2013 Nursing Praxis 29 3 November by Nursing Praxis in NZ

IN NEW ZEALAND Journal of Professional Nursing

INSIDE THIS ISSUE... Nurses and heart failure education in medical wards Nurse perceptions of the Diabetes Get Checked programme Barriers in education of Indigenous nursing students: A literature review

Volume 29. No. 3

NOVEMBER 2013

Praxis: “The action and reflection of people upon their world in order to transform it.” (FREIRE, 1972)

E D IT O RIAL BO ARD EDITOR-IN-CHIEF: Denise Wilson RN, PhD, FCNA (NZ) Norma Chick Willem Fourie Thomas Harding Dean Whitehead Stephen Neville Michelle Honey Jean Gilmour

RN, RN, RN, RN, RN, RN, RN,

RM, PhD PhD, FCNA PhD PhD, FCNA PhD, FCNA PhD, FCNA PhD

(NZ) (NZ) (NZ) (NZ)

COVER: Crimson was deliberately chosen by the Editorial Group as the colour for this journal as it represents, for us, imagination, intuition, potentiality, struggle and transformation.

KORU: Designed for this journal by artist, Sam Rolleston: The central Koru indicates growth, activity and action. The mirrored lateral Koru branches indicate reflection.

PO Box 1984, Palmerston North 4440, New Zealand P/Fx (06) 358 6000 E admin@nursingpraxis.org W www.nursingpraxis.org ISSN 0112-7438 HANNAH & YOUNG PRINTERS

CO NTE NTS EDITORIAL .......................................................................................................................................... 2

ARTICLES: Nurses and heart failure education in medical wards. Jean Gilmour, Alison Strong, Mona Hawkins, Rachel Broadbent, Annette Huntington ................... 5 Nurse perceptions of the Diabetes Get Checked programme. Jill Clendon, Jenny Carryer, Leonie Walker, Vicky Noble, Rosemary Minto, Rachael Calverley, Deborah Davies, Hilary Graham-Smith ..................................................................................... 18 Barriers in education of Indigenous nursing students: A literature review. Donna Foxall .............................................................................................................................. 31

NOTES FOR CONTRIBUTORS............................................................................................................. 38

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Vol. 29 No. 2 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand EDITORIAL Avoidance of Inappropriate Authorship and Self-Plagiarism

Transgressions relating to authorship can stem simply from a lack of awareness, and possibly confusion, about what constitutes authorship and the associated criteria

Publication ethics are the foundation for the quality

that need to be met. The International Committee of

of published peer-reviewed articles, and are essential

Medical Journal Editors (2013) outline four criteria that

for maintaining the trust of a journal’s readership.

specify conditions that each author must meet in order

Publication ethics were a central focus of the 2013

to be considered a legitimate author of a manuscript:

International Nurse Academy of Editors’ (INANE)

1. Substantial contributions to the conception or

Conference held in Cork, Ireland at the end of July. It

design of the work; or the acquisition, analysis, or

was during the sessions about authorship that I reflected

interpretation of data for the work; AND

on the occasional conversations we have as an Editorial

2. Drafting the work or revising it critically for important intellectual content; AND

Board about the quality of a manuscript and the degree of involvement some named authors actually had in its

3. Final approval of the version to be published; AND

preparation. It semms not all authors are aware of their

4. Agreement to be accountable for all aspects

ethical obligations when considering the publication of

of the work in ensuring that questions related

research or discursive works? In this editorial, I have

to the accuracy or integrity of any part of

focused on two areas in which authors need to be

the work are appropriately investigated and

vigilant - areas that can be easily overlooked. These are

resolved (http://www.icmje.org/roles_a.html).

inappropriate authorship and self-plagiarism. A study that examined authorship using the ICMJE and Plagerism is the area most commonly in question with

the COPE (Committee on Publication Ethics) guidelines

respect to publication ethics. Yet concerns extend to

for authorship in the articles in 10 peer-reviewed nursing

authorship, and include a range of areas such as self-

journals with impact factors, Honorary and Ghost

plagiarism, fabrication and fraudulent presentation of

Authors in Selected Nursing Journals, was presented

data. Without doubt attention to publication ethics, such

at the INANE Conference by Maureen Kennedy, Jane

as ensuring manuscripts are free from error, plagiarism,

Barnsteiner and John Daly. They found:

and fabrication, is crucial so that those accessing

•

42% honorary authors, 27.6% ghost authors, 30.2%

published literature can have trust in the authorship and

corresponding authors did not meet all three

veracity of the articles. Ethical transgressions range in

authorship criteria (see criteria 1 to 3 above);

severity from those constituting unintentional author-

•

26% did not approve the final version; and

error up to more serious forms of misconduct that

•

Of those who used ghost or paid authors

include intentional wrongdoings such as fraud. Whether

(that is, co-authors that were not listed),

the errors are intentional or non-intentional it is the

41.5% did not acknowledge this in any way.

responsibility of the authors to verify that a manuscript accurately portrays the research it is reporting, and that

Each author must actively contribute to the writing

it has not been published elsewhere. With the aid of the

of the manuscript. Inappropriate authorship falls into

internet, transgressions are now much easier to detect.

two main categories: (a) Honorary or Guest authors, such as, academics, supervisors, department heads, or

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand someone who is known in the publication’s area but

and plagiarism detection tools like iThenticate are

has had little involvement in the actual production and

being increasingly used by journal editors to minimise

submission of a manuscript; and (b) Ghost authors, such

incidences of text recycling and plagiarism.

as paid writers or sponsors, who are unnamed authors. Inappropriate authorship is an increasing phenomenon.

Authors also need to realise that there are implications

The current academic environments where there is

associated with recycling text. Most journals, including

increasing pressure to submit manuscripts and publish

Nursing Praxis, get authors to sign over copyright

is a contributing factor leading some academics to

to the journal that is going to publish their work. In

engage in practices considered as misconduct. In

doing so, authors verify that the work has not been

addition, there is an increase in number of submissions

previously published or submitted elsewhere. From

from developing and non-English speaking countries,

an editor’s perspective, publishing work that has

where pressure on academics to publish can lead to

been published elsewhere has copyright implications:

transgressions in order to satisfy this demand. These

first, the authors no longer hold the copyright to sign

are not necessarily related to knowingly tolerating, or

over to the journal considering their manuscript; and

sometimes deliberately promoting transgressions. But

second, by publishing the manuscript, the journal itself

they may involve unequal power relationships among

has unknowingly breached copyright. At the INANE

authors with the expectation that authorship occurs

conference, over half the editors present were using

without undertaking any of the associated research

iThenticate to detect plagiarism in articles they were

and/or writing of the publication. Those considered

intending to publish. In incidences where an ethical

inappropriate authors may mistakenly believe they

transgression has occurred, editors are also taking the

avoid scrutiny because authorship decisions belong

step of informing the author’s employer of the situation.

solely with the writer. Authors need to be attentive to authorship and selfThe other area of concern is that of self-plagiarism or

plagiarism. In addition to being ethical issues, these

‘text recycling’, for publications later than 2004. I hear

transgressions reflect adversely on the author’s

authors saying, “But if I wrote it, I can use it anywhere

credibility, the quality of the work, and importantly

I want!” Yes, an author may have written something,

have legal consequences. These consequences may be

but once published you give up your right to publish it

either the rejection of a manuscript pre-publication,

elsewhere. COPE considers self-plagiarism constitutes

or if already published, the publication of a correction

the recycling of text, and occurs “. . . when sections of

notice, or the retraction of a published article. Authors

the same text appear in more than one of an author’s

and co-authors need to be mindful that:

own publications” (http://publicationethics.org/text-

1. Each author must meet all of the above criteria

recycling-guidelines). COPE indicate that the recycling

outlined for authorship. Otherwise, authorship is

of text in the methods section of manuscripts or minor

considered undeserved, and in some instances,

overlap may be considered for publication, but this

constitutes ethical misconduct. All authors need to

decision is at the discretion of individual journal editors.

have an active role in the writing and review of the

It is unacceptable to duplicate or replicate similar text

manuscript, as well as those who have had a role

from an author’s prior publication, not referencing

in the preparation, but are not named and should

the original publication, and provide insufficient new

have been named.

information in a manuscript under consideration, or one

2. If you have published work elsewhere, think very

that is already published. Search engines like Google

carefully about recycling the text. If you do need

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand to do this, for example in a methods section, then

Preventive action can avoid the distress likely to be

reference the previous publication and make it

experienced when the credibility and ethical integrity

clear that the work has been published elsewhere

of authorship or content of a manuscript or published

- just like you would do for any other authors’

work is questioned.

works. If in doubt, discuss the issue with the journal editor. In the covering letter to the editor

Associate Professor Denise Wilson

accompanying the manuscript, ensure you outline

Editor-in-Chief

any text recycling and the rationale for doing so.

Reviewers - We need you! Nursing Praxis is calling for new reviewers in 2014 to join our existing panel. If you have experience reviewing manuscripts or expertise in any areas of nursing and research, please apply now. Nursing Praxis needs an extensive database of reviewers from many different expertise areas for manuscripts that are submitted across a wide range of subjects related to nursing. Nursing Praxis manuscripts all go through a blind peer review process before the reviews are considered by the Editorial Board for final recommendations, the authors and Editorial Board do not know who is reviewing the manuscripts. As a reviewer you may be sent a few requests each year to review papers. You have aprox 3 weeks to complete the review questionaire. If you are requested to complete a review and you are not able to complete the review in the time frame available, just let us know and we will send it to another reviewer. If you have experience or a specific area of expertise and could spare the time to review one or two papers a year we would appreciate you registering your interest to join the reviewers database. We have an online link for Reviewers to register for our reviewers database go to the Reviewers page under ‘About us’ on our website Page 6

www.nursingpraxis.org

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand NURSES AND HEART FAILURE EDUCATION IN MEDICAL WARDS Jean Gilmour, RN, PhD, Senior Lecturer, School of Nursing, Massey University. Wellington, NZ. Alison Strong, RN, MN, Clinical Nurse Specialist - Heart Failure. Hawkes Bay DHB. Hastings, NZ. Mona Hawkins, RN, MN, Clinical Nurse Specialist - Cardiology. Hutt Valley DHB. Lower Hutt, NZ. Rachel Broadbent, RN, MN, Registered Nurse, Capital and Coast DHB. Wellington, NZ. Annette Huntington, RN, PhD, Associate Professor, School of Nursing, Massey University. Wellington, NZ.

Abstract Heart failure is a chronic debilitating disease with significant hospitalisation rates. Information and education are foundational elements in making the lifestyle changes required for effective self-management of the symptoms of heart failure. This paper reports a study of medical nurses’ education activities with heart failure patients in terms of the topics they addressed and the educational resources they found most useful. A random sample of 540 medical ward nurses were surveyed in 2009 using a postal questionnaire. The response rate was 47% (234 medical ward nurses who cared for patients with heart failure). Quantitative data were analysed using descriptive statistics, qualitative data through a content analysis approach. The majority of respondents (66.7%) cared for patients with heart failure several times each week. The total time spent on educational activities by most respondents (70.6%) was estimated as 20 minutes or less over the hospitalisation. Printed material was the most commonly used education resource although 35 respondents also referred to online information and 84 nurses did not use educational material at all. The most frequent education topics discussed were medication, signs and symptoms and general information about heart failure. Psychological factors and prognosis information were the topics least discussed with patients. Respondent suggestions to improve patient access to heart failure information included more printed information in wards such as pamphlets in various languages, information about useful websites and having key resources available in te reo Māori. The heart failure educator was identified as an important resource for both nurses and patients. The study highlighted the limited time many respondents spent on educational activities and the need for readily available educational resources to optimise patient heart failure education opportunities.

Keywords: Nurses, medical wards, heart failure education, survey Introduction

failure present with wide ranging symptoms and signs including fluid retention, fatigue, shortness of breath

Heart failure is a common chronic and debilitating

and the inability to tolerate exercise (Arroll, Doughty,

disease with significant hospitalisation rates. Heart

& Anderson, 2010). In New Zealand the median length

failure is defined as a “syndrome of symptoms and

of hospital admission for heart failure patients in 2008

signs that suggest impairment of the heart as a pump

was 5 days (Wasywich, Gamble, Whalley, & Doughty,

supporting physiological circulation. It is caused by

2010); 6% of acute medical admissions in 2007 were

structural or functional abnormalities of the heart” (National Clinical Guideline Centre, 2010, p.19). Hospitalised patients with acute symptoms of heart

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Gilmour, J., Strong, A., Hawkins, M., Broadbent, R. & Huntington, A. (2013). Nurses and heart failure education in medical wards. Nursing Praxis in New Zealand, 29(3), 5-17. Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand for heart failure (Tester et al., 2009). Heart failure

Background

has a high mortality rate, in an English study of 6162 heart failure patients the mortality rate was 9% per

Heart failure is a complex disease with multiple

year (Hobbs et al., 2010). There are also significant

symptoms which can impact on quality of life. A study

heart failure ethnic disparities. Māori male and female

of the last 6 months of life identified 21 symptoms

heart failure mortality rates for those 65 years old

from 80 medical records, the most common being

and over are significantly higher as compared to non-

breathlessness, pain and fatigue (Nordgren & Sörensen,

Māori (males RR 2.80, females RR 1.70) along with

2003). Anxiety, physical activity limitations, nausea,

Māori hospitalisation rates (males RR 4.73, females

ankle swelling, constipation and loss of appetite also

RR 4.85) (Ministry of Health, 2011). Pacific people also

featured strongly. Similarly, another study of heart

have higher rates of morbidity being twice as likely to

failure patients (n = 66) found dyspnoea, angina and

have a hospital discharge diagnosis of heart failure

tiredness were the most troublesome symptoms

as compared to the total New Zealand population

reported (Anderson et al., 2001). Sleep disorders are

(Sopoaga, Buckingham, & Paul 2010).

also prevalent with sleep difficulty being ranked as the most burdensome symptom in a study by Zambroski,

The symptoms of heart failure can be managed with

Moser, Bhat and Ziegler (2005). Managing these

interventions that improve function and reduce

symptoms on an every-day basis requires considerable

hospitalisations and mortality. The American Heart

expertise to maximise quality of life. Education about

Failure Practice Guideline recommends that during

heart failure management includes weight monitoring

an acute hospital stay essential education is provided

and action in response to changing signs and

with respect to understanding heart failure and

symptoms, medication knowledge, dietary and fluid

treatment goals, along with medication and follow

precautions and an appropriate exercise programme

up arrangements (Heart Failure Society of America,

(National Heart Foundation of New Zealand, 2010a).

