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Diversity and inclusion in health

Hi, my name is Siȃn Munson. I am a Community Clinical Nurse for people with long term conditions. I am also an NZNO delegate, a mum, a friend, a lesbian and many other things too of course.

My journey to nursing

My Grandmother and one of my cousins are nurses, so nursing was always a possibility for me, however my journey to nursing took a while! I left school after the 6th form, went to the UK for year and applied to take an enrolled nurse course when I got back. That didn’t end up happening. Instead I got married and had three wonderful children, one of whom has significant learning and support needs. I also did an extramural degree over 6 years at Massey University. I majored in Women’s Studies which gave me a passion for women’s health.

I got divorced and made a decision to move to Palmerston North to do my nursing training. I studied at UCOL when my children were 7, 9 and 10 and I was a solo mum. I tell you what – if you can handle being a solo mum, you can handle anything!

When I started I thought I wanted to work in Mental Health but over the course of my studies I realised I wanted to focus on Women’s Health.

After a few years of working as a civilian Army Nurse in a women’s and sexual health role, I got my current role. I’ve been here for three years now and I love it.

Starting post grad study

While I was working in sexual health I began my Masters Degree at Massey University. I started with the Women’s Health paper and it snowballed from there. During my study I realised that there was very little New Zealand literature about lesbian women’s experience of healthcare – and what I was seeing in my practice made me think something needed to be done about that. As a result my final paper was the Research Report and I graduated in 2015.

I was extremely lucky to have a wonderful supervisor, Dr Catherine Cook, who is a senior lecturer at Massey University.

Coming out at work

When I started at Central PHO my manager was really supportive of my studies and when I knew what my research topic was going to be I thought I should probably “come out” to her. So, I officially told her I identify as a lesbian.

It’s a big deal to come out to someone, especially your manager. I mean, sometimes you know people know, or it’s an open secret or whatever, but actually officially telling someone you are queer is pretty scary. If you are not queer it might be hard to understand that, but people who are lesbian or bi or gay will understand that being “out” and “coming out” is something that happens every single day. Every day we have to evaluate our personal and professional safety and comfort in every single situation we are in. And that includes with patients as well as colleagues.

In this case, it was the best decision I ever made! It’s been a really positive experience for me to be out at work with my colleagues, although with patients it’s still a case-by-case thing. I’ve heard people say things like “no one needs to know” or “I don’t know why gay people have to come out”, but believe me, it matters. Being in the closet is awful. You’re constantly second guessing everything you say. You’re editing your life. It’s tiring and it’s soul destroying. I didn’t know until I came out how important it is to come out and how life affirming it is to live an authentic life. Not to hide who you are. And most importantly to be accepted for who you are in all your rainbow glory. Life is far better since I came out. One of the great things I’ve gotten to do since I came out was to attend Wellington Pride Parade with NZNO – Out At Work.  Three years ago I’d never have done that!

My research

Anyway, my research… My research topic was “Cloaked in Invisibility – Experiences of Lesbian and Bisexual Women in their Encounters with Health Professionals for Cervical Screening and Sexual Health”. For this research I interviewed six lesbian and bisexual women about their experiences receiving sexual and gynaecological healthcare in New Zealand. There is very little research on lesbian and bisexual women’s health in a New Zealand context, and this research adds to and expands that knowledge.

It was such a privilege to hear their stories.

My findings show that lesbian and bisexual women suffered quite major barriers to receiving timely and culturally-appropriate healthcare.

The healthcare system is heteronormative – healthcare professionals make (probably unconscious) assumptions that everybody is heterosexual. For example, if your GP asks about your husband, that’s heteronormative and it means that the patient is instantly having to make a heap of decisions instead of being able to focus on the appointment: “O, should I say I’m a lesbian? Is it not worth it? Shall I just leave it? Maybe I should say? Why is he/she making assumptions? Etc “

There is both implied and overt homophobia in health care. While being gay is becoming more socially acceptable, not all of society is accepting. Some of the participants had experienced horrific homophobia from health care professionals which had seriously impacted their lives.  Experiencing homophobia makes it difficult to return for further health care.

There is a conundrum of safer sex – What does safer sex look like for women who have women sexual partners? Many lesbian and bisexual women assume they are having safer sex because they are not having sex with men. Some believe they can’t contract sexually transmissible infections. There are no specific barrier protection methods for use by women having sex with women, and the current choices such as latex gloves, dental dams and condoms are not very user friendly for safer sex between two women.

Engagement with health promotion – it’s hard to engage with public health promotions when you are invisible in them. There is very little sexual health information available for lesbian and bisexual women. There are no posters on the walls at surgeries that depict lesbian families. Women found ways of finding the health information they needed when they didn’t feel ok about seeking advice from health professionals.

Resilence – the amazing thing I found was that, despite the barriers, lesbian and bisexual women do find ways of navigating the health system, through friends and the queer community.

I find this fascinating! I can see so many ways that we can change our thinking and practice to become inclusive and start providing care in a more appropriate and equitable way to our patients. Even understanding that there ARE queer patients on your books, even if they are not out to you, is a good start. My research found that when a woman has a positive experience coming out to a health professional it makes it more likely that she will come out to another health professional.

And I want to get these learnings out as widely as I can. I want to change practice. The thought of my work gathering dust in a library somewhere gives me the shivers. That’s why I have written a journal article with my supervisor.  That’s why I am speaking out about it. My research report has been published this month in the Journal of Clinical Nursing. It’s exciting to be adding to the body of knowledge in this under-researched area. If you have ideas about how we can create inclusive environments for our patients and clients I’d love to hear them. Please add your thoughts in the comments.

