ANMJ March 2017 by Australian Nursing & Midwifery Journal

V O LU M E 2 4 , N O. 8 M A R C H 2 0 1 7

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CONTENTS REGULARS

02 DIRECTORY 03 EDITORIAL 04 NEWS 14 WORLD

PACIFIC

POWER NURSING PARTNERSHIPS ACROSS THE BLUE CONTINENT

15 INDUSTRIAL EMPLOYER CAMPAIGN TO DEREGULATE WORKING HOURS

16 RESEARCH 18 FEATURE PACIFIC POWER 25 WORKING LIFE

MIDWIFE BLOSSOMS INTO AFL STAR

26 ISSUES

COMMUNICATION IS KEY

27 ETHICS

ETHICS, EVIDENCE AND THE ANTI-VACCINATION DEBATE

28 CLINICAL UPDATE

DO AGED CARE NURSES PERCEIVE MORE PROFIT EQUALS LESS AUTONOMY?

32 BOOKS / APPS

33 FOCUS

INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

45 MAIL 46 CALENDAR 48 SALLY

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March 2017 Volume 24, No. 8 1

Canberra

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Editorial

Melbourne & ANMJ

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Federal Secretary Lee Thomas

Assistant Federal Secretary Annie Butler

Editor: Kathryn Anderson Journalist: Natalie Dragon Journalist: Robert Fedele 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

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Branch Secretary Lisa Fitzpatrick

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The Australian Nursing & Midwifery Journal is delivered free monthly to members of ANMF Branches other than New South Wales, Queensland and Western Australia. Subscription rates are available on (03) 9602 8500. Nurses who wish to join the ANMF should contact their state branch. The statements or opinions expressed in the journal reflect the view of the authors and do not represent the official policy of the Australian Nursing & Midwifery Federation unless this is so stated. Although all accepted advertising material is expected to conform to the ANMF’s ethical standards, such acceptance does not imply endorsement. All rights reserved. Material in the Australian Nursing & Midwifery Journal is copyright and may be reprinted only by arrangement with the Australian Nursing & Midwifery Federation Federal Office Note: ANMJ is indexed in the cumulative index to nursing and allied health literature and the international nursing index ISSN 2202-7114

Moving state? Transfer your ANMF membership If you are a financial member of the ANMF, QNU or NSWNMA, you can transfer your membership by phoning your union branch. Don’t take risks with your ANMF membership – transfer to the appropriate branch for total union cover. It is important for members to consider that nurses who do not transfer their membership are probably not covered by professional indemnity insurance.

New South Wales

Queensland

Tasmania

Western Australia

Branch Secretary Brett Holmes

Branch Secretary Beth Mohle

Branch Secretary Neroli Ellis

Branch Secretary Mark Olson

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

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2 March 2017 Volume 24, No. 8

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

134,148

TOTAL READERSHIP

Based on ANMJ 2014 member survey pass on rate Circulation: 91,882 BCA audit, Sept 2016

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EDITORIAL

Editorial Lee Thomas, ANMF Federal Secretary Last month I mentioned that aged care would be a top priority for the ANMF in 2017. ANMF representatives from across the country met in Melbourne last month to discuss how the union could be most effective in improving outcomes in aged care. While it’s too early to say how this campaign will be shaped, it’s evident that each state and territory is committed to working for change in this sector particularly around skill mix and safe staffing levels. With the backing of solid research we have never felt as prepared as we do now to launch this campaign. Though for us to succeed we need everybody to get on board and participate. Enforcing change in aged care will be tough but together I know we will be unquestionably up for the challenge. In the coming months we will give you more information about the campaign and how you can participate to help create better aged care for all.

On a different matter, the feature delves into the overwhelming health challenges in the Pacific. On the back of the South Pacific Nurses Forum ( SPNF), held late last year, and attended by more than 300 nurses and midwives from around the regions, the feature explains how nurses and midwives are banding together to strive for universal access to quality healthcare. As close neighbours the ANMF, which is also the secretariat of the SPNF, has been integral to this process as well as helping to advance the development of nurses and midwives within the region. Geographical hurdles, limited resources, nursing and midwifery shortages and the burden of communicable and noncommunicable diseases are just some of the issues the region has to contend with. This month’s Focus section looks at infection prevention and control practices as well as wound care. With antibiotic resistance becoming dangerously prevalent, this section is a ‘must read’ for every nurse and midwife.

Along the theme of aged care in the journal this month the Industrial report looks at a five year aged care employer campaign to remove protection over employees’ part time hours. To date the ANMF has hindered their efforts, but if successful in the future the employer will have rights to change an employee’s number of hours or starting and finishing times. The clinical update looks at research into the RN’s ability to work autonomously in a changing aged care industry. The study seeks to understand the relationship between perceived autonomy and aged care organisations, and makes recommendations to ensure positive workplace environments in which staff feel valued and are able to contribute to policies and innovation in work practices.

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March 2017 Volume 24, No. 8 3

NEWS

RISE IN LIVER DEATH TOLL Latest cancer statistics show an alarming increase in liver deaths and lost opportunities in bowel screening. The incidence and death rates of cancer continue to drop according to new national cancer data released by the Australian Institute of Health and Welfare (AIHW). The AIHW report showed 68% of people diagnosed with cancer survive at least five years – a 20% increase from the 1980s. Liver cancer was the only common cancer where mortality rates had increased.

MENTAL HEALTH NURSE SAMANTHA BROUGHTON

VICTORIAN MENTAL HEALTH NURSES STRIKE NEW AGREEMENT After almost a year of campaigning, Victoria’s public sector mental health nurses have given the green light to a new Enterprise Bargaining Agreement (EBA) that will significantly improve wages, implement ratios in high dependency units, and deliver an occupational violence and aggression action plan. The four-year agreement, Victorian Public Mental Health Services Enterprise Agreement 2016-2020, was unanimously endorsed last September during a statewide meeting of mental health members. The approval marked the end of rolling industrial action that began last June. A formal vote canvassing the views of all Victorian mental health service employees concluded last month, with 99.2% voting in favour of the EBA. The agreement heralds a 3% pay increase in 2017 and a 3.25% pay increase in 2018. Depending on classification, public sector 4 March 2017 Volume 24, No. 8

mental health nurses will receive a wage increase between 4 and 26.72% in 2019, bringing them into line with pay rates received by NSW nurses and midwives. Nurses will begin receiving their new pay rates once the EBA comes into effect, plus a 1.5% total remuneration good faith payment and back pay from last October. Another key development within the agreement includes an historic 125.8 additional mental health nurse EFT allocation, to directly assist with workload problems in bed-based services, as well as 17.8 EFT for Forensicare, which runs Thomas Embling Hospital, to provide clinical support and assist with early intervention and deescalation measures. Across other areas, the agreement features improved fatigue management methods, including additional breaks for staff working double shifts, a process for reviewing the discipline mix within community services to assess nursing levels, and 20 days paid family violence leave. The agreement resolution now ends a spirited campaign run by the Australian Nursing and Midwifery Federation (Victorian Branch) that involved tense industrial action where nurses spoke out in the media, placed bans on working overtime, and refused to be deployed to other areas. ANMF (Victorian Branch) Assistant Secretary Pip Carew said the agreement would help make mental health services safer places to work. “After 125 days of protected industrial action the new mental health nurses agreement achieved historic staffing and pay increases.”

“This is likely to be due to increases in Hepatitis B and C infection and risk factors such as high body mass and excess alcohol consumption,” Cancer Council CEO and President of the International Union for Cancer Control Professor Sanchia Aranda said. “Governments and health services everywhere need to do more to help improve the management of people who may be at increased risk of liver cancer.” While cancer continued to be the biggest cause of disease burden in Australia, there were low participation rates in the three lifesaving cancer screening programs – for bowel, breast and cervical cancer. Bowel cancer screening had the highest lost opportunity to drive cancer death rates down with less than 40% uptake to the free program. If bowel cancer screening participation increased to 60% by 2020, 83,700 premature deaths could be prevented over the next two decades, Professor Aranda said. Lung cancer continued to be the biggest cancer killer. The report found some of the most common cancers were also the most preventable. “Among the most common cancer types are breast, bowel, melanoma and lung cancer reinforcing the continued important of healthy lifestyle habits including quitting smoking, maintaining a healthy weight and diet, reducing alcohol intake, being physically active, being SunSmart and getting checked,” Professor Aranda said.

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NEWS

GREG HUNT AT PETER MACCALLUM CANCER CENTRE, VICTORIA

WARY WELCOME FOR NEW HEALTH MINISTER New Federal Health Minister Greg Hunt has been put on notice by the ANMF and other health organisations to stop the blistering attacks on Medicare and restore the billions of dollars axed from the public health purse. Minister Hunt outlined his health agenda last month which included “rock-solid commitment” to support Medicare and universal healthcare and for the public and private health systems. Priority areas the new Minister outlined included mental health, preventive health and support for Indigenous health and medical research. ANMF Assistant Federal Secretary Annie Butler said the union and its members were hopeful that Minister Hunt would work with frontline nurses and midwives, unlike his predecessor. “Minister Hunt must enter this crucial portfolio by working with the ANMF, other healthcare stakeholders and economists in finding solutions to the mounting challenges the nation faces in the health sector.” anmf.org.au

Consumers Health Forum of Australia CEO Leanne Wells said balancing the fiscal challenges were not easy but urged the minister to recognise the value of Medicare. “It is time for the government to move away from the current budgetary requirement for all new health expenditures to be offset by savings in the health portfolio.”

“MR HUNT MUST ENTER THIS CRUCIAL PORTFOLIO BY WORKING WITH THE ANMF, OTHER HEALTHCARE STAKEHOLDERS AND ECONOMISTS IN FINDING SOLUTIONS TO THE MOUNTING CHALLENGES THE NATION FACES IN THE HEALTH SECTOR.” Previous policy decisions designed to streamline the system and save money such as the freeze on Medicare rebates had resulted in significant out-of-pocket costs and patients delaying seeking medical care, Australian Healthcare and Hospitals Association Chief Executive Alison Verhoeven said. “Delays in seeking care can lead to higher costs later on for the health system if that patient presents later in a worse state of health through lack of medical attention. Mr Hunt must consider these issues as the 2017-18 Budget is formulated.” The AMA immediately called on the Health Minister to scrap the government’s freeze on

Medicare patient rebates. The best way of ensuring fair and equal access to quality health and aged care was to create efficiencies within the health system not to outsource care services to private, for profit providers, as part of a US-style privatisation, ANMF’s Ms Butler said. National Rural Health Alliance CEO David Butt said as the Member for Flinders, Minister Hunt would bring an understanding of the current issues of his own rural electorate to the health portfolio. “People living in rural and remote Australia need people who understand the issues they face on a daily basis to lead the development of health and aged care policy.” Health bodies also congratulated Ken Wyatt on his appointment to Minister for Aged Care and Minister for Indigenous Health. National Aboriginal Community Controlled Health Organisation (NACCHO) Chair Matthew Cooke said Minister Wyatt was highly regarded and respected in the Aboriginal community and health sectors across Australia. “Minister Wyatt has many years of experience working in both Indigenous health and education, which is invaluable at a ministerial level and the understanding needed to make progress towards Close the Gap targets.” Ms Butler urged Minister Wyatt to establish a long-awaited workforce strategy for the aged care sector. March 2017 Volume 24, No. 8 5

NEWS patients and staff over the coming months to evaluate whether it has helped trigger less Code Black incidences. SA Health Minister Jack Snelling said the government maintained a zero tolerance for the minority of people who feel it is okay to assault health professionals merely trying to do their jobs and care for people in need. “There is absolutely no excuse for violence, threats or any form of aggressive behaviour toward our doctors and nurses, whether in an ED, an ambulance or on a ward,” he said.

SOCIAL MEDIA CAMPAIGN TACKLES VIOLENCE AGAINST NURSES IN SA HOSPITALS The South Australian state government has launched a confronting social media campaign depicting an abusive hospital patient threatening staff in a bid to highlight the prevalence of occupational violence faced by frontline nurses and doctors working across emergency departments (ED). Unveiled last month, the 30-second video, captured through security camera lenses,

portrays an irate man abusing staff after being told he must wait to be seen for his non-urgent medical complaint. The video concludes with the catchphrase: “Waiting is not an emergency – Let us treat the people who need it most, first”. Latest figures reveal there has been a total of 6,245 Code Blacks (calls for security) made so far in 2016-17, an alarming 1,480 more calls than the same time last year. The new campaign aims to replicate the 2015 success of the SA government’s ‘Keep Your Hands off Our Ambos!’ social media blitz, which resulted in a 13% reduction in violence against the state’s paramedics. The ED campaign overlaps with a trial program currently underway at the Lyell McEwin Hospital, where the installation of real-time information boards is spelling out the number of critical care patients being attended to by ED staff and the expected waiting time for less serious cases. The ED trial will be tested and reviewed by

The Australian Nursing and Midwifery Federation (SA Branch) has continued to highlight longstanding issues related to occupational violence faced by nurses. The union has repeatedly lobbied the state government and Health Department to take action in improving the system and addressing enduring issues such as overcrowding. In March last year, the Australian Nursing and Midwifery Federation (SA Branch) handed an ultimatum to the Health Department indicating potentially violent patients would be turned away until they were well behaved. It also called for a detox area for drunk and drug affected patients and greater prosecution rates when a serious assault occurs. Andrew McGill, Nursing Director Critical Care Emergency at the Northern Adelaide Local Health Network, claimed violence was common and scary to deal with. “Sometimes there may be a medical reason why someone is aggressive or violent but often it’s just that people think they should be seen immediately, often not realising there are patients who are a higher priority.”

QUEENSLAND UNI PUSH TO DELIVER MORE MIDWIVES The north Queensland hubs of Cairns and Noosa have been chosen to deliver a new midwifery degree aimed to help alleviate Queensland’s shortage of midwives. The Cairns and Noosa campuses of Central Queensland University will be key residential school delivery sites for its new Bachelor of Midwifery (Graduate Entry). Midwifery Discipline Leader Tanya Capper said the new course designed as an educational pathway for registered nurses now provided residential schools at both ends of the state. “Our residential schools in Cairns and Noosa are vital to our new midwifery students coming through to help fill future vacancies.”

6 March 2017 Volume 24, No. 8

CQUNI MIDWIFERY RESIDENTIAL SCHOOL AT CAIRNS CAMPUS WITH L-R RENEE NEILSON (STUDENT), TANYA CAPPER (ACTING HEAD OF MIDWIFERY), ANNA MUELLER (STUDENT), JOANNA SMITH (STUDENT), BRIDGET FERGUSON (MIDWIFERY LECTURER)

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NEWS

AIMS TO TACKLE INDIGENOUS DISADVANTAGE MISFIRE Just one of the seven Closing the Gap targets is on track to be met almost a decade after the federal government’s commitment to addressing Indigenous disadvantage was set in motion. The ninth Closing the Gap report card, unveiled by Prime Minister Malcolm Turnbull last month, arguably paints the bleakest snapshot yet of the widening disparity between Indigenous and non-Indigenous Australians when it comes to critical areas like health, life expectancy, and employment. Other than modest gains in education, the report revealed the bulk of goals are failing to achieve meaningful progress. The target to close the gap in life expectancy by 2031 is not on track, with a 10-year discrepancy remaining. While Indigenous smoking rates have

improved, particularly among those aged 15 and over, the number of deaths caused by cancer continues to rise and the gap is growing. The target to halve infant mortality rates by 2018 is another falling short. However, Indigenous child mortality rates have declined by 33% since 1998 and the government believes greater access to antenatal care and reducing the rates of smoking during pregnancy hold the potential to make the necessary inroads. Disappointingly, the target to halve the gap in employment by 2018 has also stalled. In 2014-15, the Indigenous employment rate was 48.4%, compared with 72.6% for non-Indigenous Australians. Prime Minister Turnbull said the government could not shy away from the stark reality that sufficient national progress had not been made on the Closing the Gap targets. He added that the targets set by the Council of Australian Governments (COAG) now required greater urgency, pledging to work together with Indigenous leaders and their communities in order to create local solutions that improve the lives of Aboriginal and Torres Strait Islander people. Reflecting on the report, National Aboriginal and Community Controlled Health Organisation (NACCHO) CEO Pat

Turner said governments across all levels needed to make a long-term investment in addressing the social and cultural determinants of health. She suggested the current 140 Aboriginal medical services that operate around the country should be doubled to improve health outcomes. “The acceptance that our Aboriginal controlled health services deliver the best model of integrated primary healthcare in Australia is a clear demonstration that every Aboriginal and Torres Strait Islander person should have ready access to these services, no matter where they live.” The latest Closing the Gap report card coincided with Aboriginal leaders seeking a new relationship with government through the historic Redfern Statement. Australia’s peak Aboriginal and Torres Strait Islander leaders delivered the document directly to Parliament House, calling for support in developing a road map to better address the appalling disadvantage between Australia’s first Peoples and non-Indigenous Australians. The Redfern Statement, backed by more than 30 organisations including the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM), demands long-overdue action in the areas of health, justice, children and families, disability, and family violence prevention.

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NEWS

HAVE YOUR SAY ON WOMEN’S HEALTH National not-for-profit organisation Jean Hailes for Women’s Health has launched its annual survey investigating the wide range of health issues affecting women such as body image, mental health, and diet and lifestyle. Now in its third year, the survey remains the only national survey focussing on women’s health behaviour and information needs and has received significant uptake from thousands of Australian women across different demographics in recent years. This year’s responses will be collated anonymously and statistically analysed. Each response is essential in order to shine the light on health information needs

REMOTE HEALTH WORKFORCE ONGOING SAFETY AND SECURITY RISKS Workplace bullying, violent assaults and widespread safety and security flaws underline a damning report into the rising challenges facing remote health workers. The report, sparked by the tragic murder of Remote Area Nurse Gayle Woodford a year ago, was undertaken by remote health professional body CRANAplus. The report, which investigated safety and security, backs a three-pronged approach to overcoming problematic issues. These include reducing the risk of assaults, boosting workplace safety knowledge, and eliminating bullying by promoting supportive environments. After conducting a survey of 90 practicing RANs, the report found 48% had experienced or directly observed abuse, violence, or bullying, that threatened the wellbeing of staff and compromised their ability to continue working.

8 March 2017 Volume 24, No. 8

and will help develop material for health professionals, government, and women, in the form of free resources covering a wide range of important issues.

understanding of complex health issues.

The content will also form the backbone of the Jean Hailes’ annual Women’s Health Week, held in September.

All responses are anonymous and participants can also opt to have the survey results sent to them later in the year.

Jean Hailes for Women’s Health, which encompasses medical centres, education initiatives, and delivering access to trusted information, is an organisation committed to improving women’s knowledge and

Survey respondents can also enter a draw to win two free 6-month memberships to Fernwood Fitness, with a winner to be announced from each state and territory, totalling eight membership packages all up.

Horizontal violence, perpetrated by clinicians against peers usually working in the same clinic, was the type of bullying most reported. Around 30% of respondents said their workplace did not have policies in place to ensure nurses don’t attend call-outs alone. Similarly, a quarter of the surveyed health workers felt accommodation was unsafe and not secure, with 10% revealing they had been broken into during the past year.

HORIZONTAL VIOLENCE, PERPETRATED BY CLINICIANS AGAINST PEERS USUALLY WORKING IN THE SAME CLINIC, WAS THE TYPE OF BULLYING MOST REPORTED. Some 85% of respondents felt their health service vehicle was reliable and adequately serviced, while 7% said the vehicle had GPS tracking equipment fitted, though many reported Satellite phones to be either unavailable or unreliable. Many remote workforce members were scathing of the lack of staff training for bush driving, indicating that basic 4WD courses did not adequately prepare someone for driving long distances on dirt roads in hazardous weather conditions. Alarmingly, the report found some managers did not understand their legal responsibility to ensure the safety and security of staff and that some clinicians themselves were

Women can access the 10-minute survey by visiting bit.ly/jeanhailessurvey

undermining safety. “Many clinicians identified that they felt bullied into not implementing safety guidelines by staff who did not agree that risk exists, or who allegedly preferred to work alone so their poor clinical practice was not observed by others,” the report said. CRANAplus’ latest report forms part of its wider 12-month Safety and Security project, funded by the Commonwealth Department of Health. A literature review and industry consultation was also undertaken as part of the new report, which suggested severe assaults were more likely to evolve from criminal events rather than actual workplace violence. It also found violence was just one of many risk factors facing RANs. “Other issues warranting research and intervention include: vehicle and travel safety, dog attack, bullying and harassment, and personal health and wellbeing,” the report stated. CRANAplus Chair Paul Stephenson said the report offered a sobering depiction of the sector’s woes. “Information in the report is at times confronting, however, it provides a valuable description of the conditions under which many of the remote health workforce practice. Working remote differs from many other areas of healthcare, requiring enhanced self-reliance, skills, and professional capability.” anmf.org.au

NEWS In a similar vein, Professor Bin-Sallik said her award was a reflection of years of hard work.

NURSES TAKE OUT AUSTRALIA DAY HONOURS

“It’s absolutely a great honour to be acknowledged for your lifetime of work and especially because I was acknowledged for the things that I was always so passionate about.” Professor Bin-Sallik grew up in the 1950s when Aboriginal girls were expected to simply be domestic. She shunted convention and overcame a challenging era to become the first Indigenous nurse to train in Darwin.

The first Indigenous nurse trained in Darwin and a remote area nurse who doubles as an international humanitarian were among the esteemed list of people recognised at this year’s Australia Day awards.

“It was [hard] but I was 17 and bright eyed and bushy tailed and determined to be a nurse. I was determined to see it through. So I sort of weathered all the racism.”

