The link between unhappy patient and too few nurses per patient in England’s National Health Service (NHS) hospitals was found in a major quantitative study led by researcher Linda Aiken.
The study, published in the British Medical Journal earlier this year, is the first to bring together data on patient to RN staffing ratios, missed nursing care and patient satisfaction with NHS hospital care in England. Researchers say their findings refutes claims that quality of care deficits in NHS hospitals were due to uncaring nurses.
The study, led by Aiken, the professor of nursing at the University of Pennsylvania, said, highly publicised reports citing preventable deaths and deficiencies in hospital care in England, like in Mid-Staffordshire, had uniformly concluded that inadequate hospital professional nurse (RN) staffing was a contributing factor.
But she said that despite that leading to national guidance on safe staffing there was still substantial variation in staffing levels across NHS hospitals and the value of more RNs per patient was still questioned at the policy level.
Data gathered during the RN4CAST study found that nurse workloads averaged 8.6 patients per RN during the day, and ranged from 5.6 patients per RN to 11.5 patients per RN across the 46 hospitals involved in the English arm of the international research study.
“National survey data from patients experiencing a hospitalisation in an NHS hospital in England confirm that patients have a high level of trust and confidence in RNs.” The study said this evidence refuted the media reports blaming quality of care deficits in NHS hospitals on uncaring nurses.
“However, only 60% of patients indicated that there were always enough RNs to care for them, and 1 in 10 patients indicated that there were never rarely enough RNs. The importance to patients of adequate RN staffing is evident in their responses; 57% of patients who indicated that there were always or nearly always enough RNs to care for them rated care as excellent, compared with only 14% of the patients who said there were rarely or never enough.”
The researchers said additional analyses undertaken indicated that patients in hospitals with poorer RN staffing were much less likely to say there were always enough nurses to care for them.
“We estimate, from models that took account of numerous confounds, that the likelihood of patients saying there were always enough nurses to take care of them were about 40% lower in hospitals in which the average nurse took care of 10 patients than in hospitals in which the average nurse took care of 6 patients. These findings reinforce from patients’ perspectives the importance of adequate hospital RN staffing.”
The researchers concluded that the evidence showed that English patients expressed a high level of confidence and trust in nurses; and their satisfaction with hospital care was less favourable when they perceived there weren’t enough nurses available.
“The narrative that quality deficits in hospitals in England are due to ‘uncaring’ nurses is not supported by the evidence. On the contrary, our findings suggest that reducing missed nursing care by ensuring adequate numbers of RNs at the hospital bedside and improved hospital clinical care environments are promising strategies for enhancing patient satisfaction with care.”
The full study can be viewed at: http://bmjopen.bmj.com/content/bmjopen/8/1/e019189.full.pdf
]]>The study by Otago, Auckland and Victoria university physician, nurse and health researchers, just published in the international journal Annals of Family Medicine, follows the interactions that 32 patients had with their GPs, nurses and other health professionals in the first six months after being diagnosed with type 2 diabetes.
Professor Tony Dowell of University of Otago, Wellington, and the lead author, said the study found that despite many health professionals having high communication and technical skill levels, there were still many opportunities to communicate and consult more effectively with their patients.
The researchers videoed the first post-diagnosis consultation and all the patients’ subsequent consultations with health professionals over the six months, which ranged from just one consultation to up to 12 consultations. The time spent with all health professionals over that six months ranged from just 27 minutes for one patient to seven hours and 12 minutes for another patient* (see details below).
The average GP consultation was 22 minutes (range = 6 minutes to 56 minutes), the average nurse consultation was 41 minutes (range = 8 minutes to 95 minutes) and the average dietitian consultation was 24 minutes (range = 17 to 52 minutes).
Dowell said that strengths found by the researchers included high levels of communication skills, enthusiasm to co-ordinate services, and good allocation of time to patients.
But researchers believed optimal care for newly diagnosed patients could be improved in a number of ways, including questioning and listening to patients more in initial consultations to gain insight into what they already knew about diabetes and their personal circumstances.
Researchers found that often initial consultations were driven by biomedical explanations that patients did not relate to. Clinicians also often assumed patients knew little about diabetes, when many already had some diabetes knowledge from other family members or had had pre-diabetes symptoms.
