Nursing Review issue 2 2017 by NZME. Educational Media

Issue 2 March/April 2017

NursingReview $10.95

New Zealand’s independent nursing Series

Learning & Management Time management tips & HCA training

Patients & PJs An unhealthy relationship?

Students Reflections & study tips

Special report from Manila Filipino nursing Innovation & Technology App of the Month, case studies & Webscope

Free 60-minute

Professional Development learning activity

International Nurses Day

Kiwi flavour

www.nursingreview.co.nz

NursingReview New ZealaNdâ&#x20AC;&#x2122;s iNdepeNdeNt NuRsiNg seRies

Nursing Review keeps nurses up to date with developments affecting their profession Subscribe to get your hands on your own print copy

Stay informed by signing up to receive fortnightly news online

www.isubscribe.co.nz/ Nursing-Review-MagazineSubscription.cfm

www.nursingreview.co.nz/ subscribe

Inside:

ED’s letter Would Florence approve?

I think Florence Nightingale might approve of the intellectual energy, spirit and commitment shown by nurses in our International Nurses Day edition. On 12 May every year, nurses around the world celebrate the founder of modern nursing’s birthday as International Nurses Day. Eulogised as ‘The Lady with the Lamp’, Nightingale was also a skilled statistician, effective lobbyist and healthcare innovator who wanted nurses to be valued as professionals and not just caring handmaidens. “No man, not even a doctor, ever gives any other definition of what a nurse should be than this… ‘devoted and obedient’. This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman,” she wrote in her classic 1860 Notes on Nursing. In her Notes on Hospitals she also wrote: “It may seem a strange principle to enunciate as the very first requirement in a hospital that [nursing] should do the sick no harm”. That’s the spirit behind nurse Brian Dolan’s social media campaign (see p.4) to encourage older patients out of their pyjamas and into civvies. Likewise, nursing leaders in the Philippines (see special report p.8 onwards) do their best to bolster the profession’s status at home so that more nurses – like Jossel Ebesate – resist the pull of nursing abroad to serve the nation’s many poor. This year we’ve chosen this International Nurses Day edition to relaunch Nursing Review with a fresh look and a sharpened focus. Our new sections honour other aspects of Nightingale – including her tireless focus on improving healthcare (Innovation & Technology), her ability to lead (Leadership & Management) and her fostering of the profession’s next generation (Students). We hope that you approve too and would love to get your feedback on both what you liked and what you’d like to see in future editions. Fiona Cassie, Editor editor@nursingreview.co.nz www.nursingreview.co.nz

NEWS 2

Round-up: News briefs + Bulletin board + Nurses on the move

FOCUS 4 7 8 12

Patients and PJs: an unhealthy relationship? International Nurses Day: Kiwi flavour to global toolkit Special report: Filipino nurses – our fastest-growing RN workforce Filipino nurse migration: Should I stay or should I go now?

PROFESSIONAL DEVELOPMENT 15 20 21

FREE 60-MINUTE professional development activity Nursing portfolios: a simple guide to competency self-assessment Evidence-based practice: Does ‘fast track’ equal fewer infections? Natural diversity: understanding and supporting intersex people

INNOVATION & TECHNOLOGY 24 24 25

Health Navigator’s App of the Month Webscope: website recommendations from Kathy Holloway Case studies: virtual clinics make their mark

LEADERSHIP & MANAGEMENT 27 28

HCA training: making a difference to both staff and patients Time management tips for busy nurse leaders

STUDENTS 29 30 30 31

Fresh eyes: leaders in the making Student reflection: cultural protocols around death Student reflection: being a learner and critical observer Nursing study tips: cultural safety articles

OPINION 32

College of Nurses: Liz Manning on new resources

CONFERENCES 33

Upcoming conferences May-November 2017

Editor

Fiona Cassie 03 981 9474 editor@nursingreview.co.nz

Advertising

Yvonne Gray 04 915 9783 yvonne.gray@nzme-ed.co.nz

commercial manager N.B. This edition’s 60-minute PD learning activity (p.15) is a must-read – it provides a simple ‘howto’ guide on how to assess yourself against the Nursing Council competencies. cover PHOTO: iStock. The Florence Nightingale

monument in central London.

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).

Fiona Reid

production

NursingReview Vol 17 Issue 2

NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6011, New Zealand PO Box 200, Wellington 6140

Aaron Morey

Subscriptions

Fiona Reid 04 915 9795 fiona.reid@nzme-ed.co.nz

images iStock

© 2017. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 1173-8014

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

nursingreview.co.nz Issue 1 2017 1

Round-up News Briefs

News briefs

Read the full versions of these online articles at www.nursingreview.co.nz/ subject/news. Trial of third level of nurse prescribing underway

Nearly 70 primary health and family planning nurses from Invercargill to Whangarei are trialling a third level of nurse prescribing. The new limited level of prescribing rights – to be known as registered nurse prescribing in community health – is a step below the collaborative registered nurse prescribing in primary health and specialty teams, which got underway in September last year. Primary health and specialty team prescribing requires nurses to complete a postgraduate diploma (including a prescribing practicum), while the new third level of community health prescribing requires experienced nurses to undergo a period of supervised practice and a Nursing Council-approved recertification programme. The first and highest level of nurse prescribing has been carried out by nurse practitioners since 2003. Nurse practitioners (who require a clinical master’s degree) can work autonomously, diagnose and have the same authorised prescriber status as doctors and dentists.

Strong to steady demand for nursing degree places Ongoing media reports of nursing graduates struggling to find work is not deterring applicants, with an informal nursing school survey finding generally buoyant to steady demand for 2017 intakes. Seventeen of the 18 nursing schools offering pre-registration nursing degrees responded to Nursing Review’s survey of 2017 enrolment trends.

Nurse flu vaccine uptake rates vary widely The top region for nurse flu vaccination rates last year was once again Tairāwhiti – topping Waikato and Northland, which both have ‘vaccinate or mask’type policies. Eighty-three per cent of Tairāwhiti District Health Board nurses had a free flu vaccination at work last year, compared with 81 per cent at Northland DHB and 80 per cent at both Waikato and Auckland DHBs. All four were well above the national average of 67 per cent of DHB nurses.

Survey finds mixed support for EN graduates Interest in enrolled nursing programmes is mixed across the country, with nursing schools reporting employment rates varying from poor to very good. The findings of the informal Nursing Review survey are backed by graduate

For more news from your sector, go to www.nursingreview.co.nz

2 Issue 2 2017

nursingreview.co.nz

destination surveys that indicate that just over a third (37–38.5 per cent) of those in the last three enrolled nursing cohorts obtained a nursing job within three months. This compares with about 60 per cent of registered nurse graduates surveyed at the same point by nurse educator group NETS.

”It’s getting harder to do the work we are trained for…” In an open letter to the public, the NZNO is calling for people to enrol and vote for political parties committed to increasing health funding.

$2 billion pay equity deal boosts caregivers’ incomes The long-awaited pay equity settlement for health workers will see the hourly rate of caregivers match the current pay rate of new graduate nurses within five years.

Where are new graduates getting jobs? Once again around 60 per cent of new nurses have obtained a graduate placement by March, leaving 551 still job-hunting. The latest job statistics also provide a region-by-region breakdown (see online table) of those areas that are employing the greatest proportion of new graduates.

Bulletin board

Round-up Bulletin Board

New NP scope now in effect A new broader and more flexible nurse practitioner (NP) scope of practice came into effect on 6 April. The new scope means future NPs will no longer be restricted to a specific area of practice and are trusted to practise with their areas of competence and experience. More information at www.nursingcouncil.org.nz/Nurses/Scopes-ofpractice/Nurse-practitioner.

Feedback sought on suicide prevention strategy Public submissions are sought on the Ministry of Health’s new suicide prevention strategy, which aims to reduce risk factors and increase protective factors to reduce suicidal behaviour. Consultation closes on 12 June. The draft strategy can be viewed at www.health.govt.nz/publication/ strategy-prevent-suicide-new-zealand-draft-publicconsultation.

Free eLearning dementia course for primary health A free online course targeted at supporting practice nurses and GPs in building confidence in assessing and managing mild dementia has been released. The eLearning Dementia Education Resource for GPs and Practice Nurses was developed through a collaboration between dementia specialists and is available through the Goodfellow Unit at www.goodfellowunit.org/courses/dementia.

Clinicians’ Challenge entries sought

New ‘last days of life’ toolkit released

Nurses and other clinicians with innovative ideas for using IT to improve health care now or in the future are invited to enter the annual Clinicians’ Challenge. The joint initiative between the Ministry of Health and Health Informatics New Zealand (HiNZ) has been run since 2013. Entries close on 16 June. More details at www.hinz.org.nz/page/ CliniciansChallenge.

A new toolkit of checklist, flowcharts and patient resources has been released alongside the second edition of the Ministry of Health’s Te Ara Whakapiri: Principles and guidance for the last days of life. They can be downloaded at www. health.govt.nz/publication/ te-ara-whakapiri-principles-andguidance-last-days-life.

Adult Palliative Care Action Plan

Mental Health and Addiction Workforce Action Plan A record 167,840 people accessed specialist mental health and addiction services in 2015–16. In late February the Ministry released the Mental Health and Addiction Workforce Plan 2017–2021 that sets four priority areas to meeting that growing need, including having a workforce that is the “right size and skill mix”. Download this at www.health.govt.nz/ publication/mental-health-andaddiction-workforce-actionplan-2017-2021.

Better coordinated services, improved quality and an increased emphasis on primary palliative care are amongst the five priority areas of the Adult Palliative Care Action Plan drawn up following the Review of Adult Palliative Care Services The review identified that currently palliative care practices are variable across the country and there is not equal access to high-quality and responsive care when and where people need it. The plan is available at www.health.govt.nz/ publication/palliative-careaction-plan.

Asthma and COPD eLearning and master class The Asthma and Respiratory Foundation launched in April a new Asthma and COPD Fundamentals Course consisting of an online eLearning series and a classroom-based master class. More information at https://cpd.whitireia.ac.nz.

Nurses on the move LORRAINE HETARAKA-STEVENS, the former director of nursing for Auckland’s ProCare primary health organisation (PHO) is now the nurse leader for the National Hauora Coalition, a PHO collective of Māori service providers in Auckland, Waikato, Tairawhiti and Whanganui regions that also administers South Auckland’s successful nurse-led Mana Kidz school-based programme. CAROLYN COOPER, a health leader with extensive nursing experience, has been appointed director of clinical service improvement for Bupa. Cooper returned to New Zealand in April from Australia where she had been a clinical operations executive director.

IAN CRABTREE is the new head of school of Otago Polytechnic’s Faculty of Nursing. The English-trained nurse was head of nursing at Leeds Children’s Hospital before coming to New Zealand in early 2015. He facilitated a leadership programme at Otago Polytechnic then became service manager at Southern District Health Board’s adult surgery directorate before returning to Otago Polytechnic late last year. ASSOCIATE PROFESSOR STEPHEN NEVILLE is the new New Zealand representative on the executive committee of the Council of Deans of Nursing and Midwifery (Australia & New Zealand). Neville is head of department (nursing)

at Auckland University of Technology, co-director of the AUT Centre for Active Ageing and current president of the NZ Association of Gerontology. CATHERINE BYRNE took up the post of director of nursing in November at Taranaki District Health Board, where she initially trained. Byrne was formerly the nurse unit manager at Starship Children’s Hospital and is currently chair of the Nursing Council of New Zealand, of which she has been an elected member since 2009.

nursingreview.co.nz Issue 2 2017 3

Focus Clinical Practice

Patients and PJs: an unhealthy relationship?

Getting hospital patients out of their pyjamas and into clothes has became a worldwide social media-led movement. FIONA CASSIE finds out about #endPJparalysis and the Christchurch nurse leader behind it.

Brian Dolan.

Karyn Bousfield.

Rose Kennedy. 4 Issue 2 2017

t started simply enough with a single tweet late last year. “I tweeted that nursing was born in the church, raised in the army and the ‘uniform’ we put patients in is pyjamas. And we need to fix it,” recalls Brian Dolan. He argues that getting patients out of their pyjamas or hospital gowns and dressed each day is not only more dignified but also healthier. Within a week the Irish-born, Christchurch-based nurse and consultant (with the help of a mate in Dublin) had created the Twitter hashtag #endPJparalysis to tie twitter conversations on the topic together. Just a few months later the hashtag has gathered more than 40 million Twitter impressions and nurse leaders across the UK, Australia, Ireland, Canada, New Zealand and further afield are encouraging their staff to get more patients up and dressed each day. The idea behind the #endPJparalysis movement is that keeping patients in their pyjamas (or gowns) until the day they go home keeps them ‘paralysed’, dependent, and may lengthen their stay in hospital, which – particularly for elderly medical ward patients – puts them at increased risk of deconditioning or muscle wastage.

nursingreview.co.nz

“You don’t start out to create a global social media movement but I seem to have done so somehow,” says Dolan in bemused pride.

The Last 1,000 Days No movement starts in a vacuum. The #endPJparalysis movement builds on The Last 1,000 Days concept that Dolan has been working on for several years – the premise being that the majority of the patients being cared for, and cared about, in the health systems of the developed world are older people in the last 1,000 days of their lives. Dolan argues that every extra day an older person spends in hospital is stealing precious last days and getting patients out of pyjamas and into clothes is one way to help them return home both sooner and healthier. And #endPJparalysis also builds on the enhanced recovery after surgery (ERAS) protocols and research – which likewise encourage early mobilisation and getting dressed – but widens it beyond surgical wards to include patients across various medical ward settings. Dolan developed The Last 1,000 Days while wearing his multiple hats as a consultant and nurse leader who splits his time between New Zealand, the UK and Australia. In Christchurch – where he spends roughly half the year – his

main hat is as director of service improvement at Canterbury District Health Board. He proudly describes the Canterbury health system as the best “by a country mile” that he’s ever worked with anywhere around the world. Wearing his other hats, as director of UK-based consultancy Health Service 360 and as an honorary and visiting professor at two UK institutions – he spends about four months of the year in the UK and two months in Australia. His work in the UK has included working with England’s Chief Nursing Officer Jane Cumming and NHS Improvement, who are both backing the #endPJparalysis movement. But institutional support aside, Dolan says #endPJparalysis would never have taken off as a movement if it didn’t resonate with nursing leaders and nurses on the floor. With 23 million Twitter impressions, countless Facebook photos from Wagga Wagga to Great Yarmouth, and several cute Lego memes later – there is no doubt it is resonating. “And it’s so bleeding obvious… that’s what people keep saying to me.” He says he has also been “really, really clear” that he never wants #endPJparalysis to turn from a bedside movement into a project with KPIs (key performance indicators) and “a beginning, middle and end”.