Pioneering Northern Territory nurse MaryAnn Bin-Sallik was awarded the prestigious Officer of the Order of Australia for her service as an academic and lifetime spent elevating Indigenous studies and culture into the mainstream agenda. NSW based Remote Area Nurse Elizabeth Bowell, who for the past decade has also worked as a Red Cross aid worker responding to disasters and conflicts overseas, was awarded an Order of Australia medal for her service to nursing and international natural disaster healthcare assistance. For Ms Bowell, the award adds to the Florence Nightingale Medal she received in 2015 for her work fighting the outbreak of the devastating Ebola disease in Liberia. Ms Bowell is currently working as a RAN in the Northern Territory Indigenous community of Wadeye, a setting she has come back to on and off since the late 90s. Ms Bowell also worked for CRANAplus up until last year as its Director of Education, but called it quits to focus on remote area nursing

SA TO OUTSOURCE NDIS SERVICES TO PRIVATE SECTOR

Professor Bin-Sallik worked as a nurse for 17 years in various places across the Top End, from Indigenous communities to cattle stations before she turned her mind to education and became an academic. REMOTE AREA NURSE AND RED CROSS AID WORKER ELIZABETH BOWELL

and her international deployments with the Red Cross.“It’s the work. It’s not so much the adventure. I really like the work. Whether it’s remote Australia or international emergencies or epidemics the needs are there. The vulnerability of people and the way they live just means that there’s huge needs there.” Ms Bowell said she was “hugely proud” of the award but felt Ebola often gains undue exposure. “It’s a bit of shame that people just grab onto Ebola. It was big. It was enormous for all of us globally but it was one mission. I think it gets the focus because it drew so much attention but really it’s my contribution to remote and international.”

She counts becoming the first Indigenous Australian to earn a doctorate from Harvard University in 1989 as her greatest achievement. Professor Bin-Sallik remains a strong supporter of the nursing profession and said she feels immense pride at the fact that Indigenous people have come such a long way. “My sense of pride comes from the fact that we now have Indigenous lecturers, Deans, Pro Vice Chancellors, in universities across the country and also that in 2015 the national graduation rate for Indigenous graduates surpassed 2,000 for the first time.”

provided by the government are to be transferred to the private sector.

affected by the changes, along with about 700 staff.

South Australian Minister for Ageing Zoe Bettison made public assurances last month current staff would not lose jobs.

Mr Bonner said most of the union’s members employed at the Highgate Centre were not affected by these changes. Nurses at the centre provided high level healthcare including end of life care, and care of tracheostomies and PEGs. “These are people with profound disability requiring high level care – will they be in the healthcare system or as part of the NDIS? These are questions we are working through at the moment.

However ANMF SA Branch Director Operations and Strategy Rob Bonner said undercutting of the private sector to deliver the services would have an impact.

Some disability and aged care services are to be outsourced to the private sector in South Australia which unions fear will jeopardise quality of care.

“In many jurisdictions including ours, government services are no longer competitive and there is undercutting by the private sector to deliver these services. We are having conversations with government on how quality of care will be delivered in the future.”

The services which fall under the National Disability Insurance Scheme and currently

About 380 staff and 6,000 clients in the domiciliary care area are expected to be

anmf.org.au

During her lengthy academic career Professor Bin-Sallik became a role model and mentor though her work championing Indigenous studies and culture.

“What is disappointing I think is that we have now got NSW, ACT, and SA whose governments have decided to get out of delivery of what is a really important part of our social support system. We have a national disability program with dismembering of public sector delivery.”

March 2017 Volume 24, No. 8 9

Four Steps to Building Dementia Practice in Primary Care

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Modules • Step 1: Building dementia knowledge • Step 2: Building a process towards dementia diagnosis • Step 3: Building an approach to dementia support • Step 4: Building sustainable dementia practice www.apna.asn.au/onlinelearning admin@apna.asn.au | 1300 303 184 The Supporting GPs and Practice Nurses in the Timely Diagnosis of Dementia Project is funded by the Australian Government. It is delivered by a partnership between Alzheimer’s Australia, the Australian Primary Health Care Nurses Association, Alzheimer’s Australia Victoria, Dementia Training Study Centres, and the Australian Primary Health Care Research Institute.

How to access the education?

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It’s easy! Follow the simple steps below and if you get stuck APNA is just a phone call or email away. 1. Open up Google Chrome as your web browser (please note – Internet Explorer is not compatible for these online modules) 2. Head to www.apna.asn.au/onlinelearning 3. Under ‘Courses Available Online’ click ‘View Courses’

Existing APNA Users

New APNA Users

4. Under ‘Existing APNA Users’ click ‘Login Now’ 5. Enter in your username and password (call APNA if you have forgotten these details) 6. On the left hand side of the page click on ‘Clinical Education’ and scroll down the page until you find all four Building Dementia Practice in Primary Care module 7. Click ‘Buy’ on all four modules 8. Once all four modules are in your Shopping Cart (at the top of your page) click on ‘Proceed to Checkout’ 9. The transaction should be complete and you can access the education by clicking on ‘My Training’ at the top of the page

4. Under ‘New Users’ click ‘Start Shopping’ 5. On the left hand side of the page click on ‘Clinical Education’ 6. Scroll down the page until you find all four Building Dementia Practice in Primary Care modules 7. Click ‘Buy’ on all four modules 8. Once all four modules are in your Shopping Cart (at the top of your page) click on ‘Proceed to Checkout’ 9. You will then be asked to register your account, please complete the fields required and then click on ‘Next Step’ 10. The transaction should be complete after this step and you can access the education by clicking on ‘My Training’ at the top of the page

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NEWS

TRAILBLAZING UNION LEADER HONOURED

FUNDING FOR THUNDERSTORM ASTHMA RESEARCH

Marilyn Beaumont believes in the adage many hands make light work. The former Federal Secretary of the Australian Nursing Federation, now ANMF, was quick to commend the support of countless people throughout her career upon being awarded an Order of Australia Medal in this year’s Australia Day Honours list for her service to the community, particularly women’s health, and wider impact as a nurse and activist. “I think I’m just one of those people that just gets on with my work. It just felt extraordinary. Then of course as I told people, as I told my brother and my sisters and they all burst into tears, then all of the reflection of just so many people along the way and campaigns and achievements,” she said.

“I DO THINK THAT WE COULD DO MORE TO BRING NURSES’ VOICES OUT. I’VE BEEN ON HEALTH BOARDS FOR MANY YEARS NOW AND I THINK WE SHOULD BE MAKING SURE THAT NURSES GET THEMSELVES INTO GOVERNANCE TRAINING AND UNDERSTAND THE ROLE OF CLINICAL EXPERIENCE IN A GOVERNANCE SENSE AND HOW THAT CAN BE INFLUENTIAL.” Born in Canberra, Ms Beaumont rose from humble beginnings, leaving school at 15 to work in a department store, before venturing to Sydney to train as a nurse just before turning 17. “I came from a family that did not think about further education for girls and could not afford it anyway. We didn’t even think about continuing on from school once we reached the age when we could leave. It was either nursing or teaching.” Ms Beaumont trained at the now defunct Prince Henry Hospital before progressing to psychiatric nursing in country NSW, then working in various places and fields across Australia. After moving to South Australia in 1980 Ms Beaumont, a staunch union supporter, became increasingly involved with the nursing federation before taking up a role as a Branch Organiser. She went on to became the State Secretary from 1982-1987 and then Federal Secretary of the Australian Nursing Federation, a position she held from 1987-1995. anmf.org.au

MARILYN BEAUMONT

As a union leader, she oversaw a period of significant change as nursing education transferred into the tertiary sector. She was pivotal in lifting the professional standing of nurses, building state and national delegates’ conferences, and unifying state bodies. Reflecting on her achievements, Ms Beaumont counts integrating New South Wales and Queensland nurses into the national union as possibly her greatest legacy.

The Victorian government has committed to fund new research on pollen monitoring and thunderstorm asthma. The announcement last month coincided with the release of the Victorian Inspector-General’s preliminary report into the unprecedented thunderstorm asthma event which resulted in nine deaths last November.

In other areas of her working life, highlighting the importance of women’s health has been a constant.

The report found that never before had Victoria experienced a rapidonset event on such a scale. Nor had its ambulance services and hospitals experienced such demand in a condensed period of time and across a large geographical area.

Ms Beaumont is the current National Board Chair of the Australian Women’s Health Network. “I think there’s a better understanding that women’s health is impacted by different things than men and there is a difference between men and women’s health and how they experience wellbeing. Early on in my life there was no understanding of that.”

“Based on the evidence analysed to date…hospitals acted swiftly,” Victoria’s Inspector-General for Emergency Management Tony Pearce said. “I commend the work of all involved in the emergency response in responding quickly, flexibly and professionally to the unforeseen circumstances.”

One of Ms Beaumont’s most significant causes emerged in coordinating a five-year campaign that led to the removal of abortion from the Victorian Crimes Act in 2009.

However Mr Pearce found limited communication and information sharing meant agencies did not have a proper understanding of the situation.

“When I worked in NSW women would come from Queensland because access to termination was so difficult. I found that very perverse to think about what these women were going through,” she recalled.

“An early observation is that thunderstorm asthma is not well understood. Similarly, nor are the factors that enable thunderstorm asthma to be predicted.”

Ms Beaumont said the long, hard-fought campaign, was driven by wanting to implement a more forward-thinking agenda that removed the silence and shame surrounding abortion.

The Victorian government announced $1 million: $700,000 to support research into the underlying causes of thunderstorm asthma and how to forecast such events; and $300,000 to expand the state’s current pollen monitoring network.

Ms Beaumont, who lives in Denver in country Victoria, is enjoying taking it easier in retirement but still keeps up with the evolution of the professions. “I feel immensely proud of the position that the nurses federation is in today. I feel extraordinary pride. “I do think that we could do more to bring nurses’ voices out. I’ve been on health boards for many years now and I think we should be making sure that nurses get themselves into governance training and understand the role of clinical experience in a governance sense and how that can be influential.”

The Inspector-General is due to provide a final report to the Victorian government in April with recommendations on preparedness and responses to future, rapid onset, time critical health emergencies.

March 2017 Volume 24, No. 8 11

NEWS

GAYLE WOODFORD MEMORIAL SCHOLARSHIP WINNER ANNOUNCED Remote Area Nurse Vesna Balaban has been named the inaugural recipient of the Gayle Woodford Memorial Scholarship, a joint initiative of remote health professional body CRANAplus and the Centre for Remote Health. Officially launched at last year’s CRANAplus conference in Hobart, the scholarship will cover all course fees for the annual recipient to undertake the Graduate Certificate of Remote Health Practice offered through Flinders University and the Centre for Remote Health. Ms Woodford, tragically murdered in South Australia in early 2016, was a committed RAN who obtained the Graduate Certificate of Remote Health Practice as part of her studies. The scholarship is open to registered nurses, Indigenous health practitioners, allied health practitioners, and medical officers. Inaugural recipient Vesna Balaban, a RAN at the Health Centre in Yirrkala,

OUM’s innovative teaching style is fantastic and exciting. Truly foreword thinking, OUM allows the student to benefit from both local and international resources. Brandy Wehinger, RN OUM Class of 2015

REMOTE AREA NURSE VESNA BALABAN

East Arnhem, for the past two years, commenced the course last month.

Northern Territory to work as a Remote Area Nurse.

Ms Balaban was born in Serbia and trained as a nurse in 1985 before relocating to New Zealand, where she worked as an EN at a nursing home in Wellington, while studying to become an RN.

In 2014, she committed to the venture by completing several courses offered by CRANAplus for RANs and immersing herself in Indigenous culture.

In 2001 she moved to Australia and began working at the Alfred Hospital in Melbourne in the perioperative ward, before working among a variety of settings across Australia over the last decade. Keen for a career change, Ms Balaban’s life changed when she met her partner, an Indigenous man from Darwin, and for the first time considered moving to the

Ms Balaban and her partner soon moved to Nhulunbuy in the Northern Territory, where she is currently employed as an RN in Yirrkala, for Miwatj Health. Her duties include providing primary healthcare, including emergency care, managing chronic conditions, and promoting and delivering health education in a bid to increase the life expectancy of Yolngu clients.

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NEWS

LOCAL EXPOSURE TO ATTRACT GRADUATES TO REMOTE AREAS Local exposure may help attract graduates to remote areas but more needs to be done to encourage them to stay, according to a WA study released last month. The University of Notre Dame study found local exposure one of the most influential factors on whether a graduate nurse chose to work in a remote Kimberley hospital.

However one of the biggest challenges was the notion that graduates would have to leave the Kimberley on completion of a graduate program either to gain more experience or due to limited employment after graduation, Dr Clark said. “Nurses working in the system were trying to put their own personal views across of students going to Perth to gain extra experience and then to come back; and that graduate programs in the city are more valuable than in the country – this was a point of view which is not necessarily accurate. The value of the experience gained in the city can be overrated.” Ms Clark said often graduate nurses who moved to Perth then found it difficult for several reasons to return.

Local exposure underpinned both personal and professional factors on the decision to work in remote WA.

STRATEGIES TO ENCOURAGE NURSES TO WORK IN THE REGION WERE CRUCIAL TO THE HEALTH OF THE LOCAL POPULATION, THE STUDY RECOMMENDED.

At the time of the study, 170 nursing students had graduated from the University of Notre Dame, Broome with 30% having entered the nursing workforce in hospitals within the Kimberley. The role of the Notre Dame University campus in Broome cannot be underestimated, according to lead researcher and Deputy Head of Campus, Broome and Associate Dean of Nursing Sally Clark. “It offered a unique experience in remote health and remote nursing. Graduates as students were immersed in the culture and climate of the Kimberley, which included lifestyle and exposure to the community within the context of remote area living.” The friendly nature and support of the people was also a significant factor in retaining graduates to the Kimberley.

Another challenge was employment after an initial post-graduate year. More needed to be done to both encourage graduates to stay and upskill at the same time, Ms Clark said. “Nurses were told they probably wouldn’t be employed after their initial postgraduate year, that they were too junior. There weren’t enough positions in A&E, or theatre for graduate nurses. We need to look at how to provide that clinical bedside education that enables nurses to be able

to work in those areas rather than just the theoretical.” Strategies to encourage nurses to work in the region were crucial to the health of the local population, the study recommended. “Recruitment from outside the area provides short-term relief, but providing nursing education within this remote region may well provide a more self-sufficient, sustainable workforce.” Other study recommendations included a “rural pipeline” opportunity for nurses with a focus on transition from new to career status professional; continuing professional development for nurses in remote areas; and develop graduate programs for ENs in remote hospitals to support them while converting to a RN qualification.

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Salary: $140,626 - $179,856 per annum plus Dean’s Allowance (Plus 12% Superannuation and 17.5% Leave Loading)

The University of Notre Dame Australia is a private Catholic university with campuses in Fremantle, Broome and Sydney. The Objects of the University are the provision of university education within a context of Catholic faith and values and the provision of an excellent standard of teaching, scholarship and research, training for the professions and the pastoral care of its students.

An exciting opportunity exists for an outstanding academic to fill the role of Dean, School of Nursing on the Sydney Campus. Reporting to the Senior Deputy Vice Chancellor & Head of the Sydney Campus, the Dean is responsible for inspiring and leading staff and students to develop, deliver and promote the School’s objectives in teaching and learning, research, scholarship, and student and community engagement. The Dean will take an active role in the recruitment of a high quality student body and provide support and development to staff. This role provides leadership in the disciplines of Nursing within the School and is a significant leadership position in communicating the Catholic Intellectual Tradition throughout the Campus. The successful candidate will have strong experience in teaching, researching and communicating key aspects of the Catholic tradition and will have qualifications and significant experience in Nursing. To be considered for this role, applications should address the selection criteria as listed in the position job pack. The application pack for this position is available at:

www.nd.edu.au/jobs/sydneyjobs or email sydney.staffing@nd.edu.au or phone (02) 8204 4424.

Applications close 13th March 2017 or when appointment is made. The University reserves the right to appoint by invitation or to make no appointment at all.

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WORLD

CANADA

Medical assistance in dying framework The Canadian Nurses Association (CNA) has released its national framework on medical assistance in dying (MAID) which outlines a set of guidelines for nurses when caring for patients considering endof-life decisions. The framework responds to changes to the Criminal Code and other federal laws made in June, 2016, under new legislation, which permits medical assistance in dying under certain circumstances. Following the passing of legislation last year, the CNA created a national taskforce to develop a guide for nurses and nurse practitioners (NPs) when discussing end-oflife with patients. The framework covers diverse ethical nursing values and responsibilities including providing safe and compassionate care, promoting informed decision making, preserving dignity, and maintaining privacy and confidentiality. The framework also addresses the right to conscientious objection by nurses participating in medically assisted dying. The framework offers nurses key considerations for pursuing a medically assisted dying pathway including determining eligibility, ensuring safeguards are met, and reporting accurate information. “The federal MAID legislation shows a clear understanding and recognition of nurses’ roles as part of the interdisciplinary healthcare team,” CNA president Barb Shellian said. “This thoughtful and comprehensive framework will be a useful tool for nurses, employers and patients as it clearly outlines the ethical expectations, responsibilities and limitations surrounding complex and sensitive end-of-life discussions with patients.”

14 March 2017 Volume 24, No. 8

UNITED KINGDOM

Nurses lobby to lift pay cap Nurses from across the United Kingdom are ramping up their lobbying efforts in a bid to lift a pay cap on their wages which has been in place since 2010, and is reportedly crippling the sector. Royal College of Nursing members from across the UK met with MPs at the beginning of the year to highlight the longstanding stalemate in pay. The debate was triggered after an online petition created by an RCN member netted 100,000 signatures and follows on from the RCN urging the National Health Service Pay Review Body (PRB), which advises the government on NHS staff pay, to recommend a meaningful pay rise for nurses moving forward. Positively, ongoing lobbying efforts triggered a Parliamentary debate in late January where several MPs discussed how pay restraint was crippling nursing staff and eroding goodwill. A number of MPs expressed strong views in support of nurses deserving a decent pay increase. Responding on behalf of the government, Health Minister Phillip Dunne acknowledged the concerns raised regarding the hike in the cost of living, but added that it was a complex issue which would need time to be resolved. The PRB was expected to submit its report to minsters by the end of last month.

IRELAND

Staffing, recruitment and retention crisis continues The Irish Nurses and Midwives Organisation (INMO) remains locked in talks to secure meaningful strategies to address staffing, recruitment, and retention problems plaguing the country’s nursing and midwifery workforce.

A campaign to stimulate action kicked off in late January and led to intensive discussions at the Workplace Relations Commission (WRC) with a range of stakeholders including the Department of Health, Department of Public Expenditure and Reform, and the Health Service Executive (HSE). It also involved the Services Industrial Professional and Technical Union (SIPTU). Initial talks revealed health service management had no workforce plan to address ongoing unsafe staffing levels that are compromising patient care and negatively impacting upon the health and safety of nurses and midwives. Health management acknowledged the crisis but also confirmed that no resources were available to fix the situation. The INMO believes the lack of action is unacceptable and said the crisis in recruitment and retention would only deepen. While management has since pledged to attempt to produce a funded plan to address issues, they also stood firm on refusing to commit to restoring staffing to 2008 levels, despite official HSE figures revealing that at the end of 2016 there were 3,200 less nursing and midwifery posts compared to a decade earlier. A recent national ballot conducted by the INMO showed 90% of its members are prepared to take industrial action to resolve the stand-off. “The meeting was very disappointing and confirmed that health service management are either unable, or unwilling, to address this crisis on both a short and medium term basis,” INMO General Secretary Liam Doran said. Talks were scheduled to continue last month, with wider movement including a submission made by the INMO to the Public Service Pay Commission as part of its consideration of labour market challenges facing groups within the public service. The Pay Commission will make recommendations to government on how challenges, including pay and conditions, should be addressed. anmf.org.au

INDUSTRIAL

Nick Blake, Senior Federal Industrial Officer

EMPLOYER CAMPAIGN TO DEREGULATE WORKING HOURS Over the past five years the ANMF has been resisting a concerted campaign by aged care employers to remove important protections that give part time employees a level of predictability in their hours and days on which they are required to work. Presently part time nurses and carers covered by the Nurses Award are protected by a provision in the award that states: “Before commencing part-time employment, the employer and employee will agree in writing the guaranteed minimum number of hours to be worked and the rostering arrangements which will apply to those hours.” These provisions are also reflected in many enterprise agreements. This means that when a part time nurse or carer is first engaged they must be advised of their minimum number of hours per week and the days on which those hours are to be worked. Changes to these arrangements must be agreed and in writing.

THE REGULATION OF HOURS OF WORK HAS AN IMPORTANT AND LONG HISTORY IN AUSTRALIA AS PART OF THE DEVELOPMENT OF REASONABLE HOURS, FAIR PAY AS WELL AS THE PAYMENT OF LOADINGS, ALLOWANCES AND PENALTIES IN CIRCUMSTANCES WHERE AN EMPLOYEE IS REQUIRED TO WORK ON WEEKENDS OR AS A SHIFT WORKER.

