Nursing Review 2018 issue 2

Issue 2 June/July 2018

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NEW ZEALAND’S INDEPENDENT NURSING SERIES

Mental health Inquiry insights from the ward floor

Free 60-minute PD learning activity Blood clots in pregnancy Leadership & Management Heading towards a tough winter

Long-term conditions Heartfelt heart nursing Winter respiratory care Diabetes nurse researcher WWW.NURSINGREVIEW.CO.NZ

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• Culture and Cultural Competency • Working with Migrant Patients

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• Intercultural Competence for the Migrant Workforce • Managing Cultural Diverse Teams

Contents

ED’s letter

Inside:

New Government’s first health budget big but not bold

As Nursing Review was close to press, the Health Minister presented his first budget.

Expectations were running high, particularly in the DHB nursing sector, where a winter strike is on the cards if funding isn’t found to deliver a pay offer that meets frustrated nurses’ safe staffing and fair pay concerns.

But the budget did not make any signals about how much the Government was ready to commit, with Finance Minister Grant Robertson not ready to reveal how much of its tagged contingencies fund was labelled ‘nursing’ while negotiations were still underway. (Links to full details of the health budget are online at www.nursingreview.co.nz, including extending nurses in secondary schools’ service.)

Memo Musa, NZNO president, says it is now a case of waiting to see how the Government prioritises nursing when distributing the contingencies fund.

“We hope that nursing will be a high priority due to the fact that nursing is the biggest health professional workforce and really the backbone of the health system,” he says.

Overall, he says, while operational funding has not not greatly increased, the budget does show a roadmap to rebuilding the health service – literally, in the case of the large capital investment being put into infrastructure.

Meanwhile College of Nurses executive director Professor Jenny Carryer is frustrated that once again budget documents talked about reducing GP fees rather than making it clear that increases in capitation funding covered the whole general practice team, including nurse practitioners, practice nurses and others.

“Why do we have a brand new minister still talking about GP fees? NPs will get the funding, so why don’t we talk about the general practice team, not just GPs? Why do we keep one workforce invisible in the public eye?”

Carryer says she had been looking for the budget to provide signs that the Government was ready to do things differently and this hasn’t happened. This budget, she says, needed to focus on topping up funding for core services and infrastructure.

“But I’m hoping, going forward, that the coalition government has the courage to be a lot more courageous about doing some things differently.”

N.B. Our 60-minute professional development article and learning activity this edition looks at deep vein thrombosis – check out Preventing and managing blood clots in pregnancy on page 16.

Fiona Cassie, Editor editor@nursingreview.co.nz www.nursingreview.co.nz

News

2

Round-up: News briefs + bulletin board

Focus: Long-Term Conditions

4 8 10 13

Mental health: Pressures on the ward floor Diabetes: Curiosity turns nurse into leading researcher Respiratory tips for winter Heartfelt heart failure nursing

Professional Development

15 16

24

CAT: Does oxygen help post-stroke?

FREE 60-MINUTE professional development activity: Preventing and managing blood clots in pregnancy Blood management – treasuring every drop

Innovation & Technology

25 26

App of the month: MS Energise Nurse-developed app for saving client texts

Leadership & Management

27

Winter is coming – a director of nursing prepares

Students 29 30

Traffic jams: Using metaphors to learn pathophysiology Student leader: From autopsies to advocacy

Opinion 31

College of Nurses: NGAIRA HARKER – School nurses deserve better

Conferences 32

Upcoming conferences

EDITOR

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

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Rob Tuitama 04 915 9783 rob.tuitama@nzme.co.nz

COMMERCIAL MANAGER Fiona Reid

PRODUCTION

Vol 18 Issue 2

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

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Round-up News briefs

News briefs

Read the full versions of these online articles at www.nursingreview.co.nz/subject/news.

Waiting game for strike ballot, Budget and panel

After a heady few months of district health board nurses’ pent-up frustration over safe staffing and pay issues rising to the surface, it was a waiting game as Nursing Review went to press whether a resolution could be reached without a winter strike.

A week out from the May 17 Budget, the independent panel set up to attempt to resolve the impasse had delivered confidential, interim recommendations to the New Zealand Nurses Organisation and the 20 DHBs on a possible resolution to the deal that affects around 27,000 nurses, midwives and healthcare assistants.

In the same week, an NZNO delegation made a last-minute Budget appeal at Parliament, meeting with Finance Minister Grant Robertson and Health Minister Dr David Clark as well as, unexpectedly, Prime Minister Jacinda Ardern. It was now a matter of waiting to see whether that positive meeting was reflected in the Budget.

NZNO’s DHB nurse, midwife and healthcare assistant members started voting on April 23 in a month-long secret ballot to decide whether to take two 24hour strikes on July 5 and 12. This follows rejecting in March a revised offer of a 2 per cent pay rise per year over two years, with the carrot of a possible pay equity settlement starting on July next year.

DHB spokesperson Helen Mason said on the announcement of the strike ballot that the DHBs remained optimistic that the independent panel process would find a pathway to address the pay and workload issues raised. She added that the NZNO #HealthNeedsNursing rallies held across the country had made the frustration of NZNO members very clear and DHBs understood the purpose of the strike ballot. The DHBs started working in late March on a contingency plan for possible strike action.

The strike ballot was to close on May 25 with any new DHB pay offer resulting from the panel also expected to be tabled 2 Issue 2

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in late May, with NZNO pencilling in possible ‘face-to-face’ ratification meetings in June if the union decides to put the offer to members.

Caps, capes and umbrellas: nurses march nationwide for safer staffing Thousands of nurses and their supporters – braving rain in much of the North Island – joined marches from Whangarei to Dunedin to mark International Nurses Day (May 12) by calling for safer staffing.

Brought together by the ‘Nurse Florence’ #hearourvoices social media movement, nurses donned paper caps, hired red capes, created banners and placards and put on their special t-shirts. The mood was often festive, but the placard messages were sobering and direct: “These cuts won’t heal”, “Patient safety can’t wait” and

“Fighting for life”. In all, there were 15 marches and rallies organised across the country. March organisers read a message from the two anonymous Nurse Florence founders to the gatherings, in which the pair said the marches were a response to nurses working too long in unsafe, understaffed environments that put them and their patients at risk. Meanwhile, the Nurse Florence petition, also addressing safe staffing issues and addressed to Prime Minister Jacinda Ardern, was just short of 33,500 signatures on May 15. The Nurse Florence founders – a new graduate registered nurse and an enrolled nurse working in mental health – were strangers before launching the ‘New Zealand, please hear our voice’ Facebook page in early March, in which membership quickly snowballed to more than 45,000.

A short history of DHB pay campaigns and strikes 1985: ’Nurses are Worth More’ campaign – first nurses’ march on Parliament.

1989: Public hospital nurses hold first and only national strike.

1991: Employment Contracts Act (1991) breakdown of national bargaining.

1992-3: Several regions take strike action.

1999-2001: Waikato Hospital and Christchurch Hospital nurses strike.

2003: NZNO launches ‘Fair Pay’ campaign, including a call for mandated nurse-topatient ratios.

2004: National negotiations begin between NZNO and DHBs, but stall until mandated nurse-to-patient ratios are taken off the table. Pre-Christmas deal settled for 20–30 per cent fair pay ‘jolt’.

2005-7: Safe Staffing/Healthy Workplaces (SSHW) Inquiry begins and leads to the setting up in 2007 of SSHW Unit as joint NZNO/DHB initiative.

2009: Three demonstration sites set up to develop SSHW Unit’s Care Capacity Demand Management (CCDM) safe staffing tools.

June 2017: NZNO/DHB MECA talks get underway. Only one DHB has fully implemented CCDM tools to ensure safe staffing levels on all wards.

Dec 2017-March 2018: DHB NZNO nurses vote to reject DHBs’ offer in December, parties go into mediation and revised offer is voted down in March.

April 23-May 25 2018: DHB NZNO nurses vote in secret ballot whether to strike on July 5 and July 12. At the same time, an independent panel hears submissions from DHBs and NZNO with the aim of finding a solution to prevent a winter strike.

Round-up Bulletin board

Bulletin board Action plan launched to boost nursing’s ability to enhance Kiwis’ health Pay equity, a national nursing model of care, training for all charge nurse managers, boosting the Māori nursing numbers, and safe staffing are all part of a new NZNO action plan for nursing.

The New Zealand Nurses Organisation in late March launched its Strategy for Nursing 2018–2023 to inform its work plan for the next six years with a focus on addressing funding and other barriers to nurses’ ability to improve the health of all New Zealanders. The strategy builds on the current work plan for pay equity, pay parity, safe staffing and full employment for new graduate nurses and adds new focuses, including developing a nationwide core model of care for nursing, increases in postgraduate funding, promoting nursing as a career, and the mandatory provision of leadership training for charge nurse managers.

Positive evaluation of NP ‘registrar’ programmes An evaluation of the pilot registrar-style Nurse Practitioner Training Programme (NPTP) was positive, but the Ministry of Health sought further feedback on whether to fund more. The positive evaluation report of the first cohort of NP graduates from the two NPTP programmes was released in March by the Ministry of Health.

Three NZ nursing schools make global top 100 For the first time, three New Zealand nursing schools have made the top 100 in a global university ranking survey.

Now in its eighth year, the annual QS World University Rankings rank 1,130 institutions across 48 subjects – including nursing since 2016 – by comparing academic reputation, employer reputation, research citations and impact. The highest-ranked New Zealand university school this year is the University of Auckland at 41st-equal with Queensland’s Griffith University (up from 50th last year) and for the first time the Auckland University of Technology (AUT) and University of Otago nursing schools have both made the top 100.

Rural Nurses working party form partnership with RGPN A rural new graduate programme and a workforce stocktake are on the agenda for Rural Nurses New Zealand, who in April announced their partnership with the Rural General Practice Network during the National Rural Health conference. The announcement was made by Rural Nurses New Zealand (RNNZ) chair Rhonda Johnson and the RGPN chair and nurse practitioner Sharon Hansen. Nurses attending last year’s conference kicked off the creation of RRNZ after a number of nurses expressed concern that the nursing voice had slowly got lost in the RGPN and it was perceived by some as more doctor-focused. Johnson said the group had looked at a number of partnering options and RGPN had been very supportive of the group’s mission to raise the profile of rural nursing.

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Focus Mental health

Nurses should not be scared to come to work

FIONA CASSIE talks to some inpatient mental health nurses about the pressures on the ward floor leading up to the previous and most recent Mental Health and Addictions Inquiries.

“My partner fears for my safety every shift now.” – Enrolled nurse, acute inpatient mental health care “A frightened bunch of young nurses who want to be good nurses but are constantly in fear.” – Mental health registered nurse with 35 years’ experience “You see staff getting injured and leaving – some being injured permanently – physically and emotionally for the rest of their lives…” – Registered nurse providing professional supervision for mental health nurses for more than two decades The above are mental health nurses describing to Nursing Review some of the worst of working in today’s acute inpatient settings.

Below are excerpts from submissions to the most recent ministerial inquiry into mental health – back in 1995.

“Bed numbers have been reduced to such an extent that most services now run on the seat of their pants.”

“This hospital has experienced a gradual leaching-out of experienced registered nurse staff over the last several years … replaced by nurses with reduced levels of experience in mental health nursing.” “… seen the growth of a deep-seated defensive mentality among many staff in response to resource shortages, degenerating facilities, future service uncertainty and burn-out in the face of rising workloads and the high risk of violence.”

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T

here may never have been a ‘good old days’ in mental health.

While progress has been made in the intervening decades between inquiries, the cyclical falling in and out of the spotlight of mental health has meant that investment in services, facilities and staff has not matched the recent dramatic growth in demand. In 2016-17 more than 170,000 people used specialist mental health and addiction services – 71 per cent up on a decade earlier.

Nobody is saying that today’s services are all bad – too often stretched and stressed, yes, and staff too often feeling unsafe – but despite this, clinicians work hard to make a positive difference for their clients. And 79–80 per cent of 6,610 consumer respondents in a 2016 survey expressed overall satisfaction with the services they received and were ready to recommend services to friends and family in need.

Among those committed clinicians are mental health nursing veterans Sally McPherson and Kathryn Brankin, who a generation ago were so concerned about mental health services that they joined forces to make a submission in person to Judge Ken Mason – the chair of the 1995-96 ministerial inquiry that bears his name.

Brankin recalls that in the 1990s acute wards were often just expected to stretch to fit whoever came through the door.

“If you needed a bed you just went under the stairwell and physically pulled out a bed and moved it into an

interview room or a doctor’s office.”

When she and McPherson spoke to Mason about the stress staff were under and their fears for the safety of patients being discharged too early, she had 13 years of mental health nursing under her belt.

In the 23 years since, many things have improved – including patients no longer being put in eight-bed dormitories, families included more, the decreasing use of seclusion, and increases in postgraduate study opportunities for new and existing mental health nurses.

But in recent years there have been growing reports of a mental health and addictions service, both in the community and inpatient, struggling to meet the demands being placed on it.

This has resulted in some people falling between the gaps, sometimes tragically, and some staff being injured, sometimes permanently, and the announcement of the country’s sixth major inquiry into mental health now being underway.

That was then – this is now “The pressure is completely different now,” says Brankin, comparing 1995 with now.

McPherson, who retired in mid-April after 45 years in mental health nursing, agrees.

She’s been around long

Focus Mental health

enough to see not only the cyclical waxing and waning in investment and support for mental health services between the spotlight of inquiries, but also a spiralling trend upwards in patient demand, acuity and assaults on staff.

“The amount of violence that nurses are exposed to over the last 15 years is much more than it ever was last century,” says McPherson. Although for much of her later career she worked in the ‘sanctuary’ of older people’s mental health, she was for decades the listening ear, as their professional supervisor, to many mental health nurses working in acute inpatient units.

“You see the people who are damaged, the people who can’t go to work, the people who are depressed, who are anxious and who are permanently injured – physically and emotionally,” she says.

“And you think, [nurses] shouldn’t go to work to have that happen [to them].”

It wasn’t always like this. McPherson was a charge nurse at Christchurch’s Sunnyside Hospital in the heady days of de-institutionalisation in the 1970s and ‘80s and loved the challenge and chance to innovate that it brought. “The whole of Sunnyside Hospital felt like what it was meant to be – which was a therapeutic community.”

