FOCUS n Healthy Year Ahead
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NEW ZEALAND’S INDEPENDENT NURSING SERIES
Q&A with new NETS chair Sally Dobbs
Are statins good for the heart and brain?
Nursing in China and New Zealand: what are the issues?
Patient moving and handling: making it safe
THE NURSING BLUES: Free 60-minute
Professional Development learning activity
Caring for the carers Stress-proofing tips www.nursingreview.co.nz
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LETTER FROM THE EDITOR
Caring for the carers For most of us work is a big part of our lives. The days that go well feed our self-respect while the days that don’t go so well can leave us both physically and emotionally weary. When the nature of the work is already emotionally demanding – like nursing – it can be doubly rewarding… or draining. This edition takes a look at depression and anxiety in nursing and how to better support the mental health and wellbeing of the caring profession in the workplace. As a ‘worrier’ myself, I hope that nurses never feel they are ‘letting down the badge’ if they ask for help or need support when feeling fragile at work. Caring for the carers is essential if our families, friends and other loved ones are to keep receiving both compassionate and clinically competent care in today’s often stressful health workplaces.
Manila musings
I was lucky enough to holiday in the Philippines in December and grabbed the chance to meet up with some wonderful nursing leaders (thanks to Monina Gesmundo, the president of the Filipino Nurses Association of New Zealand). In the next edition of Nursing Review you can read some of the insights gained during a flying visit to the home country of a growing number of Kiwi nurses.
60-minute PD learning activity now available to all
All print copies of Nursing Review now include Nursing Review’s regular RRR professional development article. Read the article, reflect on it, and apply it to the reality of your nursing practice and you will have earned 60 minutes towards the Nursing Council’s requirement of 60 hours’ professional development over three years. Our latest RRR PD article – found in the middle of this issue – looks at reducing the risks of complications from IV devices.
Inside: FOCUS: HEALTHY YEAR AHEAD 4 8 9 10
The nursing blues: caring for the carers ANNETTE MILLIGAN shares tips for stress-proofing yourself Nurses on wheels: ED nurse and racing car driver ALEX CLARK Nurses on wheels: KATE GIBB on mindful motorbiking
ProfessionalDevelopment
11 Peripheral IV cannulae (PIVC): Saving a line might just save a life Reading, Reflection, and application in Reality To subscribe go to www.nursingreview.co.nz/subscribe
15 17 18
Patient moving and handling: making it safe iNature: research into digital complementary therapies Food for thought: can nutrients nurture better mental health?
PRACTICE, PEOPLE & POLICY 20
Nursing in China and New Zealand: the issues
REGULARS 2 3 23 24
Q&A profile: new NETS chair Sally Dobbs A day in the life of… Police watch-house nurse STEVE HOWIE Evidence-based practice: are statins good for the heart and brain? College of Nurses: JENNY CARRYER on the national nursing taskforce
Fiona Cassie
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COVER PIC: The nursing blues… see our cover story on page 4 exploring the issue of high levels of depression and anxiety in nursing and how to better support the mental health and wellbeing of nurses in the workplace. PHOTO CREDIT: iStock Nursing Review is distributed to key decision makers in the nursing sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
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NursingReview Vol 17 Issue 1
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www.nursingreview.co.nz | Nursing Review 2017 1
Q&A
Sally Dobbs JOB TITLE
Sally Dobbs
Q A
Where and when did you train? The Nightingale School, St Thomas’ Hospital, London. I sat state finals in July 1982.
Q A
Other qualifications/professional roles? Bachelor of Nursing; Master of Art Education (Health Education/ Promotion); Master of Science (Medical Science); Postgraduate Diploma in Travel Medicine (Royal College of Physicians and Surgeons Glasgow [RCPSG]); Postgraduate Certificate Education; Doctor of Education. I am also a reservist nursing officer in the Royal New Zealand Nursing Corps (RNZNC).
Q A
When and/or why did you decide to become a nurse? I wanted to be a soldier when I was little (I was a real tomboy as a child). After a period of being in hospital as a 10 year old, I wanted to become a nurse, but then changed my mind and wanted to become a doctor in the Army. I realised that I wasn’t going to get the grades, so I applied to study pharmacy at university. I failed physics, so applied to study nursing in London. I have been in nursing ever since, apart from a very short spell as a kennel maid in Cyprus!
Q A
What was your nursing career up to your current job? After qualifying as a nurse in 1982, I spent one year as a staff nurse at St Thomas’ Hospital and then joined the Queen Alexandra’s Royal Army Nursing Corps in 1983. I had a wide and varied 16-year career as an army nurse, 13 years of which were within nurse education. This involved continuing nurse education for qualified nurses who were serving in Germany, Cyprus, Northern Ireland and throughout the UK. I also spent six months as a deputy matron of a field hospital in Bosnia. I left the British Army in 1999 and accompanied my army husband to Nepal, Germany and Cyprus, where I was able to nurse throughout this time. I have also worked on a hospital ship on the Amazon in Peru.
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Academic and Relationship Leader, School of Nursing, Southern Institute of Technology, Invercargill
Dr Sally Dobbs is the new chair of NETS (Nursing Education in the Tertiary Sector). Find out about her career spanning a position as deputy matron of an army field hospital in Bosnia and nursing on a hospital ship in the Amazon. We moved to New Zealand at the end of 2008 for a stress-free life! I came straight to SIT as a lecturer and became the head of school after one year. I joined the RNZNC after my arrival in New Zealand and have been lucky enough to be involved in a Pacific partnership as a health educator in Samoa and Tonga. I was also very privileged to travel to Gallipoli for the Chunuk Bair centennial commemorations.
Q A
So what is your current job all about? SIT delivers pre-entry nursing; the New Zealand Diploma in Enrolled Nursing; Bachelor of Nursing, and the Postgraduate Diploma in Health Science programmes. I oversee the management and delivery of all these programmes. I have a significant teaching component throughout all the programmes, which allows me to know many of the students. My teaching interests are the history of nursing, evidence-based practice, health education/promotion, and leadership. We have close relationships with the Southern District Health Board (DHB) and I also teach on the preceptorship programme delivered through the DHB. As the Head of the Nursing School, every day is different and presents a diversity of challenges. I spend a lot of time dealing with multiple emails requests and enquiries, liaise with various stakeholders and attend various meetings, participate in research, and prepare teaching sessions. In my spare time I enjoy my role as a reservist nursing officer within the New Zealand Defence Force.
Q A
Can you recall the moment in your early nursing days when you first felt you were really a nurse? As a third-year nursing student working on a busy neuromedical ward at St Thomas’. Third-year nursing students were known as ‘frillies’ because we got to wear a frilly cap!
Q
If there was a fairy godmother of nursing, what three wishes would you ask to be granted for the New Zealand nursing workforce? Greater recognition for enrolled nurses as a regulated body of nurses; regulation
A
of nursing students and nurse educators as a scope of practice; to have a greater influence in the promotion of healthy lifestyles for New Zealanders.
Q A Q
What do you think are the most important personal characteristics required to be a nurse? Resilience, professionalism, and compassion. As a leader in nurse education what do you believe are the strengths of nurse training in the 21st century? And where is there room for improvement? The nursing programmes that are currently being delivered are very comprehensive and demonstrate the diversity of nursing opportunities. We really need to strengthen the promotion of health and primary health education within the New Zealand population and improve the image of nursing older people as an attractive career option.
A
Q A
What do you do to try and keep fit, healthy, happy and balanced? Running, boxing, walking my lovely rescue dog, and knitting. After my doctorate, I am now learning how to cook!
Q A
What is your favourite way to spend a Sunday? Catch up on Coronation Street on MySky, go for a long run and make a new meal, and spend time with my husband and dog and have a glass of Pimms on our deck (which has fabulous views of Invercargill and the Takitimu mountains). Sundays are such a luxury since I finished my doctorate a year ago, so I like to indulge myself!
Q A Q A
What is number one on your ‘bucket list’ of things to do? Cross the Antarctic Circle.
What is your favourite meal? Anything that has crème brulée as a pudding!
A day in the life of ... a police watchhouse nurse NAME | Steve Howie JOB TITLE | Watch-house Nurse, Canterbury District Health Board LOCATION | Christchurch Central Police Station
5.30
AM WAKE Wake to alarm, shower, eat breakfast while reading Stuff News online.
6.15
AM ON THE ROAD Travel to work, taking the car today instead of my usual motorcycle ride as it’s drizzling and cold. There’s minimal traffic on the motorway this morning because it is a public holiday and car parking is also easy, so I arrive 15 minutes early for work. I trained as a registered psychiatric nurse at the former Sunnyside Hospital and have been nursing for Canterbury District Health Board mental health services for 33 years. For the past eight years I’ve been working alongside police custody staff in the Christchurch Police watch-house to assess people in custody for mental health issues, their risks to themselves and others, and for alcohol and other drug issues. In the 18 months prior to the watch-house initiative there were three suicides in the Christchurch Police cells. Since the initiative started in 2008 there have been no deaths in the cells due to suicide or medical issues. My colleague Neil McNulty and I were humbled last year to receive Police District Commanders’ Commendations for our work. Today I am on a 7am to 3.30pm shift.
7.00
AM HANDOVER I greet my nightshift colleague and receive a verbal handover. There is more than the usual amount of chaos in the custody unit today, with 30 detainees going from the cells to court, two of them requiring further review by the mental health service (MHS) teams at the courts. Two also require a review by me before leaving for court at 8.30am and one detainee needs a review once they are sober enough to be released from custody. There is also a juvenile detainee under youth mental health services, who will need to be notified that he’s in court this morning.
7.10
AM WORK WHIRLWIND BEGINS The next three hours are a whirlwind of activity, including assessments, the handover of risk issues to court escort staff, and arranging for two reviews by MHS at court for detainees with ongoing mental health and risk issues, as well as communicating risk and health information to the court liaison nurse and the prison health unit. Unfortunately I missed the Police District Command Centre daily briefing meeting this morning due to the pressure of work. Today is particularly busy for a day shift – on average the watch-house nurse team sees 40–60 people a week, with the weekends usually being busier due to more intoxicated people. Once the people head to court the watch-house calms down a little and I’m able to review another person, resulting in a referral to the DHB’s Single Point of Entry (SPOE) service for adult mental health services. I also fit in several consultations with police officers dealing with people in the community with mental health issues. Then two more people are brought into custody requiring my attention. One is threatening suicide and my input is required to de-escalate him to the point where he can be received into custody. The other is a woman who appears to be psychotic, possibly due to methamphetamine use. I decide to observe her for a while in the cell to see whether she improves over time and see exactly what is happening for her.
10.00
AM GRAB COFFEE AND BACK INTO IT I manage to grab the first coffee for the day and drink this while discussing how best to assess the two new detainees. The next three and a half hours involve assessment of the woman with
Steve Howie methamphetamine psychosis, who requires a referral to the DHB’s crisis team for further assessment under the Mental Health Act, plus the assessment of three other detainees not requiring further referrals. The young man who was threatening suicide settles down rapidly and appears to have been decompensating (deteriorating) behaviourally, which had led to him catastrophising his situation. I also hold several more phone discussions with police on matters involving people with mental health issues in the community.
1.30
PM HANDOVER AND LATE LUNCH I provide a handover to the court escorts who are taking the man who had earlier threatened suicide to court. No follow-up is possible with this man as he intends to leave Christchurch this afternoon, has no phone or family to contact, and is declining further MHS input. I have a quick lunch and a coffee at my desk. The crisis team arrives for a Mental Health Act assessment of the woman with methamphetamine psychosis, which requires handover and liaison. A further assessment of a detainee takes me up to 3.15pm, when the afternoon shift nurse arrives to take over. I provide handover for three people who require assessment, plus the ongoing Mental Health Act assessment. Today has been a particularly busy day so I leave 30 minutes late after catching up on documentation.
4.30
PM HEAD HOME I arrive home after mental de-stressing on the way home. I contemplate a number of concerns around some of the people I have seen today and think about some of the decisions I have made. The job we do carries a lot of risk, given the nature of the people we see, the environment we see them in and the pressure of police and court processes that determine the time available for the assessments we do. I sit in the sun with a coffee and a book for an hour and say “hi” to my wife, Susie, when she arrives home. We then go for a walk together, and talk a bit about about our respective days at work. We cook dinner, have a couple of red wines and a general chat while we watch a movie on TV.
10.45
PM BED I head to bed, reflecting on what has been a very busy day for me and contemplating with some trepidation that tomorrow is New Year’s Eve, which is normally extremely busy at work. I wonder what that might bring. www.nursingreview.co.nz | Nursing Review 2017 3
FOCUS n Healthy year ahead
The nursing are we caring blues: enough for the carers?
Anxiety and depression are expected to be the leading causes of missed work days worldwide in the next five years. International research indicates that nurses already have higher levels of depression and anxiety than the general population. Nursing Review explores the issue.