Munson, S. and Cook, C. (2016), Lesbian and bisexual women’s sexual healthcare experiences. Journal of Clinical Nursing. doi: 10.1111/jocn.13364

http://onlinelibrary.wiley.com/doi/10.1111/jocn.13364/abstract

 


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International Nurses Day 2016

IND resources

An International Nurses Day message from NZNO chief executive, Memo Musa.

On Thursday we celebrate International Nurses Day, Florence Nightingale’s birthday, a very special day for our profession. It seems to come around quickly, which I think is an indication of the busy lives and careers nurses’ juggle. Nice that it does, too – because nurses are worth celebrating often!

After listening to presentations about some of you work at regional conventions around the country recently, I concluded that every day we should celebrate international nurses day, as nurses are involved every hour of the day in caring for someone in our health system.

Nurses are the largest profession in the health system, and without you the health outcomes for people receiving care and treatment in the health system would not be improving as they are.

Nurses, we couldn’t do what we do, without you. Thank you.

I often reflect that nurses hold the world together. We are in every community, culture and society the world over. Nurses are the woman and men who see health holistically and are able to innovate and advocate for whole person, whole whānau and whole population health.

The theme for this year’s International Nurses Day is Nurses: A Force for Change: Improving health systems’ resilience and here at NZNO we are certainly taking that challenge on board.

NZNO members are at every level advocating for a resilient New Zealand health system where everyone can access the healthcare they need, where and when they need it.

Our policy advisers and researchers are providing government and other decision makers with the evidence needed to make good and sustainable decisions.

NZNO members like you are making the difference to healthcare in your workplaces and communities and beyond.

Along with the World Health Organisation and the International Council of Nurses, NZNO believes that action on the social determinants of health should be a core part of nurses’ business. Not only does it improve clinical outcomes, and saves money but taking action to reduce health inequalities is a matter of equity and social justice.

“Every health professional has the potential to act as a powerful advocate for individuals, communities, the health workforce and the general population, since many of the factors that affect health lie outside the health sector, in early years’ experience, education, working life, income and living and environmental conditions health professional may need to use their positions both as experts in health and as trusted respected professional to encourage or instigate change in other areas.” Institute of Health Equity (2013), p.5

Nurses, people in the health system can’t reach their goals without you, and we can’t reach our goals without you too.

Tēnā koutou, tēnā koutou, tēnā koutou katoa.

Yours in nursing solidarity
Memo Musa
Chief executive
New Zealand Nurses Organisation

 

 

 

 


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Shining a light on depression

By Grant Brookes, NZNO president

A light was shone into a dark corner last month, when NZ Doctor magazine published a blog on depression among nurses.

It generated a strong reaction. When I shared the blog on social media, a lot of nurses responded.

Some of the responses were public comments. But other nurses shared stories of depression with me privately – including traumatic events which aren’t talked about.

I have learned of several suicides of some people in our profession in recent months.

But the overwhelming response was relief at being able to speak about this taboo subject, and a desire to get it out in the open. The nurses I spoke with also talked about why the problem is so big, and what might help.

And the problem is big ­– much bigger than it appears. For reasons I’ll get to, nurses are not disclosing their depression.

As one nurse put it, “I’m seeing more depressed nurses trying to hide it under a smile these days”. Another said that according to her GP, over 60 percent of the health professionals enrolled at that practice were on anti-depressants.

With almost two decades of experience working in adult mental health, I have an understanding of depression, from a nursing perspective.

I’ve practised long enough to remember old concepts like “reactive depression” (occurring in response to stressful events) and “endogenous depression” (with no previous stressor). These days, all depression is seen as linked to stress in some way.

Some of the nurses who spoke with me talked about stressors specific to their group. For the Internationally Qualified Nurses, who make up over a quarter of our workforce, there is separation from family support networks, and often cultural dislocation as well.

One mental health nurse talked about the emotional impact of “dealing with out of control behaviour”. “It’s a thankless job”, he said.

A former prison nurse told me, “During my year working as an RN in prisons I witnessed violence and experienced cases involving sexual violence, self-harm/suicide, physical assault and death. That there was no support available from my employer is still shocking to me”.

But there were also common themes. The reality for all of us in the acute care setting is that we relate to people in distress. As one nurse put it, we have “constant experiences of vicarious trauma”.

Another common theme was expressed by a rural nurse. She told me that her team all love nursing. “We do it because we like caring. But it compromises your personal values when you can’t give that care, when you know it’s not ideal. It creates a conflict within yourself”.

A younger nurse described the same thing. She said she had done postgrad last year and learned to name the problem. “It’s moral distress”, she said. Many others talked about how their mental health was affected by this stressor, too.

The increasing demands on nurses, including more and more time being spent at work, were also widely reported. “I have colleagues who work many extra unpaid hours and are constantly exhausted”, a Senior Nurse told me. “It is commonplace to hear colleagues tell of how they cannot sleep at night. Some are gaining weight, others losing it, and tears are not uncommon. The relentlessness of the work is demoralizing and there is the constant fear of making a mistake”.

More hours at work also means less time for the family. This leads to feelings of guilt. These are strongly associated with depression.

Sometimes these feelings of guilt are deliberately created by managers. One nurse said, “I have been told that ‘it is an expectation of nurses to work beyond your scheduled hours’, ‘you are reluctant to change’, ‘what if it was your mother?’, to list a few”.

This is related to the problem of workplace bullying, another stressor linked to depression which was mentioned by many.

Some who shared their stories spoke of colleagues who expressed negative attitudes towards nurses with depression. But on the other hand, all mentioned others in the nursing team who had supported them.

The range of attitudes among managers appears narrower, however. I was told that nurses with depression are not supported by their managers in the way that, say, staff with health conditions like asthma or diabetes are.

“There needs to be a general acceptance that you can work with depression”, a ward nurse told me. Others named what it means when nurses with depression are treated differently by employers: “stigma”. A number of people said they think this is why depression is not disclosed by nurses.

