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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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A demand to be taken seriously

dilbert-ceo-payNZNO delegate Ady Piesse is an activist for fairness at work and an advocate for collective action. This blog post has previously been published as a comment on Facebook. 

I’m a thinker….I think a lot. Sometimes I’m accused of over thinking, but generally my thinking usually provides me with ideas or helps me problem solve.

So, a couple of weeks ago, I got to thinking – what do I do in my job that is so different from my CEO’s that justifies our salaries?

At the start of every shift I check my equipment so if that cardiac arrest, acute SOB, trauma or the blue floppy baby arrives unannounced, I have the confidence that myself and my colleagues will be able to use that equipment to potentially save a life.

My CEO makes sure his lap top ‘on’ button works.

I monitor numerous pieces of equipment attached to my patients, checking for those spiralling trends so I can intervene early if I need to.

My CEO monitors computer screens that check to make sure my patients are meeting the six hour targets.

I do ‘end-of-bed-o-grammes’ all day every day, with new patients, existing patients, other nurses’ patients, to monitor change, deterioration or improvement.

My CEO looks at spread sheets to see how hard I’m working or how much harder I can be made to work.

I hold in my hand medication that has the potential to kill or to cure.

My CEO holds a pen, an iPhone.

I sit holding a patient’s hand while a doctor tells her and her family her condition is terminal. I hold a child’s hand. I hold the hand of a terrified patient who can’t breathe. I hug people I only met today and know won’t be here tomorrow.

I don’t know if my CEO has ever held a hand or given a stranger a hug.

Every day I take home people’s stories; for some it will be the worst day of their lives. These people have faces and I know some will never leave my memory.

My CEO takes home statistics.

Some days I leave wondering if I have it in me to keep doing what I’m doing – less is not more in my job – but my CEO seems to think so.

I know it’s all more complex than that.

I use my knowledge and observation skills to think ahead and intervene early to avoid a failure to rescue situation, my CEO uses their knowledge and observations to think strategically, for example.

What I’m thinking doesn’t take away from the important role my CEO plays in the day to day running of my organisation, but thinking simply – that’s about the bones of it.

Then some more thinking. I play a damned important role in this organisation too, so how is it I only get paid maybe a quarter of what my CEO earns?

And why should I feel guilty or scared of standing up and asking for more? So I’ve decided I owe nobody an apology for feeling the way I do.

More thought. Stand up and be counted, get as many colleagues on board as I can to speak out and say enough is enough!

I’ve become quite vocal in the past couple of weeks –I’ve decided to stand up for myself. I’ve realised that complaining to colleagues is not going anywhere. We need to be the very visual faces behind our MECA.

I’m guilty like many of having not gone to meetings in the past, been so apathetic to expect Government and the Boards to realise my worth and support me accordingly – I’ve been ridiculously naive! I know there are many colleagues feeling the same way and I’m hoping my ranting will given colleagues the confidence to stand up too and speak out for change!

MECA representatives at these current negotiations can only push the “we’re serious about this…” boat so far – we need to make ourselves visible to Government and our Boards and not just ask, but demand to be taken seriously,  otherwise we have another long three years of the same and more than likely, a lot worse to come.

So, be at those MECA meetings that are coming up and come with ideas! It’s time we got tough!

 

 


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When bad things happen in good hospitals

Film-Colour-133A serious adverse event is one which has led to significant additional treatment, is life threatening or has led to an unexpected death or major loss of function. District health board (DHB) providers are required to review these events and report them to the Health Quality and Safety Commission.

Over the past year 454 serious adverse events were reported; more than one a day.  248 (55 percent) of these events were falls that resulted in serious harm – fractures, serious wounds and serious head injuries.

We’re concerned about this for many reasons.

Each one of these ‘events’ happened to a person, a family, a community. Each event will have caused considerable pain and suffering, loss of mobility, confidence, independence and increased length of stay in hospital, along with the increased costs that go with all those outcomes.

