Appendices

Contents

Part One
Part Two
Part Three
Part Four
Part Five

Appendix One
Appendix Two
Appendix Three
Appendix Four
Appendix Five
Appendix Six

Consumer Questionnaire

The questionnaire was sent out to 200 people randomly selected from names in the Dargaville and Districts telephone book. 86 were returned, with 26 being incorrect addresses or from people who hadn't had any contact with nurses in the area. This left 60 completed questionnaires from which the following results were assessed.

Question One Demographics

Table One

This table shows the majority of respondents are over 60 years of age. This is an indication of the age groups who use the health services. Older people can and do want to input into health services that involve them and complete questionnaires.

When given the opportunity, older people will participate in written questionnaires.

Table Two

The table shows 50% of the respondents were male, 33% female and 17% returns from people who refused to indicate their sex.

The return from males is probably a result of the questionnaires being sent to the name in the phone book. However it also indicates men contribute to consumer feed back on health when given the opportunity.

Table Three

This table gives the geographic spread of the respondents. The majority of which came from the town which is a reflection of the population density. The remaining respondents are from a variety of the outlying rural areas.

Table Four

This table gives the ethnicity data gained from the respondents.

63% were non Maori, 13% Maori 12% Other and 12% did not respond to the question.

Nursing Service Questionnaire

Question Two:

Which of the following nurses do you use and what other nurses would you use if available? (Multiple choice)

A. Services already available from nurses.

Table Five

Options:

A. Visiting you when you are sick
B. Health promotion in schools
C. Health checks for the Well Elderly
D. New mother and baby clinics
E. Te Ha community nursing
F. Home visits from nurses
G. Nurses at Doctors' rooms
H. Diabetic Nurse
I. Public Health Nurses

This table shows the practice nurses at the doctors rooms are the nurses most frequently used by the respondents, followed by health checks for the elderly, the public health nurse and district nurses. A,F and C probably refer to Public Health Nurses, Te Ha o Te Oranga and Plunket.

The response reflects the respondent's ages. However it should be noted that the personal comments made by the respondents indicates confusion about the nurses roles as employees and tended to muddle the public health nurse with the hospital nurse.

B. Services not available from nurses - but would use if they were.

Table Six

Options:

A. Taking blood and other samples in the home
B. Asthma clinic
C. Youth health clinics
D. Men's health clinics
E. An evening nursing service
F. Women's health clinics
G. Nurse led clinics in all schools
H. Wound clinics

This question asks about the services not currently available from nurses. The three services indicated by the respondents as services they would use if available are: women's health clinic , taking of bloods and samples in the home and nurse led clinics in schools.

While the other options gained some responses the nurse led clinic available in the evening received the lowest responses. The high responses that came from men in the total survey were not reflected in a men's health clinic although that could be part of the age of the respondents.

Question Three

How do you rate your satisfaction with the following nursing service?

Table Seven

Table Seven shows that the Public Health Nurses register over the span of options as both excellent and very poor. However there is an indication the Public Health Nurse category is not well understood and that some of the respondents have used this category for all or any nurse.

Respondents do show a satisfaction with nurses with the majority in the very good to excellent range. The Dr nurses see more patients and this is reflected in the numbers of respondents who see the patients.

Question Four

How do you rate your satisfaction with the current emergency service?

Table Eight

This table gives responses to a question the consumers wanted feed back on. The majority of responses indicate a satisfaction with emergency services from good to excellent. Six respondents indicated lower levels of satisfaction with the services but these were not always directly related to the Dargaville service.

See the following pages for all consumer comments/suggestions to questions 3 & 4.