Based on this, the things which might help address this hidden epidemic start to become clear. Firstly, campaigns to destigmatise mental illness in society at large are part of the solution, to enable safe disclosure and help-seeking. The experiences of the former prison nurse also point to the need for debriefing after traumatic incidents.

Professional and clinical supervision were also raised by some of those I spoke with – and not just by mental health nurses, who use it much more often than anyone else. As one nurse said, “Supervision is not individual therapy, but it can help with problems before they get that big, and it can signal the need for extra mental health support”.

But the helping strategy which was mentioned most often was EAP (Employee Assistance Programme). For employers who opt into it, EAP provides short-term counselling for staff, for free. This appears to be reasonably accessible in DHBs, but Primary Health Care Nurses told me that it’s sometimes harder for them to get.

While many appreciated EAP, there was this also this comment from an Enrolled Nurse: “A service like EAP is needed to help staff acknowledge and alleviate some of the pressures, but I also understand they’re not a cure and that the Ministry of Health and the government need to own some accountability for why there’s added stress of late in the workplace”.

This leads onto a final point, made by a Primary Health Care Nurse. Depression, and the stressors which cause it, are not just individual and workplace issues. They are social problems, too.

“There is this view among nurses that things are getting tough and that we can’t do much about it. Depression can be related to the feeling that we have no control. Until nurses collectively realise this and use our influence, then I would anticipate that depression and burnout will only increase”.

We all feel down from time to time, but symptoms of depression should be taken seriously if they last for more than two weeks. You might be showing a number of the warning signs, or none in particular – everyone is different. If you are in any doubt, talk to your doctor or try the Self-Test on the depression.org.nz site.

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Arohanui Christchurch

I’m a mental health nurse and I know how challenging the role can be at the best of times. So when Canterbury DHB announced that, because of funding cuts being forced on them by the current Government, they may have to cut funding to mental health services I was very worried.

Today is the anniversary of that awful 2011 quake. My thoughts are with the people of Christchurch and with the families of those who were killed. My thoughts are with every person who still bears the scars of the earthquakes, be they physical or mental.

Things are pretty tough in Christchurch and I fear they’re going to get tougher.

I have been talking with some of my Christchurch-based mental health colleagues over the last couple of days and I share their concerns.

Mental health needs

  • The anniversary of the February 2011 quake is today. This, along with the recent earthquakes is re-traumatising people.
  • The long-term prognosis for mental health in the city is deteriorating, because young people aren’t getting early intervention from specialist mental health services. There is a rise in young people who have little resilience left and just aren’t coping being referred onto adult mental health services.
  • The referral rate to child and adolescent mental health services has doubled, and there’s been a huge increase in presentations to the Crisis Resolution Team. It’s really hit home in the last 12-18 months.
  • People are moving from place to place, relationships are breaking down, and children’s mental health is suffering.
  • Some Special Education Services staff have been told not to give a diagnosis of PTSD to children they are working with, partly because there is not enough funding to treat them.
  • People with long-term, chronic mental illness have been destabilised after being ousted from their council house, losing the support of nearby friends and familiar shops.
  • There has been an increase in Alcohol and Other Drug (AOD) use.
  • 100,000 people have come to Christchurch for the rebuild. The guys are working up to 16-hour days, burning out and turning to alcohol and drugs. A lot of them are turning up in mental health services. The DHB is expected to absorb that increase out of existing budgets.
  • There is noticeable rise in mental health problems among Canterbury farmers.

Impact on mental health services

  • There are long delays to be seen in specialist mental health services, especially for new referrals and especially for children and young people. There is a waiting list at Whakatata House, a community mental health service for children and families.
  • The delays are due to wider system pressures, as well as rising need among Christchurch residents. So, for example:
    • The biggest and widest impact of funding cuts has been felt by NGOs who support people in the community, so they don’t become so unwell that they need specialist services (this trend is expected to continue).
    • All sexual assault support services were closed last year, along with Relationships Aotearoa.
    • Recently, The Pacific Island Trust has gone, and the drop-in centre at Latnam House has been forced to shut its doors.
    • Even some DHB mental health services have shut down. The Day Programme at the Youth Inpatient Unit at Princess Margaret Hospital closed about a month ago.
    • Caseloads for community mental health nurses are 30-40. This means nurses do not have enough time to do their job. Case managers are staying at work until 6pm routinely – doctors even later, until 7 or 8 in the evening. This is overtime is unpaid. Running a service on the goodwill of staff in this way is not sustainable.
    • Staff in community mental health were recently told that they’re not allowed to organise taxis any more, to help clients get to appointments. Now the next cut which they have been told is coming, is that they are going to lose some of their DHB cars, so staff will be less able to visit clients in their homes.
    • The increasing use of “Level 2 specials” (ie. one-to-one care in the inpatient unit, for high needs service users) has meant that nurses have to push to get the extra staff they need.
    • Staff are being cut by not filling vacancies.

The mental health of the nursing team

  • Staff are having to deal with the same issues as the rest of Canterbury: dealing with EQC, fighting Fletchers, moving house. People are tired.
  • All the staff are on edge. Some say it’s almost like they are suffering from post-traumatic stress themselves.
  • There is huge staff turnover. Since last weekend’s earthquake, three staff in one ward have resigned. They say they are looking for work in other regions and who can blame them?

All the people I spoke to said they and their colleagues are dismayed and disgusted at this Government’s decision to not adequately fund Christchurch’s mental health services.

It doesn’t have to be like this. We all chose to prioritise some things in our lives over others. And the Government is no different. They have not prioritised the health and well-being of Christchurch people.

