Injections, intravenous (IV) lines, blood tests and implanted ports can lead, not surprisingly, to children being anxious and fearful about needles. Child health nurses muster all their skills to reduce the risk of distress – using the right words, play and distraction techniques, the support of the children’s caregivers and appropriate pain relief.

The ‘go-to-treatment’ for topical pain relief, says Rachel Wilson, a clinical nurse specialist at Christchurch Hospital’s Children’s Haematology and Oncology Centre (CHOC), has been topical anaesthetic creams, but they come with their own side effects and complications. And, as she told the recent Clinical Nurse Specialist Society conference, for some children the most distressing part of a procedure can be removing the dressing holding the anaesthetic cream in place. Or if a child is needing urgent intravenous fluids or medication, there may not be enough time for the anaesthetic cream to do its job, resulting in a painful experience for the child.

The research literature shows that children who are exposed to poorly managed and painful healthcare procedures are more likely to demonstrate increased pain perception, pain behaviours and medical fear later in life, says Wilson. That is why her eye was drawn to an item in the Children’s Healthcare Australasia (CHA) newsletter about a simple pain-numbing device being used at the Royal Children’s Hospital in Melbourne for more than 5,000 intravenous (IV) cannulations, with overwhelmingly positive feedback from patients.

Called CoolSense, the small handheld device was first developed for dulling the pain of Botox injections and the like in the cosmetic sector. The device has a temperature-controlled head that cools and numbs the injection site. “It takes only 10 seconds to work before the injection can be given,” says Wilson. “It is simple, it is allergy-free and it is immediate – a no-brainer.”

And, unlike using an ice pack on a wriggling child, the device’s small round head enabled a precise and controlled numbing of the injection site area. Wilson says that, also surprisingly, despite the sudden chill, using the device didn’t cause vasoconstriction of a child’s vein so veins still ‘popped up’ and were accessible.

So with the support of CHOC charge nurse manager Chrissy Bond, it was decided to trial CoolSense on CHOC patients in May 2016, using the numbing applicator not only for IV cannulation but also venepuncture, accessing ports and giving subcutaneous and intramuscular injections. The CHOC nurses were trained in using CoolSense and, depending on the age of the child, prepared the children for the sudden cold of the device by talking about it being like a frosty Canterbury morning or giving younger children a lick of an iceblock.

“Very quickly the CoolSense became known as the magic wand,” says Wilson. “One of our patients – she loved it – said the only thing that was wrong with it [the ‘magic wand’] was that it wasn’t pink and it didn’t have ‘bling’.”

The trial was not without its hiccups: a week in there were reports of skin tissue injuries so the team stopped using the devices to investigate. They discovered there was an undetected fault with one device, which meant the cold metal applicator head (or pin) had shifted
and was no longer touching the alcohol gel pad.

“It is the alcohol that protects the skin from the very cold [applicator] head that you are pushing against the skin [for 10 seconds],” says Wilson. “So we were, in fact, causing [ice] burns to these children.” This led to refining the procedures and updating the education package to ensure that nurses checked there was no gap between the metal head and the gel pad, recorded which device they used, used a watch to time the 10-second application, and the devices were not stored in a freezer colder than -10oC.

The team then reintroduced CoolSense and, the second time around, the ‘magic wand’ was rated a winner in a survey of CHOC parents (31 respondents or 80 per cent of CHOC children in trial). More than 83 per cent of respondents believed that CoolSense was more effective than the creams; more than 90 per cent agreed that using the numbing devices saved time; about 85 per cent believed it worked well in numbing their child’s skin before needle insertion; and 87 per cent would recommend the device to other parents.

Less pain and fewer dollars

Wilson says another plus for the numbing applicator was the potential for cost savings.

“Even though as nurses we like to pretend we don’t want to know about it [money], it is actually very important as we all work with a budget that is limited.”

She says the topical anaesthetic creams they traditionally used took an hour for optimal effect and cost between $6.75 and $9 per 5g tube, leading to an annual bill for Canterbury DHB’s child health services in excess of $60,000.

In comparison, a CoolSense applicator costs about $160 and each device comes with an alcohol cartridge lasting 350 applications. Wilson says the cost of the device and replacement cartridges average out at 22 cents per use – so potentially there could be a saving of $8,780 per 1,000 uses.

CoolSense training is now a routine part of orientation for new nursing and medical staff in child health, says Wilson. The numbing device was also being used beyond child health services in other hospital areas where children are treated, including intensive care, radiology, emergency and operating theatres.

