V O LU M E 2 3 , N O. 9 / A P R I L 2 0 1 6
HOW AUSTRALIA’S ASYLUM SEEKER POLICY IS DAMAGING CHILDREN www.anmf.org.au
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CONTENTS
16
Directory 02 Editorial 03 News 04 World 13 Ethics 14 Industrial 15 Feature – Asylum Seekers 16 Issues – Improving Cardio 22 Research
23
Issues – Safety in Health 24 Working life
25
Education – Diabetes 26 Clinical Update HOW AUSTRALIA’S ASYLUM SEEKER POLICY IS DAMAGING CHILDREN
28
Focus – Diabetes 32 Calendar 45 Mail 46
04
Maree 48
26 32 anmf.org.au
April 2016 Volume 23, No. 9 1
Canberra
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A portrait of asylum seeker Mohammad Sohail, 6, from Afghanistan. Photo: Alex Ellinghausen
Editorial
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EDITORIAL
Editorial Lee Thomas, ANMF Federal Secretary Last month the ANMF made a formal submission to the Senate Inquiry into the Future of Australia’s Aged Care Sector Workforce. The significance of this Inquiry is monumentally important to our aged care workforce to ensure it is well resourced to provide safe and quality care to older Australians, now and into the future. With a sector already suffering a shortage of 20,000 nurses, our key recommendations detailed in the submission were: mandated staffing ratios include a registered nurse on duty 24/7 at all facilities with high care residents; closing the wage gap for nurses and care workers; and minimum education and licensing for personal care workers. Many ANMF members also made submissions to the Inquiry. The frustration and distress about their working conditions and lack of respect to the elderly by aged care providers detailed in the submissions were clearly a reflection of a sector in desperate need. The situation has become distinctly critical. Therefore it is imperative Senators listen to the ANMF and to the membership for the sake of the sector and all older Australians. The ANMF will closely monitor this Inquiry as it progresses. We will be sure to let you know the outcomes as they occur. In this month’s ANMJ the feature looks at the issues surrounding children in detention, asylum seekers and nurses and midwives who are doing what they can to support the needs of these vulnerable people. While many nurses and midwives were unable to speak to the ANMJ because of the Border Force Act banning health professionals from speaking out, those that did painted a bleak picture of the conditions asylum seekers live under in detention centres. As I implored the government in last month’s editorial, I implore them again. The Turnbull government must show compassion and humanely address this situation immediately.
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OUR KEY RECOMMENDATIONS DETAILED IN THE SUBMISSION WERE: MANDATED STAFFING RATIOS INCLUDE A REGISTERED NURSE ON DUTY 24/7 AT ALL FACILITIES WITH HIGH CARE RESIDENTS; CLOSING THE WAGE GAP FOR NURSES AND CARE WORKERS; AND MINIMUM EDUCATION AND LICENSING FOR PERSONAL CARE WORKERS.
On the journal’s world page this month is a report on a presentation made by leading academic in political economy and sociology at Oxford University, Professor David Stuckler. Professor Stuckler has been visiting Australia, warning of the harmful effects austerity can have on healthcare. Basing his assertions on personal observations of other countries and his research, he states austerity is often detrimental to healthcare outcomes and in turn fails to improve outcomes for the economy. Reading this account only shores up my conviction that economic cuts must come second to the healthcare needs of Australians. To this end we will continue to fight against cuts to Medicare and other measures that erode our healthcare system.
www.anmf.org.au
April 2016 Volume 23, No. 9 3
NEWS ANMF KEY RECOMMENDATIONS • Mandated minimum staffing levels
and skill mix
• Closing the gap between aged care
and public hospital wages
• Dedicated funding allocated to
closing the wages gap
• Licensing and regulation of all
personal care workers
• Minimum standard of qualifications
of all personal care workers
• Mandated/legislated 24 hour
registered nurse cover for all high care residents
“Skilled staff are required to truly raise the profile of aged care into the specialty that it is and be dynamic enough to attract a new cohort of clinicians. This cannot be achieved without increasing the numbers of skilled registered nurses.” Rod Wyber, Residential Aged Care Facility Manager —
ANMF CALLS FOR 24/7 RN COVER AND BETTER WAGES IN AGED CARE
“Not to invest in adequate numbers of qualified nurses at appropriate nurse to patient ratios, assisted by closely supervised ‘carers’ is a false economy which lines the pockets of ‘aged care’ providers at the expense of the clients and the taxpayer. It’s time we stopped privatising profits and socialising losses to the detriment of the frail, aged, their families and the wider community.” Marian Geyde, RN, Clinical Specialist in Critical Care —
Mandated staffing ratios including a Registered Nurse on duty 24/7 at all facilities with high care residents is one of six key recommendations in the ANMF’s submission to the Senate Inquiry into the aged care sector workforce. Closing the wages gap, minimum education requirements and licensing of personal care workers are other top priorities highlighted by the ANMF. The Senate Inquiry into the Future of Australia’s aged care sector workforce was announced in December. It will assess future workforce requirements; attracting and retaining staff; remuneration; staffing ratios; regulation and qualifications of workers; challenges in regional and remote areas; and the impact of the government’s cuts to the Aged Care Workforce Fund. ANMF Federal Secretary Lee Thomas said the union’s six key recommendations were aimed at strengthening the current underresourced workforce with a shortage of 20,000 nurses. Staffing levels needed to be 4 April 2016 Volume 23, No. 9
urgently addressed, she said. “The elderly cannot receive decent care unless there is an appropriate number and mix of skilled and experienced staff, which includes registered nurses, enrolled nurses and assistants in nursing or personal care workers. “Without legislated requirements in all Australian jurisdictions to mandate a minimum number and type of nursing and care staff, safe and quality care for the elderly cannot be assured. That is a huge concern for all of us.” Nurses and care workers in aged care continued to be unpaid, with many “increasingly frustrated and distressed”, Ms Thomas said. “They talk of poor working conditions and wages, inadequate staffing levels coupled with high workloads and the unreasonable professional and legal responsibilities placed on them. It’s a perfect storm and the reason why we struggle to retain, let alone recruit staff into the aged care sector.” The Committee is due to report 30 June. To read the submissions, visit www.aph.gov.au
“People who enter RACFs (residential aged care facilities) are increasingly frail with complex care needs, needs that occur outside of business hours and that fluctuate and change quickly. How can we guarantee quality care for our older citizens without minimum staffing requirements, nationally recognised training requirements and registration and regulation of all workers?” Joanne Russell —
“Aged care is a specialty area of nursing requiring a very high standard of clinical assessment skills. …the government should never again not have ‘professionally trained registered nurses’ in facilities. Not only in management roles but on the floor and with clinical rotations being increased across all years of training and facilities on medicine, nursing, pharmacy and allied health to further develop and refine assessment skills.” Sue Tettman, former Clinical Manager in aged care and educator of personal care workers —
anmf.org.au
NEWS
CORONIAL INQUEST SUPPORTS RNS IN AGED CARE 24/7 A Victorian Coroner has bolstered the ANMF’s campaign for having registered nurses in all residential aged care facilities 24/7. Victorian Coroner Phillip Byrne found in the Inquest into the death of 76-yearold Ena Vickers who fell in a nursing home in Rosebud, initial assessment “inadequate/deficient”. An experienced enrolled nurse undertook the initial assessment and recommended an ambulance be called. However the assistant manager after discussion with the LMO decided Ms Vickers be monitored at the facility. The Coroner found an “absence of continuity” in the management of Ms Vickers’ care, including handover to the RN on the next shift. While observations were recorded, no formal neurological or clinical observations were documented. Nor was any plan in place in the event of deterioration of Ms Vickers’ condition. The Coroner noted the various conditions suffered by Ms Vickers, particularly her inability to verbally communicate and dementia, made assessment problematic. “That, together with the obvious head strike, should have resulted in a thorough examination and assessment being undertaken by, at least a Division 1 Registered Nurse…” Ms Vickers was transferred by ambulance following assessment by the RN who came on duty some four to five hours after the fall. At Frankston Hospital, Ms Vickers was found to have a fractured neck of femur; a fractured C7; an acute subdural haematoma; and a subarachnoid haemorrhage. She died five days later. While earlier transfer may not have prevented her death, Coroner Byrne found “Ms Vickers’ distress/pain experienced later in the afternoon may have been avoided”. A NSW Inquiry made recommendations last year to have a registered nurse on duty at all times. The NSW government is currently reviewing its state regulation.
anmf.org.au
BRIEFS
INCREASE IN MALE SUICIDES The incidence of suicide is growing at an alarming rate according to a report released by the Australian Bureau of Statistics (ABS). According to the report 2,864 people took their lives in 2014, an increase of almost 13.5% from 2013 and the highest rates of deaths in the last 10 years. Approximately 75% of those deaths were male, making intentional self-harm the tenth leading cause of death for this group. “These numbers indicate that our exposure to and the impact of suicide is on the rise. One death by suicide is one too many so seeing an increase is extremely concerning. We must change the way we approach prevention if we are to have any chance of reducing suicides in this country,” Suicide Prevention Australia (SPA) Chief Executive Sue Murray said. The National Mental Health Commission has recommended a 50% suicide reduction target by 2020 be adopted.
DEMENTIA RATES EXPECTED TO REACH ONE MILLION The number of Australians with dementia is expected to more than double by 2050, researchers at the University of Canberra say. According to estimates the number of people with dementia will rise to almost one million. Deputy Director at the Institute for Governance and Policy Analysis Professor Laurie Brown said dementia presented a significant burden of illness in the Australian community and was accompanied by high social and economic costs. “It is something that governments should be planning for already and setting those plans in motion.” Professor Brown said there was a strong relationship with age, gender and lifestyle factors that affected a person’s risk of developing dementia.
REGISTRATION EXPLAINED NEW SOCIETY FOR DIABETES The University of Melbourne has set up a society for primary care professionals caring for those living with diabetes. The Primary Care Diabetes Society of Australia is a not-for-profit organisation that will support clinicians to provide high quality clinically effective care. Department of General Practice, University of Melbourne Associate Professor Mark Kennedy said the majority of the one million people in Australia with diabetes receive most of their care in primary care yet there was no primary-care based multidisciplinary society to support those health practitioners. “Education will be the key role of the society. We are establishing a quarterly online journal, online continuing professional development and will hold the first annual conference in Melbourne on 30 April next year,” he said. Go to: www.pcdsa.com.au for more information.
Over 360,000 nurses and midwives are due to renew their general or nonpractising registration with the Nursing and Midwifery Board of Australia (NMBA) by 31 May. To assist nurses and midwives with registration a video explaining the renewal process is available on the NMBA website and via YouTube. NMBA Chair, Dr Lynette Cusack, said the video explained the renewal process and she urged, in particular, nurses and midwives who are soon to renew their registration for the first time to watch it. ‘In less than four minutes the video explains how to access online renewal, what you must declare about your previous 12 months’ practice, how to pay the registration fee and what happens next.’ Online renewal was launched at the end of March. A series of email and hard copy reminders will be sent by AHPRA on behalf of the NMBA throughout the renewal period. To renew registration go to: www.ahpra.gov.au/Login.aspx#loginFld To view the video go to: www.nursingmidwiferyboard.gov. au/Registration-and-Endorsement/ Registration-Renewal.aspx or go to YouTube: www.youtube.com/watch ?v=LLKCEyufuMg&feature=youtu.be
April 2016 Volume 23, No. 9 5
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NEWS
COMMITMENT NEEDED TOWARDS EQUALITY While Australians recognised Close the Gap Day on Indigenous inequity last month, politicians and health leaders discussed how to maintain and improve Aboriginal and Torres Strait Islander health outcomes at the recent Australian Health Care Reform Alliance’s (AHCRA) National Health Reform Summit.
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ABORIGINAL LED MATERNITY UNIT SET TO CLOSE A successful Aboriginal led ante/post natal service is under threat of closure with neither the state nor federal government committed to its funding after the end of June. The Moort Boodjari Mia (MBM), in north Perth, helps Aboriginal women aged under 20 years with pregnancy and parenting issues. It has provided care to more than 200 Aboriginal mothers, over 80% deemed high risk, since the service opened in 2011. The program has seen a reduction in incidences of smoking and drinking alcohol during pregnancy, and increased average birth weights of babies to 3.1 kg. MBM received the Team Excellence Award at the 2013 HESTA Primary Health Care Awards and runner up in the National Lead Clinicians Award in 2014. MBM Coordinator Alison Gibson said the service was unique with each case managed by a midwife, Aboriginal Health Officer and Aboriginal Liaison Grandmother. “Our staff understand the differing needs and culturally appropriate ways of working with the Aboriginal community and continually developing a service that meets these specific needs.” The service provided ante/post natal care to young Aboriginal women but also worked with partners, grandparents and significant others. MBM was set up in 2011 under a Council of Australian Governments (COAG) five-year agreement between the federal and WA governments as part of the Closing the Gap initiative. Neither government has committed to ongoing funding for the service which ends on 30 June. The Moort Boodjari Mia Advocacy Group had almost 25,000 signatures in a petition to WA Minister for Health Dr Kim Hames to keep the service open. The service was effective as it had been developed by the local Aboriginal community, says the group. “The state government consistently promises to Close the Gap, but instead is Closing the Door on a proven solution for Aboriginal babies and families. “This program is changing the health of Aboriginal people for generations to come.”
anmf.org.au
Speaking at the Forum federal Assistant Minister for Health Ken Wyatt said the government was aware of the issues but simply doing more of the same was not the answer. “I think we are heading in the right direction but all Australian governments need to intensify efforts, partner with Aboriginal and Torres Strait Islander people and all Australians to effect change.” According to the Minister $3.3 billion was being allocated to Indigenous health programs over the next four years to help improve efforts in areas such as child and maternal health, chronic disease prevention and mental health, including suicide prevention. “We are improving our efforts in each of these areas, building on what works. I acknowledge we are tackling significant challenges in Indigenous health and mental health but the good news is that we are heading in the right direction. In the long term we will see improvements.” But Senior Lecturer in Indigenous Health at the University of Sydney and AHCRA Executive Member Vanessa Lee, who also spoke at the forum, questioned where the money would actually be going. “If you break it down 80% of Indigenous funding goes to non-Indigenous services and we are not seeing the health outcomes we need. Why are we not evaluating policy and health outcomes across Indigenous organisations? Why are we not effectively closing the gap?” Ms Lee said since the Abbott government came into power there had been funding cutbacks to Aboriginal health services resulting in a substantial decline in health outcomes. “I hope the government is serious about developing positive health outcomes because we have just seen decline after decline and if we don’t work on this as a collective we are going to see the decline continue.” Though strategic partnerships were still needed between Indigenous and non-Indigenous Australians there had been significant inroads in the way the health system operated in terms of commitment and goodwill, according to Carmen Parter, Adjunct Associate Professor at the Nursing and Midwifery School, Sydney University. “Sadly though in recent times we have witnessed the erosion in a range of preventive health mechanisms including a reconfiguration of the primary healthcare sector and programs.” Yet Ms Parter, who until recently was the Director of Aboriginal Health in NSW, said she was highly supportive of the Australian governments National Aboriginal and Torres Strait Islander Health Plan. “But critical to that plan will be engagement of the National Health Leadership Forum and what we know with history in regards to these great policies.” Ms Parter said the plan addressed the social inequities in the health system, social determinates as well as issues pertinent to racism. “The plan has all the ingredients, I believe, that could make real inroads. However we could have the best policy ever but it’s about implementation.”
April 2016 Volume 23, No. 9 7
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NEWS
NATIONAL E-HEALTH SYSTEM RELAUNCHED A renewed push for the stalled national e-health system has been welcomed but industry experts caution problems still lie ahead. Federal Health Minister Sussan Ley officially launched the government’s revamped My Health Record last month. The government announced $485 million in last year’s Budget for the failing national electronic health records system. Part of the package involves op-out rather than opt-in trials for more than one million residents in Western Sydney and North Queensland aimed to address the low uptake. An independent review recommended an opt-out system after less than one in 10 Australians signed up to the PCEHR launched in 2012. Legislation for the opt-out trials was passed in the Senate last November. Consumer Health Forum CEO Leanne Wells said the opt-out approach would see faster development and enable people to access their health records electronically as they do banking, telecommunications and online shopping. “Once it is operating well and all health professionals and providers are using it to routinely log patient information and refer to that record, it should lead to better coordination, a decrease in duplication of tests and fewer adverse medical events.” University of Queensland Senior Lecturer in the Centre for Online Health in Medicine and Biomedical Sciences Sisira Edirippulige said critical to the success of the e-health system was people using it. “People haven’t entertained this opportunity. We need the numbers to make it viable. “My initial understanding is that GPs are still going to have to create the electronic health record and have to collate them whether they are in a position is still questionable.” The other difficulty was whether enough information would be collated in the clinical summaries and whether clinicians could make correct decisions based on the information available. “It is also dependent on how accurate the information is as well as how much. This is essential for people to use the system.” Estonia was the first country in the world to introduce electronic health records which were mandated, Edirippulige said. “The one thing they have done is have them mandated so everybody has to use it.” Denmark had also seen successful implementation of a national electronic health record system. “It’s very important we look at those success stories,” he said. Health Informatics Society of Australia former Chair Lis Herbert was an e-health Project Officer on an 18-month contract introducing e-health to GPs and Medicare Locals on the Gold Coast in 2013. The difficulty was the variability of practices in their readiness for implementing e-health records, she said. “It was very practice dependent. The take-up from some GPs was minimal, for others the incentive payments inspired a lot of them. The health summaries were not an onerous task but there was a lot of misinformation.” Ms Herbert said she hoped government would put in place the training required for clinicians to use the system.
anmf.org.au
AGEISM TRIGGERS ELDER ABUSE IN AGED CARE A leading aged rights advocate believes staff working in aged care should be screened for ageist views in a bid to reduce the incidence of elder abuse currently pervading the sector. Addressing the 4th National Elder Abuse Conference in Melbourne in February, Adelaide-based Aged Rights Advocacy service’s Brenton Pope (pictured), argued ageism is directly causing elder abuse within residential aged care facilities. Mr Pope said ageism, an inherent part of society that exists in many forms, has become problematic in aged care. “One of the most dangerous assumptions we can make is that aged care is in some way immune from ageism.” Mr Pope said ageism, defined as stereotyping or discrimination against groups based on age, can negatively impact how people define and respond to elder abuse in aged care settings. Mr Pope illustrated numerous cases of misconception that regularly occur that were often overt or covert. An overt example was that staff might believe older people bruise easily, and therefore fail to investigate signs of potential physical assault, for example. Covert abuse, which includes “insidious forms of abuse operating under the surface”, is harder to detect but no less damaging, Mr Pope said. “[It’s] the removal of rights, freedoms and liberties that are generally afforded to all members of our society. People in residential aged care are often excluded from these rights and freedoms on no other basis than their age,” Mr Pope said. Mr Pope said a screening tool assessing ageist views within aged care facilities would help shift discrimination and build positive culture throughout all levels of organisations. The action would also directly help reduce elder abuse in aged care. Alzheimer’s Australia NSW General Manager Policy Research Brendan Moore also spoke at the conference on preventing financial abuse on older people. Research recently published by Alzheimer’s Australia NSW, detailing its experience establishing an interagency response to the problem, acknowledged that reducing financial abuse is difficult to address, and even more tricky for people suffering dementia. “For people with dementia, abuse can be very invisible to them, in that they are not aware that it is occurring, they may not recall it, and yet their dependence on others increases over time and increases their vulnerability to this.” The research made several recommendations, including calling for the establishment of a Public Advocate position in the state. April 2016 Volume 23, No. 9 9
NEWS
CARING FOR COGNITIVE IMPAIRMENT Nurses are increasingly providing care to more patients who have cognitive impairment. Caring for people with cognitive impairment can be challenging and often requires the acquisition of new knowledge and skills.
NSW NURSES AND MIDWIVES PROTEST AT MEDICARE CUTS NSW nurses and midwives have ramped up their campaign against the federal government’s plan to axe a further $650 million in Medicare funding. The NSW Nurses and Midwives’ Association (NSWNMA, ANMF NSW Branch) held a community forum to save Medicare at Trades Hall in Sydney last month. It followed a community led rally and national door knock in February. The government’s proposed funding cuts of 23 MBS items for pathology and diagnostic imaging services, including ultrasounds and Pap smears, announced in December has outraged the health sector and the ANMF. “The cuts will affect some of the most vulnerable and disenfranchised in our community, putting a cost barrier in the way of those who need access to these services the most,” NSWNMA Acting General Secretary Judith Kiejda said. The campaign was to stop the government from cutting funding, outsourcing Medicare and Americanising Australia’s universal healthcare system, Ms Kiejda said.
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This is one reason why the Australian Commission on Safety and Quality in Health Care recently launched the national Caring for Cognitive Impairment campaign, which aims to improve knowledge and care practices to provide better outcomes and reduce the risk of harm to people with cognitive impairment in hospital. Patients in hospital with conditions such as dementia or delirium are at much greater risk of adverse events and preventable complications while they are in hospital. Of course, this can have long-term consequences. Harm can be minimised if a person’s cognitive impairment is identified early, and their risk of harm, such as falls or pressure injuries are identified and acted upon. Delirium can be prevented with the right care. Small measures can make a huge difference. Nurses play a critical role in the provision of the day to day care for patients with cognitive impairment, and are rewarded when they see how they can make a difference to patient outcomes.
Nurses can prevent delirium through ensuring good hydration and nutrition, enough sleep and normal sleep patterns, checking for pain, and encouraging independence and mobility. Simple measures like making sure patients have their glasses and their hearing aids handy helps. Nurses can be alert to any confusion and act on it, learn how to identify delirium and make sure that the underlying cause is investigated and treated. They can encourage carers and families to be involved and ask them for tips on how to reduce a person’s distress in the unfamiliar environment so that sedation is not the first response to a person’s agitation. Nursing leaders are improving systems to support highquality care. The Caring for Cognitive Impairment campaign is for everyone who cares for people with cognitive impairment. Many nurses are joining the campaign as it matters to them professionally, but also because it often touches them personally. Many nurses have parents or loved ones who have cognitive impairment and want their hospital experience to be positive. The Australian Nursing and Midwifery Federation ( ANMF) has committed to the campaign as a key supporting organisation in recognition of the critical role nurses have in providing high quality care for people with cognitive impairment. Go to the campaign website: cognitivecare.gov.au and commit to cognitive care to receive a certificate on what action you’ll take. You can sign up to receive a regular newsletter, listen to webinars, view the videos, or learn from other nurses about how they have made a difference.
