V O LU M E 2 4 , N O. 6 / D E C E M B E R 2 0 1 6 / J A N U A RY 2 0 1 7
WHY VOLUNTARY EUTHANASIA IS A QUESTION OF CHOICE www.anmf.org.au
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CONTENTS
18
REGULARS
02 DIRECTORY 03 EDITORIAL 04 NEWS 14 WORKING LIFE COMMUNITY OUTREACH SERVICE TAKES FLIGHT
Heading out into the community to provide healthcare for older people in their homes keeps Clinical Nurse Consultant (CNC) Diane Gellatly on her toes.
15 WORLD 17 INDUSTRIAL TESTED TO THE LIMITS
FEATURE
18 DEATH AND DIGNITY
24 ISSUES MORAL DISTRESS
WHY VOLUNTARY EUTHANASIA IS A QUESTION OF CHOICE
The prospect of voluntary euthanasia has created strong debate for decades and provoked passionate opinions from both sides of the fence. While not legal in Australia, a recent revived push for national voluntary euthanasia legislation has once again opened up the conversation and nurses have been encouraged to join the debate. Robert Fedele investigates the latest thinking and why more people are supporting voluntary euthanasia and the right to die with dignity.
For nurses and midwives, every new round of collective bargaining for the next enterprise agreement involves another series of tough negotiations and, more often than not, members take some form of industrial action in support of their claims to achieve a fair and reasonable outcome.
Australia has an ageing nursing workforce with many nurses due to retire (Health Workforce Australia, 2014). Coupled with increasing service demands, the need for workers will outstrip the supply (CEPAR - ARC Centre of Excellence in Population Ageing Research, 2014).
25 WORKING LIFE NURSE’S ROLE IN A FOREIGN LAND
04
For many years a team of specialist Gynaecologists and Anaesthetists from The Women’s Hospital in Melbourne have travelled to the beautiful, nomadic land of Mongolia. They have helped train Mongolian doctors in advanced practices related to laparoscopic-gynaecological surgery and anaesthesia, facilitating a number of ground-breaking ‘firsts’ in hospitals across several regions of the country.
26 RESEARCH 27 ETHICS THE ETHICS OF ‘NUDGING’
Over the past several years increasing attention has been given to the social engineering process of ‘nudging’ (also called ‘choice architecture’) and its impact as a mechanism designed to deliberately manipulate and incentivise people to think and act in a presumably beneficial direction.
28 CLINICAL UPDATE A BALANCING ACT: MAINTAINING ACCURATE FLUID
25
BALANCE CHARTING
Fluid balance charting is not a new practice based issue in nursing (Chung et al. 2002; Jeyapala et al. 2015). Evidence reveals that fluid balance charts have been poorly and inaccurately maintained since 1985 (Chung et al, 2002; Scales & Pilsworth, 2008).
32 BOOKS 35 REFLECTIONS 36 FOCUS
DRUG & ALCOHOL NURSING
47 CALENDAR 48 ANNIE
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The Australian Nursing & Midwifery Journal is delivered free monthly to members of ANMF Branches other than New South Wales, Queensland and Western Australia. Subscription rates are available on (03) 9602 8500. Nurses who wish to join the ANMF should contact their state branch. The statements or opinions expressed in the journal reflect the view of the authors and do not represent the official policy of the Australian Nursing & Midwifery Federation unless this is so stated. Although all accepted advertising material is expected to conform to the ANMF’s ethical standards, such acceptance does not imply endorsement. All rights reserved. Material in the Australian Nursing & Midwifery Journal is copyright and may be reprinted only by arrangement with the Australian Nursing & Midwifery Federation Federal Office Note: ANMJ is indexed in the cumulative index to nursing and allied health literature and the international nursing index ISSN 2202-7114
Moving state? Transfer your ANMF membership If you are a financial member of the ANMF, QNU or NSWNMA, you can transfer your membership by phoning your union branch. Don’t take risks with your ANMF membership – transfer to the appropriate branch for total union cover. It is important for members to consider that nurses who do not transfer their membership are probably not covered by professional indemnity insurance.
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EDITORIAL
Editorial Lee Thomas, ANMF Federal Secretary It never ceases to amaze me how quickly a year passes and 2016 has been no exception. Reflecting over the past 12 months, there have been plenty of highs and lows for the ANMF and its members. Yet no matter what arises I am constantly inspired and driven because of the guts, determination and collective spirit many of you have shown to stand up for what matters to nurses and midwives and for healthcare.
NO MATTER WHAT ARISES I AM CONSTANTLY INSPIRED AND DRIVEN BECAUSE OF THE GUTS, DETERMINATION AND COLLECTIVE SPIRIT MANY OF YOU HAVE SHOWN TO STAND UP FOR WHAT MATTERS TO NURSES AND MIDWIVES AND FOR HEALTHCARE.
Looking back, we launched a very public campaign, If you don’t care we can’t care, during the lead up to the federal election. We asked political parties to commit to reversing cuts of $57 billion to healthcare over 10 years, oppose the attacks made on rebates for Medicare and bulk billing, to remove the threat to penalty rates for all workers, and to stop the erosion of funding and services to aged care, all of which were planned by the Coalition government at that time.
The ANMF has also partnered with Go Gentle Australia to support and campaign for voluntary euthanasia. While a Bill supporting voluntary euthanasia was recently defeated in the South Australian Parliament by one vote, there is hope that Victoria’s bid to introduce laws supporting this choice will soon occur. The feature this month delves into the voluntary euthanasia debate in more detail.
While the Coalition government was returned to power at the election, we gained some moderate wins as a result of our campaign.
Positively, ANMF’s membership grew significantly over the past 12 months. With a 4.2% growth, membership stood at 258,989 as of 30 June 2016, cementing the ANMF as the largest union in the country. This is a testament to the ANMF as well as the membership, and is why we remain as a robust and resilient union today.
Despite this we have maintained our fight against ongoing attacks to health and aged care and will continue to do so until we are satisfied patients, nurses and midwives are not unduly compromised.
As I sign off my final editorial for the year I would like to take this opportunity to wish you and your family season’s greetings. While many of you will be working over the Christmas break, I hope you get the opportunity to relax, rejuvenate and spend some quality time with family and friends.
Only last month we gave testimony to a Senate Inquiry into the workforce in aged care. Here we used evidence from the aged care survey we conducted earlier in the year that informed us about the difficult conditions and compromised care due to inappropriate staffing that occurs in many aged care facilities. Throughout the year we have been strongly supporting paid parental leave (PPL). Recently there have been reports that Federal Social Services Minister Christian Porter will attempt to introduce a Bill in the Senate stripping women of this right. Assistant Federal Secretary Annie Butler and I have been lobbying senators to ensure this Bill is not supported and that Australian families get the essential assistance they need.
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December 2016 / January 2017 Volume 24, No. 6 3
NEWS and into the decrease of an appropriately skilled workforce to meet the needs of the sector. “The majority of the direct-care workforce is personal care attendants,” PCNA’s Lara McIntyre said. “I think we still need that higher level of supervision and assessment…which comes only with the skill set of a registered nurse, a nurse practitioner or a care coordinator.” Already at some nursing homes, it was not uncommon to have just the one RN and few carers caring for up to 150 residents, Ms Thomas said. “With a rapidly ageing population, it’s only going to get worse unless the government reverses the cuts to the aged care sector and delivers a sustainable workforce strategy to ensure safe staffing and skills mix in residential care.” NSW Nurses and Midwives’ Association (NSWNMA) General Secretary Brett Holmes gave evidence on the need for minimum staffing ratios in aged care.
“THE GOVERNMENT’S OWN MODELLING HAS REVEALED THAT AGED CARE BUDGET CUTS WILL SEE THE FUNDING FOR SOME FRAIL RESIDENTS WITH HIGH CARE NEEDS IN NURSING HOMES DROP FROM $46 A DAY PER RESIDENT, TO JUST $16.”
“We believe that if 80% of the residents have high or complex care and they are being funded by the Commonwealth for that, there must be a correlation: if you are being funded for high care, surely you should be able to afford to have registered nurses to at least supervise the care that is being given.”
SENATE HEARS WORKFORCE CRISIS IN AGED CARE A Senate Inquiry into the aged care workforce was told of the devastating impact of declining RN numbers and diluted skills mix with funding cuts to the sector. 4 December 2016 / January 2017 Volume 24, No. 6
The federal government’s $1.8 billion in funding cuts had created a crisis in aged care, ANMF Federal Secretary Lee Thomas said. “The government’s own modelling has revealed that aged care budget cuts will see the funding for some frail residents with high care needs in nursing homes drop from $46 a day per resident, to just $16.” Current trends in the aged care workforce were worrying, Alzheimer’s Australia National President Professor Graeme Samuel said. “Most significant to people with complexcare needs, such as dementia, is the startling decrease in the proportion of qualified nursing staff positions across aged care, particularly in residential care.” Palliative Care Nurses Australia (PCNA) called for an urgent review of the ACFI (Aged Care Funding Instrument) for complex care
A comparison of wages of Woolworths workers to assistants in nursing found across all comparable types of job people at the checkout got paid better than assistants in nursing, Mr Holmes said. “It is pretty sad that a trolley collector gets paid more than an assistant in nursing. If you are going to deliver quality care you have to get enough people there to do it, and you will not do that if you do not pay them, and you have to get those numbers right.” “Attracting nurses in the present environment to move into aged care is already difficult, particularly with the competitive salaries and career pathways offered in other healthcare settings,” Australian College of Nursing CEO Adjunct Professor Kylie Ward said. Public hearings have now concluded, with the Senate Community Affairs Reference Committee due to hand down its report on 28 April, 2017. anmf.org.au
NEWS
HEALTH CARE HOMES HOOPS AHEAD Patients will choose the clinician responsible for overseeing their care under the Health Care Homes (HCH) model to be rolled out next year, a leading government advisor has affirmed. The HCH initiative has outlined a multidisciplinary package of care for chronic and complex diseases overseen by a GP, Nurse Practitioner, or Aboriginal Medical Service. “The aim is to put patients in control of their own care,” Dr Steve Hambleton, Former Chair of the Primary Health Care Advisory Group, told delegates at the Australian Disease Management Association (ADMA) annual conference held in Melbourne. “This is for better use of care coordination and team-based care. Patients too often experience fragmented services. The care
provided by Health Care Homes will be flexible to meet the needs of the patient.” Deputy Chair of the MBS Schedule Review Taskforce, Dr Hambleton said payment reform was so important. Bundled payments will be tiered for the level of patient complexity and risk. “The payment system is in conflict with the model of care for multi-morbidity and does not encourage provider accountability for patient outcomes or promote teamwork.” The RACGP and consumer groups have lashed out at the latest details on HCH which reveal a cap on non-chronic care visits to GPs to five a year. “On their sixth and subsequent nonchronic disease related visits, they will either have to pay full out of pocket costs for the service, or they will wind up in an emergency department,” RACGP President Dr Bastien Seidel said. Rural Doctors Association of Australia Vice President Dr John Hall said the proposed approach appeared to limit patient access to healthcare. “What if that patient develops an ear infection, has an aggravation of an old injury, contracts a seasonal flu or a bad stomach virus, or needs a referral or prescription for a condition not related to their chronic
disease? Five visits can quickly add up.” Consumers Health Forum of Australia said the plans could discourage providers and patients from signing up to the initiative in July. “It makes no sense in terms of consumer centred care to separate out and cap the number of conditions related to chronic illnesses. Surely the purpose of HCH is to treat the whole person and provide them with a medical service which tailors their care to their needs?” Professor Anthony Scott of the Melbourne Institute of Applied Economic and Social Research said caution around Health Care Homes was warranted. Bundled payments shifted the risk onto providers, he said. “There is a risk that actual costs are greater than the payment. There is an ability to keep savings if patients cost less than the payment.” Questions remained such as how ‘fixed’ the bundled payment would be; how risk adjustment of payments would be conducted; and would fee for service still be used? “There is no mention of rewarding for value or paying for better quality of care,” Professor Scott said.
ACCESS DENIED ON REFUGEE HEALTH Access to appropriate primary care for refugees in Australia is beyond politics, a leading expert told delegates at the recent Australian Disease Management Association conference. There was inadequate access across the primary healthcare system and limited availability of refugee focussed health services, Monash University Professor of General Practice Research Dr Grant Russell said. “There is delayed and patchy transition of clients between services. They may have differing eligibility for services depending on visa type.” Improved access, coordination and quality of care were needed, systematic reviews had shown. This included appropriate use of interpreters and bilingual staff; cultural sensitivity training of staff; flexibility of services such as outreach or longer clinic opening hours or transport assistance; and anmf.org.au
case management by specialist workers. “Having a refugee focused health service nearby improves the capacity to deliver quality care,” Professor Russell said. As of December 2015 there were 65.3 million forcibly displaced persons worldwide – a 5.7 million increase on the previous year. Of these 21.3 million were refugees and 3.2 million asylum seekers; the majority from Syria and Afghanistan. Australia’s refugee intake had been stable since 1996, with about 13,000 per year, Professor Russell said. Statistics of June 2016 showed 1,570 refugees in closed immigration detention in Australia with 1,309 in offshore processing
centres Manus or Nauru – 50 of which were children. Only 658 had community detention arrangements and 28,329 were on bridging visas. “Few other countries go to such lengths to deliberately inflict suffering on people seeking safety and freedom,” Anna Neistat, Senior Director for Research at Amnesty International said of Australia in October. “Many people of refugee background have undiagnosed medical conditions of those that are uncommon in Australia,” Professor Russell said. This included tropical infectious disease such as malaria, TB, hepatitis and STIs; trauma; chronic disease; and nutritional deficiencies. December 2016 / January 2017 Volume 24, No. 6 5
NEWS
INDIGENOUS NURSING AND MIDWIFERY ORGANISATIONS UNIFY
A pledge to establish a South Pacific Alliance for First Nations nursing and midwifery organisations is considered the first step towards promoting greater collaboration among peak Indigenous bodies and boosting global identity. The proposal, put forward at the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) International Health Workforce Meeting in Melbourne last month, marks a significant push in relation to sharing strategies and uniting to strengthen the Indigenous voice. Last month’s CATSINaM conference, run under the theme ‘unmasking our collective history and pride in our global identity’, was the first time that First Nations nursing and midwifery organisations from across the world had been involved in an official capacity. The proposed alliance will seek to pinpoint shared aspirations and strategies, raise the priority given to Indigenous knowledge, such as nursing and midwifery organisations being included in key policy decisions, and look at 6 December 2016 / January 2017 Volume 24, No. 6
ways of circumventing geographical distance by staying connected through channels like social media.
SOUTH PACIFIC REPRESENTATIVE ESETA FUNAU SIGNING THE ALLIANCE AS CATSINAM CEO JANINE MOHAMED LOOKS ON. PHOTO: WIRRIM MEDIA
A commitment to exploring the alliance was signed off by several international delegates who spoke at the conference, including Kerri Nuku, Kaiwhakahaere of the New Zealand Nurses Organisation (NZNO), and Dr Lisa Bourque Bearskin, the current president of the Canadian Indigenous Nurses Association. The development of the alliance will involve establishing a working group, seeking endorsement from respective nursing and midwifery organisations to proceed with the plan, and setting a date to review the value of the alliance.
CATSINaM CEO Janine Mohamed said the alliance developed from the lack of a united global voice. “It’s really about what can we achieve together in our aspirations. How can we share strategies? And how can we lend support to each other?”
At the conference, a panel session dissecting the enablers and barriers to improved collaboration delivered valuable insights into some key considerations moving forward.
In terms of enablers, she said the legacy left by elders formed a trust, but added that time was now of the essence. “We’ve been given a simple task, which is to increase recruitment and retention of our Indigenous nurses and midwives. But I think we can say that we’ve been tired, and we’re in a hurry to solve the problem. So time is very much a barrier.”
Strategies proposed to consolidate collaboration included improving mentorship, securing greater research funding, staying connected via social media, and introducing an Indigenous textbook featuring the work of nursing and midwifery organisations from around the world. Having delegates of Indigenous professionals attend next year’s International Council of Nurses Congress was also deemed a high priority in order to bring the Indigenous voice to a bigger platform. Ms Nuku pointed out that each nursing and midwifery organisation was at different stages of their development. “I think one of the enablers is to look where we’re up to inside each of our countries and to select some common goals as a collective group and look at how we can share those and move them forward.”
Ms Mohamed listed colonisation, including inter-generational trauma and the commonality of racism as a barrier that could also be viewed as an enabler due to the subsequent strength and resilience displayed by Indigenous people.
CATSINaM president Shane Mohor said systemic racism in Australia coupled with a government that had run out of ideas presented ongoing hurdles. “For me, the barriers are always going to be governments because the governments are tied to budgets and the budgets for us are an enabler to allow people to get into training and actually achieve what they want to achieve.” He said an alliance and its bold stand through strength in unity could provide a newfound voice. “For us to be unified will be a major strength and enabler to change governments because they don’t want these voices directing the way and reminding them of what has happened in the past.” anmf.org.au
NEWS
STROKE SURVIVORS LEFT ALONE NEW NURSE SCHOLARSHIP PROGRAM FOR WESTERN SYDNEY UNIVERSITY Two first year nursing students have been awarded $9,000 to kick-start their studies in a new scholarship program at Western Sydney University. Western Sydney Dean of Nursing and Midwifery Associate Professor Deborah Hatcher said the scholarships would educate talented young students who may otherwise be lost to the health system. “For some promising young students looking to become a nurse, chasing their dreams and enrolling in university is simply not possible, because of severe financial hardship or other commitments.” “Becoming a carer for one of our children, together with family commitments and not having worked in a while, made coming back to university as a mature age student a ‘not-so-easy’ decision to make,” Scholarship recipient Mercy Dorai said. The Baxter Healthcare scholarships will be open each year.
Stroke survivors and their families are lacking support for their ongoing needs due to hindered hospital systems and processes to provide best practice. According to the recently released 2016 Rehabilitation Services Report there were significant advancements in the treatment and care for stroke patients, yet Australia’s rehabilitation stroke care system had made little or no improvement in this area. “It is inexcusable that services are not meeting the essential care elements and ignoring best practice guidelines,” Stroke Foundation Chief Executive Officer Sharon McGowan said. “Australia has some of the best and brightest health professionals working in stroke rehabilitation but a lack of appropriate hospital systems and processes continues to hinder best practice. “This is compromising patient outcomes,
leading to unnecessary suffering and adding increased cost to the health system.” Stroke Foundation Clinical Council Member, health services researcher and occupational therapist Dr Annie McCluskey said the audit results highlighted the emotional and psychological needs of patients continued to be neglected. “It is well recognised that mental and emotional wellbeing can significantly impact a patient’s rehabilitation and ultimately their quality of life, yet there has been no improvement in this area since the audit began in 2008. “Too many patients are not getting an assessment for those common complications, and patients who have been identified as needing support or treatment are not being provided with the necessary care. “Even more alarmingly, patients are not being prepared for the often long and challenging recovery journey which continues after hospital discharge. Half of patients are discharged without information about the cause of their stroke, let alone lifestyle advice and medication essential to preventing further strokes.” The Stoke Foundation is calling on federal and state governments to invest in resources to ensure the quality and consistency of stroke treatment and care across Australia.
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NEWS
NEW PROGRAM BREATHES LIFE INTO BIRTHING ON COUNTRY The establishment of a landmark Birthing on Country maternity services program has opened the door to more Aboriginal women giving birth to their children on the lands of their ancestors. Birthing on Country, a term which represents Aboriginal women giving birth closer to home, has long been viewed as a vital step towards maintaining connection to country and improving maternal and child health outcomes. Officially launched at the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) International Indigenous Health Workforce Meeting in Melbourne last month, the Birthing on Country program signals a partnership between CATSINaM, the Australian College of Midwives (ACM), the University of Queensland (UQ), and the University of Sydney (USyd). Key aims of the program include increasing the knowledge of health services in culturally competent maternity care, establishing primary maternity units, and boosting the Indigenous maternity workforce. CATSINaM member and midwife Marni Tuala, who addressed the topic at the Lowitja Institute’s International Indigenous Health and Wellbeing Conference in Melbourne last month, welcomed the initiative. “It’s empowering,” she said. “It’s potentially life changing and it’s taking maternity services in this country where they’ve needed to go for a long time. It’s been talked about 8 December 2016 / January 2017 Volume 24, No. 6
and we’ve gone around and around and finally we have an agreement and something in writing and some money behind it to try and produce the evidence to support what we’ve been saying for so long. This is what our women need and this is what is going to improve our health outcomes.”
access to 24-hour obstetric care or operating theatres that you’ll have poor outcomes. But the evidence suggests that the further women are away from home the poorer their outcomes. So we need to keep these women Birthing on Country in the communities that they’re from and not helicoptering them out at 36 weeks’ gestation to birth in regional centres.”
“FOR MANY WOMEN LIVING IN REMOTE AND REGIONAL AREAS, THE CHALLENGES ARE OFTEN GREATER. THEY ARE ADVISED OR EVEN COERCED TO LEAVE THEIR COMMUNITIES AND FAMILY FOR LONG PERIODS OF TIME IN THE LATTER STAGES OF THEIR PREGNANCIES TO TRAVEL TO A MAJOR CENTRE FOR BIRTH.”
Aboriginal midwife Karel Williams said the development of a Birthing on Country framework could trigger significant change. “For many women living in remote and regional areas, the challenges are often greater. They are advised or even coerced to leave their communities and family for long periods of time in the latter stages of their pregnancies to travel to a major centre for birth.