I guess the good thing about priorities is that they can changed. I’d like this Government to prioritise mental health services in Canterbury. I urge them to do it!

by Grant Brookes, NZNO president


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Its tough out there for new grads

NETPNZNO associate professional services manager Hilary Graham-Smith talks about the realities of too few Nurse Entry to Practice (NEtP)places and too many new grad nurses not getting the support they should have.

It’s a busy time of year for everyone, especially for the hundreds of newly graduated nurses out there who have just got the results of their state finals and are now looking for jobs.

It’s tough out there. We know it. And that’s why we’re feeling pretty disappointed that the Minister of Health is putting out press statements painting a rosy picture of the nursing landscape.

NZNO, and the other national nursing organisations have a goal of 100% Nurse Entry to Practice places for all new grad nurses by 2018. We’re pushing hard to make it happen and pursuing every avenue for change.

The issues are complex:

  • There just aren’t enough NEtP places
  • The Government has not allocated enough funding to the NEtP programme
  • Employers want ‘experienced’ registered nurses
  • No NEtP programme for new graduate enrolled nurses
  • New graduates in their first year of practice working outside of the NEtP programme have inadequate support

The results of the latest Advanced Choice of Employment (ACE) round for graduating nurses makes for depressing reading. Of the 1451 applicants including first time and repeat applicants, 51% (735) gained employment in a Nurse Entry to Practice programme. November 2015 graduate numbers were 1245 and of those 568 did not gain employment through the ACE round. We can endlessly slice and dice the numbers every which way but the point is that we still have large numbers of graduating nurses who do not gain employment on a NEtP programme. Just hold that thought in your head as you read on.

The Minister’s press release celebrating this will have been of no comfort to unsuccessful applicants and makes those of us who know the real story shake our heads in dismay. For the Minister to say “This result is in line with the pattern seen in the first four years of ACE” suggests that the status quo is OK? Really?

In November 2013 the National Nursing Organisations convened a workshop with Health Workforce New Zealand (HWNZ). The purpose of that meeting was to inform HWNZ’s and the Office of the Chief Nurse’s direction for education, workforce development programmes and innovations. It was agreed that one of the key action points from that meeting should be “a balanced approach to the nursing pipeline, including full utilisation of Nurse Entry to Practice funding to support a goal of 100 per cent employment of new graduates”*. The timeframe for achieving this was 2018 at the latest.

One could reasonably expect that two years on we would see some improvement in the numbers of new registered nurses being employed through the ACE programme.

In the same press release the Minister goes on to say “The data also shows from past ACE rounds that the vast majority of graduate nurses find employment over the next year”.  The salient truth about this statement is that the new graduates may well find employment outside the NEtP programme but this is likely to be in environments where they will be given too much responsibility and will not have the support and oversight of more experienced nurses. Our experience is that  these new graduates end up in competency reviews, disciplinary proceedings, in front of the coroner’s court or being reported to the Health and Disability Commission. NZNO lawyer, Margaret Barnett-Davidson had this to say, “In rest home/hospitals where nurses faced allegations relating to their practice, there were a number of common issues that increased the nurse’s vulnerability….. unsupportive managers and caregivers, time pressures too challenging for the skill set, busy environments and accepting responsibilities beyond manageability or competence level.” (Kai Tiaki Nursing New Zealand, November 2013)

Remove the gloss and spin from the rhetoric and the fact is that the registered nurse workforce is being disadvantaged by systemic unfair funding models that do not recognise it as the largest health workforce in New Zealand and one that is pivotal to providing safe and effective care for our populations and communities.

Yes the issues are multi layered as are the solutions, yes there needs to be collaboration between the education providers and employers and yes we need a strategic plan that takes account of the nursing workforce shortage predicted for 2035. But first of all we need an equity lens passed over the funding that is made available to nursing, in particular our new graduate nurses.

* (Summary of selected themes and some agreed actions that emerged from discussions at the Health Workforce New Zealand (HWNZ) Nursing workshop held on 29th November 2013).

 

 

 

 


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Memo Musa – conference address

Memo Musa AGM4Last week NZNO held its AGM and conference. This year around 300 delegates and college and section members met at the Museum of New Zealand Te Papa Tongarewa to discuss and make decisions about our organisation, nursing and the wider health sector. We learned new skills, to celebrated our successes and took up the challenges that were laid down.

Our new elected leaders were welcomed and our our departing leaders were thanked for their mahi. One of the highlights of the AGM and conference were the wonderful speakers, from within NZNO, around the motu and throughout the world. 

Here is the address given by NZNO chief executive, Memo Musa on the morning of the first day. 

Tēnā koutou, tēnā koutou, tēnā koutou katoa

I am Memo Musa, Chief Executive of NZNO.

It gives me great pleasure to welcome you all to NZNO’s 22nd Annual General Meeting. And to our exhibitors and sponsors who are here today and for conference tomorrow, welcome. I know that Marion and Kerri have welcomed you already but it is important that I do so too.

This is my second report to the AGM on NZNO’s performance during the past financial year.

I hope you have had the opportunity to read our Annual Report 2014/15 and reflect on our operational and financial performance as well as our achievements.

I would like to take a few minutes to take you through some of the key highlights of the year. Before I do so, I would like to comment briefly about the AGM today. You will have seen from the information you received that we have a total of seven remits and twelve policy remits. These should provide us today an opportunity to fine tune some aspects of the constitution as well as debate or discuss policy matters that are important to you and require our collective action as an organisation. I accept that it is a democratic process to amend aspects of the constitution. I would like to sound alarm bells that this can equally create a state of inertia as it makes it difficult to work within rules that are continually changing. That said, some improvement are required.

Back to key highlights from the past year:

We started the year with five priorities.