But the health reforms of the 1990s that followed were, in McPherson’s view, too driven by balance sheet bottom lines and not enough by patient need. So after being challenged by Judge Mason during their 1995 submission to think about their roles as nurses and leaders in supporting a system they felt was too often failing clients, she made the call in the late 1990s to step back from the management path

and become a clinician in older people’s mental health. It is a move she has not regretted and she is proud to have been part of Christchurch’s innovative service to older clients.

“And there is no way I would be able to survive in acute inpatient mental health services as it is now,” she adds.

Changing acuity: caring for the most unwell of the unwell The new millennium brought with it a nationwide push for setting new benchmarks in practice standards for inpatient mental health, including minimising the use of restraint and, more recently, seclusion for clients behaving violently.

Clinicians largely agree with the philosophy and the use of seclusion has decreased by 25 per cent since 2009.

But McPherson, for one, argues there should have been a matching push for ensuring minimum staffing numbers, so nurses can consistently deliver the new strategies safely.

“What they’ve brought in its [physical restraint and seclusion] place is not enough to keep staff safe,” she says. “Now staff are having to ring for the police to come and manage patient behaviour in inpatient wards, rather than staff managing that themselves.”

At the same time, she says, the focus on treating and supporting more acute mental health clients in the community means the clients who do make it “through the gates” into acute inpatient care are now the most unwell of the unwell. “I don’t think staffing has changed to reflect the increasing acuity of patients.”

Brankin adds that even though there are more nurses on the floor than in 1995, other expectations on them are up too, including faster turnaround of patients, more documentation requirements, and a lot more involvement with family members.

“It’s what we should be doing, but it [working with families] is timeconsuming … that is, if families are still

around and aren’t burnt out themselves.”

Then there is the time spent orientating and supporting agency or new staff who are plugging the gap left by experienced staff who are on sick leave or ACC leave or who have left the service.

Safety, assaults and compassion When things go wrong, they can go really wrong.

“I think our unit has the most disreputable reputation for having the most assaults and seclusion events – maybe in the South Island,” says Keith Knight.

A clinical nurse specialist, Knight has been in mental health nursing for 20 years. Most recently he has been working in a small inpatient unit caring for people with intellectual disabilities with challenging behaviours, alongside forensic clients being held under the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003.

Knight says the biggest issue facing the unit has been housing these two groups in an unfit-for-purpose building, resulting in the unit’s next biggest issue, the number of times staff have been assaulted, including himself.

“Head injuries are the main ones – when we get a kick or a punch to the head. Or bitten.”

Changes have been made in the care of one client, which have reduced the assaults, but Knight says the unit still has staff on extended ACC leave, and the incidents have left their mark on the predominantly mature female staff working with clients who are often large and male.

“Are we expecting 50-year-old-plus women to be rolling around on the floor? … it’s not very nice,” he says. “That then creates its own issues, with staff feeling anxious, not wanting to come to work, and fearful.”

His DHB has promised staff new, purpose-built pods to better meet client and staff needs, but that is at least two years away. nursingreview.co.nz Issue 2 5

Focus Mental health An enrolled nurse who has been working in an acute mental health inpatient ward since graduating five years ago, says every day she wonders whether this will be the day she is seriously assaulted.

“I have already been assaulted, which required time off for concussion; other times it’s the ‘not so serious’ slapped, spat at, verbally abused and continuous threats of assaults,” says the nurse, who wishes to remain anonymous. “I have witnessed many assaults … that appear to be brushed under the mat or minimised. It is not okay. I have also witnessed vulnerable patients who have been assaulted by other patients.”

“The pressure is completely different now.”

She says her partner fears for her safety every shift and is saving money in the hope she will leave mental health if she knows he can support her until she finds other work. The EN chose acute mental health as she wanted to care for the people “others had stopped caring for” but, says much of her shift is spent running around trying to keep her patients safe and just doing basic nursing tasks.

Staff are frequently on double shifts or extra duties and she says at times she has wanted to walk out when asked to stay, but is stopped by the fear of what would happen if she did. The EN says she can also find herself overseeing new RNs who find themselves in charge of acute wards when fresh out of training.

Another acute inpatient nurse with five years under her belt told Nursing Review that an assault at work has left her suffering panic attacks and the only thing that has stopped her moving on is the need to pass on skills and support to the new graduates staffing the wards.

Brankin, who left acute inpatient care two years ago for an inpatient extended care ward, says she has been attacked just once, when a cup of hot water was thrown over her by an older psychotic woman in the 1980s.

While she personally doesn’t feel unsafe at work, she is well aware of people at risk around her, and the impact of the lack of experienced role models for new nurses working in acute inpatient care.

“A frightened bunch of young nurses who want to be good nurses but are constantly in fear … they are thrown into the deep end…”

Brankin confesses to sometimes having compassion fatigue “up to her back teeth”, not just with patients but with her colleagues. “You want to be a good teacher and role model, but…”

Swearing, drugs and social change

Knight reiterates that some things have changed for the better this millennium.

“I think we can manage people without secluding them or without putting hands on people – though not always…” And when fully staffed with the right skill mix, his specialist unit has a very good staff-topatient ratio.

But the old hands also agree that patient acuity and demand has impacted not only on workloads and safety in the past few decades – but also social change.

“I think we’ve become a little more tolerant of staff being hit and injured then we used to be,” says McPherson.

“Society’s expectations have changed and therefore what we are exposed to in hospitals has changed.”

Exposure in hospitals is now including the problematic impact of P use and synthetic cannabis on mental health presentations, which Knight believes is one of the causes behind the growing violence against staff, along with ongoing addiction issues like alcohol and tobacco in the smokefree facilities.

“Years ago when I was working in acute, if I got assaulted by a psychotic person I could be accepting of that – particularly if

it was part of their delusion,” says Knight.

“But not when it’s someone who has got an antisocial personality disorder who just comes and hits you because they can’t get a cigarette.”

While physical abuse is now not uncommon – McPherson has a friend who has been left slightly deaf in one ear after a patient assault that also left her with a dislocated jaw and broken teeth – she says what can really wear staff down in the adult acute mental health wards is the constant verbal abuse.

“You do expect if somebody is really upset they may go off and say “you f*** c***” or whatever, and you brush that off. But when it’s happening with every interaction and they are calling you every name under the sun, and you have other patients around adding in insults about your race, gender or age…”

Brankin agrees that verbal abuse is constant, and recalls the irony of once getting feedback that data entry staff were “really distressed” at having to input the swearing and abuse that nurses write up in patient incident forms. “I said, ‘you imagine standing there and that’s being said to you’.”

Nurses’ hopes for the 2018 inquiry?

So what do these nurses hope to gain from this year’s Ron Paterson-chaired Mental Health and Addictions Inquiry?

“That they walk a day in the shoes of both patients and staff,” suggests Brankin.

Nobody has a simple, fast solution to the complex issues faced by the sector. But they do agree that in order to sustainably recruit and retain new and experienced nurses in acute inpatient health more nurses need to feel safe at work.

And for that to happen they need not only the right pay but the right staffing numbers and the right skill mix to meet patient demand and acuity, and the right fit-for-purpose facilities to deliver the right quality care at the right time.

Nurses simply should not be scared to come to work.

MH NURSING NUMBERS – STATIC OR IN DECLINE? ▶▶ 1996 census figures show there were 1,101 (heads) registered nurses working in mental health (4.1 per cent of all RNs) rising to 1,731 by the 2006 census (5.2 per cent of all RNs).

▶▶ Last year then-health minister Jonathan Coleman said that Health Workforce New Zealand (HWNZ) statistics showed 4,206 RNs (heads) working in mental health and addiction services in 2016.

▶▶ Nursing Council 2015 statistics show a total of 4,327 (heads) mental health RNs: 2,176 inpatient (4.3 per cent of RN workforce) and 2,221 community (4.4 per cent of RN workforce).

▶▶ The updated 2018 edition of the Ministry of Health’s Mental Health and Addiction Workforce Action Plan 2017-21 said in 2016 there were 3,616 full-time equivalent (FTE) mental health nurses: 1,893 community FTEs and 1,723 inpatient FTEs.

▶▶ Statistics also show 343 RNs working in addiction services in 2015 (0.5 per cent of all RNs) – up on 243 in 2010.

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▶▶ By 2026 the plan predicts 2,010 community FTEs and 1,734 inpatient FTEs and the number of mental health RNs per 100,000 to fall.

Focus Diabetes

From caring curiosity

to leading diabetes research

More than a decade ago, Wellington diabetes clinical nurse specialist Lindsay McTavish began research that may transform the treatment worldwide of diabetic hypoglycaemic events.

JODY HOPKINSON reports.

A

question with no answer prompted Lindsay McTavish to start researching how to help the children he cared for.

More than a decade later, the Capital & Coast DHB diabetes clinical nurse specialist has been the lead on four internationally published research papers on hypoglycaemic episodes in children and adults with diabetes.

Current international guidelines are to give children 10g of glucose and adults 15g if they are hypoglycaemic, no matter what their size. But McTavish and his research team of doctor colleagues from CCDHB and the University of Otago did trials – firstly with children attending a diabetes camp and then later with adults with type 1 and then type 2 diabetes – to determine if the dose should vary with the patient’s weight.

“We carried out four clinical trials over 10 years to try to find whether there is a faster and more effective way to treat hypoglycaemia in children and adults with diabetes,” says McTavish.

The team’s recently published results indicate there is. The findings show larger people need more glucose – so a weightbased method is the best way of managing hypoglycaemia. The Wellington team’s research – if reviewed and adopted – could lead to guideline changes worldwide in how hypoglycaemia is managed.

Starting on the clinical research path So how did a clinical nurse specialist end up leading the world in this type of diabetes research?

“I joined what is now Capital & Coast DHB as a paediatric diabetes nurse in the diabetes service in 2000 – just a month 8 Issue 2

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before 9/11,” recalls McTavish. “Back then the international recommendation was to give those with diabetes 10 grams of glucose to anyone having a hypoglycaemic event, regardless of whether the child was three or 15 years old.

“I wondered about this, and asked ‘why do we do it this way when with every other medicine given to a child it is measured on how much that child weighs?’,” says McTavish.

McTavish dug deeper and found that the international research literature recommending the dosage amount for children was based on professional opinion and not on clinical evidence.

McTavish – who now has 25 years’ nursing in diabetes and a clinical master’s under his belt – at that point wasn’t sure about the next step. So he talked to paediatrician colleague Associate Professor Esko Wiltshire, whose own research specialty is diabetes, and Wiltshire recommended he go to the UK to do a short course being offered at Cambridge University by the International Society for Paediatric and Adolescent Diabetes (ISPAD). There McTavish learnt how to do both qualitative and quantitative research on diabetes in children.

“Once I’d got the ethics sorted, I was able to do our first research at a camp for children with diabetes in Otaki in 2007.”

Both the children and their families were surprisingly supportive of the research at this stage, says McTavish.

“We were looking at what types of glucose should be used when treating a hypo and looked at their weight. We tested the different groups of common carbohydrate treatments, including glucose tablets, jelly beans, fruit juice and mints, to see what was the most effective.”

Lindsay McTavish.

Together with his team, McTavish presented their children’s camp research – which found that treatment with 0.3g/kg of carbohydrate (excluding jellybeans) effectively resolved hypoglycaemia in most children within 15 minutes – to an international meeting.

Moving to adult research From there someone suggested doing the same study on adults with type 1 diabetes and McTavish said ‘yes let’s give it a go, let’s do it’.

This later led to a research paper on adults with type 1 diabetes, then children and adults on insulin pumps, then a research paper on what amount of glucose best helps someone with type 2 during a hypoglycaemic event.

The research all showed that treating someone with more glucose, if they were larger, and less, if they weighed very little, was more effective than the current guidelines. As a result, Capital & Coast and Hutt Valley DHBs switched 10 years ago to a weight-based approach for children and five years ago for adults.

The impact of treating hypos with glucose tied to the weight of the patient has been huge, says McTavish.

“If you give the right amount of glucose in the beginning, you can actually shorten the duration of the hypo. A hypo can last for more than 15 minutes for the symptoms of shakiness etc. to return to normal. But they can be resolved in 10 to 12 minutes if treated properly.

“If you don’t get the right amount of glucose into the patient, they will be having longer and more hypos over time.

“Cognitive gaps and signs of dementia are now being seen in long-term diabetes patients as a result of too many hypos,”

Focus Diabetes says McTavish. “So you may as well do it right once rather than follow the international guidelines and give them several doses of glucose throughout one hypo.”

Minimising the shock From the get-go, McTavish was drawn to diabetes nursing.

He sees one of the most important elements of what is a multi-faceted role is first and foremost minimising the shock of a diagnosis to the families affected by diabetes – particularly a child diagnosed with type 1 diabetes.

“Some of those families are injecting insulin two to five times a day. A lot of families and kids hate getting, or administering, injections. It is an ongoing process of matching their food with their insulin and activity to get it right.”

McTavish didn’t always plan on being a nurse; he did two years of pharmacy training before changing tack.

“If you give the right amount of glucose in the beginning, you can actually shorten the duration of the hypo.”

“I actually chose nursing after coming across a motorbike accident one day and finding I was totally useless at the scene. I later went to Sydney Children’s Hospital to start one of the last hospital-based nursing programmes – I didn’t think I was cut out for learning in a classroom.”

WHAT IS A HYPO? A ‘hypo’ or hypoglycaemic event, is when the blood glucose level of a person with diabetes falls below 4mmol/L. Hypos are most common for people with diabetes – particularly type 1 diabetes – who take insulin or certain other glucose-lowering medication (in the ‘sulphonylurea’ medication class). The medications can put them at risk of their blood sugar levels dropping too low, for example if they miss or delay a meal.

The main symptoms associated with hypoglycaemia are sweating, fatigue and feeling dizzy. They can also include being pale, feeling weak and or hungry, having a higher heart rate than usual, blurred vision, confusion and, at their worst, convulsions, loss of consciousness and, in extreme cases, coma.

The goal of giving a quick-acting carbohydrate to a person having a hypo is to bring low blood glucose levels back into the normal range (4–8mmol/L).