RN to MD
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NEWS GETTING TO KNOW THE NENA COMMITTEE NENA President Louise Dearman has been an Enrolled Nurse for 32 years. For the past 15 years she has been employed at the North Eastern Health Centre, currently as Clinical Manager. “I am extremely passionate about the role of the Enrolled Nurse, their varying scope of practice and for a greater understanding of this within our profession.” EN LOUISE DEARMAN PRESIDENT OF NENA WITH PATIENT. PHOTO: GRANT NOWELL
NEW DIRECTIONS FOR ENROLLED NURSES The National Enrolled Nurse Association of Australia (NENA) is setting a future direction following its biennial conference and a dynamic newly elected committee. NENA’s new vision will include a Facebook page and re-launch of NENA News. NENA is a special interest group of the ANMF. Membership to NENA is open to all enrolled nurses and student enrolled nurses around Australia. The 12th NENA conference, held in Adelaide in October, theme ‘Focusing on Today’s Enrolled Nurse’ included an update on the latest news for enrolled nurses. This included the national competency standards for the enrolled nurse; development of the new enrolled
ELDER ABUSE IN THE PUBLIC SPHERE A national forum has drawn attention to the rise of elder abuse within the community and collectively backed the implementation of comprehensive strategies to protect the rights of older Australians. The 4th National Elder Abuse Conference, run by Seniors Rights Victoria, was held in Melbourne in February, with the forum appropriately reflecting the current period of newfound recognition of elder abuse within society. Marking the occasion, federal Attorney General George Brandis anmf.org.au
nurse standards for practice; and review of the national codes. NENA formed in 1994 and has been a driving force in the evolution and recognition of Australian enrolled nurses, ANMF Assistant Federal Secretary Annie Butler said. “From lobbying for a consistent national approach to EN education to increasing the awareness of the value of the EN in the healthcare system today, NENA has promoted, educated and valued the contribution of ENs on a national level.” NENA wants to hear from enrolled nurses. “Wherever you work, no matter how long you have been qualified, NENA wants to hear from you,” NENA President Louise Dearman said. NENA is calling on enrolled nurses to submit material or ideas for the revamped NENA News. “We want people to send through content – stories, ideas, abstracts of articles – of what they are doing or specific issues for them.” To submit stories to NENA email, info@nena.org.au For more information, visit www.nena.org.au
NENA Secretary Siobhan Bidgood started nursing in mental health in 1982. She is back working in the field after having worked also in HIV/AIDs and oncology. “My ambition for NENA is for us to reach all ENs in Australia and to be the space for ENs to join the conversation about nursing now and in the future.” NENA Public Relations Officer Hollie Purton completed her diploma of nursing in 2012. She works in a small rural hospital in Victoria. “I work with a dynamic team of enrolled nurses overseen by an ANUM each shift. We nurse acute and aged care working across the National and Aged Care Standards. I’m confident the future of NENA has great things in store and I hope to spark interest in younger enrolled nurses to fully value their careers.” NENA Committee Member and EN of 30 years plus, Sue White works at Coffs Harbour Health Campus, NSW. “During my time as an EN, I have always been passionate to promote the integral role we play as part of the healthcare team. This is the vision I have for NENA. I have been a NSWNMA Branch Official and NSWNMA Councillor for many years: I want to bring this experience and knowledge to my role on NENA.”
highlighted the importance of the issue by announcing an Inquiry into laws and frameworks in a bid to help combat elder abuse. The investigation adds weight to the upsurge in elder abuse scrutiny taking place across the country, namely the current Inquiry into elder abuse being undertaken in New South Wales. One of the major issues was speaking out about elder abuse, which remains taboo. While a lack of concrete data makes it difficult to pinpoint its exact prevalence, statistics show family members, and more specifically sons, as the most likely perpetrators of elder abuse. Such relationships of dependence can often result in victims being unwilling to press charges against perpetrators for fear of repercussions and losing ties with the family member. Financial abuse remained the most
common form of elder abuse, followed by psychological and physical abuse, according to the presenters. Speaking at the conference, Dr John Chesterman, from the Office of the Public Advocate said service coordination to prevent elder abuse needed to be encouraged and developed. He said the lack of a systematic and rigorous study of elder abuse was a fundamental shortcoming and called for the federal government to initiate a large-scale prevalence study and trigger a royal commission. Dr Chesterman also raised the potential for stand-alone elder abuse response units and legislating mandatory reporting as ways to achieve progress. Yet, according to the speakers, there is a growing awareness of elder abuse which is is partly attributed to annual elder prevention campaigns. April 2016 Volume 23, No. 9 11
NEWS BRIEF
EMPOWERING PATIENTS WORLD WIDE
DEFINING QUALITY IN AGED CARE The age of Consumer Directed Care (CDC) is upon us, with clients and aged care providers moving towards individually tailored care plans that pinpoint needs and goals and help significantly shape improved quality of life. A candid exploration of the meaning of quality through the eyes consumers, providers, government, and advocates was delivered at the Quality in Aged Care Conference run by the peak consumer body for older Australians COTA Australia, delivered in Sydney last month. CDC connects with recent aged care reform across all home care packages that have given consumers greater flexibility to choose how they would like to manage their package and spend funds. The Aged Care Legislation Amendment (Increasing Consumer Choice) Bill 2016 was passed by the Senate in March. The changes signal the evolution of a consumer driven aged care system that will increasingly support older people to make choices in both community and, eventually, residential aged care.
12 April 2016 Volume 23, No. 9
The national program, which is voluntary for providers and has drawn heavily from a successful Victorian model run for the past decade, has received support from more than 300 organisations. However, keynote speaker Dr Stephen Judd, CEO of independent provider HammondCare, argued that quality is subjective and warned that CDC will not automatically address aged care. “The subjective nature of quality does apply to aged care but it applies differently in different environments. If you asked ten people to define what a quality aged care service is you might get ten different answers. I fear the way the standards and quality reporting have been approached has led to a standardisation of care rather than a proliferation of innovation and client direction in care.” Dr Judd described the growth of CDC as an opportunity to improve aged care but stressed that a service has to deliver more than just safety and compliance. COTA Australia CEO Ian Yates said the peak body would push for a consumer support platform that delivers quality advice to people as the changes become embedded in care plans. “What we’re saying is you’ve got the funding arrangements around providers, you’ve got a regulatory environment, and you’ve got consumers increasingly being handed the resources. But we need a range of information and advisory and support services.”
Have you or your nursing team got an idea or initiative that helps empower patients? Whether it is implementing peer to peer support in your local area or getting care givers and family members involved in patient education, submit your idea to Care Challenge’s Patient Empowerment Campaign. All projects submitted by 12 April are eligible for award at International Nurses Day. Entries after 12 April will be considered up to November 2016. Care Challenge is the ideas-sharing website of the nursing community worldwide created by Connecting Nurses. The website allows nurses to propose ways to improve patient and healthcare professional education, disease prevention and care and more generally innovate the nursing profession. Nurses share ideas that benefit their colleagues all over the world. Care Challenge is supported by the International Council of Nurses (ICN). Go to www.care-challenge.com/en/innovations for more information and to register your idea.
NURSES AND MIDWIVES FROZEN OUT Nurses and midwives in Western Australia have been left out in the cold since the government placed a sector wide external recruitment freeze across the general government sector, including health last December. The freeze, which applies until 30 June 2016, means vacant positions can only be filled by existing employees within the general government public sector. The directive is part of a $1.3 billion saving package to further clamp down on expenses due to a forecasted state budget deficit for 2015-16 of $3.1 billion. Consequently, nurses in WA say graduates are finding it more difficult to find employment and nurses that are employed are overworked, stressed and exhausted. A WA graduate nurse, who is looking for work and wished to remain anonymous, said the situation was dire. Not only for nurses but more so for patients. “My partner who is an experienced RN is working six days a week to make up the shortfall in staff, both in public and in private. She is thinking of quitting nursing as she cannot see an end to the exhaustion. If she leaves along with the senior nurses being made redundant [as part of the cost cutting exercise] there goes all that experience and knowledge that we as new nurses need.” The WA graduate nurse said the problem layed not with the hospital management but by the way they are being hamstrung by fiscal policy. “I applaud them for doing the best they can.” anmf.org.au
WORLD
AN OUNCE OF PREVENTION TO SAVE OUR HEALTHCARE A leading academic in political economy and sociology has warned austerity measures in healthcare will lead to tremendous hardship and suffering for many Australians if applied. Speaking at Melbourne University last month, Professor of Political Economy and Sociology at Oxford University David Stuckler said countries that applied austerity to health and social protection measures during times of economic downturns had worse health outcomes and slower economic recoveries than counties that opted for stimulus over austerity. Professor Stuckler said it was important to learn from policy made during past financial crises and how those lessons are relevant to Australia today. “Too often decisions are made about economies with little regard to the human costs about those choices. The voices of those affected are so often unheard and unnoticed in the debate.” Using Greece as a current example, Professor Stuckler said the nation was facing deepening economic turmoil despite severe austerity measures being implemented. “The country made a number of economic mistakes, which resulted in deep cuts. But it was the magnitude of austerity that Greece took that is eye watering.” To meet deficit-reduction targets set by the International Monetary Fund, Greece applied austerity measures that included cuts to hospital funding by 40% in one year as well as rapid slashing of public health services. Professor Stuckler said 35,000 doctors, nurses and health workers lost their jobs and essential basic hospital equipment such as gloves, gowns and alcohol wipes were made in short supply. Subsequently, Greece has found itself in the middle of a public health disaster with people left unable to access care. Major health issues that have emerged as a result of the cuts include HIV. “When Greece cut its HIV program by half, including its needle exchange program, it became the only European country during the Global Financial Crisis (GFC) to experience a significant HIV outbreak,” Professor Stuckler said. “Greece also cut its mosquito spraying programs that kept Malaria at bay for three decades, the results of which saw a return [of the disease] when the cuts took effect.” anmf.org.au
While Greece had one of the lowest suicide rates in Europe when the labour market was slashed and cuts were made to mental health prevention programs, suicide rates substantially increased, Professor Stuckler said. “Further to this mortality rates, including infant mortality rates, rose by 40%,” he said. “The irony that Greece now faces with HIV, TB, Malaria and drug resistance on the wards is that it is costing more to control than it would have been to prevent.”
THE AIM OF AUSTERITY HAS HAD THE OPPOSITE EFFECT COSTING THE TAXPAYER MORE WHILE PUTTING SOME OF THE MOST VULNERABLE GROUPS IN HARM’S WAY
or access to medication and there was no significant increase in suicide, said Professor Stuckler. “To top it off, according to the world’s first happiness report produced by the UN, in the middle of the worst banking crisis we know, Iceland came out as one of the world’s happiest nations. The International Monetary Fund also ended up with 5% growth and unemployment [shrank to 4%].” Professor Stuckler suggested even if Australia wanted to follow the path of austerity there was a smart evidence based way to do it, which essentially is to protect health and education. “That’s the opposite of what we have seen in Europe, and yet despite this the plan in Europe has not changed. Greece is still undergoing deep austerity with little end in sight.”
In contrast Iceland avoided a public health disaster during its largest banking crisis in history during 2008, which resulted in soaring unemployment and the value of its currency crumbling, Professor Stuckler said.
Professor Stuckler said there was clear evidence that austerity harms and that it fails to accrue. Alternatively he said economic policy should be guided by “do no harm”. He said good economic policy should help people return to work. “The correlation of unemployment with alcoholism and suicidal thoughts is long known. Workers who have lost their jobs should be supported to be employed and when done correctly, this reduces spending on healthcare bills, unemployment cheques and helps economies.”
In an unusual step, Iceland’s politicians put austerity to the vote resulting in the country overwhelmingly wanting to pay creditors gradually, rather than all at once through austerity. Subsequently, the economy largely recovered, no one lost health coverage
According to Professor Stuckler the age old cliché, ‘an ounce of prevention is worth a pound of cure,’ is really true. “That’s the thing about public health; it’s a wise choice in the good times and an urgent necessity in the worst times.” April 2016 Volume 23, No. 9 13
ETHICS
PROFESSIONAL ETHICS, BULLYING AND WORKPLACE CLIQUES Megan-Jane Johnstone Megan-Jane Johnstone
There is growing recognition in the international literature that bullying in nursing is a widespread although underreported phenomenon (Johnson 2009). Worryingly, research suggests that despite legislative provisions and a plethora of organisational polices and guidelines aimed at reducing the incidence and harmful impact of bullying in the workplace, it remains pervasive in the healthcare sector. The problem of bullying is also believed to be growing in the higher education sector where a ‘culture of competition’ for positions, status and recognition has seen people cross the boundaries of acceptable behaviour.
References Crothers, L.M., Lipinski, J., & Minutolo, M.C. 2009. Cliques, rumors, and gossip by the water cooler: female bullying in the workplace. The Psychologist-Manager Journal, 12:97-110. Hutchinson, M., Vickers, M., Jackson, D., & Wilkes, L. 2006. Workplace bullying in nursing: towards a more critical organisational perspective. Nursing Inquiry, 13(2): 118-126. Johnson, S.L. 2009. International perspectives on workplace bullying among nurses: a review. International Nursing Review, 56:34-40.
Megan-jane Johnstone is Professor of Nursing in the School of Nursing and Midwifery at Deakin University in Victoria. Professor Johnstone has extensive interest and expertise in the area of professional ethics in nursing.
Bullying is conventionally positioned as an occupational health and safety issue. While this positioning is correct, in the case of the nursing profession, it is incomplete since it overlooks its standing as also being a matter of professional ethics. Regardless of what form it takes, bullying entails a breach of the accepted ethical standards of the profession and ought to be censured accordingly.
A question of nursing ethics
As research on the prevalence of bullying has demonstrated, laws are not and cannot be the only solution (Johnson 2009). Something much more is required if the incidence and harmful outcomes of bullying are to be redressed. For example, there needs to be a greater emphasis on the ethical dimensions of bullying and the moral obligations of nurses to: correctly recognise bullying behaviours, support the implementation of feasible processes to stop bullying, and make notifications to nurse regulating authorities particularly when the bullying is placing patient safety at risk.
Bullying as unethical conduct Value Statement 2(3) of the NMBA’s (2008) Code of ethics for nurses in Australia (www. nursingmidwiferyboard.gov.au) makes clear that ‘dismissiveness, indifference, manipulativeness and bullying are intrinsically disrespectful and ethically unacceptable’.
14 April 2016 Volume 23, No. 9
Bullying by its very nature is disrespectful, dismissive, and indifferent to the humanity of another. It also often involves the most insidious manipulation of the truth about what is going on. When viewed against Statement 2(3), even at its most basic level, bullying is unethical professional conduct.
Correctly recognising bullying
Linchpin to redressing bullying is recognising the many forms it can take. Bullies who yell and scream and ‘throw themselves around’ are more easily identified and their behaviours easier to verify by independent onlookers. Those who engage in more insidious and subtle forms of bullying, however, are much more difficult to recognise. ‘Relational aggression’ (also called social aggression and indirect aggression) is especially difficult to verify particularly if perpetuated via workplace cliques or ‘in-groups’ united by an unspoken ‘culture of friendship’ and empowered by ‘having friends in high places’ (Crothers et al. 2009; Johnson, 2009). Relational aggression and workplace cliques have been identified as being a particularly female form of bullying and, as such, have particular resonance for the nursing profession. This form of aggression, which is calculated and unrelenting, aims to intentionally harm another via a range of behaviours such as: constant gossiping, rumour-mongering, ignoring or belittling the targeted person’s achievements and successes, withholding information, undermining the targeted person’s authority in the workplace, ‘putting them down’, removing key areas of responsibility from them, subtly sabotaging their ideas for innovation or else the bully manipulatively taking credit for them. It can also involve social exclusion and alienation from the ‘in-group’ together with intentional isolation (eg. not returning phone calls, not replying to or delaying replies to email, ignoring the target when passing them in the corridor, avoiding eye contact). Individually these and like behaviours can seem insignificant. over time, however, their cumulative effects can be devastating for victims leaving them feeling isolated, marginalised and alienated (as if having suffered a ‘social death’), low
in self-esteem, anxious, depressed and even suicidal (Johnson, 2009; Hutchinson et al. 2006).
Feasible processes
Those who are being bullied simply want the bullying to stop. Processes to achieve this range from: confronting the bully directly (‘if the victim feels confident to do so’), or lodging a formal complaint with a supervisor or human resource manager. In either case, the victim is required to have some ‘evidence’ of the behaviour being confronted. To this end, antibullying policies and guidelines advise victims to ‘document all instances of the bullying behaviour including witnesses’. This requirement, however, may be impossible to meet, particularly in the case of relational aggression perpetrated in the context of workplace cliques and where bullies, aligned with the clique, have been able to create a ‘veneer of legitimacy and ensure their abusive behaviour remain[s] officially undetected’ (Hutchinson et al. 2006). Because of a bully’s ‘network of alliances’, which may involve management acquiescence, a victim’s complaint may not be taken seriously, the bullying behaviour itself normalised and tolerated (eg. ‘Oh, don’t take it so seriously.That’s just Jan…’), and the recipient of the bullying increasingly regarded and stigmatised as ‘the problem’ (Hutchinson et al. 2006). In the face of a bully lying and manipulating the truth, it can be near impossible for a victim to dispel this impression – even more so if passive bystanders, who fear becoming a target themselves, are unwilling to speak up about what they know.
Censuring unprofessional conduct
Bullying behaviour, which may encompass relational aggression and workplace cliques, is unconscionable and must be stopped. It harms not only the recipient, but bystanders to the aggression and the productivity of the employer organisation. The degree to which bullying has been normalised, tolerated and even rewarded in some contexts needs to be exposed and the perpetrators held to account. Meanwhile, processes that place an unfair burden of proof on the silent victims of bullying must be overhauled. anmf.org.au
INDUSTRIAL
ALP SEEKS IMPROVEMENTS TO WORKERS’ PROTECTIONS Nick Blake, Senior Federal Industrial Officer
One of the great disappointments of the Productivity Commission (the Commission) Report into Australian workplaces undertaken in 2015 was that the Commission appeared to proceed on the assumption that their ultimate goal was to enhance the arrangements of employers and government and simply ignore any employee unfairness. Accordingly, readers may recall that the Commission recommendations to government focussed on reducing penalty rates for all employees, further reductions in award entitlements, making it more difficult for trade unions to engage with members and proposing substantial increases in penalties for both trade unions and employees. Interestingly the Commission undertook its review at a time when there were a number of well publicised examples of employees being exploited by well-known Australian companies. These included: • Myers employing their cleaning staff as sub-contractors resulting in the cleaners being paid below the award wage, been denied penalty rates and not getting their superannuation entitlements. • The well-publicised exploitation of overseas workers at 7 Eleven stores throughout Australia involving the underpayment of wages, the doctoring of pay records and the intimidation of employees. • Pizza delivery drivers being paid at $6 per hour in bogus contracting arrangements. • The widespread exploitation of migrant workers in the agricultural and the food processing sectors being required to work dangerously long hours for less than the award wage. Sadly, despite these blatant examples, they were ignored by the Productivity Commission and, to date, there has been no positive action by the federal government. Given the foregoing it was very pleasing to hear the announcement the ALP opposition is pursuing changes to the current laws specifically targeting dishonest employers who exploit employees. The changes, set out in the Fair Work Amendment (Protecting Australian Workers) Bill 2016, were introduced into the Parliament in March 2016. The Bill seeks to change existing industrial laws in a number of significant ways designed to
anmf.org.au
discourage the mistreatment of vulnerable workers such as: • strengthening the test for sham contracting; • making company directors liable for wages owed to workers as a result of ‘’ ‘phoenixing’; • increasing the penalty for companies (other than small businesses) that intentionally contravene provisions of the Fair Work Act relating to terms and conditions of employment; • introducing criminal offences for serious contraventions of the Act; • clarifying that the Fair Work Act applies to all workers irrespective of their immigration status.
involves the transfer of assets from one company with debts to a new company to avoid paying creditors, tax or employee entitlements. Existing debts are left with the old company, often placing that company into administration or liquidation, leaving nothing to pay wages and other accrued entitlements. Meanwhile, a new company, often operated by the same directors and in the same industry as the old company, continues the business under a new structure. By engaging in this illegal practice, the directors avoid paying debts, including outstanding wages and other entitlements owed to workers. This dodgy practice has become much more widespread over the last 10 to 15 years across the Australian economy, including in health and aged care, and must be stamped out.
GIVEN THE FOREGOING IT WAS VERY PLEASING TO HEAR THE ANNOUNCEMENT THE ALP OPPOSITION IS PURSUING CHANGES TO THE CURRENT LAWS SPECIFICALLY TARGETING DISHONEST EMPLOYERS WHO EXPLOIT EMPLOYEES.
The ANMF is also pleased to see that the Bill seeks to improve protections for overseas workers. Overseas workers are ripe for exploitation and there have been numerous examples of this. Foreign workers here illegally are presently unable to take action under Australian laws to recoup underpayment of wages. And while many may believe that ‘illegals’ should not be protected, it is important that Australian laws remove any incentive for employers to favour the employment of illegal workers over legal workers. It is important our laws treat all workers equally. This is in the interest of foreign and local workers because in the long run the exploitation of foreign workers undermines wages and conditions for everyone.
While we support all of these improvements, the ANMF is particularly pleased the Bill seeks to introduce changes to prevent employers escaping liability through ‘phoenixing’, by making directors of companies personally liable for debts in relation to outstanding entitlements owing to workers.
The Bill to be debated in the Parliament seeks to rectify a number of serious shortcomings in our industrial laws that are long overdue to be fixed. And with industrial relations again shaping up as a battleground in the 2016 federal election it is incumbent on all political parties to reveal how Australian workplace laws will be fair and balanced for all.
Broadly speaking ‘phoenixing’
The ANMF will watch with interest. April 2016 Volume 23, No. 9 15
FEATURE
“AUSTRALIA HAS A MORAL AND LEGAL OBLIGATION TO TREAT EVERY HUMAN BEING COMPASSIONATELY AND WITH RESPECT, COURTESY, AND CONSIDERATION, IRRESPECTIVE OF THE PLACE OF TREATMENT.” LEE THOMAS A PORTRAIT OF ASYLUM SEEKER MOHAMMAD SOHAIL, 6, FROM AFGHANISTAN, TAKEN IN 2013 WHEN LIVING IN THE INDONESIAN TOWN OF CISARUA. WITHOUT DOUBT, THE POIGNANT IMAGE REFLECTS AN ONGOING GLOBAL ISSUE THAT DEMANDS COLLECTIVE ACTION. PHOTO: ALEX ELLINGHAUSEN
16 April 2016 Volume 23, No. 9
anmf.org.au
FEATURE
HOW AUSTRALIA’S ASYLUM SEEKER POLICY IS DAMAGING CHILDREN
Australia’s asylum seeker policy continues to polarise opinion, with growing unrest confirming the time has come to definitively decide what the nation considers its ethical and moral obligations. Unwaveringly, nurses and health professionals believe the government’s current policy of indefinite detention is causing immeasurable and irreparable harm and must end. Robert Fedele speaks to the key campaigners reforming the debate.
I
t has been described as nothing more than a human warehouse. A place where men, women, and unforgivably, children, feel so utterly hopeless that they sometimes imagine they would be better off dead. The unbearable living conditions make getting by difficult but nothing rivals the episodes of sexual assault, self-harm, and abuse reported as commonplace. People sit and wait, sometimes for years, as the prospect of freedom fades. This is the harsh, unmasked reality, of life in detention at one of Australia’s offshore immigration processing centres. For community services worker Samantha Betts, detention was an eye-opener. Working anmf.org.au
as a Child and Youth Recreation Officer with charity Save the Children, Samantha spent almost a year on Nauru during 2013/14 trying to improve the daily lives of children and adult females. “It was a very rude shock when I got there,” she recalls. “The living conditions are just absolutely abhorrent. It’s just unacceptable. We were basically just trying to give the kids a bit of an outlet to actually play and have a bit of psychosocial development and get away from the trauma of the camp.” Samantha still finds the memories from Nauru hard to erase. One scene which sticks out surrounds the flooding of the camp and its subsequent evacuation. Staff were shuffled out until water subsided, but children and families were left behind. “The fact we were cleared out to safety and the kids and parents weren’t was just really hard hitting in terms of how they were treated and seen in not being important enough to be kept safe.” Since Nauru, Samantha has become an active voice against the Australian government’s treatment of asylum seekers. Last year, she made a submission to and appeared before a Senate Inquiry into Recent Allegations relating to Conditions and Circumstances at the Regional Processing Centre in Nauru. Samantha’s submission alleged numerous shortcomings.
She pinpointed inadequate housing and lack of privacy, the welfare and healthcare of children being overlooked, frequent reports of sexual and physical abuse, a lack of access to proper legal representation and residents being referred to by identification numbers. “It is our moral obligation to these people to minimise the suffering they have already endured as the product of our immigration policy,” Samantha wrote in her submission. “We now have the opportunity to change their lives for the better, and we can only ask for their forgiveness of the crimes we’ve committed against them in years to come.” On reflection, Samantha says speaking out was imperative. “I think remaining silent on something like this is being complicit,” she says purposefully. We can dig our head in the sand and just hope it goes away but the kids don’t have that option.” Samantha admits the contentious issue has ventured into black and white territory. “A lot of advocates, including myself, we’re not for open borders. We don’t say yes, let’s let everyone in. There does have to be a check and balance and people need to be processed. However, the international standards on processing of asylum seekers for detention are 71 days for an adult and we’re going over that by detaining people for years. It’s ridiculous.” April 2016 Volume 23, No. 9 17
FEATURE
THOUSANDS ATTEND A RALLY IN MELBOURNE EARLIER THIS YEAR IN A BID TO SAVE ASYLUM SEEKERS. PHOTOS: SAVE THE CHILDREN AUSTRALIA
“WHEN I THINK ABOUT THE RAPE THAT IS HAPPENING IN NAURU I THINK IT WILL HAPPEN TO ME. I MISS MY FRIENDS. I AM STAYING HERE – WE CAME IN THE SAME BOAT BUT THEY ARE FREE. SOMETIMES I THINK IF I HURT MYSELF WE WILL GET OUT.” GIRL, 15 (SOURCE: REPORT TO AUSTRALIAN HUMAN RIGHTS COMMISSION, MONITORING VISIT TO WICKHAM POINT DETENTION CENTRE, DARWIN, NT}
Charting Australia’s asylum seeker policy
The Australian Human Rights Commission (AHRC) began investigating the treatment of asylum seeker children back in 2004 when it released its landmark report, A last resort? National Inquiry into Children in Immigration Detention. It focused on the then most recent wave of boat people seeking a better life on Australian shores, painting a bleak picture of the harm caused by mandatory long-term detention on children, and demanding governments end the regime.
and development, by examining evidence from children detained in detention centres including Nauru and Christmas Island. The damning report found children in detention, including 186 detained on Nauru, experienced higher rates of mental health problems and suffered extreme levels of physical, emotional, psychological and developmental distress. An unaccompanied 17-year-old in detention on Christmas Island, cited in the report, illustrates the pervasive broken mentality. “My hope finished now. I don’t have any hope. I feel I will die in detention.”
