V O LU M E 2 3 , N O. 4 / O C T O B E R 2 0 1 5
CULTURAL DIVERSITY & INCLUSIVITY Where are we at?
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POSTGRADUATE NURSING AND MIDWIFERY AT ECU At ECU, we offer working nurses and midwives the flexibility of online study within most of our postgraduate nursing and midwifery programs. Our tutorials are delivered via virtual classrooms which you can access anywhere at any time from your desktop computer, laptop, tablet or smartphone. During the tutorial, you can ask questions in real time and have discussions with your lecturer and fellow students. You’ll also have access to lecturers online, or can meet with them on-campus. Our range of postgraduate courses include: • Graduate Certificate in Children and Young
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CONTENTS Directory 02
18
Editorial 03 News 04 News – Forensic special 15 Working life
17
Feature
18
World 24 Reflections – Clinical Supervision 25 Research 26 Legal 27 Reflections – Timor Leste 28 Professional 29 Books 30 Clinical update
CULTURAL DIVERSITY AND INCLUSIVITY Where are we at?
31
Focus – Rural / Remote 34 Calendar 45 Mail 46
FEATURE
Sally 48
04
28 NEWS
REFLECTIONS
TIMOR LESTE
34
48 FOCUS anmf.org.au
RURAL / REMOTE
SALLY October 2015 Volume 23, No. 4 1
Canberra
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Editorial
Melbourne & ANMJ
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Federal Secretary Lee Thomas
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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
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Western Australia
Branch Secretary Brett Holmes
Branch Secretary Beth Mohle
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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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EDITORIAL
Editorial Lee Thomas, ANMF Federal Secretary Last month I gave evidence at a Senate Inquiry in Canberra, about the detrimental effects the proposed changes to the current paid parental leave (PPL) scheme will have on working families.
DISCRIMINATION NOT ONLY IMPACTS WOMEN BUT REMAINS GLARINGLY PROMINENT IN OTHER AREAS IN OUR SOCIETY. THE ONGOING MISTREATMENT OF REFUGEES IN AUSTRALIA IS ONE SUCH EXAMPLE. THE AUSTRALIAN GOVERNMENT’S REFUSAL TO ACKNOWLEDGE MARRIAGE EQUALITY IS ANOTHER
As previously mentioned, the government is planning to abolish current PPL from 80,000 new mothers, suggesting under current arrangements women are ‘double dipping’. Not only is this simply untrue and quite offensive, but it is clearly discriminatory. As I recently pondered the thought of discrimination in Australia, a report crossed my desk highlighting the gender pay gap that exists between men and women. On average women earn $285 less per week than men and retire with an average of $90,000 less in superannuation. A disgraceful fact in our society which is supported by the recent release of the Australian Bureau of Statistics gender indicators showing there are significantly fewer women than men in positions of leadership in both the public and private sectors. The report also states that when it comes to reward and recognition, women receive far fewer nominations than men for the Order of Australia. Discrimination not only impacts women but remains glaringly prominent in other areas in our society. The ongoing mistreatment of refugees in Australia is one such example. The Australian government’s refusal to acknowledge marriage equality is another. Discrimination, whether it is against women, men, refugees, the LGBTIQ community, or other cultures within our society, only serves to foster social exclusion and stigma. This has been shown to compound health inequities and worsening health outcomes for those discriminated against, such as poorer mental and physical health, poorer health service access, poorer sexual health and in some cases poorer life expectancy.
@AustralianNursingandMidwiferyFederation
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Our political leaders have a responsibility to ensure inclusivity through good policy and governance for the wellbeing of our community; but so must we all, whether that be in our workplaces or the community at large. Let’s hope that Prime Minister Turnbull and his new ministry can work with stakeholders such as the ANMF to ensure we can address these and many other issues that affect our communities. In this month’s feature we look at inclusivity and multiculturalism in our nursing and midwifery classrooms, which can be equally applied in the clinical setting. Interestingly, we may not be aware when we are being biased, but as nurses, midwives, educators and members of our community we need to acknowledge and accept perspectives different to our own and become culturally competent to ensure understanding and equality for all. While the benefits of inclusiveness are plainly obvious, perhaps the necessity for equality is best explained in this simple statement by the Dalai Lama: “In our quest for happiness and the avoidance of suffering, we are all fundamentally the same, and therefore equal. This is an important point. For if we can integrate an appreciation of this fundamental human equality into our everyday outlook, I am very confident that it will be of immense benefit, not only to society at large, but also to us as individuals.” Wise words to live by..
www.anmf.org.au
October 2015 Volume 23, No. 4 3
NEWS NURSE PRACTIONER STEPHANIE DOWDEN
ANMF leads fight to protect paid parental leave The Australian Nursing and Midwifery Federation (ANMF) along with committed union members, have spoken out about protecting paid parental leave at a hearing, held by the Community Affairs Legislation Committee at Parliament House in Canberra last month.
ANMF pledges support to nurse practitioners The Australian Nursing and Midwifery Federation (ANMF) has formally proposed establishing a working group with the Australian College of Nurse Practitioners (ACNP) so that issues affecting the specialist field can be tackled collectively. Addressing the 10th Conference of the Australian College of Nurse Practitioners in Melbourne last month, ANMF Federal Secretary Lee Thomas invited members to voice their concerns on current issues facing the sector. The offer yielded a flood of robust dialogue which exposed some core issues nurse practitioners across the country consider important. Issues raised included a lack of visibility in the community and understanding and acceptance of the nurse practitioner role, unnecessary red tape requiring GPs to sign off on tests such as mammograms that fall within the scope of the nurse practitioner, ongoing difficulties accessing the Pharmaceutical Benefits Scheme (PBS), and the need to substantially increase the payment for Medicare Benefits Schedule (MBS) items for NPs in private practice to ensure their viability. Ms Thomas, said there was strength in numbers and that both organisations should band together to campaign for better work environments. “You can see that there are many issues that we could absolutely work on together to make a real difference.” Foundations for the nurse practitioner role in Australia were laid down in the early 90s and gained momentum in late 2000 when the first NPs were authorised in Australia. Today the country has more than 1,200 nurse practitioners working in a 4 October 2015 Volume 23, No. 4
variety of settings. Key points of interest evident at the conference surrounded confusion over what the role is by the public and wider health sector, and a strong desire to celebrate the role and improve recognition. Nurse practitioner and paediatric nurse Stephanie Dowden, who is the Nurse Practitioner Course Coordinator at Curtin University in Western Australia, said many people are still unsure what NPs are. “It’s poorly understood what the role is and what the difference is. “Is it just another level of nursing? A lot of people don’t understand that you need an extra Master’s degree and that you have to be working at an advanced practice level as well. There is quite a misconception that maybe it’s just another diploma or something like that.” Ms Dowden was involved in early discussions regarding the evolution of nurse practitioners in Victoria and said her own choice to become one stemmed from wanting to fully utilise her decades of skills and experience. According to guidelines on endorsement as a nurse practitioner set by the Nursing and Midwifery Board of Australia, requirements include registration as a nurse, at least three years’ full-time experience in an advanced practice nursing role within the past six years, and completion of an approved nurse practitioner qualification at Master’s level. Ms Dowden said nurse practitioners as a collective have failed to appropriately promote themselves and underline their true value, suggesting that advertising campaigns should be implemented to address the gap in understanding. “We’re not visible, partly because we’ve got small numbers, but also because we don’t work hard enough to make ourselves visible.”
The inquiry into the Fairer Paid Parental Leave Amendment Bill 2015 is now underway and parents around the country are understandably anxious about potential cuts that could leave some 80,000 out of pocket by as much as $11,000 and also force them to return to work sooner than desired. Flanked by members and their babies, ANMF Federal Secretary Lee Thomas delivered evidence at the hearing, urging the Senate to comprehensively reject the changes on the basis that the existing system allows nurses and midwives crucial time to bond with their newborns, which leads to improved mental and physical health for both mother and baby. “It’s absolutely vital that we have a decent paid parental leave scheme in this country and we need to do it for these women and all of those other women and families who are planning to have children.” ANMF (Tas Branch) President Emily Shepherd, who is expecting her first child, attended the hearing and argued that paid parental leave was essential for all Australian women starting a family. “I’d be really concerned if I had to return prior to 26 weeks,” she said. “It’s our first child and obviously it’s a fairly anxious time in making sure that you’re well prepared and well positioned to provide the best start for your child.”
anmf.org.au
NEWS
National health program for substance use Australia’s regulatory watchdog should consider health programs to support nurses and midwives with substance use or mental impairment, says a Queensland Coroner.
Several recommendations were made in the recent Inquest of Queensland registered nurse Katie Lee Howman, 30, who died from an intravenous dose of fentanyl at home in December 2013. The drug was most likely obtained from her workplace in the critical care ward at the Toowoomba Base Hospital. She was battling an opiate addiction. A key recommendation was the Australian Health Practitioner Regulation Authority (AHPRA) considers adopting the Nursing and Midwifery Health Program in Victoria (NMHP). Alternatively a service that solely provides rehabilitation services be directly funded by government. Ms Howman was under AHPRA’s supervision after a first fentanyl overdose on return to work following maternity leave in 2010. Ms Howman had a broad opiate dependency problem that developed while under AHPRA’s supervision, the Coroner found. Ms Howman visited 30 different doctors in the Toowoomba area over 13 months for prescriptions for opiates, namely tramadol and oxycodone. In the last three months before her death, she had prescriptions for 340 doses of tramadol. Only one of the 30 doctors suspected a pattern of drug use. “The information was recorded by Medicare and accessible by any doctor who treated her,” the Coroner noted. “AHPRA could have made an application to review the prescription history and record of attendances on doctors but did not do so. They indicated some resistance to the release of such information by Medicare at that time.” Ms Howman’s husband Heath described his wife as a “wonderful person, always helping others more than herself and a great mother of their two children”. She also “loved her work as a nurse”. When challenged by her husband anmf.org.au
in the months before her death, Ms Howman acknowledged that she might have a problem. NMHP Victoria CEO Glenn Taylor said Ms Howman could have accessed a similar program if available in Queensland, either through self-referral or her husband or doctor. “People historically are fearful of identification and fearful of punitive measures, they need a safe place to access appropriate health services that is underpinned with confidentiality and independent from their employer.”
A KEY RECOMMENDATION WAS THE AUSTRALIAN HEALTH PRACTITIONER REGULATION AUTHORITY (AHPRA) CONSIDERS ADOPTING THE NURSING AND MIDWIFERY HEALTH PROGRAM IN VICTORIA (NMHP).
Consultant Psychiatrist Dr Ross Phillipson told the Inquest there were difficulties in treating health professionals due to reporting requirements to AHPRA or other regulatory authorities. “There are a lot of people out there – nurses, doctors, whoever have illnesses which don’t come close to the definition of impairment but, my feeling is that a lot of our colleagues are worried that if they say they have depression, anxiety, whatever, that they’re going to be reported to
AHPRA and I think that acts as a block in terms of full disclosure.” Dr Phillipson proposed changes to current reporting requirements for health professionals receiving treatment. Namely that a treating practitioner limit details to that: a person was being treated; was compliant with treatment; and when might be able to gradually return to work. The critical issue was that neither the hospital nor AHPRA had any evidence to confirm their suspicions, the Coroner said. A spokesperson for AHPRA said the agency and national boards were considering the Coroner’s recommendations for health programs. The NMHP Victoria is only funded by the Australian Nursing and Midwifery Board until June 2016.
Recommendations • AHPRA routinely seek doctor
attendance and prescription history of health practitioners under supervision. • More limited reporting
requirements that meet public safety and allows therapeutic environment of health professional to receive treatment. • AHPRA consider a more
rehabilitative capability, such as the Nursing and Midwifery Health Program in Victoria. • Government directly fund a
service which solely provides rehabilitation services and is exempted from any requirement to report to AHPRA while a practitioner is receiving treatment.
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NEWS
Indigenous health scholarships up for grabs Applications are being sought for the Puggy Hunter Memorial Scholarship Scheme (PHMSS), a federal government initiative designed to support Aboriginal and Torres Strait Islander undergraduate students in healthrelated disciplines to complete their studies and join the health workforce.
HESTA AGED CARE AWARD WINNERS FROM LEFT TO RIGHT, JAN HORSNELL FROM SOUTHERN CROSS CARE (VIC), PAUL BROPHY FROM BROTHERHOOD OF ST LAURENCE AND, KRISTEN GRAINGER FROM CHARLES O’NEILL HOSTEL.
HESTA Aged Care Awards announced The achievements of unsung individuals and organisations working in aged care across the country have been recognised at the 2015 HESTA Aged Care Awards in Canberra. ‘A Safe Place to Call Home’ program team, which provides care to older Australians experiencing mental illness. The team, which includes a registered nurse, provides specialist care for people with mental health disorders such as schizophrenia, bipolar disorder, and depression. Victorian Paul Brophy, a Brotherhood of St Laurence’s Sambell Lodge employee, received the Individual Distinction Award for staging music events for more than 6,000 residents across 20 different homes. Many residents who attend the events come from disadvantaged backgrounds with little family contact. Winners shared in a $30,000 prize pool, with the Outstanding Organisation and Team Innovation Award recipients receiving a $10,000 development grant, while the Individual Distinction winner netted $5,000 towards further education.
To apply, visit: www.acn.edu.au/phmss
THE PROGRAM INCLUDES ALMOST 20 INITIATIVES INCLUDING FORMAL EDUCATION OPPORTUNITIES IN AGED CARE, LEADERSHIP, COMPUTER LITERACY, AND A MONEY-MINDED PROGRAM TO INCREASE FINANCIAL LITERACY AMONG STAFF.
anmf.org.au
October 2015 Volume 23, No. 4 7
ACHIEVEMENT BY INDIGENOUS ARTIST MARK HUDDLESTON
The annual awards, which celebrate the contribution people working in the sector make to improve the quality of life of older Australians, comprise three categories: Outstanding Organisation, Team Innovation, and Individual Distinction. Victorian aged care organisation Southern Cross Care (Vic) took out the Outstanding Organisation Award for its Employee Development and Empowerment Program that is geared towards improving the skills, health, and lives of its predominantly female and culturally and linguistically diverse workforce. The program includes almost 20 initiatives including formal education opportunities in aged care, leadership, computer literacy, and a MoneyMinded Program to increase financial literacy among staff. In the Team Innovation Award, the Newcastle-based Charles O’Neill Hostel was honoured for its unique
The scholarships are open to people who are studying nursing and midwifery, health work, allied health, dentistry/oral health, and medicine. Funding is provided for the duration of the course, with a fulltime scholarship awardee receiving up to $15,000 per year and part-time recipients getting up to $7,500. The prestigious scholarships are awarded on the recommendation of an independent selection committee who assess applicants on their influences and motivations for wanting to become a health professional, their involvement in community activities promoting the health and wellbeing of Aboriginal and Torres Strait Islander people, and what they hope to accomplish as a health professional in the next 5-10 years. The scholarship scheme was established in recognition of Dr Arnold ‘Puggy’ Hunter’s significant contribution to Aboriginal and Torres Strait Islander health through his role as Chair of the National Aboriginal Community Controlled Health Organisation. Funding for the scholarships is provided by the Department of Health and administered by the Australian College of Nursing. Applications close on 12 October with winners announced in early December.
NEWS
Nurse practitioner joins NMBA The Nursing and Midwifery Board of Australia has appointed its first nurse practitioner. Nurse practitioner Chris Helms (pictured) from Canberra was appointed to the board in September, after he applied last year. “To be perfectly honest it’s overwhelming,” Mr Helms said. “But also really exciting to know that I’ll be able to
see from a much wider perspective the issues that are affecting nursing more generally and how that relates to nurse practitioners.” Mr Helms is currently undertaking a PhD at the Australian Catholic University where he is researching nurse practitioner metaspecialties within clinical practices. He also works one day per week at a GP practice and about once a month at a homeless clinic. Mr Helms trained as a nurse practitioner in the United States and moved to Australia in 2006 to further his career. “My experience as an NP has been a rather positive one,” he said. “When I started working in private practice I was able to practice in a way that complemented GPs. “For me, it’s been a very positive thing, and for the people I work with, because they’ve seen that there is currently an imbalance in primary healthcare and there seems to be benefits in bringing in an expert nurse.” Mr Helms will take up his new position
immediately and said he’s looking forward to making a difference. Asked about the greatest challenges facing nurse practitioners, Mr Helms believes the sector is approaching a critical stage where its status within the health system needs to be strengthened. “I think that we are so busy as NPs working clinically that we’re not able to get the publications out about what we’re doing to actually improve the health of our communities that we work in. “Our greatest challenge right now is getting our voice out there and showing people what we’re actually doing.” On a personal note, Mr Helms said once his PhD is completed he will look to increase his clinical workload in private practice while also publishing relevant academic material surrounding the sector and its issues. “I actually think Australia, in some respects, is light years ahead of our North American colleagues with respect to the science of nurse practitioners. I think some of the greatest thought leaders and the theory behind our practice are actually based here.”
Tasmanian hospitals feeling the pressure The Australian Nursing and Midwifery Federation (ANMF, Tasmanian Branch) is actively helping to address long-term infrastructure and workload issues at Tasmania’s two biggest hospitals, the Launceston General Hospital and the Royal Hobart Hospital. The ANMF met with Launceston General Hospital’s management after attending a crisis meeting called by nurses working in the Emergency Department (ED), in September. The talks attempted to resolve critical issues confronting the department, specifically a lack of beds coupled with rising demand that is causing increasing pressures across the board. Measures such as developing an escalation policy and improved nurse-led criteria discharge were discussed. ANMF Tasmanian Branch Secretary Neroli Ellis said patients were waiting at least two days to get a bed, with about 30 patients waiting for beds at any given time. In one of the more drastic cases that helped trigger the latest emergency talk, nurses revealed a patient was forced to wait more than a week in the emergency room for a bed on a ward. Ms Ellis blamed the situation on the closure of a 32-bed medical ward back in 2011 due to budget cuts. “The presentations are fairly stable now. 8 October 2015 Volume 23, No. 4
They’ve been increasing each year but they’ve stabilised. It’s actually the acuity and the complexity of each presentation to the ED. There’s an increasing trend of those patients.” Ms Ellis said the ANMF has had a positive relationship with the hospital, however cautioned that the proof would be in the pudding in achieving outcomes. “The budgets are incredibly tight and there is no additional funding, so clearly, we’ll be taking that issue through to the Minister.” Ms Ellis said despite rising pressures, nurses remained resolute in their duty of care. “Clearly, these are not just nursing issues, but nurses end up having to cope with the pressures in the ED. The nurses are doing everything possible to provide quality care, but certainly in a pressure situation.” At the Royal Hobart Hospital, problems are similarly reaching boiling point, but for different reasons. The lack of permanently employed nurses at the hospital has resulted in a spike in the amount of double shifts undertaken
ANMF TASMANIAN BRANCH SECRETARY NEROLI ELLIS AND TASMANIAN HEALTH MINISTER MICHAEL FERGUSON CHAT WITH NURSE RICARDA BAKKER AT THE ROYAL HOBART HOSPITAL ABOUT IMPORTANT ISSUES.
by staff. “This is becoming unsustainable. It’s clearly exhausting and not in the best interests of the patients or the bottom line,” Ms Ellis said. The union met with nurse unit managers at the hospital and helped develop a range of strategies and solutions aimed at improving staffing. Consequently, management has agreed to employ an additional 26 nurses in the Emergency Department, along with an additional 40 full-time equivalents to join the Permanent Pool. anmf.org.au
NEWS
ANMF VIC BRANCH SECRETARY LISA FITZPATRICK & ASSISTANT SECRETARY PAUL GILBERT.