Ms Tuala said Birthing on Country had been a term misunderstood for decades.
“They are dislocated from important family and social networks, including the knowledge, skills, and roles of elders, Aunties, and grandmothers, during this important time and therefore put at cultural risk.”
She said the word country means more than just the ground we stand on and holds deeper links to spirituality, connection, ancestry and songs. “A lot of people have a misconception of what it actually means. They believe it means that all Aboriginal women want to have their babies in the dirt. That’s not what it’s about. It’s about bringing birthing closer to the home and understanding and appreciating the cultural competency required to facilitate those services for Aboriginal women.” Ms Tuala added that fear was another hurdle. “People believe that if you don’t have
CATSINaM CEO Janine Mohamed said incorporating the knowledge of Indigenous people into clinical practice would have a flow on effect to more Aboriginal people entering the health workforce. “Birthing on Country is not something new. It is a continuation of thousands of years of knowledge and practice. What this project is doing differently is making sure that health services have in place the knowledge and skills they need to make their practice culturally safe and accessible for Aboriginal and Torres Strait Islander women and their children.” anmf.org.au
Now’s the time to book “The Book” and share in rewards valued at over $26,000* Last year our pre-publication promotion was a huge success, with many happy winners. Thus, we would like to continue to offer professional business rewards to support you the nurse, the midwife, the allied health professional. All you have to do is purchase the 2017 AMH book or any current resource – between November 14 and December 31 – and you will receive an automatic entry to win one of these great rewards* to help you further in your quest for knowledge and excellence. Prizes include attending a conference related to your profession, new laptop computers and future editions of AMH resources. National Winner A major prize comprising flights, accommodation, conference registration, transfers & meal vouchers for up to 2 people to attend an Australian conference in their field, to the maximum value of $6,000.
Regional Winners (NSW/ACT, VIC/TAS, QLD/NT, SA/WA) 4 x first prizes of either an Apple MacBook, a Microsoft Surface Pro or HP Spectre Rose Gold to the maximum value of $3,500. Each region will also have 6 secondary runners-up who will receive a free copy of the next edition of Australian Medicines Handbook (Book or Online) valued at $210 each. Each region will also have 3 supplementary runners-up who will receive a free copy of the next edition of the AMH Children’s Dosing Companion (Book or Online) valued at up to $109 each. Maximum total prize pool of $26,348*. *Terms & Conditions Apply. For full details and conditions of entry and to order your AMH resource, just go to www.amh.net.au. NSW Permit No. LTPS/16/08354. ACT Lic. No: TP 16/02127. SA Lic. No: T16/1892. The promoter is Australian Medicines Handbook, Level 13, 33 King William St, Adelaide SA 5000. The random prize draw will take place at Level 13, 33 King William St. Adelaide 2pm on 24/1/17. Winners will be notified by email by 27/1/17 and draw results published on AMH website on 31/1/17.
NEWS
HIGH MORTALITY IN MIDDLE-AGED ABORIGINAL PEOPLE DRIVEN BY CHRONIC DISEASE A cluster of chronic diseases including heart disease and cancer is driving the premature deaths of middle-aged Aboriginal people and leaving a gaping hole in leadership for the next generation, according to a prominent Indigenous health researcher. Keynote speaker at the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) International Health Workforce Meeting held in Melbourne last month, Professor Alex Brown, Program Leader in Aboriginal Research at the South Australian Heath and Medical Research Institute (SAHMRI), said chronic disease was responsible for the “bulge of mortality” among Aboriginal people aged between 35 and 54. Professor Brown said the disparity between the life expectancy of Aboriginal people and non-Indigenous Australians ranged from 10 to 20 years and that 80% of that gap was being triggered by chronic disease, predominantly heart disease. Professor Brown said Closing the Gap required building a better health system, acknowledging social determinants, and changing tired approaches. “Policy rarely asks the right questions. They always ask how can you implement my plan for me that I have developed without talking to any Aboriginal people. “We need to choose the right target and be ruthless about it. Don’t be distracted. Focus on the job at hand. You need to deliver that and maximise what you can get out of that.” Using South Australian data as a platform, Professor Brown revealed that Aboriginal people experience 70 excess deaths due to chronic diseases each year compared to non-Indigenous Australians. Cancer is a sleeping giant, he added, with the disease tripling in number in recent decades, contrary to the significant improvements in outcomes experienced by mainstream populations.
10 December 2016 / January 2017 Volume 24, No. 6
LEADING ABORIGINAL HEALTH RESEARCHER PROFESSOR ALEX BROWN. PHOTO: SOUTH AUSTRALIAN HEALTH AND MEDICAL RESEARCH INSTITUTE (SAHMRI)
“POLICY RARELY ASKS THE RIGHT QUESTIONS. THEY ALWAYS ASK HOW CAN YOU IMPLEMENT MY PLAN FOR ME THAT I HAVE DEVELOPED WITHOUT TALKING TO ANY ABORIGINAL PEOPLE.”
Professor Brown dismissed the view that fixing Aboriginal health is too problematic, arguing that uncovering social determinants and their impacts on health could provide a way forward. He listed examples such as the links between depression and heart disease among Aboriginal men and exposure to childhood trauma increasing the chances of smoking. “This is not a phenomenon of bad choices. This is a phenomenon of choices made within a context which is fundamentally toxic. We have a government that thinks chronic disease is all about people’s choices. You’re fat, you’re lazy, you’re stupid, and you should have done all these things I told you to do. Your chronic disease is a result of your own stupid failures. “This is the worst possible framework for change. It’s the worst possible framework
for engaging patients with difficult challenges ahead with behavioural change and modification.” Professor Brown’s research team have developed significant interventions and managed to make inroads. A recent study into the high mortality rate of Aboriginal people following heart attacks in central Australia triggered a rehabilitation program that has reportedly reduced deaths by almost 60%. A similar study into diabetes and its complications is about to be undertaken with 4,000 Aboriginal people across Australia, while funding was recently received to develop interventions within the social determinants space. Professor Brown said one of his toughest jobs was influencing policy makers to fund much needed projects. Re-imagining a better future for Aboriginal people, Professor Brown said change was possible with a commitment to research, meaningful engagement, and an overhaul of the current health system. He called on Aboriginal people to take the lead and thrive. “Can Aboriginal people save the world? You bet we can. You just need to let us.”
anmf.org.au
NEWS
RESOURCE FOR PEOPLE WITH DEMENTIA AND THEIR CARERS A new resource that sets out the level of care that people with dementia, their carers and families should expect was launched last month. The Consumer Companion Guide, Diagnosis, treatment and care for people with dementia is one of a kind and follows the Clinical Practice Guidelines and Principles of Care for People with Dementia 2016, which was launched earlier this year. “The objective of this project was to develop a companion guide for members of the public to complement the Clinical Practice Guidelines to ensure that the information in the Guidelines is more accessible to those who need it the most, regardless of their level of health literacy,” lead coordinator of the Consumer Companion Dr Kate Laver, NHMRCARC Dementia Research Development Fellow at the Department of Rehabilitation, Aged and Extended Care Faculty of Medicine, Nursing and Health Sciences at Flinders University, said. The Consumer Companion Guide includes information about the ten Principles of Dignity of Care, which are: • zero tolerance of all forms of abuse; • support people with the same respect you would want for yourself or a member of the family; • treat each person as an individual by offering personalised service; • listen and support people to express their needs; • respect people’s privacy; • ensure people feel able to complain without fear of retribution; • engage with family members and carers as care partners; • assist people to maintain confidence and positive self-esteem; • act to alleviate people’s loneliness and isolation. The development of the Clinical Practice Guidelines and the Consumer Companion Guide were funded through the NHMRC Partnership Centre: Dealing with Cognitive and Related Functional Decline in Older People.
anmf.org.au
AUTISM SPECTRUM DISORDER BEHAVIOUR STUDY Parents of children with autism in primary or secondary school are encouraged to take part in an online survey aimed to help better understand certain exhibited behaviours. Mental health Nurse Practitioner and Southern Cross University researcher Professor Andrew Cashin (pictured) said there were two elements that formed the diagnosis of autism spectrum disorder (ASD). While understanding was strong on communication and social skills, there was little research on the restricted and repetitive behaviours exhibited by people with ASD.
SUGAR HIGH FOR INDIGENOUS AUSTRALIANS Indigenous Australians are consuming the amount of sugar contained in almost two cans of soft drink a day, according to latest statistics. Aboriginal and Torres Strait Islander people consumed about 14% of their total energy intake as free sugars, the Australian Bureau of Statistics (ABS) data showed. The World Health Organization recommendation is that free sugars account for less than 10% of total energy intake. Indigenous Australians consumed on average 18 teaspoons (75 grams) of free sugars daily – four teaspoons more than nonIndigenous people. “Beverages were the source of two thirds of free sugars, with soft drinks, sports and energy drinks providing 28%, followed by fruit and vegetable juices 12%, cordials 9.5%, sugars added to beverages such as tea and coffee 9.4%, alcoholic beverages 4.9% and milk drinks 3.4%,” ABS Director of Health Louise Gates said. “Free sugars include the sugars added by consumers in preparing foods and beverages plus the added sugars in manufactured foods, as well as honey and the sugar naturally present in fruit juice.” Free sugars contributed 18% of dietary intake for teenage boys aged 14-18 years – the equivalent of more than two and a half cans of soft drink. Women aged 19-30 years consumed 17% of free sugars, about 21 teaspoons.
HEARING HEALTH UNDER REVIEW
“While central to the diagnosis of ASD, restrictive and repetitive behaviours often change over time and increase and decrease in intensity. We are not clear, however, why this happens, what the typical patterns are, and we definitely have no structured way of predicting when someone will get locked into these behaviours,” Professor Cashin said. “For those diagnosed with ASD, outcomes in terms of independent living, engagement in work or study and maintaining intimate relationships postschooling are worse than most other disability groups, despite the great advances made.” The online survey is for parents or guardians of people with ASD participating in some form of primary or secondary schooling (six to 18 years). The survey takes 25 minutes and can be completed in more than one session. To view survey: https://scuau.qualtrics. com/jfe/form/SV_1TSQUwi88YlQFrn
The House of Representatives Standing Committee on Health, Aged Care and Sport has commenced an Inquiry into Hearing Health and Wellbeing in Australia. The Inquiry will investigate the causes and costs of hearing loss, opportunities for improving access to hearing services, and research into new treatments. Hearing loss affects one in six Australians and as the population ages it has been forecasted that by 2050 this could rise to one in four Australians. Hearing impairment can impact a person’s participation in social situations, education and employment opportunities. Economically, hearing loss cost Australia $11.75 billion in 2005, according to estimates made by Access Economics. Submissions from interested individuals and organisations are open to 23 December 2016. More information can be found on the Committee’s website: www.aph. gov.au/Parliamentary_Business/ Committees/House/Health_Aged_ Care_and_Sport/HearingHealth
December 2016 / January 2017 Volume 24, No. 6 11
NEWS
TACKLING BULLYING While the culture of bullying in nursing is a well-established fact, a new research project is taking a different approach to try and tackle the issue. James Cook University researcher Peter Hartin is embarking on a four year mission to end bullying amongst nurses. He said while bullying in the profession had been documented for 30 years, few studies had approached nurses directly and asked them what to do about it. “I want to find out why bullying continues to flourish in the nursing profession in Australia and what can we learn from nurses themselves about ways to stop it,” Mr Hartin said. “Research from this perspective will assist nurse leaders, educators and policymakers to better understand bullying in the Australian healthcare workforce and thus inform strategies to address the problem.”
MORE FUNDING FOR BREAST CARE NURSES McGrath Breast Care Nurses have received a further $20.5 million in funding from the government to ensure ongoing support for people being treated for breast cancer. The commitment over four years will fund up to 57 of the McGrath Foundation’s nurse positions in approximately 55 locations across the country, with most of these working in regional and rural communities. The breast care nurses provide physical, psychological and emotional support to people diagnosed with breast cancer, their families and their carers, from diagnosis and continuing throughout their treatment. They also act as the main liaison between the patient and specialists who coordinate their treatment.
NATIONAL IMMUNISATION PROGRAM ADDS SHINGLES VACCINE The shingles vaccine will now be available free to seventy-year-old Australians and a catch up program for adults aged 71-79 years. Shingles is particularly debilitating for older people, with one in three adults at risk of developing the virus in their lifetime. Minister for Health Sussan Ley said that as people get older they are at greater risk of experiencing more and long lasting pain associated with shingles infection. “Prevention with vaccination is always a better option than treatment once you have contracted the virus.” The shingles vaccine is the first adult vaccine for a new disease added to the National Immunisation Program since 2005.
Four Steps to Building Dementia Practice in Primary Care
Free online learning. Promoting an evidence-based approach to dementia detection, diagnosis and support in a primary care setting.
TO UPre e
Modules • Step 1: Building dementia knowledge • Step 2: Building a process towards dementia diagnosis • Step 3: Building an approach to dementia support • Step 4: Building sustainable dementia practice www.apna.asn.au/onlinelearning admin@apna.asn.au | 1300 303 184 The Supporting GPs and Practice Nurses in the Timely Diagnosis of Dementia Project is funded by the Australian Government. It is delivered by a partnership between Alzheimer’s Australia, the Australian Primary Health Care Nurses Association, Alzheimer’s Australia Victoria, Dementia Training Study Centres, and the Australian Primary Health Care Research Institute.
How to access the education?
F P D BagRrSy! 4C ia OU HD &
It’s easy! Follow the simple steps below and if you get stuck APNA is just a phone call or email away. 1. Open up Google Chrome as your web browser (please note – Internet Explorer is not compatible for these online modules) 2. Head to www.apna.asn.au/onlinelearning 3. Under ‘Courses Available Online’ click ‘View Courses’
Existing APNA Users
New APNA Users
4. Under ‘Existing APNA Users’ click ‘Login Now’ 5. Enter in your username and password (call APNA if you have forgotten these details) 6. On the left hand side of the page click on ‘Clinical Education’ and scroll down the page until you find all four Building Dementia Practice in Primary Care module 7. Click ‘Buy’ on all four modules 8. Once all four modules are in your Shopping Cart (at the top of your page) click on ‘Proceed to Checkout’ 9. The transaction should be complete and you can access the education by clicking on ‘My Training’ at the top of the page
4. Under ‘New Users’ click ‘Start Shopping’ 5. On the left hand side of the page click on ‘Clinical Education’ 6. Scroll down the page until you find all four Building Dementia Practice in Primary Care modules 7. Click ‘Buy’ on all four modules 8. Once all four modules are in your Shopping Cart (at the top of your page) click on ‘Proceed to Checkout’ 9. You will then be asked to register your account, please complete the fields required and then click on ‘Next Step’ 10. The transaction should be complete after this step and you can access the education by clicking on ‘My Training’ at the top of the page
NEWS PAID FAMILY AND DOMESTIC VIOLENCE SUPPORTERS RALLY OUTSIDE THE FAIR WORK COMMISSION IN MELBOURNE LAST MONTH.
FAMILY AND DOMESTIC VIOLENCE AFFECTS ONE IN SIX WOMEN, WITH TWO THIRDS OF THESE WOMEN IN PAID EMPLOYMENT.
biggest contributor to death, illness or disability of women between 15 and 44 years of age. “Australian Unions will not stand by and watch as innocent people lose their lives or their livelihoods because the federal government and big business think it’s not their problem. This is a problem for every single one of us.” Family and domestic violence affects one in six women, with two thirds of these women in paid employment.
PUSH FOR PAID FAMILY AND DOMESTIC VIOLENCE LEAVE
Research into workplaces that have existing family and domestic violence leave in place shows it can have significant benefits for affected employees, their employers, and workplaces.
Employees suffering at the hands of family and domestic violence across Australia could be eligible for 10 days paid leave if a landmark case is successful at the Fair Work Commission.
as finding a new home or attending court. Outside the Fair Work Commission, ACTU President Ged Kearney and Victorian Trades Hall Secretary Luke Hilakari joined fellow domestic violence campaigners in supporting a national day of action that included simultaneous rallies across the country.
The Australian Council of Trade Unions (ACTU) launched its case for a new modern award entitlement featuring 10 days paid family and domestic violence leave at the Fair Work Commission in Melbourne last month.
The ACTU’s case is supported by a widerange of groups including the Human Rights Commission, National Retail Association, and Australian Nursing and Midwifery Federation (ANMF).
Its claims include 10 days paid leave per year and an additional two days unpaid leave per occasion, with the new entitlement expected to make it easier for survivors of family and domestic violence to remain in paid employment and manage stressful tasks such
Ms Kearney said family and domestic violence was an “insidious issue” and that addressing it would enable women, men, and children to escape the cycle of violence. “If we don’t do something now we will be guilty of turning a blind eye to the single
ICE TRAINING FOR VICTORIAN NURSES
anmf.org.au
State-wide training started for Victorian nurses on how to respond safely and effectively to people affected by Ice last month. The training for nurses, paramedics, emergency services workers, human services workers, teachers and pharmacy workers will be rolled out over the next four years. Nurses took part in the first training session organised by the ANMF Victorian Branch. Training
“Cultural change is not enough, action must be taken to support workers affected by violence and establishing a basic standard on paid leave will ensure that all workplaces do this,” Ms Kearney said. Victorian Trades Hall Council Secretary Luke Hilakari said community expectations surrounding the issue had changed in recent years in line with increased knowledge and that employers now needed to be fully understanding of family violence. At last count, a petition set up to support family violence leave for all workers had netted several thousand signatures. “If we’re serious about addressing domestic and family violence, then that means we need real action to support people escaping family violence. It’s reasonable to expect that women shouldn’t have to worry about losing their job while they’re trying to escape a violent partner.”
includes how to manage chaotic and violent behaviour associated with Ice and better protection for personal safety. New data on alcohol and other drugrelated ambulance attendances during 2014 to 2015 showed a 29% increase in attendances for illicit substances – in particular amphetamine, which increased by 48%.
December 2016 / January 2017 Volume 24, No. 6 13
WORKING LIFE
COMMUNITY OUTREACH SERVICE TAKES FLIGHT
“TO BE ABLE TO GO IN AND INTERVENE AND SUPPORT THAT PERSON TO HAVE A MORE PRODUCTIVE SAFE QUALITY OF LIFE IS BENEFICIAL. WORKING WITH FAMILIES AND OTHER HEALTH PROVIDERS, IT’S SATISFYING TO KNOW YOU’VE BEEN ABLE TO GO IN AND HELP SOMEONE THROUGH THAT CRISIS PERIOD.”
Heading out into the community to provide healthcare for older people in their homes keeps Clinical Nurse Consultant (CNC) Diane Gellatly on her toes.
CLINICAL NURSE CONSULTANT AND GERIATRIC FLYING SQUAD MANAGER DIANE GELLATLY
“We often see people when they’re in a crisis,” she says. “The wheels are falling off. It might have been working for the last two years but for whatever reason, they’ve had a urinary tract infection (UTI), they’ve had a recent hospitalisation where they’ve been unwell, they’re just getting older and frailer. “To be able to go in and intervene and support that person to have a more productive safe quality of life is beneficial. Working with families and other health providers, it’s satisfying to know you’ve been able to go in and help someone through that crisis period.” Diane is the CNC and manager of the Sydney-based War Memorial Hospital’s innovative Geriatric Flying Squad (GFS), a team of health professionals including nurses, social workers, dieticians, and psychologists, who visit and treat elderly people in the community in a bid reduce unnecessary hospitalisations. The GFS was established seven years ago to prevent Emergency Department presentations and admissions. Diane lists falls, cognitive decline, polypharmacy, social isolation, and functional decline as common issues that can be managed in the home and subsequently reduce the burden on the acute sector. As referrals are received, the GFS makes a comprehensive assessment and determines which clinician is best suited to attend a call out. “Most referrals we get are people declining at home due to cognitive impairment. They might have been travelling along okay for a couple of months or a couple of years and as their cognition starts to decline they’re not managing so well at home. Whether it’s because they don’t have family to support them or they just haven’t been linked to services, it’s about identifying what are the risks for this person? What are 14 December 2016 / January 2017 Volume 24, No. 6
their goals? Do they want to remain at home and what can we put in place to manage them at home?” A member of the New South Wales Nurses and Midwives’ Association (NSWNMA, ANMF NSW Branch), Diane started out as an Assistant in Nursing (AIN) 20 years ago before becoming a Registered Nurse. Her career to date has included looking after disabled children, community care, acute care at Sydney’s Westmead Hospital, and a seven-year stint working at Lenox Hill Hospital in New York, which is renowned for its cardiac care. Diane counts working abroad as a defining experience due to the opportunity to improve her skill-set and work more independently in an acute setting. “I always say that the human body works the same whether you’re in Sydney or New York. It’s just the health system that you work in. It was very eye-opening and I think we’re lucky to have the healthcare system that we do in Australia because it’s more equitable than the American model.” On return to Australia, Diane put her newfound skills to use in the area of geriatrics and helping elderly people in the community. “What I love most about my job is you never know what the day is going to hold. Every day is different. “We do have those cases where they might be acutely unwell and we try to manage them at home. Whether that’s a chest infection or a UTI or cellulitis, to the complicated cases like elder abuse or hoarding or squalor, we try help that person through making the situation safe for them.” An example of the GFS’ growth in scope evolved after recently purchasing Uscan, a portable urological imaging and bladder measurement system able to make on the spot health assessments.