Prior to beginning the research, McTavish remembers reading just one line in an American Diabetes Association publication talking about studies in the 1990s suggesting tying glucose to weight.

“Otherwise it hadn’t been studied.

Previously the adult patient would feel symptoms like feeling shaking and difficulty concentrating at a blood glucose of around 3.1 mmol/L then they would be told to have, say, 15 grams of glucose.

“The longer and more frequent the hypos, the higher the likelihood of brain damage of one form or another, or it could lead to poor diabetes control and bigger problems later on, like eye disease and renal failure.”

McTavish says diabetes burn-out for clients is a real thing. “You feel empathetic towards them; they’ve been doing injections and testing for many years and surviving with a chronic illness. It’s a tightrope managing both hypo and hyper events.

The juggle – of nursing and research – is also real, says McTavish. “I have to be conscious about having ringfenced time for research. Clinical time is clinical time and you think differently.”

Nurses – give research a go “I came up with a simple algorithm for the type of research any nurse can do,” says McTavish. “You have a question you need the answer to. You just have to find the energy to answer it.

“You shouldn’t have to do it alone; you need a statistician and people who are willing to edit your work, as well as a librarian to help you do the literature search.

“It doesn’t have to be complicated.

Research adds to the body of evidence we use every day in our clinical nursing practice.”

Hilary Graham-Smith, associate professional services manager for the New Zealand Nurses Organisation, agrees.

She says nurses are conducting research as part of their job sometimes without even realising they’re doing it.

“Nurses are doing research when they are trialling a new wound care product, for example. They bring huge experience and knowledge to research, so if they come up with a theory and put it to the test, the benefits can be fantastic for consumers.”

While there are not many positions where nurses focus solely on research, nurses can do research as part of their programme of study, including as part of their master’s study.

Nurses have insights into a patient’s experience that other health professionals do not, says Graham-Smith. “Patients can find it easier to talk to nurses about what is going on for them. Nurses are at patients’ bedsides in hospitals and that can give them a lot of insight into how patients are feeling and about their treatment.”

Graham-Smith says that while there are barriers to nurses being involved in research, such as a lack of time and a heavy workload, McTavish is an example of the power of nursing research. “Lindsay has a lot of passion, experience and knowledge and has put it to excellent use.”

Next research question in the pipeline For McTavish’s research on adults with type 2 diabetes, the average weight of patients was 90kg.

Next up, Lindsay wants to look at the effects of a higher amount of glucose for some bigger people, weighing around 140kg.

“I never get tired of research – there’s always another question to be asked and answered. All the studies set the path for the next one.” nursingreview.co.nz Issue 2 9

Focus Respiratory

Tips for good respiratory care this winter Winter is fast approaching and with it the annual rise in respiratory hospitalisations. Respiratory nurse specialist SUE JONES shares advice on preventing or managing respiratory illness this winter – both inpatient and in the community.

O

n the worst day in winter our respiratory department can have as many as 70 inpatients – the vast majority ‘outliers’ dotted in non-respiratory wards across the hospital.

Ward rounds become a ‘safari’ that can take a whole day and involve visiting most of the wards in the hospital. During winter – despite careful bed allocation by managers – nurses on surgical or gynae wards can find themselves nursing patients with acute respiratory needs.

Often these nurses struggle to remember nursing priorities for these patients, and the respiratory teams managing these patients can also forget that this is maybe the first unwell respiratory patient that nurse has had to care for in up to a year – that is, since last winter saw very sick respiratory patients arrive on their ward.

Understanding this and providing timely, easy to understand and easily accessible education can help prevent tempers becoming frayed.

Managing inpatient asthma People still die from asthma in New Zealand – more than 60 a year – often because they have poor understanding of their disease and how to treat it. Sometimes, however, deaths can be due to mixed messages from healthcare professionals or difficulty accessing inhalers. Many who die have been in hospital in the year before their deaths – a missed opportunity for a consistent education message.

Asthma patients need to continue their preventative medicine at all times, well or ill, so early access to their usual inhalers, or those prescribed by the team, is key. Most preventative inhalers are taken twice a day, so not realising until the evening drugs round that the inhaler needs to be ordered from pharmacy can mean the patient goes without their preventative corticosteroid (ICS) inhalers for up to 36 hours. Not the message we want to give them in winter!

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requested from pharmacy as soon as they are prescribed.

Checking the patient’s inhaler technique is also key to ensuring they treat their illness properly. All patients (and often many clinicians) think they know how to use inhalers correctly, but in reality patients’ inhaler technique is often poor and likewise clinicians’ observations, corrections, and documentation of inhaler techniques. (To see how bad – and to give yourself a smile – search for the ‘inhaler’ clip from the House TV series on YouTube.)

Refresher on using inhalers Clinicians need to know how to use inhalers correctly according to the manufacturer’s instructions.

The best way to do this is to read the instructions from the packet before you give the inhaler to the patient, but it helps to have a crib sheet in the medication room, such as the poster I developed for wards around Waikato Hospital.

The worst thing a clinician can do is give the wrong information as this creates a false belief, and confusion and distrust in the future.

There are many inhaler devices on the market, but basically they fall into two groups – aerosol and dry powder.

It is generally accepted now that all metered dose aerosol inhalers (MDI) are best taken via a spacer and in our hospital we advocate the tidal breathing method (see Figure 1). Only one puff of the inhaler should be put into the spacer at any time (any others are not absorbed).

Dry powder inhalers are prepared differently for each inhaler (adding a capsule, checking the dose and twisting the base or opening a lid) but the inhalation technique is the same – emptying the lungs of air by breathing out, sealing lips around the mouthpiece and then breathing in for as long as possible to place the drug in the lungs, finally holding that breath for as long as possible (see Figure 2).

PRIORITIES FOR INPATIENTS ▶▶ Access inhalers as soon as possible. ▶▶ Asthma patients need peak flows on arrival and then twice daily. ▶▶ Patients with infection need early sputum samples. ▶▶ Observe patients using their inhalers and document. ▶▶ Give consistent correct information. ▶▶ Carefully planned discharge and follow up plan. ▶▶ Prioritise rest, careful nutrition and observation.

PRIORITIES IN THE COMMUNITY ▶▶ Keep well respiratory patients away from the medical centre in winter (to reduce the risk of being exposed to sick patients in the waiting room). ▶▶ For the same reason, consider having dedicated after-hours flu immunisation clinics. ▶▶ Ensure patients have clear treatment plans and access to medication. ▶▶ Know your vulnerable patients and plan for the worst weeks of winter. ▶▶ Collect sputum samples early to speed up treatment. ▶▶ Follow up discharged respiratory patients who may need support.

The aerosol respimat inhaler (usually only used in COPD) has many steps to using correctly so nurses should always familiarise themselves with the instructions before educating patients (see Figure 3).

Patients should always be observed taking their inhalers in the same way you should watch a patient swallowing a tablet. This is still a prescribed drug, and only if you yourself have observed a patient taking an inhaler, do you know if their technique is correct. And then make sure you document it!

Oxygen therapy should only be given as prescribed. For asthmatics it is only required if saturations cannot be maintained. It should only be used for COPD patients if their saturations fall below 88 per cent; administration when unnecessary can cause >> harm.

Focus Respiratory Careful observations and assessments needed Asthma patients are often worse at night so need careful observation and easy access to their reliever medication – often salbutamol or a short - acting bronchodilator (SABA).

In contrast, other respiratory patients are often exhausted by the effort of breathing and need plenty of rest at night, so may need a quieter bay or single room.

Eating is always an effort when breathless so careful observation of dietary intake, more time to eat, smaller portions and sometimes direct help maybe needed.

Severity of asthma is assessed by many criteria including peak flow reading and often a patient’s suitability for discharge is judged by improvement in peak flow reading. Asthma patients should have a peak flow done as early in their admission as possible, when low, to help facilitate discharge when the reading improves.

After that initial reading, peak flow needs to be done just twice daily. Single-patientuse peak flow meters should be used and sent home with the patient on discharge.

Medication adherence reduces risk of winter hospitalisations An admission to hospital with asthma is almost always due to poor control.

Careful questioning of patients often reveals that they forgot or ran out of inhalers or ignored avoidance advice. Therefore it is really important that any asthmatic patients that end up in hospital for an exacerbation of asthma are followed up by specialist clinicians as outpatients.

They should also have a written plan outlining their medication, how and when to take it and what to do if their symptoms FIGURE 1: MDI INHALER AND SPACER TECHNIQUE

▶▶ Shake inhaler. ▶▶ Insert inhaler into spacer. ▶▶ Put ONE puff into spacer. ▶▶ Seal lips around the spacer mouthpiece. ▶▶ Take 4–6 long slow normal/deep breaths without removing lips. ▶▶ Wait ONE minute. ▶▶ Repeat again exactly as listed above.

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worsen or in an emergency. If no local forms are available, the New Zealand Asthma Guidelines and Asthma Foundation both have accessible versions that can be used.

Patients who have run out of medication should have a prescription for medication to avoid further admissions during the peak season.

Respiratory patients should spend as little time as possible in hospital as they are prone to hospital acquired infections, and so managing their acute illness as quickly as possible during their admission is key.

Average length of stay can be two to three days. This means they may be discharged while still in the early recovery period of their illness, so may need earlier review and easier access to their usual medications in the community – remember it can take up to one week for every decade the person has lived, to start to recover properly from their infection. This can mean they need support in the community.

Discharged respiratory patients may need a ‘rescue prescription’ of antibiotics and oral steroids to allow them to start treatment while waiting for contact with their GP or NP (but not instead of contact).

This prescription is always best managed by their general practice to monitor appropriate use. Patients should have clear instructions for initiating and completing the course and about contacting their general practice.

Community support in winter Respiratory patients are among the group that can suffer the most serious complications of flu and so immunisation is key.

There is a misconception among patients that the flu vaccine causes illness, but often FIGURE 2: DRY POWDER INHALER TECHNIQUES

▶▶ Follow instructions for preparing the particular inhaler (e.g. accuhaler, turbuhaler). ▶▶ Breathe out as far as possible. ▶▶ Seal lips around the inhaler and breathe in:as deep as possible ▶▶ for as long as possible ▶▶ and, if turbuhaler, as hard as possible ▶▶ Hold breath for 10 seconds (or as long as able).

the cause is attending the healthcare provider and sharing a waiting room with sick people, so dedicated flu clinics outside of normal surgery hours can help prevent this.

It is important to identify the cause of infection quickly, so a sputum sample should be collected in the first 12 hours (before antibiotics kick in). Identifying the causative pathogen can prevent further admissions by tailoring antibiotic treatment.

It is important that the sample is sputum, not saliva, as this won’t be processed by the laboratory. They may often need physiotherapy intervention for sputum clearance and breathing control.

Having a sputum sample before treating an infection is just as valuable in the community and providing a labelled sample pot for when the patient becomes unwell can often inform future prescribing and shorten the illness.

During flu season nasopharyngeal swabs for influenza are often requested.

These need to be specific swabs and must be documented as nasopharyngeal on the form to be processed.

When bad weather is expected, taking time to check the most vulnerable patients have access to their usual medications can often also help prevent illness and hospital admissions. The UK’s Met Office found that hospitalisations peaked seven to 10 days after a cold weather event.

With nurses in the community and hospitals working together to support respiratory patients, it is hoped that more patients will keep well or have shorter illnesses this winter.

FIGURE 3: AEROSOL RESPIMAT INHALER

▶▶ Check dose available. ▶▶ Prime the inhaler by twisting round base until it clicks. ▶▶ Open inhaler. ▶▶ Breathe out, put inhaler into mouth, seal lips around the inhaler. ▶▶ Start to breathe in long and slow and press the large button (to fire inhaler) halfway through breath. ▶▶ Continue to breath in long and slow, then hold breath for as long as able. ▶▶ Wait ONE minute. ▶▶ Repeat process exactly for second breath.

Focus Cardiovascular disease

Heart failure research could benefit all Kiwis

REBEKAH FRASER talks to heart failure clinical nurse specialist Dr Simone Inkrot, who hopes to validate years of nursing intuition when she presents her research findings at an international conference in June.

D

r Simone Inkrot is a heart failure nurse with a long-standing interest in how empathy influences people’s ability to look after themselves.

In 2015 the Waikato District Health Board clinical nurse specialist received a Heart Foundation research grant to undertake a study alongside coinvestigator Debbie Chappell on the link between health professional empathy and patient self-care.

In June she leaves the Coromandel, where she works as part of Waikato DHB’s nurse-led integrated heart failure service, to present the findings at the EuroHeartCare congress in Dublin.

The Wintec-trained nurse, who has a Master of Science and a PhD from Berlin’s Charité University Hospital, says heart failure care is about supporting people’s self-care skills.

“People need to know what to do to keep themselves well,” Inkrot says. “When a patient becomes unwell, education and support are key [to] getting well again.

“We know that in combination with medical treatment self-care can play a major role in preventing deterioration and hospitalisation for people with a chronic condition such as heart failure. What we’re not sure on is what ingredient it is that makes or breaks a person’s ability to self-care.”

Inkrot’s research examines the levels of empathy perceived during consultations between health professionals and their patients. “Is there a correlation? My hypothesis was that higher perceived empathy leads to higher self-care ability.”

Patients were asked to rank their ability to self-care, as well as whether they thought their health practitioner was

empathetic towards them. She also asked practitioners to complete the survey to see if a patient’s perceived ability to self-care matched the practitioner’s thoughts.

Data on Māori patients was also analysed during the cross-sectional study.

“We know that, statistically speaking, Māori patients generally have lower healthcare outcomes, so that part of the research was very important,” she says.

Inkrot believes her research has the potential to benefit many New Zealanders, not just those living with heart failure.

“People need to know what to do to keep themselves well.”

“Every New Zealander is likely to have encounters with healthcare providers at some point in their lives. I’m hoping to encourage clinicians to use the power of interpersonal connections in their interactions with patients.”

NZ’s only nurse-led community heart failure service Inkrot has also recently heard that she has been nominated by European Society of Cardiology (ECS) as a finalist for the ESC Nursing and Allied Professions Investigator Award and in August will get to present some of her results at the ESC congress in Munich – one of the largest of its kind in the world.

The research that she’s sharing on the world stage was carried out while doing her day job as a CNS offering heart failure clinics across the Coromandel Peninsula.