Focus Clinical Practice

“It really is about trusting the clinical nurse managers to do what works best in the ward in which they lead.”

But patients are really sick… Getting patients dressed each morning was once upon a time common nursing practice. But so was patients regularly convalescing a fortnight or more in hospital. Nurses in today’s modern wards face constant bed churn and are caring for patients who are older and sicker than in the past. So isn’t expecting nurses or health care assistants to get patients up and dressed just adding to already pressured workloads? And aren’t many patients just too sick? To the former question Dolan argues no – it is no more work for nurses and could actually reduce workloads (see West Coast sidebar on p.6). To the second question he answers that of course nurses need to make a judgment call over

whether it is clinically appropriate to get a patient dressed. “So if somebody is really crook then yes, they should be in their PJs or gown in bed. Or if somebody has drips and drains hanging out of them…” He says the movement is more about questioning whether everybody needs to stay in bed all of the time – and was finding that in more instances than expected people can get out of bed and be dressed the day after admission. “Under a restorative model of care – the risk is greater for staying in bed than it is for getting up – particularly of de-conditioning.” Dolan says patients who are hospitalised walk an average of fewer than 900 steps a day. “And if you are over the age of 80 and spend 10 days in hospital you lose 10 per cent of muscle mass,” says Dolan. He says staying in bed for too long unnecessarily also affects your breathing, your bowel function and

“If somebody is really crook then yes, they should be in their PJs or gown in bed. Or if somebody has drips and drains hanging out of them…” takes away your independence and dignity.

Cost-saving a by-product, not a goal Getting a patient fully dressed in clothes rather than into a fresh gown may take a little longer in the morning but down the track it actually makes less work, argues Dolan. Once a patient is up, nurses will be chasing fewer ringing bells and bringing fewer bedpans or bottles as patients are more mobile and independent. Hospitals may also reduce food wastage as patients up and about are more likely to feel hungry. Continued on next page >>

Want to target a netWork of active and engaged nurses With your recruitment Listings?

To find out more about our 2017 Recruitment Packages, please contact: Yvonne GRaY P: 04 915 9783 | E: yvonne.gray@nzme-ed.co.nz nursingreview.co.nz Issue 2 2017 5

Focus Clinical Practice

Also, in the spirit of patient-centred care, not every patient wants a daily shower and might prefer to expend the energy getting dressed instead. The reward for the patient of getting up and dressed is the carrot of getting home both faster and healthier. “Sometimes we treat old people as if they’ve got all the time in the world,” says Dolan. “But to my mind they are the ones in a hurry because they have had many more yesterdays than they are going to have tomorrows.”

“And if you had a 1,000 days left to live, how many would you choose to spend in hospital?” A small study by Hillingdon Hospital in north-west London found that patients wearing their own clothes in hospital spent 0.75 fewer days in hospitals than patients who wore gowns or pyjamas. “If you scale that up, you don’t have patients lying needlessly in corridors waiting to access a hospital bed.” And yes, Dolan acknowledges that getting patients home quicker also saves hospitals money, but stresses that’s a by-product of #endPJparalysis rather than a goal. ‘It’s not about money or throwing people out, it’s how do we ensure we value patients’ time above all else. It’s about patient dignity and retaining their autonomy. And if they choose to stay in their pyjamas that is their choice.” But when patients are willing and able to get dressed it also changes the dynamic in the relationship between the health professional and the patient, argues Dolan. It humanises the relationship, as no

longer are they are a patient in a ‘uniform’. “If you want to find an object of clothing that takes away so much… then just give a person a hospital gown. It is a horrendous piece of clothing. It is very practical but would you want to be in one day after day if you had a choice?” While getting an patient out of a gown and into clothes could not only boost both their morale and recuperation, it could also mean that nurses won’t have to waste time and energy on things that add no value to the patient’s day. “And when you have happy patients, you absolutely have happier staff.” It appears #endPJparalysis is simple but not simplistic. Resources: Kortebein P (2008). Functional impact of 10 days of bed rest in healthy older adults. Journal of Gerontology www.ncbi.nlm.nih.gov/ pubmed/18948558

Coasters quick to jump on board The country’s smallest DHB is the quickest to join the #endPJparalysis movement. That’s no coincidence believes West Coast District Health Board director of nursing Karyn Bousfield, as being small means the West Coast can get on and do things that fit with the Coast’s philosophy. And #endPJparalysis “absolutely fitted” with the DHB’s overarching restorative model of care, because putting people into pyjamas turns them into a patient and limits their mobility, which can result in things being done for them that many can still do for themselves. “For an older person, that does them a real disservice because people get muscle wastage and are not following a restorative model of care where they are encouraged to remain as independent as possible,” says Bousfield. For Rose Kennedy #endPJparalysis was a “lightbulb” moment. The clinical nurse manager of Grey Base Hospital’s medical and rehabilitation services had long seen the potential for bringing some of the ERAS principles –

6 Issue 2 2017

nursingreview.co.nz

like getting surgical patients mobilised and dressed as soon as possible after surgery – into the care of her medical ward patients. “Its great to have the #endPJparalysis view as we really haven’t had anything like this as a framework for medical wards.”

“There’s a lot more dignity in getting dressed during the day then having one of those lovely hospital gowns.” “And there’s a lot more dignity in getting dressed during the day then having one of those lovely hospital gowns,” adds Bousfield. Reality on the ward Getting patients up and dressed hasn’t added to the nursing workload, but it has reshaped the start of the ward’s working day, says Kennedy.

The new shift starts the day at 6.45am and now after patient handover the nurse assesses which patients are appropriate for #endPJparalysis and which are not. Those who can are helped to be up and dressed for breakfast and the medication round follows in due course (the ward routine has built in a two-hour window for completing medications). “Whereas prior to that nurses were diving into the medication room and those things overtook the patient care. So we’ve had a reversal of daily routine.” Kennedy says patients who can get up and about feel a lot better and are mobilising around the ward interacting with staff and their families. She says about a quarter of its medical ward patients are taking part in #endPJparalysis each day, with families on board and willing to bring in clothes. Bousfield says #endPJparalysis is just part and parcel of a big programme of change the DHB is going through in readiness for the new Grey Base Hospital due in just over a year.

Focus Nursing Voice

International Nurses Day: make your voice heard

This year’s International Nurses Day (IND) toolkit has a Kiwi flavour. Nursing Review talks to JILL WILKINSON about her contribution to a resource used by more than 20 million nurses worldwide.

JiIl Wilkinson.

chief nurse to her new ICN chief executive hat every nurse can be a leader is know their elected representatives, making one of the beliefs driving this year’s submissions, sharing expertise, speaking to post in Geneva. International Nurses Day theme, media or standing for election themselves. The new-format toolkit is out now and Nurses, a Voice to Lead. is available to download from the ICN Nurses’ key role in achieving SDGs International Nurses Day is held each website. For the first time it will be linked The Sustainable Development Goals that year on the birthday (12 May) of Florence to an accompanying website and will the ICN wants nurses to help achieve call Nightingale, the astute founder of the also see ICN encouraging nurses to use for the world to work together on ending modern nursing movement who also social media to raise awareness, including poverty, achieving zero hunger and pioneered using statistics to lobby for using the Twitter hashtags #IND2017 improved access to healthcare, reducing health reforms. and #VoiceToLead (see www.icn.ch/ inequalities, and meeting the 13 other Kiwi nursing academic Dr Jill Wilkinson publications/2017-nursing-a-voice-to-leadgoals by 2030. believes nurses don’t have to be a achieving-the-sustainable-developmentThe toolkit argues that nurses are Florence Nightingale – or have ‘leader’ goals). primary providers of health across the in their job titles or descriptions – to also ’Everyday’ nurses can make a world so are key to achieving the SDGs. make a difference to the health of their Likewise, investment in the nursing difference communities, be it locally, nationally or profession worldwide is essential. “Every action, no matter how small, internationally. “Are nurses really expected to go out and counts,” is noted in the ICN toolkit that For six weeks last year Wilkinson was solve all the world’s problems when we are Wilkinson helped to write. She advocates based in Switzerland helping to write the overworked, underpaid, under-resourced that ‘everyday’ nurses on the ward or material for this year’s IND toolkit that and exhausted?” is a question in the toolkit. practice floor are an essential first link in encourages nurses globally to take a lead. The answer is that nurses are already the policy development chain. The kit is particularly focused on how doing that. The kit shares stories such as For example, chief nursing officers nurses can help to meet the UN’s that of Syrian nurse Khaled Naanaa, whose rely on hearing from nurses what’s really 17 Sustainable Development Goals (SDGs) patients in the besieged town of and shares inspiring examples of Madaya faced starvation until she how nurses’ daily work is already achieving that around the world – “Every action, no matter how small, counts.” sent videos and photos to a news outlet that went viral and saw the from Zambia to New Zealand and Syrian Government finally permit China to Syria. a UN convoy through, although it happening in clinical practice and other Wilkinson, whose usual day job is was too late for 28 of the residents. policy influencers – such as national associate head of Massey University’s Wilkinson says the SDGs are fantastic nursing organisations – and also rely on School of Nursing, was working as a goals and, ranging from water and members’ participation and feedback health policy intern for the International sanitation to gender equality, are as diverse to prepare submissions and lobby Council of Nurses, which each year creates as the nursing workforce. government. the IND toolkit. She first heard about “There is something in there that any Wilkinson believes it is important for the internship when briefing Dr Frances nurse could pick up and be interested in,” nurses to be active politically, even if in Hughes – the Kiwi who has been leading she says. a small way. ‘Liking’ a news item about a the International Council of Nurses (ICN) Nurses can then be a voice to lead – health issue on Facebook can contribute to since February 2016 – on advanced nursing whether as a leader with a small ‘l’ or a big practice and prescribing when Hughes was awareness being spread worldwide. Other ‘L’. in transit from her post as Queensland’s actions can range from nurses getting to nursingreview.co.nz Issue 2 2017 7

Focus Special Report

Filipino nurses:

our fastestgrowing nursing workforce

Filipino nurses are fast becoming a mainstay of the New Zealand health and aged care sector. FIONA CASSIE gained some insights into the nursing culture in the Philippines – a country estimated to have up to a staggering 200,000 unemployed nurses – during a brief visit to Manila, including why we shouldn’t take this workforce for granted.

hen Dr Teresita Barcelo’s nursing classmates have their reunions they choose Las Vegas or New York. With 90 per cent of the former Philippine Nursing Association president’s class living in the States, they argue it just makes sense. The Philippines is a country whose economy has long been bolstered by an estimated 10 million of the 100-million-plus Filipinos living and working abroad sending money home to their loved ones – around US$2.5 billion a month. Filipino nurses began arriving in New Zealand in increasing numbers towards the end of the last decade, helped by a major glut of Filipino nursing degree graduates unable to find work in the traditional mecca, the US. At the same time, interest from New Zealand’s traditional source of migrant nurses, the UK, dwindled (see Table 3, page 11. Fiona Cassie and Teresita Barcelo. 8 Issue 2 2017

nursingreview.co.nz

Philippine-trained nurses have very quickly become a quarter of New Zealand’s IQN workforce and in 2015 made up six per cent of the total nursing workforce. In addition, an unknown number of Filipino nurses, without New Zealand registration, are bolstering the caregiver workforce in the residential aged care and home care sectors.

Call centres staffed by unemployed nurses That person politely answering your query about a phone account or mobile plan may well be a nurse. Call centres in the Philippines are one of the biggest employers of nursing graduates unable to get nursing jobs either in the Philippines or abroad. The exact number of unemployed nurses in the Philippines is unknown but the Alliance of Health Workers union and others have estimated that a glut of up to a staggering 200,000 nursing graduates have been unable to find nursing work in recent years. Most of these underemployed nurses graduated in the midst of a nursing school boom that started last decade when they enrolled with the dream of well-paid nursing jobs in the US – like their cousins

or aunts – but ended up instead working in call centres, health spas and department stores. Dr Cora Anonuevo, a retired nursing professor and a current member of the Philippine Board of Nursing (the equivalent of the Nursing Council of New Zealand) says that nursing education in the Philippines is unfortunately market driven. The upsurge in demand for places in the first decade of the new millennium saw nursing schools mushrooming from around 300 turning out 20,000–30,000 graduates a year to about 500 schools in 2010 producing around 80,000-plus graduates a year. To put this in proportion, Anonuevo says the Board of Nursing estimates that currently there are about 186,000 actively practising registered nurses in the Philippines; a further 280,000 Philippine-trained nurses are believed to be working abroad. Getting a clear picture of how many licensed, i.e. registered, nurses are actually nursing in the Philippines is difficult. Until this year, nurses were not required to be actively practising to apply for the threeyearly renewal of their professional identification card – or to provide employment details.

Focus Special Report Nursing students at the University of the Philippines (UP) College of Nursing.

“We are into details – our hospitality, our cultural sensitivity and our caring – these are the characteristics of the Filipino nurses as described by others.”

Dr Teresita Barcelo, a nursing professor as well as former president (from 2009 to 2011) of the 60,000-strong Philippine Nurse Association (PNA), says such a rapid expansion in nursing schools could not be matched by an equal increase in hospital training places and nursing academics so, obviously, some students were at schools that were not of a high standard. Most of those schools are probably closed now. Demand tumbled when it became clear overseas job opportunities couldn’t absorb the number of inexperienced graduates swamping the market – due partly to the global recession and the tightened US immigration rules – and the glut could not be absorbed locally.

Anonuevo says that stricter monitoring has also seen the number of approved nursing schools drop to just 305 in 2016. The number of graduates sitting the Board’s twice-yearly Nurse Licensure Examination also shrank from more than 40,000 candidates each exam session a few years ago to just 14,600 sitting in November 2016. And around 40 per cent of these are repeat candidates.

