrocolloid and all operate on the principle that they add moisture to the wound bed.

FOCUS n Wound Care

These dressings are usually changed three or four times a week until the slough can be removed by simply washing the wound. Autolytic is the least invasive of the debridement techniques, says Schmidt. It doesn’t require specialist skill and should be able to be applied in many healthcare settings. Some of the advantages are that it is virtually pain free. However, autolytic debridement also has its disadvantages. It is a slow process, can lead to maceration of the surrounding skin and the moist environment can potentially allow bacteria to multiply.

”If we don’t prepare the wound properly, modern wound dressings are a waste of time and money.”

Lack of guidelines in Australasia for sharp and surgical debridement

Patients with chronic wounds have been treated with topical application of proteolytic enzymes, found naturally in fruits like papaya and kiwifruit, for hundreds of years. Enzymatic debridement uses proteolytic enzymes (proteinases) to help break down proteins in the wound or slough. Few commercially available enzyme products are available here in New Zealand.

Mechanical debridement

Traditionally mechanical debridement involves applying a dry gauze dressing to a wound. After the wound dries out – and the dead tissue sticks to the gauze – the dressing is ripped off, removing the dead tissue and dry slough with it. “That can be very, very painful and is not recommended practice,” says Schmidt. Recently another form of mechanical debridement became available in New Zealand using a monofilament pad (Debrisoft) that is said to be a less painful method.

Larval (or biosurgery) debridement

Direct debridement

In recent years a number of new high-tech forms of debridement have been introduced – mostly for use in hospitals but also some specialist clinics. These include Versajet, in which a high-flow jet of sterile water is directed at the wound to wash away dead tissue (also known as hydrosurgery) while the patient is under anaesthetic. Another form is low frequency ultrasound debridement (LFUD) that uses ultrasonic waves combined with highly charged

Surgical debridement

Surgical debridement is more extensive and deeper than sharp debridement and includes cutting into bleeding, living tissue. It is often, but not exclusively, done in an operating theatre.

Enzymatic debridement

Larval debridement (maggot therapy) is now more readily available in New Zealand. The local supplier of sterile medical maggots last year reported up to several orders a week from nurses and doctors using larval debridement on hard-to-heal wounds. Schmidt says the method is most often used by wound care specialists and specially trained district nurses. “It has to be the right diagnosis, tissue type and patient who can tolerate this type of treatment. “The larvae feed on dead tissue and exudates within the wound and therefore remove devitalised tissue. The digestive juices secreted by larvae contain proteolytic enzymes which selectively debride dead tissue, leaving viable tissue unharmed. “Maggots are like micro-surgeons as they won’t touch living tissue,” says Schmidt. Special protocols need to be followed to ensure it is the right method for the wound and the larvae can do their job effectively.

Sharp debridement is often done in an outpatient clinic setting. Local anaesthetic may be required for painful wounds.

An ulcer wound before debridement showing 100 per cent yellow tenacious slough (top); two weeks after autolytic debridement with hydrogel (middle); and finally after four weeks autolytic debridement (bottom).

saline bubbles to debride wounds. LFUD can be safely used on the bedside or in an outpatient setting, saving theatre time and aiding early discharge. This technique has been used overseas for a decade but hardly ever in New Zealand. Schmidt has been using the only system available in the country for almost three years. He and his vascular team colleagues are currently undertaking a three-year-long, randomised control trial in Dunedin Hospital on all patients with lower limb wounds and he says that early results are very promising.

Conservative sharp debridement

Conservative sharp debridement requires training, experience and confidence to perform safely. This form of debridement involves using a sterile sharp spoon (curette), scissors or scalpel to remove necrotic tissue. A thin margin of non-viable tissue is left surrounding the wound bed. “So it doesn’t go into bleeding tissue”, says Schmidt.

Schmidt, in his role as president of the New Zealand Wound Care Society, is very conscious of the lack of a recognised training framework or guidelines for sharp and surgical debridement in Australasia. Nurses are expected to use their professional judgement of what is within their skills and scope, so only experienced wound care nurses will carry out sharp or surgical debridement. But at present there is no formal certification programme to assure the patient, (or the nurse) that they have the necessary skills, unlike the United States where individual state boards of nursing set out clear guidelines on what skills are required to be competent to perform sharp debridement. “It is a complex topic, not only inNew Zealand but throughout the Australasia region, as lots of colleagues debride [sharp or surgical] but there is no standardised training programme,” says Schmidt. Often nurses specialising in wound care first learn by watching others and then hone their skills under the supervision of a surgeon, podiatrist or other specialists, so in time it can become part of their own practice skill set. The New Zealand Wound Care society always includes a sharp debridement training workshop at its conference where nurses can learn some theory and do some practical debridement sessions. Those workshops are extremely popular and are booked out very quickly. But there is no national, standardised training framework where a recognised qualification can be obtained, which is a concern as sharp debridement can be potentially dangerous. “Nursing colleagues tell us that they want more formal training,” Schmidt says. He says the New Zealand and Australian wound care societies have worked successfully together to write guidelines for leg ulcer and the prevention of pressure injuries and he is hopeful that in the future the societies will also develop standards and an educational framework for debridement. Meanwhile, unless nurses are trained to the point that they are competent, they should not attempt sharp debridement and opt instead for a less invasive debridement form. It’s most important to remember that if a wound is not healing within a certain timeframe then help should be sought from a wound care specialist.

