ANMJ March 2015 by Australian Nursing & Midwifery Journal

A U S T R A L I A N N U R S I N G & M I D W I F E RY J O U R N A L VOLUME 22, NO. 8

MARCH 2015

INDIGENOUS HEALTH

Stepping into the gap www.anmf.org.au

Clinician Fact Sheet:

Antimicrobial Stewardship The goal of the Antimicrobial Stewardship Clinical Care Standard is to ensure that a patient with a bacterial infection receives optimal treatment with antibiotics. This means that patients are offered the right antibiotic to treat their condition, the right dose, the right route, at the right time and for the right duration. This should be based on accurate assessment and timely review as to lessen the risk of adverse effects and reduce the emergence of antibiotic resistance.

UNDER THIS CLINICAL CARE STANDARD A patient with a life-threatening condition due to a suspected bacterial infection receives prompt antibiotic treatment without waiting for the results of investigations.

A patient with a suspected bacterial infection has samples taken for microbiology testing as clinically indicated, preferably before starting antibiotic treatment.

A patient with a suspected infection, and/or their carer, receives information on their health condition and treatment options in a format and language that they can understand. When a patient is prescribed antibiotics, whether empirical or directed, this is done in accordance with the current version of the Therapeutic Guidelines (or local antibiotic formulary). This is also guided by the patient’s clinical condition and/or the results of microbiology testing. When a patient is prescribed antibiotics, information about when, how and for how long to take them, as well as potential side effects and a review plan, is discussed with the patient and/or their carer.

When a patient is prescribed antibiotics, the reason, drug name, dose, route of administration, intended duration and review plan is documented in the patient’s health record. A patient who is treated with broad-spectrum antibiotics has the treatment reviewed and, if indicated, switched to treatment with a narrow-spectrum antibiotic. This is guided by the patient’s clinical condition and the results of microbiology tests. If investigations are conducted for a suspected bacterial infection, the responsible clinician reviews these results in a timely manner (within 24 hours of results being available) and antibiotic therapy is adjusted taking into account the patient’s clinical condition and investigation results. If a patient having surgery requires prophylactic antibiotics, the prescription is made in accordance with the current Therapeutic Guidelines (or local antibiotic formulary), and takes into consideration the patient’s clinical condition.

More information on the Clinical Care Standards program is available from the Australian Commission on Safety and Quality in Health Care website at www.safetyandquality.gov.au/ccs. Antimicrobial Stewardship Clinical Care Standard Clinician Fact Sheet, 2014

Australian Nursing & Midwifery Journal - www.anmf.org.au

Editorial Lee Thomas, ANMF Federal Secretary Many of you would be aware that the Productivity Commission is reviewing Australia’s workplace relations framework with the aim of industrial relations reform. Reminiscent of the Howard government’s doomed industrial relations reform, better known as WorkChoices, the agenda of this review is clearly to erode workers’ rights and conditions. Recently, the Productivity Commission released five issues papers for consultation. One of the most contentious issues discussed in this paper was the role and necessity of penalty rates – a key workplace entitlement essential to many of you working in the professions. Penalty rates and shift loadings comprise a significant portion of a nurse’s or midwife’s remuneration. Penelty rates also compensates for working unsociable hours, often at the expense of family, friends and other activities. While this is not news to you I am sure that you are as baffled as I am about how the government proposes to address recruitment and retention issues already plaguing the professions if it plans to rob nurses and midwives of these essential entitlements. As nurses and midwives we are the backbone of healthcare. But, as numerous of you have indicated, there are many nurses and midwives that will be forced to leave the professions if there entitlements are lost. To this end we have warned the Abbott government that stripping away penalty rates and other allowances will clearly compromise healthcare provided to Australians.

later this month. Part of this response is your overwhelming and invaluable feedback from our online survey. Thanks to all of you who participated. To gain more insight into the Productivity Commission’s review, particularly in relation to penalty rates and other workplace entitlements, see the Federal Industrial team’s column in this month’s journal. Equally important to the future of quality healthcare are nurse/patient ratios. In a pre-election promise the incoming state Labor government in Queensland said they would mandate patient/nurse ratios once in office. Additionally Victoria will soon become the first state to legislate ratios, under the Andrews’ government who were elected into power last year. The ANMF applauds these positions and will hold both governments accountable to their promises. The ANMF has also been lobbying politicians to mandate staffing levels - skill mix in aged care. Recently I met with the Palmer United Party (PUP) member Senator Glenn Lazarus to discuss this issue and our ongoing campaign to save Australia’s system of universal healthcare. As a result Senator Lazarus has committed to our fight, and we will work with him and all other committed MPs and Senators for the rights of older Australians and to defend our health system. In no uncertain terms, we will do what it takes to protect penalty rates, just as we fought hard against WorkChoices. We will also fight for mandated nurse/patient ratios to ensure quality care for all. Together our collective voice will be heard.

The ANMF will be responding to the Productivity Commission’s five issues paper

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March 2015 Volume 22, No.8 1

Australian Nursing & Midwifery Federation National Office www.anmf.org.au

Canberra

Editorial

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Editor: Kathryn Anderson Journalist: Natalie Dragon Production Manager: Cathy Fasciale Level 1, 365 Queen Street, Melbourne Vic 3000 Phone (03) 9602 8500 Fax (03) 9602 8567 Email anmj@anmf.org.au

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Northern Territory

South Australia

Victoria

Branch Secretary Yvonne Falckh 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

Branch Secretary Elizabeth Dabars 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

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

Branch Secretary Beth Mohle 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

Branch Secretary Neroli Ellis 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

Branch Secretary Mark Olson 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 March 2015 Volume 22, No.8

143,792

TOTAL READERSHIP

Based on ANMJ 2014 member survey pass on rate Circulation: 98,488 BCA audit, September 2014

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Contents

Volume 22, No 8.

INDIGENOUS HEALTH Stepping into the gap

News

Industrial 15 World 16 Tech Talk

Feature – Indigenous health 18 Issues

Education 24 Clinical Update

Ethics 30 Wellbeing 31 Focus – Mental Health 32 Calendar 47

News

Tech Talk

Exoskeletons to revolutionise rehabilitation

Wellbeing Be like Water

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Coral 48

Focus

Mental Health

March 2015 Volume 22, No.8 3

News

Nurse and midwife to patient ratios victory for QLD by Karen Keast

Queensland will introduce nurse and midwife to patient ratios in the public sector after Labor secured enough seats to form government. The newly elected Palaszczuk Government has promised to enshrine in legislation safe patient ratios for nurses and midwives. Queensland Nurses’ Union (QNU) Branch Secretary Beth Mohle labelled the new state government’s commitment to mandated nurse and midwife to patient ratios and endorsed skill mix levels “a great outcome.” “We had our Ratios Save Lives Campaign and it was based on the evidence of International patient safety researcher Professor Linda Aiken and the like,” she said. “The international evidence shows having mandated minimum nurse or midwife to patient ratios helps save lives.” Ms Mohle said the Branch will now use its ratios claims document to enter into

negotiations with the new government as it works to implement the ratios legislation. She said the Branch, as part of its longterm agenda, will also aspire to achieve legislation covering nurse and midwife to patient ratios and skill mix levels for acute private health facilities and across the aged care sector. “It’s an ambitious claim but our members across all sectors and, more importantly, the patients, the community of Queensland, deserve mandated minimum nurse to patient ratios. “We think both the community and our members deserve us striving for this and that’s what we will be doing.” With three years of health cuts under the previous LNP government, Ms Mohle said members were concerned about their ability to provide quality of care in the current dollar-driven health system. Ms Mohle said legislated ratios will provide nurses and midwives with certainty and the ability to deliver high quality care. “We can transform the system through providing high quality care but also in providing innovations in care that will save money in the long run. “We have got a commitment to legislate this and so we will be working very hard to get

the best outcome we can for our members.” The move to ratios in Queensland comes after the success of mandated ratios in Victoria and New South Wales. Ratios were first introduced in Victoria through the public sector enterprise agreement in 2001. Victoria will soon become the first state in Australia to legislate ratios, after the Andrews’ government was elected to power in November last year. The ANMF Victorian Branch is working with the new state government to shape the ratio legislation, based on existing ratios, which is expected to be introduced into Parliament this year. Branch Secretary Lisa Fitzpatrick said the Federation will then focus on adding ratio improvements that will form part of amendments to the legislation. “We will be seeking for the amendments to occur in 2016 and we’re seeking that those amendments would be staggered over a number of years.” As part of its campaign for mandated staffing levels in aged care, the ANMF Federal Office recently received support from Palmer United Party (PUP) Senator Glenn Lazarus.

Support for safe staffing levels in aged care Mandating staffing levels in aged care and saving Australia’s system of universal healthcare has gained the support of Senator Glenn Lazarus from the Palmer United Party (PUP). Senator Lazarus met with ANMF Federal Secretary Lee Thomas and Assistant Federal Secretary Annie Butler last month to discuss concerns about the lack of nurse to patient staffing ratios which is compromising the amount of quality care being provided to elderly, vulnerable

4 March 2015 Volume 22, No.8

people living in nursing homes. Ms Thomas said the presentation to Senator Lazarus gave them the opportunity to outline the staffing crisis in aged care and the urgent need to address this at a time when there is a current shortfall of 20,000 nurses in the sector. “The Senator appreciated these concerns and the lack of quality care in some nursing homes because of poor staffing, as these issues had also been raised by community members in his home state of Queensland.”

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News Dementia investment welcome but more needs to be done Health unions and organisations have welcomed the federal government’s million dollar announcement for aged care residents experiencing severe dementia but urge further investment is needed. The government announced the $54.5 million investment over four years to establish Severe Behaviour Response Teams (SBRTs). The teams will be a mobile workforce of clinical experts who will provide advice and visit residential aged care facilities to provide assistance for those with severe behavioural and psychological symptoms of dementia (BPSD). ANMF Federal Secretary Lee Thomas said the move was a step in the right direction but the government needed to do more right across the aged care sector, for patients, nurses and carers. “With the number of dementia cases set to increase to almost one million people by 2050, the ANMF and our members call on the government to look at new ways of assisting some of the most vulnerable living in aged care facilities as well as their families.” The government’s new package uses redirected funding from the Labor government’s previous Dementia Supplement which was scrapped by the Abbott government last year. Catholic Health Australia (CHA) Chief Executive Officer Suzanne Greenwood said the announcement of the SBRTs in response to last year’s axing of Labor’s Dementia and Behaviour Supplement would be useful for some facilities but did not provide a comprehensive response. “It will not meet the funding needs of those aged care services that have employed specialised and skilled staff using the former supplement and now face the added costs of meeting the needs of residents with behavioural and psychological symptoms of dementia.” CHA urged the government to include

Male and female nurses’ health differs Australian and New Zealand male nurses have a higher BMI, sit for longer, sleep less time and are more likely to smoke than their female nurse counterparts, an observation study lead by the University of Queensland has found. The study also showed male nurses reported greater rates of respiratory disease and cardiovascular disease,

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a more comprehensive strategy in the upcoming federal budget. The federal government ceased what it calls Labor’s ‘bungled Dementia and Severe Behaviour Supplement’ as it had blown its budget by over ten-fold. Aged & Community Services Australia Chief Executive Officer Professor John Kelly said it was clear to those in the sector that the supplement’s budget would be overspent. “This need did not disappear when the funding was withdrawn.” There was unanimous support across the industry for the need for greater support for people with severe behaviours, he said. “Roaming teams of experts may work in the first instance but building capacity across the sector through a whole-of-workforce approach needs to be part of the future workforce development policy and funding.” Professor Kelly said, the idea of severe behaviour response teams had merit but whether they could provide resources and expertise quickly enough in regional, rural and remote areas would need monitoring. “If this is a city-centric fix to a large problem, it will disadvantage many people with severe behaviours all across Australia.” The review of current dementia services is estimated at $132 million. Combined Pensioners & Superannuants Association of NSW’s Senior Advisor, Research & Advocacy Charmaine Crowe said good dementia care could not be delivered on an ad hoc basis. “These teams will be of little use unless

including a three times greater incidence of myocardial infarction, and were more likely to have metabolic problems. Despite this, male nurses were more likely to feel calm and peaceful with less worry about their health. In stark contrast female nurses reported higher stress levels at home and in the workplace than men. Female nurses indicated they were tired, worn out and challenged to accomplish all they wanted to do. Due to the significant differences in

nursing homes have enough qualified staff, including registered nurses, to provide ongoing, high quality care for people with dementia. There is no national requirement to have a registered nurse on duty at all times in a nursing home, nor are there any staff-toresident ratios.” COTA Australia Chief Executive Ian Yates said aged care providers had to do much better than most do now in responding to the needs of people with advanced dementia. “For example there is emerging evidence that many so-called ‘severe behaviours’ attributed to dementia are in fact due to dementia sufferers being in preventable pain exacerbated by provider responses that ignore the pain and blame dementia. The government needs to encourage providers to deal better with aged care residents who are dementia sufferers.” Carers Australia Chief Executive Officer Ara Cresswell said the psychological and physical strain for someone with advanced dementia, especially if they become aggressive, suffer severe mood swings and become extremely disoriented, could be totally overwhelming for family and friends. “Carers will clearly benefit from any program which will assist in the provision of better practice dementia care in both residential and home care settings and assist with the remediation of BPSD.” Alzheimer’s Australia Chief Executive Officer Carol Bennett said she hoped the initiative would lead to a reduction in the use of physical and chemical restraints. “This is a good result for people with dementia and their families. It is even better that this measure has been developed in consultation with the sector and consumers.” The first phase of the new SBRTs is expected to start later this year, with a second phase from 2016-2017.

health and wellbeing concerns between the genders, the authors recommend workplaces provide targeted men and women-centred workplace health promotion programs. By investing in such health promotion programs, administrators could meaningfully advance nurses’ health and their collective capacity to provide optimal care, the authors suggest. The study was published in the American Journal of Men’s Health.

March 2015 Volume 22, No.8 5

News VIC ANMF continues to meet RDNS over job cuts The ANMF Victorian Branch has continued to meet with Royal District Nursing Service employees with the organisation’s plans to make 84 jobs redundant from the end of April. being forced to compete for new and in some case, lower-graded positions, Working party consultation groups were according to the ANMF Victorian Branch. held last month to resolve various issues. The Royal District Nursing Service (RDNS) has maintained patient care will not be compromised under the changes, despite the cutting of 84 roles and the reduction of its 14 centres to four regional hubs. The staffing changes will affect client service managers, operations managers, coordinators of clinical services, clinical nurse consultants, grade 3 specialist district nurses and four regional coordinator positions. The move will see over 150 employees

Almost 200 nurses attended a members’ meeting in January where issues were raised by nurses regarding patient care. ANMF Victorian Branch Acting Secretary Paul Gilbert said there were critical patient care issues that had been identified which needed to be addressed following the members’ meeting. “We have a number of serious concerns about the proposal if it were to proceed in its current form.” The RDNS has maintained it is not a public sector organisation and the job

redundancies have been around uncertainty about future funding. Under the new structure, in the four regional hubs, management positions will be reduced to 12 with 34 field operations staff. Of the 100 full-time-equivalent (FTE) grade 3 specialist district nurse positions, 24 will be assigned to grade 2, seven roles will remain unchanged and RDNS nurses will have to compete for the remaining 69 FTE positions. After ANMF Victorian Branch negotiations in February, all affected classifications will now be eligible to apply for voluntary redundancies. Others are able to decide whether to apply for a new role. Negotiations between the ANMF Victorian Branch, members and the RDNS were continuing at the time the ANMJ went to print.

Call for national surveillance program to reduce infections New research supports the introduction of a national data surveillance program for healthcareassociated infections, according to a leading healthcare body. An estimated 175,000 Australians are affected by healthcare-associated infections (HAI) each year. The latest research was published in the journal Australian Health Review last month. The Australian Healthcare and Hospitals Association (AHHA) highlighted while there were a number of Australian states

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and territories that had HAI surveillance programs, they were not standardised like other countries. “As a result, the use of the data collected by these disparate surveillance programs is very limited,” AHHA Chief Executive Alison Verhoeven said. The United States, Germany, United Kingdom, Spain, France, Scotland and the Netherlands had all implemented national data surveillance programs. Ms Verhoeven said Australia could “cherry pick” what worked and what didn’t. “A national HAI surveillance program,

modelled on successful local and international programs could help provide more reliable and valid data that would reduce the incidence of HAIs.” An effective surveillance program that could detect clusters or outbreaks of HAIs, identify programs and evaluate prevention and control measures could ultimately stimulate action and drive improvement, Ms Verhoeven said. The open access articles in the February edition of the Australian Health Review are available at www.ahha.asn.au/ahr

March 2015 Volume 22, No.8 7

News Leaked document shows further risk to public health

NSW launches TV ads against privatisation

Wide-ranging reforms to national public health systems, including the promotion of health insurance for offshore medical procedures have raised serious concerns by both unions in Australia and internationally.

A new television advertising campaign was launched across New South Wales ahead of the state election this month.

The NSW Nurses and Midwives’ Association’s (NSWNMA, ANMF NSW Branch) Patients before Profits campaign aired from 8 February and highlights the effects of what a heavily privatised, American-style health system would have on the state. NSWNMA General Secretary Brett Holmes said the current state Liberal-National government had been “picking off parts of our public health system and paving the ways for its Americanisation”. “It’s a combination of the attempts to dismantle Medicare, the privatisation of public hospitals and health services, as well as scope for private insurers to enter primary care, that will lead to an Americanisation of our health system.” Mr Holmes said sub-acute mental health services had been privatised, new palliative care services had been gifted to the forprofit sector and disability services would cease to be government-run by 2018 under the current state government. “Last December, the government signed a 20-year contract with private operator Healthscope to build and run the new Northern Beaches Hospital in Sydney, despite the fact publicprivate partnerships in health have a history of failure in NSW – take Port Macquarie Base Hospital for example.” An undeniable pattern had emerged in the first-term government which was not in the best interests of NSW patients, Mr Holmes said. “Patients who can afford and choose to utilise private hospitals for medical treatment should be able to, however, private hospitals should not be handed public funding on a platter.” The NSW Labor Opposition said recent 8 March 2015 Volume 22, No.8

privatisation and outsourcing steps by the current government included the: • refusal to release details of private hospital plans for the new MaitlandLower Hospital; • putting out of contracts to provide private day surgery at the new Byron Central Hospital; • privatisation of the x-ray unit at Kempsey District Hospital; • awarding a $1 billion contract to Healthscope to set up a private hospital on Sydney’s northern beaches; and • privatisation of distribution of medication supplies and equipment within NSW Healthshare which removed 130 staff at five sites. NSWNMA General Secretary Brett Holmes said the state government had been operating under direction from Canberra to bring “price signals” into health. ANMF Federal Secretary Lee Thomas said nurses and midwives stood united against the Americanisation of Australia’s health system under the current federal government. The attempt to introduce a $7 GP co-payment, which was defeated by public outcry, was an example of the federal government’s attack on Australia’s public health system, she said. “The Abbott government has finally decided to enter into consultation with the sector. However the ANMF’s support for Medicare and a universal public healthcare system is unwavering.” Ms Thomas said the ANMF would continue to fight any attempts by the government to introduce any co-payment. The ANMF would also oppose the proposal to reduce penalty rates. “We will fight for health funding which will ensure quality care for all Australians.”

The reforms, in a leaked discussion paper by Associated Whistle-Blowing Press, show negotiators of the Trade in Services Agreement (TISA) would include increased privatisation of health services. The trade deal with TISA is being negotiated by Australia and other countries including the United States and the European Union. NSW Nurses and Midwives’ Association (NSWNMA, ANMF NSW Branch) Assistant General Secretary Judith Kiejda said under such an agreement health dollars could potentially be taken out of Australia and redirected overseas, as patients travel abroad for medical procedures. “The only winners would be the shareholders of large health corporations and insurance companies, not patients. We are extremely worried that under the TISA, privatisation of health services would be irreversible.” It was another example of the federal government’s intention to Americanise the healthcare system, through increased privatisation of services, Ms Kiejda said. The federal government needed to be transparent about what was being negotiated in the TISA, she said. According to Global Trade Union Federation, Public Services International (PSI), the TISA proposal assumed health services were like a commodity that could be handled by the market and ignored the role of public health. “Health is a human right and is not for sale or for trade,” PSI General Secretary Rosa Pavanelli said. The NSWNMA has called on the Prime Minister and Trade Minister Andrew Robb to insist on exclusion of healthcare services and medicines from the TISA and any other free trade agreement. For more information about the leaked discussion paper, visit www. world-psi.org/issue/asia-pacific

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When pain is gone, the smile is back.