2010). The New Zealand guidelines (National Heart

The development of a plan of action to ensure a

Foundation of New Zealand, 2010a) suggest that

timely response to deterioration in condition is also

education should be delivered in a structured manner

important (Arroll, Doughty & Anderson, 2010). As

and ideally by heart failure trained professionals.

Grange (2005) suggests, “patients with heart failure

Nurses working in medical wards also contribute

need to understand their condition, how to manage it,

to heart failure education, particularly as specialist

and above all when to ask for assistance” (p.ii41).

heart failure nurses are not available across all District Health Boards (Tester et al., 2009). Nurses have the

However, local and international evidence suggests

opportunity to rectify patient knowledge gaps during

that some patients with heart failure have knowledge

hospitalisations for symptom management. The study

gaps and that there are significant issues with health

reported in this paper aimed to describe medical

literacy levels. Successful health self-management

ward nurses’ educational activities with heart failure

requires an adequate degree of health literacy

patients, thus providing baseline data about topic

incorporating the ability to access and understand

areas addressed by medical nurses, along with their

health information. In addition that knowledge

use of heart failure information in patient education.

needs to be applied to personal health circumstances through informed decision making (Keleher & Hagger 2007; Peerson & Saunders, 2009). In an English qualitative study participants were able to provide

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand descriptions of what happened in acute heart failure

The literature highlights the complexity of heart

but “most lacked a clear understanding of why they

failure symptom management, the need for ongoing

had developed heart failure, what it was, and what

education throughout the disease trajectory and the

this implied for them.” (Rogers et al., 2000, p. 606).

evidence of patient knowledge gaps. Nurses have a

Another New Zealand study found that 40% (n = 62)

professional responsibility to promote health, providing

of the people interviewed with diagnosed heart failure

information about the condition and self-management

were not aware of having heart failure or were unable

strategies are all part of providing health education.

to describe it, some saying they had little information

As nurses convey this information to patients and

from health care providers (Buetow & Coster, 2001).

families, they can clarify any misunderstandings about

Clarke and Lan (2004) also found when recruiting for

the condition or other preconceived ideas and alleviate

a study, that 13 out of 54 heart failure patients were

any concerns (Jaarsma, Abu-Saad, Halfens, & Dracup,

unaware of their diagnosis.

1997). The rationale for the present research study was to identify the contribution of medical nurses to heart

Lack of knowledge about heart failure can effect

failure education during hospitalisation in order to

active engagement with treatment. A Hawaiian

ascertain any education barriers and gaps, and identify

study found that Pacific Island participants believed

resources and activities that could be highlighted.

that along with fear, knowledge gaps and lack of understanding about the diagnosis led to avoidance

The study

and illness denial (Kaholokula, Saito, Mau, Latimer, & Seto, 2008). Similarly, a Dutch survey of 954 heart

Aim

failure patients (van der Wal, Jaarsma, Moser, van

The study aim was to describe medical nurses’

Gilst, & van Veldhuisen, 2007) found a lower level of

education activities with heart failure patients in terms

knowledge was associated with a perception of greater

of the time nurses spent with heart failure patients, the

medication and diet barriers as well as greater issues

topics they addressed and the educational resources

with symptom recognition. An English qualitative

they found most useful.

study with 27 patients noted that participants talked about being unable to discriminate between heart

Design

failure symptoms and the side effects of medications

A descriptive cross sectional survey design was used.

and feeling confused about what action they should

The heart failure education questions were included

take (Rogers et al., 2002).

in a postal questionnaire that also covered nurses use of Internet health information (Gilmour, Huntington,

The reasons for patient lack of education and

Broadbent, Strong, & Hawkins, 2012).

understanding about heart failure include problems with retaining information such as a poor memory, not

Ethical considerations

wishing to know the full ramifications of the disease and

Ethics approval was gained from the University Human

health professionals who are unwilling to communicate

Ethics Committee (Application 09/06). Information

the seriousness of the condition (Barnes et al. 2006;

explaining the survey background and purpose and a

Buetow & Coster, 2001). Patients have also commented

statement that respondents were anonymous to the

on helpful educative strategies such as clear simple

researchers was included with the questionnaire. The

descriptions of physiological changes and using visual

administrator managing the mail out and follow up

resources such as diagrams (Barnes et al. 2006).

processes signed a confidentiality agreement.

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Nursing Praxis in New Zealand Sample

Respondents were asked open ended questions about

Five hundred and forty questionnaires were mailed

specific interventions that could improve access and

out to a random sample of medical ward nurses

use of heart failure information along with a question

selected from the Nursing Council of New Zealand

on Māori access and use of heart failure information

database (N = 3682 eligible medical ward nurses at

given the high rates of Māori hospitalisation with heart

the time of questionnaire posting) in 2009. The aim

failure (Curtis, Harwood, & Riddell, 2007).

was to get 200 responses (to detect a correlation at .2 there was an 83% probability of getting a statistically

Data analysis

significant result based on an alpha level of 0.05 with

Sample characteristics such as the demographic

200 responses). Reminders were sent out at 2 and 4

data, the frequency of use of educational resources

weeks after the initial mail out. Forty-one nurses in

and educational topics taught have been presented

the sample proved to be ineligible due to no longer

using descriptive summary statistics. Spearman’s

working in medical wards. Overall there were 293

rank correlation co-efficient (rs) was used to

responses and of these 234 worked with heart failure

measure nonparametric data correlations testing

patients (47% of total sample).

associations between nursing education and time spent on educational activities. The statistical software

Data collection

programme SPSS 19.0 (IBM SPSS Inc., Chicago, IL, USA)

The questions were primarily quantitative with some

for Windows was used for the quantitative analysis.

open ended qualitative questions developed from

The sample size varies by question as respondents did

literature sources and the clinical expertise of team

not have to answer all questions. A content analysis

members including heart failure specialist nurses.

was conducted on the qualitative data generated

The questionnaire was piloted for face validity and

from the open-ended items. The texts were coded

questionnaire clarity with 20 nurses working in

and categorised to enable a numerical analysis of

hospital settings. The initial questions focused on the

the comments along with an identification of key

total time respondents estimated they spent with

categories (Bryman, 2012). One researcher generated

patients on heart failure education. The two questions

the categories which were then reviewed and critiqued

on time spent were phased as (i) the time spent with

by a second researcher. Illustrative quotes from the

last patient and (ii) the usual time spent with each

responses are included in Tables 2 and 3 in order to

patient with heart failure and or their family /whānau

validate the categories.

members during the hospital stay providing education to improve their knowledge of, and/or management of

Results

heart failure (see Table 1). Respondents’ recollection

Nearly all of the respondents were female (97.4%), the

of the time spent on education for the last patient they

mean age was 43.47 years and ages ranged from 21

had cared for was strongly correlated with the usual

to 70 years of age. Nearly half the group (48.7%) had

time spent on education (rs = .746, n = 228, P < 0.001).

worked as a nurse for over 15 years, 19% for 1 to 5 years

Other questions explored the use of the key heart

and 5.8% for less than 1 year. A small group (13.8%)

failure resources available at the time of the survey

had a hospital certificate as the highest qualification,

and a range of possible education topics derived from

63.8 % were tertiary educated with a diploma or

previous research identifying areas patients ranked as

bachelor degree and 22.2% had a postgraduate

the most important to know (Hagenhoff, Feutz, Conn,

qualification. The majority were on the Professional

Sagehorn, & Moranville-Hunziker, 1994; Paul, 2008).

Development and Recognition Programme (83.6%)

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand and 47.5% of the sample were at proficient or expert

spent providing education during the hospital stay

level. By comparison in the overall medical registered

was generally short with 70.6% estimating 20 minutes

nurse workforce 93.4% are female, 39% have a post

or less (Table 1). There was a significant but small

graduate qualification and the mean age of the overall

positive correlation between length of usual time

New Zealand workforce is 45.6 years (Nursing Council

spent on educational activities and level on the nursing

of New Zealand, 2011).

competency based Professional Development and Recognition Programme (rs = .219, n = 220, P = 0.001)

The majority of respondents (66.7%, n = 156) cared for

but no correlation with level of nursing qualification

people with heart failure several times a week. From

(rs = -.039, n = 219, P = 0.565).

the respondentsâ&#x20AC;&#x2122; recollection, the usual total time Table 1 Time Spent on Heart Failure Education During Each Patients Hospital Stay Question

Time spent with last patient

Usual time spent with patient

Category

Comments

Number of comments

Cardio-respiratory outreach service providing education on marae Community initiatives/education

Māori health support groups

Use Māori community educators Māori centred education

Increase Māori health input-Te Reo (Māori language) pamphlets

resources

Would like the Living with Heart Failure in Māori

Referral to cardiac nurse educator Access to specialist support

A resource centre where can access the internet

services

Dietician referral

Seminars by community nurses Māori health educators Increase Māori health workforce

Māori support person while in hospital

More Māori nurses Whānau examples and word of mouth Whānau /family involvement

Speak with/educate younger family members re medicines,

healthy living and warning signs Advertising information-large posters around marae, hospital, including humour Advertising/health promotion

Increase awareness of what’s available

More publicity about risks on TV, medical centres, shopping centres Some patients don’t go to GP due to cost Barriers

Compliance is often the failing point not the education Education is not always effective, sometimes need the reality of

an admission to help the patient understand

Use simple and direct language Accessibility of information

Good discussions through therapeutic relationships followed up

with simple pamphlets

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Discussion

block, together with teaching the ward staff to educate patients in a more effective manner utilising a ‘teach

Evidence suggests that heart failure patients have

back method’ which encourage patients to explain

significant educational needs throughout the illness

what they understand so ensuring comprehension.

trajectory (Barnes et al. 2006; Buetow & Coster, 2001;

Patient education material was also updated and

Rogers et al., 2002). Research findings also indicate

translated into other languages.

education contributes to reduced hospitalisations for symptom control. A United States randomised

An important research finding that could be addressed

controlled trial (n = 223) of a 1 hour nursing education

by medical nurses in a systematic manner within short

session as part of the hospital discharge preparation

timeframes is to ensure all patients have access to

found a reduction in days hospitalised during the 180

understandable information. Driscoll, Davidson, Clark,

days of the trial (Koelling, Johnson, Cody, & Aaronson,

Huang and Aho (2009, p. 136) point out that hospital

2005). Other studies have also demonstrated that

stay is “an ideal opportunity to provide patients and

education interventions reduced hospitalisations in NZ

carers with a consumer resource”. These authors

(Doughty et al., 2002) and internationally (Anderson,

note that there is time during hospitalisation to draw

Deepak, Amoateng-Adjepong, & Zarich, 2005; Jovicic,

attention to important aspects of the information.

Holroyd-Leduc, & Straus, 2006).

Penney, McCreanor and Moewaka Barnes (2006) also found in a study of Māori and health practitioners

Most of the nurses in this study who cared for patients

perspectives on heart disease management in Te Tai

with heart failure estimated they spent less than 20

Tokerau that Māori with heart disease value written

minutes on educational activities during each patient’s

information to complement face to face discussions.

hospital stay. However, patients have multiple

However, over a third of the nurses in the study

encounters with numerous health professionals

reported in this paper did not use any educational

during hospitalisation, a New Zealand study finding

material to support their educational activities and

that medical ward patients saw on average 10.7

there was comment about the lack of readily available

nurses during their stay (Whitt, Harvey, McLeod, &

educational materials in some wards.