C
aring can be hazardous to your mental health. The new Health and Safety at Work Act puts the onus on employers to eliminate or minimise risks to their workers’ health and safety – including their mental health. Studies both here and overseas show that caring for others – who are often at their most vulnerable – in today’s fast-paced, high acuity, high workload health sector can come at a cost to the mental health and wellbeing of the carers. It can lead to unhealthy stress levels, fatigue, emotional exhaustion, cynicism, compassion fatigue, moral distress and burnout. It can also be a trigger for anxiety and depression disorders. But while nurses may talk about stress or feeling emotionally drained at the end of a day, it appears that few are likely to share that they have a mental health disorder like anxiety and depression. Nursing blogger Barbara Docherty last year described depression as nurses’ “best kept secret” in a blog that went viral, attracted many social media comments and led to nurses taking the opportunity to confidentially share their stories. It should not be a surprise that nurses suffer depression and anxiety as the 2012–13 New Zealand Health Survey found that one in six New Zealand adults (16 per cent) had been diagnosed with common mental health disorders (including depression and anxiety) at some time in their lives, and one in five New Zealand women. Literature reviews also indicate that mental health issues are more prevalent in nursing and the other health professions than they are in the general population – probably because of the high stress and emotional demands of the work. For example, a major review of the health and wellbeing of Britain’s NHS staff by
Dr Steve Boorman released in 2009 found that sick leave taken by NHS staff was 50 per cent higher than in the private sector. About £1.3 billion of the £1.7 billion estimated annual cost could be attributed to mental health problems. A recent study of nearly 3,500 Chinese nurses found an estimated 38 per cent had depressive symptoms. A 2012 study of 1,171 American nurses funded by the Robert Wood Johnson Foundation found that nurses had twice the rate of depressive symptoms of the general public (18 per cent, compared with 9.4 per cent).
practising. She believes that if both the profession and sector acknowledged that nursing is a vulnerable workforce under high emotional stress they would be more open to providing the early intervention and support required. “I think we would be much healthier,” says Kidd, who is also a Waikato-based senior lecturer for the University of Auckland and teaches and coordinates a mental health new graduate programme She says programme leaders tell nurses starting out in their first mental health jobs that after a honeymoon period all of them will hit the wall and think they are hopeless nurses and wish they’d never chosen mental health nursing as a career. But the programme leaders also reassure them that when that happens they will be supported with whatever help they need, and that they will come through it. Kidd thinks this type of approach should be extended to nurses throughout their careers because not only does the public place “huge” expectations on nursing as a caring profession, but the profession also puts high expectations on itself. The fear of letting their colleagues or ‘the badge’ down may be one reason few nurses are ready to speak up when they are struggling, believes Kidd. “In the beginning, depression and anxiety can feel like you are doing something wrong … you feel you’re not quite as good or as fast as everybody else and you are struggling to cope with patients and families that your colleagues just seem to be sailing through with.” Kidd says by covering up and putting on a brave front of ‘coping’, struggling nurses can miss the early warning signs and the opportunity for early interventions to prevent mental health issues affecting their work. Pushed nursing colleagues may also struggle to feel compassion for a
“I think we are in an ever-decreasing circle – we’ve got less and less soulfeeding happening and yet we are giving more and more.”
4 Nursing Review 2017 | www.nursingreview.co.nz
An Australian retrospective study found elevated rates of suicide amongst nurses and female doctors, compared with other occupations, with one explanation raised being greater exposure to workrelated stressors. These are stark statistics. What are the possible reasons behind them and how could the mental health and wellbeing of nurses be better supported?
Emotional work
“I think we should work with the assumption that all nurses at some time are going to struggle because of the emotional work we do,” believes Dr Jacquie Kidd, a researcher in the field of nursing and depression. Kidd’s PhD research drew on the experiences of 18 Kiwi nurses experiencing mental illness while
FOCUS n Healthy year ahead
struggling colleague because they are worried about the impacts on their own workloads and mental health if they offer support and help. Dr Stacey Wilson, a mental health nurse with a research interest in emotional competency, says there is also a sense that nurses should know better, as depression is somehow seen as “quite self-absorbing or selfish” and “nurses aren’t really allowed to be like that”. Wilson acknowledges the irony that as a profession nurses encourage clients to seek help for mental health or addiction issues and are positive about mental health recovery. But personally it may be a different story because there is still a stigma attached to disclosing mental health issues as a nurse. “I don’t know many nurses who would say that they are off on leave because of a mental health or a drug or alcohol issue,” says Wilson. “Some might say they are on stress leave.” Both Kidd and Wilson believe that contributing to nurses’ stress and distress is the disjoint between what draws many nurses to the profession in the first place and the reality of the modern workplace. “My impression is that what makes us resilient is the time we spend engaging with patients and families – because that’s where we get the sense we are doing a good job,” says Kidd. But working at full capacity can leave nurses little time to foster the relationships that give them energy. “I think we are in an ever-decreasing circle – we’ve got less and less soul-feeding happening and yet we are giving more and more.” Wilson says constant change in the health sector is another factor, along with nurses trying to juggle the demands of work with the pressure to do postgraduate work, look after families and attempt a semblance of work/life balance. So what steps could be taken to better care for the carers?
“I don’t think that because [managers] are at the top of the food chain they are any more resilient to work pressures – maybe they are even more vulnerable.” Riegen says that any healthy workplace strategy needs to be holistic and look at all work aspects that can impact on staff health and wellbeing. “Because what the evidence tells us is that one-off things are no good.” The DHB have used the World Health Organisations ‘Healthy Workplace’ (2010) definition and action model as a basis for the work, along with New Zealand’s Te Whare Tapa Whā model. So, for example, offering mindfulness and wellbeing sessions is good – but a strategy needs to permeate an organisation’s culture and address psychosocial risks as well. Riegen says that doesn’t mean you shouldn’t do anything in the interim – she points out that Waitemata’s strategy has been five years in the making and is still a work in progress – but that the bigger picture should always be kept in mind. Including that there is a very good business case for investing in healthy workplaces as having healthy staff – both physically and mentally – results in less absenteeism, ‘presenteeism’ and staff turnover and leads to greater productivity. “Also in the last few years the research about the inextricable link between staff health and wellbeing and the safety and quality of the experiences and outcomes for the patients has nearly doubled,” says Riegen.
Teamwork and managers
The nursing literature agrees that teamwork – and good managers who foster it – is a very important component of nurse wellbeing in the workplace. For instance, the Magnet Hospital research, which distilled the common characteristics of hospitals able to attract and retain satisfied nurses during nurse shortages, found that these hospitals not only had adequate staffing, but also offered professional autonomy, participatory management styles, well-prepared leaders and teamwork. Alison Ogier-Price, who leads the Working Well programme for the Mental Health Foundation and Continued on next page >>
RESOURCES
Healthy workplaces
“If we expect the healthcare workforce to care for patients, we need to care for the workforce.” This quote from the National Patient Safety Foundation’s Lucian Leape Institute is one of the philosophical drivers for nurse Janice Riegen’s work. The clinical nurse specialist in occupational health and safety is passionate about the urgent need to create healthy workplaces in the health sector, including reducing the risk factors for anxiety and depression. “What the literature is telling us is that anxiety and depression are going to be the leading cause of workplace absence for everybody in the next five years – not just in healthcare,” says Riegen. Contributing factors to this include psychosocial risks which Riegen says are becoming one of the biggest health and safety challenges in the modern day workplace worldwide. Riegen’s master’s research was into what contributes to a healthy workplace and she has presented on the topic internationally. Waitemata District Health Board, who Riegen works for, has created a Healthy Workplace steering group – inclusive of the main unions. Last year the DHB’s board and senior management gave the goahead to a Healthy Workplaces Strategy for the organisation and its staff. The three-year programme lists 15 actions ranging from developing an age-friendly working environment to offering mindfulness and wellbeing sessions, and from supporting best practice workload management to promoting good shiftwork and fatigue management practices.
Safe staffing is definitely one part of a healthy workplace, Riegen says, and if you talk to nurses anywhere their main safety focus is on workload pressures. Excessive workload is a psychosocial risk (according to European Agency for Safety and Health at Work) that can contribute to mental health issues, along with a lack of involvement in decision-making and a lack of support from management or colleagues. “I used to do bureau work and I could tell how healthy the workplace was straight away after walking in – just based on how I was greeted and welcomed.”
HELPLINES »» Lifeline 24/7 helpline on 0800 543 354 or (09) 522 2999 within Auckland. www.lifeline.org.nz/corp_Home_378_2001.aspx »» Depression Helpline Free 24/7 advice from trained counsellors. Phone 0800 111 757 or txt 4202. https://depression.org.nz
HELPFUL WEBSITES »» Depression.org.nz Resources include a self-test for depression and the online journal tool. https://depression.org.nz »» Mental Health Foundation Information on mental health conditions, the Five Ways to Wellbeing and the Working Well programme. www.mentalhealth.org.nz »» MoodGYM training programme Offers cognitive behaviour therapy (CBT) skills for preventing and coping with depression. https://moodgym.anu.edu.au/ »» Black Dog Institute Information, advice and online tools for both individuals and health professionals on mood disorders like depression. www.blackdoginstitute.org.au »» Worksafe Guide to new Health and Safety at Work Act (2015) and other resources. www.worksafe.govt.nz/worksafe »» NHS Health and Wellbeing Final Report 2009 www.goo.gl/jn7826 »» Good Day at Work (UK) Free online iResilience tool – test your resilience and get feedback. www.robertsoncooper.com/gooddayatwork www.nursingreview.co.nz | Nursing Review 2017 5
FOCUS n Healthy year ahead
has been working for a number of DHBs to help develop wellness programmes, sees training and supporting managers as crucial “I see teams that function so well,” she says, “and the heart of it is always that manager who gets it – someone who likes people and gives people a sense that they are participating in decisions that are happening around them.” But sometimes charge nurse managers (CNMs) are in the role due to seniority or their clinical skills and don’t have the skills to run a team of people. Or they are scared to raise mental health concerns with staff because of uncertainty around what is okay to ask about and what is not. Sometimes managers themselves are affecting the mental wellbeing of their staff because of their communication styles and, on occasions, bullying behaviour. “Sometimes bullying issues arise through lack of training – they don’t realise what they are doing,” says Ogier-Price. She says that is why it is important to invest in training managers to listen to what’s going on, acknowledge it and respond by using positive and communicative management styles. Training should include communication skills, conflict resolution and teambuilding skills to create cultures where teams work well together and feel free to raise issues of concern. Kidd suggests that charge nurse managers may do well to have the ongoing support of HR, rather than HR stepping in when things go pear-shaped. Riegen says the evidence indicates that line managers should also be trained in supporting staff at risk of mental health issues because if staff have trusting relationships with their managers then they will turn to these people first when they are struggling at work. But line managers, who can be the meat in the sandwich between staff and senior management, also need the skills and the tools to take care of themselves. “It seems to me it doesn’t matter what position you are in the hierarchy of nursing – the level of stress and the potential for developing a mental health problem that is work-related is pretty high,” says Wilson, who provides professional supervision for nurses, from new graduates to charge nurses. “I don’t think because [managers] are at the top of the food chain that they are any more resilient to the work pressures – maybe they are even more vulnerable.” Everyone who Nursing Review spoke to agreed that in an ideal world one-on-one professional supervision would be more widely available to help both managers and their nursing staff to critically reflect on their practices, plan their careers and work through some of the challenges facing them in their work. Wilson says it could also help to defuse anger and conflict in a team if an issue could be resolved by confidential supervision rather than “spreading around like a virus” and infecting everybody.
is paid to listen to you and talk about your woes … can really help to crystallise what you might need to do to help yourself feel better.” Ogier-Price says organisations should also promote or offer programmes that help people to maintain and sustain their mental wellbeing. Encouraging exercise is one example, as there is a growing body of evidence that physical exercise can be effective for people with mild to moderate depression. Programmes that can help people to relax, such as yoga, meditation or mindfulness, are also available, plus others that focus on the other important components of wellbeing, such as nutrition and sleep. Wellbeing workshops such as those offered at Canterbury DHB can teach nurses how to better care for themselves as carers. Ogier-Price says an absolutely ‘core concept’ that she emphasises in her workshops is the need to build social networks at work, as this is where people spend so much of their lives. This includes creating a work environment where socialising can occur, such as a lunchroom, which she acknowledges can be challenging in busy wards with little private space. Finding a way for staff to get together regularly should be a priority, she says, even if it is just getting together for special morning teas once in a while. After listening to nurses offload during wellbeing sessions, Ogier-Price is also interested in whether the idea of facilitated support groups, similar to those offered by Alcoholics Anonymous, could be helpful. Another approach that Ogier-Price encourages in her workshops is for nurses to boost their wellbeing by “basically doing the stuff you enjoy doing”. She says that to avoid chronic stress nurses need to routinely and frequently de-stress during the working day. “People need five minutes off every hour to de-stress so for the next hour they can function that much better.” This may be as simple having a laugh or an enjoyable conversation. In a particularly busy day it may be just grabbing a minute to go into the corner and take some deep, calming breaths. In longer breaks it could be grabbing a chance to take a walk outside, knit or do a Sudoku puzzle – whatever helps them to relax. Apart from stress management, Ogier-Price says other training programmes that could benefit nurses include assertiveness training and boundary setting to help them deal with both difficult patients and colleagues (see p.8 for some stress management tips). Wilson and Kidd also believe that pre-entry and ongoing nurse education should acknowledge that nursing is emotionally draining work and help them to build the self-awareness and emotional competency skills needed to be resilient and care for themselves and others. But it is not up to nurses alone to care for themselves – what is also needed is a health sector that cares for its carers. Creating a healthy workplace for carers – to paraphrase the World Health Organization’s healthy workplace motto – is the “smart thing, the legal thing and the right thing to do”.
“We need a little reminding that nurses are valuable people and it is worth spending a little time being a little compassionate to yourself and working on your emotional competency so you are in good shape for work.”