Nurse and midwife to patient ratios move step closer NEW ZEALAND COLLEGE OF MIDWIVES MEMBERS GATHER OUTSIDE THE WELLINGTON HIGH COURT
Historic discrimination case filed by NZ midwives The New Zealand College of Midwives has launched landmark legal action against its government in a bid to prove their workforce is paid less because they are women. The allegations of long-standing discrimination on the basis of gender were officially lodged in the Wellington High Court in late August, with hundreds of midwives endorsing the pay challenge by congregating outside the premises in a show of support. The case is now undergoing preliminary examination and an official hearing is expected to be called this month. The pay equity claim centres on alleged discrimination based on gender in breach of section 19 of the New Zealand Bill of Rights Act 1990, which the College says has resulted in midwives being paid less than male-dominated professions that require a similar level of qualifications and skills. The College has more than 3,000 members and it hopes successful legal action will boost the appeal of midwifery as a financially rewarding career choice and also prevent experienced midwives leaving the industry. The College’s Chief Executive Karen Guilliland said midwives have been short-changed for the past 20 years and that the situation had become untenable. “What we’re saying is that they’re actually discriminating against us because we’re women. “This is about valuing the work of anmf.org.au
women and valuing the work of midwives who spend months with women on a 24hour basis. It’s time that we demanded equality.” The College says the responsibilities and workload of its community midwife Lead Maternity Carer (LMC) workforce have increased significantly since 1993 when it successfully fought for better pay at the Maternity Benefits Tribunal. Currently, LMC midwives are paid set fees by the Ministry of Health, but since 2007 there have only been two small increases which the College claims have not adequately reflected an increased scope of practice. “Midwives haven’t been paid properly since 1996, so this claim has been about 20 years in the making,” Ms Guilliland said. This year the Ministry allocated $2.1 million towards a fee increase for payments made available to about 1,000 LMC midwives and more than 52,000 mothers and babies. The College says the increase equates to about $41 extra per birth for a 7-9 month, 24-hour on-call personal service and is not good enough. “It is the last straw. The Ministry of Health cannot continue to ignore and undervalue its female workforce and the thousands of mums and babies that rely on our midwives.”
Victoria will become the second region in the world to legislate nurse and midwife to patient ratios after the historic regulation was officially introduced into Victorian Parliament in September. The long awaited The Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Bill 2015 was debated in the Lower House during September and now moves to the Upper House for final approval. Once passed, the Bill will guarantee nurse and midwife to patient ratios fall in line with the Public Sector Enterprise Agreement 2012-2016, which encompasses both metropolitan and regional health services. This includes certain wards within the Victorian public health service, public hospitals, and residential agedcare facilities. ANMF (Vic Branch) Secretary Lisa Fitzpatrick said the legislation would ensure patients receive exceptional healthcare now and into the future. “Enshrining ratios in law will mean Victoria’s public hospitals and aged care facilities are world leaders in safe care and will ensure that patient care is not up for negotiation every three to four years. This is something that cannot be argued with,” Ms Fitzpatrick said. In July, the Queensland government also announced its commitment to legislating nurse to patient ratios from July 2016. Victoria and Queensland will join California, in the US, and Wales, as the only parts of the world to take a stand on quality patient care. October 2015 Volume 23, No. 4 9
NEWS
Bending the gender pay gap Inquiry into prevalence of elder abuse A new inquiry investigating elder abuse in New South Wales has been established to better protect the elderly against neglect, financial abuse, and physical or sexual abuse. Established by the Upper House Committee ‘General Purpose Standing Committee No. 2’, the inquiry will examine the prevalence of abuse experienced by the elderly. Public hearings will begin in late November, with the committee expecting to finalise their report by May 2016. Public submissions are now being sought up until Sunday, 15 November, and can be lodged online via www.parliament.nsw. gov.au/gpsc2 New South Wales opposition Ageing Minister Sophie Cotsis said the inquiry would prove crucial in lifting the lid on a regrettable reality.“As many as 50,000 older people in NSW have experienced some form of abuse and only one in five cases of elder abuse are reported – this needs to change.” The NSW inquiry follows changes in Victoria to the Power of Attorney Act 2014 in August in a bid to shield the elderly against the abuse of powers of attorney. The need for reform was uncovered at the Royal Commission into Family Violence, which heard Victorians unlawfully lost almost $57 million through the abuse of powers of attorney in 2013-14. New legislation came into effect in September that now clarifies and consolidates the existing laws, while also expanding the Victorian Civil and Administrative Tribunal’s (VCAT) jurisdiction so it can order compensation for victims of elder abuse. The Australian-first legislation includes the option of appointing a ‘supportive attorney’, which will allow individuals to retain the power to make their own decisions while appointing an attorney to help them with communication and the collection of information. 10 October 2015 Volume 23, No. 4
September marked Equal Pay Day across Australia, an initiative created to highlight the striking differences between the amount of money women and men earn each year. The national gender pay gap is calculated annually by the Workplace Gender Equality Agency using the Australian Bureau of Statistics’ labour force data. The gap currently sits at 17.9% and has floated between 15 and 19% for the past two decades. Reasons behind the ongoing pay inequity include “women’s work” being undervalued, women interrupting their careers more frequently due to events such as having a child, and gender role stereotypes still dominating many workforce sectors where women are impeded in moving on to senior positions even though they possess the same qualifications as men. Statistics show a woman needs to work on average an extra 65 days each year to earn the same wage as a man and that women earn about $285 less per week than men and retire with about $90,000 less superannuation. Australian Council of Trade Unions President Ged Kearney labelled the government’s response to gender
$285 LESS PER WEEK.
inequality as “appalling” and called for action to be taken to ensure the problem doesn’t worsen. “Women are facing out-dated workplace practices and inadequate laws that make it difficult to return to work after having children,” Ms Kearney said. “The coalition’s response to this is to make things worse for working women now, and when they retire. Simultaneously cutting wages, penalty rates, parental leave and family support payments leaves low paid women and those with caring responsibilities in an impossible situation,” said Mr Kearney This year, an alliance of women’s organisations launched a website to coincide with Equal Pay Day, hoping to inspire women to overcome the long-term impact of the pay gap. The website, which can be found at http://security4women.org.au/letter-tomy-younger-self/ encourages all women to think about their financial security and lists actions they can take to boost their savings and retirement income.
RETIRE WITH ABOUT $90,000 LESS SUPERANNUATION.
STATISTICS SHOW A WOMAN NEEDS TO WORK ON AVERAGE AN EXTRA 65 DAYS EACH YEAR TO EARN THE SAME WAGE AS A MAN AND THAT WOMEN EARN ABOUT $285 LESS PER WEEK THAN MEN AND RETIRE WITH ABOUT $90,000 LESS SUPERANNUATION.
anmf.org.au
NEWS
National Boards fees set for 2015/16
The right to die The possibility of legislating euthanasia in Australia over the next three to five years is unlikely, according to a leading expert.
Speaking at an Australian Healthcare and Hospitals Association (AHHA) Health Law seminar in Sydney last month, Dr Tim Smyth, Special Counsel on health, aged care and life sciences from Holman Webb Lawyers, said while community interest and public debate was growing, the interest from members of Parliament to pass legislation was very low. “I think it’s highly unlikely in this climate that such legislation will pass.” Dr Smyth said good palliative care, the ability of courts to uphold the rights of health professionals to cease futile treatment, as well as an individual’s right to be allowed to die if the court is satisfied, reduced the need for such legislation. “Arguably the need for such specific legislation is actually lessening, but the argument that people have the right to make an advanced care directive and be able to control their lives is continuing and will accelerate.” Dr Smyth said withdrawing life sustaining treatment was lawful in a range of circumstances through the Australian Courts. “A competent adult can decide not to have or continue to have treatment through an Advanced Care Directive. Consent can also be made by a substitute decision maker such as a person that has been appointed.” A parent can also consent for their child as long as it is in the best interest of the child, Dr Smyth said. According to Dr Smyth there is no law that forces someone to treat another even if that leads to the death of a person. “Where there is a dispute particularly with the patient but also importantly family members, the doctor may quite sensibly go and seek a court agreement from that decision and the court authorises the discontinuation of treatment.” anmf.org.au
Six boards have reduced their fees and three others kept them unchanged, under new practitioner registration fees set for 2015/16, National Boards has announced. The fees set by each of the 14 National Boards varies to reflect the cost of regulating each profession under National Law.
WHILE PALLIATIVE CARE IS LAWFUL IN AUSTRALIA, THERE HAS BEEN DEBATE IN THE PAST WHETHER ADMINISTRATING SEDATION SETTLING THE PERSON DOWN, OFTEN IN THE LAST FEW HOURS OF THEIR LIVES IS MURDER
While palliative care is lawful in Australia, there has been debate in the past whether administrating sedation settling the person down, often in the last few hours of their lives is murder said Dr Smyth . “It’s not murder, it’s not manslaughter, it’s just very good palliative care.” However Dr Smyth said one size does not fit all to whether the circumstances are going to permit the discontinuation of treatment. “Each situation depends on its facts,” he said. “Factors that need to be taken into account include if they have a terminal illness with no reasonable prospect of success; that they may need some independent persons to assist determining whether that circumstance exists; if the patient is an adult and competent, and if they have a directive that they no longer wish to receive that treatment, even though it would lead to their death.” With consideration of these factors Dr Smyth believes individuals can make the decision to die. “While assisted suicide and euthanasia is a crime, the law actually does allow you to die.”
Fees for Nursing and Midwifery, the Aboriginal and Torres Strait Islander Practice, and Chinese Medicine Boards remain the same. The Medical Radiation Practice, Occupational Therapy, Optometry, Osteopathy, Physiotherapy, and Podiatry Boards have all reduced their fees. The Chiropractic, Dental, Medical, Pharmacy and Psychology Boards made small fee increases in line with the national consumer price index (CPI) of 1.3%. Australian Health Practitioner Regulation Agency (AHPRA) Chief Executive Officer Martin Fletcher said fees set for all National Boards reflect prudent financial management. “The National Boards and AHPRA have set fees so that we can meet our regulatory responsibilities under the National Scheme, while also aiming to be effective and efficient regulators of registered health practitioners.” Detailed information about each board’s budget will be published in the National Scheme’s annual report to be released in November.
THE MEDICAL RADIATION PRACTICE, OCCUPATIONAL THERAPY, OPTOMETRY, OSTEOPATHY, PHYSIOTHERAPY, AND PODIATRY BOARDS HAVE ALL REDUCED THEIR FEES.
October 2015 Volume 23, No. 4 11
NEWS
Five funding reform options • State funding public hospitals • Hospital benefits • Individualised care packages for
chronic disease • Regional purchasing agencies • Full Commonwealth funding PROFESSOR ALLAN FELS
Chronic disease costs complex Economic models including a single funder of healthcare to tackle burgeoning costs of chronic disease were examined by Australia’s leading health economists in Melbourne recently. A green paper showcases five options for major changes to the funding and structures of Australia’s healthcare system which go beyond electoral changes. One option includes individualised care packages for chronic disease. Victorian Department of Health Director Terry Symonds told Melbourne’s Economic Forum there had been consensus on tacking chronic disease between states and territories at COAG. Victoria and Tasmania had been tasked to undertake work. States and territories bore considerable financial risk around interventions in chronic disease, he said. “Community based interventions are scaled up then costs increase and the benefits take longer to pay off. It’s very difficult and a policy dilemma.” Under funding reform options, Mr Symonds said it was more realistic that
systems would be “aligned rather than shifting risk and cost.” University of Melbourne Professor Anthony Scott described the green paper as “blue sky”. “To solve issues we need a single funder - states or Commonwealth – it seems quite clear,” he said. Issues included whether the Commonwealth had sufficient local knowledge; however a funding split between governments maintained fee for service, Professor Scott said. Federal and state governments effectively turned on and off the tap, said Victoria University Director Professor Rosemary Calder. Australia invested more on hospital care than at the tailend such as Canada, Germany and Netherlands. “We continue to spend at quite an alarming rate – we need to look at where we are putting that expenditure that might be more effective.” Prevention had been underestimated in health policy debates in the past two decades, she said. “Our efforts at prevention have not been effective no matter how energetic they have been. No interventions and no policies are having a strong economic impact, particularly in workforce participation.”
Early intervention showed significant gains in the six main risk factors for chronic disease: smoking; excess alcohol use; obesity; physical inactivity; inadequate diet; and inter-partner violence. Grattan Institute Director Professor Stephen Duckett described healthcare funding as an “alphabet soup of arrangements”. He argued for redistribution of funding within the existing budget rather than increasing costs. “Our health system was designed in the 60s based on a fee for service model. There has been substantial change in the primary care sector; government is not keeping pace of that.” The National Health and Hospitals Reform Commission recommended shifts in primary care funding and blended funding that had not been adopted. Professor Duckett said there needed to be both payment and system reform. Payment reform included increases in annual payments and performance for payment. System reform would involve: improved care pathways, both in primary and secondary care; substantial increase in measurements and monitoring; and population management.
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NEWS
Hasty decisions cause missed injuries Quick decisions are the most common cause of misdiagnosis, a leading United States emergency nurse practitioner (ENP) warned nurses in Melbourne last month. Nurses were under pressure to make split second decisions which often led to quick diagnosis, Californian ENP Karen Hoyt told delegates at the 6th Australian Emergency Nurse Practitioners’ Symposium. “You land on things very quickly and most of the time you’re right – but what if you’re wrong, especially with trauma? You can miss injuries with trauma.” In St Mary’s Medical Center in Long Beach where Professor Hoyt practices, two ENPs see 200 patients a day from 9am to 1pm. “We are always on the clock. We see 75% of all patients and discharge 50%.” Adjunct Clinical Professor of the University of San Diego and ENP of 15 years, Professor Hoyt described seven areas of clinical errors. The most common area “premature closure” included jumping to conclusions, not looking for a second injury, making a quick diagnosis or suspected diagnosis not confirmed by appropriate testing. Faulty assessment included over- or under-estimating a disease likelihood; and failure to consider all relevant possibilities. Editor of the Advanced Emergency Nursing Journal, Professor Hoyt said ENPs should consider as many differential diagnoses as possible. “Ninety per cent is in the history. Your differential diagnoses are swirling about in your head before you even walk in the room.
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THE MORE YOU PRACTICE, THE MORE YOU SEE, THE MORE YOU GET BETTER BUT DON’T HONE INTO THE DIAGNOSIS TOO QUICKLY BECAUSE YOU CAN BE FOOLED. YOU NEED TO THINK WIDE, BIG AND DEEP IN TRAUMA.
“The more you practice, the more you see, the more you get better but don’t hone into the diagnosis too quickly because you can be fooled. You need to think wide, big and deep in trauma.” No practitioner was immune to missed injuries, no matter how good they were, said SA Emergency Physician Dr Andrew Wilkinson. “When you find the first injury, do not stop looking - always look for the second injury. With paediatric fractures there are often more than one.” Dr Wilkinson’s tips included having all x-rays reviewed by a consultant radiologist; ignoring external pressures when walking in to a patient cubicle; and having a systematic, methodical approach. “There might be other things in your head. You might be thinking about the 15 patients waiting or the patient you’ve just seen that isn’t sorted out yet. “We cannot obliterate missed injuries but we can reduce the likelihood of them.”
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NEWS
Palliative care support for carers An online training program to assist those working in community and palliative care is available through the Australian Healthcare and Hospital Association (AHHA) website.
Concerns new emergency healthcare role sells out NPs A new advanced clinical practitioner (ACP) role, which will include for nurses, paramedics, and physician assistants, will be rolled out in the United Kingdom from next year, in an overhaul to its emergency care system. However the new role has seen significant backlash from some nursing quarters for “selling out” the emergency nurse practitioner (ENP) movement. The UK’s emergency care shakeup will also see new “urgent and emergency care networks”, Professor of Emergency Care and Consultant Nurse at the University Hospital of Southhampton Robert Crouch NP said. Some EDs would provide higher levels of care and others less urgent, he told delegates at the 6th Australian Emergency Nurse Practitioner Symposium in Melbourne last month. The reform is partly in response to a lack of national standards of emergency nurse practitioners (ENPs) and to tackle a growing medical workforce crisis. Less than 50% of emergency medicine trainee positions were filled at registrar level in 2012-2014. “We have a middle grade workforce at less than 50% capacity: in four to five years we will see this in a lower number of consultants,” Professor Crouch said. The UK was losing many of its medics to overseas countries, with Australia one of the biggest importers. While the UK has had ENPs in practice for over 20 years, Australia was ahead in many ways, Professor 14 October 2015 Volume 23, No. 4
Crouch said. “You have got regulation and protection of the ENP title – we have no regulation and no protection of the title.” While some NPs held a Masters, others had as little as eight weeks’ training. “There is a lack of standards, scope of practice and education preparation,” Professor Crouch said. “There is significant variation, we need national standards.” Applicants for the ACP role will be required to have five years registration, three in a specialty. The three year curriculum is at Masters’ level with the option to specialise in adult, paediatric or a combination of both. “Where is the nursing?” has been an issue raised by some nursing sectors, Professor Crouch said, who makes no apologies. “If you are a nurse or a paramedic, whatever background you have, you will bring that unique professional experience to the role. If we are seeing the same patients then we should be functioning at the same level. If an ACP is trained in Birmingham I will know what level of standard they will be at if they come to Southhampton.” ACP Assessor training is planned for January 2016 with the credentialling process to follow in March.
The program, aimed at aged care and community care workers, is based on the Guidelines for a Palliative Approach for Aged Care in the Community Setting, which addresses legal responsibilities and best practice guidelines for those working in the area. Commissioned by the Commonwealth Department of Health, the resource was developed by AHHA. AHHA’s Chief Executive Alison Verhoeven said the program’s purpose was to support and empower workers in the community and aged care settings. “Some of these workers may not be highly trained or skilled to deliver palliative care, in what can be trying circumstances when people are dying and families are involved,” she said. “Additionally, there is not always good support available, particularly for people who live in remote and rural areas.” According to Ms Verhoeven the program is an interactive resource that encourages aged and community care workers to reflect on their own practice as well as their own circumstances. “It assists in the conversation about dying, which many of us ignore in our own lives.” There are four online modules including two new units on pain management and the deteriorating patient, which were recently introduced based on extensive consultation with aged and community care workers. “These were areas that were identified as particularly challenging for aged and community care workers, so we invested time and effort to develop a program which responds to some of those needs,” Ms Verhoeven said. The program also focuses on legal responsibilities to ensure aged and community workers understand the limitations of their role and responsibility, said Ms Verhoeven. “This is an area people felt most anxious about, particularly in relation to their role and responsibility and to what extent they are liable if something goes wrong.” Additionally the program delves in to Advance Care Directives. “It differentiates what a plan is and what a directive is,” Ms Verhoeven said. “The program tries to tease out quite a complex legal issue at a conversational level to make it understandable.” To date 22,000 people have used the resource, Ms Verhoeven said. “There is ongoing engagement, [once they have completed the course] as well. They remain part of the community with the ability to access the course whenever they require.” The course is free of charge and is available at: http://ahha.asn.au/pallcareonline anmf.org.au
Forensic special
NEWS
Queensland’s push to strengthen forensic nursing workforce The future supply of forensic nurse examiners in Queensland is at risk, with the absence of a training course threatening to trigger a shortfall if no new blood replaces staff leaving the sector. To combat the gap in the interim, the sector will allow the less specialised cohort of Sexual Assault Nurse Examiners (SANE’s), most likely Emergency Department nurses who have completed appropriate study, to perform sexual assault examinations. The state will also attempt to find and adopt an already established training course that mirrors its needs, and begin the process of developing its own program. Prior to the implementation of a Forensic Nurse Examiner Program in 2005, only forensic medical officers and general medical officers performed forensic examinations. From 2006-2010, government funding helped 64 nurses gain Graduate Certificate Level qualifications by undertaking a one-year part-time distance education program offered by Monash University in Melbourne. The course was scrapped in 2011 and the lack of a replacement has meant the state’s production of new forensic nurse examiners has stalled. Queensland has 34 practising forensic nurse examiners spread across the state, three of them holding down full-time positions, and the remainder employed casually. Since 2008, forensic nurse examiners in Queensland have performed more than 700 sexual assault exams. The job can involve injury interpretation, specimen collection, attending court and presenting evidence, custodial nursing, and education in schools. Speaking at the National Forensic Nursing Forum in Melbourne recently, Forensic Nurse Examiner Allison De Tina said not having a training course was “leaving a big hole in our service” and additionally contributing to existing nurses feeling overwhelmed and unsupported. In 2008, a state-wide network for forensic nurses was created, involving quarterly teleconferences to discuss relevant issues and an annual three-day refresher workshop with presentations anmf.org.au
and updates covering statement writing, pathology and toxicology, and police and social worker perspectives. Ms De Tina said the role of a forensic nurse examiner was often demanding and that the maintenance of a network was essential to retaining staff. Queensland’s main aims surround strengthening its workforce and boosting the perception of the job as a valuable role. “It just keeps us connected together because they [nurses] just feel like they’re floating out there and a little bit neglected.”