  • To increase and maintain membership
  • To increase the visibility of NZNO’s role as a professional association of nurses
  • To promote nurses and the nursing profession
  • To contribute to health sector workforce planning
  • To improve organisational health

Strong operational management and transparent reporting are critical to the long term success and creation of value. This is why, with support from the Board, during the past two years we have completely revamped the Annual Report to give you more information, detailed highlights, successes and challenges. This provides us an opportunity to celebrate successes and face up to what we could have done better. Often we hear that we do not celebrate or showcase our successes enough.

Now the key highlights. I will only pick a few to illustrate key points.

Increase and maintain membership

The biggest challenge for any member organisation is maintaining membership, let alone increase it. Membership levels have a big impact on the viability and sustainability of NZNO.

The solid work you are doing, including the work by our organisers, industrial advisors, professional nurse advisors and other staff through our organising ethos, models and approaches, including our communication, has resulted in us maintaining our membership numbers at above 46,675 based on 2013/14 year with a very modest increase of 103 members to 46,778 members.

Our biggest growth was in the registered nurse members were we saw an increase of 918 members from the previous year totalling 35,275. This makes up 72 percent of practicing registered nurses. According to the Nursing Council there are 48,406 registered nurses practicing.

However we had challenges with student nurse membership which declined from 4,225 in 2011 to 2,700 by the end of March this year a drop of 36 percent. This a concern we must address.

Fellow colleagues, we cannot ‘rest on our laurels’ when it comes to membership, as during the past five years union membership in New Zealand has been in decline.

In 2010 there was a decline of 2.1 percent

2011 it fell by 1.3 percent

Then 1.4 percent in 2012

By 2013 it had fallen by 2.0 percent and at the end of March 2014 this had fallen by 1.8 percent. I am waiting for the 2015 figures to be published. My guess is that the same trend will continue.

Whilst overall we are doing better than some unions and professional associations we have room to improve.

Increasing NZNO’s role as a professional association

Promoting nurses and the nursing profession

At our AGM last year some of you may recall my report and reflections. I stated that advocacy and lobbying are at the core of what we do to advance the agenda for nursing teams both from an industrial and professional perspective. Being an election year, I observed that on one hand there is a sense that we are not visible, not adversarial or political enough, that we need to be out there and showing leadership on key issues, on the other hand some argue and lament that we are politically biased or in favour of a particular political leaning whilst others say we are negative and adversarial, whilst other say we are doing ok.

The profile of our role as a professional association, promoting nurses and the nursing profession is critical to our future existence at the same par as membership.

Demonstrating relevance and value add to patient outcomes, healthy families and communities should be the cornerstone or platform upon which we build our profile as an association and by promoting nurses and the nursing profession.

I am pleased to report that during the last year we continued to push forward our agenda to promote NZNO, nurses and the nursing profession by increasing our clarity of relevance and value add.

On Wednesday 28 August 2013 the main headlines in the Dominion Post read “Nurses ration patient care” “Families pitch in as staff stretched”. This article reported nursing shortages at Wairarapa and Hutt Valley hospitals stating that nurses are ‘rationing’ their care to patients. It referred to essential care being prioritised over patient ‘comfort’ or ‘non-essential’ tasks.

The following day Thursday 29 August 2013 the main headline read ”Rationed care cuts deep says patients” reporting that ‘care rationing in understaffed hospitals is affecting basic medical needs as well as comfort, patients say.”

There was the usual follow up discussion and debate in the media and between nurse leaders with attention being on nurses’ decisions and actions about patient care when faced with nursing shortages or the wrong skill mix.

What was missing in all the dialogue was the fact that in reality it was not nurses rationing care, it the public health system; the way it is funded resulting in not having enough nurses, inadequate time, and the right skill mix to provide complete care.

Our policy and research teams, with member input and consultation, developed a position statement on Care Rationing which was presented to all District Health Boards, the Ministry of Health and the Minister of Health. This helped change the dialogue and inform the debate on this very complex area which often is very emotive.

You will hear about this more this afternoon.

We also embarked on a project to increase the visibility of nurses of which the first phase establish a theme which is “Nurses – Making the Difference in Healthcare”. A website has been set up where nurses can share stories. You can access this through our website under the campaigns banner. The second phase involves identifying and training nurse champions. A third phase to promote and increase the visibility of nursing is yet to commence.

You will hear more about this in more detail this afternoon.

Another highlight is our work is with the Service and Food Workers Union Ngā Ringa Tota on the campaign for equal pay “All the way for equal pay”. The sterling legal defence work which saw the Court decline Terranova’s leave to appeal on and directing the Employment Court to establish equal pay principles to resolve the equal pay claim.

Again we will hear about this in more detail this afternoon.

One last key highlight under this section is the work we do to represent members, whether it be through Health and Disability Commissioner investigations, employment related matters, Professional Conduct Committee and Health Practitioner’s Tribunal hearings. Approximately 237 ‘events’ were taken up involving more than about 3000 members. We noticed an upward trend in the request for representation and the number of complaint against nurses which are being made to the Health and Disability Commissioner. We have also noticed an increase in the number of nurses that the Health and Disability Commissioner finds in breach of the Code of Health and Disability Services Consumer Rights. Last year we challenged the Commissioner by asserting that some of the breaches could be at the system level not the individual nurses’, and primarily caused by inadequate funding which leads to poor staffing levels impacting on patient care. We asked him what approach he intended to take to address some the breaches we considered to be at a system level. His response was that his concern was “primarily to assess the quality of health and disability services” and the system issues I had raised were better addressed by District Health and and/or the Ministry of Health’. This I found astounding.

Fellow colleagues, I will make no apologies for saying that if we fail to show relevance and to add value it will be to our detriment. Some antagonists might think what we do is ‘all about us’. Clearly that is not true. Promoting the profession of nursing and nursing standards is a key foundation to strive for recognising the mutual interdependency with our industrial focus and that getting the balance right is very critical.