Stress management, emotional competence and building resilience
So in the real world what can you do, as a nurse, to contribute to the mental wellbeing of yourself and your colleagues in a pressured work environment? 6 Nursing Review 2017 | www.nursingreview.co.nz
For a start, be kinder and more compassionate to yourself and be kind to your colleagues, who may be struggling around you. “We’re a highly educated workforce that works in very difficult and challenging situations in some of the most dire times in people’s lives,” says Wilson. “We need a little reminding that nurses are valuable people and it is worth spending a little time being a little compassionate to yourself and working on your emotional competency so you are in good shape for work.” Ogier-Price, who specialises in applying positive psychology to organisational wellbeing, agrees, saying that nurses generally don’t take good care of themselves and – strangely enough – don’t always have the information or skills to recognise when and how much support they need. She has been offering wellbeing workshops in collaboration with the quake-challenged Canterbury DHB for the past three years, and after being called in to support other DHBs has come to believe that ‘care for the carers’ information is lacking in the health sector. In her role with the Mental Health Foundation she was commissioned to write a white paper for the Ministry of Health on the topic – something like a ‘working well’ guide for the health sector. Ogier-Price says a health and wellbeing culture should permeate an entire organisation and include reducing the stigma of mental health illness so that people struggling with anxiety and depression feel more able to speak up. In larger organisations this can include having access to EAP (Employee Assistance Programmes) that typically offer three free and confidential sessions with a counsellor or psychologist about personal and work issues that may be affecting workers’ productivity. Kidd, for one, thinks that nurses could be making much more use of EAP. “Just having somebody who
TAPsPP5881
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FOCUS n Healthy year ahead
Stress-proofing
yourself Annette Milligan, a nurse entrepreneur who has run stress management courses and seminars for 27 years, shares some of her top stress-proofing tips. Physical fitness
»» It’s easier to manage stress when you’re physically fit. The news gets better – exercise is an impressive treatment for mild–moderate depression. »» Exercise and stretch throughout the day. »» Huffing/puffing exercise will help you to generate endorphins, which lift mood.
Humour
»» Smile – when you smile your brain automatically produces endorphins – so smile. When you lift your face into the smile position, your brain thinks you’re happy and so produced endorphins. »» Laugh – laughter produces even more endorphins so laugh on the way home about one funny thing of the day. »» Surround yourself with positive imprints – draw a smiley face to make you smile. »» Play funny games, jokes, read cartoons and books, watch videos.
Separate home from work
»» Leave unfinished work at work. »» Leave work while you still have energy – otherwise you will grind yourself to a standstill. »» Never work in bed – the bedroom should be a place of fun and relaxation. »» Have a shower and change your clothes when you get home from work – it will help to separate you from work. »» If work is crowding your thoughts when you want to get rest, get your mind absorbed into something else – a good book, movie, conversation, or try juggling. »» Technology is our servant, not our master. Use your phone to best advantage – try shifting the email icon off your home page. That way you can access emails if you want to, but you don’t see an envelope icon with rising numbers in a red circle every time you turn on your phone.
Make life easier on yourself
»» There are some terrific apps which help us to organise our lives. Try them out, and swap ideas for the most useful ones. »» Carry things in a backpack or trolley rather than loading yourself with a heavy bag. »» Wear comfortable clothes – buy the right size (especially shoes and trousers) and wear low heels.
Boost your stress immune system
»» Change your perception of what is happening around you by changing the words you use to describe events. »» Feel the difference between saying “I’m depressed” and “I’m feeling a bit down” or between “I’m stressed” and “I’m challenged”. »» In a difficult situation tell yourself “that’s interesting” and notice the difference. »» Physical touch boosts our immune system, so have a massage or stroke the cat. 8 Nursing Review 2017 | www.nursingreview.co.nz
Develop support networks
»» Take time out to nurture your relationships – go for walks, do things together, welcome loved ones home. »» You don’t have to go through life alone – share problems and successes with other trusted people. »» Be ready to admit that you need help.
Change patterns of beliefs
»» Take a good look at your beliefs and challenge them – they often feel comfortable because we’ve had them a long time but they’re not always true. »» Look at some of the beliefs and expectations you have about yourself and see if they’re really relevant, eg, “I’ve always been like that”, “It’s easier to do it myself”, “No pain, no gain” or “Life wasn’t meant to be easy”. »» Change the beliefs you want to change by changing your thoughts, mixing with positive people or listening to motivational tapes.
Nutrition
»» Eat breakfast. »» Eat from the food pyramid. »» Be especially careful to eat nourishing food when you’re under a lot of stress.
Give yourself bonuses »» Send yourself flowers. »» Buy in takeaways. »» Go to a movie.
Always have a purpose in life
»» If you’re not happy with something, do something about it. »» Change one thing in your life at a time and stick to it for six weeks to set a pattern that will last for a long time. »» The most long-term changes are the ones we slowly absorb into our life.
Set boundaries
»» Learn to say “No”. »» Decide how much time you’re going to give and stick with that, i.e. “When I’m on, I‘m on, and when I’m off, I’m off”. About the author: Annette Milligan is the founder of Nelson’s INP Medical Clinic (formerly known as the Independent Nursing Practice)
The ten commandments for reducing stress 1. Thou shalt not be perfect, or even try to be. 2. Thou shalt not try to be all things to all people. 3. Thou shalt leave things undone that ought to be undone. 4. Thou shalt not spread thyself too thin. 5. Thou shalt learn to say “No”. 6. Thou shalt schedule time for thyself, and for thy supportive network. 7. Thou shalt switch off and do nothing regularly. 8. Thou shalt be boring, untidy, inelegant and unattractive at times. 9. Thou shalt not even feel guilty. 10. Especially thou shalt not be thine own worst enemy, but be thy best friend. Copyright Ramazzini Ltd 2011
FOCUS n Healthy year ahead
There’s more to life than work:
Nurses on wheels
Nursing Review reports on two nurses – one a racing car driver and the other a motorcyclist – and why they believe their passion for wheels is good for their wellbeing.
Calming a
racing heart ED nurse and racing car driver Alex Clark loves the rush of not knowing what’s around the corner.
W
hen Alex Clark grabs a break from a stressful ED shift, she pictures herself putting the ‘pedal to the metal’ around a racetrack. “It is quite calming – I know most people wouldn’t think that. But I guess it is like a meditation… and that’s also what I do when I’m readying to race.” The alter ego of this 25-year-old Middlemore emergency department nurse is a BMW racing car driver, who this season took out her first victory on the track. This may not be the stress release you would expect from a nurse who sees the aftermath of road crashes, but Clark says the sport she loves is safe. And both her job and hobby are good fits for a young woman who has come to realise that she thrives on adrenalin. Clark grew up around motor racing. With a dad who dabbled in racing Minis when she was a little girl and a grandad who raced, she spent a lot of time as a kid at Western Springs Speedway. So when seven years ago her father once again got back on the racetrack in the BMW Race Driver series, the then-19year-old nursing student took the chance to try it for herself. Once she got behind the wheel during a motor sport fun day she fell in love with the technical demands and concentration that racing demands, as well as the buzz it provides. The rush Clark got from the racetrack made her realise that she was more of an adrenalin junkie than she had ever thought. “I think it must definitely be in the blood.” Nursing was also in the blood, with her mother being a nurse. Her career choice was sealed by seeing how well the nurses cared for her grandfather during his frequent hospital stays at the end of his life. ED was not her first choice on graduating from AUT in mid-2014 – that was paediatrics – but the rush of never knowing what was around the corner appealed, so she applied successfully for a new graduate place at Middlemore Hospital’s ED. “And I can’t imagine doing anything else. Every day is different, every patient is different and in every presentation the condition is different. I like that change – the not knowing is a big drawcard for me, as well as the adrenalin when the ambulances radio ahead with an ‘R40’ and you think ‘oh, what is coming in?’ And you try to stay calm while being absolutely terrified inside.” Adrenalin is something her job shares with her hobby. “I’m an adrenalin junkie – I never thought I would be, but I am.” Clark’s first motor racing season was six years ago after a family friend, former motorsport champion Todd Pelham, helped to prepare her for her debut on the BMW Race Driver Series. First up she had to qualify by racing around the track against “big, fast, scary cars”, getting up to around 180 kilometres per hour.
“Terrifying, but so exhilarating!” Clark raced for three years with the support of her family ‘pit crew’ then, after two seasons off, she started racing again for the 2016-17 season. The season kicked off well, with her first ever victory in the 2 Litre category of the Castrol BMW Race Driver Series held at Hampton Downs’ race circuit in September.
“I’m an adrenalin junkie – I never thought I would be, but I am.” Feeling safe
As an ED nurse Clark sees the aftermath of crashes on the road but says she feels very safe in her racing car on the track. “Motor racing is so safe nowadays. I have all the safety gear – the belts, a roll cage and special neck restraints – so I’m at very little risk of being badly injured. Driving on the general road in a general road car is actually probably more dangerous.” But she adds that being an ED nurse has put her off riding a motorcycle again. “And I can’t watch motorcycle racing – it terrifies me as all I can see is the injuries that can happen,” she says. So what do her ED colleagues think of her racing? “Most of them don’t know,” she laughs. “The ones who do know think I’m mad.” But Clark highly recommends that other nurses give this meditative and addictive sport a spin. www.nursingreview.co.nz | Nursing Review 2017 9
FOCUS n Healthy year ahead
“It is very meditative. Total mindfulness, it really is – you must be so fully focused and can’t think of anything else.”
Mindful motorbiking Kate Gibb, a nursing director for older people’s health, is a born-again biker who is totally smitten with her new motorcycle.
K
ate Gibb admits she turns a few heads when she rocks up in her bike leathers to work meetings. She doesn’t do it often, but if she has a meeting on her way home she will ask to be excused her for turning up in her leathers with a helmet over her arm. Since getting back into motorcycling three years ago and buying her dream bike only last year, the director of nursing for older people’s health for the Canterbury District Health Board chooses two wheels over four wheels as often as she can. And after a hiatus of seven or eight years without a motorcycle, this born-again biker wonders how she let herself go so long without an activity that she finds so good for her wellbeing. Gibb first became hooked on riding dirt bikes around a cousin’s farm as a kid and took it up again in her early 20s. Her first motorcycle was a 250cc – the largest you could ride at the time on your learner’s licence. “It was a little old dunger and I ended up taking it to bits in the garage for quite some time. And then we moved house and I couldn’t remember how to put it back together. So we ended up selling that one for parts.” Without a motorbike to progress through to her full bike licence, however, motorbiking just fell off her radar over time. But three years ago Gibb bought a Suzuki GSX 650cc and started progressing through her licence again. “It took me 19 years to go from my learner’s to my full licence,” laughs Gibb. “I finally got it just last year.”
Meditation on wheels
As soon as she got her full licence, Gibb got her dream bike – a Triumph Street Triple R 675cc – the bike she had been coveting since it first came onto the market in 2008. She says it is light, quick, nifty and just the perfect fun package. “It just flies around the race track.” She says that the few times she has taken her bike around a track she has had so much fun she is very tempted to enter a race, but meanwhile she just enjoys track training days. “It is very meditative,” says Gibb. “Total mindfulness, it really is – you must be so fully focused and can’t think of anything else. Particularly on the track as you are fully concentrating on hitting your lines perfectly and everything else goes out of your head – it is just the most beautiful, serene concentration with all the power and exhilaration at the same time.” Riding on the road is admittedly less meditative as you need to focus on the other traffic, but Gibbs says that making sure she gets plenty of time on her bike is one of her key ways to wellbeing. “It’s sort of a unique regenerative kind of activity.” Bike shop owners no longer do a double take if a woman turns up to buy parts, with motorbiking now an activity being taken up by a growing number of women. But there is always the safety issue. Gibb acknowledges that motorcylists are more vulnerable on a motorbike than in a car. “You’ve just got to do your best to make sure you’re riding safely and defensively, and there
10 Nursing Review 2017 | www.nursingreview.co.nz
are some really fantastic safety initiatives since I’ve come back to riding.” One of these initiatives is the excellent ACCsupported Ride Forever training programme (see resources box for details). Bikers also need to invest in the best protective gear they can get their hands on and wear it, says Gibb. “But at the end of the day you do need to accept that at any time somebody can come out at you and, if something does go wrong, you are more vulnerable.” Gibb says that she actually feels safer on her motorbike than she does on a bicycle. And she adds that people can also get a false sense of security in a car. “I’m not denying there isn’t a significant risk … but I love it so much that I’m prepared to take the risk.” And Gibb says she has given some more passive and less risky ‘ways to wellbeing’ a go. “For a while I thought I should try mindful colouring or whatever you call it. But it didn’t quite ring the bell for me…” Whereas time on her bike… well, that’s the ultimate stress-buster and path to relaxation for this nurse leader. Please visit the Nursing Review website for reflections from Massey nursing school head Dr Mark Jones on how his first schoolboy motorbike back in England gave him his nursing vocation and a lifelong passion for bikes.
NursingReview Professional Development ReaDing, Reflection, anD aPPlication in Reality
By Beverley Hopper
Reading this article and undertaking the learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council competencies 1.1, 1.4, 2.1, 2.8, 2.9, 4.1, 4.2 and 4.3.
learning outcomes
Reading and reflecting on this article will enable nurses to:
» Recognise the signs and symptoms of phlebitis. » Summarise the distinguishing features of the four types of phlebitis.