The report’s release did trigger change, with noticeable improvements made in the treatment of asylum seeker children and their families and a substantial cohort of children being removed from detention.
The report made more than a dozen recommendations, including calling for a Royal Commission to fully examine Australia’s policy.
By 2005, all asylum seeker children had been removed from immigration detention. Yet those years of hard earned gains were punctured with the introduction of Operation Sovereign Borders in 2013, an attempt by the government to ‘stop the boats’ and curtail people smuggling into Australia by enforcing a zero tolerance approach. By 2013, a record number of 1,992 children were placed in immigration detention.
Elizabeth Elliott AM, Professor in Paediatrics and Child Health at the University of Sydney, was engaged as a consultant for the 2014 Inquiry into Children in Immigration Detention and contributed to the Forgotten Children report. Professor Elliott says the investigation offered renewed opportunity to give voice to children and families who had been “out of sight and out of mind”.
A decade on from its initial report, the AHRC released findings from a second investigation into the issue in 2014 with The Forgotten Children – National Inquiry into Children in Immigration Detention. The report assessed the impact of prolonged immigration detention on children’s health, wellbeing, 18 April 2016 Volume 23, No. 9
Life in detention
Despite the importance of its findings, the report was largely met with scepticism and claims of exaggeration by the government. “We felt the report was an opportunity to give voice to some of their [asylum seekers] concerns. I think it did so, and there was a certain degree of public support that followed the report, despite the fact that it was virtually ignored and dismissed by government.”
Professor Elliott says the report was unequivocal in outlining how Australia’s asylum seeker policy, perpetuated by flip flopping governments, must end. In 2015, Professor Elliott was again called on by the AHRC as a consultant for a similarly geared report, titled The health and wellbeing of children in immigration detention – Monitoring Visit to Wickham Point Detention Centre, Darwin, NT. Visiting Wickham Point, Professor Elliott interviewed more than 60 children who had been living on Nauru but whose families had been sent to Darwin for medical assessment. Unsurprisingly, the Wickham report echoed previous investigations into the health of children in detention. Specifically, it conducted three formal evaluations, screening for Post-Traumatic Stress Disorder (PTSD), developmental problems, and hopefulness and despair. Paediatricians found 95% of children over 8 years of age were at high risk of PTSD, and alarmingly, more than 95% felt their situation was hopeless. “That’s significant because if you’re living in a condition of adversity and you have some hope then that gives you resilience and it’s a protective factor,” Professor Elliott explains. “On the other hand, if you’re feeling hopeless then that signifies an increased risk of later depression, anxiety and other related mental health problems. “It’s very difficult to determine what traumatic episode causes what. There’s a sort of cumulative trauma. There’s the trauma anmf.org.au
FEATURE
IMAGES FROM FREE THE CHILDREN NAURA FACEBOOK PAGE, CURATED BY CHILDREN LIVING BOTH IN THE COMMUNITY AND IN THE DETENTION CENTRE.
FEATURE
ANMF ASSISTANT FEDERAL SECRETARY ANNIE BUTLER AT A FORUM ORGANISED BY THE AMA ON THE HEALTHCARE OF ASYLUM SEEKERS.
of what was witnessed at home. There’s the trauma of a boat journey. There’s the trauma of being put into a detention centre with big fences. There’s trauma then to witnessing peoples’ distress inside the detention centre. Then there’s the trauma to do with the loss of hope when there’s no processing of asylum claims and no future in sight.” At Wickham, Professor Elliott was given rare insight into how children felt. One child, who had been cutting herself, crying, and refusing to go to school, is characteristic of the moving accounts. “There was one little child who was nine who drew us a picture of the boat journey to Australia and she was crying on the boat. It was a traumatic journey. Then she drew us a picture of herself in Nauru surrounded by high fences. Then she drew a picture of herself on the ground and she said that was herself dead because she’d climbed up and jumped off a building.” Another child was even blunter. ‘You can do anything to me but don’t send me back to Nauru,’ he told Professor Elliott. While reports published by the AHRC have failed to generate major changes, the government has agreed to review cases deemed clinically concerning. Critically, the fluctuating fortunes surrounding the issue took a nosedive when the High Court dismissed a legal challenge in February opposing the Australian government’s system of sending asylum seekers to Nauru. The decision backed the government’s plans to send 267 asylum seekers, including 37 babies and 54 children, currently in Australia for medical treatment back to Nauru. Widespread outcry followed with rallies across the country facilitated through the Let Them Stay campaign. “Effectively, what we’ve done as a nation is to relieve ourselves of the responsibility for the health and mental health of these children,” Professor Elliott says. Professor Elliott, who spoke 20 April 2016 Volume 23, No. 9
SAMANTHA BETTS, SECOND FROM LEFT, AND HUMAN RIGHTS BARRISTER JULIAN BURNSIDE, SPEAKING AT A PANEL DISCUSSION IN TASMANIA LAST YEAR EXAMINING AUSTRALIA’S REFUGEE POLICY.
at the Australian Nursing and Midwifery Federation’s (ANMF) Biennial in Adelaide last October, says the time has come to draw a line in the sand. “We’re a civilised country and we have got to come to a solution that is going to protect our borders without doing harm, particularly to children.”
Challenging the Australian Border Force Act
“I don’t think that visit will ever leave me,” says Registered Nurse Alanna Maycock when asked to revisit the five days she and colleague Professor David Isaacs spent on Nauru in late 2014 as consultants for International Health and Medical Services (IHMS), the private operator charged with providing healthcare at Australia’s mainland and offshore detention centres. “It’s still as vivid now as when we went. We still can’t believe how horrendous it was.” A paediatric nurse at Sydney’s Children’s Hospital at Westmead, Alana witnessed living conditions on Nauru first-hand and was understandably disturbed. Among her most shocking recollections is a six-year-old girl who attempted to hang herself with fence ties and a mother who had been raped. On return to Australia, Alana and Professor Isaacs felt compelled as health professionals to tell their stories. Growing unease about Australia’s immigration policy intensified when the federal government introduced the Australian Border Force Act on 1 July, a new disclosure offence that carries a jail term of up to two years for nurses, health professionals and humanitarian workers who blow the whistle on their experience at detention centres. Alana was part of a collective of more than 40 health workers and humanitarian staff, and the sole nurse, to sign an open letter defying the laws. Alana admits taking a stand was difficult. “When the Border Force
Act came out I stopped [talking] because I was absolutely petrified about my own kids. But at the end of the day this is important evidence so we kind of have a duty of care to report that evidence.” Alana and others have unsuccessfully called on the government to repeal the Act and believe their refusal reflects a strategic measure aimed at gagging future staff. “They’ve come out and said they don’t want to prosecute anybody. But from our point of view, if you don’t want to prosecute doctors and nurses, then repeal the Act. But they won’t.” As the asylum seeker issue continues to dominate public debate, Alana remains committed to ending detention. Last February, she was one of several guest speaker at a forum organised by the Australian Medical Association (AMA) examining the healthcare of asylum seekers and harm caused by detention. Numerous strategies were canvassed, including one spearheaded by AMA president Brian Owler, who wants medical staff working in the system to boycott the policy by pulling out of working in immigration detention centres.
Nurses take a stand
Health professionals like Alana offer a public voice necessary to frame the debate but it is frontline nurses like Erin Killion who illustrate the power of unity. An Emergency Department nurse from Newcastle, Erin launched the Facebook page Nurses Against the Border Force Act last year. “I’ve cared about refugee issues for a while but I felt a bit helpless to do anything about it,” Erin explains. “But when the government decided to try and fire its health workers, who were just telling it like it is in detention centres, it was a step too far. I couldn’t believe that they would dare try and do this to my colleagues who are just looking out for their patients. It just stirred something inside me and made me really angry.” anmf.org.au
FEATURE
“WHEN THE BORDER FORCE ACT CAME OUT I STOPPED [TALKING] BECAUSE I WAS ABSOLUTELY PETRIFIED ABOUT MY OWN KIDS. BUT AT THE END OF THE DAY THIS IS IMPORTANT EVIDENCE SO WE KIND OF HAVE A DUTY OF CARE TO REPORT THAT EVIDENCE.” ALANNA MAYCOCK
Since the Border Force Act came into effect, Erin has continued organising regular rallies to highlight the injustice of the laws and raise awareness about harm caused by indefinite detention. She describes attending a rally as uplifting.“You go to these things and hear from really passionate, determined people, and get inspired by activists that are doing really good work and you sort of feel stronger to go back to your community and make points that need to be made and try and change hearts and minds because I do think it will be that that changes the policy.”
Mr Dutton added that the government would not be blackmailed into abandoning the hard-line scheme. “Let me be very clear to these people [people smugglers]. We will not be held to ransom.”
Erin believes significant change is occurring and suggests a national network of nurses interested in campaigning on the issue could be established to help raise further awareness. Registered Nurse Alanna Maycock, spoke at a public meeting in Newcastle organised by Erin’s network. “It just gave us a more relatable first-hand account. As a nurse, I could feel how hard it must have been for her to see those conditions. It strengthened my resolve to stay involved and keep fighting to close the camps.”
Shifting public opinion
ANMF upholds codes of conduct
“THEN SHE DREW US A PICTURE OF HERSELF IN NAURU SURROUNDED BY HIGH FENCES. THEN SHE DREW A PICTURE OF HERSELF ON THE GROUND AND SHE SAID THAT WAS HERSELF DEAD BECAUSE SHE’D CLIMBED UP AND JUMPED OFF A BUILDING.” ELIZABETH ELLIOTT
“I COULDN’T BELIEVE THAT THEY WOULD DARE DO THIS TO MY COLLEAGUES WHO ARE JUST LOOKING OUT FOR THEIR PATIENTS. IT JUST STIRRED SOMETHING INSIDE ME AND MADE ME REALLY ANGRY.” ERIN KILLION
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Collectively, the Australian Nursing and Midwifery Federation (ANMF) has been unrelenting in its push to end Australia’s current asylum seeker policy. At the ANMF’s Biennial in Adelaide last October, delegates from across the country passed a series of resolutions condemning the regime. Delegates resolved to stand in solidarity against mandatory detention as well as continue to campaign for the repeal of the “gag order” placed on nurses and midwives through the Border Force Act. ANMF Federal Secretary Lee Thomas says the importance of nurses working in detention centres being allowed to fulfil the inherent ethical codes and practice standards of the profession cannot be understated. She says asylum seekers, like everyone, deserve a fair go. “Australia has a moral and legal obligation to treat every human being compassionately and with respect, courtesy, and consideration, irrespective of the place of treatment.” Without doubt, the asylum seeker debate reached fever pitch in February when nurses, doctors, and medical staff at Lady Cilento Children’s Hospital in Brisbane refused to allow baby Asha to be discharged and returned to Nauru. The stand resulted in national and international media coverage and inspired heartfelt rallies and vigils across the country. While the government relented to public pressure and placed baby Asha in community detention, Immigration Minister Peter Dutton was later resolute in declaring the move temporary, and a return to Nauru imminent and inevitable. Probed in Parliament by Greens MP Adam Bandt about the government’s policy, Mr Dutton said, “we have been able to stare down the threat from people smugglers” and that “we know that it works in stopping the boats”.
As baby Asha’s fate remains in limbo, Ms Thomas reiterates the urgent need for empathy. “Our concerns extend beyond the safety and welfare of baby Asha and her family. Our concerns are for the health of all asylum seekers and the harms caused by immigration detention.” The Asylum Seeker Resource Centre’s (ASRC) Detention Rights Advocate Pamela Curr believes a revolt is transpiring. “Something is happening in the community that we have not seen for a long time,” she says. “The community is waking up and they are very disquieted about the sight of babies and children behind bars. “It’s really up to the public now because the politicians have dug a hole for themselves and they don’t know how to get out. But we, the people, know what’s right and what humanity is.” Ms Curr joined the ASRC in 2004, starting as a campaign coordinator, before sidestepping to advocating for people in detention as numbers and need swelled. “Unfortunately, arbitrary indefinite detention is the legal policy in this country,” she says. “I can tell you that all are surrounded by four and a half metre non-scalable metal fences, by heavy locked iron gates, and by airlocks. They are, for all intents and purposes, like prisons.” Ms Curr’s role as Detention Rights Advocate involves visiting detention centres and speaking to its residents, and altogether lobbying for improved conditions and boosting community awareness. She describes detention as a dark place filled with uncertainty that sucks out hope. “Peoples’ spirits are broken when they have no autonomy and no freedom to make even the smallest of decisions about their lives. They either die in detention, they go mad, or one day a politician, a minister wakes up, feels a little kindly and signs them out.” Ms Curr considers Australia’s current immigration detention policy “untenable”. “The so-called offshore solution is no solution. It is simply a way of warehousing people until something happens and the government doesn’t know what that something is going to be.” Quizzed on how the situation can be fixed, Ms Curr says a Royal Commission would provide a raw and honest investigation into the problematic issue. “We need a change of policy and we need people to sit down together and decide, politicians, human rights groups, churches, the community, and decide what we believe Australia should look like. April 2016 Volume 23, No. 9 21
ISSUES Improving cardio
IMPROVING CARDIOVASCULAR NURSELED HEALTH SERVICES
References Boyle RM. 2007. Value of rapid-access chest pain clinics. Heart;93:415-416. Clark RA, Conway A, Poulsen V, Keech W, Tirimacco R, Tideman P. 2013. Alternative models of cardiac rehabilitation: a systematic review. Eur J Prev Cardiol;Aug13.
By Carolyn Astley and Robyn Clark Cardiovascular nurse-led services are recognised as an area where health-service capacity can be developed (McAllister et al. 2004; Collins et al. 2013; Neubeck et al. 2011; Neubeck et al. 2012; Clark et al. 2007). Leadership, mentoring and collaboration are important in the advocacy of cardiovascular nurse roles and can develop skills in culture and system change, competencies and connecting people to networks that can develop the emerging leader (Lanuza et al. 2011). Former Dean of Johns Hopkins University School of Nursing and Midwifery, USA (2002-2013), Professor Martha Hill RN, PhD is a researcher who has mentored nurses in research and leadership. As the first nonphysician President of the American Heart Association (1997-1998), Dr Hill has shared her skills in nursing advocacy, identifying the important issues, gaining consensus and advocating for change.
Mentoring masterclass
A masterclass with Dr Hill was held at Flinders University School of Nursing (South Australia) in 2013. The aim was to encourage wide-ranging discussion regarding nurse-led cardiovascular health services. Dr Hill presented on the growing burden of cardiovascular disease projected population factors driving change to the delivery of healthservices in our current environment. Following, discussions on how to meet patient and health system demands, measure practice and what future practice would look like were held. From these discussions emerging themes occurred including: Data systems: The importance of measuring health service disparities and effectiveness using standardised processes was identified, as increasingly metrics reporting is required by hospital administrators. The electronic medical record was 22  April 2016 Volume 23, No. 9
recognised as valuable in providing access to real-time reporting on patient quality of care and clinical outcomes, which can be used to guide improvements in practice. However participants reported in most institutions, processes for data extraction or reports on services were problematic, highlighting duplication of data entry, delays, lack of expert analytics and the need for data and reporting to be integrated into the nursing role.
Collaboration and having a voice: This group were encouraged to continue meeting and develop strategy for advocacy, identifying the key topics that lend themselves to action. These include encouraging early career cardiovascular nurses into clinical doctoral studies ; innovative ideas in the development of future health services such as, considering those comorbid conditions that are linked and common and collaborating with other groups with similar issues.
Advocacy: Sustainable business models are required to develop and support effective nurse-led services. There is need for advocacy to improve the Australian Medicare benefits scheme item numbers, which reimburse nurse consultations at a level that ensures sustainability of the service.
Nursing should be represented on influential committees, come armed with supporting data and possible problem solutions.
System efficiency: Hospitals present a complex system for patients to navigate when seeking healthcare and increasingly timely communication between hospital and primary care is required. Improved hospital systems should support efficient referral between specialties, integrate systems for pathology, diagnostics and imaging and ensure adequate accessibility. The future: Community-based healthservices (ie. heart failure and cardiac rehabilitation) should be accessible to both primary and tertiary care however joint funding and contractual models need to be developed to support this. Characteristics of services should place the patient at the centre. More formalised and coordinated care partnerships between metropolitan and country hospitals may also facilitate equitable access to healthcare. The increasing focus on risk-stratified, rapid assessment, ambulatory care health-services should be explored (Than et al. 2012, Sekhiri et al. 2007; Boyle, 2007).
Conclusion
Following the masterclass participants had a clear vision of the barriers and enablers in their practice and felt more empowered to activate change for better outcomes in cardiovascular patients.
Acknowledgements
The cardiovascular nursing community of South Australia, would like to thank Emeritus Professor Martha Hill for her willingness to share her insights, experience, interest and support in our endeavours.The masterclass was supported by the Flinders University School of Nursing and Midwifery, South Australia. This work has not been supported by any financial grants. Carolyn Astley is Research Manager, Heart Foundation SA and Senior Lecturer at Flinders University Robyn Clark is Professor of Nursing (Acute Care & Cardiovascular Research) in the School of Nursing and Midwifery at Flinders University This article is based on the views and research of the author(s) and has not been peer reviewed.
Collins SP, Pang PS, Fonarow GC, Yancy CW, Bonow RO, Gheorghiade M. 2013. Is hospital admission for heart failure really necessary?: The role of the emergency department and observation unit in preventing hospitalization and rehospitalization. J Am Coll Cardiol;61:121-6. Lanuza DM, Davidson PM, Dunbar SB, Hughes S, DeGeest S. 2011. Preparing nurses for leadership roles in cardiovascular disease prevention. Eur J Cardiovasc Nurs;(10):S51. McAlister FA, Stewart S, Ferrua S, McMurray JJJV. 2004. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol;44:810-9. Neubeck L, Freedman SB, Briffa T, Bauman A, Redfern J. 2011. Four-year followup of the Choice of Health Options In prevention of Cardiovascular Events randomized controlled trial. Eur J Cardiovasc Prev Rehabil;18(2):278-86. Neubeck L, Freedman SB, Clark AM, Briffa T, Baumann A, Redfern J. 2012. Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data. Eur J Cardiovasc Prev Rehabil;19(3):494-503. Than M, Cullen L, Aldous S, Parsonage WA, Reid CM, Greeslade J, Flaws D, Hammett CJ, Beam DM, Ardagh MW, Troughton R, Brown AF, George P, Florkoski CM, Kline JA, Peacock WF, Maisel AS, Lim SH, Lamanna A, Richards AM. 2-Hours accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol. 2012 Jun 5;59(23):2091-8. Sekhiri, N, Feder GS, Junghans C, Hemingway H, Timmis AD. 2007. How effective are rapid access chest pain clinics? prognosis of incident angina and non cardiac chest pain in 8762 consecutive patients. Heart;93:458-463.
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RESEARCH
SCRAP FEE-FORSERVICE FOR INTEGRATED TEAM CARE GP fee-for-service payments for one-off visits should be scrapped in favour of a broader payment for integrated team care, a report released last month recommends. Poor management of chronic disease costs the Australian healthcare system more than $320 million a year, according to the Grattan Institute. The chronic failure in primary care report released last month shows ineffective management of heart disease, asthma, diabetes and other chronic diseases. Only one quarter of the nearly one million Australians diagnosed with type 2 diabetes receive recommended monitoring and treatment. Three quarters of Australians over the age of 65 have at least one chronic condition. “Each year there are more than a quarter of a million admissions to hospital for health problems that potentially could have been prevented,” Grattan Health Program Fellow Professor Hal Swerissen said. “Yet each year the government spends at least $1 billion on planning, coordinating and reviewing chronic disease management and encouraging good practice in primary care.” Primary Health Networks should be given more responsibility for coordination of local primary care services and in regional areas, Professor Swerissen said. “Our primary care system is not working anywhere near as well as it should because the way we pay for and organise services goes against what we know works.” “The focus of chronic disease funding needs to move away from a patient-related payment to a general practice and towards a broader payment for integrated care. “Prevention and management of chronic disease in primary care is not easy. It requires sustained effort by people with chronic conditions working in partnership with a team of health professionals.” The proposed recommendations are cost neutral with funding for Primary Health Networks already allocated, the report authors argue.
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TELEHEALTH NUMBERS SOAR IN NT TRIAL A telehealth trial is set to be expanded in the Northern Territory after a massive increase in uptake. Telehealth consultations have soared from 200 to more than 1,000 under a NT government trial. The trial telehealth project expanded to include patients in Alice Springs, Katherine and Tennant Creek. Results showed an increase in uptake of 737% in Tennant Creek from 62 in 2013-14 to 519 between July 2014 and September 2015. Attendances were up 481% in Alice Springs, from 33 to 192 consultations in the same period; and up 231% in Katherine, from 100 to 331.
AGENCY STAFF LARGEST UNPLANNED COST A national survey shows the cost of agency and locum staff is the highest driver of unplanned costs in healthcare. Victoria, Queensland and Western Australia were most affected by agency costs, in the national survey of 168 members of the Australian Healthcare and Hospitals Association. Participants included mostly chief nurses, CEOs, executive directors, and managers, across public and private hospitals, aged and community care, and primary and allied health.
Specialist appointments available included for cardiac, orthopaedic, haematology, oncology, dermatology and urology.
Agency and locum staff costs rated of greater concern, in the survey conducted by Allocate Software, than staff shortages, technology, patient safety, organisational efficiency, and staffing allocations.
An evaluation report of the trial recommended the project continue and the telehealth network be further developed until the service became routine practice in the NT.
Salary and wages remained the largest single cost healthcare organisations faced, with the payroll bill over 65% of total operating costs in many cases, Managing Director Peter Croft said.
The report found an estimated savings of $1.189 million to the Patient Travel Assistance Scheme on travel costs alone. Non-attendance to appointments was also substantially lower for hospital outpatient clinics.
One in three healthcare decisionmakers recognised the problem. However, only 23% planned to make efficiencies in agency and locum costs.
Trial Project Leader and Alice Springs Hospital Acting Executive Director of Medical and Clinical Services Dr Sam Goodwin said at the end of the trial patients were accessing telehealth, rather than the Patient Travel Assistance Scheme. “Clinicians on the frontline have summarised the telehealth pilot very nicely – it is not often you can say that you have saved money and everyone has really good healthcare for that saving and you are not losing anything – usually when you make savings of money you have lost something.”
“Of concern is that at least 10% of respondents who faced these costs as their biggest issue admitted they were not addressing it, the consequence being continual unnecessary spend, resulting in stubbornly high operation costs,” Mr Croft said. Private hospitals (42%) and aged care (40%) were the sectors worst hit by agency staffing costs. “In general, average salaries tend to be lower in aged care rather than acute care…In the context of lower average salaries, agency fees introduce a high and often unpredictable cost,” Mr Croft said.
NT Health Minister John Elferink said the government would consider the report recommendations and extending the use of telehealth in the territory.