The device also has ultrasound capabilities which can examine broader areas of the body such as the abdomen and pelvic floor muscles. Diane says the bladder scanner enables thorough continence assessment, including making sure that catheters are in working order. “Instead of just looking at the clinical symptoms we can actually do the diagnostics to say what’s actually going on with the bladder. We can provide more comprehensive treatment and more accurate knowledge.” The War Memorial Hospital’s GFS outreach program was recently successful in receiving funding from the Primary Health Network to enhance the service. The expansion will include a Nurse Practitioner led model of care after hours to cater to increased demand from nursing homes. “There’s very few GFS models out there at the moment. There’s geriatric outreach services into nursing homes but a lot of areas don’t have outreach services into the community so we’re looking at how we can promote our service to help inspire other LHDs and hospitals to want to have a flying squad to service their communities.” Diane is also growing professionally in line with the service and will begin a Master’s Degree at the University of Sydney next year to become a Nurse Practitioner specialising in geriatrics.“I feel that geriatrics is the perfect field for NPs to have an important role in. Often the issues aren’t acute surgical issues that need an acute hospital. They’re often quite chronic issues, social issues, and family issues, cognitive issues, which I think an NP has the skills to manage and to provide that person centred care that’s comprehensive.” anmf.org.au
WORLD
GLOBAL
EUROPE
Develop nursing for universal health coverage
Nurse drive for chronic disease management in Europe
Universal health coverage will only be achieved by raising the profile of nursing and enabling nurses to work to their full potential, according to a global report.
A move for nurses to provide chronic disease management in primary care is a common theme in Europe yet many countries are struggling with implementation.
Increasing the number of nurses and developing nursing will have a triple impact on health, gender equality and economics, according to the All-Party Parliamentary Group on Global Health (APPG). The APPG held numerous hearings and consultations over several months, including with the International Council of Nurses, Royal College of Nursing UK, and the World Health Organization. Recommendations include raising the profile of nursing and making it central to health policy. Nurses are too often undervalued and their contribution underestimated, says the report. “Nurses are by far the largest part of the professional health workforce and achieving universal health coverage globally will depend on them being able to use their knowledge and skills to the full.” It outlines the “enormous innovation and creativity in nursing” seen for example in nurse-owned clinics in Africa, village ‘wise women’ in Central Asia and nurse specialists in the UK. “These sorts of developments are needed if countries throughout the world are to ensure that all their citizens have access to healthcare.” The findings resonate with the HighLevel Commission on Health Employment and Economic Growth which showed links between investments in the health workforce and economic growth. Royal College of Nursing, UK Chief Executive & General Secretary Janet Davies said the APPG report was significant as it set out the far-reaching benefits of properly investing in nursing.“This report makes abundantly clear that the nursing workforce should not be seen as a cost to be managed or reduced, but an investment in our future health, economic prosperity and gender equality.” anmf.org.au
Coordinator at the European Observatory Dr Ellen Nolte presented findings at the Australian Disease Management Association (ADMA) conference held in Melbourne recently. Thirteen European countries with social health insurance and tax based systems efforts to provide more coordinated care to persons with chronic disease were examined. About 50 chronic disease management [CDM] models were being implemented. “The move to use nurses for a more proactive multidisciplinary approach in primary care is a common theme across Europe,” Dr Nolte said. “Countries like England, Netherlands and Spain have adapted far easier than others which are GP practice dominant such as Denmark, France, Austria and Germany. To change systems to get nurses [doing CDM] in primary care is a huge cultural change for some.” The nature of chronic disease which was lengthy and indefinite required a different approach to service delivery, Dr Nolte said. “Systems are usually for acute episodic care. These [chronic] diseases do not have a cure. It’s about redesigning models of care, trying to change delivery structure.” Half of all GP appointments were for people with chronic disease, Dr Nolte said. Global expenditure on diabetes in 2015 was US $673 billion, estimated to increase to US $802 billion in 2040. Only 5% of health spending in Europe was spent on health prevention, said Dr Nolte. A key challenge was that most CDM programs were disease oriented and most patients had co-morbidities, Dr Nolte argued. “The challenge is how to deal with complex patients. There is no single best service delivery model for people with chronic disease. Models are highly context dependent. You need to develop approaches targeted at those most likely
to benefit. Not a one-size-fits-all but how to tailor programs to those most likely to benefit.” Models that combined a number of approaches were more likely to improve outcomes and also those that sought to structure relationships between providers and patients. Continued institutional divide hindered coordination along the care continuum, Dr Nolte said. “The current financing system pays the doctors and pays the nurses but doesn’t pay working together and doesn’t pay selfmanagement of patients.” Dr Nolte said governments needed to provide the context to enable innovation. “Allow those who have the capacity to do it: nurses are not given the capacity or time to implement [CDM].”
UNITED STATES
Chronic disease post Hurricane Katrina Hospital admissions for heart attacks are three times higher in New Orleans 10 years after Hurricane Katrina. Data was compared to the two years before the storm hit in August 2005 (pre-Katrina). Findings were presented at the American Heart Association’s Scientific Sessions 2016 last month. Post-Katrina patients were also significantly more likely to have other risk factors for heart attack, including coronary artery disease, diabetes, high blood pressure, high cholesterol and smoking. “Although the general emphasis after an event such as Katrina is on rebuilding, we should not neglect the health of those affected by a disaster. This massive disaster may have had a greater impact on the development of chronic medical diseases than originally realised,” study lead and Professor of Medicine at Tulane University School of Medicine Anand Irimpen said. Patients were more than twice as likely to abuse drugs and/or have a psychiatric condition as their pre-Katrina counterparts. Unemployment and a lack of health insurance were also more frequent for those who had gone through Hurricane Katrina.
December 2016 / January 2017 Volume 24, No. 6 15
australian nursing & midwifery federation continuing professional education online
Bigger & Better The ANMF’s Continuing Professional Education (CPE) website has provided quality, affordable online education to members for over 9 years. Although the website has changed and grown in that time to meet members’ needs, it has come time for a little makeover. We are making some much needed changes and adding more educational tools to assist you to meet your annual CPD requirements as easily as possible. There will be videos, webinars, research journals and resources. We are very excited to be able to improve your learning website, however it does mean that we will need to close the website temporarily to apply the changes. Don’t worry, all your records and purchases are safe and will be available to you in no time. We plan to close the website from the 12 December 2016 and plan to restart the following week. If you have any queries or concerns, please contact the education team at education@anmf.org.au or phone 02 6232 6533.
New clinical tools for early life care Mood, breastfeeds, sleep and crying Possums Education The Possums Conference 2017 Dates: 2nd-4th February, 2017 Venue: Brisbane Convention Centre
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INDUSTRIAL
TESTED TO THE LIMITS
Debbie Richards, Federal Industrial Research Officer
For nurses and midwives, every new round of collective bargaining for the next enterprise agreement involves another series of tough negotiations and, more often than not, members take some form of industrial action in support of their claims to achieve a fair and reasonable outcome. This of course, is not possible without the collective strength, determination and commitment of ANMF members working together to achieve significant improvements in wages and conditions including a range of workplace issues such as safe staffing levels and workloads. With enterprise agreement negotiations commonly occurring every two, three or four years, most nurses and midwives are now familiar with industrial relations processes and are regularly involved in work based industrial campaigns in their various forms. The long list of gains made by ANMF members through collective action is a reminder that the right to take industrial action is fundamental to our system of collective bargaining and essential to promote and protect our industrial interests.
FOR VICTORIAN NURSES AND MIDWIVES, IT WAS THE VOTE TO REMOVE THE ‘NO-STRIKE’ CLAUSE FROM THE UNION’S FEDERAL RULES IN 1983 THAT OPENED UP OPTIONS FOR EFFECTIVE INDUSTRIAL ACTION IN RESPONSE TO THE CRITICAL ISSUES AT THAT TIME. Nationally, the terms and conditions of employment of the vast majority of nurses and midwives are now determined by this process with all public sector, private acute hospitals and 90% of residential aged care facilities covered by enterprise agreements. Enterprise agreements are also negotiated across other areas of employment including, blood services, flying doctor services, correctional facilities, schools, diagnostic services and general practice, to name a few. A recent industrial campaign by Victorian public sector nurses and midwives earlier this year has resulted in significant improvements in wages and conditions, building on the success of previous hard fought campaigns in support of better agreement outcomes. While thousands of Victorian nurses and midwives have just completed the process of voting on their new enterprise agreement, many may anmf.org.au
also reflect on the historic 50 day campaign of strike action that took place back in late 1986. An on-line exhibition commemorating the 30 year anniversary of this ground breaking strike is available on the ANMF Victorian Branch website: anmfvic.asn.au/86strike
leading to series of stop work meetings, work bans, and ultimately walkouts and 24 hour picket lines. Key among many grievances, was that the majority of nurses and midwives, many with 10, 20 and up to 30 years of experience, would be downgraded to the lowest classification level in the career structure. In addition, those who had certificate allowances for additional qualifications relevant to their practice, were going to lose those allowances resulting in a small pay increase at best and even a pay reduction for some.
The exhibition covers the background, the issues, personal accounts, the hardships and sacrifice and the aftermath, including interviews with nurses and footage from the time. Of course many of the issues leading to the strike in 1986 will be familiar. As we know, never-ending budget pressures and cost cutting means negotiations for improvements in wages and conditions are always challenging, and will always need the strength and determination of ANMF members to support their claims. For Victorian nurses and midwives, it was the vote to remove the ‘no-strike’ clause from the Union’s Federal rules in 1983 that opened up options for effective industrial action in response to the critical issues at that time. Top of the list was the growing frustration among members over ongoing staff shortages and impossible workloads, low wages and the lack of career structure which ultimately led to the first five day stoppage in October 1985. This was later described as the precursor to the events leading to the 1986 dispute.
The 1986 strike
Frustration levels continued to increase over staff shortages, workload and wages issues. The problems only became worse as many nurses and midwives resigned their positions. Also in May that year, following the retirement of the Branch Secretary Barbara Carson, Irene Bolger was elected to the leadership position. Against this background, in June 1986, the Victorian Industrial Relations Commission handed down a decision on the Registered Nurses Award. It was the government’s interpretation of the award and consequent impact on classifications and pay rates that triggered the unprecedented response
NURSES DEMONSTRATE CREDIT: MAGGIE DIOZ
The series of events that followed is well documented in this digital exhibition, highlighting the walkouts at different hospitals across the state and picket lines which became an important focal point for public support and media coverage, as well as ‘home’. It is clear from the extraordinary stories and accounts provided by the nurses and midwives involved that their strength and determination was tested to the limits. They also responded to the constant barrage of attacks particularly from politicians and certain sections of the media by becoming even more determined. That determination paid off in the end with nurses and midwives voting, on 19 December, to accept a $30 million dollar package offer providing wage increases, the return of qualifications allowances and a new career structure. The actions of these nurses serves as a clear reminder persistence and collective spirit can achieve great outcomes, even against the odds.
December 2016 / January 2017 Volume 24, No. 6 17
FEATURE
ANDREW DENTON PHOTOGRAPHER: BEN SEARCY
FEATURE
WHY VOLUNTARY EUTHANASIA IS A QUESTION OF CHOICE The prospect of voluntary euthanasia has created strong debate for decades and provoked passionate opinions from both sides of the fence. While not legal in Australia, a recent revived push for national voluntary euthanasia legislation has once again opened up the conversation and nurses have been encouraged to join the debate. Robert Fedele investigates the latest thinking and why more people are supporting voluntary euthanasia and the right to die with dignity.
I
t was a moment both poignant and defining and one which Andrew Denton will never forget. Earlier this year, the media player known for everything from telling jokes to hosting talk shows, travelled to the coastal town of Port Pirie, South Australia, to meet 35-year-old cancer sufferer Kylie Monaghan. Kylie had been battling cancer for several years and the dreaded disease had now spread to her liver and bones. In the face of a bleak outlook Kylie pledged her support to a national voluntary euthanasia campaign pushing for legislation formed by Denton’s advocacy group Go Gentle Australia and the Australian Nursing and Midwifery Federation (ANMF). More precisely, Kylie had agreed to become ‘the face’ of the campaign, sharing her story so that people with similar incurable illnesses could be spared unnecessary suffering. Denton recalls sitting across from Kylie in her family home and having an indescribable conversation about her inevitable death. At the time her health was declining so rapidly that doctors said there was no more meaningful treatment left to give. At one point Denton turned to Kylie and whispered that if she wanted to walk away then and there all she had to do was say the word. Kylie cast aside the suggestion, instead reaffirming her wish to help others, no doubt fully anmf.org.au
understanding that any new laws would arrive far too late to assist her. Sadly, Kylie lost her fight and died in October. In a bittersweet by-product, her strength, resolve, and courage in supporting voluntary euthanasia leaves behind a powerful legacy that typifies why dying with dignity is considered fundamental. “Once you understand it on a human level it’s hard to then not think of it that way again,” Denton explains. “It ceases to be a dry piece of legislation. You think about that human being.” Denton’s personal experience with death, and the catalyst behind his drive to introduce voluntary euthanasia laws across Australia, traces back to the passing of his father Kit almost two decades ago. Denton was rocked by the traumatic event, calling it the most profoundly shocking experience of his life, and crediting its enduring impact with leading him to search for a better way to die.
“ONCE YOU UNDERSTAND IT ON A HUMAN LEVEL IT’S HARD TO THEN NOT THINK OF IT THAT WAY AGAIN. IT CEASES TO BE A DRY PIECE OF LEGISLATION. YOU THINK ABOUT THAT HUMAN BEING.” GO GENTLE AUSTRALIA DIRECTOR ANDREW DENTON
Presently, Australia is in the middle of a revived effort to implement laws to allow voluntary euthanasia. In South Australia, its Death with Dignity Bill, the 15th time such a piece of legislation has been put forward, was narrowly defeated by one vote last month after painstaking consideration by state politicians. Similarly, Victoria appears poised for change on December 2016 / January 2017 Volume 24, No. 6 19
FEATURE the back of a Victorian Parliamentary Inquiry into End-of-Life Choices earlier this year that endorsed voluntary euthanasia. Denton began his quest to trigger change two years ago, undertaking research both locally and overseas, where assisted dying laws already exist in countries such as Belgium and the Netherlands. The countless hours of interviews with nurses, doctors, politicians, academics, and palliative care specialists from both sides of the debate formed the content for his podcast series Better Off Dead, released earlier this year.
“IT’S THE RIGHT THING TO DO AND I THINK PEOPLE SHOULD HAVE THE RIGHT TO DIE IN A PLACE AND IN A MANNER THAT IS SUITABLE TO THEM WITH THEIR FAMILY AROUND THEM AND AS PAINLESS AS POSSIBLE, RATHER THAN THE ALTERNATIVE, WHICH IS HAPPENING NOW, WHICH IS OFTEN PRETTY UGLY.”
Denton says the series was his way of “informing and inflaming” the debate in Australia. True to his mission, Denton’s informed and pragmatic approach, coupled with his intelligence and humour, is noticeably helping dispel a lot of the myths surrounding voluntary euthanasia. Denton says increasing dialogue is the key to greater understanding, and with any luck, acceptance. “We’ve definitely started to change the public debate and I think the more opportunity we get to talk, not just with politicians, but with doctors and nurses and palliative care people, the more dialogue there is, the more it’s possible to understand that these laws can be written in a way which work first and foremost for patients of course, but also for doctors and nurses, and that nobody is being pressured into doing anything that they don’t want to do.”
THE STATE OF PLAY
Australia’s association with voluntary euthanasia legislation is longstanding. Australia was the first country to introduce assisted dying laws back in 1995 in the Northern Territory. But history shows only four people were able to use the law before it was swiftly repealed just two years later. In subsequent years, dozens of Bills have been presented before state parliaments only
to be curtailed by politicians unable to vote unanimously in favour of legislation. Most attempts have been thwarted at their earliest stages and failed to even reach meaningful debate, such as New South Wales’ most recent foray dating back to its Rights of the Terminally Ill Bill in 2013, when proposed laws were soundly voted down in the upper house. Still, recent voluntary euthanasia legislation considered by the South Australian Parliament and defeated narrowly is providing advocates real hope that genuine consideration is being given into the nuts and bolts of how a law would work in reality. Many supporters now deem Victoria, where the state government is set to respond to its EndOf-Life-Choices Inquiry in December, as the best chance yet of getting over the line. Denton adds each state is “chipping away” at voluntary euthanasia laws in their own time, with Tasmania, New South Wales, and Queensland also working hard to pave the way for renewed efforts. He says the single biggest reservation relayed by politicians, and opponents of the movement, is the misunderstanding around the likelihood of “granny being bumped off by the grandkids”. “I think prospects are improving but it’s still difficult,” Denton cautions. “There’s entrenched opposition. Mostly, there’s a real lack of comprehension and I don’t mean that to sound critical. Politicians, I don’t think they’ve ever really had it explained to them very well how the law works.”
WHY NURSES ARE INTEGRAL
The partnership between Go Gentle Australia and the ANMF was motivated by a mutual understanding of the vital role nurses play in end of life care. “As a nurse I think that many of us when we’re
NSWNMA PRESIDENT CORAL LEVETT
20 December 2016 / January 2017 Volume 24, No. 6
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FEATURE working at the bedside see people who are at the end of their life and whilst palliative care is fantastic for some people it doesn’t provide the relief they need,” ANMF Federal Secretary Lee Thomas says.
cancer who shot himself with a nail gun.
Ms Thomas spoke passionately at the national campaign launch in South Australia in late September, illuminating her own past experiences on the ward. “I too remember the patients who asked me to help them die a peaceful and merciful death. I remember their names, their faces, and their families,” she revealed.
Of interest to the push for voluntary euthanasia legislation has been the Legal and Social Issues Committee’s review of existing laws in other countries and how they impacted on society. These countries included the Netherlands, Switzerland, Canada and the USA.
The Coroner estimated that one person each week takes their own life in Victoria under these circumstances.
The committee noted that while jurisdictions differed slightly in their models, such as whether a patient must be an adult or whether patients are required to take lethal medication themselves, common themes did emerge, specifically that of robust regulatory frameworks which focus on transparency, patient-centred care and choice.
Ms Thomas considers voluntary euthanasia a logical option for members of the community suffering incurable illnesses. She stresses it would always come down to a personal choice and isn’t for everyone. “One of the reasons why it’s so important that we’re involved is because we do see it all. Nurses and midwives see people who are in intractable pain for which very little or nothing is helpful to them.” Ms Thomas says the ANMF has continued to update its stance on voluntary euthanasia to reflect changing community attitudes. She points to the fact that upwards of 75% of people across the country now believe laws should be available. She says one of the most important ways nurses can help is by actively joining the debate and lobbying politicians. “Whether you personally agree with voluntary euthanasia or not it’s a choice for people who might want to take that choice. That’s why it’s voluntary. Even if you wouldn’t choose it for yourself, don’t stop other people from making that choice if nothing else is helping them.”
THE EVIDENCE
In June, a Victorian Parliamentary Inquiry into End-Of-Life Choices handed down its final report, with the analysis marking one of the most comprehensive investigations into voluntary euthanasia undertaken in this country. The report tabled 49 recommendations emphatically backing the introduction of assisted dying laws. Chiefly, it outlined six key areas to justify its assessment, including doctors already practising unlawful assisted dying, the limitations of palliative care, and the widespread acceptance of palliative sedation. Alarmingly, the report found many people experiencing incurable illnesses were resorting to taking their own lives in a desperate bid to ease pain. As part of the evidence submitted to the Inquiry, the Victorian Coroner stated that between January 2009 and December 2013, 2,879 suicides took place in Australia, and that of those more than 200 related to people with incurable diseases. The largest demographic affected were people aged over 65 and half the cases involved cancer, including a 75-year-old man with prostate anmf.org.au
“I’VE ALWAYS FELT THAT EVEN THOUGH ACCESS TO GOOD PALLIATIVE CARE IS FIRST AND FOREMOST IN END OF LIFE CARE, THERE ARE JUST SOME OCCASIONS WHERE DESPITE EVERYONE’S BEST EFFORTS, YOU’RE LEFT FEELING SHOCKINGLY DISAPPOINTED AND A LITTLE BIT TRAUMATISED BY THE DEATHS THAT SOME PEOPLE HAVE TO ENDURE.”
In regards to how many people used the legislation, statistics showed assisted dying accounted for less than 2% of all annual deaths in Belgium, and less than 4% in the Netherlands. The Netherlands’ Termination of Life on Request and Assisted Suicide (Review Procedures) Act, which came into effect in 2002, saw 5,306 people use the law in 2014. In terms of eligibility and safeguards there, the attending doctor must be satisfied that the patient’s suffering is unbearable with no prospect of improvement, must consult at least one other independent doctor, and must conclude together with the patient that there is no reasonable alternative. The laws apply not only to the terminally ill, but also to the chronically ill and people with mental suffering. In Oregon, USA, their Death with Dignity Act came into effect in 1997. Doctors can prescribe patients who meet strict criteria a lethal medication that they administer themselves without the presence of their doctor or healthcare provider. Eligibility requirements include being over 18, a resident of Oregon, suffering a terminal disease from which one will die in the next six months, and being required to make three separate requests. In assessing and granting a request to access lethal medication, two doctors must confirm the diagnosis, that the request is voluntary, and ensure that the patient is making an informed decision. Last year, 132 deaths occurred in Oregon from prescribed medicine under the law.