Peripheral iV cannulae (PiVc): Saving a line might just save a life. It is estimated that over half of all hospital patients have an intravenous catheter inserted. Inserting peripheral intravenous cannulae (PIVC) is now a commonplace procedure; however, more can be done to reduce the risk of complications from these invasive devices. This article highlights the importance of meticulous care, maintenance and documentation of PIVC by nurses. “Sam” (64) was admitted for elective surgery on his shoulder. He had had a few PIVCs during his admission. Medication from one of these cannulae (in his forearm), had infiltrated the surrounding tissue and the tissue then became necrotic. He required grafts and further surgery. This became infected. The infection went to his shoulder and he required further washouts of his shoulder1. Insertion of a PIVC is one of the most common invasive clinical procedures performed in hospitals globally2 yet nurses are still not observing, assessing nor documenting the state of these regularly enough to reduce the risk of complications to the patient. PIVCs provide direct access into the venous system. Nurses must ensure that their knowledge and skills are up to date and based on current evidence-based practice to reduce the risk of patients with PIVCs preventing complications3.
Phlebitis Phlebitis is one of the main complications from PIVC, with research indicating that the
incidence can vary widely from less than 3 per cent up to more than 65 per cent depending on the clinical setting. This broad range suggests poor identification of phlebitis or poor reporting protocols4. Phlebitis is defined as inflammation of the tunica intima or inner layer (see Fig. 1) of the vein, characterised by pain, redness and swelling5. The area may feel warm with a cordlike appearance of the vein and the patient may feel pain or discomfort when medication is administered. There are four main types of phlebitis. chemical phlebitis is caused by fluid or medication being infused through the cannula. Key factors such as pH and osmolarity (the concentration of a solution) are known to have an effect on the incidence of phlebitis6. Blood has a pH of 7.35-7.45. Medications outside this range have the potential to damage the tunica intima (Fig. 1), the delicate inner layer of the vein (see Fig. 1), increasing the risk of patients developing phlebitis. This increases the risk
» Take appropriate action to reduce the risks of phlebitis. » Identify the risk factors and potential causes for IV cannula complications. » Reflect on improvements that can be made to nursing practice to reduce IV complications.
of further injury to the vein, such as sclerosis, infiltration or thrombosis7. Mechanical phlebitis happens when there is movement of the PIVC within the vein causing inflammation. This can be due to unskilled insertion or with placement of the cannula near a joint or venous valve, poorly secured cannulae, and manipulation of the cannula during administration of medication or fluid8. Having an insecure PIVC increases the risk of mechanical and infective phlebitis, with movement of the cannula causing migration of bacteria into the vein9. infective phlebitis is caused by bacteria entering the vein. Inflammation of the vein may begin as a non-infectious process caused by manipulation of the cannula or irritation from an infusion. Both chemical and mechanical phlebitis can produce inflammatory debris, which may serve as a culture medium for micro-organisms to multiply10. Once bacteria come into contact with the PIVC, they secrete a glue-like substance that causes the bacteria to stick to the plastic. This slimy protective substance is called biofilm. Antibiotics and white blood cells can’t penetrate this layer to kill the bacteria. Flushing and infusions can cause the biofilm to break off and travel into the patient’s bloodstream, with the associated risk of bacteraemia11. Post-infusion phlebitis is an inflammatory response occurring after a PIVC has been removed. While most low-grade phlebitis will resolve when the cannula is removed, phlebitis may occur up to 48 hours later, with some evidence of occurrence up to 96 hours later8. The Infusion Therapy Standards of Practice12 published in 2016 by the Infusion Nurses Society (INS), highly recommends the use of a phlebitis scale that is valid, reliable and clinically
Professional Development Septic thrombophlebitis Septic thrombophlebitis is a rare but serious complication characterised by venous thrombosis and inflammation in the presence of bacteraemia requiring a period of IV antibiotics and a longer hospital admission6. Assessment and diagnosis involves removal of the IV cannula; medical intervention includes ultrasound for clear diagnosis, blood cultures and commencement of appropriate antibiotic treatment.
FIG.1 Diagram of a vein showing the three tunica layers
Valve
Endothelium of tunica interna (intima) Connective tissue (elastic and collagenous fibers) Tunica media
fig. 2 ViSual infuSion PHleBitiS ScoRe (ViP) IV. site appears healthy
0
No sign of phlebitis » Observe cannula
One of the following is evident » Slight pain near IV site » Slight redness near IV site
1
Possible first signs of phlebitis » Observe cannula
Two of the following are evident » Pain near IV site » Erythema » Swelling
2
Early stage of phlebitis » Resite cannula
All of the following are evident » Pain near along the path of the cannula » Erythema » Induration
3
Medium stage of phlebitis » Resite cannula » Consider treatment
All of the following are evident and extensive » Pain along the path of the cannula » Erythema » Induration » Palpable venous cord
4
Advanced stage of phlebitis or start of thrombophlebitis » Resite cannula » Consider treatment
All of the following are evident and extensive » Pain along the path of the cannula » Erythema » Induration » Palpable venous cord » Pyrexia
5
Advanced stage of thrombophlebitis » Initiate treatment » Resite cannula
Developed by Andrew Jackson. Consultant Nurse IV Therapy. Rotherham General Hospital. NHS. UK
Tunica externa (adventitia)
feasible; for example, the Jackson VIP Scale (Fig. 2). Intravenous Nursing New Zealand13, supports the use of the Infusion Therapy Standards of Practice to promote a consistent approach to catheter management when monitoring phlebitis. Interestingly, a systematic literature review published in 201414 identified more than 70 different phlebitis assessment scales in use worldwide. Nurses still need to be aware of the treatment required for the different types of phlebitis.
Management of phlebitis Nurses should determine the possible aetiology of the phlebitis as noted below; apply a warm compress; elevate the limb; provide pain relief as needed; consider other pharmacologic interventions, such as anti-inflammatory agents; and use a visual scale, like the Jackson VIP Scale (Fig. 2), to consider whether removal (resiting) of the cannula is necessary10, 11. For example, if two of the following three are evident: pain near the IV site, erythema or swelling, no matter what the aetiology of the phlebitis, the PIVC must be removed and resited.
chemical phlebitis: evaluate the infusion therapy and need for different IV access (e.g. central venous access device), different medication, or a slower rate of infusion; determine if removal of the PIVC is needed. Provide interventions as above10, 11. Mechanical phlebitis: stabilise the IV cannula, apply heat, elevate the limb, and monitor closely. If signs and symptoms persist after 48 hours, consider removing PIVC as per Jackson VIP Scale (Fig. 2)10, 11. infective phlebitis: if suspected, (pain, erythema, swelling), remove the PIVC. Follow local policy regarding microbiology culture to identify the organism and incident reporting. Medical assessment will be required for the
initiation of any antibiotic treatment. Monitor for signs of systemic infection10, 11. Post-infusion phlebitis: if this appears to be a bacterial source, ensure that medical review is initiated, monitor for signs of systemic infection; if nonbacterial, apply warm compress, elevate limb, provide analgesics as needed, and consider other pharmacologic interventions. such as anti-inflammatory agents or corticosteroids as necessary10, 11.
Reducing the risks of phlebitis Having a skilled practitioner or IV team inserting IV cannulae is proven to reduce many complications of PIVC15. IV teams are not always practical for all settings, but having skilled, trained IV practitioners who regularly update their skills and knowledge is a necessity for improving clinical quality and reducing risk. It has been demonstrated that skilled cannulators have a significantly higher firsttime insertion rate, which is associated with a lower incidence of phlebitis and failure16.
chemical phlebitis » patients at risk may need to be referred for a central venous access device, such as a peripherally inserted central catheter (PICC) depending on the pH and tonicity of the medications to be administered7. Mechanical phlebitis » Prevent movement by carefully securing the cannula with a sterile, occlusive, transparent semipermeable polyurethane dressing9. » Ensure the cannula hub is not directly accessed close to the insertion site9. » Keep dressing dry and redress if the dressing loses its integrity. » Select the smallest practical cannula for the largest possible vein. » Avoid placing PIVCs near to joints i.e. ante-cubital fossa, to reduce irritation of the vessel wall by the tip of the cannula during movement6.
infective phlebitis As above (mechanical phlebitis), plus: » Strict hand hygiene. » Clipping excess hair from the preferred insertion site. » Ensure strict aseptic non-touch technique during insertion of the cannula. » Perform skin antisepsis with >0.5 per cent Chlorhexidine/70 per cent alcohol12, cleansing the skin with friction for 30 seconds and allow the solution to dry naturally. If a Chlorhexidine/alcohol solution is contraindicated, consider using povidoneiodine or 70 per cent alcohol wipes. » No repalpating of the preferred site after cleansing. » Use appropriate sterile IV dressing. » ‘Scrub the hub’ of the needleless connector every time the cannula is accessed with single use disinfecting agent e.g. 70 per cent alcohol wipes or >0.5 per cent Chlorhexidine/70 per cent alcohol wipe, for at least 15 seconds12. » Check the integrity of the PIVC dressing. » Carefully remove the dressing that has lost its integrity and replace with new sterile dressing, taking care not to manipulate the sited cannula. » Only use flush solutions from a single use system. Minimum of 10mL pre- and post-IV medication or according to local medication policy11. Post-infusion phlebitis A recent Australian study17 noted that the main predictor of post-infusion phlebitis was cannulae inserted under emergency situations, reinforcing the following recommendations: » Replace all PIVC inserted under emergency conditions as soon as feasibly possible, i.e. within 24 to 48 hours12. » Observe the insertion site for at least 48 hours after removal of the cannula. » Educate the patient or family on discharge about signs and symptoms of phlebitis17.
Peripheral iV cannulae (PiVc): Saving a line might just save a life. Reducing the risk of other PIVC complications
Correct PIVC placement and observation
Nurses also need to be cognisant of other complications leading to PIVC failure. A quarter of PIVCs fail through accidental dislodgement or occlusion. Infiltration and extravasation (see Definitions box), haematoma formation or thrombophlebitis and septic thrombophlebitis may then occur18. It has been suggested that the use of visualisation devices (infrared or ultrasound) can increase the success of first-attempt insertion and decrease trauma to the patient19.
Key factors to a successful infusion include ensuring correct placement and stabilisation of the cannula (with the patient reporting no pain or burning), and no swelling around the insertion site. The recommended guides should be carefully adhered to during infusion of any medication or fluid to reduce the risk of tissue injury and loss of the PIVC. The cannula insertion site should also be assessed and observed at least every four hours20. Placement of PIVCs is recommended in forearm veins as opposed to the hand, wrist or ante-cubital fossa as the forearm sites are less prone to occlusion, accidental dislodgment and phlebitis21. Nurses are well placed to advocate for their patient to have a central venous access device (CVAD) placed for the administration of vesicant medications18.
Definitions Infiltration: the inadvertent leakage of nonvesicant solution into surrounding tissue. Extravasation: the inadvertent leakage of a vesicant solution into surrounding tissue13. Vesicant: medications that can cause blistering on infusion – generally not suitable for infusion via a peripheral IV cannula13,18.
Good PIVC management Early identification and intervention are critical to prevent serious adverse events, such as extensive tissue injury or nerve injury leading to compartment syndrome requiring surgical intervention20. If a patient reports any burning or stinging at or around the insertion site or anywhere along the venous pathway: » stop infusion immediately » disconnect the IV tubing from the PIVC » attempt aspiration of the residual medication from the cannula » remove the cannula » notify the medical team or senior nurse as further intervention may be required depending on the factors related to the injury13. Elevation of the affected limb for up to 48 hours may help with reabsorption of the infiltrate. Local thermal treatment depends on the pharmacological agent infused and expert advice should be sought as to whether heat or cold is appropriate20. If an extravasation injury does occur, ensure that the appropriate documentation is completed using an approved extravasation scale and following local policy for reporting13.
REFERENCES
1. Personal anecdote of Beverley Hopper. 2. AHLQVIST M, BERGLUND B, NORDSTROM G, KLANG B ET AL. (2010). A new reliable tool (PVC assess) for assessment of peripheral venous catheters. Journal of Evaluation in Clinical Practice 16 (6), 1108-15. 3. NURSING COUNCIL OF NEW ZEALAND (2007). Competencies for Registered Nurses. Retrieved September 2016 from www.nursingcouncil.org.nz/ Publications/Standards-and-guidelines-for-nurses. 4. OLIVEIRA A & PARREIRA P (2010). Nursing interventions and peripheral venous catheter-related phlebitis. Systematic literature review. Referência: Scientific Journal of the Health Sciences Research Unit: Nursing 3(2), 137-47. 5. DOUGHERTY L (2008). Peripheral Cannulation. Nursing Standard 22 (52), 49-56. 6. HIGGINSON R (2011). Phlebitis: treatment, care and prevention. Nursing Times 107 (36), 18-21. 7. KOKOTIS K (2015). Preventing chemical phlebitis. Nursing 28 (11), 41-7. 8. MACKLIN D (2003).Phlebitis: A painful complication of peripheral IV catheterization that may be prevented. The American Journal of Nursing 103(2), 55-60. 9. HIGGINSON R (2015). IV cannula securement: protecting the patient from infection British Journal of Nursing (8)24, S23-S28. 10. MALACH T, JERASSY Z, RUDENSKY B, SCHESINGER Y ET AL. (2006). Prospective surveillance of phlebitis associated with peripheral intravenous catheters. American Journal of Infection Control 34 (5), 308-12.
Flushing protocols and administration of IV medications There is very little research and a high degree of practice variation in the maintenance of PIVC, including the role of flushing to prevent complications. It is highly recommended that nurses refer to the manufacturer’s guidelines and local organisational policy for the recommended preparation and speed of infusion in order to prevent vein injury21. For example: 1.2g Amoxicillin plus Clavulanic Acid (Augmentin). Administration notes: Inject slowly over three to four minutes22.