Consumer Responses

1. Fortunately, my family and I are in good health at present but would like to se more home visits (like the good old days). The last thing we need is to go and wait at the Medical Center (sometimes for ages) and wait. Surely a floating doctor or nurses could be employed for day to day visits to homes - not for serious illness - but for people with really bed flu etc. We have not received any help from nurses so feel unable to answer your questions.
2. We haven't needed any home visits yet, but one of us has a health condition that will need home visits in a year or so.
3. Having to wait so long for Emergency services. i.e. ring the doctor several times and then having to go to the doctors rooms to get a doctor to attend the patient.
4. Had day surgery at Whangarei Hospital on a Friday - told I would be seen by a health Nurse over the weekend - nobody came. Finally had a visit by a nurse late Monday afternoon. Because nobody had been into the office over the weekend, nobody knew of my case.
5. We have no complaints with the efficiency of any of the nurses.
6. The scope of services available to the Well Elderly should be made better known.
7. Unfortunately I have only had one contact in the last 10years with a nurse at the doctors to take some stitches out - so I am not a very useful respondent.
8. We have just had the use of the Kowhai Room at Dargaville Hospital, an excellent place to spend the last days with our loved one. The nurses were absolutely wonderful, with such loving care.
9. We need someone who can come easily when Mum has a concern about Dad. When he is having a turn, but not bad enough for an Ambulance.
10. Have not needed the emergency service at this time
11. We have had excellent follow-up care from all nurses who have attended to us after discharge from Whangarei and Dargaville hospitals.
12. I think there is not enough District Nurses for health promotion in schools - primary and secondary
13. I have had no experience of, nor made any use of, any of the above since restructuring, so I an unable to make any comment other than to say I hope this survey is cost effective - not finding "work" from bureaucrats nor taking funding from chalk face nursing which most surveys, in my opinion, tend to do.
14. Over the last few years we have had no direct contact with nurses so have not filled out the questionnaire opposite. However in September 1998, we did have contact in the emergency situation with our daughter. The service we received then was first class and of high standard. Our daughter was in care of Kaipara area for approximately 4 hours before being moved to Starship via helicopter.
15. Frustration at the amount of waiting time to get an appointment to see your family doctor e.g. often in excess of a week. Can this be improved? Now we have a one stop health shop which service does one contact first. The medical centre or hospital?
16. All the nurses that nursed me through my life have all done excellent jobs, but I think they are under paid for their services. Nursing elderly at home is excellent, and schools and anywhere nurses are needed. All the medical centers in the Kaipara areas and everywhere, need all the support they can get from anywhere they can get it.
17. The public health Nurse has made me aware of a service for a health problem. I have appreciated this.
18. Emergency services are good in Dargaville. A and E in Whangarei is terrible. There is no volunteer to even give you a drink of water when you sit there for 4 hours waiting for a doctor to attend you. (Broken ankle.) I have taken two elderly people there at different times with pneumonia. Each time we have waited for 4 hours for attention as their illness was not life threatening, both were aged 96 years. There could be more volunteers to help with patient's comfort when the medical staff hasn't time.
19. Fortunately I have not needed nursing services as of yet for myself but appreciate the assistance that is available for many of our local citizens and their response to the care they are being given and added security for those staying in their own homes.
20. Doctors and nurses are the only ones I have needed.
21. I have not used KCI but in the past I have found DMC was very good. My son is a diabetic and is very pleased to see you have a good team on this project.
22. Have not used emergency services. Have not used nursing services except Dr's nurse at the medical centre.
23. I take it the public health nurses means hospital nurses - Excellent. Doctors nurse Gerard in Ruawai also excellent. District nurse - had very little to do with them but also excellent.
24. Ambulance good. No experience of any other Emergency service. I have lived here for 20 years, 15 of them caring for a hemi plegic wife at home, but most of the above services are new to me.
25. Indicated poor for emergency service. This result may not be the fault of the service more a break down in communication and centralisation of the services where local location is unknown by answering staff.
26. With compassion all these nurses inform advise and follow up. Much encouragement for a healthy lifestyle.
27. Have had a day emergency with a toddler grandson. The service was prompt and transparent.
28. A choice of services is essential for all people in both nursing and emergency services. Have had to insist on visits and urgency needed.
29. Doctor shows, in attitude, reluctance to come out and see patients even if it is surgery office hours - not impressed.
30. Have been fortunate enough not to use the emergency services as yet.