She is one of six CNS working for the Waikato Integrated Heart Failure Service’s nurse-led service, established in 2009, which aims to increase access to heart failure services in the community.

Inkrot first worked in cardiology and internal medicine at Waikato Hospital after graduating from Wintec in 2002. The bilingual nurse grew up in Germany and in 2004 went to Germany to work as a district nurse and then on to agency nursing in London – mainly in cardiology, oncology and A&E. She moved to Berlin in 2007 to take up a Charité University Hospital research position in cardiology as lead nurse trial coordinator, during which she completed her Master of Science in Nursing and started her PhD (which she completed when back in New Zealand). In 2012 she returned to help develop the Waikato heart failure service, including setting up the service on the Coromandel Peninsula.

Inkrot says the service is the only one of its kind in the country. “While most DHBs have heart failure services, we’re the only one out there in the community, where the people are.”

The nurse-led service’s home is Waikato Hospital’s cardiology department but offers CNS services – including expert care, support and education – in the wider Waikato community. Only the three CNS serving the Hamilton city area are based at Waikato Hospital with the other three based in Tokoroa, Te Kuiti Hospital and Inkrot at Thames Hospital.

“We want to improve outcomes for patients. GPs can refer to us, and we work with patients that have already been admitted too.”

While Inkrot is unable to prescribe medication, she says she works in nursingreview.co.nz Issue 2 13

Focus Cardiovascular disease collaboration with the patient’s doctors and specialists and makes suggestions to help with diagnoses and management plans.

Self-care skills important Teaching self-care skills is an important part of the nurse specialists’ clinical monitoring and management role, as is working with families and whānau.

“We want to reduce hospitalisation and teach people how to recognise the warning signs of a bad day,” says Inkrot.

Self-care for patients includes following a healthy diet, managing their weight, getting rest as well as regular exercise and taking their medication as prescribed.

Inkrot says there is no “typical patient” that she works with. “Generally though, those that we see are in their late 60s to early 70s. Patients’ experiences of heart failure can differ vastly too.

“Heart failure isn’t just one thing. There are symptoms in common though; fatigue, breathlessness, swollen legs. It can be tricky to do everyday things.”

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She says heart failure is complicated and there is no single trajectory. “It can be something of a rollercoaster. You can have bad days and good days.”

Inkrot’s aim is to reduce hospitalisation by teaching patients how to recognise the warning signs of a bad day. “We want to prevent and avoid hospitalisation. It’s about empowering patients to look after themselves.”

While there is no cure for heart failure, there is plenty that can be done to help.

“It is true that there is no cure. But we can improve both heart function and quality of life. Early treatment and support is so important.”

Inkrot says patients using the service are generally discharged within six months, once they have the support and tools needed. “We do have a small number who need palliative care, and we support them and their families with that too.”

The prevalence of heart failure is rising. “We have an aging population so it is becoming more common. Better health care also means the numbers are increasing.”

The importance of collaborative education Education is also an important part of Inkrot’s collaborative work with both primary and secondary health professionals and community teams.

“The service is not possible without the support of the cardiologists, the general practitioners, the nurses.

They are integral to this. It’s a multidisciplinary effort where we work together.”

She is also excited about the future of the sector.

“Five to 10 years ago, heart failure was in the too-hard basket. It wasn’t sexy, it was super-complicated and hard.”

Having a patient with heart failure was a challenge when she first trained as a nurse. “But now, we’ve worked out how to improve things significantly for the patient. We’ve worked out how to reduce costs and how to decrease mortality.

“I’m so passionate about this work because I can make a difference.”

Professional Development CAT: oxygen

Does oxygen help post-stroke?

This edition’s critically appraised topic (CAT) asks whether oxygen therapy soon after a stroke reduces disability.

CLINICAL BOTTOM LINE Low-dose oxygen for patients who have had an acute stroke – but haven’t got severe hypoxia – is safe. But it doesn’t reduce disability or other stroke-related outcomes, indicating that routine oxygen supplementation is not necessary unless needed for other reasons.

CLINICAL SCENARIO You work on a medical unit where low-dose oxygen is given routinely to patients after acute stroke. This practice is thought to reduce neurological damage and long-term disability. However, you wonder whether it is necessary for all patients and decide to review the evidence.

QUESTION In patients with acute stroke – for whom oxygen is otherwise not indicated – does routine oxygen supplementation reduce stroke-related disability compared with no supplementation?

SEARCH STRATEGY PubMed Clinical Queries (therapy, broad): acute stroke AND oxygen supplementation.

CITATION Roffe C, Nevatte T, Bishop J, et al. Routine low-dose continuous or nocturnal oxygen for people with acute stroke: three-arm Stroke Oxygen Supplementation RCT. Health Technol Assess. 2018;22(14):1-88.

STUDY SUMMARY A three-arm, randomised control trial (RCT) conducted in acute stroke wards in 136 British hospitals from April 2008 to June 2013. Included were adults with a clinical diagnosis of acute stroke within 24 hours

of hospital admission and 48 hours of stroke onset. Excluded were definite indications for, or contraindications to, oxygen treatment, or serious lifethreatening conditions likely to lead to death within the next 12 months.

In total, 8,003 patients were enrolled and then randomised; consent was obtained from either patients (6,991) or relatives (1,012). All participants received standard care including, at physicians’ discretion, oxygen required for reasons other than stroke.

Intervention 1: (n=2,668) Continuous oxygen via nasal cannula (day and night) for three days. Oxygen flow rate was set at three litres per minute (LPM) if baseline oxygen saturation was ≤ 93% or two LPM if baseline saturation > 93%.

Intervention 2: (n =2,667) Nocturnal oxygen via nasal cannula for three consecutive nights (9pm–7am), flow rate as for continuous oxygen group.

Control: (n=2,668 ) No oxygen supplementation during the three days after randomisation.

Primary outcome: Disability assessed by the modified Rankin Scale (mRS) at 90 days.

Secondary outcomes: Neurological improvement (National Institutes of Health Stroke Scale, NIHSS), mortality (day 7); lowest/highest oxygen saturations during the 72-hour treatment period. Mortality, mRS, independence, living at home, Barthel Index, quality of life (European Quality of Life-5 Dimensions) and Nottingham Extended Activities of Daily Living scale at three, six and 12 months.

ODDS RATIO (95% CONFIDENCE INTERVAL) OUTCOME

COMBINED – CONTINUOUS AND NOCTURNAL – OXYGEN GROUPS (N = 5,152) VS NO OXYGEN (N = 2,567)

CONTINUOUS OXYGEN (N = 2,668) VS NOCTURNAL OXYGEN (N = 2,667)

REDUCED DISABILITY AT THREE MONTHS (MRS)

0.97 [95% CI 0.89 TO 1.05)

1.03 (95% CI 0.93 TO 1.13)

STUDY VALIDITY Randomisation – yes, computer-generated; allocation concealment – yes, web-based; complete follow-up – minimal loss in all groups; intention-to-treat (ITT) analysis – yes ; blinding – outcome assessors for postal questionnaires only; equal treatment between groups – appears so; groups similar at baseline – yes. overall impression: high-quality study.

RESULTS Participants’ mean age was 72 years; 55 per cent were male and 82 per cent had ischaemic strokes. The baseline median Glasgow Coma Scale score was 15 (interquartile range 15-15), mean and median NIHSS scores were 7 and 5 (range 0-34), respectively. Mean oxygen saturation at randomisation was 96.6 per cent in the treatment groups and 96.7 per cent in the control group. Oxygen supplementation (either continuous or nocturnal) did not reduce disability at three months compared with the control group.

There was no statistically significant difference in disability between the continuous oxygen and the nocturnal oxygen groups (see table). Oxygen supplementation significantly increased oxygen saturation but did not affect any other secondary outcomes. Oxygen had no effect on patients’ levels of disability at any time point, whether given continuously or at night only. Planned subgroup analyses did not detect any benefit on mRS disability score based on risk factors that included stroke severity, baseline oxygen saturation, oxygen treatment before randomisation, time since stroke onset, final diagnosis, GCS score and age.

Comments ▶▶ Large, pragmatic, multicentre RCT. Original sample size calculation of 6,000 patients was revised to 8,000 patients to give greater power to detect an interaction between stroke severity subgroups and the effect of oxygen, compared with control. ▶▶ Adverse event rates were similar between groups for the study duration. ▶▶ Results do not apply to patients with severe hypoxia (oxygen saturations < 90%) or with indications for oxygen treatment unrelated to stroke.

Reviewer: Cynthia Wensley RN PhD. Honorary Professional Teaching Fellow, University of Auckland c.wensley@auckland.ac.nz.

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Professional Development Learning activity

Preventing and managing blood clots in pregnancy Every year in New Zealand around 4,000 people develop a blood clot in a vein. This article looks at venous thromboembolism – in particular why pregnancy puts women at increased risk – and how to help prevent, diagnose and treat pregnancy-associated venous blood clots.

Introduction In New Zealand there are around 60,000 pregnancies per year1. It is estimated that between 30 and 140 of those births each year (0.5–2.2 per 1,000 deliveries2) will be affected by pregnancy-associated venous thromboembolism (PA-VTE).

By Tracey Woulfe

The prevalence of PA-VTE may grow – with the trend for women to have babies later and the rising obesity levels – as risk factors include women being older than 35 and obesity.

Pregnancy-associated blood clots are recognised in the developed world as an important cause of maternal death and morbidity2,3. The 2015 Perinatal and Maternal Mortality Review Committee reported two out of 11 maternal deaths were directly attributed to PA-VTE1.

Venous thromboembolism: what is it?

Venous thromboembolism (VTE) is a collective term used to describe blood clots within the veins of the body.

Deep vein thrombosis (DVT) occurs predominantly in the legs; however, it can occur in the veins of the arm, abdomen or head. Any of these blood clots can break off, creating an embolus that travels to the lungs, where it is renamed a pulmonary embolus (PE) and is potentially lifethreatening.

In pregnancy, the risk of developing VTE is four to five times greater than in non-pregnant women4,5, increasing in the

post-partum period 20-fold6. Although the actual number of deaths remains low, the social and economic cost of associated morbidity is high4.

Midwifery researchers7 report that many women feel PA-VTE is trivialised by health professionals as only a short-term problem that is treatable with anticoagulants, while the long-term impact of the disease is not recognised. The known impact of PA-VTE on women during pregnancy or soon after birth can include or contribute to: ▶▶ post-thrombotic syndrome (PTS) ▶▶ pulmonary hypertension ▶▶ increased maternal ill health ▶▶ reduced quality of life.

In the general population, studies8,9 have found that patients who develop post-thrombotic syndrome (PTS) have a much poorer quality of life. Symptoms of post-thrombotic syndrome in the leg include chronic pain, redness, itching and swelling, and can lead to darkening of the skin and ulceration.

The psychosocial impact on the mother, her newborn and the family can also be considerable7. As some mothers struggle with the anxiety associated with PA-VTE,

Learning outcomes Reading and reflecting on this article will enable you to: ▶▶ understand the pathophysiology of venous thromboembolism and Virchow’s triad ▶▶ apply this knowledge to understand why pregnancy increases the risk of venous thromboembolism (VTE) in this population

▶▶ identify additional risk factors associated with pregnancy associated venous thrombosis ▶▶ identify appropriate diagnostic and treatment options in pregnancy-associated VTE (PA-VTE).

This learning activity is relevant to the Nursing Council of New Zealand competencies: 1.1, 1.4, 2.2, 2.4, 2.7, 3.3 & 4.1.

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Professional Development Learning activity the likelihood of developing postnatal depression and bonding and attachment issues increases7.

The pathophysiology of VTE In the mid-1800s, pathologist Rudolph Virchow described three factors associated with the development of blood clots, known today as Virchow’s triad10. These factors consist of: ▶▶ venous stasis ▶▶ a hypercoagulable state ▶▶ vascular wall injury.

Venous stasis occurs in pregnancy due to increased venous dilation and the obstruction of venous return11. Obstruction is due to the compression of the left common iliac vein by the right common iliac artery and by the gravid uterus13. This compression of the left common iliac vein likely explains why 85 per cent of PA-DVT occurs in the left leg rather than the right leg13.

A hypercoagulable state develops because the body is preparing for the homeostatic changes that need to occur before delivery to prevent haemorrhage.

Natural anticoagulants decrease in contrast to the pro-coagulant factors increasing11.

Vascular wall injury occurs as the growing foetus in-utero compresses the iliac artery onto the iliac vein, causing endothelial damage within the vein and activating the clotting cascade.

Venous stasis is believed to be the most clinically significant factor, and – when combined with either a hypercoagulable state or vascular wall injury – the risk of developing a blood clot is increased11.

Only one of these factors needs to be present for a blood clot to occur. However, in pregnancy all three factors are present11,12.

The risk of PA-VTE is the same across all trimesters13, which may suggest that the hypercoagulable state is more important over this time. Additional endothelial damage, which occurs to the pelvic vessels during delivery3, may explain why up to a third of VTE occurs in the post-partum period, with 80 per cent of post-partum VTE occurring in the first three weeks following delivery. Data now suggests that this risk, albeit reduced, persists for up to 12 weeks after giving birth2,3,6.

Additional VTE risk factors Additional risk factors in association with pregnancy increase the risk of developing PA-VTE. According to Australasian guidelines14, these include: ▶▶ previous VTE ▶▶ age >35 ▶▶ high body mass index (BMI) >30kg/m2 ▶▶ active medical illness ▶▶ smoking

▶▶ family history VTE ▶▶ immobility ▶▶ varicose veins ▶▶ multiparity (>2) ▶▶ multiple pregnancy ▶▶ pre-eclampsia ▶▶ assisted reproduction ▶▶ hyperemesis gravidarum (associated with dehydration and immobility) ▶▶ Caesarean section delivery (greater risk if an emergency vs elective) ▶▶ postpartum infection ▶▶ postpartum haemorrhage ▶▶ placental abruption.

Of note: inherited thrombophilia is absent from this list of additional risk factors and internationally this remains a debated issue. The presence or absence of known thrombophilia does not usually alter the acute or future management of VTE, therefore testing may create unnecessary anxiety for women15.