Contribute to health sector workforce planning

I am going to tell you something you already know.

Nursing is the biggest workforce in the New Zealand public health and disability system. According to a report on health workforce released by the Ministry of Health and Health Workforce New Zealand in November last year, nursing makes up about 54 percent of the regulated health workforce in New Zealand, based on annual practicing data of all regulated professions. Internationally there are between 16 and 19 million nurses according to estimates by the International Council of Nurses.

We are the backbone of the public health and disability system. We nurses are everywhere, in patient’s homes, general practice, clinics, hospitals, prisons, community homes, residential care, education, research units, management and leadership, policy development and regulation.

After many years of advocating and lobbying for a national workforce plan for nursing, last year we were successful, together with other nurse leaders, in convincing Health Workforce New Zealand to set up a national nurse workforce programme. Whilst progress continues to be slow, a joint governance group and working group have been put into place. The areas agreed to be given priority attention are:

  1. Improving the integrity of nursing workforce information and data
  2. Graduate nurse employment
  3. Nurse retention
  4. Nursing workforce plan

This is a major step forward. However results are yet to be evident.

On the New Graduate Employment front the online petition urging the Minister of Health to fund a one year Nurse to Entry Practice Programme for every graduate nurse drew more than 8000 signatures in a week. Thank you to all who contributed to this petition. This resulted in two key achievements as steps in the right direction:

  1. Additional funding of $2.8m per annum from this year was granted by the Minister of Health to fund an additional 200 places.
  1. The eligibility period was increased from one year to two years.

This firmly remains on our horizon with a goal of 100 percent funded places by 2018.

We got behind, supported and were involved in the proposal by Auckland University for a funded nurse practitioner education programme linked to employment. It took a long time for this to work its way through the bureaucracy of Ministry of Health and Health Workforce New Zealand. Eventually funding was granted for a programme to commence in March 2016. Auckland and Massey universities will run this programme.

We supported the Nursing Council’s application for nurse prescribing. This is important as an enabler for us to work at the top of our scopes of practice; which in time will result in an increase to access to nurse-led services for vulnerable populations and those with long-term health conditions.

Working with the Fiona Unac, Chair of the Perioperative Nurses College we saw Auckland University endorse a new Certificate of Proficiency for Registered Nurse Assistant to the Anaesthetist.

The work by the Enrolled Nurses Section to develop a dedicated Supported Entry to Practice Programme was completed. Now the challenge that lies ahead is to advocate and lobby for this to be funded.

Lastly we successfully got onto the Governance Group for the Kaiāwhina Workforce Action Plan. This was in response to concerns raised by the Enrolled Nurses Section. We argued that the Kaiāwhina workforce is a continuum of the nursing team, and that it is important that the action plan be developed within that context. This will remain a challenge but we will continue to influence, advocate and lobby.

Workforce development is complex with multiple strands to which we need to be tuned into all the time. There is no ‘one size fits all’ and our messages on these areas going forward need to be targeted at getting results for you.

Improve organisational health

Improving organisational health is controversial and a challenging philosophical concept.

From a financial perspective we are making in-roads into recovering financial losses from the past. We ended the year with a positive financial result which David will present to you later. The Board has worked hard with me and the Management Team to tackle a few areas to manage costs.

We should always be mindful and keep an eye on our financial reserve and not to use them to support organisational operational structures. Alarm bells should ring if we head in that direction.

Our staff are key to the achievements and the highlights I have reported on and those in the annual report. I applaud their commitment and relentless effort, their willingness to go the extra mile to do what is right for members. In response to key pressures we supported our staff by putting more resources into the following areas;

  1. Professional Nurse Advisors, an increase from 7.7 FTEs to 9.1 FTEs with a focus on Hamilton and Christchurch.
  2. Industrial Advisor increase of 0.5 FTE
  3. Finance Office 1.0 FTE

These organisational growth areas are in response to our commitment to get to member issues quickly.

Fellow colleagues from time to time you will hear all sorts from people about what is happening within the organisation.

I will stress to you that you need context and background to know what is going on and sometimes what you hear may not be correct and other times it may be. It pays to contact me directly on operational matters.

In conclusion,

My assessment is that NZNO has done well during the past year. Some of you may say not enough in some areas, and I acknowledge that.

We can never do enough!

Acknowledgements

I would like to place on record my sincere appreciation of the work you have done in the past year and will continue to do this year, the work done on your behalf by our staff and the support of the Board and Management Team.

I will mention again the point I made at last year’s AGM

“What we do comes with its own challenges and tensions but let us remember and work together as united we stand, divided we fall. We are one profession with many roles and voices, we are a collective and together we can continue to make a massive influence. Together we make an effective team.” Together we can be effective in shaping healthcare in New Zealand.

Lastly but not least I would to thank all our exhibitors and sponsors at this AGM and conference tomorrow.

I hope you enjoy the AGM and conference and that you get the best networking opportunities, so you can take away important ideas to innovate and to champion for changes in whatever health setting you work within.

No reira tēnā koutou, tēnā koutou, tēnā koutou, tēnā koutou katoa.

 


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Ethical end of life care

Film-Colour-71Jane MacGeorge is NZNO’s nursing and professional services manager and a nurse with a deep understanding of palliative care and end of life issues.

There has been a lot of discussion lately about “assisted suicide” or “euthanasia”, a lot of it stemming from the case of patient with brain cancer, Lecretia Seales, who petitioned the court to allow her GP to assist her to die. Lecretia lost her bid to die with the dignity she desired but her situation has opened the way for discussions that might previously have been taboo.

Talking about end of life decisions and care is important, as every NZNO member knows. The work we do to ease pain and lighten the path to dying is a fundamental part of our role as nurses and caregivers.

