ANMJ Feb 2016 by Australian Nursing & Midwifery Journal

Expanded Pregnancy, Birth and Baby service supporting parents from pregnancy to preschool.

Who can parents talk to about behavioural and development concerns? Pregnancy, Birth and Baby offers additional support when parents cannot access your services. Pregnancy, Birth and Baby is a free Australian Government service available 7 days a week operated by maternal and child health nurses to provide parents with guidance and reassurance about their childâ&#x20AC;&#x2122;s behaviour and development. We can also refer to local services such as early child health and speech therapy. Our social workers and psychologists provide parents with support for perinatal anxiety and depression. Pregnancy, Birth and Baby is not prescriptive and uses a family partnership model to guide practice.

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CONTENTS Directory 02

Editorial 03 ANMF Priorities 2016

News 09 Super 14 Industrial 15 Feature – Generation Next 16 World 22 Ethics 23 Issues – AHPRA 24

NEXT GENERATION

Working life – Joanne Dean

Clinical update

Issues – Finance and health 30 Viewpoint – Mental Health 31 Relection – App challenged 32

HELPING GRADUATE NURSES AND MIDWIVES FIND JOBS

Working life – Anne Holland

Education 34

Viewpoint – Cognitive impairment care 36 Books 37 Focus – Aged Care 38 Calendar 53 Mail 54 Sally 56

25 38

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February 2016 Volume 23, No. 7 1

Canberra

3/28 Eyre Street, Kingston ACT 2604 Phone (02) 6232 6533 Fax (02) 6232 6610 Email anmfcanberra@anmf.org.au

Front cover: St Vincent’s Hospital grad nurses L-R Taz Gooding, Tori Burek and Natasha Tabone Photograher: Chris Hopkins

Melbourne & ANMJ

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Editorial Federal Secretary Lee Thomas

Assistant Federal Secretary Annie Butler

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Australian Capital Territory Branch Secretary Jenny Miragaya Office address 2/53 Dundas Court, Phillip ACT 2606 Postal address PO Box 4, Woden ACT 2606 Ph: (02) 6282 9455 Fax: (02) 6282 8447 E: anmfact@anmfact.org.au

Northern Territory

South Australia

Victoria

Branch Secretary Yvonne Falckh

Branch Secretary Elizabeth Dabars

Branch Secretary Lisa Fitzpatrick

Office address 16 Caryota Court, Coconut Grove NT 0810 Postal address PO Box 42533, Casuarina NT 0810 Ph: (08) 8920 0700 Fax: (08) 8985 5930 E: info@anmfnt.org.au

Office address 191 Torrens Road, Ridleyton SA 5008 Postal address PO Box 861 Regency Park BC SA 5942 Ph: (08) 8334 1900 Fax: (08) 8334 1901 E: enquiry@anmfsa.org.au

Office address ANMF House, 540 Elizabeth Street, Melbourne Vic 3000 Postal address PO Box 12600 A’Beckett Street Melbourne Vic 8006 Ph: (03) 9275 9333 Fax (03) 9275 9344 Information hotline 1800 133 353 (toll free) E: records@anmfvic.asn.au

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.

New South Wales

Queensland

Tasmania

Western Australia

Branch Secretary Brett Holmes

Branch Secretary Beth Mohle

Branch Secretary Neroli Ellis

Branch Secretary Mark Olson

Office address 50 O’Dea Avenue, Waterloo NSW 2017 Ph: 1300 367 962 Fax: (02) 9662 1414 E: gensec@nswnma.asn.au

Office address 106 Victoria Street West End Qld 4101 Postal address GPO Box 1289 Brisbane Qld 4001 Phone (07) 3840 1444 Fax (07) 3844 9387 E: qnu@qnu.org.au

Office address 182 Macquarie Street Hobart Tas 7000 Ph: (03) 6223 6777 Fax: (03) 6224 0229 Direct information 1800 001 241 (toll free) E: enquiries@anmftas.org.au

Office address 260 Pier Street, Perth WA 6000 Postal address PO Box 8240 Perth BC WA 6849 Ph: (08) 6218 9444 Fax: (08) 9218 9455 1800 199 145 (toll free) E: anf@anfwa.asn.au

2 February 2016 Volume 23, No. 7

ANMJ IS PRINTED ON A2 GLOSS FINESSE, PEFC ACCREDITED PAPER. THE JOURNAL IS ALSO WRAPPED IN BIOWRAP, A DEGRADABLE WRAP.

144,175

TOTAL READERSHIP

Based on ANMJ 2014 member survey pass on rate Circulation: 98,750 BCA audit, September 2015

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EDITORIAL

Editorial Lee Thomas, ANMF Federal Secretary With the dawn of another year our batteries are recharged and, with plenty of gusto, we are ready to take on the challenges 2016 will bring.

THE ANMF STRONGLY BELIEVES IT IS A BASIC RIGHT THAT ALL WORKERS BE FINANCIALLY COMPENSATED FOR THE UNSOCIABLE SHIFTS THAT THEY DO.

Yet just like a bad New Year’s hangover, many of the remnant issues we faced in 2015 will continue to plague us in the year ahead. As in 2015, the degradation of Medicare, health and our aged care system remains a high priority on the political agenda, as does the attack on penalty rates in the retail and hospitality sectors. This was made clearly evident in the days leading up to Christmas when the government announced yet another measure to attack the affordability of essential healthcare. The attack was made during December’s Mid-Year Economic and Fiscal Outlook (MYEFO), which comprised of $650 million in cuts from bulk billing incentive payments for essential pathology services and diagnostic procedures. This included pap smears, MRI’s, urine/blood tests, STI checks, x-rays and ultrasounds. The government argued the cuts marked the end of a five year agreement to pay incentive payments directly to pathology services, and would not affect Medicare rebates. Yet there is great concern these costs will now inevitably be passed on to patients, many of whom can least afford it, anyway. Further to these measures, our already precarious aged care sector suffered another blow with the government planning to strip $1 billion over four years from aged care and health workforce funding. This includes the axing of two aged care education and training programs and comes just six months after cuts were made to the workforce development fund. Needless to say these measures will add further pressure on attracting, retaining and adequately training nurses and Personal Care Assistants (PCAs) into the sector.

@AustralianNursingandMidwiferyFederation

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@anmfbetterhands

In addition to this, $472 million was slashed from the Aged Care Funding Instrument, which is used to pay subsidies to residential aged care services. While the government said these cuts would better ‘align services’, there is real risk the financial costs will shift to aged care service providers and residents instead. Still on the table from 2015 are the government’s plans to remove penalty rates from the hospitality and retail sectors. While nurses and midwives may not be directly affected as yet, there are real concerns the professions will be next in the firing line. The ANMF strongly believes it is a basic right that all workers be financially compensated for the unsociable shifts that they do. Another significant issue the ANMF is set on addressing is the lack of employment opportunities for graduate nurses and midwives nationally. Plainly, our next generation of nurses and midwives are the future of healthcare so it is essential that we find them jobs now. Discussions we have already held with key stakeholders have resulted in some progress in tackling this issue. More roundtable discussions are due early this year through which we plan to significantly improve the job prospects for graduates furthermore. This month’s feature gives an indepth account about this matter, the impact it is having on graduates and what is being done to increase opportunities for employment. These are just some of the issues we will continue to fight the government on. We are under no illusions that we will have a battle on our hands but together, as always, our determination to protect the rights of patients and the professions alike, will ensure that we will make a difference to the welfare of all Australians. Rest assured our voice will be heard. Watch this space!

www.anmf.org.au

February 2016 Volume 23, No. 7 3

2016 PRIORITIES

A new year a new promise: ANMF’s 2016 priorities Staring down the barrel of cuts and unrelenting compromises to Australia’s healthcare the Australian Nursing and Midwifery Federation (ANMF) has determined its priorities for 2016 to fight for an equitable system for the professions and all Australians. Late last year a further $2.1 billion in cuts to health and aged care were announced. The slashing of Medicare rebates for pathology and imaging as well as funding cuts ripped out of an already vulnerable aged care system, were widely condemned by the sector. The cuts have set the tone for 2016 and have only strengthened the resolve of the ANMF, Australia’s largest union, to protect Australia’s public health system. ANMF Federal Secretary Lee Thomas said the last two years had been extremely tough, with the federal government slashing billions of dollars from states and territories’ health and aged care budgets, Medicare threatened with privatisation, and direct attacks on our penalty rates. “But the ANMF has come together and fought hard. We need to keep the pressure on the new Prime Minister Malcolm Turnbull to ensure his government stops the industrial attacks on nurses and midwives and the assault on our health system.” The ANMF National Biennial conference held last October laid the foundation for the federation’s agenda for the next two years across the health, aged care, industrial and political arenas. Penalty rates, aged care and maintaining Australia’s universal public health system are at the core.

Penalty rates The ANMF is fighting to preserve its members’ penalty rates and allowances with a review from the Productivity Commission (PC) into Workplace Relations. Serious concerns surround recommendations, including the cutting of penalty rates in the retail and hospitality sector. “The penalty rates of retail and hospitality workers have been singled out this time round and there is no guarantee from the government that nurses and midwives won’t be next,” ANMF Federal Secretary Lee Thomas said. The ANMF has urged the government to rule out wage cuts to millions of workers, including aged care nurses and assistants in nursing. Penalty rates and shift loadings make up to 40% of a registered nurse or midwife’s remuneration. Nurses and midwives working in the public sector could expect a pay cut of 2% or $1,921 a year if Sunday penalty rates were reduced to the level of Saturday penalty rates as proposed by the ANMF VIC BRANCH MEMBERS FIGHT FOR PENALTY RATES

PC for the retail and hospitality sector (The McKell Institute, 2015). “Penalty rates and other allowances are critical to our members – and they’ll fight to save them,” Ms Thomas said. A survey conducted by the ANMF last year of more than 13,000 Australian nurses and midwives showed an overwhelming 93% prepared to take action to protect their penalty rates: 60% said this would include stop work or strike action. More than nine in 10 respondents currently worked shifts outside of regular Monday to Friday day shifts. Nine in 10 reported that shift work affected their life outside work - particularly night and weekend shifts. An alarming 87% of those surveyed indicated they would stop working shift work if penalty rates were removed or lowered. Any loss of penalty rates or allowances could lead to a significant number of nurses, midwives and assistants in nursing no longer signing up for shift work, Ms Thomas said. “Undoubtedly, this would have serious ramifications on the amount of quality care they can deliver to Australians at all hours of the day and night. “As part of the government’s new

ANMF VIC BRANCH MEMBERS FIGHT FOR PENALTY RATES

agenda, we need a progressive and cooperative IR system which assists in recruiting and retaining a sustainable health and aged care workforce, now and into the future.”

“WE SACRIFICE PUBLIC HOLIDAYS AND WEEKENDS AND A LOT OF FAMILY TIME. IRRESPECTIVE OF WHETHER YOU ARE A NURSE, PARAMEDIC, FIREFIGHTER OR WORK IN HOSPITALITY YOU SHOULD BE PAID PENALTY RATES.” David Lewis, QLD

4 February 2016 Volume 23, No. 7

anmf.org.au

2016 PRIORITIES

Aged care A Senate Inquiry into the aged care workforce was announced late last year. The Inquiry will examine future aged care workforce requirements and the challenges in attracting and retaining aged care workers. It will also look at particular challenges in regional towns and remote communities. Factors vital to aged care workers and central to the ANMF’s campaign in aged care including remuneration, working environment, staffing ratios, education and training, skills development and career paths are part of the Inquiry’s brief due to report by 30 June. It will also assess the impact of the government’s cuts to the Aged Care Workforce Fund. More than $40 million has been ripped from the fund in aged care workforce development, scholarships and training. The development of a sustainable workforce strategy, including wages

and training must be the number one priority in aged care, ANMF Assistant Federal Secretary Annie Butler said. “The increasing complexity of the conditions of ageing we see today requires sophisticated health management.” Australian Institute of Health and Welfare figures last September show the increasing care needs of aged care residents - with 83% of people in permanent care needing high level care; compared to 76% in 2008. More than half (52%) of all people in permanent care had dementia. “The government must recognise that these needs demand a suitably skilled and qualified workforce,” Ms Butler said. “This means providing proper investment in aged care, most critically proper staffing.” The ANMF would continue to fight for mandated staffing levels in aged care, Ms Butler said. “With a rapidly ageing population, it is crucial that we have enough qualified nurses working in aged care, because the lack of mandated staffing levels is currently putting patients at risk.”

DELEGATES AT THE ANMF’S NATIONAL BIENNIAL CONFERENCE 2015

“IT IS UNCONSCIONABLE FOR US THAT WE AS A NATION CANNOT LOOK AFTER OUR FRAIL OLDER PEOPLE IN THEIR SENIOR YEARS; THEY ARE THE BACKBONE OF THIS COUNTRY. EVERYONE IN AGED CARE DESERVES DIGNITY AND RESPECT. WE WILL BE JUDGED BY THAT AS A NATION AND WE FALL SHORT.” Debbie Lang, NSW

ABOVE: NSW 24/7 CAMPAIGN BELOW: NSW DELEGATES AT THE ANMF’S NATIONAL BIENNIAL CONFERENCE 2015

NSW 24/7 campaign In a win for nurses and aged care, a NSW Upper House Inquiry last October recommended enforcing registered nurses in all residential aged care facilities with people with high level care needs. It followed evidence given by nurses and the NSW Nurses and Midwives’ Association (NSWNMA) and the union’s high profile 24/7 campaign. The Legislative Council Committee report confirmed RNs were pivotal to the skill mix of staffing in residential aged care facilities, particularly sites with high and complex care residents. It also recommended addressing discrepancies between NSW and Commonwealth laws. “The Committee has recognised the need for minimum staffing ratios to be established and recommends the NSW government urge the Commonwealth to adopt ratios throughout the aged care sector,” NSWNMA General Secretary Brett Holmes said. The NSWNMA also welcomed the recommendation for COAG to address the wage disparity between RNs in aged care and those in the public health system. The NSW Minister for Health was due to make a final decision on the report late last year. anmf.org.au

February 2016 Volume 23, No. 7 5

2016 PRIORITIES

ANMF FEDERAL PRESIDENT SALLY-ANNE JONES, SECRETARY LEE THOMAS, ASSISTANT SECRETARY ANNIE BUTLER & VICE PRESIDENT MAREE BURGESS

Healthcare cuts The ANMF is calling on the government to restore the billions slashed from the public health system. Evidence given to the Senate Select Committee on Health has shown how funding cuts are impacting the quantity and quality of care being delivered to hospitals across the country. The $50 billion torn from the Australian healthcare system in last year’s budget is the equivalent of sacking one in five nurses and shutting one in 13 hospital beds. ANMF Assistant Federal Secretary Annie Butler said states and territories had really suffered with the withdrawal of the National Partnership Agreement. “Fifty per cent of funding from the Commonwealth for growth in hospital costs has been cut. States and territories have lost billions of dollars in varying proportions. “The government cannot expect to slash billions from the states and territories’ health budgets without seeing dramatic repercussions, such as fewer hospital beds and longer surgery waiting times.” In South Australia, $650 million has been cut by the federal liberal party since 2014 - the equivalent of 600 hospital beds and sacking of 3,000 nurses and midwives. Queensland has been under attack from both federal and state liberal national which admitted to cutting 5,000 hospital 6 February 2016 Volume 23, No. 7

and health service jobs, including 1,800 nurses and midwives. The Tasmanian government announced only mid-December that 80 full time equivalent jobs in the health service were to go through voluntary redundancy. Under the current trajectory, NSW is set to lose $16.5 billion over the next decade as a result of cuts to the previous hospital funding agreement. “The delivery of safe patient care cannot be guaranteed if vital health and hospital funding continues to be slashed by governments,” NSW Nurses and Midwives’ Association (NSWNMA, ANMF NSW Branch) General Secretary Brett Holmes said. The federal government is currently undertaking broad-ranging reforms to Medicare, including a review of all 5,700 items on the Medicare Benefits Schedule. ANMF Federal Secretary Lee Thomas said what was needed was genuine structural reform as has been proposed by health groups, rather than quibbling about funding for Medicare. “Medicare is an extremely efficient means of funding healthcare and continues to serve people in urban locations very well, however inequities do exist in access and outcomes for those disadvantaged and those in rural and remote areas.” The government’s attacks on Medicare had been bad policy and did not have the support of the Australian people, Ms Thomas said. “Any policies that lead to more out of pocket costs that hurt more and more Australians will eventually result

TOP: QLD DELEGATES AT ANMF’S NATIONAL BIENNIAL CONFERENCE 2015, ABOVE: ANMF VIC BRANCH MEMBERS

in the erosion of our universal healthcare system as we know it. “We need to work together to protect Medicare and the future sustainability of Australia’s universal healthcare system. Medicare must not be undermined or dismantled.” Reference The McKell Institute. 2015. The Importance of Penalty Rates for Our Health Workforce: the economic & health impacts of cutting penalty rates.

“IF THE LIBERAL PARTY GET BACK IN, ANYTHING WE WANT IN AGED CARE, OUR PENALTY RATES AND ADDRESSING CLIMATE CHANGE WILL BE IN JEOPARDY. THE UNION AND NURSES ARE VERY CONCERNED ABOUT FELLOW AUSTRALIANS ON LOW INCOMES.” Katy Taggart, QLD

anmf.org.au

2016 PRIORITIES The ANMF has been tasked with action on resolutions debated and passed by members at the union’s National Biennial Conference last October. Six key areas were covered: professional; industrial; aged care; workforce; social justice; and political.

“UNI TASMANIA PROVIDES MORE AND MORE GRADS THAN THE GOVERNMENT HAS JOBS FOR. THEY ARE ONLY OFFERED 12 MONTH CONTRACTS. WE LOSE OUR GRADS TO THE MAINLAND. ONCE WE LOSE THEM TO THE MAINLAND WE NEVER GET THEM BACK.” “WE WORK AN INCREDIBLE AMOUNT OF DOUBLE SHIFTS. THERE ARE ROSTER GAPS, TOO MANY VACANCIES ON THE ROSTER WITH NOT ENOUGH STAFF EMPLOYED. IT’S AN ONGOING ISSUE.” Kim Ford, TAS

“ACROSS THE WORLD THE DEATH PENALTY IS USED NOT EQUITABLY. IT DOES NOT DETER PEOPLE FROM CRIME. IT IS APPLIED AT RANDOM. THE MENTALLY ILL ARE BEING EXECUTED. GIVEN CAPITAL PUNISHMENT IS IRREVERSIBLE AND MISCARRIAGES OF JUSTICE ARE PROVEN IN SOME CASES, THE DEATH PENALTY SHOULD BE ABOLISHED WORLDWIDE.”

James Lloyd, TAS

“DESPITE THE PUSH FOR BETTER WAGES, IT TENDS TO BE WOMEN WHO TAKE TIME OFF FOR FAMILY AND CHILDREN NOT MEN. WE NEED THE GOVERNMENT TO SUPPORT LOW INCOME FAMILIES IN AUSTRALIA.” Phillip Jackson, QLD

Jodi Knopp, SA

“LAST YEAR WE ENDURED THE HOTTEST 12 MONTHS ON RECORD, BREAKING MORE THAN 120 HEAT RECORDS ACROSS THE COUNTRY. WE KNOW THE PLANET IS WARMING AND WE ARE SEEING THE HEALTH IMPACTS. THE STATISTICS SHOW INCREASING RESPIRATORY ISSUES AND A NUMBER OF DEATHS OF PEOPLE IN TIMES OF HEAT. IT’S NOT JUST HAPPENING IN AUSTRALIA BUT INTERNATIONALLY. WE NEED TO PUT IT BACK ON THE AGENDA.” Marisa Bell, SA

anmf.org.au

“THE MAIN ISSUE IS WORKLOAD - WE HAVE A REAL ISSUE WITH BURNOUT OF NURSES. IF YOU HAVE 10 PATIENTS INSTEAD OF FIVE, IT’S A DIFFERENCE IN A DAY’S WORK. THE STRESS IN NOT PROVIDING CARE YOU ARE TRYING TO PROVIDE WHEN YOU ARE SPREAD SO THIN. WE HAVE ONLY ONE MAJOR HOSPITAL IN DARWIN, THERE IS NO BYPASS WE HAVE TO MAKE SPACE EVEN IF WE’RE FULL.” Shirel Nomoa, NT

February 2016 Volume 23, No. 7 7

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NEWS

Study draws attention to missed patient care

Deteriorating patients, unexpected surges in patient numbers, and intense admission and discharge activity top the leading reasons behind Victorian nurses and midwives missing care, a new survey has found. The study, conducted by Flinders University in Adelaide, was released last December and adds to previous investigations into missed care trends in New South Wales, South Australia, and New Zealand. Missed care was defined as required patient care that is omitted or delayed due to multiple demands and inadequate resources. The latest instalment of the survey received responses from 1,683 nurses, midwives, personal care workers (PCW) and Assistants in Nursing (AIN) working in public and private health facilities across Victoria. The study found nursing care tasks most often missed included assisting ambulation three times per day as ordered, skin and wound care, oral hygiene, and providing patient education about illness, tests and results. It also found missed care in Victoria was at its highest during morning shifts and more prevalent within rural hospitals.

Pathology and diagnostic cuts spark national debate Proposed federal government plans to slash bulk billing incentives for pathology services and diagnostic procedures have ignited sweeping debate across the country as opposing sides clash over whether the changes will send costs soaring. The plans, set to begin from 1July this year, were revealed in the government’s Mid-Year Economic and Fiscal Outlook (MYEFO) released last December. The changes will trigger a $650 million cut from bulk-billing incentives under Medicare for pathology and diagnostic imaging, impacting a range of procedures including Pap smears, blood and urine tests, x-rays, and ultrasounds. Last month, discussion surrounding the plans had escalated to the point of prompting widespread backlash, with many fearing the cuts would lead to the pathology sector making patients pay for services which had historically been free. Opposition Health spokeswoman Catherine King slammed the proposed plans, describing the cutbacks as alarming and forecasting an inevitable anmf.org.au

Interestingly, 34% of nurses and midwives surveyed said they worked two to three shifts over the past three months despite being sick or injured, with 32% stating they felt an obligation to their colleagues to go to work. The study succinctly compared Victorian results with SA, NSW, and New Zealand studies. For example, Victorian nurses cited greater issues with teamwork and communication than other jurisdictions. When comparing Victoria and New South Wales, the study highlighted that unlike NSW, certain missed episodes of care occurring in Victoria, such as assisting with toileting or monitoring fluids, tended to pervade and extend throughout the day’s three shifts rather than fluctuate. “This pattern does suggest that the elements of Victorian care are not just missed by one shift of staff, but extend for much longer periods, suggesting that some aspects of care are not given at all,” the report said Further, New South Wales and South Australian respondents listed workload unpredictability and resource issues as major contributors to missed care, whereas Victorian nurses and midwives believed lack of teamwork was a greater trigger. The Missed Care study has also been undertaken in Tasmania and Queensland, with results expected shortly. blow to women’s health. She claimed cuts to bulk-billing incentives would hurt patients by forcing those with critical health conditions to either pay more or worryingly, skip vital scans and tests Australian Nursing and Midwifery Federation (ANMF) Federal Secretary Lee Thomas said the ANMF was extremely concerned about the impact the changes would have, particularly on Australian women if they are forced to pay increased fees for critical preventative cancer checks, like Pap smears. “Most concerning is that these increased fees could result in patients deferring or declining essential, and in some cases such as Pap smears, life-saving tests.” Ms Thomas said about 800 women were diagnosed with cervical cancer each year. Health Minister Sussan Ley said suggestions that patients would pay more, were “misleading”. “There are no changes proposed in MYEFO regarding the cost of either receiving or delivering a physical Pap smear examination undertaken by your GP or specialist, nor their billing practices,” Ms Ley said in a statement. “Nor is there any reduction in the dollar-value of the Medicare rebate a patient receives to undertake associated pathology tests. “Alleged claims by pathologists

Valentines competition We nurses We midwives …..and we know you do too. To celebrate Valentine’s day this month nominate a colleague with the biggest heart. Tell us why in 25 words or less and both you and your colleague could win a dvd box set each. Email for your chance to win at valentinesday@anmf.org.au Entries close 29 February 2016

about the potential cost of raising their prices as a result of any changes are also misleading, because they have omitted the value of the Medicare rebate a patient receives from the government to help cover this very cost.” However Minister Ley did concede in a recent media interview that some patients “may be worse off”. The ANMF is calling on Health Minister Sussan Ley to come clean on exactly what these cuts would mean for women requiring their vital Pap smear screenings. Other consumer groups also remain sceptical and believe patients will almost certainly end up absorbing the cuts by paying more. An online petition started in early January to fight the cuts and protect basic healthcare services attracted almost 150,000 signatures in its first 36 hours. Titled Keep Pap smears and pathology services free! the petition directly squares off against the government. The importance and concern regarding the issue has been further underscored by rallies to be held around the country in all major cities on 20 February. To sign the petition go to: www.change.org/p/health-ministersusan-ley-keep-pap-smears-andpathology-services-free February 2016 Volume 23, No. 7 9

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NEWS

Queensland cements mandated nurse-to-patient ratios in law Queensland has followed in the footsteps of Victoria to become the second state in the country and just fifth worldwide to introduce mandated nurse-to-patient ratios legislation across its public hospitals.