The innovation was the runner-up in the improved quality and safety experience category of Canterbury DHB’s Innovation Awards last year and Wilson and the Child Health team have also presented their findings across the Tasman, as well as at the recent Australasian Nurse Educators Conference.

“We are providing the evidence and getting it out there for people to show how this very little piece of technology can change outcomes for children,” says Wilson. She says pushing for innovations and implementing something new did take some courage and tenacity.

“You have to have passion for it – people ask me do I actually have shares in CoolSense because I keep going on and on … and I still am,” laughs Wilson. “But it just goes to show that small innovations can grow into evidence-based best practice, delivering improved health experience outcomes for our patients.”

And maybe fewer children will now have memories of their time in hospital as human pincushions.

RESEARCH STUDY

The initial research into using CoolSense at Melbourne’s Royal Children’s Hospital was recently published in the journal Anaesthesia and Intensive Care by paediatric anaesthetist Philip Ragg.

The prospective observational audit of 100 children and adolescents (aged 6-18 years) looked at the patient and carer satisfaction rates with using the device and how effective it was in reducing the pain of intravenous cannulation.

The study found that 94 per cent of patients rated the pain during cannulation as less than or equal to three on a numerical pain rating scale of zero to 10.

Patient and carer satisfaction with the device and cannulation success rates were also high; 66 per cent of patients and 82 per cent of carers ‘really liked’ the device and 28 per cent of patients and 12 per cent of carers ‘liked’ it. Ninety-five percent of patients were cannulated on the first attempt.

The article concluded that the device appeared to be a useful tool that provided effective analgesia for intravenous cannulation in children with minimal complications.

Source: Ragg P et al. (2017) A clinical audit to assess the efficacy of the Coolsense^® Pain Numbing Applicator for intravenous cannulation in children. Anaesthesia and Intensive Care 45(2)

The Bay of Plenty District Health Board says infection control measures are in place, including the restriction of access to the unit by both visitors and staff.

Chief operating officer Peter Chandler says everyone infected has been isolated.

He says visitors are being urged to stay away from the unit unless their visit is absolutely essential.

The DHB says the public shouldn’t visit the hospital’s emergency department unless their case is an emergency.

A likely norovirus outbreak has also affected 11 people at Whangarei Hospital and  strict infection control measures have been put in place on a ward.

The viral gastroenteritis outbreak was identified within Whangarei Hospital’s Ward One on around September 14. The outbreak, likely norovirus, has affected 11 patients who were isolated to prevent other patients being infected. As a further precaution, the ward was closed to new admissions and visiting restricted.

Strict infection control measures were put in place to reduce the risk for other patients within the hospital, said Clinical Microbiologist David Hammer.

Dr Hammer said that norovirus is currently widespread in the community and urged members of the public with any gastroenteritis-like symptoms not to visit patients in hospital. “We are asking members of the public – if you are unwell or have been around people who have been unwell – please do not visit the hospital for at least 48 hours,” he said.

I asked Health Minister Jonathan Coleman to come on the programme this morning to respond to some of the failings of Waikato Hospital; if you tuned in yesterday, you would have heard an interview with the Waikato DHB.

The DHB was damning of the health minister and said Waikato Hospital had a funding shortfall to the tune of $32.5 million, and it was a life-threatening situation.

And the DHB described a culture of spin coming from the ministry and the minister, and said everyone was under pressure to talk positively about a situation that was anything but. That pressure, the DHB said, comes from the top.

So we spent much of yesterday requesting an interview with Jonathan Coleman.
What did he make of these criticisms? He was entitled to a right of reply and we offered that to him. In the end, a text came back from his press team. It said, “Thanks, but we’re declining.”

EARLIER SEPT 14 OPINION:

Rachel Smalley: Health Minister Jonathan Coleman is out of touch

What is your number one concern ahead of the election? Well, according to the latest Newshub-Reid Research poll, it’s health.

And so it should be. Yes, housing and immigration are big issues too – but if you don’t have your health, what do you have?

In the past 24 hours, health has come catapulting up the news agenda.

First, the concerns raised by Jacinda Ardern.

Elective surgeries other than cancer or other emergency type surgeries were also cancelled  as the hospital dealt with the overflow of patients. Patients slept on beds in the corridors of the ED on Monday night as there were no beds left in the wards.

Waikato Hospital is not the only hospital feeling the pressure. Last month Middlemore Hospital put up a sign on the door of its ED telling patients the hospital was full and to expect delays of up to eight hours to be seen in the emergency department.

