Dr Michal Boyd, an aged care NP and  nurse leader who last week was celebrating at last being able to issue death certificates for her patients’ families said it was a “terrible blow” to discover that NPs were still blocked from signing cremation certificates.

More than a decade in the making, the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill was passed in late 2016 but the changes made only come into effect on January 31.

The complex Bill amended eight Acts to replace references to ‘doctors’ or ‘medical practitioners’ where nurse practitioners (NPs), and other health practitioners like pharmacists, registered nurses and physiotherapists are now qualified to carry out those roles – but did not amend the related Cremation Regulations. This means cremation certificates still have to be signed by a medical practitioner, which is a particular frustration for NPs working in aged care.

Ministry of Health chief nursing officer Jane O’Malley said the Ministry was aware of the oversight of not amending the Cremation Regulations to allow NPs to complete cremation certificates and was “working as quickly as possible to remedy this”.  She said the Ministry was currently in the process of informing stakeholders of its plan and timeline.

“In essence, not being able to do cremation certificates basically keeps in place the barrier to completing death certificates for over 80% of those I serve,” Michal Boyd said in a Facebook post to fellow Nurse Practitioners of New Zealand (NPNZ) members. “This development is so disappointing and frustrating. To feel that one of the last barriers to my practice in aged care was gone and to see it back again is very disheartening.”

She said apparently the cremation referee, who overseas cremation certificates, had let the Ministry of Health know of his concerns late last year about the regulations around cremation certificates being missed out.

NPNZ members shared Boyd’s frustration about the ongoing major barrier to NP practice,  with one reporting that it cost her practice $90 every time it had to ask an outside GP to sign a death or cremation certificate for her patients. There was a call for action on the issue and concerns were expressed whether NPs would again to have wait years for this barrier to be removed.

Nursing Review sought comment on the NPs concerns from the Health Minister Dr David Clark and Ministry of Health.  A spokesperson for the minister’s office said the Minister was aware of the issue and had asked the Ministry for a solution to the problem “which was inherited from the previous government”.

NB this article was updated on February 12 to include additional comment supplied in a revised response from the Ministry of Health and to clarify that it was the cremation regulations needed to be amended not the related legislation.

More than a decade in the making, the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill was passed in late 2016 but the changes made will only come into effect on 31 January. The Bill amended eight Acts to replace references to ‘doctors’ or ‘medical practitioners’ where nurse practitioners (NPs), nurses and other health practitioners are now qualified to carry out those roles.

“One of the things I’m most excited about is overseeing the enactment of this legislation that is coming in at the end of the month,” said Clark.

“This means that nurses will be able to issue sick notes for work and NPs can issue death certificates,” he said.

The amended Acts also remove the current anomaly where NPs can sign ACC forms and sickness benefit forms but cannot sign a certificate for ordinary sick leave from work.

Roles changing under the new legislation (see full details at end of story) include:

• signing death certificates
• taking blood specimens from drunk drivers
• declaring people unfit to drive
• prescribing controlled drugs
• signing sick leave certificates.

Outgoing chief nursing officer Jane O’Malley described the passing of the bill in 2016 as the “culmination of years of work” from the nursing sector, the Ministry of Health and other agencies.

“We’ve got to make the most of particularly the nursing workforce, with its 53,000 nurses who oversee the largest unregistered workforce in the sector,” said Clark. “If we have these people active and practising at top of scope, there’s a huge opportunity for our health system to deliver more care within the fiscal restraints that we have.”

The Minister talked about the legislative changes in an interview with Nursing Review this week in which he also discussed pay expectations and briefly touched on pay relativity for nurses working in sectors such as aged care and Māori and iwi health providers.

Clark said pay relativity was something that needed to be looked as part of the primary health care review. It is understood that the terms of reference are currently being worked on for the review of the primary care funding system promised by the incoming government within its first 18 months.

“I do want to see different models of care looked at,” said Clark. “I think that is required if we’re going to have a sustainable sector that actually delivers better access to quality care for New Zealanders.