“Silent’ policy to export nurses In the past, sitting the nursing licensure exam was often just a stepping stone towards the ultimate goal of passing NCLEX (the National Council Licensing

Examination) and becoming licensed to nurse in the US or Canada. The nursing curriculum of the former American colony has long been influenced by the NCLEX goal and, Barcelo says, the government has a ‘silent policy’ of encouraging nurses to migrate. With well-paid overseas jobs not forthcoming for the inexperienced ‘boom’ graduates the government in 2011 responded by working with the Board of Nursing and PNA to give some nursing experience by sending them out to work in poor and remote communities around the country. In the first year about 10,000 unemployed nurses were hired under the RN Heals

Kiwi Filipino nurses supporting ex-pats down under Monina Gesmundo struggles sometimes when she reads media reports of New Zealand nursing graduates finding it hard to get their first nursing jobs. “Of course I do feel bad for them, but I think ‘oh back home there is more than 100,000 of them’… and it’s always that way.” Gesmundo is president of the Filipino Nurses Association of New Zealand, which was formed in 2015 to help unify Kiwi Filipino nurses and now has 200-plus formal members and 1,400 informal (screened via social media) members. The association also advises nurses looking to come here about how to avoid unscrupulous recruitment immigration practices. Now a lecturer at Massey University, Gesmundo was directly recruited from the Philippines by Counties Manukau District Health Board and left a job as a lecturer for her alma mater, the University of Philippines’ College of Nursing, to come to New Zealand in late 2009. She and fellow Philippines-trained nurse and AUT lecturer Dr Jed Montayre are very aware that not all Filipino nurses follow the advice on the Nursing Council of New Zealand’s

website to wait until their registration application is approved and they have a place on a CAP course before coming to New Zealand. Instead some are enticed by ambiguous advertisements and unscrupulous migration agents back in the Philippines (including some who are New Zealand citizens) to come here on a student visa to take, for instance, a healthcare management course and work as a caregiver. Some come with the false hope – even if they haven’t had the required two years nursing experience – that their New Zealand experience will help them win registration. “One of the driving forces is, of course, that they [migrating nurses] are young and adventurous, but at the same time they do know they are not going to be employed in a nursing job in the Philippines in the next few years, unless they know a politician or someone in authority who can help them get a job,” says Gesmundo. So, she says, some also weigh up trying to maintain their status as a registered nurse versus getting a non-nursing job with lower pay (such as being a healthcare assistant), which satisfies their economic needs, for the moment at least.

Montayre, joint winner of last year’s NZNO Young Nurse of the Year award, is a poster boy for following the right way to migrate to New Zealand but has much empathy for those Filipino nurses whose stories don’t end anywhere near as well as his own. This includes nurses arriving on student visas who end up going home still unregistered and in debt to their families. “People don’t believe friends [already in New Zealand] who try and warn them off,” says Montayre. “They don’t believe it until they actually experience it.” He says it is the nurses’ choice to come to New Zealand before their registration applications are approved. “But how they [some Filipino migration agents] advertise is really, really concerning,” says Montayre. “They give false hopes to people.” Gesmundo and Montayre are also currently surveying Filipino HCAs working in aged care facilities to find out more about their situations. More information is available at the association’s Facebook page www.facebook.com/FNANZInc. N.B. The full version of this article is available online at www.nursingreview.co.nz. nursingreview.co.nz Issue 2 2017 9

Focus Special Report Table 1: Skilled Migrant Resident applications approved 2015–16 Great Britain

India

Philippines

Registered nurse (aged care)

193

287

Registered nurse (all other categories)

148

TOTAL

232

435

Table 2: Essential Skills work visa applications* approved in 2015–16 Great Britain

India

Philippines

Nurse manager

Nurse practitioner

Registered nurse (aged care)

146

Registered nurse (all other)

127

Total (RN visas)

274

Community and personal service workers

666

832

1,156

TOTAL* (RN and caregiver visas)

691

919

1,430

Source: Immigration New Zealand. NB: Immigration New Zealand says information does not include visas/residency granted on relationship grounds or other residence policies * Work visa application statistics are for applications approved not individual people. People can have more than one application approved in a year.

(Registered Nurses for Health Enhancement and Local Service) programme. This year the programme, now known as the Nurse Deployment Project, is employing around 15,000 nurses on limited one- to two-year community contracts. Having two years’ nursing experience is one of the minimum requirements for IQNs wanting to register in New Zealand. Desperate to find work, some graduates come anyway, often as students, and end up working as caregivers or healthcare assistants in our residential aged care and home care sector (see related article in online version). Experienced Filipino

10 Issue 2 2017

nursingreview.co.nz

nurses are also boosting our HCA and caregiver numbers. In return, New Zealand gains a low-paid, highly qualified workforce caring for its elderly. Positive stereotypes usually abound when you ask Kiwis about Filipino nurses and caregivers. But working in residential aged care is not what these nurses with four-year university degrees trained for.

Love of God, people and country Rest homes are very rare in a family-centred culture such as the Philippines. “In the Philippines you are looked down on if you don’t care for your parents,” says Barcelo. Those strong family values, she believes, is one of the reasons that Filipino nurses are so appreciated in aged care. The national education standards for the four-year nursing degree also state clearly that caring is the ‘core of nursing’ and should be emphasised in the curriculum, along with the other core values of “love of God, love of people and love of country”. Anonuevo believes putting such values at the core of Philippine nursing education is part of what

has made Filipino nurses – apart from their being English-speaking – so attractive to the world market. “We are into details – our hospitality, our cultural sensitivity and our caring – these are the characteristics of the Filipino nurses as described by others.” Dr Lourdes Marie Tejero, Dean of the University of the Philippines (UP) College of Nursing points out that there is an atheist society at her university, but agrees that a love of God is a core value that influences the caring culture in a country that is 80 per cent Catholic (and most of the remaining 20 per cent are other Christian denominations or Muslim). But all the nursing leaders spoken to also stress that the Filipino nursing workforce is about more than just being good at the soft skills of caring. Since the 1980s all Philippine-trained registered nurses from the long-established schools have undergone a four-year degree programme to ground them in the ‘hard’ skills required to be clinically competent nurses. That degree has largely supplied graduates for the US market. Tejero shares an anecdote of meeting a nurse manager of a big New York hospital at an international forum, who told her that half her nurses were Filipinos and they “really like they way they are trained”. Both Barcelo, who has nursed in the US and Germany, and Tejero, who did her post-doctoral study in Sydney, express sadness and some frustration that New Zealand sets so many hoops for Filipino nurses to jump through for registration and that so many end up in the low-paid aged care sector.

Deskilling a skilled workforce? If Filipino nurses meet the Nursing Council’s English language, educational equivalency and work experience requirements, the final hoop they must jump through is coming to New Zealand to complete and pass a competence assessment programme (CAP). There are limited places on the six- to eight-week, work-based CAP courses, so most people go on waiting lists for the extra hoop not required by most other countries in which Filipino nurses seek work.

Focus Special Report

The courses are also expensive – with providers charging $6,000 to $8,000 and, in addition, nurses face the cost of airfares, accommodation and food. This is no small amount to a New Zealand nurse, let alone a Filipino nurse, with some earning as little as 12,000 peso (about NZ$350) a month. “I am saddened by the fact you require us to take a bridging (CAP) course,” says Tejero, who wonders how many years nurses have to work to be able to pay for the course. She is also unhappy that so many Filipino nurses in New Zealand end up in the lower-paid aged care sector, despite having been experienced theatre or ICU nurses back home. “Let’s give justice to their education,” says Tejero. This is echoed by Barcelo, who is concerned that experienced Filipino nurses risk being deskilled by being pigeonholed in the aged care sector. She met with Nursing Council of New Zealand chief executive Carolyn Reed during Reed’s information-gathering visit to the Philippines back in 2009 at the height of the nursing school boom. “My position then, and the position I continue to hold, is that our nurses have the necessary competencies,” says Barcelo. Barcelo does reluctantly accept the Nursing Council’s right to require a CAP course as an acculturation process for Filipino nurses entering the New Zealand health system, but asks why nurses can’t at least come on a temporary working visa. “If you don’t pass [the CAP] you don’t get a working visa and you have to come home – but you’ve spent so much money.” The other option is to seek a job as a caregiver or HCA. Barcelo is a little cynical that the economic spin-off for New Zealand of Filipino nurses failing to meet New Zealand’s stringent registration requirements is access to a ‘nursing’ workforce to whom you don’t need to pay a nurse’s salary. Reed told Nursing Review that with a lot of Filipino nurses working here as registered nurses “obviously they are a very important part of our workforce”. She says the CAP course is asked for as “no one would suggest the practice setting in the

Philippines is similar to the practice setting in New Zealand and we have a commitment to the New Zealand public to test those people in our practice setting to see whether they are competent to practice”. One practice area that some New Zealand nursing leaders in the past have suggested is an issue is Filipino nurses being too respectful of hierarchy. Barcelo says this is not the fault of the curriculum, which trains nurses to be decision-makers and advocates for their patients. “The disconnect comes in the hospitals – particularly in private hospitals owned by doctors – it’s very difficult to be assertive otherwise you lose your job.” She adds as an aside that that is why nurses like herself had worked in the community, as community health was really the turf of nurses, in which they could take charge. Tejero says it would also be fair to say that Filipinos are not confrontational as a people. “So we try not to hurt the feelings of others. And if we don’t feel good about something, we don’t shout about it.” And one feeling commonly shared by the Filipino nursing leaders spoken to was that the US – which so many Filipinos already call home – remains a mecca for nurses who are currently looking to the UK, Canada, New Zealand and Australia for work.

So when, inevitably, a global nursing shortage returns and the US opens it doors wider again to Filipino nurses (although probably not under the current president) little old New Zealand may well fall off the map. Because if the choice for Filipino nurses is between a nursing job in a Californian hospital in a state that is already home to 1.5 million Filipinos, or working as a caregiver or nurse in New Zealand’s residential aged care sector, it’s obvious which choice the majority will make. And with New Zealand still reliant on overseas nurses for a quarter of its workforce – the majority of these coming from the Philippines – the impact could be major.

N.B. The full article is available online at www.nursingreview.co.nz.

Table 3: Internationally qualified nurses registered in New Zealand 2007–08

2015–16

Philippines

206

643

India

232

529

Other

392

186

TOTAL

1,207

1,153

Source: Nursing Council of New Zealand

nursingreview.co.nz Issue 2 2017 11

Focus Special Report

Should I stay

Philippine General Hospital (PGH), Manila.

or should I go now?

FIONA CASSIE talks to Filipino nursing leaders about Filipino pay and working conditions, what makes them stay and how they hope to entice others to stay or return to the Philippines.

ossel Ebesate is a charge nurse at a state-funded tertiary hospital that serves not only Manila’s poor but the country’s poor. His aunts and uncles in the US regularly urge him to join them, but the orthopaedic ward nursing supervisor at Manila’s Philippine General Hospital always answers, “I’m more needed here”. When the nurse from the provinces first started at PGH (as the 100-year-old hospital is mostly commonly called) he was introduced to the local branch of the Alliance of Health Workers – a national organisation of health workers’ unions. “It was an eye opener to the real situation in the country”. And he has been a passionate advocate for improving his nation’s health system ever since. The decision to stay nursing in the Philippines is not a light one to make. Few nurses around the world would say they are paid what they worth but in the Philippines the reality is that many get paid a pittance and there is an expectation, 12 Issue 2 2017

nursingreview.co.nz

private hospital sector, is led by an even tacit encouragement, that a independent director of nursing. high percentage will nurse overseas. Barcelo says nurses have a voice at And the nation’s economy benefits PGH as doctors are their colleagues majorly from the foreign exchange and not their lords. “Unfortunately sent home by the hundreds of too often doctors here [the thousands of nurses who are Philippines] think they are the kings pushed or pulled to work abroad. of hospitals.” Dr Teresita Barcelo, the former Working conditions like this, and president of the Philippine Nurse the special mandated pay rates, lead Association, says for nurses to long waiting lists of experienced working in the private hospital nurses wanting to work at the 1,500sector – roughly half of the nursing bed teaching hospital, which is run workforce – the only mandate is the by the neighbouring University of minimum wage so nurses can be the Philippines in Manila (UP). paid the same as a hospital janitor. But Ebesate, who chairs the All This means that a nurse working in UP Workers Union’s health and a small private hospital in Manila – occupational safety committee who may have invested around one and its research and education million pesos in getting their fourcommittee, says even at PGH a staff year degree – can legally be paid 481 nurse’s pay falls short of providing a pesos (just under US$10) per day. comfortable living for a family. One Dr Cora Anonuevo, a member of think tank estimates that to support the Philippine Board of Nursing, a family of five or six in Manila says that some nurses working costs about 1,000 pesos a day (i.e. under local government health 30,000 pesos a month) but the PGH units can even be paid half that nurse salary is around 19,600 pesos rate – far below the wage rates per month. mandated for the regions – on the pretext that they are engaged as ‘contractors’. The best pay and working conditions are for statefunded hospitals like PGH. For example, the PGH nursing workforce, unlike in the often physician-owned Jossel Ebesate, Fiona Cassie and Lourdes Marie Tejero.

Focus Special Report Paediatric Orthopaedic Ward, PGH.

Walking tour of hospital catering for Manila’s poorest PGH is also a drawcard for nurses because the premier teaching hospital delivers best practice care. After being given a quick walking tour through the hospital built by the Americans in 1910, you realise that the state-funded hospital delivers that care on a shoestring budget bolstered by charitable donations. The wards are immaculately clean, organised and – the visit is in the late afternoon – remarkably calm and quiet with no bells ringing or harried nurses rushing down corridors. Which is surprising given the sheer numbers of beds and people packed into the 100-yearold hospital and how comparatively few nurses there are to care for them. The trade-off for working in a government hospital is much, much higher nurse-to-patient ratios than in the private hospital sector. Ebesate’s orthopaedic ward has a 60-bed capacity and on a normal day shift will have four nurses caring for about 56 patients. Step into an adult orthopaedic room and you’ll soon see what helps to make this possible. Nearly every patient in the eight to 10 beds – crammed into a space where most New Zealand hospitals would have three or maybe four – has family at the bedside. Ebesate says the hospital allows at least one immediate family member to be with the patient 24 hours a day. He stops to talks to one patient, Joselito Obena (see photo), a hit and run victim from north of Manila, whose main concern is not having any family to support him. PGH’s nurses are also supported by nursing attendants (like HCAs) and utility workers (orderlies) but if they were working at one of Manila’s private hospitals their wages might be lower but their patient load would be much closer to the norm in a New Zealand hospital. Also – in a country where the gap between rich and poor can be staggering – the private hospitals serving the privately insured include glossy facilities with private rooms and technology that would not look out of place in Chicago or Los Angeles. With a quarter of the nation’s population living in poverty, the national health insurance programme PhilHealth was set up in 1995 with a mandate to “serve as the means for the healthy to pay for the care of the sick and for those who can afford medical to subsidise those who cannot”.