North Shore, Waitakere, Auckland City, Palmerston North and Hawke’s Bay Hospitals have also been at capacity at least once this winter.

The Waikato DHB posted a video on its Facebook page at Tuesday lunchtime telling patients to check with their GPs or call Healthline first and only go to the emergency department it was a “real emergency” or be prepared for a long wait.

The email reveals “ground zero” pressures on the South Auckland hospital and details strategies for staff to clear beds and get patients out.

It has brought a concession from management at Counties Manukau District Health Board that staff are under pressure and have raised concerns about “staffing and capacity”.

Despite this, Health Minister Jonathan Coleman said in a statement: “This isn’t unusual for this time of year, and the reality is that the hospital can cope.”

The pressure at Middlemore Hospital was revealed last month when it emerged staff had created a sign urging patients to go elsewhere or face waiting eight hours in the Emergency Department.

While the sign was removed after management learned of it, the NZ Herald has since found it had been used on a number of occasions for at least eight weeks.

The internal email – provided to Labour’s Mangere MP Aupito Su’a William Sio – showed the extent of the pressure placed on the South Auckland hospital, and how those issues existed beyond the Emergency Department.

The memo told staff the total hospital occupancy was at 104 per cent and stated: “The hospital is full.”

Other areas of the hospital were stretched even further, with medicine and surgical areas at 116 per cent capacity.

The memo detailed coping strategies, telling staff to get people into the “discharge lounge as soon as possible” to help move patients from the Emergency Department.

It stated that there had been 355 patients through the Emergency Department the previous day and there were still 119 patients there.

The Emergency Care section had 45 patients waiting for a hospital bed while the 12 operating theatres had 50 people waiting for surgery.

Staff were told: “We need a total of 58 beds before today’s patients arrive.”

Sio told the NZ Herald he believed the pressures on the Emergency Department were – in part – a reflection of the scarcity of money for doctor’s visits among families in South Auckland.

He said those in Middlemore Hospital’s area were “working class” people who had little to spare after rent, power and food.

“They won’t go to the doctors because there’s a charge so go to the A&E because it’s free. That hospital just isn’t coping.”

Sio said doctor’s fees of $20 or more was a “big chunk” out of a family’s budget. “And it’s not just the doctor’s fee, it’s the medicine.”

Sio’s own family experienced a lengthy delay at the Emergency Department in May when his father Aupito Pupu Lolesio, 79, waited 10 hours for an x-ray after suffering a cut to the face.

A spokeswoman for the health board said August had been “particularly busy” with illness among not only among the community but those working at the hospital, which had made staffing difficult.

“We encourage our staff to report their concerns so that we are able to respond where possible.

“Our staff have raised with us (through internal reporting and through their unions) concerns about staffing and capacity – particularly recently during winter.”

The spokeswoman said the health board’s planning for winter used data from the previous year to predict the numbers of patients. “This year an additional 40 beds were included for winter planning.”

The expected winter increase came early in mid-May meaning the extra beds were started early and kept available.

She said the “hospital full” memo was sent on “extremely busy days” when Middlemore Hospital started with “a full hospital, a full Emergency Department and patients already waiting for a bed before the next wave of patients arrive”.

It was sent out across the hospital “letting them know that everyone needs to help”.

Coleman said there had been a “sustained rise” in demand across the region which “isn’t unusual” for winter and the hospital could manage.

He said the current occupancy was 98.6 per cent and “there are pressures that hard-working staff are dealing with”.

Coleman said those with illnesses that could be managed by their family doctor should seek care there.

He said National had supported GP visits with free care for those aged under 13, a low-cost scheme and expansion of the Community Services Card capping doctor visits at $18 for 600,000 New Zealanders.

“These policies mean around half of all New Zealanders have either free or cheap doctor’s visits.”

The findings are the latest analysis from the RN4CAST study that connected nursing levels, the outcomes of more than 400,000 patients and survey data from 25,000 nurses working across 300 hospitals in nine European countries (including England, the Netherlands and Ireland). The latest research was lead by Dr Jane Ball of the University of Southampton and fellow authors included co-director of the RN4CAST study, Professor Linda Aiken of the University of Pennsylvania.

Ball said for years it was known there was a relationship between nurse staffing levels and hospital variation in mortality rates, but there had not been a good explanation as to how or why. However, links had now been found between lower RN staffing levels, missed patient cares and increased risks of patient death. Each 10 per cent increase in cares left undone was associated with a 16 per cent increase in the likelihood of a patient dying.