Child, 2007). When the collective nature of care is taken into account there is a considerable amount

There are freely available publications such as Staying

of nursing time that is or could be used to enhance

Well with Heart Failure (National Heart Foundation of

patient understanding of heart failure. Chan, Reid,

New Zealand, 2010) which covers a comprehensive

Farvolden, Deanne and Bisaillon (2003) suggest that

range of topics and also includes symptom recording

best practice is providing educational programmes

sheets and the basis of an action plan. This publication

during hospitalisation for heart failure; but with less

could be the foundation of a patient education plan

time available as a result of shortened stays more

that is revisited during hospitalisation for acute

effective education means matching patients learning

symptoms of heart failure. Health Navigator NZ also

needs with the education provided. Chur (2012)

has a consumer focused website that provides a

described a heart failure programme which reduced

gateway to reviewed national and international health

30 day readmissions by nearly 50%. The 90 day

information and other resources aimed at enabling the

readmission rate also reduced from 45% to 27%. One

effective management of chronic health conditions

element of the programme was improved education

(www.healthnavigator.org.nz). While useful resources

over the course of the admission rather than in one

are available but not used fully, it is also noteworthy

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand that a barrier to information accessibility noted by the

should be provided during an acute hospital stay such

respondents was a lack of health failure resources in te

as understanding the condition, medication and follow

reo Māori and other languages.

up arrangements. Research evidence from the patient’s perspective also indicates that a substantial group of

Respondents’ suggestions to improve access and

patients want more information about their prognosis.

use of heart failure educational resources included

In an American study of 47 heart failure patients aimed

better access and use of online sites. The provision

at identifying the need for prognosis discussion, almost

of patient computer terminals in wards was also

half the group who were interviewed near the end of

mentioned suggesting that there is the opportunity

their hospital stay on the fifth day wanted a discussion

during hospitalisation to support patient skills with

on their prognosis (Howie-Esquivel & Dracup, 2012).

accessing and using online information. A Canadian

This aspect of care and education requires an in-

survey exploring the feasibility of using Internet

depth knowledge of the condition, how heart failure is

cardiac education resources found over 80% of

impacting on health at an individual level and the likely

respondents would find specific Internet education

trajectory of the disease. Medical ward nurses may

support moderately or very useful (Thomson &

well feel ill equipped to engage in conversations about

Micevski, 2005). Online information is an important

likely prognosis given the complexity involved. But

health information source, in an American survey

nurses do have a responsibility to ensure patients can

75% of respondents with a chronic illness (n=268)

discuss their prognosis through referral to appropriate

were influenced by online information in treatment

specialists such as medical clinicians. Specialist heart

decision making, 69% questioned medical advice or

failure nurses were also suggested as a key source for

sought another opinion and just over 50% altered

patient education and support by some respondents in

coping strategies and reviewed lifestyle changes (Fox

this study. Grange (2005) supports this role suggesting

2007). Some caution is also suggested by a study of the

that these nurses make multiple contributions to in-

discursive representations of heart failure available

depth patient and family education.

through online sites (Strong & Gilmour, 2009). Most sites at the time of the research privileged biomedical

As stated earlier in the discussion there were comments

representations and there were notable absences

from respondents in this study about developing more

with little attention to the emotional and spiritual

Māori centred educational health resources. Given

dimensions of heart failure. The point is made in this

significant heart failure disparities (Curtis, Harwood,

study that “nurses should be critical in their reading of

& Riddell, 2007; Ministry of Health, 2011) attention

health information, so that they are able to analyse the

to Māori specific educational and other resources is

quality of websites before making recommendations

a priority. Additionally Māori centred services were

to patients” (Strong & Gilmour, p. 603).

also suggested, that being an approach supported in the literature promoting culturally competent heart

The most common education topics covered during

failure services (Riddell, 2005). At the time of a 2006

hospital admissions were medication, signs and

stock take of the heart failure services offered in DHBs,

symptoms, general education and diet. This education

12 out of the 14 DHBs that responded did not offer

focus is congruent with the American Heart Failure

culturally specific programmes for people with heart

Practice Guideline (Heart Failure Society of America,

failure (Connolly et al., 2009) although the majority

2010) which recommends that essential education

had cultural support staff.

Page 16

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Limitations of this study include the response rate

health professional that has the most interaction with

of 47%. The heart failure questions were included as

patients with heart failure.

part of a larger study of online health information use. Nurses engaged with online resources may well have

There is a range of nursing implications deserving

been more interested in completing the questionnaire

consideration that have been generated from the

so resulting in the possibility of respondent bias.

findings of this study. A key finding is the time limited

Another limitation is that the amount of time spent on

nature of education activities undertaken by nurses.

educational activities is self-reported and estimated.

However, in medical wards if the actual frequency

We did not distinguish between those who spend no

of nursing encounters is considered in a collective

time educating their patients and those who spend at

sense there is a considerable amount of time during a

least a minimal amount of time. The time education

patientâ&#x20AC;&#x2122;s hospital stay that could be used for targeted

was delivered in the wards and the stage of heart

education. It is important that nurses are encouraged

failure were not part of the data collection. It would be

and supported to view the interactions they have

useful to do a comparative study of nurses who work in

with patients as a time when brief, focused education

a coronary care unit or cardiology ward to explore the

information can be provided alongside interventions

impact of confidence and preparation on education

such as specific care-related tasks. Developing a

activities. It would also be useful to identify whether

systematic approach to education with the use of

nurses make a choice about not using educational

existing hard copy and online patient publications

resources or if availability of resources is the major

in conjunction with nursing and other heart failure

determinant.

specialist support is foundational to addressing patient knowledge gaps. Nurses also have a role in advocating

Conclusion

for resources that will enhance the health literacy of groups that have disproportionate rates of heart failure

Heart failure is a medical condition that permeates

mortality and morbidity. Resources required include

everyday life necessitating ongoing decision making

publications in a range of languages and culturally

about lifestyle choices and medication adherence.

specific support staff and programmes. Increasing the

People with heart failure need information so they

education provided to patients with heart failure has

can understand their condition, symptoms, impact of

the potential to not only improve quality of life for

their lifestyle choices and ongoing treatment. While

people, but also to result in fewer hospitalisations if

access to a dedicated heart failure nurse specialist

lifestyle choices and adherence to treatment regimens

is desirable and this level of expertise is available in

are improved.

larger institutions, medical ward nurses may be the

References Anderson, C., Deepak, B., Amoateng-Adjepong, Y., & Zarich, S. (2005). Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure. Congestive Heart Failure, 11, 315321. doi:10.1111/j.1527-5299.2005.04458.x Anderson, H., Ward, C., Eardley, A., Gomm, S., Connolly, M., Coppinger, T., ... Makin, W. (2001). The concerns of patients under palliative care and a heart failure clinic are not being met. Palliative Medicine, 15, 279-286. doi:10.1191/026921601678320269

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Nursing Praxis in New Zealand Arroll. B., Doughty, R., & Andersen, V. (2010). Investigation and management of congestive heart failure. British Medical Journal, 341, 190-195. doi:10.1136/bmj.c3657 Barnes, S., Gott, M., Payne, S., Seamark, D., Parker, C., Gariballa, S., & Small, N. (2006). Communication in heart failure: Perspectives from older people and primary care professionals. Health Social Care in the Community, 14(6), 482-90. doi:10.1111/j.13652524.2006.00636.x Bryman, A. (2012). Social research methods (4th ed.). Oxford: Oxford University Press. Buetow, S., & Coster, G. (2001). Do general practice patients with heart failure understand its nature and seriousness, and want improved information? Patient Education and Counseling, 45, 181-185. doi:10.1016/S0738-3991(01)00118-5 Chan, A., Reid, G., Farvolden, P., Deanne, M., & Bisaillon, S. (2003). Learning needs of patients with congestive heart failure. Canadian Journal of Cardiology, 19, 413-417. Chur, E. (2012). UCSF Heart failure program: Improving outcomes. UCSF Department of Medicine: Frontiers of Medicine, 14(1), 3-4. Retrieved from http://medicine.ucsf.edu/ news/fom/frontiers.html?key=45 Clarke, J., & Lan, V. (2004). Heart failure patient learning needs after hospital discharge. Applied Nursing Research, 17, 150-157. doi:10.1016/j.apnr.2004.06.009 Connolly, M., Fung, M., Jordan, D., Kolbe, J., Doughty, R., Devlin, G., … Mahony, F. (2009). Alleviating the burden of chronic conditions in New Zealand (The ABCC NZ Study). Report: Disease specific analysis. Auckland: Uniservices, University of Auckland. Retrieved from http://dhbrf.hrc.govt.nz/media/documents_abcc/Final_ Draft_ABCc_ Disease_Specific_report_15.10.09.pdf Curtis, E., Harwood M., & Riddell T. (2007). Cardiovascular disease. In B. Robson & R. Harris (Eds.), Hauora Māori standards of health IV. A study of the years 2000-2005 (pp.141-158). Wellington, New Zealand: Te Rōpū Rangahau Hauora a Eru Pōmare. Doughty, R., Wright, S., Pearl, A., Walsh, H., Muncaster, S., Whalley, G., …Sharpe, N. (2002). Randomized, controlled trial of integrated heart failure management. European Heart Journal, 23, 139-146. doi:10.1053/euhj.2712 Driscoll, A., Davidson, P., Clark, R., Huang, N., & Aho, Z. (2009). Tailoring consumer resources to enhance self-care in chronic heart failure. Australian Critical Care, 22, 133-140. doi:10.1016/j.aucc.2009.05.003 Fox, S. (2007). E-patients with a disability or chronic illness. Washington: The Pew Internet and American Life Project. Retrieved from http://www.pewinternet.org/Reports/2007/ Epatients-With-a-Disability-or-Chronic-Disease.aspx Gilmour. J,. Huntington, A., Broadbent. R., Strong, A., & Hawkins. M. (2012). Nurses’ use of online health information in medical wards. Journal of Advanced Nursing, 68,1349-1358. doi:10.1111/j.1365-2648.2011.05845.x Grange, J. (2005). The role of nurses in the management of heart failure. Heart, 91, ii39-ii42. doi:10.1136/hrt.2005.062117 Hagenhoff, B., Feutz, C., Conn, V., Sagehorn, K., & Moranville-Hunziker. M. (1994). Patient learning needs as reported by congestive heart failure patients and their nurses. Journal of Advanced Nursing, 19(4), 685-690. doi:10.1111/j.1365-2648.1994.tb01139.x Heart Failure Society of America. (2010). Executive summary: HFSA 2010 Comprehensive heart failure practice guideline. Journal of Cardiac Failure, 16, 475-539. doi:10.1016/ j.cardfail.2010.04.005 Hobbs, F.D.R., Roalfe, A.K., Davis, A., Davies, M.K., Hare1 R., & the Midlands Research Practices Consortium (MidReC). (2007). Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the echocardiographic heart of England screening study (ECHOES). European Heart Journal, 28, 1128-1134. doi:10.1093/eurheartj/ehm102 Howie-Esquivel. J., & Dracup, K. (2012). Communication with hospitalized heart failure patients. European Journal of Cardiovascular Nursing, 11(2),216-22. doi:10.1016/j.ejcnurse.2011.03.006. Jaarsma, T., Abu-Saad, H. H., Halfens, R., & Dracup, K. (1997). Maintaining the balance: Nursing care of patients with chronic heart failure. International Journal of Nursing Studies, 34 (3), 213 – 221. doi:10.1016/S0020-7489(97)00008-4 Jovicic, A., Holroyd-Leduc, J., & Straus, S. (2006). Effects of self-management intervention on health outcomes of patients with heart failure: A systematic review of randomized controlled trials. BioMed Central Cardiovascular Disorders, 6 (43). doi:10.1186/14712261-6-43 Kaholokula, J., Saito, E., Mau, M., Latimer, R., & Seto, T. (2008). Pacific Islanders’ perspectives on heart failure management. Patient Education and Counseling, 70, 281-291. doi:10.1016/j.pec.2007.10.015 Keleher H. & Hagger V. (2007). Health literacy in primary health care. Australian Journal of Primary Health, 13(2), 24-30. doi:10.1071/ PY07020 Koelling, T., Johnson, M., Cody, R., & Aaronson, K. (2005). Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation: Journal of the American Heart Association, 111, 179-185. doi:10.1161/01.CIR.0000151811.53450.B8