Nothing is more effective than Children’s Panadol® 1 –4† Suitable from 1 month of age, Children’s Panadol®‡ effectively relieves pain and fever caused by teething, headache, earache, immunisation, and symptoms of cold and flu.1–3

†

Refers to non-prescription medicines at the recommended Australian doses for paediatric paracetamol (15 mg/kg) and ibuprofen (10 mg/kg).‡Guidelines recommend paracetamol for the first-line treatment of pain and fever in children.5

References: 1. Autret-Leca E et al. Curr Med Res Opin 2007;23:2205–11. 2. Walson PD et al. Am J Dis Child 1992;146:626–32. 3. Schachtel BP et al. Clin Pharmacol Ther 1993;53:593–601. 4. Celebi S et al. Indian J Pediatr 2009;76:287–91. 5. NSW Department of Health. Policy Directive: Paracetamol Use. Available at: http://www.health.nsw.gov.au/policies/pd/2009/PD2009_009.html. Accessed January 2015. Children’s Panadol® contains paracetamol. For the temporary relief of pain and fever. PANADOL® and package design elements are registered trade marks of the GlaxoSmithKline group of companies. GlaxoSmithKline Consumer Healthcare, 82 Hughes Avenue, Ermington, NSW 2115 Australia. GSK1481/UC 02/15. CHANZ/CHPAN/0021/15b.

News ACT walk-in centre

Online tool for patients with fatigue A new online tool is now available to support health professionals, including nurses, with patients who present with fatigue. The National Prescribing Service (NPS) MedicineWise’s Back to basics for fatigue: a diagnostic approach resource is aimed to help discussion between health professionals and patients on the many possible causes of fatigue and to help identify and address lifestyle factors. The tool provides patient information and management tips, such as healthy diet, drinking less alcohol and caffeine, sleep hygiene and looking after emotional and mental health. NPS MedicineWise Clinical Adviser Dr Andrew Boyden said people often sought medical advice due to fatigue. However it was not often associated with underlying disease, particularly in young to middle aged adults and may remain unexplained. “The new information prescription tool provides patients with clear explanations about the association between fatigue and lifestyle, psychological and physical causes, or a combination of these,” he said. The tool also supported information about whether diagnostic testing for fatigue was appropriate. Patientspecific information can be customised and saved in PDF format and emailed to a patient or printed out during a consultation. The fatigue information online tool can be accessed at www.nps.org.au/ fatigue-information-prescription

10 March 2015 Volume 22, No.8

NSW Opposition commits to nurse-led walk-in centres NSW Labor has committed to setting up four free, nurse-led walk-in centres if elected to government later this month. The Opposition announced the $40 million initiative last month which would employ 45 nurses in four centres – two in western Sydney and one each in the IllawarraShoalhaven district and on the central coast. Under the centres, nurses would provide free medical advice between 7.30am and 10pm for patients aged two and older with minor injuries and illnesses, seven days a week on a walk-in basis. The centres would be based on those introduced in the United Kingdom in 2000 and in the ACT in 2010. NSW Labor said in the past five years 100,000 people had accessed the clinics in the ACT. “Having this free option will relieve the pressure on local hospital emergency departments which are struggling to cope with the Abbott and Baird funding cuts,” NSW Opposition Leader Luke Foley said. The initial ACT walk-in centre based in the Canberra Hospital has now moved and expanded to two centres in the community

in Tuggeranong and Belconnen with increased demand. Acting Assistant Director of Nursing of the walk-in centres in the ACT Michelle Lambert said she thought the NSW initiative was “fantastic”. “We have been growing; we are seeing an increasing number of people.” Since the two walk-in centres expanded last July, about 20,000 people had accessed both clinics, Ms Lambert said. The nurse-led centres treat minor injuries and illnesses, one-off-episodic care, such as musculoskeletal injuries, sprains, fractures, lacerations and upper respiratory tract infections. Ms Lambert said results showed an 84% positive feedback rate. “We operate in a safe model of care within our scope of practice.” Opposition Leader Luke Foley said while nurse-led centres were a bold new initiative, the evidence in other jurisdictions showed they worked. “As political leaders we must find better and smarter ways to improve the health of NSW rather than just resorting to old practices.” Shadow Minister for Health Walt Secord said he was disappointed Premier Mike Baird and Health Minister Jillian Skinner had rejected the plan and did not have confidence in the state’s nurses. anmf.org.au

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News NMBA Update NMBA has initiated a new stakeholder engagement initiative One of the Nursing and Midwifery Board’s (NMBA) priorities for 2014/15 is to strengthen relationships between the NMBA and our stakeholders. There are a number of improvement initiatives in plan that focus on fostering stakeholder relationships, improving and strengthening the National Registration and Accreditation Scheme (the National Scheme), and driving operational excellence. In line with the National Scheme’s objective of providing for the protection of the public and acting in public interest, the NMBA has undertaken a stakeholder engagement initiative that seeks to identify opportunities to enhance and optimise stakeholder education and communication. PricewaterhouseCoopers in collaboration with Colmar Brunton have been contracted to undertake an objective analysis of the current stakeholder communication activities of the NMBA and delegates. This initiative aims to inform the Australian Health Practitioner Regulation Agency (AHPRA) and the NMBA of opportunities to enhance communications and education about the role and regulatory functions of the NMBA as one of 14 National Boards. As part of the project there will be

workshops in every state and territory, both metropolitan and regional, in March and early April. There will also be an online survey providing additonal opportunities for feedback throughout the month of March while the workshops are being conducted . More information will be available on the NMBA website in the coming weeks. A new approach for international criminal history checks As of 4 February 2015, a new procedure for checking international criminal history has taken affect, that provides greater public protection. This approach requires certain applicants and practitioners to apply for an international criminal history check from an Australian Health Practitioner Regulation Agency (AHPRA) approved supplier and was first announced in November last year. The supplier will provide the international criminal history check report to the applicant and directly to AHPRA. AHPRA CEO, Martin Fletcher said, “Public protection is at the heart of everything we do. We are providing the Australian community with greater assurance by implementing additional safeguards in managing risks to the public from someone’s international criminal history. The new approach aligns our international criminal history checks with our domestic history checks and aims to be fair and reasonable for practitioners.” Under the Health Practitioner Regulation

National Law, as in force in each state and territory, National Boards must consider the criminal history of an applicant who applies for registration, including any overseas criminal history. The National Law defines criminal history as: (a) every conviction of the person for an offence, in a participating jurisdiction or elsewhere, and whether before or after the commencement of this Law; (b) every plea of guilty or finding of guilt by a court of the person for an offence, in a participating jurisdiction or elsewhere, and whether before or after the commencement of this Law and whether or not a conviction is recorded for the offence; (c) every charge made against the person for an offence, in a participating jurisdiction or elsewhere, and whether before or after the commencement of this Law While every case is decided on an individual basis, the NMBA considers a number of factors when determining how the criminal history may affect your eligibility for registration. The criminal history registration standard is available under registration standards on our website. There will be no change to existing domestic criminal history check requirements. For more information on criminal checks and NMBA’s initiatives go to www.nursingmidwiferyboard.gov.au/

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Nursing and Midwifery Health Program cares for the carers By Stephanie Francis

The job of being a nurse or midwife can be tough: constantly looking after others’ health and welfare, with never enough time. Add any personal issues with colleagues, friends or family, and a nurse or midwife can find themselves in deep water. If stress leads to abusing alcohol or other drugs, a confidential source of support can be invaluable, especially if the support person also knows what the job entails. and we have to look after each other.” The Nursing and Midwifery Health Program, based in Victoria, has been providing confidential support to nurses and midwives since 2006. Initially focusing on support for substance use issues, the independent program has since broadened its scope and provides counselling to nurses and midwives with a range of concerns. Run by nurses, the program is the only support service specifically for nurses and midwives in Australia and has provided more than 1,200 ‘episodes of care’. CEO Glenn Taylor (pictured) said that prior to the program being established, the taboo surrounding substance abuse by nurses and midwives had meant nurses and midwives were often reluctant to seek help. “We have to promote the fact that we are flesh and blood and have the capacity to fall over and break sometimes –

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While nurses and midwives with alcohol and other drug use issues still seek support from the program, nowadays about 70% of clients come for support with mental health issues – from work discontent and burn-out to psychotic episodes. “We see a lot of people who were going along nicely when something happened – it might be an injury, it might be a relationship breakdown, it might be violence…,” Mr Taylor said. “Bullying and stress are two of the biggest reasons why people come to us.” For situations with no immediate concrete solution, Nursing and Midwifery Health Program staff encourage clients’ resilience and support them to plan a way forward. “Sometimes it’s about helping clients work

out what to do for themselves and providing renewed hope and some direction that can be taken,” Mr Taylor said. The program, in conjunction with ANMF (Vic Branch), is also supporting nurses and midwives to build their resilience through the third Wellness Conference to be held on Friday 8 May, at the Melbourne Convention and Exhibition Centre. Visit the ‘events and conferences’ section of the ANMF (Vic Branch) website anmfvic.asn.au for more details and to register. The program is funded by the Nursing & Midwifery Board of Australia until June 2016. The Nursing & Midwifery Health Program can be contacted by phone (03) 9415 7551 or email admin@ nmhp.org.au Visit www.nmhp.org.au for further information about the program and resources.

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Industrial The business community, lobbying long and hard for a reduction in minimum wages, weekend penalties and shift allowances. Already, employers in a number of industries, including retail, hospitality, pharmacy and hair and beauty have made application to the Fair Work Commission to reduce penalty rates in respective Awards as part of the four year Award Review process.

Industrial

Debbie Richards, Federal Industrial Research Officer Who really ever believed Tony Abbott’s declaration that WorkChoices was ‘dead, buried and cremated’? While we may never hear the term WorkChoices uttered by Coalition members and their supporters ever again, processes have already been set in place to achieve the same end, albeit by different means. This time the Abbott government is using the Productivity Commission to conduct a review into the entire industrial relations system. This is despite a promise before the 2013 federal election, that there would not be wholesale changes to industrial relations legislation. Described as wide ranging, details recently released by the Productivity Commission show that every aspect of the rules governing the employment relationship will be up for grabs. As demonstrated more than once in recent history, the Coalition’s idea of industrial relations reform is only ever about cutting wages and removing and reducing conditions. No matter how it is characterised by government spin doctors and conservative commentators, the bottom line is that we lose! Before WorkChoices the broad scope of this review (see box) is an ominous sign, as is the appointment of the Productivity Commission to conduct the review. As the name suggests, this is a body whose primary focus is economic efficiency, placing too much faith in theoretical models that have no application in the real world. anmf.org.au

While the wide ranging scope of this Inquiry is effectively a review of employment law and the industrial relations system as a whole, the issue of penalty rates is front and centre in this process and is central to the question of identifying our priorities as a community and integral to shaping the type of society we would wish to live in. The Australian Nursing and Midwifery Federation (ANMF) maintains that the regulation of labour is necessary to protect and promote the nature and dignity of humanity and work. This means employees cannot be treated as commodities, nor can their labour be treated in purely economic terms. Labor regulation is essential to a functional economy. Properly set and enforced, these standards guard against exploitation and ensure that minimum standards are established and periodically reviewed. In the process, they promote broad and rising prosperity, as well as public confidence. Employees have the right to just minimum wages, fair and safe working conditions and the right of collective representation. Employment and labour laws should reflect the values that are important to our society including the public interest, the fair go, institutional independence, due process and the transparent recognition, application and regulatory support for collective representation. Our health system is totally dependent on the thousands of nurses and midwives prepared to work all sorts of different shifts, at all hours of the day, over seven days a week, on public holidays, Saturdays and Sundays year in, year out, over an entire working life. They should be fairly compensated and remunerated for the hours they are required to work and the impact it has on all aspects of life. This places nurses and midwives front and centre of this debate and your voices must be heard. Those advocating for the abolition of penalty rates completely ignore the impact on

weekly income and the effect on individuals and families, and the flow on effects from lower income levels more broadly in the community. Nurses and midwives, working a roster which includes working afternoon shifts and weekends, stand to lose up to 40% of their weekly wages if penalty rates are removed or reduced. While the Abbott government and their supporters talk in abstract terms about the impact of penalty rates on business competitiveness and profitability, no comment is made about the personal financial effects of losing a large chunk of your weekly wage. Over the coming months the ANMF will be responding to the PC Inquiry with comprehensive submissions covering all aspects of the Review including the importance of penalty rates. We have already had a huge response from ANMF members who have responded to an online survey asking: • What do your penalty rates mean to you? • Do they compensate for shift work? • How does shift work affect your life? In addition, ANMF will be involved in ongoing activities to ensure the voice of nurses and midwives is heard loud and clear.

The Productivity Commission (PC) has been asked by the government to ‘assess the performance of the workplace relations framework’ and make recommendations to improve workplace relations laws. While the PC has been asked to look at ‘fair and equitable pay and conditions for employees, including the maintenance of a relevant safety net’, the other 10 factors listed in the terms of reference are focused on economic questions and the interests of business including unemployment, productivity, flexibility for businesses, competitiveness and the red tape and compliance burden for business. The PC released five issues papers in January, asking for submissions by 13 March 2015. A draft report will be released by the PC in June/July 2015 and public hearings will be held in August/September. The final report to government is due by 30 November 2015. Further details of the inquiry and Issues papers can be found at: www.pc.gov.au/inquiries/current/ workplace-relations/issues

March 2015 Volume 22, No.8 15

World Immunisation rates set to increase Around 300 million children in some of the world’s poorest countries will have the opportunity to be immunised, thanks to a financial pledge totalling US $7.5 billion made by world leaders at a pledging conference held in Germany last month. The pledges were made to the international vaccine alliance, Gavi who has provided 440 million children with immunisations in developing countries against diseases such as whooping cough, tetanus, diphtheria since 2000. As a result of its immunisation programs, Gavi estimates the lives of over seven million people have been saved.

return on investment and that by pledging to the vaccination initiative was a wonderful use of Australian aid dollars. “By 2017 it will cost as little as $1.53 per dose to help prevent diarrhoea, one of the leading causes of death among children under five. It’s exactly this type of life saving work that Australian aid should be proud of.”

At the conference, Australia joined other countries in renewing its commitment to the immunisation cause, pledging $250 million to Gavi over the next five years.

However, Mr Ronalds also said with recent cuts to the aid budget, the funding must not come at the expense of other life-saving interventions such as access to frontline health workers when ensuring humanitarian assistance is provided when disaster hits.

Save the Children CEO Paul Ronalds said vaccinations boasted an unparalleled

Safe staffing levels set to be mandatory in Wales A draft Bill for mandatory nurse patient-ratios in Wales is under consultation this month.

The draft ‘More Nurses’ Bill, drawn up by Welsh Democrats leader Kristy Williams, and with the full backing of the Royal College of Nursing (RCN), was introduced in January to the National Assembly of Wales prior to being released for consultation. The RCN, who has long campaigned for safe nursing staff legislation to be introduced in Wales, argued the potential new law would greatly improve patient safety and better quality care. Studies have indicated wards with lower staffing levels have a 26% higher mortality rate, whereas in places like California, where similar legislation has been introduced, the mortality rate drops by 1013%, the College said. According to UK media reports Wales has an average of 10.5 patients per nurse compared to 8.5 in England and 7.2 in Northern Ireland.

Profession overhaul to attract nurses United Arab Emirates city of Dubai is planning to increase nurses’ wages in an attempt to make the profession more attractive. In addition, the Dubai Health Authority plans to adopt a flexible shift policy for nurses such as part time and day time hours, as well as the establishment of five nursing schools in Dubai by 2025. The initiatives are part of Dubai’s Clinical Services Capacity Plan which was developed based on a study that indicated the city would need an extra 8,510 nurses, 7,323 doctors and 3,917 hospital beds by 2020, to meet the demand on services. 16 March 2015 Volume 22, No.8

Need based healthcare projects, medical education programs and three extra medical colleges will also be developed as part of the plan. Director General of the Dubai Health Authority His Excellency Engineer Essa Al Maidoor said the Dubai Clinical Services Capacity Plan would be reviewed and updated every two years to ensure that it was consistent with emerging situations such as health services, human resources and technology over the years.

Ms Williams said current nurse patientratios in Wales were unacceptable and that safe nursing levels were the bedrock for effective care. “Nurses provide round the clock care for patients, and work in every kind of healthcare setting. Quite simply, nurse staffing levels are too important to be left to ‘guidance’.” RCN Welsh Board Chair and RCN Council Member said the College was grateful to Ms Williams for helping bring the issue of safe nurse staffing levels to the fore of political conscience in Wales. “The RCN in Wales has supported this bill from its fruition and through working collaboratively with Kristy Williams we have seen an increasingly positive reception from both the public and political sphere.” Wales will become the first country in the UK to set legal ratios, if the Bill is legislated. anmf.org.au

Tech Talk Exoskeletons to revolutionise rehabilitation

Ekso Bionics™

Gurney Khera, B.E, B.Sc (Computer Science)