REFERENCE Strohal R, Apelqvist J, Dissemond J et al. EWMA Document: Debridement. Journal of Wound Care 2013; 22 (Suppl. 1): S1–S52.

Nursing Review series 2015

FOCUS n Wound Care

Pressure injuries

reporting brings results Attempts to have pressure injury data regularly collected and reported as a nationwide quality indicator have been unsuccessful to date. But four district health boards decided not to wait for the rest of the country. FIONA CASSIE finds out about the Northern Region’s successful campaign to reduce harm from pressure injuries.

‘Y

ou can’t improve what you can’t measure’ is a maxim that Karen O’Keeffe fully supports. To reduce patient harm from pressure injuries in the future, she believes, you first need to know how often they are causing harm now. The experienced nurse manager has been clinical lead for the Northern Region’s First, Do No Harm patient safety campaign since before its launch in 2012. Reducing harm from pressure injuries is one of the six key focuses of the campaign, which set an initial goal of reducing pressure injuries to patients across the four DHBs (Northern, Waitemata, Auckland and Counties Manukau) by 20 per cent. O’Keeffe says back in 2012 the four DHBs had been measuring pressure injuries (PIs) in a variety of ways, including annual prevalence audits. But Counties Manukau had already implemented a monthly audit process for measuring PIs so the other DHBs decided to follow their lead and use monthly audits to establish a baseline and then track the impact the quality improvement programme was making (go to www.nursingreview.co.nz for more details on the quality campaign elements and measures). “When we first started out there was quite a difference in the median [incidence rate] between each DHB,” says O’Keeffe. Counties Manukau DHB had been focusing on reducing pressure injuries for some time so their rate for all pressure injuries (including low level grade 1) had already reduced from 12 per cent, when they first started monthly audits in February 2011, down to 3 per cent a year later. A low rate has been maintained by CMDHB ever since.

”It is much easier to learn when you are all measuring the same thing… ”

Huge improvement

Karen O’Keeffe

Nursing Review series 2015

“It’s a huge improvement in two and a half years,” says O’Keeffe. “Having a clear strategy and having agreed outcomes has made a big difference.” The data is collected using the same means and with the same motivation – to learn and improve – so DHBs openly compare and discuss their results. Some DHBs have managed to reduce their grade 3 and grade 4 pressure injuries ‘significantly’, to the point where they are now quite rare events. “DHBs are looking at each other and asking ‘how did you do that?’ so there is a lot of sharing of resources and learning going on.” Auditing for pressure injuries on a monthly basis is also part of the learning process. O’Keeffe says when the auditors – usually wound care nurses – come across a grade 1 pressure injury during a ward audit, awareness is immediately raised and staff proactively ensure the injuries don’t get worse. She says setting the audit threshold for reporting pressure injuries at grade 1 – a non-blanchable reddening of a bony prominence like a heel – is a tougher benchmark than that set by most harm reduction strategies, according to the research literature. The DHBs also adopted the policy of accepting any grade 1 PI found as hospital-acquired, rather than fighting over whether it happened before admission. If the DHBs left out reporting the grade 1 PIs, it would bring the overall rate across the Northern Region down to just one PI per 100 patients. Consistent reporting standards means the region has baseline data from before and after its campaign so when it introduces new tools or systems it can see whether the changes are making pressure injury incidence better or worse. O’Keeffe believes nursing plays a large role in reducing the risk of pressure injuries but using pressure injury incidence as a ‘nurse sensitive’ indicator has its challenges. She says the cause of pressure injuries are multifactorial and PIs could be better viewed as a systems-sensitive indicator of having the right resources, education and equipment

When the other three DHBs also began to focus on reducing pressure injuries the prevalence rate across the whole northern region reduced by 36.4 per cent – well exceeding the 20 per cent target. Two of the DHBs dropped their pressure injury rate by between 60 and 70 per cent.

FOCUS n Wound Care

Check out online-only material at www.nursingreview.co.nz to read more about the Northern Region’s campaign and moves afoot for national PI reporting.

Unstageable pressure injury (due to slough) on sacrum

A pressure injury on the hip

available. “You have to have all your systems working well for people to have a good experience of care.” The reduction in pressure injuries in general across the Northern Region means DHBs can now focus on pressure injuries that fall outside the traditional ‘bedsore’ variety; for instance, devicerelated PIs of noses and ears caused by oxygen therapy, babies in neonatal ICU or unwell people on bypass machines.

Aged care sector

The Northern Region’s pressure injury harm reduction strategy has gone beyond the four DHB’s hospital walls to include the residential aged care sector. With the rest home sector having long-term residents, they needed a different reporting regime from that of acute care so are using an incident monitoring system to measure their pressure injury trends. There is yet to be consolidated data for the sector across all four DHBs so there is also no report yet on trends. But 100 per cent of Northland’s residential aged care facilities are now reporting on pressure injuries and falls, and around a quarter of facilities in the other DHB areas. “We are working towards the point that the facilities can see who is doing well and who can we learn from,” says O’Keeffe. The facilities are organised into clusters and just recently the campaign had more than 70 facilities from across the region at a learning event focused on pressure injuries and falls. The First Do No Harm campaign has from the outset linked pressure injury and falls education. O’Keeffe says of the two indicators reducing falls is the more challenging as, while there is quite good evidence to build a pressure injuries campaign, there are many more factors involved in reducing falls.