“We need to recognise that in many areas, particularly those that are rural or underserved, they have workforces – and nursing workforces – that are actually practising at the top of their scope.” Clark said he believed that was where the opportunities were – ensuring that people were supported to practise at the top of their scope.

Clark added that his job as Minister of Health was to defend the interests of the patient.

“I’m not there to represent any particular workforce but to ensure the best outcomes for the public patient, and that involves ensuring that the workforce is sustainably funded and we have healthy workforces and safe staffing levels.

“I think the only reason our health system is in the good shape that it is, is because of the good grace of the workforces that have been subject to underfunding over the last nine years,” Clark told Nursing Review.

He said the new Government was committed to putting that money back into the sector, but it would take time. It would also take time to build a sustainable health workforce and the capacity to employ more new graduate nurses, he said.

LEGISLATION CHANGES FOR 2018

• Seven of the amendment Acts with their new terminology will commence on 31 January 2018 and the Transport Amendment Act will commence on 8 November 2018.
• The amendments enable competent health practitioners (as defined under the Health Practitioners Competence Assurance Act 2003 or HPCA Act) working within their prescribed scope of practice (e.g. registered nurses) to carry out new roles as defined by the amended Acts.
• This does not mean that all health practitioners regulated under the HPCA Act will be able to undertake all the amended statutory functions.
• The Ministries of: Health; Transport; Business, Innovation and Employment; and Social Development are responsible for the affected legislation. Other agencies, including ACC and the New Zealand Police, will also need to implement the changes.

AMENDED ACTS

Holidays Act 2003: Health practitioners will be able to certify proof of sickness or injury.

Burial and Cremation Act 1964: Nurse practitioners will be able to issue certificates for the cause of death for patients in their care.

Medicines Act 1981: Nurse practitioners will be able to supervise designated prescribers (such as authorised registered nurse prescribers or RN prescriber candidates).

Mental Health (Compulsory Assessment and Treatment) Act 1992: Nurse practitioners, or registered nurses working in mental health, will be allowed to complete a health practitioner certificate for applications for assessment under the Act. An NP will also be able to conduct an assessment examination if approved by the Director of Mental Health. The Director can delegate this approval to the Director of Area Mental Health Service.

Accident Compensation Act 2001: Health practitioners providing treatment to a client will be given the opportunity to participate in preparing clients’ individual rehabilitation plans. Suitably qualified health practitioners will also be able to prescribe aids and appliances.

Oranga Tamariki Act 1989 (formerly the Children, Young Persons, and Their Families Act 1989): Health practitioners will be able to carry out medical examinations ordered by the court when considering whether children or young people have been abused, if the court considers that these health practitioners are qualified for that purpose. In addition, a social worker will be able to ask for medical examinations to be completed by health practitioners qualified for that purpose.

Misuse of Drugs Act 1975: Nurse practitioners, registered nurses working in addiction services and pharmacist prescribers will be allowed to prescribe controlled drugs for the purposes of treating addiction.

Land Transport Act 1998: Health practitioners will be able to request blood tests from drivers and assess and report on their fitness to drive. It will be illegal for someone to refuse a blood test from a health practitioner. Other amendments enable health practitioners to take blood, handle evidential specimens and appear in court to give evidence.

The graduate destination survey of the 502 graduates who passed state finals this winter found that 346 had jobs by September 30.

That is equivalent to 77 per cent of the nearly 420 mid-year graduates who responded to the annual NETS (Nurse Education in the Tertiary Sector) survey or 69% of the 502 new graduates who passed state finals in July).

Of the remaining 156 mid-year graduates 64 (12.7%) were actively looking for work, eight were not seeking RN work and there was no data from 83 (16.5%)*.

About 294 of the graduates had gained places in NETP (nurse entry to practice) programmes by the end of September, which is up on the 278 mid-year graduates known to have gained NETP jobs by the end of August, according to the Ministry of Health statistics released in September.  Most of the NETP positions were in medical (74) or surgical wards (68) followed by 47 in mental health (i.e. NESP or new entry to specialist practice positions), 29 in child health and 23 in primary health care.