Many readers will be familiar with the image of a soldier or a starwars character wearing an electro-mechanical external body ‘suit’ which gives the wearer superhuman powers. Marvel Comics created the Invincible Iron Man back in March 1963 which was reprised in the movie ‘The Avengers’ recently with Robert Downey Jr playing the role. The convergence of computer science, electrical and mechanical engineering coupled with materials and biomedical sciences have collaborated to create ‘exoskeletons’ which are now on the verge of revolutionising many facets of human mobility notably in the area of healthcare and rehabilitation. Exoskeletons are basically wearable robots, ie. mecatronic systems designed around the shape and function of the human body and the technology is employed for telemanipulation, strength amplification, neuromotor control and rehabilitation, and to assist with impaired human limbic and motor function. Applications using this technology in patient care have been developed by Japanese engineers designed to help lift and carry patients. For paraplegics the promise is even greater with exoskeletons enabling them to “walk” again. Exoskeletons are being applied in the area of rehabilitation of stroke and spinal cord injury patients. Such exoskeletons are sometimes also called Step Rehabilitation Robots, and will reduce the number of therapists needed by allowing even the most impaired patient to be trained by one therapist. American company Ekso Bionics, is a leader in exoskeleton technology, and its medical product, the ‘Ekso’, is available at rehabilitation centres throughout the US. CEO Eythor Bender says, “We’re starting with paralysed people because their needs are great but you can imagine exoskeletons for workers using tools too heavy to hold for more than a few minutes, and a consumer version for people who want to run a marathon or climb Mount Kilimanjaro.” Exoskeletons, he dreams, will be “the jeans of the future”, being practical, fashionable, and streamlined enough to wear in everyday use. According to Ekso Bionics website, The Ekso™ is a wearable bionic suit which enables individuals with any amount of lower extremity weakness to stand up anmf.org.au

and walk over ground with a natural, full weight bearing, reciprocal gait. Walking is achieved by the user weight shifts to activate sensors in the device which initiate steps. Battery-powered motors drive the legs, replacing deficient neuromuscular function. It is a gait training exoskeleton intended for medically supervised use by individuals with various levels of paralysis or hemi-paresis due to neurological conditions such as stroke, spinal cord injury or disease, traumatic brain injury and more. Brian Shaffer, a paraplegic since 2010, tested an exoskeleton at a rehabilitation facility in Nashville, Tennessee. He recalls, “My kids have started calling me ‘Ironman’. It’s unbelievable to stand up again. It takes concentration to use it at first but, once you catch on, it’s not that hard: The device does all the work. I don’t expect that it will completely replace the wheelchair, but there are some situations, like walking your daughter down the aisle at her wedding or sitting in the bleachers watching your son play football, where it will be priceless.” However the rehabilitation process and learning to use these exoskeletons may be more difficult than imagined. According to Clare Hartigan, a physical therapist at Shepherd Center, Atlanta, Georgia, a person has to be physically fit to use them: “They have to keep their weight below 220 pounds, develop adequate upper body strength to use a walker or forearm crutches and maintain flexibility in their shoulder, hip, knee and ankle joints which is not that easy when a person has relied on a wheelchair for months or even years.” One of the largest problems of exoskeletons is the power supply. There are currently few power sources of sufficient energy density to sustain a full-body powered exoskeleton for more than a few hours. Research into lighter, more efficient batteries and possibly small combustible engines will improve the power cycle or the design of hybrid electro-hydro-fuel systems will allow a full days use before being replenished. Cost is also another significant impediment, as with any new technologies it takes time and mass market acceptance to drive costs of manufacture down. American company, ReWalk, manufactures walking exoskeletons

and sells its devices to Americans for private use. Each device has a likely cost of between US$65,000 to $68,000. This is much cheaper than the current cost of $150,000 - $300,000 for rival products. ReWalk’s device straps on user’s bodies and helps those with certain spinal-cord injuries to sit, stand, and walk. Users have to wear a backpack to carry the ReWalk’s computer and battery and wear a wrist device with buttons to tell the motorised legs when to stand up, sit down or start walking. It is the first such device to earn US Food and Drug Administration approval. There have now been numerous academic studies and papers presented on the benefits and issues of medical exoskeletons and some of the key benefits statements are reproduced here: “Using Ekso as a platform for full weight bearing, over ground ambulation in SCI patients is feasible for a wide range of patients and produces improvements in walking speed and distance, fluidity, gait and balance. There also appears to be a training effect and increased muscle firing which requires further study.” Gail Forrest, PhD., et. al (Sept. 2012). “Reduction in pain in persons with complete spinal cord injury was the most notable finding in this study exploring the multifaceted responses to over ground bionic ambulation.” Kressler, Jochen, PhD et al. (May 2014) “Two robotic exoskeletons were evaluated as a mobility alternative for a wheelchair. Positive results such as reduction in pain and spasticity were reported, as well as improvements in overall wellbeing and quality of life. Neither exoskeleton was currently considered a viable alternative to a wheelchair and one stood apart as an effective therapeutic training device.” Jane Nitschke, BG Kliniken Bergmannstrost, (May 2014). March 2015 Volume 22, No.8 17

Feature

18 March 2015 Volume 22, No.8

anmf.org.au

Feature

Indigenous health

STEPPING INTO THE GAP It has been seven years since former Australian Prime Minister Kevin Rudd made a formal apology to Aboriginal people and the Stolen Generations on 13 February 2008. But how far have we come since then? As the Aboriginal and Torres Strait Islander Healing Foundation paused with Indigenous communities across the country to commemorate the anniversary of the National Apology last month, a disappointing Closing the Gap report card was released. On the eve of National Close the Gap Day on 19 March 2015, we still have a long way to go to end Indigenous health inequality in Australia, writes Karen Keast and Natalie Dragon.

Health and education A deep divide still exists in the health and education outcomes between Aboriginal and non-Aboriginal Australians. Indigenous Australians experience poorer health outcomes at higher rates and also at a younger age than non-Indigenous Australians, with increased rates of chronic disease, disability, alcohol and other drug use, mental health conditions and suicide. Despite their overwhelming healthcare needs, today’s Indigenous Australians continue to face barriers when it comes to receiving equal access to quality healthcare. The Prime Minister’s Closing the Gap 2015 report shows only slight improvements have been made in health and education outcomes in the past 12 months, with targets for life expectancy and several other key performance indicators failing to be met. The report found Australia is not on track to close the gap in life expectancy by 2031. While Indigenous life expectancy is improving, increasing 1.6 years for males, to 69.1 years, and 0.6 years for females, to 73.7 years, Aboriginal and Torres Strait Islander peoples are still likely to die a decade younger than non-Indigenous Australians. The report card states progress is on course anmf.org.au

to halve the gap in mortality rates for Indigenous children under five by 2018. The Indigenous child death rate fell 31%, leading to a 35% narrowing of the gap in child death rates between Indigenous and non-Indigenous children between 1998 and 2013. In literacy and schooling, the report shows no overall improvement in Indigenous reading and numeracy since 2008. The target aims to halve the gap in reading, writing and numeracy achievements by 2018. On the bright side, the aim to halve the gap for Indigenous Australians aged 20-24 in achieving Year 12 or its equivalent by 2020 is on track, with the proportion of those achieving Year 12 increasing from 45.4% in 2008 to 58.5% in 2012-13. But progress has not been met in ensuring access for all Indigenous four-year-olds in remote communities to early childhood education. In 2013, 85% of Indigenous four-year-olds were enrolled compared to the target of 95%.

Funding health In response to the report card, several peak organisations called on the federal government to better fund and resource primary healthcare service providers to

detect, treat and manage chronic health conditions in Aboriginal and Torres Strait Islander communities. The Close the Gap Campaign, in its own 2015 Close the Gap Progress and Priorities Report, argued that continued investment is the only way to improve health equality. The campaign has called on the government to develop a dedicated Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing plan, and to restore and increase funding for the successful Tackling Indigenous Smoking program, which has seen the proportion of Indigenous smokers fall from 51 to 41% in 10 years. In launching the 2014 Social Justice and Native Title Report in December last year, Aboriginal and Torres Strait Islander Social Justice Commissioner Mick Gooda, who is also co-chair of the Close the Gap Campaign, says there have been marked improvements in smoking rates as well as in maternal and child health, child mortality rates and a narrowing in literacy. “[They] are extremely promising and show that we are making headway, albeit on a long term path to change.” However, Mr Gooda describes the government’s approach to health equality March 2015 Volume 22, No.8 19

Feature as a “muddled narrative”. “We are now experiencing one of the largest upheavals of Indigenous Affairs….this upheaval is causing immense anxiety and stress amongst our communities.”

are just 2,200 Aboriginal and Torres Strait Islander nurses registered in Australia yet conservative figures reveal more than 12,700 Indigenous nurses are needed to meet population parity and burden of disease.

disadvantages confronting Aboriginal and Torres Strait Islander peoples in the labour market means these health sector workers are particularly vulnerable to threats to their career development.

The report found that more than 150 programs and activities have been transferred to the Department of Prime Minister and Cabinet, involving over 1,400 organisations with nearly 3,040 grants and contracts. There are plans to collapse the 150 programs down to five while budget cuts of over $400 million have been earmarked for the next four years. “I would argue that the far more reaching change and the more drastic the budget cuts, the more engagement is needed within the community and its representative organisations,” he says.

Likewise, there are just 186 Aboriginal and Torres Strait Islander registered midwives but CATSINaM estimates more than 850 are required to achieve population parity, not factoring in infant mortality rates.

The ‘Shifting gears in career: identifying drivers of career development for Aboriginal and Torres Strait Islander workers in the health sector’ paper found the working conditions and service delivery practices associated with contemporary health settings presents diverse challenges for the formation and development of careers.

Mr Gooda says the responsibility to grapple with the challenges facing Indigenous Australians must be owned by every Australian. “That is, by Aboriginal and Torres Strait Islander communities, by the Australian public, and by our businesses and governments,” he says. “With a clear vision, targets and accountability, this is not a fantasy or an unrealistic dream. Together, we can – and we must – achieve social justice and equality for Aboriginal and Torres Strait Islander peoples.”

Nursing and midwifery Nurses and midwives play an integral role in working to improve the health of Aboriginal and Torres Strait Islander peoples living in cities, rural communities and some of the furthest corners of Australia. Aboriginal and Torres Strait Islander nurses and midwives, in particular, are an essential element in closing the life expectancy gap for Indigenous Australians.

Ms Mohamed says recruiting and retaining Aboriginal and Torres Strait Islander nurses and midwives is a pipeline problem that begins when Indigenous people first consider their career paths. “There are some social surveys that demonstrate that kids think they can be an AFL player or an actress but they don’t actually think that they’re smart enough to become a nurse or a midwife - they don’t actually believe that they could do this as a career.” Those that do go on to attend university often fail to complete their undergraduate degrees due to a lack of readiness, support and inability to feel culturally safe. Ms Mohamed says the nursing student completion rate for Aboriginal and Torres Strait Islander peoples is just 36.3% compared to 64.6% for nonIndigenous nursing students. “It’s a foreign environment for many of the students,” she says. “Issues such as leave restraints may not be able to cater to students to go back home to a family commitment that they have to meet, then there’s financial barriers, navigating the foreign pathways those are just some of the barriers.”

Janine Mohamed, the CEO of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM), the peak body representing Indigenous nurses and midwives, says improving the recruitment and retention of Aboriginal and Torres Strait Islander peoples in the nursing and midwifery professions is paramount.

As part of its focus to increase the Indigenous nursing and midwifery workforce, CATSINaM has released three national policies on recruitment and retention, clinical placements and cultural safety. The policies assist primary, secondary and tertiary education providers, health institutions and other key industry stakeholders to bolster Australia’s Indigenous nursing and midwifery workforce.

“There’s not enough Aboriginal and Torres Strait Islander peoples working in health,” she says. “We’re under-represented per population head. There’s a very substantial body of evidence out there that says if you want to close the gap in life expectancy, then an essential ingredient is an Aboriginal and Torres Strait Islander health workforce.”

“Aboriginal and Torres Strait Islander peoples have a long and rich history of working as nurses and particularly midwives,” Ms Mohamed says. “The silver lining in that cloud is that we are not starting with nothing - we are actually starting with good mentors and role models further carving out a history in this workforce.”

A proud Narrunga Kaurna woman from South Australia, Ms Mohamed says there

Career development

20 March 2015 Volume 22, No.8

A new paper has found the multiple

“The ability of the health system to maintain high quality standards of patient care emerges directly from the sector’s ability to source, recognise, retain and reward appropriately skilled labour – in this instance, Aboriginal and Torres Strait Islander workers in health,” according to author Tanya Bretherton of the Lowitja Institute. The report points to increasing foundation levels of education for Australia’s First People and lifting job-specific education and training of Aboriginal and Torres Strait Islander workers within the health sector. It also highlights the importance of enticing new workers into the sector, and increasing the resilience of workers through the provision of additional supports, such as mentoring.

Cultural safety A three-year study conducted in 2011 by the Menzies Centre for Health Policy, based at the Australian National University and University of Sydney, found health organisations that provide culturally appropriate services and treat their customers with respect are imperative to the health and wellbeing of Indigenous Australians. CATSINaM is championing the benefits of cultural safety - not only to nurses and midwives, but to all health professionals and health organisations, to enable them to provide the best care for Aboriginal and Torres Strait Islander patients. Ms Mohamed says racism and a lack of cultural safety often embedded in institutions affects the care and health outcomes of Indigenous people. While Aboriginal and Torres Strait Islander peoples are culturally, linguistically and ethnically diverse, most share a holistic understanding of health which is different to the one often used in Australian health institutions. The National Aboriginal Health Strategy anmf.org.au

Feature

MICK GOODA

JANINE MOHAMED

FAY E C L A R K E

WHILE ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES ARE CULTURALLY, LINGUISTICALLY AND ETHNICALLY DIVERSE, MOST SHARE A HOLISTIC UNDERSTANDING OF HEALTH WHICH IS DIFFERENT TO THE ONE OFTEN USED IN AUSTRALIAN HEALTH INSTITUTIONS. defines Aboriginal health as: ‘…not just the physical wellbeing of an individual but…the social, emotional and cultural wellbeing of the whole community in which each individual is able to achieve their full potential as a human being thereby bringing about the total wellbeing of their community. It is a whole of life view and includes the cyclical concept of life-death-life.’

“This text will, in my strong hope, challenge students to understand their role in the dominant discourse, as well as encourage students to examine their own individual beliefs, values and attitudes as a very necessary step to being able to practice cultural safety,” Dr Bryant says.

Providing care

The Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) launched a book in November, introducing nursing students to the specific healthcare needs of Aboriginal and Torres Strait Islander peoples. Commonwealth Chief Nurse and Midwifery Officer Dr Rosemary Bryant OA officially launched the book,Yatdjuligin.

A 2009-2011 study of a rural maternity unit in Mareeba, in Far North Queensland, for women receiving midwifery-led care shows while the unit provided care to twice as many young women, it provided care to almost five times as many Aboriginal and Torres Strait Islander women. A total of 506 women booked to receive care through a midwifery group practice (MGP), and 377 (74.5%) gave birth at the local facility as planned. The midwifery group practice is located about one hour from the nearest surgical service.

The book features case studies, scenarios and critical thinking questions to challenge nursing students to think in a non-prejudicial manner about their current practice on topics such as the history of health service provision for Aboriginal and Torres Strait Islander peoples, midwifery, gender, caring for elders and remote area nursing.

Researcher and University of Queensland School of Nursing and Midwifery Professor Sue Kruske says the results challenge the notion that birthing services can only be offered in rural areas with onsite surgical capability. She says more primary maternity units should be made available in rural areas, in line with national and state policy

Education

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and international evidence. “I think we really need to look both federally and in Queensland at the commitment for women to birth as close to home as possible,” she says. “There is this belief that women need to birth where there is the facility for a caesarean section. What the Mareeba model clearly shows is this is not necessarily the case if you have a well networked, highly qualified midwifery model of care with a referral centre.” The study found clinical outcomes for women and babies birthing both at the primary maternity unit and those transferred were as good, if not better. “I have heard of many stories where women have been told services are not available or they are dangerous, with doctors telling them to go to the next regional centre. We are uprooting these women and their families,” she says. “The Mareeba model shows highly qualified professional midwives offering care to women with multiple risks – from low to those requiring more complex care.”

Reconciliation action The Australian Nursing and Midwifery Federation (ANMF) recently completed March 2015 Volume 22, No.8 21

Feature “IT’S HIDEOUS THAT IN A WEALTHY COUNTRY LIKE AUSTRALIA WE HAVE SEGMENTS OF OUR COMMUNITY WHO AREN’T ENJOYING THE SAME HEALTH THAT MOST OF US DO.” the first review of its Reconciliation Action Plan (RAP), created in 2007. Reconciliation Action Plans work to develop relationships, show respect and increase opportunities for Aboriginal and Torres Strait Islander peoples. The updated Reconciliation Action Plan, developed by the ANMF’s Federal Office, is an opportunity for nurses and midwives to contribute to reparation of damage done to Aboriginal and Torres Strait Islander peoples, and the disastrous and ongoing effects to their health and wellbeing. ANMF Federal Professional Officer Elizabeth Foley, who is also Chair of the Reconciliation Action Plan Working Group, says it is vital the federation, as a health professional organisation, shows leadership in addressing the health equality of Aboriginal and Torres Strait Islander peoples. “It’s hideous that in a wealthy country like Australia we have segments of our community who aren’t enjoying the same health that most of us do,” she says. “We don’t think anything of the fact that we should be able to expect a healthy life through to our 70s and 80s, we just take all of that for granted. “We take for granted that we are going to be able to access health services, that when we go to the health services we will just be accepted, that we won’t have to really fight to get the services. “But the Aboriginal and Torres Strait Islander peoples who lived here before we (non-Indigenous Australians) did, they don’t enjoy any of that. They still face discrimination when they front up to health services and they face discrimination in the

sorts of services that they get.” Ms Foley says the ANMF is working alongside Indigenous health organisations, such as CATSINaM, to model and encourage promotion of reconciliation through the nursing and midwifery professions. The Reconciliation Action Plan has four key objectives around relationships, respect, opportunities, and tracking progress and reporting. Ms Foley says it outlines actions, work plans, measurable targets and whether those targets are achieved. One key target is for the ANMF to work closely with and support CATSINaM in its aspirations, including its aim to increase the number of Aboriginal and Torres Strait Islander peoples working in nursing and midwifery. Other targets include the ANMF supporting significant events such as Close the Gap Day and National Reconciliation Week, and for the ANMF to engage with, support and provide opportunities to its Aboriginal and Torres Strait Islander members. The Reconciliation Action Plan provides a framework for each of the state and territory branches to now forge their own reconciliation actions, specific to their jurisdictions. The ANMF will also provide an annual progress report on the Reconciliation Action Plan to Reconciliation Australia, which will be published on the ANMF website. As part of the initiative, Federal Office staff are also participating in cultural awareness, cultural sensitivity and cultural safety activities and training.

Aboriginal nurse leader Faye Clarke, a member of both CATSINaM and the ANMF, was heavily involved in developing the Reconciliation Action Plan. Ms Clarke, a registered nurse whose family originates from the Gunditjmara, Wotjaboluk and Ngarrindjeri people of Victoria and South Australia, says the ANMF Reconciliation Action Plan will go a long way towards reconciliation and better health outcomes for Aboriginal and Torres Strait Islander peoples.“I think it’s hugely important because nursing is one of the biggest health professions that comes into contact with Aboriginal people, so as a profession, nursing is really where we can make a big difference.” Ms Clarke hopes Aboriginal nurses and midwives will get involved with their ANMF branches to develop Reconciliation Action Plans for their own jurisdictions.“For Aboriginal nurses and midwives, I think it’s a very supportive thing to have your union backing you up - that they are committed to Aboriginal health and that they want to make a difference to you as an Aboriginal person. “For Aboriginal health in general, I think if across Australia we can make a big difference in our nursing services and midwifery services being more culturally appropriate then Aboriginal health can benefit.” Ms Clarke says non-Indigenous ANMF members can also get involved in Reconciliation Action Plans or support RAP events. “Being able to do something - that’s what people are interested in,” she says. “I think that really captures the energy that people have and turns it into something practical and meaningful.”

Close the Gap Day Last year, more than 150,000 people took part in 1,298 separate registered events around the country as part of National Close the Gap Day. Oxfam Australia is aiming for 200,000 people to raise awareness and take action in support of ending the health equality gap by 2030 - within a generation - as part of this year’s National Close the Gap Day on 19 March. For more information or to participate in a local event or host an activity visit www.oxfam.org.au CATSINaM is asking nurses and midwives to change their social media profile picture to the Close the Gap logo on 19 March, to demonstrate their commitment to helping achieve health equality.

22 March 2015 Volume 22, No.8

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Issues

Where are the drug keys? By Katharine McCreath, Clinical Nurse Specialist

A quality improvement project at the Intensive Care Unit at Sydney Children’s Hospital in Randwick.

After years of hearing, “where are the drug keys?” and “anyone got the drug keys”? I undertook a project based on the premise that many nursing hours were being wasted searching for the controlled drug keys.

An incident occurred during phase one whereby a patient required emergency intubation. Two nurses performed two laps of the unit in order to find the keys therefore delaying the administration of medication.

Prior to the project, the current practice on the intensive care unit (ICU) allowed any nurse to carry the controlled drug keys. The keys were passed from nurse to nurse throughout the shift.

Phase two, also conducted over a two week period, involved the keys residing in bedspace 13 with the bedside nurse carrying them at all times.

The project objective was to prove it would take less time finding the controlled drug keys if the keys were to stay in one bedspace with one nurse all shift compared with current practice on the intensive care unit. After formatting a project timeline and consulting senior nursing management, the project commenced.

Bedspace 13 was thought to be an appropriate bedspace, as it was close to the nurses’ station and close to the drug cupboard. A red key was placed on the patient name board symbolising where the keys were residing.

Negatives from phase two included not all times were written down and overall less times were written down. The results from both phases were analysed and presented in a pie chart.

Conclusion From the results collected, it was found that it took less time to find the keys when keeping them at a specific bedspace than the previous practice, allowing more time for patient care at the bedside.

Phase 1

Phase 2

How long did it take to find the keys?

How long did it take to find the keys using 2 weeks of recorded data.

Emails were sent out to staff and posters placed in staff areas informing them of the proposal and their participation. The chosen methodology was time analysis charts. The charts were placed on the door of the controlled drug cupboard for nursing staff to write down how long it took them to find the keys.