April 016 Volume 23, No. 9 23
ISSUES Safety in health
WALKING THE TIGHTROPE IN SAFETY AND IN HEALTH
PHYSICAL ACTIVITY & SAFETY
health
By Lesley Jean Roberts
The term high safety, means an activity embodying the least likelihood of misadventure while low safety the presence of uncontrolled hazards. The following graph depicts on the horizontal axis left to right an increasing level of physical dexterity. The vertical axis has increasingly good outcome from bottom to top.
working above the line
Increasing health / safety
Pressure on business has never been stronger to avoid workplace injuries and yet the people I see with work related injuries are amongst the safest people I could imagine.
safety
The safety line
The truth of the safety line’s downward slope becomes evident when the extremes are considered. To stay in bed is amongst the safest of daily activities. The chance of a fall, trip, strain and eye injuries reduces to nil excepting exceptional circumstances, like a rarity such as a plane landing on your bedroom. Following the safety line on its downward trend towards less safe activities is employment. Less safe than going to work is activities like footy which can result in ankle, achilles, knee, hamstring, and neck strains. Continuing the line to the right are extreme sports (tightrope walking, rock climbing, ballet).
The health line
The left of the health line displays the deleterious effect on health for staying in bed. The deterioration on a body in bed rest is observable within 24 hours. The muscles break down and weaken as calcium from the bones absorbed. Position change is the main factor in building muscle and bone strength and as the line approaches running health is plotted at a much higher level. Tightrope walking with its continual fine and gross muscle corrections benefits posture, muscle mass as well as mental stimulation, focus and calm. A successful walk along the tightrope is beneficial to health, while falling, is penalised heavily.
Working above the line
A line must been drawn somewhere, below which the attendant hazard level is considered unacceptable. The corporate sponsored lunch time footy match with its potential for slips, sprains and strains is working below the line for most Australian 24 April 2016 Volume 23, No. 9
in bed
employment
corporate footy match
extreme sport
activiy intensity construction work
businesses and has been largely abandoned in favour of healthy eating, reduce weight and quit smoking campaigns. The risks assumed in a game of football would never be tolerated on the building site and hence are not tolerated during corporate leisure. Businesses, from kindergartens to the retirement village, need to manage risk and safety. School play grounds are supervised to ensure children learn early about Three Points of Contact on the climbing frame. Yet to be healthy one must move. Working above the line in safety is misconstrued by the majority to be a message of correct and necessary behaviour rather than a ‘not on my watch’, responsibility prevention strategy. The tightrope walker, ballerina and rock climber all have vastly superior health to the sedentary.
Cost to business
The most costly injuries to business that I see are from people who model their personal time on work time safety principles. They are safe at work and at home forbidding themselves risk as required at work. No rough jogging round the block for them, but yet they are the ones with injuries, their WorkCover Certificate ticked with ‘Injuries consistent with stated cause’. Attempts to eliminate hazard by prohibiting risk will ultimately be futile as no control measures can protect a weak worker from
athlete
injury and the flexible are always more resilient to unplanned impact. Living with safety as an exclusive consideration has been shown to be ineffective in keeping workers injury and disease free.
The way forward
Business needs to find a way to promote workers to be more active outside of the work environment; to extend their physical prowess, to move, to run, to jump, to climb. To challenge fine and gross motor skills while balancing in unusual positions. To accept personal and individual responsibility for the setbacks and to strive to overcome them. A person who accepts some risk develops strength and skill, along with judgement to avoid hazard. The best workers for business are those who bring fitness from their own personal activities. Perhaps construction should more favourably recruit the extreme sports person to their ranks. The ideal worker is working above the line in safety on business time and above the line in health on their own. Lesley Jean Roberts is an RN Medic within construction work This article is based on the views and research of the author(s) and has not been peer reviewed. anmf.org.au
WORKING LIFE The biggest change in the D&A sector and with clients and the community is acceptance that seven days will not cure someone, says Rose. “It is a huge emotionally filled area with clients and families; there is often the view ‘just get them into detox’. “People come in here wanting the seven day miracle but you cannot reverse in seven days what has been done for years and years. It is long term.” Seven days builds resilience and keeps them going, says Rose. “It’s a life skill and education based program.” Inpatient group programs include: yoga; art therapy; liver care; relapse prevention; and goal setting.
WORKING LIFE: ROSE MCCROHAN By Natalie Dragon The first drug and alcohol nurse practitioner in Victoria, Rose McCrohan received the Clinician Award by The Australasian Professional Society on Alcohol and other Drugs in late 2015. With almost 25 years’ experience in the area, Rose has managed or helped establish multiple withdrawal programs, including setting up Victoria’s first mother and baby withdrawal service due to open in October. “It’s a very inspirational field to work in and very different from what the community perhaps perceives. We work with people who essentially have the ability to recover. “Most of our people have had heartbreaking things happen to them; there are very high levels of violence and abuse. As a result of their drug use they have made poor decisions on top of that – it is remarkable they continue to find hope.”
on site phenomenal access for patients to prescribe methadone and suboxone (for opiate addiction). There is virtually no drug of dependence that I cannot treat.” As with all D&A treatment, the cornerstone is supportive care, says Rose. “The human spirit is very strong and people have a willingness to recover. Most people never thought they would cross the boundaries they have. The choices they have made to sustain their habit do not rest easily on their soul. A lot of people have suicidal thoughts – just to be here, they choose to live.
MOST OF OUR PEOPLE HAVE HAD HEARTBREAKING THINGS HAPPEN TO THEM; THERE ARE VERY HIGH LEVELS OF VIOLENCE AND ABUSE. AS A RESULT OF THEIR DRUG USE THEY HAVE MADE POOR DECISIONS ON TOP OF THAT – IT IS REMARKABLE THEY CONTINUE TO FIND HOPE.
Rose did an elective in her final year of study. “I was inspired by the lecturer. Then a job came up at a D&A hospital which has since closed. I took a grad position and the rest is history.”
“People come to believe there’s a lot to be gained in giving up substance use: they sleep better, eat better, and are less emotionally reactive. They take action to create change.”
Rose has been at Uniting Care’s 16-bed nurse run ReGen unit in North West Melbourne for 10 years. She is the Nurse Unit Manager and a NP. “It’s a dual role. I am a manager but still have a high clinical load. I switch hats.”
Most inpatients are poly-drug users with methamphetamine now the primary drug of choice, says Rose. “A lot of academics are saying there isn’t an ICE crisis but our numbers have skyrocketed, consistent with other facilities.”
As a NP, Rose has a provider number and manages her own admissions along with three other GPs in the community. “The timing of my endorsement could not have been better (2009). This role allows the NP
While for 6% of ReGen inpatients in 2010-11 ICE had been the first substance of choice, that figure increased to 12% in 2012-13; 15% in 2013-14; and 20% in 2014-15. Already in 2015-2016 the number has risen to 30%.
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“We see them relapse – it’s a normal part of the journey but they get a little bit closer (to recovery). We are very aware that it is a chronic relapsing condition.”
Mother and baby service
The four-bedded mother and baby service, funded by the DHHS, is due to open in ReGen in October. It is based on the mental health model for mothers with babies up to 12 months, says Rose. “It is a service for the mother to keep her child with her while she withdraws.” ReGen has cared for 15 mothers with babies in the unit over the past 10 years. “The idea is that women come here first and then on the way to a rehab program and take the children with them or return to the community with supports. “We won’t take babies imminently to be removed from parents’ care. But for those that if they had sought treatment six months earlier, just may have prevented removal of children from their care,” Rose says. “We will work with a range of different hospitals, all different clinics and D&A services. We expect an increase in antenatal referrals and maternal child and health services and postnatal depression referrals.” There are currently four D&A NPs and another five mental health NPs who work in D&A roles in Victoria, says Rose. A mental health and drug and alcohol collaborative with a membership of 60 has seen an increase in NPs and NP Candidates who have done the methadone and suboxone prescriber course. “We are promoting NPs to fill the biggest rural gaps,” says Rose, already seen at Albury-Wodonga Health and Traralgon, Gippsland. “We are seeing an increase in skill base in mental health and dual diagnoses.” Nurses who work in the D&A field are big on social justice, says Rose. “I think there is an element to their work here – advocating for people who are significantly disempowered. I love it. It’s very fulfilling.” For more information go to: www.regen.org.au April 2016 Volume 23, No. 9 25
EDUCATION
DIABETES This tutorial covers the aetiology of diabetes Types 1 and 2 as well as gestational diabetes. Symptoms, treatment and management are discussed in detail along with the complications of diabetes. The ANMF diabetes tutorial is relevant to all levels of nurses and midwives. Diabetes affects an estimated 800,000 Australians, and many of these are not aware they have the disease. If undetected or poorly controlled, diabetes can lead to vision impairment, renal failure, lower limb amputation, MI, CVA and impotence. The process of insulin releasing the blood glucose into the body’s cells is known as glucose metabolism. In diabetes, the pancreas cannot make insulin or the insulin it does make is insufficient. Without insulin the glucose channels are closed. Glucose builds up in the blood leading to high blood glucose levels (hyperglycaemia) which cause the health problems linked to diabetes. World-wide, diabetes is becoming epidemic. In collaboration with the World Health Organization (WHO) in Geneva, the International Diabetes Institute produced new global predictions for the number of people with diabetes in various countries. It was estimated that in 2000 there were approximately 160 million people with diabetes in the world. This will climb to over 26 April 2016 Volume 23, No. 9
280 million by the year 2025, the majority of them with Type 2 diabetes.
• One of the most common chronic
Changes in society over recent decades have impacted on lifestyle leading to lower levels of physical activity and unfavourable changes in our diet with consequent increase in obesity. These factors, and the ageing of the Australian population, have led to high levels of morbidity from a number of chronic diseases which contribute greatly to national health costs. Diabetes and cardiovascular disease are two of these conditions. As a result they have been included by the federal, state and territory governments in the six National Health Priority Areas which also include cancer, trauma, asthma and mental health.
IDDM (Insulin Dependent Diabetes Mellitus) is one of the most common childhood diseases in developed nations and constitutes about 10% of all persons with diabetes in Australia. It is believed to be caused by an auto-immune process which results in a slow destruction of pancreatic islet beta-cells by the body’s own immune system. There is a strong family link with Type 1 diabetes however it appears to require a trigger such as a viral infection. While Type 1 diabetes can and does occur at any age, it usually affects children and young adults. It is the less common form of diabetes with just 10-15% of all people with diabetes having Type 1 diabetes.
Diabetes is recognised as:
• The second most common cause for
commencing renal dialysis. • The most common cause of blindness in people under the age of 60 years. • The most common cause of nontraumatic lower limb amputation.
diseases in children.
In Type 1 diabetes, the pancreas cannot produce enough insulin due to the relevant cells having been destroyed by the body’s immune system. This insulin must be replaced. People with Type 1 diabetes must have insulin every day to live. While insulin anmf.org.au
EDUCATION
The following excerpt is from our Diabetes tutorial on the Continuing Professional Education (CPE) website. The complete course is allocated 5 hours of CPD with the reading of this article giving you 15 minutes of CPD towards ongoing registration requirements.
can only be injected at this time, other ways of administering it may be possible in the future.
dietary management and oral hypoglycaemic medications that improve insulin sensitivity or reduce glucose production by the liver.
While the cause of Type 1 diabetes has nothing to do with lifestyle, a healthy lifestyle is important in its management. There is no known prevention or cure for Type 1 diabetes at this time. Current treatment includes closely monitoring the blood glucose (sugar) levels, modifying the diet and daily insulin injections.
There are numerous theories as to the exact cause of Type 2 diabetes. Central obesity (fat concentrated around the waist in relation to abdominal organs, but not subcutaneous fat) is known to predispose individuals for insulin resistance. Abdominal fat is especially active hormonally, secreting a group of hormones called adipokines that may possibly impair glucose tolerance. Obesity is found in approximately 55% of people diagnosed with Type 2 diabetes. Other factors include ageing and family history.
Symptoms of Type 1 diabetes include: polyuria - frequent urination; polydipsia excessive thirst (increase in fluid intake and consequent increase in output); polyphagia increased hunger; weight loss; fatigue; visual disturbances, such as blurred vision; pruritis, particularly around the genitals; nausea and vomiting. Symptoms may develop quite rapidly (weeks or months), particularly in children. NIDDM (non-insulin dependent diabetes mellitus) is sometimes described as a ‘lifestyle disease’ because it is more common in people who do insufficient physical activity and are overweight or obese. It is strongly associated with high blood pressure, high cholesterol and an ‘apple’ body shape, where excess weight is carried around the waist. Type 2 diabetes is the most common form of diabetes. It affects 85-90% of all people with diabetes. It usually affects mature adults although younger people are also now being diagnosed in greater numbers as rates of overweight and obesity increase. The causes of Type 2 diabetes are known and in some cases it can be prevented. However there is no cure. Type 2 diabetes is characterised differently due to insulin resistance or reduced insulin sensitivity combined with reduced insulin secretion. In the early stage the predominant abnormality is reduced insulin sensitivity characterised by elevated levels of glucose in the blood. At this stage hyperglycaemia can be reversed by a variety of measures such as anmf.org.au
OBESITY IS FOUND IN APPROXIMATELY 55% OF PEOPLE DIAGNOSED WITH TYPE 2 DIABETES. OTHER FACTORS INCLUDE AGEING AND FAMILY HISTORY. Risk factors for type 2 diabetes include: People with pre-diabetes; Aboriginal and Torres Strait Islander people aged 35 and over; Pacific Islanders, those from the Indian subcontinent or of Chinese origin aged over 35 years; people aged 45 and over who are obese or overweight, have high blood pressure or have a first-degree relative with Type 2 diabetes; people aged 55 and over; people with cardiovascular disease such as myocardial infarction (MI), angina, cerebrovascular accident (CVA) or atherosclerosis (narrowed blood vessels); women with polycystic ovarian syndrome who are overweight; women who have had gestational diabetes; people aged 55 and over. Lifestyle factors that increase the risk of
developing Type 2 diabetes include: being overweight or obese, especially around the waist; low levels of physical activity; unhealthy eating habits, such as regularly choosing high fat, high sugar, high salt or low fibre foods; high blood pressure; high blood cholesterol; cigarette smoking. Type 2 diabetes the symptoms develop much more slowly than with Type 1 and may be quite subtle or completely absent, they include: polydipsia - being more thirsty than usual; polyuria - passing more urine; feeling tired and lethargic; slow-healing wounds; pruritis and skin infections; blurred vision; mood swings. Management options of type 2 diabetes: It is usually first treated by increasing physical activity, decreasing carbohydrate intake and losing weight. These can restore insulin sensitivity even when the weight loss is moderate eg. 5kg, most especially when it is in abdominal fat deposits. It is sometimes possible to achieve long-term, satisfactory glucose control with these measures alone, however, the underlying tendency to insulin resistance is not lost, and so attention to diet, exercise and weight loss must continue. The aim of diabetes treatment is to maintain blood glucose levels within the normal range, which is between 4 and 6mmol/L before meals and 4 and 8mmol/L two hours after meals. Keeping blood pressure and cholesterol within the recommended range is important (cholesterol < 5.5.mmol, BP 140/90 mmHg). Healthy eating, achieving and maintaining a healthy weight and doing regular physical activity are also important. Sometimes oral hypoglycaemic medication and then insulin may be required. The information presented here is just the tip of the iceberg in relation to the content in the tutorial. To learn more about, or just refresh your knowledge on diabetes, go to http://anmf.org.au/pages/ cpe For further information, contact the education team on: 02 6232 6533 or education@anmf.org.au April 2016 Volume 23, No. 9 27
CLINICAL UPDATE
PREGNANCY, CROHN’S DISEASE AND AZATHIOPRINE: A CASE STUDY AND LITERATURE REVIEW By Jenna Austin and Amy Vaccaro The interaction between Crohn’s disease, medical maintenance therapy and pregnancy has been a long debated subject in the literature. Historically, women with Crohn’s disease (CD) were advised to avoid pregnancy due to the common misconception that CD is a serious contraindication in pregnancy (Smith, & Sanderson, 2010).
28 April 2016 Volume 23, No. 9
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CLINICAL UPDATE However, current research indicates that most women with CD are able to conceive and experience a normal pregnancy, particularly when she conceives and remains in remission throughout her pregnancy (Smith, & Sanderson, 2010; Habal & Huang, 2012; Schulze et al. 2014). This begs the question of how to safely induce and maintain inactive disease in the pregnant woman with CD. Penny is an expectant mother who has Crohn’s disease and has been prescribed Azathioprine to take throughout her pregnancy. Within the context of Penny’s case, this article will present an overview of the main arguments in current literature and outline important midwifery care relevant to Penny.
What is Crohn’s Disease?
CD is a chronic autoimmune inflammatory disorder characterised by periodic transmural inflammation and fibrosis which can affect any of the gastrointestinal tract from the oesophagus to the anus (Thomas, 2009; Ananthakrishnan, et al. 2012; Oron et al. 2012). It is well recognised in the literature that CD is commonly diagnosed and active during a woman’s reproductive years, with the highest incidence between the ages of 20 and 29 years (Gawron, Hammond & Keefer, 2014; Habal & Huang, 2012; Tunc et al. 2013; Schulze, Esters, & Dignass, 2014; Hatch et al. 2014; Oron et al. 2012; Jharap et al. 2014; Hutson et al. 2013). Despite the continuous debate in the literature about the safety of CD medical therapy during pregnancy and lactation, the use of Azathioprine is advised by nine out of 10 gastroenterologists to achieve optimal outcomes and prevent maternal and fetal complications of active disease (Singh et al. 2011; Biroulet-Peyrin, et al, 2011; Schulze et al. 2014). Therefore, undoubtedly midwives will care for women with CD on medical therapy and consequently need to be aware of the potential implications of disease activity and medication use.
Introducing Penny*
Penny is a 26 year old woman who is 27 weeks pregnant with her first child. She was diagnosed with CD approximately four years ago and was in remission when she conceived. Currently, standard medical management of CD involves the use of aminosalicylates and corticosteroids during relapse and then commencement of an immunosuppressant if there have been more than two relapse episodes requiring steroids in a 12 month period (Skelly, Tobin, & Iqisbal, 2009). For Penny, this was the case and she was commenced on anmf.org.au
STUDENTS REPORT THAT THEY FEEL MORE CONFIDENT IN INITI DESPITE THE CONTINUOUS DEBATE IN THE LITERATURE ABOUT THE SAFETY OF CD MEDICAL THERAPY DURING PREGNANCY AND LACTATION, THE USE OF AZATHIOPRINE IS ADVISED BY NINE OUT OF 10 GASTROENTEROLOGISTS TO ACHIEVE OPTIMAL OUTCOMES AND PREVENT MATERNAL AND FETAL COMPLICATIONS OF ACTIVE DISEASE ATING THERAPEUTIC RELATIONSHIPS THAT ARE WOMEN CENTRED. Azathioprine, an immunosuppressant medication, by her gastroenterologist prior to her becoming pregnant. When she conceived she saw her gastroenterologist at six weeks gestation and was advised to continue Azathioprine during her pregnancy. She is currently on 50mg daily and has not reported any issues associated with the medication during her pregnancy to date. According to the National Midwifery Guidelines for Consultation and Referral (Australian College of Midwives [ACM], 2008) the risk code for Penny’s pregnancy at booking-in is ‘B’ (6.1.6) requiring continued consultation with medical staff. Thus, on top of her regular antenatal midwifery appointments, Penny attends regular appointments with her gastroenterologist, obstetrician and dietician so that her body’s response to the medication and the pregnancy can be closely monitored, which is recommended best practice (Skelly et al. 2009). In addition to Azathioprine, Penny has also been prescribed Lantus (18 units nocte) and Metformin (1000mg twice daily) during her pregnancy to manage gestational diabetes mellitus (GDM). The link between high doses of corticosteroids and the risk of diabetes is an important one. When
Penny experienced relapses in CD she was treated with corticosteroids, which led to chronic instability in blood glucose levels. Consequently, Penny was investigated for and diagnosed with GDM at 13 weeks gestation which increases her pregnancy risk code to ‘C’ (ACM, 2008). Early detection of GDM has helped Penny and the multidisciplinary team to develop an effective glycaemic control strategy. At her first antenatal visit, Penny identified several significant life stresses in addition to her health concerns. Hagen-Hurley (2008) and Smith and Sanderson (2010) urge clinicians to be aware of the psychosocial issues involved in having CD through pregnancy. Penny lives 10 hours’ drive away from her immediate family, has been experiencing a number of issues at work and also experiences significant depression. Her Edinburgh Postnatal Depression Score (EPDS) was 11/30 at this visit and Penny continues to see a counsellor and mental health worker throughout her pregnancy.
Literature Review
Maintaining adequate disease control before, during and after pregnancy is crucial for both mother and baby. Recent studies suggest disease activity at time of conception best predicts disease activity over the duration of the pregnancy, with one-third of patients improving, onethird staying the same and one-third deteriorating (George & Leech, 2012; Hagen-Hurley, 2008; Thomas, 2009; Czymek et al. 2009; Habal & Huang, 2012; Hatch et al. 2014). Active disease at time of conception has been shown to be associated with worsening or persistent inflammation during pregnancy. In these conditions the incidence of stillbirths, preterm birth, low birth weight (LBW) and congenital anomalies increases (Czymek et al. 2009; Gawron et al. 2014; Habal & Huang, 2012; Schulze et al. 2014; Oron et al. 2012; Smith & Sanderson, 2010; Toomey & Waldron, 2013; Hutson et al. 2013). It is generally agreed upon in the literature that active inflammation of CD potentially causes the greatest risk of harm to mother and baby, rather than the medication used to treat it (Thomas, 2009; Czymek et al. 2009; Skelly et al. 2009; Habal & Huang, 2012; Schulze et al. 2014; Toomey & Waldron, 2013; Jharap et al. 2014; Biroulet-Peyrin et al. 2011; Hutson et al. 2013). As the risk of relapse during pregnancy and postpartum is significantly lower in women with inactive disease, treatment should be designed to induce or maintain remission and to minimise acute exacerbations (Thomas, 2009; Skelly et al. 2009;
References Ananthakrishnan, A.N., Zadvornova, Y., Naik, A.S., Issa, M., & Perera, L.P. (2012). Impact of pregnancy on health-related quality of life of patients with inflammatory bowel disease. Journal of Digestive Diseases, 13, 472-477. doi:10.1111/j.17512980.2012.00618.x Australian College of Midwives. (2008). National midwifery guidelines for consultation and referral (2nd ed.). ACT: Author Australian Medicines Handbook. (2015). Azathioprine, pp. 640 – 641. Adelaide: Author. Biroulet-Peyrin, L., Oussalah, A., Roblin, X., & Sparrow, M.P. (2011). The use of azathioprine in Crohn’s disease during pregnancy and in the post-operative setting: a worldwide survey of experts. Alimentary Pharmacology & Therapeutics, 33, 707713. doi:10.1111/j.13652036.2011.04577.x. Bryant, B., & Knights, K. (2009) Pharmacology for health professionals (2nd ed.). Ch. 55, p. 892-893. Sydney: Elsevier. Czymek, R., Limmer, S., Kleemann, M., Hildebrand, P., Schmidt, A., Jungbluth, T., Bruch, H.P. (2009). Crohn’s disease- a chameleon during pregnancy. Langenbeck’s Archives of Surgery, 394, 517-527. doi: 10.1007/s00423008-0431-2. Gawron, L.M., Hammond, C., & Keefer, L. (2014). Documentation of reproductive health counseling and contraception in women with inflammatory bowel diseases. Patient Education and Counseling, 94, 134-137. Retrieved from CINHAL Plus with full text database. George, C., & Leech, P. (2012). A young woman’s journey through the ravages of Crohn’s disease and pregnancy. Journal of Stomal Therapy Australia, 32(2), 12-15. Retrieved from CINHAL Plus with full text database.