Thinking nationally, acting regionally

Falls are one of the four quality and safety markers that were adopted by the Health Quality & Safety Commission in 2012 to evaluate the effectiveness of its national patient safety campaign Open for Better Care.

Stage II pressure injury on toe due to too tight TED (thrombo-embolus deterrent) stockings post-surgery

Unstageable pressure injury on heel

Pressure injuries didn’t make the Commission’s short list because of concern there was still work to be done on finalising a quality indicator that could be used consistently across all DHBs. O’Keeffe says the Commission has been looking at a pressure injury quality indicator once again and the Northern Region has been sharing its findings and suggestions on national reporting guidelines for both pressure injuries and falls. She believes a national quality indicator for pressure injuries is definitely possibly, and desirable.

Pressure Injury Classification System »» Grade 1: Non-blanchable erythema (redness) of an area usually over a bony prominence like a heel »» Grade 2: Partial thickness skin loss »» Grade 3: Full thickness skin loss »» Grade 4: Full thickness tissue loss (exposing bone, tendon or muscle) »» Ungradable pressure injury: Depth or grade (stage) of the PI can’t be determined because wound is covered by slough or dead tissue

“It is much easier to learn when you are all measuring the same thing – then you can compare apples with apples as people are all reporting a grade 2 pressure injury the same way.” She also believes the Northern Region monthly audit process has proven to be robust and helped results improve ‘dramatically’. “I think one of our biggest successes has been that the DHBs have been very proactive, supportive and put the time and effort into [getting the data] and the patients are reaping the benefit of having a lot less harm related to pressure injury. Because we’ve been able to see what we’ve been doing is making a difference.”

Latest ACC statistics for pressure injuries »» In the last decade* 2,001 (2.5 per cent) of the 80,777 treatment injury claims processed by ACC were related to pressure injuries. »» 1,320 (66 per cent) of the pressure injury claims were accepted by ACC. »» The annual claims for pressure injuries have steadily increased since the law changed a decade ago and have doubled in the past five years to nearly 400 a year. »» 14 claims in the past decade were lodged and accepted for deaths related to pressure injuries. »» In all, ACC has reported 172 adverse events related to pressure injuries to the Ministry of Health. The majority of these (140) were in the last five years. (Since late 2014, ACC has also been informing the Health Quality and Safety Commission.) »» The average age of people with ACC pressure injury claims was 71 years old and the vast majority were over 65 years old. »» Of the 1320 claims, the vast majority (1,212) related to public hospitals and only 41 related to residential aged care facilities. »» More than 950 claims (72 per cent) were regarded as being related to nursing care; claims were often accepted because there was no documented evidence of the provision of pressure area care.

*1 July 2005 to 30 June 2015. N.B. Treatment injury data dates from 1 July 2005 when ACC rules were changed to replace ‘medical misadventure’ with ‘treatment injury’. Treatment injuries need to prove a ‘direct causal link between the treatment and the injury’.

Nursing Review series 2015

Evidence-based practice

Raising legs helps heart return to a steady rhythm This edition's critically appraised topic (CAT) looks at research into a new addition to an established technique to restore a steady rhythm to a rapidly beating heart. CLINICAL BOTTOM LINE: In patients with stable supraventricular tachycardia (SVT), using a modified Valsalva manoeuvre, involving leg elevation and supine positioning at the end of the usual strain, is a simple, no cost, well-tolerated procedure that is about 26 per cent more likely to restore sinus rhythm than the standard semi-recumbent Valsalva manoeuvre. It should be considered as a routine first treatment.

CLINICAL SCENARIO: As a nurse working in the Emergency Department (ED), you frequently admit patients requiring emergency treatment for SVT. ED protocol recommends trying the standard Valsalva manoeuvre for initial treatment, which involves patients straining with force against a closed airway. However, successful reversion to sinus rhythm is uncommon and you decide to review the evidence for the effectiveness of this treatment option.

QUESTION: In patients presenting acutely with supraventricular tachycardia, how effective is the Valsalva manoeuvre as the first-line treatment for restoring sinus rhythm?

SEARCH STRATEGY: PubMed Clinical Queries (therapy, broad): Valsalva manoeuvre AND supraventricular tachycardia

CITATION: Appelboam, A., Reuben, A., Mann, C., Gagg, J., Ewings, P., Barton, A., Benger, J. (2015). Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet .

STUDY SUMMARY: The Randomised Evaluation of Modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study is a randomised, controlled, parallel group trial conducted in 10 emergency departments in England between 2013 and 2014. Inclusion criteria were patients older than 18 years presenting with SVT (regular, narrow complex tachycardia with QRS duration <0·12 s on ECG). Exclusion criteria were unstable patients with systolic blood pressure < 90mmHg or an indication for immediate cardioversion, atrial fibrillation or flutter (or suspected), contraindications to Valsalva manoeuvre, an inability to perform or tolerate the study procedure, third trimester pregnancy, or previous inclusion in this study. The 711 patients presenting to ED with suspected SVT were formally screened (241 did not meet eligibility criteria, 20 eligible were not enrolled, 26