The study analysed nurses’ responses to the survey question: “On your most recent shift, which of the following activities were necessary but left undone because you lacked the time to complete them?” and presented nurses with a list of 13 activities (see list below).

The nurses surveyed were also asked how many staff were providing direct care on their last shift and how many patients were on the ward at the time.

Previous analysis of the survey showed that lower nurse staffing levels are associated with higher mortality, but Ball said the further analysis gave the “clearest indication yet that RN staffing levels were not just associated with patient mortality, but that the relationship may be causal”.

“If there are not enough registered nurses on hospital wards, necessary care is left undone and people’s lives are put at risk,” added Dr Ball.

Co-author Luk Bruyneel from KU Leuven in Belgium said the findings had implications for healthcare managers and policymakers. “Monitoring missed care may offer a more responsive and sensitive early-warning system for hospitals to detect problems before patients die,” he said. “More work needs to be done worldwide to ensure we utilise this data for the benefit of patients.”

The analysis also looked at nurses’ qualifications and confirmed that hospitals with higher numbers of registered nurses trained at degree level had a lower risk of patient mortality.

Professor Peter Griffiths, Chair of Health Services Research at the University of Southampton, said the study reinforced the importance of RNs who were trained to degree level. “It is more evidence that shows that you cannot substitute fully qualified RNs with less qualified staff without taking a risk with patient safety,” said Griffiths. “It is the number of RNs on duty that is key to ensuring complete care and minimising the risk of patients dying.”

Article reference:

Jane Ball, Luk Bruynell, Linda H. Aiken et al (2017). Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. International Journal of Nursing Studies (published online open access)

The patient cares asked about in the RN4CAST nursing survey were:

• adequate patient surveillance
• skin care
• oral hygiene
• pain management
• treatments and procedures
• administering medication on time
• frequently changing the patient’s position
• comforting/talking with patients
• educating patients and family
• preparing patients and families for discharge
• developing or updating nursing care plans/care pathways
• documenting nursing care
• planning care.

Clinical director Dr David Richards says the department normally has about 250 admissions a day at this time of year, but in the past three weeks it’s been more like 300.

He says the hospital has been at capacity, so on average they’re having to treat 10 or 12 patients in the ED corridors, which he says is “unacceptable”.

“It’s unpleasant for the patients and family members, it means staff have to navigate the trolleys, and it provides very little privacy,” he said.

]]> https://www.nursingreview.co.nz/overloaded-christchurch-hospital-treating-patients-in-ed-corridors-due-to-surge-in-numbers/feed/ 0 https://www.nursingreview.co.nz/hospital-visitors-professional-development-article/ https://www.nursingreview.co.nz/hospital-visitors-professional-development-article/#respond Wed, 01 Apr 2015 22:31:27 +0000 http://test.www.nursingreview.co.nz/?p=343 Reading this article and undertaking the learning activity is equivalent to 60 minutes of professional development.

This learning activity is relevant to the Nursing Council competencies: 1.2, 1.4, 1.5, 3.2, 4.2

Learning outcomes

Reading and reflecting on this article will enable you to:

• Consider the impact of institutional visiting hours on patients, their family or whānau
• Reflect on your personal and professional response to visitors in your work area
• Compare staff responses to visiting in your own work area
• Formulate strategies that will allow you to effectively manage and maintain the safety of patients and staff, while still maintaining a partnership approach that values the input of families and whānau.

Introduction

As I was pushing my niece in a wheelchair to see her new premature baby the day after her emergency caesarean section, the unit receptionist asked who I was. Her response to that information was to tell me I could visit this time (as I was pushing the wheelchair), but in future would have to wait for visiting hours. She then recited the visiting rules. What a welcome, and not what my niece needed at that time¹.

Visiting hours in New Zealand’s public hospitals have been a moveable feast over recent decades. While the rules around visiting may be becoming more accommodating, restrictions remain in many parts of the country with a significant variation in official visiting hours between DHBs.

Although restrictions in hospital visiting may follow historical precedents², it is often difficult to identify the rationale behind current restrictions. The most common explanation found on DHB websites was the need to allow patients to rest. Other reasons included:

• Increased staff workload, which is then disrupted by visitors
• Lack of space
• Patients requiring treatments
• Privacy issues associated with medical rounds
• Visitors being inconsiderate to other patients
• Concerns about theft and vandalism, especially after hours
• Cross-infection.