The aim is universal coverage of the nation’s poor. But Ebesate says that only 30 per cent of PGH’s patients – a hospital serving the poor of a city believed to have the world’s largest homeless population, with millions living in slums and unknown numbers living on the street – are covered by PhilHealth. “The problem is that most often the ones who were identified [by PhilHealth] as ‘indigent’/entitled families are also supporters of the local politicians,” says Ebesate. “That’s why there are still people in the streets who are not covered by our social insurance.” In the past two years, Ebesate says, the previous government has provided a direct subsidy of 50,000 pesos for ‘indigent patients’, after a successful Supreme Court challenge by some lawyers saw funding from a ‘pork barrel’ slush fund for senators and congressmen redirected to health. Just before Christmas the new President Rodrigo Duterte announced he would boost Department of Health funding in 2017 to cover the hospital and medical bills of the poor who are not PhilHealth members. But that is not enough to deliver premiere care for all the needy – a fact that is brought home when we enter a large, old-school, open paediatric ward. The walls are brightly painted with characters from kids’ animated movies, but it is also packed, including little babies on ventilators, because the paediatric and neonatal ICU units are full to capacity. On the way to PGH’s emergency room (ER), Ebesate introduces the ER nurse supervisor who shares that it is “very full”. “As of now we have 130 patients in the ER observation unit. That’s 130 patients with a 60-bed capacity.” These are patients triaged as needing admission, but the wards are so

Joselito Obena.

full that they are stuck in limbo – beyond the 24-hour recommended waiting time. Entering the ER space the noise level rises – so many people lying in corridors or crammed into every available space in rooms, while others queue to apply for financial assistance for their care or their family member’s drug bill. We emerge outside and cross over to the space outside emergency obstetrics where husbands crouch and wait– with up to 80 women in a ward with a capacity for 20 there is no chance that these expectant fathers can hold their wives’ hands during labour or pregnancy crises.

Getting nurses to stay: educating the poor to care for the poor The need to retain skilled nurses in the Philippines is obvious. For a start, the state-funded and local government-funded community health system – delivering primary health nursingreview.co.nz Issue 2 2017 13

Focus Special Report

care to people spread across the Philippines’ 7,100 islands – can be spread as thin as one nurse per 20,000–25,000 people in rural remote areas, and nursing numbers need to double to deliver the services required. Lack of jobs and low pay is a major barrier and the lure of decent pay and better working conditions is a major driver for nurses to go offshore. Nurse leaders are also constantly lobbying for better conditions for their profession and in January this year a technical working group called for a proposed new Nursing Bill to include private hospital

“We say it is your right to go… but just come back and share your knowledge and expertise.” nurses being legally guaranteed the same starting salary as government hospital nurses and to bring in maximum 1:12 nurse patient ratio in general wards. But meanwhile they stress Filipino nursing’s core values of love of country, love of God and love of people – to try and hold nursing’s best in the country for as long as possible. Dr Lourdes Marie Tejero, dean of the UP College of Nursing – one of the oldest and most prestigious nursing schools in the Philippines – can count on her fingers how many of her near 60-strong nursing class are still in the Philippines – and many of those have retrained as doctors. She says most private nursing schools (the majority of nursing training is delivered by private universities) promote themselves as readying graduates to work anywhere in the world, but the ethos of state-funded UP is different. “We are the only ones who would say, ‘No, we need the good ones here’.” The low-fee nursing school, along with the rest of the UP’s health faculty linked to the PGH teaching hospital, is known for attracting the 14 Issue 2 2017

nursingreview.co.nz

brilliant but financially challenged, says Tejero. This includes a slum dweller who topped the Board of Nursing exam nationwide despite working at nights to cover costs because he gave his scholarship money to his family. The school’s reputation means that during the peak of the recent boom the College of Nursing received 14,000 applications for just 70 places, though this has since settled down to just “usually a few thousand”. Tejero says the students they get are the ‘cream of the cream’, a delight to teach and from the first year to the fourth year they are reminded that “your country needs you”. The college’s curriculum, which strongly influenced the national curriculum standards, is community focused and Tejero says this is because they hope graduates will serve the communities after graduating. “You could call it our corporate culture – a belief in training the poor to help the poor.” Students across the health faculty also sign a bonding contract that states for every two years of education they will give at least one year to serve their country. Tejero acknowledges that still many leave but now they don’t speak of the diaspora of Filipino

nurses as a ‘brain drain’ and instead talk about re-circulation. “We say it is your right to go… but just come back and share your knowledge and expertise.” And return they do – a few to settle but many to volunteer their expertise with lectures and seminars or to serve in the provinces. Teresita Barcelo, ex-president of the Philippine Nurses Association, says there are affiliated PNAs across the world with the largest, the PNA of America, returning regularly to the Philippines to hold combined conferences with the PNA. Likewise, Tejero says that when invited to address UP College of Nursing reunions in the United States she is always asked for a ‘wish list’ by alumni keen to donate or help. One imagines that the wish list of most nurse leaders would be topped by a well-funded health service that nurses don’t feel compelled to leave in the first place.

Adult Orthopaedic Ward, PGH.

Professional Development Learning Activity

Nursing portfolios:

a simple guide to competency self-assessment RRR

Reading the article and completion of this Nursing portfolios: a simple guide to competency selfassessment learning activity is equivalent to 60 minutes of professional development.

By Liz Manning

Developing a portfolio and interpreting the Nursing Council of New Zealand competencies remains a confusing landscape for many nurses. This article provides supportive advice and examples of how to effectively self-assess nursing practice against the competencies, especially for nurses randomly selected for a recertification audit. Learning outcomes ▶▶ Understand rationale for developing a nursing portfolio. ▶▶ Know how to approach a self-assessment against the competencies using everyday practice examples. ▶▶ Increase familiarity with the Nursing Council of New Zealand website. ▶▶ Locate and review guidelines that underpin nursing practice.

NCNZ competencies addressed Registered Nurse competencies 1.1, 2.8, 2.9.

Introduction “What is a portfolio? Is it a PDRP? Is it a massive file of information about your practice? How do I even begin to selfassess when the competencies aren’t specific? Anyway, this will take weeks to put together…won’t it? I am good at my job, WHY are you auditing ME?” This article looks at why nurses need to develop a portfolio and offers advice on how to effectively self-assess nursing practice against the Nursing Council of New Zealand competencies if faced by a recertification audit. There are two circumstances when nurses need to present a portfolio: Being randomly selected for a recertification audit of the continuous competence requirements by the Nursing Council of New Zealand (NCNZ). OR Being employed by an organisation with an approved Professional Development and Recognition Programme (PDRP)8 and being required to submit a portfolio on a three-yearly cycle or wishing to apply for another level of practice. (Nurses on a PDRP should seek specific advice from their PDRP coordinator.)

Why portfolios? The Health Practitioners Competence Assurance Act (2003)¹ provides a framework for the regulation of health practitioners to protect the public where there is risk of harm from professional practice. The Act identifies responsible

authorities (e.g. NCNZ) that have the role of ensuring all registered health practitioners, issued with an annual practising certificate (APC), are competent in their scope of practice. The Council has the role of protecting the public by setting standards and ensuring that nurses are competent to practise under the Act. Each year the Council randomly selects five per cent of practising nurses for a recertification audit14. Question: When you receive your APC notification from NCNZ, do you tick the boxes that declare: ☑☑ you have the required 450 practice hours (over three years)? ☑☑ you have the required 60 professional development hours (over three years)? ☑☑ you are competent to practice? Answer: Yes? Then the NCNZ recertification audit is asking you to provide validated evidence for those ticks.

TIPS BOX 1 ▶▶ ONLY include the requested items from the checklist. ▶▶ Filling a portfolio does not need to be a linear process. Start with the items you already have. ▶▶ Write about your everyday practice, in your own words. ▶▶ This isn’t about your best day ever, it’s about what you do every day.

nursingreview.co.nz Issue 2 2017 15

Professional Development Learning Activity

What is a portfolio? A portfolio is a standardised way of storing information that describes your competence to practice. It’s generally an A4 folder, or an electronic equivalent, with predefined sections making it easier to collate and audit.

Filling a portfolio for recertification Content The NCNZ provide a checklist14 on their recertification webpage. Only include the items requested, keep it simple. Three forms of verified evidence are required: ▶▶ Record of practice hours. ▶▶ Record of professional development hours. ▶▶ Assessment against the competencies ▶▶ Self-assessment ▶▶ Senior nurse or peer review Check the NCNZ website for templates7, 14, 15 and information. If you cannot meet one or more of the requirements, contact the NCNZ to explain your situation and they will advise you what to do.

Verification The evidence you provide in your portfolio must be verified, which means signed by someone who has either observed your practice or can confirm that the evidence you have provided is correct and that it is your work. This is often a manager or senior nurse. They must provide their name, designation and contact details.

Currency A portfolio is about your current practice. All the evidence/practice examples you provide must be from the previous three years.

Privacy Any inclusion of third party information without consent is a breach of privacy3, 17.

Assessment against the RN competencies Which competencies? The majority of New Zealand’s approximately 50,000 registered nurses

TIPS BOX 2 ▶▶ Put your practice examples into the domains then start with the competency you think is the easiest to describe. The indicators may help you decide. ▶▶ Write a statement about your practice then support it with an objective example (an actual situation that occurred). ▶▶ See the examples provided for the RN clinical competencies.

16 Issue 2 2017

nursingreview.co.nz

(RNs) are in ‘direct-care’ clinical roles16 and will complete the RN clinical competencies. However, there are nurses working across health in myriad different roles who do not provide direct nursing care but still influence nursing practice and/or the nursing workforce. The Council has created competencies to recognise and accommodate the breadth of the scope and RNs must select a competency set that reflects their current practice. There are competencies for RNs in: ▶▶ clinical⁴ (the majority of RNs) ▶▶ management6/clinical management⁶ ▶▶ education6, policy6, and research6. This article looks at the clinical competencies⁴ in the four domains: Domain 1: Professional responsibility (five competencies) Domain 2: Management of nursing care (nine competencies) Domain 3: Interpersonal relationships (three competencies) Domain 4: Interprofessional healthcare and quality improvement (three competencies) Nurses must provide ONE practice example for every competency. Each competency has ‘indicators’ listed – these are guides to help you select your example.

The RN domains and competencies with general examples and tips to guide you Domain 1: Professional responsibility Competency 1.1 Accepts responsibility for ensuring that his/her nursing practice and conduct meet the standards of the professional, ethical and relevant legislated requirements. This covers legislation, acts, ethics, codes, policies and standards that underpin practice. e.g. Privacy Act, the Code of Rights and workplace health and safety requirements. Refer to the NCNZ Code of Conduct⁵ and other guidelines. Competency 1.1 Statement about your practice: We had a refresher on the NCNZ Code of Conduct, social media guidelines and professional boundaries last year (see PD hours), which was great, and we keep copies in the office. I am very aware of the Privacy Act, the patient’s right to confidentiality and how that affects who I can talk to about the patient Actual practice example: Last month I was caring for a gentleman whose neighbour rang to ask for results of a recent blood test; she said she was helping to care for him and he had asked her to call. I explained that I could not discuss the patient’s condition or blood tests because… etc.

Competency 1.2 Demonstrates the ability to apply the principles of the Treaty of Waitangi/Te Tiriti o Waitangi to nursing practice. This is specific to Māori, in relation to the Treaty. How do you partner in care? How do you protect or advocate? How do you facilitate patient/whānau participation?10 Competency 1.3 Demonstrates accountability for directing, monitoring and evaluating nursing care that is provided by enrolled nurses and others. Delegation occurs up, down or sideways e.g. asking a colleague for help (sideways), escalating a difficult situation to a manager (up), directing a student, healthcare assistant (HCA), or a patient’s family or carers (down). Refer to the NCNZ Direction and Delegation Guidelines12, 9. Competency 1.4 Promotes an environment that enables client safety, independence, quality of life, and health. How do you promote a safe working environment? How do you anticipate and mitigate clinical risk? How do you promote patient wellbeing and safety e.g hazard identification, reporting incidents, infection control guidelines? Competency 1.5 Practises nursing in a manner that the client determines as being culturally safe. How do you care for patients who have different cultural¹⁴ requirements from your own? How do you ascertain their beliefs and how you do respond? How do you know if the patient determines your care is culturally safe? Think broadly and beyond ethnicity. Culture includes many things that are part of our everyday lives e.g. religion, disability, sexuality, beliefs, food, family culture and language.

Domain 2: Management of nursing care Competency 2.1 Provides planned nursing care to achieve identified outcomes. How do you plan care? Do you use nursing models of care? Consider how you plan for an acute episode or a chronic illness, long term or short term. Who do you involve in the planning? Competency 2.2 Undertakes a comprehensive and accurate nursing assessment of clients in a variety of settings. How do you conduct your assessments? Do you use an assessment framework e.g. SOAP (subjective, objective, assessment, plan), mini-mental state examination, falls risk, InterRai? This could be initial assessment or assessment following a procedure, new medication or a regular reassessment. Consider how often you assess; you may have noticed something using your observation skills that prompted you to undertake a more focused assessment.

Professional Development Learning Activity

Recommended resources: The Nursing Council of New Zealand Code of Conduct, guidelines, continuing competency guides, examples and templates plus recertification audit information available at www.nursingcouncil.org.nz/Nurses. The NZNO Guide to Privacy in relation to portfolios etc. Available in the ‘practice’ section www.nzno.org.nz/resources/nzno_publications.

competency 2.2 Statement about your practice: We see walk-in patients and also take phone calls from patients. We need to be able to quickly assess in a variety of ways. Actual practice example: Walk-in: Last week a new patient presented with chest pain. As he came through the door I saw he was pale and sweaty, rubbing his chest. I immediately used the OLD CARTS chest pain assessment tool … etc. Phone call: A young mum rang about her child who had a fever of 38.8 and had been unwell overnight with an ‘odd’ cough’. I used the Traffic Light System to identify the immediate risks: I asked for the child’s colour, activity … etc.

