A survey of nurses prescribing in diabetes care: Practices, barriers and facilitators in New Zealand and the United Kingdom.

AIMS AND OBJECTIVES: To compare diabetes-related prescribing practices, barriers and facilitators amongst nurse prescribers in New Zealand and the United Kingdom. BACKGROUND: Nurses have been prescribing in the United Kingdom for many years but nurse prescribing in New Zealand is relatively recent. It is unknown whether similar system factors act to facilitate or limit prescribing. DESIGN: A survey of 250 nurses prescribing in diabetes care in New Zealand (n = 111) and the United Kingdom (n = 139). METHODS: A SurveyMonkey questionnaire was used to survey nurses about the extent of their prescribing practices, and barriers and facilitators experienced. Quantitative data were explored descriptively, and qualitative responses were grouped according to content, with quotes provided to exemplify thematic content. This study is reported following STROBE guidelines. RESULTS: Insulin, metformin and sulphonylureas are the drugs most frequently prescribed in both countries. Considerably more New Zealand than United Kingdom nurses reported prescribing for cardiovascular and renal disease. In both countries, direct prescribing to the patient was most common, followed by remote prescribing in New Zealand and via recommendation to other prescribers in the United Kingdom. Most common barriers were lack of time and inadequate mentoring. Most common facilitators were as follows: good supervision; collegial relationships with specialists, pharmacists and peers; and ongoing education. CONCLUSIONS: These New Zealand and United Kingdom nurses are prescribing a broad range of diabetes-related medications. Similar barriers and facilitators were identified in both countries. Adequate supervision, support from multidisciplinary team colleagues and prescribing education and guidelines are paramount. RELEVANCE TO CLINICAL PRACTICE: Important insights on barriers and facilitators to implementation of nurse prescribing in two countries are highlighted and, despite a considerable difference in the longevity of prescribing practice, similar issues were identified.

Support for living well with long-term conditions: How people manage.

AIMS AND OBJECTIVES: To explore how people self-manage their long-term conditions and the support enabling them to do so. BACKGROUND: People with long-term conditions are required to engage in daily self-management with the support of health practitioners, family and friends. DESIGN: A qualitative interview study. METHODS: Thirty-two New Zealand European and Pacific people with long-term conditions were interviewed about how they manage their condition/s at home with support from family, neighbours, agencies and general practice doctors and nurses. Interviews were recorded, transcribed, checked and analysed for thematic content. The COREQ checklist was used. RESULTS: Three themes emerging from the data were as follows: 'acceptance' of conditions, limitations, support and advice; 'making it work' regarding life with long-term conditions; and the need for health practitioners to 'work alongside me'. CONCLUSIONS: People with long-term conditions struggle with acceptance of a diagnosis and symptoms, and acceptance of help which conflicts with their need to maintain independence and personal control. They self-manage every day, learning to plan, choose what and what not to do and negotiate with others to get tasks done and maintain quality of life. They manage better with support from understanding health practitioners, especially advanced nurses, with whom they have established a positive, sustained relationship. RELEVANCE TO CLINICAL PRACTICE: Active support for people to self-manage has been shown to assist people to achieve their goals and improve overall health and well-being. Nurses are well positioned to provide self-management support for people with long-term conditions but require allocated time and system changes to enable this. Practitioners need to acknowledge that it is difficult for people to accept diagnoses and symptoms and provide individualised support for this process. The desire to remain independent may limit acceptance of help, making it harder for people to maintain life quality. A change in length and content of consultations is required in order for practitioners to really get to know people and provide the self-management support they need to meet their goals.

Accounting for differences in cognitive health between older adults in New Zealand and the USA.