These reasons link to broader concerns about maintaining a safe environment for staff, patients and other visitors. In 2010, Waikato Hospital was reported as being about to trial new restricted visiting hours in response to what they referred to as “chaotic, overcrowded wards” in the hope of “regaining control” over patients’ recoveries³. In late 2014, an unnamed staff member at Whanganui Hospital claimed in the media that nurses feared for their safety at the hospital because of a lack of control over what were described as “volatile” visitors⁴. While these concerns are real for the staff concerned, are restrictions on visiting always the answer or are they sometimes the problem?

Applying the rules

Even within the one hospital there can be considerable variation in visiting hours between wards and units, as well as
differences between institutions in the same DHB. Regardless of what the official visiting hours may be, inconsistencies in adherence to those hours are common and problematic for everyone. At a ward/unit level, some staff may be prepared to put patients’ needs ahead of the policy, as the following anecdote demonstrates:

I was the identified support person for a close friend recovering from extensive abdominal surgery. My friend was deeply shocked by her diagnosis, as well as recovering from the surgery. She wanted somebody with her constantly to support her for the first few days post-op. The ward was closed to visitors for several hours each afternoon. Some nurses were quite comfortable with me reading quietly in her room, as long as I didn’t disturb her rest or that of any other patient. Other staff were sticklers for pushing everyone out the door and locking it fast¹.

Working out whether staff are ‘sticklers’ or not puts additional stress on patients and families who have to decipher the rules⁵. Having to plead for access out of hours can be demeaning for visitors, and patients may be left distressed:

I was scared that I was going to die because of my previous reaction to Fentanyl. My husband knew, my mother knew, but they weren’t there. That terrifying situation happened because the hospital’s rules wouldn’t allow my family to stay with me⁶.

Not only was this patient distressed, but it is likely that her family were also discomforted – wanting to be there, knowing they should be there and not being allowed. This raises the issue of whether ‘visitor’ is even the correct term for family members, whānau or significant others?

Visitor status

I’d been staying with Mum in hospital, showering her, taking her to the toilet, doing whatever she needed. The nurses watched her drip. We have a pākehā friend who is like family to us. Mum calls her ‘her other daughter’. I’d been there for three nights, and was exhausted, so my ‘sister’ took over being with Mum for the night shift. I told the nurse I was going home, and that my sister would be with her. I rang later to check how Mum was, and the nurse said, “Oh, you are supposed to be up here with your mother”. I asked if anyone was with Mum, and she replied, “There’s a blonde person sitting out there with her”. That doesn’t sound very nice, does it⁷?

In this situation, staff were comfortable with family members being present 24 hours a day, and undertaking much of their mother’s personal care. Unfortunately, assumptions were made based on cultural stereotypes about who could be a whānau member, and without understanding that a kaupapa whānau includes others not related by kinship.

Contemporary families are complex and diverse and it is always dangerous to make assumptions as to who is the most significant patient supporter, or to attempt to determine ethnic identity on the basis of physical characteristics.

One useful approach is to adopt personcentred visiting, where the patient and their family decide who are the significant people to be present when someone is in hospital.

Use of a ‘nominated contact person’ or ‘identified support person’ goes some way in enabling patients and family to identify significant supporters, but the missing component is free access to provide the necessary support.

Box 1: Family presence and participation

Restrictive visiting policies are often based on long-held beliefs that the presence and participation of families interferes with care, exhausts the patient, is a burden to families, or spreads infection. These are myths and misperceptions. There is no current evidence to support those beliefs⁵

Working in partnership?

As Taima Campbell, the then Director of Nursing and Midwifery for the Auckland DHB, noted in 2012: “On the one hand we talk about patient-centred care; for a lot of patients, part of their healing is having their family. On the other hand, we kick [families] out.⁸”

Restricting visiting not only limits family access to the patient, it also reduces the important opportunities for staff and families to interact. Restricting opportunities for families to communicate with staff conflicts with nurses’ professional and legal responsibilities to work in partnership with the patient and their family (refer to related competencies and standards sidebar).

The New Zealand Health Quality and Safety Commission9 recently published the results of its survey of 6,000 people who were inpatients in DHB hospitals in November 2014. Only 55 per cent of respondents reported that the hospital staff included their family or whānau or someone close to them in discussions about their care.

The people who are essential to the ongoing support, comfort, and wellbeing of the patient must be identified and included. As argued by Clisset et al¹⁰ in a study of the experiences of family carers of older people with mental health problems who were admitted to general hospital wards: “Health care professionals need to be more consistent in working in partnership with family carers, recognising them as a source of expertise in the specific needs of a person …” This theme of the need for nurses and families to work in partnership recurs in the literature supporting open visiting policies¹¹.