Call for elder abuse units A leading forensic nursing expert is calling for independent elder abuse units to be established to investigate reported abuse of older people. Flinders University School of Nursing and Midwifery Associate Professor Linda Starr said elder abuse review teams already worked well in the United States. The teams or units would be
multidisciplinary and multiagency and include health professionals, magistrates, lawyers and police. They would review cases that had gone before them and been actioned. “The elder abuse units would investigate and report facilities internally and externally,” Professor Starr said. “If a person has a reasonable suspicion they would directly report to an investigator who prepares a report and interviews staff separately and before they talk to one another.” There had been as many as 12,000 reported sexual assault and excessive use of force cases in Australian residential aged care facilities in the past five years, Professor Starr told the recent National Forensic Nursing Forum in Melbourne. “We need better access to justice for those who are living silent in residential aged care facilities.” One of the current difficulties was that reportable offences of Commonwealth and states and territories laws differed. National law similar to how national regulation of health professionals was introduced, for elder abuse could be adopted by every state and territory, Professor Starr said. “Elder abuse has to get on the political agenda. Despite reports in the media we are not able to get the government to respond.” October 2015 Volume 23, No. 4 15
NEWS
Forensic special
There should also be forensic focussed education for healthcare professionals and providers, including forensic care resource packages, she said. “We are losing a wealth of knowledge that we have.”
Why location and context matter in forensic nursing – a Victorian perspective A key discussion at The National Forensic Nursing Forum examined how location and context can have a direct impact on carrying out forensic nurse examinations. “Wherever we work it is different and our experiences are different,” said Suzanne Wallis, a Rural Sexual Health Nurse Practitioner at Goulbourn Valley Health. The history of forensic nursing in Victoria dates back to 2006, when the Victorian Institute of Forensic Medicine helped develop a Forensic Nurse Network (FNN) under the Victorian Department of Justice’s Sexual Assault Reform strategy. The aim of FNN was to provide suitable forensic medical examinations to adult victims of sexual assault by female practitioners. The process involved the Victorian Institute of Forensic Medicine (VIFM) training 33 nurses to qualify as Forensic Nurse Examiners who were able to undertake examinations involving sexual and other physical assaults across regional and metropolitan Victoria. Ms Wallis told the forum that location can have a significant impact on many considerations that need to be taken into account. Focusing on the regional process, Ms Wallis used a case study where a 22-year-old girl had come forward after non-consensual sex. Initial considerations included examining medical and general trauma, taking non-intimate photography, and providing emergency contraception. The offender was known to the victim, but not well, the forum heard, with all decisions at the time needing to take into account the nature of the assault and preference of the patient. “They need to give permission for any or all of this to occur,” Ms Wallis said. Given the assault occurred in a 16 October 2015 Volume 23, No. 4
rural area, Ms Wallis said one of the most important concerns is invariably, disclosure. She said the potential for victims to encounter people they know in medical wards is far greater than in metropolitan areas and therefore needs to be considered. The regional process usually involves a victim contacting police, then being referred to the Centre Against Sexual Assault (CASA), VIFM staff, and a forensic nurse examiner on call.
THE HISTORY OF FORENSIC NURSING IN VICTORIA DATES BACK TO 2006, WHEN THE VICTORIAN INSTITUTE OF FORENSIC MEDICINE HELPED DEVELOP A FORENSIC NURSE NETWORK (FNN) UNDER THE VICTORIAN DEPARTMENT OF JUSTICE’S SEXUAL ASSAULT REFORM STRATEGY.
During the exam, the victim presented with tender abrasions and tender areas on the anus and vagina. Forensic specimens were collected, antiviral drugs administered, and the patient also consulted with a physician. A pregnancy test was conducted six weeks later and the patient was referred to a psychologist and other services. Ms Wallis said rarely do patients visit GPs for follow ups, but there are other options, such as Primary Care Connect in Shepparton, and headspace for people 25 and under. Last October, the Victorian government opened a new $10 million sexual support centre in Dandenong, bringing together sexual assault counselling, child protection, and nursing and forensic medical services all in the one location. Similar sites are in the works in regional Victoria and should be operational in Bendigo and Morwell by mid next year.
Victorian forensic mental health bed crisis Victoria is in dire need of forensic mental health beds with only the exceptionally mentally unwell in prison admitted to hospital. An extra eight beds allocated to forensic mental health in Victoria is not enough to meet current need, Swinburne University Associate Professor of Forensic Psychiatry Dr Andrew Carroll said at the recent National Forensic Nursing Forum. “In the two kilometres of where we are sitting, there is around a backlog of 10 acutely psychotic men locked up in prison certified under the Mental Health Act. They cannot transfer to Thomas Embling Hospital until someone is transferred back to prison. They can suffer weeks of acutely post-psychotic symptoms.” Victoria has 116 forensic mental health beds with less than 30% available to prisoners as many are occupied by long term forensic patients. This is compared to Scotland with a similar population as Victoria, which has 522 forensic mental health beds. The Victorian Ombudsman in 2014 recommended an increase in forensic mental health beds. The prevalence of mental health disorders in prisoners in Victoria was three to five times greater than in the general population, Dr Carroll said. “Resourcing for this is inadequate in Australia. We need a better configuration of services than what Australia has in the next five to 10 years.” Forensic mental health services were expensive, with public protection the main aim. However there was a reciprocal obligation in keeping the public safe which was humane integration of prisoners with mental health problems, Dr Carroll said. “We need resources for rehabilitation and public protection.” Despite this, Victoria was a world leader and had the best functioning off campus leave system, Dr Carroll said. In five to 10 years Victoria would also be a world leader in therapeutic interventions for those who voiced self-harm. “There is a huge onus not to take any risks which is not a very grown up approach,” Dr Carroll said. “There are very clear signs Victoria is going to adopt a grown up approach to the problem and we will see systems at play over the next few years.” anmf.org.au
WORKING LIFE
Paying it forward from the bedside to the screen Since surviving childhood cancer registered nurse Katharine Vine has taken every opportunity to give back to the community. Her latest venture is to support Alzheimer’s Australia.
The South Australian nurse plans to raise money and awareness for the disease by holding a movie night fundraiser, featuring the new Australian movie, The Dressmaker a film that she played an extra in. The movie, which stars actors such as Kate Winslet, Liam Hemsworth, Hugo Weaving and Judy Davis, was written by Katharine’s aunt, Rosalie Ham, who requested family members audition as extras for the film. Following Katharine’s successful audition she spent time on set filming around Melbourne and country Victoria late last year.
KATHARINE’S REASONING FOR BECOMING A NURSE WAS ALSO TO GIVE BACK TO THE COMMUNITY. “I GOT TO THE STAGE WHERE I COULDN’T SEE MYSELF DOING ANYTHING ELSE,” SHE SAID. Katharine said not only did she find the experience of being part of the cast amazing and special, but was thrilled how the movie turned out. “I viewed the movie [recently] with the cast and crew and it’s fantastic. I may be biased but in my opinion it’s a great movie. It’s got all those moments where you laugh, you cry and where you sit on the edge of your seat.” On the date of the movie’s national release Katharine plans to hold the fundraiser. She said she wants to bring awareness to Alzheimer’s because her uncle, Rosalie Ham’s husband, has early onset of the disease. “Alzheimer’s anmf.org.au
The Dressmaker movie night for Alzheimer’s is being held on 29 October at the Piccadilly Cinema, North Adelaide. For more information and ticket details go to: www.facebook.com/ events/1458001297834935/ is often seen as a normal part of ageing, but in fact it is not. It can be really hard for families especially spouses and carers, and if I can raise some awareness and money, that can only be a good thing. Every bit helps.” Paying it forward is not a new concept for Katharine. After recovering from childhood cancer she volunteered for Camp Quality. “My best experience [during that time] was seeing the kids happy and enjoying themselves amongst a group of people that had similar issues,” she said. “It was great to take them away from their environment of medical wards and tests and see them functioning as children. I found that very rewarding.” Katharine’s reasoning for becoming a nurse was also to give back to the community. “I got to the stage where I couldn’t see myself doing anything else,” she said. After working as an assistant in nursing, Katharine went on to become an enrolled nurse before becoming a registered nurse five years ago. She completed her Graduate Nurse Program (GNP) at Adelaide’s Women’s and Children’s Hospital on the paediatric oncology ward where she was once treated. “I really enjoyed it,” she said. “It was really emotionally draining but the kids were brilliant to nurse. I think they have a certain type of resilience. If they wake up feeling good then it’s a good day. They don’t have any insight into their illness so they don’t dwell on it.” While Katharine was offered a job back on the same ward after her GNP, she decided to
experience something different and moved to Darwin where she worked in a clinic conducting preemployment medicals for mining and construction companies. “It was a completely different type of nursing, to which I discovered I really needed to be looking after people more so than passing people for medicals.” When Katharine returned to Adelaide she found there were no jobs at the Women’s and Children’s Hospital, but gained employment at a private orthopaedic hospital where she has worked for the past two years. “I enjoy surgical nursing and I work with a great team of nurses.” Katharine has also commenced studies in naturopathy, an area that she has always held an interest in. “As a result of my childhood illness I have had a few ongoing health issues that will need monitoring for the rest of my life and I just wanted to have the knowledge to live the healthiest life possible and I think a lot of that comes from diet and lifestyle.” Katharine thinks overall we work “a little too much” against nature when it comes to our health. “Definitely conventional medicine is absolutely necessary but I do believe a lot of our preventable health issues today are as a result of diet and lifestyle and the changes in technology that modifies just about everything we consume”, she said. “I think as a result we are seeing a lot more chronic diseases such as diabetes and heart disease. “It’s about eating the right food for your body and I think we should let food be the medicine more than we do.” October 2015 Volume 23, No. 4 17
FEATURE
18 October 2015 Volume 23, No. 4
anmf.org.au
FEATURE
CULTURAL DIVERSITY & INCLUSIVITY WHERE ARE WE AT?
Cultural diversity is becoming widely prevalent and accepted in today’s society; no more so than in our schools and universities. But do nursing and midwifery classrooms provide an inclusive environment for all? Dr Kechinyere (Kechi) Iheduru-Anderson explains how to ensure cultural inclusiveness in the classroom to the ward.
As well-meaning nurses, midwives and educators we like to think that we are not biased. We believe we should treat everyone the same way. However in fact this should not be the case. All people should be treated as individuals. In education one size does not fit all. As globalisation takes hold in the 21st century monoculturalism is becoming a thing of the past. This has resulted in a changing demographic within classrooms, which has necessitated a change in the way teachers teach. However, teaching in racially diverse classrooms, often leaves people feeling uncertain about how to behave. As one of the nursing students I spoke to said: “Sometimes,
anmf.org.au
white teachers don’t know how to behave with black students.” The idea of inclusive and diverse teaching can be intimidating even to the most seasoned professor. This in part is because of the various ways in which human experience differs, and fear of offending people whose culture is different from ours. When we talk about diversity, it is not just about race and ethnic origin, it is also about a different ability, religion, class, wealth, age, migration status, native language, gender, sexual orientation and/or socioeconomic status. In today’s learning environment there is pressure to acknowledge and accept students with perspectives other than our own,
to diversify our syllabi, to be more aware of classroom dynamics, and to pay more attention to how our students are experiencing the learning process. In other words, it is important that nurse and midwifery educators become more culturally competent.
Cultural competency, inclusive teaching and inclusive teaching strategies
The National Education Association based in the United States describes cultural competence as: “Having an awareness of one’s own cultural identity and views about difference, and the ability to learn and build on the varying cultural and community norms of students and their families. It is the
October 2015 Volume 23, No. 4 19
FEATURE ability to understand the withingroup differences that make each student unique, while celebrating the between-group variations that make our country a tapestry. This understanding informs and expands teaching practices in the culturally competent educator’s classroom.” Cultural competency is the ability to work effectively and sensitively across cultural contexts. It involves learning, communicating and connecting respectfully with others regardless of differences. As educators, regardless of background or identity, we must bring both cultural understanding and self-awareness to our work. As nurse and midwifery educators we should view cultural competence as a moral and ethical responsibility, to create a warm environment for our students to succeed. To do this we must be inclusive in our teaching and use inclusive strategies to ensure that our students do not feel left out. Nurse and midwifery educators should understand the development of cultural competence is a process along an upward curve of learning and practice rather than an endpoint (Purnell, 2005). Inclusive teaching is:
“teaching in ways that do not exclude students, accidentally or intentionally, from opportunities to learn” (Center for Instructional Development and Research (CIDR), 2001). While inclusive teaching strategies “refer to any number of teaching approaches that address the needs of students with a variety of backgrounds, learning styles, and abilities. These strategies contribute to an overall inclusive learning environment, in which students feel equally valued” (Cornell University Center for Teaching Excellence, 2015).
Why is it important to be inclusive in nursing education? By including people from diverse cultural backgrounds in our curriculum, we enhance the scientific rigor and validity of nursing education. Additionally, students may benefit emotionally, cognitively and psychologically when they are exposed to people from culturally diverse backgrounds and diverse perspectives. They may also feel comfortable in the classroom environment to voice their ideas/ thoughts/questions.
Students are more likely to experience success in a course through activities that support their learning styles, abilities, and backgrounds as well. Yet despite the underscored benefits associated with inclusive teaching many nursing tutors and lecturers are reluctant to make changes in their classrooms. Some worry their competence related to diverse students and issues is not sufficient to qualify them to address diversity in classrooms or that in trying to be inclusive will unintentionally offend their students. The fact is no one is fully culturally competent. To achieve this is a lifelong undertaking. Yet despite this inclusive education can occur in classes across the nursing curriculum. So how do we start to introduce diversity and teach inclusively in the classroom? The process of introducing and creating inclusive classroom environments includes several key components: • self-awareness; • knowledge; and • skills. I suggest nurse and midwifery
References Ambrose, S., Bridges, M., Lovett, M., DiPietro, M., & Norman, M. (2010). How learning works: 7 research-based principles for smart teaching. San Francisco, CA: Jossey Bass. Armstrong, M. A. (2011). Small world: Crafting an inclusive classroom (no matter what you teach). Thought & Action, 51-61. Retrieved 4 May 2015 from www.nea.org/ assets/docs/2011Tand AArmstrongFINAL.pdf Campinha-Bacote, J., (2003). The Process of Cultural Competence in the Delivery of Healthcare Services: A Model of Care. Journal of Transcultural Nursing, 13(3), 181-184. Retrieved 18 May 2015 from http://coe. stanford.edu/courses/ ethmedreadings10/ Process%20of%20 Cultural%20 Competence.pdf
Figure 1: Cultural Competence Continuum is adapted from Purnell’s model for cultural competence (2002).
UNCONSCIOUS INCOMPETENT
CONSIOUSLY INCOMPETENT
CONSIOUSLY COMPETENT
UNCONSCIOUSLY COMPETENT
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• Not being aware that one is lacking knowledge about another culture • Not knowing what you do not know
• Being aware that one is lacking knowledge about another culture • May knowingly act in a culturally insentive manner, exhibiting biased
behaviours
• Learning about the student’s culture, verifying generalisations about the
student’s culture, and providing culturally specific interventions to learning.
• Automatically using culturally congruent educational methods for students
from diverse cultural backgrounds
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educators ask these questions to reflect on their own level of cultural competence.
Self-awareness Ask what are my own cultural values and biases toward students and people from diverse backgrounds? According to Purnell & Salmond (2013) self-awareness in cultural competence is: “a deliberate and conscious cognitive and emotional process of getting to know yourself: your personality, your values, your beliefs, your professional knowledge standards, your ethics, and the impact of these factors of the various roles you play when interacting with individuals different from yourself”. The critical analysis of our own values and beliefs in relation to cultural differences allows us to be less apprehensive of those whose values and beliefs are different from ours. Awareness occurs when we are conscious of our personal reactions to people who are different (Martin & Vaughn, 2007). Self-awareness begins with self-assessment or critical reflection. However, developing cultural self-awareness is easier said than anmf.org.au
done. We tend to take many aspects of our own social action and everyday life for granted. Have you ever wondered how individuals who are culturally different from you, view you? How would they describe their encounter with your culture, and your social life? I bet you may be amused, amazed, defensive, or even annoyed by their outside viewpoints. You may even resent being stereotyped to a certain degree. The ability to understand one self is the foundation for incorporating new knowledge related to cultural differences into the nurse and midwifery educators’ knowledge base, learning differences, teaching methods, and the impact these factors have when interacting with students and colleagues from diverse backgrounds (Purnell & Salmond, 2013). Ask yourself, what have I done in the last few years to increase my self-awareness? A number of cultural competency self-assessments exist that can help to determine this. To enhance cultural self-
awareness, we should ask ourselves the following questions: • How does issues of sameness, difference and power impact interactions with colleagues, students and families? • How might my own culturalbound assumptions influence my interactions with students? • How might the backgrounds and experiences of my students influence their motivation, engagement, and learning in the classroom? • How can I modify course materials, activities, assignments, and/or exams to be more accessible to all students in my class? Additionally, it is important to recognise people from cultures other than your own who may not share the same cultural beliefs and practices.