Penny* = pseudonym to protect woman’s confidentiality and privacy
April 2016 Volume 23, No. 9 29
CLINICAL UPDATE Habal & Huang, 2012; Smith & Sanderson, 2010; Hutson et al. 2013). The literature clearly points to good disease control at time of conception and throughout pregnancy as the key to good outcomes for both mother and baby. Azathioprine is a commonly used immunosuppressant shown to be effective for inducing and maintaining remission, tapering steroid use and treating fistulas in CD (BirouletPeyrin et al. 2011; Bryant & Knights, 2009; Skelly et al. 2009; Smith & Sanderson, 2010; Habal & Huang, 2012; Hutson et al. 2013).). However its safety throughout pregnancy and lactation is a matter of active debate. In Australia, Azathioprine is a category D drug according to the Australian categorisation system for prescribing medications in pregnancy (Therapeutic Goods Administration, 2014). This means that the use of Azathioprine throughout pregnancy is not advised due to the potential adverse effects on the infant, which theoretically may include neonatal immunosuppression (Therapeutic Goods Administration, 2014). MIMS Australia (2015) also state Azathioprine is contraindicated in pregnancy and lactation. However, despite this lack of approval by official authorities and pharmaceutical manufacturers, current research suggests most established medications for CD therapy are safe or classified as low risk in pregnancy, with exception to Methotrexate and Thalidomide which are strongly contraindicated (Habal & Huang, 2012; Smith & Sanderson, 2010; Thomas, 2009; Czymek et al. 2009; Schulze et al. 2014; Biroulet-Peyrin et al. 2011; Singh et al. 2011; Hutson et al. 2013). The Australian Medicines Handbook (2015) states Azathioprine is relatively safe to continue during pregnancy in cases where stopping its use would be harmful (such as in the case of inflammatory bowel disease). Azathioprine acts by altering the purine synthesis that primarily suppresses T- and B-cell production, cell-mediated hypersensitivity and antibody production (Bryant & Knights, 2009). This raises concerns about the effects of Azathioprine exposure on the fetus. Azathioprine belongs to a classification of drugs known as Thiopurines. Azathioprine (AZA) is readily absorbed orally and rapidly metabolised by the liver into 6-mercaptopurine (6-MP) and 6-thioinosinic acid (Singh et al. 2011; Bryant & Knights, 2009). Whilst the available data is scarce, some studies have demonstrated that the placenta serves as relative barrier to AZA and its metabolites (Czymek et al. 2009; Jharap et al. 2014; Biroulet-Peyrin 30 April 2016 Volume 23, No. 9
et al. 2011). In a small pilot study conducted by Jharap and colleagues (2014), which involved 30 infants of mothers on a standard dose of Thiopurine during pregnancy, they found AZA and 6-MP concentrations in the fetal blood were 1–5% and 1–2%, respectively, compared with maternal blood levels. Similar findings have been reported by Singh et al. (2011), Biroulet-Peyrin et al. (2011) and Czymek et al. (2009). Jharap et al. (2014) conclude that pregnancy has a significant effect on maternal Thiopurine metabolism, leading to decreased levels of active metabolites in the fetus; this alteration in Thiopurine metabolism did not lead to biochemical toxicity or adverse events in the mother or baby.
THERE IS ALSO LIMITED EVIDENCE REGARDING THE SAFETY OF AZATHIOPRINE WITH BREASTFEEDING. MOST STUDIES IN THIS LITERATURE REVIEW REPORTED THE CONCENTRATION OF AZATHIOPRINE AND OTHER THIOPURINES AS VERY LOW IN HUMAN BREAST MILK AND ALMOST UNDETECTABLE (< 1%) IN THE SERUM OF BREASTFED INFANTS
Conflicting data exists regarding the association between Thiopurine use in pregnancy and adverse pregnancy outcomes. Animal studies have demonstrated teratogenicity in mice and rats exposed to high doses of AZA, however in humans, multiple case series have not shown any increase in congenital anomalies (Biroulet-Peyrin et al. 2011; Hutson et al. 2013). It has also been suggested that the fetal liver lacks enzymes required to metabolise AZA into an active metabolite, which helps protect the fetus from teratogenic effects in early pregnancy (HagenHurley, 2008; Habal & Huang, 2012; Smith & Sanderson, 2010). Several studies using large control groups of pregnant women receiving
Thiopurines did not find higher rates of spontaneous abortion, congenital malformation and prematurity or any negative influence on long-term development of immune function of infants exposed to intra-uterine maternal use of AZA compared to their non-exposed controls (Schulze et al. 2014). Jharap et al. (2014) report congruent findings except they found 60% of infants in their study did have mild anaemia at birth. On the contrary, Biroulet-Peyrin et al. (2011) report some well-conducted studies have shown an increased risk of preterm birth. Interestingly Hutson et al. (2013) found a significant difference between malformations, LBW and prematurity between women with inflammatory bowel disease (IBD) receiving Thiopurines during pregnancy compared to their healthy controls, yet when the study group was compared to other women with IBD who were not receiving Thiopurines there was no significant difference noted. This suggests adverse outcomes may be associated with active disease rather than Thiopurine use (Hutson et al. 2013). Whilst research evidence is limited and often conflicting, the overall consensus is that Azathioprine is a safe and well tolerated drug when used in pregnancy (Habal & Huang, 2012; Hagen-Hurley, 2008; Smith & Sanderson, 2010; Hutson et al. 2013; Jharap et al. 2014; Schulze et al. 2014). . There is also limited evidence regarding the safety of Azathioprine with breastfeeding. Most studies in this literature review reported the concentration of Azathioprine and other Thiopurines as very low in human breast milk and almost undetectable (< 1%) in the serum of breastfed infants (Singh et al. 2011; Schulze et al. 2014; Habul & Huang, 2012; Smith & Sanderson, 2010). In an observational case series conducted by Singh et al. (2011) involving 10 mother-baby pairs, there was no clinically significant adverse effects on the immunological or haemotaological profile of these babies. Further, breastfeeding is not associated with any worsening of disease activity (Schulze et al. 2014). Although drug manufacturers will usually suggest avoiding breastfeeding, the current available evidence suggests Azathioprine is likely to be safe as there is no known evidence of harm (Smith & Sanderson, 2010). The Australian Medicines Handbook (2015) acknowledges that small amounts of Azathioprine are excreted in breastmilk as mercaptopurine, but that it appears safe to use suggesting monitoring of the infant for any adverse reactions.
Habal, F.M., & Huang, V.W. (2012). Review article: a decisionmaking algorithm for management of pregnancy in the inflammatory bowel disease patient. Alimentary Pharmacology & Therapeutics, 35, 501515. doi:10.1111/j.13652036.2011.04967.x Hagen-Hurley, T. (2008). Conception, fertility and pregnancy in women with inflammatory bowel disease. Gastrointestinal Nursing, 6(4), 34- 39. Retrieved from CINHAL Plus with full text database. Hatch, Q., Champagne, B.J., Maykel, J.A., Davis, B.R., Johnson, E.K., Bleier, J.I., Steele, S.R. (2014). The impact of pregnancy on surgical Crohn disease: an analysis of the Nationwide Inpatient Sample. Journal of Surgical Research, 190(1), 41-46. doi: 10.1016/j. jss.2014.03.028. Hutson, J.R., Matlow, J.N., Moretti, M.E., & Koren, G. (2013). The fetal safety of thiopurines for the treatment of inflammatory bowel disease in pregnancy. Journal of Obstetrics and Gynaecology, 33(1), 1-8. doi:10.3109/014436 15.2012.716106. Jharap, B., Boer, N.K., Stokkers, P., Hommes, D.W., Oldenburg, B., Dijkstra, G., Bodegraven, A.A. (2014). Intrauterine exposure and pharmacology of conventional thiopurine therapy in pregnant patients with inflammatory bowel disease. Gut, 63(3), 451-457. doi:10.1136/ gutjnl-2012-303615. MIMS Australia (2015, March). Azathioprineproduct information [Fact sheet]. Retrieved from www-mimsonlinecom.au.ezproxy.csu. edu.au/ Search/AbbrPI. aspx?ModuleName= Product Info&searchKeyword= Azathioprine&Previous Page=~/Search/ QuickSearch. aspx&SearchType=&ID= 15560001_2 Oron, G., Yogev, Y., Shkolnik, S., Hod, M., Fraser, G., Wiznitzer, A., & Melamed, N. (2012). Inflammatory bowel disease: risk factors for adverse pregnancy outcome and the impact of maternal weight gain. The Journal of Maternal-Fetal and Neonatal Medicine, 25(11), 2256-2260. doi: 10.3109/14767058. 2012.684176.
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CLINICAL UPDATE
Singh, M., Qualie, J., Currie, A., Howarth, E.S., & Khare, M.M. (2011). Is breastfeeding safe with azathioprine? Obstetric Medicine, 4(3), 104-107. doi:10.1258/ om.2011.110013 Skelly, M.M., Tobin, E., & Iqisbal, M. (2009). Module 1: Autoimmune diseases. Part 7: Monitoring is key in Crohn’s disease. World of Irish Nursing & Midwifery, 17(7), 35- 36. Retrieved from Medline database.
Information sharing and midwifery care
Historically, women with CD were discouraged from becoming pregnant and as a result various misconceptions persist about their ability to conceive and the risks involved in being pregnant (Smith, & Sanderson, 2010). Many women report feeling anxious and fearful about interactions between their pregnancy, disease activity and medication, sometimes resulting in unnecessary childlessness (Hagen-Hurley, 2008; Habal & Huang, 2012; Schulze et al. 2014; Czymek et al. 2009). Research has shown gastroenterologists and general practitioners (GPs) do not often raise the subject of family planning for women with CD (Gawron et al. 2014; Toomey & Waldron, 2013). Gawron et al. (2014) suggest that women are first to initiate this conversation with their gastroenterologist as most were already pregnant or considering pregnancy. Toomey and Waldon (2013) also found that 77% of women felt there was a need to discuss this interaction between their pregnancy, disease and medications but only 32% had such a discussion, and 58% said they would like their GPs to raise these issues in the future. This highlights the important need for information sharing and continuity of care from midwives, as women may not receive this from their primary physicians. Information sharing is paramount to enable informed choice regarding treatment and management of disease during pregnancy (HagenHurley, 2008; Habal & Huang, 2012; Schulze et al. 2014). According to the research, Penny should be encouraged to continue her medication during pregnancy and breastfeeding, with a full anmf.org.au
understanding of the known risks and benefits of doing so (Czymek et al. 2009; Habal & Huang, 2012; Toomey & Waldron, 2013; Schulze et al. 2014). Penny was well informed about her current disease activity and her medication use primarily because she initiated the discussion with her gastroenterologist early in gestation and was also very proactive herself in researching Azathioprine use during pregnancy and breastfeeding. Research has highlighted the importance of midwifery continuity of care, especially in high risk pregnancies. Penny received midwifery care through a caseload model of care which enabled her and the primary midwife to develop a trusting relationship where she felt comfortable and supported to make informed decisions throughout her pregnancy. Tracy and colleagues (2013) in their M@NGO trial found that caseload midwifery is a safe, affordable and acceptable form of maternity care regardless of the risk factors. Penny reports feeling a stronger sense of satisfaction and personal control, better communication and information sharing, and less anxiety and stress which mirrors the experiences of other women as reported in research (Tracy et al. 2013). In addition to her regular antenatal midwifery visits, Penny is also cared for holistically by a multidisciplinary team, made up of the same gastroenterologist, diabetes nurse specialist, dietician, physician, GP and counsellor. This further maximises the support and care she receives, and is identified in the research as best practice (Hagen-Hurley, 2008; Czymek et al. 2009; Habal & Huang, 2012).
Smith, M.A., & Sanderson, J.D. (2010). Management of inflammatory bowel disease in pregnancy. Obstetric Medicine, 3(2), 59-64. doi:10.1258/ om.2010.100010.
Conclusion
The interaction between Crohn’s disease, Azathioprine use and pregnancy remains an issue of active debate within the literature. Overall, researchers do agree that women with CD can experience a normal healthy pregnancy when they conceive and remain in remission throughout their pregnancy, and that the risks associated with active disease are greater than those of CD medications. However, limited and conflicting data does not only make clinicians confused and nervous about prescribing, but can be a cause of fear and concern for women of childbearing age, like Penny. Undoubtedly, future studies with appropriate controls, larger sample sizes and well defined variables are needed to clearly direct the safe use of Azathioprine during pregnancy and lactation (Oron et al. 2012; Hatch et al. 2014). However in the interim, it is important that midwives are aware of the current evidence available and provide women with the appropriate support to ensure they can make informed decisions. As stated by Habal and Huang, “most importantly, the mother’s decision on disease management and drug therapy should be respected and they should be supported throughout this lifechanging event” (2012, p.512). Jenna Austin is a Registered Midwife and Registered Nurse. Amy Vaccaro is a Registered Midwife and Nurse, Lecturer for School of Nursing, Midwifery and Indigenous Health, Charles Sturt University This article is based on the views and research of the author(s) and has not been peer reviewed.
Schulze, H., Esters, P., & Dignass, A. (2014). Review article: the management of Crohn’s disease and ulcerative colitis during pregnancy and lactation. Alimentary Pharmacology & Therapeutics, 40(9), 991-1008. doi: 10.1111/ apt.12949. Therapeutic Goods Administration. (2014). Prescribing medications in pregnancy database: Azathioprine. Retrieved from: www.tga. gov.au/prescribingmedicines-pregnancydatabase#searchname Thomas, R. (2009). Use of biological therapy during pregnancy in the treatment of IBD. Gastrointestinal Nursing, 7(3), 4-11. Retrieved from CINAHL Plus with full text database. Toomey, D., & Waldron, B. (2013). Family planning and inflammatory bowel disease: the patient and the practitioner. Family Practice, 30(1), 64-68. doi:10.1093/fampra/ cms035. Tracy, S.K., Hartz, D.L., Tracy, M.B., Allen, J., Forti, A., Hall, B., White, J., Lainchbury, A., Stapleton, H., Beckman, M., Bisits, A., & Kildea, S. (2013). Caseload midwifery care versus standard midwifery care for women of any risk: M@NGO, a randomized controlled trial. The Lancet, 382(9906), 17231732. Tunc, B., Akbulut, S., Parlak, E., Kocak, M., Alkim, C., Kurt, M., Ulker, A. (2013). Pregnancy outcomes of women with inflammatory bowel disease. Medical Gazette, 18(48), 1123. Retrieved from Academic Search Complete database.
April 2016 Volume 23, No. 9 31
FOCUS Diabetes Health
DIABETES, OLDER PEOPLE AND EXERCISE: RECOMMENDATIONS FOR HEALTH PROMOTION PROGRAMS By Rebekkah Middleton, Lorna Moxham and Dominique Parrish Around 346 million people globally have diabetes. As this figure is estimated to double by 2030 (WHO, 2015), the time is now for health professionals to be proactive rather than reactive in managing diabetes. One way to achieve this in older people is through physical activity and exercise. The significance of exercise and health promotion programs, which can enhance engagement in physical activity, cannot be underestimated. Quite simply, exercise is a good means of controlling diabetes. Considerable research has elucidated the physical benefits of exercise and nutrition programs for people with diabetes (Darawad et al. 2016; Hu et al. 2015). However, little is known about how to best construct and then deliver these particular health promotion programs, ensuring they have meaning to those who engage in them. Drawing on the lead authors PhD research, the following recommendations are important considerations for health professionals who are constructing, delivering and evaluating health promotion programs. The research found that if participants don’t find 32 April 2016 Volume 23, No. 9
meaning, they won’t stay engaged. In order to enhance motivation and commitment to these valuable means of managing diabetes the following recommendations are offered: • Exercise and health promotion
programs for people with diabetes need to be person-centred. Incorporating those people whom the program targets at the centre of planning, and where possible, delivery of the program is essential.
• Programs must accommodate
participant choice and enable flexibility so as to foster individual engagement without feeling ‘boxed’.
• Shift the mindset of seeing people
with diabetes as ‘clients’ or ‘patients’ who require ‘care’ to one of seeing people who have lived experiences that can meaningfully contribute to programs.
• Establish healthy relationships
with the people (including family), organisations, and materials (including the built environment) required to contribute to good health.
• Target education campaigns
specifically for people with diabetes about the value of them engaging in physical activity and exercise as a
positive means of managing their disease. • Exercise should be prescribed as
a treatment/therapy for people with diabetes and include both resistance and aerobic training elements. Programs should be inclusive of a minimum of two sessions per week involving physical training (resistance and aerobic). Programs should also include one session every week or second week for health promotion and education appropriate to diabetes, along with opportunity for social engagement outside of exercise.
• Education sessions must include
relevant, current, evidence based information. Information and discussion need to be delivered to participants in a forum and manner that is inclusive and informal.
It is hoped that the findings and recommendations above will inform and ultimately contribute to personcentred, effective future practice and promotion of health for people with diabetes. Empowering end users by including them in program design and delivery will enhance their motivation and facilitate their ongoing commitment to engage in physical activity. This will be of great benefit to them and to society more generally.
References Darawad, M. W., Mosleh, S., Khalil, A. A., Maharmeh, M., Hamdan-Mansour, A. M., Samarkandi, O. A. 2016. Investigating physical exercise among Jordanians with diabetes mellitus. Health 8:181-189 Hu, J., Wallace, D. C., McCoy, T. P. and Amirehsani, K. A. 2015. A family-based intervention for Hispanic adults and their family members. Diabetes Educator 40:48-59 World Health Organization. 2015. Diabetes facts sheet 312. www.who.int/ mediacentre/factsheets/ fs312/en/ Accessed 5 February 2016
Rebekkah Middleton is a Lecturer and PhD Candidate and Professor Lorna Moxham is Professor in Mental Health. Both are in the School of Nursing at the University of Wollongong Dominique Parrish is Associate Dean Education in the Faculty of Science, Medicine and Health at the University of Wollongong anmf.org.au
Diabetes Health FOCUS
GENERAL PRACTICE NURSE DIABETES CARE: WHAT DO PATIENTS EXPERIENCE? By Eileen Boyle, Rosemary Saunders and Vicki Drury In Australia Type 2 Diabetes (T2D) prevalence is rising rapidly and is expected to become the leading cause of disease burden in 2030 (AIHW, 2010). The General Practice Nurse (GPN) role is increasingly recognised as playing an important part in T2D management through clinical assessment and education supporting patient self-management as part of the general practice multidisciplinary care team (The Royal Australian College of General Practitioners and Diabetes Australia, 2014). In 2012 a qualitative research study was undertaken in an urban general practice setting in Western Australia to gain insight into the patients’ perception of the GPN diabetes consultation. Patients in the study had a 15 minute GPN consultation as part of routine diabetes care immediately prior to their GP appointment. The GPN consultation is guided by the practice-specific template where the nurse assesses blood pressure, height, weight, body mass index, visual acuity and foot review, diet, exercise and personal goals as well as reviews all optometrist and podiatrist appointments. All ten patients who participated in face-to-face interviews recalled their consultations as a series of ‘checks’ where the GPN gathered clinical data to be passed onto their GP, but did not recount in any detail discussions regarding ongoing management strategies: ‘She looks at my feet, pricks me with a needle, tests my blood pressure and my eyes, asks me about my diet, weighs me then I go and see the anmf.org.au
to the answer, don’t just accept OK, interrogate them.” (Participant 10)
FINDINGS INDICATE THAT THE GPN HAS AN IMPORTANT ROLE TO PLAY IN ASSISTING PATIENTS TO MANAGE THEIR T2D, HOWEVER THIS ROLE NEEDS TO BE MORE CLEARLY DEFINED TO PATIENTS SO THAT THEY CAN MORE ACTIVELY ENGAGE IN THE CONSULTATIONS
doctor’. (Participant 5) Participants openly admitted they did not ask the GPN questions but all the participants appreciated the consultation and even recommended it; “I never think to say to her how I am going.” (Participant 6) “It gives you more time being listened to and validated by having that nurse where the doctor may not have time to do that.” (Participant 3) “I convinced him [husband] to come here because of the nursing facilitates cause his doctor’s doesn’t have a diabetic clinic.”(Participant 8) Participants provided feedback to enhance GPN consultation approaches: “Ask a few leading questions, listen
Beyond gathering clinical data participants struggled to clearly identify the GPN role in assisting them to manage their diet, medication use, exercise or establish goals: “I don’t think actually seeing the nurse helps me manage my diabetes…the nurse does a little check: your height your weight your BMI … then you go and see the GP.” (Participant 1) “I’ll be quite honest I don’t know what the brief is for a practice like this are, they are just doing the checks to see where you’re at or is it to educate and I don’t know that it is to educate.” (Participant 9) Findings indicate that the GPN has an important role to play in assisting patients to manage their T2D, however this role needs to be more clearly defined to patients so that they can more actively engage in the consultations. Eileen Boyle, DipNurs, BHlth. Sc(Nsg), GradDipEd(Adult/ Tertiary), GradDipLangStud, MNsg(Research), School of Physiotherapy and Exercise Science, Curtin University Rosemary Saunders is Associate Professor in the School of Population Health at The University of Western Australia Vicki Drury is Academic Consultant at the Singapore National Eye Centre, Singapore; and Principal Consultant Educare Consulting, Australia
References AIHW. 2010. Australia’s health 2010. Australia’s health no. 12. Cat. no. AUS 122. Canberra: AIHW. The Royal Australian College of General Practitioners and Diabetes Australia. 2014. General practice management of type 2 diabetes – 2014–15. Melbourne Australia.
April 2016 Volume 23, No. 9 33
FOCUS Diabetes Health
References Australian Institute of Health and Welfare. 2011. Prevalence of Type 1 diabetes in Australian children 2008. Diabetes series no. 15. Cat. no. CVD 54. Canberra: AIHW. Australian Institute of Health and Welfare. 2014. Incidence of insulin-treated diabetes in Australia 20002011. Cat. no. CVD 66 Canberra: AIHW.
INSULIN THERAPY AT PRIMARY SCHOOL By Anne Marks, Lesley Wilkes, Rhonda Griffiths and Stacy Blythe Every year approximately 80,000 children develop type 1 diabetes worldwide (Craig et al. 2014). Of particular concern is the rising incidence of new cases among children aged 5-9 years (Australian Institute of Health and Welfare, 2011, 2014; Craig et al. 2014; Diabetes Australia, 2013; Imkampe & Gulliford, 2011). This increase places additional demands on health and education systems due to the number of children with diabetes attending early primary school (children aged 4–8 years). Intensive insulin therapy (four daily injections of insulin or insulin pump therapy) is now the current recommended treatment regime for children with type 1 diabetes (International Diabetes Federation, 2011; Svoren et al. 2007). This 34 April 2016 Volume 23, No. 9
therapy also requires blood glucose testing a number of times per day to adjust insulin and detect hypoglycaemia (International Diabetes Federation, 2011).
CURRENTLY THERE IS A LACK OF CONSISTENCY ACROSS AUSTRALIAN STATES AND TERRITORIES IN REGARDS TO SUPPORT PROVISION FOR CHILDREN WITH DIABETES AT SCHOOL
Young children in early primary school might find insulin delivery and blood glucose testing difficult, and therefore may not receive adequate diabetes care at school (Marks, Wilson, & Crisp, 2014a). In addition, parents report challenges with participation in school activities (Marks, Wilson, & Crisp, 2014b). To ensure that children experience a safe inclusive school environment, the appropriate level of education, staffing and ongoing
support is required (Marks et al. 2014b).
Research project
Currently there is a lack of consistency across Australian states and territories in regards to support provision for children with diabetes at school (Marks et al. 2014b). Therefore, Australian research is required to guide national policy and practice development. This qualitative study is exploring the experiences of Australian parents, diabetes educators and school teachers, who are caring for a child with type 1 diabetes using intensive insulin therapy in early primary school. Interviews are currently being conducted and the project should be completed by early 2017.