The NETs graduate destination survey also captures data on graduates who find jobs outside of the NETP scheme, with 53 known to have gained non-NETP positions.

The majority of the non-NETP jobs were once again in continuing care elderly – with 33 in the residential aged care sector. Concern was expressed last year by the New Zealand Nurses Organisation at the high number of new graduates being employed in aged care without the support of a mentored NETP programme. Nursing Review also reported earlier this year that the number of new graduates employed into supported NETP places in the aged care sector had nearly halved to 16 at the start of this year compared to 30 at the same time the previous year.

The next most common areas for non-NETP jobs were primary health (8) and surgical (3). One new graduate had gained a nursing position overseas.

Eight nursing schools had mid-year cohorts sitting state finals in July (a further eight graduates from five other schools also successfully sat state finals in July). The nursing schools’ graduate job rates, ranged from 68 per cent to 90 per cent of their mid-year graduates having nursing jobs by the end of September.

*No survey data was received for the 50 Unitec new graduate nurses who passed state finals in July or from 33 graduates from five other schools. 

Pharmac announced last week that it will fully fund the shingles vaccine Zostavax for 65-year-olds from April 1 next year and also fund a catch-up programme for people aged 66-80 years until March 2020.

It is envisaged that people will receive their Zostavax vaccine the same time they receive their annual influenza vaccine but it will only be available at general practices and not pharmacies at this point.

Pharmac said some concerns were raised during the consultation process about the extra workload the shingles vaccine could bring in an already busy time for general practice, but it believed the net overall impact would be positive as it would reduce the incidence of shingles and the more serious complications that can arise for older adults.

Pharmac director of operations, Sarah Fitt, said the vaccine would make a big difference to the one in three New Zealanders who would have at least one attack of shingles in their lifetime.

“Shingles can occur in people at any age but older people are the most affected and complications can be more serious and require admission to hospital,” Fitt said.

“While most cases of shingles can be managed at home, these attacks can sometimes lead to other serious health complications. Some people may continue to experience pain for months to years after an initial shingles attack.”

Shingles is caused by the same virus as chickenpox, varicella-zoster. Anyone who has had chickenpox is at risk of developing shingles later in life, although the most significant risk factor for developing shingles is age.

During the consultation some respondents had called for the vaccine to be available for people younger and older than the selected 65-80 years age range. Pharmac said its Pharmacology and Therapeutics Advisory Committee considered the costs and benefits of different age bands and opted for age 65, plus catch-up vaccinations to the age of 80 years, as the clinical evidence showed that vaccine efficacy dropped to 18 per cent in people aged over 80 years at time of vaccination. In addition, the vaccine’s efficacy waned over time and if people were vaccinated when younger than 65 they might not remain protected when they were older when the incidence of the herpes zoster virus was higher and the risk of complications also higher.

Fitt said the shingles vaccine would help to reduce the number of serious cases, and provide many flow-on benefits to families and whānau, as well as the wider health system.

Zostavax will be available from general practices from 1 April 2018.

Kiwi Family Otago, which owned Woodhaugh Rest Home in North Dunedin, is to pay former facility nurse manager Stephanie Breen $15,000 compensation and over $16,000 in lost wages, KiwiSaver contributions and holiday pay. The rest home has since changed hands, according to a lawyer for the company.

The Employment Relations Authority (ERA), which released its decision today, heard that the company was generally pleased with Breen’s performance until November 2015, when concerns were raised about a failure to keep the facility’s system updated.

Then-general manager Janice van Mil found some records were still not up to date the following month and in March 2016 audited the rest home’s files, telling Breen she was “very upset” that some her assessments were so far behind.

“I expect to see significant improvement in your work performance over the next month, when your performance will be reviewed,” van Mil said in a subsequent letter.

In July 2016 the facility was subject to a “spot audit” that Breen was not supposed to be present for, however, because of staffing issues Breen was covering someone else’s shift when the auditor showed up.

The auditor raised concerns about the absence of completed staff appraisals, non-adherence to the staff education programme and issues with medication charts.