Knowledge Do I know what I need to know about my students’ worldviews and experiences that may influence their learning experiences? Cultural knowledge, according to Campinha-Bacote (2002), is the process of seeking and obtaining a
Center for Instructional Development and Research. (2008). Inclusive Teaching. Retrieved 28 April 2015 from http:// depts.washington.edu/ cidrweb/OLD/inclusive/ background.html#faculty Center for Instructional Development and Research. (2001). Inclusive Teaching. Teaching and Learning Bulletin, 5(2) 1-2. Retrieved 6 May 2015 from http://depts. washington.edu/ cidrweb/OLD/Bulletin/ Inclusive.pdf Cornell University Center for Teaching Excellence. (nd). Inclusive Teaching Strategies. Retrieved 5 May 2015 from www.cte. cornell.edu/teachingideas/building-inclusiveclassrooms/inclusiveteaching-strategies.html Derek Bok Center for Teaching and Learning Harvard University. (2010). Teaching in racially diverse college classrooms. Retrieved 29 April from http://isites. harvard.edu/fs/html/icb. topic58474/TFTrace. html Littleford, L. N. & Nolan, S. A. (2013). Your sphere of influence: How to infuse cultural diversity into your psychology classes. Psychology Teacher Network. Retrieved 8 May 2015 from www.apa.org/ed/ precollege/ptn/2013/05/ cultural-diversity.aspx
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FEATURE sound educational base concerning the various worldviews of different cultures and knowledge regarding specific physical, biological, and physiological variations among ethnic groups. To become culturally competent it is critical that nurse and midwifery educators continuously educate themselves, discovering all that they can about their students and their backgrounds. Nurse and midwifery educators must understand important ways in which cultures differ and how this affects the ways in which their students behave. When working with students from different ethnic backgrounds, it is crucial to understand their degree of acculturalisation (from highly assimilated to highly traditional), as this may affect how they perform in a course and interact with the educator and other students. Diverse students benefit when educators participate in professional development opportunities focused on working with diverse student populations. Reading and sharing professional journals, books or blogs related to anti-bias and inclusive education can augment professional development. When interacting with students not proficient in English, recognising their limitations in English proficiency in no way reflects their level of intellectual functioning. Be proactive in listening, accepting, and welcoming people and ideas that are different from your own.
educators, we should recognise that to engage students in the decisions that affect their learning can empower them beyond the classroom. Greater student engagement is a strong predictor of success. Additionally, students who are more engaged in class are more likely to
Skills
earn higher grades. Mixing diverse students in group activities will also help improve cultural awareness while fostering their communication skills. Part of developing culturally competent skills is to remember that treating all students the same could actually result in unfair treatment. It is therefore important to utilise a variety of teaching strategies, assessment tasks, activities, assignments and assessment methods that will accommodate the needs of students with diverse learning styles, abilities, backgrounds, and experiences. In doing so, students can demonstrate in different ways that they have met learning outcomes. Finally, it is equally as important that we are mindful of self in relationship to others.
Am I using teaching strategies that are inclusive of students from culturally diverse backgrounds? It is important to understand how the students’ cultural identity affects learning. What are the cultural differences that impact on the students’ learning? In a culturally diverse classroom it is essential to employ inclusiveteaching methods to encourage students to question, inquire, and search for new knowledge, hence improving learning outcomes. It is also imperative to maintain high expectations and standards for all students and to use assessment criteria that is equally challenging for every student, irrespective of their cultural background. Student-centred learning is a process that actively involves students in their education. As 22 October 2015 Volume 23, No. 4
DIVERSE STUDENTS BENEFIT WHEN EDUCATORS PARTICIPATE IN PROFESSIONAL DEVELOPMENT OPPORTUNITIES FOCUSED ON WORKING WITH DIVERSE STUDENT POPULATIONS. READING AND SHARING PROFESSIONAL JOURNALS, BOOKS OR BLOGS RELATED TO ANTI-BIAS AND INCLUSIVE EDUCATION CAN AUGMENT PROFESSIONAL DEVELOPMENT.
Educating students towards cultural competence I asked a minority nurse, who I will call Darlene, to tell me what she thought about diversity in nursing. These were here exact words: “I think nurses and educators pay lip service to cultural diversity in nursing and nursing classrooms. The point is that they really need to start teaching cultural diversity in nursing, so that those who are coming in will be able to adjust and also help the culturally diverse patients who are in the hospitals and nursing homes. There is always this conflict between foreign patients, patients from different backgrounds and the American educated white nurses who work in these places. But when there is a good mixture of nurses in a health system I think that it minimises the conflict, so they (nursing) really have to work on the cultural diversity in the profession. They need to work on it, believe in it, do it, practice it and I mean really practice it, and not pay it lip service like they have been doing so far. They can’t merely say it. They have to believe it, adopt it and practice it.” As educators employ culturally diverse teaching in the nursing classrooms, it is important to also help our students develop cultural competency. It is very important to understand that no amount of lecture slides and stories could replace real cultural experience. If you want to teach students something about culture and promote increased cultural competence among students, you need to change your teaching approach. In order to do this designing class activities that help the students gain their own cultural experiences and explore their own responses to these experiences is most beneficial. According to Littleford and Nolan (2013), as we formulate our teaching objectives and design our courses to be more culturally inclusive, it is important to consider the following questions and relevant activities and assignments: • What curriculum-related activities can help students become more aware of their own cultural backgrounds and attitudes toward people who are different? This can include activities that encourage students to question their assumption that their experiences, views and
Martin, M. A. & Vaughn, B. E. (2007). Cultural Competence: The Nuts & Bolts of Diversity & Inclusion. Retrieved 12 May 2015 from http:// diversityofficermag azine.com/culturalcompetence/ cultural-competencethe-nuts-bolts-ofdiversity-inclusion/ Purnell, L., (2005). The Purnell Model for Cultural Competence. The Journal of Multicultural Nursing & Health 11(2), 7 – 15. Purnell, L. D & Salmond, S., (2013). Individual Cultural Competence and Evidence-Based Practice. In L. D. Purnell (Ed), Transcultural Healthcare: A Culturally Competent Approach (4th ed., pp. 45 - 59). Philadelphia PA: F. A. Davis Company.
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behaviours.
• Nurse and midwifery
educators should incorporate research from multiple disciplines because each offers different ways of understanding human behaviours. I also encourage nurse and midwifery educators to read research and reflections on diversity and teachings published by scholars outside of nursing. (eg. psychology, sociology and social work). • What skills should students acquire in order to be culturally competent? Student nurses and midwives should be able to interact effectively and sensitively with people of diverse abilities, backgrounds and cultural perspectives. This can be achieved by creating opportunities for your students to engage in cross-cultural interactions. • How can I present research in my courses in a way that is inclusive and diverse? Make a point of including studies that include participants from minority groups or conducted in other countries. • How can I highlight the diversity among researchers in the field when I present the content in my courses? When possible, include first names or photos in your classroom presentations when introducing researchers to highlight diversity among nurses and midwives. Learn how to pronounce names correctly, this is an important part of creating a classroom climate that is welcoming of diversity.
Nursing classroom climate The classroom climate is very crucial for learning. This includes the clinical learning environment, even though the dynamics may be different and the instructor may have less control. Amborse et al. (2010) defined classroom climates as: “the intellectual, social, emotional, and physical environments in which our students learn. Climate is determined by a constellation of interacting factors that include faculty-student interaction, the tone instructors set, instances of stereotyping or tokenism, the course demographics studentstudent interaction, and the range anmf.org.au
of perspectives represented in the course content and materials”. The learning environment will dictate how well or poorly a student will learn. The primary responsibility of an educator should be to assure that every student feels a sense of belonging and security within the classroom. The atmosphere must be conducive to taking safe challenges without fear of ridicule. Incivilities that are not addressed properly not only negatively impact learning within the course in which it is experienced, but may also negatively influence a student’s success at an institution. No student should feel alienated in the classroom. The tone of a class environment is influenced strongly by the educator. Faculty-student interactions also play a key role in creating positive classroom climate. From everyday experience of bias and prejudice sometimes students may expect to be treated poorly by some of their classmates in the classroom but not the educator. How educators and those in authority deal with negative interactions among students has impacted on student learning. It is crucial that nurse and midwifery educators monitor their classroom climate. By recognising the needs of students, and being mindful of cultural diversity when organising learning activities, we bring inclusive teaching to all our students. Below is an excerpt from an African migrant student nurse discussing her feeling of isolation and lack of inclusion by a nurse educator? “I have to say that the teachers’ behaviour towards me was very surprising to me. I expected bias and prejudice from students but not from teachers and instructors. That is a problem, getting that kind of treatment and reception from an instructor who has more education than most and should know better, that was really surprising and made me feel very sad. I felt like I don’t belong there. The teacher when she sees a person of colour in the class she doesn’t feel comfortable. And when they (teachers) ask questions and the person of color stand up to answer it they ignore you. Sometimes when you stand up to answer the question they say okay, but when the white student stand up and answer, they say oh yay, very good answer. Very, very good,
you did very well. Most times the answer given by the white student is the same. So why is the treatment different? So I stopped answering questions, they don’t want to know what I have to say anyway.” Think for a moment - could this be you? Does this happen in your classroom? Do any of your students feel unwelcome, and/or excluded from the class discussion? Have you been insensitive consciously or unconsciously about the examples you use in class discussions? Do you ignore responses from certain students in your class? Be intentional about creating a safe learning environment and connecting with your students. The goal is to ensure that students are able to participate in class in ways that will help them achieve the course learning outcomes. Connecting with the students allows nurse and midwifery educators to build rapport in a classroom and enhance student engagement in their learning process.
Conclusion Given the increasingly diverse nature of our nursing and midwifery classes and the vast diversity within the field of nursing and healthcare overall, it is important for nurse and midwifery educators to address both the diversity of our students and of the topics of our courses. Developing skills and attitudes that bridge cultural differences such as empathy, flexibility, listening without judgement, appreciation for multiple cultural perspectives and cross-cultural communication is crucial. Genuinely seeing diversity as a strength and an opportunity, rather than a problem is also essential. Additionally, thinking about what each of us still needs to learn, and engaging in relevant professional development, dialogue, study or personal reflection as well as understanding how one’s own life experiences can help build relationships with students and enhance curriculum. Commitments to cultural competency and building inclusive classroom require ongoing effort, reflection and personal humility. Remember that cultural incompetence can lead to dire consequences for the students and the education community at large.
Dr Kechinyere (Kechi) IheduruAnderson is a professor of nursing and the interim dean of academic and laboratory experiences at Quincy College, Quincy Massachusetts and Adjunct faculty at Regis College Weston and Laboure College Milton Massachusetts. Kechi earned her Doctor of Nursing Practice degree in nursing education and master’s degree in nursing leadership and healthcare administration from Regis College Weston Massachusetts in 2014 and 2012. Kechi created and maintains the website www. westafrican educated nurses.com a resource for newly migrated West African internationally educated nurses and other internationally educated nurses as they transition into clinical practice in the United States.
October 2015 Volume 23, No. 4 23
WORLD
1. UNITED KINGDOM 2. INDIA & SOUTH ASIA 3. NEW ZEALAND 4. SIERRA LEONE
1. School nurses essential in solving child health crisis UK’s Royal College of Nursing (RCN) fears a lack of investment in school nursing is leading to an escalating health crisis among children and young people. A recent government report found that five more children die per day in the UK than Sweden. Experts from across the UK advocated the importance of school nurses at the annual Royal College of Nursing’s School Nurses Conference. Despite a growing number of school pupils, figures show a drop in school nurses since 2010. There is currently about 8.4 million pupils attending 24,317 schools – yet the number of school nurses has fallen to just 3,053 employed by the National Health Service. England recently experienced cuts to its public health budget and experts believe school nurse funding could be slashed to plug gaps in other areas. The conference heard that school nurses have a unique opportunity to help shape key issues facing children’s health such as obesity, mental and emotional health, and disability. Fiona Smith, Professional Lead for Children and Young People’s Nursing at the RCN, said school nurses were essential in educating children and their families about these issues. “School nurses play a critical role in the health of our children yet their work is so often overlooked and undervalued. “Investment is fundamental if we are to begin solving this crisis in children’s health and build a healthy and prosperous future population.”
2. Research set to help prevent lifestyle-related diseases Public health experts from Australia and India will team together to undertake new research in a bid to
24 October 2015 Volume 23, No. 4
tackle non-communicable, lifestylerelated diseases such as diabetes, heart disease, stroke, and cancers. Funded by the University of Melbourne for the next three years, ENCORE (Excellence in Non-COmmunicable disease REsearch) will train a new generation of researchers in non-communicable disease prevention and control in India and other low and middle-income countries in South Asia. ENCORE will be co-led by senior researchers from the University of Melbourne and India’s top public health and medical research institutes. Project lead, Professor Brian Oldenburg, said non-communicable diseases have become the leading causes of death in the developing world, with 80% of deaths involving people from poorer countries. “To address the burden of chronic conditions, there is an urgent need for more research to improve disease prevention and management.”
3. Graduate nurses struggle to enter the sector The New Zealand Nurses Organisation (NZNO) has challenged its government to fund a one-year training program for all graduate nurses to address the troubling crisis of large numbers of graduates unable to find work. The union, which represents more than 46,000 nurses and health workers, believes government intervention is required in order to adequately educate the next generation of nurses, which the country will look to in coming years to fill a looming workforce shortage. In a recent July intake, just 285 out of 667 recent graduates were able to find places on nurse entry to practice program across the country. In a development that mirrors Australia’s own predicament, the NZNO is calling for funding to ensure more places are made available to new graduates so that they can be supported and mentored
in their crucial first year of practice. “It’s a complete waste of resources educating nurses and then leaving large numbers of new graduates unable to find work in a clinical setting due to limited places on nurse entry to practice programs” NZNO Associate Professional Services Manager Hilary Graham-Smith said. “The program means new graduate nurses get the benefit of growing and developing their skills as registered nurses with support and mentorship throughout their first year in the workforce. All new grads need that, not just a lucky few.” Associate Professor Graham-Smith warned New Zealand would face a significant shortage over the next decade and it was essential a highly skilled nursing workforce be invested in to ensure quality care for the future.
4. Winning the war against Ebola The lengthy battle against the deadly Ebola virus is finally being won in Sierra Leone. An epidemiological week has now passed with no new Ebola cases for the first time since the outbreak. “This is very good news but we have to keep doing this intensive work with communities to identify potential new cases early and to rapidly stop any Ebola virus transmission,” World Health Organization (WHO) Representative in Sierra Leone, Dr Anders Nordstrom said. Sierra Leone’s Ebola response has now moved to phase 3, which focuses on tracking every chain of Ebola virus transmission and closing down the remaining chains as quickly as possible. Sierra Leone is now down to a single chain of transmission. Tracking chains of transmission requires finding every person who has been in contact with someone proven to be infected with Ebola, monitoring them closely for symptoms for 21 days, and rushing them to a treatment centre if they develop Ebola symptoms. anmf.org.au
REFLECTIONS
Refining your art and maintaining enthusiasm for nursing – The role of Reflective Clinical Supervision Mary Hendrey A nursing career is dynamic. Ebbing and flowing, chasing evidence based best practice to produce optimal outcomes. Many challenges are faced and dealt with by nurses on a daily basis. The way a nurse responds to any situation on any given day will depend on many things – who is involved, the urgency, the resources (including skills) available, the environment and not to be underestimated the mood and attitude of the people involved. Nurses will work different shifts, different wards, different sites, for different employers, and perform a vast range of roles throughout their nursing life. Many of us become nurses because we care. Nursing is a vocation; it is a privilege to be trusted to care for people during their most frail and vulnerable moments in life. Day after day, year after year takes its toll. It is not uncommon for nurses to burn out or become complacent. Some feel bullied and/or undervalued. Some lose focus and unintentionally become bullies or becomes apathetic subordinates. As a nurse your nursing journey is yours. AHPRA requires continued professional development and this is your responsibility. Your education, your experience, your experiences, your goals, and your expectations in nursing are unique. Clinical Supervision is not new and there are many professional articles touting its benefits. However this term still holds ambivalence in its meaning. It is not point-of-care supervision or line management supervision/ professional facilitation. It is thoughtful and reflective. Clinical supervision (CS) is first and foremost a confidential encounter between professionals. It is the supervisees work using a process guided by a trained clinical supervisor. CS is self-sourced, self-directed and a anmf.org.au
form of continuing professional development for life long learning. Various forms of guided reflection are used. As John Dewey an American philosopher, psychologist and educational reformer (1859 – 1952) is quoted:
“WE DO NOT LEARN FROM EXPERIENCE… WE LEARN FROM REFLECTING ON EXPERIENCES”
Reflecting on situations can take the logic (head) and emotion (heart) out of an issue enabling mindfulness and patience for clarity in hindsight and imaginative inspiration moving forward. As a professional with skills and knowledge if you listen to your inner self carefully and long enough the answer for you will become apparent. You have the answer that will work for you. By identifying the players and their roles allows for empathy and creative ways to embrace the numerous roles (both
real and ideal) of a nurse. CS allows for different perspectives to be recognised, different attitudes to be seen and acknowledged. With the guidance of a trained clinical supervisor the issue can be viewed with a fresh vision from your eyes. Kind of like SUPERvision. Paul Spurr founder of Clinical Supervision Consultancy, an inspiration behind the establishment of the Reflective Clinical Supervision Network (Vic) and a committee member of the Australian Clinical Supervision Association advocates: “The need and importance for confidential supervision outside your own management system … believes strongly that regular clinical supervision helps you remain vibrant, spontaneous, less anxious and more creative.” The benefits of CS increase with practice. Rapport building, trusting the process, and slowing down all take time and persistence. The more you are engaged with the process the more you WILL get back. It is work and at times not easy but almost always enlightening and inspiring leaving you the supervisee (and often the supervisor) with a new enthusiasm for the art of nursing.
Reference Spurr P, (2008), Clinical Supervision for Role Development: a booklet to accompany training, Paul Spurr, NSW. www. goodreads.com/author/ quotes/42738John. Dewey June 2015
Mary Hendrey, RN is a Mental Health Nurse and Member of the Reflective Clinical Supervision Network (Vic)
October 2015 Volume 23, No. 4 25
RESEARCH
Chlamydia screening can prevent harm to newborns Screening pregnant women aged between 16 and 25 for chlamydia can prevent harm to babies and save health dollars, according to a University of Melbourne study. The research is the first Australian costeffectiveness study undertaken in a bid to help convince more clinicians to implement chlamydia screening. The study analysed the costeffectiveness of chlamydia screening for all pregnant women between 16 and 25 compared with no screening at all, and
selective screening for those at higher risk of contracting the infection. Researchers found that every chlamydia case detected with a screening program as part of their routine antenatal care cost $1,641 to treat. The cost is far less than treating the associated complications of chlamydia such as managing a low birth weight baby (up to $6,000), managing neonatal pneumonia (up to $3,695) and managing pelvic inflammatory disease (up to $3,636). Chlamydia is one of the most common sexually transmitted infections in Australia, with prevalence rates ranging from 3 to 14% among young pregnant women. Chlamydia in pregnancy can lead to complications for both mother and baby, including miscarriage and premature
birth, but many women experience no symptoms. Screening can help identify and treat infections before complications develop. While the Australian government recommends screening for all pregnant women aged 25 and under at their first antenatal visit, a recent survey of 1,600 Australian obstetricians and gynaecologists found just 21% reported screening of all pregnant women aged under 25. “The advantage of incorporating chlamydia screening into antenatal care means that chlamydia can be detected and treated promptly and there are no additional costs of attending another screening program,” Study co-author Dr Jason Ong said
Hospital admission rates increase due to falls A rise in hospital admissions due to injuries is being attributed to a growing prevalence in falls, according to new research by the Australian Institute of Health and Welfare (AIHW).