Practical outcomes
It is hoped that this research will inform both health and education systems and guide the development of legal policy to ensure equity for children with diabetes. Anne Marks is PhD Candidate and Lecturer; Professor Rhonda Griffiths is Dean and Dr Stacy Blythe is Lecturer. All are in the School of Nursing and Midwifery at Western Sydney University Professor Lesley Wilkes is Professor of Nursing at the Clinical Nursing Research Unit Nepean Blue Mountains Local Health District, School of Nursing and Midwifery, Western Sydney University
Craig, M. E., Jefferies, C., Dabelea, D., Balde, N., Seth, A., & Donaghue, K. C. 2014. Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatric Diabetes, 15 (Suppl 20), 4-17. Diabetes Australia. 2013. Diabetes map Retrieved January, 2015, from www.ndss.com.au/ en/Research/AustralianDiabetes-Map/Map/ Imkampe, A. K., & Gulliford, M. 2011. Trends in Type 1 diabetes incidence in the UK in 0-to 14-year-olds and in 15-to 34-year-olds, 1991–2008. Diabetic Medicine, 28(7), 811814. International Diabetes Federation. 2011. Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence. Marks, A., Wilson, V., & Crisp, J. 2014a. The management of type 1 diabetes in Australian primary schools. Issues in comprehensive pediatric nursing, 37(3), 168-182. Marks, A., Wilson, V., & Crisp, J. 2014b. Type 1 diabetes in Australian primary schools: Parental concerns and strategies for improvement. Australian Diabetes Educator, 17(4), 12-18. Svoren, B. M., Volkening, L. K., Butler, D. A., Moreland, E. C., Anderson, B. J., & Laffel, L. M. B. 2007. Temporal Trends in the Treatment of Pediatric Type 1 Diabetes and Impact on Acute Outcomes. The Journal of Pediatrics, 150(3), 279-285. doi: 10.1016/j. jpeds.2006.12.009
anmf.org.au
Diabetes Health FOCUS
SIMULATED PATIENTS ENHANCE DISCHARGE PROCESSES FOR PATIENTS WITH TYPE 2 DIABETES By Sharon Maclean, Fiona Geddes, Michelle Kelly and Phillip Della Today’s healthcare environment presents unique challenges for nurses who are more frequently caring for patients with multiple acuities and complex care issues (Elfrink et al. 2012). As hospital lengths of stay are reduced and patients are organised to return home with the expectation of managing more complex issues, preparing patients and their families for discharge becomes more challenging. Patients with chronic health conditions, such as type 2 diabetes typically have poorer health outcomes post discharge and higher readmission rates (Peter et al. 2015). Preparing nurses to perform safe, complex patient discharge will likely lead to improved patient confidence in self-management, and potentially better outcomes. Advances in technology to support clinical and communication practices provides nurses with both opportunities and obstacles to optimally perform a range of tasks, including assisting patients to prepare for their transition home. Importantly, the role and environment in which nurses operate necessitates them developing comprehensive communication skills and applying a high level of critical thinking and clinical judgment (Lasater, 2007). While patient discharge is an everyday occurrence, teaching student nurses the importance of ensuring patients’ understanding of complex healthcare instructions is a challenging task. Providing the opportunity for nursing students to develop discharge communication skills is often limited to the clinical setting they are allocated during placements. Unfortunately, many nursing students anmf.org.au
approach discharge communication with patients apprehensively due to a perceived lack of exposure during clinical placements or their theoretical coursework. Modeling of the approach to patient discharge is most often attained during clinical placements and variable as students observe the practices of registered nurses.
RESEARCH OUTCOMES WILL BE USED TO IMPROVE CURRENT DISCHARGE TEACHING PRACTICES ACROSS THE BACHELOR OF NURSING PROGRAM WITH THE GOAL OF BETTER PREPARING GRADUATE NURSES TO ASSIST PATIENTS WITH CHRONIC HEALTH CONDITIONS, SUCH AS TYPE 2 DIABETES, ACROSS TRANSITIONS OF CARE. Significance of the project
The research is a mixed method, quasiexperimental control group design using simulation as an educational intervention. Undergraduate nursing students at Curtin University, Western
Australia form the sample population. Three simulation scenarios, students were designed to increase students’ appreciation of the complex discharge needs of a type 2 diabetic patient and develop their communication competence. Simulated patients are employed to role-play patients with type 2 diabetes and case studies from actual patient notes are used to realistically frame the scenarios. Each student-patient dyad is video-recorded for analytic and reflective feedback purposes. On completion of the intervention students are invited to watch their discharge video and complete a questionaire on their simulation experience before participating in a group debriefing. The quality of the discharge is measured from three perspectives: the student, simulated patient, and researcher; focusing on the informational and interactional strategies utilised. The unique design of the research project allows students to both individually reflect on and critique their own performance; and receive direct feedback from simulated patients and facilitators to improve their communication and discharge skills. Research outcomes will be used to improve current discharge teaching practices across the bachelor of nursing program with the goal of better preparing graduate nurses to assist patients with chronic health conditions, such as type 2 diabetes, across transitions of care. Sharon Maclean is a PhD Candidate; Dr Fiona Geddes is in Research; Dr Michelle Kelly is Associate Professor and Professor Phillip Della is Head of School. All are located at Curtin University
References Elfrink, V. L., Kirkpatrick, B., Nininger, J. and Schubert, C. Using learning outcomes to inform teaching practices in human patient simulation. Nursing Education Perspectives 31, no. 2 (2010): 97-100 Lasater, K. Clinical judgment development: Using simulation to create an assessment rubric. Journal Nursing Education 46, no. 11 (2007): 496-503 Peter, D., Robinson, P., Jordan, M., Lawrence, S., Casey, K., and SalasLopez, D. Reducing readmissions using teach-back: Enhancing patient and family education.” Journal of Nursing Administration 45, no. 1 (2015): 35-42.
April 2016 Volume 23, No. 9 35
FOCUS Diabetes Health
MANAGING DIABETES AND MENTAL ILLNESS By Ian Munro Managing diabetes is a challenging area of healthcare, particularly as 61% of the population within Australia is gaining weight placing them at risk from some form of the disease (www.aihw.gov.au/diabetes-indicators/overweightand-obesity).
Ian Munro
Adding to this picture of what might seem like an epidemic of diabetes is the impact of mental illness. Some forms of mental illness are treated with second generation anti-psychotics medication and these medications are likely to add to the number of people with diabetes (Rummel-Kluge et al. 2010). Second generation anti-psychotics are the preferred medication for many mental illnesses today, as they treat the problem without many of the side effects of previously used drugs, while still producing very good therapeutic effects. Although as with many other medications, they do come with some risk. The metabolic effects of these medications have been known about for some time (Edward, Rassmussen & Munro, 2009). However, mental health facilities have been slow to respond in addressing the physical health needs of clients. Recently many mental health facilities have been attempting to address this health problem and most are now screening clients and creating healthcare plans that incorporate physical activity as a central part of mental healthcare. To be able to address this major health problem also requires the cooperation of diabetes health experts in providing their assistance to mental health clients. This can be difficult as the diabetes expert may struggle with both the additional case load, and the fact that they may not feel equipped to address the overlap with mental healthcare.
ARE YOU AN ENROLLED NURSE AND WANT TO BE PART OF A SPECIAL INTEREST GROUP?
MENTAL HEALTH FACILITIES HAVE BEEN SLOW TO RESPOND IN ADDRESSING THE PHYSICAL HEALTH NEEDS OF CLIENTS References www.aihw.gov.au/ diabetes-indicators/ overweight-and-obesity/
Clearly this complex problem requires cooperation between areas of healthcare. There is often a hurdle placed in the road of mental health clients seeking general healthcare, as the perception is that the mental health service should address all of these health needs.
Join other Enrolled Nurses at the National Enrolled Nurse Association of Australia (ANMF SIG) at www.nena.org.au To find out more about NENA read the news article on page 11.
36 April 2016 Volume 23, No. 9
However it’s a question of expertise and clearly whilst mental health practitioners are ‘experts’ in mental health, but not diabetes and vice versa with the diabetes practitioners, a meeting of professions needs to occur so that holistic healthcare can be achieved. The need for inclusive healthcare for all people to be addressed underscores the imperative for strong mental health educational content within undergraduate nursing programs. This will ensure that future nurses are aware of the problems mental health clients have to cope with. Additionally mental health content should be included in all post graduate areas, rather than just the post graduate degree. Dr Ian Munro is a Senior Lecturer at Monash University, Nursing and Midwifery, Victoria
Edward, K., Rassmussen, B., & Munro, I. 2009 Nursing care of clients treated with atypical antipsychotics who have a risk of developing metabolic instability and/or type 2 diabetes. Archives of Psychiatric Nursing Rummel-Kluge C., Komossa K., Schwarz S., Hunger H., Schmid F., Lobos C. A., Kissling W., Davis J. M., Leucht S. 2010 Head-tohead comparisons of metabolic side effects of second generation antipsychotics in the treatment of schizophrenia: a systematic review and meta-analysis. Schizophrenia Research 2010 Nov;123(2-3):22533. doi: 10.1016/j. schres.2010.07.012. Epub 2010 Aug 7.
anmf.org.au
Diabetes Health FOCUS
Judy Currey
Bodil Rasmussen
AN INNOVATIVE ONLINE SELFMANAGEMENT INTERVENTION FOR YOUNGER ADULTS WITH TYPE 1 DIABETES By Bodil Rasmussen and Judy Currey In Australia, 25,924 people aged 21-39 years are registered with the National Diabetes Service Scheme. Of those 5,962 come from Victoria, many of which live in regional and rural areas (NDSS, 2015) often with little access to appropriate health services.
live with and produce change in their environment (Zoffmann, 2004). The GSD is designed to guide both young adults with persistent poor glycaemic control and professionals managing young adults with diabetes through mutual reflection drawing on a number of semi-structured reflection sheets.
To help address the issue, an online interactive version of an evidencebased self-management program for young people with type 1 diabetes (T1DM) living in regional and rural Victoria is being developed and trialed as part of a pilot study. The program, based on the Guided Self Determination (GSD) method, was developed by a Danish nurse researcher Professor Vibeke Zoffmann (Zoffmann, 2004).
Participants in the study are prompted to systematically explore and express their personal difficulties and experiences with diabetes through words and drawings. Reflections are recorded on worksheets designed to increase the participant’s ability to express their views and prepare them for active participation in the care process. GSD is a problem-solving and decision-making method designed to overcome barriers to empowerment in adult participant-health professional interactions (Zoffmann and Kirkevold, 2012). As such, GSD is underpinned by life-skills theory, empowerment theory and motivational theory of self-determination. The program has been tested and proven to reduce HbA1c (by 0.4%) and improve life skills in adults with persistently poor glycaemic control of type 1 diabetes (Zoffmann and Lauritzen, 2006).
The GSD program aims to improve the life skills of people between 20 to 40 years of age with diabetes. Life skills include those personal, social, cognitive and physical skills that enable people to control and direct their lives, and to develop the capacity to
This novel evidence-based program seeks to address the complexity of diabetes self-management and improve control of blood glucose targeting younger adults in regional and rural Australia who might otherwise not access services.
An Australian study has found current health services in rural and regional Victoria are not meeting the information and support needs of local communities (Speight et al. 2012); therefore placing this target group at risk of developing serious diabetes complications.
anmf.org.au
References
Significantly, such control results in fewer complications from T1DM for life, resulting in lower Australian healthcare costs and an improved lifestyle for individuals. An interactive, flexible and relevant educational tool like GSD online will provide equity in healthcare access for those with T1DM regardless of location. This study, which is currently being finalised, is supported by Centre for Quality and Patient Safety Research (QPS), Deakin University. The research team is led by Associate Professor Bodil Rasmussen and Professor Judy Currey from the School of Nursing and Midwifery, Deakin University. The team comprises of Associate Professor Vibeke Zoffmann, The Juliane Marie Center, Rigshospitalet, Copenhagen University Hospital, Denmark; Mr Bill Haigh, Simulation Coordinator, Blended Learning and Research, School of Rural Health - Latrobe Valley, Monash University; Professor Trisha Dunning, Chair, Barwon Health-Deakin University; Dr Ian Story, Educational Developer, Faculty of Health, Deakin University; Mrs Karen Crawford, Diabetes Victoria and Mrs Carolyn Hines, Diabetes Victoria. Associate Professor Bodil Rasmussen and Professor Judy Currey are from the School of Nursing and Midwifery at Deakin University in Victoria
National Diabetes Services Scheme (NDSS) Statistical snapshot, December 2015, accessed 10 February 2016 www.ndss.com. au/en/Research/DataSnapshots Speight, J., Browne, J. L., Holmes-Truscott, E., Hendrieckx, C., and Pouwer, F. 2012. Diabetes MILESAustralia (management and impact for longterm empowerment and success): methods and sample characteristics of a national survey of the psychological aspects of living with type 1 or type 2 diabetes in Australian adults.” BMC Public Health 12(1): 120. Zoffmann V. 2004. Guided selfdetermination: a life skills approach developed in difficult type 1 diabetes. Department of nursing science, University of Aarhus, Denmark. Zoffmann, V. and Lauritzen, T. 2006. Guided selfdetermination improves life skills with Type 1 diabetes and A1C in randomized controlled trial.” Participants’ Education and Counseling, 64 (1-3): 78-86. Zoffmann, V., & Kirkevold, M. 2012. Realizing empowerment in difficult diabetes care: a guided self-determination intervention. Qualitative Health Research, 22(1), 103-118.
April 2016 Volume 23, No. 9 37
FOCUS Diabetes Health
FACTORS INFLUENCING BREASTFEEDING WOMEN LIVING WITH TYPE 1 AND TYPE 2 DIABETES Discover your Personal and Professional Potential in Canberra with Mental Health, Justice Health, and Alcohol & Drug Services (MHJHADS) Are you a Registered Nurse, Social Worker, Occupational Therapist, Psychologist or Medical Officer? Do you have a specialist range of skills in the areas of Mental Health, Justice Health or Alcohol or Drug Services? If you have answered yes to the questions above then we want to hear from you as we are recruiting now. Do you know that Canberra is not rated as the Number 1 City in the world to live? The Canberra community has diverse culture and a population of 379,000 people with all the amenities of a city but without the stress. Now for a little about us; the ACT Health Division of Mental Health, Justice Health and Alcohol & Drug Services (MHJHADS) delivers a broad range of acute and community services delivered through partnerships with community and other government organisations. There is a major focus on Consumer & Carer participation in all aspects of service planning and delivery. Our innovative Models of Care have been developed utilising a population health framework and are informed through extensive consultation, and designed to embrace best evidence practice to meet National Standards and the principles of Person Centred Care. The range of specialises services includes programs in the following areas; • Child & Adolescent Mental Health Services (CAMHS) • ACT Wide Services • Adult Mental Health Services • Justice Health Services • Alcohol & Drug Services For more information, please go to www.health.act.gov.au and click on: Employment – Current vacancies Jodie Bowden Manager - Service Development Mental Health, Justice Health and Alcohol & Drug Services Phone: 02 6207 6279 Mobile: 0407207800 Email: jodie.bowden@act.gov.au www.health.act.gov.au For more information visit http://www.canberrayourfuture.com.au
38 April 2016 Volume 23, No. 9
By Bodil Rasmussen Breastfeeding has well recognised maternal, infant and public health benefits (Australian Institute of Health and Welfare, 2010). The World Health Organization (WHO) recommends exclusive breastfeeding (only breast milk and medicines) for infants to six months of age, and the continuation of breastfeeding for at least two years together with complementary foods (WHO, 2002). Despite strong evidence underpinning the WHO recommendations, there are marked regional variations in breastfeeding rates and even in some ‘at risk’ groups, such as women with type 1 diabetes (T1DM) and type 2 diabetes (T2DM), breastfeeding rates are suboptimal (Finkelstein et al. 2013). The prevalence of T1DM and T2DM in pregnancy is approximately 0.5% in Australia (Australian Institute of Health and Welfare, 2010b). Diabetes is associated with increased maternal morbidity, longer periods of hospitalisation, impairment of quality of life (Qol) and higher rates of medical intervention in labour and birth (Dalfrà et al. 2012; Wahabi et al. 2012). In addition, there is a greater risk of adverse perinatal outcomes, increased perinatal mortality and morbidity, congenital anomalies, prematurity, macrosomia, neonatal hypoglycaemia, respiratory distress syndrome, prematurity, polycythaemia and jaundice (Balsells et al. 2009, Crowther et al. 2005). In fact, women with T2DM have comparable risk of perinatal mortality and congenital malformation. A study is currently underway that brings together Deakin University, Royal Women’s Hospital, Mercy Hospital for Women and Western Health, Victoria, in partnership to identify facilitators and barriers to the intention to breastfeed, and the initiation and continuation of any breastfeeding from birth to six months in Victorian women with either T1DM or T2DM. The study also aims to identify physical, psychosocial and cultural risks and protective factors associated with women with T1DM and T2DM ceasing to breastfeed during the first six months following birth. This study is the first in Australia to investigate the complexity of the psychosocial contexts of breastfeeding among women with T1DM and T2DM. In summary, the study will establish new indepth knowledge that can assist nurses and midwives to develop new support programs and health policies for women with T1DM and T2DM in order to maximise the commencement and continuation of breastfeeding for up to six months following childbirth. Furthermore, this study will identify the physical, cultural and emotional factors that are associated with commencing and continuing breastfeeding. These factors include balancing competing demands: from caring for a baby, to work, family and leisure commitments that result in mothers neglecting their health. This can also profoundly impact glycaemic control and increase the risk of short and long term complications and unnecessary use of healthcare resources and costs. The study is funded by the Nurses Board Victoria Legacy Limited Grant, Australasian Diabetes in Pregnancy Society (ADIPS) and Centre for Quality and Patient Safety Research (QPS), Deakin University. The research team is led by Associate Professor Bodil Rasmussen, School of Nursing and Midwifery, Deakin University. The team comprises of Associate Professor Alison Nankervis, The Royal Women’s Hospital; Professor Helen Skouteris, Deakin University; Associate Professor Cate Nagle, Deakin University; Mrs Cath McNamara, Mercy Health and Mrs Cheryl Steele, Western Health Associate Professor Bodil Rasmussen is from the School of Nursing and Midwifery at Deakin University in Victoria
References Australian Institute of Health and Welfare. National infant feeding survey: 2010 Australian national infant feeding survey: indicator results. In: Australian Institute of Health and Welfare, ed. Canberra: Australian Institute of Health and Welfare; 2011. Australian Institute of Health and Welfare. Diabetes in pregnancy: Its impact on Australian women and their babies. In: Australian Institute of Health and Welfare, ed. no.14 ed. Canberra: AIHW 2010. Balsells, M., GarcíaPatterson, A., Gich & Corcoy, R. R. Maternal and fetal outcome in women with type 2 vs type 1 diabetes mellitus: A systematic review and metaanalysis. Journal of Clinical Endocrinology & Metabolism. 2009;94: 4284–91. Crowther, C. A., Hiller, J. E., Moss, J. R., McPhee, A. J., Jeffries, W. S. & Robinson, J. S. 2005. Effect of treatment of gestational diabetes Mellitus on pregnancy outcomes. New England Journal of Medicine 352(24): 2477-2486. Dalfrà, M., Nicolucci, A., Bisson, T., Bonsembiante, B. & Lapolla, A. 2012. Quality of life in pregnancy and post-partum: a study in diabetic patients. Quality of Life Research, 2012; 21:291-298. Finkelstein, S. A, Keely, E., Feig, D. S., Tu, X., Yasseen, A. S., Walker, M. Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study. Diabetic Medicine, 2013; September; 30:9:1094-101. Wahabi, H., Esmaeil, S. A., Fayed, A., AlShaikh, G. & Alzeidan, R. Pre-existing diabetes Mellitus and adverse pregnancy outcomes, BMC Research Notes, 2012, 5:496-501. World Health Organization. The optimal duration of exclusive breastfeeding: Report of an expert consultation. 2002; Department of Nutrition for Health and Development & Department of Child and Adolescent Health and Development, Geneva, Switzerland.
anmf.org.au
Diabetes Health FOCUS
DIABETES HEALTH AT THE BEDSIDE: WHAT CAN YOU DO? By Pauline Hill Pauline Hill
We constantly hear about type 2 diabetes mellitus reaching pandemic status from the media, Diabetes Australia and various researchers (Shaw and Tanamas, 2012). As a nurse or midwife working at the bedside or in the community, you would have noticed the increasing number of people with type 2 diabetes using health services. While some people will be newly diagnosed and require significant input from the diabetes education and management team, the majority will have had diabetes for some time. Most people with type 2 diabetes manage their condition independently at home on a daily basis. When in hospital this responsibility is sometimes taken away from the person with diabetes due to their inability to self-manage due to illness, a health service policy or a well-meaning health professional. Irrespective of who manages the diabetes, every health interaction is an opportunity to check in with the person with diabetes about the management of their condition.
So what can you do?
Reference Shaw, J. and Tanamas, S. 2012. Diabetes: the silent pandemic and its impact on Australia Diabetes Australia, Canberra
anmf.org.au
Talk with the person with diabetes or their carer about their management. Ask what they do on a daily basis to manage their diabetes. This will give you a lot of useful information about their type of diabetes and current management while also providing insight into the knowledge and skills of the person with diabetes or their
carer. These conversations will also help you understand any issues they are currently facing which make their management challenging. This will enable you to suggest other health professionals and services which could assist in their management and to make appropriate referrals.
YOU DO NOT NEED TO BE AN EXPERT IN DIABETES MANAGEMENT. YOU NEED TO LISTEN TO THE PERSON WITH DIABETES AND THEIR CARER AND REFER AS NECESSARY You do not need to be an expert in diabetes management, but you need to listen to the person with diabetes and their carer and refer as necessary. In your daily work as a nurse or midwife you can talk to the person or carer about their diabetes management, check their ability to monitor their blood glucose level and the level/ range they are aiming to achieve, ask about their medications and how
they manage them at home. You can also discuss their shopping and meal preparation as well as how they fit exercise into their busy daily schedule. Assess their risk for foot complications and check their feet for circulation, sensation and any signs of deformity or damage. Ask how they check their feet at home or if they see a podiatrist. If there are any concerns about any of these issues, then ask if they have seen a diabetes educator, dietitian or podiatrist or if they would like a referral. Every health professional has a significant role to play in reducing the impact of diabetes. Make a difference today and have a conversation about diabetes management with people in your care. You can get more information from: Diabetes Australia www.diabetesaustralia.com.au Diabetes Services Country Health SA (CHSA) www.chsa-diabetes.org. au/default.asp Department of Health www.health.gov.au Pauline Hill is a Lecturer in the Faculty of Medicine, Nursing and Health Sciences at Flinders University April 2016 Volume 23, No. 9â&#x20AC;&#x192;â&#x20AC;&#x192;39
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ASSOCIATE NURSE DIRECTORS Two exciting new positions! • • • •
Great opportunity to lead, drive change, and grow your career! Strengthen nursing workforce across the healthcare system New Zealand’s largest and most respected teaching and learning hospital Enjoy the Auckland lifestyle!
At ADHB, we are strengthening the nursing workforce through the introduction of two new roles. Both roles will work closely with the Chief Nursing Officer and Nurse Directors to provide a mechanism to support excellence in clinical practice, teaching, research and innovation ensuring we have a workforce ready to respond to future needs of our patients, their families and the organisation. A culture change is required within ADHB and across the system to strengthen the role of nurses and nursing and its place within the healthcare system and these two new positions will play a critical role in driving that change. These are full-time senior nursing leadership positions, requiring previous experience in developing, implementing, monitoring and evaluating nursing practice. You will work in the ADHB Nursing Development Unit team reporting to the Nurse Director (Professional Development and Practice). You will also work closely with key stakeholders across the organisation. You will lead a variety of professional practice initiatives, providing effective management of projects and demonstrating commitment to evidenced based practice and research. For a more detailed position description please go to our careers site. You’ll need to be a registered nurse with a current practicing certificate and a relevant postgraduate qualification. Previous experience in a nursing leadership role is essential. Other attributes include knowledge and understanding of the New Zealand health sector, a sound understanding of professional ethics, proven ability operationalize strategy, vision and values to achieve change, the ability to remain self-directed in your work and work within teams, work across a number of projects concurrently and an aptitude for computer programmes such as Word and Excel. For further information about these great career opportunities, contact Di Roud, Nurse Director (Professional Development & Practice), dir@adhb.govt.nz, phone (++64) 09 307 4949 ext 22716 or (++64) 021 769 888. For assistance with your online application, contact AqeelaR@adhb.govt.nz To apply, please visit www.careers.adhb.govt.nz quoting position number 092561. Closing date for applications is Friday, 22nd April 2016.
www.careers.adhb.govt.nz FREEPHONE 0800 733 968
Diabetes Health FOCUS
DIABETES NURSE PRACTITIONER: CONVERTING PRACTICE INTO VALUE By Michelle Woods and Giuliana Murfet After attending the Australian College of Nurse Practitioners annual conference in 2015, ANMF federal professional officers gave an overview in the ANMJ of the milestones that have been made in establishing pathways for the developing role of the Nurse Practitioner (NP) in the Australian
healthcare system (Bryce et al. 2015). Although these developments are significant, there continues to be a number of systematic and legislative barriers that impede NPs integration into the Australian healthcare system. Over the course of the past five years two NP specialising in diabetes and chronic disease management have worked for a public health system. In setting up these positions, and in the continuity of validating the role, they have been acutely aware of the necessary onus and opportunity for practising NPs to articulate how their role and practice ‘value adds’ to the healthcare system that they serve. In the case of working in the public sector, this is particularly important in lieu of not having access to MBS provider numbers to ‘request and refer’, as is the case for medical interns and colleagues (Bryce et al. 2015). The following is a synopsis of practice research conducted by these NPs.
