Concurrent sessions 'pull it all together'.

Concurrent sessions were a major feature of the conference, running over both days and divided into three themes: clinical practice, readership and management, and research/education. The 27 half-hour sessions offered something for everyone, with initiatives from up and down the country illustrating the conference theme of "Pulling it all together".

In addition, two plenary sessions Led by chair of the NZNO Primary Health Care Nurses Advisory Council Chiquita Hansen and council member Rosemary Minto looked at the role of the council providing leadership and advice both within NZNO and to external organisations. A second session looked at changes to the Investing in Health 2007 document and ways forward for primary hearth care nurses.

RUN BY YOUTH FOR YOUTH

Evolve Wellington Youth Clinic is a nurse-led, multidisciplinary service in the central city, providing a free service for ten-to 25-year-olds. Started three years ago with funding from the Ministry of Health, the service is now funded through Capital and Coast District Health Board, with additional funding from the Ministry of Youth Development. It is run by youth for youth, explained nurse team leader Rebecca Zonneveld. Eight nurse clinics are run each week, along with four afternoon doctors' clinics. Staff comprise two nurses, two part-time doctors, two co-managers, one social worker, one community youth worker, eight youth support workers (YSWs) and six counsellors. Zonnefeld specialises in sexual health, visiting He Huarahi Tamaraki, the school for teenage parents in Porirua, weekly. Other services include assessment, diagnosis and treatment using standing orders, mental health, alcohol and drug addiction, stopping smoking and healthy eating. "Young people want a one-stop health shop. They also want to be involved in the design and delivery of services," said Zonnefeld. "Youth participation is one of our core principles. We have young people on our governance board; our YSWs are involved in the day-to-day running of the clinic and also run a number of youth development programmes. We've run African nights, which have sometimes provided a safe meeting place for the police and young Africans; we've had a kapa haka group; a hip hop project; a Pasifika dance group; and a kick boxing group. YSWs will also help young people get their learner driving licenses or assist with citizenship or other social issues."

The clinic includes a "hang out" space with computers, a pool table and tea and coffee making facilities. Young people will spend time there, sometimes over a couple of weeks, sussing out the staff, before gaining the confidence to make an appointment to see the nurse or doctor.

Working with young people is hard, Zonneveld said. "Everyone has to have their say. Sometimes we find we have to do a lot of nagging to make sure our standards are maintained. Standing back and letting a young person run a project can be a challenge and they can also be defensive about feedback. On the other hand, it is great to see the YSWs grow in confidence and skills. They keep our service real and help young people feet comfortable accessing it. They are the face of our service and make it the success that it is."

Nurses at Evolve are now seeing a lot of young people with mental hearth issues, many referred to the service by GPs. Others are referred by schools because of behavioural issues. "A lot of young people start falling out of school at the intermediate level Stopping young people offending at this age is a real challenge. I think the Ministry of Education should be funding more alternative schooling for these young people," Zonneveld said.

COMMUNITY BCG CLINICS

The number of BCG vaccinations to prevent TB has been gradually rising in Hamilton since 1994. That year, public health nurses (PHNs) administered 20 BCG vaccinations. Last year, this number reached 418.

Within the PHN team, six nurses are currently gazetted to provide BCG vaccinations to eligible neonates, explained PHNs Nicky McCormack and Maria Crawford. Before 2004, the PHN service delivered these via a home visit. However, home visiting was found to be time and resource intensive, requiring the nurse to be in the home for up to an hour. This allowed sufficient time for informed consent to be obtained, the vaccine to be administered, and 20 minutes of surveillance for adverse reactions post vaccination. "Home visiting certainly had some benefits for new migrant and refugee populations who often experience cultural, language and transport difficulties," said McCormack, "but with the rise in the number of BCGs, we needed to re-evaluate how to deliver the service."

In 2004, planning began for the nationwide Meningococcal B school-based immunisation programme. It was recognised the BGG service needed to be streamlined to enable one nurse to work alone while the other PHNs were involved in the "MenzB" programme.

"The BCG working group put together a proposal to establish a community BCG clinic at the Waikato Migrant Resource Centre. Holding the clinic here had several advantages, particularly as the centre housed a range of agencies providing social and cultural services to refugee and new migrant people. Co-locating primary health services with social and cultural services has been shown to improve health outcomes. Recently relocated, the centre is also easily accessed by both public and private transport," said McCormack.

The new clinics began in January 2005, held one morning a week, with appointments for eight babies. Over time, it became apparent that many new migrant families were not aware of the Hamilton Plunket Society. Other health issues such as breast feeding problems and car seat safety were also identified. Early this year, a Plunket nurse began attending each weekly BCG clinic, using the 20-minute recovery time to work with families.

Currently BCG gazetters (vaccinators) are trained and registered from Auckland District Health Board (DHB). Waikato BCG gazetters would like to establish their own training service in Hamilton, as well as increase the number of BCG gazetters. "We would also like to involve other child and family health services at the centre, work more closely with GPs and midwives so the criteria and referrals remain adequate, and conduct a formal evaluation with parents/caregivers and users of the service to ensure it is meeting the needs of our multicultural client base."