Competency 2.3 Ensures documentation is accurate and maintains confidentiality of information. How do you maintain clear, concise, organised and current documentation? Competency 2.4 Ensures the client has adequate explanation of the effects, consequences and alternatives of proposed treatment options. How do you describe and explain a treatment, medication or a procedure to the patient? Do you encourage questions? Do they need a support person/interpreter/ family member? Do you describe the alternatives and possible outcomes? Do you use printed information?

competency 2.3 Statement about your practice: I document as soon as possible after a patient interaction; I always write things down in accurate detail as soon as I can with a time, date and signature, and then print my name.

competency 2.6 Statement about your practice: I regularly meet with patients (and, if appropriate, their families) to discuss their requirements and preferences for their care.

Actual practice example: About eight months ago a visitor made a complaint, claiming I gave their elderly relative the wrong advice about a medication. My manager checked back into the patient’s notes and I had written the conversation down in detail, timed and dated it, with a note that I had confirmed everything with the patient … etc.

Actual practice example: I care for an elderly gentleman who is now unable to attend appointments for wound care because of chronic pain, transport issues and living alone. I recently organised to meet with him to review the options for his situation so he could get the care he needed in a way which met his planned care needs and his preferences starting with… etc.

Competency 2.5 Acts appropriately to protect oneself and others when faced with unexpected client responses, confrontation, personal threat or other crisis situations. What systems does your workplace have for crisis situations and what is your role in managing these? For example, cardiac arrest, security threat, anaphylaxis and other significant events. Competency 2.6 Evaluates client’s progress toward expected outcomes in partnership with clients. How do you assess if your care is safe and effective? How have you involved patients in care planning? How do you contribute to discussions and planning for the patients?

Competency 2.7 Provides health education appropriate to the needs of the client within a nursing framework. Why is health education important and how do you ensure you are offering it in a timely, consistent and appropriate way? Do you use printed resources or websites? Is it age and ability appropriate e.g. quit smoking, green prescription or a new medication? It could be to a patient, family or caregivers. How do you evaluate the effectiveness of your education? Competency 2.8 Reflects upon, and evaluates with peers and experienced nurses, the effectiveness of nursing care. How do you support your colleagues and peers to reflect on their practice? Does your employer have a system for nursingreview.co.nz Issue 2 2017 17

Professional Development Learning Activity seeking advice or debriefing? Have you made changes to patient care following reflection or professional discussion? Do you attend professional supervision? Competency 2.9 Maintains professional development (PD). You should include your PD record, but you can always add a reflection on a specific PD activity and how it affected your practice.

Domain 3: Interpersonal relationships Competency 3.1 Establishes, maintains and concludes therapeutic interpersonal relationships with client. It’s all about communication. How do you approach people every day; new patients or patients you have known for a long time? How do you form trusting relationships quickly and how do you maintain your longer term professional relationship with patients? How do you demonstrate knowledge of verbal and nonverbal skills (body language) in your communication with patients? Competency 3.2 Practises nursing in a negotiated partnership with the client where and when possible. Consider the patient’s right to refuse treatment – do you practice informed consent? How will the planned care work for the patient e.g. can they get to an appointment? What do you discuss with the patient to get the care they need in the right way, at the right time and place? Competency 3.3 Communicates effectively with clients and members of the health care team. Consider the many techniques you use to communicate with patients and to the team. How do you know they are effective?

Competency 3.3 Statement about your practice: I think communication and listening is key to good practice. I always assess carefully when I meet patients to find out how they need to communicate and what works best for them. Actual practice example: Recently a new resident, an elderly gentleman who is profoundly deaf, had staff shouting instructions to him. I felt this undermined his dignity and was ineffective. I introduced myself to him and asked if I could sit next to him. I asked him if I could use a pen and paper to get my messages across in writing which he really liked … etc.

Domain 4: Interprofessional healthcare and quality improvement Competency 4.1 Collaborates and participates with colleagues and members of the healthcare team to facilitate and coordinate care. This is about the wider team, sometimes outside your own organisation. How do you work with other providers? How do you approach handover, multi-disciplinary meetings or case reviews? How do you organise a referral e.g. to a dietician or podiatrist, or discuss and plan care with other members of the healthcare team? Competency 4.2 Recognises and values the roles and skills of all members of the healthcare team in the delivery of care. Do you recognise when different skills are needed e.g. a physiotherapist, a social worker, a doctor? How do roles and

clinical skills differ? How do you recognise and coordinate this e.g. in a discharge plan, patient deterioration, coordination of a procedure or appointment? Competency 4.3 Participates in quality improvement activities to monitor and improve standards of nursing. This could be participation in a clinical audit, survey, or nursing care quality initiative e.g. procedure technique, wound dressing, medication administration, documentation or communication process. Hazards, unsafe equipment or incident reporting. Focus on nursing practice. In conclusion, a portfolio does not need to be confusing. Just step back, reflect on your practice and start recording your examples, competency by competency.

About the author: Liz Manning, RN, BN, MPhil (Nursing), FCNA(NZ) is a director of Kynance Consulting and is a nurse consultant who has worked in the area of portfolios, assessment, auditing and PDRP for many years.

This article was peer reviewed by: Linda Adams RN PG Cert HSc is a quality advisor for MedScreen. She is a former PDRP nurse advisor, recertification and PDRP auditor and competence assessor for NCNZ. Lorraine Hetaraka-Stevens RN PG Dip (nursing), MNurs (in progress) is an experienced competence assessor and nurse leader who is currently nurse leader of the National Hauora Coalition.

References Competence Assessment Form for Registered

Guidelines: Professional Boundaries. Wellington:

ASSURANCE ACT (2003). Retrieved December 2016

Nurses Practising in Policy.

Author.

from www.legislation.govt.nz/act/public/2003.

Competence Assessment Form for Registered

1. HEALTH PRACTITIONERS COMPETENCE

2. MANNING L (2015). Tips for a top nurse portfolio.

Nursing Review 15(2) 28. 3. NEW ZEALAND NURSES ORGANISATION (2016).

Nurses Practising in Research. 7. NURSING COUNCIL OF NEW ZEALAND (2014).

Examples for self-assessment and senior nurse

Guideline: Privacy, Confidentiality and Consent in

assessment for the registered nurse scope of

the Use of Exemplars of Practice, Case Studies, and

practice.

Journaling, 2016.

8. NURSING COUNCIL OF NEW ZEALAND (2013).

4. NURSING COUNCIL OF NEW ZEALAND (2007).

Framework for the approval of professional

Competencies for Registered Nurses. Wellington:

development and recognition programmes to

Author.

meet the continuing competence requirements for

5. NURSING COUNCIL OF NEW ZEALAND (2012).

Code of Conduct. Wellington: Author. 6. NURSING COUNCIL OF NEW ZEALAND (2011).

Competence Assessment Form for Registered Nurses in Clinical Management.

nurses. Wellington: Author. 9. NURSING COUNCIL OF NEW ZEALAND (2011).

Guideline: Direction and Delegation of Care by a Registered Nurse to a Health Care Assistant. 10. NURSING COUNCIL OF NEW ZEALAND (2011).

Competence Assessment Form for Registered

Guidelines for Cultural Safety, the Treaty of

Nurses Practising in Education.

Waitangi and Māori Health in Nursing Education

Competence Assessment Form for Registered Nurses Practising in Management.

18 Issue 2 2017

nursingreview.co.nz

and Practice. Wellington: Author. 11. NURSING COUNCIL OF NEW ZEALAND (2012).

12. NURSING COUNCIL OF NEW ZEALAND (2011).

Guideline: Responsibilities for Direction and Delegation of Care to Enrolled Nurses. 13. NURSING COUNCIL OF NEW ZEALAND (2012). Guidelines: Social Media and Electronic

Communication. Wellington: Author. 14. NURSING COUNCIL OF NEW ZEALAND

Recertification Audits & Recertification Audit Checklist. 15. NURSING COUNCIL OF NEW ZEALAND (2011).

Template for Evidence of Professional Development Hours. 16. NURSING COUNCIL OF NEW ZEALAND (2015).

The New Zealand Nursing Workforce: A Profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2014–15. Wellington: Author. 17. PRIVACY ACT (1993). Retrieved December 2016 from www.legislation.govt.nz/act/public/1993/0028/latest/ DLM296639.html.

Professional Development Learning Activity

Learning outcomes ▶▶ Understand rationale for developing a nursing portfolio. ▶▶ Know how to approach a self-assessment against the competencies using everyday practice examples. ▶▶ Increase familiarity with the Nursing Council of New Zealand website. ▶▶ Locate and review guidelines that underpin nursing practice.

NCNZ competencies addressed Registered Nurse competencies 1.1, 2.8, 2.9.

Reading the article and completion of this Nursing portfolios: a simple guide to competency self-assessment learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the NZNC RN competencies 1.1, 2.8, 2.9. Please discuss all your answers with your peer/s. A

Reading

Select and read the NCNZ guidelines that you are least familiar with i.e. Code of Conduct⁵, Professional Boundaries11 or Social Media13 www.nursingcouncil.org.nz/Nurses.

Further suggested reading: ▶▶ ‘Tips for a top nursing portfolio’² www.nursingreview.co.nz/issue/april-2015-vol-15-2/tips-for-a-top-nurse-portfolio/#. WC5bYuZ95PY ▶▶ NZNO privacy guidelines in relation to portfolios, case studies and exemplars www.nzno.org.nz/resources/nzno_ publications

Reflection

Reflect on your routine practice. Think about how you approach patients, how you develop trusting relationships, and how you routinely plan, deliver and coordinate care with health professional teams.

Choose a relatively common occurrence in your everyday practice. Think back to the most recent example of how you dealt with this. Review and reflect on what went well, what was the outcome and what, if anything, you would do differently next time.

Reality

Identify and write down FOUR examples of your own practice (refer to exemplar examples in article). Identify which domain and then which competency they apply to.

Discuss with a colleague how you would approach their peer assessment; what specific examples of their practice you would use and to which competencies did they apply?

Verification by a colleague of your completion of this activity Colleague name

Designation

Date

Nursing council ID

Work address

Contact # nursingreview.co.nz Issue 2 2017 19

Professional Development Evidence-based Practice

Fast track = fewer infections?

Our clinically appraised topic (CAT) looks at the impacts of enhanced recovery after surgery (ERAS) protocols on infections. Clinical bottom line Adults having abdominal and pelvic surgery experienced significantly fewer postoperative lung infections, urinary tract infections and surgical site infections when cared for on an enhanced recovery after surgery (ERAS) or fast track surgery (FTS) protocol, compared with standard care.

Clinical scenario Healthcare-associated infections (HAIs) are a significant problem after surgery and you are frustrated in your efforts to reduce these. A number of perioperative strategies are known to reduce risk of HAIs but current protocols do not ensure these are consistently applied. You have heard that enhanced recovery after surgery (ERAS) protocols are associated with reducing HAIs and decide to review the evidence.

Question In adults undergoing surgery, does an ERAS protocol reduce hospital acquired infection (HAI) in comparison with standard care?

Search strategy PubMed-Clinical Queries (Therapy/ Narrow): enhanced recovery after surgery AND infection

Citation Grant MC, Yang D, Wu CL et al., Impact of Enhanced Recovery After Surgery and Fast Track Surgery Pathways on Healthcareassociated Infections: Results From a Systematic Review and Meta-analysis. Ann Surg, 2017. 265(1): p. 68-79 10.1097/ sla.0000000000001703

Study summary A systematic review evaluating whether ERAS and FTS protocols reduce HAIs. Inclusion criteria were: Type of study: Randomised controlled trials Participants: Adults (age>18) undergoing general anaesthesia for abdominal and pelvic surgery Intervention: Perioperative care using either ERAS or FTS protocols, compared with standard care

Outcomes: Primary outcomes: postoperative incidence of lung infection (LI), urinary tract infection (UTI), and surgical site infection 20 Issue 2 2017

nursingreview.co.nz

(SSI). Secondary outcomes: length of stay (LOS), serum protein markers of inflammation, neurogenic stress, humoral immunity, and cellular immunity.

Study validity Search strategy: Electronic databases searched to locate eligible English-language studies were PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library from inception to June 2015. Review process: Two authors independently searched for and screened potentially relevant studies, extracted data using a standardised form and assessed risk of bias within included studies. Disagreements resolved by group consensus. Quality assessment: Risk of bias was assessed using the Cochrane Collaboration tool (assesses sequence generation, allocation concealment, blinding of participants/outcome assessment, incomplete outcome data, selective outcome reporting, and other potential sources of bias). Overall validity: A high-quality review involving a large number of randomised controlled trials but with moderate risk of bias.

Study results After removal of 365 duplicates, 855 abstracts were screened for eligibility. Full text of 47 studies were assessed, from which 36 RCTs (41 comparisons) involving 4,142 participants were included in this review. Twenty-five comparisons involved open surgical procedures, 15 comparisons involved laparoscopic procedures and one study involved both. Studies commonly involved colorectal surgery (26 comparisons). Other studies involved gastrectomy (7), abdominal aneurysm repair (2), hepatectomy (2), general intestinal (2), oesophagectomy (1), and prostatectomy (1). Most studies followed patients up to 28 days postoperatively (29 comparisons; 71 per cent). Studies compared multimodal ERAS or FTS protocol administration with standard care (refer comments). ERAS

Table: Summary of results

or FTS was associated with a statistically significant reduction in postoperative LI, UTI and SSI, compared with standard care (refer table). Subgroup analysis of studies involving colorectal surgery also showed statistically significant reductions in LI, UTI and SSI compared with standard care. Subgroup analysis of studies involving open incisions showed statistically significant reductions in LI, UTI but not SSI, compared with standard care. Hospital LOS was also significantly reduced with use of ERAS/FTS protocols.

Comments: ▶▶ Sensitivity analysis involving exclusion of studies at high risk of bias did not substantially change the findings. Funnel plot analysis of primary outcome data showed no evidence of publication bias (no missed studies). ▶▶ ERAS and FTS protocols commonly involved preoperative counselling, avoiding bowel preparation, preoperative carbohydrate, avoiding nasogastric tubes, preventing hypothermia, goal directed fluids, avoiding peritoneal drainage, regional analgesia, early urinary catheter removal, early oral feeding and early mobilisation, in comparison with standard care. ▶▶ One explanation is that ERAS and FTS protocols promote comprehensive, multidisciplinary best practice care that is more effective than isolated infection-reducing strategies. The significant reductions in inflammatory markers observed in FTS or ERAS patients suggests that reduced systemic inflammation may also be a contributing factor. ▶▶ Implementing these findings requires a multidisciplinary quality improvement effort including (from personal experience) ensuring sufficient nursing resource to support safe, early mobilisation. Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD Candidate, Deakin University, Melbourne. cwensley@deakin.edu.au

Statistical heterogeneity I2

Risk ratio (95% confidence interval (CI))

Number of studies (number of participants)

Outcome

0.38 (0.23-0.61)

16 (1,287)

Lung infection

0.42 (0.23-0.76)

16 (1,310)

Urinary tract infection

0.75 (0.58-0.98)

27 (3,279)

Surgical site infection

Professional Development Patient Diversity

Natural diversity: understanding and supporting intersex people

Not all people are ‘typical’ males or females. Nurse educator CRAIG WATERWORTH is keen to raise awareness amongst nurses about intersex people so they can be better supported.