Their purpose in this research was to illustrate how NPs value add to the healthcare outcomes. Over the course of three years they developed a peer mentorship relationship and adapted Kim’s (1999) ‘Critical Reflective Inquiry’ (CRI) method. The method involved sharing clinical cases and working through them by applying a cycle of three phases; a descriptive phase involving contextual writing; a reflective phase examining, contrasting narratives of practice with one’s beliefs and assumptions; and, synthesis of knowledge (scientific, ethical and aesthetic). This process led to illustrating evidence of how NPs value add to the populations that they serve and practice insight for responsive design of NP models in care. In using a thermical analysis of the CRI application, we formed five headings that represented our practice as; Specialised Care Access, Complications and Diagnostics Interventions, Pharmaceutical Treatment, Vulnerable Populations and Leadership.
Summation of results: Practice themes, NP interventions and innovations and value to healthcare systems Practice themes
NP interventions and innovations
Value to healthcare systems
Specialised care access
• Development of clinics responsive
• Improved access to specialty care • Aversion of emergency department and hospital
Diagnostic and complications
Pharmaceutical treatment
Vulnerable populations
Leadership
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to service gaps; eg. rapid response and consistent care/ systematic clinics
• Clinical expertise and clinical
alignment in advance practice interventions in the review of people with complex healthcare issues and the interplay of complications and comorbidities
• Timely and functional review
and prescribing, titration and monitoring of medication • Advocacy and development of pharmacotherapeutic options for poorly controlled patients living with multiple complications and comorbidities • Targeted intervention for
vulnerable populations; including delivery of multidisciplinary clinics and changes in models of care to address poor health outcomes
• NP participation, representation
and leadership roles in strategic initiatives in forming alliances between tiers of healthcare systems
admission
• Decreased waiting times for specialty care clinics • Reduction on adverse health outcomes • Concerted and patient specific care plans that
address multifactorial factors that contribute to patient poor health outcomes; such as deteriorating glycaemic control, increased infections and risk to mental health status • Detection of other conditions impacting on healthcare not previously identified
• Improvement in patient knowledge and efficacy in
medication management
• Responsive communication channels developed for
patients to engage with NP to obtain individualised and achievable biomedical, metabolic and glycaemic targets in effective timeframe • Advocacy and coordination of innovative treatment options for patients with demonstrable improvements compared to status quo treatment • Significant reduction in congenital malformation
pre and post-delivery of GDM care model of care
• Quantifiable improvement in screening and
treatment of metabolic syndrome and diabetes for patients living with schizophrenia
• Contribution to development of statewide referral
pathways for improving care for patients living with diabetes • NP committee participation for healthcare reform has provided a voice for the role and demonstration of the clinical leadership
References Bryce, J., Foley, E. and Reeves, J. 2015. In celebration of Nurse Practitioners. ANMJ. Viewed11/2/16 http://anmf.org.au/ pages/professionaloctober-2015 Kim, H., 1999. Critical reflective inquiry for knowledge development in nursing practice. Journal of Advanced Nursing. 29(5): 1205-1212.
Michelle Woods is a Nurse Practitioner / Senior Lecturer at the Royal Hobart Hospital Diabetes Centre, Tasmania Giuliana Murfet is a Nurse Practitioner Diabetes/CDE in the Diabetes Centre at North West Regional Hospital in Burnie Tasmania
April 2016 Volume 23, No. 9 41
FOCUS Diabetes Health
DIABETES AND MENTAL HEALTH: A HOLISTIC APPROACH IS NEEDED By Christopher Patterson and Lorna Moxham No one illness can be totally compartmentalised. Associations between illnesses commonly exist. As such, nurses need to be mindful of holistic care requirements of clients. One such example of this is diabetes and mental illness. There is a clear bidirectional association between diabetes and mental illness (Snoek, 2015). Statistics show that Australians with diabetes have a higher prevalence of poor mental health than those without diabetes (AIHW, 2011). Conversely, those with mental health issues have a higher prevalence of diabetes than the general population. In fact, statistics from the Australian National Health Survey 2014-2015 estimate that 25.4% of people with diabetes have high or very high levels of psychological distress (ABS, 2015). This is compared to 11.7% of the general population (ABS, 2015). In terms of categorised mental health issues, including alcohol and drug issues, mood (affective) disorders and anxiety issues, the National Health Survey 2014-2015 identified that for those with a primary diagnosis
VO LU M
of diabetes, over a quarter (27.5%) will have a comorbid mental and behavioural issue (ABS, 2015). This is compared to the much lower rates of 17.5% of the general population. People with a psychotic illness experience diabetes at a rate three times that of the general population (Morgan et al. 2011). One-fifth (20.5%) of people with a psychotic illness have diabetes compared with 6.2% of the general population (Morgan et al. 2011). Additionally, diabetes is increasingly being recognised as a risk factor for mental health problems, and vice versa. A recent analysis of 23 longitudinal studies concluded that depressive symptoms are associated with a significantly increased risk for diabetes (Rotella & Mannucci, 2013). It is also recognised that when people with diabetes find it difficult to cope, they are at risk of developing mental
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health problems (Britneff & Winkley, 2013). Nurses have key roles in the separate treatment of people with diabetes and mental health problems. But, as we become increasingly specialised, we need to be mindful that we do not move away from holism. Nurses working with people with mental illness need to be able to identify those affected by diabetes and ensure they receive appropriate care (Britneff & Winkley, 2013). Equally, nurses working with people with diabetes need to identify those affected by mental health problems and ensure they too receive appropriate care. Christopher Patterson is a Lecturer in Mental Health Nursing and Lorna Moxham is a Professor of Mental Health Nursing. Both are at the University of Wollongong.
References ABS (Australian Bureau of Statistics) 2015, National Health Survey 2014-15, Cat. No. 4364.0.55.001, Canberra AIHW (Australian Institute of Health and Welfare) 2011, Diabetes and poor mental health and wellbeing: An exploratory analysis, Cat. No. CVD 55, AIHW, Canberra Britneff, E. & Winkley, K. 2013, The role of psychological interventions for people with diabetes and mental health issues, Journal of Diabetes Nursing, vol. 17, pp. 305-310 Morgan, V. et al. 2011, People living with psychotic illness 2010: Report on the second Australian national survey, Commonwealth of Australia Rotella, F. & Mannucci, E. 2013, Depression as a risk factor for diabetes: a meta-analysis of longitudinal studies, Journal of Clinical Psychiatry, vol. 74, pp. 31-37 Snoek, F.J. 2015, Constructs of depression and distress in diabetes: time for an appraisal, The Lancet, vol. 3, pp. 450-460
Diabetes Health FOCUS
THE WOMEN’S WELLNESS WITH TYPE 2 DIABETES PROGRAM By Amanda McGuire and Debra Anderson The health and economic cost of diabetes is increasing, making it an important health priority at a global and national level (WHO, 2014). Compared to women in the general population, women with diabetes are at much higher risk of other illnesses including cardiovascular disease, kidney disease, and vision loss. Further, women with diabetes are more likely to experience psychological distress (AIHW, 2015). While diabetes is being diagnosed earlier now than previously, the physiological changes in metabolism and body composition that occur during midlife may increase vulnerability in women even further (Lovejoy et al. 2008). Previous studies have shown that lifestyle modifications like increased physical activity and improved diet, not only helps prevent the development of type 2 diabetes, but in those with type 2 can also help prevent further complications such as cardiovascular and renal disease, and stroke (AIHW,
2015; Alberti et al. 2007). Researchers from Queensland University of Technology, Griffith University and King’s College London are undertaking a collaborative project (Anderson et al. 2015) to develop, trial and evaluate the clinical benefits and cost impacts of an e-health enabled, structured health promotion intervention directed at midlife women living with type 2 diabetes (The Women’s Wellness with Type 2 Diabetes Program). This program aims to
PERSON-CENTRED CARE IN DIABETES: A MUST HAVE By Toni Rice Why is person-centred care in diabetes important? In Australia, person-centred care is defined as: ‘healthcare that is respectful of, and responsive to, the preferences, needs and values of patients and consumer’ (ACSQHC, 2014). Health professionals who acknowledge health literacy needs of individuals and provide person-centred care, help facilitate people to engage with health services in a relevant and timely manner, make effective decisions about their health, and participate in mutually-agreed evidence-based selfmanagement strategies. People with diabetes take an active role in managing their condition, and may provide up to 95% of their own care (Krichbaum et al. 2003). Daily self-care responsibilities include complex medication schedules, following dietary recommendations, glucose monitoring, participating in physical activity and preventative care strategies (Cavanaugh, 2011). These activities can be particularly challenging if healthcare interventions are not person-centred.
The answer
The Australian Diabetes Educators Association (ADEA) is committed anmf.org.au
to the highest standards of practice including the provision of person-centred care in diabetes management. ADEA, through the Person Centred Care Project, funded by the National Diabetes Services Scheme, has developed resources for Credentialled Diabetes Educators (CDEs) and other health professionals to assist them with implementing person-centred care practices. The project has resulted in the development of a dedicated PersonCentred Care website. The website houses a range of ADEA resources (including information sheets on person-centred care and health literacy, literature reviews, webinars, consumer stories, examples of person-centred care and educational cartoons) as well as links to relevant external resources. A key resource of the Person-Centred Care Project is the Person-Centred Care Toolkit. The Person-Centred Care Toolkit aims to assist CDEs and other health professionals to deliver, monitor and evaluate person-centred care for people with diabetes. It was developed through a partnership
improve health related quality of life and reduce key chronic disease risk factors. Diabetes Nurse Educators will deliver the 12 week program in addition to usual diabetes selfmanagement care. Health coaching and goal setting targets physical activity, diet, body weight, sleep, stress and psychological wellbeing, preventive health and risk screening with reinforcement of diabetes selfmanagement principles. Considering the preventable nature of type 2 diabetes and the proven benefits of lifestyle modification on disease progression and complications, there is an urgent need to develop and test interventions that are innovative, flexibly delivered and tailored to women with diabetes. Amanda McGuire is at the Institute of Health and Biomedical Innovation at the Queensland University of Technology Debra Anderson is at the Menzies Health Institute at Griffith University
between ADEA and the International Centre for Allied Health Evidence (iCAHE) at the University of South Australia (www.unisa.edu.au/CAHE/). A set of ten Person-Centred Care Principles form the basis of the Person-Centred Care Toolkit. There are three components to the PersonCentred Care Toolkit, including a: • quality improvement tool for CDEs and diabetes services; • consumer survey; • consumer interview. The Person-Centred Care Toolkit has been developed to enable CDEs, health professionals and diabetes services to determine what delivering person-centred care means for their practice. It will help to describe what their service will look like if they are providing person-centred care, and if they are not. In this sense, the PersonCentred Care Toolkit is designed to be used as a basis for monitoring quality practice. The Person-Centred Care Toolkit is available as interactive PDF documents hosted on the dedicated ADEA Person-Centred Care website. For further information including how to adapt the toolkit to suit other healthcare settings contact Toni Rice, NDSS Project Manager: toni.rice@adea.com.au Toni Rice is National Diabetes Services Scheme (NDSS) Project Manager at Australian Diabetes Educators Association (ADEA)
References Alberti, K. G. M. M., Zimmet, P. & Shaw, J. 2007. International diabetes federation: a consensus on type 2 diabetes prevention. Diabetic Medicine. 24: 451-463. Anderson, D., Sturt, J., McGuire, A., Tjondronegoro, D., Song, W., Seib, C. and Dennick, K. The women’s wellness with diabetes program: A feasibility study. 2015. Diabetes Queensland Research Grant. Australian Institute of Health and Welfare (AIHW) 2015. Diabetes complications. Retrieved from: www.aihw.gov.au/ diabetes/complications/ Accessed 11 February 2016. Lovejoy, J. C., Champagne, C. M., de Jonge, L., Xie, H., & Smith, S. R. 2008. Increased visceral fat and decreased energy expenditure during the menopausal transition. International Journal of Obesity. 32: 949-958. World Health Organization (WHO). 2014. Global status report on noncommunicable diseases 2014. Retrieved from http:// apps.who.int/iris/ bitstream/10665/14811 4/1/9789241564854_ eng.pdf?ua=1 Accessed 11 February 2016.
References Australian Commission on Safety and Quality in Health Care (ACSQHC) 2014. Australian Safety and Quality Framework for Health Care, Patient and Consumer Centred Care. Available at www. safetyandquality.gov.au/ our-work/patient-andconsumer-centred-care/ Accessed 7 October 2015 Cavanaugh K, 2011. Health literacy in diabetes care: explanation, evidence and equipment’, Diabetes Management, vol. 1, pp. 191-199. Accessed 22 September 2015. Krichbaum K, Aarestad V, Buethe M 2003. ‘Exploring the Connection Between Self-Efficacy and Effective Diabetes Self-Management’, The Diabetes Educator, vol. 29, pp. 653-664. Accessed 22 September 2015.
April 2016 Volume 23, No. 9 43
FOCUS Diabetes Health THE NEED TO REVIEW AND UPDATE NURSING CARE PRACTICE AND EDUCATION HAS LED TO A NEW DIABETES RESEARCH PROJECT AT RDNS
IMPROVING ACCESS AND SUPPORT FOR PEOPLE WITH TYPE 2 DIABETES COMMENCING INJECTABLE THERAPY By Rajna Ogrin and Tracy Aylen In Australia over one million people have type 2 diabetes (NDSS, 2015), many aged 65 years or older (65 years > 43%; 75 years > 18.4%) (AIHW, 2012). A quarter of people with type 2 diabetes in Australia have an HbA1c >8% (Maclsaac et al. 2009), whereas the optimum range is <7% (UKPDS, 1998). Allowing for some who may need a higher HbA1c targets due to frailty or other health considerations, there are still many Australians with sub-optimal HbA1c levels likely to benefit from more intensive diabetes management. Injectable therapies, including insulin and GLP1 agonists, are necessary to manage diabetes when maximal oral therapy is no longer effective. On average, injectable therapies are currently started when glycaemic levels have been above target for almost eight years (Calvert et al. 2007). This is inconsistent with national and international therapeutic guidelines (IDF, 2012). Reductions in HbA1c by 1% can result in a reduction of end stage kidney disease, amputation, advanced eye disease and myocardial infarction (Palmer et al. 2004). For older people with diabetes, disability, falls risk and co-morbidities are often interrelated (IDF, 2012): there is a significant increased risk of fractures (Bonds et al. 2006) and poor glycaemic management is associated with changes in mental performance and memory (Ryan et al. 2006). An Australian study has shown that almost two thirds of all people with type 2 diabetes had their insulin therapy initiated by a specialist, while just under 20% of cases had their insulin therapy initiated by a GP alone (AIHW, 2009). RDNS has for many years been involved in supporting clients to commence and maintain insulin therapy on referral from a GP and specialist, however the need to review and update nursing care practice and education delivery has led to a new research project within our organisation. RDNS in collaboration with General Practice, Northern Health and the Australian Centre of Behavioural Research in Diabetes is implementing a community-based intervention, 44 April 2016 Volume 23, No. 9
Home Initiation of Injectable Therapy in people with type 2 diabetes (HIIT-D). Registered nurses working with RDNS in the northern region of metropolitan Melbourne receive training on initiation of injectable therapy for referred clients, following prescription and provision of a medical authorisation by the GP. There are health professional engagement and education sessions, as well as support for the project RNs through the regional Diabetes Clinical Nurse Consultant. This is anticipated to reduce current delays in the implementation of evidence-based practice for the initiation of injectable therapy in people with sub-optimally managed type 2 diabetes by providing a home based support option. The research is examining the experience of GPs, RNs and clients who participate in the project, in addition to reporting on a range of clinical indicators. The research includes access for people from non-English speaking backgrounds: Turkish, Arabic, Assyrian, Italian and Greek. We gratefully acknowledge funding from The Ian Potter Foundation, H&L Hecht Trust managed by Perpetual, RDNS Charitable Trust and the support by an unrestricted grant from Sanofi in supporting this research. Tracy Aylen is Senior Clinical Nurse Advisor Diabetes, RDNS Dr Rajna Ogrin is Senior Research Fellow, RDNS Institute
References AIHW. Diabetes: Australian Government; 2012 (cited 2012 10 August 2012). Available from: www.aihw.gov.au/ diabetes/prevalence/ AIHW. SAND abstract No. 135 from the BEACH program: diabetes in general practice patients. Sydney: University of Sydney, 2009. Bonds, D.E., Larson, J.C., Schwartz, A.V., Strotmeyer, E.S., Robbins, J., Rodriguez BL, et al. Risk of fracture in women with type 2 diabetes: the women’s health initiative observational study. The Journal of Clinical Endocrinology & Metabolism. 2006;91(9):340410. PubMed PMID: 16804043. Calvert, M., McManus, R., Freemantle, N. Management of type 2 diabetes with multiple oral hypoglycemic agents or insulin in primary care: retrospective cohort study. British Journal of General Practice. 2007;57(539):455-60. IDF. Global guideline for type 2 diabetes. Brussels: International Diabetes Federation, Force CGT; 2012. MacIsaac, R.J., Jerums, G., Weekes, A.J., and Thomas, M.C. Patterns of glycaemic control in Australian primary care (NEFRON 8). Internal Medicine Journal. 2009;39(8):512-8.
NDSS, Diabetes Australia. Data snapshot: Type 2 diabetes December 2015 (22 February 2016). Available from: https:// static.diabetesaustralia. com.au/s/fileassets/ diabetes-australia/ f614b801-9a27-432da4d0-8dada4412270.pdf Palmer, A.J., Roze, S., Valentine, W.J., Minshall, M.E., Foos, V., Lurati, F.M., et al. Validation of the CORE diabetes model against epidemiological and clinical studies. Current Medical Research and Opinion. 2004;20(s1):S27-S40 Ryan, C.M., Freed, M.I., Rood, J.A., Cobitz, A.R., Waterhouse, B.R., Strachan, M.W.J. Improving metabolic control leads to better working memory in adults with type 2 diabetes. Diabetes Care. 2006. 1 February 2006; 29(2):345-51 UKPDS. United Kingdom prospective diabetes study 24: a 6-year, randomized, controlled trial comparing sulfonylurea, insulin, and metformin therapy in patients with newly diagnosed type 2 diabetes that could not be controlled with diet therapy. United Kingdom Prospective Diabetes Study Group. Annals of Internal Medicine. 1998. 1 February;128(3):165-75. PubMed PMID: 9454524. Epub 1998/02/07. eng
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CALENDAR
APRIL International Forum on Quality and Safety in Healthcare Change. Save. Sustain. In partnership with patients 12-15 April, Gothenburg, Sweden. http://internationalforum.bmj.com/ Lung Health Promotion Centre at The Alfred 14-15 April – Managing COPD 18-19 April – Spirometry Principles & Practice P: (03) 9076 2382 E: lunghealth@alfred.org.au Timely Diagnosis of Dementia in Primary Care – APNA workshop 15 April, 8:30am–1:30pm, Wagga Wagga, NSW. Free event - worth up to 3 CPD hours. www.apna.asn.au/ scripts/cgiip.exe/WService=APNA/ ccms.r?PageId=12804 ANMF Vic Branch - Health and Environmental Sustainability Conference 29 April, Melbourne Convention and Exhibition Centre. As the major and most trusted health workforce, we have an incredible opportunity to lead on sustainability in health and there are already many nurses and midwives leading the charge by instigating remarkable workplace projects. The ANMF Vic Branch conference will continue to present these inspiring projects. www.anmfvic.asn.au/eventsand-conferences
MAY International Day of the Midwife 5 May. www.internationalmidwives.org/ events/idotm/ Timely Diagnosis of Dementia in Primary Care – APNA pre-conference workshop 5 May, 1:30pm–5:00pm, Albert Park, Victoria. Preconference workshop at APNA National Conference - worth up to 3 CPD hours. http://apnaconference. asn.au/workshops/ Australian Primary Health Care Nurses Association (APNA) National Conference Nurses the heart of primary healthcare 5-7 May, Pullman Melbourne, Albert Park. The conference for nurses working in primary healthcare. www.apnaconference.asn.au
NETWORK RAH Nurses, Group 762, 40-year reunion 16 April from 6.30pm onwards. Private (city fringe) address will be forwarded. RSVP 9 April to Alison James M: 0414 722 463 E: alison.james@tafesa.edu.au or Heather Crosby M: 0417 806 674 E: heather@sambrook.com.au
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Lung Health Promotion Centre at The Alfred 9 May – Paediatric Respiratory Update 31 May – Respiratory Update P: (03) 9076 2382 E: lunghealth@alfred.org.au International Nurses Day Nurses: A force for change: Improving health systems’ resilience 12 May. www.icn.ch/publications/2016nurses-a-force-for-change-improvinghealth-systems-resilience/ ATSA Independent Living Expo Australasia’s largest display of rehabilitation and assistive technology equipment 18–19 May, Melbourne Showground. The ATSA Independent Living Expo will have over 100 exhibitors displaying a wide range of products and services in assistive technology, mobility solutions, pressure care, employment support, modified motor vehicles and a lot more. www.atsaindependentlivingexpo.com. au ANMF Vic Branch - Prevention of Workplace Bullying Conference 26 May, Carson Conference Centre, Melbourne. Workplace bullying is a significant psychological hazard and a risk to the health and safety of many nurses, midwives and carers and it should not be tolerated in any workplace. www.anmfvic.asn.au/eventsand-conferences
JUNE Deakin University – Nurse Practitioner Masterclass 2-3 June, Melbourne City Centre. Masterclass covers scopes of practice for Nurse Practitioners, clinical decision making and current issues. www.deakin. edu.au/nursing-midwifery/upcomingevents Lung Health Promotion Centre at The Alfred 3 June – Theory and Practice of NonInvasive Ventilation (Bi-Level and CPAP Management) 20 June – Asthma Management Update 23-24 June – Spirometry Principles & Practice P: (03) 9076 2382 E: lunghealth@alfred.org.au
Adelaide Children’s Hospital, Group 276, 40-year reunion 27 May. Contact Anne Bartholomew (nee Lennox) E: wald06@tpg.com.au or M 0417 854 015 Royal Adelaide Hospital, Group 764, 40-year reunion 18 June. Private room at pub with small charge to cover cost of food platters. Contact Patrice O’Loughlin M: 0405 399 171 E: patrice_oloughlin@mail.com
ANMF Vic Branch Annual Delegates Conference & Health and Safety Rep Conference 23-24 June, Melbourne Convention and Exhibition Centre. This two day conference focuses on exploring occupational health and safety issues for nurses and midwives as well as giving Job Reps the opportunity to vote on resolutions and help shape the direction of the branch for the next 12 months. www.anmfvic.asn.au/eventsand-conferences Active Ageing Conference Wellness, reablement and restorative care in aged care 30 June, Swissotel Sydney. The Active Ageing Conference is a one-day conference and series of workshops to share the latest evidence on wellness, reablement and restorative care, and to equip community care providers with strategies to meet their new requirements. www. activeageingconference.com.au
JULY Lung Health Promotion Centre at The Alfred 13-15 July/17-18 August – Respiratory Course (Modules A & B) 13-15 July – Respiratory Course (Module A) 20-22 July - Asthma Educator’s Course 28-29 July – Smoking Cessation Course P: (03) 9076 2382 E: lunghealth@alfred.org.a ANMF Vic Branch - Mental Health Forum: Advocacy 29 July, Carson Conference Centre, Melbourne. www.anmfvic.asn.au/eventsand-conferences
AUGUST ANMF Vic Branch - Working Hours, Shifts and Fatigue Conference 18 August, Carson Conference Centre, Melbourne. Find out how working hours, shifts and fatigue affect the health and safety of nurses, midwives and patients in this exciting one-day conference. Get practical strategies for reducing the impact of shiftwork and fatigue. Aimed at all levels of nursing and midwifery, this conference will be particularly useful if you roster or manage staff. www.anmfvic.asn.au/ events-and-conferences
St Vincent’s Hospital, Melbourne, August 1986, 30-year reunion 5 August. Contact Celia Kenny (nee Murphy) E: paulandcelia@hotmail.com or search Facebook page AUGUST 86 30YR REUNION 2016 Woden Valley Hospital, L Group, 35-year reunion 1-3 October. Contact Murray Harper M: 0448 211 059 E: dodgerlily21@bigpond. com Facebook: Search for page “Woden Valley Hospital L Group”
SEPTEMBER ANMF Vic Branch - Australian Nurses and Midwives Conference 8-9 September, Melbourne Convention and Exhibition Centre. This Conference brings together nursing and midwifery professionals from across Australia and overseas. The two-day program features a range of international, interstate and Victorian speakers exploring professional and clinical issues and innovations in nursing, midwifery, mental health and aged care. www. anmfvic.asn.au/events-and-conferences Australasia-Pacific Post-Polio Conference Polio: Life stage matters 20–22 September. Four Seasons Hotel, Sydney. This conference will facilitate better care and build international connections by bringing together health care providers, researchers, polio survivors, their caregivers and patient organisation representatives. www. postpolioconference.org.au
OCTOBER Australasian Rehabilitation Nurses’ Association 26th Annual Conference Hands, hearts and minds: Capturing the essence of rehabilitation 10-11 October, Betty Cuthbert Room, MCG, Melbourne. www.arna.com.au/ Childbirth and Parenting Educators of Australia Bi-Annual National Conference (hosted by SA Branch) Nurture the primal instinct 12-14 October, ‘The Sanctuary’, Adelaide Zoo. https://www.ivvy.com/ event/CAPEA/ Australian Disease Management Association 12th Annual National Conference Person centred healthcare: Achievements & challenges 20-21 October, Melbourne Convention Centre (MCEC). www.adma.org.au/ E: info@adma.org.au T: (03) 9076 4125
NOVEMBER Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) Annual Conference 8-10 November, Melbourne Convention Centre. http://catsinam.org. au/conference/conference-catsinamv
Royal Melbourne Hospital October 1976, 40-year reunion 8 October, Naughtons Parkville Hotel. Contact mezzarankin@gmail.com or Kris Alderson(nee McGuigan) E: pjka@ ozemail.com.au or Jane Beetham(nee Collyer) E: beethams@mmnet.com.au
Email cathy@anmf.org.au if you would like to place a reunion notice
April 2016 Volume 23, No. 9 45
MAIL FEATURE LOUISE DEARMA
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TAKING ENROLLED INTO A NENWURSING ERA
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As a new team takes the helm foundations to champion of enrolled the to strengthen nursing education and enrolled nursing workf orce, major practice in the future of Austra changes enrolled nurse s - our nation lia. Together, these devel are reshaping the ’s ‘essential nurses’, writes opments are working Karen Keast .