NURSES AS ADVOCATES SA NURSES SUPPORTING CHOICES IN DYING CONVENOR SUSIE BYRNE
Registered nurse and President of the NSW Nurses and Midwives’ Association (NSWNMA ANMF NSW Branch) Coral Levett has been a longstanding supporter of voluntary euthanasia. Ms Levett became a patron of Dying with Dignity NSW many years ago in a bid to trigger change. “I suspect back from my clinical days I just always thought there was an anomaly there. “We weren’t empowered to have the right conversations with patients who made requests December 2016 / January 2017 Volume 24, No. 6 21
FEATURE for voluntary assisted dying. It was always something I noticed that seemed to have something else missing. “Not only did we not have laws to allow assisted death, when death is imminent, but it was even difficult to have the conversation because there was no law. It’s hard to have a conversation about something that is illegal so I always found that frustrating.” Ms Levett says it’s only been the last 10 to 15 years that the conversation has opened up. She maintains that voluntary euthanasia laws will give people greater choice to experience a more meaningful death. “It’s simply about hastening one’s own death once we know it’s imminent and the pain is intolerable and unbearable and not one someone wants to go through. “It’s the right thing to do and I think people should have the right to die in a place and in a manner that is suitable to them with their family around them and as painless as possible, rather
basically saying to them ‘No. There’s nothing I can do’. You’ve got to suffer.” Ms Levett says opponents of voluntary euthanasia, including nurses, are entitled to their views, but to deny people the choice to determine the manner of their death is unjust. Ms Levett is openly encouraging nurses to engage in the debate and stresses that nobody will be forced to do anything against their will. “I think nurses need to go with their heart and do what’s right for them. If they believe this is the right thing to do for their patients, they need to support legislative change so that patients can have their say.”
FINDING A BETTER WAY
In 2011, registered nurse Susie Byrne spotted a newspaper article talking about a South Australian group established for nurses supporting voluntary euthanasia. “I was really pleased because I’ve been a
“IT CAUSES HUGE MORAL DISTRESS TO NURSES TO WATCH PATIENTS GO THROUGH TREATMENTS THEY KNOW ARE NOT GOING TO BENEFIT THAT PERSON SIMPLY BECAUSE THE FAMILY CAN’T ACCEPT THAT PERSON DYING.” FLINDERS UNIVERSITY RESEARCHER SANDRA BRADLEY than the alternative, which is happening now, which is often pretty ugly.” Ms Levett’s first-hand accounts feature as part of a book published by Go Gentle Australia titled The Damage Done. Her piece, People know when they’ve had enough, addresses when patents ask nurses for help to die. “It’s absolutely heart-wrenching when somebody looks you in the eye and begs you to help them die,” she says. “They don’t ask you to do that until they’re in such terrible agony that life is unbearable. Sometimes they do know you’ve got the means to do it; that’s why they ask you. To say no to someone like that can be profoundly damaging to yourself. You feel like you’ve let your patient down because you’re 22 December 2016 / January 2017 Volume 24, No. 6
lifelong believer in assisted dying legislation and I was encouraged to know that there was somebody who was providing a forum for nurses to have their say, either side of the debate,” Ms Byrne recalls. Today Ms Byrne is the convenor of group, the SA Nurses Supporting Choices in Dying. A cancer research nurse at Flinders University, Ms Byrne’s strong beliefs stem from first-hand experience seeing patients, friends, and family members suffer. Three of her close relatives have passed away from cancer, including her father-in-law, who died in “unnecessary pain and suffering”. “I’ve always felt that even though access to good palliative care is first and foremost in anmf.org.au
FEATURE end of life care, there are just some occasions where despite everyone’s best efforts, you’re left feeling shockingly disappointed and a little bit traumatised by the deaths that some people have to endure.” Ms Byrne says the group’s objective is to offer a forum for nurses to engage in the debate. “It’s important for nurses’ voice to be heard on both sides of the argument. There are a lot of nurses that perhaps think that helping with assisted dying might be something that goes against their value system and that’s perfectly fine. But the ANMF have made it very clear that no nurse or allied health professional would be impacted unfairly if that was their decision.”
“WHETHER YOU PERSONALLY AGREE WITH VOLUNTARY EUTHANASIA OR NOT IT’S A CHOICE FOR PEOPLE WHO MIGHT WANT TO TAKE THAT CHOICE. THAT’S WHY IT’S VOLUNTARY. EVEN IF YOU WOULDN’T CHOOSE IT FOR YOURSELF, DON’T STOP OTHER PEOPLE FROM MAKING THAT CHOICE IF NOTHING ELSE IS HELPING THEM.” ANMF FEDERAL SECRETARY LEE THOMAS
Positively, Ms Byrne believes nurses are currently more willing to express their views on the issue, triggered in part by the ANMF’s national campaign together with improved understanding. When faced with opposing views, Ms Byrne says she carries out every conversation in a respectful manner. “I try and make them understand that they would never be put in a position where they would feel compelled to act against their beliefs in the same way now that some nurses and doctors refuse on moral grounds to assist with a termination of pregnancy.”
CONSIDERING ETHICS
Fellow registered nurse Sandra Bradley, an educator and researcher at Flinders University, formed the SA Nurses Supporting Choices in Dying group back in 2010 after being approached by the South Australian Voluntary Euthanasia Society. Ms Bradley holds a degree in Environmental Science and has always viewed the debate from a scientific standpoint. A decade ago she worked in palliative care, but left to pursue teaching and research in a bid to uncover why people were allowed to suffer in death. “When I started nursing and worked in palliative care the care provided by the team was fantastic but as a scientist I could not understand why we were allowing people to go through a prolonged form of dying.” Ms Bradley says that in some instances there are medical interventions which repeatedly bring people back to life over and over again. “It causes huge moral distress to nurses to watch patients go through treatments they know are not going to benefit that person simply because the family can’t accept that person dying.” Ms Bradley, who also runs an advanced care directive consultancy business, says people invariably ask about voluntary euthanasia during workshops or individual consultations. She says the Advanced Care Directives Act had historically thwarted the opportunity to discuss the issue without fear of repercussion but adds that the conversation is now easier to raise given new legislation before Parliament. Ms Bradley believes it is vital nurses join the
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debate and question practices. “I’m asking them not to engage in that discussion necessarily with patients and families, but they need to engage with their peers. I think it’s important to understand that there are nurses who don’t believe in voluntary euthanasia legislation or having the choice. And it’s also important to me to understand that those who do want it – why?” Also an ethics tutor at Flinders University, Ms Bradley regularly attempts to introduce the voluntary euthanasia discussion into the classroom in an effort to help prepare students for potential future conflicts in the workplace. “I don’t make it taboo. I think it’s my responsibility to make sure the students understand what’s happening in that area, especially if the legislation goes through.”
THE ROAD AHEAD
The national campaign for voluntary euthanasia is making genuine progress and Denton is clearly in it for the long haul. “I’m hoping that the organisation I’ve set up to push for law reform and also educate people, Go Gentle Australia, is going to have a long life and part of the challenge is to seek out sufficient financial support to enable that to continue. “Even if a law passes in Victoria, which will give a significant leg up to the possibility in other states, there are still campaigns that need to be won in those other states.” Denton’s profile has noticeably shaped the debate in a manner perhaps never seen before. But he is adamant that public recognition can only take him so far. “It might get you on to the stage but then it’s what you have to say. I’ve spent almost two years now seriously researching this and continue to do so. I’m pretty much spending all my time talking with doctors, nurses, politicians, reading materials, so when I talk about this I talk about it now with the weight of a lot of work.” In travelling the country, Denton has listened to endless stories on bad deaths. One of the most heartrending involved a young man from South Australia whose grandmother had cancer and was facing yet another major operation. “She invited all her family to lunch and what they didn’t know, until later, is that it was a farewell lunch, and using illegal methods, she took her own life in her apartment later that night. When he found her note, explaining what she’d done and why, it clearly had tear stains visible on it and he thought ‘How awful my beloved grandmother had to die alone’.” In this vein, Denton says it is easy to draw inspiration from the people he meets along the way. “I’ve had the great privilege over the last couple of years of spending time with people who are dying or who have died. I’ve seen the level of distress, trauma, anguish, fear [associated with it]. I’ve seen very clearly the enormous injustice that exists in this country as a result of not having a law for voluntary euthanasia. So I feel like I’m carrying a trust. A trust from those people I’ve met who are seeking or who sought help and didn’t get it.” December 2016 / January 2017 Volume 24, No. 6 23
ISSUES
MORAL DISTRESS By Adam Burston, Robert Eley, Deborah Parker and Dr Anthony Tuckett Australia has an ageing nursing workforce with many nurses due to retire (Health Workforce Australia, 2014). Coupled with increasing service demands, the need for workers will outstrip the supply (CEPAR - ARC Centre of Excellence in Population Ageing Research, 2014). The aged care workforce is no exception. Not only does the current workforce need looking after, workers need to feel empowered to fulfil their capacity in delivering healthcare; we need to create a desirable place of work. It is against this context we propose active workplace discussions of moral distress. Moral distress is a real issue for workers dealing with the complex moral challenges of delivering healthcare. An array of contributing factors and detrimental effects, including burnout and leaving the profession, are evident in the literature (Burston and Tuckett, 2013). Recurrent exposure to moral distress has been shown to build ‘moral residue’ when incidents of moral distress remain unresolved (Epstein and Hamric, 2009). The moral distress literature tends to focus on the ‘problem’ of moral distress, the negative consequences for the healthcare worker, the care receiver or the system more broadly (Burston & Tuckett, 2013; Lamiani et al. 2015). While identification of these negatives are valid and important, more recognition should be given to the heightened sense of autonomy and potential for moral growth emerging from morally challenging situations (Meaney, 2002a; Green & Jeffers, 2006). Moral distress can be a positive experience; a learning experience that supports personal and professional growth (Green & Jeffers, 2006). Our contention is that not only should moral distress be expected, it might even be desirable. How might moral distress be inevitable and potentially desirable? Nurses have an obligation to provide morally responsible care, and to act as moral agents (Carnevale, 2013). Practicing within a moral framework is expected professionally and framed within documents such as the Code of Ethics for Nurses in Australia (Nursing & Midwifery Board of Australia, 2013a) and Code of Professional Conduct for Nurses in Australia (Nursing &
Midwifery Board of Australia, 2013b). Due to the complexity of healthcare delivery, resource pressures, and different beliefs on what constitutes health and healthcare; moral challenges are inevitable. The moral agency of nurses is frequently challenged; as such moral stress is unavoidable and moral distress an inevitable consequence in many situations. However nurses generally, and especially in aged care, are uniquely positioned to recognise challenges as they emerge and facilitate resolution of these.
MORAL DISTRESS IS A REAL ISSUE FOR WORKERS DEALING WITH THE COMPLEX MORAL CHALLENGES OF DELIVERING HEALTHCARE.
Our current research clearly identified moral distress as existing and causing moderate levels of distress in Australian aged care workers. The most common solution proposed by participants was to engage in communication with residents, family members, other nurses, and other health workers. Commonly this desired communication centred on the idea of ‘being heard’, of feeling included in the process; with recognition of the professional moral capacity of aged-care nurses to critically appraise situations and share valid, informed opinions. However opportunities to do so where identified as limited or non-existent, a clear gap between the solution desired by workers and actual clinical practice exists. Sendjaya et al (2008) (describing a servant leadership approach) proposed a responsible morality; combining moral reasoning and moral action. Applying this approach
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with a view to facilitating agedcare nurses ‘being heard’, could be achieved through the use of ethicsbased education and ethics forums. This would support nurses to better understand and deal with moral challenges, moral stress, and moral distress. Importantly this should occur within the context of individual organisations and specific facility cultures. We propose a better solution resides in using these education and forum opportunities to facilitate such a deep understanding of moral challenges faced, that aged-care nurses learn to re-frame their perception of morally challenging situations. When faced with moral challenges, this would enable an empowered and proactive approach to addressing the challenge. So while moral stress is inevitable, it would be managed more effectively, reducing development of moral distress and the subsequent build-up of moral residue that occurs. We argue moral distress is poorly understood and managed within aged-care; therefore effects are commonly perceived as negative or as detrimental to the aged-care nurse. The challenge is for the profession to embrace our role as moral agents, actively educate staff and provide forums for multi-disciplinary teams to discuss and debate ethical challenges in practice. Moral distress can then be re-framed and perceived as an expected but very manageable moral stress. Adam Burston is a PhD candidate, The University of Queensland School of Nursing, Midwifery and Social Work; Lecturer and 1st Year BN Course Advisor, Australian Catholic University School of Nursing, Midwifery & Paramedicine Dr Robert Eley is an Academic is Research Manager, The University of Queensland – School of Medicine, Princess Alexandra Hospital Emergency Department Research Program Professor Deborah Parker is a Professor of Nursing, Director, Centre for Applied Nursing Research, Western Sydney University and Honorary Associate Professor, The University of Queensland School of Nursing, Midwifery and Social Work Dr Anthony Tuckett is Program Lead, Master of Nursing Program, The University of Queensland, School of Nursing, Midwifery and Social Work
ADAM BURSTON
References Burston, A. S. & Tuckett, A. G. 2013. Moral distress in nursing: Contributing factors, outcomes and interventions. Nursing Ethics, 20, 312-324. Carnevale, F. A. 2013. Confronting moral distress in nursing: recognizing nurses as moral agents. Revista Brasileira De Enfermagem, 66 Spec, 33-38. CEPAR - ARC Centre of Excellence in Population Ageing Research 2014. Aged care in Australia: Part 1 - Policy, demand and funding. Epstein, E. G. & Hamric, A. B. 2009. Moral Distress, Moral Residue, and the Crescendo Effect. The Journal of Clinical Ethics, 20, 330-342. Green, A. E. & Jeffers, B. R. 2006. Exploring Moral Distress in The Long Term Care Setting. Perspectives: The Journal of the Gerontological Nursing Association, 30, 5-9. Health Workforce Australia 2014. Australia’s Future Health Workforce - Nurses Detailed. Canberra: Department of Health. Lamiani, G., Borghi, L. & Argentero, P. 2015. When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates. Journal of Health Psychology. Meaney, M. 2002. Moral distress: I just can’t take it anymore! The Case Manager, 13, 32-33. Nursing & Midwifery Board of Australia 2013a. Code of Ethics for Nurses in Australia. Nursing & Midwifery Board of Australia 2013b. Code of Professional Conduct for Nurses in Australia. Sendjaya, S., Sarros, J. C. & Santora, J. C. 2008. Defining and Measuring Servant Leadership Behaviour in Organizations. Journal of Management Studies, 45, 402-424.
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WORKING LIFE
NURSE’S ROLE IN A FOREIGN LAND By Shanez Sinnathamby For many years a team of specialist Gynaecologists and Anaesthetists from The Women’s Hospital in Melbourne have travelled to the beautiful, nomadic land of Mongolia. They have helped train Mongolian doctors in advanced practices related to laparoscopic-gynaecological surgery and anaesthesia, facilitating a number of ground-breaking ‘firsts’ in hospitals across several regions of the country. The role of nurses in this expedition was never established, and in 2015 a team of perioperative clinical nurse specialists joined the medical team to Mongolia for the first time.
being twice as likely to contract Hepatitis C (World Health Organization, 2016). We also identified cultural points of difference in relation to patient privacy, confidentiality and dignity. It was not unusual for women to be walked into theatre naked and be physically restrained on the operating table while still conscious, nor for patient consultations to be overheard by others in the vicinity. Yet this is simply how things are done in Mongolia.
Operating Theatre Mongolia
Despite these confronting experiences we were inspired by the potential for improvements that we could suggest and initiate. Rather than criticise or dictate, our role as visitors was to guide the Mongolians to facilitate changes in their own practice, equipping them with evidence-based tuition and clinical skills.
mother of two by performing a hysterectomy on her. This may not seem so astonishing except that the hysterectomy was performed inside her home (*a ger), after the team drove 180km across the desert to reach her. With a BP of 53/32mmHg she had haemorrhaged 7.5L of blood from a ruptured uterine artery. Amazingly, she was transfused with eight units of blood products simultaneously donated by one of the doctors and two members of the rural community. After being transported by minibus to a hospital, she awoke, complained only of mild pain around the surgical site, and remains well today. In 2016 Kate and I returned to Mongolia. We were elated to observe ‘sharp-safety’ being adhered to by surgeons and instrument-nurses during laparoscopic surgery. Not only did it signify progress, it validated and consolidated our role in Mongolia, and our contribution to helping improve the health of Mongolian women. Kate continued her essential work in theatre whilst I spent time teaching Basic Life Support (BLS) to classrooms full of doctors and nurses. I was disheartened to learn that not a single nurse we encountered had ever been taught how to perform BLS, and if indicated, nurses would just “wait for a doctor”. Those education sessions will remain among the most professionally rewarding experiences of my career.
The Mongolian theatre nurses from our base hospital collaborated well with our Australian team. They greeted Kate and me exuberantly when during our initial introduction I earnestly expressed, “We are all the same!”
Shanez & Kate Conference Passes
Unsure of how our skills could be utilised, we envisaged using the experience for reconnaissance, with prospects of nurses revisiting Mongolia in the future. Although we proceeded with open minds, culture-shock hit us on our first day in surgery. We saw practices that would be considered unsafe, unethical and unacceptable by Australian standards. These included poor intra-operative counting of instruments and consumables which could therefore be left inside a patient and lead to post-operative complications. Inappropriate handling and disposal of contaminated needles and scalpel blades were also common; a practice that results in patients who undergo surgery in Mongolia anmf.org.au
I felt compelled to ask one of our anaesthetists whether he’d had such positive interaction with the nurses the previous year, to which he replied, “Shanez, last year the nurses didn’t even speak to us”. Simply through our presence, barriers in communication and hierarchy between the teams had been dismantled, the implications of which were tremendous.
Kate and I look forward to returning to Mongolia again in 2017, and anticipate expanding the role of our nursing team for the future.
Clinically, our teaching relied heavily on the availability of an English-speaking doctor or nurse. As a result we often found ourselves waiting around, unable to do anything until one could be arranged. Although frustrating, this was satiated by how enthusiastic and receptive the Mongolians were to what knowledge and skills we could offer.
*A ger is a style of home that is unique to Mongolian people (some refer to it as a yert). Because they are nomads, the ger is able to be dismantled, packed up, and carried by horses/camels/trucks which allows families to move across the land and settle elsewhere based on the season, for agricultural purposes.
The adaptability and drive of Mongolian doctors and nurses to operate with such skill in sometimes difficult and modestly resourced conditions is remarkable. We were awe-inspired by stories of lives saved under circumstances utterly inconceivable in Australia. We learnt of a surgical and anaesthetic team whom, one month prior to our arrival, saved the life of a 35 year old
Ulaanabaatar City
Reference Hepatitis: a crisis in Mongolia 2016, World Health Organization, Western Pacific Region: www.wpro.who.int/hepatitis/resource/ features/mongolia_story/en/
Shanez Sinnathamby is a Clinical Nurse Specialist, Anaesthetics & PACU, Perioperative Services, The Royal Women’s Hospital December 2016 / January 2017 Volume 24, No. 6 25
RESEARCH
NURSING ASSISTANTS DO NOT IMPROVE PATIENT OUTCOMES
The use of nursing assistants in hospital wards does not improve patient outcomes, according to latest WA research. School of Nursing and Midwifery researchers analysed patient outcomes of hospital wards where nursing assistants had been employed in addition to, not as a replacement, for existing nurses. Records of patients who spent time in surgical, medical or rehabilitation wards in metropolitan Perth hospitals between 2006 and 2010 were examined. Rates of mortality, failure to rescue, falls, urinary tract infections (UTI), pressure injuries, pneumonia and sepsis were measured in wards with and without nursing assistants. “We hypothesised that the addition of nursing assistants would have improved patient outcomes due to the additional help they could provide to regulated staff on the wards,” Edith Cowan University Dean of the School of Nursing and Midwifery Professor Di Twigg said. “However, we found that the addition of nursing assistants had a significant adverse impact on three measures – failure to rescue, UTI and falls.” Co-researcher Helen Myers at the Sir Charles Gairdner Hospital said one possible reason was that overall skill mix
of the staff on the ward was reduced. “Although adding nursing assistants to wards did not reduce the number of registered nurses, it still diluted the overall skill mix on the ward.” Ms Meyers said the study showed diluting the skill mix may be detrimental to the quality of care and should be implemented only with careful consideration. “This study demonstrated that improving patient outcomes is not just about adding more staff and supports skilled nursing care.” However, one measure, mortality, showed an improvement with the addition of nursing assistants. The results raised issues about the introduction of assistants in nursing into the ward system without data to support the benefit on patient outcomes, the researchers concluded. “If nursing assistants are to be added to the existing complement, there should be clear implementation guidelines and training in delegation, accountability and teamwork to ensure consistent role utilisation,” Professor Twigg said. The study was published recently in the International Journal of Nursing Studies.
NIR technology uses multiple wavelengths to separate body components such as temperature, melanin, water, dermis, muscle or fat under the skin. Fat absorbs NIR and fat levels can be determined at five wavelengths, Dr McEwan said. 26 December 2016 / January 2017 Volume 24, No. 6
Western Sydney University (WSU) research found it is not just simplified words and frequent repetition that makes it attractive to babies but the sounds of baby talk with its characteristic structure, rhythm and use of emotion. “Baby talk has a higher pitch and more up-and-down patterns, which attract infants’ attention,” WSU Professor Denis Burnham said. “It also has more hyperarticulated vowels and consonants, which exaggerate the differences between sounds. This exaggeration helps language development.
“BABY TALK HAS A HIGHER PITCH AND MORE UP-ANDDOWN PATTERNS, WHICH ATTRACT INFANTS’ ATTENTION,”
Compared with usual adult-directed speech, infant-directed speech had more emotion, irrespective of the words used, Professor Burnham said.
Portable low cost devices designed by NSW researchers to measure early stages of infant malnutrition are currently being trialled in Africa.