“A

Craig Waterworth.

re you a boy or a girl?” The answer for some people is neither, as an estimated 1–2 per cent of people are born intersex. Intersex is a term used to describe people who are born with sexual anatomy and/or chromosomes that are not typically male or female. These variations are differences in sexual development that have occurred throughout history and across all cultures. Our sex, be it male, female or intersex, is usually defined at birth by health professionals. In Aotearoa New Zealand, sex can be officially designated as ‘indeterminate’ on birth certificates. Intersex describes more than 30 different sex-related conditions, the vast majority of which result in no health problems. Some people are born with genital differences, some people are born with internal organs that are typically male, while their external genitals are typically female, or vice versa. Some people are born with forms of intersex that manifest solely as a degree of infertility, or as hypospadias. This means that sometimes an intersex status is obvious at birth, but for others this status is not realised until puberty, or they attempt to conceive. You may not have heard of intersex, but you will have met intersex people, as the percentage of intersex people is believed to be similar to the incidence of people with ginger hair worldwide. Many intersex people have suffered greatly as a result of secrecy, stigma and unnecessary

medical interventions that have attempted to make people appear typically male or female through surgery. This was controversially known as ‘normalising’ surgery (including the removal of gonads and the excision or manipulation of genital tissues) with an early proponent being Baltimore-based New Zealander Dr John Money. Medical interventions have also included hormonal medications, like the questionable use of prenatal dexamethasone,. From the 1950s until the early 1990s, the ‘normalising’ approach was promoted, alongside a belief that nurture was stronger than nature. This theory has now been refuted by the likes of Dr Charles Phoenix’s ‘organisation-activation’ theory, and the evidence now points to nature being the prime

influence when it comes to gender (your sense of self identity in terms of perceiving yourself as a man, woman or gender-fluid/non-binary person), and that you cannot be reared into thinking you are one gender, when in fact you define yourself as another gender.

Care implications In 2006 a highly influential medical ‘consensus statement’ (known as the Chicago statement) on the management of intersex ‘disorders’ was published in the official journal of the American Academy of Pediatrics. This publication was criticised by many in the intersex community for pathologising intersex as a “disorder of sexual development (DSD)”, and for also supporting ‘normalising’ surgical interventions. The Chicago nursingreview.co.nz Issue 2 2017 21

Professional Development Patient Diversity

… the percentage of intersex people is believed to be similar to the incidence of people with ginger hair worldwide.

statement was seen as a step backwards by many from the more progressive guidelines published in 1997 by Dr Milton Diamond in the Archives of Pediatrics and Adolescent Medicine. The earlier 1997 guidelines were well received by the intersex community, as they discouraged all unnecessary medications and surgeries for intersex people, and affirmed the right of informed consent for the intersex person. A major concern with ‘normalising’ surgery, and related medical procedures, is that, in addition to the physical trauma, frequently a surgically manipulated gender (created during infancy) may not match with an intersex person’s desired gender (as a child or adult). And usually the surgery, and other medical interventions, cannot be reversed. There is also the risk of infection or scarification, and the loss, or impairment of fertility, sexual and genitourinary functioning, often due to infections and repeated surgeries or procedures. Psychosocial damage can follow on from this, increasing the risks of mental ill health. Alternatively, decisions around surgery, procedures or hormone medication can wait until the intersex person is old enough to consent to this, or they may decide that they are happy as they are and desire no interventions. 22 Issue 2 2017

nursingreview.co.nz

Only two conditions that affect a small minority of intersex people require immediate medical intervention. These are cloacal exstrophy and salt-wasting congenital adrenal hyperplasia (salt-wasting CAH). In cloacal exstrophy the neonate is born with some of their abdominal organs exposed, and this can also involve the genitalia, so surgery is required immediately to prevent massive infection and organ failure. Salt-wasting CAH is a different condition that results in a lack of cortisol and aldosterone production. This severe form of CAH causes an adrenal crisis that can become life-threatening, so steroid treatments are required. CAH is routinely screened for as part of the heel prick blood testing that occurs shortly after birth.

Culturally safe approach to gender The ways in which intersex people are described and engaged with are also very important, and a culturally safe approach is particularly important to help nurses establish a respectful and productive therapeutic relationship. An online course from Massey University is available to help nurses develop this knowledge (see resources). It is a good idea to ask everyone about their preferred pronouns; do they wish to be referred to as he,

she, them, or another phrase? It is also important to refer to intersex conditions as differences of sexual development, not disorders of sexual development. Additionally, intersex people should not be referred to as hermaphrodites. The only true hermaphrodites are nonhuman creatures, including snails, slugs and worms, hence the phrase is usually seen as derogatory. Intersex people are not the same as transgender people. Intersex people may, when they are old enough to provide informed consent, wish to undergo interventions to make themselves masculine or feminine, or they may not. They may identify their gender as being a man, a woman, non-binary, gender fluid, gender queer, fa’afafine, fakaleiti, whakawāhine, or they may use other terms and concepts to describe their gender. If intersex people do undergo interventions to become masculine or feminine, then they may then refer to themselves as transgender, or they may not. What is most important is that we respect the ways in which people wish to define themselves. One of the other key differences between intersex and transgender people, especially when they are young, is that intersex people often have treatments imposed on them without their consent,

Professional Development Patient Diversity

whereas transgender people often have to battle very hard to get the treatments they need. It is also worth noting that intersex people have sexuality, just as males and females do. Sexuality is the phrase used to describe what types of people we find sexually or interpersonally attractive. Intersex people may therefore describe themselves as heterosexual, gay, lesbian, bisexual, pansexual, asexual or takatāpui, just as males and females do.

Gender identity Due to the fact that we live in a society that has difficulty accepting intersex people, it is recommended – by both the medical fraternity and the intersex community – that intersex infants and children are reared as girls or boys, in order to prevent the stress of continual questions and challenges to a young person’s identity. The 1997 guidelines provided advice on which intersex conditions should be reared as which genders, on the basis of the available evidence that indicates which condition is most associated with which gender. This is social gender selection, which is free of surgical or hormonal interventions. Importantly, the 1997 guidelines also clearly state that when the young person begins to express a gender identity, that this must be supported, even if this differs from socially selected gender. Supporting the young person’s emerging identity removes the risk of psychosocial damage and promotes psychosocial wellbeing, and the absence of any surgical or hormonal intervention preserves the intersex person’s right to bodily autonomy, should they decide to have, or not have, surgical or hormonal intervention. Stigma, prejudice and discrimination are problems that are significant for the intersex community. Recent Australian research (see resources) shows that more than a third of intersex people negatively rate their experience with health care services, that intersex people experience significant socioeconomic disadvantage, and that suicide attempts by intersex people are 19 per cent, compared with the general population rate of less than three per cent.

A number of legal instruments support an informed consent approach to care that is founded on human rights. The Human Rights Act 1993 makes it illegal for people to be discriminated against on the basis of their sex, gender or sexuality. The 1996 Code of Health and Disability Services Consumers’ Rights states: “Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer”. Section 195a of the Crimes Act 1961 makes it an offence to fail to protect a child or vulnerable adult from risk of grievous bodily harm; this can include inappropriate medical interventions.

Recent developments In 2013 the Australian Senate’s Community Affairs Reference Committee undertook an inquiry into the “involuntary or coerced sterilisation of intersex people in Australia” resulting in 15 recommendations that were consistent with and added to the 1997 guidelines. Also in 2013, the United Nations Special Rapporteur on torture issued recommendations that all states should “repeal any law allowing forced genital normalising surgery”. In 2015 the Council of Europe Commissioner for Human Rights produced a research paper making eight recommendations, which again stated that ‘normalising’ surgery should be ended by member states. It added that there was an urgent need to develop public awareness and professional training with regard to intersex. Also in 2015, Malta became the first country in the world to enact legislation that explicitly prohibits sex assignment treatments until a minor is able to give informed consent. New Zealand’s Human Rights Commission reported on intersex concerns as part of its ‘To Be Who I Am’ inquiry and roundtable consultations. One of the next steps, following on consultation in 2016, is to look at establishing a government-supported advisory group. In 2016 the government also received recommendations arising from the United Nations review of the Convention on the Rights of the Child that related

to intersex children. These included developing a care protocol, mechanisms for legal redress following inappropriate medical interventions, and increased education for healthcare professionals.

Advocating for an ‘invisible’ minority Intersex people are largely invisible, which is a consequence of the society in which we live, dominated by the expectations of a gender binary between men and women. Intersex people can suffer physically, emotionally and socially as a result of this, and as a result of undergoing operations and hormone interventions to which they did not consent. Nurses have a responsibility to advocate for and support people who are experiencing social

It is a good idea to ask everyone about their preferred pronouns; do they wish to be referred to as he, she, them, or another phrase? injustice, inequality and the consequences of poor practice. Nursing has an important role in developing improved understanding and respect for intersex people’s human rights, and I invite all of you to become part of this movement. Author: Craig Waterworth, RN, PGCertTT, MSc, Professional Clinician – Massey University.

Further resources: Intersex Awareness Trust www.ianz.org.nz NZ Intersex Roundtable Report and Project www.hrc.co.nz/news/intersexroundtable-report Organisation Intersex International Allies https://oii.org.au/allies Intersex Stories and Statistics from Australia http://tinyurl.com/jh8bnnz Massey University short course Understanding and Supporting Intersex People www.tinyurl.com/jbtbtjh nursingreview.co.nz Issue 2 2017 23

Innovation & Technology

Health Navigator

App of the Month

FoodSwitch (nutrition app)

Webscope Check out these website recommendations from Kathy Holloway.

Dr Kathy Holloway

MakerNurse http://makernurse.com We know that nurses along with other health professionals, are innovative and skilled at providing ‘workarounds’ to meet the needs of those they serve. These innovations, however, often rarely make it out of the service in which they were created. This is recognised and celebrated in the US by the MakerNurse™ (a subsite of MakerHealth) website, launched in September 2013 with the support of the Robert Wood Johnson Foundation. The site was created with the goal of empowering nurses and to encourage nurse ‘making’ to change the face of healthcare. The site links to MakerHealth, which contains useful tools and resources that could help more nurses bring their ideas to fruition and lead improvements in patient care.

Site accessed 6 April 2017.

Lippincott Nursing Center www.nursingcenter.com Support your innovative practice by accessing this website created by American nurses for nurses. The longstanding site is a great portal destination for peer-reviewed nursing journals and continuing education resources. Joining the centre is free (just choose a login and password) and you can then access peer-reviewed journals, with more than 1,900 continuing education activities. Twice each month, the site features a nursing journal from the more than 70 nursing journals available on the site, enabling free online access to every article in the latest issue (the current one is Journal of Addictions Nursing). You also have access to free eNewsletters focused on your areas of interest, drug news updates, patient education materials and more.

Site accessed 6 April 2017.

Author: Dr Kathy Holloway is the director of Victoria University’s Graduate School of Nursing, Midwifery and Health. 24 Issue 2 2017

nursingreview.co.nz

app Overview ▶▶ Clinical score ▶▶ NZ relevance ▶▶ Technical score ▶▶ User score Pending ▶▶ Formal review (MARS) 4.2 out of 5 ▶▶ Availability Free for Apple & Android ▶▶ Full review https://goo.gl/P6J2uq

his New Zealand-developed app allows the user to search and compare nutritional information, ingredients and claims on 8,000 New Zealand food products. Using their smartphone or tablet the user can scan the barcode of a food label and get easy to interpret nutritional information on the product using a traffic light-style colour rating for levels of total fat, saturated fat, sugar, and salt. This allows them to compare products at a glance. They also receive immediate suggestions for ‘healthier’ alternative foods or products. PROS include: Produced by trustworthy organisations: The University of Auckland’s National Institute for Health Innovation, The George Institute for Global Health, and Bupa New Zealand. CONS include: Does not include information and messages on portion size. More information on this and other reviewed apps at: www.healthnavigator.org.nz/app-library.

The NZ App Project: Health Navigator, a health website run by a non-profit trust, is using technical and clinical reviewers to develop a New Zealand-based library of useful and relevant health apps. Nurses are invited to support the project by either recommending consumer-targeted health apps for review and/or offering to be app reviewers. Email sandra@healthnavigator.org.nz to find out more.

Innovation & Technology

Virtual clinics make their mark

Three nurses from diverse specialties share case studies of using telehealth technology in their respective practices.

Sensitive timing for rural cancer patient (Fiona Sayer, Thames Hospital)

iona Sayer got a call this particular day from Waikato Hospital’s oncology department to say that the latest blood test of Julie – a 54-yearold breast cancer patient who had had metastatic disease in her bones – did not look good, with disturbing liver function results. They were requesting a CT scan. Sayer, the oncology/haematology nurse coordinator of the small rural hospital in Thames, rang Julie, who already knew that something was wrong as new and worrying symptoms had emerged. Julie came into Thames ED, which was very busy that day, and after her scan

was transferred with her husband to Sayer’s chemotherapy room to wait for the rushed ED doctor to interpret the result. However, underway next door was the weekly telehealth clinic run by Julie’s Hamilton-based oncologist and Julie jumped at the opportunity to have her own oncologist deliver – via the TV screen – what she expected could be, and was, devastating news, rather than an ED doctor. With her husband holding her left hand and Sayers her right hand, Julie heard that the cancer was now in her liver, there were no further intervention options and the care plan would be comfort cares and symptom management.