Aboriginal communities have world’s highest dementia rate Remote Aboriginal communities experience the highest rate of dementia in the world, with head injuries and age the greatest contributing factors, new research has confirmed. The latest study involved University of Western Australia’s (UWA) Centre for Health and Ageing revisiting a target group of Aboriginal people based in WA’s remote Kimberley region, originally tested ten years ago, to review the clinical and socioeconomic factors contributing to dementia. The review’s ultimate aim is to improve detection rates and target preventative measures. UWA researchers found 21 out of every 1,000 Aboriginal Australians over the age of 60 develops dementia each year, a rate more than double the general Australian population. Data was collected from 363 remote and rural Aboriginal Australians aged over 45 living in the Kimberley, who were originally recruited between 2004 and 2006 and then reassessed between 2011 and 2013. Researchers found 75% of the original group who had already been living with dementia had died. Professor Leon Flicker, WA Centre for Health and Ageing Director and Chair of 26 October 2015 Volume 23, No. 4
Geriatric Medicine, said the world-first study has provided comprehensive clinical data on the cognitive health of a group of older Indigenous Australians. “We were looking at the incidence, predictors and progress of cognitive impairment and dementia in Aboriginal Australians using culturally appropriate assessment tools,” Professor Flicker said. “Dementia is placing a strain on these Aboriginal communities. The greatest risk factors we found were head injuries, stroke, a low body mass index and high blood pressure. “Head injuries can be explained in the main by the higher than average number of car and other accidents, and falls.” Researchers will now further explore the contributing risk factors and look to target preventative measures such as reducing head injuries and controlling stroke. “Further research is needed to intervene and help prevent the onset of dementia and improve long term health outcomes for Aboriginal Australians who live in remote areas.”
The study, Trends in hospitalised injury, Australia 1999-00 to 2012-13, investigated injuries that required hospitalisation from 1 July 1999 to 30 June 2013. It found the yearly number of cases rose from 327,000 to 447,000 during this period. “The injury rate was about 1,700 per 100,000 people at the beginning of the period, but had risen to almost 1,900 by the end,” said AIHW spokesperson Professor James Harrison. The study found the most common causes of injury in 2012-13 were falls (40%) and transport crashes (12%). During that year, more than 170,000 people were hospitalised as a result of a fall, with more than half the cases involving women aged over 65. Transport crash injuries were more common in males (36,880) than females (17,730), with rates the highest in the 15-24 age group. Overall, injuries were more common among males than females (250,440 cases compared to 196,233). The average length of stay in hospital as a result of an injury was found to be four days, but increased to seven days if a person was aged over 65. anmf.org.au
LEGAL
Linda Starr
Reference ‘Alleged fake nurse facing more than 100 charges’ Australian Doctor 17 August 2015. ‘Dentist pleads guilty to more assault charges’, Australian Doctor, 3 September 2015. ‘Duped by Nurse’ The Advertiser, 20 March 2015 p 33. ‘Fake gynaecologist faces court’ Australian Doctor, 16 March 2015. ‘Fake dentist should be in jail admits judge’ Australian Doctor, 14 August 2015. Nursing & Midwifery Board Australia v Morley [2014] SAHPT 17 ‘Public warning over health firm’s dental care’ Australian Doctor, 6 December 2013.
An expert in the field of nursing and the law Associate Professor Linda Starr is in the School of Nursing and Midwifery at Flinders University in South Australia anmf.org.au
Weeding out fake and rogue practitioners – a duty owed to consumers Consumers of healthcare generally place a good deal of trust in health professionals who provide them with care. They have a right to expect that only suitably qualified and registered practitioners have a role in healthcare delivery whether that be in private practice or the public healthcare system. This article highlights two examples of how that trust can be breached by rogue and fake practitioners. A series of alarming headlines about ‘fake’ health practitioners is likely to shake public confidence in the professions. In March 2015 the media ran a story titled `Duped by nurse’ exposing a 64 year old woman who deceived six nursing homes over a four year period falsely claiming to be a qualified health professional. She was employed as a registered nurse and a Director of Nursing. Reed will now face court charged with six counts of deception. The headline ‘Fake gynaecologist faces court’ describes how the Medical Board of Australia took action to protect the public against a man who was posing as an obstetrician gynaecologist and IVF expert despite the fact that he had never been registered to practice in Australia. Pretending to be a registered health professional is an offence under the national regulation law which led to charges being laid against Di Paolo (Australian Doctor, 2015). Then in August 2015 another story of a fake nurse emerged when it was discovered that a man was posing as a nurse in remote hospitals. It was alleged that Crawford used forged documents when he sought and gained employment at a primary health centre in far north Queensland. Of even greater concern was the fact that it is alleged that during the six weeks he was employed he ‘gave drugs to children and assaulted patients over 60 years of age’, (Australian Doctor, 2015). It is further alleged that Crawford worked five shifts as
an agency nurse in the Northern Territory – he is now facing 15 charges in Western Australia and 115 charges in Queensland. Next, is the case of the fake dentist – a story about a backyard dentist who ran a clinic from his garage for more than ten years before he was reported. In this case Velipasaoglu had trained and worked as a dentist in Turkey but had never been registered in Australia. He was charged with holding himself out to be a dentist, found guilty and fined $20,000 although the magistrate stated that he would have jailed the defendant if that option were open to him.
NEXT, IS THE CASE OF THE FAKE DENTIST – A STORY ABOUT A BACKYARD DENTIST WHO RAN A CLINIC FROM HIS GARAGE FOR MORE THAN TEN YEARS BEFORE HE WAS REPORTED This discovery led to another four backyard dental clinics being raided sparking concerns that patients visiting these clinics have been exposed to blood borne diseases such as Hepatitis B and C and HIV (Australian Doctor, 2015). While it can be difficult to detect forged documents, AHPRA has a public register of all health professionals on their website which can quickly identify practitioners who are not registered or have conditions or undertakings on their license. However, the public may also be at risk when registered health professionals choose to practice in a manner that is unprofessional and criminal. The following two cases concern practitioners who were out for financial gain at the expense of their clients. The first case concerns a Sydney dentist who filed down the teeth of elderly residents in a nursing home when it was not clinically indicated – to make extra money. Istephan was contracted by NSW-based Elderlink Consolidated Services to provide dental services to elderly nursing home residents. It has been revealed that more than 60 elderly residents had their teeth filed down on their first consultation with the dentist in preparation for
later crown and bridgework. Many of these clients had dementia and were unable to give their consent to treatment, those who had mental capacity to give consent had the work done without explanation or their consent. In 2013 Istephan was found guilty of five counts of assault occasioning actual bodily harm when the judge described his conduct as a ‘deliberate, callous and systematic exploitation of the residents with the view of financial reward’ (Australian Doctor, 2013). Recently Istephan faced another seven charges of assault but has now pleaded guilty to three, the Crown has dropped the other matters. A pattern of dishonest conduct was evident in the case of Nursing & Midwifery Board of Australia v Morley [2014] SAHPT 17. In 2004 Morley, an enrolled nurse, was charged with dishonestly obtaining a financial advantage for herself from another when she defrauded Centrelink of $11,000. Morley was found guilty of this charge in 2008 and was sentenced to six months imprisonment suspended upon her entering a good behaviour bond for eighteen months. From 2009-2012 Morley failed to declare that she had a criminal history when she renewed her registration and so made false and misleading statements on her renewal application. Nonetheless, in 2012 Morley was looking after a patient in need of palliative care due to end stage metastatic prostate cancer when she took his credit card and pin number without his knowledge to pay her $600 Telstra bill, purchase a shopping voucher with AGL and pay Courts Administration Authority $463. Morley was charged and convicted of four counts of aggravated deception by conduct in 2013. This behaviour is clearly not only criminal in nature but a serious breach of trust, breach of the Code of Professional Conduct and the Code of Ethics for Nurses. The tribunal found the practitioner guilty of professional misconduct, reprimanded the practitioner and cancelled her registration until at least 2018. While all of these incidences are rare that they occur at all is alarming and serve as a reminder that we all have a responsibility to ensure healthcare consumers receive care from registered practitioners who practice in accordance with the law and the standards set down by their professions. October 2015 Volume 23, No. 4 27
REFLECTIONS
L TO R: FED UNI NURSING AND MIDWIFERY STUDENTS TOUR TIMOR LESTE, TRANSLATOR JOHN INSTRUCTS NURSING STUDENT MICHELLE ON HOW HIV IS NOT TRANSMITTED.
Students take Asia bound Timor Leste mobility tour By Rosey King Ten students studying the Bachelor of Nursing and Graduate Diploma of Midwifery at Federation University (FedUni), Victoria were successful in getting Asia Bound mobility grants to undertake a 12 day immersion and study tour of healthcare delivery in Timor Leste. Overall the welcome in Timor Leste was very warm with all staff of the NGOs, clinics and hospitals being accommodating and willing to share their work and experiences with students. Some of the highlights included visiting PRADET which was a community based service with some in-patients facilities providing care for men and women experiencing mental health problems, trauma and sexual assault. The service, situated within the grounds of Dili Hospital, has programs for prevention as well as attending to the care and forensic needs of women and men who have been abused and assaulted. PRADET also provides a refuge for women, counselling, and teaches skills for women to build capacity for economic independence. During the tour we also visited Klibur Domin, situated at Tibar just outside of Dili. Klibur Domin is funded by Ryder Cheshire, an Australian based organisation. The health centre’s main objectives included tuberculosis identification, screening, outreach, treatment and support and rehabilitation of people living with disabilities in the community. While there, students and staff were able to speak with registered nurses, pathologist and public health administrators on creating programs that are sensitive to the social determinants to improve this public health issue in Timor. The visit to HIAM Health was another highlight. This non-government organisation which relies upon international donors provides an in-patient facility for children and babies suffering malnutrition. Up to 47% of children under five are malnourished in Timor Leste, with many suffering irreversible long term consequences. The facility provides 28 October 2015 Volume 23, No. 4
children and their families rehabilitation and education about nutritional requirements, growing sustainable gardens and cooking nutritious food. Additionally, parents are educated about the benefits of exclusive breastfeeding for six months. HIAM Health also offers educational programs to villages and communities on how to add vegetables, meat and eggs to traditional rice porridge so children get more essential nutrients in their diets. Much of the program is about re-educating the community about healthy diet, clean water, sewage disposal, washing of hands and other public health measures. Part of the tour also gave students an opportunity to observe clinical service provision in health centres and hospitals in Dili and Maubisse. Comoro Clinic is a busy health centre in the suburbs of Dili. Interestingly, students were able to observe population vaccination compliance monitoring being undertaken by the Red Cross for the World Health Organization (WHO). Vaccinations of mothers and infants were being administered and students observed the practices of midwives and public health workers in family planning and birthing services. Maubisse Referral Hospital is a wellresourced facility situated 70 kilometres (four hours travel) from Dili. Travelling to Maubisse was arduous and presented some challenges with potholes and boulders and rubble on the road, but after a bumpy journey students arrived to picturesque scenes of mountainous regions with grass huts, and palm constructed housing with the occasional lean-to-home. The local market place was bustling with young people playing basketball on the dirt court and vendor
selling their grown produce and wears. While there was some evidence of malnutrition and poverty, the people were welcoming and very curious about the westerners who had arrived in the village. At the hospital, students had the opportunity to speak with other university students in nursing and medicine and compare treatment practices for medical, surgical and midwifery patients across Timor and in Australia. Students found comparative approaches to nursing and medicine, but were also interested in the cultural differences of care in theses regional and remote regions. Outreach to remote villages, health promotion and development of trusting relationships with village elders was paramount for trust of the service in those communities. Opportunities were afforded to share clinical experiences with nursing and medical staff. Students were also interested in how care can be given with limited resources. The visit was a great success, staff and students gained a greater awareness of the context of healthcare provision in resource poor countries such as Timor Leste and a number of valuable friendships were established. Staff and students from FedUni would like to thank the many people in Timor Leste working in NGO’s and health services who took the time to meet and educate the students about their day to day activities, providing explanations, guidance and advice to all our group members. Rosey King is the Program Coordinator Graduate Diploma of Midwifery at Federation University, Victoria anmf.org.au
PROFESSIONAL
In celebration of Nurse Practitioners
Julianne Bryce
Elizabeth Foley
Julie Reeves ANMF Federal Professional Officers
Recently we attended the Australian College of Nurse Practitioners (ACNP) annual conference in Melbourne, with the theme Celebrating the past and embracing the future. The nurse practitioner role has developed slowly in Australia, since initial planning to introduce positions into the healthcare workforce began in the early 1990’s. Despite some set-backs over the years, there is cause for celebrating achievements. The first nurse practitioner appointments were made in New South Wales. In 2001, Ollie Johnson (dec) was appointed the first nurse practitioner to work in a remote area which didn’t have a practicing doctor. Shortly after, Jane O’Connell, was endorsed as an emergency nurse practitioner. Momentum built, with more advanced practice registered nurses gaining the qualifications and demonstrating the necessary experience for endorsement in the role.
THE ‘SHARED CARE’ AND ‘CONTINUING THERAPY ONLY’ ARRANGEMENTS CONTINUE TO RESTRICT NURSE PRACTITIONER PRACTICE UNNECESSARILY FRUSTRATING NURSE PRACTITIONERS AND INCONVENIENCING THE PEOPLE FOR WHOM THEY PROVIDE CARE.
Now, in 2015, there are 1,214 endorsed nurse practitioners providing care in Australia. Although frustrating, slowly and steadily building the ranks of nurse practitioners has allowed us to learn many lessons from our international counterparts, many of whom covet our: anmf.org.au
regulated, protected title; agreed definition for the role; Masters level qualification; national standards for nurse practitioner practice, and • national accreditation standards and process for accreditation of programs. We did the ground work and built the framework for the nurse practitioner role in Australia. Then, we consistently and persistently promoted and advocated for the role. We had to be thick skinned to deal with negativity and criticism thrown at us by other health professionals, many of whom still articulate their opposition. In May 2009 the Labor Federal government, with Nicola Roxon as health minister, introduced historic health reform enabling access to the MBS and PBS for nurses and midwives. The resultant Health Legislation Amendment (Midwives and Nurse Practitioners) Act 2010 provided the legal framework for those receiving care from nurse practitioners and eligible midwives to access MBS and PBS funding. While the then ANF and ACNP were lead groups among the nursing organisations involved in the Australian government’s advisory groups, we were given absolutely no say at all when it came to determining the dollars for MBS rebate amounts. The PBS too was an extremely laborious negotiation around access to each medicine, with limited ability to influence these decisions. The ‘shared care’ and ‘continuing therapy only’ arrangements continue to restrict nurse practitioner practice unnecessarily - frustrating nurse practitioners and inconveniencing the people for whom they provide care. The Australian government’s current ‘Healthier Medicare’ initiative, allows the ANMF to work with the ACNP in renewing our efforts to influence changes which will see nurse practitioners being able to practice to their full scope. This initiative includes three priorities: • MBS Review Taskforce; • Primary Health Care Advisory Group, and • review of Medicare compliance rules. The first and third reviews are yet to include public consultations. Regarding the second, the ANMF Professional team attended a nursing sector specific briefing, • • • •
and a general forum, with Primary Health Care Advisory Group, as well as making a written submission (http://anmf.org.au/pages/anmfsubmissions). This review has given us another important opportunity to reiterate with government the way primary healthcare should be provided and funded to enable nurses (including nurse practitioners) and midwives to be utilised more fully. This especially relates to the management of chronic and complex physical and mental illness. Some of the long overdue changes we are advocating for are: • funding for designated nurse practitioner positions in the public sector, including in small rural and remote communities, • access to ‘request and refer’ MBS provider numbers for nurse practitioners in the public sector, as is the case for medical interns, • a substantial increase in payment for MBS items for nurse practitioners in private practice, to enable them to establish viable and sustainable practice, • recurrent incentive funding for nurse practitioners in private practice to work in areas of designated District Workforce Shortage, • infrastructure funding for nurse practitioners to establish private practice, and • allowing nurse practitioners to employ other nurses, in the same way as GPs do, under the Practice Nurse Incentive Payment. In a presentation at the ANMF South Australian Branch Professional Conference in August, ANMF member and nurse practitioner Sally Hampel, gave a call to action to all nurses to get behind nurse practitioners and the work they do. She said acknowledging and supporting nurse practitioners is advancing the whole of the profession. We agree, and following Sally’s lead we encourage our members to take every opportunity to promote the importance of nurse practitioners. We want you to be persistent and heard – to speak, write, present, Facebook, tweet, blog – do what it takes to make sure everyone knows about nurse practitioners, works with nurse practitioners, and wonder what the health and aged care workforce ever did without them. October 2015 Volume 23, No. 4 29
BOOKS
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PIXIE ANNAT: CHAMPION OF NURSES BY COLLEEN RYAN CLUR
Publisher: University of Queensland Press ISBN: 978-0-7022-5372-0
US
LOVE LETTERS FROM TRANSLYVANIA
FOUR SEASONS OF GRIEVING
A memoir of blood cancer, identity and storytelling
A Nurse’s Healing Journey With Nature
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$34.99
OUTBACK MIDWIFE From the city to the bush One woman’s labours of love BY BETH MCRAE
BY HUGH KIERNAN
BY A. LYNNE WAGNER
Publisher: Michael Hanrahan Publishing
Publisher: Sigma Theta Tau International Honor Society of Nursing
ISBN: 978-0-85798-394-7
ISBN: 978-1-938-83596-4
Before going to Maningrida, an Aboriginal town in the heart of Arnhem Land, Beth McRae had no idea of whether she’d “hack it living and working in the outback”, taking a leap of faith and leaving her family behind to give up everything to move to the Northern Territory. However living in Maningrida proved every bit as overwhelming and tough as she’d expected and reaffirmed the reason she’d chosen to take on the biggest challenge of her career – working as a remote area midwife. Outback Midwife is the heartwarming story of Beth McRaes’ 40 years as a midwife from the bush to the city and back again before moving to a remote Aboriginal community in Arnhem Land. Her decision leads to a whole other adventure and changes her life, and many others, forever. This memoir shows real insight into the world of a midwife in the outback.
ISBN: 978-0-994-27354-3
Biography of former Royal Australian Nursing Federation (Queensland Branch) Secretary Pixie Annat features a woman who fought throughout her 50-year career to improve the training and working conditions for nurses. Isobel Mary (Pixie) Annat, who turned 85 in March, grew up in rural Queensland and trained as a nurse shortly after World War II. She was matron at the Royal Brisbane Hospital and CEO of St Andrew’s War Memorial Hospital in Brisbane. Pixie was passionate and campaigned tirelessly for nursing education. She recounts Queensland Director-General of Health Dr Fryberg saying to her: “You know dearie nurses only have to rub backs and carry pans”. To which she replied: “Well, I hope you are not very sick when you come to hospital, because if that’s all they do for you, you will die.” Later in her career, Pixie campaigned on behalf of the elderly and homeless women. This biography showcases both an inspirational woman and nurse leader.
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Author Hugh Kiernan was diagnosed in 2007 with multiple myeloma. This memoir recounts his journey after completion of his treatment and the impact of illness on his daily life. As he writes: “These reflections on my present, my past and my future – and the threat to each of those that illness can represent – have opened a new door for me.” These reflections explore the relationship between illness, everyday life and identity. He describes his shock, pain, impact on his personal identity, the physical symptoms of illness and treatment to acceptance, and will to live in a descriptive poetic narrative that has an engaging style. A published writer, Hugh Kiernan’s other works include reviews, interviews and a children’s book on photography. In 2011, he retired after he commenced kidney dialysis. This unique memoir has both a fictional and non-fictional feel.
30 October 2015 Volume 23, No. 4
In this beautifully illustrated full-colour part guidebook and part memoir, author and US nurse consultant Lynne Wagner reveals her journey in losing her mother. While exploring her own pain and vulnerability, she focuses on the universal experience of human grieving; and for nurses exposed each day to patient trauma, endof-life situations and their own grief of loss of partners, parents and families. A nurse of more than 40 years, Lynne Wagner’s many professional titles include Professor Emerita of Nursing at Fitchburg State University and board member for the International Association for Human Caring. The four seasons of grieving: winter surrender; spring forgiveness; summer gratitude; and autumn compassion take the reader through reflective pauses, ‘nurses’ corner’, and inspirational words of wisdom in each stage. This book is a special healing present for anyone experiencing loss of life.