“Patients who have just been diagnosed with diabetes or other long-term conditions bring their own expertise and experience to the situation and healthcare professionals need to listen to this. We need to rethink our usage of technical biomedical language when talking to these patients,” said Professor Dowell.
“Despite the high levels of generic communication expertise by clinicians, many patients found the style and content of health promotion and lifestyle advice did not apply to their lives.”
The researchers found patients were also concerned about the overuse of checklists, and suggested a need for more effective methods of sharing patient information.
The time spent with patients over the first six months was also found to vary considerably – which researchers said was partly due to patients’ varying complexities of needs, but they also found much of the time variation was due to repeating educational information because of a lack of co-ordination between GPs, nurses and other health professionals. The researchers said this meant time that could have been spent on motivation interviewing was often undermined by a duplication of information and advice.
“These findings suggest that time spent in consultations should be reviewed for appropriateness, and health professionals should agree on who will cover various aspects of education so that repetition is avoided unless intended,” found the study.
Dowell said that although there had been a huge amount of research into diabetes, this was the first study to directly observe the patient journey and interactions with different health professionals from the onset of diabetes.
“Our results highlight the important role that communication plays in diabetes management, and the overall commitment of primary care teams to delivering patient care.”
The study authors recommend that clinicians employ a framework for communications with diabetes patients that acknowledges the importance of the patient’s own particular situation and social needs and that time could be allocated more effectively and efficiently when patients see multiple clinicians.
“Our main aim is to improve our patients’ health, and this research shows that appropriate communication with patients is a key component,” said Dowell.
“The research makes us appreciate the importance of listening more and possibly talking less in consultations. It helps with understanding and improving healthcare one sentence at a time.”
*The patient with seven hours and 12 minutes of consultation time had their first post-diagnosis consultation with a nurse and in total had three Care Plus GP/nurse consultations, two nurse consultations, one GP consultation, two podiatrist consultations and two dietitian consultations.
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But workplace and incivility is less common in hospitals where line managers show ‘authentic leadership’ behaviours, reported researcher Professor Stephen Teo at this month’s Australian and New Zealand Academy of Management Conference.
He reported that 59 per cent of the 230 nurses surveyed recounted witnessing bullying in their workplace, while 48 per cent reported being a target. Of the bullying targets, 39 per cent experienced bullying now and then, while 12 per cent went through the ordeal several times a week.
Teo, of Cowan University’s Centre for Work and Organisational Performance, said the high level of bullying partly reflected the healthcare sector where people were often promoted primarily based on their clinical skills and the soft skills, such as managing people and relationships, were considered secondary.
“The pressure of the medical field can expose weaknesses, so a manager may react abruptly and be snappy, and if that isn’t addressed, it can become normal,” said Teo. “This has a trickle-down effect on how those around them act.”
His research considered the impact of civility – which included not just traditional workplace bullying but also behaviours like rudeness, creating feelings of exclusion, unfair work distribution and negative body language or tone.
He said nurses that witnessed or experienced incivility were 52 per cent more likely to report psychological stress, which had been linked to increased health problems, turnover and decreased efficiency.
But in workplaces were line managers, like charge nurse mangers, demonstrated ‘authentic leadership’ characteristics like honesty than nurses’ perception of incivility was 37.5 per cent lower, which in turn reduced stress.
“Authentic leaders model positive social behaviours while being self-aware and open and honest,” Teo said. “They embody the organisation’s professed values, even if they aren’t perfect.”
His research also found that nurses who felt they and their organisation had shared values, experienced lower levels of workplace incivility and psychological stress.
“Overall, our research suggests healthcare organisations need to put more emphasis on training to provide line managers with skills and tools to navigate the human side of work,” Teo said.
BULLYING RESOURCES
Victoria University researcher Dr Helen Rook’s recently completed PhD research found Kiwi nurses felt conflicted and anxious at being unable to deliver care true to their nursing values because of pressures on the ward to discharge patients quickly, keep-up the paper work and keep costs down.
She said the nurses’ response– sometimes conscious and sometimes not – was to focus on essential duties like documentation and nursing tasks as a coping strategy. Sometimes this also lead to nurses cutting short patient conversations, ignoring call bells and in other ways withdrawing from their patients to protect themselves emotionally.
