Evaluation of a diabetes nurse specialist prescribing project.

AIMS AND OBJECTIVES: To evaluate the diabetes nurse specialist prescribing project with the aim of determining whether diabetes nurse specialist prescribing is safe and effective and to inform the implementation and extension of registered nurse prescribing. BACKGROUND: Registered nurses in many countries are able to prescribe medicines, but in New Zealand, prior to the diabetes nurse specialist project, nurse practitioners were the only nurses who could prescribe medicines. New regulations allowed the nurses to prescribe a limited number of prescription medicines. DESIGN: The study was a process and outcome clinical programme evaluation. METHODS: The project took place between April-September 2011 and involved 12 diabetes nurse specialist in four localities. Quantitative data were collected from clinical records maintained by the diabetes nurse specialist for the project (1274 patients and 3402 prescribing events), from surveys with stakeholders (general practitioners, n = 30; team members, n = 19; and patients, n = 89) and audits from patient notes (n = 117) and prescriptions (n = 227), and qualitative data from interviews with project participants (n = 18) and patients (n = 19). All data were analysed descriptively. RESULTS: Diabetes nurse specialist prescribing was determined to be safe, of high quality and appropriate. It brought important benefits to the effectiveness of specialist diabetes services, was acceptable to patients and was supported by the wider healthcare team. CONCLUSIONS: These findings are consistent with the findings reported in the international literature about nurse prescribing in a range of different practice areas. Clarification of the education and competence requirements and resourcing for the ongoing supervision of nurses is recommended if the prescribing model is to be extended. RELEVANCE TO CLINICAL PRACTICE: Diabetes nurse specialist prescribing improved access to medicines by providing a more timely service. Nurses felt more satisfied with their work because they could independently provide a complete episode of care. As novice prescribers, nurses need to be well prepared educationally and have access to supportive clinical supervision.

Extending the prescribing framework to nurses: lessons from the past.

This paper highlights the parallels between the journey to prescribing for nurse practitioners when the role was initially introduced in New Zealand and the journey now towards extending the prescribing framework to registered nurses. Nurse practitioners are the only nurses who can prescribe medicines, and their numbers are few. There are several thousand experienced registered nurses who meet the education requirements to be a nurse practitioner but who have not applied to the regulatory body for registration. Attention has begun to turn from this model, in which nurse practitioners are the only category of nurse who can prescribe, towards independent and supplementary nurse prescribing models. The New Zealand government is yet to fully commit to a specific plan for extending prescribing responsibilities to registered nurses, but feedback has been sought on two different proposals. Dependent prescribing arrangements used elsewhere appear to disregard the implications for professional autonomy. The proposed models of nurse prescribing for New Zealand impose oppressive restrictions, which nurse leaders over the last decade have fought hard to resist. Regulations are needed to allow nurses who have the appropriate education to be designated prescribers in their named area of specialisation. The difference between advanced practice nurses with prescribing rights and nurse practitioners must be clarified to minimise the impact of other prescribers on the nurse practitioner role. Lessons from the past and from the United Kingdom's experience could be drawn upon in order to better utilise the existing well-educated nursing workforce.

Health practitioner experience of Health and Disability Commissioner investigations.

INTRODUCTION The New Zealand Health and Disability Commissioner (HDC) Act 1994 was designed to protect the rights of consumers and provide a fair, simple, speedy, and efficient resolution to complaints. No recent studies have been published about the health practitioner experience of HDC investigations following a patient complaint, and none that include nurses and midwives. AIM To use a restorative inquiry framework to understand the impacts and needs of health practitioners arising from an event that led to an investigation by the HDC during the last 10 years. METHODS A descriptive qualitative approach was used with data collected using semi-structured interviews with doctors, nurses, and midwives (n = 13). The data were analysed using thematic analysis. RESULTS Participants worked in primary care, aged care, and services provided by public hospitals. The emotional impacts arising from the event and investigation were profound, with long-lasting effects on participants' sense of self, reputation, and how, or if, they continued to practice. Participants indicated a need for support from colleagues and employers, a fair and relational investigation process, and a meaningful way of connecting to put things right. DISCUSSION A shift to a restorative approach whereby people involved in a complaint come together to speak truthfully about what happened and its impact on their lives, offers hope for a process that repairs relationships and improves health services. Restorative approaches clarify accountabilities and could lead to more satisfactory outcomes for all parties. This study contributes to emerging thinking about the use of restorative approaches in health-care contexts.

Practice nurse use of evidence in clinical practice: a descriptive survey.