Breen said that her office had recently been emptied due to renovations so her files were spread throughout the building. She told the ERA she felt misled by van Mil for not telling her about the audit.

“Ms Breen says that Ms van Mil asked her whether she was motivated to fix the problems but that, as Ms Breen had been up for 36 hours without sleep and had been subject to a surprise audit without any input, she replied ‘at this particular moment, no’,” the decision said.

“According to Ms van Mil, she understood Ms Breen to mean she was not motivated to fix the problems generally.”

An investigation meeting was organised, however, due to the unavailability of representatives of both parties a date could not be agreed upon.

After numerous cancellations, counsel for the rest home, Len Anderson, said it was taking too long and the meeting would go ahead, stating he was sure Breen could organise someone from the New Zealand Nurses Organisation (NZNO) to attend as her representative.

Anderson also stated that “while every effort had been made to allow Ms Breen to have her choice of representative at the meeting, that has not been possible”.

“The meeting will be proceeding this morning and Ms Breen is required to attend.”

Breen did not attend and she was dismissed for “serious misconduct”.

“Ms Breen said that she did not know that she risked being dismissed if she did not
attend the meeting on 7 October 2016,” the decision said.

She said she had not been prepared to attend without representation and believed the meeting was going to be adjourned when no one from the NZNO could attend.

ERA member David Appleton accepted Breen’s evidence.

He found that the delay in finalising a meeting lay equally in the hands of the rest home bosses as it did with Breen and the NZNO.

“I find that, in all the circumstances, no fair and reasonable employer could have proceeded with the disciplinary meeting on 7 October 2016 without either Ms Breen or her representative being present, and without first having obtained a full written response from Ms Breen to the concerns. The dismissal was therefore procedurally unjustified,” he concluded.

A company director had said she had no option but to dismiss Breen because of risk to the business.

However, they did not have any idea what Breen’s responses to the allegations were but “simply accepted the audit findings and Ms van Mil’s comments,” the decision said.

“In fact, I am not convinced that the findings of the audit report, even if all correct, reasonably enabled the respondent to find that Ms Breen had committed misconduct at all, as that implies a wilfulness for which there appears to be little cogent evidence.”

Breen said she had felt a huge loss of confidence following her dismissal after a 40-year career. She had became constantly worried and anxious about undertaking small tasks.

“She felt that all the joy had gone out of her life, and she found herself withdrawing from social contacts,” the decision said.

The ERA said Breen was in no way blameworthy for not attending the meeting, however, she did bear a proportion of the responsibility for shortfalls at the rest home and so reduced her remedies by 25 per cent.

Anderson said the decision may be appealed.

“[Breen] refused to attend an investigation meeting. It is difficult to see what else the employer could have done when she wouldn’t go to the meeting,” he said.

The NZNO, which is acting for Breen, declined to comment due to the possibility of an appeal.

Rosie Winters, an Older Adult Nurse Practitioner, said staff got in their pyjamas to launch their Let’s Get Moving campaign. “We wanted to start a conversation about the impact even a few days’ bed rest can have on reducing muscle strength and increasing the risk of complications for patients, particularly for older patients in hospital,” said Winters.

Key themes of the week included a focus on getting patients dressed in their normal clothes again as soon as possible and staying active. Patient feedback was very positive and the experience of wearing pyjamas to work proved thought-provoking for staff.

“One of our staff said how unmotivated she felt because she was wearing her pyjamas,” said Winters. “It brings home the psychology of clothes. We’ve used this as an opportunity to talk to patients about being conscious of their activity levels each day.

“With patients, once they come in and change into gowns they tend to retract into a passive role. For the older person even a few days’ bed rest can cause a rapid decline in muscle strength and lead to an increased stay in hospital and complications.”

The Bay of Plenty Let’s Get Moving campaigns is based on the #endPJparalysis movement co-founded by Christchurch-based nurse and consultant Brian Dolan.

The #endPJparalysis movement was started early this year by Dolan, who spends part of the year based in the UK, and his Irish business partner as a twitter hashtag linking twitter conversations on the topic of getting older patients up and dressed.