Conclusion

There is some evidence that the respondents do not identify nurses by their employers ie practice nurse or district nurse but by the fact they are nurses in a generic sense.

This particular phenomenon has been identified by other researchers, both in the community and in hospitals where nurses have been identified as "they" rather than by their names or employer.

It seems it is nurses who are somewhat precious about their title named, whom employs them, what they are called and what they do.

The consumers indicate that, for them, there is nursing service available.

The Nurse Management Team has taken note of this information, and in some instances changes have already been made. They feel the charts indicate the results, so no conclusions have been included.

Nurse Questionnaire

Current Skills and Knowledge

This chart shows the confidence levels of nurses in the following subject areas, with 1 being very confident and 5 not confident. (See colour indicator)

A. Palliative Care
B. Wound Management
C. Diabetes Care
D. Asthma Care
E. Aged Care
F. Cord
G. Oxygen Therapy
H. Continence
I. Colostomy Care
J. Computer Skills
K. Teaching Skills
L. Team Work
M. Quality Management
N. Treaty Of Waitanga
O. Bio Ethics
P. Health & Illness (A Cultural Perspective)
Q. Leadership

Question One - Generic Nursing
Confidence relating to supervision of family/care givers in carrying out delegated nursing tasks.
1 - 5 with number one showing the most confidence

Question Two - Nursing Management

1 - 5 with number one showing the most confidence

A. Nursing Assessments
B. Planning Care With Patients
C. Setting Goals With Patients
D. Evaluation Care And Goals With Patients
E. Working In Patients Homes

Question Three - Cultural Issues

A. Cultural perspectives and language of local iwi.
B. Affect of cultural worldviews and values on health behavior.

Question Four - Communication

1 - 5 (See colour indicator) with number one showing the most confidence

A. Working in multi-disciplinary teams.
B. Empowerment of patients and others involved in patient's care.
C. Documentation of patient care.
D. Planning, writing and implementation of BPG for nursing practice.
E. Taking the initiative in quality management.
F. Collection of data.
G. Using Computer technology.

Resource Analysis and Comparison of Time Spent and Utilised for District Nurses and Practice Nurses in the Kaipara

Introduction
A time resource allocation analysis and comparison between District Nurses, Practice nurses and Te Ha o Te Oranga Nurses was conducted in the Kaipara District during the month of March 1999. The objective of this analysis and comparison was to aid the Kaipara Care Incorporated Nurse Project participants, and to examine the similarities and differences which make up these three groups of nurses - arbitrarily divided by means of employment rather than co-ordinated to provide an integrated nursing service.

Practice Nurses
The practice nurses involved in this study are employed by Dargaville Medical Centre. They work primarily from the centre ,although they do attend school and Marae clinics with the visiting GP's. There is a Practice Nurse Manager responsible for the nursing input to the medical practice. 9 practice nurses are employed as full or part-time employees with 6-7 working at any one time.

District Nurses
The district nurses are employed by Northland Health Ltd. They have, until recently, been supervised and accountable to the district managers based at Whangarei Hospital. There was a team leader at Dargaville. Recent changes have re-focused on the supervision of these nurses which now falls on the Clinical Supervisor of the inpatient ward at Dargaville Hospital. There are a total of 5 -7 district nurses employed on a full or part time basis. 3 district nurses work Monday to Friday with one working on Saturday mornings.

The Te Ha o Te Oranga Nurses
Te Ha o Te Oranga is an Iwi based mobile nursing service in the Kaipara, under the auspices of Te Runanga O Ngati Whatua. There are 5 Fill time Registered Nurses, a full time community nurse and a part time administrator . The time and task activity was carried out in the main by 2 full time nurses with some input from the team leader who has a dual RN and managerial position.