“Light in the NIR range is used where our skin is transparent; this type of light is not visible to humans for example on a TV remote control, but can be sensed by nocturnal animals and snakes,” University of Sydney’s Dr Alistair McEwan said.
Cooing and babbling to babies helps in language development, research shows.
“When mothers use more exaggerated vowels in their baby talk their babies are better able to distinguish speech sounds. And exaggerated vowels help children acquire larger vocabularies.”
LIGHT DEVICE TO DETECT EARLY INFANT MALNUTRITION
The near infrared (NIR) device uses light to measure the amount of fat under the skin so infants don’t need to be placed in a scanner or have a skin pinch test.
BABY TALK GOOD FOR BABIES
Parents naturally adjusted how they communicated with their baby during their child’s first year to match their developmental level, he said. The device can be made at low cost with only five sensors required. Specialist in maternal and child health and researcher on the team, Professor Heather Jeffery said there were potential benefits worldwide. “Low fat composition in newborns exposes them to an immediate risk of increased mortality and morbidity, and to diabetes and obesity diseases in later life. The lack of convenient, low-cost devices for monitoring nutrition has led to difficulties for health workers trying to identify malnourished infants, and in monitoring changes in the nutritional status of an infant who has received interventions.”
“The developmental adjustments mothers make actually follow infants’ speech preferences across ages: more emotional at three months; approving at six months; and directive at nine months.” How mothers talk to their baby is automatically in synch with their baby’s preferences. However under certain circumstances, baby talk can differ from the norm, Professor Burnham said. “For instance, baby talk by postnatally depressed mothers tends to have less exaggerated pitch intonation, and baby talk to hearing-impaired infants does not contain exaggerated vowels.”
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ETHICS
THE ETHICS OF ‘NUDGING’
Justifying the nudge
Over the past several years increasing attention has been given to the social engineering process of ‘nudging’ (also called ‘choice architecture’) and its impact as a mechanism designed to deliberately manipulate and incentivise people to think and act in a presumably beneficial direction. Megan-Jane Johnstone
References Blumenthal-Barby, J & Burroughs, H. 2012. Seeking better health care outcomes: the ethics of using the “nudge”. American Journal of Bioethics, 12(2): 1-10 Garvey, J. 2016. The persuaders: the hidden industry that wants to change your mind. Icon Books, London. Saghai, Y. 2013. Salvaging the concept of nudge. Journal of Medical Ethics, 39(8)487-493. Thaler, R & Sunstein, C. 2008. Nudge: improving decisions about health, wealth and happiness. Penguin Books, London.
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. anmf.org.au
Informed by the principles of behavioural economics and psychology, nudging has power applications (Garvey, 2016). For example, nudging in the form of neuromarketing has been used successfully for years to covertly influence consumer ‘choice’ and purchasing behaviours in shopping centres and supermarkets (consider the last time you went shopping and bought products you had not intended to buy). More recently, nudging has gained momentum in healthcare, notably as a mechanism for designing public health interventions (Saghai, 2013). In healthcare contexts nudging is being increasingly used to subconsciously influence people toward making particular decisions, to change their minds, or to change their behaviours related to health or healthcare. Notable examples include the use of salient emotional narratives, images and other media to encourage people to quit smoking, reduce their sugar intake, to increase their physical exercise, and to wash their hands after going to the toilet (Blumenthal-Barby & Burroughs 2012). More controversial applications recently proposed include the use of ‘defaults’ in end-of-life decision making – eg., defaulting to ‘Not for Resuscitation’ in patients with dementia, or other life-limiting illnesses; presuming consent for organ donation unless someone opts out; and euthanasia. Despite its apparent good intentions and the growing adoption of nudging mechanisms by a range of entities including governments, critical commentary on the subject highlights that structuring people’s choices irrespective of its benevolent intent is not without moral concern (see American Journal of Bioethics, www. tandfonline.com/toc/uajb20/15/10; Journal Medical Ethics, http://jme. bmj.com/content/39/8.toc; New Scientist www.newscientist.com/ issue/2922/). Particular concerns relate to the ‘pokes and prods’ used by choice architects to subconsciously prime and persuade people to decide and act in predetermined ways. These processes are problematic since, by their very nature, they are manipulative and coercive. They also undermine people’s autonomy
and capacity to engage in reasoned argument otherwise necessary to justify their decisions and actions.
A question of nursing ethics
Nudging raises a number of important ethical issues for the nursing profession. This is because: just as nudging can be used to manipulate ‘better choices’ to improve people’s health and wellbeing, worryingly they can also be misused to manipulate ‘poorer choices’ and ones that undermine rather than improve people’s genuine moral interests. This, in turn, raises the important questions of: What counts as a nudge? On what grounds might nudges in healthcare be morally justified? And who ultimately ought to decide what nudges and intended outcomes are appropriate, reasonable and responsible?
IN HEALTHCARE CONTEXTS NUDGING IS BEING INCREASINGLY USED TO SUBCONSCIOUSLY INFLUENCE PEOPLE TOWARD MAKING PARTICULAR DECISIONS, TO CHANGE THEIR MINDS, OR TO CHANGE THEIR BEHAVIOURS RELATED TO HEALTH OR HEALTHCARE.
‘Nudging’ defined
Nudging has been defined as ‘any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentive’ (Thaler & Sunstein 2008, p6). Nudging works by fostering subconscious priming through the use of auditory and visual prompts that target pervasive biases in human cognition and elicit emotional associations that are ‘readily available in memory and as a result powerfully shape decisions and behaviours’ (Blumenthal-Barby & Burroughs, p4).
If, as suggested by Thaler and Sunstein (2008), nudges can truly improve people’s decisions about health and other things, then it is difficult to argue against its growing adoption by governments and healthcare organisations committed to improving public health and the economic sustainability of public healthcare. It remains a moot point, however, as to whether nudging can really improve these things. Also in question is the capacity of nudging to address complex and long term problems, lead to long-term and sustainable change, and avoid societies becoming intrusive ‘nanny states’. Adding to this are the unspoken risks and consequences of what happens if choice architects ‘get it wrong’ – which in healthcare is a real risk particularly if the choices being engineered are not evidence-based, or fail to benefit already vulnerable and disadvantaged populations. Also worrying is the lack of truth and transparency implicit in nudging and the possible harmful impact this could have on healthcare provider-patient relationships.
Who decides?
In healthcare contexts the moral justifications for judging and deciding what behaviours ought to be nudged, when, where, how and by whom have largely been assumed rather than shown. Moreover, the questions of who should rightly decide these things and upon what basis remain unanswered. The normative question and related debates of ‘who decides’ has a long tradition in bioethics dating back to the 1970s and controversies about end-of-life decision-making and care. There are valuable lessons that can be learned from these often forgotten debates and their possible application to the practice of nudging. In the past it was the preserve of the most powerful to decide – albeit benevolently – ‘who shall live and who shall die’, with those directly affected having little say. Much has changed over the decades with patients, families and other members of the healthcare team now expected to participate in decision making about end-of-life care. Moreover end-oflife decision making is expected to be truthful, transparent and fair. The practice of nudging must uphold these hard-won standards of decisionmaking or else risk returning us all back to an era of assumed benevolent paternalism that while well-intended, might nonetheless be misplaced. The moral benefits of nudging cannot be merely assumed. They must be substantively shown and repeatedly if its practice is to be morally justified.
December 2016 / January 2017 Volume 24, No. 6 27
CLINICAL UPDATE
A BALANCING ACT: MAINTAINING ACCURATE FLUID BALANCE CHARTING By Dimitra Georgiades Fluid balance charting is not a new practice based issue in nursing (Chung et al. 2002; Jeyapala et al. 2015). Evidence reveals that fluid balance charts have been poorly and inaccurately maintained since 1985 (Chung et al, 2002; Scales & Pilsworth, 2008).
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CLINICAL UPDATE What makes fluid balance charting so difficult is a question and concept that healthcare professionals constantly enquire about (Chung et al. 2002; Jeyapala et al. 2015; McGloin, 2015). Although fluid balance charting seems straightforward, the issue in nursing practice remains present with a number of external influences that effect the important role fluid balance charting has in patient care (Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008). This paper identifies the issue of inaccurate fluid balance charting, the social, political and external factors that contribute to and effect this issue, and finally, recommendations to ensure consistency and continuous improvement for this issue.
Overview
Fluid balance refers to the balance between the volume of water lost from the body and volume of water gained (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; McLafferty et al. 2014). The fluid balance chart has been a document in the healthcare system for over 50 years and is a non-invasive tool to assess the hydration status of patients (Chung et al, 2002; Scales & Pilsworth, 2008; Jeyapala et al, 2015; McGloin, 2015; Castledine, 2003; Chavin & Chow, 2008). It is a chart that documents the input and output that a patient has taken in and out in a 24-hour period (Chung et al, 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Chavin & Chow, 2008). The importance of this, is to guide clinical decisions including medication administration and prescription as well as surgical interventions (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Chavin & Chow, 2008). The issue with fluid balance charting is that they can be counterproductive and extremely dangerous if the data is inaccurate or inadequate (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Chavin & Chow, 2008). Medical staff, nurses and dieticians expect accurate fluid balance totals in order to plan appropriate care and reduce the risk of post-operative complications that may be associated with dehydration, malnutrition and electrolyte imbalances (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Chavin & Chow, 2008). Medical staff want to know the exact output, urine/ diarrhoea measure, intravenous therapy, oral intake, nasogastric aspiration and drainage, wound anmf.org.au
drainage, vomit in order to assess hydration, electrolytes and avoid fluid overloading (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008). Nursing practice does not remain consistent and thus keeping an accurate fluid balance chart becomes a balancing act in itself. The ability to enforce change requires empowering others to act on the vision in order to overcome obstacles for change. To enlist all staff to become empowered can be challenging given different backgrounds, contributing factors and the culture of the environment. The importance of identifying the recurring issue of inadequate and inaccurate fluid balance charting is to identify what inhibits the practice of maintaining accurate fluid balance charting, ways to improve the practice that will sustain and ensure that fluid balance charting is completed accurately in any practice environment (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008).
NURSING PRACTICE DOES NOT REMAIN CONSISTENT AND THUS KEEPING AN ACCURATE FLUID BALANCE CHART BECOMES A BALANCING ACT IN ITSELF.
ANALYSIS Political
The practice of fluid balance charting seems simple; record the intake and output. However, based on diverse backgrounds and different ways fluid balance charting has been educated and taught, this creates a confliction between the correct and incorrect practice of recording fluid balance charting (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008). What constitutes being recorded or not remains a subject that is often open to debate. Whilst there are differing opinions about the correct practice of fluid balance charting, this creates an opportunity that encourages staff to share their
knowledge and skills in order to improve their practice (Chung et al. 2002;.McGloin, 2015; Chavin & Chow, 2008).
Social
Education is a large aspect in the practice environment as the support and role from the clinical educator aims to provide and facilitate education and learning for all staff for clinical and practice based issues that remain uncertain or questionable (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow; 2008; Warburton, 2010). Inservices provide an opportunity to clarify what is required and answer questions that staff may have (Chung et al. 2002; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008). For staff to understand what is required for fluid balance charting, this information is retrieved and collected from the doctors that perform the surgeries. The senior doctors have clear and specific instructions of what care postoperatively should be and this information is then delivered in these inservice or made aware to staff informally. Inaccuracy and the lack of compliance with maintaining fluid balance charts tends to infuriate both nurses and doctors, and this prompts to initiate a change in the workplace (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Castledine, 2003; Chavin & Chow, 2008). The ward that supports an environment where staff have the opportunity to engage in further education enables a more welcome use of initiatives to improve and reduce the uncertainty and inconsistency in regards to inadequate fluid balance charting (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008). However, factors contributing to inadequate and inconsistent fluid balance charting such as lack of time, increased acuity, lack of education inhibit these workplace initiatives and therefore change is unsuccessful. (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008). These contributing factors decrease and effect the ward compliance in maintaining accurate fluid balance charting. In addition, these factors are universally acknowledged by evidence as the main issues that effect and inhibit accurate fluid balance charting (Chung et al, 2002; Scales & Pilsworth, 2008; Jeyapala et al, 2015, McGloin, 2015; Castledine, 2003; Chavin &
Reference List Astle, S., 2005. Restoring electrolyte balance. Rn, 68(5), 34-40 7p. Castledine, G., 2003. Professional misconduct case studies. Case 95: fluid balance recording. Nurse who did not keep accurate fluid balance records and was rude. British Journal of Nursing, 12(12), 717717 1p. Chavin, G., & Chow, G., 2008. Maintaining proper fluid balance in the postoperative urologic patient. Contemporary Urology, 20(1), 30-35 6p. Chung, L., Chong, S., & French, P., 2002. The efficiency of fluid balance charting: an evidence-based management project. Journal of Nursing Management, 10(2), 103-113 11p. doi:10.1046/j.09660429.2001.00296.x Daffurn, K., Hillman, K., Bauman, A., Lum, M., Crispin, C., & Ince, L., 1994. Fluid balance charts: do they measure up? British Journal of Nursing, 3(16), 816-820 5p.
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CLINICAL UPDATE Chow, 2008).
Time related to acuity
Fluid balance charting is part of charting and managing clinical information, which is therefore considered as part of a nurse’s workload (NMBA, 2016; Chung et al.2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008). As a result, allocating time to complete fluid balance charting during the shift should be made (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Castledine, 2003; Chavin & Chow, 2008). Often, evidence shows that due to lack of time related to increased acuity, information on the fluid balance chart is either duplicated or omitted. Poor documentation leads to compromising patient safety and quality of care (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Castledine, 2003; Chavin & Chow, 2008). Maintaining and recording accurate documentation is part of providing safe and competent nursing care according to the Nursing and Midwifery Board of Australia. Anything outside of that scope could be considered negligent in providing patient care (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Castledine, 2003; Chavin & Chow, 2008). Limited available time to record fluid balances that is related to patient care is inexcusable where patient monitoring and safety is concerned (Chung et al, 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Castledine, 2003; Chavin & Chow, 2008). Research states that nurses must understand and demonstrate the competence knowledge that caring for patients require, and this includes clinical indications and importance of a fluid balance chart (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Castledine, 2003; Chavin & Chow, 2008, Daffurn et al. 1994, McLafferty et al. 2014).
Education
Insufficient training and education is another barrier that effects accurate fluid balance recording (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Daffurn et al. 1994, McLafferty et al. 2014). Evidence illustrates that lack of education or inadequate training is a significant contributor to poorly maintained fluid balance charting (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Daffurn et al. 1994, McLafferty et al. 2014). New staff, new graduate
nurses and even nursing students and senior staff members may find it difficult to know what to record, not record and how to record properly (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Daffurn et al. 1994, McLafferty et al. 2014). This could be due to the ever-changing practice environment and need for further professional development to understand more about fluid balance charting (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Daffurn et al. 1994, McLafferty et al. 2014; NMBA, 2016; Stanley et al. 2008). For example, when a patient is on a fluid balance chart, urine measure must be recorded. It is quite common to see the abbreviation “PUIT” which stands for ‘passing urine in toilet’ or “PU” for ‘passed urine’ and are used as a substitute for actual values of measurement (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Daffurn et al. 1994, McLafferty et al. 2014; NMBA, 2016; Stanley et al. 2008). This is neither recording nor maintaining a fluid balance accurately nor is it recording urine measure accurately, as the urine must be measured (Chung et al. 2002; Scales & Pilsworth, 2008; Jeyapala et al. 2015, McGloin, 2015; Daffurn et al. 1994; McLafferty et al. 2014; NMBA, 2016; Stanley et al. 2008). This is where further education is required for staff to understand how and what to record and to reinforce and provide education to the patient about the importance of keeping an accurate fluid balance.
RECOMMENDATIONS FOR BEST PRACTICE Patient involvement
There are many inexpensive initiatives that nursing staff can initiate on the ward to improve the practice of fluid balance charting (Chung et al. 2002; Jeyapala et al. 2015). Best practice recommends that patient involvement is key in enabling more accurate fluid balance charting (Chung et al. 2002; Jeyapala et al. 2015). The major focus in providing patient care, is of course the patient (Chung et al. 2002; Jeyapala et al. 2015; NMBA, 2016). Including the patient in their own care while in hospital, exerts a feeling of independence and autonomy and promotes a level of control for the patient in an otherwise wellcontrolled environment (Chung et al. 2002; Jeyapala et al. 2015; NMBA, 2016). Promoting and encouraging autonomy in the provision of care for a patient is a key ingredient in enhancing patient care and satisfaction (Chung et al. 2002; Jeyapala et al. 2015; NMBA, 2016).
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RESEARCH STATES THAT NURSES MUST UNDERSTAND AND DEMONSTRATE THE COMPETENCE KNOWLEDGE THAT CARING FOR PATIENTS REQUIRE, AND THIS INCLUDES CLINICAL INDICATIONS AND IMPORTANCE OF A FLUID BALANCE CHART
Educating the patient and suggesting they monitor their intake for the day (given they are alert and orientated) enables more accurate charting as the patient is able to recall what they have had (Chung et al. 2002; Jeyapala et al. 2015; NMBA, 2016).
Pamphlets/posters/signs
Developing fact sheets or posters that can be kept inside the patient chart and around the ward again promotes education for both staff and patients (Chung et al. 2002; Jeyapala et al. 2015; NMBA, 2016). Additionally, signs that alert staff that a patient needs to have a fluid balance maintained can be stuck on the front of the chart or written on the patient identification boards by the bedside. Providing group staff education sessions such as inservices on fluid balance monitoring can assist in improving and promoting educational and clinical gaps in providing care for all staff (Chung et al. 2002; Jeyapala et al. 2015). One study found that high staff turnover and shift patterns affect fluid balance charting (Chung et al. 2002; Jeyapala et al. 2015). Therefore, the application of promoting further education will assist in overcoming this barrier. These education sessions can be 10 minutes in duration and cover the most relevant information for staff including calculating balances every four hours, avoiding abbreviations such as ‘PU’ and ‘PUIT’ for passing urine (Chung et al. 2002; Jeyapala et al. 2015). This same strategy could be adopted and used at handover over a month so all staff have the benefit to get regular updates and ask questions about fluid balance charting. Developing pamphlets, posters, signs and conducting education sessions are inexpensive strategies that cost little to nothing to overcome this practice based issue whilst enhancing education and knowledge for both staff and patients (Chung et al. 2002;
Jeyapala S, Gerth A, Patel A, Syed N., 2015. Improving fluid balance monitoring on the wards, BMJ Quality Improvement Reports doi:10.1136/bmjquality. u209890.w4102 Kotter J P., 1995. Leading Change: Why Transformation efforts Fail. Harvard Business Review Kotter J P., 2011. ‘HR Management, Leadership. What leaders really do’ reproduced in Harvard Business Review. McGloin, S., 2015. The ins and outs of fluid balance in the acutely ill patient. British Journal of Nursing, 24(1), 14-18 5p. doi:10.12968/ bjon.2015.24.1.1400 McLafferty, E., Johnstone, C., Hendry, C., & Farley, A., 2014. Fluid and electrolyte balance. Nursing Standard, 28(29), 42-49 8p. doi:10.7748/ ns2014.03.28.29.42. e5531
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CLINICAL UPDATE
Jeyapala et al. 2015).
Auditing
Auditing the number of charts that are correctly filled out and assessing the knowledge healthcare workers have regarding fluid balance monitoring can aim to assist in reducing inadequate fluid balance charting (NMBA, 2016, Chung et al. 2002; Jeyapala et al. 2015; Stanley et al. 2008). Auditing can assist in showing where strengths and weakness are in fluid balance charting and where improvement is required (NMBA, 2016, Chung et al. 2002; Jeyapala et al. 2015; Stanley et al. 2008). It is a good tool to use prior to implementing a change on the ward and then at the end of the initiative to extrapolate data and compare results (NMBA, 2016; Chung et al. 2002; Jeyapala et al. 2015; Stanley et al. 2008). This can enable the ward to regularly review their practice as part of achieving and sustaining change as well as meeting quality and safety requirements for patient care (NMBA, 2016; Chung et al. 2002; Jeyapala et al. 2015; Stanley et al. 2008).
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Conclusion
The fluid balance chart has been a longstanding tool that assists clinicians in monitoring and assessing the euvolemic status of a patient (Chung et al. 2002; Jeyapala et al. 2015; Scales & Pilsworth, 2008; Tang & Lee, 2010). The importance and role of accurate fluid balance charting is often forgotten or neglected and thus has become a practice based issue that requires constant review, intervention and attention (Chung et al. 2002; Jeyapala et al. 2015; Scales & Pilsworth, 2008; Tang & Lee, 2010; McGloin, 2015; McLafferty et al. 2014; Astle, 2005). This paper has examined the contributing factors that inhibit accurate fluid balance charting such as lack of time related to patient acuity and inadequate training and education (Chung et al. 2002; Jeyapala et al. 2015; Scales & Pilsworth, 2008; Tang & Lee, 2010; McGloin, 2015; McLafferty et al. 2014; Astle, 2005). In summary, a number of recommendations have been suggested to improve the practice of accurate fluid balance charting.
These include enhancing and promoting patient involvement, the use of posters and signs on the ward, in the patient chart and on patient identification boards in the bedside, conducting group staff education sessions at change of shift times and finally auditing in a timely manner to determine where improvement, education and further interventions are required in order to overcome the barriers associated with inaccurate fluid balance charting (Chung et al. 2002; Jeyapala et al. 2015, Scales & Pilsworth, 2008; Tang & Lee, 2010; McGloin, 2015; McLafferty et al. 2014; Astle, 2005). By implementing these changes to the practice environment, successful achievement of maintaining and increasing ward compliance with accurate fluid balance recording can be sustained for more diligent, and safer patient care.