The landmark changes, to be introduced in stages across Queensland from 1 July, signal a new era focused on better patient care and safer workloads for nurses. It is anticipated that around 250 additional nurses will need to be

New resuscitation guidelines released The Australian and New Zealand Committee on Resuscitation (ANZCOR) has released new resuscitation guidelines backed by both the Australian and New Zealand resuscitation Councils. Of some 75 existing guidelines, 47 have been replaced by the latest ANZCOR guidelines released last month. The new guidelines draw on findings outlined within the international consensus statements on resuscitation that were released last October. The recommended approach to basic life support remains the same and ANZCOR reinforces managing emergencies using a DRS ABCD approach, administering CPR using a compression to rescue breath ratio of 30:2, and early defibrillation. The only change to CPR surrounds the rate at which chest compression is delivered. Normally 100 compressions per anmf.org.au

recruited to meet the increased ratios. Under the legislation and regulation, hospitals will be required to maintain a minimum of one nurse to four patients for morning and afternoon shifts, and one nurse to seven patients for night shifts. The government will review the changes once they have been in operation for a year and then consider whether the ratios should be extended to other wards and facilities or modified. The Queensland Nurses’ Union (QNU, ANMF Queensland Branch) has long campaigned for safe workloads and skill mix in hospitals. “Queensland’s nurses and midwives campaigned vigorously with the QNU to gain a commitment to ratios,” QNU Secretary Beth Mohle (pictured) said. “The introduction of minimum nurse ratios will save lives in Queensland, it’s that simple.” The ratios legislation will apply across dozens of Queensland’s public hospitals including Atherton, Bundaberg, Caloundra, Gold Cost University, Hervey Bay, and Redcliffe. minute, the new guidelines stipulate a range from 100-120 compressions per minute. Rescuers are reminded to push hard, aiming for one-third the depth of the chest with each compression. Notable changes to First-Aid and prehospital care involve removing the need for semi-rigid cervical collars where a spinal injury is suspected, as managing the airway is viewed as a higher priority in life-threatening situations where resuscitation is needed. Rescuers are nevertheless encouraged to care for a suspected spinal injury by manually supporting the person’s head. The new guidelines also contain some recommendations for resuscitation in advanced care settings, namely to do with specific treatment options and medicines and equipment used. ANZCOR acknowledges it may take healthcare providers time to adjust to the new guidelines and stresses that the new recommendations are part of natural progress rather than a correction of poor practice. ANZCOR guidelines can be found at www.resus.org.au

Report highlights preventable hospitalisations Patients suffering from a cluster of five conditions account for the majority of potentially preventable hospital admissions, a new report by the National Health Performance Authority (NHPA) has found. The report, Healthy Communities: Potentially preventable hospitalisations in 2013-14 reveals almost half (47%) of potentially preventable hospital visits and close to two-thirds (62%) of bed days were caused by diabetes complications, heart failure, kidney and urinary tract infections, cellulitis, and chronic obstructive pulmonary disease. The report states that in 201314, more than 600,000 hospitalisations across Australia, or 6% of the 9.7 million total hospitalisations, were potentially preventable. It also highlights that older people, those from regional and remote areas, and people of lower socioeconomic status cause the highest rate of potentially preventable hospitalisations. Australian Healthcare and Hospitals Association Chief Executive Alison Verhoeven said the report illustrates clear justification for improved health delivery. “These figures show both the importance of primary care in easing the burden on our hospital system, and the opportunity for primary health networks to identify and respond to regional need by commissioning well-targeted health services, Ms Verhoeven said. “Better care coordination at a regional level, supported by appropriate funding mechanisms and greater patient engagement could assist in managing chronic conditions such as heart failure and diabetes, and lowering the rate of potentially preventable hospitalisations in Australia.” February 2016 Volume 23, No. 7 11

Allergy Update Day This program will provide an update on the management of a variety of allergic diseases with an insight into recent advances. Topics include managing aeroallergy, food & drug allergy, childhood allergy & anaphylaxis & management. 15 March

NEWS

Integrated domestic violence service spared A domestic violence service available to child and maternal health nurses has been given a lifeline with the federal government’s million dollar funding injection into the sector.

Asthma Educator’s Course Covering the latest advances in asthma care the course will provides participants with the knowledge & skills to work effectively with people with asthma to improve their health outcomes. 16 – 18 March 20 – 22 July 16 – 18 November

Respiratory Course This 5 day, two part, course is for participants wanting to update & increase their skills & theoretical knowledge in the area of respiratory care & holistic management of the person with respiratory illness. 29 February – 2 March / 3 – 4 March 13 – 15 July / 17 – 18 August

Theory & Practice of Non Invasive Ventilation (NIV) Bi-Level & CPAP Management This comprehensive, practical course is for participants wanting an increased understanding of & skills in the management of NIV, Bi-level & CPAP from ICU to the community carer. 3 June

Managing COPD This program is for participants wanting to improve their understanding of & update their knowledge in the current treatment & management of COPD. 25 – 26 February 14 – 15 April 6 – 7 October

Smoking Cessation This evidence-based course aims to give participants the knowledge & skills to treat & manage nicotine dependency to help people addicted to smoking to quit. 10 – 11 March 28 – 29 July 24 – 25 November For further information about these courses contact the: Lung Health Promotion Centre at The Alfred Phone: (03) 9076 2382 E: lunghealth@alfred.org.au www.lunghealth.org

DONNA ASKEW AND BELINDA LO

The Eastern Community Legal Centre’s (ECLC) Health Justice Partnership integrates lawyers and domestic violence advocates with maternal and child health nurses (MCHN). The centre lost 20% of its funding before the federal government’s announcement in September of $100 million for domestic violence prevention services. While the details hadn’t been “fleshed out yet”, the ECLC secured funding under the new package over three years, ECLC’s Project Manager Donna Askew said. “We were looking at closing down an office - eight months later and look where we are at now.” The clinic opened in June 2015 and had seen more than 60 referrals for domestic violence to October. “We were absolutely surprised by that number,” Ms Askew said. “The numbers are high for any new legal project.” The ECLC is based in the Broader East Metro Region with two lawyers, two domestic violence advocates, a project manager and project coordinator that work with nurses employed by two councils. “The key feature is that there are three professionals that offer healthcare, legal advice and development of a safety plan,” Ms Askew said. “I think the health-justice partnership program is different in that we have a lawyer and domestic violence advocate co-located in the community setting on site. When nurses have identified behaviour that may constitute domestic violence they refer on site.” About 36% of women experienced domestic violence during pregnancy; with 17% during their first pregnancy, Ms Askew said. “With that in our minds if it’s the first time of controlling 12 February 2016 Volume 23, No. 7

behaviours, nurses need to identify for early intervention and provide advice before there is escalation of violence on a physical level.” Women may disclose or nurses may detect something, ECLC Principal Lawyer Belinda Lo said. “A woman may say ‘I had to ask for the car to come to this appointment.’ It may alert nurses just to ask a few more questions. Nurses are really skilled at picking up; they are intimate with these women who have just had their babies.” The ECLC’s project started in January and opened in June. “We have had the benefit of trust and capacity building and understanding of each other’s roles and professional obligations and also respecting boundaries – that is so important for this to work. We gently support a woman from one professional to the next,” Ms Askew said. It takes up to eight times for a woman to leave a relationship, Ms Lo said. “In so many situations women will not act straight away. They may not come back for a year.” “Women are the best judges of their own safety,” Ms Askew said. “That women elected to come see us shows they exercise some empowerment already.” “If people are informed, they have options and hopefully feel supported in whatever choices they do make,” Ms Lo said. Under the new funding package, the health-justice partnership model would continue with a lawyer; social worker/ advocate/counsellor and a cultural liaison role, Ms Askew said. “Our aim for the health-justice partnership is for best practice in the early parenting and childhood setting working with nurses.” anmf.org.au

NEWS

Nurses urged to speak out on problems in aged care The Australian Nursing and Midwifery Federation (ANMF) is calling on nurses to share their experiences within the troubled aged care sector by making personal submissions to an upcoming Parliamentary Inquiry set to examine the future delivery of the workforce. The Community Affairs References Committee is seeking input from individuals and organisations as it undertakes the Inquiry, Future of Australia’s aged care sector workforce, with the submission period closing 4 March. The Inquiry will consider several key issues, including the current structure of the aged care workforce, its future requirements, and ongoing challenges in attracting and retaining staff. It will also explore factors impacting aged care workers such as low pay, working environment, and career pathways. The ANMF has been a long-time advocate for improved quality in aged care and continues to lobby for mandated staffing levels, the increased scrutiny of aged care facilities, and meaningful national leadership and investment

Aged Care Complaints Commissioner assumes control The federal watchdog charged with resolving thousands of complaints each year against Commonwealth funded residential or home-based aged care services has been granted new responsibility and full independence to operate the scheme moving forward. The existing complaints service has been in place for several years and was controlled by the Department of Health until an official transfer of powers to an improved independent statutory office in January. Australia’s Aged Care Complaints Commissioner, Ms Rae Lamb (pictured) welcomed the service’s newfound scope, describing her previous influence as “limiting” while acknowledging an underlying consumer concern regarding true independence. “It’s very exciting because it means I’ll have a much greater ability to be involved in ensuring that people receive good quality care,” she said. “Before, I was very much looking at how complaints are handled, and now I’ll be looking at more of the actual issues, what the complaints are about, and how we’re responding to anmf.org.au

to ensure residents, staff, and family members can have faith in the system. The ANMF will be filing a comprehensive submission to the Inquiry and appear before hearings. The union is imploring nurses to do the same in a bid to provide a collective insight that exposes the true state of the sector and its shortcomings. Debate surrounding the aged care sector escalated in the past year on the back of several issues but perhaps none more crucial than a NSW Parliamentary Inquiry to determine whether current laws requiring at least one registered nurse be on duty at all times across the state’s high care nursing homes should be retained. The subsequent report tabled by the Legislative Council Committee backed the retention of the law, as well as the need to address the wage disparity between registered nurses in aged care and their

counterparts in the public health system. The report’s 17 recommendations are still being considered by the NSW government. Adding to the sectors woes, dramatic cuts to aged care were announced by the federal government as part of its Mid-Year Economic and Fiscal Outlook (MYEFO) at the end of 2015. About $472.4 million over four years will be ripped from aged care services through changes to the Aged Care Instrument, while aged care training education and training initiatives were also hacked. In the same vein, several reports were released last month painting a disturbing picture of the sector. A Department of Health report revealed assaults at Australia’s aged care services increased by more than 10% to 2,625 in the past year, while the latest annual survey of aged care homes conducted by Bentleys Chartered Accountants found profits of facilities rose 40% in the past year. The ANMF believes the future of the aged care sector has reached a critical juncture and now depends on joining together and finding a voice that demands dignity in aged care for all. To make a submission to the Inquiry visit http://www. aph.gov.au/Parliamentary_Business/ Committees/Senate/Community_Affairs/ Aged_Care_Workforce

those concerns.” She said her key priorities surround boosting consumer confidence concerning the service’s independence, and implementing a nationally consistent response so Australians can expect a similar level of care regardless of where they live. Last year, the service dealt with 3,700 complaints, with typical issues drawing attention to care, medication management, falls, and nutrition. Ms Lamb said one of her ongoing aims was to create a culture where complaints were encouraged. “Complaints are a really important part of the quality improvement framework. Sometimes it’s overlooked and complaints get treated as a bad thing out there and are not seen as a valuable opportunity to identify things that you can do to improve your care.” She added that while complaints are tough to make and can leave people feeling exposed and vulnerable, the service offers complete confidentiality. “Try to see complaints as a good thing. I know that it can be really hard having a complaint potentially against you. But it’s important to recognise that they do expose opportunity to improve care. Along with having ultimate ruling on the nation’s complaints system, Ms Lamb has also been issued a formal education function where she will work

collaboratively with service providers and encourage them to own up to, apologise, and address any sub-standard care. Ms Lamb admitted the aged care sector was at an incredibly important juncture in its lifespan but was reluctant to voice any broader views. “I have to be very careful about jumping to any conclusions about the standard of care based on what I see because it’s a tiny window and it tends to be only the times when things have gone wrong that it comes to my attention.” Any person can make a complaint to the commissioner, including care recipients, family members, friends, staff, and volunteers The 1800 550 552 helpline is staffed 9am to 5pm Monday to Friday or visit www.agedcarecomplaints.gov.au February 2016 Volume 23, No. 7 13

SUPER

Superannuation reform aiming to rebalance bias against women By Robert Fedele When it comes to superannuation, there is little doubt women face greater obstacles than men in accumulating enough money to live off in old age. Additionally, women are more likely to face significant economic hardship given a problematic gender pay gap coupled with periods of workforce disruption raising children. In a positive move, a proposed overhaul of superannuation policy is now underway in a bid to help make the system fairer for women. An Inquiry into economic security for women in retirement commenced late last year, with public hearings held in Adelaide and Sydney. Several key stakeholders, including the Australian Nursing and Midwifery Federation (ANMF), made submissions to the Inquiry and appeared at hearings before the Senate Economics Committee. The ANMF backed key recommendations put forward by the Queensland Nurses Union (QNU ANMF Queensland Branch) and superannuation fund HESTA, which manages the income of thousands of nurses across the country. HESTA’s three chief recommendations involved protecting low-income superannuation contribution measures, removing the current $450 threshold that impedes employees who make under $450 per month by not paying them super, and highlighting the value of unpaid caring roles at the time they are performed. ANMF Federal Secretary Lee Thomas said the flaws in the system must be addressed. “Almost half the population of nurses and midwives currently works part time. That is less than 35 hours per week, with a significant proportion of our members taking time out of the paid workforce to care for children during their careers. “These breaks and the need to continue to work part time for a number of years while caring for their young families means 14 February 2016 Volume 23, No. 7

that our members are significantly disadvantaged by the current structural arrangements for superannuation.” During the hearings the ANMF provided feedback, detailing the union’s recommended model for a fairer distribution of superannuation tax concessions, strategies and policy directions that could achieve savings within the health system. The ANMF believes Industry Super Australia’s submission to the Inquiry is the most appropriate model to rebalance superannuation tax concessions. HESTA’s General Manager Business Development Mary Delahunty, commended the ideal of the Inquiry and longoverdue focus on debate and reform. “I’ve got a genuine belief that there’s momentum behind this at the moment and I think we will see some change.” She said HESTA’s concern partly stems from a recent strategic plan outlining an obligation for greater advocacy work on behalf of its members. Ms Delahunty is particularly invested in the superannuation struggle of women and recently completed a study investigating international retirement systems in countries such as Denmark, Belgium, France, and Chile,as part of a Churchill Fellowship. An objective of the study analysed noteworthy retirement systems and dissecting what campaigns may had led to fairer gender equity provisions. Somewhat unexpectedly, Ms Delahunty found many countries, unlike Australia, viewed

recompenses for women taking time out of the workforce a priority so as to prevent poverty in retirement. “The greatest lesson I learnt was that pretty much every system has recognised the structural deficiency of people taking time out of the workforce and dealt with it on a policy level. When I sought to understand what campaigns had led to that I realised that it came down to fairness.” Ms Delahunty spent the most time in Chile, which has a system closely aligned with Australia’s own superannuation model. She said Chile uses a bond system whereby people taking time out of the workforce are compensated at the time it’s taken. “There are a number of other measures but we think having some sort of bond system, replicating that South American model, actually values the caring role in a way that’s important for a government to do.” Ms Delahunty concedes sweeping changes to superannuation policy though will not alleviate the risk of poverty in retirement that many older workers face. The average HESTA member is around 43 years old and has only $16,000 in superannuation, she said. The current Inquiry is more about laying foundations for the future and safeguarding the next generation, said Ms Delahunty, adding closing the gender pay gap was also pivotal. “The disappointing thing is that we will always be behind our male counterparts doing exactly the same job unless there is political and social will to improve the gender pay gap.”

HESTA’S GENERAL MANAGER BUSINESS DEVELOPMENT MARY DELAHUNTY

anmf.org.au

INDUSTRIAL

The Australian Parliament to examine long service leave

• Nurses, midwives and assistants

Nick Blake, Senior Federal Industrial Officer

Nick Blake

In December 2015 the Australian Senate called for submissions on proposals that would allow all employees to maintain their long service leave entitlements when they transferred between jobs or took breaks in employment. The ANMF has provided our views on these issues and our submission can be read in full here: www.anmf. org.au/documents/submissions/ ANMF_Submission_to_Senate_ Inquiry_Long_Service_Leave.pdf At present the measures for the accrual and taking of long service leave entitlements are a bit of a dog’s breakfast. There is presently a significant degree of variation between different states and territories in terms of the accrual of long service leave. The minimum length of service required to activate the entitlement to accrue and take long service leave ranges from seven years in the Australian Capital Territory to 15 years in Tasmania. In most industries long service leave cannot be transferred on ceasing or changing employment, even where the change involves a transfer within the same industry and locality. In a minority of industries, however, long service leave does transfer with the worker. The source of the entitlement also varies, and can be created by award, industrial agreement or statute. These inconsistencies are confusing and inequitable. In recent times, it has been recognised that employees in some industries suffer adverse consequences in terms of their entitlement to accrue long service leave as a result of qualities specific to the industry in which they work. For example, workers within the building and construction, coal mining and cleaning industries have been protected through the introduction of portable long service leave schemes which allow employees to take their long service leave entitlements when they move from one employer to another. For nurses and midwives there is presently little opportunity to take transfer leave entitlements beyond the public hospital sectors in some states or territories. In its submission ANMF have argued these restrictions deeply disadvantage nurses and midwives

anmf.org.au

and should be remedied. The ideal position for nurses, midwives and assistants in nursing is a flexible, seamless health system in which moving employment between employers can be achieved without losing entitlements or having to ‘cash them out’ when it is not the intention to either cease employment or to take LSL at that point.

IN MOST INDUSTRIES LONG SERVICE LEAVE CANNOT BE TRANSFERRED ON CEASING OR CHANGING EMPLOYMENT, EVEN WHERE THE CHANGE INVOLVES A TRANSFER WITHIN THE SAME INDUSTRY AND LOCALITY. IN A MINORITY OF INDUSTRIES, HOWEVER, LONG SERVICE LEAVE DOES TRANSFER WITH THE WORKER.

ANMF supports the establishment of a portable LSL scheme to cover all nurses, midwives and assistants in nursing across the health industry (broadly defined), including public and private acute health, public and private aged care and the community sector. Our support for such a scheme is based on a range of reasons including that:

•

in nursing are employed in the nursing/health industries for all of their working lives in most cases. It makes sense that long service leave is based on service to the industry, not service to a particular employer. The common funding source of most health providers is either state or Commonwealth funding (and health insurance in the private sector) and it would be relatively easy administratively to establish provided there was sufficient seed funding. It is desirable to ensure that there are minimal barriers to mobility for nursing care staff both within the public sector and between the public sector and the private sectors (including both the for-profit and not-for-profit health and aged care providers). Lack of portability of LSL creates an artificial barrier which acts as a disincentive to move and potential discrimination when nurses do move employment. A significant minority of nurses and midwives are employed in two or more jobs – about 10% of the workforce. Lack of portability affects the ability for nursing care staff to take career breaks, especially to re-skill and up-skill which is becoming increasingly important in the health industry. The lack of true portability disadvantages women in particular, especially those who take a short career break (a) beyond paid and unpaid parental leave provided under industrial instruments, to be the primary carer for a child or children or (b) increasingly, to look after ageing parents.

The ANMF has called on the Parliament to recognise that the changes to employment arrangements for many workers has meant that access to long service leave is becoming a distant goal. Parliament needs to legislate for portable long service leave schemes to protect this important entitlement for all workers and to recognise that long service leave arrangements need to move from being based on service with one employer, to service in an industry or profession, with the accrual and access of entitlements being completely portable. February 2016 Volume 23, No. 7 15

FEATURE

ST VINCENT’S HOSPITAL GRADUATE NURSES L-R TAZ GOODING, TORI BUREK AND NATASHA TABONE. PHOTOGRAPHY: CHRIS HOPKINS

FEATURE

GENERATION

HELPING GRADUATE NURSES AND MIDWIVES FIND JOBS Despite a shortage of 109,000 nurses predicted to hit Australia by 2025, thousands of new graduate nurses and midwives struggle to find employment each year. The resulting bottleneck is locking out the next generation and taking away their right to supportive transition into the workforce. As many graduates ponder their future, Robert Fedele investigates the complex and critical dilemma facing the profession.

essica Westmoreland is all trained up with nowhere to go. After finishing high school she pursued a career in nursing, undertaking a three-year degree at the University of South Australia, and eventually graduating in March, 2015. Regrettably, the 21-year-old currently belongs to a disillusioned cohort of nursing graduates unable to find work. “It’s been a year and a half that I’ve been applying for jobs full on. “I will keep applying for nursing jobs but I am considering going into another field. As much as it’s what I wanted to do, if I knew from the start that this is what was going to happen I wouldn’t have even bothered.” Like many students, Jessica thought landing a job as a nurse would be straightforward given the outlook of a looming workforce shortage on the horizon. But these days her mood has swung to disbelief as she continues to struggle to find a permanent job. As the end of her degree approached in late 2014 Jessica began methodically applying for graduate placements. She applied for a position within SA Health, hoping to snare a spot at one of the state’s public hospitals, but was unsuccessful. She applied anywhere and everywhere, including interstate and in rural and remote anmf.org.au

areas. Again she came up short. An interview with a public hospital in Sydney appeared promising but ended in another knock back due to ‘excessive applicants’.

left home for the first time to follow her dream. But the move quickly turned sour and she soon returned to Adelaide. “It was a full-time contract but once I got over there they only gave me 16 hours and they said for the first two years I’d be a carer and the last year an RN. I was like ‘Well hang on that’s not what you told me when I came over here”, she says. “I couldn’t afford to pay my rent or eat pretty much so I stayed there until I could and just got back home at the start of the year (2015). I’ve been working as a cleaner, kitchenhand, and waitress ever since.”

Walking away LAST YEAR ALONE, JESSICA ESTIMATES SHE APPLIED FOR MORE THAN 300 NURSING JOBS. Last year alone, Jessica estimates she applied for more than 300 nursing jobs. “I just want something. I want to be in theatre eventually but I understand I’m not going to get that straight away. Whether I work up from aged care, I don’t care. I just want to start off as a nurse.” In November last year, Jessica was offered a three-year graduate position at an aged care facility in Melbourne. Packing her bags she

Jessica’s story is not uncommon and supports a rising problem. Latest figures released by Graduate Careers Australia (GCA), which conducts an annual survey examining the fate of graduates four months after the completion of their qualifications, reveal a steady decline over the past decade in the number of nursing graduates who manage to find full-time jobs. In 2007, 97.4% of the nation’s nursing graduates found full-time work four months after graduating. But by 2014 the figure plummeted to just 80.5%. Queensland resident Chantelle, who studied nursing at Griffith University and graduated in December last year, claims just half

THEN

97.4%

IN 2007, 97.4% OF THE NATION’S NURSING GRADUATES FOUND FULL-TIME WORK FOUR MONTHS AFTER GRADUATING

February 2016 Volume 23, No. 7 17

FEATURE

of the 300 students of her intake found jobs. Chantelle was one of the unlucky ones. “I’m freaking out. I live on my own and I don’t have a job now,” she says. “I’ve done heaps of placements that I didn’t like. Staff treated me horribly but I pushed through and finished the degree and now I have nothing to show for it.” Chantelle is keen on securing a role within mental health nursing but has been unsuccessful so far. Last year she begrudgingly turned to agency work, assuming the role of an assistant in nursing at an aged care facility. But she quickly became overwhelmed by the lack of support and quit. “I just didn’t want to do something that I’ll end up hating and will make me not want to do nursing at all. “You’re put on a different area every shift. You don’t know where you’re going to go or who you’re going to meet. Being a grad I have no idea what I’m doing.” Chantelle’s struggles have forced her to reconsider her place in the profession. She now regrets pursuing nursing and says she has “nothing to look forward to”. International student Ranjit Dhillon is another graduate at the crossroads. The 31-year-old mature age 18 February 2016 Volume 23, No. 7

student from India studied nursing at Flinders University in South Australia, graduating in December last year. Ranjit completed placements in general medicine, theatre (OT), and orthopaedics throughout her degree, but says potential employers still grill her credentials. Ranjit, who has applied for permanent residency, spent almost $60,000 to complete her degree. She is currently working as a carer across nursing homes in South Australia and will keep plugging away for a little while longer. “I think I’ll keep going for another six months. But I’m not interested in any other fields or other jobs. I just want to be a nurse.”

Pinpointing problems In late 2014, the Australian Nursing and Midwifery Federation (ANMF) pulled together dozens of nursing and midwifery leaders and key stakeholders for a Roundtable to canvass strategies to help around 3,000 graduates who miss out on jobs each year. Progress lead to the ANMF surveying new graduate nurses and midwives late last year in a bid to gain clearer insight into their employment experience. The information yielded will

provide a platform for debate at a second Roundtable to be held this year in Melbourne. Shedding light on the ‘growing’ problem, ANMF Assistant Federal Secretary Annie Butler blames the workforce bottleneck on a cluster of triggers ranging from budget cuts, the global financial crisis, the impact of migrant labour, poor workforce planning, and an overarching disconnect between governments, universities, and hospitals. The obvious complexity of the issue has helped fuel conflict among key stakeholders regarding the extent of the problem and exactly who is responsible, she adds. “We believe that it’s not just one single thing that is at fault,” Ms Butler says categorically. “There’s a number of factors. Governments come and go. Governments don’t care about the long-term. Governments care about shortterm, politically expedient solutions, by and large.” Ms Butler elaborates, pinpointing an inability to spark dialogue with governments as well as private employers, many whom run very successful graduate programs, as an ongoing barrier to achieving progress. “We’re trying to get employers to tell us how many

TAZ GOODING AND NATASHA TABONE. PHOTOGRAPHY: CHRIS HOPKINS

anmf.org.au

FEATURE graduates they’re taking in 2016, whether they could take more, what is stopping them, and what would help them.” Ms Butler admits the employment of foreign workers under the temporary 457 visa scheme is having an impact on available positions in some areas. “We don’t have a genuine skills shortage. What we have is some employers saying to us that they’re using 457 visa workers because they don’t have the resources to support the new graduates.” She is hopeful the ANMF’s upcoming Roundtable will renew focus and prompt the development of a national framework to tackle the problem. Importantly, Ms Butler says one of the biggest objectives will entail attempting to collate and examine an extensive range of diverse data sets for the first time. “Finding ways of getting as many of the graduates into the workforce right now and keeping them there is critical,” she says. “If we’re not getting these people into employment and educating them we’re going to have this massive shortfall in our skilled workforce.”

The impact of 457 visa workers A Parliamentary Inquiry, launched in June last year, is currently examining the impact of skilled migrant work programs on Australia’s workforce. The ANMF provided an extensive submission to the Inquiry and appeared before a public hearing in Melbourne where it called for changes to the 457 scheme that would safeguard the employment of local graduates. The 457 visa program was devised to engage temporary migrant workers to fill unexpected shortages but the ANMF insists the scheme is being misused by some employers and making it tougher for nursing and midwifery graduates to find a job. “We believe that it’s being taken as a shortcut and that employers see it as a quick fix,” ANMF Assistant Federal Secretary Annie Butler said. ANMF Senior Federal Industrial Officer Nick Blake, who also appeared before last year’s hearing, urged the committee to consider several recommendations to fix the widespread problem. Chiefly, Mr Blake suggested a anmf.org.au

“I THINK I’LL KEEP GOING FOR ANOTHER SIX MONTHS. BUT I’M NOT INTERESTED IN ANY OTHER FIELDS OR OTHER JOBS. I JUST WANT TO BE A NURSE.” Ranjit one-for-one rule, where employers would be required to hire a graduate for every 457 worker they employ. “While the ANMF continues to support migration, our union, along with most nursing and midwifery professionals and regulatory authorities, are increasingly concerned of the negative impact the high numbers of temporary migrant workers are having on the employment opportunities of domestic graduate nurses and midwives.” The committee tabled an interim report to the Senate last October and the Inquiry has now been extended. A public hearing will next take place in Canberra in early February as the issue is further explored.