And with the majority of workers in the aged care sectors employed on a part time or casual basis some certainty or predictability in the number of hours and the days required to attend work is very important. In some ways these protections recognise that often nurses and carers are attracted to part time work anmf.org.au

as this allows them to meet other professional, economic and social requirements , including having other part time employment in order to earn a reasonable wage. This was the view expressed by the Fair Work Commission in 2014 in response to one unsuccessful attempt by aged care employers to change part time arrangements. Here the tribunal observed, “This requirement for reasonable predictability in hours of work stems, we consider, from the originating concept of part-time employment as being suitable for and attractive to persons who have other significant and reasonably predictable family, employment and/or educational commitments and therefore require some certainty as to the days upon which they work and the times they start and finish work. It follows that the other provisions of the Award applying to part-time employees must so far as the language permits be read as giving content to the definitional requirement of reasonable predictability in hours of work.” For their part the aged care employers detest this requirement and argue that the rostering provisions in an award or enterprise agreement should be the only impediment, if any, to the employer’s right to change the employee’s number of hours or starting and finishing times. In February 2017 this view was expressed by Bupa Aged Care in a court proceeding where they argued, as paraphrased below; “Part time protections does not require Bupa to reach agreement with part time employees on their days of work or their starting and finishing times. Rather, subject to compliance

with roster provisions, rosters are to be determined by Bupa and can be determined without the agreement of the employee.” Given that roster arrangements normally only require seven days advanced notice of any change, the position of the aged care employers is clear. This being they want to unilaterally change the days of the week and starting and finishing times of part time nurses and carers with minimal notice and without regard to the impact on the employee. The regulation of hours of work has an important and long history in Australia as part of the development of reasonable hours, fair pay as well as the payment of loadings, allowances and penalties in circumstances where an employee is required to work on weekends or as a shift worker. Broadly speaking the regulations provide that a full time employee is one that works 38 hours or more per week. A part time employee works less than 38 hours per week and a casual is an employee who does not have regular or systematic hours of work or an expectation of continuing work. In Australia casual employees receive a 25% increase on their hourly wage rate in recognition of the irregular nature of their work and that they normally do not accrue sick, annual and other leave benefits. Should the aged care employers be successful in their campaign to effectively deregulate part time employment then part timers will simply be casuals without the 25% loading. In workplaces such as hospitals and aged care where there is such a high reliance on part time labour, this would be a disastrous outcome for both part time employees and casuals. March 2017 Volume 24, No. 8 15

RESEARCH

MOLECULE COULD SLOW PARKINSON’S PROGRESSION A naturally occurring molecule in the brain, when used as a therapy, could hold the key to slowing the progression of Parkinson’s disease, research has found. Laboratory trials have shown the potent anti-inflammatory effects of the molecule activin A offers protection against the loss of dopamine neurons, the brain cells that are destroyed through Parkinson’s disease. Conducted by the University of Technology Sydney, lead researcher Bryce Vissel, Professor of Neuroscience, said the findings formed an important step to understanding why the death of certain nerve cells develops in Parkinson’s and importantly how the occurrence could be prevented. He said the underlying causes of Parkinson’s remained largely unknown but that the latest research found exciting beneficial effects. “This study shows that activin A can slow loss of dopamine nerve cells, providing a possible approach to slowing the disease. An exciting aspect of our previous research is that we’ve shown the activin A molecule has the potential to trigger regeneration in the nervous

system. It raises the question as to whether this could lead to a treatment that could also repair the damaged brain areas in Parkinson’s disease.”

Australians who work more than 39 hours per week are putting their mental and physical health at risk, new research has revealed.

About one in 350 Australians, mostly over the age of 60, suffer from Parkinson’s disease, a chronic and incurable neurodegenerative condition typified by a range of symptoms including tremor, muscle rigidity, and gait disturbance.

A study by the Australian National University (ANU) found the work limit for a healthy life should be set at 39 hours per week instead of the 48 hour week limit set internationally 80 years ago.

Dr Sandy Stayte, who co-led the research, said identifying the disease earlier would help with delivering a therapeutic strategy to halt the cell-death process.

The research, part of the Household, Income and Labour Dynamics in Australia (HILDA) Survey, used data from about 8,000 adults.

“Often sufferers have lost 70% or more of their dopamine neurons and have serious movement problems by the time they’re diagnosed,” Dr Stayte said.

Lead researcher, ANU Research School of Population Health’s Dr Huong Dinh, said about two in three Australians in fulltime employment worked more than 40 hours a week, with longer hours a greater problem for women who carry out more unpaid work at home.

“Our goal is to try to slow down or halt further degeneration in the brain by protecting surviving neurons.”

INFANT LUNG FUNCTION A PREDICTOR OF ADULT ASTHMA Reduced lung function in infants is an accurate predictor of persistent asthma in young adults, a study by the University of Western Australia has found. The ground-breaking research assesed data from 253 subjects who were tested for lung function at 1, 6, and 12 months of age, and then later at the ages of 6, 11, 18, and 24.

Dr Louisa Owens, from the University of Western Australia’s School of Paediatrics and Child Health, said the research would provide important insights into the future diagnosis of the chronic disease, which makes breathing difficult.

A variety of factors influence reduced lung 16 March 2017 Volume 24, No. 8

“Long work hours erode a person’s mental and physical health because it leaves less time to eat well and look after themselves properly,” Dr Dinh said. Dr Dinh said the optimum healthy work limit for women, once other commitments were considered, was 34 hours per week, compared to 47 hours per week for men because they generally spend less time on care or domestic duties than women. “Despite the fact that women on average are as skilled as men, women on average have lower paid jobs and less autonomy than men, and they spend much more time on care and domestic work.

The research found infants in the lowest quartile of lung function were five times more likely to carry asthma into adulthood.

“While there have been studies involving children and asthma it’s the first time that we’ve looked at the lung function of infants who have only just been born,” Dr Owens said. “We also looked retrospectively and found that the 24-year-olds we tested who have persistent asthma symptoms had a defect in lung development or growth either in utero or very early in life that persisted as a reduction in lung function as they grew older.”

AUSTRALIANS IGNORING HEALTHY WORK LIMITS

“Given the extra demands placed on women, it’s impossible for women to work long hours often expected by employers unless they compromise their health.” function in infants: genetics and the mother’s blood pressure and lifestyle. The research also looked at why some 30% of children who suffer asthma seem to grow out of it by the time they reach adulthood. “We found that those whose asthma stopped after childhood had normal lung function as infants. However those with asthma that persisted into adulthood had low lung function as infants,” Dr Owens said.

Co-researcher Professor Lyndall Strazdins said Australians needed to strike a better balance between work and home life and do more to change attitudes such as supporting men to share the role of caring for children without penalty or prejudice.

anmf.org.au

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FEATURE

PACIFIC

POWER

NURSING PARTNERSHIPS ACROSS THE BLUE CONTINENT Since it was first formed 35 years ago, the South Pacific Nurses Forum has been working to improve cross-cultural understanding and regional cooperation in nursing. Despite overwhelming health challenges in the Pacific, nurses and midwives are banding together to strive for universal access to quality healthcare, writes Karen Keast.

FEATURE

ften referred to as the blue continent, the South Pacific is home to thousands of islands scattered from Papua New Guinea, Australia and New Zealand all the way to South America.

pre-eminent nursing leaders, including International Council of Nurses president Dr Judith Shamian, and representatives of the region’s National Nursing Associations (NNAs), including the Australian Nursing and Midwifery Federation (ANMF), which has been elected Secretariat of the SPNF.

It’s a region home to nations including New Caledonia, Vanuatu, the Solomon Islands, Nauru, Wallis and Futuna, Fiji, Tonga, Niue, Samoa, Tuvalu, Tokelau, the Cook Islands and Tahiti.

ANMF Assistant Federal Secretary Annie Butler says the forum provides a vital voice to nurses and midwives throughout the South Pacific, enabling nurses and midwives to work together to address the issues impacting the health of their local communities.

The South Pacific is as culturally and economically diverse as it is vast. Many nations in the Pacific have their own languages and cultures, developed over centuries, and face a wide range of challenges that affect the health of their communities. Despite their differences, South Pacific nurses and midwives share a common bond - a determination to improve the health outcomes of their nation’s peoples.

South Pacific Nurses Forum

Every two years, hundreds of nurses, midwives and health leaders from across the South Pacific gather to discuss and debate the issues at the heart of nursing and midwifery’s contribution to the region’s healthcare. The South Pacific Nurses Forum (SPNF) first began in 1982. Last year, the 18th forum was held from October 31 to November 4 in Honiara, in the Solomon Islands. More than 300 delegates attended from 10 Pacific nations, including Australia, the Cook Islands, Fiji, Kiribati, PNG, New Zealand, Samoa, Tonga, the Solomon Islands and Vanuatu. Featuring the theme Towards Nursing Excellence for Universal (Pacific) Health, the forum showcased presentations which brought together the latest evidence, experience and innovations in nursing throughout the South Pacific. But the SPNF is much more than a biennial conference event - it’s a collective of nursing and midwifery leaders working to advance the development of nurses and midwives, and the professions internationally. The forum promotes closer links between nurses and midwives throughout the South Pacific, forging friendships and partnerships between nurses and midwives in a bid to foster cooperation and activities - designed to problem solve, strengthen the professions, and improve public health services.

“We’re working to achieve better health and universal health for all of the communities in the South Pacific,” Ms Butler says.

— “WE NEED TO BE ABLE TO RESPOND TO, RETAIN AND RECRUIT INDIGENOUS NURSES INTO THE WORKFORCE.” — Kaiwhakahaere, New Zealand Nurses Organisation (NZNO), Kerri Nuku,

“It’s very difficult for these smaller island nations to be able to make the changes that they need but as a group we can collectively work for implementing change that will actually allow nurses and midwives to bring about the differences they need to, for the health of their communities.”

Health challenges

Many nations in the South Pacific face a barrage of health challenges, from nursing and midwifery workforce shortages to limited resources and often a double burden of communicable diseases and noncommunicable diseases (NCDs). They also face incredible geographical hurdles. Pacific nurses and midwives work to provide care to an estimated 10 million people spread over thousands of islands, many of which are hindered by unreliable access to internet and irregular transport links. The Solomon Islands alone features 900 islands and a fast growing population of more than 600,000 people. Eighty per cent of the population lives in rural and remote areas. To access a hospital, many residents must travel via boat but the distance between the islands often hampers timely access to care. More than 1000 kilometres away on the smallest state in the Pacific, the oval-shaped island of Nauru, 10,000 residents live in a 21 square kilometre area with one hospital. Once known for having one of the highest rates of obesity in the world, Nauru has been battling escalating rates of type 2 diabetes as a result of poor nutrition, alcohol consumption, smoking and physical inactivity.

As a conference, the SPNF is a colourful showcase of local culture, from cultural dress and prayers to ceremonial singing and dancing. It brings together a range of dignitaries, such as Solomons Prime Minister Manasseh Sogavare, who officially opened the 2016 forum.

Adding to the mounting health challenges, many South Pacific nations are suffering from the effects of poverty, fragile environments, water and sanitation problems. Climate change is also taking a toll. Pacific island countries are known to be among the most vulnerable in the world to climate change - and it’s feared some of these nations may completely disappear under water.

And it features some of the world’s

A 2015 report from the World Health

anmf.org.au

March 2017 Volume 24, No. 8 19

FEATURE Organization (WHO) revealed climate change is threatening the health of Pacific Islanders, as well as impacting on their economic and social development. Extreme weather events, such as cyclones, floods and droughts, are not only displacing communities but causing injuries and psychological trauma.

the world but, with the NCD program, every community has an NCDs nurse and they are absolutely making a difference to obesity, diabetes and cardiovascular disease and a lot of that really has been nurse-led,” she says. Professor White and Professor Mary Chiarella recently collaborated with Tonga Chief Nurse and immediate past Chair of the Alliance, Dr Amelia Afuha’amango Tuipulotu, to review the nation’s nursing and midwifery regulation.

‘Hotter and wetter climates are increasing the risks for vector-borne disease. Disasters related to climate change are disrupting the delivery of healthcare services and are increasing the risks of disease and death among vulnerable groups, especially young children, women of reproductive age, older people and people with disabilities,’ Dr Shin Young-soo, WHO Regional Director for the Western Pacific, writes in the Human health and climate change in Pacific island countries report. “Climate change is a defining challenge of our time and could prove to be the most significant human health threat of the 21st century. For future generations in high-risk locations in the Pacific, climate change presents a risk to their survival. We must act now.”

Nursing advancement in Tonga

Jill White AM, Professor of Nursing and Midwifery at the University of Sydney, says Australia has an absolute responsibility to assist our closest neighbours - one of the most overlooked regions in the world. “I think some of that is because of the way maps are drawn with most maps that put America and Europe front and centre. The Pacific tends to fall off the edge of the map and I think it falls out of people’s minds as well,” she says. “But also in terms of natural disasters, in terms of effects of trade agreements, in terms of effects of climate change, they are absolutely battered by both natural and man-made disasters and I think we have a real responsibility in that.” Professor White, who gave three presentations at the SPNF, has not only been instrumental in nursing education, policy and regulation nationally, her work has impacted beyond Australian shores. Professor White founded the South Pacific Chief Nursing and Midwifery Officers Alliance (SPCNMOA) on the back of a series of conferences with Chief Nurses from the Pacific.

The work focused on reviewing, evaluating and assessing the Nurses Act 2001, and identifying any gaps or amendments before embarking on consultation meetings with key stakeholders.

— “INTERNATIONAL HEALTH IS SOMETHING THAT NEEDS TO BE CONSIDERED - TO BE MORE CONNECTED WITH OUR SOUTH PACIFIC NEIGHBOURS, TO LEARN FROM EACH OTHER AND TO HELP EACH OTHER PROVIDE THE BEST STANDARD OF CARE WE CAN.” — Nursing student Lucy Osborn

Professor White has also worked with the Polynesian Kingdom of Tonga, which spans 169, mostly uninhabited, islands on a range of initiatives, including the development of a novel NCD curriculum for nurses.

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While Australia is home to an established and well-resourced health system, Professor White says we can learn a lot from nurses in the Pacific, particularly when it comes to primary healthcare. “Primary healthcare is the basis of the health systems in all Pacific countries and I wish that it were here as well. It does make you realise that we’re a bit too hospital focused we’re too much about the ambulance at the bottom of the cliff rather than building the fence at the top.”

Chief Nurses and Midwives Alliance

Alongside the forum, the chief nursing and midwifery leaders joined senior leaders in regulation and education from across the region for the seventh South Pacific Chief Nursing and Midwifery Officers Alliance. The Alliance, which runs in conjunction with the SPNF, has been meeting since it was founded in 2004. With the support of and in partnership with WHO Western Pacific Regional Office, the Alliance aims to bolster nursing and midwifery to improve population health in the Pacific. Commonwealth Chief Nursing and Midwifery Officer Adjunct Professor Debra Thoms, who attended the Alliance meeting, says both the SPNF and the Alliance are crucial to improving the health of the region. “It is that opportunity to bring together nations from across the Pacific to look at shared issues, to share learnings, also to share successes, and that there are some very specific challenges for that part of the region,” she says.

The NCD curriculum produced the nation’s first 20 nurses with Advanced Nursing Diplomas in the prevention, detection and management of NCDs in 2013. “Tonga had the highest obesity statistics in

The end result is a comprehensive Nurses Act that describes the criteria for registration, the standards for professional practice, notifications and complaints, and the accreditation of education programs and providers.

LUCY OSBORN WITH COOK ISLANDS NURSING SCHOOL PRINCIPAL MARY MCMANUS AT THE OPENING CEREMONY OF SPNF.

“We know that many of the countries are still building their systems, there is also the impact of climate change for some of them, and I think countries like Australia and New anmf.org.au

FEATURE Zealand have things that we can offer but also things that we can learn.” At the recent meeting, Alliance leaders made a raft of recommendations, prioritised to address the Pacific health challenges charting a new direction until the Alliance meets in the Cook Islands in 2018. Recommendations included reviewing each nation’s legislations and regulations impacting on nursing and midwifery services, and exploring regulatory mechanisms to enable registered nurses, midwives and educators to gain clinical experience through country to country agreements.

— “IT’S VERY DIFFICULT FOR THESE SMALLER ISLAND NATIONS TO BE ABLE TO MAKE THE CHANGES THAT THEY NEED BUT AS A GROUP WE CAN COLLECTIVELY WORK FOR IMPLEMENTING CHANGE THAT WILL ACTUALLY ALLOW NURSES AND MIDWIVES TO BRING ABOUT THE DIFFERENCES THEY NEED TO, FOR THE HEALTH OF THEIR COMMUNITIES.”

The Alliance also prioritised a recommendation to work with the SPNF to establish two working groups to explore opportunities to not only align regional regulatory frameworks but for postgraduate education requirements to be developed in line with health workforce needs.

WHO support

Michele Rumsey is director of the WHO Collaborating Centre for Nursing, Midwifery and Health Development at the University of Technology Sydney. The centre has contributed to more than 50 projects in 25 countries working towards universal health coverage, and has also been the Secretariat of the Alliance since 2008, supporting member countries and coordinating actions in a bid to strengthen nursing and midwifery throughout the region. Since 2009, the Collaborating Centre has led an Australia Awards Fellowship leadership study program, funded by the Australian Government, which has assisted more than 100 nurses and midwives from Pacific nations to build their leadership skills while developing, implementing and strengthening projects for their own health systems. “The program is a mentorship model so

although the participants run a project, they are actually coordinated by their Chief Nursing and Midwifery Officer. Years later we can see nine of those fellows hold very senior positions now within the Pacific,” Michele, a registered nurse, says. “The program has been very much a leadership program but it’s also been about succession planning for the Ministries, to enable them to have colleagues who can continue the good work. “One of the reasons this is really important is that for many of the Pacific islands, people have to retire at 55 - so you just get to a point of knowledge, expertise and ministerial credibility, and then you have to retire. It’s really important that there’s some succession planning.” Also involved in research, the Collaborating Centre recently worked on a project examining how climate change is impacting on Australia’s capacity to respond to disasters in the Pacific, and provide humanitarian assistance such as nutrition, sanitation and healthcare. Among its findings and recommendations, the research showed an urgent need for specific training and capacity building, particularly for nurses as the first responders.

Creating perioperative standards

When Sally Sutherland-Fraser and Menna Davies launched their Sydney nursing consultancy, Health Education and Learning Partnerships, four years ago, they never imagined their business venture would enable them to work with their nursing colleagues in the Pacific. For the past 18 months, the experienced perioperative nurses have worked with Fijibased, and Australian Government funded, organisation Strengthening Specialised Clinical Services in the Pacific (SSCSiP) to

— ANMF Assistant Federal Secretary Annie Butler

A GROUP PHOTO OF COOK ISLAND THIRD YEAR NURSING STUDENTS AND UNI SA STUDY TOUR STUDENTS.

March 2017 Volume 24, No. 8 21

FEATURE

FACTS: About The South Pacific

Communicable diseases

Poor climate health

Malaria is endemic in the Solomon Islands.

Tropical states in the South Pacific are increasingly paying the price of global warming.

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The Pacific Ocean is the largest ocean on the planet, covering almost half of the world’s water surface. The equator divides the Pacific into the North Pacific and South Pacific oceans.

Dengue fever, which occurs in most Pacific islands, is one of several infectious tropic diseases, including typhoid fever, leptospirosis, zika and chikungunya, which are on the rise.

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The islands are not only spread across a vast area but are culturally and geographically diverse.

The WHO says lymphatic filariasis, one of the world’s leading causes of permanent and long-term disability, is endemic in 11 nations.

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The Solomon Islands consists of six major islands and more than 900 smaller islands, spanning a land area of about 28,400 square kilometres, while the Republic of Fiji is an archipelago of more than 330 islands, covering about 18,300 square kilometres.

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In 2011, Tuvalu experienced a droughtinduced outbreak of diarrhoeal diseases, in 2012 Fiji experienced a post-flood leptospirosis outbreak followed by a dengue outbreak in 2013-14, and in 2014 floods triggered an epidemic of diarrhoeal disease in the Solomon Islands.

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While industrialised countries are largely responsible for the carbon dioxide emissions that lead to global warming, Pacific island nations are being left vulnerable to the effects of climate change, such as rising sea levels. —

The 2014 Intergovernmental Panel on Climate Change’s Fifth Assessment Report found Pacific Islanders are ‘suffering the effects of climate-sensitive health problems’ related to extreme weather, from tropical cyclones to storm surges, flooding and drought. —

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FEATURE Scientists are also examining the links between climate change and outbreaks of infectious diseases, such as dengue fever, which is on the rise in some Pacific nations. —

Climate change also places a greater burden on overstretched health services and a greater risk of disease and death among vulnerable populations.

Health initiatives Expanded immunisation programs are combating preventable diseases such as diphtheria, tetanus, pertussis, poliomyelitis, TB, measles and hepatitis B in all South Pacific nations, while some nations are also embracing life-saving vaccines protecting against rubella and Haemophilus influenzae type B (Hib). —

The Pacific Island Health WHO report for 2014-2015 shows eight countries and areas have increased tobacco taxes by an average of 21%, with two also strengthening their tobacco control legislation. —

Thirteen nations have improved their health sector preparedness with national climate change and health action plans, and six countries have improved safe drinking-water supplies. —

As part of the Healthy Islands vision, member islands have prioritised working to address the escalation of NCDs and the challenges of communicable and tropical diseases.

develop a practice bundle of infection prevention standards in perioperative nursing. With support from the Australian College of Perioperative Nurses (ACORN), Sally and Menna used ACORN’s latest standards for perioperative nursing as a basis for developing standards for 14 Pacific nations - Fiji, Solomon Islands, Vanuatu, Federated States of Micronesia, Kiribati, Marshall Islands, Nauru, Palau, Cook Islands, Niue, Samoa, Tokelau, Tonga and Tuvalu. In collaboration with nursing colleagues spanning the nations, Sally and Menna developed the Pacific Perioperative Practice Bundle (PPPB) featuring six standards, practice audit tools and practice audit instructions - specifically designed to suit the operating theatre practice environments of the different Pacific nations. The standards cover hand hygiene, perioperative attire, aseptic technique, protective apparel, scrubbing, gowning and gloving, along with skin preparation and draping. While ACORN has more than 20 standards for perioperative nurses, Sally says it was important to target the standards that would have the biggest impact, in the shortest amount of time, to improve the health of patients. “We believe if you can improve compliance with those practices then you will get a difference in the outcomes of the patients because these standards are designed to minimise infection risk,” she says. “Equally because the standards are also about protecting the staff, you can improve staff outcomes by reducing occupational exposure.”