Rook’s PhD research – prompted in the wake of the inquiry into patient neglect in Mid-Staffordshire – involved spending 300 hours observing nurses on medical wards in three district health boards, multiple interviews, checking nurse sensitive indicator statistics (like falls and pressure injuries), and measuring burnout levels. She concluded that the conflict that the nurses felt – between their personal and professional values and how they actually were able to practice nursing because of the constraints of modern healthcare – caused anxiety, exhaustion, cynicism and burnout.
Building and supporting nursing leadership at the ward level upwards was one recommendation by Rook to help nurses speak up and act on their concerns. Another was for district health board and other healthcare providers to put in place strategies to help mitigate the organisational dysfunction and financial constraints that lead to nurses feeling unable to consistently deliver compassionate, clinically competent care.
Withdrawing from patients a coping strategy for conflicted nurses
“In all of the wards the nurses said they were practising team nursing and yet there was very little evidence of that,” said Rook. Instead they were observed to be mostly focussed on tasks and “getting things done”. “They are very skilful at that,’ said Rook. “In order to protect themselves they use defensive strategies to protect themselves from anxiety.”
She said the conflicted nurses also used the coping strategy of withdrawing a little bit from the patients they were caring for. So they tried not get caught in conversations with patients by using strategies like giving a quick smile. “Or say ‘I’ll be with you in a minute’ and then pull themselves away as they know they have all this other stuff they need to get done.”
Rook said she also observed more overt withdrawal by busy nurses. “I watched nurses walking past patients who were calling out for help, and call bells that were unanswered, not because nurses were uncaring but because they had so many other things to do, to comply with.”
When she spoke to nurses about the organisational values at their DHBs – and the DHB’s strategies for improving patients care – she said a number expressed cynicism that while DHBs talked about focusing on partnership and respect most improvement projects were actually about discharging patients quicker, balancing the budget and ensuring the required documentation was done. She said there was also a sense that the DHB’s emphasis on economics and managerialism was becoming more prevalent not less.
But she added that for her Phd she drew on the iconic nursing research carried out in a London hospital in the late 1950s by Isabel Menzies, who wrote about how nurses de-personalised patients to protect themselves from the anxiety of their work.
“That’s a long time ago – we’re 2017 now – but a lot of things that she found in that research I also found in my research. Not a lot has changed in healthcare in the intervening years really…”
Be consciously present not emotionally numb
“Nurses go into the profession with an assumption that they will be caring for people who are sick, taking a moment to talk with them and build caring relationships,” said Rook.
But said the current culture didn’t allow for that and DHB’s managerial imperatives to get patients out of hospital quickly, combined with financial constraints, meant that it just wasn’t possible. So nurses often responded by focussing on doing the essential nursing tasks.
“I think there is a bit of guilt in that we focus on tasks,” said Rook. “I don’t think it’s such a bad thing if we do. Because that is what the public expect – they expect us to be able to do things for them.”
Rook said if the reality was that nurses’ coping strategy for pressured workloads was to focus on tasks, then nurses should take ownership of this new reality. They needed to be vocal about the type of nursing care they were able to deliver, and why, and then deliver the task excellently.
“We need to be very clear that ‘okay we are going to focus on a task but we are going to be excellent in that task and in our interactions with people….even if is only a minute or two.”
She said nurses need to aim to be fully present with their patient even if “just doing a task” as that would be much more beneficial therapeutically.
“We need to be consciously present rather than emotionally numb in our patient interactions.”
But in the long-term she said it was imperative that nurses on the frontline were supported to build leadership skills and find their voice so the culture was changed and they could provide the nursing care that matched their personal and professional values. Also organisations had to introduce strategies that removed the constraints currently preventing nurses from delivering that care.
Rook, who is currently the Programme Director at the Graduate School of Nursing, Midwifery and Health at Victoria University of Wellington, graduates next week with her PhD in nursing.
She has a background in critical care nursing in the United Kingdom, Ireland and New Zealand, and has worked as a nursing academic in New Zealand and Ireland delivering undergraduate and post-graduate education.