Budget blues When government dollars get stretched it is invariably the health system which gets hacked first. The outcome results in less beds equalling less places for nurses. With government instability commonplace, it is easy to see how the health fortunes of most states continue to fluctuate. In Tasmania, the landscape has remained in a precarious position since budget cuts in 2011 drastically reduced beds. Today, almost half of the state’s 300 annual graduates struggle to secure a graduate position. Queensland experienced similar hurdles until a change in government last year spurred a revival. The state government has guaranteed funding for 1000 new

graduate positions every year over the next four years under a $111 million plan. The funding intertwines with the government’s promise to legislate nurse-to-patient ratios, set to be carried out in stages from July. The upturn appears promising across the board, with the Sunshine Coast Hospital and Health Service (SCHHS) employing a record number of nursing graduates for 2016 under its Graduate Registered Nurse program. More than 80 new graduates will begin their 12-month program this month and be placed on rotation throughout medical and surgical wards at hospitals including Caloundra and Gympie. As Queensland climbs from the depths, ANMF (Tas Branch) Acting Secretary Caroline Saint proposes her state look at alternatives such as implementing shorter graduate placements so larger numbers can be rolled over. “Many new nurses believe the graduate year is important and should be undertaken – preferably in the acute sector. The private sector as well as the aged care sector have some limited placements for graduate programs. It might be better to have a shorter transition program which would allow a larger number of graduates to get experience, rather than running for a full-year for half of the students.” Ms Saint says workforce issues currently plaguing the state are having an untold impact. “Don’t fear the loss of a generation of nurses. But we could lose many very capable nurses who, if they cannot get early experience, may start to lose confidence in their ability to work in the health system.”

Global financial crisis Asked to consider reasons behind the graduate conundrum, Queensland Nurses’ Union (QNU ANMF QLD Branch) Secretary Beth Mohle identified the global financial crisis as the leading cause behind her state’s challenges. “The turnover, in Queensland Health particularly, really fell off a cliff,” she recalls. “It dropped significantly so there was understandably less places for graduates. “There was always going to be this hump of new graduates coming through who we would need in a few years’ time but because of the global financial crisis in 2008, a lot of our older nurses put off their retirement

NOW

80.5%

BY 2014 THE FIGURE PLUMMETED TO JUST 80.5%.

February 2016 Volume 23, No. 7 19

FEATURE because they took a big hit.” As the state’s situation improves, Ms Mohle admits many graduates who failed to find jobs in the murky years of 2012 and 2013 have most likely been irreversibly disconnected. “No one keeps good data so they’re lost to the system. Some went to the private sector, but not many. Some went interstate. Some went overseas. Some went to NSW to meet their increased numbers for ratios. Some actually left nursing and midwifery altogether and undertook further education in another field. This is the incalculable human and systems cost of not having a proper plan.” Ms Mohle welcomed the Queensland government’s recent funding investment in new graduates, but stressed the need to back it up with ongoing support and mentorship if long-term change is to occur.

Finding solutions According to ANMF Assistant Federal Secretary Annie Butler, creative thinking, the development of innovative models, and national collaboration, underline the primary ways to solving the problem. The ANMF continues to spruik potential strategies like waiving HECS fees for graduates who accept employment in areas of high need, such as rural and remote health; and establishing solid partnerships between large metropolitan and rural hospitals, and similar relationships between hospitals and primary health networks. Ms Butler says evidence of encouraging change is emerging, with some hospitals, for example, implementing specific casual pools for graduates unable to secure a formal placement in a bid to keep them connected in the profession. St Vincent’s Hospital in Melbourne is one such hospital making inroads. The hospital appoints about

NO ONE KEEPS GOOD DATA SO THEY’RE LOST TO THE SYSTEM. SOME WENT TO THE PRIVATE SECTOR, BUT NOT MANY. SOME WENT INTERSTATE. SOME WENT OVERSEAS. SOME WENT TO NSW TO MEET THEIR INCREASED NUMBERS FOR RATIOS. SOME ACTUALLY LEFT NURSING AND MIDWIFERY ALTOGETHER AND UNDERTOOK FURTHER EDUCATION IN ANOTHER FIELD. THIS IS THE INCALCULABLE HUMAN AND SYSTEMS COST OF NOT HAVING A PROPER PLAN. Beth Mohle

hospital’s nurse executive, which regularly dissects nursing numbers and workforce patterns on a broader level. One of St Vincent’s newest strategies involves its Care of the Older Person Graduate Nursing Program, a specialised aged care pathway that offers an alternative option to graduates who miss out on the hospital’s mainstream acute program. “We’ve noticed a niche and we’ve got graduates coming in that way,” Ms Riddington explains. “It gets them into St Vincent’s. It gives them career opportunities down the track. Whether they stay in aged care is completely up to them. We want people to stay full stop. Like a typical big hospital, there’s lots of opportunities when they finish their graduate year to play in the diversity of healthcare.” Ms Riddington’s core advice to future graduates centres around getting exposure to as much robust, diverse, and engaging clinical placement as possible. “I think there’s a responsibility that the universities have to ensure the student has lots of opportunity to consolidate because it’s the clinical skills and communicating with patients that matters. They’ll be able to do anything if they can do that well.”

Opening doors 115 graduates each year, receiving funding from the Victorian government for the first 10 graduates and a percentage from there on. “We interviewed 500 and we took 115,” says Deanne Riddington, Director of the hospital’s Nursing Education Centre. “We interview a lot because we want to meet them. It’s very labour intensive but we want to meet them. We don’t want them to be a name on a piece of paper.” Ms Riddington sits on the

Professor Maxine Duke, Head of the School of Nursing and Midwifery at Deakin University, agrees that clinical placements can pave the way to future employment. The university maintains formal partnerships with seven healthcare organisations across Victoria. “We try and work with our clinical partners and have the students keep going to those placements for a great deal of their course so that they’re familiar with the organisation and the organisation is familiar with them,”

National Data on the Labour Market for Registered Nurses – 2007 to 2014 2007

2008

2009

2010

2011

2012

2013

2014

Percentage employed full time

97.4

96.7

80.5

Percentage employed part time or casual & seeking full time

1.8

2.3

2.5

5.6

14.2

Percentage unemployed

0.8

1.2

2.5

5.3

Nursing Graduates (4 months after graduation)

SOURCE: GRADUATE CAREERS AUSTRALIA (GCA) ANNUAL AUSTRALIAN GRADUATE SURVEY

20 February 2016 Volume 23, No. 7

anmf.org.au

FEATURE

Professor Duke says. “So when it comes to choosing students they’re likely to choose ones they have experience of.” Deakin University operates across three campuses and takes in about 700 nursing students each year. According to figures, about 87% of the university’s nursing graduates find jobs after completing their degree, ranking the school among the nation’s leaders. Professor Duke says students are thoroughly drilled on making the transition from university to the workforce and encouraged to consider a range of entry options. “We talk about opportunities other than the metropolitan area and acute tertiary hospitals. We talk about rural and interstate. Some of our students find employment very easily in Perth and so forth,” Professor Duke explains. “The majority [of students] still feel they should be in an acute setting to consolidate but that’s a historical, cultural artefact. Subacute is now as acute used to be and acute is intensive care these days. “And aged care has incredible opportunities for nurses. Within a very short time they’ll move through the ranks to doing case management or leading teams much quicker than they would in an acute environment.” Professor Duke believes the anmf.org.au

shortage of places for graduates has improved since the easing of the global financial crisis. She said it is now incumbent on all key stakeholders to work together to promote careers across the health service in places such as mental health and aged care in order to debunk traditional perceptions regarding the need to complete a graduate year in an acute setting.

Don’t give up Despite the graduate situation persisting, ANMF Assistant Federal Secretary Annie Butler remains optimistic. “Stick it out. Come to us. Tell us your story. Let us know what your circumstance is so that we can find out more ways to try and help,” she says. In the same vein, while the short-sightedness of governments and lack of funding may rightly be to blame for the crisis, there’s one fundamental area perhaps still often overlooked in the battle to find a job: diligence and luck. Registered nurse Tori Burek is testament to the adage persistence pays. Tori experienced the feeling of isolation and soul-searching firsthand after completing a nursing degree at Victoria University’s St Albans campus in October, 2014. Her failure to secure a graduate position left her flattened and wondering where she had gone wrong. Over the next six months,

Tori applied for hundreds of nursing jobs but kept getting rejected. “It was six months’ long of constantly going to work, coming home, and applying for jobs. It gets a bit tedious after a while and you come to a point where you think is it even worth it?” During the state of limbo, Tori kept connected by undertaking training courses offered by the ANMF, agency jobs, and nonnursing jobs. In a stroke of luck, Tori was able to secure a graduate position at St Vincent’s Hospital in Melbourne via a mid-year intake. She finally began her career as a nurse last September, starting off on the orthopaedics ward. “It sounds clichéd but I really do think everything happens for a reason because in that six months I learned to work harder and to pick myself up, and everything I learned about nursing in that time will help me now as well. So I don’t regret that time.” Reflecting on her journey, Tori’s message to graduates confronting similar uncertainty is simple: keep persevering. She says she feels humbled to work at St Vincent’s and is looking forward to a long career. “The thing I love the most is the place I’m working at. If you come to work every day with people who are as passionate as you are then it makes the whole difference.”

TORI BUREK PHOTOGRAPHY: CHRIS HOPKINS

300

ANNUAL GRADUATES FROM TASMANIA

TODAY, ALMOST HALF OF THE STATE’S 300 ANNUAL GRADUATES STRUGGLE TO SECURE A GRADUATE POSITION.

February 2016 Volume 23, No. 7 21

WORLD

GLOBAL

MELBOURNE

International Council of Nurses selects new CEO New Zealand native Dr Frances Hughes has been appointed the new Chief Executive Officer of the International Council of Nurses (ICN). Dr Hughes officially takes up the post this month, moving on from her most recent role as Queensland’s Chief Nurse and Midwifery Officer, which she has held since 2012. Dr Hughes’ background includes positions as the Chief Advisor (Nursing) to New Zealand’s Ministry of Health; a consultant with the World Health Organization (WHO), and CommandmentColonel of the Royal New Zealand Army Nursing Corps. She was also the first Professor of Nursing at the University of Auckland. Dr Hughes’ commitment to championing a strong nursing community is illustrated by a significant background as a health clinician, manager, and educator, and working abroad in relief efforts on several natural disasters such as the Boxing Day tsunami and Hurricane Sandy. Dr Hughes, who will move to ICN headquarters in Geneva, Switzerland, said she felt privileged to be given the opportunity and hopes to impart knowledge garnered in New Zealand and Australia to Northern Hemisphere and European cultures. “Often it is seen that big nursing activity is only happening in the Northern Hemisphere, but an awful lot is happening down here and we have contributed to a great deal to world health, through New Zealand in particular.” 22 February 2016 Volume 23, No. 7

AUSTRALIA

New app finds reliable way to record causes of death

Physical activity thrown in the spotlight

Researchers from the University of Melbourne have developed a revolutionary new app that accurately captures global cause of death data on tablets and mobile phones.

A substantial review of physical activity and public health across the globe has uncovered the need for a comprehensive policy response in Australia, according to the Heart Foundation.

Globally, two in three deaths, or 35 million each year, remain unregistered. About 180 countries that are home to 80% of the world’s population do not collect reliable cause of death statistics. The app is the result of a decadelong worldwide collaboration, led by the University of Melbourne and researchers at the Institute of Health Metrics and Evaluation (IHME) at the University of Washington. The research team redesigned a short ‘verbal autopsy’ questionnaire and tested it in India, the Philippines, Mexico and Tanzania. The app was then field tested in China, Sri Lanka, and Papua New Guinea. Family members of the deceased were given surveys in hand-held devices. A computer then analysed the data to make a diagnosis, bypassing the need to rely on doctors to do this work. University of Melbourne Professor Alan Lopez, who led the study, said pinpointing what kills people in poor countries will help monitor disease and injury trends and keep track of emerging health problems. “Up-to-date, reliable information on what people are dying from and at what age is really important for policies to prevent premature death. Our app provides a way to do this, quickly, simply, cheaply, and effectively, with the power of technology.”

The Global Observatory for Physical Activity (GoPA) unveiled its latest Physical Activity Country Cards, including for Australia, at an announcement in London late last year. The Observatory is a council for the International Society of Physical Activity and Health (ISPAH). Of the 131 participating countries, 37 have specific national plans for the promotion of physical activity and another 65 include physical activity as part of plans for the prevention of noncommunicable diseases. However, Australia does not currently have a comprehensive funded National Physical Activity Action Plan. “The need for action is all too clear with only 43% of Australian adults active enough for good health, ranking us 94th out of the 131 countries,” Adjunct Professor Trevor Shilton, of the National Heart Foundation said. Professor Shilton said the opportunity now exists for the federal government to develop a nationally coordinated policy response. He said the release of Physical Activity Country Cards represents an ideal opportunity to push for costeffective reform. “If 37 other countries, including the United States and United Kingdom, see fit to implement a national physical activity plan, then there’s no good reason for us not to follow suit.” anmf.org.au

ETHICS

Privacy, professionalism and social media Megan-Jane Johnstone

References Acquisti, A., Brandimarte, L. & Loewenstein, G. 2015. Privacy and human behavior in the age of information. Science, 347(6221): 509-514. Larter, A. 2014. Tweet your conscience. Nursing Review, 6 (July): 28-29. Spector, N. & Kappel, O. 2012. Guidelines for using electronic and social media: the regulatory perspective. OJIN: The Online Journal of Issues in Nursing, 17(3): (September 30; Manuscript 1).

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

The widespread use of social media is an everyday reality that is transforming the way people communicate. Because of its immediacy and accessibility, social media platforms have become the key means by which many people participate in and keep informed about breaking news and events and about ongoing developments, discussions and discoveries in the world at large. Social media has also become a key mechanism by which information on the developments, discussions and discoveries in nursing and healthcare are disseminated. Sharing information via conference tweets, YouTube presentations, Facebook, LinkedIn, ResearchGate, classroom discussion boards, podcasts, blogs, webinars and other social media – once unimaginable – is now commonplace. Twitter discussions (eg. ‘Tweet your conscience’) have even been heralded, controversially, as providing a key platform for nurses to voice their concerns about ethics (Larter, 2014). Despite the merits of social media, it is important to remember that it is not benign: the messages it carries can be profane as well as profound, and its potential consequences can be harmful as well as beneficial (Spector and Kappel 2010). It is for these reasons that nurses must always be cautious in their use of social media and consider the possible implications of posting information via this mode, whether of a personal or professional nature.

A question of nursing ethics There are at least two domains where nurses who use social media and other information technologies may be vulnerable, notably when posting information that may: i. breach privacy considerations; and/or ii. besmirch the personal and/ or professional reputations of themselves or others. Here two questions arise: first, what privacy challenges do nurses face when engaging in online communications? And second,

what processes will influence nurses when deciding whether to protect or surrender their own or another’s privacy and reputation?

Privacy and confidentiality In addressing the above questions it is necessary first to clarify what a claim of privacy entails. Privacy entails the right of individuals to have control over ‘who can sense them’ – ie., who can see, hear, and touch them, literally and virtually. This is in contrast to confidentiality (sometimes confused with privacy) which entails the obligation to keep secret information of a private nature that has been gained for a specific purpose (eg., healthcare) in a specific relationship or context (eg. a professional-client relationship). Today the widespread use of social media and information technologies is challenging the boundaries of privacy. Some have even argued that in this age of information technology conventional notions of privacy have become obsolete and privacy itself is little more than an illusion (Acquisti et al. 2015). One reason for this is that information technologies have made it virtually impossible for individuals and even whole societies to maintain control over ‘who can sense them’. Vast amounts of information are collected on people every day – often without even being aware of it – via such things as official electronic records, smart phone tracking devices, security cameras, and the ‘fingerprints’ that are left on the internet when using email and search engines, making online purchases, and so forth. Although privacy laws offer some protection, as Acquisti et al. (2015) observed, in the online world ‘the boundaries between public and private become less defined’ and the capacity of people to meet expectations concerning privacy ‘more difficult and consequential’.

‘Poor’ online behaviours Privacy protection scholars are cautioning that all people have ‘digital skeletons in their closets’, underscoring the need for people in all walks of life to be careful when using social media. Acquisti et al.(2015) identify three processes which, they contend, influence human behaviour in relation to privacy concerns: 1. Uncertainty or ignorance about

the consequences of crossing the boundaries between the private and public spheres of life; 2. Context-dependency, which may vary by situation, be learned over time, be moderated by cultural norms and values, and swayed by an illusion of anonymity; 3. The degree of malleability and influence, eg. the capture and use (manipulation) of personal data for commercial and political purposes. These processes, they suggest, have ultimately contributed to people making ‘privacy tradeoffs’ and disclosing private information that ordinarily they would not divulge and which may ultimately be contrary to their own and others’ best interests.

Guidelines for nurses Nursing organisations around the world including the International Council of Nurses (ICN), the International Nurse Regulators Collaborative (INRC), the Australian Health Practitioner Regulation Agency (AHPRA), the Australian Nursing and Midwifery Federation (ANMF), and the Australian College of Nursing (ACN) have published guidelines on the use of social media and online networking by nurses. These guidelines remind nurses of their professional responsibilities to uphold the ethical, legal and professional standards of nursing when using social media, and the possible consequences of failing to do so. The guidelines also make plain that when using social media (whether in a personal or professional capacity) nurses have an overriding obligation to maintain professional boundaries, comply with privacy and confidentiality requirements, avoid making statements of a defamatory nature, and to generally behave in a professional manner. Nurses need to be aware that a failure to uphold the social media guidelines set by the profession may not only cause them embarrassment and reputational damage, but, depending on the seriousness of the breaches in question, could also result in disciplinary action being taken against them. http://www.heti.nsw.gov.au/ Global/nm/Social-medianurses.pdf February 2016 Volume 23, No. 7 23

ISSUES

AHPRA

AHPRA – Notifications, investigations, processes and outcomes By Jayr Teng Nursing is often referred to as a science and an art. A science in the sense that the nursing profession is based on research and an art because nursing is a profession grounded in caring for others. When things go wrong however, nurses are held accountable as professionals. This article examines the notification and investigative processes by which registered nurses can be held to account under the Health Practitioner Regulation National Law (National Law) as in force in each state and territory.

AHPRA and the Nursing and Midwifery Board of Australia The Nursing and Midwifery Board of Australia (NMBA) is one of 14 national boards established under section 31 of the National Law. The NMBA replaced the former, state and territory nursing and midwifery boards. The Australian Health Practitioner Regulation Agency (AHPRA) receives notifications and complaints about nurses and midwives on behalf of the NMBA. In 2014, AHPRA received 2,010 notifications in relation to registered nurses and midwives. This accounted for 20% of the total notifications (10,047) made in that year. The types of issues notifications were made about included, adequacy of clinical care, communication, confidentiality, documentation and informed consent.

Types of notifications A notification can either be a voluntary notification or mandatory notification. Anyone can make a voluntary notification under the National Law about a registered nurse or registered midwife (practitioner) or nursing/midwifery student. The grounds for making a voluntary notification against practitioners include that (among others): a. The practitioner’s professional conduct is or may be of a lesser standard than which might be expected; b. The practitioner’s knowledge, skill or judgment may be below the standard reasonably expected of the practitioner; c. The practitioner is not a fit and proper person. Mandatory notifications are required to be made by a registered health practitioner (eg. nurse, doctor, physiotherapist, or pharmacist) where, in the course of practising their health profession they form a reasonable belief that another registered health practitioner (eg. nurse, doctor, physiotherapist, or pharmacist) has behaved in a way that constitutes notifiable conduct. For the purposes of mandatory 24 February 2016 Volume 23, No. 7

notifications, notifiable conduct means: a. practicing while intoxicated by alcohol or drugs; b. engaging in sexual misconduct in connection with the practitioner’s practice; c. placing the public at risk of harm because of an impairment; d. placing the public at risk of harm through practicing the profession in a way which is a significant departure from accepted professional standards. It is important to note that mandatory notification provisions apply to nurses individually and the NMBA may take action against a nurse who fails to notify it of notifiable conduct. Each state and territory Health Services Commission may also refer matters to the NMBA.

IT IS IMPORTANT TO SEEK ADVICE EARLY AND ENSURE THAT YOU PROVIDE THE NMBA WITH CLEAR, INSIGHTFUL AND HONEST RESPONSES TO THE MATTERS ON WHICH SUBMISSIONS HAVE BEEN SOUGHT. Investigation process Once notification has been received by AHPRA, the NMBA has 60 days to conduct a preliminary assessment of the notification and decide what further action may be required. The NMBA on assessment of a notification may decide: a. to take no further action; or b. conduct an investigation in respect of the notification received; or c. take immediate action to cancel, suspend or impose a condition/ undertaking on the Practitioner’s registration. The NMBA may take no further action where a notification is frivolous, vexatious, misconceived or lacking in substance. Conversely, immediate action is taken where the NMBA believes that immediate action is necessary to protect public health or safety. Investigations are commenced where the NMBA considers that a Practitioner’s practice or conduct may be unsatisfactory.

An investigator from AHPRA is appointed by the NMBA to conduct the investigation in a timely manner. On conclusion of the investigation, the investigator appointed by AHPRA provides their report to the NMBA who then determines what further action may be required. The NMBA may, after considering the investigators report: a. take no further action; or b. caution the practitioner; or c. impose conditions/require undertakings (including for further education or supervision);or d. refer the matter to a performance and professional standards panel; or e. refer the matter to a Tribunal. At various points, a practitioner may be asked to provide a written submission to assist the NMBA make an appropriate decision in respect of the notification. It is important to seek advice early and ensure that you provide the NMBA with clear, insightful and honest responses to the matters on which submissions have been sought. Examples of conduct/practice which have resulted in disciplinary consequences for the registered include lack of clinical competence, breaches of confidentiality and lack of documentation.

What should nurses do when faced with a notification? A notification to AHPRA and the subsequent investigation process is stressful. This process involves preparing statements and may also involve having to appear personally before a panel or Tribunal. All notifications made to AHPRA should be taken seriously, even if you personally think that the allegations that have been made are baseless or without merit. Even if you consider that the allegations are baseless, they may in fact still result in you being cautioned by the NMBA. If you are the subject of a notification, at first instance you should seek professional assistance for advice on the most appropriate next steps to deal with the notification/complaint made against you. Jayr Teng, LLB (Monash), LLM (Melb), BNurs (Deakin), BAppSc (HealthProm) (Deakin), GDLP, GCMgmt (VU), FTI, Solicitor, works for Meridian Lawyers. This article is based on the views and research of the author(s) and has not been peer reviewed. anmf.org.au

Forensic

WORKING LIFE

“IF YOU’RE GETTING ONE STORY ONE MINUTE AND THEN YOU GO BACK AND YOU GET TOTALLY DIFFERENT STORIES, THAT’S WHAT MAKES THE HAIRS PRICK UP ON THE BACK OF YOUR NECK.” FORENSIC PAEDIATRIC NURSE, JOANNE DEAN

Questions of science By Robert Fedele Nothing tends to shock Joanne Dean anymore. Working as a forensic paediatric nurse specialising in examining the physical and sexual assault of minors aged up to 18, Joanne is continually exposed to shocking callousness of the greatest scale. Scenarios like a child being hit on the head repeatedly with a toy train, parents violently shaking their newborns, and children living in a meth lab, have become the norm. Joanne recalls one of the most heartbreaking cases involved a boy who presented to hospital on a Tuesday with breathing problems, then was discharged after treatment and analysis. Later that Friday, Joanne got word from the intensive care unit that the boy had been admitted with cardiac arrest following another assault at home. The boy passed away. “That’s when you actually see a child and you interact with them,” Joanne explains. “I gave him cuddles and a pencil and book that day and then they’re on life support and he actually died the next day. You sort of think what did I miss?” Joanne is one of three nurses employed by the Victorian Forensic Paediatric Service (VFPS), a state-wide operation providing assessment and care for abused, assaulted and neglected children and young people. VFPS runs out of two centres, one at the Royal Children’s Hospital, and the other at the Monash Medical Centre. Joanne is the Nurse Unit Manager at the Royal Children’s site, a bustling catchment area that last year assessed anmf.org.au

more than 1,000 patients. “They’re kids that have been physically assaulted or even sexually assaulted that they need an inpatient stay,” Joanne says. Joanne began her nursing career working on the cardiology and general medical wards at the Royal Children’s, then as a midwife, followed by a stint at the Royal Women’s Hospital in intensive care. One of Joanne’s most rewarding roles came later when working with the Newborn Emergency Transport Service (NETS), covering Victoria, Tasmania, and southern NSW, and flying out in a helicopter to stabilise critical babies and move them to the city for further treatment. Joanne’s turning point arrived in 2006 when the VFPS was established. She thought the idea of forensics sounded interesting and was immediately attracted to the newly evolving speciality. The service was initially funded for four years as a pilot project but quickly turned permanent. “It was really interesting [the early days]. You were able to put your stamp on what you wanted to do and how you wanted things run. But it was a very steep learning curve,” she says. On any day, Joanne can take a phone call from anywhere across Victoria reporting a physical or sexual assault. “We’ve got to know when people ring up and they’re asking for assistance where to send them. For example, if it was strangulation, has there been any loss of consciousness? Then we’ve got to look at what’s the best facility for that child to go to.” The speciality services liaise heavily with police and child protection workers. Forensic assessments the nurses attend too involve interviewing parents and children, taking swabs, obtaining blood and ordering bone scans, and

investigating injuries. Joanne says the role is tricky given that parents or family members are often found to be the culprits. “We’re seeing if the injury fits the mechanism. If we don’t believe that’s occurred then child protection and police will conduct a formal investigation. “You can never tell exactly who’s telling the truth but sometimes the body cues are quite interesting, and if a story changes. If you’re getting one story one minute and then you go back and you get totally different stories, that’s what makes the hairs prick up on the back of your neck.” Joanne says most patients are seen once but in some cases there is ongoing treatment. “There were children living in a meth lab. When we had them we had to do all the toxicology testing. They’d been having a bath where the drugs were being made up so it had been absorbed into them. “They were placed in care and we saw them every six months for about two years to show the development of these children and how far they’d come and then that gets written into a report for child protection.” A key component of the Royal Children’s site’s outfit is a DNA lab capable of analysing crucial evidence, says Joanne. Joanne describes her job as interesting and rewarding. As well as her main role, she is also responsible for delivering educational workshops across Victoria to enhance knowledge of the specialty area among health practitioners. “It’s a really emerging area. All the different technologies that are coming through and things that we thought we could never interpret are being interpreted. Things are evolving and changing constantly and you do have to keep up with your study.” February 2016 Volume 23, No. 7 25

CLINICAL UPDATE

The role of sleep in patient recovery By LJ Delaney Sleep is a fundamental physiological phenomenon essential to human survival and supports optimal functionality both physiologically and psychologically. Despite the general acknowledgement of its importance, patients’ ability to sleep within the hospital setting is widely reported as grossly impaired. Clinical studies have consistently reported patients’ poor sleep quality, characterised by decreased total sleep time and frequent disruptions which inhibit the ability to acquire consolidated sleep (Elliott et al. 2013). The interest in sleep within the inpatient population and its role in recovery is an emerging area of clinical research, in particular the relationship between delirium and sleep disturbance, (Van Rompaey et al. 2012; Slatore et al. 2012) its contribution to length of hospital stay, and management of circadian rhythm disturbances (Madrid-Navarro et al. 2015). The impediments to patients’ ability to sleep have been attributed to external (clinical environment: noise, light, clinical interventions) and intrinsic factors related to illness and injury. Primarily, the external environment has been identified as the attributing cause, with considerable research reporting the subjective accounts of patients who cite noise and the provision of clinical care as the principle sleep disturbing factors (Van Rompaey et al. 2012; Delaney 26 February 2016 Volume 23, No. 7

et al. 2014). These claims have been reiterated in objective studies which report noise levels in excess of the World Health Organization’s (WHO) recommended 30dB, and documented frequency of clinical interactions. (Elliott et al. 2013; Li et al. 2014; Hu et al. 2010). Despite these findings, few studies have been able to successfully implement strategies and demonstrate a sustained reduction in noise and light, with some studies (Gabor et al. 2003; Freedman et al. 2001) within the critical care environment demonstrating little biophysiological indication that sleep disturbance is associated with noise events and light stimulus. Whilst findings regarding principle causes of sleep disturbance are conflicting and most likely to be multifactorial, sleep plays an important role in the overall recovery and wellbeing

of individuals, and should be considered within the context of providing holistic clinical care.