Good documentation Documentation is essential for accountability, as well as the maintenance of a high standard of professional practice; however, it is often
overlooked, especially when the workload is high21. The use of a pre-printed care plan can be useful. An example used in one New Zealand hospital includes documentation of: » Patient information and consent » date and time of insertion » name and signature of cannulator » location, type and gauge of cannula » indication for use. Ongoing care documentation should include: » cannula checked & cannula required » needleless access device insitu » dressing intact & dated » cannula flushed (flush solution) » VIP score & indication for use » cannula removed – including date, time and reason12,13,21.
Conclusion
Early recognition of IV complications through regular assessment and observation enables appropriate and timely intervention, minimising disruption to the patient’s treatment, improving patient outcomes, as well as reducing healthcare costs involved in extra treatment and procedural requirements and increased bed days from unnecessary complications. The following quote reinforces the intent of this article: “Penetration of a patient’s natural protective skin barrier with a foreign body that directly connects the outside world to the bloodstream for a prolonged period of time is not to be taken lightly. Insertion of an IV catheter is an invasive procedure that introduces multiple risks and potential morbidities, and even mortalities, and should be given the respect that it deserves.”23
Recommended Resources
aVataR is an Australian-based teaching and research group aimed at “making vascular access complications history”: www.avatargroup.org.au intravenous nursing new Zealand (IVNNZ Inc.) is an affiliated international member of the Infusion Nurses Society (INS) and is dedicated to Best Practice Recommendations and Standards of Practice for Infusion Therapy: www.ivnnz.co.nz infusion nurses Society (2016.) Infusion Therapy Standards of Practice Journal of Infusion Nursing 39 (1S).
About the author:
» Beverley Hopper RN MHPrac (Nursing), PG Cert (Orthopaedics), BHSc (Nursing) is the Clinical Nurse Specialist (Outpatient IV Antibiotics) at Waitemata District Health Board.
This article was peer reviewed by:
» Catharine O’Hara RN MN, Clinical Nurse Specialist (Lead) Intravenous and Related Therapy at MidCentral District Health Board’s Department of Anaesthesia and ICU » Rachael Haldane RN BN PGDip HSc, Clinical Nurse Specialist, Infusion Services, Nurse Maude, Christchurch. 11. RYDER M (2005). Catheter related infections: It’s all about the bio-film. Topics in Advanced Practice Nursing eJournal 5 (3). 12. INFUSION THERAPY STANDARDS OF PRACTICE (2016). Retrieved September 2016 from www.anzctr.org.au/AnzctrAttachments/369954-INSper cent20Standardsper cent20ofper cent20Practice%202016.pdf . 13. INTRAVENOUS NURSING NEW ZEALAND. (2012). Retrieved September 2016 www.ivnnz.co.nz/files/file/7672/IVNNZ_Inc_Provisional_Infusion_Therapy_ Standards_of_Practice_March_2012.pdf 14. RAY-BARRUEL G, POLIT D, MURFIELD J & RICKARD C (2014). Infusion phlebitis assessment measures: a systematic review. Journal of Evaluation in Clinical Practice 20 (2), 191-202. 15. WALLIS M, MCGRAIL M, WEBSTER J, MARSH N et al (2014). Risk factors for peripheral intravenous catheter failure: a multivariate analysis of data from a randomised control trial. Infection Control and Hospital Epidemiology 35 (1), 63-8. 16. DA SILVA G, PRIEBE S, DIAS F (2010). Benefits of establishing an intravenous team and the standardisation of peripheral intravenous catheters. Journal of Infusion Nursing 33 (3), 156-60.
17. WEBSTER J, MCGRAIL M, MARSH N, WALLIS M ET AL (2015). Post-infusion phlebitis: incidence and risk factors. Nursing Research and Practice, 2015. 18. SIMONOV M, PITTIRUTI M, RICKARD C, CHOPRA V (2015). Navigating venous access: A guide for hospitalists. Journal of Hospital Medicine 10 (7), 471-8. 19. SALGUIRO-OLIVEIRA A, PARREIRA P, VEIGA P (2012). Incidence of phlebitis in patients with peripheral intravenous catheters: the influence of some risk factors. Australian Journal of Advanced Nursing 30 (2), 32-9. 20. DOELLMAN D, HADAWAY L, BOWE-GEDDES L A, FRANKLIN M, ET AL. (2009). Infiltration and extravasation: Update on prevention and management. Journal of Infusion Nursing 32 (4), 203-11. 21. BROOKS N (2016). Intravenous cannula site management. Nursing Standard 30, 53-62. 22. New Zealand Hospital Pharmacists Association (2015). Notes on injectable drugs (7th ed.) Wellington, New Zealand. 23. HELM R, KLAUSNER J, KLEMPERER J, FLINT L, ET AL (2015). Accepted but unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing 38 (3), 189-203.
Professional NursingReview Development
ReaDing, Reflection, anD aPPlication in Reality
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Reading the article and completion of this Peripheral IV Cannulae (PIVC): Saving a line might just save a life learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the NZNC competencies 1.1, 1.4, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 3.1, 3.2, 3.3, 4.1, and 4.3. Please discuss all your answers with your peer/s. a
learning outcomes
Reading and reflecting on this article will enable nurses to:
» Recognise the signs and symptoms of phlebitis. » Summarise the distinguishing features of the four types of phlebitis. » Take appropriate action to reduce the risks of phlebitis. » Identify the risk factors and potential causes for IV cannula complications. » Reflect on improvements that can be made to nursing practice to reduce IV complications.
ReaDing
1 Read your organisational policy on IV cannulation, care and maintenance. Is it reflective of current evidence-based guidelines?
B
Reflection
1 Reflect on how to increase awareness of the human and financial cost of PIVC complications and failure.
2 Reflect on your own practice of caring for a patient who has an IV cannula. What was the reason for the IV cannula insertion? Was the time and date of insertion documented?
c
applying in Reality
1 Review the documentation practices in your workplace and discuss with a peer how this could be improved.
2 Identify which Phlebitis Scoring Tool your workplace uses. Discuss the advantages of using a Phlebitis Scoring Tool with a peer.
3 What are some changes that you could implement to improve patient outcomes in your workplace with regard to PIVC care and maintenance?
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Photo courtesy of ACC
Patient handling:
getting it right for both staff and patient Moving a patient without harming them or yourself is basic, but not simple, care. Getting it right requires not only good training, equipment and bedside spaces but also a good workplace culture. Nursing Review finds out more.
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very person at some point in their life or death will be moved by somebody else, says moving and handling consultant Anne McMahon. The trick is doing it safely. “We need to make sure that that event is safe, dignified and appropriate,” says the nurse who is also the chair of the Moving and Handling Association of New Zealand (MHANZ). Getting it right optimises the therapeutic potential of moving the patient and reduces the risk of falls and pressure injuries. Getting it wrong, however, may be life-altering and career-ending for a healthcare worker. Statistics from ACC indicate that too often the health sector is getting the moving and handling of patients wrong. In 2015 there were 494 new patient manual handling injury claims by healthcare workers in the acute hospital sector and 868 in the residential aged care sector. The cost to ACC in 2015 of the new and ongoing patient handling claims by healthcare workers was $3.3 million. On top of that is the personal cost – financial, physical and emotional – to the injured healthcare worker and their family. Then there are the flow-on effects on wards and rest homes when healthcare workers’ injuries and pain lead to absenteeism, burnout, staff turnover and early retirement. When all the ingredients for a good moving and handling culture are absent, the risk of a patient
falling can also increase; a 2012 report suggested that inpatient falls may cost New Zealand hospitals around $5 million a year. Not being repositioned regularly also puts patients at a higher risk of pressure injuries and the 2015 KPMG report into pressure injury (PI) reduction estimates that PIs cost the country $690 million every year. McMahon says it is no coincidence that one of the countries with the best record in reducing pressure injuries – the Netherlands – also has one of the best moving and handling programmes in the world. After specialising in moving and handling for more than a decade, McMahon says one of the key differences between New Zealand and countries like the Netherlands and the UK is regulations that help to embed moving and handling programmes into the health sector. In New Zealand there are no dedicated regulations, but there are extensive guidelines published by ACC with the most recent version – Moving and Handling People: The New Zealand Guidelines 2012 – being co-edited by McMahon. (Note ACC is currently updating the guidelines in league with Worksafe.) The need for good moving and handling strategies keeps growing as patients in our hospitals and residential aged care sector get sicker, older and larger. Clients are also being discharged earlier from hospital and staying at home longer, creating the need for greater moving and handling support in the community. So what do you need to reduce the risk to nurses and other healthcare workers of being injured by handling the people they care for? And at the same time reduce the risk of patients falling or sustaining pressure injuries because of moving and mobility issues?
Training an essential
You can’t have safe patients unless you’ve got safe staff and vice versa, says McMahon. The aim when moving patients is to maximise their function – as well as their independence and dignity – while minimising the risk to both parties. The ACC guidelines include having buy-in from senior management, the right equipment, ongoing staff training, the right assessment protocols and adequate space. Not forgetting a culture of safety where the “way things are done around here” is the safe way.
DEFINITIONS High-risk client handling tasks
Tasks that have a high risk of musculoskeletal injury for staff performing the tasks. These include – but are not limited to – transferring, lifting, repositioning, bathing patients in bed, making occupied beds, dressing patients, turning patients in bed, and tasks with long durations.
Unsafe manual lifting
Lifting, transferring, repositioning and moving patients using a carer’s body strength without the use of moving and handling equipment or aids to reduce forces on the carer’s musculoskeletal structure. Source: Moving and Handling People: The New Zealand Guidelines 2012
McMahon has put theory into practice by developing and implementing a comprehensive moving and handling programme for her employer, Waitemata District Health Board. She says the integrated policy has made a “significant difference” to the dollar cost of injuries and has led to a “huge culture change”. That culture change began when McMahon decided to rewrite the moving and handling training programme soon after becoming the DHB’s moving and handling coordinator in 2005. She decided the ‘train the trainer’-type model wasn’t adequate, wrote the strategy and approached ACC to fund a pilot strategy in 2006. The pilot was successful and remains the DHB’s current model with five levels of training. Two of these are mandatory and involve one-day day moving and handling training for new staff, followed up by an annual training session. That basic training is also supported by area, patient and task-specific training where needed, e.g. proning in ICU. A major focus of the training is communication. McMahon says the importance of this was brought home to her following a patient satisfaction study designed and delivered by her team. The semiqualitative study interviewed 65 WDHB patients and showed several outcomes from the patients’ www.nursingreview.co.nz | Nursing Review 2017 15
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perspective, including 100% satisfaction in being moved with equipment. A surprising outcome was the slight increase in anxiety for patients being moved with slide sheets rather than hoisting. McMahon says this is possibly because hoisting is a process where staff have to actively engage and communicate with patients, whereas moving patients with slide sheets can often become a secondary task and nurses can end up talking over the patient rather than to them. She adds that the moving and handling team don’t introduce any new techniques or equipment unless they have tested it on each other and are happy that it is an improvement.
Photo courtesy of ACC
Ceiling hoists and culture
A good moving and handling programme also requires the right equipment and the right infrastructure. “We can have the best training in the world but if the individual goes back to an area where the space is too small to use the equipment, well, it is pointless,” says McMahon. She says while bed technology has evolved, the space around the bed has not grown to match the amount of equipment and people needed for bedside care of today’s high acuity patients. McMahon believes ceiling hoists should be considered standard rather than gold standard, with international research indicating that the cost of investing in ceiling tracking and hoists can be recouped in three years through the reduction in injury costs. When it comes to the purchasing and upgrading of equipment like beds and hoists, McMahon believes this is best done centrally to prevent individual departments having to lobby for funding. While the equipment is purchased centrally, it needs to be safely stored closely to hand – preferably within 20m of handling areas and within 10m of nurse stations. Having the right equipment, training and environment are all part of building a culture of safety for moving and handling but the ACC guidelines point out that psychosocial factors and work climate are also important components. “Negative work climate factors, such as working irregular or long shifts and having inadequate sleep owing to long working hours, are associated with musculoskeletal problems including back pain, back injury and sick leave among healthcare staff,” says the ACC publication. It adds that negative outcomes are more prevalent when workers feel they have little control over their work and perceive their work environment as unsupportive. Psychosocial factors affecting health care workers include the type and length of work shifts, fatigue, physical and verbal abuse from clients, family members or other staff, and the type of carer role. The MHANZ chair agrees and says most staff who don’t follow good moving and handling practices don’t do so because ‘they can’t be bothered’ but instead because either they don’t know how or perceive there just isn’t the time or resource to be able to do it. “I do believe the pressure on nurses at the moment is unlike it has ever been,” says McMahon. At the same time, the average nurse is getting older and their patients are becoming older, heavier and higher acuity.
Employers’ obligations
April last year saw the Health and Safety at Work Act come into force, placing greater responsibility on employers to manage risks to their staff. Continued on next page >> 16 Nursing Review 2017 | www.nursingreview.co.nz
RESOURCES »» MHANZ Moving and Handling Association of New Zealand www.mhanz.org.nz »» ACC Moving and Handling People: The New Zealand Guidelines 2012 Internationally peer reviewed. https://goo.gl/JKAOiR »» Royal College of Nursing Guide to members on correct moving and handling techniques and employer/ employee obligations www.rcn.org.uk/get-help/rcn-advice/ moving-and-handling
Moving and handling programmes: core components POLICY: Written policy statement – including patient assessment tools and set techniques for moving clients/patients – that is endorsed and resourced by senior management TRAINING: Induction training of all health care workers involved in moving people and then annual updates EQUIPMENT: Providing equipment needed to use the set techniques, for example, ceiling tracking, hoists, mobile hoists, wheeled equipment, slide sheets, etc. ENVIRONMENT: Providing the right spaces in the facility to allow effective moving and handling, i.e. sufficient space around bed. Renovate/upgrade facilities if needed
»» A Practical Guide to Bariatric Safe Patient Handling and Mobility: Improving Safety and Quality for the Patient of Size By Susan Gallagher
CULTURE: Create a culture of safety including recognising that psychosocial factors like irregular/long shifts, inadequate sleep, high workload and staff feeling unsupported are also associated with back injuries/pain and sick leave
N.B. MANZ hopes to bring Gallagher to New Zealand for its next road show.