Methodology
Some time was spent in discussion between the resource management group of the nurse project to attempt to get the most user friendly method for the data collection, given the group was relying on the nurses to take time to this as part of an already busy day. However, the group was also mindful of the necessity for accurate information.

It was determined not to categorise the sorts of tasks the group believed the nurses do. Instead it was decided to give the nurses a blank time sheet with 5 minute blocks in which they could identify the tasks they were involved in. It was postulated that the tasks could be categorised by the group at a latter date.

The proposed method was piloted for one week by the nurses and the method was found to be both nurse friendly and also allowed for specific categorisation on tasks into 5 minute blocks of time as part of the data analysis.

A letter was given to each of the nurses involved with enough blank task time forms to last each nursing group. The forms were handed into the nurse project resource person in the area and returned to the project manager for data compilation/computer capture of the data and analysis. The nurses were not asked to put their names on the forms although many did. Confidentiality was maintained throughout the time involved.

Data Explanation of Tables
Each table identifies the categories, and the task. The time refers to how many times the task was actually carried out and the units column gives the actual units as measured by five minute lots. For example, a nurse may have been involved in doing a dressing which will be one task but it may have taken 30 minutes which equals 6 units.
Data Collected and Categorised
Practice Nurses
There were a total of 45 practice nurse responses over a two week period. The data was gathered during the hours of 0830 -1630. Not all of the nurses in the practice responded and not all of the time sheets were completed. The responses did not include the practice nurse who works at Ruawai, nor the work done by nurses on Saturday Mornings.

Results

Table 1

Description of Table One
This table identifies the categories given to each of the tasks. The time represents how many times a certain activity was noted. The units are represented in 5 minute units.

Figure 1 - Practice Nurses Time Resource Utilisation

Analysis

Results

The data collected was sorted into eight categories under which specific tasks were allocated. The categories are: administration
direct nursing tasks
wound management
indirect nursing tasks
direct work with the GP
education and advice
meetings
own time.

55 percent of the total time spent was on direct patient contact, 36 percent on administration, 5 percent on meetings and 4 percent own time.

Category One - Administration
The administration time and tasks fell into six main areas:

This result confirms the anecdotal evidence the practice nurses give themselves as to the amount of time they spend on filing and answering the telephone.

Categories Two and Three Wound Management and Direct Nursing Tasks
Wound management has been singled out as a significant task undertaken 91 times taking 165 units, or 5 percent of the total time. The direct nursing tasks refer to other tasks a nurse undertakes independently. They involved 13 percent of the total time. Out of a total of 27 tasks the ones most frequently undertaken were blood pressures (59 times), contraception and immunisation (49 times), BM testing (41 times). All the others were less than 12 times except for the office triage which was being trialed at the time. It has not subsequently been included as part of the daily schedule. The units of time do not equate with the times a task was undertaken. Some of the tasks were done in combination with other tasks while some other tasks undertaken less often took longer.

Category Four - Indirect Nursing Tasks
These tasks can quite correctly be termed as those activities that are associated with infection control, ensuring the clinic is safe and well stocked. These activities took up 8 percent of the nurse's time.

Category Five - Direct Work with GP
17 percent of the nurse's time was involved in working directly with the doctor. The time is divided into eight areas, the task undertaken the most often involved arranging scripts and medical certificates but the most time involved assisting and consulting the GP, minor surgery and triage.

Category Six - Education and Advice
This category shows a total of 12 percent of the nurses time was involved in giving patients advice 104 times over the phone taking a total time of 115 units and there were 93 patient consultations taking a total time of 200 units. The remaining time was allocated to asthma education (9 times, a total of 37 units of time) and diabetes education (2 times, a total of 21 units of time).

Category Seven - Meetings
A total of 5 percent of time was spent attending a variety of meetings, the majority of which was spent at meetings associated with KCI both in terms of occurrences and units of time.