Circadian rhythms Sleep/wake cycles are regulated by the circadian rhythm which oscillates around a 24 hour clock. The principle regulatory mechanism of circadian patterns is located in the suprachiasmatic nucleus (SCN) within the hypothalamus which promotes arousal during the day. In contrast the ventrolateral preoptic nucleus (VLPO) located in the anterior hypothalamus is considered to be the sleep generating centre. The SCN determines the timing of sleep and wakefulness, but also plays a role in regulating other circadian processes independent of sleep such as cortisol levels, core body temperature and melatonin release (Hastings et al. 2010). The maintenance of the circadian rhythm is achieved via zeitbegers (external or environmental cues) which provide cues for the induction and maintenance of sleep (Berry, 2012). As the circadian pacemaker is regulated by photoperiodic information the strongest regulator is light exposure including artificial light, followed by social (meal times) and non-photic cues such as endogenous melatonin secretion which initiates sleep

References Berry, R.B. (2012). Fundamentals of sleep medicine. ElsevierSaunders. Philadelphia. Born L, Besedocsky T, Lange J. (2012) Sleep and immune function. European Journal of Physiology.781 2012;463:121–37 Bosma, K., Ferreyra, G., Ambrogio, C., Pasero, D., Mirabella, L., Braghiroli, A. & Ranieri, V. M. (2007). Patientventilator interaction and sleep in mechanically ventilated patients: Pressure support versus proportional assist ventilation*. Critical Care Medicine, 35(4), 1048-1054. Carskadon, M. & Dement, W. (2005). Normal human sleep: An overview. In M.R. Kryger. Principles and Practice of Sleep Medicine. 4th Ed. Philadelphia. Elsevier Saunders. Pp. 13-23. Chen HI, & Tang YR. (1989) Sleep loss impairs inspiratory muscle endurance. American Review of Respiratory Disease 128(6):907–9. Cooper, A.B., Thornley, K.S., Young, G.B., Slutsky, A.R., Stewart, T.E. & Hanly, P.J. (2000). Sleep in critically ill patients requiring mechnical ventilation . Chest.117(3):809-818

anmf.org.au

CLINICAL UPDATE onset (Lack and Wright 2007). These zeitgebers can be altered as a result of acute illness, decreased mobility and environmental design which can preclude patients exposure to natural light, result in prolonged exposure to artifical light throughout the day and night, inability to view clocks to orientate to time, and the provision of enteral and parental nutrition support. Altered circadian patterns can contribute to changes in physiological homeostasis, such as the onset of delirium, greater variability in peak flow measures in asthmatic airways (Durrington et al. 2013) and increased hospital length of stay and morbidity (Weinhouse et al. 2014).

Overview of sleep architecture Normal sleep architecture (Figure 1) is comprised of multiple sleep stages which are cycled through five to six times per night over a duration of 90-110 minutes, with each stage having unique physiological characteristics (Frisk and Nordstorm, 2003). Non rapid eye movement (NREM) sleep is comprised of stages N1, N2 and N3, with stages N1 and N2 being colloquially referred to light sleep and make up the majority (50-50%) of total sleep time (Geyer et al. 2012). The first stage (N1) acts as a transition between wakefulness and deep sleep, and is characterised by the physical state of drowsiness, decreased ocular movements and reduced muscle activity (Geyer et al. 2012). Transitioning into stage N2 the individual becomes decreasingly unaware of their surrounding environment, whilst cortical activity is increased which is purported to be important in memory consolidation (Cox et al. 2012). The restorative stages of sleep, N3 and rapid eye movement (REM) are fundamental to support physiological recovery and emotional wellbeing, and are the two phases that clinical studies have identified as being abnormal in patients, particularly those admitted to the Intensive care setting. Stage N3 is considered to be the most restful and deepest stage of the sleep cycle, during which anabolic restoration takes place, growth hormone is secreted which promotes protein synthesis, tissue healing and physical restoration (Honkus, 2003). In contrast, REM sleep is an active sleep stage with anmf.org.au

a high degree of cerebral and physiological activity, making up 20 to 25% of sleep and progresses in length over the night (Berry 2012). REM is characterised by saccades of conjugate eye movements, (Geyer et al. 2012; Carskadon and Dement, 2005) increased heart rate and the brains metabolic rate, whilst muscle tone is suppressed (Karachman et al. 1995). This sleep stage is considered to be essential for mental restoration and emotional healing (Frisk and Nordstorm, 2003).

Sleep issues within the clinical environment Sleep disturbance has been attributed to a vast range of adverse physiological and psychological effects. Developing an understanding of these factors is important for the clinician in order to appreciate the need for adequate patient sleep to facilitate recovery. Education regarding sleep and the processes that occur during the stage are not a primary focus of nursing education and as a result nurses knowledge in this area may be lacking (Radtke et al. 2014; Gellerstedt et al. 2015). As sleep is a passive state its importance in recovery can be deprioritised in comparison to clinical activities and tasks, and the perception that high quality clinical care is equated to frequent clinical interactions (Ye et al. 2013). Sleep restriction to less than six hours has been associated with adverse health effects such as decreased immune function, cardiovascular health and endocrine instability. Clinical studies involving bio-psychological monitoring of sleep via polysomnography report that patients total sleep time is variable between 3 hours (Cooper et al. 2000) to 5.5 hours (Bosma et al. 2007). This lack of sleep can be compounded by the frequency of clinical interactions which has been reported to be as high as 79 times/ hour for mechanically ventilated patients (Parthasarathy and Tobin, 2002). Limited research has been conducted in general ward environments, however subjective studies reveal that patients report sleep disturbance as a stressor associated with their admission, with nocturnal noise levels ranging between 50-60 dB(A) in the critical care setting, with general ward environment experiencing levels between 40-55dB(A) (Delaney et al. 2014).

Figure 1 Characteristics of the stages of the sleep cycle.

N1: • Transitioning phase • Increased drowsiness • Decreased occular

movements

• Decreased muscle

activity

• Decreased minute

ventilation

N2: • Light sleep stage • Decreased awareness of

external environment • Increased cortical activity • Contributes to memory consolidation • Decreased minute ventilation

N3: • Deep, restorative sleep • Slow wave activity • Anabolic state • Increased release of

growth hormone

• Protein synthesis and

tissue repair • Decreased minute ventilation • Inhibition of thyroid stimulating hormone

REM: • Active sleep stage • Conjugate eye

movement • Increased heart rate • Increased metabolic demand by the brain • Decreased sympathetic tone • Muscle atonia

Cox, R., Hofman, W. F., & Talamini, L. M. (2012). Involvement of spindles in memory consolidation is slow wave sleepspecific. Learning & Memory, 19(7), 264-267. Delaney, L.J., Lopez, V., Currie, M. et al (2014) Canberra Hospital Sleep Study Report. Canberra Hospital. Canberra. Durrington, H. J., Farrow, S. N., Loudon, A. S., & Ray, D. W. (2013). The circadian clock and asthma. Thorax, thoraxjnl-2013. Donga E, Van Dijik M, Van Dijik JG, Biermasz NR, Lammers G-J, van Kralingen KW, et al. (2010) A single night partial sleep deprivation induces insulin resistance in multiple metabolic pathways in healthy subjects. Journal of Clinical Endocrinology and Metabolism. 807; 95(6):2963–8. Elliott, R., McKinley, S., Cistulli, P., & Fien, M. (2013). Characterisation of sleep in intensive care using 24-hour polysomnography: an observational study. Critical Care, 17(2), R46. Freedman, N.S., Gazendam, J., Levan, L., Pack, A.I. & Schwab, R.J. (2001). Abnormal sleep/wake cycles and the effect of environmental noise on sleep disruption in the intensive care unit. American Journal of Respiratory and Critical Care Medicine.163; 451-457 Frisk, U. & Nordstrom, G. (2003). Patients’sleep in an intensive care unit – patients’and nurses’perception. Intensive and Critical Care Nursing. 19:342349. Gabor, J.Y., Cooper, A.B., Crombach, S.A., Lee, B., Kaikar, N., Bettger, H.E. & Hanly, P.J. (2003). Contribution of the intensive care unit environmental to sleep disruption in mechanically ventilated patients nd healthy subjects. American Journal of Respiratory and Critical Care Medicine.167:708-715

February 2016 Volume 23, No. 7 27

CLINICAL UPDATE The role of sleep on psycho-physiology health Sleep deprivation induces physiological stress leading to the activation of the HypothalamusPituitary-Adrenal (HPA) axis. Stimulation of the HPA results in the release of catecholamine’s; Noradrenaline and adrenaline, and cortisol which activates the sympathetic nervous systems flight/ fight response and suppresses sleep. The presence of cortisol adversely affects the activity of antiinflammatory cytokines, increases catabolism and carbohydrate metabolism resulting in insulin resistance and glucose clearance, and oxygen consumption (Wright et al. 2015). The effect of which can induce circadian misalignment whereby the patient is awake and active, when the normal internal circadian clock is attempting to induce sleep, and exacerbates illness and disease processes. Allostatic overload; the accumulated effect of stress on the body, as a result of sleep disturbance can impact on the chemoreceptors of the brain and imposed complications for patients with respiratory disorder such as Chronic Obstructive Pulmonary Disease (COPD). Studies have demonstrated decrease responsiveness to hypoxic and hypercapnic states (White et al. 1983), along with noted reduction in inspiratory muscle strength (Chen and Tang, 1989), FEV1 and FVC with short term sleep loss (Phillips et al. 1987). These effects can have implications on the recovery of respiratory patients, and patient groups undergoing weaning from mechanical and non-invasive ventilation support and preparedness for tracheostomy decannulation. Furthermore, the physiological burden imposed due to poor quality of sleep can result in neuroimmunological effects resulting in increased productions of inflammatory mediators. Although the relationship between sleep deprivation and the immune function is not fully understood in humans, research suggests that sleep deprivation has an effect on cellular immunity and cytokine function. Specifically, studies have shown a reduction in the function of T-helper cells and natural killer cells and an increased activation of pro-inflammatory mediators such as Interleukin (IL)-1 and Tumor 28 February 2016 Volume 23, No. 7

Necrosis Factor (TNF) with partial sleep deprivation (Born, 2012). These findings may translate to an increased susceptibility to opportunistic infections, impaired ability to fight acquired infection, and increased adverse outcomes in incidences of sepsis, which have been reported in animal studies.

it is important for clinicians to recognise and identify delirium, and attributing causes. Implementing quick assessments such as the Confusion Assessment Method for the assessment of delirium and non-delirium states, may facilitate the appropriate initiation of clinical management.

Nursing interventions

ALLOSTATIC OVERLOAD; THE ACCUMULATED EFFECT OF STRESS ON THE BODY, AS A RESULT OF SLEEP DISTURBANCE CAN IMPACT ON THE CHEMORECEPTORS OF THE BRAIN AND IMPOSED COMPLICATIONS FOR PATIENTS WITH RESPIRATORY DISORDER SUCH AS CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD).

The manifestations of the sleep deprivation commonly recognised by clinicians are related to neurocognitive changes detected. The relationship between sleep deprivation and delirium has not been fully elucidated, and as a result it is unclear if sleep deprivation results in delirium or if delirium is the contributor to sleep disturbance. Regardless, the impact of delirium on recovery has been well recognised and has been associated with adverse patient outcomes such as increased length of hospital stay, persistent decline in cognitive functioning and increased patient mortality (Wang and Greenberg, 2013; Donga et al. 2010). In addition, confusion and hallucinations can impact on individuals’ mental health, and can result in altered affect, anxiety and post-traumatic stress disorder (PTSD) associated with their admission. In order to optimise clinical management of patients

Nurses are well positioned to identify patients experiencing sleep disturbance and to undertake interventions that may support the ability to acquire sleep to facilitate recovery. Providing a diurnal environment that appropriately supports the ability to sleep, can be challenging due to the constraints imposed by clinical design, shared patient rooms, and balancing the chasm between a functional working environment and individuals’ need for sleep. Providing a nocturnal environment in which patients can sleep needs to integrate an awareness of exposure to sleep disturbing noise, noise reverberation, and presence of artificial light, temperature and rationalisation of interventions that disturbed sleep. Through collaboration with medical teams and consideration of timing of care interventions such as medication administration, timing of routine pathology and radiological assessment can facilitate patients’ capacity to acquire uninterrupted sleep. Consideration to these aspects of clinical care can assist in maintaining the circadian patterns of patients and potentially reducing the onset of delirium, and recognition of the zeigebers that maintain these patterns such as exposure to natural light, patient’s ability to view clocks and meal schedules, along with limiting nocturnal exposure to artificial lights. Providing simple interventions such as eye masks and ear plugs can be effective strategies to reduce the environmental burden on patients (Hu et al. 2010). Modifications to the clinical environment to reduce the impact of noise and light have reported as being effective strategies such as the installation of noise absorbing tiles and dimmer lights, Perspex screens around nursing stations, and noise absorbing curtains. These in combination with considering nocturnal setting of devices and their alarms can assist in providing a nocturnal environment

Gellerstedt, L., Medin, J., Kumlin, M., & Rydell Karlsson, M. (2015). Nurses’ experiences of hospitalised patients’ sleep in Sweden: a qualitative study. Journal of Clinical Nursing. Geyer, J.D., Dillard, S., Carney, P.R., Thai, Y. & Talathi, S. (2012). Chapter 5 Sleep and normal human physiology. In P.R. Carney, R.B. Berry & D. Geyer. Clinical Sleep Disorders. 2en edition. LWW-Wolters Kluwer. Philadelphia. Hastings, M., O’Neill, J. S., & Maywood, E. S. (2007). Circadian clocks: regulators of endocrine and metabolic rhythms. Journal of Endocrinology,195(2), 187-198. Hu, R. F., Jiang, X. Y., Zeng, Y. M., Chen, X. Y., & Zhang, Y. H. (2010). Effects of earplugs and eye masks on nocturnal sleep, melatonin and cortisol in a simulated intensive care unit environment. Critical Care, 14(2), R66. Honkus, V. (2003). Sleep deprivation in critical care. Journal of Critical Care Nursing. 26(3):179-91 Karachman, S., D’Alonzo, G. & Criner, G. (1995). Sleep in the intensive care unit. Chest.107:1713-1719. Lack, L. C., & Wright, H. R. (2007). Clinical management of delayed sleep phase disorder. Behavioral Sleep Medicine, 5(1), 57-76. Li, S. Y., Wang, T. J., Vivienne Wu, S. F., Liang, S. Y., & Tung, H. H. (2011). Efficacy of controlling night-time noise and activities to improve patients’ sleep quality in a surgical intensive care unit. Journal of Clinical Nursing, 20(3-4), 396407. Madrid-Navarro ,J., Sanchez-Galvez, C, Martinez-Nicolas, R., Marina, A., Garcia, R.A., Madrid, J.A. & Rol, M. (2015). Disruption of Circadian Rhythms and Delirium, Sleep Impairment and Sepsis in Critically ill Patients. Potential Therapeutic Implications for Increased Light-Dark Contrast and Melatonin Therapy in an ICU Environment. Current pharmaceutical design, 21(24), 3453-3468. Parthasarathy, S., & Tobin, M. J. (2002). Effect of ventilator mode on sleep quality in critically ill patients. American Journal of Respiratory and Critical Care Medicine, 166(11), 1423-1429.

anmf.org.au

CLINICAL UPDATE Figure 2 The physiological and psychological impacts of sleep deprivation. ABBREVIATIONS: IL-1: INTERLEUKIN 1, TNF; TUMOR NECROSIS FACTOR, FEV1: FORCED EXPIRATORY VOLUME 1, FVC: FORCED VITAL CAPACITY

Immunological:

• Decreased Helper T Cells

• Decreased Natural Killer cells • Increased proinfammatory

mediators: IL-1, TNF

Physiological effects

Sleep deprivation

Hormonal: • Catecholamine release: Adrenaline & Noradrenaline • SNS stimulation • Increased cortisol release • Reduction in insulin release • Gluconeogenesis • Supression of melatonin

Cardio-respiratory:

• Increased heart rate

Increased bloodpressure • Reduced FEV1 & FVC • Reduced respiratory muscle strength

Psychological effects

which reduces the impact of environmental stressors. Sleep plays an important role in patient recovery and acknowledging its contribution on initial admission via care planning processes to identify sleep hygiene practices of individuals, in combination with implementing validated sleep assessment such as the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index and the Verran Snyder-Halpern Sleep Scale. The implementation of these can be beneficial in identifying patients with sleep disturbance issues and to provide the impetus to implement individually tailored strategies to minimise sleep disturbance. Further, the prohibiting of daytime napping due to concerns regarding patients not sleeping at time, may contribute further to sleep disturbance by not anmf.org.au

permitting recovery sleep to be acquired. Consideration regarding daytime rest periods, their timing and duration should not be dismissed; however they do need to be assessed on an individual basis. Clinicians need to be aware of strategies to implement to support patient sleep, rather than proceeding directly to pharmacological interventions. Although commonly prescribed sleep promoting medications such as benzodiazepines promote states which superficially reflect sleep and reduce sleep onset, they have an inhibitory effect on the critical states of the sleep cycle (N3 and REM) which provide the restorative aspects of sleep, and induce longer phases of N2 sleep. Understanding the physiology of sleep and its contribution to

• Delirium • PTSD • Confusion

• Hallucinations • Decreased working memory

patient recovery provides clinicians with the ability to critically consider opportunities to enhance clinical care, and promote holistic concepts of psycho-physiological health. Although clinical research has identified a number of causal factors and proffered strategies to enhance and support sleep, little has been accomplished in successfully addressing this issue. Nurses have the capacity to identify and advocate for changes to enhance patients’ ability to acquire the necessary rest they need to support their recovery. LJ Delaney is Assistant Professor in Clinical Nursing, University of Canberra; PhD Scholar, College of Medicine, Biology and Environment, Australian National University

Phillips BA, Cooper KR, & Burke TV.(1987) The effect of sleep loss on breathing in chronic obstructive pulmonary disease. Chest. 91(1):29–32. 768 Radtke, K., Obermann, K., & Teymer, L. (2014). Nursing knowledge of physiological and psychological outcomes related to patient sleep deprivation in the acute care setting. Medsurg Nursing, 23(3), 178. Slatore, C. G., Goy, E. R., O’Hearn, D. J., Boudreau, E. A., O’Malley, J. P., Peters, D., & Ganzini, L. (2012). Sleep quality and its association with delirium among veterans enrolled in hospice. The American Journal of Geriatric Psychiatry, 20(4), 317-326. Van Rompaey, B., Elseviers, M. M., Van Drom, W., Fromont, V., & Jorens, P. G. (2012). The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients. Critical Care, 16(3), R73. Weinhouse, G. L., Schwab, R. J., Watson, P. L., Patil, N., Vaccaro, B., Pandharipande, P., & Ely, E. W. (2009). Benchto-bedside review: delirium in ICU patientsimportance of sleep deprivation. Critical Care, 13(6), 234. White DP, Douglas NJ, Pick CK. (1983) Sleep deprivation and the control of 765 ventilation. American Review of Respiratory Disease. 128(6):984–6. 766 Wright, K. P., Drake, A. L., Frey, D. J., Fleshner, M., Desouza, C. A., Gronfier, C., & Czeisler, C. A. (2015). Influence of sleep deprivation and circadian misalignment on cortisol, inflammatory markers, and cytokine balance. Brain, Behavior, and Immunity.47:24-34. Ye, L., Keane, K., Johnson, S. H., & Dykes, P. C. (2013). How do clinicians assess, communicate about, and manage patient sleep in the hospital? Journal of Nursing Administration, 43(6), 342-347. Wang J, & Greenberg H.(2013) Sleep and the ICU. Open Critical Care Medical Journal. 6(S1:M6):80–7.

February 2016 Volume 23, No. 7 29

ISSUES

Finances and health

Impact of financial difficulty on health and aged care choices By Bernadette Pasco There is no doubt financial difficulty impacts on people’s mental and physical health. While anyone can be the victim of financial hardship, older Australians are particularly at risk. Life events such as a death of a family member, accident, acute illness, diagnosis of a chronic or life-limiting illness, change in family circumstances, family violence or simply getting older can result in financial difficulty. Unequivocally financial difficulty creates health issues, impacts significantly on how people negotiate their older years, be included, and maintain quality of life. The new age of financial inclusion and choice should benefit older people, however it can result in financial exclusion for many. Credit legislation has promoted responsible lending and other consumer credit issues, and yet increasingly, older Australians are seeking financial counsellors to assist with hardship around credit card debt, reverse mortgage products, mortgage arrears and hardship, financial and economic abuse, as well as many other issues resulting from accessing cash through non-mainstream ( eg. payday) lenders. Removal of age discrimination around lending allows older people to obtain a mortgage if they can demonstrate capacity to pay. This appears to financially include people, but there is in fact a risk of homelessness and financial hardship for these people if their care needs suddenly increase, or their partner dies. There is an assumption at a systemic level that older Australians are financially secure and yet, over 39% of people over 55 do not own their own home (Housing for the Aged Action Group – HAAG – Victoria 2014). Rental costs, scams, unfair contract terms, gambling to relieve social isolation and many other factors driving increased financial difficulty. Access to Residential Care and Home Care (CDC) packages for older Australians is accompanied by onerous financial assessments, which are often evaluated by personnel trained in social work or other roles. There are no questions asked about debt – just income and assets. Debt is often passed 30 February 2016 Volume 23, No. 7

on to families who do not know their rights. This disadvantages care recipients, and creates barriers to appropriate care decisions. Those eligible for Home Care packages within the new CDC framework, are confronted with a reduction in household income available for costs such as utilities, food, transport and other vitals due to interpretation of how these packages can be used; eg. meals on wheels not being allowed to be purchased from package funds. As a result people in great need are choosing not to take up care packages due to the cost implications and inability to meet ordinary cost of living . It is crucial that families are supported to understand their rights around their ageing parent(s)/ family member’s debt and be able to seek appropriate advice and solutions. It is equally vital that all older people entering care understand the provisions within care contracts. The Australian Consumer Law demands that contracts for services are clear, just and fair. The fact that most people entering aged care contracts do not know about the hardship provisions in the Aged Care Act suggests that there may be breaches of this law. Financial counsellors are trained professionals who use Australian law, Industry Codes of Practice and other tools to assist people in debt and financial difficulty with advocacy. Financial counsellors work to resolve individual financial difficulty, effect systemic change and educate worker groups and communities. Referral to a financial counsellor will assist with the following: • Full financial assessment including assessment of debt and whether debts are legally owed; • advocacy for debt and other financial difficulty; • advocacy with Centrelink and related government agencies; any creditors including utility companies, telcos, debt collectors etc.; • referral to other services –

eg. mental health services, counselling, family services, health services, legal services. ‘Dignity and Debt’ is an initiative of the Financial and Consumer Rights Council (FCRC, the peak body for financial counsellors in Victoria) funded by the Lord Mayor’s Charitable Foundation. This pilot, the first of its kind, is being run in the Hume region of Victoria with partner organisations, Goulburn Valley Health, Mansfield Shire Council and Hutchinson Eldercare Legal and focuses on appropriate financial and debt assessment as people enter the aged care system. Staff qualified in nursing, aged care and financial counselling are employed to provide one on one casework and education for aged care providers and their staff; reference group members include local ACAS, Seniors Rights Victoria, health, residential and community care professionals. Reducing financial stress is known to improve health and wellbeing, ensuring a more successful journey into aged care whilst supporting families and building more resilient communities. Financial Counselling Services are free and can be accessed by anyone in Australia who is in financial difficulty by calling 1800 007 007 People interested in the FCRC Aged Care initiative can contact Bernadette Pasco on bpasco@fcrc.org.au

Bernadette Pasco is a Financial counsellor/ Registered nurse and ManagerTraining and Sector Development, Financial and Consumer Rights Council; (peak body for financial counsellors in Victoria) This article is based on the views and research of the author(s) and has not been peer reviewed. anmf.org.au

VIEWPOINT

Mental illness: part of the noncommunicable diseases epidemic By Mick Hawkins Mental illness is one of the non-communicable diseases inflicting the modern human race, all of which are associated with inflammation and gut bacteria, according to the worldwide organisation Development Origins of Health and Disease. This claim was made by Professor Susan Prescott from the University of Western Australia at an informative presentation I attended last year. Brogan (2014) also supports this view through identifying the relationship of white blood cell activity to depression and bipolar disorder.

Gut bacteria Prescott (2015) states there are ‘friendly’ bacteria in the gut but also gut bacteria that can induce inflammation. This view is supported by Brogan (2014) who suggests 70% of our immune system is in our gut wall and any disturbance to this will trigger inflammation which in turn can be a factor in mental illness. It has also been theorised that a diet encouraging proliferation and activity of ‘friendly’ gut bacteria may provide a more acceptable treatment for depression than psychotropic medication (Dalth et al. 2015).