BACKGROUND: National differences in cognitive health of older adults provide an opportunity to shed light on etiological factors. We compared the cognitive health of older adults in New Zealand and the USA, and examined differences in known risk factors. METHODS: Two nationally representative samples were derived from the 2010 waves of the New Zealand Longitudinal Study of Ageing (n = 953) and the US Health and Retirement Study (HRS) (n = 3,746). Data from comparable measures of cognitive function, gender, age, income, education, prevalence of cancer, diabetes, heart disease, hypertension and stroke, exercise, alcohol consumption, smoker status, depression, and self-reported health were subjected to hierarchical regression analysis to examine how national differences in cognitive function might be explained by differences in these risk factors. RESULTS: The New Zealand sample scored 4.4 points higher on average than the US sample on the 43 point cognitive scale. Regression analyses of the combined samples showed that poorer cognitive health is more likely in those who are male, older, less educated, have suffered a stroke, consume alcohol less frequently, are more depressed, and report worse overall health. Controlling for age and sex reduced the mean difference to 2.6 and controlling for risk factors further reduced it to 2.3. CONCLUSIONS: Older New Zealand adults displayed better cognitive function than those in a US sample. This advantage can be partially explained by age and sex differences and, to some extent, by differences in known risk factors. However, the national advantage remained even when all measured risk factors are statistically controlled.

Handlers' Expectations and Perceived Compatibility regarding the Partnership with Their First Guide Dogs.

The main function of a guide dog is as a mobility aid, but they can also fulfill psychosocial roles as companions, social facilitators, and objects/providers of affection. This study examined the outcome of 50 peoples' (handlers) partnerships with their first guide dog. Overall compatibility and the fulfilment of the handlers' expectations regarding mobility and social factors related to guide dog usage were measured, and relationships between putative risk factors and the outcome of matching success were identified. The findings demonstrate that the dogs are generally exceeding expectations. The high average ratings of compatibility were notable, particularly with respect to the emotional compatibility between handler and dog. Comparing responses of those who felt the handler-dog pairing was a good match with those who felt it was a mismatch revealed it was the working aspects of the relationship that differentiated the two groups. However, the many aspects of life with a guide dog, beyond the complexities of the working relationship, suggest that a more nuanced compatibility measure accommodating both positive and negative aspects of the relationship could assist with matching, training and follow up of the handler-dog team to maximize success.

The End of the Partnership With a Guide Dog: Emotional Responses, Effects on Quality of Life and Relationships With Subsequent Dogs.

Guide dogs are mobility aids that facilitate independent travel of people who are blind or visually impaired. Additional benefits imparted to the guide dog handler include companionship, and increased: social-function, self-esteem and confidence. Some evidence shows that the end of the guide dog partnership can result in reduced mobility, and may have profound psychosocial effects on the handler due to feelings of bereavement and loss of self-esteem. However, this evidence is limited. This study examined the experiences and feelings of 36 people across New Zealand, who experienced the ending of at least one partnership with a guide dog (77 pairings), to explore issues arising at the end of the partnership and how this may impact on relationships with subsequent dogs. Results indicate that the majority of handlers experienced a reduction in their quality of life due to a decrease in independent mobility followed by the loss of a friend and companion, curtailment of social interactions, and loss of self-esteem/confidence. The end of the partnership affected people in different ways. Most handlers "accepted" the partnership had ended, but some felt guilty or angry with the guide dog school. Most applied for another dog immediately, as the need for mobility was high, while others preferred to wait and a smaller number did not reapply. Feelings at this time also affected the handlers' relationships with subsequent guide dogs, with over a quarter expressing a negative effect. Retiring a guide dog (for whatever reason) is not only difficult for the handler, but also for the handler's family, friends, co-workers, and doubtlessly, the dog. The majority of handlers expressed feelings of extreme grief when the partnership ended, whether it was successful or not. Feelings of extreme grief were more common for first than subsequent dogs. The depth of emotion was compared to losing a family member or other loved one, which has been reported in some person and pet relationships. A better understanding of issues surrounding the end of the partnership, including the human-animal bond, will help inform the guide dog industry of how best to support their clients during this time and when transitioning to another dog. Findings may be applied to other service/assistance dog users and the pet owning community.

Chronic pain: good management of practical pain control strategies is associated with being older, more health activated and having better mental health.