The role of practice nurses is a specific feature of the modernisation agenda of the New Zealand health service. Increasing importance is being placed on service improvement through effective decision making and enhanced clinical performance. To contribute to the development of primary health care it is crucial that nurses have the skills to appropriately implement research based and other evidence in practice. This study involved 55 West Auckland practice nurses working in the general practice setting. The aim of the study was to describe nurses' perceptions of their use of evidence-based practice, attitudes toward evidence-based practice and perceptions of their knowledge/skills associated with evidence-based practice. An additional aim was to determine the effect of educational preparation on practice, attitudes and knowledge/skills toward evidence-based practice. A descriptive survey design was selected for this study. The results demonstrated that nurses' attitudes toward evidence-based practice, knowledge and skills relevant to the implementation of evidence-based practice and the educational preparation of the nurses were important factors influencing the effective utilisation and application of research results in practice. Educational interventions are identified as an integral aspect of implementing evidence-based practice and enhancing practice nurses' knowledge and skill relevant to the use of evidence in practice. Further research is needed to assess the contextual factors which can inhibit or promote achievement of evidence-based practice by practice nurses.

Self-management support? Listening to people with complex co-morbidities.

OBJECTIVES: The study aimed to explore how people with complex, established co-morbidities experience long-term condition care in New Zealand. Despite the original conception as appropriate for people with early stage disease, in New Zealand the self-management approach dominates the care provided to people at all stages of diagnosis with long-term conditions, something reinforced through particular funding mechanisms. METHODS: A multiple case study followed the lives of 16 people with several long-term conditions. Data collection comprised two interviews, four weekly contacts with patients over an 18-month period and an interview with their primary health care clinicians. RESULTS: This paper reveals a cohort of tired, distracted patients struggling to manage their lives in the face of multiple conflicting challenges, with insufficient energy for the level of personal agency required to deal with the self-management approach. DISCUSSION: Participants described aspects of care received, which does meet their needs but sit outside the self-management approach, that resonate with the ideas behind current approaches to palliative care. The potential of an approach to care built upon these ideas is explored as a more compassionate, effective way of meeting the needs of people with advanced, multiple long-term conditions. Further research is warranted to explore the acceptability of such an approach.

The Ministerial Taskforce on Nursing: a struggle for control.

It is now ten years since the Ministerial Taskforce on Nursing released its report identifying the barriers that prevented nursing from realising its full potential. A key recommendation was the development of advanced clinical nursing roles that went beyond traditional and institutional boundaries. The constitution and work of the Taskforce is traced in this study, along with the struggle that arose between nursing groups for power to control the future of advanced nursing practice. The convergence of political discourses with those that were dominant in nursing during this period produced considerable tension and contributed to the eventual withdrawal of New Zealand Nurses Organisation representation from the Taskforce membership.

Constructing consensus: developing an advanced nursing practice role.

Following the release of the Ministerial Taskforce on Nursing in August 1998 and the withdrawal of the New Zealand Nurses Organisation from the Taskforce membership, a 'decision-making' workshop was held to further advance nursing practice roles in New Zealand. Momentum about advanced nursing roles had been gathering spurred on by political reform and the research about established nursing practitioner and clinical nurse specialist roles overseas. This study uses a discourse analytical approach to trace the ongoing struggle between nursing groups for power to control the future of advanced nursing practice. The convergence of political discourses with those that were dominant in nursing during this period produced considerable tension, but eventually led to a consensus position concerning the location of a nurse practitioner role within the regulatory framework of the Nursing Council of New Zealand.

The complexity of food for people with multiple long-term health conditions.

INTRODUCTION The prevalence of long-term health conditions (LTCs) continues to increase and it is normal for people to have several. Lifestyle is a core feature of the self-management support given to people with LTCs, yet it seems to fail to meet their needs. From a larger study exploring the experiences of this group, this paper reports on the role of food and mealtimes, and the effect of the nutritional advice on the lives of people with several LTCs. METHODS The experiences of 16 people with several advanced LTCs were explored using multiple qualitative case studies. Over an 18-month period, contact with participants included monthly conversations, two longer, semi-structured interviews and one interview with their primary care clinicians. The data were analysed inductively using thematic analysis. RESULTS There was profound social, psychological and cultural significance of food to the participants. These aspects of food were then described using the Whare Tapa Wha model of health. The approach to food and nutrition participants experienced in health care was closely associated with conventional weight management. They found this advice largely irrelevant and therefore ineffective. DISCUSSION The pressure people with several LTCs experience during clinical encounters has perverse effects on wellbeing and reinforces an overall sense of failure. This research challenges the assumption that all people have the will, agency and income to follow the advice they receive about nutrition and exercise. Considering people's needs using the Whare Tapa Wha model of health offers clinicians a framework to re-conceptualise the core features of self-management support and provide realistic, compassionate care that will optimise the quality of life for people with multiple LTCs.