Current applicability While we still have much to learn about human organic responses, if the nexus between inflammation and gut bacteria and mental illness can be established, and accepted, this could make a radical change to the way we deal with mental illness; both diagnosis and treatment. In January 2015, the medical journal, The Lancet proclaimed, “Nutritional medicine should now be considered as a mainstream element of psychiatric practice with research, education, policy, and health promotion supporting this new framework.” anmf.org.au

Basic microbiology 1. DNA is within the nucleus of every human cell. 2. A gene is a length of DNA that codes for a specific protein. 3. Genes (we have around 25,000) account for 3% of DNA. 4. Not all genes are ‘switched on’. Many are dormant. Those that are switched on give our bodies the protein needed to function (eg. insulin for pancreas cells). If this switching is awry, then we are susceptible to non-communicable diseases including mental illness. 5. Which genes are switched on and which are dormant depends on three factors, which are: • Genetics - What is in our DNA - direct from our forebears. • Epigenetics - Lifestyle choices that can lead to gene modification (some turned off, some turned on), but no basic change to DNA. And this can be inherited. • Environment and Lifestyle - Lifestyle choices we make or an environment inflicted on us that act independently of genetics and epigenetics. (Virtual Genetics Education – Gene Expression and Regulation, University of Leicester, 2015) According to Lewis (2014), “Epigenetic changes can be the result of your diet, lifestyle and environmental toxins you may be exposed to. But they can also be programmed before birth due to the diet and experiences of your mother, father or even grandparents.” She adds, “In epigenetic changes…modifications to the DNA or to the proteins that help to pack the long strands of DNA into our cells are added or removed. These modifications can determine whether or not a gene is active in a particular cell.” Evidence in regards to the impact of prenatal physical constraints on mental health has been acknowledged. For example: • As a result of the famine in the Netherlands during 1946, malnourished women in their first trimester gave birth to children with increased incidence of schizophrenia. Those in their second and third trimester had children

“EPIGENETIC CHANGES CAN BE THE RESULT OF YOUR DIET, LIFESTYLE AND ENVIRONMENTAL TOXINS YOU MAY BE EXPOSED TO. BUT THEY CAN ALSO BE PROGRAMMED BEFORE BIRTH DUE TO THE DIET AND EXPERIENCES OF YOUR MOTHER, FATHER OR EVEN GRANDPARENTS.”

with increased incidence of depression (Jacka 2015). • Restricted paternal diet resulting in lack of dietary foliate has been associated with autism and schizophrenia (Jacka 2015). • Giving birth vaginally allows the baby to absorb vaginal flora (first dose of probiotic) to optimise physical and mental development. Though antibiotic treatment before conception can have an adverse effect on vaginal flora (Johnson-Cash, 2014).

Points to ponder 1. What are the incentives for potential parents to acknowledge and act on to make the best preparation for offspring pre-conception, in utero, and post-delivery? 2. Are there any steps health professionals can make to encourage their clients to take into account the effects of poor diet on their mental health and that of their offspring? 3. Pre-school children in Australia have a diet likely to aggravate the incidence of mental illness as they mature. What coordination is possible between paediatrics and mental health services to help manage this? Mick Hawkins is a Mental Health Nurse from South Australia This article is based on the views and research of the author(s) and has not been peer reviewed.

References Brogan K. (12 May 2014) Psychoneuroimmunology : How Inflammation Affects your Health. http://articles.mercola. com/sites/articles/ archive/2014/04/17/ psychoneuroimmunology -inflammation.aspx (Retrieved 2015) Dalth, Clarke, Berk, and Jacka, (2015) The Gut Microbiome and Diet in Psychiatry: Focus on Depression, Current Opinion Psychiatry 2015,:28(1) 1-6 http:// www.medscape.com/ nurses (Retrieved 2015) Lewis, D. (April 2014) ABC Health and Wellbeing, www.abc. net.au/health/features/ stories/2014/04/10/39 82655.htm, (Retrieved 2015) Jacka, F. (May 2015), GP Update, Women’s and Children’s Health Seminar (Healthed), As part of presentation quoted American Journal of Psychiatry, Feb 2000 157(2), 190195 and British Journal of Psychiatry, May 1995, 16d(5), 601-606 Johnson-Cash, J. The Human Microbiome: Considerations for Pregnancy, Birth, and Early Mothering, Midwife Thinking, http://midwifethinking. com/2014/01/15/ the-human-microbiomeconsiderations-forpregnancy-birth-andearly-mothering/ (Retrieved 2015). Prescott, S. (2015) Origins- Early Life Solutions to The Modern Health Crisis , UWA Publishing. Virtual Genetics Education – Gene Expression and Regulation, University of Leicester www2.le.ac.uk/ departments/genetics/ vgec/schoolscolleges/ topics/geneexpressionregulation (Retrieved 2015).

February 2016 Volume 23, No. 7 31

REFLECTIONS

App challenged: Are midwives prepared? By Joyce Hendricks, Deborah Ireson and Carol Pinch In the 21st century, technology will continue to advance rapidly and become the norm in healthcare rather than the exception.

In a recent study by Ireson (2015) it was found pregnant adolescents preferred to consult internet ‘apps’ to obtain information and education about pregnancy, birth and parenthood. Smartphones now play an essential role in pregnancy and delivery, and the influence on self-education and health-seeking behaviour. This presents midwives with a significant challenge as this age cohort, are already deemed a high risk group and often do not engage with midwifery care. Ireson found when attending the antenatal clinic, pregnant adolescents challenged the midwife’s knowledge and advice based on an ‘app’. This issue is not exclusive to adolescents as many pregnant women use interactive apps to record and track information. Some apps allow questions that might be uncomfortable to ask a healthcare professional, to be asked in a mask of privacy which may contribute to an intimate and non-judgmental relationship with a smartphone (Tripp et al. 2014). Midwives in the academic setting have also noted the increase in students challenging course content based on the use of apps. A cursory search, in October 2015, of pregnancy, birth and parenthood applications in the Apple store found in excess of 1200 apps. The Google Play store had in excess of 700 apps. According to Tripp et al. (2014), there are more pregnancy apps than for any other health topic, enabling women to track their pregnancies, communicate with others and to potentially alleviate anxieties 32 February 2016 Volume 23, No. 7

through interactive consultations. These apps provide a broad range of maternal and foetal topics, many offer advice and guidance creating a plethora of information at the touch of a button. Midwives often find communication with young adults to be confounding. This may be due to the midwives’ approach to working with younger adults being influenced by long held beliefs and traditional midwifery practice. Today’s young adults are a part of the millennial generation (18 to 29 years) who are computer literate. Those who are pregnant and under 18 are more smartphone and ‘app’ reliant than their predecessors (Frazer et al. 2015). What is known is that midwives are an older age group and the increase in technologies in healthcare are adverse to its use (Pugh et al. 2013). Many are overwhelmed by the plethora of technologies, information and now the use of smartphone apps which bombard their senses. Moreover, midwives may not be familiar with the software that is available for educational purposes and lack confidence in their own abilities to cope with new technologies. This begs the question: Are ‘apps’ replacing the need to have midwives undertake antenatal care? When an ‘app’ is user friendly and instantaneous in response to concerns and does not reply in a condescending or judgmental way (Courtney-Pratt et al. 2012). Daniels & Wedler (2015) asks how health professionals can educate expectant parents when everything they need to know appears at their

fingertips or the push of a button. For midwives many questions need consideration. Do they have the time to discuss information drawn from ‘apps’ with the app user? If so, how will the authenticity of the information be determined? How will models of care need to change to acknowledge use of ‘apps’ as a care option rather than a divergence from ‘real’ hands on midwifery? How will midwives manage having women contest their advice? How will current health service policies accommodate the use of and access to smartphonetype technologies? Exploring the myriads of educational technology and tools that can be used can be overwhelming. In preventing what could be a potential undermining of the profession, midwifery educators must now meet this onslaught by supporting currently practising midwives and preparing new generations of midwives to utilise current technology to create avenues that bring midwifery services closer to women and not further away. Joyce Hendricks is a PHD, RM, RN Senior Lecturer, Deborah Ireson, PHD candidate RM, RN Clinical Midwife and Carol Pinch is a MM, RM, RN Lecturer. All are based at the School of Nursing and Midwifery , Faculty of Computing, Health and Science Edith Cowan University This article is based on the views and research of the author(s) and has not been peer reviewed.

References Courtney-Pratt, H., Cummings, E., Turner, P., Cameron-Tucker, H., Wood-Baker, R., Walters, E., & Robinson, A. (2012). Entering a World of Uncertainty. CIN: Computers, Informatics, Nursing, 30(11), 612-619. doi:10.1097/ nxn.0b013e318266caab Ireson, D (2015). Antenatal clinic: using ethnographic methods to listen to the voices of pregnant adolescents, unpublished thesis, Edith Cowan University, Western Australia. Daniels, M., & Wedler, J. (2015). Enhancing Childbirth education through technology. International Journal of Childbirth Education, 30(3), 28-32. Frazer, C., Hussey, L., Bosch, E., & Squire, M. (2015). ‘Pregnancy Apps: a closer look at the implications for childbirth educators’. International Journal of Childbirth Education, 30(3), 12-16. Pugh, J., Twigg, D., Martin, T., & Rai, T. (2013). Western Australia facing critical losses in its midwifery workforce: A survey of midwives’ intentions. Midwifery, 29(5), 497-505. http:// dx.doi.org/10.1016/j. midw.2012.04.006 Tripp, N., Hainey, K., Liu, A., Poulton, A., Peek, M., Kim, J., & Nanan, R. (2014). An emerging model of maternity care: Smartphone, midwife, doctor? Women and Birth, 27(1), 64-67. http:// dx.doi.org/10.1016/j. wombi.2013.11.001

anmf.org.au

WORKING LIFE

Minutes matter to save a life By Natalie Dragon Victorian nurse Anne Holland was hanging the washing on the line when her husband Paul had a myocardial infarction upstairs in their two-storey home in Brighton 2008. “He had been doing his back exercises on the floor after going for a two-hour bike ride along Beach Road. Our son Daniel was at the dining table with his maths tutor. I heard him go upstairs,” Anne says. “I thought the hedges need trimming he can’t be going for a shower. I was still hanging the washing on the line when our son Xavier (22) found him.” Paul Holland died aged 56, leaving behind five children – four sons and a daughter. Although Paul wasn’t found for 45 minutes, Anne has launched a public awareness campaign for saving lives with the use of automated external defibrillators (AED). She argues there are too few defibrillators in the community and too few people know what to do with them. “It’s about getting the message across. People hear the stats about the safety of fire extinguishers and smoke alarms. The biggest killer is cardiac arrest. There are more deaths from cardiac arrests than fire-related causes and we have smoke alarms.”

THERE ARE 33,000 CARDIAC ARRESTS EVERY YEAR WITH 75% OF THOSE OUT OF HOSPITAL,

There are 33,000 cardiac arrests every year with 75% of those out of hospital, Anne says. “It is the one cause of death that the person next to you needs you to do something about. Defibrillators have to be as common as fire extinguishers. It’s not a big deal, defibrillators cost $2,500.” Anne launched not-for-profit Urban Lifesavers late last year with a gala dinner at Crown Towers in October. Her message is simple: Minutes matter. “The first three to five minutes are critical: it is a window to get the best outcome. This resonates with people.” anmf.org.au

The biggest problem is education, Anne says. “People are terrified they are going to do something wrong.” A critical care nurse, Anne is also a nurse immuniser and first aid trainer. She started ‘Defib First’ in 2012, a business initially aimed for organisations and workplaces. “I wanted to start educating people to use defibrillators. There has been a focus on getting defibrillators out there and that’s great but there is not a lot of knowledge and confidence about how to use them.” A lot of businesses and workplaces can benefit from the use of defibrillators, says Anne. The Victorian government announced funding of $3 million in May for 1,000 sporting clubs to have AEDs. Anne wants to see them within every 3km radius within the community, such as supermarkets and workplaces with 10 or more people. “I teach what a normal heartbeat is. I teach people there are lots of causes of cardiac arrest: drug overdose, choking, asthma, strangulation, smoke inhalation, drowning. It starts to dawn on people the urgency of those first few minutes. Minutes matter to save a life. I talk about cardiac arrest how it happens, why it happens and debunk some of the myths.” Anne says there needs to be a national awareness campaign similar to that of the national road toll. “In 1969, there were 1,034 deaths on the road. There was a blitz with the introduction of seatbelts and drink driving messages - 1,193 people died on Australian roads in 2013 - compare this with 33,000 cardiac arrests.” Public awareness campaigns, are needed, says Anne. “There have been huge awareness campaigns and investment into skin, breast and prostate cancers which are important but there is a huge lack of understanding of how significant this is (cardiac arrest) and reversible. One bystander can do something. You can save someone’s life within three minutes. Everybody in the country can learn how to be an

Back in a Heart Beat By Anne Holland

RRP: $29.99 Publisher: Writing Matters Publishing www.writingmatterspublishing.com ISBN: 978-0-9575440-5-5 urban lifesaver.” Anne wants to raise awareness of Urban Lifesavers similar to that of the Organ Donor Campaign. An urban lifesaver does not have to have had first aid training. She is calling on her colleagues in the profession to help raise awareness. “If we can educate our own profession to teach the ordinary person and empower them to be an urban lifesaver to take action and save a life, we can build community awareness. We need a groundswell and lobbying from the baseline up instead of the top down.” Anne’s book ‘Back in a Heart Beat’ was published late last year on busting the myths about sudden cardiac arrest and why bystanders can safely use defibrillators. She plans to be a keynote speaker at community events to spread the message to empower people to feel comfortable with defibrillators. www.urbanlifesavers.org.au www.defibfirst.com.au February 2016 Volume 23, No. 7 33

EDUCATION

Leukaemia

Haematological malignancies This tutorial is designed to introduce common haematological malignancies. It covers the main types of leukaemia and lymphoma, as well as multiple myeloma and myelodysplastic syndromes. You will learn about the epidemiology, pathology, symptoms and diagnosis, and available treatment options for each of these cancers. The tutorial on the website offers detailed graphics and animations to show the proliferation of each of the cancers. The word cancer refers to a group of diseases made up of over 100 different types. This tutorial focuses on cancers affecting the blood and blood-forming tissues. In 2008, the latest year for which global statistics are available, the number of cancer cases worldwide, excluding nonmelanoma skin cancer, was estimated to be 12.7 million. Cancer is a condition in which cells become abnormal and start to grow and multiply uncontrollably. Cancer cells can also invade surrounding tissues and form metastases, spreading from where it initially developed to other organs. Leukaemia is a cancer of the blood and bone marrow, and is characterised by an overproduction of leukocytes and their precursor cells. There are four main types of leukaemia 1. Acute lymphocytic leukaemia (ALL) 2. Acute myeloid leukaemia (AML) 3. Chronic lymphocytic leukaemia (CLL) 4. Chronic myeloid leukaemia (CML) Acute leukaemia progresses rapidly and involves immature cells 34 February 2016 Volume 23, No. 7

Lymphoma

with a low degree of differentiation, whereas chronic leukaemia progresses slowly and involves dysfunctional, mature, and well-differentiated cells. Lymphocytic leukaemia involves cells from the lymphoid lineage, while myeloid leukaemia involves cells from the myeloid lineage. Both ALL and CLL are more common in males than females and are more common in white people than black people. ALL is primarily a disease of childhood and accounts for 75% of leukaemia in children younger than six years old. It is uncommon in adults and accounts for about 15% of adult leukaemia cases. The risk of developing ALL is at its highest in people younger than five years; it then declines slowly until they reach their mid-20s, before slowly rising again past the age of 50 and reaching a second, much lower peak, past the age of 70. In contrast CLL is extremely rare in children, but is the most common type of leukaemia among adults living in Western countries. Approximately 90% of CLL patients are over 50 years, with a median age of 70 years; there are nearly no cases of CLL in people younger than 30 years. CLL is rare in Asia. ALL is a heterogenous disease with many different subtypes, which are currently categorised according to the WHO classification. Typical symptoms of ALL reflect the low blood counts resulting from the multiplication of malignant lymphoblasts impairing hematopoietesis. They include: • fever; • fatigue (associate with anaemia); • bleeding (associated with thrombocytopenia); • infections (associated with low counts of normal mature white blood cells). CLL tends to evolve slowly. Most

Multiple myeloma

APPROXIMATELY 90% OF CLL PATIENTS ARE OVER 50 YEARS, WITH A MEDIAN AGE OF 70 YEARS; THERE ARE NEARLY NO CASES OF CLL IN PEOPLE YOUNGER THAN 30 YEARS. CLL IS RARE IN ASIA.

patients do not exhibit symptoms when they receive their diagnosis, which often occurs after a blood count was performed for another reason. If symptoms are present, they tend to be non-specific and include: • fatigue; • frequent infections; • night sweats; • enlarged lymph nodes; • weight loss; • anorexia. Diagnosis for both ALL and CLL include a full blood count (FBC); bone marrow biopsy; flow cytometry; and immunohistochemistry. There are three main treatment options for ALL, chemotherapy, targeted therapy and stem cell transplantation. Unlike other leukaemias, immediate treatment initiation may not be necessary following a diagnosis of CLL, as the disease, where the majority of patients affected are 70 years or older, usually evolves very slowly. However, treatment options include chemotherapy; monoclonal antibodies; and stem cell transplantation. anmf.org.au

EDUCATION

This excerpt is from our Body Systems Training Room website. The complete course is 75 minutes in duration and this excerpt will give you 0.5 hours of CPD towards ongoing registration requirements.

Myelodysplastic syndromes

In regards to the myeloid leukaemias, AML and CML, both diseases are slightly more common in males than females. While AML is more common in white people than black people, ethnicity doesn’t seem to have an impact on the incidence of CML. Both have been known to occur at any age, the incidence of both increases with age, peaking in the later decades of life. The median age at diagnosis is 64 years for AML and 60 years for CML. AML is a cancer involving immature cells from the myeloid lineage. The description of its pathology is largely based on the genetic abnormalities underlying the disease. Most of the time AML progresses rapidly. In half of AML cases, fatigue is the first symptom. In 10% of patients, the first symptom is fever, while in 5% of patients, it is bleeding or bruising easily. Anorexia and weight loss are also commonly reported. The WHO divided CML into three phases, depending on the amount of immature myeloid cells present in the blood or bone marrow. A myeloblast level lower than 10% corresponds to the chronic phase; a level between 10% and 20% corresponds to the accelerated phase; and a level of 30% or more corresponds with the blast or acute phase. CML patients carry the Philadelphia chromosome or the BCR-ABL gene. Similar to CLL, CML is often discovered when patients undergo blood tests for an unrelated reason or routine screening. Although many patients are asymptomatic at the time of diagnosis, symptoms may include: • Weakness • Fatigue • Malaise • Night sweats anmf.org.au

Weight loss Fever Spleen enlargement Sensation of fullness in the stomach, even after a small meal. Tests used in the diagnosis of AML include, FBC; bone marrow biopsy; cytochemistry; flow cytometry and immunohistochemistry; and cytogenic tests. For CML, FBC; bone marrow biopsy; and cytogenic tests. • • • •

THERE ARE THREE MAIN TREATMENT OPTIONS FOR ALL, CHEMOTHERAPY, TARGETED THERAPY AND STEM CELL TRANSPLANTATION.

Because AML progresses quickly, treatment often needs to be initiated shortly after diagnosis is made. The initial goal is complete remission. Chemotherapy is the main treatment however a stem cell transplant is also sometimes used after chemotherapy. Due to patients either carrying the Philadelphia chromosome or BCR-ABL gene, gene-targeted therapy is now the standard treatment option for CML. The term lymphoma is used to describe various cancers characterised by the uncontrolled multiplication, usually within the lymph nodes, of white blood cells known as lymphocytes. Approximately 85% of lymphomas involve mature B cells. Unlike leukaemia, in which malignant cells are usually found

throughout the blood and bone marrow, lymphoma tends to form discrete tumours. Lymphomas are divided into two types, Hodgkin and Non-Hodgkin lymphomas. Hodgkin lymphoma is characterised by the presence of Reed-Sternberg cells, which are giant, abnormal B cells. It spreads in an orderly fashion throughout a single, contiguous chain of lymph nodes, but rarely invades tissue outside of the lymph nodes. In contrast, Non-Hodgkin lymphoma spreads in a disorderly fashion and effects multiple noncontigous lymph nodes, as well as extranodal tissues. Multiple myeloma involves the formation of solid tumours in the bone marrow. Tumours consisting of malignant plasma cells are known as plasmacytomas. When a patient only has one tumour, the condition is called isolated or solitary plasmacytoma. When several plasmacytomas are disseminated in many foci, the term multiple myeloma is used instead. Malignant plasma cells produce only one type of abnormal antibody, which is unable to fight infection. Myelodysplastic syndromes encompass multiple conditions in which a malignant multipotent stem cell divides, leading to a progeny (offspring) of abnormal clones that replace normal bone marrow. It used to be called pre-leukaemia because of the approximately 30% chance they have to transform to AML. However, because transformation does not actually occur in the majority of patients, this term is no longer in use. To view the complete tutorial go to: www.anmf.adamondemand.com. au/Home/AOD1Index and either login or register to access this anatomy and physiology website. For further information contact the Federal Education Team at education@anmf.org.au or phone 02 6232 6533. February 2016 Volume 23, No. 7 35

VIEWPOINT

Advancing initiatives in care of cognitively impaired patients in acute care settings Fred Graham, Catherine Travers, Elizabeth Beattie and Amanda Henderson The Australian Commission on Safety and Quality in Health Care (ACSQHC) released in November 2014, “A better way to care: Safe and high quality care for patients with cognitive impairment (dementia and delirium) in hospital”. The handbook is available as three separate resources for the three audiences: clinicians, service managers and consumers. These resources are designed to inform and guide improved care for older patients with cognitive impairment (CI) (dementia, delirium) in acute care settings. In particular, the service managers resource recommends that organisations comprehensively prepare themselves so that they are alert to delirium and the risk it poses for patients, that they can recognise and respond to patients with CI, and that they are able to provide safe and high quality care tailored to individual patient’s needs. Service managers and clinicians should carefully consider the information provided in the resources and judiciously explore how best to modify and adapt everyday care practices where appropriate. It is important that clinical teams respond to the available information as the ACSQHC identifies that dementia and/or delirium is associated with adverse outcomes, including functional decline, increased risk of falls, and increased morbidity and mortality. The Princess Alexandra Hospital (PAH), in Brisbane, Queensland, is embarking on an ambitious journey to embed best practices associated with caring for hospitalised people with CI into routine patient care. To date, PAH has introduced a range of best practices that have been identified as suitable for the hospital setting, including clinical assessment tools for delirium and pain that assist in tailoring care as well as resources that optimise the psychosocial and physical hospital setting to make it less threatening for people with CI. Practices that aim to accommodate the patient’s regular lifestyle and maintain their normal daily routine and 36 February 2016 Volume 23, No. 7

activities are encouraged as much as is practical within a hospital environment. For example, using the patient’s preferred name when speaking with him/her; normalising meal-times by sitting together with patients at a table so that they can engage in conversation; providing opportunities for the patient to engage in recreational and social activity such as playing cards or going for a walk. There are also display charts that aid in person-centred communication and act as a quickreference for staff about the ‘life story’ of the person with CI. This can facilitate topics for conversation and for staff to gain a greater appreciation for the patient as an individual. Further measures include the use of diversional resources such as fiddle blankets’ (blankets covered in textually stimulating materials for distraction) and indwelling-urinary catheter decoy aprons. Although PAH has introduced the above tools and resources to create better psychosocial and clinical care, the adoption of these best practice processes by ward nurses appears inconsistent and haphazard. It is therefore necessary to develop and investigate an educational and cultural intervention that will facilitate a practice change so that best practice nursing care is consistently deployed and embedded as everyday care practices. The project team is mindful of the many barriers in acute care contexts to implementing guidelines and furthermore sustaining best practices. A grant from the Department of Social Services seeks to address the cultural, motivational and clinical mechanisms required to sustainably embed best practice nursing care toward this vulnerable population of hospital patients. The grant will target education of nurses, be facilitated through change champion nurses and involve the adoption of a range of local leadership and support mechanisms. The project aims to provide comprehensive evidencebased delirium education for nurses, implement clinical practice guidelines for delirium identification, prevention and management,

THESE RESOURCES ARE DESIGNED TO INFORM AND GUIDE IMPROVED CARE FOR OLDER PATIENTS WITH COGNITIVE IMPAIRMENT (CI) (DEMENTIA, DELIRIUM) IN ACUTE CARE SETTINGS. and embed these guidelines within routine nursing practices and procedures to promote sustainability. A sound, evidencebased implementation strategy will be adopted to promote learning and understanding including the use of validated educational modules, developed specifically for nurses, interactive workshops and input from key organisations including the Queensland Dementia Training Study Centre (DTSC). Proven change management strategies will be utilised to facilitate the project’s implementation including providing staff with regular project updates to raise awareness of the project, involving nursing staff as much as possible in the process to promote engagement, using audit and feedback to provide regular, timely feedback to staff regarding progress, and incorporating tools and strategies within standard processes (eg. the incorporation of cognitive assessment tools within the medical record) to routinise their use. Most importantly, the project has been endorsed by the hospital executive and has the support of key nursing personnel – critical to the success of any such initiative. It is anticipated that because staff will have a greater understanding about how best to engage with cognitively impaired patients when they are hospitalised that there will be a reduction in adverse events such as falls and pressure ulcers. The project team is happy to talk with any clinicians who are interested in this work that is presently being undertaken. www.safetyandquality.gov.au/ our-work/cognitive-impairment This article is based on the views and research of the author(s) and has not been peer reviewed.