Cultural considerations

The need for families to be present when a family member is sick is an almost universal cultural value5. The configuration of our public hospitals poses some challenges in relation to person-centred visiting. Our older hospitals
have a predominance of shared rooms, where four-bedded cubicles are common, patient privacy is at a premium, and small, uninviting patient lounges provide limited opportunities for visiting family groups. These environmental factors create problems for nurses, and also for families:

My uncle was in hospital, and all the whānau came in to see him because that’s what he wanted and expected. He had many visitors, and there wasn’t enough space in his room so others were waiting quietly in the lounge. Just feeling those vibes from staff like ‘you shouldn’t be here, there are too many of you in there’. I was feeling a bit stressed out ‘cause they were all looking at us, but uncle didn’t want us to go. They had their rules, even down to the numbers of visitors he was allowed, but those rules were a problem for uncle, and therefore for us⁷.

In this example, space for a large whānau caused challenges, however so did the style of communication between nurses and the whānau. The whānau were the ones caughtbetween the rules, the patient’s need for family support, and the whānau obligations to care. The importance of the whānau to patient recovery is well recognised12. While some new hospitals now include visitor lounges/rooms to accommodate larger family groups, these are not available in all hospitals, however they should be prioritised.

Open all hours?

Research has identified the impact on patient outcomes when family members are present, including benefits such as a reduction in patient falls⁶. In one of the few randomised trials comparing restricted with unrestricted visiting in an intensive care unit¹³, researchers identified positive outcomes for patients when visiting was unrestricted including reduced anxiety scores, lower levels of stress hormones, reduced cardiovascular complications, and no increase in sepsis. The National Health Service Scotland has produced a short film celebrating the many positive effects resulting from their implementation of person-centred visiting¹⁴.

This includes family support when staff are busy, staff gaining an increased understanding of the patient’s background, and improved safety and effectiveness of care. They note that when visitors are not constrained to
specific short periods of visiting, they are much more likely to leave when the patient is tired, knowing they can come back again later. In many overseas countries, families are expected to be present 24 hours a day to provide all of the personal cares that a patient requires. In New Zealand’s professionalised health care system, the roles of families in providing care have changed, but staff then frequently report they are unable to provide such care because they are too busy¹⁵. There are opportunities for enhancing nursing roles when families who are able are supported to take responsibility for activities such as ensuring the patient is assisted at meal times. However, ongoing communication between the staff, patients and family members about caregiving roles is crucial for safe care¹⁶. In organisations where open visiting is supported, additional responsibilities have been identified for nurses, including transitioning from patientcentred to family-centred care and caring for family members¹⁶. With person-centred visiting, there are few, if any, restrictions on the hours during which visitors may be present. However there are guidelines to maintain a safe environment and a core component is the need for communication between all parties.

Ensuring the safety of visitors during emergency situations must also be considered. The evidence from institutions that have moved to this system is that it has been positive for patients, families and staff^14,17,18,19 although a formal change management process is essential for success.

Clear guidelines are necessary to ensure patient, visitor and staff safety. These may include:

• Patients and families nominating who is to have unlimited access
• Guidance about supporting patient recovery through rest periods
• Acceptance by families that staff may require them to leave temporarily when treatments are being undertaken
• Emergency management plans also include strategies to support family/visitors present at the time of an emergency
• Appropriate security arrangements, especially after hours, when there are fewer staff present
• Adequate space for visitors to avoid disturbing other patients
• Consistent communication with patients and families via information from staff, appropriate signage, and information booklets.

Conclusion

Restricting visiting hours limits the opportunity for working in partnership with patients and their family or whānau. Reconsideration of what constitutes visiting, and who visitors are, is long overdue. One perspective worthy of further consideration is the notion that it is hospital staff who are visitors in the patients’ lives, rather than their families being visitors in the life of the hospital6. Changes in attitudes, policy and practice, and most importantly, communication, are required to ensure that the visiting experience is a positive one for the patient, their family/whānau and all members of the health care team.

View PDF of this article (and related learning activity) here >>

About the authors: 

• Lesley Batten, RN PhD and Marian Bland, RN PhD are both experienced nurses and researchers, and regular hospital visitors supporting hospitalised family and friends.
• Lesley works in the Research Centre for Māori Health & Development, Massey University, Palmerston North. Marian is Quality Coordinator, Ranfurly Residential Care Centre, Feilding, and a health care auditor.