Thromboprophylaxis: preventing VTE Risk assessment both antenatal and postnatal, plus the appropriate implementation of preventative measures, are all important steps in the prevention of PA-VTE5. However, there is a lack of large trials in pregnancy to provide the evidence from which to guide thromboprophylaxis decision-making.

In a review of international evidencedbased guidelines5, eight out of nine guidelines recommended women be assessed either pre-conception or early in their pregnancy for risk factors associated with VTE. Three guidelines also recommend reassessment during pregnancy if a woman is hospitalised or develops additional complications such as pre-eclampsia.

A single risk factor, such as a high BMI, is not in itself felt to be sufficient to warrant thromboprophylaxis. However, if a woman has more than one risk factor

– or subsequently develops an additional risk factor such as immobility – then thromboprophylaxis is recommended5.

In New Zealand, when chemothromboprophylaxis is indicated, the standard of care is the low molecular weight heparin (LMWH), Clexane® 40mg subcutaneous, once daily. The Australasian guideline recommends Clexane 40mg twice a day if BMI >30kg/m2. 11

DIAGNOSING VTE IN PREGNANCY The diagnosis of PA-VTE is challenging, as many of the normal pathophysiological changes that occur in pregnancy can be difficult to differentiate from the signs and symptoms of VTE, such as leg swelling and dyspnoea3,5.

Differential diagnosis may include musculoskeletal pain, chest infection or cellulitis. Making the diagnosis even more difficult is that approximately 80 per cent of DVTs remain clinically silent and woman do not present with the expected red, hot or swollen leg7. It is hypothesised that a delay in diagnosis in the post-partum period due to attention focusing on the newborn may explain why more women with proximal DVT in the post-partum period are more likely to develop PTS18.

Signs and symptoms (red flags) of pregnancy-associated deep vein thrombosis: ▶▶ Unilateral leg pain and swelling (more commonly in the left leg). ▶▶ Redness or discolouration of the limb. ▶▶ Warmth. ▶▶ Heaviness. ▶▶ Lower abdominal pain. ▶▶ Low-grade pyrexia.

Signs and symptoms (red flags) of pulmonary embolus: ▶▶ Dyspnoea. ▶▶ Chest pain. ▶▶ Haemoptysis. nursingreview.co.nz Issue 2 17

Professional Development Learning activity Blood tests An elevated D-dimer may indicate the formation of a new blood clot; however, as levels rise with other factors, such as trauma, surgery, cancer or pregnancy – especially in the last trimester and postpartum – testing is not recommended as it is not helpful in these situations12.

Clinical prediction rules Outside of pregnancy, the Well’s score is a widely used and accepted predictive tool because of the high positive predictive value. To date there are no validated, structured prediction rules that can be applied in pregnancy15.

Objective testing In mid to late pregnancy, DVT is 85 per cent more likely to occur in the left leg than the right leg13, largely due to the compression of the left iliac vein by the gravid uterus, as discussed earlier.

When compared with the nonpregnant population, it is also much more likely to occur proximally, with 72 per cent involving the veins in the pelvis in pregnancy as opposed to only 9 per cent outside of pregnancy3. This makes diagnosis by ultrasound scan (USS) challenging, as a negative scan from groin to ankle can miss an isolated pelvic vein clot, therefore clinicians and midwives should be advised to investigate further if high clinical suspicion exists of a DVT. When a PE is suspected, a ventilation perfusion (VQ) scan is the preferred diagnostic scan in pregnancy13, as is it more likely to see smaller lung clots.

Computed tomography pulmonary angiogram (CTPA) can miss up to 30 per cent of smaller lung clots due to the higher circulating blood volume in pregnancy; with total body water increasing up to eight litres in pregnancy19. Furthermore, radiation exposure to the breast tissue is significantly higher with CTPA; although if CTPA is the only choice then breast shields should be used to reduce the radiation exposure.

There is a low radiation risk to the foetus (<50 mGy) with either VQ scan or CTPA, which is far below the threshold linked to childhood malignancies6,15.

TREATMENT Anticoagulants Due to ethical issues associated with pregnancy research, there is a lack of pharmacokinetic data specific to pregnancy, and recommendations are based on observational studies and basic pharmacology principles19. In pregnancy, drug absorption usually decreases, whereas drug excretion increases, leading to lower plasma concentrations19.

Warfarin has been the mainstay of VTE treatment for over 50 years. However, its use in antenatal PA-VTE is usually contraindicated because of the known 18 Issue 2

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teratogenic effects on the foetus, along with the potential to cause foetal loss and bleeding2. The exceptions to this, outside of PA-VTE, are women at high risk of arterial vein thrombosis due to mechanical heart valves, where warfarin is more efficacious than low molecular weight heparin (LMWH) in preventing arterial thrombosis11.

As the foetus has low levels of clotting factors and is vitamin K-deficient at birth, therapeutic warfarin levels in the mother will likely over-anticoagulate the foetus, posing significant haemorrhagic risk if the mother delivers early11. Therefore, the use of antenatal warfarin in the context of PA-VTE is not recommended, and its use should only be considered in exceptional circumstances15.

New direct oral anticoagulants (DOACs) such as Pradaxa® or Xarelto® have recently been licensed for VTE treatment in New Zealand; however, there is no data to support their use in pregnancy. Direct oral anticoagulants could potentially be a suitable option in the post-partum period if the mother were not breastfeeding.

Currently the use of low molecular weight heparin (LMWH) is the only recommended anticoagulant treatment supported in international and local guidelines. In New Zealand we use Clexane®, which restricts the formation of new clots and provides time for the breakdown of an existing clot to occur13.

In New Zealand the accepted weightbased therapeutic dosing of Clexane® is either 1mg/kg twice a day or 1.5mg/ kg once a day16. Anti-factor Xa levels, which measure the effect of LMWH, are generally used only if a woman has a second clot while on treatment, or in obese patients2.

Pregnancy increases renal blood flow by 60–80 per cent, with drug elimination increasing by 50 per cent due to an increase in the glomerular filtration rate19.

Increased renal clearance and greater volume of distribution would indicate a

need for higher dosing requirements18.

In reality, there remains a lack of data on once-daily versus twice-daily dosing2,3.

The Sanofi datasheet16 suggests that twicedaily dosing may be beneficial in obese patients with pelvic vein clots, but refrains from giving any pregnancy-specific dosing guidelines.

Graduated compression stockings Guidelines20 still recommend the use of graduated compression stockings for treating symptoms of PA-VTE, such as reducing oedema, along with initial leg elevation; however, they stipulate that the evidence to support their use in preventing post-thrombotic syndrome (PTS) is unclear. The ACCP guidelines21 do still suggest that graduated compression stockings may have some symptomatic benefit in the acute treatment stage.

MANAGEMENT Antenatal In the antenatal period, low molecular weight heparin (LMWH) is the preferred treatment option because the doseresponse is more predictable than unfractionated heparin (UFH). The long-term use of UFH is also associated with a 30 per cent reduction in bone density (osteopenia), leading to an increase in osteoporotic fractures and a higher incidence of heparin-induced thrombocytopenia marked by a drop in platelets2,6.

The dosing of LMWH in the antenatal period is dependent on the size, location and timing of the DVT or PE. Labour and delivery All pregnant women should be advised to withhold LMWH at the first sign of labour, as the timing and amount of their last dose will affect whether or not they will be able to have an epidural22.

Post-partum In woman with confirmed PA-VTE in the antenatal period it is recommended that post-partum anticoagulation should be recommenced as soon as haemostasis

Professional Development Learning activity is achieved; usually six hours postnormal vaginal delivery and 12 hours post-caesarean section6, however please refer to your local guidelines as recommendations may differ.

New PA-VTE that occurs in the postpartum period can be managed the same way as a provoked DVT or PE outside of pregnancy with warfarin therapy, and potentially a direct oral anticoagulant if the mother is not breastfeeding. Choice and duration of anticoagulation will again depend on the size and location of the clot. If a woman was at high risk of bleeding, intravenous UFH would be indicated in the first instance before switching to a LMWH and establishing oral anticoagulation.

SYNTHESIS OF CURRENT BEST PRACTICE The prevention, treatment, and management of PA-VTE is challenging due to the scarcity of high-quality evidence and data specific to pregnancy, complicated by both maternal and foetal concerns.

The evidence for the use of thromboprophylaxis to prevent PA-VTE is an extrapolation of data from studies involving non-pregnant participants, so identifying the right target population within pregnancy is challenging.

There is consensus in the international

guidelines5 that each woman needs to be individually assessed so an informed decision can be made collaboratively once the woman understands the balance of risk versus benefit.

No consensus exists for prophylactic dosing of LMWH in obese patients or in the treatment dosing of antenatal PAVTE and further studies are required to address this issue. The use of direct oral anticoagulants may have a place in the post-partum treatment of PA-VTE in nonbreastfeeding women.

Warfarin and LMWH are both safe to use in the post-partum period as neither passes through the breast milk. The choice of anticoagulation depends on factors such as size, location and timing of the DVT or PE, the required duration of treatment, and patient choice22. (It should be noted that in New Zealand Clexane® is only funded antenatally and for up to six weeks post-partum.) If anticoagulation treatment were indicated for longer in the post-partum period, oral anticoagulation would be the only option.

Diagnosis of VTE in pregnancy is complicated and challenging due to the normal physiological changes that occur in pregnancy, which can mirror a differential diagnosis and lead to a delay in timely investigation and treatment. Ultrasound scans remains

ABOUT THE AUTHOR Tracey Woulfe RCompN PGDip MHSc is a thrombosis clinical nurse specialist at Waitemata District Health Board.

This article was peer reviewed by Rhonda J Robertson RN RM BSc(Hons) PGCert CT PGDip(Mid), who is a clinical midwife educator at the Canterbury District Health Board and Daryl Pollock RN MN, who is a thrombosis/haemostasis clinical nurse specialist at MidCentral District Health Board.

REFERENCES 1. PERINATAL AND MATERNAL MORTALITY REVIEW COMMITTEE (2015). Eleventh annual report of the perinatal and maternal mortality review committee: Reporting mortality 2017. Health Quality and Safety Commission, Wellington.

2. BATES S, MIDDLEDORP S & RODGER M et al (2016). Guidance for treatment and prevention of obstetric-associated venous thromboembolism. Journal of Thrombosis and Thrombolysis 41.

3. GREER I A (2015). Pregnancy complicated by venous thrombosis.

The New England Journal of Medicine 373(6).

4. KOURLABA G, RELAKIS J et al (2016). A systematic review and meta-analysis of the epidemiology and burden of venous thromboembolism among pregnant women. International Journal of Gynecology and Obstetrics 132(1).

5. OKOROCH E, AZONOBI I et al (2012). Prevention of venous thromboembolism in pregnancy: A review of guidelines 2000-2011. Journal of Women’s Health 21(6).

6. MARSHALL A (2014). Diagnosis, treatment, and prevention of venous thromboembolism in pregnancy.

Postgraduate Medicine 126(7).

7. CARTER K & MUNRO J (2015). The shadow of venous thromboembolism.

Midwives 18.

8. KAHN S, SHBAKLO H et al (2008).

Determinants of health-related quality of life during the 2 years following deep veins thrombosis. Journal of Thrombosis and Haemostasis 6(7).

9. VAN KORLARR I, VOSSEN C et al (2004).

The impact of venous thrombosis on quality of life. Thrombosis Research 114(1).

10. KUMAR D, HANLIN E et al (2010).

Virchow’s contribution to the understanding of thrombosis and cellular biology. Clinical Medicine & Research 8(3/4).

11. MCLINTOCK C (2014).

Thromboembolism in pregnancy: Challenges and controversies in the prevention of pregnancy-associated venous thromboembolism and management of anticoagulation in women with mechanical prosthetic heart valves. Best Practice & Research Clinical Obstetrics and Gynaecology 28.

the most convenient and accessible means of diagnosing DVT. The choice of lung scanning is more uncertain, with the decision often coming down to accessibility, clinician and patient preference, and local guidelines.

While there no longer appears to be a role for the use of graduated compression stockings in preventing PTS, these stockings might still provide symptomatic relief in some patients and should still be considered.

Summary PA-VTE remains in many instances a preventable disease, provided patient risk factors are adequately assessed and appropriate interventions taken. As society changes, the prevalence of some risk factors for PA-VTE are increasing, such as increasing age and BMI, coupled with caesarean delivery.

Identifying risk factors, and implementing preventative measures, is achievable and would go a long way in reducing the social and economic cost inked to maternal death and morbidity.

Empowering the mother through education and addressing her concerns early may reduce the anxiety associated with PA-VTE. RECOMMENDED RESOURCES New Zealand VTE prevention programme – National Policy Framework (2012): This comprehensive document includes risk assessment tools and patient information: https://bit.ly/2GYVu2x Clinical Pathway for Deep Vein Thrombosis: This two - page flowchart developed for the Auckland region includes the Wells’ Score: https://bit.ly/2Gvzr3M.

12. SIMCOX L, ORMESHER L et al (2015).

Pulmonary thromboembolism in pregnancy: diagnosis and management. Breathe 11(4).

13. BOURJEILY G, PAIDAS M et al (2010b).

Pulmonary embolism in pregnancy.

Lancet 375.

14. 1MCLINTOCK C, BRIGHTON T et al (2012). Recommendations for the prevention of pregnancy-associated venous thromboembolism. Australian and New Zealand Journal of Obstetrics and Gynaecology 52(1).

15. CHAN W, REY E & KENT N (2014).

Venous thromboembolism and antithrombotic therapy in pregnancy.

Journal of Obstetrics and Gynaecology Canada 36(6).

16. SANOFI-AVENTIS (NZ) Ltd. (2015).

New Zealand Datasheet. Retrieved from www.medsafe.govt.nz.

17. WIK H, JACOBSEN A et al (2012).

Prevalence and predictors for post-thrombotic syndrome 3 to 16 years after pregnancy-related venous thrombosis: a populationbased, cross-sectional, case-control study. Journal of Thrombosis and Haemostasis 10.

18. GANDAR E, CARRIER M & RODGER M (2014). Management of pregnancy associated venous-thromboembolism: a survey of practices. Thrombosis Journal 12(12).

19. DAWES M & CHOWIENCZYK P (2001).

Pharmacokinetics in pregnancy.

Best Practice & Research Clinical Obstetrics and Gynaecology 15(6).

20. ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS (2015).

Reducing the risk of venous thromboembolism during pregnancy and puerperium. Green-top guideline No. 37a.

21. KEARON C, AKL E et al (2016).

Antithrombotic therapy for VTE disease. CHEST 149(2).

22. CHANDRARAJAN L & NELSONPIERCY C (2015). Risk of venous thromboembolism during pregnancy and birth. British Journal of Midwifery 23(9).

23. TAPSON V (2008) Acute Pulmonary Embolism. New England Journal of Medicine 358.

nursingreview.co.nz Issue 2 19

Professional Development Learning activity

Professional Development

Learning Activity

Reading and reflecting on this article will enable you to: ▶▶ understand the pathophysiology of venous thromboembolism and Virchow’s triad ▶▶ apply this knowledge to understand why pregnancy increases the risk of venous thromboembolism (VTE) in this population ▶▶ identify additional risk factors associated with pregnancy associated venous thrombosis ▶▶ identify appropriate diagnostic and treatment options in pregnancy-associated VTE (PA-VTE).

Reading the article Preventing and managing blood clots in pregnancy and undertaking this learning activity is equivalent to 60 minutes of professional development. This learning activity is relevant to the Nursing Council of New Zealand competencies: 1.1, 1.4, 2.2, 2.4, 2.7, 3.3 & 4.1.

A

Reading

1

Read “The shadow of venous thromboembolism” (reference 7).

2

Also read and familiarise yourself with your local PA-VTE guideline if available or refer to the Australasian guidelines (reference 15).

B

Reflection

1

Consider the impact of PA-VTE in your patient in relation to her maternal mental health, the psychosocial impact on the newborn and other key family members, and identify ways to support your patients.

C

Reality

1

Familiarise yourself with VTE risk factors in association with Virchow’s triad and apply this knowledge to patient assessments in your area.

2

Educate woman regarding the red flags for early detection of VTE in pregnancy.

3

Consider ways of improving and developing nursing practice in the prevention and management of PA-VTE in your area.

4

Identify which diagnostic scans/resources are available in your area.

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

Designation

Date

Nursing council ID

Work address

Contact #

Body.

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Sponsored Article eCald

Why do nurses need

cultural competency training?

N

ew Zealand is an increasingly ethnically diverse society and is set to become more so.

Auckland in particular has growing Asian, Pacific, Middle Eastern, Latin American and African communities. Our people come from everywhere, with over 213 ethnic groups represented in New Zealand.

In 2016, almost a quarter of Auckland residents were Asian and a quarter had lived here for less than five years. This is significant as many newcomers will be unfamiliar with our health system, how our services function and where to get help.

The Health Practitioners Competence Assurance (HPCA) Act 2003 requires registration bodies to develop standards of cultural competence and to ensure that practitioners meet those standards.

Sue Lim, the national programme director for eCALD® Services, says eCALD® has been contracted by the Ministry of Health as the national provider of CALD (culturally and linguistically diverse) cultural competence training for the health workforce in New Zealand.

“Over 25,000 health practitioners (with nurses making up about a third of those) have participated in our CALD cultural competency training since 2010,” says Lim. The eCALD® programme began in Auckland – now one of the most superdiverse cities in the world – as there was an increasing need to prepare the health workforce and to improve patient experience and outcomes for the many CALD patients and families entering health services in the region.

Dr Annette Mortensen, the eCALD® project manager for research and development, says CALD patients’ experience disparities in health outcomes compared to mainstream populations in migrant receiving countries like New Zealand, and Australia and Canada.

“The cultural factors that influence patient and health practitioner decisionmaking and interactions are variations in patients’ health beliefs, values,

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preferences, and helpseeking behaviours,” says Mortensen.

“Variations in patient recognition of symptoms; thresholds for seeking care; the ability to communicate symptoms to a provider who understands their meaning; the ability to understand the prescribed intervention and treatment strategy; expectations of care; and adherence to preventive measures and medications.”

“For example, CALD clients may have been used to using herbal medicines, undertaking various forms of meditation, consulting an imam over health and mental health matters, seeking help from a monk to lift a curse, reading religious texts or wearing amulets containing various preparations when they are unwell.

“Some may have used these treatments in conjunction with western medicines. CALD clients who are welleducated are just as likely to have used some of these traditional treatments as the less well-educated members of their communities.”

Lim adds that many health professionals consider cultural competency to be simply having the skills necessary for addressing language barriers with clients by booking an interpreter.

“Others think that cultural competency is about learning as much as you can about specific cultures,” says Lim. “Other views include understanding the key practice ‘do’s and don’ts’ for caring for the ‘culturally diverse’ patient.”

“While learning about a particular culture can be helpful in most situations, a closer examination of the definition of culture, highlights that these efforts can lead to stereotyping. Besides which this is an impossible task with over 200 cultural groups in New Zealand.”

She says the eCALD® courses use Hofstede’s cultural dimensions model to develop the knowledge, skills and attitudes that health professionals need

to work with any culture different from their own. Hofstede’s model of six dimensions of national cultures – including Power Distance, Uncertainty Avoidance, Individualism vs Collectivism and Masculinity vs Femininity – provides a useful paradigm for nurses to compare New Zealand cultural values with those of other cultural backgrounds.

“If we can recognise our own values and biases, as well as the values and biases of patients different from ourselves, then this can help us adjust our attitudes and behaviours to improve our cross-cultural interactions,” says Lim. HOW CAN NURSES ACCESS FREE CULTURAL COMPETENCY TRAINING? ▶▶ Visit the eCALD® website www.ecald.com. ▶▶ Start with the CALD 1: Culture and Cultural Competency course. ▶▶ CALD 1 is the prerequisite course to all our Working with CALD Patient courses. ▶▶ You can choose either online or face-to-face learning. ▶▶ The courses are free and accredited to meet the professional development requirements of your profession’s registration body. ▶▶ Best of all, it’s fun learning with many interactive exercises, videos and quizzes to keep learning interesting.

General Practice Conference & Medical Exhibition

Professional Development Blood management

Treasuring every drop of blood FIONA CASSIE talks to two Patient Blood Management nurses about keeping patients’ own blood in their veins and reducing wastage of the special gift that is donated blood.

S

ome call them “the bloodhounds”.

It’s a nickname the nurses of Waikato Hospital’s Patient Blood Management (PBM) team can laugh about as one part of their job is to ‘sniff out’ and reduce blood product wastage.

But the service’s wider mission is ‘promoting and supporting everything blood’ and its ethos is that every drop of blood – whether a patient’s own or donated – is a valuable resource and should be respected as such.

Russelle Westleigh, one of the three senior nurses working for Waikato District Health Board’s thought-to-be-unique PBM service, says they see themselves as advocates for the people who donate blood, the patients needing blood support, and the DHB that spends about $13 million a year on blood products.

The team was founded in 2015 under the clinical lead of anaesthetist Dr Scott Robinson and works closely with the New Zealand Blood Service to try and reduce unnecessary blood transfusions and keep staff informed about ‘everything blood’. The team’s work includes pre-operative anaemia (POA) assessment to help boost patients’ haemoglobin and iron stores; educating doctors and nurses on transfusion best practice; and looking for ways to minimise blood loss.

The ‘bloodhounds’ have been effective.

Julie Retter, a senior nurse who has been with the team since it started, told the recent Clinical Nurse Specialist Society conference that in its first year the team’s work saved the DHB around $2.4 million.

Treating pre-operative anaemia

Transfusions are one of the most overused treatments in modern medicine, says Retter.

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The former midwife and women’s health nurse says research shows that people do much better if they “keep their own blood in their own veins”.

Unnecessary transfusions not only increase the risk of adverse transfusion reactions or infections, but also use up the limited, and costly, resource that is donated blood.

So ensuring that a patient’s blood is as good as it can be before elective surgery in order to reduce the need for blood transfusions is a major role for the team’s nurses because alongside the increasing numbers of older patients requiring hip and knee surgery is an increase in anaemia.

Patients at risk of pre-operative anaemia are identified at the anaesthetic assessment clinic and the PBM team ensures that those with anaemia are put on oral iron – and sometimes IV iron – so they have boosted haemoglobin and ferritin levels before they go into theatre.

“So the chances of them requiring a blood transfusion just because they are anaemic is really quite reduced,” says Retter.

And the research shows that getting through surgery without needing a transfusion shortens patients’ lengths of stay and reduces their risks of readmission through infections and other complications.

Fast-track cancer patients are usually given iron infusions of ferric carboxymaltose, as they need to be ready for surgery within a month, but hip and knee patients are often given oral iron for the two months or so before their surgery is scheduled.

In 2016 the PBM team had 1,153 patients go through its pre-operative anaemia service, with 146 receiving some form of treatment and monitoring before their surgery. An average of 66 patients every three months had their GPs contacted regarding their anaemia and some patients had surgery delayed due to more life-threatening conditions being diagnosed.

‘Why use two, when one will do?’

The aim is not only to keep people’s own blood in their veins, but also not to waste blood that other people have donated.

So now blood products having to be ‘binned’ will see a PBM team nurse turning up on a ward to find out why.

This led to the nickname ‘bloodhound’ and sometimes being seen as a “little bit precious”, says Westleigh, a former orthopaedic nurse.

But Westleigh and Retter stress that their job is not about blaming busy nurses on the ward but about taking a patientcentred approach to educating staff about good transfusion practice and making the point that donated blood is precious in more ways than one.

“Some person has walked off the street and given that blood in good faith that it will be used to help someone,” says Retter.

Blood is also a substantial cost to the DHB. ‘Why use two, when one will do?’

– a slogan adopted by a 2010 Auckland DHB evidence-based project to promote the use of single unit transfusion of red blood cells (RBC) rather than the formerly routine two – is also being used

by Waikato. The DHB now has a policy

Health Navigator that, apart from critical or trauma patients, the norm should be a single unit transfusion and the patient then being clinically reassessed before deciding whether a second unit is needed.

Not only does the research indicate that the risk of adverse effects increases with every unit transfused but, if a transfusion for any reason does not go ahead, the blood bank only allows a half-hour window for ‘redepositing’ a blood unit back in the bank – otherwise it is discarded.

“If you are a minute over, you’re a minute over and the unit gets discarded,” says Retter. (Blood units can be safely transfused within four hours of leaving blood bank refrigeration.)

Thinking twice about taking blood samples Educating doctors and nurses to think twice about whether blood tests are appropriate is another plank of the team’s work.

A blood test takes up to 5ml of blood a time and Retter says some of its ICU patients can have 15–20ml a day taken from them.

“That 15–20ml can drop your haemoglobin quite dramatically – particularly in some of our elderly patients,” says Retter. “If you keep taking blood tests off patients, then all of a sudden you may have a patient with anaemia you’ve got to treat.”

She says historically such tests were just done without a second thought and the team’s job is to encourage people to stop and think, “Do they really need all that blood?” or “Is that test necessary?”

“We are challenging those historic practices.”

And if a patient is anaemic, they may encourage clinicians to do a ‘micro-collect’ which involves taking a much smaller amount of blood, as they would for a baby. “It [a micro-collect] is not the ideal, but sometimes we need to go outside the ideal for a patient. It is doable, but we wouldn’t expect them to do it for every patient.”

But there are some patients that require clinicians to look outside the norm – including, adds Westleigh, Jehovah’s Witness patients who have indicated they won’t accept some blood products, which puts limitations on the treatments available if the patients become severely anaemic. “So we try and prevent them from becoming anaemic in the first place, like preventing too much blood-taking.”

It’s all part of the brief for nurses whose job is ‘everything blood’. The results to date have been a steady downward trend since the service began in RBC usage per patient discharge – saving both dollars and drops of that precious donated blood for patients who need them.

App of the Month

MS Energise

APP OVERVIEW ▶▶ Clinical score ▶▶ Availability

Free for Apple

Full review https: www.healthnavigator.org.nz/app-library/m/ ms-energise-app/#Overview

T

he app aims to help people with multiple sclerosis (MS) manage their fatigue using research-proven cognitive behavioural therapy (CBT) principles.

The interactive app includes a sleep tracker and an activity tracker. It has modules centred on areas that impact on fatigue – behaviour, thoughts, emotions, body (physiological), world (environmental) and future. Each module has an education section and self-management tips and techniques.

PROS include: ▶▶ Easy to navigate and use. ▶▶ Allows users to record their fatigue and energy levels. ▶▶ Removes barriers to accessing CBT support. ▶▶ Developed by a research project team from the Auckland University of Technology (AUT) and two UK universities. ▶▶ The app is based on the project team’s successful randomised controlled trial (RCT) into the impact of CBT on fatigue, including a pilot of online-delivered CBT. CONS include: ▶▶ Only available on iTunes as currently not available on Android.

Waikato’s patient blood management team from left: Dr Scott Robinson, Lucia Best, Russelle Westleigh and Julie Retter.

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. nursingreview.co.nz Issue 2 25

Innovation Technology

Nurse-developed app for saving clients’ texts

A winning app for saving the texts of youth clients in crisis, developed by mental health nurse Dion Howard, is moving on to stage two, reports REBEKAH FRASER.

A

n app that allows mental health nurses to save young clients’ texts and calls directly to their clinical record is now a step closer.

Called Ask Ruru, the app, which logs text messages and calls made between a community mental health clinician and a young person in crisis, is into its second round of development.

Created by Capital & Coast District Health Board nurse Dion Howard, the idea for the app grew out of his own work with youth. “There are limitations that make communication within the sector quite rigid. Letters, faxes and emails seem to be the way we communicate,” he says.

However young people can find those ‘old school’ forms of communication hard to respond to. “Even phone calls: if it’s not a number they know, they won’t answer it.”

Howard believes the solution is using text messaging, so he went about creating an app that uses this now ubiquitous way of communicating.

“SMS [text messaging] is really effective. People don’t think of SMS as an app, but it is. However, the downfall is that texts doesn’t translate easily into clinical records.”

He says staff have even resorted to photocopying their phone screen to get a physical copy of a text conversation to add to patient records.

Howard’s prototype app enables workers to insert into messages the crisis and mental wellbeing skills they have previously discussed with clients and ensures that text message information can be easily transferred to a patient’s health record.

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“The app has pre-configured protocols inserted into it, but it also allows for a personal response.