Fred Graham is Clinical Nurse Consultant at Princess Alexandra Hospital Catherine Travers is a Researcher at Dementia Collaborative Research Centre: Carers and Consumers Elizabeth Beattie is Professor of Aged Care at Queensland University of Technology Amanda Henderson is Nursing Director at Princess Alexandra Hospital anmf.org.au

BOOKS RRP:

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A MODERN EPIDEMIC

BEDPAN BLUES

Expert perspectives on obesity and diabetes

The hilarious, true story about a bushie’s two-month stay in a Sydney public hospital

EDITED BY LOUISE A BAUR, STEPHEN M TWIGG AND ROGER S MAGNUSSON

Publisher: Sydney University Press

ISBN: 978-1-920899-85-1

Diabetes, obesity and their related diseases present some of the greatest challenges to human health in the 21st century. In A modern epidemic: expert perspectives on obesity and diabetes, a diverse group of clinicians from the University of Sydney dissect strategies to tackle these major health challenges. Critically, the book points out that obesity and diabetes are not just problems for the individual, but can also pose risks to the environmental, psychological and economic stability of the globe. Therefore, it suggests solutions need to be equally wide-ranging and accessible to all. Acknowledging this, the authors detail the current landscape in an engaging style, listing the causes and consequences of obesity and diabetes, as well as prevention and treatment approaches. The end goal, it says, is identifying and mitigating the risk factors that lead to obesity and diabetes by delivering targeted and effective healthcare and formulating world-wide strategies to curb one of the 21st century’s most devastating diseases. anmf.org.au

BY SANDY THORNE

Publisher: ST Publishing ISBN: 978-0-9751627-3-6

Bush poet, humourist, and best-selling author Sandy Thorne has faced many challenging situations and adventures throughout her life. But nothing quite prepared her for a two-month ‘incarceration’ in a major public hospital in Sydney. With trademark humour and unflinching candour, Thorne shares her experiences in Bedpan Blues. Her first book, I’ve Met Some Bloody Wags, became an instant bestseller, and her bush humour and outback yarns went on to capture the attention of people for the next 30 years, including the likes of talk-show hosts David Letterman and Michael Parkinson. In Bedpan Blues, Thorne is at her witty best as she vividly recounts her stay in a Sydney public hospital with doctors, nurses and a never-ending stream of patients in her ward. Thorne deals with lack of sleep, daily bowel interrogations, hospital tucker and a constant fear of contracting the dreaded Golden Staph. Her account is hilarious and proves once again that laughter is the best medicine.

FOSTERING NURSE-LED CARE

WRITING AT WORK How to write clearly, effectively and professionally

Professional practice for the bedside leader from Massachusetts General Hospital

BY NEIL JAMES

Publisher: Allen & Unwin ISBN: 978-1-74175-218-2

BY JEANETTE IVES ERICKSON, DOROTHY A. JONES, AND MARIANNE DITOMASSI

Publisher: Renee Wilmeth ISBN: 978-1-935-47630-6

Nurse leaders exist at every level, from the bedside to the boardroom. But these days, nurse leaders and managers face major challenges in healthcare delivery models that pressure them to improve patient care while at the same time boosting efficiency and lowering costs. Add to this the demand to provide adequate nursing education and curb retention rates and you have a recipe that can create overwhelming stress for an organisation. Fostering Nurse-Led Care, compiled by three of Massachusetts General Hospital’s top nurse executives, reveals secrets of the professional practice model that has improved system outcomes and increased patient, family, and staff satisfaction over the past 20 years. The book provides details surrounding the development, implementation and evaluation of a professional practice environment, focusing on lifting standards, adopting patient safety measurements, and balancing cost with quality.

Based on workshops developed by the Plain English Foundation, Writing at Work: How to write clearly, effectively and professionally, is an informative guide to writing well in the workplace. Professionals including lawyers, engineers, healthcare workers, financial advisors, academics and public servants all spend significant amounts of time at work writing documents, letters, reports, and submissions. It is understandable then, that getting your message across clearly and effectively can make all the difference to a successful career. Writing at Work gives you a practical toolbox to assist you with that impending writing task, whether you need help with planning a document, structuring text, selecting the appropriate tone of voice, or editing the final product. Author Neil James uses real examples throughout the book to offer the reader a real insight into how important the principles of effective writing in the workplace can be.

February 2016 Volume 23, No. 7 37

FOCUS

Aged care

Using sound therapy to ease agitation amongst persons with dementia: a pilot study

THE GREATEST DIFFERENCES WERE OBSERVED IN THE PHYSICALLY NON AGGRESSIVE BEHAVIOURS. A 50% REDUCTION WAS OBSERVED AMONGST RESIDENT PARTICIPANTS IN THIS DOMAIN.

By Caroline Bulsara, Karla Seaman and Silke Steuxner

This paper reports on the outcomes of a one month intervention using TSBT amongst a group of 16 residents within a large residential aged care facility in Western Australia. This study was granted ethical approval from the Human Research Ethics Committee at the University of Western Australia.

Method Resident internal records for the following areas over a six month period prior to the intervention were obtained in order to establish a resident profile for the facility for the 16 residents. The validated Cohen Mansfield Agitation Inventory (CMAI) (Cohen-Mansfield,

Participants Participants were residents of two of seven houses which comprise of the 131 bed facility and staff who are directly involved in caring for persons in the two participating houses. Consent to participate in

Figure 1 Scores for all three CMAI domains amongst residents over the three time points for the one month intervention period. 3

2.5

Braden, B. A. and P. M. Gaspar. 2014. Implementation of a baby doll therapy protocol for people with dementia (innovative practice). Dementia: 1471301214561532 Chang, F. Y., et al. 2010. The effect of a music programme during lunchtime on the problem behaviour of the older residents with dementia at an institution in Taiwan. Journal of Clinical Nursing 19(7-8): 939-948

Cotter, V. T., et al. 2014. Avoiding restraints in hospitalized older adults with dementia. Journal of Nursing 11: 95-101

Hynninen, N., et al. 2015. The care of older people with dementia in surgical wards from the point of view of the nursing staff and physicians. Journal of Clinical Nursing 24(12): 192-201

1.5 2 Time Period

1 Aggressive Behaviour

Verbally Agitated Behaviour

3 Physically Non-Aggressive Behaviour

Table 3 Observed behaviour reduction (physically non aggressive agitated) over the one month intervention period Time Period

Agitated

% participants

Not agitated

% participants

87.5

12.5

68.75

31.25

37.5

62.5

38 February 2016 Volume 23, No. 7

References

Cohen-Mansfield, J. 1997. Conceptualization of agitation: results based on the CohenMansfield Agitation Inventory and the agitation behavior mapping instrument. International Psychogeriatrics 8(S3): 309-315

Mean

There is increasing evidence that the use of sound therapy such as Tibetan Singing Bowls (TSBT) to ease the effects of certain illnesses and chronic conditions is effective. A number of small scale studies have been conducted regarding the therapeutic effects of TSBT on those who are ill and/or recovering from illnesses such as cancer. Furthermore, there is a growing body of research around the therapeutic effects of sound therapy for calming those with dementia and agitation (Chang et al. 2010; Raglio et al. 2012; Ridder et al. 2013).

1997) was administered at baseline, midpoint and at the end of the one month intervention. The CMAI has three subscales measuring: 1. physically aggressive behaviour 2. physically non aggressive behaviour 3. verbally agitated behaviour

Raglio, A., et al. 2012. Music, music therapy and dementia: a review of literature and the recommendations of the Italian Psychogeriatric Association. Maturitas 72(4): 305-310 Ridder, H. M. O., et al. 2013. Individual music therapy for agitation in dementia: an exploratory randomized controlled trial. Aging & Mental Health 17(6): 667-678

anmf.org.au

Aged care the study was obtained through next of kin/guardian for the residents with additional clause for permission to film a resident. Overall, 16 full data sets were completed. Resident demographics were as follows with mean age of 85 years. The male female ratio was seven (44%) males and nine (56%) females. The challenging behaviours recorded on a database of residents from time of admission over the six month period prior to the intervention were: • hitting both self, staff and other residents; • verbal aggression towards staff and residents-pacing and restlessness; • tasks to complete activities of daily living (ADLs) requiring more staff (up to three direct care staff for one resident) to complete.

Results The greatest differences were observed in the physically non aggressive behaviours. A 50% reduction was observed amongst resident participants in this domain. The overall scores across three domains are shown in Figure 1 for the 16 resident datasets and are shown to be visually trending downwards across all domains.

Discussion It is becoming widely recognised that chemical restraints are no longer the preferred mode of helping to calm persons with dementia (Braden and Gaspar, 2014; Cotter, DrNP et al. 2014). Other proposed methods to reduce agitation levels in persons with dementia are becoming more widespread (Braden and Gaspar, 2014; Hynninen et al. 2015). Although a great deal more research is required in the area of sound and music therapy, the signs are positive. Furthermore, ongoing therapy sessions provide greater maintenance of calmer less agitated behaviours for longer time periods. Associate Professor Caroline Bulsara is in the School of Nursing and Midwifery at the University of Notre Dame Ms Karla Seaman is Senior Research Officer at Brightwater Care Group Silke Steuxner is an RN working for Peaceful Heart anmf.org.au

FOCUS

The resilience of aged care nurses By Vicki Cope The aged care nursing workforce in Australia is a workforce under pressure where the rapidly increasing turnover of more acutely ill or co-morbid patients and staff retention issues, place those staff that remain under extra stress to maintain a quality service.

Yet many Registered Nurses (RNs) do remain in the aged care work setting displaying tenacity and resilience despite well documented trials and tribulations. The population of Australia is ageing rapidly with a concomitant increase in demand for facilities and staff to care for the frail elderly. Nationally the number of persons aged 65 years and over now constitutes 14.7% of the population with a massive increase in the number of people over 85 years of age to 4.4% of the population. There are now also over 4,000 people who are over 100 years old (Australian Bureau of Statistics, 2014). These factors are placing increased demands on the predominately female residential/ aged care nursing workforce which is also ageing (AIHW, 2010). When studying nurses working within aged care or residential settings, Cope (2012) found that the aged care nurses felt under pressure to work harder and were dissatisfied with staff numbers, skill mix and workplace policies. The nurses also expressed very serious concerns about pay, workload, stress, and the physical and the emotional demands of nursing work. The residential aged care nurses consider their jobs to be poorly rewarded, reporting they cannot complete their work to their own satisfaction due to excessive paperwork impeding care. However, the study also unearthed the resilience of aged care nurses. Portraiture, a qualitative methodology, provided an overarching insight of the aged

care nurse participant’s world view and why each continues in her work. The major themes uncovered by the portraits included personal qualities of self-control, focusing on the positive with perseverance and hope, trust and a love of learning. The sense of accomplishment that comes from confronting a challenge, the importance of ‘paying it forward’ and the related volunteerism and opportunity for involvement to help and assist others. This is achieved with a sense of humour, with robust assertiveness, self-regulatory skills, peer group belonging and strong personal beliefs. These qualities in turn, help others to be, or become resilient, and display successful positive outcomes (Cope et al. 2015a). A proactive health promotion approach to building resiliency capacity which enhances psychological capital to take on challenging tasks; to be optimistic about success and to persevere is recommended to management (Cope et al. 2015b). Although the past cannot be changed, nor the influences of one’s childhood, coping strategies, problem solving and emotional intelligence and positivism can be developed, enhanced and sustained through education and training. The effect of increasing these resilient capabilities increases coping mechanisms and is instrumental in ultimately increasing nurses’ satisfaction levels which in turn aid retention levels, nurse staffing and patient safety outcomes (Cope et al. 2015c).

References Australian Bureau of Statistics. 2014. Australian population by age and sex, 3101.0 Australian Institute of Health and Welfare. 2010. Australia’s health 2010. In AIHW cat. No. AUS122. AIHW (Australia’s health series no. 12). Canberra: AIHW Cope, V.C. 2012. Portraits of nursing resilience: listening for a story. PhD thesis Cope, V.C., Jones, B., and Hendricks, J.M. 2015a. Portraiture: a methodology where success and positivity can be explored and reflected, Nurse Researcher, 22 (3), 6-12 Cope, V.C., Jones, B., and Hendricks, J.M. 2015b Resilience as resistance to the new managerialism: Portraits that reframe nursing through quotes from the field, Journal of Nursing Management, 1-8 Cope, V.C., Jones, B., and Hendricks, J.M. 2015c. Why nurses chose to remain in the workforce: portraits of resilience, Collegian, 1, 1-9

Dr Vicki Cope is Research & Higher Degree Coordinator in the School of Nursing and Midwifery at Edith Cowan University in Western Australia

February 2016 Volume 23, No. 7 39

FOCUS

Aged care

Virtual human technology researches decisions about care for patients with dementia By Frederick Graham Rates of adverse events and length-of-stay of hospitalised people with dementia are double that of people not experiencing dementia, according to evidence (Australia, Commission on Safety and Quality in Healthcare, 2014). Additionally, Moyle et al. (2010) suggest the behavioural and psychological symptoms of dementia (BPSD), such as aggression, agitation and wandering, are regularly mismanaged, with nurses inappropriately using physical and chemical restraint.

CRANAplus Position Paper: Older Persons – remote context By Marcia Hakendorf Australians are ageing. By 2042, the number of Australians aged 65 and over will constitute Australia’s fastest growing age group, from 13% (2002) to around 25% of the population – that’s 6.2 million (Australia’s Demographic Challenges). Longevity, declining birth rates and shrinking workforce, these demographic considerations will drive national health, social and economic outcomes (Australia’s Demographic Challenges). The fact is ageing is becoming a worldwide concern. The challenge is how to live well throughout the course of one’s life, and to know what is required to ensure health, and wellbeing [quality of life] for, and in later years. Active ageing is integral to maintaining quality of life of older persons, and this is no less important for those living in remote 40 February 2016 Volume 23, No. 7

The Australian Commission on Safety and Quality in Healthcare (2014) has recently recognised the urgent need for hospitals to take action in order to improve care for people with dementia and delirium. The Commission argued that hospitals must better prepare their staff in the area of dementia care. However It is unclear how we should better prepare hospital nurses to manage BPSD. My research is a descriptive correlational study of nurses’ clinical decision-making in relation to the hospitalised person with dementia. The research is designed around a virtual patient scenario. The simulation has been developed from a validated clinical vignette that describes a hospitalised person with dementia who develops new behavioural symptoms and confusion as a result of untreated pain. It investigates associations between independent variables such as level of experience, place of work, and level of education and training. This project uniquely and innovatively incorporates a range of multimodal technological

features including virtual human avatars, video clips and virtual clinical documentation. The avatars spontaneously interact with users by speaking while simultaneously using non-verbal body language including facial expressions and bodily gestures. It is hypothesised that such realistic interactions within the virtual world will enhance the clinical reality of the simulation for the user. The research projects unique virtual design will offer new opportunities for e-learning and virtual training in nursing. Furthermore, the new multimodal research approach contributes to the literature on methods of building virtual simulations. Finally, the research outcomes will make an important contribution in preparing the acute care nursing workforce to provide high quality nursing care for people with dementia.

and isolated areas across Australia. The older population in remote and isolated areas of Australia has its own unique characteristics, with a high representation of Aboriginal and Torres Strait Islanders and the ‘grey nomads’. The ‘grey nomads’ are known for being a highly mobile group of older Australians touring remote and isolated areas for extended periods of time who have complex health needs, often requiring management in remote locations. Grey nomads are isolated from their normal support structures and health systems, with relatively rudimentary health literacy. The Aboriginal and Torres Strait Islander population is 3% of the total Australian population, 26% of those live in remote and very remote areas. This equates to approximately 63% of the total remote and very remote populations, recognising variations do exist across the jurisdictions (Ninti One). Whilst there have been some improvements in the gap between the life expectancy of Aboriginal and Torres Strait Islander and non Aboriginal and Torres Strait Islander populations, there still remains a 10 year gap (Closing the Gap, 2015). Aboriginal and Torres Strait

Islanders are subjected to a higher burden of disease with subsequent consequences of chronic disease at a younger age. Generally, for all older persons who permanently reside in remote and isolated areas, there is limited access to specific services, such as allied health and specialist services. Relocation is a reality, in order to access residential services, leading to significant social, emotional, cultural and financial implications for the elderly, their families and the wider community. CRANAplus, the peak professional body for the remote and isolated workforce across Australia, recognises the importance of having a workforce highly skilled, in dealing with the complexities of health needs and services required for older persons. In April 2015 CRANAplus launched the Older Persons Position Paper, which is reflective of the remote context, strongly advocates remote health services to adopt ‘agefriendly principles and practices’, and for health professionals to integrate them in their practice. For more information regarding the CRANAplus Position Paper: Older Persons visit our website: www.crana.org.au

Frederick Graham is a PhD candidate in the School of Nursing, Faculty of Health at the Queensland University of Technology

Frederick Graham

References Australia, Commission on Safety and Quality in Healthcare. 2014. A better way to care: Safety and high quality care for patients with cognitive impairment (dementia and delirium) in hospital - Actions for health service managers. Sydney: ACSQHC Moyle, W. Borbasi, S. Wallis, M. Olorenshaw, R. & Gracia, N. 2010. Acute care management of older people with dementia: a qualitative perspective. Journal of Critical Care Nursing, 20, 420-428

References Australian Government: The Treasury: Australia’s Demographic Challenges, Appendix – the economic implications of an ageing population. Accessed 24/11/2015. http://demographics. treasury.gov.au/ content/_download/ australias_demographic_ challenges/html/adc-04. asp Ninti One: Cooperative Research Centre Remote Economic Participation. Accessed 25/3/15. http://crc-rep. com/about-remoteAustralia Closing the Gap: Progress and Priorities Report 2015: Closing the Gap Campaign Steering Committee. Accessed 24/11/2015. https://www. humanrights.gov.au/ sites/default/files/ document/publication/ CTG_progress_and_ priorities_report_2015. pdf

Marcia Hakendorf is Professional Officer, Professional Services at CRANAplus anmf.org.au

Aged care

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What do people over 55 want from mobility aids? By Eliza de Vet It’s no secret that Australia’s population is ageing. Over the next 50 years, the proportion of people 55 years or older will rise from one-quarter to one-third (ABS, 2013). This growing demographic presents a challenge for Australia’s already overstretched aged care system.

To meet demand, the Australian Productivity Commission (2011) recommends that “the aged care system should aim to: promote the independence and wellness of older Australians and their continuing contribution to society”. Maintaining mobility with age is important to physical and psychological wellbeing. It preserves muscle strength, balance and functional ability, decreases the risk of chronic disease and health conditions (including depression), and facilitates social connection. Importantly it improves the feasibility of ageing at home, a situation seen by many to improve quality of life (APC, 2011; AIHW, 2013). Striving to support the mobility of older people, the Enabilise Project, funded by the University of Wollongong’s Global Challenges Program, is aiming to identify and respond to mobility issues

Family focus on bladder cancer research By Susan M Heyes, Ann Harrington, Ingrid Belan and Malcolm J Bond According to the government’s 2010 Intergenerational Report, Australia’s ageing population is growing rapidly, with the number of people in Australia aged 85 and older expected to increase from 0.4 million to 1.8 million by 2050. It is expected Australians will live longer but with co-morbidities such as cancer. Bladder cancer (BlCa) accounts for approximately 2% of cancer diagnoses in Australia with around anmf.org.au

facing people over 55 which are not adequately met by existing assistive mobility technology (AMT). The project has brought together numerous disciplines from within the University of Wollongong, as well as Aged and Community Services Association of NSW/ACT, Illawarra Forum Inc. and AusIndustry. Through three stages, the interdisciplinary team has set out to: 1. identify mobility issues through focus groups with people over 55 who have mobility issues, their carers, allied health professionals, managers of aged care service providers, and representatives from mobility equipment distributors and repairers; 2. understand the significance of these issues using a large-scale survey; and 3. respond to issues of significance by prototyping, trialling and

potentially manufacturing new ATMs. The project will provide the opportunity for local businesses and manufacturers to generate solutions to consumer-identified needs. It’s about gathering information from lived experience, and then looking for person centred solutions. Stage 1 of the project identified a range of issues including those relating to: walking frames, walking sticks, wheelchairs, scooters, stairs, toileting, car access, footwear, and equipment aesthetics. Stage 2 is now underway. If you would like more information please call (02) 4221 4261 or visit www. globalchallenges.uow.edu.au

200 new cases diagnosed in South Australia each year. It is most prevalent among people aged over 50 years, with men three times more likely than women to be affected. Ms Susan Heyes, a PhD candidate in the School of Nursing and Midwifery at Flinders University is examining the impact of bladder cancer on couples and families. People with bladder cancer are a forgotten group who receive limited support or resources. Results from phase one of Ms Heyes’ study have revealed that many people with bladder cancer are struggling to cope. Participants have reported significant lifestyle disruption caused by incontinence, a common side effect of treatment. In some cases this has caused participants to retire and led to psychosocial health concerns for others. The impact being that some participants felt lonely and socially isolated.

Ms Heyes is now completing the next phase of her study in which people with bladder cancer, their partners and families were asked to complete a specifically formulated questionnaire to test the theories revealed from the earlier phase. This mixed methods study is hoped to lead to building a better model of care for people with BlCa, their partners and family in South Australia. For more information email Susan on susan.heyes@ flinders.edu.au

Dr Eliza de Vet is Enabilise Project Principal Investigator, Global Challenges Program at the University of Wollongong

References Australian Bureau of Statistics. 2013. Population Projections, Australia, 2012 (base) to 2101. Canberra, Australian Bureau of Statistics. Cat.no 3222.0 Australian Institute of Health and Welfare. 2013. Canberra: Australian Institute of Health and Welfare. Cat. no. AUS 174 Australian Productivity Commission. 2011. Caring for older Australians: Overview. Canberra: Australian Productivity Commission. Cat.no. 53

Susan M Heyes

Susan M Heyes is a PhD candidate; Ann Harrington (PhD) is Associate Professor and Ingrid Belan (PhD) is Senior Lecturer – all in the School of Nursing and Midwifery at Flinders University Malcolm J Bond (PhD) is Associate Professor in the School of Medicine at Flinders University February 2016 Volume 23, No. 7 41

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Aged care

Dementia: Responding to a national and international health priority. By Fran McInerney Around 340,000 people in Australia have a dementia diagnosis. Consistent with population ageing, numbers are expected to triple between now and 2050. Dementia is the second leading cause of death overall, and the major cause of disability in those over 65 (AIHW, 2015). These trends are reflected internationally, with dementia being described by the World Health Organization (WHO 2012) as “one of the greatest societal challenges for the 21st century”. In 2012 the Wicking Dementia Research and Education Centre (WDREC) at the University of Tasmania developed a Massive Open Online Course (MOOC) called the Understanding Dementia

(UD) MOOC. MOOCs are designed to provide quality content on topics of interest to a diverse audience. The WDREC initiative arose out of our awareness of the extent of the dementia health challenge, underpinned by our research in neuroscience and health science. The course responds to the issues faced by those living and working with people with dementia. The UD MOOC is an online, nine week course catering to a variety of learning styles. It contains three modules: • the Brain, outlining normal neuro-anatomy; • the Diseases, exploring common dementia pathologies, and; • the Person, identifying dementia-related needs and care strategies. The MOOC is experiential and conversational in design focus to make often complex content accessible and relevant. The MOOC has run four times since 2013, attracting more than 70,000 registrants from over 150 countries. Our completion rates are above 35%, compared with an

Community health, aged care and a stable home: an important relationship By Victoria Cornell Housing is fundamental to everyone’s wellbeing, particularly older people. Many health, home care and successful ageing policies are premised on the fact that older people’s housing is stable and meets their needs. While the distribution of older people across tenures has remained relatively constant in recent decades, levels of home ownership are falling (Australian Institute of Health and Welfare, 2015) and projections indicate that by 2028 over 500,000 older Australians will require rental accommodation (Beer and Faulkner, 2011). The decrease in public housing and tight targeting of housing assistance to those with complex requirements means the demand on the private and public rental sectors is considerable. A lack of affordable, appropriate housing for older people will challenge the capacity of care providers to deliver effective home care services (Council on the Ageing, 2010). The recent Australian aged care reforms aim to increase flexibility in the provision of home care services anmf.org.au

and deliver greater choice and control for recipients; with a goal of improving the ability to age at home. Little attention has been paid to older people with limited control over their home because of their tenure; yet tenure, especially renting, has an influence on receipt of home care and may bring entry to residential aged care forward (Faulkner and Bennett, 2001). Rental properties can be expensive and may be inappropriate for older people’s needs, for example due to distance from healthcare and community facilities, and landlords’ reluctance or refusal to make modifications. Despite the proliferation of policy documents, there is limited practical understanding of how the aged care reforms will interact with other welfare systems, including housing support and community

average of between 5-10% (Jordan, 2014), making this one of the most successful MOOCs in the world. Participants include nurses, care workers, other health professionals, family members of people with dementia and people living with dementia themselves. Importantly, completion is not dependent on educational background; those with university preparation complete at a similar rate to those with lower levels of education (Goldberg et al. 2015). Evaluation of the UD MOOC has been overwhelmingly positive, both in terms of completions, testimonials, and knowledge improvements. The WDREC aims to explore the translation of these gains to dementia care in future projects. The UD MOOC will be offered again in 2016 – those interested can lodge this at www.utas.edu.au/wicking/wca/ mooc/expression-of-interest Fran McInerney is Professor of Dementia Studies and Education, Wicking Dementia Research and Education Centre, University of Tasmania health. If people who are assessed as eligible to receive a home care package have no suitable accommodation in which to receive it, they may prematurely be admitted to residential aged care or hospital. They may also present a challenge to community nursing and general practice, including nurse practitioners who have been shown to assist communication between home-based care providers and inpatient providers (Clarke et al. 2013). Research underway at the University of Adelaide is exploring the important relationship between Australia’s community health, aged care and housing sectors, seeking to optimise outcomes for older people in the context of choice, independence, housing security, participation in community life and wellbeing; and assist them to age in place. Dr Victoria Cornell is Postdoctoral Research Fellow in the Centre for Housing Urban and Regional Planning in the School of Social Sciences, Faculty of Arts at the University of Adelaide

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References: AIHW. 2015. Dementia. http://www.aihw.gov.au/ dementia/ Accessed 27 November 2015. Goldberg, L, Bell, E. King, C, O’Mara, C, McInerney, F, Robinson, A, and Vickers, J., 2015. Relationship between participants’ level of education and engagement in their completion of the Understanding dementia Massive Open Online Course. BMC Medical Education. Doi http:// www.biomedcentral. com/1472-6920/15/60 Jordan, K. 2014. Initial trends in enrolment and completion of massive open online courses. International Review of Research in Open and Distance Learning. 15: 133-59. World Health Organization. 2012. Dementia: A public health priority. Geneva: World Health Organization.

References Australian Institute of Health and Welfare. 2015. Australia’s welfare 2015: in brief. Canberra. AIHW. Cat. no. AUS 193 Beer, A. and Faulkner, D. 2011. Housing transitions through the life course: Needs, aspirations and policy. Bristol. Policy Press Clark, S., Parker, R., Prosser, B. and Davey, R. 2013. Aged care nurse practitioners in Australia: Evidence for the development of their role. Australian Health Review. 37: 594-601 Council on the Ageing. 2010. Submission to the Productivity Commission Inquiry into Aged Care. Adelaide. COTA Australia Faulkner, D. and Bennett K. 2001. Linkages among housing assistance, residential (re)location and use of community health and social care among xold adults: shelter and non-shelter implications for housing policy development. Adelaide. Australian Housing and Urban Research Institute, Southern Research Centre

February 2016 Volume 23, No. 7 43

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Aged care

Costs of complications in hospitalised dementia patients By Kasia Bail Kasia Bail

Reference Bail, K, Goss, J, Draper, B, Berry, H, Karmel, R, Gibson, D. 2015. The cost of hospitalacquired complications for older people with and without dementia; a retrospective cohort study. BMC Health Services Research, vol 15, no 91

Related Group, with separate identification of fixed and variable costs (all in Australian dollars). These four complications were found to be associated with 6.4% of the total estimated cost of hospital episodes for people over 50 (A$226million/A$3.5billion), and

Increased length of stay and high rates of adverse clinical events in hospitalised patients with dementia is stimulating interest and debate about which costs may be associated and potentially avoided within this population. A retrospective cohort study (Bail et al. 2015) was designed to identify and compare estimated costs for older people in relation to hospital-acquired complications and dementia.