This article was peer reviewed by:

• Denise Wilson RN BA MA (hons) PhD (Nursing) is Professor of Māori Health and director of the Taupua Waiora Centre for Māori Health Research at Auckland University of Technology.
• Sue Wood RN MNS is the former director of nursing for MidCentral District Health Board and currently Quality & Patient Safety Director for Canterbury District Health Board.

Recommended resources

• The American Joint Commission on Healthcare website has resources on effective communication and cultural competence related to family-centred care: www.jointcommission.org/Advancing_Effective_Communication 
• Better Together: Partnering with Families is an initiative of the American Institute for Patient and Family-Centred Care: http://www.ipfcc.org/bestpractices/better-together.html
• White Coat, Black Arts is a Canadian radio programme discussing various aspects of visiting hours, the restrictions imposed when patients are in shared rooms, and the consequences for the family of a terminally ill patient: www.cbc.ca/radio/whitecoat/the-end-of-visiting-hours-1.2801166 
• Health Safety and Quality Commission New Zealand outlines a number of strategies for getting feedback from health consumers about services: https://www.hqsc.govt.nz/our-programmes/partners-in-care/publications-and-resources/publication/784/

Health and Disability Sector (Core) Standards 200821

Standard 1.12 Consumers are able to maintain links with their family/whānau and their community.

Criteria 1.12.1 Consumers have access to visitors of their choice.

Guidance: Consumers have access to visitors of their choice (including children) when the safety of the consumer and others is not compromised. The safety of consumers in the presence of visitors needs to be assured. This may include, but is not limited to:

1. Clinical stability of consumer
2. Legal status of consumer
3. Safety in relation to room size and/or other consumers in a shared room
4. Appropriate behaviour of visitors – such as behaviours that impinge on the safety of the consumer, other consumers,and/or service providers

REFERENCES

1. Personal anecdotes freely shared with the authors about visiting in New Zealand hospitals when people heard they were developing this article.
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Suddenly, a head pokes around the door. “Look Doctor Bob, it’s our friend Anna*.” A second head looks in at the puzzled pair sitting on the hospital bed.

You could forgive their quizzical expressions as the duo in the doorway are wearing white lab coats but have bright red noses. Dr Bob Brrooom! and Dr Bluebottle, are clown doctors.

Clown Doctors New Zealand is a charity active in Christchurch, Wellington, and Auckland. The aim is to spread joy and laughter to children in need, and it clearly works in this case. Within minutes of Dr Bluebottle playing ‘The Wheels on the Bus’ on her ukulele, Anna is laughing and singing along while her mother smiles and visibly relaxes.

The Clown Doctors New Zealand Charitable Trust was co-founded in 2009 by chief executive and creative director Thomas Petschner, a health scientist with a particular interest in humour in medicine, and programme director Rita Noetzel.

Nurses who’ve interacted with clown doctors will know they are not medical doctors or anything like circus clowns with their large wigs, outlandish costumes, and garish make-up. The only reference to Drs Bob and Bluebottle being clowns are their red noses. Under his lab coat, Dr Bob has a green Hawaiian shirt, brown shorts, and knee-high purple socks, while Dr Bluebottle wears a flowery dress with a blue hem and matching hat. They look a little strange compared to the regular staff, but there’s nothing over-the-top that might frighten anyone.

Clown doctors are also not just for patients as hospital staff can have fun with them, too. It’s something Lisa Wingfield, aka Clown Dr Bluebottle, enjoys.

“We were with one of the nurses when she was doing some blood pressure tests with a child, and the kid was laughing away. She said ‘Oh this is marvellous, their blood pressure has gone right down.’ So there’s an absolute direct response,” says Wingfield.

“If they had a little stress-reducing thing on the wall, that would be even better because we would see that dropping too.”

Clown doctors have also been incorporated into patient rehabilitation therapy.

“There was a child who broke both legs in a car accident, so he had to learn to walk again. But because of the pain he didn’t want to,” says Petschner. “He wasn’t responding to therapy, and the physiotherapists and nurses were desperate because they wanted the kid to walk.

“So two clown doctors started a race with him through a corridor. The kid was in the middle and the clowns started moon-walking. They were going backwards for every half-step the child took. He was so motivated, he actually walked the whole length of the 30-metre corridor.”

Clown doctors are increasingly becoming a normal part of hospital routine.

“We can use them as a distraction for people who are going to have a painful or a scary procedure,” says Noetzel.

“We’ve seen it time-and-time again. The hospital staff knows the clown doctors will be on the ward and they wait until the clown doctors are there so there’ll be a distraction. It won’t be as traumatic for the child, it won’t be as traumatic for the family; everyone will just be happier.”