Nursing Review series 2015

17 declined consent); 433 were randomised and 428 analysed; five were excluded after randomisation as they were repeat enrolments. »» Standard care for both groups: All participants performed the initial straining component of the Valsalva manoeuvre in a semi-recumbent position. The Valsalva manoeuvre strain was standardised to a pressure of 40mmHg (measured by aneroid manometer) and sustained for 15 seconds (s). The Valsalva manoeuvre was repeated once if sinus rhythm was not restored. A 12-lead ECG was recorded if return to sinus rhythm was achieved at one minute after Valsalva manoeuvre, and one minute after the second manoeuvre even if unsuccessful. »» Interventions: (n = 214) Modified ‘lying down with leg lift’ Valsalva manoeuvre: participants performed the standardised strain in a semi-recumbent (at 45 degrees) position but immediately at the end of the strain were laid flat and had their legs raised to 45 degrees for 15 seconds. Participants were then returned to the semi-recumbent position for a further 45 seconds before re-assessment of cardiac rhythm. »» Control: (n = 214) Standard ‘sitting’ Valsalva manoeuvre: participants performed the standardised strain in a semi-recumbent (at 45 degrees) position. They remained in the semi-recumbent position for 60 seconds before reassessment of cardiac rhythm. »» Outcomes: Primary outcome – presence of sinus rhythm one minute after intervention. Secondary outcomes – use of adenosine or any other emergency SVT treatment, hospital admission, length of stay in ED and adverse events.

all data. Clinicians and participants could not be blinded but trial paperwork and explanations didn’t indicate to participants which Valsalva manoeuvre was the intervention and which was the control. There was no loss to follow up. Analyses were performed on an intention-to-treat basis. Study groups were similar and groups were treated equally. Study quality was high.

STUDY RESULTS: In both groups, around 85 per cent of participants achieved the desired strain pressure and duration. Significantly more participants reverted to sinus rhythm at one minute with the modified Valsalva manoeuvre than with the standard manoeuvre (table). Use of adenosine, or any emergency anti-arrhythmic treatment, was significantly lower in the modified Valsalva manoeuvre group (table). There was no significant difference between groups for rates of adverse events, time spent in ED or need for admission to hospital.

COMMENTS: »» This simple postural modification to the standard Valsalva manoeuvre reduced the need for unpleasant, higher risk anti-arrhythmic treatment (number needed to treat = 4). »» The procedure was well tolerated in the study population – adverse events were self-limiting and none were serious. »» The modified procedure can be easily taught to patients and staff; the open access publication has links to a training video and the authors advise that blowing into a 10ml syringe to just move the plunger generates a similar pressure to a 40mmHg strain (no fancy equipment required).

STUDY VALIDITY:

Reviewer:

Randomisation was by an independent statistician. Allocation was concealed using serially numbered, opaque, sealed, tamper-evident envelopes. Investigators blinded to treatment allocation independently analysed

Cynthia Wensley RN, Honorary Professional Teaching Fellow, The University of Auckland and PhD candidate, Deakin University, Melbourne cwensley@deakin.edu.au

Table: Results with 95% Confidence Intervals (CI) Standard VM n = 214

Modified VM n = 214

Absolute Difference (95% CI)

Adjusted OR (95% CI)

P Value

Presence of sinus rhythm at one minute after Valsalva manoeuvre

37 (17%)

93 (43%)

26% (18–35%)

3.7 (2.3–5.8)

< 0.0001

Adenosine given

148 (69%)

108 (50%)

19% (10–28%)

0.45 (0.30–0.68)

0.0002

Any emergency antiarrhythmic treatment (including adenosine)

171 (80%)

121 (57%)

23% (15–32%)

0.33 (0.21–0.51)

<0. 0001

Outcome

VM - Valsalva manoeuvre; CI - Confidence Intervals; OR - Odds Ratio

College of nurses

Time for nurses to speak up for

health equity? I

was recently fortunate to be exposed to the ideas of a number of indigenous health leaders during the recent symposium on accelerating indigenous health gain. The Counties Manukau Health-hosted symposium, a precursor to the APAC forum on healthcare innovation and improvement, was an opportunity to showcase examples of indigenous health excellence. Including examples of indigenous health improvement and innovation sitting alongside development in tribal governance and indigenous leadership; like American Indian and Alaska Natives being able to exercise control over their health system on behalf of their customer-owners i.e. patients.

Common history The event was inspiring not only for the examples of indigenous health excellence presented, but also for the sharing of common stories and values that remain poorly understood by the mainstream. Like Māori, indigenous peoples share a longstanding bond with ancestral lands, and a common ancestry or whakapapa with unique cultures and language. Like Māori, many indigenous peoples also share a common history of impoverishment, the disruption of traditional economies, and socioeconomic and cultural degradation as a result of colonisation. As a consequence, indigenous peoples suffer from poorer health and are more likely to experience disability, a reduced quality of life and decreased life expectancy. Discrimination, structural racism and inadequate healthcare and disease prevention services exacerbate this situation.

Are we doing enough? Many international speakers leave Aotearoa with the belief that we are leading the way in terms of improving indigenous health and honouring indigenous human rights. As a country, we take pride in our human rights track record and take our international obligations seriously. Yet without exception, all United Nations Treaty body reports have noted poorer health outcomes for Māori, particularly with regard to life expectancy and infant mortality. From a state point of view, this is not in dispute and is highlighted in the New Zealand country report (our international report card) to the United Nations Committee

Nursing Review series 2015

TAIMA CAMPBELL argues it is time for nursing as a profession to face up to and speak out about the health inequities that result in poorer health outcomes for Māori. on Economic, Social and Cultural Rights. So as nurses and citizens, are we doing enough? The Medical Council recently called on doctors to work in partnership with Māori and address the issues of inequity they face in the health system. Cultural competence and genuine partnership with Māori were identified as important aspects of achieving

To not address the privileging of one group over another is to remain complicit in the perpetuation of the status quo. excellence in clinical practice. The Medical Council restated that health inequities are unacceptable and that doctors have a professional and moral obligation to address inequity. In terms of nursing, cultural safety has been part of clinical practice for decades – so is it time that nursing follows suit and makes a conscious and informed decision to lift standards to ensure the survival, dignity, wellbeing and rights of our indigenous people? The answer must be yes.