Sally joined SSCSiP project coordinator Mabel Hazelman Taoi to co-present on the PPPB project at the SPNF. Mabel says having Sally and Menna’s support has been a stroke of good luck for the Pacific. “Not only are they very experienced perioperative nurses but they also understood the Pacific context as they have worked in several Pacific Island countries,” she says. Sally and Menna are now working with SSCSiP through key elements of the standards and strategies for implementation. Despite a few obstacles, Sally says the standards are now being audited in the Solomon Islands, Fiji and Samoa, and she hopes that the practice audits will be underway right across the nations within the coming year. Nurses in the Pacific regularly demonstrate “awe-inspiring” resilience and resourcefulness, Sally says. “In some nations, they may not have sterile gowns some days, they may not have water coming out of their taps, they can have really unexpected injuries, for example shark bite injuries, and they very often have to work in a situation where they have no protective equipment, such as eye shields. “Within those conditions they do a mighty job - they adapt and they provide the safest care they can.”

A voice on the world stage

As a leading light for New Zealand’s Indigenous nurses, Kerri Nuku says a collaborative working relationship, with member states and NNAs across the South

—

Member nations are also focused on improving maternal and child health, addressing high vulnerability to natural disasters and climate change, and boosting health infrastructure.

LUCY OSBORN (SECOND FROM RIGHT), JESSICA WEBER (RIGHT) AND TWO COOK ISLANDS PRIMARY STUDENTS WHO WERE SCREENED.

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March 2017 Volume 24, No. 8 23

Pacific, is key to elevating the voice of regional and Indigenous nurses to the global decision-making table. The Kaiwhakahaere of the New Zealand Nurses Organisation (NZNO), who has worked as a nurse and midwife, manager and nursing advocate for more than 30 years, is standing for election to the board of the International Council of Nurses this year, the highest authority in nursing, in a bid to take the issues facing Pacific nurses to the world. While health is a fundamental right of every human, Ms Nuku says nurses across the Pacific are bracing for a major health crisis, with a nursing workforce shortage and a rapid rise in NCDs compounded by the impact of climate change, natural disasters and underlying poverty.

— “TONGA HAD THE HIGHEST OBESITY STATISTICS IN THE WORLD BUT, WITH THE NCD PROGRAM, EVERY COMMUNITY HAS AN NCDS NURSE AND THEY ARE ABSOLUTELY MAKING A DIFFERENCE TO OBESITY, DIABETES AND CARDIOVASCULAR DISEASE AND A LOT OF THAT REALLY HAS BEEN NURSE-LED.” — Professor Jill White

JILL WHITE AM (RIGHT), PROFESSOR OF NURSING AND MIDWIFERY AT THE UNIVERSITY OF SYDNEY, WITH TONGA CHIEF NURSE AND IMMEDIATE PAST CHAIR OF THE SPCNMOA, DR AMELIA AFUHA’AMANGO TUIPULOTU (LEFT), FOLLOWING THEIR JOINT PRESENTATION ON REGULATION IN TONGA.

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Ms Nuku, who presented on the challenges facing Indigenous nurses at the SPNF, says there is a lack of Indigenous autonomy or ‘mana motuhake’ - “to have our own power, to make our own decisions, for our own people”. She says it’s crucial to build and support a resilient Indigenous workforce to ensure nurses are able to respond to the changing health needs of Indigenous populations. “Particularly here in New Zealand, our Indigenous workforce is 7% of total workforce population, it has been since the 1990s, and we need to respond to an ageing Maori or Indigenous workforce with complex co-morbidity. We need to be able to respond to, retain and recruit Indigenous nurses into the workforce.”

Learning in the Pacific

With her mum and her sister working as nurses in critical care, it’s little surprise Lucy Osborn, with a name similar to Nightingaletrained Australian nursing pioneer Lucy Osburn, wanted to follow in their nursing footsteps. The 22-year-old from Adelaide is also determined to carve out her own niche in the profession, particularly after a two week study tour in the Cook Islands, jointly funded by the Australian Government New Colombo Plan and the University of South Australia, opened her eyes to the possibilities of nursing in the South Pacific. Lucy was one of 10 University of South Australia third year nursing students selected to travel to the island paradise as part of a novel primary healthcare nursing placement in April 2016. The group of students worked with Rarotongan health professionals and Cook Island nursing students to screen more than 2000 school children for rheumatic heart disease, while recording and collating data for the nation’s Ministry of Health. They also worked with public health nurses as they completed postnatal visits, home care and wound management.

Lucy says it was a unique experience that enabled the students to develop their clinical and personal skills, knowledge and practice while gaining an international perspective of nursing. And that was just the beginning. The experience propelled Lucy on to the region’s nursing stage, where she became the first student to speak at the SPNF in its 34-year history. Lucy, who recently began work at the Queen Elizabeth Hospital in Adelaide, for her graduate year, has now been selected to participate in the Australian College of Nursing’s 2017 Emerging Nurse Leader program. While Lucy’s SPNF presentation has generated interest in expanding the study tour initiative to other nations in the South Pacific, her adventure has also prompted her to encourage other nursing students and early career nurses to embrace the nursing opportunities on offer among Australia’s nearest neighbours. “International health is something that needs to be considered - to be more connected with our South Pacific neighbours, to learn from each other and to help each other provide the best standard of care we can.”

Working in partnership

At the end of the forum, NNA nurse leaders called on Pacific governments, health funders, policy planners, health educators, economists and Chief Nursing Officers to invest in nursing. Among the range of initiatives, the forum leaders called for entry to practice programs for new nurses, policies for tackling the causes of climate change, exchange of nurses and students for clinical placements, education, training and professional development for all nurses, and an investment in information technology and internet connectivity to support nurse education and care delivery. With the Cook Islands set to host the next SPNF in 2018, Ms Butler says the ANMF will continue to work with forum members and participate on the steering committee to advance nursing and midwifery in the Pacific. “We’ve really started a listening and a communication process. We are going to work on the resolutions and the key issues, and we understand that this is going to take time,” she says. “It’s important for nurses and midwives everywhere - in Australia, our region and in the world to take the lead on issues we know are critically important to the health of our communities. “It really is time we supported the nurses and midwives working right beside us.” * For more information on the SPNF visit www.spnf.org.au

anmf.org.au

WORKING LIFE

MIDWIFE BLOSSOMS INTO AFL STAR

midwifery also holds a special place in her heart. It’s a career she continues alongside her burgeoning sporting commitments. After finishing high school, Daisy completed a double degree in Nursing and Midwifery at La Trobe University. She then undertook her graduate year at Box Hill Hospital in 2001, where she has remained since.

By Robert Fedele Victorian midwife Daisy Pearce has swapped her medical gloves for footy boots on the way to chasing her sporting dream.

At the beginning of 2016, as football was starting to take off, she put midwifery on hold and started working at the Melbourne Football Club. “It wasn’t an easy decision to walk away from it because it was a job that I really loved. “I reckon I’ll definitely come back to it at some point and I’m working pretty hard to make sure I keep all my CPD hours up and my registration up so that it’s an option later on.” Daisy had always wanted to work in healthcare and became captivated by midwifery during the period her mother gave birth to her younger brothers. “I was always very fascinated and loved the cycle of pregnancy and when she had her babies and being involved in all that. So that is probably where the initial passion came from.”

Growing up Daisy Pearce always stood out as the lone girl playing in a local Aussie rules football team. Only it was not her gender turning heads but, rather, an instinctive and canny ability to find the football that in years to come would see her arguably become the most formidable player of her generation. Born into a footy-mad household, Daisy grew up in the Victorian country town of Bright, where her Dad coached the junior Aussie rules footy team. Her handful of brothers played the game and after years of persistence Daisy finally negotiated her way into pulling on the boots at age 11. Daisy describes the local footy club as one typically found in most country towns: the heartbeat of the community. “Because I’d been around the footy club for so long I was just part of the furniture and they didn’t think any differently of me within the team and the club. “Occasionally I did get a bit of sledging and carry on when I played against other teams but it wouldn’t usually last long. It’s a bit of a small country league and everyone knew that Bright had a girl called Daisy that played for them so it just became normal.” Daisy does not remember being a child prodigy but a hard-working forward who kept plugging away, and kept getting better. Her modesty disguises the beginnings of a legitimate star; a teenager so talented she topped the club’s goal-kicking. When she was 14, Daisy moved to Melbourne to live with her mother, giving anmf.org.au

up football altogether. She was unaware a women’s league existed, and resigned herself to a world in which women don’t play Aussie rules. One day, while playing school footy at Eltham High School, she discovered the Victorian Women’s Football League. She resumed playing league footy in 2005 with the Darebin Falcons, whom she would help to become an all-conquering force over the next decade. “It’s exciting having 21 teammates that you rely on, and to try and achieve goals as a team is something I really enjoy. The nature of footy means there are so many different shapes and sizes and different types of people, and it makes it really interesting all the time.” Just last month the Australian Football League (AFL) launched its new women’s league where Daisy was appointed captain of the newly formed Melbourne Women’s Football Club. Reflecting on that moment Daisy says she thought that day might never have come. “I grew up dreaming of playing in the AFL but once you hit the age of about 11 or 12 your heart gets broken because you realise all your heroes are boys and it’s not going to happen. “It’s a huge shift for Aussie rules football but also for society that females are going to be able to play this game on the big stage in televised matches.” Football remains Daisy’s first love but

Daisy describes being a midwife as a privilege. “It’s a funny thing that at times you only meet people the day before or that day that they come to have their baby but to share that moment with them and be there to help guide them through that moment is really special. It does create a real connection that is almost addictive.”

“IT’S EXCITING HAVING 21 TEAMMATES THAT YOU RELY ON, AND TO TRY AND ACHIEVE GOALS AS A TEAM IS SOMETHING I REALLY ENJOY. THE NATURE OF FOOTY MEANS THERE ARE SO MANY DIFFERENT SHAPES AND SIZES AND DIFFERENT TYPES OF PEOPLE, AND IT MAKES IT REALLY INTERESTING ALL THE TIME.” The new women’s AFL league is an eight team competition that features six homeand-away rounds, plus finals, culminating with the Grand Final on 25 March. The competition, which has been well received by the public, has quickly made Daisy a household name. Yet despite overnight fame proving challenging, Daisy is happy to embrace her new status as a role model who would love to attract more girls to play Aussie rules football. “To see people start to take notice of female footballers and all female sport is exciting. It’s pretty strange at times to be at the forefront of that but I’m taking it in my stride and doing the best I can.” March 2017 Volume 24, No. 8 25

ISSUES

COMMUNICATION IS KEY Carmen Marlow Nursing is a career with an ever changing landscape of opportunities and difficulties. We work hard to stay at the forefront of modern medicine and healthcare practice. Health outcomes for our patients have never been better, and still we strive forward to keep learning and be as broadly knowledgeable and skilled as possible. Communication is key to our success in our aims, and the multiple disciplines involved in that care delivery complete a flourishing network of healthcare professionals. It’s with this career goal of life-long learning in mind that the Barwon Medical Imaging (BMI) Visibility and Communication Program was created. During the 2014-2015 financial year, Barwon Health saw 63,000 emergency department attendances, with 71,000 admissions at University Hospital Geelong. Barwon Medical Imaging provided over 36,000 inpatient images for diagnostic and treatment purposes. Radiology interventional consultants were concerned that patients were returning for corrective treatment after care missteps on wards, while ward nursing staff were dissatisfied that the radiology department absorbed too much of their time with seemingly ambiguous or inconsistent instructions. Herein lay the communication breakdown which was having negative effects on the quality of patient care. One nursing staff member, Carmen Marlow, working both in radiology and on a surgical ward, identified this communication breakdown and put in motion changes to address it. Over 12 months, Carmen

26 March 2017 Volume 24, No. 8

delivered 50 in services, distributed a feedback survey, created and introduced multiple documents for common information clarification, refortified the existing avenues of communication, published an article for the organisation’s newsletter and presented to a state wide conference of other medical imaging nurses. These efforts to address ongoing concerns have been well received with significant anecdotal positive changes to practice made, and would not have occurred without the support of the medical imaging department and its nursing staff.

relevant and current. Clinical handover is defined as, the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis (Australian Commission on Safety and Quality in Health Care, 2012). A 2012 study of 459 clinical incidents relating to handover by Thomas et al. identified several common errors occurring as a result of handover errors. These included; the transfer of patients without adequate handover 28.8% (n=132), and omissions of critical information about the patient’s condition 19.2% (n=88) (Thomas et al. 2013).

AS A DIRECT RESULT OF THIS PROGRAM, AND THE INSIGHTS IT HAS DELIVERED, MULTIPLE CHANGES HAVE BEEN IMPLEMENTED AND CONSIDERABLE WORK HAS GONE INTO CREATING A MORE COHESIVE TEAMWORK ENVIRONMENT.

Conducted during double staff time and tailored to cover information clinically relevant to each specific ward, the in services addressed staff concerns and addressed knowledge gaps. An open table conversation was found to be the best means of creating dialogue, and an accessible and non-judgmental arena for learning. These knowledge gaps included; CT scan preparation and explanation of contrast medium, guided procedures (eg. tissue biopsies), fluoroscopy and angiography intervention, MRI safety and nursing handover expectations.

Educational methods included distribution of relevant documentation, demonstrations with relevant equipment, and use of clinically relevant images to convey concepts. Exploring specific procedures and aftercare requirements has been an essential component, as therein lay many of the nursing staff’s concerns. An integral element to this program was open disclosure and giving a voice to staff who have long felt their concerns have been unaddressed.

If reading this and thinking, ‘many of my patients have imaging done, and I don’t know some of those things myself’, this is your perfect opportunity to ask your medical imaging department.

As a direct result of this program, and the insights it has delivered, multiple changes have been implemented and considerable work has gone into creating a more cohesive teamwork environment.

Nursing handover was repeatedly identified as an ongoing source of concern for both ward and medical imaging nurses. Unlike a full medical history handover when transferring between care facilities, handover needs when transferring to medical imaging vary significantly. Each facility will have different measures in place, though ultimately, information exchanged during care responsibility transition must be comprehensive,

Utilising various means of tailored education has led to fewer missed scans, decreased errors in procedural preparation and aftercare needs, and less representation to the radiology department for corrective treatments. This all in turn reduces admission length and aids in reducing preventable complications. The nature of modern healthcare is such that multiple specialties will be involved in each patient’s care. Hence, communication between care providers is essential to delivering holistic care. You are invited to consider, what aspects of your workload overlaps with other departments, such as medical imaging, and actively look at ways you can improve your own knowledge of that care stream.

References Australian Commission on Safety and Quality in Health Care. Standard 6: Clinical Handover. NSQHS Standards. 2012. https://www. safetyandquality. gov.au/wp-content/ uploads/2012/10/ Standard6_Oct_2012_ WEB.pdf (accessed 2016). Barwon Health. Annual report 2014/2015. http:// www.barwonhealth.org. au/annual-reports/88annual-report-2014-15/ file (accessed 2016). Thomas, J.W. M., Schultz, T.J., Hannaford, N., Runciman, W.B. Failures in Transition: Learning from Incidents Relating to Clincal Handover in Acute Care. Journal for Healthcare Quality 35, no. 3 (2013): 49-56

Carmen Marlow is a Registered Nurse and Registered Nurse Immuniser in the Radiology and Colo-rectalUrological surgery ward at Barwon Health in Victoria anmf.org.au

ETHICS

ETHICS, EVIDENCE AND THE ANTI-VACCINATION DEBATE On 11 October 2016 the Nursing and Midwifery Board of Australia (NMBA) released a position statement on ‘Nurses, midwives and vaccination’ (www.nursingmidwiferyboard. gov.au/News/2016-10-11-position-statement-vaccination.aspx). Megan-Jane Johnstone

References Gostin, L.O. 2015. Law, ethics, and public health in the vaccination debates: politics of the measles outbreak. JAMA, 313(11): 10991100. Grabenstein, J.D. 2013. What the world’s religions teach, applied to vaccines and immune globulins. Vaccine, 31(16): 2011-2023. Hendrix, K., Sturm, L.A., Zimet, G.D., & Meslin, E.M. 2016. Ethics and childhood vaccination policy in the United States. Public Health Ethics, 106(2): 273-278. Lusk, B.L., Keeling, A.W., & Lewenson, S.B. 2016. Using nursing history to inform decisionmaking: infectious diseases at the turn of the 20th century. Nursing Outlook, 64(2): 170-178.

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

In this statement the NMBA made clear its expectation that, when providing advice on immunisation, nurses and midwives have a fundamental responsibility to make use of ‘the best available evidence’ and to uphold their respective profession’s code of conduct and code of ethics. It further warned that any nurse or midwife who failed to uphold the standards of evidence based immunisation or who published or gave advice on immunisation that was ‘false, misleading or deceptive’ could face prosecution by the Australian Health Practitioner Regulation Agency. Significantly, the NMBA released its statement after it became aware that a small number of nurses and midwives were promoting anti-vaccination statements via social media.

A question of nursing ethics

Here it might be asked: What makes anti-vaccination attitudes among nurses and midwives an ethical issue of professional significance? Why might support by nurses and midwives of what has been dubbed the ‘anti-vaxx movement’ fall within the parameters of a code of ethics for nurses/midwives?

Vaccine ethics

The anti-vaccination stance taken by the nurses and midwives noted by the NMBA falls within the domain of what has been termed ‘vaccine ethics’. Vaccine ethics has been conceptualised as ‘a set of issues at the intersection of public health policy, clinical ethics and professional ethics’ (Hendrix et al. 2016, p274). In the case of the latter, ethical issues arise when clinicians have to decide how best to assess and fulfil their responsibilities when confronted by parents and individuals who refuse immunisation (either of themselves or their children). This issue becomes paramount in contexts where people’s willingness or reticence to be immunised risks an increase in the morbidity and mortality of vaccine-preventable diseases (eg. measles, mumps, rubella, diphtheria, pertussis, polio, tetanus, varicella, hepatitis, etc.). The issue becomes especially pressing when those refusing immunisation reach a sufficient number to undermine what is termed ‘herd immunity’ (ie. where

a critical percentage of a community is immunised so that those who are not immunised are nonetheless protected) (Gostin, 2015). Anti-vaccination attitudes are not trivial. In instances where such attitudes motivate either delays in vaccination, selective vaccination, or outright vaccine refusals an increase in the risk and rise of vaccinepreventable diseases may result (Gostin, 2015). It is the risk and rise of vaccinepreventable diseases and the harms and suffering associated with them that make anti-vaccination an ethical issue of concern for the nursing and midwifery professions. The International Council of Nurses (ICN) Code of ethics for nurses (www.icn.ch/who-we-are/code-ofethics-for-nurses/) has long codified the moral responsibilities of nurses ‘to promote health, to prevent illness, to restore health and to alleviate suffering’. When consideration is given to the devastating impact that a vaccine-preventable disease can have on individuals, families, and even whole communities it is clear that failures by nurses and midwives to promote the benefits of immunisation and debunk the myths promulgated anti-vaccination proponents contravenes the standards of nursing/ midwifery ethics. It also undermines these professions’ integrity and credibility.

Vaccine hesitancy and need to be informed The World Health Organization (WHO) recognises that people’s anti-vaccination stance or ‘vaccine hesitancy’ (a term regarded as being less pejorative than ‘antivaccination’) is ‘complex and context specific, varying across time, place and vaccines’ (www.who. int/immunization/programmes_ systems/vaccine_hesitancy/ en/). Notable among the factors influencing vaccine hesitancy are: confidence (ie. in the effectiveness and safety of vaccines; the reliability and competence of the system and health professionals delivering them; the motivation of policy makers); complacency (ie. about the perceived risk and harmful impact of vaccine-preventable diseases);

and convenience (ie. the availability, accessibility, and affordability of vaccinations) (termed the ‘3 Cs model of hesitancy’). Vaccine hesitancy is also informed by various personal, religious and philosophical beliefs many of which are based on misinformation, misperception and opinion. A growing populist distrust of science, the medical profession, and governments mandating immunisation programs is also fueling vaccine-hesitancy despite substantial evidence demonstrating the safety and exemplary success of modern vaccines and associated programs. Efforts to persuade those strongly opposed to vaccination about the benefits of immunisation and to educate them about the harms that a resurgence of vaccine-preventable disease could cause tend to fail. This is so even in the case of those who cite religious grounds for their hesitancy despite the fact that a majority of the world’s religions are not theologically opposed to and actively support vaccination based on imperatives that call for ‘the preservation life, caring for others, and duty to community’ (Grabenstein, 2013, p2019).

Countering vaccine hesitancy

Nurses and midwives have a fundamental responsibility to counter vaccine hesitancy in the individuals, groups and communities they serve. In determining how best to fulfil this responsibility, valuable lessons can be learned from the historical experiences of nurses who cared for affected population during the prevaccination era and who witnessed firsthand the deaths of thousands of children and the destruction of whole families by what today are regarded as common vaccine-preventable diseases (Lusk et al. 2016). In keeping with prescribed competency, practice and ethical standards, nurses and midwives have an unequivocal responsibility to be appropriately informed not only about the evidence based risks and benefits of vaccination, but also ‘vaccine ethics’. Curtailing behaviours that threaten public health is not an assault on civil liberties as some contend. Rather it is a reminder that ‘we are all in this together’ and have a collective responsibility to ensure the health and wellbeing of our communities. March 2017 Volume 24, No. 8 27

CLINICAL UPDATE

DO AGED CARE NURSES PERCEIVE MORE PROFIT EQUALS LESS AUTONOMY? Shirley Papavasiliou The number of Australians aged 85 years and over is projected to double by 2032 with an additional 82,000 residential care places required by 2025 (Sudholz 2016).