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Nursing Praxis in New Zealand Ministry of Health. (2011). Tatau kura tangata: Health of older Māori chart book 2011. Wellington, New Zealand: Author National Clinical Guideline Centre. (2010) Chronic heart failure: The management of chronic heart failure in adults in primary and secondary care. London: National Clinical Guideline Centre. Retrieved from http://guidance.nice.org.uk/CG108/Guidance/pdf/ English National Heart Foundation of New Zealand. (2010a). New Zealand guideline for the management of chronic health failure (2009 update). Auckland, New Zealand: Author. Retrieved from http://www.Heartfoundation.org.nz/uploads/Guideline-ManagementChronic-Heart-Failure-5%2820%29.pdf National Heart Foundation of New Zealand. (2010b) Staying well with heart failure. Auckland, New Zealand: Author. Retrieved from http://www.heartfoundation.org.nz/uploads/HF1060_Staying_Well_with_Heart_Failure_WEB.pdf Nordgren, L., & Sörensen, S. (2003). Symptoms experienced in the last six months of life in patients with end-stage heart failure. European Journal of Cardiovascular Nursing, 2, 213-217. doi:10.1016/S1474-5151(03)00059-8 Nursing Council of New Zealand. (2011). The New Zealand nursing workforce: A profile of nurse practitioners, registered nurses , nurse assistants and enrolled nurses 2011. Wellington, New Zealand: Author. Retrieved from http://www.nursingcouncil. org.nz/index. cfm/1,144,html/Workforce-Statistics Paul, S. (2008). Hospital discharge education for patients with heart failure: What really works and what is the evidence? Critical Care Nurse, 28(2), 66-82. Peerson, A., & Saunders. M. (2009). Health literacy revisited: What do we mean and why does it matter? Health Promotion International, 24(3):285-296. doi:10. 093/heapro/dap 014 Penney, L., McCreanor, T., & Moewaka Barnes, H. (2006). New perspectives on heart disease management in Te Tai Tokerau: Māori and health practitioners talk. Auckland, New Zealand: Te Rōpu Whariki, Massey University. Retrieved from http://www.shore. ac.nz/projects/FINAL%20REPORT%20ALL%20PHASES.pdf Riddell, T. (2005). Heart failure hospitalisations and deaths in New Zealand: patterns by deprivation and ethnicity. New Zealand Medical Journal, 118(1208), U1254. Retrieved from http://journal.nzma.org.nz/journal/118-1208/1254/ Rogers, A., Addington-Hall, J., Abery, A., McCoy, A., Bulpitt, C., Coats, A., & Gibbs, J. (2000). Knowledge and communication difficulties for patients with chronic heart failure: Qualitative study. British Medical Journal, 321, 605-607. doi:10.1136/bmj.321.7261.605 Rogers, A., Addington-Hall, J.M., McCoy, A.S., Edmonds, P.M., Abery, A.J., Coats, A.J., & Gibbs, J.S. (2002). A qualitative study of chronic heart failure patients’ understanding of their symptoms and drug therapy. European Journal of Heart Failure, 4(3),2837. doi:10.1016/S1388-9842(01)00213-6 Sopoaga, F., Buckingham., K., & Paul, C. (2010). Causes of excess hospitalizations among Pacific peoples in New Zealand: Implications for primary care. Journal of Primary Health Care, 2(2), 105-110. Strong, A., & Gilmour. J. (2009). Representations of heart failure in Internet patient information. Journal of Advanced Nursing, 65(3), 596-605. doi:10.1111/j.1365-2648.2008.04921.x Tester, B., Dewar, J., McDonald, R., O’Sullivan, C., Bent, M., McLeod, J., ... Baker, K. (2009). Heart failure – model of integrated care. Wellington, New Zealand: Central Region’s Technical Advisory Services Limited. Thomsom, N., & Micevski, V. (2005). A descriptive project evaluation to determine Internet access and the feasibility of using the Internet for cardiac education. Heart and Lung, 34(3), 194-200. doi: 10.1016/j.hrting.2004.12.001 Wasywich, C.A., Gamble, G.D., Whalley, G.A., & Doughty, R.N. (2010). Understanding changing patterns of survival and hospitalization for heart failure over two decades in New Zealand: Utility of ‘days alive and out of hospital’ from epidemiological data. European Journal of Heart Failure, 12, 462-8. doi:10.1093/eurjhf/hfq027. Whitt N., Harvey R., McLeod,G., & Child S. (2007). How many health professionals does a patient see during an average hospital stay. Journal of the New Zealand Medical Association, 120 (1253), U2517. Retrieved from http://journal.nzma.org.nz/ journal/120-1253/2517/ van der Wal, M., Jaarsma, T., Moser, D., van Gilst, W., & van Veldhuisen, D. (2007). Unraveling the mechanisms for heart failure patients’ beliefs about compliance. Heart & Lung, 36(4), 253-261. doi:10.1016/j.hrtlng.2006.10.007 Zambroski, C.H., Moser, D.K, Bhat, G., & Ziegler. C. (2005). Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. European Journal of Cardiovascular Nursing, 4(3),198-206.

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Nursing Praxis in New Zealand NURSE PERCEPTIONS OF THE DIABETES GET CHECKED PROGRAMME The content of this article is reproduced with the permission of NZNO. Jill Clendon, RN, PhD, Nursing Policy Adviser/Researcher, New Zealand Nurses Organisation, Nelson, NZ. Jenny Carryer, RN, PhD, Professor of Nursing, Massey University, Palmerston North, NZ. Leonie Walker, PhD, Researcher, New Zealand Nurses Organisation, Wellington, NZ. Vicky Noble, RN, BA(Hons), MA(Appl), Director of Nursing, Capital and Coast DHB, Wellington, NZ. Rosemary Minto,RN,NP,MHPrac (Hons), Adult Family Nurse, Katikati Medical Centre, KatiKati, NZ. Rachael Calverley, RN, BSc(Hons), MN, Director of Nursing, Waitemata PHO, Albany, NZ. Deborah Davies, RN, MPhil, Clinical Nurse Specialist - Primary Health Care, Mid Central DHB, Palmerston North, NZ. Hilary Graham-Smith, RN, BN, BSoc Sc (Hons)., PGDipPH, Associate Professional Services Manager, New Zealand Nurses Organisation, Wellington, NZ.

Abstract Aim: The Diabetes Get Checked programme provided a free annual diabetes check to people diagnosed with diabetes. The aim of the present study was to ascertain the impact this programme had on the practice of nurses; identify factors that nurses consider contributed to the success or failure of the programme in their work setting; and to elicit nurses’ suggestions for future improved management and outcomes for people with diabetes. Method: An observational study utilising an online survey was undertaken. A total of 748 people completed the survey – the majority being nurses. Data were analysed descriptively. Results: The Diabetes Get Checked programme was shown to have had a substantial impact on the practice of nurses, enabling the development of new models of nursing care, improved educational levels among nurses (and doctors), improved confidence in the management of diabetes, and increased satisfaction in their work. Nurses in the study suggested future interventions and programmes designed to support people with diabetes. These include implementation of a multi-disciplinary wrap-around approach, enhanced case management and self-management, implementing direct funding for nurse-led services, and improving population-based approaches such as policy changes and social marketing. Discussion: The study sought nurse’s perspectives with regard to a recently terminated programme designed to provide care to people with diabetes. It identified areas that worked well in programme implementation and those that could be improved. These findings provide useful information for funders and planners developing new programmes designed to support people with diabetes.

Key words: Diabetes, nurses, New Zealand, primary health care

Clendon, J., Carryer, J., Walker, L., Noble, V., Minto, R., Calverley, R., ... Graham-Smith, H., (2013). Nurse perceptions of the Diabetes Get Checked programme. Nursing Praxis in New Zealand, 29(3), 18-30. Page 20

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Introduction

other than clinical indicators. These included allowing time for the health provider to focus on management

Diabetes is a group of diseases characterised by

of a single complex condition, more consistent care

high levels of blood glucose resulting from defects in

for people with diabetes, and enhanced educational

the production and/or action of insulin (Centre for

opportunities for health practitioners (McClenaghan,

Disease Control, 2012). Diabetes can lead to a range of

Dovey, Tilyard & Tomlin, 2007). The Office of the

complications including increased risk of cardiovascular

Auditor General (2007) noted the programme improved

disease, nerve and blood vessel damage, kidney

monitoring of people with diabetes, offered better

damage, and premature death (Ministry of Health,

guidance to general practitioners on diabetes treatment

2011). The prevalence of diabetes in New Zealand

and referral, and removed barriers for some people

is 7%, with a further 25.5% of people demonstrating

accessing diabetes care. Further anecdotal reports

signs of pre-diabetes (Coppell et al., 2013). Incidence

suggest the programme gave nurses significant

is greatest amongst Pacific peoples and those who are

opportunities to build effective relationships with people

obese (Coppell et al., 2013). Globally, the number of

experiencing diabetes, and improved relationships

people with diabetes is predicted to increase by 50.7%

between primary and secondary providers (Diabetes

between 2011 and 2030 â&#x20AC;&#x201C; an annual increase of 2.7%

Nurse Specialist Section NZNO, 2011).

(Whiting, Guariguata, Weil & Shaw, 2011). With such large numbers of people experiencing this chronic

These diverse outcomes suggest that while the Diabetes

disease and many more likely to do so, special efforts

Get Checked programme may not have improved clinical

are being made to detect, treat, and support people to

outcomes, it may have had an impact on other areas

manage their diabetes.

of importance in the provision of health services. It is important that a full range of outcomes from such

The Ministry of Health invests significant funding into

programmes is identified, and to this end the aim of

the prevention and management of diabetes and

the present study was to determine what impact the

associated complications. One of the larger Ministry

Diabetes Get Checked programme had on nursesâ&#x20AC;&#x2122;

of Health programmes established to address the

practice, to acertain those factors nurses consider

prevalence of diabetes was the Diabetes Get Checked

contributed to the success or failure of the programme

programme. Over the course of 11 years, at a cost

in their work setting, and to elicit nursesâ&#x20AC;&#x2122; suggestions

of approximately $8,000,000 annually, the Diabetes

for improved future management and outcomes for

Get Checked programme provided people diagnosed

people with diabetes.

with diabetes a free annual health check. Programme evaluation suggested that this arrangement did not

The Minister of Health remains committed to continuing

systematically result in improved management or

investment into diabetes primary care in New Zealand

outcomes for people with diabetes (Kenealy, Orr-Walker,

(Ryall, 2011) and it is important that nurses are involved

Cutfield, Robinson & Simmons, 2011; Office of the

in developing appropriate, evidence-based policy to

Auditor General, 2007), and as a result the Minister of

support this investment. The findings from this study

Health ended the programme in 2011.

provide useful data to support the Ministry of Health as it develops future interventions for diabetes prevention

However, other research into the Diabetes Get Checked

and care.

programme, reported a number of successful outcomes

Page 21

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Method

As a result, it is not possible to calculate a response rate. However, despite this uncertainty, the findings provide a

An observational study utilising an online survey was

useful overview of nurses’ perspectives on the Diabetes

undertaken. In order to ensure reliability, the survey

Get Checked programme. A number of managers also

was iteratively designed and piloted following a review

completed the survey and their perspectives have been

of the literature, consultation with New Zealand Nurses’

included in the overall results as all, with one exception,

Organisation (NZNO) and the College of Nurses Aotearoa

were registered nurses.

(NZ) members. Pretesting was undertaken with a small number of primary health care nurses, and some

Data were collected during November and December

minor amendments were subsequently made before

2011. The quantitative data were analysed using

implementation of the full survey. The questionnaire

descriptive statistics. The free text responses were

covered a range of aspects pertinent to the Diabetes Get

grouped thematically using NVivo 9 software to support

Checked programme and the provision of nursing care to

analysis. An expedited ethical approval to undertake the

people with diabetes in general, including information

study was obtained from the Chairperson of the Mutli-

about workplace, respondent demographics, how the

region Ethics Committee (MEC/11/EXP/120).

Diabetes Get Checked appointment is undertaken, what type of preparation the respondent had for

Respondents

undertaking the checks, and what if any changes had

The majority of respondents identified themselves as

occurred in their practice as a result of being involved

registered nurses (n=669), followed by managers (n=55),

in the programme. Regulated nurse members of the

and nurse practitioners (n=20). Nine enrolled nurses

New Zealand Nurses Organisation (registered nurses

completed the survey and one general practitioner.

(RNs), enrolled nurses, and nurse practitioners, (NPs))

The majority of respondents were female (97.7%) and

identified as working in primary health care settings, and

aged between 30 and 55 years of age (62%). Seventeen

all members of the College of Nurses Aotearoa (RNs,

men completed the survey, the majority of these (n=12)

NPs) were sent an email inviting them to complete the

being registered nurses. With regard to ethnicity,

online survey.

respondents were NZ European (78.4%), Māori (11.5%), other European (6.6%) or of Pacific descent (3.7%). Over

The approximate sample was around 4000 (a specific

44% of respondents held a postgraduate qualification

sample could not be determined as participants were

of some type (postgraduate certificate, postgraduate

also invited to forward the email invitation on to others

diploma, Master’s or PhD degree).

who might be interested in the study, resulting in a number of non-nurse practitioners completing the

Findings

survey). In total there were 748 respondents. Email recipients were asked to complete the survey only if

The diabetes check

they, or their organisation, specifically provided care

Both registered nurses and general practitioners

to people with diabetes on the Diabetes Get Checked

undertook the diabetes checks as part of the Diabetes

programme. As it was not possible prior to the mail out

Get Checked programme. This study identified

to determine which nurses worked in a Diabetes Get

registered nurses (94.3%) as the most likely to conduct

Checked programme and which did not, the decision

the check, followed by general practitioners (47.9%),

was made to send the survey out as widely as possible.

suggesting that in up to 50% of practices nurses were

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand the only practitioners to undertake the checks. Aside

and interventions specific to the spiritual needs of the

from the standard interventions included as part

individual, family and/or whﾄ］au.

of a diabetes check such as retinopathy screening, foot checks, dietary advice, green prescriptions, and

Preparation for implementation of the Get Checked

other diabetes specific interventions, a range of other

programme

concurrent interventions were undertaken by health

Most nurses (88.5%) had received some additional

practitioners in the context of a diabetes check. These

education on diabetes management before

are outlined in Figure 1. The most common included

implementing the Diabetes Get Checked programme.

quit smoking advice, cardiovascular risk assessment,

The most usual was a short course of between 2 and 5

arrangements for follow-up care, and a full health

days duration and/or on the job training.