Tough news to receive via a television screen, but Sayer points out that telehealth meant the care outcomes for this patient was a timely prognosis from her own oncologist – a person whom she knew and who knew her – and with whom she was comfortable asking clarification questions. Sayer says it also gave her patient and her husband a chance to thank the oncologist and bid him farewell. And she left the telehealth clinic with a developed care plan, the necessary referrals completed and prescriptions signed for her immediate needs. Continued on next page >>

HiNZ CONFERENCE 2017 & NZ Nursing Informatics Conference HiNZ CONFERENCE 2017 1-3 NOVEMBER 2017

\ Energy Events Centre Rotorua

Call for NZ nursing abstracts closes 16 June includes Nursing Informatics Conference \\Thursday 2 November Read more at hinz.org.nz/NZNICfP17

APPLY NOW FOR A HiNZ SCHOLARSHIP WORTH $998 Upskill yourself in digital health. Learn how technology is used by nurses around NZ and network with the experts. Conference organised by

Scholarship recipients get a free 3 day registration and full access to sessions across both conferences.

APPLICATIONS CLOSE 30 JUNE 2017 To find out more about the conferences go to hinz.org.nz

To view the eligibility criteria and apply online go to hinz.org.nz/scholarships In collaboration with

nursingreview.co.nz Issue 2 2017 25

Innovation & Technology

Zoom conferences reduce infection risk for CF adults (Robyn Baird, Christchurch Hospital)

obyn Baird is a clinical nurse specialist working with the about 85 adult clients with cystic fibrosis (CF) spread across the South Island – both urban and rural. New treatments mean that more and more people with CF are surviving into adulthood, with about 50 per cent of the CF population now aged over 16. The Christchurch Hospital-based nurse says recommended best practice for CF patients is quarterly review by a multidisciplinary team and since 2012 Canterbury’s Adult CF Service has been offering telehealth video conferencing for clients from secure hospital-to-hospital video conferencing facilities. But Baird says not all areas have these facilities; many patients still have to travel and the risk of infection or cross-infection is a major concern for CF adults. So the service decided to investigate in-home telehealth options and decided on the option of clients downloading the free videoconferencing software Zoom to the clients’ own devices (like laptops, home computers or tablets). Pros included easier access for clients, reduced infection risk and minimal costs. But cons included individuals needing adequate broadband speed, additional equipment to allow videoconferencing (i.e. camera/ headphones/laptop), and some clients being unable to upload information to the conference, such as portable spirometry. After a trial and pilot with suitable patients, the Zoom conferencing is being used successfully to replace the inpatient scheduled review for some rural remote patients, and also for some palliative patients and those awaiting transplant. It has also been used to review patients on home IV treatment and those requiring close follow-up. Baird envisages that future uses could include virtual exercise classes for CF adults to reduce the infection risk of in-person classes.

Virtual vascular clinic gives patient power (Sandra Almeida, Auckland City Hospital)

andra Almeida looked to nurseled virtual clinics by telephone to provide a more timely and convenient service for the abdominal aortic aneurysm (AAA) patients she works with as a clinical speciality nurse (CSN) at Auckland City Hospital’s vascular services. These clinics are particularly useful for patients needing ongoing surveillance after an endovascular aneurysm repair (EVAR) of an AAA and those undergoing AAA surveillance (EVAR uses stents and has replaced open aortic surgery as the treatment of choice for AAA, but it can have post-op complications years down the track.) Almeida says normal practice was that patients on surveillance have scans (usually six-monthly) and then wait for a face-to-face appointment with a consultant for the results. The feedback from the often elderly patients was that coming into an outpatient clinic just to be told that their results were okay was seen as a waste of time.

HiNZ scholarships These three stories were case study presentations at the Nursing Informatics arm of the Health Informatics New Zealand (HiNZ) 2016 conference. Thirty HiNZ conference scholarships are available to nurses and allied health professionals wanting to attend this year’s HiNZ conference in Rotorua from 1–3 November. For more information on each scholarship package (worth nearly $1,000) go to www.hinz.org.nz/page/scholarships. 26 Issue 2 2017

nursingreview.co.nz

After investigating the evidence for virtual clinics, Almeida proposed and piloted the option of virtual clinic appointments by phone instead. Under the virtual clinic model, Almeida attends the multidisciplinary meeting where the vascular team discusses the scan; she then phones the patient to inform them of the outcomes and any proposed investigations and management, as well as offering them education, answering questions and giving advice on what to do if they get any adverse symptoms – i.e. head to ED straightaway. Almeida stresses that virtual clinic patients are given the opportunity for a face-to-face appointment to discuss any concerns; patients who are cognitively impaired or mentally ill always have faceto-face appointments. She says telephone consultation requires a significant amount of knowledge, skill and judgement because of the lack of visual interaction and the decreased chances for patients to raise concerns instinctively. Some elderly patients and cultures also believed they should only see a doctor, but overall the five-month pilot – involving 116 patients in the first half of last year – showed high patient satisfaction and the take-up of clinic offers is still growing. Almeida says the virtual clinic is improving patient satisfaction and is also freeing up outpatient clinic appointments for new referrals and saving the service funding.

Leadership & Management

HCA training: making a difference to both staff and patients Nurse educator LYNLEY DAVIDSON outlines the impact a training framework for Waitemata District Health Board’s healthcare assistants has made on both HCAs and patient care.

“I

t’s given me confidence in myself – I feel that I can advocate for my patients now.” “Thanks so much for this opportunity – it’s changed my life.” This is just a taster of feedback received from healthcare assistants (HCAs) after experiencing a variety of training opportunities offered through Waitemata District Health Board’s (WDHB) HCA education framework. The unregulated HCA workforce provides a vital contribution to the frontline delivery of health care. While nationally there have been calls to standardise HCA education, employers still have a responsibility to ensure they are valued, have sufficient knowledge and skills to provide the highest standard of care and are supported to grow and develop. There is also an expectation that the workforce reflects the population. This article outlines how WDHB addresses these responsibilities. Waitemata employs over 500 HCAs. Over half are employed into adult medical/ surgical and rehab patient care areas, a third in mental health and the rest in the community, internal bureau and child and family (including midwifery). Those involved in direct patient care delivery work within different models of care but always under the direction and delegation of a registered nurse or midwife. Five years ago, WDHB had no formal structure or programme to educate and develop HCAs. Through a process of needs analysis and collaboration with charge nurses/midwives, managers, the nursing development service and Māori/ Pacific Island workforce development and recruitment, a robust framework is

now in place. This framework includes orientation, regular annual study days, a clear and easy to follow merit recognition programme (as per NZNO MECA), job descriptions and appraisals that encourage development, the opportunity to complete a Level 3 national qualification and a ‘New to HCA’ programme that targets Māori and Pacific peoples. While ongoing development work is still happening in specific clinical areas, the framework is embedded and we are seeing a difference to both care delivery and in the lives of the HCAs themselves. Two aspects of our programme are highlighted to demonstrate this difference.

New Zealand Level 3 Certificate Programme Gaining a healthcare qualification has two key positive outcomes. These are the impact that an increase in knowledge and skills has on patient care delivery, and the effect the attainment of the qualification has on the person who gains it. A formal evaluation of the pilot certificate programme, completed in 2013, clearly indicated an improvement in patient care delivery and a sense of personal achievement for the participants. The programme, now offered yearly, is integrated and modulised – a collaborative development between Waitemata and Waikato DHBs and Careerforce. Yearly evaluation from the HCA participants continues to provide rich narrative about the difference the course is making to their care delivery and consequently to the patients’ experience. Jeanne wrote: “I used to limit my contact with prisoners. I learnt that we can’t

discriminate and everyone should be treated with respect and dignity. Next time a prisoner came – I welcomed him and made sure he felt respected. The guard said later he had never seen the prisoner so calm”.

New to HCA Course This course is offered to Māori and Pacific people who wish to enter the health workforce but have no formal work experience. While some have cared for whānau, with no formal work record the chance of being employed in an acute healthcare environment is often low. Selection criteria are few, but include a passion to work in healthcare, reliability, and availability for full-time shift work. Once the participants have successfully completed the class work and three weeks of clinical placement with an experienced HCA, they can apply for vacancies within WDHB. In three years, 43 out of 47 have completed the course, with approximately 80 per cent then employed. While one outcome is employment, there are other benefits. Naomi has now been employed in the DHB for three years. “Both the New to HCA course and the Level 3 qualification (completed in 2016) have made such a difference to me. Knowing someone was prepared to support me and encourage me to develop means I can see my worth and what I can contribute”. (Her sister completed the course last year and is also now employed.) For 41-year-old Keileen, the New to HCA course and subsequent employment are a stepping stone to tertiary study as she is planning to begin a degree programme in nursing. nursingreview.co.nz Issue 2 2017 27

Leadership & Management

Time management tips for busy nurse leaders Nursing Review asked some nursing leaders to share some of their best time management tips. Michael McIlhone, Director of Nursing, Pegasus Health

Michael McIlhone.

Carey Campbell. 28 Issue 2 2017

Time management, or more specifically balancing your precious time, is a constant challenge for nurse leaders. The following are a few things that work for me. You might notice that some of my tips appear to be contrary to time management; however, if you can’t maintain a good balance during your working day then potentially you set yourself up for a pretty unproductive day! In no particular order: ▶▶ Don’t sit longer than 30 minutes; even in meetings, stand up and walk about. ▶▶ Turn off your incoming email alerts. ▶▶ When you read your emails, deal with at least 75 per cent of them when they arrive. ▶▶ Avoid too much caffeine. ▶▶ Block out your diary with tasks you need to do (i.e. writing papers). ▶▶ Use headphones or earplugs (a clear ‘do not disturb’ sign). ▶▶ Block 30 minutes a day for lunch. ▶▶ Always make time for someone who is distressed. ▶▶ If you need to work longer hours, compensate yourself with a walk or power breaks. ▶▶ Look out the window and see if the sun is shining. nursingreview.co.nz

Carey Campbell, Chief Nurse Advisor, Southern Cross Hospitals How to make the best use of your time (and that of others): Know your work style and most productive times ▶▶ Work out when you are at your most productive – for some it’s first thing in the morning, for others it may be later in the day – and work on your most challenging tasks at that time. ▶▶ Try to mitigate any probable interruptions and deal with those before concentrating on your most important and challenging task. ▶▶ Work on that most important task for a good period of time before having a short break. ▶▶ We can’t all work at 100 per cent constantly – so complete some of the more mundane or easier tasks when your energy levels have waned. ▶▶ Strangely enough, I tend to get heaps done on a Friday – so that’s often when I ‘catch up’ with the things that I haven’t been able to finish during the week. Be on time ▶▶ Use your Outlook calendar and set reminders to help you be on time for meetings and appointments. ▶▶ If it’s really important, or you have become ‘immune’ to your many reminders, set the alarm on your phone as well (the quacking duck noise is always a good one!). ▶▶ It’s such a timewaster for other attendees when meetings don’t

start and finish on time, so try not to be THAT person who is always late! Interruptions ▶▶ It is a totally unrealistic expectation never to have any interruptions in your work, especially as one of the key attributes of being a successful nurse leader is being available, approachable and accessible. ▶▶ The key to managing the impact of interruptions in your work is in how you react to these. Some suggestions are: ▶▶ Don’t get caught up in others’ emotions and their ‘rush’ (they will always feel their request is urgent; however, most interruptions are not genuinely crisis-driven). ▶▶ Take a deep breath and clear your head so you can assess the situation objectively and react appropriately. ▶▶ Try to stay calm on the outside (even if you feel rushed on the inside). ▶▶ If it’s genuinely important, act. ▶▶ If it’s not important, remember that others’ disorganisation/ panic/ drama should not make for your emergency!

Submissions welcome This is the debut of a new regular section sharing leadership and management tips and ideas. If you have any ideas for future topics – or have tips on time management or other areas you would like to share – feel free to email editor@nursingreview.co.nz.

Students Reflections

Student nurses:

leaders in the making

CATHLEEN ASPINALL argues that fresh eyes and critical thinking means nursing students can be leaders from their undergraduate days onwards and outlines how she and her students helped spur Nursing Review's new student-focused section.

Cathleen Aspinall.

tudent nurses can be leaders. This is a comment that polarises nursing faculty, clinical staff and student nurse opinion. Yet an essential element of strong nursing leadership is patient advocacy – and students are often best placed to do this. Fresh eyes steeped in best practice and the latest research can provide a critical commentary on the old ways of working and on organisational structures that can act as barriers to person-centred, evidence-based care. Students are often accused of being idealistic and not understanding what nursing is like in the real world; however, aligning what they may see in clinical practice with what they have been taught is often a very real dilemma for nursing students. Pedler, Burgoyne, and Boydell (2010) describe leadership as being an activity which generates socially useful outcomes. Students are also able to start practising leadership in this way. Rather than complaining about their experiences and walking away, students are challenged to investigate and critically analyse issues they come across in the clinical environment so as to help inform and add value to their nursing practice. Students are taught the need to be assertive, the need to challenge what they consider to be poor practice and to share what they know to be the best. This can be rather daunting for student nurses on clinical practice – as traditionally they have had little influence in the clinical settings they visit. Therefore students must become as competent in these areas as all others during their undergraduate studies.

Encouraging student voices Educating and developing students as leaders is a central purpose of the Bachelor of Nursing programme at the University of Auckland where I teach. To this end we have developed an assignment for second year students in which they are expected to demonstrate an informed perspective of their clinical experience that is underpinned by relevant literature, evidence, policies or guidelines. The assignment is solution focused, they are required to seek out evidence about issues identified and to provide practice recommendations. The work is presented in the form of a journal article that students will be encouraged to submit to publications like Nursing Review. While developing the assignment, I approached Nursing Review to see whether they were interested in developing a section specifically for nursing students to present critical reflections and other items relevant to student nurse life. Our students were surveyed and found to be overwhelmingly positive about their desire to read and contribute to such a section. Although similar

platforms exist internationally, the new Nursing Review section will be the first of its kind in New Zealand. Using a solution-focused, analytical approach, students will develop a wider understanding of what they see and experience in the clinical environment. Finding a voice, albeit in print or online, demonstrates leadership by informing the community as a whole. This process will contribute to the development of pre-registration students who can challenge practice issues in a reasoned way. Ultimately it provides the scaffold to developing new graduate nurses who are leaders in nursing practice, simultaneously contributing to new initiatives which will showcase a student nurse perspective of the clinical practice environment.