Source: adapted from Moving and Handling People: The New Zealand Guidelines 2012
Combined electronic risk assessment tool Since Sandy Blake was appointed clinical lead to the Health Quality & Safety Commission’s Reducing Harm From Falls programme in 2012 she has been working on testing and refining an electronic risk assessment and care plan tool using the patient acuity software TrendCare. The tool – piloted at Whanganui District Health Board, where Blake is Director of Nursing, Patient Safety & Quality – has now evolved to be a combined risk assessment tool covering falls, pressure injuries and mobility. The tool’s questions cover areas like the patient’s usual home environment, mobility, falls history, their hearing and vision, a brief neurological assessment, continence, medication history, nutrition and skin integrity.
The tool has space for comments and includes prompts and triggers for an action plan including whether a further specialised ‘mobility and manual handling needs assessment’ is required. A printout of this secondary assessment is left at the bed end and lists how many nurses and what equipment is needed to assist a patient in a wide variety of manual handling moves including rolling the patient, moving from sitting to lying, transferring to a chair and becoming mobile. Blake emphasises that it is important nurses include the patient’s family or carers in safe mobilisation plans as maintaining a consistent approach ensures the patient is confident both while in hospital and when they return home.
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iNature:
can delivering nature digitally reduce anxiety and pain? Visiting American nursing professor Margaret Hansen has set out to establish whether delivering complementary therapies – like nature and music – through mobile technologies is a feasible way of reducing anxiety and pain for surgical patients.
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he days leading up to surgery can leave patients fretful and anxious. What if listening to bamboo flute music on an iPod or viewing images of mountains or swimming turtles on an iPad could help to allay some of that fear and distress that can hinder healing? That is a question that Margaret Hansen, professor of nursing at the University of San Francisco, is keen to find out. She presented the findings of her feasibility pilot – into delivering complementary therapies via mobile technologies to surgical patients in Iceland – to the Nurse Informatics Conference, which was held in conjunction with the Health Informatics New Zealand (HINZ) conference late last year in Auckland. In 1987 Hansen was diagnosed with an malignant but operable brain tumour. In the days leading up to her surgery she was introduced to a visualisation technique aimed to help prepare her for surgery. Using the technology of the day – a cassette tape deck – she listened to around two hours of recordings that led her through visualising her blood cells attacking the tumours in her brain. She says this visualisation technique significantly reduced her anxiety and fear and improved her post-operative healing. Nearly three decades on, Hansen says this experience influenced her research into using complementary therapies to assist surgical patients. She also has a research interest in using mobile technologies to promote patient health and wellbeing and to enhance student learning. Hansen says she chose to present on her complementary therapies feasibility study, which she carried out while on a Fulbright Scholarship to Iceland, for the Auckland conference because she “really, truly believed that New Zealand has a rich history of turning to nature – both the beach and the bush – to soothe and heal”. She says there is growing evidence to back the idea of nature aiding healing and one influence on her study was a book called Blue Mind by marine biologist Wallace J Nicholls, which looks at the effects that being near or in water can have on people. Her resulting study, which randomised 105 day surgery patients in Iceland to either one of four complementary interventions (delivered via mobile technologies) or a control group, confirmed the feasibility of using the technologies in a clinical setting without disrupting staff or causing physical complications.
<< Continued from previous page The new legislation puts the onus on employers to eliminate all risks they are ‘reasonably able’ to do and otherwise to do their best to minimise the risk to their workers’ health and safety. For the healthcare sector, suggests the Worksafe website, this would include eliminating manual lifting of patients (except in life-threatening situations) by providing appropriate mechanical aids and equipment, and by training workers to ensure the equipment is used and maintained properly. Beyond the legal requirements, McMahon says investing in moving and handling programmes makes financial sense as – beyond the injury costs borne by ACC – poor moving and handling also impacts on patient outcomes, sick leave, absenteeism and retention of staff.
And although the pilot study didn’t show any statistically significant differences in anxiety, pain levels, or perceived self-efficacy between the four intervention and one control group, there were “some interesting trends towards significance”. In addition, among the group participants there were statistically significant findings, especially in the increase in perceived self-efficacy scores. Hansen believes that continued empirical research into the helpful effects of nature for peri-operative patients coping with anxiety and pain, and self-efficacy in healing, is merited. The four interventions used in the study, published in 2015 in the Journal of the International Society for Complementary Medicine Research, were: audio relaxation technique (ART) or music intervention (MI), both delivered by iPod, or a nature video app with music (NVAM) or nature video app without music (NVA) that were both delivered on an iPad. The participants were encouraged to listen and/or view the interventions twice a day – for a minimum of 15 minutes each time for each of the four days prior to surgery day and each of the five days following discharge from hospital.
Investing in moving and handling should also be seen as an ethical requirement, believes McMahon. Evidence worldwide indicates that injuries and pain are one of the major reasons nurses leave the profession. “As a middle-aged woman you are going to find it very difficult to prove that that degeneration in your spine that comes up on a scan is due to moving and handling and not just your ageing.” As MHANZ chair, she would like to see employers and professional organisations take leadership in the area so, in particular, moving and handling practice became consistent and regular nationwide – and ideally a requirement for registration and ongoing competence. She says at present staff training programmes and supporting infrastructure vary widely across
the country’s 20 DHBs and the situation is more problematic again for nurses and carers working in the residential aged care and community sector. Her vision is to see district health boards across the country become centres of excellence for their regions and hubs for a national moving and handling programme with consistent training, assessments and auditing so standards could be measured and improved. “I want to make nurses’ (and other workers’) lives easier, and their working lives longer and more productive, while also making the environment safe for patient care,” says McMahon. “Otherwise we are turning our nurses into patients.”
www.nursingreview.co.nz | Nursing Review 2017 17
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Food for thought:
can nutrients nurture better mental health? When people are suffering from a mental illness, eating healthily often falls by the wayside. But what if nutritional deficiencies are a contributing cause in the first place? Nursing Review talks to psychology professor Julia Rucklidge about the links between nutrition and mental illness.
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laims about wonder foods that can soothe nerves, enhance mood and reduce stress have been around since time immemorial. Julia Rucklidge is no believer in there being one magic ingredient or wonder food. “I just don’t think it’s out there,” says the professor of clinical psychology at the University of Canterbury. But the researcher is increasingly convinced that there are strong links between nutrition and mental illness. For the past decade she has been running randomised controlled trials (RCT) to investigate the impacts of a cocktail of micronutrients on mental health issues, from ADHD (attention deficit hyperactivity disorder) to the anxiety, stress and trauma associated with the Canterbury earthquakes. Her findings, which have been published in the British Journal of Psychiatry, saw her receive the New Zealand Psychological Society’s Ballin Award in 2015 for contributions to psychology and a 2014 TEDx talk on her work has been viewed more than 350,000 times – and that number is still growing. Rucklidge was initially very sceptical that nutrients could be effective in helping to treat mental illness. “I thought if it was that simple we would have figured this out already.” But prompted by initial positive findings by her PhD supervisor back in her native Canada – and frustration at poor outcomes from conventional treatments for ADHD – she began her own research in the field upon arriving in New Zealand (see box). “I’ve now been running clinical trials over the last 10 years and all our data are very robust in finding that, over and over again, giving broad-spectrum micronutrients – 36 vitamins and minerals in 18 Nursing Review 2017 | www.nursingreview.co.nz
combination with no one magic ingredient – can help many people (experiencing mental illness). Certainly not everyone is cured by nutrients, but we can help a lot.”
NO SINGLE ANSWER
Rucklidge is quick to point out that she does not see nutrition as a standalone treatment for mental illness. Neither does she believe that bad diets, or nutritional deficiencies, are the root causes of mental illness, but are instead just one more contributing factor. Her research trials focus on the impact of that one variable – taking micronutrients – but in the ‘real world’ she advocates a multi-layered, evidence-based approach to preventing and treating mental illness, including lifestyle factors such as exercise and eating healthily (adding supplements when required), and using stress reduction techniques such as mindfulness and psychological therapies such as cognitive behaviour therapy (CBT). She is also not advocating that people who are currently on medications should stop taking them and swap to micronutrients (any change of medication should always be discussed with the patient’s prescriber and, if undertaken, done slowly and under close professional monitoring). But she would like to see a shift to people being prescribed, or seeking out, medications such as antidepressants only when other approaches have been deemed unsuccessful, and says, “I think we need to stop seeing them [medications] as frontline treatment.”
ADHD study Rucklidge’s largest published study to date, in the British Journal of Psychiatry in 2014, was a blinded, randomised, controlled trial looking at the impact of a nutrient supplements on 80 adults with ADHD who were not currently taking any psychiatric medications. For eight weeks 42 of the participants took a broad-spectrum micronutrient formula (15 capsules a day of 14 vitamins, 16 minerals, three amino acids and three antioxidants) and the other 38 took 15 placebo capsules (containing a small amount of riboflavin to mimic the smell and urine colour associated with taking vitamins). The study found significant differences in self and observer ADHD rating scales between those who were taking the active supplements and those who were not. Clinicians did not observe differences between the groups on ADHD rating scales but did rate those taking the micronutrients as being more improved in their global psychological functioning and their ADHD symptoms. Further analysis also found a greater improvement in mood for the participants with moderate to severe depression who were taking the active capsules.
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She, for one, believes that many medications are oversubscribed, with one in eight New Zealand adults currently taking antidepressants and about a quarter of a million Kiwis being on prescription sleeping pills. “We know that the data is very clear that medications (like antidepressants) are very effective in the short-term,” she says. But people are often on medications long-term and it is the long-term efficacy data published within the past decade that Ruckledge believes people should be concerned about, as this indicates, for example, that in the long-term antidepressants are having little impact on depression recovery and relapse rates.
WHY MICRONUTRIENTS?
So if taking a cocktail of micronutrients is having an effect on some people’s mental illnesses, it begs the question: why does it work? “That is the million-dollar question,” says Rucklidge. “We are trying to figure that one out – we have lots of ideas and hypotheses about why [micronutrients] might work.” One hypothesis is that people aren’t eating diets as rich in nutrition as they once did. Epidemiology studies have indicated that the more that people eat a modern western diet – high in processed foods, refined grains and sugary drinks and low in vegetables and fruits – the more likely it is that mental health issues will emerge. Rucklidge points out there are a host of other factors contributing to the rise in mental health issues – including poverty, genetic predisposition, the stress of modern life and domestic violence – but eating a sensible, whole-food diet that is high in fruit and vegetables may contribute to curbing the trend. She adds that even people who do eat well may not be getting the nourishment they did a century ago because of factors such as mineral depletion in the soil resulting in less nutrient-dense plants, and an emphasis on appearance and shelf-life over the nutrient values of food. So some people, she argues, because of their genetic programming, may be more vulnerable
to developing mental illnesses because they are getting insufficient nutrients for their metabolisms – even if they are eating what are considered ‘good’ diets. Supplementing those people’s diets with micronutrients may potentially correct that nutrient imbalance. Rucklidge points to the work of Bruce Ames, a biochemist and emeritus professor at the University of California, Berkeley, whose research has included looking at the role that the 30 essential vitamins and minerals play in the formation of proteins and enzymes. Ames’s findings include that high doses of some vitamins could successfully treat more than 50 genetic diseases, particularly inherited metabolic diseases caused by defective enzymes, and he believes that eliminating vitamin and mineral deficiencies in the general population may restore what he calls “metabolic harmony”. Rucklidge says this makes her team wonder whether Ames’s work also applies to mental illness, because vitamins and minerals are required for the enzymes needed to make neurotransmitters such as serotonin, dopamine and adrenalin. “So are we [with the broad-spectrum supplement] providing the nutrients necessary for these neurotransmitters? Very potentially, yes.” Likewise, they hypothesise, they could be helping to feed the mitochondria that are the energy factories of human cells and possibly helping to overcome some people’s issues with the gut absorption of nutrients. The micronutrient formulas that Rucklidge uses for the trials (she points out that neither she nor the university sells or makes money from the brands they use) take a ‘shotgun’ approach by delivering 14 vitamins, 16 minerals, three amino acids and three antioxidants in much higher doses than you would find on your supermarket shelves. The research team doesn’t know which of the array of shotgun pellets, i.e. ingredients, are making a difference – or what dosage – and she says it may be that different ingredients are important for different people. In the future, researchers may be able to personalise micronutrient formulas to meet an individual’s needs based on their genetic profile and nutrient levels. “But we are not there yet so we take the shotgun approach that our bodies have evolved to know what to do with nutrients – so those you don’t need you will pee out.” She says that to date they have observed no side effects from their research participants and are currently monitoring and collecting data on long-term users. Taking high-dose micronutrients poses potential risks for some people – for example, those people with genetic disorders causing copper metabolising difficulties or haemochromatosis (iron overload).