Nurses must speak out If we want to make improvement in longstanding health inequalities for Māori, then we must speak out about structural discrimination in the health system; where rules and practices disadvantage less empowered groups while serving to advantage the dominant group. To not address the privileging of one group over another is to remain complicit in the perpetuation of the status quo. We also need to value and nurture the growing number of Māori nursing and midwifery indigenous leaders. Shortly, over

Taima campbell

200 Māori nurses and midwives will have completed the Ngā Manukura o Āpōpō leadership programme. These graduates have been tasked with promoting wider acceptance of Māori thinking, frameworks and ideologies and integration of these into New Zealand’s health system. In turn, this investment will lead to more culturally appropriate services and, in the longer term, more equitable care for Māori. It is up to us to seek the talents of these emerging indigenous health leaders and work with them to develop robust models of indigenous health excellence for our customer-owners. That’s the conference I’m looking forward to. Author: Taima Campbell RGON Ngati Tamatera; Ngati Maru; Ngati Kiriwera is a health consultant and former director of nursing for Auckland District Health Board. N.B. References will be published in the online version of the article at www.nursingreview.co.nz

Southcentral Foundation’s Nuka System of Care, based in Anchorage, Alaska, is a result of a customer-driven overhaul of what was previously a bureaucratic system centrally controlled by the Indian Health Service. Alaska Native people are in control as the customer-owners of this healthcare system. The vision and mission focus on physical, mental, emotional, and spiritual wellness and working together as a native community. Coupled with operational principles based on relationships, core concepts and key points, this framework has fostered an environment for creativity, innovation and continuous quality improvement. Alaska Native people have received national and international recognition for their work and have set high standards for performance excellence, community engagement, and overall impact on population health.

Practice, People & Policy TRIBUTE

Articles, profiles and opinion pieces from across the nursing spectrum

Practice, People & Policy Tributes for nursing treasure Putiputi O’Brien Ngaira Harker: on behalf of the College of Nurses Aotearoa at the passing of their patron Putiputi O’Brien Ngāti Awa has laid one of its most precious taonga to rest with the passing of Putiputi O’Brien. The daughter of Ngāti Awa chief Eruera Manuera and his wife, Pareake, Putiputi was born and raised in Te Teko in the eastern Bay of Plenty. Her tribal affiliations include Ngāti Awa, Te Arawa and Tūhoe. Putiputi O’Brien was one of the first Māori nurses in New Zealand. She began her training at Waikato Hospital School of Nursing in 1941 and graduated in 1945 as a registered general and obstetric nurse. She began her career as a public health nurse in Te Teko when the only way into the remote country areas was by horseback. Later she completed her maternity and Plunket training, and worked for more than 50 years in the eastern Bay of Plenty, central North Island and south Waikato areas. She is still remembered in Wairoa, my hometown, where she worked as a public health nurse and supported many whānau in Wairoa. It was here she met her husband Tom O’Brien. On retiring from the Health Department, Putiputi worked in community health with Midland Health as a district health coordinator and the manager of the Ngāti Awa ki Rangitaiki health initiative, during which time she was behind many innovative health promotions. As a Māori nurse, Nanny Puti was able to walk in both worlds and throughout the years has articulated eloquently the positive influence that nursing has made within Aotearoa. It is indeed a long career that Putiputi has had and she has shared freely her knowledge to all within nursing.

Patron and proverbs Putiputi O’Brien became a founding trustee of the Tipu Ora Charitable Trust in 1991 and was also the patroness of Smokefree Nurses Aotearoa. She was a recipient of the Akenehi Hei award from Te Rūnangao Aotearoa NZNO for her contribution to Māori health. In 1987, she was awarded the Queen’s Service Order for her contribution to a wide range of community and welfare organisations at local and national levels. She had been the patron of Te Kaunihera o Nga Neehi Māori (National Council of Māori Nurses) since 1984. On becoming the patron of the College of Nurses, Aotearoa (New Zealand), Nanny Puti gifted to the College a whakatauki (proverb): “Kia taha, kia puawai, te maramatanga The illumination and blossoming of enlightenment.”

Nursing taonga Putiputi O’Brien RN QSO passed away in August aged 93. NGAIRA HARKER, HEMAIMA HUGHES and KERRI NUKU pay tribute to this special nurse. Putiputi O’Brien

This epitomised her positive attitude to life and her approach to care and was also the source for the name of the College newsletter Te Puawai (The Blossoming). Nanny Puti has always been known and respected at a national level; however, it is in Te Teko where her loss has truly been felt. Nanny Puti was the ‘Queen of Te Teko’ and the community of Te Teko is only now coming to terms with the gap she has left in the community. She was an icon within this region and remained in her whare next to her marae surrounded by her whānau within Te Teko where she continued to support her community.