Every member of the nursing team caught up in a serious event will also have found the experience very distressing. Nobody ever goes to work expecting that a serious event is going to occur on their shift, and nurses only ever want the best outcome for their patients.

NZNO is also concerned about the overall increase of events since the last report – especially in those events that are considered nurse sensitive outcome indicators – pressure areas, infections and falls.

The number of falls reported has gone from 56 in the 2008 report to 248 in 2014; a staggering increase that cannot be attributed to improved reporting alone. The fact of the matter is that for all of those falls which caused serious harm, there will be numerous others that don’t meet the severity threshold, so do not appear in the report. There will be even more that are not reported at all.

So what might be contributing to this alarming trend?

We are aware of changes to DHB policies in regard to specials and watches – these are expensive and need special approval. Are they not being approved when they should be?

We know that older adults are coming to us more unwell and with complex needs. Is it increased acuity that is contributing to the increase in serious adverse events?

Nurses are telling us that they are stressed at work – finding it challenging to meet patients’ needs. Sometimes bells don’t get answered in time…  serious accidents can result. Are staffing numbers and skill mix not adequate to meet patient demand?

And if that’s the case, we have to ask, why not?

We believe that health services must be funded appropriately, so every patient receives the care they need, when they need it. And so every member of the healthcare team can go to work knowing all the supports and resources are in place to provide excellent care to every patient.

More needs to be done to investigate why and how serious adverse events occur and steps put in place so they no longer happen. If that means extra funding and a different number and skill mix of staff, so be it.


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My journey, my patient’s journey

emotional-intelligenceHere’s another blog by West Coast mental health nurse Teniah Howell. This blog is cross-posted with permission  from the Nurses Station blog “The Tea Room”. You can read Teniah’s previous post here.

The topic of emotional intelligence has come up multiple times in my journey through nursing school and into the “real world” of nursing. When the topic was first mentioned to me, I had never heard of such a thing before, and really never considered the need to become competent in this area.

Emotional intelligence, essentially, is the ability to recognise your own feelings, emotions, and responses, as well as those of others. Now, we recognise these emotions in different ways – some people journal, some people simply contemplate, and others discuss with trusted mentors/supervision/work place support etc. The importance in understanding where we are at in our own lives allows us to more easily interpret the emotions and responses of the patients we work alongside. It is easier to help our patients find strategies for coping that work for them, if we have first acknowledged and recognised our own strengths and abilities to cope. Nurses cannot relate to patients and help them if they are themselves in an emotionally unstable place.

One thing that I have noticed in my own practice, is that in order to truly develop a therapeutic relationship with a patient, I must be able to differentiate between my own thoughts/emotions and the situation. I have to be able to know what I think and believe about myself and yet not push my own thoughts and beliefs onto my patient. I have to be able to recognise that my patient’s strengths and ways of coping will be different than my own. In my experience this ties into the idea that we all possess a “shared humanness”. While we share a lot of the same emotions, experiences, desires etc.; each one of us is unique and individual. While we all have different strengths and ways of coping with the challenges of life, we all still share the experience of being human. Therefore, we can offer each other grace, knowing that we are in many ways the same.

A patient’s journey can be made easier by having a nurse who will walk alongside them, who understands that human experience; a nurse who has her/himself faced challenges and experienced a range of emotions; a nurse who can relate to them, and also recognise their uniqueness. It takes an emotionally intelligent, competent nurse to do this. It takes someone who has explored their own thoughts and beliefs; someone who is not only able to recognise their own strengths, but can also recognise the individual strength of their patient.


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Building confident nurses

bigstock-D-Knob-Confidence-Level-46141444-583x437Teniah Howell is a newly graduated nurse, NZNO member and advocate for young nurses. She currently works as a mental health nurse on the West Coast having spent the previous 18 months in the medical surgical unit at Grey Hospital. This blog is cross-posted from the Nurses Station blog “The Tea Room”

I have had many recent conversations with young nurses from my graduating class, as well as the new graduates who joined our nursing team in January, about the process of building confidence in nursing practice.