Thinking about health care differently: nurse practitioners in primary health care as social entrepreneurs.

INTRODUCTION Challenges facing the primary health-care sector mean that policymakers and clinicians need to think and act differently to move forward. The principles of social entrepreneurship have been implemented successfully for improved health outcomes in other developed nations. There is a knowledge gap around whether nurse practitioners (NPs) in New Zealand primary health care (PHC) align with these principles. AIM To explore whether and how the innovative activities of primary care NPs can be described as socially entrepreneurial. METHODS A descriptive qualitative approach was used with data collected using semi-structured interviews with NPs working in primary care (n = 7). Data were analysed using general inductive thematic analysis techniques. RESULTS Nurse practitioners interviewed worked in government-subsidised private general practice businesses. Two main themes emerged: (1) the nursing model of care aligned with social entrepreneurship; and (2) building social capital. NPs described a desire to see health care delivered differently and this aligned with acting as a social entrepreneur. Social capital emerged through the requirement to establish significant collaborative relationships. DISCUSSION It was found that NPs' work can be described as socially entrepreneurial. The holistic, person and community-centred model of NP care has an ultimate mission of improved health outcomes. Social capital is built through collaborative relationships with other health-care providers, individual service users and the community. However, the juxtaposition of the business model in primary care prevents NPs from initiating and leading sustainable change.

RN Prescribing: An Expanded Role for Nursing.

PURPOSE: With the implementation of the Affordable Care Act, recommendations of the Future of Nursing Report, and recent regulatory changes by state boards of nursing, registered nurse (RN) roles are expanding. In this article, we advocate for RN prescribing as an expanded role in the United States. METHODS: We reviewed the literature on RN prescribing, the background in both high- and low-resource countries, levels of prescribing, specialized settings for RN prescribing, both RN and patients views/perceptions of prescribing, and evaluation research. From this review, we developed a proposal for RN prescribing. FINDINGS: Due to expansion of RNs into prescribing worldwide to meet unmet healthcare needs in both primary and specialty settings, we propose a role for RN prescribing within both primary care and outpatient specialty settings. The differences between RN and advanced practice RN prescribing are defined, and U.S.-based regulatory challenges are examined. CONCLUSION: Considering unmet healthcare needs and patients' need for medication and medication education, we advocate for RN prescribing as expanded scope and role change for experienced RNs to practice to the highest level of their education.

Proposals for registered nurse prescribing: perceptions and intentions of nurses working in primary health care settings.

INTRODUCTION: In 2013, the Nursing Council of New Zealand consulted on a proposal for introduction of registered nurse (RN) prescribing at two levels (specialist and community) within the designated class of prescriber. The proposal builds on the success of the diabetes nurse specialist prescribing project and the experience of other countries where RN prescribing is well established. AIM: To describe the views and intentions of nurses who work in primary health care (PHC) settings about the two levels of RN prescribing proposed. METHODS: The study involved a self-reported survey using a non-probability sample of RNs working in PHC settings (N=305). Quantitative and qualitative data were analysed descriptively. RESULTS: The respondents were experienced nurses. Overall, 82.3% expressed interest in becoming a community nurse prescriber, and 62.6% expressed interest in the specialist prescriber level. RN prescribing was expected to improve efficiency and access to medicines for high-needs populations, clarify accountability and improve nurses' autonomy. The education requirements for the specialist level were viewed as appropriate but too onerous for many. Requirements were viewed as inadequate for the community level. Concerns were raised about funding for education and support for RN prescribing roles. DISCUSSION: Nurses were positive about the proposals and see a potential to meet significant unmet health need. Nurses are already engaged in the provision of medicines to patients and prescribing authority would ensure they are suitably qualified to engage in these tasks. A clear policy platform will be needed if the proposed levels of RN prescribing are to be successfully implemented.

Nurses' reported use of standing orders in primary health care settings.

INTRODUCTION: The Medicines (Standing Order) Amendment Regulations 2011 allow medicines to be supplied or administered to a patient by a nurse in the absence of a medical practitioner and without a prescription. Regulations have been in place since 2002, but no substantive research has occurred in New Zealand concerning their use. AIM: This paper reports a survey of registered nurses (RNs) who work in primary health care (PHC) settings and explores aspects of their practice relating to their use of standing orders. METHODS: A self-reported survey using a non-probability sample of RNs working in PHC who use standing orders in their practice (n=231). Data were analysed descriptively. RESULTS: The sample were experienced RNs (mean 24 years since registration) and 53% have a postgraduate qualification. Some nurses' understanding of a standing order included provision of a prescription to a patient. Standing orders were used frequently (42% reported use 1 to >5 times/day) for a wide variety of conditions. There is a significant relationship between undertaking the stated professional development requirements and confidence in the clinical decisions made (p=0.025). Over half (52%) would like to use standing orders more often. DISCUSSION: Standing orders are used extensively in PHC settings. The conditions nurses are involved in treating are usually already differentiated or have a high degree of diagnostic certainty. Nurses can effectively provide medicines under standing orders when doctors support their use, issue evidence-based orders, and have confidence in nurses with advanced skills. Doctors need to meet their responsibilities under the Regulations.