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The study, carried out by Victoria University of Wellington nurse researchers, involved analysing 54 reflective essays written by 27 graduate nurses during their nursing entry to practice (NETP) programme.
The research team, led by Professor Jo Ann Walton, said the analysis shed light on the experiences of new graduates and showed that the reflective essay was a “powerful tool” for helping both new graduates (and their lecturers) to learn from clinical practice.
The analysis also backed other researchers who found that new graduates find it “challenging to deal with their own emotional reactions, to stand up for themselves and their patients,to feel part of the team, and to ask for help (which they fear may signal failure)”.
“We suggest that there is scope for more focus on emotional labour, resilience, and professional composure in programmes leading to nursing qualifications,” said the researchers. “Arming new graduates with these skills would ease their transition into a workplace where emotional work is core.”
The researchers identified five key themes (see below) and shared examples illustrating these themes from some of the graduates’ reflective essays.
For example Clare identified a situational challenge that required her to regain her composure and draw on both personal and professional attributes:
It was a typical busy afternoon. I went in to the patient’s bedroom to take
a set of observations. I noticed his breathing appeared laboured and a slight
decrease in consciousness. I had a bad ‘gut feeling’ about the situation. I
called over a nursing colleague and the nurse in charge to assist with my
assessment.
At the time I was feeling anxious, I was not sure how I was going to
objectively describe the slight change nor did I know how to explain my ‘gut
feeling’ to the nurse in charge. I was feeling worried because if I did not act
quickly he may rapidly deteriorate. I knew at that point I was stressed. I
remember my face feeling hot, palms sweaty, thoughts becoming disorganised
and feeling like I just wanted to cry. I knew I needed a minute to
compose myself and so I stepped out of the room while the nurse in charge
waited for me to handover my assessment. I took two deep breaths and wiped
away the tears. I walked back into the room with a smile on my face and
spoke to my nursing colleague, nurse in charge and patient in a concise, kind
and succinct manner.
In another example Lucy reflected on the situational challenge of dealing with a very distressed client with an intellectual disability and her own inexperience in dealing with the distressing verbal assault:
This experience was so emotionally challenging that it shook and tested
my whole philosophy as a genuinely kind and caring nurse. The insults were
extremely derogatory and against my cultural values. I resented the patient
and knew I definitely had disengaged with the patient. I was feeling and
thinking like a victim and not the nurse that I knew I was.
Through my training I learnt that a good nurse needs to know when to
ask for help. I had to ask for assistance from my mentor who advised administering
a depot [intramuscular injection] to settle the patient for safety
reasons. After the incident I had a good talk with my preceptor which made
me feel better. My colleagues said I had looked defeated, so maybe the client
had noticed as well and responded negatively. It also helped when my colleagues
gave me their maximum support by validating my feelings, sharing
similar experiences and checking on me regularly to give me breaks. I wish I
had talked to them sooner.
In a third example a pressured new graduate Paula gets spoken to abruptly by charge nurse manager (CNM) after Paula intervened to stop a patient being discharged:
I felt uncomfortable and embarrassed, as she had belittled me, my nursing
practice and rationale in front of the wider multi-disciplinary team
(MDT) who are my professional colleagues. The CNM made me feel as
though I was doing an inadequate job, when in fact I knew I was delivering
safe, kind and patient centred care.
When discussing the situation privately with a fellow nursing colleague, I
learnt that this outburst was not personal towards me or my nursing practice.
I was able to better understand the ward culture and I felt more positive that
my nursing practice was not inadequate. In hindsight, I realise I could have
requested the RMO (doctor) to review the patient’s pain and whether they
were (ready) for discharge earlier. I had not done this due to the pressure he was also
put under to complete discharge paperwork. I also should have discussed the
concerns I had with the shift coordinator. This could have prevented the
situation from arising, as the coordinator and CNM communicate (about) where
patients are regarding their discharge.
The researchers concluded that their analysis showed the reflective process worked and could be used as a “means of unearthing students’ concerns” and helping them understand what they had done well, could have done differently, why something arose and how to handle challenging events.
“It can be used as a means to bolster their confidence, and to discriminate between personal success (or failure) and systemic strengths and weaknesses,” said the team. “It also provides teachers with rich data on which to build discussions, support students and aid them in their transition to fully fledged professionals.”