13-01 Original Manuscript - March 2013

assessment. Free text comments also reflected a range of other opportunistic interventions undertaken by

Awareness of Diabetes Knowledge and Skills Framework

FIGURES AND TABLES practitioners. These included family violence screening,

Less than half the respondents (42.8%) were aware of the

alcohol use screening, assessment of social situation,

National Diabetes Knowledge and Skills Framework (Mid

Concurrent intervention

Quit smoking implemented CVRA undertaken referral to a social service provider made

Never Sometimes

referral to other health professional made

Mostly Always

arrangements for follow up care made agreed plan of care made Full health assessment undertaken 0

Time concurrent intervention was undertaken (%) Figure 1. Concurrent interventions with the diabetes check

Figure 1. Concurrent interventions with the diabetes check Page 23

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Central Health Board, 2009) for nurses, and only 27.6%

diabetes with predictable health care needs). Eleven

used the framework in their workplace to validate the

point six percent (n=66) considered themselves specialty

knowledge and skills of nurses working with people with

diabetes nurses (require specialist diabetes knowledge

diabetes. Although the majority of nurses were either

and care for people with diabetes who are at high

not aware of the Framework or were uncertain about it,

risk for disease progression and complications). Three

most nurses (n=571) were able to self-categorise their

percent (n=17) were specialist diabetes nurses (require

practice at some point on the Framework based on the

advanced knowledge and skills in diabetes care and is

descriptions given in the survey. Forty one percent of

typically a clinical nurse specialist), and 13.8% (n=79)

nurses (n=234) categorised themselves as able to apply

were unsure of their position on the framework (see

generic diabetes nursing knowledge and skills to meet

Figure 2).

the health needs of individuals (described as â&#x20AC;&#x2DC;all nursesâ&#x20AC;&#x2122; on the Diabetes Knowledge and Skills Framework).

Diabetes Get Checked and nursing practice

Thirty point six percent (n=175) categorised themselves

Respondents were asked to consider the impact that

as aOriginal generalist diabetes nurse (may2013 care frequently 13-01 Manuscript - March

implementing the Diabetes Get Checked programme had

or for short intensive periods of time for people with

on their nursing practice. Most respondents indicated

45 40

Percentage

35 30 25 20 15 10 5 0 All nurses

Generalist diabetes nurse

Specialty diabetes Specialist diabetes nurse nurse

Not sure

Category Figure 2. Self-categorisation on the Diabetes Knowledge and Skills Framework

Figure 2. Self-categorisation on the Diabetes Knowledge and Skills Framework that the programme enabled them to spend more

Diabetes Get Checked programme had increased their

time with people with diabetes, build a professional

confidence with diabetes management.

relationship with them, and enabled them to target their work to high needs or at risk patients. Figure 3 outlines

Respondents also offered a wide range of free text

the results from this set of questions. In addition,

comments regarding the impact that offering the

78.1% of respondents indicated that implementing the

Diabetes Get Checked programme had on their

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand

13-01 Original Manuscript - March 2013

It made no difference It improved relationships with the wider primary health care team It improved relationships with social services

Nursing practice

It improved relationships with the PHO It improved relationships with DHB/secondary services It improved relationships with GPs

Never Sometimes

It enabled me to target my work to high needs/at risk patients

Mostly

It enabled me to build a professional relationship with people with diabetes that I was unable to previously It added to my working day with no additional time allocation It took me away from other more important nursing work It enabled me to spend more time with people with diabetes

Respondents (%) Figure 3. Differences the Diabetes Get Checked programme made to nursing practice

Figure 3. Differences the Diabetes Get Checked programme made to nursing practice practice as a nurse. Many of these comments revolved

the nurses with virtual access to secondary care,

around the impact on the patient as well as on their

our service has been endorsed by secondary care

own practice. Of note was the wide range of differing

and they are very happy with what we are doing

practices reported across the sector. Some areas took full

to help the load of secondary services. It has

advantage of the scope of nursing practice, while others

also shown our GPs that nurses are competent

offered checks solely by the general practitioner with

to manage these areas and we now have great

no nurse involvement at all, with a range of examples

relationships, which include respect and trust

in between. Where nurses were able to practice to the

from the GPs. It has led the way to us starting

full extent of their scope, satisfaction with practice

asthma/CVD clinics where the nurses are entirely

appeared to be higher, although we would be cautious

responsible for these patients. It has motivated

about making that interpretation on these data alone.

our nurses into postgraduate study and two have chosen to start the NP [Nurse Practitioner] route.

It was the Get checked programme which led

It is empowering for both staff and patients,

to our clinic [setting up] autonomous...nurse

who get more time, more education and more

led clinics. Currently we donâ&#x20AC;&#x2122;t refer patients to

empowerment to take responsibility for their

secondary care, they are managed entirely by

conditions.

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Diabetes Get Checked and the nurses perspective on

the results from this question. Nurses also commented

the impact on the patient

further on their perspectives in the free text comments.

With respect to a range of self-management tasks, we

For example:

were interested in ascertaining how often, if ever, the nurses noticed improvements in how people who took

Clients were happier and they had an improved

part in the Diabetes Get Checked programme managed

confidence and appreciation of their General

these tasks. Fifty seven percent of nurses indicated the

Practice. They were pleased to know that the

programme mostly improved peopleâ&#x20AC;&#x2122;s knowledge of

Ministry of Health cared and thought it important

diabetes and 41.6% indicated it sometimes did. Fifty

enough to put money into looking after their health.

percent of nurses noted that the programme mostly improved peopleâ&#x20AC;&#x2122;s confidence in self-management, and

With intensive input people are able to develop

50% indicated it sometimes did. Actual implementation

skills to self-manage, but frequency needs to be

of self-management was less frequently noted with

more than annually for some people and less for

40.2% indicating the programme mostly resulted in 13-01 Original Manuscript March 2013 improved implementation of -self-management, and

others. Group sessions are effective for some. At

58.6% suggesting it sometimes resulted in improved

diabetics are.

least we have a register and know who the practice

implementation of self-management. Figure 4 shows

Aspect of diabetes management

Uptake of lifestyle programmes

Adherence to medication

Implementation of self-management of diabetes

Never Sometimes Mostly

Confidence in self-management of diabetes

Knowledge of self-management of diabetes 0

Percentage

Figure 4. How often (if ever) did the nurse notice improvements made by people with diabetes in certain aspects of diabetes management

Figure 4. How often (if ever) did the nurse notice improvements made by people with diabetes in certain aspects of diabetes management Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand Page 26

Nursing Praxis in New Zealand Table 1 Barriers and Enablers to Establishing a Diabetes Get Checked Programme Barriers in Order of Importance 1.

Lack of time allocated to implementation

Lack of knowledge and understanding of diabetes

Lack of support from doctors

Lack of space

People not turning up for appointments

Enablers in Order of Importance 1.

Good support from nurse colleagues

Time allocated to undertake checks

Good support from doctors

Implementing a Diabetes Get Checked Programme in

positive and negative aspects of providing the Diabetes

the workplace

Get Checked programme in their workplace. While a

Respondents were questioned about factors enabling,

substantial number of respondents were not aware

and what barriers existed, in the implementation of

of negative aspects to the Diabetes Get Checked

Diabetes Get Checked in their workplaces. Table 1

programme, others had a range of comments that

outlines the barriers and enablers to implementation

provide useful information on things to avoid in future

of the Diabetes Get Checked programme.

programme implementation. Table 2 outlines the positive and negative aspects of providing the Diabetes Get Checked programme.

Respondents were also asked to comment on the

Table 2 Positive and Negative Aspects of Providing the Diabetes Get Checked Programme in the Workplace Positive aspects •

Enabling regular contact with people who have

Negative aspects •

diabetes •

Providing an opportunity to build a relationship with the person with diabetes

•

programme. •

who did, the lack of observable behavioural change.

people with diabetes Enabling focused time to discuss diabetes with people

•

Increased knowledge of staff

•

Development of a multi-disciplinary approach to diabetes care

•

Professional reward from seeing improvements in people with diabetes

•

Reduction in barriers to access

•

Financial benefits to the practice.

Page 27

Annual check offers insufficient time to make progress with people.

•

The development of systems and models of care to manage diabetes

•

Significant frustration around both the difficulty of getting people to attend appointments and for those

Building understanding and improving outcomes for

•

Insufficient time to effectively implement the

The lack of access to appropriate and affordable follow up resources.

•

Diabetes Get Checked programme a ‘tick box exercise’ for many.

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Suggestions for improved management and outcomes

Discussion

for people with diabetes Respondents were asked for suggestions on how

Our study demonstrates that the Diabetes Get Checked

they saw management and outcomes for people

programme had a substantial impact on the practice

with diabetes could be improved. Many respondents

of nurses. The programme enabled the development

supported continuation of the Diabetes Get Checked

of new models of nursing care, stimulated improved

programme and were critical of the Kenealy et al.

educational levels among nurses (and doctors), led to

(2011) evaluation report. Many made potentially

improved confidence in the management of diabetes,

useful comments regarding improving the programme,

and increased nurses’ satisfaction in their work. These

particularly addressing the need for more time and

findings support those of McClenaghan et al. (2007)

more money in order to undertake the programme

who found similar outcomes in their study into the

effectively. Others had more explicit examples of

sustainability of the programme for general practices,

how diabetes management and outcomes could be

suggesting the findings of both studies are reliable.

improved and these are found in Table 3.

Respondents in the study reported here also believed the programme led to improved levels of understanding of diabetes among people with the condition.

Table 3 Suggestions for Improved Management and Outcomes for People with Diabetes

• •

Ensure nurses and doctors have access to appropriate and consistent education as a base level and that continuous upskilling of both practitioners occurs. Extend nurse prescribing

•

Improve training for health practitioners in self-management strategies e.g. Flinders, chronic care model.

•

Provide support for initiating insulin in general practice.

•

Develop and implement a multi-disciplinary wrap-around approach to diabetes care including easy (funded) access to podiatry, dieticians, social workers, retinopathy screening, and pharmacy services.

•

Address continuity of care and ensure links between primary, secondary and tertiary care are seamless and integrated.

•

Extend diabetes services further into the community including home visits, utilising community support workers and providing marae and church based services.

•

Improve individually focussed interventions such as more regular monitoring and visits, increased education, case management and follow up telephone support.

•

Increase the funding and time to undertake the checks and provide the follow-up care required.

•

Implement effective public health initiatives including policy change, early intervention, targeted resourcing, advertising/ population education and addressing the social determinants of health.

•

Implement nurse-specific strategies: targeted funding for nurses to provide more care to people with diabetes and establish nurse-led clinics.

•

Ensure any new programme enables the establishment and maintenance of an effective therapeutic relationship with the person diagnosed with diabetes.

•

Improve IT systems including shared clinical records, development of a national database, improvements to the Get Checked template, patient held records, a universal, evidence based website suitable for patient access, and improved ICD codes.

Page 28

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand The findings from this study suggest that nurses were

evaluation is designed to identify where implementation

the primary providers of the diabetes check offered

is successful, where modification may be required,

as part of the Diabetes Get Checked programme; yet

and discern whether impact results are true or simply

despite this, the impact of the programme on nursing

the result of poor implementation (Wolber & Ward,

practice was never evaluated on a national basis. It

2010). Due in part to apparently poor improvements

is essential that the specific perspectives of those

in HBA1c results for clients attending Diabetes Get

providing direct patient care in programmes such as

Checked appointments, the Kenealy et al. (2011) report

the Diabetes Get Checked programme are sought and

suggested that investment in Diabetes Get Checked

considered when evaluating outcomes. While nurses

would be better redirected to other programmes.

did contribute to the evaluation work on the Diabetes

However, lack of evaluation of the programme from the

Get Checked programme done by McClenaghan et al.

perspective of the main providers (that is, nurses) and

(2007), the small sample size in the McClenaghan et

from consumers, suggests that a decision to cancel the

al. study limits the generalisability of their findings to

programme may have been premature. Findings from

nurses, although as noted above, the overall findings

this present study suggest there are many more nuanced

were similar to the present study.

benefits of such programmes that are worthy of closer exploration and are potentially useful for integration

Difficulties with the programme identified by participants

into future programmes. Of further importance is the

in this study included inconsistency in the way it was

need to study the patient’s perspective with respect to

implemented in differing workplaces, inconsistent levels

receiving increased direct contact with nurses as a result

of education of providers and therefore inconsistent

of the Diabetes Get Checked programme.

information passed onto people with diabetes, and a lack of time to effectively implement the programme. In

Snell (2011) noted that getting to know each other was

the clinical judgement of nurse respondents, there was a

described by participants with diabetes as an important

belief that an annual appointment did not appear on its

element in forming the therapeutic relationship. Health

own to have a significant impact on outcomes. However,

practitioners taking a personal interest in the individual

where nurses and the wider multidisciplinary team

and their life, knowing their medical and social history,

worked collaboratively outcomes did appear to improve.

and the interventions that had been tried before, and what was or was not effective for them, were aspects

The Diabetes Get Checked programme can be seen

described by many patients in Snell’s study as critical to

as an attempt to introduce a population health

developing faith in the recommendations of clinicians.