Trailblazer fostering next generation We have been fortunate to have Nanny Puti as our ‘covergirl’, together with her beautiful daughter Pare, in promoting and supporting Te Ōhanga Matora Paetahi – Bachelor of Health Science Māori Nursing. They have been inspirational in their support of establishing a Māori nursing school within Whakatane. At the inaugural opening of the programme we had Nanny Puti as our guest of honour and to everyone’s delight, including Putiputi, we relived her experiences through some old footage riding on her horse and reliving some of her amazing experiences and challenges within her career. We were all delighted to watch her laughing as she realised that she was the focus of the clips. She was a trailblazer and the tauira (students) who were fortunate enough to relive this with Nanny Puti will have this memory of her in this magic moment. We were so fortunate to be able to fulfill one of her dreams, which was to see Te Ōhanga Mataora Paetahi delivered from within the culturally strong environment of Te Whare Wānanga o Awanuiārangi.

Nanny Puti dedicated her life to what she later described as ‘absolutely, positively nursing’. In Nanny Puti’s words: “Nursing by its very essence is about positive impact, we just need to tap its full potential in every setting and every context … Let’s together reach out and grasp the fullness of what we have to offer and turn all our energy to achieving a ‘positive impact’ rather than wasting energy on what leads to negativity. Let us collectively agree we are absolutely, positively nursing.” The College of Nurses has been truly privileged to have had Putiputi O’Brien as our patron and we thank her whānau for sharing her with us all. “Hāere, hāere, hāere atu rā koe e kui ka moe nei o whatu, ka mahue nei te manehurangi O te putiputi o te rātā whakaruruhau ki ritoroti a to pā harakeke ka heke nei tōna momo.”

Kerri Nuku:

kaiwhakahaere of Rūnanga o Aotearoa NZNO Te Rūnangao Aotearoa pay tribute to Putiputi O’Brien and honour her outstanding Māori leadership. Putiputi worked tirelessly to improve the health and wellbeing of our people. As a recipient of our most prestigious award, Putiputi was acknowledged and admired by her peers for maintaining the integrity and values of manaakitanga, kaitiakitanga and wairuatanga as she went about fulfilling her vision of building a strong and resilient Māori workforce, in what were challenging times. There is a Māori proverb that reads: “A totara is a huge tree that grows for hundreds of years. For one of them to fall is a great tragedy.” Although we have lost a significant wahine toa we must take comfort from her vision that has inspired many of the young and old, Māori and non-Māori, who follow in her footsteps and her dream will continue and remain in our hearts.

Nursing Review series 2015

Practice, People & Policy TRIBUTE

Hemaima Hughes: on behalf of Te Kaunihera o Ngā Neehi Māori o Aotearoa (National Council of Māori Nurses), of which Putiputi O’Brien was also patron.

“E te whānau pani, tēnā koutou katoa. Kua hinga koe ataahua Whaea Putiputi E te pohutukawa nui, Takoto mai i runga i te rangimarie o te Karaiti, Ko koe te kawa whakaruruhau o tātou ākonga me ngā neehi Māori o Aotearoa. E te pou tokomanawa e kore rawa koe e warewaretia Takoto i runga i te aroha Kei te maumahara tonu tō kōrero i o tātou ākonga me ngā neehi Māori o Aotearoa mo te hauora o ngā iwi Māori me ngā tangata katoa. ‘Tomo mai ki te akoranga hauora whakahokia ki te ao whanui’ Haere atu rā koe i runga tō waka tūpuna o Mataatua. No reira, e te rangatira whaea, haere, haere, haere atu rā. Moe mai i tō moengaroa.” To the bereaved family, greetings. You have fallen beautiful Aunty Putiputi O giant pohutukawa, lie in the peace of Christ You are the shelter of our Māori nursing students and nurses of New Zealand Our great pillar, you will never be forgotten Lie peaceful in our love Your advice to all Māori students and Māori nurses to ‘enter to learn and go forth to serve’ (for the health of the people) will always be remembered. Go to your waka Mataatua to the gathering place of your ancestors Therefore Aunty our esteemed leader, farewell, farewell, rest in peace.

Nursing Review series 2015

opinion

Nursing down under: an Irish nurse’s experience Young Irish nurse GRACE McDONALD shares how and why she chose to get her “fantastic” OE nursing experience here in New Zealand.

, like me, you enjoy travelling, meeting new people and furthering your nursing career, then I would highly recommend a leap from your comfort zone. I trained as an RN in Northern Ireland, studied and worked in the United States and Finland, before my first nursing job in a busy ED in England, which was an amazing experience. But I wanted something more; a new experience, a new lifestyle, and New Zealand had the answer. Many career paths are very transferable in today’s society, none more so than nursing. So many countries are in need of nurses. As a nurse there are several big countries to choose from, including Canada, Australia and Saudi Arabia. For me none of these was appealing. Saudi nurses are extremely well paid; however, there are lifestyle restrictions and the heat would kill me. And if the heat didn’t kill me in Australia, I thought surely some creature would. I chose New Zealand as it was an English-speaking country, had many links to the United Kingdom, is known worldwide for its beauty and outdoor activities … and has less dangerous wildlife. To me it was, and is, perfect. I suppose you could call what I’m doing an OE but I feel this is a life experience, and perhaps an extended one. I started the process of moving to New Zealand in February this year and by the end of May I had made the move. It does take time and effort to move country; including applying for visas, saving your pennies, vaccine updates, becoming registered with the Nursing Council of New Zealand and then the dreaded packing up your life. I applied for multiple jobs prior to arriving, mostly in acute areas as that was my field of expertise. After four weeks I began working in an accident and medical clinic, which was a great experience but I missed the acute setting. Once I had a foot in the door with my first New Zealand nursing job, everything was so much easier. I started to get replies to my job applications and recently moved to a busy