A child health psychologist at Christchurch Hospital, Tony White, agrees.

“While they are being silly, they are always highly respectful of patients and staff. They religiously keep detailed records of all interactions with patients and they are very responsive to feedback from medical staff. They also give the medical professionals a ‘permit’ to laugh again in those humourless hospital environments, so we would always like to keep them clowning around,” says White.

Lynda Driscoll, the ward clerk for Christchurch Hospital’s Children’s Acute Assessment Unit, believes clown doctors connecting with staff is almost as important as their connections with patients.

“It is always a pleasure to see the clown doctors. They bring a sense of fun that gives a lift to the whole atmosphere on the ward. I think they make a very valuable contribution to the well-being of children in hospital.”

April 7 was New Zealand Smile Day, the annual awareness day for Clown Doctors – an opportunity for us each year to share joy and laughter with children who don’t usually receive a visit from us.

A great way for nurses around the country to join in the celebrations next year is to incorporate a little humour into their daily routine.

The first step, Petschner says, is not taking yourself too seriously and finding the humour in everyday situations.

“Place a (clean) pencil horizontally between your teeth. This puts the mouth in the smile position,” he says.

“Then with the pencil there, first try to tell yourself in the mirror, and afterwards your colleagues, about last night’s dinner or what you did in the weekend. You will feel better right away because your mouth is smiling, which has the same biological effect as a genuine smile.”

“It may sound unrealistic but even just thinking about laughing, even when you don’t feel like it, can have a positive effect on your mood,” says Petschner.

“Try to consciously laugh for one minute. It may seem a little strange but you will soon start to laugh naturally. While laughing you are stimulating the nerves in your face, the brain registers ‘something is funny’ and everything else follows.”

It’s easy to share a smile and incorporate humour everyday, especially on Smile Day.

*Name changed.

For more about New Zealand Smile Day and Clown Doctors, visit www.clowndoctors.org.nz

Further investigation was carried out to identify the key problems. This revealed delay in patient discharge occurred for a number of reasons including, waiting for reviews, blood or other test results, equipment, or transport – most of which could be organised in advance. Charge nurse Charlotte Porter and a multi-disciplinary project team identified that lack of communication or miscommunication was a key cause of the delays.

To tackle this, a simple solution called ‘daily rapid rounds’ (DRR) was piloted in December 2009 in the general medicine ward and then rolled out across all medicine in 2010.

The rapid round is a short daily stand-up meeting chaired by the charge nurse where all team members (medical staff, nurses, and allied health) review their patients working diagnosis, plan for their day and the patient’s stay, and work towards a shared estimated discharge date. All the information discussed at the meeting is captured on a visible patient status board situated where everyone can see it throughout the day.

Since DRR was introduced in general medicine, the average length of stay for patients has reduced by almost half a day and released an additional 2000 bed days in the first year. An added bonus has been that staff taking part in rapid rounds unanimously agreed they have improved teamwork and communication.

The implementation of DRR has been so effective that it has been successfully replicated in the Orthopaedic department and rolled out to several other parts of the organisation. It has even been shared with other DHBs.

Nurse Facilitated Discharge

Patients who were well enough for discharge were sometimes spending hours or days longer than they needed to in hospital waiting for the next doctor’s ward round.

At the same time, patients in the emergency department were waiting for a bed to become available so they could be admitted to a ward. This led to frustrations for both patients and staff.

Charge nurses and clinical nurse advisors have the ability to discharge patients if medical teams set the criteria. However, very few or no patients were being discharged using this approach.

A nurse-led project was put in place, initially to increase the percentage of weekend discharges by using nurse facilitated discharge (NFD), but it became apparent that NFD could also be a solution in allowing patients to be discharged earlier in the day during the week.

Engaging with the necessary teams of people and listening to patients was a key part of the process. Doctors needed to be confident and supportive of the process as their approval was critical to the success. Patients who were ready to be discharged were identified as part of the daily rapid rounds. Short term wins were shared with the team creating some healthy competition

Since implementation, NFD has contributed to a sustained reduction in length of stay. It has also created greater capacity on the wards and improved patient safety and care. NFD was first trialled in general medicine, where an average 282 hours of patient time has been saved per month! To date, the project has saved 306 bed days which equates to a financial saving of around $153,000.

So successful has it been that nurse facilitated discharge has been adapted for other wards and there has been tremendous interest from other DHBs.

Articles contributed by Auckland DHB special projects communications