INTRODUCTION Chronic pain affects a large proportion of the adult population and people in pain need to learn how to manage it in order to maintain quality of life. AIM This study aimed to examine how well people with long-term conditions make use of self-management strategies to control their pain, and to identify personal attributes associated with a higher degree of success. METHODS People with chronic pain who participated in the first phase of a longitudinal long-term conditions study in the MidCentral region made up the study sample (N=326, response rate 21%). They completed a questionnaire by mail or online, which included items on pain management, general health, patient activation, experiences with general practice and demographics. RESULTS Pain control strategies were managed fairly well overall. Taking pain medication and avoiding caffeine, alcohol, heavy meals and exercise before bed were managed best, whereas sleep, relaxation breathing and remaining socially active were managed least well. A multiple regression analysis found higher scores on patient activation, self-rated overall pain management at home, mental health and older age (≥75 years) to be associated with better management. DISCUSSION This study identified pain control strategies that are managed well, and less well, outside of a specific intervention. Results highlight topics for discussion in consultations and identify areas where general practice could provide better self-management support, such as sleep and exercise. Better overall pain control strategy management was most strongly associated with patient activation; that is, a combination of knowledge, skills and confidence to manage health and health care that is amenable to intervention. Improving the level of activation in people with long-term conditions may enhance their use of pain control strategies.

The role and measurement of patient activation in the management of long-term conditions in New Zealand.

AIM: Patient activation represents people's knowledge, skills and confidence to manage their own health. We provide information regarding the nature of patient activation and use New Zealand data to consider its utility in New Zealand. METHODS: Self-report data using the patient activation measure (PAM) and seven health and general practice experience measures were collected from 544 general practice patients in the MidCentral region. PAM scores were used to categorise respondents into four levels of activation. Mean scores were calculated by activation level, separately for Maori (14.9%) and non Maori (85.1%). RESULTS: Patterns of activation similar to those reported in earlier research were found. More positive health and general practice experience scores were found for those at higher levels of activation for both ethnicities. The magnitudes of the differences by activation level were similar for both groups and overall differences were significant for all variables for non Maori and for three for Maori. CONCLUSIONS: The PAM behaved as it has done in previous overseas studies with respect to score distribution, reliability and validity. We recommend its use for research and clinical practice in New Zealand to assist with designing appropriate levels of LTC education and self-management support aimed at increasing health engagement.

Nurses' understandings of the Professional Development Recognition Programme.

Professional Development and Recognition Programmes (PDRP) for nurses have developed out of the Clinical Career Pathways (CCP) of the 1990s. The Health Practitioners Competence Assurance Act (2003) has now required all health professionals to provide evidence that their practice meets criteria set by the individual regulatory body, which, for nursing, is the Nursing Council of New Zealand. In 2002 a tool was developed to measure knowledge and attitudes of the then CCP which was tested with 239 nurses. This paper is a report on the second application of the tool in the same hospital in New Zealand. Results show that knowledge and attitudes of the PDRP are similar to those found in the previous study. It also suggests that greater understanding of the PDRP and the implementation process increases the likelihood of a positive response to the programme.

Public health nurses' views on their position within a changing health system.

To date nursing research exploring the relevance of the practice environment has focused substantially on the experiences of hospital-based nurses. More recently greater attention has been paid to the community nursing environment and nurses involved in primary health care. This study considers the context of public health nursing in New Zealand, firstly by exploring the creation and development of the public health nursing role and secondly by presenting the results of a survey of nurses' views of their practice environments and of their professional positioning at the time of the introduction of Primary Health Organisations (PHOs). One hundred and sixty seven public health nurses across New Zealand firstly provided quantitative ratings of aspects of their practice environment (utlising the Nursing Work Index Revised (NWR-I)), and secondly gave written responses to: (a) the aspects of a work environment that make it a good place to practice as a public health nurse; (b) preferences for employment within Public Health Units, in PHOs or with Maori health providers; and (c) advantages and disadvantages of all three settings. This paper focuses on the qualitative questions only as the NWI-R findings will be reported elsewhere. Findings suggested the importance of good leadership, education/orientation, support, recognition and resources within a public health nursing environment. The main preference of the participants was for working within a District Health Board Public Health Unit, although disadvantages were acknowledged.

An Investigation of the Complexities of Successful and Unsuccessful Guide Dog Matching and Partnerships.