emergency department in one of Auckland’s major hospitals. In my department there is a high number of ex-pats, which makes it easier. They range from nurses like myself who have just arrived to those who moved here 30 years ago. New Zealand is a long way from everywhere else, therefore being able to make friends, make memories, explore the country or just talk about homesickness and the things you miss can be really helpful. Nurses trained in the UK and New Zealand are very similar in many ways and I haven’t found many differences when it comes to actual nursing. There are also many similarities and differences with regards to healthcare between UK and here. Both are ahead and behind each other in multiple areas. For example, years ago an initiative to protect meal times was introduced in the UK and I read that only six months ago this initiative was brought to New Zealand. But New Zealand medication and preparation appear to be more advanced than the UK. I think as nations we learn from each other, each growing and developing in different stages. There are some differences I am still getting used to, such as people walking barefoot and why it’s colder inside many houses than outside. I love the outdoorsy spirit of this country and its opportunities to climb a mountain, paddle a canoe to an offshore island or explore glaciers. One thing I am not excited about is a warm Christmas! Yes, New Zealand is a long way away but it so far has proven a fantastic experience for my career and life. Of course, I miss my family but with Facetime and Skype the world has never felt so small… just remember that time difference! I would strongly recommend having an overseas experience at least once in your life.

“Many career paths are very transferable in today’s society, none more so than nursing.”

Practice, People & Policy

Simulation:

research

coaching Oscar performances from Millennial nursing students GWEN URLAM set out in her doctoral research to bridge the generation gap and find the best way to reach and teach Millennial nursing students using simulated learning environments.

is now widely believed that generational tendencies can be tracked by birth cohort. Nurses currently working in the health sector span four generation cohorts (see box). The oldest cohort began training in the 1960s, the newest this millennium, so each generation has been prepared for professional practice in quite different ways. Today’s data-rich infosphere has profoundly influenced the youngest generation in their attitudes toward family, career, risk, romance, politics and religion. Generational theorists argue that the generational tendencies indicate a clear break between those born from 1982 onwards and those born before. The newest generational persona, the Millennials, are said to be unique and to have seven distinguishing characteristics. They believe they are: »» Special: Millennials have an inculcated sense that they are, collectively, vital to the nation and to their parents’ sense of purpose. »» Sheltered: With the explosion of children’s safety rules and devices, Millennials are the focus of the most sweeping youth safety movement in history. From car seats to bike helmets and vaccinations to private tutoring, Millennials have been provided for and protected like no previous generation. »» Confident: Due to high levels of trust and optimism and a strong connection with parents and the future, millennial teens are often boastful of their generation’s power and potential. »» Team-oriented: With the new emphasis on classroom learning, Millennials prefer group learning and working in teams. Relationships are characterised by tight peer bonds. »» Achieving: With increased accountability and higher academic standards, Millennials are on track to become the best-educated and bestbehaved adults in history. »» Pressured: Millennials are pushed to study hard, avoid personal risks, and take full advantage of the collective opportunities adults are offering them. Receiving awards, trophies, medals and certificates since an early age has produced a ‘trophy mentality’ in this generation, which can be used to maximise their effort and engagement with learning. »» Conventional: In contrast with previous generational cohorts, Millennials take pride in their improved behaviour and are more comfortable with their parents’ values than any other generation in living memory. Millennials support convention – the idea that social rules can help.*

Speaking to millennial nursing students When considering all these characteristics collectively, it occurred to me that we as educators

The generations »» The Silents (born between 1925 and 1942) »» The Baby Boomers (born between 1943 and 1960) »» The Generation Xrs (born between 1961 and 1981) »» The Millennials (born between 1982 and 2002 and also known as Generation Y) might be preparing nursing students in a manner that fits with our own preparation, but does not ‘speak’ to millennial learners. The focus of my doctoral research, using action research methodology, was to design more effective platforms to ‘reach’ millennial students through simulated learning. Simulation as a teaching and learning tool maximises many of the above identified tendencies in millennial learners, allowing them to construct their learning in ways uniquely personal and engaging.

Gwen Urlam

clinical environments. This modelling aspect of my simulation design was the most valued feature reported in a post-simulation questionnaire of 125 students. The students reported that this modelling made the goals clear, and enabled struggling students to improve without losing face. As stated above, millennial students consider themselves ‘special’ and are accustomed to individual feedback. This was given in the debriefing section of the simulation. Students were able to take the feedback and perfect their performance. Debriefing feedback fuelled engagement and motivation to improve in both clinical reasoning and skill performance in the simulation. In order to tie into the ‘trophy pursuits’ of many millennial students, I produced a certificate that was given to each student upon completion of their simulation experience. This ‘trophy’ was highly valued by these Millennials, who have earned trophies and certificates all their lives. They often emailed me if their certificate did not arrive within a few days of their simulation experience in order to ensure that I did not forget how well they did! This often made me smile as I realised