REDUCING ED ADMISSIONS

Having a community nurse and social worker working alongside the emergency department (ED) team is proving good for patients and reducing unnecessary presentations of elderly people to the MidCentral District Health Board ED. The nurse/social worker team is known as PEDAL--post ED assessment and liaison.

"Between 2002 and 2006, presentations to ED increased by 20 percent, with nearly half of them over the age of 65," said clinical nurse specialist Denise White. "Our re-presentations also increased by 42 percent. Nearly 14 percent of our population is over 65, but they are using 67 percent of acute hospital beds. PEDAL was established a year ago to reduce the unnecessary hospital admission rates and to help keep people well in the community, managing their pain better and reducing their risk of falls, a major reason for their presentation to the ED."

The PEDAL team is available to people 24-48 hours after discharge, drawing up a care plan in collaboration with the family and making a home visit if required. "We need to get a good picture of what is affecting the patient's health and what help they need, eg district nursing or physiotherapy."

Since its establishment, PEDAL has provided assistance to 387 people, with 308 of them supported to return home. Only 2.84 percent of this number represented within 72 hours.

"PEDAL brings a primary health care lens and approach to an environment not traditionally resourced for complex discharge planning," said White. "We find out what is realty going on for the patient and help those who are falling through the cracks. Basically it is all about getting better care for older adults."

CO-ORDINATING MENTAL HEALTH CARE

Building relationships with people is the most important role of a nurse co-ordinating mental health care for clients in a high-needs community, said Newtown Union Health Service nurse Kieran Monaghan.

Monaghan works in both clinic and outreach settings, working alongside mental health clients and other service providers to help clients re-establish and maintain individual health and well-being.

"I am one of many people and agencies these people have contact with. The important thing is to work with what is uppermost for the client, which might be about an eviction notice or problems with debt. Those things have to be solved first before work can be done on other health issues."

With more than 400 people with chronic psychiatric illnesses registered with the service and others with milder conditions, Monaghan believes working closely with other mental health services and networks is vital. "We need to expand our networks, not work in silos," he said.

He focuses on clients' physical health by conducting thorough assessments. Meeting clients in the community also gives him a chance to create a different relationship with them. Every two weeks, he visits the Clubhouse, a day centre set up by the mental health consumers' union, where he conducts general health checks and has helped set up some therapeutic and social activities. One of the most successful has been a drumming session, held weekly and led by a skilled drummer. "It's great to see these people engaging in something creative and fun. Those who don't feel like talking don't have to. It's a very safe activity. We now have some guitarists joining the sessions too."

Monaghan also makes fortnightly visits to residents at Te Menenga Pai Trust, commonly known as Blossoms. This 24-hour facility is home to around 12-18 Maori residents, many of them former forensic inmates. And he calls into Courtenays, another day centre for mental health clients.

An annual mental health expo held in Newtown provides a great opportunity for service providers to make themselves better known to the Local community and service users.

RURAL NURSES CONFRONT ISOLATION

West Coast District Health Board (DHB) nurse consultant Michele Barber has recently completed some research into the distinctive nature of rural nursing. A number of different themes emerged during this project, including the professional and personal isolation most rural nurse specialists have to cope with.

"There are currently nine rural nurse specialist clinics on the West Coast, scattered from Karamea in the north to Haast in the south. The DHB area is 700kms Long, with a population of only 30,000. This means the area has some unique needs. Fortunately, the Minister of Health Pete Hodgson recognises the population-based funding model doesn't apply to our DHB. The terrain is rugged, with the area having twice the average rainfall We get cut off by snow several times a year. There are also high levels of deprivation in the area, with the average salary only $21.000. Patients with complex health needs nave to travel 250kms to Christchurch Hospital.

"Our rural nurse specialists live in very isolated communities, work long hours and are really unable to relax, even at home, because of the fear of their pagers going off. They are highly visible in their communities, working at the boundary of their scope of practice. They use standing orders, assessing, diagnosing and treating patients in collaboration with the GPs." Barber described these rural nurses as "specialist generalists". Three-quarters of them have clinical master's degrees and postgraduate diplomas, with more considering upskilling in this way. Conditions of employment were often more important to these nurses than their salaries, she said. "I would like to see a minimum of two nurses working in each location. We also hope to be able to develop a formal career pathway in rural nursing, with competencies refined to meet the needs of West Coast nursing."

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Best abstract poster was won by CarePlus co-ordinator at Manaia Health Primary Health Organisation in Whangarei, Jayne Hill. Best clinical concurrent paper went to Newtown Union Health service primary health nurse Dianne Theobald; best leadership and management paper was won by Starship Children's Hospital nurse educators Emma Collins and Nicola Fair; best education/research paper to Nelson-Marlborough DHB nurse consultant Brenda Bunning; and best first-time presenter was team Leader at Evolve Wellington Youth Service, Rebecca Zonneveld.