An incident occurred during phase two involving a rapidly deteriorating child. The drug keys were found in less than two seconds allowing the patient to receive lifesaving drugs quickly.

13%

56% 31%

Phase one involved the nursing staff writing down times using the current practice on the ICU. The analysis was conducted over a two week period. During phase one, problems occurred. For example, not all times were written down and there was a lack of staff motivation. Strategies to overcome these included reminding staff of the aims of the project and sending frequent emails. anmf.org.au

96% 165 entries made over two weeks. Total time: three hours and seven minutes. Less than 1 minute

94 entries made over two weeks. Total time: 15 minutes and 13 seconds.

1 to 3 minutes

More than three minutes

March 2015 Volume 22, No.8 23

Education

Perinatal depression and anxiety The following excerpt is from our new Perinatal Depression and Anxiety tutorial available on the ANMF’s Continuing Professional Education (CPE) website. The complete course is 3 hours in duration and this excerpt will give you 0.5 hours of CPD towards ongoing registration requirements.

This tutorial has been authored by Sara Hristov, RN, TAE, MNursing (Clinical Studies), CNC Women’s Health SWSLHD and Jodie Davis RN, TAA, ANMF Federal Education Officer with contributions from Julie Stevenson - CNC; Child and Family (WSLHD), Noeleen Horswell - CNC; Child and Family (Nepean and Blue Mountains LHD), Jean Hawkins - CNC; Clinic Liaison Psychiatry (WSLHD, Blacktown Perinatal Service), Michael Gillen - MW RPN; Acute Care (WSLHD, Blacktown Perinatal Service), and Dr. Sara Ghaly - Consultant Psychiatrist; (WSLHD, Blacktown Perinatal Service). A big thank you to you all for your valued input into this comprehensive and important learning program. On completion of this tutorial you will have a better understanding of: • The definition of perinatal depression in both the antenatal period and the postnatal period; • Perinatal mood disorders including antenatal and postnatal mood disorders; • Postnatal depression vs the Baby Blues; • Different types of postnatal depression; • Risk factors for perinatal depression; • Symptoms of perinatal depression; • Causes and influences of perinatal depression; • The impact of perinatal depression on women, partners, infants and children; • Assessment and identification of perinatal depression including use of an approved assessment tool; • Suicide risk and management; • Puerperal psychosis; • Treatment options available. The perinatal period is a major transitional life stage, it is also a time of increased risk for mental health disorders for women. It commences at 20 completed weeks (140 days) of gestation and ends 24 March 2015 Volume 22, No.8

28 completed days after birth. The term perinatal depression includes both antenatal depression and postnatal depression. Mental health problems can present at any time during the perinatal period and can contribute to adverse outcomes for the mother, the baby as well as the partners and other family members. Research indicates that anxiety, depression or both are the most common mental health disorders experienced by women during this period. Perinatal depression and anxiety can adversely affect the emotional, behavioural and cognitive development of the child. Certain risk factors increase the risk of developing anxiety or depression during this period. Ascertaining potential risk factors during routine pregnancy care is important for providing appropriate follow up and care as necessary for the woman and her family, including the child, partner and other family members. Detection of perinatal anxiety and depression is difficult, as many of the symptoms are also normal for pregnancy and being a new mum such as poor sleep, worry and fatigue. Any of the mental health disorders can occur in the perinatal period and symptoms can predate conception and then continue into pregnancy, or start at any time after conception, birth or during the year following birth. While previous approaches to mental health in the perinatal period focused on ‘postnatal depression’, more recent studies suggest that antenatal depressive symptoms are as common as postnatal symptoms; depression identified postnatally begins antenatally in up to 40% of women and anxiety disorders may be as common

as depression in the perinatal period. Antenatal depressive episodes can be a reaction to the pregnancy itself, to associated health issues or to other major life stressors. Depressive symptoms in pregnancy can also be due to a continuation or relapse of a pre-pregnancy condition — especially among women who stop taking medication on confirmation of pregnancy. Antenatal anxiety may occur in response to fears about aspects of the pregnancy (eg. parenting role, miscarriage, congenital disorders), or as a continuation of a pre-pregnancy condition and/or comorbidly with depression. It has been found that higher levels of self-reported anxiety or anxiety disorder in pregnancy increase the risk of depression postnatally. Non-psychotic disorders occurring in the postnatal period include depression, a range of anxiety disorders (including generalised anxiety, phobias, obsessive compulsive disorder and post-traumatic stress disorder, adjustment disorder, panic disorder and agoraphobia. Psychotic disorders such as new onset puerperal psychoses are uncommon but may occur within two to three weeks of birth. Bipolar disorder may occur during pregnancy or after birth as a first episode or continuation or relapse from an episode before the pregnancy. More women fulfil criteria for minor rather than major depression in the postnatal period. However, minor depression often occurs with anxiety and other disorders and a significant number of women who experience minor depression will develop major depression. Depression experienced postnatally sometimes persists through more than one pregnancy – between 20 and 40% of anmf.org.au

Education women with a past episode of depression in the postnatal period will relapse after the birth of a subsequent child. Complex perinatal presentations frequently include the confounding effects of childhood abuse, drug and/or alcohol abuse and domestic violence. Mental health disorders have been identified as a leading cause of maternal morbidity and mortality in the UK and as one of the top three causes of indirect maternal mortality in Australia. Maternal suicide rates are thought to be as high as 20%. In some cases it may have been prevented through early identification, rapid referral and treatment. Many women experience mood swings after the birth of a baby. However, postnatal depression (PND) describes the more severe or prolonged symptoms of depression (clinical depression) that last more than a week or two and interfere with the ability to function on a daily basis with normal routines including caring for a baby. It is important to note that PND is different from the baby blues that are common during the first week after childbirth.

The baby blues are quite common (5080% of women) with onset during the early days after childbirth. They usually clear spontaneously within the first week to ten days without treatment and are not regarded as a clinical disorder. When symptoms of depression are severe after childbirth and persist for longer than a week or two, professional assessment is needed to establish if this is the onset of postnatal depression or another type of postnatal disorder. For approximately one in seven women the stresses and emotional changes that accompany their postnatal experiences can be intense and include strong depressive mood swings, anxiety, social withdrawal, irritability and loss of enjoyment in usual activities. It can be helpful to know that there are different types of PND. Why? Because not only can the symptoms vary between the different types but they tend to respond best to different treatment approaches. These are covered in detail in the complete tutorial. PND is a multi-factorial condition with biological, psychological and social factors all playing some part. A different combination of factors is probably responsible for each woman’s unique

experience of PND. It is very important for women to learn to recognise the signs and symptoms of PND so that they can ask for help as early as possible. This forms the basis of the biopsychosocial understanding of PND. All biopsychosocial factors need to be considered when assessing women for PND, as well as being important when making plans for treatment. The impact of PND will depend on the number and severity of the symptoms and the length of time that the mother’s depression goes unidentified or inadequately treated. With early identification and skilled treatment and support most women with PND will recover, their recovery can mean an enhancement of their life skills and emotional development, and the re-building of relationships. To read the complete tutorial go to www.anmf.org.au/cpe and log in for your state or territory. For further information contact the federal education team at education@anmf. org.au or phone 02 6232 6533.

How will you gain your required CPD hours? The ANMF provides affordable, best practice CPD online learning for ANMF, NSWNMA and QNU members to meet their CPD registration standards. Topics are applicable to all areas of practice. Non members can also access the online training at non member rates.

The Continuing Professional Education (CPE) website provides you with access to practical and affordable CPD that can be undertaken at your own pace, at a time that suits you. It is one of the ANMF’s solutions for your continuing professional development needs, allowing you to fulfil the NMBA’s annual CPD requirements. The CPE currently provides over 50 best practice topics including those modules that are deemed mandatory annual competencies by large health organisations and nursing agencies. For members of the ANMF (including NSWNMA & QNU) – you can access CPE topics for just $7.70 each, there are also over ten free topics for members. Members receive a free CPD portfolio where topics undertaken through the CPE are automatically entered and there is also provision for CPD undertaken outside of the CPE to be entered, to create a comprehensive portfolio for NMBA audit requirements. Non members can access all topics for $30.00 each. Non members receive a certificate of completion. For more information contact the Federal Education Team, via email to education@anmf.org.au or by phoning 02 6232 6533.

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Clinical update Near death experience and nursing practice: lessons from the palliative care literature

Deb Rawlings and Kim Devery Patients often share their thoughts, feelings, beliefs and dreams with nurses who deliver healthcare to them. It is unsurprising then, that patients will sometimes disclose events and experiences things that are hard to explain. Our experience with this has been of the disclosure of deathbed phenomena (DBP) where patients report a significant dream or perception of an out of the ordinary phenomena in the days or weeks before death. Similarly, there has been interest for decades in near-death experiences (NDEs), which have been described as powerful emotional and psychological events associated with a close brush with death (James 2004). These two phenomena have been brought to our attention within a systematic review (SR) that we conducted on the experiences of those close to an expected death (Devery et al In press). During this SR process we found similar published reports from acute care settings, with patients relating their experiences at the time of the event, and often many years later (Greyson 2007). This paper looks at our findings from the palliative care literature, aiming to draw parallels with acute care experiences of NDE’s, and provide some strategies for clinical practice.

Background We undertook a Systematic Review (SR) 26 March 2015 Volume 22, No.8

into deathbed phenomena (DBP) with palliative care patients at the end of life (Devery et al In Press). We found that DBP’s are considered relatively common and even thought to be an intrinsic part of dying (Brayne et al 2006) and as a result we established strategies for practice, a way in which clinicians can respond to such reports.

many decades, as the search parameters had allowed for this, with citations found from as far back as 1892. While the majority of papers retrieved were in relation to end of life care due to the explicit search criteria, there were still over 450 that covered acute settings.

During the SR process it became apparent within the screened literature that there were similar reports from within acute care settings. These were near death experiences (NDE’s), often reported following an acute event and more often following resuscitation. In these cases patients appeared to be reporting similar occurrences as those who were on their deathbed. While this population or clinical practice setting was outside of the parameters of our SR, the similarities of the reports indicated that the implications for practice that we had developed for palliative care nurses could be applicable and transferable to the acute care setting.

What is being experienced? Reports of NDEs vary but there are commonalities with those described by people at the end of life, such as seeing a bright light or a tunnel, seeing deceased relatives or religious figures, or a feeling of warmth and comfort. However for those who return after an acute event there are additional phenomena to consider such as: out of body experiences (Manley et al 1996), seeing their own resuscitation (Bucher et al 1997), undergoing a life review (Stevenson and Williams Cook 1995), having to decide whether to stay or return (James 2004), and also feeling a sense of returning to their body and knowing it was not a dream (Duffy and Olson 2007). Other reported consequences of a NDE include a resultant increase in psychic phenomena (Sutherland 1989), and an increased ability to respond to stress (Brumm 2006).

Methods The SR was undertaken during 2012, and comprised a search strategy of database and internet searches which was pertinent to end of life care (Devery et al In Press). The review had a key question in mind, search terms were relative to the topic under investigation, and the authors screened against the inclusion and exclusion criteria. This paper is as a direct result of the SR, and as such a second literature search has not been undertaken. The authors screened the existing EndNote database of 8,489 citations for articles with an acute care focus or interest. The literature spanned

Results

Where is it happening? Populations and geography These phenomena have been reported in diverse patient populations including: paediatrics (Hertzog and Herrin 1985; Serdahely 1989; Morse 1994); psychiatry (Greyson 2003); those who have attempted suicide (Ring and Franklin 1982; Greyson 1986; Kuruppuarchchi 2008), those who have been in accidents (Spencer 1976), dialysis patients (Lai et al 2007) and those anmf.org.au

Clinical update returned from combat (Strom-Paikin 1995). By far the most reports though, were of those patients who had suffered a cardiac arrest (van Lommel et al 2001; Parnia et al 2007; Panditrao et al 2010). This phenomenon also crosses geographical and cultural boundaries and divides, with studies reported from Australia (Kellehear and Heaven 1989), India (Pasricha and Stevenson 1986), China (Feng and Liu 1992), the USA (Green and Friedman 1983), Thailand (Murphy 2001) and Europe (Pacciolla 1996; Knoblauch et al 2001; Palacios-Ceña et al 2011). There also appears to be no cultural or religious basis for these experiences (Belanti et al 2008; Fracasso et al 2010).

Theme A particular theme in end of life literature is that the experience is generally comforting and that there is often a ‘take away’ purpose (as in a guide taking the person towards death) whereas in acute care literature the focus is still that of transition but more related to lifestyle, attitudes and behaviours with NDE seen as a significant event or a major life transition (Walker 1989; Dougherty 1990). From reviewing the literature on NDEs many themes became evident, but there was one overarching theme and that is of NDE as a significant event or a major life transition (Walker 1989). James (2004) has alluded to NDEs as a powerful emotional and psychological event associated with a close brush with physical, psychological, emotional, and/or spiritual death. An NDE appears not to be minimised over time nor are they easily forgotten, and Walker (1989) has reported that there can be difficulty in adjusting back to ordinary life. This difficulty in adjustment has also seen reports of negativity from spouses, with resultant relationship break up or divorce (Manley et al 1996). For some, a NDE can lead to a major life transition (Dougherty 1990) or an opportunity to consider or re-consider their spirituality. Sutherland (1990) reports on interviews conducted with 50 people who had a NDE (over two years beforehand) finding that participants very strongly felt that they had undergone a spiritual transformation rather than one of faith. Of the respondents, 24% would have described themselves as religious before the event but only 6% after, and 16% would have described themselves as spiritual before the event and 76% after. anmf.org.au

This ‘major event’ theme is supported in the work of Greyson (2007) who looked at the NDE accounts of 72 people, finding that reports of their positive affect were consistent over a period of almost two decades, indicating that the experience remained with them. Other authors have highlighted the change in beliefs that many of these people undergo, including Sutherland (1990), who identified six significant changes in relation to: spirituality or spiritual growth (31%), love (11%), knowing God (9%), inner peace (9%), more responsible, caring (7%), no fear of death (7%). This author also highlighted a dramatic (positive) change in attitude towards suicide, supported by Manley et al (1997 pg 314) who found that people valued life more and that “suicide is not an option”. Groth-Marnat and Summers (1998) also identified areas of change that included increased concern for others, reduced death anxiety, reduced interest in material possessions and increased self-worth. These authors also found a strengthened belief in an afterlife, increased transcendental experience, increased appreciation for natural phenomenon, an enhanced awareness of paranormal phenomenon, or belief in reincarnation (Wells 1993). Duffy and Olson (2007) also discuss that people are inclined to take more risks after a NDE as well as feeling reconnected to everything. Manley and colleagues (1997) found that some people embark on new service-oriented careers, although Wilde and Murray (2009) found that some individuals may just incorporate meaningful elements of their experience into their lives rather than undergo a life changing transformation. That these experiences are real to the patients and families involved is undisputed. It also demonstrates the need to consider guidelines for the nurses who are involved with patients who may disclose their experiences.

Discussion With the advent of cardiopulmonary resuscitation and other techniques of modern medicine more patients who have been declared clinically dead are surviving, whereas previously this would not have been the case (Duffy and Olson 2007). This indicates that there are many patients who have gone through a NDE, who will survive to live into old age and perhaps report their experiences.

Implications for practice In end of life care, deathbed experiences

are reported as common, although we found that not all nurses are conversant with these phenomena or recognise them for what they are. Others may be sceptical about their existence, or they may for example, attribute them to hallucinations, delirium or even an intensive care unit psychosis (Simpson 2001). However there is an imperative for nurses to set aside personal opinion and look to professional responsibilities in terms of supportive and above all, non-judgemental care. How receptive nurses are to these patient accounts, and how they respond, can decide whether disclosure will occur at all, with Duffin (2002) describing nurses attitudes as causing patients to doubt themselves and become reluctant to tell anyone. It is apparent that these experiences have an enormous impact on patients, and may continue to do so, with many struggling to understand it. Health professionals need to help patients accept an NDE by validating the experience (Serdahely et al 1988). Bucher and colleagues (1997) looked at critical care nurses’ attitudes towards NDEs and any interventions when caring for NDE survivors. In their study of 1,000 conference participants (n=448), 87% (n=390) were familiar with the concept, with suggested interventions including: supporting the person, listening to them, discussing what has happened with them, encouraging them to express their feelings and acceptance. Duffy and Olson (2007, pg 47) talk of creating a therapeutic environment and use the term “opening the door to dialogue” which involves strategies for advocating for patients such as what you can do during a resuscitation attempt. These authors also highlight that education is required for families and staff and to potentially include a patient who has had NDE. Patients who undergo experiences following resuscitation have reported that they saw or heard the events at the time, although the mechanisms for this are unclear (Morse 1994; Parnia et al 2007). Following a successful resuscitation nurses need to be aware that these perceptions may have occurred and that the patient could have questions about the events surrounding the resuscitation and what they experienced. Simpson (2001, pg 525) has highlighted that nurses need to look at patient’s subsequent behaviour that may indicate a NDE has occurred “such as wanting to keep the lights on, March 2015 Volume 22, No.8 27

Clinical update talking about having a strange dream and appearing withdrawn and scared”. Puntillo (1996) conducted interview of nine patients soon after successful resuscitation with a theme emerging of the need to make sense of what had happened to them. For some this caused them to feel overwhelmed and distressed and they felt that they needed help to integrate the NDE into their lives. Walker (1989) also recounts stories of disbelieving clinicians denouncing or silencing patients’ accounts and of significant others’ feeling uncomfortable hearing them. In the end of life literature we found that many patients who had experienced a DBP were reluctant to talk about it for fear of being thought mad or being ridiculed (Barbato 1999) with some experiencing difficulty in decision making around disclosure of the event (James 2004). In the NDE literature patients have recounted that they have had to decide whether to stay or return (James 2004; Duffy and Olson 2007), with Serdahely and colleagues (1988) highlighting that health professionals should also expect patients to experience anger as not all are always grateful to staff for bringing them back from such a beautiful experience. Our recommendations for any clinician, is to follow the reactions of those telling the story of deathbed experience and help them to find the meaning within. Listen and be guided by the patient.

Strategies for practice Familiarity with an event does not automatically translate into an ability to manage it clinically and therein lie implications for nurses. From the initial SR we proposed some strategies for clinical practice. While these are related to end of life care, parallels can be drawn with patients in acute care setting who relate similar experiences:

Clinical practice improvement • Be aware of the manifestations of DBP or NDE that can include, visions, seeing or hearing dead relatives, observing their own resuscitation; • Consider the patient (following resuscitation) who wants to keep the lights on, talks about having a strange dream or appearing withdrawn and scared; • Comprehensively assess the patient and exclude organic or metabolic causes. Do not assume that a hallucination is the result of medication, delirium or an intensive care unit psychosis. If the patient is lucid, they may have experienced a NDE; • Ensure that you are comfortable with the conversation. Try to keep an open mind and be aware of your own personal feelings (such as disbelief or cynicism); • Don’t minimise the impact of a NDE, which can be tremendous for the patient or the family and may resonate for many years; • Think about why the patient or family

member has told you about this phenomenon. It could be that they feel most comfortable to do so and are seeking your support/guidance/ understanding.

For the patient and family • The patient and family need reassurance that this is a common experience. Validate and normalise the experience and reassure them that they are not going mad; • If the patient or family do talk about an experience, ask them to describe it and then listen without labelling or judging; • Ask the patient what the phenomenon meant to him or her, and if they experienced anything like this before; • What is the impact of this phenomenon for the patient and those close to him or her? There may be opportunities to further discuss spirituality or existential beliefs. The power of these experiences to heal and comfort both patients and their carers or families. (Taken and adapted from Devery et al In Press)

Limitations The search strategy undertaken for the aforementioned SR did not include search terms that would have been used had this been undertaken now. The search terms included those relative to setting (eg. hospice) and context (eg. dying) and did

Table 1: Definitions Deathbed Phenomena (DBP)

Near Death Experience (NDE)

Death Bed Phenomena (DBP) “death may be heralded by deathbed phenomena such as visions that comfort the dying and prepare them spiritually for death” (Brayne et al 2006, Page 17)

Near Death Experience (NDE) Powerful emotional and psychological events associated with a close brush with death (James 2004).