“When designed well, simulation has the ability to meet the needs of Millennial learners in ways that traditional classrooms may not.” Their team orientation makes simulation an effective teaching and learning platform when used in groups of three to four. Each group is viewed as a team and encouraged to communicate and build roles into their simulation performance in order to maximise collaboration with other team members. The ISBAR (Identity, Situation, Behaviour, Assessment, and Recommendation) communication tool was used to communicate with other professionals encouraging interprofessional collaboration. Due to Millennials’ focus on achievement, coupled with their potential risk aversion, I found it was important to design simulation opportunities that allow for a repeat performance after being given feedback. This means the millennial student is given an opportunity to perfect their performance in what I called their ‘Oscar performance’. I often modelled the expected performance (performing all roles myself) in order to help these ‘performance-oriented’ students see what was expected. This modelling was a form of tutoring, and also a way of encouraging riskaverse Millennials to continue to improve in their management of deteriorating situations in real

I was designing the kind of classroom that they enjoyed engaging with. They pursued their ‘Oscar performance’ with a vengeance. It was a win-win for everyone involved. In summary, I found that effective millennial classrooms embodied a different design from the classrooms many Baby Boomer and Gen Xrs were accustomed to. Due to collaborative tendencies, Millennials enjoy working in teams. Due to privileged and protected upbringings, many Millennials are risk averse and prefer modelling and repeated attempts in order to ‘get it right’. When designed well, simulation has the ability to meet the needs of millennial learners in ways that traditional classrooms may not, thus paving the way for simulation to become the ‘preferred classroom’ for future Millennial healthcare students.

*Howe N & Nadler R. (2008). Millennials rising. Leadership for Student Activities, 36(8), 17-21. Retrieved from www.principals.org The author: Gwen Erlam BSN MA is a senior lecturer in nursing and a doctoral student at AUT.

Nursing Review series 2015

Practice, People & Policy policy

Steady but slow steps towards

RN prescribing Nursing Review updates the next steps towards widened registered nurse prescribing in, hopefully, 2016.

obody is ready to set a date yet for when widened prescribing for approved registered nurses will come into being. But with a draft cabinet paper and regulatory impact statement expected with the Minister in October, the concept is one step closer and RN prescribing may be a reality sometime in 2016. The proposal would allow experienced registered nurses working in primary healthcare settings with patients with long term and common conditions, as well as RNs working in specialist teams in outpatient settings, to apply for Nursing Council authority to prescribe commonly used medicines in their specialty area. The nurses will be required to first complete a postgraduate diploma in RN prescribing and to continue to be supervised during the first 12 months of prescribing practice. It was back in February 2013 that the Nursing Council first consulted, at the invitation of then health minister Tony Ryall, on extending prescribing to ‘suitably qualified’ registered nurses. This move followed the successful demonstration sites for prescribing by diabetes nurse specialists. The Nursing Council lodged a formal application with the Ministry of Health back in October 2014 for designated prescribing rights for RNs practising in primary health and specialty teams. After initial analysis and feedback, the Minister of Health Jonathan Coleman this winter agreed to Ministry of Health officials progressing the application to the next step, which is the drafting of a cabinet paper and regulatory impact. Coleman’s office said it was expecting the draft papers to be with the Minister in October but there was no timeline beyond that for when RN prescribing could come into effect. The Ministry of Health says once Cabinet had considered the prescribing Cabinet paper, the next step was drafting prescribing regulations. Carolyn Reed, chief executive of the Nursing Council, says it is expecting the next steps in the process to take some time and realistically it could be about 12 months before prescribing regulations were gazetted. She says meanwhile the council was not silent behind the scenes as it was doing a

Nursing Review series 2015

“We’re anticipating that when we get to the finishing line and it becomes legal, there will be people ready to apply who already have met all the [education] requirements.” Carolyn Reed

lot of work with postgraduate education providers preparing the proposed new postgraduate diploma in registered nurse prescribing in readiness for when the RN prescribing regulations are introduced. It had also consulted on adding an ophthalmology schedule of medicines to the proposed regulations and developing a plan for ongoing updating of all the schedules of medicine. It is also working on a safety framework for monitoring RN prescribing, informing the public about what RN prescribing entails, and establishing a ‘grandparenting’ arrangement for already prescribing diabetes nurse specialists. Reed says it has agreed to education standards for the new diploma but until the prescribing regulations are gazetted the Council can’t approve prescribing diploma programmes. “But we’re anticipating that when we get to the finishing line

and it becomes legal, there will be people ready to apply who already have met all the [education] requirements,” she says. This refers in particular to nurses who have a clinical master’s degree, though some may still need to do a supervised prescribing practicum. It is estimated that around 1,000 nurses may already have a clinical master’s degree but Reed points out that prescribing RNs require not only the qualification but also a supervised working environment for their first year of practice. “I don’t think there will be 1,000 workplaces ready to go with that … it [RN prescribing] also requires workplace readiness.”

New education standards for NPs due A new ‘broad and generic’ nurse practitioner scope of practice is due to be announced soon, along with new draft education and registration standards for NPs. Nursing Council chief executive Carolyn Reed said the Council adopted a new scope for NPs in September that was basically a refined and tightened version of its consultation document in late 2014. Reed says analysis showed that 77 per cent of submissions supported the proposed ‘broad, generic’ scope of practice and removing specific areas of practice for nurse practitioners. A similar percentage supported the proposed new narrower focus on leadership in clinical practice, rather than current requirements for prospective NPs to demonstrate leadership on a national level. The council also adopted in September some draft proposed NP education standards and options for a new registration process for NPs, including alternative options to the current panel requirement. The Council hoped to release a consultation document shortly on the draft standards and registration process options.

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