Coaching Non-technical Skills Improves Surgical Residents' Performance in a Simulated Operating Room.

OBJECTIVE: To investigate the effect of coaching on non-technical skills and performance during laparoscopic cholecystectomy in a simulated operating room (OR). BACKGROUND: Non-technical skills (situation awareness, decision making, teamwork, and leadership) underpin technical ability and are critical to the success of operations and the safety of patients in the OR. The rate of developing assessment tools in this area has outpaced development of workable interventions to improve non-technical skills in surgical training and beyond. METHOD: A randomized trial was conducted with senior surgical residents (n = 16). Participants were randomized to receive either non-technical skills coaching (intervention) or to self-reflect (control) after each of 5 simulated operations. Coaching was based on the Non-Technical Skills For Surgeons (NOTSS) behavior observation system. Surgeon-coaches trained in this method coached participants in the intervention group for 10 minutes after each simulation. Primary outcome measure was non-technical skills, assessed from video by a surgeon using the NOTSS system. Secondary outcomes were time to call for help during bleeding, operative time, and path length of laparoscopic instruments. RESULTS: Non-technical skills improved in the intervention group from scenario 1 to scenario 5 compared with those in the control group (p = 0.04). The intervention group was faster to call for help when faced with unstoppable bleeding in the final scenario (no. 5; p = 0.03). CONCLUSIONS: Coaching improved residents' non-technical skills in the simulated OR compared with those in the control group. Important next steps are to implement non-technical skills coaching in the real OR and assess effect on clinically important process measures and patient outcomes.

Reasons for non-attendance: audit findings from a nurse-led clinic.

BACKGROUND AND CONTEXT: Evidence has shown that non-attendance at clinics occurs for a variety of reasons and impacts negatively on client outcomes and effective use of clinic resources. This paper reports an audit of non-attendance at Care Plus and diabetes clinics undertaken between October 2007 and October 2008, in a large general practice in the Wellington region. ASSESSMENT OF PROBLEM: A retrospective and prospective audit of the non-attendance rate at nurse-led wellness clinics was completed using the Query Builder function in Medtech32, collecting data from 142 people who did not attend a scheduled appointment. RESULTS: Thirty-three people were unable to be contacted about their reason for not attending. Of those contacted, 68 did not attend because they were unaware of the appointment, confused regarding the appointment time, or simply forgot. Eighty-four people were aged between 18 and 65 years, yet of those contacted, only four cited work had prevented their attendance at the clinic. Difficulty with transport was reported by only two people. STRATEGIES FOR IMPROVEMENT: The audit highlighted the importance of administration processes for scheduling routine appointments and reminding patients about appointments. It provided evidence that administrative support for nurse-led clinics is necessary. LESSONS: Involvement in clinical audit was a new experience for many of the staff and the usefulness of the findings led to more positive views about how audit can be used. The importance of appropriate administrative support was highlighted. Lessons learned for future audits included the importance of a complete data set and consistent use of codes for data entry.

Return visits to the emergency department and related hospital admissions by people aged 65 and over.

AIM: To describe the factors most commonly associated with re-presentation to the emergency department (ED) and related hospital admissions by those aged 65 years and over in one New Zealand district health board (DHB) region. METHODS: Computerised and paper-based records of 59 patients were examined. The sample was selected using proportionate stratified random sampling to ensure equivalent proportions of patients re-presenting to the tertiary hospital's ED and the secondary hospital's accident and medical department. RESULTS: Those who re-presented to the ED within 3 months had an average of 3.4 comorbidities. Hypertension and ischaemic heart disease were the most common comorbidities. Abdominal pain, chest pain and shortness of breath were the most frequently presenting complaints. Patients were less likely (p=0.05) to re-present within 7 days if their capacity to mobilise prior to presentation, and on discharge, was documented. Few patients were instructed to see their primary care provider within any given timeframe. CONCLUSION: Better documentation about changes in levels of function, both prior to presentation and on discharge, is needed to ensure that patients are physically able to manage at home. Specific interventions could be targeted to improve function if needs have been identified. The frequency of cardiovascular comorbidities and cardiac discharge diagnoses suggest that those aged 65 years and over re-present with an acute illness and not because of failure to cope at home. Findings support early primary healthcare follow-up since the majority of re-presentations occur within 2 weeks.