An AUT study of 650 GPs found 359 had made decisions such as withdrawing treatment or alleviating pain, taking into account the probability they may hasten death. One of the findings of the study was that even though it was doctors prescribing, in most cases it was nurses who were administering the drugs.

That finding opens a can of worms… End of life care and decisions are extremely complex, challenging and fraught with ethical dilemmas. Nurses need to understand all viewpoints to advocate in the best interest of the patient and to make sure the patients’ rights are respected and supported. Understandably, health care professionals may sometimes need to be mindful of legal and ethical implications.

The reality is that patients die within every health setting; in the community under the care of the primary health team, in EDs, in wards, in rest homes and in other palliative care settings. Nurses need to work within their scopes of practice and be aware of the ethical issues involved in supporting patients and whānau who are experiencing dying and death.

The role of the nurse is critical in the delivery and planning of a dying person’s care. We are advocates for safe, compassionate and ethical end of life care. We have a professional responsibility to provide appropriate care to our patients.

We need to have a good understanding of legislation and regulation and ensure we comply with the code of rights and the policy and guidelines within our practice specialty and organisation.

We are often faced with challenging decisions when caring for people at the end of life. It is important we question any medications that are not prescribed in an appropriate manner. In these situations our hope is that the whole healthcare team can discuss different treatment options and decisions with the prescriber to support quality end of life care.

Above all, it is important we understand our patient’s wishes. A healthy healthcare system places the patient at the centre of every decision. When we use this as the basis for our decision-making, at the end of life, at the beginning and everywhere in between, we can be sure that we will provide the right care at the right time in the right place.


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An ordeal with the flu

Kate and Sam Pohe

Sam Pohe (on the right) with her sister, Kate.

Community clinic nurse Sam Pohe’s job was to endorse the flu vaccine to her high-risk patients but, as she lay in a coma at death’s door, her body riddled with complications deriving from influenza, it became obvious she’d forgotten to get one herself. She shares her ordeal with Jodi Fraser.

The Whangarei 45-year-old was usually one to practise what she preached but, last year, got so busy vaccinating her patients, she forgot to get immunised herself.

Sam recalls leaving work early one day in August, thinking she had a cold.

“I was just feeling rather poorly. I left work early and went home to bed. I think I slept for three days. On the third day I woke for some reason, went to the bathroom, as I knew something wasn’t right, and I was blue.

“I text my friend to say ‘Why am I a blue colour?’ I called the ambulance and was taken to hospital ED. My oxygen sats (oxygen-saturated) were about 70 per cent and dropping.”

She was admitted to ICU soon after and placed on a bipap machine to help her breathe.

“I was struggling to breathe for six or seven days – it was terrifying. I never want to experience that again.”

A day later Sam’s doctor told her ‘We have to talk’.

“I remember looking at him and saying: ‘This is it? I’m going to die? … I need to make a few calls.’

That was Sam’s last lucid memory for the next three and a half weeks as she sank into a coma with multi organ failure.

While her beloved dogs pined for their mistress at home, her family and friends rallied round her bedside where she had been flown to Auckland, with her best friend flying over from Australia.

Sister Kate says she was shocked when she saw the state of her close sibling.

“There were tubes and wires everywhere. Just seeing Sam like that – it was awful. It was the worst experience of my life but Sam is stubborn and strong-minded and I never had any doubt that we would lose her.

“We had a family meeting and, despite being told we shouldn’t get our hopes up, looked into all the options.

“A lot of research doctors came in and I just signed her up for everything.”

While doctors considered placing Sam on the ECMO (heart and lung) machine, Kate spent the long tough days giving her sister foot and head massages, singing and reading to her.

“We all handled it differently – our nephew, who is usually really tough, just sat in the corner sobbing his little heart out. I’d wake in the middle of the night and hear dad crying which would set me off.”

While her family fretted and grieved, Sam was off in India having crazy exploits which still give her nightmares today.

“I remember having many vivid dreams while in the coma. I think I was in India with random people and we were at this place praying for forgiveness. I was paying penance I think, but I’m not sure what for. Another time I was in a bus and the oxygen was running out – I kept reaching for the handle to get out but I couldn’t move my arms. It was horrific. Other things happened but I won’t talk about them – they are too freaky.

“After I came out of the coma, a spiritual friend of mine asked me who Renee was. That is my aunt who’s passed so I believe I met with her.”

As Sam came out of her coma she remembers everyone peering down at her.

“I don’t remember what my thoughts were but my nephew told me the first thing I said was **** off to the nurses. I was shocked. I was terrified, frustrated, hallucinating. I could not walk or talk. I had a tracheostomy in situ. I was literally a dead weight. I couldn’t even lift my arms they felt so heavy. My hair was a mess, I hated being turned and my bottom wiped, I was on dialysis, I had double pneumonia, H1N1, influenza A – you name it, I had it all. I was one sick puppy.

“My emotions were all over the place and I heard I was a bit of a struggle for the nurses but I felt hopeless, useless and trapped against my own will. I just wanted to get out of bed and walk home. I said to my brother, ‘Just back the car up and I’ll pull all these lines out’ and I was trying to do just that.”

Despite the odds, Sam made a miraculous recovery and, cited a ‘medical mystery’, was finally told she could go home seven weeks later.

“I would have run if I could. “My dogs were so happy to see me, they were doing somersaults.”

Since then, she has pushed her limits every day, despite a damaged lung capacity which causes shortness of breath – the only long-lasting physical effect.

After four month’s rehabilitation, Sam has returned to work, albeit in a different less stressful job and says she absolutely advises her patients to get the flu vaccine.

“Sometimes they say to me, ‘But it’s just a little chest infection’ and I say, ‘Yeah? I had a little chest infection and it nearly killed me’.”

And there is no way Sam will get too busy to have the vaccine herself.

“Life is different now. I live like never before. I don’t feel as stressed anymore and I’m happy to be alive.”