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CLINICAL UPDATE The financial investment required to meet projected industry demands and economies required to remain competitive in the face of rising costs, is resulting in a global standardisation of the industry (Bankwest 2016). Australia is following global trends with a steady decline in the number of smaller and ‘not-for-profit’ residential care facilities, historically owned by religious or community groups, charities, private groups and local or state governments (Ronald et al. 2016). Larger, ‘for-profit’ facilities operated by shareholder, private operators or corporations and owned and operated as businesses are gradually gaining a greater share of the aged care industry through a process of mergers, acquisitions and takeovers (Scourfield 2011). Registered Nurse (RN) scope of practice enables nurses to work autonomously in aged care facilities to provide, coordinate and make clinical decisions regarding care and treatment of residents requiring increasingly more complex care (ACN 2016). Although autonomous practice is dictated by many factors related to individuals, there are also factors outside the control of individual nurses which can impact clinical decision-making and ability to attain professional autonomy. These factors include the freedom and empowerment from recrimination or coercion to make decisions which may not fall within defined or implied organisational policies, the availability and access to resources, support and information and input into organisational policies (Kieft et al. 2014). Nurses have a responsibility to maintain professional standards in practice, however maintaining high standards of quality care can be difficult in an environment that discourages nursing autonomy (Weston 2010). * A ‘for-profit’ organisation type is the variable that showed the greatest influence on nursing practice, autonomy and care issues, according to a study of South Australian aged care nurses

Overview of the problem

The consequence of standardisation is a market-driven and bureaucratic approach to maximise profit and minimise costs. Regardless of the type of organisation, all aged care facilities must have enough profits and access to funding to remain competitive and survive. The ‘marketdriven’ approach which drives the ‘for-profit’ sector however, causes a change in workplace environments and organisation structures to meet anmf.org.au

the demands for quality care within efficiency, performance management and accountability restrictions (Garavaglia et al. 2011). Compliance can be enforced with rigid organisational policies, regulations and bureaucracy, demanding performance management and standardisation which can downplay the professional judgement and autonomy of nurses (Sturgeon 2010). There are benefits to a standardised industry with large companies having competitive advantages related to decreased costs, additional income related to ‘brand recognition’ and greater financial access to increase staff, resources and training (KordaMentha 2014). Research has established links between organisational structures that promote nursing autonomy and continuity of care, resource adequacy, enough staffing and support, and quality of care provided within the aged care industry (Garavaglia et al. 2011).

THE ‘MARKET-DRIVEN’ APPROACH WHICH DRIVES THE ‘FOR-PROFIT’ SECTOR HOWEVER, CAUSES A CHANGE IN WORKPLACE ENVIRONMENTS AND ORGANISATION STRUCTURES TO MEET THE DEMANDS FOR QUALITY CARE WITHIN EFFICIENCY, PERFORMANCE MANAGEMENT AND ACCOUNTABILITY RESTRICTIONS (GARAVAGLIA ET AL. 2011).

Studies of overseas aged care facilities however, have identified consistent trends of decreased quality care provided in ‘for-profit’ nursing homes in comparison to the level of care provided in ‘notfor-profit’ or ‘government’ owned facilities. Studies used indicators of quality such as failure to meet accreditation standards, number of sanctions imposed and high numbers of transfers to acute sector (dela Rama et al. 2010). Australian government policy places strict controls on the type, number and location of aged care beds, yet places no restriction on the profit status of the provider or the effect these changes may have on resident outcomes (Baldwin et al. 2015).

Study

Despite the poor outcome recognised overseas, the effects on the workplace culture and the ability of RNs to work autonomously as a result of a changing industry in South Australia have not been significantly researched. This study sought to understand the relationship between perceived autonomy and type of aged care organisation in South Australia using an online survey to collect data. Survey development was guided by Kanter’s (1993) theory of structural empowerment which maintains attitudes and behaviours of employees are influenced more by organisational and workplace conditions than the qualities or personalities of the individual involved. Empowerment suggests that employees who are provided with access to power and opportunity within organisational structures, are able to contribute effectively to both individual and organisational goals and are supported in professional autonomy (Laschinger et al. 2010). Power refers to resources, support and the information necessary to work effectively, and opportunity includes development of knowledge and skills and ability for growth within the organisation.

Aims

1. To describe the degree of perceived autonomy amongst aged care nurses. 2. To describe the organisational factors that nurses’ perceive effect nursing autonomy. 3. Examine the relationship between perceived autonomy and type of aged care organisation.

Participants

One hundred and three RNs participated in an online survey promoted through the ANMF (SA) e-bulletin and Facebook page. Participation was voluntary and no identifiable data was collected. Ethics approval was received through Flinders University Social and Behavioural Research Ethics Committee (Project. 7148).

Data analysis

Survey data was collected using the CareSearch Research Data Management System and analysed using the statistical package for social sciences program, version 23 (SPSS Inc. V23). Demographic characteristics were used to assess if a relationship existed between personal characteristics of individual participants. Analysis involved running a cross tabulation of all the variables testing chi squared, then using lambda and phi testing. Qualitative responses were collected in two areas,

References ACN 2016. The role of registered nurses in residential aged care facilities: Position statement. Australian College of Nursing. Baldwin, R., Chenoweth., L. & dela Rama,M. 2015. Residential Aged Care Policy in Australia – Are We Learning from Evidence. Australian Journal of Public Administration. 74(2):128-41. Bankwest. 2016. Connect Insights for Business: Aged Care Residential Services Industry Report. Bankwest. Bjornsdottir, K. 2013. The place of standardisation in home care practice: an ethnographic study. Journal of Clinical Nursing. 23:1411-20. Cassidy, A. & McIntosh, B. 2014. The return of autonomy in nursing: a way forward. British Journal of Nursing. 23(11):562-3. dela Rama, M., Edwards, M., Dalton, B. & Green, J. 2010. Honourable intentions? Analysing the interests of private equity in the aged-care sector. Third Sector Review. 16(3):63-82.

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CLINICAL UPDATE one as a response to providing an example of where workplace policies have limited ability to practice and the second as a general additional comment. Use of the respondents’ own comments has the potential to generate complex insights and add depth and understanding to the quantitative data provided.

Results

Findings provided clear indication that the type of organisation was the variable that showed the greatest influence on nursing practice, autonomy and care issues, with a consistent pattern of lesser autonomy in ‘for-profit’ organisations. An environment that empowers nurses by supporting professional nursing autonomy, allows for nurses decision-making in accordance with the needs of individual residents. An organisation working within a business model however, has the potential to place the support and resources required by RNs within the control of management and so disempowers nurses (Cassidy & McIntosh 2014). The first aim of this study was to ask RNs to rate their perceived level of autonomy and ability to provide clinical skills in their workplace, giving consideration to their scope of practice. The definition of autonomy was provided as the ability of a nurse to exercise professional judgement, using evidence-based knowledge, personal experience and skills in providing appropriate and ethical, quality care for residents within expected professional standards (Cassidy & McIntosh 2014). Despite the need for RNs to work autonomously in aged care facilities to make clinical decisions regarding care and treatment of residents, the reported degree of autonomy was lower than expected. Nurses working in ‘for-profit’ organisations however, reported a lower perceived level of autonomy, felt less valued as a member of the clinical team and reported a lesser ability to plan the nursing care for residents in their workplace than their peers in other organisations. The second aim of this study was to describe the organisational factors that nurses’ perceived as effecting nursing autonomy. Consideration of data from this study supports data already known regarding the significant influence on nursing autonomy and clinical decisionmaking from workplace policies and structure. While clinical guidelines and protocols within the aged care industry seek to promote efficient and effective practice and limit 30 March 2017 Volume 24, No. 8

the potential for poor practice, standardisation may also lead to low staffing levels, a perception of low skill requirement, and a lack of resources and support (Sabatino et al. 2014). Cost-effectiveness is not specific to an organisation type; it is prevalent throughout the aged care industry, in order for all facilities and organisations to continue to survive. A standardised, market-driven approach does not necessarily allow the freedom for RNs to use their clinical skills and experience in combination with evidence-based practice, to make an appropriate decision for the individual resident involved.

THE STUDY HIGHLIGHTED THE GREATEST WORKPLACE INFLUENCE ON NURSING AUTONOMY WAS FROM THE ENVIRONMENT FOUND IN ‘FOR-PROFIT’ ORGANISATIONS. THE MAJORITY OF RESPONDENTS HIGHLIGHTED WORKPLACE POLICIES AIMED AT MINIMISING COSTS, STAFFING SHORTAGES AND A LACK OF RESOURCES.

The study highlighted the greatest workplace influence on nursing autonomy was from the environment found in ‘for-profit’ organisations. The majority of respondents highlighted workplace policies aimed at minimising costs, staffing shortages and a lack of resources. Nurses described in their narratives how their autonomy and practice was limited by restrictive workplace policies, financial considerations and a lack of support for nursing clinical decision-making. These same nurses reported feeling capable of providing appropriate clinical care, therefore the context of lesser autonomy is not about a lack of skill but about a context which limits the capacity to demonstrate this skill. Despite a generally low perception of the clinical skills required, the aged care environment requires advanced skills in relation to clinical-decision making for frail elderly residents. Overseas studies support the study finding, highlighting the trend for facilities owned by large ‘for-profit’ aged care providers to focus on profit rather than quality care (Baldwin et al. 2015). Transferring residents to acute sector was an indication of concern for resident safety and quality of care that was attributed to workplace policies

by the majority of nurses working in ‘for-profit’. Clearly, transfer to acute can be appropriate due to an acute episode, symptom management or per resident or family choice and may be necessary due to a lack of advance care planning. However, many of the comments provided by nurses working in ‘for-profit’, attributed the policy to transfer for symptom management or treatment as a measure related to cost saving or a fear of litigation. Remaining at the facility would not only reduce the burden on the health system but reduce the inconvenience, risk of iatrogenic infections, and decreased quality of life for residents. Indeed, the narrative provided by nurses working in ‘for-profit’ highlighted the belief that many of the residents transferred could have been cared for within the facility and the nurses felt capable to provide appropriate care if resources such as imprest stock was available. The importance of implementing initiatives to manage resident care as disease trajectories transition from curative to palliative is pertinent when considering the disproportionate number of permanent aged care residents who die in hospital rather than their preferred location. Using palliative care approaches could help GPs, decision-makers and aged care staff to focus on the resident’s preferences for future care through improved communication, advance care directives, appropriate medication orders and ensuring medication was on site when needed. Further research to confirm the findings related to increased number of acute admissions from ‘forprofit’ residents is needed to better understand the underlying reasons for transfers and to enable interventions to be implemented to improve resident care. The final aim of the study was to examine this relationship between perceived autonomy and type of aged care organisation. As expected from overseas trends, the overwhelming contributing factor was ‘for-profit’ type of organisation in all areas of autonomy, clinical skills and resources. Age of the nurse, gender, years of experience or level of qualifications was not found to effect perceived autonomy. Nurses reported having the clinical skills to provide appropriate care to residents yet faced organisational barriers which prevented RNs from utilising their full level of experience and knowledge. An unexpected finding was that a primary language other than English also influenced perceived professional autonomy.

Garavaglia, G., Lettieri, E., Agasisti, T. & Lopez, S. 2011. Efficiency and quality of care in nursing homes: an Italian case study. Healthcare Management Science. 14:22-35. Kanter, R. 1993. Men and Women of the Corporation. 2nd. Edn. Basic Books: New York. Kieft, R., de Brouwer, B., Francke, A. & Delnoij, D. 2014. How nurses and their work environment affect patient experiences of the quality of care: a qualitative study. Bio Med Central Health Services Research. 14(249). KordaMentha. 2014. Residential aged care industry: Consolidation and convergence. 1407. Kordamentha. Laschinger, H., Gilbert, S., Smith, L.M. & Leslie, K. 2010. Towards a comprehensive theory of nurse/patient empowerment: applying Kanter’s empowerment theory to patient care. Journal of Nursing Management. 18:4-13. Ronald, L.A., McGregor, M.J., Harrington, C., Pollock, A. & Lexchin, J. 2016. Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When is There Enough Evidence for Policy Change?. PLOS Medicine. 21(6):659-72.

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CLINICAL UPDATE

Although nurses reported decreased autonomy from all organisation types, nurses who reported a primary language other than English, were more likely to also work in ‘for-profit’ organisations. These nurses were also more likely to report a lack of support, decreased confidence to nurse initiate medication and inability to access resources in narratives. This study does not suggest these RNs lack the qualifications, experience or English language competence to work autonomously to make appropriate clinical decisions. Australia is a diverse, multicultural country and RNs from countries in which English is not the primary language are increasingly required to meet staff shortages in the aged care industry. The lower level of perceived autonomy and support could be related to a lack of cultural or linguistic understanding of the workplace practices, rather than the actual workplace practices inhibiting nursing care. The operational strategies implemented to ensure facilities could expand and grow as a viable business may have failed to keep pace with the clinical practices needed to maintain a caring industry. Changes may become evident in areas such as developing management strategies to value feedback and input from RNs and formats of delivering training to help anmf.org.au

staff with difficulty understanding the cultural differences in management structure and workplace practices in Australia.

Limitations

The small number of participants may limit generalisability to the whole aged care sector. The reporting of organisation type by the broad categories of ‘for-profit’, ‘government’ and ‘not-for-profit’ provided no details related to size of facility, part of a chain, etc. which could skew results. The use of an online survey to collect data may have excluded some nurses from participating. Although the survey was anonymous and no participant identifiable data was collected, some nurses may have been hesitant to participate. Despite this, the study highlights some issues with the trend towards a dominance of a market driven approach to the aged care sector in South Australia which warrants further study.

Conclusion

It is important to address factors that negatively influence professional autonomy in the aged care sector in order to ensure provision of quality, person-centred care. This study highlights the complex issues involved in a ‘caring’ industry, within the constraints of a market driven by the need for efficiency and productivity due to ageing population

and increased dependency on aged care facilities. ‘A one size fits all’ approach to management of an aged care facility will not guarantee a positive outcome for residents. Every facility has a different mix of resident types, varying levels of resource available and a different mix of staff skills, experience and cultures. There is no doubt that the private sector will be supplying increasingly more beds and health services in the future, with the large corporations best placed to capitalise on the industry growth. In developing strategies for maintaining professional nursing autonomy and maintaining quality care, the bureaucrats and administrators of aged care organisations need to address issues not only related to organisational and workplace conditions. This includes ensuring staff in leadership positions have not only marketing, planning and financial management skills but are also capable and trained in meeting the needs of culturally diverse staff. This could assist to establish positive workplace environments in which staff feel valued and are able to contribute to policies and innovation in work practices. Shirley Papavasiliou, RN, BN, Grad. Cert. Pall. Care, works for Country Health SA

Sabatino, L., Stievano, A., Rocco, G., KIallio, H., Pietila, A.M. & Kangasniemi, M.K. 2014. The dignity of the nursing profession: A meta-synthesis of qualitative research. Nursing Ethics. 21(6):659-72. Scourfield, P. 2011. Caretilization revisited and the lessons of Southern Cross. Critical Social Policy. 32(1):13748. Sturgeon, D. 2010. ‘Have a nice day’: consumerism, compassion and healthcare. British Journal of Nursing. 19(16): 1047-51. Sudholz, A. 2016. Japara Healthcare: Overview on Residential Aged Care Market in Australia. Japara Healthcare Limited. Victoria. Weston, M.J. 2010. Enhancing Autonomy and Control over Nursing Practice. The Online Journal of Issues in Nursing. 15(1).

March 2017 Volume 24, No. 8 31

BOOKS / APPS HEART OF THE SKY B O O K S

BY FIONA MCARTHUR PUBLISHER: PENGUIN RANDOM HOUSE AUSTRALIA ISBN: 978-0-14-379983-2

RRP:

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BY EMMA GREY & AUDREY THOMAS PUBLISHER: EXISLE PUBLISHING ISBN: 978-1-925335-32-3

NURSE DIARY APP

AVAILABLE: ITUNES - IOS

A P P S

The Nurse Diary App offers a handy electronic diary that allows users to plug in their rosters and set up shift reminder alarms. It also provides specialist features for nurses including access to feature articles and handy contacts. The shift planner allows nurses to enter upcoming shifts by clicking on simple icons that incorporate both regular and irregular shift times. The app also allows users to record the hospital name they work at, set alarms for shifts, and add shift notes. The Nurse Diary identifies the user’s location

Sitting at the arrivals hall at Canberra airport on a Sunday RRP: for six and a half hours with two teenage girls waiting for a $29.99 glimpse of their idol American YouTuber Colleen Ballinger seemed a waste of time to co-author Emma Grey. Until she learned of her daughter’s friend’s mother diagnosis with early-onset dementia in her 40s a few weeks later. That was the defining moment when Grey realised with unwavering certainty that she wanted to spend more time hanging around arrivals lounges with teenage fangirls. I Don’t Have Time. 15 minute ways to shape a life you love is an inspiration to prioritise what is really important to you. Through humour in stories, theories and exercises and checklists, this practical guide helps the reader make progress in the areas that matter most.

and automatically displays state and national holidays and other dates significant to nurses. A nurse or midwife can enter and store daily notes from their workplace for relevant events. The app features articles specifically for nurses ranging from stress management guides, social media tips, information on working with clients with dementia, violence in the workplace, and codes of conduct. A homepage monthly calendar displays shift types for morning, afternoon, and night, with rosters able to be inserted in easy blocks or by individual days if required. Adding a shift reminder alarm is simple and has a range of options. The Nurse Diary App is an ideal tool for nurses working within the hustle and bustle of the health sector as it provides a handy way to remember important events.

AUSMED CPD APP

AVAILABLE: ITUNES - IOS

32 March 2017 Volume 24, No. 8

FREE

clearly outline achievable objectives relating to gaps in practice. The app’s biggest plus is that it can record a CPD activity in one tap and stores photos of certificates along with documentation, allowing users to keep track of their ongoing CPD hours. Other handy features include recording conference/seminars and online learning, the ability to track two professions at the same time for those with dual qualifications, a built in reflection tool with helpful questions, and weekly or monthly documentation reminders. You can also automatically synch documentation with Ausmed’s online website, so users can write a more extensive reflection on their CPD at a later time. When information is required, all you need to do is download a full PDF summary of documentation from the website.

A P P S

FREE

Ausmed has created a free CPD app that gives nurses and midwives the ability to record their CPD on the go and build a handy portfolio of important documentation. The Nursing and Midwifery Board of Australia (NMBA) has started auditing nurses and midwives for compliance with CPD and now expects solid evidence that learning needs have been identified and prioritised prior to education. From the get go, the Ausmed app allows users to develop a learning plan and

B O O K S

I DON’T HAVE TIME. 15-MINUTE WAYS TO SHAPE A LIFE YOU LOVE

Leaving behind tragedy in a seaside town, oncology nurse Tess Daley takes up a position as a breast care nurse with the Royal Flying Doctor Service in Mica Ridge. A mysterious new pilot also arrives but with a secret that will change the life of someone at the station forever. Heart of the Sky reveals the stoicism of Australia’s outback women and shines a light on the work of the RFDS in the lives of women distanced from medical facilities. Author Fiona McArthur worked as a rural midwife and clinical midwifery educator. McArthur says she wanted Heart of the Sky, her fourth novel, to highlight some of the extra challenges rural and remote cancer sufferers deal with and how their families rise to the challenge.

anmf.org.au

INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

FIGURE 1 - IWII WOUND INFECTION CONTINUUM

FOCUS

BIOFILM

Increasing microbial virulence and/or numbers

Contamination

Colonisation

Local infection

Vigilence required

Spreading infection

Systemic infection

Intervention required

No antimicrobials indicated

Topical antimicrobials

Systemic and topical antimicrobials

WOUND INFECTION IN CLINICAL PRACTICE UPDATE By Terry Swanson and Donna Angel The International Wound Infection Institute (IWII) launched the updated consensus document Wound infection in clinical practice: Wounds International 2016 at their AGM held during the Wound Australia Inaugural Conference in Melbourne, November last year https://www.woundsaustralia.org.au This document is a resource to guide and inform clinical practice regarding wound infection. It is free to download on http:// www.woundinfection-institute. com/2016/11/wound-infection-inclinical-practice-update2016 This 30-page document has 10 chapters: • • • • • • • • • •

Principles of best practice The wound infection continuum Biofilm in the wound Diagnosis of wound infection Holistic management Wound bed preparation Topical antimicrobial therapy Antibiotic therapy Future developments Glossary.

This easy to read consensus document also has practice points, tables and diagrams that clinicians can use to educate others. A collaborative team effort developed this document through a comprehensive review of the literature, and conducted a formal Delphi process to reach consensus on wound infection issues for which scientific research was minimal or lacking. anmf.org.au

THE IWII IS A VOLUNTARY INTERDISCIPLINARY ORGANISATION THAT IS DEDICATED TO ADVANCING AND IMPROVING PRACTICE RELATING TO PREVENTION AND MANAGEMENT OF WOUND INFECTION.

Highlights of this document includes updated definitions, presentation of new paradigms and advances in the management, and diagnosis of wound infection as well as discussion of controversial areas as noted in Figure 1 of the Wound Infection Continuum. This 2016 version has included biofilm, changed the terminology from bacteria to microbes, and emphasised virulence, deleted the term critical colonisation and added action arrows.

To complement the wound infection continuum a table is also provided that provides the signs and symptoms (S&S) associated with each stage of the continuum. Further information regarding criteria indicative of biofilm is noted and effective management strategies for holistic care of the person with an infection or at risk of an infection are included. The IWII is a voluntary interdisciplinary organisation that is dedicated to advancing and improving practice relating to prevention and management of wound infection. Membership is free and the website provides members with free to download information to enhance everyday practice.