Publisher: Bantam Australia
anmf.org.au
CLINICAL UPDATE
Breathing retraining in anxiety and panic disorder Mary Birch Hyperventilation or over-breathing is often a key component in anxiety and panic disorders, and also in the condition known as dysfunctional breathing/hyperventilation syndrome. This paper examines the role of breathing retraining in these conditions and provides a case study on the subject.
Generalised anxiety disorder is a common condition characterised by excessive anxiety and worry which is out of proportion to the event or the circumstance that is the focus of the worry. Panic disorder is a condition that causes repeated unexpected attacks of intense fear or panic attacks. Generalised anxiety disorder, panic disorder and a condition known as dysfunctional breathing/hyperventilation syndrome (DB/HVS) share many similarities, but are generally viewed as separate conditions. According to one estimate, approximately 50% of patients with panic disorder manifest hyperventilation as a symptom, and an estimated 25% of patients with DB/HVS also manifest panic disorder (Kern, 2014). However, the incidence of hyperventilation preceding or during panic attacks is arguable, because of the difficulty of monitoring real-life panic attacks (Meuret & Ritz, 2010). For the purposes of this article, DB/HVS will be referred to as hyperventilation syndrome (HVS).
Hyperventilation syndrome HVS is a respiratory disorder, which may be psychologically or physiologically based. In HVS, erratic breathing patterns such anmf.org.au
as breath-holding, sighing and yawning may be seen and the patient may complain of “air hunger,” difficulty in breathing or shortness of breath. HVS can result in significant patient morbidity and may contribute to several symptoms including dyspnoea, breathlessness, chest tightness, dizziness, tremor, faintness, apprehension and paraesthesia (Jones et al. 2013). Paradoxically, HVS may also present with numerous symptoms including respiratory, cardiac, neurologic, or gastrointestinal but without any obvious or apparent hyperventilation. Dysfunctional or disordered breathing patterns in adults may be subtle and are not always evident (see table) and patients with chronic hyperventilation may undergo extensive testing in an attempt to discover organic causes of their complaints. Hypocapnoea or decreased carbon dioxide (CO2) levels due to excessive exhalation of CO2 seen in hyperventilation may be present without any obvious change in breathing volume if the patient exhibits frequent sighs interspersed with normal respirations (Kern, 2014). Respiratory physician and pioneer on hyperventilation research, the late Dr Claude Lum, maintained that chronic
hyperventilation was not always evident and in fact, he referred to classic or obvious hyperventilation as “the tip of the iceberg”, occurring in only 1% of cases (Lum, 1975). According to a 2013 Cochrane review, the estimated prevalence of HVS in the general adult population is 9.5%, yet the review acknowledges there is little consensus regarding the most effective management of this patient group (Jones et al. 2013). Further, the review states that although various types of breathing exercises are used in this patient group, no conclusions regarding breathing exercises for HVS could be drawn because of a lack of appropriate clinical trials.
ACCORDING TO ONE ESTIMATE, APPROXIMATELY 50% OF PATIENTS WITH PANIC DISORDER MANIFEST HYPERVENTILATION AS A SYMPTOM, AND AN ESTIMATED 25% OF PATIENTS WITH DB/HVS ALSO MANIFEST PANIC DISORDER Anxiety and panic Anxiety signs symptoms may include sleep problems, appetite changes, altered mood, decreased confidence, worry, rumination, October 2015 Volume 23, No. 4 31
CLINICAL UPDATE fatigue, muscle tension, difficulty in breathing, and shortness of breath. During a panic attack, the respiration rate increases, the heart rate increases, and the person may experience shortness of breath, chest pressure, a feeling of dread, nausea, dizziness, vertigo, sweating, a feeling of unreality, and paraesthesia or tingling in the extremities. The symptoms of panic attacks and myocardial infarction may appear very similar, and patients who are having a panic attack (sometimes called hyperventilation or anxiety attack) are often taken to an emergency department and assessed for myocardial infarction. The initial trigger for anxiety, panic disorder and HVS may be unknown in some people. These conditions may be initiated by significant or prolonged physiological or psychological stressors. Physiological stressors such as a major illness, surgery, trauma, or accident may precipitate symptoms as well as psychological stressors such as work-related pressures, bullying, job loss, relationship issues, divorce or bereavement. Stress hormones may be increased in patients with stressrelated breathing disorders due to sympathetic arousal. Increases in adrenaline, the fight or flight hormone, lead to increases in heart rate, breathing rate, and blood flow to muscles. Energy requirements increase as glycogen from the liver is released and used as glucose. In addition, insulin levels may increase temporarily in order to use glucose for energy and allow the person to fight or flee. Consequently, hypoglycaemia may develop when glucose stores are used up, which in turn increases the feelings of nervousness, shaking, anxiety, or light-headedness. The stress hormone, cortisol, is released in response to prolonged trauma or stress and increased levels may interfere with sleep patterns.
Hyperventilation Hyperventilation can be defined as breathing too fast or too deeply, or a combination of these, which does not allow adequate exchange of gases in the body. As in anxiety and panic disorder, the aetiology of hyperventilation may be unclear but it may be related to significant emotional or physical stressors. Chronic hyperventilation 32 October 2015 Volume 23, No. 4
leads to numerous physical and psychological symptoms, thereby increasing stress levels, and if not corrected may contribute to an increasing cycle of ill-health and decreased quality of life. Decreased cerebral oxygen levels associated with hyperventilation may trigger physical symptoms such as breathlessness, anxiety and panic. Shortness of breath may be related to upper chest breathing associated with hyperventilation (thoracic breathing as opposed to diaphragmatic breathing) and may cause a high residual volume and over-expanded chest. Because of the high residual volume, the person is then unable to take a normal tidal volume with the next breath and may experience dyspnoea (Kern, 2014). In addition, hyperventilation causes constriction of arterial blood vessels, leading to impaired blood flow to the body and brain (Fried, 1999 p.53). Central nervous system symptoms such as dizziness, confusion and syncope which occur during panic attacks are consistent with the presence of hypocapnoea-induced cerebral hypoxia (Laffey & Kavanagh, 2002). Hyperventilation is common in stress-related breathing disorders, according to Professor Robert Fried, and may range in frequency between 10 and 25% in the general population (Fried, 1999). Hypocapnoea is a common component in several disease states (Laffey & Kavanagh, 2002), therefore, medical assessment and diagnosis are essential in order to rule out any underlying pathology. Breathing into a paper bag, once traditionally used to increase CO2 levels in acute hyperventilation, is contraindicated in several conditions and may be harmful in some instances. Patients suffering with generalised anxiety, panic attacks, or hyperventilation need to be assessed by a medical doctor. Professional help may include medication, breathing retraining and counselling if required.
The Buteyko Method The Buteyko Method of breathing retraining was developed in Russia by physician and researcher, Professor Konstantin Buteyko in the 1950s. Underpinning the Buteyko method of breathing retraining is the Bohr Effect, a phenomenon discovered by Danish scientist, Christian Bohr,
(father of Nobel Prize winner Nils Bohr) in 1903. Hyperventilation causes disturbances in acid-base balance due to decreased CO2 levels. In hyperventilation, the bond between haemoglobin and oxygen increases as pH becomes more alkaline, thus reducing the release of oxygen from red blood cells and lowering oxygenation at tissue level. Breathing retraining exercises taught in the Buteyko Method are aimed at normalising the individual’s CO2 levels and restoring homeostasis. Several studies and clinical trials of the Buteyko Method have been conducted for asthma, many of which demonstrate decreases in hyperventilation, ie. a reduction in minute volume and/or increased end-tidal carbon dioxide (ETCO2) levels. There are currently no trials of the Buteyko Method for HVS, anxiety or panic disorder.
HVS - a case study Kate (pseudonym used), a 17 year old student, was enrolled by her mother in a breathing retraining program using the Buteyko Method. The program consisted of five consecutive daily sessions of 90 minutes duration, plus a followup review two weeks later. Kate’s mother reported that Kate had been diagnosed with anxiety and HVS at a major hospital six months prior to enrolment. A course of counselling sessions had not been found to be helpful. Kate had been prescribed inhaled Salbutamol to relieve dyspnoea but she reported that she had not found it effective. There was no significant health history or history of asthma. Kate’s enrolment form indicated that she experienced anxiety, panic attacks and migraine headaches several times per week. Signs and symptoms included shortness of breath, mouth-breathing and dryness in the mouth, frequent deep breaths, insomnia, dizziness, fatigue, and tingling in her hands and fingers. These symptoms were very distressing and were making study difficult and affecting quality of life. On day one of the course, Kate looked pale and tired, her posture was slumped and she was experiencing difficulty in nosebreathing. When speaking, it was obvious that Kate was taking deeper breaths, although her breathing rate of nine breaths per minute (BPM) at rest was within
References Fried, R., 1999. Breathe Well, Be Well. New York. John Wiley & Sons Inc. Jones, M., Harvey, A., Marston, L., O’Connell, N.E., 2013. Breathing exercises for dysfunctional breathing/ hyperventilation syndrome in adults. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD009041. DOI: 10.1002/14651858. CD009041.pub2. Kern, B., Hyperventilation Syndrome, http:// emedicine.medscape. com/article/807277overview. Updated 4 Sept 2014 (Accessed June 2015). Laffey, J.G., Kavanagh, B.P., 2002. Medical Progress: Hypocapnia. New England Journal of Medicine, 347(1) 43-53. Lum, L.C., 1975. Hyperventilation: the tip and the iceberg. Journal of Psychosomatic Research. Pergamon Press. 19, 375-383. Meuret, A.E., Ritz, T. 2010. Hyperventilation in Panic Disorder and Asthma: Empirical Evidence and Clinical Strategies. Int J Psychophysiol. 78(1): 68-79. Published online May 2010.
anmf.org.au
CLINICAL UPDATE the normal range (8-14 BPM). Guidelines to encourage breathing awareness, to unblock the nose, to promote nasal breathing and to improve posture were described. Capnometry was used to measure Kate’s ETCO2 levels at rest. At the start of breathing retraining, Kate’s ETCO2 levels were found to average 23 mmHg, indicating severe to serious hyperventilation, expressed in mmHg, range as follows: • 35-45 normal breathing • 30-35 mild to moderate over-breathing • 25-30 serious to moderate over-breathing • 20-25 severe to serious over-breathing During the breathing retraining course, recommendations on dealing with symptoms and improving sleep were provided and Kate was encouraged to keep a diary on sleep and symptoms. A series of short comfortable
breathing pauses were described, and these were to be performed and the results documented on a diary sheet three times per day. During these breathing pauses, CO2 levels are temporarily increased, thereby enabling the client to adapt to increasing levels of CO2 over time. Elevated levels of carbon dioxide have been demonstrated to induce panic symptoms in a majority of patients with panic disorder (Kern, 2014). Therefore, it is important to proceed slowly with breathing retraining in HVS and panic disorder. On day five of the course, Kate said she was feeling better and was sleeping well. Her pallor had improved and she reported that her symptoms were decreasing. However, Kate’s ETCO2 level was still low at 26 mmHg. With increasing awareness, Kate’s posture was improving and nasal breathing was becoming easier and
more comfortable. Kate and her mother attended a follow-up review two weeks later. Kate’s symptoms sheet showed that she was no longer experiencing fatigue, panic attacks, anxiety or migraines and she reported that she had been able to exercise without feeling short of breath. In addition, all of the symptoms associated with hyperventilation (shortness of breath, paraesthesia, dyspnoea, and dizziness) had ceased. Kate’s ETCO2 was now up to 31 mmHg, which still indicated mild to moderate hyperventilation, but both Kate and her mother considered that Kate was recovering steadily after a devastating six months with numerous debilitating symptoms. Kate was advised to continue with the breathing retraining exercises until certain targets were reached in her breathing pauses, in order to further improve and normalise her breathing pattern.
Mary Birch is an RN and a breathing retraining consultant based in Melbourne Mary Birch has conducted breathing retraining programs based on the Buteyko Method since 1999. For further information, please see www. buteykobay side.com
NORMAL BREATHING VS. DYSFUNCTIONAL BREATHING PATTERNS Normal Breathing
Dysfunctional Breathing
Effortless
Struggling for air, cannot take a deep enough breath, air hunger, shortness of breath, breathlessness.
Regular rhythm
Erratic or irregular breathing pattern, episodes of shallow breathing, intermittent deep breaths. Daytime apnoeas or pauses in breathing pattern, often resuming with a gasp.
Gentle nose-breathing at rest and when walking.
Mouth-breathing at rest or on walking, deep breathing at rest or while walking.
Comfortable nasal breathing
Blocked nose, increased mucus, dry mouth, post-nasal drip.
Inaudible breathing at rest
Noisy or audible breathing at rest. Sighing or yawning excessively, gasping for air. Throat-clearing or tickly cough evident. Taking audible or deeper breaths when speaking
Refreshing sleep
Increased waking; poor, unrefreshing sleep. Waking with a dry mouth, needing water by the bedside.
Posture upright, shoulders back and relaxed
Slumped posture, head thrust forwards, shoulders raised and forwards, tension in neck, jaw or shoulders.
Breathing from the diaphragm
Breathing from upper chest (thoracic breathing), upper chest expansion obvious on inhalation.
A breathing rate of 8-14 breaths/min.
Increased breathing rate at rest – though not always evident if breathing deeply or mouth-breathing.
Pulse rate regular and within normal range.
Increased pulse rate, palpitations, irregular pulse.
Minute volume: 4-6L/min.
Minute volume in excess of 6L/min.
End-tidal CO2 level within normal range
Decreased ETCO2 level
Contrasting normal and dysfunctional breathing patterns in adults. © Mary Birch 2015 anmf.org.au
October 2015 Volume 23, No. 4 33
FOCUS
Rural / Remote
Face to face and person to person: rural clinicians’ views on engaging with mental health consumers By Nicholas Procter and Monika Ferguson The strategic purpose of UniSA’s Mental Health and Substance Use Research Group is to demonstrate through research and practical example, how much mental health consumers, nurses, policy makers and academic faculty can achieve working together. Deep scholarship, deep connectivity and diffusion of the insights are at the heart of the current research program. In the group’s most recent research (Procter et al. in press), South Australian rural mental health clinicians, primarily nurses, have identified how they engage with consumers in the community setting. Through a semi-structured focus group, participants first identified some well-established limitations in providing mental healthcare in the rural environment, such as increased consumer vulnerability, limited services, and increased risk and stigma. They then identified how they use engagement skills and techniques to counter this. Universal skills, widely used in other settings, such as adopting a consumer-focussed approach, appropriate communication, facilitating a connection, and normalising the experience, were discussed. Building on this knowledge, participants described 34 October 2015 Volume 23, No. 4
THROUGH THE OPPORTUNITY TO REFLECT ON THEIR CLINICAL PRACTICE, PARTICIPANTS HIGHLIGHTED THE IMPORTANT CHARACTERISTICS OF THE RURAL ENVIRONMENT FOR ENHANCING ENGAGEMENT, SUCH AS A GREATER SENSE OF ‘COMMUNITY’ AND CONNECTEDNESS.
skills and attributes more specific to the rural environment, such as flexible and creative delivery of care, a whole of community approach, being multi-skilled, and use of technology. Through the opportunity to reflect on their clinical practice, participants highlighted the important characteristics of the rural environment for enhancing engagement, such as a greater sense of ‘community’ and connectedness.
Creative ways to engage were also discussed, such as the use of wider networks and community support to facilitate the provision of care. This was seen as reducing the layers between services, largely attributed to pre-existing relationships between service providers. Participants also described the important role members of the community play, particularly as key sources of information and attention raising when a consumer requires care. This could be regarded as a positive spinoff of the greater visibility in rural environments, which can also be viewed as a barrier to providing care. These research findings have important implications for rural mental health nurses working as part of multi-disciplinary teams. In drawing upon their experiences, participants have stressed the importance of maintaining wellestablished relationships with other service providers and the wider community. Informal relationships outside of the working environment, which are often characteristic of the rural setting, mean that the clinician’s role is something that extends outside of working hours. Active reflection on these practices at work with colleagues may be a useful way to discuss and strengthen these collaborative relationships, with the ultimate aim of improving engagement and the provision of mental healthcare.
Reference Procter, N.G., Ferguson, M., Backhouse, J., Cother, I., Jackson, A., Murison, J. & Reilly, J.A. (in press). You carry your position wherever you go : Clinicians’ views on engaging people with mental illness in an Australian rural community, Australian Journal of Rural Health.
Professor Nicholas Procter is Chair: Mental Health Nursing and Dr Monika Ferguson is a Research Associate. Both are in the School of Nursing and Midwifery at the University of South Australia anmf.org.au
Rural / Remote
FOCUS LEFT AND BOTTOM RIGHT: INSTRUCTOR - MS CAREY MATHER PROVIDING VERBAL ADVICE AND VISUAL GUIDANCE USING THE TELE-ASSISTANCE TECHNOLOGY TOP RIGHT: THE LEARNER, DR CHONA HANNAH WITH HEAD MOUNTED DEVICE PERFORMING A PROCEDURE ON A MANIKIN
Rural and remote tele-assistance for procedural skills: the ‘helping hands’ project By Tony Barnett, Weidong Huang and Carey Mather Have you ever been stuck in a situation not knowing how to perform a procedure and having no one around to help? This can happen in rural and remote practice. The safe and correct performance of clinical procedures requires guidance, feedback and practice. Students, new graduates and practitioners who may not feel 100% confident in performing a procedure or doing so for the first time in an unfamiliar environment can benefit from a little assistance. Direct supervision is not always available and can be resource intensive. To help rectify this situation, a team from the University of anmf.org.au
Tasmania (UTAS) are working on a project that uses tele-assistance technology to better link a practitioner or student in a rural or remote location with an expert who could be located many kilometres away. This technology allows an instructor to provide both audio and visual cues to assist the learner perform a procedure, thus making guidance and expertise more accessible in real-time, without requiring an on-site instructor. As shown the device has two units that are connected through a network. The head mounted device is worn by the learner who is with the patient. This device includes a near-eye display, a camera and an audio headset. The focus of attention, the procedure, is captured by the camera. The headset enables verbal communication with the instructor. Looking at the near-eye display, the learner can see the “helping hands” images sent from the instructor, overlaid on their visual field. On the instructor side a computer screen displays what the learner is doing. A camera mounted on a support arm captures the
instructor’s hand movements when placed on the screen. An instructor may say “stop”, then demonstrates the correct technique or movement before (“here, I’ll show you”) or at the same time as the learner (“follow my hands, I can guide you”). The project is in the prototype stage as the team refine software programing and customise the hardware to improve its usability and portability. Work carried out in the clinical laboratory has confirmed that the technology works. Importantly, this device could be used to support practitioners working in more isolated settings and students whilst on placement. Our aim is to customise a wearable, hands-free, low cost audio-visual guidance system that has broad applicability across healthcare environments. Grants from the Tasmanian Clinical Education Network (TCEN) and the Commonwealth government’s Office of Learning and Teaching (OLT) have enabled work on this project to progress. A field trial of the technology is planned for later this year.