strategy very much in line with the primary health

In her research, Snell drew attention to differences in

strategy (Ministry of Health, 2001). Of note is that

styles associated with different disciplinary approaches,

the programme was introduced into an environment

for instance, how nurses and medical practitioners

generally more familiar with, or used to responding to,

provide explanations and invite different types of

acute presenting problems. As such its methods and the

contributions from patients. Patients in Snell’s study

success of implementation have clearly been variable

commented during nurse consultations that they felt

across practice settings. Variable outcomes have also

more acknowledged as a person with a particular life

been identified in other research where traditional

context. This is of direct relevance to nurses’ reports

patterns of care, such as providing diabetes care in

in this study that related to the value of the focused

acute care settings, have been shifted to primary health

time provided by Diabetes Get Checked funding for

care settings (Wolber & Ward, 2010). Effective process

more considered and less rushed nurse consultations

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand with patients. Juul, Maindal, Frydenberg, Kristensen

disciplinary wrap-around approach, enhanced case

and Sandbaek (2012) reported that well-implemented

management and self-management, implementing

nurse-led diabetes clinics improved clinically relevant

direct funding for nurse-led services, and improving

patient outcomes (including HBA1c) when compared

population-based approaches such as policy changes

with traditionally delivered primary care. Rather than

and social marketing. Figure 5 outlines a model

annual diabetes checks, as provided by the Diabetes

addressed to future participantsâ&#x20AC;&#x2122; with respect to

Get Checked programme, nurses should advocate for

diabetes care in New Zealand. The individual and their

properly funded diabetes specialist nurse-led clinics

family are shown at the centre of care, with a range

that would enable patients to better manage their

of wrap-around services that extend from individually

diabetes, along with greater funding for education in

focussed care out to the preventative measures that

self-management strategies for patients.

government must implement to address diabetes in New Zealand. The Ottawa Charter for Health Promotion (World Health Organisation, 1986) provides a useful

Positive aspects of the programme included the ability

framework for implementing a multi-pronged approach

to build a therapeutic relationship with a person

to diabetes care and the key tenets of the charter can

with diabetes, the focused time that was offered, the

be seen in the diagram. Such multi-pronged, health

development of a multi-disciplinary approach to care,

promotion approaches have shown some success in

and the development of systems and models of care

addressing issues such as smoking (Wilson, 2007), and

that would not have otherwise occurred. Suggestions

may be equally successful in improving diabetes care

for future programmes designed to support individuals

in New Zealand.

with diabetes included the implementation of a multi-

Figure 5. Nursesâ&#x20AC;&#x2122; perceptions of future diabetes care in New Zealand Page 30

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Recommendations

Limitations

The findings from this study resulted in a range of

Due to an inability to determine a specific sample size,

recommendations related to the role of nurses in the

it is difficult to cite an exact response rate. However,

care of people with diabetes. These, as listed below,

despite this limitation, as the views and perspectives

may be useful for policy makers, funders and planners

of nurses on the implementation of broad policy

as they seek to provide the best possible care for people

imperatives are not frequently sought, this study has the

with diabetes.

potential to contribute to future policy development.

1. Comprehensive process evaluation must be built into future programme implementation.

Conclusion

2. Evaluation must take into account provider and user perspectives.

Although according to Kenealy et al. (2011), the Diabetes

3. Future programmes should ensure sufficient

Get Checked programme has had little clinical impact

funding is included to ensure initial, ongoing and

on people with diabetes, this study suggests that

consistent education of practitioners.

the programme actually directed focus towards, and

4. Future programmes should encompass culturally

resulted in, improved systems and models of care for

appropriate wrap-around services that enable

managing people with diabetes. As well, there has been

home visits, marae and church-based programme

significant development of health workforce capacity

implementation, and more effective use of

across the sector. Future programmes must take into

community health workers.

account the impact of funding on outcomes for people

5. Nurses should be enabled (through the provision of appropriate education and funding) to practice

with diabetes as well as the outcomes associated with systems and workforce development.

to the full extent of their scope of practice and take a lead role in the provision of care to people with diabetes across the sector.

References Centre for Disease Control. (2011). CDC provides national estimates, general information on diabetes. Chart, 110(4), 5-8. Editorial (2011) CDC Provides National Estimates, General Information on Diabetes, CHART, Journal of Illinois Nursing Volume 11, Number 4 CDC (2011) http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm is the statistical source reported. Coppell, K. J., Mann, J. I., Williams, S. M., Jo, E., Drury, P. L., Miller, J. C., & Parnell, W. R. (2013). Prevalence of diagnosed and undiagnosed diabetes and prediabetes in New Zealand: Findings from the 2008/09 Adult Nutrition Survey. New Zealand Medical Journal, 126(1370), 23-42. Retrieved from http://journal.nzma.org.nz/journal/126-1370/5555/ Juul, L., Maindal, T., Frydenberg, M., Kristensen, J., & Sandbaek, A. (2012). Quality of type 2 diabetes management in general practice is associated with involvement of general practice nurses. Primary Care Diabetes, 6(3), 221-228. doi:10.1016/j.pcd.2012.04.001 Kenealy, T., Orr-Walker, R., Cutfield, R., Robinson, E., & Simmons, D. (2012). Does a diabetes annual review make a difference? Diabetic Medicine, 29, e217-e222. doi:10.1111/j.1454-5491.2011.03533.x McClenaghan, T., Dovey, S., Tilyard, M., & Tomlin, A. (2007). Checking â&#x20AC;&#x2DC;Get Checkedâ&#x20AC;&#x2122;. New Zealand Family Practitioner, 34, 177-182. Mid Central Health Board. (2009). National diabetes knowledge and skills framework 2009. Palmerston North, New Zealand: Mid Central Health Board. Retrieved from http://www.nzssd.org.nz/documents/dnss/National%20Diabetes%20Nursing%20Knowledge%20 and%20Skills%20Framework%202009.pdf Page 31

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Ministry of Health. (2001). The primary health care strategy. Wellington, New Zealand: Author. Retrieved from http://www.health. govt.nz/publication/primary-health-care-strategy Ministry of Health. (2011). Targeting diabetes and cardiovascular disease. Wellington, New Zealand: Author. Retrieved from http:// www.health.govt.nz/publication/targeting-diabetes-and-cardiovascular-disease New Zealand Society for the Study of Diabetes. (2012). Virtual diabetes register as at 31 Dec 2012. Dunedin, New Zealand: Author. Retrieved from http://www.nzssd.org.nz/news/Virtual%20Diabetes%20Register%20release%2031%20Dec%202012.pdf Office of the Auditor General. (2007). Ministry of Health and District Health Boards: Effectiveness of the â&#x20AC;&#x2DC;Get Checkedâ&#x20AC;&#x2122; diabetes programme. Wellington, New Zealand: Author. Retrieved from http://www.oag.govt.nz/2007/diabetes/docs/oag-diabetes.pdf Ryall, T. (2011). Ministry of Health position statement on Get Checked programme. Wellington, New Zealand: Ministry of Health. http:// www.hiirc.org.nz/page/28594/ministry-of-health-position-statement-on/?tab=2613&section=10535 Snell, H. (2011). Igniting the diabetes self-care pilot light: Understanding influences on health activation (Doctoral thesis, Massey University). Retrieved from http://mro.massey.ac.nz/handle/10179/2672. Whiting, D., Guariguata, L., Weil, C., & Shaw, J. (2011). IDF diabetes atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Research & Clinical Practice, 94, 311-321. doi:10.1016/j.diabres.2011.10.029 Wilson, N. (2007). Review of the evidence for major population-level tobacco control intervention. Wellington, New Zealand: Ministry of Health. Wolber, T., & Ward, D. (2010). Implementation of a diabetes nurse case management program in a primary care clinic: A process evaluation. Journal of Nursing & Healthcare of Chronic Illnesses, 2, 122-134. doi:10.1111/j.1752-9824.2010.01051.x World Health Organisation. (1986). Ottawa charter for health promotion. Geneva, Switzerland: Author. Retrieved from http://www. who.int/healthpromotion/conferences/previous/ottawa/en/

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand BARRIERS IN EDUCATION OF INDIGENOUS NURSING STUDENTS: A LITERATURE REVIEW Donna Foxall, RN, PGDip HSc, BN, Nursing Lecturer, Eastern Institute of Technology, NZ.

Abstract The poor health status of indigenous people has been identified internationally as a critical issue. It is now commonly accepted that the ability to address this concern is hindered, in part, by the disproportionately low number of indigenous health professionals, including nurses. This paper reports the findings of a review of literature that aimed to identify key barriers in the education of the indigenous undergraduate nursing students in the tertiary sector, to identify strategies to overcome these, and discuss these elements within the New Zealand context. A number of health-related databases were searched and a total of 16 peer-reviewed articles from Canada, USA, Australia and New Zealand were reviewed. Key barriers to recruitment and retention and strategies to overcome these are presented. Barriers to recruitment included: academic unpreparedness; poor understanding of cultural needs; and conflicting obligations, and financial constraints. Barriers to retention included lack of cultural and academic support, family obligations and financial hardship. Strategies to address recruitment barriers included: addressing pre-entry education requirements; targeted promotion of nursing programmes; indigenous role models in the recruitment process; and streamlining enrolment processes to make programmes attractive and attainable for indigenous students. Strategies to address retention barriers included: cultural relevance within the curriculum; identifying and supporting cultural needs of indigenous students with active participation of indigenous staff; engaging communities and funding support. The crucial development of partnerships between academic institutes and indigenous communities to ensure the provision of a culturally safe, supportive environment for the students was stressed. In New Zealand, while government-level policy exists to promote the success of Māori nursing students, the translation of what is known about the recruitment and retention of indigenous students is an area for development. Keywords: recruitment, retention, indigenous, nurse education, Māori, cultural safety

Introduction

the inequalities in health outcomes experienced by New Zealand Māori, while Curran et al. (2008) and Adams et

Indigenous peoples’ poor health has been identified as

al. (2005) comment on the poor health outcomes of the

an issue of international concern (Adams et al., 2005;

indigenous peoples of Canada and Australia respectively.

Anonson, Desjarlais, Nixon, Whiteman, & Bird, 2008; Curran, Solberg, LeFort, Fleet, & Hollett, 2008; Curtis,

It is now commonly accepted that the ability to address

Wikaire, Stokes, & Reid, 2012; DeLapp, Hautman, &

this concern is hindered, in part, by the disproportionately

Anderson, 2008; Martin & Kipling, 2006; Meiklejohn,

low number of indigenous health professionals, including

Wollin, & Cadet-James, 2003; Smith, McAlister, Gold,

nurses. According to Goold (as cited in Meiklejohn et al.,

& Sullivan-Bentz, 2011; Usher, Lindsay, & Mackay,

2003), in Australia “indigenous registered nurses make

2005; Wilson, McKinney, & Rapata-Hanning, 2011). In

up to 0.05% of the registered nurse population, which

particular, international researchers including nurse

is well below the 2.6% total Australian population” (p.

educators highlight the disparity between the health status of indigenous versus non-indigenous people as an area of significant concern. Wilson et al. (2011) noted

Page 33

Foxall, D. (2013). Barriers in education of Indigenous nursing students: A literature review. Nursing Praxis in New Zealand, 29(3), 31-36. Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand 1). A similar situation exists in Aotearoa New Zealand

retention of indigenous nursing students, and to discuss

where Māori (the indigenous peoples of New Zealand)

the findings within the context of Māori nursing students.

comprise 15% of the total population. In New Zealand there are 48,563 Nursing Council New Zealand practising

Research method

registered nurses, but less than 7% are Māori and 4% Pacific ethnicities (Nursing Council New Zealand, 2011).

To identify relevant articles the following keywords were

Developing and building the Māori health workforce is

used when searching the literature: indigenous, aboriginal,

considered crucial to improving Māori health outcomes

native, nursing, student, support. These were entered

and health status, yet according to Wilson et al. (2011)

into the following databases: CINAHL (Cumulative Index

the recruitment and retention of Māori into nursing is

to Nursing & Allied Health Literature); Pro-Quest Central;

a persistent challenge. Curtis et al. (2012) argue that

Scopus (SciVerse Scopus); and Google Scholar. All articles

there are “multiple explanations for the shortage of

accessed were from peer-reviewed journals, and in total

indigenous health professionals reflecting a mixture of

16 articles were selected for this review. The aim was

supply and demand issues associated with historical,

to understand the connection between tertiary health

political, demographic, cultural, academic and financial

studies and the dearth of indigenous health professionals,

factors” (p. 4). In 2002, Ngā Manukura o Āpōpō designed

particularly nurses. Thirteen articles were sourced from

a programme to “provide emerging and advanced Māori

international authors (seven from Australia and six from

leaders in nursing and midwifery with theory, practical

Canada) and three were from New Zealand authors. The

tools and opportunities to gain the skills and knowledge

articles were thoroughly reviewed and the information was

to take on and excel in clinical leadership roles” (2012, p.

recorded into a matrix format to categorise article details

1). Digital Indigenous delivers this programme, along with

and findings, providing a very useful method of synthesising

other leadership programmes for Māori in public health,

the information. The dataset was then further categorised

disability and nursing. Together, they share the goal to

into barriers to recruitment and retention, and strategies

build and increase Māori health workforce through clinical

to overcome these barriers.

leadership, professional development, and recruitment and profile raising (Ngā Maukura o Āpōpō, 2012).

Findings

Central to the imbalance is the inability of academic

This section details the key findings from the reviewed

institutes to recruit and retain undergraduate indigenous

literature in each of the following general themes: overall

students within their nursing programmes (Anonson et

strategies for success; barriers to recruitment; overcoming

al., 2008; Hinton & Chirgwin, 2010; Martin & Kipling,

recruitment barriers; barriers to retention; and overcoming

2006; Meiklejohn et al., 2003; Nakata, Nakata, & Chin,

retention barriers.