Nine months later Sam still gets emotional while recalling her experience.

“When I was in hospital and I’d see the helicopter come in, I’d just cry because they are awesome, just awesome,” she says, tearing up. “I’m into raising money for the helicopter now – they are so good.”

A pioneer in setting up rural health clinics for vaccination, Sam is a strong advocate for making sure that health services are accessible for Northlanders.

“We used to find out which children hadn’t been vaccinated and go out and search for them.  It would be like, down this dirt road, hang a right, down a gully to find the brown house.

“I knew the people from a whanau perspective and they trusted me. Very often they didn’t have a car so they welcomed us to go to them and vaccinate their children. I will never forget sitting in a paddock with sea views, surrounded by babies playing in the dirt, while we watched them for 20 minutes after they had had their vaccinations.”

Her advice to others, having come so close to death?

“Make sure you get your flu vaccination because life is for living – oh and don’t sweat the small stuff.”


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Patients’ rights, nurses’ rights

stress-feature01NZNO delegate, Erin Kennedy asks an important question: “Is unsafe staffing a breach of the Code of Health and Disability Services Consumers’ Rights?”

Like most nurses, I am not easily shockable, but I found myself almost speechless last week on learning that three nurses had been forced into the position of caring for 40 patients overnight on a heavy orthopaedic ward. (A pool nurse also came to help for part of the shift.)

NZNO organisers and delegates have argued strongly for safe staffing for years now, but unfortunately, the level of permanent and pool staffing means that staffing levels including skill mix are often unsafe, with sick staff unable to be replaced. The constant push to avoid financial penalty when the 6-hour Emergency Department rule is breached also leads to patients being moved from the Emergency Department to areas where there are simply not enough nurses to care for all the patients safely.

Under the Code of Health and Disability Services Consumers’ Rights, patients have a number of rights, including the right to co-operation amongst providers to ensure quality and continuity of services, and the right to informed consent. The right to be fully informed means information must be conveyed to the patient in a way that enables the patient to understand the treatment or advice. Right 6 of the code states that every consumer has ‘the right to the information that a reasonable consumer, in that consumer’s circumstances, would expect to receive’. Specifically, it states that patients are entitled to an explanation of his or her condition and an explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option.

Given the unsafe staffing levels at some of our DHBs, it is high time that explanations around surgery, for example, go further than simply outlining the procedure and its risks and benefits. Patients should ask, and should be told, whether their post operative care will be safe. A “reasonable consumer” clearly has the right to know whether their recovery might be hampered because of unsafe staffing. Certainly, if I have surgery any time soon, I will be asking whether there are enough nurses rostered on to provide all of the care I and other patients require. Will there be enough staff to ensure that I can obtain analgesia or other medications on time? Will the nurses be able to check my vital signs often enough to notice if I am bleeding, or have arrested or need medical intervention? If I need help mobilising to the toilet, will there be someone to help me or will I risk a fall and further injury? Will there be someone to answer my call bell if I need help?

Nurses do not like being forced to ration care, but until all DHBs accept that in many instances staffing levels are unsafe (for both patients and nurses), it is a fact of life and one which can seriously impact patients’ wellbeing and recovery. Not warning patients that their post-operative care may not be optimal, and could be downright dangerous, is, in my opinion a breach of the code.

 

 

 


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Care rationing a sad reality

Care rationing web headerNZNO believes every patient has the right to receive quality care, every shift, every day. Nurses, midwives and health-care assistants also have the right to work in safe, supportive environments and be enabled to provide quality care.

The Safe staffing healthy workplaces unit defines care rationing as: “Any occasion when an aspect of a patient’s required care is either missed altogether, unduly delayed, performed to a suboptimal standard or inappropriately delegated to someone not qualified to perform the activity.”

Is care rationing the “new normal” in patient care?  Are failing to take observations and administer medications on time, inability to turn bedridden patients two hourly, skipping hygiene cares, inability to mobilise patients  regularly, failing to provide comprehensive patient education, not answering call bells, all too familiar aspects of too many nurses’ shifts, too often?

Care rationing is unacceptable because it means patients do not receive all the care they require, it exposes patients to unacceptable risks, it can have serious consequences, it increases patient morbidity and mortality, and contravenes people’s rights to health services of an appropriate standard.

Drawing on national and international research, NZNO’s newly-released position statement attributes care rationing to a systems failure due to inadequate staffing or inappropriate skill mix or insufficient time or a combination of these factors.

The position statement was developed to articulate that care rationing is a systems failure, not a failure of individual nurses. We have chosen the term ‘care rationing’ because terms such as ‘missed care’ or ‘care left undone’ imply that an individual nurse is to blame.

Care rationing is not just another form of prioritisation. Prioritisation occurs at the start of a shift when nurses consider the work that has to be done over their shift and what needs to be done first. Care rationing happens in a chaotic way when there are simply not enough staff to do the work and nurses have no control over the situation.”

It doesn’t have to be this way. NZNO has a plan to eliminate care rationing. What we need is:

  • increased funding for DHBs;
  • nursing care made a priority in decision-making;
  • nursing seen as an investment, not a cost;
  • patient-centred models of care;
  • a focus on early intervention and prevention, and nurses working to the full extent of their scope;
  • full implementation of the care capacity demand management programme in all DHBs;
  • effective workforce planning;
  • transparency about staffing levels;
  • funding to address its cultural impacts;
  • immediate action when staffing requirements are not met to ensure patients get the care they need; and
  • patients who are empowered to complain when their needs are not met because of inadequate staffing.

To find out more about care rationing and what NZNO is doing to eliminate it, go to www.nzno.org.nz/carerationing

 

This blog post was developed from an article first published in Kai Taiki Nursing NZ, vol 20, no 6, July 2014.