Terry Swanson NPWM, FAWMA is the Immediate Past Chair of the International Wound Infection Institute and Chair of 2016 Consensus Document Donna Angel NPWM BN MSc PGDip MACN is Secretary of the International Wound Infection Institute March 2017 Volume 24, No. 8 33

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INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

INFECTION PREVENTION: PERIPHERAL INTRAVENOUS CATHETER ASSESSMENT AND CARE By Gillian Ray-Barruel Peripheral intravenous catheters are the most common device in hospital patients, but they do come with infection risks. Awareness of the complications and regular assessment can reduce risks and improve patient outcomes. Around 10 million patients are admitted to Australian hospitals annually (AIHW, 2015), and 70% will need at least one peripheral intravenous catheter (PIVC) during their hospital stay (Zingg and Pittet, 2009). Despite the prevalence of PIVCs, they are not without risk. Unfortunately, one-third of PIVCs stop working or fall out before treatment is completed (Wallis et al. 2014). This means another PIVC often has to be inserted: a time-consuming and uncomfortable procedure. A common problem with PIVCs is phlebitis, or inflammation of the vein, which can be mechanical, chemical or infective (Campbell, 1998). Mechanical phlebitis is caused by movement of the catheter within the vein. Chemical phlebitis results when the intravenous (IV) medication or fluid irritates the tunica intima, the internal lining of the vein. And infective phlebitis occurs when microorganisms colonise the catheter and begin an infective process. Clinical signs of phlebitis include pain, redness, swelling, hardness of tissues, palpable cord, or purulent discharge from the insertion site (Ray-Barruel et al. 2014). The PIVC should be removed if any signs of phlebitis are detected because local infection can lead to serious bloodstream infection. There are four possible pathways to PIVC infection: 1. During catheter insertion microbes from the patient’s skin, contaminated disinfectant or healthcare worker’s hands may migrate down the catheter tract into the bloodstream; 2. Inadequate decontamination of the catheter hub prior to administering fluids or medications may facilitate microbial entry; 3. Bacteria already circulating in the bloodstream may attach to the PIVC and cause a local infection; and 4. Contaminated IV fluids or medications may introduce microbes into the bloodstream (Crnich and Maki, 2002). The PIVC insertion site is a breach of skin integrity leading directly to the bloodstream. Therefore, asepsis principles must be applied during catheter insertion, dressing changes or whenever the catheter is accessed. Handwashing is essential before touching a patient and their lines and dressings, and when preparing medications and IV fluids (Morris and Heong Tay, 2008). Scrubbing the catheter hub and allowing it to air-dry before accessing will reduce the risk of microbial entry (Moureau and Flynn, 2015).

34 March 2017 Volume 24, No. 8

CLINICAL SIGNS OF PHLEBITIS INCLUDE PAIN, REDNESS, SWELLING, HARDNESS OF TISSUES, PALPABLE CORD, OR PURULENT DISCHARGE FROM THE INSERTION SITE (RAY-BARRUEL ET AL. 2014).

Ensuring the IV dressing is clean, dry and intact, and that IV lines are secured, will reduce micromotion of the catheter within the vessel (Marsh et al 2015). It’s also best to check that prescribed IV medications can be delivered via peripheral veins, as many medications are irritating to smaller veins and may need to be delivered via a central venous device. Regular assessment is the key to prevention and early detection of IV complications. Phlebitis scales are not recommended (Ray-Barruel et al. 2014). Instead, nurses need to routinely ask, “Is the IV needed? Is the IV working? Is the IV tolerated?” If the answer to any of these is “No”, or if there are any signs of infection, the PIVC should be removed. Prevalence studies have shown that 25–30% of PIVCs are left in situ when not in use, which greatly increases infection risk (Limm et al. 2013; New et al. 2014; Alexandrou et al. 2015). Overall catheter dwell time is a risk factor for PIVC infection (Zhang et al. 2016). However, routine changing of PIVCs does not reduce the risk of infection (Webster et al. 2013). Instead, daily consideration of the patient’s continued need for IV access should be a priority, and catheters not in use should be promptly removed. Adherence to these principles can reduce risks of IV access and improve patient outcomes. Gillian Ray-Barruel, RN, PhD is Research Fellow, Alliance for Vascular Access Teaching and Research (AVATAR) group, National Centre of Research Excellence in Nursing (NCREN), Menzies Health Institute Queensland at Griffith University in Queensland

References Australian Institute of Health and Welfare. 2015. Admitted patient care 2013–14: Australian hospital statistics. http://www. aihw.gov.au/publicationdetail/?id=60129550483 Alexandrou, E., RayBarruel, G., Carr, P.J., Frost, S., Inwood, S., Higgins, N., Lin, F., Alberto, L., Mermel, L., and Rickard, C.M. 2015. International prevalence of the use of peripheral intravenous catheters. Journal of Hospital Medicine. 10(8):530–533. Campbell, L. 1998. I.V.-related phlebitis, complications and length of hospital stay: part 1. British Journal of Nursing. 7(21):1304– 1306,1308–1312. Crnich, C.J. and Maki, D.G. 2002. The promise of novel technology for the prevention of intravascular devicerelated bloodstream infection: 1. Pathogenesis and shortterm devices. Clinical Infectious Diseases. 34(9);1232–1242. Limm, E.I., Fang, X., Dendle, C., Stuart, R.L., and Egerton Warburton, D. 2013. Half of all peripheral intravenous lines in an Australian tertiary emergency department are unused: pain with no gain? Annals of Emergency Medicine. 62(5):521525. Marsh, N., Webster, J., Mihala, G., and Rickard, C.M. 2015. Devices and dressings to secure peripheral venous catheters to prevent complications. Cochrane Database of Systematic Reviews. 6: CD011070. Morris, W. and Heong Tay, M. 2008. Strategies for preventing peripheral intravenous cannula infection. British Journal of Nursing. 17:S14–S21.

Moureau, N.L. and Flynn, J. 2015. Disinfection of needleless connector hubs: clinical evidence systematic review. Nursing Research and Practice. 796762. Ray-Barruel, G., Polit, D.F., Murfield, J.E. and Rickard, C.M. 2014. Infusion phlebitis assessment measures: a systematic review. Journal of Evaluation in Clinical Practice. 20(2):191–202. Wallis, M.C., McGrail, M., Webster, J., Marsh, N., Gowardman, J., Playford, E.G., and Rickard, C.M. 2014. Risk factors for peripheral intravenous catheter failure: a multivariate analysis of data from a randomized controlled trial. Infection Control and Hospital Epidemiology. 35(1):63–68. Webster, J., Osborne, S., Rickard, C.M. and New, K. 2013. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews. 4: CD007798. Zhang, L., Cao, S., Marsh, N., Ray-Barruel, G., Flynn, J., Larsen, E., and Rickard, C. M. 2016. Infection risks associated with peripheral vascular catheters. Journal of Infection Prevention. 17(5), 207-213. doi:10.1177/1757177 416655472 Zingg, W. and Pittet, D. 2009. Peripheral venous catheters: an underevaluated problem. International Journal of Antimicrobial Agents. 34(Suppl. 4): S38–S42.

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INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

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References Edwards, J., and Stapley, S., 2010. Debridement of diabetic foot ulcers. Cochrane Database of Systematic Review. Issue 1. Art: CD003556. DOI: 10.1002/14651858. CD003556.pub2. Gibson D, Cullen B, Legerstee R, Harding KG, Schultz G. 2009. MMPs Made Easy. Wounds International 2009; 1(1): Available from http://www. woundsinternational. com

DEBRIDING WOUNDS TO REDUCE BIOBURDEN By Gabrielle Munro Approximately 60-90% of chronic wounds have bioburden, which is associated with non-viable tissue in the wound bed and is often difficult to detect with the naked eye (Harries et al. 2016). It is well evidenced that debridement is an effective method to remove the bioburden when managing chronic wounds. Debridement is defined by Wounds UK, 2013, as, the removal of dead, non-viable/devitalised tissue, infected or foreign material from the wound bed and surrounding tissue. In some chronic wounds bacteria may colonise in the wound bed without impairing the healing process. When wounds are in the inflammatory phase of healing the body releases inflammatory cells; neutrophils and macrophages, along with cytokines and proteases that produce matrix metalloproteinases (MMPs) to assist with wound healing. The MMPs cut up the attachment between the bacterial biofilms and the wound bed assisting the wound to move through the phases of healing (Gibson et al. 2009). As the chronicity of the wound increases so does the bacterial load, and the body’s ability to self debride becomes impaired and the wound becomes delayed in the inflammatory phase of healing (Powers et al. 2015). More is being understood about the role of matrix metalloproteinases in wound healing. At this stage we do not know the level of proteases needed for actual wound healing. Chronic wounds often have elevated MMPs. The balance is to have the right amount of MMPs to assist with anmf.org.au

debridement, but not too many for too long as the MMPs then start to degrade the growth factors and receptors preventing angiogenesis and the contraction and remodelling of the ECM (Norman et al. 2016).

THE QUESTION IS NOT ONLY IF DEBRIDEMENT SHOULD OCCUR, IT IS HOW, WHO AND WHEN DEBRIDEMENT IS APPROPRIATE.

Despite the level of MMPs, nonviable tissue and bioburden delays healing. Debridement is considered gold standard to remove nonviable tissue and disturbs the cell cycle at a molecular level. It forces the chronic wound back into the inflammatory phase where healing can be resumed, with normal extracellular formation of granulation tissue, angiogenesis and epithelialization (Madhok et al. 2013; Wounds UK 2013; Harris 2009; Lebrun et al. 2010).

There are a number of techniques clinicians may choose to debride a wound in clinical practice. These methods include; autolytic, mechanical, enzymatic, biological, conservative sharp, surgical sharp, ultrasonic and hydrosurgical. In 2010, a systematic review by Edwards and Stapley conceded the best method to debride is not well evidenced due to low quality and methodological flaws of studies. More research needs to be done on debridement per se and the different methods of debridement to achieve wound healing. The question is not only if debridement should occur, it is how, who and when debridement is appropriate. Then the decision is about what method or mode of debridement promotes the better, safer more officious outcome for the client and is adaptable to multisite settings for implementation into everyday practice. Future research should evaluate multiple methods of debridement; in combination at different stages of the healing process with an outcome of total wound healing. Gabrielle Munro is a Nurse Practitioner Candidate, Goulburn Valley Health West Hume Region and Wound Consultant- Regional Wounds Victoria.

Harris, R.J. 2009. The Nursing Practice of Conservative Sharp Wound Debridement: Promotion, education and proficiency. Wound Care Canada. 7(1):.2230. Harries, R., Bosanquet, D., Harding, K., 2016. Wound bed preparation: TIME for an update. International Wound Journal. 13 (suppl. S3):8-14. Lebrun, E., TomicCanic, M., Kirsner, R., 2010. The role of surgical debridement in healing diabetic foot ulcers. Wound Repair and Regeneration.18 (5): 433-438.DOI: 10.1111/j.1524475x.2010.00619.x Madhok, B., Vowden, K., & Vowden, P., 2013. New Techniques for wound debridement. International Wound Journal. 10: 247-251. Norman, G., Westby, M.J., Stubbs, N., Dumville, J.C., Cullum, N., 2016. A ‘test and treat’ strategy for elevated protease activity for healing in venous leg ulcers (Review). Cochran Database of Systematic Review. Issue 1. Art. No.: CD011753. DOI:10.1002/14651858. CD011753.pub.2. Powers, J., Higham, C., Broussaard, K., Phillips, T., 2015. Wound Healing and treating wounds- Chronic wound care and management. American academy of Dermatology. DOI.org/10.1016/j. jaad.2015.08.070 Wounds UK. 2013. Effective debridement in a changing NHS: a UK consensus. London: Wounds UK. Available from www. wounds-uk.com/pdf/ content_10761.pdf. Assessed: Dec 2016

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NURSING AND MIDWIFERY STUDENTS TEACHING INFECTION CONTROL IN INDONESIA By Michele Wurst, Katherine Boyd and Wendy Abigail Morbidity, mortality and quality of life are impacted on by healthcare-associated infections (HAI) which are preventable. According to the World Health Organization 2016), in developing countries, around 10% of patients will contract HAI. The importance of effective infection control practices and education is recognised by services in Indonesia. However, services also realise that much more work needs to be conducted to address the burden of disease that these preventable infections cause. On a recent nursing and midwifery undergraduate study abroad program to Surabaya, Indonesia, six Flinders University students were invited to use the knowledge and skills learnt in their undergraduate degrees to conduct an infection control health promotion activity at Airlangga Hospital. The focus of this exercise was to educate patients and staff members on infection control and the impact individuals can have on reducing the spread of disease in the community and in hospital settings. The three 20 minute presentations covered the spread of disease in the 36 March 2017 Volume 24, No. 8

home, safe coughing and sneezing, and appropriate hand hygiene. Each group used props in the education sessions to encourage deeper understanding of the concepts of infection control. The session on preventing spread of diseases in the home used a PowerPoint presentation that featured clear visual messages using universal symbols or words and emoticons to illustrate points. Simple cartoon drawings of areas in the home where infection control could be improved were used to illustrate the importance of home hygiene. The audience were receptive to these and understanding was confirmed with nods of agreement, laughter and subsequent discussion with interpreters. The safe coughing and sneezing session used a lip balm and blue

glitter paste to demonstrate how sneezing into a hand could transfer microorganisms. The paste was placed in one hand and then transferred to many other hands by the simple act of shaking hands with another audience member who then shook hands with another person. The participants were then invited to examine their own hands and hold them up to see if they could see the glitter. This simple technique was very effective in demonstrating how infections can spread as nearly all the participants were showing their glittered hands. The hand hygiene session used short videos to offer visual cues and included popular music to aid in communicating the steps of hand washing. The ‘Gangnam Style’ song and YouTube video had all patients, staff and students dancing and singing along as they copied the steps. As the language barrier was a consideration, all presentations were developed with mostly visual cues to allow minimal use of interpreters. Lessons learnt by the students included the need to: use open body language, use slow and deliberate speech, and use direct eye contact. Further to this, creating a common physical space by inviting audience participation increased the learning experience. Feedback from the Director of Nursing of the hospital was extremely positive with the plan to implement the teaching strategies in future education sessions.

PARTICIPANTS AT THE INFECTION CONTROL HEALTH EDUCATION SESSION, AIRLANGGA HOSPITAL, SURABAYA, INDONESIA

Reference World Health Organization 2016, Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level, World Health Organization, viewed 10 January 2017, http://www.who.int/ gpsc/ipc-componentsguidelines/en/

Michele Wurst is a Bachelor of Midwifery student Katherine Boyd is a Bachelor of Nursing and Bachelor of Health Science student Dr Wendy Abigail is a Lecturer in the School of Nursing and Midwifery All are at Finders University, Adelaide anmf.org.au

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STANDARD PRECAUTIONS BUT NO STANDARD ADHERENCE

IGNITING THE POTENTIAL OF WOUND CARE CHAMPIONS

By Stéphane Bouchoucha and Kathleen Moore Infection Prevention and Control (IPC) measures are the foundation of best practice by healthcare workers for their own safety and that of their patients, yet low adherence rates place all parties at risk. IPC practices have evolved since Semmelweiss introduced handwashing in the obstetric context, to what are now termed the Standard Precautions Guidelines (SP). These guidelines evolved to protect healthcare workers from unknown pathogens in the wake of the HIV epidemic (CDC 1987) and subsequently, have patient and healthcare workers’ safety in mind. The guidelines require healthcare workers to routinely take precautions, regardless of patients’ known or suspected infection status and to use personal protective equipment (PPEs) such as gloves, gowns, masks and eye coverings to prevent possible exposure during any procedure involving patients’ bodily fluids. The SP were updated in 2007 (Siegel et al.) in response to the emergence of new pathogens and increases in the incidence of infections caused by multi-drug resistant organisms, as well as to cover healthcare settings other than hospitals. Consequently, the use of SP is mandated across all health facilities and removes any need for staff to make judgements around their use. Despite this and the demonstrated efficacy of use, it is of great concern that staff fail to adhere to at least some if not all aspects of the guidelines (Pereira et al., 2015). Research reveals that many healthcare workers exert some judgement before deciding whether or not to implement SP. Our interviews with nurses and midwives in a large regional hospital revealed that most judged a patient’s health status, their own skill level and whether they were working with an aged patient or a baby, to decide whether or not they would adhere to the guidelines. Comments where the staff judged or evaluated the patient and/or the situation and where the use of SP was dependent on this judgement include: “Sometimes, depending on the patient, if it is a normal patient I don’t wear gloves but if it is a patient that has very flaky skin, does not look very well kept and looked after then I would put gloves on to protect myself. You kind of eyeball the patient and decide”, and “I think also that we tend to use [PPE] more when our patients are like of an unkempt appearance…” 38 March 2017 Volume 24, No. 8

A typical comment where staff judged their own skill level was: “I weigh up the risks and if I feel I am going to be successful and I am pretty damn sure I am going to get it in and I am the best person for the job in the room then I will do it and I won’t wear the gloves and usually I am ok”. All these participants had knowledge of the guidelines and their criteria for use but make conscious judgements on whether or not to use them. A worrisome aspect associated with staff making individual judgements is what might be considered a sense of invincibility. The apparent lack of fear of consequences, or perhaps more so the over confidence in their abilities, is clearly linked to violations of the guidelines (Neves et al. 2011). A sense of invincibility is re-enforced by the typical distal effect of any harm incurred as a result of non-adherence. For staff to introduce an element of judgement into their application of SP is a deviation from mandated practice. While deviance from SP by healthcare workers on the basis of their own best judgement might be considered by them to be harmless, the potential for harm is great, particularly so if these deviances are generalised and become the new norm (Price and Williams, 2015). Any deviance from accepted standards puts patients and staff themselves at risk. Furthermore, if no immediate consequences of the deviance from best practice are observed, this can act as an enabler which permits staff to justify their judgements, enhances their sense of invincibility, and reenforces their lack of adherence to the guidelines. Clearly, training institutions, managers, and the health organisations all need to address these issues for the health and wellbeing of both patients and staff. Stéphane Bouchoucha is a Lecturer in Nursing and a Researcher for the Quality and Patient Safety Research at Deakin University. Kathleen Moore is a Professor of Psychology at Federation University

By Ai Wei Ng and Sarah Sage Melbourne Health is celebrating the 13th year of a wound care champion program that has transformed 85 ward nurses into a unique group of Wound Resource Nurses (WReNs) to meet the challenges and demands of implementing evidence based wound care practices.

References Centers for Disease Control and Prevention, 1987. Recommendations for prevention of HIV transmission in healthcare settings. Mortality and Morbidity Weekly Report 36 (S), 3-18. Neves, H.C.C., Souza, A.C.S.e., Medeiros, M., Munari, D.B., Ribeiro, L.C.M., Tipple, A.F.V., 2011. Safety of nursing staff and determinants of adherence to personal protective equipment. Revista Latino-Americana de Enfermagem 19 (2), 354-361. Newson, S.W.B., 2001. The history of infection control: Semmelweis and handwashing. British Journal of Infection Control 2 (4), 24-25. Pereira, F.M.V., Lam, S.C., Chan, J.H.M., Malaguti-Toffano, S.E., Gir, E., 2015. Difference in compliance with Standard Precautions by nursing staff in Brazil versus Hong Kong. American Journal of Infection Control 43 (7), 769-772. Price, M., Williams, T., 2015. When doing wrong feels so right: normalization of deviance. Journal of Patient Safety 00 (00), 00-00. Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., Committee, H.I.C.A., 2007. Guidelines for isolation precaution: preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention, Atlanta.

This program defines WReNs as advocates and leaders to their respective wards who influence change by identifying gaps, prioritising the needs of stakeholders and promoting innovations. The success of the program is due to a group of committed nurses with passion and persistence to shift attitudes with the intention to reinforce evidence based care (EBC).

THIS PROGRAM DEFINES WRENS AS ADVOCATES AND LEADERS TO THEIR RESPECTIVE WARDS WHO INFLUENCE CHANGE BY IDENTIFYING GAPS, PRIORITISING THE NEEDS OF STAKEHOLDERS AND PROMOTING INNOVATIONS. WReNs attend 10 meetings/year for 90 minutes, which cover: • organisational direction (review of pressure injury data, wound prevalence data); • provide input on any changes to skin related policies, education and forms; • review of a journal or education; • up and coming WReN focus (e. local audit, study days); • local projects; • collegial support to the group. The WReNs complete annual online education modules, a face-to-face study day and two to three local area audits supporting the organisational direction, for example mattress age and use, appropriateness and use of prophylactic dressing, and Wound Prevalence Survey. The completion of these has led to direct changes at Melbourne Health, such as additional funding for new mattresses, research anmf.org.au

INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

around optimal beds and changes to mandatory training for staff. Implementing the program structure, maintaining WReN monthly meeting attendance, preserving the sense of role identification and meaningfulness across the organisation is challenging. Despite the obvious benefits of the program, WReNs are often confronted by their own struggle in promoting positive changes while faced with a shortfall of support and recognition by their colleagues. Finding ways to promote the value of the role to the wider Hospital community and build resilience amongst the WReNs has been a focus of the Wound Clinical Nurse Consultants (CNCs) who coordinate the program. One approach is to improve communication and collaboration by having regular informal face-to-face discussions with WReNs and nurse unit managers to identify problems, make clinical decisions and evaluate processes. Other essential components are: • ensure WReN portfolio aligns responsibilities and performance standards with the organisation goals; • develop WReN Intranet page that showcases WReN members and online resources; • WReN newsletter; • wound notice board that intrigues others in the WReNs’ activities and updates in wound care practices and policies; • wound care related quality projects produced by WReNs are celebrated during Wound Awareness Week via the staff bulletin, and • the WReN role is highlighted in organisational campaigns such as Pressure Injuries Prevention and Management. It is inevitable that these aspiring ward wound care nurses who are enthusiastic in making a difference will continue to face multi-faceted challenges. As their facilitators, Wound CNCs at Melbourne Health understand that aligning shared vision and purpose with the patients, healthcare colleagues, managers and executives is integral, but constantly adjusting the structure and function of these ‘local experts’ as they continue to evolve is vital to keep their passion ignited. Ai Wei Ng is Clinical Nurse Consultant-Wound Management at the Royal Melbourne Hospital, Victoria Sarah Sage is a Clinical Nurse Consultant-Wound Management; Coordinator Chronic Wound Service, Wound CNC team at the Royal Melbourne Hospital, Victoria anmf.org.au

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USING POSITIVE CLINICAL LEADERSHIP TO SUPPORT A CULTURE OF PRESSURE INJURY PREVENTION By Sarah Sage and Hannah Tudor The Royal Melbourne Hospital (RMH) is an 800 bed tertiary referral service within metropolitan Melbourne. While the hospital acquired pressure injury (HAPI) incidence rate is low (2.5%), there is still work to be done in this area. A culture of continuous learning is primarily driven by ward leadership (Wang et al. 2013). It is charactered by: a positive reporting culture (ie. Not punishing individuals who report risk or near misses); viewing adverse events as an opportunity for learning; understanding that adverse events are a failure of the systems rather than the individual; clear statement by the nursing leadership that HAPI prevention is important and that a reduction is possible, (Dellefield and Magnabosco, 2014).