More information: »» International Society for Nutritional Psychiatry Research Lists research published in the area of nutritional approaches to the prevention and treatment of mental disorders www.isnpr.org »» Mental Health and Nutrition Research Group, University of Canterbury Information and contact details for Julia Rucklidge’s research projects www.psyc.canterbury.ac.nz/research/Mental_Health_and_Nutrition/index.shtml »» TEDx Talk: What if nutrition could treat mental illness? by Julia Rucklidge (2014) www.youtube.com/watch?v=3dqXHHCc5lA
EATING OURSELVES BETTER
Can we just eat our way to better mental health? Rucklidge says she can’t recommend the perfect diet for better mental health – the clinical psychologist says it isn’t her area of expertise. Research into different dietary regimes also indicates that a person’s genotype may influence why some lose weight under diet ‘x’ and others don’t – similar effects are likely to apply to any mental health benefits. “But what I can say very confidently is the more you eat crap food, the worse you are going to feel. And there isn’t a single study out there that shows the modern western diet has been of great assistance to us.” So the simple message she would share is for people to reduce the amount of processed food they eat. “That is a general comment I can feel confident about, as I haven’t seen any studies that show eating highly processed, packaged foods is having a wonderful outcome for people.” She also endorses food activist Michael Pollen’s simple guide Eat food. Not too much. Mostly plants. But Rucklidge’s research, and that of others interested in the field, indicates that what people are eating right now might not adequately meet the nutritional needs of those with mental health issues. Some people may be able to meet those nutritional deficiencies by dietary change, but Rucklidge believes, after observing hundreds of people in her studies, that other people may need to take additional nutrients, probably because of their particular genotype. “I’ve seen some people on some unbelievably excellent diets – diets that I could not fault – who have made all the lifestyle changes, yet they are still depressed or anxious. But they have had favourable responses to taking broad-spectrum micronutrients.” Food for thought indeed.
Quake stress study Another study compared the impacts of two micronutrient formulas on Christchurch adults who were experiencing heightened anxiety or stress two to three months after the February 2011 earthquake. The 91 adults were randomly assigned to take either an over-the-counter micronutrient formula, a lower dose of a specialist micronutrient formula, or a higher dose of the specialist micronutrient formula. All three treatment groups were monitored during the one-month trial and for one month afterwards. All participants experienced significant declines in psychological symptoms but those taking specialist micronutrients experienced a greater reduction in intrusive thoughts, with the high-dose specialist micronutrient group reporting greater improvements in mood, anxiety and energy. A year after completing the study, 64 of the original participants (plus 21 of the 29 non-randomised controls) were reassessed. The study found that all groups had experienced significant psychological improvements, but treated participants had better long-term outcomes and those who had stayed on micronutrients (or stopped all treatment) reported better functioning than those who had switched to other treatments, including medication. www.nursingreview.co.nz | Nursing Review 2017 19
Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy PROFESSIONAL DEVELOPMENT
Nursing in China and New Zealand: what are the issues?
A leadership course last year led to a nursing director from China experiencing her first taste of nursing beyond China and some Kiwi nurse academics experiencing their first teaching outside New Zealand. In the following articles they share some nursing insights from this cultural exchange.
Baby booms to delirium: an experience of overseas dialogue in nursing practice Two Kiwi nursing academics invited to China to teach an acute care nursing workshop were nonplussed to find themselves also quasi-advisors on managing nursing shortages in the wake of China’s one-child policy coming to an end.
Bao’an was our first experience of teaching outside New Zealand and it followed meeting Zheng Ying Wang, the nursing director of Bao’an Central Hospital, earlier that year, when she undertook a 12-week Leadership and Management Workshop offered by Waikato Institute of Technology (Wintec) in Hamilton (see related article). She invited us to conduct a workshop in Bao’an on a variety of different topics focusing on acute care. We arrived in Shenzhen, a city of 20 million people just north of Hong Kong, in June and spent a week working with our Chinese nursing colleagues and also meeting several times with the hospital’s management team. We delivered sessions on the New Zealand health system, delirium, research, family-centred care and the development of critical thinking through simulation. We found we shared many of the same nursing interests and concerns and discovered many similarities and differences in nursing management and nursing culture.
THE NURSING WORKFORCE Jolanda Lemow
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Jenny Song
n our address to a group of nurses from the 600-bed Bao’an Central Hospital we mentioned that our local Waikato Hospital also had 600 inpatient beds, and a nursing staff of 2,260. There was a collective gasp from the audience. It was this nurse-to-patient ratio that elicited this response. Their hospital serves a population of 580,736 in the Bao’an district of the southern Chinese city of Shenzhen. The hospital has a staff of 1,564, but only 515 of these are nurses – and this figure includes nurses working in the community. This made us realise how lucky we are in New Zealand, as in China a registered nurse’s patient load can be anywhere between 10–20 patients.
The surprise at New Zealand’s nurse-to-patient ratios led to conversations with the nurses and the management team on how to manage staff shortages. We were surprised to find ourselves in this advisory role but discussed our experiences of staff shortages and potential ways of managing them. Hospital management told us that Bao’an is facing a critical nursing shortage. Ten percent of the nursing workforce is pregnant or planning to have a baby within the next year. This is in direct response to the Chinese government’s recent decision to end its onechild policy and allow families to have two children. The nursing shortage is compounded by the fact that in China most nurses retire around the age of 50. There was mutual amazement when we compared this with the New Zealand nursing workforce, in which 43 per cent of nurses are aged 50 years or older.
20 Nursing Review 2017 | www.nursingreview.co.nz
The nursing shortage, and accompanying workload issues, were areas of great concern to the management team of Boa’an Central Hospital. We had conversations with the hospital leaders around effective ways of using available nursing resources, such as having agency nurses or a casual resource pool. We thought this might draw interest from our Chinese colleagues. However, it became obvious that there is no one-size-fits-all solution to the challenges of a nursing workforce shortage, and the concept of a pool of nurses was difficult for us to convey to the management team. The chance to further discuss such nursing concerns would have helped us critically examine the nursing context in China and gain more insights into challenges like China’s nursing shortage. Alongside these meetings we were delivering education sessions to groups of around 100 nurses. Prior to arriving in China we had identified potential challenges, including presenting to such large groups of nurses, the language of delivery, and whether the New Zealand-developed content would make sense in China. The sessions were to be conducted in English, as all nurses attending had indicated this was what they wanted. However, soon into the first session it became apparent that many nurses did not have the level of English required. This resulted in the two of us delivering the sessions in English, but with Jenny (a native Chinese speaker who has lived in New Zealand for the past 13 years) immediately translating what we said into Chinese.
THE CHALLENGES OF TEACHING DELIRIUM ASSESSMENT IN THE CONTEXT OF CHINA Our first session was on nursing critically ill clients with acute confusion or delirium. Delirium is a word used to describe a state of acute confusion in a client, which is a common and
PROFESSIONAL DEVELOPMENT Group at Bao’an Central (front row from l-r Zheng YIng Wang, Jenny Song, Jolanda Lemow, Mr Zhou. Bao’an Hospital CEO.
severe clinical concern particularly in intensive care units (ICUs). Recent Chinese research by Zhang et al. has found that delirium contributes to a longer duration of ventilator use and high mortality rates in ICUs. However, other research indicates that nurses in China lack the knowledge and skills required to assess and manage clients with delirium. The Confusion Assessment Method (CAM) is the most widely used assessment tool for an effective and accurate detection of delirium by health professionals. During the delirium session, built around the CAM assessment tool, we discussed the nursing assessment skills needed to manage patients’ care, such as observing skills, communication skills and a holistic approach to assessing a patient’s mental status. All the Chinese nurses attending were interested in delirium and actively shared clinical stories and personal experiences of working with clients/family members with acute confusional mental status. The immediate challenge for us though was discovering the cultural differences that could affect the nurses’ understanding of such a westernised method of assessing delirium.
MODIFICATIONS NEEDED FOR CULTURALLY APPROPRIATE LANGUAGE While it can be argued that using CAM to assess delirium is relevant in both western and Chinese contexts, we discovered that Chinese nurses could benefit from some modifications to the tool. CAM was developed in a western context and has a series of questions and instructions written in English that are used to determine a client’s level of orientation. Some questions, such as inattention assessment questions that ask clients to count the letter ‘A’, must be modified to suit Chinese patients. So not only does the tool’s language need to be translated into Chinese, but the content also needs to be adapted.
We encouraged the Chinese nurses to review CAM and to consider how it could be adapted to meet their hospital’s needs. Adapting western tools to fit into the Chinese context has been done before, but it is not a simple process and requires intensive translation and a robust assessment of content validity.
FAMILY-CENTRED DECISION-MAKING IN TRADITIONAL CHINESE CULTURE We also identified that family-centred decision-making is an important concept in traditional Chinese culture. Chinese people have strong family ties, with most patients accompanied by and cared for by their family members when in hospital. It is quite common for a patient to have more than one family member staying with them throughout their hospital stay. It is also expected that family members will provide basic patient care, such as washing, feeding and toileting. So when teaching the nursing management of delirium, we emphasised the importance of family education and family-centred decisionmaking. Providing information on delirium to family members can increase their understanding of the patient’s health situation and directly reduce their distress. This approach helps to improve a family member’s competence and confidence in providing safe and effective care and
can also empower them in family centred-decision making. We were also asked to deliver a session on client-centred or patientcentred care. Given that family members were present for almost all health professional interactions with patients, we chose to focus on familycentred care. This seemed to be a novel idea for many of the audience, with one nurse asking, “If my patient has a headache, I give them a pill. What am I supposed to do with the family?” The importance of providing ongoing explanations and education to family members as well as to patients led to good discussions and hopefully some changes in nursing practice.
RESEARCH AND SIMULATION The other topics we discussed – nursing research and assessment through simulation – were also well received. Informing nurses on research methods and clinically focused research generated many potential topics for future research. This was an area in which the management team was particularly interested and is an area for future collaboration and development. Simulation is also an area of potential growth in China as, while there appeared to be an understanding of how simulation can be used to develop practical clinical skills, there was little understanding of how it could be used to develop
communication skills, teamwork and critical thinking. We only touched on these topics in our teaching but simulation is definitely worthy of further discussions. The workshop sessions were very successful. Participant feedback showed they appreciated the opportunity to gain valuable clinical knowledge and skills in nursing critically ill patients with acute confusion. Some ICU nurses mentioned in group discussions that they now had increased confidence in their nursing assessment and management of delirium skills and in family-centred care. Some nurses even mentioned that they would like to step up to work on the CAM assessment tool and teach the valuable skills to their colleagues. Some nurses discussed research they could initiate within their areas of practice. We believe that we have made a difference to nursing practice in Bao’an Central Hospital and therefore a positive difference to the nursing care delivered to patients and their families. We appreciate the amazing hospitality given by our Chinese colleagues and the leaders of Bao’an Central Hospital, and we also appreciate the privileged insight we were given into nursing in China. AUTHORS: Jolanda Lemow and Jenny Song are academic staff members at Wintec, Hamilton. To see references, go to the online version of the article at www.nursingreview.co.nz.
www.nursingreview.co.nz | Nursing Review 2017 21
Articles, profiles and opinion pieces from across the nursing spectrum
Practice, People & Policy PRACTICE
Nursing in China: how does it compare?
A baby boom, not retiring nurses, is one of the major nursing workforce issues in China. Chinese nursing director Zheng Ying Wang reflects on other differences and similarities in nursing practice between our two countries.
L
ast year I was given the opportunity to attend a nursing leadership programme in New Zealand – my first experience of education outside China. China is undertaking significant reform of its healthcare system to promote an international level of health practice. The government realises that nursing education and practice need to be further developed to meet the healthcare needs
Zheng Ying Wang
22 Nursing Review 2017 | www.nursingreview.co.nz
of an ageing population and growing demand for quality nursing care. After 23 years in nursing my first overseas education opportunity came when the Shenzhen city government selected me as one of 10 nurses and midwives to participate in the Waikato Institute of Technology’s Leadership and Management programme (see story page 20). Even though we all came from a variety of different backgrounds we were all nurse managers in one way or another. During the 12 weeks I participated in lectures and workshops on topics such as the New Zealand health system, nursing ethics, communication, client-centred care, nursing assessment, critical thinking and simulation. I also visited primary healthcare settings, a variety of Waikato Hospital units, Hospice Waikato and some aged care facilities. I got to understand the New Zealand healthcare system’s structure and nursing practice and learned about the similarities and differences in nursing practice and culture between China and New Zealand.
BABY BOOM HITTING NURSING WORKFORCE Although there are staffing and workload issues in both countries, I think it is more serious in China. This is because of the two-child policy recently introduced by the Chinese government, where families are now allowed two children rather than just one. Following last year’s workshop I returned to China, where I’m the nursing director at Bao’an Central Hospital, and did some investigations into the current nursing workforce in the Bao’an district of the city of Shenzhen*. This was six months after the implementation of the government’s new twochild policy. I found that 10 per cent of the nurses were pregnant and more than 20 per cent intended to conceive in the next six months. This means that many nurses are going to be on six-month maternity leave around the same time, which will result in a critical nursing shortage in China. According to the National Health and Family Planning Commission of the People’s Republic of China (NHFPC) the ratio of beds to nurses should not be less than 1 to 0.4. This means that if a 40-bed ward is full it should be allocated at least 16 nurses in total to cover all shifts across the week.