FIVE KEY THEMES
Source: Jo Ann Walton, Natalie Lindsay, Caz Hales & Helen rook. Glimpses into the transition world: New graduate nurses’ written reflections. Nurse Education Today. (published online prior to print publication in 2018)
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Results of the randomised controlled trial, lead by nurse and University of Auckland Associate Professor Andrew Jull, have just been published in the British Medical Journal.
Nursing Review last year reported on the research project – one of New Zealand’s first ever nurse-led the randomised controlled trials (RCTs) – and Jull’s hope that low-dose aspirin might help prove a new treatment to aid the slow-healing wounds.
But the Aspirin4VLU trial – funded by the New Zealand Health Research Council and conducted by Jull and other researchers at Auckland’s National Institute for Health Innovation – found 150 mg aspirin a day, in addition to the proven treatment of compression bandaging, did not increase venous ulcer healing.
Seven out of every 10 people with leg ulcers who took aspirin healed within six months compared with eight out of every 10 people in the placebo group.
Jull said while he had hoped aspirin might help with healing, it was still good news. “It means people who have a venous leg ulcer and who have to take aspirin for other reasons still heal at a pretty good rate if they use compression.”
The trial had kicked off in March 2015 in district nursing services in five centres around the country: Auckland, South Auckland, Waikato, Christchurch and Dunedin. Each centre had a senior site investigator – a senior nurse who was a wound care specialist – and a part-time research nurse seconded from the district nursing team. Just over 250 participants were recruited to the trial.
Jull said the researchers would shortly be getting in touch with the participants to let them and their doctors know which drug they were taking. “We remain very grateful to those people who came forward to be part of the study – without them we would not have the evidence to help others.”
About 1 percent of the adult population will develop a venous leg ulcer during any one year. Compression therapy, either in the form of bandage systems or hosiery, is the main treatment. But in trials of venous leg ulcers about half the participants remain unhealed after three months of treatment.
Jull told Nursing Review last year that the research was prompted by the belief that aspirin might aid venous leg ulcer (VLU) healing because firstly VLUs result from chronic venous insufficiency (CVI), which is associated with platelet aggregation, and aspirin is known to inhibit platelet aggregation. Secondly, aspirin might also have an effect on the underlying inflammatory pathway associated with ulcers.
Aspirin4VLU is the world’s largest aspirin trial yet conducted for patients with venous ulcers and the only trial of low dose aspirin.
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The three-term Hawke’s Bay DHB member and Hastings Health Centre primary care liaison and long-term conditions nurse specialist received her PhD from Massey University’s School of Nursing. Her studies included following 16 people with significant long-term conditions over about 18 months, alongside their primary care clinicians.
She was driven to embark on the study after identifying gaps in the self-management approach to healthcare, which was geared to meet the needs of people with only one serious illness, the money or the connections to fully take advantage of that care.
“The families I talked to had all sorts of awful things going on in their lives – poverty and other disadvantages – and their health never really gets to the top of their pile of priorities, and the care we offer does not meet their needs as well as it could.
“One woman in my study was really, really sick, but she was also a caregiver for her brother, who was far more ill than she was. She couldn’t look after her health because her priority was looking after her brother.”
She said another woman had had heart attacks, asthma, diabetes, arthritis, and more. Her daughter had serious mental health issues, so she also took on six grandchildren aged from 4 to 16.
“As health professionals we say to you go for a walk or stop smoking – you may or may not do that, there’s not much stopping you.
“But for other people who may be looking after their grandchildren, have no money, are unemployed, or who are really sick and caring for other people it’s really hard for these people to pay attention to their own health.”
She said the doctors and nurses she spoke to found this frustrating because often they would be caring for other members of the patient’s families.
They had a good idea of what would work, but working within a system where forms had to be filled in and boxes ticked they felt they were not meeting their needs as well as they could be.
“We need to look at other ways of doing things,” Dr Francis said.
Having now completed her studies, she was also preparing to step down after 10 years at Hastings Health Centre, where she was working as a contractor until Christmas.
She said the plan was to create some space to see if she could do something with the findings of her study.