IN CONCLUSION, URINARY TRACT INFECTIONS, PRESSURE AREAS, PNEUMONIA AND DELIRIUM ARE POTENTIALLY PREVENTABLE HOSPITAL-ACQUIRED COMPLICATIONS.

Australia’s most populous state provided a census sample of 426,276 discharged overnight public hospital episodes for patients aged 50+ in the 2006–07 financial year. Four common hospital-acquired complications (urinary tract infections, pressure areas, pneumonia, and delirium) were risk-adjusted at the episode level. Extra costs were attributed to patient length of stay above the average for each patient’s Diagnosis

24.7% of the estimated extra cost of above-average length of stay spent in hospital for older patients (A$226million/A$914million). Dementia patients were more likely than non-dementia patients to have complications (RR 2.5, p <0.001) and these complications comprised 22.0% of the extra costs (A$49 million/A$226million), despite only accounting for 10.4% of the hospital

Rates of complications in hospitalised dementia patients

of the 12 complications: urinary tract infections, pressure ulcers, delirium, pneumonia, physiological and metabolic derangement (all at p <0.0001), sepsis and failure

By Kasia Bail

Reference

Dementia patients are vulnerable to complications of hospitalisation, which contributes to increased length of stay, mortality and higher rates of transfer to residential care. The extent to which specific potentially preventable complications occur for dementia patients has not been elucidated.

Bail, K, Berry, H, Grealish, L, Draper, B, Karmel, R, Gibson, D, Peut, A, 2013. Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study. BMJ Open, vol 3, no 6.

The objective for this study was to compare rates of nurse sensitive complications for people with and without dementia (Bail et al. 2013). Controlling for age and comorbidities, surgical dementia patients had higher rates than non-dementia patients of seven

44 February 2016 Volume 23, No. 7

THE OBJECTIVE FOR THIS STUDY WAS TO COMPARE RATES OF NURSE SENSITIVE COMPLICATIONS FOR PEOPLE WITH AND WITHOUT DEMENTIA

to rescue (at p<0.05). Medical dementia patients also had higher rates of these complications than non-dementia patients. The highest rates and highest relative

episodes (44,488/426,276). For both dementia and non-dementia patients, the complications were associated with an eightfold increase in length of stay (813%, or 3.6 days/0.4 days) and doubled the increased estimated mean episode cost (199%, or A$16,403/ A$8,240). In conclusion, urinary tract infections, pressure areas, pneumonia and delirium are potentially preventable hospitalacquired complications. This study shows that they produce a burdensome financial cost and reveals that they are very important in understanding length of stay and costs in older and complex patients. Once a complication occurs, the cost is similar for people with and without dementia. However, they occur more often among dementia patients. Advances in models of care, nurse skill-mix and healthy work environments show promise in prevention of these complications for dementia and non-dementia patients. Kasia Bail is a PhD candidate, Dementia Collaborative Research Centres and Assistant Professor in Nursing in the Health Research Institute, Synergy Nursing and Midwifery Research Centre, Faculty of Health at the University of Canberra risk for dementia compared to non-dementia patients, in both medical and surgical populations, were found in four common complications: urinary tract infections, pressure areas, pneumonia and delirium. In summary, hospitalised dementia patients have much higher rates of potentially preventable complications, particularly urinary tract infections, pressure ulcers, pneumonia and delirium, than do hospitalised non-dementia patients. These complications are known to be responsive to nursing care. Further exploration of the role of nursing in preventing these complications in dementia patients is warranted. Kasia Bail is a PhD candidate, Dementia Collaborative Research Centres and Assistant Professor in Nursing in the Health Research Institute, Synergy Nursing and Midwifery Research Centre, Faculty of Health at the University of Canberra anmf.org.au

Aged care

Care collaboration

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GEDI CNC ANDREA TAYLOR CARING FOR ELDERLY RESIDENT IN ED

By Alison Craswell, Andrea Taylor, Kaye Coates and Marc Broadbent Hospital emergency departments (EDs) are increasingly overwhelmed with presentations, have long waiting times, resulting in potential negative outcomes for patients. For older adults, transferring to an ED from the community or a Residential Aged Care Facility (RACF) can escalate their presenting condition and lead to iatrogenic conditions. Reducing the amount of time patients spend in ED is a key performance indicator of healthcare quality in Australia. For older adults, it can be the difference between the simple solution of a problem and the worsening of their condition. Innovative solutions to improve the management of older people presenting to ED can provide a way forward for nurses to manage these challenges. The Care Collaboration through Emergency Department Residential Aged Care and Primary Health Collaboration (CEDRiC project) operates at Nambour Hospital Emergency Department and Sundale Ltd Aged Care Facility. The CEDRiC project aims to improve care of older people in the residential aged care facility, and should hospital transfer be required, improve care in the ED. To do this, the project has two interconnected components; a Nurse Practitioner Candidate (NPC) in place at anmf.org.au

Sundale Ltd. and advanced practice Registered Nurses working in ED. General Practitioners who work in private practice find it extremely difficult to leave a busy practice to visit RACF residents (Clark et al. 2013). The NPC based at Sundale Ltd. is able to provide timely assessment, care and referral for resident older people. Being on site five days a week enables staff to access comprehensive assessment for residents who become unwell. Should a resident require transfer to hospital, the GEDI (Geriatric Emergency Department Intervention) nurses practicing in the ED aim to provide elders 70 years of age and over with specialist gerontology care. These GEDI nurses have highly developed gerontology assessment skills and a focus on issues particular to older people. GEDI nurses identify elders from either RACFs or the community to fast track their care and either get them home or

facilitate their admission to hospital when admission is appropriate. The CEDRiC project is being evaluated by a team of researchers at the University of the Sunshine Coast to determine effectiveness, economic impact and acceptance by health professionals and consumers. The evaluation is supported by a Department of Social Services, Aged Care Service Improvement and Healthy Ageing Grant. Dr Alison Craswell is a Research Fellow, School of Nursing, Midwifery and Paramedicine at the University of the Sunshine Coast, Ms Andrea Taylor is CNC GEDI Nurse program, Queensland Health, Kaye Coates is a Nurse Practitioner candidate at Sundale Ltd, and Dr Marc Broadbent is Senior Lecturer, also University of the Sunshine Coast.

Reference Clarke S, Parker R, Prosser B. Davey R. (2013) Aged care nurse practitioners in Australia: evidence for the development of their role. Australian Health Review, 37, 594-601

February 2016 Volume 23, No. 7 45

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Aged care

Healthy ageing strategies By Caroline Vafeas, Joyce Hendricks, Anne Wilkinson and Heather Blakely The recent shifts towards Consumer Directed Care and Active Living in Aged care in Australia have moved the aged care agenda towards health promotion and prevention activities aimed to keep the older person well, active and engaged. Recent studies have shown the adoption of healthy ageing strategies may increase quality in the extended years of life (Nathan et al. 2012; Van Uffelen, 2015) as well as delaying physical and cognitive decline. As part of new industry/university collaboration between Edith Cowan University and the Royal Australian Air Force Association WA (RAAFAWA), research has been undertaken to provide the organisation with new, comprehensive and clinically useful data on the unmet needs of their

independent living residents. As RAAFA’s residents live longer and age-in-place, the organisation has recognised the need to adopt an “active-ageing” agenda and support residents to remain in their own homes as long as possible through the more efficient and effective use of existing communitybased services. The data gathered will enable the organisation to proactively, and in concert with the organisation’s residents, to develop and provide an “active and healthy ageing” supportive care management approach to their elderly residents ageing in place. These residents are identified on a scale of “at risk” for a social or health crisis. This information will form the basis for the development of a larger, integrated social, health and social service intervention to test the model’s feasibility, acceptability, and effectiveness. The main objectives of the collaboration are to support active ageing in independent living residents; to assist in the developments of programs to delay physical and cognitive decline; and to enable RAAFA residents to remain in their independent living units. An

Achieving person-centredness with older people in residential aged care By Catherine Wilson, Cheryle Moss and Georgina Willetts A research project was conducted during 2015 to gain an understanding of the perspectives and actions of the nurses and personal care assistants, (participants) as they sought to provide person centred care (PCC) in a residential care setting. The research was undertaken by Catherine Wilson as part of a Master of Nursing degree, and the project was supervised by Cheryle Moss and Georgina Willetts from Monash University. Research about PCC in residential care previously has mainly focused on the philosophy and the development of theoretical frameworks. There is limited research regarding the operationalisation of PCC by healthcare workers. Internationally and nationally PCC is seen as a central aspect of providing the best quality of care for older people in residential care (McCormack et al. 2010; Rosvik et al. 2011). There is a growing impetus to ensure that staff working in residential care use a PCC framework. The demand for residential aged care places in anmf.org.au

Australia is increasing in line with the ageing population (AIHW, 2015). King et al. (2013) acknowledge reform for the Australian aged care workforce is required to enhance recruitment and retention. King et al. (2013) revealed in their study that care providers described a ‘good worker’ as not only having knowledge and experience in aged care but also identified the importance of possessing attributes to care for older people effectively. These attributes are closely aligned with the philosophy of PCC. The VIPS model (Rosvik et al. 2011) for PCC was used as the conceptual framework in this qualitative descriptive study. The VIPS framework has four constructs, comprising of: ‘valuing the person’, ‘individualised care’, ‘understanding

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initial survey was conducted, with results indicating that there were a high number of independent living residents suffering falls (28%) and chronic pain (34%) within the previous 12 months. Other notable resident concerns were issues with sleep (38-19%) and memory (30-23%). By early identification of these areas of ‘at risk’ among residents, tailored interventions can begin to be established to increase healthy ageing and reduce hospital presentation. Dr Caroline Vafeas is a Senior Lecturer in the areas of gerontology and dementia at Edith Cowan University Dr Joyce Hendricks is a Senior Lecturer in the area of research at Edith Cowan University Professor Anne Wilkinson is an experienced researcher with expertise in palliative care Heather Blakely (Research Assistant) is a recent graduate with a Bachelor of Arts (English & Cultural Studies) from The University of Western Australia

THE STUDY HAS REVEALED NEW INSIGHTS INTO HOW NURSES AND PCA’S FEEL ABOUT PCC the person’s perspective’, and ‘positive social psychology’. The VIPS framework resonated with the participants. VIPS proved to be a useful structure for participants to discuss what they did in practice, and how they achieve PCC. The study has revealed new insights into how nurses and PCA’s feel about PCC, and how they make PCC work in their context. The application of the VIPS framework in this way has not been reported before. The findings suggest this may be useful for further studies. Catherine Wilson, Cheryle Moss and Georgina Willetts are all located in the School of Nursing and Midwifery at Monash University

References Nathan, A., Wood, L., Giles-Corti, B. 2012. Environmental Factors Associated with Active Living in Retirement Village Residents: Findings from an Exploratory Qualitative Enquiry Research on Aging. Research on Aging, 35(4): 459-480. Van Uffelen, J. 2015. Active and Healthy Ageing: The Benefits of Physical Activity and Exercise. Sport Health, 33(1): 36-41.

References Australian Institute of Health and Welfare. 2015. Aged Care. Retrieved from www. aihw.gov.au/aged-care/ King, D., Mavromaras, K., Zhang, W., Bryan, H., Healy, H., Macaitis, K., Smith, L. 2013. The Aged Care Workforce, 2012 Final Report. Canberra Retrieved from www.dss.gov.au/sites/ default/files/.../rdp004nacwcas-report.docx McCormack, B., Karlsson, B., Dewing, J., & Lerdal, A. 2010. Exploring personcentredness: A qualitative metasynthesis of four studies. Scandinavian Journal of Caring Sciences, 24(3), 620-634. Rosvik, J., Kirkevold, M., Engedal, K., Brooker, D., & Kirkevold, O. 2011. A model for using the VIPS framework for personcentred care for persons with dementia in nursing homes: a qualitative evaluative study. International Journal of Older People Nursing, 6(3), 227-236.

February 2016 Volume 23, No. 7 47

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Aged care

Get paid while you study and work

POSTGRADUATE DIPLOMA IN NURSING (MENTAL HEALTH) IN CANBERRA Full scholarships First Semester 2016 February Intake Annual Salary RN 1 $60,772-$81,180 Closing date 30 June 2016 A nursing scholarship to study at the University of Canberra is offered by the Division of Mental Health, Justice Health, Alcohol & Drug Services (MHJHADS) and is an excellent opportunity for Registered Nurses to build their knowledge and skills base in caring for people experiencing a range of mental health conditions. Successful applicants are employed via temporary contract, studying either parttime or full-time. During the program, RNs rotate through the diverse services, both inpatient and community based, provided by MHJHADS. Eligibility /other requirements: • Registered with the Nursing and Midwifery Board of Australia. • Hold a current driver’s licence. • Have Australian citizenship or permanent residency. For full details of how to apply contact Jo McDougal, Clinical Support Officer on (02) 6205 3661

Consumer Directed Care: A client experience By Kylie Elder, Tracy Aylen and Fleur O’Keefe ‘Aged care’: two words that have arguably never had so much space in the media and political and healthcare arenas as today. With the ushering in of Consumer Directed Care (CDC) we will all be hearing much more. It is always good to present a real life scenario to describe the advantages of CDC and we will endeavour to do that in this article. But to set the scene it is important to point out that RDNS already promotes a consumer focussed approach and this will be further developed as CDC becomes common practice nationally. RDNS aims to assist people to live in the community as independently and autonomously as possible. In practice, RDNS clinicians explore individual client goals and needs, discuss selfmanagement opportunities and develop an agreed care plan together. Incorporated into this process is consideration of the individual’s strengths, their values and beliefs, and their existing supports and resources. But what exactly is CDC and what does it mean for providers and clients? Firstly, it has been introduced across the disability and aged care sectors in Australia. Secondly, Consumer Directed Care allows an individual and their carer more power to influence and choose the services they require (DSS, 2015). Aged care is an area where the number of people needing services is increasing. This number will continue to grow with population demand and it will require targeted use of resources.

THE RDNS NURSE WORKED WITH MR C ON IDENTIFYING HIS GOALS, CAPACITY TO PARTICIPATE IN SELF-CARE AND HIS CARE PREFERENCES. Traditionally, a service may assess an individual and decide what care is provided. With the formal introduction of CDC all services must now change this approach. To illustrate this, our case scenario shows how a typical client feels more empowered to take ownership of his health condition and to direct the way services are provided: Mr C, 79 years, has type 2 diabetes and longstanding suboptimal glycaemic levels. Mr C’s GP referred him to a range of services in an effort to improve his diabetes care, however attendance was minimal and Mr C was labelled as ‘non-compliant’. After Mr C sustained a leg wound, the GP referred him to RDNS for management. The RDNS nurse worked with Mr C on identifying his goals, capacity to participate in self-care and his care preferences. Mr C had no family support and was reluctant to have visits to his own home. Great importance was placed on maintaining his social network, which involved attending a men’s group. Because his diabetes had caused no physical symptoms, multiple medical appointments were not seen as essential. After discussing his situation and developing an agreed care plan, visits for wound management were attended at the men’s group and basic diabetes education refreshed. Mr C became re-engaged with his diabetes care, started monitoring blood glucose levels and taking his oral medication more consistently. Prior to discharge his wound had healed and glycaemic levels had improved. ‘Consumer Directed Care’: three words that will certainly be occupying space in the media, political and healthcare arenas. Indeed, three words that should be a positive influence in achieving better care outcomes for older Australians and promoting effective and efficient use of resources.

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Reference Department of Social Services. 2015. What is consumer directed care? Accessed 25 November 2015. www.myagedcare. gov.au/aged-careservices/home-carepackages/consumerdirected-care-cdc

Kylie Elder, Tracy Aylen and Fleur O’Keefe are Senior Clinical Nurse Advisors with the Royal District Nursing Service anmf.org.au

Aged care

The McKellar Guidelines: helping plan care for older people with diabetes By Trisha Dunning AM, Sally Savage and Nicole Duggan Diabetes prevalence is high in older people (>age 60) due to increased longevity of people with type 1 and type 2 diabetes, changes in glucose homeostasis and tissues and organs associated with ageing and hyperglycaemia. Over 18% of older people have diabetes and a further 18% are at high risk but undiagnosed (AIHW, 2003). One in four older people in aged care facilities (RACF) has diabetes (Sinclair et al. 2001). Diabetes is associated with cardiovascular, renal and liver disease, neuropathy and some forms of cancer, which leads to polypharmacy and affects functional status and quality of life and increases the risk of premature death (IDF 2013). Most older people with diabetes have three to five comorbidities and take an average of seven medicines (IDF 2013) and are at high risk of medicine-related adverse events. Significantly, chronological age does not indicate functional status. Older people with diabetes are highly individual have differing health issues and life experiences; therefore care must be individualised to suit their functional status, safety, life expectancy and personal preferences, self-care

capability, nutritional status and managing cardiovascular risk (IDF, 2013; Dunning et al. 2013). Individualising blood glucose target ranges and HbA1c is an important aspect of safe personalised care and quality of life. Although many recent ‘diabetes clinical guidelines’ include a small section about older people, and advocate personalising metabolic targets, they do not address the care issues that concern nurses such as functional status and life trajectories that influence safety, quality of life, and palliative and end of life care. The McKellar Guidelines for Managing Older People with Diabetes in Residential and other Care Settings (McKellar Guidelines) were developed to help nurses deliver optimal evidence-based diabetes care for older people in all

care settings. They can be used as a benchmark to assess the standard and quality of diabetes care of older people. The guidelines advocate engaging the older person and/ or their family in deciding care targets and goals where practical, and adopt a holistic, proactive, risk identification/minimisation approach to care. There are 18 individual guidelines and five risk assessment tools. Each guideline includes three sections: care context, assessment and care planning. The care planning section includes information about how to use the recommendations to plan personalised care. This is a key point of difference between the McKellar and most other clinical guidelines. Trisha Dunning AM, is Chair in Nursing and Director Centre for Nursing and Allied Health Research Deakin University and Barwon Health Geelong, Victoria Nicole Duggan is a Nurse Researcher in the Centre for Nursing and Allied Health Research Deakin University and Barwon Health Geelong, Victoria Sally Savage is a Research Fellow in the Centre for Nursing and Allied Health Research Deakin University and Barwon Health Geelong, Victoria

Impact of the Guidelines The Guidelines are currently being implemented in various practice settings. • They became policy at Barwon Health in 2014, which indicates they are

•

• •

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sustainable after the research is completed. They were awarded the Barwon Healthcare Innovation Award in 2013. Medical record audits undertaken before the Guidelines were implemented in 2014 and approximately nine months after implementation in 2015 show changes consistent with the Guidelines in McKellar Centre residents’ care plans including evidence that care is personalised. McKellar Centre staff are required to attend annual professional development sessions that encompass the McKellar guidelines. The risk assessment tools (diabetes risk screen for older people who do not have a diagnosis of diabetes, hypoglycaemia, risk of glucose lowering medicine adverse event, diabetes-specific falls risk, diabetes specific pain risk) were translated into Norwegian in late 2014 and being used in Norway. Preliminary discussions about translating the Guidelines into Chinese were held with a geriatrician from China in September 2015. The Guidelines were cited in the Australian government Australian National Diabetes Strategy 2016–2020 released on World Diabetes Day, 14 November 2015. The Guidelines led to several peer-review and invited papers and presentations including presenting at the Better Practice Conferences in 2014 and National Association for Diabetes Centres (NADC) Best Practice Conference. Figure 1: The McKellar Guidelines and The McKellar Way (Dunning et al. 2013)

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FOCUS

References Australian Institute of Health and Welfare. 2003 The burden of disease and injury in Australia. (cat number PHE 82), Canberra AIHW. Dunning T, Savage S, Dugan N. 2013 The McKellar Guidelines for managing older people with diabetes in residential and other care settings. Geelong Centre for Nursing and Allied health research, Deakin University and Barwon Health. International Diabetes Federation (IDF) IDF Diabetes Atlas 6th edition. 2013. www.idf. org/sites/default/files/ EN_6E_Atlas_Full_0.pdf National Health and Medical Research Council. 1995. Guideline for the development and implementation of clinical practice guidelines. Canberra, Australian Publishing Service. Sinclair A, Gadsby R, Penfold S, Croxson S, Bayer A. 2001. Prevalence of diabetes in care home residents Diabetes Care.24(6):1066–1068.

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Accessing mental health services for older people in rural South Australia By Suzanne Dawson, Adam Gerace, Eimear Muir-Cochrane, Deb O’Kane, Julie Henderson, Sharon Lawn and Jeffrey Fuller Mental healthcare for older people is primarily delivered in the community with informal carers, usually family providing much of this. Older people often require input from a range of services across sectors.

In Australia, the different funding and governance structures of these services makes for a complex landscape for older people, their families and mental health workers to navigate. As many people now care into later life, the consequences of not getting the required support include the potential for increased carer burden and reduced capacity to fulfil caring tasks. To help address this, partnerships between carers and service providers are recommended. We were interested in exploring rural carers’ experiences of accessing care from a range of services for older people with mental health problems with the view to identify what was currently working, as well as what could be changed to improve service access, coordination of care and positive experience of care. Method: In-depth interviews

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conducted with 11 carers of older people with a mental health problem. Interviews explored their journeys to and through the range of care services. Framework analysis was used to explore carers’ experiences of care with a focus on access enablers and barriers. Results: Carers played a primary role in navigating services and operationalising care for their relative. Enablers to accessing care included carers mental health literacy, knowledge of services and carers actively involved in care planning. Barriers included poor mental health literacy, consumers and carers lack of readiness for services, and lack of information from workers. Lack of information resulted from workers misinterpretation of confidentiality and privacy laws and lack of linking between workers across services. There was no over-arching care-

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coordination across all service sectors, with carers having to take on this role. In the smaller rural locations, carers reported knowing the mental health worker helped facilitate service access. Conclusion: Carers should be considered key partners in mental healthcare planning that bridges service sectors. Carers need to be included in case conferences and receive regular information and feedback from workers. Mental health staff may benefit from training in interpreting confidentiality and privacy policy. Opportunities for joint care planning between different service sectors would help facilitate this, particularly when conducted face to face. Suzanne Dawson is a Research Assistant and PhD Candidate; Adam Gerace is a Senior Research Fellow and Professor Jeffrey Fuller is Professor in Nursing. All are in the School of Nursing & Midwifery at Flinders University in SA Professor Eimear MuirCochrane is Chair of Nursing (Mental Health) in the School of Nursing & Midwifery at Flinders University and Adjunct Professor at the University of South Australia Deb O’Kane is a Lecturer currently delivering training in undergraduate and post graduate mental health nursing at Flinders University Julie Henderson is a Senior Research Fellow in the School of Health Sciences at Flinders University Professor Sharon Lawn is the Director of the Flinders Human Behaviour and Health Research Unit, Department of Psychiatry at Flinders University

Reference Dawson, S.K., Gerace, A., Muir-Cochrane, E.C., O’Kane, D., Henderson, J.A., Lawn, S.J., et al. 2015. Carers’ experiences of accessing and navigating mental healthcare for older people in a rural area in Australia. Aging & Mental Health

Aged care

FOCUS EXAMPLE OF AGED CARE SIMULATION ROOM IN PREPARATION FOR STUDENT PARTICIPATION AT USC

References

Simulation: Preparation of Bachelor of Nursing students for aged care practice By Penelope Harrison and Patrea Andersen Aged care is a health priority (Robinson et al. 2006). In comparison to the national statistics where 11% of the population is over the age of 65, 16% of population at the Sunshine Coast falls within this age category (Australian Bureau of Statistics (ABS) 2014). Developing capacity in nursing graduates to care for this population is important and has become a major focus in nursing programs. For many undergraduate nursing students their first exposure to clinical practice is in the aged care environment. Unfortunately nursing students often greet the aged care environment in a negative light as it is seen as an undemanding practicum experience, with students often making an early decision that acute care is the area in which they intend to specialise (Carlson, 2013). Igniting an interest in aged care practice can be a challenge. Simulation has been used in The School of Nursing, Midwifery and anmf.org.au

Paramedicine at the University of the Sunshine Coast (USC) to instil an appreciation of the complex care requirements of the older adult and assist students in their preparation for practice. The University of the Third Age (U3A) volunteers play the role of simulated patients in first year course simulation. Case studies are used to frame scenarios where students have the opportunity to initiate assessment skills, provide safe nursing care and engage in therapeutic communication, documentation and PPE practices. Learning environments have been developed to replicate clinical situations. In doing so learning opportunities have been created

by exposing students to placement situations where they can implement communication, problem solving and team work practices. The Satisfaction with Simulation Experience (SSES) survey was used to evaluate student responses (n=216) to the simulation (LevettJones, 2011). Outcomes were positive with 98% of students agreeing or strongly agreeing the experience enhanced their communication skills; 93% felt more prepared for practice and performing nursing intervention; 96% thought the simulation enhanced the development of clinical reasoning and 90% believed the simulation experience assisted them to develop confidence and competence. This builds the capacity of USC graduates to participate in the aged care sector. Penelope Harrison is Associate Lecturer, Nursing and Patrea Andersen is Associate Professor, Nursing. Both are located at the University of the Sunshine Coast

Australian Bureau of Statistics (ABS). 2014. Queensland – Total Population. Canberra: Australian Bureau of Statistics. www.abs.gov. au/AUSSTATS/abs@.nsf/ Latestproducts/3235.0 Main%20Features 252014?open document &t abname=Summary& prodno=3235 .0&issue =2014&num =&view accessed 24/11/15 Carlson, E. 2013. Meaningful and enjoyable of boring and depressing? The reasons student nurses give for and against a career in aged care. Journal of Clinical Nursing. 24: 602-604. Levett-Jones, T., McCoy, M., Lapkin, S., Noble, D., Hoffman, K., Dempsey, J., Arthur, C. & Roche, J. 2011. The development and psychometric testing of the Satisfaction with Simulation Experience Scale. Nurse Education Today. 31(7), 705-710. Robinson, A., Abbey, J., Toye, C., Barnes, L., Abbey, B., Saunders, R., Lea, E., Hill, O., Parker, D., Roff, A., Andrews-Hall, S., Marlow, A., Venter, L., André, K. 2006. Modelling Connections in Aged Care: Development of an evidence-based/ best practice model to facilitate quality clinical placements in Aged care - Report on Stages 1-3. Tasmania: School of Nursing and Midwifery, University of Tasmania.