A ‘take away’ purpose (as in a guide taking the person towards death). A transition to death.

A significant event or a major life transition. A transition related to lifestyle, attitudes and behaviours.

Terminology: deathbed apparitions; deathbed emanations; deathbed visions; pre-death visions; near death phenomena; nearing death awareness; end of life experiences; death related sensory experiences; visions of the dying; veridical hallucinations; and parapsychological phenomena.

Terminology: out of body experiences.

Experience: Usually positive: A significant dream or vision experienced either awake or in a dreaming state; Seeing, hearing, or feeling something such as a bright or warm light, lovely music, or a beautiful place; Seeing heavenly places or experiencing religious visions such as God, Jesus or Angels; Travel analogues such as going on a journey or getting in a car; The presence of a dead pet or a deceased relative; Moments of lucidity following from states of unconsciousness; Patients being aware of the time of their own death.

Experience: Strong positive affect: Seeing a bright light or a tunnel; Seeing deceased relatives or religious figures; A feeling of warmth and comfort; Out of body experiences; Seeing their own resuscitation; Undergoing a life review; Having to decide whether to stay or return; Feeling a sense of returning to their body and knowing it was not a dream; A resultant increase in psychic phenomena; an increased ability to respond to stress; Not to be minimised over time and not easily forgotten; Difficulty in adjusting back to ordinary life.

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Clinical update not include search terms that would more accurately describe the population under discussion here (eg. Intensive Care Unit or resuscitation). This has limitations in what else could have been retrieved.

Conclusion Near death experiences occur not only at the expected end of a life, as in a palliative population, but also in acute care populations as patients are surviving sudden life threatening events. NDE’s have been reported in many different countries, settings, patient populations and religions. They have often been reported as a significant event that live on in a person’s memory and can precede a change in beliefs, views or lifestyle. Nurses need to be able to handle these events sensitively as patients try to come to terms with what happened, and there are implications in how nurses can manage conversations in a receptive and responsive way. Our findings from the palliative care literature can offer clinical guidance to nurses in any practice setting who enter into discussions on hard to explain near death experiences and death bed phenomena. Acknowledgements: Jennifer Tieman and Raechel Damarell were authors on the original paper and therefore contributed to the original searches and subsequent findings. References Barbato, M. Blunden, C. Reid, K. Irwin, H. Rodriguez, P. 1999. Parapsychological phenomena near the time of death. Journal of Palliative Care. 15(2):30-37. Belanti, J. Perera, M. and Jagadheesan, K. 2008. Phenomenology of Near-death Experiences: A Crosscultural Perspective. Transcultural Psychiatry. 45(1): 121–133. Brayne, S. Farnham, C. Fenwick, P. 2006. Deathbed phenomena and their effect on a palliative care team: a pilot study. American Journal of Hospice & Palliative Medicine. 23(1):17-24. Brumm, K. 2006. A Study of Near-Death Experiences and Coping with Stress. Journal of Near Death Studies. 24(3): 153-173. Bucher, L. Wimbush, F.B. Hardie, T. and Hayes, E.R. 1997. Near death experiences: critical care nurses’ attitudes and interventions. Dimensions of Critical Care Nursing. 16(4):194-201. Devery, K. Rawlings, D, Tieman, J and Damarell, R (IN PRESS). What are the clinical responses and opportunities to reported deathbed phenomena of patients in a palliative care context?” A Systematic Review. Dougherty, C. 1990. The near death experience as a major life transition. Holistic Nursing Practice. 4 (3): 84-90. Duffin, C. 2002. Near death experiences ‘must be taken seriously’ Nursing Standard. Jan 9- 15, 16, 17; 9. Duffy, N. and Olsen, M. 2007. Supporting a patient after a near-death experience. Nursing, 37 (4): 46-48.

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Feng, Z.-y. and J.-x. Liu. 1992. Near-death experiences among survivors of the 1976 Tangshan earthquake. Journal of Near Death Studies. 11(1): 39-48.

Parnia, S. Spearpoint, K. and Fenwick, P. 2007. Near death experiences, cognitive function and psychological outcomes of surviving cardiac arrest. Resuscitation. 74 (2): 215—221.

Fracasso, C. Aleyasin, Seyed, A. Friedman, H. and Young, M. 2010. Near-death experiences among a sample of Iranian Muslims. Journal of Near Death Studies. 29(1): 265-272.

Pasricha, S. and Stevenson, I. 1986. Near death experiences in India. The Journal of Nervous and Mental Disease. 174 (3): 165-170.

Green, J. and Friedman, P. 1983. Near-death experiences in a southern California population. Anabiosis: The Journal of Near Death Studies. 3(1): 77-95.

Puntillo, K. A. 1996. Commentary on The meaning of survival: the early aftermath of a near-death experience [original article by Orne RM appears in RES NURS HEALTH 1995;18(3):239-47]. AACN Nursing Scan In Critical Care. 6(3): 4-5.

Greyson, B. 1986. Incidence of near-death experiences following attempted suicide. Suicide & Life-Threatening Behavior. 16(1): 40-45.

Ring, K. and S. Franklin. 1982. Do suicide survivors report near-death experiences? Omega. 12(3): 191-208.

Greyson, B. 2003. Near-Death Experiences in a Psychiatric Outpatient Clinic Population. Psychiatric Services. 54 (12): 1649-1651. Greyson, B. 2007. Consistency of near-death experience accounts over two decades: Are reports embellished over time? Resuscitation. 73, 407—411. Groth-Marnat, G. and Summer, R. 1998. Altered beliefs, attitudes, and behaviors following near-death experiences. The Journal of Humanistic Psychology. 38.(3) 110. Hertzog, D. and Herrin, J. 1985. Near death experiences in the very young. Critical Care Medicine. 13 (12): 1074-1075. James, D. 2004. What Emergency Department Staff Need to Know About Near-Death Experiences. Topics in Emergency Medicine. 26 (1):29–34. Kellehear, A. and P. Heaven. 1989. Community attitudes toward near-death experiences: An Australian study. Journal of Near Death Studies. 7(3): 165-172. Knoblauch, H. Schmied, I. and Schnettler, B. 2001. Different kinds of near-death experience: A report on a survey of near-death experiences in Germany. Journal of Near Death Studies. 20(1): 15-29. Kuruppuarchchi, K. Gambheera, H. Padmasekara, G. and Perera, M. 2008. Near-death experiences in suicide attempters in Sri Lanka. Journal of Near Death Studies. 26(4): 295-301. Lai, C. F. Kao, T-W. Wu, M-S. Chiang, S-S. Chang, C-H. Lu, C-S. Yang, C-S. Yang, C-C. Chang, H-W. Lin, S-L. Chang, C-J. Chen, P-Y. Wu, K-D. Tsai, T-J. and Chen, W-Y. 2007. Impact of Near-Death Experiences on Dialysis Patients: A Multicenter Collaborative Study. American Journal of Kidney Diseases. 50(1): 124-132.e122. Manley, L. 1996. Enchanted journeys: Near-death experiences and the emergency nurse. Journal of Emergency Nursing. 22 (4):311-16. Morse, M.L. 1994. Near-death experiences of children. Journal of Pediatric Oncology Nursing. 11 (4):139-144. Murphy, T. 2001. Near-death experiences in Thailand. Journal of Near Death Studies. 19(3): 161-178. Pacciolla, A. 1996. The near-death experience: A study of its validity. Journal of Near Death Studies. 14(3): 179-185. Palacios-Ceña, D. Losa-Iglesias, M. E. Salvadores-Fuentes, P. and Fernández-de-las-Peñas, C. 2011. Sudden cardiac death: the perspectives of Spanish survivors. Nursing and Health Sciences. 13(2): 149-155. Panditrao, M. Singh, C. and Panditrao, M. 2010. An unanticipated cardiac arrest and unusual postresuscitation psycho-behavioural phenomena/near death experience in a patient with pregnancy induced hypertension and twin pregnancy undergoing elective lower segment caesarean section. Indian Journal of Anaesthesia. 54 (5):467-9.

Serdahely, W. J. 1989. A pediatric near-death experience: Tunnel variants. Omega: Journal of Death and Dying. 20(1): 1989-1990. Serdahely, W. Drenk, A. and Serdahely, J. 1988. What Carers Need To Understand About the Near-Death Experience. Geriatric Nursing. 9 (4): 238-241. Simpson, S. 2001. Near death experience: a concept analysis as applied to nursing. Journal of Advanced Nursing. 36(4), 520-526. Spencer, C. S. 1976. The effect of near-death experience on death anxiety. Journal of Undergraduate Psychological Research. 3(1): 21-26. Stevenson, I. and Williams Cook, E. 1995. Involuntary memories during severe physical illness or injury. The Journal of Nervous and Mental Disease. 183 (7): 452-458 Sutherland, C. 1989. Psychic phenomena following neardeath experiences: An Australian study. Journal of Near Death Studies. 8(2): 93-102. Sutherland, C. 1990. Changes in religious beliefs, attitudes and practices following near-death experiences: An Australian study. Journal of Near Death Studies. 9 (1): 21-31. Strom-Paikin, J. E. 1995. A soldier remembers: near-death experiences. Journal of Military Nursing & Research. 1(3): 34-39. van Lommel, P, van Wees, R. Meyers, V. and Elfferich, I. 2001. Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands. Lancet. 358 (9298): 2039–45. Walker, B. A. 1989. Healthcare professionals and the neardeath experience. Death Studies. 13(1): 63-71. Wells, A. D. 1993. Reincarnation beliefs among near-death experiencers. Journal of Near Death Studies. 12(1): 17-34. Wilde, D. and Murray, C. 2009. The evolving self: finding meaning in near-death experiences using Interpretative Phenomenological Analysis. Mental Health, Religion & Culture. 12 (3): 223–239.

Deb Rawlings is a Lecturer and Research Officer (CareSearch) Palliative and Supportive Services, at the School of Health Sciences, Flinders University, South Australia Kim Devery is the Head of Discipline and Course Coordinator, Palliative Care, Senior Lecturer Palliative and Supportive Services at the School of Health Sciences, Flinders University, South Australia March 2015 Volume 22, No.8 29

Ethics Call for a convention on the rights of older people Megan-Jane Johnstone

Older people especially the frail elderly are among the most vulnerable members of society, nationally and internationally. Of particular concern is the vulnerability of older people to abuse (which may be physical, sexual, financial, psychological, and/or social in nature), abandonment and neglect. In one international study as many as 43% of respondents revealed that they were afraid of personal violence (UNFPA & HelpAge International 2012). It is not just in society generally that older people are vulnerable. Older people are also unacceptably vulnerable in health and aged care contexts, where their health rights are not always recognised or respected. For example, in healthcare contexts, particularly acute care hospitals, the problem of ageism and the dehumanisation and moral exclusion of older people remains an ongoing problem (Johnstone 2013, in press). A recent Australian Government report, meanwhile, has shown an alarming increase in the reportable assaults of residents in aged care facilities (Department of Social Services 2014). In keeping with the definition of reportable assaults, these assaults have involved the: • unreasonable use of force on a resident, ranging from deliberate and violent physical attacks on residents to the use of unwarranted physical force; or • unlawful sexual contact, meaning any sexual contact with residents where there has been no consent (Department of Social Services 2014, p 74).

Question of nursing ethics In the ANMJ September 2013 issue, nurses were reminded of the International Council of Nurses (ICN) position on the Nursing care of the older person. In this position statement the ICN makes clear that nurses and their professional associations have an obligation to safeguard the safety of older people. To this end, the ICN advocates that nurses ‘should influence debates on global ageing, the determinants of health and the impact of social environments’ (www.icn. ch/publications/position-statements/). Here the question arises what can (and 30 March 2015 Volume 22, No.8

ought) nurses and their professional associations do in order to improve the safety of older people (particularly in health and aged care contexts) and foster the moral respect that older people are due as fellow human beings?

Championing the rights of older people There is growing recognition that the current system of health rights in countries around the world is not sufficient to protect the rights and interests of older people (Johnstone, in press). In response to this situation HelpAge International (2014) and the Global Alliance for the Rights of Older People (www. rightsofolderpeople.org/) are using their networks to spearhead a global movement for recognising the rights of older people. As has been reported elsewhere (Johnstone, in press), a growing number of campaigners, including non-government organisations (NGO), academics, lawyers and UN member states and individuals, HelpAge International and the Global Alliance for the Rights of Older People (involving a collaboration of nine organisations – including HelpAge International) are calling for the development of a Convention on the rights of older people together with the creation of ‘a new special rapporteur on older people’s rights’ who would report to the Human Rights Council (www.helpage.org/whatwe-do/rights/towards-a-convention-onthe-rights-of-older-people/). HelpAge International argues that, in addition to enabling the rights of older people to be protected under international law, such a convention would also: • Provide a definitive, universal position that age discrimination and ageism are morally and legally unacceptable; • Provide clarity on governments’ human rights obligations towards older people; • Create an enforceable monitoring mechanism to hold those in authority to account for their actions towards older people; • Put age discrimination and older people’s rights higher up on governments’, donors’ and NGOs’ agendas; • Encourage a shift in attitude from older people being considered recipients of welfare to rights holders with responsibilities (HelpAge International 2014). In terms of the specific rights that are relevant to the experience of ageing and that should be protected for older people, the Global Alliance for the Rights of Older

People (www.rightsofolderpeople.org/) has identified the following rights to: • freedom from discrimination; • freedom from violence; • social security; • health; • work; • property and inheritance.

Engagement by nurses Nurses and their professional associations are in a good position to actively engage with the processes of championing the development and adoption of a ‘Convention on the rights of older people’ and the creation of a new special rapporteur on older people rights (Johnstone, in press). A first step to engage in these processes would be for organisations to join the Global Alliance for the Rights of Older People (www.rightsofolderpeople. org/) and for individuals to sign the HelpAge International petition to support a convention on older people’s rights (available at www.helpage.org/getinvolved/campaigns/what-is-agedemands-action/sign-the-ada-petition/). By engaging with and supporting these campaigns, the nursing profession will be able to demonstrate its ongoing commitment to influencing debates on global ageing, the determinants of health and the impact of social environments. References Department of Social Services. 2014. 2013–14 Report on the Operation of the Aged Care Act 1997. The Australian Government, Department of Social Services, Canberra. HelpAge International (2014) Global Age Watch Policy Brief 4: Older people count: Making data fit for purpose. HelpAge International, London. Online. Available: www. helpage.org/global-agewatch/reports/global-agewatchpolicy-brief-4-older-people-count-making-data-fit-forpurpose/ [accessed 29 January 2015] Johnstone, M-J. In press. Bioethics: a nursing perspective, 6th edn. Churchill Livingstone/Elsevier, Sydney Johnstone, M-J. 2013. Ageism and moral exclusion of older people. Australian Nursing and Midwifery Journal, 21(3): 27. United Nations Population Fund (UNFPA) and HelpAge International. 2012. Ageing in the 21st century: A celebration and a challenge. United Nations Population Fund (UNFPA) and HelpAge International, New York and London. Online www.unfpa.org/public/home/ publications/pid/11584 [accessed 29 January 2015]

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

Wellbeing Tactic three: Break it down Choose one of your goals from tactic one; what are five small steps you can do today to take some action? Before you know it, your five small steps today, have become 150 actions in 30 days... very cool! Which means your top goal will be complete sooner than you think, and you will be on to the next one.

Tactic four:

Be like water

with change. Water is gentle, adaptable, and a powerful fluid. Mr Bruce Lee certainly knew a thing or two.

Mr Bruce Lee has seen, and done many amazing things in his life, and I love his take on life with his words here…. ‘Be like water’

If you can’t adapt, you won’t succeed. Tough words I know.

Bron Watson

With the ever changing world of nursing, it can be at times, very challenging to keep up with changes… changes to work structure, best evidence based practice, the rostering system, not enough staff, leaving feelings of exhaustion, overwhelm and ‘who knows what it will be like at work’ syndrome. Gone are the days, when you knew what to expect coming back to work after your days off, when it seemed structure and process would allow you to be your best, all day, every day. Those days are long gone, and now, we all have many hats to wear every day. For me… mother to my five boys, educator, nurse, peace keeper, innovator, mentor, taxi driver, and laundromat to name a few… you will no doubt, have many too! Chaos is the new norm, and learning to adapt to constant change is not something many are gifted with naturally. What I do know, when you have many hats… family, work, and life, adapting to change is a must; to get the results you are looking for. Without it, overwhelm and stress will sky rocket. Being static in a dynamic and ever changing environment is a recipe for disaster. Simply…be like water, to cope anmf.org.au

Being adaptable means learning new things, developing skills you never thought you would need, overcoming a fear or two...whatever it is for you. Here are five tactics you can start to use today, to keep on top of chaos.

Tactic one: Start with the knowing what is important to you Like most of us, your career is very important, there may be things on your professional bucket list, which have not been achieved yet. Start with what you really want this year, it could be a postgrad, it may be more time, more money, or a health goal. Choose the top five, and create your goals for the year, both personal and professional is a great start.

Tactic two: Do a daily review of tactic one We live in a world of intense noise, full of distraction, both in the physical sense and online. Becoming distracted with being busy is very easy... confusion is now the norm. Staying focused on what is important can be tough. Start each day, (however that works with your rostered hours) in the quiet of your home, and take a good look at your top five goals (tactic one). What can be done today to start implementing the steps to get the results you want? Consistently meet the minimum requirement every day to reach what is important.

Have a complaint free day When you focus on something negative, or something that is annoying, you give it power, you let it be front of mind. When the negative thought is verbalised, it is given more strength to turn your day into a nightmare. Try the seven-day complaint free challenge! Choose to have a week of being complaint free…it is well worth the effort.

Tactic five: What if things don’t work out the way you want? What do you do if your day, week or perhaps the month does not work out as you have planned? Be adaptable. Adapt to the changes, work around the challenges with a consistent minimum approach. I write in pencil for this very reason, I can erase what I don’t need and replace it with what is going to work. To recap, focus on what you WANT, rather than what you DON’T. Keep a daily track on tactic one, your goals. Break your goals down, take five mini steps today and get started. Tactic four – have a complaint free day…if every person in your team took the pledge of the seven-day complaint free challenge, what outcome could be had? Interesting question. Last, but not least…what happens when things do not work the way you want…Be like water… move over, under and around whatever comes your way and get on with it. Now it is your turn, please give the five tactic steps a go, and share your results! Wishing you an amazing week.

Bron is a registered nurse, educator, mentor, mother of five boys and founder of Nurse Power bron@nursepower.com.au March 2015 Volume 22, No.8 31

Focus – Mental health ARE FIRST YEAR NURSING STUDENTS ENROLLED IN THE BN COURSE AT MURDOCH UNIVERSITY ANXIOUS WHEN CONFRONTED WITH SCIENTIFIC LABORATORY EXPERIMENTS? L to R: Mrs Susan Russell, Dr Sheila Mortimer-Jones, Mr Timothy Daniel (Science Laboratory Manager) and Mr Peter Wall

Is anxiety an issue for first year nursing students enrolled in bioscience units?