“It’s a bit difficult in Hawke’s Bay being quite far away from the main centres but I will look at what opportunities there are and how I can use my studies to help people regionally and nationally.
“I really hope my research might go some way to making people think differently about how we approach this sector of the community.”
]]>The Ministry of Health today released the key indicators from the 2016/2016 survey which showed that 99,000 or 12.3 per cent of children aged 2 to 14 are obese up from 10.7 per cent in the 2015/16 survey and 8.4 per cent a decade ago.
The biggest increase though was in the number of obese pre-schoolers (aged 2-4) which jumped three per cent to 10.5 per cent.
This result reversed a trend of childhood obesity rates starting to stabilise in previous annual surveys, in particular pre-schooler obesity rates had fallen in the 2015/16 survey to 7.3 per cent which had been the lowest rate since the surveys began ten years ago. (A child is classified as obese if they have a BMI equivalent to an adult BMI of 30 or more.) The one positive childhood obesity trend was a stabilising of Pacific childhood obesity rates – while they remained at a high 29.1 per cent this was down on the 29.8 recorded last year.
The statistics are based on face-to-face interviews with adults that were conducted between July 2016 and June 2017. Over 13,000 adults, and the parents or primary caregivers of over 4,000 children took part in the survey which includes weighing and measuring the adults and children to calculate their body mass index (BMI).
Adult obesity results from the 2016-17 survey also showed an increase with 32.2 per cent of adults obese – up on 26.5 per cent in 2006/2007 and slightly up on the 31.6 per cent rate in 2015/16.
The survey showed that while obesity rates continue to rise parents appear not to be concerned about the impact on their children’s health with 98.1 per cent of parents rating their child’s health as good to excellent. Likewise 88.2 per cent of adults rate their own health as good.
The full statistics can be viewed here.
]]>An initial trial of the drug, ZGN-1061, had promising results in relation to both weight loss and glucose control in overweight or obese patients with type 2 diabetes who did not use insulin.
Dr Richard Carroll, an endocrinologist in Wellington who is helping run the study in the area, said the phase one trials saw patients lose between 10 and 12 per cent of their body weight over a matter of weeks and hoped phase two would be just as positive.
“We’re talking about 5 per cent weight loss being beneficial [for diabetes patients]. It’s a degree of weight loss that we haven’t yet seen in one medicine alone. It’s promising data,” he said.
About 250,000 New Zealanders had diabetes, he said, most with type 2, and many more had not been diagnosed or had pre-diabetes.
Today is World Diabetes Day and around the world more than 422 million people live with diabetes. In 2015 an estimated 1.6 million deaths were directly caused by diabetes with more attributed to high blood glucose.
With such a high prevalence of diabetes, and the latest figures suggesting almost a third of New Zealanders were obese with a further 35 per cent overweight, more treatment options were needed, Carroll said.
New Zealand’s “treatment armoury” was limited compared to much of the rest of the world and many drugs which helped people with diabetes actually resulted in weight gain, he said.
One of the cornerstones of diabetes management was a lifestyle change, which included weight loss, Carroll said, but losing weight and keeping it off was incredibly hard for many people.
“We’d like to see that focus in early diabetes with weight loss through lifestyle changes and complementing that with medicine,” he said.
Weight loss and glucose levels were areas medicine could not control, he said, but the new drug being trialled could change that.
The hope was that by improving people’s glucose control there would be fewer people reliant on insulin, he said.
Graham Manning, 41, was diagnosed with type 2 diabetes almost 10 years ago and did not hesitate to sign up for the trial.
“You never know,” he said. “I might get on to one that’s a winner, then I’m cured.”
The disease was not debilitating for him, Manning said, but did leave him with pain in his feet and feeling tired.
“If it’s successful and you get other people into it, then that’s why [I do it].”
The Auckland man had tried to lose weight without success before and hoped the drug would help get him on the right track.
“As you lose weight you start to feel better and that might just give me the kick I need,” he said. “With traditional methods it just takes so much time before you see the benefits.”
He also hoped it would help him keep control of the disease and prevent him from getting to the point where he was reliant on insulin.
About the study
• 140 participants needed across Australia and New Zealand.