The West Coast DHB was the first DHB to get behind the movement, with medical ward clinical nurse manager Rose Kennedy saying it provided a framework for medical wards like her own to support a restorative model of care and hadn’t added to the nursing workload, just reshaped it.

Dr Frances Healey, a nurse and deputy director of Patient Safety for the National Health Service (England), said the three nations faced similar challenges and had similar programmes but were all in slightly different places on the journey. She said what many of the forum conversations centred on were the “smaller, human aspects” of falls prevention work, like a recent initiative in the UK using firefighters to deliver exercise programmes for the elderly at the local fire station.

“It is much more attractive to elderly men because it was very manly,” said Healey.

Julie Windsor, the patient safety clinical lead for older people for NHS (England), told Nursing Review that the firefighter initiative grew out of firefighters being so successful in raising fire awareness and fire safety that they had “almost done themselves out of a job”.

She said the chief fire officers realised they had a highly skilled workforce that was possibly being underutilised. Firefighters were also highly trusted and had no particular stigma attached to them as a fire could happen to anybody.

In 2015 firefighters joined forces with the NHS, Age UK, Public Health England and the Local Government Association to sign a new health partnership to help tackle health and social problems, including turning fire service ‘Home Safety’ checks into ‘Safe and Well’ visits to help the vulnerable and those with complex conditions in particular. The aim was not only to reduce the risks of a fire but also to look at reducing falls, loneliness and isolation by spotting hazards like loose rugs, and to signpost people – from the elderly to young families – to local groups for help, support or company.

Windsor said what grew out of this partnership was a further initiative for firefighters to offer exercise programmes for the elderly to help reduce their chances of falling.

She said firefighters were required to be physically fit, “so they looked the part”, and they already had spaces at their stations with exercise equipment. Existing falls prevention services stepped in and trained the firefighters in the correct, evidence-based exercise programme, which the firefighters deliver at the neighbourhood firestation to the elderly in the area.

“The older men, and some of the older woman I must say, have found it a very attractive proposition to go along to the local firestation to be trained by the fire crew,” said Windsor. She said they are run as adjuncts to existing community balance and safety classes but the firefighter classes seemed to be a popular alternative – particularly for the men who might prefer not to go to community classes that are often mostly women.

(Recently New Zealand launched the Live Stronger for Longer website to promote approved community exercise classes for the over-65s to help build leg and core strength to improve balance and reduce the risk of falls. More information at live stronger.org.nz.)

New Zealands’ positive imagery and Oz’s sensitive questions

Healey believes the real value of the tri-nations forum was not in sharing the high-end level areas – such as educational programmes and service provision, where the three countries were already going in the same direction – but in the “little human differences” that fascinate people. So major projects, such as the UK’s now well-established national hip fracture database that had been a “very powerful force” for improvements in service provision and service delivery for older people, had not been discussed at great length.

But what had captured many at the tri-nations forum had been initiatives such as the UK firefighters. Another was an approach to reducing falls by dementia patients in hospital – shared by  Lorraine Lovitt, the lead for the New South Wales falls prevention programme – which involved nurses asking the patient’s families what the five most important things were for them to know about their loved one.

Healey said as a visitor from the UK something that particularly struck her was how “positive, cool, fun and even trendy” the images were of older people in the New Zealand falls awareness material. “And that positive imagery is so important to have, rather than the person with the Zimmer frame.”

She said the UK had a variation on this with its ‘Don’t mention the F-word’ campaign, which was where older people used “some fairly colourful analogies” about not wanting to be associated with ‘falls’ and ‘frailty’.

Kat Groenewald, who graduated in 2014 and currently works in aged residential care, is this year’s Donny Scholar.

The two-year palliative care nurse specialist nursing programme scholarship is offered by the Donny Trust in partnership with host organisations, which this year is Wellington’s Mary Potter Hospice and Capital & Coast District Health Board’s hospital palliative care service.

“Palliative care is all I’ve ever wanted to do,” said Groenewald. “I love the holistic approach to providing quality of life and care to patients.”