Reference: Pedler M, Burgoyne J, & Boydell T (2010). A Manager's Guide to Leadership. McGraw-Hill Education (UK). AUTHOR: Cathleen Aspinall is a professional teaching fellow at the University of Auckland school of nursing. nursingreview.co.nz Issue 2 2017 29

Students Reflections

Reflection: on the cultural protocols of a death RENAE PORTER, a third year nursing student at Te Whare Wānanga o Awanuiārangi, reflects on the clinical, cultural and personal experience following the release of a tūpāpaku (deceased person’s body). Renae Porter.

n my third day of my emergency department placement at Whakatane Hospital, I arrived on shift and was making my way to the nurses’ station. I passed a room and noticed the curtains closed, lights out and a laminated picture of butterflies pinned to the curtain. Upon entering the nurses’ station, I learnt a death had occurred in that room and the butterfly picture signified this. I questioned the tikanga and kawa (protocols) surrounding patient deaths and asked if I could take part in the blessing of that room as I had a compelling urge to participate. As a ‘Te Ōhanga Mataora Paetahi’ nursing student from Te Whare Wānanga o Awanuiārangi, the principles of kawa whakaruruhau (cultural safety) are promoted as part of my nursing practice.

I met with the priest on her arrival to the ward. Following whakawhanaungatanga, she retrieved a notebook from the nurse’s station in which she recorded details of her duty and placed an identification sticker of the deceased underneath. We entered the room and I closed the curtains behind me. She filled a cup with water and began to karakia over it. The priest acknowledged the deceased before making her way around the room performing karakia and sprinkling water. I remained behind her during this stage with my hands clasped in front of me and my head slightly bowed. A sense of ‘presence’ surrounded me and my wairua (spirit) and hinengaro (mind) were fully engaged. Once the entire room was blessed she began to recite the Lord’s Prayer in Māori. At this stage I moved up beside her instinctively and joined in the karakia.

Following this process, the tapu had been lifted and a state of noa was imposed upon the room and ourselves. We exited the room and shared whakawhanaungatanga once again before returning to work. Upon reflection, this clinical experience highlighted both the importance of tikanga Māori and kawa whakaruruhau following the release of a tūpāpaku and personally for me the importance of identifying and applying knowledge of cultural safety within my nursing practice. It allowed me to pay tribute to and provided (without me even knowing at the time) closure and acceptance of the passing of someone with significant mana who offered manaaki and tautoko throughout my studies – someone I knew and respected. I would encourage students to embrace cultural practices throughout their placements.

Reflection:

TRISTIN SLATER, a third year student nurse at the University on being both a learner and critical observer of Auckland, I was only a small needed a tetanus he had been this event. Not because stabbed. By her and helpless nursing injection, an idea she of what I watched the reflects on trying sister. Three student, tripping over strongly opposed. As I nurse do, but because times. But it my feet trying to keep approached her, needle of what I did not do. to administer a wasn’t until days later up with the busyness in hand, she winced, My knowledge and tetanus injection when I was trying of a fully qualified and then cried, screamed, capabilities made me sleep after a late competent registered swore and pushed me responsible for my own to an attack toshift, that this fact nurse. At least that’s away. It was at that inaction. victim. finally settled into my how she saw me. I saw point that my nurse On reflection I

Tristin Slater. 30 Issue 2 2017

consciousness enough to bring tears to my eyes. Amanda (pseudonym) was only 14 years old when she came into my care. Although it wasn’t really my care but the care of the nurse I was following around for the day, like a shadow.

nursingreview.co.nz

myself as someone who was well educated, with practical skills to boot. Perhaps a bit shell-shocked and out of my comfort zone, but otherwise completely capable. Because of her injuries, Amanda

took command of the situation. She took the needle from my hand, administered the injection and briskly left the room, apologising for interrupting my learning experience. Through my nursing career, I will remember

wonder, faced with this situation again, would I have done anything differently? Would I have spoken up? Would I follow the principles of patient-centred care we are taught? In a hospital environment, people

Students Reflections

Nursing study tips:

cultural safety articles Nursing Review will now regularly share some useful articles from our online archive on topics of interest to student nurses and others. First up, cultural safety (kawa whakaruruhau). What is cultural safety and why does it matter? Nursing Review, August 2011

Glossary ▶▶ Te Ōhanga Mataora Paetahi: ▶▶ the face that cradles wellness ▶▶ Tikanga: practices and beliefs or that which is right within a Māori worldview ▶▶ Whakawhanaungatanga: the process of getting to know each other or building relationships. ▶▶ Karakia: prayer or incantation ▶▶ Noa: no longer sacred or having no spiritual restrictions ▶▶ Manaaki: to take care of ▶▶ Tautoko: support

Article by Fran Richardson looking at nurses using cultural safety in everyday practice. ▶▶ https://goo.gl/u6Pv90

Cultural safety bibliography celebrates ‘coming of age’ Nursing Review, April 2013 Article and link to Nursing Council bibliography tracing cultural safety from its origins in the late 1980s to 2013. ▶▶ https://goo.gl/EYqYay

Māori nursing history: Kaunihera celebrates 30th anniversary Nursing Review, December 2014

perceive students in very different ways. Perhaps the most common image is a young, immature student, inexperienced and hesitant. However, my time as a student nurse has taught me something that others may find surprising: we are valuable. As students, we learn best practice, research key topics, study pathophysiology, familiarise ourselves with legislation and

codes and perhaps most importantly, we are a fresh set of eyes. However, we also have a responsibility to speak up, ask questions, be confident and to critically analyse our nursing practice and that of the registered nurses who are our role models. Throughout my nursing degree, I am learning to find the balance between being a learner and a critic of professional practice.

A Māori nurse leader looks back to the early 1980s and the cultural groundswell that led to the founding of Te Kaunihera o Ngā Neehi Māori o Aotearoa and the cultural safety movement. ▶▶ https://goo.gl/kle49B

Cultural safety: developing self-awareness through reflective practice Nursing Review, April 2016 The first of three articles by Katrina Fyers and Sallie Greenwood on aspects of putting cultural safety into practice. The first focuses on using reflective writing to foster self-awareness. ▶▶ https://goo.gl/k8cOVu

Cultural safety and relational practice: ways of being with ourselves and others Nursing Review, August 2016 The second Fyers/Greenwood article looks at how self-knowledge enhances relational practice. ▶▶ https://goo.gl/T4BBZP

Cultural safety: becoming a reflexive practitioner Nursing Review, October 2016 The third Fyers/Greenwood article focuses on using reflexive thinking to help nurses be more culturally safe practitioners. ▶▶ https://goo.gl/jEZWT6

nursingreview.co.nz Issue 2 2017 31

Opinion College of Nurses

New resources: LIZ MANNING outlines a raft of new resources developed by the College of Nurses.

ver the past six months the college has made a significant investment into creating new membership resources. This article provides an overview of these and how they benefit college members.

Website The website has been reviewed and redesigned with a whole new colour palette. Online navigation is simpler and presents a professional, streamlined portal to access the new and existing resources.

Nurseportfolio.nz The college is delighted to have the opportunity to provide an ePortfolio to its members and institution partners. The whole site, including the help guides, have been redesigned to support users to create their professional nursing portfolios. There are seven collections (templates) of Nursing Council of New Zealand (NCNZ) competencies available. A new collection, for nurses in clinical management roles, has been added and all the other collections have been completely refreshed and updated. Available collections are: ▶▶ Registered Nurse: clinical, clinical management, education, policy, research, management ▶▶ Nurse Practitioner. The links and resources box provides you with information to help you complete your portfolio. Access is via the college website and access is free for members. Organisations who wish to set up their own pages on the site should contact the college administrator.

Professional supervision Nursing supervision provided by nurses for nurses. The college is offering providers of professional nursing supervision the chance to have an endorsed profile on the college website.

32 Issue 2 2017

nursingreview.co.nz

supervision to ePortfolios

Nurses seeking supervision can check out the supervisor profiles on the the Professional Nursing Supervision section of the website and choose which supervisor they would like to approach. Supervision arrangements and costs are between the supervisor and supervisee and are independent of the college. Supervisors do not have to be college members, but do need to be a registered nurse (RN) or nurse practitioner (NP) with an annual practising certificate. Potential supervisors can apply for selection through the new section: www.nurse.org.nz/professional-nursingsupervisors.html

Professional support resources A suite of professional support guides is also now available on the college website. The four powerpoint presentations cover common themes and provide general advice. The presentations are: ▶▶ About the college – an overview of what the college offers. ▶▶ Portfolios – Why we do portfolios and how to set up a portfolio hard copy or ePortfolio. ▶▶ Bullying – Being bullied? Managing a bullying situation? ▶▶ Practice issues: ▶▶ Employer: how to manage performance improvement or disciplinary processes. ▶▶ Employee: how to engage successfully in a performance improvement process and deal with a disciplinary process. The presentations are self-paced and provide accessible pragmatic advice and information to underpin the support the college already offers: www.nurse.org.nz/ powerpoint-presentations.html

Endorsements for conferences, workshops and journals The college already provides endorsement for conferences, workshops and seminars

but is now also endorsing journal articles, supporting nursing professional development activities in Nursing Review magazine and also NZ Doctor magazine. More information is available on the relevant websites and on the college website. Also check the college website for conference and workshop endorsement opportunities and for journal items please contact the college administrator at admin@nurse.org.nz.

Supervisors for NP candidates The college has created a suite of online resources for the supervisors of NP candidates in recognition that this group is often under-supported but is vital for the development of New Zealand’s nurse practitioner (NP) workforce. The multimedia resources include five short video clips, web links, key documents and guidelines. They are aimed to concisely deliver important messages to very busy people about becoming a supervisor to an NP candidate in a variety of settings, including district health boards and GP practices. The topics included are: Supervising to best effect; the NP scope, domains and competencies (what they are and how to use them); the NP application process (the evidential requirements); prescribing practice (reviewing practice against prescribing competencies); employing NP candidates (contractual and employment considerations). Any health professional supervising an NP candidate – or who has been approached to be a supervisor – is welcome to view and share these resources. The college also continues to provide workshops, indemnity insurance and networking opportunities to members – you can find out more about membership at www.nurse.org.nz.

Conferences

Upcoming conferences To submit a nursing conference or related event, please email editor@nursingreview.co.nz

New Zealand Wound Care Society 8th National Conference 2017 ▶▶ 18-20 May 2017 ▶▶ Rotorua ▶▶ www.nzwcs.org.nz

Combined New Zealand Rheumatology Association/ Australian Rheumatology Association and Rheumatology Health Professionals Association Annual Scientific Meeting 2017 ▶▶ 20-23 May 2017 ▶▶ Auckland ▶▶ www.araconference.com

Women’s Health College NZNO Inaugural Conference 2017 ▶▶ 25-27 May 2017 ▶▶ Auckland ▶▶ https://goo.gl/BxFAYn

Perinatal Society of New Zealand Annual Scientific Meeting 2017 ▶▶ 14 June 2017 ▶▶ Wellington ▶▶ https://goo.gl/F6ejVJ

NZNO Mental Health Nurses Section Forum 2017 ▶▶ 4 August 2017 ▶▶ Wellington ▶▶ https://goo.gl/C7EtdS

NZNO Indigenous Nurses Aotearoa Conference 2017 ▶▶ 4-6 August 2017 ▶▶ Auckland ▶▶ www.nzno.org.nz/groups/te_runanga

New Zealand Dermatology Nurses’ Society 12th National Conference ▶▶ 17-18 August 2017 ▶▶ Queenstown ▶▶ www.nzdermatologynurses.nz/358618

New Zealand Association of Clinical Research 13th Annual Conference ▶▶ 17-18 August 2017 ▶▶ Auckland ▶▶ www.nzacres2017.org.nz

New Zealand Faith Community Nursing Association Conference 2017

Infection Prevention and Control Nurses College NZNO Conference 2017

▶▶ 8-9 September 2017 ▶▶ Auckland ▶▶ www.faithcommunitynursing.nz

▶▶ 15-18 October 2017 ▶▶ Auckland ▶▶ https://goo.gl/c1cxi2

New Zealand Nurses Organisation Conference and AGM 2017

44th Annual Conference of the Perioperative Nurses College of NZNO

▶▶ 19-21 September 2017 ▶▶ Wellington ▶▶ https://goo.gl/My09vB

New Zealand Occupational Health Nurses’ Association Conference 2017 ▶▶ 21-22 September 2017 ▶▶ New Plymouth ▶▶ https://goo.gl/UkRbD6

18th Australasian Nurse Educators Conference 2017 ▶▶ 28-30 September 017 ▶▶ Christchurch ▶▶ http://anec.ac.nz

Palliative Care Nurses New Zealand Conference 2017 ▶▶ 9-10 October 2017 ▶▶ Wellington ▶▶ www.eenz.com/pcnnz17

5th International Conference of Te Ao Maramatanga/New Zealand College of Mental Health Nurses ▶▶ 10-11 October 2017 ▶▶ Hamilton ▶▶ https://goo.gl/0YZgeD

New Zealand Urological Nurses Society/Urological Society of Australia and New Zealand (New Zealand section) Conference 2017 ▶▶ 11-13 October 2017 ▶▶ Tauranga ▶▶ https://goo.gl/AdkmQQ

26th Annual College of Emergency Nurses New Zealand Conference 2017

▶▶ 19-21 October 2017 ▶▶ Napier ▶▶ www.confer.co.nz/periop2017

The Australian and NZ Orthopaedic Nurses Association Conference 2017 ▶▶ 25-27 October 2017 ▶▶ Perth ▶▶ www.anzonaconference.net

NZNO Nurse Managers Section 2017 Conference ▶▶ 2-3 November 2017 ▶▶ Dunedin ▶▶ https://goo.gl/Fuyxae

Health Informatics New Zealand (HiNZ) and NZ Nursing Informatics Conference 2017 ▶▶ 1-3 November 2017 ▶▶ Rotorua ▶▶ www.hinz.org.nz/?page=2017HINZConf

NZNO/College of Air and Surface Transport Nurses Aeromedical Symposium ▶▶ 13 November 2017 ▶▶ Christchurch ▶▶ https://goo.gl/m7UtTy

NZ Gastroenterology Annual Scientific Meeting 2017 NZ Society of Gastroenterology/ NZNO Gastroenterology Nurses Section ▶▶ 22-24 November 2017 ▶▶ AUCKLAND ▶▶ www.gastro2017.co.nz

▶▶ 13-14 October 2017 ▶▶ Queenstown ▶▶ www.cennz2017qtown.co.nz nursingreview.co.nz Issue 2 2017 33

Seriously tired? NTA1731

Shift workers are 6 times more likely to die in crashes caused by tiredness. If you finish your shift and you feel more tired than usual, have a 15 minute nap before you drive home. It could save your life.