Dimitra Georgiades is a Registered Nurse at the Royal Brisbane and Women’s Hospital. (Bachelor of Nursing, Master of Nursing specialising in Acute Care)
Nursing and Midwifery Board of Australia, 2016. Code of Professional conduct for Nurses www. nursingmidwiferyboard. gov.au/CodesGuidelines-Statements/ Professional-standards. aspx [Accessed 16 April 2016] Scales, K., & Pilsworth, J., 2008. The importance of fluid balance in clinical practice. Nursing Standard, 22(47), 50-58 9p. Stanley J, Gannon J, Gabuat J, Hartranft S, Adams N, Mayes C, Shouse G, Edwards B, Burch D., 2008. The Clinical Nurse Leader: A catalyst for improving quality and patient safety, Journal of Nursing Management 16, 614-622 Tang, V., & Lee, E., 2010. Fluid balance chart: do we understand it? Clinical Risk, 16(1), 10-13 4p. doi:10.1258/ cr.2009.090005 Warburton, P., 2010. Numeracy and patient safety: the need for regular staff assessment. Nursing Standard, 24(27), 42-44 3p.
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Any interested applicants are directed to the Ambulance Victoria website to read the full advertisement and position description. Select ‘Non-Paramedic Careers’ and follow the prompts. For any enquiries regarding the position, please contact the recruitment team at Ambulance Victoria on 03 9840 3653.
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Are you a Enrolled Nurse, Registered Nurse, Social Worker, Occupational Therapist, Psychologist or Medical Officer? Do you have a specialist range of skills in the area of Mental Health, Justice Health and/ 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. The range of specialist services include Programs in the following areas; • Adult Acute Mental Health Services • Adult Community Mental Health Services • Alcohol and Drug Services • Child and Adolescent Mental Health Services • Justice Health Services • Rehabilitation and Speciality Mental Health Services Do you know that Canberra is consistently ranked as one of the top cities in the world to live? The Canberra community has diverse culture and a population of 400,000 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.
For more information, please go to www.health.act.gov.au and click on: Employment – Current vacancies Or Contact Jodie Bowden Manager - Service Development Mental Health, Justice Health and Alcohol & Drug Services Phone: 02 6207 6279 Email: jodie.bowden@act.gov.au For more information visit http://www.canberrayourfuture.com.au http://www.actmentalhealthjobs.com
HEALTH WORLD TIMES UPDATE
HealthTimes UPDATE
NOVEL TECHNIQUE AIMS TO TRANSFORM BREASTFEEDING By Karen Keast, provided by A Queensland midwife has developed a simple breastfeeding technique that will be piloted at a Brisbane hospital with new mothers, their babies, and midwives next year. With AIHW statistics showing only 15% of babies are breastfed after six months despite a 96% initial breastfeeding rate, it’s hoped the project will change the way midwives help women to breastfeed. With more than 40 years’ midwifery experience in hospitals and in her own private practice, Dr Robyn Thompson (PhD) realised that women who birthed at home didn’t have the same breastfeeding complications, such as nipple trauma, as women who birthed at hospital. “I wanted to know why women were presenting to me with these horrific complications and trauma,” she says. “Babies were resisting, mothers were forceful. They were being taught what they describe as breastfeeding that felt awkward - holding their babies by the base of the head, along the neck, and into the shoulders, and they were trying to get the baby’s mouth to open wide and then shove the baby on.” Robyn’s observations led to her PhD research, based on data spanning four years, which analysed the records of more than 650 women who presented with complications to an in-home breastfeeding service.
A crucial element in Robyn’s technique is midwives not touching the mother and baby during breastfeeding, unless it’s absolutely essential. “It’s the same as any mammal - if you were out in the wild, you wouldn’t touch that baby,” she says. “Midwives feel like we have to be doing all the time rather than taking a step back. It’s important to sit down beside the mother, don’t stand over her, be quiet, be gentle and elevate her confidence.” Brisbane’s Mater Hospital is preparing to introduce the Thompson Method early next year to tackle the 25% drop in breastfeeding rates at the time of discharge. As part of the project, Robyn is filming an online TV show detailing the Thompson
journey for some mums - they get terrible pains, engorgement, cracked nipples, bleeding nipples. That stuff is pretty awful really and some of them still continue to try and feed over the top of that - they are so committed, it’s amazing. “If we can do something to help women to stop all this pain and this trauma and to feel more confident, then that’s a fantastic thing.” The project’s breastfeeding rates will be compared with the hospital’s past decade of breastfeeding data. Professor Kildea says she’s excited to see the potential of the method. “Breastfeeding is so important - it’s important to women, it’s important to babies, it’s important to society, and we
She began investigating the impact of the common ‘cross cradle’ breastfeeding technique that directs the nipple to the baby’s nose, while also examining the anatomy of the cranio-cervical spine and the intra-oral cavity. Robyn’s study shows the common breastfeeding method not only restricts movement of the baby’s head, neck and shoulders but limits its instinctive skills to seek the breast, while the way the baby is positioned often results in the baby hyperextending its head, resulting in painful feeding and trauma. The research found the nipple-to-nose technique also results in the nipple being drawn only as far as the baby’s anterior hard palate, instead of into the intra-oral cavity to the distance of the soft palatal cleft. Robyn went on to develop the Thompson Method of breastfeeding, enabling babies to self-navigate breastfeeding while ensuring symmetrical face to breast contact, which fills the unique shape of the baby’s oral cavity. “Little babies know what to do. All my work is about the mother and the baby working together and the baby actually locates the nipple by itself. It’s really very simple,” she says. 34 December 2016 / January 2017 Volume 24, No. 6
Method with breastfeeding women, while resources are being developed for women, alongside an education package for the hospital’s midwives. Resources for mothers and midwives, including the show, will also be available on Robyn’s website. Leading midwifery researcher Sue Kildea, a Professor of Midwifery at Mater Health Services and director of the Midwifery Research Unit in the Mater Research Institute, says the project will target the crucial first and second breastfeeds, with midwives supporting women to breastfeed using the method, regardless of their birthing journey.
want to do absolutely everything we can to help facilitate, encourage and support women to breastfeed and breastfeed successfully without complications.” Robyn hopes her career and education journey, which culminated in the technique, will empower midwives to better assist women and boost breastfeeding rates in Australia. “It’s not hard, it’s so easy and it’s not cumbersome. It’s just going back to breastfeeding basics really.”
“We’ve got 98 per cent of women wanting to breastfeed at the Mater,” she says. “At the moment, it can be such a traumatic
More articles at HealthTimes.com.au anmf.org.au
REFLECTIONS
TAKING ACTION TO IMPROVE OUTCOMES FOR MEN LIVING WITH AND BEYOND PROSTATE CANCER By Patsy Yates, Wei-Hong Liu and Cyril Dixon In Australia prostate cancer is the most commonly diagnosed cancer in men, with around 20,000 diagnosed each year (AIHW 2013, 2014). The many who survive it often battle with significant side-effects from treatment such as incontinence, loss of sexual function, fatigue and psychology issues. Most current prostate cancer services fail to meet the needs of men throughout their cancer journey. A global collaborative initiative led by the Movember Foundation aims to provide practical, cost-effective solutions to improve the lives and experiences of men with prostate cancer as well as the experience of their partners, carers and family members. Bringing together expert clinicians, academics, patients and
A GLOBAL COLLABORATIVE INITIATIVE LED BY THE MOVEMBER FOUNDATION AIMS TO PROVIDE PRACTICAL, COSTEFFECTIVE SOLUTIONS TO IMPROVE THE LIVES AND EXPERIENCES OF MEN WITH PROSTATE CANCER AS WELL AS THE EXPERIENCE OF THEIR PARTNERS, CARERS AND FAMILY MEMBERS.
organisations, TrueNTH program was launched in Australia in 2014. The program is currently piloting at two demonstration sites to deliver the following care and support through localised and central care coordination, as well as remote access via telehealth to both lifestyle and specialised clinical support from across the country: • decision support and information provision; • lifestyle management including exercise and nutrition management; • practical and social support; • specialised clinical support including sexual health, psychological services and continence services; • advanced prostate cancer comorbidities management; and • partner or carer support.
16P-1565 T2 - ANMJ Master of Advanced Nursing – Peri-op specialisation.indd 1
A care plan is developed and tailored for each participant based on screening and assessment, individual preferences, availability of local resources, and ongoing monitoring. Conducted by an experienced prostate cancer nurse coordinator, either locally or centrally, care coordination underpins each component of the program. The primary role of the nurse involves liaising with treating specialist/ team and General Practitioner, clinical assessment and care planning, supportive care, information provision and education, and facilitating referral to relevant prostate cancer specialist support services for incontinence, sexual recovery and psychological needs. A cloud based technology platform, called cdmNET (Chronic Disease Management Network) is used to share communication and care management within the care team from across Australia which also links with the participant. Aiming to roll out to a number of health regions in South Australia, Queensland, Victoria and New South Wales and incorporating the Prostate Cancer Outcomes Registry for a demonstration phase, the pilot program is under evaluation for its feasibility in partnership with the Queensland University of Technology (QUT) and Deakin University. Professor Patsy Yates is Head, School of Nursing and Dr Wei-Hong Liu is a Research Fellow. Both are at the Queensland University of Technology. Mr Cyril Dixon is TrueNTH Program Manager Asia Pacific.
References Australian Institute of Health and Welfare 2013. Prostate cancer in Australia. Cancer series no. 79. Cat. no. CAN 76. Canberra: AIHW. Australian Institute of Health and Welfare 2014. Cancer in Australia: an overview 2014. Cancer series No 90. Cat. no. CAN 88. Canberra: AIHW.
27/10/2016 4:18 PM
FOCUS – Drug & Alcohol nursing
STACY BLYTHE
References Bagley, S.M., Wachman, E.M., Holland, E., and Brogly, S.B. 2014. Review of the assessment and management of neonatal abstinence syndrome. Addiction Science and Clinical Practice, 9(19), 1-10.
NEONATAL ABSTINENCE SYNDROME AND INFANT MENTAL HEALTH By Stacy L Blythe Neonatal Abstinence Syndrome (NAS) is a term used to describe withdrawal symptoms of infants who became physically dependant on drugs of addiction while in utero (Prabhakar, 2014). These infants often require treatment and monitoring in special and intensive care units. The incidence of NAS is increasing in Western countries (Davies et al. 2015). Research into the care of this vulnerable population is also increasing with much emphasis upon relieving the signs and symptoms of withdrawal and promoting physiologic health (eg. Bagley et al. 2014). However, there is a scarcity of research into the promotion of mental health in this vulnerable group of infants (Marcellus, 2007). Research has demonstrated the development of the infant brain to be experientially and environmentally
dependant. Of particular importance to optimal brain development is the relationship between the infant and the primary care-giver (who is most often the birth mother) (Zeanah et al. 2011). Infants who experience a poor or absent relationship with a primary care-giver often develop significant mental health issues later in life (Vela, 2014). Although current policy recognises the significance of this relationship in terms of infant health and wellbeing, the reality is many infants with NAS have limited to no interaction with their mothers during their hospitalisation (Fraser et al. 2007). The reasons for this lack of interaction may include, but are not limited to; poor maternal physical
36 December 2016 / January 2017 Volume 24, No. 6
Davies, H., Gilbert, R., Johnson, K., Petersen, I., Nazareth, I., O’Donnell, M., Gonzalez-Izquierdo, A. 2015. Neonatal drug withdrawal syndrome: cross-country comparison using hospital administrative data in England, the USA, Western Australia and Ontario, Canada. Archives of Disease in Childhood: Fetal and Neonatal Edition, 101(1), f26-f30.
or mental health, maternal issues of addiction and intervention from child protection services.
Research project
There is a lack of literature discussing infant mental health in the absence of an infant-mother dyad. Further, there are no evidence based interventions to support/promote the mental health of infants hospitalised with NAS. This study seeks to identify strategies that promote the mental health and development of infants with NAS who have limited access to their birth mothers. Ethical approval is currently being sought and the project should commence in 2018.
Practical outcomes
It is hoped that this research will inform both health and social systems and lead to the development of new policy and practice which actively support and promote the mental health of hospitalised infants with NAS. Dr Stacy Blythe is Lecturer, Director Engagement and International in the School of Nursing and Midwifery at Western Sydney University
Fraser, J.A., Barnes, M., Biggs, H.C., and Kain, V.J. 2007. Caring, chaos and the vulnerable family: Experiences in caring for newborns of drug-dependent parents. International Journal of Nursing Studies, 44(8), 13631370. Marcellus, L. 2007. Neonatal abstinence syndrome: Reconstructing the evidence. Neonatal Network, 26(1), 33-40. Prabhakar, K. 2014. Neonatal abstinence syndrome. Pediatrics, 134(2), e547-e561. Vela, R.M. 2014. The effect of severe stress on early brain development, attachment and emotions. The Psychiatric Clinics of North America, 37(4), 519-534. Zeanah, C.H., Berlin, L.J., and Boris, N.W. 2011. Practitioner review: Clinical applications of attachment theory and research for infants and young children. Journal of Child Psychology and Psychiatry, 52(8), 819-833.
anmf.org.au
Drug & Alcohol nursing – FOCUS
STUDENT KNOWLEDGE OF PROVIDING CARE FOR WOMEN WHO EXPERIENCE ALCOHOL-USE DISORDERS
References
44% Australians exceed the Australian guidelines to reduce health risks from drinking alcohol
The DSM-5 refers to Alcohol-use Disorders (AUDs) as alcohol-related psychiatric disorders characterised by a cluster of behavioural and physical symptoms (APA, 2013). These disorders are public health concerns, particularly if you are a woman. When men and women’s alcohol consumption patterns are compared lower levels of drinking show minimal differences for ill health. However as average daily alcohol consumption increases, a woman’s risk for lifetime chronic disease rises by approximately 50% compared to men (Rehm et al. 2008). The key, therefore, is prevention and early intervention, both of which are major determinants of treatment outcomes (NSW Health, 2007). In order to be able to provide treatment and to intervene effectively staff need to be educated and this can begin with Australian nursing curriculum. What is currently known though, is that the level of education provided in Bachelor of Nursing programs is disproportionate to the increasing incidence of harmful alcohol consumption (Mollica et al. 2011). This knowledge deficit holds serious implications for the women seeking treatment (Russell, 2011). Despite the obvious need for knowledge, little is known about the perceived needs of first year, pre-registration nursing students in anmf.org.au
Women progress quicker from episodic drinking to developing an Alcohol-use Disorder than men Alcohol -related harm is attributable to
3.3
By Rebecca Bosworth, Lorna Moxham and Renee Brighton Harmful alcohol consumption is associated with detrimental health and social consequences, yet this modifiable and preventable risk factor for serious noncommunicable diseases remains an unmet challenge (Spanagel et al. 2013; WHO, 2014, 2016).
American Psychiatric Association. 2013. Substance-related and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric Association Publishing.
MILLION Drinking larger amounts of alcohol per day, women experience higher levels of alcohol-related injury and disease than men
terms of the provision of effective and adequate care for a woman with an Alcohol-use Disorder. In order to find out more, a study was undertaken by the first author, an RN who embarked on a Honours research project with the aim of exploring perceptions first year, pre-registration nursing students ascribed to providing care for a woman with an Alcohol-use Disorder. One of four key themes emerging from this study was ‘Education and Training’. Participants perceived that in order to provide non-judgemental, effective care and treatment to women with an AUD, they need ‘knowledge’. Acknowledging providing care for a woman with an AUD would be part of their role, participants identified a knowledge deficit as a barrier to providing appropriate and evidence based care. In addition to wanting more knowledge, a range of beliefs as to whether the women are responsible/moral agents perpetrating acts of mayhem on themselves or victims of a disorder (Russell, 2011) emerged. Feeling underprepared and unsure of what knowledge a nurse would need to provide quality care for a woman with an AUD was echoed by participants. Being informed, educated and prepared by acquiring knowledge on the disorder and learning about the signs and symptoms were seen as vital skills for all nurses, as identified by participants. Participants felt these skills would provide them with more of an understanding to adequately treat the women, resulting in the provision of person-centred care. Overall, to be able to provide effective
deaths per year globally & over 200 disease & injury conditions (Rehm et al. 2008; NHMRC, 2015; WHO, 2014)
and adequate care for a woman with an AUD, nursing students perceived the need for ‘knowledge’. Participants were aware of their knowledge deficits about the harmful use of alcohol but articulated how knowledge would lead to increased levels of understanding, empowering nursing students to acknowledge their own moral position, set these aside, and move forward to ultimately provide personcentred care. Moxham et al. (2016) describe the importance of nursing students familiarising themselves prior to entering the workforce with regard to specific clinical issues. Given the degree to which harmful levels of alcohol use affect society and place pressure and burden on healthcare systems, a recommendation of this Honours project is that drug and alcohol content be incorporated into nursing curricula. This will deepen clinical knowledge and skills and increase the confidence of nurses to work with women with AUDs when entering the profession. Such a proactive approach will work towards ensuring opportunities to intervene with women who are at risk are not missed. Brighton et al. (2015) supports that an increase in nursing attention is required to identify and prevent alcohol-related conditions. Rebecca Bosworth is a BN honours student and RN Dr Renee Brighton is a Lecturer and Professor Lorna Moxham is Professor of Mental Health Nursing. All are in the School of Nursing at the University of Wollongong
Brighton, R., Moxham, L. and Traynor, V. 2015. Women and alcoholrelated harms. Australian Nursing and Midwifery Journal. 22(10): 52. Mollica, M.A. Hyman, Z. and Mann, C.M. 2011. Alcohol-related content in undergraduate nursing curricula in the north eastern United States. Journal of Psychosocial Nursing and Mental Health Services. 4 Moxham, L., Taylor, E., Patterson, C., Perlman, D., Brighton, R., Sumskis, S. and Keough, E. 2016. Can a clinical placement influence stigma? An analysis of measures of social distance. Nurse Education Today. 44:170174 New South Wales Health. 2007. Nursing and midwifery management of drug and alcohol Issues in the delivery of health care. www.health.nsw. gov.au/policies/pd/2007/ pdf/PD2007_091.pdf. Accessed 08/06/16. Spanagel, R., Durstewitz, D., Hansson, A., Heinz, A., Kiefer, F., Köhr, G., Matthäus, F., Nöthen, M.M., Noori, H.R., Obermayer, K., Rietschel, M., Schloss, P., Scholz, H., Schumann, G., Smolka, M., Sommer, W., Vengeliene, V., Walter, H., Wurst, W., Zimmermann, U.S., Stringer, S., Smits, Y. and Derks, E.M. 2013. A systems medicine research approach for studying alcohol addiction. Addiction Biology. 18(6): 883-96. The World Health Organization. 2014. Global status report on alcohol and health. http://apps.who.int/iris/ bitstream/10665/112736 /1/9789240692763_eng. pdf?ua=1 Accessed 09/06/16. The World Health Organization. 2016. Global strategy to reduce harmful use of alcohol. www.who. int/substanceabuse/ activities/gsrhua/en/ Accessed 09/06/16. National Health and Medical Research Council. 2015. Alcohol guidelines. www.nhmrc. gov.au/health-topics/ alcohol-guidelines Accessed 23/08/16. Rehm, J., Room, R. and Taylor, B. 2008. Method for moderation: measuring lifetime risk of alcohol-attributable mortality as a basis for drinking guidelines. International Journal of Methods in Psychiatric Research. 17(3):141-151
December 2016 / January 2017 Volume 24, No. 6 37
FOCUS – Drug & Alcohol nursing Benzodiazepines 13%, GHB 11% and Heroin 10%. Alcohol was the only substance reported in 46% (N=548) of patients. Single, other drug use was reported by only 9%. In contrast, polysubstance use (PSU), the use of more than one substance consecutively or concurrently, was reported by 45%. The profile of PSU was: benzodiazepines 99% cannabis 97%, ATS 95%, heroin 87%, GHB 79%, alcohol 44%.
THIS DATA HIGHLIGHTS THE HIGH PREVALENCE OF ALCOHOL AND OF PSU IN ED PRESENTATIONS, WITH EACH ACCOUNTING FOR ALMOST HALF OF THE PRESENTATIONS DURING THE STUDY PERIOD.
POLYSUBSTANCE USE IN A TERTIARY HOSPITAL EMERGENCY DEPARTMENT IN AUSTRALIA By Stephanie Fry and Yvonne Bonomo Alcohol and Other Drug (AOD) presentations are common in the Emergency Department (ED) especially on weekends (Parkinson et al. 2016) and the presence of AOD use can account for substantial healthcare costs (Butler et al. 2016). To address this important impact on limited resources, in January 2014, two Alcohol and Other Drug Clinical Nurse Consultants (AODCCs) were embedded within the Emergency Department (ED) of a tertiary metropolitan hospital on weekends. Twelve hours of specialist clinical contact between the hours of 0630-1300 was provided, with a focus on screening, assessment, brief intervention (BI) and where appropriate, referral of patients with moderate to severe AOD use problems to further treatment. All patients were screened for AOD use if they presented with two of the following; a triage category commonly associated with AOD use, clinical signs of AOD use, breath or blood alcohol concentration >0.05%.