The scholarship pays Groenewald’s salary for two years, during which time she will work in four clinical placements, including inpatient hospice care at Mary Potter Hospice, hospice community palliative care and tertiary hospital palliative care at Wellington Regional Hospital. She will also be funded to do her postgraduate diploma in palliative care and will receive regular supervision and mentoring from the DHB’s palliative care nurse practitioner Alison Rowe.

Previous host organisations for the scholarship have included Manawatū’s Arohanui Hospice and Auckland’s Mercy Hospice.

It is the first time Wellington has hosted a Donny Nurse Scholar and Rowe said it had had an “overwhelming response” from applicants, which showed the appeal of the training programme.

“Collaborating with the hospice and provide training across all situations is the best way to develop advanced nursing practice in palliative care,” said Rowe.

Andrea McCance, the DHB’s executive director of nursing and midwifery, congratulated Kat on receiving the prestigious scholarship.

“This programme fits nicely with the nursing priority of growing its workforce in this important and expanding area of need,” she said.

Pictured: Palliative care nurse practitioner Alison Rowe (L) and Donny Nurse Specialist Training Programme Scholar Kat Groenewald.

The team at Lady Allum were rewarded for their efforts in reuniting their residents with music from their youth in a ‘I Love Music’ programme that also encouraged them to talk about the memories that music evoked. Lady Allum was also awarded the QPS Innovative Delivery Award.

Selwyn Foundation took home the MediMap Community Connections Award for their baby buddies initiative. The initiative involves Selwyn’s care home residents playing host to mums and their babies and toddlers each week. “The visits bring back a lot of happy memories for residents of raising their own children,” says Baby Buddies programme organiser and diversional therapist Orquidea Mortar. “But the benefits go two-way, with the mums appreciating the opportunity to connect with others, not to mention all the collective parenting wisdom and reassurances they get from our residents.”

The Jackson van Interiors Built & Grown Environment Award went to Summerset by the Ranges in recognition of its circular design for dementia residents.

The Argo Huntleigh Staff & Training Development Award went to Ultimate Care Group’s Bishop Selwyn, which demonstrated the benefits of collaborating with training institutions when it came to workforce training initiatives.

Capella House took home the Invacare Small Operator Award; the Leecare Individual Award went to Bev Inwood; and the VCare Legendary Service to the Aged Residential Care Sector Award went to Pat Jermyn.

Jen Gow, the Southern DHB’s Releasing Time to Care charge nurse manager, said its Sit Up, Get Dressed and Keep Moving initiative would encourage patients to get dressed and moving as quickly and as safely as possible to avoid the potential negative impacts of being bed-bound.

She said the Southern campaign was aimed at supporting patients of all ages and particularly encouraging and reassuring older people it was okay to wear clothes and walk around.

“For an older patient the effect of being in a hospital bed can be far-reaching,” said Gow. She said unnecessary bed rest could lead to reduced muscle strength, increased risk of falls, reduced mobility and loss of confidence. This could delay to delays in re-establishing normal routines and older people being able to return home.

Gow said Dolan would be running a workshop for health professionals and colleagues from across the Southern health system next week in Dunedin. Dolan is director of service improvement at Canterbury District Health Board but spends about four months of the year in the UK as a consultant and an honorary and visiting professor at two UK institutions.The workshop will be based on Dolan’s TODAY model for change programme.

Southern DHB’s new Chief Nursing & Midwifery Officer Jane Wilson said Dolan’s message was clear that patient time was the “most important currency in healthcare” and this was supported by the DHB.

Sit Up, Get Dressed, and Keep Moving was being launched today by the DHB, with displays in the foyers of Dunedin and Southland Hospital and information in the hospital wards through posters and leaflets to educate staff, patients and visitors.

The #endPJparalysis movement started early this year as a twitter hashtag linking twitter conversations on the topic of getting older patients up and dressed. The West Coast DHB was the first DHB to get behind the movement, with medical ward clinical nurse manager Rose Kennedy saying it provided a framework for medical wards like her own to support a restorative model of care and hadn’t added to the nursing workload, just reshaped it.