2008; Usher et al., 2005; Wilson et al., 2011). In recent years nurse student retention and completion in tertiary

Overall strategies for success

education has been the focus of researchers in the United States of America (USA), Canada, United Kingdom (UK),

The literature showed a number of strategies that

Australia, and more recently in New Zealand (Adams et al.,

aim to redress the imbalance of indigenous peoples’

2005; Anonson et al., 2008; Curran et al., 2008; DeLapp et

health through addressing the shortage of indigenous

al., 2008; Martin & Kipling, 2006; Meiklejohn et al., 2003;

health workers. These strategies are not unique to the

Smith et al., 2011; Usher et al., 2005; Wilson et al., 2011;

programmes discussed in this literature (De Lapp et al.,

Zepke et al., 2005). The purpose of this article is to report

2008; Meiklejohn et al., 2003), but highlight some common

the findings of a literature review on the recruitment and

themes that may ultimately lead to improved outcomes.

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand An ultimate goal is the empowerment of indigenous health

et al., 2008., Curtis et al., 2012). Cheh et al.’s (2011) study

professionals to help their people to achieve an improved

found that financial constraints and a lack of information on

state of health.

accessing supportive funding also existed, although this was not such a prominent feature as the researchers predicted.

Curtis et al. (2012) identified six broad principles that

Finally, many indigenous students described experiencing

they considered significant for Māori or indigenous health

separation anxiety when they were required to move away

workforce development success. These were: Framing

from their families and known communities to continue their

initiatives within indigenous worldviews; Demonstrating

studies (Cech et al., 2011; Metz et al., 2011; West et al., 2011).

a tangible institutional commitment to equity; Framing interventions to address barriers to indigenous health

Strategies to overcome recruitment barriers

workforce development; Incorporating a comprehensive

Curtis et al. (2011) advocated better support for indigenous

pipeline model; Increasing family and community

secondary school students to achieve success in subjects that

engagement; and Incorporating quality data tracking and

will facilitate their acceptance into nursing and other health

evaluation.

professional studies. They argued that such support is “a key mechanism to attract more indigenous students into what

They go on to state that “achieving equity in health

are often rigorous and demanding academic pathways” (p.

workforce representation should remain both a political

4). A partnership between Ngā Maukura o Āpōpō (http://

and ethical priority” (p. 3). Ngā Maukura o Āpōpō (2012)

www.ngamanukura.co.nz/) and Kia Ora Hauora (http://www.

concur and identified the following three key work streams

kiaorahauora.co.nz/) focused on health careers for rangatahi

to address current and future workforce needs for Māori

Māori at secondary levels, an approach used successfully

nurses and Māori midwives: Clinical leadership, professional

in Canada and Australia with their indigenous populations

development in the current health sector, and recruitment

(Anonson et al., 2008; De Lapp et al., 2008; Meiklejohn et

profile-raising within the secondary school sector.

al. 2003). Ngā Maukura o Āpōpō (2011) promote a three phase approach to increasing the profile of health career

Barriers to Recruitment

pathways to secondary students and mature adults. A Māori

Before nursing schools can begin the process of educating

equity advisor at one of the largest New Zealand universities

indigenous nursing students they must first overcome the

ensures Māori students are supported through the enrolment

challenges of recruitment. The literature reviewed identified

phase (Ngā Maukura o Āpōpō, 2011), an approach endorsed

a number of barriers that hindered or prevented indigenous

by Meiklejohn et al. (2003), Anonson et al. (2008) and De

students from enrolling in nursing courses. These barriers

Lapp et al. (2008).

included a lack of understanding about a career in health (De Lapp et al., 2008; Meiklejohn et al., 2003), a lack of

A number of researchers (Adams et al., 2005; Smith et

confidence in their ability to study at tertiary level, and a fear

al., 2011; Usher et al., 2005; West, West, West & Usher,

of failure and being unprepared academically (Anonson et

2011) profiled specifically designed indigenous community-

al., 2008; Smith et al., 2011; West et al., 2010., Curtis et al.,

based transition education programmes. In Australia, the

2012). A number of researchers found that once indigenous

government funds a Health Services Assistance programme,

students chose to enrol in a nursing course the complexity

named ‘Tjiratamai’. This programme is organised by local

of the enrolment process, poor cultural understanding by

Aboriginal people and was considered a means to deal with

the institution, and limited awareness of their specific needs

“the challenges faced by Aboriginal people when they enter

and cultural obligations often resulted in them not following

nursing education courses and as a way to increase the local

through with their enrolments (Cech, Metz, Babcock & Smith,

number of Aboriginal nurses” (West et al., 2011, p. 39).

2011; Curran et al., 2008; Meiklejohn et al., 2003; Nakata

Indigenous Australian nursing students identified common

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand themes of separation from families and community, and

academically not prepared (Cech et al., 2011; Meiklejohn

feelings of isolation (Adams et al., 2005; Usher et al.,

et al., 2003; Smith et al., 2011; Usher et al., 2005; Wilson

2005), similar to those identified by Wilson et al. (2011).

et al., 2011). One Australian study by Nakata et al. (2008)

To overcome these disincentives, government support

found that many students had not completed primary and

through stipends and community funding was utilised in

secondary schooling. Wilson et al. (2011) found a failure

the more remote areas where students indicated their

to complete high school education was widespread; this

preference to remain in the area as nurses (West et al.,

contributed to students’ families not fully understanding

2011). Hinton et al. (2010) found that accommodation,

the demands of tertiary study and often resulted in

meals, transportation and childcare provision were utilised

students being unsupported. Their study found that many

as effective retention strategies. In addition, academic

families did not have role models or family members who

preparedness for those enrolling in nursing programmes

had completed or attended tertiary studies.

was addressed by locally integrating and locating academic centres within the indigenous people’s communities

The Australian studies by Smith et al. (2011), Hinton et al. (2010) and Usher et al. (2005) all identified financial

Barriers to Student Retention

hardship as a significant barrier for indigenous nursing

The literature highlights a range of barriers identified by

students, and further identified the effects of financial

the students that impeded their ability to complete their

hardship experienced by students were not only course-

nursing studies. Canadian authors identified subtle overt

related but also impacted on meeting family and cultural

prejudice, including insensitivity to non-European students,

obligations. This has also been a finding in New Zealand.

and found curricula to be Eurocentric (Cech et al., 2011).

Wilson et al. (2011) described how indigenous students

Martin and Kipling (2006) and Turale and Miller (2006)

often have backgrounds of financial hardship, and

described how students were exposed to, and experienced,

education costs become an additional burden for these

racial and discriminatory practices by faculty staff and

students who juggle family, cultural and community

their peers. Martin and Kipling reported that “students

commitments.

observed and detected racism from individuals, groups, and processes within schools, hospitals and community

Both Australian and New Zealand studies (Hinton et al.,

placements” (p. 4). Such practices included allowing

2010; Wilson et al., 2011 respectively) indicated that a high

racist discussions about indigenous and minority people

proportion of indigenous students were mature students,

during classes, without considering the presence of

often with children and other family commitments, and

students belonging to these groups in the classroom. In

discuss the impact that these commitments had on their

addition, in Australia Adams et al. (2005) and Meiklejohn

study. Usher et al. (2005) found university staff were

et al. (2003) showed cultural dispossession and alienation

unsympathetic to Torres Strait Island students’ family

were significant issues for Aboriginal students. Cultural

obligations, and reported this negatively impacted on

safety, as a concept developed in New Zealand by Irihapeti

the students’ ability to focus on study. In addition, the

Ramsden, has been instrumental in New Zealand nursing

impact of students having to move away from family and

school education to develop self-awareness, culturally

communities to complete their studies often led to feelings

sensitive and safe practice for Māori, including Māori

of isolation (Smith et al. 2011; Wilson et al. 2011). In

nursing students (Nursing Council of New Zealand, 1992).

Anonson et al.’s (2008) Canadian study and Wilson et al.’s

Yet, reports of cultural insensitivity and the presentation of

New Zealand study, students described how adjusting to

curricula devoid of Māori content exist (Wilson et al., 2011).

an urban way of life was challenging. They also reported a lack of indigenous knowledge and experience on the part

Nearly all the authors noted that indigenous students were

Page 36

of teaching staff was evident.

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Overcoming Retention Barriers

in operation. This document identified the lack of a co-

Once nursing schools had overcome the initial barriers to

ordinated approach for mentoring (Ako Aotearoa, 2010).

recruitment, schools were then faced with the challenges

Adams et al. (2005) noted how the utilisation of indigenous

of retaining students in training programmes. Curtis

staff members and partnerships with elder members of

et al. (2012) recognised the importance of the tertiary

the communities provided students with positive role

sector providing a foundation course as a bridge for

models and mentors, and also allowed the integration of

students entering into the Bachelor of Nursing degree.

traditional knowledge into the programmes. Anonson et al.

They also highlighted the importance of commitment to

(2008) acknowledged indigenous elders were the bearers

achieving equity with the use of institutional admission

of traditional knowledge, and described how their liaison

policies, quotas and mission statements. A number of

and counselling was beneficial for indigenous students.

New Zealand institutions have implemented Komiti

Furthermore, their presence enhanced retention in, and

Kawa Whakaruruhau (Cultural Safety Committees) within

completion of, nursing programmes by bridging the cultural

schools, which can provide guidance and advice about

gap that generally occurs for indigenous students. De Lapp

retention, completion and recruitment strategies. Other

et al. (2008) also described how Alaskan student nurse

studies also found that indigenous students’ financial

success is supported by the relationships and connections

hardship was addressed by stipends and assistance with

made in the local community. “Connection is an essentail

course and living allowances including childcare, and

component of caring as a relational process and is central

travel (Curran et al., 2008; Hinton et al., 2010). In New

to Alaska Native/American Indian worldview” (p. 294).

Zealand iwi or tribal scholarships can be sought with the assistance of Te Pou Whirinaki or Māori student support

Discussion

liaison officers, although securing a scholarship has become increasingly competitive.

Government-level policy exists with regard to improving Māori access to tertiary education and the achievement

Commitment to retaining indigenous students includes

of qualifications, and recognises the vital part the

academic and pastoral support as well as the provision of

government and the tertiary sector has in promoting

safe learning environments. West et al. (2011) and Smith

Māori success and improving outcomes. The Tertiary

et al. (2011) identified how community-based delivery

Education Commission’s (TEC’s) Statement of Intent has

of nursing programmes, such as via satellite campuses,

“doing better for Māori and Pacific” as its first outcome

provided a more supportive environment. Usher et

(TEC, 2012). The TEC promotes best practice within the

al. (2005) and West et al. (2010) used the success of

tertiary institutions, and also has available equity funding

the Torres Straits Islanders as an example of how well

to improve Māori access and achievement. This year the

a satellite campus can be made to work by allowing

TEC established the Tū Māia: Working Group, and one of

indigenous students to study and remain within their

its roles is to dialogue with tertiary providers, particularly

communities. They also highlighted the positive impact of

with regard to best practice (see http://www.tec.govt.nz/

utilising indigenous staff to bridge the language barriers,

Tertiary-Sector/Reviews-and-consultation/T-Mia-Working-

and to provide the cultural support sought by students.

Group/). In addition, Health Workforce New Zealand recognises the under-representation of Māori within the

The benefits of mentoring are clearly identified in the

health workforce, and its annual plan highlights the need

literature. Nonetheless, in a recent document, Kaiako

to develop and grow the capability of the workforce that is

Pono – Mentoring Māori Student Learners in the

“sustainable, fit for purpose”. In addition, Health Workforce

Tertiary Sector, reporting the mentoring activities in

New Zealand notes the need to support the development

21 institutions, 13 had informal models of mentoring,

of Māori to work in the area of whānau ora (family health

eight had formal models although only six of these were

and wellbeing) (HWNZ, 2012, p. 6). Furthermore, the

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Ministry of Health has invested in strengthening and

qualifications. At a national level, groups like the Nursing

developing the Māori nursing and midwifery workforce,

Council of New Zealand, and the Nurse Educators in

establishing Ngā Manukura ō Āpōpō in 2008 to undertake

the Tertiary Sector (NETS) could adopt a more strategic

this. On its agenda is the recruitment and retention

approach to address and monitor the inequities that exist

of Māori within nursing schools, and in 2011 they

for Māori nursing students. The future identification of

produced the first national benchmark that reported the

other supportive strategies and best practice for nurse

responsiveness of nursing schools to Māori students (see

educators is important, and requires further research.

www.ngamanukura.co.nz/Professional_Development/

In addition to this, the development of key performance

Scorecard).

indicators is essential to monitor the performance of nursing schools with regard to indigenous nursing student

High-level policy exists with regard to improving the

recruitment and retention.

recruitment and retention of Māori into nursing, and as such there should be an appreciable growth in Māori

Conclusion

registering as nurses. However, this is not the case with the proportion of Māori nurses registering remaining