Category Eight - Own Time
The final category refers to the time the nurses spent in lunch and morning / afternoon tea breaks.

District Nurses
Data Collected and Categorised
The District Nurses submitted 28 responses over the two week period. The data was gathered during the hours of 0800hrs and 1630. The information did not include the nurses in Southern Kaipara, the fee for service nurses nor the Saturday morning nurse.

Table 2

District Nurses Activity results - Time and task Utilisation March 1999

Figure 2 - District Nurses Time Resource Utilisation

The data collected was sorted into nine categories under specific tasks were allocated. The categories are:

Administration and preparation
Travel
Palliative Care
Home Visits
Wound Management
Liason
Other
Meetings
Own Time

Category One - Administration and Preparation 12%
Explanation of data
12 % of time is taken up in this category. The major proportion of the time in this category was spent in taking notes and documentation. It is uncertain if these are one and same thing but in any event it involves time in the office completing paper work.

The amount of time the nurses spend on the phone are not of long duration and are significantly lower than the times and length of time Practices Nurses spend on the phone.
Planning daily workloads consume the next bulk of time units while statistics rate the third to lowest in time allocation with organising travel allowance and diaries, taking less time.

Category Two - Preparation (see above)
This category involves preparing the nurses bags and equipment into the cars for home visits.

Category Three - Travel - 57%
A total of 57% of the District Nurses time is taken up in travel.

Category Four - Palliative Care - 2%
This category was identified as a separate category from home visits because anecdotal evidence suggested it consumed up to 50% to 75% of all home visiting time. At the time of this analysis palliative care took up 2% of all time involved in home visiting. This is far below the anecdotal evidence. It may also be the result of having no clear definition for the nurses to work to and a lack of indicators for palliative care categories. To get a better idea of total time and extent of palliative care needs in the Kaipara, the data GPs hold on prescriptions for medication control may be of better value. The work to develop a national definition on palliative care may also be of benefit.

Category Five - Home Visits - 9%
This category indicates the types of tasks a district nurse carries out while in the home. It also mingles with wound care and education as all may have taken place in the same home at the same time. By far, the most common task is the taking of the Blood pressure with medication and giving support next. While few showers and assistance with ADL s were given, they consumed a relativity high unit score. Home visits around continence supplies, equipment and linen consume 38 units which is only marginally less than assessments at 39.

Category Six - Wound Care - 8%
Wound care takes up 8% of the nurses total time and just under half the home visits. It was noted in the raw data that first assessments in complex dressings, where underlying medical conditions existed, involved significant time.

Category Seven - Liaison with Other Providers - 2%
A total of 2% of the district nursing time is taken up in liaison activities with a variety of other providers. No mention here was made of co-ordination activities.

Category Eight - Other - 4%
This category includes both health promotion and clients not at home. The health promotion here represents that carried out when other tasks were being attended to. Some of the raw data indicated the DN visited for health education alone. There is no elaboration on this category or the reasons for why the District Nurse was referred to a patient for health education alone.

Category Nine - Meetings 3%
Meetings account for 3% of the nurses time, and include a variety such as team meetings, KCI meetings, CART and rehabilitation meetings. There may be some overlap here with the KCI meetings actually being the CART or the case review meetings.

Category Ten - Own Time 3%
The district nurses have not included their own time, in fact most of them did not indicate any breaks at all. Some indicated they worked while having their break, most did not have a lunch break.

Te Ha o Te Oranga
Data Collected and Categorised
Te Ha o Te Oranga submitted 19 responses over the two week period. The data was gathered during the hours of 0800hrs and 1800hrs

Figure 3

Figure 3 - Te Ha Resource Utilisation Analysis

Results

Category One and Two - Administration/Phonecalls - 23%
23% of time is spent on Administration. The largest portion of this time is involved in the collection and computing of statistics, and documentation. Some of the responses indicate the computer entry was taking time which takes up the largest proportion of all time in this category and is also related to the documentation a