• Eleven clinics in Christchurch, Wellington, Auckland, Hamilton, Hawkes Bay and the Bay of Plenty taking part with another 12 clinics in Australia.
• Four week screening period for potential participants and 12 weeks of treatment.
• Participants must have type 2 diabetes and not be using insulin.
• Participants must be between 18 and 65, have a BMI of 27 or over and have HbA1c levels of between 53 and 97mmol/mol.
• Go to www.diabetes2clinicaltrial.com to find the nearest clinic offering the trial and see if you are eligible.
Natalia D’Souza, a Massey PhD student, held in-depth interviews with eight nurses who reported experiencing cyberbullying – harassment or other unwanted bullying behaviour via electronic means from texts to social media posts – from both within and outside their workplace. As a result, she has made a number of recommendations for nurse employers, including incorporating cyber ill-treatment and bullying into existing bullying guidelines, and having clear mechanisms for reporting and investigating digital evidence of bullying.
D’Souza said while five of the eight nurses she spoke to experienced cyberbullying from within their organisation – from colleagues or workplace superiors – three reported cases of bullying were from outside the organisation, including in two cases the parents of patients and, in the third case, the defamatory bullying of a nurse academic.
She said the research showed that, particularly in small communities, public incidents of cyberbullying – via social media or public blogs – had the potential to damage not only the reputation of the nurse target but also the organisations they work for.
The cases of external bullying included defamatory Facebook posts involving false sexual allegations made by the mother of a patient against the nurse victim. Another patient’s mother had bullied a nurse by leaving hostile and aggressive voicemail messages and sending hostile texts. The third external case involved a defamatory and anonymous blog post that was suspected to have been made by the student of a nurse academic. D’Souza said in least two of these cases, cyberbullying not only impacted upon the targeted individuals, “but also created negative publicity for the organisations involved, with the potential to hamper the provision of health services, particularly within small communities”.
She said bullying behaviour via social media or blogs or email chains not only increased the audience but were also used to damage social and professional networks and isolate the bullying target. “In one case of anonymous cyberbullying, this not only increased the threat level for the target, but also prevented effective resolution by the organisation.”
D’Souza said her study participants also indicated that two key features of cyberbullying were generally perceived to be more harmful: cyberbullying that resulted in a blurring of home/work boundaries and/or cyberbullying that was played out in a relatively public domain.
She said unlike face-to-face encounters, cyberbullying can persist beyond the physical workplace and working hours as digital devices provide continued access to targets.
“In this way, aggressive or unwanted cyber behaviours are not only repeated, but can transcend traditional safety strategies such as the use of security staff, being removed from the premises, and trespass notices,” said D’Souza. “More importantly, at present there is little that organisations can do to successfully resolve such incidents, as workplace cyberbullying currently remains beyond the scope of current organisational, industry, and national-level policy. In fact, many cases in this study often lacked a clear resolution to the cyberbullying and targets were often left feeling uncertain and anxious about future incidents.”
D’Souza said for most of the eight bullying targets the cyberbullying was part of a broader pattern of bullying behaviour within the workplace, including “unwarranted disciplinary and excessive performance management”, undermining comments, being ignored or excluded, plus offensive and aggressive emails and texts.
All eight participants indicated that other nurses within their organisation had also been cyberbullied. Many bullying targets had not reported the cyberbullying, said D’Souza, as they believed they could or should deal with it on their own, but only in one case had the cyberbullying been successfully resolved by the target’s own efforts. In a couple of cases the targets believed the ‘bully’ was supported by upper management and this had discouraged them from reporting the bullying.
A few participants had also noted that underfunding in healthcare meant that nurses were being blamed for system-level issues, such as shortages of staff, increased workloads, time constraints and insufficient resources. “Such environments largely support the occurrence and tolerance of workplace bullying.”
D’Souza concluded that cyberbullying in nursing is a “growing workplace psychosocial safety hazard that needs to be addressed immediately”.
Cyberbullying involves unwanted aggressive behaviours that may harm, threaten, demoralise or embarrass the person on the receiving end. This can occur through a range of electronic media including text and instant messages, emails, social media, blogs and public web forums. Workplace Cyberbullying can occur outside of the workplace and after hours.
*Resources section added November 9 2017
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