By Sheila Mortimer-Jones, Peter Wall and Susan Russell Knowledge of the biological sciences is an integral part of nursing care and hence an important component of the Bachelor of Nursing (BN) course. Although bioscience content has important relevance to nursing, students traditionally find bioscience difficult (Jordan et al 1999; Wharrad et al 1994) and anxiety-provoking (Nicoll and Butler 1996). This has important ramifications, as anxiety can hinder comprehension (Coy et al 2011) and lead to poor exam performance (Trifoni and Shahini 2011). This raises the following questions: Are first year nursing students enrolled in the BN course at Murdoch University anxious when confronted with scientific laboratory experiments? How do these anxiety levels compare with their anxiety levels prior to commencing ‘typical’ nursing clinical practice simulations? Dr Sheila Mortimer-Jones, a registered mental health nurse and lecturer at the School of Health Professions, Murdoch University, will lead the research team that will measure the anxiety levels of first year nursing students enrolled in the BN course 32 March 2015 Volume 22, No.8

at Murdoch University prior to commencing bioscience laboratory classes and clinical laboratory classes/tutorials over the first semester 2015. Comparisons will be made across the units. Should anxiety be found to be an issue, strategies could be put in place to help alleviate this, for example, an increased focus on case-based learning could be applied, which can increase confidence and also enhance the ability for students to recall information later on (Thomas et al 2001). References Coy, B., O’Brien, W. H., Tabaczynski, T., Northern, J., & Carels, R. (2011). Associations between evaluation anxiety, cognitive interference and performance on working memory tasks. Applied Cognitive Psychology. 25(5):823-832. Jordan, S., Davies, S., & Green, B. (1999). The biosciences in the pre-registration nursing curriculum: staff and students’ perceptions of difficulties and relevance. Nurse Education Today. 19(3):215-226.

Teaching from lived experience: a way to make mental health nursing more popular?

By Brenda Happell and Louise Byrne The challenge of attracting graduate nurses into mental health nursing has been demonstrated over the years. Despite hard work and innovation from many dedicated mental health nurses from academia and clinical practice, and funded programs such as the major in mental health nursing, not much has changed. Mental health nursing consistently emerges as less popular than nearly every other specialty. The increased

Brenda Happell

Nicoll, L., & Butler, M. (1996). The study of biology as a cause of anxiety in student nurses undertaking the common foundation programme. Journal of Advanced Nursing. 24(3):615-624. Thomas, M. D., O’Connor, F. W., Albert, M. L., Boutain, D., & Brandt, P. A. (2001). Case-based teaching and learning experiences. Issues in Mental Health Nursing. 22:517-531. Trifoni, A., & Shahini, M. (2011). How does exam anxiety affect the performance of university students? Mediterranean Journal of Social Sciences. 2(2):93-100. Wharrad, H. J., Allcock, N., & Chapple, M. (1994). A survey of the teaching and learning of biological sciences on undergraduate nursing courses. Nurse Education Today. 14(6):436-442.

Dr Sheila Mortimer-Jones and Peter Wall are lecturers at the School of Health Professions, Murdoch University, WA Susan Russell is a tutor at the School of Health Professions, Murdoch University, WA anmf.org.au

Focus – Mental health

profile of mental health challenges in contemporary society does not seem to have adequately addressed negative attitudes and students often express views of mental health settings as dangerous and unpredictable. Recent research suggests embedding lived experience of mental health challenges in mental health nursing curricula may be at least part of the solution. Nursing students completing a unit of study taught by a person with lived experience were asked to complete a survey before and after undertaking the unit. The survey measured the impact of undergraduate mental health curricula on student attitudes to people with mental illness, and career interest in mental health nursing. A comparison was made with another group of students completing a more traditional mental health nursing unit, taught by a mental health nurse academic. Notable differences were evident. The students from the lived experience unit showed a reduction in negative attitudes and stereotypes about mental illness and indicated they were significantly more likely to pursue a career in mental health nursing than the nurseled group, however the nurse-led group showed a positive change in appreciating the valuable contribution of mental health nursing. These findings suggest the active involvement of academics or educators with lived experience may be an important contributor to improving the popularity of mental health nursing, as a companion to, rather than a replacement for the more traditional nurse-led curriculum. This is an exciting development that shows great potential. Professor Brenda Happell is a Professor of Nursing, and Executive Director for the Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health, and ACT Health, Research Centre for Nursing and Midwifery Practice, Canberra Hospital, ACT Dr Louise Byrne is a Lecturer and Lived Experience Mental Health Academic at the School of Nursing and Midwifery, CQUniversity Australia

anmf.org.au

Physical health focus at Wellness Clinic By Anne Gartner

Improving the physical wellbeing of people with ongoing mental health issues is the aim of the nurse-led Wellness Clinic at Fremantle Hospital and Health Service (FHHS). Nurse practitioner Lucia Ferguson, who is the first permanent nurse practitioner to work in community mental health in WA, said it was challenging to get people with mental health issues to seek medical advice about their physical health. “Often a person’s mental health issues become a barrier to improving other aspects of their health and many feel they can not engage with a general practitioner (GP). This means that their ongoing physical health is compromised.” The Wellness Clinic, the first of its kind in WA which opened in 2014 at the FHHS Alma Street Centre, aims to re-engage these people with medical care and connect them to a GP in the community. Ms Ferguson’s role as a nurse practitioner is key to this, with the clinic also boasting a GP and a clinical nurse specialist on staff. “The clinic has a very holistic model of helping people,” Ms Ferguson said. “The focus is on physical health, although with my psychiatric background I can relate and assess their mental health if necessary. “It is about looking at the whole person, rather than just their mental health.” The clinic is designed to capture a true reflection of a patient’s health, with tests such as blood pressure, metabolic screening, cholesterol and lung function standard. Education is also a priority.

Lucia Ferguson is the first nurse practitioner in WA to work in community mental health

exercise and sexual health. “We also want to provide information about the importance of maintaining their physical health and engaging with a GP regularly. “It is about empowering people and supporting lifestyle change.” Curtin University researchers are monitoring the effect the clinic has in improving patient wellbeing which Ms Ferguson said would build on research already undertaken overseas of similar clinics.“Research done in the United States of America suggests that having a clinic onsite at a facility like the Alma Street Centre works because there are links between practitioners.

“We have a captive audience at the clinic, the patients are already at the Alma Street Centre so we have a great opportunity to speak to them about their entire health mental and physical,” Ms Ferguson said.

“There are definitely benefits to being able to connect with a patient’s wider support network, for example if I know someone has a medical problem that we need to monitor, I can alert case managers to try and get that patient back into our service. They are less likely to slip through the gaps with this model.”

“Many of these people are coming from a low knowledge base so we want to educate them about healthy lifestyles, diet,

Anne Gartner, Public Relations Officer, Fremantle Hospital and Health Service, WA March 2015 Volume 22, No.8 33

NURSING & MIDWIFERY SCHOLARSHIPS Open 2 March 2015 â&#x20AC;&#x201C; Close 8 April 2015 Scholarships for all nurses and midwives are available for:

Including scholarships for:

> Continuing Professional Development

> Emergency Department

> Nursing and Midwifery Re-entry

> Rural and Remote

> Midwifery Prescribing

> Aboriginal Medical Service

Apply online www.acn.edu.au | scholarships@acn.edu.au | 1800 117 262 An Australian Government Department of Health initiative supporting nurses and midwives. Australian College of Nursing is proud to be the fund administrator for this program.

Focus – Mental health

University of Wollongong nursing, psychology and dietetics students create lasting memories on a five day therapeutic recreation camp with people living with a mental illness

Building clinical confidence and skills: a placement with a difference By Lorna Moxham, Shane Pegg, Susan Sumskis, Dana Perlman, Renee Brighton, Chris Patterson and Ellie Taylor The location and duration of clinical placements impact on student learning and clinical confidence (Chuan and Barnett 2012). However, mental health clinical placements are scarce and typically situated within inpatient settings where consumers are acutely unwell. A team at the University of Wollongong, led by Professor Moxham, developed a five day immersive program called Recovery Camp addressing the need for quality mental health clinical placements. Recovery Camp, the first of its kind in Australia, is strengths-focused and individualised, facilitating personal recovery. The camp occurs each May near Richmond, NSW. People with lived experience of mental illness attend, with therapeutic recreation and social connectedness the focus. Consisting of mindfulness activities like Tai Chi, and challenges like rock climbing and alpine rescue, the week is rewarding. Future health professionals, like nursing and psychology students, also attend. The interdisciplinary mix reflects real-world, collaborative, holistic practice. In 2014, nursing students who attended anmf.org.au

Recovery Camp (n = 20; M = 30.65 years, SD = 10.49; 17 females) were compared to students who undertook a ‘traditional’ mental health clinical placement (n = 19; M = 30.53 years; SD = 11.81; 17 females). The 7-item Social Distance Scale (SDS) (Bogardus 1925) was used to capture perceptions about people with mental illness.

and holistic care.”

A repeated measures ANOVA demonstrated that, for nursing students who attended Recovery Camp, the difference in selfreported social distance from pre-camp (M = 13.75, SD = 3.54), to post-camp (M = 11.05, SD = 3.83), and at follow-up (M = 11.30, SD = 2.16) was statistically significant, F(1, 19) = 9.18, p = .001.

Chuan, O.L. and Barnett, T. (2012). Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Education in Practice. 12(4): 192-197.

Findings demonstrated Recovery Camp involvement significantly reduced stigma amongst nursing students. This effect was maintained at three month follow-up and was not evident for the comparison group. The value of active, immersive interaction with consumers who are living in the community is clear. David Pritchard, a student who attended camp in 2013 and now works as a mental health nurse, stated: “I look back to the Recovery Camp and can utilise what I learnt into my practice in a way that improves my practice, makes me a better nurse and provides more individualised

Sponsorship is currently being sought. For information contact Ellie Taylor at elliejo@uow.edu.au References Bogardus, E.S. (1925). Measuring social distances. Journal of Applied Sociology. 1-2: 216-226.

Professor Lorna Moxham is Professor of Mental Health Nursing & Leader; Living Well, Longer, UOW Global Challenges Programme Dr Shane Pegg is a Senior Lecturer in the School of Business at the University of Queensland Dr Susan Sumskis is a Lecturer and Postgraduate Coordinator in the School of Nursing at UOW Dr Dana Perlman is a Senior Lecturer in the School of Education at UOW Renee Brighton and Chris Patterson are Lecturers in the School of Nursing at UOW Ellie Taylor is a Research Officer for the Global Challenges Program at UOW March 2015 Volume 22, No.8 35

Focus – Mental health Perinatal mental health nurse service at Flinders Medical Centre By Deb Clissitt and Jane Woolmer

The Perinatal Mental Health Nurse Service at Flinders Medical Centre, South Australia, is predominantly funded by the National Perinatal Depression initiative, a Commonwealth and State funded project. The Perinatal Mental Health Nurse, Clinical Practice Consultants are Deb Clissitt and Jane Woolmer. The aim of the initiative is to extend routine and universal screening, increase workforce training and development, further develop pathways of care and raise community awareness. At Flinders Medical Centre, universal screening occurs at the first obstetric booking appointment using the Edinburgh

A three dimensional view on mental health recovery By Sini Jacob

In recent decades ‘mental health recovery’ has become a relatively familiar term in mental healthcare. Indeed, mental health policy has a focus on supporting mental health practitioners to enhance recovery-oriented practices in their service delivery (Department of Health 2011; Department of Health and Ageing 2013a, 2013b). However, little is known about the recovery experiences or perceptions, of patients, their carers and mental health nurses. A PhD study being undertaken by Sini Jacob at Monash University’s School of Nursing 36 March 2015 Volume 22, No.8

Postnatal Depression Scale and The Antenatal Risk Questionnaire. Women who are identified as at risk of antenatal and/or postnatal depression or anxiety are referred to the perinatal mental health nurses for further assessment and treatment, and to be linked in with community services with whom they have developed pathways of care. The strongest predictor of postnatal depression is antenatal depression (Beck 1996; O’Hara & Swain 1996, Beck 2001). Early identification of risk and early intervention hopefully reduces the devastating impact of Perinatal Mental Health disorders. Psychiatric disorders are among the top three causes of indirect maternal mortality in Australia (Austin et al 2007). The Perinatal Mental Health Nurses work closely with the midwives and conduct regular education and training on perinatal disorders both face-to-face and through online programs. Postnatal Depression Awareness Week in November each year provides the opportunity to raise the profile of postnatal depression and anxiety. In 2014, Flinders Medical Centre set up information stands in the women’s health clinic, postnatal ward and the psychiatric

unit as well as helped to facilitate the stand at the Helen Mayo House conference. Highlighting the importance of this area of work, Maternal Mental Health Alliance Chair Dr Alain Gregoire states: “Perinatal mental health problems are common and costly. They affect up to 20% of women at some point during pregnancy or in the year after childbirth and are a major public health issue impacting on both women and baby. The good news is that women recover when they get the right treatment. It is vital that all women, wherever they live get the specialist help they need.” At this stage the National Perinatal Depression Initiative is funded until 30 June 2015. We remain hopeful that funding will be ongoing and the Perinatal Mental Health Nurse Service can continue to help reduce the risk of poor mental health outcomes for women and children. Deb Clissitt is a Perinatal Mental Health Nurse, Clinical Practice Consultant at Flinders Medical Centre, Adelaide Jane Woolmer is a Clinical Practice Consultant, Perinatal Mental Health at Flinders Medical Centre, Adelaide

and Midwifery is providing valuable insights into what mental health recovery really means to these groups. Part one of the results: Mental health recovery: Lived experiences of consumers, carers and nurses (Jacob, Munro, & Taylor 2014) has been published, with further findings to follow.

embrace and implement recovery oriented principles including education and training for major stakeholders on the recovery process. Sini emphasises that to move towards a recovery-oriented service, mental health consumers must be involved in every aspect of their care, and practice the slogan ‘Nothing about me without me’.

The study findings provide a three dimensional view of what mental health recovery means from the perspective of consumers, carers and nurses. Sini, a mental health nurse, identified that each group considered the meaning of recovery quite differently. Some consumers and nurses viewed recovery as a process that notably, involved identification of the person’s sense of ‘self’. In contrast, some carers’ believe that mental health recovery is not possible. This study also explored factors that enhanced or inhibited mental health recovery, and participants’ views on moving towards a recovery-oriented mental health system. Other findings highlight the need for a major shift in attitudes and belief systems of mental health stakeholders. There is a clear need to

References Department of Health (2011). Framework for Recoveryoriented Practice. Melbourne: Mental Health, Drugs and Regions Division, Victorian Government. Retrieved from docs.health.vic.gov.au Department of Health and Ageing (2013a). A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Canberra: Commonwealth of Australia. Department of Health and Ageing (2013b). A national framework for recovery-oriented mental health services: Policy and theory. Canberra: Commonwealth of Australia. Jacob, S, Munro, Ian, & Taylor, J. B. (2014). Mental health recovery: Lived experience of consumers, carers and nurses. Contemporary Nurse,, 4588-4613.

Sini Jacob is a PhD student at Monash University, School of Nursing and Midwifery in Victoria anmf.org.au

Focus – Mental health

THE AIM OF THE EXHIBITION WAS TO PROMOTE ARTWORKS WHICH DISPLAYED SOCIAL AND EMOTIONAL WELLBEING TO THE COMMUNITY, (L-R) Robert, artist, describing his woodcarving to gallery patrons. Painting by Brian Abrahams 2014

Artwork touches the heart of rural Tasmania By Derith M Harris and Malcom Bywaters

Tasmanians who experience mental health issues have had their brilliant artwork showcased at the Minds do Matter art show. The show, put together by the University of Tasmania School of Health Science partnered with MI Fellowship Aspire services – Launceston, was timed to coincide with National Mental Health Week last October so as to raise community awareness about mental health issues. The aim of the exhibition was to promote artworks which displayed social and emotional wellbeing to the community, encouraging people to maximise their health potential and increase their understanding, while also enhancing the mental health literacy of communities, families, individuals, and stimulate community discussion about mental health recovery. The exhibition will be strengthened by The Rural Art Roadshow: Promoting Positive Mental Health in Rural Communities through Art where Dr Derith Harris and her colleagues from the University of Tasmania plan to visit four disadvantaged rural anmf.org.au

communities to give them the opportunity to meet the artists in person and discuss their creatively, the recovery and how art helped them to express their experiences. The Rural Roadshow team will engage with local government, community groups (Lions, Rotary, CWA, and fellowships), schools, healthcare organisations and media to facilitate and support the project. Local artists that have exhibited in the Minds do Matter art exhibition have also been invited to participate in the Roadshow where they will offer community talks at each Roadshow site to offer insight into their experiences as an artist and as a person affected by mental illness and promote a positive image of mental health and wellbeing. The World Health Organization (WHO) attributes 14% of the global burden of disease to mental health conditions. In particular, mental health conditions

account for 50% of the total disease burden among young people, with anxiety and depression being the leading causes. Despite this, young people do not access healthcare at levels commensurate with this need (Lancet, 2012). Rural communities across Tasmania are also often socially disadvantaged, characterised by high rates of unemployment, social isolation, lack of qualified professionals and stigma in small communities. Through art, however, people affected by mental illness may experience enhanced perceived control, the building of a sense of self, transformation of the illness experience, a sense of purpose and increased social support. This project is funded by UTas community engagement scheme. Reference The Lancet (2012). Global Burden of Disease Study, 380, p.2053–2103.

Dr Derith M Harris is Senior Lecturer, University of Tasmania, Senior Research Fellow, University of Melbourne Dr Malcom Bywaters is Senior Lecturer, Director, Academy Gallery & NEW Gallery Tasmanian College of the Arts, Inveresk, University of Tasmania March 2015 Volume 22, No.8 37

Focus – Mental health Holistic care approach

By Dianne Goeman, Susan Koch, Beth Fogerty and Laura Collister People with severe mental illness live between 10 to 32 years less than the general population and co-morbidities such as obesity, heart disease and lung disease are also much higher in this group (ABS 2008). The World Health Organization (WHO) recognised in 2004 that mental health was more than the absence of illness and is intimately connected with physical health and forms an integral part of health. They also noted that the organisational and conceptual division between physical and mental health was a barrier to the improvement of health more generally (WHO 2004-2005).

generally accepted in the voluntary sector and some research circles due to strong correlations between ‘quality of life’ and ‘life satisfaction’. It would therefore seem pertinent for mental health providers to use a holistic wellbeing approach in the delivery of care to those with mental illness (Annual Report CMO 2013). Holistic care addressing both mental and physical health issues, it would appear, has the potential to improve the overall health outcomes for those with mental illness (The Lancet 2014). However, in Australia, the separation of mental and clinical healthcare funding has made integration of care impossible to achieve in the practical setting. RDNS and Mental Illness Fellowship Victoria (MI Fellowship) propose to overcome this barrier by partnering to trial a ‘wellness and re-enablement’ model of integrated physical, social and mental healthcare for MI Fellowship Victoria clients and those with a diagnosis of mental illness who are receiving care from RDNS.

to provide clients greater autonomy to direct their own care. Clients will be given the opportunity to direct their own care needs including additional supports to enhance their social participation. The overall project aim is to identify what will unlock the barriers to improving physical health outcomes and social participation in those with mental illness. References Annual Report of the Chief Medical Officer (2013), Public Mental Health Priorities: Investing in the Evidence, UK, 2014. Australian Bureau of Statistics, (2008). National Survey of Mental Health and Wellbeing: Summary of results, 2007 Cat. No. 4326.0. Canberra. ABS. Editorial, The Lancet, (2014); 384: 1072. World Health Organization Report 2004-2005.

Dr Dianne Goeman is a Senior Research Fellow at RDNS Institute Associate Professor Susan Koch is Director at RDNS Institute

In policy, the notion that improving ‘wellbeing’ will improve mental health and reduce the prevalence of mental illness in the population is now also

In addition to this holistic approach that addresses the physical, social and mental healthcare needs of clients, the ‘wellness and enablement model’ will incorporate a Consumer Directed Care (CDC) framework

Ms Beth Fogerty is Regional Manager, Mental Illness Fellowship Victoria

Finding my ‘own beat’ in a multidisciplinary team

as a nurse, would fit into a team of several disciplines each with their own specialised training, education and experience. What unique skills and expertise did I bring and how was I going to show these abilities?

and participants ‘giving a beat’ ie. clapping hands, stamping feet. While this could be called silly and seen to trivialise these very real concerns of our clients, I believe this was an example of my flexible and unique approach for showing understanding, caring and connectedness.