ouise Dearm an at North Easternis an enrolled nurse develop their Adelaide, where Health Centre in scope of practic a nurse-led e. established about 10 years clinic was “A lot of enrolled nurses enrolle ago. are a vital part workforce at knowledgeab d nurses are so Louise is passion of the health a time when le ate about increasing challen the sector faces amazing, and and their skill sets are nursing, so every nurses’ much so that enrolled ges. is very differen scope of practic she recentl up her hand y put t in accordance to become e “As we that they’re the nationa of enrolled to the role go forward doing and l face nurses into the future, need to have the preparation National Enrolle as President of the we a workforce that they’ve education together,” had for that she says. Australia (NENA d Nurse Association she says. “In that works well role,” of ). general, we seen that registe have nurses do work red nurses and enrolle “You can’t While enrolle just d well togeth d nurses are very comple one box and box all enrolled nurses healthcare mentary and er, they work in a in the say system’s ‘essentrenowned as our collaborative enrolled nurse’ ‘an enrolled nurse is partner with ial nurses’, way. an registered who - you’ve got “In acute care history, their nurses to deliver more direct to look at their them for but then also knowledge patient care, the continu base, their and their scope workin iders use are used for often conced enrolled nurses g um, prov across skill base e of practice.” ion s, they different parts as people move throug stigma attache there’s an unwarranted icula, they graduate es “Educat h d to the role. new ing curr opportunities of the health system, Enrolled nursin there’s develop students and ss enrolled nurs t to for enrolled g g it is challen wan Enrolled nurses “The minute ging at times nurses but I think assessin be used to asse rseas and you announ have transfo for everybody have a full ove landscape d ce you’re an enrolled nurse rmed also apprec the cate of to nursing care can iation of what you are stigma . nurses can the second been edu go - ‘you’re enrolled tised. People contribute. level practiti provision since just who’ve registration here oner role was introduced says. “I actuall an enrolled nurse’,” es if in Australia Louise y apply for lled nurs for “We’re meant under the title first ‘nursing aides’ just an enrolle still hear myself say ss enro to be using of ‘I’m d to asse the profession within our healthc all the worker with ‘enrolle in 1950, and later replace so much from nurse’ because you e used d nurses’ in s hear it are system d so many differen tice and y from “They’r 1981. and we are you just start ENTgoing to need them been awa to return to practhat we’re to refer to yourse t places that in the future, t Over the years, VERNM it’sRK important that they’ve nt so I think lf as that. L dGO ent if “Then you walk away and and wan the eve theERA enrolle enrolled nurses, we look at people workfo just an enrolle think - ‘no, nursing E TO WO a while used in ance assessm like hasFED flourish I’m not Midwif rce d nurse, I am NU THE also be nurse to have who are a good flexible NTI The member of ON a well educat Nursing and T WE they’d to do a perform ” she adds. ery Board ofTOed. CO D in the the LLE workfo nursing ed THA on ion, rce.” September TOR Australia’s (NMBA fraternity’.” VE CA RC required n a notificat to the professi S 2015 quarte ENSURE) E SEC Louise, TO bee rly statistic almost ng “WE HA NURSE who began RS 60,000DE and they Louise says while FO s show belo there’s es s RK LED enrolle her many nurs OL career dard country nurses WO r registe experie registered LL-S KEH areKIL red to practic d WE THEnced now ls before spendiworking in nurses apprec “The stan ng to enrolled guides thei SUR15Eyearshospita e in Austral ANDiate extra 5,043 ER OF WITH STA as a skilled that ng the last enrolle in general practic ia, while TO EN MBare concurrent and NTLdYnurses an RS - they belo document NUred nurses provide IGEpart e, says enrolle / registe dgable enrolled nurse nursing workfo knowleDIL key SECTO of theEQUATE d more handsrce, she ALLor dual are the AD registeRO SSnurse on care. enrolled nurse ve the stigma .” tes from some finds ensiemana / AC red midwif e. RE.” practice “It’s all about HAVEofAN corners profession. a compreh the SYSTEM giving that It also stems ALITY CA lic direct care patient - facilitat arked on from professionals IN THEnursing EnrolleQU d nursing practic to the ding pub BA emb lled and the wider other health MASe has advocate, and ing their care, being in the past LEE THO The NM process, inclu tion of enro also evolved community. their decade on about being those are all the things enrolled nurses, . A growing numbe observa evaluati the newIt’s and a stigma Louise an enrolled I love r of and all new tion and , to develop ion wants nurse,” now sulta icat Enrolled nurses graduates, to stamp educated she says. con tice are should be judged out. commun mormerit, e than in prac “As an enrolled nursesto administer medicines. she says. nurses s. As part of its on their While connec enrolled nurse, you have are required sulted es con the stat it to supervision tion with the a closer all ess, standard of registered work under patient becaus s across “Enroll actually get . nurses can ent proc nurses, enrolle e you to spend the also suppor recruitm es and midwive s of practice ed nurses are a valuab d t and superv patient.” time with the workers and of the nursing text ise other students in fraternity, who le member 3,000 nurs s and con some contex educat torie ts. a moreed and who can go are well and terri Major chang Commonwea on and result is with lth es the end Behind the ument Officer Adjunc Chief Nurse and Midwif scenes oran says -friendly doc l and t Professor are redeveloping , several pivotal initiativ Debra Thoms ery Ms Hall essiona , and and user es says the backbo nurse educat of care g.au relevant domains - prof isionanmf.or ion and practic ne of enrolled e prov e in Austral just thre tive practice, practice. ia. al
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Concern LOUISE stered e could organisation ct in lled lled the regi nurse. effe packag kage enro ing enro es into Pac new s ed train s qualified lders, lled nurs h came tice standard Training enrolled s, whic is enro in register to produce Health eho Standard ut that accessible standard the core prac assessing ing stak on in a bid able year, the updated, new e abo g The nurs last say bein and acti rk for oran we wer Late define prompted F, to take supply of named “What Ms Hall ewed and lled nurses standards January, ide the framewoIt replaces the nurses have a times,” sn’t have n enro was revi . pted the ANM need to nurse at all editatio s for the tice for that prov nurse practice including ee an uninterru s. ed nurse nurse doesame place ed for Prac while the accr Standard register e registered enrolled . d, develop enrolled Competency to guarantnursing graduate in the d to unveile and accredit l was first says. “Th sically located they do nee and g revised ss Nationa Nurse, which hority’s enrolled ct to asse s are now bein lity Aut is to be phy lled nurse but about dire Enrolled Skills Quaqualification wifery talk enro program tralian to ea nurses as the , so we and Mid in 2002. space.” “The Aus s said onc got 12 months tactable Nursing unveiled its new e enrolled in that ions rule be con tralian ervision ses also dards stat king; use ’ve only and complet (ASQA) is sup Nur you MF) stan The Aus fully for rect thin sion ded nts indi ervi ion (AN dards The new “analytical ence; and skill the new superse your enrolme ent and Federat Practice Stan h builds on the ures all in direct sup teaching e alerted e with l s state is actually pres es and /or evid engage icat and finish off you must be dard wer mun Nationa Practice, whic tice, and feat a e ding .“W lt in , guid rmation tically com The stan supervisor eral ks with care, inclu ily and then Ms Davis says going to resu nurse info sed” s for Prac st both well the in Gen empathe provision of ” r fam “when erves, woris being supervi Standard Toolkit to assi lled was as rse, thei and es obs BA’s enro that cou the lly and g nurs in NM the who care onal fact that RTOs and the persona stered ges mpanyin involved person is when professi to the receiving the chan an acco nurses and regi cts the act on ervision e facility or person ity, and health dire imp cation sup gether, e the edu lled s.To rect hug sam does ing tice enro mun ce. while indi works in the lled nurse but eral prac en enrolled nurs lting in the and com es”. s got workfor sor as gen a scope eholder the enro r activities. supervi ately resu strength colleagu or stak ASQA and got while the vary tion as aim to tice while ultim care. new itor thei of the maj owledge hed organisa e will ent tly mon “Some and approac lification to the and prac of better pati dards ackn enrolled nurs cation, for constan e stan not qua labl ther edu The r each old avai toge provision e tice for and thei y to provide n for the must be es. “What is of prac the context ervisor transitio , g Packagmunity Services stat capacit reflective . sup it text e on inin the tion e d con ss,” “Th Tra in Com ther have base on the qualifica ble acce nurses Health ntly defunded s Council released , engage care iders out and depend reasona e trate enrolled indirect care , g receiving lot of proved about that ble, will The rece Industry Skill ning Packag , demons tice, and were a two reasona of the person on who is bein lth Trai the direct and al practice concern now a “There tive prac ds port and Hea ional Health qualification, lytic e really there is still take the nee of the pers collabora cate and sup and ana that wer rest easy that needs er. a new Nat lled nursing edu it onal and they can they’re and the Decemb enro professi ropriate, can workers when they can sition time, so course while sed.” point for the of Nursing, in re app healthcare ify the supervi old tran a ie Davis . whe clar the lom year Jod care also Dip ted of cer ble for nts into rse.” dards cation on Offi unregula the provision enrolme their new cou accounta sed stan that nal Edu Educati ber es to e and The revi lled nurses are provide and ry ping l Vocatio Federal mem com nurs F in wife a map iona ed and ANM ster they and Mid has ee r actions that enro of the Nat) Committee says the , a regi Nursing gated care ty for thei y Committ is Chair NMBA, MAC) Halloran tralian the dele in responsibili ning (VET dards set e Advisor and the ncil (AN Petrina the old r for the The Aus and Trai ning Packag e sed stan nurses’ manage tation Cousition tool from lable on its they reta care. Packag policy ciple-ba lled Accredi ng of the Trai lth Training ning Package. and prin to assess enro document kage, avai s to be ed a tran deliveri Hea broad develop to the new pac st provider “The for the ity Services Trai chmark NMBA assi e dards ons the ben nce to practise. that the ld packag that works to ation stan Commun medicati dard s edit core pete wou stan add lic m com website, with the accr into the review minimu the pub nt ications . .au is says the nurses, sets the ect and that complia on delivery Ms Dav intravenous med for enrolled e anmf.org es. exp cati would lled nurs for edu its e including oma of Nursing“It’s a much mor ria of enro .au crite expect practic BA published anmf.org of the Dipl better course. assessment NM ly rds for ses. a the previous Standa r last year, thefor Enrolled Nur creating ensive course, than was s from 23 In Octobes for Practice compreh h more rigorous that graduate k re_v2.indd wor h16_Featu Standard in it is mucI would presumeand be more ” J Marc . ing. out 20-25_ANM lable e runn avai com 4:58 pm ground rse will 19/02/2016 this cou able to hit the ready and T
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ACCEPTING A DIFFERENT POINT OF VIEW To call a person deluded and out-dated because she holds views different to myself sounds discriminatory. To call a person’s beliefs repressive attitudes of the past and laughable is not the language of logical and fair debate or of acceptance of another person’s right to have differing views.
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ENS DESERVE RECOGNITION I have just finished reading March’s ANMJ feature about ENs. I work in a private hospital on a maternity ward. I am an EEN, Medication and IV Endorsed. There are a good handful of us on the ward, and this topic has been raised between us many, many times, over many years. I not only speak for myself, but the stigma attached to ENs and EENs is degrading and uncalled for. I have on many occasions helped RNs and midwives with things they are having trouble with, things they cannot do and even corrected them when they have made a mistake. My patients think I am a midwife and call me as such. I know my education on paper may be less than an RN or midwife but on the postnatal ward it’s equal. It is completely unfair how we get looked down on and degraded when we know we are bloody good at what we do! The fact the we are called ‘enrolled nurse’ sounds as though we are enrolled not registered, just like being enrolled in a course, making us sound like a student. But we have to be registered to be able to practice. When I have corrected patients calling me a midwife, they look down at me and request a nurse that is registered that knows what they are doing... On many occasions within the ward that I work, I have heard RNs, midwives and ANUMS say that EENs are at times better and that we work even harder than RNs and midwives. But in all honesty we have to be. We have to prove ourselves every shift that we know what we are doing; that we are competent and qualified.
When I read in the February edition of the ANMJ Tracy Murphy’s letter in response to Christine Schreiber’s letter, I went back to the December issue to read what strong and abusive things she had written. I was surprised to find a quite mildly expressed viewpoint. I am confident that if Christine had a patient who was homosexual she would give her/him as good treatment as a heterosexual person, and she probably wouldn’t give them an ear-bashing about being homosexual. One does not have to agree with a person to be non-discriminatory. We can disagree, but still treat them kindly. I am not sure that Tracy was being kind to Christine. Her language suggested nonacceptance of a differing point of view, and portrayed discrimination. Hopefully that was not intended. Some may think that I have an outdated view that the use of drugs like Ice is not good for society. People may think that I am deluded, even that it is a repressive attitude from my past. Young people especially may disagree with me. But that is no reason to discriminate against me. I have the freedom to express my opinions, even if they are a minority. Logical, caring debate could be entered into on the issue. It is probably not rational to conclude that because something is modern it is good. I have had patients who are homosexual and heterosexual. I have had patients who have killed other people, been violent and raped people. All professional nurses would, as I do, still treat them with care and not discriminate. However, it doesn’t mean I have to agree with them, with their actions or attitudes.
We deserve the recognition...
I agree with the statement that marriage is a sacred, lifelong covenant relationship between one man and one woman. Two men or two women can have a legally accepted relationship, but it is different. So why not give it a different name. But, still treat them as valuable people.
Sharne EEN, VIC
Chris Georg, RN
We are registered. We are competent. We are qualified. We are knowledgeable. And WE are bloody good at what we do.
46 April 2016 Volume 23, No. 9
anmf.org.au
AGED CARE WORKFORCE REPUTATION Having just read Generation Next (AMMJ, February 2016), and completing a submission to the Future of Australia’s aged care sector, I feel compelled to write this letter. The comment made in the article by a recent graduate lamenting her inability to find a job, “I just want something… Whether I work up from aged care, I don’t care,” (Fedele, 2016), paints a sorry picture of the standing nurses working in aged care have within the nursing community, and contributes to the reason aged care is in such a mess. Nurses working in aged care are believed to ‘sit around drinking cups of tea’. This could not be further from the truth. They work extremely hard, most times with a ratio of patients (residents) to RNs exceeding 50:1. Were this to happen in an acute setting outrage would occur, however it seems to be tolerated in aged care because the people being cared for are perceived not to have acute needs. Many of the people for whom they deliver care have dementia, in addition to the multi-morbidities they also have. Their needs are both acute and dynamic, and require sensitive and skilled care provision. Unless the skills required to work in this environment are appreciated and supported, change will not occur. It is very sad that within our ranks such a poor reputation is held by its own, from the very beginning it would seem by the comments read in the journal. Amanda Crombie RN, Victoria
AN ENS ROLE In regards to March’s ANMJ feature, Taking Enrolled Nursing Into a New Era, the term, ‘essential nurse’ for Enrolled Nurses (ENs) is offensive. ALL nurses are essential. I have been an EN for 30 years. I have witnessed much in nursing during that time. ENs have not really come that far. I started training in a large public hospital. Once there was a transplant organ to collect from the courier service. Only an Registered Nurse (RN) could be trusted to collect this labelled container. Perhaps they thought ENs couldn’t read? Back then only RNs could perform venepuncture. Now any walk of life can be trained to do this. Unfortunately most RNs struggle with EN scope of practice, as in what can be done and not done. There is much confusion out there that needs rectifying. I get sick of constantly having to remind RNs of my role. The biggest failure to EN practice was getting up to speed with Medication Endorsement. There was a stage where a PCA was more valued in aged care than an EN because they could dispense from a Webster Pack. This was not permissible for the EN as it was seen as giving out drugs which would put their registration at risk. The pay rate for becoming medication endorsed also does not reflect the study and responsibility involved.
LETTER OF THE MONTH
CUTS TO CLIMATE CHANGE IS BAD FOR HEALTH As a healthcare worker who has worked in the aged care sector for decades, I am dismayed at the Australian government’s response to climate change and especially the cuts to climate research at the CSIRO. The elderly, young and infirm are particularly vulnerable to extremes in weather, such as heat waves, which often impact negatively on their health and wellbeing. Without the ongoing research that the CSIRO performs into future occurrences of heat waves and other extreme weather events, how can our health services possibly plan and respond adequately to the care needs of our community? Ongoing research and monitoring of our climate provides essential information for health providers to ensure preparedness for these weather events. And the government’s lack of response to the planned cuts to CSIRO send a clear message to the public that the communities health and wellbeing comes second to alternative agendas. Clare Wilson, RN Victoria
The winner of the ANMJ best letter competition receives a $50 Coles Myer voucher. If you would like to submit a letter to the ANMJ email anmj@anmf.org.au Letters may be edited for clarity and space.
Another important issue was the removal of RN2 to EN. I am a nurse and I am appropriately registered, so that should make me an RN. Seeing a new EN in the workplace usually evokes the question of, so when are you starting your RN training? It seems like to stay an EN is a waste. I can understand this, as until the scope widens for ENs, there are far more opportunities for RNs. There needs to be a huge education push so facilities know what ENs are able to do. Unfortunately there is still much confusion out there . EN, Victoria
anmf.org.au
April 2016 Volume 23, No. 9 47
MAREE
THE AUSTRALIAN OF THE YEAR On the eve of Australia Day 2016, I settled in to watch the Australia Day awards ceremony on the ABC. The nominees in all categories had made outstanding contributions to Australian society. The breadth of their achievements and their collective passion to make a difference made for inspirational viewing and cause for reflection too. Maree Burgess, ANMF Vice President
The Australian of the Year awards began in 1960, with the first award going to Sir Macfarlane Burnett, a recipient of a Nobel Prize for Medicine. Since that time there has been an array of recipients from fields such as Sport, the Arts, Medicine, Academia, Business and the Military. As described by Dr Samuel Furphy in his report, Australian of the Year Awards: A Fiftieth Anniversary History (2010), the awards originated in Victoria and eventually became more truly national in the 70’s when the selection became part of the National Australia Day Council remit. As highlighted by Furphy (2010), the awards have not been without controversy given only one in five have been female, the predominance of sporting nominees as opposed to the arts, the commemoration occurring on a day marking the colonisation of Australia by the British to name just a few of the issues. The nominations do provide an opportunity for us all to reflect
attention to their particular field of interest/passion. The 2014 Australian of the Year Adam Goodes was a champion Australian Rules Footballer, who played for the Sydney Swans, a dual Brownlow medallist and advocate for Indigenous Australians. He has an outstanding record as a footballer and also in his community work with Indigenous youth. Adam has experienced the best and worst of Australian sporting culture. In responding to vilification from a spectator at a football game in 2014, he experienced racial abuse with part of the crowd persistently booing him every time he touched the football. This persisted into the 2015 season and ultimately led to his earlier retirement from the game. There is an inherent risk for recipients of this prestigious award, that in raising the profile of issues such as racial vilification, domestic violence, climate change, gender equality, that divided community opinion can become destructive, rather than
HE DESCRIBED DOMESTIC VIOLENCE AS THE SCOURGE OF OUR SOCIETY AND THOUGH IT MAY TAKE YEARS TO FULLY ADDRESS, HE WAS PREPARED TO BE AN ADVOCATE OF CHANGE.
on what it is to be Australian, our aspirations as a nation and to raise the profile of important cultural, social and intellectual thought. The individual awards have expanded over time to include a young Australian, an older Australian and a local community hero nomination also. The role of Australian of the Year brings with it a raised profile for the recipient enabling to draw the nation’s 48 April 2016 Volume 23, No. 9
bringing about healthy debate and growth as a community. I had the privilege of hearing the 2015 Australian of the Year, Rosie Batty speak to the Victorian ANMF’s Delegates Conference in July 2015. Her courage and commitment in raising the community’s understanding of domestic violence and its impact on women and children is ground breaking. She has worked tirelessly
over the year and in establishing the Luke Batty Foundation, will sustain that impact into the years ahead. She has also experienced the breadth of public opinion, much of it supportive, but also including that of former Federal Labor leader Mark Latham, who was quoted as saying that Australian of the Year Rosie Batty was part of a feminist group using domestic violence for political gain and a campaign “against all Australian men”. Multimedia provides an opportunity for discussion but some of this commentary is quite vitriolic. The 2016 Australian of the Year, former Head of Army, Lieutenant-General David Morrison in his acceptance speech, vowed to continue the work of Rosie Batty, adding that she has created a new benchmark in the role. He described domestic violence as the scourge of our society and though it may take years to fully address, he was prepared to be an advocate of change. He also committed to gender equality in the forces, building on his dramatic speech in 2014 urging his forces to “get out” if they couldn’t accept women as equals. In his role as Chair of the Diversity Council of Australia he hopes to continue his work in promoting a more diverse and inclusive society. David Morrison AO has faced early criticism of his appointment as Australian of the Year from his former speech writer and now transgender advocate, Group Captain Catherine McGregor. In the days after the ceremony, she criticised his appointment by the Australia Day Council as a weak choice and a missed opportunity to advance LGBTI and Transgender issues. She was reported as saying that David Morrison has a lot to learn. (Shannon Power, Star Observer 27January, 2016) She made these comments, despite David Morrison supporting her transition back in 2012, urging her not to resign from the Army. Catherine issued an apology to both the Australia Day Council and also to David Morrison. I believe we should support the Australian of the Year recipients as they challenge us all to think critically about issues that should matter to all Australians. anmf.org.au
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