Tony Barnett is the Director in the Centre for Rural Health, Weidong Huang is Senior Lecturer in the School of Engineering and ICT and Carey Mather is a Lecturer in the School of Health Sciences. All are at the University of Tasmania
October 2015 Volume 23, No. 4 35
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Improving the physical health of people with schizophrenia in regional Australia By Mellissa Kruger and Martin Jones People with serious mental illness (SMI) die 10-15 years earlier than the general population. If you have a SMI and live in regional Australia, you are likely to face additional challenges in accessing healthcare professionals. To help address physical health needs in people living with a SMI we have developed the Health Improvement Profile (HIP) (White
et al. 2010). The HIP is a health improvement schedule which helps clinicians to work with people living with a SMI to access physical healthcare services. The HIP has been used extensively in the UK for use by Mental Health Nurses (MHN) (White et al. 2010). In Australia, particularily regional Australia, there is a shortage of MHN. To partly meet this shortfall a lot of the care for people with a SMI is provided by Non-Government Organisations (NGO) comprised of a nonregistered workforce. Over the past 12 months the University of South Australia Department of Rural Health has prepared a number of nongovernment workers to conduct physical health checks with people living with SMI in regional South Australia. This preparation has been supplemented with monthly
supervision sessions faciliated by a registered nurse (RN). The supervision sessions have enabled the NGO practitioners to reflect on their practice, in particular exploring what aspects of the physical health conversation are working well and areas in which their practice needs to further develop. The supervision sessions have been used to explore the potential road blocks in the workplace to conducting the physical health checks and how these road blocks could be overcome. Our preliminary findings are that NGO workers, with the appropriate supervision from a RN, can use the HIP to help people living with a SMI to better manage their physical healthcare and access physical healthcare services. A comment from one of the NGO workers, which best captures the experience of the NGO experiences, is: “The tool has opened up conversations which have helped the consumer to manage their physical health, where previously this would not have occurred. The tool has helped me to have conversations with consumers which would previously not have occurred in the areas of sexual health and help in stopping smoking”. The project has run in regional South Australia. The application of the HIP for use by regional NGO workers may help to improve the physical health wellbeing of people living with a SMI. Its application may help address workforce shortages across regional Australia. We would recommend however that the NGO workforce may require supervision from a RN to support its routine application.
References Barnett A.H., Mackin P., Chaudhry I., et al. (2007). Minimizing metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. Journal of Psychopharmacology 21, 357–373. White J., Gray R., Jones M. (2009). The development of the serious mental illness physical Health Improvement Profile. Journal of Psychiatric and Mental Health Nursing 16(5), 493–498.
Mellissa Kruger is the Manager and Associate Professor Dr Martin Jones is the Director of the Department of Rural Health at the University of South Australia
Rural / Remote WELLNESS WHEREVER YOU ARE. DEBRA ANDERSON, AMANDA MCGUIRE AND JANINE PORTER-STEELE
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Virtual tours of rural and remote healthcare facilities By Merylin Cross and Tony Barnett
References AIHW. (2012). Cancer survival and prevalence in Australia: cancers diagnosed from 1982 to 2010. Cancer series no. 69. Cat. No. CAN 65. Canberra: AIHW
The women’s wellness after cancer program: a nurse led model of care By Janine Porter-Steele, Amanda McGuire and Debra Anderson Breast cancer has a big impact on the health and wellbeing of Australian women. Approximately 15,000 women are diagnosed with breast cancer in Australia each year (AIHW 2012). Many of these women live in rural, regional and remote areas of Australia with differing access to healthcare services and survivorship care. Despite these numbers, survival from breast cancer has improved in recent times due to early detection and multi-modal treatment. For example, 97% of women with early stage breast cancer are likely to survive for five years (AIHW 2012). However, this good news is tempered by evidence that survivors are at higher risk of other chronic health conditions (Mann et al. 2010). There are also psychosocial sequela such as anxiety and depression and ongoing side effects of treatment (Howard–Anderson, 2012). There is a need for appropriate, evidence based, cost effective interventions to address these longer term health concerns. Evidence from the Pink Women’s Wellness Program trial suggests that a nurse led structured 12 week health promotion program was effective in reducing BMI, menopausal symptoms and improving sleep in women following breast cancer treatment (Anderson et al. 2015) Building on this study, The anmf.org.au
Women’s Wellness after Cancer and Younger Women’s Wellness after Cancer Programs are novel nurse led behavioural interventions that are currently being trialled in younger and older women who have been treated for breast and gynaecological cancer. The programs use an interactive e-book, website and online health consultations delivered by community based cancer nurses. Health coaching targets a range of health behaviours including exercise, healthy eating, sleep and stress management. The program also addresses common issues reported by female cancer survivors including fatigue, menopausal symptoms and sexual concerns. Flexible delivery enables those in geographically isolated areas to participate easily, with the consultations being delivered virtually from a central health hub. The website facilitates peer support though a moderated private discussion board where program participants can talk to one another about common concerns. These programs afford nurses an exciting new tool to effectively deliver an evidence based health promotion program to female cancer survivors. It is expected results of the current trials will provide robust evidence of the efficacy of this nurse led model of care that will allow the program to be incorporated into standard survivorship care.
Anderson, D. J., Seib, C., McCarthy, A., Yates, P., Porter-Steele, J., McGuire, A., Young, L. (2015). Facilitating lifestyle changes to manage menopausal symptoms in women with breast cancer: A randomized controlled pilot trial of The Pink Women’s Wellness Program©. Menopause, 20 Jan, epub ahead of print. doi: 10.1097/GME. 000000000000421 Howard-Anderson, J., Ganz, P. A., Bower, J. E. & Stanton, A. L. (2012). Quality of life, fertility concerns, and behavioural health outcomes in younger breast cancer survivors: a systematic review. Journal of the National Cancer Institute, 104(5), 396-405. Mann, D. L., Krone, Ronald J. (2010). Cardiac Disease in Cancer Patients: An Overview. Progress in Cardiovascular Diseases 53(2): 80-87
Professor Debra Anderson is the Director of Research, Dr Amanda McGuire is a Postdoctoral Research Fellow and Janine PorterSteele is a PhD Candidate and Clinical Nurse Manager for the Women’s Wellness Programs. All are in the School of Nursing, Institute of Health and Biomedical Innovation at the Queensland University of Technology
A virtual tour project that develops Virtual Orientation Tours (VTs) of rural and remote healthcare practice settings is being undertaken by a team at the Centre for Rural Health, University of Tasmania (UTAS). In collaboration with the Tasmanian Aboriginal Centre, the project also includes Aboriginal health centres at Burnie, Launceston and Hobart. Currently, 15 ‘tours’ have been developed which can be readily accessed via the government of Tasmania Department of Health and Human Services website. The objectives of these tours are to: • attract students from a range of health disciplines and education sectors to rural and remote placements; • allay students’ pre-placement anxiety by demystifying the rural/remote practice settings; • help prepare students for rural and remote practice by increasing their awareness of the facilities, services, learning opportunities and resources available; • familiarise visitors, patients to the facility and, as a recruitment device, potential employees to the health service. The VTs have followed a template and their features include: • 360 degree panoramic tour of the facilities; • a floor plan to orientate students to the physical layout of the building; • a short welcome video by the director of nursing, site manager, nurse unit manager or similar. Feedback of the VTs has been extremely positive. The most views recorded have been for more remote locations such as King Island. The team plans to extend the features of these VTs to support more clinically focussed features that may directly contribute to improvement patient outcomes. Dr Merylin Cross is a Senior Lecturer and Dr Tony Barnett is the Director at the Centre for Rural Health at the University of Tasmania October 2015 Volume 23, No. 4 37
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References Australian Department of Health. (2009). The Australian Government’s national palliative care program. Retrieved from www.health.gov.au Australian Nursing Federation. (2009). Primary Healthcare in Australia. A nursing and midwifery consensus view. Retrieved from http://anmf.org.au/ documents/reports/ PHC_Australia
Palliative care experiences in regional NSW By Melissa Jansson, Kathleen Dixon and Deborah Hatcher A project that explores the experiences of palliative care adults living in an inner regional area of New South Wales (NSW) may help inform future policy development and service provision. Background People living in regional and remote areas of Australia are often disadvantaged in accessing a range of healthcare services. Palliative care is an area that is particularly affected (Australian Nursing Federation, 2009; Department of Health, 2009). Predominantly, Australian palliative care services are concentrated in more densely populated areas, such as major cities, rather than regional or remote areas (Australian Nursing Federation, 2009). While the impact of reduced access to palliative care services on people living in these areas is poorly understood (Department of Health, 2009), patients who are receiving palliative care, can often be reluctant and sometimes unwilling to relocate outside of their community to access treatment and services, even when relocation is anmf.org.au
beneficial to their physical health and wellbeing (Zucca et al. 2011). Additionally, relocation to access care can often cause hardship in varying degrees and may present in the form of physical and social isolation or financial burden due to travel costs (Hegney et al. 2005; McGrath, 2007). Government bodies have acknowledged the need for increased palliative care services in regional and remote areas, suggesting this can be achieved through the creation of key strategic objectives targeting poor service accessibility. In order to achieve this outcome the World Health Organization (WHO) (1978) suggests formulating strategies based on sustainable primary healthcare as part of a collaborative comprehensive national health system. Australia’s National Health Reform recommendations, which aim to refocus emphasis to health promotion, disease and injury prevention, and the elimination of health inequities for all Australian populations (Australian Nursing Federation, 2009), further supports this direction.
Project importance In order to align service provision with current public health policy and inform future policy development and implementation in all geographic areas of Australia, additional investigation is needed. Therefore this project explored the experiences of palliative care adults living in an inner regional
Hegney, D., RogersClark, C., & Buikstra, E. (2005). Close, but still too far. The experience of Australian people with cancer commuting from a regional to a capital city for radiotherapy treatment. European Journal of Cancer Care. 14:75-82.
PREDOMINANTLY, AUSTRALIAN PALLIATIVE CARE SERVICES ARE CONCENTRATED IN MORE DENSELY POPULATED AREAS, SUCH AS MAJOR CITIES, RATHER THAN REGIONAL OR REMOTE AREAS (AUSTRALIAN NURSING FEDERATION, 2009). area of NSW using a qualitative exploratory method allowing the experiences of participants to be explored and described in-depth. Eight participants were recruited from a local community palliative care support group. Participants were asked to discuss their experiences of palliative care living in an inner regional area in one time semi-structured interviews.
Practical outcomes While the story of each individual participant is unique, it is hoped their experiences can create positive change for others. The anticipated practical outcomes for this project are to inform future policy development and service provision. The results of this project will also be used as the foundation for a larger research project.
McGrath, P. (2007). I don’t want to be in that big city; this is my country here: Research findings on Aboriginal peoples’ preference to die at home. Australian Journal of Rural Health. 15:64-268. Pearse, J., Mazevska, D., & Sheehan, J. (2011). Demographic and utilisation changes for rural and remote populations – subacute admitted care. Retrieved from www.nintione. com.au World Health Organization. (1978). Declaration of Alma-Ata. Retrieved from www.who. int/publications/almaata_ declaration_en.pdf Zucca, A., Boyes, A., Newling, G., Hall, A., & Girgis, A. (2011). Travelling all over the countryside: Travelrelated burden and financial difficulties reported by cancer patients in New South Wales and Victoria. The Australian Journal of Rural Health. 19:298-305.
Melissa Jansson is an Associate Lecturer, Dr Kathleen Dixon is a Senior Lecturer and Dr Deborah Hatcher is a Senior Lecturer. All are located at the University of Western Sydney
October 2015 Volume 23, No. 4 39
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Preparing nurses to practice evidence based suicide prevention skills in the bush
FOCUS LYNNE JAMES, OFFICE OF THE CHIEF PSYCHIATRIST
By Monika Ferguson, Martin Jones, Nicholas Procter, Lee Martinez, Kathryn Cronin, Lynne James, Jim Dollman and Bronwyn Ryan Suicide is a major public health concern, particularly in rural and remote Australia where rates are up to 30% higher than in major cities (ABS, 2011). This is in partly due to reduced access to services and availability of healthcare professionals. One specific strategy to overcome this is to deliver training in evidence based suicide prevention to the existing healthcare workforce in regional Australia. As the largest professional group in regional Australia, nurses are ideally placed to identify and provide care to those most risk of suicide, particularly when the majority of people who die by suicide have contact with a health professional in the year prior to their death (Akmedani et al. 2014; De Leo et al. 2013). Arguably, one of the most effective approaches to suicide prevention in the clinical setting is the development of therapeutic working relationships, a core skill of nurses at the vanguard of extended and close care with the communities they serve. Preparing nurses to practice evidence based suicide prevention strategies may increase their knowledge and skills and improve their confidence in working with people at risk. Although a range of suicide prevention training opportunities are available, these are less widely delivered in regional Australia and are rarely rigorously evaluated. Additionally, much of the training in suicide prevention has been focussed on specific disciplines rather than working with other key stakeholders outside of health who also have a role to play in suicide prevention. anmf.org.au
Recognising these gaps, a team of researchers and clinicians from the University of South Australia (UniSA) and SA Health is currently implementing a community-based suicide prevention education program. Although primarily targeted at nurses, the program aims to equip all health and human service professionals with the knowledge and skills to assist them to effectively engage people at risk of suicide and self-harm. The program will emphasise the practice of active engagement and collaborative actions between people in rural settings. The one-day training program will be delivered in eight regional South Australian towns in late 2015, with content largely drawn from the recently produced document ‘Engaging with the suicidal person: A resource from Shared Learning in Clinical Practice’, developed jointly by SA Health and UniSA. Through a series of short surveys and focus groups, the research team will evaluate how attending the training influences health and human service professionals’ attitudes towards working with individuals who are experiencing suicidal crisis, and their confidence in suicide management. It is anticipated that this will shed light on furthering our understanding of the important contribution nurses, and other health professionals make to address the safety needs of at risk people and, ultimately, contribute to reducing suicide in rural South Australia. Engaging with the suicidal person: A resource from Shared Learning in Clinical Practice will soon be freely accessible on the SA Health website.
Dr Monika Ferguson is a Research Associate in the School of Nursing and Midwifery, Division of Health Sciences, University of South Australia Associate Professor Martin Jones is Associate Research Professor/Project Director: Department of Rural Health, University Department of Rural Health, Division of Health Sciences, University of South Australia Professor Nicholas Procter is Chair: Mental Health Nursing in the School of Nursing and Midwifery, Division of Health Sciences, University of South Australia Lee Martinez is a Mental Health Academic, University Department of Rural Health, Division of Health Sciences, University of South Australia References
Kathryn Cronin is Network Senior Mental Health Clinician, Country Health SA, North West Lynne James is Principal Project Officer Suicide Prevention, Mental Health Unit, System Performance, SA Health Associate Professor Jim Dollman is in the School of Health Sciences, Division of Health Sciences, University of South Australia Bronwyn Ryan is a Community Engagement Project Officer, Country Health SA, Mental Health Services
Ahmedani, B.K., Simon, G.E., Stewart, C. et al. (2014). Healthcare contacts in the year before suicide death. Journal of General Internal Medicine, 29, 870-877. Australian Bureau of Statistics. (2011). Australian social trends, March 2011, Health outside major cities cat. no. 4102.0. Canberra: Commonwealth of Australia. De Leo, D., Draper, B.M., Snowdon, J., & Kolves, K. (2013). Contacts with health professionals before suicide: Missed opportunities for prevention? Comprehensive Psychiatry, 54, 11171123.
October 2015 Volume 23, No. 4 41
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42 October 2015 Volume 23, No. 4
A key role for Mental Health Clinicians (MHC) practicing in regional and remote communities is to prevent the number of consumers who experience a mental illness relapse. The impact of relapse in regional Australia can result in people being hospitalised away from their community. Treatment with antipsychotic medication is an effective approach to prevent relapse and consequentially support people who live with schizophrenia to stay in the community. However, relapse through non-adherence to medication is common (Birchwood & Spencer 2001, Birchwood et al. 2000 and Dibben et al. 2009). There remains a lack of understanding how to support MHC to use evidence based care to help people who live with schizophrenia to adhere to their medications. The University of South Australia’s (UniSA) Department of Rural Health in partnership with clinicians in Country Health SA are exploring this area of practice together. The team has developed a model to support rural MHC to use adherence therapy to help people with schizophrenia to adhere with medication. The project has prepared a rural community mental health team to practice Adherence Therapy (AT) in preventing relapse in people living with schizophrenia. The training program involved six one-day AT training sessions delivered monthly over a six-month period, supplemented with monthly team supervision using a variety of technological approaches to support practitioners. The training has prepared MHC to explore consumers’ beliefs about treatment, help consumers solve practical problems with their medication,
and use a medication timeline to review past experiences of illness and treatment. The training prepared MHCs to test consumers’ beliefs about medication, help consumers move forward in their lives and the role medication might play in achieving these. The project outcome will be the development of a sustainable model for regional practitioners to assist people living with schizophrenia to adhere to their medication.
THE TRAINING PROGRAM INVOLVED SIX ONE-DAY AT TRAINING SESSIONS DELIVERED MONTHLY OVER A SIXMONTH PERIOD, SUPPLEMENTED WITH MONTHLY TEAM SUPERVISION USING A VARIETY OF TECHNOLOGICAL APPROACHES TO SUPPORT PRACTITIONERS. This will be achieved by adapting various electronic technologies to support practitioners in their clinical practice to utilise the skills covered in the training program. The evaluation will examine changes in consumer’s attitudes towards using antipsychotic medicines and changes in the time the consumer has spent in hospital. The mental health workers will be asked what they thought about the training, and how the technology has helped or hindered the application of the skills covered in the training program.
References Birchwood, M. & Spencer, E. (2001). Early intervention in psychotic relapse. Clinical Psychology Review, 21 (8), 1221–1226. Birchwood, M., Spencer, E. & McGovern, D. (2000). Schizophrenia: Early warning signs. Advances in Psychiatric Treatment, 6, 93–101. Dibben, C., Rice, C., Laws, K. & McKenna, P. (2009). Is executive impairment associated with schizophrenic syndromes? A metaanalysis. Psychological Medicine, 39 (3), 381–392.
Associate Professor Dr Martin Jones is Director, Lee Martinez is a Mental Health Academic and Kuda Muyambi is an Evaluation Officer. All are in the Department of Rural Health at the University of South Australia Julie Murison is a Mental Health Team Leader at Country Health SA Local Health Network anmf.org.au
Rural / Remote
Why the grass is greener amongst the red dirt By Lizzie Uhr Have you found yourself wondering if your skills and experience could be put to better use and help those who really need it? You are not alone. An increasing number of Australian health professionals are looking overseas to utilise their skills helping those in need of health service. However there are also many taking the opportunity to make a difference in Australia in remote Indigenous communities. According to General Manager of the Remote Area Health Corps (RAHC), Philip Roberts an increasing number of urban-based health professionals are looking to make a difference in closing the gap in Indigenous health outcomes as well as supporting the permanent health workforce in the Northern Territory (NT). The Australian government established RAHC as a part of the Stronger Futures program to recruit, orientate and place health professionals to assist in service delivery in remote NT Indigenous communities. “There is a strong emphasis on attracting urban-based health professionals to ensure that the program was assisting the permanent workforce rather than redistributing it. Over 93% of RAHC’s health professionals come from urban and regional locations anmf.org.au
with the majority coming from New South Wales, Victoria and Queensland,” said Mr Roberts. The pool of highly motivated and experienced health professionals continues to grow with over 75% of placements undertaken by returning health professionals. Together, these health professionals have provided the equivalent of 305 years of healthcare service delivery to the Territory. While daunting at first, there are plenty of supports and resources available to help with adjusting to remote living and working in remote Indigenous settings. Karen Wright, a Registered Nurse (RN) from Canberra, who has worked in various central Australian communities, including Kings Canyon, Docker River and Harts Range to name a few, said she finds the experience of working remote extremely empowering, especially knowing that she had played a significant role in improving patient outcomes. “I am so glad I took that leap to try something different and have a go. If you don’t, you never know what you are missing,” she said. If Karen was to ever require help, there are many resources she can call on, including the CARPA manual (a clinical handbook used in the NT by GPs and RNs), district medical officers, remote midwives and diabetic educators to name a few. According to Karen her list of resources “could go on and on.” There are also remote specific support mechanisms available which help to transition health professionals successfully into working in remote locations by
building upon their established skillsets. These include the Bush Support Line (run by CRANAplus) and the Remote Educator program (run by RAHC). The Bush Support Line is a confidential, free, 24-hour, nationwide telephone service staffed by nine registered psychologists who have experience working in remote and rural areas. The service has the capacity for repeat callers to speak with the same psychologist, where possible, with confidentiality guaranteed. RAHC has extensive support mechanisms for health professionals including free eLearning, cultural and clinical orientation programs and in-person support from the RAHC placement and operational teams. In 2011, RAHC launched the Remote Educator (RE) program. RE support in the clinic setting includes orientation, induction, training and assessment to take the burden off the permanent staff. This program is designed to assist with the transition into the remote environment both clinically and culturally. Since the program’s inception, the 14 REs have supported 108 health professionals comprised of registered nurses and general practitioners. All of these resources help to create a supportive working environment where health professionals can learn new and interesting clinical and cultural information to assist in the delivery of healthcare to those most in need in Australia. For this reason, many health professionals find it an extremely rewarding experience, both on a professional and personal level.