By Tracey Hill

The Statewide Eating Disorder Service (SEDS) is a new service dedicated to providing assessment, treatment and support options for individuals and carers who experience eating disorders in SA. SEDS incorporates the former Weight Disorder Unit at Flinders Medical Centre which included a community mental health nursing service. I was part of this very small community team operating in an autonomous role. However, SEDS incorporated a multidisciplinary approach which is widely recognised as the best practice for the patient with disordered eating (National Institute for Clinical Excellence 2004). This represented a huge change for me. I had to consider where I, 38 March 2015 Volume 22, No.8

I soon discovered that regardless of our different disciplines, each clinician was working towards the same outcome for our clients. That is, to overcome their challenges and to make improvements to their lives nonetheless treatment, perhaps delivered in a different language. So what was mine? I have been complimented on my ability to use myself as a therapeutic tool throughout my career. For me this became the essence of myself as a mental health nurse and I think allowed a more eclectic, flexible and unique approach to treatment. As well as my usual use of kindness and compassion, colleagues and participants appreciated my use of fun and laughter as a great relief in what can be a very serious setting. Recently, as a distress tolerance exercise, I used music in the form of a rap, some rhyming lyrics relevant to the group’s experience, with urban slang and the team

Ms Laura Collister is Director, Mental Illness Fellowship Victoria

After several months working within our new service I now know the true essence of multidisciplinary teams is with acceptance and appreciation for our professional differences, believing in and having an understanding for our shared goals and the richness of our unique way of addressing these. I feel very confident that the SEDS team are happy to share their knowledge and expertise and just as importantly appreciate my unique contributions to the team. Reference National Institute for Clinical Excellence (NICE), (2004), Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. London: NICE.

Tracey Hill, Clinical Practice Consultant, Statewide Eating Disorder Service, Flinders Medical Centre, SA anmf.org.au

Focus – Mental health The meaning of safety in an acute mental health inpatient services By Natalie Ann Cutler, Lorna Moxham and Moira Stephens

Safety is a priority in acute mental health inpatient services (MHS). In the health context, safety is defined and measured as the absence or reduction of risk (AIHW 2013; ACSQHC 2012). National safety priorities in MHS (AHMAC 2005) focus on reducing adverse events such as suicide, restraint and medication errors, and the primary performance indicator for safety in Australian public MHS is the rate of seclusions per 1,000 patient days (AHMAC 2011). Concerns about a predominate focus on risk in the name of safety in MHS have been raised, however. Morgan (2007) argues risk-averse approaches in mental health can give rise to defensive practices which, rather than promoting safety, can themselves be harmful. Likewise, Jenkins (2013) suggests that ‘(we) have allowed a mental health system to evolve which… has focused on managing risk, at the expense of quality care and treatment’. When safety is defined and measured through the lens of risk, resources are more likely to be directed toward remediating risk, rather than promoting safety. Assumptions about the meaning of safety may be driving this paradox. Just as health is more than just the absence of disease (WHO 1948), there may be scope for safety to be redefined as more than just the absence of risk. A recent study suggests MHS users relate safety to the presence of certain positive factors, rather than the absence of risk (ACSQHC 2014). Investigating what safety means for, and with, MHS users offers a broader view of safety. A study currently underway through the School of Nursing at the University of anmf.org.au

Wollongong, NSW Australia, is exploring the meaning of safety from the perspective of people who have experienced admission to acute mental health inpatient units. Through semi-structured interviews, participants are invited to share with a nurse researcher what safety meant to them when they were in that setting. A novel qualitative research approach, phenomenography, enables the diverse and common meanings of safety, rather than objective aspects of safety, to be explored (Ackerlind 2012). Understanding what safety means for people with lived experience of mental illness adds a new dimension to safety in the acute mental health inpatient setting. This study aims to transform the nursing focus in acute mental health inpatient services from one of ‘managing risk’ to one where, through collaborative redefinition, safety is seen as a consequence of proactive and authentic partnerships with MHS users. References Akerlind, G. (2012). Variation and commonality in phenomenographic research methods. Higher Education Research & Development, 31(1): 115-127. Australian Commission on Safety and Quality in Health Care (ACSQHC). (2012). Australian safety and quality goals for health care: development and consultation report. Retrieved from www.safetyandquality.gov. au/wp-content/uploads/2012/01/Safety-and-QualityGoals-Development-and-consultation-report.pdf, on 10 December 2014. Australian Commission on Safety and Quality in Health Care (ACSQHC). (2014). Recognising and responding to deterioration in mental state: a scoping review. Retrieved from www.safetyandquality.gov.au/wpcontent/uploads/2014/07/Recognising-and-respondingto-deterioration-in-mental-state.-A-scoping-review.pdf, on 12 December 2014 Australian Health Ministers’ Advisory Council (AHMAC). 2005. National safety priorities in mental health: a national plan for reducing harm. Retrieved from www. health.gov.au/internet/main/publishing.nsf/Content/

DB6FC7B04519D195CA257BF000217B28/$File/safety. pdf, on 15 December 2014. Australian Health Ministers’ Advisory Council (AHMAC). (2011). Key performance indicators for Australian public mental health services (2nd edn). Retrieved from http:// amhocn.org/static/files/assets/b5b51e47/KPIs_2011.pdf, on 10 December 2014. Australian Institute of Health and Welfare (AIHW). (2013). Definitions of safety and quality in health care. Retrieved from www.aihw.gov.au/, on 15 December 2014. Jenkins, P. 2013. Our risk averse mental health system is wasting money and harming recovery. The Independent Online. Retrieved from www.independent.co.uk/voices/ comment/our-risk-averse-mental-health-system-iswasting-money-and-harming-recovery-8471518.html, on 10 December 2014. Morgan, J. (2007). Giving up the culture of blame: risk assessment and management in psychiatric practice. Briefing paper for Royal College of Psychiatrists. Retrieved from www.rcpsych.ac.uk/pdf/Risk%20Assessment%20 Paper%20-%20Giving%20up%20the%20Culture%20 of%20Blame.pdf, on 10 December 2014. World Health Organization (WHO). (1948). WHO definition of health. Retrieved from file:///Volumes/ NO%20NAME/PhD_Article%205%20Jan%202015/ WHO.webarchive, on 15 December 2014.

Natalie Ann Cutler is a Mental Health Nursing Practice Coordinator at South Eastern Sydney Local Health District, NSW Professor Lorna Moxham is Professor of Mental Health Nursing at the School of Nursing and Midwifery, University of Wollongong, NSW Dr Moira Stephens is a Senior Lecturer at the School of Nursing and Midwifery, University of Wollongong, NSW All authors are affiliated with the School of Nursing, University of Wollongong, NSW March 2015 Volume 22, No.8 39

Focus – Mental health Managing aggression By Rebecca Thompson, Honie Thomson and Virginia Plummer

RiSCE Coordinators Rebecca Thompson and Honie Thomson undertook an analysis of the data on Code Grey* calls at Peninsula Health’s Frankston Campus from 2010 to 2014 and found that there was an increasing incidence of reported assaults on the acute care wards and the majority occurring during provision of care from the over 65 age group. This placed great demand on acute care staff caring for this patient group.

skills regarding appropriate and effective techniques for such behaviour (Kynoch, Wu & Chang 2010). This is further supported by Taylor and Rew who identified the highest risk included staff of acute health wards. Staff attitude about the causes of aggression can influence the management of the situation (Duxbury et al 2008).

An education based intervention for staff of the general wards was developed – a DVD and presentation entitled ‘Managing Aggression: A holistic approach to challenging behaviours’. This package includes eight 3-5 minute scenarios based on real life events, it was produced by a film maker, utilising paid actors and staff from the health service who volunteered their time. The scenarios are alcohol withdrawal, delirium, acute confusion state, family conflict, pain, mental health, waiting times and reception staff dealing with agitated people. A mixed methods study of the intervention was undertaken including a pre-test, post-test for nursing staff, open ended questions and face to face interviews with nurse unit managers. Mental health nurses have specific training The staff of four wards (N=71) were invited for dealing with aggression and violence; to attend 11 education sessions and the however general nurses are often expected results show favourable shifts between to care for patients exhibiting aggression NEDAdvertisement02_v2.pdf 1 22/01/2015 3:37 pm pre and post intervention which were and violence with limited knowledge and

maintained at six weeks post intervention. Further research is planned. *Clinical aggression that cannot be managed within the current clinical resources. The production of the DVDs was funded by Peninsula Health and ethics approval was provided by Peninsula Health HREC References Duxbury, J. Hahn, S., Needham, I and Pulsford, D. (2008). The management of aggression and violence attitude scale (MAVAS): a cross-national comparative study. Journal of Advanced Nursing 62 (5), 596-606. Kynoch, K. Wu, C & Chang, A. (2011) Interventions for preventing and managing aggressive patients admitted to an acute hospital setting: A systematic review. Worldviews on Evidence-Based Nursing. Vol.8(2), Jun 2011, pp. 76-86. Taylor, J. L and Rew. L. ( 2010). A systematic review of the literature: Workplace violence in the emergency department. Journal of Clinical Nursing, 20 1072-1085.

Rebecca Thompson and Honie Thomson are RiSCE Coordinators (Risk identification Safety Communication Environment) at Peninsula Health, Frankston Hospital, Victoria Virginia Plummer is an Associate Professor Nursing Research at Monash University and Peninsula Health, Victoria

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Focus – Mental health A still image of ‘Jessica’ during the filmed interview, conveying the emptiness and lack of hope which can accompany an individual in the sequel of attempted suicide

Responding to youth suicide: a film for nurses and health workers

interviewer, Jessica describes the impact that this has had on her mental health and suicidality.

A report by the Australian Human Rights Commission (2014) reveals that between 2007 and 2012, 333 children aged 4-17 years died due to intentional self-harm (64% male; 20% Aboriginal). Of these deaths, 81% were by hanging and 76% occurred at the young person’s home.

Important aspects featured in the filmed interview are Jessica’s pathways to suicidal behaviour. Jessica’s unsuccessful attempt to die by suicide features (i) a high lethality event (large paracetamol overdose and hanging); (ii) low rescueability of Jessica at the time of the event (home alone, in a locked house) and (iii) Jessica’s unfettered access to means (easily assembled apparatus and ligature points). As Jessica’s story unfolds, so too does her clear intent to die. In this instance and in the field of suicidology more broadly, intent to die possibility is quantified as anything greater than zero.

By Nicholas Procter and Monika Ferguson

While a range of factors are known to contribute to suicidal and self-harming behaviour among young people, there is increasing recognition of the harmful role that cyberbullying can play in contributing to mental deterioration, despair and suicidal ideation. Aware of such alarming findings, UniSA’s Mental Health and Substance Use Research Group, in partnership with MOSH (Minimisation of Suicide Harm), CAMHS (Child and Adolescent Mental Health Services) and SA Health’s Office of the Chief Psychiatrist, have collaborated on a new training film for use by nurses and other health professionals as a guide to better engage with and respond to intentional self-harm among young people. The film’s development was guided by UniSA’s focus on person-centred mental anmf.org.au

healthcare in teaching, research and clinical education (Procter et al 2014). Additional evidence on youth suicide following coronial investigations, and from nurses, psychiatrists and those with lived experience of suicide and self-harming behaviour, helped illuminate characteristics of the suicidal mind, and frame a mental health response to engaging with young people. The film features ‘Jessica’, aged 19, and follows her non-fatal attempt at suicide by paracetamol overdose and hanging in her family home. Jessica is studying towards a Bachelor of Arts and living at home with her parents and younger brother. On the day before the filmed interview, Jessica did not attend her class. After receiving a worried call from one of Jessica’s friends, Jessica’s mother returned home from work to find Jessica unconscious on the bathroom floor. An ambulance was called and Jessica was taken to the hospital emergency department. The filmed interview with Jessica takes place the following morning. ‘Throughout the interview, Jessica begins to reveal her story. She tells of recent and accumulating experiences of social isolation and bullying, particularly through online and social media. Through a supportive and encouraging interaction with the

The film is freely accessible on YouTube: https://www.youtube.com/ watch?v=WdC3nhxA66U References Australian Human Rights Commission. (2014). Children’s rights report 2014: National Children’s Commissioner. Canberra: Australian Human Rights Commission. Procter, N.G, Baker, A., Grocke, K. and Ferguson, M. (2014). Introduction to mental health and mental illness: Human connectedness and the collaborative consumer narrative, in NG Procter, H Harmer, D McGarry, R Wilson and T Froggatt, Mental health: A person centred approach. Melbourne: Cambridge University Press, pp. 1-24.

Professor Nicholas Procter is Chair in the Mental Health Nursing, School of Nursing and Midwifery, University of South Australia Dr Monika Ferguson is a Research Associate at the School of Nursing and Midwifery, University of South Australia March 2015 Volume 22, No.8 41

Focus – Mental health Adjusting to mental health nursing in Australia

By Bindu Joseph, Cheryle Moss and Wendy Cross Mental illness represents a leading cause of disability burden in Australia; approximately 45% of adults have a mental health disorder in their lifetime (Australian Institute of Health & Welfare 2009; The Royal Australian & New Zealand College of Psychiatrists 2011). Australia needs a multicultural nursing workforce, and nowhere is communication and cultural understanding more important than in mental health nursing. Ironically, to be able to provide this culturally expert nursing care, nurses who have migrated from other countries need to culturally adapt to the Australian healthcare System generally, and mental healthcare in particular. Background assessment identified that mental health nursing workforce consists of many overseas trained nurses, with a significant percentage from India. For example, in 20112012, 35.5% of the overseas trained nurses migrating to Australia arrived from India (Health Workforce Australia 2011). Kerala is a small state located in the south west of India, however traditionally Kerala nurses represent

about 80% of these migrating Indian nurses. It is clear that the experiences faced by migrant professionals are different from that of domestic professionals especially with a diverse range of additional ‘transition’ challenges in the new country. Available research in this topic highlight themes such as isolation, separation issues, communication problems, underestimation by patients and colleagues, issues related to enculturation and lack of orientation to the new healthcare system and new culture (Department of Health 2009). In addition, contemporary mental health practice in Australia focuses on primary care and client-led recovery models of care with ongoing carer participation and collaborative planning. It also demands teamwork, assessing clients in their cultural context, engagement, communication and working within the specific legal boundary. Above all, this is likely to be a new experience for migrant professionals, since most of the developing countries still follow a ‘medical model’ rather than a ‘recovery model’. Previous international research in this subject matter mainly focused on overseas nurses working in general nursing areas with a minimal number of studies completed in Australia. Aware of these cultural challenges for nurses, Bindu Joseph, a PhD student at Monash University and a Clinical Educator at Peninsula Health Mental Health Service decided to investigate this social process more fully. Currently, Bindu is interviewing nurses from Kerala, India and working in mental health in Australia so as to gain insight into what

it has been like to make the shift in their work and life cultures, and to contribute to mental healthcare. The project is being supervised by Professor Wendy Cross and Associate Professor Cheryle Moss, who are both interested in cultural issues confronting the nursing workforce. This research will help nurses working in mental health in Australia to understand these transitions and should inform workforce practice and policy. References Australian Institute of Health and Welfare. (2009). Health Workforce in Australia and Factor for Current Shortage (1). Melbourne. Retrieved from www.ahwo.gov.au/ Department of Health and Ageing. (2009). Victorian Mental Health Reform Strategy, 2009-2019. Retrieved from http://docs.health.vic.gov.au/docs/doc/Because-Mental-Health-Matters--Victorian-Mental-Health-Reform-Strategy-2009--2019 Health Workforce Australia. (2011). National Health Workforce Innovation and Reform (Strategic Framework for Action 2011–2015. (Retrieved from https://www.hwa. gov.au/sites/uploads/hwa-wir-strategic-framework-foraction The Royal Australian and New Zealand College of Psychiatrists. (2011). Support World Mental Health Day. Retrieved from https://www.ranzcp.org/News-policy/Media-Centre/ Media/Support-World-Mental-Health-Day.aspx

Bindu Joseph is a PhD student at the School of Nursing and Midwifery, Faculty of Medicine, Nursing & Health Sciences at Monash University and Clinical Educator Peninsula Health (Mental Health Service) in Victoria Cheryle Moss PhD RN and Wendy Cross PhD RN are at the School of Nursing and Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Victoria

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Focus – Mental health Hearing voices By Matthew Ball

A significant number of individuals in society hear voices. Auditory hallucinations – hearing voices – have traditionally been seen as an aberrant symptom of schizophrenia (Longden 2013). A movement led by ‘voice hearers’ in the form of international, national and local networks has been growing over the last 30 years in support of ‘voice hearers’ and their recovery journeys. In Southern Adelaide, a mental health nurse practitioner candidate (NPC) identified an unmet need for voice hearers in the region. A common theme had emerged amongst a consumer group identified as having complex needs: many of the individuals have ‘voice hearing’ experiences that are not understood by themselves or the professionals working with them. This lack of understanding caused distress and difficulties in their lives. Over 50% of individuals in ‘treatment’ referred in the past year identified an ongoing ‘voice hearing’ experience that was a primary concern. Southern Adelaide Local Health Network (SALHN) has embraced the opportunity to

support individuals to explore meaning of their voices and other unusual realities to be better able to assist them in their individual journey toward the recovery. The hearing voices movement identifies the individual as arbiters of the meaning of their own experience and values collaboratively working with another person in midwifing the enquiry into the ‘voice hearing’ experience (Coleman 2000). The NPC has been facilitating the Maastricht interview of voice hearing and ‘Talking with voices’ (Corstens, Longden and May 2012) and has been working collaboratively towards finding strategies to manage the distress and developing an understanding of meaning of the voices. Hearing voices groups have become an opportunity for individual ‘voice hearers’ in South Australia to find support and acceptance with one another in managing the reality of their experiences. Hearing voices groups have been established in three areas of South Australia and includes collaboration between voice hearers and providers. In addition, the voice hearing individuals and workers shared learning experiences in the form of a workshop with Ron Coleman (workingtorecovery.co.uk). The emergence of the hearing voices network of South Australia is now underway and includes an online presence. This has been developed by independent trainer and facilitator Sarah K Reece (http://hvnsa.org.au/). Understanding and changing relationships

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with voices is an important and valuable part of recovery for individual voice hearers. The philosophy of accepting and working with voices (Corstens, Escher and Romme, 2008) has facilitated the discussion within a nursing paradigm. Nursing theorists such as Travelbee, Pelau and Paterson and Zderad identified the importance of the human relationship in nursing and complement the theoretical approach to voice hearing. Nursing theory has supported the NPC to share concepts both within nursing and other disciplines, enabling individuals to take control of their own recovery journeys. Embracing the nature of empowerment and the value of the lived experience has supported SALHN to take positive steps towards individuals with lived experiences being the greatest resource in their own recovery. References Longden, E. (2013). The voices in my head. www.ted. com/talks/eleanor_longden_the_voices_in_my_head 22/12/14 Coleman, R. (2000). Recovery, an alien concept? Gloucester: Handsell. Corstens, D., Longden, E. and May, R. (2012). Talking with voices: exploring what is expressed by the voices people hear. Psychosis: Psychological, Social and Integrative Approaches. 4: 95-104. Corstens, D., Escher, A. and Romme, M. In: Moskowitz (ed) Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Wiley & Sons.