Patients screening positive received a comprehensive AOD assessment, tailored BI within the ED and referral to further AOD services if required. Between January 2014 and June 2016, 1,580 patients met criteria for screening and 76% (N=1,179) were screened and 1,126 patients were provided with a BI. Of this population 60% (N=709) were assessed as having moderate to high risk associated with their substance use. In 48% (N=339), this was the first contact with a specialist AOD service and 33% (N=367) of patients received direct referral to another service. Alcohol was the most common substance of concern reported by 82% of the patients. Prevalence of other substances of concern were: Amphetamine Type Stimulants (ATS) 26%, Cannabis 14%,
38 December 2016 / January 2017 Volume 24, No. 6
This data highlights the high prevalence of alcohol and of PSU in ED presentations, with each accounting for almost half of the presentations during the study period. This raises questions about the most effective intervention for PSU presentations in the ED context, especially given that for nearly half of all patients, this was the first contact with AOD treatment services. A recent systematic review of the efficacy of BI in the ED on alcohol consumption found it could have a measurable population effect (McGinnes et al. 2016). There is, however, little research about the effect of BI on substances other than alcohol and even less data about effective interventions for PSU. The high proportion of ATS in our data also highlights the need to explore targeted interventions for people who typically defer abstinence and maintain dependent or harmful use of the substance for some time (Quinn et al. 2016). Further research into these different patient groups, who account for a high proportion of emergency presentations, is needed to enhance practice and improve outcomes in this clinical setting. Stephanie Fry is an Alcohol and Other Drug Clinical Consultant at St Vincent’s Hospital in Melbourne Yvonne Bonomo is Director in the Department of Addiction Medicine at St Vincent’s Hospital in Melbourne and Associate Professor at the University of Melbourne
References Butler, K., Reeve, R., Arora, S., Viney, R., Goodall, S., Van Gool, K., and Burns, L., 2016. The hidden costs of drug and alcohol use in hospital emergency department. Drug and Alcohol Review. 35(3):359-366 McGinnes, R., Hutton, J., Weiland, T., Fatovich, D., and Egerton-Warburton, D. 2016. Effectiveness of ultra-brief interventions in the emergency department to reduce alcohol consumption: a systematic review. Emergency Medicine Australia. http:// onlinelibrary.wiley.com/ doi/10.1111/17426723.12624/full, accessed 24/08/16. Parkinson, K., NewburyBirch, D., Phillipson, A., Hindmarch, P., Kaner, E., Stamp, E., Vale, L., Wright, J. and Connolly, J. 2016. Prevalence of alcohol related attendance at an innercity emergency department and its impact: a dual prospective and retrospective cohort study. Emergency Medical Journal, 33:187193. Quinn, B., Stoove, M. and Dietze, P. 2016. One-year changes in methamphetamine use, dependence and remission in a community-recruited cohort. Journal of Substance Use, 21(3):279-286.
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Drug & Alcohol nursing – FOCUS
ALCOHOL, TOBACCO AND OTHER DRUGS NURSING WITHIN A CORRECTIONAL SETTING By Andrew Wiley and Susan O’Neill In Australia 67% of prisoners report previous illicit drug use (AIHW, 2015) with 39% reporting high risk of alcohol-related harm. The links between effective ATOD health programs and outcomes are clearly linked to reduced recidivism (Ombudsman report, 2015) and better biopsychosocial determinates. Correctional nurses’ work in challenging environments but their adaptability and passion are key to the provision of community equivalent care. South Australian Prison Health Services (SAPHS) nurses provide first line drug and alcohol assessment and intervention within the correctional setting. SAPHS nurses expertly provide symptom management, including the use of Standing Drug Orders and, in conjunction with our medical staff, refer clients to inpatient units when a higher level of
clinical intervention is required. Irrespective of the client’s journey our nurses professionally provide care and therapy that actively manages drug dependence, reduces the risks of adverse outcomes such as overdose or substance withdrawal seizures. Eight per cent of South Australian’s undergoing Medicated Assisted
NURSING ATTITUDES TOWARDS PEOPLE WITH COMORBID SUBSTANCE ABUSE: A BRIEF REVIEW OF LITERATURE By Roopalal Anandan, Wendy Cross and Ian Munro A new study in Melbourne aims to assess knowledge, skills and attitudes of mental health nurses employed in a large mental health service. The study will use an observation as well as surveys and interviews to explore knowledge, skills, and attitude of nurses towards consumers with comorbid substance use. Many people diagnosed with schizophrenia are often likely to not comply or engage with their treatment regimen at some stages of their illness due to many factors including substance abuse. Mental health nurses play a pivotal role in preventing non-compliance (Pinikahana et al. 2002) and disengagement with the service.
and 50.8% had a lifetime history of cannabis abuse or dependence. This survey recommended integrated and comprehensive models of recovery to enhance the quality of life of these people (Morgan et al. 2014).
Obviously illegal drug use in mental health settings has become a major concern not only for managing the consumers but it also hinders continuity of care and engagement with services. Such disengagement may be worsened due to negative attitudes of staff (Howard and Holmhaw, 2010).
A study on attitudes, beliefs, knowledge, and of nurses towards substance abuse and mental illness in Victoria (n=302) showed that despite nurses’ positive attitude, knowledge and skills gaps still exist in their assessment and management of people with drug and alcohol problems. Therefore training to enhance nurses’ skills in assessment and management is needed (Happell et al. 2002).
An Australian national survey of adults aged 18-64 years found that of the 1,642 people who had psychotic disorders, 49.8% had a lifetime history of alcohol abuse or dependence
A comparative Canadian and Australian study showed that alcohol and drug dependence is more prevalent in Australia and recommended the implementation of
anmf.org.au
Treatment for Opioid Dependence reviewed their treatment in a correctional setting (AIHW, 2015). Our teams’ adaptability and leadership has assisted in statewide access to services for prisoner-patients by embracing and innovatively using videoconferencing and telemedicine clinics. Whether SAPHS nurses are safely providing methadone within a maximum security prison, counselling clients on harm minimisation approaches, providing nicotine replacement therapy or working on overdose prevention they are invaluable members of the South Australian healthcare team. Andrew Wiley is the Nursing Director at the South Australian Prison Health Services Susan O’Neill is the Nurse Management Facilitator, Compliance at the South Australian Prison Health Services the National Mental Health Policy in Australia to provide the best model of care (Tempier et al. 2009). The ‘Drug and Drugs Problems Perceptions Questionnaire’ (DDPPQ) aims to identify staff attitudes and experiences with comorbid substance use. The DDPPQ results showed that staff had less negative attitudes after training despite their clinical or work experiences and recommended for this type of training to be incorporated routinely into nursing development programs (Howard and Holmshaw, 2010). Nurses’ attitudes can be influenced by the stigma surrounding comorbid substance abuse and such attitudes impact negatively on the therapeutic nurse-patient relationship, rapport, and trust which are necessary for better consumer outcomes (FarleyToombs, 2012). Several mental health nurses reinforce the stigma of mental illness and to change this stigma nurses need to change their attitudes and perceptions (Coming out. My experience as a mental patient, J Psychosocial Nursing 1993). Roopalal Anandan is a PhD Nursing Student; Professor Wendy Cross is Associate Dean in Nursing and Allied Health and Director, External Relations and Dr Ian Munro is Senior Lecturer. All are located in Nursing and Midwifery at Monash University in Victoria
References AIHW. 2015. The health of Australian prisoners 2015, Australian Institute of Health and Welfare 2015 cat no PHE 207, Canberra AIHW AIHW. 2015. National Opioid Pharmacotherapy Statistics Annual Data Collection, Canberra AIHW. Ombudsman Report. 2015. Investigation into the rehabilitation and reintegration of prisoners in Victoria, Office of the Victorian Ombudsman, September 2015.
References Coming out. My experience as a mental patient. 1993. J Psychosocial Nursing Mental Health Serv. 31(5): Pp.17-20. Farley-Toombs, C. 2012. The stigma of a psychiatric diagnosis: prevalence, implications and nursing interventions in clinical care settings, Critical Care Nurse Clin North Am, 24(1) Pp. 149-56. Abstract Happell, B., Carta, B. and Pinikahana, J. 2002. Nurses’ knowledge, attitudes and beliefs regarding substance use: a questionnaire survey, Nursing Health Science, 4(4). Pp. 193-200. Howard, V and Holmshaw, J. 2010. Inpatient staff perceptions in providing care to individuals with cooccurring mental health problems and illicit substance use. Journal of Psychiatric Mental Health Nursing, 17(10), Pp. 862-72. Morgan et al. 2014. Psychosis prevalence and physical, metabolic and cognitive comorbidity: data from the second Australian national survey of psychosis, Psychology Med, 44(10), pp.216376. Pinikahana et.al. 2002. Exploring the complexity of compliance in Schizophrenia, Issues Mental Health Nursing, 23(5), Pp. 513-28. Tempier et al. 2009. Mental disorders and mental health care in Canada and Australia: comparative epidemiological findings, Social Psychiatry Epidemiology, 44(1), Pp. 63-72.
December 2016 / January 2017 Volume 24, No. 6 39
FOCUS – Drug & Alcohol nursing
THE ROLE OF NURSING IN METHAMPHETAMINE HARM REDUCTION AND TREATMENT By Brendan Clifford and Jennifer Cant Methamphetamine is a growing drug and alcohol problem in Australia, and nurses are key to implementing interventions as well as leading new models of care that deliver them.
users while inpatients, linking them in to treatment after discharge, as well as providing brief interventions and harm reduction education to users. There is also continuing research looking at strengthening the evidence for adjunct pharmacotherapy options for those with severe dependence, with a large scale randomised controlled trial of Lisdexamfetamine planned to begin later this year.
Media portrayals of methamphetamine use often reinforce stigma and hopelessness, so it is important to recognise that there are evidence based interventions available and continuing research efforts to address methamphetamine use disorders. St Vincent’s Hospital Sydney has been a leading innovator in the treatment of methamphetamine dependence since 2006, being one of the first Stimulant Treatment Programs in NSW set up to provide counselling interventions. Further work since then has focused on broadening engagement with
stimulant users. A recent evaluation has shown the value of an early intervention model of care that seeks to provide a non-judgemental stimulant “checkup” service for people who haven’t identified their use as problematic. This provides an opportunity to assess psychosocial and physical health, as well as provide harm reduction education so that transitions into harmful use can be recognised. The recent appointment of a Stimulant Hospital Nurse is also geared towards increasing engagement of dependent
Given the challenges in engaging stimulant users in treatment, nurses in sectors outside of drug and alcohol services, especially in primary care and emergency department services, have an important position in identifying stimulant use. Nurses who are able to engage with patients and clients around their drug use have an ideal opportunity to identify ‘red flags’ of problem use before the user may themselves recognise them. Recognising that anxiety, depression and insomnia are frequent sideeffects of stimulant use should be a trigger for the use of instruments such as ASSIST-Lite.
OPIOID DEPENDENCY IN PREGNANCY
pressure to enrol in maintenance therapy programs. The key to treating these women is not abstinence but education and maintenance therapy.
while providing a safe level of opioid exposure to the fetus, reducing the risk of adverse outcomes (Mattick et al. 2014).
Heroin is the most commonly abused opioid drug in pregnancy. Once in the maternal circulation it crosses the placental barrier within one hour (McKeever et al. 2015). If abstinence occurs in a dependant woman, withdrawal symptoms will occur which can be dangerous to both mother and baby. Although not often fatal for women, they may experience tachycardia, hypertension and increased anxiety. Opioid dependency in pregnancy increases the risk of intrauterine growth restriction (IUGR), placental abruption, prematurity, antepartum bleeding, malpresentation, poor felt heart patterns, neonatal abstinence syndrome and mortality if not treated (Brocato, 2015; McKeever et al. 2015). Women with opioid dependency often indulge in other harmful substances such as cigarettes, alcohol and other illicit drugs. This type of behaviour coupled with IV drug use puts women at increased risks of other health complications such as endocarditis, blood borne viruses, cellulitis, chorioamnionitis, and sexually transmitted diseases (Malek, 2013).
Neonates exposed to both Methadone and Buprenorphine will experience some degree of Neonatal Abstinence Syndrome, with approximately 50% requiring treatment. Symptoms include hyperactivity of the central and autonomic nervous system, psychological changes, behaviours and poor adaption processes (Wiegand et al. 2015). Infants may experience uncoordinated sucking reflexes resulting in poor feeding, irritability, high pitched scream and potential risk of respiratory symptoms (Brocato, 2015). Withdrawal symptoms usually appear within 72 hours post-birth and can last for days to several weeks. If untreated neonates can experience serious complications such as diarrhoea, weight loss, seizures and difficulty feeding which often require prolonged hospital stays and medication therapy (McKeever et al. 2015).
By Claire Gibson and Sadie Geraghty Substance use (illicit and licit) in pregnant women has consistently increased over the past 50 years, more recently with an escalation of opioid use. Opioid dependency in pregnancy is associated with very specific health and social risks for both mother and baby. Opioid dependency can result from continued use of opioids such as Heroin, Morphine, Oxycodone, Oxycontin, Codeine, Hydrocodone and any other opioid based drug. The use of these drugs often gives a euphoric feeling as the opioids bind to the opioid receptors in the brain. Drug addiction is often characterised by drug seeking behaviour, dependence and increased tolerance, impaired behaviour control, significant problems with interpersonal relationships and dysfunctional emotional response (Brocato, 2015). Women with opioid dependency have specific needs in pregnancy and are often difficult to identify as they have poor antenatal attendance and often do not present until later in pregnancy due to the fear of stigma, shame and
Opioid maintenance therapy is the treatment of choice for pregnant women. There are two recommended opioid therapies available, Methadone and Buprenorphine. Both of these medications suppress the mother’s cravings and withdrawal
40 December 2016 / January 2017 Volume 24, No. 6
Opioid dependency requires early intervention in pregnancy to prevent adverse maternal and neonatal outcomes and reduce the severity of neonatal abstinence syndrome. Claire Gibson is an RN and Midwifery student and Sadie Geraghty is an RM, Midwifery and Nursing Lecturer. Both are in the School of Nursing and Midwifery at Edith Cowan University in WA.
Brendan Clifford is a Clinical Research Nurse and Jennifer Cant is a Registered Nurse, Stimulant Treatment Program. Both are at St Vincent’s Hospital in Sydney
References Brocato, C., L. 2015. Managing opioid addiction in pregnancy. The Clinical Advisor: For Nurse Practitioners, 18(10), 28-35. Malek, A. 2013. Effects of prenatal opiates exposure on human pregnancy and breastfeeding. Pharmaceutica Analytica Acta. Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. 2014. Buprenorphine maintenance versus placebo or Methadone maintenance for opioid dependence. The Cochrane Library. McKeever, A. E., SpaethBrayton, S., & Sheerin, S. 2015. The role of nurses in comprehensive care management of pregnant women with drug addiction. Nursing for Women’s Health, 18(4), 286-293. Wiegand, S., Stringer, E., Stuebe, A., Jones, H., & Seashore, C. 2015. Buprenorphine and Naloxone compared with Methadone treatment in pregnancy. Obstetrics and Gynaecology, 125(2), 363-368.
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FOCUS – Drug & Alcohol nursing
References Australian Institute of Health and Welfare. 2011. Drugs in Australia 2010: Tobacco, alcohol and other drugs. Cat. no. PHE 154. Canberra: AIHW Australian Institute of Health and Welfare. 2007. Statistics on drug use in Australia 2006. Cat. no. PHE 80. Canberra: AIHW
NEONATAL ABSTINENCE SYNDROME AND THE ATTACHMENT RELATIONSHIP By Jaylene Shannon, Stacy Blythe and Kath Peters Approximately 4.2% of pregnant women consume illicit drugs during pregnancy (AIHW, 2011). Drug exposed infants are more likely to be born small for gestational age, be preterm, and be admitted to special care or intensive care nurseries (AIHW, 2007). In addition to this, drug exposed infants are more likely to demonstrate insecure attachment patterns with their caregivers (Swanson et al. 2000; Twomey et al. 2010) and are more at risk of mental health concerns later in life (Behnke et al. 2013). The post-natal period is crucial for infants in establishing a connection and security in a primary-caregiver and can have long-standing impacts on emotional-regulation and attachment patterns (Bystrova et al. 2009). However due to the need for symptom management, many infants born with Neonatal Abstinence Syndrome (a compilation of withdrawal symptoms after prenatal drug exposure) may be separated from primary caregivers and cared for in special care nurseries soon after birth (Backes et al. 2012; Hudak et al. 2012).
Research project
Australian guidelines have limited recommendations for enhancing infant attachment for drug exposed infants and fail to identify specific interventions for nurses/midwives to implement into practice (New South Wales Health, 2013). Therefore,
THIS RESEARCH HAS THE POTENTIAL TO PROVIDE INSIGHTS INTO HOW NURSES/MIDWIVES PROMOTE AND SUSTAIN AN ATTACHMENT RELATIONSHIP FOR DRUG EXPOSED INFANTS.
further research is needed in order to identify the role nurses play in promoting the infant-caregiver attachment for substance exposed infants in the post-natal period. After gaining ethical approval, this qualitative study will explore nurses’/ midwives’ experiences of promoting the infant-caregiver attachment for infants with Neonatal Abstinence Syndrome and explore methods
42 December 2016 / January 2017 Volume 24, No. 6
they use to facilitate an attachmentrelationship for these infants. Registered nurses and/or midwives who fit the outlined criteria will be recruited using purposive sampling and data will be collected via semistructured interviews.
Practical outcomes
This research has the potential to provide insights into how nurses/ midwives promote and sustain an attachment relationship for drug exposed infants. These insights may provide the basis for nursing/ midwifery interventions that ensure drug exposed new-borns have the opportunity to develop an attachment relationship. Jaylene Shannon is an Honours Candidate and Registered Nurse at Port Macquarie Base Hospital; Dr Stacy Blythe is Lecturer and Director of Engagement & International and Associate Professor Kath Peters is Director of Academic Programs (International Programs). All are in the School of Nursing and Midwifery at Western Sydney University
Backes, C.H., Backes, C.R., Gardner, D., Nankervis, C.A., Giannone, P.J., & Cordero, L. 2012. Neonatal abstinence syndrome: Transitioning methadone-treated infants from an inpatient to an outpatient setting. Journal of Perinatology, 32(6): 425-430. Behnke, M., Smith, V.C., Levy, S., Ammerman, S.D., Gonzalez, P.K., Ryan, S.A., & Cummings, J.J. 2013. Prenatal substance abuse: short-and long-term effects on the exposed fetus. Pediatrics, 131(3): e1009-e1024. Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A., Ransjö-Arvidson, A., Mukhamedrakhimov, R., & Widström, A. 2009. Early contact versus separation: effects on mother-infant interaction one year later. Birth: Issues in Perinatal Care, 36(2): 97-109. New South Wales Health. 2013. Neonatal Abstinence Syndrome Guidelines. Document No. GL2013_008. NSW Health. Swanson, K., Beckwith, L., & Howard, J. 2000. Intrusive caregiving and quality of attachment in prenatally drug-exposed toddlers and their primary caregivers. Attachment & Human Development, 2(2): 130-148. Twomey, J.E., MillerLoncar, C., Hinckley, M., & Lester, B.M. 2010. After family treatment drug court: Maternal, infant, and permanency outcomes. Child Welfare, 89(6): 23-41.
anmf.org.au
Drug & Alcohol nursing – FOCUS
ELEANOR KITSON
WHERE THERE’S SMOKE: UNCOVERING THE BENEFITS OF A NON-RESIDENTIAL CANNABIS WITHDRAWAL By Eleanor Kitson Drug and alcohol dependence continues to ignite the interest of the media. The ‘epidemic’ of methamphetamine use, the controversy of private residential rehabs and the burden of substance use on the healthcare system are prominent in the news and across social media. Service review and improvement within the Drug and Alcohol sector is not a new phenomenon. Nevertheless, despite extensive industry demand and public outcry, there are still no miracle ‘cures’ for substance abuse. Chronic relapsing and remitting conditions such as drug and alcohol dependence, rarely have miracle cures. If my role as a Pharmacotherapy Nurse Practitioner Candidate in the Drug and Alcohol sector has taught me one thing, it is that achieving reduction or abstinence from substances takes time. For the majority of users, simply physically ceasing and experiencing withdrawal from a substance is not treatment enough. I have repeatedly observed the impact of a client having completed withdrawal, relapsing on return to their substance use home environment. With a limited number of public residential rehabilitation beds and the cost of private facilities being too high for the majority, the alternative of a non-residential withdrawal (NRW) program should be considered. A anmf.org.au
nurse facilitated NRW offers clients the opportunity for cessation and medication of withdrawal in their own home or to have NRW nurse support following a week of residential withdrawal. Previously working as a NRW nurse assisting clients with cannabis dependence, has for me highlighted a number of unexpected benefits to the ‘at home’ approach. Firstly, it allows for an enhanced therapeutic relationship with clients and their family in their own context. The benefits of professional, consistent, honest positive regard cannot be overestimated for this client group. Secondly, it allows for family involvement in the process, as well as education and support to family and friends. Thirdly, it allows for the exploration and modification of triggers at home. Sights, smells, sounds and environments trigger memories of cannabis use and often lead to relapse. Helping clients to recognise and modify these triggers in the home can significantly help to reconfigure their smoking context to promote a
holistically drug-free environment. An effective example of this in practice was to encourage clients to improve ventilation and use room fragrances and scented candles to eliminate the smell of cannabis.
A NURSE FACILITATED NRW OFFERS CLIENTS THE OPPORTUNITY FOR CESSATION AND MEDICATION OF WITHDRAWAL IN THEIR OWN HOME OR TO HAVE NRW NURSE SUPPORT FOLLOWING A WEEK OF RESIDENTIAL WITHDRAWAL.