THE CNCs ARE NOW ABLE TO IDENTIFY BARRIERS TO EVIDENCE BASED CARE AND ORGANISATIONAL TRENDS THAT MAY NOT BE VISIBLE AT THE LOCAL WARD LEVEL.

Over the last 16 months, RMH has been using ‘Pressure Injury Leadership Rounding’ between the Clinical Consultant-Wound Management (CNC wound) team and ward Nurse Unit Managers (NUMs) in order to support the development of a continuous learning culture in relation to pressure injury prevention. As well as rostered leadership rounds, additional rounds occur when a ward has: • high reported HAPIs; • very low reported HAPIs or • requests a round. The pressure injury (PI) round reviews: • The local PI data - whether it’s trending up or down? Are there particular patterns? Eg. related to

medical equipment;

• how does the ward feel about

their trend;

• what would the ward like more

help with;

• what are they feeling proud of.

Whether this can be celebrated to the wider hospital community and can this approach be helpful to other units; • a walk around the ward including a review of the equipment and clinical assessments. The PI round process supports a positive reporting culture by celebrating the successes, honestly looking at the data and valuing how the ward perceives their progress and priorities. In the RMH ICU department a more frequent PI round has taken place (fortnightly) for the past 12 months, the HAPIs reduced by 21% over six months (51) when compared to the same period in 2015 (64), following the introduction of this approach. The rounds have led to safety huddles focused on skin topics (skin tears and the correct use of dynamic air mattresses) delivered by the WReN and NUM. The CNCs are now able to identify barriers to evidence based care and organisational trends that may not be visible at the local ward level. This has increased visibly of ward challenges to the hospital executive leadership and lent support to collaboration, research projects and a quality improvement project studying better procurement and monitoring of purchased hospital beds, mattresses and their effects on patient and staff safety. Sarah Sage is Clinical Nurse Consultant-Wound Management; Coordinator Chronic Wound Service, Wound CNC team at the Royal Melbourne Hospital, Victoria Hannah Tudor is Clinical Nurse Consultant-Wound Management at the Royal Melbourne Hospital, Victoria

References: Dellefield, M.E. and Magnabosco, J. L. (2014). Pressure Ulcer prevention in nursing homes: Nurse descriptions of individual and organization level factors. Geriatric Nursing. Vol. 35, pp 97-104. Wang, W., Liu, K., You, L., Xiang, J., Hu, H., Zhang, L. and Zhu, X. (2013). The relationship between patient safety culture and adverse event: questionnaire survey. International Journal of Nursing Studies. Vol. 51 pp 1114-1122.

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being conducted by the School of Nursing and Midwifery, Uni SA, supported by an Industrial Commonwealth grant to determine whether the scanner is reliable, accurate and usable for midwives during the childbirth continuum. This bladder scanner has real time imaging and the ability to edit results. See figure 1. The Uscan Bladder Scanner.

FIGURE 1 – THE USCAN BLADDER SCANNER

The first phase of the study will determine the reliability of the scanner. During this phase, two midwives scanned n=12 pregnant (over 36 weeks) and newly birthed women consecutively, to compare the urine volumes measured between the two practitioners. The results demonstrated that the scanner was not accurate antenatally. Engineers changed algorithms and editing function to combat the problems identified. The bladder scanner will be re-tested on pregnant women. The scanner has been tested on n=12 newly birthed mothers and results demonstrated that the scanner is reliable to use postnatally. Intraclass correlation between two raters for absolute agreement, single measures was found to be 0.97 (95% confidence interval 0.833-1.00).

POTENTIAL TO REDUCE URINARY TRACT INFECTIONS WITH THE USE OF BLADDER SCANNERS IN MATERNITY CARE By Belinda Lovell and Mary Steen The National Medical Research Council Australia website states that 20% of hospital acquired infections are urinary tract infections (UTIs). This percentage is derived from a study involving 75,694 participants, undertaken in England, Wales, Northern Ireland and the Republic of Ireland and of the reported UTIs, 40-57% are caused by urinary catheters (Smyth et al. 2008). During labour and following birth some women will be catheterised, but there is potential to use bladder scanners to determine bladder volume as an alternative to catheterisation. Bladder scanners are used to detect the volume of urine in the bladder of a person unable to void, showing signs of voiding dysfunction or urinary retention. However, the accuracy and reliability of bladder scanners appears to be inconclusive, during the childbirth continuum. Catheterisation has remained a standard treatment for voiding dysfunction in pregnancy, 40 March 2017 Volume 24, No. 8

labour and for newly birthed mothers with urinary retention. There are several risk factors associated with catheterisation such as: UTI, urethral trauma, discomfort, negative psychological effects and unnecessary insertion. The use of bladder scanners have the potential to reduce these associated risks however, research using the latest technology is required.

Bladder scanner study

A new bladder scanner has been developed by a South Australian company and research is currently

The second phase will involve recruiting a group of midwives at the Women’s and Children’s Hospital, Adelaide to undertake education and training to use the bladder scanner. These midwives will then go on to recruit women who have been assessed as requiring catheterisation after vaginal birth and during labour (if shown to be reliable in phase one). The women will be scanned before and after catheterisation and the volume of urine estimated by the bladder scanner will be compared to the volume of urine drained from the catheter. Finally, focus groups will be conducted to gain feedback from midwives about the usability of the scanner. There is potential, if the bladder scanner is deemed reliable, accurate and usable by midwives that it could become a valuable tool to decrease the number of catheters required in the childbirth continuum which will in turn reduce the number of UTIs, urethral trauma, uncomfortable sensation and embarrassment for women which will positively impact healthcare costs, length of hospital stay and family separation. Belinda Lovell is Project Officer – Midwifery at the University of South Australia Dr Mary Steen is Professor of Midwifery at the University of South Australia

References Smyth, E., G. McIIvenny, J. E. Enstone, A. M. Emerson, H. Humphreys, F. Fitzpatrick, E. Davies, R. G. Newcombe, R.C. Spencer. 2008. Four country healthcare associated infection prevalence survey 2006: overview of the results. Journal of Hospital Infection. 69(3): 230-248.

anmf.org.au

INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

PERINEAL WOUND CARE: EDUCATION AND TRAINING IN AUSTRALIA By Monica P Diaz and Mary Steen In Australia, approximately 75% of women who have a vaginal birth will sustain some form of perineal trauma (AIHW 2013); and over half of perineal injuries will require suturing. Perineal wound care is an important aspect of women’s health and many newly birthed mothers will require follow up care, some well beyond the postnatal period (Steen, 2012). A number of studies have demonstrated that the success of a perineal repair and associated morbidity outcomes for women who sustain perineal wounds during childbirth is influenced by the skill of the operator (Dahlen & Homer, 2008; Cioffi & Arundell, 2010, Selo-Ojeme et al. 2015 and Wilson et al. 2012). Perineal wound management and repair education in Australia currently lacks standardisation and access (Dahlen & Homer, 2008). Education and training programs, including regular accreditation and updates vary significantly across Australian organisations (Dahlen & Homer, 2008).

Acknowledging the importance of perineal wound care Effective perineal wound care education and training requires dedicated time of a skilled and experienced clinician to provide the education (theory and practical) and supervise perineal wound repair practice. Adding to this is the time required for midwives to be away from the clinical setting to attend education and training workshops in order to develop and maintain their

knowledge and skills. Undertaking, continual profession development has significant implications on the already stretched staffing resources. Therefore, perineal wound care education and training often takes a back seat when other essential mandatory updates are required. The lack of educational opportunities leads to a limited number of qualified midwives being able to repair perineal wounds, thus increasing the demands on accredited staff members, who more often than not are medical officers. As a result, women who sustain perineal trauma can be left waiting for significant periods of time for a qualified clinician to undertake the perineal repair. Women in turn feel a great sense of dissatisfaction with healthcare providers as they feel ‘dismissed, devalued and disregarded’ Priddis et al. (2012, p. 753). Women who experience severe perineal trauma during childbirth are prone to social isolation and marginalisation as a result of their ongoing symptoms; such as faecal and urinary incontinence, sexual dysfunction, pain and depression (Priddis et al. 2012). These issues have a profound negative impact on a mother’s physical, mental and social wellbeing (Halperin et al. 2010). It can affect maternal attachment with their newborn and also relationships

with partners/family. Perineal trauma following childbirth is a costly affliction on healthcare provision, yet one that through appropriate and ongoing education of the risks, how to recognise and repair, prevent infection, promote healing and the importance of alleviating perineal pain, and follow up care could be significantly reduced.

The perineal wound care project

The Wound Healing Institute Australia (WHIA) and Wound Management Innovation Cooperative Research Centre (WMI CRC) both have acknowledged the current deficit in perineal wound care education and training across Australia and funded a collaborative project. Currently, these organisations are working in collaboration with the School of Nursing and Midwifery at the University of South Australia on the development of an online module for perineal wound care. The overall aim of the program will be to provide midwives and midwifery and medical students with a standardised education and training program that is evidence based and accessible. There is currently no such educational and training program in Australia thus, pioneering the way for better perineal wound care. In addition, this online module will be linked to some practical simulation workshops being offered and an impact evaluation will be undertaken to assess participant levels of pre and post knowledge, confidence and clinical skills. Monica P Diaz is a Clinical Midwife/ Registered Nurse, WCHN and Research Midwife at the University of South Australia Dr Mary Steen is Professor of Midwifery at the University of South Australia

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References Dahlen, H.G. and Homer, C.S.E. 2008. What are the views of midwives in relation to perineal repair? Science Direct. 21:27-35. Cioffi, J.M., Swain, J. and Arundell, F. 2010. The decision to suture after childbirth: cues, related factors, knowledge and experience used by midwives. Midwifery. 26:246-255 Halperin, O., Raz, I., Ben-Gal, L., Or-Chen, K. and Granot, M. 2010. Prediction of perineal trauma during childbirth by assessment of striae gravidarum score. Journal of Obstetric and Gynaecologic Neonatal Nursing. 39:292-297. Priddis, H., Dahlen, H. and Schmied, V. 2012. Women’s experiences following severe perineal trauma: a metaethnographic synthesis. Journal of Advanced Nursing. 69(4):748-759. Steen, M. 2012. Risks, Recognition and Repair of perineal Trauma. British Journal of Midwifery. 20(11):768772 Wilson, A.E. 2012. Effectiveness of an educational programme in perineal repair for midwives. Midwifery. 28:236-246. Australian Institute of Health and Welfare. 2015. Australia’s mothers and babies 2013—in brief. Perinatal statistics. series no. 31. Cat no. PER 72. Canberra: AIHW. Selo-Ojeme, S., Pathak, S. and Joshi, V. 2015. The knowledge, practice and opinion of midwives in the UK on their training in obstetric perineal repair. Archives Gynecology Obstetrics. 291:1265-1270.

MONASH WOUND CARE: COURSES THAT FIT AROUND YOU. CRICOS provider: Monash University 00008C

If you’re looking to build your skills in an area of growing demand, our graduate wound care course could help you take the next step. And because we realise that scheduling can be tough enough for nurses as it is, we offer much of the course online, so you can study when it suits you.

EARN A GRADUATE CERTIFICATE, A GRADUATE DIPLOMA OR A MASTER’S We know a whole master’s isn’t for everyone. That’s why our course is designed with multiple exit points, so you can leave with a graduate certificate or graduate diploma instead if you prefer. Applications for semester 1, 2017 close November 30, 2016

monash.edu/wound-care

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INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

IMPROVING INFECTION PREVENTION AND CONTROL PRACTICES IN A CULTURALLY, LINGUISTICALLY AND SPIRITUALLY DIVERSE ENVIRONMENT

STOP THE CYCLE OF CONTAMINATION AND DEATH

By Vanessa L Sparke, David MacLaren, Jane Mills, Rowena Asugeni, Kenny Moutoa and Caryn West

By Catherine A Sharp and Mary-Louise McLaws

Atoifi Adventist Hospital (AAH) in the Solomon Islands serves a population of 80,000 people, many living in small remote villages. Atoifi is situated on the east side of the island of Malaita in the East Kwaio region. Kwaio is one of 12 language groups on Malaita and most people engage in the subsistence economy.

Pressure ulcers (PUs) are a serious adverse event for patients that could be prevented (Thomas, 2001). Immobility and the resulting unrelieved pressure (Sharp and McLaws, 2006; Gefen et al. 2008) on muscle tissue overlying bony prominences is thought to be a major risk factor for deep tissue injury (Gefen et al. 2008).

Oral language is the dominant form of communication and most traditional (and contemporary) knowledge is handed down this way. Ninety-five percent of Solomon Islanders identify as belonging to a Christian denomination however the mountain residents of Kwaio retain many traditional practices and ancestral religious beliefs (MacLaren 2009). This includes interacting with spirits of the Kwaio ancestors who are integral to everyday life and who watch their descendants to ensure they keep to a complex set of rules. Following these rules brings prosperity while violation of these rules brings punishment in the form of sickness, death, social and economic misfortune (MacLaren 2009). Since its opening in 1966, AAH has had a solid reputation for delivering high quality patient care. However due to the hospitals’ layout, location of maternity ward and toilet arrangements that do not reflect Kwaio cultural beliefs, many Kwaio who worship their ancestors do not access hospital services. Being in a tropical environment, a remote location and with limited financial resources AAH faces many IP&C challenges. A 2014 local measles outbreak and a 2015 dysentery outbreak resulted in high (56%) hospitalisation rates (Diau et al. 2014). Although there was community action in response to the outbreaks such as vaccination and hygiene awareness, there was a lack of formalised Infection Prevention and Control (IP&C) practices. AAH, in partnership with JCU is aiming to develop, implement and evaluate the introduction of an IP&C program at AAH. Developing and implementing an IP&C program at AAH requires a sustainable ‘bottom-up’ approach and needs to be targeted to the local context, yet at the same time meet the 42 March 2017 Volume 24, No. 8

minimum requirements of world-wide IP&C practices. Locally appropriate approaches are therefore needed to progress this important work. Photovoice is one such approach that can be used by a variety of people, across a variety of languages and world views. Photography is used to document people’s needs, experiences and perceptions. As a result photovoice enables people to record and reflect their community’s strengths and concerns, promote dialogue and share knowledge about issues (Wang & Burris 1997). With staff and patients of AAH being from multiple language groups and having differing religious and cultural beliefs, photovoice offers a powerful means of providing insight into the perceptions of IP&C as well as highlighting the IP&C deficits and opportunities. This bottom-up development allows for an appropriate IP&C plan to be collaboratively developed to heighten implementation challenges and successes in this remote Pacific island hospital. Vanessa L Sparke is a Lecturer in Nursing Midwifery & Nutrition; Dr David MacLaren is Senior Research Fellow in the College of Medicine and Dentistry and Associate Professor Caryn West is Director WHOCC in Nursing Midwifery & Nutrition All are at James Cook University, Cairns Campus, Qld Professor Jane Mills is Pro ViceChancellor in the College of Health, Te Kura Hauora Tangata at Massey University in New Zealand Rowena Asugeni is Director of Nursing and Kenny Moutoa is Infection Control Nurse. Both are at Atoifi Adventist Hospital in the Solomon Islands.

References Diau, J , Jimuru, C, Asugeni, J, Asugeni, L, Puia, M, Moomatekwa, J, Harrington, H, MacLaren, D, Speare, R & Massey, P 2015 ‘Measles outbreak investigation in a remote area of Solomon Islands, 2014’, Western Pacific Surveillance and Response Journal, vol. 6, no. 3, pp. 17-21. http://ojs.wpro.who.int/ ojs/index.php/wpsar/ article/view/329/551 MacLaren, D, Asugeni, J, Asugeni, R, & Kekeubata, E 2009 ‘Incorporating sociocultural beliefs in mental health services in Kwaio, Solomon Islands’, Australasian Psychiatry, 17 Supplement 1: S125-127. Wang, C., & Burris, M. A. 1997 ‘Photovoice: Concept, methodology, and use for participatory needs assessment’, Health Education & Behavior, Vol 24, no. 3, pp. 369-387

Pressure damage can start within an hour of unrelieved pressure therefore relief of pressure every few minutes is vital (Sharp and White, 2015). Once a patient develops a Stage II PU or higher (ie. open wound) the risk of subsequent methicillinresistant Staphylococcus aureus (MRSA) infection increases in patients colonised with MRSA (Ramarathnam, 2015; Collins, 2007). The prevalence of MRSA colonisation of patients with a PU has been estimated to be as high as 43.5% and colonisation preceded MRSA sepsis (Pirett et al. 2007). Patients with PUs colonised with MRSA have an increased risk of death due to associated sepsis (Collins, 2007; Pirett et al. 2007). Nursing dependence of patients with a PU at Stage II or higher includes regular dressing changes over prolonged hospitalisation increasing the risk of contamination of healthcare workers’ hands during patient care (Pirett et al. 2007) in the absence of high hand hygiene compliance. To eradicate PUs and therefore PUs colonised with MRSA an alternating pressure air mattress for immobile patients is the only feasible method (Bliss, 1967; Bliss, 1995). Catherine Sharp is a PhD candidate at UNSW and a Pressure Ulcer Prevention and Infection Control Wound Care Consultant at The Wound Centre in Sydney Mary-Louise McLaws is Professor of Epidemiology, Healthcare Infections and Infectious Diseases Control at UNSW. anmf.org.au

INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

FOCUS

BOLA FASUGBA AND PROF ANNE GARDNER

References Bliss MR, McLaren R, Exton-Smith AN. (1967) Preventing pressure sores in hospital: controlled trial of a large-celled ripple mattress. British Medical Journal. Feb 18;1(5537):394-7. Bliss MR. (1995) Preventing pressure sores in elderly patients: a comparison of seven mattress overlays. Age and Ageing. 24(6):543. Cely Christine Nery Silva Pirett IAB, Rosineide Marques Ribas, Paulo P. Gontijo Filho, Augusto Diogo Filho (2012) Pressure Ulcers Colonized by MRSA as a Reservoir and Risk for MRSA Bacteremia in Patients at a Brazilian University Hospital Wounds UK. March;24 (3):67-75. Collins KA, Presnell SE. (2007) Elder neglect and the pathophysiology of aging. The American Journal of Forensic Medicine and Pathology. Jun;28(2):157-62.

CATHETER ASSOCIATED URINARY TRACT INFECTIONS (CAUTIS): A RESEARCH UPDATE By Oyebola Fasugba and Anne Gardner Infections associated with indwelling urinary catheters (IDCs) are one of the most frequently reported healthcare associated infections (Elvy and Colville 2009). Approximately 26% of patients in Australian hospitals receive a catheter while on admission (Gardner et al 2014).

Sharp CA and White RJ. (2015) Pressure ulcer risk assessment: do we need a golden hour? Journal of Wound Care. 24(3):157-9.

Management of IDCs is mainly a nursing role hence nurses need to be informed about strategies aimed at prevention of CAUTIs. Professor Anne Gardner and Bola Fasugba have worked on this topic for several years. Recent completion of the Surveillance to Reduce Urinary Tract Infections (STRUTI) project, funded by the Ian Potter Foundation and Australian Catholic University (ACU), marked a milestone in CAUTI surveillance in Australia. The STRUTI project aimed to provide evidence for proof of concept by testing a protocol for CAUTI surveillance (Mitchell et al. 2014) using an online process. A dedicated website and surveillance process were developed by a team of researchers, infection control experts and information technology specialists from ACU’s School of Nursing, Midwifery and Paramedicine; Avondale College for Higher Education; Canberra Hospital; and Victorian Healthcare Associated Infection Surveillance Coordinating Centre. Nurses, infection control practitioners and nursing aides from 82 acute care hospitals and 17 aged care facilities collected and submitted Australian data using the online database. The findings have recently been published (Mitchell et al. 2016). National online CAUTI surveillance would provide accessible Australian data to inform clinical practice improvements.

Thomas DR. (2001) Are all pressure ulcers avoidable? Journal of the American Medical Directors Association. Nov-Dec;2(6):297-301.

Other measures to prevent CAUTIs, such as reducing bacterial colonisation around the meatal area have been investigated but with poor evidence on their effectiveness. A

Gefen A, van Nierop B, Bader DL, Oomens CW. (2008) Strain-time cell-death threshold for skeletal muscle in a tissue-engineered model system for deep tissue injury. Journal of Biomechanics. 41(9):2003-12. Ramarathnam V, De Marco B, Ortegon A, Kemp D, Luby J, Sreeramoju P. (2013) Risk factors for development of methicillin-resistant Staphylococcus aureus infection among colonized patients. American Journal of Infection Control 7//;41(7):625-8. Sharp CA, McLaws ML. (2006) Estimating the risk of pressure ulcer development: is it truly evidence based? International Wound Journal. 4(3):344-353.

anmf.org.au

systematic review and meta-analysis of published studies was undertaken at ACU (Fasugba et al 2016), funded by the Australian College for Infection Prevention and Control. The results, the most comprehensive to date, identified no benefits of using antiseptics such as povidoneiodine or chlorhexidine over non-antiseptics for meatal cleaning in the prevention of CAUTIs but antibacterial agents were possibly beneficial. Methodological issues within individual studies greatly reduced generalisability of findings. Given the potential for CAUTIs to increase mortality, further exploration of meatal cleaning agents in preventing CAUTIs including costeffectiveness and patient care implications need to be explored. Nursing practice based on research evidence is imperative to ensuring better outcomes for patients.

THE RESULTS OF THIS QUANTITATIVE RESEARCH HAVE FILLED A CRITICAL GAP AND HAVE THE POTENTIAL TO INFORM POLICY REGARDING FUTURE ENACTMENT OF THE BCN ROLE.