Matching a person who is blind or visually impaired with a guide dog is a process of finding the most suitable guide dog available for that individual. Not all guide dog partnerships are successful, and the consequences of an unsuccessful partnership may result in reduced mobility and quality of life for the handler (owner), and are costly in time and resources for guide dog training establishments. This study examined 50 peoples' partnerships with one or more dogs (118 pairings) to ascertain the outcome of the relationship. Forty-three of the 118 dogs were returned to the guide dog training establishment before reaching retirement age, with the majority (n = 40) being categorized as having dog-related issues. Most (n = 26) of these dogs' issues were classified as being behavioral in character, including work-related and non-work-related behavior, and 14 were due to physical causes (mainly poor health). Three dogs were returned due to matters relating to the handlers' behavior. More second dogs were returned than the handlers' first or third dogs, and dogs that had been previously used as a guide could be rematched successfully. Defining matching success is not clear-cut. Not all dogs that were returned were considered by their handlers to have been mismatched, and not all dogs retained until retirement were thought to have been good matches, suggesting that some handlers were retaining what they considered to be a poorly matched dog. Almost all the handlers who regarded a dog as being mismatched conceded that some aspects of the match were good. For example, a dog deemed mismatched for poor working behavior may have shown good home and/or other social behaviors. The same principle was true for successful matches, where few handlers claimed to have had a perfect dog. It is hoped that these results may help the guide dog industry identify important aspects of the matching process, and/or be used to identify areas where a matching problem exists.

To have or to take: discourse, positioning, and narrative identity in women's accounts of HRT.

Using 'social cognitive' frameworks, attitudes to HRT have been examined as if they were stable entities located within individuals. However, qualitative studies have revealed variations and contradictions in women's 'attitudes'. We seek to explain these apparent contradictions by using a social constructionist approach to the analysis of qualitative data from 7 focus group discussions about HRT with 48 women in New Zealand. A discourse analysis of 'interpretative repertoires', subject positions and narrative identity was undertaken to explain the construction of HRT in situated practice, and the negotiation and accomplishment of a unitary orientation to HRT across situations. The results summarize the interpretative repertoires used by the women, and one example of a subject position negotiated at a moment of patently problematic intersecting interpretative repertoires, to highlight the construction of subject positions using discursive resources. The importance of the study of subjectivity in applied areas of psychology is discussed.

Measuring perceptions of the clinical career pathway in a New Zealand hospital.

Clinical Career Pathways (CCPs) for nurses were introduced in the 1970s and they were first established in New Zealand during the late 1980s. The implementation of CCP programmes has met with mixed response; many nurses view it negatively as an extra and unnecessary demand from their employers while others perceive it to be a valuable form of professional development. This paper introduces a new instrument, the Clinical Career Pathway Evaluation Tool (CCPET) designed to assess nurses' and midwives' knowledge of and attitudes towards their Clinical Career Pathway. The 51 item instrument takes the form of a self-report questionnaire in two sections. The first tests knowledge of the CCP, as implemented at the study hospital, the second measures attitudes towards CCP and professional development. In this paper we describe the development of the CCPET and present some of the results from an initial application of the instrument with 239 nurses and midwives in a New Zealand hospital. Results indicate that knowledge levels were moderate in this sample and were correlated with both positive and negative attitudes. Results of t-test comparisons indicated that, on average, the group who had already completed a CCP portfolio had greater knowledge and more positive attitudes than the group who had not. The authors suggest firstly that the CCPET is useful for measuring CCP knowledge and attitudes in a constantly restructuring nursing environment, and secondly that the instrument can be easily adapted for use in other hospitals and organisations.

Taking the PACIC back to basics: the structure of the Patient Assessment of Chronic Illness Care.

RATIONALE, AIMS AND OBJECTIVES: The Patient Assessment of Chronic Illness Care (PACIC) is a widely used 20-item measure consisting of five subscales. Published factor analyses of PACIC scores have produced conflicting results on the measure's factorial validity, and therefore some confusion as to the utility of its subscales. We aim to reduce this confusion by reviewing the evidence on the PACIC's factorial validity, exploring the statistical issues it raises, and considering more broadly what such analyses can reveal about the validity of the PACIC. METHODS: To achieve these aims we review six published studies on the PACIC's factorial validity, present confirmatory factor analyses of our own PACIC data from 251 chronic care patients, and assess the PACIC with respect to its status as a reflective or a formative measure. RESULTS: Our statistical analyses support the view that a 5-factor model does not fit the structure of the PACIC, and highlight a variety of technical issues that confront researchers who wish to factor analyse the measure. However, we argue that, as the PACIC is more accurately seen as a formative measure, such analyses do not provide information that should be used to assess the PACIC's validity. CONCLUSIONS: We conclude that, while it is important to continue examining the reliability and validity of the PACIC in a variety of ways, traditional analyses of its factorial validity (and internal consistency) are inappropriate. Meanwhile, use of the subscales is defensible as long as they continue to meet other types of reliability and validity requirements.