There’s also a library of short videos to support staff.”

The name Ask Ruru is based on the Māori word for the morepork.

“Owls are wise and people told us that when they hear the morepork they felt reassured. Those are the values we want our clinicians to mimic.”

Howard says the app is specifically designed for health professionals, not youth. “We have an emphasis on wisdom and reaching out to your ‘wise person’.

Sometimes it’s a therapist or a medical health professional. This [app] gives the professionals the right tools at their fingertips.”

Turning a good nursing idea into an app

Howard first took his idea for the app to the Health Informatics New Zealand’s (HiNZ) Wellington Hackathon in 2015.

A hackathon weekend begins on a Friday night with people from clinicians to software developers giving a short pitch for a healthcare technology idea and then forming teams to work on a project solution to present to a judging panel on the Sunday afternoon. Developers Jaymesh Master, Michael Smith and Rosie Parry came on board with Howard’s pitch and his team won the Hackathon.

Late last year Ask Ruru was runner-up in the Active Project category of the 2017 Clinicians’ Challenge – a joint Ministry of Health and HiNZ initiative that seeks innovative healthcare technology.

The $2,000 prize money is being put into developing the app further, says Howard. “A second round of development is underway now and we’re ensuring it meets the Ministry of Health’s digital safety standards.”

Howard is hoping to get approval from Capital & Coast DHB to test the app as a user case study shortly.

He says other nurses and health professionals should not be afraid to test out new ideas. “In the information technology sector there’s a very strong practice about user-centred design. It’s never the user’s fault. That approach could be used to innovate the health sector.”

“In the information technology sector there’s a very strong practice about usercentred design. It’s never the user’s fault.

That approach could be used to innovate the health sector.”

He encourages other nurses to put their hands up with ideas.

“Don’t be afraid. At the Clinicians’ Challenge, the people there weren’t all technical people. They were people who had a problem they needed to solve.”

His work developing the app has also helped him see things more impartially. “If you build a website and nobody clicks on it, it’s because the user doesn’t want it or they don’t know how to use it. It’s been an interesting way to approach things.”

Howard says his ultimate aim is to see Ask Ruru used internationally.

“We’re excited to build on the name recognition that has come through the Challenge and Hackathon and get people using Ask Ruru in their work supporting young people in mental health crisis.”

Leadership & Management

Winter is coming… and so is the flu

FIONA CASSIE talks to long-standing director of nursing Dr Jocelyn Peach about the good, the bad and the challenging of planning for the coming flu season in the country’s fastest growing and most expensive city.

N

o winter is easy in the health sector, but this winter brings the prospect not only of a tough flu season but also of a nurses’ strike.

So this season – when winter illnesses see the demand for acute patient beds go up at the same time as the staff available to nurse them goes down – could be tougher than usual.

Dr Jocelyn (‘Jos’) Peach, the director of nursing at Waitemata District Health Board since 1999 and a nurse for 44 years, is very conscious of the pressures that nurses are under and the need for DHBs to respond to nurses’ growing and very real frustration over pay and workloads.

But meanwhile, winter is still coming.

“The challenge as a leader is to help the staff see the big picture,” says Peach.

The many pieces of the big picture for Peach include gathering accurate data to calculate safe staffing workloads, dealing with the staffing consequences of Auckland real estate prices, planning for the DHB’s population swelling by 100,000 or more in the next decade, and helping to refine systems to better manage demand and free up resources to fund more staff.

TransforMED – freeing up beds this winter It is the initial success of one of those systems’ projects – called TransforMED – that Peach and the executive leadership team hope will help the DHB meet their winter goal of maintaining timely access to care and treatment for both acute and elective patients in its North Shore and Waitakere Hospitals (a goal post

that, of course, could be dramatically moved if the flu season is unusually severe and nurses vote to strike in July).

One of the starting points for TransforMED was the reality that Waitemata’s population was growing rapidly and there was no space to expand at North Shore Hospital and no likelihood of getting a new hospital anytime soon.

“It means the staff are working under pressure … we are very, very fortunate to have good, flexible nurses.”

Work began on system improvements to make better use of the beds and space the DHB has already got. Last spring the DHB launched TransforMED in North Shore’s Admission and Diagnostic Unit (ADU) first, then on through the hospital’s general medicine wards and beyond, with the aim of reducing unnecessary admissions and, whenever feasible, getting admitted patients home earlier with the appropriate aftercare in place.

“It’s had a huge impact on our hospital,” says Peach. A report to the DHB’s May Hospital Advisory Committee shows that TransforMED, ADUcare and a ‘Home Warding’ pilot initiative have combined to improve patient flow and shorten the average length of stay by 18 per cent since their inceptions.

The initiatives have also allowed North Shore Hospital to operate

a ‘flexing bed’ programme by opportunistically closing beds if they are not needed. The combined bed savings of reduced length of stay and closing beds has to date has been just over $1 million, according to the DHB’s latest financial report.

The TransforMED project includes elements of the #endPJparalysis movement founded by Christchurchbased nurse and consultant Brian Dolan and his Irish colleague that encourages older medical ward patients to get out of their pyjamas and get dressed and mobile in order to maintain condition and return home sooner. Waitemata has developed its own variation – the ‘3G’ (Get up, Get dressed, Get moving) campaign.

Other elements of TransforMED are daily multidisciplinary board rounds, increased rounding in the ADU, daily bed management reviews, and doctors being assigned to patients in just one of the hospital’s six general medicine wards to help streamline patient care.

“We also have ‘red to green’ days,” says Peach.

Jocelyn Peach

Continued on next page >>

Leadership & Management

“So no patient just sits around waiting for something to happen and every day is a green day. A green day is making sure patients get the treatment they need so they can get home – it’s about reducing length of stay but also reducing the risks of pressure injuries, falls, and deconditioning.”

Peach says the results to date have been fantastic and mean that the DHB – while, of course, they enter winter always concerned with what the season could bring – now has systems more responsive to patient needs and an ADU system that supports patients who can go home safely to do so, reserving beds for those patients who need to be admitted.

The hospital’s winter plan is also built on the assumption that TransforMED will continue to deliver a 10 per cent reduction in occupied medical ward beds, allowing those beds to be flexibly used to meet winter demand.

The first test was a much busier than expected summer and Peach says, while it was a very busy time, the DHB still managed to deliver clear care plans for patients and keep patient flows on track.

Another key requirement for TransforMED to work is, of course, a flexible nursing staff ready to respond not only to patient needs but to the ‘flexing bed’ policy of opening and closing beds in response to patient demand and staff availability.

“It means the staff are working under pressure – don’t get me wrong…” acknowledges Peach. “We’ve got more patients but fewer bed days. Our staff have been really amazing, they’ve been really flexible. Staff go from Waitakere Hospital to North Shore and vice versa to help out if beds are closed on their ward.

We are very, very fortunate to have good, flexible nurses.”

And while Peach agrees that nurses “absolutely” face higher patient churn, she adds that nurses do not like seeing their patients languishing or having to face families frustrated because of the lack of an action plan.

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Recruiting and retaining nurses in the Big Smoke This year DHB nurses nationwide have been taking to social media to express pentup frustrations at pay and workload issues and a result could be a national strike this winter if an independent panel does not result in an offer that the majority are ready to accept.

So how tough is it currently to recruit and retain nurses in the country’s biggest and most expensive city?

“It’s not perfect,” says Peach. “We still get raided every so often from Australia and the Middle East … everybody suffers from that.”

She says the DHB’s nursing workforce has good retention of long-serving staff and new graduates, but where it struggles most often with turnover churn is some of its internationally qualified nurses (IQNs). “We have had a lot of people who come from overseas, they do their time with us and then they go off to Australia.”

Improved pay may help reduce turnover, but Peach says there are several reasons why nurses leave, including IQN nurses crossing the Tasman because their husbands have been unable to find work in Auckland. Other nurses and their families leave Auckland for jobs in the provinces because houses are more affordable.

“So yes, dollars may help but they may not help enough because there are costs associated with living with Auckland – which are getting ridiculous.”

For example, she says, the DHB has a marvellous new graduate nurse with four children who has relocated to Auckland for a new start but is forced to spend nearly all her wages on rent.

“She’s having to go to WINZ saying she can’t afford to feed her kids – we are trying to help her as much as we can … but the new grad salary is the new grad salary …”

Likewise, Peach says the DHB tries so hard to recruit Māori and Pacific nurses from the provinces and other centres to work for Waitemata, but when they try and find a house to buy or rent they tell the DHB that they just cannot afford to take up the job.

Safe staffing and CCDM Another major platform in the current stalled nursing pay talks is safe staffing and a commitment from all DHBs to fully implement the Care Capacity Demand Management (CCDM) safe staffing tools by 2021.

“I absolutely understand that we need to look at staffing and how our patient acuity has changed … it’s good work – nobody denies our patients are more complex and that we need adjustments around staffing,” says Peach.

Nonetheless, she says, the work involved to gather a year’s accurate acuity data from each of the 47 wards and units in which nurses are inputting daily information into the Trendcare acuity software – is “so huge, so massive” that it is “mind-boggling”.

Peach has taken on extra staff to help pull out the data from Trendcare, but says it will be a very tight work plan to deliver by the 2021 deadline. And once CCDM reveals the gaps between what is a reasonable workload and what is not, the next question is how DHBs will pay for the extra staff.

“Do we do the CCDM work? Definitely, but I don’t know how all DHBs will be able to afford the increases that are potentially there.”

Peach also doesn’t believe that CCDM is the ‘silver bullet’ and just one element – although a very important one – of her ‘big picture’ systems work to make nurses’ workloads more reasonable, fair and consistent.

“I understand the complexity of what nurses are facing … we’ve got to try and reduce the pressure by making the systems more efficient and effective.”

And all going well – although she acknowledges being concerned about what this year’s flu season might bring, and the chance of a July nurses’ strike in peak flu time “doesn’t bear thinking about” – Peach hopes that the big-picture systems will make a difference this winter.

Students

Traffic jams and heart failure: using metaphors to learn pathophysiology BRAIN (Waikato University)

MORAG MacKENZIE and PATRICIA McCLUNIETRUST share how the everyday experience of being stuck in traffic can be used to teach and learn pathophysiology.

T

eaching pathophysiology to undergraduate nursing students is challenging because there is a need to apply theory into the everyday clinical reality of nursing patients.

Students may understand the abstract concepts but actually recognising pathophysiological changes when assessing a patient is another challenge.

In this article, we present an example of everyday teaching moments using metaphors to provide a bridge between understanding the theory of pathophysiology and putting it into clinical practice.

Roundabouts and exits MacKenzie teaches undergraduate nursing students at Wintec, including working with students on clinical practice placements in the third semester of the degree.

This is the first time students undertake in-depth patient assessments and case studies and MacKenzie has noticed that they sometimes struggle to make meaning from the physiological patterns they encounter when working with patients.

MacKenzie bridges this gap using everyday ideas – or metaphors – that are familiar to students. Sometimes she might talk about the Starship Enterprise being under attack or a car breaking down, and other times about going shopping or traffic jams. The example we share here is traffic jams or congestion.

The idea of ‘traffic congestion’ came about when students were struggling to understand the mechanics of heart failure.

The aim of using a metaphor (see box) is to demystify the pathophysiology and bridge the student’s gap in understanding by using a practical example. Over time this metaphor has developed into a more comprehensive narrative, with

LUNGS (Burger restaurant)

HEART (Cambridge Road roundabout)

LOOP OF HENLE (Hamilton Gardens carpark)

URETHRA (Galloway Street exit) Illustrations by Kalei Esteves & original layout by Jordan Foster

KIDNEYS (Hamilton Gardens roundabout)

nuances allowing for further clinical complications to be examined.

Using the experience of traffic congestion as an analogy for the pathophysiology of congestive heart failure calls on an everyday experience for many people living in cities.

Wintec’s home is Hamilton – the country’s fourth-largest city and home to more than 140,000 people. Traffic congestion is a problem, particularly around the south-east area of the city that contains the university and many schools. The main arterial route to the south is Cobham Drive (State Highway 1), which is dissected by various landmarks, secondary roads and roundabouts.

The Cobham Drive metaphor for heart failure Students driving to class often experience traffic congestion, making the commute slow and difficult.

Various locations on the Cobham Drive route have been selected by Morag to represent anatomical locations so the causes and effects of congestive heart failure can be illustrated by what happens when the traffic (circulation) slows heading into the city. If the traffic

OEDEMA (Feet)

backs up, the roundabouts get clogged – a good analogy for the backwards and forwards flow effects of congestive heart failure (CHF).

HEART (Cambridge Road roundabout) ▶▶ Congestion and reduction in traffic flow at peak traffic times puts pressure on the flow and efficiency of the roundabout and roading. Does a larger roundabout help cardiomegaly or hypertrophy? ▶▶ Restricted traffic flow due to close proximity of housing so traffic backs up in the roading system – like the backwards and forwards flow effects of congestive heart failure. What happens if passengers get out of the cars – pulmonary and peripheral oedema?

LUNGS (Burger store roundabout) ▶▶ Students consider how the burger store’s drive-thru becomes congested with increased traffic at peak time.

Customers now opt to go into the store to order instead. This can be viewed as nursingreview.co.nz Issue 2 29

Students

pulmonary oedema – fluid accumulation into the alveoli/air sacs space. ▶▶ The burger store is now experiencing congestion difficulties as it is unable to process orders because of the volume of foot and vehicle traffic – this is the lungs now experiencing dyspnoea, pulmonary oedema, increased respiratory rate, adventitious breath sounds and decreased gas exchange.

KIDNEYS (Hamilton Gardens roundabout) ▶▶ Progression of traffic through roundabout is limited with reduced flow.

This is the decreased cardiac output that accompanies congestive heart failure, resulting in decreased perfusion to the kidneys that can lead to renal insufficiency or failure5.

LOOP OF HENLE (Hamilton Gardens car park) ▶▶ Traffic flows through car park, picking up and dropping off passengers, and then vehicles proceed towards Galloway Street and out of main roading system.

This can be likened to filtration and collection in the kidney where water and

electrolytes are reabsorbed and collected in the collecting tubule, where the production of urine begins.