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KAREN WRIGHT FAR LEFT.
Lizzie Uhr is Marketing Coordinator at Aspen Medical in the ACT
October 2015 Volume 23, No. 4 43
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OCTOBER Lung Health Promotion Centre at The Alfred 5-6 October - Spirometry Principles & Practice 14-15 October - Respiratory Course (Module B) 22-23 October - Managing COPD P: (03) 9076 2382 E: lunghealth@alfred.org.au 40th National Conference of the Australian Association of Stomal Therapy Nurses Proactive and Innovative Strategies in Stomal Therapy Nursing 5–7 October, Melbourne Convention Centre. www. stomaltherapy.com/conferences.php Australian College of Midwives 19th Biennial Conference Super midwives - making a difference 5-8 October, Gold Coast, Qld. www.acm2015.com/ International Indigenous Women’s Convention Our families, our communities: nothing about us without us 6-9 October, Sydney NSW. http://dreamtimepr.com/save-thedate-international-indigenouswomens-convention-sydneyoctober-2015/ 13th International Conference for Emergency Nursing Emergency Care: Accept the Challenge, Lead the Change 7-9 October, Brisbane Convention & Exhibition Centre, Queensland. www.icen.com.au/2015/ Australian College of Mental Health Nurses 41st International Mental Health Nursing Conference Mental health nurses: shifting culture, leading change 7-9 October, Brisbane Convention Centre. www.acmhn2015.com/ Anti Poverty Week 11-17 October. www. antipovertyweek.org.au Perioperative Nurses Week 12-19 October. www.acorn.org.au/ events/perioperative-nurses-week/ Australian College of Nursing National Nursing Forum Advancing nurse leadership 14-16 October, Brisbane Convention & Exhibition Centre. http://acn.edu.au/forum_2015 International Day of Rural Women 15 October. www.timeanddate. com/holidays/un/rural-women-day
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2nd Australian Nursing and Midwifery Conference Aspiration, inspiration and imagination: nursing and midwifery quality, research and education 15-16 October, Newcastle City Hall, Newcastle, NSW. www. nursingmidwiferyconference.com.au CRANAplus 33rd Annual Conference Telling tales - The power of the narrative 15-17 October, Alice Springs Convention Centre. NT. https:// crana.org.au/about/conference/2015conference/ Long Women’s Lunch 16 October www.thelongwalk.com.au/ Australian Day Surgery Nurses Association Conference Surfing the waves of day surgery 17-18 October, Gold Coast Convention Centre, Queensland. http://adsna.info/conference/ Australian Men’s Shed Association 6th National Conference 17-20 October 2015, Civic Precinct Newcastle, NSW. www.dcconferences.com.au/ mensshed2015/ 12th Biennial National Enrolled Nurse Association of Australia (ANMF SIG) Conference 21 October, InterContinental, Adelaide SA. P: 1300 972 315 E: info@nena.org.au, www.nena.org. au/2015NENAConference.html Australian Transplant Nurses’ Association 24th Annual Conference Transplantation in the Tropics: Cruising the Reef and Navigating New Ways 21-23 October, Cairns, Qld. www.tna.asn.au/ 7th Australian Rural & Remote Mental Health Symposium Closing the gap: Innovation and opportunity 26-28 October, Novotel Forest Resort Creswick, Victoria. http:// anzmh.asn.au/rrmh/index.html
NOVEMBER Australian Association of Gerontology 48th National Conference 4-6 November, Alice Springs Convention Centre. www.aag.asn.au/ national-conference/2015-conference Australian Diabetes Educators Association (ADEA) Inaugural Thought Leadership Program on Emotion, Behaviour and Applied Psychology in Diabetes Education 6 November, The University of Qld – The psychological side of diabetes: What healthcare professionals need to know
10 November, Deakin University, Melbourne – Understanding depression and diabetes burnout 11 November, University of Technology, Sydney – Engaging the disengaged: Behavioural strategies for promoting successful diabetes self-management www.adea.com.au/?p=12359144
NETWORK Royal Adelaide Hospital, Class of 756, 40-year reunion Contact Karen Braithwaite or Frances Woodcock on M: 0422 812 187 or E: woodcock7@gmail.com
Annual Scientific Alcohol and Drug Conference 8-11 November, Perth, WA. www.apsadconference.com.au Lung Health Promotion Centre at The Alfred 11–13 November - Asthma Educator’s Course 19-20 November - Smoking Cessation Facilitator’s Course P: (03) 9076 2382 E: lunghealth@alfred.org.au Australian & New Zealand Orthopaedic Nurses Association (ANZONA) Conference Climbing to the Summit: Bridging research and practice in orthopaedic nursing 11-13 November, Hilton Hotel, Sydney. www.anzonaconference.net/ Hospital In The Home Society, 8th Scientific Meeting HITH at 21: Maturity, Responsibility and Quality 11-13 November, Rydges World Square, Sydney. http://conference.hithsociety.org.au/ Australian and New Zealand Society for Vascular Nursing Conference Working Together for an Integrated Vascular Approach 13-14 November, Adelaide Convention Centre, SA. www.anzsvn.org/ Melbourne Practice Nurse Clinical Education Australia’s leading event for nurses working in General Practice. Earn 18 CPD hours. 13–15 November. www.pnce.com.au
2016 FEBRUARY Lung Health Promotion Centre at The Alfred Spirometry Principles & Practice 12-13 February 2016 P: (03) 9076 2382 E: lunghealth@alfred.org.au
MARCH Lung Health Promotion Centre at The Alfred Asthma Educator’s Course 4-6 March 2016 Smoking Cessation Course 19-20 March 2016 P: (03) 9076 2382 E: lunghealth@alfred.org.au
Box Hill Hospital, Group 99, 30-year reunion Contact Clare D’Arcy-Evans E: clarebears21@icloud.com or M: 0416 399 881 The Alfred Hospital, group 3/75 40-year reunion 10 October. Contact Penny McCarthy (nee Jaffray) E: p.mccarthy@alfred.org.au or Mary Rhodes (nee Woods) M: 0438 897 578 E: rhodesmary@gmail.com 97th Annual General Meeting of the Alfred Hospital Nurses League 24 October at 1.30pm at the Mt Erica Hotel, Prahran following lunch at 12noon. Contact Dorothy Owen E: dorothy@e-owen.com Royal Hobart Hospital, 4/75 PTS, 40-year reunion 30 October, 6.30pm, Janne Gordon’s, 94 Nelson Road, Mount Nelson, Tasmania 7007. BYO drinks and $20 towards pizzas, nibbles and cake. Contact: Janne E: gordies@ southernphone.com.au, Alex E: therandalls3@netspace. net.au, Heather E: hknichols@ gmail.com or Sue E: susan. cunningham57@hotmail.com LaTrobe University, LaTrobe/Bendigo Campus nursing group (19881991), 25-year reunion 20 February 2016, Bendigo. Contact Steven Graham E: sgraham@ bendigohealth.org.au or Sarah Shipp (nee Prudham) E: sshipp@bendigohealth.org. au or search Facebook page LaTrobe 1991 reunion St Vincent’s Hospital, February 1976, 40-year reunion. 19 March 2016. Contact Mary Hibble (nee Ross) E: maryhibble@yahoo.com.au or Ra Cunningham (nee Savaris) E: vtcunningham@hotmail. com or Seach Facebook page: St Vincents Hospital Nurses Class of 1976
Email cathy@ anmf.org.au if you would like to place a reunion notice October 2015 Volume 23, No. 4 45
Thanks ANMJ ! I have been an avid reader of the ANMJ for many years and wanted to congratulate the editorial team on the journal’s fresh new look that I’ve seen crop up in recent months. The cover images have been striking and engaging, particularly the August edition which featured a poignant portrait of domestic violence campaigner Rosie Batty. Most of the articles have also been informative and thought-provoking, but there are two which especially stuck out for me lately. The first is the September feature “No Place Like Home” on nurses and midwives working with the homeless. The article told the story of a longterm homeless man named Justin who battled drug addiction for many years before recently getting his life back on track through the help of RDNS nurses. It was a touching article and one that opened up my eyes to the often hidden problem of homelessness, but it also gave me an insight into the possibilities of working in other areas of nursing that I never considered. I commend all nurses and midwives working within the homelessness sector trying to make a difference and believe we can all do our bit to raise awareness.
Clinical leadership and nursing The article ‘Clinical leadership and nursing’ (Ogrin R and Barrett E, August 2015 ANMJ) at first glance seems reasonable. Of course care should be efficient and effective, and if being evidence-based and person-centred helps, that is desirable. But it is built upon assumptions that do not withstand critical scrutiny. Although it may be uncomfortable, I want to explore some doubts about the article, in the hope of finding something more substantial. The first sentence is “Health systems… are grappling with the task of providing system-wide evidence based, personcentred, efficient and effective care”. The word ‘system’ is entirely misleading. Health bureaucracies (private and public) consist of chaotic groups of people all trying to get by in this world with their own agendas. The claim that “clinical leadership, particularly 46 October 2015 Volume 23, No. 4
The second article I wanted to mention was the column by ANMF ME OME Vice President HEO H ss EmC KLA nessLI KE I L eless P E o O h homelessne N Cwivenurs Maree Burgess on kling wives tackling LA NO s taces and mid PLA P CE LIKE HO ME id m O d N nurses an nurses and midwives tackling homeles sness the ongoing racism experienced by Sydney Swans football star Adam Goodes. Like Maree, I was appalled by the behaviour of many fans across the country who chose to boo Goodes during matches and forced him to take time out from the game. While the booing stopped for a game or two, it reared its ugly head once again during the AFL final series and now Goodes has chosen to retire. This type of public hate articles because I believe there are lots of important issues going on in our country is not only a blight on the game but a blight on society as well and it’s extremely right now that nurses and midwives can disappointing that an underbelly of racism have a significant impact on. still exists in Australia. Whether it be homelessness, racism, I wanted to praise Maree for tackling gay marriage, or penalty rates, we can all make a difference by joining together to this issue in her column and making it known that this type of behaviour won’t be fight for common causes. tolerated. I chose to highlight these two specific Anita Jones, RN, Victoria V O LU
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of nursing staff, is proposed to be integral in reaching this goal” is equally erroneous. Nurses are supposedly professionals. That means commitment to study and reflective practice, to taking responsibility for one’s decision-making actions and acting autonomously. If the core problem in providing healthcare is attributed to nurses, to such an extent that they all need clinical leadership, then professional education is a massive failure. It’s embarrassing that the RDNS does not define its acronym, given that it claims the authority to define what clinical leadership is. The definition it does give, of involving “individuals … at all levels of an organisation” is profoundly absurd. It’s an absurdity illustrated by a remark in the film Superheroes, that “when everyone becomes a Superhero, then no-one will be”. It goes on to suggest that nurses in formal leadership positions are not effective enough in an age of “increasing urgency to improve efficiency”. Just why is there an “increasing urgency”? Is it because of pressures to increase profit
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margins and reduce costs? So the cause and solution of the problem does not arise from nursing. It advocates adding the role of leadership to every nurse. If (formal) leadership is inadequate in improving efficiency and effectiveness, then how will non-formal leadership be different? The suggestion is that it will build up nurses’ “decision-making capabilities”. We’ve heard this before. Now though, ‘professionalism’ is replaced by ‘clinical leadership’. The RDNS is researching ‘what it takes’ to be a clinical leader. But this is the wrong question, being asked of the wrong people. The answers from those in formal leadership positions will not necessarily be relevant to people who are not formally clinical leaders. Developing an understanding how front-line staff do work, and how they could be supported in working as professionals, would be welcome. It would be more realistic for nursing groups such as the RDNS, to tackle that question. Dr Niko Leka, EN, NSW anmf.org.au
Letter of the month
Newborn falls are not a priority ANMJ’s July 2015 Clinical Update, “Need for improved recognition of in-hospital newborn falls”, a recent study by Teuten et al. highlights the under recognised but highly significant incidences of in-hospital newborn falls. It is interesting to note that the reason these falls are under recognised is mainly due to under reporting, and this is quite often due to the ‘lack of transparent no-blame culture’. There are strong feelings of guilt and culpability from the parent if a newborn fall occurs, therefore requiring non-judgemental response from health professionals. Although the study highlights the importance of healthcare staff being aware of the many methods to reduce in-hospital newborn falls, there is not sufficient focus on how to reduce the under-reporting. As noted by the authors there is limited research into the area of inhospital newborn falls. The focus in
healthcare institutions is generally on the adult population and falls, which has led to a body of evidence in this area to help prevent falls occurring. Research into newborn falls does not appear to be a priority which is also due to the focus on adult population falls and the associated healthcare costs which is thought to require more urgent attention. Even so, the incidence of newborn falls should not be ignored and further research should be implemented to help address the under-reporting of incidences. The authors concede that the incidence data of falls rates of 1.6 to 4.4 per 10,000 live births is an underestimate due to under-reporting. This study highlights the importance of effective communication between healthcare professionals and patients to improve patient safety and overall quality of care to mothers and babies. Providing support and education to parents in hospital pre and post birth will be valuable tools in enabling them to feel more comfortable reporting a newborn fall. Michelle Burnett, Clinical Research Nurse, Vic
Letter of the month The winner of the ANMJ best letter competition receives a $50 Coles Myer voucher. If you would like to submit a letter to the ANMJ email anmj@anmf.org.au Letters may be edited for clarity and space.
Risking nurses and midwives There were a number of articles in August’s ANMJ about new Commonwealth legislation that could see nurses and midwives working in detention facilities face imprisonment for speaking out. According to Megan-Jane Johnstone’s ethics article, the ANMF Federal Office released a media statement which said, “It’s important that nurses working in detention centres are allowed to meet their Codes of Ethics and Professional Practice Standards in the provision of proper, basic healthcare and not be working under the fear that they themselves could be jailed for trying to deliver proper, basic health services.” I agree with their sentiments; however I am greatly concerned about the same paragraph, seen from the other direction. To re-state it, “Codes of Ethics and Professional Practice Standards require nurses to break laws that have been legislated by the Parliament of this nation.” I think it is incumbent on the various bodies that set these Codes of Ethics and Professional Practice Standards to change them so as to fall in line with legal requirements, and not put nurses at risk of a prison sentence. Garry Trethewey, RNM, SA
anmf.org.au
October 2015 Volume 23, No. 4 47
SALLY
Sally-Anne Jones, ANMF Federal President
I was fortunate enough to hear Dr Alessandro Demaio (pictured) speak about the global burden of Non Communicable Diseases (NCDs) at the 70th Annual New South Wales Nurses and Midwives’ Association Conference in July this year. His inspiring and empowering presentation showed how nurses and midwives all over the world could individually and collectively participate in combating this growing global issue.
perpetuated by poverty. They are not diseases of the aged – Diabetes is a global epidemic affecting more children every day. NCDs are rooted in the social determinants of health – employment, education, urban planning and investment and social equity. Death from non-communicable diseases can be deterred. The World Health Organization (WHO) states to lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs,
hospitals, healthcare environments, schools and communities. In the 20th century approximately 100 million people died world-wide from tobacco-related illnesses. Nurses and midwives can promote education about food choices and lobby for access for all too safe, affordable, healthy food. Literature is available that explains how food deserts can occur in any city in the world where lesser quality food is available in lower socio-economic suburbs for the same prices as better quality food in higher socioeconomic
THEY ARE NOT DISEASES OF THE AGED – DIABETES IS A GLOBAL EPIDEMIC AFFECTING MORE CHILDREN EVERY DAY. NCDS ARE ROOTED IN THE SOCIAL DETERMINANTS OF HEALTH – EMPLOYMENT, EDUCATION, URBAN PLANNING AND INVESTMENT AND SOCIAL EQUITY.
60% MORE PEOPLE DIE OF NCDS THAN ANY OTHER CAUSE, ACCOUNTING FOR MORE THAN 60% OF GLOBAL MORTALITY TODAY
NCDs are a group of diseases that share determinants and therefore offer an opportunity for global action in prevention and mitigation. NCDs include cardiovascular disease, cancer, diabetes and chronic respiratory diseases. More people die of NCDs than any other cause, accounting for more than 60% of global mortality today. All of these diseases are in some way impacted by the same causal factors – harmful use of alcohol, diet, physical activity and tobacco use around which political lobbying and clinical action can be mobilised. It is a common assumption that the NCDs are afflictions of wealthy and more developed societies and have arisen out of lifestyle change associated with those things. The facts are that NCDs are not diseases of the rich. Eighty five per cent of NCDs occur in the poorest countries and are poverty cycle catalysts. NCDs causes, result in and are
48 October 2015 Volume 23, No. 4
education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote the interventions to prevent and control them. The opportunities presented to us to reduce the prevalence of NCDs are to create healthier cities, stronger economies, more sustainable living and understand the synergies with other diseases. The most effective action is political. Lobbying and societal advocacy is imperative to produce the changes necessary to reduce the impact of NCDs across the globe. You may ask how you can make a difference to a global problem as big as this...the answer is in targeting the causal factors of NCDs, which are within our remit as health professionals, health teachers and health promoters. Nurses and midwives can become involved in reducing smoking, tobacco use and the harmful use of alcohol in our everyday roles in
areas within one city; or where access to quality affordable food is restricted by distance and transport availability. Nurses and midwives can support and participate in screening programs for early detection and treatment of NCDs. We can lobby for urban environments that encourage physical activity and promote healthy lifestyles. In 2015 the WHO in conjunction with countries will begin to set national targets and measure progress on the 2010 baselines reported in the Global status report on noncommunicable diseases 2014. The UN General Assembly will convene a third high-level meeting on NCDs in 2018 to take stock of national progress in attaining the voluntary global targets by 2025. So now is the time to think…what will I do to make a difference? Not just to my patient, family, client, or resident, but to the health of every global citizen… anmf.org.au
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Caring for the people who care
2014 winners, left to right: Outstanding Graduate: Zoe Sabri, Nurse of the Year: Stephen Brown, and Team Innovation: Prof Jeanine Young representing the Pepi-pod® Program.
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