Unsurprisingly, people need ongoing support as the neurobiological changes of dependence of cannabis persist for months to years and risk of relapse is high. Many clients bring with them motivating factors for reducing their substance use including exacerbation of mental health issues or involvement with the legal system. For people who use cannabis, harm minimisation strategies to reduce the risk associated with its use is fundamental. Helping clients to recognise and alter the triggers in their home environment, which prompt them to use cannabis, enhances the likelihood of changing their substance use. Whilst helping them to clear the smoke, we must also help them extinguish the fire. Eleanor Kitson is a Pharmacotherapy Nurse Practitioner Candidate at Monash Health Drug & Alcohol Service December 2016 / January 2017 Volume 24, No. 6 43
FOCUS – Drug & Alcohol nursing
ANDREA STONE
References Hoenigl, M., Chaillon, A., Moore, D., Morris, S., Smith, D. 2016. Sexual risk behavior: A cohort study among men who have sex with men. Journal of Acquired Immune Deficiency Syndromes 71 (5): 551–557.
LITERATURE SEARCH: STI SCREENING AND DRUG USE IN YOUNG PEOPLE By Andrea Stone Alcohol and other drug use are almost synonymous with increased risky sexual activity in young people (12-25 years). There is a direct correlation between initiation into methamphetamine use and an increase in sexual risk behaviours (Hoenigl et al. 2015).
It has been identified in several studies that risk taking behaviours in young people tend to ‘cluster’ – these include drug and alcohol misuse (alcohol consumption until intoxication) and unsafe, risky sex (Madkpour et al. 2010; Kang et al. 2014). To date the current focus within health services has been the significant increases in psychotic behaviours associated with methamphetamine use thus creating numerous problems for staff in emergency departments (Roxburgh and Burns, 2013). However of equal concern is that enhanced sexual activity/arousal and often poor decision making whilst intoxicated increases the likelihood of unsafe sex and an increase in the number of sex partners and the end consequence is undiagnosed STI’s and increased risk of blood borne
viruses (BBVs) (Lea et al. 2015). Young people referred to drug and alcohol services are primarily screened for drug and alcohol use and mental health, given the high incidence of STIs in young people, particularly chlamydia (The Kirby Institute, 2013) it is imperative that STI screening is included in all assessments both symptomatic and asymptomatic. If left untreated the complications from STIs can range from reproductive morbidity and HIV transmission (Natoli et al. 2015). Sexual health screening should be included and promoted as an integral component of a drug and alcohol assessment. Staff must be encouraged to complete and attend education and training on STIs and BBVs and include safe sex as a component of harm minimisation education to all clients that access the service.
44 December 2016 / January 2017 Volume 24, No. 6
HOWEVER OF EQUAL CONCERN IS THAT ENHANCED SEXUAL ACTIVITY/AROUSAL AND OFTEN POOR DECISION MAKING WHILST INTOXICATED INCREASES THE LIKELIHOOD OF UNSAFE SEX AND AN INCREASE IN THE NUMBER OF SEX PARTNERS AND THE END CONSEQUENCE IS UNDIAGNOSED STI’S AND INCREASED RISK OF BLOOD BORNE VIRUSES. Andrea Stone is a Nurse Practitioner, Drug Health Service at Sydney Local Health District
Kang, M., Rochford, A., Skinner, R., Mindel , A., Webb, M., Peat, J., Usherwood, T. 2014. Sexual behaviour, sexually transmitted infections and attitudes to chlamydia testing among a unique national sample of young Australians: Baseline data from a randomised controlled trial. BMC Public Health 14(12):1-12. Lea, T., Bryant, J., Ellard, J., Howard, J., Treloar., C. 2015. Young people at risk of transitioning to injecting drug use in Sydney, Australia: Social disadvantage and other correlates of higher levels of exposure to injecting. Health and Social Care in the Community 23(2): 200-207. Madkour, A.S., Farhart, T., Halpern, C.T. 2010. Early adolescent sexual initiation as a problem behaviour: A comparative study of five nations. Journal of Adolescent Health 47: 389–398. Natoli, L., Guy, R.J., Shephard, M., Donovan, B., Fairley, C.K., Ward, J., Regan, D.G., Hengel, B., Maher, L. 2015. Chlamydia and gonorrhoea point-ofcare testing in Australia: where should it be used? Sexual Health 12(1) 51-58. http:// dx.doi.org/10.1071/ SH14213. Roxburgh, A. and Burns, L. 2013. Drugrelated hospital stays in Australia, 1993-2012. Sydney: National Drug and Alcohol Research Centre. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2013. Sydney: The University of New South Wales; 2013.
anmf.org.au
LANGUAGE AND MEANING While it is wonderful that ANMF Federal President Sally-Anne Jones is taking an interest in her children’s Japanese language studies, I think it is quite telling that she introduced her article ‘Walking Together’ (ANMJ November 2016, p. 48) by saying that it was they who were studying Japanese and not her.
LETTER OF THE MONTH
If she had studied the language herself and had some understanding of it she would have been able to interpret it more accurately. I have studied Japanese for many years, at high school, at university and independently ever since and will therefore attempt to clarify some aspects of the language upon which her article is based. The grey box at the beginning of the article has the Romanisation ‘de arukimasu’, juxtaposed to the Japanese 歩く, followed by ‘= to walk’. The Romanisation of 歩く would be ‘aruku’, not ‘de arukimasu’, which would be written as either ~で 歩きます, which is the semi-honorific form of ‘walk by means of’ or ‘walk via’, which must be preceded by a noun, or 出歩きます, meaning ‘walk out’. 歩くitself is simply the verb ‘to walk’ and it does now imply walking with another person unless it is used in conjunction with 一 緒 (Romanised ‘Issyo’, meaning ‘together’) as in 一緒に歩く(‘Issyo ni aruku, walk together) or 一緒に歩きます (‘issyo ni arukimasu’, a similar meaning), depending on whether the person to whom they were speaking was a familiar equal in the first instance or either unfamiliar or of higher status in the second. While it is true that Ms Jones may well have found that the concept of walking together came to mind when she heard the word from her children, we are left with a rather tenuous connection between her inspiration and what the term she heard actually means, which to the bilingual reader feels somewhat disconcerting. The article concludes with the Romanisation ‘chowa’ with the translation ‘harmony’ in parentheses. While it is true that chowa (調和) refers, in a sense, to harmony, I am not convinced that it does so in the sense that the author intended. 調和 is a kind of harmony that is concerned with balance, consistency and conformity, which are associated with a tranquil social state that is free of conflict, but not necessarily in the way that we would expect. Japanese social relations place a great deal of emphasis on social dualism; on the distinction between 本音 and 建前 (hon-ne and tatemae), which are social terms referring to one’s inner thoughts and feelings and the diplomatic façade used to avoid imposing upon the feelings of those around us. It is hard to think of a Japanese word appropriate to refer to the kind of harmony we pursue in Australia, which includes a diverse range of components such as give and take, tolerance and valuing of difference, appreciation of frankness, bonding through conflict and respectful but direct disagreement; something I hope this letter conveys. The word 和 (wa, meaning harmony in the sense of peace and balance) may come close, but it is also synonymous with Japanese national identity, since it is used to identify things as Japanese (eg. 和食, wa-syoku, Japanese food) and thus distinguish them from that which is foreign or different. This latter sense being at odds with a fair amount of the Australian concept of harmony seems to me to render the term inappropriate in such a context despite the relevance of its denotation. Languages are a rich source of meaning and ideas, and it is a wonderful thing that people do find inspiration in them and that Australia’s education system facilitates opportunities for children to benefit from language learning. What this experience is telling us is not that we should be afraid of doing so, but rather that we should all be digging deeper and looking beyond the immediate word associations that spring to mind when we see decontextualised translations, especially those of new learners. I hope that Ms Jones and her readers will not be offended by my critique of her article, but will rather use it as the beginning of a journey of further exploration.
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I am so thrilled as yesterday I was sitting in my office of the Vinmec International Hospital in Hanoi, Vietnam and a man came to deliver my copy of the ANMJ (October, 2016). I had spoken earlier this year to one of your colleagues and she said she would send it to me as I was a long time subscriber. It makes me feel connected to the nursing profession again because as you can imagine my life here immersed in a different culture has been very interesting. Nursing is at a very different stage (possibly where we were about 30 years ago). It is still heavily dominated by medicine and lacks the confidence to be heard. But the nurses are keen for change and so enthusiastic for opportunities to share and learn. The system is difficult to maneuver. Yvonne Osborne RN, Hanoi Vietnam
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.
David N. Webb, Research and Learning Support Information Officer at Institute of Health Management, Victoria Editor’s note: The imagery on Federal President Sally-Anne Jones’ column was supplied by ANMJ editorial. We apologise for any anomalies or misinterpretations and any offence taken. anmf.org.au
December 2016 / January 2017 Volume 24, No. 6 45
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CALENDAR
DECEMBER World AIDS Day 1 December. http:// worldaidsdayworldwide.org/ Adelaide Nurses’Conference 1-2 December, The Lakes Resort Hotel, Adelaide. www.ausmed.com.au/ International Indigenous Health Conference 1-3 December, Pullman Cairns International Hotel, Cairns Qld. www.indigenousconferences.com/ Law and Nursing 8-9 December, The Lakes Resort Hotel, Adelaide. www.ausmed.com.au/ 8th International Conference on Healthcare, Nursing and Disease Management 21-22 December, Flora Grand Hotel, Deira, Dubai, United Arab Emirates. http://iaphlsr.org/index.php
2017 JANUARY
Women’s Cancer Foundation (Ovarian Cancer Institute) We can walk it out 2017 at The Tan Track, Melbourne 26 February 2017. In aid of ovarian cancer research and awareness. Mark your calendar and tag your friends! #WeCanWalkItOut or #GetRealSupportTeal #womenscancer #donate
MARCH Lung Health Promotion Centre at The Alfred Asthma Educator’s Course 1-3 March 2017 Smoking Cessation Course 9-10 March 2017 P: (03) 9076 2382 E: lunghealth@alfred.org.au 35th Annual Dermatology Nurses Association Convention Embracing the world of dermatology 1-4 March 2017, Orlando, Florida. http://www.dnanurse.org/ International Women’s Day 8 March 2017. www.internationalwomensday.com/
International Conference on Impact of Global Issues on Women 9-12 January 2017, Manipal University, India. http://conference.manipal.edu/ ic2017/
Australasian Cardiovascular Nursing College Conference 10-11 March 2017, Brisbane Convention & Exhibition Centre, Queensland. http://www.acnc.net.au/
FEBRUARY
41st National Australian Association of Stomal Therapy Nurses Conference Into the sunshine: Storytelling in stomal therapy 12-15 March 2017, Royal International Convention Centre, Brisbane, Qld. http://stomaltherapyconference.com/
Ovarian Cancer Awareness Month www.womenscancerfoundation.org.au/ World Cancer Day We Can. I Can. 4 February 2017. www.worldcancerday.org/ Anniversary of the Apology (2008) 13 February 2017 Lung Health Promotion Centre at The Alfred Spirometry Principles & Practice 16-17 February 2017 P: (03) 9076 2382 E: lunghealth@alfred.org.au 8th Annual National Dementia Conference 23-24 February 2017, Adelaide, South Australia. http://ow.ly/wMGM3050zTg
NETWORK Prince Henry’s Hospital, PTS 88th January Group, 50th reunion weekend 21 & 22 January 2017. For details contact Jan Kendrick E: fjlewo@bigpond.net.au Royal Adelaide Hospital, Group 771, 40-year anniversary 22 January 2017, Cremorne Hotel Unley @2pm. $10 per head. Contact E: berniesykes2@bigpond.com or E: michael.regan21@gmail.com Mercy Private A’77 40-year reunion 29 January 2017, Lunch from 1200 (venue TBC) Contact Megan Burgmann E: mburgmann@optusnet.com.au or Cathy Sullivan (nee Mulchay)
anmf.org.au
6th eMedication Management Conference 14-15 March 2017, Swissotel Sydney. www.informa.com.au/conferences/ health-care-conference/electronicmedication-management St Patrick’s Day 17 March 2017. http://www.timeanddate.com/holidays/ australia/st-patrick-day National Close the Gap Day 17 March 2017. https://www.oxfam. org.au/what-we-do/indigenousaustralia/national-close-the-gap-day/ Earth Hour 19 March 2017
E: Catherine.Sullivan58@gmail.com or via facebook A77 – 40 year reunion Prince Henry’s Hospital Melbourne, 1/77 group 40 -year reunion 4 February 2017 ,12.30 pm onwards at Wheeler’s Hill Hotel ,Wheelers Hill. Interested? Contact by email: 177phh@ gmail.com or Search Facebook page, Prince Henry’s Hospital 1/77 reunion for further information Prince Henry’s Hospital Melbourne, Group 2/2/1972, 45-year reunion 4 February 2017. Contact Jacky Dow (nee Conway) E: g_jdow@internode. on.net or Janet Molan (nee Craig) E: j.em2008@hotmail.com
Harmony Day Australia 21 March 2017. http://www.harmony.gov.au/ Building Children’s Nursing for Africa Conference Pillars of Practice 28-30 March 2017, The River Club, Observatory, Cape Town, South Africa. www.buildingchildrensnursing.co.za Digital Health Show 29-30 March 2017, Melbourne Convention & Exhibition Centre. www.digitalhealthshow.com.au
APRIL 15th World Congress on Public Health Voices Vision Action 3-7 April 2017, Melbourne Convention and Exhibition Centre. http://www.wcph2017.com/ Lung Health Promotion Centre at The Alfred Managing COPD 20–21 April 2017 Spirometry Principles & Practice 27-28 April 2017 P: (03) 9076 2382 E: lunghealth@alfred.org.au 14th National Rural Health Conference 26-29 April 2017, Cairns, North Queensland. www.ruralhealth.org.au/14nrhc/
MAY Lung Health Promotion Centre at The Alfred Respiratory Course (Modules A & B) 1–4 May 2017 Respiratory Course (Module A) 1–2 May 2017 Respiratory Course (Module B) 3–4 May 2017 Asthma Update 26 May 2017 P: (03) 9076 2382 E: lunghealth@alfred.org.au National Sorry Day 26 May 2017.
National Reconciliation Week 27 May-3 June 2017. http://www.reconciliation.org.au/nrw/
JUNE Lung Health Promotion Centre at The Alfred Spirometry Principles & Practice 5-6 June 2017 Paediatric Respiratory Update 26 June 2017 Theory & Practice of Non Invasive Ventilation (Bi-Level & CPAP Management) 30 June 2017 P: (03) 9076 2382 E: lunghealth@alfred.org.au 20th Cancer Nurses Society of Australia Annual Congress Evolving cancer care: Enhancing quality Embracing innovation 15-17 June 2017, Adelaide Convention Centre, South Australia. www.cnsacongress.com.au 13th Conference of the European Council of Enterostomal Therapists Building bridges – from west to east, from south to north Ostomy – Continence – Wound 18-21 June 2017, Berlin, Germany. www.ecet2017.org 31st International Confederation of Midwives Triennial Congress Midwives - Making a difference in the world 18-22 June 2017, Toronto, Canada. www.midwives2017.org/
JULY NAIDOC Week 2-9 July 2017. http://www.naidoc.org.au/ Lung Health Promotion Centre at The Alfred Asthma Educator’s Course 19-21 July 2017 Respiratory Update 28 July 2017 P: (03) 9076 2382 E: lunghealth@alfred.org.au
International Council of Nurses (ICN) Congress Nurses at the forefront transforming care 27 May-1 June 2017, Barcelona, Spain. http://www.icnbarcelona2017.com/en/
St Vincent‘s Hospital Melbourne Jan 1977, 40-year reunion 11 February 2017. Venue TBC via email invitation. Contact Trish Kunek (nee Crommy) E: pkunek@ gmail.com Also, our contact base needs updating since last reunion 20 years ago, it would be appreciated if you could circulate this address to your contact group RAH, group 772, 40-year reunion 25 February 2017, 12 midday-1600. Venue TBA. Contact Bronwyn Glitheroe (nee Deed), Anne-Marie McBride (nee Rogers), Helen Kirby (nee Osborn) or Rhona Edwards (nee McGarrigle) E: rah772reunion@gmail. com or search Facebook page rah772
Royal Melbourne Graduate Nurses Association 100-year anniversary Luncheon 18 March 2017, 12–3pm, Leopard Lodge, Melbourne Zoo. Entry via Zoo Rail Gate, Poplar Road. Complimentary Zoo Access from 11am. Parking $2 for 5 hours. RSVP: Lara Taylor 0415 628 131 or Simone Cooley (AH) 0417 587 745. Cost: $85. Book online at www.trybooking.com/236298
Email cathy@anmf.org.au if you would like to place a reunion notice
December 2016 / January 2017 Volume 24, No. 6 47
ANNIE
LISTENING IS THE KEY Assistant Federal Secretary, Annie Butler
I’m writing this column, the final back page column for 2016, exactly one week after Donald Trump was elected 45th President of the United States of America and wondering what this will mean for us and for the world. Like millions of others, I’m not a fan of Donald Trump. The positions he champions are, almost entirely, ones I completely oppose. And he’s against almost everything I believe is needed to build a better, happier society: universal healthcare, quality public education, respect for women, equal opportunity for every citizen and compassion for non-citizens, fair distribution of wealth and, most importantly, honesty, tolerance and acceptance.
WHY DOES THIS MATTER TO US? BECAUSE NO-ONE UNDERSTANDS THE IMPORTANCE OF LISTENING BETTER THAN NURSES AND MIDWIVES. ALLOWING OUR PATIENTS TO FEEL HEARD IS AT THE CORE OF WHAT WE DO, AND PART OF WHY OUR COMMUNITIES RESPECT US THE WAY THEY DO. Having spent the month of October in the USA, where I met many wonderful people, had many terrific experiences and really saw much of the greatness the country has to offer, I naively thought it would be impossible for Americans to elect Donald Trump as the next president.
Reference The Guardian (2016), online at: https://www. theguardian.com/ business/2016/jan/18/ richest-62-billionaireswealthy-half-worldpopulation-combined IMAGE: HTTPS:// THELEAPBLOG.ORG/ IF-THERE-ARE-NONURSES-I-DONT-WANTTO-BE-PART-OF-YOURREVOLUTION/
But elect him they did, and when it comes on the back of Brexit and the return of One Nation to the Australian Parliament, that fact demands attention. The people who voted for Trump, Brexit and One Nation are frequently characterised as ‘rednecks and racists’. An easy conclusion to draw if based on the political platforms of their chosen candidates but also, in my view, a little simplistic. From my observation it’s most definitely true that Donald Trump, the proponents of Brexit and the One Nation Party advocate positions which can be described as redneck and racist and which I consider to be unfair, uneducated and
48 December 2016 / January 2017 Volume 24, No. 6
USA UNION NATIONAL NURSES UNITED ENDORSED BERNIE SANDERS FOR PRESIDENT
unsophisticated. But that doesn’t mean I necessarily think this about all the people who voted for them. If I did, I think that would make me, firstly, hypocritical because I claim to support fairness, tolerance and acceptance, and secondly, superficial because I would be making that decision on the basis of politicians’ platforms not on understanding what’s actually happening in people’s lives that makes them find these platforms appealing. It seems to me that something in these politicians’ messages somehow made many people in the USA, the UK and Australia feel heard. Something I think that ‘establishment’ politicians such as the ALP and the Coalition in Australia, and the Democrats and less ‘hard-line’ Republicans in the USA have recently failed to do. As increased support has emerged for these far right politicians, so has support for a resurgent left as people, especially young people, have drifted from traditional centre left political parties to support the likes of the UK’s Jeremy Corbyn and the USA’s Bernie Sanders. While I admit that I find the platforms of these left politicians far more palatable than those of the far right, I think the most significant thing is that they too have attracted a following that is disengaging from ‘middle of the road’ political parties and made their supporters feel heard. I’m not suggesting that the concerns of people from both sides are all legitimate or must be addressed, but I am suggesting that they have a right to be heard. Too often, those on the left automatically dismiss the views of those on the right, and vice-versa, without pausing to explore what lies beneath those views. But if you stopped to listen and got to the heart of their concerns I’m not
convinced you’d find that what troubles both sides is actually so different. Most people just want to be safe, healthy, have value and to be heard. Why does this matter to us? Because no-one understands the importance of listening better than nurses and midwives. Allowing our patients to feel heard is at the core of what we do, and part of why our communities respect us the way they do. Nurses and midwives do not, and cannot, ignore or dismiss someone because of where they’re from or their political views. We are obliged, by the codes of ethics that underpin our practice, to determine the cause of a person’s troubles, regardless of who they are, and make sure they get the help they need. The world could learn a lot from nurses and midwives. The polarisation of views we’re seeing emerge across the western world, not coincidentally in my view, as inequality is increasing across the western world, is happening for a reason. The gap between the rich and poor continues to grow, with just 1% of the world’s population owning 50% of the world’s wealth (The Guardian 2016). As a result, increasing numbers of people from all sides are living in despair and without hope. And in their desperation to improve their own lives they are finding some sort of connection with those espousing more extreme views, who are often seeking to blame someone else for the problem. But I don’t think they’ve found the answer, I definitely don’t think Donald Trump, ironically part of the ‘elite’ wealthiest 1%, is the answer. I think the answer is to listen. To start listening, even when we don’t agree, without fear, anger or righteousness but with understanding. Nurses and midwives do this all the time, perhaps we need to start showing the world how it’s done. Wishing a safe and enjoyable festive season and happy new year to all. anmf.org.au
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