One of the common recommendations for indigenous

relatively static between 6% and 7%. Having a nursing

nursing students’ academic achievement is a collaborative

workforce that is representative of the Māori population

approach between academics, training schools and the

in New Zealand is crucial for addressing the quality of

community. The literature reviewed here has suggested a

health service delivery by nurses. Yet the recruitment

number of strategies to overcome barriers to recruitment

and retention issues for indigenous nursing students,

into nursing programmes for indigenous peoples. These

like Māori, persist despite the barriers and strategies

include efforts to improve the academic preparedness

to overcome these being well documented in the New

of potential students prior to admission, and flexibility

Zealand and international literature. Despite endeavours

around the enrolment process with the inclusion of

by individual nursing schools to address recruitment and

culturally appropriate people and processes. Several

retention barriers, this is insufficient to make a difference

approaches were also identified in the literature to

nationally as the proportion of Māori within the nursing

increase the likelihood of indigenous student nurse

workforce (which includes both registered and enrolled

course completion. Structured academic support, access

nurses) remains constant between 6 % and 7% (Wilson

to indigenous role models and mentors, opportunity

et al., 2011).

to maintain their cultural and community obligations, relevant clinical experiences, and having supportive

Nonetheless, the literature is clear on the issues

teaching and learning environments that include

surrounding indigenous and Māori experiences within

indigenous content incorporated in curricula were

nursing schools. The barriers are well documented,

identified as strategies that promote indigenous student

and strategies to promote Māori success are evident.

retention, and ultimately lead to success and programme

It is possible that the translation of what is known

completion. Mentoring and academic support, in

about recruitment and retention of indigenous nursing

particular, have also been highlighted throughout the

students into the practice of nursing schools is an area

literature as significant for academic success. Improving

that needs further work and time. Tertiary institutes and

recruitment and retention rates of indigenous nursing

nursing schools can contribute to indigenous success by

students, like Māori, are critical to the development of a

ensuring the implementation of Kawa Whakaruruhau

robust indigenous nurse workforce that can contribute

Komiti (Cultural Safety Committees) to advise and

to addressing the inequalities in health outcomes that

support nursing schools to address local issues for Māori

indigenous people experience.

nursing student retention and completion of nursing Page 38

Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand References Adams, M., Aylward, P., Heyne, N., Hull, C., Misan, G., Taylor, J., & Walker-Jeffreys, M. (2005). Integrated support for Aboriginal tertiary students in health-related courses: The Pika Wiya Learning Centre. Australian Health Review 29(4), 482-488. doi:10.1071/AH050482. Ako Aotearoa. (2010). Kaiako pono: Mentoring for Māori learners in the tertiary sector. Wellington, New Zealand: Ako Aotearoa. Anonson, J. M., Desjarlais, J., Nixon, J., Whiteman, L., & Bird, A. (2008). Strategies to support recruitment and retention of First Nations youth in baccalaureate nursing programs in Saskatchewan, Canada. Transcultural Nursing, 19(3), 274-283. doi:10.1177/1043659608317095 Broodkoorn, M., (2010, April 1). Where are all the Māori nurses and midwives. Nursing Review. Retrieved from www.nursingreview.co.nz Cech, E. A., Metz, A. M., Babcock, T., & Smith, J. (2011). Caring for our own: The role of institutionalized support structures in Native American nursing student success. Journal of Nursing Education 50(9), 524-531. Curran, V., Solberg, S., LeFort, S., Fleet, L., & Hollett, A. (2008). A responsive evaluation of an Aboriginal nursing education access program. Nurse Educator, 33(1), 13-17. doi:10.1097/1001.NNE.0000299496.0000223119.0000299468. Curtis, E., Wikaire, E., Stokes, K., Reid, P. (2012) Addressing indigenous health workforce inequities: A literature review exploring ‘best’ practice for recruitment into tertiary health programmes. International Journal for Equity in Health, 11, Article 13. doi:10.1186/14759276-11-13 DeLapp, T., Hautman, M. A., & Anderson, M. S. (2008). Recruitment and Retention of Alaska Natives into Nursing (RRANN). Journal of Nursing Education, 47(7), 293-297. doi:10.3928/01484834-20080701-06 Hinton, A., & Chirgwin, S. (2010). Nursing education: Reducing reality shock for graduate indigenous nurses: It’s all about time. Australian Journal of Advanced Nursing, 28(1), 60-66. Martin, D. E., & Kipling, A. (2006). Factors shaping Aboriginal nursing students’ experiences. Nurse Education in Practice, 6(6), 380-388. doi:10.1016/j.nepr.2006.07.009 Meiklejohn, B., Wollin, J. A., & Cadet-James, Y. l. (2003). Successful completion of the Bachelor of Nursing by indigenous people. Australian Indigenous Health Bulletin, 3(2), Brief report 1. Retrieved from http://www.healthinfonet.ecu.edu.au/ Metz, A. M., Cech, E. A., Babcock, T., & Smith, J. L. (2011). Effects of formal and informal support structures on the motivation of Native American students in nursing. Journal of Nursing Education, 50(7), 388-394. doi:10.3928/01484834-20110415-01 Nakata, M., Nakata, V., & Chin, M. (2008). Approaches to the academic preparation and support of Australian indigenous students for tertiary studies. Australian Journal of Indigenous Education, 37(Supplement), 137-145. Ngā Manukura o Apōpō. (2012). The performance of New Zealand schools of nursing: Responsivesness to Māori nursing students – Scorecard 2010. Auckland, New Zealand: Author. Nursing Council of New Zealand. (1992). Guidelines for the cultural safety component in nursing and midwifery educatuon. Wellington, New Zealand: Author. Nursing Council of New Zealand. (2011). The New Zealand nursing workforce: A profile of nurse practitioners, registered nurses and enrolled nurses 2011. Wellington, New Zealand: Author. Smith, D., McAlister, S., Gold, S. T., & Sullivan-Bentz, M. (2011). Aboriginal recruitment and retention in nursing education: A review of the literature. International Journal of Nursing Education Scholarship, 8(1), 1-22. doi:10.2202/1548-923x.2085 Tertiary Education Commission Te Amorangi Matāuranga Matua, (2012). Statement of Intent 2012/13-2014/15. Retrieved from : http:// www.tec.govt.nz/Documents/Publications/Statement-of-Intent-2012.pdf Turale, S., & Miller, M. (2006). Improving the health of Indigenous Australians: Reforms in nursing education. An opinion piece of international interest. International Nursing Review, 53(1), 171-177. doi:10.1111/j.1466-7657.2006.00476.x Usher, K., Lindsay, D., & Mackay, W. (2005). An innovative nurse education program in the Torres Strait Islands. Nurse Education Today, 25(6), 437-441. doi:10.1016/j.nedt.2005.04.003 West, R., West, L., West, K., & Usher, K. (2010). Tjirtamai -- ‘To care for’: A nursing education model designed to increase the number of Aboriginal nurses in a rural and remote Queensland community. Contemporary Nurse, 37(1), 39-48. doi:10.5172/conu.2011.37.1.039 Wilson, D., McKinney, C., & Rapata-Hanning, M. (2011). Retention of indigenous nursing students in New Zealand: A cross-sectional survey. Contemporary Nurse, 38(1/2), 59-75. doi:10.5172/conu.2011.38.1-2.59 Zepke, N., Leach, L., Prebble, T., Campbell, A., Coltman, D., Dewart, B., . . .Wilson, S. (2005.) Improving tertiary student outcomes in the first year of study. Retrieved from http://www.tlri.org.nz/sites/default/files/projects/9209_finalreport.pdf

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Nursing Praxis in New Zealand NOTES FOR CONTRIBUTORS The initial and continuing vision for Nursing Praxis in New Zealand is that, within the overall aim of fostering publication as a medium for the development of research and scholarship, the Journal should: • Inform and stimulate New Zealand nurses. • Encourage them to reflect critically upon their practice, and engage in debate and dialogue on issues important to their profession. Nursing Praxis in New Zealand publishes material that is relevant to all aspects of nursing practice in New Zealand and internationally. The Journal has a particular interest in research-based practice oriented articles. Articles are usually required to have a nurse or midwife as the sole or principal author. There is no monetary payment to contributors, but the author will receive a complimentary copy of the Journal on publication. The ideas and opinions expressed in the Journal do not necessarily reflect those of the Editorial Board. Nursing Praxis in New Zealand original research, discursive (including conceptual, position papers and critical reviews that do not contain empirical data), methodological manuscripts, commentaries, research briefs, book reviews, and practice issues and innovations. Contributions are also accepted for Our Stories, which are short pieces profiling historical and contemporary stories, which reveal the contributions of individual nurses to our profession

Guidelines for Manuscripts While we encourage authors to be creative in the way they present their information, the following requirements must be met: •

Manuscripts should be word processed, formatted for A4 size paper, with double line spacing, page numbers on the bottom right side of the page and the manuscript title in the header of each page.

•

Use a plain font (Arial, Calibri, or Times New Roman).

•

Include an abstract of no more than 300 words, summarising the article. For research articles the abstract must include information about the research design, participants, and data collection and analysis methods.

•

Include a maximum of six (6) keywords.

•

Generally manuscripts will not exceed 3,500 words, however longer articles will be considered as long as they are focused and concise.

•

If the article is a research report then details of ethical processes followed must be included in the body of the manuscript.

•

Tables and figures each need to be presented on a separate page at the end of the manuscript. Insert into Manuscript <INSERT TABLE NO. / FIGURE NO. ABOUT HERE> where the table or figure should be inserted. Generally these should be inserted AFTER the pece of text where they are first referred to.

Further details are available on the Nursing Praxis in New Zealand website - www.nursingpraxis.org The Editorial Board reserves the right to modify the style and length of any article submitted, so that it conforms to the Journal format. Major changes to an article will be referred to the nominated author for approval prior to publication.

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Manuscript Submissions •

Please supply manuscripts as a Word Document by e-mail to admin@nursingpraxisnz.org

•

Manuscripts must be word processed, with double spacing, the title in the header and page numbers in the lower right of the footer. on each page.

•

All tables and figures must be included at the end of the document each on a seperate page.

•

Check you have used a plain font (Calibri, Arial or Times Roman).

• •

No details of the author are to be displayed on the manuscript, please include this as a separate document (see below). An authors submission form must accompany your submission, this can be downloaded from the Nursing Praxis website www.nursingpraxis.org This form details each author (and the contribution they have made to the manuscript), a corresponding address and each author must sign the form.

Referencing It is the author’s responsibility to ensure that all references and citations are accurate and that all referencing follows 2010 APA (6th edition) conventions (see the Nursing Praxis website for examples). This includes all electronic references, which must include doi number for journal articles. References in the text should cite the author’s name(s), followed by the date of publication. Where direct quotations are used, page numbers must be given. References at the end of a manuscript should be listed alphabetically on a separate sheet formatted with a hanging indent and italicised, not underlined. E.g: American Psychological Association (APA). (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author. Smythe, L., & Giddings, L. S. (2007). From experience to definition: Addressing the question ‘What is qualitative research?’ Nursing Praxis in New Zealand, 23(1), 37-57.

In the case of historical research, referencing compliant with the New Zealand Journal of History is acceptable.

Review Process All manuscripts will be blind critiqued by at least two reviewers prior to a decision being made by the Editorial Board. Subsequently the author will be notified of acceptance (along with any recommended changes) or rejection of the manuscript. Regular features are not peer reviewed. The review process takes, on average, three months.

Copyright Authors are responsible for the accuracy of their articles. After publication the article and its illustrations become the property of the Nursing Praxis in New Zealand journal.

Letters to the Editor Should not exceed 200 words. A nom de plume is acceptable provided full name and address are supplied. Please e-mail as a Word document.

Commentaries Nursing Praxis welcomes commentaries on papers published in its pages. These should be approximately 1000 words in length and should offer a critical but constructive perspective on the published paper. Original authors will be given the opportunity to respond to published commentaries.

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

Nursing Praxis in New Zealand Research Briefs Generally should not exceed 1500 words. Content must include a statement of the topic and purpose of the research; participants and the mode of recruitment; what was done (method and procedure for data collection and analysis); and a brief indication of the findings and their implications for nursing. As the material will be read by a broad cross-section of nurses, abstracts from theses are often not suitable in their original form and so require reworking.

Our Stories Nursing Praxis in New Zealand welcomes submissions to ‘Our Stories’. We are interested in publishing short articles that focus on nursing experiences over time. Our Stories will profile historical and contemporary stories, which reveal the contributions of individual nurses to our profession. Short articles, not exceeding 1500 words, are welcomed which provide insight to the contribution that a New Zealand nurse has made to the profession either locally, nationally, internationally. Such articles could include the stories behind the research, interviews with key nurses or the stories of those who have inspired and influenced their colleagues through their passion and commitment to the profession.

Book Reviews Book reviews should not exceed 500 words. Content must include a statement about the book’s topic and purpose, key points of interest in the book, a critique of the contents, and an indication of the implications or relevance for nursing or health practice.

Practice Issues and Innovations Articles are welcomed which highlight practice issues and innovations. Such articles might constructively discuss current nursing policy, practice or describe new approaches to nursing practice. This should be prepared as outlined for manuscripts above.

Send all Submissions via: E-mail – as a Word document together with scanned original copy of signed author information to: admin@nursingpraxis.org OR Post – One hardcopy of all documents together with a copy on a disk as a Word document to: Nursing Praxis in New Zealand P O Box 1984 Palmerston North 4440 New Zealand

Indexes Nursing Praxis in New Zealand is indexed in: • CINAHL (Cumulative Index of Nursing and Allied Health Literature), and • ProQuest.

The entire list of articles previously published in Nursing Praxis are available on the Nursing Praxis website www.nursingpraxis.org

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Vol. 29 No. 3 2013 - Nursing Praxis in New Zealand

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