PRACTICE
In reality, there are still many wards that have insufficient nurses to meet this benchmark. It is also stated by the government that a nurse should not be nursing more than 15 patients. This is in comparison with a nurse in New Zealand who will have a patient load of four to five patients. At present nurses in China can only work in one health institution and most institutions only employ full-time nurses. However, Guangdong provincial health authorities are now considering the options of employing part-time nursing staff. This may promote a better lifestyle for nurses but may not solve the issues of the nursing workforce shortage.
NURSING SCOPES AND PROGRESSION In New Zealand every nurse has a scope of practice under the Health Practitioners Competence Assurance Act (2003) and a registered nurse progresses from competent to proficient to expert. This is similar to what happens in China, where the progression is from junior nurse to senior nurse to nursing expert. In China nurses can be promoted to senior nurses or nurse-in-charge by passing an examination held by the NHFPC. It is difficult to reach a senior professional title in China. There is a four-part examination, as well as a requirement to pass some professional papers (including research) and complete a certain number of night shifts. Just passing these requirements does not guarantee a position as a chief nurse or associate chief nurse. In Guangdong Province there is an expert review panel made up of chief nurses. These panels assess potential applicants based on individual oral presentations and face-to-face interviews.
nursing assessments. These are the cards that nurses have attached to their pockets showing information about pain assessments, phlebitis assessment, falls risk and so on. Chinese nurses also have many guidelines for their work; however, they are required to memorise these. I have considered the possibility of adapting these cards for Chinese nurses to use, to save them time, and to give them more time to care for their patients. Both China and New Zealand use many of the same nursing assessment skills and tools. For example, we use the same pain score scales, falls risk assessment tools and pressure ulcer risk tools. We follow identical infection control guidelines and apply the same nursing management theories as well.
WESTERN AND CHINESE MEDICINES I discovered that New Zealand pharmacists have an important role and are active in medication management. In Chinese hospitals some pharmacists work at the hospital’s western medicine pharmacy and some, especially trained pharmacists, work at the hospital’s Chinese pharmacy. We use both western and Chinese medicines. In Bao’an Central Hospital only controlled medications are locked in cabinets and are
counted and recorded every day. To promote safe nursing care, Chinese nurses will need to utilise technological advances, such as New Zealand’s computerised medication storage and dispensing systems, while working closely with other health professionals, such as pharmacists and doctors. This 12-week nursing workshop gave me a valuable experience of overseas nursing practice and encouraged me to work on innovative ways to promote safe and quality nursing practice in China. As the nursing director of Bao’an Central Hospital, patient safety and the competency of nursing staff are always my major concerns. Giving nurses opportunities for professional development is important. Even though there are many challenges in promoting nurses’ learning – including a lack of time available for studying and increased workload – continuing education must be implemented to equip Chinese nurses with sound nursing knowledge and skills to meet patient needs. *Shenzhen is a city of 20 million people just to the north of Hong Kong in the southeast China province of Gaungdong. References for this article can be viewed in the online version of the article at www.nursingreview.co.nz.
… many nurses are going to be on six-month maternity leave around the same time, which will result a critical nursing shortage in China. NURSING CARE: SIMILAR BUT DIFFERENT During the past 20 years person-oriented care has been significantly developed in China, yet I was impressed with how patient-centred care is emphasised in New Zealand and how much information is given to patients. The concept of culturally safe care was new to me. Chinese nurses need to understand that culture is a broad concept including beliefs, values, knowledge, customs, and life practice. Therefore, nurses need to take into account the diverse human care needs and consider cultural safety principles in their nursing practice. In New Zealand there are multiple ‘flashcards’ that nurses can use to help them perform ongoing www.nursingreview.co.nz | Nursing Review 2017 23
EVIDENCE-BASED PRACTICE
Is what’s good for the heart
also good for the brain? Does taking statins reduce the risk of dementia as well as cardiovascular disease? This edition’s Clinically Appraised Topic (CAT) looks at the evidence.
Outcomes: Primary outcomes: Objective diagnosis of dementia, AD, or vascular dementia; change in accepted objective and standardised tests of cognitive performance; and the incidence and severity of adverse effects. Secondary outcomes: Change in cognitive status accounting for prior cholesterol level, ApoE genotype and cognitive level; quality of life; change in ADLs; and change in behaviour.
STUDY VALIDITY CLINICAL BOTTOM LINE There is good evidence that the taking of statins later in life by people at risk of vascular disease has no more impact on preventing cognitive decline or dementia than a placebo. A healthy lifestyle is considered important for reducing dementia risk but more research is needed to clarify the relationship between cholesterol and development of dementia in other populations.
CLINICAL SCENARIO Dementia is a significant healthcare concern and advising people of effective prevention strategies is part of your nursing role. You have heard that cardiovascular risk factors such as high cholesterol are also risk factors for developing dementia and wonder if people at risk of dementia because of their age should be encouraged to take cholesterol-lowering medication such as statins. You decide to review the evidence.
QUESTION Do statins taken by people late in life prevent dementia, compared with no treatment or placebos?
SEARCH STRATEGY PubMed- Clinical Queries (Therapy/Narrow): dementia AND statins
CITATION McGuinness B, Craig D, Bullock R & Passmore P, Statins for the prevention of dementia, Cochrane Database Syst Rev 2016 (1), 10.1002/14651858. CD003160.pub3
STUDY SUMMARY A Cochrane systematic review evaluating the efficacy and safety of statins for the prevention of dementia in people at risk of dementia due to their age and to determine whether the efficacy and safety of statins for this purpose depends on cholesterol level, apolipoprotein E (ApoE) genotype or cognitive level. Inclusion criteria were: Type of study: Randomised, double-blind, placebocontrolled trials in which a statin was given for at least 12 months. Participants: People with normal cognitive function and of sufficient age to be at risk of Alzheimer’s disease (AD) (mean age 65 years or over) including those with evidence of, or at high risk of vascular disease. Intervention: Any statin given within the licensed dose range compared with a placebo. 24 Nursing Review 2017 | www.nursingreview.co.nz
Search strategy: The authors sought eligible studies via ALOIS (the specialised register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, trial registers and sources of grey (unpublished) literature until 11 November 2015. Review process: Two authors independently searched and screened potentially relevant studies for eligibility. Disagreements were resolved by discussion amongst four authors. A standardised form guided data extraction. Quality assessment: Included studies were assessed for risk of bias using the following criteria: random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessment, incomplete outcome data and selective reporting. Overall validity: A high-quality review involving two randomised, controlled trials (RCTs) at low risk of bias.
STUDY RESULTS After removal of duplicates, 288 articles were screened for eligibility. Full text of 36 articles were assessed, from which two RCTs involving 26,340 participants were included in this review. Participants were between 40 and 82 years old with 44 per cent (11,610 participants) 70 years or older. On study entry, participants’ mean total cholesterol was 5.9 mmol/L (standard deviation (SD) 1.0) in one study and 5.7 mmol/L (SD 0.9) in the other. Mean follow-up was 3.2 years in one study and five years in the other. There was no difference in the incidence of dementia between those given statins and those given placebo (one study), the quality of this evidence was graded as moderate because of wide confidence intervals (refer table). Both studies assessed cognitive function and found no significant differences between those who took statins and
those in the placebo group for the five different cognitive function tests involved (high-quality evidence). Results were not suitable for meta-analysis. Adverse events were low in both the statin and placebo groups. There was no difference between groups in the risk of withdrawal from the trial due to adverse events (refer table).
COMMENTS: »» These results are an example of an intervention that is biologically plausible and appeared promising based on results from observational studies but testing via randomised controlled trials has failed to identify any benefit. »» Participants were at moderate to high risk of vascular events and the results may not be generalisable to people of low vascular risk. »» Risk factors for dementia are complex and no single factor has been identified as the cause of dementia. Limitations within the primary studies means there is still much to know about the relationship between cholesterol and development of dementia, including the benefit of starting statins at an earlier age and in those with a family history of AD. In the meantime, Alzheimers New Zealand 1 recommends lifestyle changes to reduce the risk of developing dementia in later life that include following a healthy diet.
REFERENCE 1. Alzheimers New Zealand. Reduce the risk of developing dementia. Available from www.alzheimers. org.nz/about-dementia/reducing-the-risk. Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD candidate, Deakin University, Melbourne. cwensley@deakin.edu.au.
Table: Summary of results Quality of the evidence**
Statistical
heterogenity I2
Odds ratio (95% CI)
No. of studies (no. of participants)
Outcome
Moderate
NA*
1.00 (0.61 to 1.65)
1 (20,536)
Incidence of dementia
High
0%
0.94 (0.83 to 1.05)
2 (26,340)
Risk of withdrawal due to adverse events
*NA: Not applicable, variability in results between studies is only calculated when results from two or more studies are statistically combined (meta-analysis). **Grade Working Group criteria: High quality – further research is very unlikely to change reviewer’s confidence in the estimate of effect.
Nursing taskforce on task
COLLEGE OF NURSES
JENNY CARRYER reports back on the issues, goals and tasks on the agenda of the national nursing taskforce.
N
urses will be aware that Health Workforce New Zealand (HWNZ) is currently supporting taskforces addressing workforce challenges for nursing, medicine, midwifery and the kaiāwhina workforce. As chair of the National Nurse Leaders group, I have been chairing the nursing taskforce (known as the Nursing Workforce Governance Group) and would like to take this opportunity to share the project with the wider profession. The five major issues addressed by the taskforce in 2016 were:
2. Aged care
1. Primary health models of care or models of service delivery
Levers to assist the nursing aged care workforce are considered to be: »» Nurse Entry to Practice (NETP) funding »» the Voluntary Bonding Scheme (more dollars for working in aged care) »» removing aged care from Immigration’s Essential Skills in Demand (ESID) Lists (noting this will need to be a staged approach) »» a review of the allocation of postgraduate nursing funding.
We agreed that the primary health care and community health nursing workforce needs to be better aligned to the needs of the community and more able to deliver the patient or person-centred care signaled by the refreshed 2016 New Zealand Health Strategy. This strongly echoes the goals of the Investing in Health document produced by the Ministry’s Primary Health Care Nursing Expert Advisory Group back in 2003. We consider that current, siloed-approaches to funding, contracts, and some employment relationships are limiting the best deployment of primary health care nurses. Communitybased and primary health care nurses should be pivotal to the achievement of better integrated services across the full continuum from wellness promotion to management of long-term conditions. We are not convinced that levers are in place to ensure the necessary changes. Issues discussed by the taskforce include: »» the need for greater investment and uptake in postgraduate funding of primary health care nurses »» increased deployment of nurse practitioners (NPs) in general practice and in boundary-spanning roles between primary, aged care and child health settings »» more courageous and speedy consideration of innovative models of service delivery »» better alignment between aged care and primary health care nursing
The aged care nursing workforce is forecast to decline at the same time as demand is increasing due to the growth in the older population and its increasing share of the total population. Aged care considerations should be refocused to be: »» inclusive of all of the aged care workforce »» focused on the care that people require wherever they are »» mindful that the aged care workforce needs to be linked to primary and community teams.
In addition it is agreed that: »» there should be more Māori/Pasifika nursing academics as this is fundamental to student retention in nursing degree programmes »» areas/populations should reflect the demographics they serve e.g. Auckland has a high Pasifika population.
4. Nurse practitioners Members are universally committed to the need to support and increase the NP workforce, especially, but not exclusively, in the areas of primary health care and aged care.
5. Review of vocational training funding
It was noted by the taskforce that pay parity is not expressed as an issue in the workforce in the Health of Older People’s strategy.
3. Māori nursing workforce The taskforce has accepted a goal of parity by 2028 between Māori nurse numbers in the workforce and the percentage of Māori in the population. This is an ambitious but critically important goal. Four levers have been accepted so far to encourage the growth of the Māori nursing workforce: »» Establish and lead a cross-government working group. »» Strengthen DHB regional planning guidance towards increased participation of Māori and Pacific in the health workforce. »» Require organisations receiving HWNZ funding to have an action plan for workforce diversity. »» Publish a biennial report tracking progress towards the Māori nursing workforce matching the proportion of Māori in the population.
The taskforce agrees that the historical patterns for allocating post-entry education funding (of the health workforce) should be examined to see how closely the funding allocation aligns with meeting the needs of the population in the most cost-effective manner. Opportunities exist to influence the future direction of postgraduate funding for nursing, especially in the context of the 2016 New Zealand Health Strategy and HWNZ’s review of medical vocational funding. We see postgraduate funding as crucial to ensuring nursing is well placed to contribute effectively to future health needs, and we will remain fully engaged in all relevant discussions.
IN SUMMARY The nursing taskforce will consistently argue for a whole-of-workforce, fresh approach to aligning the workforce to meet identified person, patient and community needs. Instead of funding, training for and replicating old styles and roles of delivery, we see value in asking what ‘disruptions’ would support cost-effective and more sustainable service delivery. AUTHOR: Professor Jenny Carryer is the Executive Director of the College of Nurses and Professor of Nursing at Massey University’s School of Nursing.
www.nursingreview.co.nz | Nursing Review 2017 25
IS THIS NEW ZEALAND’S
BEST O P E R AT I O N ? The patients we’ve cared for over the years say so. In fact our latest patient satisfaction surveys tell us, again, that Southern Cross Hospitals is up with the best in Australasia. They rate us highly for our level of care, our modern facilities, medical technology, and of course our people. It’s why we’ve become NZ’s largest notfor-profit private hospital network with hospitals throughout New Zealand. Our objective has always been, and always will be, to offer high quality surgical care at the lowest price we can. So, when you’re considering where to have your operation, ask your doctor if one of ours is an option. If you’re looking for the best.
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