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Changing clinical education and stamping out the stigma By June Colgrave and Katrina Austen A crisis is emerging in attracting and retaining qualified staff to work in Residential Aged Care Facilities (RACF). Graduate nurses are not being attracted to aged care. The reasons identified include: • undergraduate clinical

placements within RACF have traditionally been used for developing basic nursing skills; • students not experiencing or understanding the role of the Registered Nurse (RN); students often viewed aged care as having no career pathway and a career end point (Abbey, 2006; Robinson et al., 2008; Stevens, 2011; Xiao, Kelton, & Paterson, 2012). With a shortage of clinical placements in Australia and internationally it is vital to develop placements to meet the needs of nursing curriculum. As the world’s population ages there is a need to attract RNs with leadership 52 February 2016 Volume 23, No. 7

capabilities to work in RACF. Previously, providing students access to nursing leaders, and developing leadership skills, has been problematic in undergraduate curriculums. The opportunity exists to highlight the role of the RN in RACF as a leader. Collaboration between a RACF and a regional university led to the development of an innovative model of clinical education where third year undergraduate nursing students work with leaders in RACF (DON, DDON, Educator and RN). The educational experience provides exposure to skilled, positive nurse leadership in RACF. The clinical placement aimed to: 1) develop nursing students’ appreciation of the specialised skills and knowledge the RN requires for the complexities that exist in aged care; 2) remove the stigma attached to the aged care industry currently held by many undergraduate nursing students; 3) promote aged care as a viable career choice. Key elements were implemented to ensure a quality undergraduate clinical placements within RACF including; students had RN support and supervision; student access to senior nursing staff DDON, DON, and Educator; students

having clinical learning objectives on leadership; a clinical teacher with credible gerontic nursing and clinical teaching knowledge. The successful clinical placement leadership model has resulted in the RACF developing a new graduate program and employment of new graduates.

Significance of the project Innovative clinical placement models are required to grow clinical capacity and aged care facilities need to have creative professional career pathways to attract RNs. This project aims to incorporate these elements to create an undergraduate clinical placement that improves attitudes and removes the stigma attached to the aged care industry currently held by many nursing students. This shift in attitudes will promote aged care as a viable career choice.

June Colgrave is Lecturer, Nursing, at Southern Cross University in NSW Katrina Austen is Educator/ Quality Manager/ Development Support at Grafton Aged Care in NSW

References Abbey, J., Abbey, B., Bridges, P., Elder, R., Lemcke, P., Liddle, J., and Thornton, R. 2006. Clinical placements in residential aged care facilities: The impact on nursing students perception of aged care and the effect on career plans. Australian Journal of Advanced Nursing, 23(4), 14-19. Robinson, A., AndrewsHall, S., Cubit, K., Fassett, M., Venter, L., Menzies, B., & Jongeling, L. 2008. Attracting students to aged care: The impact of a supportive orientation. Nurse Education Today, 28, 354-362. Stevens, J. A. 2011. Student nurses’ career preferences for working with older people: A replicated longitudinal survey. International Journal of Nursing Studies, 48(8), 944-951. Xiao, L. D., Kelton, M., & Paterson, J. 2012. Critical action research applied in clinical placement development in aged care facilities. Nursing Inquiry, 19(4), 322-333.

anmf.org.au

CALENDAR

FEBRUARY Ovarian Cancer Awareness Month www.womenscancerfoundation.org.au/ World Cancer Day We Can. I Can. 4 February. www.worldcancerday.org/ Chinese New Year 8 February Anniversary of the Apology (2008) 13 February Lung Health Promotion Centre at The Alfred 11-12 February - Spirometry Principles & Practice 25-26 February – Managing COPD 29 February-2 March – Respiratory Course (Module A) 29 February-2 March / 3-4 March – Respiratory Course (Modules A & B) P: (03) 9076 2382 E: lunghealth@alfred.org.au National Disability Services Conference 18-19 February, Hilton Hotel, Sydney. www.nds.org.au/ events/1413497081 4th National Elder Abuse Conference Ageism, rights and innovation 23-25 February, Pullman Melbourne on the Park. http://elderabuseconference.org.au/ Women’s Cancer Foundation – Ovarian Cancer Institute We Can Walk it Out 28 February, In aid of ovarian cancer research and awareness, this is a day for the entire family

NETWORK Royal Adelaide Hospital, class of 756, 40-year reunion Contact Karen Braithwaite or Frances Woodcock on M: 0422 812 187 or E: woodcock7@gmail.com Box Hill Hospital, group 99, 30-year reunion Contact Clare D’Arcy-Evans E: clarebears21@icloud.com or M: 0416 399 881 Royal Adelaide Hospital, 12/01/1976, group 761, 40-year reunion 19 February, 1600 onwards at The Mile End Hotel, 30 Henley Beach Road, Mile End. Please BYO name tag, memento &/or decoration. RSVP to Kate M: 0403 996 094 or E: jokape56@yahoo.com.au or P: (08) 8443 4756

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- even the pet pooch! As well as the 4km walk, and the 4km and 8km runs, there will be family entertainment, a free BBQ, fruit and water for all to enjoy. www. womenscancerfoundation.org.au/

MARCH Lung Health Promotion Centre at The Alfred 3-4 March - Respiratory Course (Module B) 10-11 March - Smoking Cessation Course 15 March - Allergy Day 16-18 March - Asthma Educator’s Course P: (03) 9076 2382 E: lunghealth@alfred.org.au Nurses Christian Fellowship Australia- Victoria and Tasmania Art and science of spiritual care course 5 March, Ashburton Baptist Church, Melbourne. Australian College of Nursing endorsed course for 8 CPD points. For more information E: ncfavictoria@gmail.com or 0412 328 672 International Women’s Day Theme: Pledge for Parity 8 March. www.internationalwomensday.com/ ADMA Evidence-based Primary & Secondary Prevention of Chronic Disease Seminar 11 March, AMREP Lecture Theatre, The Alfred Hospital, Melbourne. http://www.adma.org.au/ E: info@adma.org.au T: 0390764125 3rd Commonwealth Nurses and Midwives Conference Toward 2020: Celebrating nursing and midwifery leadership 12-13 March, London UK. www.commonwealthnurses.org/ conference2016/

Ballarat Base Hospital, class 76A, 40-year reunion 20 February. Contact Mandy van Leeuwen (nee Akers) E: timmandy@ bigpond.net.au M: 0437 002 658 LaTrobe University, LaTrobe/ Bendigo Campus nursing group (1988-1991), 25-year reunion 20 February, Bendigo. Contact Steven Graham E: sgraham@ bendigohealth.org.au or Sarah Shipp (nee Prudham) E: sshipp@ bendigohealth.org.au or search Facebook page LaTrobe 1991 reunion Geelong Hospital Nurses League (Barwon Health) annual reunion 19 March. All members, past trainees and current staff are invited to attend. Contact Secretary Bev Lodge E: terrylodge@bigpond.com P: (03) 5243 7794 M: 0419 107 995

21st World Council of Enterostomal Therapists Biennial Congress Embrace the circle of life 13-16 March, Cape Town South Africa. www.wcet2016.com/

healthcare 5-7 May, Pullman Melbourne, Albert Park. The conference for nurses working in primary healthcare. www.apnaconference.asn.au

6th Florence Nightingale Foundation Annual Conference 17-18 March, Queen Elizabeth II Conference Centre, London. www.florence-nightingalefoundation.org.uk/

Lung Health Promotion Centre at The Alfred 9 May – Paediatric Respiratory Update 31 May - Respiratory Update P: (03) 9076 2382 E: lunghealth@alfred.org.au

National Close the Gap Day 17 March

International Day of the Midwife 5 May. www.internationalmidwives. org/events/idotm/

RHDAustralia 2 day Workshop Think ARF Stop RHD 22-23 March, Brisbane Convention Centre. This workshop aims to improve early detection, diagnosis and reporting of acute rheumatic fever and rheumatic heart disease in Australia. www.rhdaustralia.org.au or E:info@rhdaustralia.org.au

International Nurses Day Nurses: A Force for Change: Improving health systems’ resilience 12 May. www.icn.ch/ publications/2016-nurses-a-forcefor-change-improving-healthsystems-resilience/

APRIL World Health Day 7 April. www.who.int/campaigns/ world-health-day/ World Indigenous Cancer Conference 12-14 April, Brisbane Convention and Exhibition Centre, Qld. www.menzies.edu.au/ Lung Health Promotion Centre at The Alfred 14-15 April – Managing COPD 18-19 April - Spirometry Principles & Practice P: (03) 9076 2382 E: lunghealth@alfred.org.au

MAY Australian Primary Health Care Nurses Association (APNA) National Conference Nurses | the heart of primary St Vincent’s Hospital, February 1976, 40-year reunion 19 March. Contact Mary Hibble (nee Ross) E: maryhibble@yahoo. com.au or Ra Cunningham (nee Savaris) E: vtcunningham@hotmail. com or Seach Facebook page: St Vincents Hospital Nurses Class of 1976 50 years of Nursing Reunion Tour, Group 80 21 March at 10am, RGH Concord. Contact Victoria Stevenson 0414 670 226 Adelaide Children’s Hospital, Group 276, 40-year reunion 27 May. Contact Anne Bartholomew (nee Lennox) E: wald06@tpg.com.au or M 0417 854 015

ATSA Independent Living Expo Australasia’s largest display of rehabilitation and assistive technology equipment 18–19 May, Melbourne Showground. The ATSA Independent Living Expo will have over 100 exhibitors displaying a wide range of products and services in assistive technology, mobility solutions, pressure care, employment support, modified motor vehicles and a lot more. www. atsaindependentlivingexpo.com.au

NOVEMBER ICIN2016 24-25 November 2016, Parmelia Hilton Perth. Showcasing innovation and leadership in clinical practice, research and education. Abstracts open on 1 February 2016. www.icinperth.com Royal Adelaide Hospital, Group 764, 40-year reunion 18 June 2016, Private room at pub with small charge to cover cost of food platters. Contact Patrice O’Loughlin M: 040 539 9171 E: patrice_oloughlin@mail.com St Vincent’s Hospital, Melbourne, August 1986, 30-year reunion 5 August, Melbourne, Venue TBA. Contact Celia Kenny (nee Murphy) E: paulandcelia@hotmail.com or search Facebook page AUGUST 86 30YR REUNION 2016

Email cathy@anmf.org.au if you would like to place a reunion notice

February 2016 Volume 23, No. 7 53

MAIL

The facts about low dose methotrexate

The answer is not RNs

We are writing in response to the article Cytotoxic Chemotherapy Administration in the Community: A Case Study which was published in the December 2015 edition of the ANMJ. It was disappointing to read this misleading article about a patient with rheumatoid arthritis (RA) whose treatment included intramuscular low dose methotrexate (LDM) and the need for full cytotoxic PPE.

I guess I am writing this to vent after reading the feature story in November 2015 volume 23 edition of the ANMJ, The Age of Reason.

There were many factual inaccuracies in the article. Firstly subcutaneous LDM is the preferred method of administration of parenteral LDM in the rheumatological patient rather than intra-muscular as stated in the article. Secondly the mistaken belief that LDM must be treated the same as high dose Methotrexate (HDM) leads to the unnecessary scaremongering of many patients with RA. They then unnecessarily reject Methotrexate, which is a cornerstone drug in treating their RA, and suffer increased harm from their poorly treated RA. We argue that the need for full cytotoxic PPE is not necessary when using doses at or below 30mg weekly and furthermore this is supported by current literature. Robinson, Lim, and Barrett (2014) state that “low dose methotrexate should not be considered chemotherapy” as at low dose the mode of action is purely as a strong anti-inflammatory agent with no evidence that the LDM exerts its effects by cellular cytotoxicity and thus should not be treated as such. Methotrexate is not lipophilic and is not absorbed through the skin in tablet or liquid form. This was demonstrated in an experiment where six human volunteers deliberately exposed themselves to 25mg methotrexate solution on their skin for 30 minutes. The study failed to show any quantifiable serum and urine methotrexate in the volunteers (Wong, Tymms, & Buckley, 2009). The authors further suggest that the risk of inhalation from LDM is negligible. We would like to reassure the nurses of Australia that they are safe to use standard precautions (gloves) when administering subcutaneous LDM. In 2013 the UK Royal College of Nursing released updated guidelines on the administration of subcutaneous LDM and state that “aprons, goggles and masks no longer need to be worn.” This document can be found at www.rcn.org.uk/professional-development/publications/pub-004377 and is a wonderful educational tool for health professionals and patients alike. We would encourage any nurse who needs further information on LDM to review this document. Methotrexate is the cornerstone of treatment for inflammatory arthritis and many patients decline treatment due to misinformation from members of the public and health professionals who have experienced this drug in the oncology setting. A patient who visits their local GP surgery to have their weekly subcutaneous methotrexate may find the presentation of their nurse in full cytotoxic PPE confronting, compounding the idea that this drug is unsafe and dangerous creating unnecessary fear and anxiety for our patients. Unfortunately it is an all too common story to hear of a patient with RA rejecting LDM because of such misinformation. We hope that a sensible discussion leads to the common sense view that LDM can be administered by nurses across Australia using standard precautions and not full PPE.

I have worked 20 years in the aged care sector for a leading provider. I have worked my way through different roles within the care home, but have been an enrolled nurse for five years. I don’t think the answer to aged care is employing registered nurses. This is not the answer to better care because in my experience I have seen some very poor decisions and practices by registered nurses with extreme consequences. Aged care needs a huge shake up. I agree it’s sadly a sector that employs anyone really and it’s a shame it’s seen as acceptable. If this was our children being cared for by substandard care everyone would be up in arms but when it comes to our elderly it seems anything goes. I believe aged care courses need to be governed and be more stringent in training and assessment, including English courses for those with language difficulties. Everyone can complete good assessment and critical thinking if trained well, not just registered or enrolled nurses. I also think we need to focus more on the spiritual wellbeing and take a holistic approach to care, incorporating more lifestyle activities and activities of interest. We are not an acute setting, we are managing chronic conditions. All staff need more time, more hands and more money to achieve the day to day care for our ageing population. So let’s join together to make their final years ones to remember to incorporate families to join in and help us in return have time to sit and listen to their stories and lives. It’s not all clinical so let’s not get caught up in am I a registered nurse enrolled nurse or carer. Lisa Aquilina EN, Vic FEATU RE

Reference Robinson, P. C., Lim, I., & Barrett, C. (2014). The safety and handling of low dose methotrexate: myths and realities. Australian Pharmacist, 33(5), 68-70.

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Wong, L. S., Tymms, K. E., & Buckley, N. A. (2009). Potential for methotrexate exposure through contamination during parenteral use as an immunosuppressant. Internal Medicine Journal, 39(6), 379-383. doi:10.1111/j.14455994.2008.01716.x

Emma Bavage RN, Rheumatology CNC Royal Hobart Hospital

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check ptom larly aske embedd of an aged Sche care sect atic d to ed AINs with dule 8 drug or About with shortcom so she qualifica out the auth s with could ings. experienc a year ago ority or tions supp herself , the with the osedly reali She witn to do so. took up ed registere of care gn company essed d nurs visa work . a coho e supervisoa role as the ’s mod rt of night-du el “The acceptin ers become care facil r at a shiny bullied 457 as they y made my new agedty of fear g back-to-b life as could the Gold ity that had ack shift into of difficult on day was very losin sprung Coa duty She also g their jobs s out up on The facil st. was atro little staff and . There . saw nurses ity cious.” the care floors, worked graduate which boasted four Whe unwittin to quickly 160 resid gly train the bone and continuen the poor prac shuffled ents unsafe in practices ed to carry Victoria . saw as d Victoria took tices out her only covered by man Follo nights option what she shift a “I was Queensl wing talks with agement. as the week, heading s three and Nurs point whe just getting and quit. the only regi ANM the to es team duty with F Qld the stered downhill re mentally Branch), Union (QNU, nurse decided I was goin in Nurs around seve on Victoria the lies . I couldn’t cope ing (AIN g n Assistan with her to confront anymore, down managem concerns ts “I que the fort. ) helping her ” she with stioned ent . “I said hold It was wanted whether recalls. I wasn do that to be I even time at not long into [check ’t prepared the facil The QNU a nurse anym AINs] her to narcotics became and ity that ore. is action with point whe it got dow against currently purs ” consider uneasy abo Victoria n to the to force the facil re the uing ut we all becominged imprope what she need our manager said address it to acknowle ity in a bid mortgag the norm r practices jobs. We dge and its flaw es.” s. . all have Victo Managem sector ria says the ent transferr aged care is ing Victo retaliated by direction heading in a dangerou ria onto securing and believes day duty s each yearmore and morfacilities are e resid without ents backing up the

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54 February 2016 Volume 23, No. 7

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MAIL Letter of the month

Respect

Money crunching in aged care makes it impossible

I am writing in response to the RN, Melbourne “dignity and self-respect in the face of bullying”, mail section ANMJ Vol 23, No. 6.

After reading the feature article The Age of Reason ANMJ, November 2015, I felt compelled to write. In 2004 I became a PCA (Assistant in Nursing). Back then the course I completed was over 12 weeks and quite comprehensive. I worked at a local nursing home where staffing levels were not only adequate, but on every shift there was an RN and EN as well as a good amount of PCAs. The EN took a lot of the pressure from the RN in terms of wound dressings, and was a good back up to the RN, not just in checking scheduled medication but clinically as well. The EN would also act as a type of team leader ensuring residents were cared for properly and overseeing the PCAs in their care. While I was working at this nursing home I decided to do my EN training. The manager of the nursing home loved telling all and sundry that I was increasing my skills, (including families visiting with the hope of placing their loved one there). Despite having many high distinctions and distinctions on my record when I completed my course in 2007, I was told I was welcome to stay on at the facility but ‘only as a PCA’. In other words they did not want to pay me for my newly acquired skills. I loved working in aged care but was forced out due to the money crunching of management. I ended up with a successful career in acute care in a hospital after completing my medication endorsement in 2007. While I love working at the hospital, my true love is aged care. Why would I want to go back now? I am even thinking about completing the Bachelor of Nursing but I shudder to think what would become of me in aged care if I was asked to do things that were against what I have been taught all along. No wonder there is no incentive for anyone to want to work in aged care. There are too many unskilled workers and too few skilled ones. In any other industry it would be branded as nonsense yet it continues in most nursing homes today. I only hope that enough pressure can be put on the government to ensure a mandatory skills mix in aged care ie. one RN, one EN and an appropriate number of AINs for every shift - It’s that simple really. Not only would the residents be better cared for, the families would have peace of mind knowing that their loved ones were being looked after as they should be with the appropriate skill level in place at all times. Naomi Edwards, EN Vic

Letter of the month 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. anmf.org.au

How can the nursing industry be respected, supported and valued when we don’t treat our own colleagues that way. There is a group of bullies on the ward which sadly includes management, making it difficult to complain. Everyone on the ward is aware of this as it is often quietly talked about. Situations occur with witnesses commenting, yet too scared to confirm when the matter is taken further. The ward is wonderful when these people are not rostered on at the same time. These bullies are selfish as they have to go on breaks together, turn up for a shift and leave together making others wait or go without. I ended up taking annual leave and was in therapy as I was informed after 10 years that suddenly I did not belong. Now I realise these so called bullies are really just pathetic people. They are insecure, paranoid, jealous and sad. They bully others to make themselves feel superior and personally attack others to conceal their own short comings as well as advertise others mistakes to hide their own. They have to be in a pack together to feel strong as they are prisoners in their own circle. It’s funny when they are on a shift alone; they look lost and are quiet. Everyone is responsible. Unless you speak up you too are a bully as you are confirming that bullying is acceptable. We need to support each other against these pathetic people. We all need to speak up - we wouldn’t tolerate it if our children had to endure this, yet we accept it at work. Why do we do nothing when we observe it? Let us all be like RN Melbourne and strive to set good examples. Name withheld, EEN Vic

Marriage equality and discrimination I am saddened to read Christine Schreiber’s letter (ANMJ Vol. 23 No. 6) and her deluded belief that she is somehow being discriminated against because she holds out-dated views on marriage equity. Conduct statement four of the nurses code of conduct requires nurses to “refrain from expressing racist, sexist, homophobic, ageist and other prejudicial and discriminatory attitudes and behaviours toward colleagues, co-workers, persons in their care and their partners, family and friends.” As nurses I believe we also have a responsibility to the wider community and should set an example by demonstrating our support for human rights including marriage equity. LGBTI individuals are not second class citizens and should have the right to have their relationships recognised both legally and socially. Using any term other than marriage suggests their union is seen as somehow inferior. Thankfully the majority of Australians agree with marriage equality especially the younger ones who have not been brought up with the repressive attitudes of the past. Christine’s beliefs would be as laughable as fish eating bananas in trees if they were not so harmful to the health and welfare of LGBTI Australians. Tracy Murphy RN VIC February 2016 Volume 23, No. 7 55

SALLY

Sally-Anne Jones, ANMF Federal President

There is increasing reporting in the media of alcohol fuelled violence in Australia. The impact on individuals, families and communities is immeasurable – far beyond the number of deaths and injuries we can count. Nurses and midwives are often at the frontline of dealing with patients or their significant others who are victims or perpetrators of alcohol related incidences from intoxication to alcohol poisoning, violent related injuries such as ‘one punch’, harm to pregnant mothers and unborn babies due to alcohol related risk taking behaviours, and alcohol related domestic and family violence.

THE NATIONAL ALLIANCE FOR ACTION ON ALCOHOL (NAAA) CONTINUES TO STRONGLY ENCOURAGE THE AUSTRALIAN FEDERAL GOVERNMENT TO PROVIDE LEADERSHIP AND STRENGTHEN ALCOHOL POLICY AT THE NATIONAL LEVEL, AND FOR THE STATE AND TERRITORY GOVERNMENTS TO PROACTIVELY CONTRIBUTE TO BETTER PROTECTING THE COMMUNITY.

3.8% OF DEATHS GLOBALLY ARE FROM ALCOHOL CONSUMPTION

6.2% OF INDIGENOUS AUSTRALIANS EXPERIENCED A MUCH GREATER BURDEN OF ALCOHOLRELATED HARM

A January 2016 press release from the Royal Australasian College of Surgeons informs us that for every death related to ‘coward punch’ there are 15 other brain injured victims of alcohol related harm in Queensland. Some remain affected permanently, requiring health services and support for the rest of their lives. Alcohol consumption is also major risk factor contributing to the burden of disease in Australia. An estimated 3.8% of deaths globally and 4.6% of disability-adjusted life-years (DALYs) are attributable to alcohol use. Indigenous Australians experienced a much greater burden of alcohol-related harm, estimated in 2003 to be 6.2% of the total burden of disease in the Indigenous population. In 2004–05, the total net tangible cost of alcohol use (which included lost productivity, healthcare costs, road accidentrelated costs and crime-related costs) was $10.8 billion (Doran, et

56 October 2015 Volume 23, No. 4

al. 2010). Doran et al. (2010) stated that Australian governments do have some familiarity with success in the area of alcohol policy. For instance, the drink-driving countermeasures introduced in Australia progressively since the 1970’s have transformed our attitudes and behaviours, and massively reduced the number of fatalities and injuries from road crashes. The key ingredients to this public health success story has been a combination of legislative and policy reform, strict enforcement, and well-funded and sustained public education. We now recognise this as a proven formula for changing drinking culture in an Australian context, and it therefore comes as no surprise that drinkdriving countermeasures is the one alcohol policy area where most jurisdictions do well. But there is more work to do to change Australia’s drinking culture that fuels violence and produces long-term health consequences. In 2010, The National Preventative Health Taskforce recommended an optimal package of interventions, in order of costeffectiveness, which included volumetric taxation, advertising bans, an increase in the minimum legal drinking age to 21 years, brief intervention by primary care practitioners, licensing controls, a drink-driving mass media campaign and random breath testing. The National Alliance for Action on Alcohol (NAAA) continues to strongly encourage the Australian federal government to provide leadership and strengthen alcohol policy at the national level, and for the state and territory governments to proactively contribute to better protecting the community. The Queensland government is working hard to achieve the goal of changing Queensland’s drinking culture with a recently tabled Amendment Bill. This follows work in other states who have successfully introduced changes to Legislation of this kind. On 12 November 2015, Hon. Yvette D’Ath introduced an Amendment Bill to the Queensland Parliament entitled Tackling Alcohol-Fuelled Violence Legislation Amendment Bill 2015. In her introductory speech, Ms D’Ath stated that, “Despite previous liquor reforms, alcohol fuelled violence continues to be a problem that claims lives, destroys

families, discourages patronage in entertainment precincts and drains valuable resources from our police and emergency services. Queensland cannot afford the human and economic costs related to the abuse and misuse of alcohol. The research could not be clearer: for every hour of reduced liquor trade, there is a significant decrease in alcohol related assaults.” Amendments proposed (to a number of Acts) include, but are not exclusive to: • stopping the service of alcohol at 2am; • 3am liquor trading with a 1am lock out in safe night precincts; • prohibiting new extended trading approvals for takeaway liquor; • banning the sale of high alcohol content and rapid consumption drinks after midnight; • improving existing intervention and therapeutic program referral processes; • creation of new offences; • proof of age changes; • ability for approved 3am safe night precincts to be declared or revoked by regulation. The Amendments Bill has been sent to the Queensland Legal Affairs and Community Safety Committee for consideration, which is due to report to the House on the Tackling Alcohol-Fuelled Violence Legislation Amendment Bill by 8 February 2016. Australia has a window of opportunity to significantly expand activities to reduce alcohol-related harm, physical injury and death from alcohol-related violence but also, with the same interventions, to address overall population health status and alcohol related comorbidities. It is important that federal and state governments take this opportunity to reform alcohol policy in Australia. Nurses and midwives have a role to care for the people affected by alcohol and alcohol related injury, but also, as trusted, leading health professionals, to lobby state and federal governments to implement legislation that reforms the advertising, sale and consumption of alcohol in order to improve the health and safety of individuals, families and communities we serve. References: Doran, C.M., Hall, W.D., Shakeshaft, A.P., Vos, T. and Cobiac, L.J. Alcohol policy reform in Australia: What we can learn from the evidence, Med J Aust 2010; 192 (8): 468-470.

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Caring for the people who care

Sarah believes everybody deserves Sarah believes everybody deserves respect, including the homeless. respect, including the homeless. She fights for their rights to She fights for their quality health care. rights to quality health care. She becomes a familiar face She becomes familiar face for those that aneed help. for those that need help.

Do Do you you know know someone someone like Sarah? like Sarah?

Nominate them Nominate them for the 2016 HESTA for the 2016 HESTA Australian Nursing Awards Australian Nursing Awards

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