Learning from people with chronic pain: messages for primary care practitioners.

INTRODUCTION: A large number of people live with chronic, non-malignant pain, which impacts on their work, social activity and quality of life. For many people pain appears to be inadequately treated and controlled, in part due to a reluctance to take appropriate medication. The aim of this study was to learn more about people's experience of pain in the context of long-term illness, in order to inform primary health care practice. METHODS: Twenty people previously identified from a survey about chronic illness care were interviewed about their pain-related experiences. Interviews were taped and transcribed and a thematic analysis was carried out to identify the key themes relating to practitioners' support of people with chronic pain. FINDINGS: Three main themes, which were common to all authors' analyses and are considered most relevant to practice, are presented and discussed. These themes were labelled 'medication concerns', which encompasses side-effects, reluctance to take pills and pain medication as a choice; 'coping with pain', including acceptance, pacing yourself and non-pharmaceutical pain relief; and 'seeking help for pain', which included negative and positive experiences and lack of care continuity. CONCLUSION: Pain limited how participants lived, yet many were reluctant to take pain relief as prescribed, if at all. They found other ways of coping, and accepted their pain. Messages for practitioners include the importance of asking people about their pain, listening and acknowledging the reality of pain and its effect on daily life and providing education, reassurance and support for taking pain medication.

Rural nurse to nurse practitioner: an ad hoc process.

INTRODUCTION: Despite a 10-year history of nurse practitioner (NP) development in New Zealand (NZ) there is no formalised or universal process for ensuring the transition of willing nurses to NP status. This unmet need is of particular interest in the rural context where workforce issues are paramount. The aim of this study was to explore the transition from rural nurse to NP in NZ. METHOD: A qualitative descriptive survey was sent to all NZ nurses with a rural address. Ninety-two questionnaires were returned, of which 21 respondents were working in a rural location and aiming to become an NP. Data analysis included description of demographic data and thematic analysis of open-ended question responses. FINDINGS: Four themes encompassed the experiences of the 21 potential NP candidates: uncertainty about opportunities for employment as an NP and legislative and funding barriers for NP practice; support or resistance from GPs and nurse colleagues, self-doubt, and the importance of mentoring; difficulties with the NP authorisation process; and meeting the NP competencies within the challenges imposed by rural location. CONCLUSION: At the systems level of workforce design, stronger linkages between policy development, investment, employment creation, funding streams, professional regulation and overall communication require attention.

Modifying the PACIC to assess provision of chronic illness care: an exploratory study with primary health care nurses.

INTRODUCTION: In line with Wagner's Chronic Care Model, the Patient Assessment of Chronic Illness Care (PACIC) has been developed to evaluate chronic illness care delivery from the patient's perspective. Modification of the instrument to assess the same aspects of care delivery from the health practitioner's perspective would enable individual practitioners to evaluate their own provision of self-management support, and would also enable a more direct comparison between care provided and care received within the chronic illness context. AIM: To explore the potential of a modified PACIC instrument to assess individual health practitioners' delivery of care to chronic illness patients with a sample of primary health care nurses. METHODS: Seventy-seven primary care nurses completed the modified PACIC, reworded to ask about care provision rather than receipt of care. An additional seven cultural sensitivity items were included, as were questions about the suitability of the types of chronic illness care and who should be providing the care. RESULTS: The modified PACIC items appear to be appropriate for use with health practitioners. Agreement that the types of care described in the PACIC should be provided was almost unanimous, and the predominant view was that self-management support should be provided by both nurses and doctors. Mean scale scores were higher than those generally reported from studies using the PACIC. DISCUSSION: The results of this first evaluation of a modified PACIC suggest that the original items plus the cultural sensitivity items can be used to assess self-management support by individual health practitioners.