Matthew Ball is a Nurse Practitioner Candidate, Outer South Mental Health Service, Southern Adelaide Local Health Network, SA

Focus – Mental health Mental health consumers’ recovery in the emergency department

By Donna Marynowski-Traczyk, Lorna Moxham and Marc Broadbent The Emergency Department (ED) plays a significant role in the provision of care to people experiencing mental health issues. As the interface between community care and specialist mental health inpatient services the ED is integral to supporting consumers’ transition between service sectors. Within Australia mental healthcare is underpinned by a recovery orientation. This is now firmly embedded within Australian national policy including the National Framework for Recovery-Oriented Mental Health Services 2013 (Australian Health Ministers Advisory Council 2013) and the Roadmap for National Mental Health Reform 2012-2022 (Council of Australian Governments 2012). Diverse healthcare environments have their own unique culture, practices and language. The disparity in language between mental health services and the clinical ED environment is highlighted by the polarity regarding the meaning of the word recovery as it is understood within these healthcare domains. Recovery has different meanings depending on the lens through which it is viewed. This has significant implications for the delivery of care to people that access the ED for mental health crisis assessment and intervention. New models of care have been implemented within the ED in response to concerns regarding the appropriateness of the ED in providing care to people experiencing mental illness; however Registered Nurses (RNs), many with no formal mental health training, continue to care for this cohort as part of their daily practice. Understanding how ED RNs conceptualise recovery for mental health consumers within the ED was the focus of PhD research undertaken at the University of Wollongong. A conceptual separation of physical and mental health can perpetuate the view by generalist nurses that the care of mental health consumers is not their role (Ross & Goldner 2009). However, recovery as understood by people with lived experience of mental illness is not bound to the confines of health services and 44 March 2015 Volume 22, No.8

organisations but is part of their everyday lives. As such, nurses working in the ED who care for mental health consumers are involved in the consumers’ personal recovery journey. This research elucidates that this notion is not well understood by ED RNs. Furthermore, it highlights that although language can be a barrier to recovery, it can also be a powerful tool to nurture recovery. Therefore, embracing recovery oriented language within the ED environment is a practical way in which RNs can support consumers’ recovery and promote optimal care experiences and outcomes for this vulnerable group. References Australian Health Ministers Advisory Council. (2013). A national framework for recovery-oriented mental health services: guide for practitioners and providers. Commonwealth of Australia. Canberra. Council of Australian Governments. (2012). The roadmap for national mental health reform 2012-2022. Commonwealth of Australia. Canberra. Ross, C., & Goldner, E. (2009). Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. Journal of Psychiatric and Mental Health Nursing. 16(6): 558-567.

Donna Marynowski-Traczyk, PhD Candidate RN BN (Honours) is at the School of Nursing and Midwifery, Faculty of Science, Medicine and Health, University of Wollongong in NSW Professor Lorna Moxham is Professor of Mental Health Nursing, School of Nursing and Midwifery, Faculty of Science, Medicine and Health, University of Wollongong in NSW Dr Marc Broadbent is at the School of Nursing and Midwifery, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast in Qld

Security guards in mental health settings: starting the conversation

By Eimear Muir-Cochrane and Mike Musker An increase in hospital based violence has seen a rise in the number of security guards placed in Australia’s hospitals. The amount of training and preparation between agencies and individual staff is not standardised and may place vulnerable patients at risk. Some security firms have set their minimum standard of training as Certificate Level 2 (a five day training course). It appears that security guards in hospital environments are here to stay; hence close examination of their role in the health workforce is required to ensure the provision of safe and effective healthcare delivery at all times. An example of the potential risk in using personnel with limited training can be seen in interventions with a patient who is experiencing severe symptoms of psychosis such as paranoia and hallucinations due to mental illness or drug intoxication. Whereas health professionals can offer expert therapeutic interventions and de-escalation, guards are more likely to contain and restrain as this is the sole function of their role. Very little is known about the effect of security guards in hospitals on the care that patients receive and patient’s perceptions about security guards in clinical environments. It’s time to have this conversation around the use of security as a component of the provision of healthcare in clinical areas and the actual and potential implications for care. Professor Eimear Muir-Cochrane is Chair of Nursing (Mental Health) at Flinders University, SA Dr Mike Musker is a Research Fellow, Mind and Brain, SA Health and Medical Research Institute, SA anmf.org.au

Focus – Mental health THE PROGRAM PROVIDES CONSUMERS WITH AN OPPORTUNITY TO EXPLORE AND BUILD ON SELFMANAGEMENT STRATEGIES THAT THEY CAN UTILISE WHILE IN AN INPATIENT SETTING AND BEYOND HOSPITAL. the consumers attention span given their complex mental health conditions. It is used to facilitate empowerment, selforganisation, relaxation, sensory awareness, communication, reality-orientation, activity tolerance and general awareness of self, peers and the environment. The program provides consumers with an opportunity to explore and build on selfmanagement strategies that they can utilise while in an inpatient setting and beyond hospital.

Introduction of restraint and seclusion reduction program in Margaret Tobin Centre 5J By Dulcey Kayes and Elizabeth Humphris The Margaret Tobin Centre (MTC) is a 33 bed inpatient mental health facility co-located at the Flinders Medical Centre. Within MTC, is an eight-bed Psychiatric Intensive Care Unit (PICU), closed ward which provides a statewide service for complex mental health consumers and consumers who may have physical or intellectual co-morbidity and an overflow facility for corrections/forensic services consumers. In 2014, the Southern Adelaide Local Health Network (SALHN) Inner South Mental Health team instigated a restraint and seclusion reduction program in response to a large number of episodes of restraint and seclusion in 5J during 2012/13. This has resulted in a 54.5% reduction in restraint and seclusion incidents in 2013/14 compared to 2012/13. anmf.org.au

One of the key initiatives of this program was the introduction of a restraint and seclusion review panel to oversee the management of and review all incidences of restraint and seclusion within the unit. The program has had an impact on reducing the levels of and extreme durations of restraint and a decrease in challenging behavioural type incidents in the second half of the 2013/14 financial year compared to the first half. These programs have been implemented to meet the broad aims of the SA Health Challenging Behaviour program. One of the key strategies of the program has been to implement group therapy activities on the unit. Since the beginning of the program there have been 26 evaluated sessions that have focused on shared activities, stress management, sensory modulation and relaxation activities. The program aims to offer a nurturing, person-centred sensory oriented supportive environment taking into consideration

Incidents of restraint and seclusion can be traumatic for consumers and staff. The reduction of these potentially traumatic experiences on the ward has led to an improvement in the everyday lives of staff and consumers. Recent formulation of a post seclusion event debriefing tool is being implemented. This tool aims to understand from the patient’s perspective, what it is like to be secluded, and supports the development of a post seclusion recovery plan. With respect to staff this has resulted in less time being confined to behavioural management activities which has allowed them to dedicate more time to build therapeutic relationships with consumers. Feedback gained from patients regarding the group program highlights and confirms that it is beneficial and has supported a reduction in boredom. Consumers have also reported enhanced therapeutic relationships with staff, (feeling listened to). This program won the 2014 SA Health Award for Improving Patient Safety. Dulcey Kayes is a Clinical Services Coordinator and Elizabeth Humphris is an occupational therapist, both at the Margaret Tobin Centre, South Australia March 2015 Volume 22, No.8 45

Focus – Mental health ‘Sicoko’

He had been found collapsed in a park in a nearby country town, with two large fungating wounds under his arm and on his shoulder. These were believed to be basal cell carcinomas or squamous cell carcinomas or possibly melanomas, but after a week in the surgical ward he was still refusing all medication and all treatment.

An attempt at a comprehensive mental health assessment had been made the day before, and was already in his file. To me, it seemed that the priority was basic nursing care. However, he refused everything I offered. He declined a shower (“I had one yesterday”), dressings (though he did agree to change them himself but he would not allow me to do more than assist with taping at the end), any sort of medication including pain relief, observations (“they are all right”) or even a urinal (he preferred to “piss in the corner” as he explained to me). He was very hungry however, and ate all of his continental breakfast (cereal, toast, juice) and then asked for more, which I found for him. His hunger overrode his delusional belief that his yogurt was full of dead insects. And he was very pleased with his cups of black tea, and scathing about the brew which had been offered overnight. Security took him outside for a cigarette while I made his bed, picked up assorted rubbish, mopped the floor and attempted to air the room.

He was psychotic, very thin, and unable to give much history or identify his next of kin. He had no possessions. He might have been in his mid-thirties, perhaps forty, that was all.

He had a handful of intricate drawings he had made of the rays which were causing his problems. There was a tapeworm in his gut, he told me, and an insect in his wounds which he wanted to remove.

The aim was to get him to the base hospital which had an involuntary mental health unit as well as higher level medical and surgical care.

I did my best to develop some kind of rapport with him, though when he became impatient, I would leave. He told me that he was “sicoko”, and when I could not understand this and tried to clarify what he meant, he carefully spelled it out for me twice. He then said the word “psycho” but amended it to “psychic”. Remembering themes of earlier discussions, I asked him if he meant “spiritual” and he was absolutely delighted and commented that that was the first intelligent thing I had ever said in my life. Pushing my luck a bit, I suggested, “Maybe the second intelligent thing?”, and

By Anna Treloar He was waiting in the Mental Health Room in the Emergency Department (ED). He had been made involuntary and was to be taken to the base hospital as soon as transport could be arranged. As the ED Mental Health Nurse I was to special him until he left.

Overnight, before I arrived for the morning shift, his door had been kept closed because of the smell of the fungating wounds. Somebody had brought him a cup of sweet milky tea but apart from that he had been left alone. In the room there was a bed and two low armchairs. The window did not open.

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HE WAS PSYCHOTIC, VERY THIN, AND UNABLE TO GIVE MUCH HISTORY OR IDENTIFY HIS NEXT OF KIN. HE HAD NO POSSESSIONS. HE MIGHT HAVE BEEN IN HIS MID-THIRTIES, PERHAPS FORTY, THAT WAS ALL. he actually smiled and there was a twinkle in his eye. Naively I believed that the base hospital would be able to treat his wounds and that he would recover. At the time I specialled him I did not realise that as well as being acutely mentally ill he was also a palliative care patient. For this reason I am glad that the Director of ED decided not to forcibly sedate him. I am glad that the Patient Transport team agreed to take him (without sedation he was not eligible for ambulance transport). He was looking forward to travelling in the van because he wanted “to be able to look out and see the view”. He left in blue hospital scrubs wrapped in a white cotton blanket and clutching a bag of food which he had saved from his large breakfast. I did not manage to provide all basic physical nursing care, but in some measure I hope I provided basic mental health nursing care (though the two should never be separated). He did not have much time left, and in the short time he was in ED, I believe he experienced at least some kindness. Anna Treloar is an RN, MA, MPHC, Credentialed Mental Health Nurse, and Lecturer at the School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle

AL JOURN W I F E RY & MID A U S T R A L I A N N U R S I N G & M I D W I F E RY J O U R N A L VOLUME 22, NO. 5 AUSTRALI AN VOLUME 22, N U R S I N G & M I D W I F E RY J O NO. 4 URNAL N OV E M B E R 2 014

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Calendar MARCH Inaugural Student Recruitment and Retention Forum 2–3 March Sydney Harbour Marriott, Sydney. With Australian Higher Education becoming more and more competitive and the Federal government proposing the deregulation of university fees, student recruitment and retention has become increasingly important in the area of higher education. This conference will examine the latest strategies to attract students to universities and more importantly prevent student attrition from occurring. www.informa.com.au/ Lung Health Promotion Centre at The Alfred 4–6 March Asthma Educator’s Course 19–20 March 2015 Smoking Cessation Course P: (03) 9076 2382 E: lunghealth@alfred.org.au Diabetes study day with Kathy Mills, RN, MEd, Dip Business, Credentialled Diabetes Educator. This study day for enrolled and registered nurses covers contemporary and evidence based research on dietary, exercise, psychological and pharmacological management of diabetes mellitus. 6 March from 9am–4pm at Inner East Melbourne Medicare Local, 6 Lakeside Drive, Burwood East. Free parking. Morning tea, lunch and notes are provided. This study day is eligible for 6 hours professional education. Full registration fee: $250. All queries to Kathy via email only at diabetes. ed@optusnet.com.au 19th National Otorhinolaryngology Head & Neck Nurses meeting and ASHONS 65th scientific meeting Excellence and innovation 7–9 March Australian Technology Park, Sydney NSW. www.ohnng.com.au/ national_conference.html International Women’s Day 8 March www.unwomen.org/ World Kidney Day (Australia) 12 March www.kidney.org.au/ Florence Nightingale Foundation Annual Conference 12–13 March Queen Elizabeth II Conference Centre, London. www.fnfalumni. org/event-1717850

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Australian College of Mental Health Nurses 8th Primary Mental Health Care Conference Primary mental health care in the digital age 13–14 March The Canberra Rex Hotel, ACT. www. acmhn.org/news-events/conferencenews/pmhc-conf-2015 Australasian Cardiovascular Nursing College 9th Annual Conference 13–14 March Crowne Plaza, Coogee, Sydney. www.acnc.net.au ACMHN 8th Primary Mental Health Care Conference Primary mental health care in the digital age 13–14 March Canberra ACT. www.acmhn.org/ news-events/conference-news/ pmhc-conf-2015 The person centred approach to healthy weight management. If not dieting, then what?® 13–14 March 2015 - Brisbane 20–21 March 2015 - Sydney https://www.apna.asn.au/ ifnotdieting Australian Pain Society 35th Annual Scientific Meeting Managing Pain: from Mechanism to Policy 15–18 March Brisbane Convention Centre, Qld. www.dcconferences.com.au/ aps2015 Australian Disease Management Association Primary & Secondary Prevention Seminar 20 March AMREP Centre, Alfred Hospital, Melbourne www.adma.org.au/ E: b.shen@ alfred.org.au T: (03) 9076 4125 National Close the Gap Day 20 March www.facebook.com/ closethegapcampaign Health & Environmental Sustainability Conference 20 March Melbourne Town Hall. Learn from Victorian nurses and midwives leading the way towards sustainable healthcare. Explore how climate change is impacting our emergency services and their response to natural disasters. Create achievable and practical action plans to take back to your workplace. Earn up to eight hours CPD. www.anmfvic.asn. au/events-and-conferences World Down Syndrome Day 21 March www.worlddownsyndromeday.org

APNA Continuing Education Workshops for Nurses in Primary Care 27–28 March 2015 – Melbourne 1–2 May 2015 – Perth 29–30 May 2015 – Adelaide www.apna.asn.au/ educationworkshops

APRIL Lung Health Promotion Centre at The Alfred 16–17 April Managing COPD 20-21 April Spirometry Principles & Practice 29 April–27–28 May Respiratory Course (Mod A &B) 29 April–1 May Respiratory Course (Module A) P: (03) 9076 2382 E: lunghealth@alfred.org.au

MAY Lung Health Promotion Centre at The Alfred 7 May Respiratory Update 27–28 May Respiratory Course (Module B) P: (03) 9076 2382 E: lunghealth@alfred.org.au Nurses & Midwives Wellness Conference Create your healthy footprint 8 May Melbourne Convention & Exhibition Centre. Learn how to manage stress and anxiety, conflict and negative relationships. Be opened up to new ways to build resilience, improve motivation and increase your energy levels. Earn up to eight hours CPD. www.anmfvic.asn.au/events-andconferences

JUNE Lung Health Promotion Centre at The Alfred 11–12 June Spirometry Principles & Practice 18 June Paediatric Respiratory Update 24 June Asthma Management Update P: (03) 9076 2382 E: lunghealth@alfred.org.au

JULY VPNG (Victorian Perioperative Nurses’ Group) State Conference Strategies for Success: Safety and Quality in Perioperative Care 30–31 July Pullman in Albert Park, Melbourne. www.vpng.org.au

Geelong Hospital Nurses League 81st Annual reunion and AGM 21 March 2015 If you have a connection to the Geelong Hospital (Barwon Health), are a past trainee or current employee and are interested in attending this reunion, please contact Bev Lodge P: (03) 5243 7794 or E: terrylodge@bigpond.com Royal Adelaide Hospital, Group 753, 40-year reunion 1 May Contact Denise Morris E: dmorris@adam.com.au M: 0407 195 773 Royal Children’s Hospital, Parkville, League of Former Trainees & Associates (including RCH Graduate Nurses) reunion Luncheon, with AGM & Guest Speaker 16 May RACV Club, Melbourne. Contact Sue Scott E: sue.scott@rch.org.au M: 0402 092 601 www.rch.org.au/loft/ Alfred Hospital Melbourne, Group 2/75 40-year reunion 13 June Royal Yacht Club of Victoria, Williamstown. Contact Fiona Williams E: fiona.williams777@ gmail.com or Denise Peterson (nee Letcher), snail mail: 3 Sienna Close, Strathfieldsaye, Vic. 3551 Royal Adelaide Hospital, Group 754, 40-year reunion 19 June Contact Liz Strachan E: lizstrachan1@hotmail.com M: 0405 535 762 Prince Henry’s Hospital, 2/85 Reunion 25 July Venue and time not yet decided. Contact Vivienne Jose E: vivvy38@hotmail.com or search Prince Henry’s Hospital Melbourne Memorial Page for further details.

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

March 2015 Volume 22, No.8 47

Coral THE PHOTO IS COURTESY OF LANCIA JORDANA.

The value of Australian citizenship Coral Levett, Federal President

Australia Day is celebrated on 26 January each year. Although this day means different things to each of us, it is an opportunity for us to think about the importance and value of being Australian. We celebrate what we have achieved as a nation together and recommit to making Australia an even better place for the future. It is also important that we give thought to our past and reflect on what Australia Day means to Aboriginal and Torres Strait Islander peoples. I had the great privilege on Australia Day this year to be the guest speaker at the Australian Citizenship Ceremony held at the Australian National Maritime Museum in Sydney. It was an extraordinary day and a wonderful opportunity to talk with some of our newest citizens, including around 20 nurses and midwives receiving their Australian citizenship on the day. To my surprise, after the conclusion of the ceremony, other people (Australian citizens and others) present were invited to affirm their commitment to Australia by reciting the following pledge: As an Australian citizen, *I affirm my loyalty to Australia and its people, whose democratic beliefs I share, whose rights and liberties I respect, and whose laws I uphold and obey. *Non-Australian citizens could join the affirmation at this line. Making the affirmation was voluntary and everyone was invited to join in. I did this along with everyone else, and found it a very humbling experience. Since the first Australian citizenship ceremony in 1949, more than four million people have chosen to become Australian citizens. I have no idea about how many of these are nurses and midwives, but I suspect the numbers are significant. Seeing these exciting and enthusiastic health 48 March 2015 Volume 22, No.8

The nurses receiving their citizenship are (left) Bui Thi To Nga Ngo, an RN working at Liverpool Hospital originally from Vietnam, (centre) Coral Levett, (right) Supaphorn Wong, an RN working at Royal Prince Alfred Hospital originally from Malaysia.

professionals on this day gave me the opportunity to do my own reflection on the value and importance of having Australian citizenship, something many of us take for granted. Becoming an Australian citizen not only means that you can call yourself an Australian, it also means you can call Australia home with all the privileges and responsibilities of a person who was born here. It means you join a unique national community with plenty of privileges and rewards. Becoming an Australian citizen means that you are making an ongoing commitment to Australia, and the values that this country stands for. Australia is a democratic nation; one that places great importance on the dignity, respect and freedom of all individuals, the equality of men and women and the rule of law. Australian citizenship is about being able to live in harmony with others, including the first Australians – Aboriginal Australians. For some of the nurses and midwives taking part in the citizenship ceremony on Australia Day this year, it meant giving up their country of birth citizenship in order to become an Australian citizen. A difficult decision to make for some, as although Australia allows its citizens to hold dual nationality, other countries may not. Interestingly, prior to 4 April 2002, Australian citizens who became citizens of another country lost their Australian citizenship automatically. Fortunately, this is not the case anymore.

As well as making the new citizenship pledge to Australia publicly, potential new citizens are required now to take a test. Out of curiosity, I asked the nurses and midwives about the types of questions they were asked in the test. They had been instructed (as part of the process) not to share the details of the questions with others, but all made the comment that the test was not particularly onerous or difficult if you attended the prescribed reading and watched the video offered by the Department of Immigration and Border Protection. So I went to the Department’s web page and had a look to see if I could learn more about the questions. Although the actual test was not available, there were plenty of practice questions to give you a feel for the types of questions that would be asked. The ones I looked at included questions about our history, ANZAC Day, the Aboriginal flag, our system of government, our constitution and how it gets changed, citizen responsibilities under Australian law and definitions and examples of equality. With all that said and done, I was very proud to be present among this small group of nurses and midwives who have chosen to make Australia their home and to pursue their careers in this wonderful country of ours. The health of all Australians will now benefit from this wonderful gesture. For more information about obtaining Australian citizenship, the following website should be able to answer most of your questions: www.citizenship.gov.au/ anmf.org.au

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