URETHRA (Galloway Street exit) ▶▶ Traffic exits from roundabout and is rerouted down Galloway Street reducing the traffic volume. This is like urine produced and transferred to the urinary system for elimination – blood volume and oedema are reduced, lessening the workload of the heart and the effects of congestive heart failure.

OEDEMA (feet or lower extremities) ▶▶ Traffic congestion at the above roundabouts has a backflow effect at this city intersection, exacerbated by more traffic entering the system from Hamilton City. If traffic is at a standstill, passengers might alight from cars – like oedema in the lower extremities or feet.

Conclusion Learning moments are expected in formal education settings like classrooms or practice suites. But important learning opportunities also happen in clinical settings when students try to make sense of situations they are confronted with,

including the clinical signs presenting in the patient in front of them.

Students try to unravel and analyse client assessment data to relate it to the theory they have learnt from textbooks.

It is important to understand that students sometimes struggle to connect theory to practice and meet expectations of what they need to safely recognise and interpret in practice.

After being introduced to the ‘Cobham Drive’ story, students report a greater understanding of pathophysiology, in particular cardiac presentation, and appear to have ‘aha!’ moments as they become engaged with the traffic jam metaphor.

Students then take the ‘driver’s seat’ and take the concept further, suggesting ways to interpret clinical findings within the metaphor of the roads and helping to build their own bridges between theory and practice reality.

AUTHORS: Morag MacKenzie RN PG Dip HSci is a nursing lecturer at Wintec and Patricia McClunie-Trust RN PhD is the principal academic at Wintec’s Centre for Health and Social Practice.

Student leader:

from autopsies to advocacy

I

f nursing students wanted their National Student Unit (NSU) chair to be relatable and highly capable, they couldn’t have chosen a more perfect candidate than Nadine Everson.

Everson was elected last year to chair the New Zealand Nurses Organisation’s NSU after eight months as the student representative at the Rotorua campus of Toi Ohomai Institute of Technology, where she is a third-year nursing student.

The 32-year-old is Pākeha, was adopted by an Indian family and raised in Rotorua.

Everson’s journey to nursing includes working on a deep sea fishing trawler for a time.

“It was a large-scale operation with 50-plus people on the boat. It taught me a lot about how to work with people; about how teamwork is essential for remaining safe. It also taught me how to motivate people – because after six weeks together on a boat you’re not going to be at your best by the end.”

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She also worked as a mortician’s assistant, doing autopsies in a district health board setting. “It taught me the true value of working with families, and at their lowest point. And it piqued my interest in clinical skills.”

Everson says working with a girl with Down syndrome, whose family continues to employ her as a support worker, also taught her how to be patient-centred.

What solidified Everson’s decision to go nursing was being a carer for her father when he had terminal cancer.

“When he was in hospital, I saw the true value of nurses. I saw how integral to the quality of care nurses are. How they are the patient’s eyes and ears and how intuitively perceptive they have to be to help keep a patient’s spirits up and look for any changes needed in the patient’s care and for any deterioration in the patient.

Becoming the NSU chairperson was a natural progression for the passionate nursing student. “I really believe in

Kai Tiaki

advocacy. I think that it is a big part of what we do for patients, for colleagues and for ourselves. “ She says students don’t necessarily view the debate around the safe staffing problem as all negative. “For us it’s not a negative, we see this conversation as a progression to better pay outcomes, and better health outcomes for patients, and better education opportunities when we are on placements.”

A big issue for students is the ‘struggle of the juggle’.

“It’s helping students find a balance.

I see the pressures of the long hours on practicum combined with the academic work.”

This is an edited version of the full article, which can be read at http://nursingreview.co.nz/ student-leader-on-the-struggle-of-the-juggle.

Opinion College of Nurses

School nurses

deserve better pay and support

NGAIRA HARKER calls for pay parity and better professional support for essential school nurses.

T

he role of the school nurse is essential in primary healthcare – it gives Ngaira Harker. students access to a health professional specialised in engaging with their age group.

School nurses also support educational outcomes by supporting health and wellness during these critical years.

When I was a public health nurse working in both primary and secondary schools in Rotorua, I was fortunate to have an experienced team of expert public health nurses, teachers, Māori health professionals, social workers and psychologists as mentors and advisors.

We were provided with a structured professional development pathway and regular connections with nursing peers. We were able to discuss our schools – and the many diverse issues needing consideration – with colleagues clinically, ethically and professionally.

Delivering care within schools is a specialised role requiring a high level of autonomy and expertise, together with the confidence to engage and collaborate with the wider health professional groups working in this area. It requires an understanding of child and adolescent health, health promotion, mental health issues, sexual health, Māori and Pasifika, refugee, and acute and chronic health issues.

The role’s comprehensive nature means it is imperative that all school nurses are provided with a well-structured professional development plan. This ensures they are safe as registered nurses to meet best care practice standards and the Nursing Council requirements. Critical to professional development is support and funding by employers.

Currently, school nurses’ employment conditions and access to professional development can be variable depending on their employer. For school nurses employed

by DHBs, there is generally a link with professional development recognition programmes (PDRPs) and DHB support pathways. This allows for a structured professional development plan, access to mentorship and supervision and access to HWNZ postgraduate education funding.

In contrast, for nurses employed by schools (funded via Vote Education, not Vote Health), there is no such link and they can lack professional nursing support to strengthen their student services.

The role’s comprehensive nature means it is imperative that all school nurses are provided with a well-structured professional development plan.

The College of Nurses is regularly contacted by a steady number of Vote Education-employed school nurses voicing risks including: ▶▶ having to navigate their own professional development; for example, sexual health is a requirement but anecdotally some schools are not aware or are not supporting nurses in this area ▶▶ salary variations – some are paid a minimum salary that doesn’t reflect their experience and are not paid in the school holidays ▶▶ work conditions, expectations and boundaries are not clearly understood by employers and/or nurses, creating professional and ethical dilemmas

▶▶ confusion about patient confidentiality, with school principals assuming nurses should share information provided by young patients.

An excellent foundation guideline for employers is the Guide to employing a registered nurse within a secondary school setting. It is a well-developed guide – for both employee and employer – on the employment requirements of secondary school registered nurses.

Another useful resource is Youth health care in secondary schools: A framework for continuous quality improvement, which provides self-assessment checklists of youth health quality indicators, as well as practical strategies.

It is essential that schools are wellinformed and school nurses are supported to remain current and competent through well-planned professional development.

Also important is the need to integrate care across health services. Ideally, school nurses are part of a broader, communitybased primary health team ensuring no fragmentation between the various NGO, general practice, secondary and other services. This should be of interest to the Mental Health and Addictions Inquiry team as an area in which youth health in particular can be improved.

It is timely to consider equity for nurses employed by schools – not only supporting salaries that match their expertise, but also recognising the importance of our rangatahi and their right to quality care to support their future wellness.

Ngaira Harker is co-chair of the College of Nurses Aotearoa and Nurse Director Māori Health at the Hawke’s Bay District Health Board.

References for this article are available in the online version at www.nursingreview.co.nz.

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Conferences

Upcoming conferences Cardiac Society of Australia and NZ Annual Scientific Meeting ▶▶ 14–16 June 2018 ▶▶ Christchurch ▶▶ www.csanzasm.nz

Mental Health & Addiction Nurse Educators Forum 2018 ▶▶ 13–14 September 2018 ▶▶ Auckland ▶▶ www.nzcmhn.org.nz/events/regionalevents

Infection Prevention and Control Nurses NZNO Conference 2018 ▶▶ 30 October–2 November 2018 ▶▶ Lower Hutt ▶▶ www.ipcconference.co.nz

New Zealand Nurses Organisation Conference and AGM ▶▶ 19–20 September 2018 ▶▶ Wellington ▶▶ www.nzno.org.nz

IUSTI Asia Pacific Sexual Health Congress (including NZ Sexual Health Society) ▶▶ 1–3 November 2018 ▶▶ Auckland ▶▶ http://iustiap18.com

NZ Dermatology Nurses Society Conference 2018 ▶▶ 9–10 August 2018 ▶▶ Auckland ▶▶ www.nzdermatologynurses.nz

23rd Hospice NZ Palliative Care Conference 2018 ▶▶ 19–21 September 2018 ▶▶ Auckland ▶▶ www.hospice.org.nz/conference-2018

College of Gerontology Nursing Conference 2018 ▶▶ 5–6 November 2018 ▶▶ Hamilton ▶▶ www.comingintoage2018.org.nz

Indigenous Nurses Aotearoa Conference 2018 ▶▶ 10–11 August 2018 ▶▶ Auckland ▶▶ www.nzno.org.nz/hui

International Society of Nurses in Cancer Care Conference 2018 ▶▶ 23–26 September 2018 ▶▶ Auckland ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/cancer_nurses_college

Gastro 2018 (NZ Society of Gastroenterology/NZNO Gastroenterology Nurses’ College Annual Scientific Meeting) ▶▶ 21–23 November 2018 ▶▶ Dunedin ▶▶ www.gastro2018.co.nz/gastro18

Drug and Alcohol Nurses of Australasia Conference 2018 ▶▶ 26–27 July 2018 ▶▶ Melbourne ▶▶ www.danaonline.org/events/dana-2018conference

Involve 2018 (Youth sector conference supported by Society of Youth Health Professionals Aotearoa NZ) ▶▶ 13–15 August 2018 ▶▶ Wellington ▶▶ www.arataiohi.org.nz/initiatives/ involve#reg South General Practice Conference and Medical Exhibition (GP CME) 2018 ▶▶ 16–19 August 2018 ▶▶ Christchurch ▶▶ www.gpcme.co.nz NZ Rheumatology Association/NZ Health Professionals in Rheumatology Annual Scientific Meeting 2018 ▶▶ 30 August–2 September ▶▶ Wellington ▶▶ www.eenz.com/nzra18 All Together Better Health International Conference (Collaborative Practice and Interprofessional Education) ▶▶ 3–6 September 2018 ▶▶ Auckland ▶▶ www.atbhix.co.nz New Zealand Association of Gerontology Conference ▶▶ 6–8 September 2018 ▶▶ Auckland ▶▶ www.gerontology.org.nz New Zealand Faith Community Nursing Association Conference ▶▶ 7–9 September 2018 ▶▶ Tauranga ▶▶ www.faithcommunitynursing.nz 32 Issue 2

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Neonatal Nurses College Aotearoa Symposium 2018 ▶▶ 28 September 2018 ▶▶ Hamilton ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/neonatal_nurses_ college/conferences_events Selwyn Foundation Gerontology Nursing Conference 2018 ▶▶ 1 October 2018 ▶▶ Auckland ▶▶ www.selwynfoundation.org.nz/ learning/learn/2018-gerontologynursing-conference Perioperative Nurses College NZNO Annual Conference 2018 ▶▶ 11–13 October 2018 ▶▶ Nelson ▶▶ www.confer.nz/periop2018 College of Emergency Nurses NZ Conference 2018 ▶▶ 26–27 October 2018 ▶▶ Napier ▶▶ www.nzno.org.nz/groups/colleges_ sections/colleges/college_of_ emergency_nurses

NZNO Nurse Managers Conference 2018 ▶▶ 8–9 November 2018 ▶▶ Napier ▶▶ www.nzno.org.nz/groups/colleges_ sections/sections/nzno_nurse_ managers_new_zealand eHealth in Nursing @ HiNZ Conference 2018 ▶▶ 21 November 2018 ▶▶ Wellington ▶▶ www.hinz.org.nz NZ Respiratory Conference 2018 ▶▶ 22–23 November 2018 ▶▶ Auckland ▶▶ www.nzrc2018.org

2019 Nurse Practitioners New Zealand Conference ▶▶ 10–12 April 2019 ▶▶ Marlborough ▶▶ www.nurse.org.nz/npnz

TO SUBMIT A NURSING CONFERENCE OR EVENT, EMAIL EDITOR@NURSINGREVIEW.CO.NZ

Failure to deliver medication to the target site can lead to inadequate asthma control in children Only extrafine QVAR reaches the very smallest of airways 2

QVAR patients have consistently better outcomes compared to fluticasone patients

1

fluticasone-salmeterol (standard pMDI)

QVAR beclomethasone dipropionate

16% lung deposition

58% lung deposition

(extrafine pMDI)

3

2

2

References: 1. Gelfand EW & Kraft M. The importance and features of the distal airways in children and adults. J Allergy Clin Immunol. 2009; 124(6 Suppl): S84-7. 2. Leach CL, et al. Characterization of respiratory deposition of fl uticasone-salmeterol hydrofl uoroalkane-134a and hydrofl uoroalkane-134a beclomethasone in asthmatic patients. Ann Allergy Asthma Immunol. 2012;108(3):195-200. 3. Price D, et al. Prescribing practices and asthma control with hydrofl uoroalkane-beclomethasone and fl uticasone: A real-world observational study. J Allergy Clin Immunol. 2010;126(3):511-8. Qvar Inhaler and Qvar Autohaler are Prescription Medicines containing 50 mcg and 100 mcg of beclomethasone dipropionate per inhalation. Please refer to the data sheet available at www.medsafe.govt.nz before prescribing. Indications: Prophylactic anti-infl ammatory treatment of reversible obstructive airways disease including asthma. Contraindications: Hypersensitivity to beclomethasone dipropionate or any other ingredient in Qvar. Not for use in children under 5 years. Precautions: Not for relief of acute attack, pregnancy and lactation. Adverse Eff ects: Candidiasis of mouth and throat, hoarseness, throat irritation. Qvar Inhalers contain Ethanol and the CFCfree propellant Norfl urane (HFA134a). Interactions: No clinically signifi cant drug interactions have been associated with therapeutic doses of BDP. Dose: The recommended total daily dose of Qvar is lower than that for current CFC-BDP products and should be adjusted to the individual patient. Starting and Maintenance Dose: Adults: For mild to moderate asthma: 50 mcg to 200 mcg twice daily. For more severe asthma: doses up to 400 mcg twice daily. Maximum recommended daily dose: 800 mcg. Children: 5 years and over 50 mcg twice daily. In more severe cases this may be increased up to 100 mcg twice daily. Maximum recommended daily dose is 200 mcg. To minimise the systemic eff ects of orally inhaled steroids, the dose should be titrated down to the lowest that provides eff ective asthma control. Qvar is a fully funded Prescription Medicine.

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