Providing and receiving self-management support for chronic illness: patients' and health practitioners' assessments.

INTRODUCTION: Providing care for people with chronic illness is a major issue for health practitioners around the world, especially as populations age. Encouraging self-management is beneficial in terms of relieving the burden on the health system and promoting better health and adherence to medication and advice amongst this group. AIM: To measure the level of self-management support being provided to and received by people living with chronic illness in a District Health Board (DHB) region. METHODS: Self-report questionnaires (PACIC) were completed by 341 people living with chronic illness to measure the self-management support they receive from general practitioners and nurses. A modified version of the PACIC was used with 12 GPs and 77 primary health nurses in the same region to assess the provision of self-management support. RESULTS: Patients' assessments suggest that they are receiving intermittent self-management support for their chronic illness. A comparison of ratings of different health practitioners revealed that nurses were reported to be providing support more consistently than GPs. The health practitioners rated themselves as providing self-management support more often than the patients reported receiving it. Many clinicians also suggested that not all forms of support are appropriate for everyone, suggesting the need to tailor support to the individual. DISCUSSION: Chronic illness support needs to be considered within the context ofthe individual and to be embedded in an ongoing relationship between the person and the provider. Findings highlightthe benefits of a multidisciplinaryteam approach to self-management support and education in chronic illness care.

Organizational attributes valued by hospital, home care, and district nurses in the United States and New Zealand.

PURPOSE: To determine whether hospital-based, home care, and district nurses identify a core set of organizational attributes in the nursing work environment that they value as important to the support of professional practice. DESIGN: Survey data, collected in 2002-2003 from 403 home care nurses in the United States (US) and 320 district nurses in New Zealand (NZ), were pooled with an existing data set of 669 hospital-based nurses to conduct this descriptive, nonexperimental study. METHODS: The importance of organizational attributes in the nursing work environment was measured using the Nursing Work Index-Revised (NWI-R). Frequency distributions and analysis of variance were used to analyze the data. FINDINGS: At least 80% of hospital-based, home care, and district nurses either agreed or strongly agreed that 47 of the 49 items comprising the NWI-R represented organizational attributes they considered important to the support of their professional nursing practice. Mean importance scores among home care nurses, however, were significantly lower than were those of the other two groups. CONCLUSIONS: Overall, hospital-based, home care, and district nurses had a high level of agreement regarding the importance of organizational traits to the support of their professional practice. The intensity of the attributes' importance was less among home care nurses. Further research is needed to determine whether this set of organizational traits, measured using the NWI-R, is associated with positive nurse and patient outcomes in home care and district nursing practice, as has been shown in acute care settings.

Health correlates of autonomy, control and professional relationships in the nursing work environment.

BACKGROUND: Internationally, nursing is facing a variety of challenges including changes in health systems, an ageing workforce and escalating shortages of Registered Nurses. New Zealand is no exception. Here as elsewhere these challenges are taking their toll on the resources and demands of hospital environments, on the health and well-being of nurses themselves and most certainly on the people for whom they care. In the United States of America (USA), three aspects of the nursing work environment--autonomy, control and nurse-physician relations--have been identified as linked to staff retention, levels of staff burnout and needlestick injury, as well as to a range of patient outcomes. AIM: To examine the New Zealand nursing situation and to see whether aspects of the work environment are associated with health status. METHODS: A total of 225 Registered Nurses in a general hospital completed the Revised Nursing Work Index (NWI-R) and Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey (SF-36). RESULTS: Ratings indicated that the New Zealand hospital environment was characterized by less autonomy and control and better nurse-physician relations than in USA hospitals. Results of correlations demonstrated that more positive ratings of the three workplace attributes were associated with better health status amongst the nurses. The results of regression analyses were indicative either of a confounding relationship or of a mediating relationship such that nurses' relations with physicians, administration and other departments mediate the associations between autonomy, control and health status. CONCLUSIONS: The study offers an insight into a New Zealand hospital environment and suggests the importance of good relationships with physicians and other departments for the health of nurses.