It would seem that for many, confidence is something that progressively builds over time. As our skills, knowledge, and experiences increase, we become more certain that the decisions we make are indeed the right ones. We learn to adapt more quickly, and to trust our instincts. For me personally as a new grad, I found that it took several months to really feel that I could trust my instincts and my decisions and stand strong in advocating for my patient’s care and for the decisions that I believed were the right interventions for my patient. I would say that there was probably a significant jump in my confidence at about five months into my nursing career. I felt at that point that I had learned to trust myself a bit more, and had gained valuable skills and experiences along the way.

At our DHB, the new graduates do a department switch at six months. This meant getting “knocked back” a bit with my confidence as I was then in a completely new environment and relying on skills and judgment that I had not yet developed. I found, however, that this time around my confidence grew faster and within a few months I felt much more capable. In talking to others it would seem this is a common theme.

I have found that confidence is something that grows (almost in a step-ladder type of fashion). It builds on the experiences and skills that you gain as you continue your nursing career. I say this to really encourage those young nurses out there who are starting out and are only just beginning to realise your potential within the nursing team. Remember that it is a process. It will come with time. Offer yourself the grace to recognise that it will take time to build the trust in yourself, and for the team in which you work to trust your judgment as well.

It has also been my experience that the team you work with can either build or break down your confidence depending on how they respond to your nursing practice and your suggestions for patient interventions and care. Working with a nurse who is demoralising and cuts you down every moment of the day can really make you feel small and insignificant. It can be extremely hard to build your confidence in this circumstance. On the contrary, when someone encourages you and says that you have made the right decision, it can do wonders for building your confidence and your trust in your own decision making. I would like to challenge you to be type of nurse that lifts others up. Be the one who helps to build other’s confidence by offering words of encouragement to your colleagues. (Especially the young nurses and student nurses whom you might be working alongside).

I am moving into a new role next week, and will once again be starting off in an area where my experience is limited. As I embark on this new journey, I am aware that at first my confidence may “take a hit”, but through my past experience I know that it will quickly build back up again. I am encouraged by this, and do hope that I will be lucky enough to be supported along the way by my colleagues. We can only hope that if we give good out, we will have good returned to us.

As Mahatma Gandhi said, “Be the change you wish to see in the world.”


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Nelson ED nurses get together to create change

successNZNO members at Nelson Hospital have had their voices heard. They have successfully advocated for quality patient care and a safe environment for staff.

ED staff have been concerned for some time that their work is being compromised by a lack of staff, and all the flow on effects of that situation.

Reportable events about staffing levels had been logged but no action taken. NZNO College of Emergency Nurses guidelines for nurse/ patient ratios were not being met and nursing staff were concerned about the potential for breaches of the Health and Disability Commission code of patient rights.

The ED was experiencing an increased number of high acuity patients and Government targets were not being met. Staff vacancies were not being filled in a timely way and staff were worried that more vacancies were coming up. Annual leave requests were being turned down and staff were becoming more and more stressed and fatigued. They were overworked and overwhelmed.

It’s pretty hard on morale if you work in an emergency department and you don’t have the resources to deal with an emergency!

It’s often difficult to see the wood for the trees when you’re feeling like that, so it is a testament to the courage and wisdom of NZNO members that they made a decision to do something about it, and then followed through.

A meeting with the Director of Nursing and Midwifery and the Nelson Associate Director of Nursing was called and members told their stories one by one. It was a powerful and moving meeting. Staff were honest, passionate and resolute that the situation needed to change. That was 2 weeks ago.

Within 2 days the numbers had been crunched and ED staff were notified that an extra 2.14FTE had been approved and were being advertised. In the interim, casual staff are being used to ease the workload.

It’s a great outcome, and one that only happened because NZNO members worked collectively to address their concerns. When we stand together we are heard.

Ehara taku toa i te toa takitahi. Engari, he toa takitini.

Success is not the work of one, but the work of many.