The authors gratefully acknowledge coinvestigators to one or both studies by Associate Professor Brett Mitchell, Ms Wendy Beckingham, Dr Noleen Bennett and Dr Jane Koerner. Oyebola Fasugba is a Research Assistant and Anne Gardner is a Professor of Nursing. Both are in the School of Nursing, Midwifery and Paramedicine at the Australian Catholic University (Canberra campus)

References Elvy, J. and Colville, A. 2009. Catheter associated urinary tract infection: what is it, what causes it and how can we prevent it? Journal of Infection Prevention. 10(2): 36-41. Fasugba, O., Koerner, J., Mitchell, B. G. and Gardner, A. 2016. A systematic review and meta-analysis of the effectiveness of antiseptics for meatal cleaning in the prevention of catheter associated urinary tract infections. Journal of Hospital Infection. doi: 10.1016/j. jhin.2016.10.025 Gardner, A., Mitchell, B.G., Beckingham, W. and Fasugba, O. 2014. A point prevalence cross-sectional study of healthcare-associated urinary tract infections in six Australian hospitals. BMJ Open. 4(7): e005099. doi:10.1136/ bmjopen-2014-005099 Mitchell B, Gardner A, Beckingham W & Fasugba O. 2016. Healthcare associated urinary tract infections: a protocol for a national point prevalence study. Healthcare Infection. 19 (1): 26-31 Mitchell, B., Fasugba, O., Beckingham,W., Bennett, N. and Gardner, A. 2016. A point prevalence study of healthcare associated urinary tract infections in Australian acute and aged care facilities. Infection, Disease & Health. 21(1): 26-31.

March 2017 Volume 24, No. 8 43

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INFECTION PREVENTION AND CONTROL PRACTICES / WOUND CARE

STANDARDS FOR WOUND PREVENTION AND MANAGEMENT

AUSTRALIAN STANDARDS FOR WOUND PREVENTION AND MANAGEMENT (3RD EDITION)

By Keryln Carville, Juliet Scott and Emily Haesler Wounds Australia (previously known as the Australian Wound Management Association) has launched the Australian Standards for Wound Prevention and Management (3rd edition).

Standards of care play a role in identifying expected levels of care that should be delivered to individuals receiving wound prevention and management. Standards contribute to ensuring that care delivery is of a consistent high level and that unwarranted variation is reduced. They also play a role in improving safety of the individual and promoting positive outcomes of care. The Standards presented in the 3rd edition of this document are intended for use by individual healthcare professionals and healthcare workers for monitoring their own care delivery and identifying areas for professional development. Additionally, they can be used by healthcare services to develop policies and procedures, design education programs, audit clinical care and undertake staff appraisal. Individuals receiving care and their informal carers can also use the standards to identify what standard of care to expect when receiving wound prevention. The Standards should be used in conjunction with other clinical care standards, accreditation standards and professional standards. There are seven core Standards in the 3rd edition of Standards for Wound Prevention and Management which are: • Scope of Practice; • Collaborative Practice; • Clinical Decision Making: Assessment; • Clinical Decision Making: Planning and Practice; • Documentation; • Education; • Corporate Governance. 44 March 2017 Volume 24, No. 8

INDIVIDUALS RECEIVING CARE AND THEIR INFORMAL CARERS CAN ALSO USE THE STANDARDS TO IDENTIFY WHAT STANDARD OF CARE TO EXPECT WHEN RECEIVING WOUND PREVENTION.

Each Standard outlines an expected level of care and includes a rationale and evidence criteria that demonstrate that the Standard has been reached. A background and context is included as extended information. The Standards presented in this 3rd edition build on those in previous editions with an expanded focus on wound prevention. A targeted literature search was undertaken in medical databases, legislature databases and Google Scholar to identify relevant references published since the previous edition in 2008. Relevant key documents were reviewed from other organisations such as Australian Health Practitioner Regulation Agency and Australian Commission on Safety and Quality in Health Care and relevant evidencebased clinical guidelines were reviewed. The references included in the previous editions were also reviewed for their ongoing relevance to current practice. The 3rd edition of Standards for

Wound Prevention and Management underwent an extensive stakeholder review that was advertised on the Wounds Australia website. Over 30 key organisations including professional bodies, educational organisations and peak bodies were also invited to review the Standards. All feedback was reviewed by the development team and incorporated into the Standards as appropriate. It is the ongoing vision of Wounds Australia that these Standards will continue to be adopted by health professionals, educators and service providers across Australia, and that the challenge associated with validating and embedding the Standards across all practice and educational settings be taken up enthusiastically. The Standards can be downloaded free from www.woundsaustralia. com.au or information obtained for purchase of hard copies.

Keryln Carville is Professor Primary Health Care and Community Nursing Silver Chain Group and Curtin University, School of Nursing, Midwifery and Paramedicine Juliet Scott is a Wound Management Nurse Practitioner, Wound Innovations Emily Haesler is Adjunct Associate Professor Curtin University, School of Nursing, Midwifery and Paramedicine anmf.org.au

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The profession has seen a lot of changes since I started PTS at Latrobe Valley Hospital in Moe, fresh out of high school and living 2km away from home in the nurses’ home. What fun with old and new friends, doing laundry listening to Fleetwood Mac, or eating Vegemite on toast for dinner because our $79 per week salary didn’t stretch very far.

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FOOD FOR THOUGHT A huge pat on the back must go to celebrity cook Maggie Beer for putting her culinary knowledge to good use by trying to improve the quality of food served in nursing homes. In the article ‘Come to the Table’ (ANMJ Feb 2017) Maggie talks about her work in providing Master Classes to chefs in regional aged care homes through her Maggie Beer Foundation Having worked in the aged care sector for many years, and with my mother now in a nursing home, I have been able to see first-hand how little attention most facilities pay to the standard of their food offerings. Lots of residents complain about the lack of variety they are dished up week in, week out. Some families try to counter this by bringing in food from home but what about the residents who don’t have families or friends to bring them food in? I agree with Maggie that the time is right for a new approach and mindset in order to improve the food experience for everyone as they get older. For too long, residents have been force-fed meals without a real focus on their experience and what they would actually like to eat. I really believe that improving the quality of food will also have a ripple effect and lead to other benefits like improving energy, pleasure, and mental health. As Maggie says, it’s about providing real food with the right nutrients that residents actually enjoy. So kudos to her for showing the initiative in setting up the Maggie Beer Foundation and fingers crossed her venture arrives at all nursing homes soon. Cassandra Morley, RN, Vic

anmf.org.au

This week I celebrate the 40 year anniversary of the beginning of my nursing career. It has been a wild and interesting ride for the most part, with some moments of excruciating boredom (Christmas Eve night duty).

Since then I studied at university gaining a Bachelor degree, midwifery and maternal and child health qualifications, a Masters, and many others. I’ve kept on learning and staying fresh in the profession I love. A couple of times I’ve thought of leaving. The bleakest years of economic rationalism; health for profit and user pays; my training hospital shut down by the Kennett razor gang; erosion of penalty rates and entitlements; and the preference for 457 visa holders over properly funded grad programs as an investment in the future of health for our country. But I’ve always found a way to reinvigorate myself, working different specialties, studying, changing tack from clinical to management to regulation and academia, and now back to clinical. A typical woman’s crazy career ladder that produces little in the way of ‘advancement’, but much in intrinsic rewards. I’ve also been able to give back. Supporting and mentoring students is a delight. Promoting the profession in the multidisciplinary team benefits the patient in the long run, while raising the profile of nursing amongst the public ensures their trust. Being a job rep helps my colleagues and myself to improve and maintain the conditions which keep us healthy and happy at work, and thus more able to help our clients and patients. At almost 60 I feel I have a lot of my career left. The wage is still important, but I’ve found a contented place and lack of restlessness as I near the last decade of work. I think this might be my last job in nursing, but I won’t stop learning, questioning, agitating for positive change, calling out the politicians who vindictively punish the poorest for being sick, and congratulating community leaders for ethical policy and programs that promote social justice and a healthy environment. There have been many role models for me over my career, not just amongst the tutors and academics, nurse managers, union leaders and researchers, but also amongst my peers, my students, the enrolled nurses and even catering staff, orderlies and cleaners, who all do their jobs with pride and the best interests of the team, the organisation and mostly, the patient, at heart. Proud to be a nurse and midwife now, and for the rest of my days. Trish Grant (nee Ainsworth, formerly David) RN RM MCH; BHSc; MN; IBCLC Job Rep ANMF Vic Branch, Vic

The winner of the ANMJ best letter competition receives a $50 Coles Myer voucher. If you would like to submit a letter to the ANMJ email anmj@anmf.org.au Letters may be edited for clarity and space.

March 2017 Volume 24, No. 8 45

CALENDAR

MARCH Lung Health Promotion Centre at The Alfred Asthma Educator’s Course 1-3 March Smoking Cessation Course 9-10 March P: (03) 9076 2382 E: lunghealth@alfred.org.au 35th Annual Dermatology Nurses Association Convention Embracing the world of dermatology 1-4 March, Orlando, Florida. http://www.dnanurse.org/ International Women’s Day 8 March. www.internationalwomensday.com/ 12th Commonwealth Nurses and Midwives Federation Europe Region Conference 10-11 March, Ajax Hotel Limassol, Cyprus. All CNMF members and friends are invited to attend. https://cyna.org/ pfds/recent-advances-in-nursing-future. pdf Australasian Cardiovascular Nursing College Conference 10-11 March, Brisbane Convention & Exhibition Centre, Queensland. http://www.acnc.net.au/ 41st National Australian Association of Stomal Therapy Nurses Conference Into the sunshine: Storytelling in stomal therapy 12-15 March, Royal International Convention Centre, Brisbane, Qld. http://stomaltherapyconference.com/ 6th eMedication Management Conference 14-15 March, Swissotel Sydney. www.informa.com.au/conferences/ health-care-conference/electronicmedication-management St Patrick’s Day 17 March National Close the Gap Day 17 March. https://www.oxfam.org. au/what-we-do/indigenous-australia/ national-close-the-gap-day/ Earth Hour 19 March Harmony Day Australia 21 March. http://www.harmony.gov.au/

NETWORK The Queen Elizabeth Hospital, South Australia, Group 3/86 reunion Please contact Justine Grant (nee Reddaway) regarding a reunion to be held later this year. E: justine.grant@sa.gov.au St Vincent’s, Feb 1981 group, 36year reunion 4 March, 12.30pm, Pumphouse, Nicholson Street, Fitzory. Pub meal prices. RSVP to Mary McIntyre M: 0419 310 619 or Facebook Mary McIntyre using maiden name or E: rechargerejuvenation@yahoo.com. au Spread the word, or turn up on the day

46 March 2017 Volume 24, No. 8

World Down Syndrome Day 21 March

ANZAC Day 25 April

21st National Conference on Otorhinolaryngology Head and Neck Nurses Group Ingenuity at work 23-26 March, Adelaide Convention Centre, SA. www.ohnng.com.au

14th National Rural Health Conference A World of Rural Health in Australia... 26-29 April, Cairns Convention Centre, North Qld. www.ruralhealth.org.au/14nrhc/

National Education Toolkit on Female Genital Mutilation/ Cutting Awareness (NETFA) A national forum on FGM/C Foundations for Change 24 March, 9am-5pm, Woodward Conference Centre, University of Melbourne https://2017foundationsforchange. eventbrite.com.au

14th World Organisation of Family Doctors (WONCA) World Rural Health Conference 29 April–2 May, Cairns Convention Centre, North Qld. www.aworldofruralhealth.org.au/

Building Children’s Nursing for Africa Conference Pillars of Practice 28-30 March, The River Club, Observatory, Cape Town, South Africa. www.buildingchildrensnursing.co.za Digital Health Show 29-30 March, Melbourne Convention & Exhibition Centre. www.digitalhealthshow.com.au

MAY Lung Health Promotion Centre at The Alfred Respiratory Course (Modules A & B) 1–4 May Respiratory Course (Module A) 1–2 May Respiratory Course (Module B) 3–4 May Asthma Update 26 May P: (03) 9076 2382 E: lunghealth@alfred.org.au

APRIL

Star Wars Day 4 May

World Autism Awareness Day 2 April

International Day of the Midwife 5 May

15th World Congress on Public Health Voices • Vision • Action 3-7 April, Melbourne Convention and Exhibition Centre. http://www.wcph2017.com/

Australian College of Dermatology (ACD) Annual Scientific Meeting 6-9 May, International Convention Centre, Darling Harbour NSW. www.adna.org.au/

7th Biennial Leaders in Indigenous Medical Education (LIME) Network Conference The Future of Indigenous Health Education: Leadership, Collaboration, Curriculum 4-7 April, Melbourne. www.limenetwork.net.au World Health Day 7 April Lung Health Promotion Centre at The Alfred Managing COPD 20–21 April Spirometry Principles & Practice 27-28 April P: (03) 9076 2382 E: lunghealth@alfred.org.au

Geelong Hospital Nurses League 83rd Annual Reunion and AGM 18 March. If you have a connection to the Geelong Hospital (University Hospital) are a past trainee or current employee and are interested in attending this reunion please contact Bev Lodge Ph:(03) 5243 7794 or E: terrylodge@bigpond.com Royal Melbourne Graduate Nurses Association 100-year anniversary Luncheon 18 March, 12–3pm, Leopard Lodge, Melbourne Zoo. Entry via Zoo Rail Gate, Poplar Road. Complimentary Zoo Access from 11am. Parking $2 for five hours. RSVP: Lara Taylor 0415 628 131 or Simone Cooley (AH) 0417 587 745. Cost: $85. Book online at www.trybooking.com/236298

Holistic Nurses/Midwives Retreat Bali 8-12 May Relax, Recuperate, Renew, Replenish 25 CPD hours (tax deductible) Contact Angeline von Doussa E: angeline@nurses-healing.com http://nurses-healing.com/holisticnurses-retreat-bali-may-2017/ International Nurses Day 12 May Australian College of Critical Care Nurses Paediatric Conference Basics to bizarre 19 May, Mantra Bell City, Preston, VIC. www.acccn.com.au/

Royal Melbourne Hospital, April 1967 Group, 50-year reunion 1 April. Contact Maureen O’Brien (nee Hastings) E: j.mobrien@bigpond.com Prince Henry’s Hospital Melbourne 89th PTS April Group 50-year reunion weekend 22-23 April. Contact Lyn Kirby E:lynmkirby@gmail.com Royal Prince Alfred Hospital, PTS March 1976 reunion 7 June. Contact: Trish Walcott M: 0402 159 352 E: reunion.rpa@gmail.com Prince Henry’s Hospital, 1/73, 45-year reunion 27 January 2018. Planning well underway. Trying to locate Carol Ball, Sue Ball, M de Graaf, Barb Gilmore,

Helping Older People to Avoid Hospital Admissions 25-26 May, Sydney NSW. www.changechampions.com.au National Sorry Day 26 May International Council of Nurses (ICN) Congress Nurses at the forefront transforming care 27 May-1 June, Barcelona, Spain. http://www.icnbarcelona2017.com/en/ National Reconciliation Week 27 May-3 June. http://www.reconciliation.org.au/nrw/

JUNE Lung Health Promotion Centre at The Alfred Spirometry Principles & Practice 5-6 June Paediatric Respiratory Update 26 June Theory & Practice of Non Invasive Ventilation (Bi-Level & CPAP Management) 30 June P: (03) 9076 2382 E: lunghealth@alfred.org.au World Environment Day 5 June World Blood Donor Day 14 June World Elder Abuse Awareness Day 15 June 20th Cancer Nurses Society of Australia Annual Congress Evolving cancer care: Enhancing quality Embracing innovation 15-17 June, Adelaide Convention Centre, South Australia. www.cnsacongress.com.au

SEPTEMBER International Wound Practice and Research Conference 6-7 September, Brisbane Convention & Exhibition Centre. http://iwprc2017.com.au

Sue Gladigau, Hilary Hammond, Barb Dunne, Narelle Harley, Chris Horton, Sue Ramage and Pam Walsh. Contact Jeanne O’Neill (nee Pinder) E: ej_oneill@yahoo.com NDSN Bendigo School 71, 50th reunion 2018 Seeking students from Bendigo, Castlemaine, Echuca, Swan Hill, Mildura. Contact E: margie_coad@hotmail.com or M: 0427 567 511

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

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continuing professional education online

Bigger & Better The ANMF’s Continuing Professional Education (CPE) website has provided quality, affordable online education for nurses and midwives for over 9 years. The CPE website has had a makeover and now provides you with more educational tools to assist you to meet your CPD requirements and we are very excited to announce our new and refreshed website is now live Immediately you will notice streamlined menus, simple navigation and access to the courses and information you need, any time of day. There is a whole host of other impactful changes such as videos, webinars, journals and resources, all to make your experience on the ANMF CPE better for you. Have a quick look at the user guide on the website to help you to navigate the new system.

Visit the CPE website today at http://anmf.org.au/cpe

SALLY

Sally- Anne Jones, ANMF Federal President

STANDING UP FOR GLOBAL HEALTH AND WORLD SECURITY Already 2017 is shaping up to be a year that we may never forget. While many things change in the world and our lives every year, I have a feeling that this one will be different. For those that are open to the astrological influences on our fate (www.raymond-lo.com/ news/100044/the-year-of-therooster), there is some alignment forecast between these and world events that have already occurred this year. Believer or not, there are markers that portend a year we may not forget… On 27 January 2017, the Doomsday Clock’s hands were moved to two minutes and 30 seconds to midnight. The Doomsday Clock is a symbolic timepiece, devised and maintained since 1947 by the Bulletin of Atomic Scientists’ Science and Security Board following the historic bombing of Hiroshima and Nagasaki that ended the war in the Pacific (WWII). The clock is widely viewed as an indicator of the world’s vulnerability to nuclear disaster – midnight signifying catastrophic nuclear war ending civilisation as we know it. This year, scientists have reset the symbolic Doomsday Clock to its closest time to midnight since 1953, (which marked the start of the nuclear arms race between United States and Soviet Union), concluding that the world is closer to catastrophe due to threats such as nuclear weapons, climate change and Donald Trump’s election as US President. Its hands were moved to two minutes and 30 seconds to midnight, from three minutes last set in 2015. The commentary that accompanies the Doomsday Clock’s time each year is interesting to read as global political tensions and humanitarian issues change over time; from peace and trade treaties, nuclear armistices, carbon emissions to the natural disaster effects of climate change (see http://thebulletin.org/). However, the message consistently warns of the failures of governments to ensure and preserve the health and vitality of human civilization, and

48 March 2017 Volume 24, No. 8

encourages “wise citizens” of the globe to action. While the language of these posts may be viewed as somewhat catastrophising, the cause and intent strikes similarity with developments in the past few months. Referenced in pop culture especially throughout the Cold War, the Doomsday Clock has been a feature of films, books, songs and television. In 1991, at the end of the Cold War and dissolution of the Soviet Union, the clock was set back to 17 minutes to midnight as the tensions of the world stood down and the world breathed a sigh of relief – we had survived 45 years without a nuclear war. From that time, the hands of the clock vacillated forwards and backwards, inching towards midnight again. After the September 11, 2001 terrorist attacks, the US expressed increasing concerns about the enormous amount of unsecured, and sometimes unaccounted for, weapon-grade nuclear materials throughout the world, voicing a desire to design new nuclear weapons that could destroy hardened and deeply buried targets. When it also rejected a series of arms control treaties and announced that it would withdraw from the Anti-Ballistic Missile Treaty co-signed with the Soviet Union in 1972, the clock moved to seven minutes to midnight. In 2007, emerging global events triggered the Scientists to include threats to humanity other than atomic annihilation – climate change, biological agents, new kinds of warfare at which time the clock was at five minutes to midnight. So in the era of President Trump, while the world is still taking its measure of the man, what can be expected from his presidency that will stay the hands of the clock for all humanity’s sake and what has it got to do with us? I believe nuclear disquiet; climate change and renewable energy plans have everything to do with us. It is difficult to identify any alignment between Trump’s inauguration speech and the objectives of the international institutions the US has helped create to keep peace and stability in the world. It leads me to question whether US compliance with the commitments made through those institutions will lessen now, and early indicators are that this will be the case. On climate change, for example, US and G20 priorities no longer align. The G20 supports climate

change and renewable energy activities. However, President Trump’s priorities include accelerating fossil fuel production; cancelling climate financing to the UN; and pulling out of the Paris Agreement. On the day of his inauguration, all references to climate change were removed from the White House website. It is further example of US protectionism of the new President, similar to the TransPacific Partnership decision – perhaps a reactionary move, perhaps strategic, but most definitely with consequences for more than just the U.S. And so you ask, how do global politics, the Doomsday Clock and the shenanigans of an elected person in another country affect me as a nurse or midwife in Australia? I believe there has been a shift in the world status quo. As nurses and midwives, attuned to the impacts of the social determinants of health on the people we care for, we know that climate change affects clean air, safe drinking water, sufficient food and secure shelter- even in Australia. World Health Organization states that reducing emissions of greenhouse gases through better transport, food and energy-use choices can result in improved health, particularly through reduced air pollution. As Presidentelect, Mr Trump tweeted, “the US must massively boost its nuclear capability until the “world comes to its senses”, in response to the Russian president saying that strengthening their own nuclear capabilities should be a chief military objective in the coming year. Are nurses and midwives not the ‘wise citizens’ called upon by the Scientists of the clock to step up and act? Do we not talk of the changes we experience in our weather, the emergence of more virulent diseases, the expense of food and electricity and the impact these things have on our patients? We have no influence over another country’s leaders, but we can be present and participate in discussion of the things that impact our country and our citizens. I am not a doomsday prophet, nor am I despairing of our future but I feel responsibility to stand up for our planet and every person on it. The Doomsday Clock rests at two minutes and 30 seconds to midnight, the time has come for nurses and midwives to join together as activists to redirect world resources toward health and true global security. It begins by watching and understanding world events, no matter how remote they seem, and continues in our work to leave the world in a state fit for generations to come. anmf.org.au

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